Risk factors predicting cervical spine fracture on CT in craniocervical trauma - retrospective study.

INTRODUCTION: The study identifies risk factors predicting cervical spine fracture on CT based on information in the referral form. METHODS: All patients aged over 18 years with a CT scan of the head and cervical spine completed at the University Hospital Brno in the year 2019 to exclude any fresh trauma were included in the retrospective study. The analyzed potential risk factors included gender, age over 65 years, unconsciousness or impaired consciousness, mechanism of injury, paresthesia or plegia suspected to be associated with trauma, cervical spine pain, other neurological symptomatology, presence of cervical collar, presence of intracranial hemorrhage on head CT, and presence of skull fracture on head CT. RESULTS: In total, a cervical or upper thoracic spine fracture was described in 51 of 1177 patients (4.3%). Statistically significant risk factors for cervical spine fracture on CT scan were identified as mechanism of injury similar to car accident or jumping into water (OR 2.52; p=0.004), pain of the cervical spine (OR 1.81; p.

Biomarkers as prognostic and predictive factors in patients with hepatocellular carcinoma undergoing radiological oncological interventions.

BACKGROUND: Hepatocellular carcinoma is the most common malignant liver tumor in adults and thermal ablation and transarterial embolization are important methods of therapy. Thermal ablation can be used in early stages. Methods based on the transarterial approach, especially transarterial chemoembolization, play an important role in intermediate stage diseases. The success of procedures depends not only on the biological nature and the size of the tumor, on the technical design of the procedure and on the patient's response to treatment, but also on the molecular changes associated with these procedures. In addition to classic predictive and prognostic factors including age, patient comorbidities, Child-Pugh score, tumor characteristics, presence of large surrounding vessels, and portal vein thrombosis, molecular prognostic and predictive factors (serum biomarkers) are often mentioned in studies. Currently, only a-fetoprotein is routinely used as a prognostic biomarker; however, there are studies referring to new serum biomarkers that can potentially help to classical markers and imaging methods to determine the cancer prognosis and predict the success of therapy. These biomarkers most often include g-glutamyltranspeptidase, des- g-carboxyprothrombin, some types of microRNAs, inflammatory and hypoxic substances, whose serum levels are changed by the intervention therapies. Evaluation of these molecules could lead to the optimization of the medical intervention (choice of therapy method, timing of treatment) or change the management of patient follow-up after interventions. Although several biomarkers have shown promising results, most serum biomarkers still require validation in phase III studies. PURPOSE: The aim of this work is to present a comprehensive overview of classical and molecular biomarkers that could potentially help in the prognostic stratification of patients and better predict the success and effect of radiological intervention methods.

Experimental model of occluded biliary metal stent recanalization using irreversible electroporation via a tubular catheter.

PURPOSE: To demonstrate the feasibility of irreversible electroporation (IRE) for treating biliary metal stent occlusion in an experimental liver model. METHODS AND MATERIALS: IRE was performed using an expandable tubular IRE-catheter placed in nitinol stents in the porcine liver. A 3-electrode IRE-catheter was connected to an IRE-generator and one hundred 100µs pulses of constant voltage (300, 650, 1000, and 1300 V) were applied. Stent occlusion was simulated by insertion of liver tissue both ex vivo (n = 94) and in vivo in 3 pigs (n = 14). Three scenarios of the relationship between the stent, electrodes, and inserted tissue (double contact, single contact, and stent mesh contact) were studied. Electric current was measured and resistance and power calculated. Pigs were sacrificed 72 h post-procedure. Harvested samples (14 experimental, 13 controls) underwent histopathological analysis. RESULTS: IRE application was feasible at 300 and 650 V for the single and double contact setup in both ex vivo and in vivo studies. Significant differences in calculated resistance between double contact and single contact settings were observed (ex-vivo p ˂ 0.0001, in-vivo p = 0.02; Mann-Whitney). A mild temperature increase of the surrounding liver parenchyma was noted with increasing voltage (0.9-5.9 °C for 300-1000 V). The extent of necrotic changes in experimental samples in vivo correlated with the measured electric current (r2 = 0.39, p = 0.01). No complications were observed during or after the in-vivo procedure. CONCLUSION: Endoluminal IRE using an expandable tubular catheter in simulated metal stent occlusion is feasible. The relationship of active catheter electrodes to stent ingrowth tissue can be estimated based on resistance values.

