Prognostic factors following surgical resection of distal bile duct cancer

Neuroendocrine Component in Extrahepatic Cholangiocarcinoma is Associated with Better Survival: Data from the SEER Study

INTRODUCTION

This study was performed to evaluate the prognostic value of the neuroendocrine component in patients with extrahepatic cholangiocarcinoma (EHCC).

METHODS

Cases with EHCC derived from the SEER database were retrospectively reviewed and analyzed. The clinicopathological features and long-term survival were compared between patients with neuroendocrine carcinoma (NECA) and those with pure adenocarcinoma (AC).

RESULTS

A total of 3277 patients with EHCC were included (62 patients with NECA and 3215 patients with AC). T stage (P = 0.531) and M stage (P = 0.269) were comparable between the two groups. However, lymph node metastasis was more frequently detected in NECA (P = 0.022). NECA was correlated with more advanced tumor stage than pure AC (P < 0.0001). Inconsistent differentiation status was also observed between the two groups (P = 0.001). The proportion of patients who received surgery was significantly higher in the NECA group (80.6% vs 62.0%, P = 0.003) while chemotherapy was more frequently performed among patients with pure AC (45.7% vs 25.8%, P = 0.002). Comparable incidence of radiotherapy was acquired (P = 0.117). Patients with NECA shared a better overall survival than those with pure AC (P = 0.0141), even after matching (P = 0.0366). The results of univariate and multivariate analyses indicated that the neuroendocrine component was a protective factor as well as an independent prognostic factor for overall survival (HR < 1, P < 0.05).

CONCLUSION

Patients with EHCC with a neuroendocrine component shared a better prognosis than those with pure AC, and NECA could serve as a favorable prognostic factor for overall survival. Considering various unprovided but potentially confounding factors, future more well-conducted research is required.

Postoperative Prognostic Predictors of Bile Duct Cancers: Clinical Analysis and Immunoassays of Tissue Microarrays

Background/Aims

Cholangiocarcinoma frequently recurs even after curative resection. Expression levels of proteins such as epidermal growth factor receptor (EGFR), Snail, epithelial cadherin (E-cadherin), and interleukin-6 (IL-6) examined by immunohistochemistry have been studied as potential prognostic factors for cholangiocarcinoma. The aim of this study was to investigate significant factors affecting the prognosis of resectable cholangiocarcinoma.

Methods

Ninety-one patients who underwent surgical resection at Samsung Medical Center for cholangiocarcinoma from 1995 to 2013 were included in this study. Expression levels of E-cadherin, Snail, IL-6, membranous EGFR, and cytoplasmic EGFR were analyzed by immunohistochemistry using tissue microarray blocks made from surgical specimens.

Results

Patients with high levels of membranous EGFR in tissue microarrays had significantly shorter overall survival (OS) and disease-free survival (DFS): high membranous EGFR (score 0-2) 38.0 months versus low membranous EGFR (score 3) 14.4 months (p=0.008) and high membranous EGFR (score 0-2) 23.2 months versus low membranous EGFR (score 3) 6.1 months (p=0.004), respectively. On the other hand, E-cadherin, Snail, cytoplasmic EGFR, and IL-6 did not show significant association with OS or DFS. Patients with distant metastasis had significantly higher IL-6 levels than those with locoregional recurrence (p=0.01).

Conclusions

This study showed that overexpression of membranous EGFR was significantly associated with shorter OS and DFS in surgically resected bile duct cancer patients. In addition, higher IL-6 expression was a predictive marker for recurrence in cholangiocarcinoma patients with distant organ metastasis after surgical resection.

Diagnosis of Cholangiocarcinoma

Cholangiocarcinoma (CCA), a tumor of the bile duct epithelium, is increasing in incidence. CCA remains a highly fatal malignancy because early diagnosis is difficult. Based on its anatomical location, CCA can be categorized into the following three groups: perihilar, intrahepatic, and extrahepatic. Patients with CCA complain of asymptomatic jaundice, weight loss, and right upper quadrant abdominal discomfort. Imaging modalities, including transabdominal ultrasound, computed tomography, and magnetic resonance imaging, play an important role in detecting tumors as well as guiding biopsy procedures and staging workups in CCA. Characteristically, extrahepatic CCA shows abrupt changes in ductal diameter with upstream ductal dilation. Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are recommended as the next step in the evaluation of extrahepatic CCA. Tissue is obtained through EUS-FNA or ERCP (biopsy, brush cytology), and therapeutic intervention (such as stent insertion) is performed with ERCP. Moreover, several serum tumor markers (carbohydrate antigen 19-9 and carcinoembryonic antigen) can be useful in diagnosing CCA in some patients.

