title: The impact of portal vein resection on outcomes for hilar cholangiocarcinoma: a multi-institutional analysis of 305 cases.
abstract: BACKGROUND. Surgical strategy for hilar cholangiocarcinoma often includes hepatectomy, but the role of portal vein resection (PVR) remains controversial. In this study, the authors sought to identify factors associated with outcome after surgical management of hilar cholangiocarcinoma and examined the impact of PVR on survival.
  
  
  METHODS
  Three hundred five patients who underwent curative-intent surgery for hilar cholangiocarcinoma between 1984 and 2010 were identified from an international, multi-institutional database. Clinicopathologic data were evaluated using univariate and multivariate analyses.
  
  
  RESULTS
  Most patients had hilar cholangiocarcinoma with tumors classified as T3/T4 (51.1%) and Bismuth-Corlette type II/III (60.9%). Resection involved extrahepatic bile duct resection (EHBR) alone (26.6%); or hepatectomy and EHBR without PVR (56.7%); or combined hepatectomy, EHBR, and PVR (16.7%). Negative resection (R0) margin status was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 64.2%; with PVR, 66.7%) versus EHBR alone (54.3%; P < .001). The median number of lymph nodes assessed was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 6 lymph nodes; with PVR, 4 lymph nodes) versus EHBR alone (2 lymph nodes; P < .001). The 90-day mortality rate was lower for patients who underwent EHBR alone (1.2%) compared with the rate for patients who underwent hepatectomy plus EHBR (without PVR, 10.6%, with PVR, 17.6%; P < .001). The overall 5-year survival rate was 20.2%. Factors that were associated with an adverse prognosis included lymph node metastasis (hazard ratio [HR], 1.79; P = .002) and R1 margin status (HR, 1.81; P < .001). Microscopic vascular invasion did not influence survival (HR, 1.23; P = .19). Among the patients who underwent hepatectomy plus EHBR, PVR was not associated with a worse long-term outcome (P = .76).
  
  
  CONCLUSIONS
  EHBR alone was associated with a greater risk of positive surgical margins and worse lymph node clearance. The current results indicated that hepatectomy should be considered the standard treatment for hilar cholangiocarcinoma, and PVR should be undertaken when necessary to extirpate all disease. Combined hepatectomy, EHBR, and PVR can offer long-term survival in some patients with advanced hilar cholangiocarcinoma.
authors.affiliation: Division of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: Mechteld C
authors.initials: MC
authors.lastname: de Jong
authors.forename: Hugo
authors.initials: H
authors.lastname: Marques
authors.forename: Bryan M
authors.initials: BM
authors.lastname: Clary
authors.forename: Todd W
authors.initials: TW
authors.lastname: Bauer
authors.forename: J Wallis
authors.initials: JW
authors.lastname: Marsh
authors.forename: Dario
authors.initials: D
authors.lastname: Ribero
authors.forename: Pietro
authors.initials: P
authors.lastname: Majno
authors.forename: Ioannis
authors.initials: I
authors.lastname: Hatzaras
authors.forename: Dustin M
authors.initials: DM
authors.lastname: Walters
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Barbas
authors.forename: Raquel
authors.initials: R
authors.lastname: Mega
authors.forename: Richard D
authors.initials: RD
authors.lastname: Schulick
authors.forename: Michael A
authors.initials: MA
authors.lastname: Choti
authors.forename: David A
authors.initials: DA
authors.lastname: Geller
authors.forename: Eduardo
authors.initials: E
authors.lastname: Barroso
authors.forename: Gilles
authors.initials: G
authors.lastname: Mentha
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Capussotti
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic / Q000473:pathology / Q000601:surgery*; D017024:Chemotherapy, Adjuvant; D018281:Cholangiocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006498:Hepatectomy; D006499:Hepatic Artery / Q000473:pathology / Q000601:surgery; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011169:Portal Vein / Q000473:pathology* / Q000601:surgery*; D018714:Radiotherapy, Adjuvant; D013997:Time Factors; D016896:Treatment Outcome; D019043:Vascular Neoplasms / Q000556:secondary / Q000601:surgery