title: Recurrence Rate and Pattern of Perihilar Cholangiocarcinoma after Curative Intent Resection.
abstract: BACKGROUND
  The aim of this study was to investigate the rate and pattern of recurrence after curative intent resection of perihilar cholangiocarcinoma (PHC).
  
  
  METHODS
  Patients were included from 2 prospectively maintained databases. Recurrences were categorized by site. Time to recurrence and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to identify independent poor prognostic factors.
  
  
  RESULTS
  Between 1991 and 2012, 306 consecutive patients met inclusion criteria. Median overall survival was 40 months. A recurrence was diagnosed in 177 patients (58%). An initial local recurrence was found in 26% of patients: liver hilum (11%), hepaticojejunostomy (8%), liver resection margin (8%), or distal bile duct remnant (2%). An initial distant recurrence was observed in 40% of patients: retroperitoneal lymph nodes (14%), intrahepatic away from the resection margin (13%), peritoneum (12%), and lungs (8%). Only 18% of patients had an isolated initial local recurrence. The estimated overall recurrence rate was 76% at 8 years. After a recurrence-free period of 5 years, 28% of patients developed a recurrence in the next 3 years. Median RFS was 26 months. Independent prognostic factors for RFS were resection margin, lymph node status, and tumor differentiation. Only node-positive PHC precluded RFS beyond 7 years.
  
  
  CONCLUSIONS
  Perihilar cholangiocarcinoma will recur in most patients (76%) after resection, emphasizing the need for better adjuvant strategies. The high recurrence rate of up to 8 years justifies prolonged surveillance. Only patients with an isolated initial local recurrence (18%) may have benefited from a more extensive resection or liver transplantation. Node-positive PHC appears incurable.
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: b.grootkoerkamp@erasmusmc.nl.
authors.forename: Bas
authors.initials: B
authors.lastname: Groot Koerkamp
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Jimme K
authors.initials: JK
authors.lastname: Wiggers
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Allen
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Marc G
authors.initials: MG
authors.lastname: Besselink
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Leslie H
authors.initials: LH
authors.lastname: Blumgart
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Olivier R C
authors.initials: OR
authors.lastname: Busch
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Coelen
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Michael I
authors.initials: MI
authors.lastname: D'Angelica
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Ronald P
authors.initials: RP
authors.lastname: DeMatteo
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: T Peter
authors.initials: TP
authors.lastname: Kingham
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: William R
authors.initials: WR
authors.lastname: Jarnagin
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: van Gulik
mesh_terms: D000368:Aged; D001650:Bile Duct Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy; D006801:Humans; D007582:Jejunostomy; D018285:Klatskin Tumor / Q000401:mortality* / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology* / Q000473:pathology; D009367:Neoplasm Staging; D012307:Risk Factors; D016896:Treatment Outcome