Cholangiocarcinoma

Ultrasound of focal liver masses

Detecting and characterizing focal liver lesions is one of the most difficult challenges in imaging today. All standard noninvasive imaging modalities are less sensitive than generally perceived, and characterization is imperfect. Liver sonography's main strengths are its ability to definitively characterize common benign lesions (eg, cysts and hemangiomas), safety, low cost, and its ability to guide biopsy. Sonography's weaknesses include its inability to image the entire liver in many patients and its inferiority to CT as a means of detecting extrahepatic malignant disease. Sonography is less sensitive than CT or MRI in detecting focal lesions. Ultrasound contrast agents will certainly improve liver lesion detection and characterization, but their impact is not yet clear. Typical findings in common focal liver lesions are discussed, and some hints to improve sonographic diagnosis are presented. Increased color Doppler flow should bring the possibility of hepatocellular carcinoma and focal nodular hyperplasia to mind, but Doppler diagnosis is ultimately not highly specific. Sonography, including Doppler analysis, is useful to assess the resectability of malignant masses. Intraoperative ultrasound is the most sensitive imaging modality in detecting focal liver lesions.

Palliative treatment of unresectable bile duct cancer: which stent? which approach?

Nonsurgical options for the palliative treatment of unresectable bile duct cancer are discussed. Despite all of the available approaches, the disease remains uniformly fatal. The goal of managing unresectable bile duct cancer is to treat the symptoms that still contribute to significant morbidity and mortality. Further development of new treatment strategies and modalities is needed to improve the quality of life and survival of patients with this disease.

Detecting cholangiocarcinoma in patients with primary sclerosing cholangitis

BACKGROUND

Primary sclerosing cholangitis is a progressive cholestatic liver disease associated with cholangiocarcinoma. Brush cytology and serum tumor markers (carcinoembryonic antigen, carbohydrate antigen 19-9 [CA19-9]) have been used to diagnose cholangiocarcinoma, but there are few data comparing their effectiveness.

METHODS

The effectiveness of brush cytology, carcinoembryonic antigen, and CA19-9 for the diagnosis of cholangiocarcinoma was retrospectively studied by review of patients with primary sclerosing cholangitis. Receiver operator curves were used to identify cutoff points for carcinoembryonic antigen and CA19-9.

RESULTS

Of 692 patients with primary sclerosing cholangitis screened, adequate follow-up was obtained in 333, 44 (13%) of whom had a diagnosis of cholangiocarcinoma. Three hundred eighteen brush cytology specimens were obtained in 151 patients; serum carcinoembryonic antigen and CA19-9 levels were obtained in 144 and 55 patients, respectively. The overall sensitivity and specificity of brush cytology were, respectively, 46.4% (95% CI [27.5, 64.5]) and 100% (95% CI [97.2, 100]). A carcinoembryonic antigen >5.2 ng/mL had a sensitivity of 68.0% (95% CI [47.5, 83.9]) and specificity of 81.5% (95% CI [73.9, 87.7]). A CA19-9 >180 U/mL had a sensitivity of 66.7% (95% CI [34.9, 87.7]) and specificity of 97.7% (95% CI [88.2, 99.9]). In the subset of patients in which all 3 tests were obtained, (n = 45, cholangiocarcinoma = 8) the combination of an abnormal carcinoembryonic antigen or CA19-9 had the highest sensitivity: 100% (95% CI [65.1, 100.0]) with a specificity of 78.4% (95% CI [63.1, 89.7]). The combination of a positive brush cytology or an abnormal CA19-9 had a sensitivity and specificity of, respectively, 87.5% (95% CI [50.0, 99.4]) and 97.3% (95% CI [86.2, 99.9]).

CONCLUSIONS

Screening patients with primary sclerosing cholangitis for cholangiocarcinoma with CA19-9 and carcinoembryonic antigen is reasonable, but the ideal intervals at which to obtain these tests and the cost-effectiveness require further study.

Radiotherapy and multimodality management of cholangiocarcinoma

PURPOSE

To evaluate the results of radiotherapy in cholangiocarcinoma patients managed with various combinations of chemotherapy and surgical resection with selective liver transplantation.

METHODS AND MATERIALS

From January 1990 to December 1995, 61 patients with histologically confirmed biliary duct adenocarcinoma were seen in the Radiation Oncology Department of the University of Pittsburgh. Median follow-up was 22 months (1 to 91 months). The extent of surgery was complete resection in 23 patients (including 17 with orthotopic liver transplant), partial resection in 4, and biopsy in 34. All patients had radiotherapy; median dose was 49.5 Gy. Thirty patients received chemotherapy: 5-fluorouracil (5-FU)-leucovorin with interferon alpha (IFNalpha) in 27, and taxol in 3.

RESULTS

The median survival was 20 months (95% CI 15-25 months). The 5-year actuarial survival was 23.8 +/- 6.8%. The only significant variable in multivariate analysis was achieving a complete resection with negative margins through conventional surgery or liver transplantation (p = 0.001, hazard rate ratio [HRR] = 0.25, 95% CI 0.12-0.54). Patients with complete resections had a 5-year actuarial survival of 53.5 +/- 10.9%.

CONCLUSION

Combined modality therapy that includes complete surgical resection with or without transplantation can be curative in the majority of patients with biliary duct carcinoma. Further study is needed to better define the roles of chemotherapy and radiotherapy in cholangiocarcinoma.