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76 POSTER Preoperative biliary drainage influences survival in perihilar cholangiocarcinoma
S24 74
Poster session: Hepatobiliary and pancreatic cancer POSTER
Radiofrequency ablation: valuable addition of a local treatment method in the management of patients with liver metastases M.P. van den Tol 1 , M.R. van den Bergh 1 , M.R. Meijerink 2 , M.A. Cuesta 1 , S. Meijer 1 . 1 Vrije Universiteit Medical Center, Surgery, Amsterdam, The Netherlands; 2 Vrije Universiteit Medical Center, Radiology, Amsterdam, The Netherlands Resection is considered the gold standard for management of patients with hepatic malignancies. However, despite evolving indications of resectability, still 70-80% of patients are unsuitable for hepatic resection. Radiofrequency ablation (RFA) is a liver-directed treatment strategy with promising results in achieving local tumor control. The aim of this retrospective singlecentre study is to describe the results of RFA alone or in combination with resection in patients with secondary hepatic malignancies. All patients were followed to assess complications, treatment response and recurrence. From June 2001 to February 2006 40 patients (24 male, 16 female) with a median age of 66.5 years (22-82) were treated 44 times with RFA. The primary tumor was colorectal carcinoma in 34 patients, gonadal malignancies in 4 patients (ovarian (n=2), testicular (n=2)) and renal cell carcinoma in 1 patient. One patient had hepatic metastases from an unknown primary. In total, 85 lesions with a mean diameter of 2.3 cm (0.2-8.0) were ablated with a median number of 2 metastases (1-7) per patient. In 9 patients RFA was combined with resection and 14 patients received chemotherapy before the RFA-procedure. Four patients that were treated with RFA had intrahepatic recurrent disease following previous resection. There were no procedurerelated deaths. Minor complications occurred in 5 patients. Two patients had a pleural effusion, necessitating a chest tube in one patient. One patient developed a pneumonia and another patient was diagnosed cholangitis. One patient had an unexplained neuropathy of the right femoral nerve, unrelated to the RFA-procedure. After a median follow-up of 18.5 months (3-56) 21 (53%) patients had recurrent disease. There was one local recurrence at the RFA site, 13 elsewhere intrahepatic and 6 extrahepatic metastases. One patient developed new liver as well as lung metastases. Six (15%) patients had died, 3 of metastatic disease. This study suggests that if hepatic metastases are unresectable, RFA can be of great value to achieve a considerable prolongation of survival. Unfortunately, recurrent disease is a common phenomenon. Proper patient selection and multidisciplinary management of patients with colorectal liver metastases are equally crucial. An aggressive treatment strategy can provide prolongation of survival and even curation in selected cases, emphasizing the necessary close collaboration between surgical and medical oncologists. 75
POSTER
Outcomes of chemoradiation for locally advanced pancreatic cancer at Ipswich hospital 2002 – 2005 T. Satyadas, A. Shawyer, J. Kalyan, C. Maton, K. Tipples, H. Watson, M.T. Sinclair, T. Groot-Wassink, D.M. Rae, R. Soomal. Ipswich Hospital NHS Trust, Eastern Pancreatobiliary Unit, Ipswich, United Kingdom Background and Aim: 30-40% of all pancreatic cancers are locally advanced at diagnosis and median survival is 8 – 12 months [1]. Radical radiotherapy has been employed for selected patients with locally advanced pancreatic cancer, in conjunction with either 5-FU [2] or capecitabine chemotherapy. Our aim was to assess overall survival and toxicity in patients at Ipswich Hospital who received external beam radiotherapy at a radical dose with concurrent chemotherapy between 2002–2005. We also compared survival in this cohort to survival data from the period 1999-2001. Method: A retrospective review was performed of the patients who received external beam radiotherapy with chemotherapy for locally advanced pancreatic adenocarcinoma, diagnosed by histology and/or CT criteria. Results: There were 20 patients, 11 men and 9 women, performance status was 0-2, with a mean age 62 (range 55–73). 80% had histological confirmation of adenocarcinoma. Mean radiotherapy dose was 43.8 Gy (range 40-50.4 Gy). 2 patients were simulated and treated with parallel opposed fields in 2002. The rest were CT planned using a co-planar 3 field technique and 3-D conformal radiotherapy. 1 patient was treated with IMRT with a co-planar 7 field technique. 55% of patients received concurrent capecitabine at a dose of 800 mg/m2 twice daily and the rest infusional 5-FU at a dose of 200mg/m2 /day. 55%
