Radiotherapy and multimodality management of cholangiocarcinoma

Current status of liver transplantation for cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common liver cancer with a median survival of 12-24 mo without treatment. It is further classified based on its location into intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. Surgical resection is the mainstay of treatment, but up to 70% of these tumors are inoperable at the time of diagnosis. CCA was previously an absolute contraindication for liver transplantation (LT) due to poor outcomes primary due to early recurrent disease. However, improvement in patient selection criteria and neoadjuvant treatment protocols have improved outcomes for inoperable pCCA patients with recent studies reporting LT may improve survival in iCCA. Future advances in the treatment of CCA should include refining patient selection criteria and organ allocation for all subtypes of CCA, determining effective immunotherapies and the evolving role of personalized medicine in patients ineligible for surgical resection or LT. Our article reviews the current status of LT in CCA, along with future directions in managing patients with CCA.

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

Cholangiocarcinoma and gallbladder malignancies are aggressive gastrointestinal malignancies with management dependent on resectability, comorbidities, and location. A multidisciplinary discussion with medical oncologists, radiation oncologists, and surgeons is necessary to determine the optimal treatment approach for each patient. Surgical resection offers the best chance for a long-term cure. Recent studies, such as the phase II SWOG S0809 and the phase III BILCAP study have highlighted the importance of adjuvant treatment with radiation therapy and chemotherapy, respectively, in resected disease. In patients with unresectable disease chemotherapy and chemoradiation therapy to a high dose can improve overall survival and locoregional control. In this expert panel we have brought together radiation oncologists and a medical oncologist to provide case-based feedback on their institutional practices.

Role of adjuvant radiotherapy for localized extrahepatic bile duct cancer

OBJECTIVE

To evaluate the benefit of adjuvant radiotherapy (RT) after surgical resection for extrahepatic bile duct (EHBD) cancer.

METHODS

From 1997 to 2015, 59 patients with EHBD cancer were the subject of this study; 36 patients not undergoing adjuvant treatment after surgery (observation group) and 23 patients receiving adjuvant RT (RT group) were compared. Microscopic residual disease (R1) was in 9 (25%) patients and 5 (22%) patients, and macroscopic residual disease (R2) was in 2 (6%) patients and 6 (26%) patients in the observation and RT groups, respectively. Adjuvant RT was delivered to the tumour bed and regional lymph nodes up to 50.4 Gy (range, 45-61 Gy).

RESULTS

With a median follow-up of 19 months, local recurrence was observed in 10 (28%) patients and 2 (9%) patients in the observation and RT groups, respectively. On univariate analysis, the 5-year local recurrence-free survival (LRFS) rates were 50% in the observation group and 54% in the RT group (p = 0.401). The 5-year overall survival (OS) rates were 29.3% in the observation group and 26.3% in the RT group (p = 0.602). On multivariable analysis, however, adjuvant RT significantly improved LRFS [hazard ratio (HR), 0.310; 95% confidence interval (CI), 0.100-0.963; p = 0.043] and had a trend towards increased OS (HR, 0.491; 95% CI, 0.219-1.102; p = 0.085). Resection margin (RM) status was also correlated with LRFS (HR for R1 6.134, 95% CI 2.051-18.344; and HR for R2 18.551, 95% CI 3.680-93.520; p < 0.001) and OS (HR for R1 1.816, 95% CI 0.853-3.867; and HR for R2 3.564, 95% CI 1.175-10.809; p = 0.054).

CONCLUSION

RM status was a significant prognosticator of EHBD cancer, and adjuvant RT improved local control rate; thereby, survival rate might be increased. Advances in knowledge: The benefit of adjuvant RT in EHBD cancer was demonstrated via comparison with observation group.

Liver transplantation for cholangiocarcinoma: Current status and new insights

Cholangiocarcinoma is a malignant tumor of the biliary system that can be classified into intrahepatic (iCCA), perihiliar (phCCA) and distal. Initial experiences with orthotopic liver transplantation (OLT) for patients with iCCA and phCCA had very poor results and this treatment strategy was abandoned. In the last decade, thanks to a strict selection process and a neoadjuvant chemoradiation protocol, the results of OLT for patients with non-resectable phCCA have been shown to be excellent and this strategy has been extended worldwide in selected transplant centers. Intrahepatic cholangiocarcinoma is a growing disease in most countries and can be diagnosed both in cirrhotic and in non-cirrhotic livers. Even though OLT is contraindicated in most centers, recent investigations analyzing patients that were transplanted with a misdiagnosis of HCC and were found to have an iCCA have shown encouraging results. There is some information suggesting that patients with early stages of the disease could benefit from OLT. In this review we analyze the current state-of-the-art of OLT for cholangiocarcinoma as well as the new insights and future perspectives.

Patterns of failure and prognostic factors in resected extrahepatic bile duct cancer: implication for adjuvant radiotherapy

PURPOSE

To find the applicability of adjuvant radiotherapy for extrahepatic bile duct cancer (EBDC), we analyzed the pattern of failure and evaluate prognostic factors of locoregional failure after curative resection without adjuvant treatment.

