Preoperative assessment of cholangiocarcinoma: meeting the challenge

Hilar cholangiocarcinoma: surgical and endoscopic approaches

HCCa remains an uncommon malignancy, though increasing use of more radical surgery has led to prolonged survival in those patients who undergo curative resection. The extent of these resections suggest that the best results are likely to be obtained in centers with the resources and experience to conduct these operations in a safe fashion. Until major advances in the systemic therapy of HCCa are made, however, the management should focus on optimal preoperative imaging and palliation of jaundice with improvement in quality of life.

Clinicopathologic review of 58 patients with biliary papillomatosis

BACKGROUND

Biliary papillomatosis (BP) is a rare disease that is characterized by multiple numerous papillary adenomas in the biliary tree. The clinical features and outcome, however, are not well known. The authors retrospectively analyzed their clinicopathologic features and long-term follow-up results.

METHODS

Between March 1995 and January 2003, 58 patients were diagnosed with BP by cholangioscopic and histologic findings at a tertiary referral center, Asan Medical Center (University of Ulsan College of Medicine, Seoul, Korea). The authors retrospectively reviewed the medical records to obtain demographic, radiologic, cholangioscopic, and pathologic data.

RESULTS

The common clinical manifestations at the presentation of patients were repeated episodes of abdominal pain, jaundice, and acute cholangitis. Acute cholangitis was more common in patients with mucin-hypersecreting BP (MBP), whereas patients with nonmucin-producing BP (NMBP) were more asymptomatic (P < 0.05). Papillary adenocarcinoma and mucinous carcinoma were detected in 48 patients (83%) with papillary adenomas. Overall survival rates of NMBP and MBP were 89% and 69% at 1 year, 57% and 37% at 3 years, and 52% and 19% at 5 years, respectively. The mean survival period of NMBP and MBP was 52.27 +/- 6.72 months and 30.84 +/- 8.36 months, respectively.

CONCLUSIONS

BP should be regarded as a premalignant disease with high malignant potential. The pathogenesis of progression from benign to malignant disease may follow the adenomacarcinoma sequence. Although clinical presentations were somewhat different for patients with NMBP and MBP, the long-term survival rate was similar.

MR cholangiography versus cholangioscopy for evaluation of longitudinal extension of hilar cholangiocarcinoma

BACKGROUND

The utility of magnetic resonance cholangiography for assessment of longitudinal tumor extension of hilar cholangiocarcinoma was investigated with reference to findings by percutaneous transhepatic cholangioscopy.

METHODS

Ninety-nine patients with hilar cholangiocarcinoma underwent both magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy. Longitudinal tumor extension was described with the Bismuth-Corlette classification. Hilar cholangiocarcinoma was classified morphologically into stenotic, diffuse sclerosing, and polypoid types based on selective cholangiographic findings obtained during percutaneous transhepatic cholangioscopy. Agreement between percutaneous transhepatic cholangioscopy and magnetic resonance cholangiography according to the Bismuth-Corlette classification was compared. The degree of agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy according to each morphologic type was also compared in each subgroup without reference to Bismuth-Corlette type.

RESULTS

The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy with regard to Bismuth-Corlette types was 87.9% (kappa = 0.832, p < 0.01). The agreement of magnetic resonance cholangiography for each Bismuth-Corlette type with reference to percutaneous transhepatic cholangioscopy was as follows: type I (n = 18), 16/18 (88.9%); type II (n = 16), 14/16 (87.5%); type IIIa (n = 23), 19/23 (82.6%); type IIIb (n = 14), 14/14 (100%); and type IV (n = 28), 24/28 (85.7%). The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy for Bismuth-Corlette type according to selective cholangiographic findings was as follows: stenotic type, 58/61 (95.1%, kappa = 0.929, p < 0.01); diffuse sclerosing type, 12/16 (75%, kappa = 0.619, p < 0.01); and polypoid type, 17/22 (77.3%, kappa = 0.696, p < 0.01).

CONCLUSION

There is good overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy on longitudinal extension of hilar cholangiocarcinoma. Especially for the stenotic type of hilar cholangiocarcinoma (based on selective cholangiographic findings), magnetic resonance cholangiography may replace percutaneous transhepatic cholangioscopy in the determination of longitudinal tumor extension. For polypoid or diffuse sclerosing types, however, percutaneous transhepatic cholangioscopy is required for accurate evaluation of longitudinal tumor extension.