1
|
Kendall T, Overi D, Guido M, Braconi C, Banales J, Cardinale V, Gaudio E, Groot Koerkamp B, Carpino G. Recommendations on maximising the clinical value of tissue in the management of patients with intrahepatic cholangiocarcinoma. JHEP Rep 2024; 6:101067. [PMID: 38699072 PMCID: PMC11060959 DOI: 10.1016/j.jhepr.2024.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 05/05/2024] Open
Abstract
Background & Aims Patients with intrahepatic cholangiocarcinoma can now be managed with targeted therapies directed against specific molecular alterations. Consequently, tissue samples submitted to the pathology department must produce molecular information in addition to a diagnosis or, for resection specimens, staging information. The pathologist's role when evaluating these specimens has therefore changed to accommodate such personalised approaches. Methods We developed recommendations and guidance for pathologists by conducting a systematic review of existing guidance to generate candidate statements followed by an international Delphi process. Fifty-nine pathologists from 28 countries in six continents rated statements mapped to all elements of the specimen pathway from receipt in the pathology department to authorisation of the final written report. A separate survey of 'end-users' of the report including surgeons, oncologists, and gastroenterologists was undertaken to evaluate what information should be included in the written report to enable appropriate patient management. Results Forty-eight statements reached consensus for inclusion in the guidance including 10 statements about the content of the written report that also reached consensus by end-user participants. A reporting proforma to allow easy inclusion of the recommended data points was developed. Conclusions These guiding principles and recommendations provide a framework to allow pathologists reporting on patients with intrahepatic cholangiocarcinoma to maximise the informational yield of specimens required for personalised patient management. Impact and Implications Biopsy or resection lesional tissue from intrahepatic cholangiocarcinoma must yield information about the molecular abnormalities within the tumour that define suitability for personalised therapies in addition to a diagnosis and staging information. Here, we have developed international consensus guidance for pathologists that report such cases using a Delphi process that sought the views of both pathologists and 'end-users of pathology reports. The guide highlights the need to report cases in a way that preserves tissue for molecular testing and emphasises that reporting requires interpretation of histological characteristics within the broader clinical and radiological context. The guide will allow pathologists to report cases of intrahepatic cholangiocarcinoma in a uniform manner that maximises the value of the tissue received to facilitate optimal multidisciplinary patient management.
Collapse
Affiliation(s)
- Timothy Kendall
- University of Edinburgh Centre for Inflammation Research and Edinburgh Pathology, University of Edinburgh, Edinburgh, UK
| | - Diletta Overi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Maria Guido
- Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Chiara Braconi
- School of Cancer Sciences, University of Glasgow, CRUK Scotland Cancer Centre, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Jesus Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute, Donostia University Hospital, CIBERehd and University of the Basque Country (UPV/EHU), San Sebastian, Spain
- Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
| | - Vincenzo Cardinale
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Guido Carpino
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
2
|
Golriz M, Ramouz A, Hammad A, Aminizadeh E, Sabetkish N, Khajeh E, Ghamarnejad O, Carvalho C, Rio-Tinto H, Chang DH, Joao AA, Goncalves G, Mehrabi A. Promising Results of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Perihilar Cholangiocarcinoma in a Systematic Review and Single-Arm Meta-Analysis. Cancers (Basel) 2024; 16:771. [PMID: 38398162 PMCID: PMC10887221 DOI: 10.3390/cancers16040771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND ALPPS popularity is increasing among surgeons worldwide and its indications are expanding to cure patients with primarily unresectable liver tumors. Few reports recommended limitations or even contraindications of ALPPS in perihilar cholangiocarcinoma (phCC). Here, we discuss the results of ALPPS in patients with phCC in a systematic review as well as a pooled data analysis. METHODS MEDLINE and Web of Science databases were systematically searched for relevant literature up to December 2023. All studies reporting ALPPS in the management of phCC were included. A single-arm meta-analysis of proportions was carried out to estimate the overall rate of outcomes. RESULTS After obtaining 207 articles from the primary search, data of 18 studies containing 112 phCC patients were included in our systematic review. Rates of major morbidity and mortality were calculated to be 43% and 22%, respectively. The meta-analysis revealed a PHLF rate of 23%. One-year disease-free survival was 65% and one-year overall survival was 69%. CONCLUSIONS ALPPS provides a good chance of cure for patients with phCC in comparison to alternative treatment options, but at the expense of debatable morbidity and mortality. With refinement of the surgical technique and better perioperative patient management, the results of ALPPS in patients with phCC were improved.
Collapse
Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Clinic of General and Visceral Surgery, Diakonie in Südwestfallen, 57076 Siegen, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Ahmed Hammad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Nastaran Sabetkish
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Carlos Carvalho
- Digestive Oncology Unit, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - Hugo Rio-Tinto
- Department of Radiology, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - De-Hua Chang
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Ana Alagoa Joao
- Hepato-Pancreato-Biliary Surgery Unit, Department of Digestive Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (A.A.J.); (G.G.)
| | - Gil Goncalves
- Hepato-Pancreato-Biliary Surgery Unit, Department of Digestive Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (A.A.J.); (G.G.)
