Serosal invasion in TNM staging of mass-forming intrahepatic cholangiocarcinoma

Background/Purpose The Liver Cancer Study Group of Japan established a tumor-nodule-metastasis (TNM) staging system for mass-forming intrahepatic cholangiocarcinoma, with T determined by tumor number and size and vascular or serosal invasion. Serosal invasion is not considered in the designation established by the International Union Against Cancer. Methods Sixty-three patients who underwent hepatic resection for mass-forming intrahepatic cholangiocarcinoma were investigated retrospectively, with the investigation including univariate and multivariate analyses of potential prognostic factors. Results By log-rank test, tumor size more than 3.0 cm, vascular invasion, lymph node metastasis, intrahepatic metastasis, and involved resection margin, but not serosal invasion, were associated significantly with poor prognosis. Even in patients with serosal invasion, the postoperative outcome was much better in those without than in those with vascular invasion. Multivariate analysis identified vascular invasion, lymph node metastasis, and an involved resection margin as independent prognostic factors. When serosal invasion was excluded from tumor staging, the 5-year survival rates became more clearly stratified: 100% in those with stage I disease, 62% in those with stage II, 25% in those with stage III, and 7% for patients with stage IV. Conclusions Serosal invasion showed no survival impact after hepatic resection for mass-forming intrahepatic cholangiocarcinoma. When serosal invasion was omitted from the TNM staging proposed by the Liver Cancer Study Group of Japan, stratification of postoperative survival between stages was more effective.     

Aggressive surgical resection for hilar-invasive and peripheral intrahepatic cholangiocarcinoma

Abstract The clinicopathology and surgical outcome of intrahepatic cholangiocarcinomas are not fully understood. The objective of this study was to clarify the clinicopathologic features of intrahepatic cholangiocarcinoma and evaluate prognostic factors influencing survival. Forty consecutive patients with intrahepatic cholangiocarcinomas undergoing surgical resection at Chiba University Hospital between October 1981 and October 1997 were analyzed retrospectively. Intrahepatic cholangiocarcinomas were classified as hilar-invasive type (n = 26) or peripheral type (n = 14). Patients with peripheral-type tumors had a significantly (p = 0.005) better 5-year survival rate (43%) than those with the hilar-invasive type (4%). Hilar-invasive-type tumors had perineural invasion (100%) and nodal involvement (85%) more frequently than did peripheral-type tumors. Despite aggressive surgical resection, the surgical margin was positive in 88% of patients with hilar-invasive type tumors (23/26) and 29% of patients with peripheral-type tumors (4/14). There was no evidence of a survival benefit of vascular resection for patients with a hilar-invasive intrahepatic cholangiocarcinoma. Patients with lymph node metastasis had a significantly worse prognosis (p = 0.0004). No patients with nodal involvement survived more than 38 months. Negative perineural invasion (p = 0.008) and a negative microscopic margin (p = 0.008) were significantly associated with improved survival. Better survival results could be achieved by curative resection with a free margin for hilar-invasive and peripheral intrahepatic cholangiocarcinoma. Electronic Publication     

Outcome of radical surgery for stage IV gallbladder carcinoma

BACKGROUND/PURPOSE: The role of aggressive surgery for patients with stage IV gallbladder carcinoma was examined. METHODS: Cancers were classified according to the TNM system of the Japanese Society of Biliary Surgery. The survival of 37 patients with stage IV cancer (stage IVa, n = 15; stage IVb, n = 22) treated by surgical resection during the period January 1990 to December 2004 was examined and compared with the survival of 41 patients with stage IV disease not treated by surgical resection during the same period. RESULTS: The postoperative survival rate was significantly better for patients with resected stage IVa cancer than for patients with resected stage IVb disease and for those with nonresected stage IV disease. Survival in patients with N3 lymph node metastasis, liver metastasis, peritoneal dissemination, or vascular invasion was poor, like that in the nonresected group. Surgical resection without residual tumors (curability A and B) yielded a significantly better outcome than that with residual tumor (curability C). There were three 5-year survivors that were treated successfully by curative resection (curability A and B) and all had T4N0 disease. CONCLUSIONS: These results suggest that surgical resection significantly improves survival even in patients with stage IV gallbladder carcinoma when N3 metastasis, liver metastasis, peritoneal dissemination, and vascular invasion are absent. Curative resection can be expected to produce long-term survival in selected patients with stage IV gallbladder carcinoma.     

Indications for surgical treatment of intrahepatic cholangiocarcinoma with lymph node metastases

BACKGROUND/PURPOSE: The postoperative outcome of patients who have intrahepatic cholangiocarcinoma with lymph node metastases is extremely poor, and the indications for surgery for such patients have yet to be clearly established. METHODS: The demographic and clinical characteristics of 133 patients who underwent lymph node dissection during hepatic resection of intrahepatic cholangiocarcinoma were retrospectively analyzed. RESULTS: Multivariate analysis identified three independent prognostic factors: intrahepatic metastasis, nodal involvement, and tumor at the margin of resection. Of the patients with tumor-free surgical margins, none of the 24 patients who had both lymph node metastases and intrahepatic metastases survived for 3 years. In contrast, the survival rates for the 23 patients who had lymph node metastases associated with a solitary tumor were 35% at 3 years and 26% at 5 years. CONCLUSIONS: Surgery alone cannot prolong survival when both lymph node metastases and intrahepatic metastases are present, while surgery may provide a chance for long-term survival in some patients who have lymph node metastases associated with a solitary intrahepatic cholangiocarcinoma tumor.     

Surgical treatment of malignant mediastinal neurogenic tumors in children.

INTRODUCTION: The aim of this study was to identify the role of surgical resection in the treatment of malignant mediastinal neurogenic tumors in children. MATERIALS AND METHODS: Thirty-eight consecutive children, who underwent surgical resection of a malignant mediastinal neurogenic tumor between 1986 and 2004, were included in this study. The tumor cell types were neuroblastoma in 23 patients (60.5%), ganglioneuroblastoma in 14 (36.8%), and malignant neuroepithelioma in 1 (2.6%). Surgery was performed for curative resection in localized tumors and salvage resection of residual mediastinal masses after chemotherapy in stage IV tumors. Of the 16 patients (42.1%) who underwent salvage resection, 14 had neuroblastoma and 2 ganglioneuroblastoma. RESULTS: Mean patient age was 3.4+/-3.0 years (1 month-13 years) and 26 patients (68.4%) were symptomatic at presentation. Adjacent structure invasion was found in eight patients (21.1%), invasion of chest wall in four, heart and vena cava in two, lung in one, and chest wall and lung in one. Complete gross resection was possible in 30 patients (78.9%) and there was no surgical mortality. Surgical morbidity occurred in 10 patients (26.3%) and Horner's syndrome was the most frequent complication (n=7). The 5-year survival was 95.2% for a localized tumor and 52.5% for a stage IV tumor (p=0.004). The significant risk factors of long-term survival were adjacent structure invasion (p=0.002) and a stage IV tumor (p=0.002) by multivariate Cox regression analysis. CONCLUSIONS: Surgical resection of localized malignant mediastinal neurogenic tumor in children showed good long-term survival, and salvage operations after chemotherapy showed acceptable long-term survival.     

Clinicopathological factors predicting outcome after resection of mass-forming intrahepatic cholangiocarcinoma.

BACKGROUND: The prognosis for patients with intrahepatic cholangiocarcinoma differs according to macroscopic type. The identification of clinical and pathological features that predict outcome in patients with mass-forming intrahepatic cholangiocarcinoma is required in order to determine optimal surgical strategies for patients with this type of tumour. METHODS: The details of 35 patients with resected mass-forming intrahepatic cholangiocarcinomas were analysed retrospectively. Univariate analysis of potential prognostic factors was performed. RESULTS: The cumulative survival rate at 1, 3 and 5 years after operation was 58, 33 and 33 per cent respectively. Patients with stage II tumours had a better outcome than those with advanced stage tumours. By univariate analysis, lymphatic invasion, lymph node metastasis, intrahepatic satellite lesions and microscopic resection margin involvement were found to be highly significant variables and were identified as possible risk factors for a poor outcome after operation. CONCLUSION: When frozen-section examination of lymph nodes reveals negative nodal metastasis, extensive anatomical hepatic resection is indicated for mass-forming intrahepatic cholangiocarcinomas. Intraoperative frozen-section examination of the resection margin to confirm the absence of cancer cells is recommended.     

胆管细胞性肝癌外科治疗的预后因素分析

目的探讨影响胆管细胞性肝癌外科治疗预后的因素。方法回顾性分析2000年1月至2010年1月天津医科大学附属肿瘤医院行外科治疗的99例胆管细胞性肝癌患者的临床资料。所有患者行常规淋巴结清扫,清扫范围包括肝门及第12、13和8组淋巴结。根据肿瘤的大小、位置、数目及肝功能状况确定肝切除的范围。患者术后半年内每个月门诊复查,半年后每3个月复查1次,2年后每半年复查1次,对怀疑有复发或疾病进展者每月复查1次。对未能按时就诊的患者进行电话随访。随访时间截至患者死亡或2013年3月。生存分析采用Log—rank检验。经过单因素分析有统计学意义的变量进一步采用COX逐步回归模型进行预后多因素分析。结果99例胆管细胞性肝癌患者中,40例行半肝切除术,27例行扩大半肝切除术,20例行肝段切除术,12例行半肝切除＋楔形切除术。99例患者均获得随访,中位随访时间为33个月（21．1～44．9个月）。患者术后1、3、5年的无复发生存率及总生存率分别为64．6％、29．2％、22．7％和78．8％、46．4％、30．3％。单因素分析结果表明：病毒性肝炎、术前CAl9—9、TNM分期、淋巴结转移、微血管侵犯、结节数目和R。切除是影响患者无复发生存率的危险因素（Log—rank值=5．048,5．982,20．128,13．148,29．632,32．488,50．574,P〈0．05）;术前CAl9—9、TNM分期、淋巴结转移、微血管侵犯、结节数目和R。切除是影响患者总生存率的危险因素（Log—rank值=4．302,17．267,11．756,23．840,36．411,47．126,P〈0．05）。进一步分析发现：TNM分期患者（I期20例、Ⅱ期44例、Ⅲ期8例、Ⅳ期27例）中,各期患者的无复发生存时间和总生存时间比较,差异均有统计学意义（Log—rank值=20．128,17．267,P〈0．05）。I期与Ⅲ、Ⅳ期和Ⅱ期与Ⅳ期患者无复发生存时间比较,差异有统计学意义（Log—rank值=10．807,19．368,6．347,P〈0．05）;I期与Ⅱ、Ⅲ、Ⅳ期和Ⅱ期与Ⅳ期患者总生存时间比较,差异有统计学意义（Log-rank值=6．119,4．015,16．282,4．929,P〈0．05）;其余各期患者比较,差异无统计学意义（P〉0．05）。多因素分析结果表明：TNMm期和Ⅳ期、微血管侵犯、多结节和Rn切除是影响无复发生存时间独立危险因素（RR=1．413,3．073,2．737,3．916,95％可信区间：1．119～1．784,1．837～5．140,1．338～4．207,1．849～8．291,P〈0．05）;淋巴结转移、微血管侵犯、多结节和R。切除是影响总生存时间的独立危险因素（RR=2．025,2．948,0．327,3．494,95％可信区间：1．215～3．374,1．774～4．900,0．183～0．583,1．670～7．310,P〈0．05）。结论TNMHI期和Ⅳ期、淋巴结转移、微血管侵犯、多结节、非R0切除导致胆管细胞性肝癌患者术后无复发生存时间和总生存时间明显缩短,是预后不良的主要影响因素。R0切除是改善胆管癌患者预后的最大希望。     

Extended hepatectomy for intrahepatic cholangiocellular carcinoma (ICC): when is it worthwhile? Single center experience with 27 resections in 50 patients over a 5-year period

