PERIHILAR CHOLANGIOCARCINOMA

New Classification and

Treatment JM.TUBIANA

Hôpital Saint-Antoine jean-michel.tubiana@sat.aphp.fr

PERIHILAR CHOLANGIOCARCINOMA

•  In the past two decades , with the advances in diagnostic ,interventional imaging and surgical techniques , many surgeons have adopted an agressive approch to perihilar CC as surgical resection is the only way to cure this intractable disease .

•  So the surgical outcomes and survival rates have gradually improved .

PERIHILAR CHOLANGIOCARCINOMA

•  Tumors located in the extra-hepatic biliiary tract proximal to the origine of the cystic duct.

•  Potentially include 2 types of tumors : one arising from the large hilar bile duct and the other with intrahepatic component and secondary invasion of the porta hepatis.

INTRA-HEPATIQUE

EXTRA-HEPATIQUE DISTAL

EXTRA-HEPATIQUE PROXIMAL

AJCC 7EME EDITION 2011

60 %

10 %

30 %

30%

Mass-forming CC 12%

 Periductal  infiltra.ng  CC  84% sub-mucosal extension

Intraductal 4% Mucosal extension

 The  Liver  Cancer  Study  Group  of  Japan    

PERIHILAR CHOLANGIOCARCINOMA Role of Imaging

•  Imaging US ,CT, MRI , IR, is mandatory for :

•  - Diagnostic •  - Tumor extent •  - Before surgery

PERIHILAR CHOLANGIOCARCINOMA Role of Imaging

•  Imaging US ,CT, MRI , IR, is mandatory for :

•  - Diagnostic •  - Tumor extent •  - Before surgery

Frequently the initial Imaging modality performed

CT / MRI

•  The accuracy of CT and MRI with MRCP for prediction of the extent of ductal involvement ( 84-91 % ) , hepatic artery and portal invasion (86 – 98 % ) ,hepatic volumetry , lymph nodes and metastasis ( 74 – 84 % ) .

INFILTRATING

INTRADUCTAL

CCH INFILTRANT

DETECTION ADC

ADC

PERIHILAR CHOLANGIOCARCINOMA Role of Imaging

•  Imaging US ,CT, MRI , IR, is mandatory for :

•  - Diagnostic •  - Tumor extent •  - Before surgery

Longitudinal Extension : Bismuth /Corlette classification

Mucosal extension :

intraductal ,nodular, mean length 10-20mm ,surgical margin >2 cm for negative margins

Submucosal extension :

infiltrative form,length 6-10mm , surgical for negative margin>10 mm

Direct infiltration along lymphatic and perineural tissues

CCH B / C I

•  Reverchon

CCH II B / C

CCH B / C III b

CCH B / C IV

VERTICAL EXTENSION

•  Direct invasion of the surrounding structures : •  - Pancreas , Duodenum . •  - Hepatoduodenal ligament including

adjacent hepatic artery and portal vein . •  - Hepatic parenchyma .

•  Distant metastasis and lymph nodes .

INVOLVEMENT HA / PV

INVOLVEMENT HA / PV

INVOLVEMENT LPV

INVOLVEMENT MAIN PV

HEPATIC INVOLVEMENT

STAGING N

METASTASIS MALIGNANT ASCITIS

PERIHILAR CHOLANGIOCARCINOMA Role of Imaging

•  Imaging US ,CT, MRI , IR, is mandatory for :

•  - Diagnostic •  - Tumor extent •  - Before surgery

PORTAL VEIN EMBOLIZATION

•  Now widely used in the presurgical treatmentof patients undergoing an extended hepatectomy to minimize the post-operative liver dysfunction .

PORTAL VEIN EMBOLIZATION

•  Can benefit patients requiring a future liver remnant of 25 % of the total liver volume if liver function is normal and 40 % if liver function is compromised .

BILIARY DRAINAGE

•  Remain controversial •  Has provred to be beneficial in case of

cholangitis , severe malnutrion and coagulation abnormalities .

•  Absolutely indicated for patients requiring major hepatic resection .

•  Unilateral BD for future remnant lobe is recommanded in B / C III and IV tumors .

B.Guiu. Cardiovasc Intervent Radiol 2013

STAGING / CLASSIFICATION

•  Staging should ideally be performed before and after surgery to include all inta-operative informations and results from macroscopic and microscopis examinations

STAGING / CLASSIFICATION

Systems most commonly used to evaluate PCH

•  - Bismuth / Corlette •  - MSKCC ( Memorial Sloan-Kettering Cancer Center ) •  - AJCC ( American Joint Commission on Cancer

Staging 7 th edition ) : TNM •  - EHPBA (European Hepato-Pancreato-Biliary

Association )

SURGERY

SURGERY

•  Resectional procedures depend on the location of the primary tumor.

•  - Rigth hepatectomy is applied to B/C I ,II and III a tumor.

•  - Left hepatectomy to B/C IIIb .

SURGERY

•  In B / C IV , the type of hepatectomy is determined by considering the predominant tumor location , the presence or absence of portal vein or hepatic artery invasion and liver function.

SURGERY

•  In B / C IV

•  - Right predominant tumor : right trisectionectomy ( trisegmentectomy or hight extensive hepatectomy ) 4,5,6,7,8+ 1

•  - Left predominant : left trisectionectomy : 2,3,4,5,8 + 1

OTHERS THERAPIES

•  Neo-adjuvant / Adjuvant therapy . •  Photodynamics therapy . •  Intra-luminal brachytherary . •  External radiation . •  Liver transplantation .

REPORT

•  Tumor morphology : localisation ,size , form . •  Vascular anatomy : PV , HA , Arcuate ligament •  Longitudinal extension : B / C . •  Vertical extension : PV , HA ,Liver . •  Liver remnant volume . •  Underlying liver disease . •  Lymph nodes . •  Metastasis . •  IR necessary .