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Dar FS, Abbas Z, Ahmed I, Atique M, Aujla UI, Azeemuddin M, Aziz Z, Bhatti ABH, Bangash TA, Butt AS, Butt OT, Dogar AW, Farooqi JI, Hanif F, Haider J, Haider S, Hassan SM, Jabbar AA, Khan AN, Khan MS, Khan MY, Latif A, Luck NH, Malik AK, Rashid K, Rashid S, Salih M, Saeed A, Salamat A, Tayyab GUN, Yusuf A, Zia HH, Naveed A. National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma. World J Gastroenterol 2024; 30:1018-1042. [PMID: 38577184 PMCID: PMC10989497 DOI: 10.3748/wjg.v30.i9.1018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/03/2024] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.
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Affiliation(s)
- Faisal Saud Dar
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Zaigham Abbas
- Department of Hepatogastroenterology and Liver Transplantation, Dr. Ziauddin University Hospital, Karachi 75600, Sindh, Pakistan
| | - Irfan Ahmed
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
- University of Aberdeen, Aberdeen B24 3FX, United Kingdom
| | - Muhammad Atique
- Department of Pathology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Usman Iqbal Aujla
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | | | - Zeba Aziz
- Department of Oncology, Hameed Latif Hospital, Lahore 54000, Pakistan
| | - Abu Bakar Hafeez Bhatti
- Division of Hepatopancreatic Biliary Surgery & Liver Transplantation, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Tariq Ali Bangash
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Shaikh Zayed Hospital and Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Amna Subhan Butt
- Department of Medicine, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Osama Tariq Butt
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Abdul Wahab Dogar
- Department of Liver Transplant, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat 66020, Pakistan
| | - Javed Iqbal Farooqi
- Department of Medicine & Gastroenterology, Lifecare Hospital and Research Centre, Peshawar 25000, Khyber Pakhtunkhwa, Pakistan
| | - Faisal Hanif
- Department of Hepatopancreatobiliary & Liver Transplant, Bahria International Hospital, Lahore 54000, Pakistan
| | - Jahanzaib Haider
- Department of Surgery, Hepatopancreatobiliary & Liver Transplant, Dow University of Health Sciences, Karachi 74800, Pakistan
| | - Siraj Haider
- Department of Surgery, Hepatopancreatobiliary & Liver Transplant, Dow University of Health Sciences, Karachi 74800, Pakistan
| | - Syed Mujahid Hassan
- Department of Gastroenterology, Hepatology & Nutrition, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat 66020, Pakistan
| | | | - Aman Nawaz Khan
- Department of Radiology, Rehman Medical Institute, Peshawar 25000, Pakistan
| | - Muhammad Shoaib Khan
- Army Liver Transplant Unit, Pak Emirates Military Hospital, Rawalpindi 46000, Pakistan
| | - Muhammad Yasir Khan
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Amer Latif
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Shaikh Zayed Hospital and Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Nasir Hassan Luck
- Department of Gastroenterology, Sindh Institute of Urology and Transplantation, Karachi 75500, Pakistan
| | - Ahmad Karim Malik
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Kamran Rashid
- Rashid Nursing Home and Cancer Clinic, Rashid Nursing Home and Cancer Clinic, Rawalpindi 46000, Pakistan
| | - Sohail Rashid
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Mohammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Abdullah Saeed
- Department of Radiology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Amjad Salamat
- Department of Gastroenterology and Hepatology, Quaid-e-Azam International Hospital, Rawalpindi 44000, Pakistan
| | - Ghias-un-Nabi Tayyab
- Department of Gastroenterology and Hepatology, Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Aasim Yusuf
- Department of Internal Medicine, Division of Gastroenterology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore 54000, Pakistan
| | - Haseeb Haider Zia
- Division of Hepatopancreatic Biliary Surgery & Liver Transplantation, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Ammara Naveed
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
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Ruff SM, Cloyd JM, Pawlik TM. Annals of Surgical Oncology Practice Guidelines Series: Management of Primary Liver and Biliary Tract Cancers. Ann Surg Oncol 2023; 30:7935-7949. [PMID: 37691030 DOI: 10.1245/s10434-023-14255-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/22/2023] [Indexed: 09/12/2023]
Abstract
Primary cancers of the liver and biliary tract are rare and aggressive tumors that often present with locally advanced or metastatic disease. For patients with localized disease amenable to resection, surgery typically offers the best chance at curative-intent therapy. Unfortunately, the incidence of recurrence even after curative-intent surgery remains high. In turn, patients with hepatobiliary cancers commonly require multimodality therapy including a combination of resection, systemic therapy (i.e., targeted therapy, cytotoxic chemotherapy, immunotherapy), and/or loco-regional therapies. With advancements in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for surgical management and optimal patient selection. Given the complex and evolving nature of treatment, this report highlights the latest practice guidelines for the surgical management of hepatobiliary cancers.
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Affiliation(s)
- Samantha M Ruff
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Tian Y, Wen N, Li B, Lu J, Wang Y, Wang S, Cheng N. A meta-analysis of prognostic factors for early recurrence in perihilar cholangiocarcinoma after curative-intent resection. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106982. [PMID: 37487828 DOI: 10.1016/j.ejso.2023.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/26/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Perihilar cholangiocarcinoma (pCCA) is a type of cancer that has a high rate of recurrence after curative-intent surgery, with about half of all recurrences occurring within the first year. The primary aim of this study was to identify prognostic factors (PFs) for early recurrence (ER, within 12 months) after surgery. METHODS Systematic searching was conducted from database inception to September 28th, 2022, with duplicate independent review and data extraction. Data on eight predefined PFs were collected, and meta-analysis was performed on PFs for ER, summarized using forest plots. RESULTS The study enrolled 11 studies comprising 2877 patients. In the risk-of-bias assessment, seven studies were rated as low risk and four as moderate risk. More than 34.3% (95% confidence interval [CI], 26.1-42.5%) of the patients experienced ER after curative-intent pCCA resection. Of the PFs, vascular invasion (HR, 2.41; 95% CI, 1.47-3.95; OR, 1.60; 95% CI, 1.17-2.18), lymph node metastases (HR, 2.54; 95% CI, 1.92-3.37; OR, 4.26; 95% CI, 2.40-7.57), and R1 resection (HR, 3.27; 95% CI, 1.81-5.92; OR, 2.40; 95% CI, 1.36-4.22) were associated with an increased hazard for ER. The combined OR values also showed that tumor size, poor tumor differentiation, and perineural invasion were linked to an elevated risk of ER, but all of them had apparent heterogeneity. CONCLUSION These findings from the review could be used to plan surveillance of ER and guide post-operative individualized management in pCCA. Furthermore, prospective studies are needed to explore more prognostic factors for ER of pCCA.
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Affiliation(s)
- Yuan Tian
- Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ningyuan Wen
- Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Bei Li
- Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jiong Lu
- Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yaoqun Wang
- Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Shaofeng Wang
- Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Nansheng Cheng
- Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Guven DC, Yildirim HC, Chalabiyev E, Kus F, Yilmaz F, Yasar S, Akyildiz A, Aktas BY, Yalcin S, Dizdar O. Emerging treatment strategies in hepatobiliary cancer. Expert Rev Anticancer Ther 2023; 23:243-256. [PMID: 36803258 DOI: 10.1080/14737140.2023.2183844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION There have been significant advances in the treatment of hepatobiliary cancers, especially for advanced-stage disease. However, data is limited for optimal therapy selection in the first line and sequencing of available options. AREAS COVERED This review covers the systemic treatment of hepatobiliary cancers with an emphasis on the advanced stage. The previously published and ongoing trials will be discussed to create an algorithm for the current practice and to give future perspectives on how the field could go forward. EXPERT OPINION While there is no standard-of-care option in the adjuvant treatment of hepatocellular cancer, capecitabine is the standard of care for biliary tract cancer. The efficacy of adjuvant gemcitabine and cisplatin and the added benefit of radiotherapy to chemotherapy are yet to be defined. For the advanced stage, immunotherapy-based combinations became the standard of care for both hepatocellular and biliary tract cancers. The molecularly targeted therapy has profoundly changed the second-line and later treatment for biliary tract cancers, while the optimal second-line treatment for advanced hepatocellular cancer is yet to be defined due to rapid advances in the first-line setting.
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Affiliation(s)
- Deniz Can Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Hasan Cagri Yildirim
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Elvin Chalabiyev
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Fatih Kus
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Feride Yilmaz
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Serkan Yasar
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Arif Akyildiz
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Burak Yasin Aktas
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Suayib Yalcin
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Omer Dizdar
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
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Liu ZP, Chen WY, Wang ZR, Liu XC, Fan HN, Xu L, Pan Y, Zhong SY, Xie D, Bai J, Jiang Y, Zhang YQ, Dai HS, Chen ZY. Development and Validation of a Prognostic Model to Predict Recurrence-Free Survival After Curative Resection for Perihilar Cholangiocarcinoma: A Multicenter Study. Front Oncol 2022; 12:849053. [PMID: 35530316 PMCID: PMC9071302 DOI: 10.3389/fonc.2022.849053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/24/2022] [Indexed: 12/29/2022] Open
Abstract
Background Recurrence is the main cause of death in perihilar cholangiocarcinoma (pCCA) patients after surgery. Identifying patients with a high risk of recurrence is important for decision-making regarding neoadjuvant therapy to improve long-term outcomes. Aim The objective of this study was to develop and validate a prognostic model to predict recurrence-free survival (RFS) after curative resection of pCCA. Methods Patients following curative resection for pCCA from January 2008 to January 2016 were identified from a multicenter database. Using random assignment, 70% of patients were assigned to the training cohort, and the remaining 30% were assigned to the validation cohort. Independent predictors of RFS after curative resection for pCCA were identified and used to construct a prognostic model. The predictive performance of the model was assessed using calibration curves and the C-index. Results A total of 341 patients were included. The median overall survival (OS) was 22 months, and the median RFS was 14 months. Independent predictors associated with RFS included lymph node involvement, macrovascular invasion, microvascular invasion, maximum tumor size, tumor differentiation, and carbohydrate antigen 19-9. The model incorporating these factors to predict 1-year RFS demonstrated better calibration and better performance than the 8th American Joint Committee on Cancer (AJCC) staging system in both the training and validation cohorts (C-indexes: 0.723 vs. 0.641; 0.743 vs. 0.607). Conclusions The prognostic model could identify patients at high risk of recurrence for pCCA to inform patients and surgeons, help guide decision-making for postoperative adjuvant therapy, and improve survival.
