Biliary Tract Tumors Research Articles

Does radiotherapy still have a role in unresected biliary tract cancer?

The benefits of radiotherapy for inoperable biliary tract cancer remain unclear due to the lack of randomized data. We evaluated the impact of radiotherapy on survival in elderly patients using the SEER‐Medicare database. Patients in the SEER‐Medicare database with inoperable biliary tract tumors diagnosed between 1998 and 2011 were included. We used multivariate logistic regression to evaluate factors associated with treatment selection, and multivariate Cox regression and propensity score matching to evaluate treatment selection in relation to subsequent survival. Of the 2343 patients included, 451 (19%) received radiotherapy within 4 months of diagnosis. The use of radiotherapy declined over time, and was influenced by receipt of chemotherapy and patient age, race, marital status, poverty status, and tumor stage and type. Median survival was 9.3 (95% CI 8.7–9.7) months among patients who did not receive radiation and 10.0 (95% CI 9.1–11.3) months among those who received radiation, conditional on having survived 4 months. In patients who received chemotherapy (n = 1053), receipt of radiation was associated with improved survival, with an adjusted hazard ratio of 0.82 (95% 0.70–0.97, P = 0.02). In patients who did not receive chemotherapy (n = 1290), receipt of radiation was not associated with improved survival, with an adjusted hazard ratio of 1.09 (95% 0.91–1.30, P = 0.34). Propensity‐scored matched analyses showed similar results. Despite the survival benefit associated with the addition of radiotherapy to chemotherapy, the use of radiation for unresectable biliary tract cancers has declined over time.

The rise of the FGFR inhibitor in advanced biliary cancer: the next cover of time magazine?

Cholangiocarcinomas (CCAs) are heterogeneous tumors arising from the biliary tract with features of cholangiocyte differentiation. CCAs are aggressive tumors with limited treatment options and poor overall survival. Only a subset of CCA patients with early stage disease can avail potentially curative treatment options. For advanced biliary tract tumors, currently there are limited effective treatment modalities. Recent advances have provided greater insight into the genomic landscape of CCAs. The fibroblast growth factor receptor (FGFR) pathway is involved in key cellular processes essential to survival and differentiation. Accordingly, aberrant FGFR signaling has significant oncogenic potential. Recent discovery of FGFR2 gene fusions in CCA has heightened interest in FGFR inhibition in advanced biliary tract cancer. These findings have served as a catalyst for ongoing clinical investigation of FGFR inhibition in CCA patients with various FGFR signaling abnormalities. Herein, we review FGFR aberrations in CCA and their prognostic implications, FGFR targeting as a viable therapeutic option in advanced biliary tract malignancies, and future directions for development of combination approaches utilizing FGFR inhibition.

Long-term outcomes and prognostic factors of surgical resection of hilar cholangiocarcinoma

