Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery

BACKGROUND

Right or right-extended hepatectomy including the caudate lobe is the most common treatment for hilar cholangiocarcinoma (HC). A 5-year survival of up to 60% can be achieved using this procedure if R0-resection is obtained. However, for some patients a left-sided liver resection is necessary to obtain radical resection. The close relationship between the right hepatic artery and the HC in these patients frequently limits the ability to achieve a radial R0-resection without difficult vascular reconstruction. The aim of the present study was to describe the outcome of patients who underwent pre-operative embolization of the proper hepatic artery in an effort to induce development of arterial collaterals thus allowing the resection of the proper and right hepatic artery without vascular reconstruction.

METHODS

In patients presenting with HC who were considered to require a left hepatic lobectomy and in whom pre-operative work up revealed possible tumour invasion of the right hepatic artery, transcatheter arterial embolization (TAE) of the proper hepatic artery or the left and right hepatic arteries was performed. Three weeks later, a left-sided hepatectomy with resection of all portal structures except the portal vein was performed.

RESULTS

In six patients, pre-operative embolization of the proper hepatic artery was performed. Almost instantaneously in all six patients arterial flow signals could be detected in the liver using Doppler ultrasonography. No patient died peri-operatively. In all six patients an R0 radial resection was achieved and in three an R0 proximal transection margin was obtained. All post-operative complications were managed successfully using percutaneous drainage procedures. No patient developed local recurrence and two patients remain disease free more than 7 years after surgery.

SUMMARY

After pre-operative embolization of the proper hepatic artery, resection of the HC with left hepatectomy is a promising new approach for these technically demanding patients, giving them the chance of a cure.

Latent Risk Intrahepatic Cholangiocarcinoma Susceptible to Adjuvant Treatment After Resection: A Clinical Deep Learning Approach

Background: Artificial Intelligence (AI) frameworks have emerged as a novel approach in medicine. However, information regarding its applicability and effectiveness in a clinical prognostic factor setting remains unclear. Methods: The AI framework was derived from a pooled dataset of intrahepatic cholangiocarcinoma (ICC) patients from three clinical centers (n = 1,421) by applying the TensorFlow deep learning algorithm to Cox-indicated pathologic (four), serologic (six), and etiologic (two) factors; this algorithm was validated using a dataset of ICC patients from an independent clinical center (n = 234). The model was compared to the commonly used staging system (American Joint Committee on Cancer; AJCC) and methodology (Cox regression) by evaluating the brier score (BS), integrated discrimination improvement (IDI), net reclassification improvement (NRI), and area under curve (AUC) values. Results: The framework (BS, 0.17; AUC, 0.78) was found to be more accurate than the AJCC stage (BS, 0.48; AUC, 0.60; IDI, 0.29; NRI, 11.85; P < 0.001) and the Cox model (BS, 0.49; AUC, 0.70; IDI, 0.46; NRI, 46.11; P < 0.001). Furthermore, hazard ratios greater than three were identified in both overall survival (HR; 3.190; 95% confidence interval [CI], 2.150-4.733; P < 0.001) and disease-free survival (HR, 3.559; 95% CI, 2.500-5.067; P < 0.001) between latent risk and stable groups in validation. In addition, the latent risk subgroup was found to be significantly benefited from adjuvant treatment (HR, 0.459; 95% CI, 0.360-0.586; P < 0.001). Conclusions: The AI framework seems promising in the prognostic estimation and stratification of susceptible individuals for adjuvant treatment in patients with ICC after resection. Future prospective validations are needed for the framework to be applied in clinical practice.

A combined Cox and logistic model provides accurate predictive performance in estimation of time-dependent probabilities for recurrence of intrahepatic cholangiocarcinoma after resection

Background

Intrahepatic cholangiocarcinoma has heterogeneous outcomes after resection. There remains a need for broadly applicable recurrence-specific tool offering precise evaluation on curativeness of resection.

Methods

A four hospital-based clinical cohort involving 1,655 patients with intrahepatic cholangiocarcinoma who received surgical resection were studied. Cox and logistic models were networked into one system containing risk categories with distinctive probabilities of recurrence. Prediction of time-to-recurrence was performed by formulizing time-dependent risk probabilities. The model was validated in three clinical cohorts (n=332).

Results

From the training cohort, 10 and 11 covariates, including diabetes, cholelithiasis, albumin, platelet count, alpha fetoprotein, carbohydrate antigen 19-9, carcinoembryonic antigen, hepatitis B virus infection, tumor size and number, resection type, and lymph node metastasis, from Cox and logistic models were identified significant for recurrence-free survival (RFS). The combined Cox & logistic ranking system (CCLRS)-adjusted time-dependent probabilities were categorized into seven ranks (5-yr RFS for lowest and highest ranks were 75% vs. 0%; hazard ratio 18.5, 95% CI: 14.7-24.9, P<0.0001). The CCLRS was validated with a minimum area under curve value of 0.8086. Prediction of time-to-recurrence was validated to be excellent (Pearson r, 0.8204; P<0.0001).

Conclusions

The CCLRS allows precise estimation on risk of recurrence for intrahepatic cholangiocarcinoma after resection. It could be applicative when estimating time-dependent disease status and stratifying individuals who sole resection of the tumor would not be curative.

Digital Image Analysis has an Additive Beneficial Role to Conventional Cytology in Diagnosing the Nature of Biliary Ducts Stricture

BACKGROUND & AIM

Conventional cytological evaluation (CCE) fails to identify nature indeterminate biliary duct stricture (IBDS) in many cases. Digital image analysis (DIA) has the ability to identify and analyze the DNA content of cells. This study assesses the role of DIA in recognizing the nature of IBDS compared to CCE.

METHODS

A prospective observational study was conducted at the Al-Rajhi University Hospital. Fifty patients with IBDS, based on abdominal imaging, were subjected to endoscopic retrograde cholangiopancreatography (ERCP) and brush sampling. These samples were evaluated with CCE and DIA. Follow-up for at least 9 months and cost-analysis had also been done.

RESULTS

Based on the final diagnosis, 32 (64.0%) patients had malignant stricture, and 39 (78.0%) had distal stricture. DIA had 84.40% (95% CI; 67.20-94.70) sensitivity and 94.40% (95% CI; 72.70-99.90) specificity in identifying nature of IBDS, whereas CCE had 19.0% (95% CI; 7.20-36.40) sensitivity and 89.0% (95% CI; 65.30-98.60) specificity. Combination of both modalities had 84.40% (95% CI; 67.20-94.70) sensitivity and 83.30% (95% CI; 58.60-96.40) specificity in identification nature of IBDS. Based on CCE alone, only 6/32 (18.80%) of malignant stricture were diagnosed, and 26/32 (81.20%) were missed. However, DIA alone was able to diagnose 27/32 (84.40%) of malignant stricture, and only 5 cases were missed. Both procedures had detection rate of malignant stricture as DIA alone. Benign stricture was correctly diagnosed in 16/18 (88.80%), 17/18 (94.40%), and 15/18 (83.30%) using CCE alone, DIA alone, and both procedures together, respectively. Cost per detection additional one malignant stricture using DIA required 99.4$.

CONCLUSION

DIA is substantially better than CCE in diagnosing the nature of IBDS but at an increase cost and thus suggests its application in a wider role in clinical practice.

CLINICAL TRIAL NUMBER

NCT04112030.

Evaluating Biliary Malignancy with Measured and Calculated Ultra-high b-value Diffusion-weighted MR Imaging at 3T

PURPOSE

Although diffusion-weighted imaging (DWI) with ultra-high b-values is reported to be advantageous in the detection of some tumors, its applicability is not yet known in biliary malignancy. Therefore, this study aimed to evaluate the impact of measured b = 1400 s/mm2 (M1400) and calculated b = 1400 s/mm2 (C1400) DWI on image quality and quality of lesion discernibility using a modern 3T MR system compared to conventional b = 800 s/mm2 DWI (M800).

