Radical resection of hilar bile duct carcinoma and predictors of survival

Time to Surgery Does Not Affect the Survival Outcome in Patients with Perihilar Cholangiocarcinoma

BACKGROUND

The impact of time to surgery (TTS) on survival in patients with perihilar cholangiocarcinoma (PHC) is uncertain.

METHODS

Data from PHC patients scheduled for surgery between 2011 and 2020 were reviewed. Patients were grouped based on the median TTS, defined as the time from diagnosis to surgery. Survival outcomes were analyzed for all patients and those undergoing potentially curative resection (resection without distant metastasis).

RESULTS

Of 224 patients, the median TTS was 64 days (range 19-212), with the patients being divided into two groups: long-TTS group (TTS ≥64 days, n = 116) and short-TTS group (TTS <64 days, n = 108). The long-TTS group showed higher rates of preoperative biliary infection (52% vs. 33%; p = 0.004) and portal vein embolization (84% vs. 49%; p < 0.001) compared with the short-TTS group. Forty-seven patients (18%) had unresectable tumors or distant metastasis, with a median overall survival (OS) of 18 months. The rate of potentially curative resection tended to be lower in the long-TTS group (74%) compared with the short-TTS group (84%), although it was not statistically significant (p = 0.063). However, OS for the entire cohort was comparable between the long-TTS and short-TTS groups (median OS 40 vs. 36 months; p = 0.986). Multivariable analysis revealed that TTS was not associated with survival in patients who underwent potentially curative resection.

CONCLUSIONS

Although the potentially curative resection rate tended to be lower in the long-TTS group, TTS did not impact survival in patients undergoing potentially curative resection for PHC.

Transmembrane serine protease 4 expression in the prognosis of radical resection for biliary tract cancer

BACKGROUND

Recent advancements in biliary tract cancer (BTC) treatment have expanded beyond surgery to include adjuvant therapy, yet the prognosis remains poor. Identifying prognostic biomarkers could enhance the assessment of patients who have undergone radical resection for BTC.

AIM

To determine transmembrane serine protease 4 (TMPRSS4) utility as a prognostic biomarker of radical resection for BTC.

METHODS

Medical records of patients who underwent radical resection for BTC, excluding intrahepatic cholangiocarcinoma, were retrospectively reviewed. The associations between TMPRSS4 expression and clinicopathological factors, overall survival, and recurrence-free survival were analyzed.

RESULTS

Among the 85 patients undergoing radical resection for BTC, 46 (54%) were TMPRSS4-positive. The TMPRSS4-positive group exhibited significantly higher preoperative carbohydrate antigen 19-9 (CA19-9) values and greater lymphatic invasion than the TMPRSS4-negative group (P = 0.019 and 0.039, respectively). Postoperative overall survival and recurrence-free survival were significantly worse in the TMPRSS4-positive group (median survival time: 25.3 months vs not reached, P < 0.001; median survival time: 28.7 months vs not reached, P = 0.043, respectively). Multivariate overall survival analysis indicated TMPRSS4 positivity, pT3/T4, and resection status R1 were independently associated with poor prognosis (P = 0.032, 0.035 and 0.030, respectively). TMPRSS4 positivity correlated with preoperative CA19-9 values ≥ 37 U/mL and pathological tumor size ≥ 30 mm (P = 0.016 and 0.038, respectively).

CONCLUSION

TMPRSS4 is a potential prognostic biomarker of radical resection for BTC.

Klatskin Tumor in the Light of ICD-O-3: A Population-Based Clinical Outcome Study Involving 1,144 Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (2001-2012)

Introduction

Klatskin tumors (KTs) occur at the confluence of the right and left extrahepatic ducts and are classified based on their anatomical and histological codes in the International Classification of Diseases for Oncology (ICD-O). The second edition of the ICD-O (ICD-O-2) allocated a distinctive histological code to KT, which also included intrahepatic cholangiocarcinoma (CC). This unclear coding may result in ambiguous reporting of the demographic and clinical features of KT. The current study aimed to investigate the demographic, clinical, and pathological factors affecting the prognosis and survival of KT in the light of the updated third edition of ICD-O, Ninth Revision (ICD-O-3).

Methods

Data of 1,144 patients with KT from the Surveillance, Epidemiology, and End Result (SEER) database (2001-2012) were extracted. Patients with KT were analyzed for age, sex, race, stage, treatment, and long-term survival. The data were analyzed using chi-square tests, t-tests, and univariate and multivariate analyses. The Kaplan-Meier analysis was used to compare long-term survival between KT and subgroups of all biliary CCs.

Results

Of all biliary CCs, KT comprised 9.35%, with a mean age of diagnosis of 73±13 years, and was more common in men (54.8%) and Caucasian patients (69.5%). Histologically, moderately differentiated tumors were the most common (38.9%) followed by poorly differentiated (35.7%), well-differentiated (23.3%), and undifferentiated tumors (2.2%) (p<0.001). Most tumors in the KT group were 2-4 cm in size (41.5%), while fewer were >4 cm (29.7%) and <2 cm (28.8%) (p<0.001). ICD-O-3 defined most KTs in extrahepatic location (53.5%), while the remainder were in other biliary locations (46.5%) (p<0.001). Most KT patients received no treatment (73%), and for those who were treated, the most frequent modality was radiation (52.7%), followed by surgery (28.1%), and both surgery and radiation (19.2%) (p<0.001). Mean survival time for KT patients treated with surgery was inferior to all CCs of the biliary tree (1.72±2.61 vs. 1.87±2.18 years) (p=0.047). Multivariate analysis identified regional metastasis (OR=2.8; 95% CI=2.6-3.0), distant metastasis (OR=2.1; 95% CI=1.9-2.4), lymph node positivity (OR=1.6; 95% CI=1.4-1.8), Caucasian race (OR=2.0; 95% CI=1.8-2.2), and male sex (OR=1.2; 95% CI=1.1-1.3) were independently associated with increased mortality for KT (p<0.001).

Conclusion

The ICD-O-3 has permitted a greater understanding of KT. KT is a rare and lethal biliary malignancy that presents most often in Caucasian men in their seventh decade of life with moderately differentiated histology. Surgical resection does not provide any survival advantage compared to similarly treated biliary CCs. In addition, the combination of surgery and radiation appeared to provide no added survival benefits compared to other treatment modalities for KT.

Chronological analysis of surgical and oncological outcomes after the treatment of perihilar cholangiocarcinoma

Backgrounds/Aims

Despite advances in surgical techniques and perioperative supportive care, radical resection of hilar cholangiocarcinoma is the only modality that can achieve long-term survival. We chronologically investigated surgical and oncological outcomes of hilar cholangiocarcinoma and analyzed the factors affecting overall survival.

Methods

We retrospectively enrolled 165 patients with hilar cholangiocarcinoma who underwent liver resection with a curative intent. The patients were divided into groups based on the period when the surgery was performed: period I (2005-2011) and period II (2012-2018). The clinicopathological characteristics, perioperative outcomes, and survival outcomes were analyzed.