OBJECTIVE: To evaluate the role of extended hepatectomy in locally advanced intrahepatic cholangiocarcinoma (ICC). SUMMARY BACKGROUND DATA: ICC is a rare tumor which has to be clearly distinguished from hepatocellular carcinoma and extrahepatic bile duct carcinoma. It is believed that long-term survival can only be achieved by surgical resection. METHODS: Between April 1998 and March 2003, 50 patients with locally advanced ICC (tumor involvement of more than 4 liver segments) underwent surgical exploration. Data were analyzed with regard to patients' characteristics, intraoperative details, pathologic findings, and outcome measured by tumor recurrence, treatment of recurrence, and survival. RESULTS: Resectability rate was 27 of 50 (54%). There were 19 extended right and 8 extended left hepatectomies. In addition, in 16 patients the following 29 procedures were performed: resection of hilar bifurcation (n = 12), partial resection of diaphragm (n = 6), partial resection of vena cava (n = 4), resection and reinsertion of left liver vein (n = 1), portal vein resection (n = 5), resection and reconstruction of right hepatic artery (n = 1). Complete tumor removal (R0-resection) was achieved in 16 patients. In 11 cases, there was microscopic tumor at the cutting margin (R1-resection). Following resection, the overall 1- and 3-year-survival rates were 69% and 55%. After R1-resection and explorative laparotomy, median survival was 5 and 7 months, respectively. Following R0-resection, the calculated median survival and 1- and 3-year-survival rates are 46 months, 94% and 82% (P = 0.0039; log-rank test). Tumor recurred in 6 of 16 patients, and so far 2 patients died of recurrence 28 and 46 months after operation. CONCLUSIONS: R0-resection can provide prolonged survival, even in patients with advanced ICC. In particular in solitary tumors without vascular invasion (UICC stage I, sixth classification) there is a major chance for long-term survival and cure. The poor results after R1-resection and the high operative morbidity do not justify palliative resections but underline the need for an improved preoperative assessment of resectability, as well as an aggressive intraoperative approach, to achieve complete tumor resection.     

Indications for extended hepatectomy in the management of stage IV hilar cholangiocarcinoma

HYPOTHESIS: In operations for hilar cholangiocarcinoma, simultaneous extended hepatectomy and removal of extrahepatic bile ducts are considered curative resection. However, the effect of extended operations for stage IV hilar cholangiocarcinoma on survival is still unclear. DESIGN: Retrospective review of the treatment of hilar cholangiocarcinoma from 1981 to 2001.Patients and METHODS: Fifty-seven patients with stage IVA or IVB hilar cholangiocarcinoma were enrolled. Thirty-three of these patients underwent extended hepatectomy to achieve macroscopic radical resection (surgical group). A self-expandable metallic biliary stent (EMBS) was implanted in 24 patients (EMBS group) in whom radical treatment was judged to be impossible.Main Outcome Measure Survival in patients with stage IV hilar cholangiocarcinoma treated by means of extended operation or stenting. RESULTS: Survival was 25.7 +/- 40.9 months in the surgical group vs 6.5 +/- 5.8 months in the EMBS group (P =.03). In the surgical group, radical resection results were macroscopically and histologically successful in 21 patients (64%). In patients with stage IVB disease, survival did not differ between the surgical and EMBS groups. CONCLUSIONS: In patients with stage IVA disease, radical extended hepatectomy should be performed after excluding patients who have extensive invasion of the hepatic artery or portal vein. However, in patients with stage IVB disease with carcinomatous peritonitis or distant metastasis, there is little possibility of achieving long-term survival with surgery, and stent implantation should be the first choice.     

Hepatectomy with portal vein resection for hilar cholangiocarcinoma: audit of 52 consecutive cases

OBJECTIVE: To better determine the role of portal vein resection and its effect on survival, as well as to appreciate the impact of portal vein invasion on prognosis in hilar cholangiocarcinoma. SUMMARY BACKGROUND DATA: Hepatectomy with portal vein resection is sometimes performed for locally advanced hilar cholangiocarcinoma. However, the significance of microscopic invasion of the portal vein has not been determined. METHODS: Medical records of 160 patients with hilar cholangiocarcinoma who underwent macroscopically curative hepatectomy with (n = 52) or without portal vein resection (n = 108) were reviewed. Invasion of the portal vein was assessed histologically on the surgical specimen, and results were correlated with clinicopathologic features and survival. RESULTS: Surgical mortality, including all hospital deaths, was similar in patients who did and did not undergo portal vein resection (9.6% vs. 9.3%), but the primary tumor was more advanced in patients who underwent portal vein resection. Histologically, no invasion was found in 16 (30.8%) of resected portal veins. However, dense fibrosis adjacent to the portal vein was common, and the mean distance between the leading edge of cancer cells and the adventitia of the portal vein was 437 +/- 431 mum. The prognosis was worse in patients with than without portal vein resection (5-year survival, 9.9% vs. 36.8%; P < 0.0001). The presence or absence of microscopic invasion of the resected portal vein did not influence survival (16.6 months in patients with microscopic invasion vs. 19.4 months in those without; P = 0.1506). Multivariate analysis identified histologic differentiation, lymph node metastasis, and macroscopic portal vein invasion as independent prognostic factors. CONCLUSIONS: Microscopic invasion of the portal vein may be misdiagnosed clinically in patients with hilar cholangiocarcinoma. However, the distance between tumor and adventitia is so narrow that curative resection without portal vein resection is unlikely to be possible. Gross portal vein invasion has a negative impact on survival, and hepatectomy with portal vein resection can offer long-term survival in some patients with advanced hilar cholangiocarcinoma.     

