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Ma Z, Li Z, Cao J, Sun J, Huang S, Zhou Q, Li B. What eliminates the chance for cure: a multi-center evaluation on 10-year follow-up of gallbladder cancer after surgical resection. Ann Med 2024; 56:2402072. [PMID: 39262385 PMCID: PMC11395872 DOI: 10.1080/07853890.2024.2402072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/13/2024] Open
Abstract
Curative resection stands as the sole potential cure for gallbladder cancer (GBC); nevertheless, a dearth of knowledge persists regarding long-term follow-up data and prognostic factors that hinder achieving a cure post-surgery. A retrospective cohort study was conducted by analyzing pathologically confirmed initial resections for GBC between 2000 and 2013 across three Chinese medical centers. The concept of observed cure refers to a 10-year survival period devoid of any disease recurrence. Employing a semiparametric proportional hazards mixture cure model enabled the identification of clinicopathological factors impeding a cure for GBC post-surgery. In our current study, a total of 331 patients were included, with a follow-up period exceeding a decade. The median overall survival (OS) was recorded at 31.6 months, with 39 patients (11.78%) achieving a 10-year OS, classified as 10-year survivors. Within this subset, 36 patients reached a 10-year relapse-free survival, denoting cure, and yielding an observed cure rate of 10.88%. Notably, factors such as combined surgical resection involving invaded organs, positive lymph node metastasis, and R1 resection (below 1%) were identified as virtually precluding a cure. Additionally, patients with T3-4 stage, hepatic invasion, advanced AJCC stage or poor tumor differentiation exhibited a low likelihood of achieving cure (below 5%). The discovery of these prognostic factors holds significant value in tailoring individualized treatment strategies and enhancing clinical decision-making processes.
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Affiliation(s)
- Zuyi Ma
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhenchong Li
- Junior Clinical Cooperation Unit Translational Gastrointestinal Oncology and Preclinical Models, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jiasheng Cao
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jia Sun
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shanzhou Huang
- Department of General Surgery, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Southern Medical University, Guangzhou, China
| | - Qi Zhou
- Department of General Surgery, Hui Ya Hospital of The First Affiliated Hospital, Sun Yat-sen University, Huizhou, China
- Department of hepatic Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Binglu Li
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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van Keulen AM, Buettner S, Olthof PB, Klümpen HJ, Erdmann JI, Izquierdo-Sanchez L, Banales JM, Goeppert B, Roessler S, Zieniewicz K, Lamarca A, Valle JW, La Casta A, Hoogwater FJH, Donadon M, Scheiter A, Marzioni M, Adeva J, Kiudeliene E, Fernández JMU, Vidili G, Mocan T, Fabris L, Krawczyk M, Folseraas T, Dopazo C, Detry O, Voiosu T, Scripcariu V, Biancaniello F, Braconi C, Macias RIR, Groot Koerkamp B. Comparing Survival of Perihilar Cholangiocarcinoma After R1 Resection Versus Palliative Chemotherapy for Unresected Localized Disease. Ann Surg Oncol 2024; 31:6495-6503. [PMID: 38896226 PMCID: PMC11413094 DOI: 10.1245/s10434-024-15582-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024]
Abstract
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.
