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Malik AK, Davidson BR, Manas DM. Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024:108248. [PMID: 38467524 DOI: 10.1016/j.ejso.2024.108248] [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: 02/26/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.
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Affiliation(s)
- Abdullah K Malik
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK.
| | - Brian R Davidson
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Derek M Manas
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK; NHS Blood and Transplant, Bristol, UK
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2
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Rushbrook SM, Kendall TJ, Zen Y, Albazaz R, Manoharan P, Pereira SP, Sturgess R, Davidson BR, Malik HZ, Manas D, Heaton N, Prasad KR, Bridgewater J, Valle JW, Goody R, Hawkins M, Prentice W, Morement H, Walmsley M, Khan SA. British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma. Gut 2023; 73:16-46. [PMID: 37770126 PMCID: PMC10715509 DOI: 10.1136/gutjnl-2023-330029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023]
Abstract
These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.
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Affiliation(s)
- Simon M Rushbrook
- Department of Hepatology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | - Timothy James Kendall
- Division of Pathology, University of Edinburgh, Edinburgh, UK
- University of Edinburgh MRC Centre for Inflammation Research, Edinburgh, UK
| | - Yoh Zen
- Department of Pathology, King's College London, London, UK
| | - Raneem Albazaz
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Richard Sturgess
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Brian R Davidson
- Department of Surgery, Royal Free Campus, UCL Medical School, London, UK
| | - Hassan Z Malik
- Department of Surgery, University Hospital Aintree, Liverpool, UK
| | - Derek Manas
- Department of Surgery, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Nigel Heaton
- Department of Hepatobiliary and Pancreatic Surgery, King's College London, London, UK
| | - K Raj Prasad
- John Goligher Colorectal Unit, St. James University Hospital, Leeds, UK
| | - John Bridgewater
- Department of Oncology, UCL Cancer Institute, University College London, London, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust/University of Manchester, Manchester, UK
| | - Rebecca Goody
- Department of Oncology, St James's University Hospital, Leeds, UK
| | - Maria Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Wendy Prentice
- King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Shahid A Khan
- Hepatology and Gastroenterology Section, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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3
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Rahul, Haldeniya K, Singh A, Bhatt N, Mishra P, Singh RK, Saxena R. Determinants of curative resection in incidental gallbladder carcinoma with special reference to timing of referral. Ann Hepatobiliary Pancreat Surg 2021; 25:492-499. [PMID: 34845121 PMCID: PMC8639303 DOI: 10.14701/ahbps.2021.25.4.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022] Open
Abstract
Backgrounds/Aims Re-resection of incidental gallbladder carcinoma (IGBC) is possible in a select group of patients. However, the optimal timing for re-intervention lacks consensus. Methods A retrospective analysis was performed for a prospective database of 91 patients with IGBC managed from 2009 to 2018. Patients were divided into three groups based on the duration between the index cholecystectomy and re-operation or final staging: Early (E), < 4 weeks; Intermediate (I), > 4 weeks and < 12 weeks; and Late (L), > 12 weeks. Demographic data, tumor characteristics, and operative details of patients were analyzed to determine factors affecting the re-resectability of IGBC. Results Twenty-two patients in ‘E’, 48 in ‘I’, and 21 in ‘L’ groups were evenly matched. Nearly two thirds were asymptomatic. Curative resection was possible in 48 (52.7%) patients. Metastasis was detected during staging laparoscopy (SL)/laparotomy in 26 (28.6%) patients. The yield of SL was more in the ‘L’ group (30.8%) than in the ‘I’ (11.1%) or ‘E’ (nil) group, avoiding unnecessary laparotomy in 13.6%. Only 28.5% of patients in the ‘L’ group could undergo curative resection (R0/R1 resection), significantly less than that in the ‘E’ (50.0%) or ‘I’ group (64.6%) (both p < 0.001). On multivariate analysis, presentation in intermediate period and tumor differentiation increased the chance of curative resection (p < 0.05). Conclusions Asymptomatic patients in the ‘I’ group with well differentiated IGBC have the best chance of obtaining a curative resection.
