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


BACKGROUND
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.


CONCLUSIONS
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.
Witzigmann
Helmut
H
Department of Surgery II, University of Leipzig, Leipzig, Germany. Helmut.Witzigmann@medizin.uni-leipzig.de
Berr
Frieder
F
Ringel
Ulrike
U
Caca
Karel
K
Uhlmann
Dirk
D
Schoppmeyer
Konrad
K
Tannapfel
Andrea
A
Wittekind
Christian
C
Mossner
Joachim
J
Hauss
Johann
J
Wiedmann
Marcus
M
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000188:drug therapy / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic / Q000187:drug effects / Q000601:surgery*; D001663:Bilirubin / Q000097:blood; D018281:Cholangiocarcinoma / Q000188:drug therapy / Q000601:surgery*; D017323:Dihematoporphyrin Ether / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D006414:Hematoporphyrin Photoradiation; D006801:Humans; D017567:Karnofsky Performance Status; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009361:Neoplasm Invasiveness; D010166:Palliative Care; D011379:Prognosis; D011446:Prospective Studies; D015607:Stents; D015996:Survival Rate; D016896:Treatment Outcome
D017323:Dihematoporphyrin Ether; D001663:Bilirubin