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Biliary Tract Cancers: Standards of Care and Emerging Therapies Michael A. Choti, MD Department of Surgery UT Southwestern Medical Center Great Debates.

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Presentation on theme: "Biliary Tract Cancers: Standards of Care and Emerging Therapies Michael A. Choti, MD Department of Surgery UT Southwestern Medical Center Great Debates."— Presentation transcript:

1 Biliary Tract Cancers: Standards of Care and Emerging Therapies Michael A. Choti, MD Department of Surgery UT Southwestern Medical Center Great Debates & Updates in GI Malignancies March 28-29, 2014 The Role of Surgery

2 Disclosures none

3 LOCATION Peripheral 7-20% Intrahepatic mass Cirrhosis uncommon Etiology unknown Hilar 40-60% Biliary confluence Most common Distal 20-30% 10-15% of peripancreatic tumors Cholangiocarcinoma

4 SEER: Shaib et al. Semin Liver Dis (2004) Trends in Incidence of Cholangiocarcinoma in the United States

5 Assessment of Surgical Resectability Intrahepatic Cholangiocarcinoma Capability to remove all gross disease (R0 resection) and leave an adequate inflow, outflow, and remnant liver volume

6 5-year: 33% Prognosis Following Resection Intrahepatic Cholangiocarcinoma Satellitosis MVI + Nodes MDACC (2006)

7 Controversies Regarding Surgical Resectability Intrahepatic Cholangiocarcinoma 1.Multifocal disease and satellitosis 2.Intraoperative findings of positive perihepatic nodes 3.Preoperative findings of nodal involvement 4.Role of hilar lymphadenectomy

8 Pancreaticoduodenectomy (Whipple) Surgical Management Distal Cholangiocarcinoma

9 Assessment of Surgical Resectability Historic Method Current Method Distal Cholangiocarcinoma

10 Assessment of Surgical Resectability Distal Cholangiocarcinoma More likely locally resectable than pancreatic adenoCa Patients often present with a distal CBD stricture and no mass Brushings and biopsies can be negative Ca19-9 elevation Consider resection in patient with stricture and no mass

11 Gerald Klatskin, MD (Yale University) Thirteen cases reported in 1965 Adenocarcinoma at hepatic duct bifurcation Klatskin, G. American Journal of Medicine (1965) 38: Hilar Cholangiocarcinoma

12 Complete resection is the only effective therapy Outcomes after R0 resection: –5-year overall survival of % –DFS of 15-25% The minority of patients are resectable R1 resections are common Palliating the effects of biliary obstruction is often the primary treatment objective Hilar Cholangiocarcinoma Treatment

13 Patient-Related Factors Medical contraindication to major abdominal surgery Cirrhosis or insufficient remnant hepatic volume Metastatic Disease N2 lymphadenopathy Distant metastases Hilar Cholangiocarcinoma CRITERIA OF UNRESECTABILITY

14 Local Tumor-Related Factors Tumor extension to secondary biliary radicles bilaterally Encasement or occlusion of the main portal vein proximal to its bifurcation Unilateral tumor extension to secondary bile ducts with contralateral vascular encasement or occlusion Atrophy of one hepatic lobe with contralateral portal vein encasement or secondary biliary extension Hilar Cholangiocarcinoma CRITERIA OF UNRESECTABILITY

15 ESTABLISHED: Excision of supraduodenal bile duct Cholecystectomy Restore bilioenteric continuity Hilar Cholangiocarcinoma Goal of Resection: Complete Tumor Excision with Negative Margins LESS CONTROVERSIAL: Routine hepatectomy/caudate (left resections) Portal lymphadenectomy Selected major vascular reconstruction MORE CONTROVERSIAL: Routine PV resection (Neuhaus) Recommended

16 Controversies Regarding Surgical Resectability Hilar Cholangiocarcinoma 1.Vascular reconstruction of portal vein and/or hepatic artery 2.Hilar lymph node involvement and role of lymphadenectomy 3.Small remnant volume and use of preoperative right portal vein embolization

17 Neoadjuvant Chemoradiation Therapy Followed By Liver Transplantation for Hilar CholangioCa Murad et al. Gastroenterology 2012

18 Neoadjuvant Chemoradiation Therapy Followed By Liver Transplantation for Hilar CholangioCa Murad et al. Gastroenterology 2012

19 Gallbladder Cancer

20 1.How extensive of a preoperative evaluation is required? 2.When is radical surgery indicated? 3.How extensive of surgical resection is required? 4.What is the role of adjuvant therapy? Gallbladder Cancer QUESTIONS

21 Fong et al. Ann Surg 232:557 (2000) Radical resection Cholecystectomy Outcomes Following Resection for T2 Gallbladder Cancer

22 ESTABLISHED: Liver resection of gallbladder bed Hilar lymphadenectomy CBD resection/reconstruction if cystic duct margin + Selected use of more major resection Gallbladder Cancer EXTENDED RESECTION FOR T2-T3 SOMEWHAT CONTROVERSIAL: Routine segment 4/5 liver resection Routine CBD resection/reconstruction Routine trocar site excision MORE CONTROVERSIAL: Routine trisectorectomy Routine radical lymphadenectomy

23 Most useful to rule out metastatic disease Less helpful for cholangiocarcinoma than GB Ca Consider in locally advanced cases. Hilar Cholangiocarcinoma and Gallbladder Cancer LAPAROSCOPIC STAGING

24 STAGING LAPAROSCOPY Hilar Cholangiocarcinoma and Gallbladder Cancer Weber et al. Ann Surg 235:392 (2002) 100 patients with potentially resectable biliary cancer hilar cholangioca = 56 gallbladder ca = 44 All underwent staging laparoscopy prior to surgical exploration RESULTS: 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 cholangiocarcinoma Most useful at detecting peritoneal or liver metastases.

25 Role of FDG-PET Hilar Cholangiocarcinoma and Gallbladder Cancer Anderson et al. J Gastrointest Surg 8:90 (2004) Not useful for infiltrating cholangiocarcinoma False negatives due to low volume metastases False positives due to stents or recent cholecystectomy

26 Summary Surgical Management of Biliary Cancer 1.Bile duct cancers are uncommon malignancies with a rising incidence and poor prognosis. 2.In particular, intraheptic cholangiocarcinoma is increasing in incidence. 3.Surgery remains the only curative therapy, and curative resection is the most important prognostic factor. 4.Controversial indications for surgery include satellitosis and nodal involvement 5.Transplantation combined with neoadjuvant therapy is an emerging therapy in unresectable hilar CCC.


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