Survival of Cholangiocarcinoma Patients in Northeastern Thailand after Supportive Treatment

Background: Cholangiocarcinoma (CCA) is a very common cancer in Northeastern Thailand. Most CCApatients see a physician at a late stage when curative surgery is not possible. After diagnosis, they generally aretreated by partial surgery/percutaneous drainage, chemotherapy and supportive treatment. Objective: Thisstudy aimed to assess the survival rates of CCA patients after supportive treatment. Methods: A retrospectivecohort design was applied in this study. Data for 746 CCA patients were extracted from the hospital-based cancerregistry of Srinagarind Hospital, Khon Kaen University. The patients were diagnosed (at least by ultrasonography)between 1 January, 2009 and 31 December, 2009 and then followed up for current status until 30 June, 2011.The cumulative survival rate was calculated by the Kaplan-Meier method, and independent prognostic factorswere investigated using Cox regression. Results: The total follow-up time was 5,878 person-months, and thetotal number of deaths was 637. The mortality rate was therefore 10.8 per 100 person-year (95%CI : 10.1-11.7).The cumulative 3, 6, 9, 12 and 24 month survival rates were 59%, 39%, 31%, 24% and 14%, respectively. Themedian survival time after supportive treatment was 4 months. After adjusting for gender, age, stage, distantmetastasis, histological grading and treatment, stage was a significant predictor of survival of CCA patients.Those in stage III and stage IV had a 6.78 fold higher mortality than the stage I and stage II cases (95% CI :1.6-28.7). Conclusion: It is very important to encourage patients to see health personnel at an early stage.     

Cholangiocarcinoma Patient Outcome in Northeastern Thailand: Single-Center Prospective Study

Background: Cholangiocarcinoma is relatively rare worldwide. Most previous reports collected only patients with pathological diagnosis. In fact, however, many patients coming to hospital are diagnosed by clinical suspicion with radiologic imaging and receive treatment without histological confirmation. Real survival data and outcome of each treatment, especially for patients that do not have histologic confirmation, are lacking. In this study, therefore, we aimed to analyze the survival rates of CCA patients and the proportions of patients receiving different treatments. Materials and Methods: A total of 270 patients clinically suspected of CCA and visiting Srinagarind Hospital in May-July 2010, were prospectively followed until December 2014. After checking their clinical records, 163 of 270 patients were finally diagnosed as having CCA, and the data of this group were analyzed for survival rate and received treatments. Results: Of the 163 patients, 96 (58.9%) had intrahepatic, 56 (34.4%) had perihilar and 11 (6.7%) had distal CCA. The majority [107 (65.6%, 95%CI, 57.8-73.0)] received only supportive care. Overall median survival was 4 months (95%CI, 3.3-4.7), and 2-years survival was only 8.1% (95%CI,4.5-12.9). However, the 4 year survival of the R0 resection group was 100%. Conclusions: The present results show that the prognosis of CCA is very poor in North-east Thailand. Most CCA patients receive only treatment to alleviate symptoms due to their advanced stage of disease. Complete surgical resection at the early stage is the only treatment that significantly improves patient survival.     

Outcome of curative resection for perihilar cholangiocarcinoma in Northeast Thailand

AIM: To examine survival outcomes of perihilar cholangiocarcinoma (PCCA) resection including mortality, morbidity and prognostic factors.METHODS: Multivariate analyses were carried out based on the survival data of all patients with histologically confirmed PCCA who underwent curative resection at Srinagarind Hospital from January 2006 to December 2011.RESULTS: There were 29 (19%) cases of intrahepatic CCA that involved hilar and 124 (81%) with hilar bile-duct cancer. R0 resection was carried out on 66 (43.1%) patients of whom 50 (32.7%) also had lymph node metastasis. The other patients underwent R1 resection. The overall 5-year survival rate was 20.6% (95%CI: 13.8-28.4) and median survival time was 19.9 mo. Postoperative mortality was 2%, and 30% of patients had complications. Patients without lymph node metastasis were 60% less likely to die than those with metastasis. Achieving R0 led to a 58% reduction in the chance of mortality as compared to R1.CONCLUSION: To achieve a better survival outcome, focus should center on performing radical surgery and detection of patients with early stage cancer.     

