Guidelines for the diagnosis and management of intrahepatic cholangiocarcinoma

Purpose This study aimed to establish an effective prognostic nomogram for intrahepatic cholangiocarcinoma (ICC) after partial hepatectomy. Patients and Methods The nomogram was based on a retrospectively study on 367 patients who underwent partial hepatectomy for ICC at the Eastern Hepatobiliary Surgery Hospital from 2002 to 2007. The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index) and calibration curve and compared with five currently used staging systems on ICC. The results were validated using bootstrap resampling and a prospective study on 82 patients operated on from 2007 to 2008 at the same institution. Results On multivariate analysis of the primary cohort, independent factors for survival were serum carcinoembryonic antigen, CA 19-9, tumor diameter and number, vascular invasion, lymph node metastasis, direct invasion, and local extrahepatic metastasis, which were all selected into the nomogram. The calibration curve for probability of ...

https://ascopubs.org/doi/pdf/10.1200/JCO.2012.41.5984

Prognostic Nomogram for Intrahepatic Cholangiocarcinoma After Partial Hepatectomy

PURPOSE: To identify factors associated with outcome after surgical management of intrahepatic cholangiocarcinoma (ICC) and examine the impact of lymph node (LN) assessment on survival. PATIENTS AND METHODS: From an international multi-institutional database, 449 patients who underwent surgery for ICC between 1973 and 2010 were identified. Clinical and pathologic data were evaluated using uni- and multivariate analyses. RESULTS: Median tumor size was 6.5 cm. Most patients had a solitary tumor (73%) and no vascular invasion (69%). Median survival was 27 months, and 5-year survival was 31%. Factors associated with adverse prognosis included positive margin status (hazard ratio [HR], 2.20; P < .001), multiple lesions (HR, 1.80; P = .001), and vascular invasion (HR, 1.59; P = .015). Tumor size was not a prognostic factor (HR, 1.03; P = .23). Patients were stratified using the American Joint Committee on Cancer/International Union Against Cancer T1, T2a, and T2b categories (seventh edition) in a discrete step-wise fashion (P < .001). Lymphadenectomy was performed in 248 patients (55%); 74 of these (30%) had LN metastasis. LN metastasis was associated with worse outcome (median survival: N0, 30 months v N1, 24 months; P = .03). Although patients with no LN metastasis were able to be stratified by tumor number and vascular invasion (N0; P < .001), among patients with N1 disease, multiple tumors and vascular invasion, either alone or together, failed to discriminate patients into discrete prognostic groups (P = .34). CONCLUSION: Although tumor size provides no prognostic information, tumor number, vascular invasion, and LN metastasis were associated with survival. N1 status adversely affected overall survival and also influenced the relative effect of tumor number and vascular invasion on prognosis. Lymphadenectomy should be strongly considered for ICC, because up to 30% of patients will have LN metastasis.

/pdf/intrahepatic-cholangiocarcinoma-an-international-multi-3dmz6ewh8m.pdf

Intrahepatic Cholangiocarcinoma: An International Multi-Institutional Analysis of Prognostic Factors and Lymph Node Assessment

Importance Data on outcomes following surgical management of intrahepatic cholangiocarcinoma (ICC) are limited. The incidence of ICC is increasing and it has a poor prognosis. No consensus has been reached regarding the optimal treatment modalities. Objective To systematically review and synthesize the available evidence regarding treatment and prognosis in patients with ICC. Data Sources The PubMed database was searched for relevant articles published between January 1, 2000, and April 1, 2013. Study Selection Only studies assessing predictors of survival or recurrence in patients undergoing curative-intent surgical treatment of ICC were included. Small series, studies reporting on mixed types of cholangiocarcinoma, or exclusively on hepatolithiasis-associated cholangiocarcinoma, and those published in a language other than English, French, German, Italian, or Greek, were excluded. Fifty-seven of 960 articles were therefore analyzed. Data Extraction and Synthesis Data on preoperative, intraoperative, and postoperative variables were extracted by 3 independent reviewers. Multiple studies reporting on the same population were excluded. Data were pooled using a random-effects model. Main Outcomes and Measures We hypothesized that preoperative variables and tumor characteristics affect patient survival. The outcomes of the study were overall survival and recurrence-free survival. The hypothesis was formulated before data collection. Results Fifty-seven studies (4756 patients) were included in the review. Median patient age ranged from 49 to 67 years, and 57% were male. Most patients had a solitary (69%), large (median size, 4.5-8.0 cm) tumor of the mass-forming type (86%). Approximately one-third of the patients had lymph node metastasis (34%) or vascular (38%), perineural (29%), or biliary invasion (29%). Most underwent a major hepatectomy (82%), often accompanied by lymphadenectomy (67%) and sometimes by extrahepatic bile duct resection (23%). Median and 5-year overall survival (OS) generally were approximately 28 months (range, 9-53 months) and 30% (range, 5%-56%), respectively; factors predicting shorter OS included large tumor size, multiple tumors, lymph node metastasis, and vascular invasion. Adjuvant chemotherapy or radiotherapy did not appear to be beneficial. Seven studies (2132 patients) provided data for the meta-analysis. Factors associated with shorter OS included older age (pooled hazard ratio, 1.10; 95% CI, 1.03-1.17), larger tumor size (1.09; 1.02-1.16), presence of multiple tumors (1.70; 1.43-2.02), lymph node metastasis (2.09; 1.80-2.43), vascular invasion (1.87; 1.44-2.42), and poor tumor differentiation (1.41; 1.17-1.71). Conclusions and Relevance The prognosis of ICC is dictated mainly by tumor factors. Future research could focus on the usefulness of adjuvant treatment as well as other multidisciplinary treatment modalities.