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Affiliation(s)
- Rahul
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kulbhushan Haldeniya
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ashish Singh
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Neha Bhatt
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Prabhakar Mishra
- Department of Biostatistics & Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rajneesh Kumar Singh
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rajan Saxena
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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4
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Abstract
Cholangiocarcinomas (CC) are rare tumors which usually present late and are often difficult to diagnose and treat. CCs are categorized as intrahepatic, hilar, or extrahepatic. Epidemiologic studies suggest that the incidence of intrahepatic CCs may be increasing worldwide. In this chapter, we review the risk factors, clinical presentation, and management of cholangiocarcinoma.
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Esnaola NF, Meyer JE, Karachristos A, Maranki JL, Camp ER, Denlinger CS. Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma. Cancer 2016; 122:1349-69. [PMID: 26799932 DOI: 10.1002/cncr.29692] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 12/13/2022]
Abstract
Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.
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Affiliation(s)
- Nestor F Esnaola
- Department of Surgery, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Andreas Karachristos
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer L Maranki
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - E Ramsay Camp
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Crystal S Denlinger
- Department of Hematology/Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
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Tsirlis T, Ausania F, White SA, French JJ, Jaques BC, Charnley RM, Manas DM. Implications of the index cholecystectomy and timing of referral for radical resection of advanced incidental gallbladder cancer. Ann R Coll Surg Engl 2015; 97:131-6. [PMID: 25723690 PMCID: PMC4473390 DOI: 10.1308/003588414x14055925060073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2014] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Advanced (pT2/T3) incidental gallbladder cancer is often deemed unresectable after restaging. This study assesses the impact of the primary operation, tumour characteristics and timing of management on re-resection. METHODS The records of 60 consecutive referrals for incidental gallbladder cancer in a single tertiary centre from 2003 to 2011 were reviewed retrospectively. Decision on re-resection of incidental gallbladder cancer was based on delayed interval restaging at three months following cholecystectomy. Demographics, index cholecystectomy data, primary pathology, CA19-9 tumour marker levels at referral and time from cholecystectomy to referral as well as from referral to restaging were analysed. RESULTS Thirty-seven patients with pT2 and twelve patients with pT3 incidental gallbladder cancer were candidates for radical re-resection. Following interval restaging, 24 patients (49%) underwent radical resection and 25 (51%) were deemed inoperable. The inoperable group had significantly more patients with positive resection margins at cholecystectomy (p=0.002), significantly higher median CA19-9 levels at referral (p=0.018) and were referred significantly earlier (p=0.004) than the patients who had resectable tumours. On multivariate analysis, urgent referral (p=0.036) and incomplete cholecystectomy (p=0.048) were associated significantly with inoperable disease following restaging. CONCLUSIONS In patients with incidental, potentially resectable, pT2/T3 gallbladder cancer, inappropriate index cholecystectomy may have a significant impact on tumour dissemination. Early referral of breached tumours is not associated with resectability.
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Affiliation(s)
- T Tsirlis
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - F Ausania
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - SA White
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - JJ French
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - BC Jaques
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - RM Charnley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - DM Manas
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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7
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Abstract
Among biliary tract cancers, gallbladder cancer (GBC) is a potentially lethal malignancy with abysmal long-term survival. Surgery is central to the management of GBC, and presently, provides the only ray of hope for long-term survival. Radical cholecystectomy, which includes cholecystectomy with a limited hepatic resection, regional lymphadenectomy and adjacent organ resection if required is used to encompass the tumor with negative margins - R'0' resection is the standard surgical treatment for the management of GBC. Absence of randomized controlled trials to address various surgical controversies due to rarity of disease in western world, advanced disease at presentation, high frequency of unresectability/inoperability at surgery, deficient neoadjuvant/adjuvant strategies and nihilistic views of oncologists due to aggressive disease biology has resulted in marked heterogeneity in surgical strategies employed to manage GBC across the surgical centers globally.