Distal Bile Duct Cancer: Radical (R0 > 1 mm) Resection Achieves Favorable Survival

OBJECTIVE

Evaluation of the outcome after resection for distal bile duct cancer (DBC) with focus on the impact of microscopic histopathological resection status R0 (>1 mm) versus R1 (≤1 mm) vs R1 (direct).

SUMMARY BACKGROUND DATA

DBC is a rare disease for which oncologic resection offers the only chance of cure.

METHODS

Prospectively collected data of consecutive patients undergoing pancreaticoduodenectomy for DBC were analyzed. Histopathological resection status was classified according to the Leeds protocol for pancreatic ductal adeno carcinoma (PDAC) (PDAC; R0 >1 mm margin clearance vs R1 ≤1 mm vs R1 direct margin involvement).

RESULTS

A total of 196 patients underwent pancreaticoduodenectomy for DBC. Microscopic complete tumor clearance (R0>1 mm) was achieved in 113 patients (58%). Median overall survival (OS) of the entire cohort was 37 months (5- and 10-year OS rate: 40% and 31%, respectively). After R0 resection, median OS increased to 78 months with a 5-year OS rate of 52%. Negative prognostic factors were age >70 years ( P < 0.0001, hazard ratio (HR) 2.48), intraoperative blood loss >1000 mL ( P = 0.0009, HR 1.99), pN1 and pN2 status ( P = 0.0052 and P = 0.0006, HR 2.14 and 2.62, respectively) and American Society of Anesthesiologists score >II ( P = 0.0259, HR 1.61).

CONCLUSIONS

This is the largest European single-center study of surgical treatment for DBC and the first to investigate the prognostic impact of the revised PDAC resection status definition in DBC. The results show that this definition is valid in DBC and that "true" R0 resection (>1 mm) is a key factor for excellent survival. In contrast to PDAC, there was no survival difference between R1 (≤1 mm) and R1 (direct).

The short- and long-term outcomes of pancreaticoduodenectomy for distal cholangiocarcinoma

BACKGROUND

The aim of the study was to calculate the short-term and long-term outcomes of curative-intent surgery in distal cholangiocarcinoma (DCC) patients to identify potential prognostic factors.

PATIENTS AND METHODS

A retrospective cohort study of 32 consecutive DCC patients treated with pancreaticoduodenectomy between 2009-2017. The clinicopathological and histopathological data were evaluated for prognostic factors using the univariable Cox regression analysis. The Overall Survival (OS) was estimated using the Kaplan-Meier analysis.

RESULTS

The study comprised a total of 32 patients, with a mean age of 65.8 (± 9.0) years at the time of surgery. R0 resection was achieved in 25 (86.2%) patients, 19 (65.5%) patients received adjuvant oncological therapy. The OS rates at 1, 3 and 5 years were 62.5%, 37.5% and 21.9%, respectively. The 90-day mortality was 3/32 (9.4%) accounting for one-fourth of the first-year mortality rate. The median OS was 28.5 months. The only statistically significant prognostic factor was vascular resection, which was associated with worse OS in the univariable analysis (HR: 3.644; 95%-CI: 1.179-11.216, P=0.025). An age less than 65 years, ASA grade I/II, hospital stay of fewer than 15 days, R0 resection, lymph node ratio less than 0.2 and adjuvant oncological therapy tended to be associated with better OS but without statistically significant relevance.

CONCLUSION

The main factor directly influencing the survival of DCC patients is surgical complications. Surgical mortality comprises a significant group of patients, who die in the first year following pancreaticoduodenectomy. Vascular resection is the most important negative prognostic factor for long-term survival.

Surgical Treatment of Distal Cholangiocarcinoma

Distal cholangiocarcinoma (dCCA) is a rare malignancy arising from the epithelial cells of the distal biliary tract and has a poor prognosis. dCCA is often clinically silent and patients commonly present with locally advanced and/or distant disease. For patients identified with early stage, resectable disease, surgical resection with negative margins remains the only curative treatment strategy available. However, despite appropriate treatment and diligent surveillance, risk of recurrence remains high with nearly 50% of patients experiencing recurrence at 5 years subsequent to surgical resection; therefore, it is prudent to continue to optimize neoadjuvant and adjuvant therapies in order to reduce the risk of recurrence and improve overall survival. In this review, we discuss the clinical presentation, workup and surgical treatment of dCCA.