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Affiliation(s)
- Zhi-Peng Liu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Wei-Yue Chen
- Department of Clinical Research Institute, Lishui Hospital of Zhejiang University, Lishui, China
| | - Zi-Ran Wang
- Department of General Surgery, 903rd Hospital of People’s Liberation Army, Hangzhou, China
| | - Xing-Chao Liu
- Department of Hepatobiliary Surgery, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Hai-Ning Fan
- Department of Hepatobiliary Surgery, Affiliated Hospital of Qinghai University, Xining, China
| | - Lei Xu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yu Pan
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Shi-Yun Zhong
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dan Xie
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jie Bai
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yan Jiang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yan-Qi Zhang
- Department of Health Statistics, College of Military Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hai-Su Dai
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- *Correspondence: Zhi-Yu Chen, ; Hai-Su Dai,
| | - Zhi-Yu Chen
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- *Correspondence: Zhi-Yu Chen, ; Hai-Su Dai,
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Chen Y, Zhang B, Liu C, Cao Y, Lyu C, Qiu M. Clinical efficacy of adjuvant treatments for patients with resected biliary tract cancer: a systematic review and network meta-analysis. BMJ Open 2022; 12:e051421. [PMID: 35440445 PMCID: PMC9020290 DOI: 10.1136/bmjopen-2021-051421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE This study aimed to determine the benefits of adjuvant therapy in patients with resected biliary tract cancer (BTC) and identify the optimal adjuvant treatment scheme. DESIGN Systematic review and network meta-analysis. DATA SOURCES Studies comparing different adjuvant therapies in patients with BTC were searched in PubMed, Embase, CINAHL, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases from inception to December 2021. Additionally, the references were manually searched for the related literature. MATERIALS AND METHODS Eligible studies were identified, and data were extracted independently by two authors. A random-effects network meta-analysis was performed using R software. The pooled outcomes of overall survival (OS) and disease-free survival (DFS) were measured using the combined HRs with 95% CIs. RESULTS Nineteen eligible studies reporting three types of adjuvant therapies were included in our network meta-analysis. Adjuvant radiotherapy (ART, HR 0.62; 95% CI 0.42 to 0.93), adjuvant chemoradiotherapy (ACRT; HR 0.71; 95% CI 0.54 to 0.83) and adjuvant chemotherapy (ACT; HR 0.84; 95% CI 0.68 to 0.98) were more effective in prolonging OS than that of observation, with no significant difference between the three adjuvant therapies. Moreover, the improvement in DFS was also found in ACRT and ACT compared with that of observation (HR 0.60; 95% CI 0.45 to 0.75; HR 0.82; 95% CI 0.68 to 0.97, respectively). Furthermore, ACRT obtained a slightly better DFS benefit compared with that of ACT (HR 0.73; 95% CI 0.53 to 0.95). CONCLUSIONS Our primary results demonstrated that, compared with that of observation, ACRT and ACT after radical resection could provide better OS and DFS benefits in patients with BTC. However, ART only showed improvement in OS, but not in DFS. Due to the lack of head-to-head studies of ACT, ACRT and ART, the above results need to be further verified by prospective randomised controlled trials.
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Affiliation(s)
- Ye Chen
- Department of Medical Oncology, Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Baoxia Zhang
- Department of Medicine, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Chang Liu
- Department of Medicine, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Ye Cao
- Department of Medicine, Ascentage Pharma (Suzhou) Co. Ltd, Suzhou, China
| | - Cheng Lyu
- Department of Medicine, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Meng Qiu
- Department of Medical Oncology, Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
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Song S, Yang W, Tian H, Gong S, Lei C, Lv K, Lu T, Cheng Q, Yang K, Guo T. The efficacy and safety of 5-fluorouracil based adjuvant therapy in resected biliary tract cancer: A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2022; 46:101788. [PMID: 34389530 DOI: 10.1016/j.clinre.2021.101788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/08/2021] [Accepted: 07/28/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The adjuvant therapy (AT) for biliary tract cancer (BTC) patients after surgery has always been controversial. More therapeutic regimens and high-quality evidence were needed to evaluate AT's survival benefit further. Thus, this study was performed to investigate the efficacy and safety of the 5-fluorouracil (5-FU) regimen in resected BTC patients. METHODS PubMed, Cochrane Library, Web of Science, and the Embase were systematically searched from inception to Feb.3, 2021, for eligible studies. The pooled analyses were performed using Review Manager, Stata, and SPSS software. RESULTS A total of 9 trials involving 1339 participants were included in the meta-analysis. Resected BTC patients could significantly benefit from a 5-FU regimen (HR:0.51, 95%CI, 0.38-0.69, P<0.0001), regardless of gallbladder carcinoma (GBC) or cholangiocarcinoma (CCA). Moreover, both adjuvant chemotherapy (HR:0.61, 95%CI, 0.47-0.79, P=0.0003) and chemoradiotherapy (HR:0.35, 95%CI, 0.14-0.83, P=0.02) could significantly improve clinical survival of resected BTC patients than the surgery alone group. In the subgroup analyses, patients with node-positive (P=0.02) or vascular invasion disease (P=0.002) could better benefit from postoperative AT. CONCLUSION This study provides the latest evidence to support the 5-FU regimen in resected BTC patients regardless of GBC or CCA. Furthermore, high-risk patients are more likely to benefit from it, such as node-positive or vascular invasion disease.
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Affiliation(s)
- Shaoming Song
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China; Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Wenwen Yang
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hongwei Tian
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China; Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China; Key Laboratory of Molecular Diagnosis and Precision Therapy of Surgical Tumors of Gansu Province, Lanzhou, China
| | - Shiyi Gong
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Caining Lei
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Kun Lv
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Tingting Lu
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Qinghao Cheng
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China.
| | - Tiankang Guo
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.
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Patterns of Regional Failure after Pancreaticoduodenectomy in Patients with Distal Extrahepatic Cholangiocarcinoma: Suggestion of the Clinical Target Volume for Elective Nodal Irradiation. Clin Oncol (R Coll Radiol) 2021; 34:e45-e51. [PMID: 34598842 DOI: 10.1016/j.clon.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/24/2021] [Accepted: 09/17/2021] [Indexed: 11/22/2022]
Abstract
AIMS To evaluate the pattern of locoregional recurrence (LRR) after pancreaticoduodenectomy in patients with distal extrahepatic cholangiocarcinoma (DEHC) and to identify an optimal target volume for elective nodal irradiation. MATERIALS AND METHODS We analysed the medical records of DEHC patients who underwent pancreaticoduodenectomy and had LRR between 1991 and 2015. Among these patients, 30 received adjuvant chemotherapy alone, 14 underwent radiotherapy with or without chemotherapy and 28 received no treatment. After reviewing computed tomography or magnetic resonance imaging scans, the sites of LRR were identified and mapped to the corresponding locations on the representative computed tomography images. RESULTS In total, 136 LRRs were identified in 72 patients from four institutions. Local recurrences were observed at 44 sites (32.4%): tumour bed in 15, choledochojejunostomy in 25 and pancreaticojejunostomy in four. Regional recurrences were observed at 92 sites (67.6%); the most common site was the portal vein area (n = 18), followed by the para-aortic area (n = 17). Based on the mapped plots of regional recurrence, a clinical target volume covering 90% of regional recurrences was generated using the appropriate margin for the vascular structures of the portal vein, celiac axis, superior mesenteric artery, left gastric artery and aorta. CONCLUSIONS Given the pattern of LRR, we showed that the nodal clinical target volume based on vascular structures could appropriately cover high-risk regions of nodal involvement. These findings may help physicians construct a target volume in postoperative radiotherapy for DEHC patients undergoing pancreaticoduodenectomy.
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Analysis of Post-operative Adjuvant Chemotherapy Versus Adjuvant Chemoradiation Therapy Outcomes in Non-metastatic Cholangiocarcinoma: an NCDB Review. J Gastrointest Cancer 2021; 53:700-708. [PMID: 34486086 PMCID: PMC9436866 DOI: 10.1007/s12029-021-00696-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Each year, approximately 8000 cases of cholangiocarcinoma are recorded in the USA. Surgical resection is considered to be the only curative option. Despite surgery as a curative approach, many patients will require adjuvant therapies in the form of chemotherapy (ChT) or chemoradiotherapy (CRT). As such, we sought to analyze outcomes in patients with non-metastatic cholangiocarcinoma receiving adjuvant ChT or CRT following surgical resection. METHODS We queried the National Cancer Database (NCDB) for patients with a diagnosis of non-metastatic cholangiocarcinoma between the years 2010 and 2015 who underwent adjuvant ChT or CRT following surgery. Overall survival (OS) was calculated using Kaplan Meier method. Cox proportional hazard ratios were used to identify predictors of overall survival, and logistic regression was used to identify predictors of receiving each treatment. RESULTS A total of 875 patients were identified who met the above eligibility criteria. Of these patients, 818 received adjuvant chemotherapy alone with 57 patients receiving adjuvant chemoradiation therapy. The median OS in patients receiving CRT was 19.8 months versus 11.9 months for ChT (p value < 0.0238). The 1- and 5-year survival rates between ChT and CRT were 50% vs 61% and 6% vs 13%, respectively (hazard ratio 0.7005; 95% CI 0.51-0.97; p value < 0.0294). CONCLUSION The results of this study suggest a potential benefit of chemoradiation therapy in the adjuvant setting, although the trends appear to show rare utilization. Given the limitations of our study, prospective corroboration is warranted.
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10
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Choi SH, Rim CH, Shin IS, Yoon WS, Koom WS, Seong J. Adjuvant Radiotherapy for Extrahepatic Cholangiocarcinoma: A Quality Assessment-Based Meta-Analysis. Liver Cancer 2021; 10:419-432. [PMID: 34721505 PMCID: PMC8527906 DOI: 10.1159/000518298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/05/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The benefits of adjuvant radiotherapy (ART) for extrahepatic cholangiocarcinoma are uncertain largely because existing publications lack clear comparisons between ART and non-ART arms. METHODS PubMed, Medline, Embase, and the Cochrane library were systematically searched until December 2020. The primary endpoint was overall survival (OS). Sensitivity analysis was performed for studies with reliable comparability (i.e., no favorable prognosticators in the ART arm that could skew the data). RESULTS Twenty-three studies involving 1,731 patients with extrahepatic cholangiocarcinoma were reviewed. The overall median of all median prescribed doses was 50.4 Gy; brachytherapy or an intraoperative boost of 10-21 Gy was applied in 5 studies. The pooled 1-, 3-, and 5-year OS rates in the non-ART and ART arms were 69.2% versus 81.0%, p = 0.035; 34.3% versus 44.7%, p = 0.025; 25.6% versus 31.7%, p = 0.115, respectively. The corresponding pooled locoregional recurrence rates were 52.1% versus 34.9% (p = 0.014). The pooled rate of grade ≥3 gastrointestinal complications was 9.8%. Sensitivity analysis performed on 14 eligible studies showed that the ART arms had a lower pooled R0 rate (36.8% vs. 63.2%, p = 0.02) and a higher rate of positive lymph nodes (47.4% vs. 34.9%, p = 0.08). The pooled 1-, 3-, and 5-year OS rates in the non-ART versus ART arms of the selected studies were 78.2% versus 84.9%, p = 0.143; 38.5% versus 49.2%, p = 0.026; and 27.8% versus 34.5%, p = 0.11, respectively. CONCLUSIONS ART was shown to improve OS in all studies and in those selected for their reliable comparability.
