Survival analysis of intrahepatic cholangiocarcinoma after resection

The significance of resection margins on R0 results in intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma is the second most common primary liver cancer after hepatocellular carcinoma with an increasing incidence worldwide. Surgical resection is still the only potential cure, and survival rates are dismal due to disease relapse after resection and/or metastatic disease. Positive resection margins are associated with recurrence, with conflicting studies regarding the benefits of wide resection margins to reduce recurrence rates.

METHODS

126 patients with an R0 resection treated with hepatic surgery for intrahepatic cholangiocarcinoma at the Surgical Department at the Medical University Centre Essen, Germany were identified in a database and retrospectively analysed. Patients were grouped into three groups according to margin width, <1 mm (very narrow margin width) 1-5 mm (narrow margin width) and >5 mm (wide margin width). Epidemiological as well as perioperative data was analysed, and a univariate analysis as well as Kaplan-Meier plots carried out to investigate recurrence-free and overall survival.

RESULTS

Wider resection margins did not lead to better recurrence-free survival. A wider resection margin >5 mm was not significantly associated with improved overall survival. Positive lymph nodes (HR 2.50, 95% CI 1.11-5.61, p=0.027) and non-anatomic resections (HR 2.06, 95% CI 1.13-3.75, p=0.019) are significantly associated with poorer overall survival. Regarding recurrence-free survival, V2 vascular invasion was the only risk factor statistically significantly associated with poorer recurrence-free survival (HR 8.83, 95% CI 0.85-2.83, p=0.005).

CONCLUSION

Resection margins did not have a significant impact on disease free survival or overall survival following hepatic resection for intrahepatic cholangiocarcinoma. Non-anatomical resections, lymph node and vascular invasion all significantly impacted oncological outcomes.

HBV infection effects prognosis and activates the immune response in intrahepatic cholangiocarcinoma

BACKGROUND

The impact of HBV infection on the prognosis of patients with intrahepatic cholangiocarcinoma (ICC) remains uncertain, and the underlying mechanism has not been elucidated. This study aims to explore the potential mechanism via clinical perspectives and immune features.

METHODS

We retrospectively reviewed 1308 patients with ICC treated surgically from January 2007 to January 2015. Then, we compared immune-related markers using immunohistochemistry staining to obtain the gene expression profile GSE107943 and related literature for preliminary bioinformatics analysis. Subsequently, we conducted a drug sensitivity assay to validate the role of TNFSF9 in the ICC organoid-autologous immune cell coculture system and in the patient-derived organoids-based xenograft platform.

RESULTS

The analysis revealed that tumors in patients without HBV infection exhibited greater size and a higher likelihood of lymphatic metastasis, tumor invasion, and relapse. After resection, HBV-infected patients had longer survival time than uninfected patients (p<0.01). Interestingly, the expression of immune-related markers in HBV-positive patients with ICC was higher than that in uninfected patients (p<0.01). The percentage of CD8+ T cells in HBV-positive tissue was higher than that without HBV infection (p<0.05). We screened 21 differentially expressed genes and investigated the function of TNFSF9 through bioinformatics analyses. The expression of TNFSF9 in ICC organoids with HBV infection was lower than that in organoids without HBV infection. The growth of HBV-negative ICC organoids was significantly inhibited by inhibiting the expression of TNFSF9 with a neutralizing antibody. Additionally, the growth rate was faster in HbsAg (-) ICC patient-derived organoids-based xenograft model than in HbsAg (+) group.

CONCLUSIONS

The activation of the immune response induced by HBV infection makes the prognosis of HBV-positive patients with ICC differ from that of uninfected patients.

Development of a nomogram to predict survival in advanced biliary tract cancer

The prognosis of advanced biliary tract cancer (BTC) patients remains poor due to limited efficacy of chemotherapy and difficulties in management. Thus, prediction of survival is crucial for the clinical management of advanced BTC. The aim was to develop and validate a nomogram to predict 6-month and 12-month survival in advanced BTC patients treated with chemotherapy. A multivariable Cox regression model was used to construct a nomogram in a training set (JCOG1113, a phase III trial comparing gemcitabine plus S-1 [GS] and gemcitabine plus cisplatin, n = 351). External validity of the nomogram was assessed using a test set (JCOG0805, a randomized, phase II trial comparing GS and S-1 alone, n = 100). Predictive performance was assessed in terms of discrimination and calibration. The constructed nomogram included lymph node metastasis, liver metastasis, carbohydrate antigen 19-9, carcinoembryonic antigen, albumin, and C-reactive protein. Uno's concordance index was 0.661 (95% confidence interval [CI] 0.629-0.696) in the training set and 0.640 (95% CI 0.566-0.715) in the test set. The calibration plots for 6-month and 12-month survival showed good agreement in the two analysis sets. The present nomogram can facilitate prediction of the prognosis of advanced BTC patients treated with chemotherapy and help clinicians' prognosis-based decision-making.

Influence of surgical margin width on survival rate after resection of intrahepatic cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVES

Hepatectomy is the best treatment for patients with intrahepatic cholangiocarcinoma (ICC) at present, but there has been controversy about the width of surgical margins. In this study, we systematically investigated the effects of different surgical margin widths on the prognosis of patients with ICC undergoing hepatectomy.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase and Web of Science databases were systematically searched from inception to June 2022.

ELIGIBILITY CRITERIA

Cohort studies reported in English with patients who underwent negative marginal (R0) resection were included. The effects of surgical margin width on overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS) in patients with ICC were assessed.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently conducted literature screening and data extraction. Risk of bias was assessed using funnel plots and quality was assessed by the Newcastle-Ottawa Scale. Forest plots of HRs and their 95% CIs for outcome indicators were plotted. Heterogeneity was assessed and determined quantitatively using I², and the stability of the study results was evaluated using sensitivity analysis. Analyses were performed using Stata software.

RESULTS

Nine studies were included. With the wide margin group (≥10 mm) as the control, pooled HR of OS in the narrow margin group (<10 mm) was 1.54 (95% CI 1.34 to 1.77). HRs of OS in three subgroups where the margin was less than 5 mm ranged from 5 mm to 9 mm, or was less than 10 mm in length were 1.88 (1.45 to 2.42), 1.33 (1.03 to 1.72) and 1.49 (1.20 to 1.84), respectively. Pooled HR of DFS in the narrow margin group (<10 mm) was 1.51 (1.14 to 2.00). Pooled HR of RFS in the narrow margin group (<10 mm) was 1.35 (1.19 to 1.54). HRs of RFS in three subgroups where the margin was less than 5 mm ranged from 5 mm to 9 mm, or was less than 10 mm in length were 1.38 (1.07 to 1.78), 1.39 (1.11 to 1.74) and 1.30 (1.06 to 1.60), respectively. Neither lymph node lesions (HR 1.44, 95% CI 1.22 to 1.70) nor lymph node invasion (2.14, 1.39 to 3.28) was favourable for postoperative OS in patients with ICC. Lymph node metastasis (1.31, 1.09 to 1.57) was unfavourable for RFS in patients with ICC.

CONCLUSION

Patients with ICC who underwent curative hepatectomy with a negative margin ≥10 mm may have a long-term survival advantage, but lymph node dissection also needs to be considered. In addition, tumour-related pathological features need to be explored to see if they affect the surgical outcome of R0 margins.

Prognostic Role of the Intrahepatic Lymphatic System in Liver Cancer

Although several prognosticators, such as lymph node metastasis (LNM), were reported for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), the prognostic impact of intrahepatic lymphatic vessel invasion (LVI) in liver cancer has rarely been reported. We sought to clarify the prognostic impact of intrahepatic lymphatic system involvement in liver cancer. We systematically reviewed retrospective studies that described LVI and clinical outcomes of liver cancer and also included studies that investigated tumor-associated lymphangiogenesis. We conducted a meta-analysis using RevMan software (version 5.4.1; Cochrane Collaboration, Oxford, UK). The prognostic impact of intrahepatic LVI in HCC was not reported previously. However, tumor-associated lymphangiogenesis reportedly correlates with prognosis after HCC resection. The prognostic impact of intrahepatic LVI was reported severally for ICC and a meta-analysis showed that overall survival was poorer in patients with positive LVI than with negative LVI after resection of ICC. Lymphangiogenesis was also reported to predict unfavorable prognosis in ICC. Regarding colorectal liver metastases, LVI was identified as a poor prognosticator in a meta-analysis. A few reports showed correlations between LVI/lymphangiogenesis and LNM in liver cancer. LVI and lymphangiogenesis showed worse prognostic impacts for liver cancer than their absence, but further study is needed.

Major complications and mortality after resection of intrahepatic cholangiocarcinoma: A systematic review and meta-analysis

BACKGROUND

Evaluation of morbidity and mortality after hepatic resection often lacks stratification by extent of resection or diagnosis. Although a liver resection for different indications may have technical similarities, postoperative outcomes differ. The aim of this systematic review and meta-analysis was to determine the risk of major complications and mortality after resection of intrahepatic cholangiocarcinoma.

METHODS

Meta-analysis was performed to assess postoperative mortality (in-hospital, 30-, and 90-day) and major complications (Clavien-Dindo grade ≥III).