Results

The patients’ age, serum CA19-9 levels, and serum bilirubin levels at diagnosis were significantly higher in the period I group. There were no differences in pathological characteristics such as tumor stage, histopathologic status, and resection status. However, perioperative outcomes, such as estimated blood loss (1528.8 vs. 1034.1 mL, p=0.020) and postoperative severe complication rate (51.3% vs. 26.4%, p=0.022), were significantly lower in the period II group. Regression analysis demonstrated that period I (hazard ratio [HR]=1.591; 95% confidence interval [CI]=1.049-2.414; p=0.029), preoperative serum bilirubin at diagnosis (HR=1.585; 95% CI=1.058-2.374; p=0.026), and tumor stage (III, IV) (HR=1.671; 95% CI: 1.133-2.464; p=0.010) were significantly associated with poor prognosis. The 5-year survival rate was better in the period II patients than in the period I patients (35.1% vs. 21.0%, p=0.0071).

Conclusions

The surgical and oncological outcomes were better in period II. Preoperative serum bilirubin and advanced tumor stage were associated with poor prognosis in patients with hilar cholangiocarcinoma.

Minimally invasive surgery for hilar cholangiocarcinoma: a multicenter retrospective analysis of 158 patients

BACKGROUND

Curative resection of hilar cholangiocarcinoma (HC) is typically carried out using open surgery. In the present study, we examined the safety (postoperative complication) and effectiveness (resection margin status and patient survival) of minimally invasive surgery (MIS) for HC.

METHODS

This retrospective analysis included 158 patients receiving MIS for HC at 10 participating centers between December 2013 and November 2019. Patient demographics, surgical outcomes, and oncological outcomes were retrospectively analyzed.

RESULTS

Clinical information obtained from 10 different clinical centers did not show any evident cohort-bias clustering. One hundred and twenty-six (79.7%) patients underwent LRHC, 12 (7.6%) patients underwent RARHC, conversion to an open procedure occurred in 20 (12.7%) patients. The operation time and estimated blood loss were 410.8 ± 128.9 min and 477.8 ± 706.3 mL, respectively. The surgical radicality of the 158 patients was R0, 129 (81.6%); R1, 20 (18.4%) and R2, 9 (5.7%). Grades I-II complications was occurred in 68 (43.0%) patients. Severe morbidity (grade III-V) occurred in 14 (8.7%) patients. The median overall survival in whole cohort was 25.4 months. The overall survival rate was 67.6% at year 1, 28.8% at year 3, and 19.2% at year 5. Comparing the first half of MISHC performed by each center with the following cases, the operation time and postoperative hospital stay does not decrease with the increasing cases. On literature review, MISHC is non-inferior to open surgery at least in perioperative period.

CONCLUSIONS

In this Chinese MIS for HC multicenter study, the largest to date, long-term overall survival rates after MIS appear comparable to those reported in current open series. Further randomized controlled trials are necessary to assess the global impact of MISHC.

Long-term Survival after resection for perihilar cholangiocarcinoma: Impact of UICC staging and surgical procedure

BACKGROUND/AIMS

Perihilar cholangiocarcinoma is a rare disease with unfavorable prognosis resulting in low survival rates. This study aims to retrospectively assess the beneficial histopathological features and surgical procedures in long-term survivors (i.e., patients surviving perihilar cholangiocarcinoma for at least 2 y).

MATERIAL AND METHODS

In total, 322 patients with perihilar cholangiocarcinoma underwent surgery at our center. The follow-up ended in 2017; 76 patients survived for >2 y. The type of resection, UICC stage, and histopathological features were compared between three survival groups (>2-3, >3-5, and >5 y).

RESULTS

The >5-year-survival rate in our selected study cohort was 43.4% (>3-5 y,31.6% and >2-3 y, 25.0%), and 14.5% of the patients survived for >10 y after surgery. Patients with non-regional lymph node positive tumors and/or distant metastasis (i.e., UICC stage IVb; p=0.0112), R2 status (p=0.0288), and exploratory laparotomy only (p=0.0157) showed the poorest survival rates. Perineural invasion had no significant impact on the overall survival. However, 29.0% patients surviving for >5 y displayed the lowest perineural infiltration prevalence. Interestingly, Bismuth-Corlette stage IIIa (p=0.0467), especially caudate lobectomy (p=0.0034), was associated with disease-specific overall survival of >5y.

CONCLUSION

Complete/extended tumor resection with additional caudate lobe resection is strongly associated with long-term survival. Perineural infiltration as a negative prognostic marker for prolonged survival needs to be evaluated in larger study cohorts.

Regional lymphadenectomy vs. extended lymphadenectomy for hilar cholangiocarcinoma (Relay-HC trial): study protocol for a prospective, multicenter, randomized controlled trial

BACKGROUND

The prognostic benefits and safety of extended lymphadenectomy for hilar cholangiocarcinoma remain uncertain. The available evidence is still insufficient concerning its retrospective aspect. The aim of this study is to explore the clinical effect and safety of extended lymphadenectomy compared to regional lymphadenectomy in patients with hilar cholangiocarcinoma.

METHODS

The Relay-HC trial is a prospective, multicenter, and randomized controlled trial. Seven hundred and thirty-four eligible patients with resectable perihilar cholangiocarcinoma across 15 tertiary hospitals in China will be randomly assigned (1:1) to receive either regional lymphadenectomy or extended lymphadenectomy. The primary objective is to determine the overall survival after the two approaches. Secondary objectives of the study include the evaluation of perioperative mortality, postoperative complication, and disease-free survival. This study has been approved by the ethics committee of each participating hospital.

DISCUSSION

The Relay-HC trial is designed to investigate the prognostic benefits and safety of expanded lymphadenectomy for hilar cholangiocarcinoma. Currently, it has never been investigated in a prospective randomized controlled clinical trial.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR), ChiCTR1800015688 . Registered on 15 April 2018.

Neoadjuvant chemoradiotherapy followed by liver transplantation is a promising treatment for patients with unresectable hilar cholangiocarcinoma: A case report

Hilar cholangiocarcinoma is a highly malignant tumor and is currently treated by surgical resection or liver transplantation; however, these treatments result in poor patient prognosis accompanied with high recurrence and low patient mortality rates. Neoadjuvant therapy with liver transplantation is a novel treatment that exhibits promising clinical application, with a reported 5-year survival rate of 82%. However, transplantation centers conducting research into this treatment are limited due to its length and complexity. In the current study, the effects of brachytherapy and chemoradiotherapy followed by orthotopic liver transplantation (OLT) were investigated in a patient with unresectable hilar cholangiocarcinoma. Following treatment, the liver function of the patient normalized and physical status significantly improved. Furthermore, tomographic evaluation demonstrated no sign of recurrence 8 months later following continued adjunct chemotherapy. Therefore, neoadjuvant therapy followed by OLT may be an effective novel therapeutic strategy to treat patients with unresectable hilar cholangiocarcinoma.

[Klatskin tumor: long-term survival following surgery]

BACKGROUND

Perihilar cholangiocarcinoma (Klatskin tumor) is a rare tumor entity with an unfavorable prognosis despite optimal treatment.

OBJECTIVES

The aim of the study is to investigate beneficial histopathological features and recommendations for surgery in perihilar cholangiocarcinoma to improve patients' long term survival.

MATERIAL AND METHODS

192 patients suffering from perihilar cholangiocarcinoma underwent attempted tumor resection between 1998 and 2008 at our clinic. 50 patients survived more than 2 years. The follow-up ended in December 2013. The resection type, the UICC stage and histopathological features were compared between three groups (2-3-year, 3-5-year and > 5-year survival groups).

