Multimodal management of hilar cholangiocarcinoma
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| Year of publication | 2012 |
| Type | Conference abstract |
| Citation | |
| Description | The most common symptom of cholangiocarcinoma is painless jaundice. Even though the cause of jaundice could be a small-size tumour, the unfavourable localisation of the common perihilar type greatly influences the prognosis of patients. Hilar cholangiocarcinoma (Klatskin type tumor) arises from the epithelium of the intrahepatic bile ducts and more than 95% of them correspond to adenocarcinomas (other rare types are squamous cell carcinoma, undifferentiated carcinoma, papillary carcinoma, etc.). Hilar cholangiocarcinoma is predominantly a slowly growing tumor with longitudinal spreading along the bile ducts. This type of macroscopic appearance corresponds to periductal-infiltrating type. Typical mass forming lesion with rich fibrous stroma is more common on periphery of liver. A modified Bismuth–Corlette classification is widely used for the description of tumors invading hilus of liver. It is essential for preoperative planning of surgical, multimodality treatments as well as sole palliative procedures. The key issue of all techniques (palliative and curative) is to achieve accurate bile duct patency. Bile duct obstruction, if not adequately compensated, can result in intrahepatic cholestasis with significant reduction of the patient's quality and length of life. Long-term survival (survival of 5 years and more) of patients with hilar cholangiocarcinoma depends primarily on surgical treatment. However, Bismuth type III tumors are resectable at the cost of hemihepatectomy or extended hemihepatectomy, and Bismuth type IV tumors are resectable only in selected cases and the peak incidence of cholangiocarcinoma in Western countries between 60 and 70 years of age favours only limited interventions of surgeons. Median survival of resected patients due to more aggressive surgical approach and improved perioperative care rise from 16 to 30 months in the last 20 years as referred from Italian centres. R0 resection margins still mean only possible chance of cure for cholangiocarcinoma with median survival up to 47 months with significant drop to 17 months in R1 resection margins. T stage, lymphatic node status and histopathological grade are widely accepted independent factors of patients’ prognosis. Especially, histopathological grade as an independent factor of prognosis is frequently missing in descriptions of patient groups referred to multimodal palliative treatments. Currently, a wide choice of palliative treatments of biliary obstruction is offered. In addition to palliative surgical procedures, there are many endoscopic therapeutic methods (e.g. nasobiliary drainage, implantation of plastic prostheses or selfexpandable metallic stents (SEMS)) and percutaneous therapeutic methods such as percutaneous drainage (PTBD) and implantation of plastic endoprostheses or metallic stents. The median survivals have varied between 12 and 16 months in several studies and have not clearly shown the advantage in a large group of patients. In conclusion, favorable prognosis for patients with unresectable hilar cholangiocarcinoma can be achieved using a complex tailored oncological therapy. Later retrospective studies with stereotactic radiotherapy have shown very promising results and randomized studies of this are critically needed. In future trials, it is necessary to count not only on diagnosis and localizations of cholangiocarcinoma but also on morphological characteristics (growth pattern, vascularisation) and grade of tumor, which can greatly influence the prognosis of patients as shown by the results from large studies of the resectable disease. |