1. Great Debates & Updates in GI Malignancies
March 28-29, 2014
Biliary Tract Cancers: Standards of Care and Emerging Therapies
The Role of Surgery
Michael A. Choti, MD
Department of Surgery
UT Southwestern Medical Center

2. Disclosures
none

3. LOCATION Peripheral Hilar Distal Cholangiocarcinoma 7-20%
Intrahepatic mass
Cirrhosis uncommon
Etiology unknown
40-60%
Biliary confluence
Most common
20-30%
10-15% of peripancreatic tumors

4. Trends in Incidence of Cholangiocarcinoma in the United States
SEER: Shaib et al. Semin Liver Dis (2004)

5. Assessment of Surgical Resectability
Intrahepatic Cholangiocarcinoma
Assessment of Surgical Resectability
Capability to remove all gross disease (R0 resection) and leave an adequate inflow, outflow, and remnant liver volume

6. Prognosis Following Resection
Intrahepatic Cholangiocarcinoma
Prognosis Following Resection
Satellitosis
5-year: 33%
MVI
+ Nodes
MDACC (2006)

7. Controversies Regarding Surgical Resectability
Intrahepatic Cholangiocarcinoma
Controversies Regarding Surgical Resectability
Multifocal disease and satellitosis
Intraoperative findings of positive perihepatic nodes
Preoperative findings of nodal involvement
Role of hilar lymphadenectomy

8. Distal Cholangiocarcinoma
Surgical Management
Distal Cholangiocarcinoma
Pancreaticoduodenectomy (Whipple)

9. Assessment of Surgical Resectability
Distal Cholangiocarcinoma
Historic Method
Current Method

10. Assessment of Surgical Resectability
Distal Cholangiocarcinoma
More likely locally resectable than pancreatic adenoCa
Patients often present with a distal CBD stricture and no mass
Brushings and biopsies can be negative
Ca19-9 elevation
Consider resection in patient with stricture and no mass

11. Hilar Cholangiocarcinoma
Gerald Klatskin, MD (Yale University)
Thirteen cases reported in 1965
Adenocarcinoma at hepatic duct bifurcation
Klatskin, G. American Journal of Medicine (1965) 38:

12. Hilar Cholangiocarcinoma
Treatment
Complete resection is the only effective therapy
Outcomes after R0 resection:
5-year overall survival of 25-40%
DFS of 15-25%
The minority of patients are resectable
R1 resections are common
Palliating the effects of biliary obstruction is often the primary treatment objective

13. CRITERIA OF UNRESECTABILITY
Hilar Cholangiocarcinoma
CRITERIA OF UNRESECTABILITY
Patient-Related Factors
Medical contraindication to major abdominal surgery
Cirrhosis or insufficient remnant hepatic volume
Metastatic Disease
N2 lymphadenopathy
Distant metastases

14. CRITERIA OF UNRESECTABILITY
Hilar Cholangiocarcinoma
CRITERIA OF UNRESECTABILITY
Local Tumor-Related Factors
Tumor extension to secondary biliary radicles bilaterally
Encasement or occlusion of the main portal vein proximal to its bifurcation
Unilateral tumor extension to secondary bile ducts with contralateral vascular encasement or occlusion
Atrophy of one hepatic lobe with contralateral portal vein encasement or secondary biliary extension

15. Complete Tumor Excision with Negative Margins
Hilar Cholangiocarcinoma
Goal of Resection:
Complete Tumor Excision with Negative Margins
Recommended
ESTABLISHED:
Excision of supraduodenal bile duct
Cholecystectomy
Restore bilioenteric continuity
LESS CONTROVERSIAL:
Routine hepatectomy/caudate (left resections)
Portal lymphadenectomy
Selected major vascular reconstruction
MORE CONTROVERSIAL:
Routine PV resection (Neuhaus)

16. Controversies Regarding Surgical Resectability
Hilar Cholangiocarcinoma
Vascular reconstruction of portal vein and/or hepatic artery
Hilar lymph node involvement and role of lymphadenectomy
Small remnant volume and use of preoperative right portal vein embolization

17. Neoadjuvant Chemoradiation Therapy Followed By Liver Transplantation for Hilar CholangioCa
Murad et al. Gastroenterology 2012

18. Neoadjuvant Chemoradiation Therapy Followed By Liver Transplantation for Hilar CholangioCa
Murad et al. Gastroenterology 2012

19. Gallbladder Cancer

20. QUESTIONS How extensive of a preoperative evaluation is required?
Gallbladder Cancer
QUESTIONS
How extensive of a preoperative evaluation is required?
When is radical surgery indicated?
How extensive of surgical resection is required?
What is the role of adjuvant therapy?

21. Outcomes Following Resection for T2 Gallbladder Cancer
Radical resection
Cholecystectomy
Fong et al. Ann Surg 232:557 (2000)

22. EXTENDED RESECTION FOR T2-T3
Gallbladder Cancer
EXTENDED RESECTION FOR T2-T3
ESTABLISHED:
Liver resection of gallbladder bed
Hilar lymphadenectomy
CBD resection/reconstruction if cystic duct margin +
Selected use of more major resection
SOMEWHAT CONTROVERSIAL:
Routine segment 4/5 liver resection
Routine CBD resection/reconstruction
Routine trocar site excision
MORE CONTROVERSIAL:
Routine trisectorectomy
Routine radical lymphadenectomy

23. Hilar Cholangiocarcinoma and Gallbladder Cancer
LAPAROSCOPIC STAGING
Most useful to rule out metastatic disease
Less helpful for cholangiocarcinoma than GB Ca
Consider in locally advanced cases.

24. Hilar Cholangiocarcinoma and Gallbladder Cancer
STAGING LAPAROSCOPY
100 patients with potentially resectable biliary cancer
hilar cholangioca = 56
gallbladder ca = 44
All underwent staging laparoscopy prior to surgical exploration
RESULTS:
Overall 69% were unresectable (HC = 59%, GB = 82%)
Laparoscopy yield: 48% in patients with gallbladder cancer
(56% in those w/o previous cholecystectomy)
25% in patients with hilar cholangiocarcinoma
Most useful at detecting peritoneal or liver metastases.
Weber et al. Ann Surg 235:392 (2002)

25. Hilar Cholangiocarcinoma and Gallbladder Cancer
Role of FDG-PET
Not useful for infiltrating cholangiocarcinoma
False negatives due to low volume metastases
False positives due to stents or recent cholecystectomy
Anderson et al. J Gastrointest Surg 8:90 (2004)

26. Surgical Management of Biliary Cancer
Summary
Bile duct cancers are uncommon malignancies with a rising incidence and poor prognosis.
In particular, intraheptic cholangiocarcinoma is increasing in incidence.
Surgery remains the only curative therapy, and curative resection is the most important prognostic factor.
Controversial indications for surgery include satellitosis and nodal involvement
Transplantation combined with neoadjuvant therapy is an emerging therapy in unresectable hilar CCC.