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Yu M, Lu L, Wu R. Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients? GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:691-701. [PMID: 37806347 DOI: 10.1016/j.gastrohep.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
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.
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Affiliation(s)
- Min Yu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China.
| | - Lina Lu
- Digestive Department, Jinhua Wenrong Hospital, Jinhua, China
| | - Rongjin Wu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
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Bröring TS, Wagner KC, von Hahn T, Oldhafer KJ. Parenchyma-Preserving Hepatectomy in Perihilar Cholangiocarcinoma: A Chance for Critical Patients? Visc Med 2024; 40:53-60. [PMID: 38584859 PMCID: PMC10995988 DOI: 10.1159/000537884] [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: 07/14/2023] [Accepted: 02/15/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Surgery for perihilar cholangiocarcinoma (pCCA) is associated with high rates of postoperative morbidity and mortality. Extended liver resection (EXT) increases R0 resection rate and survival; however, patients with high perioperative risk are not suitable for extended resection. This study aimed to compare overall survival and surgical morbidity in patients with extended liver resection and parenchyma-preserving hepatectomy (PPH). Methods Between January 2010 and November 2020, 113 consecutive patients with pCCA underwent surgery at our institution. Eighty-two patients were resected in curative intent. Sixty-four patients received extended liver resection, and 18 patients PPH. Outcomes of resections were evaluated. Results There was no significant difference in overall survival in patients with PPH compared to extended liver resection (log-rank p = 0.286). Patients with PPH experienced lower rates of postoperative morbidity and mortality. There was no case of in-house mortality in PPH-resected patients compared to 10 cases (16%) in patients that received EXT (p = 0.073). Conclusion PPH shows similar overall survival with lower rates of postoperative morbidity and mortality. Our findings support the role of a PPH, in selected patients with pCCA, that are not suitable for extended resection due to increased perioperative risk.
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Affiliation(s)
- Tobias S. Bröring
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Kim C. Wagner
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Thomas von Hahn
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
- Department of Gastroenterology and Interventional Endoscopy, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J. Oldhafer
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
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Togasaki K, Hosokawa I, Takayashiki T, Takano S, Ohtsuka M. Impact of the course of the segment 4 hepatic artery on proximal ductal margin status in right hepatectomy for perihilar cholangiocarcinoma. Surgery 2024; 175:947-954. [PMID: 38160087 DOI: 10.1016/j.surg.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/03/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The relationship between the course of the segment 4 hepatic artery and proximal ductal margin status in the right hepatectomy (H15678-B) for perihilar cholangiocarcinoma is unclear. This study aimed to evaluate proximal ductal margin status according to the course of the segment 4 hepatic artery in patients with perihilar cholangiocarcinoma treated with right hepatectomy. METHODS Consecutive patients with perihilar cholangiocarcinoma who underwent a right hepatectomy between January 2006 and August 2021 were retrospectively reviewed. The course of the segment 4 hepatic artery was classified based on the positional relationship with the umbilical portion of the left portal vein into R-UP and L-UP types. The R-UP type had the segment 4 hepatic artery running along the right caudal position of the umbilical portion of the left portal vein, whereas the L-UP type had the segment 4 hepatic artery running along the left cranial position of the umbilical portion of the left portal vein, with or without another branch running along the right caudal position of the umbilical portion of the left portal vein. Proximal ductal margin status after the right hepatectomy was compared between types. RESULTS Among 102 patients, 72 (70.5%) were R-UP type, and 30 (29.5%) were L-UP type. Rates of negative proximal ductal margin were higher with the L-UP type (27/30, 90.0%) than with the R-UP type (51/72, 70.8%; P = .04). On multivariate analysis, Bismuth-Corlette type II and IIIa (risk ratio 4.13, 95% confidence interval 1.52-11.5; P = .005) and L-UP type (risk ratio 4.03, 95% confidence interval 1.18-18.8; P = .04) were independent predictors of negative proximal ductal margin after a right hepatectomy for perihilar cholangiocarcinoma. CONCLUSION For the course of the segment 4 hepatic artery, L-UP type rather than R-UP type might be anatomically advantageous for achieving negative proximal ductal margin in a right hepatectomy for perihilar cholangiocarcinoma.
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Affiliation(s)
- Kentaro Togasaki
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan.
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Onoe S, Mizuno T, Watanabe N, Yokoyama Y, Igami T, Yamaguchi J, Sunagawa M, Kawakatsu S, Shimoyama Y, Ebata T. Utility of modified pancreaticoduodenectomy (Hi-cut PD) for middle-third cholangiocarcinoma: an alternative to hepatopancreaticoduodenectomy. HPB (Oxford) 2024; 26:530-540. [PMID: 38216429 DOI: 10.1016/j.hpb.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/05/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND The standard procedure for middle-third cholangiocarcinoma (MCC) is pancreaticoduodenectomy (PD); hepatopancreaticoduodenectomy (HPD) is often performed despite its high risk. There is no clear selection guidance for these procedures. METHODS Patients with MCC who underwent HPD or PD were retrospectively evaluated. The conventional PD was modified (mPD) to transect the bile duct beyond or close to the cranial level of the portal bifurcation. RESULTS The mPD group (n = 55) was characterized by older age, shorter operation time, less blood loss, and less frequent complications than were observed in the HPD group (n = 34). The median grossly tumor-free margin of the proximal bile duct (GM) was 13 mm vs 20 mm (P = 0.006). Overall survival did not differ significantly between groups (48% vs 53% at 5 years, P = 0.399). Multivariate analysis identified positive surgical margin as a sole independent prognostic factor (hazard ratio, 1.89; P = 0.043), which was statistically associated with GM length. Five-year survival for mPD patients with GM ≥15 mm was significantly better than that for those who had GM <15 mm (69% vs 33%, P = 0.011) and comparable to that of HPD patients (53%, P = 0.450). CONCLUSION The mPD may be recommended in patients with MCC, provided that GM ≥15 mm is expected from the preoperative radiological imaging. Otherwise, HPD should be considered.