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
| |
Collapse
|
3
|
Lederer AK, Rasel H, Kohnert E, Kreutz C, Huber R, Badr MT, Dellweg PKE, Bartsch F, Lang H. Gut Microbiota in Diagnosis, Therapy and Prognosis of Cholangiocarcinoma and Gallbladder Carcinoma-A Scoping Review. Microorganisms 2023; 11:2363. [PMID: 37764207 PMCID: PMC10538110 DOI: 10.3390/microorganisms11092363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/09/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Cancers of the biliary tract are more common in Asia than in Europe, but are highly lethal due to delayed diagnosis and aggressive tumor biology. Since the biliary tract is in direct contact with the gut via the enterohepatic circulation, this suggests a potential role of gut microbiota, but to date, the role of gut microbiota in biliary tract cancers has not been elucidated. This scoping review compiles recent data on the associations between the gut microbiota and diagnosis, progression and prognosis of biliary tract cancer patients. Systematic review of the literature yielded 154 results, of which 12 studies and one systematic review were eligible for evaluation. The analyses of microbiota diversity indices were inconsistent across the included studies. In-depth analyses revealed differences between gut microbiota of biliary tract cancer patients and healthy controls, but without a clear tendency towards particular species in the studies. Additionally, most of the studies showed methodological flaws, for example non-controlling of factors that affect gut microbiota. At the current stage, there is a lack of evidence to support a general utility of gut microbiota diagnostics in biliary tract cancers. Therefore, no recommendation can be made at this time to include gut microbiota analyses in the management of biliary tract cancer patients.
Collapse
Affiliation(s)
- Ann-Kathrin Lederer
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
- Center for Complementary Medicine, Department of Medicine II, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Hannah Rasel
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
| | - Eva Kohnert
- Institute of Medical Biometry and Statistics (IMBI), Faculty of Medicine and Medical Center, University of Freiburg, 79104 Freiburg, Germany
| | - Clemens Kreutz
- Institute of Medical Biometry and Statistics (IMBI), Faculty of Medicine and Medical Center, University of Freiburg, 79104 Freiburg, Germany
| | - Roman Huber
- Center for Complementary Medicine, Department of Medicine II, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Mohamed Tarek Badr
- Institute of Medical Microbiology and Hygiene, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany;
| | - Patricia K. E. Dellweg
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
| | - Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
| |
Collapse
|
4
|
Mixed Hepatocellular Cholangiocarcinoma: A Comparison of Survival between Mixed Tumors, Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma from a Single Center. Cancers (Basel) 2023; 15:cancers15030639. [PMID: 36765596 PMCID: PMC9913586 DOI: 10.3390/cancers15030639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the most frequent primary liver malignancy, followed by intrahepatic cholangiocarcinoma (ICC). In addition, there is a mixed form for which only limited data are available. The aim of this study was to compare recurrence and survival of the mixed form within the cohorts of patients with HCC and ICC from a single center. METHODS Between January 2008 and December 2020, all patients who underwent surgical exploration for ICC, HCC, or mixed hepatocellular cholangiocarcinoma (mHC-CC) were included in this retrospective analysis. The data were analyzed, focusing on preoperative and operative details, histological outcome, and tumor recurrence, as well as overall and recurrence-free survival. RESULTS A total of 673 surgical explorations were performed, resulting in 202 resections for ICC, 344 for HCC (225 non-cirrhotic HCC, ncHCC; 119 cirrhotic HCC, cHCC), and 14 for mHC-CC. In addition, six patients underwent orthotopic liver transplant (OLT) in the belief of dealing with HCC. In 107 patients, tumors were irresectable (resection rate of 84%). Except for the cHCC group, major or even extended liver resections were required. Vascular or visceral extensions were performed regularly. Overall survival (OS) was highly variable, with a median OS of 17.6 months for ICC, 26 months for mHC-CC, 31.8 months for cHCC, and 37.2 months for ncHCC. Tumor recurrence was common, with a rate of 45% for mHC-CC, 48.9% for ncHCC, 60.4% for ICC, and 67.2% for cHCC. The median recurrence-free survival was 7.3 months for ICC, 14.4 months for cHCC, 16 months for mHC-CC, and 17 months for ncHCC. The patients who underwent OLT for mHC-CC showed a median OS of 57.5 and RFS of 56.5 months. CONCLUSIONS mHC-CC has a comparable course and outcome to ICC. The cholangiocarcinoma component seems to be the dominant one and, therefore, may be responsible for the prognosis. 'Accidental' liver transplant for mHC-CC within the Milan criteria offers a good long-term outcome. This might be an option in countries with no or minor organ shortage.
Collapse
|
5
|
Wang WQ, Li J, Liang BY, Lv X, Zhu RH, Wang JL, Huang ZY, Yang SH, Zhang EL. Anatomical liver resection improves surgical outcomes for combined hepatocellular-cholangiocarcinoma: A propensity score matched study. Front Oncol 2022; 12:980736. [PMID: 36059669 PMCID: PMC9433922 DOI: 10.3389/fonc.2022.980736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe efficacies of anatomical resection (AR) and non-anatomical resection (NAR) in the treatment of combined hepatocellular-cholangiocarcinoma (cHCC-CCA) remain unclear. This study aimed to compare the prognostic outcomes of AR with those of NAR for cHCC-CCA.MethodPatients diagnosed with pathology-confirmed cHCC-CCA, and who underwent curative resection at Tongji hospital between January 2010 and December 2019 were included in this retrospective study. A one-to-one propensity score matching (PSM) analysis was used to compare the long-term outcomes of AR to those of NAR.ResultsA total of 105 patients were analyzed, of whom 48 (45.7%) and 57 (54.3%) underwent AR and NAR, respectively. There were no significant differences in short-term outcomes between the two groups, including duration of postoperative hospital stay, the incidence of perioperative complications, and incidence of 30-day mortality. However, both, the 5-year overall survival (OS) and recurrence-free survival (RFS) rates of AR were significantly better than those of NAR (40.5% vs. 22.4%, P=0.002; and 37.3% vs. 14.4%, P=0.002, respectively). Multivariate analysis showed that NAR, multiple tumors, larger-sized tumors (>5 cm), cirrhosis, lymph node metastasis, and vascular invasion were independent risk factors for poor prognoses. Stratified analysis demonstrated similar outcomes following AR versus NAR for patients with tumors > 5cm in diameter, while AR had better survival than NAR in patients with tumors ≤5 cm in diameter. After PSM, when 34 patients from each group were matched, the 5-year OS and RFS rates of AR were still better than those of NAR.ConclusionPatients with cHCC-CCA who underwent AR had better long-term surgical outcomes than those who underwent NAR, especially for those with tumors ≤5 cm in diameter. However, no differences in the risk of surgical complications were detected between the two groups.
