Risk And Prognostic Factors For Hilar Cholangiocarcinoma And Curative Effect Of Different Surgical Procedure

PART1Risk Factors for Hilar Cholangiocarcinoma:A Case-Control Study in ChinaBackground and Aim:Hilar cholangiocarcinoma(HC) is a rare and highly malignant cancer of bile duct, and its etiology remains poorly understood. Recently, the incidence of HC has been increasing in China. Based on the situation, a hospital-based case-control study was conducted to examine the association of HC with the pre-existing medical conditions.METHODS:Cases were 313 HC patients referred to the Eastern Hepatobiliary Surgery Hospital in China between 2000-2005. Controls were 608 healthy individuals. Ajusted odds ratios(ORs)were calculated in logistic regression analysis.RESULTS:Several risk factors were significantly more prevalent among cases. These included choledocholithiasis(adjusted odds ratio,2.704; 95%CI:1.054-6.941; P=0.039), hepatolithiasis (adjusted odds ratio,3.278; 95%CI:1.226-8.766; P=0.018), cholecystolithiasis(adjusted odds ratio,4.499; 95%CI:2.990-6.769; P<0.0001), cholecystectomy(adjusted odds ratio,7.012; 95%CI:1.895-25.954; P=0.004), biliary ascariasis(adjusted odds ratio,7.188; 95%CI:2.245-23.015; P=0.001), liver fluke(adjusted odds ratio,10.088; 95%CI:1.085-93.775; P=0.042) and liver Schistosomiasis(adjusted odds ratio,9.913,95%CI:2.702-36.368; P=0.001).CONCLUSION:This case-control study shows that biliary tract stone disease and parasitic liver disease are the risk factor for HC. Although cholecystectomy was more frequent in cases than in controls, it was excluded as a risk factor because the symptoms that caused cholecystectomy may be a result of the underlying cancer. Chronic infectious liver diseases, alcoholic liver disease, diabetes mellitus typeâ…¡and smoking are not the risk factor for HC. Primary seclerosing cholangitis(PSC) and ulcerative colitis(UC) both show no significant association with HC which could be due to the low incidence of PSC and UC in the Chinese population.PART 2Preoperative Serum CA19-9 Levels is an Independent Prognostic Factor in Patients with Resected Hilar CholangiocarcinomaBackground and Aim:To investigate the appropriate cutoff point of CA19-9 for prognosis and other potential prognostic factors that may affect survival of patients with hilar cholangiocarcinoma (HC) after radical surgery.Methods:168 patients who had undergone radical surgery for hilar cholangiocarcinoma and resultant macroscopic curative resection (R0 and R1) were discreetly selected for analyses. Categorized versions were used in univariate model to determine the appropriate cutoff point of CA19-9. CA19-9 and other clinicopathologic factors were analyzed for influence on survival by univariate and multivariate methods.Results:The strongest univariate predictor among the categorized preoperative CA19-9 measures was CA19-9 less than 150U/ml(P=0.000). In univariate analysis, age, tumor size, differentiation, Bismuth-Corlette classification, portal vein invasion, Lymph node metastasis, hepatic artery invasion, liver invasion, preoperative biliary drainage, resection margin and preoperative CA19-9 levels were identified as significant prognostic factors. In multivariable analysis, differentiation, lymph node metastasis, hepatic artery invasion, resection margin and preoperative CA19-9 levels were independent prognostic factors. The Ors and 95%CI are as follows::3.359 (1.440-7.837),2.973 (1.927-4.587),2.096 (1.271-3.455),2.238 (1.356-3.694) and 2.954(1.890-4.618). Conclusions:our results demonstrated that preoperative CA19-9 levels was also an independent prognostic factor for hilar cholangiocarcinoma, and the most discriminative cutoff point of CA19-9 for prognosis proved to be at 150U/ml.PART 3Curative Effect of Left Hepatectomy or Right Hepatectomy for Typeâ…¢andâ…£Hilar CholangiocarcinomaBackground and Aim:Combined with left hepatectomy or right hepatectomy is the standard surgical procedure for hilar cholangiocarcinoma(HC). The extrahepatic part of the right hepatic duct (remnant side after L-H) is obviously shorter, and the distance from the hepatic bifurcation to the sectional ramification in the right liver is also much shorter than in the left liver. Furthermore, there are so many anatomic variations in the right sectional bile ducts. These anatomic issues may increase the difficulty of achieving tumor-free stumps for right sectional ducts as a part of L-H, when compared with R-H.. Our aim is to evaluate the clinicopathologic outcomes in patients with HC after L-H.Methods:A total 127 patients with HC underwent surgical resection with curative intent at our institution:L-H for Bismuth typeâ…¢b and IV tumors in 87 patients, and R-H mainly forâ…¢a andâ…£tumors in 40 patients. In this study, clinicopathologic outcomes and perioperative morbidity and mortality rates after L-H and were investigated and compared with those after R-H.Results:Histologically negative margin(RO) was achieved in 70 cases(80%) with L-H, similar to the results for R-H(33/40,85%), Positive rate of L-H in proximal ductal stumps is 82.3%, and that of R-H is 66.7%. The overall 5 year survival rate of L-H and R-H are 18.4% and 17.1% respectively. The perioperative morbidity of L-H and R-H are 17.2% and 42.5% respectively, however,8 patients occurred anastomotic leakage in L-H and no one occurred in R-H.. Multivariate analysis revealed 5 independent factors influencing survival after L-H:differentiation, lymphnode metastasis, hepatic artery invasion, resection margin and CA19-9 level. Univariate analysis of survival identified differentiation, lymphnode metastasis, perineural invasion, portal vein invasion, total bilibubin, resection margin and CA19-9 as prognostic factors in patients who underwent R-H.Conclusion:There's no significant difference in resection margin, survival and perioperative morbidity between L-H group and R-H group. L-H for HC is generally considered to be a more complicated procedure, requiring greater skill. We believe that L-H should be aggressively performed for Typeâ…¢b tumor, if curative resection is possible, even in cases with portal involvement.