Improved Outcome of Resection of Hilar Cholangiocarcinoma (Klatskin Tumor)

Practice guidelines for managing extrahepatic biliary tract cancers

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.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

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

A comprehensive study and extensive review of the Caudate lobe: The last piece of "Jigsaw" puzzle

Many liver surgeons have updated their understanding of the liver in recent years because of detailed studies on the liver anatomy and the rapid advances in laparoscopic liver surgery. Despite newer approaches, concepts and methods, research on the caudate lobe continues to be based on case reports and several persistent challenges concerning caudate lobe surgery that are worth discussing. Based on the literature and the author's experience, this study considers and addresses the challenges associated with caudate lobectomy encountered by most liver surgeons. We searched PubMed for relevant articles in English for 'caudate lobe', 'cholangiocellular carcinoma', 'laparoscopic caudate resection', 'right-side boundary of the caudate lobe' and 'assessment of hepatic functional reserve' published up to May 2022. This study reviewed the anatomical history of the caudate lobe, focusing on the challenges associated with caudate lobe-related surgical resection. Due to the unique anatomical position of the caudate lobe, surgical strategy for caudate lobe resection is particularly important, and the technical requirements for hepatobiliary surgeons are also extremely strict. Therefore, understanding the anatomical history of the caudate lobe and discussing the challenges associated with caudate lobectomy is essential.

The value of total caudate lobe resection for hilar cholangiocarcinoma: a systematic review

Hilar cholangiocarcinoma (HCCA) is widely considered to have a poor prognosis. In particular, combined caudate lobe resection (CLR) as a strategy for radical resection in HCCA is important for improving the R0 resection rate. However, the criteria for R0 resection, necessity of CLR, optimal extent of hepatic resection, and surgical approach are still controversial. This review aimed to summarize the findings and discuss the controversies surrounding CLR. Numerous clinical studies have shown that combined CLR treatment for HCCA improves the R0 resection rate and postoperative survival time. Whether surgery for Bismuth type I or II is combined with CLR depends on the pathological type. Considering the anatomical factors, total rather than partial CLR is recommended to achieve a higher R0 resection rate. In the resection of HCCA, a proximal ductal margin greater than or equal to 10 mm should be achieved to obtain a survival benefit. Although there is no obvious boundary between the right side (especially the paracaval portion) and the right posterior lobe of the liver, Peng's resection line can serve as a reference marker for right-sided resection. Laparoscopic resection of the caudate lobe may be safer, more convenient, accurate, and minimally invasive than open surgery, but it needs to be completed by experienced laparoscopic doctors.

Left-sided Hepatectomy Leads to Less Postoperative Liver Failure and Comparable Overall Survival to Right-sided Hepatectomy in Type II or IV Perihilar Cholangiocarcinoma

INTRODUCTION

Right-side hepatectomy (RH) is used in oncological resection for perihilar cholangiocarcinoma (PHC); however, the decision between performing left-side hepatectomy (LH) or RH is still controversial. We compared surgical and oncologic outcomes of LH and RH in PHC type II or IV where either hepatectomy was expected to have a negative margin.

METHODS

From 2001 to 2020, 99 patients underwent major liver resection for type II or IV PHC. Patients with unilateral vascular invasion, unilateral tumor growth, and atrophy of unilateral liver were excluded. Preoperative characteristics, perioperative, and long-term outcomes were compared between the remaining RH and LH patients.

RESULTS

After excluding 47 cases with side predominance, the RH group (n = 29) and LH group (n = 23) were compared. Clinical characteristics and disease severity did not differ between the groups. Portal vein embolization (RH: 48.3% vs. LH: 0.0%, p < 0.001) and days from diagnosis to operation (RH: 31.0 ± 16.2 vs. LH: 18.8 ± 13.4, p = 0.006) were significantly higher in the RH group. The RH group had statistically higher rate of postoperative hepatic failure (RH: 55.2% vs. LH: 21.7%, p = 0.015) and a higher mortality rate that was not significant (RH: 13.8% vs. LH: 0%, p = 0.120). The R0 resection rate (RH: 72.4% vs. LH: 78.3%, p = 0.629), median disease-free (p = 0.620), and overall (p = 0.487) survival did not differ between groups. R1 resection and lymph node metastasis were significant risk factors for disease-free survival in multivariate analysis.

CONCLUSIONS

In type II or type IV PHC where either LH or RH was feasible, LH provided a shorter period of preoperative preparation, lower postoperative hepatic failure rate, similar R0 rate, and comparable long-term outcomes. LH should be considered a reasonable option in type II or IV PHC.

A critical appraisal of the ISGLS definition of biliary leakage after liver resection

PURPOSE

The International Study Group of Liver Surgery (ISGLS) defined post-hepatectomy biliary leakage as drain/serum bilirubin ratio > 3 at day 3 or the interventional/surgical revision due to biliary peritonitis. We investigated the definition's applicability.

METHODS

A retrospective evaluation of all liver resections over a 6-year period was performed. ROC analyses were performed for drain/serum bilirubin ratios on days 1, 2, and 3 including grade A to C (analysis I) and grade B and C biliary leakages (analysis II) to test specific cutoff values.

RESULTS

A total of 576 patients were included. One hundred nine (18.9%) postoperative bile leakages occurred (19.6% of the whole population grade A, 16.5% grade B/C). Areas under the curve (AUC) for analysis I were 0.841 (day 1), 0.846 (day 2), and 0.734 (day 3). The highest sensitivity (78% on day 1/77% on day 2) and specificity (78% on day 1/79% on day 2) in analysis I were obtained for a drain/serum bilirubin ratio of 2.0. AUCs for analysis II were similar: 0.788 (day 1), 0.791 (day 2), and 0.650 (day 3). The highest sensitivity (73% on day 1/71% on day 2) and specificity (74% on day 1/76% on day 2) in analysis II were detected for a drain/serum bilirubin ratio of 2.0 on postoperative day 2.

CONCLUSION

Biliary leakages should be defined if the drain/serum bilirubin ratio is > 2.0 on postoperative day 2.

Does Caudate Resection Improve Outcomes of Patients Undergoing Curative Resection for Perihilar Cholangiocarcinoma? A Systematic Review and Meta-Analysis

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.

ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction

This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses primary drainage modality (percutaneous transhepatic biliary drainage [PTBD] vs endoscopic biliary drainage [EBD]), drainage strategy (unilateral vs bilateral), and stent selection (plastic stent [PS] vs self-expandable metal stent [SEMS]). Regarding drainage modality, in patients with MHO undergoing drainage before potential resection or transplantation, the panel suggests against routine use of PTBD as first-line therapy compared with EBD. In patients with unresectable MHO undergoing palliative drainage, the panel suggests PTBD or EBD. The final decision should be based on patient preferences, disease characteristics, and local expertise. Regarding drainage strategy, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placement of bilateral stents compared with a unilateral stent in the absence of liver atrophy. Finally, regarding type of stent, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placing SEMSs or PSs. However, in patients who have a short life expectancy and who place high value on avoiding repeated interventions, the panel suggests using SEMSs compared with PSs. If optimal drainage strategy has not been established, the panel suggests placing PSs. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

The value of lymphadenectomy in surgical resection of perihilar cholangiocarcinoma: a systematic review and meta-analysis

Surgical resection is the only potentially curative treatment for patients with resectable perihilar cholangiocarcinoma (PHC). There is still no consensus on the value of lymphadenectomy despite evidence indicating lymph node (LN) status is an important prognostic indicator for postoperative long-term survival. We sought to perform a meta-analysis to summarize the current evidence on the value of lymphadenectomy among patients undergoing surgery for PHC. The PubMed (OvidSP), Embase and Cochrane Library were systematically searched for studies published before July 2020 that reported on lymphadenectomy at the time of surgery for PHC after curative surgery. 7748 patients from 28 studies were included in the meta-analysis. No survival benefit was identified with increased number of LN resected (all P > 0.05). Meanwhile, overall LN status was an important prognostic factor. Patients with lymph node metastasis had a pooled estimate hazard ratio of death that was over two-fold higher than patients without lymph node metastasis (HR 2.07, 95% CI 1.65-2.59, P < 0.001). The examination of 5 LNs on histology was associated with better staging of lymph node status and stratification of patients into positive or negative LN groups. While the extent of LN dissection was not associated with a survival benefit, examination of more than 5 LNs better staged patients into positive or negative LN groups with a lower risk of nodal understaging.

