1. For patients with multifocal intrahepatic cholangiocarcinoma (iCCA), floxuridine chemotherapy delivered through a hepatic arterial infusion pump (HAIP) was associated with lower 30-day postoperative mortality compared to surgical resection, and similar overall survival outcomes.
Evidence Rating Level: 2 (Good)
Intrahepatic cholangiocarcinoma (iCCA) often presents multifocally when diagnosed, and is therefore associated with poor prognosis. Resection is indicated only in limited multifocal disease, and so palliative chemotherapy is used in most cases. One way to deliver chemotherapy to the liver is through a hepatic arterial infusion pump (HAIP): It minimizes systemic toxicity due to the chemotherapy being metabolized by the liver after passing through the hepatic artery. The current study determined the overall survival (OS) of patients managed with HAIP floxuridine, the most effective chemotherapy treatment, compared to surgical resection. Only patients with multiple iCCA lesions were included, and patients receiving HAIP floxuridine were those considered to have unresectable iCCA. Overall, the study found no differences in median OS between either group, but postoperative mortality was significantly higher in the resection group, suggesting that both treatments have similar survival outcomes, but with resection having a higher risk for complications.
In-Depth [retrospective cohort]: The study population consisted of 141 HAIP floxuridine patients from a single centre in the USA, and 178 resection patients from 12 centres in the USA, Asia, Australia, and Europe. The HAIP cohort had a greater incidence of bilobar disease (88.0% vs 34.3%), larger tumour size (median [IQR] 8.4 [5.9-11.3] cm vs 7.0 [5.0-9.5] cm), and more patients with ≥4 lesions (66.7% vs 24.2%). The study showed that patients in the HAIP group had a significantly lower 30-day postoperative mortality, at 0.8% (95% CI 0.0-2.1%) compared to 6.2% (95% CI 2.3-9.7%, p = 0.01) in the resection group. The median OS for HAIP patients was higher, but not significantly, at 20.3 months compared to 18.9 months for resection (p = 0.32). Additionally, 5-year OS for the HAIP group was 12.5% (95% CI 7.4-21.1%) compared to 20.7% (95% CI 14.4-29.7%). After adjusting for factors that decreased OS, namely tumour diameter, lymph node metastases, and number of lesions, the hazards ratio for HAIP vs resection was 0.75 (95% CI 0.55-1.03, p = 0.07). Overall, this study demonstrated that HAIP is associated with lower postoperative mortality than surgical resection for multifocal iCCA, and that both treatments have comparable survival outcomes, despite HAIP patients in this cohort having a higher proportion of factors associated with lower OS.
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