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Affiliation(s)
- Pankaj Kumar Garg
- Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Dilshad Garden, Delhi 110095, India
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Hilgard P, Dechene A, Canbay A, Herzer K, Schlaak JF, Treichel U, Gassel AM, Baba H, Zoepf T. Mini-laparoscopy is superior in detecting liver cirrhosis and metastases in liver cancer: an over 10-year experience in 1,788 cases. Digestion 2014; 89:156-64. [PMID: 24577116 DOI: 10.1159/000354829] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/02/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Mini-laparoscopy has, since its first description in 1998, proven to be a valuable diagnostic method in liver diseases. We re-evaluated the significance of mini-laparoscopy for diagnosis and staging of liver disease and primary liver and bile duct cancer. PATIENTS AND METHODS 1,788 consecutive patients who received a diagnostic mini-laparoscopy between 10/1998 and 06/2011 were included in this retrospective cohort study. RESULTS In chronic liver disease, cirrhosis was detected by mini-laparoscopy in 27% of cases. A comparison of microscopic versus macroscopic diagnosis of cirrhosis revealed a sampling error for histology alone of 21%. Macroscopic inspection of the liver surface contributed to the diagnosis of unknown liver diseases in approximately 38%. In patients with bile duct or liver cancer, mini-laparoscopy led to upstaging of the disease in 33 and 23%, respectively. Major complications (bowel perforation and delayed bleeding) occurred in 0.39% of cases. CONCLUSIONS Mini-laparoscopy is a valuable procedure with significant diagnostic impact in known and unknown inflammatory and malignant liver diseases. It can be safely performed even in patients with acute liver failure and severe coagulopathy and the diagnostic value does not differ from diagnostic laparoscopy performed with standard instruments.
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Affiliation(s)
- Philip Hilgard
- Department for Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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9
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Abstract
Cholangiocarcinoma (CC) is a rare cancer arising from the epithelium of the biliary tree, anywhere from the small peripheral hepatic ducts to the distal common bile duct. Classification systems for CC typically group tumours by anatomical location into intrahepatic, hilar or extrahepatic subtypes. Surgical resection or liver transplantation remains the only curative therapy for CC, but up to 80% of patients present with advanced, irresectable disease. Unresectable CC remains resistant to many chemotherapeutic agents, although gemcitabine, particularly in combination with other agents, has been shown to improve overall survival. Ongoing investigation of biological agents has also yielded some promising results. Several novel interventional and endoscopic techniques for the diagnosis and management of non-operable CC have been developed: initial results show improvements in symptoms and progression-free survival, but further randomised studies are required to establish their role in the management of CC.
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Affiliation(s)
- J R A Skipworth
- Department of Surgery and Interventional Science, University College London, London, UK
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10
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The role of staging laparoscopy in primary gall bladder cancer--an analysis of 409 patients: a prospective study to evaluate the role of staging laparoscopy in the management of gallbladder cancer. Ann Surg 2013; 258:318-23. [PMID: 23059504 DOI: 10.1097/sla.0b013e318271497e] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the role of staging laparoscopy (SL) in the management of gallbladder cancer (GBC). METHODS A prospective study of primary GBC patients between May 2006 and December 2011. The SL was performed using an umbilical port with a 30-degree telescope. Early GBC included clinical stage T1/T2. A detectable lesion (DL) was defined as one that could be detected on SL alone, without doing any dissection or using laparoscopic ultrasound (surface liver metastasis and peritoneal deposits). Other metastatic and locally advanced unresectable disease qualified as undetectable lesions (UDL). RESULTS Of the 409 primary GBC patients who underwent SL, 95 had disseminated disease [(surface liver metastasis (n = 29) and peritoneal deposits (n = 66)]. The overall yield of SL was 23.2% (95/409). Of the 314 patients who underwent laparotomy, an additional 75 had unresectable disease due to surface liver metastasis (n = 5), deep parenchymal liver metastasis (n = 4), peritoneal deposits (n = 1), nonlocoregional lymph nodes (n = 47), and locally advanced unresectable disease (n = 18), that is, 6-DL and 69-UDL. The accuracy of SL for detecting unresectable disease and DL was 55.9% (95/170) and 94.1% (95/101), respectively. Compared with early GBC, the yield was significantly higher in locally advanced tumors (n = 353) [25.2% (89/353) vs 10.7% (6/56), P = 0.02]. However, the accuracy in detecting unresectable disease and a DL in locally advanced tumors was similar to early GBC [56.0%, (89/159) and 94.1%, (89/95) vs 54.6% (6/11) and 100% (6/6), P = 1.00]. CONCLUSIONS In the present series with an overall resectability rate of 58.4%, SL identified 94.1% of the DLs and thereby obviated a nontherapeutic laparotomy in 55.9% of patients with unresectable disease and 23.2% of overall GBC patients. It had a higher yield in locally advanced tumors than in early-stage tumors; however, the accuracy in detecting unresectable disease and a DL were similar.
