Changing trends in the management of Klatskin tumor

BACKGROUND/AIMS: To evaluate the long-term outcome of a multidisciplinary approach for advanced Klatskin tumor involving the hepatic hilus. METHODOLOGY: A retrospective analysis was undertaken in 110 patients between 1993 and 2003. The patients were divided into Group A (n=42) and Group B (n=58). Group A patients underwent local excision of the tumor and Group B patients underwent combined tumor and liver resection with or without resection of the regional vascular structures. On admission, all patients underwent percutaneous transhepatic biliary drainage. Where hepatectomy was planned, portal vein branch ligation and transection was done ipsilateral to the liver lobe where the tumor was present. An arterial catheter was introduced into the hepatic artery at the end of the surgery, for adjuvant locoregional immunochemotherapy, which was carried out in all patients. The second-stage resectional surgery was carried out 35 days later. RESULTS: The overall mean survival for Group A patients was 29 months (range 14 to 76). The mean disease-free survival was 28 months (range 10-52). Five-year survival rate was 5% and five-year disease-free survival was 0%. The overall mean survival for Group B patients was 39 months (range 28 to 79). The mean disease-free survival was 32 months (range 17-72). Five-year survival rate was 20% and five-year disease-free survival was 10%. CONCLUSIONS: The concept of a multidisciplinary approach has significantly improved survival in patients with a grave disease like Klatskin tumor.     

Carcinoma of the head of the pancreas

BACKGROUND/AIMS: Extended radical surgery might provide a survival advantage for patients with carcinoma of the head of the pancreas. METHODOLOGY: Between January 1980 and December 1999, 144 patients with carcinoma of the head of the pancreas were treated in a community hospital setting, of whom 69 patients who underwent radical surgery were retrospectively reviewed. Surgical procedures included standard pancreaticoduodenectomy (27 patients), pylorus-preserving pancreaticoduodenectomy (27 patients), and total pancreatectomy (15 patients). Portal vein resection was performed for 15 patients. Retroperitoneal lymphadenectomy was performed for 35 patients. No patients received adjuvant chemotherapy or radiotherapy. RESULTS: The surgical resection rate was 47.9% with a surgical mortality rate of 4.3% during this period. The overall 5-year survival rate after radical surgery was 16.1% with a median survival of 12 months. Seven patients survived five years, making 16.3% of the patients available for a more than 5-year follow-up. Long-term survivors had less than two positive lymph nodes in the posterior pancreatic head. Fourteen of 15 patients undergoing portal vein resection died within 21 months. One patient having no portal vein invasion microscopically survived 27 months without recurrence. CONCLUSIONS: Extended radical surgery did not prolong survival for patients with carcinoma of the head of the pancreas.     

Two-stage liver surgery for advanced liver metastasis synchronous with colorectal tumor

BACKGROUND/AIMS: To evaluate the efficacy of two-stage surgery and multidisciplinary approach, in the treatment of primary colorectal cancer, synchronous with advanced liver metastases. METHODOLOGY: Sixty-two patients who underwent two-stage surgery for advanced metastatic liver disease synchronous with colorectal tumor were studied. In the first-stage surgery, the primary colorectal tumor was resected. Depending on the location of the main tumor mass, ligation and transection of the relevant (right or left) main portal vein branch was done. Subsequently, the metastatic nodules in the contralateral lobe were ablated by microwave therapy. An arterial jet port catheter was also introduced into the hepatic artery via the gastroduodenal artery for locoregional chemoimmunotherapy. Two days after the first-stage surgery locoregional transarterial targeting chemoimmunotherapy was given. The second-stage hemihepatectomy was carried out forty to forty-five days after the initial surgery. As an adjuvant treatment locoregional targeting chemoimmunotherapy was carried out in all patients via the arterial chemoport. RESULTS: Mean survival was 66+/-4 months. There were no operative deaths. CONCLUSIONS: Two-stage liver surgery including, portal vein branch ligation, microwave ablative therapy and transarterial targeting locoregional chemoimmunotherapy is the best treatment for advanced, synchronous metastatic liver disease of colorectal origin. It results in an increase in the overall survival of these patients with good postoperative quality of life, which encourages the hepato-biliary surgeon to venture upon this herculean task thus increasing the resectability rate of the tumor.     

Multimodality approach towards advanced rectal carcinoma. "Its efficacy and safety"

BACKGROUND/AIMS: To evaluate the efficacy and safety of multimodality approach towards advanced rectal cancer. METHODOLOGY: In a prospective, randomized trial, two hundred and ten patients with advanced carcinoma of the rectum were studied. Patients were randomly divided in two groups A and B. Patients in group A underwent total mesorectal excision (TME) with adjuvant systemic chemotherapy and radiotherapy. Group B patients underwent TME with adjuvant stop-flow perfusion along with systemic chemotherapy RESULTS: The five-year survival for Group A patients was 72% and for Group B patients the overall five-year survival was 92% and the disease-free survival was 87%. CONCLUSIONS: Multimodality approach to advanced rectal cancer leads to substantial prolongation of survival and optimization of quality of life.     

New frontiers in the management of advanced hepatocellular carcinoma. "A new look to an old problem"

BACKGROUND/AIMS: To evaluate the benefits of two-stage liver surgery with main portal branch ligation and transection combined with transarterial targeting locoregional neo and adjuvant immunochemotherapy in patients suffering from hepatocellular carcinoma. METHODOLOGY: 43 consecutive patients underwent two-stage liver surgery for advanced hepatocellular carcinoma. First we performed ligation and transection of the main portal vein branch corresponding to the liver lobe occupied by the tumor. Subsequently we introduced an arterial jet port catheter towards the hepatic artery via the gastroduodenal artery. After locoregional transarterial targeting immunochemotherapy regimen the patient underwent a second laparotomy for hemihepatectomy. Following surgery, locoregional transarterial targeting immunochemotherapy was given to all patients via the arterial port of the gastroduodenal artery as an adjuvant treatment. RESULTS: Mean survival was 41 months. There were no operative deaths. CONCLUSIONS: Two-stage liver surgery and transarterial targeting locoregional immunochemotherapy is the favorable option of treatment for advanced hepatocellular carcinoma. It not only results in an increase in the overall survival of these patients, but also increases the rate of resectability of these tumors by the hepatobiliary surgeon.     

Regional chemoimmunotherapy for nonresectable metastatic liver disease of colorectal origin. A prospective randomized study

BACKGROUND/AIMS: The study has been designed to assess the potential advantages of regional targeting chemoimmunotherapy versus systemic chemotherapy and immunotherapy in a number of patients suffering from nonresectable metastatic liver disease of colorectal origin. METHODOLOGY: From January 1996 to January 2001 (86) patients with unresectable metastatic liver disease of colorectal origin were randomly assigned to two groups. Group A (n = 44 patients), who received regional targeting chemoimmunotherapy through an arterial catheter introduced subcutaneously under echo guidance into the hepatic artery. Group B (n = 42 patients) received systemic chemoimmunotherapy. RESULTS: Survival of Group A patients ranged from 9 to 48 months (mean: 33 months), while Group B patients' survival ranged from 8 to 18 months (mean: 10 months). Response to treatment was 75% for Group A patients versus 52% for Group B. There were statistically significant differences in survival between the two groups (P = 0.0001). CONCLUSIONS: We believe that the data of this study reconfirms previously reported experience about the advantages of regional chemoimmunotherapy when compared with systemic chemoimmunotherapy for the management of advanced metastatic liver disease.     

Preoperative main portal branch transection combined with liver locoregional transarterial neo and adjuvant immunochemotherapy for patients with hepatocellular carcinoma

BACKGROUND/AIMS: Main portal branch embolization was developed several years before in an attempt to improve prognosis and outcome for patients suffering from advanced liver malignancies. METHODOLOGY: From September 1993 to September 2000 43 patients with advanced hepatocellular carcinoma underwent main portal branch transection and neo- and adjuvant transarterial immunochemotherapy. Forty days after initial surgery, all patients underwent a phase II surgical exploration for liver resection. RESULTS: Survival ranged from 18 months to 64 months with a median of 41 months. Two- and 5-year survival was 75% and 57%, respectively. CONCLUSIONS: Main portal branch transection combined with major liver resection and neoadjuvant and adjuvant locoregional immunochemotherapy fulfilled our expectations firstly for increasing the resectability rate and secondly for increasing the overall survival and the disease-free survival.     

Preoperative defining system for pancreatic head cancer considering surgical resection

AIM: To provide appropriate treatment, it is crucial to share the clinical status of pancreas head cancer among multidisciplinary treatment members. METHODS: A retrospective analysis of the medical records of 113 patients who underwent surgery for pancreas head cancer from January 2008 to December 2012 was performed. We developed preoperative defining system of pancreatic head cancer by describing "resectability- tumor location- vascular relationship- adjacent organ involvement- preoperative CA19-9(initial bilirubin level)- vascular anomaly". The oncologic correlations with this reporting system were evaluated.RESULTS: Among 113 patients, there were 75 patients(66.4%) with resectable, 34 patients(30.1%) with borderline resectable, and 4 patients(3.5%) with locally advanced pancreatic cancer. Mean disease-free survival was 24.8 mo(95%CI: 19.6-30.1) with a 5-year diseasefree survival rate of 13.5%. Pretreatment tumor size ≥ 2.4 cm [Exp(B) = 3.608, 95%CI: 1.512-8.609, P = 0.044] and radiologic vascular invasion [Exp(B) = 5.553, 95%CI: 2.269-14.589, P = 0.002] were independent predictive factors for neoadjuvant treatment. Borderline resectability [Exp(B) = 0.222, P = 0.008], pancreatichead cancer involving the pancreatic neck [Exp(B) = 9.461, P = 0.001] and arterial invasion [Exp(B) = 6.208, P = 0.010], and adjusted CA19-9 ≥ 50 [Exp(B) = 1.972 P = 0.019] were identified as prognostic clinical factors to predict tumor recurrence. CONCLUSION: The suggested preoperative defining system can help with designing treatment plans and also predict oncologic outcomes.     

Nodal involvement is strongest predictor of poor survival in patients with invasive adenocarcinoma of the head of the pancreas

BACKGROUND/AIMS: Pancreatic cancer is a devastating disease with an extremely poor prognosis. The outcome of pancreatic head cancer after surgical resection is still difficult to predict. METHODOLOGY: Between September 1992 and December 2003, 100 consecutive patients with invasive adenocarcinoma of the head of the pancreas who underwent surgical resection were retrospectively analyzed to clarify the influence of clinicopathological factors. RESULTS: The overall 1-, 3-, and 5-year survival rates for the 100 patients with pancreatic head cancer were 55%, 16%, and 6%, respectively. Among the 16 clinicopathologic factors, 9 were significantly associated with outcome in univariate analysis: tumor type (invasive ductal cancer), poor histological differentiation, extrapancreatic plexus invasion, bile duct invasion, duodenal invasion, intrapancreatic nerve invasion, lymphatic invasion, venous invasion, and nodal involvement. Multivariate analysis confirmed that nodal involvement (p = 0.005) and extrapancreatic plexus invasion (p = 0.03) were significant independent factors for overall survival. CONCLUSIONS: Nodal involvement was the strongest predictor of poor survival after pancreatic resection for invasive adenocarcinoma of the head of the pancreas.     

Consecutive re-explorations for final resection of initially unresectable pancreatic head carcinoma.

BACKGROUND/AIMS: The lack of high surgical expertise and specialization of the practicing surgeon may lead some patients with pancreatic cancer to die. This study also investigates the role of combined neo and adjuvant locoregional immunochemotherapy in patients considered initially as non-amenable to resection. METHODOLOGY: 32 patients underwent re-exploration aiming at pancreatic resection. After the initial diagnostic work-up 22 of them underwent pancreatic resection during the first re-exploration. The remaining 10 patients were judged again as unresectable. All 32 patients had 2 catheters introduced into a side arterial branch of the jejunal artery and vein for locoregional immunochemotherapy. Seven out of 10, considered as unresectable initially, had pancreatic resection after immunochemotherapy regimen. RESULTS: All patients survived surgery. Early morbidity included wound infection in 3, bleeding in 1 and leakage of gastric stump in 1 patient. Treatment related toxicity included leukopenia in 4 patients, anemia in 3 and fever and chills in 21. Mean follow-up was 62 +/- 1.2 months. One-, 2-, 3- and 5-year survival was 100, 80, 70 and 48% respectively. CONCLUSIONS: Our results strongly support the necessity for neo and adjuvant locoregional immunochemotherapy and its contribution to prolongation of survival.     

