Clinical commentaryCholangiocarcinoma with spinal metastasis: Single center survival analysis
Introduction
Cholangiocarcinoma (CCA) is an epithelial cell malignancy arising from various locations within the biliary tree, presenting the marker for cholangiocyte differentiation [1]. CCA tends to progress locally and regionally by spreading through the lymphatic system with metastases through the venous and lymphatic systems [2], [3], [4], [5]. The incidence of CCA varies worldwide and the highest incidence is in Khon Kaen province, Thailand, where the incidence is 44.3 and 17.6 per 100,000 males and females, respectively [6]. A definite diagnosis of CCA is based on pathological examination; however, in general practice, diagnosis of CCA is usually based on clinical signs and symptoms with corroborative radiographic imaging (CT and MRI) [6].
The spine is the most commonly affected musculoskeletal metastasis [2], [7], [8], while the most commonly identified primary sites of metastases are the lungs, breasts, prostate, kidneys, and the hematopoietic system [2], [3], [9]. We recently reported that CCA was the second most common primary site metastasizing to the spine [2].
In a recent review of CCA with spinal metastases, Goodwin et al. [2] identified 16 CCA patients with spinal metastases. Most of the patients had multiple levels of spinal metastases at diagnosis. The median survival time was very poor (1.5 months after diagnosis) of the primary and/or spinal metastases. This is poorer than the median survival time of 4 months for primary CCA regardless of any treatment interventions [2], [10], [11], [12].
Our institute—Khon Kaen University Hospital—is a tertiary hospital and referral center centrally located in northeastern Thailand. This region is endemic for CCA. For example, our hospital had 661 new CCA patients diagnosed between 2008 and 2009 [6], [13]. Notwithstanding, survival analysis of CCA patients with spinal metastases is not well understood due to the relatively small number of patients.
The aim of this study was (a) to investigate median survival time of CCA patients with spinal metastases and (b) to compare survival outcomes between the various treatment modalities employed at Srinagarind Hospital for spinal metastasis.
Section snippets
Study design
Single center, retrospective study.
Selection of patients and grouping
We retrospectively reviewed 176 patients with a diagnosis of spinal metastases of CCA who received treatment in the Department of Orthopaedics between January 1993 and December 2013. The inclusion criteria were: (a) a diagnosis of CCA by clinical and imaging study with or without tissue diagnosis either from (i) an incisional or excisional biopsy at the primary tumor site or (ii) biopsy from the metastases site; (b) clear metastatic spinal lesions diagnosed by
Results
The demographic data are presented in Table 1. CCA with spinal metastases occurred predominately in males (61.8%). Most had incomplete cord lesions and more than two-thirds had two or more than two levels spinal metastases. The most commonly affected region was the thoracic spine followed by the lumbar spine. The mean Kanofsky functional score was intermediate (50.18 ± 22.65). One-third (29.1%) presented with associated appendicular bone metastases. Only 4 patients received CCA resection surgery
Discussion
CCA is an aggressive carcinoma arising in the biliary system with a generally poor prognosis because of late presentation and metastases. CCA is endemic in Khon Kaen province, Thailand [13], [16], [17]. Luvira et al. [6] reported 163 newly diagnosed cases of CCA within the 3 months of their survey, mostly diagnosed by CT or MRI/MRCP, with only 8.6% confirmed by a pathology report. Until recently, the prevalence of CCA with spinal metastases has been limited. A systematic review performed by
Conclusion
CCA is an aggressive and rare non-hepatocellular carcinoma, originating from the biliary system. Khon Kaen, Thailand is an endemic area for the disease. CCA with spinal metastases has a poor median survival time (4 months). Significantly longer median survival time was associated with: one affected spinal level; no appendicular skeletal metastasis; Frankel scale of C or better; a moderate to high Kanofsky score; and, radiation therapy. Further studies are needed on prognostic factors in CCA with
Conflict of interest
None of the authors have any conflict of interest to declare. All are medical practitioners, lecturers and researchers at the Department of Orthopedics, Faculty of Medicine, Khon Kaen University.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by our university ethical committee board. The ethical reference number is HE571095.
Acknowledgements
This study was granted by Faculty of medicine, Khon Kaen University, Thailand. The authors thank (a) the Hospital Records Division for their assistance and (b) Mr. Bryan Roderick Hamman for assistance with the English-language presentation of manuscript through the Publication Clinic, Research Affairs, Faculty of Medicine, Khon Kaen University.
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Pawalee Dowsiriroj and Permsak Paholpak are co-first authors and they contributed equally to this paper.