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Adam MA, Glencer A, AlMasri S, Winters S, Bahary N, Singhi A, Lee KK, Paniccia A, Zureikat AH. Neoadjuvant Therapy Versus Upfront Resection for Nonpancreatic Periampullary Adenocarcinoma. Ann Surg Oncol 2023; 30:165-174. [PMID: 35925536 PMCID: PMC11186695 DOI: 10.1245/s10434-022-12257-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/30/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND In contrast to pancreatic ductal adenocarcinoma (PDAC), neoadjuvant therapy (NAT) for periampullary adenocarcinomas is not well studied, with data limited to single-institution retrospective reviews with small cohorts. We sought to compare outcomes of NAT versus upfront resection (UR) for non-PDAC periampullary adenocarcinomas. PATIENTS AND METHODS Using the National Cancer Database (NCDB), we identified patients who underwent surgery for extrahepatic cholangiocarcinoma, ampullary adenocarcinoma, or duodenal adenocarcinoma from 2006 to 2016. We compared outcomes between NAT versus UR groups for each tumor subtype with 1:3 propensity score matching. Cox regression was used to identify predictors of survival. RESULTS Among 7656 patients who underwent resection for non-PDAC periampullary adenocarcinoma, the proportion of patients who received NAT increased from 6 to 11% for cholangiocarcinoma (p < 0.01), 1 to 4% for ampullary adenocarcinoma (p = 0.01), and 5 to 8% for duodenal adenocarcinoma (p = 0.08). Length of stay, readmission, and 30-day mortality were comparable between NAT and UR. All tumor subtypes were downstaged following NAT (p < 0.01). The R0 resection rate was significantly higher in patients with extrahepatic cholangiocarcinoma who received NAT, and these patients had improved median overall survival (38 vs 26 months, p < 0.001). After adjustment for clinicopathologic factors and adjuvant chemotherapy, use of NAT was associated with improved survival in patients with cholangiocarcinoma [hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.54-0.89, p = 0.004] but not duodenal or ampullary adenocarcinoma. The survival advantage for cholangiocarcinoma persisted after propensity matching. CONCLUSION This national cohort analysis suggests, for the first time, that neoadjuvant therapy is associated with improved survival in patients with extrahepatic cholangiocarcinoma.
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Affiliation(s)
- Mohamed Abdelgadir Adam
- Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA.
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
| | - Alexa Glencer
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Samer AlMasri
- UPMC Network Cancer Registry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sharon Winters
- UPMC Network Cancer Registry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan Bahary
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aatur Singhi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Lv TR, Wang JM, Ma WJ, Hu YF, Dai YS, Jin YW, Li FY. The consistencies and inconsistencies between distal cholangiocarcinoma and pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Front Oncol 2022; 12:1042493. [PMID: 36578941 PMCID: PMC9791204 DOI: 10.3389/fonc.2022.1042493] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological features and long-term prognosis. Methods PubMed, the Cochrane Library, and EMBASE were searched to find comparative studies between DCCA and PDCA. RevMan5.3 and Stata 13.0 software were used for the statistical analyses. Results Eleven studies with 4,698 patients with DCCA and 100,629 patients with PDCA were identified. Pooled results indicated that patients with DCCA had a significantly higher rate of preoperative jaundice (p = 0.0003). Lymphatic metastasis (p < 0.00001), vascular invasion (p < 0.0001), and peri-neural invasion (p = 0.005) were more frequently detected in patients with PDCA. After curative pancreaticoduodenectomy (PD), a significantly higher R0 rate (p < 0.0001) and significantly smaller tumor size (p < 0.00001) were detected in patients with DCCA. Patients with DCCA had a more favorable overall survival (OS) (p < 0.00001) and disease-free survival (DFS) (p = 0.005) than patients with PDCA. However, postoperative morbidities (p = 0.02), especially postoperative pancreatic fistula (POPF) (p < 0.00001), more frequently occurred in DCCA. Conclusion Patients with DCCA had more favorable tumor pathological features and long-term prognosis than patients with PDCA. An early diagnosis more frequently occurred in patients with DCCA. However, postoperative complications, especially POPF, were more frequently observed in patients with DCCA.
