Presentation on theme: "Surgical Management of Cholangiocarcinoma"— Presentation transcript:
1 Surgical Management of Cholangiocarcinoma Michael A. Choti, MDDepartment of SurgeryJohns Hopkins Medicine, Baltimore, MD
2 Proposed Questions How do we identify unresectable tumors? What is the management of surgically unresectable tumors?How should we manage suspected cholangiocarcinomas without definitive tissue diagnosis?
3 EPIDEMIOLOGY Relatively uncommon malignancy CholangiocarcinomaEPIDEMIOLOGYRelatively uncommon malignancyMore common outside the United States, particularly in South America and Eastern/Central EuropeLess common than gallbladder cancerIncidence per 100,000 in U.S.: 1.0 in females1.5 in malesIncreasing incidence with age70% of cases in over 65 yearsHilar location most common
7 Hilar Cholangiocarcinoma TreatmentComplete resection is the only effective therapy.Outcomes after R0 resection:5-year overall survival of 25-40%DFS of 15-25%Few patients are resectable.R1/2 resections are not uncommon.Palliating the effects of biliary obstruction is often the primary treatment objective.
8 Questions to Ask When Considering Surgery? Defining Resectability for Hilar CholangiocarcinomaQuestions to Ask When Considering Surgery?Is complete (R0) resection possible?Can it be done with enough remaining liver, adequate blood supply and good biliary drainage?Extent of diseaseVascular involvementLobar atrophyMetastatic diseaseUnderlying liver diseaseOther comorbidities
9 CRITERIA OF UNRESECTABILITY Hilar CholangiocarcinomaCRITERIA OF UNRESECTABILITYPatient-Related FactorsMedical contraindication to major abdominal surgeryCirrhosis or insufficient remnant hepatic volumeMetastatic DiseaseN2 lymphadenopathyDistant metastases
10 CRITERIA OF UNRESECTABILITY Hilar CholangiocarcinomaCRITERIA OF UNRESECTABILITYLocal Tumor-Related FactorsTumor extension to secondary biliary radicles bilaterallyEncasement or occlusion of the main portal vein proximal to its bifurcationUnilateral tumor extension to secondary bile ducts with contralateral vascular encasement or occlusionAtrophy of one hepatic lobe with contralateral portal vein encasement or secondary biliary extension
11 Bismuth-Corlette Classification of Biliary Extent of Hilar Cholangiocarcinoma
12 Complete Tumor Excision with Negative Margins Hilar CholangiocarcinomaGoal of Resection:Complete Tumor Excision with Negative MarginsRecommendedESTABLISHED:Excision of supraduodenal bile ductCholecystectomyRestore bilioenteric continuityLESS CONTROVERSIAL:Routine hepatectomy/caudate (left resections)Portal lymphadenectomySelected major vascular reconstructionMORE CONTROVERSIAL:Routine PV resection (Neuhaus)
14 Anatomical Considerations Hilar CholangiocarcinomaAnatomical ConsiderationsFrequent submucosal tumor extension beyond gross margin (5 – 20 mm)Often unilateral extension to 2o biliary radicles and beyondHepatic resection requiredShimada et al. Int Surg 1988;73:87
15 Results Of Resection for Hilar Cholangiocarcinoma Author (year) N Concomitant Liver % R YearResection (%) Resection Survival (%)Cameron (1990)Gerhards (2000)Su (1996)Hadjis (1990)Jarnagin (2001)Klempnauer (1997)Neuhaus (1999)Kosuge (1999)Nimura (1990)Increasing inclusion of liver resectionIncreasing R0 resection rateImproving survival
16 PREOPERATIVE EVALUATION Hilar CholangiocarcinomaPREOPERATIVE EVALUATIONCholangiographyAssessment of extent of biliary ductal involvementERCP vs MRCP vs PTC2. Cross-sectional imagingSoft tissue extent, lobar atrophy, vascular involvement, remnant volume, metastasesCT vs MRIControversies:Role of preoperative stentingFDG-PETStaging laparoscopy
17 Non-Invasive Imaging: MRI/MRCP High quality images of the biliary tree - as good as cholangioscopy for assessing biliary tumor extent*.Provides additional data regarding metastases, vascular involvement, lobar atrophy.Masselli et al Eu J Radiol (2008)*Lee et al. Gastrointest Endosc 2002;56:25
19 Hilar Cholangiocarcinoma LAPAROSCOPIC STAGINGMost useful to rule out metastatic disease.Less helpful for cholangiocarcinoma than for GB cancer.Consider in locally advanced cases.
20 Hilar Cholangiocarcinoma and Gallbladder Cancer STAGING LAPAROSCOPY100 patients with potentially resectable biliary cancerhilar cholangioca = 56gallbladder ca = 44All underwent staging laparoscopy prior to surgical explorationRESULTS:Overall 69% were unresectable (HC = 59%, GB = 82%)Laparoscopy yield: 48% in patients with gallbladder cancer(56% in those w/o previous cholecystectomy)25% in patients with hilar cholangiocarcinomaMost useful at detecting peritoneal or liver metastases.Weber et al. Ann Surg 235:392 (2002)
21 Hilar Cholangiocarcinoma Role of FDG-PETNot useful for infiltrating cholangiocarcinomaFalse negatives due to low volume metastasesFalse positives due to stents or recent cholecystectomyAnderson et al. J Gastrointest Surg 8:90 (2004)
22 Biliary Stents for the Management of Surgically Unresectable Cholangiocarcinoma
23 Management of Surgically Unresectable Cholangiocarcinoma Percutaneous vs. Endoscopic Stenting?RCT (n=75)Superior technical and clinical success with endoBetter control of bilirubin levelsSignificantly fewer complicationsLower 30-day mortality rateSpeer et al. Lancet (Jul 1987)
24 Percutaneous vs. Endoscopic Stenting for Palliating Hilar Cholangiocarcinoma? RCT comparing metallic percutaneous stent vs. endoscopic stent54 patientsSuccess rate = 75% (p) vs 58% (e)Complication rate 61% (p) vs 35% (e)No difference in freedom from recurrent obstructionMedian survival better in percutaneous group (3.7 vs 2.0 mo, p=0.02)Pinol et al, Radiology 2002
25 Selective Unilateral Stent Drainage for Unresectable Hilar Cholangiocarcinoma MRCP & CT: guide selective guidewire accessGoal: drain only largest intercommunicating segmental ducts with 1 uncovered metal stent35 patients, success rate = 71%Percutaneous stenting required in 3 patients30-day morbidity = 0Median patency of metal stent = 8.9 monthsFreeman, Gastrointest Endosc 2003
26 Single versus Double Endo Stents Prospective RCT of 157 hilar CA (Bismuth I-III)Unilateral drainage adequateFewer technical failuresLess instrumentationFew early complicationsAttempts to place 2nd biliary stent: early complications (cholangitis) w/o survival benefitDe Palma, Gastrointest Endosc 2001
27 Surgical Management of Cholangiocarcinoma SummaryAchieving complete margin negative resection remains the goal in selected patients with hilar cholangiocarcinoma, requiring hepatic resection in nearly all cases.Advances in non-invasive imaging have allowed better identification of unresectable cases.The role of PET, laparoscopic staging remain controversial.The choice of stent palliation approach (endo vs perc) should individualized.