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Affiliation(s)
| | - Stefan Buettner
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Heinz-Josef Klümpen
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris I Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laura Izquierdo-Sanchez
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute, Donostia University Hospital, University of the Basque Country (UPV/EHU), San Sebastian, Spain
- National Institute for the Study of Liver and Gastrointestinal Diseases, Instituto de Salud Carlos III" (ISCIII), CIBERehd, Madrid, Spain
| | - Jesus M Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute, Donostia University Hospital, University of the Basque Country (UPV/EHU), San Sebastian, Spain
- National Institute for the Study of Liver and Gastrointestinal Diseases, Instituto de Salud Carlos III" (ISCIII), CIBERehd, Madrid, Spain
- Department of Biochemistry and Genetics, School of Sciences, University of Navarra, Pamplona, Spain
- Basque Foundation for Science, Bilbao, Spain
| | - Benjamin Goeppert
- Institute of Pathology and Neuropathology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
- Institute of Pathology, Kantonsspital Baselland, Liestal, Switzerland
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stephanie Roessler
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Angela Lamarca
- Department of Oncology - OncoHealth Institute, Fundación Jiménez Díaz University Hospital, Madrid, Spain
- Department of Medical Oncology, The Christie NHS Foundation, Manchester, England
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation, Manchester, England
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Adelaida La Casta
- Medical Oncology Department, OSI Donostialdea/Biodonostia, San Sebastián, Spain
| | - Frederik J H Hoogwater
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Matteo Donadon
- Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Marco Marzioni
- Clinic of Gastroenterology and Hepatology, Universita Politecnica delle Marche, Ancona, Italy
| | - Jorge Adeva
- Department of Medical Oncology, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Edita Kiudeliene
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Gianpaolo Vidili
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
- Department of Internal Medicine, Day Hospital of the Medical Area, Azienda Ospedaliero Universitaria, AOU, Sassari, Italy
| | - Tudor Mocan
- Babeș-Bolyai University - UBB Med Department, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Luca Fabris
- Department of Molecular Medicine, University of Padua School of Medicine, Padua, Italy
- Digestive Disease Section, Yale University School of Medicine, New Haven, CT, USA
| | - Marcin Krawczyk
- Laboratory of Metabolic Liver Diseases, Medical University of Warsaw, Warsaw, Poland
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Trine Folseraas
- Section of Gastroenterology and the Norwegian PSC Research Center, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Cristina Dopazo
- Department of HPB Surgery and Transplants, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
| | - Theodor Voiosu
- Gastroenterology Department, Faculty of Medicine, Colentina Clinical Hospital, UMF Carol Davila, Bucharest, Romania
| | - Viorel Scripcariu
- University of Medicine and Pharmacy "Gr T Popa", Regional Institute of Oncology, Iasi, Romania
| | - Francesca Biancaniello
- Department of Translational and Precision Medicine, Sapienza" University of Rome, Rome, Italy
| | - Chiara Braconi
- Royal Marsden NHS Trust, London, Surrey, UK
- Beatson West of Scotland Cancer Centre, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Rocio I R Macias
- Experimental Hepatology and Drug Targeting (HEVEPHARM) Group, University of Salamanca, IBSAL, CIBERehd, Salamanca, Spain
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Koca F, Petrova E, El Youzouri H, Heil J, Heise M, Sliwinski S, Bechstein WO, Schnitzbauer AA. Prognostic value of resection margin and lymph node status in perihilar cholangiocarcinoma. HPB (Oxford) 2024:S1365-182X(24)02329-3. [PMID: 39455409 DOI: 10.1016/j.hpb.2024.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 09/23/2024] [Accepted: 09/26/2024] [Indexed: 10/28/2024]
Abstract
BACKGROUND The impact of resection margin and lymph node status on survival in patients undergoing resection for perihilar cholangiocarcinoma (pCCA) is controversial. The aim of this study was to investigate the influence of nodal and resection margin status on long-term survival after resection for pCCA. METHODS Retrospective analysis of patients resected for pCCA at the University Hospital Frankfurt, Germany between 1999 and 2022. The patients were categorized in four groups according to resection margin (R) and nodal status (N). Survival was analyzed with univariable and multivariable Cox regression. RESULTS Out of 123 patients, 100 with long-term survival were included in the survival analysis. In the univariable analysis, negative resection margin (p = 0.02) and lower grade (p = 0.004) were the only significant positive prognostic factors, while the difference between N0 and N+ was not statistically significant (p = 0.062). Median survival in the groups R0N0, R0N+, R + N0 and R+N+ groups was 40.1, 29.9, 18.4 and 18.9 months, respectively (p = 0.03). In the multivariable analysis, after adjusting for grade, nodal and resection margin status, only grade and resection margin had prognostic significance. CONCLUSION Patients with negative resection margin after resection for pCCA have a better prognosis, regardless of the presence of lymph node metastases.
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Affiliation(s)
- Faruk Koca
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany
| | - Ekaterina Petrova
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany
| | - Hanan El Youzouri
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany
| | - Jan Heil
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany
| | - Michael Heise
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany
| | - Svenja Sliwinski
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany
| | - Wolf O Bechstein
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany
| | - Andreas A Schnitzbauer
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Frankfurt, Germany.