Histologic bile duct invasion by a mass-forming intrahepatic cholangiocarcinoma

Abstract. Background/Purpose: Although curative surgical resection provides the best chance of long-term survival for patients with intrahepatic cholangiocarcinoma, the presence of bile duct invasion decreases postoperative survival rates in patients with mass-forming intrahepatic cholangiocarcinoma. We carried out this study to determine a surgical strategy for patients with bile duct invasion of these tumors. Methods: Forty-one patients with mass-forming intrahepatic cholangiocarcinoma were classified as either having bile duct invasion (n= 26) or not having bile duct invasion (n= 15). Clinicopathologic findings, including postoperative outcomes, were compared between these two groups. Results: Perineural invasion, lymphatic invasion, and a positive resection margin were more frequent in patients with ductal invasion. Patients with ductal invasion had lower survival rates than those without ductal invasion. Conclusions: Intraoperative frozen section examination of the bile duct stump to confirm a clear resection margin is required in patients with mass-forming tumors. Resection of the extrahepatic bile duct should be considered when tumor cells are identified at the surgical margin of the resected bile duct. Received: October 30, 2001 / accepted: November 16, 2001     

肝内胆管癌淋巴结转移规律、术中清扫范围及意义

肝内胆管癌（ICC）是起源于肝内小叶间胆管至二级胆管以上的胆管上皮源性恶性肿瘤，约占胆管源性恶性肿瘤的10%。根治性手术切除是ICC惟一可能治愈的手段。而淋巴结转移是影响ICC预后最重要的独立危险因素。对于ICC根治性切除术中是否需要行淋巴结清扫、清扫范围及意义，国际上对此尚有不少争议。多数研究认为对于可手术切除的ICC病人，区域淋巴结清扫是外科治疗的标准部分，有助于术后准确分期及选择有效的辅助治疗方法。同时伴有淋巴结转移的ICC病人都应接受术后系统性治疗。但也有研究表明单纯化疗相对于手术切除能为已有淋巴结转移的ICC病人提供更好的生存获益。     

Intrahepatic Lymphatic Invasion Independently Predicts Poor Survival and recurrences after Hepatectomy in Patients with Colorectal Carcinoma Liver Metastases

BACKGROUND: D2-40 monoclonal antibody immunoreactivity is specific for lymphatic endothelium and therefore provides a marker of lymphatic invasion. We hypothesized that intrahepatic lymphatic invasion reflects the nodal status of colorectal carcinoma liver metastases and may function as an adverse prognostic factor. METHODS: A retrospective analysis of 105 consecutive patients who underwent resection for colorectal carcinoma liver metastases was conducted. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity for D2-40 monoclonal antibody. The median follow-up time was 124 months. RESULTS: Of 105 patients, 13 were classified as having intrahepatic lymphatic invasion. All tumor foci of intrahepatic lymphatic invasion were detected within the portal tracts. Intrahepatic lymphatic invasion was significantly associated with hepatic lymph node involvement (P = 0.039). Survival after resection was significantly worse in patients with intrahepatic lymphatic invasion (median survival time of 13 months; cumulative five-year survival rate of 0%) than in patients without (median survival time of 40 months; cumulative five-year survival rate of 41%; P < 0.0001). Patients with intrahepatic lymphatic invasion also showed decreased disease-free survival rates (P < 0.0001). Intrahepatic lymphatic invasion thus independently affected both survival (relative risk, 7.666; 95% confidence interval, 3.732-15.748; P < 0.001) and disease-free survival (relative risk, 4.112; 95% confidence interval, 2.185-7.738; P < 0.001). CONCLUSIONS: Intrahepatic lymphatic invasion is associated with hepatic lymph node involvement and is an adverse prognostic factor in patients with colorectal carcinoma liver metastases.     