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11
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Zhuang PY, Tang ZH, Liu YB, Quan ZW, Zhang YJ. Diagnostic and prognostic role of laparoscopic staging for gallbladder carcinoma. Dig Surg 2012; 29:367-73. [PMID: 23108362 DOI: 10.1159/000343926] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 09/30/2012] [Indexed: 01/18/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the diagnostic and prognostic role of staging laparoscopy in gallbladder carcinoma (GBC). METHODS From January 2007 through December 2010, 79 GBC patients without evidence of metastatic disease on preoperative imaging underwent staging laparoscopy. Peritoneal and liver metastases were assessed by a single surgeon in a systematic manner. Resection rate, safety, and survival analysis were compared between the laparoscopy group and no laparoscopy group. RESULTS Disseminated disease was detected in 27 patients and no further surgery was performed; the overall accuracy for detecting unresectable disease was 67.5% (27/40), with 39 (75%) and 27 (51.9%) receiving resection and curative resection. In 203 GBC patients undergoing laparotomy, 90 (44.3%) and 53 (26.1%) patients received resection and curative resection; therefore, the resection rate and curative resection rate were significantly much higher in the laparoscopy group (p < 0.000). CONCLUSIONS Staging laparoscopy in GBC is sensitive in detecting disseminated disease and increases the curative resection rate, shortens the recovery time, and has no negative implications on overall survival; therefore, we suggest the routine use of staging laparoscopy in patients with GBC without evidence of disseminated disease on preoperative imaging.
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Affiliation(s)
- Peng-Yuan Zhuang
- Department of General Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
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12
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Abstract
Cholangiocarcinoma is the second most common primary hepatobiliary malignancy after hepatocellular carcinoma and remains among the most difficult management problems faced by surgeons. Curative surgery is achieved in only 25% to 30% of patients. Local tumor extent, such as portal vein invasion and hepatic lobar atrophy, does not preclude resection. Long-term survival has been seen only in patients who underwent extensive liver resections, suggesting that bile-duct excision alone is less effective. The majority of patients have unresectable disease, with 20% to 30% incidence of distant metastasis at presentation. Unresectable patients should be referred for nonsurgical biliary decompression, and in potential curative resection candidates the use of biliary stents should be reduced. Liver transplantation provides the option of wide resection margins, expanding the indication of surgical intervention for selected patients who otherwise are not surgical candidates due to lack of functional hepatic reserve.
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13
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Skipworth JRA, Olde Damink SWM, Imber C, Bridgewater J, Pereira SP, Malago’ M. Review article: surgical, neo-adjuvant and adjuvant management strategies in biliary tract cancer. Aliment Pharmacol Ther 2011; 34:1063-78. [PMID: 21933219 PMCID: PMC3235953 DOI: 10.1111/j.1365-2036.2011.04851.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The majority of patients with cholangiocarcinoma present with advanced, irresectable tumours associated with poor prognosis. The incidence and mortality rates associated with cholangiocarcinoma continue to rise, mandating the development of novel strategies for early detection, improved resection and treatment of residual lesions. AIM To review the current evidence base for surgical, adjuvant and neo-adjuvant techniques in the management of cholangiocarcinoma. METHODS A search strategy incorporating PubMed/Medline search engines and utilising the key words biliary tract carcinoma; cholangiocarcinoma; management; surgery; chemotherapy; radiotherapy; photodynamic therapy; and radiofrequency ablation, in various combinations, was employed. RESULTS Data on neo-adjuvant and adjuvant techniques remain limited, and much of the literature concerns palliation of inoperable disease. The only opportunity for long-term survival remains surgical resection with negative pathological margins or liver transplantation, both of which remain possible in only a minority of selected patients. Neo-adjuvant and adjuvant techniques currently provide only limited success in improving survival. CONCLUSIONS The development of novel strategies and treatment techniques is crucial. However, the shortage of randomised controlled trials is compounded by the low feasibility of conducting adequately powered trials in liver surgery, due to the large sample sizes that are required.