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Affiliation(s)
- Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan; Division of Perioperative Medicine, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Sunagawa
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan; Division of Perioperative Medicine, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shoji Kawakatsu
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshie Shimoyama
- Department of Pathology and Clinical Laboratories, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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De Bellis M, Mastrosimini MG, Capelli P, Alaimo L, Conci S, Campagnaro T, Pecori S, Scarpa A, Guglielmi A, Ruzzenente A. The Relevance of Radial Margin Status in Perihilar Cholangiocarcinoma: A State-of-the-Art Narrative Review. Dig Surg 2024; 41:92-102. [PMID: 38447545 DOI: 10.1159/000535995] [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: 08/25/2023] [Accepted: 12/02/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Prognosis of perihilar cholangiocarcinoma (PHCC) is poor, and curative-intent resection is the most effective treatment associated with long-term survival. Surgery is technically demanding since it involves a major hepatectomy with en bloc resection of the caudate lobe and extrahepatic bile duct. Furthermore, to achieve negative margins, it may be necessary to perform concomitant vascular resection or pancreatoduodenectomy. Despite this aggressive approach, recurrence is often observed, considering 5-year recurrence-free survival below 15% and 5-year overall survival that barely exceeds 40%. SUMMARY The literature reports that survival rates are better in patients with negative margins, and surprisingly, R0 resections range between 19% and 95%. This variability is probably due to different surgical strategies and the pathologist's expertise with specimens. In fact, a proper pathological examination of residual disease should take into consideration both the ductal and the radial margin (RM) status. Currently, detailed pathological reports are lacking, and there is a likelihood of misinterpreting residual disease status due to the missing of RM description and the utilization of various definitions for surgical margins. KEY MESSAGES The aim of PHCC surgery is to achieve negative margins including RM. More clarity in reporting on RM is needed to define true radical resection and consistent design of oncological studies for adjuvant treatments.
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Affiliation(s)
- Mario De Bellis
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy,
| | - Maria Gaia Mastrosimini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Paola Capelli
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Laura Alaimo
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Simone Conci
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Tommaso Campagnaro
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Sara Pecori
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Alfredo Guglielmi
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
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Panettieri E, Vega EA, Salirrosas O, Harandi H, Kozyreva O, Mellado S, Conrad C. Does adjuvant treatment improve survival in R1 resected perihilar cholangiocarcinoma? The risk of overtreatment. J Gastrointest Surg 2024; 28:S1091-255X(24)00019-2. [PMID: 38577811 DOI: 10.1016/j.gassur.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/10/2023] [Accepted: 01/05/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Resection of perihilar cholangiocarcinoma (pCCA) is associated with positive margins in up to half of the patients. It remains unclear whether adjuvant therapies contribute to improved survival in patients undergoing R1 resection for pCCA. METHODS The National Cancer Database was queried for patients diagnosed with pCCA between 2004 and 2016. Patients with metastatic disease at the time of diagnosis were excluded. RESULTS A total of 1756 patients were included (286 surgical patients and 1470 nonsurgical patients). Patients who underwent R0 resection showed a significantly better median overall survival (OS) than that of patients who underwent R1 resection (41.7 vs 21.4 months, respectively; P = .003). Nevertheless, OS was better in patients who underwent R1 resection than in nonsurgical patients (21.4 vs 6.3 months, respectively; P < .001). Patients undergoing chemoradiation after R1 resection had similar OS to that of those receiving any other adjuvant therapy (21.4 vs 19.4 months, respectively; P = .789) or no adjuvant treatment (21.4 vs 19.8 months, respectively; P = .925). After uni- and multivariable analyses, T stage ≥3 and R1 margins were independently associated with worse survival after surgery. CONCLUSION As currently neither radiation, chemoradiation, nor chemotherapy seem to significantly improve survival in patients who underwent R1 resection for pCCA, high-quality surgical resection remains critically important. Moreover, the concern of overtreatment of patients who underwent R1 resection with current adjuvant therapeutic regimes exists.
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Affiliation(s)
- Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States; Hepatobiliary Surgery, Fondazione "Policlinico Universitario A. Gemelli", Scientific Institute for Research, Hospitalization and Healthcare, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Olga Kozyreva
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, Massachusetts, United States
| | - Sebastian Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States; Tufts University School of Medicine, Boston, Massachusetts, United States
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States.
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Chiu TJ, Liu YW, Yong CC, Yin SM, Yeh CH, Chen YY. Combined Serum ALBUMIN with Neutrophil-to-Lymphocyte Ratio Predicts the Prognosis of Biliary Tract Cancer after Curative Resection. Cancers (Basel) 2023; 15:5474. [PMID: 38001734 PMCID: PMC10670262 DOI: 10.3390/cancers15225474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The mainstay treatment of biliary tract cancer is complete tumor resection. Prior to surgery, risk stratification may help to predict and plan treatment approaches. In this study, we investigated the possibility of combining serum albumin concentrations and neutrophil-to-lymphocyte ratios (NLR) to create a score as ANS to predict the prognoses of biliary tract cancer before surgery. METHODS This study retrospectively collected serum albumin concentration, neutrophil, and lymphocyte data measured in biliary tract cancer patients slated to receive complete tumor resections within two weeks before surgery. From January 2013 to December 2019, 268 biliary tract cancer patients who had received tumor resections at our hospital were categorized into 3 ANS groups: ANS = 0 (high albumin and low NLR), ANS = 1 (low albumin or high NLR), and ANS = 2 (low albumin and high NLR). RESULTS Five-year survival rates were 70.1%, 47.6%, and 30.8% in the ANS = 0, 1, and 2 groups, respectively. The median overall survival time for the ANS = 0 group could not be determined by the end of the study, while those for ANS = 1 and ANS = 2 groups were 54.90 months and 16.62 months, respectively. The results of our multivariate analysis revealed that ANS could be used as an independent predictor of overall and recurrent-free survival. A high ANS was also correlated with other poor prognostic factors. CONCLUSIONS The ANS devised for this study can be used to predict postoperative survival in patients with BTC and to guide treatment strategies.
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Affiliation(s)
- Tai-Jan Chiu
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
- Kaohsiung Chang Gung Cholangiocarcinoma and Pancreatic Cancer Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-W.L.); (C.-C.Y.); (S.-M.Y.); (C.-H.Y.)
| | - Yueh-Wei Liu
- Kaohsiung Chang Gung Cholangiocarcinoma and Pancreatic Cancer Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-W.L.); (C.-C.Y.); (S.-M.Y.); (C.-H.Y.)
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Chee-Chien Yong
- Kaohsiung Chang Gung Cholangiocarcinoma and Pancreatic Cancer Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-W.L.); (C.-C.Y.); (S.-M.Y.); (C.-H.Y.)
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Shih-Min Yin
- Kaohsiung Chang Gung Cholangiocarcinoma and Pancreatic Cancer Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-W.L.); (C.-C.Y.); (S.-M.Y.); (C.-H.Y.)
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Cheng-His Yeh
- Kaohsiung Chang Gung Cholangiocarcinoma and Pancreatic Cancer Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-W.L.); (C.-C.Y.); (S.-M.Y.); (C.-H.Y.)
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Yen-Yang Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
- Kaohsiung Chang Gung Cholangiocarcinoma and Pancreatic Cancer Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-W.L.); (C.-C.Y.); (S.-M.Y.); (C.-H.Y.)