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Affiliation(s)
| | | | | | | | | | | | - Fu-Yu Li
- *Correspondence: Yan-Wen Jin, ; Fu-Yu Li,
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Cloyd JM, Prakash L, Vauthey JN, Aloia TA, Chun YS, Tzeng CW, Kim MP, Lee JE, Katz MHG. The role of preoperative therapy prior to pancreatoduodenectomy for distal cholangiocarcinoma. Am J Surg 2019; 218:145-150. [PMID: 30224070 DOI: 10.1016/j.amjsurg.2018.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/31/2018] [Accepted: 08/31/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although increasingly administered to patients with pancreatic ductal adenocarcinoma, the role of preoperative therapy for patients with distal cholangiocarcinoma is undefined. METHODS All patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy between 1999 and 2014 were retrospectively reviewed. Differences in clinicopathologic characteristics and overall survival (OS) were compared between patients who underwent surgery de novo and those who received preoperative therapy. RESULTS Twenty-one patients (46.7%) received preoperative therapy and 24 (53.3%) did not. Five-year OS rates were not statistically significantly different between patients who received preoperative therapy and those who did not (46.6% vs 49.1%, p > 0.05). On multivariate cox proportional hazards analysis, lymph node positivity was the strongest predictor of OS (HR 4.68 (95%CI 1.52-14.42)). Whereas preoperative therapy was not associated with improved OS (HR 1.06 (95%CI 0.42-2.66)), the receipt of either pre- or post-operative therapy was (HR 0.40 (95%CI 0.16-1.00)). CONCLUSION While these results do not support the routine administration of preoperative therapy to patients with distal cholangiocarcinoma, it may be an alternative treatment strategy appropriate for a subset of patients with high risk clinical or pathologic features.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA.
| | - Laura Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Michel P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
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Gonzalez RS, Bagci P, Basturk O, Reid MD, Balci S, Knight JH, Kong SY, Memis B, Jang KT, Ohike N, Tajiri T, Bandyopadhyay S, Krasinskas AM, Kim GE, Cheng JD, Adsay NV. Intrapancreatic distal common bile duct carcinoma: Analysis, staging considerations, and comparison with pancreatic ductal and ampullary adenocarcinomas. Mod Pathol 2016; 29:1358-1369. [PMID: 27469329 PMCID: PMC5598556 DOI: 10.1038/modpathol.2016.125] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 01/04/2023]
Abstract
Distal common bile duct carcinoma is a poorly characterized entity for reasons such as variable terminology and difficulty in determining site of origin of intrapancreatic lesions. We compared clinicopathologic features of pancreatobiliary-type adenocarcinomas within the pancreas, but arising from the distal common bile duct, with those of pancreatic and ampullary origin. Upon careful review of 1017 pancreatoduodenectomy specimens with primary adenocarcinoma, 52 (5%) qualified as intrapancreatic distal common bile duct carcinoma. Five associated with an intraductal papillary neoplasm were excluded; the remaining 47 were compared to 109 pancreatic ductal adenocarcinomas and 133 ampullary carcinomas. Distal common bile duct carcinoma patients had a younger median age (58 years) than pancreatic ductal adenocarcinoma patients (65 years) and ampullary carcinoma patients (68 years). Distal common bile duct carcinoma was intermediate between pancreatic ductal adenocarcinoma and ampullary carcinoma with regard to tumor size and rates of node metastases and margin positivity. Median survival was better than for pancreatic ductal adenocarcinoma (P=0.0010) but worse than for ampullary carcinoma (P=0.0006). Distal common bile duct carcinoma often formed an even band around the common bile duct and commonly showed intraglandular neutrophil-rich debris and a small tubular pattern. Poor prognostic indicators included node metastasis (P=0.0010), lymphovascular invasion (P=0.0299), and margin positivity (P=0.0069). Categorizing the tumors based on size also had prognostic relevance (P=0.0096), unlike categorization based on anatomic structures invaded. Primary distal common bile duct carcinoma is seen in younger patients than pancreatic ductal adenocarcinoma or ampullary carcinoma. Its prognosis is significantly better than pancreatic ductal adenocarcinoma and worse than ampullary carcinoma, at least partly because of differences in clinical presentation. Use of size-based criteria for staging appears to improve its prognostic relevance. Invasive pancreatobiliary-type distal common bile duct carcinomas are uncommon in the West and have substantial clinicopathologic differences from carcinomas arising from the pancreas and ampulla.
