SSAT Annual Meeting
 

 
Back to SSAT Site
Annual Meeting
  Home
  Program and Abstracts
  Ticketed & Highlighted Sessions
  Past & Future Meetings
  Photo Gallery
  Past DDW on Demand
Winter Course
Other Meetings of Interest
 

Back to 2018 Program and Abstracts


TRENDS IN MANAGEMENT AND OUTCOMES OF HILAR CHOLANGIOCARCINOMA ACROSS A UNIVERSITY HOSPITAL HEALTHCARE NETWORK - A 15-YEAR EXPERIENCE
Aditya Gutta*, Lara Dakhoul, Mark A. Gromski, Attila Nakeeb, Michael G. House, Evan L. Fogel, James L. Watkins, Glen A. Lehman, Stuart Sherman, Jeffrey J. Easler
IU School of Medicine, Indianapolis, IN

INTRODUCTION: Multiple disciplines offer unique interventions for management of cholangiocarcinoma (CCA). Heterogeneity exists across centers for approach to CCA based on location of tumor, experience and expertise. Hilar cholangiocarcinoma (HCCA) adds further complexity to multidisciplinary decision-making due to variable presentation among individual patients and nuances of staging, hepatic drainage/resection and selecting among therapies. As novel diagnostic and therapeutic modalities have emerged, the management of HCCA has also evolved. Literature is lacking regarding trends for referrals, management and outcomes in large, networked healthcare systems that offer the entire range of therapies for HCCA.

AIM: Describe trends in referrals, management and outcomes in CCA and HCCA over the past 15-years within our academic health care system.

METHODS: We identified all patients with CCA that received care from 01/2001 to 12/2015 within the Indiana University Health Network (IUHN) tracked in the Indiana State Cancer Registry. Demographics, clinical data, initial stage and survival from diagnosis were collected from this prospectively maintained database. We reviewed medical records to clarify ambiguous/missing data and analyzed the results in 5 year eras.

RESULTS: A total of 352 patients (51% female, median age 67) with CCA (36% HCCA) were identified. Forty-two% of the patients (55% HCCA) were diagnosed at the academic health center (AHC). Despite an increasing volume of referrals, pre-diagnosis referrals to AHC decreased (p=0.031). For CCA, initial management strategies of hospice/palliative care (p=0.007), IR embolization (p=0.002) or resection (p=0.078) were increasingly deployed with each era. (Table 1) For HCCA an increase in initial referrals for palliative care/hospice (p=0.004) with fewer patients resected (p=0.027) was observed. MRI/MRCP (p=0.011) and ERCP (p=0.004) were increasingly utilized as diagnostic and/or palliative modalities. (Table 2) Despite these shifts in management strategies, no improvement in survival was observed for either groups.

CONCLUSION: In spite of clear shifts in management strategies and increased utilization of advanced diagnostic/therapeutic modalities (i.e. MRI/MRCP and ERCP), we observed little change in outcomes for CCA and HCCA over the past 15 years. An increasing proportion of patients referred to our centers are advanced stage and immediately transitioned to hospice. Novel strategies for early diagnosis, pre-referral screening and rapid consultation are needed to identify CCA patients at early stages and refer for potential curative therapy. Deployment of a dedicated, multi-disciplinary, system-wide CCA tumor board may have value in improving triage, access, management and outcomes.