Survival analysis and prognostic nomogram for patients undergoing resection of extrahepatic cholangiocarcinoma

BackgroundTumor location of extrahepatic cholangiocarcinoma (CCA) might influence survival after resection.MethodsA consecutive series of 175 patients who had undergone a potentially curative resection of extrahepatic CCA was analyzed. We calculated concordance indices of different constructed prognostic models for survival including TNM (tumour–node–metastasis) staging and developed a nomogram of the most sensitive model.ResultsOverall cancer-specific survival rates were 83%, 58%, and 26% at 1, 2, and 5 years, respectively. Cancer-specific survival according to location was 42% for proximal, 23% for mid, and 19% for distal CCA after 5 years. Tumor location was not an independent significant predictor (P = 0.06). A prognostic model using all potential prognostic variables predicted survival better compared with TNM staging (concordance index 0.65 versus 0.63). A reduced model containing only lymph node status, microscopically residual tumor status, and tumor differentiation grade, also outperformed TNM staging (concordance index 0.66).ConclusionsTumor location of extrahepatic CCA does not independently predict cancer-specific survival after resection. We developed a nomogram, based on a prognostic model with lymph node status, microscopically residual tumor status of resection margins, and tumor differentiation grade, that predicted survival better than TNM staging.     

Impact of ductal resection margin status on long-term survival in patients undergoing resection for extrahepatic cholangiocarcinoma

BACKGROUND: The current study was performed to clarify whether the presence of residual carcinoma in situ at ductal resection margins differs prognostically from residual invasive ductal lesions in patients undergoing surgical resection for extrahepatic cholangiocarcinoma. METHODS: A retrospective analysis of 84 patients with extrahepatic cholangiocarcinoma who underwent surgical resection was conducted. The ductal resection margin status was classified as negative (n = 64 patients), positive with carcinoma in situ (n = 11 patients), or positive with invasive carcinoma (n = 9 patients). The median follow-up period was 105 months. RESULTS: Ductal margin status was found to be a strong independent prognostic factor by both univariate (P = 0.0002) and multivariate (P = 0.0039) analyses. The outcome after surgical resection was comparable between patients with negative ductal margins (median survival time of 45 months; cumulative 10-year survival rate of 40%) and those with positive ductal margins with carcinoma in situ (median survival time of 99 months; cumulative 10-year survival rate of 23%; P = 0.4742). In patients with positive ductal margins, the outcome was found to be significantly better in patients with residual carcinoma in situ than in those with residual invasive carcinoma (median survival time of 21 months; cumulative 5-year survival rate of 0%; P = 0.0003). Of 11 patients with residual carcinoma in situ, 4 died of tumor recurrence and the initial site of the disease recurrence was local. All 9 patients with residual invasive carcinoma died of disease recurrence (local recurrence with or without distant metastases) within 40 months after surgical resection. CONCLUSIONS: After surgical resection for extrahepatic cholangiocarcinoma, invasive carcinoma at ductal resection margins appears to have a strong adverse effect on patient survival, whereas residual carcinoma in situ does not.     

Survival Rate of Intrahepatic Cholangiocarcinoma Patientsafter Surgical Treatment in Thailand

Intrahepatic cholangiocarcinoma (ICC), one of the primary liver cancers, is frequent in the northeasternpart of Thailand. Surgical resection remains the best method of treatment, but patients suffering from ICCusually present at a late stage of the disease. Studies of survival and prognostic factors after surgery remain rare.The aim here was to evaluate the survival rate and factors affecting the survival of patients with intrahepaticcholangiocarcinoma after surgery. The study used a retrospective cohort design. The subjects were 73 consecutivepatients with ICC, who were admitted for surgery to Srinagarind Hospital, Khon Kaen University, during theperiod 2005-2009. The censoring date was 31 December, 2011, data being evaluated using uni- and multivariateanalyses. Postoperative survival analysis was performed by the Kaplan-Meier method, and the Cox proportionalhazard model was used to identify independent prognostic factors. The total follow-up time was 99 person-years.The total number of deaths was 59, giving a mortality rate of 59 per 100 person-years. The cumulative 1-, 3-,and 5-year survival rates were 52.1%, 21.7%, and 11.2%, respectively. The median duration of survival afterresection was 12.4 months. Univariate analysis revealed stage of disease, lymph node metastasis, histologicaltype, histological grade and macroscopic classification to be statistically significant (p-value<0.05) prognosticfactors. In the multivariate analysis, only macroscopic classification was statistically significant (p-value<0.05).In conclusion, macroscopic classification was the only independent factor found to be significantly associatedwith survival following surgical treatment of ICC.     

