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Malikowski T, Levy MJ, Gleeson FC, Storm AC, Vargas EJ, Topazian MD, Abu Dayyeh BK, Iyer PG, Rajan E, Gores GJ, Roberts LR, Chandrasekhara V. Endoscopic Ultrasound/Fine Needle Aspiration Is Effective for Lymph Node Staging in Patients With Cholangiocarcinoma. Hepatology 2020; 72:940-948. [PMID: 31860935 DOI: 10.1002/hep.31077] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 12/09/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Presence of malignant regional lymph nodes (MRLNs) precludes curative oncological resection or liver transplantation for cholangiocarcinoma (CCA). Limited data support the utility of endoscopic ultrasound (EUS)/fine needle aspiration (FNA) for detection of MRLNs in extrahepatic CCA, but there are no data for its role in intrahepatic CCA (iCCA). The aim of this study is to evaluate the staging impact of EUS for CCA, including analysis by subtype. APPROACH AND RESULTS We identified consecutive patients with CCA who underwent EUS staging at a single tertiary care center from October 2014 to April 2018. Among this cohort, we abstracted clinical demographic, radiographical, procedural, cytopathological, and surgical data. STATA 15 software was used for comparative analysis calculations (StataCorp LP, College Station, TX). The study cohort included 157 patients; 24 (15%), 124 (79%), and 9 (6%) with intrahepatic, perihilar, and distal CCA, respectively. EUS was able to identify regional lymph nodes (RLNs) in a higher percentage of patients compared to cross-sectional imaging (86% vs. 47%; P < 0.001). FNA was performed in 133 (98.5%) patients with RLNs, with a median of three passes per node. EUS-FNA identified MRLN in 27 of 31 (87.1%) patients ultimately found to have MRLNs. For iCCA, EUS detected a higher percentage of RLN compared to cross-sectional imaging (83% vs. 50%; P = 0.048), with MRLNs identified in 4 (17%) patients. Among the entire cohort, identification of at least one MRLN by EUS was associated with lower median survival (353 vs. 1,050 days; P < 0.001) and increased risk of death (hazard ratio = 4.1; P < 0.001). CONCLUSIONS EUS-FNA is effective for identifying MRLN in patients with CCA, and should be routinely incorporated into staging of all CCA subtypes given the impact of MRLN on prognosis and management decisions.
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Affiliation(s)
- Thomas Malikowski
- Department of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | - Andrew C Storm
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | - Eric J Vargas
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
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Gao Y, Xu D, Wu YS, Chen D, Xiong W. Increasing negative lymph node count is independently associated with improved long-term survival in resectable perihilar cholangiocarcinomas. Medicine (Baltimore) 2019; 98:e14943. [PMID: 30985643 PMCID: PMC6485858 DOI: 10.1097/md.0000000000014943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
To evaluate the prognostic value of numbers of negative lymph nodes (NLNs) for patients with perihilar cholangiocarcinomas.The surveillance, epidemiology, and end results database was used to screen for patients with perihilar cholangiocarcinomas. Kaplan-Meier and Cox regression analyses were used for statistical evaluations. Subsequently, propensity score matching (PSM) was performed to confirm the results.A total of 938 patients with perihilar cholangiocarcinomas met the inclusion criteria. The cut-off number for the grouping of patients with different numbers of NLNs was 17. Both the univariate and multivariate survival analyses demonstrated that there was a significant improvement in terms of cancer-specific survival for patients with >17 NLNs, compared with patients with ≤17 NLNs. Then, the above results were confirmed via a PSM procedure. Additionally, the independent prognostic value of NLNs was evaluated in subgroup univariate and multivariate analyses of patients with stage I or stage II tumors.The numbers of NLNs were evaluated and determined to be important independent prognostic factors for the cancer-specific survival of patients with perihilar cholangiocarcinomas.
