Biliary Tract Tumors Research Articles

Mo2032 Small Cell Carcinoma of the Ampulla of Vater

[Background/Aim] An extensive hepatic resection is required in cases of malignant hepatic and biliary tract tumor. The prognosis is influenced by a shortage of functional capacity of the remnant liver. Since preoperative portal vein embolization (PVE) was first reported, this technique has become widely used in such cases. However, the indication for PVE and its outcome are unclear. In the present study, we retrospectively analyzed preoperative PVE patients. [Patients] From January 2002 to December 2011, 58 patients underwent preoperative PVE at our institute. In this study, we analyzed 46 patients (29 cases of hilar bile duct cancer [no liver damage group] and 17 colorectal liver metastatic tumor cases after chemotherapy [liver damage group]). In cases of hilar bile duct cancer or colorectal hepatic metastasis, we compared the resection rate and prognosis of these patients before and after PVE introduction. [Results] Two of 46 patients had complications caused by preoperative PVE (minimal bleeding into the biliary tract). Four cases in the group without liver damage (13.8%) could not undergo hepatectomy (3 cases, progressive disease; 1 case, no hypertrophy of the remnant liver). Five cases in the liver damage group (29.4%) could not undergo hepatectomy (1 case, severe steatohepatitis; 4 cases, no hypertrophy of the remnant liver). The median rates of hypertrophy of the remnant liver in the group without liver damage and the liver damage group were 9.4% and 7.5%, respectively (no statistical difference). The median maximum total bilirubin levels after hepatectomy in the group without liver damage and the liver damage group were 4.3 and 1.9 mg/dL, respectively (no statistical difference). In cases of hilar bile duct cancer and colorectal hepatic metastasis, the resection rate and the prognosis improved significantly after PVE introduction (resection rate: 56.7% vs. 90.2% and 30.0% vs. 58.2%, respectively; 3-year survival rate: 35.2% vs. 70.2% and 35.2% vs. 45.2%, respectively). [Conclusion] In the present study, no statistical difference was noted between the liver damage group and the group without liver damage in the rate of hypertrophy of the remnant liver after PVE and postoperative complications. However, the incidence of unresectability because of lack of hypertrophy of the remnant liver was higher in the liver damage group than in the group without liver damage. Thus, we believe that PVE has potential benefits for hilar bile duct cancer patients and colorectal liver metastasis patients because of the associated improved resection rate and prognosis.

A comparison between intraductal papillary neoplasms of the biliary tract (BT-IPMNs) and intraductal papillary mucinous neoplasms of the pancreas (P-IPMNs) reveals distinct clinical manifestations and outcomes

Intraductal papillary mucinous neoplasm of the biliary tract (BT-IPMN) has been increasingly recognized as a biliary counterpart of intraductal papillary mucinous neoplasm of the pancreas (P-IPMN). However, there is limited information regarding whether BT-IPMNs and P-IPMNs behave in a similar fashion. We retrospectively compared clinicopathological variables between 9 patients with BT-IPMN and 44 patients with P-IPMN. There was no significant difference in age between patients with BT-IPMN and those with P-IPMN. The male/female ratio was significantly higher in patients with P-IPMN than in those with BT-IPMN (P=0.012). Clinical presentation with jaundice was more common in patients with BT-IPMN (67%) than in those with P-IPMN (4.5%, P=0.002). In addition, serum levels of CEA and CA19-9 were higher in patients with BT-IPMN than in those with P-IPMN (P=0.019 and P=0.002, respectively). The pathological diagnosis of malignancy was significantly more common in patients with BT-IPMN (89%) than in those with P-IPMN (23%, P=0.002). The association with invasive carcinoma was significantly more frequent in patients with BT-IPMN (44.4%) than in those with P-IPMN (6.8%, P=0.008). Furthermore, survival time after surgical resection was significantly shorter in patients with BT-IPMN than in those with P-IPMN (P=0.002). These findings reveal differences in clinicopathological features and prognosis between BT-IPMN and P-IPMN, thereby suggesting distinct biological pathways underlying the pathogenesis of these neoplasms.

