Additional Resection of an Intraoperative Margin-Positive Proximal Bile Duct Improves Survival in Patients With Hilar Cholangiocarcinoma

Ribero, Dario; Amisano, Marco F.; Tesoriere, Roberto Lo; Rosso, Stefano; Ferrero, Alessandro; Capussotti, Lorenzo

doi:10.1097/sla.0b013e3182368f85

Cited by 91 publications

(87 citation statements)

References 26 publications

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“…Just like the results as reported by Ribero et al63 for their European center, Zhang et al65 demonstrated that additional resection of a positive proximal or distal ductal margin was associated with improved survival after curative‐intent resection in patients with perihilar cholangiocarcinoma (Table 2). They concluded that every attempt should be made to achieve a carcinoma‐negative ductal margin when technically feasible.…”

Section: Outcome Of Additional Resection For Carcinoma‐positive Ductamentioning

confidence: 56%

“…In contrast, Ribero et al63 reported that additional resection of a positive proximal ductal margin offered a survival benefit in patients with perihilar cholangiocarcinoma. In their study, survival in patients with a negative proximal ductal margin achieved by additional resection was comparable with that in patients with a primary negative proximal margin and was significantly better than that in patients with a positive ductal margin (Table 2).…”

Section: Outcome Of Additional Resection For Carcinoma‐positive Ductamentioning

confidence: 92%

“…In addition, they attributed the inconsistent results between the different studies of the effect of additional resection of a positive proximal ductal margin on outcomes to differences in the tumor characteristics of the study population. The rates of Bismuth type IV disease in the studies by Oguro et al64 and Shingu et al57 were reported to be 40% and 38.9%, respectively, whereas the rate was 14.6% in the study by Ribero et al63 This suggests that the study by Ribero et al63 included more patients with less advanced tumors, where additional resection of a positive proximal ductal margin may have contributed to more favorable outcomes.…”

Section: Outcome Of Additional Resection For Carcinoma‐positive Ductamentioning

confidence: 96%

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Surgical management of carcinoma in situ at ductal resection margins in patients with extrahepatic cholangiocarcinoma

Wakai

Sakata

Katada

et al. 2018

Annals of Gastroent Surgery

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Recent advances in dimensional imaging, surgical technique, and perioperative patient care have resulted in increased rates of complete resection with histopathologically negative margins and improved surgical outcomes in patients with extrahepatic cholangiocarcinoma. However, achieving cancer‐free resection margins at ductal stumps in surgery for this disease remains challenging because of longitudinal extension, which is one of the hallmarks of extrahepatic cholangiocarcinoma. When the ductal resection margins are shown to be positive on examination of frozen sections, discrimination between carcinoma in situ and invasive carcinoma is clinically important because residual carcinoma in situ may lead to late local recurrence whereas residual invasive carcinoma is associated with early local recurrence. Residual invasive carcinoma at the ductal margins should be avoided whenever technically feasible. Residual “carcinoma in situ” at the ductal margins appears to be allowed in resection for the advanced disease because it has less effect on survival than other adverse prognostic factors (pN1 and/ or pM1). However, in surgery for early‐stage (pTis‐2N0M0) extrahepatic cholangiocarcinoma, residual carcinoma in situ at the ductal margins may have an adverse effect on long‐term survival, so should be avoided whenever possible. In this review, we focus on the histopathological term “carcinoma in situ,” the biological behavior of residual carcinoma in situ at ductal resection margins, intraoperative histological examination of the ductal resection margins, outcome of additional resection for positive ductal margins, and adjuvant therapy for patients with positive margins.

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Section: Outcome Of Additional Resection For Carcinoma‐positive Ductamentioning

confidence: 56%

Section: Outcome Of Additional Resection For Carcinoma‐positive Ductamentioning

confidence: 92%

Section: Outcome Of Additional Resection For Carcinoma‐positive Ductamentioning

confidence: 96%

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Surgical management of carcinoma in situ at ductal resection margins in patients with extrahepatic cholangiocarcinoma

Wakai

Sakata

Katada

et al. 2018

Annals of Gastroent Surgery

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“…25 Ribero et al 26 demonstrated that reresection of positive proximal bile duct margin to gain secondary R0 resection in patients with hilar cholangiocarcinoma improved median OS to a level similar to that of patients who underwent primary R0 resection. However, the success rate of obtaining secondary R0 resection is limited because of procedural difficulties.…”

