Malignant invasion of the portal bifurcation is of particular relevance and can be identified by PTC with some success [ 16 , 17 ]. Positron-emission computed tomography PET-CT may increasingly become important in the determination of local and distant disease spread [ 18 ]: a recent study demonstrated that high tracer uptake was a significant prognostic factor for overall survival in patients with BTC, and may therefore be a useful adjunct in guiding treatment strategies [ 19 ].
However, the current use of PET-CT remains limited by the large proportion of BTC patients that present with cholangitis, which renders interpretation of results difficult. Involvement of the hepatic artery or portal vein was previously considered a common contraindication to resection; however, many centres now advocate en bloc resection of vascular structures with vascular reconstruction [ 20 ].
Current contraindications to surgery include extension of the tumour to segmental bile ducts of both right and left liver lobes, and significant pre-existing lobar atrophy [ 11 ]. Up to one third of presenting patients are found to have lymph node, peritoneal or hepatic involvement upon radiological imaging [ 21 ]; however, staging laparoscopy may be crucial in assessment of disease extent, even in those patients assessed as resectable following extensive imaging review, as it can lead to identification of unresectability criteria in up to a third of patients [ 21 , 22 ].
Pre-Operative Optimisation Preoperative jaundice is an independent risk factor for poor post-operative outcome [ 23 ]; however, studies investigating the effects of pre-operative biliary drainage have shown that, although they are effective in reducing bilirubin levels [ 23 ], such techniques confer no significant effect upon post-operative morbidity and mortality rates [ 24 ].
Further, in patients with distal bile duct obstruction preoperative biliary drainage has been associated with increased rates of cholangitis and prolonged length of hospital stay [ 25 ]. However, drainage should still be considered in patients at high-risk of cholangitis and liver failure from unrelieved biliary obstruction [ 6 , 14 ]. However, the precise indications, approaches and types of embolic material to be used for portal vein embolisation, as well as the most optimal method of assessing the function of the future liver remnant, vary between centres and there are no randomised controlled trials to guide management [ 29 ].
Surgical Resection of BTC The precise nature and extent of surgery depends upon tumour location and spread. Intrahepatic tumours necessitate segmental liver resection; whereas, extrahepatic tumours affecting the common bile duct CBD require resection of the liver hilum, biliary tree and lymphatics, with additional partial hepatic resection if the bile duct confluence is also affected [ 30 ]. Hilar tumours often require concurrent resection of an affected caudate lobe. Thus, the necessity for aggressive procedures, to provide potentially curative outcomes, must be balanced by the fact that post-operative morbidity and mortality, including the risk of hepatic failure, increases with the size of resection [ 34 , 36 ].
A multitude of past series have demonstrated that the most significant factor leading to increased peri-operative morbidity and mortality is the undertaking of extended resection or vascular resection, as compared to wide local excision [ 26 , 37 — 39 ]. More recently, however, data suggests that all cause mortality between patients undergoing extended resection including portal vein resection and those without, may be similar [ 40 ], despite the fact that patients undergoing portal vein resection are likely to have more advanced tumours [ 20 ].
Independent prognostic factors for survival include early stage, R0 resection, well-differentiated tumour grade, the absence of multiple hepatic tumours, regional node disease or macroscopic portal vein invasion, and small tumour size [ 4 , 9 — 11 , 20 ]. Figure 4 Treatment pattern and 5-year relative survival rate of localized and regional SEER stage biliary tract cancer according to tumor location. Full size image Intrahepatic bile duct cancer Among 14, patients with localized and regional stage intrahepatic BD cancer, From period I to II, the proportion of patients undergoing surgical first course of treatment increased and that of patients receiving no active anti-cancer treatment decreased in the localized stage The overall 5YRS of the localized and regional stage intrahepatic BD cancer between and was Extrahepatic bile duct cancer Among 22, patients with localized and regional stage extrahepatic BD cancer, The overall 5YRS of the localized and regional stage extrahepatic BD cancer between and was Ampulla of Vater cancer Among 6, patients with localized and regional stage AoV cancer, From period I to II, the proportion of patients undergoing surgical first course of treatment increased and that of patients undergoing no active anti-cancer treatment decreased in the localized stage Discussion BTCs in various tumor locations share a number of characteristics, including pathophysiologic traits, use of surgical resection as a mainstay of potentially curative treatment, and dismal prognosis, especially in the advanced stages However, the results of studies on BTCs, in whole or in part, have been inconsistent regarding the inclusion of various tumor locations.
