a review of the clinical diagnosis and therapy of cholangiocarcinoma

Journal of International Medical Research http://imr.sagepub.com/ A review of the clinical diagnosis and therapy of cholangiocarcinoma Denghua Yao, Vamsi Krishna Kunam and Xiao Li Journal of International Medical Research 2014 42: originally published online 23 December 2013 DOI: 10.1177/0300060513505488 The online version of this article can be found at: http://imr.sagepub.com/content/42/1/3 Published by: http://www.sagepublications.com Additional services and information for Journal of International Medical Research can be found at: Email Alerts: http://imr.sagepub.com/cgi/alerts Subscriptions: http://imr.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> Version of Record - Jan 16, 2014 OnlineFirst Version of Record - Dec 23, 2013 What is This? 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The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0300060513505488 imr.sagepub.com A review of the clinical diagnosis and therapy of cholangiocarcinoma Denghua Yao1,2, Vamsi Krishna Kunam3 and Xiao Li1,2 Abstract Cholangiocarcinoma (CCA) is the second most common primary hepatic malignancy worldwide The incidence of intrahepatic CCA is increasing, whereas that of extrahepatic CCA is decreasing This review looks at the new advances that have been made in the management of CCA, based on a PubMed and Science Citation Index search of results from randomized controlled trials, reviews, and cohort, prospective and retrospective studies Aggressive interventional approaches and new histopathological techniques have been developed to make a histological diagnosis in patients with high risk factors or suspected CCA Resectability of the tumour can now be assessed using multiple radiological imaging studies; the main prognostic factor after surgery is a histologically negative resection margin Biliary drainage and/or portal vein embolization may be performed before extended radical resection, or liver transplantation may be undertaken in combination with neoadjuvant chemotherapy or chemoradiotherapy Though many advances have been made in the management of CCA, the standard modality of treatment has not yet been established This review focuses on the clinical options for different stages of CCA Keywords Cholangiocarcinoma, diagnosis, therapy, malignant biliary obstruction, photodynamic therapy, review Date received: July 2013; accepted: 20 July 2013 Introduction Cholangiocarcinoma (CCA) is a fatal cancer of the biliary epithelium; it arises either within the liver (intrahepatic cholangiocarcinoma; ICC) or in the extrahepatic bile Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China Department of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, China Department of Radiology, Cleveland Clinic, Cleveland, OH, USA Corresponding author: Professor Xiao Li, Department of Interventional Radiology and Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu 610041, Sichuan Province, China Email: simonlixiao@gmail.com Downloaded from imr.sagepub.com at University of Waikato Library on July 12, 2014 Journal of International Medical Research 42(1) ducts (extrahepatic cholangiocarcinoma; ECC) Globally, CCA is the second most common primary hepatic malignancy, with a reported incidence of one to two cases per 100 000 in the USA.1 Several epidemiological studies have shown that the incidence and mortality rates of ICC are increasing, while those of ECC are falling.2–7 The exact aetiology of CCA is unknown There are several well-defined risk factors, however, including primary sclerosing cholangitis, liver fluke infestation, congenital fibropolycystic liver disease and intrahepatic biliary stones.2,5,8,9 Other risk factors include exposure to dioxin, Thorotrast or nitrosamines.10 As there are no specific symptoms in early malignant lesions, patients with CCA mostly present in the advanced stages of the disease, which contributes to its poor prognosis With the advent of new techniques such as intraductal ultrasonography and in situ hybridization for clinical screening in patients with high risk factors, early detection of CCA has become feasible: this can lead to successful surgical resection of these lesions and an improved outcome In patients with advanced CCA, margin-negative (R0) resection can be achieved in increasing numbers of patients using preoperative portal vein embolization followed by extended radical resection or neoadjuvant chemoradiotherapy, and then organ transplantation, with an improved prognosis In patients with unresectable CCA, new technologies such as photodynamic therapy and endoscopic or percutaneous stent implantation have significantly