Skip to main content
SpringerLink
Log in

Approach to Resectable Biliary Cancers

  • Upper Gastrointestinal Cancers (JD Berlin, Section Editor)
  • Published:
Current Treatment Options in Oncology Aims and scope Submit manuscript

Opinion statement

Biliary malignancies, although rare, can be some of the most challenging to manage surgically. Intrahepatic cholangiocarcinomas are resectable if there is no evidence of metastatic disease. These tumors are managed with anatomic resection and portal lymphadenectomy when centrally located or multiple in a single lobe. Non-anatomic resection can be performed for solitary peripheral tumors with minimally invasive techniques. It is not our practice to routinely employ neoadjuvant chemotherapy prior to resection of these tumors. Hepatic arterial infusion chemotherapy is utilized at our institution in highly selected patients in the context of an ongoing clinical trial for unresectable tumors. Hilar cholangiocarcinomas, when resectable (i.e., ipsilateral arterial involvement or lack of vascular involvement), are managed with right or left (extended) hepatectomy, caudate resection, and portal lymphadenectomy. Distal cholangiocarcinomas are managed with pancreaticoduodenectomy. Neoadjuvant chemotherapy is not routinely used in our treatment algorithm of extrahepatic cholangiocarcinomas. Nodal involvement and positive margin (R1) resection necessitates adjuvant chemotherapy. Finally, gallbladder carcinoma is managed with radical cholecystectomy, anatomic segment IVb/V resection, and portal lymphadenectomy. Adjuvant chemotherapy is employed routinely amongst patients with T2 or higher tumors and those with positive lymph nodes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References and Recommended Reading

  1. Le VH, O’Connor VV, Li D, et al. Outcomes of neoadjuvant therapy for cholangiocarcinoma: a review of existing evidence assessing treatment response and R0 resection rate. J Surg Oncol. 2020:1–8. https://doi.org/10.1002/jso.26230.

  2. Bartolini I, Risaliti M, Fortuna L, et al. Current management of intrahepatic cholangiocarcinoma: from resection to palliative treatments. Radiol Oncol. 2020;54(3):263–71.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Bartsch F, Eberhard J, Ruckert F. Repeated resection for recurrent intrahepatic cholangiocarcinoma: a retrospective German multicenter study. Liver Int. 2021;41:180–91.

    Article  PubMed  Google Scholar 

  4. Jung P, Cho EH, Kim SB, et al. Comparison of the clinical results of surgical resection for extrahepatic cholangiocarcinomas: hilar cholangiocarcinoma and mid-to-distal cholangiocarcomina. Ann Hepatobiliary Pancreat Surg. 2019;23:319–26.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Cidon EU. Resectable cholangiocarcinoma: reviewing the role of adjuvant strategies. Clin Med Insights Oncol. 2016;10:43–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Huang XT, Huang CS, Li JH, et al. Evaluating the adequacy of nodal status in node negative gallbladder cancer with T1b–T2 stages: use of nodal staging score. HPB. 2020;S1365-182x(20):31163–1. https://doi.org/10.1016/j.hpb.2020.09.018 Online ahead of print.

    Article  Google Scholar 

  7. AlMasri S, Nassour I, Tohme S, et al. Long-term survival following minimally invasive extended cholecystectomy for gallbladder cancer: a 7-year experience from the National Cancer Database. J Surg Oncol. 2020;122:707–15.

    Article  Google Scholar 

  8. Bohan PMK, Kirby DT, Chick RC, et al. Adjuvant chemotherapy in resectable gallbladder cancer is underutilized despite benefits in node-positive patients. Ann Surg Oncol. 2020. https://doi.org/10.1245/s10434-020-08973-x.

    Article  PubMed  Google Scholar 

  9. Buyyounouski M, Choyke P, Kattan M, et al. AJCC cancer staging manual. 8th ed. Chicago: Springer; 2017. p. 317–25.

    Google Scholar 

  10. Chen Y, Xu Y, Zhang Y. Current status of laparoscopic radical hilar cholangiocarcinoma in Mainland China. Biosci Trends. 2020;14(3):168–73.

    Article  PubMed  Google Scholar 

  11. Wu R, Zhang G, Feng J, et al. Proposal of the optional numbers of examined and positive lymph nodes to the 8th edition of American Joint Committee on Cancer (AJCC) staging for 758 patients with distal cholangiocarcinoma. PLoS ONE. 2020;15(6):e0234464. https://doi.org/10.1371/journal.pone.0234464.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Nitta N, Ohgi K, Sugiura T, et al. Prognostic impact of paraaortic lymph node metastasis in extrahepatic cholangiocarcinoma. World J Surg. 2021;45(2):581–9.