MATERIALS AND METHODS

In 97 patients with resected EBDC, the location of tumor was classified as proximal (n = 26) and distal (n = 71), using the junction of the cystic duct and common hepatic duct as the dividing point. Locoregional failure sites were categorized as follows: the hepatoduodenal ligament and tumor bed, the celiac artery and superior mesenteric artery, and other sites.

RESULTS

The median follow-up time was 29 months for surviving patients. Three-year locoregional progression-free survival, progression-free survival, and overall survival rates were 50%, 42%, and 52%, respectively. Regarding initial failures, 79% and 81% were locoregional failures in proximal and distal EBDC patients, respectively. The most common site was the hepatoduodenal ligament and tumor bed. In the multivariate analysis, perineural invasion was associated with poor locoregional progression-free survival (p = 0.023) and progression-free survival (p = 0.012); and elevated postoperative CA19-9 (≥37 U/mL) did with poor locoregional progression-free survival (p = 0.002), progression-free survival (p < 0.001) and overall survival (p < 0.001).

CONCLUSION

Both proximal and distal EBDC showed remarkable proportion of locoregional failure. Perineural invasion and elevated postoperative CA19-9 were risk factors of locoregional failure. In these patients with high risk of locoregional failure, adjuvant radiotherapy could be considered to improve locoregional control.

Liver transplantation for hepatic tumors: A systematic review

Improvements in the medical and pharmacological management of liver transplantation (LT) recipients have led to a better long-term outcome and extension of the indications for this procedure. Liver tumors are relevant to LT; however, the use of LT to treat malignancies remains a debated issue because the high risk of recurrence. In this review we considered LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), liver metastases (LM) and other rare tumors. We reviewed the literature, focusing on the past 10 years. The highly selected Milan criteria of LT for HCC (single nodule < 5 cm or up to 3 nodules < 3 cm) have been recently extended by a group from the University of S. Francisco (1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm) with satisfying results in terms of recurrence-free survival and the “up-to-seven criteria”. Moreover, using these criteria, other transplant groups have recently developed downstaging protocols, including surgical or loco-regional treatments of HCC, which have increased the post-operative survival of recipients. CCA may be treated by LT in patients who cannot undergo liver resection because of underlying liver disease or for anatomical technical challenges. A well-defined protocol of chemoirradiation and staging laparotomy before LT has been developed by the Mayo Clinic, which has resulted in long term disease-free survival comparable to other indications. LT for LM has also been investigated by multicenter studies. It offers a real benefit for metastases from neuroendocrine tumors that are well differentiated and when a major extrahepatic resection is not required. If LT is an option in these selected cases, liver metastases from colorectal cancer is still a borderline indication because data concerning the disease-free survival are still lacking. Hepatoblastoma and hemangioendothelioma represent rare primary tumors for which LT is often the only possible and effective cure because of the frequent multifocal, intrahepatic nature of the disease. LT is a very promising procedure for both primary and secondary liver malignancies; however, it needs an accurate evaluation of the costs and benefits for each indication to balance the chances of cure with actual organ availability.

Impact of adjuvant radiation therapy for microscopic residual tumor after resection of extrahepatic bile duct cancer

OBJECTIVES

The effect of adjuvant radiation therapy (RT) in extrahepatic bile duct (EHBD) cancer patients with microscopic-positive resection margins (R1 resection) is still controversial.

METHODS

Between January 2000 and March 2010, 52 patients with EHBD cancer underwent surgery at our institution, of whom 36 were subjected to a retrospective analysis. Eleven patients received adjuvant RT after resection [surgery (S)+RT group], which included 9 patients with R1 resection and 2 with para-aortic lymph node metastasis. Their oncological outcomes were analyzed and compared with those of the 25 patients with R0 resection who did not receive adjuvant RT (S group).

RESULTS

Patients in the S+RT group had significantly more advanced disease than those in the S group. However, there was no significant difference in disease-free survival or overall survival between the 2 groups. Median survival times for the S+RT and the S groups were 44 and 47 months, respectively, whereas the 5-year survival rates were 38.9% and 46%, respectively (P=0.707). Locoregional recurrence was less frequent in the S+RT group as compared with the S group, but the incidence of distant metastasis was unaffected by the adjuvant RT.

CONCLUSIONS

Our results support the beneficial effect of adjuvant RT in EHBD cancer patients with R1 resection. This effect seems to result from an improved control of the locoregional tumor by adjuvant RT.

Nonsurgical therapy of biliary tract cancer

PURPOSE OF REVIEW

The management of biliary tract cancers (BTCs) has been challenging partly because of the lack of robust data to define a treatment standard. This in turn has been because of the difficulty in conducting large clinical studies in an uncommon cancer, as well as managing elderly and unwell patients.