Collapse
Affiliation(s)
- Wen-qiang Wang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian Li
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin-yong Liang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xing Lv
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong-hua Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jin-lin Wang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhi-yong Huang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shu-hong Yang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Er-lei Zhang, ; Shu-hong Yang,
| | - Er-lei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Er-lei Zhang, ; Shu-hong Yang,
| |
Collapse
|
6
|
Lang H, Baumgart J, Heinrich S, Huber T, Heuft LK, Margies R, Mittler J, Hahn F, Gerber TS, Foerster F, Weinmann A, Marquardt JU, Kloeckner R, Straub BK, Bartsch F. Liver Resection for Intrahepatic Cholangiocarcinoma-Single-Center Experience with 286 Patients Undergoing Surgical Exploration over a Thirteen Year Period. J Clin Med 2021; 10:jcm10163559. [PMID: 34441855 PMCID: PMC8396970 DOI: 10.3390/jcm10163559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/05/2021] [Accepted: 08/10/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Intrahepatic cholangiocarcinoma (iCCA) accounts for about 10% of primary liver cancer. Surgery is the only potentially curative treatment. We report on our current series of 229 consecutive hepatic resections for iCCA, which is one of the largest Western single-center series published so far. Methods: Between January 2008 to December 2020, a total of 286 patients underwent 307 surgical explorations for intended liver resection of iCCA at our department. Data were analyzed with regard to (1) preoperative treatment of tumor, (2) operative details, (3) perioperative morbidity and mortality, (4) histopathology, (5) outcome measured by tumor recurrence, treatment of recurrence and survival and (6) prognostic factors for overall and disease-free survival. Results: the resectability rate was 74.6% (229/307). In total, 202 primary liver resections, 21 repeated, 5 re-repeated, and 1 re-re-repeated liver resections were performed. In primary liver resections there were 77% (155/202) major hepatectomies. In 39/202 (20%) of patients additional hepatic wedge resections and in 87/202 (43%) patients additional 119 other surgical procedures were performed next to hepatectomy. Surgical radicality in first liver resections was 166 R0-, 33 R1- and 1 R2-resection. Following the first liver resection, the calculated 1-, 3- and 5-year-survival is 80%, 39%, and 22% with a median survival of 25.8 months. Until the completion of data acquisition, tumors recurred in 123/202 (60.9%) patients after a median of 7.5 months (range 1–87.2 months) after resection. A multivariate cox regression revealed tumor size (p < 0.001), T stage (p < 0.001) and N stage (p = 0.003) as independent predictors for overall survival. N stage (p = 0.040), preoperative therapy (p = 0.005), T stage (p = 0.004), tumor size (p = 0.002) and M stage (p = 0.001) were independent predictors for recurrence-free survival. Conclusions: For complete surgical removal, often extended liver resection in combination with complex vascular or biliary reconstruction is required. However, despite aggressive surgery, tumor recurrence is frequent and long-term oncological results are poor. This indicated that surgery alone is unlikely to make great strides in improving prognosis of patients with iCCA, instead clearly suggesting that liver resection should be incorporated in multimodal treatment concepts.
Collapse
Affiliation(s)
- Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
- Correspondence: ; Tel.: +49-61-3117-7291
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
| | - Stefan Heinrich
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
| | - Tobias Huber
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
| | - Lisa-Katharina Heuft
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
| | - Rabea Margies
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
| | - Jens Mittler
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
| | - Felix Hahn
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.H.); (R.K.)
| | - Tiemo S. Gerber
- Department of Pathology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (T.S.G.); (B.K.S.)
| | - Friedrich Foerster
- 1st Department of Internal Medicine, Gastroenterology and Hepatology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.F.); (A.W.)
| | - Arndt Weinmann
- 1st Department of Internal Medicine, Gastroenterology and Hepatology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.F.); (A.W.)
| | - Jens U. Marquardt
- 1st Department of Medicine, University Medical Centre Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany;
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.H.); (R.K.)
| | - Beate K. Straub
- Department of Pathology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (T.S.G.); (B.K.S.)
| | - Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (J.B.); (S.H.); (T.H.); (L.-K.H.); (R.M.); (J.M.); (F.B.)
