Treatment of hilar cholangiocarcinoma (Klatskin tumors) with hepatic resection or transplantation

Changing strategies in diagnosis and management of hilar cholangiocarcinoma

Hilar cholangiocarcinoma is one of the most difficult tumors to stage and treat. This study aims to evaluate (1) the best diagnostic imaging, (2) the usefulness of preoperative biliary drainage, (3) the resectability rate, and (4) the results of palliative treatments and surgical resection. Seventy-six patients with hilar cholangiocarcinoma with a mean age of 64 +/- 11 years were treated at our institution from 1989 to 1999. Patients were studied preoperatively using ultrasound, computed tomography (CT), and percutaneous cholangiography or magnetic resonance cholangiography. Forty-eight patients (63%) underwent palliative treatment. Twenty-eight patients underwent surgical curative therapy; 20 resections and 8 orthotopic liver transplantations (OLTs). Percutaneous transhepatic cholangiography was performed in 18 of 28 patients (64%), and magnetic resonance cholangiography in 5 patients; both methods were equally effective in establishing tumoral invasion of the biliary ducts. Five patients did not undergo either diagnostic modality. Excluding the patients who underwent OLT, no significant differences were found in surgical mortality (1 v 2 patients) or postoperative morbidity (100% v 66%) for patients with and without preoperative biliary drainage. The postoperative mortality rate was 11% (3 of 28 patients). The overall resectability rate was 37%. Mean survival in the surgical and palliative groups was 35 and 6 months, respectively (P <.0001). Patients who underwent OLT had a better 5-year survival rate than those treated by tumor resection (36% v 21%; P =.02). Combined chemotherapy and radiotherapy apparently did not provide a significant survival benefit. Helical CT and magnetic resonance cholangiography are useful techniques to delineate tumor extent and rule out vascular invasion and lymph node or liver metastases. No clear conclusions regarding preoperative drainage can be drawn from this study. A high resectability rate (37%) is feasible with major hepatectomy.

Treatment options for other hepatic malignancies

1. Resection rates for cholangiocarcinoma (unrelated to primary sclerosing cholangitis) have increased to 54% to 79%, and the subsequent 5-year survival rates are 24% to 31%. 2. Multimodality approaches involving various combinations of chemotherapy, irradiation, and surgery increasingly are being used to treat cholangiocarcinoma. 3. The role of liver transplantation in the management of cholangiocarcinoma is limited by the perception that it is inappropriate to use scarce organs when 5-year survival rates are 25%. 4. Liver transplantation is an important intervention in patients with tumors that remain unresectable after chemotherapy. The role of liver transplantation in patients with extrahepatic disease that responds to chemotherapy is controversial. Careful timing of surgery is required to avoid secondary drug resistance. 5. Liver transplantation has been successfully applied to a range of rare hepatic malignancies, but small numbers preclude strong recommendations on the appropriateness of this practice.

Cholangiocarcinoma of the extrahepatic bile ducts

Malignancies of the biliary tree, particularly the extrahepatic bile ducts, remain difficult clinical problems. Because experience with these uncommon tumors has been limited to a small number of centers, meaningful clinical trials have been difficult to perform. Complete resection remains the most effective therapy, but is usually possible in the minority of patients. Palliating the effects of biliary obstruction is thus often the primary therapeutic goal. Chemotherapy and radiation therapy have not been proven to reduce the incidence of recurrence after resection nor to improve survival in patients with unresectable disease. This review focuses on cholangiocarcinoma of the extrahepatic bile ducts.

Transplantation for liver and biliary cancer

The early survival of patients transplanted for liver and biliary cancer is excellent, but the overall mid- to long-term survival is poor. In an era of severe donor organ shortage, it is not justified to allocate donor liver to patients with a suboptimal outcome. Patients with non-resectable hepatocellular carcinoma in a non-cirrhotic liver should not be assigned to liver transplantation. Although patients with the fibrolamellar variant have a somewhat better outlook, they are still likely to recur, and the young age of many of these patients is likely to overwhelm any rational approach. The results of transplantation for early-stage hepatocellular carcinoma in a cirrhotic liver are similar to those achieved with benign disease. The inclusion of such cases as a group is justified, but attempts should be made to resect tumors whenever possible and to not assign the entire group to transplantation as the first and only option. The value of pre- and postoperative adjuvant therapy for this group is still under debate, but the present waiting period is so long that some form of therapy to slow growth and prevent dissemination of tumor cells is probably required. The results following transplantation for cholangiocarcinoma can only be regarded as dismal, and the diagnosis of cholangiocarcinoma is a contraindication for the procedure. Liver transplantation has a definite place in the treatment of epithelioid hemangioendothelioma and unresectable chemo-responsive hepatoblastoma when confined to the liver, and in a limited number of metastatic neuroendocrine tumors.