Serum carcinoembryonic antigen and carbohydrate antigen 19-9 as preoperative diagnostic biomarkers of extrahepatic bile duct cancer

BACKGROUND

Serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 have been proposed as useful preoperative biomarkers of extrahepatic bile duct cancer (EBDC). This study investigated the accuracy of CEA and CA19-9 for preoperative diagnosis of EBDC.

METHODS

Patients who underwent surgery for EBDC at a tertiary centre between 1995 and 2018 were studied, and those with concurrent hepatobiliary diseases (including gallbladder cancer, intraductal papillary mucinous neoplasms of pancreas), which could affect CEA or CA19-9 levels, were excluded. The control group included patients who underwent cholecystectomy for benign gallbladder diseases during the same period. Diagnostic accuracy was determined using sensitivity, specificity and area under the receiver operating characteristic curve (AUC).

RESULTS

After excluding 23 patients, 687 patients (488 men and 199 women, mean age 65.8 years) were compared with the control group of 2310 patients. Median CEA and CA19-9 levels were 1.8 μg/l and 47.0 kU/l in patients with EBDC. CEA (cut-off 5.0 μg/l) showed AUC of 0.541, sensitivity 9.0 per cent and specificity 99.2 per cent, whereas CA19-9 (cut-off 37.0 kU/l) showed AUC of 0.753, sensitivity 56.2 per cent and specificity 94.5 per cent. Sensitivity of CA19-9 was lower in early (T stages 0-II) than advanced (T stages III and IV) cancer (47.0 versus 64.9 per cent), and also lower in N0 stage cancer than lymph node metastasis (50.1 versus 68.8 per cent).

CONCLUSION

Serum CEA and CA19-9 showed low sensitivity limiting their usefulness as diagnostic biomarkers of EBDC.

Three Thousand Consecutive Pancreaticoduodenectomies in a Tertiary Cancer Center: A Retrospective Observational Study

(1) Aim: To evaluate clinicopathological features and postoperative outcomes including survival in patients who underwent pancreaticoduodenectomy (PD) for periampullary diseases. (2) Methods: We retrospectively reviewed 3078 cases of PD performed in our center for 25 years. Periampullary diseases were divided into benign and malignancy groups. All cases were also classified by location. The time of 25 years was divided to different periods (5 years per period) to compare outcomes. Overall survival was compared between subdivided periods. (3) Results: Hospitalization became significantly shorter from 28.0 days in the 1st period to 13.8 days in the 5th period. Overall complication rate was significantly increased since the 3rd period. The rate without postoperative pancreatic fistula (POPF) was high at 98.7% in the 1st period. This might be because drain amylase on the 3rd day after PD was not routinely checked in the past. Thus, POPF was not detected. In survival analysis of adenocarcinoma of pancreas, bile duct, and ampulla, overall survival was found to be improved significantly in recent years. (4) Conclusions: Our study revealed that outcomes were improved with increasing number of PDs performed. Although POPF and overall complications showed increases more recently, those were detected and managed, resulting in shorter hospitalization and improved outcomes.

Comparison of pancreaticoduodenectomy and bile duct resection for middle bile duct cancer: A multi-center collaborating study of Japan and Korea

Background

It is currently unknown whether bile duct segmental resection (BDSR) is an acceptable method for localized middle bile duct cancer (mid‐BDC) when R0 resection can be achieved. This study aimed to investigate the short‐ and long‐term outcomes of mid‐BDC patients treated with pancreaticoduodenectomy (PD) compared to those for BDSR.

Methods

This was a retrospective, Japanese and Korean multi‐center collaboration study based on patients' medical records.

Results

A total of 663 patients, including 245 BDSR and 418 PD cases, were enrolled. The incidence of postoperative pancreatic fistula (3.3% vs 44.1%, P < .0001), surgical site infection in the organ space (6.1% vs 17.7%, P < .0001) and clinically problematic morbidities (15.9% vs 32.8%, P < .0001) was significantly higher in the PD group. There was no difference in the mortality rate (0.8% vs 1.7%, P = .3566). Local (33.9% vs 14.4%, P < .0001) and lymph node (22.4% vs 11.0%, P < .0001) recurrence rates were significantly higher in the BDSR group. Relapse‐free survival (25.0 vs 34.0 months, P = .0184) and overall survival (41.2 vs 60.1 months, P = .0019) were significantly longer in the PD group. The PD group had significantly better prognosis in stage IA/IB cases (58.3 vs 111.5 months, P = .0067), which were the best indicators for BDSR, even when R0 resection was achieved. In multivariate analysis, BDSR was an independent poor prognostic factor.

Conclusion

Despite the inferior perioperative short‐term outcomes, our data advocate that PD should be the standard procedure for mid‐BDCs and that BDSR should be avoided even if R0 resection can be achieved. (UMIN000017914).

