Influence of age on surgical treatment of peripheral cholangiocarcinoma

doi:10.1016/j.amjsurg.2003.12.051

The American Journal of Surgery

Volume 187, Issue 4, April 2004, Pages 559-563

https://doi.org/10.1016/j.amjsurg.2003.12.051 Get rights and content

Abstract

Background

Peripheral cholangiocarcinoma (PCC) constitutes the second most common primary liver cancer. Information is lacking on patients with PCC <40 years old undergoing surgical treatment. The aim of this study was to evaluate the influence of age on surgical treatment of patients with PCC based on reviewing the clinicopathologic features and survival rate of 23 patients with PCC <40 years old who received surgical treatment.

Methods

The clinical features of 23 younger patients with PCC (<40 years old) who underwent surgical treatment between 1977 and 2000 were reviewed. Clinical features of 284 patients with PCC >40 years old were used for comparison.

Results

Three hundred seven patients with PCC with an age range between 28 and 93 years (mean 57.2, median 56.0) were investigated. The fiftieth decade was the peak PCC age in the series. Clinical presentations and physical findings were similar between younger and older PCC groups. Similar positive serum carcinoembryonic antigen and carbohydrate antigen 19-9 rates (42.9% and 66.7% vs 41.2% and 74.4%, respectively) and a similar rate of hepatolithiasis associated with PCC were also observed between the 2 groups (43.5% vs 48.9%). Younger patients with PCC tended to show less mucobilia, less papillary-type PCC, and a more advanced stage of tumor compared with older patients with PCC. However, postoperative adjuvant chemotherapy and radiotherapy were used more frequently in the older patients with PCC. Operative morbidity and mortality were similar between the 2 groups (surgical mortality rate 7.8%). Follow-up ranged from 1.0 to 167.6 months (mean 13.0, median 5.7). The 1- and 2-year actuarial survival rates were 6.3% and 0% in the younger PCC group and 31.3% and 15.0% in the older PCC group, respectively. Prognosis was dismal for the younger patients with PCC (P = 0.0008), but they may benefit from hepatic resection.

Conclusions

Younger patients with PCC had a significantly worse survival rate than older patients with PCC. Hepatectomy is rational and may benefit younger patients with PCC.

Section snippets

Methods

From 1977 to 2000, 518 consecutive patients with bile duct adenocarcinoma underwent surgical treatment at the Department of Surgery, Chang-Gung Memorial Hospital, Taipei, Taiwan. The 518 patients were classified into common bile duct cancer (n = 89, 17.2%), PCC with hilar invasion (n = 122, 23.6%), and PCC (n = 307, 59.3%). Three hundred seven patients with PCC were enrolled in this investigation. PCC was defined as carcinoma arising from second order or more distal branches of the intrahepatic

Results

Three hundred seven PCC patients with ages ranging between 28 and 93 years (mean 57.2, median 56.0) were studied. The fiftieth decade was the peak PCC age in the series, and 23 patients with PCC were <40 years old (7.49%; Fig. 1). There were 9 men and 14 women (male-to-female ratio 0.64) in the younger PCC group and 121 men and 163 women (male-to-female ratio 0.74) in the older PCC group. The gender ratio was similar between the 2 groups (P = 0.746).

Right hypochondralgia was the most common

Comments

The average patient age at clinical diagnosis of PCC in Japan and the United States is 60 to 65 years; the hilar type is normally detected somewhat earlier than the peripheral type. In the United Kingdom, average patient age at clinical diagnosis of PCC is 48 ± 11 years for the peripheral type and 52 ± 12.5 years for the hilar type [9]. This study showed that Taiwanese PCC age distribution peaked for patients >50 years of age. PCC commonly affects older people, and only 7.7% of patients with