RECENT FINDINGS

Recent data and improvements in multidisciplinary patient management have established a standard of care and delivered insights into the natural history of this uncommon cancer. This is critical at a time when the incidence of this malignancy is increasing. This article describes the improving multidisciplinary management as well as seminal randomized data describing standard management. Current clinical trials that are likely to further impact on future management are described.

SUMMARY

These large datasets provide insights into the natural history of BTCs hitherto not forthcoming from the many smaller studies which formed the historical evidence base. This increasing standardization of care will improve outcome for patients with BTCs and provide a platform for further research.

Phase I/II study of hepatic arterial infusion chemotherapy with gemcitabine in patients with unresectable intrahepatic cholangiocarcinoma (JIVROSG-0301)

OBJECTIVES

No established therapy exists for unresectable intrahepatic cholangiocarcinoma (ICC). We conducted a phase I/II study to ascertain the recommended dose (RD) of hepatic arterial infusion using gemcitabine (GEM) for ICC and to assess the efficacy and safety.

METHODS

For patients with unresectable ICC, GEM was administered through the hepatic artery via the port system as a 30-minute infusion on days 1, 8, and 15 every 4 weeks for 5 cycles. In phase I, dosage for levels 1, 2, and 3 was set at 600, 800, and 1000 mg/m, respectively, and was increased in 3 to 6 patients at a time. Maximum tolerated dose was defined as a dosage resulting in dose-limiting toxicity in 2 of 3 patients or 3 of 6 patients, and RD was estimated during the first cycle. In the phase II, more RD patients were added to assess tumor response and toxicity.

RESULTS

During the phase I, 16 patients were enrolled. Maximum tolerated dose was not reached. Assuming RD at 1000 mg/m, the phase II enrolled a total of 13 patients. The following Grade 3 toxicities were observed: neutropenia 20%, increased gamma-glutamyl transpeptidase 8%, increased aspartate aminotransferase 4%, increased alanine aminotransferase 4%, increased bilirubin 4%, nausea 4%, and fatigue 4%. The tumor response rate was 7.7% (complete response 0, partial response 1, stable disease 8, and progressive disease 4).

CONCLUSION

Whereas the toxicity of hepatic arterial infusion with 1000 mg/m GEM for ICC was tolerable, expected efficacy could not be obtained, thus suggesting only minimal activity.

Dosimetry of conformal dynamic arc radiotherapy and intensity modulated radiotherapy in unresectable cholangiocarcinoma

Background: Radiotherapy in cholangiocrcinoma has to overcome organ tolerance of the upper abdomen. Hi-technology radiotherapy may improve conformity and reduce dose to those organ. Objective: Quantitatively compare the dosimetry of conformal dynamic arc radiotherapy (CD-arcRT) and intensity modulated radiotherapy (IMRT) in unresectable cholangiocarcinoma. Material and methods: Eleven cases of unresectable cholangiocarcinoma were re-planned with IMRT and CDarcRT at King Chulalongkhorn Memorial Hospital between 20 September 2004 and 31 December 2005. Both the planning techniques were evaluated using the dose volume histogram of the planning target volume and organ at risk. The conformation number and dose to critical normal structures were used to determine the techniques. Results: IMRT technique was significantly conformed to the planning target volume than CD-arcRT in term of conformation number. For critical structure, IMRT significantly reduced the radiation dose to liver in terms of mean liver dose, V30Gy and V20Gy of the right kidney. Conclusion: The advantage of IMRT was more conformity and reduced dose to critical structure compared with CD-arcRT, but there was no difference between these techniques in terms of V20Gy of left kidney and maximum dose to the spinal cord.

Extrahepatic bile duct cancers: surgery alone versus surgery plus postoperative radiation therapy

PURPOSE

The goal of this study was to determine the role of radiotherapy after curative-intent surgery in the management of extrahepatic bile duct (EHBD) cancers.

METHODS AND MATERIALS

From 1997 through 2005, 78 patients with EHBD cancer were surgically staged. These patients were stratified by the absence of adjuvant radiation (n = 47, group I) versus radiation (n = 31, group II) after resection. Pathology examination showed 27 cases in group I and 20 cases in group II had microscopically positive resection margins. The patients in group II received 45 to 54 Gy of external beam radiotherapy. The primary endpoints of this study were overall survival, disease-free survival, and prognostic factors.

RESULTS

There were no differences between the 5-year overall survival rates for the two groups (11.6% in group I vs. 21% in group II). However, the patients with microscopically positive resection margins who received adjuvant radiation therapy had higher median disease-free survival rates than those who underwent surgery alone (21 months vs. 10 months, respectively, p = 0.042). Decreasing local failure was found in patients who received postoperative radiotherapy (61.7% in group I and 35.6% in group II, p = 0.02). Outcomes of the patients with a positive resection margin and lymph node metastasis who received postoperative radiation therapy were doubled compared to those of patients without adjuvant radiotherapy. Resection margin status, lymph node metastasis, and pathology differentiation were significant prognostic factors in disease-free survival.

CONCLUSIONS

Adjuvant radiotherapy might be useful in patients with EHBD cancer, especially for those patients with microscopic residual tumors and positive lymph nodes after resection for increasing local control.