Modification and comparison of CT criteria in the preoperative assessment of hepatic arterial invasion by hilar cholangiocarcinoma

OBJECTIVE

To compare the diagnostic performance of three CT criteria and two signs in evaluating hepatic arterial invasion by hilar cholangiocarcinoma.

METHODS

In this study, we retrospectively reviewed the CT images of 85 patients with hilar cholangiocarcinoma. Modified Loyer's, Lu's, and Li's standards were used to evaluate hepatic arterial invasion by hilar cholangiocarcinoma with the reference of intraoperative findings and/or the postoperative pathological diagnosis. Arterial tortuosity and contact length were also evaluated.

RESULTS

Loyer's, Lu's, and Li's standards showed sensitivities of 91.7%, 90.3%, and 72.2%, specificities of 94.0%, 94.5%, and 95.6%, and accuracies of 93.3%, 93.3%, and 89.0%, respectively, in evaluating hepatic arterial invasion by hilar cholangiocarcinoma. Loyer's and Lu's standards and contact length performed better than Li's standard (P < 0.001). Arterial tortuosity performed worse than other criteria (P < 0.001). The CT criteria performed best in evaluating proper hepatic arterial invasion compared with the left and right hepatic artery. When the cut-off contact length of 6.73 mm was combined with Loyer's standard, 4 false-negative cases could be avoided.

CONCLUSIONS

Loyer's and Lu's standards and the contact length performed best in evaluating hepatic arterial invasion by hilar cholangiocarcinoma on preoperative CT images, particularly in assessing the proper hepatic artery. Arterial tortuosity could serve as an important supplement. The combination of the contact length and Loyer's standard could improve the diagnostic performance.

The Evolving Role of Radiation Therapy in the Treatment of Biliary Tract Cancer

Biliary tract cancers (BTC) are a disease entity comprising diverse epithelial tumors, which are categorized according to their anatomical location as intrahepatic (iCCA), perihilar (pCCA), distal (dCCA) cholangiocarcinomas, and gallbladder carcinomas (GBC), with distinct epidemiology, biology, and prognosis. Complete surgical resection is the mainstay in operable BTC as it is the only potentially curative treatment option. Nevertheless, even after curative (R0) resection, the 5-year survival rate ranges between 20 and 40% and the disease free survival rates (DFS) is approximately 48–65% after one year and 23–35% after three years without adjuvant treatment. Improvements in adjuvant chemotherapy have improved the DFS, but the role of adjuvant radiotherapy is unclear. On the other hand, more than 50% of the patients present with unresectable disease at the time of diagnosis, which limits the prognosis to a few months without treatment. Herein, we review the role of radiotherapy in the treatment of cholangiocarcinoma in the curative and palliative setting.

Significance of HMGA2 expression as independent poor prognostic marker in perihilar and distal cholangiocarcinoma resected with curative intent

BACKGROUND

Extrahepatic cholangiocarcinoma requires invasive surgery and is associated with poor prognosis; thus, a prognostic biomarker is highly needed. Extrahepatic cholangiocarcinoma is sub-classified into two types based on their location, namely perihilar and distal. Perihilar cholangiocarcinoma requires lobectomy as curative surgical resection, whereas the distal requires pancreatoduodenectomy. HMGA2 overexpression is reported to correlate with progression, aggressiveness, dissemination and poor prognosis in several types of cancers. Although its association with extrahepatic cholangiocarcinoma has been reported, none of the previous studies assessed its significance in each subtype.

METHODS

We assessed the expression of HMGA2 protein in surgical specimens after curative intent surgery in 80 patients including 41 with perihilar cholangiocarcinoma and 39 with distal cholangiocarcinoma by immunohistochemistry. We then examined its association with clinicopathological findings and patient survival outcomes.

RESULTS

We found that HMGA2 was expressed in 51% (21 of 41) of perihilar cholangiocarcinoma and 41% (16 of 39) of distal cholangiocarcinoma samples. In perihilar cholangiocarcinoma, we found significant correlations between expression and vascular invasion and perineural invasion. In distal cholangiocarcinoma, we found that protein levels correlated with tumor grade. Univariate and multivariate analyses demonstrated that HMGA2 expression was an independent poor prognostic factor for patients with both subtypes of disease.

CONCLUSIONS

Our results revealed that HMGA2 expression as an independent prognostic marker for both perihilar and distal cholangiocarcinoma that were resected with curative intent.

The effect and safety of preoperative biliary drainage in patients with hilar cholangiocarcinoma: an updated meta-analysis

Background

The effect and safety of preoperative biliary drainage (PBD) in patients with perihilar cholangiocarcinoma are still controversial; the aim of our study is to evaluate all aspects of PBD.

Methods

All included studies featured PBD versus non-PBD (NPBD) groups were from 1996 to 2019 and were extracted from Cochrane Library, Embase, PubMed, and Science Citation Index Expanded.

Results

Sixteen studies met the inclusion criteria and were included in this analysis. PBD may lead to a significantly higher incidence of overall morbidities (OR 0.67, 95% CI 0.53, 0.85; P = 0.0009) and intraoperative transfusions (OR 0.72, 95% CI 0.55, 0.94; P = 0.02); moreover, bile leakage (OR 0.58, 95% CI 0.24, 1.41; P = 0.04), infection (OR 0.31, 95% CI 0.20, 0.47; P < 0.00001), and cholangitis (OR 0.18, 95% CI 0.007, 0.48; P = 0.0007) are also related to PBD. However, NPBD was associated with more frequent hepatic insufficiency (OR 3.09, 95% CI 1.15, 8.31; P = 0.03). In the subgroup meta-analysis, the differences in the outcomes of bile leakage and overall morbidity lost significance between the PBD and NPBD groups when the mean total serum bilirubin (TSB) concentration was above 15 mg/dl.

Conclusion

Meta-analysis demonstrated that compared to NPBD, PBD is associated with a greater risk of several kinds of infection and morbidities, but its ability to reduce postoperative hepatic insufficiency cannot be ignored. In patients with a high TSB concentration, PBD tends to be a better choice. However, these results need to be confirmed in a future prospective randomized trial with large samples to clarify the effects and find a specific TSB concentration for PBD.

A systematic review and meta-analysis of caudate lobectomy for treatment of hilar cholangiocarcinoma

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.

Right-side versus left-side hepatectomy for the treatment of hilar cholangiocarcinoma: a comparative study

Background

Radical resection is the only curative treatment for patients with hilar cholangiocarcinoma. While left-side hepatectomy (LH) may have an oncological disadvantage over right-side hepatectomy (RH) owing to the contiguous anatomical relationship between right hepatic inflow and biliary confluence, a small future liver remnant after RH could cause worse surgical morbidity and mortality. We retrospectively compared surgical morbidity and long-term outcome between RH and LH to determine the optimal surgical strategy for the treatment of hilar cholangiocarcinoma.

