Surgical resection of localized cholangiocarcinoma
- Christopher D Anderson, MD, FACS
Christopher D Anderson, MD, FACS
- James D. Hardy Professor and Chair, Department of Surgery
- Chief, Transplant and Hepatobiliary Surgery
- University of Mississippi Medical Center
- Section Editor
- Stanley W Ashley, MD
Stanley W Ashley, MD
- Section Editor — Pancreatic and Hepatobiliary Surgery
- Chief Medical Officer and Senior Vice President for Clinical Affairs
- Brigham and Women’s Hospital
- Frank Sawyer Professor of Surgery
- Harvard Medical School
Cholangiocarcinomas are rare malignancies arising from the epithelial cells of the intrahepatic and extrahepatic bile ducts. Surgical resection can be offered to patients in whom disease appears to be localized and potentially resectable, and is individualized according to the location of the tumor within the biliary tree: intrahepatic, perihilar, or distal. True resectability can often only be determined at the time of exploration.
Surgical resection of localized cholangiocarcinoma is reviewed here. The clinical evaluation, diagnosis, and treatment, including when to consider orthotopic liver transplantation, are discussed elsewhere. (See "Epidemiology, pathogenesis, and classification of cholangiocarcinoma" and "Clinical manifestations and diagnosis of cholangiocarcinoma" and "Treatment of localized cholangiocarcinoma: Adjuvant and neoadjuvant therapy and prognosis" and "Treatment options for locally advanced cholangiocarcinoma" and "Systemic therapy for advanced cholangiocarcinoma".)
CLASSIFICATION OF BILIARY TRACT CANCERS AND STAGING
Biliary tract cancers are classified according to their locations along the biliary tracts and the TNM cancer staging system (figure 1 and table 1A-C). These are reviewed in detail elsewhere. (See "Epidemiology, pathogenesis, and classification of cholangiocarcinoma", section on 'Anatomy, tumor classification, and staging'.)
Unfortunately, neither the Bismuth-Corlette classification nor the American Joint Committee on Cancer (AJCC)’s TNM stage accurately assesses resectability, and true resectability may be ultimately determined only at surgical exploration. (See 'Surgical approach' below.)
A preoperative clinical staging system that accurately assesses resectability would be of value clinically. Such a classification, the Blumgart staging system, has been proposed that is based upon biliary tumor extent, the presence or absence of portal vein involvement, and the presence or absence of hepatic lobar hypertrophy [1,2]. In a series of 376 patients diagnosed with a perihilar cholangiocarcinoma whose disease could be adequately staged, this clinical T staging system accurately predicted resectability, metastatic disease, and the likelihood of a microscopically complete (R0) resection . Independent confirmation of these results is needed.
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- CLASSIFICATION OF BILIARY TRACT CANCERS AND STAGING
- SURGICAL MANAGEMENT FOR CURE
- Criteria for resectability
- Prognostic factors
- PREOPERATIVE ASSESSMENT
- Preoperative imaging
- Preoperative biliary decompression
- Preoperative portal vein embolization
- SURGICAL APPROACH
- Intrahepatic cholangiocarcinoma
- Perihilar cholangiocarcinoma
- Distal cholangiocarcinoma
- PERIOPERATIVE MORBIDITY AND MORTALITY
- LONG-TERM OUTCOMES
- SUMMARY AND RECOMMENDATIONS