Mary Carcinoma

A Review of 109 Cases

Frederick Alexander, MD, Boston Massachusetts

Rlcardo I.. Rossi, MD, Burlington, Massachusetts

Michael O’Bryan, MO, New Orleans, Louisiana

Urmlb Wry, MD, Boston, Massachusetts

John W. baasch, MD, Burlington, Massachusetts

Elton Watkins, Jr, MD, Burlington, Massachusetts

Bile duct tumors, although commonly associated with a poor prognosis, may often be treated suc- cessfully for prolonged periods of time. They are an uncommon, if not rare, type of tumor occurring in between 0.01 and 0.85 percent of autopsy subjects [I, 21. They are often recognized late in the clinical course and, because of their infiltrative, fibrotic na- ture, can be difficult to diagnose histologically. Their close proximity to the liver parenchyma, hepatic artery, and portal vein and their tendency to spread along bile ducts make surgical resection difficult. Bile duct tumors have little tendency to metastasize and for this reason, although seldom curable, may often be palliated for extended periods of time.

The surgical treatment of bile duct tumors has been aimed primarily at resection for cure. However, given a resectability rate of only 15 percent in most series [3], relief of biliary obstruction is often the most realistic objective. This may be accomplished today by percutaneous [4], endoscopic [5], or surgical techniques [6,7], depending on the location and ex- tent of the tumor, the patient’s condition, and the expertise available in each institution. Although surgical drainage procedures are, in general, believed safer than radical resection, both carry an apprecia- ble mortality rate in the predominantly older popu- lation.

Recent progress in operative technique has de- creased operative mortality and generated renewed

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interest in attempts at resective therapy. Now that pancreatoduodenectomy, partial hepatectomy, and excision of the bifurcation of the hepatic duct can be carried out with relative safety, these procedures would seem to offer major advantages as compared with nonoperative decompression advocated by many clinicians. This report presents the results of surgical treatment of all bile duct tumors at the Lahey Clinic from 1965 to 1978 inclusive with a minimum follow-up of 4 years.

Material and llMhods

The records of 109 consecutive patients including 51 men and 58 women operated on at the Lahey Clinic between 1965 and 1978 for bile duct tumors were reviewed. The mean age was 59 years (range 27 to 82 years). Fifty percent of the patienta had a history of previous cholecystactomy, and 25 percent of the patients had other previous biliary tract surgery. Ninety percent of the patients presented with obstructive jaundice. Other signs and symptoms included abdominal pain in 47 percent, weight loss in 45 percent, pruritus in 42 percent, and fever in 22 percent. The dura- tion of symptoms extended from less than 1 month to 120 months with a peak occurring in the first 2 months. Fifty percent of the patients demonstrated hepatomegaly; however, less than 3 percent presented with spider angio- mas, splenomegaly, or ascites. Four patients presented with a palpably enlarged gallbladder.

Elevated levels of serum bilirubin above 5 mg/dl and serum alkaline phosphatase above twice normal were found in 60 and 78 percent of the patients, respectively. Elevated values of serum transaminase were found in 24 percent of the patients. Prolongation of prothrombin time was seen in 22 percent of the patients, and depression of the level of serum albumin below 3.5 g/d1 was seen in 37 percent of the patients. Fifty-five percent of the entire group of patients exhibited guaiac-positive stools, although none presented

Votuma 147, April 1984 503

Alexander et al

TABLE I Operative Procedures

No. of Procedure Patients

Curative resection Pancreakx%odenectomy 13’ Left hepatectomy 1 Right hepatectomy 1 Trisegmentectomy 1 Total

Number 16 Percent 15

Palliative resection Left hepatectomy 2 Trisegmentectomy 1 Pancreatoduodenectomy 3 Skeletonization with resection and 4t

hepatojejunostomy Total

Number 10 Percent 9

Strictly palliative procedures Dilation and one stent 19 Dilation and two stents 36 Dilation alone 2 Laparotomy and biopsy 16 Hepaticojejunostomy (bypass) 10 Total

Number 63 Percent 76

+ Pancreatoduodenectomy for cure was performed in 2 patients for mkiduct tumors and in 11 patients for distal tumors.