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Ratti F, Marino R, Pedica F, Gardini AC, Cipriani F, Rimini M, Della Corte A, Cascinu S, De Cobelli F, Colombo M, Aldrighetti L. Radial and longitudinal margins in surgery of perihilar cholangiocarcinoma: When R1 definition is associated with different prognosis. Surgery 2023; 174:447-456. [PMID: 37357095 DOI: 10.1016/j.surg.2023.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/15/2023] [Accepted: 05/24/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Infiltrated margins of resection (R1) and lymph node invasion are dominant negative predictors of survival in patients with a resectable perihilar cholangiocarcinoma. Less clear is whether survival predictors stratify differently between R0 (tumor-free margins) and R1 patients and whether the prognosis of the latter patients is influenced by the pattern of neoplastic infiltration (ie, radial versus longitudinal infiltration). We retrospectively evaluated a series of reported resected perihilar cholangiocarcinoma to obtain insights on the predictive power of these histologic features. METHODS The study includes 264 patients with perihilar cholangiocarcinoma treated between 2004 and 2019 in our center and followed up for >18 months. There were 176 patients with R0 (66.6%) and 88 patients with R1 (33.3%), 31 with radial infiltration only, 30 with longitudinal infiltration only, and 27 with both infiltration patterns. In all patients, the criteria for resection was the absence of metastatic involvement (ie, distant organ metastases, liver metastases, and lymph node metastases beyond the hepatoduodenal ligament). Histopathologic specimens of the resected tumors were centrally reviewed by a pathologist unaware of the clinical outcomes. RESULTS Three- and 5-year long-term survival were significantly better in R0 (respectively) compared to R1 patients (55% and 42% vs 42% and 18%, respectively, P < .05). In R1 patients with radial infiltration only and those with radial + longitudinal infiltration, both disease-free and overall survival were worse than those with longitudinal infiltration only (median disease-free survival of 18 and 23 months, respectively, P < .05, median overall survival of 33 and 39 months, respectively, P < .05). At multivariable analysis, nodal status, side of hepatectomy, grading, and presence of radial margin infiltration were associated with long-term outcome. CONCLUSION Radial infiltration of resection margins enhances the negative prognostic value of R1 margins in perihilar cholangiocarcinoma patients and should specifically be accounted for in the prediction of the outcome of adjuvant therapy.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, Ospedale San Raffaele, Milan, Italy.
| | - Rebecca Marino
- Hepatobiliary Surgery Division, Ospedale San Raffaele, Milan, Italy
| | - Federica Pedica
- Department of Experimental Oncology, Pathology Unit, San Raffaele Hospital, Milan, Italy
| | | | | | - Margherita Rimini
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Stefano Cascinu
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | | | - Luca Aldrighetti
- Hepatobiliary Surgery Division, Ospedale San Raffaele, Milan, Italy
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Hosokawa I, Takayashiki T, Kuboki S, Takano S, Togasaki K, Miyazaki M, Ohtsuka M. Prognostic impact of proximal ductal margin status in perihilar cholangiocarcinoma according to the presence or absence of lymph node metastasis. Surgery 2023:S0039-6060(23)00159-9. [PMID: 37120380 DOI: 10.1016/j.surg.2023.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/01/2023] [Accepted: 03/20/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Although both proximal ductal margin status and lymph node metastasis status influence the survival of patients with perihilar cholangiocarcinoma, the effect of proximal ductal margin status on survival according to lymph node metastasis status is unclear. The aim of this study was, thus, to evaluate the prognostic impact of proximal ductal margin status in perihilar cholangiocarcinoma according to the presence or absence of lymph node metastasis. METHODS Consecutive patients with perihilar cholangiocarcinoma who underwent major hepatectomy between June 2000 and August 2021 were retrospectively reviewed. Patients with Clavien-Dindo grade V complications were excluded from the analysis. Overall survival was assessed according to the combination of lymph node metastasis and proximal ductal margin status. RESULTS Of the 230 eligible patients, 128 (56%) were lymph node metastasis negative, and 102 (44%) were lymph node metastasis positive. Overall survival was significantly better in lymph node metastasis negative than lymph node metastasis positive patients (P < .0001). Of the 128 lymph node metastasis-negative patients, 104 (81%) were proximal ductal margin negative, and 24 (19%) were proximal ductal margin positive. In lymph node metastasis-negative patients, overall survival was worse in the proximal ductal margin positive than the proximal ductal margin negative group (P = .01). Of the 102 lymph node metastasis-positive patients, 72 (71%) were proximal ductal margin negative and 30 (29%) were proximal ductal margin positive. In these patients, overall survival was similar between the 2 groups (P = .10). CONCLUSION In patients with perihilar cholangiocarcinoma, the prognostic impact of proximal ductal margin positivity on survival might differ according to the presence or absence of lymph node metastasis.
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Affiliation(s)
- Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kentaro Togasaki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaru Miyazaki
- Narita Hospital, International University of Health and Welfare, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
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Nakagohri T, Takahashi S, Ei S, Masuoka Y, Mashiko T, Ogasawara T, Hirabayashi K. Prognostic Impact of Margin Status in Distal Cholangiocarcinoma. World J Surg 2023; 47:1034-1041. [PMID: 36735046 DOI: 10.1007/s00268-023-06889-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND A positive ductal margin is strongly associated with poor survival in patients with distal cholangiocarcinoma. However, the significance of the radial margin status and its effect on survival are not fully clarified. METHODS All patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy between January 2000 and December 2018 at Tokai University Hospital were retrospectively analyzed. Positive margins were divided into positive ductal margin and positive radial margin. RESULTS One hundred and eight consecutive patients with distal cholangiocarcinoma underwent pancreatoduodenectomy. Margin-negative R0 resection was performed in 85 patients (79%). Twenty-three patients (21%) had a positive resection margin (R1 resection). The 5-year survival rate and median overall survival for patients with R0 resection and those with R1 resection was 64%, 98 months and 25%, 26 months, respectively. There was a significant difference in survival between patients with R0 resection and those with R1 resection (p < 0.001). Patients with positive radial margin (n = 10) had a significantly worse outcome than those with positive ductal margin (n = 13) (p = 0.016). Univariate analysis showed that R1 resection, lymph node metastasis, tumor depth, portal vein invasion, pancreatic invasion, lymphatic invasion, and venous invasion were significant prognostic factors. Multivariate analysis confirmed that R1 resection and nodal involvement were significant independent prognostic indicators after surgical resection for distal cholangiocarcinoma. CONCLUSIONS Positive surgical margin and nodal involvement were the strongest predictors of poor survival in patients with distal cholangiocarcinoma. Patients with a positive radial margin had a significantly worse outcome than those with a positive ductal margin.
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Affiliation(s)
- Toshio Nakagohri
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa Prefecture, 259-1193, Japan.
| | - Shinichiro Takahashi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa Prefecture, 259-1193, Japan
| | - Shigenori Ei
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa Prefecture, 259-1193, Japan
| | - Yoshihito Masuoka
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa Prefecture, 259-1193, Japan
| | - Taro Mashiko
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa Prefecture, 259-1193, Japan
| | - Toshihito Ogasawara
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa Prefecture, 259-1193, Japan
| | - Kenichi Hirabayashi
- Department of Pathology, Toyama University School of Medicine, 3190 Gohuku, Toyama, Toyama Prefecture, 930-8555, Japan
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11
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Efficacy of Extended Modification in Left Hemihepatectomy for Advanced Perihilar Cholangiocarcinoma: Comparison Between H12345'8'-B-MHV and H1234-B. Ann Surg 2023; 277:e585-e591. [PMID: 35129528 DOI: 10.1097/sla.0000000000005248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to verify the prognostic impact of the tumor exposure at the liver transection margin (LTM) in left-sided perihilar cholangiocarcinoma and the impact of middle hepatic vein (MHV) resection on this exposure. BACKGROUND In perihilar cholangiocarcinoma, tumors are unexpectedly exposed at the LTM during left hemihepatectomy (LH). METHODS Patients who underwent LH for perihilar cholangiocarcinoma during 2002 to 2018 were retrospectively evaluated. LH was classified into conventional and extended types, which preserved and resected the MHVs, respectively. Positive LTM was defined as the involvement of invasive carcinoma at the liver transection plane and/or the adjacent Glissonean pedicle exposed. The clinicopathologic features and survival outcomes were compared between procedures. RESULTS Among 236 patients, conventional and extended LHs were performed in 198 and 38 patients, respectively. The LTM was positive in 31 (13%) patients, with an incidence of 14% versus 8% ( P = 0.432) and 24% versus 0% in advanced tumors ( P = 0.011). Tumor size ≥ 18 mm ( P = 0.041), portal vein invasion ( P = 0.009), and conventional LH ( P = 0.028) independently predicted positive LTM. In patients with negative LTM, the survival was comparable between the two groups: 60.4% versus 59.2% at 3 years ( P = 0.206), which surpassed 17.7% for those with positive LTM in the conventional group ( P < 0.001). Multivariable analysis demonstrated that LTM status was an independent prognostic factor ( P = 0.009) along with ductal margin status ( P = 0.030). CONCLUSIONS The LTM status is an important prognostic factor in perihilar cholangiocarcinoma. Extended LH reduced the risk of tumor exposure at the LTM with a subsequent improvement in the survival, particularly in advanced tumors.
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12
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Concors SJ, Snyder RA. Accepting Our Technical Limitations: Intraoperative Bile Duct Margin in Perihilar Cholangiocarcinoma Reflects Disease Biology. Ann Surg Oncol 2023; 30:3180-3181. [PMID: 36737529 DOI: 10.1245/s10434-023-13200-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Seth J Concors
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA. .,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA.
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13
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Asai Y, Yamaguchi J, Mizuno T, Onoe S, Watanabe N, Igami T, Uehara K, Yokoyama Y, Ebata T. Impact of preoperative muscle mass and quality on surgical outcomes in patients undergoing major hepatectomy for perihilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:202-211. [PMID: 35861026 DOI: 10.1002/jhbp.1220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/06/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022]
Abstract
PURPOSES This study sought to define the impact of skeletal muscle mass and quality on postoperative outcomes in patients with perihilar cholangiocarcinoma. METHODS Patients who underwent major hepatectomy for perihilar cholangiocarcinoma were included. The normalized total psoas area (TPA) (psoas muscle index [PMI]) and average Hounsfield units of the TPA (psoas muscle density [PMD]) were measured using preoperative computed tomography images. The cohort was dichotomized using the following indices: sex-specific lowest tertile (low PMI and low PMD) and other (normal PMI and normal PMD). Intraoperative and postoperative outcomes were compared, focusing on PMI and PMD. RESULTS A total of 456 patients were analyzed. The intraoperative blood loss (IBL) was 21.3 ml/kg in the low PMI group and 17.2 ml/kg in the normal PMI group (P = .008). Patients in the low PMI or PMD group experienced postoperative infectious complications more frequently than those in the other groups. The median survival time was 37.8 months in the low PMI group and 54.2 months in the normal PMI group (P = .027). CONCLUSIONS PMI and PMD were closely associated with IBL and postoperative infectious complications. Additionally, PMI impacted long-term survival. These results suggest an importance of improving muscle mass and quality before surgery.
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Affiliation(s)
- Yuichi Asai
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kay Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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14
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Otsuka S, Sugiura T, Okamura Y, Ashida R, Ohgi K, Yamada M, Aramaki T, Uesaka K. The proximity of the middle hepatic vein to the hepatic hilus: a retrospective radiological study. SURGICAL AND RADIOLOGIC ANATOMY : SRA 2023; 45:65-71. [PMID: 36454285 DOI: 10.1007/s00276-022-03050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE The middle hepatic vein (MHV) is an important landmark in anatomical hemihepatectomy. The proximity between the MHV and the hilar plate was suspected to be associated with tumor exposure during left hemihepatectomy for advanced perihilar cholangiocarcinoma and is reported to facilitate a dorsal approach to the MHV during laparoscopic hemihepatectomy. However, the precise distance between these locations is unknown. METHODS To investigate the "accurate and normal" distance between the MHV and the hilar plate, the present study focused on patients who presented without perihilar tumor. One hundred and sixty-eight consecutive patients who underwent pancreatoduodenectomy were included. Retrospective radiological measurement was performed using preoperative multi-detector row CT. The optimized CT slices perpendicular to the MHV were made using the multiplanar reconstruction technique. The shortest distance between the MHV and the hilar plate was measured on the left and right sides on the perpendicular slices. The diameters of the left and right hepatic ducts were also measured. RESULTS The distance was 9.0 mm (1.9-20.0 mm) on the left side and 11.3 mm (2.3-21.8) on the right side (p < 0.001). The distance on the left side was < 10 mm in 60% of patients (n = 100). Only one-third of patients (n = 55) had a distance of ≥ 10 mm on both sides. As the hepatic ducts became more dilated, the distance from the MHV to the hilar plate became shorter. CONCLUSION The MHV was located in close proximity to the hepatic hilus, especially on the left side.
