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Cancer of the biliary tree
Cancer of the Biliary Tree L. DENBESTEN, M.D. AND R. D. LIEClIT~', M.D., Iowa City, Iowa
From the Department of S,~r~ery, University Hospit~ds, Iowa City, Iowa,
ANCI~R of the biliary tree usually carries a grim prognosis. The disease involves vital structures early in its course and often becomes clinically manifest too late for curative surgical therapy. The purpose of this paper is to review a !arge series of patients with this disease seen a~'University Hospitals. This review suggests that not all cancer of the biliary tree is hopelessly fatal. In some patients manifesting the disease early, radical operation, is indicated and long term cures may result.
C
15
MATERIAL
At the University of Iowa 218 patients with carcinoma of the billary tree were operated upon between 1930 and 1960. The incidence of involvement of various portions of the biliary tree is depicted graphically in Figure 1. Only thirty-five or 16 per cent involved the ampulla of Vater where chances of cure are relatively good, whereas 141 or 64.7 per cent involved the gallbladder where chances of cure have been universally poor except for malignant papillomas. Eighty-six patients were male and 132 were female, a ratio of 2:3. (Fig. 2.) In cancer of the gallbladder the ratio is 1 : 3 which agrees with the larger series in the current literature [I,2 ]. The average age at diagnosis was sixty-one years. At the time of diagnosis 104 had widespread metastases, sixty-six had local extension, and in forty-eight the disease was localized to the organ of origin. However, only twenty-three or 10.5 per cent of the total were so located that a potentially curative procedure could be performed. (Fig. 3.)"
,\
FIG. 1. Incidence of involvement of various portions of tile biliary tree'in 218 patients.
viral tithes of 1.2 and 1.9 months, respectively. One patient had resection of the gallbladder, common bile duct, and head of the pancreas and is alive more than seventy-four months after operation without known recurrence. (Table I.) Distal Common Bile Duct. Canc~erinvolvit~g the cystic or distal common bile duet was found in fifteen patients. Nine patients had biopsy only and five had palliative diversion of bile with average survivals of 2.7 and 4.0 months, respectively. One patient had pancreatieoduodenectomy and died thirty-one months later from recurrent tumor. (Table II.) Ampulla of Vater. Ampullary carcinoma was seen in thirty-five patients. Twelve of these
LOCATION
Hepatic Ducts. There were twenty-seven patients with a neoplasm originating in the hepatic duets. At laparotomy fifteen patients had biopsy only and eleven had palliative procedures for diversion of bile, with average survot. too, May 1O#S
\
587
DenBesten
and
Liechtv
CANCIgR
male
TAIILE [ OF t l E P A T I C
Treatnmnt
DUCTS
Average Survival
Patients
(trio.) female
Biopsy ot)ly Palliative
11
Curative Total
it 27
] .7 I. 9
15
74.0
Fro. 2. Tyt)e of neoplasm and sex distrilmti0n. "fAIlLE
80 - ~r 70 " [ ]
CANC[:,R OF C'fSrlc
AMPULLA OFVATER
II
AND Co,MMON
r l l l , E DUCT.%
HEPATIC DUCTS
• []
CYSTIC 8~CBD
Average Survival ( nl~l,
Treatment
Patients
ltiopsy only Pallia tive Curative Total
9
:2, 7
5
.t. 0
1 15
:31 (I
~50 ~40 20
66
104
10 "I'AIII.E IIl
Localized to Organ
Extension Locally
CANCER
Widespread Metastases
()F TIlE
AMPULLA
OF VAI~HR
FIG. ~{. Extcnt a n d type :it diagnosis. Treatn
lent
1~;i til+'ll {s
Average Survival
(too.)
( o n e in t h r e e ) ha(l p o t e n t i a l l y c u r a b l e lesions and were usually treated by t~ancrcatio)du~(lellectOlllV. T w e n t y - t h r e e p a t i e n t s h a d a(tVallced d i s e a s e lit t h e t i m e of d i a g n o s i s . F i v e w h o h a d b i o p s y o n l y s u r v i v e d all a v e r i t g c ~f
" ................................................................