| |
Collapse
|
7
|
Bartsch F, Hahn F, Müller L, Baumgart J, Hoppe-Lotichius M, Kloeckner R, Lang H. Intrahepatic cholangiocarcinoma: Introducing the preoperative prediction score based on preoperative imaging. Hepatobiliary Pancreat Dis Int 2021; 20:262-270. [PMID: 32861577 DOI: 10.1016/j.hbpd.2020.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/10/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (ICC) still has a poor long-term outcome, even after complete resection. We investigated different parameters gathered in preoperative imaging and analyzed their influence on resectability, recurrence, and survival. METHODS All patients who underwent exploration due to ICC between January 2008 and June 2018 were analyzed retrospectively. Kaplan-Meier model, log-rank test and Cox regression were used. RESULTS Out of 184 patients, 135 (73.4%) underwent curative intended resection. Median overall survival (OS) was 22.2 months with a consecutive 1-, 3- and 5-year OS of 73%, 29%, and 17%. Median recurrence-free survival (RFS) was 9.3 months with a consecutive 1-, 3- and 5-year RFS of 36%, 15%, and 11%. Site of tumor, parenchymal localization, tumor configuration/dissemination, and estimated tumor volume had significant influence on resectability. Univariate analyses showed that site of tumor, tumor configuration/dissemination, number of nodules, and estimated tumor volume had predictive values for OS and RFS. Together with tumor size the preoperative prediction (POP) score was created showing significance for OS and RFS (all P < 0.001). In multivariate analysis, POP score (HR = 1.779; 95% CI: 1.268-2.495; P = 0.001), T stage (HR = 1.255; 95% CI: 1.040-1.514; P = 0.018) and N stage (HR = 1.334; 95% CI: 1.081-1.645; P = 0.007) were the independent predictors for OS. For RFS, POP score (HR = 1.733; 95% CI: 1.300-2.311; P < 0.001) and M stage (HR = 3.036; 95% CI: 1.376-6.697; P = 0.006) were the independent predictors. CONCLUSIONS The POP score showed to have a highly significant influence on OS and RFS. The score is easy to assess through preoperative imaging. For patients in the high risk group at least staging laparoscopy or preoperative chemotherapy should be evaluated, because they showed equal outcome compared to the irresectable group.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst, 1, 55131 Mainz, Germany
| | - Felix Hahn
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst, 1, 55131 Mainz, Germany
| | - Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst, 1, 55131 Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst, 1, 55131 Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst, 1, 55131 Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst, 1, 55131 Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst, 1, 55131 Mainz, Germany.
| |
Collapse
|
8
|
Bartsch F, Heuft LK, Baumgart J, Hoppe-Lotichius M, Margies R, Gerber TS, Foerster F, Weinmann A, Straub BK, Mittler J, Heinrich S, Lang H. Influence of Lymphangio (L), Vascular (V), and Perineural (Pn) Invasion on Recurrence and Survival of Resected Intrahepatic Cholangiocarcinoma. J Clin Med 2021; 10:jcm10112426. [PMID: 34070745 PMCID: PMC8199279 DOI: 10.3390/jcm10112426] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/21/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022] Open
Abstract
(1) Background: Intrahepatic cholangiocarcinoma (ICC) is a rare malignancy. Besides tumor, nodal, and metastatic status, the UICC TNM classification describes further parameters such as lymphangio- (L0/L1), vascular (V0/V1/V2), and perineural invasion (Pn0/Pn1). The aim of this study was to analyze the influence of these parameters on recurrence and survival. (2) Methods: All surgical explorations for patients with ICC between January 2008 and June 2018 were collected and further analyzed in our institutional database. Statistical analyses focused on perineural, lymphangio-, and vascular invasion examined histologically and their influence on tumor recurrence and survival. (3) Results: Of 210 patients who underwent surgical exploration, 150 underwent curative-intended resection. Perineural invasion was present in 41, lymphangioinvasion in 21, and vascular invasion in 37 patients (V1 n = 34, V2 n = 3). Presence of P1, V+ and L1 was significantly associated with positivity of each other of these factors (p < 0.001, each). None of the three parameters showed direct influence on tumor recurrence in general, but perineural invasion influenced extrahepatic recurrence significantly (p = 0.019). Whereas lymphangio and vascular invasion was neither associated with overall nor recurrence-free survival, perineural invasion was significantly associated with a poor 1-, 3- and 5-year overall survival (OS) of 80%, 35%, and 23% for Pn0 versus 75%, 23%, and 0% for Pn1 (p = 0.027). Concerning recurrence-free survival (RFS), Pn0 showed a 1-, 3- and 5-year RFS of 42%, 18%, and 16% versus 28%, 11%, and 0% for Pn1, but no significance was reached (p = 0.091). (4) Conclusions: Whereas lymphangio- and vascular invasion showed no significant influence in several analyses, the presence of perineural invasion was associated with a significantly higher risk of extrahepatic tumor recurrence and worse overall survival.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
| | - Lisa-Katharina Heuft
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
| | - Maria Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
| | - Rabea Margies
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
| | - Tiemo S. Gerber
- Department of Pathology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (T.S.G.); (B.K.S.)
| | - Friedrich Foerster
- 1st Department of Internal Medicine, Gastroenterology and Hepatology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.F.); (A.W.)
| | - Arndt Weinmann
- 1st Department of Internal Medicine, Gastroenterology and Hepatology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.F.); (A.W.)
| | - Beate K. Straub
- Department of Pathology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (T.S.G.); (B.K.S.)
| | - Jens Mittler
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
| | - Stefan Heinrich
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (F.B.); (L.-K.H.); (J.B.); (M.H.-L.); (R.M.); (J.M.); (S.H.)
- Correspondence: ; Tel.: +49-6131-177291
| |
Collapse
|
9
|
Bartsch F, Eberhard J, Rückert F, Schmelzle M, Lehwald-Tywuschik N, Fichtner-Feigl S, Gaedcke J, Oldhafer KJ, Oldhafer F, Diener M, Mehrabi A, Settmacher U, Becker T, Keck T, Friess H, Strücker B, Opitz S, Lemke J, Schnitzbauer A, Lang H. Repeated resection for recurrent intrahepatic cholangiocarcinoma: A retrospective German multicentre study. Liver Int 2021; 41:180-191. [PMID: 32997886 DOI: 10.1111/liv.14682] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tumour recurrence is common after resection of intrahepatic cholangiocarcinoma (ICC). Repeated resection is a potential curative treatment, but outcomes are not well-defined thus far. The aim of this retrospective multicentre cohort study was to show the feasibility and survival of repeated resection of ICC recurrence. METHODS Data were collected from 18 German hepato-pancreatico-biliary centres for patients who underwent repeated exploration of recurrent ICC between January 2008 and December 2017. Primary end points were overall (OS) and recurrence-free survival from the day of primary and repeated resection. RESULTS Of 156 patients who underwent repeated exploration for recurrent ICC, 113 underwent re-resection. CA19-9 prior to primary resection, R status of first liver resection and median time to recurrence were significant determinants of repeated resectability. Median OS in the repeated resection group was 65.2 months, with consecutive 1-, 3- and 5-year OS of 98%, 78% and 57% respectively. After re-exploration, median OS from primary resection was 46.7 months, with a consecutive 1-, 3- and 5-year OS of 95%, 55% and 22% respectively. From the day of repeated resection, the median OS was 36.8 months, with a consecutive 1-, 3- and 5-year OS of 86%, 51% and 34% respectively. Minor morbidity (grade I+II) was present in 27%, grade IIIa-IVb morbidity in 20% and mortality in 3.5% of patients. CONCLUSION Repeated resection of ICC has acceptable morbidity and mortality and seems to be associated with improved long-term survival. Structured follow-up after resection of ICC is necessary for early identification of these patients.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery - University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Johannes Eberhard
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Felix Rückert
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jochen Gaedcke
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Karl J Oldhafer
- Division of Hepatopancreatobiliary (HPB) Surgery, Department of Surgery, Asklepios Hospital Barmbek, Semmelweis University, Hamburg, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Markus Diener
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Utz Settmacher
- Clinic for General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Thomas Becker
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig Holstein, Kiel, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Benjamin Strücker
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Münster, Münster, Germany
| | - Sabine Opitz
- Department of Surgery, Regensburg University Medical Center, Regensburg, Germany
| | - Johannes Lemke
- Department of General and Visceral Surgery, Ulm University Hospital, Ulm, Germany
| | - Andreas Schnitzbauer
- Department of General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery - University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | |
Collapse
|
10
|
Ito S, Takahashi Y, Yamada T, Kawai Y, Ohira K. Intrahepatic cholangiocarcinoma with gastric infiltration misdiagnosed as gastric submucosal tumor. J Surg Case Rep 2020; 2020:rjaa359. [PMID: 33214863 PMCID: PMC7655014 DOI: 10.1093/jscr/rjaa359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 08/11/2020] [Indexed: 11/13/2022] Open
Abstract
Intrahepatic cholangiocarcinomas (ICC) are rare primary liver tumors. In few cases, they may invade nearby organs and present as extrahepatic growths, leading to poor prognosis. We report a case of a 78-year-old man who presented with fatigue. An upper gastrointestinal endoscopy was performed to find a cause for his anemia, which showed a submucosal tumor with delle at the lesser curvature of the gastric cardia. A computed tomography revealed a low-density tumor of diameter 70 mm at the cardia. It appeared to infiltrate the liver directly. We performed lateral hepatectomy, proximal gastrectomy and lymphadenectomy. The pathological findings revealed an ICC with gastric infiltration. Although adjuvant chemotherapy was administered, 12 months postoperatively, the patient developed pain and multiple bone metastases for which palliative radiation was initiated. The guidelines for lymphadenectomy and adjuvant chemotherapy in such cases are unclear. Appropriate regional lymphadenectomy and adjuvant chemotherapy can improve the prognosis of such patients.
Collapse
Affiliation(s)
- Shunichi Ito
- Department of Surgery, Tama-Hokubu Medical Center, Tokyo, Japan
| | | | - Takuji Yamada
- Department of Surgery, Tama-Hokubu Medical Center, Tokyo, Japan
| | - Yosuke Kawai
- Department of Surgery, Tama-Hokubu Medical Center, Tokyo, Japan
| | - Kei Ohira
- Department of Surgery, Tama-Hokubu Medical Center, Tokyo, Japan
| |
Collapse
|
11
|
Conci S, Viganò L, Ercolani G, Gonzalez E, Ruzzenente A, Isa G, Salaris C, Fontana A, Bagante F, Pedrazzani C, Campagnaro T, Iacono C, De Santibanes E, Pinna DA, Torzilli G, Guglielmi A. Outcomes of vascular resection associated with curative intent hepatectomy for intrahepatic cholangiocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:1727-1733. [PMID: 32360063 DOI: 10.1016/j.ejso.2020.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS We aimed to investigate the impact of vascular resection (VR) on postoperative outcomes and survival of patients undergoing hepatectomy for intrahepatic cholangiocarcinoma (ICC). METHODS A retrospective analysis of a multi-institutional series of 270 patients with resected ICC was carried out. Patients were divided into three groups: portal vein VR (PVR), inferior vena cava VR (CVR) and no VR (NVR). Univariate and multivariate analysis were applied to define the impact of VR on postoperative outcomes and survival. RESULTS Thirty-one patients (11.5%) underwent VR: 15 (5.6%) to PVR and 16 (5.9%) to CVR. R0 resection rates were 73.6% in NVR, 73.3% of PVR and 68.8% in CVR. The postoperative mortality rate was increased in VR groups: 2.5% in NVR, 6.7% in PVR and 12.5% in CVR. The 5-years overall survival (OS) rates progressively decreased from 38.4% in NVR, to 30.1% in CVR and to 22.2% in PVR, p = 0.030. However, multivariable analysis did not confirm an association between VR and prognosis. The following prognostic factors were identified: size ≥50 mm, patterns of distribution of hepatic nodules (single, satellites or multifocal), lymph-node metastases (N1) and R1 resections. In the VR group the 5-years OS rate in patients without lymph-node metastases undergoing R0 resection (VRR0N0) was 44.4%, while in N1 patients undergoing R1 resection was 20% (p < 0.001). CONCLUSION Vascular resection (PVR and CVR) is associated with higher operative risk, but seems to be justified by the good survival results, especially in patients without other negative prognostic factors (R0N0 resections).
