Effect of Margin Status on Survival after Resection of Hilar Cholangiocarcinoma in the Modern Era of Adjuvant Therapies

Introduction Studies have shown that for patients with hilar cholangiocarcinoma (HC), survival is associated with negative resection margins (R0). This requires increasingly proximal resection, putting patients at higher risk for complications, which may delay chemotherapy. For patients with microscopically positive resection margins (R1), the use of modern adjuvant therapies may offset the effect of R1 resection. Methods Patients at our institution with HC undergoing curative-intent resection between January 2008 and July 2019 were identified by retrospective record review. Demographic data, operative details, tumor characteristics, postoperative outcomes, recurrence, survival, and follow-up were recorded. Patients with R0 margin were compared to those with R1 margin. Patients with R2 resection were excluded. Results Seventy-five patients underwent attempted resection with 34 (45.3%) cases aborted due to metastatic disease or locally advanced disease. Forty-one (54.7%) patients underwent curative-intent resection with R1 rate of 43.9%. Both groups had similar rates of adjuvant therapy (56.5% vs. 61.1%, P = .7672). Complication rates and 30 mortality were similar between groups (all P > .05). Both groups had similar median recurrence-free survival (R0 29.2 months vs. R1 27.8 months, P = .540) and median overall survival (R0 31.2 months vs. R1 38.8 months, P = .736) with similar median follow-up time (R0 29.9 months vs. R1 28.5 months, P = .8864). Conclusions At our institution, patients undergoing hepatic resection for HC with R1 margins have similar recurrence-free and overall survival to those with R0 margins. Complications and short-term mortality were similar. This may indicate that with use of modern adjuvant therapies obtaining an R0 resection is not an absolute mandate.

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Impact of Preoperative Three-Dimensional Computed Tomography Cholangiography on Postoperative Resection Margin Status in Patients Operated due to Hilar Cholangiocarcinoma

Gastroenterology Research and Practice ◽

10.1155/2017/1947023 ◽

2017 ◽

Vol 2017 ◽

pp. 1-6 ◽

Cited By ~ 2

Author(s):

A. Andert ◽

P. Bruners ◽

C. Heidenhain ◽

F. Ulmer ◽

C. D. Klink ◽

...

Keyword(s):

Computed Tomography ◽

Hilar Cholangiocarcinoma ◽

Resection Margin ◽

Three Dimensional ◽

Patient Characteristics ◽

Margin Status ◽

University Hospital ◽

Preoperative Imaging ◽

R0 Resection ◽

Resection Margin Status

Introduction. The purpose of this study was to analyse the value of 3-dimensional computed tomography cholangiography (3D-ERC) compared to conventional retrograde cholangiography in the preoperative diagnosis of hilar cholangiocarcinoma (HC) with special regard to the resection margin status (R0/R1). Patients and Methods. All hepatic resections performed between January 2011 and November 2013 in patients with HC at the Department of General, Visceral and Transplant Surgery of the RWTH Aachen University Hospital were analysed. All patients underwent an ERC and contrast-enhanced multiphase CT scan or a 3D-ERC. Results. The patient collective was divided into two groups (group ERC: n=17 and group 3D-ERC: n=16). There were no statistically significant differences between the two groups with regard to patient characteristics or intraoperative data. Curative liver resection with R0 status was reached in 88% of patients in group ERC and 87% of patients in group 3D-ERC (p=1.00). We could not observe any differences with regard to postoperative complications, hospital stay, and mortality rate between both groups. Conclusion. Based on our findings, preoperative imaging with 3D-ERC has no benefit for operative planning and R0 resection status. It cannot replace the exploration by an experienced surgeon in a centre for hepatobiliary surgery.

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Significance of proximal ductal margin status after resection of hilar cholangiocarcinoma

HPB ◽

10.1016/j.hpb.2020.05.002 ◽

2020 ◽

Author(s):

Lavanya Yohanathan ◽

Kristopher P. Croome ◽

Michael Traynor ◽

Carlos A. Puig ◽

Kristin C. Mara ◽

...