Extrahepatic bile duct adenocarcinoma: patients at high-risk for local recurrence treated with surgery and adjuvant chemoradiation have an equivalent overall survival to patients with standard-risk treated with surgery alone

BACKGROUND

Patients with resected extrahepatic bile duct adenocarcinoma who have microscopically positive resection margins and/or pathologic locoregional nodal involvement (R1pN1) have a high-risk of locoregional recurrence, and therefore, we advocate the use of adjuvant chemoradiation. To evaluate the safety and effectiveness of this treatment, we compared survival and side effects outcomes between such patients and patients with negative resection margins and pathologically negative nodes (R0pN0) who did not receive adjuvant treatment.

METHODS

Between 1984 and 2005, 65 patients were treated with curative-intended resection for extrahepatic bile duct adenocarcinoma. Patients with tumors arising in the gallbladder and periampullary region were excluded. Pathology and diagnostic images were centrally reviewed. Overall survival and locoregional recurrence outcomes for patients with standard-risk R0pN0 (surgery alone, or S group, n = 23) were compared with those of patients with high locoregional recurrence risk, R1 and/or pN1 (R1pN1) status who received adjuvant chemoradiation (S-CRT group, n = 42).

RESULTS

The median follow-up for the entire group was 31 months. Patients in the S-CRT and S groups had a similar 5-year overall survival (36% vs. 42%, P = .6) and locoregional recurrence (5-year rate: 38% vs. 37%, P = .13). In the S-CRT group, three patients (7%) experienced an acute (grade 3 or more) side effect.

CONCLUSIONS

Our finding of a lack of a survival difference between the S and S-CRT groups suggests that for patients with extrahepatic bile duct adenocarcinoma at high risk for locoregional recurrence (i.e., R1 resection or pN1 disease), adjuvant chemoradiation provides an equivalent overall survival despite of these worse prognostic features.

Liver transplantation for primary and metastatic liver cancers

Liver transplantation for hepatic malignancies has emerged as a well-documented and proven treatment modality. However, early unsatisfactory results emphasized that only a highly selected patient population would benefit from transplantation. Currently, 15% of all liver transplants performed are for hepatocellular carcinoma (HCC). There is no controversy about the fact that liver transplantation for HCC in the adult population yields good results for patients whose tumour masses do not exceed the Milan criteria. It remains to be determined whether patients with more extensive tumours can be reliably selected to benefit from the procedure. In patients with small HCC at an early stage and preserved liver function, liver resection provides an alternative to transplant. Liver resection may offer similar survival results to orthotopic liver transplantation (OLT) in the short term, and does not carry the long-term effects of immunosuppression; however, long-term and disease-free survival favours liver transplantation. Very promising results have been obtained for cholangiocarcinoma treated by aggressive combination therapies, including chemo- and radiotherapy followed by OLT. Survival rate in these selected patients can approach that of patients with cholestatic liver disease, and the role of transplantation now requires re-evaluation. Similarly, hepatoblastoma is an excellent indication in paediatric patients with unresectable or recurrent tumours. Epithelioid hemangioendothelioma is also an appropriate indication for liver transplantation, even in the presence of extrahepatic metastases, unlike angiosarcoma which is associated with a very poor survival and considered as a contraindication. And finally for metastatic liver disease from neuroendocrine tumours, liver transplantation can result in long-term survival and even cure in well selected patients. Conversely, the value of transplantation for colorectal liver metastases (currently a contraindication) requires further evaluation by well-designed trials.

The role of adjuvant radiotherapy in microscopic tumor control after extrahepatic bile duct cancer surgery

OBJECTIVES

To evaluate effects of radiotherapy (RT) after surgery for extrahepatic bile duct (EHBD) cancer.

METHODS

There were 60 patients with EHBD cancer treated with postoperative RT. Surgical extents were R0 in 24 patients, R1 in 23, and R2 in 13. The indications for adjuvant RT were positive resection margin, lymph node metastasis, or more than pT2. Radiation was delivered to tumor bed and regional lymphatics, and for R1 or R2 patients, boost RT was planned. Overall survival (OS) and progression-free survival (PFS) was calculated and survival in the R0 and R1 patients with negative lymph nodes was compared. The pattern of treatment failures and prognostic factors were analyzed.

RESULTS

The 2- and 5-year survival rates were 36.6% and 12.3% for OS, and 31.2% and 16.2% for PFS. In comparison of R0 with R1 patients who had negative lymph node, 2-year OS and PFS were 53.0% and 55.0% in R0, and 40.7% and 36.7% in R1 (P = ns). The first site of failure was loco-regional in 29 patients. The lymph node metastasis was a significant prognostic factor in OS (P = 0.04) and PFS (P = 0.02).

CONCLUSIONS

Lymph node metastasis was a poor prognostic factor and adjuvant RT may be useful in patients with microscopic residual tumor. However, because there were high loco-regional recurrences, additional study is needed to determine more effective RT such as increased RT dose or use of radiosensitizers.