    Article  PubMed  Google Scholar 

  13. He M, Xu X, Feng H, et al. Regional lymphadenectomy vs. extended lymphadenectomy for hilar cholangiocarcinoma (Relay-HC trial): study protocol for a prospective, multicenter, randomized controlled trial. BMC. 2019;20:528. https://doi.org/10.1186/s13063-019-3605-z.

    Article  Google Scholar 

  14. Anderson B, Doyle MBM. Surgical considerations of hilar cholangiocarcinoma. Surg Oncol Clin N Am. 2019;28:601–17.

    Article  PubMed  Google Scholar 

  15. Bhutiani N, Scoggins CR, McMasters KM, et al. The impact of caudate lobe resection on margin status and outcomes in patients with hilar cholangiocarcinoma: a multi-institutional analysis from the US Extrahepatic Biliary Malignancy Consortium. Surgery. 2018;163:726–31.

    Article  PubMed  Google Scholar 

  16. Tran TB, Ethun CG, Pawlik TM, et al. Actual 5-year survivors after surgical resection of hilar cholangiocarcinoma. Ann Surg Oncol. 2019;26:611–8.

    Article  PubMed  Google Scholar 

  17. Ebata T, Mizuno T, Yokoyama Y, et al. Surgical resection for Bismuth type IV perihilar cholangiocarcinoma. BJS. 2018;105:829–38.

    Article  CAS  Google Scholar 

  18. Kaneoka Y, Yamaguchi A, Isogai M, et al. Survival benefit of hepatopancreatoduodenectomy for cholangiocarcinoma in comparison to hepatectomy or pancreatoduodenectomy. World J Surg. 2010;34:2662–70.

    Article  PubMed  Google Scholar 

  19. Sakamoto Y, Nara S, Kishi Y, et al. Is extended hemihepatectomy plus pancreaticoduodenectomy justified for advanced bile duct cancer and gallbladder cancer? Surgery. 2013;153:794–800.

    Article  PubMed  Google Scholar 

  20. Shimizu A, Motoyama H, Kubota K, et al. Safety and oncological benefit of hepatopancreatoduodenectomy for advanced extrahepatic cholangiocarcinoma with horizontal tumor spread: Shinshu University experience. Ann Surg Oncol. 2020;28(4):2012–25. https://doi.org/10.1245/s10434-020-09209-8 Online ahead of print.

    Article  PubMed  Google Scholar 

  21. Toyoda T, Tm Ebata, Mizuno T, et al. Cholangiographic tumor classification for simple patient selection prior to hepatopancreatoduodenectomy for cholangiocarcinoma. Ann Surg Oncol. 2019;26:2971–9.

    Article  PubMed  Google Scholar 

  22. Coimbra FJF, Torres OJM, Alikhanov, et al. Brazilian Consensus on Incidental Gallbladder Carcinoma ABCD. Arq Bras Cir Dig. 2020;33(1):e1.

    Article  Google Scholar 

  23. Lundberg O, Kristoffersson A. Port site metastases from gallbladder cancer after laparoscopic cholecystectomy. Results of a Swedish survey and review of published report. Eur J Surg. 1999;165:215–22.

    Article  CAS  PubMed  Google Scholar 

  24. Z’Graggen K, Birrer S, Maurer CA, Wehrli H, et al. Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsuspected gallbladder carcinoma. Surgery. 1998;124:831–8.

    Article  PubMed  Google Scholar 

  25. Hu JB, Sun XN, Xu J, et al. Port site and distant metastases of gallbladder cancer after laparoscopic cholecystectomy diagnosed by positron emission tomography. World J Gastroenterol. 2008;14:6428–31.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Weiland ST, Mahvi DM, Niederbuger JE, et al. Should suspected early gallbladder cancer be treated laparoscopically? J Gastrointest Surg. 2002;6:50–6.

    Article  PubMed  Google Scholar 

  27. Zhang WJ, Xu GF, Zou XP, et al. Incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy. World J Surg. 2009;33:2651–6.

    Article  PubMed  Google Scholar 

  28. Maker AV, Butte J, Oxenberg J, et al. Is port site resection necessary in the surgical management of gallbladder cancer? Ann Surg Oncol. 2012;19:409–17.