A prognostic nomogram for distal bile duct cancer from Surveillance, Epidemiology, and End Results (SEER) database based on the STROBE compliant

In this study, we aimed to develop a reliable nomogram to estimate individualized prognosis for patients with distal bile duct cancer (DBDC) and compare the predictive value with the American Joint Committee on Cancer staging system.Data of 1110 patients diagnosed with DBDC were recruited from the Surveillance, Epidemiology, and End Results database between 1973 and 2015. All patients were randomly divided into the training (n = 777) and validation (n = 333) cohorts, respectively. Multivariate Cox regression was performed to identify the independent risk factors. The Akaike information criterion was used to select covariates for constructing a nomogram. The predictive ability of the nomogram was assessed by concordance index (C-index) and area under receiver operating characteristic curve (AUROC) compared to tumor-node-metastasis (TNM) staging system.A nomogram integrating 8 risk factors was developed with a higher C-index than that of the TNM staging system (training data set, 0.70 vs 0.61; validation data set, 0.71 vs 0.57). The AUROCs of the nomogram for 1-year and 3-year overall survival (OS) predication were 0.76 and 0.78 in the training cohort, 0.78 and 0.77 in the validation cohort. However, AUROCs of the TNM stage for predicting 1-year and 3-year OS were all below 0.60. Calibration curves showed the optimal agreement in predicating OS between nomogram and actual observation. In addition, this nomogram can effectively distinguish the OS between low and high-risk groups divided by the median score (P < .01).Present study was the first one to construct a prognostic nomogram of DBDC patients, which has the potential to provide individual prediction of OS.

microRNA-329 suppresses epithelial-to-mesenchymal transition and lymph node metastasis in bile duct cancer by inhibiting laminin subunit beta 3

Bile duct cancer (BDC), also known as cholangiocarcinoma, is a highly desmoplastic cancer with a growth pattern characterized by periductal extension and infiltration. Studies have suggested that microRNAs (miRNAs) play an important role in BDC progression. Here we aim at investigating the effects of miR-329 on BDC development, focusing especially on epithelial-to-mesenchymal transition (EMT) in vitro and lymph node metastasis in vivo. Expression microarrays associated with BDC tissues were collected and differentially expressed genes were analyzed, followed by miRNA target prediction and verification. The role miR-329 played in BDC was examined using gain-of-function and loss-of-function methods. The expressions of miR-329, laminin subunit beta 3 (LAMB3), and EMT markers, in addition to cell proliferation, migration, and invasion were evaluated. Furthermore, nude mice models of BDC were established to observe tumor growth and metastatic lymph nodes. The LAMB3 was identified as an upregulated gene based on the GSE77984 and GSE45001 microarray analysis. LAMB3 was also predicted and confirmed to be a target gene of miR-329 by dual-luciferase reporter assay. Through further cell experiments, the EMT process was reversed, cell proliferation, invasion, and migration were suppressed, when miR-329 was upregulated. Furthermore, in vivo experiments exhibited that the overexpression of miR-329 inhibited tumor growth and the number of metastatic lymph nodes. This study provides in vivo and in vitro evidence that miR-329 inhibits BDC progression through translational repression of LAMB3. Therefore, the obtained results may aid as an experimental basis for improving prognosis of BDC.

Prognostic comparison of the longitudinal margin status in distal bile duct cancer: R0 on first bile duct resection versus R0 after additional resection

BACKGROUND

This study investigated survival differences following intra-operative frozen-section examination of bile duct resection margins and final longitudinal margin status (LMS) in distal bile duct cancer (BDC).

METHODS

One hundred and ninety-three patients underwent Whipple's operation for curative resection of distal BDC from 2008 to 2016. Patients were sorted into two and three groups according to LMS of the frozen-sections and the final pathological specimen results: R0 on first bile duct resection (primary R0), R0 after additional resection (secondary R0), and no evidence of residual carcinoma (FR0), carcinoma in situ or high-grade dysplasia (FR1-CIS/HGD), or invasive carcinoma (FR1-INV). Survival and prognostic factors according to LMS were analyzed.

RESULTS

The final R0 ratio increased from 82.3% to 90.1% through additional resection. The 5-year overall survival (OS) of primary and secondary R0 were 60.8%, 46.1% (P = 0.969). And disease-free survival of primary and secondary R0 were 54.6%, 54.9% (P = 0.903). The 5-year OS after FR0, FR1-CIS/HGD, FR1-INV were 59.3%, 59.5%, 14.3% (P = 0.842). LMS of the bile duct was an independent prognostic factor by multivariable analyses.