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Affiliation(s)
- Seo Hee Choi
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Korea University Ansan Hospital, Korea University Medical College, Seoul, Republic of Korea,*Chai Hong Rim,
| | - In-Soo Shin
- Graduate School of Education, AI Convergence Education, Dongguk University, Seoul, Republic of Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Korea University Ansan Hospital, Korea University Medical College, Seoul, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Medical College, Seoul, Republic of Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Medical College, Seoul, Republic of Korea
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11
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Tsilimigras DI, Dalmacy D, Hyer JM, Diaz A, Abbas A, Pawlik TM. Disparities in NCCN Guideline Compliant Care for Resectable Cholangiocarcinoma at Minority-Serving Versus Non-Minority-Serving Hospitals. Ann Surg Oncol 2021; 28:8162-8171. [PMID: 34036428 DOI: 10.1245/s10434-021-10202-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/07/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Racial/ethnic disparities in cancer outcomes may relate to variations in receipt of National Comprehensive Cancer Network (NCCN) guideline compliant care. PATIENTS AND METHODS Patients undergoing resection of cholangiocarcinoma (CCA) between 2004 and 2015 were identified using the National Cancer Database (NCDB). Institutions treating Black and Hispanic patients within the top decile were categorized as minority-serving hospitals (MSH). Factors associated with receipt of NCCN-compliant care, and the impact of NCCN compliance on overall survival (OS), were evaluated. RESULTS Among 16,108 patients who underwent resection of CCA, the majority of patients were treated at non-MSH (n = 14,779, 91.8%), while a smaller subset underwent resection of CCA at MSH (n = 1329, 8.2%). Patients treated at MSH facilities tended to be younger (MSH: 65 years versus non-MSH: 67 years), Black or Hispanic (MSH: 59.9% versus non-MSH: 13.4%), and uninsured (MSH: 11.6% versus non-MSH: 2.2%). While overall compliance with NCCN care was 73.0% (n = 11,762), guideline-compliant care was less common at MSH (MSH: 68.8% versus non-MSH: 73.4%; p < 0.001). On multivariable analyses, the odds of receiving non-NCCN compliant care remained lower at MSH (OR 0.76, 95% CI 0.65-0.88). While white patients had similar odds of NCCN-compliant care with minority patients when treated at MSH (OR 0.98, 95% CI 0.75-1.28), minority patients had lower odds of receiving guideline-compliant care when treated at non-MSH (OR 0.85, 95% CI 0.75-0.96). Failure to comply with NCCN guidelines was associated with worse long-term outcomes (HR 1.60, 95% CI 1.52-1.69). CONCLUSIONS Patients treated at MSH had decreased odds to receive NCCN-compliant care following resection of CCA. Failure to comply with guideline-based cancer care was associated with worse long-term outcomes.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Alizeh Abbas
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Soares KC, Jarnagin WR. The Landmark Series: Hilar Cholangiocarcinoma. Ann Surg Oncol 2021; 28:4158-4170. [PMID: 33829358 DOI: 10.1245/s10434-021-09871-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
Hilar cholangiocarcinoma (HC) is a rare and highly aggressive biliary tract neoplasm. As such, the data driving the management of this disease generally are not based on prospective clinical trial data but rather consist of retrospective experiences and limited level 1 data. Surgical resection offers the best chance of a long-term survival, but local and distant recurrences are common. This report presents landmark articles that form the basis of preoperative, operative, and adjuvant strategies for HC.
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Affiliation(s)
- Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
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13
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Chen X, Meng F, Xiong H, Zou Y. Adjuvant Therapy for Resectable Biliary Tract Cancer: A Bayesian Network Analysis. Front Oncol 2021; 11:600027. [PMID: 33777744 PMCID: PMC7991284 DOI: 10.3389/fonc.2021.600027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 02/17/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Selecting proper postoperative adjuvant therapy is of great importance for prolonging overall survival (OS) of patients with biliary tract cancer (BTC). OS is commonly affected by high rate of postoperative recurrence and metastasis. Purpose: The present study aimed to identify the optimal adjuvant therapy for BTC patients. Method: A comprehensive search was carried out on Pubmed, Web of science, and Embase databases to acquire articles regarding BTC therapy approaches. Subsequently, the hazard ratio (HR) and its 95% confidence intervals (CIs) were applied to evaluate the efficacy of different adjuvant therapy regimens. The GemTc (GemTc.0.8-2) and R (R.3.6.0) software were employed to perform statistical analyses. Result: Data from 22 articles, including 14,646 patients, were quantitatively analyzed. The results showed that in terms of 5-year OS, gemcitabine (GEM) was considered as the optimal adjuvant therapy for BTC compared with chemoradiotherapy (CRT; HR = 0.59; 95% CI = 0.34-0.97), observation (OB; HR = 0.49; 95% CI = 0.33-0.73), and radiotherapy (RT; HR = 0.40; 95% CI = 0.22-0.71). Additionally, 5-fluorouracil (5-FU) exhibited improved efficacy compared with RT (HR = 0.52; 95% CI = 0.29-0.91) and OB (HR = 0.63; 95% CI = 0.43-0.92). When the efficacy of 5-FU was compared with that of GEM, the results showed that 5-FU (HR = 1.29) was more effective than GEM. Furthermore, CRT and RT prolonged positive resection margin (R+)-OS (HR = 0.69; 95% CI = 0.49-1.00) and positive lymph node-(N+)-OS (HR = 0.22; 95% CI = 0.074-0.66) in BTC patients. In terms of median recurrence-free survival (RFS) and 1-year OS, the differences were not statistically significant among different therapeutic interventions. Conclusion: The present study suggested that GEM could be used as a first-line adjuvant therapy for resected BTC patients. Additionally, CRT could be the optimal treatment approach for R+ and N+ patients.
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Affiliation(s)
- Xiuqiong Chen
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fanqiao Meng
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hua Xiong
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanmei Zou
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Gkika E, Hawkins MA, Grosu AL, Brunner TB. The Evolving Role of Radiation Therapy in the Treatment of Biliary Tract Cancer. Front Oncol 2021; 10:604387. [PMID: 33381458 PMCID: PMC7768034 DOI: 10.3389/fonc.2020.604387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Biliary tract cancers (BTC) are a disease entity comprising diverse epithelial tumors, which are categorized according to their anatomical location as intrahepatic (iCCA), perihilar (pCCA), distal (dCCA) cholangiocarcinomas, and gallbladder carcinomas (GBC), with distinct epidemiology, biology, and prognosis. Complete surgical resection is the mainstay in operable BTC as it is the only potentially curative treatment option. Nevertheless, even after curative (R0) resection, the 5-year survival rate ranges between 20 and 40% and the disease free survival rates (DFS) is approximately 48–65% after one year and 23–35% after three years without adjuvant treatment. Improvements in adjuvant chemotherapy have improved the DFS, but the role of adjuvant radiotherapy is unclear. On the other hand, more than 50% of the patients present with unresectable disease at the time of diagnosis, which limits the prognosis to a few months without treatment. Herein, we review the role of radiotherapy in the treatment of cholangiocarcinoma in the curative and palliative setting.
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Affiliation(s)
- Eleni Gkika
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Thomas B Brunner
- Department of Radiation Oncology, University of Magdeburg, Magdeburg, Germany
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15
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Watson MD, Baimas-George MR, Passeri MJ, Sulzer JK, Baker EH, Ocuin LM, Martinie JB, Iannitti DA, Vrochides D. Effect of Margin Status on Survival After Resection of Hilar Cholangiocarcinoma in the Modern Era of Adjuvant Therapies. Am Surg 2020; 87:1496-1503. [PMID: 33345594 DOI: 10.1177/0003134820973401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Studies have shown that for patients with hilar cholangiocarcinoma (HC), survival is associated with negative resection margins (R0). This requires increasingly proximal resection, putting patients at higher risk for complications, which may delay chemotherapy. For patients with microscopically positive resection margins (R1), the use of modern adjuvant therapies may offset the effect of R1 resection. METHODS Patients at our institution with HC undergoing curative-intent resection between January 2008 and July 2019 were identified by retrospective record review. Demographic data, operative details, tumor characteristics, postoperative outcomes, recurrence, survival, and follow-up were recorded. Patients with R0 margin were compared to those with R1 margin. Patients with R2 resection were excluded. RESULTS Seventy-five patients underwent attempted resection with 34 (45.3%) cases aborted due to metastatic disease or locally advanced disease. Forty-one (54.7%) patients underwent curative-intent resection with R1 rate of 43.9%. Both groups had similar rates of adjuvant therapy (56.5% vs. 61.1%, P = .7672). Complication rates and 30 mortality were similar between groups (all P > .05). Both groups had similar median recurrence-free survival (R0 29.2 months vs. R1 27.8 months, P = .540) and median overall survival (R0 31.2 months vs. R1 38.8 months, P = .736) with similar median follow-up time (R0 29.9 months vs. R1 28.5 months, P = .8864). CONCLUSIONS At our institution, patients undergoing hepatic resection for HC with R1 margins have similar recurrence-free and overall survival to those with R0 margins. Complications and short-term mortality were similar. This may indicate that with use of modern adjuvant therapies obtaining an R0 resection is not an absolute mandate.
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Affiliation(s)
- Michael D Watson
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Maria R Baimas-George
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Michael J Passeri
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Jesse K Sulzer
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Lee M Ocuin
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
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16
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Sugiura T, Uesaka K, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Asakura H, Todaka A, Fukutomi A. Adjuvant chemoradiotherapy for positive hepatic ductal margin on cholangiocarcinoma. Ann Gastroenterol Surg 2020; 4:455-463. [PMID: 32724890 PMCID: PMC7382438 DOI: 10.1002/ags3.12345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/03/2020] [Accepted: 04/15/2020] [Indexed: 01/04/2023] Open
Abstract
AIM This study evaluated the effects of postoperative adjuvant chemoradiotherapy (A-CRT) for positive hepatic ductal margin (HM+) in extrahepatic cholangiocarcinoma (EHCC). METHODS Patients with EHCC who underwent surgical resection between 2002 and 2014 were included in this retrospective study. For patients with HM+, A-CRT was conducted. The clinical effect of A-CRT for HM+ on the survival and recurrence and prognostic factors of EHCC was reviewed. RESULTS Among 340 patients, the hepatic ductal margin was negative in 296 and positive in 44. Of the 44 patients with HM+, 22 received postoperative A-CRT, and 22 did not. Hepatic stump recurrence occurred in 19 patients. The incidence was significantly higher in patients with HM+ (20%, 9/44) than in those with negative hepatic ductal margin (HM-) (3%, 10/296) (P < .001). Among the patients with HM+, the incidence was almost identical between the patients with and without A-CRT: 23% (5/22) in HM+/CRT- and 18% (4/22) in HM+/CRT+ patients (P = .999). The median survival time was 49 months in HM-, 43 months in HM+/CRT-, and 49 months in HM+/CRT+ patients. The differences were not significant among the groups. A multivariate analysis revealed CA 19-9 ≥ 300 U/mL, combined vascular resection, histologic grade G2/G3, and lymph node metastasis to be significant prognostic factors. However, the performance of postoperative A-CRT did not contribute to prolonging survival. CONCLUSION A-CRT for HM+ in patients with EHCC did not affect the survival or stump recurrence.