As shown in this study, each tumor location has a different SEER stage distribution and treatment pattern, resulting in distinct survival outcomes. Over time, the proportion of the localized and regional stage disease, including potentially resectable disease, increased in GB, extrahepatic BD, and AoV cancers, which led to increased surgical first course of treatment rate and 5YRS, except for intrahepatic BD cancer. In this study, the age-standardized incidence rate of all four tumor locations were higher than that of the SEER database, especially in GB 2.
Both databases revealed male predominance in intra- and extrahepatic BD cancer, and female predominance in GB cancer However, the incidence trends of intrahepatic BD cancer decreased and extrahepatic BD cancer remained stable in Korea, while intra- and extrahepatic BD cancer had increasing trends in the SEER database.
The increasing trend of intrahepatic BD cancer in the United States have been continuously reported 9 , 22 , 23 , Despite advances in adjuvant chemotherapy and radiation therapy 1 , 25 , the overall survival outcome of BTC has not improved dramatically. This discrepancy results from the fact that the registry data include all stages of disease originating from various tumor locations with or without cancer-directed treatment.
In this study, the 5YRS for each tumor location with the localized and regional stage disease receiving surgical first course of treatment, which may approximate resectable disease with or without lymph node metastasis, was in concordance with that of clinical studies after R0 resection for American Joint Committee on Cancer AJCC stage I—II patients 29 , 30 , 31 , For each tumor location and SEER stage, surgical first course of treatment resulted in better prognosis than non-surgical first course of treatment or no active anti-cancer treatment.
Consequently, a higher proportion of no active anti-cancer treatment was related to a larger difference in 5YRS between the overall regardless of first course of treatment and surgical first course of treatment groups. Therefore, it is crucial to reduce the proportion of patients who do not receive cancer-directed treatment to improve the overall survival rate of BTC in the population.
As shown in this study, patients in their 60 s and 70 s had a 1. Considering the aging society and that the median age of BTC patients is above 70 years, treatment guidelines adjusted for elderly patients are required to broaden the scope of patients actively receiving cancer-directed treatment On the other hand, based on social norms, it was assumed that female patients would be more likely to receive no active anti-cancer treatment; however, the likelihood of receiving no active anti-cancer treatment was increased in female patients only in extrahepatic BD cancer after adjusting for period and age in the localized and regional stage disease.
This study revealed that the no active anti-cancer treatment rate of BTC was Among the localized and regional stage BTC, the no active anti-cancer treatment rate was the highest in intrahepatic BD cancer Noticeably, the proportion of no active anti-cancer treatment was higher in the localized stage than in the regional stage in extrahepatic BD and AoV cancers. The majority of these cancers present with obstructive jaundice; therefore, biliary drainage is required before surgery or chemoradiotherapy, which can be maintained for several weeks to months.
In particular, planned liver resection in patients with perihilar cholangiocarcinoma require stricter biliary decompression. Consequently, prolonged stenting for biliary decompression may lead to overestimation of the no active anti-cancer treatment rate since the cancer registry does not report on the treatment information after the first four months of the initial diagnosis.
Therefore, the localized stage no active anti-cancer treatment group of intra- and extrahepatic BD cancer may have included patients with equivocal lymph node involvement who could have been classified as regional stage if they underwent surgery. This study has several limitations. First, the inability to match the SEER stage with the AJCC TNM stage remains one of the main drawbacks of cancer registry studies, which makes it difficult to extrapolate the clinical implications of the results.
Second, the lack of information on cancer-directed treatment administered later than four months after the initial diagnosis may have overestimated the proportion of patients receiving no active anti-cancer treatment, especially for those who had prolonged preoperative biliary drainage. Third, in addition to the lack of precise pathological staging, limited information on detailed treatment including operation name, chemotherapeutic agent, or immunotherapy made it impossible to recognize the intent curative or palliative or outcomes of various treatment modalities.
Future studies in collaboration with KCCR and National Health Insurance Claim Data would improve the clarity in treatment outcomes analysis and defining a group of patients who need to be monitored closely to reduce the proportion of patients with no active anti-cancer treatment, improving the overall survival outcomes of BTC. In summary, BTC has distinct epidemiological and clinical characteristics, treatment patterns, and prognosis according to tumor location.