Methods

This study considered 83 patients who underwent surgical resection for hilar cholangiocarcinoma between 2010 and 2017. Among them, 57 patients undergoing curative-intent surgery including liver resection were enrolled for analysis—33 in the RH group and 27 in the LH group. Prospectively collected clinicopathologic characteristics, perioperative outcomes, and long-term survival were evaluated.

Results

Portal vein embolization was more frequently performed in the RH group than in the LH group (18.2% vs. 0%, P = 0.034). The proportion of R0 resection was comparable in both groups (75.8% vs. 75.0%, P = 0.948). The 5-year overall and recurrence-free survival rates did not differ between the groups (37.7% vs. 41.9%, P = 0.500, and 26.3% vs. 33.9%, P = 0.580, respectively). The side of liver resection did not affect long-term survival. In multivariate analysis, transfusion (odds ratio, 3.12 [1.42–6.87], P = 0.005) and post-hepatectomy liver failure (≥ grade B, 4.62 [1.86–11.49], P = 0.001) were independent risk factors for overall survival.

Conclusions

We recommend deciding the side of liver resection according to the possibility of achieving radical resection considering the anatomical differences between RH and LH.

[Predictors of outcomes in surgery for hilar cholangiocarcinoma]

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.

Downstaging Locally Advanced Cholangiocarcinoma Pre-Liver Transplantation: A Prospective Pilot Study

BACKGROUND

Orthotopic liver transplantation (OLT) after neoadjuvant therapy (NT) in well-selected patients with unresectable hilar cholangiocarcinoma (CCA) achieves excellent recurrence-free survival. Current criteria for NT-OLT exclude patients with locally advanced hilar and intrahepatic CCA from potential cure. We sought to evaluate the efficacy of NT in downstaging locally advanced CCA, and examine outcomes after OLT.

METHODS

Among 24 patients referred for unresectable hilar and intrahepatic CCA from January 2013 through August 2017, 18 met center-specific inclusion criteria for the NT-OLT treatment protocol: hilar tumor size ≤3.5 cm or intrahepatic ≤8 cm, and regional lymphadenopathy but without distant metastasis. Median follow-up was 22.1 mo from diagnosis.

RESULTS

Of 18 patients who initiated NT, 11 were removed from the protocol due to tumor progression (n = 6) or uncontrolled infection and failure-to-thrive (n = 5). Median NT duration tended to be shorter for patients progressing to dropout than for those surviving to OLT (5.5 versus 13.5 mo, P = 0.109). Among five patients who received OLT, 1-y post-OLT patient survival was 80%: three survive recurrence-free (14.5-29.2 mo post-OLT); one developed an isolated tumor recurrence in a single portacaval lymph node at 12 mo post-OLT; and one experienced non-tumor-related death. All dropout patients died at a median of 14.4 mo after diagnosis.

CONCLUSIONS

This is the first prospective study to show successful NT downstaging of unresectable locally advanced hilar and intrahepatic CCA before OLT. NT-OLT for select patients with locally advanced hilar and intrahepatic CCA achieved acceptable short-term recurrence-free survival.

Improved Survival in Surgically Resected Distal Cholangiocarcinoma Treated with Adjuvant Therapy: a Propensity Score Matched Analysis

BACKGROUND

Data on the efficacy of adjuvant therapy (AT) in distal cholangiocarcinoma (dCCA) is limited. This study aimed to determine the role of AT in resected dCCA and identify subgroups that benefit from AT.

METHODS

We conducted a retrospective review of surgically resected dCCA in the NCDB from 2004 to 2013. Patients who received AT or observation (OB) were matched by propensity score. Log-rank test was used to compare OS.

RESULTS

Of 1782 patients with resected dCCA, 840 (47%) were in the OB group and 942 (53%) in the AT group. AT was younger (64.0 vs. 68.7 years, p < 0.001), had less comorbidities (Charlson Deyo score 0) (74.6 vs. 68.0%, p < 0.001), and more likely to have private insurance (p < 0.001). AT was more likely to present with T3/T4 stage (72 vs. 57%, p < 0.001), N1/N2 disease (58 vs. 37%, p < 0.001), and positive surgical margins (26 vs. 16%, p < 0.001). After 1:1 propensity score matching, 500 OB and 500 AT patients were compared. AT was associated with better OS (HR 0.79; 95% CI 0.67-0.93). Median OS was 31 and 25 months for the AT and OB (p = 0.006). The 1-, 3-, and 5-year survival rates were 87, 46, and 31% for AT; 79, 39, and 24% for OB. Subgroup analysis revealed an associated survival advantage for AT in T3/T4 tumors (HR = 0.72; 95% CI 0.59-0.89), node positive disease (HR 0.70; 95% CI 0.56-0.87), and positive margins (HR 0.58; 95% CI 0.42-0.81).

CONCLUSION

AT is associated with improved OS in resected dCCA, especially in T3/T4 tumors, node positive disease, and positive margins.

A retrospective review of correlative radiological assessment and surgical exploration for hilar cholangiocarcinoma

Backgrounds/Aims

Hilar cholangiocarcinomas (HCCAs) are tumors that involve the biliary confluence; at present, radical surgery offers the only chance of long-term survival, but this can be challenging given the complexity of the hilar anatomy. Blumgart and Jarnagin described a preoperative staging system that incorporates the effect of local tumor extent and its impact on adjacent structures and that has been demonstrated to correlate better with actual surgical resectability. The primary aim of this study is to describe the correlation between preoperative Blumgart-Jarnagin staging and its correlation with surgical resectability.

Methods

Patients who underwent surgical resection for hilar cholangiocarcinoma at Singapore General Hospital between January 1, 2002, and January 1, 2013, were identified from a prospectively maintained institutional database. All patients were staged based on the criteria described by Blumgart and Jarnagin. Correlation with surgical resectability was then determined.

Results

A total of 19 patients were identified. Overall resectability was 57.8% (n=11). Patients with Blumgart-Jarnagin stage T1 had the highest rates of resectability at 80%; patients with stage T2 and T3 disease had resectability rates of 25% and 40% respectively. Median overall survival was 13.6 months.

Conclusions

The Blumgart-Jarnagin staging system is useful for predicting tumor resectability in HCCA.

Hepatic Artery Resection for Bismuth Type III and IV Hilar Cholangiocarcinoma: Is Reconstruction Always Required?

OBJECTIVE

The objective of the study is to examine the feasibility of hepatic artery resection (HAR) without subsequent reconstruction (RCS) in specified patients of Bismuth type III and IV hilar cholangiocarcinoma.

METHODS

We retrospectively reviewed 63 patients who underwent hepatic artery resection for Bismuth type III and IV hilar cholangiocarcinoma. These patients were subsequently enrolled into two groups based on whether the artery reconstruction was conducted. Postoperative morbidity and mortality, and long-term survival outcome were compared between the two groups.

RESULTS

There were 29 patients in HAR group and 34 patients in the HAR + RCS group. Patients with hepatic artery reconstruction tended to have longer operative time (545.6 ± 143.1 min vs. 656.3 ± 192.8 min; P = 0.013) and smaller tumor size (3.0 ± 1.1 cm vs. 2.5 ± 0.9 cm; P = 0.036). The R0 resection margin was comparable between the HAR group and HAR + RCS group (86.2 vs. 85.3%; P > 0.05). Twelve patients (41.4%) with 24 complications in HAR group and 13 patients (38.2%) with 25 complications in HAR + RCS group were recorded (P = 0.799). The postoperative hepatic failure rate (13.8 vs. 5.9%) and postoperative mortality rate (3.4% vs. 2.9%) were also comparable between the two groups. In the HAR group, the overall 1-, 3-, and 5-year survival rates were 72, 41, and 19%, respectively; while in the HAR + RCS group, the overall 1-, 3-, and 5-year survival rates were 79, 45, and 25%, respectively (P = 0.928).

CONCLUSIONS

Hepatic artery resection without reconstruction is also a safe and feasible surgical procedure for highly selected cases of Bismuth type III and IV hilar cholangiocarcinoma.

Relationship of tumor size with pathological and prognostic factors for hilar cholangiocarcinoma

Objective

To determine the correlation of different tumor-size cutoffs with prognostic factors and survival outcomes to provide a reference for the modification of the T-stage classification in the DeOliveira staging system for hilar cholangiocarcinoma (HCCA).

Materials and Methods

We retrospectively analyzed 216 patients who underwent curative surgery for HCCA (mean tumor diameter, 2.8 cm) between 2000 and 2013. Univariate and multivariate logistic regression were used to assess the correlation of tumor-size cutoffs with various factors.

Results

Tumor differentiation (odds ratio [OR]: 1.649, 95% confidence interval [CI]: 1.065–2.555, P = 0.025), node status (OR: 1.971, 95% CI: 1.060–3.664, P = 0.032), resection margin (OR: 2.465, 95% CI: 1.024–5.937, P = 0.044), and hepatectomy (OR: 2.373, 95% CI: 1.226–4.593, P = 0.01) were independently correlated with the 2-cm cutoff, while tumor differentiation (OR: 1.755, 95% CI: 1.062–2.091, P = 0.028), node status (OR: 2.166, 95% CI: 1.054–4.452, P = 0.035), and tumor margin (OR: 2.539, 95% CI: 1.089–5.919, P = 0.031) were independently associated with the 3-cm cutoff.

Conclusions

The 2-cm and 3-cm cutoffs were strongly correlated with resection margin, node status, tumor differentiation and survival. The 2-cm cutoff may be added to the DeOliveira staging system.

Actual Long-Term Survival Outcome of 403 Consecutive Patients with Hilar Cholangiocarcinoma

BACKGROUND

Despite aggressive surgical resection, prognosis of patients with hilar cholangiocarcinoma is still unsatisfactory. There were limited data about actual long-term survival outcome. This study was designed to explore actual long-term survival outcome of hilar cholangiocarcinoma after surgical treatment, and to investigate the characteristics of patients with actual long-term survival.

METHODS

The study cohort consisted of 403 consecutive patients with at least 5-year follow-up after surgical treatment for hilar cholangiocarcinoma at Seoul National University Hospital between 1991 and 2010. Prognostic factors were analyzed with Cox proportional hazard models, and the effect of adjuvant treatment was evaluated by propensity score analysis.

RESULTS

Of all patients, R0 resection rate was 41.2 and 63.8 % among intended curative resection. Adjuvant therapy was performed in 48.8 % after curative surgery. Actual 5-year overall survival (OS) rate was 18.9, and 30.1 % after R0 resection. Actual 5-year disease-free survival rate was 25.8 % after resection. Adjuvant treatment improved prognosis in patients with positive metastatic lymph nodes (median OS 21.9 vs. 11.5 months, p = 0.003). Overall recurrence rate was 55.0 %, and distant metastasis (39.7 %) was more frequent than loco-regional recurrence (20.8 %). Lymph node metastasis (p = 0.021) and poor histologic grade (p < 0.001) were independent prognostic factors after curative resection. Patients who survived more than 5 years had less lymph node metastasis (p = 0.025), poor histologic differentiation (p = 0.010), R2 resection (p = 0.040), and recurrence (p < 0.001).

CONCLUSION

Actual 5-year OS rate after R0 resection of hilar cholangiocarcinoma is 30.1 %. Adjuvant treatment could be beneficial in patients with lymph node metastasis.

Impact of Preoperative Three-Dimensional Computed Tomography Cholangiography on Postoperative Resection Margin Status in Patients Operated due to Hilar Cholangiocarcinoma

INTRODUCTION

The purpose of this study was to analyse the value of 3-dimensional computed tomography cholangiography (3D-ERC) compared to conventional retrograde cholangiography in the preoperative diagnosis of hilar cholangiocarcinoma (HC) with special regard to the resection margin status (R0/R1).

PATIENTS AND METHODS

All hepatic resections performed between January 2011 and November 2013 in patients with HC at the Department of General, Visceral and Transplant Surgery of the RWTH Aachen University Hospital were analysed. All patients underwent an ERC and contrast-enhanced multiphase CT scan or a 3D-ERC.

RESULTS

The patient collective was divided into two groups (group ERC: n = 17 and group 3D-ERC: n = 16). There were no statistically significant differences between the two groups with regard to patient characteristics or intraoperative data. Curative liver resection with R0 status was reached in 88% of patients in group ERC and 87% of patients in group 3D-ERC (p = 1.00). We could not observe any differences with regard to postoperative complications, hospital stay, and mortality rate between both groups.

CONCLUSION

Based on our findings, preoperative imaging with 3D-ERC has no benefit for operative planning and R0 resection status. It cannot replace the exploration by an experienced surgeon in a centre for hepatobiliary surgery.

Intranuclear accumulation of galectin-3 is an independent prognostic factor for patients with distal cholangiocarcinoma

Galectin-3 has been reported to be associated with the prognosis of patients with various malignancies; however, it has not yet been investigated in patients with extrahepatic cholangiocarcinoma (EHCC). Expression of galectin-3 was retrospectively examined in 58 patients with EHCC: 21 with perihilar cholangiocarcinoma and 37 with distal cholangiocarcinoma (DCC). The Cox proportional hazard model was used to identify independent prognostic factors. Intranuclear accumulation of galectin-3 (gal-3-INA) was associated with poorer overall survival (OS) in all patients (P=0.003), as well as in patients with DCC (P=0.004). Patients with gal-3-INA also exhibited a poorer disease-free survival (DFS) than those without gal-3-INA in all patients with EHCC (P<0.001), and in patients with DCC (P<0.001). Gal-3-INA was an independent prognostic factor of OS and DFS in all patients [OS: Hazard ratio (HR), 4.470; 95% confidence interval (CI), 1.759–11.357; P=0.002; and DFS: HR, 5.116; 95% CI, 2.025–12.925; P=0.001]. Gal-3-INA was also an independent prognostic factor in patients with DCC (OS: HR, 2.979; 95% CI, 1.035–8.570; P=0.043; and DFS: HR, 6.773; 95% CI, 1.558–29.439; P=0.011). In the analysis of patients with DCC, the number of patients with high galectin-3 expression (P=0.038), recurrence (P<0.001), distant metastases (P<0.001), R0 status (P=0.029) or microscopic vascular invasion (P=0.019) was significantly higher in the gal-3-INA-positive group than in the gal-3-INA-negative group. In conclusion, gal-3-INA was identified as a strong prognostic factor for OS and DFS in patients with DCC.

Preoperative biliary drainage in hilar cholangiocarcinoma: Systematic review and meta-analysis

BACKGROUND

The role of preoperative biliary drainage (PBD) for hilar cholangiocarcinoma (HCC) remains unclear. The aim of this meta-analysis is to investigate the role of PBD in the treatment of potentially resectable HCC.

METHODS

All studies reporting outcomes on patients with PBD vs without PBD were included. A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies published between 1980 and 2016.

RESULTS

Initial search identified 667 articles. Only 9 studies met the inclusion criteria and were included in this analysis. No significant differences in mortality were observed between the two groups (RR = 0,935; 95% CI = 0,612 to 1429; p = 0,463). Overall morbidity was significantly higher in PBD group (RR = 1266; 95% CI = 1039 to 1543; p = 0,011). No significant differences in transfusion rate, hospital stay, anastomotic leaks, abdominal collections and operative time, were found. Wound infections were significantly higher in PBD group.

CONCLUSIONS

PBD seems to be associated with higher postoperative morbidity and increases the risk of wound infections. Further prospective studies are needed to better define the impact of PBD in outcomes after surgery for hilar cholangiocarcinoma.

Success of photodynamic therapy in palliating patients with nonresectable cholangiocarcinoma: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on clinical outcomes of photodynamic therapy (PDT) in non-resectable cholangiocarcinoma.

METHODS

Included studies compared outcomes with photodynamic therapy and biliary stenting (PDT group) vs biliary stenting only (BS group) in palliation of non-resectable cholangiocarcinoma. Articles were searched in MEDLINE, PubMed, and EMBASE. Pooled proportions were calculated using fixed and random effects model. Heterogeneity among studies was assessed using the I2 statistic.

RESULTS

Ten studies (n = 402) that met inclusion criteria were included in this analysis. The P for χ2 heterogeneity for all the pooled accuracy estimates was > 0.10. Pooled odds ratio for successful biliary drainage (decrease in bilirubin level > 50% within 7days after stenting) in PDT vs BS group was 4.39 (95%CI: 2.35-8.19). Survival period in PDT and BS groups were 413.04 d (95%CI: 349.54-476.54) and 183.41 (95%CI: 136.81-230.02) respectively. The change in Karnofsky performance scores after intervention in PDT and BS groups were +6.99 (95%CI: 4.15-9.82) and -3.93 (95%CI: -8.63-0.77) respectively. Odds ratio for post-intervention cholangitis in PDT vs BS group was 0.57 (95%CI: 0.35-0.94). In PDT group, 10.51% (95%CI: 6.94-14.72) had photosensitivity reactions that were self-limiting. Subgroup analysis of prospective studies showed similar results, except the incidence of cholangitis was comparable in both groups.

CONCLUSION

In palliation of unresectable cholangiocarcinoma, PDT seems to be significantly superior to BS alone. PDT should be used as an adjunct to biliary stenting in these patients.

The safety and efficacy of nasobiliary drainage versus biliary stenting in malignant biliary obstruction: A systematic review and meta-analysis

BACKGROUND

Preoperative biliary drainage (PBD) has been widely used to treat patients with malignant biliary obstruction. However, it is still unclear which method of PBD (endoscopic nasobiliary drainage or endoscopic biliary stenting) is more effective. Thus, we carried out a meta-analysis to compare the safety and efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in malignant biliary obstruction in terms of preoperative and postoperative complications.

METHODS

We conducted a literature search of EMBASE databases, PubMed, and the Cochrane Library to identify relevant available articles that were published in English, and we then compared ENBD and EBS in malignant biliary obstruction patients. The preoperative cholangitis rate, the preoperative pancreatitis rate, the incidence of stent dysfunction, the postoperative pancreatic fistula rate, and morbidity were analyzed. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on dichotomous variables, and the pooled analyses were performed using RevMan 5.3.

RESULTS

Seven published studies (n = 925 patients) were included in this meta-analysis. We determined that patients with malignant biliary obstruction who received ENBD had reductions in the preoperative cholangitis rate (OR = 0.35, 95% CI = 0.25-0.51, P < 0.0001), the postoperative pancreatic fistula rate (OR = 0.38, 95% CI = 0.18-0.82, P = 0.01), the incidence of stent dysfunction (OR = 0.39, 95% CI = 0.28-0.56, P < 0.0001), and morbidity (OR = 0.47, 95% CI = 0.27-0.82, P = 0.008) compared with patients who received EBS.

CONCLUSIONS

The current meta-analysis suggests that ENBD is better than EBS for malignant biliary obstruction in terms of the preoperative cholangitis rate, the postoperative pancreatic fistula rate, the incidence of stent dysfunction, and morbidity. However, a limitation is that there are no data from randomized controlled trials.

Verification of the oncologic inferiority of percutaneous biliary drainage to endoscopic drainage: A propensity score matching analysis of resectable perihilar cholangiocarcinoma

BACKGROUND

Percutaneous transhepatic biliary drainage is an established biliary drainage method but is associated with a potential risk of seeding metastasis. The aim of this retrospective study was to evaluate whether percutaneous transhepatic biliary drainage really increases seeding metastasis and worsens the postoperative survival in patients with resectable perihilar cholangiocarcinoma.

METHODS

Patients who underwent resection for perihilar cholangiocarcinoma after percutaneous transhepatic biliary drainage or endoscopic biliary drainage were retrospectively reviewed. Seeding metastasis was defined as peritoneal/pleural dissemination and percutaneous transhepatic biliary drainage sinus tract recurrence. Univariate and multivariate analyses followed by propensity score matching were performed to adjust the data for the baseline characteristics of the percutaneous transhepatic biliary drainage and endoscopic biliary drainage patients.

RESULTS

Of 320 resected patients, 168 underwent percutaneous transhepatic biliary drainage and the remaining 152 received endoscopic biliary drainage before operation. The survival of the percutaneous transhepatic biliary drainage patients was significantly lower than that of the endoscopic biliary drainage patients (37.0% vs 44.3% at 5 years, P = .019). Multivariate analyses showed that percutaneous transhepatic biliary drainage was an independent predictor of poor survival (P = .011) and a risk factor for seeding metastasis (P = .005). After propensity score matching (71 patients in each group), the survival of the percutaneous transhepatic biliary drainage patients was significantly worse than that of the endoscopic biliary drainage patients (P = .018). The estimated cumulative recurrence rate of seeding metastasis was significantly higher in the percutaneous transhepatic biliary drainage patients than in the endoscopic biliary drainage patients (P = .005), while the recurrence rates at other sites were similar between the 2 groups (P = .413).

CONCLUSION

Percutaneous transhepatic biliary drainage increases the incidence of seeding metastasis and shortens the postoperative survival in patients with perihilar cholangiocarcinoma. Endoscopic biliary drainage is recommended as the optimal method for preoperative biliary drainage.

Vascular Reconstruction in Hepatic Malignancy

With surgery for hepatic malignancy, there are poor options for chemotherapy; many patients are deemed unresectable because of vascular involvement or location of tumors. Over the past few decades, advances in surgical technique have allowed resection of these tumors with vascular reconstruction to achieve negative margins and improve chances for survival. This article reviews those reconstruction techniques and outcomes in detail, including in situ perfusion and ex vivo liver surgery, and provides a discussion of implications and operative planning for patients with hepatic malignancy in order to provide surgeons with better understanding of these complicated operations.

Multisciplinary management of patients with liver metastasis from colorectal cancer

Colorectal cancer (CRC) is one of the leading causes of cancer-related death. Surgery, radiotherapy and chemotherapy have been till now the main therapeutic strategies for disease control and improvement of the overall survival. Twenty-five per cent (25%) of CRC patients have clinically detectable liver metastases at the initial diagnosis and approximately 50% develop liver metastases during their disease course. Twenty-thirty per cent (20%-30%) are CRC patients with metastases confined to the liver. Some years ago various studies showed a curative potential for liver metastases resection. For this reason some authors proposed the conversion of unresectable liver metastases to resectable to achieve cure. Since those results were published, a lot of regimens have been studied for resectability potential. Better results could be obtained by the combination of chemotherapy with targeted drugs, such as anti-VEGF and anti-EGFR monoclonal antibodies. However an accurate selection for patients to treat with these regimens and to operate for liver metastases is mandatory to reduce the risk of complications. A multidisciplinary team approach represents the best way for a proper patient management. The team needs to include surgeons, oncologists, diagnostic and interventional radiologists with expertise in hepatobiliary disease, molecular pathologists, and clinical nurse specialists. This review summarizes the most important findings on surgery and systemic treatment of CRC-related liver metastases.

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors

AIM: To determine predictors of long term survival after resection of hilar cholangiocarcinoma (HC) by comparing patients surviving > 5 years with those who survived < 5 years.

METHODS: This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center, Mansoura University, Egypt between January 2002 and April 2013. All data of the patients were collected from the medical records. Patients were divided into two groups according to their survival: Patients surviving less than 5 years and those who survived > 5 years.

RESULTS: There were 34 (14%) long term survivors (5 year survivors) among the 243 patients. Five-year survivors were younger at diagnosis than those surviving less than 5 years (mean age, 50.47 ± 4.45 vs 54.59 ± 4.98, P = 0.001). Gender, clinical presentation, preoperative drainage, preoperative serum bilirubin, albumin and serum glutamic-pyruvic transaminase were similar between the two groups. The level of CA 19-9 was significantly higher in patients surviving < 5 years (395.71 ± 31.43 vs 254.06 ± 42.19, P = 0.0001). Univariate analysis demonstrated nine variables to be significantly associated with survival > 5 year, including young age (P = 0.001), serum CA19-9 (P = 0.0001), non-cirrhotic liver (P = 0.02), major hepatic resection (P = 0.001), caudate lobe resection (P = 0.006), well differentiated tumour (P = 0.03), lymph node status (0.008), R0 resection margin (P = 0.0001) and early postoperative liver cell failure (P = 0.02).

CONCLUSION: Liver status, resection of caudate lobe, lymph node status, R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.

Strict Selection Alone of Patients Undergoing Liver Transplantation for Hilar Cholangiocarcinoma Is Associated with Improved Survival

Liver transplantation for hilar cholangiocarcinoma (hCCA) has regained attention since the Mayo Clinic reported their favorable results with the use of a neo-adjuvant chemoradiation protocol. However, debate remains whether the success of the protocol should be attributed to the neo-adjuvant therapy or to the strict selection criteria that are being applied. The aim of this study was to investigate the value of patient selection alone on the outcome of liver transplantation for hCCA. In this retrospective study, patients that were transplanted for hCCA between1990 and 2010 in Europe were identified using the European Liver Transplant Registry (ELTR). Twenty-one centers reported 173 patients (69%) of a total of 249 patients in the ELTR. Twenty-six patients were wrongly coded, resulting in a study group of 147 patients. We identified 28 patients (19%) who met the strict selection criteria of the Mayo Clinic protocol, but had not undergone neo-adjuvant chemoradiation therapy. Five–year survival in this subgroup was 59%, which is comparable to patients with pretreatment pathological confirmed hCCA that were transplanted after completion of the chemoradiation protocol at the Mayo Clinic. In conclusion, although the results should be cautiously interpreted, this study suggests that with strict selection alone, improved survival after transplantation can be achieved, approaching the Mayo Clinic experience.

Clinical value of preoperative serum CA 19-9 and CA 125 levels in predicting the resectability of hilar cholangiocarcinoma

Background

To examine the predictive value of tumor markers for evaluating tumor resectability in patients with hilar cholangiocarcinoma and to explore the prognostic effect of various preoperative factors on resectability in patients with potentially resectable tumors. Patients with potentially resectable tumors judged by radiologic examination were included. The receiver operating characteristic (ROC) analysis was conducted to evaluate serum carbohydrate antigenic determinant 19-9 (CA 19-9), carbohydrate antigen 125 (CA 125) and carcino embryonie antigen levels on tumor resectability. Univariate and multivariate logistic regression models were also conducted to analysis the correlation of preoperative factors with resectability.

Results

In patients with normal bilirubin levels, ROC curve analysis calculated the ideal CA 19-9 cut-off value of 203.96 U/ml in prediction of resectability, with a sensitivity of 83.7 %, specificity of 80 %, positive predictive value of 91.1 % and negative predictive value of 66.7 %. Meanwhile, the optimal cut-off value for CA 125 to predict resectability was 25.905 U/ml (sensitivity, 78.6 %; specificity, 67.5 %). In a multivariate logistic regression model, tumor size ≤3 cm (OR 4.149, 95 % CI 1.326–12.981, P = 0.015), preoperative CA 19-9 level ≤200 U/ml (OR 20.324, 95 % CI 6.509–63.467, P < 0.001), preoperative CA 125 levels ≤26 U/ml (OR 8.209, 95 % CI 2.624–25.677, P < 0.001) were independent determinants of resectability in patients diagnosed as hilar cholangiocarcinoma.

Conclusions

Preoperative CA 19-9 and CA 125 levels predict resectability in patients with radiological resectable hilar cholangiocarcinoma. Increased preoperative CA 19-9 levels and CA 125 levels are associated with poor resectability rate.

Intraoperative frozen section analysis of the proximal bile ducts in hilar cholangiocarcinoma is of limited value

Frozen section analysis (FS) during cancer surgery is widely used to assess resection margins. However, in hilar cholangiocarcinoma (HCCA), FS may be less reliable because of the specific growth characteristics of the tumor. The aim of this study was to determine the accuracy and consequences of intraoperative FS of the proximal bile duct margins in HCCA. Between 1990 and 2014, 67 patients underwent combined extrahepatic bile duct resection and partial liver resection for HCCA with the use of FS. Sensitivity and specificity of FS was 68% and 97%, respectively. Seventeen of 67 patients (25%) displayed a positive bile duct margin at FS. The false‐negative rate was 16% (eight patients). Ten patients (15%) with a positive bile duct margin underwent an additional resection in an attempt to achieve negative margins, which succeeded in three patients (4%). However, only one of these three patients did not have concomitant lymph node metastases, which are associated with a poor prognosis by itself. The use of FS of the proximal bile duct is of limited clinical value because of the relatively low sensitivity, high risk of false‐negative results, and the low rate of secondary obtained tumor‐free resection margins. Supported by the literature, a new approach to the use of FS in HCCA should be adopted, reserving the technique only for cases in which a substantial additional resection is possible.

Prognostic factors and long-term outcomes of hilar cholangiocarcinoma: A single-institution experience in China

AIM: To evaluate the prognostic factors of hilar cholangiocarcinoma in a large series of patients in a single institution.

METHODS: Eight hundred and fourteen patients with a diagnosis of hilar cholangiocarcinoma that were evaluated and treated between 1990 and 2014, of which 381 patients underwent curative surgery, were included in this study. Potential factors associated with overall survival (OS) and disease-free survival (DFS) were evaluated by univariate and multivariate analyses.