RESULTS

The overall 5‑year survival rate of the study groups was 32 %, and even 16 % survived more than 10 years after surgery. Patients with lymph node positive tumors (p = 0.0126) and distant metastasis (p = 0.0376) had the poorest survival rate. Perineural invasion had no significant impact on the overall survival, but patients surviving more than 5 years had the lowest incidence of perineural invasion with 18.75 %. Caudate lobectomy was significantly (p = 0.011) associated with a survival of more than 5 years in our study.

CONCLUSIONS

Complete tumor resection with additional caudate lobe resection is associated with long-term survival. Perineural invasion seems to be a negative prognostic factor for long-term survival.

Current status of liver transplantation for hilar cholangiocarcinoma

PURPOSE OF REVIEW

Liver transplantation for unresectable hilar cholangiocarcinoma is a highly controversial issue. This review will summarize results with transplantation alone and a new strategy of high-dose neoadjuvant chemoradiotherapy and subsequent liver transplantation. The review will address controversies regarding this novel approach to the treatment of hilar cholangiocarcinoma, including prioritization of patients with cholangiocarcinoma awaiting scarce deceased donor livers.

RECENT FINDINGS

Results with liver transplantation alone for patients with unresectable cholangiocarcinoma are poor and do not justify use of scarce donor livers for these patients. Several centers have recently reported excellent results combining high-dose neoadjuvant chemoradiotherapy and liver transplantation for patients with early stage disease. Patient selection, operative staging, timely transplantation, and strict adherence to protocol are keys to success.

SUMMARY

Hilar cholangiocarcinoma - once a contraindication for transplantation - has reemerged as an indication for transplantation when combined with neoadjuvant therapy. Results are comparable to results achieved with liver transplantation for other indications and exceed results with standard resection.

Radical operation for hilar cholangiocarcinoma in comparable Eastern and Western centers: Outcome analysis and prognostic factors

BACKGROUND

Extensive resection for hilar cholangiocarcinoma is the most effective treatment, but high morbidity and poor prognosis remain concerns. Previous data have shown marked differences in outcomes between comparable Eastern and Western centers. We compared the outcomes of the management for hilar cholangiocarcinoma at one Japanese and one British institution with comparable experience.

METHODS

Of 298 consecutive patients with hilar cholangiocarcinoma evaluated at Hirosaki University Hospital, Japan and St. James's University Hospital, Leeds, UK, 183 underwent radical resection. Clinicopathologic variables and postoperative outcomes were compared.

RESULTS

Significant differences were not observed between the Hirosaki and Leeds cohorts in overall outcomes despite several differences in the patient characteristics. Although there was a difference in 90-day mortality (2.5% vs 13.6%, respectively), disease-specific 5-year survival rates were 32.8% and 31.9%, respectively (P = .767). Multivariate analysis identified trisectionectomy (odds ratio = 2.32; P = .010), combined pancreatoduodenectomy (odds ratio = 7.88; P = .010), and perioperative blood transfusion (odds ratio = 1.88; P = .045) were associated with postoperative major complications, while preoperative biliary drainage associated with postoperative major complications, while preoperative biliary drainage (risk ratio = 2.21; P = .018), perioperative blood transfusion (risk ratio = 1.58; P = .029), lymph node metastasis (risk ratio = 2.00; P = .002), moderate/poorly differentiated tumor (risk ratio = 1.72; P = .029), microvascular invasion (risk ratio = 1.63; P = .046), and R1 resection (risk ratio = 1.90; P = .005) were risk factors for poor survival.

CONCLUSION

Disease-specific survival and prognostic factors were similar in both centers. Meticulous operative technique to avoid perioperative blood transfusion may improve long-term survival.

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors

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.

Left hepatectomy combined with hepatic artery resection for hilar cholangiocarcinoma: A retrospective cohort study

AIMS

To investigate the efficacy of our technique and policy on left hepatectomy (LH) with hepatic artery resection but without arterial reconstruction (HAR) in selected patients with hilar cholangiocarcinoma.

METHODS

From May 2005 to May 2012, 61 patients with hilar cholangiocarcinoma underwent left hepatectomy. These patients were divided into two groups: the LH with HAR group (n = 26) and the LH alone group (n = 35), based on whether hepatic artery resection was performed. We evaluated the serum total and direct bilirubin on postoperative day 7, length of hospital stay after surgery, postoperative complications, long-term postoperative survival and disease-free survival.

RESULTS

The improvement in jaundice after surgery was comparable between the two groups (P = 0.837). There were no significant differences in the rates of postoperative complications or mortality between the LH with HAR group and the LH group (P = 0.654 and no assessment, respectively). The cumulative 1-, 2-, 3- and 5-year survival rates were 61.5%, 49%, 40.8% and 30.6% and 71.4%, 58.7%, 51.3% and 38.5%, respectively, in the LH with HAR group and the LH group (P = 0.383, including perioperative deaths). The cumulative 1-, 2-, 3- and 5-year disease-free survival rates were 61.9%, 41.6%, 29.7% and 14.8% and 58.2%, 50.7%, 44.3% and 23.6% in the LH with HAR group and the LH group, respectively (P = 0.695, including perioperative deaths). The postoperative complication rate was higher in patients with severe jaundice than those with non-severe jaundice, but no significant difference was detected (56.3% (9/16) vs. 46.7% (46.7%), P = 0.804). Similarly, 18.8% (3/16) postoperative mortality was found in patients with severe jaundice, compared to 4.4% (2/45) in those with non-severe jaundice. The difference was not significant (P = 0.139). For the cumulative 1-, 2-, 3- and 5-year survival and cumulative 1-, 2-, 3- and 5-year disease-free survival rates, patients with severe jaundice had poorer outcomes than those with non-severe jaundice (56.3%, 43.8%, 35% and 26.3% vs. 66.7%, 58.8%, 52.2% and 41.8%, P = 0.317; 50%, 42.9%, 35.7% and 13.4% vs. 63.8%, 54%, 35.6% and 21.3%, P = 0.753).

CONCLUSION

Left hepatectomy combined with hepatic artery resection and no reconstruction for hilar cholangiocarcinoma is recommended when the following conditions are satisfied: 1) Bismuth-Corlette I, II, or IIIb hilar cholangiocarcinoma; 2) the tumor has infiltrated the hepatic artery with disappearance or markedly reduced arterial flow as detected by intraoperative ultrasound; 3) the color of the liver by visual observation does not change when the hepatic artery has been blocked for 5 min; and 4) removal of the tumor-infiltrated hepatic artery increases the probability of R0 resection for hilar cholangiocarcinoma. For obstructive jaundice from hilar cholangiocarcinoma, we recommend bile duct drainage before resection in patients with elevated preoperative serum TB.

