New score points to intrahepatic cholangiocarcinoma outcome

Last Updated: 2017-03-23

By David Douglas

NEW YORK (Reuters Health) - A simplified prognostic score may increase the accuracy of survival prediction after hepatectomy for intrahepatic cholangiocarcinoma (ICC), according to California-based researchers.

As Dr. Gagandeep Singh told Reuters Health by email, "The relative rarity of intrahepatic bile duct cancers and the paucity of data to help guide management make this cancer a difficult problem to treat."

Dr. Singh and colleagues at the City of Hope National Medical Center in Duarte analyzed data on 275 patients with a median age of 65 years who underwent liver resection. Median follow-up for all patients was 23 months.

The most common surgical complication was hemorrhage or the need for blood transfusion which was seen in 43 patients (15.6%), the team reports in JAMA Surgery, online March 15. The most common postoperative medical morbidity was respiratory complication seen in 32 patients (11.6%).

No significant differences in overall complication rate was seen between tumors that were intrahepatic, small and solitary and those that had extrahepatic extension and were large and multifocal.

However, a multivariate Cox proportional hazards model showed that multifocality, extrahepatic extension, grade, node positivity and age greater than 60 years were independently associated with worse overall survival.

For example, overall survival at one year was 55.1% for ICCs with contiguous organ involvement and 82.5% without such involvement. Corresponding proportions at five years were 18.9% and 27.2%.

The team used the variables identified to develop the MEGNA prognostic score which was validated using information on 261 patients from the non-Californian SEER registries.

“The MEGNA prognostic score," they note, "demonstrated excellent predictive accuracy for probability of survival in all prognostic groups."

The prognostic separation/discrimination index was 0.21 with the MEGNA prognostic score versus 0.17 and 0.18 with the staging systems of the American Joint Committee on Cancer sixth and seventh editions, respectively.

This new guideline, continued Dr. Singh, first demonstrates the safety "of what many may consider ambitious resections (large, multifocal or tumors with extrahepatic extension) for intrahepatic cholangiocarcinomas. Second, we establish the factors important in predicting morbidity and mortality after such resections. Most importantly, we have developed and validated a prognostic score that is very easy to use, accurate and is superior to current staging systems."

"This prognostic score," he continued, "will allow doctors to discuss the prognosis with patients and their families after surgical resection. Many times the decision to operate is complex. A surgeon must weigh the potential oncologic benefit against the risk of complications from the operation. Given that the prognostic score can be calculated from information obtained prior to surgery, we anticipate that it will also help guide the decision to perform (or not perform) a potentially morbid operation."

In an accompanying editorial, Dr. David C. Linehan of the University of Rochester School of Medicine and Dentistry, New York, and colleagues observe that this and other studies "may court more controversy than answers regarding ICC staging. Ultimately, a staging system based on only preoperative values would be ideal to predict the outcome prior to deciding whether to offer surgical treatment. However, first we need to obtain a consensus on the true predictive factors for ICC outcome."

Dr. Gregory J. Gores of the Mayo Clinic in Rochester, Minnesota, who studies liver-cancer treatments, told Reuters Health by email, "I agree this is a useful staging system further clarifying who may or may not benefit from surgery for intrahepatic cholangiocarcinoma."

However, he added, "It is disappointing they did not have the tumor marker serum CA 19-9 available for the analysis."

"The major advance," concluded Dr. Gores, "is that the staging system helps clarify the role of tumor multicentricity and outcome following surgery. Overall, outcomes are still not optimal following surgical resection of this disease highlighting the need for further advances."

SOURCE: http://bit.ly/2naloDV and http://bit.ly/2mXCGDc

JAMA Surg 2017.