    Article  PubMed  Google Scholar 

  29. Fuks D, Regimbeau JM, Pessaux P, et al. Is port-site resection necessary in surgical management of gallbladder cancer? J Visc Surg. 2013;150(4):277–84.

    Article  CAS  PubMed  Google Scholar 

  30. Lee W, Jeong C, Jang J, et al. Do hepatic-sided tumors require more extensive resection than peritoneal-sided tumors in patients with T2 gallbladder cancer results of a retrospective multicenter study. Surgery. 2017;162(5):515–24.

    Article  PubMed  Google Scholar 

  31. Lee H, Choi DW, Park JY, et al. Surgical strategy for T2 gallbladder cancer according to tumor location. Ann Surg Oncol. 2015;22:2779–86.

    Article  PubMed  Google Scholar 

  32. Park TJ, Ahn KS, Kim YH, et al. The optimal surgical resection approach for T2 gallbladder carcinoma: evaluating the role of surgical extent according to the tumor location. Ann Surg Treat Res. 2018;94:135–41.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Kwon W, Kim H, Han Y, et al. Role of tumor location and surgical extent on prognosis in T2 gallbladder cancer: an international multicenter study. BJS. 2020;107:1334–43.

    Article  CAS  Google Scholar 

  34. Lafaro K, Blakely AM, Melstrom LG, et al. Prognostic impact of tumor location in resected gallbladder cancer: a national cohort analysis. J Surg Oncol. 2020;122:1084–93.

    Article  PubMed  PubMed Central  Google Scholar 

  35. National Comprehensive Cancer Network. Hepatobiliary Cancers (Version 5.2020). Accessed January 10, 2021.

  36. Le Roy B, Gelli M, Pittau G, et al. Neoadjuvant chemotherapy for initially unresectable intrahepatic cholangiocarcinoma. BJS. 2018;105:839–47.

    Article  Google Scholar 

  37. Riby D, Mazzotta AD, Bergeat D, et al. Downstaging with radioembolization or chemotherapy for initially unresectable intrahepatic cholangiocarcinoma. Ann Surg Oncol. 2020;27:3729–37.

    Article  PubMed  Google Scholar 

  38. Baltatzis M, Jagatheeswaran S, Siriwardena A. Neoadjuvant chemoradiotherapy before resection of perihilar cholangiocarcinoma: a systematic review. Hepatobiliary Pancrea Dis Int. 2020;19:103–8.

    Article  Google Scholar 

  39. Cloyd JM, Prakash L, Vauthey JN, et al. The role of preoperative therapy prior to pancreatoduodenectomy for distal cholangiocarcinoma. Am J Surg. 2019;218:145–50.

    Article  PubMed  Google Scholar 

  40. Katayose Y, Nakagawa K, Yoshida H, et al. Neoadjuvant chemoradiation therapy for cholangiocarcinoma to improve R0 resection rate: the first report of phase II study. J Clin Oncol. 2015;33:402.

    Article  Google Scholar 

  41. Gerhards M, Gonzalez Gonzales D, ten Hoopen-Neumann H, et al. Prevention of implantation metastases after resection of proximal bile duct tumors with pre-operative low-dose radiation therapy. Eur J Surg Oncol. 2000;26:480–5.

    Article  CAS  PubMed  Google Scholar 

  42. Primrose JN, Fox RP, Palmer DH, et al. Capecitabine compared with observation in resected biliary tract cancer (BILCAP): a randomized, controlled, multicenter phase 3 study. Lancet. 2019;20(5):663–73.

    Article  CAS  Google Scholar 

  43. Shroff RT, Kennedy EB, Bachini M, et al. Adjuvant therapy for resected biliary tract cancer: ASCO Clinical Practice Guideline. J Clin Oncol. 2019;37:1015–27.

    Article  PubMed  Google Scholar 

  44. Ben-Josef E, Guthrie KA, El-Khoueiry AB, et al. SWOG S0809: A phase II intergroup trial of adjuvant capecitabine and gemcitabine followed by radiotherapy and concurrent capecitabine in extrahepatic cholangiocarcinoma and gallbladder carcinoma. J Clin Oncol. 2015;33:2617–22.

    Article  CAS  PubMed  Google Scholar 

  45. Itano O, Takemura Y, Kishida N, et al. A prospective feasibility study of one-year administration of adjuvant S-1 therapy for resected biliary tract cancer in a multi-institutional trial (Tokyo Study Group for Biliary Cancer: TOSBIC01). BMC Cancer. 2020;20:688–96.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Bergeat D, Turrini O, Courtin-Tanguy L, et al. Impact of adjuvant chemotherapy after pancreaticoduodenectomy for distal cholangiocarcinoma: a propensity score analysis from a French multicentric cohort. Lagenbecks Arch Surg. 2018;403:701–9.