Postoperative adjuvant arterial chemoembolization improves survival of hepatocellular carcinoma patients with risk factors for residual tumor:A retrospective control study

AIM:To evaluate the effect of postoperative adjuvanttranscatheter arterial chemoembolization(TACE)on theprognosis of hepatocellular carcinoma(HCC)patients withor without risk factors for the residual tumor.METHODS:From January 1995 to December 1998,549consecutive HCC patients undergoing surgical resectionwere included in this research.There were 185 patientswho underwent surgical resection with adjuvant TACE and364 patients who underwent surgical resection only.Tumorswith a diameter more than 5 cm,multiple nodules,andvascular invasion were defined as risk factors for residualtumor and used for patient stratification.Kaplan-Neiermethod was used to analyze survival curve and Coxproportional hazard model was used to evaluate theprognostic significance of adjuvant TACE.RESULTS:In the patients without any risk factors for theresidual tumor,the 1-,3-,5-year survival rates were 93.48%,75.85%,62.39% in the control group and 97.39%,70.37%,50.85% in the adjuvant TACE group,respectively.Therewas no significant difference in the survival between twogroups(P=0.3956).However,in the patients with riskfactors for residual tumor,postoperative adjuvant TACEsignificantly prolonged the patients' survival.There was astatistically significant difference in survival between twogroups(P=0.0216).The 1-,3-,5-year survival rates were69.95%,49.86%,37.40% in the control group and 89.67%,61.28%,44.36% in the adjuvant TACE group,respectively.Cox proportional hazard model showed that tumor diameterand cirrhosis,but not the adjuvant TACE,were the significantlyindependent prognostic factors in the patients without riskfactors for residual tumor.However,in the patients withrisk factors for residual tumor adjuvant TACE,and alsotumor diameter,AFP level,vascular invasion,were thesignificantly independent factors associated with thedecreasing risk for patients'death from HCC.CONCLUSION:Postoperative adjuvant TACE can prolongthe survival of patients with risk factors for residual tumor,but can not prolong the survival of patients without riskfactors for residual tumor.     

Postoperative adjuvant arterial chemoembolization improves survival of hepatocellular carcinoma patients with risk factors for residual tumor： A retrospective control study

AIM: To evaluate the effect of postoperative adjuvant transcatheter arterial chemoembolization (TACE) on the prognosis of hepatocellular carcinoma (HCC) patients with or without risk factors for the residual tumor. METHODS: From January 1995 to December 1998, 549 consecutive HCC patients undergoing surgical resection were included in this research. There were 185 patients who underwent surgical resection with adjuvant TACE and 364 patients who underwent surgical resection only. Tumors with a diameter more than 5 cm, multiple nodules, and vascular invasion were defined as risk factors for residual tumor and used for patient stratification. Kaplan-Meier method was used to analyze survival curve and Cox proportional hazard model was used to evaluate the prognostic significance of adjuvant TACE.RESULTS: In the patients without any risk factors for the residual tumor, the 1-, 3-, 5-year survival rates were 93.48%,75.85%, 62.39% in the control group and 97.39%, 70.37%,50.85% in the adjuvant TACE group, respectively. There was no significant difference in the survival between two groups (P = 0.3956). However, in the patients with risk factors for residual tumor, postoperative adjuvant TACE significantly prolonged the patients‘ survival. There was a statistically significant difference in survival between two groups (P= 0.0216). The 1-, 3-, 5-year survival rates were 69.95%, 49.86%, 37.40% in the control group and 89.67%,61.28%, 44.36% in the adjuvant TACE group, respectively. Cox proportional hazard model showed that tumor diameter and cirrhosis, but not the adjuvant TACE, were the significantly independent prognostic factors in the patients without risk factors for residual tumor. However, in the patients with risk factors for residual tumor adjuvant TACE, and also tumor diameter, AFP level, vascular invasion, were the significantly independent factors associated with the decreasing risk for patients‘ death from HCC. CONCLUSION: Postoperative adjuvant TACE can prolong the survival of patients with risk factors for residual tumor,but can not prolong the survival of patients without risk factors for residual tumor.     

Upper abdominal stop-flow perfusion as a neo and adjuvant hypoxic regional chemotherapy for resectable gastric carcinoma. A prospective randomized clinical trial.