METHODS

We evaluated 56 patients who had pathologically proven biliary malignancy. All the patients underwent preoperative or baseline 3T MRI using DWI (b = 50, 400, 800, and 1400 s/mm2). The calculated DWI was obtained using a conventional DWI set (b = 50, 400, and 800). The tumor-to-bile contrast ratio (CR) and tumor SNR were compared between the different DWI images. Likert scores were given on a 5-point scale to assess the overall image quality, overall artifacts, ghost artifacts, misregistration artifacts, margin sharpness, and lesion discernibility. Repeated-measures analysis of variance with post hoc analyses was used for statistical evaluations.

RESULTS

The CR of the tumor-to-bile was significantly higher in both M1400 and C1400 than in M800 (Pa < 0.01). SNRs were significantly higher in M800, followed by C1400 and M1400 (Pa < 0.01). Lesion discernibility was significantly improved for M1400, followed by C1400 and M800 for both readers (Pa < 0.01).

CONCLUSION

Using a 3T MRI, both measured and calculated DWI with an ultra-high b-value offer superior lesion discernibility for biliary malignancy compared to the conventional DWI.

A Rare Choledochal Cyst in a Child With Abdominal Pain

Choledochal cysts are rare anatomical anomalies of the biliary tree. These lesions possess a risk for future development of catastrophic malignancy in the form of cholangiocarcinoma if left unaddressed, which is associated with a high mortality rate in cases of malignant transformation. The presenting symptoms of choledochal cysts are often nonspecific. The age of the initial onset of symptoms can vary, and some patients with choledochal cysts do not receive a diagnosis until reaching adulthood. Here, we present a case that serves as an example of early detection of this rare clinical finding for potentially devastating malignancy in a child who presented with nonspecific symptoms.

Type VI Choledochal Cyst and the Anomalous Pancreaticobiliary Junction: A Systematic Review

Background

The type VI choledochal cyst of the cystic duct (CC-CD) is not only a taxonomical conundrum but also a matter of research in terms of its etiopathogenesis and optimal therapeutic options. The role of anomalous pancreaticobiliary junction (PBJ) and pancreatic juice regurgitation in the etiopathogenesis of CC-CD and its association with biliary malignancies has not been elucidated yet.

Objective

To evaluate the role of anomalous PBJ in the etiopathogenesis of CC-CD and generate a scientific opinion through a systematic review of the literature.

Materials and Methods

A literature review (PUBMED, PUBMED Central, PMC, Google Scholar, Google search engine) following the PRISMA guidelines revealed 32 articles of interest. Search terms included choledochal cyst, choledochal, cyst, type VI, type 6, cystic duct dilatation, dilated cystic duct and cystic anomaly. Two independent reviewers extracted the data; the third reviewer had been involved in case of discrepancy.

Results

The study-cohort comprised of 45 patients. Roughly, 30% and 60% of the patients were diagnosed in the first and first-two decades of life, respectively. Sex ratio was skewed in favor of females (M:F = 1:1.4). Although males presented earlier than females, females were twice as likely to be diagnosed in the first decade of life. Anomalous PBJ was found in only one-third of these patients and was more common in females. Patients with anomalous PBJ presented early with three-fourth presenting in the first two decades of life. Anomalous PBJ was twice as prevalent in patients with concomitant involvement of other parts of the biliary tract (Group II) as compared to those with isolated CC-CD (Group I). Besides, patients in Group II presented early when compared to Group I, within the group females presented earlier. No significant association of biliary malignancies with anomalous PBJ was seen; the incidence of biliary malignancies was higher in those with a normal PBJ.

Conclusions

Observations from the study-cohort fail to establish a strong association of anomalous pancreaticobiliary junction in the etiopathogenesis of CC-CD or the development of biliary malignancies in these patients. It is likely that there are additional or alternative mechanisms that are important in the context of CC-CD.