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Mantas A, Otto CC, Olthof PB, Heise D, Hoyer DP, Bruners P, Dewulf M, Lang SA, Ulmer TF, Neumann UP, Bednarsch J. Clinical features and prediction of long-term survival after surgery for perihilar cholangiocarcinoma. PLoS One 2024; 19:e0304838. [PMID: 38950006 PMCID: PMC11216605 DOI: 10.1371/journal.pone.0304838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/20/2024] [Indexed: 07/03/2024] Open
Abstract
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.
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Affiliation(s)
- Anna Mantas
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Carlos Constantin Otto
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Pim B. Olthof
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Dieter Paul Hoyer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Maxim Dewulf
- Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
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5
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Xu Z, Fan X, Zhang C, Li Y, Jiang D, Hu F, Pan B, Huang Y, Zhang L, Lau WY, Liu X, Chen Z. Residual biliary intraepithelial neoplasia without malignant transformation at resection margin for perihilar cholangiocarcinoma does not require expanded resection: a dual center retrospective study. World J Surg Oncol 2024; 22:161. [PMID: 38907218 PMCID: PMC11191332 DOI: 10.1186/s12957-024-03395-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/28/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Additional resection for invasive cancer at perihilar cholangiocarcinoma (pCCA) resection margins has become a consensus. However, controversy still exists regarding whether additional resection is necessary for residual biliary intraepithelial neoplasia (BilIN). METHOD Consecutive patients with pCCA from two hospitals were enrolled. The incidence and pattern of resection margin BilIN were summarized. Prognosis between patients with negative margins (R0) and BilIN margins were analyzed. Cox regression with a forest plot was used to identify independent risk factors associated with overall survival (OS) and recurrence-free survival (RFS). Subgroup analysis was performed based on BilIN features and tumor characteristics. RESULTS 306 pCCA patients receiving curative resection were included. 255 had R0 margins and 51 had BilIN margins. There was no significant difference in OS (P = 0.264) or RFS (P = 0.149) between the two group. Specifically, 19 patients with BilIN at distal bile ducts and 32 at proximal bile ducts. 42 patients showed low-grade BilIN, and 9 showed high-grade. Further analysis revealed no significant difference in long-term survival between different locations (P = 0.354), or between different grades (P = 0.772). Portal vein invasion, poor differentiation and lymph node metastasis were considered independent risk factors for OS and RFS, while BilIN was not. Subgroup analysis showed no significant difference in long-term survival between the lymph node metastasis subgroup, or between the portal vein invasion subgroup. CONCLUSION For pCCA patients underwent curative resection, residual BilIN at resection margin is acceptable. Additional resection is not necessary for such patients to achieve absolute R0 margin.
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Affiliation(s)
- Zeliang Xu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiaoyi Fan
- Department of Oncology and Southwest Cancer Center, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengcheng Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yuancheng Li
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Di Jiang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Feng Hu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Bi Pan
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yixian Huang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Leida Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Wan Yee Lau
- Faculty of Medicine, the Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Xingchao Liu
- Department of Hepatobiliary Surgery, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Qingyang District, Chengdu, 610072, China.
| | - Zhiyu Chen
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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6
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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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7
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Pawaskar R, Huang KZ, Pham H, Nagrial A, Wong M, O’Neill S, Pleass H, Yuen L, Lam VWT, Richardson A, Pang T, Nahm CB. Systematic Review of Preoperative Prognostic Biomarkers in Perihilar Cholangiocarcinoma. Cancers (Basel) 2024; 16:698. [PMID: 38398089 PMCID: PMC10886549 DOI: 10.3390/cancers16040698] [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: 01/18/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Perihilar cholangiocarcinoma (pCCA) is an uncommon malignancy with generally poor prognosis. Surgery is the primary curative treatment; however, the perioperative mortality and morbidity rates are high, with a low 5-year survival rate. Use of preoperative prognostic biomarkers to predict survival outcomes after surgery for pCCA are not well-established currently. This systematic review aimed to identify and summarise preoperative biomarkers associated with survival in pCCA, thereby potentially improving treatment decision-making. The Embase, Medline, and Cochrane databases were searched, and a systematic review was performed using the PRISMA guidelines. English-language studies examining the association between serum and/or tissue-derived biomarkers in pCCA and overall and/or disease-free survival were included. Our systematic review identified 64 biomarkers across 48 relevant studies. Raised serum CA19-9, bilirubin, CEA, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and tumour MMP9, and low serum albumin were most associated with poorer survival; however, the cutoff values used widely varied. Several promising molecular markers with prognostic significance were also identified, including tumour HMGA2, MUC5AC/6, IDH1, PIWIL2, and DNA index. In conclusion, several biomarkers have been identified in serum and tumour specimens that prognosticate overall and disease-free survival after pCCA resection. These, however, require external validation in large cohort studies and/or in preoperatively obtained specimens, especially tissue biopsy, to recommend their use.