had chemotherapy on progression with gemcitabine. Three patients had second line chemotherapy (FEM, capecitabine or capecitabine/oxaliplatin). 20% stopped chemotherapy early due to toxicity from mucositis (2 patients), nausea and vomiting (3 patients) and diarrhoea (3 patients). 1 patient stopped radiotherapy due to a possible radiation induced hepatitis and another due to grade III nausea. There were no gut perforations, treatment related deaths or other severe toxicities. The overall median survival and probabilities of surviving to specific timepoints were estimated using the Kaplan-Meier method. The overall median survival was 10.4 months (95% CI 7–13.8 months). The three longest survivors were alive until 20, 37 and 39 months post diagnosis. For the 19992001 cohort, the median survival was 11.5 months. There was no significant difference in survival between the two cohorts. Conclusion: Chemoradiation for locally advanced pancreatic cancer is generally well tolerated with acceptable toxicity. There has been no significant change in survival comparing the two time periods 1999-2001 and 20022005. Survival for the patient group at Ipswich Hospital is comparable to national and trial data. References: [1] Warshaw AL, Gu Z-Y, Whittenberg J, Waltman AC. Preoperative staging and assessment of resectability of pancreatic cancer. Arch Surg 1990;125:230-3 [2] Moertel CG, Frytak S, Hahn RG et al. Therapy of locally unresectable pancreatic carcinoma: a randomised comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-FU), and high dose radiation + 5-FU: The Gastrointestinal Tumour Study Group, Cancer. 1981;48:1705-1710 76
POSTER
Preoperative biliary drainage influences survival in perihilar cholangiocarcinoma H. Puhalla, B. Herberger, D. Tamandl, S. Schoppmann, T. Gruenberger. Medical University of Vienna, Department of General Surgery, Vienna, Austria Introduction: In perihilar cholangiocarcinoma (phCCC) radical resection offers the best patient survival. Prior potentially curative resection many patients require biliary drainage (BD) due to bile duct obstruction. There are many reports indicating that BD can increase the postoperative morbidity, but its influence on patient survival in phCCC was up today not investigated. The Influence of BD in resected phCCC was the purpose of this analysis. Description: 58 patients underwent resection for phCCC with curative intend at our institution and formed the basis of our study. BD was performed in case of biliary obstruction. 29 patients had tumor free resection margins (R0) and 29 patients had microscopic positive resection margins (R1). Summary: The TNM stage did neither correlate with the R0/R1 stage nor with the indication for BD. In R1 resected patients we excluded 3 postoperative deaths from the further investigations and the remaining 26 patients were included in the R1 group (median survival 16, 5 months). Twelve of them had a BD (46, 2%). After BD the median survival was 45, 5 months compared to 10, 9 months without BD (p=0,002). At the time of last follow-up 76% (n=20) of the R1 resected patients died cancer related. To eliminate patients with high comorbidities, postoperative death, short follow-up or not clear stated R0 resection margins, 6 patients were excluded and 23 entered into the R0 group (median survival 65, 5 months p=0,013 compared to the R1 group). A BD was performed in 14 (60, 9%) of them and these patients reached a median survival of 37, 4 months compared to 87 months for the patients without BD (p=0,034). Six patients died from cancer recurrence in the BD group (42, 8%) and 3 died from recurrent phCCC without BD (33, 3%). Conclusion: phCCC is a rare disease and the patient number in this study is small. R1 resected patients have a poor outcome but BD might have a positive influence on survival. The reason for this result can not clear be defined, but a better liver function at the time of resection might have some advantage. In R0 resected patients BD had a worse survival outcome and tumor recurrence in these patients was slightly increased. BD is commonly used in these patients and therefore a prospective randomized multicentre trail could answer the influence of BD on survival more precisely.