RESULTS: Curative surgery provided the best long-term survival with a median OS of 26.3 mo. The median DFS was 18.1 mo. Multivariate analysis showed that patients with tumor size > 3 cm [hazard ratio (HR) = 1.482, 95%CI: 1.127-1.949; P = 0.005], positive nodal disease (HR = 1.701, 95%CI: 1.346-2.149; P < 0.001), poor differentiation (HR = 2.535, 95%CI: 1.839-3.493; P < 0.001), vascular invasion (HR = 1.542, 95%CI: 1.082-2.197; P = 0.017), and positive margins (HR = 1.798, 95%CI: 1.314-2.461; P < 0.001) had poor OS outcome. The independent factors for DFS were positive nodal disease (HR = 3.383, 95%CI: 2.633-4.348; P < 0.001), poor differentiation (HR = 2.774, 95%CI: 2.012-3.823; P < 0.001), vascular invasion (HR = 2.136, 95%CI: 1.658-3.236; P < 0.001), and positive margins (HR = 1.835, 95%CI: 1.256-2.679; P < 0.001). Multiple logistic regression analysis showed that caudate lobectomy [odds ratio (OR) = 9.771, 95%CI: 4.672-20.433; P < 0.001], tumor diameter (OR = 3.772, 95%CI: 1.914-7.434; P < 0.001), surgical procedures (OR = 10.236, 95%CI: 4.738-22.116; P < 0.001), American Joint Committee On Cancer T stage (OR = 2.010, 95%CI: 1.043-3.870; P = 0.037), and vascular invasion (OR = 2.278, 95%CI: 0.997-5.207; P = 0.051) were independently associated with tumor-free margin, and surgical procedures could indirectly affect survival outcome by influencing the tumor resection margin.

CONCLUSION: Tumor margin, tumor differentiation, vascular invasion, and lymph node status were independent factors for OS and DFS. Surgical procedures can indirectly affect survival outcome by influencing the tumor resection margin.

Lymph Node Micrometastases are Associated with Worse Survival in Patients with Otherwise Node-Negative Hilar Cholangiocarcinoma

Background

Lymph node metastases on routine histology are a strong negative predictor for survival after resection of hilar cholangiocarcinoma. Additional immunohistochemistry can detect lymph node micrometastases in patients who are otherwise node negative, but the prognostic value is unsure. The objective of this study was to assess the effect on survival of immunohistochemically detected lymph node micrometastases in patients with node-negative (pN0) hilar cholangiocarcinoma on routine histology.

Methods

Between 1990 and 2010, a total of 146 patients underwent curative-intent resection of hilar cholangiocarcinoma with regional lymphadenectomy at two university medical centers in the Netherlands. Ninety-one patients (62 %) without lymph node metastases at routine histology were included. Micrometastases were identified by multiple sectioning of all lymph nodes and additional immunostaining with an antibody against cytokeratin 19 (K19). The association with overall survival was assessed in univariable and multivariable analysis. Median follow-up was 48 months.

Results

Micrometastases were identified in 16 (5 %) of 324 lymph nodes, corresponding to 11 (12 %) of 91 patients. There were no differences in clinical variables between K19 lymph node-positive and -negative patients. Five-year survival rates in patients with lymph node micrometastases were significantly lower compared to patients without micrometastases (27 vs. 54 %, P = 0.01). Multivariable analysis confirmed micrometastases as an independent prognostic factor for survival (adjusted Hazard ratio 2.4, P = 0.02).

Conclusions

Lymph node micrometastases are associated with worse survival after resection of hilar cholangiocarcinoma. Immunohistochemical detection of lymph node micrometastases leads to better staging of patients who were initially diagnosed with node-negative (pN0) hilar cholangiocarcinoma on routine histology.

Major hepatectomies for perihilar cholangiocarcinoma: Predictors for clinically relevant postoperative complications using the International Study Group of Liver Surgery definitions

BACKGROUND/AIM

Major hepatectomies are widely used in curative-intent surgery for perihilar cholangiocarcinoma, but morbidity rates are high. The aim of the study is to explore potential predictors for clinically relevant complications after major hepatectomies for perihilar cholangiocarcinoma.

METHODS

Seventy patients were included. Univariate and multivariate analyses were performed for risk factors of morbidities using the International Study Group of Liver Surgery definitions.

RESULTS

Severe morbidity rate was 36.5%. Clinically relevant posthepatectomy liver failure, bile leak, and hemorrhage rates were 24%, 22%, and 8.5%, respectively. A neutrophil-to-lymphocyte ratio > 3.3 is an independent prognostic factor for severe complications (hazard ratio = 1.258; 95% confidence interval 1.008-1.570; p = 0.042) while the number of blood units > 3 is an independent prognostic factor for clinically relevant liver failure (hazard ratio = 1.254; 95% confidence interval 1.082-1.452; p = 0.003). Biliary drainage and portal vein resection were not statistically correlated with any postoperative complication (p ≥ 0.101). Significantly higher bilirubinemia levels were observed in patients with postoperative hemorrhage (p = 0.023).

CONCLUSION

Clinically relevant morbidity rates after major hepatectomies for perihilar cholangiocarcinoma are high. Liver failure represents the main complication and is correlated with the number of transfused blood units. A patient with increased bilirubinemia appears to have a high risk for postoperative hemorrhage. Biliary drainage and portal vein resection does not appear to have a detrimental effect on morbidities. Neutrophil-to-lymphocyte ratio is a novel independent predictor for severe morbidity after major hepatectomies for perihilar cholangiocarcinoma and may contribute to better and informed decision-making.

Role of surgery in cholangiocarcinoma: From resection to transplantation

The treatment of cholangiocarcinoma (CCA) represents a major challenge to modern medicine. Diagnostics and treatment modalities are complex and require close interdisciplinary work-up. However, surgical resection currently offers the only potentially curative treatment option. Improved peri-operative strategies as well as optimized surgical techniques have generated significantly increased survival chances for patients in recent years. Complete tumor resection is the key parameter to long-term survival. In spite of expanded surgical limits R0 resection cannot be achieved in some cases as parenchymal disease may limit the extent of resection. Although liver transplantation (LT) is not a standard therapy for CCA today, it may be an option in such selected cases. Protocols including neo-adjuvant radio-chemotherapy and staging-lymphadenectomy before LT have generated impressive results in the recent past. Since palliative options generate only short-term survival extension LT for CCA has lately been discussed more extensively after the procedure had been abandoned due to dismal survival data in the 1990-years. This review offers a comprehensive picture of the current surgical treatment option for cholangiocarcinoma.

A modified Jarnagin-Blumgart classification better predicts survival for resectable hilar cholangiocarcinoma

Background

Prediction of postoperative survival for hilar cholangiocarcinoma (HCCA) remains difficult although there have been a variety of clinical classification and staging systems. This study was designed to validate and compare some of the major HCCA staging systems in use today. In addition, we sought to build up a new staging system modified from Jarnagin-Blumgart (J-B) classification for HCCA, to predict survival better.

Methods

A total of 154 consecutive cases of HCCA including 95 surgical patients between 2005 and 2014 were enrolled in this study. The clinical and pathological data were recorded retrospectively and three commonly used classification methods: Bismuth-Corlette (B-C) classification, TNM staging, and J-B classification were performed to analyze the correlations with resectability and survival. Chi-square test, Kaplan-Meier analysis, and kappa statistics were used to compare and confirm the relationships between the variables and survival.

Results

For all 154 patients, the resection rate of J-B T1 was 68.6% (48/70), higher than that of J-B T2 (44.8%, P = 0.007). J-B T2 also showed a higher resectability than J-B T3 (19.2%, P = 0.025). There was no significant difference in resectability within the groups B-C type and TNM stages. We set up a new staging system based on J-B classification, tumor differentiation, distant metastasis (N2 or M1 of TNM stage), and resection integrality. The total survival predictive accuracy was 69.5% (kappa = 0.547), higher than that of TNM staging and J-B classification.

Conclusions

J-B classification was more useful than B-C classification, while its value for predicting survival did not exceed TNM staging system. The new staging system, based on J-B classification, provides a better method to stratify HCCA patients during the operation.

Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure

BACKGROUND

Hilar cholangiocarcinoma is the most common malignant tumor affecting the extrahepatic bile duct. Surgical treatment offers the only possibility of cure, and it requires removal of all tumoral tissues with adequate resection margins. The aims of this review are to summarize the findings and to discuss the controversies on the extent of surgical resection aiming at cure for hilar cholangiocarcinoma.

METHODS

The English medical literatures on hilar cholangiocarcinoma were studied to review on the relevance of adequate resection margins, routine caudate lobe resection, extent of liver resection, and combined vascular resection on perioperative and long-term survival outcomes of patients with resectable hilar cholangiocarcinoma.

RESULTS

Complete resection of tumor represents the most important prognostic factor of long-term survival for hilar cholangiocarcinoma. The primary aim of surgery is to achieve R0 resection. When R1 resection is shown intraoperatively, further resection is recommended. Combined hepatic resection is now generally accepted as a standard procedure even for Bismuth type I/II tumors. Routine caudate lobe resection is also advocated for cure. The extent of hepatic resection remains controversial. Most surgeons recommend major hepatic resection. However, minor hepatic resection has also been advocated in most patients. The decision to carry out right- or left-sided hepatectomy is made according to the predominant site of the lesion. Portal vein resection should be considered when its involvement by tumor is suspected.

CONCLUSION

The curative treatment of hilar cholangiocarcinoma remains challenging. Advances in hepatobiliary techniques have improved the perioperative and long-term survival outcomes of this tumor.

Imaging-based evaluation of liver function: comparison of ⁹⁹mTc-mebrofenin hepatobiliary scintigraphy and Gd-EOB-DTPA-enhanced MRI

OBJECTIVES

To compare Gd-EOB-enhanced MRI and (99m)Tc-mebrofenin hepatobiliary scintigraphy (HBS) as imaging-based liver function tests for separate evaluation of right (RLL) and left liver lobe (LLL) function.

METHODS

Fourteen patients underwent Gd-EOB-enhanced MRI and (99m)Tc-mebrofenin HBS after portal vein embolization within 24 h. Relative enhancement (RE) and hepatic uptake index (HUI) were determined from MRI; and T max, T 1/2 and mebrofenin uptake were determined from HBS, all values separately for RLL and LLL.

RESULTS

Mebrofenin uptake correlated significantly with HUI and RE for both liver lobes. There was strong correlation of mebrofenin uptake with HUI for RLL (r (2) = 0.802, p = 0.001) and RE for LLL (r (2) = 0.704, p = 0.005) and moderate correlation with HUI for LLL (r (2) = 0.560, p = 0.037) and RE for RLL (r (2) = 0.620, p = 0.018). Correlating the percentage share of RLL function derived from MRI (with HUI) with the percentage of RLL function derived from mebrofenin uptake revealed a strong correlation (r (2) = 0.775, p = 0.002).

CONCLUSIONS

Both RE and HUI correlate with mebrofenin uptake in HBS. The results suggest that Gd-EOB-enhanced MRI and (99m)Tc-mebrofenin HBS may equally be used to separately determine right and left liver lobe function.

KEY POINTS

• Information about liver function can be acquired with routine Gd-EOB-MRI. • Gd-EOB-MRI and (99m) Tc-mebrofenin HBS show elevated function of non-embolized lobe. • Gd-EOB-MRI and (99m) Tc-mebrofenin HBS can determine lobar liver function.

Defining perioperative risk after hepatectomy based on diagnosis and extent of resection

Outcomes after hepatectomy have been assessed incompletely and have not been stratified by both extent of resection and diagnosis. We hypothesized that operative risk is better assessed by stratifying diagnoses into low- and high-risk categories and extent of resection into major and minor resection categories to more accurately evaluate the outcomes after hepatectomy. ACS-NSQIP was reviewed for 30-day operative mortality and major morbidity after partial hepatectomy (PH), left hepatectomy (LH), right hepatectomy (RH), and trisectionectomy (TS). Mortality was reviewed per diagnosis. "High Risk" was defined as the diagnoses associated with the greatest mortality. Major and minor resections were defined by comparison of outcomes for extent of resection by univariate analysis. Chi-square tests, t tests, Fisher's exact tests, and multivariable logistic regression were utilized to compare the outcomes across groups. Among the 7,043 patients, the greatest mortality was observed with hepatocellular carcinoma (5.2%) and cholangiocarcinoma (8.2%), either intra- or extrahepatic, which were classified "High Risk". Metastatic disease, benign neoplasms, and gallbladder cancer had a mortality rate of 1.3, 0.5, and 1.0%, respectively, and were classified "Low Risk". PH and LH were similar statistically for operative mortality and major morbidity within respective diagnosis risk groups (Low Risk: PH vs. LH and High Risk: PH vs. LH; all p > 0.05) and were defined as "Minor Resections". Similarly, RH and TS had similar operative mortality and major morbidity within respective diagnosis risk groups (Low Risk: RH vs. TS and High Risk: RH vs. TS; all p > 0.05) and were defined as "Major Resections". Risks of major morbidity and mortality increased for both diagnoses and the extent of resection. With minor resections, mortality and major morbidity were 5 and 1.6 times greater respectively for high-risk diagnosis than for low-risk diagnosis. With major resections, mortality and major morbidity were 4 and 1.6 times greater, respectively, for high-risk diagnoses than low-risk diagnoses. With low-risk diagnoses, mortality and major morbidity were 2.9 and 1.7 times greater, respectively, for major resections than minor resections (p < 0.001). With high-risk diagnoses, mortality and major morbidity were 2.3 and 1.7 times greater, respectively, for major resections than minor resections (all p < 0.001). Regardless of the extent of resection, high-risk diagnoses were independently associated with mortality (OR = 3.2 and 3.1, respectively) and major morbidity (OR = 1.5 and 1.5, respectively). Risk of hepatectomy is better assessed when stratified by both the diagnostic risk and the extent of resection. Accurate assessment of these outcomes has significant implications for preoperative planning, informed consent, resource utilization, and inter-institutional comparisons.

Perihilar cholangiocarcinoma: Current therapy

Perihilar cholangiocarcinoma, which is a rare primary malignancy, originates from the epithelial cells of the bile duct. Usually invading the periductal tissues and the lymph nodes, perihilar cholangiocarcinoma is commonly diagnosed in the advanced stage of the disease and has a dismal prognosis. Currently, complete hepatectomy is the primary therapy for curing this disease. Perioperative assessment and available surgical procedures can be considered for achieving a negative margin resection, which is associated with long-term survival and better quality of life. For patients with unresectable cholangiocarcinoma, several palliative treatments have been demonstrated to produce a better outcome; and liver transplantation for selected patients with perihilar cholangiocarcinoma is promising and desirable. However, the role of palliative treatments and liver transplantation was controversial and requires more evidence and substantial validity from multiple institutions. In this article, we summarize the data from multiple institutions and discuss the resectability, mortality, morbidity and outcome with different approaches.