Is Hepatic Resection for Large or Multifocal Intrahepatic Cholangiocarcinoma Justified? Results from a Multi-Institutional Collaboration

Abstract

Background The role of surgical resection for patients with large or multifocal intrahepatic cholangiocarcinoma (ICC) remains unclear. This study evaluated the long-term outcome of patients who underwent hepatic resection for large (≥7 cm) or multifocal (≥2) ICC. Methods Between 1990 and 2013, 557 patients who underwent liver resection for ICC were identified from a multi-institutional database. Clinicopathologic characteristics, operative details, and long-term survival data were evaluated. Results Of the 557 patients, 215 (38.6 %) had a small, solitary ICC (group A) and 342 (61.4 %) had a large or multifocal ICC (group B). The patients in group B underwent an extended hepatectomy more frequently (16.9 vs. 30.4 %; P < 0.001). At the final pathology exam, the patients in group B were more likely to show evidence of vascular invasion (22.5 vs. 38.5 %), direct invasion of contiguous organs (6.5 vs. 12.9 %), and nodal metastasis (13.3 vs. 21.0 %) (all P < 0.05). Interestingly, the incidences of postoperative complications (39.3 vs. 46.8 %) and hospital mortality (1.1 vs. 3.7 %) were similar between the two groups (both P > 0.05). The group A patients had better rates for 5-year overall survival (OS) (30.5 vs. 18.7 %; P < 0.05) and disease-free survival (DFS) (22.6 vs. 8.2 %; P < 0.05) than the group B patients. For the patients in group B, the factors associated with a worse OS included more than three tumor nodules [hazard ratio (HR), 1.56], nodal metastasis (HR, 1.47), and poor differentiation (HR, 1.48). Conclusions Liver resection can be performed safely for patients with large or multifocal ICC. The long-term outcome for these patients can be stratified on the basis of a prognostic score that includes tumor number, nodal metastasis, and poor differentiation.

Development and Validation of a Prognostic Score for Intrahepatic Cholangiocarcinoma

“…Moreover, the complications seen in this study are comparable to those observed in previous institutional reports. 5 In regard to the development of a prognostic model, our results could be influenced by missing data. We note that missing data were infrequent and were statistically addressed by multiple imputations to minimize bias as best as possible.…”

“…Data from Bergeat et al 10 suggest that extended resections for large tumors are more likely to require contiguous resections and to have a higher morbidity, but the oncologic outcomes are comparable to those of nonextended resections. Recently, a multi-institutional study of specialized hepatobiliary centers 5 demonstrated that resection of large ICCs (≥7 cm) or multifocal tumors has acceptable morbidity and mortality. Together these studies highlight the evolving role of surgical resection irrespective of tumor size, multifocality, or contiguous organ involvement in specialized hepatobiliary centers.…”

“…A cut-off of 7 cm was established previously. 5,12 Bivariate analysis of categorical variables was performed using the χ 2 test. The Kruskal-Wallis rank test was used for comparison of nonparametric variable medians.…”

Defining Post Hepatectomy Liver Insufficiency: Where do We stand?

“…Advances in operative techniques, perioperative care, and patients selection have resulted in an increase in the number of patients who are amenable to surgical resection, as well as decreased the morbidity and mortality associated with liver surgery. [1][2][3] However, one of the most serious complications following liver resection is the development of post-hepatectomy liver insufficiency/ failure (PHLF), which can be a major cause of morbidity and mortality. [4][5][6] The reported incidence of PHLF varies between 0.7 and 34 % in the literature.…”

Defining the possible therapeutic benefit of lymphadenectomy among patients undergoing hepatic resection for intrahepatic cholangiocarcinoma

“…Of note, tLND was associated with a greater survival benefit among younger patients, as well as those patients with larger tumors. The reason for the benefit in these subsets of patients is likely multifactorial and may be related to time at risk (i.e., longer among younger patients), as well as underlying risk of having node positive disease (i.e., higher among patients with large tumors) .…”