Repeat hepatectomy for colorectal liver metastases: A worthwhile operation?

BACKGROUND AND OBJECTIVES: After curative resection of hepatic colorectal metastases, 10-20% of patients experience a resectable hepatic recurrence. We wanted to assess the expected risk-to-benefit ratio in comparison to first hepatectomy and to determine the prognostic factors associated with survival. METHODS: Twenty-nine patients from a group of 152 patients resected for colorectal liver metastases underwent 32 repeat hepatectomies. RESULTS: In-hospital mortality was 3.5% (1/29 patients); the morbidity after repeat hepatectomy was lower than that after first hepatic resection. Combined extrahepatic surgery was performed on 34.5% of repeat hepatectomies vs. 6.9% of first hepatectomies (P = 0.01). Overall actuarial 3-year survival was 35.1%: four patients have survived more than 3 years and one survived for more than 5 years. The number of hepatic metastases and the carcinoembryonic antigen (CEA) serum levels were significant prognostic factors on univariate analysis. The synchronous resection of hepatic and extrahepatic disease was not associated with a lower survival rate when compared with that of patients without extrahepatic localization: three patients of the former group are alive and disease-free at more than 2 years. CONCLUSIONS: Repeat hepatic resection can provide long-term survival rates similar to those of first liver resection, with comparable mortality and morbidity. The presence of resectable extrahepatic disease must not be an absolute contraindication to synchronous hepatectomy because long-term survival is possible.     

Survival of Patients with Cholangiocarcinoma Receiving Surgical Treatment in an O. viverrini Endemic Area in Thailand: A Retrospective Cohort Study

Objective: To investigate risk factors associated with mortality in cholangiocarcinoma patients receiving surgical treatment in Thailand’s endemic area and their survival rate. Materials and Methods: Medical records of patients with histologically confirmed cholangiocarcinoma, who underwent surgical treatment at Sanpasitthiprasong Regional Hospital from  October 1, 2013 to  October, 31 2015, were retrospectively included. Patients’ vital status (death/alive) and date of death were obtained from the Interior Ministry’s death certificate. Cox proportional hazard regression was used to examine factors associated with mortality. Results: Out of 295 patients with cholangiocarcinoma (CCA), 180(58%) were intrahepatic CCA, 86(28%) were perihilar CCA, and 29 (9%) were distal CCA. Three groups were homogenous in terms of age and gender. Most of our patients referred with abdominal pain (63%), especially those who were intrahepatic CCA (77%). However, almost 80% of the perihilar CCA and distal CCA patients came with jaundice. Tumor markers (CEA and CA19-9) were not different between groups p=0.74 and p=0.43 respectively. Median survival of patients with intrahepatic CCA, perihilar CCA, and distal CCA patients was 14.6, 14.2, and 14.0 months, respectively. Factors independently associated with mortality in intrahepatic CCA patients were number and size of tumors and presence of perineural invasion (Hazard ratio (HR) 1.09[1.03 - 1.15], 1.07[1.02 - 1.13], and 2.09 [1.28 - 3.39], respectively). In perihilar CCA patients, having positive lymph nodes and resection status were independently associated with mortality. Compared to R0 resection, R1, R2, and no resection of perihilar CCA were associated with a 2-, 8- and 4-fold increase in the risk of mortality (HR 2.17 (0.99 – 4.78), 7.97 (3.22 – 19.71), and 4.21 (0.51 – 34.82), respectively). Conclusion: CCA patients in this endemic area had fairly poor survival. Factors associated with mortality in intrahepatic CCA were number and size of tumors and perineural invasion. However, risk factors for perihilar CCA included positive lymph nodes and resection status.     