CONCLUSIONS

If R0 of final LMS was achieved, it would help to improve survival regardless of R0 through additional resection. And, it should be avoided remaining invasive cancer at the longitudinal margin whenever possible.

Risk factors associated with locoregional failure and estimation of survival after curative resection for patients with distal bile duct cancer

Our aim was to identify the risk factors associated with locoregional recurrence in resected distal bile duct cancer (DBDC), and to determine the subgroup that may benefit from adjuvant radiotherapy. Between 2001 and 2013, we retrospectively analyzed 93 patients with DBDC who had undergone curative resection. Patients who received adjuvant radiotherapy were excluded. The 3-year locoregional failure-free survival (LRFFS) and overall survival (OS) rates for all patients were 50.7%, and 53.2%, respectively. On multivariate analysis, the preoperative carcinoembryonic antigen (CEA) level, resection margin, histologic grade, T stage, and N stage were significant prognostic factors for LRFFS. Locoregional recurrence was observed in more than 78% of the patients who underwent R1 resection and were node-positive, and the 3-year LRFFS rate was 19.3%. The 3-year LRFFS rate was 46.9% in the patients who underwent R0 resection and were node-negative with more than 2 risk factors (preoperative CEA level ≥ 5 ng/mL, poorly differentiated histologic grade, and T3 stage). On multivariate analysis for OS, patients with more than 2 risk factors showed a 7-fold higher risk of death, compared with patients with 1 or no risk factor. The important risk factors of locoregional failure in patients with DBDC who underwent resection were R1 resection and positive lymph nodes. Adjuvant radiotherapy should be considered for these patients to improve the oncologic outcomes. Patients undergoing selective R0 resection and those with node-negative status and multiple locoregional failure risk factors may benefit from adjuvant radiotherapy.

Inverse Prognostic Relationships of 18F-FDG PET/CT Metabolic Parameters in Patients with Distal Bile Duct Cancer Undergoing Curative Surgery

Purpose

As there were few previous studies with a small number of subjects, the purpose of this was to evaluate the prognostic significance of ¹⁸F-FDG PET/CT in patients with distal bile duct cancer undergoing curative surgery.

Methods

The study included 40 patients (M/F = 24:16; age 68.0 ± 8.0 years) who underwent preoperative ¹⁸F-FDG PET/CT followed by curative surgical resection. The participant's age, sex, Eastern Cooperative Oncology Group performance-status score, baseline serum CA 19-9 level, stage, pathologic T and N stages, tumor size, tumor grade, tumor growth pattern, R0 resection, and adjuvant therapy were included as clinicopathological variables for predicting overall survival. The PET variables were maximum standardized uptake value (SUV_max), average SUV (SUV_avg), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the tumor. The Kaplan-Meyer method and Cox proportional hazards model were used for the survival analysis.

Results

A total of 15 of 40 patients (37.5%) died during the follow-up period. In univariate analysis, low SUV_max (≤ 2.7, p = 0.0005) and low SUV_avg (≤ 2.6, p = 0.0034) were significant predictors of poor overall survival. In multivariate analyses, only low SUV_max (HR = 6.7016, 95% CI 1.9961-22.4993, p = 0.0047) was an independent prognostic factor associated with poor overall survival.

Conclusion

The SUV_max of the primary tumor measured by ¹⁸F-FDG PET/CT was an independent significant prognostic factor for overall survival in patients with distal bile duct cancer. However, different results from a previous study warrant further large sample-sized study.

Relevant prognostic factors influencing outcome of patients after surgical resection of distal cholangiocarcinoma

Background

Distal cholangiocarcinoma (DCC) is a rare but over the last decade increasing malignancy and is associated with poor prognosis. According to the present knowledge curative surgery is the only chance for long term survival. This study was performed to evaluate prognostic factors for the outcome of patients undergoing curative surgery for distal cholangiocarcinoma.

Methods

75 patients who underwent surgery between January 2000 and December 2014 for DCC in curative intention were analysed retrospectively. Potential prognostic factors for survival were investigated including the extent of surgery using purposeful selection of covariates in multivariable Cox regression modeling.

Results

Preoperative biliary stenting (Hazard ratio (HR): 2.530; 95%-CI: 1.146–6.464, p = 0.020), the extent of surgery in case of positive histological venous invasion (HR: 1.209; 95%-CI: 1.017–1.410, p = 0.032), lymph node staging (HR: 2.183; 95%-CI: 1.250–3.841, p = 0.006), perineural invasion (HR: 2.118; 95%-CI: 1.147–4.054, p = 0.016) and postoperative complications graded in points according to Clavien-Dindo (HR: 1.395; 95%-CI: 1.148–1.699, p = 0.001) were indentified as independent significant risk factors for survival. Patients receiving preoperative biliary stenting showed prolonged duration between onset of symptoms and date of operation (p = 0.048).