Predictive factors for prognosis of hilar cholangiocarcinoma: Postresection radiotherapy improves survival

AIMS

Several studies have analyzed the determinants of long-term survival in hilar cholangiocarcinoma (HCCA) patients, but the majority of these have not speculated adjuvant therapy on prognosis. We conduct this study to identify potential predictive factors for prognosis of HCCA focusing on aspects dealing with adjuvant therapy.

PATIENTS AND METHODS

Data from 75 consecutive HCCA patients undergoing surgical resection with curative intent were recorded prospectively. The survivals of patients were comparable with respect to different factors followed by a univariate and multivariate analysis.

RESULTS

Actual 1-year, 3-year, and 5-year survival rates were 84.0, 44.4 and 12.0%, respectively. By Cox proportional hazards survival analysis, the most powerful predictors of outcome was resection type (Hazard Ratio [HR] 17.4, 95% confidence interval [CI] 16.8-17.8), followed by adjuvant radiotherapy (RT) (HR 4.3, 95% CI 3.6-4.9), regional lymph nodes involvement (HR 2.1, 95% CI 1.7-2.6), and preoperative maximum serum total bilirubin level (HR 2.0, 95% CI 1.5-2.5).

CONCLUSIONS

Our study showed overall a highly significant benefit in survival in favor of RT, and the difference was especially significant after R1/R2 resection and in patients with Bismuth III/IV type tumors. Postresection chemotherapy (CTx) did not show any clinical benefits. R0 resection still significantly improves survival. Lower total serum bilirubin level, no regional lymph nodes involvement conferred survival advantage.

New advances in the management of biliary tract cancer

Biliary tract cancers are uncommon malignancies arising from biliary epithelium intrahepatically (peripheral cholangiocarcinoma), in the extrahepatic bile duct, the gall bladder and the ampulla of Vater. Treatment has been challenging because of late presentation, complex surgery, complex biliary obstruction with jaundice and a paucity of high quality data on which to establish standard care. With improvements in imaging, biliary stenting, surgical management and the establishment of a national investigational programme we hope to define the modern management of biliary tract cancers and enable a platform for further research.

Concurrent Chemoradiotherapy With Doxifluridine and Paclitaxel for Extrahepatic Bile Duct Cancer

OBJECTIVES

Bile duct cancer is a rare malignancy with poor prognosis. We sought to determine the efficacy of concurrent chemoradiotherapy with doxifluridine and paclitaxel for extrahepatic bile duct cancer.

METHODS

Nineteen patients with unresectable extrahepatic bile duct cancer received doxifluridine (600 mg/m2) daily, intravenous paclitaxel (50 mg/m) weekly (before radiotherapy), and radiotherapy of 4500 cGy for approximately 5 weeks.

RESULTS

Local response rate which reflected the reopening of occluded bile duct was 89.5% (17 out of 19). In 6 cases (31.6%), overall response, which measured the change of tumor size, was achieved with this treatment. The longest survival time was 52 months, and median survival time was 14 months. One- and 2-year survival rates were 84.2% and 31.6%, respectively. One case of gastrointestinal bleeding and 1 case of grade III leukopenia occurred during the treatment. One patient could not finish the treatment because of poor general condition.

CONCLUSIONS

Concurrent chemoradiotherapy with doxifluridine and paclitaxel seemed to produce a good clinical response without severe toxicity and improve survival rates in patients with extrahepatic bile duct cancer.

Magnitude of combination therapy of radical resection and external beam radiotherapy for patients with carcinomas of the extrahepatic bile duct and gallbladder

The present study sought to identify the therapeutic efficacy of adjuvant external beam radiotherapy (EBRT) for carcinomas of the extrahepatic bile duct (EHBD) and gallbladder. Twenty-one patients with pathologically verified EHBD carcinoma and 18 patients with gallbladder carcinoma were analyzed retrospectively by Cox regression analysis for predictors of survival. The overall 5-year survival rates after resection were 33% for EHBD carcinoma and 56% for gallbladder carcinoma. The overall 5-year survival rate for EHBD carcinoma was 60% in 8 patients without microscopic residual disease (R0), 15% in 9 patients with microscopic residual tumor (R1), and 0% in 4 patients with macroscopic residual tumor (R2). The overall 5-year survival rate of gallbladder carcinoma patients was also decreased with R status equal to 73%, 40%, and 0% for R0, R1 and R2, respectively. Adjuvant radiotherapy significantly improved the 5-year survival rate in 7 patients with R1 disease of EHBD carcinoma (P = .035), compared with survival in 2 patients who underwent resection alone. However, no significant difference was noted in the 5-year survival rate between the resection plus EBRT group and the resection alone group for gallbladder carcinoma. Multivariate analysis revealed that histopathologic grade (G) was an independent predictor of survival for EHBD carcinoma and that direct invasion of liver parenchyma was a predictor of survival for gallbladder carcinoma. This study suggests that curative resection provides the best survival for patients with EHBD and gallbladder carcinoma, and that radiotherapy may play a beneficial role in controlling local-regional residual EHBD carcinoma tumors. However, new strategies for adjuvant therapy are needed to improve survival in patients with gallbladder carcinoma.

