title: Improved survival in resected biliary malignancies.
abstract: BACKGROUND
  For many years the prognosis for patients with biliary malignancies has been poor. However, recent advances in radiology and laparoscopy have improved staging, and active biliary stent management may improve outcome in these patients. In the past the goal with surgery was to excise all gross tumor. Now, the surgical goal is to achieve negative microscopic margins even if a major hepatic resection is required. Similarly, chemotherapy or radiation was frequently given in isolation, but chemoradiation has become the standard. Therefore, the aim of this analysis was to determine whether survival has improved with better staging, active stent management, more aggressive surgery, and chemoradiation.
  
  
  METHODS
  From 1990 through 2001, 140 patients with biliary malignancies were treated at the Medical College of Wisconsin. One hundred eleven malignancies were cholangiocarcinomas (intrahepatic, 22%; perihilar, 65%; and distal, 13%), and 29 were gallbladder (GB) cancers. Eighty-six of the 140 patients (61%) underwent exploration (intrahepatic, 58%; perihilar, 57%; distal, 67%, and GB, 72%). Forty-four of these 86 patients (51%) underwent resection (intrahepatic, 64%; perihilar, 41%; distal, 70%; and GB, 52%). Chemoradiation with confocal radiation, 5-fluorouracil, and gemcitabine was used more frequently in the patients resected since 1998.
  
  
  RESULTS
  Thirty-day operative mortality was 4%. In the resected patients (n = 44) the 5-year actuarial survival was 31% and the median survival was 27.8 months. Patients resected between 1998 and 2001 (n = 25) had a median survival longer than 44 months with a 3-year actuarial survival of 70% as compared to patients resected between 1990 and 1997 (n = 19), who had a median survival of 13 months and a 3-year actuarial survival of 21% (P <.01).
  
  
  CONCLUSIONS
  These data suggest that (1) approximately one third of patients with biliary malignancies have resectable disease and (2) surgery in carefully selected patients with adjuvant chemoradiation has improved survival in resected patients. We suspect that a combination of improved staging, active biliary stenting, safe but extensive surgery to obtain negative margins, and newer techniques for chemoradiation have resulted in improved outcomes for patients with biliary malignancies.
authors.affiliation: Departments of Surgery, Radiation Oncology, Medicine, and Radiology, Medical College of Wisconsin, Milwaukee, Wis 53226, USA.
authors.forename: Attila
authors.initials: A
authors.lastname: Nakeeb
authors.forename: Khoi Q
authors.initials: KQ
authors.lastname: Tran
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Black
authors.forename: Beth A
authors.initials: BA
authors.lastname: Erickson
authors.forename: Paul S
authors.initials: PS
authors.lastname: Ritch
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Quebbeman
authors.forename: Stuart D
authors.initials: SD
authors.lastname: Wilson
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Demeure
authors.forename: William S
authors.initials: WS
authors.lastname: Rilling
authors.forename: Kulwinder S
authors.initials: KS
authors.lastname: Dua
authors.forename: Henry A
authors.initials: HA
authors.lastname: Pitt
mesh_terms: D000368:Aged; D001661:Biliary Tract Neoplasms / Q000145:classification / Q000401:mortality / Q000601:surgery*; D001662:Biliary Tract Surgical Procedures / Q000401:mortality*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D012189:Retrospective Studies; D016019:Survival Analysis; D015996:Survival Rate; D013997:Time Factors