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Affiliation(s)
- JRA Skipworth
- Department of Surgery and Interventional Science, University College London, London
| | - SWM Olde Damink
- Department of Surgery and Interventional Science, University College London, London,Department of Hepatopancreaticobiliary Surgery, Royal Free Hospital NHS Trust, London,Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - C Imber
- Department of Hepatopancreaticobiliary Surgery, Royal Free Hospital NHS Trust, London
| | | | - SP Pereira
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, and Institute of Hepatology, University College London Medical School, London, UK
| | - M Malago’
- Department of Surgery and Interventional Science, University College London, London,Department of Hepatopancreaticobiliary Surgery, Royal Free Hospital NHS Trust, London
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14
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Butte JM, Gönen M, Allen PJ, D'Angelica MI, Kingham TP, Fong Y, DeMatteo RP, Blumgart L, Jarnagin WR. The role of laparoscopic staging in patients with incidental gallbladder cancer. HPB (Oxford) 2011; 13:463-72. [PMID: 21689230 PMCID: PMC3133713 DOI: 10.1111/j.1477-2574.2011.00325.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of staging laparoscopy (SL) in patients with incidental gallbladder cancer (IGBC) is ill defined. This study evaluates the utility of SL with the aim of identifying variables associated with disseminated disease (DD). METHODS Consecutive patients with IGBC who underwent re-exploration between 1998 and 2009 were identified from a prospective database. The yield and accuracy of SL were calculated. Demographics, tumour- and treatment-related variables were correlated with findings of DD. RESULTS Of the 136 patients submitted to re-exploration for possible definitive resection, 19 (14.0%) had DD. Staging laparoscopy was carried out in 46 (33.8%) patients, of whom 10 (21.8%) had DD (peritoneal disease [n = 6], liver metastases [n = 3], retroperitoneal disease [n = 1]). Disseminated disease was identified by SL in two patients (yield = 4.3%), whereas eight were diagnosed after conversion to laparotomy (accuracy = 20.0%). The likelihood of DD correlated closely with T-stage (T1b, n = 0; T2, n = 5 [7.0%], T3, n = 14 [26.0%]; P = 0.004). A positive margin at initial cholecystectomy (odds ratio [OR] 5.44, 95% confidence interval [CI] 1.51-24.37; P = 0.004) and tumour differentiation (OR 7.64, 95% CI 1.1-NA; P= 0.006) were independent predictors of DD on multivariate analysis. DISCUSSION Disseminated disease is relatively uncommon in patients with IGBC and SL provides a very low yield. However, patients with poorly differentiated, T3 or positive-margin gallbladder tumours are at high risk for DD and targeting these patients may increase the yield of SL.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | | | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Yuman Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Leslie Blumgart
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
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15
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Gaujoux S, Allen PJ. Role of staging laparoscopy in peri-pancreatic and hepatobiliary malignancy. World J Gastrointest Surg 2010; 2:283-90. [PMID: 21160897 PMCID: PMC2999692 DOI: 10.4240/wjgs.v2.i9.283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 09/18/2010] [Accepted: 09/24/2010] [Indexed: 02/06/2023] Open
Abstract
Even after extensive preoperative assessment, staging laparoscopy may allow avoidance of non-therapeutic laparotomy in patients with radiographically occult metastatic or locally unresectable disease. Staging laparoscopy is associated with decreased postoperative pain, a shorter hospital stay and a higher likelihood of receiving systemic therapy compared to laparotomy but its yield has decreased with improvements in imaging techniques. Current uses of staging laparoscopy include the following: (1) In the staging of pancreatic adenocarcinoma, laparoscopic staging allows for the identification of sub-radiographic metastatic disease in locally advanced cancer in approximately 30% of patients and, in radiographically resectable cancer, may identify metastatic disease in 10%-15% of cases; (2) In colorectal liver metastases, selective use of laparoscopic staging in patients with a clinical risk score of over 2 identifies unresectable disease in approximately 20% of patients; (3) In hepatocellular carcinoma, laparoscopic staging could be selectively used in high-risk patients such as those with clinically apparent liver cirrhosis and in patients with major vascular invasion or bilobar tumors; and (4) In biliary tract malignancy, staging laparoscopy may be used in all patients with potentially resectable primary gallbladder cancer and in selected patients with T2/T3 hilar cholangiocarcinoma. Because of the decreasing yield of SL secondary to improvements in imaging techniques, staging laparoscopy should be used selectively for patients with pancreatic and hepatobiliary malignancy to avoid unnecessary non-therapeutic laparotomy and to improve resource utilization. Each individual surgeon should apply his or her threshold as to whether staging laparoscopy is indicated according to the quality of preoperative imaging studies and the availability of resources at their own institution.