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Affiliation(s)
- Yunfeng Gao
- Department of Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan
- Department of Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Dong Xu
- Department of Vascular Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang
| | - Yu-Shen Wu
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics
| | - Duke Chen
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wanchun Xiong
- Department of Gynecology, Chengdu Second People's Hospital, Chengdu, Sichuan
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Lin H, Wu YS, Li Z, Jiang Y. Prognostic value of retrieved lymph node counts in patients with node-negative perihilar cholangiocarcinomas. ANZ J Surg 2018; 88:E829-E834. [PMID: 30207026 DOI: 10.1111/ans.14775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/10/2018] [Accepted: 06/21/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND This study aimed to find out the prognostic value and optimal cut-off value of retrieved lymph node (LN) counts in patients with node-negative perihilar cholangiocarcinomas. METHODS The Surveillance, Epidemiology and End Results (SEER) database was used to screen out patients with perihilar cholangiocarcinoma. The cut-off number of retrieved LNs was determined by the X-tile programme. Kaplan-Meier methods with log-rank tests and Cox regression analysis were used for survival analysis. RESULTS A total of 778 patients with perihilar cholangiocarcinoma (2004-2014) met the inclusion criteria for this research, and there were 403 patients without LN metastases (N0) among them. The cut-off numbers of retrieved LNs, which were determined using the X-tile programme, were 8 and 18. Both results of univariate and multivariate survival analyses in N0 patients showed that patients with ≥18 retrieved LNs had a significantly better survival rate than patients with 1-7 retrieved LNs and patients with 8-17 retrieved LNs. In the subgroup of patients with early-stage tumours, patients with at least 13 retrieved LNs had a significantly better overall and cancer-specific survival than patients with fewer retrieved LNs. CONCLUSIONS The retrieved LN counts are an independent prognostic factor for patients with node-negative perihilar cholangiocarcinoma. Patients with at least 18 retrieved LNs had a better overall and cancer-specific survival than patients with fewer retrieved LNs. The minimum requirement for retrieving of LNs should reach 18 in perihilar cholangiocarcinoma.
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Affiliation(s)
- Huapeng Lin
- Department of Hepatobiliary Surgery, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu-Shen Wu
- Department of Oncology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhongyi Li
- Department of Obstetrics and Gynecology, First Clinical Medical College of Jinan University, Guangzhou, China
| | - Yicheng Jiang
- Department of Oncology, People's Hospital of Chongqing Hechuan, Chongqing, China
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Abd ElWahab M, El Nakeeb A, El Hanafy E, Sultan AM, Elghawalby A, Askr W, Ali M, Abd El Gawad M, Salah T. Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors. World J Gastrointest Surg 2016; 8:436-443. [PMID: 27358676 PMCID: PMC4919711 DOI: 10.4240/wjgs.v8.i6.436] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/26/2016] [Accepted: 04/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine predictors of long term survival after resection of hilar cholangiocarcinoma (HC) by comparing patients surviving > 5 years with those who survived < 5 years.
METHODS: This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center, Mansoura University, Egypt between January 2002 and April 2013. All data of the patients were collected from the medical records. Patients were divided into two groups according to their survival: Patients surviving less than 5 years and those who survived > 5 years.
RESULTS: There were 34 (14%) long term survivors (5 year survivors) among the 243 patients. Five-year survivors were younger at diagnosis than those surviving less than 5 years (mean age, 50.47 ± 4.45 vs 54.59 ± 4.98, P = 0.001). Gender, clinical presentation, preoperative drainage, preoperative serum bilirubin, albumin and serum glutamic-pyruvic transaminase were similar between the two groups. The level of CA 19-9 was significantly higher in patients surviving < 5 years (395.71 ± 31.43 vs 254.06 ± 42.19, P = 0.0001). Univariate analysis demonstrated nine variables to be significantly associated with survival > 5 year, including young age (P = 0.001), serum CA19-9 (P = 0.0001), non-cirrhotic liver (P = 0.02), major hepatic resection (P = 0.001), caudate lobe resection (P = 0.006), well differentiated tumour (P = 0.03), lymph node status (0.008), R0 resection margin (P = 0.0001) and early postoperative liver cell failure (P = 0.02).
CONCLUSION: Liver status, resection of caudate lobe, lymph node status, R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.
