Madariaga JR, Iwatsuki S, Todo S, Lee RG, Irish W, Starzl TE (1998) Liver resection for hilar and peripheral cholangiocarcinomas: a study of 62 cases. Ann Surg, 227(1):70-79
CODE: ICCJRM98
Abstract: The survival rates for HCCA and PCCA were 79% (+8%) and 67% (+8%) at 1 year; 39% (+10%) and 40% (+9%) at 3 years; and 8% (+7%) and 35% (+10%) at 5 years, respectively.The median survival was 24 (±4) months for HCCA and 19 (+8) months for PCCA.
For PCCA, multiple tumors (relative risk [RR] = 3.5; 95% confidence interval [Cl] = 1.2-10.5) and incomplete resection (RR = 8.3; 95% Cl = 2.3-29.6) were independently associated with a worse prognosis.For PCCA, tumor size >5 cm was the only factor associated with disease recurrence (p = 0.024; log rank test).
Statistical Analysis
The standard two-sample Student's t test was used to compare group means; Pearson's chi square test or Fisher's Exact test was used to compare proportions. The Wilcoxon rank sum test, a nonparametric equivalent to the standard two-sample Student's t test, was used for highly skewed data.
Patient survival was calculated from the date of liver resection until death, disease-free survival from the date of liver resection until the time of disease recurrence. Disease-free survival was calculated only for patients who had complete resection. Patients who were alive or disease-free as of December 1995 were censored.
Survival curves were generated using the Kaplan-Meier (product-limit) method37 and were compared by the log rank (Mantel-Cox) test.38 For each survival rate, Greenwood's formula was used to calculate the standard error.39
Cox's proportional hazards model was used to compute the relative risk (RR) of mortality and disease recurrence and 95% confidence intervals (CI).'41 A step-wise multivariate analysis (backward elimination method) was performed using Cox's regression to identify factors independently associated with mortality and disease recurrence. Based on univariate analyses, the criterion for inclusion in the multivariate analysis was a pvalue <0.05.
All tests were two-tailed. A p value <0.05 was considered statistically significant.
RESULTS
Clinical Manifestation
The most frequent complaints were abdominal pain (71%), hepatomegaly (34%), weight loss (15%), jaundice (12%), and fever (9%). One patient with PCCA had been exposed to Clonorchis sinensis.43
Survival
Of the 6 patients with PCCA who reached this milestone(5year) (median follow-up = 89.5; range, 75.3-67.7 months), all had complete resections, single tumors, and negative lymph nodes (see Table 5). Five of the six patients had unilobar disease.
Prognostic Factors
UNIVARIATE:Worse survival (log rank) was associated with bilobar disease (p = 0.029), multiple tumors (p = 0.0005), vascular invasion (p = 0.009), lymph node involvement (p =0.003), and incomplete resection (p < 0.00001) (see Fig.3). There was a trend for lower survival among patients whose tumor size was >5 cm and who had an advanced stage (p = 0.052). Survival was not influenced by adjuvant therapy (p = 0.423).
MULTIVARIATE: Multiple tumors (adjusted RR = 3.50; 95% CI, 1.2-10.5) and incomplete resection (adjusted RR = 8.3; 95% CI, 2.3-29.6) were independently associated with poor prognosis. Only tumor size >5 cm was associated with disease recurrence.
CODE: ICCJRM98
Abstract: The survival rates for HCCA and PCCA were 79% (+8%) and 67% (+8%) at 1 year; 39% (+10%) and 40% (+9%) at 3 years; and 8% (+7%) and 35% (+10%) at 5 years, respectively.The median survival was 24 (±4) months for HCCA and 19 (+8) months for PCCA.
For PCCA, multiple tumors (relative risk [RR] = 3.5; 95% confidence interval [Cl] = 1.2-10.5) and incomplete resection (RR = 8.3; 95% Cl = 2.3-29.6) were independently associated with a worse prognosis.For PCCA, tumor size >5 cm was the only factor associated with disease recurrence (p = 0.024; log rank test).
Statistical Analysis
The standard two-sample Student's t test was used to compare group means; Pearson's chi square test or Fisher's Exact test was used to compare proportions. The Wilcoxon rank sum test, a nonparametric equivalent to the standard two-sample Student's t test, was used for highly skewed data.
Patient survival was calculated from the date of liver resection until death, disease-free survival from the date of liver resection until the time of disease recurrence. Disease-free survival was calculated only for patients who had complete resection. Patients who were alive or disease-free as of December 1995 were censored.
Survival curves were generated using the Kaplan-Meier (product-limit) method37 and were compared by the log rank (Mantel-Cox) test.38 For each survival rate, Greenwood's formula was used to calculate the standard error.39
Cox's proportional hazards model was used to compute the relative risk (RR) of mortality and disease recurrence and 95% confidence intervals (CI).'41 A step-wise multivariate analysis (backward elimination method) was performed using Cox's regression to identify factors independently associated with mortality and disease recurrence. Based on univariate analyses, the criterion for inclusion in the multivariate analysis was a pvalue <0.05.
All tests were two-tailed. A p value <0.05 was considered statistically significant.
RESULTS
Clinical Manifestation
The most frequent complaints were abdominal pain (71%), hepatomegaly (34%), weight loss (15%), jaundice (12%), and fever (9%). One patient with PCCA had been exposed to Clonorchis sinensis.43
Survival
Of the 6 patients with PCCA who reached this milestone(5year) (median follow-up = 89.5; range, 75.3-67.7 months), all had complete resections, single tumors, and negative lymph nodes (see Table 5). Five of the six patients had unilobar disease.
Prognostic Factors
UNIVARIATE:Worse survival (log rank) was associated with bilobar disease (p = 0.029), multiple tumors (p = 0.0005), vascular invasion (p = 0.009), lymph node involvement (p =0.003), and incomplete resection (p < 0.00001) (see Fig.3). There was a trend for lower survival among patients whose tumor size was >5 cm and who had an advanced stage (p = 0.052). Survival was not influenced by adjuvant therapy (p = 0.423).
MULTIVARIATE: Multiple tumors (adjusted RR = 3.50; 95% CI, 1.2-10.5) and incomplete resection (adjusted RR = 8.3; 95% CI, 2.3-29.6) were independently associated with poor prognosis. Only tumor size >5 cm was associated with disease recurrence.
Discussion
In conclusion, 5-year survival can be obtained by resection in an occasional patient with HCCA and in as many as a third of those with PCCA. New adjuvant therapies, presumably based on different principles than current ones, are clearly needed to improve these results. This is particularly true for the historically frustrating HCCA, whose strategic location so limits radical extirpation.
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