Surgical and palliative management and outcome in 184 patients with hilar cholangiocarcinoma: palliative photodynamic therapy plus stenting is comparable to r1/r2 resection

Abstract

Objective: First, to analyze the strategy for 184 patients with hilar cholangiocarcinoma seen and treated at a single interdisciplinary hepatobiliary center during a 10-year period. Second, to compare long-term outcome in patients undergoing surgical or palliative treatment, and third to evaluate the role of photodynamic therapy in this concept.

Summary background data: Tumor resection is attainable in a minority of patients (<30%). When resection is not possible, radiotherapy and/or chemotherapy have been found to be an ineffective palliative option. Recently, photodynamic therapy (PDT) has been evaluated as a palliative and neoadjuvant modality.

Methods: Treatment and outcome data of 184 patients with hilar cholangiocarcinoma were analyzed prospectively between 1994 and 2004. Sixty patients underwent resection (8 after neoadjuvant PDT); 68 had PDT in addition to stenting and 56 had stenting alone.

Results: The 30-day death rate after resection was 8.3%. Major complications occurred in 52%. The overall 1-, 3-, and 5-year survival rates were 69%, 30%, and 22%, respectively. R0, R1, and R2 resection resulted in 5-year survival rates of 27%, 10%, and 0%, respectively. Multivariate analysis identified R0 resection (P < 0.01), grading (P < 0.05), and on the limit to significance venous invasion (P = 0.06) as independent prognostic factors for survival. PDT and stenting resulted in longer median survival (12 vs. 6.4 months, P < 0.01), lower serum bilirubin levels (P < 0.05), and higher Karnofsky performance status (P < 0.01) as compared with stenting alone. Median survival after PDT and stenting, but not after stenting alone, did not differ from that after both R1 and R2 resection.

Conclusion: Only complete tumor resection, including hepatic resection, enables long-term survival for patients with hilar cholangiocarcinoma. Palliative PDT and subsequent stenting resulted in longer survival than stenting alone and has a similar survival time compared with incomplete R1 and R2 resection. However, these improvements in palliative treatment by PDT will not change the concept of an aggressive resectional approach.

FIGURE 1. Distribution of patients by treatment depending on pretherapeutic workup and surgical findings. PDT, photodynamic therapy; R0, curative resection; R1, microscopic infiltration of the resection and dissection margins; R2, evidence of gross residual disease.

FIGURE 2. Actuarial patient survival after resection (group 1), including postoperative deaths, stratified by residual tumor status. Median survival time was 33.1 months (95% CI, 31.2–34.9), 12.2 months (95% CI, 7.7–16.7), and 12.2 months (95% CI, 4.4–20.0) after R0, R1, and R2 resection, respectively (P < 0.05, R0 vs. R1; P < 0.01, R0 vs. R2). Individual patients still alive during follow-up are indicated by marks on the curves.

FIGURE 3. Actuarial patient survival comparing R1/R2 resection and palliative treatment. Median survival was longer after both R1 (12.2 months, 95% CI, 7.7–16.7) and R2 resection (12.2 months, 95% CI, 4.4–20.0) in comparison to stenting alone (6.4 months, 95% CI, 4.2–8.5) (P < 0.05, R1, R2 resection vs. stenting alone). Median survival did not differ between R1 and R2 resection and PDT plus stenting. Median survival time was longer after PDT plus stenting than after stenting alone (P < 0.01). Individual patients still alive during follow-up are indicated by marks on the curves.