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Gomez D, Patel P, Lacasia-Purroy C, Byrne C, Sturgess R, Palmer D, Fenwick S, Poston G, Malik H. Impact of specialized multi-disciplinary approach and an integrated pathway on outcomes in hilar cholangiocarcinoma. Eur J Surg Oncol 2014; 40:77-84. [DOI: 10.1016/j.ejso.2013.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 09/21/2013] [Accepted: 10/13/2013] [Indexed: 02/07/2023] Open
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Abstract
PURPOSE OF REVIEW Cholangiocarcinoma is a malignancy arising from biliary tract epithelium that is increasing in incidence and is associated with a poor prognosis. The difficulty in diagnosis and relatively poor staging accuracy complicate management. In this review we examine the utility of endoscopic ultrasound (EUS), which is increasingly used in this setting to overcome the limitations of other imaging and biopsy techniques. RECENT FINDINGS Inherent limitations of current approaches to cholangiocarcinoma diagnosis and staging have driven the pursuit of new technologies including EUS. However, there remains a relative paucity of data and some uncertainty as to the role of EUS within the diagnostic algorithm for patients with suspected or known cholangiocarcinoma. In addition, there is controversy regarding the role of EUS fine-needle aspiration, the findings of which may enhance diagnosis, but may also predispose to tumor seeding and iatrogenic upstaging. SUMMARY An emerging indication for EUS is the diagnosis and staging of cholangiocarcinoma. This information may be used to help guide patient care and improve outcomes, but may also be employed in a manner that risks patient well being.
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Guglielmi A, Ruzzenente A, Campagnaro T, Pachera S, Valdegamberi A, Capelli P, Pedica F, Nicoli P, Conci S, Iacono C. Does intrahepatic cholangiocarcinoma have better prognosis compared to perihilar cholangiocarcinoma? J Surg Oncol 2010; 101:111-115. [PMID: 19953578 DOI: 10.1002/jso.21452] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Cholangiocarcinoma can be classified as intrahepatic (ICC) or perihilar (PCC). The objectives of this study is to evaluate the surgical outcomes of patients with PCC and ICC, identify the main prognostic factors related to survival and compare the outcome and the prognostic factors of PCC and ICC. METHODS Ninety-five out of 152 patients observed between January 1990 and December 2007 at Surgical Division of University of Verona Medical School underwent the resection of ICC (33 patients) or PCC (62 patients). RESULTS Overall median survival was 24 months with a 3- and 5-year survival rate of 45% and 23%, respectively. Prognostic factors for survival were macroscopic types of the tumor, the resection of extrahepatic bile duct, radical resection, lymph node metastases, and macro-vascular invasion. Survival was related with the macroscopic type of the tumors with a 5-year survival rate of 26% and 13% for ICC and PCC, respectively. Univariate analysis identified that negative clinico-pathological factors where significant more frequently found in PCC compared to ICC. CONCLUSION We identified that ICC have longer survival rate compared to PCC. PCC showed a higher frequency of negative clinico-pathological factors such as non-radical (R+) resection, perineural infiltration and macro-vascular invasion.
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Affiliation(s)
- Alfredo Guglielmi
- Division of General Surgery A, Department of Surgery, University of Verona Medical School, 37134 Verona, Italy.
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Ojima H, Kanai Y, Iwasaki M, Hiraoka N, Shimada K, Sano T, Sakamoto Y, Esaki M, Kosuge T, Sakamoto M, Hirohashi S. Intraductal carcinoma component as a favorable prognostic factor in biliary tract carcinoma. Cancer Sci 2009; 100:62-70. [PMID: 19038006 PMCID: PMC11159250 DOI: 10.1111/j.1349-7006.2008.01009.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2008] [Revised: 09/09/2008] [Accepted: 09/16/2008] [Indexed: 11/29/2022] Open
Abstract
The aim of this study is to evaluate the prognostic impact of an intraductal carcinoma component and bile duct resection margin status in patients with biliary tract carcinoma. An intraductal carcinoma component was defined as carcinoma within the bile duct outside the main tumor nodule consisting of a subepithelial invasive component. Surgically resected materials from 214 patients were evaluated by histological observations. Seventy-nine patients (36.9%) with an intraductal carcinoma component infrequently developed large tumors and infrequently showed deep invasion and venous, lymphatic and perineural involvement in the main tumor nodule. An intraductal carcinoma component was inversely correlated with advanced clinical stage, and was shown to be a significantly favorable prognostic factor by both univariate and multivariate analyses. Proximal (hepatic) side bile duct resection margin status was categorized into negative for tumor cells, positive with only an intraductal carcinoma component [R1 (is)], and positive with a subepithelial invasive component (R1). Forty-five patients (21.0%) with an R1 resection margin had a poorer prognosis than 148 patients (69.2%) with a negative resection margin, whereas 21 patients (9.8%) with an R1 (is) resection margin did not. In patients with an R1 resection margin, the risk of anastomotic recurrence was higher, and the period until anastomotic recurrence was shorter, than in patients with an R1 (is) resection margin. Surgeons should not be persistent in trying to achieve a negative surgical margin when the intraoperative frozen section diagnosis is R1 (is), and can choose a safe surgical procedure to avoid postoperative complications.