BACKGROUND/AIMS: Gastric cancer remains a disease with a poor and dismal prognosis even after radical surgical resection. The present study attempts to clarify whether neo and adjuvant hypoxic upper abdominal chemotherapy can improve the survival of patients with gastric cancer undergoing radical surgical resection. Patterns of failure after surgery for gastric cancer include peritoneal seeding, resection margin recurrence, and liver metastasis. METHODOLOGY: From October 1995 to February 1999, 58 patients with resectable gastric cancer were randomly assigned to three groups. Hypoxic upper abdominal chemotherapy was carried out using Mitomycin-C, 5-Fluorouracil, Leucovorin, and Farmorubicin, 10 days before surgery, and 20 days following surgery, in Group A (n=20) with or without in Group B (n=19) systemic chemotherapy; the remaining patients (Group C: n=19) had neither neo nor adjuvant treatment. RESULTS: The 4-year survival of Group C patients was 29.2%. Group A patients (surgery plus hypoxic neo and adjuvant chemotherapy and systemic chemotherapy) had a 4-year survival of 45.5% versus a 4-year survival of 39.2% of Group B patients (surgery and hypoxic neo and adjuvant abdominal perfusion). Patients of all stages, histologically confirmed, were included in this study. CONCLUSIONS: Patients suffering from gastric carcinoma have demonstrated statistically improved survival by combining resectional surgery with neo and adjuvant hypoxic upper abdominal perfusion and adjuvant systemic chemotherapy.     

Prognostic factors in patients with carcinoma of the papilla of Vater

BACKGROUND/AIMS: The prognosis after curative resection for patients with carcinoma of the papilla of Vater is relatively better than that for other peripancreatic cancer. However, prognostic factors after resection of the carcinoma have not been identified. METHODOLOGY: From 1983 to 1999, 16 patients with carcinoma of the papilla of Vater underwent standard pancreatoduodenectomy and dissection of regional lymph nodes. We followed the patients for 63 days to 17 years (median, 27 months) and analyzed clinicopathologic variables in relation to prognosis. RESULTS: The survival rate at 5 years was 50.5%. The morphologic factors predicting poor outcome were macroscopic ulcer formation and microscopic pancreatic, venous, or perineural invasion. Tumors with ulcer formation tended to infiltrate into the duodenum and pancreas, but not into veins or the perineural space. Eight of 16 patients died due to recurrence of the cancer; liver metastasis (n = 6) or peritoneal dissemination (n = 2). CONCLUSIONS: Patients with carcinoma of the papilla of Vater demonstrating ulcer formation or invasion into the pancreas, vein, or perineural space may benefit from adjuvant therapy to reduce the risk of liver metastasis. Careful observation is essential for liver metastasis or peritoneal dissemination after surgery; especially in patients with ulcer formation or venous invasion.     

Metastatic liver disease of colorectal origin: the value of locoregional immunochemotherapy combined with systemic chemotherapy following liver resection. Results of a prospective randomized study

BACKGROUND/AIMS: Liver resection for metastatic liver disease of colorectal origin, although considered as the 'gold standard' of treatment, is associated with limited long-term survival. The aim of this study was to compare overall survival, disease-free survival and the incidence of intra- or extrahepatic recurrence between patients who were randomly assigned to have locoregional chemoimmunotherapy with systemic chemotherapy group A (n = 62 patients) versus those who were treated with systemic immunochemotherapy group B (n = 60 patients). METHODOLOGY: Group A included patients who, after liver resection, received locoregional immunochemotherapy combined with systemic chemotherapy, while group B included patients who had undergone systemic immunotherapy combined with systemic chemotherapy following liver resection. The two groups were matched in terms of sex, age and stage of the disease. Prognostic factors and their impact on disease-free survival were studied in both groups. RESULTS: Two-year survival was 92% for group A versus 75% for group B, 5-year survival was 73% for group A versus 60% for group B. During the two-year period, 34% of the group A patients versus 52% of those of group B developed either intrahepatic or extrahepatic recurrence of the disease (P < 0.00212). CONCLUSIONS: From the analysis of the above results it becomes clear that regional immunochemotherapy combined with systemic chemotherapy leads to a decrease in the incidence of disease recurrence and thus to a significant prolongation of the overall survival and of disease-free survival.     

