Regional variation in routes to diagnosis of cholangiocarcinoma in England from 2006 to 2017

BACKGROUND

Incidence of cholangiocarcinoma (CCA) is rising, with overall prognosis re-maining very poor. Reasons for the high mortality of CCA include its late presentation in most patients, when curative options are no longer feasible, and poor response to systemic therapies for advanced disease. Late presentation presents a large barrier to improving outcomes and is often associated with diagnosis via mergency presentation (EP). Earlier diagnoses may be made by Two Week Wait (TWW) referrals through General practitioner (GP). We hypothesise that TWW referrals and EP routes to diagnosis differ across regions in England.

AIM

To investigate routes to diagnosis of CCA over time, regional variation and influencing factors.

METHODS

We linked patient records from the National Cancer Registration Dataset to Hospital Episode Statistics, Cancer Waiting Times and Cancer Screening Programme datasets to define routes to diagnosis and certain patient characteristics for patients diagnosed 2006-2017 in England. We used linear probability models to investigate geographic variation by assessing the proportions of patients diagnosed via TWW referral or EP across Cancer Alliances in England, adjusting for potential confounders. Correlation between the proportion of people diagnosed by TWW referral and EP was investigated with Spearman’s correlation coefficient.

RESULTS

Of 23632 patients diagnosed between 2006-2017 in England, the most common route to diagnosis was EP (49.6%). Non-TWW GP referrals accounted for 20.5% of diagnosis routes, 13.8% were diagnosed by TWW referral, and the remainder 16.2% were diagnosed via an ‘other’ or Unknown route. The proportion diagnosed via a TWW referral doubled between 2006-2017 rising from 9.9% to 19.8%, conversely EP diagnosis route declined, falling from 51.3% to 46.0%. Statistically significant variation in both the TWW referral and EP proportions was found across Cancer Alliances. Age, presence of comorbidity and underlying liver disease were independently associated with both a lower proportion of patients diagnosed via TWW referral, and a higher proportion diagnosed by EP after adjusting for other potential confounders.

CONCLUSION

There is significant geographic and socio-demographic variation in routes to diagnosis of CCA in England. Knowledge sharing of best practice may improve diagnostic pathways and reduce unwarranted variation.

Descriptive epidemiology of biliary tract cancer incidence and geographic variation in Japan

OBJECTIVE

The epidemiologic features of each biliary tract cancer (BTC) subtype have not been studied and disclosed in detail. The objective of this study was to provide an up-to-date description of the epidemiologic features of BTC by subtypes, especially in terms of the geographic variation of its incidence.

METHODS

We calculated the age-standardized incidence rate (ASR) of each BTC subtype at national and prefectural levels using the data from the national cancer registry in 2016 and 2017. The geographic distribution of each BTC subtype incidence was assessed by calculating the ASR ratio (ASRR) against median ASR at the prefectural level and reflecting them on the Japanese map.

RESULTS

A total of 58 438 people diagnosed with malignant BTC were registered in the national cancer registry in 2016 and 2017 [12 497 for intrahepatic bile duct cancer (IHBDC), 16 568 for gallbladder cancer (GBC), 24 602 for extrahepatic bile duct cancer (EHBDC), 4613 for ampulla of Vater cancer (AVC) and 158 for others]. ASR was higher in men than in women for IHBDC, EHBDC and AVC, and similar between men and women for GBC. The ASR of EHBDC was approximately 2 times higher than those of the other subtypes for men and similar to that of GBC for women. The geographic distribution of ASRR was different among BTC subtypes, with larger variability in EHBDC, which was remarkably higher in the north-eastern region in both men and women.

CONCLUSION

The pattern of the geographic distribution of incidence in each BTC subtype was different, which suggests different etiology among subtypes.

Early Cholangiocarcinoma Detection With Magnetic Resonance Imaging Versus Ultrasound in Primary Sclerosing Cholangitis

BACKGROUND AND AIMS

Early detection of perihilar cholangiocarcinoma (CCA) among patients with primary sclerosing cholangitis (PSC) is important to identify more people eligible for curative therapy. While many recommend CCA screening, there are divergent opinions and limited data regarding the use of ultrasound or magnetic resonance imaging (MRI) for early CCA detection, and it is unknown whether there is benefit in testing asymptomatic individuals. Our aims were to assess the diagnostic performances and prognostic implications of ultrasound and MRI-based CCA detection.