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Affiliation(s)
- Hidenori Ojima
- Pathology Division, National Cancer Center Research Institute, Tokyo, Japan
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EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma. Gastrointest Endosc 2008; 67:438-43. [PMID: 18061597 DOI: 10.1016/j.gie.2007.07.018] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Accepted: 07/09/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The clinical impact of EUS-guided FNA (EUS-FNA) in regional lymph-node staging in patients with unresectable hilar cholangiocarcinoma before liver transplantation has yet to be determined. OBJECTIVES To determine the frequency of regional lymph-node detection, identify EUS features predictive of benign or malignant lymph nodes, compare EUS lymph-node detection rates to CT/magnetic resonance imaging and exploratory laparotomy, and evaluate the impact of EUS-FNA on patient selection for liver transplantation. DESIGN Retrospective case series. SETTING Tertiary referral EUS unit. PATIENTS Clinical, radiographic, EUS, cytologic, and surgical data of 47 patients with unresectable hilar cholangiocarcinoma before liver transplantation were evaluated. INTERVENTIONS EUS-FNA. MAIN OUTCOME MEASUREMENTS Lymph-node morphology and echo features. RESULTS EUS identified lymph nodes in all patients. FNA of 70 lymph nodes identified metastases in 9 nodes of 8 patients (17%), who were then precluded from transplantation before a staging laparotomy. Identified lymph nodes, irrespective of malignant involvement, were typically oval and geographic in shape, of mixed echogenicity, with a hypoechoic border. There were no morphologic criteria or echo features to correlate with nodal malignancy. The EUS finding of absent regional lymph-node metastases was confirmed in 20 of 22 by a subsequent exploratory staging laparotomy. LIMITATIONS Single institution, retrospective analysis. CONCLUSIONS EUS identified lymph nodes in all patients, and confirmation of malignant lymph nodes detected by FNA precluded 17% of patients from transplantation. EUS-FNA of visualized lymph nodes irrespective of appearance is advised because morphology and echo features do not predict malignant involvement.
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Kolb A, Kleeff J, Friess H, Büchler MW. [The effect of R1 resection in the hepatobiliary pancreatic system]. Chirurg 2008; 78:802-9. [PMID: 17680231 DOI: 10.1007/s00104-007-1377-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Macroscopic and microscopic complete resection, i.e. R0 resection, is a basic principle of oncologic hepatopancreatobiliary (HPB) surgery. The reported R1 rates for different HPB tumor entities vary considerably, most likely because of ambiguities in the exact definition of R1 resection and the lack of standardized histopathologic examination and reporting. R1 resections can be interpreted as technical/surgical failure (e.g. for small, peripherally located liver tumors). In most cases, however, R1 resections are determined by the anatomic location of the tumor and the growth pattern (e.g. pancreatic cancer with perineural invasion). R0 resections have been identified as positive predictive markers for several HPB tumors (in comparison to R1 resection). Therefore HPB surgeons should always aim at macroscopic and microscopic complete resections. Nonetheless, R1 resections often provide an advantage over no resection with respect to survival and quality of life in patients with these tumors.
