Multidetector computed tomography assessment of vascular involvement in perihilar cholangiocarcinoma

The preoperative recurrence score: Predicting early recurrence in peri-hilar cholangiocarcinoma

INTRODUCTION

Despite advances in surgical techniques, the rate of early recurrence in perihilar cholangiocarcinoma (PCC) remains high. We sought to develop the Preoperative Recurrence Score (PRS), a model to estimate the risk of early recurrence after resection based on preoperative radiological characteristics.

MATERIALS AND METHODS

Data of patients who underwent surgery for PCC were retrospectively collected, and preoperative imaging was reviewed to assess tumor characteristics. A model to assess the risk of early recurrence based on preoperative radiologic characteristics was internally developed and externally validated on two cohorts of patients from two European major hepatobiliary surgery referral centers.

RESULTS

A total of 215 patients among three different patient cohorts were included in the study. Tumor size ≥18 mm (HR 2.70, 95 % CI 1.48-4.92, p = 0.001), macroscopic portal vein involvement (HR 2.28, 95%CI 1.19-4.34, p = 0.013), hepatic arteries involvement (HR 2.44, 95%CI 1.26-4.71, p = 0.008), and presence of suspicious lymph nodes (HR 1.98, 95%CI 1.02-3.83, p = 0.043) were significantly associated with recurrence-free survival (RFS). The model showed excellent discrimination both on the internal (AUC 0.83) and external validation cohorts (external 1: AUC 0.84; external 2: AUC 0.70). High PRS was associated with worse RFS among all three cohorts, with a 1-year recurrence probability of 80.1 %, 100.0 %, and 54.2 % in the internal and external validation cohorts 1 and 2, respectively.

CONCLUSIONS

The PRS is a simple tool that can accurately assess the risk of early recurrence in patients with PCC. Up-front surgery should be carefully evaluated in patients with high PRS, as it could result in a futile resection.

Comparing Survival of Perihilar Cholangiocarcinoma After R1 Resection Versus Palliative Chemotherapy for Unresected Localized Disease

BACKGROUND

Resection of perihilar cholangiocarcinoma (pCCA) is a complex procedure with a high risk of postoperative mortality and early disease recurrence. The objective of this study was to compare patient characteristics and overall survival (OS) between pCCA patients who underwent an R1 resection and patients with localized pCCA who received palliative systemic chemotherapy.

METHODS

Patients with a diagnosis of pCCA between 1997-2021 were identified from the European Network for the Study of Cholangiocarcinoma (ENS-CCA) registry. pCCA patients who underwent an R1 resection were compared with patients with localized pCCA (i.e., nonmetastatic) who were ineligible for surgical resection and received palliative systemic chemotherapy. The primary outcome was OS.

RESULTS

Overall, 146 patients in the R1 resection group and 92 patients in the palliative chemotherapy group were included. The palliative chemotherapy group more often underwent biliary drainage (95% vs. 66%, p < 0.001) and had more vascular encasement on imaging (70% vs. 49%, p = 0.012) and CA 19.9 was more frequently >200 IU/L (64 vs. 45%, p = 0.046). Median OS was comparable between both groups (17.1 vs. 16 months, p = 0.06). Overall survival at 5 years after diagnosis was 20.0% with R1 resection and 2.2% with chemotherapy. Type of treatment (i.e., R1 resection or palliative chemotherapy) was not an independent predictor of OS (hazard ratio 0.76, 95% confidence interval 0.55-1.07).

CONCLUSIONS

Palliative systemic chemotherapy should be considered instead of resection in patients with a high risk of both R1 resection and postoperative mortality.

Clinical features and prediction of long-term survival after surgery for perihilar cholangiocarcinoma

INTRODUCTION

The treatment of perihilar Cholangiocarcinoma (pCCA) poses specific challenges not only due to its high perioperative complication rates but also due its dismal long-term prognosis with only a few long-term survivors (LTS) among the patients. Therefore, in this analysis characteristics and predictors of LTS in pCCA patients are investigated.

MATERIAL AND METHODS

In this single center analysis, patients undergoing curative-intent liver resection for pCCA between 2010 and 2022 were categorized into long-term and short-term survivors (STS) excluding perioperative mortality. Binary logistic regression was used to determine key differences between the groups and to develop a prognostic composite variable. This composite variable was subsequently tested in the whole cohort of surgically treated pCCA patients using Cox Regression analysis for cancer-specific survival (CSS).

