Prospective Study
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World J Gastroenterol. Jun 7, 2014; 20(21): 6658-6665
Published online Jun 7, 2014. doi: 10.3748/wjg.v20.i21.6658
Prognostic factors in patients with middle and distal bile duct cancers
Hyung Jun Kwon, Sang Geol Kim, Jae Min Chun, Won Kee Lee, Yoon Jin Hwang
Hyung Jun Kwon, Sang Geol Kim, Yoon Jin Hwang, Department of Surgery, Kyungpook National University Medical Center, Daegu 702-210, South Korea
Jae Min Chun, Department of Surgery, School of Medicine, Kyungpook National University, Daegu 700-422, South Korea
Won Kee Lee, Department of Preventive Medicine, School of Medicine, Kyungpook National University, Daegu 700-422, South Korea
Author contributions: Kwon HJ is the first author and composed the majority of the manuscript; Chun JM prepared the literature review; Hwang YJ designed and coordinated the study and helped to draft the manuscript; Lee WK a statistician and analyzed the data; and Kim SG is the corresponding author and performed the surgery in addition to initiating and guiding the program of identifying the prognostic factors of extrahepatic bile duct cancer; all authors have read and approved the final manuscript.
Supported by Kyungpook National University Research Fund, 2012
Correspondence to: Sang Geol Kim, MD, Department of Surgery, Kyungpook National University Medical Center, 807 Hogukno, Buk-gu, Daegu 702-210, South Korea. ksg@knu.ac.kr
Telephone: +82-53-2002703 Fax: +82-53-2002027
Received: October 7, 2013
Revised: February 25, 2014
Accepted: March 12, 2014
Published online: June 7, 2014
Processing time: 242 Days and 7 Hours
Abstract

AIM: To identify the influence of the surgery type and prognostic factors in middle and distal bile duct cancers.

METHODS: Between August 1990 and June 2011, data regarding the clinicopathological factors of 194 patients with surgical and pathological confirmation were collected. A total of 133 patients underwent resections (R0, R1, R2; n = 102, 24, 7), whereas 61 patients underwent nonresectional surgery. Either pancreaticoduodenectomy (PD) or bile duct resection (BDR) was selected according to the sites of tumors and co-morbidities of the patients after confirming resection margin by the frozen histology in all cases. Univariate and multivariate analyses of clinicopathologic factors were performed, utilizing the Kaplan-Meyer method and Cox hazard regression analysis.

RESULTS: The overall 5-year survival rate for the 133 patients who underwent resection (R0, R1, and R2) was 41.2%, whereas no patients survived longer than 3 years among the 61 patient who underwent nonresectional surgeries. The 5-year survival rate of the patients who underwent a PD (n = 90) was higher than the rate of those who underwent BDR (n = 43), although the difference was not statistically significant (46.6% vs 30.0% P = 0.105). However, PD had a higher rate of R0 resection than BDR (90.0% vs 48.8%, P < 0.0001). If R0 resection was achieved, PD and BDR showed similar survival rates (49.4% vs 46.5% P = 0.762). The 5-year survival rates of R0 and R1 resections were not significantly different (49.0% vs 21.0% P = 0.132), but R2 resections had lower survival (0%, P = 0.0001). Although positive lymph node, presence of perineural invasion, presence of lymphovascular invasion (LVI), 7th AJCC-UICC tumor node metastasis (TNM) stage, and involvement of resection margin were significant prognostic factors in univariate analysis, multivariate analysis identified only TNM stage and LVI as independent prognostic factors.

CONCLUSION: PD had a greater likelihood of curative resection and R1 resection might have some positive impact. The TNM stage and LVI were independent prognostic factors.

Keywords: Distal extrahepatic bile duct cancer; Lymphovascular invasion; Tumor node metastasis; Pancreaticoduodenectomy; Bile duct resection; Prognostic factor

Core tip: The prognosis in bile duct cancer is unfavorable and varies according to the type of surgery, curability, and pathological factors. We analyzed data collected over a period of 22 years that provide valuable information regarding the prognosis. We show that pancreaticoduodenectomy (PD) has a higher chance of curative resection and suggest that BDR should be applied only to tumors located around the cystic duct or in patients with comorbidity precluding PD. Tumor node metastasis stage and lymphovascular invasion are independent prognostic factors. We believe this study to be of great value for the physician and surgeon treating patients with these rare tumors.