The course of 196 patients with proven carcinoma of the pancreas seen at Yale New Haven Hospital from 1972 to 1982 was analyzed. Only 73% of the patients were preoperatively expected to have cancer of the pancreas. The patients who underwent resection had the longest mean survival but also the longest total hospital stay. Twenty-seven patients survived 1 year or more, but nonresected patients constituted 81.5% of this group. The only 5-year survivor did not undergo resection. Forty-seven percent of patients who survived 1 year and had not undergone gastroduodenal bypass, developed duodenal obstruction. It was not possible to identify a subset of patients with a favorable prognosis. A review totaling approximately 37000 patients, of whom 4100 had undergone resections, revealed only 156 survivors, 12 of whom had not been resected, for an overall survival rate of only 0.4%. No author had more than 3.4% of the total number of patients as 5-year survivors.

Cancer of the pancreas. 50 years of surgery.

Clinical results of intraoperative radiotherapy ([OR) which have been obtained since 1964 in Japan were reviewed. In this radiotherapy a cancerocidal dose can be delivered safely to the lesions, since critical organs are shifted from the field so that the lesions may be exposed directly to radiation. Intraoperative radiotherapy has spread in Japan and the number of institutions in which this radiotherapy is performed has continued to increase to a total of 26 in 1979. The total number of patients treated was 717. It has been demonstrated that intraoperative radiotherapy has definite effects on locally advanced abdominal neoplasms and unresectable radioresistant tumors.

Intraoperative radiotherapy: the Japanese experience.

Cholangiocarcinomas are malignant tumors that arise from the epithelium of the intrahepatic or extrahepatic bile ducts. Cholangiocarcinomas are rare compared with hepatocellular carcinoma, comprising less than 10% of primary malignancies of the liver [1]. The autopsy incidence of cholangiocarcinoma is low also, being reported in 0.089–0.46% of necropsies [1]. Cholangiocarcinomas are diagnosed most frequently in the fifth and sixth decades of life [2]. There is only a slight male preponderance of cases of cholangiocarcinoma.

Biliary tract cancer.

BACKGROUND AND AIMS: Radiotherapy has been reported to be of benefit in prolonging the survival of patients with cholangiocarcinoma. This study examined whether radiotherapy in addition to endoscopic stenting improved survival. SUBJECTS: 56 patients with obstructive jaundice due to histologically confirmed non-resectable cholangiocarcinoma. METHODS: A retrospective analysis of these patients who were treated either with endoscopic biliary stenting followed by external beam radiotherapy and internal iridium-192 brachytherapy (n = 28) or with stenting alone (control group; n = 28). RESULTS: The two groups were well matched in age, sex, and stricture type. Eighteen patients had a type I stricture (control group: 11; radiotherapy group: 7) at the time of diagnosis and 38 had a type II or III stricture (control group: 17; radiotherapy group: 21). The median (range) overall survival from diagnosis was seven (1-29) and 10 (4-75) months in the control and radiotherapy groups respectively: This difference did not reach statistical significance (p = 0.06), but survival plots indicated a survival advantage in the radiotherapy group in the first nine months after diagnosis. Approximately one third survived longer than one year in both groups. More patients in the radiotherapy group required a stent change (1.9 v 0.9: p = 0.05), and also had a longer overall inpatient stay (42 days v 19: p < 0.001). When examined on the basis of stricture type, there was a survival advantage in the first 10 months after diagnosis in those with a type II/III stricture (seven and 11 months in the radiotherapy and control groups respectively: 0.01 < p < 0.05). There was no difference in survival between the groups in those with a type I stricture. Numbers surviving longer than one year, stent survival, and number of stent changes were all similar between the two groups when examined on the basis of stricture type, but length of hospital stay remained considerably longer in all patients receiving radiotherapy. CONCLUSION: The survival advantage of radiotherapy in those with a type II/III stricture is seen only in the first 10 months after diagnosis. The costs of radiotherapy and significantly increased time spent in hospital, however, raise doubts over its routine use in the management of non-resectable cholangiocarcinoma.

https://gut.bmj.com/content/gutjnl/39/6/852.full.pdf

A retrospective comparison of endoscopic stenting alone with stenting and radiotherapy in non-resectable cholangiocarcinoma.