Cholangiocarcinoma of the extrahepatic bile ducts

Malignancies of the biliary tree, particularly the extrahepatic bile ducts, remain difficult clinical problems. Because experience with these uncommon tumors has been limited to a small number of centers, meaningful clinical trials have been difficult to perform. Complete resection remains the most effective therapy, but is usually possible in the minority of patients. Palliating the effects of biliary obstruction is thus often the primary therapeutic goal. Chemotherapy and radiation therapy have not been proven to reduce the incidence of recurrence after resection nor to improve survival in patients with unresectable disease. This review focuses on cholangiocarcinoma of the extrahepatic bile ducts.

Bile Duct Carcinoma: Trends in Treatment in the Nineties

Surgical resection provides the only known chance of cure for cholangiocarcinoma, and even then the 5-year survival is only 10 to 20%, and only one-third of patients are resectable for cure at the time of diagnosis. In recent years we have had considerable experience with endoscopic stenting to palliate common bile duct cancers. This has prompted us to evaluate our results for both endoscopic and surgical treatment of cholangiocarcinoma.

From January 1990 through June 1999, we reviewed our endoscopic retrograde cholangiopancreatography registry and the hospital records for patients we treated for cholangiocarcinoma. Fifty patients were identified: 45 with cholangiocarcinoma and five with gallbladder cancer (who were excluded). The surgical group consisted of 16 patients: in 14 patients, resection for cure was possible whereas two had palliative procedures. There was one mortality (6%) and the median survival was 16 months. There have been no long-term surgical survivors, but 2 patients are alive at 24 months. We treated 29 patients with advanced disease with endoscopic stents (the endoscopic group) mainly for relief of obstructive jaundice. Six of 29 patients in the endoscopic group were critically ill and died in less than 4 weeks, whereas 23 patients who were in better condition survived for a mean of 10 months (range 2–84 months). We conclude that for common duct bile cancer surgical resection remains the treatment of choice but is applicable in only 30 to 35 per cent of cases. Endoscopic stenting effectively relieves jaundice and can provide long-term palliation comparable with surgical bypass; 12 of 29 patients in our endoscopic group survived 12 months or longer, and one is alive at 84 months after initial stenting.

Palliative decompression of obstructive hilar malignancies utilizing an extrahilar biliary approach

Hilar cancers carry a dismal prognosis. Palliation of obstructive jaundice in patients with hilar cancer can be achieved by either surgical or nonsurgical means. Selection of the appropriate palliative measures is a challenging problem. Segmental bilioenteric anastomosis procedures were performed on 19 patients with hilar cancer. Seventeen of the bypasses were done to the segment III duct, known as the ligamentum teres approach, and two bypasses were to the segment V duct. Five patients, who had already been stented percutaneously or endoscopically, were operated on after the stents were clogged and a duodenal obstruction ensued. There were two postoperative deaths (10.5%) and four postoperative complications (21%). All of the 17 surviving patients experienced improvement in the level of jaundice postoperatively and the levels of serum total and direct bilirubin decreased by 78.9% and 84.2%, respectively. Two patients developed late cholangitis before death and were treated by external biliary drainage; one developed duodenal obstruction and was treated by gastrointestinal anastomosis. The mean length of hospital stay was 15.2 days. Mean survival was 8.2 months and the mean period of well-being was 7.8 months. Median survival was 7 months and median period of well being was 7 months. Three patients are still alive at 8, 8, and 24 months. These data suggest that the ligamentum teres approach offers effective palliation for patients with unresectable hilar cancer.

Liver transplantation for cholangiocarcinoma: results in 207 patients

BACKGROUND

Because of the high incidence of recurrent tumor, many surgeons have become disenchanted with transplantation as a treatment for cholangiocarcinoma.

METHODS

The Cincinnati Transplant Tumor Registry database was used to examine 207 patients who underwent liver transplantation for otherwise unresectable cholangiocarcinoma or cholangiohepatoma. Specific factors evaluated included tumor size, presence of multiple nodules, evidence of tumor spread at surgery, and treatment with adjuvant chemotherapy and/or radiation therapy. Incidentally found tumors were compared to tumors that were known or suspected to be present before transplantation.