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Affiliation(s)
- Shimpei Otsuka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunoto-Nagaizumi, Shizuoka, 411-8777, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunoto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunoto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunoto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunoto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Mihoko Yamada
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunoto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Takeshi Aramaki
- Division of Diagnostic Radiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunoto-Nagaizumi, Shizuoka, 411-8777, Japan
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15
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De Bellis M, Mastrosimini MG, Conci S, Pecori S, Campagnaro T, Castelli C, Capelli P, Scarpa A, Guglielmi A, Ruzzenente A. The Prognostic Role of True Radical Resection in Perihilar Cholangiocarcinoma after Improved Evaluation of Radial Margin Status. Cancers (Basel) 2022; 14:cancers14246126. [PMID: 36551610 PMCID: PMC9776927 DOI: 10.3390/cancers14246126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The evaluation of surgical margins in resected perihilar cholangiocarcinoma (PHCC) remains a challenging issue. Both ductal (DM) and radial margin (RM) should be considered to define true radical resections (R0). Although DM status is routinely described in pathological reports, RM status is often overlooked. Therefore, the frequency of true R0 and its impact on survival might be biased. OBJECTIVE To improve the evaluation of RM status and investigate the impact of true R0 on survival. METHODS From 2014 to 2020, 90 patients underwent curative surgery for PHCC at Verona University Hospital, Verona, Italy. Both DM (proximal and distal biliary margin) and RM (hepatic, periductal, and vascular margin) status were evaluated by expert hepatobiliary pathologists. Patients with lymph-node metastases or positive surgical margins (R1) were candidates for adjuvant treatment. Clinicopathological and survival data were retrieved from an institutional database. RESULTS True R0 were 46% (41) and overall R1 were 54% (49). RM positivity resulted in being higher than DM positivity (48% versus 27%). Overall survival was better in patients with true R0 than in patients with R1 (median survival time: 53 vs. 28 months; p = 0.016). Likewise, the best recurrence-free survival was observed in R0 compared with R1 (median survival time: 32 vs. 15 months; p = 0.006). Multivariable analysis identified residual disease status as an independent prognostic factor of both OS (p = 0.009, HR = 2.68, 95% CI = 1.27-5.63) and RFS (p = 0.009, HR = 2.14, 95% CI = 1.20-3.83). CONCLUSION Excellent survival was observed in true R0 patients. The improved evaluation of RM status is mandatory to properly stratify prognosis and select patients for adjuvant treatment.
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Affiliation(s)
- Mario De Bellis
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Maria Gaia Mastrosimini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Simone Conci
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Sara Pecori
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Tommaso Campagnaro
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Claudia Castelli
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Paola Capelli
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Alfredo Guglielmi
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, P. le L.A. Scuro 10, 37134 Verona, Italy
- Correspondence:
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16
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Schlick K, Neumayer B, Neureiter D. What is the management of resected cholangiocarcinoma in terms of intra- and postoperative status of tumor margins and lymph nodes? A current view. Expert Rev Gastroenterol Hepatol 2022; 16:1019-1022. [PMID: 36472068 DOI: 10.1080/17474124.2022.2155633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Konstantin Schlick
- Oncologic Center, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Paracelsus Medical University, Salzburg, Austria.,Cancer Cluster Salzburg, Cancer Cluster
| | - Bettina Neumayer
- Cancer Cluster Salzburg, Cancer Cluster.,Institute of Pathology, University Clinics Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Daniel Neureiter
- Cancer Cluster Salzburg, Cancer Cluster.,Institute of Pathology, University Clinics Salzburg, Paracelsus Medical University, Salzburg, Austria
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17
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Hosokawa I, Furukawa K, Takayashiki T, Kuboki S, Takano S, Miyazaki M, Ohtsuka M. Surgical implications of the confluence patterns of the left intrahepatic bile ducts in right hepatectomy for perihilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:460-468. [PMID: 34498387 DOI: 10.1002/jhbp.1044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although the most important goal in surgery for perihilar cholangiocarcinoma (PHC) is to achieve tumor-free proximal ductal margins, little is known about the implications of confluence patterns of the left intrahepatic bile ducts for the proximal ductal margin status in right hepatectomy (RH) for PHC. METHODS Of 203 patients who underwent surgical resection for PHC with curative intent, confluence patterns of the left intrahepatic bile duct were evaluated in 94 consecutive patients who underwent RH, and they were classified into the following two types: normal type: the bile duct of segment 4 (B4) drained into the common trunk of the bile ducts of segment 2 (B2) and segment 3 (B3) at the right side of the umbilical portion of the left portal vein to form the left hepatic duct; and hepatic confluence type: B2 entered the common trunk of B3 and B4 at the hepatic confluence or B4 entered the common trunk of B2 and B3 at the hepatic confluence. The proximal ductal margin status following RH was compared between the two types of confluence patterns. RESULTS Of 94 consecutive patients, 69 (73%) were the normal type, and 25 (27%) were the hepatic confluence type. There were no significant differences in patients' characteristics, surgical characteristics, surgical outcomes, and histopathological features between the two groups. However, in patients with Bismuth-Corlette type II and IIIa PHC, the achievement rates of negative proximal ductal margins at the first dividing line were significantly higher in the hepatic confluence type group than in the normal type group (16/16 [100%] vs 34/52 [65%], respectively; P = .007). CONCLUSIONS Confluence patterns of the left intrahepatic bile ducts might affect proximal ductal margin status in RH for PHC.
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Affiliation(s)
- Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Katsunori Furukawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaru Miyazaki
- Narita Hospital, International University of Health and Welfare, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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18
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Impact of Positive Radial Margin on Recurrence and Survival in Perihilar Cholangiocarcinoma. Cancers (Basel) 2022; 14:cancers14071680. [PMID: 35406452 PMCID: PMC8996964 DOI: 10.3390/cancers14071680] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/03/2022] [Accepted: 03/21/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary The only potentially curative treatment of perihilar cholangiocarcinoma (PHC) is complete (R0) resection. This is difficult to achieve and great effort should be made to optimise surgical margins assessment and to thoroughly define their prognostic value. When considering resections for PHC, not only bile duct margins (ductal margins, DM), but also the liver transection plane and the dissection plane in the hepatoduodenal ligament (radial margins, RM) should be examined. Studies concerning PHC resections with comprehensive analyses of the recurrence and survival related to margins status most frequently consider only ductal margins. The importance of also assessing radial margins’ prognostic value was recently introduced and deserves to be further studied. To our knowledge, there is currently no evidence of prognostic value of isolated positive RM. Therefore, the aim of this study was to evaluate the incidence and to investigate the effects on the recurrence and survival of positive isolated RM in resected PHC. Abstract In resected perihilar cholangiocarcinoma (PHC), positive ductal margin (DM) is associated with poor survival. There is currently little knowledge about the impact of positive radial margin (RM) when DM is negative. The aim of this study was to evaluate the incidence and the role of positive RM. Patients who underwent surgery between 2005 and 2017 where retrospectively reviewed and stratified according to margin positivity: an isolated RM-positive group and DM ± RM group. Of the 75 patients identified; 34 (45.3%) had R1 resection and 17 had positive RM alone. Survival was poorer in patients with R1 resection compared to R0 (p = 0.019). After stratification according to margin positivity; R0 patients showed better survival than DM ± RM-positive patients (p = 0.004; MST 43.9 vs. 23.6 months), but comparable to RM-positive patients (p = 0.361; MST 43.9 vs. 39.5 months). Recurrence was higher in DM ± RM group compared to R0 (p = 0.0017; median disease-free survival (DFS) 15 vs. 30 months); but comparable between RM and R0 group (p = 0.39; DFS 20 vs. 30 months). In univariate and multivariate analysis, DM positivity resulted as a negative prognostic factor both for survival and recurrence. In conclusion, positive RM resections appear to have different recurrence patterns and survival rates than positive DM resections.
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19
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Perihilar cholangiocarcinoma: What the radiologist needs to know. Diagn Interv Imaging 2022; 103:288-301. [DOI: 10.1016/j.diii.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 11/17/2022]
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20
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Redefining resection margins and dissection planes in perihilar cholangiocarcinoma-radical resection is a rare event. Virchows Arch 2021; 480:557-564. [PMID: 34783866 PMCID: PMC8989813 DOI: 10.1007/s00428-021-03231-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/04/2021] [Accepted: 10/30/2021] [Indexed: 11/06/2022]
Abstract
Radical tumor resection (pR0) is prognostic for disease-free and overall survival after resection of perihilar cholangiocarcinoma (pCCA). However, no universal agreement exists on the definition of radical resection and histopathological reporting. The aim of this study was to provide a standardized protocol for histopathological assessment and reporting of the surgical specimen obtained after resection for pCCA. All consecutive patients operated for pCCA with curative intent at the Karolinska University Hospital, Stockholm, Sweden between 2012 and 2021 were included. A standardized protocol for histopathological assessment and reporting of the surgical specimen after liver resection for pCCA is presented. A detailed mapping of the transection margins and dissection planes was performed. The results of applying different existing pR0 definitions were compared. Sixty-eight patients with pCCA were included. Five transection margins and two dissection planes were defined. By defining pR0 as cancer-free margins and planes tolerating distances <1mm, the pR0 rate was 66%. However, when pR0 was set as >1mm from invasive cancer to all resection margins and dissection planes, the pR0 rate fell to 16%. This study supports the use of thorough and standardized pathological handling, assessment and reporting of resection margins and dissection planes of surgical specimens of pCCA.
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21
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Transhepatic Direct Approach to the "Limit of the Division of the Hepatic Ducts" Leads to a High R0 Resection Rate in Perihilar Cholangiocarcinoma. J Gastrointest Surg 2021; 25:2358-2367. [PMID: 33403562 DOI: 10.1007/s11605-020-04891-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/22/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have shown that curative resection (R0 resection) was among the most crucial factors for the long-term survival of patients with PHCC. To achieve R0 resection, we performed the transhepatic direct approach and resection on the limits of division of the hepatic ducts. Although a recent report showed that the resection margin (RM) status impacted PHCC patients' survival, it is still unclear whether RM is an important clinical factor. OBJECTIVE To describe a technique of transhepatic direct approach and resection on the limit of division of hepatic ducts, investigate its short-term surgical outcome, and validate whether the radial margin (RM) would have a clinical impact on long-term survival of perihilar cholangiocarcinoma (PHCC) patients. METHODS Consecutive PHCC patients (n = 211) who had undergone major hepatectomy with extrahepatic bile duct resection, without pancreaticoduodenectomy, in our department were retrospectively evaluated. RESULTS R0 resection rate was 92% and 86% for invasive cancer-free and both invasive cancer-free and high-grade dysplasia-free resection, respectively. Overall 5-year survival rate was 46.9%. Univariate analysis showed that preoperative serum carcinoembryonic antigen level (> 7.0 mg/dl), pathological lymph node metastasis, and portal vein invasion were independent risk factors, but R status on both resection margin and bile duct margin was not an independent risk factor for survival. CONCLUSION The transhepatic direct approach to the limits of division of the bile ducts leads to the highest R0 resection rate in the horizontal margin of PHCC. Further examination will be needed to determine the adjuvant therapy for PHCC to improve patient survival.
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22
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Zou W, Zhu C, Wang Z, Tan X, Li C, Zhao Z, Hu M, Liu R. A Novel Nomogram Based on Log Odds of Metastatic Lymph Nodes to Predict Overall Survival in Patients With Perihilar Cholangiocarcinoma After Surgery. Front Oncol 2021; 11:649699. [PMID: 34367951 PMCID: PMC8340771 DOI: 10.3389/fonc.2021.649699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023] Open
Abstract
Background Various lymph node staging strategies were reported to be significantly correlated with perihilar cholangiocarcinoma(pCCA) prognosis. This study aimed to evaluate their predictive abilities and construct an optimal model predicting overall survival (OS). Methods Patients with pCCA were collected as the training cohort from the Surveillance, Epidemiology, and End Results (SEER) database. Four models were constructed, involving four LNs staging strategies. The optimal model for predicting OS was evaluated by calculation of the concordance index (C-index) and Akaike information criterion (AIC), and validated by using the area under curve (AUC) and calibration curves. The clinical benefits of nomogram were evaluated by decision curve analysis (DCA). A Chinese cohort was collected to be an external validation cohort. Results There were 319 patients and 109 patients in the SEER database and Chinese cohort respectively. We developed an optimal model involving age, T stage, tumor size, LODDS, which showed better predictive accuracy than others. The C-index of the nomogram was 0.695, the time-dependent AUC exceeded 0.7 within 36 months which was significantly higher than that of the American Joint Committee on Cancer (AJCC) stage. The calibration curves for survival probability showed the nomogram prediction had good uniformity of the practical survival. The DCA curves exhibited our nomogram with higher clinical utility compared with the AJCC stage and single LOODS. Conclusions LODDS is a strong independent prognostic factor, and the nomogram has a great ability to predict OS, which helps assist clinicians to conduct personalized clinical practice.