Biopsy Olliy 1 'a Ilia ti ve Curative Tc, tal
;5 1S 12
7.1 2-I. 3
:¢5
;:I.5 m o n t h s , w h e r e a s d i v c r . q o n of b i l e r e s t l l t e d i n a n a v c r a ~ c 7.1 m ~ , n t h s u r v i v a l in t h e r e -
re:lining e i g h t e e n . ( T ; i b l c Ill.) (;al/b[addcr. ()no h u n d r e d f o r t y - o n e (t;-l.5 p e r cc.ntl of t h e 2 I S l i n t ; c u t s w i t h c a n c e r of tim b i l i a r v t r e e h a d tile p r i m a r y t u n l o r in tile gallbladder. Nine patients t i r e ' resccti, m. All b u t
nt'tqil;i~ms
TAm.t~ v¢ ca-;cv:n oF'lm-:,iAt.t.m.aimVR .\vt-rilgc
(6.;I p e r c e n t ) h a d c u r t ; -
w e r e mnall p a p i l l a r y tilt: ;gallbladder tit p a t i e n t Ilad exit.list,in
Treat nlettt
Pat ;cuts
,'4urvival
14i~q~sy only
t!rl
2 .G "_'~ 9
~,ne
¢lisc(~vert,¢l ill
c h ~ l l e c v s t e c t t l l n v . ()tit. illb~ tilt" f¢aIllfladder tied t r e a t e d b y w e d / , " reseclitill, a l l d died St'vt'lltct'll vt, i i r s l ; l t c r uf a l l o t h e r di~t,;t~c. T h e r e l n a i n i n ~ 132 d i e d an ilvcrll~t.
Palliative Curative Total
31 :~ 1tl
7~..t
h a d tllillOrs f l i t w t l i c h c u r a t i v t , f~pt.r;itifm> c~Jilld be t l e r f t t r l l l e d . M o s t of these ( t w t ' I v c ~f lilt" l w e n t y - t h r e ~ : / w e r e l~)c;ltt'd t:itht.r ill t h e lllllptlllil t)f Vatt~r. n l ; l l l i f t t s t t ' d t l v e ; i r l y j a l l l l d i t ' t ' , ltr
t'oM .Ml.;NTS
ill t h e galll>lildder (tittle ,,f t w e l i t y - t h r e t , ) , di~c~,vered ;it C|l, d e c v s l c c t o n l v . A l l h t l t l g h t w e n t y live o t h e r l l n n t i r s w e r e w e l l i - c a l i z e d , c t l r a t i v c
/ a l l c e r ,,i" tile l i i l i ; i r v l r l ' e is ;i ~ i n i s i e r d i - e a - e . I J l i i v 11t.5 p e r t't.ill (2;I in '21xl +ff +~lir ltiiliciit-~ ~'l,~t,~
, ! . I ¢ H , a n . # a m ' n a l , >i ?¢ur~¢r y
Cancer of Biliary Tree o p e r a t i o n s could u o t be p e r f o r m e d becatlse of a d v a l w e d ,we o t h e r serious diseases, o r extensive invoh, e m e n t of vital s t r u c t u r e s . Cholelithiasis was p r e s e n t in SO per c e n t of our patielltS with cancer of t h e gallbladder. l)oes this llieatl t h a t gallstones nre etiologically related to tile ileoplasn~ ? Ill 1-t,I)t)6 c o n s e c u t i v e atltopsies r e p o r t e d b y Mihler {5'1, gallstones were found ill 13 per c e n t and c a n c e r of tile g a l l b l a d d e r ill It.