improved quality of life and survival time This review was based on literature searches in PubMed and the Science Citation Index using the following search terms: cholangiocarcinoma and diagnosis; aetiology; surgery; extended surgery; liver transplantation; neoadjuvant chemoradiation; chemotherapy; radiotherapy; palliative biliary drainage; and photodynamic therapy Results from reviews, case reports, randomized controlled trials, and cohort, prospective and retrospective studies for which the title and abstract were available in English were included Studies with A polymorphism was associated with a favourable clinical outcome.19 In patients with suspected CCA, transabdominal ultrasonography and other noninvasive imaging should be performed to confirm the diagnosis Transabdominal ultrasound is sensitive for visualizing the bile ducts, confirming ductal dilatation and ruling out choledocholithiasis For precise characterization of the neoplasm and planning further management, however, other imaging modalities such as computed tomography (CT), contrast-enhanced CT (including three-dimensional reconstruction, three-phase CT and CT angiography), cholangiography, positron emission tomography (PET) and magnetic resonance imaging (MRI), including magnetic resonance cholangiopancreatography (MRCP), should be carried out preoperatively Computed tomography and contrastenhanced CT can not only visualize the local anatomical structures, measure the size of the tumour and the extent of the bile duct dilatation, and detect regional lymph node enlargement, atrophy of the lobe and satellite nodules, but also have the advantage of being able to perform precise multidirectional assessment of biliary and vascular involvement, which helps in the accurate prediction of resectability.20–25 Similarly, MRCP in combination with MRI is a reliable non-invasive diagnostic method for the pre-therapeutic staging of CCA Due to its intrinsic high tissue contrast and multiplanar ability, MRI with MRCP is capable of examining all the structures involved, such as bile ducts, vessels and hepatic parenchyma, and a precise preoperative assessment of the tumour can therefore be achieved.26–29 There are no major differences between CT and MRI for preoperative appraisal for patients with CCA,30 and these imaging techniques play complementary roles in the process of clinical diagnosis and preoperative assessment PET using the radiotracer [18F]fluorodeoxyglucose has become a useful staging technique for many neoplasms One study of 123 patients with suspected and potentially operable CCA demonstrated that PET-CT was more accurate than CT in the diagnosis of regional lymph node metastases (75.9% versus 60.9%, P ¼ 0.004) and distant metastases (88.3% versus 78.7%, P ¼ 0.004), but had no statistically significant advantage over CT or MRI/MRCP in detecting local lesions.31 Although the rapid development of imaging technology and instrumentation has enabled the accurate demonstration of lesions, these imaging modalities are of limited value in early CCA, when there are small or even no changes in morphology In addition, differentiating between benign and malignant bile duct stricture is very difficult, but this distinction is important in treatment planning These clinical problems can be addressed by the use of cytology or tissue biopsy via endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), Downloaded from imr.sagepub.com at University of Waikato Library on July 12, 2014 Journal of International Medical Research 42(1) cholangioscopy or endoscopic ultrasonography (EUS)-guided fine needle aspiration Due to its relative ease and safety, many studies have suggested that cytology during ERCP, despite its low sensitivity, remains a good choice for the diagnosis of causes of biliary stricture.32–35 To improve the sensitivity, further refinements in technique and procedure have been suggested One study of cytodiagnosis through ERCP showed that intraductal aspiration had a significantly higher sensitivity (89% versus 78% for adequate samples and 89% versus 37% for all samples) and significantly superior cellular adequacy (92.8% versus 35.7%) than brushing in patients with suspected malignant biliary stricture.36 In patients with negative results on ERCP-guided bile duct biopsy, biopsy sensitivity was improved by the use of intraductal ultrasonography (IDUS)-guided forceps during ERCP.37 Similarly, cytology or biopsy during PTC has been shown to be effective and safe In the study of Jung et al.,38 patients with obstructive jaundice underwent transluminal forceps biopsy during or after percutaneous transhepatic biliary drainage (PTBD), with a