Cholangiocarcinoma with intraductal tubular growth pattern versus intraductal papillary growth pattern

Intraductal neoplasms of the bile duct are macroscopically characterized by exophytic or polypoid growth patterns and have a favorable prognosis. Although some tumors with a predominantly tubular microscopic pattern have been reported, they have not been well characterized clinicopathologically. The purpose of the present study was to compare the newly recognized cholangiocarcinoma with an intraductal tubular growth pattern and cholangiocarcinoma with an intraductal papillary growth pattern and to investigate the pathological and prognostic significance of the former. This study analyzed 161 patients with tumors with exophytic or polypoid growth patterns from a large series of 733 cholangiocarcinoma cases surgically resected from January 1998 to May 2013. The study patients were divided into two groups: those whose tumors showed a predominantly tubular growth pattern (n=52) and those whose tumors exhibited a predominantly papillary growth pattern (n=109). Tubular growth pattern was associated with combined vascular resection and the absence of macroscopic mucin. Several histological indexes were significantly higher for the tubular growth pattern than the papillary one, including tubular adenocarcinoma, depth of invasion, microscopic lymphatic invasion, venous invasion, perineural invasion, and necrosis. Although the survival curves overlapped (P=0.693), the rate of liver metastasis was significantly higher for the tubular growth pattern than for the papillary one (P=0.012). Genomic DNA analysis focusing on somatic mutations in codons 12 and 13 of KRAS and codon 600 of BRAF revealed only one (4%) KRAS and no BRAF mutation among the 25 tubular cases examined. In conclusion, the tubular growth pattern exhibited differences in some histologic indexes, in addition to a higher hepatic metastasis rate and a lower KRAS mutation frequency, compared with the papillary growth pattern, but no difference in prognosis was observed. The distinctiveness of this tubular neoplasm should be further examined in the future.

Liver transplantation in the management of perihilar cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary hepatic neoplasm and accounts for 10-20% of hepatobiliary cancer-related deaths. The prognosis of patients with CCA is poor with 5-year survival rates of 10%, partially due to the limited effective treatment options that exist for this disease. In this review, we discuss the evolving role of liver transplantation in the management of patients with perihilar CCA (pCCA). We specifically discuss the Mayo Clinic protocol of neoadjuvant chemoradiation followed by liver transplantation in selected patients with pCCA and describe pretransplant, peritransplant, and post-transplant considerations and challenges with this approach. Finally, we review local, national and international outcomes and discuss future directions in optimizing this treatment strategy for patients who otherwise have few therapeutic options and limited survival.

Perioperative blood transfusion as a poor prognostic factor after aggressive surgical resection for hilar cholangiocarcinoma

BACKGROUND

Blood transfusion is linked to a negative outcome for malignant tumors. The aim of this study was to evaluate aggressive surgical resection for hilar cholangiocarcinoma (HCCA) and assess the impact of perioperative blood transfusion on long-term survival.

METHODS

Sixty-six consecutive major hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for HCCA were performed using macroscopically curative resection at our institute from 2002 to 2012. Clinicopathologic factors for recurrence and survival were retrospectively assessed.

RESULTS

Overall survival rates at 1, 3, and 5 years were 86.7, 47.3, and 35.7 %, respectively. In univariate analysis, perioperative blood transfusion and a histological positive margin were two of several variables found to be significant prognostic factors for recurrence or survival (P<0.05). In multivariate analysis, only perioperative blood transfusion was independently associated with recurrence (hazard ratio (HR)=2.839 (95 % confidence interval (CI), 1.370-5.884), P=0.005), while perioperative blood transfusion (HR=3.383 (95 % CI, 1.499-7.637), P=0.003) and R1 resection (HR=3.125 (95 % CI, 1.025-9.530), P=0.045) were independent risk factors for poor survival.

CONCLUSIONS

Perioperative blood transfusion is a strong predictor of poor survival after radical hepatectomy for HCCA. We suggest that circumvention of perioperative blood transfusion can play an important role in long-term survival for patients with HCCA.

Optimal indications for additional resection of the invasive cancer-positive proximal bile duct margin in cases of advanced perihilar cholangiocarcinoma

BACKGROUND

The survival benefits of additional resection of the positive proximal ductal margin in cases of perihilar cholangiocarcinoma remain to be elucidated. The purpose of this retrospective study was to clarify the optimal indications for additional resection of the invasive cancer-positive proximal ductal margin (PM) METHODS: All patients who underwent hepatectomy for perihilar cholangiocarcinoma between 2000 and 2011 were analyzed. Surgical variables, the status of the PM, prognostic factors, and survival were evaluated.

RESULTS

A total of 224 patients were enrolled. Additional resection was performed in 52 of 75 positive PMs of invasive cancer, resulting in 43 negative PMs. The survival of patients with a negative PM treated with additional resection (n = 43) was significantly worse than that of the patients with a negative PM treated without additional resection (n = 149; P = 0.031) and did not significantly differ from that of the patients with a positive PM (n = 32; P = 0.215). A multivariate analysis demonstrated that the carbohydrate antigen 19-9 (CA19-9) level (<64 or ≥64), combined vascular resection, pN, pM, the histological grade, perineural invasion, liver invasion, and R status were independent prognostic factors. Only in the subgroups of CA19-9 < 64 and pM0, the survival of the patients with a negative PM treated with additional resection was significantly better than that of the patients with a positive PM (P = 0.019 and P = 0.021, respectively).

CONCLUSIONS

Additional resection of the invasive cancer-positive PMs may be warranted only in limited patients with a lower level of CA19-9 and no distant metastatic disease.

Perihilar cholangiocarcinoma: Current therapy

Perihilar cholangiocarcinoma, which is a rare primary malignancy, originates from the epithelial cells of the bile duct. Usually invading the periductal tissues and the lymph nodes, perihilar cholangiocarcinoma is commonly diagnosed in the advanced stage of the disease and has a dismal prognosis. Currently, complete hepatectomy is the primary therapy for curing this disease. Perioperative assessment and available surgical procedures can be considered for achieving a negative margin resection, which is associated with long-term survival and better quality of life. For patients with unresectable cholangiocarcinoma, several palliative treatments have been demonstrated to produce a better outcome; and liver transplantation for selected patients with perihilar cholangiocarcinoma is promising and desirable. However, the role of palliative treatments and liver transplantation was controversial and requires more evidence and substantial validity from multiple institutions. In this article, we summarize the data from multiple institutions and discuss the resectability, mortality, morbidity and outcome with different approaches.

Patterns and prognostic significance of lymph node dissection for surgical treatment of perihilar and intrahepatic cholangiocarcinoma

INTRODUCTION

The prognostic significance of lymph node dissection (LND), the number and status of harvested lymph nodes (LNs), and the lymph node ratio (LNR) are still under debate in intrahepatic (ICC) and perihilar (PCC) cholangiocarcinoma. The aims of this study were to evaluate the prognostic value of the extent of LN dissection, the number of positive LNs, the distribution of positive LNs along different LN stations, and the LNR in a cohort of patients with ICC and PCC who underwent surgical resection and to compare the different prognostic values of lymph node involvement.

MATERIAL AND METHODS

A retrospective analysis was done evaluating extent of LND, number, status, and location of harvested LNs in a cohort of 145 patients with cholangiocarcinoma submitted to surgical resection with curative intent from 1990 to 2012.

RESULTS

Seventy patients had ICC and 75 had PCC. The median survival times of patients with N0 and N+ tumors were 42 and 19 months in ICC patients (p = 0.05) and 42 and 22 months in PCC patients (p = 0.01). In patients without LN metastases, the median survival times of patients with up to three LNs retrieved and with more than three LNs retrieved were 38 and 69 months in ICC patients (p = 0.05) and 18 and 43 months in PCC patients (p = 0.04), respectively. In N+ patients, the location of positive LNs (hepatoduodenal ligament or other regional stations) did not influence overall survival in ICC or PCC patients (p = 0.6). The median survival times of patients with LNRs of 0 and >0.25 were 43 and 19 months in ICC patients (p = 0.01); the 0-0.25 group did not reach the value. In PCC patients, median survival of 0, 0-0.25, and >0.25 groups of patients were 42, 23, and 11 months (p = 0.01), respectively.

