title: Surgical management of intrahepatic cholangiocarcinoma--a population-based study.
abstract: BACKGROUND
  Cholangiocarcinoma (CCA) is associated with poor survival and therapeutic nihilism. To date, there has not been an examination of the surgical management of CCA at a population level.
  
  
  METHODS
  Using the Surveillance, Epidemiology and End Results (SEER) database, we identified all patients with intrahepatic CCA diagnosed between 1988 and 2003. Tumors categorized as a single, unilobar lesion with no evidence of vascular invasion were defined as localized. It was then determined whether patients received cancer directed surgery (CDS). Multivariable logistic regression was used to evaluate factors associated with CDS in patients with localized disease. The influence of CDS on overall survival (OS) was evaluated using Kaplan-Meier curves and Cox proportional hazards modeling.
  
  
  RESULTS
  Only 446 (12%) of 3,756 patients with intrahepatic CCA underwent CDS. On multivariable analysis, non-Klatskin tumor (p < 0.01) and younger age (p = 0.02) was associated with CDS. Localized disease was strongly associated with CDS (p < 0.01); however, only 91 (37%) of these 248 patients underwent CDS. Of patients with localized disease, those who had CDS had significantly better survival than those who did not (p < 0.01), with median overall survival (OS) of 44 months versus 8 months, and five-year OS of 42% versus 4%, respectively.
  
  
  CONCLUSIONS
  Patients with localized CCA who are selected for CDS are strongly associated with improved survival, with rates approaching that found in single institution studies. However, many patients with localized tumors do not receive potentially curative cancer-directed surgery. Further study is warranted to address the barriers to the delivery of appropriate care to these patients.
authors.affiliation: Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Canada.
authors.forename: Jensen C C
authors.initials: JC
authors.lastname: Tan
authors.forename: Natalie G
authors.initials: NG
authors.lastname: Coburn
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
authors.forename: Alex
authors.initials: A
authors.lastname: Kiss
authors.forename: Calvin H L
authors.initials: CH
authors.lastname: Law
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000453:epidemiology / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000453:epidemiology / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008875:Middle Aged; D016017:Odds Ratio; D015995:Prevalence; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018426:SEER Program; D014481:United States / Q000453:epidemiology