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Affiliation(s)
- Sebastien Gaujoux
- Sebastien Gaujoux, Peter J Allen, Hepatobiliary Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, C-887, New York, NY 10021, United States
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Aljiffry M, Walsh MJ, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009. World J Gastroenterol 2009; 15:4240-62. [PMID: 19750567 PMCID: PMC2744180 DOI: 10.3748/wjg.15.4240] [Citation(s) in RCA: 186] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.
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Chirurgie radicale des cholangiocarcinomes périphériques. ACTA ACUST UNITED AC 2009; 33:187-93. [DOI: 10.1016/j.gcb.2008.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 12/19/2008] [Accepted: 12/24/2008] [Indexed: 01/04/2023]
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Strong VE, Galanis CJ, Riedl CC, Longo VA, Daghighian F, Humm JL, Larson SM, Fong Y. Portable PET probes are a novel tool for intraoperative localization of tumor deposits. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2009; 3:2. [PMID: 19232133 PMCID: PMC2649935 DOI: 10.1186/1750-1164-3-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 02/21/2009] [Indexed: 12/03/2022]
Abstract
Background Positron emission tomography (PET) identifies cancer deposits by detecting sites of gamma emissions that are released from radioactively labeled molecules targeting tumor to formulate a PET image. Correlating preoperative PET scans with intraoperative findings remains a challenge. We investigated whether high-energy gamma emissions detected by a novel hand-held PET probe would detect tumors and offer a real-time method to localize tumor intraoperatively. Furthermore, we investigated the novel beta probe, which detects emissions at a shorter range than gamma emissions, making them undetectable by PET scanners, but potentially valuable for close range intraoperative detection of tumor deposits. Methods Six-to-eight-week-old athymic mice were injected with one of four possible tumor cell lines: gastric, pancreas, squamous cell and breast cancer. After tumors reached at least 1 cm in size, they were euthanized and imaged with a micro-PET imager. Hand-held gamma and beta probes were then used in vivo and ex vivo to measure high-energy gamma and beta emissions. Results The portable PET probes detected high-energy gamma and beta emissions from all tumors evaluated. These emissions were reproducible and we established that beta emissions correlate with high-energy gamma emissions and conventional PET scans. There was a strong positive correlation (R = 0.8) between gamma and beta counts. Beta emission showed a stronger correlation than gamma emission with overall tissue radioactivity. Conclusion This study is the first to demonstrate that gamma emission detected by conventional PET imaging correlates with beta emissions. This study shows that compared to detection of gamma emissions, beta counts may offer superior real-time localization of tumor deposits. Intraoperative portable PET probe may become a useful way to exploit tumor biology and PET technology to guide real-time tissue characterization during surgery.
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Affiliation(s)
- Vivian E Strong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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Abstract
Intrahepatic cholangiocarcinoma (ICC) is a rare primary liver cancer with a global increasing trend in recent years. Symptoms tend to be vague and insidious in development, often are diagnosed at an advanced stage when only palliative approaches can be used with a median survival rate of months. Comparing with HCC, ICC tends to spread to lymph nodes early, and is rarely limited to the regional lymph nodes, with a frequent postoperative recurrence. Surgery is the only choice of curative therapy for ICC, but recently no consensus has been established for operation. Thus, more data from multiple centers and more cases are needed. Generally speaking, current adjunctive therapy cannot clearly improve survival. Further research is needed to find more effective radio- and chemotherapeutic regimens.