-t5 per cent. Of the sixty-six with c a n c e r f i f t y - t w o (or 79 per ceut) imd gallstones. \Ve would agree timt an etiologic relatiollship b e t w e e u the two has m)t been established. Ill c>tiwr w~>rds, c h o l e c y s t e c t o m y shonltl be perfornied for cholelithiasis, b u t cholecysteet~mly perforillcd for the p r e v e u t i o n of c a n c e r is nut a valid o p e r a t i v e indieatitm. In the past. callcer o[ the g a l l b l a d d e r ilas 1)Cml t r e a t e d hv c h o l e c y s t e c t o m y . If t h e disease had s p r e a d into the galllfl'tdder bed or if tilere wt, re nodes alon,g tile eOlllillOil bile d u c t , t i m i m l c e d u r e was ustuilly ahalldoued. R e c e n t l y , llrastield has r e p o r t e d perfornfiug right h e p a l i c lobectonlics wllell tile disease has spread i n l o the ~4aliblctdder bed [-tJ. I h m 'c v e r , l l l a l l V patients tire of such age or d e b i l i t y t h a t stlrger}"f tile g a l l b l a d d e r lie treated 1)v ,.ville w c dgc cxcisioli ~>f lhe ,a'allbliidder and its bed i.ot4eliler w i i | l skclct,miz:ition of the hepatic t riad to rt.liloVt, :ill ll~llt'-l,'t-lrill~ li>sne ill the area. ("lilt: q)|" t i l l r [ ~ , ~ l l , ~ e s i . . q i l r v i v o i " > j l l S l t h i s i ) r ( ! e e l l l l r t - ~evt, l l t e e l l v e a l s
lill~]erwelll { l ~ l i a l l / l is
alivt' wilh~ml kii~)wil ret'llrrt-llt-e. Alllt~lllkiry carcilllnlla veils lllali;l~t'(l Ill" palit'reatlidilO+lellt,CtOllly ill :ill p a l i e n t s ill tills -cries hi Wll<,m t i t l e was l}loll.~}ll l,,ssible. In lilt' 1;151 f~illr vt'ars, f i l l [ C~JV('It'¢} ill i } l i S M i l d } ' , f~qir ll;llil'iils h:ivt, been ni:ili;i.~ed hv ,,vit|c b~c:l]
i'./ m~, .I#., Io,',~;
5,~9
excision of tile a u i p u l l a tlf V a t e r alid ulucosa to IIIIICOS~I a l l a S t O l l l O S i S o f d t l O d e l l t l l l l t o duet. It will be interesting to see if tills p r o c e d u r e witli its lesser m o r b i d i t y a n d n l o r t a l i t y will <~ffer p o t e n t i a l for cure c o u i p a r a b l e tl~ p;uicreatoduodelteetOlliy, lhllliative proccdtlrcs were l)erf(ii'uled eli sixty-five l):ttielltS. ('l':dfles x, il, Iti, aud IV.) A v e r a g e strrvival was increased in all four t y p e s of neoplasul, k\;e believe t i l a t i u i p r o v e u l e u t ill p a t i e n t colllfort al{llle justifies sileh i}r{}cedures Wileil t h e y ('till be perforuied. D e t e c t i o n of e:mcer of t h e bile d u c t is ofteu delayed. Wh e n p o t e n t i a l l y curahle, adequate excision of the tlllliOr togetiler witil fl>rlllatiOll of a s u b s t i t u t e bile c o n d u i t fronl liver to duodelitilli ililist be ectrried otlt. S U M M : \ R't"
1. T w o h u n d r e d cigilteen p a t i e n t s ~qlc,r:tte~l Ill)Otl for Callecr of the 1)iliary tree ;ire r e p o r t e d O11.
'2. Ill 90 per cent t~l" t h e s e paticltts, c u r a b l e resccliollS were llOt possible. ;'}. In the It! per ccut Wile are ~)l)erablc. adetitltlte treatlllelit e{lll l)r~)dilCe h~ll~- tcrlll sllr"lri VOIFS,
-I. Palliative pr~>cetlurcs perforlned ~ll sixtyfive Imtielits increase tile s u r v i v a l alld COllff~wt of t h e palient. R t" F1.]R I" Nt.'I,]S
