Prognostic significance of tumor DNA content in carcinoma of the hepatic duct confluence.

BACKGROUND: In an attempt to identify prognostic factors in carcinoma of the hepatic duct confluence, the value of tumor DNA content was studied in 58 patients with this type of malignancy. METHODS: Of 58 patients (ages 26 to 74 years) surgically treated for carcinoma of the hepatic duct confluence, tumor DNA content was assessed in relationship to clinical-pathologic characteristics and patient survival. Thirty-three patients underwent additive radiotherapy. Nuclear DNA content was analyzed by flow cytometry. RESULTS: Resection was radical in only three patients with negative surgical resection margins and dissection (cleavage) margins. Twenty-eight patients (48%) had diploid tumors, and 30 patients (52%) had aneuploid tumors. No significant correlation was found between tumor DNA ploidy, degree of tumor differentiation, lymph node status, and hepatic infiltration. Aneuploid tumors were significantly associated with neural invasion. The median overall survival was 18 months. The survival period of patients with diploid tumors was significantly (p < 0.0003) longer than the survival period of those with aneuploid tumors (median survival, 26 months and 11 months, respectively). Additive radiotherapy improved survival significantly only in patients with aneuploid tumors. When tested by univariate survival analysis, DNA ploidy, additive radiotherapy, and the state of the surgical resection margins were significant prognostic factors. With multivariate survival analysis, only DNA ploidy, age, hepatic infiltration, and lymph node status were significantly related to prognosis. CONCLUSIONS: This survival analysis shows that DNA ploidy is a powerful prognostic determinant of carcinoma of the hepatic duct confluence.

Benign fibrosing disease at the hepatic confluence mimicking Klatskin tumors.

BACKGROUND: Hilar obstructions remain a challenge with regard to diagnosis and treatment. METHODS: In the period from 1984 to 1990, 82 patients underwent resective surgery under the presumptive diagnosis of hilar cholangiocarcinoma (Klatskin tumor). The diagnosis was based on the combined appearances on direct cholangiography and ultrasonography in all cases, with the use of various other imaging modalities in some cases. RESULTS: The perioperative findings from an experienced surgical team were usually thought to be compatible with bile duct carcinoma. However, histologic examination of the resected specimens revealed benign fibrosing or localized sclerosing lesions in 11 patients (13.4%). CONCLUSIONS: The current state of diagnostic imaging fails as yet to discriminate reliably between benign and malignant hilar lesions. Whereas the immediate therapeutic consequences may be equal (resection followed by hepaticojejunostomy), the late consequences differ in a major way because benign disease has a much better prognosis. In the presence of suspicious hilar obstruction, operable lesions should not be treated by "palliative" intubational techniques and radiation therapy without a firm diagnosis of malignancy. However, overtreatment (extended liver resection, vascular reconstruction, and liver transplantation) should be avoided as well when a benign lesion has not been ruled out.

Morphologic changes of extrahepatic bile ducts during obstruction and subsequent decompression by endoprosthesis.

The morphologic changes of the extrahepatic biliary tract during obstruction and the effects of biliary decompression by means of an endoprosthesis on the bile duct wall were studied by light microscopy and scanning electron microscopy. Common hepatic duct biopsy specimens and bile cultures were obtained during surgery from 30 patients with a distal common bile duct obstruction caused by a tumor. Thirteen patients had obstructed bile ducts of 3 weeks' duration (group A). Seventeen patients had had jaundice for a period of 4 weeks and had subsequently undergone preoperative endoscopic biliary stenting for a period of 4 weeks (group B). Three autopsy specimens from patients without hepatobiliary disease served as controls. The results showed that the initial dilatation and thickening of the obstructed ducts in group A were associated with a mild inflammation, a moderate degree of fibrosis, and local epithelial disintegration. The presence of an endoprosthesis, however (group B), induced severe inflammatory changes with considerable fibrosis and ulcerative lesions, resulting in markedly thickened ducts with lumina approximating the diameter of the stent. Three of 13 (24%) bile cultures in group A were positive and 14 of 17 (82%) in group B were positive.

Surgical approaches to the management of primary biliary cholangiocarcinoma of the porta hepatis: the decision-making dilemma.

Fifty patients with proximal malignant biliary obstruction confined to or above the junction of the main hepatic ducts underwent surgical treatment. Group A patients (n = 30) underwent complete or partial removal of the tumor with no supplementary procedure, group B patients (n = 20) complete removal of the tumor and a supplementary procedure. Additional procedures were liver resection alone (11/20), and liver resection plus resection and reconstruction of regional vascular structures (9/20). Reconstruction of the intrahepatic biliary tree was carried out in all patients using intrahepatic cholangiojejunostomies between common segmental hepatic stomata and a Roux-en-Y jejunal loop. In each common segmental hepatic stoma, two or three segmental hepatic ducts were drained. Transanastomotic tubes were used only temporarily. Eight patients died, three from group A (3/30) and five from group B (5/20). Survivors were relieved of jaundice and had no subsidiary cholangitis or problems associated with the anastomotic tubes. Seventeen patients of group A and 12 of group B are alive, with a mean survival of 29 and 31 months, respectively. Both alternatives offer good results. The choice of the surgical approach should be based on a precise evaluation of each patient's anatomical and individual clinical peculiarities.

Early postoperative complications after (sub)total pancreatoduodenectomy: the AMC experience.

