Surgical MaCholangio

Michael A. DepartmentDepartment

Johns Hopkins Medi

nagement of ocarcinoma

Choti, MDt of Surgeryt of Surgeryicine, Baltimore, MD

Proposed QProposed Q

1. How do we identify

2 Wh t i th2. What is the manageunresectable tumors

3. How should we mancholangiocarcinomagtissue diagnosis?

QuestionsQuestions

unresectable tumors?

t f i llement of surgically s?

nage suspected as without definitive

EPIDEMCholangioc

EPIDEM

Relatively uncommon malignRelatively uncommon malignMore common outside the USouth America and Eastern/

Less common than gallbladd

Incidence per 100,000 in U.S

Increasing incidence with ag70% of cases in over 6

Hilar location most common

IOLOGYcarcinoma

IOLOGY

nancynancyUnited States, particularly in /Central Europep

der cancer

S.: 1.0 in females1.5 in males

ge65 years

LCholangioc

LocaPeripheral HiPeripheral Hi

• 7-20%• Intrahepatic mass• Cirrhosis uncommon

• 40-60%• Biliary co• Most com• Cirrhosis uncommon

• Etiology unknown• Most com

ticarcinoma

ationlar Distallar Distal

onfluencemmon

• 20-30%• 10-15% of peripancreaticmmon peripancreatic tumors

CholangiocJ h H ki EJohns Hopkins Expe

Intrahepatic8%Di t l 8%Distal

42%

Perihilar50%

De Oliviera et al. Ann Surg (2007)

carcinomai (1973 2004)erience (1973-2004)

25%

38%

12%25%

CholangiocJohns Hopkins S

00

Overall S

Johns Hopkins S0.

751.

0.2

50.

500.

000.

0 20l

p < .001

p < .001Palliated (n

anal

Resected Margin n(n = 259)( )

5-year Survival 30 %Median Survival 28 mo

carcinoma: Series (All Sites)Survival

Series (All Sites)

Resected margin pos (n=172)

Resected margin neg (n=259)

40 60i ti

Resected margin pos (n=172)n=133)

ysis time

eg Resected Margin pos(n = 172)

Palliated(n = 133)( ) ( )

10 % 2 %16 mo 8 mo

Hilar Cholang

T t• Complete resection is th

TreatComplete resection is th

• Outcomes after R0 rese5 ll i l f– 5-year overall survival of

– DFS of 15-25%

• Few patients are resecta

R1/2 resections are not• R1/2 resections are not

• Palliating the effects of bgthe primary treatment ob

giocarcinoma

t the only effective therapy.

tmenthe only effective therapy.

ection:f 25 40%f 25-40%

able.

ncommonuncommon.

biliary obstruction is often ybjective.

Defining Resectability for

Questions to Ask When

1. Is complete (R0) rese

Questions to Ask When

p ( )2. Can it be done with en

adequate blood suppladequate blood suppldrainage?

• Extent of disease• Extent of disease• Vascular involveme• Lobar atrophy• Lobar atrophy• Metastatic disease

U d l i li di• Underlying liver dis• Other comorbidities

r Hilar Cholangiocarcinoma

n Considering Surgery?

ction possible?

n Considering Surgery?

pnough remaining liver, y and good biliaryy and good biliary

ent

seases

Hilar Cholang

CRITERIA OF UNCRITERIA OF UN

Patient-Related Factors• Medical contraindication • Cirrhosis or insufficient re

M t t ti DiMetastatic Disease• N2 lymphadenopathy• Distant metastases

giocarcinoma

RESECTABILITYRESECTABILITY

to major abdominal surgery emnant hepatic volume

Hilar Cholang

CRITERIA OF UN

Local Tumor Related Fact

CRITERIA OF UN

Local Tumor-Related Fact• Tumor extension to seco

bilaterallybilaterally • Encasement or occlusion

proximal to its bifurcationproximal to its bifurcation• Unilateral tumor extensio

with contralateral vasculawith contralateral vascula• Atrophy of one hepatic lo

vein encasement or secovein encasement or seco

giocarcinoma

RESECTABILITY

tors

RESECTABILITY

torsondary biliary radicles

n of the main portal vein nn on to secondary bile ducts ar encasement or occlusionar encasement or occlusionobe with contralateral portal ondary biliary extensionondary biliary extension

Bismuth-Corlette ClassifiHilar CholangHilar Cholang

ication of Biliary Extent of giocarcinomagiocarcinoma

Hilar Cholang

Goal of ReGoal of ReComplete Tumor Excisio

ESTABLISHED:• Excision of suprad

Ch l t ted • Cholecystectomy• Restore bilioenter

mm

ende

LESS CONTROVER• Routine hepatecto• Portal lymphaden

Rec

om

• Portal lymphaden• Selected major va

MORE CONTROVERMORE CONTROVER• Routine PV resec

giocarcinoma

esection:esection: n with Negative Margins

duodenal bile duct

ric continuity

RSIAL:omy/caudate (left resections)

nectomynectomyascular reconstruction

RSIALRSIAL:ction (Neuhaus)

Anatomical CoHilar Cholang

•

Anatomical Co

••

•

onsiderationsgiocarcinoma

Frequent submucosal t t i b d

onsiderations

tumor extension beyond gross margin (5 – 20 mm)Often unilateral extensionOften unilateral extension to 2o biliary radicles and beyondHepatic resection required

Shimada et al. Int Surg 1988;73:87

Results Of Resection for

Author (year) N ConcomResec

Cameron (1990) 39 2

Gerhards (2000) 112 2

Su (1996) 49 5

Hadjis (1990) 27 6j ( )

