Abstract
Background/purpose
Hilar cholangiocarcinoma (HCCA) is a rare cancer with a low resectability rate, frequent recurrence after resection and an overall poor outcome. It is widely accepted that en bloc partial hepatectomy is a necessary part of the surgical therapy, but controversy surrounds other areas, including extent of lymphadenectomy and preoperative use of biliary drainage of the future liver remnant (FLR). This study analyzes the authors’ experience with HCCA, emphasizing outcome after resection in a more recent cohort.
Methods
All patients with HCCA evaluated at Memorial Sloan-Kettering Cancer Center (MSKCC) since 1991 were included in the initial analysis. Outcome after resection was specifically assessed in patients submitted to operation between January 2001 and September 2008. Patient demographics, preoperative evaluation, resection type, margin status, lymph node status, complications, morbidity and survival were examined. Preoperative disease staging was performed in all patients according to the Blumgart classification. Separate analyses were conducted to assess the impact of preoperative biliary drainage on the FLR and the optimal lymph node harvest. Outcomes for resected patients were analyzed by Fisher’s exact test and log rank tests.
Results
Three hundred and fifty-two patients with HCCA were evaluated since 1991, of which 118 were seen between 2001 and 2008. During this latter period, 105 (89%) patients underwent exploration, and of the 60 patients that underwent resection with curative intent, 48 (80%) had R0 resections. There were 3 perioperative deaths (5%), and 22 (28%) patients had complications. Patients with an R0 resection had the highest disease-specific survival followed by those with R1 resection when compared to unresected patients. The median follow-up period was 18 months. Classification by the Blumgart preoperative staging system predicted resectability and the likelihood of R0 resection. The benefit of pre-operative biliary drainage of the FLR appeared to be limited to patients with a predicted FLR volume of <30%. In patients with node-negative tumors, survival was greater in those with more than 7 lymph nodes harvested.
Conclusions
R0 resection including hepatectomy with negative lymph nodes is feasible in the majority of patients with resectable HCCA. This strategy is associated with a prolonged disease-specific survival.
Similar content being viewed by others
References
Altmeier WA, Gall EA, Zinninger MM, et al. Sclerosing carcinoma of the major intrahepatic bile ducts. Arch Surg. 1957;75:459–61.
Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatic. An unusual tumor with distinctive clinical and pathological features. Am J Med. 1965;38:241–56.
Nakeeb A, Pitt HA, Sohn TA, et al. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors. Ann Surg. 1996;224:463–73.
Launois B, Reding R, Lebeau G, et al. Surgery for hilar cholangiocarcinoma: French experience in a collective survey of 552 extrahepatic bile duct cancers. J Hepatobiliary Pancreat Surg. 2000;7:128–34.
Vauthey JN, Blumgart LH. Recent advances in the management of cholangiocarcinomas. Semin Liver Dis. 1994;14:109–14.
Endo I, Gonen M, Yopp AC, et al. Intrahepatic cholangiocarcinoma: rising frequency, improved survival, and determinants of outcome after resection. Ann Surg. 2008;248(1):84–96.
Jarnagin WR, Schoup M. Surgical management of cholangiocarcinoma. Semin Liver Dis. 2004;23:189–99.
Kosuge T, Yamamoto J, Shimada K, et al. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg. 1999;230:663–71.
Neuhaus P, Jonas S, Bechstein WO, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg. 1999;230:808–18.
Burke EC, Jarnagin WR, Hochwald SN, et al. Hilar cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative operation, and a presurgical clinical staging system. Ann Surg. 1998;228(3):385–94.
Seyama Y, Kubota K, Sano K, et al. Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Ann Surg. 2003;238:73–83.
Nagino M, Takada T, Miyazaki M, et al. Preoperative biliary drainage for biliary tract and ampullary carcinomas. J Hepatobiliary Pancreat Surg. 2008;15(1):25–30.
Nagino M, Kamyia J, Nishio H, et al. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Ann Surg. 2006;243:364–72.
Corvera CU, Blumgart LH, Akhurst T, et al. 18F-fluorodeoxyglucose positron emission tomography influences management decisions in patients with biliary cancer. J Am Coll Surg. 2008;206(1):57–65.
Anderson CD, Rice MH, Pinson CW, et al. Fluorodeoxyglucose PET imaging in the evaluation of gallbladder carcinoma and cholangiocarcinoma. J Gastrointest Surg. 2004;8:90–7.
Weber SM, DeMatteo RP, Fong Y, et al. Staging laparoscopy in patients with extrahepatic biliary carcinoma: analysis of 100 patients. Ann Surg. 2002;235:392–9.
Connor S, Barron E, Wigmore SJ, et al. The utility of laparoscopic assessment in the preoperative staging of suspected hilar cholangiocarcinoma. J Gastrointest Surg. 2005;9:476–80.
Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Obs Gyn. 1975;140:170–6.
Greene FL, Page DL, Fleming ID, et al., editors. American joint committee on cancer staging. 6th ed. New York: Springer; 2002.
Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, respectability and outcome in 225 patients with hilar cholangiocarcinomas. Ann Surg. 2001;234(4):507–19.
Sano T, Shimada K, Sakamoto Y, et al. One hundred two consecutive hepatobiliary resections for perihilar cholangiocarcinoma with zero mortality. Ann Surg. 2006;244(2):240–7.
Nagino M, Kamiya J, Arai T, et al. One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome. Surgery. 2005;137(2):148–55.
Sewnath ME, Karsten TM, Prins MH, et al. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg. 2002;236:17–27.
Abdalla EK, Hicks ME, Vauthey JN. Portal vein embolization: rationale, technique and future prospects. Br J Surg. 2001;88:1463–6.
Hochwald SN, Burke EC, Jarnagin WR, et al. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg. 1999;134(3):261–6.
Kennedy TJ, Yopp A, Qin Y, et al. Role of preoperative biliary drainage of liver remnant prior to extended liver resection for hilar cholangiocarcinoma. HPB (Oxford). 2009;11(5):445–51.
Ito K, Ito H, Allen PJ, et al. Adequate lymph node assessment for extrahepatic bile duct adenocarcinoma. Ann Surg (in press).
Schwartz RE, Smith DD. Lymph node dissection impact on staging and survival of extrahepatic cholangiocarcinomas, based on US population data. J Gastrointest Surg. 2007;11(2):158–65.
Author information
Authors and Affiliations
Corresponding author
About this article
Cite this article
Rocha, F.G., Matsuo, K., Blumgart, L.H. et al. Hilar cholangiocarcinoma: the Memorial Sloan-Kettering Cancer Center experience. J Hepatobiliary Pancreat Sci 17, 490–496 (2010). https://doi.org/10.1007/s00534-009-0205-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00534-009-0205-4