APPROACH AND RESULTS

This is a multicenter review of 266 adults with PSC (CCA, n = 120) who underwent both an ultrasound and MRI within 3 months. Images were re-examined by radiologists who were blinded to the clinical information. Respectively, MRI had a higher area under the curve compared with ultrasound for CCA detection: 0.87 versus 0.70 for the entire cohort; 0.81 versus 0.59 for asymptomatic individuals; and 0.88 versus 0.71 for those listed for CCA transplant protocol. The absence of symptoms at CCA diagnosis was associated with improved 5-year outcomes including overall survival (82% vs. 46%, log-rank P < 0.01) and recurrence-free survival following liver transplant (89% vs. 65%, log-rank P = 0.04). Among those with asymptomatic CCA, MRI detection (compared with ultrasound) was associated with reduction in both mortality (hazard ratio, 0.10; 95% confidence interval, 0.01-0.96) and CCA progression after transplant listing (hazard ratio, 0.10; 95% confidence interval, 0.01-0.90). These benefits continued among patients who had annual monitoring and PSC for more than 1 year before CCA was diagnosed.

CONCLUSIONS

MRI is superior to ultrasound for the detection of early-stage CCA in patients with PSC. Identification of CCA before the onset of symptoms with MRI is associated with improved outcomes.

Biliary tract cancer

Biliary tract cancers, including intrahepatic, perihilar, and distal cholangiocarcinoma as well as gallbladder cancer, are low-incidence malignancies in most high-income countries, but represent a major health problem in endemic areas; moreover, the incidence of intrahepatic cholangiocarcinoma is rising globally. Surgery is the cornerstone of cure; the optimal approach depends on the anatomical site of the primary tumour and the best outcomes are achieved through management by specialist multidisciplinary teams. Unfortunately, most patients present with locally advanced or metastatic disease. Most studies in advanced disease have pooled the various subtypes of biliary tract cancer by necessity to achieve adequate sample sizes; however, differences in epidemiology, clinical presentation, natural history, surgical therapy, response to treatment, and prognosis have long been recognised. Additionally, the identification of distinct patient subgroups harbouring unique molecular alterations with corresponding targeted therapies (such as isocitrate dehydrogenase-1 mutations and fibroblast growth factor receptor-2 fusions in intrahepatic cholangiocarcinoma, among others) is changing the treatment paradigm. In this Seminar we present an update of the causes, diagnosis, molecular classification, and treatment of biliary tract cancer.

Intestinal ultrasonography in adults with Crohn's disease: a 2020 update

In the last years intestinal ultrasonography (IUS) has increased its role in the management of inflammatory bowel diseases (IBD), that include Crohn's disease (CD) and ulcerative colitis. This is due to the fact that IUS is a non-invasive, inexpensive, and well-tolerated examination technique. Furthermore, it allows a real-time diagnosis with no radiation exposure. Usually, convex and linear probes with frequency between 3.5 and 12 MHz are used, also with the Color- Power Doppler. Focusing on CD, the IUS images of clinical interest are: bowel wall thickening (greater than 3 mm), pseudostratification and the wall vascularization. Moreover, IUS demonstrates inflammatory mass, loss of colonic haustration and the complications of the disease, such as stenosis, abscesses, and fistulas as well as other extraintestinal manifestations, such as lymph node enlargement and changes in the appearance of the mesenteric adipose tissue (creeping fat). Oral and intravenous contrast are used to obtain a better visualization of the bowel wall and to increase the diagnostic accuracy of IUS. In particular, intravenous contrast, administered during the procedure, allows to differentiate between active disease (bowel wall enhancement) and the fibrostenotic complications. Contrast-enhanced ultrasonography (CEUS) was proven to be useful in the follow-up and the disease recurrence detection. Beyond the support in the initial diagnosis, IUS has an important role in the follow-up of patients with CD, to monitor the response to the medical therapy and to detect possible complications. Furthermore, it can predict the recurrences after surgery, with more accuracy if Color-Doppler is used.