Results of vascular resections during pancreatectomy from two European centres: an analysis of survival and disease-free survival explicative factors

Objectives

The object of our study was to report on the experience with vascular resections at pancreatectomy in two European specialist hepatopancreatobiliary centres and evaluate outcome and prognostic factors.

Patients and methods

From 1989 to 2002, 45 patients (21 men, 24 women) underwent pancreatectomy for a pancreatic mass: Whipple''s procedure (n=33), total pancreatectomy (n=10) or left splenopancreatectomy (n=2), along with a vascular resection, i.e. venous (n=39), arterial (n=1) or venous + arterial (n=5).

Results

Operative mortality was nil, postoperative mortality was 2.2% (n=1); 34 patients had an uneventful postoperative course. Reoperations were performed for portal vein thromobosis (n=1), pancreatic leak (n=1), gastric outlet syndrome (n=1) and gastrointestinal bleeding (n=1). In all, 43 patients had cancer on pathology examination, with retropancreatic invasion in 72% and lymph node extension in 62.8%. Resection was R0 in 21 cases. Vessel wall invasion was present in 13 cases and 19 had perivascular invasion. Disease-free survival (DFS) at 1, 2 and 3 years was 36.0%, 15.0% and 12.0%, respectively. Median DFS length was 8.7 months (95% CI: 7.2; 10.2). Overall survival rates were 56.6%, 28.9% and 19.2%, respectively. Median survival length was 14.2 months (95% CI: 9.8; 18.6). A multivariate analysis of prognostic variables identified tumour location (other than head of pancreas), neoadjuvant chemotherapy and advanced disease stage as adverse factors for DFS.

Conclusion

Survival and DFS rates of these patients are comparable to those without vascular resection. Tumour localization, tumour stage, neoadjuvant treatment and tumour recurrence are explanatory variables of survival. Tumour localization, tumour stage and neoadjuvant treatment were explanatory variables for DFS. However, the type and extent of vascular resections as well as vessel wall invasion does not affect survival and DFS.     

Prognostic factors of intrahepatic cholangiocarcinoma after hepatic resection: univariate and multivariate analysis

BACKGROUND/AIMS: Intrahepatic cholangiocarcinoma is clinicopathologically distinct from hepatocellular carcinoma and hilar cholangiocarcinoma, and the prognostic factors after hepatic resection of these rare tumors are not well documented. The aim of this study was to evaluate prognostic factors of intrahepatic cholangiocarcinoma after hepatic resection. METHODOLOGY: We retrospectively studied 20 consecutive patients with intrahepatic cholangiocarcinoma who underwent hepatectomy over a 15-year period from 1984 to 1998. Fifteen prognostic factors were evaluated for their association with overall and disease-free survivals in univariate and multivariate analysis (Cox's proportional hazards model). RESULTS: Eighty percent of the resected patients had major hepatectomy. Operative morbidity and mortality rates were 30% and 0%, respectively. Four patients (20%) survived more than 5 years without recurrence after hepatic resection. The 1-year, 3-year, and 5-year overall or disease-free survival rate after hepatic resection were 56.0% or 49.5%, 43.8% or 43.3%, and 43.8% or 37.3%, respectively. Univariate analysis showed young age and periductal invasion tumor or the presence of vascular invasion, lymphatic invasion, and lymph node metastasis as significant poor prognostic predictors contributing overall and disease-free survivals. Multivariate analysis revealed only lymph node metastasis as an independent prognostic factor affecting disease-free survival. During the same time, 17 unresectable patients were treated by intrahepatic arterial infusion chemotherapy (12), systemic chemotherapy (4), or radiation (1). Median overall survival time in resected patients (16 months) was significantly better than in unresectable patients (5 months) (P = 0.005). CONCLUSIONS: Hepatic resection remains to be the best current therapeutic option. The prognosis after hepatic resection for intrahepatic cholangiocarcinoma was determined by lymph node metastasis. New adjuvant chemotherapy after surgery is imperative for such patients.     

