Hilar cholangiocarcinoma: the Memorial Sloan-Kettering Cancer Center experience.
OBJECTIVE
Hilar cholangiocarcinoma (HCCA) is a rare cancer with a low resectability rate, frequent recurrence after resection and an overall poor outcome. It is widely accepted that en bloc partial hepatectomy is a necessary part of the surgical therapy, but controversy surrounds other areas, including extent of lymphadenectomy and preoperative use of biliary drainage of the future liver remnant (FLR). This study analyzes the authors' experience with HCCA, emphasizing outcome after resection in a more recent cohort.


METHODS
All patients with HCCA evaluated at Memorial Sloan-Kettering Cancer Center (MSKCC) since 1991 were included in the initial analysis. Outcome after resection was specifically assessed in patients submitted to operation between January 2001 and September 2008. Patient demographics, preoperative evaluation, resection type, margin status, lymph node status, complications, morbidity and survival were examined. Preoperative disease staging was performed in all patients according to the Blumgart classification. Separate analyses were conducted to assess the impact of preoperative biliary drainage on the FLR and the optimal lymph node harvest. Outcomes for resected patients were analyzed by Fisher's exact test and log rank tests.


RESULTS
Three hundred and fifty-two patients with HCCA were evaluated since 1991, of which 118 were seen between 2001 and 2008. During this latter period, 105 (89%) patients underwent exploration, and of the 60 patients that underwent resection with curative intent, 48 (80%) had R0 resections. There were 3 perioperative deaths (5%), and 22 (28%) patients had complications. Patients with an R0 resection had the highest disease-specific survival followed by those with R1 resection when compared to unresected patients. The median follow-up period was 18 months. Classification by the Blumgart preoperative staging system predicted resectability and the likelihood of R0 resection. The benefit of pre-operative biliary drainage of the FLR appeared to be limited to patients with a predicted FLR volume of <30%. In patients with node-negative tumors, survival was greater in those with more than 7 lymph nodes harvested.


CONCLUSIONS
R0 resection including hepatectomy with negative lymph nodes is feasible in the majority of patients with resectable HCCA. This strategy is associated with a prolonged disease-specific survival.
Rocha
Flavio G
FG
Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
Matsuo
Kenichi
K
Blumgart
Leslie H
LH
Jarnagin
William R
WR
D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000368:Aged; D001650:Bile Duct Neoplasms / Q000453:epidemiology / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D006498:Hepatectomy / Q000379:methods / Q000706:statistics & numerical data*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D008297:Male; D009519:New York City / Q000453:epidemiology; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome