Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution

Abstract

Objective: To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer.

Summary background data: The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most series.

Methods: We studied 564 consecutive patients with bile duct cancer operated upon between 1973 and 2004. Patients were divided into intrahepatic, perihilar, and distal groups. Principle outcome measures were complications, 30-day mortality, and survival.

Results: Of the 564 patients, 44 (8%) had intrahepatic, 281 (50%) had perihilar, and 239 (42%) had distal tumors. Approximately half (294, 52%) were treated before 1995, while 270 (48%) were treated thereafter. The perioperative mortality rate was 4%. In log-rank analyses, survival was higher in the later time period (P = 0.002), in patients with intrahepatic disease (P = 0.001), with negative resection margins (P < 0.001), with well/moderately differentiated tumors (P < 0.001), and those with negative lymph nodal status (P < 0.001). In multivariate analysis, negative margins (P < 0.001), tumor differentiation (P < 0.001), and negative nodal status (P < 0.001), but not tumor diameter, were significant independent prognostic factors. In R0-resected patients, lymph node status (P < 0.001), but not tumor diameter, histology, or differentiation, further predicted survival. The median survivals for R0-resected intrahepatic, perihilar, and distal tumors were 80, 30, and 25 months, respectively, and the 5-year survivals were 63%, 30%, and 27%, respectively.

Conclusion: R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.

FIGURE 1. Overall survival for the entire group (A) and by tumor location (B).

FIGURE 2. Overview of survival analyses by tumor location and pathology. All graphs depict surviving fraction on the y-axis. For analysis of margins, dashed line represents R0 resections, solid line R1/R2 resections, and dotted line palliations. For analysis of lymph nodes, dashed lines represent negative status and solid lines positive status. For analysis of tumor diameter, dashed lines represent tumor diameter ≤2 cm, and solid lines >2 cm. For analysis of differentiation, dashed lines represent well/moderately differentiated tumors and solid lines poor/unknown lesions.

FIGURE 3. Survival according to time period. Early period (1973–1995) versus late period (1996–2004).