Table 1: Clinical and tumor characteristics of all CCA patients
  2001 - 2005 2006-2010 2011-2015 P
‡ No of patients (n=352)65125162-
Median Age (years)6668670.207
Female, n (%)35 (53.8%)56 (44.8%)91 (56.2%)0.41
Type of CCA, n (%)    0.033 (overall)
Intrahepatic32 (49.2%)52 (41.6%)87 (53.7%)-
Hilar18 (27.7%)51 (40.8%)58 (35.8%)-
Distal15 (23.1%)21 (16.8%)16 (9.9%)-
* Stage, n (%)   0.568 (overall)
1/221 (32.3%)54 (43.2%)51 (31.5%)-
317 (26.2%)31 (24.8%)15 (9.3%)-
423 (35.4%)38 (30.4%)72 (44.4%)0.072
Metastasis15 (23.1%)17 (13.6%)39 (22.1%)0.601
^ Diagnosis at Academic Health Center (AHC)29 (44.6%)57 (45.6%)61 (37.7%) 0.031
Diagnostics    
MRI/MRCP, n (%)10 (15.4%)37 (29.6%)74 (45.7%) <0.0001
ERCP, n (%)28 (43.1%)67 (53.6%)84 (51.9%)0.257
Treatment modalities, n (%)    
Hospice5 (7.7%)13 (10.4%)32 (19.8%) 0.007
Resection28 (43.1%)65 (52%)57 (35.2%)0.078
Exploratory Laparotomy9 (13.8%)6 (4.8%)14 (8.6%)0.443
Transplant3 (4.6%)3 (2.4%)2 (1.2%)0.129
Radiation18 (27.7%)14 (11.2%)24 (14.8%)0.131
IR Embolization0 (0%)5 (4%)16 (9.9%) 0.002
Chemotherapy28 (43.1%)45 (36%)62 (38.3%)0.643
     
Survival (days)    
All patients7006104710.06
Received treatment (n=262/74.4%)8607306330.212
Resection (n=150/42.6%)9908848060.646

‡ 86.1% with positive histopathology.

  • * Staging recorded at the point of contact with an IU Health Facility using the AJCC/UICC staging system - 7th edition.
  • ^ Academic Health Center (AHC): Indiana Univeristy Hospital. Other IU facilities: Arnett, Frankfort, Methodist, Morgan, North, Springmill, Saxony and West.


    Table 2: Clinical and tumor characteristics of patients with HCCA
      2001 - 2005 2006-2010 2011-2015 P
    ‡ No of patients (n=127)185158-
    Median Age (years)7071670.861
    Female, n (%)10 (55.6%)21 (41.2%)31 (53.4%)0.714
         
    * Stage, n (%)   0.091 (overall)
    1/24 (22.2%)21 (41.2%)20 (34.5%)-
    36 (33.3%)15 (29.4%)9 (15.5%)-
    45 (27.8%)14 (27.5%)26 (44.8%)0.074
    Metastasis1 (5.6%)7 (13.7%)13 (22.4%)0.306
         
    ^ Diagnosis at Academic Health Center (AHC)8 (44.4%)32 (62.7%)30 (51.7%)0.991
         
    Diagnostics    
    MRI, n (%)3 (16.7%)21 (41.2%)30 (51.7%) 0.011
    ERCP, n (%)12 (66.7%)41 (80.4%)54 (93.1%) 0.004
         
    Treatment modalities, n (%)    
    Hospice1 (5.6%)9 (17.6%)20 (34.5%) 0.004
    Resection9 (50%)22 (43.1%)15 (25.9%) 0.027
    Exploratory Laparotomy1 (5.6%)3 (5.9%)8 (13.8%)0.169
    Transplant0 (0%)3 (5.9%)0 (0%)0.439
    Radiation6 (33.3%)8 (15.7%)7 (12.1%)0.058
    IR Embolization0 (0%)0 (0%)0 (0%)-
    Chemotherapy8 (44.4%)14 (27.5%)18 (31%)0.486
         
    Survival (days)    
    All patients6535764080.262
    Received treatment (n=80/62.9%)7946236760.687
    Resection (n=46/36.2%)8716487070.68

    ‡ 75.6% with positive histopathology.
  • * Staging recorded at the point of contact with an IU Health Facility using the AJCC/UICC staging system - 7th edition.
  • ^ Academic Health Center: Indiana Univeristy Hospital. Other IU facilities: Arnett, Frankfort, Methodist, Morgan, North, Springmill, Saxony and West.

Back to 2018 Program and Abstracts



© 2018 Society for Surgery of the Alimentary Tract. All Rights Reserved. Read the Privacy Policy.