Perihilar cholangiocarcinoma: A different concept for radical resection

Residual biliary intraepithelial neoplasia without malignant transformation at resection margin for perihilar cholangiocarcinoma does not require expanded resection: a dual center retrospective study

BACKGROUND

Additional resection for invasive cancer at perihilar cholangiocarcinoma (pCCA) resection margins has become a consensus. However, controversy still exists regarding whether additional resection is necessary for residual biliary intraepithelial neoplasia (BilIN).

METHOD

Consecutive patients with pCCA from two hospitals were enrolled. The incidence and pattern of resection margin BilIN were summarized. Prognosis between patients with negative margins (R0) and BilIN margins were analyzed. Cox regression with a forest plot was used to identify independent risk factors associated with overall survival (OS) and recurrence-free survival (RFS). Subgroup analysis was performed based on BilIN features and tumor characteristics.

RESULTS

306 pCCA patients receiving curative resection were included. 255 had R0 margins and 51 had BilIN margins. There was no significant difference in OS (P = 0.264) or RFS (P = 0.149) between the two group. Specifically, 19 patients with BilIN at distal bile ducts and 32 at proximal bile ducts. 42 patients showed low-grade BilIN, and 9 showed high-grade. Further analysis revealed no significant difference in long-term survival between different locations (P = 0.354), or between different grades (P = 0.772). Portal vein invasion, poor differentiation and lymph node metastasis were considered independent risk factors for OS and RFS, while BilIN was not. Subgroup analysis showed no significant difference in long-term survival between the lymph node metastasis subgroup, or between the portal vein invasion subgroup.

CONCLUSION

For pCCA patients underwent curative resection, residual BilIN at resection margin is acceptable. Additional resection is not necessary for such patients to achieve absolute R0 margin.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

How to Determine Unresectability in Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is considered a biologically aggressive disease for which surgical resection remains the only curative treatment. Preoperative evaluation for resectability is challenging given tumor proximity to the porta hepatis, but minimal benefit and increased morbidity precludes recommendation for margin positive resection. This article reviews the determination of unresectability in hilar cholangiocarcinoma through discussion of the preoperative assessment, the intraoperative assessment, and key steps of surgical resection, as well as treatment options for unresectable tumors. Overall, evaluating patients preoperatively for resectability requires a multidisciplinary, holistic, and individualized approach to accurately determine resectability and optimize clinical outcomes for patients with hilar cholangiocarcinoma.

Systematic sequential therapy for ex vivo liver resection and autotransplantation: A case report and review of literature

BACKGROUND

Perihilar cholangiocarcinoma (pCCA) is a highly malignant tumor arising from the biliary tree. Radical surgery is the only treatment offering a chance of long-term survival. However, limited by the tumor's anatomic location and peri-vascular invasion, most patients lose the chance for curative treatment. Therefore, more methods to increase the resectability of tumors as well as to improve outcomes are needed.

CASE SUMMARY

A 68-year-old female patient had a hepatic hilar mass without obvious symptoms. Laboratory results showed hepatitis B positivity. Magnetic resonance imaging indicated that the mass (maximum diameter: 41 mm) invaded the left and right branches of the main portal vein, as well as the middle, left and right hepatic veins; enlarged lymph nodes were also detected in the hilum. The patient was diagnosed with pCCA, and the clinical stage was determined to be T4N1M0 (stage IIIC). Considering the tumor's anatomic location and vascular invasion, systematic conversion therapy followed by ex vivo liver resection and autotransplantation (ELRA) was determined as personalized treatment for this patient. Our original systemic sequential therapeutic strategy (lenvatinib and tislelizumab in combination with gemcitabine and cisplatin) was successfully adopted as conversion therapy because she achieved partial response after three cycles of treatment, without severe toxicity. ELRA, anastomotic reconstruction of the middle hepatic vein, right hepatic vein, root of portal vein, inferior vena cava and right hepatic artery, and lymph node dissection were performed at one month after systemic therapy. Pathological and immunohistochemical examination confirmed the diagnosis of pCCA with lymph node metastasis. Although the middle hepatic vein was partially obstructed four months later, hepatic vein stent implantation successfully addressed this problem. The patient has survived for 22 mo after the diagnosis, with no evidence of recurrence or metastasis.

