Current Surgical Management of Peri-Hilar and Intra-Hepatic Cholangiocarcinoma

Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.

Large-Scale Profiling of Signaling Pathways Reveals a Distinct Demarcation between Normal and Extended Liver Resection

Despite numerous studies addressing normal liver regeneration, we still lack comprehensive understanding of the biological processes underlying failed liver regeneration. Therefore, we analyzed the activity of 271 intracellular signaling pathways (ISPs) by genome wide profiling of differentially expressed RNAs in murine liver tissue biopsies after normal hepatectomy (nHx; 68% of liver removed) and extended hepatectomy (eHx; 86% of liver removed). Comprehensive, genome-wide transcriptome profiling using RNAseq was performed in liver tissue obtained from mice (sham, nHx, and eHx) harvested 1, 8, 16, 32, and 48 h after operation (n = 3 per group) and the OncoFinder toolkit was used for an unsupervised, unbiased identification of intracellular signaling pathways (ISP) activity. We observed that the normal regenerative process requires a transient activation and silencing of approximately two dozen of ISPs. After nHx, the Akt Pathway represented with 13 branches, the Chromatin Pathway and the DDR Pathways dominated. After eHx, the ATM main pathway and two of its branches (Cell Survival; G2_M Checkpoint Arrest) dominated, as well as the Hypoxia Pathways. Further, 14 ISPs demonstrated a strong inverse regulation, with the Hedgehog and the Brca1 Main Pathways as chief activators after nHx, and the ATM Pathway(G2_M Checkpoint Arrest) as the dominating constraining response after eHx.

Avoiding liver transplantation in post-treatment extent of disease III and IV hepatoblastoma

BACKGROUND

Primary liver transplantation is recommended for central post-treatment extent of disease (POST-TEXT) III and IV hepatoblastoma. The aim of this study was to prospectively assess the safety and oncological efficacy of aggressive non-transplant extended hepatic resection in these patients.

METHODS

A prospective study involved 18 children with central pretreatment extent of disease (PRETEXT) III and IV: three had primary liver transplantation whereas 15 underwent hepatic resection after neoadjuvant chemotherapy.

RESULTS

Median tumor volume was 317 mL (range, 135-546 mL). After four cycles of chemotherapy, POST-TEXT stage was III in 12 patients and IV in three patients. There was no perioperative mortality. Postoperative complications consisted of two bile leaks, one temporary decompensation and one sub-phrenic collection requiring drainage. One and 3 year disease-free survival was 93.3% and 73.3% respectively. The 3 year overall survival was 86.6%. Four patients developed recurrence, of whom two died. Early recurrence in 1 year occurred in one patient. All recurrences were distant metastases.

CONCLUSIONS

Extended major hepatic resection for selected cases of POST-TEXT III and IV hepatoblastoma is a technically challenging but feasible approach with acceptable morbidity and mortality rates. Oncological outcomes are similar to liver transplantation without the long-term commitment of immunosuppression or donor risk and morbidity, but a potential donor should always be organized on standby.