Objectives. To evaluate, in hilar cholangiocarcinoma (HCCA), the prognostic impact of specific preoperative radiologic parameters on resectability, metastases, and yield of laparoscopy, and to evaluate the currently used staging systems. Methods. Consecutive patients with HCCA presenting in our center from January 2003 through August 2010 were evaluated. Suspicion on lymph node metastasis, portal vein and hepatic artery involvement, lobar atrophy, and proximal extent of ductal invasion was scored. The prognostic value of these parameters for predicting resectability, yield of diagnostic laparoscopy, likelihood of metastatic disease, R0 resection, and survival was assessed. The Bismuth-Corlette classification and MSKCC staging system were evaluated. Results. Of all 289 evaluated patients, 158 patients (55%) had unresectable disease based on cross-sectional imaging studies or diagnostic laparoscopy; 131 patients (45%) underwent exploration. 83 patients (64%) underwent resection, of whom 67 (87%) had a radical (R0) resection. Suspicious lymph nodes and involvement of the hepatic artery were important prognostic factors for resectability. Predictive power of the evaluated staging systems was limited. Conclusions. Current staging systems predict resectability, but there is room for improvement. Hepatic artery involvement and nodal status might be important factors for prediction of resectability and should be considered in future staging systems. 1. Introduction Hilar cholangiocarcinoma (HCCA), or Klatskin tumor, is a rare cancer arising at the confluence of the right and left hepatic ducts. Radical surgery is still the only curative treatment, although this can only be performed in a minority of patients. Many different imaging techniques are used for staging of HCCA. Nonetheless, only 50–60% of patients who are surgically explored are ultimately amenable to a potentially curative resection, due to peritoneal, nodal, or liver metastases, as well as locally advanced disease [1]. Already in 1975 the Bismuth-Corlette (BC) classification was proposed [2], which has been modified in 1992 [3]. This classification system is based on proximal, ductal extent of the tumor. Since the BC classification was not able to predict resectability [4, 5], the Memorial Sloan-Kettering Cancer Center (MSKCC) developed a new presurgical T-staging system in 1998 [6] that also took into account portal vein involvement, lobar atrophy, and ductal extent of the tumor. This staging system was further modified in 2001 [7]. Lastly, in 2009 the TNM staging system for malignant tumors was
References
[1]
F. Ito, C. S. Cho, L. F. Rikkers, and S. M. Weber, “Hilar cholangiocarcinoma: current management,” Annals of Surgery, vol. 250, no. 2, pp. 210–218, 2009.
[2]
H. Bismuth and M. B. Corlette, “Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver,” Surgery Gynecology and Obstetrics, vol. 140, no. 2, pp. 170–178, 1975.
[3]
H. Bismuth, R. Nakache, and T. Diamond, “Management strategies in resection for hilar cholangiocarcinoma,” Annals of Surgery, vol. 215, no. 1, pp. 31–38, 1992.
[4]
J. J. Kloek, F. J. Ten Kate, O. R. C. Busch, D. J. Gouma, and T. M. van Gulik, “Surgery for extrahepatic cholangiocarcinoma: predictors of survival,” HPB, vol. 10, no. 3, pp. 190–195, 2008.
[5]
S. Kondo, S. Hirano, Y. Ambo et al., “Forty consecutive resections of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins: results of a prospective study,” Annals of Surgery, vol. 240, no. 1, pp. 95–101, 2004.
[6]
E. C. Burke, W. R. Jarnagin, S. N. Hochwald, P. W. T. Pisters, Y. Fong, and L. H. Blumgart, “Hilar cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative operation, and a prosurgical clinical staging system,” Annals of Surgery, vol. 228, no. 3, pp. 385–394, 1998.
[7]
W. R. Jarnagin, Y. Fong, R. P. DeMatteo et al., “Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma,” Annals of Surgery, vol. 234, no. 4, pp. 507–519, 2001.
[8]
L. H. Sobin, M. K. Gospodarowicz, and C. Wittekind, Eds., TNM Classification of Malignant Tumours, Wiley-Blackwell, Oxford, UK, 7th edition, 2009.
[9]
S. Dinant, M. F. Gerhards, E. A. J. Rauws, O. R. C. Busch, D. J. Gouma, and T. M. Van Gulik, “Improved outcome of resection of hilar cholangiocarcinoma (Klatskin tumor),” Annals of Surgical Oncology, vol. 13, no. 6, pp. 872–880, 2006.