Conclusions

Preoperative biliary stenting reduces survival possibly due to delayed surgery. The extent of surgery is not an independent risk factor for survival except for patients with concomitant histological venous invasion. Oncological factors and postoperative surgical complications are independent prognostic factors for survival.

Predictive Factors of Early Recurrence in Patients with Distal Cholangiocarcinoma after Pancreaticoduodenectomy

Aim

To determine the factors associated with early recurrence in patients with distal cholangiocarcinoma after pancreaticoduodenectomy (PD).

Patients and Methods

Sixty-one patients with distal cholangiocarcinoma were enrolled. The clinical data and histopathological findings were collected retrospectively.

Results

Patients were divided into two groups as follows: 16 patients (26%) with early recurrence and 45 patients (74%) with late recurrence or no recurrence. In a univariate analysis, lymph node metastases (P = 0.0016), lymphatic invasion (P < 0.0001), pancreatic invasion (P = 0.0006), and perineural invasion (P = 0.0004) were significantly different between the two groups. In a multivariate analysis, a higher incidence of lymphatic invasion was the only independent risk factor for early recurrence (odds ratio: 5.772, 95% confidence interval: 1.123–29.682, P = 0.036). Moreover, the disease-free survival and overall survival of patients with a higher incidence of lymphatic invasion were significantly worse compared with those of patients with a lower incidence of lymphatic invasion (P < 0.001).

Conclusions

Our study showed that a higher incidence of lymphatic invasion was a significant predictor of early recurrence in patients with distal cholangiocarcinoma. Therefore, lymphatic invasion might be useful in determining the optimal adjuvant therapy in the early postoperative stage for distal cholangiocarcinoma.

Gene copy number variation and protein overexpression of EGFR and HER2 in distal extrahepatic cholangiocarcinoma

EGFR and HER2 are among the most promising therapeutic targets in solid cancers. The expression status of EGFR and HER2 are associated with the prognosis, and with a number of clinicopathological factors, in many cancers. However, few studies have examined this association in distal extrahepatic cholangiocarcinoma (EHCC). Therefore, we investigated EGFR and HER2 protein expression and gene copy number variation (CNV) in distal EHCC. We also studied the association of these factors with clinicopathological parameters and prognosis. Immunostaining, using antibodies against EGFR and HER2, was performed on 84 cases of distal EHCC. All positive (3+) and equivocal (2+) EGFR and HER2 expression cases, together with randomly selected negative (1+ and 0) cases, were evaluated for EGFR and HER2 CNV. Among distal EHCC samples, 6.0% (n=5) were positive (3+) for EGFR expression and 6.0% (n=5) were equivocal (2+). HER2 expression was positively identified in 2.4% of samples (n=2), and was equivocal in 1.2% of samples (n=1). All cases of positive EGFR expression showed amplification (n=1) or high polysomy (n=4) involving the EGFR gene; three cases (60%) of equivocal EGFR expression showed high polysomy of the EGFR gene. All cases of positive or equivocal HER2 expression (n=3, 3.6%) showed amplification of the HER2 gene. In univariate analysis, EGFR expression and CNV were associated with shorter cancer-specific overall survival (p=0.003 and p=0.018, respectively). Multivariate analysis also showed that EGFR CNV was a significant prognostic factor in distal EHCC (p=0.015). Although further study is warranted, our findings suggest that EGFR expression and CNV are factors associated with poor prognosis, and that anticancer therapeutics against EGFR and HER2 receptors may be promising therapeutic options for patients with distal EHCC.

Outcome and evaluation of prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma

Background

The aim of the present study was to examine the outcomes and prognostic factors after surgery with curative intent for distal cholangiocarcinoma during a modern timespan, in a Swedish tertiary referral center.

Methods

All patients who underwent pancreaticoduodenectomy for distal cholangiocarcinoma between April 2008 and December 2015 were identified. Survival was estimated using the Kaplan-Meier analysis. Demographic, clinical, laboratory and histopathological data were evaluated for prognostic factors relating to mortality, using univariable and multivariable statistical analysis.