I. I)I.'.RXS:XX, 11., GF.RnER~;, I). S., Kv.'I.L',', J . PARKI':R, S., tllIl| SI."4(;I.]R, J.
Arc
ll.,
i~;tllsll~llt*s lllld
gallbladder carcilmma rclated? .I..I.31.A., 176: -150, lt.R;l. , 2. (.I,:RSl, I'. It. l>rim:uy" carcin~lul:l ,,l the g a l l l d a d , h ' r ,
a t | l i r l y yP;ir slllllllltlr%'.. [ #l~#..k'ttr,.f., I ~-I~'l: ;{(;(I, [~.t(ll. :I. ~lil.Xl..'R, I., R. I._';illCt'r ot" l h c g M l l f l a d d c r : i l s rcl:iti~mshi D ll:idlh,r : ci live y e a r f l i r t . . . . | ,,1t.~. .~'llyLv., ltS,:,~k2, 19111. D. FAIIIM, R. I{ , FI:.RRIS, I). 1),, : l i l d )ICl)l~N;%l.ll, J. 1{. (_'dtl'iiil,tii;i ,,f lilt" Kiiiltll,ld~h'r, :ill : i t l l m l i s : l l o f ils
From the Department of S,~r~ery, University Hospit~ds, Iowa City, Iowa,
ANCI~R of the biliary tree usually carries a grim prognosis. The disease involves vital structures early in its course and often becomes clinically manifest too late for curative surgical therapy. The purpose of this paper is to review a !arge series of patients with this disease seen a~'University Hospitals. This review suggests that not all cancer of the biliary tree is hopelessly fatal. In some patients manifesting the disease early, radical operation, is indicated and long term cures may result.
C
15
MATERIAL
At the University of Iowa 218 patients with carcinoma of the billary tree were operated upon between 1930 and 1960. The incidence of involvement of various portions of the biliary tree is depicted graphically in Figure 1. Only thirty-five or 16 per cent involved the ampulla of Vater where chances of cure are relatively good, whereas 141 or 64.7 per cent involved the gallbladder where chances of cure have been universally poor except for malignant papillomas. Eighty-six patients were male and 132 were female, a ratio of 2:3. (Fig. 2.) In cancer of the gallbladder the ratio is 1 : 3 which agrees with the larger series in the current literature [I,2 ]. The average age at diagnosis was sixty-one years. At the time of diagnosis 104 had widespread metastases, sixty-six had local extension, and in forty-eight the disease was localized to the organ of origin. However, only twenty-three or 10.5 per cent of the total were so located that a potentially curative procedure could be performed. (Fig. 3.)"
,\
FIG. 1. Incidence of involvement of various portions of tile biliary tree'in 218 patients.
viral tithes of 1.2 and 1.9 months, respectively. One patient had resection of the gallbladder, common bile duct, and head of the pancreas and is alive more than seventy-four months after operation without known recurrence. (Table I.) Distal Common Bile Duct. Canc~erinvolvit~g the cystic or distal common bile duet was found in fifteen patients. Nine patients had biopsy only and five had palliative diversion of bile with average survivals of 2.7 and 4.0 months, respectively. One patient had pancreatieoduodenectomy and died thirty-one months later from recurrent tumor. (Table II.) Ampulla of Vater. Ampullary carcinoma was seen in thirty-five patients. Twelve of these
LOCATION
Hepatic Ducts. There were twenty-seven patients with a neoplasm originating in the hepatic duets. At laparotomy fifteen patients had biopsy only and eleven had palliative procedures for diversion of bile, with average survot. too, May 1O#S
\
587
DenBesten
and
Liechtv
CANCIgR
male
TAIILE [ OF t l E P A T I C
Treatnmnt
DUCTS
Average Survival
Patients
(trio.) female
Biopsy ot)ly Palliative
11
Curative Total
it 27
] .7 I. 9
15
74.0
Fro. 2. Tyt)e of neoplasm and sex distrilmti0n. "fAIlLE
80 - ~r 70 " [ ]
CANC[:,R OF C'fSrlc
AMPULLA OFVATER
II
AND Co,MMON
r l l l , E DUCT.%
HEPATIC DUCTS
• []
CYSTIC 8~CBD
Average Survival ( nl~l,
Treatment
Patients
ltiopsy only Pallia tive Curative Total
9
:2, 7
5
.t. 0
1 15
:31 (I
~50 ~40 20
66
104
10 "I'AIII.E IIl
Localized to Organ
Extension Locally
CANCER
Widespread Metastases
()F TIlE
AMPULLA
OF VAI~HR
FIG. ~{. Extcnt a n d type :it diagnosis. Treatn
lent
1~;i til+'ll {s
Average Survival
(too.)
( o n e in t h r e e ) ha(l p o t e n t i a l l y c u r a b l e lesions and were usually treated by t~ancrcatio)du~(lellectOlllV. T w e n t y - t h r e e p a t i e n t s h a d a(tVallced d i s e a s e lit t h e t i m e of d i a g n o s i s . F i v e w h o h a d b i o p s y o n l y s u r v i v e d all a v e r i t g c ~f
" ................................................................