sensitivity, specificity and accuracy of 78.4%, 100% and 79.2%, respectively, without any major complications related to the biopsy procedures Other studies have also demonstrated that biopsy during PTBD is a safe procedure and can provide relatively high accuracy in the diagnosis of malignant biliary obstructions.39,40 Currently, there are no significant differences in sensitivity and complications between cytology/biopsy with ERCP or PTC, but more attention should be paid to the fact that catheter tract implantation metastasis is not a rare complication following PTBD in ECC.41,42 The study of Kim et al.43 indicated that PTC in combination with IDUS was highly accurate for assessing Bismuth type in patients with hilar CCA, which may help in the identification of an optimal surgical plan for the treatment of hilar CCA, especially in Bismuth type III and IV IDUS images also have important clinical significance in the differentiation of malignant and benign lesions Tamada et al.37 reported that when IDUS images showed a polypoid lesion, localized wall thickening, intraductal sessile tumour or sessile tumour outside of the bile duct, the sensitivities of the biopsy were 80%, 50%, 92% and 53%, respectively, and that the presence of sessile tumour (intraductal or outside of the bile duct), tumour size >10.0 mm and interrupted wall structure on IDUS images could predict malignancy in patients with a negative ERCP-guided bile duct biopsy In addition, a number of studies have demonstrated the safety and high accuracy, sensitivity and specificity of EUS and EUS-guided fine needle aspiration in patients with negative results after endoscopic brush cytology and biopsy.43–48 These results suggest that these techniques can play a significant role in planning further management As patients with primary sclerosing cholangitis have a high risk of developing CCA, attention should be paid to early detection of malignant lesions in these patients Tumour serology combined with IDUS and cross-sectional liver imaging and cytology during ERCP/PTC have been shown to be helpful for CCA screening and diagnosis in patients with primary sclerosing cholangitis.49–51 Naitoh et al.52 reported that IDUS findings were useful for distinguishing immunoglobulin G4-related sclerosing cholangitis from CCA In addition, Huddleston et al.53 described the use of UroVysionTM fluorescence in situ hybridization on bile duct brushing for the detection of CCA in a 17-year-old boy with primary sclerosing cholangitis Treatment Resection Surgical resection is the only potentially curative approach currently available, Downloaded from imr.sagepub.com at University of Waikato Library on July 12, 2014 Yao et al although distant metastasis to the lung, peritoneum or other organs is a contraindication for resection Preoperative evaluation of the future remnant liver volume and the patient’s general condition is important in deciding whether or not they are suitable for surgery The prognosis of patients with CCA after surgery is generally poor, with a reported 5-year survival rate in all patients of A, Mcl1 À386C>G) in extrahepatic cholangiocarcinoma Cancer Invest 2010; 28: 472–478 20 Unno M, Okumoto T, Katayose Y, et al Preoperative assessment of 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73: 148–153 McMasters KM, Tuttle TM, Leach SD, et al Neoadjuvant chemoradiation for extrahepatic cholangiocarcinoma Am J Surg 1997; 174: 605–608 Fuks D, Bartoli E, Delcenserie R, et al Biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma with jaundice J Gastroenterol Hepatol 2009; 24: 1745–1752 Harewood GC, Baron TH, Rumalla A, et al Pilot study to assess patient outcomes following endoscopic application of photodynamic therapy for advanced cholangiocarcinoma J Gastroenterol Hepatol 2005; 20: 415–420 Cheon YK, Lee TY, Lee SM, et al Longterm outcome of photodynamic therapy compared with biliary stenting alone in patients with advanced hilar cholangiocarcinoma HPB (Oxford) 2012; 14: 185–193 Downloaded from imr.sagepub.com at University of Waikato Library on July 12, 2014 ... imr.sagepub.com A review of the clinical diagnosis and therapy of cholangiocarcinoma Denghua Yao1,2, Vamsi Krishna Kunam3 and Xiao Li1,2 Abstract Cholangiocarcinoma (CCA) is the second most common primary... chemoradiation; chemotherapy; radiotherapy; palliative biliary drainage; and photodynamic therapy Results from reviews, case reports, randomized controlled trials, and cohort, prospective and retrospective... in CCA Dealis et al evaluated the activity of sorafenib in advanced CCA and showed control of the disease in 31.7% of patients,93 while the study of Bengala et al showed that sorafenib as a single