Comparison of short- and long-term outcomes between anatomical subtypes of resected biliary tract cancer in a Western high-volume center

Prediction of survival after pancreatoduodenectomy for distal cholangiocarcinoma: independent external validation of a prognostic model for 3-year overall survival in Sweden

OBJECTIVES

The only treatment with curative potential for distal cholangiocarcinoma (dCCA) is radical surgery which can be complemented with adjuvant chemotherapy. The aim of the present study was to perform an independent external validation of a prognostic model for 3-year overall survival based on routine clinicopathological variables for patients treated with pancreatoduodenectomy for dCCA.

MATERIALS AND METHODS

All patients with a histopathological confirmed dCCA that underwent pancreatoduodenectomy in Sweden from 2009 through 2019 were identified in the Swedish National Registry for Pancreatic and Periampullary Cancer. Model performance was estimated using the C-index and calibration plots.

RESULTS

In total 220 patients were included in the study. The median survival was 33 months (IQR 26-40) and 3-year survival rate 47% (95% CI 40-53%). The prognostic model had a C-index of 0.69 (95% CI 0.62-0.72). Calibration plots revealed overestimated risk of death across risk groups in the full cohort. Calibration was good in the subgroup of patients that did not receive adjuvant treatment.

CONCLUSIONS

The prognostic model showed reasonable discriminative ability but some miscalibration likely since the effect of adjuvant treatment is not included in the model. Given that the model was developed in cohorts treated prior to the current adjuvant standard of care the model can be used to estimate baseline risk prior to risk/benefit decision for adjuvant treatment as well as stratification for clinical trials but with a risk to underestimate 3-year overall survival for patients that receive adjuvant treatment.

Preoperative factors predicting outcomes in patients with suspected perihilar cholangiocarcinoma referred for curative resection- a single-center 10-year experience

PURPOSE

Perihilar cholangiocarcinoma (pCCA) is a rare malignancy requiring resection of extrahepatic bile ducts with or without hepatectomy. Prognostic models for post-operative outcomes in pCCA are unusable in pre-operative decision-making as most are based on post-operative variables. Additionally, no pre-operative models include futile laparotomy or benign hilar stenosis (BHS) as possible outcomes. We investigated pre-operative predictive factors for non-resectability, disease-free survival (DFS), and overall survival (OS), in patients referred for resection of suspected pCCA.

METHODS

Patients with suspected pCCA evaluated at multidisciplinary team (MDT) conference and referred for curative resection at Rigshospitalet, from 2013-2023. Outcomes were preoperative factors related to OS, DFS and non-resectability.

RESULTS

Ninety-three patients with suspected pCCA were considered resectable at MDT, of which 84 (90.3 %) were confirmed pCCA. Nineteen (20.4 %) with pCCA were non-resectable. Patients with non-resectable pCCA had higher pre-operative p-bilirubin and ECOG-performance status (ECOG-PS) compared to resected pCCA and BHS (p=0.02 and 0.01). Portal vein embolization (PVE), higher ECOG-PS and elevated p-bilirubin were associated with worse OS in patients with pCCA undergoing surgical exploration [(HR 2.45 (95% CI 1.32-4.56), p=0.004), (HR 2.32 (95% CI 1.30-4.09), p=0.004) and (HR 2.03 (95% CI 1.17-3.51), p=0.01), respectively]. PVE and larger tumor size were associated with poorer DFS [HR 3.29 (95 % CI 1.64- 6.60), p=0.001) and (HR 1.02 (95% CI 1.00-1.04), p=0.003) respectively].

CONCLUSION

Poor ECOG-PS, PVE, elevated p-bilirubin and larger tumor size were associated with adverse survival in patients with pCCA undergoing surgical exploration. Non-resectable pCCA were associated with higher rates of elevated p-bilirubin and larger tumor size.

