Prognostic analysis of surgical treatment of peripheral cholangiocarcinoma: Two decades of experience at Chang Gung Memorial Hospital

Table 1 Clinical manifestations and histological classification of 373 PCC patients who underwent surgical treatment.

Symptoms	Case No	%
Right hypochondria	266	71.7
Fever and chills	135	36.4
Body weight loss	99	26.7
Jaundice	76	20.5
Negative	14	3.8
Physical findings
Abdominal tenderness or rebounding pain	160	43.1
Icteric sclera and yellow discoloration	72	19.4
Abdominal mass	17	4.6
Negative	109	29.4
Histological classifications
Papillary adenocarcinoma	50	14.9
W-D adenocarcinoma	32	15.8
M-D adenocarcinoma	66	20.5
P-D adenocarcinoma	56	15.8
Mucinous adenocarcinoma	32	8.6
Adenosquamous carcinoma	14	3.8
Hepatocholangiocarcinoma	9	2.4
Adenocarcinoma; unclassified	56	15.1

W: well; M: moderately; P: poorly; D: differentiated.

Table 2 Surgical procedures of 373 PCC patients.

Surgical procedures	Patient Number	%
Hepatectomy	187	50.1
Left hepatectomy	125
Segment 1, 2, 3, and 4	6
Segment 2, 3, and 4	67
Segment 2 and 3	49
Segment 2, 3, and bile duct resection	2
Segment 1	1
Right hepatectomy	36
Segment 5, 6, 7, and 8	15
Segment 5, 6, 7, 8, and bile duct resection	5
Segment 5, 6, and 7	1
Segment 5 and 6	9
Segment 6 and 7	4
Segment 7 and 8	2
Bilateral hepatectomy	14
Segment 4, 5, 6, 7, and 8	9
Segment 4, 5, and 8	3
Segment 2, 3, 4, and 5	1
Segment 2, 3, 4, 5, and 8	1
Partial hepatectomy	12
Choledochotomy with T-tube	104	27.9
Laparotomy with biopsy	82	22
Total	373	100

Table 3 Operative mortality of 373 PCC patients undergoing surgical treatment.

	Hepatectomy (n = 187)	Non-hepatectomy (n = 186)
Cause of death
Sepsis (biliary)	2	8
GI bleeding	0	1
Intra-abdominal bleeding with shock	0	2
Terminal status of cancer	0	6
Necrotizing fascitis with sepsis	0	1
CVA	0	1
Hepatic failure	1	0
Respiratory failure	0	1
Gastrocutaneous fistula	2	0
Total	5	20
Mortality rate	2.70%	10.80%

GI: gastrointestinal, CVA: cerebrovascular accident; mortality rate of hepatectomy vs non-hepatectomy: 2.7% vs 10.8% (P = 0.002); whole series mortality rate: 25/373 = 6.7%.

Table 4 Univariate analysis of factors influencing the overall survival of the 312 PCC patients.

Factors	Survival time (mo)				P
	Median	mean	3-yr (%)	5-yr (%)
Gender
Male (n = 128)	7.79	14.66	11.78	2.27
Female (n = 184)	6.84	18.41	10.88	8.61	0.941
Age (yr)
≤58 (n = 163)	6.21	17.07	11.69	6.86
>58 (n = 149)	8.35	17.15	10.7	6.05	0.471
Symptoms
Positive (n = 303)	6.9	16.58	10.75	6
Negative (n = 9)	20.45	41.67	30.48	30.48	0.024
Physical examination
Positive (n = 222)	6.64	15.7	8.08	4.54
Negative (n = 90)	9.67	20.55	20.46	13.56	0.053
AST (IU/L)
≤34 (n = 121)	7.89	15.69	11.56	5.51
>34 (n = 161)	7.30	18.85	12.02	7.28	0.936
ALT (IU/L)
≤36 (n = 139)	7.33	14.94	9.26	5.15
>36 (n = 107)	8.35	21.38	15.12	9.3	0.326
ALP (IU/L)
≤94 (n = 63)	10.39	16.31	12.12	3.64
>94 (n = 214)	6.64	17.22	10.75	6.46	0.2143
Serum CEA (ng/dL)
>5 (n = 70)	4.57	9.58	1.99	1.99
≤5 (n = 103)	10.39	23.17	17.96	9.95	0.0001
Serum CA 19-9 (ng/dL)
>37 (n = 76)	7.4	11.93	10.27	N.A.
≤37 (n = 29)	13.28	25.49	23.76	15.84	0.008
Associated with biliary stones
With biliary stones (n = 186)	6.94	17.86	11.96	7.18
Without biliary stones (n = 126) 7.40	16.50	9.77	5.86	0.693
Type of operation
Hepatectomy (n = 157)	12.99	25.31	17.88	10.15
Non-hepatectomy (n = 155)	3.65	9.03	4.42	2.76	<0.0001

AST: aspartate aminotransferase; ALT: alanine aminotransferase; ALP: alkaline phosphatase; CEA: carcinoembryonal antigen; CA 19-9: carbohydrate antigen; IU: international unit.

Table 5 Univariate analysis of factors influencing the overall survival of the 312 PCC patients.

Factors	Survival time (mo)				P
	Median	mean	3-yr (%)	5-yr (%)
Mucobilia
Positive (n = 33)	24.07	45.79	40.3	25.65
Negative (n = 279)	6.48	13.05	7.41	3.89	<0.0001
Tumor spreading type
Papillary (n = 57)	22.59	38.19	31.77	20.42
Non-papillary (n = 255)	5.85	12.32	6.35	3.3	<0.0001
TNM staging
I (n = 17)	45.9	50.54	60.00	45
II (n = 58)	24.07	37.74	28.89	17.78
III (n = 88)	8.52	11.45	2.65	N.A
IV (n = 149)	4.18	7.66	6.08	N.A.	<0.0001
Tumor staging
Early stage (I+II) (75)	24.99	41.19	35.29	22.83
Advanced stage (III+IV) (237)	5.03	9.09	3.92	N.A.	<0.0001
Post-operative chemotherapy
With chemotherapy (n = 118)	11.44	24.25	17.74	11.88
Without chemotherapy (n = 194)	4.64	12.35	7.16	3.58	<0.0001
Post-operative radiotherapy
With radiotherapy (n = 63)	11.7	22.12	16.63	6.65
Without radiotherapy (n = 249)	6.25	15.89	9.65	7.17	0.0197

Table 6 Cox’s proportional hazards analysis.

Factors	Relative risk (95% confidence interval)	P
Mucobilia (without mucobilia/mucobilia )	2.185 (1.324–3.605)	0.002
Tumor spreading type (non-papillary/papillary)	1.455 (1.028–2.060)	<0.001
Type of operation (non-hepatectomy/hepatectomy)	1.946 (1.477–2.564)	<0.001
Tumor staging
(II/I)	1.637 (0.786–3.406)	0.188
(III/I)	3.334 (1.615–6.882)	0.001
(IV/I)	4.049 (1.940–8.449)	<0.001
Post-operative chemotherapy (no chemotherapy/chemotherapy)	1.823 (1.413–2.353)	<0.001