RESULTS

A total of 32 studies that reported on 19,503 patients were included. Pooled in-hospital, 30-day, and 90-day mortality were 5.9% (95% confidence interval 4.1-8.4); 4.6% (95% confidence interval 4.0-5.2); and 6.1% (95% confidence interval 5.0-7.3), respectively. Pooled proportion of major complications was 22.2% (95% confidence interval 17.7-27.5) for all resections. The pooled 90-day mortality was 3.1% (95% confidence interval 1.8-5.2) for a minor resection, 7.4% (95% confidence interval 5.9-9.3) for all major resections, and 11.4% (95% confidence interval 6.9-18.7) for extended resections (P = .001). Major complications were 38.8% (95% confidence interval 29.5-49) after a major hepatectomy compared to 11.3% (95% confidence interval 5.0-24.0) after a minor hepatectomy (P = .001). Asian studies had a pooled 90-day mortality of 4.4% (95% confidence interval 3.3-5.9) compared to 6.8% (95% confidence interval 5.6-8.2) for Western studies (P = .02). Cohorts with patients included before 2000 had a pooled 90-day mortality of 5.9% (95% confidence interval 4.8-7.3) compared to 6.8% (95% confidence interval 5.1-9.1) after 2000 (P = .44).

CONCLUSION

When informing patients or comparing outcomes across hospitals, postoperative mortality rates after liver resection should be reported for 90-days with consideration of the diagnosis and the extent of liver resection.

The influence of resection margin width in patients with intrahepatic cholangiocarcinoma: a meta-analysis

BACKGROUND

Some studies have pointed out that a wide resection margin can improve the prognosis of intrahepatic cholangiocarcinoma, but some researchers disagree and believe that a wide margin may increase complications. The optimal margin length of intrahepatic cholangiocarcinoma is controversial.

METHOD

The literature was searched in PubMed, MedLine, Embase, the Cochrane Library, and Web of Science until December 31, 2021, to evaluate the postoperative outcomes of patients with different margin width after resection. Odds ratios (ORs) with 95% confidence intervals were used to determine the effect size.

RESULT

A total of 11 articles were included in this meta-analysis, including 3007 patients. The narrow group had significantly lower 1-, 3-, and 5-year overall survival rates and recurrence-free survival rates than the wide group. Postoperative morbidity and prognostic factors were also evaluated.

CONCLUSION

A resection margin width of over 10 mm is recommended in intrahepatic cholangiocarcinoma patients, especially in patients with negative lymph node and early tumor stage. When the resection margin width cannot be greater than 10 mm, we should ensure that the resection margin width is greater than 5 mm.

The epidemiological trends of biliary tract cancers in the United States of America

BACKGROUND

Biliary tract cancers (BTCs) are a series of heterogeneous malignancies that are broadly grouped based on the anatomical site where they arise into subtypes including intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), gallbladder cancer (GBC), and ampulla of Vater cancer (AVC).

METHODS AND RESULTS

The present study provides an overview of the epidemiology of the various BTCs based on data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2018. Distinct differences in both incidence and mortality rates were observed for these BTCs as a function of age, sex, ethnicity, and calendar year. In 2018, BTCs emerged as the fifth most prevalent form of alimentary tract cancer in the USA. While the incidence and mortality of ICC appear to be increasing, the incidence rates of GBC, ECC, and AVC have remained stable, as have the corresponding mortality rates. The most common and deadliest BTCs in 2018 were ICC and GBC among males and females, respectively. The ethnic groups exhibiting the highest incidence rates of these different BTCs were American Indians and Alaska Natives for GBC, and Asian and Pacific Islanders for ICC, ECC, and AVC. The incidence of all of these forms of BTC rose with age. There were some variations in BTCs in terms of staging, locoregional surgical treatments, adjuvant therapies, and prognostic outcomes from 2000 to 2018.

CONCLUSIONS

The epidemiological characteristics, staging, locoregional surgical treatments, adjuvant therapies, and prognostic outcomes were distinct for each of these BTCs.

Neoadjuvant and Adjuvant Therapy in Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer and causes major economic and health burdens throughout the world. Although the incidence of ICC is relatively low, an upward trend has been seen over the past few decades. Owing to the lack of specific manifestations and tools for early diagnosis, most ICC patients have relatively advanced disease at diagnosis. Thus, neoadjuvant therapy is necessary to evaluate tumor biology and downstage these patients so that appropriate candidates can be selected for radical liver resection. However, even after radical resection, the recurrence rate is relatively high and is a main cause leading to death after surgery, which makes adjuvant therapy necessary. Because of its low incidence, studies in both neoadjuvant and adjuvant settings of ICC are lagging compared with other types of malignancy. While standard neoadjuvant and adjuvant regimens are not available in the current guidelines due to a lack of high-level evidence, some progress has been achieved in recent years. In this review, the available literature on advances in neoadjuvant and adjuvant strategies in ICC are evaluated, and possible challenges and opportunities for clinical and translational investigations in the near future are discussed.

Prognostic impact of tumor vascularity on CT in resectable intrahepatic cholangiocarcinoma

BACKGROUND

We investigated the vascularity of intrahepatic cholangiocarcinoma (ICC) on computed tomography (CT) images and its association with ICC recurrence after surgery and prognosis after recurrence.

METHODS

In this retrospective study, the data of patients who underwent resection with curative intent for ICC between March 2001 and July 2017 were reviewed. Clinicopathologic factors including tumor vascularity (hypovascular, rim-enhancement, and hypervascular) on CT that could affect recurrence-free survival (RFS) were assessed. The association between the vascularity of recurrent ICC and survival after recurrence was also analyzed.

RESULTS

Overall, 147 patients were enrolled and followed up for a median of 36.1 months of which, 101 (68.7%) experienced ICC recurrence. Hypervascularity of ICC showed better RFS than other vascularities [rim-enhanced image hazard ratio (HR), 3.893; 95% confidence interval (CI), 1.700-8.915, p = 0.001; hypovascular image HR, 6.241; 95% CI, 2.670-14.586, p < 0.001]. The hypervascular recurrent ICC was also significantly associated with better survival after recurrence (log-rank test, p < 0.001).

CONCLUSION

Hypervascular ICC was associated with a longer RFS and better prognosis after recurrence. The vascularity of ICC on CT may be a noninvasive, accessible, and useful prognostic index, and should be considered while planning treatment.

Prognostic value and predication model of microvascular invasion in patients with intrahepatic cholangiocarcinoma: a multicenter study from China

BACKGROUND

At present, hepatectomy is still the most common and effective treatment method for intrahepatic cholangiocarcinoma (ICC) patients. However, the postoperative prognosis is poor. Therefore, the prognostic factors for these patients require further exploration. Whether microvascular invasion (MVI) plays a crucial role in the prognosis of ICC patients is still unclear. Moreover, few studies have focused on preoperative predictions of MVI in ICC patients.

METHODS

Clinicopathological data of 704 ICC patients after curative resection were retrospectively collected from 13 hospitals. Independent risk factors were identified by the Cox or logistic proportional hazards model. In addition, the survival curves of the MVI-positive and MVI-negative groups before and after matching were analyzed. Subsequently, 341 patients from a single center (Eastern Hepatobiliary Hospital) in the above multicenter retrospective cohort were used to construct a nomogram prediction model. Then, the model was evaluated by the index of concordance (C-Index) and the calibration curve.

RESULTS

After propensity score matching (PSM), Child-Pugh grade and MVI were independent risk factors for overall survival (OS) in ICC patients after curative resection. Major hepatectomy and MVI were independent risk factors for recurrence-free survival (RFS). The survival curves of OS and RFS before and after PSM in the MVI-positive groups were significantly different compared with those in the MVI-negative groups. Multivariate logistic regression results demonstrated that age, gamma-glutamyl transpeptidase (GGT), and preoperative image tumor number were independent risk factors for the occurrence of MVI. Furthermore, the prediction model in the form of a nomogram was constructed, which showed good prediction ability for both the training (C-index = 0.7622) and validation (C-index = 0.7591) groups, and the calibration curve showed good consistency with reality.

CONCLUSION

MVI is an independent risk factor for the prognosis of ICC patients after curative resection. Age, GGT, and preoperative image tumor number were independent risk factors for the occurrence of MVI in ICC patients. The prediction model constructed further showed good predictive ability in both the training and validation groups with good consistency with reality.

Resectable intrahepatic and hilar cholangiocarcinoma: Is margin status associated with survival?

BACKGROUND

Prior studies evaluating the effect of margin status on clinical outcome in patients undergoing resection for intrahepatic and extrahepatic hilar cholangiocarcinoma include small numbers of patients with histologically positive margins. The value of margin negative resection in these cases remains unclear.

METHODS

We queried the National Cancer Database to identify patients undergoing resection for clinical stage I to III intrahepatic and extrahepatic hilar between 2004 and 2015. Patients receiving neoadjuvant therapy and those having <3 lymph nodes examined were excluded. Patients undergoing positive resection were 1:1 propensity matched to those undergoing negative resection. Kaplan-Meier methods were used to compare overall survival for the matched cohorts.

