1
|
Donati M, Stang A, Stavrou GA, Basile F, Oldhafer KJ. Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved? Future Oncol 2018; 15:193-205. [PMID: 30378439 DOI: 10.2217/fon-2018-0413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Until the 1980's, Klatskin tumors were considered 'desperate cases' and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.
Collapse
Affiliation(s)
- Marcello Donati
- Department of Surgery & Medical-Surgical Specialties, Surgical Clinic Unit, University Hospital of Catania (CAST), University of Catania, 95122 Catania, Italy.,Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany
| | - Axel Stang
- Oncology Unit, Asklepios Barmbek Hospital, Hamburg, Germany
| | - Gregor A Stavrou
- Department of General, Visceral, Thoracic & Pediatric Surgery, Saarbrucken Hospital, Saarbrucken-Saarland, Germany
| | - Francesco Basile
- Department of Surgery & Medical-Surgical Specialties, Surgical Clinic Unit, University Hospital of Catania (CAST), University of Catania, 95122 Catania, Italy
| | - Karl J Oldhafer
- Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany.,Department of General & Abdominal Surgery, Asklepios Barmbek Hospital, Hamburg, Germany
| |
Collapse
|
2
|
Poruk KE, Pawlik TM, Weiss MJ. Perioperative Management of Hilar Cholangiocarcinoma. J Gastrointest Surg 2015; 19:1889-99. [PMID: 26022776 PMCID: PMC4858933 DOI: 10.1007/s11605-015-2854-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/04/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cholangiocarcinoma is the most common primary tumor of the biliary tract although it accounts for only 2 % of all human malignancies. We herein review hilar cholangiocarcinoma including its risk factors, the main classification systems for tumors, current surgical management of the disease, and the role chemotherapy and liver transplantation may play in selected patients. METHODS We performed a comprehensive literature search using PubMed, Medline, and the Cochrane library for the period 1980-2015 using the following MeSH terms: "hilar cholangiocarcinoma", "biliary cancer", and "cholangiocarcinoma". Only recent studies that were published in English and in peer reviewed journals were included. FINDINGS Hilar cholangiocarcinoma is a disease of advanced age with an unclear etiology, most frequently found in Southeast Asia and relatively rare in Western countries. The best chance of long-term survival and potential cure is surgical resection with negative surgical margins, but many patients are unresectable due to locally advanced or metastatic disease at diagnosis. As a result of recent efforts, new methods of management have been identified for these patients, including preoperative portal vein embolism and biliary drainage, neoadjuvant chemotherapy with subsequent transplantation, and chemoradiation therapy. CONCLUSION Current management of hilar cholangiocarcinoma depends on extent of the tumor at presentation and includes surgical resection, liver transplantation, portal vein embolization, and chemoradiation therapy. Our understanding of hilar cholangiocarcinoma has improved in recent years and further research offers hope to improve the outcome in patients with these rare tumors.
Collapse
Affiliation(s)
- Katherine E Poruk
- Department of Surgery, The Johns Hopkins University School of Medicine, Halsted 614 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Halsted 614 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Halsted 614 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
| |
Collapse
|
3
|
Multimodal treatment strategies for advanced hilar cholangiocarcinoma. Langenbecks Arch Surg 2014; 399:679-92. [PMID: 24962146 DOI: 10.1007/s00423-014-1219-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 06/17/2014] [Indexed: 12/17/2022]
Abstract
Cholangiocarcinoma (CCA) is the second most common primary malignancy of the liver arising from malignant transformation and growth of biliary ductal epithelium. Approximately 50-70 % of CCAs arise at the hilar plate of the biliary tree, which are termed hilar cholangiocarcinoma (HC). Various staging systems are currently employed to classify HCs and determine resectability. Depending on the pre-operative staging, the mainstays of treatment include surgery, chemotherapy, radiation therapy, and photodynamic therapy. Surgical resection offers the only chance for cure of HC and achieving an R0 resection has demonstrated improved overall survival. However, obtaining longitudinal and radial surgical margins that are free of tumor can be difficult and frequently requires extensive resections, particularly for advanced HCs. Pre-operative interventions may be necessary to prepare patients for major hepatic resections, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and portal vein embolization. Multimodal therapy that combines chemotherapy with external beam radiation, stereotactic body radiation therapy, bile duct brachytherapy, and/or photodynamic therapy are all possible strategies for advanced HC prior to resection. Orthotopic liver transplantation is another therapeutic option that can achieve complete extirpation of locally advanced HC in judiciously selected patients following standardized neoadjuvant protocols.
Collapse
|
4
|
Soares KC, Kamel I, Cosgrove DP, Herman JM, Pawlik TM. Hilar cholangiocarcinoma: diagnosis, treatment options, and management. Hepatobiliary Surg Nutr 2014; 3:18-34. [PMID: 24696835 DOI: 10.3978/j.issn.2304-3881.2014.02.05] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/30/2013] [Indexed: 12/16/2022]
Abstract
Hilar cholangiocarcinoma (HC) is a rare disease with a poor prognosis which typically presents in the 6(th) decade of life. Of the 3,000 cases seen annually in the United States, less than one half of these tumors are resectable. A variety of risk factors have been associated with HC, most notably primary sclerosing cholangitis (PSC), biliary stone disease and parasitic liver disease. Patients typically present with abdominal pain, pruritis, weight loss, and jaundice. Computed topography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are used to characterize biliary lesions. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) assess local ductal extent of the tumor while allowing for therapeutic biliary drainage. MRCP has demonstrated similar efficacies to PTC and ERCP in identifying anatomic extension of tumors with less complications. Treatment consists of surgery, radiation, chemotherapy and photodynamic therapy. Biliary drainage of the future liver remnant should be performed to decrease bilirubin levels thereby facilitating future liver hypertrophy. Standard therapy consists of surgical margin-negative (R0) resection with extrahepatic bile duct resection, hepatectomy and en bloc lymphadenectomy. Local resection should not be undertaken. Lymph node invasion, tumor grade and negative margins are important prognostic indicators. In instances where curative resection is not possible, liver transplantation has demonstrated acceptable outcomes in highly selected patients. Despite the limited data, chemotherapy is indicated for patients with unresectable tumors and adequate functional status. Five-year survival after surgical resection of HC ranges from 10% to 40% however, recurrence can be as high as 50-70% even after R0 resection. Due to the complexity of this disease, a multi-disciplinary approach with multimodal treatment is recommended for this complex disease.
Collapse
Affiliation(s)
- Kevin C Soares
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ihab Kamel
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David P Cosgrove
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- 1 Department of Surgery, Division of Surgical Oncology, 2 Department of Radiology, 3 Department of Oncology, 4 Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
5
|
Colangiocarcinoma hiliar: el número de ganglios positivos y la relación ganglios positivos/ganglios totales son un factor pronóstico importante de supervivencia. Cir Esp 2014; 92:247-53. [DOI: 10.1016/j.ciresp.2013.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/11/2013] [Accepted: 07/12/2013] [Indexed: 12/12/2022]
|
6
|
Ramacciato G, Nigri G, Bellagamba R, Petrucciani N, Ravaioli M, Cescon M, Del Gaudio M, Ercolani G, Di Benedetto F, Cautero N, Quintini C, Cucchetti A, Lauro A, Miller C, Pinna AD. Univariate and Multivariate Analysis of Prognostic Factors in the Surgical Treatment of Hilar Cholangiocarcinoma. Am Surg 2010. [DOI: 10.1177/000313481007601129] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Surgery is the only effective treatment able to improve survival of patients with hilar cholangiocarcinoma (CCA). However, the significance of prognostic factors on overall survival is still debated. We evaluated early and long-term outcomes of patients resected for hilar cholangiocarcinoma over a 3-year period to determine the role of prognostic factors and their effect on overall survival. Medical records of patients with hilar CCA who underwent resection between January 2001 and December 2004 were retrospectively reviewed. Univariate and multivariate analysis was performed to identify prognostic factors associated with survival. Thirty-two of 45 patients underwent surgical resection with curative intent. Morbidity was 24.4 per cent; perioperative mortality was 0 per cent. Overall median survival was 22.3 months. Well-differentiated tumor grading and R0 resection were independently associated with better survival at multivariate analysis. Aggressive surgery, including biliary resection combined with major hepatectomy, is a safe procedure with low morbidity and mortality in a tertiary referral hepatobiliary center. The main aim of an aggressive surgical approach is to obtain a microscopic margin-negative resection, which is associated with better prognosis. Another important prognostic factor is tumor grading, which is independently associated with survival.