[10]
M. Nagino, J. Kamiya, T. Arai, H. Nishio, T. Ebata, and Y. Nimura, ““Anatomic” right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma,” Annals of Surgery, vol. 243, no. 1, pp. 28–32, 2006.
[11]
H. Y. Lee, S. H. Kim, J. M. Lee et al., “Preoperative assessment of resectability of hepatic hilar cholangiocarcinoma: combined CT and cholangiography with revised criteria,” Radiology, vol. 239, no. 1, pp. 113–121, 2006.
[12]
T. M. Van Gulik, J. J. Kloek, A. T. Ruys et al., “Multidisciplinary management of hilar cholangiocarcinoma (Klatskin tumor): extended resection is associated with improved survival,” European Journal of Surgical Oncology, vol. 37, no. 1, pp. 65–71, 2011.
[13]
A. T. Ruys, O. R. Busch, D. J. Gouma, and T. M. van Gulik, “Staging laparoscopy for hilar cholangiocarcinoma: is it still worthwhile?” Annals of Surgical Oncology, vol. 18, no. 9, pp. 2647–2653, 2011.
[14]
E. H. Tilleman, S. M. De Castro, O. R. Busch et al., “Diagnostic laparoscopy and laparoscopic ultrasound for staging of patients with malignant proximal bile duct obstruction,” Journal of Gastrointestinal Surgery, vol. 6, no. 3, pp. 426–431, 2002.
[15]
W. de Graaf, K. P. van Lienden, S. Dinant et al., “Assessment of future remnant liver function using hepatobiliary scintigraphy in patients undergoing major liver resection,” Journal of Gastrointestinal Surgery, vol. 14, no. 2, pp. 369–378, 2010.
[16]
W. De Graaf, K. P. Van Lienden, T. M. Van Gulik, and R. J. Bennink, “99mTc-mebrofenin hepatobiliary scintigraphy with SPECT for the assessment of hepatic function and liver functional volume before partial hepatectomy,” Journal of Nuclear Medicine, vol. 51, no. 2, pp. 229–236, 2010.
[17]
J. Valle, H. Wasan, D. H. Palmer et al., “Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer,” The New England Journal of Medicine, vol. 362, no. 14, pp. 1273–1281, 2010.
[18]
A. T. Ruys, H. S. van, O. R. Busch, E. A. Rauws, D. J. Gouma, and T. M. van Gulik, “Long-term survival in hilar cholangiocarcinoma also possible in unresectable patients,” World Journal of Surgery, vol. 36, no. 9, pp. 2179–2186, 2012.
[19]
W. R. Jarnagin, Y. Fong, R. P. DeMatteo et al., “Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma,” Annals of Surgery, vol. 234, no. 4, pp. 507–519, 2001.
[20]
M. Nagino, Y. Nimura, H. Nishio et al., “Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases,” Annals of Surgery, vol. 252, no. 1, pp. 115–123, 2010.
[21]
S. M. Weber, R. P. DeMatteo, Y. Fong, L. H. Blumgart, and W. R. Jarnagin, “Staging laparoscopy in patients with extrahepatic biliary carcinoma: analysis of 100 patients,” Annals of Surgery, vol. 235, no. 3, pp. 392–399, 2002.
[22]
M. L. Deoliveira, R. D. Schulick, Y. Nimura et al., “New staging system and a registry for perihilar cholangiocarcinoma,” Hepatology, vol. 53, no. 4, pp. 1363–1371, 2011.
[23]
A. T. Ruys, F. J. Kate, O. R. Busch, M. R. Engelbrecht, D. J. Gouma, and T. M. van Gulik, “Metastatic lymph nodes in hilar cholangiocarcinoma: does size matter?” HPB, vol. 13, no. 12, pp. 881–886, 2011.
[24]
A. T. Ruys, B. E. van Beem, M. R. Engelbrecht, S. Bipat, J. Stoker, and T. M. van Gulik, “Radiologic Staging in Patients with hilar cholangiocarcinoma: a systematic review and meta-analysis,” British Journal of Radiology, vol. 85, no. 1017, pp. 1255–1262, 2012.