Collapse
Affiliation(s)
- Simone Conci
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy.
| | - Luca Viganò
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano (Milan), Italy
| | - Giorgio Ercolani
- Department of General and Emergency Surgery and Organ Transplantation, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Esteban Gonzalez
- Department of Surgery, Division of General and Endocrine Surgery, University of Cagliari, Cagliari, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Giulia Isa
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Claudia Salaris
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy; Department of Surgery, Division of General and Endocrine Surgery, University of Cagliari, Cagliari, Italy
| | - Andrea Fontana
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano (Milan), Italy
| | - Fabio Bagante
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Corrado Pedrazzani
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Tommaso Campagnaro
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Calogero Iacono
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Eduardo De Santibanes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniele Antonio Pinna
- Department of General and Emergency Surgery and Organ Transplantation, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Guido Torzilli
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano (Milan), Italy
| | - Alfredo Guglielmi
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| |
Collapse
|
12
|
Beetz O, Weigle CA, Cammann S, Vondran FWR, Timrott K, Kulik U, Bektas H, Klempnauer J, Kleine M, Oldhafer F. Preoperative leukocytosis and the resection severity index are independent risk factors for survival in patients with intrahepatic cholangiocarcinoma. Langenbecks Arch Surg 2020; 405:977-988. [PMID: 32815017 PMCID: PMC7541380 DOI: 10.1007/s00423-020-01962-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/09/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The incidence of intrahepatic cholangiocarcinoma is increasing worldwide. Despite advances in surgical and non-surgical treatment, reported outcomes are still poor and surgical resection remains to be the only chance for long-term survival of affected patients. The identification and validation of prognostic factors and scores, such as the recently introduced resection severity index, for postoperative morbidity and mortality are essential to facilitate optimal therapeutic regimens. METHODS This is a retrospective analysis of 269 patients undergoing resection of histologically confirmed intrahepatic cholangiocarcinoma between February 1996 and September 2018 at a tertiary referral center for hepatobiliary surgery. Regression analyses were performed to evaluate potential prognostic factors, including the resection severity index. RESULTS Median postoperative follow-up time was 22.93 (0.10-234.39) months. Severe postoperative complications (≥ Clavien-Dindo grade III) were observed in 94 (34.9%) patients. The body mass index (p = 0.035), the resection severity index (ASAT in U/l divided by Quick in % multiplied by the extent of liver resection graded in points; p = 0.006), additional hilar bile duct resection (p = 0.005), and number of packed red blood cells transfused during operation (p = 0.036) were independent risk factors for the onset of severe postoperative complications. Median Kaplan-Meier survival after resection was 27.63 months. Preoperative leukocytosis (p = 0.003), the resection severity index (p = 0.005), multivisceral resection (p = 0.001), and T stage ≥ 3 (p = 0.013) were identified as independent risk factors for survival. CONCLUSION Preoperative leukocytosis and the resection severity index are useful variables for preoperative risk stratification since they were identified as significant predictors for postoperative morbidity and mortality, respectively.
Collapse
Affiliation(s)
- Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
| | - Clara A Weigle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Sebastian Cammann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Kai Timrott
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Ulf Kulik
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Hüseyin Bektas
- Department of General, Visceral and Oncological Surgery, Hospital Group Gesundheit Nord, Bremen, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Moritz Kleine
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| |
Collapse
|
13
|
Bartsch F, Hahn F, Müller L, Baumgart J, Hoppe-Lotichius M, Kloeckner R, Lang H. Relevance of suspicious lymph nodes in preoperative imaging for resectability, recurrence and survival of intrahepatic cholangiocarcinoma. BMC Surg 2020; 20:75. [PMID: 32295646 PMCID: PMC7161232 DOI: 10.1186/s12893-020-00730-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/26/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (ICC) is often diagnosed at an advanced stage resulting in a low resectability rate. Even after potentially curative resection the risk for tumor recurrence is high. Although the extent and value of lymphadenectomy is part of ongoing discussion, the role of preoperative imaging for assessment of suspicious lymph nodes (suspLN) has only been studied modestly. Aim of this study is to demonstrate the influence of suspicious lymph nodes in preoperative imaging on resectability, recurrence, and long-term outcome. METHODS All patients who underwent exploration for ICC between January 2008 and June 2018 were included. Preoperative imaging (CT or MRI) was analysed with focus on suspLN at the hepatoduodenal ligament, lesser curvature, interaortocaval, and superior to the diaphragm; suspLN were classified according to the universally accepted RECIST 1.1 criteria; histopathology served as gold standard. RESULTS Out of 187 patients resection was performed in 137 (73.3%), in 50 patients the procedure was terminated after exploration. Overall, suspLN were found preoperatively in 73/187 patients (39%). Comparing patients who underwent resection and exploration only, suspLN were significantly more common in the exploration group (p = 0.011). Regarding lymph node stations, significant differences could be shown regarding resectability: All tumors with suspLN superior to the diaphragm were irresectable. Preoperative imaging assessment showed a strong correlation with final histopathology, especially of suspLN of the hepatoduodenal ligament and the lesser curvature. Sensitivity of suspLN was 71.1%, specificity 90.8%. Appearance of tumor recurrence was not affected by suspLN (p = 0.289). Using a short-axis cut-off of <> 1 cm, suspLN had significant influence on recurrence-free survival (RFS, p = 0.009) with consecutive 1-, 3-, and 5-year RFS of 41, 21, and 15% versus 29, 0, and 0%, respectively. Similarly, 1-, 3- and 5-year overall survival (OS) was 75, 30, and 18% versus 59, 18, and 6%, respectively (p = 0.040). CONCLUSION Suspicious lymph nodes in preoperative imaging are predictor for unresectability and worse survival. Explorative laparoscopy should be considered, if distant suspicious lymph nodes are detected in preoperative imaging. Nevertheless, given a sensitivity of only 71.1%, detection of suspicious lymph nodes in the preoperative imaging alone is not sufficient to allow for a clear-cut decision against a surgical approach.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
| | - Felix Hahn
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst. 1, 55131, Mainz, Germany.