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Affiliation(s)
- Raul S. Gonzalez
- Department of Pathology, University of Rochester Medical Center, Rochester, NY, USA
| | - Pelin Bagci
- Department of Pathology, Marmara University, Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Serdar Balci
- Department of Pathology, Emory University, Atlanta, GA, USA
| | | | - So Yeon Kong
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Bahar Memis
- Department of Pathology, Emory University, Atlanta, GA, USA
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nobuyuki Ohike
- Department of Pathology, Showa University School of Medicine, Tokyo, Japan
| | - Takuma Tajiri
- Department of Pathology, Tokai University Hachiouji Hospital, Tokyo, Japan
| | | | | | - Grace E. Kim
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
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Elias Y, Mariano AT, Lu Y. Detection of Primary Malignancy and Metastases with FDG PET/CT in Patients with Cholangiocarcinomas: Lesion-based Comparison with Contrast Enhanced CT. World J Nucl Med 2016; 15:161-6. [PMID: 27651736 PMCID: PMC5020788 DOI: 10.4103/1450-1147.167605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The current National Comprehensive Cancer Network (NCCN) Guidelines consider the role of 2-deoxy-2-18F-fluoro-d-glucose positron emission tomography/computer tomography (FDG PET/CT) in the evaluation of cholangiocarcinoma (CCA) as "uncertain," and have recommended contrast enhanced computed tomography (CECT) but not FDG PET/CT as a routine imaging test for CCA workup. We set out to compare the diagnostic performance of FDG PET/CT and CECT in patients with CCA. The retrospective study included patients with CCA who underwent FDG PET/CT and CECT within 2-month interval between 2011 and 2013 in our hospital. Lesion-based comparison was conducted. Final diagnoses were made based on the composite clinical and imaging data with minimal 6-month follow-up. A total of 18 patients with 28-paired tests were included. There is a total of 142 true malignant lesions as revealed by the 6-paired pre-treatment and 22-paired post-treatment tests. On a lesion-based analysis, the sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs), and accuracies of PET/CT and CECT for detection of CCA were 96.5%, 55.5%, 97.2%, 50.0%, 94.1% and 62.2%, 66.7%, 96.7%, 10.0%, 62.5%, respectively. FDG PET/CT detected more intrahepatic malignant and extrahepatic metastases; and had significant higher sensitivity, NPV, and accuracy than CECT, while similar in specificity and PPV. No true positive lesion detected on CECT that was missed on PET/CT, and none of the false negative lesions on PET/CT were detected on CECT. Six patients had paired pretreatment tests, and FDG PET/CT results changed planned management in three patients. Our data suggest that FDG PET/CT detect more primary and metastatic lesions and lead to considerable changes in treatment plan in comparison with CECT.
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Affiliation(s)
- Youssef Elias
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Aladin T Mariano
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Yang Lu
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
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Kato Y, Takahashi S, Gotohda N, Konishi M. Prognostic Impact of the Initial Postoperative CA19-9 Level in Patients with Extrahepatic Bile Duct Cancer. J Gastrointest Surg 2016; 20:1435-43. [PMID: 27250990 DOI: 10.1007/s11605-016-3180-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/26/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study was to investigate the prognostic impact of the initial serum postoperative CA19-9 levels in patients with extrahepatic bile duct cancer. METHODS Data of a total of 143 patients of extrahepatic bile duct cancer with elevated preoperative serum CA19-9 levels (>37 U/ml) who underwent surgery with curative intent were reviewed retrospectively. The patients were divided into the "Normalization group" and "Non-normalization group" (initial postoperative serum CA19-9 ≤37 and >37 U/ml, respectively), and the clinicopathological factors and survival outcomes in these groups were comparatively analyzed. RESULTS The cumulative 5-year overall survival (OS) rate and median survival time (MST) were 39.2 % and 42.9 months, respectively, in the Normalization group and 17.9 % and 24.0 months, respectively, in the Non-normalization group (P < 0.001). Presence of jaundice, a poorer histological differentiation grade (G3-4), lymph node metastasis, and initial postoperative serum CA19-9 level (>37 U/ml) were significant independent predictors of a poor prognosis on multivariate analysis. CONCLUSION Non-normalization of the serum CA19-9 level in the initial postoperative phase is a strong predictor of a poor prognosis and is a useful marker to identify patients who would need additional treatments and stricter follow-up.