Objective To investigate the long-term outcomes and prognostic factors of surgical resection of hilar cholangiocarcinoma. Methods The retrospective case-control study was adopted. The clinicopathological data of 129 patients with hilar cholangiocarcinoma who underwent surgery at the First Affiliated Hospital of Sun Yat-sen University between January 2007 and August 2014 were collected. The follow-up of outpatient examination and telephone interview was performed to observe the survival of patients, tumor recurrence and metastasis up to October 2015. (1) Long-term outcomes (1-, 3-, 5-year survival rates and survival time) were observed. (2) Prognostic factors were collected, including gender, age, preoperative CA19-9, tumor diameter, curative degree of tumor (R0 resection or R1 resection), vascular resection and reconstruction, modified T stage, lymph node metastasis, TNM stage and tumor differentiation. (3) The stratified analyses were used for the independent prognostic factors. The survival curve was drawn by Kaplan-Meier method, and the survival rate was analyzed using the Log-rank test. The univariate analysis and multivariate analysis were respectively done using the chi-square test and COX regression model. Results (1) Of 129 patients, 4 patients were dead in the perioperative period, 112 were followed up for a median time of 19 months (range, 1-98 months). During the follow-up, 75 patients were dead. The overall median survival time and 1-, 3-, 5-year survival rates of the 129 patients were 23 months, 71.1%, 31.4% and 14.6%, respectively. (2) The results of univariate analysis showed that curative degree of tumor, modified T stage, lymph node metastasis, TNM stage and tumor differentiation were the related factors affecting the prognosis of patients undergoing surgical resection of hilar cholangiocarcinoma (χ2=5.566, 5.450, 4.558, 4.033, 6.093, P<0.05). The results of multivariate analysis showed that R1 resection, stage Ⅲ-Ⅳ and low-differentiated tumor were the independent risk factors affecting the poor prognosis of patients undergoing surgical resection of hilar cholangiocarcinoma (HR=2.328, 1.691, 1.750, 95% confidence interval: 1.224-4.427, 1.035-2.762, 1.205-2.542, P<0.05). (3) The median survival time and 1-, 3-, 5-year survival rates were 24 months, 75.5%, 36.0% , 15.8% in 110 patients with R0 resection, the median survival time and 1-, 3-year survival rates were 12 months, 47.1% and 7.1% and the 5-year survival rate missed in the 19 patients with R1 resection, with a statistically significant difference (χ2=5.566, P<0.05). The median survival time and 1-, 3-, 5-year survival rates were 30 months, 75.0%, 42.5%, 20.1% in 55 patients with stageⅠ-Ⅱ and 18 months, 68.1%, 22.2%, 7.0% in 74 patients with stage Ⅲ-Ⅳ, respectively, showing a statistically significant difference (χ2=4.033, P<0.05). The median survival time and 1-, 3-, 5-year survival rates were 30 months, 82.4%, 49.5%, 49.5% in 19 patients with high-differentiated tumor, 24 months, 69.6%, 30.4%, 11.8% in 62 patients with moderate-differentiated tumor, 18 months, 63.5%, 24.2%, 0.0 in 33 patients with low-differentiated tumor, respectively, with a statistically significant difference (χ2=6.093, P<0.05). Conclusions Long-term outcomes of surgical resection of hilar cholangiocarcinoma are unsatisfactory. Moreover, R1 resection, stage Ⅲ-Ⅳ and low-differentiated tumor are the independent risk factors affecting the poor prognosis of patients undergoing surgical resection of hilar cholangiocarcinoma. Key words: Biliary tract neoplasms, hilar; Surgical resection; Prognostic factors

Blood expression of matrix metalloproteinases 8 and 9 and of their inducers S100A8 and S100A9 supports diagnosis and prognosis of PDAC-associated diabetes mellitus

BackgroundBased on the knowledge that matrix metalloproteinases (MMPs) and S100A8/A9 synergistically work in causing PDAC-associated type 2 diabetes mellitus (T2DM), we verified whether tissue and blood MMP8, MMP9, S100A8 and S100A9 expression might help in distinguishing PDAC among diabetics. MethodsRelative quantification of MMP8, MMP9, S100A8 and S100A9 mRNA was performed in tissues obtained from 8 PDAC, 4 chronic pancreatitis (ChrPa), 4 non-PDAC tumors and in PBMCs obtained from 30 controls, 43 T2DM, 41 ChrPa, 91 PDAC and 33 pancreatic–biliary tract tumors. ResultsT2DM was observed in PDAC (66%), in pancreatic–biliary tract tumors (64%) and in ChrPa (70%). In diabetics, with or without PDAC, MMP9 tissue expression was increased (p<0.05). Both MMPs increased in PDAC and MMP9 increased also in pancreatic–biliary tract tumors PBMCs. In diabetics, MMP9 was independently associated with PDAC (p=0.025), but failed to enhance CA 19-9 discriminant efficacy. A highly reduced S100A9 expression, found in 7 PDAC, was significantly correlated with a reduced overall survival (p=0.015). ConclusionsAn increased expression of tissue and blood MMP9 reflects the presence of PDAC-associated diabetes mellitus. This finding fits with the hypothesized role of MMPs as part of the complex network linking cancer to diabetes.