RESULTS

In the study, 3,618 patients met the inclusion criteria, and 3,018 (83.4%) underwent negative resection; 600 (16.6%) positive resection. Patients undergoing negative resection had smaller tumors (2.97 ± 0.07 cm vs 3.49 ± 0.15 cm), were less likely to have stage 3 disease (16.7% vs 25.7%) and to receive adjuvant radiation (27.1% vs 45.7%) and chemotherapy (49.4% vs 61.0%) than those undergoing positive resection (all P < .05). On comparison of matched cohorts, patients undergoing negative resection had longer median overall survival (24.5 ± 0.02 vs 19.1 ± 0.02 months) and higher rates of 5-year overall survival (24.5% vs 16.7%) than those undergoing positive resection (P < .01).

CONCLUSION

In patients presenting with resectable intrahepatic and extrahepatic hilar, negative resection is associated with improved overall survival. Extended resections performed in an effort to clear surgical margins are warranted in patients fit for such procedures.

Alterations in chemokine receptor CCR5 activity influence tumor cell biology in human cholangiocarcinoma cell lines

INTRODUCTION AND OBJECTIVES

Intrahepatic (I-CCA) and extrahepatic (E-CCA) cholangiocarcinoma (CCA) have different growth patterns and risks for tumor metastasis. Inhibition and/or activation of the chemokine receptor CCR subclasses have been reported to alter tumor cell biology in non-CCA cancers. In this study we documented CCR expression profiles in representative human I-CCA and E-CCA cell lines and the in vitro effects of CCR antagonists and agonists on tumor cell biology.

MATERIALS AND METHODS

CCR expression profiles were documented by real-time reverse transcription polymerase chain reaction; cell proliferation by WST-1; spheroid formation by sphere dimensions in anchorage-free medium; cell migration by wound healing and invasion by Transwell invasion chambers.

RESULTS

All 10 CCR motifs (CCR1-10) were expressed in the I-CCA, HuCCT1 cell line and six (CCR4, 5, 6, 8, 9 and 10) in the E-CCA, KMBC cell line. In HuCCT1 cells, CCR5 expression was most abundant whereas in KMBC cells, CCR6 followed by CCR5 were most abundant. The CCR5 antagonist Maraviroc significantly inhibited cell proliferation, migration and invasion in HuCCT1 cells, and spheroid formation and invasion in KMBC cells. The CCR5 agonist RANTES had no effect on HuCCT1 cells but increased cell proliferation, migration and invasion of KMBC cells.

CONCLUSION

These results suggest that CCR expression profiles differ in I-CCA and E-CCA. They also indicate that CCR5 antagonists and agonists have cell-specific effects but in general, CCR5 inactivation inhibits CCA tumor cell aggressiveness. Additional research is required to determine whether CCR5 inactivation is of value in the treatment of CCA in humans.

Association of KRAS Variant Subtypes With Survival and Recurrence in Patients With Surgically Treated Intrahepatic Cholangiocarcinoma

Question

What is the prevalence of KRAS variant subtypes and their association with survival and recurrence in patients with surgically treated intrahepatic cholangiocarcinoma (ICC)?

Findings

In this cohort study including 1024 patients, a total of 14 different subtypes of KRAS somatic variants affecting 127 patients with ICC (12.4%) were identified, including G12D (43.3%), G12V (19.7%), G12C (7.1%), and G13D (6.3%). G12 KRAS variants but not non-G12 KRAS variants were independently associated with worse overall and disease-free survival, and the G12V KRAS variant was the strongest prognostic determinant for the worst overall and disease-free survival.

Meaning

This cohort study characterized the distribution of KRAS variant subtypes in a large cohort of patients with ICC and showed an association with patient outcome.

Importance

KRAS variants are associated with tumor progression; however, the prevalence of KRAS variant subtypes and their association with survival and recurrence in patients with intrahepatic cholangiocarcinoma (ICC) after curative resection are largely unknown.

Objective

To explore the prognostic association of KRAS variant subtypes with survival and recurrence in patients with ICC.

Design, Setting, and Participants

In this cohort study, patients who underwent curative resection for ICC from January 2009 through December 2016 at a single hospital in China were recruited, and whole-exome sequencing, targeted sequencing, and Sanger sequencing were performed to identify KRAS variants. Kaplan-Meier and log-rank tests were used to compare overall survival (OS) and disease-free survival (DFS). Univariate and multivariate analyses were performed using the Cox proportional hazards regression model. Data were analyzed from April 2020 to January 2021.

Interventions

Hepatectomy in patients with ICC.

Main Outcomes and Measures

The association of KRAS variant subtypes with OS and DFS.

Results

Of 1024 included patients with ICC, 621 (60.6%) were male, and the mean (SD) age was 59.2 (10.2) years. A total of 14 different subtypes of KRAS somatic variants affecting 127 patients (12.4%) were identified. G12D was the most frequent allele in this cohort, accounting for 55 of 127 identified KRAS variants (43.3%), followed by G12V (25 [19.7%]), G12C (9 [7.1%]), and G13D (8 [6.3%]). Compared with patients with wild-type KRAS, patients with variant KRAS were more likely to have high levels of carbohydrate antigen 19-9 (92 of 127 [72.4%] vs 546 of 897 [60.9%]; P = .01) and γ-glutamyltransferase (72 of 127 [56.7%] vs 420 of 897 [46.8%]; P = .04). Multivariable analysis revealed that G12 KRAS variants but not non-G12 KRAS variants were independently associated with worse OS (hazard ratio [HR], 1.69; 95% CI, 1.31-2.18; P < .001) and DFS (HR, 1.47; 95% CI, 1.16-1.88; P = .002). Among the patients with G12 KRAS variants, the G12V KRAS variant was the strongest prognostic determinant for the worst OS (HR, 3.05; 95% CI, 1.94-4.79; P < .001) and DFS (HR, 1.79; 95% CI, 1.13-2.85; P = .01).

Conclusions and Relevance

In this cohort study, the distribution of KRAS variant subtypes was characterized in a large cohort of patients with ICC from China. The presence of G12 KRAS variants but not non-G12 KRAS variants was associated with worse survival and increased risk of recurrence. Patients with the G12V variant exhibited the worst outcomes in the whole cohort.

Diffuse reduction of spleen density is a novel prognostic marker for intrahepatic cholangiocarcinoma after curative resection

BACKGROUND

Diffuse reduction of spleen density (DROSD) is related to cancer prognosis; however, its role in intrahepatic cholangiocarcinoma (ICC) remains unclear.

AIM

To assess the predictive value of DROSD in the prognosis of ICC after curative resection.

METHODS

In this multicenter retrospective cohort study, we enrolled patients with ICC who underwent curative hepatectomy between 2012 and 2019. Preoperative spleen density was measured using computed tomography. Overall survival (OS) and recurrence-free survival (RFS) rates were calculated and compared utilizing the Kaplan–Meier method. Univariable and multivariable Cox regression analyses were applied to identify independent factors for OS and RFS. A nomogram was created with independent risk factors to predict prognosis of patients with ICC.

RESULTS

One hundred and sixty-seven ICC patients were enrolled. Based on the diagnostic cut-off values (spleen density ≤ 45.5 Hounsfield units), 55 (32.9%) patients had DROSD. Kaplan–Meier analysis indicated that patients with DROSD had worse OS and RFS than those without DROSD (P < 0.05). Cox regression analysis revealed that DROSD, carcinoembryonic antigen level, carbohydrate antigen 19-9 level, length of hospital stay, lymph node metastasis, and postoperative complications were independent predictors for OS (P < 0.05). The nomogram created with these factors was able to predict the prognosis of patients with ICC with good reliability (OS C-index = 0.733). The area under the curve for OS was 0.79.

CONCLUSION

ICC patients with DROSD have worse OS and RFS. The nomogram is a simple and practical method to identify high-risk ICC patients with poor prognosis.

Comparison of ICC patients with hepatitis B infection to those with no major risk factors for HCC

BACKGROUND

There has been renewed interest in HBV-associated ICC, because it could share a common carcinogenesis disease process with HCC. We investigated whether there is a difference in clinical outcome between ICC patients with HBV infection and those without any major risk factors for HCC.

METHODS

A total of 253 curatively resected, surgically diagnosed ICC patients were analyzed and divided into two groups according to the presence or absence of major risk factors for HCC: an HBV group (n = 45) and a non-HCC-risk (NHR) group (n = 208).

RESULTS

Lymph node metastasis was more frequently observed in the NHR group (HBV vs. NHR: 8.89% vs. 24.52%, P = 0.027). Patients in the HBV group demonstrated more favorable survival than those in the NHR group. However, this difference was not statistically significant (5-year survival rate, 54.7% vs. 42.3%, P = 0.128). Cumulative recurrence rate in the HBV group was 62.2%, which was not significantly different from 63.0% in the NHR group (P = 1.000).

CONCLUSION

This study found that while ICC patients with HBV infection showed some favorable tumor characteristics, patients' stage-specific survival and recurrence rates were not significantly different compared to those without any major risk factors for HCC.