Results

Fifty-four patients were included. The mean age was 68±8 years and 21 (39%) of the patients were female. Jaundice was present at diagnosis in 73% of the patients. There was no 90-day mortality. Complications graded as Clavien-Dindo ≥3 occurred in 10 (19%) of the patients. Twenty-eight (52%) received adjuvant therapy. Overall survival rates at 1, 3, and 5 years were 80%, 21%, and 9.2%, respectively. Median survival was 22.2 months. The presence of lymph node metastases was found to be the only independent predictor of survival (hazard ratio 2.88, 95% confidence interval 1.22-6.84; P=0.016). The total number of lymph node metastases, lymph node ratio or total number of resected nodes did not improve the prediction.

Conclusions

We found that the recurrence rate was higher and the survival poorer after surgery for distal cholangiocarcinoma than has previously been reported. Lymph node status at the time of resection was the most important prognostic factor for survival in the current material.

Benefit of neoadjuvant concurrent chemoradiotherapy for locally advanced perihilar cholangiocarcinoma

AIM

To clarify the role of neoadjuvant concurrent chemoradiotherapy (NACCRT) followed by surgical resection for localized or locally advanced perihilar cholangiocarcinoma (CCA).

METHODS

We retrospectively reviewed 57 patients who underwent surgical resection with or without NACCRT for perihilar CCA; 12 patients received NACCRT and 45 patients did not received NACCRT. Patients with locally advanced perihilar CCA requiring NACCRT were defined as follows: (1) a mass involving unilateral branches of the portal vein or hepatic artery with insufficient volume of the anticipated remnant lobe; or (2) an infiltrating mass in the main portal vein that was too long for reconstruction, identified at preoperative staging.

RESULTS

The median disease-free survival (DFS) durations of the neoadjuvant and non-neoadjuvant CCRT groups were 26.0 and 15.1 mo, respectively (P = 0.91). The median overall survival (OS) durations of the neoadjuvant and non-neoadjuvant CCRT groups were 32.9 and 27.1 mo, respectively (P = 0.26). The NACCRT group showed a downstaging tendency compared to the non-NACCRT group as compared with the tumor stage confirmed by histological examination after surgery and the tumor stage confirmed by imaging test at the time of diagnosis (P = 0.01).

CONCLUSION

NACCRT does not prolong DFS and OS in localized or locally advanced perihilar CCA. However, NACCRT may allow tumor downstaging and improve tumor resectability.

Over 700 Whipples for Pancreaticobiliary Malignancies: Postoperative Morbidity Is an Additional Negative Prognostic Factor for Distal Bile Duct Cancer

BACKGROUND

Distal cholangiocarcinomas and pancreatic cancers both arise from pancreaticobiliary epithelium. Despite their common origin, there is a possible discrepancy in outcome. We analysed the surgical, pathological and survival outcome of resected distal cholangiocarcinoma compared with pancreatic cancer.

METHODS

All cases of resected distal cholangiocarcinoma and pancreatic cancer from 1998 to 2014 were extracted from our database. Outcomes were compared.

RESULTS

There were 54 (7.6%) cases of cholangiocarcinoma and 656 (92.4%) pancreatic cancer. Cholangiocarcinoma showed lower T and N stage, lymphatic and perineural invasion (p < 0.05), worse surgical outcome (p < 0.05) and less access to adjuvant therapy if compared with pancreatic cancer (72.7 vs. 83.1%, p = 0.05). Both showed a similar disease-specific survival (35 vs. 29 months, p = 0.3). Independent predictors of prognosis for pancreatic cancer were resection margin, grading, perineural invasion, T and N status, whereas for cholangiocarcinoma were grading and occurrence of POPF.

CONCLUSION

Considering a large cohort of resected periampullary cancers, cholangiocarcinoma is extremely rare. An earlier diagnosis is associated with better pathological predictors of outcome but increased postoperative morbidity compared to pancreatic cancer, particularly POPF. Consequent decrease in the access to adjuvant therapy for complicated cholangiocarcinoma might explain why survival is as poor as for pancreatic cancer.

Validation of T Stage According to Depth of Invasion and N Stage Subclassification Based on Number of Metastatic Lymph Nodes for Distal Extrahepatic Bile Duct (EBD) Carcinoma