Long-term results following resectional surgery for Klatskin tumors. A twenty-year personal experience

BACKGROUND/AIMS: The purpose of this study was to assess whether long-term survival in patients suffering from cholangiocarcinomas of the porta hepatis is significantly different when comparing results between local and extended procedures in order to justify increased mortality and morbidity following extensive resections. METHODOLOGY: From November 1991 to May 2000, 46 patients with Klatskin tumor were assigned to two groups. Group A patients (n = 25) had local resection and group B patients (n = 21) had local resection plus hemihepatectomy. On admission, all patients were drained via percutaneous transhepatic biliary drainage. In all patients we proceeded with an internal biliary drainage in order to anticipate jaundice and decompensated liver function. Internal biliary drainage was carried out 35-40 days before surgery. At the end of the operation an arterial catheter was introduced into the common hepatic artery for adjuvant locoregional targeting immunochemotherapy, which was initiated 20 days following surgery in all patients. RESULTS: Overall survival for group A patients ranged from 14 months to 76 months (mean: 29). Disease-free survival ranged from 10-52 months (mean: 25). Five-year survival rate was 10%. Five-year disease-free survival was 0%. Overall survival for group B patients ranged from 28 months to 79 months (mean: 39). Disease-free survival ranged from 17-72 months (mean: 32). Five-year survival rate was 20%. Five-year disease-free survival rate was 10%. CONCLUSIONS: Combined tumor and liver resection is associated with significantly better results when compared with those following tumor resection alone.     

Factors influencing recurrence after surgical treatment for T2 gallbladder carcinoma

BACKGROUND/AIMS: The overall outcome of T2 gallbladder carcinoma has not been favorable, although there is a modest hope for long-term survival after radical resection. The aim of this study was to examine factors influencing postoperative disease-free survival of patients with T2 gallbladder carcinoma to clarify optimal treatment. METHODOLOGY: Of 53 patients with gallbladder carcinoma who had undergone surgical resection from 1985 to 2000, 22 had T2 carcinoma histologically proved. The significance of variables for disease-free survival was examined retrospectively by the Kaplan-Meier method and the log-rank test. RESULTS: There were 16 patients with stage II (T2N0M0), 6 with stage III (T2N1M0) disease. Eleven patients were treated by extended cholecystectomy with resection of the extrahepatic bile duct, 10 patients underwent extended cholecystectomy without resection of the extrahepatic bile duct, and 1 patient underwent cholecystectomy. All patients underwent lymph node dissection in the hepatoduodenal ligament, below the pancreatic head, and along the common hepatic artery. Lymph node metastasis was present in 6 patients. Lymphatic, venous, and perineural invasions were found in 9, 4, and 4 patients, respectively. The absence of lymphatic invasion was a significant factor related to good postoperative disease-free survival (5-year disease-free survival rate, 88.9% vs. 31.3% in the presence of lymphatic invasion). Lymph node, venous, or perineural invasion, and surgical procedure were not significant factors to good postoperative disease-free survival. CONCLUSIONS: For patients with T2 gallbladder carcinoma, the presence of lymphatic invasion is an unfavorable prognostic indicator that calls for additional treatment after radical surgery.     

Locoregional chemotherapy in pancreatic cancer

BACKGROUND/AIMS: Investigating whether or not locoregional chemotherapy has an effect on survival among patients with pancreatic cancer. The possibility of radical surgical interventions for treatment of cancer of the pancreas is very low. Locoregional chemotherapy is one of the modalities advocated to increase survival of such patients. METHODOLOGY: Twenty-nine patients with cancer of the pancreas underwent surgery in our clinic. Eleven patients were female and 18 were male. Surgical procedures and adjuvant locoregional chemotherapy applied to these patients as well as survival obtained are evaluated and compared to those reported in the literature. RESULTS: Eight of the 9 patients that received curative surgery and adjuvant locoregional chemotherapy are still alive after 5, 6, 7, 7, 9, 12, 13, and 17 months. Seventeen patients with advanced stage pancreatic cancer had palliative diversion procedures. Mean survival was 10.5 months for the seven that received locoregional chemotherapy, but 6.2 months for the 10 patients that did not receive locoregional chemotherapy. Mean survival of 3 patients that had only laparotomy was 2.3 months. CONCLUSIONS: Neoadjuvant or adjuvant locoregional chemotherapy has a beneficial effect on the survival of patients that undergo curative or palliative surgery for pancreatic cancer. However further multicenter trials are necessary.