Poster session: Hepatobiliary and pancreatic cancer POSTER
Radiofrequency ablation: valuable addition of a local treatment method in the management of patients with liver metastases M.P. van den Tol 1 , M.R. van den Bergh 1 , M.R. Meijerink 2 , M.A. Cuesta 1 , S. Meijer 1 . 1 Vrije Universiteit Medical Center, Surgery, Amsterdam, The Netherlands; 2 Vrije Universiteit Medical Center, Radiology, Amsterdam, The Netherlands Resection is considered the gold standard for management of patients with hepatic malignancies. However, despite evolving indications of resectability, still 70-80% of patients are unsuitable for hepatic resection. Radiofrequency ablation (RFA) is a liver-directed treatment strategy with promising results in achieving local tumor control. The aim of this retrospective singlecentre study is to describe the results of RFA alone or in combination with resection in patients with secondary hepatic malignancies. All patients were followed to assess complications, treatment response and recurrence. From June 2001 to February 2006 40 patients (24 male, 16 female) with a median age of 66.5 years (22-82) were treated 44 times with RFA. The primary tumor was colorectal carcinoma in 34 patients, gonadal malignancies in 4 patients (ovarian (n=2), testicular (n=2)) and renal cell carcinoma in 1 patient. One patient had hepatic metastases from an unknown primary. In total, 85 lesions with a mean diameter of 2.3 cm (0.2-8.0) were ablated with a median number of 2 metastases (1-7) per patient. In 9 patients RFA was combined with resection and 14 patients received chemotherapy before the RFA-procedure. Four patients that were treated with RFA had intrahepatic recurrent disease following previous resection. There were no procedurerelated deaths. Minor complications occurred in 5 patients. Two patients had a pleural effusion, necessitating a chest tube in one patient. One patient developed a pneumonia and another patient was diagnosed cholangitis. One patient had an unexplained neuropathy of the right femoral nerve, unrelated to the RFA-procedure. After a median follow-up of 18.5 months (3-56) 21 (53%) patients had recurrent disease. There was one local recurrence at the RFA site, 13 elsewhere intrahepatic and 6 extrahepatic metastases. One patient developed new liver as well as lung metastases. Six (15%) patients had died, 3 of metastatic disease. This study suggests that if hepatic metastases are unresectable, RFA can be of great value to achieve a considerable prolongation of survival. Unfortunately, recurrent disease is a common phenomenon. Proper patient selection and multidisciplinary management of patients with colorectal liver metastases are equally crucial. An aggressive treatment strategy can provide prolongation of survival and even curation in selected cases, emphasizing the necessary close collaboration between surgical and medical oncologists. 75
POSTER
Outcomes of chemoradiation for locally advanced pancreatic cancer at Ipswich hospital 2002 – 2005 T. Satyadas, A. Shawyer, J. Kalyan, C. Maton, K. Tipples, H. Watson, M.T. Sinclair, T. Groot-Wassink, D.M. Rae, R. Soomal. Ipswich Hospital NHS Trust, Eastern Pancreatobiliary Unit, Ipswich, United Kingdom Background and Aim: 30-40% of all pancreatic cancers are locally advanced at diagnosis and median survival is 8 – 12 months [1]. Radical radiotherapy has been employed for selected patients with locally advanced pancreatic cancer, in conjunction with either 5-FU [2] or capecitabine chemotherapy. Our aim was to assess overall survival and toxicity in patients at Ipswich Hospital who received external beam radiotherapy at a radical dose with concurrent chemotherapy between 2002–2005. We also compared survival in this cohort to survival data from the period 1999-2001. Method: A retrospective review was performed of the patients who received external beam radiotherapy with chemotherapy for locally advanced pancreatic adenocarcinoma, diagnosed by histology and/or CT criteria. Results: There were 20 patients, 11 men and 9 women, performance status was 0-2, with a mean age 62 (range 55–73). 80% had histological confirmation of adenocarcinoma. Mean radiotherapy dose was 43.8 Gy (range 40-50.4 Gy). 2 patients were simulated and treated with parallel opposed fields in 2002. The rest were CT planned using a co-planar 3 field technique and 3-D conformal radiotherapy. 1 patient was treated with IMRT with a co-planar 7 field technique. 55% of patients received concurrent capecitabine at a dose of 800 mg/m2 twice daily and the rest infusional 5-FU at a dose of 200mg/m2 /day. 55%