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Factors associated with failure to rescue after major hepatectomy for perihilar cholangiocarcinoma: A 15-year single-center experience
2022, Surgery (United States)
Citation Excerpt :
Among other factors, age was found to be an independent risk factor for postoperative mortality after MH for PHC.28,29 Contradictory to these results, 2 further studies found that surgery for PHC can be safely performed in elderly patients.30,31 However, it has been shown that the comparison of mortality rates between Eastern and Western centers is difficult, at least in part, owing to significant differences in patient characteristics.32
The management of complications after major hepatectomy in perihilar cholangiocarcinoma may not always be successful, leading to failure to rescue. The present study seeks to identify independent risk factors for failure to rescue after major hepatectomy in perihilar cholangiocarcinoma.
We retrospectively analyzed the postoperative course of all consecutive patients who underwent major hepatectomy in a curative intent for perihilar cholangiocarcinoma between 2005 and 2019 at our department. A multivariate logistic regression analysis was performed to identify independent risk factors for failure to rescue.
Of 287 patients, 186 (65%) had major complications (Dindo-Clavien grade ≥IIIa), of which 142 (76%) were grade IIIa to IVb (rescue group). Failure to rescue (FTR group, Dindo-Clavien grade V) occurred in 44 of 186 patients (24%). Age >65 years (odds ratio = 4.001, 95% confidence interval 1.025–15.615, P = .046) and right-sided resection (odds ratio = 17.040, 95% confidence interval 1.926 – 150.782, P = .011) were independently associated with failure to rescue. Preoperative carbohydrate antigen 19-9 levels >100 kU/mL as well as preoperative chemotherapy appear to increase odds for failure to rescue as well; however, the association was short of statistical significance (P = .070 and .079, respectively).
Elderly patients as well as patients undergoing right-sided hepatectomy for perihilar cholangiocarcinoma with high preoperative carbohydrate antigen 19-9 levels are at high risk for failure to rescue. Thus, patients should be assessed critically preoperatively. Postoperatively, close monitoring, especially of patients who are at risk, is mandatory.
Cholangiocarcinoma
2017, Critical Reviews in Oncology/Hematology
Citation Excerpt :
Survival is related to the pathological grading of the tumour: better survival observed in well-differentiated cancers (mean survival 10 months, anaplastic tumours 2 months). A 2004 publication describes a worse survival-rate in younger patients (<40 years) after curative resection in case of peripheral carcinoma of the biliary tract (Yeh et al., 2004). Diagnosis of CCA can be a challenge because of its anatomic location and late clinical presentation.
Biliary tract cancer accounts for <1% of all cancers and affects chiefly an elderly population, with predominance in men. We distinguish cholangiocarcinoma (intrahepatic, hilar and distal) and gallbladder cancer, with different pathogenesis and prognosis.
The treatment is based on surgery (whenever possible), radiotherapy in selected cases, and chemotherapy. The standard cytotoxic treatment for advanced/metastatic disease is represented by the combination of gemcitabine and cisplatin, whereas fluoropyrimidines are generally administered in second line setting. At the present time, no biologic drug demonstrated a clear efficacy in this cancer, although the molecular characterisation could provide a promising basis for experimental treatments. A good supportive care and an early palliative care are warranted in most patients and should be delivered as a part of a global approach.
Outcomes following resection of intrahepatic cholangiocarcinoma
2015, HPB
Citation Excerpt :
Predictors of poor survival in the present series were transfusion requirements and perineural invasion. Independent predictors of survival in other published studies were age <40 years, lymphatic invasion, and preoperative CA 19-9 levels of >37 ng/dL.3,10-12 Interestingly, the current series did not demonstrate an association between positive margins and poor survival.
The aim of this analysis was to examine prognostic features and outcomes in patients undergoing resection for intrahepatic cholangiocarcinoma (ICC).
A retrospective chart review was performed in all patients who underwent R0 or R1 resection for primary ICC between 1995 and 2011. Clinical data were abstracted and statistical analyses were conducted in the standard fashion.
A total of 82 patients underwent curative hepatectomy for primary ICC; 51 patients in this cohort developed recurrence. The median follow-up of survivors was 27 months (range: 1–116 months). Recurrences were intrahepatic (65%), associated with multiple tumours (54%) and occurred during the first 2 years after hepatectomy (86%). The main factor associated with recurrence after resection was the presence of satellite lesions. Overall 5-year disease-free survival after primary resection was 16%. Factors associated with poor survival were transfusion and perineural invasion. Treatment of recurrence was undertaken in 89% of patients and repeat surgical resection was performed in 15 patients. The 3-year survival rate after recurrence was 25%. Prolonged survival after recurrence was associated with a solitary tumour recurrence.
Despite curative resection of ICC, recurrence can be expected to occur in 79% of patients at 5 years. Predictors of survival and recurrence after resection vary in the literature. In patients with recurrence, selection of the optimal treatment remains challenging.
Cholangiocarcinoma
2009, Critical Reviews in Oncology/Hematology
Citation Excerpt :
Survival is related to the pathological grading of the tumour: better survival is seen with well-differentiated cancers (mean survival 10 months, anaplastic tumours 2 months). A recent publication describes a worse survival-rate in younger (<40 years) than in older patients after curative resection in case of peripheral carcinoma of the biliary tract [27]. The clinical signs and symptoms depend on the location of the tumour.