CONCLUSIONS

LN metastasis is a major prognostic factor after surgical resection of cholangiocarcinoma. The number of harvested LNs and the LNR showed a high prognostic value in ICC and PCC.

Inflammation-based prognostic score is a useful predictor of postoperative outcome in patients with extrahepatic cholangiocarcinoma

BACKGROUND/PURPOSE

Recent studies have revealed that the Glasgow prognostic score (GPS), an inflammation-based prognostic score, is useful for predicting outcome in a variety of cancers. This study sought to investigate the significance of GPS for prognostication of patients who underwent surgery with extrahepatic cholangiocarcinoma.

METHODS

We retrospectively analyzed a total of 62 patients who underwent resection for extrahepatic cholangiocarcinoma. We calculated the GPS as follows: patients with both an elevated C-reactive protein (>10 mg/L) and hypoalbuminemia (<35 g/L) were allocated a score of 2; patients with one or none of these abnormalities were allocated a s ore of 1 or 0, respectively. Prognostic significance was analyzed by the log-rank test and a Cox proportional hazards model.

RESULTS

Overall survival rate was 25.5 % at 5 years for all 62 patients. Venous invasion (p = 0.01), pathological primary tumor category (p = 0.013), lymph node metastasis category (p < 0.001), TNM stage (p < 0.001), and GPS (p = 0.008) were significantly associated with survival by univariate analysis. A Cox model demonstrated that increased GPS was an independent predictive factor with poor prognosis.

CONCLUSIONS

The preoperative GPS is a useful predictor of postoperative outcome in patients with extrahepatic cholangiocarcinoma.

Outcome of surgical resection in Klatskin tumors

Cholangiocarcinomas are the second most frequent primary hepatic malignancy, and make up from 5% to 30% of malignant hepatic tumours. Hilar cholangiocarcinoma (HCC) is the most common type, and accounts for approximately 60% to 67% of all cholangiocarcinoma cases. There is not a staging system that permits us to compare all series and extract some conclusions to increase the long-survival rate in this dismal disease. Neither the extension of resection, according to the sort of HCC, is a closed topic. Some authors defend limited resection (mesohepatectomy with S1, S1 plus S4b-S5, local excision for papillary tumours, etc.) while others insist in the compulsoriness of an extended hepatic resection with portal vein bifurcation removed to reach cure. As there is not an ideal adjuvant therapy, R1 resection can be justified to prolong the survival rate. Morbidity and mortality rates changed along the last decade, but variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Conclusion: Surgical resection continues to be the main treatment of HCC. Negative resection margins achieved with major hepatic resections are associated with improved outcome. Preresectional management with biliary drainage, portal vein embolization and staging laparoscopy should be considered in selected patients. Additional evidence is needed to fully define the role of orthotopic liver transplant. Portal and lymph node involvement worsen the prognosis and long-term survival, and surgery is the only option that can lengthen it. Improvements in adjuvant therapy are essential for improving long-term outcome. Furthermore, the lack of effective chemotherapy drugs and radiotherapy approaches leads us to can consider R1 resection as an option, because operated patients have a longer survival rate than those who not undergo surgery.

Carcinoid tumor of the extrahepatic bile duct: report of a case

We report a rare case of carcinoid tumor of the extrahepatic bile duct. A 69-year-old woman with a history of hyperthyroidism was diagnosed to have a tumor of the extrahepatic bile duct. Laparotomy, for presumed cholangiocarcinoma, revealed a 2.5-cm-long, firm mass of the hilar-upper bile duct. The extrahepatic bile duct resection and lymphadenectomy was performed. Her postoperative course was uneventful and has been asymptomatic without recurrent tumor during 2 years of follow-up. Primary carcinoid tumors of the extrahepatic bile duct are very rare. Herein we report this rare case with a review of the literature.

Current management of cholangiocarcinoma

Cholangiocarcinoma is the second most common primary hepatobiliary malignancy after hepatocellular carcinoma and remains among the most difficult management problems faced by surgeons. Curative surgery is achieved in only 25% to 30% of patients. Local tumor extent, such as portal vein invasion and hepatic lobar atrophy, does not preclude resection. Long-term survival has been seen only in patients who underwent extensive liver resections, suggesting that bile-duct excision alone is less effective. The majority of patients have unresectable disease, with 20% to 30% incidence of distant metastasis at presentation. Unresectable patients should be referred for nonsurgical biliary decompression, and in potential curative resection candidates the use of biliary stents should be reduced. Liver transplantation provides the option of wide resection margins, expanding the indication of surgical intervention for selected patients who otherwise are not surgical candidates due to lack of functional hepatic reserve.

Management of perihilar cholangiocarcinoma in the era of multimodal therapy

Perihilar cholangiocarcinoma (CCA) is the second most common primary malignant tumor of the liver. In the USA, there are approximately 3000 cases of CCA diagnosed annually, with approximately 50-70% of these tumors arising at the hilar plate of the biliary tree. Risk factors include advanced age, male gender, primary sclerosing cholangitis, choledochal cysts, cholelithiasis, parasitic infection, inflammatory bowel disease, cirrhosis and chronic pancreatitis. Patients typically present with jaundice, abdominal pain, pruritus and weight loss. The mainstays of treatment include surgery, chemotherapy, radiation therapy and photodynamic therapy. Specific preoperative interventions for patients with perihilar CCA include endoscopic retrograde cholangiopancreatography, percutanteous transhepatic cholangiography and portal vein embolization. Surgical resection offers the only chance for curative therapy in perihilar CCA. R0 resection is of utmost importance and has been linked to improved survival. Major hepatic resection is needed to achieve both longitudinal and radial margins negative for tumor. Fractionated stereotactic body radiotherapy has shown promising results in CCA. Perihilar CCA typically presents with advanced disease, and many patients receive systemic therapy; however, the response to current regimens is limited. Orthotopic liver transplantation offers complete resection of locally advanced tumors in select patient groups.

Surgical management of proximal bile duct cancers

INTRODUCTION

Tumors arising from the proximal biliary tree remain particularly challenging with respect to their evaluation and treatment. Complete resection with negative histologic margins is the most effective treatment modality.

RESULTS

However, the majority of patients are not candidates for surgery. Over the last decades, advances have evolved to improve resectability and morbidity after major liver and bile duct resection. However, these disease processes still pose a management challenge. Herein, we provide an overview of proximal bile duct cancers, hilar cholangiocarcinoma (HCCa) and intrahepatic cholangiocarcinoma (ICCa).

Cholangiocarcinoma: Aggressive Surgical Intervention Remains Justified

Cholangiocarcinoma (CCA) continues to be a difficult disease to both diagnose and treat. Optimal treatment includes resection to histologically negative margins. In recent years, advanced imaging, including magnetic resonance cholangiography and endoscopic ultrasound, has presumably improved the accuracy of determining resectability. From 2004 to 2009, a total of 61 patients with cholangiocarcinoma were evaluated for resection. The majority were men (37) and ages ranged from 29 to 87 years (mean, 67 years). Only 31 per cent were found to be obviously unresectable based on imaging alone. The remaining 69 per cent underwent exploration, at which time resection was found unfeasible in an additional 25 per cent (overall 56% unresectable). Although all resection specimens had grossly negative margins, 37 per cent were ultimately found to be microscopically positive. The overall 5-year actuarial survival for patients undergoing resection was 39.2 per cent with no survival difference between those with positive and negative margins. Despite advances in diagnostic imaging, more than half of patients with CCA presenting for surgical evaluation are ultimately found to be unresectable. However, the final determination can still only be made at the time of exploration. Even in the presence of microscopic residual disease, surgical intervention results in improved survival. An aggressive stance toward surgical intervention in patients with CCA remains justified.