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Affiliation(s)
- Yuichiro Kato
- Division of Hepatobiliary Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Shinichiro Takahashi
- Division of Hepatobiliary Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Naoto Gotohda
- Division of Hepatobiliary Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaru Konishi
- Division of Hepatobiliary Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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Qureshi K, Jesudoss R, Al-Osaimi AMS. The treatment of cholangiocarcinoma: a hepatologist's perspective. Curr Gastroenterol Rep 2014; 16:412. [PMID: 25183579 DOI: 10.1007/s11894-014-0412-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Cholangiocarcinoma (CCA) is a rare but lethal adenocarcinoma with cholangiocyte differentiation that arises within the biliary tree at variable locations. Curative options are available in the form of surgical resection and/or liver transplantation (LT) in early stage CCA; however, these are offered to a small fraction of patients as they are usually asymptomatic and remain undiagnosed. Primary sclerosing cholangitis (PSC) is a well-known risk factor of CCA, and cirrhosis, viral hepatitis, and metabolic syndrome are recently identified as risk factors of CCA. This emerging evidence places hepatologists in a vital position to diagnose, prognosticate, and manage CCA by planning treatment of each individual patient based on the stage and extent of malignancy. With appropriate selection of patients and the involvement of a multidisciplinary team, surgical resection of localized CCA, LT coupled with neoadjuvant chemoradiation for perihilar CCA, or locoregional or systemic chemotherapy and/or endoscopic interventions for advanced CCA can be offered.
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Affiliation(s)
- Kamran Qureshi
- Division of Hepatology, Department of Medicine, Temple University Health System, 3440 N. Broad Street, Kresge Building West, Philadelphia, PA, 19140, USA,
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9
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Berardi R, Mocchegiani F, Pierantoni C, Federici A, Nicolini D, Morgese F, Onofri A, Risaliti A, Vivarelli M, Cascinu S. Resected biliary tract cancers: a novel clinical-pathological score correlates with global outcome. Dig Liver Dis 2013; 45:70-4. [PMID: 22999058 DOI: 10.1016/j.dld.2012.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 08/15/2012] [Accepted: 08/16/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Biliary tract cancer presents a poor prognosis. AIMS The objective of this study is to find clinical-laboratory parameters like prognostic factors to select patients who can benefit from surgery and post-operative treatments. METHODS Between 2005 and 2010, 41 patients underwent radical surgery at our Institution. A novel score was retrospectively calculated assigning a grade to the clinical-laboratory findings at diagnosis. 0 and 1 point were respectively assigned to the normal or abnormal parameter. Two groups were identified: SCORE 0 and SCORE 1. RESULTS Patients with cholangiocarcinoma or Klatskin tumours or asymptomatic at diagnosis presented a significantly better overall survival (OS) than patients with different primary sites or who presented pain, jaundice or cholangitis. At univariate analysis, high levels of aspartate aminotransferase, alanine aminotransferase and CA19-9 before surgery, hyperbilirubinemia before and after surgery had a negative correlation with OS. A worse OS was observed in patients with a higher score (median OS in the "score 0" group=30.79 months vs. median OS in the "score 1"=17.98 months). CONCLUSION Our results suggest that pre and post-surgery clinical-laboratory parameters and the novel score, could be useful, especially for intrahepatic tumours, in predicting the outcome in patients undergoing surgery and in selecting patients to receive adjuvant therapy.
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Affiliation(s)
- Rossana Berardi
- Medical Oncology, Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria Ospedali Riuniti Umberto I, GM Lancisi, G Salesi, Ancona, Italy.
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Kawamata F, Kamachi H, Einama T, Homma S, Tahara M, Miyazaki M, Tanaka S, Kamiyama T, Nishihara H, Taketomi A, Todo S. Intracellular localization of mesothelin predicts patient prognosis of extrahepatic bile duct cancer. Int J Oncol 2012; 41:2109-18. [PMID: 23064529 DOI: 10.3892/ijo.2012.1662] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/14/2012] [Indexed: 12/28/2022] Open
Abstract
Mesothelin is expressed in various types of malignant tumors, and we recently reported that the expression of mesothelin was related to unfavorable patient outcome in pancreatic ductal adenocarcinoma and gastric adenocarcinoma. In this study, we examined the clinicopathological significance of mesothelin expression in extrahepatic bile duct cancer (EHBDCA), especially in terms of its association with the staining pattern. Tissue samples from 61 EHBDCA (16 hilar cholangiocarcinoma, 17 upper bile duct adenocarci-noma, 20 middle bile duct adenocarcinoma and 8 distal bile duct adenocarcinoma) were immunohistochemically examined. The expression levels of mesothelin in tumor cells was classified into the localization of mesothelin in luminal membrane and/or cytoplasm, in addition to high and low according to the staining intensity and proportion as a conventional analysis. 'High-level expression' of mesothelin (47.5%) was statistically correlated with liver metastasis (P=0.013) and poorer patient outcome (P=0.022), while 'luminal membrane positive' of mesothelin (52.5%) was more significantly correlated with liver metastasis (P=0.006), peritoneal metastasis (P=0.024) and unfavorable patient outcome (P=0.017). Moreover, we found that 'cytoplasmic expression' isolated from 'luminal membrane negative' of mesothelin represented the best patient prognosis throughout this study. We describe the expression pattern level of mesothelin, i.e., in luminal membrane or cytoplasm both high and low level, evidently indicate the patient prognosis of EHBDCA, suggesting the pivotal role of mesothelin in cancer promotion depending on its intracellular localization.