Biopsy Olliy 1 'a Ilia ti ve Curative Tc, tal
;5 1S 12
7.1 2-I. 3
:¢5
;:I.5 m o n t h s , w h e r e a s d i v c r . q o n of b i l e r e s t l l t e d i n a n a v c r a ~ c 7.1 m ~ , n t h s u r v i v a l in t h e r e -
re:lining e i g h t e e n . ( T ; i b l c Ill.) (;al/b[addcr. ()no h u n d r e d f o r t y - o n e (t;-l.5 p e r cc.ntl of t h e 2 I S l i n t ; c u t s w i t h c a n c e r of tim b i l i a r v t r e e h a d tile p r i m a r y t u n l o r in tile gallbladder. Nine patients t i r e ' resccti, m. All b u t
nt'tqil;i~ms
TAm.t~ v¢ ca-;cv:n oF'lm-:,iAt.t.m.aimVR .\vt-rilgc
(6.;I p e r c e n t ) h a d c u r t ; -
w e r e mnall p a p i l l a r y tilt: ;gallbladder tit p a t i e n t Ilad exit.list,in
Treat nlettt
Pat ;cuts
,'4urvival
14i~q~sy only
t!rl
2 .G "_'~ 9
~,ne
¢lisc(~vert,¢l ill
c h ~ l l e c v s t e c t t l l n v . ()tit. illb~ tilt" f¢aIllfladder tied t r e a t e d b y w e d / , " reseclitill, a l l d died St'vt'lltct'll vt, i i r s l ; l t c r uf a l l o t h e r di~t,;t~c. T h e r e l n a i n i n ~ 132 d i e d an ilvcrll~t.
Palliative Curative Total
31 :~ 1tl
7~..t
h a d tllillOrs f l i t w t l i c h c u r a t i v t , f~pt.r;itifm> c~Jilld be t l e r f t t r l l l e d . M o s t of these ( t w t ' I v c ~f lilt" l w e n t y - t h r e ~ : / w e r e l~)c;ltt'd t:itht.r ill t h e lllllptlllil t)f Vatt~r. n l ; l l l i f t t s t t ' d t l v e ; i r l y j a l l l l d i t ' t ' , ltr
t'oM .Ml.;NTS
ill t h e galll>lildder (tittle ,,f t w e l i t y - t h r e t , ) , di~c~,vered ;it C|l, d e c v s l c c t o n l v . A l l h t l t l g h t w e n t y live o t h e r l l n n t i r s w e r e w e l l i - c a l i z e d , c t l r a t i v c
/ a l l c e r ,,i" tile l i i l i ; i r v l r l ' e is ;i ~ i n i s i e r d i - e a - e . I J l i i v 11t.5 p e r t't.ill (2;I in '21xl +ff +~lir ltiiliciit-~ ~'l,~t,~
, ! . I ¢ H , a n . # a m ' n a l , >i ?¢ur~¢r y
Cancer of Biliary Tree o p e r a t i o n s could u o t be p e r f o r m e d becatlse of a d v a l w e d ,we o t h e r serious diseases, o r extensive invoh, e m e n t of vital s t r u c t u r e s . Cholelithiasis was p r e s e n t in SO per c e n t of our patielltS with cancer of t h e gallbladder. l)oes this llieatl t h a t gallstones nre etiologically related to tile ileoplasn~ ? Ill 1-t,I)t)6 c o n s e c u t i v e atltopsies r e p o r t e d b y Mihler {5'1, gallstones were found ill 13 per c e n t and c a n c e r of tile g a l l b l a d d e r ill It.-t5 per cent. Of the sixty-six with c a n c e r f i f t y - t w o (or 79 per ceut) imd gallstones. \Ve would agree timt an etiologic relatiollship b e t w e e u the two has m)t been established. Ill c>tiwr w~>rds, c h o l e c y s t e c t o m y shonltl be perfornied for cholelithiasis, b u t cholecysteet~mly perforillcd for the p r e v e u t i o n of c a n c e r is nut a valid o p e r a t i v e indieatitm. In the past. callcer o[ the g a l l b l a d d e r ilas 1)Cml t r e a t e d hv c h o l e c y s t e c t o m y . If t h e disease had s p r e a d into the galllfl'tdder bed or if tilere wt, re nodes alon,g tile eOlllillOil bile d u c t , t i m i m l c e d u r e was ustuilly ahalldoued. R e c e n t l y , llrastield has r e p o r t e d perfornfiug right h e p a l i c lobectonlics wllell tile disease has spread i n l o the ~4aliblctdder bed [-tJ. I h m 'c v e r , l l l a l l V patients tire of such age or d e b i l i t y t h a t stlrger}"