CONCLUSION

An effective therapeutic strategy for conversion therapy greatly increases the feasibility and efficiency of ELRA.

Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients?

INTRODUCTION

As the population ages, surgeons are growing frequently faced with hard choices among a vast array of treatment options for the elderly. This study was to investigate safety and efficacy of resection in elderly patients with perihilar cholangiocarcinoma (PHCC).

PATIENTS AND METHODS

Literature reading and meta-analysis unveiled that elderly PHCC patients held a higher risk of death within 90 days after hepatectomy relative to younger patients, but their 5-year overall survival and disease-free survival were comparable. Among PHCC patients who underwent hepatectomy, the proportion of elderly patients with tumor classification Bismuth I-II and tumor stage pStage 1-3 was significantly higher than that of younger patients.

RESULTS

Curative resection R0 was more common in elderly patients than younger patients, but the difference was not statistically significant. Because of more comorbidities and less physiological reserve of elderly patients, they seemed to suffer more postoperative complications.

CONCLUSION

Considering improved life expectancy, it is crucial to treat elderly PHCC patients appropriately and attempts should be made to radical surgery based on comorbidities and functional status.

Improved Diagnosis of Adjacent Organ Invasion of Extrahepatic Cholangiocarcinoma by Adding Arterial and Delayed Phases

PURPOSE

To clarify the role of dynamic computed tomography (CT) in diagnosing extrahepatic cholangiocarcinoma (eCCA) involving adjacent organs.

MATERIAL AND METHODS

We retrospectively analyzed patients diagnosed with eCCA in Iwate Medical University Hospital (Morioka, Japan) during January 2011-December 2021 who underwent dynamic contrast-enhanced CT before biliary intervention, surgery, or chemotherapy. For surgical cases, two radiologists independently reviewed CT images in the portal, dual (adding arterial phase), and triple (adding delayed phase) phases. The mean attenuations of the abdominal aorta, portal vein (PV), hepatic parenchyma, pancreatic parenchyma, and eCCA were measured. The biliary segment-wise longitudinal tumour extent, arterial and PV invasion, organ invasion (liver, pancreas, and duodenum), and regional lymph node metastasis were assessed on a five-point scale. Image performances were compared using the sensitivity, specificity, and area under the curve (AUC).

RESULTS

We included 120 patients (mean age, 71.7 ± 8.9; 84 males). The PV and liver differed most from the bile duct tumour in the portal phase. The abdominal aorta and pancreas differed most from eCCA in the arterial phase. For 80 patients evaluated on the five-point scale, adding phases increased the AUC for pancreatic, duodenal, and arterial invasion for each observer (observer 1, 0.79-0.93, p<0.01, 0.71-0.86, p = 0.04, 0.74-0.99, p = 0.02; observer 2, 0.88-0.96, p = 0.01, 0.73-0.94, p<0.01, 0.80-0.99 p = 0.04; respectively). The AUC for biliary segment-wise longitudinal tumor extent, hepatic, and PV invasion remained unchanged with additional phases.

CONCLUSIONS

Portal-phase information is sufficient to evaluate the segmental extent of bile duct and liver/PV invasion. Arterial- and delayed-phase information can help evaluate pancreatic, duodenal, and arterial invasion.

Should more aggressive surgical resection be considered in the treatment for Bismuth types I and II hilar cholangiocarcinoma? A meta-analysis

Evidence regarding the optical surgical extent for Bismuth type I/II HCCA is lacking. we aims to evaluate the optimal surgical methods for Bismuth type I/II HCCA. Studies comparing bile duct resection (BDR) and BDR combined with liver resection (BDR + LR) for all types of HCCA patients were searched for analyses, and 14 studies were finally included. The main outcomes were the R0 resection rate and overall survival (OS). For all types of HCCA patents, BDR + LR resulted with higher R0 resection rates when comparing with BDR only (RR = 0.70, 95%CI, 0.63-0.78), and patients with R0 resections had eight times longer median survival and more long-time survival outcomes (3 and 5 year OS) comparing to those with non-R0 resections. Bismuth I/II HCCA patients also showed longer median survival and 3-year OS after R0 resections (P = 0.04). Moreover, there was no significant difference in 3-year OS between BDR and BDR + LR (P = 0.89) and we additionally found BDR resulted in less mortality or morbidity rates. In Europe and US, they resulted the R0 resection rates could be comparable between BDR and BDR + LR (P = 0.18), and Bismuth type I HCCA accounted for 75.8%, while in Asia, BDR + LR still resulted with higher R0 resection rates (P < 0.0001) and the Bismuth type I HCCA accounted for only 40.3%. The surgical approaches may not directly impact patient prognosis, patients with R0 resections are usually associated with improved survival outcomes; for selected Bismuth type I/II HCCA, BDR may be an acceptable option with regard to lower morbidity and comparable R0 resection rate comparing with BDR + LR.