Influence of Lymphangio (L), Vascular (V), and Perineural (Pn) Invasion on Recurrence and Survival of Resected Intrahepatic Cholangiocarcinoma

(1) Background: Intrahepatic cholangiocarcinoma (ICC) is a rare malignancy. Besides tumor, nodal, and metastatic status, the UICC TNM classification describes further parameters such as lymphangio- (L0/L1), vascular (V0/V1/V2), and perineural invasion (Pn0/Pn1). The aim of this study was to analyze the influence of these parameters on recurrence and survival. (2) Methods: All surgical explorations for patients with ICC between January 2008 and June 2018 were collected and further analyzed in our institutional database. Statistical analyses focused on perineural, lymphangio-, and vascular invasion examined histologically and their influence on tumor recurrence and survival. (3) Results: Of 210 patients who underwent surgical exploration, 150 underwent curative-intended resection. Perineural invasion was present in 41, lymphangioinvasion in 21, and vascular invasion in 37 patients (V1 n = 34, V2 n = 3). Presence of P1, V+ and L1 was significantly associated with positivity of each other of these factors (p < 0.001, each). None of the three parameters showed direct influence on tumor recurrence in general, but perineural invasion influenced extrahepatic recurrence significantly (p = 0.019). Whereas lymphangio and vascular invasion was neither associated with overall nor recurrence-free survival, perineural invasion was significantly associated with a poor 1-, 3- and 5-year overall survival (OS) of 80%, 35%, and 23% for Pn0 versus 75%, 23%, and 0% for Pn1 (p = 0.027). Concerning recurrence-free survival (RFS), Pn0 showed a 1-, 3- and 5-year RFS of 42%, 18%, and 16% versus 28%, 11%, and 0% for Pn1, but no significance was reached (p = 0.091). (4) Conclusions: Whereas lymphangio- and vascular invasion showed no significant influence in several analyses, the presence of perineural invasion was associated with a significantly higher risk of extrahepatic tumor recurrence and worse overall survival.

Postoperative adjuvant transarterial chemoembolization for intrahepatic cholangiocarcinoma patients with microvascular invasion: a propensity score analysis

Background

Microvascular invasion (MVI) is an independent risk factor associated with tumor recurrence and poor survival in patients with intrahepatic cholangiocarcinoma (ICC) after partial hepatectomy (PH). The potential impact of adjuvant TACE on the prognosis of patients with ICC involving MVI (ICC-MVI) remains uncertain. Our aim was to investigate the effectiveness of postoperative adjuvant transarterial chemoembolization (TACE) on ICC involving MVI.

Methods

Multicentric data consisted of 223 patients who underwent curative-intent PH for ICC-MVI from 2002-2015 were retrospectively analyzed. The impact of adjuvant TACE was evaluated using inverse probability of treatment weighting (IPTW) and propensity-score matched (PSM) analyses.

Results

No association between the TACE and the overall survival (OS) and recurrence rates was observed among the overall ICC-MVI patients. However, subgroup analyses revealed that adjuvant TACE favored OS (HR, 0.62; 95% CI, 0.39-0.99; P=0.047) and time to recurrence (TTR) (HR, 0.59; 95% CI, 0.36-0.97; P=0.037) among patients with elevated CA19-9 and those without lymphadenectomy (HR, 0.53; 95% CI, 0.30-0.93; P=0.027 for OS, and HR, 0.49; 95% CI, 0.28-0.87; P=0.015 for TTR, respectively). In the CA19-9 ≥39 U/L subgroup and Nx subgroup, adjuvant TACE was associated with higher 1-, 3-, and 5-year OS rates (P=0.033 and P=0.034, respectively) and lower corresponding recurrence rates (P=0.024 and P=0.023, respectively).

Conclusions

Among the ICC-MVI patients undergoing curative-intent PH, only those have elevated CA19-9 or who did not undergo lymphadenectomy might be suitable for adjuvant TACE.

Radiomics signature on dynamic contrast-enhanced MR images: a potential imaging biomarker for prediction of microvascular invasion in mass-forming intrahepatic cholangiocarcinoma

OBJECTIVE

To develop a radiomics signature based on dynamic contrast-enhanced (DCE) MR images for preoperative prediction of microvascular invasion (MVI) in patients with mass-forming intrahepatic cholangiocarcinoma (IMCC).

METHODS

One hundred twenty-six patients with surgically resected single IMCC (34 MVI-positive and 92 MVI-negative) were enrolled and allocated to training and validation cohorts (7:3 ratio). Findings of clinical characteristics and MR features were analyzed. A radiomics signature was built on the basis of reproducible features by using the least absolute shrinkage and selection operator (LASSO) regression algorithm in the training cohort. The prediction performance of radiomics signature was evaluated by receiver operating characteristics curve (ROC) analysis. Internal validation was performed on an independent cohort containing 38 patients.

RESULTS

Larger tumor size and higher radiomics score were positively correlated with MVI in both training cohort (p < 0.001, < 0.001, respectively) and validation cohort (p = 0.008, 0.001, respectively). The radiomics signature, consisting of seven wavelet features, showed optimal prediction performance in both training (AUC = 0.873) and validation cohorts (AUC = 0.850).

CONCLUSION

A radiomics signature derived from DCE-MRI of the liver can be a reliable imaging biomarker for predicting MVI of IMCC, which could aid in tailoring treatment strategies.

KEY POINTS

• The radiomics signature based on dynamic contrast-enhanced magnetic resonance imaging can be a useful tool to preoperatively predict MVI of IMCC. • Larger tumor size is positively correlated with MVI of IMCC.

A Novel Prognostic Scoring System of Intrahepatic Cholangiocarcinoma With Machine Learning Basing on Real-World Data

Background and Objectives

Currently, the prognostic performance of the staging systems proposed by the 8th edition of the American Joint Committee on Cancer (AJCC 8th) and the Liver Cancer Study Group of Japan (LCSGJ) in resectable intrahepatic cholangiocarcinoma (ICC) remains controversial. The aim of this study was to use machine learning techniques to modify existing ICC staging strategies based on clinical data and to demonstrate the accuracy and discrimination capacity in prognostic prediction.

Patients and Methods

This is a retrospective study based on 1,390 patients who underwent surgical resection for ICC at Eastern Hepatobiliary Surgery Hospital from 2007 to 2015. External validation was performed for patients from 2015 to 2017. The ensemble of three machine learning algorithms was used to select the most important prognostic factors and stepwise Cox regression was employed to derive a modified scoring system. The discriminative ability and predictive accuracy were assessed using the Concordance Index (C-index) and Brier Score (BS). The results were externally validated through a cohort of 42 patients operated on from the same institution.

Results

Six independent prognosis factors were selected and incorporated in the modified scoring system, including carcinoembryonic antigen, carbohydrate antigen 19-9, alpha-fetoprotein, prealbumin, T and N of ICC staging category in 8th edition of AJCC. The proposed scoring system showed a more favorable discriminatory ability and model performance than the AJCC 8th and LCSGJ staging systems, with a higher C-index of 0.693 (95% CI, 0.663–0.723) in the internal validation cohort and 0.671 (95% CI, 0.602–0.740) in the external validation cohort, which was then confirmed with lower BS (0.103 in internal validation cohort and 0.169 in external validation cohort). Meanwhile, machine learning techniques for variable selection together with stepwise Cox regression for survival analysis shows a better prognostic accuracy than using stepwise Cox regression method only.

Conclusions

This study put forward a modified ICC scoring system based on prognosis factors selection incorporated with machine learning, for individualized prognosis evaluation in patients with ICC.

Locoregional therapies in patients with recurrent intrahepatic cholangiocarcinoma after curative resection

BACKGROUND

Hepatectomy is one potential treatment for intrahepatic cholangiocarcinoma (IHCC). Recurrent rate is high after curative resection and most recurrences occur within residual liver parenchyma. The aim of this study was to elucidate the impact of different treatment modalities on recurrent diseases in patients with IHCC after primary liver resection.

METHODS

Between February 1999 and December 2015, we retrospectively identified patients who received curative resection for IHCC. Patients who experienced recurrences were included. Locoregional therapies included re-hepatectomy, radiofrequent ablation, and transhepatic arterial chemoembolization. These patients were categorized into three groups: intrahepatic recurrence without locoregional therapies (group A), intrahepatic recurrence with locoregional therapies (group B) and extrahepatic metastases (group C).

RESULTS

Forty-three patients were included and there were 12, 15, and 16 patients in groups A, B, and C, respectively. The median disease-free survival times were 8.3, 9.1, and 8.7 months in groups A, B, and C (p = 0.099). The median after-recurrence overall survival times (period between recurrence and death/censor) were 6.4, 34.0, and 8.3 months in groups A, B, and C (p = 0.001). Locoregional therapies showed favorable benefit in multivariant analysis (hazard ratio: 0.274, confidence interval: 0.083-0.908, p = 0.010).

CONCLUSION

Locoregional therapies offered favorable benefits for patients with recurrent intrahepatic cholangiocarcinoma.

Anti-EGFR Monoclonal Antibodies in Advanced Biliary Tract Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Despite several clinical trials and advances in understanding the genetic basis of biliary tract cancer (BTC), the addition of epidermal growth factor receptor (EGFR) targeted therapy does not seem to enhance the activity of first-line chemotherapy (CHT).

MATERIALS AND METHODS

We carried out a meta-analysis of available randomized clinical trials to assess the efficacy and safety of gemcitabine-based first-line CHT plus monoclonal antibodies against EGFR (EGFR-mAbs) in advanced or metastatic BTC.