Survival after Diagnosis of Cervical Cancer Patients at a Tertiary Referral Hospital in Northeast Thailand

Background: Cervical cancer (CC) is the third most common cancer in women globally, including Thailand, where the incidence rate was 16.2 cases per 100,000 individuals in 2018. Survival rates for patients with this condition have not improved over recent years. This study evaluated the survival rate and median survival time after diagnosis among CC patients, and investigated factors associated with survival in Northeast Thailand. Methods: This study included CC patients admitted to the gynecological ward at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand from 2010 to 2019. Survival rates and median survival time since the date of diagnosis and 95% confidence intervals (CIs) were calculated. Multiple cox regression was performed to investigate factors associated with survival which were quantified by adjusted hazard ratios (AHR) and their 95% CIs. Results: Of 2,027 CC patients, the overall mortality incidence rate was 12.44 per 100 person-years (95% CI: 11.7 - 13.22), median survival time was 4.82 years (95% CI: 3.92 - 5.72), and 10-year survival rate was 43.16% (95% CI: 40.71 - 45.59). The highest 10-year survival rate was 87.85% (95% CI: 82.23 - 91.78) found among those with stage I CC, followed by those who received surgical treatment, which was 81.22% (95% CI: 74.47 - 86.35). Factors that were associated with decreased survival included age ≥60 years (AHR = 1.25; 95% CI: 1.07 - 1.46), health insurance with the Universal Health Coverage Scheme (UCS) (AHR = 6.26; 95% CI: 5.13 - 7.64), malignant neoplasms histopathology (AHR = 1.36; 95% CI: 1.07 - 1.74), and treatment with supportive care (AHR = 7.48; 95% CI: 5.22 - 10.71). Conclusion: Among patients diagnosed with CC, those with stage I had the highest 10-year survival rate. CC patients with older age, UCS, malignant neoplasms histopathology, and received supportive care showed the highest survival association.     

Extent of oesophageal resection for adenocarcinoma of the oesophagogastric junction.

AIMS: The optimal extent of oesophageal resection and surgical approach in patients treated for adenocarcinomas of the oesophagogastric junction (OGJ) are still uncertain. We report the correlations between resection margin involvement and outcome. METHODS: Patients with positive proximal resection margin (PPRM) and those with negative proximal resection margin (NPRM) were compared. RESULTS: Of 94 patients with macroscopically complete resection, eight were PPRM. There was no difference between the two groups in postoperative mortality or morbidity rates, in anastomotic leakage or in recurrence rates. The median survival in the PPRM group was 11.1 months compared with 36.3 months in the NPRM group (P=0.02). No infiltration was observed in patients whose proximal margin exceeded 7 cm. The extended transthoracic approach was the only prognostic factor for tumours type II (P=0.03, RR=1.4, 95% CI: 1.1-1.8). CONCLUSION: Histologic infiltration of oesophageal resection margin influences 5-year survival rate. In adenocarcinomas of the OGJ that can be treated curatively, a transection with a 8 cm oesophagectomy above the tumour in fresh specimen should be performed, and by thoracoabdominal approach for tumours type I and II.     

Numbers of New Cases and Trends of Cancer 1993-2012: Srinagarind Hospital Based Population,Khon Kaen,North-East Thailand

Background: Cancer is the most common cause of death in Thailand, where treatment outcomes andprognosis are poor and mortality rates remain high. This study reports new cancer cases and trends of allcancers registered in Srinagarind Hospital from 1993 to 2012 and also provides a picture of the cancer situationin Northeast Thailand. Materials and Methods: All new cases of cancer registered in the hospital-based cancerregistry at Faculty of Medicine, Srinagarind Hospital, Khon Kaen University during 1993-2012 were included inthe study. Results and Conclusions: The number of new cancer cases has gradually increased each year duringthe last 20 years. The three most common cancers at present in males are liver and bile duct cancer, lung cancerand colorectal cancer, respectively. In females, liver and bile duct, breast and thyroid cancers are now the mostfrequent. Interestingly, the number of cases of both liver and bile duct cancer and colorectal cancer in malesnoticeably increased during the second decade of the study. Additionally, breast cancer greatly increased in thesame decade and lung cancer in females climbed into the top five most common cancers. Thyroid cancer hasalso risen steadily in the last decade. Trends of common cancers are similar to those throughout Thailand.     