Postoperative factors predicting outcomes in patients with Perihilar cholangiocarcinoma undergoing curative resection-a 10-year single-center experience

BACKGROUND

Perihilar cholangiocarcinoma (pCCA) has a 5-year overall survival (OS) ranging from 10-40%, following resection. However, prognostic models for postoperative outcomes are limited by long study timespan and variations in work-up. We investigated postoperative outcomes in patients resected for pCCA in a high-volume center with standardized work-up.

METHOD

Patients resected with confirmed pCCA, between 2013 and 2023, were included. Cox-regression investigated association between postoperative factors and OS as well as disease-free survival (DFS).

RESULTS

Totally, 65 patients were resected for pCCA. The 1-, 3- and 5-year OS rates were 86.1%, 56.5% and 32.6% respectively. The 1-, 3- and 5-year DFS rates were 67.7%, 40.0% and 26.8%, respectively. Portal vein embolization (PVE) (HR 4.52 [CI 1.66-12.27], p = 0.003), lymph node metastasis (LNM) (HR 6.37 [CI 2.06-19.67], p = 0.001) and Clavien-Dindo (CD) ≥3a (HR 2.83 [CI 1.43-5.56], p = 0.002) were associated with inferior OS. Clavien-Dindo (CD) ≥3a (HR 2.10 [CI 1.05-4.22], p = 0.03) and T-stage >2 (HR 2.36 [CI 1.01, 5.05], p = 0.04) were associated with inferior and superior DFS, respectively.

CONCLUSION

PVE, T-stage >2, LNM and CD ≥ III were associated with worse prognosis in resected pCCA. Research is needed to improve pre-operative detection of oncological features and patients with risk of major surgical complications.

Preoperative prognostic stratification and prediction of long-term outcomes after pancreatoduodenectomy for distal cholangiocarcinoma

BACKGROUND

Patients with distal cholangiocarcinoma (DCC) frequently receive adjuvant chemotherapy in preoperative and postoperative settings, but prediction of prognostic risk at the time of treatment selection remains challenging.

METHODS

This single-center retrospective study enrolled DCC patients who underwent initial pancreatoduodenectomy (PD) between 2009 and 2022. Preoperative clinical parameters were collected, and Cox regression analysis was used to identify risk factors for overall survival (OS).

RESULTS

Among 170 patients examined, the median tumor depth was 10 mm, and 37 % of the patients were diagnosed with pT3. Overall, 46 % of patients had lymph node metastasis. The median and 5-year OS was 58.2 months and 50 %, respectively. Multivariate analysis revealed tumor size on computed tomography (CT) ≥15 mm and main pancreatic duct (MPD) dilatation (≥3 mm) as independent risk factors for OS among various preoperative parameters; the prognosis was stratified based on these two parameters. Patients with one risk factor had similar outcomes (5-year OS: 39 %) to pStage IIB DCC (pT2N1 or pT3), while those with two risk factors had a prognosis akin to pStage IIIA (pN2), with a high early recurrence rate of 64 % (5-year OS: 8 %). Among non-risk group patients with low carbohydrate antigen (CA)19-9 levels (<37 U/mL), the prognosis was comparable (5-year OS: 72 %) to those with pStage I DCC.

CONCLUSION

A simple stratification approach was developed to predict long-term postoperative outcomes. To improve poor prognosis, intensive therapy, including neoadjuvant chemotherapy, should be considered for patients with two risk factors.

Different biliary tract cancers, same operation: Importance of cancer origin in patients with hilar-invading tumors

BACKGROUND AND AIMS

For patients with biliary tract cancer involving the hepatic hilum, major hepatic resection with extrahepatic bile duct resection may be required. In addition to perihilar cholangiocarcinoma (PHCC), the same extent of surgery is used in advanced gallbladder cancer (GBC) and intrahepatic cholangiocarcinoma (IHCC) with hilar involvement. Few studies compare prognostic factors and long-term outcomes across tumor types. This study compared risk characteristics and outcomes after surgery in all subtypes of biliary tract cancer with hilar involvement.