104例肿块型肝内胆管细胞癌病人的临床病理特征、诊断和外科治疗研究

目的分析外科手术治疗后的肝内胆管细胞癌病人临床病理特征与生存时间的相关性。方法从1996年11月至2000年5月共有104例肝内胆管细胞癌病人接受手术治疗。对其临床资料进行归纳,并随访调查。成功回访79例(76·0%)。对16个临床病理因素(年龄、性别、慢性肝病史、HBsAg携带、手术方式、辅助治疗、腹水、淋巴结转移、邻近器官侵犯、肿瘤大小、肿瘤坏死、肿瘤包膜、肝内转移、TNM分期、组织学分级、肝硬化)进行了单因素和多因素相关分析,以了解它们对治疗预后的影响。结果79例病人的1,3,5年生存率分别为49·4%,17·3%和9·6%。单因素相关分析显示性别(P=0·0221),HBsAg携带(P=0·0115),手术方式(P=0·0042),辅助治疗(P=0·0389),腹水(P=0·0001),临近器官侵犯(P=0·0220),肝内转移(P=0·0000),TNM分期(P=0·0001)与生存时间相关。多因素分析表明HBsAg携带、腹水和TNM分期与预后显著相关。结论早期诊断和早期治疗以及规则性肝切除是改善肝内胆管细胞癌外科治疗效果的关键因素。     

Aggressive surgical approach for stage IV gallbladder carcinoma based on Japanese Society of Biliary Surgery classification

BACKGROUND/PURPOSE: The role of aggressive surgery for stage IV gallbladder carcinoma remains controversial. Survival and prognostic factors were analyzed in patients with stage IV disease, based on the Japanese Society of Biliary Surgery (JSBS) classification, to identify the group of patients who could benefit from radical surgery. METHODS: A retrospective analysis was done of 79 patients with JSBS stage IV gallbladder carcinoma who had undergone surgical resection with curative intent at our institution. The standard procedures were anatomical S4a + S5 subsegmentectomy (n = 29) with extrahepatic bile duct resection and extended lymphadectomy, but when right Glisson's sheath and/or the hepatic hilum were involved, right extended hepatectomy (n = 34) or right trisegmentectomy (n = 3) was selected. To achieve a tumor-free margin combined pancreaticoduodenectomy was performed in 12 patients, and major vascular resection in 17 patients. RESULTS: In the patients with stage IV gallbladder carcinoma, the curative resection rate was 65.8% and the hospital mortality rate was 11.4%. The postoperative 5-year survival rate following curative resection was 13.7%. Univariate analysis indicated that curability, hepatoduodenal ligament invasion, nodal involvement, and vascular resection were significant prognostic factors. Neither hepatic invasion nor liver metastasis was a significant factor. CONCLUSIONS: Aggressive surgical resection should be considered even in stage IV patients when hepatoduodenal ligament invasion and nodal involvement are absent or limited. Acceptable survival may be expected among such patients only when curative resection is achieved.     

肝内胆管细胞癌外科手术治疗的现状与进展

肝内胆管细胞癌(ICC)是原发于肝脏的恶性肿瘤,其恶性程度高、远期预后差。根治性手术切除是目前治疗ICC的唯一有效手段。而近年来,随着对ICC生物学行为和临床特点认识的不断深入,其临床分期、手术指征、手术方式、淋巴结清扫等外科治疗策略也在发生着转变。本文结合近年来临床最新研究进展,针对ICC的外科手术治疗的现状进行综述。     