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Affiliation(s)
- Teiichi Sugiura
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Katsuhiko Uesaka
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Yukiyasu Okamura
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Takaaki Ito
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Yusuke Yamamoto
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Ryo Ashida
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Katsuhisa Ohgi
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Hirofumi Asakura
- Radiation and Proton Therapy CenterShizuoka Cancer CenterShizuokaJapan
| | - Akiko Todaka
- Division of Gastrointestinal OncologyShizuoka Cancer CenterShizuokaJapan
| | - Akira Fukutomi
- Division of Gastrointestinal OncologyShizuoka Cancer CenterShizuokaJapan
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Lamarca A, Edeline J, McNamara MG, Hubner RA, Nagino M, Bridgewater J, Primrose J, Valle JW. Current standards and future perspectives in adjuvant treatment for biliary tract cancers. Cancer Treat Rev 2020; 84:101936. [PMID: 31986437 DOI: 10.1016/j.ctrv.2019.101936] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/23/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Abstract
Biliary tract cancer, including cholangiocarcinoma (CCA) and gallbladder cancer (GBC) are rare tumours with a rising incidence. Prognosis is poor, since most patients are diagnosed with advanced disease. Only ~20% of patients are diagnosed with early-stage disease, suitable for curative surgery. Despite surgery performed with potentially-curative intent, relapse rates are high, with around 60-70% of patients expected to have disease recurrence. Most relapses occur in the form of distant metastases, with a predominance of liver spread. In view of high tumour recurrence, adjuvant strategies have been explored for many years, in the form of radiotherapy, chemo-radiotherapy and chemotherapy. Historically, few randomised trials were available, which included a variety of additional tumours (e.g. pancreatic and ampullary tumours); most evidence relied on phase II and retrospective studies, with no high-quality evidence available to define the real benefit derived from adjuvant strategies. Since 2017, three randomised phase III clinical trials have been reported; all recruited patients with resected biliary tract cancer (CCA and GBC) who were randomised to observation alone, or chemotherapy in the form of gemcitabine (BCAT study; included patients diagnosed with extrahepatic CCA only), gemcitabine and oxaliplatin (PRODIGE-12/ACCORD-18; included patients diagnosed with CCA and GBC) or capecitabine (BILCAP; included patients diagnosed with CCA and GBC). While gemcitabine-based chemotherapy failed to show an impact on patient outcome (relapse-free survival (RFS) or overall survival (OS)), the BILCAP study showed a benefit from adjuvant capecitabine in terms of OS (pre-planned sensitivity analysis in the intention-to-treat population and in the per-protocol analysis), with confirmed benefit in terms of RFS. Based on the BILCAP trial, international guidelines recommend adjuvant capecitabine for a period of six months following potentially curative resection of CCA as the current standard of care for resected CCA and GBC. However, BILCAP failed to show OS benefit in the intention-to-treat (non-sensitivity analysis) population (primary end-point), and this finding, as well as some inconsistencies between studies has been criticised and has led to confusion in the biliary tract cancer medical community. This review summarises the adjuvant field in biliary tract cancer, with evidence before and after 2017, and comparison between the latest randomised phase III studies. Potential explanations are presented for differential findings, and future steps are explored.
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Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Julien Edeline
- Department of Medical Oncology, Centre Eugene Marquis, Rennes, France
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Masato Nagino
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - John Bridgewater
- Department of Medical Oncology, UCL Cancer Institute, London, United Kingdom
| | - John Primrose
- Department of Surgery, University of Southampton, Southampton, United Kingdom
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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Ren B, Guo Q, Yang Y, Liu L, Wei S, Chen W, Tian Y. A meta-analysis of the efficacy of postoperative adjuvant radiotherapy versus no radiotherapy for extrahepatic cholangiocarcinoma and gallbladder carcinoma. Radiat Oncol 2020; 15:15. [PMID: 31941520 PMCID: PMC6964081 DOI: 10.1186/s13014-020-1459-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 01/05/2020] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Bixin Ren
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Qi Guo
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Yongqiang Yang
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Lei Liu
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China.,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Shaohua Wei
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Wei Chen
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Ye Tian
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China. .,Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China. .,Suzhou Key Laboratory for Radiation Oncology, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China.
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Mukai Y, Matsuyama R, Koike I, Kumamoto T, Kaizu H, Homma Y, Takano S, Sawada Y, Sugiura M, Yabushita Y, Ito E, Sato M, Endo I, Hata M. Outcome of postoperative radiation therapy for cholangiocarcinoma and analysis of dose-volume histogram of remnant liver. Medicine (Baltimore) 2019; 98:e16673. [PMID: 31374045 PMCID: PMC6709052 DOI: 10.1097/md.0000000000016673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to analyze dose-volume histogram (DVH) of the remnant liver for postoperative cholangiocarcinoma (CCA) patients, to find toxicity rates, and to confirm efficacy of postoperative radiation therapy (RT).Thirty-two postoperative CCA patients received partial liver resection and postoperative RT with curative intent. The "liver reduction rate" was calculated by contouring liver volume at computed tomography (CT) just before the surgery and at CT for planning the RT. To evaluate late toxicity, the radiation-induced hepatic toxicity (RIHT) was determined by the common terminology criteria for adverse events toxicity grade of bilirubin, aspartate transaminase, alanine transaminase, alkaline phosphatase, and albumin, and was defined from 3 months after RT until liver metastasis was revealed. The radiation-induced liver disease (RILD) was also evaluated.Tumor stages were distributed as follows: I: 1, II: 8, IIIA: 1, IIIB: 6, IIIC: 14, IVA: 2. Median prescribed total dose was 50 Gy. Median follow-up time was 27 months. Two-year overall survival (OS): 72.4%, disease-free survival: 47.7%, local control: 65.3%, and the median survival time was 40 months. The median "liver reduction rate" was 21%. The OS had statistically significant difference in nodal status (P = .032) and "liver reduction rate" >30% (P = .016). In the association between the ≥grade 2 RIHT and DVH, there were significantly differences in V30 and V40 (P = .041, P = .034), respectively. The grade ≥2 RIHT rates differ also significantly by sex (P = .008). Two patients (6.2%) were suspected of RILD.We suggest that RT for remnant liver should be considered the liver V30, V40 to prevent radiation-induced liver dysfunction.
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Affiliation(s)
| | - Ryusei Matsuyama
- Departments of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Japan
| | | | - Takafumi Kumamoto
- Departments of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Japan
| | | | - Yuki Homma
- Departments of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Japan
| | | | - Yu Sawada
- Departments of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Japan
| | | | - Yasuhiro Yabushita
- Departments of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Japan
| | - Eiko Ito
- Department of Radiation Oncology
| | | | - Itaru Endo
- Departments of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Japan
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20
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Jung W, Kim K, Min SK, Nam EM, Lee JK. Mapping of local recurrence after pancreaticoduodenectomy for distal extrahepatic cholangiocarcinoma: implications for adjuvant radiotherapy. Br J Radiol 2019; 92:20190285. [PMID: 31145644 DOI: 10.1259/bjr.20190285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To generate a map of local recurrences after pancreaticoduodenectomy (PD) for patients with distal extrahepatic cholangiocarcinoma (DEHC) and to evaluate the adequate target volume coverage encompassing the majority of local recurrences when the clinical target volume (CTV) for pancreatic cancer was applied. METHODS We retrospectively reviewed the records of DEHC patients who underwent pancreaticoduodenectomy and had postoperative CT scans acquired between 1991 and 2015 available. The sites of local recurrence were delineated on individual CT scans, and then, mapping was manually performed onto template CT images. Coverage of each site of local recurrence was evaluated by applying the CTV defined according to Radiation Therapy Oncology Group (RTOG) consensus guidelines (CTVRTOG ) for target delineation in the postoperative treatment of pancreatic head cancer. RESULTS Of the 99 patients, 36 patients had a total of 62 local relapses identifiable by postoperative CT scans; the relapses were the most frequent in the choledochojejunostomy (CJ) site, 11 sites (17.7%); para-aortic area, 10 sites (16.1%), superior mesenteric artery area, 10 sites (16.1%); and portal vein area, 9 sites (14.5%). 21 sites (33.9%) were not covered by the CTVRTOG, and the most common site of local recurrence outside the CTVRTOG was the CJ site. CONCLUSION When mapping of local relapses was evaluated according to the CTVRTOG, the choledochojejunostomy site was identified as a high-risk area of local recurrence but was insufficiently covered within the CTVRTOG. These findings may help construct a target volume for postoperative radiotherapy in DEHC. ADVANCES IN KNOWLEDGE Mapping local recurrences can aid in defining appropriate target volume for postoperative radiotherapy in DEHC.
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Affiliation(s)
- Wonguen Jung
- 1 Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Kyubo Kim
- 1 Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Seog Ki Min
- 2 Department of Surgery, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Eun Mi Nam
- 3 Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Jeong Kyong Lee
- 4 Department of Radiology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
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Koo T, Park HJ, Kim K. Radiation therapy for extrahepatic bile duct cancer: Current evidences and future perspectives. World J Clin Cases 2019; 7:1242-1252. [PMID: 31236388 PMCID: PMC6580339 DOI: 10.12998/wjcc.v7.i11.1242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/02/2019] [Accepted: 04/19/2019] [Indexed: 02/05/2023] Open
Abstract
Extrahepatic bile duct cancer (EBDC) is a rare malignancy that involves neoplastic changes extending from both hepatic ducts to the common bile duct. The treatment of choice is surgical resection, but the predominant pattern of initial treatment failure is locoregional recurrence. Accordingly, adjuvant radiotherapy has been administered after surgical resection based on these rationales. At this time, there is minimal evidence supporting adjuvant radiotherapy, because there have been no phase III trials evaluating its benefit. Relatively small retrospective studies have tried to compare outcomes associated with EBDC treated with or without radiotherapy. We aimed to review studies investigating adjuvant radiotherapy for resected EBDC. Because less than one-third of EBDC cases are amenable to curative resection at diagnosis, other locoregional treatment modalities need to be considered, including radiotherapy. The next aim of this review was to summarize reports of definitive radiotherapy for unresectable EBDC. Patients with advanced EBDC often experience biliary obstruction, which can lead to jaundice and progress to death. Biliary stent insertion is an important palliative procedure, but stents are prone to occlusion after subsequent ingrowth of the EBDC. Radiotherapy can be effective for maintaining the patency of inserted stents. We also reviewed the benefit of palliative radiotherapy combined with the biliary stent insertion. Lastly, we discuss the existing gaps in the evidence supporting radiotherapy in the management of EBDC.