One hunded nine patients operated on for bile duct carcinoma were reviewed Herein, we reported 83 proximal duct tumors, 12 mid-duct tumors, and 14 distal third tumors Resectability was 10 percent, 33 percent, and 100 percent, respectively, with an operative mortality of 0 percent, 25 percent, and 23 percent The median survival time and 5 year survival rate for these resected groups were 21 months and 25 percent for proximal duct tumors, 8 months and 0 percent for mid-duct tumors, and 16 months and 20 percent for distal third tumors Eighty-three patients were treated with strictly palliative procedures with an operative mortality of 19 percent, an adjusted median survival rate of 109 months, and a 5 year survival rate of 0 The 2 and 5 year survival rates of patients with well-differentiated tumors were 73 percent and 15 percent, respectively, whereas for patients with poorly differentiated lesions, it was 6 percent and 0 Although most patients require palliative decompressive procedures, resection should be attempted whenever possible It is expected that nonoperative techniques will have an increased role in the treatment of poor-risk patients or those who have unresectable disease

Biliary carcinoma: A review of 109 cases☆

Since November 1973, intraoperative radiotherapy has been performed on five patients with unresectable, advanced carcinoma of the bile duct at the hepatic hilus and six patients with unresectable carcinoma of the gallbladder. A treatment cone with a diameter ranging from 4--10 cm was directly applied at the lesion. A single dose of 2500--3000 rad with 11 to 20 meV electrons was delivered. In all patients, recanalization of the obstructed bile duct was observed by the postoperative cholangiography. The local efficacy was confirmed histopathologically in eight autopsied materials and a specimen resected 105 days after radiotherapy. Mean survival time of patients with unresectable tumors was 10.9 +/- 5.6 (SD) months after this radiotherapy. Intraoperative radiotherapy increased the effectiveness and length of palliation for the unresectable lesion.

https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/1097-0142%2819801115%2946%3A10%3C2179%3A%3AAID-CNCR2820461014%3E3.0.CO%3B2-Y

Intraoperative radiotherapy for advanced carcinoma of the biliary system

A detailed retrospective analysis of the efficacy of intraoperative radiotherapy (IOR) in advanced carcinoma of the pancreas is presented. During a 10-year period from 1973 through 1982, 70 patients with advanced carcinoma of the pancreas were treated by multimodal methods, separate or combined therapy of surgery, IOR, and chemotherapy in two different institutions. Among these, 33 patients underwent IOR, mostly combined with additive surgery. A single dose of 20.1 to 40.0 Gy with 8 to 25 meV electrons was delivered through radiation cones ranging from 6 to 10 cm in diameter. Excellent relief was noticed in 50% of the patients who had complained of pain. Among Stage IV patients, a significant difference of survival rate was observed between IOR and control groups (P less than 0.05); the mean survival time of the IOR group was 4.6 +/- 2.6 (SD) and that of the control group 2.5 +/- 1.4 (SD) months. Intraoperative radiotherapy proved to be effective in prolonging the survival of patients with advanced stage of the lesion.

Intraoperative radiotherapy for advanced carcinoma of the pancreas.

Two cases of carcinoma of the bifurcation of the main hepatic ducts are presented. The tumors were successfully removed by resection of the bifurcation in one case, and by left hepatic lobectomy in the other. Some other 38 cases of the same condition collected from the world literature are briefly reviewed and discussed with particular reference to their surgical interventions.

Successfully resected carcinoma of the bifurcation of the main hepatic ducts--report of two cases.

胆道系癌の根治治療を目標として, 術中照射療法を導入した.昭和49年11月から昭和50年12月までに切除不能な胆管癌4例, 胆嚢癌4例の計8例に術中照射を施行した.最大照射野10cmφ, または8×10cm, 最大エネルギー18MeV, 病巣線量3,000radで, 手術時1回に照射した.照射野内に十二指腸, 膵などが同時に含まれた症例は5例あるが, いずれも重篤な合併症はみられなかつた.全例に腫瘍縮少効果を認め, 最長11ヵ月生存中の症例を得ている.以上の経験から本治療法は安全に施行出来, 遠隔成績の向上が期待できる.

Masao Nakano

Papers

Intraoperative radiotherapy for advanced carcinoma of the biliary system

Intraoperative radiotherapy for advanced carcinoma of the pancreas.

Successfully resected carcinoma of the bifurcation of the main hepatic ducts--report of two cases.

Intraoperative radiotherapy of advanced carcinomas of bile ducts and gallbladder

Effects of source-degrader distance on depth dose distribution in total skin electron beam irradiation