Effectiveness of Radiation Therapy After Surgery for Hilar Cholangiocarcinoma

PURPOSE

Some studies suggest that giving radiation therapy after surgery for hilar cholangiocarcinoma improves the survival rate; however, many of these studies did not specify numbers of subjects or provide an impartial analysis. Thus, we evaluated the effectiveness of radiation therapy as adjuvant treatment after surgery and attempted to establish appropriate adaptation standards.

METHODS

We reviewed the records of 69 patients who underwent surgery for hilar cholangiocarcinoma between June 1980 and April 1998. Thirty-nine patients were treated with surgery followed by radiation therapy and 30 were treated with surgery alone.

RESULTS

The clinicopathologic features that might have influenced prognosis were similar in the patients who received radiation therapy and those who did not. Radiation as adjuvant therapy did not have a beneficial effect on overall survival (P = 0.554, log-rank test); however, it tended to improve survival in the group of patients who underwent curative resection for with p-stage III or IVa disease (P = 0.042, log-rank test).

CONCLUSIONS

Radiation therapy after surgery did not show any clinical benefits for patients with hilar cholangiocarcinoma. However, it may be effective as adjuvant therapy after curative resection in a small subgroup of patients with p-stage III or IVa disease.

Living donor liver transplantation and tolerance: a potential strategy in cholangiocarcinoma

BACKGROUND

Donor-specific immune tolerance has been reported in isolated cases of kidney transplantation associated with bone marrow transplantation. The following is a description of a living donor liver transplantation for a hilar cholangiocarcinoma in a previous recipient of an allogeneic bone marrow transplant.

METHOD

A right hemi-liver transplantation was performed using a liver allograft obtained from the same previous bone marrow donor. A neoadjuvant chemo-irradiation protocol was implemented before the procedure. Because of the presence of full chimerism, no immunosuppression has been necessary for the last 22 months.

RESULTS

Liver graft function has remained excellent, and a magnetic resonance imaging scan at one and a half years has shown no tumor recurrence. A control liver biopsy at 1 year showed no rejection.

CONCLUSIONS

Neoadjuvant chemo-irradiation therapy and removal of all immunosuppression after liver transplantation formed the basic structure of this approach. Additional benefits provided by living donor liver transplantation included limitation of tumor progression by diminishing the pretransplantation waiting time, radical excision of the tumor through a complete hepatectomy, and optimal timing of the transplant procedure within a neoadjuvant chemo-irradiation protocol.

Cholangiocarcinoma: the impact of tumor location and treatment strategy on outcome

The purpose of this study was to evaluate how the outcome of patients with extrahepatic cholangiocarcinoma (EHBC) may have been influenced by tumor location and treatment selection. The primary endpoint of this study is overall survival (OS). Between January 1983 and December 1997, 221 patients with biliary tumors were evaluated at Thomas Jefferson University Hospital. Of these, 118 fit the inclusion criteria for this study. The extent of disease was assessed by computed tomography, percutaneous transhepatic cholangiography or endoscopic retrograde cholangiopancreatography, magnetic resonance imaging, and ultrasonography. All patients had histologic confirmation of malignancy. Roux-en Y, hepaticojejunostomy, or choledochojejunostomy followed surgical resection of the primary tumor. Palliative measure (PS) included biliary catheter placement without brachytherapy or external beam irradiation (RT). RT was delivered via high-energy photons. Intraluminal brachytherapy was performed via percutaneous biliary catheterization with iridium-192 ribbon sources. Chemotherapy consisted of either intravenous 5-fluorouracil alone or in combination with doxorubicin, mitomycin C, or paclitaxel. PS consisted of metal bile duct stent placement. Median follow-up time for the entire group was 102 months and 43 months for patients who were still alive at the conclusion of the study period. Patients with proximal tumors underwent resection (n = 5), surgery and RT (n = 23), RT only (n = 31), chemotherapy only (n = 6), or PS (n = 12). Patients with distal tumors were treated with surgical resection (n = 17) or a combination of surgery and RT (n = 13), RT only (n = 6), or PS (n = 4). Median survival time (MST) for all 118 patients was 22 months. The MST for patients with distal tumors was 47 months versus 17 months for those with proximal tumors. The MST has not been reached for patients with distal EHBC treated with surgical resection and postoperative RT, whereas the median survival for those treated with surgery alone is 62.5 months. However, 4 of 17 of these patients had in situ carcinoma. Six patients had distal tumors treated with RT only with a MST of 6 months. Patients with proximal tumors treated with surgery and RT had a superior OS at 5 years compared to patients treated with RT alone (24 vs. 13 months; p = 0.007). There was an improved OS in patients with proximal tumors treated with surgical resection and RT compared to surgery alone (p = 0.023). There is no discernable influence of chemotherapy on outcome in patients with proximal EHBC. The MST for patients treated with PS was 3.5 months. Surgery and postoperative RT appear to be better than either surgery or RT alone in patients with proximal EHBC. In patients with distal EHBC, the addition of resection and RT appears to offer an advantage, which is increasingly apparent with longer follow-up time. The prognosis remains dismal for patients treated with palliative intent.