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Affiliation(s)
- Futoshi Kawamata
- Department of General Surgery, Hokkaido University School of Medicine, Sapporo 060-8638, Japan
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Conrad C, Fernández-Del Castillo C. Preoperative evaluation and management of the pancreatic head mass. J Surg Oncol 2012; 107:23-32. [PMID: 22674403 DOI: 10.1002/jso.23165] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 05/01/2012] [Indexed: 12/16/2022]
Abstract
The differential diagnosis of a pancreatic head mass encompasses a wide range of clinical entities that include both solid and cystic lesions. This chapter focuses on our approach to the patient presenting with a newly found pancreatic head mass with the main goals of determining the risk of the lesion being malignant or premalignant, resectability if the patient is appropriate for surgical intervention, assessment of need for multimodality treatment and determination the patient's surgical risk.
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Affiliation(s)
- Claudius Conrad
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 021114, USA.
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Radiofrequency ablation of hepatic metastases after curative resection of extrahepatic cholangiocarcinoma. AJR Am J Roentgenol 2012; 197:W1129-34. [PMID: 22109330 DOI: 10.2214/ajr.11.6420] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The objective of our study was to retrospectively evaluate local control and survival after radiofrequency ablation (RFA) in patients with liver metastases arising from extrahepatic cholangiocarcinoma who had previously undergone curative resection. MATERIALS AND METHODS From May 2003 to May 2009, RFA using an internally cooled electrode was performed on 29 metachronous liver metastases (mean number of tumors per patient, 1.6) arising from extrahepatic cholangiocarcinoma in 18 patients (mean age, 66 years). Tumor size ranged from 0.9 to 4.6 cm in maximum dimension (mean, 2.3 cm). As historical comparisons, we included 24 patients diagnosed with recurrent metastasis limited to the liver between February 1997 and April 2003 and who met the inclusion criteria for RFA: 16 patients received supportive therapy only and eight patients underwent chemotherapy with or without radiation. RESULTS Five patients had major complications (liver abscess, n = 4 patients; biliary stricture, n = 1; 17% per-treatment complication rate [5/29]), but there were no procedure-related deaths. Complete tumor necrosis was achieved in all 29 tumors after one session of RFA. The local tumor progression rate was 38% (median time to detection, 5 months). From the first diagnosis of liver metastasis, the median overall survival was 12.4 months and the 3-year survival rate was 10%. Patients who received RFA lived significantly longer than patients who received chemoradiotherapy (median survival, 5.6 months) and those who received supportive treatment (median survival, 5.3 months) (p < 0.001). CONCLUSION Percutaneous RFA results in effective local tumor control and may prolong survival in patients with recurrent hepatic metastases after curative resection for extrahepatic cholangiocarcinoma.
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Abstract
BACKGROUND A 72-year-old hypertensive woman presented with a 2-month history of right upper quadrant abdominal pain. She had a 15-day history of jaundice, fever with chills and shivering, nausea, vomiting, weight loss and generalized pruritus. INVESTIGATIONS Physical examination, laboratory evaluation, transabdominal ultrasonography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, brush cytology, laparotomy and histopathology. DIAGNOSIS Bile duct duplication with coexistence of distal cholangiocarcinoma. MANAGEMENT En bloc resection (including the duodenum, pancreatic head and adjacent lymph nodes), hepaticojejunostomy and pylorus-saving Whipple operation.
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Lee M, Banerjee S, Posner MC, Cartwright CA. Distal extrahepatic cholangiocarcinoma presenting as cholangitis. Dig Dis Sci 2010; 55:1852-5. [PMID: 20499173 DOI: 10.1007/s10620-010-1282-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 05/04/2010] [Indexed: 01/04/2023]
Affiliation(s)
- Maximilian Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Stanford, CA 94305-5187, USA.