Improved outcomes after aggressive surgical resection of hilar cholangiocarcinoma: a critical analysis of recurrence and survival

BACKGROUND

Hilar cholangiocarcinoma (HC) is invariably fatal without surgical intervention. The primary aim of the current study was to report overall survival and recurrence-free survival outcomes after surgical resection of HC.

METHODS

Between December 1992 and December 2009, 85 patients were evaluated; of these, 42 patients underwent potentially curative surgery. These patients are the principal subjects of this study. Patients were assessed monthly for the first 3 months and then at 6-month intervals after treatment. Recurrence-free survival and overall survival were determined; 18 clinicopathologic and treatment-related factors associated with recurrence-free survival and overall survival were evaluated through univariate and multivariate analyses.

RESULTS

No patient was lost to follow-up evaluation. The median follow-up period was 20 months (range, 0-106 mo). The median recurrence-free survival and overall survival after resection was 15 and 28 months, respectively. The 5-year survival rate was 24%. Two factors were associated with overall survival: histologic grade (P = .002) and margin status (P = .033). Only histologic grade (P = .029) was associated with recurrence-free survival.

CONCLUSIONS

Surgical resection is an efficacious treatment for HC. Patient selection based on identified prognostic factors can improve treatment outcomes.

Surgical strategy for bile duct cancer: Advances and current limitations

The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon's ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud's segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.

Post-operative morbidity results in decreased long-term survival after resection for hilar cholangiocarcinoma

BACKGROUND

The purpose of the present study was to demonstrate that post-operative morbidity (PM) associated with resections of hilar cholangiocarcinoma (HCCA) is associated with short- and long-term patient survival.

METHODS

Between 1998 and 2008, 51 patients with a median age of 64 years underwent resection for HCCA at a single institution. Associations between survival and clinicopathologic factors, including peri- and post-operative variables, were studied using univariate and multivariate models.

RESULTS

Seventy-six per cent of patients underwent major hepatectomy with resection of the extrahepatic bile ducts. The 30- and 90-day operative mortality was 10% and 12%. The overall incidence of PM was 69%, with 68% of all PM as major (Clavien grades III-V). No difference in operative blood loss or peri-operative transfusion rates was observed for patients with major vs. minor or no PM. Patients with major PM received adjuvant chemotherapy less frequently than patients with minor or no complications 29% vs. 52%, P= 0.15. The 1-, 3- and 5-year overall (OS) and disease-specific survival (DSS) rates for all patients were 65%, 36%, 29% and 77%, 46%, 35%, respectively. Using univariate and multivariate analysis, margin status (27% R1), nodal metastasis (35% N1) and major PM were associated with OS and DSS, P < 0.01. Major PM was an independent factor associated with decreased OS and DSS [hazard ratio (HR) = 3.6 and 2.8, respectively, P < 0.05]. The median DSS for patients with major PM was 14 months compared with 40 months for patients who experienced minor or no PM, P < 0.01.

CONCLUSION

Extensive operations for HCCA can produce substantial post-operative morbidity. In addition to causing early mortality, major post-operative complications are associated with decreased long-term cancer-specific survival after resection of HCCA.

Cholangiocarcinoma: A position paper by the Italian Society of Gastroenterology (SIGE), the Italian Association of Hospital Gastroenterology (AIGO), the Italian Association of Medical Oncology (AIOM) and the Italian Association of Oncological Radiotherapy (AIRO)

The incidence of Cholangiocellular carcinoma (CCA) is increasing, due to a sharp increase of the intra-hepatic form. Evidence-ascertained risk factors for CCA are primary sclerosing cholangitis, Opistorchis viverrini infection, Caroli disease, congenital choledocal cist, Vater ampulla adenoma, bile duct adenoma and intra-hepatic lithiasis. Obesity, diabetes, smoking, abnormal biliary-pancreatic junction, bilio-enteric surgery, and viral cirrhosis are emerging risk factors, but their role still needs to be validated. Patients with primary sclerosing cholangitis should undergo surveillance, even though a survival benefit has not been clearly demonstrated. CCA is most often diagnosed in an advanced stage, when therapeutic options are limited to palliation. Diagnosis of the tumor is often difficult and multiple imaging techniques should be used, particularly for staging. Surgery is the standard of care for resectable CCA, whilst liver transplantation should be considered only in experimental settings. Metal stenting is the standard of care in inoperable patients with an expected survival >4 months. Gemcitabine or platinum analogues are recommended in advanced CCA whilst there are no validated neo-adjuvant treatments or second-line chemotherapies. Even though promising results have been obtained in CCA with radiotherapy, further randomized controlled trials are needed.

Prognostic relevance of the lymph node ratio in surgical patients with extrahepatic cholangiocarcinoma

AIM

Few studies have investigated the influence of the lymph node ratio (LNR), the ratio of the number of lymph nodes harboring metastatic cancer to the total number of lymph nodes removed, on the outcome after surgery for extrahepatic cholangiocarcinoma. This study was conducted to examine the prognostic impact of LNR in patients undergoing resection for extrahepatic cholangiocarcinoma.

PATIENTS AND METHODS

We retrospectively analyzed a total of 60 consecutive patients who underwent resection for extrahepatic cholangiocarcinoma. We focused on the LNR, which was classified as 0 in 34 patients, between 0 and 0.2 in 13 patients, and greater than 0.2 in 13 patients.

RESULTS

The overall five-year survival rates for patients with LNRs of 0, 0 to 0.2, and ≥0.2 were 44%, 10%, and 0%, respectively (p = 0.023). LNR was an independent predictive factor for estimated survival by both univariate (p = 0.016) and multivariate (p = 0.022) analyses including LNR, the sites of the primary tumors, and surgical margin as the variables. There were no statistically significant differences between patients who had less than 12 lymph nodes removed and those who had 12 or more lymph nodes removed (p = 0.484).

CONCLUSION

LNR was a powerful, independent predictor of estimated survival in patients undergoing surgical resection for extrahepatic cholangiocarcinoma. LNR should be considered when stratifying patients for future clinical trials.

Liver transplantation for cholangiocarcinoma

Liver transplantation following high dose neoadjuvant radiotherapy with chemosensitization achieves excellent results for patients with early stage, unresectable hilar cholangiocarcinoma or cholangiocarcinoma arising in the setting of primary sclerosing cholangitis.

Current surgical management of hilar and intrahepatic cholangiocarcinoma: the role of resection and orthotopic liver transplantation

Cholangiocarcinoma (CCA) is a rare but devastating malignancy that presents late, is notoriously difficult to diagnose, and is associated with a high mortality. Surgical resection is the only chance for cure or long-term survival. The treatment of CCA has remained challenging because of the lack of effective adjuvant therapy, aggressive nature of the disease, and critical location of the tumor in close proximity to vital structures such as the hepatic artery and the portal vein. Moreover, the operative approach is dictated by the location of the tumor and the presence of underlying liver disease. During the past 4 decades, the operative management of CCA has evolved from a treatment modality that primarily aimed at palliation to curative intent with an aggressive surgical approach to R0 resection and total hepatectomy followed by orthotopic liver transplantation.

