Impact of medical and surgical intervention on survival in patients with cholangiocarcinoma

AIM:To examine surgical and medical outcomes for patients with cholangiocarcinoma using a populationbased cancer registry.METHODS:Using the California Cancer Registry's Cancer Surveillance Program,patients with intrahepatic cholangiocarcinoma treated in Los Angeles County from 1988 to 2006 were identified and evaluated for clinical and pathologic factors and therapies received(surgery,radiation,and chemotherapy).The surgical cohort was further categorized into three treatment groups:patients who received adjuvant chemotherapy,adjuvant chemoradiation,or underwent surgery alone(no chemotherapy or radiation administered).Survival was assessed by Kaplan-Meier method;and Cox proportional hazard modeling was used in multivariate analysis.RESULTS:Of 825 patients,60.2% received no treatment.Of the remaining 328 patients,18.5% chemotherapy only,7.4% chemoradiation,and 13.8% underwent surgery.More male patients underwent surgical resection(P = 0.004).Surgical patients were younger than the patients receiving chemotherapy or chemoradiation(P < 0.001).Of the surgical cohort(n = 114),60.5% underwent surgery alone while 39.5% underwent surgery plus adjuvant therapy(chemotherapy n = 20;chemoradiation,n = 21)(P < 0.001).Median survival for all patients in the study was 6.6 mo.Median survival was highest for patients who underwent surgery(23 mo),whereas both chemotherapy(9 mo) and chemoradiation(8 mo) alone were each less effective(P < 0.001).By multivariate analysis,extent of disease,receipt of surgery,and administration of chemotherapy(with/without surgery) were independent predictors of overall survival.CONCLUSION:This study demonstrates that surgery is a critical treatment modality.Multimodality treatment has yet to be standardized,but play a role in optimal therapy for cholangiocarcinoma.

Selecting incision-dominant cases for robotic liver resection:towards outpatient hepatectomy with rapid recovery

Background:The premise of minimally invasive surgery(MIS)is to minimize facial and muscle injury in order to enhance recovery from surgery.Robotic MIS surgery for resection of tumors in solid organs is gaining traction,though clear superiority of this approach is lacking and robotic surgery is more expensive.Our philosophy in robotically-assisted hepatectomy has been to employ this approach for cases where location of tumors make difficult a classical laparoscopic approach(superior/posterior tumors),and cases where the incision for an open operation dominates the course of recovery.Methods:This is a retrospective review of a prospectively collected database.Results:In this study we report 97 cases of liver resection subjected to the robotic approach,of which 90%were resected robotically.The mean operative time was 186±9 min;mean blood loss was 111±15 mL,and complications occurred in 9%.Two thirds of the patients remained in hospital 3 days or less,including three patients subjected to hemihepatectomy(2 left and 1 right).Fourteen individuals were discharged on the same day.The strongest predictors of long hospital stay(>3 days)were major hepatectomy(P=0.007),complications(P=0.008),and operative time>210 min(P=0.001).Conclusions:With thoughtful case selection,this is a first demonstration that hepatectomy can be conducted as an out-patient or short-stay procedure.

Rising trends in intrahepatic cholangiocarcinoma incidence and mortality: getting at the root cause

Several epidemiologic studies over the years have demonstrated that there is a worldwide increase in the incidence of intrahepatic cholangiocarcinoma(ICC)(1-5).Given the aggressive biology of ICC and poor survival,it is not surprising that the mortality rate mirrors the incidence rate(6).

A prognostic nomogram for patients with resected fibrolamellar hepatocellular carcinoma

Background: Fibrolamellar hepatocellular carcinoma (FLHC) is a unique entity compared to conventional hepatocellular carcinoma. The aim of this study was to examine post-resection outcomes and prognostic indicators for survival in this group of FLHC patients. Methods: A retrospective analysis of the National Cancer Database (NCDB) for patients with FLHC who underwent resection from 2004 to 2014 was performed. Univariate and multivariate Cox proportional hazard models were used to identify factors associated with overall survival, and a prognostic nomogram was generated. Results: There were 197 patients identified, 171 (86.8%) of whom had long-term follow-up data. Univariate and multivariate analyses were performed using patient and tumor demographics with the outcome variable of overall survival. On multivariate analysis, age [hazard ratio (HR) 1.03, P=0.003], vascular invasion (HR 1.75, P=0.05), tumor size >7 cm (HR 2.18, P=0.044), multifocal disease (HR 3.34, P=0.002), and node positive (pN+) disease (HR 2.75, P=0.003) were all negative predictors of overall survival. A prognostic nomogram was generated using these factors with a c-statistic superior to that of American Joint Committee on Cancer (AJCC) staging (0.710 vs. 0.654). Conclusions: Independent predictors of decreased overall survival in patients with FLHC include age, vascular invasion, tumor size >7 cm, multifocal disease, and pN+ disease. This is the first study to develop a nomogram exclusively for FLHC that may predict survival in future studies.