Abstract
The first separate staging system for perihilar cholangiocarcinoma was introduced by the seventh edition American Joint Committee on Cancer (AJCC) manual. To determine whether it strengthens the prognostic value, a comparative analysis with the sixth edition was performed, through which some areas for improvements were identified. The tumor-nodes-metastasis (TNM) stage and R status of 378 operated perihilar cholangiocarcinoma patients between 1990 and 2011 were reviewed. Survival analyses were conducted. Although the stages were up-numbered from I to II and II to III, the sixth and seventh editions had intercorresponding stages providing similar classifications. Applying the seventh edition, 9.8 % were downstaged and 1.3 % upstaged. Several issues were identified. First, both editions did not discriminate node-free locally advanced resectable diseases and node-positive resectable diseases. Second, stages IVA and IVB in the seventh edition had different prognoses suggesting misclassification of stage IVA. Third, the prognosis of liver invasion (T2b) resembled that of T3 more than T2a in the seventh edition, warranting investigation into the downstaging of liver invasion. Lastly, curative resections were possible in some Bismuth type 4 tumors allowing for better survival, suggesting that classifying them as unresectable disease (T4) should be revised. A discrete staging for perihilar cholangiocarcinoma is necessary; however, some points need further clarifications.
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Nakeeb A, Pitt HA, Sohn TA, Coleman J, Abrams RA, Piantadosi S, Hruban RH, Lillemoe KD, Yeo CJ, Cameron JL. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors. Ann Surg 1996;224:463-73; discussion 73-5.
Greene FL, American Joint Committee on Cancer., American Cancer Society. AJCC cancer staging manual. 6th ed. New York: Springer-Verlag; 2002.
Edge SB, American Joint Committee on Cancer. AJCC cancer staging manual. 7th ed. New York: Springer; 2010.
Juntermanns B, Sotiropoulos GC, Radunz S, Reis H, Heuer M, Baba HA, Canbay A, Schuler M, Gerken G, Paul A, Kaiser GM. Comparison of the Sixth and the Seventh Editions of the UICC Classification for Perihilar Cholangiocarcinoma. Ann Surg Oncol 2013;20:277-84.
Ebata T, Kosuge T, Hirano S, Unno M, Yamamoto M, Miyazaki M, Kokudo N, Miyagawa S, Takada T, Nagino M. Proposal to modify the International Union Against Cancer staging system for perihilar cholangiocarcinomas. Br J Surg 2014;101:79-88.
de Groen PC, Gores GJ, LaRusso NF, Gunderson LL, Nagorney DM. Biliary tract cancers. N Engl J Med 1999;341:1368-78.
Hong SM, Kim MJ, Pi DY, Jo D, Cho HJ, Yu E, Ro JY. Analysis of extrahepatic bile duct carcinomas according to the New American Joint Committee on Cancer staging system focused on tumor classification problems in 222 patients. Cancer-Am Cancer Soc 2005;104:802-10.
DeOliveira ML, Cunningham SC, Cameron JL, Kamangar F, Winter JM, Lillemoe KD, Choti MA, Yeo CJ, Schulick RD. Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution. Ann Surg 2007;245:755-62.
Ebata T, Nagino M, Kamiya J, Uesaka K, Nagasaka T, Nimura Y. Hepatectomy with portal vein resection for hilar cholangiocarcinoma: audit of 52 consecutive cases. Ann Surg 2003;238:720-7.
Aljiffry M, Abdulelah A, Walsh M, Peltekian K, Alwayn I, Molinari M. Evidence-based approach to cholangiocarcinoma: a systematic review of the current literature. J Am Coll Surg 2009;208:134-47.
Sasaki R, Kondo T, Oda T, Murata S, Wakabayashi G, Ohkohchi N. Impact of three-dimensional analysis of multidetector row computed tomography cholangioportography in operative planning for hilar cholangiocarcinoma. Am J Surg 2011;202:441-8.
Endo I, Shimada H, Sugita M, Fujii Y, Morioka D, Takeda K, Sugae S, Tanaka K, Togo S, Bourquain H, Peitgen HO. Role of three-dimensional imaging in operative planning for hilar cholangiocarcinoma. Surgery 2007;142:666-75.
Madariaga JR, Iwatsuki S, Todo S, Lee RG, Irish W, Starzl TE. Liver resection for hilar and peripheral cholangiocarcinomas: a study of 62 cases. Ann Surg 1998;227:70-9.
Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet 1975;140:170-8.
Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg 1992;215:31-8.
Jarnagin WR, Fong Y, DeMatteo RP, Gonen M, Burke EC, Bodniewicz BJ, Youssef BM, Klimstra D, Blumgart LH. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001;234:507-17; discussion 17-9.
Hiriart JB, Laurent C, Blanc JF. Perihilar cholangiocarcinoma, the need for a new staging system. Clin Res Hepatol Gastroenterol 2011;35:697-8.
Deoliveira ML, Schulick RD, Nimura Y, Rosen C, Gores G, Neuhaus P, Clavien PA. New staging system and a registry for perihilar cholangiocarcinoma. Hepatology 2011;53:1363-71.
Jang JY, Kim SW, Park DJ, Ahn YJ, Yoon YS, Choi MG, Suh KS, Lee KU, Park YH. Actual long-term outcome of extrahepatic bile duct cancer after surgical resection. Ann Surg 2005;241:77-84.
Kondo S, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, Furuse J, Saito H, Tsuyuguchi T, Yamamoto M, Kayahara M, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Hirano S, Amano H, Miura F. Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment. J Hepatobiliary Pancreat Surg 2008;15:41-54.
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This study was supported by a grant from Yongang Foundation, Korea.
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This study was presented at the 11th World Congress of the International Hepato-Pancreato-Biliary Association, Seoul, Korea, March 2014.
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Kwon, W., Jang, JY., Chang, Y.R. et al. Suggestions for Improving Perihilar Cholangiocarcinoma Staging Based on an Evaluation of the Seventh Edition AJCC System. J Gastrointest Surg 19, 666–674 (2015). https://doi.org/10.1007/s11605-014-2732-9
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DOI: https://doi.org/10.1007/s11605-014-2732-9