Stereotactic fractionated radiotherapy for Klatskin tumours

BACKGROUND AND PURPOSE

In spite of various efforts perihilar cholangiocellular carcinoma (Klatskin tumour) has still a bad prognosis. The treatment of patients with inoperable Klatskin tumours by stereotactic fractionated radiotherapy (SFRT) was analysed retrospectively. PATIENTS, METHODS AND MATERIALS: In our department 13 patients were treated for Klatskin tumours by SFRT (32-56 Gy, 3 x 4 Gy/week) from 1998 to 2008. The treatment technique was developed from stereotactic body frame radiotherapy to image guided (IGRT) stereotactic radiotherapy with control of patient positioning by cone beam computer tomography (CBCT). 6/13 patients received additional chemotherapy before or after SFRT.

RESULTS

A median survival of 33.5 (6.6-60.4) months after diagnosis was reached by SFRT. The median time of freedom from tumour progression was 32.5 (6.1-60.4, last patient died without tumour progression) months. The therapy was tolerated very well. Nausea was the most common side effect. 5/13 patients suffered from recurrent cholangitis caused and enhanced by the primary tumour and drainages or stents in the bile ducts.

CONCLUSIONS

In the context of reaching local control being still the main problem of Klatskin tumour patients, SFRT seems to be a very promising method for the treatment of these tumours.

Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery

BACKGROUND

Right or right-extended hepatectomy including the caudate lobe is the most common treatment for hilar cholangiocarcinoma (HC). A 5-year survival of up to 60% can be achieved using this procedure if R0-resection is obtained. However, for some patients a left-sided liver resection is necessary to obtain radical resection. The close relationship between the right hepatic artery and the HC in these patients frequently limits the ability to achieve a radial R0-resection without difficult vascular reconstruction. The aim of the present study was to describe the outcome of patients who underwent pre-operative embolization of the proper hepatic artery in an effort to induce development of arterial collaterals thus allowing the resection of the proper and right hepatic artery without vascular reconstruction.

METHODS

In patients presenting with HC who were considered to require a left hepatic lobectomy and in whom pre-operative work up revealed possible tumour invasion of the right hepatic artery, transcatheter arterial embolization (TAE) of the proper hepatic artery or the left and right hepatic arteries was performed. Three weeks later, a left-sided hepatectomy with resection of all portal structures except the portal vein was performed.

RESULTS

In six patients, pre-operative embolization of the proper hepatic artery was performed. Almost instantaneously in all six patients arterial flow signals could be detected in the liver using Doppler ultrasonography. No patient died peri-operatively. In all six patients an R0 radial resection was achieved and in three an R0 proximal transection margin was obtained. All post-operative complications were managed successfully using percutaneous drainage procedures. No patient developed local recurrence and two patients remain disease free more than 7 years after surgery.

SUMMARY

After pre-operative embolization of the proper hepatic artery, resection of the HC with left hepatectomy is a promising new approach for these technically demanding patients, giving them the chance of a cure.

Disease recurrence patterns after R0 resection of hilar cholangiocarcinoma

BACKGROUND

There is little information regarding the clinical behaviour of hilar cholangiocarcinoma after curative resection.

METHODS

A retrospective study was undertaken of 79 consecutive patients with hilar cholangiocarcinoma who had undergone major hepatectomy (three or more Couinaud segments) concomitant with caudate lobectomy, and had negative resection margins. Sites of initial disease recurrence were classified as locoregional (porta hepatis) or distant (intrahepatic, peritoneal, para-aortic lymph nodal or extra-abdominal). Univariable and multivariable analyses were performed to determine the factors potentially related to recurrence.

RESULTS

Disease recurrence was observed in 42 (53 per cent) of the 79 patients. Cumulative recurrence rates at 3 and 4 years after surgery were 52 and 56 per cent respectively. Locoregional recurrence alone was observed in eight (10 per cent) and distant metastasis in 34 (43 per cent) of the 79 patients after R0 resection. Positive nodal involvement and high International Union Against Cancer tumour (T) stage were independent prognostic factors associated with distant metastasis.

CONCLUSION

Distant metastases are more common than locoregional recurrence after R0 resection for hilar cholangiocarcinoma, and associated with nodal involvement and high T stage.

Isolated recurrence of distal adenocarcinoma of the extrahepatic bile duct on a draining sinus scar after curative resection: case report and review of the literature

Background

Surgical resection remains the gold standard for the treatment of localized adenocarcinoma of the extrahepatic bile ducts. Yet, treatment of loco-regional recurrences is not well defined.

Case Presentation

We present an unusual case of distal adenocarcinoma of the extrahepatic bile ducts that was treated with surgery and relapsed two years later with a solitary recurrence on the tract of a previous Redon drain. In addition, a review of the literature on management of loco regional relapses is presented.

Conclusions

The ideal management of these patients still remains undefined. Decisions are made based on clinical parameters from retrospective series, such as tumor grade, surgical margins or lymph node involvement. Prospective studies, that include molecular and genetic markers, are needed to improve patient selection and outcomes on this population.

Major hepatectomy for perihilar cholangiocarcinoma

BACKGROUND/PURPOSE

Hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma involving the hepatic hilus are defined as "perihilar cholangiocarcinoma". The principle of surgical treatment is hemi-hepatectomy or trisectionectomy of the liver, caudate lobectomy, and resection of the extrahepatic bile duct for complete resection of the tumor. The aim of this study was to review the outcomes of major hepatectomy for perihilar cholangiocarcinoma.

METHODS

Using the Kaplan-Meier method and the Cox proportional hazards model, we analyzed the results in 125 patients with perihilar cholangiocarcinoma who had undergone major hepatectomy.

RESULTS

Right hepatectomy, right trisectionectomy, left hepatectomy, and left trisectionectomy were performed in 66, 8, 49, and 2 patients, respectively. Curative resection was achieved in 79 patients (63.2%). Mortality and morbidity rates were 8.0 and 48.7%, respectively. The overall 1-, 3-, and 5-year survival rates of all patients were 73.2, 36.7, and 34.7%, respectively. The median survival was 26.8 months. Multivariate analysis showed that the independent prognostic factors for overall survival were gender, histopathological grading, curative resection, and American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) pT.

CONCLUSIONS

Major hepatectomy for perihilar cholangiocarcinoma was acceptable and showed satisfactory outcomes. For long-term survival in these patients, the surgeon should aim for complete resection of the tumor with negative margins.

Photodynamic therapy is associated with an improvement in survival in patients with irresectable hilar cholangiocarcinoma

BACKGROUND

The majority of patients with hilar cholangiocarcinoma have irresectable disease and require palliation with biliary stenting to alleviate symptoms and prevent biliary sepsis. Chemotherapy and radiotherapy have proved ineffective, but recent studies suggest photodynamic therapy (PDT) may improve the outlook for these patients. This prospective clinical cohort study has evaluated the efficacy of radical curative surgery, standard palliative therapy (stent +/- chemotherapy) and a novel palliative therapy (stent +/- Photofrin-PDT) in 50 consecutive patients treated for hilar cholangiocarcinoma over a 5-year period.