An observational and comparative study on intraductal papillary mucinous neoplasm of the biliary tract and the pancreas from a Chinese cohort

Intraductal papillary mucinous neoplasms of the biliary tract (BT-IPMNs) are unique but very rare biliary tumors. The relationship between BT-IPMNs and intraductal papillary mucinous neoplasm of the pancreas (P-IPMNs) was still unclear and controversial. We aimed to evaluate the clinical, radiological, histopathological, and prognostic characteristics of BT-IPMNs and P-IPMNs to achieve a better understanding of these two rare bilio-pancreatic diseases and their connections. Data of a total of 116 patients who were all surgically treated and histopathologically diagnosed as BT-IPMNs or P-IPMNs from January 2004 to December 2014 in our single institution was all retrospectively collected and analyzed. This study respectively enrolled 32 patients with BT-IPMNs and 84 ones with P-IPMNs. The differences between BT-IPMNs and P-IPMNs in age, sex ratios, clinical presentation, elevated tumor markers and proportion of malignancy were not statistically significant (P>0.05), while the tumor diameter of BT-IPMNs was notably smaller than P-IPMNs (1.72cm, 4.56cm, respectively; P=0.028). Patients with BT-IPMNs were more likely manifest the symptoms of cholangitis, compared to those with P-IPMNs who showed pancreatitis (75%, 30%, respectively; P=0.039). Bile duct dilatation (100%), tumor of bile duct cavity (50%) or/and cystic dilatation of the bile duct (50%) were the typical manifestations of preoperative imaging examinations of BT-IPMNs, in which tumors were mainly located in intrahepatic or hepatic hilar region (26, 81%). Surgery has been the curable treatment for BT-IPMNs in which left hepatic lobectomy was the most commonly performed procedure (20, 63%). Finally, compared with P-IPMNs, the overall mean survival time of patients with BT-IPMNs was a little shorter (59.1mon, 86.7mon, respectively; P=0.002). BT-IPMNs are a sort of rare and separate biliary tract neoplasm, which might be related with the stones of biliary tract or the infections of parasite. Although arising in different organs and representing different features, BT-IPMNs and P-IPMNs shared considerable clinical and pathological similarities which might represent related or similar development process in the bilio-pancreatic duct systems.

Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma.

Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.

Predictive factors of difficult procedure in octogenarians undergoing elective laparoscopic cholecystectomy: a single center experience.

To assess the feasibility and safety of laparoscopic cholecystectomy (LC) in very elderly patients with particular attention to the predicitive factors of difficulty. All patients aged ≥ 80 undergoing elective LC for lithiasis at our institution since 1st January 2015 to 31st December 2015 were included in the study. Exclusion criteria were: a) acute cholecystitis; b) biliary pancreatitis; c) biliary tract neoplasms; d) urgent procedure. Pre-, intra- and postoperative data were recorded. During the study period, we performed 72 LC and we enrolled 17 patients aged ≥ 80 with a M:F = 5:12. Of these, 10 patients had a "difficult" cholecystectomy. In seven cases an intraoperative cholangiography (IOC) was performed. Postoperative course was regular but in two patients we had an Oddian spasm in 1st postoperative day. Female sex (p=0.03) and preoperative high level of serum amylase (p= 0.02) were significantly associated to difficult cholecystectomy in elderly patients. LC in octogenarians is feasible and safe. However, sex and serum amylase can help the surgeon to predict a more difficult procedure in elective LC. In this group of patients an approach based on the individual risk is desirable and the patient could be referred to a multidisciplinary approach.