METHODS

Patients with biliary tract cancer with hilar involvement undergoing major liver resection and extrahepatic bile duct resection between 2011 and 2021 at a single center were retrospectively analyzed. The primary postoperative outcome was overall survival. Secondary outcomes were recurrence-free survival and postoperative complications. Survival analysis was performed with Cox regression analysis and Kaplan-Meier method.

RESULTS

One-hundred and eight patients were included. Seventy-three (67%) had PHCC, 24 (22%) had GBC, and 11 (10%) had IHCC. Hilar-invading IHCC and GBC had more adverse histopathological factors like lymph node positivity (p = 0.021), higher number of positive nodes (p = 0.043), and larger tumor size (p < 0.001) compared with PHCC. Peritoneal invasion and lymph node positivity were significant independent predictors for survival (p = 0.011 and p = 0.004, respectively). Median overall survival was 29 months for PHCC, 22 months for GBC and 21 months for IHCC (p = 0.53). IHCC tended to recur earlier (p = 0.046) than GBC and PHCC (6, 15, and 18 months, respectively).

CONCLUSION

Patients with biliary tract cancer with hilar involvement undergoing major liver resection and resection of extrahepatic bile ducts had similar overall survival regardless of subtype, while IHCC recurred earlier. Peritoneal cancer invasion was common in all subtypes, including PHCC, and was an independent prognostic factor. This finding may support routine reporting of peritoneal invasion-status in resected biliary tract cancer.

Thioredoxin System Protein Expression in Carcinomas of the Pancreas, Distal Bile Duct, and Ampulla in the United Kingdom

Background: Poor survival outcomes in periampullary cancer highlight the need for improvement in biomarkers and the development of novel therapies. Redox proteins, including the thioredoxin system, play vital roles in cellular antioxidant systems. Methods: In this retrospective study, thioredoxin (Trx), thioredoxin-interacting protein (TxNIP), and thioredoxin reductase (TrxR) protein expression was assessed in 85 patients with pancreatic ductal adenocarcinoma (PDAC) and 145 patients with distal bile duct or ampullary carcinoma using conventional immunohistochemistry. Results: In patients with PDAC, high cytoplasmic TrxR expression was significantly associated with lymph node metastasis (p = 0.033). High cytoplasmic and nuclear Trx expression was significantly associated with better overall survival (p = 0.018 and p = 0.006, respectively), and nuclear Trx expression remained significant in multivariate Cox regression analysis (p < 0.0001). In distal bile duct and ampullary carcinomas, high nuclear TrxR expression was associated with vascular (p = 0.001) and perineural (p = 0.021) invasion, and low cytoplasmic TxNIP expression was associated with perineural invasion (p = 0.025). High cytoplasmic TxNIP expression was significantly associated with better overall survival (p = 0.0002), which remained significant in multivariate Cox regression analysis (p = 0.013). Conclusions: These findings demonstrate the prognostic importance of Trx system protein expression in periampullary cancers.

A Novel Approach to Quantify Heterogeneity of Intrahepatic Cholangiocarcinoma: The Hidden-Genome Classifier

PURPOSE

Intrahepatic cholangiocarcinoma (IHC) is a heterogeneous tumor. The hidden-genome classifier, a supervised machine learning-based algorithm, was used to quantify tumor heterogeneity and improve classification.

EXPERIMENTAL DESIGN

A retrospective review of 1,370 patients with IHC, extrahepatic cholangiocarcinoma (EHC), gallbladder cancer (GBC), hepatocellular carcinoma (HCC), or biphenotypic tumors was conducted. A hidden-genome model classified 527 IHC based on genetic similarity to EHC/GBC or HCC. Genetic, histologic, and clinical data were correlated.