According to the current AJCC staging system, the T stage of distal extrahepatic bile duct carcinoma (EBD) is classified according to the extent of the tumor within or beyond the bile duct wall. However many invasive carcinoma accompany stromal desmoplasia that obscure lower boundary of bile duct wall; it is frequently difficult to clearly define the extent of tumors using the current T classification system. In this study, we validated an alternative T classification system by depth of invasion (DoI; T1: < 5  mm, T2: 5 to 12  mm, and T3: ≥ 12  mm). Specifically, we evaluated DoI in 114 cases of distal EBD carcinoma using digital scan images to achieve more objective measurements of tumor DoI. In addition, we evaluated the effect of the number of metastatic lymph nodes (LNs) as well as the number of total examined LNs on the survival rate in the same patient group, and performed a comparative analysis of these data to assess patient survival. We also analyzed 114 cases of distal EBD carcinoma using the current T and N classification of the AJCC staging system (7th edition). The T stage of the current AJCC staging system was not associated with significant differences in patient survival, especially between T2 and T3. However, T staging by DoI was associated with statistically significant differences in patient survival (P < 0.001 in DoI-1, P = 0.002 in DoI-2). With respect to N stage, we divided patients into 3 tiers comprising class 1 (no nodal metastasis), class 2 (1-3 nodal metastases), and class 3 (4 or more nodal metastases). In 3-tier classification analysis, the median survival times for classes 1, 2, and 3 were 79.2, 28.8, and 10.9 months, respectively. The difference in survival among the 3 classes was statistically significant (P < 0.001). We found the cut-off value of 11 LNs (1 to 10 vs  ≥ 11) for N0 stage showed most significant difference (P = 0.007). We think at least 11 LNs should be examined for more accurate evaluation of N stage in distal EBD carcinoma. We propose an alternative T classification using DoI and 3-tier sub-classification of N stage for distal EBD carcinoma.

Prognostic Accuracy of the Seventh Edition of the TNM Classification Compared with the Fifth and Sixth Edition for Distal Cholangiocarcinoma

BACKGROUND

The TNM classification for distal cholangiocarcinoma was first introduced in the 7th edition, which was published in 2009; however, prognostic accuracy compared with the 5th and 6th editions has not yet been evaluated and requires validation.

METHODS

A prospective histological database of patients with distal bile duct cancer was analyzed, and histological parameters and stage of the distal cholangiocarcinoma were assessed according to the 5th, 6th, and 7th editions of the TNM classification.

RESULTS

Between 1994 and 2012, a total of 516 patients underwent pancreatic head resection, of whom 59 patients (11.4 %) experienced histologically confirmed distal cholangiocarcinoma. The median overall survival time was 22.2 months (13.1-31.4). Tumor recurrence occurred in 23 patients after a median disease-free survival time of 14.1 months. The 7th edition showed a monotonicity of all gradients, with a stepwise increase of mortality related to a stepwise increase of tumor stage (log-rank test; p < 0.05) demonstrating best discrimination of all tested editions [area under the receiver operating characteristic curve (AUC) 0.82; 95 % CI 0.70-0.95; p = 0.012]. The discrimination rate was low for the 5th (AUC 0.67; 95 % CI 0.42-0.91; p = 0.18) and 6th editions (AUC 0.70; 95 % CI 0.47-0.93; p = 0.11), while the log-rank test did not reach statistical significance. On multivariate analysis, lymph node involvement and positive resection margins were positive and independent predictors of inferior survival (p < 0.05).

CONCLUSIONS

The 7th edition of the TNM classification was favorable in terms of predicting outcome, and generated a monotonicity of all grades. Strikingly, the 7th edition, but not the 5th and 6th editions, was of prognostic significance to predict outcome.

Survival after surgical resection of distal cholangiocarcinoma: A systematic review and meta-analysis of prognostic factors

BACKGROUND/OBJECTIVE

This study aimed to assess the available evidence on the survival of distal cholangiocarcinoma (DCC) patients following resection with curative intent and analyze the prognostic factors.

METHODS

Relevant studies published between January 2000 and January 2015 were identified by searching PubMed and Embase and reviewed systematically. Summary relative risks (RR) and 95% confidence intervals (95% CI) were estimated using random-effects models.

RESULTS

A total of 39 observational studies involving 3258 patients were included in the review. R0 resection was achieved in 84% (range, 46-100%) of patients. The median 5-year overall survival rate after resection was 37% (range, 13-54%), with corresponding rate of 44% (range, 27-63%) in R0 resection. The meta-analysis for 25 studies showed that R1 resection (RR 2.36, 95% CI 1.89-2.93), lymph node metastasis (RR 2.35, 95% CI 1.89-2.93), perineural invasion (RR 1.96, 95% CI 1.64-2.34), lymphatic invasion (RR 1.84, 95% CI 1.47-2.31), vascular invasion (RR 1.99, 95% CI 1.40-2.82), pancreatic invasion (RR 2.13, 95% CI 1.39-3.27), and pathological tumor stage ≥ T3 (RR 1.56, 95% CI 1.25-1.93) were associated with shorter survival.

CONCLUSION

In general, prognosis of DCC after resection is poor. R0 resection results in a substantially improved survival and represents one of the most important prognostic variables.