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Affiliation(s)
- Taeryool Koo
- Department of Radiation Oncology, Hallym University Sacred Heart Hospital, Anyang 14068, South Korea
| | - Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, Seoul 04763, South Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul 07985, South Korea
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22
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Peng DZ, Lu J, Li B, Hu HJ, Ye XW, Xiong XZ, Cheng NS. A simple scoring system to predict early recurrence of Bismuth-Corlette type IV perihilar cholangiocarcinoma. Gastroenterol Rep (Oxf) 2019; 7:345-353. [PMID: 31687154 PMCID: PMC6821250 DOI: 10.1093/gastro/goz012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/31/2019] [Accepted: 03/05/2019] [Indexed: 02/06/2023] Open
Abstract
Background Early recurrence has been reported to be predictive of a poor prognosis for patients with perihilar cholangiocarcinoma (pCCA) after resection. The objective of our study was to construct a useful scoring system to predict early recurrence for Bismuth–Corlette type IV pCCA patients in clinic and to investigate the value of early recurrence in directing post-operative surveillance and adjuvant therapy. Methods In total, 244 patients who underwent radical resection for type IV pCCA were included. Data on clinicopathological characteristics, perioperative details and survival outcomes were analyzed. Survival curves were generated using the Kaplan–Meier method. Univariate and multivariate logistic-regression models were used to identify factors associated with early recurrence. Results Twenty-one months was defined as the cutoff point to distinguish between early and late recurrence. Univariate and multivariate analysis revealed that CA19-9 level >200 U/mL, R1 resection margin, higher N category and positive lymphovascular invasion were independent predictors of early recurrence. The scoring system was constructed accordingly. The early-recurrence rates of patients with scores of 0, 1, 2, 3, 4, and 5 were 23.9%, 38.7%, 60.0%, 78.6%, 83.4%, and 100%, respectively. Adjuvant therapy was significantly associated with higher overall survival rate for patients with early recurrence, but not for those with late recurrence. Patients in the early-recurrence group with scores ≥2 had better prognoses after adjuvant therapy. Conclusions A simple scoring system using CA19-9 level, N category, resection margin and lymphovascular invasion status could predict early recurrence, and thus might direct post-operative surveillance and adjuvant therapy for patients with type IV pCCA.
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Affiliation(s)
- Ding-Zhong Peng
- Department of biliary surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P. R. China
| | - Jiong Lu
- Department of biliary surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P. R. China
| | - Bei Li
- Department of biliary surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P. R. China
| | - Hai-Jie Hu
- Department of biliary surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P. R. China
| | - Xi-Wen Ye
- Department of biliary surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P. R. China
| | - Xian-Ze Xiong
- Department of biliary surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P. R. China
| | - Nan-Sheng Cheng
- Department of biliary surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, P. R. China
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Abstract
Cholangiocarcinoma is a rare malignancy and accounts for 2% of all malignancies. Incidence is on the increase in the Western world. Cholangiocarcinoma arises from the malignant growth of the epithelial lining of the bile ducts and can be found all along the biliary tree. It can be classified into subtypes based on location: intrahepatic (arising from the intrahepatic biliary tract in the hepatic parenchyma), perihilar (at the hilum of the liver involving the biliary confluence) and distal (extrahepatic, often in the head of the pancreas). Margin status and locoregional lymph node metastases are the most important determinants of postsurgical outcomes.
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Affiliation(s)
- Adeel S Khan
- Section of Abdominal Transplant Surgery, Washington University St Louis, One Barnes-Jewish Hospital Plaza, Suite 6107 Queeny Tower, St Louis, MO 63110, USA.
| | - Leigh Anne Dageforde
- Division of Transplant Surgery, Massachusetts General Hospital, 55 Fruit Street, White 511, Boston, MA 02114, USA
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Krasnick BA, Jin LX, Davidson JT, Sanford DE, Ethun CG, Pawlik TM, Poultsides GA, Tran T, Idrees K, Hawkins WG, Chapman WC, Majella Doyle MB, Weber SM, Strasberg SM, Salem A, Martin RC, Isom CA, Scoggins C, Schmidt CR, Shen P, Beal E, Hatzaras I, Shenoy R, Maithel SK, Fields RC. Adjuvant therapy is associated with improved survival after curative resection for hilar cholangiocarcinoma: A multi-institution analysis from the U.S. extrahepatic biliary malignancy consortium. J Surg Oncol 2018; 117:363-371. [PMID: 29284072 PMCID: PMC5924689 DOI: 10.1002/jso.24836] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 08/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Curative-intent treatment for localized hilar cholangiocarcinoma (HC) requires surgical resection. However, the effect of adjuvant therapy (AT) on survival is unclear. We analyzed the impact of AT on overall (OS) and recurrence free survival (RFS) in patients undergoing curative resection. METHODS We reviewed patients with resected HC between 2000 and 2015 from the ten institutions participating in the U.S. Extrahepatic Biliary Malignancy Consortium. We analyzed the impact of AT on RFS and OS. The probability of RFS and OS were calculated in the method of Kaplan and Meier and analyzed using multivariate Cox regression analysis. RESULTS A total of 249 patients underwent curative resection for HC. Patients who received AT and those who did not had similar demographic and preoperative features. In a multivariate Cox regression analysis, AT conferred a significant protective effect on OS (HR 0.58, P = 0.013), and this was maintained in a propensity matched analysis (HR 0.66, P = 0.033). The protective effect of AT remained significant when node negative patients were excluded (HR 0.28, P = 0.001), while it disappeared (HR 0.76, P = 0.260) when node positive patients were excluded. CONCLUSIONS AT should be strongly considered after curative-intent resection for HC, particularly in patients with node positive disease.
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Affiliation(s)
- Bradley A. Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Linda X. Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Jesse T. Davidson
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Dominic E. Sanford
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | | | | | | | - Thuy Tran
- Stanford University Medical Center, Stanford, CA
| | | | - William G. Hawkins
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - William C. Chapman
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | | | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Steven M. Strasberg
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Ahmed Salem
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | | | - Carl R. Schmidt
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Perry Shen
- Wake Forest University, Winston-Salem, NC
| | - Eliza Beal
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | | | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
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25
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Park Y, Kim K, Paik JH, Chie EK, Jang JY, Kim SW, Oh DY. High expression of MMP-9 is associated with better prognosis in extrahepatic bile duct cancer patients. Eur J Surg Oncol 2018; 44:638-643. [PMID: 29422250 DOI: 10.1016/j.ejso.2018.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/24/2017] [Accepted: 01/05/2018] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To evaluate the prognostic value of matrix metalloproteinase-9 (MMP-9) in patients with extrahepatic bile duct (EHBD) cancer undergoing surgical resection and adjuvant radiotherapy. METHODS Between January 2000 and August 2006, patients who underwent complete resection followed by adjuvant radiotherapy for EHBD cancer were enrolled in this study. The expression of MMP-9 was assessed with immunohistochemical staining. The prognostic values of the MMP-9 expression and other clinicopathologic factors were evaluated in univariate and multivariate analyses. RESULTS Sixty-six patients were included in this study. All received radiotherapy with a median dose of 40 Gy (range, 40-56), and 61 patients received concomitant fluoropyrimidine chemotherapy. MMP-9 was highly expressed in 33 patients (50.0%). MMP-9 expression was significantly associated with locoregional recurrence-free survival (LRRFS) and overall survival (OS) but not with distant metastasis-free survival (DMFS). The 5-year LRRFS and OS rates were 50.8% versus 86.5% (p = .0281), and 23.3% versus 68.1% (p = .0087) in patients with low and high expression of MMP-9, respectively. Among the clinicopathologic factors, tumor location was associated with DMFS and OS (p = .0292 and .0003, respectively). Nodal stage and histologic differentiation showed significant association with DMFS (p = .0277 and .0060, respectively). Based on multivariate analysis for OS, tumor location was the only significant prognostic factor (p = .0021), while MMP-9 expression showed marginal significance (p = .0633). CONCLUSION MMP-9 expression is a useful prognostic factor for predicting LRRFS and OS in patients with EHBD cancer after surgical resection and adjuvant radiotherapy.
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Affiliation(s)
- Younghee Park
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Republic of Korea.
| | - Jin Ho Paik
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Youn Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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26
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Abstract
Cholangiocarcinomas (CC) are rare tumors which usually present late and are often difficult to diagnose and treat. CCs are categorized as intrahepatic, hilar, or extrahepatic. Epidemiologic studies suggest that the incidence of intrahepatic CCs may be increasing worldwide. In this chapter, we review the risk factors, clinical presentation, and management of cholangiocarcinoma.
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Adjuvant concurrent chemoradiation therapy in patients with microscopic residual tumor after curative resection for extrahepatic cholangiocarcinoma. Clin Transl Oncol 2017; 20:1011-1017. [PMID: 29256155 DOI: 10.1007/s12094-017-1815-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/27/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE We investigated the role of adjuvant concurrent chemoradiation therapy (CCRT) in patients with a microscopically positive resection margin (R1) after curative resection for extrahepatic cholangiocarcinoma (EHCC). METHODS/PATIENTS A total of 84 patients treated with curative resection for EHCC were included. Fifty-two patients with negative resection margins did not receive any adjuvant treatments (R0 + S group). The remaining 32 patients with microscopically positive resection margins received either adjuvant CCRT (R1 + CCRT group, n = 19) or adjuvant radiation therapy (RT) alone (R1 + RT group, n = 13). RESULTS During the median follow-up period of 26 months, the 2-year locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), and overall survival rates (OS) were: 81.8, 62.6, and 61.5% for R0 + S group; 71.8, 57.8, and 57.9% for R1 + CCRT group; and 16.8, 9.6, and 15.4% for R1 + RT group, respectively. Multivariate analysis revealed that the R1 + CCRT group did not show any significant difference in survival rates compared with the R0 + S group. The R1 + RT group had lower LRRFS [hazard ratio (HR) 3.008; p = 0.044], DFS (HR 2.364; p = 0.022), and OS (HR 2.417; p = 0.011) when compared with the R0 + S and R1 + CCRT group. CONCLUSIONS A lack of significant survival difference between R0 + S group and R1 + CCRT group suggests that adjuvant CCRT ameliorates the negative effect of microscopic positive resection margin. In contrast, adjuvant RT alone is appeared to be inadequate for controlling microscopically residual tumor.