RESULTS

In this study, 410 IHC (78%) had >50% genetic homology with EHC/GBC; 122 (23%) had >90% homology ("biliary class"), characterized by alterations of KRAS, SMAD4, and CDKN2A loss; 117 IHC (22%) had >50% genetic homology with HCC; and 30 (5.7%) had >90% homology ("HCC class"), characterized by TERT alterations. Patients with biliary- versus non-biliary-class IHC had median overall survival (OS) of 1 year (95% CI, 0.77, 1.5) versus 1.8 years (95% CI, 1.6, 2.0) for unresectable disease and 2.4 years (95% CI, 2.1, NR) versus 5.1 years (95% CI, 4.8, 6.9) for resectable disease. Large-duct IHC (n = 28) was more common in the biliary class (n = 27); the HCC class was composed mostly of small-duct IHC (64%, P = 0.02). The hidden genomic classifier predicted OS independent of FGFR2 and IDH1 alterations. By contrast, the histology subtype did not predict OS.

CONCLUSIONS

IHC genetics form a spectrum with worse OS for tumors genetically aligned with EHC/GBC. The classifier proved superior to histologic subtypes for predicting OS independent of FGFR2 and IDH1 alterations. These results may explain the differential treatment responses seen in IHC and may direct therapy by helping stratify patients in future clinical trials.

The road to tailored adjuvant chemotherapy for all four non-pancreatic periampullary cancers: An international multimethod cohort study

BACKGROUND

Despite differences in tumour behaviour and characteristics between duodenal adenocarcinoma (DAC), the intestinal (AmpIT) and pancreatobiliary (AmpPB) subtype of ampullary adenocarcinoma and distal cholangiocarcinoma (dCCA), the effect of adjuvant chemotherapy (ACT) on these cancers, as well as the optimal ACT regimen, has not been comprehensively assessed. This study aims to assess the influence of tailored ACT on DAC, dCCA, AmpIT, and AmpPB.

PATIENTS AND METHODS

Patients after pancreatoduodenectomy for non-pancreatic periampullary adenocarcinoma were identified and collected from 36 tertiary centres between 2010 - 2021. Per non-pancreatic periampullary tumour type, the effect of adjuvant chemotherapy and the main relevant regimens of adjuvant chemotherapy were compared. The primary outcome was overall survival (OS).

RESULTS

The study included a total of 2866 patients with DAC (n = 330), AmpIT (n = 765), AmpPB (n = 819), and dCCA (n = 952). Among them, 1329 received ACT, and 1537 did not. ACT was associated with significant improvement in OS for AmpPB (P = 0.004) and dCCA (P < 0.001). Moreover, for patients with dCCA, capecitabine mono ACT provided the greatest OS benefit compared to gemcitabine (P = 0.004) and gemcitabine - cisplatin (P = 0.001). For patients with AmpPB, no superior ACT regime was found (P > 0.226). ACT was not associated with improved OS for DAC and AmpIT (P = 0.113 and P = 0.445, respectively).

DISCUSSION

Patients with resected AmpPB and dCCA appear to benefit from ACT. While the optimal ACT for AmpPB remains undetermined, it appears that dCCA shows the most favourable response to capecitabine monotherapy. Tailored adjuvant treatments are essential for enhancing prognosis across all four non-pancreatic periampullary adenocarcinomas.

Diagnostic value of new biliary biopsy cannulae for malignant bile duct strictures via endoscopic retrograde cholangiopancreatography pathway

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the diagnosis of malignant biliary strictures. ERCP fluoroscopy-guided biliary biopsy is more sensitive than brushing, but it is more difficult to perform and less successful. Therefore, a new technique of biliary biopsy using a new biliary biopsy cannula via the ERCP route was developed in our center with the aim of improving the diagnosis rate of malignant biliary strictures.

METHODS

This is a retrospective study that included 42 patients who underwent ERCP-guided biliary brushing and biliary biopsy for biliary strictures using a new biliary biopsy cannula in our department from January 2019 to May 2022. The final diagnosis was determined after brushing, biliary biopsy under the new biliary biopsy cannula or adequate follow-up. Diagnostic rates were calculated and analyzed for relevant factors.

RESULTS

The satisfactory rates of pathological specimens of 42 patients who underwent bile duct biopsy with bile duct brush and new bile duct biopsy cannula were 57.14% and 95.24% respectively. Cholangiocarcinoma was diagnosed in 45.23% and 83.30% of the samples by biliary brush examination and biliary biopsy using the new biliary biopsy cannula, respectively (p < 0.001).

