Increasing the Survival Rate for Biliary Cancer Patients

A study of patients treated for biliary malignancies at the Medical College of Wisconsin shows greatly improved survival rates achieved through careful screening of candidates for surgery, active management of the use of stents, aggressive surgery where appropriate, and chemoradiation.

Approximately 7,000 biliary malignancies are diagnosed in the US each year, but the prognosis for these patients has been poor. "The term 'biliary malignancies' actually includes two groups of patients - one group with cancers of the gallbladder and one with cancers of the bile duct," said study co-author Henry A. Pitt, MD, Professor of Surgery at the Medical College of Wisconsin. "In the bile duct the tumor can be located in the liver, between the liver and the pancreas, or just in the pancreas."

Surgical removal of the cancerous malignancies (resection) offers the only chance for cure. However, as the study said, "advances in radiology and laparoscopy have improved staging, but in most series less than half of the tumors are resectable." The study, which included 140 patients treated at the Medical College, also noted that an aggressive approach to using stents in bile channels might delay liver failure and reduce cholangitis, an infection throughout the body that starts in the bile ducts.

"Our findings are similar to those of other large centers such as Memorial Sloan-Kettering," said Dr. Pitt. "For a certain percentage of the patients that are staged through various scans, usually we can determine that malignancies have spread or involve blood vessels so much that they cannot be removed."

"About 60% of the patients look like they might be amenable to surgery on the basis of the pre-operative evaluation. When we explore those 60%, about half of those patients wind up with tumors that can be resected. So overall, about 30% to one-third of the patients that are referred to us have malignancies that can be removed."

Radiation, Chemotherapy and Stenting
"The one thing that is really significant and different in this series from most that have been published," said Dr. Pitt, "is that the group of 25 patients we removed tumors from over a recent four-year period, who we also gave radiation and chemotherapy to, had a significant increase in survival. That was compared to our own prior results over an eight-year period and also compared to most other publications in the literature. I think (the improved survival rate) is a combination of careful selection, trying to do operations that are big enough to get all of the tumor out - but not so big that they're not safe - and adding the radiation and chemotherapy."

Surgeons also employ stenting by running tubes into the bile ducts after the operation. "We think that stents help," said Dr. Pitt. "Many times these people die either because their liver fails or their liver has a lot of infection even when the tumor has not spread tremendously. We feel that these stents play a role in improving liver function and liver infection."

"The stents are there as a safety valve. They keep bile flowing. But if somebody gets a fever, we can open the stents up and let the bile drain out. It allows us to take the pressure off the system when there's a problem. Normally the bile is flowing all the time, and when it gets blocked up that either creates jaundice or infection."

Gallbladder and bile duct cancer patients are now living much longer after surgery than they did before 1998. The study at the Medical College showed that 19 patients who had resections between 1990 and 1997 had a median survival of 13 months and a 3-year actuarial survival of 21%. The 25 patients resected between 1998 and 2001 had a median survival longer than 44 months, with a 3-year actuarial survival of 77%.

Many of the lessons about treating biliary malignancies at the Medical College have also been learned throughout the world, Dr. Pitt said. "What we do surgically here is not dramatically different from what's done elsewhere," he said. "There is a debate as to the role of the stents, and there is a debate as to the role of the chemoradiation. We use all these tools here, and we've had some promising results."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.