Section: Discussionmentioning

confidence: 99%

Role of adjuvant radiotherapy for localized extrahepatic bile duct cancer

Kim

Min

et al. 2017

The British Journal of Radiology

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Objective: To evaluate the benefit of adjuvant radiotherapy (RT) after surgical resection for extrahepatic bile duct (EHBD) cancer. Methods: From 1997 to 2015, 59 patients with EHBD cancer were the subject of this study; 36 patients not undergoing adjuvant treatment after surgery (observation group) and 23 patients receiving adjuvant RT (RT group) were compared. Microscopic residual disease (R1) was in 9 (25%) patients and 5 (22%) patients, and macroscopic residual disease (R2) was in 2 (6%) patients and 6 (26%) patients in the observation and RT groups, respectively. Adjuvant RT was delivered to the tumour bed and regional lymph nodes up to 50.4 Gy (range, 45-61 Gy). Results: With a median follow-up of 19 months, local recurrence was observed in 10 (28%) patients and 2 (9%) patients in the observation and RT groups, respectively. On univariate analysis, the 5-year local recurrence-free survival (LRFS) rates were 50% in the observation group and 54% in the RT group (p 5 0.401).The 5-year overall survival (OS) rates were 29.3% in the observation group and 26.3% in the RT group (p 5 0.602). On multivariable analysis, however, adjuvant RT significantly improved LRFS [hazard ratio (HR), 0.310; 95% confidence interval (CI), 0.100-0.963; p 5 0.043] and had a trend towards increased OS (HR, 0.491; 95% CI, 0.219-1.102; p 5 0.085). Resection margin (RM) status was also correlated with LRFS (HR for R1 6.134, 95% CI 2. and HR for R2 18.551,; p , 0.001) and OS (HR for R1 1.816, 95% CI 0.853-3.867; and HR for R2 3.564, 95% CI 1.175-10.809; p 5 0.054). Conclusion: RM status was a significant prognosticator of EHBD cancer, and adjuvant RT improved local control rate; thereby, survival rate might be increased. Advances in knowledge: The benefit of adjuvant RT in EHBD cancer was demonstrated via comparison with observation group.

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“…In a recent report of Ribero et al [81] , in the analysis of 82 cases, the group of patients who had primary R0 was compared with those patients who achieved a secondary R0 after an intraoperative additional resection, and also with the patients who were R1. The 1-, 3-and 5-year survival rates were similar in the groups with primary R0 and secondary R0, but different in R1 patients (5-year survival rate: 50%, 30.8% and 0% respectively).…”

Section: Liver Resection: How Much Is Enough?mentioning

confidence: 99%

Outcome of surgical resection in Klatskin tumors

Serrablo

Tejedor²

2013

WJGO

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vein embolization and staging laparoscopy should be considered in selected patients. Additional evidence is needed to fully define the role of orthotopic liver transplant. Portal and lymph node involvement worsen the prognosis and long-term survival, and surgery is the only option that can lengthen it. Improvements in adjuvant therapy are essential for improving long-term outcome. Furthermore, the lack of effective chemotherapy drugs and radiotherapy approaches leads us to can consider R1 resection as an option, because operated patients have a longer survival rate than those who not undergo surgery. INTRODUCTIONCarcinomas arising from the confluence of the hepatic ducts were first described by Altemeier et al [1] . Klatskin [2] Alejandro Serrablo, Luis Tejedor Outcome of surgical resection in Klatskin tumors TOPIC HIGHLIGHT AbstractCholangiocarcinomas are the second most frequent primary hepatic malignancy, and make up from 5% to 30% of malignant hepatic tumours. Hilar cholangiocarcinoma (HCC) is the most common type, and accounts for approximately 60% to 67% of all cholangiocarcinoma cases. There is not a staging system that permits us to compare all series and extract some conclusions to increase the long-survival rate in this dismal disease. Neither the extension of resection, according to the sort of HCC, is a closed topic. Some authors defend limited resection (mesohepatectomy with S1, S1 plus S4b-S5, local excision for papillary tumours, etc .) while others insist in the compulsoriness of an extended hepatic resection with portal vein bifurcation removed to reach cure. As there is not an ideal adjuvant therapy, R1 resection can be justified to prolong the survival rate. Morbidity and mortality rates changed along the last decade, but variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Conclusion: Surgical resection continues to be the main treatment of HCC. Negative resection margins achieved with major hepatic resections are associated with improved outcome. Preresectional management with biliary drainage, portal José M Ramia, MD, PhD, Series Editor

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Additional Resection of an Intraoperative Margin-Positive Proximal Bile Duct Improves Survival in Patients With Hilar Cholangiocarcinoma

Abstract: Additional resection of a positive proximal (BD(Marg)) , albeit associated with an increased risk of biliary fistula, offers a significant survival benefit and should be attempted whenever possible.

Cited by 91 publications

References 26 publications

Surgical management of carcinoma in situ at ductal resection margins in patients with extrahepatic cholangiocarcinoma

Surgical management of carcinoma in situ at ductal resection margins in patients with extrahepatic cholangiocarcinoma

Role of adjuvant radiotherapy for localized extrahepatic bile duct cancer

Outcome of surgical resection in Klatskin tumors

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