Correlation of survival length after pancreaticoduodenectomy for pancreatic head adenocarcinoma depending on tumor characteristics detected by means of computed tomography and resection margins status.

Pancreatic carcinoma is an aggressive tumor with a grim prognosis. Accurate staging is essential for indicating surgery in patients with borderline resectable tumors. This paper examines the correlation between pre-operation characteristics of tumors found on CT, infiltration of individual resection margins as confirmed by a pathologist, and the survival of patients with resectable pancreatic head ductal adenocarcinoma. This prospective cohort study involved patients operated on for pancreatic head adenocarcinoma, which was clearly resectable based on the staging CT and intraoperative observation between 2011-2014. Only patients without postoperative complications who underwent adjuvant chemotherapy were analyzed. Seventy-nine patients were assessed, of which 16 (20.3%) had R0 resection and 63 (79.7%) had R1 resection. Patients with R1 results had up to 2.7 times higher risk of death than patients with R0 resection. We found a trend towards shorter survival associated with a closer relationship of the tumor to the superior mesenteric vein/portal vein (SMV/PV) wall in the pre-operation CT examination. Patients with a tumor interface between the vein wall of up to 180 ° circumference had up to 1.97 times higher risk of death than patients without (p=0.131). The results of our work confirmed that in our center, even surgically treated, clearly resectable pancreatic head tumors still have a high occurrence of positive surgical margins (R1 resection) and that tumors with R1 resection had statistically significantly reduced survival compared to R0 resection. A trend for shorter overall survival was found after tumor resection depending on the increasing interface between the tumor and the SMV/PV wall, but this result was not statistically significant.

Chemoembolization for Treatment of Hepatocellular Carcinoma - National Registry-Based Analysis.

BACKGROUND: To evaluate survival benefit in patient undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) by national registry data analysis and comparison of regions with unequal usage of interventional radiology procedures. MATERIALS AND METHODS: A total of 4,343 patients with primary diagnosis of HCC between 2010-2016 were extracted from the databases of The Czech National Cancer Registry. The analysis was supported by data from the National Registry of Paid Health Services and the Death Records Database. Primary treatment option was categorized as liver resection, ablation, TACE and chemotherapy. The regional data analysis provided information of interventional radiology procedures frequency for primary treatment of HCC. The 14 main regions were symmetrically divided to group with well-developed interventional radiology service and low-developed interventional radiology service according the frequency of stage adjusted interventional radiology procedure usage (< 15%, > 15%). Kaplan-Meier and Cox regression were used for survival and hazard ratios (HR) analyses. RESULTS: Only 1,730 patients had assessed any primary treatment option, 16.5 % (285) were treated by TACE. Median of survival were significantly different in regions with well and low developed interventional radiology service for whole study population (13.2 vs. 6.5 months, p < 0.001), patients treated in regions with well-developed interventional radiology service had lower risk of death during treatment (HR 0.73; 0.66-0.81). The patient treated by TACE had median of survival 15.8 months (13.5-18.1), while the survival was not significantly different in region groups. CONCLUSION: The usage of anticancer therapies based on interventional radiology procedures is a huge factor influences the survival of HCC patient according population-based data. Studies gathering data from cancer register databases can provide further information on treatment effectiveness. This work was created at Masaryk University in the project „Oncological radiological interventions and their benefit in complex oncological treatment, comparison of dedicated oncological treatment results data of the Czech republic II“ (MUNI/A/1574/2018), supported by Ministry of Education, Youth and Sports. This publication was additionally suported by Ministry of Health grant No. 15-32484A. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 1. 3. 2019 Accepted: 4. 3. 2019.

Dynamic Changes in Circulating MicroRNA Levels in Liver Cancer Patients Undergoing Thermal Ablation and Transarterial Chemoembolization.