| |
Collapse
|
14
|
Bartsch F, Baumgart J, Hoppe-Lotichius M, Straub BK, Heinrich S, Lang H. Intrahepatic cholangiocarcinoma - influence of resection margin and tumor distance to the liver capsule on survival. BMC Surg 2020; 20:61. [PMID: 32252724 PMCID: PMC7137203 DOI: 10.1186/s12893-020-00718-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 03/17/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (ICC) is often diagnosed in advanced stage. Aim of this study was to analyse the influence of resection margins and tumor distance to the liver capsule on survival and recurrence in a single center with a high number of extended resections. METHODS From January 2008 to June 2018 data of all patients with ICC were collected and further analysed with Kaplan Meier Model, Cox regression or Chi2 test for categorical data. RESULTS Out of 210 included patients 150 underwent curative intended resection (71.4%). Most patients required extended resections (n = 77; 51.3%). R0-resection was achieved in 131 patients (87.3%) with minimal distances to the resection margin > 1 cm in 22, 0.5-1 cm in 11, 0.1-0.5 cm in 49 patients, and < 0.1 cm in 49 patients. Overall survival (OS) for margins > 0.5 cm compared to 0.5-0.1 cm or R1 was better, but without reaching significance. All three groups had significantly better OS compared to the irresectable group. Recurrence-free survival (RFS) was also better in patients with a margin > 0.5 cm than in the < 0.5-0.1 cm or the R1-group, but even without reaching significance. Different distance to the liver capsule significantly affected OS, but not RFS. CONCLUSIONS Wide resection margins (> 0.5 cm) should be targeted but did not show significantly better OS or RFS in a cohort with a high percentage of extended resections (> 50%). Wide margins, narrow margins and even R1 resections showed a significant benefit over the irresectable group. Therefore, extended resections should be performed, even if only narrow margins can be achieved.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Beate K Straub
- Department of Pathology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| |
Collapse
|
15
|
Bartsch F, Baumgart J, Tripke V, Hoppe-Lotichius M, Heinrich S, Lang H. Resection of intrahepatic cholangiocarcinoma in elderly patients - is it reasonable? BMC Surg 2019; 19:157. [PMID: 31664988 PMCID: PMC6819605 DOI: 10.1186/s12893-019-0620-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/10/2019] [Indexed: 01/07/2023] Open
Abstract
Background Intrahepatic cholangiocarinoma (ICC) has a rising incidence in western countries. Often major or extended resections are necessary for complete tumor removal. Due to demographical trends the number of elderly patients diagnosed with ICC is rising accordingly. Aim of this study is to show whether resection of ICC in elderly patients is reasonable or not. Methods Between January 2008 and June 2018 all consecutive patients with ICC were collected. Analyses were focussed on the performed resection, its extent, postoperative morbidity and mortality as well as survival. Statistics were performed with Chi2 test for categorical data and for survival analyses the Kaplan Meier model with log rank test was used. Results In total 210 patients underwent surgical exploration with 150 resections (71.4%). Patients were divided in 70-years cut-off groups (> 70 vs < 70 years of age) as well as a young (age 30–50, n = 23), middle-age (50–70, n = 76) and old (> 70, n = 51) group, whose results are presented here. Resectability (p = 0.709), extent of surgery (p = 0.765), morbidity (p = 0.420) and mortality (p = 0.965) was comparable between the different age groups. Neither visceral (p = 0.991) nor vascular (p = 0.614) extension differed significantly, likewise tumor recurrence (p = 0.300) or the localisation of recurrence (p = 0.722). In comparison of patients > or < 70 years of age, recurrence-free survival (RFS) was significantly better for the younger group (p = 0.047). For overall survival (OS) a benefit could be shown, but without reaching significance (p = 0.072). In subgroup analysis the middle-age group had significant better OS (p = 0.020) and RFS (p = 0.038) compared to the old group. Additionally, a better OS (p = 0.076) and RFS (p = 0.179) was shown in comparison with the young group as well, but without reaching significance. The young compared to the old group had analogous OS (p = 0.931) and RFS (p = 0.845). Conclusion Resection of ICC in elderly patients is not associated with an increased perioperative risk. Even extended resections can be performed in elderly patients without obvious disadvantages. Middle-age patients have a clear benefit for OS and RFS, while young and old patients have a comparable and worse long-term outcome.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Verena Tripke
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| |
Collapse
|
16
|
Bartsch F, Paschold M, Baumgart J, Hoppe-Lotichius M, Heinrich S, Lang H. Surgical Resection for Recurrent Intrahepatic Cholangiocarcinoma. World J Surg 2019; 43:1105-1116. [PMID: 30523392 DOI: 10.1007/s00268-018-04876-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although after R0 resection of intrahepatic cholangiocarcinoma (ICC) recurrence is frequent, most guidelines do not address strategies for this. The aim of this study was to analyze the outcome of repeated resection and to determine criteria when repeated resection is reasonable. METHODS Between 2008 and 2016, we consecutively collected all cases of ICC (n = 176) in a prospective database and further analyzed them with a focus on tumor recurrence, its surgical treatment, overall survival and recurrence-free survival. RESULTS Overall, a total of 22 explorations were performed for recurrent ICC in 17 patients. Resection rate was 18 repeated resections in 13 patients. Three patients underwent repeated resection twice and one patient three times. Recurrence was solitary in 7 patients and multifocal in 11 re-resected cases. Median overall survival (OS) of patients who underwent repeated resection was 65.2 months (interquartile range 37-126.5) with a 5-year OS rate of 62%, calculated from primary resection. Patients who underwent repeated resections had a significant better OS compared to those receiving chemotherapy, transarterial chemoembolization, selective internal radiotherapy, radiofrequency ablation or best supportive care (p < 0.001). CONCLUSION Repeated resection of recurrent ICC is reasonable and associated with an improved survival. Re-exploration should be considered as long as resection is technically possible.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Markus Paschold