+ Palliatfve skeleWnlza6on with resection was performed in two patients with proximal duct Wnors and in two patients W&I m&duct

tumors.

Survival % lo(

8(

LOGRANK P

COMPLETE VI NO RESECTION 0.004 COMPLETE vs RESIDUAL TUMOR 0.30 RESIDUAL TUMOR vs NO RESECTION 0.03

61

1 2 3 4 5 6 Time ( Years 1

7

ftgure 1. Adwed swvlval accordtng to therapy for bite duct tu- mors.

(40 percent). Four patients with well-differentiated lesions had papillary components, which are generally thought to have a better prognosis.

Survival patterns were studied by life table analysis of adjusted survival with calculation of median survival time and 2 and 5 year cumulative survival rates. Significance of differences in survival patterns was determined by logrank analysis. Contingency tables were analyzed by Miettinen’s modification of the Fisher exact test. Operative mortality, defined as patient death within 30 days of operation, was excluded from life table computation.

Results

with massive gastrointestinal hemorrhage. Retrograde cholangiography was used in 10 patients and was consid- ered helpful in making the diagnosis in all of them. Per- cutaneous cholangiography was used diagnostically in only five patients in this series.

Tumors in this series were found to be in the proximal bile duds in 83 patients (76 percent), in the distal portion of the bile duct in 14 patients (13 percent), and in the midportion of the bile duct in 12 patients (11 percent). Proximal duct tumors involved the bifurcation and both the left and right hepatic ducts in 61 patients (72.5 per- cent), the bifurcation alone in 8 patients (9.5 percent), the common hepatic duct in 3 patients (3.5 percent), the common and left hepatic duct in 6 patients (7 percent), the common and right hepatic duct in 1 patient (1 percent), the right hepatic duct in 3 patients (3.5 percent), and the left hepatic duct in 2 patients (2 percent). A pathologic diag- nosis of carcinoma was made in all patients. Ninety-five pathologic specimens were available for retrospective re- view by one pathologist (UK). Tumors were classified ac- cording to glandular elements, polarity, and nuclear cri- teria. Ninety patients had adenocarcinoma, 2 had ade- noaquamous carcinoma, 1 had leiomyosarcoma, and 2 had mucoepidermoid carcinoma. Of those with adenocarcino- ma, 12 patients had well-differentiated lesions (13 percent), 42 patients had moderately differentiated lesions (47 percent), and 36 patients had poorly differentiated lesions

The operative procedures performed are listed in Table I. Patients were categorized according to resectability and residual tumor after operation. Curative resection indicates procedures in which residual tumor was not evident, and palliative re- section indicates procedures in which the tumor was partially removed with a recognized microscopic or macroscopic portion remaining. Strictly palliative procedures are those in which no tumor was removed but in which a biopsy was performed with or without biliary drainage.

Follow-up was available on 102 patients. Survival of all patients according to resectability is summa- rized in Figure 1. Sixteen patients (15 percent) un- derwent curative resection with an operative mor- tality of 19 percent. Median adjusted survival for this group was 13.1 months (range 5 to 84 months) with three patients (19 percent) surviving 5 years. One of these three patients died from disease at 65 months, whereas the other two patients died from other causes with no sign of residual tumor. The adjusted 5 year survival rate was 40.2 percent f 15.5 percent (standard error of the mean). Ten patients (9 per- cent) underwent palliative resection with removal of the main tumor mass and bilioenteric anastomosis

504 The American Journal of Surgery

LOCRANK P

DISTAL VI PROXIMAL 6.03 DISTAL YS MD-DUCT 0.03 PROXIMAL vs MID-DUCT 0.23

ISTAL DUCT

_- i _____ _ ____ __________________

\

\

:

\K

i

I

MID- *- WCT

with an operative mortality of 10 percent. Median adjusted survival for this group was 16.5 months (range 6 to 62 mon&) with four patients surviving 2 years (44 percent) and one patient with a proximal duct tumor surviving 5 years (11 percent) but dying from diseaee at 62 months. Eighty-three patients (76 with proximal duct tumors and 8 with midduct tu- mors) underwent strictly palliative procedures with an operative mortality of 19 percent. Median ad- justed survival of this group was 10.9 months (range 1 to 56 month) and one patient died from disease at 56 months. Of this group, 10 patients with high tu- mors (proximal and upper third lesions) had a high cho&gictenteric anastomosis without resection with a median survival of 125 months and an operative mortality of 40 percent. Fifty-seven patients had dilation and placement of biliary stents with a me- dian survival of 12 months (range 1 to 56 months) and an operative mortality of 15 percent. The remaining patients in the group had biowy alone with a median survival of 8 months (range 2 to 15 months) and an operative mortality of 14 percent.

Survival patterns of patients reeected for cure and resected for palliation were similar (p = 0.30). Twice as many long-term survivors were found in the group resected for cure compared with the group resected for palliation (3 of 13 patienta and 1 of 19 patients, respectively} with all patients in the latter group dying from dieeaee. Survival of patienta after curative resection and after palliative resection was signifi- cantly better than survival after strictly palliative procedures (p = 0.004 and p = 0.03, respectively). Overall, resection for either palliation or cure resulted in significantly prolonged survival compared with

I -0 Re5ectKlnr S- Intubatm - Bypass * B~qxy Only s O \ -

bma i i i Years

survival after strictly palliative procsdures (p = 0.002). The postoperative mortality rate was 16 percent in patienti who had resection compared with 21 percent in patients who had strictly palliative procedures (p = 0.72).

Survival of all patients categorized according to location of tumor is summarized in Figure 2. Of 14 patients with distal duct tumors, 11 underwent cu- rative resection and 3 underwent palliative reaection (100 percent resectability). The medii survival for this group was 16 months (range 5 to 84 months) with an operative mortality of 21 percent (3 of 14 pa- tients). Two of these patients sutived 5 years (20 percent). This group had the best overall survival, eignificantly better than those with either mid-duct or proximal duct tumors. Of the 12 patienti with mid-duct tumors, 2 underwent curative resection by Whipple operation and 2 underwent palliative re- section by skeletonization resection (33 percent resectability). The median survival of this group wae 8 months [range ‘7 to 13 months) with an operative mortality of 25 percent (one of four patients). The median survival of the remaining eight p&tie& treated strictly by palliative procedures was 12 months (range 2 to 21 months) with an operative mortality of 25 percent. Of the 83 patients with proximal duct tumors, 8 underwent resection by ei- ther hepatic resection (6 patients) or skeletonization resection (2 patienta), for cure (3 patients) or for palliation (5 patio&) (10 percent reaectability). The median survival for this group w@ 21 montha Irange 5 to 65 months) with no operative mortality. Two of these patients survived 5 years (25 percent). The remaining 75 patients were treated with strictly palliative procedures and had a median survival of 10 months (range 1 SKI 56 months), and there were no 5 year survivora. Operative mortality for this group was 16 percent. Survival of patients with proximal duct tumors is listed according to operative proce- dure in Figure 3.

Adjusted survival of patients c&gorized acco&q to tumor grade is presented In Figure 4. Survival of

505

Alexander et al

Survival

%OO

80

60

40

20

0

LOCRANK P

WELL vs MODERATE 0.04

WELL vs POOR < 0.001

POOR vs MODERATE 0.98

Time ( Years )

F&ore 4. Adjusted s~~vfval W&d to degree of tumor dtfferen- ttatton,

patients with well-differentiated tumors was signif- icantly better than that of patients with moderately or poorly differentiated lesions. The 2 year adjusted survival of patients with well-differentiated tumors (nine patients) was 73 percent, and the 5 year ad- justed survival was 15 percent. For poorly differen- tiated tumors (31 patients), the 2 year adjusted sur- vival was 6 percent and the 5 year survival was 0. The difference in survival between patients with well- differentiated and poorly differentiated tumors was highly significant (p < 0.001). However, the differ- ence between survival of patients with moderately well-differentiated and poorly differentiated tumors was not significant (p = 0.98). All long-term survivors had adenocarcinoma. The two patients with ade- nosquamous carcinoma survived 10 and 14 months, whereas the two patients with mucoepidermoid carcinoma survived 2 and 30 months.