    Article  Google Scholar 

  47. Shi X, Zhang J, Tian H, et al. Role of adjuvant (chemo)radiotherapy for resected extrahepatic cholangiocarcinoma: a meta-analysis. JZUS. 2020;21(7):549–59.

    Article  CAS  Google Scholar 

  48. Bohan PMK, Kirby D, Chick RC, et al. Adjuvant chemotherapy in resectable gallbladder cancer is underutilized despite benefits in node-positive patients. Ann Surg Oncol. 2021;28:1466–80.

    Article  Google Scholar 

  49. Cai YL, Lin YX, Xiong XZ, et al. Postsurgical radiotherapy in stage IIIB gallbladder cancer patients with one to three lymph node metastases: a propensity score matching analysis. Am J Surg. 2020.https://doi.org/10.1016/j.amjsurg.2020.08.007.

  50. Rahnemai-Azar A, Abbasi A, Tsilimigras D, et al. Current advances in minimally invasive surgical management of perihilar cholangiocarcinoma. J Gastrointest Surg. 2020;21:2143–9.

    Article  Google Scholar 

  51. Chen Y, Xu Y, Zhang Y. Current status of laparoscopic radical hilar cholangiocarcinoma in Mainland China. Biosci Trends. 2020;14:168–73.

    Article  PubMed  Google Scholar 

  52. Kang SH, Choi Y, Lee W, et al. Laparoscopic liver resection versus open liver resection for intrahepatic cholangiocarcinoma: 3-year outcomes of a cohort study with propensity score matching. Surg Oncol. 2020;33:63–9.

    Article  PubMed  Google Scholar 

  53. Ratti F, Rawashdeh A, Cipriani F, et al. Intrahepatic cholangiocarcinoma as the new field of implementation of laparoscopic liver resection programs. A comparative propensity score-based analysis of open and laparoscopic liver resections. Surg Endosc. 2020. https://doi.org/10.1007/s00464-020-07588-3.

  54. Kinoshita M, Kanazawa A, Takemura S, et al. Indications for laparoscopic liver resection of mass-forming intrahepatic cholangiocarcinoma. Asian J Endosc Surg. 2020;13:46–58.

    Article  PubMed  Google Scholar 

  55. Guerrini GP, Esposito G, Tarantino G, et al. Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: the first meta-analysis. Lagenbeck’s Arch Surg. 2020;405:265–75.

    Article  Google Scholar 

  56. Martin SP, Drake J, Wach M, et al. Laparoscopic approach to intrahepatic cholangiocarcinoma is associated with an exacerbation of inadequate nodal staging. Ann Surg Oncol. 2019;26:1851–7.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Shiraiwa DK, Carvalho PFDC, Maeda CT, et al. The role of minimally invasive hepatectomy in hilar and intrahepatic cholangiocarcinoma: a systematic review of the literature. J Surg Oncol. 2020;121(5):863–72.

    PubMed  Google Scholar 

  58. Martin SP, Drake J, Wach MM, et al. Laparoscopic approach to intrahepatic cholangiocarcinomas is associated with exacerbation of inadequate nodal staging. Ann Surg Oncol. 2019;26:1851–7.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Cercek A, Boerner T, Tan BR, et al. Assessment of hepatic arterial infusion of floxuridine in combination with systemic gemcitabine and oxaliplatin in patients with unresectable intrahepatic cholangiocarcinoma: a phase 2 clinical trial. JAMA Oncol. 2020;6(1):60–7.

    Article  PubMed  Google Scholar 

  60. Higaki T, Aramaki O, Moriguchi M, et al. Arterial infusion of cisplatin plus S-1 against unresectable intrahepatic cholangiocarcinoma. Biosci Trends. 2018;12(1):73–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 S.W. Sam Jackson, Portland, OR, 97239, USA

    Kimberly Washington MD FACS & Flavio Rocha MD FACS

Authors
  1. Kimberly Washington MD FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Flavio Rocha MD FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Flavio Rocha MD FACS.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Upper Gastrointestinal Cancers

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Washington, K., Rocha, F. Approach to Resectable Biliary Cancers. Curr. Treat. Options in Oncol. 22, 97 (2021). https://doi.org/10.1007/s11864-021-00896-3

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11864-021-00896-3

Keywords

Search

Navigation