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Aljiffry M, Abdulelah A, Walsh M, Peltekian K, Alwayn I, Molinari M. Evidence-based approach to cholangiocarcinoma: a systematic review of the current literature. J Am Coll Surg 2008; 208:134-47. [PMID: 19228515 DOI: 10.1016/j.jamcollsurg.2008.09.007] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 09/04/2008] [Accepted: 09/09/2008] [Indexed: 12/14/2022]
Affiliation(s)
- Murad Aljiffry
- Department of Surgery, Queen Elizabeth II Health Science Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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21
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Prise en charge chirurgicale du cholangiocarcinome hilaire résécable. ACTA ACUST UNITED AC 2008; 32:620-31. [DOI: 10.1016/j.gcb.2008.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Revised: 03/31/2008] [Accepted: 04/08/2008] [Indexed: 12/21/2022]
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Baton O, Azoulay D, Adam DVR, Castaing D. Major hepatectomy for hilar cholangiocarcinoma type 3 and 4: prognostic factors and longterm outcomes. J Am Coll Surg 2006; 204:250-60. [PMID: 17254929 DOI: 10.1016/j.jamcollsurg.2006.10.028] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 10/23/2006] [Accepted: 10/23/2006] [Indexed: 12/14/2022]
Abstract
BACKGROUND Radical operation for hilar cholangiocarcinoma, including major hepatectomy with vascular resection, seems to improve longterm survival. This study retrospectively evaluates several prognostic risk factors that can influence survival after resection of types 3 to 4 Klatskin tumors. STUDY DESIGN Between 1984 and 2003, 59 patients (36 men and 23 women) with types 3 to 4 hilar cholangiocarcinoma underwent liver resection with curative intent. Medical records and pathologic findings were reviewed to assess prognostic risk factors and survival. Disease-free and overall survival were analyzed using Kaplan-Meier and Cox proportional hazards models. RESULTS Survival rates at 1, 3, and 5 years were 82%, 45%, and 20% respectively. In-hospital mortality was 5% and morbidity was 42%. In multivariable analysis, male gender (relative risk [RR] = 5.4; 95% CI, 2.2 to 13.5), absence of preoperative chemotherapy (RR = 4; 95% CI, 1.5 to 10.7), R1 biliary tract margin (RR = 2.6; 95% CI, 1.1 to 4.4), and metastatic celiac lymph nodes (RR = 19.9; 95% CI, 4 to 71.4) were found to be independent factors for overall survival. Pedicular metastatic lymph nodes were not associated with poorer overall survival. If biliary positive-margin is the only risk factor, the 5-year estimated overall survival is 70%. CONCLUSIONS Major hepatectomy can improve outcomes of hilar cholangiocarcinoma. Compared with nonoperative treatment or R0 hepatectomy, R1 resection in patients with no other risk factor can offer longterm survival.
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Affiliation(s)
- Olivier Baton
- Centre Hépato-biliaire, Hôpital Paul Brousse, 94800 Villejuif, France
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Peschaud F, Alves A, Berdah S, Kianmanesh R, Laurent C, Mabrut JY, Mariette C, Meurette G, Pirro N, Veyrie N, Slim K. [Indications for laparoscopy in general and gastrointestinal surgery. Evidence-based recommendations of the French Society of Digestive Surgery]. ACTA ACUST UNITED AC 2006; 143:15-36. [PMID: 16609647 DOI: 10.1016/s0021-7697(06)73598-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Adusumilli PS, Eisenberg DP, Stiles BM, Hendershott KJ, Stanziale SF, Chan MK, Hezel M, Huq R, Rusch VW, Fong Y. Virally-directed fluorescent imaging (VFI) can facilitate endoscopic staging. Surg Endosc 2006; 20:628-35. [PMID: 16446989 PMCID: PMC1435379 DOI: 10.1007/s00464-005-0259-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2005] [Accepted: 11/15/2005] [Indexed: 11/27/2022]
Abstract
BACKGROUND Replication-competent, tumor specific herpes simplex virus NV1066 expresses green fluorescent protein (GFP) in infected cancer cells. We sought to determine the feasibility of GFP-guided imaging technology in the intraoperative detection of small tumor nodules. METHODS Human cancer cell lines were infected with NV1066 at multiplicities of infection of 0.01, 0.1 and 1. Cancer cell specific infectivity, vector spread and GFP signal intensity were measured by flow cytometry and time-lapse digital imaging (in vitro); and by use of a stereomicroscope and endoscope equipped with a fluorescent filter (in vivo). RESULTS NV1066 infected all cancer cell lines and expressed GFP at all MOIs. GFP signal was significantly higher than the autofluorescence of normal cells. One single dose of NV1066 spread within and across body cavities and selectively infected tumor nodules sparing normal tissue. Tumor nodules undetectable by conventional thoracoscopy and laparoscopy were identified by GFP fluorescence. CONCLUSION Virally-directed fluorescent imaging (VFI) is a real-time novel molecular imaging technology that has the potential to enhance the intraoperative detection of endoluminal or endocavitary tumor nodules.