BACKGROUND: Hepatic cancer patients who cannot undergo surgical resection of tumour are candidates for methods of interventional radiology - transarterial chemoembolization (TACE) or thermal ablative (TA) therapy. Both methods are causing characteristic changes in liver tissue (inflammatory immune response, hypoxia, elevated temperature, tissue destruction) which are accompanied with systemic secretion of cytokines or microRNAs (miRNAs). The aim of our study was to investigate whether the level of circulating miRNAs related to hypoxia (miR-21 and miR-210), liver injury (miR-122) and epithelial-mesenchymal transition (miR-200a) could reflect systemic effect of these intervention techniques. MATERIALS AND METHODS: Study consisted of 10 primary hepatocellular carcinoma patients treated with TACE and 10 patients with liver metastases of colorectal cancer treated with TA. Thermal ablation was performed using the radiofrequency or microwave generator (RITA, Microsulis, AngioDynamics,Inc), for TACE drug eluting beads (DCBeads, Biocompatibles Ltd.) were used. Tumours were evaluated using RECIST (Response Evaluation Criteria in Solid Tumours), mRECIST (modified RECIST) criterion and volumetry. For all patients we determined concentrations of miRNA in blood plasma samples from four time points (before intervention, immediately after intervention, 24 hours after intervention, 1 week after intervention) using TaqMan® Assays and quantitative real time polymerase chain reaction method. RESULTS: After both intervention techniques we observed changes in circulating miRNA levels. In TA cases we observed significant increase of miR-122 and miR-200a concentrations immediately after intervention, on the contrary in TACE we observed increase in miRNA concentration at time point 24 hours after intervention (miR-21, miR-210, miR-122, miR-200a). Increased concentration of circulating miRNA was followed by subsequent decline to initial level. These changes were consistent with presumed biological effect of TA and TACE on tumour tissue. CONCLUSION: Data of this pilot study show potential usage of circulating miRNA for monitoring of systemic effect of thermal ablative and intraarterial therapies. This work was created at Masaryk University as part of the project MUNI/A/1574/2018 and it was supported by Czech Ministry of Health grants No. 15-32484A, 16-31765A and 16-31314A. The authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 1. 3. 2019 Accepted: 4. 3. 2019.

Gastrointestinal Stromal Tumours of the Rectum - Evaluating the National Registry Data with Respect to its Use in Clinical Practice.

BACKGROUND: Gastrointestinal stromal tumours (GIST) are rare malignant mesenchymal tumours with an incidence of 1 in 100,000. They represent only 5% of gastrointestinal tumours. The GISTs are mainly located in the stomach (60-70%) and in the rectum in < 5% of cases. In the case of localized, resectable tumours, the treatment is surgical resection. Depending on the size and localization of the tumour in the rectum, either a local excision, rectal resection with anastomosis, or abdominoperitoneal amputation with permanent stoma can be performed. In contrast to carcinomas, the metastasis of GISTs into lymph nodes is rare; therefore, from an oncological point of view, lymphadenectomy in the form of mesorectal excision is not required. Neoadjuvant treatment using tyrosine-kinase inhibitors (TKI) is recommended for tumours larger than 5 cm and in case of tumours infiltrating surrounding organs or sphincters in order to achieve complete resectability, less mutilating and continent procedure. In GISTs with a positive resection line, re-resection can be attempted. Adjuvant TKI therapy can be considered in cases of CD117 positivity and after resections of GISTs with medium and high-risk malignant behaviour. The TKI treatment is also indicated in cases of unresectable and metastatic GISTs. METHODS: Data obtained from the GIST registry by the 1st January 2017, when 10 centres in the Czech Republic were contributing to the registry, were analysed. RESULTS: We analysed 1,095 patients out of which 45 (4.1%) had GIST localized in the rectum. The average age of the patients was 60 years. There were significantly more males (68.9%; p = 0.0007) and symptomatic patients (62.2%; p = 0.034). In total, 82% of the patients underwent surgery. Local excision was performed in 37.8%, resection of the rectum with anastomosis in 29.7%, and Miles operation in 29.7%. In the cohort, most tumours were 2-5 cm in size and almost half of the tumours presented a high risk of malignant behaviour. Systemic treatment was reported in 73% of patients. A complete remission was achieved in 80% of patients with GIST of the rectum. The median survival rate was 11.3 years and the 5-year survival rate is 90.6%. CONCLUSION: Despite the success of TKI treatment, the only potentially curative method of rectal GISTs is a surgical R0 resection. Given the relatively rare frequency of these tumours, proper diagnosis and treatment is demanding. Therefore, these patients should be preferably treated in specialised centres. This work was supported by grant MH CZ - RVO (FNBr, 65269705).  The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 19. 12. 2018 Accepted: 2. 2. 2019.