Lung Cancer Survival with Current Therapies and New Targeted Treatments: A Comprehensive Update from the Srinagarind Hospital-Based Cancer Registry from (2013 to 2017)

Background: Lung cancer (LC) is a common malignancy and leading cause of cancer death worldwide and in Thailand. An update on LC survival factors after diagnosis at Srinagarind Hospital is needed. Methods: We conducted a retrospective cohort study, and the data were sourced from the Srinagarind Hospital-Based Cancer Registry. All LC cases were diagnosed between January 1, 2013, and December 31, 2017, and followed up until November 30, 2019. Cases of LC (ICD-O-3) numbered 2,149, but only those with coding C34.0-C34.9 were included. The survival rate was estimated using Kaplan-Meier, while the Log-rank test was used to estimate survival. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazard regression models. Results: The 2,149 patients had a total follow-up of 269.6 person-years. Overall, 1,867 patients died during the study, for a corresponding case-fatality mortality rate of 86.0 per 100 person-years. The respective 1-, 3-, and 5-year survival rate was 31.2 % (95% CI; 29.21 to 33.15%), 12.9 % (95%CI: 11.49 to 14.45), and 10.2% (95%CI: 8.74 to 11.70). After patient diagnosis, the median survival time was 0.46 years (5.51 months) (95% CI: 0.42 to 0.50). Targeted therapy was associated with longer survival than non-targeted therapy (p-value < 0.001). After adjusting for sex, TNM stage, and histologic type, multivariable analysis of the entire cohort identified chemotherapy as an independent predictor of improved survival (adjusted HR= 0.48; 95% CI: 0.42 to 0.55; P < 0.001), and that sex, TNM stage, and histologic type were associated with survival. Conclusion: The study confirmed that sex, stage of disease, histology, and chemotherapy are associated with survival of LC. Primary prevention and screening for early detection improve survival. Further investigations into factors affecting survival of LC in Northeast Thailand should focus on targeted therapy.     

Survival Time and Molecular Subtypes of Breast Cancer after Radiotherapy in Thailand

Background: Breast cancer is an important cause of death among women. One way of classifying differentforms of breast cancer is by molecular features, usually in terms of the four subtypes: luminal A, luminalB, HER2-enriched, and triple negative. Objectives: This study aimed to investigate the association betweenmolecular subtypes and survival among breast cancer patients treated with radiotherapy. Materials and Methods:A retrospective cohort study was conducted. The subjects were 272 breast cancer patients who had receivedtreatment in the radiotherapy unit at Srinagarind Hospital, Thailand, between 1 January, 1999, and 31 May,2009. The end of the study was 1 June, 2014. Overall survival was defined as the time elapsing between initialregistration at the radiotherapy unit and death or the end of the study. Survival curves were estimated by theKaplan-Meier method, and a multivariate analysis was performed using Cox’s proportional hazard regressionmodel. Results: The patient mean age was 47.5±10.4 at the time of diagnosis. Of the 272 patients, 146 (53.7%)were classified as luminal A, 12 (4.4%) as luminal B, 30 (11.0%) as HER2-enriched, and 84 (30.9%) as triplenegative. The overall survival rates at 1, 3 and 5 years were 87.1%, 68.4% and 59.2%, respectively. According tomolecular subtypes, HER2-enriched patients had the lowest 5-year survival rate (30.0 %, 95%CI: 15.02-46.55).The median follow-up time was 8.37 years. In the Cox model analysis a higher risk of death was found for patientswith HER2-enriched (HRadj=3.34, 95%CI:1.96-5.67), triple negative (HRadj=2.17, 95%CI: 1.44-3.27), and stageIIlB (HRadj=2.20, 95%CI: 1.16-4.17) cancers. Conclusions: The worst survival rates were among patients classifiedas HER2-enriched, triple negative and at stage IIIB. Early detection and an advanced treatment modality areneeded to help these patients.     