Diagnosis, Staging, and Treatment of Cholangiocarcinoma

Attention has to be focused on earlier detection of cholangiocarcinoma, especially in high-risk patients such as those with primary sclerosing cholangitis (PSC). Enhanced techniques for diagnosing this disease include imaging studies such as positron emission tomography (PET) scanning, and cytologic analysis including digital image analysis (DIA) and fluorescent in situ hybridization (FISH). Magnetic resonance imaging and endoscopic ultrasonography have also improved and simplified preoperative staging. Despite recent advances in the endoscopic management of cholangiocarcinoma, this neoplastic disease is still fatal in the majority of patients. Surgical resection or liver transplantation offers the only possibility for curing this disease in its early stages. However, most patients present with advanced disease that is not amenable to such therapy. For those patients presenting with unresectable carcinoma above the cystic duct without intrahepatic or extrahepatic metastases, orthotopic liver transplantation combined with preoperative irradiation and chemotherapy is available and demonstrates improved survival on the basis of a recent study conducted at the Mayo Clinic. In the future, chemopreventive strategies aimed at blocking the links between inflammation (eg, nitric oxide synthase and cylcooxygenase 2 inhibitors) and carcinogenesis may help prevent this often fatal disease in high-risk patients (eg, patients with PSC).

Role of postoperative radiotherapy in the management of extrahepatic bile duct cancer

PURPOSE

To analyze the outcome of postoperative radiotherapy (RT) or chemoradiation for patients with extrahepatic bile duct cancer who had undergone either curative or palliative surgery, and to identify the prognostic factors for these patients.

METHODS AND MATERIALS

Between March 1982 and December 1994, 91 patients with extrahepatic bile duct cancer underwent RT at the Department of Therapeutic Radiology, Seoul National University Hospital. Of these patients, 84 were included in this retrospective study. The male/female ratio was 3.7:1 (66 men and 18 women). The median age of the patients was 58 years (range 33-76). Gross total surgical resection was performed in 72 patients, with pathologically negative margins in 47 and microscopically positive margins in 25. Twelve patients underwent surgical exploration and biopsy or subtotal resection with palliative bypass procedures. All the patients received >40 Gy of external beam RT after surgery. Concurrent 5-fluorouracil was administered during external beam RT in 71 patients, and maintenance chemotherapy was performed in 61 patients after RT completion. The minimal follow-up of the survivors was 14 months, and the median follow-up period for all the patients was 23 months (range 2-75).

RESULTS

The overall 2- and 5-year survival rate was 52% and 31%, respectively. The 2- and 5-year disease-free survival rate was 48% and 26%, respectively. On univariate analysis using the Kaplan-Meier product limit method, the use of chemotherapy, performance status, N stage, size of residual tumor, stage, and tumor location were significant prognostic factors. However, on multivariate analysis using Cox's proportional hazard model, N stage (N0 vs. N1 and N2, p = 0.02) was the only significant prognostic factor.

CONCLUSION

Long-term survival can be expected in patients with extrahepatic bile duct cancer who undergo radical surgery and postoperative chemoradiation. Regional lymph node metastasis is a poor prognostic factor for these patients.

Palliative and postoperative radiotherapy in biliary tract cancer

Local failure is the primary limitation for cure in patients with BTC. whether or not they have been resected. The use of radiotherapy with or without chemotherapy in the postoperative setting is controversial, but some studies have reported improvement in 5-year survival. In patients with unresectable BTC, EBRT offers effective palliation of symptomatic disease and has resulted in improved median and long-term survival in a small number of patients in most studies. Novel approaches, including neoadjuvant chemoradiotherapy combined with OLT, and escalated conformal irradiation, seem to be promising and warrant further investigation.

Preliminary experience with liver transplantation in selected patients with unresectable hilar cholangiocarcinoma

Previous experience with OLT for hilar CCA has been discouraging, and survival was dismal. This study demonstrates that carefully selected patients with unresectable hilar CCA can achieve long-term survival after OLT. The survival rate obtained with this protocol (5-year actuarial survival of 87%) is comparable with the overall survival rate of liver-transplant recipients at the authors' institution. In comparison, the best survival rate after OLT for hilar CCA reported in the literature is 64.8% at 5 years in a subset of nine patients with negative lymph nodes. In the absence of a control group, it is difficult to assess with certainty the role of a combination of chemotherapy and radiotherapy, but in some patients it seems to prevent or slow progression of the disease while waiting for an available organ. Treatment-related morbidity, although significant, is not prohibitive. Nevertheless, a considerable proportion of treated patients ultimately was found to have advanced disease precluding transplantation. This finding confirms the importance of the staging laparotomy as an essential component of the protocol.