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Affiliation(s)
- A Kolb
- Chirurgische Klinik, Universität Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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11
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Lang H. Erweiterte multimodale Leberresektionen bei primären und sekundären Lebertumoren. Visc Med 2007. [DOI: 10.1159/000109996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Connor S, Barron E, Redhead DN, Ireland H, Madhavan KK, Parks RW, Garden OJ. Palliation for suspected unresectable hilar cholangiocarcinoma. Eur J Surg Oncol 2007; 33:341-5. [PMID: 17175127 DOI: 10.1016/j.ejso.2006.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Accepted: 11/08/2006] [Indexed: 11/23/2022] Open
Abstract
AIM The aim of this study was to evaluate the outcome of different techniques of palliation for patients with hilar cholangiocarcinoma. METHOD All patients treated with palliative intent between 1988 and 2004 at the Royal Infirmary of Edinburgh were reviewed. Patients were analysed on an intention to treat basis. Demographics, procedure and outcome (including re-admissions) were recorded. RESULTS Two hundred and thirty-three patients underwent palliative treatment for suspected hilar cholangiocarcinoma. The diagnosis was confirmed histologically in 109 patients. The procedure related morbidity and mortality was 54/225 and 18/207 respectively. Seventy-one patients required re-admission. Twenty patients underwent surgical biliary bypass for jaundice. Those undergoing surgical palliation had a longer median (95% CI) time to re-admission (16 (0-36) vs.7 (2-12) weeks, p=0.001). Endoscopic retrograde cholangio-pancreatography (ERCP) and stenting was only successful in 28 patients and was associated with a significantly higher re-admission rate compared to patients in whom ERCP was not performed (60/179 vs. 4/27, p=0.050). The overall median (95% CI) survival was 145 (124-185) days. CONCLUSION Current options for palliation of hilar cholangiocarcinoma provide good short term success but are all associated with significant early and late morbidity. Due to its low success and association with an increased re-admission rate, ERCP for definitive palliation should not be used in the first line staging and management of these patients.
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Affiliation(s)
- S Connor
- Department of Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary, Edinburgh EH16 4SA, UK
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Abstract
Hilar cholangiocarcinoma is a rare tumor. Surgery remains the only treatment to prolong survival. There is a correlation between the extent of diagnostic work-up and the achieved resection rates. Moreover, diagnostic work-up may contribute to an improvement of the surgical technique. Due to the perihilar fibrosis, the extent of the central lesion may be overestimated, which may lead to exclude the patient from potentially curative surgery. En bloc resection is requested to achieve tumor-free resection margins. The prognosis of the patients treated with surgery is strongly influenced by negative resection margins. According to our experience, 5-year survival of 78/111 patients with tumor resection (resection rate 71%) has been 30%. Forty-eight percent of the patients with curative en bloc resection of tumor and liver survived for more than 5 years. Perioperative mortality was 5.1%. The available data are supposed to reflect the results of centers with high caseload and not the general situation.
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Affiliation(s)
- Gerd Otto
- Department of Transplantation and Hepatobiliopancreatic Surgery, Johannes Gutenberg University Mainz, Langenbeckst. 1, 55101 Mainz, Germany.
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Connor S, Wigmore SJ, Madhavan KK, Parks RW, Garden OJ. Surgical palliation for unresectable hilar cholangiocarcinoma. HPB (Oxford) 2005; 7:273-7. [PMID: 18333206 PMCID: PMC2043105 DOI: 10.1080/13651820500372442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The majority of patients who present with hilar cholangiocarcinoma will have incurable disease and require only palliation. Efficient relief of disabling symptoms is required with minimal morbidity and mortality and can be achieved by either surgical or non-operative options. A review of the indications, anatomical considerations and surgical techniques is presented. Segment III cholangio-jejunostomy is the most frequently used surgical bypass procedure and in those patients with an expected survival of more than 6 months, surgical palliation offers good quality and long-lasting palliation. There is a need for randomized controlled data to define the optimal role of surgical palliation in this difficult disease.
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Affiliation(s)
- S. Connor
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - S. J. Wigmore
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - K. K. Madhavan
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - R. W. Parks
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
| | - O. J. Garden
- Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal InfirmaryEdinburgh EH 16 4SAUK
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Lafrenière R. What’s new in general surgery: surgical oncology. J Am Coll Surg 2004; 198:966-88. [PMID: 15194080 DOI: 10.1016/j.jamcollsurg.2004.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2004] [Accepted: 03/05/2004] [Indexed: 10/26/2022]
Affiliation(s)
- Rene Lafrenière
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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