had chemotherapy on progression with gemcitabine. Three patients had second line chemotherapy (FEM, capecitabine or capecitabine/oxaliplatin). 20% stopped chemotherapy early due to toxicity from mucositis (2 patients), nausea and vomiting (3 patients) and diarrhoea (3 patients). 1 patient stopped radiotherapy due to a possible radiation induced hepatitis and another due to grade III nausea. There were no gut perforations, treatment related deaths or other severe toxicities. The overall median survival and probabilities of surviving to specific timepoints were estimated using the Kaplan-Meier method. The overall median survival was 10.4 months (95% CI 7–13.8 months). The three longest survivors were alive until 20, 37 and 39 months post diagnosis. For the 19992001 cohort, the median survival was 11.5 months. There was no significant difference in survival between the two cohorts. Conclusion: Chemoradiation for locally advanced pancreatic cancer is generally well tolerated with acceptable toxicity. There has been no significant change in survival comparing the two time periods 1999-2001 and 20022005. Survival for the patient group at Ipswich Hospital is comparable to national and trial data. References: [1] Warshaw AL, Gu Z-Y, Whittenberg J, Waltman AC. Preoperative staging and assessment of resectability of pancreatic cancer. Arch Surg 1990;125:230-3 [2] Moertel CG, Frytak S, Hahn RG et al. Therapy of locally unresectable pancreatic carcinoma: a randomised comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-FU), and high dose radiation + 5-FU: The Gastrointestinal Tumour Study Group, Cancer. 1981;48:1705-1710 76
POSTER
Preoperative biliary drainage influences survival in perihilar cholangiocarcinoma H. Puhalla, B. Herberger, D. Tamandl, S. Schoppmann, T. Gruenberger. Medical University of Vienna, Department of General Surgery, Vienna, Austria Introduction: In perihilar cholangiocarcinoma (phCCC) radical resection offers the best patient survival. Prior potentially curative resection many patients require biliary drainage (BD) due to bile duct obstruction. There are many reports indicating that BD can increase the postoperative morbidity, but its influence on patient survival in phCCC was up today not investigated. The Influence of BD in resected phCCC was the purpose of this analysis. Description: 58 patients underwent resection for phCCC with curative intend at our institution and formed the basis of our study. BD was performed in case of biliary obstruction. 29 patients had tumor free resection margins (R0) and 29 patients had microscopic positive resection margins (R1). Summary: The TNM stage did neither correlate with the R0/R1 stage nor with the indication for BD. In R1 resected patients we excluded 3 postoperative deaths from the further investigations and the remaining 26 patients were included in the R1 group (median survival 16, 5 months). Twelve of them had a BD (46, 2%). After BD the median survival was 45, 5 months compared to 10, 9 months without BD (p=0,002). At the time of last follow-up 76% (n=20) of the R1 resected patients died cancer related. To eliminate patients with high comorbidities, postoperative death, short follow-up or not clear stated R0 resection margins, 6 patients were excluded and 23 entered into the R0 group (median survival 65, 5 months p=0,013 compared to the R1 group). A BD was performed in 14 (60, 9%) of them and these patients reached a median survival of 37, 4 months compared to 87 months for the patients without BD (p=0,034). Six patients died from cancer recurrence in the BD group (42, 8%) and 3 died from recurrent phCCC without BD (33, 3%). Conclusion: phCCC is a rare disease and the patient number in this study is small. R1 resected patients have a poor outcome but BD might have a positive influence on survival. The reason for this result can not clear be defined, but a better liver function at the time of resection might have some advantage. In R0 resected patients BD had a worse survival outcome and tumor recurrence in these patients was slightly increased. BD is commonly used in these patients and therefore a prospective randomized multicentre trail could answer the influence of BD on survival more precisely.