For each tumor location, elderly patients had a higher risk of receiving no active anti-cancer treatment. Despite favorable prognosis after surgical first course of treatment, localized stages of intra- and extrahepatic BD cancer had a high proportion of patients receiving no active anti-cancer treatment, resulting in a poor overall 5YRS in the population.
In addition, addressing the survival gain in actively treated BTC patients should be emphasized.
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But while fraudulent credit-card purchases are reversible, bitcoin transactions are not. And since there is a finite number to be accounted for, there is less of a chance bitcoin or fractions of a bitcoin will go missing. A survey showed bitcoin users tend to be overwhelmingly white and male, but of varying incomes.
The people with the most bitcoins are more likely to be using it for illegal purposes, the survey suggested. Odd, since RH is OK in other states often banned. The percent change in trading volume for this asset compared to 7 days ago. News Corp is a global, diversified media and information services company focused on creating and distributing authoritative and engaging content and other products and services.
Markets Liquidity is estimated by a day running sum of transaction outputs in USD. Relative mining difficulty is defined as the ratio of the difficulty target on 9 January to the current difficulty target. Bitcoin wealth is highly concentrated, with 0. The first regulated bitcoin fund was established in Jersey in July and approved by the Jersey Financial Services Commission. Dish Network, a Fortune subscription TV provider, has been described as the first large company to accept bitcoin, in It takes control back from central authorities.
A hardware wallet peripheral which processes bitcoin payments without exposing any credentials to the computer. With any Bitcoin price change making news and keeping investors guessing. Create a chart for any currency pair in the world to see their currency history. These currency charts use live mid-market rates, are easy to use, and are very reliable. Our new digital magazine goes beyond the daily headlines to put crypto and blockchain developments in perspective.
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But there are no guarantees when it comes to investing in crypto. Other cryptocurrencies are also now strong investment options and the Shiba Inu-themed Dogecoin, whose symbol is DOGE, which was initially created as a joke, is now one of the best known tokens. This graph shows the conversion rate of 1 Bitcoin to 1 USD at the first of each month. There are also new regulations and policies that are constantly reshaping the market and causing drastic swings — and hype on social media.
The main reason for this was an increase in awareness of and capabilities for alternative coins. On Oct. Find out how much your bitcoins are worth, or compare prices, and check market cap. You can check the prices for Ethereum, Litecoin, Ripple, Dogecoin across all the top Indian exchanges here. Bitcoin set the stage for blockchain technology and decentralized finance. Time To Upgrade! Because of its size and complexity, downloading and verifying the entire blockchain is not suitable for all computing devices.
To check Bitcoin price live in the fiat currency of your choice, you can use Crypto. Sign Up NowGet this delivered to your inbox, and more info about our products and services. Is Bitcoin mining legal? Is Bitcoin Mining Legal? The legality of Bitcoin mining depends entirely on your geographic location. The concept of Bitcoin can threaten the dominance of fiat currencies and government control over the financial markets. For this reason, Bitcoin is completely illegal in certain places.
A cryptocurrency is a digital or virtual currency that uses cryptography and is difficult to counterfeit. Bitcoin is a digital or virtual currency created in that uses peer-to-peer technology to facilitate instant payments. Bitcoin was released in the aftermath of a financial crisis precipitated by the loosening of regulations in the derivatives market. In countries that accept it, you can buy groceries and clothes just as you would with the local currency.
Only bitcoin is entirely digital; no one is carrying actual bitcoins around in their pocket. These percentages show how much the exchange rate has fluctuated over the last 30 and day periods. These are the lowest points the exchange rate has been at in the last 30 and day periods. These are the highest points the exchange rate has been at in the last 30 and day periods.
Bitcoin Price Analysis Recently, there was a minor upside correction in bitcoin above the , level against the US Dollar. Finally, the price spiked towards ,, but it failed to gain momentum. Moreover, there was no proper close above , and the hourly simple moving average.
As a result, the price started a fresh decline below the , support. It even broke the , level and traded to a new monthly low at , Besides, the current price action is bearish, with an immediate resistance near the , level. The main resistance on the upside is near the , and , levels.
An intermediate resistance is near the , level, plus the Therefore, an upside break above the , and , levels is must for a decent recovery in bitcoin. The next key resistance is near the , level. If the price fails to recover above the , and , resistance levels, it could continue to decline.
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