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Affiliation(s)
- Wenbo Zou
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Chunyu Zhu
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Zizheng Wang
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Xianglong Tan
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Chenggang Li
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Zhiming Zhao
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Minggen Hu
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Rong Liu
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, China.,Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
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23
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Lang H, van Gulik TM. Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma. Ann Surg 2021; 274:33-34. [PMID: 33605597 DOI: 10.1097/sla.0000000000004821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Germany
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, location AMC, University of Amsterdam, the Netherlands
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24
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Yang PC, Chen YJ, Li XY, Hsiao CY, Cheng BB, Gao Y, Zhou BZ, Chen SY, Hu SQ, Zeng Q, Huang KW. Irreversible Electroporation Treatment With Intraoperative Biliary Stenting for Unresectable Perihilar Cholangiocarcinoma: A Pilot Study. Front Oncol 2021; 11:710536. [PMID: 34277454 PMCID: PMC8278819 DOI: 10.3389/fonc.2021.710536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background Treating perihilar cholangiocarcinoma (PHCC) is particularly difficult due to the fact that it is usually in an advanced stage at the time of diagnosis. Irreversible electroporation treatment (IRE) involves the local administration of a high-voltage electric current to target lesions without causing damage to surrounding structures. This study investigated the safety and efficacy of using IRE in conjunction with intraoperative biliary stent placement in cases of unresectable PHCC. Methods This study enrolled 17 patients with unresectable Bismuth type III/IV PHCC who underwent IRE in conjunction with intraoperative biliary stent placement (laparotomic) in two medical centers in Asia between June 2015 and July 2018. Analysis focused on the perioperative clinical course, the efficacy of biliary decompression, and outcomes (survival). Results Mean total serum bilirubin levels (mg/dL) on postoperative day (POD) 7, POD30, and POD90 were significantly lower than before IRE (respectively 3.46 vs 4.54, p=0.007; 1.21 vs 4.54, p<0.001; 1.99 vs 4.54, p<0.001). Mean serum carbohydrate antigen 19-9 (CA19-9, U/ml) levels were significantly higher on POD3 than before the operation (518.8 vs 372.4, p=0.001) and significantly lower on POD30 and POD90 (respectively 113.7 vs 372.4, p<0.001; 63.9 vs 372.4, p<0.001). No cases of Clavien-Dindo grade III/IV adverse events or mortality occurred within 90 days post-op. The median progression-free survival was 21.5 months, and the median overall survival was 27.9 months. All individuals who survived for at least one year did so without the need to carry percutaneous biliary drainage (PTBD) tubes. Conclusions It appears that IRE treatment in conjunction with intraoperative biliary stent placement is a safe and effective approach to treating unresectable PHCC. The decompression of biliary obstruction without the need for PTBD tubes is also expected to improve the quality of life of patients.
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Affiliation(s)
- Po-Chih Yang
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yan-Jun Chen
- Department of Hepatopancreatobiliary Surgery, The Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Xiao-Yong Li
- Department of Hepatopancreatobiliary Surgery, The Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Chih-Yang Hsiao
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Surgery & Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Bing-Bing Cheng
- Department of Hepatopancreatobiliary Surgery, The Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Yu Gao
- Department of Hepatopancreatobiliary Surgery, The Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Bai-Zhong Zhou
- Department of Hepatopancreatobiliary Surgery, The Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Sheng-Yang Chen
- Department of Hepatopancreatobiliary Surgery, The Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Shui-Quan Hu
- Department of Hepatopancreatobiliary Surgery, The Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Quan Zeng
- Endoscopic Center, the Fifth Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Kai-Wen Huang
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery & Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
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25
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A tailored approach in lymph node-positive perihilar cholangiocarcinoma. Langenbecks Arch Surg 2021; 406:1499-1509. [PMID: 34075473 PMCID: PMC8370897 DOI: 10.1007/s00423-021-02154-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/18/2021] [Indexed: 01/04/2023]
Abstract
Purpose Extended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases. Methods We reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité – Universitätsmedizin Berlin. Results Two hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002). Conclusion Patients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02154-4.
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26
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Soares KC, Jarnagin WR. The Landmark Series: Hilar Cholangiocarcinoma. Ann Surg Oncol 2021; 28:4158-4170. [PMID: 33829358 DOI: 10.1245/s10434-021-09871-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
Hilar cholangiocarcinoma (HC) is a rare and highly aggressive biliary tract neoplasm. As such, the data driving the management of this disease generally are not based on prospective clinical trial data but rather consist of retrospective experiences and limited level 1 data. Surgical resection offers the best chance of a long-term survival, but local and distant recurrences are common. This report presents landmark articles that form the basis of preoperative, operative, and adjuvant strategies for HC.
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Affiliation(s)
- Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
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27
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Stremitzer S, Stift J, Laengle J, Schwarz C, Kaczirek K, Jones RP, Quinn LM, Fenwick SW, Diaz-Nieto R, Poston GJ, Malik HZ. Prognosis and Circumferential Margin in Patients with Resected Hilar Cholangiocarcinoma. Ann Surg Oncol 2020; 28:1493-1498. [PMID: 32914390 DOI: 10.1245/s10434-020-09105-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/16/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Resection margin status is a known prognosticator in patients who undergo resection for hilar cholangiocarcinoma. However, the influence of an isolated positive circumferential margin on clinical outcome is unclear. METHODS Patients with resected de novo hilar cholangiocarcinoma from two European hepatobiliary centres (Medical University of Vienna and Aintree University Hospital, 2006-2016) were classified according to resection margin status (negative, surgically positive, isolated circumferentially positive) and investigated with respect to overall survival (OS), recurrence-free survival (RFS) and recurrence pattern. RESULTS Eighty-three (48 male/35 female) patients were enrolled. The median age was 64 years (range 33-80). The median follow-up was 21.7 months (range 0.3-92.4). Forty (48%) patients had negative resection margins, 25 (30%) had an isolated positive circumferential margin and 18 (22%) had a positive surgical margin. The 5-year OS rates in patients with negative, isolated positive circumferential and positive surgical resection margins were 47%, 33% and 0%, respectively. Median OS was 45.6, 32.7 and 14.5 months, respectively (log rank, P = 0.011). Upon multivariable Cox regression analysis, resection margin status and lymph node status remained statistically significant (P < 0.05). No difference with respect to RFS and recurrence pattern was found between the groups (P > 0.05). CONCLUSION Our data show that these three resection margin types were associated with different clinical outcomes. Circumferential margin status may therefore serve as a novel prognostic biomarker.
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Affiliation(s)
- Stefan Stremitzer
- Department of General Surgery, Medical University Vienna, Vienna, Austria.
| | - Judith Stift
- Clinical Institute of Pathology, Medical University Vienna, Vienna, Austria
| | - Johannes Laengle
- Department of General Surgery, Medical University Vienna, Vienna, Austria
| | - Christoph Schwarz
- Department of General Surgery, Medical University Vienna, Vienna, Austria
| | - Klaus Kaczirek
- Department of General Surgery, Medical University Vienna, Vienna, Austria
| | - Robert P Jones
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK
| | - Leonard M Quinn
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK
| | - Stephen W Fenwick
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK
| | - Rafael Diaz-Nieto
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK
| | - Graeme J Poston
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK
| | - Hassan Z Malik
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK
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28
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Nakahashi K, Ebata T, Yokoyama Y, Igami T, Mizuno T, Yamaguchi J, Onoe S, Watanabe N, Nagino M. How long should follow-up be continued after R0 resection of perihilar cholangiocarcinoma? Surgery 2020; 168:617-624. [PMID: 32665142 DOI: 10.1016/j.surg.2020.04.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/20/2020] [Accepted: 04/29/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although several studies have been conducted on the patterns of recurrence in resected perihilar cholangiocarcinoma, the appropriate follow-up period after resection is still controversial. METHODS Consecutive patients who underwent an R0 resection of perihilar cholangiocarcinoma between 2001 and 2014 were reviewed retrospectively, focusing on the time and site of initial recurrence. A Cox proportional hazards model was used for multivariate analysis. RESULTS During the study period, 404 patients underwent R0 resection, of whom 242 patients (59.9%) developed a recurrence. The most common site of recurrence was locoregional, followed by peritoneum and liver. Approximately 70% of patients were asymptomatic when recurrence was detected. The median survival time in all cohorts was 4.8 years, and the estimated cumulative probability of recurrence was 54.3% at 5 years and 65.7% at 10 years. Multivariate analyses revealed that lymph node metastasis (hazard ratio 2.80, P < .001) and microscopic venous invasion (hazard ratio, 1.70, P < .001) were independent risk factors for recurrence-free survival. The cumulative probability of recurrence in 84 patients with 2 risk factors was nearly 90% at 5 years; even in the 178 patients without risk factors, the probability at 5 years was 30%, and thereafter, the probability of recurrence gradually increased, reaching nearly 50% at 10 years. No trends in the time and site of recurrence were detected. CONCLUSION Approximately 60% of patients with perihilar cholangiocarcinoma experience recurrence after R0 resection. Even in patients without an independent risk for recurrence, the recurrence probability is high, reaching nearly 50% at 10 years. Thus, close surveillance for 10 years is necessary even after R0 resection of perihilar cholangiocarcinoma.