CONCLUSIONS

The ERCP route using a new biliary biopsy cannula for biliary biopsy technique can improve pathology positivity and benefit ratio. It provides a new approach in the diagnosis of malignant stenosis in the bile duct.

Current progress in perioperative chemotherapy for biliary tract cancer

Biliary tract cancer (BTCs) is a heterogeneous malignancy divided into cholangiocarcinoma, gallbladder cancer, and ampullary cancer. Due to little or no symptoms, most patients with BTCs are diagnosed with unresectable or metastatic disease. Only 20%-30% of all BTCs are suitable for potentially resectable diseases. Although radical resection with a negative surgical margin is the only potentially curative method for BTCs, most patients develop postoperative recurrence, which is associated with poor prognosis. Therefore, perioperative treatment is necessary to improve survival. There are very few randomized phase III clinical trials of perioperative chemotherapy due to the relative rarity of BTCs. Adjuvant chemotherapy with S-1 for patients with resected BTC significantly increased overall survival compared with upfront surgery in a recent ASCOT trial. In East Asia, S-1 is currently considered the standard adjuvant chemotherapy, while capecitabine may still be used in other areas. Since then, our phase III trial (KHBO1401), gemcitabine and cisplatin plus S-1 (GCS) has become the standard chemotherapy for advanced BTCs. GCS not only improved overall survival but demonstrated a high response rate. The efficacy of GCS as a preoperative neoadjuvant chemotherapy for resectable BTCs has been investigated in a randomized phase III trial (JCOG1920) in Japan. In this review, we summarize the current and ongoing clinical trials focusing on adjuvant and neoadjuvant chemotherapy for BTCs.

Distal Bile Duct Cancer: Radical (R0 > 1 mm) Resection Achieves Favorable Survival

OBJECTIVE

Evaluation of the outcome after resection for distal bile duct cancer (DBC) with focus on the impact of microscopic histopathological resection status R0 (>1 mm) versus R1 (≤1 mm) vs R1 (direct).

SUMMARY BACKGROUND DATA

DBC is a rare disease for which oncologic resection offers the only chance of cure.

METHODS

Prospectively collected data of consecutive patients undergoing pancreaticoduodenectomy for DBC were analyzed. Histopathological resection status was classified according to the Leeds protocol for pancreatic ductal adeno carcinoma (PDAC) (PDAC; R0 >1 mm margin clearance vs R1 ≤1 mm vs R1 direct margin involvement).

RESULTS

A total of 196 patients underwent pancreaticoduodenectomy for DBC. Microscopic complete tumor clearance (R0>1 mm) was achieved in 113 patients (58%). Median overall survival (OS) of the entire cohort was 37 months (5- and 10-year OS rate: 40% and 31%, respectively). After R0 resection, median OS increased to 78 months with a 5-year OS rate of 52%. Negative prognostic factors were age >70 years ( P < 0.0001, hazard ratio (HR) 2.48), intraoperative blood loss >1000 mL ( P = 0.0009, HR 1.99), pN1 and pN2 status ( P = 0.0052 and P = 0.0006, HR 2.14 and 2.62, respectively) and American Society of Anesthesiologists score >II ( P = 0.0259, HR 1.61).

CONCLUSIONS

This is the largest European single-center study of surgical treatment for DBC and the first to investigate the prognostic impact of the revised PDAC resection status definition in DBC. The results show that this definition is valid in DBC and that "true" R0 resection (>1 mm) is a key factor for excellent survival. In contrast to PDAC, there was no survival difference between R1 (≤1 mm) and R1 (direct).

Development and external validation of a prediction model for overall survival after resection of distal cholangiocarcinoma

BACKGROUND

Various prognostic factors are associated with overall survival (OS) after resection of distal cholangiocarcinoma (dCCA). The objective of this study was to develop and validate a prediction model for 3-year OS after pancreatoduodenectomy for dCCA.