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28
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Ecker BL, Vining CC, Roses RE, Maggino L, Lee MK, Drebin JA, Fraker DL, Vollmer CM, Datta J. Identification of Patients for Adjuvant Therapy After Resection of Carcinoma of the Extrahepatic Bile Ducts: A Propensity Score-Matched Analysis. Ann Surg Oncol 2017; 24:3926-3933. [PMID: 28952140 DOI: 10.1245/s10434-017-6095-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Resectability rates for extrahepatic cholangiocarcinoma have increased over time, but long-term survival after resection alone with curative intent remains poor. Recent series suggest improved survival with adjuvant therapy. Patient subsets benefiting most from adjuvant therapy have not been clearly defined. METHODS Patients with extrahepatic cholangiocarcinoma who underwent resection with curative intent and received adjuvant therapy (chemotherapy ± radiotherapy) or surgery alone (SA) were identified in the U.S. National Cancer Data Base (2004-2014). Cox regression identified covariates associated with overall survival (OS). Adjuvant therapy and SA cohorts were matched (1:1) by propensity scores based on the survival hazard in Cox modeling. Overall survival was compared by Kaplan-Meier estimates. RESULTS Of 4872 patients, adjuvant chemotherapy was used frequently for 2416 (49.6%), often in conjunction with radiotherapy (RT) (n = 1555, 64.4%). Adjuvant chemotherapy with or without RT was used increasingly for cases with higher T classification [reference: T1-2; T3: 1.36; 95% confidence interval (CI), 1.19-1.55; T4: 1.77; 95% CI 1.38-2.26], nodal positivity [odds ratio (OR), 1.26; 95% CI 1.01-1.56], lymphovascular invasion (OR 1.21; 95% CI 1.01-1.46), or margin-positive resection (OR 1.85; 95% CI 1.61-2.12), and was associated with significant improvements in OS for each high-risk subset in the propensity score-matched cohort. Adjuvant therapy was associated with improved median OS for hilar tumors (40.0 vs 30.6 months; p = 0.025) but not distal tumors (33.0 vs 30.3 months; p = 0.123). Chemoradiotherapy was associated with superior outcomes compared with chemotherapy alone in the subset of margin-positive resection [hazard ratio (HR), 0.63; 95% CI 0.42-0.94]. CONCLUSIONS Adjuvant multimodality therapy is associated with improved survival for patients with resected extrahepatic cholangiocarcinoma and high-risk features.
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Affiliation(s)
- Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles C Vining
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Surgery, Pancreas Institute, University of Verona, Verona, Italy
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jashodeep Datta
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. .,Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Papafragkakis C, Lee J. Comprehensive management of cholangiocarcinoma: Part II. Treatment. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii1500342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Charilaos Papafragkakis
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Clinical outcomes of salvage chemoradiotherapy for locally recurrent biliary tract cancer. TUMORI JOURNAL 2017; 103:345-352. [PMID: 28708225 DOI: 10.5301/tj.5000666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to investigate the clinical outcomes and prognostic factors of concurrent chemoradiotherapy (CCRT) for locally recurrent biliary tract cancer (BTC) after curative surgical resection. METHODS We performed a retrospective cohort study of patients with locally recurrent BTC treated with CCRT between October 2004 and December 2013. The study included and analyzed 42 patients with a history of curative-intent surgical resection of confirmed adenocarcinoma originating from the biliary tract. RESULTS The median time to recurrence after surgery was 16.1 months (range, 4.5-77.8 months). Median follow-up after CCRT was 26.9 months (range, 5.2-81.9) with no grade 3 or higher gastrointestinal toxicities. Analysis of the first site of failure showed local progression (LP) developed in 20 patients (47.6%); among these, 16 (38.1%) had isolated LP. The median values were 15.8 months (range, 1.7-81.7) for LP-free survival (LPFS), 10.6 months (range, 1.7 - 81.7) for progression-free survival (PFS) and 41.2 months (range, 5.2-81.9) for overall survival (OS). Multivariate analysis showed that the level of pre-CCRT carbohydrate antigen (CA) 19-9 and the chemotherapy regimen were significant prognostic factors for LPFS and PFS; pT stage was the only significant prognostic factor for OS. CONCLUSIONS CCRT for locally recurrent BTC showed promising outcomes as a salvage modality, but LP was still frequent. The pre-CCRT CA 19-9 level and the chemotherapy regimen were prognostic factors for LPFS and PFS.
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Kim SW, Noh OK, Kim JH, Chun M, Oh YT, Kang SY, Lee HW, Park RW, Yoon D. Adjuvant concurrent chemoradiotherapy with low-dose daily cisplatin for extrahepatic bile duct cancer. Cancer Chemother Pharmacol 2017; 79:1161-1167. [DOI: 10.1007/s00280-017-3312-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/18/2017] [Indexed: 12/27/2022]
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32
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Leng KM, Liu YP, Wang ZD, Zhong XY, Liao GQ, Kang PC, Cui YF, Jiang XM. Results of adjuvant radiation therapy for locoregional perihilar cholangiocarcinoma after curative intent resection. Onco Targets Ther 2017; 10:2257-2266. [PMID: 28461760 PMCID: PMC5408944 DOI: 10.2147/ott.s131873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Purpose This study sought to define the role of adjuvant radiation therapy (RT) for patients with curative intent resection of perihilar cholangiocarcinoma (pCCA). Patients and methods By using the Surveillance, Epidemiology and End Results (SEER) registry, 1,917 patients with non-metastatic pCCA who underwent surgical resection from 1988 to 2009 were included in this study. Propensity score methods were used to compare the survival outcomes of patients treated with and without adjuvant RT after controlling for selection bias. Results Of the 1,917 patients, 762 (39.7%) received adjuvant RT. In the unmatched population, median overall survival (OS) for patients receiving adjuvant RT compared with those undergoing surgery alone was 23 versus 22 months (P=0.651). Patients who received adjuvant RT were younger (65 vs 68 years, P<0.001), had more regional diseases (86.0% vs 76.7%, P<0.001), and had more positive lymph nodes (43.8% vs 32.2%, P<0.001). In the matched population, adjuvant RT did not show better OS (22 vs 23 months, P=0.978) or cancer-specific survival (CSS) (17 vs 18 months, P=0.554). Conclusion Adjuvant RT is not associated with improved survival of patients with resected pCCA. These data suggest that adjuvant RT should not be routinely used to treat patients with pCCA outside research trials. Ideally, prospective randomized trials should be performed to verify the conclusion of this study.
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Affiliation(s)
- Kai-Ming Leng
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Yue-Ping Liu
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Zhi-Dong Wang
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Xiang-Yu Zhong
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Guan-Qun Liao
- Department of General Surgery, Foshan Hospital Affiliated to Southern Medical University, Foshan, People's Republic of China
| | - Peng-Cheng Kang
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Yun-Fu Cui
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Xing-Ming Jiang
- Department of Hepatopan-creatobiliary Surgery, Second Affiliated Hospital of Harbin Medical University, Harbin
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Prabhu RS, Hwang J. Adjuvant therapy in biliary tract and gall bladder carcinomas: a review. J Gastrointest Oncol 2017; 8:302-313. [PMID: 28480069 PMCID: PMC5401863 DOI: 10.21037/jgo.2017.01.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 11/04/2016] [Indexed: 12/13/2022] Open
Abstract
Biliary tract carcinomas are relatively rare, but are increasingly diagnosed. They comprise several anatomically contiguous sites, so are often grouped together, but they do appear to represent distinct diseases, in part because of anatomical and surgical considerations. Complete upfront surgical resection is generally difficult because these cancers are often diagnosed at relatively advanced stages of disease. Thus, adjuvant therapy is often considered. This paper will review the evidence underpinning current recommendations for adjuvant therapy in biliary carcinomas.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Jimmy Hwang
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
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Kim YJ, Kim K, Min SK, Nam EM. Role of adjuvant radiotherapy for localized extrahepatic bile duct cancer. Br J Radiol 2017; 90:20160807. [PMID: 28118028 DOI: 10.1259/bjr.20160807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Yi-Jun Kim
- 1 Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Kyubo Kim
- 1 Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Seog Ki Min
- 2 Department of Surgery, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Eun Mi Nam
- 3 Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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Kim MY, Kim JH, Kim Y, Byun SJ. Postoperative radiotherapy appeared to improve the disease free survival rate of patients with extrahepatic bile duct cancer at high risk of loco-regional recurrence. Radiat Oncol J 2016; 34:297-304. [PMID: 27951624 PMCID: PMC5207366 DOI: 10.3857/roj.2016.01879] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/26/2016] [Accepted: 10/04/2016] [Indexed: 01/27/2023] Open
Abstract
Purpose To investigate the outcomes of postoperative radiotherapy (RT), in patients with extrahepatic bile duct (EHBD) cancer by comparing the survival rate between patients undergoing surgery alone or surgery plus postoperative RT, and to identify the prognostic factors affecting survival. Materials and Methods Between 2000 and 2013, 52 patients with EHBD cancer underwent surgical resection. Of these, 33 patients did not receive postoperative RT (group I), and 19 patients did (group II). R1 resection was significantly more frequent in group II. The median radiation dose was 5,040 cGy. Results The 3-year overall survival (OS) rate for group I and group II was 38% and 56%, respectively (p = 0.274). The 3-year disease free survival (DFS) rate for group I and group II was 20% and 31%, respectively (p = 0.049), and the 3-year loco-regional recurrence free survival (LRFS) rates were 19% and 58%, respectively (p = 0.002). Multivariate analyses showed that postoperative RT and lymphovascular invasion were independent prognostic factors for DFS and LRFS. Overall, 42 patients (80%) experienced treatment failure. Distant metastasis was the predominant pattern of failure in group II. Conclusion Postoperative RT after surgical resection appeared to improve the loco-regional control and DFS rate. More effort is needed to reduce distant metastasis, the major pattern of failure, in patients who receive postoperative RT.
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Affiliation(s)
- Mi Young Kim
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yonghoon Kim
- Department of Surgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sang Jun Byun
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Squadroni M, Tondulli L, Gatta G, Mosconi S, Beretta G, Labianca R. Cholangiocarcinoma. Crit Rev Oncol Hematol 2016; 116:11-31. [PMID: 28693792 DOI: 10.1016/j.critrevonc.2016.11.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 11/07/2016] [Accepted: 11/22/2016] [Indexed: 12/15/2022] Open
Abstract
Biliary tract cancer accounts for <1% of all cancers and affects chiefly an elderly population, with predominance in men. We distinguish cholangiocarcinoma (intrahepatic, hilar and distal) and gallbladder cancer, with different pathogenesis and prognosis. The treatment is based on surgery (whenever possible), radiotherapy in selected cases, and chemotherapy. The standard cytotoxic treatment for advanced/metastatic disease is represented by the combination of gemcitabine and cisplatin, whereas fluoropyrimidines are generally administered in second line setting. At the present time, no biologic drug demonstrated a clear efficacy in this cancer, although the molecular characterisation could provide a promising basis for experimental treatments. A good supportive care and an early palliative care are warranted in most patients and should be delivered as a part of a global approach.
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Affiliation(s)
| | - Luca Tondulli
- Medical Oncology Unit, Borgo Roma Hospital, Verona, Italy
| | - Gemma Gatta
- Italian National Cancer Institute, Milan, Italy
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Mansour JC, Aloia TA, Crane CH, Heimbach JK, Nagino M, Vauthey JN. Hilar cholangiocarcinoma: expert consensus statement. HPB (Oxford) 2015; 17:691-9. [PMID: 26172136 PMCID: PMC4527854 DOI: 10.1111/hpb.12450] [Citation(s) in RCA: 256] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/27/2015] [Indexed: 12/12/2022]
Abstract
An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists met on 15 January 2014 to review current evidence on the management of hilar cholangiocarcinoma in order to establish practice guidelines and to agree consensus statements. It was established that the treatment of patients with hilar cholangiocarcinoma requires a coordinated, multidisciplinary approach to optimize the chances for both durable survival and effective palliation. An adequate diagnostic and staging work-up includes high-quality cross-sectional imaging; however, pathologic confirmation is not required prior to resection or initiation of a liver transplant trimodal treatment protocol. The ideal treatment for suitable patients with resectable hilar malignancy is resection of the intra- and extrahepatic bile ducts, as well as resection of the involved ipsilateral liver. Preoperative biliary drainage is best achieved with percutaneous transhepatic approaches and may be indicated for patients with cholangitis, malnutrition or hepatic insufficiency. Portal vein embolization is a safe and effective strategy for increasing the future liver remnant (FLR) and is particularly useful for patients with an FLR of <30%. Selected patients with unresectable hilar cholangiocarcinoma should be evaluated for a standard trimodal protocol incorporating external beam and endoluminal radiation therapy, systemic chemotherapy and liver transplantation. Post-resection chemoradiation should be offered to patients who show high-risk features on surgical pathology. Chemoradiation is also recommended for patients with locally advanced, unresectable hilar cancers. For patients with locally recurrent or metastatic hilar cholangiocarcinoma, first-line chemotherapy with gemcitabine and cisplatin is recommended based on multiple Phase II trials and a large randomized controlled trial including a heterogeneous population of patients with biliary cancers.