Postoperative complications are listed in Table II. Partial hepatectomy was associated with a 100 per- cent complication rate but resulted in no operative deaths. Of note is the fact that pancreatic fistulas

TABLE II Operative Mortality and Morbidity

occurred in two patients after pancreatoduodenec- tomy. One fistula led directly to death. Both of the fistulas occurred in patients with a soft gland and undilated pancreatic duct directly anastomosed to the jejunum. At present, a “dunking” pancreatico- jejunostomy in which the distal cut end of the pan- creas is invaginated into the jejunum would be chosen in an attempt to avoid this complication.

Overall operative mortality was 17.4 percent. All patients undergoing resection had an operative mortality of 16.5 percent compared with all those having palliative procedures who had an operative mortality of 18 percent. No operative mortality oc- curred in patients having resection for proximal duct tumors, whereas the highest operative mortality of 40 percent occurred in patients having high cholan- gioenteric anastomosis without resection for proxi- mal duct tumors. The operative mortality for 58 pa- tients with a serum bilirubin value of less than 10 mg/dl was 10 percent, whereas the operative mor- tality for the 41 patients with a serum bilirubin value greater than 10 mg/dl was 22 percent (p = 0.13). In this series, the Whipple operation was associated with a high operative mortality. Since 1979,36 pan- creatoduodenectomies with pyloric preservation have been performed at the Lahey Clinic with no operative mortality. Only a small number of patients received adjuvant treatment after operation, and therefore no useful information can be gained regarding its use.

Comments

Previous clinical studies have suggested that at- tempts at radical resection may result in an improved prognosis compared with palliative treatment. Warren and others [S] reported a series in 1972 in which radical resective operations were performed in 31 percent of patients with an improved survival as compared with an earlier series reported by Braasch et al [3] in 1967, in which radical operations were performed in only 18 percent of patients. Lau- nois et al [9] reported improved mean postoperative survival with equivalent operative mortality when a series of patients treated with radical operations was compared with historical control patients treated with routine palliative decompression. Tomkins et

Operative Complications (%) No. of Mortality Biliary Pancreatic

Procedure Patients (%) Fever Fistula Fistula

Pancreatoduodenectomy 16 19 21 13 13 Partial hepatectomy 6 0 100 100 0 lntubation 57 15 33 46 0 Skeletonization with resection and hepaticojejunostomy 4 0 38 25 0 Hepaticojejunostomy (bypass) 10 40 22 56 0 Laparotomy and biopsy 16 14 0 UD 0

UD = undetermined

506 The American Journal ol Surgery

Blllary Carcinoma

al [IO] found resectability to be an important prog- nostic factor in a series of patients with bile duct tumors. Cameron et al [II] reported improved results for proximal duct tumors with resection and trans- hepatic intubation.

Resection tended to offer the best prognosis, par- ticularly for patients with well-differentiated tumors. Patients with distal duct tumors had the best survival of all groups (median survival 16 months, 20 percent 5 year survival). All of these patients had disease that was resectable by pancreatoduodenectomy, although resection was not necessarily for cure. The high resectability rate of the distal duct tumors probably reflects patient selection in which only those believed resectable were referred to the Lahey Clinic. The overall median survival of patients with proximal and mid-duct tumors was nearly equivalent (11.5 months versus 8.5 months) and less than that of patients with distal duct tumors. However, the median survival of patients with proximal duct tumors who underwent resection was 21 months with 25 percent 5 year sur- vival, nearly equivalent to that of patients resected for distal duct lesions. Resection did not appear to improve survival of patients with mid-duct tumors who, despite a resectability rate of 33 percent, had the worst overall survival compared with the other groups. The degree of histologic differentiation ap- peared to influence survival. Patients with well-dif- ferentiated tumors had significantly better 2 and 5 year survival rates compared with patients with less well-differentiated tumors. This finding is in con- tradistinction to other reports [ 10,111, in which little or no difference in survival relating to tumor grade has been found.