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Affiliation(s)
- P S Adusumilli
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Peschaud F, Alves A, Berdah S, Kianmanesh R, Laurent C, Mabrut JY, Mariette C, Meurette G, Pirro N, Veyrie N, Slim K. [Indications of laparoscopic general and digestive surgery. Evidence based guidelines of the French society of digestive surgery]. ACTA ACUST UNITED AC 2006; 131:125-48. [PMID: 16448622 DOI: 10.1016/j.anchir.2005.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- F Peschaud
- Service de Chirurgie Générale et Digestive, CHU de Clermont-Ferrand, Hôtel-Dieu, boulevard Léon-Malfreyt, 63058 Clermont-Ferrand, France
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Abstract
Cholangiocarcinomas are rare malignant tumors composed of cells that resemble those of the biliary tract. On the basis of their anatomic location, cholangiocarcinomas can be classified as intrahepatic, extrahepatic and hilar tumors. For reasons that are not clear, the incidence of cholangiocarcinoma is increasing globally. Established risk factors, including conditions associated with chronic biliary tract inflammation, account for a small proportion of cases. Additional risk factors such as cirrhosis, infection with hepatitis B virus and hepatitis C virus are now becoming recognized. The diagnosis of cholangiocarcinoma requires the integration of clinical information, imaging studies of the hepatic parenchyma and biliary tract, tumor markers, and histology. In terms of the treatment options for cholangiocarcinoma, surgery can be curative, although few patients are candidates for surgery. Palliative biliary decompression can provide symptomatic relief. Advances in MRI and positron-emission tomography scanning, identification of new tumor markers, improved utility of biliary cytology, and the use of photodynamic therapy for adjunct treatment are all expected to enhance the diagnosis, evaluation and management of cholangiocarcinoma.
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Affiliation(s)
- Tushar Patel
- Texas A&M Health Science Center College of Medicine, Scott and White Clinic, Temple, TX 76508, USA.
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Abstract
Cholangiocarcinoma is a devastating malignancy that presents late, is notoriously difficult to diagnose, and is associated with a high mortality. The incidence of intrahepatic cholangiocarcinoma is increasing worldwide. The cause for this rise is unclear, although it could be related to an interplay between predisposing genetic factors and environmental triggers. MRI and CT with endoscopic ultrasound and PET provide useful diagnostic information in certain patients. Surgical resection is the only chance for cure, with results depending on careful technique and patient selection. Data suggest that liver transplantation could offer long-term survival in selected patients when combined with neoadjuvant chemoradiotherapy. Chemotherapy and radiotherapy have been ineffective for patients with inoperable tumours. For most of these patients biliary drainage is the mainstay of palliation. However, controversy exists over the type and positioning of biliary stents. Photodynamic treatment is a new palliative technique that might improve quality of life.
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Affiliation(s)
- Shahid A Khan
- Liver Unit, Division of Medicine, St Mary's Hospital Campus, Faculty of Medicine, Imperial College London, London, UK.
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Abstract
Cholangiocarcinoma presents a formidable diagnostic and treatment challenge. The majority of patients present with unresectable disease and have a survival of less than 12 months following diagnosis. Progress has been made by the appropriate selection of patients for treatment options including resection, with the routine use of more aggressive resections in order to achieve margin-negative resections. This has resulted in longer survival times for these patients. Neoadjuvant and adjuvant therapies have, for the most part, not improved survival in patients with this tumor, and new strategies are needed to improve this line of therapy. The prognosis for unresectable patients is poor, and palliative measures should be aimed at increasing quality of life first and increasing survival second.
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Affiliation(s)
- Christopher D Anderson
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-4753, USA
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