lill~]erwelll { l ~ l i a l l / l is
alivt' wilh~ml kii~)wil ret'llrrt-llt-e. Alllt~lllkiry carcilllnlla veils lllali;l~t'(l Ill" palit'reatlidilO+lellt,CtOllly ill :ill p a l i e n t s ill tills -cries hi Wll<,m t i t l e was l}loll.~}ll l,,ssible. In lilt' 1;151 f~illr vt'ars, f i l l [ C~JV('It'¢} ill i } l i S M i l d } ' , f~qir ll;llil'iils h:ivt, been ni:ili;i.~ed hv ,,vit|c b~c:l]
i'./ m~, .I#., Io,',~;
5,~9
excision of tile a u i p u l l a tlf V a t e r alid ulucosa to IIIIICOS~I a l l a S t O l l l O S i S o f d t l O d e l l t l l l l t o duet. It will be interesting to see if tills p r o c e d u r e witli its lesser m o r b i d i t y a n d n l o r t a l i t y will <~ffer p o t e n t i a l for cure c o u i p a r a b l e tl~ p;uicreatoduodelteetOlliy, lhllliative proccdtlrcs were l)erf(ii'uled eli sixty-five l):ttielltS. ('l':dfles x, il, Iti, aud IV.) A v e r a g e strrvival was increased in all four t y p e s of neoplasul, k\;e believe t i l a t i u i p r o v e u l e u t ill p a t i e n t colllfort al{llle justifies sileh i}r{}cedures Wileil t h e y ('till be perforuied. D e t e c t i o n of e:mcer of t h e bile d u c t is ofteu delayed. Wh e n p o t e n t i a l l y curahle, adequate excision of the tlllliOr togetiler witil fl>rlllatiOll of a s u b s t i t u t e bile c o n d u i t fronl liver to duodelitilli ililist be ectrried otlt. S U M M : \ R't"
1. T w o h u n d r e d cigilteen p a t i e n t s ~qlc,r:tte~l Ill)Otl for Callecr of the 1)iliary tree ;ire r e p o r t e d O11.
'2. Ill 90 per cent t~l" t h e s e paticltts, c u r a b l e resccliollS were llOt possible. ;'}. In the It! per ccut Wile are ~)l)erablc. adetitltlte treatlllelit e{lll l)r~)dilCe h~ll~- tcrlll sllr"lri VOIFS,
-I. Palliative pr~>cetlurcs perforlned ~ll sixtyfive Imtielits increase tile s u r v i v a l alld COllff~wt of t h e palient. R t" F1.]R I" Nt.'I,]S
I. I)I.'.RXS:XX, 11., GF.RnER~;, I). S., Kv.'I.L',', J . PARKI':R, S., tllIl| SI."4(;I.]R, J.
Arc
ll.,
i~;tllsll~llt*s lllld
gallbladder carcilmma rclated? .I..I.31.A., 176: -150, lt.R;l. , 2. (.I,:RSl, I'. It. l>rim:uy" carcin~lul:l ,,l the g a l l l d a d , h ' r ,
a t | l i r l y yP;ir slllllllltlr%'.. [ #l~#..k'ttr,.f., I ~-I~'l: ;{(;(I, [~.t(ll. :I. ~lil.Xl..'R, I., R. I._';illCt'r ot" l h c g M l l f l a d d c r : i l s rcl:iti~mshi D ll:idlh,r : ci live y e a r f l i r t . . . . | ,,1t.~. .~'llyLv., ltS,:,~k2, 19111. D. FAIIIM, R. I{ , FI:.RRIS, I). 1),, : l i l d )ICl)l~N;%l.ll, J. 1{. (_'dtl'iiil,tii;i ,,f lilt" Kiiiltll,ld~h'r, :ill : i t l l m l i s : l l o f ils