Congruent with other reports [10,13], we found that patients with proximal duct tumors were the most numerous and the most difficult to treat. In these patients, survival was closely related to resec- tability. Resection, when possible, was most often carried out by partial hepatectomy or skeletonixation and resection. Most often, however, patients in this group were treated by palliative decompression.

In most cases, surgical exploration is indicated for tissue diagnosis, assessment of resectability, and possible palliation. For unresectable proximal duct tumors, however, intubation techniques would ap- pear preferable to attempts at high internal bypass. Improved percutaneous techniques [14] and the development of retrograde endoscopic procedures [5] are increasing the diagnostic and therapeutic options and may be used independently or in concert with operation to improve survival and lower morbidity. Specifically, percutaneous catheter decompression is being used in the management of patients with tumor involvement of the hepatic duct bifurcation and segmental ducts, in poor-risk patients, in pa- tients with known unresectable or metastatic disease, or when operation has failed. Computerized tomo- graphic scanning and arteriography have proved to

be unreliable for diagnosis and staging of disease. Percutaneous cholangiography is currently the most useful preoperative method to assess the proximal extent of tumors [15]. In the future, nuclear magnetic resonance may help to identify patients with tmre- sectable proximal duct tumors before operation and thus delineate the role of surgery versus percutaneous catheter decompression in this difficult group of patients.

The benefits of adjuvant therapy are difficult to assess because of the relative rarity of the disease. Chemotherapy has thus far appeared to be ineffec- tive, but the number of patients was small and did not allow conclusions. Potential benefits of postop- erative external radiotherapy have been suggested [16,17]. Results of intraoperative external beam ra- diation or local implantation of radioactive materials at operation or by percutaneous techniques require further experience [18-201. The use of a laser beam introduced through a percutaneous catheter tract for photocoagulation of a bleeding bile duct tumor has been reported [21].

In conclusion, patients with bile duct tumors generally have a poor prognosis. Surgical resection offers the best chance of survival. Exploration should be performed in most patients for tissue diagnosis, assessment of extent of disease, and resection when possible or for palliation. It is especially justified in patients with tumors without involvement of seg- mental ducts on cholangiography, absence of meta- static disease demonstrable by computed tomo- graphic scan, and absence of major vessel involve- ment demonstrable by angiography. Better 5 year survival is achieved by resection compared with nonresective procedures (21 percent versus 0). The resectability rate was high for distal duct tumors (100 percent) but infrequent for proximal duct tumors (10 percent). Operative mortality was similar for patients undergoing resective and nonresective operative procedures except when high palliative cholangio- jejunostomy was performed. Patients with well-dif- ferentiated tumors in general live longer than pa- tients with poorly differentiated lesions. Improve- ment of percutaneous and endoscopic diagnostic and therapeutic techniques may help select those patients most suitable for surgical intervention.

Summary

One hunded nine patients operated on for bile duct carcinoma were reviewed. Herein, we reported 83 proximal duct tumors, 12 mid-duct tumors, and 14 distal thiid tumors. Resect-ability was 10 percent, 33 percent, and 100 percent, respectively, with an op- erative mortality of 0 percent, 25 percent, and 23 percent. The median survival time and 5 year sur- vival rate for these resected groups were 21 months and 25 percent for proximal duct tumors, 8 months and 0 percent for mid-duct tumors, and 16 months

vohmo 147, Aprll1904 507

Alexander et al

and 20 percent for distal third tumors. Eighty-three patients were treated with strictly palliative proce- dures with an operative mortality of 19 percent, an adjusted median survival rate of 10.9 months, and a 5 year survival rate of 0. The 2 and 5 year survival rates of patients with well-differentiated tumors were 73 percent and 15 percent, respectively, whereas for patients with poorly differentiated lesions, it was 6 percent and 0. Although most patients require pal- liative decompressive procedures, resection should be attempted whenever possible. It is expected that nonoperative techniques will have an increased role in the treatment of poor-risk patients or those who have unresectable disease.

Acknowledgment: We appreciate the assistance of Gerald Heatley for statistical calculations and Mary Oster and Peggy Szymanowicz for their help in tabulating the data presented in this study.