Precise mapping of hilar cholangiocarcinoma with a skip lesion by SpyGlass cholangioscopy: A case report

BACKGROUND

Cholangiocarcinoma (CC) is a very aggressive cancer with a poor prognosis. As surgery is the only curative therapy, preoperative evaluation of the tumor extent is essential for surgical planning. Although high-quality image modalities such as computed tomography and magnetic resonance imaging have been used extensively in preoperative evaluation, the accuracy is low. To obtain precise localization of tumor spread arising from the hilar region preoperatively, the development of an acceptable imaging modality is still an unmet need.

CASE SUMMARY

A 52-year-old female presented to our emergency department with jaundice, abdominal pain, and fever. Initially, she was treated for cholangitis. Endoscopic retrograde cholangiopancreatography with the cholangiogram showed long segment filling defect in the common hepatic duct with dilatation of bilateral intrahepatic ducts. Transpapillary biopsy was performed, and the pathology suggested intraductal papillary neoplasm with high-grade dysplasia. After treatment of cholangitis, contrasted-enhanced computed tomography revealed a hilar lesion with undetermined Bismuth-Corlette classification. SpyGlass cholangioscopy showed that the lesion involved the confluence of the common hepatic duct with one skip lesion in the posterior branch of the right intrahepatic duct, which was not detected by previous image modalities. The surgical plan was modified from extended left hepatectomy to extended right hepatectomy. The final diagnosis was hilar CC, pT2aN0M0. The patient has remained disease-free for more than 3 years.

CONCLUSION

SpyGlass cholangioscopy may have a role in precision localization of hilar CC to provide surgeons with more information before the operation.

Prediction of prognosis and resectability using MR imaging, clinical, and histopathological findings in patients with perihilar cholangiocarcinoma

PURPOSE

To predict poor overall survival (OS) and risk of residual tumor after surgery using MR imaging, clinical, and histopathological findings in perihilar cholangiocarcinoma.

METHODS

196 patients with perihilar cholangiocarcinoma who underwent preoperative MRI and curative-intent surgery were retrospectively included. MRI findings were assessed by two radiologists. Clinical characteristics and histopathological results such as serum carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), T and N stage, and resection status, were also investigated. Cox regression analysis and the Kaplan-Meier method were used to identify prognostic factors for OS. We further analyzed the correlation between MRI features and residual tumors using logistic regression analysis.

RESULTS

The median OS was 25.0 ± 26.6 months. T stage (hazard ratio [HR] 6.26, p = 0.014), N stage (HR 1.86, p = 0.002), CA-19-9 >37 U/mL (HR 2.06, p < 0.001), enlarged LN on MRI (HR 1.69, p = 0.006), and residual tumor (HR 1.52, p = 0.034) were important predictors of poor survival. The 5-year OS of the complete resection group (n = 107) was significantly better than that of the residual tumor group (n = 89) (35.5% vs. 18.8%, p = 0.002). Additionally, peritumoral fat stranding (odds ratio[OR] 2.09, p = 0.027), Bismuth type III/IV (OR 1.95, p = 0.022), and common bile duct (CBD) involvement (OR 2.3, p = 0.008) on MRI were important predictors of residual tumors in univariate analyses. However, absence of peritumoral fat stranding was a significant independent predictor for complete resection (OR 1.99, p = 0.048) and showed the highest sensitivity, at 79.8%.

CONCLUSION

MR imaging, clinical and histopathological results are useful for predicting poor survival after surgery for perihilar cholangiocarcinoma. Furthermore, MRI findings, including peritumoral fat stranding, CBD involvement, and Bismuth type, are important for the prediction of residual tumors.