Biliary tract tumors: past, present and future

Tumors of the biliary tract (gallbladder tumors, cholangiocarcinomas and ampullary carcinomas) are low incidence tumors with poor prognosis. The five-year overall survival is 50% for stage I, 30% stage II, 10% stage III and 0% stage IV. Treatment is based on surgery for potentially resectable tumors. Chemotherapy and chemo-radiotherapy is the treatment of choice when surgery is not amenable, however it has not achieved encouraging results. These patients use to have very few symptoms, which is the reason for the delay in diagnosis and the poor prognosis. They frequently develop biliary obstruction: obstructive jaundice, right upper quadrant pain and weight loss. Ampullary carcinomas are frequently related to steatorrhea due to malabsorption. The most effective chemotherapy drugs used in monotherapy are 5FU (response rate 20%) and gemcitabine (response rate of 13%–60%), so they have been selected for further development in multiple phase II clinical trials to explore their efficacy and safety in combination with other agents. In a phase III clinical trial, combination of gemcitabine and cisplatin has been selected as the schedule of choice. Target therapies are also being developed in this malignancy. The present work reviews the most current knowledge of the pathogenesis, diagnosis and natural history of biliary tract tumors. Further, review of surgery, current adjuvant treatment and therapies for unresectable and advanced disease is provided. The most recent understanding for target therapies and molecular biology is also summarized.

Chemotherapies and molecularly targeted therapies in biliary tract cancers

Biliary tract cancer(BTC) is a malignart tumor which originates from biliary epithelia.Most patients with BTC present locally advanced stage or distant metastasis.Although the standard systemic chemotherapy approaches are emerging,the prognosis remains poor.Combination of gemcitabine and cisplatin can significantly prolong survival for patients,which is the standard treatment for locally advanced or metastatic BTC.Application of molecularly targeted therapies in advanced BTC is the new trend of clinical research. Key words: Biliary tract neoplasms; Targeted therapy

P3-157 - Chronic Myelogenous Leukaemia Following S-1 THerapy for Rectal Cancer: A Case report

ABSTRACT Introduction Therapy-related leukaemias are the one of the most common second malignancies. However therapy-related chronic myelogenous leukaemia (CML) is far more rare than therapy-related acute myeloid leukaemias or myelodysplastic syndromes. Herein we report a case of secondary CML, who had a past history treated with S-1 as post-operative therapy for rectal cancer. Case report A 59-year-old male was referred to our hospital because of leukocytosis on October 2011. His laboratory findings showed a white blood cells of 14 100/ml with 11% basophils, 7% eosinophils, 0.5% myelocytes, 66.5% neutrophils. His haemoglobin level was 13.9 g/dl and his platelet count was 393 000/ml, and his serum level of lactate dehydrogenase was 341 IU/l. He had a past history of rectal cancer received abdominoperineal resection in July 2008, and was subsequently treated with oral anti-metabolite S-1 for a year (total dosage of 33 600 mg). Bone marrow aspiration showed hypercellular bone marrow without blast increase, and karyotype analysis revealed 46,XY,t(9;22)(q34;q11.2) [20]. A diagnosis of therapy-related CML was made because of his past history of S-1 therapy. The patient was started on dasatinib therapy and rapidly achieved complete haematological response. Discussion S-1 is among the most effective anti-cancer agents for various carcinomas such as gastric cancer, lung cancer and biliary tract neoplasms. And for colorectal cancer, S-1 is recommended as a suitable treatment of adjuvant therapies. To best of our knowledge, only few cases of therapy-related CML following fluoropyrimidines therapy have been described. The frequency, clinical course and prognostic value of therapy-related CML has not been clarified yet because of its rarity, and further accumulation of cases is necessary for evaluation of the therapeutic outcome of therapy-related CML patients.

Value analysis of endoscopic management of malignant obstruction combined common bile duct and gastric outlet-duodenum obstruction

Objective To evaluate curative effects of treatment of malignant biliary and gastric out-let-duodenal obstruction with endoscopicaUy placed self-expandahle metal stents. Methods A retrospective analysis was performed in 17 patients who underwent enteral stenting after placement of the biliary stent. The success rate of insertion, the effective palliation of biliary and duodenal obstruction, the rate of complication, recurrent stent obstruction and the median patency were observed. Results In 17 patients, biliary stenting were all performed for obstructive jaundice and then enteral stents were inserted. The levels of tatal billiru-bin [from （263.4 ± 62.5 ） p, moL/L to （ 157.6 ± 25.1 ） μmol/L], direct billirubin [ from （ 1233.2 ± 66.5） μmol/L to （ 130.9 ± 27.7 ） μmol/L ] and alkaline phosphatase [ from （ 233.2 ± 66. 5 ） IU/L to （130. 9 ±27.7）IU/L] decreased significantly （P 〈 0. 01 ）, and the gastric outlet score increased signifi- cantly [ from （0. 9 ± 1.1 ） points to （2. 1 ± 0. 7 ） points ] （P 〈 0. 01 ）. No serious complication in all pa-tients. Lifetime of patients ranged from 70 days to 332 days, and the median survival time was 192 day. Conclusion Combined biliary and enteral stenting is an effective method for palliation of malignant biliary and gastric outlet-duodenal obstruction. Key words: Biliary tract neoplasms ; Cholangiopancreatography, endoscopic retrograde ; Stent ; Malignant biliary obstruction; Malignant duodenal obstruction