References

1. Sako K, Seiiinger a, G&de E. Carcinoma of ths exbahepatic blie ducts. Surgery 195?;41:416-37

2. Quattlebaum JK, Duattlebaum JK Jr. Malignant obstruction of the major hepatlc ducts. Ann Surg 1965;161:876-89.

3. Braasch JW, Kune GA, Warren KW. Malignant neoplasms of the bile ducts. Surg Clin North Am 1967;47:627-38.

4. Poilock TW, Ring ER, Oleaga JA, Lo KW, Rosato EF. Percuta- neous decompression of benign and malignant billary ob- struction. Arch Surg 1979;114:148-51.

5. wier F. Non-suTJical biliary drainage. Clin Gastroenterol 1983;12:297-316.

8. Ross1 RL, Gordon M, Braasch JW. lntubation techniques in biliary tract surgery. Surg Clin North Am 1980;60:297- 312.

7. Rossi RL, Braas& JW. Bilisry cancer sugery: when to do what. Contemp Surg 1982;20:13-29.

8. Warren KW. Mountain JC, Lloyd-Jones W. Malignant tumours of the bile-ducts. Br J Surg 1972;59:501-5.

9. Launois B, Campion JD. Brissot P, Gosselin M. Carcinoma of the hepatic hilus. Ann Surg 1979;190:151-7.

10. Tomkins RK, Thomas D, Wile A, Longmire WP Jr. Prognostic factors in bile duct carcinoma: analysis of 90 cases. Ann Surg 1981;194:447-57.

11. Cameron JL, Broe P, Zuidema GD. Proximal bile duct tumors. Ann Surg 1983;19&412-9.

12. Longmlre WP Jr, McArthur MS, Bastounis EA, Hlatt J. Carci- nome of the extrahepatic biliary tract. Ann Surg 1973; 178:333-45.

13. Chltwood WR Jr, Meyers WC, Heaston DK, Herskovic AM, Mdeod ME, Jones RS. Diagnosis and treatment of primary extrahepatic bile duct tumors. Am J Surg 1982;143:99- 106.

14. Ferrucci JT Jr, Mueller PR, Harbin WP. Percutaneous transhe- patic biliery drainage: technique. results, and applications. Radiology 1980;135:1-13.

15. Ckuda K, Tanikawa K, Emura T, et al. Nonsurgical, percuta- neous trenshepatic cholangiography-diagnostlc signifl- cance in medical problems of the liver. Am J Dlg Dis 1974;19:21-36.

18. Pilepich MV, Larnberl PM. Radiotherapy of carcinomas of the extrahepetlc biliary system. Radiology 1978;127:767-70.

17. Hsmkovic A, Heaston D, Engler MI, Flshbum RI, Jones RS, Noel1 KT. lrradfftlon of biliaty carcinoma. Radiology 1981;139: 219-22.

18. Todoroki T, lwasakl Y. Dkamura T, et al. Intraoperative radio- therapy for advanced carclnoms of the blliary system. Cancer 1980;46:2179-84.

19. Fletcher MS, Brinkley D, Dawson JL, Nunnedey H, Wheeler FG, Williams R. Treatment of hi@ bile duct carcinoma by lntemal radiotherapy with Iridium-192 wire. Lancet 1981;2:173-4.

20. Conroy RM, Shahbazian AA, Edwards KC, Moran EM, Swingle KF, Lewis 61. Pribham HF. A new method for treating car- cinomatous biliary obstruction with intracatheter radium. Cancer 1982;49:1321-7.

21. Carpenter CM, Bowers JH, Luers PR, Dixon JA. MiHer FJ. Neodymium yttrium aluminum garnet laser treatment of hemobilia via a percutaneous billary catheter track. Radi- ology 1983; 148~853-4.

Discussion

C. Elton Cahow (Woodbridge, CT): It’s always a plea- sure to listen to a presentation that encompasses a wide experience in biliary tract surgery amassed by Dr. Braasch, his associates, and his predecessors at the Lahey Clinic. This is particularly well demonstrated by the fact that in a short span of only 13 years, they have amassed 109 cases of biliary tract carcinoma, a relatively infrequent type of tumor. They have established an important and as yet unexplained feature of bile duct carcinoma, and that is the increasing frequency with which these lesions occur in the proximal bile ducts. We were all taught earlier that most lesions occurred in the distal ducts. But our experience and that of others parallels Dr. Braasch’s. This proposes sig- nificant therapeutic problems since, as they have pointed out, resection of distal lesions for cure or palliation can be carried out fairly easily, whereas resection of the more proximal lesion is much more difficult and cure is rarely accomplished.