Intrahepatic cholangiocarcinoma: resectability, recurrence pattern, and outcomes

Intrahepatic cholangiocarcinoma (IHC) is a rare primary hepatic tumor of bile duct origin for which resection is the most effective treatment. But resectability, outcomes after resection, and recurrence patterns have not been well described. Patients with IHC were identified from a prospective database. Demographic data, tumor characteristics, and outcomes were analyzed. From March 1992 to September 2000, 53 patients with hepatic tumors underwent exploration and were found to have pure IHC on pathologic analysis. Patients with mixed hepatocellular and cholangiocarcinoma tumors were excluded. At exploration, 20 patients were unresectable for an overall resectability rate of 62% (33 of 53). Median survival for patients submitted to resection was 37.4 months versus 11.6 months for patients undergoing biopsy only (p = 0.006; median followup for surviving patients, 15.6 months). Actuarial 3-year survival was 55% versus 21%, respectively. Factors predictive of poor survival after resection included vascular invasion (p = 0.0007), histologically positive margin (p = 0.009), or multiple tumors (p = 0.003). After resection, 20 of 33 patients (61%) recurred at a median of 12.4 months. Sites of recurrence included the liver (14), retroperitoneal or hilar nodes (4), lung (4), and bone (2). The median disease-free survival was 19.4 months, with a 3-year disease-free survival rate of 22%. Factors predictive of recurrence were multiple tumors (p = 0.0002), tumor size (p = 0.001), and vascular invasion (p = 0.01). About two-thirds of patients who appeared resectable on preoperative imaging were amenable to curative resection at the time of operation. Although complete resection improved survival, recurrence was common. The majority of recurrences were local or regional, which may help guide future adjuvant therapy strategies.     

Late recurrence after resection of mass-forming intrahepatic cholangiocarcinoma: report of a case

The outcome after surgical resection for intrahepatic cholangiocarcinoma has not been satisfactorily evaluated due to its malignant behavior. Surgical resection, however, has the potential to improve the prognosis and may allow surgeons to experience rare cases with long survival. This report presents the case of a patient who developed recurrence 9?years after resection of intrahepatic cholangiocarcinoma. A 76-year-old female was diagnosed to have intrahepatic cholangiocarcinoma and underwent an extended right posterior subsegmentectomy. The gross appearance showed a mass-forming type tumor. The histopathological examination revealed well to moderately differentiated adenocarcinoma associated with portal vein invasion. Subcutaneous metastasis in the head as the first sign of relapse was diagnosed 9?years after hepatectomy. The histopathological findings of the subcutaneous tumor were similar to those of the intrahepatic cholangiocarcinoma, thus suggesting metastasis from intrahepatic cholangiocarcinoma. Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-d-glucose was useful for detecting multiple metastases. Long-term follow-up for more than 5?years is recommended because the present case shows that late recurrence of intrahepatic cholangiocarcinoma occurs even 5?years after resection.     

Charlson co-morbidity index as a predictor of outcome after surgery for renal cell carcinoma with renal vein,vena cava or right atrium extension

PURPOSE: Surgery is the most effective treatment for renal cell carcinoma with tumor thrombus but predictors of outcome and patient survival are variable. Co-morbidity may affect therapeutic decision making and survival, although to our knowledge this factor has not been studied in patients with tumor thrombus. We analyzed the Charlson co-morbidity index as a predictor of outcome after surgery. MATERIAL AND METHODS: From 1970 to 1998, 303 patients underwent surgical resection. The Charlson index, surgical era, completeness of resection, patient age, sex, tumor level, TNM stage, grade and perinephric fat invasion were studied retrospectively as univariate and multivariate predictors of outcome. RESULTS: The level of tumor thrombus was 0 (renal vein only) in 127 patients, and I to IV in 66, 58, 36 and 16, respectively. At 5 years overall, cause specific and metastasis-free survival were 32%, 42% and 41%, while at 10 years they were 21%, 32% and 30%, respectively. For the whole cohort significant multivariate predictors of cause specific survival were metastasis (p = 0.0001), grade (p = 0.0001), perinephric fat involvement (p = 0.02) and tumor levels 0 versus I to IV (p = 0.048). The Charlson index did not predict outcome (univariate model p = 0.65). CONCLUSIONS: Characteristics of the primary tumor remained the most important predictors of cause specific survival in this cohort. The Charlson index did not predict cause specific survival in this cohort of surgically treated patients. Prospective assessment of co-morbidity in patients treated with surgery versus conservative therapy is warranted.     

Perioperative and long-term outcome of intrahepatic cholangiocarcinoma involving the hepatic hilus after curative-intent resection: comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma

Background

Intrahepatic cholangiocarcinoma with hepatic hilus involvement has been either classified as intrahepatic cholangiocarcinoma or hilar cholangiocarcinoma. The present study aimed to investigate the clinicopathologic characteristics and short- and long-term outcomes after curative resection for hilar type intrahepatic cholangiocarcinoma in comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma.