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Neuzillet C, Decraecker M, Larrue H, Ntanda-Nwandji LC, Barbier L, Barge S, Belle A, Chagneau C, Edeline J, Guettier C, Huguet F, Jacques J, Le Bail B, Leblanc S, Lewin M, Malka D, Ronot M, Vendrely V, Vibert É, Bureau C, Bourliere M, Ganne-Carrie N, Blanc JF. Management of intrahepatic and perihilar cholangiocarcinomas: Guidelines of the French Association for the Study of the Liver (AFEF). Liver Int 2024. [PMID: 38967424 DOI: 10.1111/liv.15948] [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: 12/29/2023] [Revised: 03/13/2024] [Accepted: 04/11/2024] [Indexed: 07/06/2024]
Abstract
Intrahepatic cholangiocarcinoma (iCCA) is the second most common malignant primary liver cancer. iCCA may develop on an underlying chronic liver disease and its incidence is growing in relation with the epidemics of obesity and metabolic diseases. In contrast, perihilar cholangiocarcinoma (pCCA) may follow a history of chronic inflammatory diseases of the biliary tract. The initial management of CCAs is often complex and requires multidisciplinary expertise. The French Association for the Study of the Liver wished to organize guidelines in order to summarize the best evidence available about several key points in iCCA and pCCA. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe the epidemiology of CCA as well as how patients with iCCA or pCCA should be managed from diagnosis to treatment. The most recent developments of personalized medicine and use of targeted therapies are also highlighted.
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Affiliation(s)
- Cindy Neuzillet
- GI Oncology, Medical Oncology Department, Institut Curie, Versailles Saint-Quentin University, Paris Saclay University, Saint-Cloud, France
| | - Marie Decraecker
- Oncology Digestive Unit, INSERM U1312, University Hospital of Bordeaux, Bordeaux, France
| | - Hélène Larrue
- Department of Hepatology, University Hospital, Toulouse III-Paul Sabatier University, Toulouse, France
| | | | - Louise Barbier
- New Zealand Liver Transplant Unit and HPB Surgery, Te Toka Tumai, University of Auckland, Auckland, New Zealand
| | - Sandrine Barge
- Centre Hospitalier Intercommunal Créteil-CHI Créteil, Créteil, France
| | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Julien Edeline
- Department of Medical Oncology, CLCC Eugène Marquis, COSS-UMR S1242, INSERM, Univ Rennes, Rennes, France
| | - Catherine Guettier
- Department of Pathology, APHP University Paris Saclay, Hôpital Bicetre, Paris, France
| | - Florence Huguet
- Radiation Oncology Department, Tenon Hospital, APHP-Sorbonne University, Paris, France
| | | | - Brigitte Le Bail
- Pathology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Sarah Leblanc
- Gastroenterology Department, Private Hospital Jean Mermoz, Ramsay Santé, Lyon, France
| | - Maïté Lewin
- Service de Radiologie, AP-HP-Université Paris Saclay Hôpital Paul Brousse, Villejuif, France
| | - David Malka
- Medical Oncology Department, Institut Mutualiste Monsouris, Paris, France
| | - Maxime Ronot
- Department of Radiology, Beaujon Hospital, APHP Nord Clichy, University Paris Cité, CRI UMR, Paris, France
| | | | - Éric Vibert
- Centre Hepato-Biliaire, AP-HP-Université Paris Saclay Hôpital Paul Brousse, Villejuif, France
| | - Christophe Bureau
- Department of Hepatology, University Hospital, Toulouse III-Paul Sabatier University, Toulouse, France
| | | | | | - Jean-Frédéric Blanc
- Oncology Digestive Unit, INSERM U1312, University Hospital of Bordeaux, Bordeaux, France
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Kim HS, Kang MJ, Kang J, Kim K, Kim B, Kim SH, Kim SJ, Kim YI, Kim JY, Kim JS, Kim H, Kim HJ, Nahm JH, Park WS, Park E, Park JK, Park JM, Song BJ, Shin YC, Ahn KS, Woo SM, Yu JI, Yoo C, Lee K, Lee DH, Lee MA, Lee SE, Lee IJ, Lee H, Im JH, Jang KT, Jang HY, Jun SY, Chon HJ, Jung MK, Chung YE, Chong JU, Cho E, Chie EK, Choi SB, Choi SY, Choi SJ, Choi JY, Choi HJ, Hong SM, Hong JH, Hong TH, Hwang SH, Hwang IG, Park JS. Practice guidelines for managing extrahepatic biliary tract cancers. Ann Hepatobiliary Pancreat Surg 2024; 28:161-202. [PMID: 38679456 PMCID: PMC11128785 DOI: 10.14701/ahbps.23-170] [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: 12/13/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 05/01/2024] Open
Abstract
Backgrounds/Aims Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021. Methods Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop. Results In November 2021, the finalized draft was presented for public scrutiny during a formal hearing. Conclusions The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.
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Affiliation(s)
- Hyung Sun Kim
- Department of Surgery, Pancreatobiliary Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Mee Joo Kang
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Jingu Kang
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bohyun Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Seong-Hun Kim
- Department of Internal Medicine, Jeonbuk National University Medical School and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Soo Jin Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Yong-Il Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Young Kim
- Department of Pathology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jin Sil Kim
- Department of Radiology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Ji Hae Nahm
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Eunkyu Park
- Division of HBP Surgery, Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Joo Kyung Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Byeong Jun Song
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Yong Chan Shin
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Keun Soo Ahn
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sang Myung Woo
- Center for Liver and Pancreatobiliary Cancer, Hospital, Immuno-Oncology Branch Division of Rare and Refractory Center, Research Institute of National Cancer Center, Goyang, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoungbun Lee
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Myung Ah Lee
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Eun Lee
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Huisong Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jung Ho Im
- Department of Radiation Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Young Jang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun-Young Jun
- Department of Pathology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hong Jae Chon
- Department of Medical Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Eun Chung
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Uk Chong
- Department of Surgery, National Health Insurance Services Ilsan Hospital, Goyang, Korea
| | - Eunae Cho
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Sae Byeol Choi
- Department of Surgery, Korea Universtiy Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seo-Yeon Choi
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ji Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye-Jeong Choi
- Department of Pathology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyung Hong
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, Seoul St. Mary’s Hospital College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shin Hye Hwang
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - In Gyu Hwang
- Division of Hemato-Oncology, Department of Internal Medicine, Chung-Ang University Hospital Chung-Ang University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Pancreatobiliary Clinic, Yonsei University College of Medicine, Seoul, Korea
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Promsorn J, Naknan P, Sookprasert A, Wirasorn K, Chindaprasirt J, Titapun A, Intarawichian P, Harisinghani M. Radiographic features predictive of recurrence and survival after surgical resection of perihilar cholangiocarcinoma. Heliyon 2024; 10:e28805. [PMID: 38617950 PMCID: PMC11015104 DOI: 10.1016/j.heliyon.2024.e28805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024] Open
Abstract
Objective To study which radiographic features were associated with recurrence and adverse outcome in patients undergoing surgical resection of perihilar cholangiocarcinoma (PCCA), as well as to evaluate the imaging patterns that signify recurrence after the resection of PCCA. Materials and methods This study was conducted in a solitary tertiary center and utilized a retrospective, analytical, case-control design. The study population consisted of patients with pathologically confirmed PCCA who underwent surgical resection and were subsequently followed up from January 2009 to December 2017. A total of 77 patients were enrolled in the study and were categorized into two distinct groups, namely recurrent and non-recurrent. The analysis encompassed the examination of demographic data and recurrence patterns. Additionally, survival and multivariate analyses were employed to assess radiographic imaging data and surgical information. Results Seventy-seven patients diagnosed with PCCA based on pathological evidence were included in the study. Among the participants, there were 28 females and 49 males, with ages ranging from 41 to 81 years (mean age of 60.65 ± 7.66). A noteworthy finding was the recurrence rate of 65 % observed following surgical resection. The presence of regional lymph node (LN) metastasis, adjacent organ invasion, and surgical margin emerged as the three independent factors that exhibited a significant association with recurrence after post-operative resection (p = 0.023, p = 0.028, and p = 0.010, respectively). The patients with PCCA who experienced regional LN metastasis had a median overall survival (OS) of 22 months, which was significantly lower than the 46 months observed in those without regional LN metastasis (p < 0.018). Furthermore, the individuals with regional LN metastasis had a death rate that was 2.08 times higher than those without (p = 0.040). In addition, those with adjacent organ invasion had an OS duration of 21 months compared with 52 months in those without (p = 0.008), and the rate of death was 2.39 times higher (p = 0.018). Patients with an R1 resection margin had an OS duration of 36 months compared with 51.56 months in those with an R0 resection margin (p = 0.006), as well as a 2.13 times higher rate of recurrence (p = 0.010) and a 2.43 times higher mortality rate (p = 0.013). Conclusion The presence of regional LN metastasis, invasion of adjacent organs, and R1 resection margin were identified as distinct factors that are linked to both disease recurrence and reduced OS. Local recurrence, as well as the spread of cancer to distant organs such as the lungs and liver, were frequently observed patterns of recurrence. To enhance the precision of staging, prognosis, and treatment, the inclusion of periductal fat or invasion of adjacent organs should be considered in the staging system for PCCA.
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Affiliation(s)
- Julaluck Promsorn
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Panjaporn Naknan
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Aumkhae Sookprasert
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Kosin Wirasorn
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Jarin Chindaprasirt
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Attapol Titapun
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | | | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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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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Takahashi R, Ishizawa T, Inagaki Y, Tanaka M, Ogasawara A, Kuriki Y, Fujita K, Kamiya M, Ushiku T, Urano Y, Hasegawa K. Real-Time Fluorescence Imaging to Identify Cholangiocarcinoma in the Extrahepatic Biliary Tree Using an Enzyme-Activatable Probe. Liver Cancer 2023; 12:590-602. [PMID: 38058421 PMCID: PMC10697719 DOI: 10.1159/000530645] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/03/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Complete resection is the only possible treatment for cholangiocarcinoma in the extrahepatic biliary tree (eCCA), although current imaging modalities are limited in their ability to accurately diagnose longitudinal spread. We aimed to develop fluorescence imaging techniques for real-time identification of eCCA using an enzyme-activatable probe, which emits fluorescence immediately after activation by a cancer-specific enzyme. Methods Using lysates and small tissue fragments collected from surgically resected specimens, we selected the most specific probe for eCCA from among 800 enzyme-activatable probes. The selected probe was directly sprayed onto resected specimens and fluorescence images were acquired; these images were evaluated for diagnostic accuracy. We also comprehensively searched for enzymes that could activate the probe, then compared their expression levels in cancer and non-cancer tissues. Results Analyses of 19 samples (four cancer lysates, seven non-cancer lysates, and eight bile samples) and 54 tissue fragments (13 cancer tissues and 41 non-cancer tissues) revealed that PM-2MeSiR was the most specific fluorophore for eCCA. Fluorescence images of 7 patients were obtained; these images enabled rapid identification of cancerous regions, which closely matched histopathology findings in 4 patients. Puromycin-sensitive aminopeptidase was identified as the enzyme that might activate the probe, and its expression was upregulated in eCCA. Conclusion Fluorescence imaging with PM-2MeSiR, which may be activated by puromycin-sensitive aminopeptidase, yielded generally high accuracy. This technique may be useful for real-time identification of the spread of eCCA during surgery and endoscopic examinations.
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Affiliation(s)
- Ryugen Takahashi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku Tokyo, Japan
- Department of Hepatobiliary-Pancreatic Surgery, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yoshinori Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku Tokyo, Japan
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Ogasawara
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Yugo Kuriki
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Kyohhei Fujita
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mako Kamiya
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Life Science and Technology, Tokyo Institute of Technology, Tokyo, Japan
| | - Tetsuo Ushiku
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuteru Urano
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku Tokyo, Japan
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Hu YF, Hu HJ, Lv TR, He ZQ, Dai YS, Li FY. Should more aggressive surgical resection be considered in the treatment for Bismuth types I and II hilar cholangiocarcinoma? A meta-analysis. Asian J Surg 2023; 46:4115-4123. [PMID: 36586821 DOI: 10.1016/j.asjsur.2022.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 12/16/2022] [Indexed: 12/31/2022] Open
Abstract
Evidence regarding the optical surgical extent for Bismuth type I/II HCCA is lacking. we aims to evaluate the optimal surgical methods for Bismuth type I/II HCCA. Studies comparing bile duct resection (BDR) and BDR combined with liver resection (BDR + LR) for all types of HCCA patients were searched for analyses, and 14 studies were finally included. The main outcomes were the R0 resection rate and overall survival (OS). For all types of HCCA patents, BDR + LR resulted with higher R0 resection rates when comparing with BDR only (RR = 0.70, 95%CI, 0.63-0.78), and patients with R0 resections had eight times longer median survival and more long-time survival outcomes (3 and 5 year OS) comparing to those with non-R0 resections. Bismuth I/II HCCA patients also showed longer median survival and 3-year OS after R0 resections (P = 0.04). Moreover, there was no significant difference in 3-year OS between BDR and BDR + LR (P = 0.89) and we additionally found BDR resulted in less mortality or morbidity rates. In Europe and US, they resulted the R0 resection rates could be comparable between BDR and BDR + LR (P = 0.18), and Bismuth type I HCCA accounted for 75.8%, while in Asia, BDR + LR still resulted with higher R0 resection rates (P < 0.0001) and the Bismuth type I HCCA accounted for only 40.3%. The surgical approaches may not directly impact patient prognosis, patients with R0 resections are usually associated with improved survival outcomes; for selected Bismuth type I/II HCCA, BDR may be an acceptable option with regard to lower morbidity and comparable R0 resection rate comparing with BDR + LR.
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Affiliation(s)
- Ya-Fei Hu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Hai-Jie Hu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Tian-Run Lv
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Zhi-Qiang He
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Yu-Shi Dai
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Fu-Yu Li
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China.
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Liu W, Xiong F, Wu G, Wang Q, Wang B, Chen Y. Biliary-enteric reconstruction in laparoscopic radical resection of hilar cholangiocarcinoma: a single-center retrospective cohort study. BMC Cancer 2023; 23:456. [PMID: 37202725 DOI: 10.1186/s12885-023-10942-y] [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: 01/04/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE To evaluate the feasibility and quality of biliary-enteric reconstruction (BER) in laparoscopic radical resection of hilar cholangiocarcinoma (LsRRH) versus open surgery and propose technical recommendations. METHODS Data of 38 LsRRH and 54 radical laparotomy resections of hilar cholangiocarcinoma (LtRRH) cases were collected from our institution. BER was evaluated via biliary residuals numbers, number of anastomoses, anastomosis manner, suture method, time consumption, and postoperative complication. RESULTS In the LsRRH group, patients were relatively younger; Bismuth type I had a higher proportion while type IIIa and IV were less and required no revascularization. In LsRRH and LtRRH groups, respectively, the biliary residuals number was 2.54 ± 1.62 and 2.47 ± 1.46 (p > 0.05); the number of anastomoses was 2.04 ± 1.27 and 2.57 ± 1.33 (p > 0.05); the time of BER was 65.67 ± 21.53 and 42.5 ± 19.77 min (p < 0.05), 15.08 ± 3.64% and 11.76 ± 2.54% of the total operation time (p < 0.05); postoperative bile leakage incidence was 15.79% and 16.67% (p > 0.05); 14 ± 10.28 and 17 ± 9.73 days for healing (p < 0.05); anastomosis stenosis rate was 2.63% and 1.85% (p > 0.05). Neither group had a biliary hemorrhage or bile leakage-related death. CONCLUSION The selection bias in LsRRH mainly affects tumor resection than BER. Our cohort study indicates that BER in LsRRH is technically feasible and equals anastomotic quality to open surgery. However, its longer and a more significant proportion of total operation time represent that BER has higher technical requirements and is one of the critical rate-limiting steps affecting the minimal invasiveness of LsRRH.
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Affiliation(s)
- Wenzheng Liu
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Fei Xiong
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Guanhua Wu
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Qi Wang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Bing Wang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Yongjun Chen
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
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8
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Gilbert RWD, Lenet T, Cleary SP, Smoot R, Tzeng CWD, Rocha FG, Martel G, Bertens KA. Does Caudate Resection Improve Outcomes of Patients Undergoing Curative Resection for Perihilar Cholangiocarcinoma? A Systematic Review and Meta-Analysis. Ann Surg Oncol 2022; 29:6759-6771. [PMID: 35705775 DOI: 10.1245/s10434-022-11990-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/25/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Margin-negative (R0) resection is the strongest positive prognostic factor in perihilar cholangiocarcinoma (PHC). Due to its anatomic location, the caudate lobe is frequently involved in PHC. This review aimed to examine the impact of caudate lobe resection (CLR) in addition to hepatectomy and bile duct resection for patients with PHC. METHODS The MEDLINE, EMBASE, and Cochrane databases were systematically reviewed from inception to October 2021 to identify studies comparing patients undergoing surgical resection with hepatectomy and bile duct resection with or without CLR for treatment of PHC. Outcomes included the proportion of patients achieving R0 resection, overall survival (OS), and perioperative morbidity. RESULTS Altogether, 949 studies were screened. The review included eight observational studies reporting on 1137 patients. The patients who underwent CLR had a higher likelihood of R0 resection (odds ratio [OR], 5.85; 95% confidence interval [CI], 2.64-12.95) and a better OS (hazard ratio [HR], 0.65; 95% CI, 0.54-0.79) than those who did not. The use of CLR did not increase the risk of perioperative morbidity (OR, 1.03; 95% CI, 0.65-1.63). CONCLUSIONS Given the higher likelihood of R0 resection, improved OS, and no apparent increase in perioperative morbidity, this review supports routine caudate lobectomy in the surgical management of PHC. These results should be interpreted with caution given the lack of high-quality prospective data and the high probability of selection bias.
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Affiliation(s)
- Richard W D Gilbert
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada
| | - Tori Lenet
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, OR, USA
| | - Guillaume Martel
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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9
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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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10
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Kim KB, Choi DW, Heo JS, Han IW, Shin SH, You Y, Park DJ. The impact of portal vein resection on outcome of hilar cholangiocarcinoma. Ann Hepatobiliary Pancreat Surg 2021; 25:221-229. [PMID: 34053925 PMCID: PMC8180392 DOI: 10.14701/ahbps.2021.25.2.221] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 12/17/2022] Open
Abstract
Backgrounds/Aims Portal vein resection (PVR) with major hepatic resection can increase the rate of curative resection for hilar cholangiocarcinoma (HC). However, the oncologic role and safety of PVR is still debatable. This study aims to analyze PVR in terms of safety and therapeutic effectiveness. Methods We retrospectively analyzed 235 patients who had undergone major hepatic resection for HC with curative intent, including patients with PVR (PVR, n=35) consisting of PV invasion (PVR-A, n=9), No PV invasion (PVR-B, n=26); and patients without PVR (No PVR, n=200). Results There was no significant difference in the 30-day mortality or postoperative morbidity between PVR and No PVR (2.9% vs. 1.0%; p=0.394 and 34.3% vs. 35.0%; p=0.875). The rate of advanced HC (T3: 40% vs. 12%; p<0.001 and nodal metastasis: 60% vs. 28%; p<0.001) was higher in PVR compared to No PVR. There was no significant difference in the 5-year overall survival rates and disease-free survival between PVR-A vs. PVR-B vs. No PVR. In multivariate analysis, estimated blood loss >600 ml (p=0.010), T3 diseases (p=0.001), nodal metastasis (p=0.001) and poor differentiation (p=0.002) were identified as independent risk factors for survival. Conclusions PVR does not increase postoperative mortality or morbidity. It showed a similar oncologic outcome, despite a more advanced disease state in patients with HC. Given these findings, PVR should be actively performed if necessary, after careful patient selection.
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Affiliation(s)
- Ki Beom Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunghun You
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae Joon Park
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
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11
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Yang M, Li WW, Chen JH, Cui MH, Liu JL. The value of caudate lobectomy in hilar cholangiocarcinoma treatment: A meta-analysis. Medicine (Baltimore) 2021; 100:e24727. [PMID: 33607815 PMCID: PMC7899860 DOI: 10.1097/md.0000000000024727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/18/2021] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To discuss the value of caudate lobectomy in hilar cholangiocarcinoma (HCCA) treatment. METHODS A systematic review was performed in PubMed, MEDLINE database, EMBASE, and Cochrane Library for trials comparing combined caudate lobectomy with controls from January 1, 1990 to December 2, 2020. The outcomes were postoperative radical cure information, survival condition, morbidity, and mortality. RESULT Ten studies were included. No difference was observed in the morbidity (odd ratio (OR) 0.93, 95% confidence interval (CI) 0.65-1.33) and mortality (OR 1.16, 95% CI 0.55-2.42) between the combined caudate lobectomy and control groups. Hepatectomy combined with caudate lobectomy was associated with higher incidence of radical resection (OR 3.88, 95% CI 2.18-6.90) and longer survival (hazard ratio 0.45, 95% CI 0.38-0.55). CONCLUSION Combining caudate lobectomy can significantly increase the incidence of radical resection of HCCA and the postoperative survival time. The morbidity and mortality were not increased after the operation. Thus, caudate lobectomy should be included when performing partial hepatectomy for HCCA.
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Affiliation(s)
- Ming Yang
- Department of hepatobiliary surgery, The Affiliated Hospital of Chengde Medical College
| | - Wei Wei Li
- Department of hepatobiliary surgery, The Affiliated Hospital of Chengde Medical College
| | - Jian Hua Chen
- Department of General Surgery, Kuancheng County Traditional Chinese Medicine Hospital, Chengde City, Hebei Province, China
| | - Miao Hang Cui
- Department of hepatobiliary surgery, The Affiliated Hospital of Chengde Medical College
| | - Jin Long Liu
- Department of hepatobiliary surgery, The Affiliated Hospital of Chengde Medical College
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12
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Liang L, Li C, Jia HD, Diao YK, Xing H, Pawlik TM, Lau WY, Shen F, Huang DS, Zhang CW, Yang T. Prognostic factors of resectable perihilar cholangiocarcinoma: a systematic review and meta-analysis of high-quality studies. Ther Adv Gastrointest Endosc 2021; 14:2631774521993065. [PMID: 33629062 PMCID: PMC7882763 DOI: 10.1177/2631774521993065] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
Data on prognostic factors associated with outcome following resection of perihilar cholangiocarcinoma vary. We sought to define and characterize current available evidence on prognostic factors associated with perihilar cholangiocarcinoma after resection. The PubMed, Embase, and Cochrane library were systematically searched for relevant studies published before December 2019. Prognostic factors were identified from multivariate regression analyses in studies. Only high-quality studies were included (Newcastle-Ottawa Scale > 6 stars). A total of 45 studies involving 7338 patients were analyzed. The meta-analysis demonstrated that serum bilirubin levels (hazard ratio: 1.76, 95% confidence interval: 1.27-2.44), serum CA19-9 levels (hazard ratio: 1.32, 95% confidence interval: 1.05-1.65), tumor size (hazard ratio: 1.27, 95% confidence interval: 1.04-1.55), major vascular involvement (hazard ratio: 1.61, 95% confidence interval: 1.09-2.38), distance metastasis (hazard ratio: 17.60, 95% confidence interval: 2.01-154.09), perioperative blood transfusion (hazard ratio: 1.36, 95% confidence interval: 1.15-1.62), T-stage (hazard ratio: 1.96, 95% confidence interval: 1.47-2.61), lymph node metastasis (hazard ratio: 2.06, 1.83-2.31), resection margin status (hazard ratio: 2.34, 95% confidence interval: 1.89-2.89), not-well histology differentiation (hazard ratio: 2.03, 95% confidence interval: 1.69-2.44), perineural invasion (hazard ratio: 2.37, 95% confidence interval: 1.59-3.55), and lymphovascular invasion (hazard ratio: 1.41, 95% confidence interval: 1.15-1.73) were prognostic factors for poorer overall survival. Adjuvant chemotherapy (hazard ratio: 0.37, 95% confidence interval: 0.25-0.55) had a positive effect on prolonged overall survival. In addition, positive resection margin status (hazard ratio: 1.96, 95% confidence interval: 1.47-2.61) and lymph node metastasis (hazard ratio: 2.06, 95% confidence interval: 1.83-2.31) were associated with poorer disease-free survival. The prognostic factors identified in the present meta-analysis can be used to characterize patients in clinical practice and enrich prognostic tools, which could be included in future trial designs and generate hypotheses to be tested in future research to promote personalized treatment.
