Treatment strategy for patients with middle and lower third bile duct cancer

Background: The prognosis for patients with middle and lower third bile duc t carcinoma remains poor. This study was conducted to identify independent predictors for survival, as well as the patterns of recurrence after curati ve resection. Methods: Sixty-seven patients with pathologically verified middle and/or lo wer third bile duct carcinoma were analysed retrospectively by Cox regressi on analysis for predictors of survival. Results: The overall 5-year survival rate after resection was 39 per cent, and 0 per cent for patients who did not undergo resection. The 5-year survi val rate was 63 per cent in 26 patients without microscopic residual diseas e (R-0), 16 per cent in 25 patients with microscopic residual tumour (R-1) and 0 per cent in six patients with macroscopic residual tumour (R-2); ten patients did not undergo resection. Radiotherapy improved the 5-year surviv al rate in eight patients who had R-1 resection compared with the rate in 1 7 patients who underwent resection alone (8 versus 0), but not significantl y so (P = 0.137); however, median survival was significantly longer (P = 0. 004) in six patients who had R-2 resection compared with that in ten inoper able patients (11.4 versus 3.5 months). Multivariate analysis revealed that the primary tumour and tumour node metastasis (TNM) stage were independent predictors of survival; 13 clinicopathological factors were not independen t prognostic factors. Of 26 patients having R-0 resection, one had a locore gional relapse only, six had distant metastases only, and five had both typ es of recurrence. The liver was the most frequent site for metastasis, and microscopic venous invasion (MVI) in the primary tumour was a significant p redictor of liver metastasis. Conclusion: Curative (R-0) resection is only one step in curing cancer, and radiotherapy may play a beneficial role in controlling locoregional residu al tumour. MVI could be a useful indicator of when systemic adjuvant therap y should be implemented to prevent liver metastasis after R-0 resection, al though no effective systemic treatment has yet been developed.