RESULTS

In the overall population, the pooled hazard ratio for overall (OS) and progression-free (PFS) survival were 0.82 (95% confidence interval=0.64-1.06) and 0.88 (95% confidence intervaI=0.73-1.08), respectively. No differences were detected in objective response rate between the two groups. Patients treated with gemcitabine-based CHT plus EGFR-mAbs showed a statistically significant increased risk of grade 3-4 neutropenia, grade 3-4 thrombocytopenia and especially grade 3-4 skin rash.

CONCLUSION

The addition of EGFR-mAbs to gemcitabine-based first-line CHT does not significantly improve overall and progression-free survival, nor the objective response rate in patients with advanced BTC and increases the risk of hematological and cutaneous adverse drug events.

Combination of intraoperative radiofrequency ablation and surgical resection for treatment of cholangiocarcinoma: feasibility and long-term survival

PURPOSE Most patients with intrahepatic cholangiocarcinoma (ICC) are not eligible for surgical resection due to advanced stage. We aimed to evaluate the feasibility, local tumor control, and long-term survival of intraoperative radiofrequency ablation (IORFA) with surgical resection to treat unresectable intrahepatic cholangiocarcinoma (ICC). METHODS From 2009 to 2016, 20 consecutive patients (12 primary ICC, 8 recurrent ICC) underwent curative IORFA with hepatic resection for surgically unresectable ICC. Patients were not qualified to undergo surgical resection due to multiple lesions causing postoperative hepatic insufficiency and undesirable tumor locations for surgical resection or percutaneous RFA. Of the 51 treated tumors (mean, 2.6±0.9 tumors/patient), 24 were treated by IORFA and 27 were surgically removed. The technical success and effectiveness, overall survival, progression-free survival (PFS), and complications were assessed retrospectively. The overall survival and PFS rates were estimated by the Kaplan-Meier method. RESULTS The technical success and effectiveness of IORFA were 100%. The overall survival rates at 6 months, 1, 3, and 5 years were 95%, 79%, 27%, and 14%, respectively. The median overall survival time was 22.0±3.45 months. The PFS rates at 6 months, 1, 3, and 5 years were 70%, 33%, 13%, and 13%, respectively. The median PFS was 9.0±1.68 months. The prognosis was significantly worse for patients with recurrent ICC than for patients with primary ICC. One patient (5%) had major complications due to IORFA such as liver abscess and biliary stricture. CONCLUSION IORFA with surgical resection can be a feasible option for ICC cases that are not amenable to treatment with surgical resection alone. This strategy provides acceptable local tumor control and overall survival.

Prognostic prediction of apparent diffusion coefficient obtained by diffusion-weighted MRI in mass-forming intrahepatic cholangiocarcinoma

BACKGROUND

We evaluated apparent diffusion coefficient (ADC) of diffusion-weighted image MRI as a prognostic factor for mass-forming intrahepatic cholangiocarcinoma (IHCC).

METHODS

We enrolled 26 patients who had undergone hepatic resections for mass-forming-type IHCC in this study, and calculated their mean ADC, using diffusion-weighted image MRI (b: 0, 20, 800 seconds/mm² ; 1.5 T MRI). Patients were divided into the ADC^High and the ADC^Low groups at the median ADC value (n = 13 for both). We also immunohistochemically evaluated hypoxia-inducible factor (HIF)-1α in tumor tissue.

RESULTS

Median age in the ADC^Low was older (P = .03), and showed significant higher rate of scirrhous tumor (P = .02). The 5-year overall survival rate in the ADC^Low group was significantly worse than in the ADC^High group (P = .04). In multivariate analysis, hilar tumor, portal vein invasion and low ADC were independent prognostic factors (P < .05). The ADC^Low group also had a higher rate of high HIF-1α expression than the ADC^High group (P < .05). Representative case of ADC^Low group showed rich stroma and high HIF-1α expression.

CONCLUSIONS

The ADC values in MRIs can predict IHCC prognosis, and correlated with stromal density and HIF-1α expression.

The Evaluation of the Eighth Edition of the AJCC/UICC Staging System for Intrahepatic Cholangiocarcinoma: a Proposal of a Modified New Staging System

BACKGROUND

The objective was to clarify the prognostic impact of the 8th edition of American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) of intrahepatic cholangiocarcinoma (ICC).

METHODS

A total of 103 ICC patients who underwent hepatectomy between 2002 and 2016 were enrolled. The survival impact of AJCC/UICC 8th edition was examined.

RESULTS

The 5-year disease-specific survival (DSS) rate was 75.9% in T1a (n = 23), 88.9% in T1b (n = 10), 14.9% in T2 (n = 24), 52.5% in T3 (n = 11), and 15.2% in T4 (n = 35). The DSS was comparable among T2, T3, and T4 (T2 vs. T3; p = 0.345, T3 vs. T4; 0.295). A multivariate analysis identified multiple tumors (hazard ratio [HR] 2.821), periductal infiltrating (HR 2.439), perforation of the visceral peritoneum (HR 1.850), and vascular invasion (HR 1.872) as independent prognostic factors that were associated with the DSS. The optimum tumor size with the greatest difference in the DSS was 2 cm (p = 0.014). The new T classification was developed as follows: T1, size ≤ 2 cm without other factors; T2, size > 2 cm without other factors; T3, vascular invasion or perforation of the visceral peritoneum; and T4, multiple tumors or periductal infiltrating. The 5-year DSS was 100% in T1 (n = 7), 76.6% in T2 (n = 28), 45.1% in T3 (n = 28), and 3.4% in T4 (n = 40). There were differences in the DSS between T2 and T3 (p = 0.035) and between T3 and T4 (p = 0.003).

CONCLUSIONS

T2, T3, and T4 of AJCC/UICC overlapped with regard to the DSS. The new staging can classify ICC patients with sufficient prognostic differences.

Effect of surgical margin width after R0 resection for intrahepatic cholangiocarcinoma: A nationwide survey of the Liver Cancer Study Group of Japan

BACKGROUND

Data are inconsistent regarding the effects of a wide surgical margin for intrahepatic cholangiocarcinoma on recurrence-free survival and overall survival. This study was performed to investigate the effect of surgical margin width in patients undergoing R0 resection for intrahepatic cholangiocarcinoma, using a nationwide database in Japan.

METHODS

In total, 635 patients with intrahepatic cholangiocarcinoma who were treated by an R0 resection from 2000 to 2007 were identified from the database of a Japanese nationwide survey. Patients were divided into quartiles of the surgical margin width as follows: marginal (<1 mm), narrow (1-4 mm), intermediate (5-9 mm), and wide groups (≥10 mm). Multivariable Cox regression models for recurrence-free survival and overall survival were constructed with adjustment for preoperative and postoperative clinicopathologic factors.

RESULTS

Compared with the marginal group, the risk-adjusted hazard ratios (95% confidence intervals) in the narrow, intermediate, and wide groups for recurrence-free survival were 0.92 (0.62-1.37), 0.91 (0.61-1.37), and 0.81 (0.56-1.17), and those for overall survival were 0.79 (0.51-1.24), 0.93 (0.59-1.47), and 0.70 (0.46-1.08), respectively. In 398 patients without lymph node metastasis, the hazard ratios for overall survival were 0.62 (0.34-1.11), 0.63 (0.34-1.17), and 0.51 (0.29-0.90), and those of mass-forming type intrahepatic cholangiocarcinoma were 0.48 (0.21-1.08), 0.43 (0.19-0.96), and 0.40 (0.19-0.82), respectively.

CONCLUSION

Surgical margin width appears to have a limited effect on the prognosis of intrahepatic cholangiocarcinoma except in patients without lymph node metastasis, where a wide surgical margin is associated with favorable outcomes. This survival benefit of a wide surgical margin is especially apparent for the mass-forming type intrahepatic cholangiocarcinoma.

Laparoscopic liver resection versus open liver resection for intrahepatic cholangiocarcinoma: 3-year outcomes of a cohort study with propensity score matching

INTRODUCTION

Laparoscopic liver resection(LLR) for intrahepatic cholangiocarcinoma is debatable due to technical challenges associated with major hepatectomy and lymph node dissection. This study aims to analyze the long-term outcomes with propensity score matching.

METHODS

Patients who underwent liver resection for intrahepatic cholangiocarcinoma from August 2004 to October 2015 were enrolled. Those who had combined hepatocellular-cholangiocarcinoma and palliative surgery were excluded. Medical records were reviewed for postoperative outcome, recurrence, and survival. The 3-year disease-free survival(DFS) and 3-year overall survival(OS) were set as the primary endpoint, and 3-year disease-specific survival, 1-year OS, 1-year DFS, operative outcome, and postoperative complications were secondary endpoints.

RESULTS

A total of 91 patients were enrolled with 61 in the open group and 30 in the laparoscopic group. Propensity score matching included 24 patients in both groups. In total, the 3-year OS was 81.2% in the open group and 76.7% in the laparoscopic group(p = 0.621). For 3-year DFS, open was 42.5% and laparoscopic was 65.6%(p = 0.122). Mean operation time for the open group was 343.2 ± 106.0 min and laparoscopic group was 375.2 ± 204.0 min(p = 0.426). Hospital stay was significantly shorter in the laparoscopic group(9.8 ± 5.1 days) than the open group(18.3 ± 14.7, p=<0.001). There was no difference in complication rate and 30-day readmission rate. Tumor size, nodularity, and presence of perineural invasion showed an independent association with the 3-year DFS in multivariate analysis.