On occasion, we have found it quite difficult to establish a definitive diagnosis in cases of high lesions for two rea- sons: They are often quite small, often buried in the hepatic parenchyma, and on inspection and palpation they have all the characteristics of sclerosing cholangitis. In addition, the prominent histologic feature is one of fibrosis, with very little evidence of mucosal malignancy except in small clumps of cells found in the perineural lymphatics, so the pathologist has difficulty helping us with them. We’ve had two patients who were diagnosed as having sclerosing cholangitis who subsequently died from cholangiocarci- noma. I wonder if the authors have had difficulty in making the diagnosis and in having it reversed.

I agree that at present, resection offers the only hope for cure, but to make this a realistic approach we need earlier diagnosis when the lesion is small and resectable. We found that in several cases, an elevated alkaline phosphatase in a nonicteric patient was the earliest sign of these lesions. I think that in all patients in whom this finding is noted, further evaluation of the biliary tract is indicated. It’s no- table that only 5 of the 109 patients underwent percuta- neous transhepatic cholangiography. We’ve come to the conclusion that all jaundiced patients who are suspected of having obstructive jaundice should undergo abdominal ultrasonography. If there’s any question whatsoever about dilatation of the bile ducts, either extrahepatic or intra- hepatic bile ducts, then I think a percutaneous cholangi- ogram is indicated. This will indicate the site and extent of the lesion, and often the definitive diagnosis. We’ve also had some experience with percutaneous needle aspiration of these lesions with pceitive diagnosis for carcinoma which has obviated operation in elderly and debilitated pa- tients.

Finally, I would like to note that if we encounter one of these high lesions at surgery, I would prefer to do an in-

508

Bitkuy Carcinoma

trahepatic cholangiojejunostomy in the periphery of the liver in appropriate cases, rather than leave transhepatic tubes in place. Although the mortality rate is no higher with the tubes, the morbidity over the long run is, and very often chemotherapists and radiation therapists are reluctant to treat these patients.

Harry D. Bear (Richmond, VA): The only comment I want to make is that this is a very large series of patients with biliary carcinoma. In view of the high morbidity and mortality that were associated with the palliative opera- tion, I was wondering if Dr. Alexander would comment on some of the work from London, where an attempt was made to identify preoperatively or without an operation those patients with bii carcinoma who are unresectable with the combined use of percutaeous cholangiography and arteriography, looking at both the hepatic arteriole and portal venous phases, and whether they think that in pa- tients who could be so identified as unresectable, they might be better served by percutaneous intubation.

Frederick Alexander (closing): It is true that in this series, only five patients underwent preoperative percu- taneous cholangiography. We would agree with Dr. Cahow that at present, all patients with the suspicion of proximal

tumor should undergo preoperative cholangiography. In our experience, preoperative computerixed tomographic scanning and angiography have proved to be very unreli- able in the preoperative diagnosis of proximal lesions. Currently, we believe that percutaneous cholangiography is the most useful diagnostic technique for determining resectability preoperatively. However, although the sen- sitivity of cholangiography is high, the specificity is rather low. Our current feeling is that when in doubt, surgery should be performed both for tissue diiosis and an at- tempt at resection. In those patients who are clearly un- resectable due to extension into the segmental ducts, sur- gery should not be entertained, and the patient should be treated simply with preoperative percutaneous biliary decompression.

Dr. Rear, I am not familiar with the work going on in London. However, as I said before, in our experience an- giography has not been proved to be useful in determining the resectabiity of d&ases. In the future, it is possible that nuclear magnetic resonance may help to identify patients with unresectable proximal tumors before surgery and, thus, perhaps better delineate the role of surgery versus percutaneous catheter decompression in this very dicult group of patients.

vohmo 147, Aprn 1984 509