Keyword(s):

Hilar Cholangiocarcinoma ◽

Margin Status

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The Proximal Margin of Resected Hilar Cholangiocarcinoma: The Effect of Microscopic Positive Margin on Long-Term Survival

The American Surgeon ◽

10.1177/000313481207800440 ◽

2012 ◽

Vol 78 (4) ◽

pp. 471-477 ◽

Cited By ~ 10

Author(s):

Jae Hoon Lee ◽

Dae Wook Hwang ◽

Sang Yeup Lee ◽

Kwang-Min Park ◽

Young-Joo Lee

Keyword(s):

Hilar Cholangiocarcinoma ◽

Positive Margin ◽

Margin Status ◽

R0 Resection ◽

Prognostic Impact ◽

Proximal Margin ◽

Term Survival ◽

Long Term Survival ◽

Number Of Patients

Achieving an R0 resection can be difficult for hilar cholangiocarcinoma (HC) because of the anatomic structures of the hepatic hilum and frequent tumor infiltration. The aim of this study was to evaluate the margin status of bile duct resected in HC and prognostic impact of R1 resection. Between 2000 and 2009, 245 patients underwent operation for HC at Asan Medical Center. We retrospectively analyzed the clinicopathologic features and surgical outcomes, focusing on the proximal margin status, of 162 cases of patients with curative intention. Curative resections were achieved in 125 (52.1%) patients, and R1 resections were performed in 43 (26.5%). Proximal ductal margin states were classified as free margin (73.5%), carcinoma in situ (3.7%), and invasive carcinoma (22.8%). The 3- and 5-year survival rates of the R1 group (39.5% and 34.9%) were not significantly different from the rates of the R0 group (55.5% and 44.5%, respectively). Multivariate analysis showed lymph node metastasis ( P = 0.001) and histologic differentiation ( P = 0.001) were independent predictors of patient survival. The aggressive surgical approach based on liver resection including caudate lobe may increase the number of patients eligible for a curative chance and improve long-term survival even if the microscopically positive margin is still achieved.

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Portal Vein Resection for Hilar Cholangiocarcinoma

The American Surgeon ◽

10.1177/000313480607200706 ◽

2006 ◽

Vol 72 (7) ◽

pp. 599-605 ◽

Cited By ~ 7

Author(s):

Alan W. Hemming ◽

Robin D. Kim ◽

Kristin L. Mekeel ◽

Shiro Fujita ◽

Alan I. Reed ◽

...

Keyword(s):

Bile Duct ◽

Portal Vein ◽

Hilar Cholangiocarcinoma ◽

Operative Mortality ◽

Margin Status ◽

Portal Vein Resection ◽

Term Survival ◽

Long Term Survival ◽

Vein Resection

Hilar cholangiocarcinoma remains a difficult challenge for the surgeon. Achieving negative surgical margins when resecting this relatively uncommon tumor is technically demanding as a result of the close proximity of the bile duct bifurcation to the vascular inflow of the liver. A recent advance in surgical treatment is the addition of portal vein resection to the procedure. Resection of the portal vein increases the number of patients offered a potentially curative approach but is technically more difficult and may increase the risk of the procedure. This study reviews the results of portal vein resection for hilar cholangiocarcinoma. Between 1998 and 2005, 60 patients underwent potentially curative resections of hilar cholangiocarcinoma. Mean patient age was 64 ± 12 years (range, 24–85 years). Liver resections performed along with biliary resection included 49 trisegmentectomies (37 right, 12 left) and 10 lobectomies (8 left, 2 right). One patient had only the bile duct resected. Four patients also had simultaneous pancreaticoduodenectomy performed. Twenty-six patients required portal vein resection and reconstruction to achieve negative margins, 3 of which also required reconstruction of the hepatic artery. Operative mortality was 8 per cent with an overall complication rate of 40 per cent. Patients who underwent portal vein resection had an operative mortality of 4 per cent, which was not different from the 12 per cent mortality in patients who did not undergo portal vein resection (P = 0.39). There was no difference in actuarial patient survival between patients who underwent portal vein resection and those who did not (5-year survival 39 per cent vs. 41 per cent, P = not significant). Negative margins were achieved in 80 per cent of cases and were associated with improved survival (P < 0.01). Five-year actuarial survival in patients undergoing resection with negative margins was 45 per cent. There was no difference in margin status or long-term survival between those patients who underwent portal vein resection and those who did not. Only negative margin status was associated with improved survival by multivariate analysis. Portal vein resection for hilar cholangiocarcinoma is safe and allows a chance for long-term survival in otherwise unresectable patients.

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