Hilar en-bloc resection for perihilar cholangiocarcinoma (PHCC); a single-center experience

Question:

Cholangiocarcinoma (CCC) is a relatively rare malignancy that is typically diagnosed at an advanced disease stage. Since its introduction by Neuhaus et al., hilar en-bloc resection with portal vein reconstruction has emerged as the mainstay of surgical treatment for patients with perihilar cholangiocarcinoma (PHCC). Despite recent advancements, the overall survival (OS) and recurrence-free survival (RFS) of patients with PHCC remains lower than for most other solid tumors and tumor recurrence after curative resection continues to impose a significant problem in the management of patients with CCC. Here we aimed at identifying prognostic markers of clinical outcome in PHCC patients that underwent hilar en-bloc surgical resection in curative intent.

Methods:

Between 2010 – 2016 ninety-five (n = 95) patients underwent hilar en-bloc surgical resection for PHCC at our institution. Surgical complications were assessed according to the Clavien-Dindo complication score and the comprehensive complication index (CCI). The associations of recurrence free- (RFS) and overall survival (OS) with clinico-pathological characteristics were assessed using univariate and multivariate survival analyses. Intrahepatic- and distal CCCs or PHCC patients who underwent associating liver partitioning with portal vein ligation for staged hepatectomy (ALPPS) were excluded from this study.

Results:

Median RFS was 36 months and median OS was 38 months. Clinico-pathological characteristics including age (p = 0.481), ASA-score (p = 0.620), gender (p = 0.193), Bismuth-classification (p = 0.591) and arterial infiltration (p = 0.591) were not associated with clinical outcome. In contrast, local lymph node metastases (p = 0.044), histological grading (p = 0.033) and lymphatic metastases (p = 0.033) were predictors of impaired OS and RFS. Even though surgical complications as assessed by CCI were higher in the right (n = 46) compared to the left (n = 36) hilar en-bloc resection group (CCI: 51 ± 32 vs. 32 ± 29 respectively, p = 0.005), we did not observe any differences with regards to clinical outcome comparing extended left versus extended right hilar en-bloc resections (median OS: 41 months vs. 30 months respectively, p = 0.875). All risk factors identified demonstrated impaired survival in the overall cohort and were equally distributed between left and right hilar en-bloc resections.

Conclusion:

Hilar en-bloc resection for PHCC is safe and feasible in experienced high-volume liver centers. Meanwhile right hepatectomy is associated with higher morbidity, the oncologic outcome does not differ between left versus right hilar en-bloc resections. Large prospective trials are needed to validate our findings.