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Affiliation(s)
- Rishaan Pawaskar
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
| | | | - Helen Pham
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
- Westmead Hospital, Sydney, NSW 2145, Australia;
- Surgical Innovations Unit, Westmead Hospital, Sydney, NSW 2145, Australia
| | - Adnan Nagrial
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia; (A.N.); (M.W.)
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW 2145, Australia;
| | - Mark Wong
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia; (A.N.); (M.W.)
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW 2145, Australia;
| | - Siobhan O’Neill
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW 2145, Australia;
| | - Henry Pleass
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
- Westmead Hospital, Sydney, NSW 2145, Australia;
- Surgical Innovations Unit, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia; (A.N.); (M.W.)
| | - Lawrence Yuen
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
- Westmead Hospital, Sydney, NSW 2145, Australia;
- Surgical Innovations Unit, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia; (A.N.); (M.W.)
| | - Vincent W. T. Lam
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
- Westmead Hospital, Sydney, NSW 2145, Australia;
- Surgical Innovations Unit, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia; (A.N.); (M.W.)
- Macquarie University Medical School, Macquarie University, Sydney, NSW 2145, Australia
| | - Arthur Richardson
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
- Westmead Hospital, Sydney, NSW 2145, Australia;
- Surgical Innovations Unit, Westmead Hospital, Sydney, NSW 2145, Australia
| | - Tony Pang
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
- Westmead Hospital, Sydney, NSW 2145, Australia;
- Surgical Innovations Unit, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia; (A.N.); (M.W.)
| | - Christopher B. Nahm
- Department of Upper GI Surgery, Westmead Hospital, Sydney, NSW 2145, Australia; (R.P.); (H.P.); (H.P.); (L.Y.); (V.W.T.L.); (A.R.); (T.P.)
- Westmead Hospital, Sydney, NSW 2145, Australia;
- Surgical Innovations Unit, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia; (A.N.); (M.W.)
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8
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Wang D, Xiong F, Wu G, Wang Q, Chen J, Liu W, Wang B, Chen Y. The value of total caudate lobe resection for hilar cholangiocarcinoma: a systematic review. Int J Surg 2024; 110:385-394. [PMID: 37738006 PMCID: PMC10793735 DOI: 10.1097/js9.0000000000000795] [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: 05/26/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Yongjun Chen
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
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9
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Sucandy I, Marques HP, Lippert T, Magistri P, Coelho JS, Ross SB, Chumbinho B, Di Sandro S, DiBenedetto F. Clinical Outcomes of Robotic Resection for Perihilar Cholangiocarcinoma: A First, Multicenter, Trans-Atlantic, Expert-Center, Collaborative Study. Ann Surg Oncol 2024; 31:81-89. [PMID: 37718337 DOI: 10.1245/s10434-023-14307-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Perihilar cholangiocarcinoma is a difficult cancer to treat with frequent vascular invasion, local recurrence, and poor survival. Due to the need for biliary anastomosis and potential vascular resection, the standard approach is an open operation. Suboptimal outcomes after laparoscopic resection had been sporadically reported by high-volume centers. In this first, Trans-Atlantic, multicenter study, we report our outcomes of robotic resection for perihilar cholangiocarcinoma. This is the largest study of its kind in the Western hemisphere. METHODS Between 2016 and 2023, we prospectively followed patients undergoing robotic resection for perihilar cholangiocarcinoma at three, high-volume, robotic, liver-surgery centers. RESULTS Thirty-eight patients underwent perihilar cholangiocarcinoma utilizing the robotic technique; Klatskin type-3 was the most common. The median age was 72 years, and 82% of the patients underwent preoperative biliary drainage. Median operative time was 481 minutes with a median estimated blood loss of 200 mL. The number of harvested lymph nodes was seven, and 11 (28%) patients yielded positive lymph nodes. Three patients required vascular reconstruction; 18% of patients had >1 biliary anastomosis. R0 resection margins were achieved in 82% of patients. Clavien-Dindo Grade ≥3 complications were seen in 16% of patients. The length of stay was 6 days. Five patients had an unplanned readmission within 30 days. One patient died within 30 days. With a median follow-up of 15 months, 68% of patients are alive without disease, 13% recurred, and 19% died. CONCLUSIONS Application of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with acceptable short-term clinical and oncological outcomes.