IgG4 Sclerosing Cholangitis - an Inflammation Imitating Tumour of the Pancreas and Biliary Tract.

BACKGROUND: Immunoglobulin (Ig) G4 associated sclerosing cholangitis is a rare inflammatory disease of the biliary tract. Although it is a very progressive condition, it responds to steroid therapy. IgG4 associated sclerosing cholangitis can mimic pancreatic carcinoma, cholangiocarcinoma, and primary sclerosing cholangitis; therefore, it is very important to obtain a differential diagnosis. IgG4 sclerosing cholangitis is a biliary form of IgG4 related systemic disease, in which afflictions of more organs is afflictions of more organs are common, typically biliary form together with pancreatic one. Nonspecific symptoms are obstructive icterus, fatigue, and weight loss. Atypical imaging of the biliary tree and pancreas can be used to distinguish it from other diseases. Laboratory data show elevation of bilirubin, liver enzymes, IgG4 and total IgG concentrations. Sometimes IgE is also elevated with the eosinophilia, oncomarker CA 19-9 and autoimmune antibody is sometimes detected. CASE: This article presents a case of IgG4 sclerosing cholangitis and its related findings. The patient was intially referred for suspected pancreatic tumour, the presumed diagnosis was later changed to cholangiocarcinoma type 4 with concurrent autoimmune pancreatitis. Atypical imaging in cholangiography made us suspect IgG4 inflammation and the diagnostic process began. CONCLUSION: The diagnosis of this disease uses so called HISORt criteria. It is a very complex process in which the success of steroid therapy as a final step can be conclusive, as it was in our case. It is essential to exclude a malign neoplastic growth. The authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 5. 12. 2018 Accepted: 10. 1. 2019.

The timing of ERCP in acute biliary pancreatitis.

Despite several studies, the role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in the case of acute biliary pancreatitis (ABP) remains a subject of discussion.There is a clear indication of early ERCP within 72 hours in patients with ABP andcholedochal obstruction, moreover the ERCP within 24 hours in cases of cholangitis. However, the role of ERCP in patients with ABP without symptoms of cholangitis or concrements obstructing the bile duct is controversial. If ABP is indicated for the ERCP, the earlier the ERCP is performed the less complications it is associated with. The decision to perform ERCP is often based on findings from a biochemical and transabdominal ultrasound examination. The results of these examinations may, but may not, confirm the presence of stones in the choledochus. An effective and safe method approaching the sensitivity of ERCP in the diagnosis of concrements in the choledochus is endoscopic ultrasonography (EUS) and magnetic resonance cho-langiopancreatography (MRCP). The cholecystectomy should be performed to prevent a recurrence of pancreatitis and biliary problems after the successfully treatment of ABP. Key words: acute biliary pancreatitis choledocholithiasis cholangitis endoscopic retrograde cholangiopancreatography.

Spontaneous retroperitoneal hematoma - our experience with surgical approach.

Spontaneous retroperitoneal hematoma is a serious complication of anticoagulation and antiplatelet therapy. Its incidence has increased in recent years due to an increasing number of patients on this treatment. A number of case series have been described in the literature. In the vast majority of cases, the hemodynamically stable patients were treated either conservatively or by selective radiological embolization of the bleeding source. A surgical approach is reported as a last choice in the cases where the conservative therapy fails, radiological intervention is unavailable, in patients with continuous bleeding or in patients who develop abdominal compartment syndrome. In our case report, we present a patient on anticoagulation therapy for deep venous thrombosis complicated by massive retroperitoneal bleeding: surgery was used as the method of first choice and the treatment was successful. Key words: retroperitoneal hematoma bleeding anticoagulation treatment surgery.

Radiofrequency ablation in pancreatic cancer.