METHODS

The derivation cohort consisted of all patients who underwent pancreatoduodenectomy for dCCA in the Netherlands (2009-2016). Clinically relevant variables were selected based on the Akaike information criterion using a multivariate Cox proportional hazards regression model, with model performance being assessed by concordance index (C-index) and calibration plots. External validation was performed using patients from the Belgium Cancer Registry (2008-2016), and patients from two university hospitals of Southampton (U.K.) and Verona (Italy).

RESULTS

Independent prognostic factors for OS in the derivation cohort of 454 patients after pancreatoduodenectomy for dCCA were age (HR 1.02, 95% CI 1.01-1.03), pT (HR 1.43, 95% CI 1.07-1.90) and pN category (pN1: HR 1.78, 95% CI 1.37-2.32; pN2: HR 2.21, 95% CI 1.63-3.01), resection margin status (HR 1.79, 95% CI 1.39-2.29) and tumour differentiation (HR 2.02, 95% CI 1.62-2.53). The prediction model was based on these prognostic factors. The optimism-adjusted C-indices were similar in the derivation cohort (0.69), and in the Belgian (0.66) and Southampton-Verona (0.68) validation cohorts. Calibration was accurate in the Belgian validation cohort (slope = 0.93, intercept = 0.12), but slightly less optimal in the Southampton-Verona validation cohort (slope = 0.88, intercept = 0.32). Based on this model, three risk groups with different prognoses were identified (3-year OS of 65.4%, 33.2% and 11.8%).

CONCLUSIONS

The prediction model for 3-year OS after resection of dCCA had reasonable performance in both the derivation and geographically external validation cohort. Calibration slightly differed between validation cohorts. The model is readily available via www. pancreascalculator.com to inform patients from Western European countries on their prognosis, and may be used to stratify patients for clinical trials.

Efficacy and Safety of Gemcitabine Plus Cisplatin as Potential Preoperative Chemotherapy in Locally Advanced Intrahepatic, Perihilar, and Mid-Cholangiocarcinoma: A Retrospective Cohort Study

BACKGROUND

In this retrospective cohort study, the potential of gemcitabine (gem)/cisplatin (cis) chemotherapy as future preoperative therapy for patients with unresectable locally advanced or borderline resectable intrahepatic, perihilar, and mid-cholangiocarcinoma was investigated.

METHODS

All patients with intrahepatic, perihilar, and mid-cholangiocarcinoma presented at Amsterdam UMC between January 2016 and October 2019 were included. The radiologic response after 3 and/or 6 cycles of gem/cis chemotherapy in patients with unresectable locally advanced or borderline resectable disease was derived from the original radiologic reports and subsequently re-evaluated for surgical exploration by consensus reading of 2 HPB surgeons and 1 radiologist.

RESULTS

Overall, 65 of 364 patients had a locally advanced or borderline resectable disease. Twenty-eight patients were treated with palliative chemotherapy, including 25 (89.3%) patients who received more than 3 cycles. Twenty-two patients (88.0%) and 13 patients (46.4%) showed RECIST stable disease or partial response after 3 and 6 cycles of chemotherapy, respectively. Three patients experienced grade 3 adverse events. Consensus reading concluded that exploration could have been reconsidered in 7 of 28 patients (25.0%).

CONCLUSION

Gem/cis may be a safe and feasible preoperative treatment in initially unresectable locally advanced or borderline resectable cholangiocarcinoma. In addition, the findings of this study support to always rediscuss patients with stable or responsive disease in multidisciplinary team meetings to reconsider resection. Besides, prospective studies are needed to investigate this effect further and, based on these preliminary data, seem feasible in this setting.