/pdf/treatment-and-prognosis-for-patients-with-intrahepatic-2e5a5ncalh.pdf

Treatment and Prognosis for Patients With Intrahepatic Cholangiocarcinoma Systematic Review and Meta-analysis

Laparoscopic cholecystectomy (LC) has become the standard of care for patients requiring removal of the gallbladder. In 1992, a National Institutes of Health (NIH) consensus development conference concluded that ‘‘laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones, laparoscopic cholecystectomy appears to have become the procedure of choice for many of these patients’’ [1]. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) first offered guidelines for the clinical application of laparoscopic cholecystectomy in May 1990. These guidelines have peri- odically been updated, and the last guideline in November 2002 expanded the guidelines to include all laparoscopic biliary tract surgery. This document updates and replaces the previous guideline. The current recommendations are graded and linked to the evidence utilizing the definitions in Appendices 1 and 2.

/pdf/sages-guidelines-for-the-clinical-application-of-10gi93yx8o.pdf

SAGES guidelines for the clinical application of laparoscopic biliary tract surgery

Background and Aim:  Our aim was to evaluate the predictive factors for survival and disease-free survival of patients with resected intrahepatic cholangiocarcinoma (ICC)



Methods:  Between October 1994 and 2005, 97 patients with ICC underwent curative hepatic resection The tumors in 97 patients were reviewed retrospectively to examine the prognosis of ICC



Results:  The 1-, 3- and 5-year survival rates were 749%, 518% and 311%, respectively The 1-, 3- and 5-year disease-free survival rates were 213%, 64% and 21%, respectively Univariate analysis showed that tumor size, tumor number, the gross type, resection margin status, T-stage and lymph node involvement were significant prognostic factors Multiple tumors and cancer cells in the resection margin were found in multivariate analysis to be significantly related to the prognosis In the multivariate analysis disease free survival was poor for the patients with a large tumor, multiple lesions, a high CA 19-9 level, cancer in the resection margin, advanced T-stage and lymph node involvement



Conclusions:  The overall 5-year survival rate of ICC was 311% Multiple intrahepatic lesions were a sign of a poor prognosis for ICC Better survival could be achieved by curative resection with a tumor-free margin

What prognostic factors are important for resected intrahepatic cholangiocarcinoma

Objective: The purpose of this study was to analyze clinicopathologic and surgical features and to determine what should be an adequate extent of resection for T1 gallbladder cancers. Summary Background Data: Simple cholecystectomy offers adequate treatment for T1a cancers; however, it remains debatable whether T1b cancers should be treated by simple cholecystectomy or by radical resection. Methods: Two hundred ninety patients with gallbladder cancer underwent surgical resection. A retrospective analysis was conducted on 52 patients with pathologic stage T1 (27 [52%] with T1a and 25 [48%] with T1b). Clinicopathologic features, extents of resection, and survival rates were investigated retrospectively. Results: No lymph node metastasis or lymphovascular or perineural infiltration was observed in those with T1a disease, but 2 of the 25 patients with T1b disease (3.8%) had lymph node metastasis and 1 patient (1.9%) had lymphatic infiltration. Twenty-one of the 52 study subjects (40.3%) underwent simple cholecystectomy. No peritoneal dissemination occurred regardless of the surgical method (laparoscopy or open surgery). Of the 23 radically resected patients (44.2%) in T1b group, 6 patients (11.5%) underwent cholecystectomy and hepatoduodenal lymph node dissection (CholeLN), and 17 patients (32.7%) underwent CholeLN combined with wedge resection of IVb and V segments of liver, common bile duct resection, or pancreaticoduodenectomy. No difference in locoregional recurrence, metastasis, or survival rate was observed regardless of combined resection of an adjacent organ. The overall survival rate for all patients was 96.2%, and for T1a and T1b these were 96.3% and 96%, respectively. Conclusion: When early gallbladder carcinoma is suspected on the basis of imaging findings, further evaluation of the depth of invasion by endoscopic ultrasonography or intraoperative frozen biopsy is advised. Then, if the disease stage is determined to be T1a, laparoscopic or open cholecystectomy alone is curative, and if T1b, cholecystectomy with hepatoduodenal lymph node dissection without combined resection of an adjacent organ is recommended.