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Affiliation(s)
- John C Mansour
- Division of Surgical Oncology, University of Texas SouthwesternDallas, TX, USA,Correspondence John C. Mansour, Division of Surgical Oncology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA. Tel: + 1 214 648 5870. Fax: + 1 214 648 1118. E-mail:
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer CenterHouston, TX, USA
| | - Christopher H Crane
- Department of Radiation Oncology, University of Texas MD Anderson Cancer CenterHouston, TX, USA
| | | | - Masato Nagino
- Department of Surgery, Nagoya UniversityNagoya, Japan
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, University of Texas MD Anderson Cancer CenterHouston, TX, USA
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Im JH, Seong J, Lee IJ, Park JS, Yoon DS, Kim KS, Lee WJ, Park KR. Surgery Alone Versus Surgery Followed by Chemotherapy and Radiotherapy in Resected Extrahepatic Bile Duct Cancer: Treatment Outcome Analysis of 336 Patients. Cancer Res Treat 2015; 48:583-95. [PMID: 26323644 PMCID: PMC4843751 DOI: 10.4143/crt.2015.091] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/01/2015] [Indexed: 12/11/2022] Open
Abstract
Purpose This study analyzed the outcomes of patients with resected extrahepatic bile duct cancer (EHBDC) in order to clarify the role of adjuvant treatments in these patients. Materials and Methods A total of 336 patients with EHBDC who underwent curative resection between 2001 and 2010 were analyzed retrospectively. The treatment types were as follows: surgery alone (n=168), surgery with chemotherapy (CTx, n=90), surgery with radiotherapy (RT) alone (n=29), and surgery with chemoradiotherapy (CRT, n=49). Results The median follow-up period was 63 months. The 5-year rates of locoregional failure-free survival (LRFFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) for all patients were 56.5%, 59.7%, 36.6%, and 42.0%, respectively. In multivariate analysis, surgery with RT and CRT was a significant prognostic factor for LRFFS, and surgery with CTx was a significant prognostic factor for DMFS, and surgery with CTx, RT, and CRT was a significant prognostic factor for PFS (p < 0.05). Surgery with CTx and CRT showed association with superior OS (p < 0.05), and surgery with RT had marginal significance (p=0.078). In multivariate analysis of the R1 resection patients, surgery with CRT showed significant association with OS (p < 0.05). Conclusion Adjuvant RT and CTx may be helpful in improving clinical outcomes of patients with resected EHBDC who have a high risk of disease recurrence, particularly R1 resection patients. Conduct of additional prospective, larger-scale studies will be required in order to confirm the benefit of adjuvant RT and CTx in these patients.
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Affiliation(s)
- Jung Ho Im
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Jung Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Ran Park
- Department of Radiation Oncology, Ewha Womans University Medical Center, Seoul, Korea
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Jia AY, Wu JX, Zhao YT, Li YX, Wang Z, Rong WQ, Wang LM, Jin J, Wang SL, Song YW, Liu YP, Ren H, Fang H, Wang WQ, Liu XF, Yu ZH, Wang WH. Intensity-modulated radiotherapy following null-margin resection is associated with improved survival in the treatment of intrahepatic cholangiocarcinoma. J Gastrointest Oncol 2015; 6:126-33. [PMID: 25830032 DOI: 10.3978/j.issn.2078-6891.2014.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The current study is the first to examine the effectiveness and toxicity of postoperative intensity-modulated radiotherapy (IMRT) in the treatment of intrahepatic cholangiocarcinoma (ICC) abutting the vasculature. Specifically, we aim to assess the role of IMRT in patients with ICC undergoing null-margin (no real resection margin) resection. METHODS Thirty-eight patients with ICC adherent to major blood vessels were included in this retrospective study. Null-margin resection was performed on all patients; 14 patients were further treated with IMRT. The median radiation dose delivered was 56.8 Gy (range, 50-60 Gy). The primary endpoints were overall survival (OS) and disease-free survival (DFS). RESULTS At a median follow-up of 24.6 months, the median OS and DFS of all patients (n=38) were 17.7 months (95% CI, 13.2-22.2) and 9.9 months (95% CI, 2.8-17.0), respectively. Median OS was 21.8 months (95% CI, 15.5-28.1) among the 14 patients in the postoperative IMRT group and 15.0 months (95% CI, 9.2-20.9) among the 24 patients in the surgery-only group (P=0.049). Median DFS was 12.5 months (95% CI, 6.8-18.2) in the postoperative IMRT group and 5.5 months (95% CI, 0.7-12.3) in the surgery-only group (P=0.081). IMRT was well-tolerated. Acute toxicity included one case of Grade 3 leukopenia; late toxicity included one case of asymptomatic duodenal ulcer discovered through endoscopy. CONCLUSIONS The study results suggest that postoperative IMRT is a safe and effective treatment option following null-margin resections of ICC. Larger prospective and randomized trials are necessary to establish postoperative IMRT as a standard practice for the treatment of ICC adherent to major hepatic vessels.
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Affiliation(s)
- Angela Y Jia
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Jian-Xiong Wu
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Yu-Ting Zhao
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Ye-Xiong Li
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Zhi Wang
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Wei-Qi Rong
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Li-Ming Wang
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Jing Jin
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Shu-Lian Wang
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Yong-Wen Song
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Yue-Ping Liu
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Hua Ren
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Hui Fang
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Wen-Qing Wang
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Xin-Fan Liu
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Zi-Hao Yu
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
| | - Wei-Hu Wang
- 1 Department of Medicine, Weill Cornell Medical College, New York City, NY, USA ; 2 Department of Abdominal Surgery, 3 Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100021, China
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Segura-López FK, Güitrón-Cantú A, Torres J. Association between Helicobacter spp. infections and hepatobiliary malignancies: a review. World J Gastroenterol 2015; 21:1414-23. [PMID: 25663761 PMCID: PMC4316084 DOI: 10.3748/wjg.v21.i5.1414] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 10/29/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatobiliary cancers are highly lethal cancers that comprise a spectrum of invasive carcinomas originating in the liver hepatocellular carcinoma, the bile ducts intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, the gallbladder and the ampulla of Vater (collectively known as biliary tract cancers). These tumors account for approximately 13% of all annual cancer-related deaths worldwide and for 10%-20% of deaths from hepatobiliary malignancies. Cholangiocarcinoma (CCA) is a devastating disease that displays a poor survival rate for which few therapeutic options are available. Population genetics, geographical and environmental factors, cholelithiasis, obesity, parity, and endemic infection with liver flukes have been identified as risk factors that influence the development of biliary tract tumors. Other important factors affecting the carcinogenesis of these tumors include chronic inflammation, obstruction of the bile ducts, and impaired bile flow. It has been suggested that CCA is caused by infection with Helicobacter species, such as Helicobacter bilis and Helicobacter hepaticus, in a manner that is similar to the reported role of Helicobacter pylori in distal gastric cancer. Due to the difficulty in culturing these Helicobacter species, molecular methods, such as polymerase chain reaction and sequencing, or immunologic assays have become the methods of choice for diagnosis. However, clinical studies of benign or malignant biliary tract diseases revealed remarkable variability in the methods and the findings, and the use of uniform and validated techniques is needed.
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Kim SW, Lim DH, Park HC, Park W, Park JO, Park YS. Salvage Radiation Therapy for Isolated Local Recurrence of Extrahepatic Cholangiocarcinoma After Radical Surgery: A Retrospective Study. Ann Surg Oncol 2014; 22:1308-14. [DOI: 10.1245/s10434-014-4146-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Indexed: 12/12/2022]
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Phosphorylated Akt Expression as a Favorable Prognostic Factor for Patients Undergoing Curative Resection and Adjuvant Chemoradiotherapy for Proximal Extrahepatic Bile Duct Cancer. Am J Clin Oncol 2014; 40:158-162. [PMID: 25171299 DOI: 10.1097/coc.0000000000000121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the prognostic significance of phosphorylated Akt (p-Akt), phosphorylated mammalian target of rapamycin (p-mTOR), and total phosphatase and tensin homolog deleted on chromosome 10 (PTEN) expressions in patients undergoing adjuvant chemoradiotherapy (CRT) for proximal extrahepatic bile duct (EHBD) cancer. METHODS Sixty-three patients with proximal EHBD cancer who underwent curative resection followed by adjuvant CRT were enrolled into this study. Postoperative radiotherapy was delivered to tumor bed and regional lymph nodes up to a median of 40 Gy (range, 40 to 54 Gy). Fifty-nine patients also received fluoropyrimidine chemotherapy as a radiosensitizer. p-Akt, p-mTOR, and PTEN expression were assessed with immunohistochemical staining on the tissue microarray. RESULTS p-Akt, p-mTOR, and PTEN were expressed in 23 (36.5%), 17 (27.0%), and 24 patients (38.1%), respectively. p-Akt expression was associated with distant metastasis and overall survival (OS), but not with locoregional recurrence. The 5-year distant metastasis-free and OS rates were 25.8% versus 58.2% (P=0.007), and 27.5% versus 50.2% (P=0.0167) in patients with negative and positive expression, respectively. On multivariate analysis, nodal involvement was the only significant prognosticator predicting inferior distant metastasis-free survival (P=0.0105), whereas p-Akt expression had a borderline significance (P=0.0541). As for OS, p-Akt expression was a marginally significant prognosticator (P=0.0635), whereas other risk factors lost the statistical significance. CONCLUSION p-Akt expression tended to be associated with a favorable prognosis in patients undergoing curative resection followed by adjuvant CRT for proximal EHBD cancer.