The postoperative course is described in 70 patients who underwent pancreatic resection for a tumor of the head of the pancreas and peri-ampullary region: 64 patients had malignant disease. Subtotal pancreatoduodenectomy was carried out in 52 patients and total pancreatoduodenectomy in 18 patients. The overall 30-day mortality was 4.3% (3 patients died: one after subtotal, 2 after total pancreatoduodenectomy). Major complications required surgical reintervention in 15 patients. Another 24 patients developed minor complications, and responded well to conservative treatment. Infective complications were the main cause of post-operative morbidity, occurring in 29 patients. Dehiscence of the pancreatico-jejunostomy required surgical reintervention in one patient. This patient died. Leakage of the pancreatico-jejunostomy was radiologically demonstrated in 10 other patients. Four of these 10 patients presented with clinical symptoms: one needed surgical intervention and 3 responded to conservative management. The results of this study confirm the present trend of decreasing mortality after pancreatoduodenectomy. Postoperative morbidity remains high. Usually, leakage of the pancreatic anastomosis was not associated with serious postoperative complications and subsided without the need of treatment in the majority of cases.

Reconstruction after subtotal duodenopancreatectomy in patients with pancreatic duct, distal bile duct and ampullary carcinoma: further experience with a personal technique.

A total of 142 patients underwent pancreatic resection for malignant (128 patients) or benign (14 patients) pancreatic disease. Of these patients, 111 had subtotal duodenopancreatectomy and are discussed in this paper. Reconstruction in these patients was carried out with a special technique. In this technique, two jejunal loops are used. One for fashioning the gastric anastomosis, the other for fashioning the pancreatic and biliary anastomosis. Two patients died in the first 30 postoperative days. Twenty patients had severe complications necessitating early reoperation. The surviving patients had a good quality of postoperative life. Postoperative sequelae like diabetes, steatorrhea and motility disturbances were easily controllable. On the basis of the results obtained, the reported surgical technique of reconstruction of alimentary continuity after subtotal duodenopancreatectomy can be considered an alternative for the surgical management of some of the patients with malignant or benign pancreatic disease considered eligible for subtotal duodenopancreatectomy.

Tumor DNA content in gallbladder carcinoma.

An abnormal DNA content has been associated with an unfavorable prognosis in a variety of cancers. In this study, tumor DNA content was measured in patients with gallbladder carcinoma in order to determine whether DNA ploidy pattern was a prognostic indicator. Thirty-six patients who had had a gallbladder carcinoma resected with curative intent were analyzed. Aneuploid tumor (20 cases, 56 per cent) was significantly associated with poorly differentiated adenocarcinoma (p < 0.05), invasion beyond the muscularis propria (p < 0.01), and a high mitotic index (p < 0.0001). A significant advantage in terms of five-year survival was demonstrated in patients with diploid tumors as compared with those with aneuploid tumors (80 per cent versus 24 per cent, respectively, p < 0.005). Aneuploid tumors invading the subserosal layer had a significantly poorer prognosis than diploid tumors with similar depth of invasion (p < 0.05). However, when tumor invasion had extended beyond the serosa, no significant advantage in survival was found between patients with aneuploid and those with diploid tumors. It is concluded that DNA ploidy pattern is a valuable addition to a staging protocol for gallbladder carcinoma.

A scanning electron microscopic study of the common bile duct epithelium in the rabbit during experimental biliary tract obstruction.

Complete biliary obstruction was induced in rabbits by distal ligation of the common bile duct (CBD). The epithelial surface of the CBD was studied with scanning electron microscopy (SEM) at 1-6 days post-ligation. Concomitant biochemical assessments and pressure measurements in the CBD were performed. SEM of non-ligated CBD showed that the epithelium is arranged in folds and clefts, the latter displaying interdigitating cellular processes. At 2 days post-ligation, the epithelial clefts were focally distended showing marked dehiscence of the cellular processes with exposure of the subepithelial connective tissue layer. At 4-6 days post-ligation, extensive defects in the epithelium were observed, frequently with a sharp demarcation between intact epithelium and exposed connective tissue stroma.

[Closure of a bronchial fistula after pneumonectomy in a case of carcinoma in a patient in chronic dialysis (author's transl)]. / Sluiten van een lekkende bronchusnaad na pneumonectomie wegens carcinoom bij een chronische dialyse patiënt.

A 53 year old patient in chronic dialysis underwent a left pneumonectomy for bronchial carcinoma. This was followed by a bronchopleural fistula. Despite the very poor condition of the patient closure of the fistula was obtained by means of a flap of the large omentum. This is a simple procedure easily tolerated by the patient and that could also be used in less complicated cases.

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

Between September 1983 and January 1990, 64 patients with Klatskin tumors were treated with resective therapy in the Academic Medical Centre Amsterdam. Twenty-nine patients received postoperative adjuvant radiotherapy, 22 patients were treated with resective therapy only and there were 13 postoperative deaths. The longterm results in the patients treated with or without adjuvant radiotherapy were retrospectively assessed. Three patients had a curative resection. Comparison of both therapeutic modalities demonstrated a statistically significant difference in survival (P less than 0.001) in favour of the patients who were treated with additive radiotherapy. The radiotherapy was generally well tolerated.

[Periampullary carcinoma as a second primary tumor following a previously treated adenocarcinoma of the colon]. / Peri-ampullair carcinoom als tweede primaire tumor na een eerder behandeld adenocarcinoom van het colon.

Three patients are presented who developed periampullary carcinoma after colectomy for adenocarcinoma. The combination of colonic carcinoma and periampullary carcinoma is rare, although wellknown in patients with colonic polyposis or Gardner's syndrome. Perhaps genetic research might help select patients with a high risk of developing multiple carcinomas in the gastrointestinal tract. The five-year survival rate for periampullary carcinoma after subtotal colectomy is higher than for pancreatic carcinoma.