New strategy for treatment of carcinoma of the hilar bile duct.

Surgical treatment for carcinoma of the hilar bile duct has been a challenging problem, because the five year survival rate is less than 5 per cent and the mean survival period is 17 to 24 months even in curatively resected instances. The prognostic factors of carcinoma of the hilar bile duct are remnant carcinoma at the bile duct stump and cancerous invasion into the lymphatics, veins, perineural spaces around the intrahepatic bile duct and caudate lobe of the liver. Based on these data, a new strategy for treatment of carcinoma of the hilar bile duct has been developed and applied clinically. The strategy consists of three procedures. The first is resection of the hilar bile duct with portajejunostomy; the second, specific anticancer therapy with mitomycin C (4 milligrams) adsorbed to the activated charcoal (MMC-CH) focused on the invasion of carcinoma to the periductal lymphatics, and third, intracavitary irradiation (32 to 40 gray) by 60Co using the remote after loading system (RALSTRON 20B, Shimazu Co. Ltd., Tokyo) through the bile duct focused on the periductal infiltration of the carcinoma and through the inferior vena cava focused on the caudate lobe of the liver. In this article, the operative procedures and theoretic background of the specific chemotherapy and irradiation are described. Seven patients have been treated using this regimen. Follow-up study ranged from seven to 38 months. All patients are alive, and five of seven are disease-free.