METHODS

Between January 2002 and December 2006, 50 patients with hilar cholangiocarcinoma were evaluated for treatment. Ten patients were considered suitable for curative resection (Cohort 1). Forty patients with irresectable disease were stratified into Cohort 2 - Stent +/- chemotherapy (n= 17); and Cohort 3 - Stent +/- PDT (n= 23). Prospective follow-up in all patients and data collected for morbidity, mortality and overall patient survival.

RESULTS

The median age was 68 years [range 44-83]. Positive cytology/histology was obtained in 28/50 (56%). One death in Cohort 1 occurred at 145 days after surgical resection. No treatment related-deaths occurred in Cohort 2 or 3, chemotherapy-induced morbidity in three patients in cohort 2, PDT-induced morbidity in 11 patients in cohort 3. Actual 1-year survival was 80%, 12% and 75% in Cohorts 1, 2 and 3, respectively. Mean survival after resection was 1278 days (median survival not reached). Mean and median survival was 173 and 169 days, respectively, in Cohort 2; and 512 and 425 days in Cohort 3. Patient survival was significantly longer in cohorts 1 and 3 (P < 0.0001; Log rank test).

CONCLUSION

This prospective clinical cohort study has demonstrated that radical surgery and palliative Photofrin-PDT are associated with an increased survival in patients with hilar cholangiocarcinoma.

Initial presentation and management of hilar and peripheral cholangiocarcinoma: is a node-positive status or potential margin-positive result a contraindication to resection?

BACKGROUND

Cholangiocarcinoma (CC) frequently presents at an advanced stage and the majority of patients are unresectable at diagnosis. We sought to examine our recent experience with surgical resection for hilar and peripheral CC.

METHODS

A review of all CC patients who presented to our multidisciplinary liver cancer center for evaluation of their CC between January 2000 and August 2008 was performed. Demographics, therapeutic management, pathologic characteristics, and overall survival were analyzed.

RESULTS

A total of 280 patients were evaluated over the 8-year period, and 222 patients (79%) were unresectable at presentation. Fifty-eight out of 280 patients were candidates for resection, of whom, 51 patients underwent resection. Hilar CC was identified in 27 patients (53%) and peripheral CC was present in 24 patients (47%). Morbidity and 90-day mortality were 61 and 9.8%, respectively. Overall, negative margin (R0) resection was achieved in 26 patients (51%). Using multivariate Cox regression analysis, only margin status was found to be a significant predictor of survival (p = 0.009). Compared with peripheral CC, hilar CC was associated with shorter overall survival (p = 0.001) and higher rates of positive margins (p = 0.001) and perineural invasion (p = 0.02), and no difference in angiolymphatic, portal vein, and lymph node involvement.

CONCLUSIONS

Survival benefits can be achieved with resection for cholangiocarcinoma. Given the lack of effective alternative therapy, when confronted with the potential risk of positive margins or isolated nodal disease, we continue to advocate aggressive surgical resection for both hilar and peripheral CC with the ultimate goal of negative margin resection.

Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009

Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

Hilar cholangiocarcinoma: current management

OBJECTIVE

To review the literature with regard to outcome of surgical management for hilar cholangiocarcinoma (Klatskin tumor).

BACKGROUND

Hilar cholangiocarcinoma is a rare tumor with a poor prognosis. Surgical resection provides the only possibility for cure. Advances in hepatobiliary imaging and surgical strategies to treat this disease have resulted in improved postoperative outcomes.

METHODS

We performed a review of the English literature on hilar cholangiocarcinoma from 1990 to 2007. This review included preoperative evaluation, surgical techniques, issues and controversies in management, prognostic variables, and considerations for future directions.

RESULTS

Complete resection remains the most effective and only potentially curative therapy for hilar cholangiocarcinoma. Negative resection margins are associated with improved outcomes, and major hepatic resections have enhanced the likelihood of R0 resection. Portal vein embolization may be indicated in selected patients before extensive hepatic resection. Staging laparoscopy should be considered to detect occult metastatic disease. Orthotopic liver transplantation might be applicable for a highly selected subgroup.

CONCLUSIONS

Surgical resection including major hepatic resection remains the mainstay of treatment of hilar cholangiocarcinoma. Additional evidence is needed to fully define the role of orthotopic liver transplantation. Improvements in adjuvant therapy are essential for improving long-term outcome.

Gemcitabine-based adjuvant chemotherapy improves survival after aggressive surgery for hilar cholangiocarcinoma

BACKGROUND

The prognosis of hilar cholangiocarcinoma is dismal although aggressive surgery including major hepatectomy has been performed. The aim of this study was to clarify useful prognostic factors and the usefulness of gemcitabine-based adjuvant chemotherapy for patients with hilar cholangiocarcinoma who had undergone aggressive surgical resection.

METHODS

Medical records of 42 patients with hilar cholangiocarcinoma who underwent surgical resection were reviewed retrospectively. Univariate and multivariate models were used to analyze the effect of various clinicopathological factors on long-term survival.

RESULTS

Overall 1-, 3-, and 5-year survival rates of the 42 patients with hilar cholangiocarcinoma were 81%, 42%, and 30%, respectively (median survival time, 21.5 months). Univariate analysis revealed that adjuvant gemcitabine-based chemotherapy, tumor differentiation, lymph node metastasis, and surgical margin status were associated significantly with long-term survival (P < 0.05). Furthermore, use of a Cox proportional hazards regression model indicated that only adjuvant gemcitabine-based chemotherapy was a significant independent predictor of a favorable prognosis (P = 0.035). The toxicity of adjuvant gemcitabine-based chemotherapy was mild. Five-year actuarial survival rates of patients who did or did not receive adjuvant gemcitabine-based chemotherapy were 57% and 23%, respectively (P = 0.026).

CONCLUSIONS

Postoperative adjuvant gemcitabine-based chemotherapy may be a promising strategy to improve survival after surgical resection for hilar cholangiocarcinoma. A prospective randomized study should be done to confirm the results of this study.

Indication for postoperative adjuvant therapy in biliary carcinoma based on analysis of recurrence and survival after surgical resection

Postoperative adjuvant therapy is mandatory for biliary carcinoma because of its unfavorable prognosis. The aim of this study was to evaluate the indication for postoperative adjuvant therapy in biliary carcinoma. The charts of 139 consecutive patients with biliary carcinoma (37 ampullary carcinomas, 36 distal carcinomas, 38 carcinomas of the gallbladder, and 28 hilar cholangiocarcinomas) who underwent surgical resection were retrospectively reviewed. Recurrence rates and survival rates after surgery were analyzed. Of the 139 carcinomas, the recurrence rates of International Union Against Cancer (UICC) stages IA, IB, IIA, IIB, and III cancers were 9%, 20%, 60%, 83%, and 100%, respectively. The recurrence rates of UICC stages II and III cancers were significantly higher than that of UICC stage I cancer (82% vs 13%, P < 0.001). The 5-year survival rates for patients with UICC stages IA, IB, IIA, IIB, and III cancers were 85%, 75%, 36%, 20%, and 0%, respectively. The 5-year survival rates for UICC stages II and III cancers were significantly lower than that for UICC stage I cancer (21% vs 82%, P < 0.001). Postoperative adjuvant therapy should be given to patients with UICC stages II and III biliary carcinomas because of their high rate of recurrence and the poor prognosis.