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Yang H, Zhou J, Wei X, Wang F, Zhao H, Li E. Survival outcomes and progonostic factors of extrahepatic cholangiocarcinoma patients following surgical resection: Adjuvant therapy is a favorable prognostic factor. Mol Clin Oncol 2014; 2:1069-1075. [PMID: 25279199 DOI: 10.3892/mco.2014.377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 07/29/2014] [Indexed: 12/19/2022] Open
Abstract
This study was conducted to investigate survival and prognostic factors for extrahepatic cholangiocarcinoma (ECC) following surgical resection and evaluate the effects of postoperative adjuvant therapy (AT) on overall survival (OS). We retrospectively collected clinical and pathological data between March, 2008 and December, 2013. The Kaplan-Meier method and the COX regression model were used to evaluate the OS and prognostic factors of 105 postoperative ECC patients, of whom 32 had received AT. The patients were stratified into seven risk subgroups and the survival rates were compared within each subgroup between patients who received AT and those who did not. The results demonstrated a median OS of 17.6 months, with 1- and 3-year survival rates of 67.9 and 19.5%, respectively, for the entire cohort. On univariate analysis, preoperative cholangitis, non-R0 surgical margins, poor differentiation grade, stage 3/4 and lymphatic metastasis were identified as adverse prognostic factors. AT was not significantly associated with improved OS. However, the subgroup analysis revealed that the effect of AT was significant only in the lymphatic metastasis group (median OS, 21.6 vs. 10.4 months; and 3-year OS, 16.6 vs. 0%, respectively; P=0.02). The survival curves of the AT and non-AT groups were significantly different only for node-positive patients. The COX regression model identified lymphatic metastasis, surgical margins and AT as independent prognostic factors for ECC. A negative resection margin may reduce the mortality rate following surgery by 47%. By contrast, lymph node metastasis was associated with a 2.18-fold higher mortality rate for ECC patients. Postoperative AT contributed to a 0.45-fold mortality rate compared to non-AT ECC patients. Therefore, we concluded that AT is a favorable prognostic factor for ECC patients and it may prolong the survival of patients with lymphatic metastasis. Our data suggest that postoperative AT should be recommended for node-positive ECC patients.
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Affiliation(s)
- Haixia Yang
- Department of Medical Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Jiupeng Zhou
- Department of Medical Oncology, Sengong Hospital of Shaanxi, Xi'an, Shaanxi 710300, P.R. China
| | - Xin Wei
- Department of Medical Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Fan Wang
- Department of Pediatrics, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Huadong Zhao
- Department of General Surgery, Tangdu Hospital, Xi'an, Shaanxi 710038, P.R. China
| | - Enxiao Li
- Department of Medical Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
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Williams TM, Majithia L, Wang SJ, Thomas CR. Defining the Role of Adjuvant Therapy: Cholangiocarcinoma and Gall Bladder Cancer. Semin Radiat Oncol 2014; 24:94-104. [DOI: 10.1016/j.semradonc.2014.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Im JH, Seong J, Lee J, Kim YB, Lee IJ, Park JS, Yoon DS, Kim KS, Lee WJ. Postoperative radiotherapy dose correlates with locoregional control in patients with extra-hepatic bile duct cancer. Radiat Oncol J 2014; 32:7-13. [PMID: 24724046 PMCID: PMC3977131 DOI: 10.3857/roj.2014.32.1.7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 01/13/2014] [Accepted: 02/13/2014] [Indexed: 12/21/2022] Open
Abstract
Purpose To evaluate the results of postoperative radiotherapy in patients with extra-hepatic bile duct cancer (EHBDC) and identify the prognostic factors for local control and survival. Materials and Methods Between January 2001 and December 2010, we retrospectively reviewed the cases of 70 patients with EHBDC who had undergone curative resection and received postoperative radiotherapy. The median radiation dose was 50.4 Gy (range, 41.4 to 54 Gy). The resection margin status was R0 in 30 patients (42.9%), R1 in 25 patients (35.7%), and R2 in 15 patients (21.4%). Results The 5-year rates of overall survival (OS), event-free survival (EFS), and locoregional control (LRC) for all patients were 42.9%, 38.3%, and 61.2%, respectively. The major pattern of failure was distant relapses (33 patients, 47.1%). A multivariate analysis showed that the postradiotherapy CA19-9 level, radiation dose (≥50 Gy), R2 resection margins, perineural invasion, and T stage were the significant prognostic factors for OS, EFS, and LRC. OS was not significantly different between the patients receiving R0 and R1 resections, but was significantly lower among those receiving R2 resection (54.6%, 56.1%, and 7.1% for R0, R1, and R2 resections, respectively). Conclusion In patients with EHBDC who had undergone curative resection, a postoperative radiotherapy dose less than 50 Gy was suboptimal for OS and LRC. Higher radiation doses may be needed to obtain better LRC. Further investigation of novel therapy or palliative treatment should be considered for patients receiving R2 resection.
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Affiliation(s)
- Jung Ho Im
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongshim Lee
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Sung Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Jung Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Lee SJ, Kwon W, Kang MJ, Jang JY, Chang YR, Jung W, Kim SW. Clinical features and survival outcome of locally advanced extrahepatic cholangiocarcinoma. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2014; 18:1-8. [PMID: 26155239 PMCID: PMC4492336 DOI: 10.14701/kjhbps.2014.18.1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 10/10/2013] [Accepted: 10/30/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUNDS/AIMS Little is known about clinical features and survival outcome in locally advanced unresectable extrahepatic cholangiocarcinoma (EHC). The aim was to investigate the clinical features and the survival outcome in these patients, and to evaluate the role of palliative resections in locally advanced unresectable EHC. METHODS Between 1995 and 2007, 280 patients with locally advanced unresectable EHC were identified. Clinical, pathologic, and survival data were investigated. A comparative analysis was done between those who received palliative resection (PR) and those who were not operated on (NR). RESULTS The overall median survival of the study population was 10±1 months, and the 3- and 5-year survival rates (YSR) were 8.5% and 2.5%, respectively. The median survival, 3- and 5-YSR of PR were 23 months, 32.1% and 13.1%, respectively. For NR, they were 9 months, 3.9% and 0%, which were significantly worse than PR (p<0.001). In univariate analysis, T classification, N classification, tumor location, palliative resection, adjuvant treatment, chemotherapy, and radiation therapy were factors that showed survival difference between PR and NR. Regional lymph node metastasis (RR, 2.084; 95% CI, 1.491-2.914; p<0.001), non-resections (RR, 2.270; 95% CI, 1.497-3.443; p<0.001), and no chemotherapy (RR, 1.604; 95% CI, 1.095-2.349; p=0.015) were identified as risk factors for poor outcome on multivariate analysis. CONCLUSIONS Without evidence of systemic disease, palliative resection may provide some survival benefit in selected locally advanced unresectable EHCs and adjuvant treatment may further improve survival outcome.
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Affiliation(s)
- Sang-Jae Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Mee Joo Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ye Rim Chang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Woohyun Jung
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Yoshioka Y, Ogawa K, Oikawa H, Onishi H, Uchida N, Maebayashi T, Kanesaka N, Tamamoto T, Asakura H, Kosugi T, Hatano K, Yoshimura M, Yamada K, Tokumaru S, Sekiguchi K, Kobayashi M, Soejima T, Isohashi F, Nemoto K, Nishimura Y. Factors influencing survival outcome for radiotherapy for biliary tract cancer: a multicenter retrospective study. Radiother Oncol 2014; 110:546-52. [PMID: 24560766 DOI: 10.1016/j.radonc.2014.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE To seek for the possible factors influencing overall survival (OS) with radiotherapy (RT) for biliary tract cancer. MATERIALS AND METHODS Data were collected retrospectively from RT database of 31 institutions in Japan. All patients underwent at least external beam RT. The factors influencing OS were investigated. RESULTS Data of 498 patients were analyzed. Median OS of the 212 patients who underwent surgery was significantly better than that of the 286 patients without surgery (31 vs. 15 months, p<0.001). The OS for the R0 or R1 resection group was significantly longer than that for the R2 or non-surgery group, as well as for n0 compared to n1 (all p<0.001). Chemoradiotherapy (CRT), both sequential and concurrent, resulted in a better OS than RT alone for the n1 group (31 vs. 13 months, p<0.001), and marginally better for the R0/R1 group (p=0.065; p=0.054 for concurrent CRT). However, no such benefit was observed for the R2/non-surgical patients. Multivariate analysis identified performance status, clinical stage, and surgery as significant factors. CONCLUSION Surgery, especially R0/R1 resection, seemed as the gold standard for treatment of biliary tract cancer including RT, even in the highly heterogeneous population obtained from the multicenter retrospective study. The possibility was shown that CRT yielded better survival benefit especially for n1 patients. We recommend that future prospective trials include an arm of adjuvant CRT at least for n1 and possibly R0/R1 patients.
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Affiliation(s)
- Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan.
| | | | | | - Nobue Uchida
- Department of Radiation Oncology, Shimane University, Japan
| | - Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Naoto Kanesaka
- Department of Radiology, Tokyo Medical University, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University of Medicine, Japan
| | | | - Takashi Kosugi
- Department of Radiology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Kazuo Hatano
- Department of Radiation Oncology, Chiba Cancer Center, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, Japan
| | - Kazunari Yamada
- Department of Radiation Oncology, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Sunao Tokumaru
- Department of Heavy Particle Therapy and Radiation Oncology, Saga University, Japan
| | - Kenji Sekiguchi
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Masao Kobayashi
- Department of Radiology, Jikei University School of Medicine, Tokyo, Japan
| | | | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Kenji Nemoto
- Department of Radiation Oncology, Yamagata University, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Kinki University Faculty of Medicine, Osaka, Japan
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Song C, Kim K, Chie EK, Kim JH, Jang JY, Kim SW, Han SW, Oh DY, Im SA, Kim TY, Bang YJ, Ha SW. Nomogram prediction of survival and recurrence in patients with extrahepatic bile duct cancer undergoing curative resection followed by adjuvant chemoradiation therapy. Int J Radiat Oncol Biol Phys 2013; 87:499-504. [PMID: 24074923 DOI: 10.1016/j.ijrobp.2013.06.2041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 05/30/2013] [Accepted: 06/14/2013] [Indexed: 01/04/2023]
Abstract
PURPOSE To develop nomograms for predicting the overall survival (OS) and relapse-free survival (RFS) in patients with extrahepatic bile duct cancer undergoing adjuvant chemoradiation therapy after curative resection. METHODS AND MATERIALS From January 1995 through August 2006, a total of 166 consecutive patients underwent curative resection followed by adjuvant chemoradiation therapy. Multivariate analysis using Cox proportional hazards regression was performed, and this Cox model was used as the basis for the nomograms of OS and RFS. We calculated concordance indices of the constructed nomograms and American Joint Committee on Cancer (AJCC) staging system. RESULTS The OS rate at 2 years and 5 years was 60.8% and 42.5%, respectively, and the RFS rate at 2 years and 5 years was 52.5% and 38.2%, respectively. The model containing age, sex, tumor location, histologic differentiation, perineural invasion, and lymph node involvement was selected for nomograms. The bootstrap-corrected concordance index of the nomogram for OS and RFS was 0.63 and 0.62, respectively, and that of AJCC staging for OS and RFS was 0.50 and 0.52, respectively. CONCLUSIONS We developed nomograms that predicted survival and recurrence better than AJCC staging. With caution, clinicians may use these nomograms as an adjunct to or substitute for AJCC staging for predicting an individual's prognosis and offering tailored adjuvant therapy.
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Affiliation(s)
- Changhoon Song
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
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