title: Intrahepatic cholangiocarcinoma: rising frequency, improved survival, and determinants of outcome after resection.
abstract: BACKGROUND
  Despite data suggesting a rising worldwide incidence, intrahepatic cholangiocarcinoma (IHC) remains an uncommon disease. This study analyzes changes in IHC frequency, demographics, and treatment outcome in a consecutive and single institutional cohort.
  
  
  METHODS
  Consecutive patients with confirmed IHC seen and treated over a 16-year period were included. The trend in IHC frequency over the study period was compared with that of hilar cholangiocarcinoma patients (HCCA) seen during the same time. Demographics and patient disposition, histopathologic, treatment, recurrence, and survival data were analyzed; changes in these variables over time were assessed.
  
  
  RESULTS
  From December 1990 through July 2006, 594 patients were evaluated (IHC = 270, HCCA = 324). Over the study period, the average annual increase in new IHC patients was 14.2% (P < 0.001). Relative to HCCA, the proportional increase in IHC was nearly 3-fold, and new IHC patients have outnumbered those with HCCA by 2:1 over the last 3 years. Conditions associated with IHC were rarely seen, with only 7 patients having a history of sclerosing cholangitis and/or inflammatory bowel disease and none with hepatolithiasis or biliary parasitic disease; however, heavy tobacco use (27%) and diabetes mellitus (16.4%) were particularly prevalent. The majority of patients were not candidates for resection, most commonly because of advanced hepatic disease. After resection (n = 82), median disease-specific survival was 36 months; recurrence was observed in 62.2% of patients at a median follow-up of 26 months, with the liver remnant involved most frequently (62.7%). Multiple hepatic tumors (P < 0.001), regional nodal involvement (P = 0.012), and large tumor size (P = 0.016) independently predicted poor recurrence-free survival. Most patients (n = 115, 73.7%) with unresectable disease were treated with chemotherapy, either systemic alone (n = 75) or combined with regional hepatic arterial floxuridine (FUDR) (n = 28). Compared with the first 10 years of the study (1990-2000), the last 6 years saw an overall improvement in disease-specific survival for all patients (22 vs. 12 months, P = 0.002), which was particularly notable for patients with unresectable disease (15 vs. 6 months, P = 0.003).
  
  
  CONCLUSIONS
  At Memorial Sloan-Kettering Cancer Center, IHC incidence has increased dramatically in the last 16 years. Resection offers the best opportunity for long-term survival but is possible in the minority, and patients with large, node-positive or multifocal IHC seem to derive little benefit. Establishing and maintaining control of the intrahepatic disease remains the biggest problem for all IHC patients. The recent increase in survival seems largely because of improved nonoperative therapy for unresectable disease.
authors.affiliation: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
authors.forename: Itaru
authors.initials: I
authors.lastname: Endo
authors.forename: Mithat
authors.initials: M
authors.lastname: Gonen
authors.forename: Adam C
authors.initials: AC
authors.lastname: Yopp
authors.forename: Kimberly M
authors.initials: KM
authors.lastname: Dalal
authors.forename: Qin
authors.initials: Q
authors.lastname: Zhou
authors.forename: David
authors.initials: D
authors.lastname: Klimstra
authors.forename: Michael
authors.initials: M
authors.lastname: D'Angelica
authors.forename: Ronald P
authors.initials: RP
authors.lastname: DeMatteo
authors.forename: Yuman
authors.initials: Y
authors.lastname: Fong
authors.forename: Lawrence
authors.initials: L
authors.lastname: Schwartz
authors.forename: Nancy
authors.initials: N
authors.lastname: Kemeny
authors.forename: Eileen
authors.initials: E
authors.lastname: O'Reilly
authors.forename: Ghassan K
authors.initials: GK
authors.lastname: Abou-Alfa
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Shimada
authors.forename: Leslie H
authors.initials: LH
authors.lastname: Blumgart
authors.forename: William R
authors.initials: WR
authors.lastname: Jarnagin
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy; D006801:Humans; D015994:Incidence; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009519:New York City / Q000453:epidemiology; D010166:Palliative Care; D016016:Proportional Hazards Models