High sensitivity of ROSE-supported ERCP-guided brushing for biliary strictures

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in biliary strictures, with brushing being a cheap and fast method to acquire a cytological specimen, despite a sensitivity around 45 %. Rapid on-site evaluation (ROSE) is widely used for endoscopic ultrasound-acquired cytological specimen adequacy, improving its sensitivity and specificity. Nevertheless, no study has evaluated its role for ERCP-guided brushing. Our aim was to assess the diagnostic yield of ERCP-guided brushing of biliary strictures when supported by ROSE. Patients and methods  This was a retrospective single-center study that included patients undergoing ERCP-guided brush cytology supported by ROSE for biliary strictures. Recorded data included patient clinical-radiological and ERCP features. Final diagnosis was determined after surgery, intraductal biopsy or adequate follow-up. The diagnostic yield was calculated and a subgroup analysis for factors associated with false-negative or true-positive results was performed. Results  Two hundred six patients were included, 57.3 % males, median age 72 years, 77.2 % having extrahepatic biliary strictures. Of the patients, 99 % had an adequate sample at ROSE after a mean of 2.6 passages. The diagnostic yield was accuracy 83 %, sensitivity 74.6 %, and specificity 98 %, positive and negative predictive values 98 % and 71 % respectively, with an area under the curve of 0.86. A diagnosis of cholangiocarcinoma was significantly more frequent among true-positive cases (68 % vs 46.8 %; P  = 0.04). Conclusions  This is the first study evaluating the use of ROSE as support for ERCP-guided brushing of biliary strictures, with a sensitivity far higher than those reported for brushing alone and at least comparable to those of more expensive and invasive techniques.

Proposal of the optimal numbers of examined and positive lymph nodes to the 8th edition of American Joint Committee on Cancer (AJCC) staging for 758 patients with distal cholangiocarcinoma

Introduction

The American Joint Committee on Cancer (AJCC) recommended retrieval of at least 12 lymph nodes and firstly classified N category by the number of positive lymph nodes (PLNs) for Distal Cholangiocarcinoma (DCC).

Objective

The end of this cohort study was to explore the optimal cut-off values of the number of examined lymph nodes (ELNs) and PLNs to better stratify patients by utilizing a population-based database.

Methods

A number of 758 patients with DCC from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled in the study and comparing by the survival analysis.

Results

Survival analysis found that patients with ELNs < 5 had a lower 3-year disease-specific survival rate than ELNs ≥ 5 in N0M0 cohort (35.3% vs. 53.0%, P = 0.001) and in M0 cohort (42.7% vs. 32.8%, P = 0.006); survival curves between patients with ELNs < 12 and ELNs ≥ 12 were overlapped in N0M0 cohort (P = 0.256) and in M0 cohort (P = 0.233). Among patients with ELNs ≥ 5, using the optimal cut-off value of the number of PLNs (0, 2) could accurately stratify patients, but the recommendation of the number of PLNs (0, 3) by the AJCC could not.

Conclusions

This study recommended examining at least 5 lymph nodes and defining PLNs = 1–2 as the N1 category and PLNs ≥ 3 as the N2 category, which may better stratify distal cholangiocarcinoma patients and improve the accuracy of the eighth edition AJCC staging.

Risk factors and characteristics of young patients with the biliary tract carcinoma: results of a project study for biliary surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

PURPOSE

This study aimed to elucidate the characteristics of biliary tract carcinoma (BTC) in young patients.

METHODS

This is a nationwide multicenter, retrospective cohort study supervised by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS). Clinicopathological data of patients aged <50 years diagnosed with BTC from January 1997 to December 2011 were collected from 211 training institutes for highly advanced surgery registered by the JHBPS.

RESULTS

Data of 774 young patients aged <50 years were obtained from 102 institutes. Pancreaticobiliary maljunction (PBM) (10.6%) was most frequently associated with young BTC. However, organic solvents caused by printing or other occupations were only 2.5%. PBM was further associated with early onset of BTC and was noted in 38.9% of patients aged <30 years. Subgroup analysis revealed that the distributions of PBM, choledochal cysts, cholelithiasis, hepatitis B virus, and past history of cancer were significantly varied depending on the site of BTC. These results suggested that each site of BTC has a different mechanism for cancer development.

CONCLUSION

Although the most frequent factor for young BTC patients was PBM, cancer-associated factors were dramatically different in each BTC site. These results might be useful to elucidate the etiology of young BTC patients.