INTRODUCTION: Clinical study evaluating the impact of intraoperative radiofrequency ablation in pancreatic cancer. METHODS: Patients with histologically proved pancreatic cancer were included. Two groups were defined. In the RFA group (n=24) intraoperative RFA of the pancreatic tumour was performed. In the control group (n=24) only the bypass procedure was indicated (gastroenteric and hepaticojejunal anastomosis). No patient received neoadjuvant chemotherapy. Three-month morbidity and mortality, overall survival, quality of life, pain relief and radiological response were studied. RESULTS: Overall three-month morbidity and mortality were 41.7% and 8.3%, respectively. RFA related morbidity and mortality reached 16.6% and 8.3%, respectively. The overall median survival time was 9.9 and 8.3 months in the RFA group and in the control group, respectively. The survival difference was not of statistical significance (p=0.758). QoL improvement after RFA was not proved. There was no statistically significant analgesic effect of RFA. Postoperative CT scan assessed as per RECIST criteria displayed progressive disease, stable disease, partial response and complete response in 41.6%, 45.8%, 8.3% and 0% cases, respectively. CONCLUSION: Intraoperative RFA of locally advanced and metastatic pancreatic cancer is a feasible palliative method. A survival benefit of this method remains doubtful, even though some positive results have been achieved in patients with localized, well-differentiated tumours. Although RFA was not associated with any impairment of the quality of life, no convincing evidence of a positive impact thereof on QoL was shown, either, during the three-month postoperative period. Pain relief was not achieved during the first 3 months after RFA.

[Gallbladder volvulus]. / Volvulus zlucníku.

INTRODUCTION: Volvulus of the gallbladder is one of very rare diseases ranked among acute abdomen conditions. Only case reports are described in the literature. The disease presents with acute biliary ailments, often reminiscent of acute cholecystitis. It is more common in frail elderly women and its preoperative diagnosis is very difficult, and therefore this finding is encountered intraoperatively in most cases. CASE REPORT: In our case report we present the case of a female patient where the volvulus of the gallbladder was found as a surprising discovery during surgery. CONCLUSION: Gallbladder volvulus is a rare disease that presents as acute abdomen. It is most often diagnosed intraoperatively. Cholecystectomy is the most appropriate therapeutic method.Key words: gallbladder volvulus - acute abdomen - floating gallbladder.

[Standardization of pancreatic cancer specimen pathological examination]. / Standardizace patologického vysetrení resekátu pankreatu.

INTRODUCTION: The frequency of R1 resections for pancreatic cancer in studies where a non-standardized protocol of pathological evaluation of the specimen is used varies from 17 to 30%. The aim of our study is to apply the standardized (so-called Leeds) protocol of resected pancreatic specimen pathological examination, and to evaluate the frequency of R1 resections for pancreatic cancer using this new protocol. MATERIAL AND METHODS: Ninety-one patients who underwent pancreatoduodenectomy for pancreatic cancer were included in the study. This group was divided into two subgroups: patients examined by the Leeds protocol (n=20) and those examined by a non-standardized pathological protocol (n=71). The R1 resection rate was evaluated separately in each group. The positivity rate of every individual resection margin was specified in the Leeds protocol group. The correlation of R1 resection rate and "tumour - resection margin distance" parameter was evaluated. The tumour infiltration of peripancreatic adipose tissue was assessed in the non-standardized group. RESULTS: In the Leeds protocol subgroup, R1 and R0 resection rate was 60% (12/20) and 40% (8/20), respectively. Resection line positivity rates were as follows: dorsal 45% (9/20), ventral 35% (7/20), VMS 20% (4/20), cervical 20% (4/20), AMS 15% (3/20). The correlation between the tumour - resection line distance and R1 resection frequency was the following: direct infiltration 30% R1, tumour-resection margin border 0.5 mm 50% R1, 1mm 60%, 1.5 mm 75% R1, 2 mm 80% R1, >2 mm 80% R1. If the criterion of resection line positivity ( 1mm) was set, the R1 resection rate difference between the two groups was of statistical significance. In the subgroup where the non-standardized protocol was used (n=71), R1 resection was recorded in 25 (35.2%) patients. The main cancer-positive areas were peripancreatic adipose tissue in 26.8% (19/71) of cases, and VMS, AMS or retroperitoneal line in 8.5% (6/71), respectively. R0 resection was achieved in 46 (64.8%) patients. The statistically significant (p=0.046) difference in R0 and R1 resection rates was detected (Leeds protocol and non-standardized one: R0 40.0% vs. 64.8% and R1 60.0% vs. 35.2%, respectively) in the studied groups. CONCLUSION: The rate of R1 resections for pancreatic cancer increased in all studies, including ours, where the standardized (Leeds) protocol of pancreatic specimen pathological examination was used. The higher R1 resection rate when using the Leeds protocol is approaching to the local recurrence rate of pancreatic cancer. Therefore, the Leeds protocol can provide more realistic evaluation of local radicality of pancreatoduodenectomy and can also offer more accurate evaluation of the surgical and adjuvant therapy of pancreatic cancer.