PTU-011 A new concept to extend resectability of liver tumours: two stage surgical strategy using an in-situ-split procedure

IntroductionToday only 20%–25% of colorectal liver metastasis are resectable at initial presentation, despite the progress made in liver surgery over the last 25 years.1 The induction of liver hypertrophy by...

Metastatic and unresectable biliary tract tumors: A single-center retrospective review.

e14733 Background: Biliary tract tumours are rare and often poor prognosis cancers that comprise cholangiocarcinomas, ampullary tumours and gallbladder cancers. Methods: Medical Electronic Records for patients diagnosed between January 2008 and December 2010 and treated at a medical oncology unit were reviewed, and clinical and epidemiological data for patients were retrieved. Results: We have found 28 patients with a distribution with a clear majority of men (60%), with a median age of 66 years (range 45-80).Patients were mostly metastatic (85%) at diagnosis and the majority of patients had intrahepatic cholangiocarcinoma (60%) as diagnosis and debuted with large intrahepatic masses and metastatic disease.Those with tumours arising outside the liver (40%) had obstructive jaundice (28%) or cholangitis (26%) at diagnosis and needed in most cases biliary stenting (33%).Six patients had PS2 at diagnosis and received gemcitabine monotherapy. Only one patient remaining progression free at 6 months and none of them received treatment at progression, the mean PFS was of 5.3 months and the OS was of 8.3 months.Of 22 patients with good performance status, 12 of them with a mean age of 60 years received polychemotherapy with GEMOX or CDDP-gem with PFS of 7. 3 months and OS of 12. 3 months.The other 10 patients (with a mean age of 65 years) received gemcitabine as monotherapy with a PFS of 7. 9 months and a OS of 11. 4 months.Eight patients were treated with second line therapy with no responses and a mean of PFS of 2 months, OS was not superior to patients who did not receive second line treatment. Conclusion: Our patients with biliary tract tumours had a mean progression free survival of 8.2 months and a mean overall survival of 12.3 months with 5 patients remaining progression free more than 20 months after beginning treatment. This survival data are compatible with those reported in recent clinical trials although we did not find improvements in survival with polychemotherapy and second line therapies. Conclusions: Taken as a whole our patients with biliary tract tumours had a mean progression free survival of 8.2 months and a mean overall survival of 12.3 months with 5 patients remaining progression free more than 20 months after beginning treatment.

Clinicopathological Features and Management of Cancers in Lynch Syndrome

Lynch syndrome (LS) is characterized by an autosomal dominant inheritance of the early onset of colorectal cancer (CRC) and endometrial cancer, as well as increased risk for several other cancers including gastric, urinary tract, ovarian, small bowel, biliary tract, and brain tumors. The syndrome is due to a mutation in one of the four DNA mismatch repair (MMR) genes MLH1, MSH2, MSH6, or PMS2. The majority of LS patients and families can now be identified, and the underlying mutation detected using genetic diagnostics. Regular surveillance for CRC and endometrial cancer has proved beneficial for mutation carriers. However, screening for other tumors is also recommended even though experiences in the screening of these tumors is limited. Prophylactic colectomy, prophylactic hysterectomy, and bilateral salpingo-oophorectomy may be reasonable options for selected patients with LS. This paper describes the features and management of LS.