RESULTS

The 1, 2, and 5-year survival estimates using life table analysis were 72, 48, and 23%. Fifty-one percent of patients had recurrence of their tumors after transplantation and 84% of recurrences occurred within 2 years of transplantation. Survival after recurrence was rarely more than 1 year. Forty-seven percent of recurrences occurred in the allograft and 30% in the lungs. Tumor recurrence, and evidence of tumor spread at the time of surgery, were negative prognostic variables. There were no positive prognostic variables. Patients with incidentally found cholangiocarcinomas did not have improved survival over patients with known or suspected tumors. A small number of patients survived for more than 5 years without recurrence. However, this group had no variable in common that would aid in the selection of similar patients in the future.

CONCLUSIONS

Because of the high rate of recurrent tumor and lack of positive prognostic variables, transplantation should seldom be used as a treatment for cholangiocarcinoma. For transplantation to be a viable treatment in the future, more effective adjuvant therapies are necessary.

Hilar cholangiocarcinoma: a review and commentary

Hilar cholangiocarcinoma is an uncommon cause of malignant biliary obstruction marked by local tumor spread for which surgery offers the only chance of cure. The diagnostic evaluation and surgical management of this disease continues to evolve. Although direct cholangiography and endoscopic biliary procedures have been used extensively to anatomically define the extent of tumor involvement, establish biliary decompression, and obtain histological confirmation of tumor, reliance on these invasive procedures is no longer necessary, and may be detrimental. Current noninvasive imaging technology permits accurate staging of the primary tumor and has improved patient selection for operative intervention without the need for invasive procedures. Overall survival has improved in accordance with an increasingly aggressive surgical approach. The propensity of this tumor for local invasion has led most experienced hepatobiliary centers to perform a partial hepatectomy in 50% to 100% of cases. Three-year survival rates of 35% to 50% can be achieved when negative histological margins are attained at the time of surgery. When resection is not feasible, either operative bilioenteric bypass or percutaneous transhepatic intubation can achieve significant palliation. There is no effective adjuvant therapy for this disease, and unless clear indications of unresectability exist, most patients should be considered for surgical exploration.

Prevention of bile duct cancer in primary sclerosing cholangitis

Patients with primary sclerosing cholangitis (PSC) have a substantial predisposition to develop bile duct carcinoma. The mechanism is still unclear but the observation that patients with chronic Clonorchis sinensis infection are also prone to cholangiocarcinoma suggests a role for long standing inflammation. However, there is still no effective medical therapy which can halt the progression of the disease or prevent the development of cholangiocarcinoma. The only effective treatment for advanced PSC is orthotopic liver transplantation (OLT) which in the absence of cholangiocarcinoma has a 5 year survival of 89%. Patients with cholangiocarcinoma who undergo liver transplantation have a high risk of recurrence and a dramatically worse survival. Therefore, the identification of patients with a sufficient deterioration in liver function to warrant OLT before they develop cholangiocarcinoma remains a central goal in the management of PSC. Ideally, screening patients with PSC would allow the identification of those with dysplastic change in the biliary epithelia before the development of overt carcinoma. However, although serum tumour markers such as CA 19.9 and CEA can be of value in aiding the diagnosis of cholangiocarcinoma in PSC there is currently no evidence that they are helpful in identifying those patients with premalignant changes of the biliary epithelia who would benefit from surgery. There are also no genetic markers to identify those at particular risk of malignant change. A recent report has suggested that regular biliary cytology sampling to detect dysplasia can predict the development of cholangiocarcinoma. However, regular instrumentation of the biliary tree to obtain cytology is unlikely to be widely adopted.

Biliary tract cancer

Recent advances in the molecular and cellular biology, diagnosis, and treatment of biliary tract cancer are reviewed. Several studies have delineated the molecular and cellular biology of cholangiocarcinoma and gallbladder carcinoma. Hepatocyte growth factor seems to be mitogenic to gallbladder carcinoma, and its inhibition may have a therapeutic role in this disease. Evidence against an adenoma-carcinoma pathway in gallbladder mucosa is presented. Helical computed tomography may improve staging accuracy in biliary tract disease and plays a definite role in diagnosis of and treatment planning in gallbladder polyps. Complete surgical resection continues to provide the best long-term prognosis, and surgical drainage is most beneficial in cholangiocarcinoma. Controversy continues about the effects of laparoscopic procedures and abdominal wall tumor recurrence.

Hepatobiliary malignancies. Primary hepatic malignant neoplasms

Primary hepatic tumors are epithelial, mesenchymal, or mixed in origin. Of these, epithelial tumors are the most common and include hepatocellular carcinoma, cholangiocarcinoma, mixed hepatocholangiocarcinoma, hepatoblastoma, and a variety of more rare tumors. Hepatocellular carcinoma, also know as hepatoma or malignant hepatoma, is the most common, followed by cholangiocarcinoma. This article discusses these two malignancies.