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Affiliation(s)
- Koichi Nakahashi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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29
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Aquina CT, Pawlik TM, Ejaz A. Cholangiocarcinoma: three different entities based on location. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:738. [PMID: 32647663 PMCID: PMC7333109 DOI: 10.21037/atm.2020.03.167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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30
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Chen RX, Li CX, Luo CH, Zhang H, Zhou T, Wu XF, Wang XH, Li XC. Surgical Strategies for the Treatment of Bismuth Type I and II Hilar Cholangiocarcinoma: Bile Duct Resection with or Without Hepatectomy? Ann Surg Oncol 2020; 27:3374-3382. [PMID: 32274664 DOI: 10.1245/s10434-020-08453-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The role of hepatic resection in the treatment of type I and II hilar cholangiocarcinoma (HCCA) remains controversial. In the present study, we aimed to identify whether hepatic resection was necessary for type I and II HCCA. METHODS A total of 23 patients classified as type I and II HCCA undergoing surgical resection were included in this study. The patients were divided into two groups: bile duct resection (BDR) group (n = 15) and hepatic resection (HR) group (n = 8). Systematic review and meta-analysis were performed to compare the R0 resection and long-term survival between BDR and HR for Bismuth type I and II HCCA. A total of 7 studies with 260 cases were included in this meta-analysis. RESULTS In our cohort, the R0 resection rate was 73.3% in BDR group and 87.5% in HR group. The HR group had a higher number of postoperative complications than the BDR group (P = 0.002). There was no difference in long-term survival (P = 0.544) and recurrence (P = 0.846) between BDR and HR in Bismuth type I and II HCCA. The meta-analysis showed that HR was associated with better R0 resection rate (RR 4.45, 95% CI 2.34-8.48) and overall survival (HR 2.15, 95% CI 1.34-3.44) compared with BDR group. There was no publication bias and undue influence of any single study. CONCLUSIONS The meta-analysis showed that HR was associated with better R0 resection rate and overall survival compared with BDR for type I and II HCCA patients. More aggressive surgical strategies should be increasingly considered for the treatment of type I and II HCCA patients.
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Affiliation(s)
- Rui Xiang Chen
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chang Xian Li
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
| | - Cheng Huan Luo
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hui Zhang
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Tao Zhou
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiao Feng Wu
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xue Hao Wang
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiang Cheng Li
- Hepatobiliary Center, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
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31
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de Wilde RF, Groot Koerkamp B. Radial margin status should be determined in resected perihilar cholangiocarcinoma. Hepatobiliary Surg Nutr 2019; 8:557-559. [PMID: 31673558 DOI: 10.21037/hbsn.2019.07.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Roeland F de Wilde
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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32
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Sun R, Liu Z, Qiu B, Chen T, Li Z, Zhang X, Xu Y, Zhang Z. Annexin10 promotes extrahepatic cholangiocarcinoma metastasis by facilitating EMT via PLA2G4A/PGE2/STAT3 pathway. EBioMedicine 2019; 47:142-155. [PMID: 31492557 PMCID: PMC6796529 DOI: 10.1016/j.ebiom.2019.08.062] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Cholangiocarcinoma (CCA), consisting of intrahepatic (IHCCA), perihilar (PHCCA), and distal (DCCA) CCA, is a type of highly aggressive malignancy with a very dismal prognosis. Potential biomarkers and drug targets of CCA are urgently needed. As a new member of the Annexin (ANXA) family, the role of ANXA10 in the progression and prognosis of CCA is unknown. Methods Potential PHCCA biomarkers were screened by transcriptome sequencing of 5 pairs of PHCCA and adjacent tissues. The clinical significance of ANXA10 was evaluated by analyzing its correlation with clinicopathological variables, and the prognostic value of ANXA10 was evaluated with univariate and multivariate analyses. The function of ANXA10 in the epithelial-mesenchymal transition (EMT), proliferation, invasion and metastasis was detected with in vitro and in vivo experiments. Moreover, we screened the key molecule in ANXA10-induced CCA progression by mRNA sequencing and evaluated the correlation between PLA2G4A and ANXA10. The effect of PLA2G4A downstream signaling, including Cyclooxygenase 2, Prostaglandin E2(PGE2) and Signal transducer and activator of transcription 3(STAT3), on EMT and metastasis was further detected with in vitro and in vivo experiments. Findings ANXA10 expression was upregulated in PHCCA and DCCA but not in IHCCA. High ANXA10 expression was significantly associated with poor tumor differentiation and prognosis. ANXA10 promoted the proliferation, migration and invasion of the PHCCA cells. PLA2G4A expression was regulated by ANXA10 and high PLA2G4A predicted poor prognosis in PHCCA and DCCA. ANXA10 facilitated EMT and promoted metastasis by upregulating PLA2G4A expression, thus increasing PGE2 levels and activating STAT3. Interpretation ANXA10 was an independent prognostic biomarker of PHCCA and DCCA but not IHCCA. ANXA10 promoted the progression of PHCCA and facilitated metastasis by promoting the EMT process via the PLA2G4A/PGE2/STAT3 pathway. ANXA10, PLA2G4A and their downstream molecules, such as COX2 and PGE2, may be promising drug targets of PHCCA and DCCA.
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Affiliation(s)
- Rongqi Sun
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Zengli Liu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Bo Qiu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Tianli Chen
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Zhipeng Li
- Department of General Surgery, Shandong Provincial Hospital, Jinan, China
| | - Xiaoming Zhang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Yunfei Xu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China.
| | - Zongli Zhang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China.
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