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| |
Collapse
|
17
|
Bartsch F, Tripke V, Baumgart J, Hoppe-Lotichius M, Heinrich S, Lang H. Extended resection of intrahepatic cholangiocarcinoma: A retrospective single-center cohort study. Int J Surg 2019; 67:62-69. [PMID: 31121329 DOI: 10.1016/j.ijsu.2019.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/21/2019] [Accepted: 05/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND For complete removal of intrahepatic cholangiocarcinoma (ICC), extended resection is often necessary. Information on the influence of visceral or vascular extension, extended resection, or postoperative morbidity on survival is scarce. The aim of this study was to show the impact of an aggressive surgical attitude on morbidity, mortality, and long-term outcome. MATERIALS AND METHODS All explorations at a high volume tertiary center between January 2008 and June 2018 with histological proof of ICC were included in this retrospective cohort study. The primary outcome was the extent of resection, secondary outcomes were postoperative morbidity, and their influence on overall survival (OS) and recurrence-free survival (RFS). RESULTS Out of 210 patients, 150 underwent curative intended resection. A total of 87 extended, 26 major, and 37 minor resections were performed.In-hospital morbidity occurred in 46% of patients, with a 90-daymortality of 8%. Severity and frequency of morbidity did not differ significantly in the extended, major, or minor resection groups. If minor or major resections with visceral and/or vascular extensions were included in the extended resection group, minor (p = 0.005) and major (p = 0.042) resection had significantly better OSthan the extended resection group. All groups had significantly better OS than the exploration group. Comparing the different extended resection groups (segmental extended resection, segmental extended resection with visceral/vascular extension, minor/major resection with visceral/vascular extension), no difference was found (p = 0.977). Regarding RFSand the extent of resection, minor resection benefitted RFS, though not significantly (p = 0.051). Morbidity had no influence on RFS (p = 0.649). CONCLUSION Extended resection results in worse OS in patients with ICC than major or minor liver resection. Minor and major resection with visceral or vascular extension should be classified as extended resection. Despite worse OS, extended resection offers a chance for long-term survival and performs significantly better than the exploration group with manageable accompanied risks.
Collapse
Affiliation(s)
- Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Verena Tripke
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
| |
Collapse
|
18
|
Waisberg DR, Pinheiro RS, Nacif LS, Rocha-Santos V, Martino RB, Arantes RM, Ducatti L, Lai Q, Andraus W, D'Albuquerque LC. Resection for intrahepatic cholangiocellular cancer: new advances. Transl Gastroenterol Hepatol 2018; 3:60. [PMID: 30363713 DOI: 10.21037/tgh.2018.08.03] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022] Open
Abstract
Intrahepatic cholangiocarcinoma (ICC) is the second most prevalent primary liver neoplasm after hepatocellular carcinoma (HCC), corresponding to 10% to 15% of cases. Pathologies that cause chronic biliary inflammation and bile stasis are known predisposing factors for development of ICC. The incidence and cancer-related mortality of ICC is increasing worldwide. Most patients remain asymptomatic until advance stage, commonly presenting with a liver mass incidentally diagnosed. The only potentially curative treatment available for ICC is surgical resection. The prognosis is dismal for unresectable cases. The principle of the surgical approach is a margin negative hepatic resection with preservation of adequate liver remnant. Regional lymphadenectomy is recommended at time of hepatectomy due to the massive impact on outcomes caused by lymph node (LN) metastasis. Multicentric disease, tumor size, margin status and tumor differentiation are also important prognostic factors. Staging laparoscopy is warranted in high-risk patients to avoid unnecessary laparotomy. Exceedingly complex surgical procedures, such as major vascular, extrahepatic bile ducts and visceral resections, ex vivo hepatectomy and autotransplantation, should be implemented in properly selected patients to achieve negative margins. Neoadjuvant therapy may be used in initially unresectable lesions in order to downstage and allow resection. Despite optimal surgical management, recurrence is frustratingly high. Adjuvant chemotherapy with radiation associated with locoregional treatments should be considered in cases with unfavorable prognostic factors. Selected patients may undergo re-resection of tumor recurrence. Despite the historically poor outcomes of liver transplantation for ICC, highly selected patients with unresectable disease, especially those with adequate response to neoadjuvant therapy, may be offered transplant. In this article, we reviewed the current literature in order to highlight the most recent advances and recommendations for the surgical treatment of this aggressive malignancy.
Collapse
Affiliation(s)
- Daniel R Waisberg
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Rafael S Pinheiro
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Lucas S Nacif
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Rodrigo B Martino
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Rubens M Arantes
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Liliana Ducatti
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Quirino Lai
- Transplant Unit, Department of Surgery, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy
| | - Wellington Andraus
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Luiz C D'Albuquerque
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| |
Collapse
|