CONCLUSION

Laparoscopic liver resection for intrahepatic cholangiocarcinoma is technically feasible and safe, providing short-term benefits without increasing complications or affecting long-term survival.

Modifications of the AJCC 8th edition staging system for intrahepatic cholangiocarcinoma and proposal for a new staging system by incorporating serum tumor markers

BACKGROUND

Several studies have noted that the discriminatory ability and stratification performance of the AJCC 8th edition staging system is not entirely satisfactory. We aimed to improve the American Joint Committee on Cancer (AJCC) 8th edition staging system for intrahepatic cholangiocarcinoma (ICC).

METHODS

A multicentric database from three Chinese mainland centers (n = 1601 patients) was used to modify the 8th edition staging system. This modified TNM (mTNM) staging system was then validated using the SEER database (n = 761 patients). A new TNM staging system, by incorporating serum tumor markers (TNMIS) into the mTNM staging system was then proposed.

RESULTS

The 8th edition staging system did not provide an adequate stratification of prognosis in the Chinese multicentric cohort. The mTNM staging system offered a better discriminatory capacity in the multicentric cohort than the original 8th edition. External validation in the SEER cohort showed that the mTNM staging system also had a good stratification performance. After further incorporating a serum marker stage into the mTNM staging, the TNMIS staging system was able to stratify prognosis even better.

CONCLUSION

The proposed mTNM staging system resulted in better stratification performance and the TNMIS staging system provided even more accurate prognostic classification than the conventional TNM system.

Risk Factors and Outcomes of Early Relapse After Curative Resection of Intrahepatic Cholangiocarcinoma

Early relapse after hepatectomy for intrahepatic cholangiocarcinoma (ICC) has a tremendous influence on the long-term survival outcomes of ICC patients. The purpose of our study was to investigate risk factors for early tumor relapse and confirm whether early relapse was correlated with ICC patients' long-term survival outcomes. Three hundred and twenty-two consecutive ICC patients undergoing partial hepatectomy at Liver Surgery Department of Zhongshan Hospital (Fudan University, Shanghai, China) between January 2005 and December 2011 were included in this retrospectively study. The definition of early relapse had been described as tumor relapse within 24 months after hepatectomy in ICC patients. We identified a total of 168 ICC patients with early relapse and 23 ICC patients with late relapse after hepatectomy. From the time of relapse, the long-term survival outcomes were worse among patients who had early vs. late relapse (median OS 16.5 vs. 44.7 months, respectively; P < 0.0001). The overall survival of the early relapse group was lower than that of the late relapse group (P < 0.0001). Multivariate Cox regression analysis indicated that multiple tumors (hazard ratio [HR], 1.951; 95% CI, 1.382-2.755; P < 0.001), lymphonodus metastasis (HR, 1.517; 95% CI, 1.061-2.168; P = 0.022), and higher serum CA19-9 levels (HR, 1.495; 95% CI, 1.095-2.039; P = 0.011) were independent risk factors of early relapse. Moreover, multiple tumors (HR, 1.641; 95% CI, 1.120-2.406; P = 0.011), lymphonodus metastasis (HR, 2.008; 95% CI, 1.367-2.949; P < 0.001), elevated NLR (HR, 1.921; 95% CI, 1.331-2.774; P < 0.001) and higher serum CA19-9 levels (HR, 1.990; 95% CI, 1.409-2.812; P < 0.001) were independent predictors of overall survival for ICC patients with early relapse. Collectively, our findings demonstrated that multiple tumors, lymphonodus metastasis, and higher serum CA19-9 levels were associated with the increased risks of early relapse and worse prognoses of ICC after curative-intent resection.

Is lymph node dissection necessary for resectable intrahepatic cholangiocarcinoma? A systematic review and meta-analysis

BACKGROUND

The objective of this meta-analysis was to evaluate the effectiveness and safety of lymph node dissection (LND) in patients with intrahepatic cholangiocarcinoma (ICC).

METHODS

A literature search with a date range of January 2000 to January 2018 was performed to identify studies comparing lymph node dissection (LND+) with non-lymph node dissection (LND-) for patients with ICC. The LND + group was further divided into positive (LND + N+) and negative (LND + N-) lymph node status groups based on pathological analysis.

RESULTS

13 studies including 1377 patients were eligible. There were no significant differences in overall survival (OS) (HR 1.13, 95% CI 0.94-1.36; P = 0.20), disease-free survival (DFS) (HR 1.23, 95% CI 0.94-1.60; P = 0.13), or recurrence (OR 1.39, 95% CI 0.90-2.15; P = 0.14) between LND + group and LND-group. Postoperative morbidity was significantly higher in the LND + group (OR 2.67, 95% CI 1.74-4.10; P < 0.001). A subset analysis showed that OS was similar between LND + N- and LND-groups (HR 1.13, 95% CI 0.82-1.56; P = 0.450). However when comparing, OS of the LND-group to the LND+N+ group there was a significant increase in OS for the LND-group (HR 3.26, 95% CI 1.85-5.76; P < 0.001).

CONCLUSIONS

LND does not seem to positively affect overall survival and is associated with increased post-operative morbidity.

Coming of a precision era of the staging systems for intrahepatic cholangiocarcinoma?

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer. Appropriate treatment of this aggressive and heterogeneous cancer requires accurate staging and prognostic stratification, as does patient selection for clinical trials. Over the past two decades, several staging systems and prognostic models for ICC have been developed. Most include independent prognostic factors such as tumor extent, clinical parameters and histopathological features and are inaccurate. Accumulating findings offer new insights into the genetic and molecular basis of ICC progression. Hence, staging systems and prognostic models that incorporate in clinicalpathological factors, molecular and genomic information, and tumor biomarkers, and hence more accurately estimate prognosis, will become a reality. This review summarizes the current staging systems and prognostic models for ICC and highlights the need to establish more precise and personalized systems and models that incorporate tumor biologic factors.

Ultrasound-guided percutaneous microwave ablation versus surgical resection for recurrent intrahepatic cholangiocarcinoma: intermediate-term results

OBJECTIVE

The aims of this study were to compare the clinical outcomes between ultrasound-guided percutaneous microwave ablation (US-PMWA) and surgical resection (SR) in patients with recurrent intrahepatic cholangiocarcinoma (ICC) and to identify the prognostic factors associated with the two treatment methods.

METHODS

This retrospective study was institutional review board approved. A total of 121 patients (102 men and 19 women) with 136 ICCs after hepatectomy from April 2011 to January 2017 were reviewed. Fifty-six patients underwent US-PMWA and 65 patients underwent SR. Survival, recurrence and liver function were compared between the two groups. Effect of changes in key parameters [i.e., overall survival (OS) and recurrence-free survival (RFS)] was statistically analyzed with the log-rank test. Univariate and multivariate analysis were performed on clinicopathological variables to identify factors affecting long-term outcome.

RESULTS

The OS and RFS after MWA were comparable to that of SR (p = .405, and p = .589, respectively). Estimated 5-year OS rates were 23.7% after MWA and 21.8% after SR; for RFS, estimated 3-year RFS rates were 33.1% after MWA and 30.6% after SR. Major complication rates in SR group were higher than that in MWA (p < .001) (SR, 13.8% vs. MWA, 5.3%). Multivariate analysis showed tumor number (p = .012), ALBI grade (p = .007), and metastasis (p = .016), may become OS rate predictors.

CONCLUSIONS

US-PMWA had comparable oncologic outcomes with SR and could be a safe and effective treatment for recurrent ICC after hepatectomy.

Mass-forming intrahepatic cholangiocarcinoma: Can diffusion-weighted imaging predict microvascular invasion?

BACKGROUND

Microvascular invasion (MVI) is a risk factor influencing the survival rate of patients with mass-forming intrahepatic cholangiocarcinoma (IMCC).

PURPOSE

To investigate whether diffusion-weighted imaging (DWI) could be useful in predicting MVI of IMCC.

STUDY TYPE

Retrospective.

SUBJECTS

Eighty patients with surgically resected single IMCC (21 MVI-positive lesions and 59 MVI-negative lesions).

FIELD STRENGTH/SEQUENCE

Preoperative hepatic MRI (1.5T), including T₁ - and T₂ -weighted images (T₁ WI, T₂ WI), DWI, and dynamic enhancement imaging.

ASSESSMENT

Morphologic characteristics including contour of the lesion, biliary dilation and hepatic capsule retraction, signal features on T₁ WI, T₂ WI, and DWI, and dynamic enhancement patterns were qualitatively evaluated. The quantitative analysis was performed for the size and apparent diffusion coefficient (ADC) values.

STATISTICAL TESTS

Chi-square test, Fisher's exact test, and the independent t-test were used for univariate analysis to determine the relationships between these radiological parameters and the presence of MVI. Logistic regression analysis was used to identify the independent predictors of MVI among these radiological parameters. Receiver operating characteristic curve analysis was performed to evaluate their diagnostic performance.