Cholangiocarcinoma is an uncommon adenocarcinoma with poor prognosis. Although the 1-year survival has increased over time, the 5-year survival has not shown any significant change (less than 5%). Cure can only be expected from surgical resection of early stage tumours but most patients initially present with advanced disease. Cancer cachexia, liver failure, and recurrent sepsis due to biliary obstruction are among the main causes of mortality.
Patients’ prognosis is strongly related to radical surgery and complete resection is the most effective therapy; the location within the biliary tree (proximal versus distal) has no impact on survival when a complete resection is achieved despite the fact the rate of resectability is up to 70% in case of distal cancer and 15–20% for high bile ducts tumours. Prognosis of cholangiocarcinoma remains poor even with aggressive surgical therapy because of the high incidence of local or regional recurrence and distant metastasis.
Based on these data many questions need an answer: is there a role for adjuvant chemotherapy or radiotherapy? Neoadjuvant treatments provide best results? There is a standard therapy in unresectable or metastatic cholangiocarcinoma?
This report tries to answer to frequently asked questions that the readers are faced with their patients every day (from diagnostic procedures to palliative treatment) and tries to suggest useful information for their professional practice.
Radical surgery in intrahepatic cholangiocarcinoma
2009, Gastroenterologie Clinique et Biologique
Le but de cette étude rétrospective était d’évaluer les résultats du traitement chirurgical du cholangiocarcinome périphérique pris en charge par une même équipe. Entre 1988 et 2005, 75 patients ont été opérés d’un cholangiocarcinome périphérique. Cinquante-trois résections ont été pratiquées dont trois itératives. La découverte peropératoire d’une tumeur non réséquable a conduit à 27 laparotomies exploratrices dont deux ont été suivies d’une transplantation hépatique en début d’expérience. Les résections ont été une hépatectomie majeure dans 85 % des cas et 40 % des résections ont été étendues à un organe de voisinage. Une lymphadenectomie de nécessité a été réalisée 32 fois. La mortalité a été de 7,8 % (deux embolies pulmonaires massives, une défaillance multiviscérale après transplantation et une péritonite postopératoire). La morbidité globale a été de 47 %. La résécabilité a été de 66 %. La survie médiane a été de 19 mois en cas de résection versus quatre mois en cas de non résection (p < 0,001). À un, trois et cinq ans, la survie actuarielle a été respectivement de 69, 31 et 27 %. L’envahissement ganglionnaire a modifié la survie (13 mois versus 20 mois, p = 0,01). Une marge de résection envahie (R1 ou R2) n’a pas influencé significativement la survie (18 mois versus 15 mois). Le cholangiocarcinome périphérique est une tumeur évoluée qui nécessite souvent le recours à une hépatectomie majeure, voire étendue. En dépit de l’âge et de l’extension tumorale au moment du diagnostic, l’obtention d’une résection complète est un objectif acceptable et raisonnable. Il n’y a pas de place pour les résections palliatives quand le caractère incomplet de l’exérèse est prévisible.
The aim of this retrospective study was to evaluate the results of surgical treatment of intrahepatic cholangiocarcinoma treated by the same team. Between 1988 and 2005, 75 patients underwent surgery for intrahepatic cholangiocarcinoma. There were 53 resections including three additional interventions for recurrence. Twenty-seven exploratory laparotomies showed non resectable tumors and two were followed by a liver transplantation at the beginning of the study. Major hepatectomy was performed in 85% of resections while hepatectic resection was extended to an adjacent organ in 40%. A lymphadenectomy was performed in 32 cases. Mortality was 7.8% (two massive pulmonary embolisms, one mutiple organ failure after transplantation and one post-operative peritonitis). Global morbidity was 47%. Resectability was 66%. In case of surgical resection, the median survival rate was 18 months versus 4 months without resection (p < 0.001). Actuarial survival rates at 1 year, 3 years and 5 years were 69, 31 and 27% respectively. Positive nodes decreased the survival rate (13 months versus 20 months, p = 0.01). A positive margin (R1 or R2 resection) did not significantly decrease the survival rate (18 months versus 15 months). In conclusion, intrahepatic cholangiocarcinoma is a tumor that often requires a major or an extended hepatectomy. Complete resection is an acceptable and reasonable goal, whatever the patient's age. This radical surgical approach can prolong survival. Palliative surgery is not an option if incomplete resection is predicted.
Very Early Recurrence after Liver Resection for Intrahepatic Cholangiocarcinoma: Considering Alternative Treatment Approaches
2020, JAMA Surgery

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Scientific paperInfluence of age on surgical treatment of peripheral cholangiocarcinoma

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Ann Oncol

Eur J Cancer

Int J Radiat Oncol Biol Phys

Gastrointest Endosc

Peripheral cholangiocarcinoma (cholangiocellular carcinoma)clinical features, diagnosis and treatment

J Gastroenterol Hepatol

Pathological aspects of cholangiocarcinoma

J Pathol

Peripheral cholangiocarcinoma, neoplasms of the liver

Cholangiocarcinomaepidemiology, mechanism of carcinogenesis and prevention

Cancer Epidemiol Biomarkers Prev

Bladder carcinoma in patients age 40 years or younger

Cancer

Carcinoma of the stomach in the young adult

Surg Gynecol Obstet

Carcinoma of the colon, rectum, mad anal canal in young patients

Surg Gynecol Obstet

Influence of age on the metastatic behavior of breast carcinoma

Hum Pathol

Clinical and pathologic features of cholangiocarcinoma

Scientific paper
Influence of age on surgical treatment of peripheral cholangiocarcinoma