Presentation on theme: "Great Debates & Updates in GI Malignancies"— Presentation transcript:
1Great Debates & Updates in GI Malignancies March 28-29, 2014Biliary Tract Cancers: Standards of Care and Emerging TherapiesThe Role of SurgeryMichael A. Choti, MDDepartment of SurgeryUT Southwestern Medical Center
4Trends in Incidence of Cholangiocarcinoma in the United States SEER: Shaib et al. Semin Liver Dis (2004)
5Assessment of Surgical Resectability Intrahepatic CholangiocarcinomaAssessment of Surgical ResectabilityCapability to remove all gross disease (R0 resection) and leave an adequate inflow, outflow, and remnant liver volume
6Prognosis Following Resection Intrahepatic CholangiocarcinomaPrognosis Following ResectionSatellitosis5-year: 33%MVI+ NodesMDACC (2006)
7Controversies Regarding Surgical Resectability Intrahepatic CholangiocarcinomaControversies Regarding Surgical ResectabilityMultifocal disease and satellitosisIntraoperative findings of positive perihepatic nodesPreoperative findings of nodal involvementRole of hilar lymphadenectomy
9Assessment of Surgical Resectability Distal CholangiocarcinomaHistoric MethodCurrent Method
10Assessment of Surgical Resectability Distal CholangiocarcinomaMore likely locally resectable than pancreatic adenoCaPatients often present with a distal CBD stricture and no massBrushings and biopsies can be negativeCa19-9 elevationConsider resection in patient with stricture and no mass
11Hilar Cholangiocarcinoma Gerald Klatskin, MD (Yale University)Thirteen cases reported in 1965Adenocarcinoma at hepatic duct bifurcationKlatskin, G. American Journal of Medicine (1965) 38:
12Hilar Cholangiocarcinoma TreatmentComplete resection is the only effective therapyOutcomes after R0 resection:5-year overall survival of 25-40%DFS of 15-25%The minority of patients are resectableR1 resections are commonPalliating the effects of biliary obstruction is often the primary treatment objective
13CRITERIA OF UNRESECTABILITY Hilar CholangiocarcinomaCRITERIA OF UNRESECTABILITYPatient-Related FactorsMedical contraindication to major abdominal surgeryCirrhosis or insufficient remnant hepatic volumeMetastatic DiseaseN2 lymphadenopathyDistant metastases
14CRITERIA 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
15Complete 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)
16Controversies Regarding Surgical Resectability Hilar CholangiocarcinomaVascular reconstruction of portal vein and/or hepatic arteryHilar lymph node involvement and role of lymphadenectomySmall remnant volume and use of preoperative right portal vein embolization
17Neoadjuvant Chemoradiation Therapy Followed By Liver Transplantation for Hilar CholangioCa Murad et al. Gastroenterology 2012
18Neoadjuvant Chemoradiation Therapy Followed By Liver Transplantation for Hilar CholangioCa Murad et al. Gastroenterology 2012
20QUESTIONS How extensive of a preoperative evaluation is required? Gallbladder CancerQUESTIONSHow extensive of a preoperative evaluation is required?When is radical surgery indicated?How extensive of surgical resection is required?What is the role of adjuvant therapy?
21Outcomes Following Resection for T2 Gallbladder Cancer Radical resectionCholecystectomyFong et al. Ann Surg 232:557 (2000)
22EXTENDED RESECTION FOR T2-T3 Gallbladder CancerEXTENDED RESECTION FOR T2-T3ESTABLISHED:Liver resection of gallbladder bedHilar lymphadenectomyCBD resection/reconstruction if cystic duct margin +Selected use of more major resectionSOMEWHAT CONTROVERSIAL:Routine segment 4/5 liver resectionRoutine CBD resection/reconstructionRoutine trocar site excisionMORE CONTROVERSIAL:Routine trisectorectomyRoutine radical lymphadenectomy
23Hilar Cholangiocarcinoma and Gallbladder Cancer LAPAROSCOPIC STAGINGMost useful to rule out metastatic diseaseLess helpful for cholangiocarcinoma than GB CaConsider in locally advanced cases.
24Hilar 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)
25Hilar Cholangiocarcinoma and Gallbladder Cancer 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)
26Surgical Management of Biliary Cancer SummaryBile duct cancers are uncommon malignancies with a rising incidence and poor prognosis.In particular, intraheptic cholangiocarcinoma is increasing in incidence.Surgery remains the only curative therapy, and curative resection is the most important prognostic factor.Controversial indications for surgery include satellitosis and nodal involvementTransplantation combined with neoadjuvant therapy is an emerging therapy in unresectable hilar CCC.