RESULTS

Larger tumor size (P = 0.006) and higher ADC values (P < 0.001) were positively correlated with MVI. Multivariate logistic regression analysis demonstrated that the ADC value (odds ratio, 3.099; P = 0.001) was an independent predictor for MVI of IMCC. The ADC value for MVI of IMCC showed an area under the receiver operating characteristic curve of 0.782 (optimal cutoff value was 1.59 × 10^-3 mm² /s).

DATA CONCLUSION

Larger tumor size was associated with MVI and higher ADC values can be a useful predictor of MVI during the preoperative evaluation of IMCC.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:315-324.

Serum tumor markers enhance the predictive power of the AJCC and LCSGJ staging systems in resectable intrahepatic cholangiocarcinoma

BACKGROUND

While several prognostic models have been developed to predict long-term outcomes in resectable intrahepatic cholangiocarcinoma (ICC), their prognostic discrimination remains limited. The addition of tumor markers might improve the prognostic power of the classification schemas proposed by the AJCC 8th edition and the Liver Cancer Study Group of Japan (LCSGJ).

METHODS

The prognostic discrimination of the AJCC and the LCSGJ were compared before and after the addition of CA 19-9 and CEA, using Harrell's C-index, net reclassification improvement (NRI) and the integrated discrimination improvement (IDI) in an international, multi-institutional cohort.

RESULTS

Eight hundred and five surgically treated patients with ICC that met the inclusion criteria were identified. On multivariable analysis, CEA5 ng/mL, 100IU/mL CA 19-9< 500IU/mL and CA 19-9500 IU/mL were associated with worse overall survival. The C-index of the AJCC and the LCSGJ improved from 0.540 to 0.626 and 0.553 to 0.626, respectively following incorporation of CA 19-9 and CEA. The NRI and IDI metrics confirmed the superiority of the modified AJCC and LCSGJ, compared to the original versions.

CONCLUSION

The inclusion of preoperative CA 19-9 and CEA in the AJCC and LCSGJ staging schemas may improve prognostic discrimination among surgically treated patients with ICC.

Benefit of adjuvant radiotherapy following narrow-margin hepatectomy in patients with intrahepatic cholangiocarcinoma that adhere to major vessels

Purpose

To evaluate the role of adjuvant radiotherapy after narrow-margin (<1.0 cm) resection in patients with intrahepatic cholangiocarcinoma (ICC) adherent to major vessels.

Patients and methods

This retrospective study included 70 ICC patients. Forty-nine patients received narrow-margin (<1.0 cm) hepatectomy and 21 patients underwent wide-margin (≥1.0 cm) hepatectomy (Group C). Twenty-six of 49 were treated with postoperative radiotherapy (Group A), while the remaining 23 did not receive radiotherapy (Group B). Clinical outcomes were compared in the 3 groups. Toxicities of radiotherapy were evaluated.

Results

With a median follow-up time of 42 months, the 3-year overall survival (OS) and disease-free survival rates were 55% and 44% for Group A, 20% and 10% for Group B, and 65% and 33% for Group C, respectively. The OS and disease-free survival in Groups A and C were comparable and improved compared to Group B (Group A vs B, P=0.011 and P=0.031; and Group C vs B, P=0.031 and P=0.105). Multivariate analysis showed that receiving narrow-margin resection only (adjusted hazard ratio: 3.73; 95% CI: 1.36–10.25; P=0.001) was a significant poor prognostic risk factor of OS. Group B experienced more intrahepatic recurrence and extrahepatic recurrence than Groups A and C. For Groups A and B, the 3-year intrahepatic recurrence rates were 36% vs 67% (P=0.133) and extrahepatic recurrence rates were 43% vs 65% (P=0.007). Only 2 patients in Group A suffered from grade 3 toxicities. No patient developed classic or nonclassic radiation-induced liver disease.

Conclusion

Postoperative radiotherapy following narrow-margin hepatectomy seems to be efficacious and well-tolerated in patients with ICC adjacent to major vessels.

Racial, Ethnic, and Age Disparities in Incidence and Survival of Intrahepatic Cholangiocarcinoma in the United States; 1995-2014

INTRODUCTION AND AIM

Despite reports of increased incidence of intrahepatic cholangiocarcinoma (iCCA) in the United States, the impact of age or influences of race and ethnicity are not clear. Disparities in iCCA outcomes across various population subgroups also are not readily recognized due to the rarity of this cancer. We examined ethnic, race, age, and gender variations in iCCA incidence and survival using data from the Surveillance, Epidemiology, and End Results Program (1995-2014).

MATERIAL AND METHODS

We assessed age-adjusted incidence rates, average annual percentage change in incidence, and hazard ratios (HRs) with 95% confidence intervals (CIs) for all-cause and iCCA-specific mortality.

RESULTS

Overall, 11,127 cases of iCCA were identified, with an age-adjusted incidence rate of 0.92 per 100,000. The incidence rate increased twofold, from 0.49 per 100,000 in 1995 to 1.49 per 100,000 in 2014, with an average annual rate of increase of 5.49%. The iCCA incidence rate was higher among persons age 45 years or older than those younger than 45 years (1.71 vs. 0.07 per 100,000), among males than females (0.97 vs. 0.88 per 100,000) and among Hispanics than non-Hispanics (1.18 vs. 0.89 per 100,000). Compared to non-Hispanics, Hispanics had poorer 5-year allcause mortality (HR = 1.11, 95%CI: 1.05-1.19) and poorer iCCA-specific mortality (HR = 1.15, 95%CI: 1.07-1.24). Survival rates were poor also for individuals age 45 years or older, men, and Blacks and American Indians/Alaska Natives.

CONCLUSION

The results demonstrate ethnic, race, age and gender disparities in iCCA incidence and survival, and confirm continued increase in iCCA incidence in the United States.

[Intrahepatic cholangiocarcinoma : Results after 84 resections]

BACKGROUND

The incidence of intrahepatic cholangiocarcinoma (ICC) is increasing worldwide. Surgical resection is the only curative treatment option.

AIM OF THE STUDY

This study analyzed the prognostic factors after resection of ICC.

MATERIAL AND METHODS

A total of 84 patients were surgically treated under potentially curative intent. Perihilar and distal cholangiocarcinomas were excluded. The 5‑year survival was analyzed with respect to tumor stage (TNM), number of lesions, complete surgical resection (R0), peritoneal carcinosis and postoperative complications.

RESULTS

The 5‑year survival was 27% and 77% of patients underwent R0 resections. In the univariate analysis a T stage >2, an N+ situation or an R+ resection as well as peritoneal and multilocular intrahepatic spread were associated with a poorer prognosis. Postoperative complications also negatively influenced survival. On multivariate analysis the absence of peritoneal spread, node-negative tumor stages, singular hepatic lesions and a low T stage as well as the absence of complications were associated with improved survival.

DISCUSSION

The prognosis of ICC is poor even after successful surgical resection. Well-known tumor characteristics such as TNM are relevant prognostic factors. Surgical resection is accompanied by postoperative complications (most frequently biliary), which negatively influence survival. Adjuvant strategies are urgently needed to improve long-term survival even after complete surgical resection.

Clinical Significance of Serum Adiponectin and Resistin Levels in Liver Cirrhosis

INTRODUCTION

Adiponectin and resistin levels are increased in patients with cirrhosis, but it prognostic significance is unknown. We sought to investigate the factors associated with adiponectin and resistin levels and its clinical significance in patients with cirrhosis.

MATERIALS AND METHODS

This was a prospective cohort study that included 122 subjects with cirrhosis who attended an outpatient clinic and were initially evaluated in 2012. Serum adiponectin and resistin levels were measured in samples collected in 2012 (adiponectin and resistin) and 2014 (adiponectin). Thirty healthy subjects served as a control group.

RESULTS

Higher adiponectin (21.59 μ g/mL vs. 12.52 μg/mL, P &lt; 0.001) and resistin levels (3.83 ng/mL vs. 2.66 ng/mL, P &lt; 0.001) were observed among patients with cirrhosis compared to controls. Patients classified as Child-Pugh B/C had higher adiponectin levels in relation to Child-Pugh A patients. At second measurement, adiponectin levels increased significantly in non-transplant patients and decreased in liver transplant recipients. Univariate Cox analysis showed that among patients with alcoholic liver disease, adiponectin levels were associated with lower transplant-free survival (HR = 1.034, 95% CI 1.006 - 1.062, P = 0.016). The transplant-free survival was significantly lower among patients with alcoholic liver disease and adiponectin ≥ 17 μg/mL (26.55 months, 95% CI 21.40-31.70) as compared to those with levels &lt; 17 μg/mL (33.76 months, 95% CI 30.70-36.82) (P = 0.045). No relationship was found between the levels of resistin and survival.

CONCLUSION

Adiponectin but not resistin levels were associated with intensity of liver dysfunction and worse prognosis in patients with alcoholic liver disease, suggesting a potential as a prognostic biomarker.

