CLINICAL INVESTIGATIONS
Benefits of adjuvant radiotherapy after radical resection of locally advanced main hepatic duct carcinoma

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Abstract

Purpose: The objective of this study was to determine the benefits of adjuvant radiotherapy after radical resection of locally advanced main hepatic duct carcinoma (Klatskin tumor).

Methods and Materials: We conducted a retrospective review of 63 patients who underwent surgical resection of Stage IVA Klatskin tumor. Of the 63 patients, 47 had microscopic tumor residue (RT1). Twenty-eight of the 47 patients with RT1 were treated by adjuvant radiotherapy and the remaining 19 patients were treated exclusively by surgical resection. Seventeen of the 28 patients with RT1 were treated by both intraoperative radiotherapy (IORT) and postoperative radiotherapy (PORT); of the remaining 11 patients with RT1, 6 underwent resection and IORT, and 5 underwent resection and PORT.

Results: The major complication and 30-day operative death rates were significantly lower in the radiation group (9.5% and 0.0%, respectively) than in the resection alone group (28.5% and 9.5%, respectively). Of the eight 5-year survivors with RT1, 6 had adjuvant radiotherapy and the remaining 2 had resection alone. Adjuvant radiotherapy for patients with RT1 yielded significantly (p = 0.0141) higher 5-year survival rates (33.9%) than in the resection alone group (13.5%). The best 5-year survival rate (39.2%) was found in patients who underwent a combination of IORT and PORT after resection. The local-regional control rate was significantly higher in the adjuvant radiation group than in the resection alone group (79.2% vs. 31.2%).

Conclusion: Our data clearly suggest the improved prognosis of patients with locally advanced Klatskin tumor by integrated adjuvant radiotherapy with IORT and PORT to complete gross tumor resection with acceptable treatment mortality and morbidity.

Introduction

Patients with main hepatic duct carcinoma often have advanced disease, making the treatment management of these patients extremely difficult. Although recent reports suggest that aggressive surgical approaches enhance the long-term survival of patients with advanced main hepatic duct carcinoma (Klatskin tumor) 1, 2, 3, 4, 5, the prognosis of these patients remains poor because of local-regional recurrence 4, 6. The eradication of post-resection tumor residue may lower the risk of local-regional recurrence. Therefore, many have advocated the use of adjuvant radiotherapy to eradicate post-resection tumor residue after resection 6, 7, 8, 9, 10, 11; however, the benefits of adjuvant radiotherapy remain controversial 12, 13.

In this retrospective study, we have evaluated the efficacy of combining radiation with radical resection in patients with locally advanced (Stage IVA) Klatskin tumor by examining operative mortality, morbidity, local control and metastasis, and long-term survival. The results of this evaluation should provide vital knowledge for deciding when and how adjuvant radiation should be applied.

Section snippets

Study population

Between October 1976 and April 1999, 102 patients with Klatskin tumor underwent resection at the Tsukuba University Hospital. The cancers were classified by the TNM/AJCC classification criteria (14) based on the pathologic findings. Sixty-three of the 102 patients were classified as having Stage IVA, and formed the study population. The histopathologic type of tumor in all 63 patients was adenocarcinoma. The Stage IVA carcinomas were classified into the following categories: T3, N0-2, and M0,

Treatment morbidity and mortality

Major complications were encountered in 10 patients. Sepsis and liver abscess were the most frequent complications, followed by multi-organ failure and liver failure. The rates of major complications and 30-day operative mortality were significantly (p < 0.05) higher in the resection alone group (28.6% and 9.5%) than in the adjuvant radiation group (9.5% and 0.0%). The overall 30-day operative mortality rate of patients with Stage IVA was 3.2% (2/63) (Table 4). Between postoperative days 41 and

Discussion

Several studies have reported the benefits of adjuvant radiotherapy after surgical resection of bile duct carcinoma; however, the effects of radiation on survival of patients with hilar bile duct carcinoma remains unclear 6, 10, 12, 15, 17, 18, 19, 20, 21. Despite the recent increase in the resection rate of advanced main hepatic duct carcinoma, improvement in the long-term survival rate has remained minimal 1, 2, 3, 4, 5, 22, 23, 24, 25. The usual tumor-related cause of death after surgical

Acknowledgements

The lead author acknowledges the late Professor Yoji Iwasaki, M.D., for encouraging us to treat patients with advanced disease.

References (37)

  • D Gonzalez Gonzalez et al.

    Results of radiation therapy in carcinoma of the proximal bile duct (Klatskin tumor)

    Semin Liver Dis

    (1990)
  • P.C Verbeek et al.

    Does additive radiotherapy after hilar resection improve survival of cholangiocarcinoma? An analysis in sixty-four patients

    Ann Chir

    (1991)
  • T Shiina et al.

    Radiotherapy of cholangiocarcinomaThe roles for primary and adjuvant therapies

    Cancer Chemother Pharmacol

    (1992)
  • Gunderson LL, Haddock MG, Burch P; et al. Future role of radiotherapy as a component of treatment in billiopancreatic...
  • Gunderson LL, Haddock MG, Foo ML; et al. Conformal irradiation for hepatobiliary malignancies. Ann Oncol Suppl...
  • Pitt HA, Nakeeb A, Abrams RA; et al. Perihilar cholangiocarcinoma. Postoperative radiotherapy does not improve...
  • S.A Ahrendt et al.

    Current management of patients with perihilar cholangiocarcinoma

    Adv Surg

    (1996)
  • I.D Fleming et al.

    AJCC cancer staging manual

    (1997)
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    This study was supported in part by a grant-in-aid for Cancer Research (No. 8-4) from the Ministry of Health and Welfare of Japan.

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