Collapse
Affiliation(s)
- Giovanni Ramacciato
- Department of General Surgery, Hepato-biliary-pancreatic Unit, University of Rome “La Sapienza,” 11° School of Medicine, Sant'Andrea Hospital, Rome, Italy
| | - Giuseppe Nigri
- Department of General Surgery, Hepato-biliary-pancreatic Unit, University of Rome “La Sapienza,” 11° School of Medicine, Sant'Andrea Hospital, Rome, Italy
| | - Riccardo Bellagamba
- Department of General Surgery, Hepato-biliary-pancreatic Unit, University of Rome “La Sapienza,” 11° School of Medicine, Sant'Andrea Hospital, Rome, Italy
| | - Niccolò Petrucciani
- Department of General Surgery, Hepato-biliary-pancreatic Unit, University of Rome “La Sapienza,” 11° School of Medicine, Sant'Andrea Hospital, Rome, Italy
| | - Matteo Ravaioli
- Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy
| | - Matteo Cescon
- Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy
| | - Massimo Del Gaudio
- Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy
| | | | - Nicola Cautero
- Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy
| | | | - Alessandro Cucchetti
- Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy
| | - Augusto Lauro
- Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy
| | - Charles Miller
- Liver Transplantation, Cleveland Clinic, Cleveland, Ohio
| | | |
Collapse
|
7
|
Yu WL, Cong WM, Zhang Y, Chen Y, Wang F, Yu G. Overexpression of ATA1/SLC38A1 predicts future recurrence and death in Chinese patients with hilar cholangiocarcinoma. J Surg Res 2010; 171:663-8. [PMID: 20605601 DOI: 10.1016/j.jss.2010.03.049] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 03/12/2010] [Accepted: 03/23/2010] [Indexed: 01/26/2023]
Abstract
System A amino acid transporter is a Na+-dependent active transport system, mediating the uptake of amino acids, dysregulation of which has been found to be associated with malignant transformation in mammalian cells. However, the role of ATA1 in hilar cholangiocarcinoma is unclear. Here, we investigated ATA1 expression and determined its clinical significance in hilar cholangiocarcinoma. Tissue microarray blocks containing tumor specimens obtained from 48 patients were constructed. Expression of ATA1 in these specimens was analyzed using immunohistochemical studies. ATA1 overexpression was observed in 22 cases (44.9%). Overexpression of ATA1 was significantly associated with lymph node metastases. ATA1 expression has a significant correlation with recurrence and poor survival in univariate analyses. Multivariate analyses revealed that ATA1 was an independent predictor for future recurrence in patients with cholangiocarcinoma. Increased expression of ATA1 is frequent in human hilar cholangiocarcinoma and significantly correlated with the progression of cholangiocarcinoma, suggesting the importance of ATA1 in cancer development and progression. ATA1 expression may be used to predict recurrence and death and can serve as a promising target for therapy of this malignancy.
Collapse
Affiliation(s)
- Wen-long Yu
- Department of Surgery, Eastern Hepatobiliary Hospital, Shanghai, People's Republic of China
| | | | | | | | | | | |
Collapse
|
8
|
|