Jarnagin (2001) 80 7

Klempnauer (1997) 147 7Klempnauer (1997) 147 7

Neuhaus (1999) 95 8

K (1999) 65 8Kosuge (1999) 65 8

Nimura (1990) 55 9

Hilar Cholangiocarcinoma

mitant Liver % R0 5-Yearction (%) Resection Survival (%)

20 15 8

29 14 -

sect

ion

ate

57 24 15

60 56 22

of li

ver r

es

sect

ion

ra

urvi

val

78 78 27

79 79 28clus

ion

o

ng R

0 re

s

prov

ing

su

79 79 28

85 61 22

88 88 33easi

ng in

Incr

easi

n

Imp

88 88 33

98 83 40

Incr

e

Hilar Cholang

PREOPERATIVPREOPERATIV

1. Cholangiographyg g p y• Assessment of extent of b• ERCP vs MRCP vs PTC

C2. Cross-sectional imagi• Soft tissue extent, lobar a

remnant volume metastaremnant volume, metasta• CT vs MRI

Controversies:Controversies:• Role of preoperative s• FDG-PETFDG PET• Staging laparoscopy

giocarcinoma

E EVALUATIONE EVALUATION

biliary ductal involvement

ngatrophy, vascular involvement, asesases

stenting

Non-Invasive Ima

• High quality images of the biliacholangioscopy for assessing

• Provides additional data regarinvolvement lobar atrophyinvolvement, lobar atrophy.

Masselli et al Eu J Radiol (2008)*Lee et al. Gastrointest Endosc 2002;56:25

ging: MRI/MRCP

ary tree - as good as biliary tumor extent*.

rding metastases, vascular

Intrabiliary MRIy

Arepally et al. (JHH)

Hilar Cholang

LAPAROSCOLAPAROSCO

• Most useful to rule out metastatic disease.

• Less helpful for cholangiocarcinoma than gfor GB cancer.

• Consider in locally yadvanced cases.

giocarcinoma

PIC STAGINGPIC STAGING

STAGING LAPHilar Cholangiocarcinoma

STAGING LAP

100 patients with potentially rese100 patients with potentially resehilar cholangioca = 56gallbladder ca = 44

All underwent staging laparosco

RESULTS:RESULTS:Overall 69% were unresectable Laparoscopy yield: 48% in patie

(56% in thos(56% in thos25% in patie

Most useful at detecting peritone

Weber et al. Ann Surg 235:392 (2002)

PAROSCOPYa and Gallbladder Cancer

PAROSCOPY

ectable biliary cancerectable biliary cancer

py prior to surgical exploration

(HC = 59%, GB = 82%)ents with gallbladder cancer se w/o previous cholecystectomy)se w/o previous cholecystectomy) ents with hilar cholangiocarcinomaeal or liver metastases.

Role of FHilar Cholang

Role of F

• Not useful for infiltrating chola• Not useful for infiltrating chola• False negatives due to low vo• False positives due to stents o

Anderson et al. J Gastrointest Surg 8:90 (2004)

FDG PETgiocarcinoma

FDG-PET

angiocarcinomaangiocarcinomaolume metastasesor recent cholecystectomy

Biliary Stents for the MaUnresectable Ch

anagement of Surgically holangiocarcinoma

Management of SurgCholangioCholangio

Percutaneous vs EnPercutaneous vs. En

• RCT (n=75)• Superior technicp

endo• Better control of • Significantly fewe• Lower 30-day moLower 30 day mo

Speer et al. Lancet (Jul 1987)

ically Unresectable ocarcinomaocarcinoma

ndoscopic Stenting?ndoscopic Stenting?

al and clinical success with

bilirubin levelser complicationsortality rateortality rate

Percutaneous vs. EndCPalliating Hilar Cho

• RCT comparing metallic endoscopic stent

• 54 patients• Success rate = 75% (p) v(p)• Complication rate 61% (p• No difference in freedom• No difference in freedom• Median survival better in

vs 2 0 mo p=0 02)vs 2.0 mo, p=0.02)

Pinol et al, Radiology 2002

doscopic Stenting for ?olangiocarcinoma?

percutaneous stent vs.

vs 58% (e)( )p) vs 35% (e)

m from recurrent obstructionm from recurrent obstruction n percutaneous group (3.7

Selective Unilaterffor Unresectable Hilar

MRCP & CT id l• MRCP & CT: guide selec• Goal: drain only largest i

t l d t ith 1segmental ducts with 1 u• 35 patients, success rate• Percutaneous stenting re• 30-day morbidity = 0y y• Median patency of metal

Freeman, Gastrointest Endosc 2003

ral Stent DrainageCr Cholangiocarcinoma

ti id ictive guidewire accessntercommunicating

d t l t tuncovered metal stente = 71%equired in 3 patients

l stent = 8.9 months

Single versus Do

• Prospective RCT of 157 hilaProspective RCT of 157 hila– Unilateral drainage adeq

• Fewer technical failureFewer technical failure• Less instrumentation• Few early complication• Few early complication

– Attempts to place 2nd bilia( h l iti ) / i l(cholangitis) w/o survival

De Palma, Gastrointest Endosc 2001

ouble Endo Stents

ar CA (Bismuth I-III)ar CA (Bismuth I III)uate

eses

nsns

ary stent: early complications b fitbenefit

SummSurgical Management o

1. Achieving complete margi

Summg p g

remains the goal in selectecholangiocarcinoma, requnearly all cases.

2. Advances in non-invasive identification of unresectab

3. The role of PET, laparoscocontroversial.

4. The choice of stent palliatipshould individualized.

maryof Cholangiocarcinoma

n negative resection

maryg

ed patients with hilar iring hepatic resection in

imaging have allowed better ble cases.

opic staging remain

on approach (endo vs perc) pp ( p )