Impact of serum carbohydrate antigen 19-9 level on prognosis and prediction of lymph node metastasis in patients with intrahepatic cholangiocarcinoma

BACKGROUND AND AIM

Lymph node metastasis is an important prognostic factor for intrahepatic cholangiocarcinoma (ICC), but accurate preoperative diagnosis is difficult. The aim of this study was to measure the concentration of serum carbohydrate antigen 19-9 (s-CA19-9) as a preoperative predictor of lymph node metastasis.

METHODS

In our department, curative-intent hepatectomy for ICC has been performed only once the absence of metastases in para-aortic lymph nodes (PALN) has been confirmed from intraoperative frozen-section pathological examinations. The present study included 13 non-resected ICC patients with PALN metastasis (PALN group) and 44 resected ICC patients without PALN metastasis (non-PALN group). S-CA19-9 was examined to evaluate predictive performance for PALN metastasis and regional lymph node metastasis (pN1) from analysis of the receiver operating characteristic curve. In the non-PALN group, univariate and multivariate analyses for survival were performed on clinicopathological variables.

RESULTS

From receiver operating characteristic curve analysis, s-CA19-9 showed good diagnostic accuracy for PALN metastasis (68%; cut-off, 200 U/mL) and pN1 (77%; cut-off, 100 U/mL). In univariate analysis, age (<65 years), s-CA19-9 (≥100 U/mL), portal vein resection, pN1, and positive resection margin (R1) were all identified as significant negative prognostic factors. Five-year survival rates of patients with high s-CA19-9 and pN1 were 6.9% and 7.3%, respectively. In multivariate analysis, high s-CA19-9 and R1 represented independent predictors of poor prognosis.

CONCLUSIONS

Preoperative s-CA19-9 appears useful as a biomarker in patients with ICC, for predicting not only lymph node metastasis but also prognosis after surgical resection with curative intent.

Intrahepatic cholangiocarcinoma patients without indications of lymph node metastasis not benefit from lymph node dissection

Background: To investigate the necessity of routine lymph node dissection (LND) in intrahepatic cholangiocarcinoma (ICC) patients without indications of lymph node metastasis (LNM) preoperatively. Methods: 422 consecutive ICC patients who undergone curative resection from January 2009 to December 2014 were enrolled and categorized as two groups (hepatectomy only or hepatectomy plus LND). Clinicopathologic data was compared between the groups by χ² or Fisher’s exact test. Overall survival (OS) and recurrence-free survival (RFS) were calculated by the Kaplan–Meier method and differences were analyzed using the log-rank test. Cox regression model was adopted for multivariable analysis. Results: The median OS time of all 422 patients was 41.4 months. One-, 3-, and 5-year OS was 67%, 47%, and 35%, respectively. A total of 73 patients had undergone curative resection combined with LND, of whom 20.5% (15/73) were confirmed lymph node positive pathologically. The clinicopathologic characteristics between LND and control groups showed no significant differences. Of the 422 patients, 271 patients had recurrence. The recurrence rates were 65.8% for the LND group and 63.9% for the non-LND group. Survival analysis revealed that, neither the OS (LND vs. non-LND: 32.2 months vs. 46.2 months; p = 0.16) nor the RFS (LND vs. non-LND: 23.1 months vs. 17.0 months; p = 0.09) had significant difference. Multivariate analysis revealed that tumor size, tumor number, carbohydrate antigen19-9, carcinoembryonic antigen, and gamma-glutamyl transpeptidase were independent predictive factors for OS and RFS. Conclusion: Routine LND may not improve survival in resectable ICC patients with negative LNM diagnosis before operation.

Patterns of care and treatment outcomes in older patients with biliary tract cancer

Background

Although biliary tract cancers (BTC) are common in older age-groups, treatment approaches and outcomes are understudied in this population.

Patients and Methods

Data from 913 patients diagnosed with BTC from January 1987 to July 2013 and treated at Princess Margaret Cancer Center, Toronto were analyzed. The differences in treatment patterns between older and younger patients were explored and the impact of age, patient and disease characteristics on survival outcomes was assessed.

Results

Three hundred and twenty one patients ≥70 years were identified. Older patients were more likely to receive best supportive care, 40% (n = 130), compared to younger patients 26% (n = 154); p < 0.0001. On multivariable analysis, factors associated with receipt of surgery included stage I/II disease (p < 0.0001) and ECOG PS < 2 (p < 0.0001). Older age was not associated with lack of surgical intervention. In comparison, older age was associated with non-receipt of palliative chemotherapy (p = 0.0007). Similar survival benefit from treatment was seen in older and younger patients. Of 626 patients that underwent either surgery or palliative chemotherapy (n = 188), the median survival was 21.1 months (95% CI 19.0–27.9) in patients >70 years of age, and 21.1 months in younger patients (n = 438) (95% CI 19.5–24.5).

Conclusion

In this large retrospective analysis, older patients with BTC are less likely to undergo an intervention. However, active therapy when given is associated with similar survival benefits, irrespective of age.

Is Surgical Resection Justified for Advanced Intrahepatic Cholangiocarcinoma?

BACKGROUNDS

Prognosis for patients with advanced intrahepatic cholangiocarcinoma (ICC) with intrahepatic metastasis (IM), vascular invasion (VI), or regional lymph node metastasis (LM) remains poor. The aim of this study was to clarify the indications for surgical resection for advanced ICC.

METHODS

We retrospectively divided 213 ICC patients treated at Kyoto University Hospital between 1993 and 2013 into a resection (n=164) group and a non-resection (n=49) group. Overall survival was assessed after stratification for the presence of IM, VI, or LM.

RESULTS

Overall median survival times (MSTs) for the resection and non-resection groups were 26.0 and 7.1 months, respectively (p<0.001). After stratification, MSTs in the resection and non-resection groups, respectively, were 18.7 vs. 7.0 months for patients with IM (p<0.001), 23.4 vs. 5.7 months for those with VI (p<0.001), and 12.8 vs. 5.5 months for those with LM (p<0.001).

CONCLUSION

When macroscopic curative resection is possible, surgical resection can be justified for some advanced ICC patients with IM, VI, or LM.

Liver resection for intrahepatic cholangiocarcinoma in AJCC‑stage Ⅳ: An evaluation of the survival benefit and prognostic accuracy of current AJCC staging system on N and M classification

Intrahepatic cholangiocarcinoma (ICC) is usually confirmed in advanced stage at the time of diagnosis or after surgical exploration, however, indication of surgical treatment is usually controversial for ICC in advanced stages. This retrospective study aims to evaluate clinical value of surgery for such tumors, in order to identify the appropriate patients who will benefit from surgery, and to evaluate the prognostic accuracy of the current staging system for advanced ICC. From January 2007 to December 2011, 387 consecutive surgically treated patients with ICC in AJCC‑stage Ⅳ were evaluated. Survival was compared among different patients grouped by different elements of AJCC staging system. The prognostic importance of extent of lymph node (LN) metastasis relative to the AJCC N and M classification system was assessed. Our data showed that survival was much better for patients in AJCC‑stage ⅣA group (median survival time, MST, 9.0 months) than in AJCC‑stage ⅣB group (MST, 5.0 months) (P<0.001). While in AJCC‑stage ⅣB group, survival for patients in AnyTN2‑3M0 subgroup (MST, 9.0 months) was much better than in AnyTN0M1 subgroup (MST, 3.0 months); and better than in AnyTN2‑3M1 subgroup (MST, 4.0 months) (P<0.001). Overall, R0 and R1 liver resection should be indicated for patients in AJCC‑stage ⅣA group and AnyTN2‑3M0 subgroup in AJCC‑stage ⅣB group, as patients in these groups will benefit from surgery with relatively better survival. Staging of advanced ICC by N2‑3 instead of M1 for extended LN metastasis classification is superior in comparison with the AJCC staging system.

Influence of surgical margins on overall survival after resection of intrahepatic cholangiocarcinoma: A meta-analysis

BACKGROUND

Surgical resection is shown to present the best chance of cure in the treatment of intrahepatic cholangiocarcinoma (ICC). However, the appropriate length of the negative margin remains unclear. The aim of the present meta-analysis was to investigate whether a clear margin of 10 mm or more (≥10 mm) conferred any survival benefit over a margin of less than 10 mm (<10 mm) in patients with resected ICC.

METHODS

The meta-analysis was conducted in adherence with the PRISMA guidelines. PubMed, Web of Science, EMBASE, and the Cochrane Library were systematically searched to identify eligible studies published in English from the initiation of the databases to February 2016. Overall survival rates were pooled by using the hazard ratio and the corresponding 95% confidence interval (CI). Random-effect models were utilized because of between-study heterogeneity.

RESULTS

Six studies (eight cohorts) reporting on 712 patients were analyzed: 269 (37.80%) were in the 10 mm or more negative margin group, and 443 (62.20%) were in the less than 10 mm negative margin group. The pooled hazard ratio for the less than 10 mm group was found to be 1.59 (95% CI: 1.09-2.32) when this group was compared with the 10 mm or more group (reference), with moderate between-study heterogeneity (I = 45.30%, P = 0.07). Commensurate results were identified by sensitivity analysis.

CONCLUSION

The result of this meta-analysis suggests a long-term survival (overall survival) advantage for negative margins of 10 mm or more in comparison with negative margins less than 10 mm for patients undergoing surgical resection of ICC.