RESULTS

Within a cohort of 209 individuals, 27 patients were identified as LTS (median CSS = 125 months) and 55 patients as STS (median CSS = 16 months). Multivariable analysis identified preoperative portal vein infiltration (OR = 5.85, p = 0.018) and intraoperative packed red blood cell (PRBC) transfusions (OR = 10.29, p = 0.002) as key differences between the groups. A prognostic composite variable based on these two features was created and transferred into a Cox regression model of the whole cohort. Here, the composite variable (HR = 0.35, p<0.001), lymph node metastases (HR = 2.15, p = 0.001) and postoperative complications (HR = 3.06, p<0.001) were identified as independent predictors of CSS.

CONCLUSION

Long-term survival after surgery for pCCA is possible and is strongly negatively associated with preoperative portal vein infiltration and intraoperative PRBC transfusion. As these variables are part of preoperative staging or can be modulated by intraoperative technique, the proposed prognostic composite variable can easily be transferred into clinical management to predict the oncological outcome of patients undergoing surgery for pCCA.

British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma

These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.

National consensus on a new resectability classification for perihilar cholangiocarcinoma - A modified Delphi method

BACKGROUND

Currently, no practical definition of potentially resectable, borderline or unresectable perihilar cholangiocarcinoma (pCCA) is available. Aim of this study was to define criteria to categorize patients for use in a future neoadjuvant or induction therapy study.

METHOD

Using the modified DELPHI method, hepatobiliary surgeons from all tertiary referral centers in the Netherlands were invited to participate in this study. During five online meetings, predefined factors determining resectability and additional factors regarding surgical resectability and operability were discussed.

RESULTS

The five online meetings resulted in 52 statements. After two surveys, consensus was reached in 63% of the questions. The main consensus included a definition regarding potential resectability. 1) Clearly resectable: no vascular involvement (≤90°) of the future liver remnant (FLR) and expected feasibility of radical biliary resection. 2) Clearly unresectable: non-reconstructable venous and/or arterial involvement of the FLR or no feasible radical biliary resection. 3) Borderline resectable: all patients between clearly resectable and clearly unresectable disease.

CONCLUSION

This DELPHI study resulted in a practical and applicable resectability, or more accurate, an explorability classification, which can be used to categorize patients for use in future neoadjuvant therapy studies.

Comparison Between Contrast-Enhanced Computed Tomography and Contrast-Enhanced Magnetic Resonance Imaging With Magnetic Resonance Cholangiopancreatography for Resectability Assessment in Extrahepatic Cholangiocarcinoma

OBJECTIVE

To compare the diagnostic performance and interobserver agreement between contrast-enhanced computed tomography (CECT) and contrast-enhanced magnetic resonance imaging (CE-MRI) with magnetic resonance cholangiopancreatography (MRCP) for evaluating the resectability in patients with extrahepatic cholangiocarcinoma (eCCA).

MATERIALS AND METHODS

This retrospective study included treatment-naïve patients with pathologically confirmed eCCA, who underwent both CECT and CE-MRI with MRCP using extracellular contrast media between January 2015 and December 2020. Among the 214 patients (146 males; mean age ± standard deviation, 68 ± 9 years) included, 121 (56.5%) had perihilar cholangiocarcinoma. R0 resection was achieved in 108 of the 153 (70.6%) patients who underwent curative-intent surgery. Four fellowship-trained radiologists independently reviewed the findings of both CECT and CE-MRI with MRCP to assess the local tumor extent and distant metastasis for determining resectability. The pooled area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of CECT and CE-MRI with MRCP were compared using clinical, surgical, and pathological findings as reference standards. The interobserver agreement of resectability was evaluated using Fleiss kappa (κ).

RESULTS

No significant differences were observed between CECT and CE-MRI with MRCP in the pooled AUC (0.753 vs. 0.767), sensitivity (84.7% [366/432] vs. 90.3% [390/432]), and specificity (52.6% [223/424] vs. 51.4% [218/424]) (P > 0.05 for all). The AUC for determining resectability was higher when CECT and CE-MRI with MRCP were reviewed together than when CECT was reviewed alone in patients with discrepancies between the imaging modalities or with indeterminate resectability (0.798 [0.754-0.841] vs. 0.753 [0.697-0.808], P = 0.014). The interobserver agreement for overall resectability was fair for both CECT (κ = 0.323) and CE-MRI with MRCP (κ = 0.320), without a significant difference (P = 0.884).