[Radiofrequency ablation of pancreatic neuroendocrine tumor]. / Radiofrekvencní ablace neuroendokrinního nádoru pankreatu.

BACKGROUNDS: Pancreatic neuroendocrine tumors (PNETs) include a broad range of neoplasms spanning from relatively benign to malignant. Radical resection has been advocated as the only curative method. Debulking (R2) resection can be indicated for locally unresectable PNETs. Debulking surgery improves the quality of life and prolongs overall survival. The disadvantages of this approach include bleeding, pancreatic fistula and tumor spread. No alternative method that would eliminate these complications has been published yet. Considering the encouraging results of the studies describing radiofrequency ablation (RFA) of locally advanced pancreatic cancer, a question arises, whether it might be possible to use RFA as a R2 resection alternative in PNETs. CASE: A 73-year-old gentleman had been admitted due to abdominal pain and hyperglycaemic syndrome. Contrast-enhanced CT showed a tumor of pancreatic head invading portal vein (PV) and superior mesenteric vein (VMS). A surgery was indicated on the basis of EUS-guided FNAB that verified a PNET of uncertain biological behaviour. The surgery confirmed a locally advanced tumor of pancreatic head invading the PV and SMV. Due to the polymorbidity, radical pancreatoduodenectomy with SMV resection was not indicated. Because of the presence of symptoms, RFA of the PNET using ValleyLab generator with cooltip cluster electrode, was performed. Postoperative course was uneventful. Final immunohistochemical examination verified a well-differentiated grade 1 PNET. The patient was regularly monitored during a three-year follow-up. The quality of life was evaluated using standardized EORT QLQ-30 questionnaire. Pain was assessed by a ten-point visual analogue scale (VAS). Ablated area was evaluated annually by contrast-enhanced CT. Postoperatively, abdominal pain ceased (pain decrease from 2 to 0 on VAS). Insulin dose was reduced from 46 IU (international units) to 20 IU of Humulin-R per day. CT verified tumor regression according to RECIST (response evaluation criteria in solid tumors). During the three-year follow-up, no local progression or tumor dissemination was observed. CONCLUSION: We present the first case report of a patient with locally advanced symptomatic pancreatic neuroendocrine tumor successfully treated by intraoperative radiofrequency ablation. More clinical studies are needed to evaluate the clinical relevance of this cytoreductive method in the PNET indication.

Bile duct malignancies.

Bile duct malignancies include intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), gall bladder carcinoma (GC) and carcinoma of Vater's ampulla (ampulloma). Bile duct neoplasms are rare tumours with overall poor prognosis. The overall incidence affects up to 12.5 per 100,000 persons in the Czech Republic. The mortality rate has risen recently to 9.5 per 100,000 persons. The incidence and mortality have been remarkably stable over the past 3 decades. The survival rate of patients with these tumours is poor, usually not exceeding 12 months. The diagnostic process is complex, uneasy and usually late. Most cases are diagnosed when unresectable, and palliative treatment is the main approach of medical care for these tumours. The treatment remains very challenging. New approaches have not brought much improvement in this field. Standards of palliative care are lacking and quality of life assessments are surprisingly not common. From the scarce data it seems, however, that multimodal individually tailored treatment can prolong patients'survival and improve the health-related quality of life. The care in specialized centres offers methods of surgery, interventional radiology, clinical oncology and high quality supportive care. These methods are discussed in the article in greater detail. Improvements in this field can be sought in new diagnostic methods and new procedures in surgery and interventional radiology. Understanding the tumour biology on the molecular level could shift the strategy to a more successful one, resulting in more cured patients. Further improvements in palliative care can be sought by defining new targets and new drug development. The lack of patients with bile duct neoplasms has been the limiting factor for any improvements. A new design of larger randomized international multicentric clinical trials with prompt data sharing could help to overcome this major problem. Defining standards of palliative care is a necessity. Addressing health-related quality of life could help to assess the real benefit of palliative treatment.