SIR RFS Case Series: Biliary-Enteric Obstruction from Recurrent Cancer
Surgical Management of Cholangiocarcinoma1].2... · ectable biliary cancerectable biliary cancer py...
Transcript of Surgical Management of Cholangiocarcinoma1].2... · ectable biliary cancerectable biliary cancer py...
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 )