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Affiliation(s)
- Lei Liang
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Chao Li
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai, China
| | - Hang-Dong Jia
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yong-Kang Diao
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Hao Xing
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai, China
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Wan Yee Lau
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai, China
| | - Feng Shen
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai, China
| | - Dong-Sheng Huang
- Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Hangzhou, China
| | - Cheng-Wu Zhang
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Tian Yang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai 200438, China
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13
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Watson MD, Baimas-George MR, Passeri MJ, Sulzer JK, Baker EH, Ocuin LM, Martinie JB, Iannitti DA, Vrochides D. Effect of Margin Status on Survival After Resection of Hilar Cholangiocarcinoma in the Modern Era of Adjuvant Therapies. Am Surg 2020; 87:1496-1503. [PMID: 33345594 DOI: 10.1177/0003134820973401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Studies have shown that for patients with hilar cholangiocarcinoma (HC), survival is associated with negative resection margins (R0). This requires increasingly proximal resection, putting patients at higher risk for complications, which may delay chemotherapy. For patients with microscopically positive resection margins (R1), the use of modern adjuvant therapies may offset the effect of R1 resection. METHODS Patients at our institution with HC undergoing curative-intent resection between January 2008 and July 2019 were identified by retrospective record review. Demographic data, operative details, tumor characteristics, postoperative outcomes, recurrence, survival, and follow-up were recorded. Patients with R0 margin were compared to those with R1 margin. Patients with R2 resection were excluded. RESULTS Seventy-five patients underwent attempted resection with 34 (45.3%) cases aborted due to metastatic disease or locally advanced disease. Forty-one (54.7%) patients underwent curative-intent resection with R1 rate of 43.9%. Both groups had similar rates of adjuvant therapy (56.5% vs. 61.1%, P = .7672). Complication rates and 30 mortality were similar between groups (all P > .05). Both groups had similar median recurrence-free survival (R0 29.2 months vs. R1 27.8 months, P = .540) and median overall survival (R0 31.2 months vs. R1 38.8 months, P = .736) with similar median follow-up time (R0 29.9 months vs. R1 28.5 months, P = .8864). CONCLUSIONS At our institution, patients undergoing hepatic resection for HC with R1 margins have similar recurrence-free and overall survival to those with R0 margins. Complications and short-term mortality were similar. This may indicate that with use of modern adjuvant therapies obtaining an R0 resection is not an absolute mandate.
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Affiliation(s)
- Michael D Watson
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Maria R Baimas-George
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Michael J Passeri
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Jesse K Sulzer
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Lee M Ocuin
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
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14
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Jingdong L, Yongfu X, Yang G, Jian X, Xujian H, Jianhua L, Wenxing Z, Renyi Q, Xinming Y, Shuguo Z, Xiao L, Bin P, Qifan Z, Dewei L, Zhao-Hui T. Minimally invasive surgery for hilar cholangiocarcinoma: a multicenter retrospective analysis of 158 patients. Surg Endosc 2020; 35:6612-6622. [PMID: 33258033 DOI: 10.1007/s00464-020-08161-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 11/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Curative resection of hilar cholangiocarcinoma (HC) is typically carried out using open surgery. In the present study, we examined the safety (postoperative complication) and effectiveness (resection margin status and patient survival) of minimally invasive surgery (MIS) for HC. METHODS This retrospective analysis included 158 patients receiving MIS for HC at 10 participating centers between December 2013 and November 2019. Patient demographics, surgical outcomes, and oncological outcomes were retrospectively analyzed. RESULTS Clinical information obtained from 10 different clinical centers did not show any evident cohort-bias clustering. One hundred and twenty-six (79.7%) patients underwent LRHC, 12 (7.6%) patients underwent RARHC, conversion to an open procedure occurred in 20 (12.7%) patients. The operation time and estimated blood loss were 410.8 ± 128.9 min and 477.8 ± 706.3 mL, respectively. The surgical radicality of the 158 patients was R0, 129 (81.6%); R1, 20 (18.4%) and R2, 9 (5.7%). Grades I-II complications was occurred in 68 (43.0%) patients. Severe morbidity (grade III-V) occurred in 14 (8.7%) patients. The median overall survival in whole cohort was 25.4 months. The overall survival rate was 67.6% at year 1, 28.8% at year 3, and 19.2% at year 5. Comparing the first half of MISHC performed by each center with the following cases, the operation time and postoperative hospital stay does not decrease with the increasing cases. On literature review, MISHC is non-inferior to open surgery at least in perioperative period. CONCLUSIONS In this Chinese MIS for HC multicenter study, the largest to date, long-term overall survival rates after MIS appear comparable to those reported in current open series. Further randomized controlled trials are necessary to assess the global impact of MISHC.
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Affiliation(s)
- Li Jingdong
- Department of General Surgery, Institute of Hepatobiliary-Pancreatic-Intestinal Diseases, Affiliated Hospital of North Sichuan Medical College, No.63 Wenhua Road, Shunqing District, Nanchong, 637000, China.
| | - Xiong Yongfu
- Department of General Surgery, Institute of Hepatobiliary-Pancreatic-Intestinal Diseases, Affiliated Hospital of North Sichuan Medical College, No.63 Wenhua Road, Shunqing District, Nanchong, 637000, China.
| | - Gang Yang
- Department of General Surgery, Institute of Hepatobiliary-Pancreatic-Intestinal Diseases, Affiliated Hospital of North Sichuan Medical College, No.63 Wenhua Road, Shunqing District, Nanchong, 637000, China
| | - Xu Jian
- Department of General Surgery, Institute of Hepatobiliary-Pancreatic-Intestinal Diseases, Affiliated Hospital of North Sichuan Medical College, No.63 Wenhua Road, Shunqing District, Nanchong, 637000, China
| | - Huang Xujian
- Department of General Surgery, Institute of Hepatobiliary-Pancreatic-Intestinal Diseases, Affiliated Hospital of North Sichuan Medical College, No.63 Wenhua Road, Shunqing District, Nanchong, 637000, China
| | - Liu Jianhua
- Department of Hepatobiliary Surgery, Second Affiliated Hospital of Hebei Medical University, Hebei, 200092, China
| | - Zhao Wenxing
- Department of Hepatobiliary Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, China
| | - Qin Renyi
- Department of Biliary Pancreatic Surgery, Affiliated Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yin Xinming
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, Changsha, 410005, China
| | - Zheng Shuguo
- Department of Biliary Surgery, The First Hospital Affiliated to Army Medical University, Chongqing, 400038, China
| | - Liang Xiao
- Department of Hepatobiliary Surgery, SirRunRunShaw Hospital of Zhejiang University, Hangzhou, 310020, China
| | - Peng Bin
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zhang Qifan
- Department of Hepatobiliary Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, 510515, China
| | - Li Dewei
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Tang Zhao-Hui
- Department of General Surgery, Xinhua Hospital Affiliated of Shanghai Jiaotong University School of Medicine, Yangpu District, No.1665 Kong jiang Road, Shanghai, 200000, China.
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15
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Hau HM, Meyer F, Jahn N, Rademacher S, Sucher R, Seehofer D. Prognostic Relevance of the Eighth Edition of TNM Classification for Resected Perihilar Cholangiocarcinoma. J Clin Med 2020; 9:E3152. [PMID: 33003424 PMCID: PMC7599593 DOI: 10.3390/jcm9103152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES In our study, we evaluated and compared the prognostic value and performance of the 6th, 7th, and 8th editions of the American Joint Committee on Cancer (AJCC) staging system in patients undergoing surgery for perihilar cholangiocarcinoma (PHC). METHODS Patients undergoing liver surgery with curative intention for PHC between 2002 and 2019 were identified from a prospective database. Histopathological parameters and stage of the PHC were assessed according to the 6th, 7th, and 8th editions of the tumor node metastasis (TNM) classification. The prognostic accuracy between staging systems was compared using the area under the receiver operating characteristic curve (AUC) model. RESULTS Data for a total of 95 patients undergoing liver resection for PHC were analyzed. The median overall survival time was 21 months (95% CI 8.1-33.9), and the three- and five-year survival rates were 46.1% and 36.2%, respectively. Staging according to the 8th edition vs. the 7th edition resulted in the reclassification of 25 patients (26.3%). The log-rank p-values for the 7th and 8th editions were highly statistically significant (p ≤ 0.01) compared to the 6th edition (p = 0.035). The AJCC 8th edition staging system showed a trend to better discrimination, with an AUC of 0.69 (95% CI: 0.52-0.84) compared to 0.61 (95% CI: 0.51-0.73) for the 7th edition. Multivariate survival analysis revealed male gender, age >65 years, positive resection margins, presence of distant metastases, poorly tumor differentiation, and lymph node involvement, such as no caudate lobe resection, as independent predictors of poor survival (p < 0.05). CONCLUSIONS In the current study, the newly released 8th edition of AJCC staging system showed no significant benefit compared to the previous 7th edition in predicting the prognosis of patients undergoing liver resection for perihilar cholangiocarcinoma. Further research may help to improve the prognostic value of the AJCC staging system for PHC-for instance, by identifying new prognostic markers or staging criteria, which may improve that individual patient's outcome.
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Affiliation(s)
- Hans-Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (F.M.); (S.R.); (R.S.); (D.S.)
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Felix Meyer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (F.M.); (S.R.); (R.S.); (D.S.)
| | - Nora Jahn
- Department of Anesthesiology, University Hospital of Leipzig, 04103 Leipzig, Germany;
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (F.M.); (S.R.); (R.S.); (D.S.)
| | - Robert Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (F.M.); (S.R.); (R.S.); (D.S.)
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (F.M.); (S.R.); (R.S.); (D.S.)
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16
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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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Complete laparoscopic radical resection of hilar cholangiocarcinoma: technical aspects and long-term results from a single center. Wideochir Inne Tech Maloinwazyjne 2020; 16:62-75. [PMID: 33786118 PMCID: PMC7991938 DOI: 10.5114/wiitm.2020.97363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/14/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction The landscape of surgical treatments for hepatobiliary disease was significantly changed after the advent of laparoscopy. Many kinds of complex laparoscopic procedures can be routinely performed at present, but radical resection of hilar cholangiocarcinoma (HC) by laparoscopy is still highly contentious. Aim To describe our primary experience with laparoscopic radical resection for HC and determine the safety and feasibility of this procedure. Material and methods Between December 2015 and November 2019, 32 patients planned to undergo curative-intent laparoscopic resection of HC in our department. The perioperative and long-term outcomes of these patients were retrospectively analyzed. Results Laparoscopic surgery with radical resection was ultimately performed in 24 (75.0%) patients; 3 (9.3%) patients were found to be unresectable at the preliminary exploration stage, and 5 (15.7%) patients converted from laparoscopy to laparotomy. The operation time and blood loss were 476.95 ±133.89 min and 568.75 ±324.01 ml, respectively. A negative margin was achieved in 19 (79.1%) of the laparoscopy patients. Three (12.5%) patients were identified with microscopic positive margins, and 2 (8.4%) patients underwent macroscopic residual tumor resection (R2). The length of postoperative stay was 23.3 ±11.7 days. Severe morbidity occurred in 4 (16.6%) patients. The actuarial 3-year overall survival and disease-free survival for patients who underwent laparoscopic surgery were 49.1% and 47.0%, respectively. Conclusions Laparoscopic radical resection for HC is safe and feasible in experienced hands for highly selected patients but is still in its initial stages. When adequate oncologic resection is performed, the laparoscopic approach does not adversely influence the prognosis of the patient.
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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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Chansitthichok S, Chamnan P, Sarkhampee P, Lertsawatvicha N, Voravisutthikul P, Wattanarath P. Survival of Patients with Cholangiocarcinoma Receiving Surgical Treatment in an O. viverrini Endemic Area in Thailand: A Retrospective Cohort Study. Asian Pac J Cancer Prev 2020; 21:903-909. [PMID: 32334449 PMCID: PMC7445979 DOI: 10.31557/apjcp.2020.21.4.903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Indexed: 01/04/2023] Open
Abstract
Objective: To investigate risk factors associated with mortality in cholangiocarcinoma patients receiving surgical treatment in Thailand’s endemic area and their survival rate. Materials and Methods: Medical records of patients with histologically confirmed cholangiocarcinoma, who underwent surgical treatment at Sanpasitthiprasong Regional Hospital from October 1, 2013 to October, 31 2015, were retrospectively included. Patients’ vital status (death/alive) and date of death were obtained from the Interior Ministry’s death certificate. Cox proportional hazard regression was used to examine factors associated with mortality. Results: Out of 295 patients with cholangiocarcinoma (CCA), 180(58%) were intrahepatic CCA, 86(28%) were perihilar CCA, and 29 (9%) were distal CCA. Three groups were homogenous in terms of age and gender. Most of our patients referred with abdominal pain (63%), especially those who were intrahepatic CCA (77%). However, almost 80% of the perihilar CCA and distal CCA patients came with jaundice. Tumor markers (CEA and CA19-9) were not different between groups p=0.74 and p=0.43 respectively. Median survival of patients with intrahepatic CCA, perihilar CCA, and distal CCA patients was 14.6, 14.2, and 14.0 months, respectively. Factors independently associated with mortality in intrahepatic CCA patients were number and size of tumors and presence of perineural invasion (Hazard ratio (HR) 1.09[1.03 - 1.15], 1.07[1.02 - 1.13], and 2.09 [1.28 - 3.39], respectively). In perihilar CCA patients, having positive lymph nodes and resection status were independently associated with mortality. Compared to R0 resection, R1, R2, and no resection of perihilar CCA were associated with a 2-, 8- and 4-fold increase in the risk of mortality (HR 2.17 (0.99 – 4.78), 7.97 (3.22 – 19.71), and 4.21 (0.51 – 34.82), respectively). Conclusion: CCA patients in this endemic area had fairly poor survival. Factors associated with mortality in intrahepatic CCA were number and size of tumors and perineural invasion. However, risk factors for perihilar CCA included positive lymph nodes and resection status.
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Affiliation(s)
- Satsawat Chansitthichok
- General Surgery division, Department of Surgery, Sanpasitthiprasong Hospital, Ubon Ratchathani,Thailand
| | - Parinya Chamnan
- Cardiometabolic Research Group, Department of Social Medicine, Sanpasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Poowanai Sarkhampee
- General Surgery division, Department of Surgery, Sanpasitthiprasong Hospital, Ubon Ratchathani,Thailand
| | - Nithi Lertsawatvicha
- General Surgery division, Department of Surgery, Sanpasitthiprasong Hospital, Ubon Ratchathani,Thailand
| | - Pim Voravisutthikul
- General Surgery division, Department of Surgery, Sanpasitthiprasong Hospital, Ubon Ratchathani,Thailand
| | - Paiwan Wattanarath
- General Surgery division, Department of Surgery, Sanpasitthiprasong Hospital, Ubon Ratchathani,Thailand
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20
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Birgin E, Rasbach E, Reissfelder C, Rahbari NN. A systematic review and meta-analysis of caudate lobectomy for treatment of hilar cholangiocarcinoma. Eur J Surg Oncol 2020; 46:747-753. [PMID: 31987703 DOI: 10.1016/j.ejso.2020.01.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/02/2020] [Accepted: 01/16/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Surgical resection remains the only potentially curative therapy for hilar cholangiocarcinoma (CCC) patients. This meta-analysis aimed to review the current evidence on perioperative and long-term outcomes of routine caudate lobe resection (CLR) for surgical treatment of hilar CCC. METHODS A systematic literature search using MEDLINE, EMBASE and Cochrane databases was performed for studies providing comparative data on perioperative and long-term outcomes of patients undergoing resection for hilar CCC with and without CLR. The MINORS score was used for quality assessment. For time-to-event outcomes hazard ratios (HRs) and associated 95% CI were extracted from identified studies, whereas risk ratios (RRs) were calculated for overall morbidity, mortality, and resection margin status. Meta-analyses were carried out using random-effects models. RESULTS Eight studies involving 1350 patients met the inclusion criteria. The quality of the included studies was low to moderate. CLR resulted in significantly improved overall survival (HR 0.49; 95%CI 0.32-0.75, P < 0.01). Postoperative morbidity (RR 0.93; 95% CI 0.77-1.13; P = 0.48) and mortality (RR 1.01; 95% CI 0.42-2.41; P = 0.99) rates were comparable between both groups. Patients without concomitant CLR were at higher risk for residual tumor at the resection margin (RR 1.40; 95% CI 1.09-1.80; P = 0.01). CONCLUSION CLR is associated with improved long-term survival and negative tumor margins after resection of hilar CCC with no adverse impact on perioperative outcomes. CLR might provide the potential to become a standard-of-care procedure in the surgical management of hilar CCC.
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Affiliation(s)
- Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Erik Rasbach
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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21
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Mehrotra S, Lalwani S, Nundy S. Management Strategies for Patients with Hilar Cholangiocarcinomas: Challenges and Solutions. Hepat Med 2020; 12:1-13. [PMID: 32158282 PMCID: PMC6986165 DOI: 10.2147/hmer.s223022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
Advances in imaging, pathology and therapy have resulted in major improvements in the management of cholangiocarcinomas; the mortality has come down and with it there has been an improved 5-year survival. Surgical resection remains the treatment of choice and reports from high volume centres have shown an increase in resectability rates, R0 resection, a decrease in mortality and an improvement in 5-year survival; however, the operative morbidity remains high, pointing towards the complexity of the management of these difficult lesions. Complete excision is also often limited by the locally advanced nature of the disease at the time of diagnosis and a proportion of patients who were earlier deemed resectable on imaging are found to have unresectable disease at the time of operation. Neoadjuvant therapy has had only a limited impact on survival. Liver transplantation is also an option in a few patients following strict criteria for selection. Since the large majority of patients are only diagnosed at the late stages of the disease palliation (endoscopic or surgical) is an important part of treatment. Portal vein embolisation and pre-operative biliary drainage have had a major impact on outcomes. Major liver resection with caudate lobe removal remains the standard operation and procedures like routine vascular resection and liver transplant should only be carried out in experienced centres. Improvements in both neo as well as adjuvant therapy may lead to a standardized protocol in the future, as well as an improvement in survival.
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Affiliation(s)
- Siddharth Mehrotra
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Shailendra Lalwani
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
- Correspondence: Samiran Nundy Email
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22
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Li CX, Zhang H, Wang K, Wang X, Li XC. Preoperative Bilirubin Level Predicts Overall Survival and Tumor Recurrence After Resection for Perihilar Cholangiocarcinoma Patients. Cancer Manag Res 2019; 11:10157-10165. [PMID: 31819648 PMCID: PMC6897510 DOI: 10.2147/cmar.s230620] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/21/2019] [Indexed: 12/25/2022] Open
Abstract
Objective Currently, the correlation between preoperative bilirubin level and overall survival (OS) remains poorly defined in respectable perihilar cholangiocarcinoma (CC). The objectives of the current study were to evaluate the outcomes of perihilar CC after resection and then to analyze factors influencing curative resection, tumor recurrence and OS. Methods 115 patients with perihilar CC underwent surgical resection were retrospectively analyzed based on clinic characteristics, operative details, tumor recurrence and long-term survival data. Results The 1-, 3-, and 5-year OS rates after resection were 75.9%, 36.5%, 21.7%, whereas the corresponding tumor recurrence rates were 29.6%, 70.8%, 85.3%, respectively. Preoperative bilirubin level combined with liver resection, resection margin, vascular invasion and perineural invasion, lymph node metastasis and TNM stage were found to be correlated with OS and tumor recurrence. Multivariate analysis showed that preoperative bilirubin level together with resection margin, perineural invasion, and TNM stage were independent predictors of OS and tumor recurrence. Furthermore, preoperative bilirubin level was related with R0 resection, lymph node metastasis, TNM stage and postoperative liver function recovery. Conclusion Preoperative bilirubin level may effectively reflect the severity of perihilar CC and predict the OS and tumor recurrence after resection for perihilar CC patients.
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Affiliation(s)
- Chang Xian Li
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Liver Transplantation, Nanjing, Jiangsu Province, People's Republic of China
| | - Hui Zhang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Liver Transplantation, Nanjing, Jiangsu Province, People's Republic of China
| | - Ke Wang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Liver Transplantation, Nanjing, Jiangsu Province, People's Republic of China
| | - Xuehao Wang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Liver Transplantation, Nanjing, Jiangsu Province, People's Republic of China
| | - Xiang Cheng Li
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Liver Transplantation, Nanjing, Jiangsu Province, People's Republic of China
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Chen C, Nelson LJ, Ávila MA, Cubero FJ. Mitogen-Activated Protein Kinases (MAPKs) and Cholangiocarcinoma: The Missing Link. Cells 2019; 8:cells8101172. [PMID: 31569444 PMCID: PMC6829385 DOI: 10.3390/cells8101172] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/18/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023] Open
Abstract
In recent years, the incidence of both liver and biliary tract cancer has increased. Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) are the two most common types of hepatic malignancies. Whereas HCC is the fifth most common malignant tumor in Western countries, the prevalence of CCA has taken an alarming increase from 0.3 to 2.1 cases per 100,000 people. The lack of specific biomarkers makes diagnosis very difficult in the early stages of this fatal cancer. Thus, the prognosis of CCA is dismal and surgery is the only effective treatment, whilst recurrence after resection is common. Even though chemotherapy and radiotherapy may prolong survival in patients with CCA, the 5-year survival rate is still very low—a significant global problem in clinical diagnosis and therapy. The mitogen-activated protein kinase (MAPK) pathway plays an important role in signal transduction by converting extracellular stimuli into a wide range of cellular responses including inflammatory response, stress response, differentiation, survival, and tumorigenesis. Dysregulation of the MAPK cascade involves key signaling components and phosphorylation events that play an important role in tumorigenesis. In this review, we discuss the pathophysiological role of MAPK, current therapeutic options, and the current situation of MAPK-targeted therapies in CCA.
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Affiliation(s)
- Chaobo Chen
- Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, 28040 Madrid, Spain.
- de Octubre Health Research Institute (imas12), 28040 Madrid, Spain.
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi 214000, China.
| | - Leonard J Nelson
- Institute for Bioengineering (IBioE), School of Engineering, Faraday Building, The University of Edinburgh, Edinburgh EH9 3 JL, Scotland, UK.
| | - Matías A Ávila
- Hepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.
- Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain.
| | - Francisco Javier Cubero
- Department of Immunology, Ophthalmology & ENT, Complutense University School of Medicine, 28040 Madrid, Spain.
- de Octubre Health Research Institute (imas12), 28040 Madrid, Spain.
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Higuchi R, Yazawa T, Uemura S, Izumo W, Ota T, Kiyohara K, Furukawa T, Egawa H, Yamamoto M. Surgical Outcomes for Perihilar Cholangiocarcinoma with Vascular Invasion. J Gastrointest Surg 2019; 23:1443-1453. [PMID: 30203230 DOI: 10.1007/s11605-018-3948-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/23/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE To investigate short- and long-term surgical outcomes for patients with perihilar cholangiocarcinoma and vascular invasion. METHODS Data from 249 patients who underwent perihilar cholangiocarcinoma surgery between 2000 and 2016 were retrospectively analyzed. Patient evaluations included short-term surgical outcomes following vascular resection and long-term outcomes in cases with histopathological vascular invasion. RESULTS Mortality was 3.6% overall; 16% for hepatic artery resections, 5.4% for portal vein resections, and 1.7% in the absence of vascular resection (p = 0.029). No between-group differences were observed in the incidence of Clavien-Dindo grade ≥ 3 complications. The factors related to perioperative mortality were hepatic artery resection (odds ratio [OR] = 25.5), right trisectionectomy (OR = 13.0), and central bisectionectomy (OR = 13.8). Multivariate analysis for overall survival identified several prognostic factors: carcinoembryonic antigen level ≥ 5 ng/mL (hazard ratio [HR] = 1.68), poor differentiation (HR = 2.39), distant metastasis (HR = 1.97), and R1 invasive resection (HR = 2.13). Five-year overall survival for patients with portal vein invasion and M0R0/1cis was 35.6%, significantly worse than the 53.4% for patients with no portal vein invasion and M0R/1cis but better than the 0% for patients with portal vein invasion and M1 or R1. Those with hepatic arterial invasion and M0R0/1cis were 24.7%, significantly worse than the 53.4% for patients with no hepatic arterial invasion and M0R0/1cis but significantly better than the 0% for patients with hepatic arterial invasion and M1 or R1. CONCLUSION Short-term outcomes for patients with perihilar cholangiocarcinoma and undergoing vascular resection were poor compared to those without vascular resection. Long-term survival in R0M0 disease was more favorable; aggressive surgery is recommended.
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Affiliation(s)
- Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Wataru Izumo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takehiro Ota
- Department of Surgery, Ebara Hospital, 4-5-10 Higashiyukigaya, Ota-ku, Tokyo, 145-0065, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics, Otsuma Women's University, 12 Sanbancho, Chiyoda-ku, Tokyo, 102-8357, Japan
| | - Toru Furukawa
- Department of Histopathology, Tohoku University Graduate School of Medicine, 2-1 Seiryomachi, Aoba-ku, Sendai, 980-8575, Japan
| | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
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Abstract
BACKGROUND Klatskin tumor (KCC) is a rare type of tumor, with an annual incidence rate of no more than 1: 100 000. Because of its rarity, KCC is difficult to investigate. The present study provides new insights into KCC by a using public database. MATERIAL AND METHODS We used the Surveillance, Epidemiology, and End Results (SEER) database to conduct the analysis. Klatskin tumor patients were identified and compared with patients that had other kinds of cholangiocarcinomas (OCC). We identified differences between the 2 groups of patients and assessed tumor characteristics. We used Cox regression analysis to identify the prognostic indicators for KCC. The propensity score 1-to-1 matching method was used to compare the survival difference between KCC and OCC. RESULTS We extracted data on 26 137 patients diagnosed with cholangiocarcinomas between 1973 and 2014 from the SEER database: 1341 cases were diagnosed with KCC and 24 796 cases were diagnosed with OCC. The number of diagnoses has gradually increased in both groups. There were significant differences in pathology grades, T stage, N stage, M stage, and SEER historic stage between the KCC and OCC groups. Survival analysis showed that the OCC group had better survival compared to the KCC group, both in matched and unmatched cohorts. The Cox regression results showed that older age, higher M stages, and higher pathology grades were associated with worse prognosis for KCC patients. CONCLUSIONS KCC patients have worse survival compared to OCC patients. Older age, higher M stages, and higher pathology grades were associated with worse survival in KCC patients.
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Affiliation(s)
- Xinying Zhang
- Department of Oncology, Xianning Central Hospital, First Affiliated Hospital of Hubei University of Science and Technology, Xianning, Hubei, China (mainland)
| | - Hui Liu
- Department of Spinal Surgery, Xianning Central Hospital, First Affiliated Hospital of Hubei University of Science and Technology, Xianning, Hubei, China (mainland)
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Kovalenko YA, Zharikov YO, Kukeev IA, Vishnevsky VA, Chzhao AV. [Predictors of outcomes in surgery for hilar cholangiocarcinoma]. Khirurgiia (Mosk) 2019:5-11. [PMID: 30531729 DOI: 10.17116/hirurgia20181015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM To determine significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma. MATERIAL AND METHODS Analysis included 49 out of 84 patients who were operated at the Vishnevsky Institute of Surgery in 2003-2016. Morphological examination (2011-2016) revealed great percentage of following positive variables: micro- (42.9%) and lymphovascular invasion (11.8%), positive resection margin (59.2%), perineural invasion (83.3%), depth of invasion - (83.3%), cells in surrounding fatty tissue (92.3%), invasion of entire thickness of bile ducts' walls (57.1%). Hemihepatectomy was carried out in 50 (59.5%) cases, advanced hemihepatectomy - in 16 (19%) patients. Left-sided hemihepatectomy (34.6%) was more common compared with right-sided hemihepatectomy (8.6%) for biliary confluence lesion (Bismuth-Corlette type IV). RESULTS TNM stage (p=0.29), tumor localization Bismuth-Corlette type (p=0.10), regional lymph nodes metastases (p=0.77) do not significantly affect survival in univariate analysis. At the same time, TNM stage was significant factor if patients dividing into groups was considered (p=0.05). In regression analysis tumor cells differentiation (p=0.00028), positive resection margin (p=0.0034), perineural invasion and depth of invasion (p=0,00086) were significant predictors of survival. Multivariate analysis confirmed prognostic role of lymphovascular invasion alone (p=0.05). There was no correlation between survival and TNM stage (η=0.057), depth of invasion (η= -0.229) and lymphovascular invasion (η= -0.143645). There was significant reverse moderate correlation between survival and perineural invasion (η= - 0.468750), resection margin (η= -0.558) and tumor differentiation grade (η= -0.481). CONCLUSION Significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma are TNM stage, lymphovascular invasion, tumor cells differentiation, perineural invasion.
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Affiliation(s)
- Yu A Kovalenko
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - Yu O Zharikov
- Sechenov First Moscow State Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - I A Kukeev
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - V A Vishnevsky
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - A V Chzhao
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
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Abstract
Cholangiocarcinoma is a rare malignancy and accounts for 2% of all malignancies. Incidence is on the increase in the Western world. Cholangiocarcinoma arises from the malignant growth of the epithelial lining of the bile ducts and can be found all along the biliary tree. It can be classified into subtypes based on location: intrahepatic (arising from the intrahepatic biliary tract in the hepatic parenchyma), perihilar (at the hilum of the liver involving the biliary confluence) and distal (extrahepatic, often in the head of the pancreas). Margin status and locoregional lymph node metastases are the most important determinants of postsurgical outcomes.
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Affiliation(s)
- Adeel S Khan
- Section of Abdominal Transplant Surgery, Washington University St Louis, One Barnes-Jewish Hospital Plaza, Suite 6107 Queeny Tower, St Louis, MO 63110, USA.
| | - Leigh Anne Dageforde
- Division of Transplant Surgery, Massachusetts General Hospital, 55 Fruit Street, White 511, Boston, MA 02114, USA
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Donati M, Stang A, Stavrou GA, Basile F, Oldhafer KJ. Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved? Future Oncol 2018; 15:193-205. [PMID: 30378439 DOI: 10.2217/fon-2018-0413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Until the 1980's, Klatskin tumors were considered 'desperate cases' and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.
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Affiliation(s)
- Marcello Donati
- Department of Surgery & Medical-Surgical Specialties, Surgical Clinic Unit, University Hospital of Catania (CAST), University of Catania, 95122 Catania, Italy.,Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany
| | - Axel Stang
- Oncology Unit, Asklepios Barmbek Hospital, Hamburg, Germany
| | - Gregor A Stavrou
- Department of General, Visceral, Thoracic & Pediatric Surgery, Saarbrucken Hospital, Saarbrucken-Saarland, Germany
| | - Francesco Basile
- Department of Surgery & Medical-Surgical Specialties, Surgical Clinic Unit, University Hospital of Catania (CAST), University of Catania, 95122 Catania, Italy
| | - Karl J Oldhafer
- Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany.,Department of General & Abdominal Surgery, Asklepios Barmbek Hospital, Hamburg, Germany
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29
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Pattern of the First Recurrence Has No Impact on Long-Term Survival after Curative Intent Surgery for Perihilar Cholangiocarcinomas. Gastroenterol Res Pract 2018; 2018:2546257. [PMID: 30158963 PMCID: PMC6109483 DOI: 10.1155/2018/2546257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/30/2018] [Accepted: 06/13/2018] [Indexed: 12/16/2022] Open
Abstract
Aim To explore the pattern of the first recurrence and impact on long-term survival after curative intent surgery for perihilar cholangiocarcinomas (PHC). Materials and Methods Patients with curative intent surgery for PHC between 1996 and 2017 were analyzed. Survival times were estimated using the Kaplan-Meier method. Comparisons were made with the log-rank test. Results A number of 139 patients were included. The median overall survival was 26 months. A recurrence was observed in 86 patients (61.9%), during a median follow-up time of 89 months. The median disease-free survival was 21 months with 1-, 3-, 5-, and 10-year estimated recurrence rates of 38%, 60%, 69%, and 77%, respectively. A number of 57 patients (41%) developed distant only recurrence, while 26 patients (18.7%) presented local and distant recurrences. An isolated local recurrence was observed in 3 patients (2.2%). The median overall survival was 15 months for patients with local recurrence, 15 months for patients with liver metastases, and 17 months for patients with peritoneal carcinomatosis (p = 0.903) as the first recurrence. Conclusion Curative intent surgery for PHC is associated with high recurrence rates. Most patients will develop distant metastases, while an isolated local recurrence is uncommon. The pattern of recurrence does not appear to have a significant impact on survivals.
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Wang Y, Fu W, Tang Z, Meng W, Zhou W, Li X. Effect of preoperative cholangitis on prognosis of patients with hilar cholangiocarcinoma: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12025. [PMID: 30142851 PMCID: PMC6112934 DOI: 10.1097/md.0000000000012025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the clinical outcomes between patients with preoperative cholangitis and noncholangitis patients to determine whether the preoperative cholangitis would be able to serve as an independent predictive factor on hilar cholangiocarcinoma (HCC) outcomes. METHODS A systematic literature search for reported preoperative cholangitis in patients with hilar cholangiocarcinoma was performed in 4 databases: PubMed, Web of Science, Embase, and the Cochrane Library, published from 1979 to 2017. RESULTS In total, the initial search identified 1228 articles. Of these studies only 9 studies met the inclusion criteria and were included in this analysis. Differences between preoperative cholangitis existing and noncholangitis patients were observed in terms of mortality (RR = 2.29; 95% CI = 1.48-3.52; P = .0002), overall morbidity (RR = 1.15;95% CI = 1.00-1.32; P = .04), Liver failure (RR = 1.15;95% CI = 1.00-1.32; P = .04), Infection (RR = 1.52;95% CI = 1.16-2.00; P = .003), sepsis (RR = 2.40;95% CI = 1.25-4.5; P = .008). CONCLUSIONS The results lend support to the notion that in hilar cholangiocarcinoma patients, the existence of preoperative cholangitis is statistically associated with the higher postoperative mortality and morbidity. Also that it increases the risk of liver failure and infection. therefore, it is very important to properly control the preoperative cholangitis before surgery.
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Affiliation(s)
- Yudong Wang
- The First Clinical Medical School of Lanzhou University
| | - Wenkang Fu
- The First Clinical Medical School of Lanzhou University
| | - Zengwei Tang
- The First Clinical Medical School of Lanzhou University
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery
- Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
| | - Wence Zhou
- The First Clinical Medical School of Lanzhou University
- The Second Department of General Surgery, The First Hospital of Lanzhou University
- Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
| | - Xun Li
- The First Clinical Medical School of Lanzhou University
- The Second Department of General Surgery, The First Hospital of Lanzhou University
- Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
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31
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Yu Z, Zhu J, Jiang H, He C, Xiao Z, Wang J, Xu J. Surgical Resection and Prognostic Analysis of 142 Cases of Hilar Cholangiocarcinoma. Indian J Surg 2018; 80:309-317. [PMID: 32288384 PMCID: PMC7102051 DOI: 10.1007/s12262-016-1581-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 12/23/2016] [Indexed: 12/12/2022] Open
Abstract
Surgical resection for hilar cholangiocarcinoma is the only curative option, but low resectability rate and poor survival outcomes remain a challenge. This study was to assess the surgical resection for hilar cholangiocarcinoma and analyze the prognostic factors influencing postoperative survival. One hundred forty-two patients with hilar cholangiocarcinoma who underwent surgical resection between January 2006 and December 2014 were analyzed retrospectively based on clinicopathological and demographic data. Univariate and multivariate analysis against outcome were employed to identify potential factors affecting prognosis. Ninety-five patients were performed with R0 resection with median survival time of 22 months; whereas, 47 patients underwent non-R0 resection (R1 = 20, R2 = 27) with that of 10 months. Of these 95 patients, 19 underwent concomitant with vascular resection and reconstruction and 2 patients underwent pancreaticoduodenectomy. 64.8% patients (n = 92) underwent combined with hepatectomy. The one-year, three-year, and five-year survival rates after R0 resection were 76.3, 27.8, 11.3%, respectively, which was significantly better than that after non-curative resection (P = 0.000). Multivariate analysis revealed that non-curative resection (RR: 2.414, 95% CI 1.586–3.676, P = 0.000), pathological differentiation (P = 0.015) and preoperative serum total bilirubin above 10 mg/dL (RR: 1.844, 95% CI 1.235–2.752, P = 0.003) were independent prognostic factors. Aggressive curative resection remains to be the optimal option for hilar cholangiocarcinoma. Non-curative resection, pathological differentiation, and preoperative serum total bilirubin above 10 mg/ dL were associated with dismal prognosis.
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Affiliation(s)
- Zhimin Yu
- Guandong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, #33 Yingfeng Road, Guangzhou, 510120 People's Republic of China
| | - Jie Zhu
- Guandong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, #33 Yingfeng Road, Guangzhou, 510120 People's Republic of China
| | - Hai Jiang
- Guandong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, #33 Yingfeng Road, Guangzhou, 510120 People's Republic of China
| | - Chuanchao He
- Guandong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, #33 Yingfeng Road, Guangzhou, 510120 People's Republic of China
| | - Zhiyu Xiao
- Guandong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, #33 Yingfeng Road, Guangzhou, 510120 People's Republic of China
| | - Jie Wang
- Guandong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, #33 Yingfeng Road, Guangzhou, 510120 People's Republic of China
| | - Junyao Xu
- Guandong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, #33 Yingfeng Road, Guangzhou, 510120 People's Republic of China
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Tang Z, Yang Y, Zhao Z, Wei K, Meng W, Li X. The clinicopathological factors associated with prognosis of patients with resectable perihilar cholangiocarcinoma: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11999. [PMID: 30142840 PMCID: PMC6112994 DOI: 10.1097/md.0000000000011999] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The refinement in surgical techniques combined with the preoperative management has improved the resectability rate of perihilar cholangiocarcinoma (pCCA). However, the prognosis of pCCA with curative resection is still dismal. This meta-analysis was performed to investigate the prognostic clinicopathological factors in resectable pCCA.PubMed, the Cochran Library, ScienceDirect, and Web of Science were searched systematically to identify reports focusing on studying the prognostic clinicopathological factors in resectable pCCA. The hazard ratios (HRs) and its 95% confidence interval (95%CI) from the identified studies using Cox proportional hazard regression model were extracted for overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) analysis.Three prospective and 35 retrospective cohort studies including 5681 resectable pCCA were included in the pooled analysis. Among more than 20 clinicopathological factors associated with negative survival of pCCA, only 6 were included in quantitative analysis which showed that lymph node involvement was associated with a reduced OS (HR = 2.04; 95%CI: 2.10-2.62), DSS (HR = 1.80; 95%CI: 1.39-2.34), DFS (HR = 4.38; 95%CI: 1.89-10.14), negative resection margin (HR = 2.04; 95%CI:1.73-2.41), operative transfusion (HR = 1.82; 95%CI: 1.06-3.11), and T3 or T4-stage (HR = 2.04; 95%CI: 2.04-2.53) were poor prognostic factors of OS, and poor or moderate differentiation was also an adverse prognostic factor of OS (HR = 2.71; 95%CI: 1.80-4.07) and DSS (HR = 1.74; 95%CI: 1.25-2.44). The overall median resectability rate (95CI%), R0 resection (95CI%), and 5-year OS (95CI%) in Eastern and Western countries were 74.9 (66.4-78.4) % and 41.3 (32.6-80.8) %, 70.7 (65.6-80.8) % and 75.9 (64.0-80.4) %, and 33.0 (29.7-39.7) % and 25.5 (20.0-31.6) %, respectively.Negative resection margin, lymph node involvement, poor or moderate differentiation grade was identified as the negative predictor factors of resectable pCCA. Operative transfusion and T3/T4 stage were also associated with a reduced survival of resectable pCCA.
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Affiliation(s)
- Zengwei Tang
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou
| | - Yuan Yang
- The First Clinical Medical School of Lanzhou University
| | | | - Kongyuan Wei
- The First Clinical Medical School of Lanzhou University
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University, Lanzhou
| | - Xun Li
- The First Clinical Medical School of Lanzhou University
- The Second Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
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Bird NTE, McKenna A, Dodd J, Poston G, Jones R, Malik H. Meta-analysis of prognostic factors for overall survival in patients with resected hilar cholangiocarcinoma. Br J Surg 2018; 105:1408-1416. [PMID: 29999515 DOI: 10.1002/bjs.10921] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/18/2018] [Accepted: 05/23/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hilar cholangiocarcinoma is staged using the AJCC staging system. Numerous other prognostically important histopathological and demographic characteristics have been reported. The objective of this meta-analysis was to assess statistically the effect of postresectional tumour characteristics on overall survival of patients undergoing attempted radical curative resection for hilar cholangiocarcinoma. METHODS Relevant studies were identified by searching the Ovid MEDLINE and PubMed databases. The search was limited to studies published between 2009 and 2017. Papers referring to intrahepatic or distal cholangiocarcinoma were excluded from review. Data extraction used standard Parmar modifications to determine pooled univariable hazard ratios (HRs). RESULTS Twenty-four articles, containing 4599 patients, were assessed quantitatively. In pooled analyses, age (HR 1·16, 95 per cent c.i. 1·04 to 1·28), T category (HR 1·49, 1·30 to 1·70), lymph node involvement (HR 1·78, 1·65 to 1·93), microvascular invasion (HR 1·49, 1·34 to 1·68), perineural invasion (HR 1·54, 1·40 to 1·68) and tumour differentiation (HR 1·54, 1·38 to 1·72) were significant prognostic factors, with low heterogeneity. Portal vein resection (HR 1·54, 1·15 to 1·70) and resection margin status (HR 1·77, 1·57 to 1·99) had significant effects, but with high heterogeneity. Sex, tumour size and preoperative carbohydrate antigen 19-9 levels did not have a statistically significant effect on postoperative prognosis. CONCLUSION Several tumour biological variables not included in the seventh edition of the AJCC classification affect overall survival. These require incorporation into prognostic models to ensure a personalized approach to prognostication and treatment.
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Affiliation(s)
- N T E Bird
- Northwest Hepatobiliary Centre, University Hospital Aintree, Liverpool, UK
| | - A McKenna
- Northwest Hepatobiliary Centre, University Hospital Aintree, Liverpool, UK
| | - J Dodd
- Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - G Poston
- Northwest Hepatobiliary Centre, University Hospital Aintree, Liverpool, UK
| | - R Jones
- Northwest Hepatobiliary Centre, University Hospital Aintree, Liverpool, UK
| | - H Malik
- Northwest Hepatobiliary Centre, University Hospital Aintree, Liverpool, UK
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Lidsky ME, Jarnagin WR. Surgical management of hilar cholangiocarcinoma at Memorial Sloan Kettering Cancer Center. Ann Gastroenterol Surg 2018; 2:304-312. [PMID: 30003193 PMCID: PMC6036362 DOI: 10.1002/ags3.12181] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/20/2018] [Indexed: 02/06/2023] Open
Abstract
Hilar cholangiocarcinoma, which represents approximately 60% of biliary tract malignancies, is increasing in incidence and presents an ongoing challenge for patients and hepatobiliary surgeons. Although the majority of patients present with advanced disease, the remaining minority of patients are best treated with surgical resection or transplant. Transplant is typically reserved for locally unresectable tumors often in the setting of underlying hepatic dysfunction and will not be discussed herein. This review, therefore, focuses on oncological resection and the strategies implemented for the treatment of hilar cholangiocarcinoma at a quaternary referral center, including preoperative considerations such as patient selection and optimization of the future liver remnant, nuances to the operative approach for these tumors such as resection under low central venous pressure and management of the bile duct, as well as postoperative management.
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Affiliation(s)
- Michael E. Lidsky
- Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
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36
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Komaya K, Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Yamaguchi J, Nagino M. Recurrence after curative-intent resection of perihilar cholangiocarcinoma: analysis of a large cohort with a close postoperative follow-up approach. Surgery 2018; 163:732-738. [PMID: 29336813 DOI: 10.1016/j.surg.2017.08.011] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/18/2017] [Accepted: 08/30/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although several studies have been conducted on the patterns of recurrence in resected perihilar cholangiocarcinoma, they have many limitations. The aim of this study was to investigate recurrence after resection and to evaluate prognostic factors on the time to recurrence and recurrence-free survival. METHODS Consecutive patients who underwent curative-intent resection of perihilar cholangiocarcinoma between 2001 and 2012 were reviewed retrospectively. The Cox proportional hazards model was used for multivariable analysis. RESULTS In the study period, 402 patients underwent resection of perihilar cholangiocarcinoma (R0, n = 340; R1, n = 62). Radial margin positivity (n = 43, 69%) was the most common reason for R1 resection. The median follow-up of survivors was 7.4 years. The cumulative recurrence probability was higher in R1 than in R0 resection (86% vs 57% at 5 years, P < .001). Seventeen R0 patients had a recurrence over 5 years after resection. There was no difference in median survival time after recurrence between R0 and R1 resection (10 vs 7 months). The proportion of isolated locoregional recurrence was higher in R1 than in R0 resection (37% vs 16%, P < .001), whereas the proportion of distant recurrence was similar. In R0 resection, the independent prognostic factors for time to recurrence and recurrence-free survival were microscopic venous invasion and lymph node metastasis. CONCLUSION More than half of patients with perihilar cholangiocarcinoma experience recurrence after R0 resection. These recurrences occur frequently within 5 years but occasionally after 5 years, which emphasizes the need for close and long-term surveillance. Adjuvant strategies should be considered, especially for patients with nodal metastasis or venous invasion even after R0 resection.
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Affiliation(s)
- Kenichi Komaya
- 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
| | - Gen Sugawara
- 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
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Capobianco I, Rolinger J, Nadalin S. Resection for Klatskin tumors: technical complexities and results. Transl Gastroenterol Hepatol 2018; 3:69. [PMID: 30363698 PMCID: PMC6182019 DOI: 10.21037/tgh.2018.09.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/27/2018] [Indexed: 12/18/2022] Open
Abstract
Klatskin's tumors, actually-redefined as perihilar cholangiocarcinoma (phCCA) do represent 50-70% of all CCAs and develop in a context of chronic inflammation and cholestasis of bile ducts. Surgical resection provides the only chance of cure for this disease but is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures at this location. Five years survival rates range between 25-45% (median 27-58 months) in case of R0 resection and 0-23% (median 12-21 months) in case of R1 resection respectively. It should be noted that the major costs of high radicality are represented by relative high morbidity and mortality rates (i.e., 20-66% and 0-9% respectively). Considering the fact that radical resection may represent the only curative treatment of phCCA, we focused our review on surgical planning and techniques that may improve resectability rates and outcomes for locally advanced phCCA. The surgical treatment of phCCA can be successful when following aspects have been fulfilled: (I) accurate preoperative diagnostic aimed to identify the tumor in all its details (localization and extension) and to study all the risk factors influencing a posthepatectomy liver failure (PHLF): i.e., liver volume, liver function, liver quality, haemodynamics and patient characteristics; (II) High end surgical skills taking in consideration the local extension of the tumor and the vascular invasion which usually require an extended hepatic resection and often a vascular resection; (III) adequate postoperative management aimed to avoid major complications (i.e., PHLF and biliary complications). These are technically challenging operations and must be performed in a high volume centres by hepato-biliary-pancreas (HBP)-surgeons with experience in microsurgical vascular techniques.
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Affiliation(s)
- Ivan Capobianco
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Jens Rolinger
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
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38
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Tang Z, Yang Y, Meng W, Li X. Best option for preoperative biliary drainage in Klatskin tumor: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e8372. [PMID: 29069029 PMCID: PMC5671862 DOI: 10.1097/md.0000000000008372] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/13/2017] [Accepted: 10/03/2017] [Indexed: 02/06/2023] Open
Abstract
The operative treatment combined with preoperative biliary drainage (PBD) has been established as a safe Klatskin tumor (KT) treatment strategy. However, there has always been a dispute for the preferred technique for PBD technique. This meta-analysis was conducted to compare the biliary drainage-related cholangitis, pancreatitis, hemorrhage, and the success rates of palliative relief of cholestasis between percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD), to identify the best technique in the management of KT.PubMed, EMBASE, and Web of Science were searched systematically for prospective or retrospective studies reporting the biliary drainage-related cholangitis, pancreatitis, hemorrhage, and the success rates of palliative relief of cholestasis in patients with KT. A meta-analysis was performed, using the fixed or random-effect model, with Review Manager 5.3.PTBD was associated with lower risk of cholangitis (risk ratio [RR] = 0.49, 95% confidence interval [CI]: 0.36-0.67; P < .00001), particularly in patients with Bismuth-Corlette type II, III, IV KT (RR = 0.50, 95% CI: 0.33-0.77; P = .05). Compared with EBD, PTBD was also associated with a lower risk of pancreatitis (RR = 0.35, 95% CI: 0.17-0.69; P = 0.003) and with higher successful rates of palliative relief of cholestasis (RR = 1.20, 95% CI: 1.10-1.31; P < .0001). The incidence of hemorrhage was similar in these 2 groups (RR 1.29, 95% CI: 0.51-3.27; P = .59). The risk of biliary drainage-related cholangitis (RR = 1.96, 95% CI: 0.96-4.01; P = .06) and pancreatitis (RR = 1.62, 95% CI: 0.76-3.47; P = .21) was similar between endoscopic nasobiliary drainage groups and biliary stenting.In patients with type II or type III or IV KT who need to have PBD, PTBD should be performed as an initial method of biliary drainage in terms of reducing the incidence of procedure related cholangitis, pancreatitis, and improving the rates of palliative relief of cholestasis. Well-conducted randomized controlled trials with a universial criterion for PBD are required to confirm these findings.
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Affiliation(s)
- Zengwei Tang
- The First Clinical Medical School of Lanzhou University
| | - Yuan Yang
- The First Clinical Medical School of Lanzhou University
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery, The First Hospital of Lanzhou University
- Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
| | - Xun Li
- The First Clinical Medical School of Lanzhou University
- The second department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
- Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
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Kimura N, Young AL, Toyoki Y, Wyatt JI, Toogood GJ, Hidalgo E, Prasad KR, Kudo D, Ishido K, Hakamada K, Lodge JPA. Radical operation for hilar cholangiocarcinoma in comparable Eastern and Western centers: Outcome analysis and prognostic factors. Surgery 2017; 162:500-514. [PMID: 28551378 DOI: 10.1016/j.surg.2017.03.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/09/2017] [Accepted: 03/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Extensive resection for hilar cholangiocarcinoma is the most effective treatment, but high morbidity and poor prognosis remain concerns. Previous data have shown marked differences in outcomes between comparable Eastern and Western centers. We compared the outcomes of the management for hilar cholangiocarcinoma at one Japanese and one British institution with comparable experience. METHODS Of 298 consecutive patients with hilar cholangiocarcinoma evaluated at Hirosaki University Hospital, Japan and St. James's University Hospital, Leeds, UK, 183 underwent radical resection. Clinicopathologic variables and postoperative outcomes were compared. RESULTS Significant differences were not observed between the Hirosaki and Leeds cohorts in overall outcomes despite several differences in the patient characteristics. Although there was a difference in 90-day mortality (2.5% vs 13.6%, respectively), disease-specific 5-year survival rates were 32.8% and 31.9%, respectively (P = .767). Multivariate analysis identified trisectionectomy (odds ratio = 2.32; P = .010), combined pancreatoduodenectomy (odds ratio = 7.88; P = .010), and perioperative blood transfusion (odds ratio = 1.88; P = .045) were associated with postoperative major complications, while preoperative biliary drainage associated with postoperative major complications, while preoperative biliary drainage (risk ratio = 2.21; P = .018), perioperative blood transfusion (risk ratio = 1.58; P = .029), lymph node metastasis (risk ratio = 2.00; P = .002), moderate/poorly differentiated tumor (risk ratio = 1.72; P = .029), microvascular invasion (risk ratio = 1.63; P = .046), and R1 resection (risk ratio = 1.90; P = .005) were risk factors for poor survival. CONCLUSION Disease-specific survival and prognostic factors were similar in both centers. Meticulous operative technique to avoid perioperative blood transfusion may improve long-term survival.
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Affiliation(s)
- Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Alastair L Young
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Yoshikazu Toyoki
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Judith I Wyatt
- Department of Pathology, St. James's University Hospital NHS Trust, Leeds, UK
| | - Giles J Toogood
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Ernest Hidalgo
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - K Rajendra Prasad
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Daisuke Kudo
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - J Peter A Lodge
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK.
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40
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Buettner S, van Vugt JLA, Gani F, Koerkamp BG, Margonis GA, Ethun CG, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Maithel SK, Guglielmi A, IJzermans JNM, Pawlik TM. A Comparison of Prognostic Schemes for Perihilar Cholangiocarcinoma. J Gastrointest Surg 2016; 20:1716-24. [PMID: 27412318 PMCID: PMC5450027 DOI: 10.1007/s11605-016-3203-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/27/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Although widely used, the 7th edition American Joint Committee on Cancer (AJCC) staging system for perihilar cholangiocarcinoma (PHC) may be limited. Disease-specific nomograms have been proposed as a better means to predict long-term survival for individual patients. We sought to externally validate a recently proposed nomogram by Memorial Sloan Kettering Cancer Center (MSKCC) for PHC, as well as identify factors to improve the prediction of prognosis for patients with PHC. METHODS Four hundred seven patients who underwent surgery for PHC between 1988 and 2014 were identified using an international, multi-center database. Standard clinicopathologic and outcome data were collected. The predictive power of the AJCC staging system and nomogram were assessed. RESULTS Median survival was 24.4 months; 3- and 5-year survival was 37.2 and 20.8 %, respectively. The AJCC 7th edition staging system (C-index 0.570) and the recently proposed PHC nomogram (C-index 0.587) both performed poorly. A revised nomogram based on age, lymphovascular invasion, perineural invasion, and lymph node metastases performed better (C-index 0.682). The calibration plot of the revised PHC nomogram demonstrated good calibration. CONCLUSION The 7th edition AJCC staging system and the MSKCC nomogram had a poor ability to predict long-term survival for individual patients with PHC. A revised nomogram provided more accurate prediction of survival, but will need to be externally validated.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA,Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen L. A. van Vugt
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Georgios Antonios Margonis
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
| | - Cecilia G. Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kamran Idrees
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A. Isom
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Charles Scoggins
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY, USA
| | - Shishir K. Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Alfredo Guglielmi
- Department of Surgery, Verona University Medical Center, Verona, Italy
| | - Jan N. M. IJzermans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, USA
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41
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Tian Y, Liu L, Yeolkar NV, Shen F, Li J, He Z. Diagnostic role of staging laparoscopy in a subset of biliary cancers: a meta-analysis. ANZ J Surg 2016; 87:22-27. [PMID: 27647697 DOI: 10.1111/ans.13762] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Accurate preoperative radiological staging of biliary cancers remains difficult. Despite the improvement in imaging techniques, a number of patients with biliary cancers who undergo laparotomy are ultimately found to have unresectable diseases. The goals of staging laparoscopy (SL) are to rule out metastatic and locally advanced unresectable diseases and better define locally advanced unresectable diseases. This study evaluates the efficiency of SL in ruling out unresectable disease in a subset of biliary cancers. METHODS Literature published between January 2000 and December 2015 on the use of SL for patients with biliary cancers was retrieved from five electronic databases. Summary estimates of sensitivity, specificity and diagnostic odds ratio were calculated. RESULTS Eight studies were included in the meta-analysis. During the laparoscopy, unresectable disease was found in 316 of 1062 patients (29.8%), of whom 32.4% were patients with suspected hilar cholangiocarcinoma (HC) and 27.6% were patients with suspected gallbladder cancer (GBC). The sensitivities were 0.556 (95% confidence interval (CI): 0.495-0.616) for patients with HC and 0.642 (95% CI: 0.579-0.701) for patients with GBC. The pooled specificity for the SL was 100% (95% CI: 0.993-1.000) for all studies. CONCLUSIONS This meta-analysis revealed that 32.4% of patients with HC and 27.6% of patients with GBC may avoid unnecessary laparotomy with the use of SL. It is worthwhile to perform SL combined with an intraoperative ultrasound in patients with suspected GBC or HC.
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Affiliation(s)
- Yunhong Tian
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Soochow University, Suzhou, China.,Department of Hepato-Biliary Surgery, Nanchong Central Hospital, Nanchong, China.,Graduate School of Soochow University, Suzhou, China
| | - Lei Liu
- Graduate School of Soochow University, Suzhou, China
| | | | - Feng Shen
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Soochow University, Suzhou, China
| | - Jun Li
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Soochow University, Suzhou, China
| | - Zhenxing He
- Department of Hepato-Biliary Surgery, Nanchong Central Hospital, Nanchong, China
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Bhardwaj N, Garcea G, Dennison AR, Maddern GJ. The Surgical Management of Klatskin Tumours: Has Anything Changed in the Last Decade? World J Surg 2016; 39:2748-56. [PMID: 26133907 DOI: 10.1007/s00268-015-3125-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Surgical treatment of hilar cholangiocarcinomas requires complex pre-, intra- and post-operative decision-making. Despite the significant progress in liver surgery over the years, several issues such as the role of pre-operative biliary drainage, portal vein embolisation, staging laparoscopy and neo-adjuvant chemotherapy remain unresolved. Operative strategies such as vascular resection, caudate lobe resection and liver transplant have also been practiced in order to improve R0 resectability and improved survival. The review aims to consolidate evidence from major studies in the last 11 years. Survival data were only included from studies that reported the results in at least 30 patients with 1-year follow-up. A significant number of patients may be prevented an unnecessary laparotomy if they underwent a staging laparoscopy. There remain no guidelines as to when portal vein embolisation or pre-operative biliary drainage should be employed but most studies agree with pre-operative biliary drainage being an absolute indication if portal vein embolisation is performed. Concomitant hepatectomy and caudate lobectomy increases R0 resection but vascular resection cannot be routinely recommended. Liver transplant at specialised centres in selective patients has had impressive results. Guidelines are required for pre-operative biliary drainage and portal vein embolisation and randomised trials are required in order to define the role of vascular resection in achieving a R0 resection and increasing survival.
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Affiliation(s)
- Neil Bhardwaj
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK.
| | - Giuseppe Garcea
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK
| | - Ashley R Dennison
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Woodville, Adelaide, Australia
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43
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Vogel A, Wege H, Caca K, Nashan B, Neumann U. The diagnosis and treatment of cholangiocarcinoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 111:748-54. [PMID: 25412632 DOI: 10.3238/arztebl.2014.0748] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 08/05/2014] [Accepted: 08/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cholangiocarcinoma (CCA) is the second most common primary hepatic tumor in Germany, with about 3500 new cases per year. In recent years, its prognosis has improved because of wider resections and the establishment of local treatment and chemotherapy in the palliative situation. METHODS This review is based on pertinent articles that were retrieved by a selective literature search in the PubMed database with the keywords "cholangiocarcinoma AND diagnostic OR therapy." Articles in English or German published up to January 2014 were considered. RESULTS The sole curative treatment for CCA is surgery, but 40-85% of all patients have recurrent disease even after radical excision. Because of this high recurrence rate, adjuvant treatments are now under intense discussion. For unresectable CCA without distant metastases, small case series have shown that liver transplantation can yield promising survival rates of over 50% at 5 years. For many patients with CCA, however, only palliative treatments can be offered, including endoscopic clearing of the biliary pathways. Because of the low prevalence of the disease, there have been only a few phase 3 studies of palliative chemotherapy for CCA. On the basis of one positive phase 3 study, chemotherapy with gemcitabine and cisplatin is considered the standard and now plays an established role in palliative care. CONCLUSION CCA presents a special challenge in gastroenterology, oncology, and visceral surgery because of the difficulty in establishing the diagnosis, local complications in the biliary pathways, and a high recurrence rate after resection. Future studies should address not only the role of adjuvant chemotherapy, but also the efficacy of combined local and systemic treatment.
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Affiliation(s)
- Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, University Medical Center Hamburg-Eppendorf, I. Department of Internal Medicine, Hamburg, Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, University Medical Center Hamburg-Eppendorf, Department of Hepatobiliary and Transplant Surgery, Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen
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Banales JM, Cardinale V, Carpino G, Marzioni M, Andersen JB, Invernizzi P, Lind GE, Folseraas T, Forbes SJ, Fouassier L, Geier A, Calvisi DF, Mertens JC, Trauner M, Benedetti A, Maroni L, Vaquero J, Macias RIR, Raggi C, Perugorria MJ, Gaudio E, Boberg KM, Marin JJG, Alvaro D. Expert consensus document: Cholangiocarcinoma: current knowledge and future perspectives consensus statement from the European Network for the Study of Cholangiocarcinoma (ENS-CCA). Nat Rev Gastroenterol Hepatol 2016; 13:261-80. [PMID: 27095655 DOI: 10.1038/nrgastro.2016.51] [Citation(s) in RCA: 854] [Impact Index Per Article: 106.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cholangiocarcinoma (CCA) is a heterogeneous group of malignancies with features of biliary tract differentiation. CCA is the second most common primary liver tumour and the incidence is increasing worldwide. CCA has high mortality owing to its aggressiveness, late diagnosis and refractory nature. In May 2015, the "European Network for the Study of Cholangiocarcinoma" (ENS-CCA: www.enscca.org or www.cholangiocarcinoma.eu) was created to promote and boost international research collaboration on the study of CCA at basic, translational and clinical level. In this Consensus Statement, we aim to provide valuable information on classifications, pathological features, risk factors, cells of origin, genetic and epigenetic modifications and current therapies available for this cancer. Moreover, future directions on basic and clinical investigations and plans for the ENS-CCA are highlighted.
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Affiliation(s)
- Jesus M Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute - Donostia University Hospital, Ikerbasque, CIBERehd, Paseo del Dr. Begiristain s/n, E-20014, San Sebastian, Spain
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Guido Carpino
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Piazza Lauro De Bosis 6, 00135, Rome, Italy
| | - Marco Marzioni
- Department of Clinic and Molecular Sciences, Polytechnic University of Marche, Via Tronto 10, 60020, Ancona, Italy
| | - Jesper B Andersen
- Biotech Research and Innovation Centre, University of Copenhagen, Ole Maaløes Vej 5, DK-2200, Copenhagen N, Denmark
| | - Pietro Invernizzi
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
- Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Guro E Lind
- Department of Molecular Oncology, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Montebello, 0310, Oslo, Norway
| | - Trine Folseraas
- Department of Transplantation Medicine, Division of Cancer Medicine, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb. 4950 Nydalen, N-0424, Oslo, Norway
| | - Stuart J Forbes
- MRC Centre for Regenerative Medicine, University of Edinburgh, 49 Little France Crescent, EH16 4SB, Edinburgh, United Kingdom
| | - Laura Fouassier
- INSERM UMR S938, Centre de Recherche Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, Fondation ARC, 9 rue Guy Môquet 94803 Villejuif, France
| | - Andreas Geier
- Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacherstrasse 6, D-97080, Würzburg, Germany
| | - Diego F Calvisi
- Institute of Pathology, Universitätsmedizin Greifswald, Friedrich-Löffler-Strasse 23e, 17489, Greifswald, Germany
| | - Joachim C Mertens
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Antonio Benedetti
- Department of Clinic and Molecular Sciences, Polytechnic University of Marche, Via Tronto 10, 60020, Ancona, Italy
| | - Luca Maroni
- Department of Clinic and Molecular Sciences, Polytechnic University of Marche, Via Tronto 10, 60020, Ancona, Italy
| | - Javier Vaquero
- INSERM UMR S938, Centre de Recherche Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, Fondation ARC, 9 rue Guy Môquet 94803 Villejuif, France
| | - Rocio I R Macias
- Department of Physiology and Pharmacology, Experimental Hepatology and Drug Targeting (HEVEFARM), Campus Miguel de Unamuno, E.I.D. S-09, University of Salamanca, IBSAL, CIBERehd, 37007, Salamanca, Spain
| | - Chiara Raggi
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Maria J Perugorria
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute - Donostia University Hospital, Ikerbasque, CIBERehd, Paseo del Dr. Begiristain s/n, E-20014, San Sebastian, Spain
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Via Alfonso Borelli 50, 00161, Rome, Italy
| | - Kirsten M Boberg
- Department of Transplantation Medicine, Division of Cancer Medicine, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb. 4950 Nydalen, N-0424, Oslo, Norway
| | - Jose J G Marin
- Department of Physiology and Pharmacology, Experimental Hepatology and Drug Targeting (HEVEFARM), Campus Miguel de Unamuno, E.I.D. S-09, University of Salamanca, IBSAL, CIBERehd, 37007, Salamanca, Spain
| | - Domenico Alvaro
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
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Hartog H, Ijzermans JN, van Gulik TM, Koerkamp BG. Resection of Perihilar Cholangiocarcinoma. Surg Clin North Am 2016; 96:247-67. [DOI: 10.1016/j.suc.2015.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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46
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Bagante F, Tran T, Spolverato G, Ruzzenente A, Buttner S, Ethun CG, Groot Koerkamp B, Conci S, Idrees K, Isom CA, Fields RC, Krasnick B, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Vitiello G, IJzermans JNM, Maithel SK, Poultsides G, Guglielmi A, Pawlik TM. Perihilar Cholangiocarcinoma: Number of Nodes Examined and Optimal Lymph Node Prognostic Scheme. J Am Coll Surg 2016; 222:750-759.e2. [PMID: 27113512 DOI: 10.1016/j.jamcollsurg.2016.02.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/07/2016] [Accepted: 02/11/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of routine lymphadenectomy for perihilar cholangiocarcinoma is still controversial and no study has defined the minimum number of lymph nodes examined (TNLE). We sought to assess the prognostic performance of American Joint Committee on Cancer/Union Internationale Contre le Cancer (7(th) edition) N stage, lymph node ratio, and log odds (LODDS; logarithm of the ratio between metastatic and nonmetastatic nodes) in patients with perihilar cholangiocarcinoma and identify the optimal TNLE to accurately stage patients. METHODS A multi-institutional database was queried to identify 437 patients who underwent hepatectomy for perihilar cholangiocarcinoma between 1995 and 2014. The prognostic abilities of the lymph node staging systems were assessed using the Harrell's c-index. A Bayesian model was developed to identify the minimum TNLE. RESULTS One hundred and fifty-eight (36.2%) patients had lymph node metastasis. Median TNLE was 3 (interquartile range, 1 to 7). The LODDS had a slightly better prognostic performance than lymph node ratio and American Joint Committee on Cancer, in particular among patients with <4 TNLE (c-index = 0.568). For 2 TNLE, the Bayesian model showed a poor discriminatory ability to distinguish patients with favorable and poor prognosis. When TNLE was >2, the hazard ratio for N1 patients was statistically significant and the hazard ratio for N1 patients increased from 1.51 with 4 TNLE to 2.10 with 10 TNLE. Although the 5-year overall survival of N1 patients was only slightly affected by TNLE, the 5-year overall survival of N0 patients increased significantly with TNLE. CONCLUSIONS Perihilar cholangiocarcinoma patients undergoing radical resection should ideally have at least 4 lymph nodes harvested to be accurately staged. In addition, although LODDS performed better at determining prognosis among patients with <4 TNLE, both lymph node ratio and LODDS outperformed compared with American Joint Committee on Cancer N stage among patients with ≥4 TNLE.
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Affiliation(s)
- Fabio Bagante
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Department of Surgery, University of Verona, Verona, Italy
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Gaya Spolverato
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | | | - Stefan Buttner
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Department of Surgery, Erasmus University, Rotterdam, the Netherlands
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | | | - Simone Conci
- Department of Surgery, University of Verona, Verona, Italy
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Bradley Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - Jan N M IJzermans
- Department of Surgery, Erasmus University, Rotterdam, the Netherlands
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | | | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
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Mao K, Liu J, Sun J, Zhang J, Chen J, Pawlik TM, Jacobs LK, Xiao Z, Wang J. Patterns and prognostic value of lymph node dissection for resected perihilar cholangiocarcinoma. J Gastroenterol Hepatol 2016; 31:417-26. [PMID: 26250532 PMCID: PMC4732906 DOI: 10.1111/jgh.13072] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Lymph node metastasis is a major prognostic factor for perihilar cholangiocarcinoma (PHC). However, prognostic significance of extent of node dissection, lymph node ratio (LNR), and number and location of positive nodes remain unclear. We aimed to evaluate whether node status, LNR, or number or location of positive nodes are independent factors for staging in PHC and to determine the minimum requirements for node examination. METHODS The Surveillance, Epidemiology, and End Results database was used to identify 1116 resected PHCs from 1998 to 2008. The correlation between nodal status and survival was analyzed retrospectively. RESULTS Lymph node metastasis occurred in 43.4% patients and was an independent predictor for overall survival and cancer-specific survival. No survival benefit was observed for an increasing number of node retrieval in node-positive patients. However, in node-negative patients, ≥13 node dissection was of more survival benefit than 3 ≤ total lymph node count (TLNC) ≤ 12 and TLNC < 3 (5-year overall survival: 52.8% vs 39.7% vs 26.3%, P = 0.001; 5-year cancer-specific survival: 60.6% vs 46.3% vs 30.0%, P = 0.001). No difference in survival between patients with regional and distant node involvement was found. Survival for patients with greater than three positive nodes was significantly worse than that for those with three or less (relative ratio: 1.466, P = 0.001). And patients with LNR > 0.27 also had unfavorable prognosis (relative ratio: 1.376, P = 0.001). CONCLUSIONS We determined that to adequately assess nodal status of this life-threatening disease, 13 or more nodes retrieval should be considered. Number of positive nodes and LNR rather than location of metastatic nodes may be defined as parameters for staging of PHC.
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Affiliation(s)
- Kai Mao
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland 21287, USA
| | - Jieqiong Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Departments of Breast Surgery, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland 21287, USA
| | - Jian Sun
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianlong Zhang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jie Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland 21287, USA
| | - Lisa K. Jacobs
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland 21287, USA
| | - Zhiyu Xiao
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jie Wang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Postoperative CA19-9 Change Is a Useful Predictor of Intrahepatic Cholangiocarcinoma Survival following Liver Resection. DISEASE MARKERS 2015; 2015:298985. [PMID: 26839445 PMCID: PMC4709676 DOI: 10.1155/2015/298985] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/13/2015] [Indexed: 12/21/2022]
Abstract
Background. To investigate the clinical significance of the perioperative CA19-9 change for predicting survival in intrahepatic cholangiocarcinoma (ICC) patients treated with surgical resection. Methods. We retrospectively reviewed the data from 74 ICC patients treated with surgical resection between April 2001 and July 2010. Perioperative CA19-9 (preoperative level, postoperative lowest level, and level at recurrence) levels were analyzed for patient distribution and survival. Results. Before surgery, there were 45 patients who had high preoperative CA19-9 levels (>37 U/mL) and 29 who had normal levels (≤37 U/mL). Of 45 patients with high CA19-9 levels, 34 had normalized CA19-9 levels after resection and 11 had persistently high levels. Of 34 patients with normalized CA19-9 levels, 18 showed recurrence. Of 29 patients with normal preoperative levels, 15 showed recurrence. Multivariate analysis presented that old age (hazard ratio [HR] = 3.881, p < 0.01), persistently high postoperative CA19-9 level (HR = 4.41, p < 0.001), perineural invasion (HR = 3.073, p = 0.01), narrow resection margin (HR = 3.152, p = 0.05), and lymph node metastasis (HR = 3.427, p = 0.02) were significant independent risk factors for survival. Conclusions. Patients who have normalized CA19-9 levels postoperatively have longer survival outcomes. Therefore, normalized postoperative CA19-9 may be a useful clinical marker for ICC survival.
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Poruk KE, Pawlik TM, Weiss MJ. Perioperative Management of Hilar Cholangiocarcinoma. J Gastrointest Surg 2015; 19:1889-99. [PMID: 26022776 PMCID: PMC4858933 DOI: 10.1007/s11605-015-2854-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/04/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cholangiocarcinoma is the most common primary tumor of the biliary tract although it accounts for only 2 % of all human malignancies. We herein review hilar cholangiocarcinoma including its risk factors, the main classification systems for tumors, current surgical management of the disease, and the role chemotherapy and liver transplantation may play in selected patients. METHODS We performed a comprehensive literature search using PubMed, Medline, and the Cochrane library for the period 1980-2015 using the following MeSH terms: "hilar cholangiocarcinoma", "biliary cancer", and "cholangiocarcinoma". Only recent studies that were published in English and in peer reviewed journals were included. FINDINGS Hilar cholangiocarcinoma is a disease of advanced age with an unclear etiology, most frequently found in Southeast Asia and relatively rare in Western countries. The best chance of long-term survival and potential cure is surgical resection with negative surgical margins, but many patients are unresectable due to locally advanced or metastatic disease at diagnosis. As a result of recent efforts, new methods of management have been identified for these patients, including preoperative portal vein embolism and biliary drainage, neoadjuvant chemotherapy with subsequent transplantation, and chemoradiation therapy. CONCLUSION Current management of hilar cholangiocarcinoma depends on extent of the tumor at presentation and includes surgical resection, liver transplantation, portal vein embolization, and chemoradiation therapy. Our understanding of hilar cholangiocarcinoma has improved in recent years and further research offers hope to improve the outcome in patients with these rare tumors.
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Affiliation(s)
- Katherine E Poruk
- Department of Surgery, The Johns Hopkins University School of Medicine, Halsted 614 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Halsted 614 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Halsted 614 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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50
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Groot Koerkamp B, Wiggers JK, Allen PJ, Besselink MG, Blumgart LH, Busch ORC, Coelen RJ, D'Angelica MI, DeMatteo RP, Gouma DJ, Kingham TP, Jarnagin WR, van Gulik TM. Recurrence Rate and Pattern of Perihilar Cholangiocarcinoma after Curative Intent Resection. J Am Coll Surg 2015; 221:1041-9. [PMID: 26454735 DOI: 10.1016/j.jamcollsurg.2015.09.005] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to investigate the rate and pattern of recurrence after curative intent resection of perihilar cholangiocarcinoma (PHC). STUDY DESIGN Patients were included from 2 prospectively maintained databases. Recurrences were categorized by site. Time to recurrence and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to identify independent poor prognostic factors. RESULTS Between 1991 and 2012, 306 consecutive patients met inclusion criteria. Median overall survival was 40 months. A recurrence was diagnosed in 177 patients (58%). An initial local recurrence was found in 26% of patients: liver hilum (11%), hepaticojejunostomy (8%), liver resection margin (8%), or distal bile duct remnant (2%). An initial distant recurrence was observed in 40% of patients: retroperitoneal lymph nodes (14%), intrahepatic away from the resection margin (13%), peritoneum (12%), and lungs (8%). Only 18% of patients had an isolated initial local recurrence. The estimated overall recurrence rate was 76% at 8 years. After a recurrence-free period of 5 years, 28% of patients developed a recurrence in the next 3 years. Median RFS was 26 months. Independent prognostic factors for RFS were resection margin, lymph node status, and tumor differentiation. Only node-positive PHC precluded RFS beyond 7 years. CONCLUSIONS Perihilar cholangiocarcinoma will recur in most patients (76%) after resection, emphasizing the need for better adjuvant strategies. The high recurrence rate of up to 8 years justifies prolonged surveillance. Only patients with an isolated initial local recurrence (18%) may have benefited from a more extensive resection or liver transplantation. Node-positive PHC appears incurable.
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Affiliation(s)
- Bas Groot Koerkamp
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Jimme K Wiggers
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Leslie H Blumgart
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Robert J Coelen
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | | | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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