ObjectiveTo evaluate different strategies for extended resections of hilar cholangiocarcinomas on radicality and survival.
Summary Background DataSurgical resection of hilar cholangiocarcinoma is the only potentially curative treatment. Resection of central bile duct carcinomas, however, cannot always comply with the general principles of surgical oncology to achieve wide tumor-free margins with no-touch techniques.
MethodsFrom 1988 to 1998, 95 patients underwent resection of hilar cholangiocarcinoma. Eighty patients had hilar and hepatic resections and 15 had liver transplantation and partial pancreatoduodenectomy (LTPP; i.e., eradication of the entire biliary tract using a no-touch technique).
ResultsThe 60-day death rate was 8%. The overall 1-and 5-year survival rates were 67% and 22%, respectively. Five-year survival rates after R0, R1, and R2 resections were 37%, 9%, and 0%. In a multivariate analysis, surgical radicality was the strongest determinant of survival (p Ͻ 0.001). The rate of formally curative resection (R0 resection) was significantly lower in hilar resections (29%) than in liver resections (left hemihepatectomy 59%, right hemihepatectomy 55%, right trisegmentectomy 65%; p Ͻ 0.05). The highest rate of R0 resection was observed after LTPP (93%; p Ͻ 0.05). Right trisegmentectomies achieved the highest rate of 5-year survival after R0 resection (57%). In a multivariate analysis of patient survival after R0 resection, additional portal vein resection was the only significant factor. The 5-year survival rate after formally curative liver resection with portal vein resection was 65% versus 28% without.
ConclusionExtended resections, especially right trisegmentectomies and LTPP, resulted in the highest rate of R0 resection. Right trisegmentectomy together with portal vein resection best represents the principles of surgical oncology and may be regarded as the surgical procedure of choice. Immunosuppression limits the applicability of LTPP.Surgical strategies in the therapy of hilar cholangiocarcinoma afford patients the best chance for significant survival. Radical resections are currently considered as optimal treatment, but Ͻ20% of patients are estimated to be amenable to a formally curative approach.1,2 Local or hilar resections including the extrahepatic suprapancreatic biliary tract represent the least extensive resection procedures and have been shown to be safe, with a surgical death rate of Ͻ1% in selected series.3 In principle, patients with Bismuth-Corlette type I or type II tumors can undergo hilar resections with a curative intent. In practice, failure, even after formally curative extrahepatic bile duct resection, occurs in a high percentage of patients (76%) with locoregional recurrence. 4 Hilar cholangiocarcinomas involving either the right or left hepatic duct (Bismuth-Corlette types IIIa/IIIb) are generally proposed to require resection of the respective hemiliver to achieve clear margins. Recent studies on prognostic parameters after resection identified only tumor-free margins as a ...
The Epstein-Barr virus (EBV) is consistently associated with undifferentiated nasopharyngeal carcinoma (NPC). There is, however, conflicting evidence as to whether squamous cell NPCs are also EBV-associated. Moreover, it has been proposed that other epithelial tumours, particularly thymomas and thymic carcinomas, should be included in the group of EBV-associated neoplasias. However, since the viral DNA in these studies was demonstrated only in extracted DNA, the cellular origin of the viral DNA is uncertain. We have therefore investigated 152 epithelial tumours from various sites for the presence of EBV-DNA by in situ hybridization with 35S-labelled probes. Sixty-eight of 77 undifferentiated NPCs showed an EBV-specific autoradiographic signal, thus confirming the strong association of this tumour type with EBV even in geographical areas where undifferentiated NPC is not endemic. None of eight squamous cell NPCs showed an EBV-specific signal. All of 15 carcinomas with a similar morphology to undifferentiated NPC but from different anatomic sites (thymus, tonsil, breast) were EBV-negative as were 9 thymomas, 26 squamous cell carcinomas of the palatine tonsil, and 14 cervical carcinomas. Our results therefore suggest a unique association of EBV with undifferentiated NPC and support concepts assigning different biological properties to undifferentiated NPC as compared with squamous cell NPC.
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