Tumors of ampulla of Vater: A case series and review of chemotherapy options

Carcinomas of the Ampulla of Vater are rare tumors, accounting for 0.2% of gastrointestinal cancers. Compared with other biliary tract neoplasms, these tumors have a relatively favorable prognosis after surgical resection. Based on their epithelium of origin, two subtypes of ampullary carcinoma have been recently distinguished: intestinal and pancreatobiliary. This study evaluates histopathological features and outcomes of ampullary carcinoma and to compares the survival of these tumors to that of other biliary tract tumors. The chemotherapic options available for ampullary cancer are also reviewed. We analyzed data from 20 consecutive patients with ampullary carcinomas and 26 patients with other biliary tract carcinomas, observed in our Institution. Statistical analysis was performed by using either Fisher's exact test or χ(2) test for categorical variables. Median time of survival was calculated and compared using the Log-Rank test. Similar distribution of demographic characteristics and stage between ampullary and other biliary tract cancers was observed. Patients with ampullary cancer underwent surgery more frequently than other biliary cancers while chemotherapy and radiotherapy were used equally. In accordance with the literature, a longer median survival was observed in the group of ampullary carcinomas.

CDK10 functions as a tumor suppressor gene and regulates survivability of biliary tract cancer cells

Cyclin-dependent kinase 10 (CDK10) is a member of the Cdc2 family of kinases, and has been demonstrated to be an important determinant of resistance to endocrine therapy for breast cancer. To investigate the expression and possible function of CDK10 in biliary tract cancer (BTC), we systematically examined CDK10 in tissues and cell lines. We found that expression of CDK10 was downregulated in both biliary tract tumors and cell lines. Remarkably, the expression of CDK10 correlated with clinical characteristics. Overexpression or knockdown of CDK10, respectively, inhibited or promoted cell proliferation, colony formation and migration. This suggests that CDK10 functions as a tumor suppressor gene in BTC. Overexpression of CDK10 caused malignant cells to become sensitive to chemotherapy and other hostile environments, suggesting that CDK10 functions to regulate survivability of BTC cells. We investigated the expression of six genes to resolve the mechanism. c-RAF was negatively regulated by CDK10 in both cells and specimens. Our results indicate that CDK10 plays a crucial role in the growth and survivability of biliary tract cancer, and offers a potential therapeutic target for this fatal disease.

Medical therapy of advanced biliary tract cancer

Medical therapy is the primary choice for patients with advanced biliary tract cancer.Gemcitabine has been proved to be one of the most effective drugs and a standard regimen has been made when combined with cisplatin.Studies of the second line therapy is few.Targeted therapy has a potential to create a new era in the future but needs to be validated in large clinical trials. Key words: Biliary tract neoplasms; Drug therapy; Molecular targeted therapy

Mrp14 is a potential biomarker for biliary tract neoplasms

Objective To provide clues to find a biomarker for early diagnosis, prognosis and therapy, as well as to understand the molecular mechanisms governing cancer progression. Methods Surgical specimens were obtained from 87 patients with histopathologically proven malignant or benign lesions. The differential protein profiles of these malignant and benign specimens were detected using two-dimensional electrophoresis (2-DE) combined with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF/MS). Western blotting and immuno-histochemistry were used to validate the results. RT-PCR was used to detect the gene expression in the tissues. Results Mrp14 was found to be overexpressed in the tumor tissues of gallbladder cancer and extra-hepatic bile duct cancer, and in the bile of patients with malignant biliary tract tumours. The result was further verified using Western blot and immuno-histochemistry. RT-PCR confirmed the overexpression of Mrpl4 at the gene level. Mrp14 is a potential biomarker for biliary tract neoplasms. Conclusions This is the first report which described the overexpression of Mrp14 in biliary tract neoplasms and further studies are needed to confirm our findings. Mrp14 may be a potential hiomarker for biliary tract neoplasms. It may provide important clues on the molecular mechanisms governing cancer progression. Key words: Bile duct cancer; Cholangiocarcinoma; Gallbladder cancer; Tumor markers; Proteomics

Relationship of CDX-2 with intestinal metaplasia and biliary tract tumor

Caudal-related homeobox transcription factor (CDX-2) is selectively localized in the fetal and adult mu-cosal epithelial nuclei of normal small and large intestines.CDX2 plays an important role in the regulation of cell proliferation and differentiation of the intestinal epithelium. Ec-topic expression of CDX-2 in the stomach, esophagus and other hollow organs might be a cause of intestinal metaplasia and adenocarcinoma. CDX-2 is expressed in both cultured and primary gallbladder carcinoma cells, and dysplasia.CDX2 is not detected in normal gallbladder and biliary tract mucosa. Ectopic CDX2 expression is an early event in gallbladder carcinogenesis. The frequency of CDX-2 expression is significantly higher in well-differentiated type than in the moderately and poorly differentiated tumors. The present study clearly showed that MUC2 expression in intestinal differentiation was dependent on the nuclear expression of CDX-2 in intraductal papillary neoplasia of the liver (IPNL)and mucinous intrahepatic cholangiocarcinoma (ICC) in the same manner as in the gastric mucosa and Barrett s esophagus. CDX-2 may also be a key factor in gallbladder carcinogenesis with intestinal differentiation and is a useful immuno-histochemical marker of intestinal differentiation in intestinal metaplasia of the gallbladder. CDX2-dependent regulation of cell proliferation may be an important factor in defining prognosis of patients with BTC. Key words: Gallbladder; Biliary tract; Intestinal metaplasia; Turner; CDX-2