Radiochemotherapy and transplantation allow long-term survival for nonresectable hilar cholangiocarcinoma

Results of liver transplantation in the treatment of cholangiocarcinoma have been poor as a result of the high incidence of locoregional dissemination and tumor recurrence. This study evaluates the effect of neoadjuvant chemoradiation therapy combined with orthotopic liver transplantation in a carefully selected group of patients with hilar cholangiocarcinoma. Seventeen patients were included in the study. The neoadjuvant protocol included 6,000 cgy biliary brachy-therapy delivered through percutaneous transhepatic catheters and intravenous infusion of 5-fluorouracil (300mg/m2/day) until transplantation. Five of the 17 patients demonstrated tumor progression precluding transplantation. One patient died of sepsis on the waiting list. Eleven patients underwent liver transplantation, a median of 3.4 months (range = 1-26 months) after diagnosis. Five of the 11 (45%) are alive without evidence of tumor recurrence with a median follow up of 7.5 years (range = 2.8-14.5 years). Six deaths occurred in the transplanted patients. Tumor recurrence was responsible for two deaths at 10 and 18months, respectively, after transplantation. Three mortalities resulted from bacterial or fungal peritonitis and sepsis. One patient underwent re-transplantation for chronic rejection and died from graft failure resulting from hepatic artery thrombosis 16 months after diagnosis without evidence of tumor recurrence. Complications of transhepatic catheter placement included bile duct perforation (n = 4) and biliary-portal vein fistula (n = 1). All these patients died of tumor recurrence or sepsis. Cholangiocarcinoma should not be considered an absolute exclusion criteria for orthotopic liver transplantation. Long-term, tumor-free survival was achieved in 45% of the transplanted patients. Complications of biliary catheter placement for brachytherapy were associated with poor outcome.

[Conformal therapy of locally advanced cholangiocarcinoma of the main bile ducts]

PURPOSE

Retrospective study of 23 patients treated with conformal radiotherapy for a locally advanced bile duct carcinoma.

PATIENTS AND METHODS

Eight cases were irradiated after a radical resection (R0), because they were N+; seven after microscopically incomplete resection (R1); seven were not resected (R2). A dose of 45 of 50 Gy was delivered, followed by a boost up to 60 Gy in R1 and R2 groups. Concomitant chemotherapy was given in 15 cases.

RESULTS

Late toxicity included a stenosis of the duodenum, and one of the biliary anastomosis. Two patients died from cholangitis, the mechanism of which remains unclear. Five patients are in complete remission, six had a local relapse, four developed a peritoneal carcinosis, and six distant metastases. Actuarial survival rate is 75%, 28% and 7% at 1, 3 and 5 years, respectively (median: 16.5 months). Seven patients are still alive with a 4 to 70 months follow-up. Survival is similar in the 3 small subgroups. The poor local control among R0N+ cases might be related to the absence of a boost to the "tumor bed". In R1 patients, relapses were mainly distant metastases, whereas local and peritoneal recurrences predominated in R2.

CONCLUSION

Conformal radiochemotherapy delivering 60 Gy represents a valuable palliative approach in locally advanced biliary carcinoma.

Length and quality of survival following external beam radiotherapy combined with expandable metallic stent for unresectable hilar cholangiocarcinoma

BACKGROUND AND OBJECTIVES

Hilar cholangiocarcinoma is a morbid disease with a poor prognosis because resection cannot be performed in many cases. The purpose of this study was to evaluate whether external beam radiotherapy (RT) combined with expandable metallic biliary stent (EMS) affects the length and quality of survival of patients with unresectable hilar cholangiocarcinomas.

METHODS

Fifty-one patients with unresectable hilar cholangiocarcinoma were retrospectively reviewed. Thirty patients received external beam radiotherapy combined with EMS (EMS+RT group), 10 patients were treated with EMS alone (EMS group), and the remaining 11 patients underwent percutaneous transhepatic biliary drainage alone (PTBD group). The length and quality of survival were analyzed and compared among the three groups.

RESULTS

The mean survival of 6.4 months in the EMS group was significantly longer than that of 4.4 months in the PTBD group (P < 0.05). The EMS+RT group with a mean survival of 10.6 months had a significantly longer survival than the EMS group (P < 0.05). The average of the monthly Karnofsky scores of 74.9 in the EMS+RT group and 68.1 in the EMS group, as a parameter of quality of survival, was significantly higher than that of 57.7 in the PTBD group (P < 0.01). The number of hospital days per month of survival was significantly smaller in the EMS+RT and EMS groups than in the PTBD group (10.4, 14.2 vs. 27.3 days; P < 0.001). The EMS+RT group had a longer stent patency than the EMS group (mean: 9.8 vs. 3.7 months; P < 0.001).

CONCLUSIONS

These results indicate that external radiotherapy combined with metallic biliary endoprosthesis can increase the length and quality of survival and consequently provide a definite palliative benefit for patients with unresectable hilar cholangiocarcinoma.