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Gian Luca GraziHepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
CholangiocarcinomaTreatment
Cholangiocarcinoma - Treatment
Bridgewater J et al., J Hepatol 2014, in press
Cholangiocarcinoma - Treatment
Bridgewater J et al., J Hepatol 2014, in press
Cholangiocarcinoma - Treatment
Bridgewater J et al., J Hepatol 2014, in press
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Razumilava N, Lancet. 2014 Feb 25.
Cholangiocarcinoma - Treatment
Assenza di problemi medici maggioriAnamnesi e visita medicaEsami di laboratorio e di funzionalità
Assenza di metastasi a distanzaStudio del torace e dell’addome
Altre indagini volte allo studio di sintomi
Periferico – stadiazione locale
Valutazione dei peduncoli glissonianiValutazione delle vene sovraepaticheCoinvolgimento del parenchimaStudio della via biliare
Distale – stadiazione locale
Valutazione della vena portaValutazione della v. mesenterica superioreValutazione delle vene sovraepaticheValutazione dell’arteria epatica
Studio della via biliare
TAC conricostruzionevascolare (laparoscopia?)
TAC conricostruzionevascolare ± Colangio RM(laparoscopia?)
Colangio RMERCPPTC
TAC total body ± PET / laparoscopia
Cholangiocarcinoma - Treatment
The major determinants of resectability are
•the extent of tumor within the biliary tree,
•the amount of hepatic parenchyma involved,
•vascular invasion,
•hepatic lobar atrophy, and
•metastatic disease.
Assessment of resectability
Cholangiocarcinoma - Treatment
Patient to be resected
•Non cirrhotic•No pre-op CHT
Major resection planned
Minor resection planned
•Cirrhotic•Pre-op CHT
Major resection planned
Minor resection planned
Maybe nothingIGR ??
VolumetryIGR ??
MELDIGR Useful
MELDIGRVolumetryBiopsy ??
Cholangiocarcinoma - Treatment
• Normal underlying liverFLR should be 20-25% of total liver volume
(TLV)
• Chemotherapy induced liver injuryFLR should be >30% of TLV
• Chronic liver disease (cirrhosis or severe fibrosis)
FLR should be >40%
Future Remnant Liver
Cholangiocarcinoma - Treatment
Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Ercolani G, Ann Surg 2010, 252: 107-113
Cholangiocarcinoma - Treatment
de Jong MC, J Clin Oncol 2011, 29: 3140-3145
• Although tumor size provides no prognostic information, tumor number, vascular invasion, and LN metastasis are associated with survival.
• N1 status adversely affected overall survival and also influenced the relative effect of tumor number and vascular invasion on prognosis.
• Lymphadenectomy should be strongly considered for ICC, because up to 30% of patients will have LN metastasis.
Cholangiocarcinoma - Treatment
de Jong MC, J Clin Oncol 2011, 29: 3140-3145
Cholangiocarcinoma - Treatment
de Jong MC, J Clin Oncol 2011, 29: 3140-3145
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
• The preoperative clinical T staging system as proposed by Jarnagin
and Blumgart defines both the radial and longitudinal extension of
hilar cholangiocarcinoma, which are critical factors in the
determination of resectability.
• This Memorial Sloan-Kettering Cancer Center (MSKCC) staging system
incorporates 3 factors based on preoperative imaging studies:
(1) location and extent of ductal involvement;
(2) presence or absence of portal vein invasion, and;
(3) presence or absence of hepatic lobar atrophy.
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
440 patients from 17 centers(From January 1, 1992, through December 31, 2007)
16 years
5/17 centers (29.4%) reported 40 or more patients who underwent resection and accounted for 317 patients (72.0%)
5 High volume centers317 procedures63.4 procedures/center3.9 procedures/year
12 Low volume centers123 procedures10.2 procedures/center0.6 procedures/year
Nuzzo G, Arch Surg 2012; 147: 26-34
Cholangiocarcinoma - Treatment
Razumilava N, Lancet. 2014 Feb 25.