贲门癌的外科治疗结果

总结贲门癌的手术治疗结果,探讨影响预后的因素。方法 对１８３２例患进行了单因素分析,生存率用寿命表法计算,差异的显性采用Ｌｏｇｒａｎｋ检验。结果 本组切除率７６．３％,根治切除率５３．４％。５年生存率：切除术２３．５％,根治性切除术２９．９％．     

Association between Pesticide Use and Cholangiocarcinoma

Background Thailand remains a primarily agricultural country and Thai farmers are heavy users of pesticides. Coincidentally the incidence of cholangio carcinoma (CCA) is high in parts of the country, but no previous study has examined any association between the two. Materials and Methods The present matched, case-control study covered patients admitted to Srinagarind Hospital, Khon Kaen University, Thailand. The case group comprised 210 cases diagnosed with CCA and the control group 840 diagnosed with other diseases. Cases and controls were matched for sex, age within five years, and date of admission within three months. Multiple conditional logistic regression was used for the analysis. Results After adjusting for potential confounders, pesticide use as compared with never used pesticide was not associated with CCA (ORadj1.11, 95% CI 0.77, 1.60) and neither was there any significant relationship between CCA and duration of pesticide use, type or number of types pesticide use. Conclusions The current study thus found no association between pesticide use and CCA.     

Outcome following repeat liver resection for colorectal liver metastases.

AIM: Our aim was to determine independent predictors of survival after second liver resection and to confirm whether the type of first resection influences survival after repeat resection. METHODS: Fifty-four patients who underwent a second liver resection for colorectal liver metastases were analyzed. To find independent predictors of survival, possible prognostic factors regarding the primary tumor, and the first and second resections were used in the Cox regression analysis. RESULTS: There were three postoperative deaths within 90 days of surgery. The 3- and 5-year overall survival rates were 53% and 46%, respectively. The size of the tumor (>50mm) (p=0.005), serum carcinoembryonic antigen level (>30microg/L) (p=0.002), and the presence of a positive surgical margin at the second resection (p=0.006) were independent predictors of poor survival following the second resection. The type of first resection was not associated with survival but was associated with the ability to achieve a histological negative surgical margin at the second liver resection (p=0.01). CONCLUSION: Three independent predictors of survival were identified. Major initial liver resection was associated with a reduced ability to achieve surgical clearance at the second resection. For colorectal liver metastases, major resection should only be performed if a negative margin cannot be achieved by minor resection.     

The impact of hepatic resection on metastatic colorectal cancer

Although liver resection is the accepted treatment for patients with metastatic colorectal cancer to the liver, there remains some controversy as to the criteria for patient selection and its impact on the recurrent disease following the operation. One hundred and sixteen patients underwent liver resection for metastaic colorectal carcinoma over the last 23 years at our institution. The actual survival was 50.5% at 5 years, and 38.6% at 10 years, excluding the 30-day operative mortality rate of 1.7%. Positive hepatic lymph nodes, extrahepatic disease, number of tumors (4 or more), and bilobar distribution of the diseases were strongly associated with poor outcome. These prognostic factors were also documented as the major prognostic determinants by 21 consecutive articles we reviewed. Among 52 (45.6%) patients with hepatic recurrence, patients who were acceptable surgical risks and had no extrahepatic diseases or a limited number (one or two) of lung metastasis were candidates for the repeat resection. Consequently, 31 patients underwent repeated hepatic resection. Their survival rate was 53.9% at 3 years and 32.3% at 5 years, with no mortality. This outcome is markedly better than that of untreated patients with an estimated survival of 3 to 24 months. Thus, an aggressive approach to surgical treatment is feasible with low risk and the potentially curative strategy even for recurrent hepatic metastases, providing the opportunity to achieve 5 year survival.     

Prognostic factors in resectable cholangiocarcinoma patients: Carcinoembryonic antigen,lymph node,surgical margin and chemotherapy

AIM: To evaluate outcomes in resectable cholangiocarcinoma patients and to determine prognostic factors. METHODS: A retrospective study was conducted among newly-diagnosed cholangiocarcinoma patients from January 2009 to December 2011 who underwent curative resection in Srinakarind Hospital (a 1000-bed university hospital). Two hundred and sixty-three cholangiocarcinoma patients with good performance were enrolled. These patients had pathological reports with clear margins or microscopic margins. Prognostic factors which included clinical factors, serum liver function test as well as serum tumor makers at presentation, tumor data, and receiving adjuvant chemotherapy were determined by uni- and multivariate analysis. RESULTS: The median overall survival time was 17 mo (95%CI: 13.2-20.7); and 1-, 2-, and 3- year survival rates were 65.5%, 45.2% and 35.4%. Serum albumin levels, serum carcinoembryonic antigen (CEA) levels, staging classifications by American Joint Committee on cancer, pathological tumor staging, lymph node metastases, tumor grading, surgical margin status, and if adjuvant chemotherapy was administered, were shown to be significant prognostic factors of resectable cholangiocarcinoma by univariate analysis. Multivariate analysis, however, established that only abnormal serum CEA [hazard ratio (HR) 1.68; P = 0.027] and lymph node metastases (HR 2.27; P = 0.007) were significantly associated with a decrease in overall survival, while adjuvant chemotherapy (HR 0.71; P = 0.067) and surgical margin negative (HR 0.72; P = 0.094) tended to improve survival time. CONCLUSION: Serum CEA and lymph node metastases which were associated with advanced stage tumors become strong negative prognostic factors in cholangiocarcinoma.     

Reevaluation of prognostic factors for survival after liver resection in patients with hepatocellular carcinoma in a Japanese nationwide survey

BACKGROUND: Advances in the diagnosis and surgical treatment of hepatocellular carcinoma (HCC) have improved the prognosis for patients with HCC who undergo liver resection. The objective of this study was to evaluate prognostic predictors for patients with HCC who underwent liver resection in a Japanese nationwide data base. METHODS: In this study, the authors analyzed 12,118 patients with HCC in a Japanese nationwide data base who underwent liver resection between 1990 and 1999 and compared them with a previous analysis of patients between 1982 and 1989. All patients were evaluated for prognostic factors. RESULTS: During the last decade, the increases in patients who were without hepatitis B virus surface antigen, who had small tumors, and who had portal vein invasion were noted. The 5-year overall survival rates for patients with HCC improved to 50.5%, compared with < 40% in the previous analysis. A multivariate analysis using a stratified Cox proportional hazards model according to associated liver disease indicated that age, degree of liver damage, alpha-fetoprotein level, maximal tumor dimension, number of tumors, intrahepatic extent of tumor, extrahepatic metastasis, portal vein invasion, hepatic vein invasion, surgical curability, and free surgical margins were independent prognostic predictors for patients with HCC. Operative mortality decreased from 2.3% in 1990-1991 to 0.6% in 1998-1999. CONCLUSIONS: Outcomes and operative mortality rates in patients with HCC improved during the last decade. Age, degree of liver damage, alpha-fetoprotein level, maximal tumor dimension, number of tumors, intrahepatic extent of tumor, extrahepatic metastasis, portal vein invasion, hepatic vein invasion, surgical curability, and free surgical margins were prognostic factors for patients with HCC who underwent liver resection.     

Role of postoperative radiotherapy in the management of extrahepatic bile duct cancer

PURPOSE: To analyze the outcome of postoperative radiotherapy (RT) or chemoradiation for patients with extrahepatic bile duct cancer who had undergone either curative or palliative surgery, and to identify the prognostic factors for these patients. METHODS AND MATERIALS: Between March 1982 and December 1994, 91 patients with extrahepatic bile duct cancer underwent RT at the Department of Therapeutic Radiology, Seoul National University Hospital. Of these patients, 84 were included in this retrospective study. The male/female ratio was 3.7:1 (66 men and 18 women). The median age of the patients was 58 years (range 33-76). Gross total surgical resection was performed in 72 patients, with pathologically negative margins in 47 and microscopically positive margins in 25. Twelve patients underwent surgical exploration and biopsy or subtotal resection with palliative bypass procedures. All the patients received >40 Gy of external beam RT after surgery. Concurrent 5-fluorouracil was administered during external beam RT in 71 patients, and maintenance chemotherapy was performed in 61 patients after RT completion. The minimal follow-up of the survivors was 14 months, and the median follow-up period for all the patients was 23 months (range 2-75). RESULTS: The overall 2- and 5-year survival rate was 52% and 31%, respectively. The 2- and 5-year disease-free survival rate was 48% and 26%, respectively. On univariate analysis using the Kaplan-Meier product limit method, the use of chemotherapy, performance status, N stage, size of residual tumor, stage, and tumor location were significant prognostic factors. However, on multivariate analysis using Cox's proportional hazard model, N stage (N0 vs. N1 and N2, p = 0.02) was the only significant prognostic factor. CONCLUSION: Long-term survival can be expected in patients with extrahepatic bile duct cancer who undergo radical surgery and postoperative chemoradiation. Regional lymph node metastasis is a poor prognostic factor for these patients.