First and repeat liver resection for primary and recurrent intrahepatic cholangiocarcinoma.
TL;DR: Tumor size more than 5 cm represents an independent risk factor for recurrence after resection of ICC and in case of recurrent ICC, when feasible, is associated with longer overall survival.
Abstract: Background Recurrence after resection of intrahepatic cholangiocarcinoma (ICC) remains common. The present study sought to evaluate risk factors for recurrence and the results of repeat liver resection (RLR) for recurrent ICC. Methods Between 1997 and 2012, clinical data and outcomes of 125 consecutive patients undergoing liver resection for ICC were retrospectively analyzed. Results The rate of R0 resection was 89% (n = 110). Overall median survival was 35 months, and 1-, 3-, and 5-year actuarial survival rates were 80%, 48%, and 28%, respectively. Recurrence occurred in 76 patients (63.5%) and was intrahepatic only for 39 patients (51%). Tumor size greater than 5 cm was identified as an independent risk factor for recurrence ( P ≤ .0001). RLR for recurrent ICC was feasible in 10 patients (25%) with a median survival after recurrence of 25 months (16 to 76). Conclusions Tumor size more than 5 cm represents an independent risk factor for recurrence after resection of ICC. RLR in case of recurrent ICC, when feasible, is associated with longer overall survival.
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TL;DR: The epidemiology and staging of intrahepatic cholangiocarcinoma is reviewed and the selection of surgical modalities and postoperative outcomes of ICC patients are highlighted via literature review.
Abstract: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer, accounting for 10-15% of primary hepatic malignancy. The incidence and cancer-related mortality of ICC continue to increase worldwide. At present, hepatectomy is still the most effective treatment for ICC patients to achieve long-term survival, although its overall efficacy may not be as good as that for patients with hepatocellular carcinoma (HCC) due to the unique pathogenesis and clinical-pathological profiles of ICC. Viral infection, lithiasis and metabolic factors may all be associated with the pathogenesis of ICC. Poor blood supply, cirrhosis (in rare cases), surrounding organ invasion, and lymph node/distal metastasis have significant impacts on the selection of surgical strategies, surgical resection rate, postoperative complications, recurrence and metastasis. Surgical treatment for ICC includes R0 resection, lymphadenectomy, total gross resection of the involved biliary tracts, blood vessels and surrounding tissues in adjacent organs, and reconstruction. Postoperative adjuvant therapy and local-regional therapy after recurrence may improve survival. Liver transplantation (LT) is reported to have a moderate treatment effect on early ICC although its efficacy remains controversial. In this article, we reviewed the epidemiology and staging of ICC and highlighted the selection of surgical modalities and postoperative outcomes of ICC patients via literature review.
51 citations
Cites background from "First and repeat liver resection fo..."
...Despite small patients size in the publication, 9–30% post-operation recurrences can be successfully re-resected (75,77,78)....
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TL;DR: In this paper, the authors evaluated the short and long-term prognoses of patients after repeat hepatic resection for recurrent intrahepatic cholangiocarcinoma.
38 citations
TL;DR: Patients who underwent repeated resections had a significant better OS compared to those receiving chemotherapy, transarterial chemoembolization, selective internal radiotherapy, radiofrequency ablation or best supportive care and should be considered as long as resection is technically possible.
Abstract: Although after R0 resection of intrahepatic cholangiocarcinoma (ICC) recurrence is frequent, most guidelines do not address strategies for this. The aim of this study was to analyze the outcome of repeated resection and to determine criteria when repeated resection is reasonable. Between 2008 and 2016, we consecutively collected all cases of ICC (n = 176) in a prospective database and further analyzed them with a focus on tumor recurrence, its surgical treatment, overall survival and recurrence-free survival. Overall, a total of 22 explorations were performed for recurrent ICC in 17 patients. Resection rate was 18 repeated resections in 13 patients. Three patients underwent repeated resection twice and one patient three times. Recurrence was solitary in 7 patients and multifocal in 11 re-resected cases. Median overall survival (OS) of patients who underwent repeated resection was 65.2 months (interquartile range 37–126.5) with a 5-year OS rate of 62%, calculated from primary resection. Patients who underwent repeated resections had a significant better OS compared to those receiving chemotherapy, transarterial chemoembolization, selective internal radiotherapy, radiofrequency ablation or best supportive care (p < 0.001). Repeated resection of recurrent ICC is reasonable and associated with an improved survival. Re-exploration should be considered as long as resection is technically possible.
36 citations
TL;DR: Repeat surgery for recurrent ICC with an appropriate selection can be associated with prolonged survival and the feasibility, nodal status, number of tumors on the primary tumor, and time to recurrence may be considered as selection criteria.
Abstract: Definitive guidelines for recurrent intrahepatic cholangiocarcinoma (ICC) do not exist. This study has focused on the repeat surgery when analyzing the survival outcomes of recurrent ICC. We evaluated the relationship between clinicopathological features of the primary tumor and implementation of the repeat surgery to identify its potential selection criteria. A total of 108 patients with recurrent ICC between 1993 and 2015 were analyzed. Of these, 15 patients underwent repeat surgery and 93 did not. Seven out of 29 patients with intrahepatic recurrence and eight out of 44 patients with extrahepatic recurrence were amenable to the repeat surgery. Thirty-five patients with simultaneous or consequent intrahepatic recurrence and extrahepatic recurrence were not amenable to the repeat surgery. Patients who underwent repeat surgery had a lower proportion of lymph node metastases (n = 0 [0%] vs. n = 47 [50.5%], p < 0.001), multiple tumors in the primary tumor (n = 1 [6.7%] vs. n = 31 [33.3%], p = 0.037), or early recurrence (≤ 1 year; n = 4 [26.7%] vs. n = 62 [66.7%], p = 0.003). Survival after recurrence (SAR) was better in patients who underwent repeat surgery than in those who did not (median SAR time: 91.6 vs. 10.4 months, and 3-year survival: 86.7 vs. 8.7%, respectively, p < 0.001). Repeat surgery for recurrent ICC with an appropriate selection can be associated with prolonged survival. Regarding the feasibility, nodal status, number of tumors on the primary tumor, and time to recurrence may be considered as selection criteria.
32 citations
01 Jun 2017
TL;DR: Predictors of the recurrence of intrahepatic cholangiocarcinoma (ICC) and the survival benefit of adjuvant chemotherapy and surgical treatment for ICC recurrence were identified and primary im+ should be considered a contraindication for surgical treatment in patients without primary im.
Abstract: Objectives of the present study were to identify predictors of the recurrence of intrahepatic cholangiocarcinoma (ICC), and to evaluate the survival benefit of adjuvant chemotherapy and surgical treatment for ICC recurrence. A multi-institutional retrospective study was carried out in 356 patients with ICC who underwent curative surgery at one of 14 institutions belonging to the Kyushu Study Group of Liver Surgery. A total of 214 patients (60%) had recurrence. Predictors of ICC recurrence were as follows: positive for pathological intrahepatic metastasis (im), positive for lymph node metastasis (n), positive for pathological lymphatic infiltration (ly), pathological bile duct invasion (b), and tumor size ≥4.4 cm. Adjuvant chemotherapy was given to 120 patients (34%) and, in the patients with im or tumor size ≥4.4 cm, adjuvant chemotherapy showed a survival benefit. Only 37 patients (17%) underwent surgical treatment for ICC recurrence. The surgical treatment resulted in a good 5-year survival rate (44%), which is similar to the rate obtained by the first operation for primary ICC. Prognosis of patients with primary im after the second operation was significantly worse (5-year survival 18%) compared to patients without primary im. Primary im+ should be considered a contraindication for surgical treatment for ICC recurrence.
25 citations
Cites background or methods from "First and repeat liver resection fo..."
...A randomized, multidisciplinary, multinational phase III trial concerning adjuvant chemotherapy with gemcitabine and cisplatin in patients with cholangiocarcinoma (the ACTICCA-1 trial) is ongoing,23 and the results of the ACTICCA-1 trial will be important information regarding the clinical efficacy of adjuvant chemotherapy in patients with ICC....
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...There have been several reports, including our own, concerning the poor prognostic factors or predictors of recurrence after curative operation for ICC.(3,6,7,15) In this report, we identified five independent predictors of ICC recurrence such as im (+), n (+), ly (+), b (+), and tumor size ≥4....
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...There have been several reports, including our own, concerning the poor prognostic factors or predictors of recurrence after curative operation for ICC.3,6,7,15 In this report, we identified five independent predictors of ICC recurrence such as im (+), n (+), ly (+), b (+), and tumor size ≥4.4 cm....
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...However, the efficacy of this strategy remains unclear because of the small numbers of patients who underwent surgical treatment for ICC recurrence in those studies (ie from four to 10 patients).(6,7,14) In the present study, we attempted to identify predictors of ICC recurrence after curative surgeries, and we evaluated the survival benefit of adjuvant chemotherapy and surgical treatment for ICC recurrence in a multi-institutional retrospective study conducted by Kyushu Study Group of Liver Surgery for an examination of a large patient sample size....
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...The surgical treatment resulted in a good 5-year survival rate (44%), which is similar to the rate obtained by the first operation for primary ICC....
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References
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TL;DR: The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4
Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature.
The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification.
Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.
23,435 citations
"First and repeat liver resection fo..." refers background or methods in this paper
...Morbidity and mortality were defined as events occurring within 90 days from surgery and were graded according to the Clavien classification.(18) Liver failure was considered by the 50–50 criteria on postoperative day 5 (serum bilirubin level ....
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...Table 2 Ninety-day morbidity and mortality after 125 liver resections for ICC Complications No. of patients % Postoperative death 6 4.8 Major complications* 25 20 Biliary fistulae 7 5.6 Hemorrhage 6 4.8 Liver failure 10 8 Surgical revision 7 5.6 Hospital stay, median (range) 17 (7–122) 90-Day postoperative morbidity 45 36 *Grades III to V according to Dindo et al.18...
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...*Grades III to V according to Dindo et al.(18) R....
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TL;DR: The revised RECIST includes a new imaging appendix with updated recommendations on the optimal anatomical assessment of lesions, and a section on detection of new lesions, including the interpretation of FDG-PET scan assessment is included.
20,760 citations
Journal Article•
TL;DR: This paper is an overview of the new response evaluation criteria in solid tumours: revised RECIST guideline (version 1. 1), with a focus on updated contents.
Abstract: This paper is an overview of the new response evaluation criteria in solid tumours: revised RECIST guideline (version 1. 1), with a focus on updated contents.
3,673 citations
"First and repeat liver resection fo..." refers methods in this paper
...Response to the preoperative treatment was assessed by comparing pretreatment and post-treatment computed tomographic scan according to Response Evaluation Criteria In Solid Tumors (RECIST).(17) After liver resection, all patients were followed-up every 3 months by clinical examination, carcinoma antigen 19-9 (CA 19-9) and/or carcinoembryonic antigen levels determination, and chest and abdomen computed tomography scan for the first 2 years, and every 6 months thereafter....
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TL;DR: R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R1 resection, according to a large series of patients with bile duct cancer.
Abstract: Objective:To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer.Summary Background Data:The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most
1,092 citations
TL;DR: The association of PT <50% and SB >50 &mgr;ml/L on POD 5 (the 50-50 criteria) was a simple, early, and accurate predictor of more than 50% mortality rate after hepatectomy.
Abstract: Objective:
To standardize the definition of postoperative liver failure (PLF) for prediction of early mortality after hepatectomy.
933 citations
"First and repeat liver resection fo..." refers methods in this paper
...50 mmol/L and prothrombin time ,50%).(19) Extent of liver resection was defined according to the Brisbane 2000 nomenclature (major liver resection 5 resection of R3 contiguous liver segments)....
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