CONCLUSION

CECT and CE-MRI with MRCP showed no significant differences in the diagnostic performance and interobserver agreement in determining the resectability in patients with eCCA.

Multidetector computed tomography assessment of venous invasion in hepatic alveolar echinococcosis

PURPOSE

The objective of this study was to correlate multidetector computed tomography (MDCT) findings in hepatic alveolar echinococcosis (HAE) with intraoperative and postoperative histopathological results to identify reliable MDCT criteria for the diagnosis of HAE venous invasion.

METHODS

A total of 136 HAE patients who underwent CT examination were included in this study. The lesion-vessel contact angle, irregular wall, lumen stenosis and occlusion were evaluated.

RESULTS

A total of 614 veins were estimated. In total, 510 veins were invaded, and 104 veins were not. The invasion rate was 83.06%. In single CT findings, with a cutoff value of > 180° determined by receiver operating characteristic (ROC) curve analysis, the lesion-vessel contact angle performed the best (area under the ROC curve, AUC = 0.907, 95% confidence interval, 95% CI 0.872-0.941, p < 0.001), with a sensitivity, specificity and positive likelihood ratio (PLR) of 84.90%, 88.46%, and 7.35, respectively. Irregular wall and lumen stenosis showed the lowest diagnostic performance. Diagnostic performance was the highest when combining these criteria and signs (AUC = 0.932, 95% CI 0.905-0.960, p < 0.001).

CONCLUSION

The lesion-vessel contact angle > 180° had the best sensitivity and specificity in the diagnosis of HAE venous invasion, and good interobserver agreement had been noted. The diagnostic performance of the lesion-vessel contact angle > 180° had been further improved with the addition of lumen occlusion accompanied by irregular wall or lumen stenosis.

Prediction model based on preoperative CT findings for carotid artery invasion in patients with head and neck masses

Objectives

To investigate the performance of a model in predicting carotid artery (CA) invasion in patients with head and neck masses using computed tomography (CT).

Methods

This retrospective study included patients with head and neck masses who underwent CT and surgery between January 2013 and July 2021. Patient characteristics and ten CT features were assessed by two radiologists. The patients were randomly allocated to a training cohort (n=106) and a validation cohort (n=109). Independent risk factors for CA invasion were assessed by univariate and multivariate logistic regression analyses. The predictive model was established as a nomogram using the training cohort. In addition, the calibration, discrimination, reclassification, and clinical application of the model were assessed in the validation cohort.

Results

A total of 215 patients were evaluated, including 54 patients with CA invasion. Vascular wall deformation (odds ratio [OR], 7.17; p=0.02) and the extent of encasement to the CA (OR, 1.02; p&lt;0.001) were independent predictors of CA invasion in the multivariable analysis in the training cohort. The performance of the model was similar between the training and validation cohort, with an area under the receiver operating characteristic curve of 0.93 (95% confidence intervals [CI], 0.88-0.98) and 0.88 (95% CI, 0.80-0.96) (p=0.07), respectively. The calibration curve showed a good agreement between the predicted and actual probabilities.

Conclusion

A predictive model for carotid artery invasion can be defined based on features that come from patient characteristics and CT data to help in improve surgical planning and invasion evaluation.

Conventional, functional and radiomics assessment for intrahepatic cholangiocarcinoma

Background

This paper offers an assessment of diagnostic tools in the evaluation of Intrahepatic Cholangiocarcinoma (ICC).

Methods

Several electronic datasets were analysed to search papers on morphological and functional evaluation in ICC patients. Papers published in English language has been scheduled from January 2010 to December 2021.

Results

We found that 88 clinical studies satisfied our research criteria. Several functional parameters and morphological elements allow a truthful ICC diagnosis. The contrast medium evaluation, during the different phases of contrast studies, support the recognition of several distinctive features of ICC. The imaging tool to employed and the type of contrast medium in magnetic resonance imaging, extracellular or hepatobiliary, should change considering patient, departement, and regional features. Also, Radiomics is an emerging area in the evaluation of ICCs.

Post treatment studies are required to evaluate the efficacy and the safety of therapies so as the patient surveillance.

Conclusions

Several morphological and functional data obtained during Imaging studies allow a truthful ICC diagnosis.