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Seyama S, World J Gastroenterol 2007;13(10):1505-1515
Cholangiocarcinoma - Treatment
Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54
Cholangiocarcinoma - Treatment
Pro ConsPTBD provides precise preoperative staging of the disease
Increases the risk of cholangitis
Contributes to improved surgical outcome
Possibly increases tumor seeding
Definitive role when portal veinembolization is needed
Could be omitted:•recent onset jaundice (<2-3 weeks), total bilirubin <200 μmol/l,•absence of sepsis,•future liver remnant 40%.
It should not be performed systematically and specialized surgical evaluation should be performed before any type of direct cholangiography or PBD is performed.
Consensus Conference on Cholangiocarcinoma, HPB, 2008; 10
Biliary stenting
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Aljiffry M,J Am Coll Surg 2009; 208, 134-147
Schulick RD,HPB, 2008; 10: 122-125
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Definition of Surgical Strategy
Definition of the extention of the tumor in the left and in the right ducts
Volumetryleft lobe – S2+S3left hemiliver – S2+S3+S4right lobe – S5+S6+S7+S8caudate lobe
Cholangiocarcinoma - Treatment
The Bismuth classification takes into account tumour
extension into the right and left biliary system; but, tumour
extension anteriorly to the quadrate lobe (segment 4) and
posteriorly to the caudate lobe (segment 1) is equally
important.
Surgical treatment, therefore, should include resection of
segments 4 and 1 which in the case of right-sided tumours
(type IIIa) comes down to extended right hemihepatectomy
en bloc with segment 1.
In conjunction with any resection, complete
lymphadenectomy of the hepatoduodenal ligament is carried
out.Van Gulik TM, 2007; 26 (Suppl 2), 127–132
Cholangiocarcinoma - Treatment
Changes in pre-, intra-, and postoperative management over the course of the study period. ENBD indicates endoscopic naso-biliary drainage; MDCT,multidetector-row computed tomography; PTBD, percutaneous transhepatic biliary drainage; PTCS, percutaneous transhepatic cholangioscopy.
Nagino M, Ann Surg 2013;258: 129–140
Cholangiocarcinoma - Treatment
Nagino M, Ann Surg 2013;258: 129–140
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Left Hepatectomy +caudate lobe
Right Hepatectomy +caudate lobe
Pro Cons Pro Cons
Smaller procedure Greater procedure
Greater liver remnant volume
Smaller liver remnant volume
No need for PVE Needs PVE
Right duct shorter Left duct longer(usually available)
Often double (triple) duct anastomosis
Often one single duct anastomosis
Quickly available Longer “evaluation to surgery” time
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
Cholangiocarcinoma - Treatment
The role of Portal Vein Embolization
colangiocarcinomacolangiocarcinoma:
3 % tumori dell’apparato digerenteetà > 65 anni 2/3 dei casi> frequenza nei paesi asiatici
COLECISTI 2/315% VB intraepatiche
VB 1/3 60 % ilari (tumori di Klatskin)
25 % VB extraepatica
The role of Portal Vein Embolization
- fattori di rischio: 2 volte più frequente nella donnacorrelazione con litiasi colecisti non dimostrata
- stadio iniziale: reperto fortuito dopo colecistectomia per calcoli- stadio avanzato: massa epatica del IV-V segm, ittero, cattiva prognosi
COLECISTI 2/315% VB intraepatiche
VB 1/3 60 % ilari (tumori di Klatskin)
25 % VB extraepatica
The role of Portal Vein Embolization
- fattori di rischio: leggera prevalenza nel maschioetà > 50 anni, colangite sclerosante primitiva
- clinica: ittero ostruttivoittero ostruttivo con epatomegalia, urine ipercromiche, feci ipocoliche, prurito, colecisti distesa (se tumore del coledoco), colangite (rara), calo PT (malassorbimento vit. K)
COLECISTI 2/315% VB intraepatiche
VB 1/3 60 % ilari (tumori di Klatskin)
25 % VB extraepatica
The role of Portal Vein Embolization
Gian Luca GraziHepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
www.chirurgiadelfegato.it
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The role of Portal Vein Embolization