Surgical Palliative Drainage in Un-resectable Malignant Biliary Obstruction

Introduction: Tumor resection is the curative therapy in the patients with malignant obstruction and in nonoperable patients non-surgical palliative therapy, is recommended. These methods may not be successful in some cases because of the various reasons, so the surgical intervention is needed to eliminate biliary obstruction. The aim of this study is to introduce and evaluate a new method for drainage in the patients with un-resectable malignant obstruction in biliary system. Method: This study included 21 patients with un-resectable tumor of biliary tract causing obstruction. After exploring the abdomen, segment II and III of liver will be dissected and then a part of segment III will be removed. In all of cases feeding tube will be put in the duct. Two to three biliary ducts will be specified; thus, feeding tube at least number 5 will be inserted inside the duct and guided through the liver so that it reaches the large ducts inside. A Roux arch will be created afterwards, and will be anastomosed to the liver capsule in parachute procedure. After operation patients will be monitored for the outbreak of cholangitis, anastomosis leakage, pruritus and the decrease of bilirubin level. Results: The new method of surgery in patients with malignant obstruction of the biliary tract was exclusively palliative in all 21 cases. The 30-day mortality in the study group was 14.3% (n=3/21). Pruritus was comparatively cured in the patients (85.7%), and prevalence of cholangitis was decreased after the intervention (19% to 14.3%). Anastomosis was leaked in just one patient. Conclusion: In patients with amalignant obstruction in biliary tract in hilum of liver which non-surgical procedures were not successful, so hepatojejunostomy might be more effective.

Molecular genetics and targeted therapeutics in biliary tract carcinoma.

The primary malignancies of the biliary tract, cholangiocarcinoma and gallbladder cancer, often present at an advanced stage and are marginally sensitive to radiation and chemotherapy. Accumulating evidence indicates that molecularly targeted agents may provide new hope for improving treatment response in biliary tract carcinoma (BTC). In this article, we provide a critical review of the pathogenesis and genetic abnormalities of biliary tract neoplasms, in addition to discussing the current and emerging targeted therapeutics in BTC. Genetic studies of biliary tumors have identified the growth factors and receptors as well as their downstream signaling pathways that control the growth and survival of biliary epithelia. Target-specific monoclonal antibodies and small molecules inhibitors directed against the signaling pathways that drive BTC growth and invasion have been developed. Numerous clinical trials designed to test these agents as either monotherapy or in combination with conventional chemotherapy have been completed or are currently underway. Research focusing on understanding the molecular basis of biliary tumorigenesis will continue to identify for targeted therapy the key mutations that drive growth and invasion of biliary neoplasms. Additional strategies that have emerged for treating this malignant disease include targeting the epigenetic alterations of BTC and immunotherapy. By integrating targeted therapy with molecular profiles of biliary tumor, we hope to provide precision treatment for patients with malignant diseases of the biliary tract.

The Emerging Role of miRNAs and Their Clinical Implication in Biliary Tract Cancer.

Biliary tract cancers are aggressive malignancies that include gallbladder cancer and tumors of intra- and extrahepatic ducts and have a poor prognosis. Surgical resection remains the main curative therapy. Nevertheless, numerous patients experience recurrence even after radical surgery. This scenario drives the research to identify biliary tract cancer biomarkers despite the limited progress that has been made. Recently, a large number of studies have demonstrated that deregulated expression of microRNAs is closely associated with cancer development and progression. In this review, we highlight the role and importance of microRNAs in biliary tract cancers with an emphasis on utilizing circulating microRNAs as potential biomarkers. Additionally, we report several single-nucleotide polymorphisms in microRNA genes that are associated with the susceptibility of biliary tract tumors.

Preoperative C-reactive protein as a prognostic factor for recurrence after surgical resection of biliary tract cancer

Purpose: C-reactive protein (CRP) has been identified to be associated with cancer development and progression. However, the role of CRP in tumor recurrence is less well defined in biliary tract cancer. Therefore, the aim of this study was to determine the clinical importance of CRP in terms of recurrence of biliary tract cancer after surgical resection. Methods: Sevent-six patients who underwent curative resection for biliary tract cancer from April 2006 to July 2014 were reviewed. Demographics and tumor characteristics were evaluated retrospectively by review of a clinical database and review of pathologic reports. Results: The study group was comprised of 48 men and 28 women, with a mean age of 62.2±10.8 years. Clinical diagnoses of these patients included intrahepatic cholangiocarcinoma (n=6), hilar cholangiocarcinoma (n=13), extrahepatic cholangiocarcinoma (n=21), gall bladder cancer (n=11), and ampullary cancer (n=25). Median follow-up was 35 months. Recurrence-free survival at 1-, 2-, and 5-year was 89%, 76%, and 53%, respectively. On univariate analysis, high CRP level (>3.0 mg/dL) was a significant risk factors for recurrence. Multivariate analysis showed high CRP, poor tumor differentiation, vascular invasion were independent risk factor for tumor recurrence. Conclusion: Preoperative CRP level is significantly associated with recurrence in patients with biliary tract cancer, suggesting the possibility of using CRP as an independent prognostic indicator for biliary cancer. Keywords: Biliary tract neoplasms, C-reactive protein, Recurrence

Unusual presentation of a distal cholangiocarcinoma

We report a case of a 51-year-old male presented with abdominal pain and itching, whereas jaundice occurred afterwards. Diagnosis was made by means of CT and better assessed by MRI and endoscopic ultrasounds. Patient was treated with an open Whipple's procedure, and after an 18-month follow-up he was doing well.

Clinical and pathological features of intraductal papillary neoplasm of the biliary tract and gallbladder

BackgroundIntraductal papillary neoplasms of the biliary tract (IPNB) and intracholecystic papillary neoplasms (ICPN) are rare tumours characterized by intraluminal papillary growth that can be associated with invasive carcinoma. Their natural history remains poorly understood. This study examines clinicopathological features and outcomes. MethodsPatients who underwent surgery for IPNB/ICPN (2008–2014) were identified. Descriptive statistics and survival data were generated. ResultsOf 23 patients with IPNB/ICPN, 10 were male, and the mean age was 68 years. The most common presentations were abdominal pain (n = 10) and jaundice (n = 9). Tumour locations were: intrahepatic (n = 5), hilar (n = 3), the extrahepatic bile duct (n = 8) and the gallbladder (n = 7). Invasive cancer was found in 20/23 patients. Epithelial subtypes included pancreatobiliary (n = 15), intestinal (n = 7) and gastric (n = 1). The median follow‐up was 30 months. The 5‐year overall (OS) and disease‐free survivals (DFS) were 51% and 57%, respectively. Decreased OS (P = 0.09) and DFS (P = 0.05) were seen in patients with tumours expressing MUC1 on immunohistochemistry (IHC). ConclusionIPNB/ICPN are rare precursor lesions that can affect the entire biliary epithelium. At pathology, the majority of patients have invasive carcinoma, thus warranting a radical resection. Patients with tumours expressing MUC1 appear to have worse OS and DFSs.

Immunotherapy of biliary tract cancer

Biliary tract cancer (BTC) is one of the most aggressive malignancies with only 10% early-stage diagnosis rate. For advanced BTC, regimen of gemcitabine and cisplatin has been regarded as the first line standard combination, but the curative effect is still unsatisfied. Infiltration of immune cells and immune-related microenvironment can inhibit various types of cancers. In BTC, higher frequencies of tumor-infiltrating CD8+ cytotoxic T cells and CD4+ T cells are closely associated with favorable prognosis. These findings have provided the rationale for further development of immunotherapies as a novel treatment modality against BTC. Key words: Biliary tract neoplasms; Immunotherapy

Abstract 2603: Combination activity of the MEK inhibitor Pimasertib and the hypoxia-activated prodrug TH-302 in pancreatic and biliary tract tumor xenograft models

Abstract The efficacy and tolerability of the MEK inhibitor Pimasertib and the hypoxia-activated prodrug TH-302 combination were explored in pancreatic and biliary tract preclinical tumor xenograft models. These studies were based on the hypotheses that combination efficacy may occur by several possible mechanisms including inhibition of DNA repair or increase of hypoxia by Pimasertib, or by differential targeting of the oxic and hypoxic tumor compartments by Pimasertib and TH-302 respectively. Since Pimasertib and TH-302 had each been tested in separate clinical trials in pancreatic cancer with gemcitabine (NCT01016483 and NCT01144455 respectively), these data could provide the rationale for clinical testing of this novel combination in pancreatic cancer. The combination was also tested in biliary tract cancer models (cholangiocarcinoma and gall bladder) based on the reported sensitivity of these tumor types to MEK inhibitors, their hypoxic nature, and the prevalence and high unmet need of these indications, particularly in Asia. The results showed that in the MIA PaCa-2 human pancreatic xenograft model, combination efficacy was observed and found to be schedule dependent. The greatest combination efficacy occurred when Pimasertib was administered first, 2 hours prior to TH-302, suggesting a unique combination mechanism in cells when the MAPK signaling pathway is suppressed first. The combination was subsequently explored in 2 additional pancreatic models and a panel of biliary tract patient-derived xenograft (PDX) models. In 10 cholangiocarcinoma PDX models tested, 3 models were responders to Pimasertib monotherapy and 4 models converted from being a non-responder with either monotherapy to a responder with the Pimasertib TH-302 combination using the%TV (tumor volume) criteria, which is related to a clinical PR RECIST response. Combination effects were not observed in 2 additional pancreatic or 6 gall bladder models tested. Some models were highly sensitive to Pimasertib or TH-302 monotherapy, making combination effects difficult to observe. Biomarker analyses are ongoing to identify markers that could predict which tumors are the most sensitive to this combination therapy. Citation Format: Jianguo Ma, Sakeena Syed, Lindsey Crowley, Jamie Shaw, Janet Ogden, Brian Elenbaas, Samantha Goodstal. Combination activity of the MEK inhibitor Pimasertib and the hypoxia-activated prodrug TH-302 in pancreatic and biliary tract tumor xenograft models. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2603. doi:10.1158/1538-7445.AM2015-2603

Blood expression of matrix metalloproteinases 8 AND 9 and of their inducers S100A8 and S100A9 Supports diagnosis and prognosis of PDAC-associated diabetes mellitus

Abstract Background Based on the knowledge that matrix metalloproteinases (MMPs) and S100A8/A9 synergistically work in causing PDAC-associated type 2 diabetes mellitus (T2DM), we verified whether tissue and blood MMP8, MMP9, S100A8 and S100A9 expression might help in distinguishing PDAC among diabetics. Methods Relative quantification of MMP8, MMP9, S100A8 and S100A9 mRNA was performed in tissues obtained from 8 PDAC, 4 chronic pancreatitis (ChrPa), 4 non-PDAC tumors and in PBMCs obtained from 30 controls, 43 T2DM, 41 ChrPa, 91 PDAC and 33 pancreatic–biliary tract tumors. Results T2DM was observed in PDAC (66%), in pancreatic–biliary tract tumors (64%) and in ChrPa (70%). In diabetics, with or without PDAC, MMP9 tissue expression was increased (p Conclusions An increased expression of tissue and blood MMP9 reflects the presence of PDAC-associated diabetes mellitus. This finding fits with the hypothesized role of MMPs as part of the complex network linking cancer to diabetes.