What is an adequate extent of resection for T1 gallbladder cancers

Background and Objectives

Intraductal papillary neoplasm of the bile ducts (IPN-B) is considered an uncommon tumor. The purpose of this study was to evaluate the clinical, radiological, and histopathological characteristics of IPN-B, and its prognosis.



Methods

From October 1995 to August 2006, a retrospective analysis was made of 25 patients that underwent surgery for IPN-B. Clinical features and radiological, pathological, and operative findings were reviewed, and survival rates were determined.



Results

In five patients (20.0%), lesions were incidentally found. Radiologically, 23 of the 25 (92.0%) showed bile duct dilatation, bile duct dilatation with or without an intraductal mass, and cystic changes of bile ducts. Twenty three of the 25 patients underwent hepatic resection with or without extrahepatic bile duct resection. No in hospital mortality occurred. Median survival time of resected patients was 59.8 months and 1-, 2-, and 4-year survival rates were 90.5%, 84.0%, and 84.0%, respectively. All six patients with benign IPN-B remained alive at a mean of 26.2 postoperative months without recurrence.



Conclusions

A diagnosis of IPN-B is usually made in patients with biliary dilatation by radiologic study. The prognosis of IPN-B, especially of the benign category, is excellent. Aggressive surgical resection is the treatment of choice for IPN-B. J. Surg. Oncol. 2008;97:508–512. © 2007 Wiley-Liss, Inc.

Intraductal papillary neoplasm of the bile ducts: the clinical features and surgical outcome of 25 cases.

The aim of this study was to review the clinical features of primary duodenal adenocarcinoma (PDA) patients and to identify factors that influence survival. The natural history of PDA and the factors that affect patient outcome remain poorly defined. The authors reviewed the medical records of 53 patients treated for PDA from January 1995 to May 2007. Altogether, 28 of the 53 patients (resectability 52.8%) underwent curative resection and 25 (47.2%) surgical palliation (bypass surgery or biopsy). Overall, the 3- and 5-year survival rates were 34.4% and 28.6%, respectively. Survival was significantly higher for patients who underwent curative resection (median survival 39 months; 3- and 5-year survivals 52.9% and 44.1%, respectively) than for those who underwent palliative surgery (median survival 8 months; 3-year survival 0%) (p < 0.001). T stage (p = 0.032) and nodal metastasis (p = 0.002) had significant negative effects on the survival of patients who underwent curative resection according to univariate analysis. However, multivariate analysis revealed that only nodal metastasis (p = 0.015) was significantly associated with survival. The resectability of PDA was associated with increased survival, and metastasis to lymph nodes was found to be associated with reduced survival of patients with PDA. Findings indicate that an aggressive surgical approach should be pursued.

Prognostic Factors for Primary Duodenal Adenocarcinoma

AIM: To compare survival between bile duct segmental resection (BDSR) and pancreaticoduodenectomy (PD) for treating distal bile duct cancers.

METHODS: Retrospective analysis was conducted for 45 patients in a BDSR group and for 149 patients in a PD group.

RESULTS: The T-stage (P < 0.001), lymph node invasion (P = 0.010) and tumor differentiation (P = 0.005) were significant prognostic factors in the BDSR group. The 3- and 5-year overall survival rates for the BDSR group and PD group were 51.7% and 36.6%, respectively and 46.0% and 38.1%, respectively (P = 0.099). The BDSR group and PD group did not show any significant difference in survival when this was adjusted for the TNM stage. The 3- and 5-year survival rates were: stage Ia [BDSR (100.0% and 100.0%) vs PD (76.9% and 68.4%) (P = 0.226)]; stage Ib [BDSR (55.8% and 32.6%) vs PD (59.3% and 59.3%) (P = 0.942)]; stage IIb [BDSR (19.2% and 19.2%) vs PD (31.9% and 14.2%) (P = 0.669)].

CONCLUSION: BDSR can be justified as an alternative radical operation for patients with middle bile duct in selected patients with no adjacent organ invasion and resection margin is negative.

Kwang Yeol Paik

Papers

What prognostic factors are important for resected intrahepatic cholangiocarcinoma

What is an adequate extent of resection for T1 gallbladder cancers

Intraductal papillary neoplasm of the bile ducts: the clinical features and surgical outcome of 25 cases.

Prognostic Factors for Primary Duodenal Adenocarcinoma

Carcinoma of the middle bile duct: is bile duct segmental resection appropriate?