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Affiliation(s)
| | - Hugo P Marques
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Trenton Lippert
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Joao Santos Coelho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | | | - Beatriz Chumbinho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio DiBenedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
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10
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Ratti F, Marino R, Muiesan P, Zieniewicz K, Van Gulik T, Guglielmi A, Marques HP, Andres V, Schnitzbauer A, Irinel P, Schmelzle M, Sparrelid E, Fusai GK, Adam R, Cillo U, Lang H, Oldhafer K, Ruslan A, Ciria R, Ferrero A, Mazzaferro V, Cescon M, Giuliante F, Nadalin S, Golse N, Sulpice L, Serrablo A, Ramos E, Marchese U, Rosok B, Lopez-Lopez V, Clavien P, Aldrighetti L. Results from the european survey on preoperative management and optimization protocols for PeriHilar cholangiocarcinoma. HPB (Oxford) 2023; 25:1302-1322. [PMID: 37543473 DOI: 10.1016/j.hpb.2023.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/24/2023] [Accepted: 06/21/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Major surgery, along with preoperative cholestasis-related complications, are responsible for the increased risk of morbidity and mortality in perihilar cholangiocarcinoma (pCCA). The aim of the present survey is to provide a snapshot of current preoperative management and optimization strategies in Europe. METHODS 61 European centers, experienced in hepato-biliary surgery completed a 59-questions survey regarding pCCA preoperative management. Centers were stratified according to surgical caseload (<5 and ≥ 5 cases/year) and preoperative management protocols' application. RESULTS The overall case volume consisted of 6333 patients. Multidisciplinary discussion was routinely performed in 91.8% of centers. Most respondents (96.7%) recognized the importance of a well-structured preoperative protocol. The preferred method for biliary drainage was percutaneous transhepatic biliary drainage (60.7%) while portal vein embolization was the preferred technique for liver hypertrophy (90.2%). Differences in preoperative pathologic confirmation of malignancy (35.8% vs 28.7%; p < 0.001), number of mismanaged referred patients (88.2% vs 50.8%; p < 0.001), biliary drainage (65.1% vs 55.6%; p = 0.015) and liver function evaluation (37.2% vs 5.6%; p = 0.001) were found between centers according to groups' stratification. CONCLUSION The importance of a correct preoperative management is recognized. Nevertheless, the current lack of guidelines leads to wide heterogeneity of behaviors among centers. This survey can provide recommendations to improve pCCA perioperative outcomes.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy.
| | - Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | | | - Krzysztof Zieniewicz
- Dept of General, Transplant and Liver Surgery, Medical University, Warsaw, Poland
| | - Tomas Van Gulik
- Academic Medical Center, Erasmus Medica Center, Amsterdam, the Netherlands
| | - Alfredo Guglielmi
- General and Hepatobiliary Surgery, University of Verona, Verona, Italy
| | | | | | | | - Popescu Irinel
- Center of General Surgery and Liver Transplant, Fundeni Clinical Institut, Bucharest, Romania
| | | | | | | | - Renè Adam
- Paul Brousse University Hospital, Paris, France; Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Padova, Italy
| | - Hauke Lang
- University Medical Center Mainz, Mainz, Germany
| | | | | | - Ruben Ciria
- University Hospital Reina Sofia, Cordoba, Spain
| | | | - Vincenzo Mazzaferro
- University of Milan, Department of Oncology and Hemato-Oncology, Istituto Nazionale Tumori, Milan, Italy
| | | | | | | | | | | | | | - Emilio Ramos
- Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | | | | | | | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
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11
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Ratti F, Marino R, Catena M, Pascale MM, Buonanno S, De Cobelli F, Aldrighetti L. The failure to rescue factor: aftermath analyses on 224 cases of perihilar cholangiocarcinoma. Updates Surg 2023; 75:1919-1939. [PMID: 37452927 DOI: 10.1007/s13304-023-01589-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
The term "failure to rescue" (FTR) has been recently introduced in the field of hepato-biliary surgery to label cases in which major postoperative complications lead to postoperative fatality. Perihilar cholangiocarcinoma (PHC) surgery has consistently high postoperative morbidity and mortality rates in which factors associated with FTR are yet to be discovered. The primary endpoint of this study is to compare the Rescue with the FTR cohort referencing patients' characteristics and management protocols applied. A cohort of 224 consecutive patients undergoing surgery for PHC, between 2010 and 2021, was enrolled. Perioperative variables were analyzed according to the severity of major postoperative complications (Clavien ≥ 3a). Kaplan-Meier survival analyses were performed to determine complications' impact on survival. Major complications were reported in 86 cases (38%). Among the major complications' cohort, 72 cases (84%) were graded Clavien 3a-4 (Rescue group), while 14 (16%) cases were graded Clavien 5 (FTR group). Number of lymph-node metastases (OR = 1.33 (1.08-1.63) p = 0.006), poorly differentiated (G3) adenocarcinoma (OR = 7.55 (1.24-45.8) p = 0.028, reintervention (OR = 16.47 (2.76-98.08) p = 0.002), and prognostic nutritional index < 40 (OR = 3.01 (2.265-3.654) p < 0.001) rates were independent predictors of FTR. Right resection side (OR 2.4 (1.33-4.34) p = 0.004) increased the odds of major complications but not of FTR. No difference in overall survival was identified. A distinction of perioperative factors associated with postoperative complications' severity is crucial. Patients developing severe outcomes seem to have different biological and nutritional profiles, showing that efficient preoperative protocols are strategic to identify and avert the risk of FTR.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy.
| | - Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Marco Maria Pascale
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Silvia Buonanno
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology, IRCCS San Raffaele Hospital, 20132, Milan, Italy
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
- Faculty of Medicine, University Vita-Salute San Raffaele, 20132, Milan, Italy
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12
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Giovinazzo F, Pascale MM, Cardella F, Picarelli M, Molica S, Zotta F, Martullo A, Clarke G, Frongillo F, Grieco A, Agnes S. Current Perspectives in Liver Transplantation for Perihilar Cholangiocarcinoma. Curr Oncol 2023; 30:2942-2953. [PMID: 36975438 PMCID: PMC10047046 DOI: 10.3390/curroncol30030225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/17/2023] [Accepted: 01/30/2023] [Indexed: 03/05/2023] Open
Abstract
Cholangiocarcinoma (CCA) encompasses all malignant neoplasms arising from the epithelial cells of the biliary tree. About 40% of CCAs are perihilar, involving the bile ducts distal to the second-order biliary branches and proximal to the cystic duct implant. About two-thirds of pCCAs are considered unresectable at the time of diagnosis or exploration. When resective surgery is deemed unfeasible, liver transplantation (LT) could be an effective alternative. The overall survival rates after LT at 1 and 3 years are 91% and 81%, respectively. The overall five-year survival rate after transplantation is 73% (79% for patients with underlying PSC and 63% for de novo pCCA). Multicenter case series reported a 5-year disease-free survival rate of ~65%. However, different protocols, including neoadjuvant therapy, have been proposed. The scarcity of organ availability represents a crucial limiting factor in recommending LT preferentially in treating pCCA. Living donor transplantations and marginal cadaveric allografts have proven to be exciting options to overcome organ shortage. Management of jaundice and cholangitis is still challenging for these patients and could impact LT listing. Whether to adopt surgical resection or LT as standard-of-care in pCCA is still a matter of debate, and more prospective studies are needed.
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Affiliation(s)
- Francesco Giovinazzo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Marco Maria Pascale
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Francesca Cardella
- Surgical Oncology of Gastrointestinal Tract Unit, Vanvitelli University, 80138 Naples, Italy
| | - Matteo Picarelli
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Serena Molica
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Francesca Zotta
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Annamaria Martullo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - George Clarke
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, UK
| | - Francesco Frongillo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Grieco
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medicine and Translational Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Salvatore Agnes
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medicine and Translational Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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