Recent advances of human epidermal growth factor receptor 2/ neu in biliary tract carcinoma

Biliary tract carcinoma (BTC) is a common malignancy in human digestive system. The lethality of BTC is essentially attributed to the asymptomatic growth of BTC and the lack of effective diagnostic options. The disease is therefore usually detected at an advanced stage and lost the opportunity of surgical therapy. Conventional chemotherapy and radiation therapy have been notably ineffective against BTC. There is now a real and urgent need to focus on developing novel and potent therapeutic strategies against BTC. Human epidermal growth factor receptor 2/ neu (HER2/ neu) is a member of the ErbB receptor tyrosine kinase family. HER2/ neu is associated with tumor proliferation, invasion, and metastasis that would impact in a significant way on clinical outcome. HER/ neu may become a new therapy target of BTC. Key words: Biliary tract neoplasms, malignancy; Human epidermal growth factor receptor 2/ neu; Therapy

Lynch syndrome: five unanswered questions.

Lynch syndrome: five unanswered questions.

The Role of Multidetector Row Computed Tomography in Biliary Tract Malignancy

Early diagnosis of biliary tract tumors is important in accurate staging, to choose the best possible treatment and improve their prognosis. Multidetector row Computed Tomography is an ideal method to evaluate patients with suspected biliary tract obstruction and thereby biliary tract malignancy. Aims and Objective: To evaluate the accuracy of Multidetector row Computed Tomography (MDCT) in evaluation of level of obstruction and to study the imaging features of various causes of biliary tract malignancy. Material and Method: MDCT of 40 patients with clinically suspicion of biliary tract obstruction were prospectively reviewed and only malignant causes were included in the study. Final diagnosis was based on endoscopic retrograde cholangiopancreatography, surgical and histopathological diagnosis. The MDCT diagnosis and final diagnosis was compared for level and imaging features of malignant lesions. Results: The sensitivity, specificity, PPV, NPV and diagnostic accuracy of MDCT in determining the level of malignant obstruction is 100%, 83.33%, 97.77%, 100%, 98%, and cause of malignant obstruction is 97.73%, 83.33%, 97.72%, 83.33%, 96%. MDCT with its high sensitivity and specificity values plays an essential role in the diagnosis of malignant tumors of biliary tract and for the evaluation of therapeutic options. Conclusion: MDCT has a vital role to play in biliary tract malignancy with its high degree of accuracy in establishing the level of obstruction and in defining the imaging features of the malignant lesions.

Biliary tract intraductal papillary mucinous neoplasm: report of 19 cases.

To gain a better understanding of biliary tract intraductal papillary mucinous neoplasm (BT-IPMN). From January 2000 to December 2013, 19 cases of BT-IPMN were retrospectively identified from a total of 343 biliary tract tumors resected in our single institution. Demographic characteristics, clinical data, pathology, surgical strategies, and long-term follow-up were analyzed. The mean age of the 19 BT-IPMN cases was 53.8 years (range: 25-74 years). The most common symptom was abdominal pain (15/19; 78.9%), followed by jaundice (7/19; 36.8%). Cholangitis was associated with most (16/19; 84.2%) of the BT-IPMN cases. Macroscopically visible mucin was detected in all 19 patients, based on original surgical reports. The most common abnormal preoperative imaging findings for BT-IPMN were bile duct dilation (19/19; 100%) and intraluminal masses (10/19; 52.6%). Thirteen (68.4%) cases involved the intrahepatic bile duct and hilum. We performed left hepatectomy in 11/19 (57.9%), right hepatectomy in 2/19 (10.5%), bile duct resection in 4/19 (21.1%), and pancreatoduodenectomy in 1/19 (5.3%) patients. One (5.3%) patient was biopsied and received a choledochojejunostomy because of multiple tumors involving the right extrahepatic and left intrahepatic bile ducts. Histology showed malignancy in 10/19 (52.6%) patients. The overall median survival was 68 mo. The benign cases showed a non-significant trend towards improved survival compared to malignant cases (68 mo vs 48 mo, P = 0.347). The patient without tumor resection died of liver failure 22 mo after palliative surgery. BT-IPMN is a rare biliary entity. Complete resection of the tumor is associated with good survival, even in patients with malignant disease.