Itaru Endo

Intrahepatic Cholangiocarcinoma : Rising Frequency, Improved Survival, and Determinants of Outcome After Resection

Background:Despite data suggesting a rising worldwide incidence, intrahepatic cholangiocarcinoma (IHC) remains an uncommon disease. This study analyzes changes in IHC frequency, demographics, and treatment outcome in a consecutive and single institutional cohort. Methods:Consecutive patients with confirmed IHC seen and treated over a 16-year period were included. The trend in IHC frequency over the study period was compared with that of hilar cholangiocarcinoma patients (HCCA) seen during the same time. Demographics and patient disposition, histopathologic, treatment, recurrence, and survival data were analyzed; changes in these variables over time were assessed. Results:From December 1990 through July 2006, 594 patients were evaluated (IHC = 270, HCCA = 324). Over the study period, the average annual increase in new IHC patients was 14.2% (P < 0.001). Relative to HCCA, the proportional increase in IHC was nearly 3-fold, and new IHC patients have outnumbered those with HCCA by 2:1 over the last 3 years. Conditions associated with IHC were rarely seen, with only 7 patients having a history of sclerosing cholangitis and/or inflammatory bowel disease and none with hepatolithiasis or biliary parasitic disease; however, heavy tobacco use (27%) and diabetes mellitus (16.4%) were particularly prevalent. The majority of patients were not candidates for resection, most commonly because of advanced hepatic disease. After resection (n = 82), median disease-specific survival was 36 months; recurrence was observed in 62.2% of patients at a median follow-up of 26 months, with the liver remnant involved most frequently (62.7%). Multiple hepatic tumors (P < 0.001), regional nodal involvement (P = 0.012), and large tumor size (P = 0.016) independently predicted poor recurrence-free survival. Most patients (n = 115, 73.7%) with unresectable disease were treated with chemotherapy, either systemic alone (n = 75) or combined with regional hepatic arterial floxuridine (FUDR) (n = 28). Compared with the first 10 years of the study (1990–2000), the last 6 years saw an overall improvement in disease-specific survival for all patients (22 vs. 12 months, P = 0.002), which was particularly notable for patients with unresectable disease (15 vs. 6 months, P = 0.003). Conclusions:At Memorial Sloan-Kettering Cancer Center, IHC incidence has increased dramatically in the last 16 years. Resection offers the best opportunity for long-term survival but is possible in the minority, and patients with large, node-positive or multifocal IHC seem to derive little benefit. Establishing and maintaining control of the intrahepatic disease remains the biggest problem for all IHC patients. The recent increase in survival seems largely because of improved nonoperative therapy for unresectable disease.

Proximal Cholangiocarcinoma. Prognostic Factor and Effectiveness of Post Operative Radiotherapy.

肝門部上部胆管癌44例を対象に, 予後規定因子と術後放射線療法 (post operative radiotherapy: PORT) の治療効果を検討した. 切除例は32例で切除率は72.7%であった. 切除例の平均観察期間は20.6か月で, 1, 3, 5生率は79.9%, 59.8%, 39.3%であった. 単変量解析ではリンパ節転移の有無とPORTの有無が, 多変量解析ではPORTの有無が予後規定因子と考えられた. 1, 3生率は, 根治度A, BかつPORT (-) 群の83.3%, 40.0%に対して根治度CかつPORT (+) 群では100%, 53.3%と, 根治度CでもPORTにより根治度A, Bと同等の生存率が得られた. PORT施行例では組織学的にhm2, em2において局所再発を認めず, 特に肝側胆管断端, 剥離面の癌遺残に対する再発抑制効果があると思われた.