The diagnostic values of bile cytology and blood tumor markers for malignant bile duct obstruction

Objective To explore the diagnostic values of bile cytology obtained in endoscopic retrograde cholangiopancreatography （ERCP） and blood tumor markers for malignant bile duct obstruction. Methods From August 2005 to April 2009, bile cytology and blood tumor markers measurement were performed in 47 cases with bile duct obstruction, in which 39 cases were confirmed to be malignant and 8 were benign. Results Malignant cells were found in bile from 26 of 39 malignant obstruction （66. 7% ）, and serum CA19-9 was positive in 28 （71.8%）. No malignant cells were detected in bile cytology from 8 cases with benign obstruction （with a specificity of 100% ） and serum CA19-9 was negative in 7 （87.5%）. In 26 patients with cholangiocarcinoma, serum CA19-9 was positive in 18 （69. 2% ）. For bile cytology and blood tumor markers test, sensitivity of parallel combination was 89. 7%, and the specificity of serial combination was 100. 0%. Conclusion Bile cytology testing during ERCP can provide the pathological evidence for malignant bile duct obstruction. The sensitivity is improved by combination tests of bile cytology and blood tumor markers. Key words: Cholangiopancreatography, endoscopic retrograde ; Biliary tract neoplasms ; Cytology; CA19-9 antigen

BILCAP: A randomized clinical trial evaluating adjuvant chemotherapy with capecitabine compared to expectant treatment alone following curative surgery for biliary tract cancer.

4125 Background: Biliary tract tumours are relatively rare, accounting for 0.7% of malignant tumours in adults, with approximately 1200 new cases registered each year in England and Wales. The 1-year and 5-year survival is poor at 22% and 9% respectively. Approximately 15-20% of cases are suitable for surgical resection but the outlook remains poor with survival at 5 years approximately 15%. Most tumours are advanced at presentation and are unsuitable for surgical resection. Methods: BILCAP is a multi-centre prospective, randomised phase III trial investigating the role of adjuvant chemotherapy with oral fluoropyrimidine (capecitabine) in patients following potentially curative surgical resection of a biliary tract cancer. Patients who have undergone macroscopically complete surgical resection will be randomised to receive either adjuvant chemotherapy with capecitabine or observation. The study is supervised by the National Cancer Research Institute (UK) Upper Gastrointestinal Studies Group and funded by Cancer Research UK. Results: The primary endpoint is progression free survival (DFS) at 2 years. The intention is to increase 2 year DFS from 15 to 28%. This will require 360 patients enabling a 2-sided significance level of 5% and 80% power. Secondary endpoints are 5-year survival, toxicity, quality of life and health economics. Toxicity has been acceptable. Conclusions: 202 of 360 patients have been successfully recruited to date. With approximately 200 resections for biliary tract cancer per year in the UK, BILCAP has recruited more than 25% of all resected patients in the UK for the last 3 years (51pts in 2008, 53 pts in 2009 and 73 patients in 2010) and 36% in 2010. As such it is the most successful adjuvant study in biliary tract cancer and will complete accrual in Q1 2012. The results of BILCAP will define the international standard of care for patients with resected biliary tract cancer. Further detail on recruitment and toxicity will be presented. ISRCTN Number: ISRCTN72785446, EudraCT Number: 2005-003318-13. Publisher's Note The abstract by Bridgewater et al entitled, “BILCAP: A randomized clinical trial evaluating adjuvant chemotherapy with capecitabine compared to expectant treatment alone following curative surgery for biliary tract cancer,” published in the 2011 Journal of Clinical Oncology 29, no. 15 suppl (May 20 2011) 4125–4125, contained errors. The authors discovered the Results section of the abstract contains errors that apply to both the definition of the primary outcome measure and the parameters of the sample size calculation. The primary outcome of the BILCAP trial was incorrectly defined as progression free survival, rather than overall survival. In addition, the stated detectable difference was incorrectly identified as 15% to 28%. This article was retracted on 17-07-2019.

Expression and clinicopathologic significance of glypican 3 in hepatocellular carcinoma

Glypican 3 (GPC3) is a glycosylphosphatidylinositol-anchored membrane protein and plays an important role in regulation of cell growth, differentiation, and migration. The aims of this study were to investigate the expression of GPC3 in human liver, biliary tract, and pancreatic tumors and to evaluate its diagnostic role in differentiating hepatocellular carcinoma (HCC) from other hepatic mimickers. Immunohistochemistry was performed on a large collection of surgically resected samples from 941 primary liver tumors, 50 metastatic adenocarcinomas, and 30 normal livers as well as primary adenocarcinomas of the pancreas (n = 17), gallbladder (n = 30), and extrahepatic bile duct (n = 20). The relationship of GPC3 expression and clinicopathologic features in patients with HCC was determined. We found that 516 (52%) of the 991 liver neoplastic tissue samples demonstrated positive staining for GPC3. A high incidence of GPC3 expression (492/757; 65%) was observed in HCC, whereas intrahepatic cholangiocarcinomas, adenocarcinomas, and benign liver lesions displayed rare positive cases. There were significant correlations between GPC3 expression and clinicopathologic characteristics, including histologic grade (P < .001), intrahepatic metastasis (P = .007), and positive serum hepatitis B surface antigen (P = .042), in patients with HCC. In conclusion, our results confirm the high expression of GPC3 in HCC and suggest its potential diagnostic value as a clinical marker for this disease.

Carcinoid tumors of the extrahepatic biliary tract: Report of four cases

Carcinoid tumors located in the biliary tree are exceedingly rare, accounting for 0.2%-2% of all gastrointestinal carcinoids. This study describes four cases of carcinoid tumors of the extrahepatic biliary tract. Four carcinoid tumors arising in the common bile duct (Case 1, 59-year-old man), gallbladder (Case 2, 49-year-old man; Case 3, 65-year-old man), and ampulla of Vater (Case 4, 52-year-old woman) were studied. All of the cases were misdiagnosed before surgery as proximal bile duct cancer, stomach cancer with liver metastasis, gallbladder cancer, and adenocarcinoma of ampulla of Vater, respectively. The clinicopathological characteristics and clinical course were reviewed. Treatment depends on the location of the tumor and the extent of the disease. Aggressive surgical therapy with a curative intention therefore offers the only chance for cure and has to be considered whenever possible.

Markers of bile duct tumors

Biliary tract carcinomas are relatively rare, representing less than 1% of cancers. However, their incidence has increased in Japan and in industrialized countries like the USA. Biliary tract tumors have a poor prognosis and a high mortality rate because they are usually detected late in the course of the disease; therapeutic treatment options are often limited and of minimal utility. Recent studies have shown the importance of serum and molecular markers in the diagnosis and follow up of biliary tract tumors. This review aims to introduce the main features of the most important serum and molecular markers of biliary tree tumors. Some considerable tumor markers are cancer antigen 125, carbohydrate antigen 19-9, carcinoembryonic antigen, chromogranin A, mucin 1, mucin 5, alpha-fetoprotein, claudins and cytokeratins.

Endoscopic precut sphincterotomy for malignant biliary obstruction

Objective To evaluate the endoscopic precut sphincterotomy for malignant biliary obstruction. Methods Endoscopic precut sphincterotomy was performed in different ways for 46 patients with malignant biliary obstruction and difficult biliary cannulation according to the anatomic structure of the papilla and cannulation. Ways of precut were summarized and complications were analyzed. Results Precut sphincterotomy was performed with bow-like knife in 4 patients, with needle-knife in 24, with trans-pancreatic sphincterotomy in 12 and with combined ways in 6. The procedure succeeded in 35 cases （76. 1%, 35/46）. Post-procedure complications included bleeding in 3 patients, pancreatitis in 1, hyper-amylasemia in 2and cholangitis in 1. No perforation was found. Conclusion Endoscopic precut sphincterotomy is not only able to improve the therapeutic endoscopy achievement rate in patients with malignant biliary obstruction, but also to lower the incidence of complications if used adequately. Key words: Biliary tract neoplasms; Cholangiopancreatography,endoscopic retrograde; Intubation; Precut sphincterotomy