Cholangiocarcinoma and Gallbladder Cases: An Expert Panel Case-Based Discussion

The multidisciplinary management of cholangiocarcinoma

Cholangiocarcinoma is a lethal malignancy of the biliary epithelium that can arise anywhere along the biliary tract. Surgical resection confers the greatest likelihood of long-term survivability. However, its insidious onset, difficult diagnostics, and resultant advanced presentation render the majority of patients unresectable, highlighting the importance of early detection with novel biomarkers. Developing liver-directed therapies and emerging targeted therapeutics may offer improved survivability for patients with unresectable or advanced disease. In this article, the authors review the current multidisciplinary standards of care in resectable and unresectable cholangiocarcinoma, with an emphasis on novel biomarkers for early detection and nonsurgical locoregional therapy options.

A rare case of intrahepatic cholangiocarcinoma with tumor thrombus in the bile duct

Intrahepatic cholangiocarcinoma (ICC) is a refractory liver malignancy; however, as its histological characteristics have been clarified, a good operative strategy for the subtypes of ICC can be expected. A 72-year-old woman was diagnosed with a large primary liver cancer with biliary tumor thrombus (BTT) and obstructive jaundice. An enhanced imaging modality showed hypervascular ICC or combined hepatocellular carcinoma (HCC). As her liver functional parameters permitted major hepatectomy, preoperative biliary drainage was performed, followed by a radical left hepatectomy accompanied by tumor thrombectomy with D2 lymphadenectomy. During the operation, the BTT was found to have widely spread into the right hepatic duct and the common bile duct and was histologically diagnosed as an adenocarcinoma. As ductal cancer invasion was not macroscopically observed, the planned operation was completed. The postoperative histological diagnosis was determined by discussion to be a rare mass-forming ICC with BTT. Her postoperative course was uneventful, and a 1-year survival without tumor relapse was observed with adjuvant chemotherapy. In the field of biliary surgery, although advanced ICC still has a poor prognosis, curable surgical intervention is possible for specific findings, such as BTT and HCC with BTT.

A meta-analysis of the efficacy of postoperative adjuvant radiotherapy versus no radiotherapy for extrahepatic cholangiocarcinoma and gallbladder carcinoma

Objective

The benefit of adjuvant radiotherapy (ART) for extrahepatic cholangiocarcinoma (EHCC) and gallbladder carcinoma (GBC) is unclear, with conflicting results from nonrandomized studies. We reported a meta-analysis to determine the impact of adjuvant radiotherapy on survival.

Methods

PubMed, EMBASE, Cochrane Library and CNKI databases were searched to identify clinical trials of postoperative ART versus no radiotherapy for EHCC and GBC. The obtained data were analyzed using RevMan 5.3 and Stata 14.0 statistical software. Differences between two groups were estimated by calculating the odds ratio (OR) and 95% confidence interval (CI).

Results

A total of 21 clinical trials involving 1465 EHCC and GBC patients were selected according to the inclusion and exclusion criteria and included in this meta-analysis. The meta-analysis showed the following: The 5-year overall survival (OS) rate was higher in the ART group than in the no radiotherapy group (OR = 0.63; 95% CI = 0.50–0.81, p = 0.0002). The 5-year OS rate was significantly higher for those with lymph node-positive disease (OR = 0.15; 95% CI 0.07–0.35; p < 0.00001) and margin-positive disease (OR = 0.40; 95% CI 0.19–0.85; p = 0.02) in the ART group than in the no radiotherapy group. ART had a tendency to bring benefit to the 5-year OS of patients with margin-negative disease but the difference was not statistically significant (OR = 0.57, 95% CI 0.30–1,07, p = 0.08). The local recurrence rate was significantly lower in the ART group than in the no radiotherapy group (OR = 0.54; 95% CI = 0.38–0.76, p = 0.0004), and there was no significant difference in the distant metastasis rate between the two groups (OR = 1.33; 95% CI = 0.95–1.87, p = 0.10).

Conclusions

A meta-analysis of the existing study results showed that compared with no radiotherapy, ART is an effective postoperative treatment for EHCC and GBC.

Nodal CTV selection according to primary tumour location and pT stage for biliary tract cancer

INTRODUCTION/PURPOSE

To assist radiation oncologists in determining the elective nodal CTV for biliary tract cancer, we aimed to provide the rules for selection of the CTV for each subsite of biliary tract with respect to the pT stage, based on the analysis of the incidence and location of metastatic lymph nodes.

METHODS

Systematic review and meta-analysis was performed to determine the rate of pathological nodal involvement of each individual lymph node station (LNS) as a function of the primary tumour pT stage (pT1-2 vs. pT3-4) separately for right intrahepatic cholangiocarcinoma (rIHC), left/hilar intrahepatic cholangiocarcinoma l/hIHC), proximal extrahepatic cholangiocarcinoma (pEHC), middle extrahepatic cholangiocarcinoma (mEHC), distal extrahepatic cholangiocarcinoma (dEHC) and gall bladder cancer (GBC). A 5% or higher risk of involvement was assumed to justify inclusion of the LNS in the CTV.

RESULTS

Coeliac LNS, which is usually included in the CTV in clinical practice, has a low risk of involvement and can presumably be omitted for pT1-2 GBC, for dEHC irrespective of pT stage and for mEHC. Para-aortic and superior mesenteric artery (SMA) LNS that are usually omitted have a high risk of involvement. Para-aortic LNS should be considered for inclusion for all the subsites except for pT1-2 dEHC, and SMA LNS for all the subsites except for pT1-2 dEHC, pT1-2 GBC and pEHC. Left gastric artery, lesser curvature and paracardial LNS should be considered for inclusion for l/hIHC.

CONCLUSION

This systematic review provides an evidence-based strategy for nodal CTV selection in biliary tract cancer according to primary tumour location and pT stage.