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Abstract
OBJECTIVE To examine the importance of adequate lymph node sampling in staging of extrahepatic bile duct cancer (EHBDCA). SUMMARY OF BACKGROUND DATA The American Joint Committee on Cancer staging manual (sixth edition) states that histologic examination of at least 3 lymph nodes is required for adequate N stage determination for EHBDCA. This recommendation has not been validated; however, there has been no comparative assessment of the proximal versus distal bile duct cancer. METHODS A total of 257 patients (144 hilar cholangiocarcinoma [HCCA] and 113 distal bile duct adenocarcinoma [DBDCA]) who underwent curative intent resection (1987-2007) were analyzed; patients with gallbladder cancer were excluded. Final disease staging, including lymph node status and total number of nodes examined (total lymph node count), was obtained from the final pathology report. Differences in disease-specific survival, according to nodal status, were compared using the log-rank test. R1 resections (n = 51) were excluded from this analysis. RESULTS Metastasis to regional lymph nodes was noted in 89 patients (34.6%) and was an independent prognostic factor of poor survival (median disease-specific survival N0 vs. N1: 53.5 vs. 19.3 months, P < 0.0001, hazard ratio = 2.1 [95% CI: 1.4-3.2]). The median total lymph node count was 6 (range: 0-42), and was significantly lower for HCCA compared with DBDCA (median = 3 [range: 0-16] vs. 12 [range: 1-42], P < 0.001, respectively). For the entire cohort, patients who underwent R0 resection and were classified as N0, based on total lymph node count <11, had a disease-specific survival that was significantly worse than that of patients classified as N0 based on total lymph node count >or=11 (52.6 +/- 9.8 months vs. not reached, P = 0.008). The estimated optimal total lymph node count for HCCA differed from that of DBDCA (n = 7 vs. n = 11, respectively). CONCLUSIONS Adequate lymph nodes assessment of EHBDCA, based on the current AJCC recommendations, results in understaging of these tumors. With respect to the optimal total lymph node count, HCCA, and DBDCA should be considered separately.
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Hatzaras I, Schmidt C, Muscarella P, Melvin WS, Ellison EC, Bloomston M. Elevated CA 19-9 portends poor prognosis in patients undergoing resection of biliary malignancies. HPB (Oxford) 2010; 12:134-8. [PMID: 20495658 PMCID: PMC2826672 DOI: 10.1111/j.1477-2574.2009.00149.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 11/08/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary tree malignancies including cholangiocarcinoma and gallbladder cancer are aggressive cancers with a high disease-specific mortality despite resection. The aim of the present study was to identify predictors of survival after resection. METHODS A retrospective review of all patients that underwent radical resection of biliary malignancies was performed. Demographics, elevated CA19-9 (>35 U/ml), treatment and outcome data were collected and compared according to tumour location. Kaplan-Meier survival curves were created and compared using log-rank analysis. Multivariate analysis was undertaken using Cox proportional hazards regression. RESULTS Ninety-one patients with biliary malignancies underwent surgical resection between 1992 and 2007. There were 46 (50.5%) extrahepatic cholangiocarcinomas (EHC), 23 (25.2%) intrahepatic cholangiocarcinomas (IHC) and 22 (24.2%) gallbladder carcinomas (GBC). The median (range) age was 64 (24-92) years. An elevated CA19-9 was recorded in 45 (55%) patients (52% of IHC, 63% of EHC, and 41% of GBC). The overall median (range) survival was 22.5 (0.3-153.3) months. All three groups were similar in terms of age, gender, pre-operative CA 19-9 level, completeness of resection and tumour histopathological characteristics. GBC were associated with the shortest median survival (14.3 months) followed by EHC (24.8 months) and IHC (30.4 months); however, this did not meet statistical significance (P= 0.971). Only elevated pre-operative CA 19-9 level (>35 U/ml) was predictive of poor median survival by univariate (P= 0.003) and multivariate analysis (15.1 months vs. 67.4, P= 0.047). CONCLUSIONS Elevated pre-operative CA 19-9 levels were found to be independent predictors of poor survival after attempted resection for biliary tree malignancies. It is recommended that CA19-9 be routinely measured prior resection.
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Affiliation(s)
- Ioannis Hatzaras
- Department of Surgery, The Ohio State University Columbus, OH 43210, USA
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