Review Article

Langenbeck's Archives of Surgery

, Volume 399, Issue 6, pp 679-692

First online:

Multimodal treatment strategies for advanced hilar cholangiocarcinoma

  • Matthew J. WeissAffiliated withDivision of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital
  • , David CosgroveAffiliated withDepartment of Medical Oncology, The Johns Hopkins Hospital
  • , Joseph M. HermanAffiliated withDepartment of Radiation Oncology, The Johns Hopkins Hospital
  • , Neda RastegarAffiliated withDepartment of Radiology, The Johns Hopkins Hospital
  • , Ihab KamelAffiliated withDepartment of Radiology, The Johns Hopkins Hospital
  • , Timothy M. PawlikAffiliated withDivision of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital Email author 

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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.


Cholangiocarcinoma Hilar Biliary neoplasm Multimodal treatment