Changing strategies in diagnosis and management of hilar cholangiocarcinoma

Abstract

Hilar cholangiocarcinoma is one of the most difficult tumors to stage and treat. This study aims to evaluate (1) the best diagnostic imaging, (2) the usefulness of preoperative biliary drainage, (3) the resectability rate, and (4) the results of palliative treatments and surgical resection. Seventy-six patients with hilar cholangiocarcinoma with a mean age of 64 ؎ 11 years were treated at our institution from 1989 to 1999. Patients were studied preoperatively using ultrasound, computed tomography (CT), and percutaneous cholangiography or magnetic resonance cholangiography. Forty-eight patients (63%) underwent palliative treatment. Twenty-eight patients underwent surgical curative therapy; 20 resections and 8 orthotopic liver transplantations (OLTs). Percutaneous transhepatic cholangiography was performed in 18 of 28 patients (64%), and magnetic resonance cholangiography in 5 patients; both methods were equally effective in establishing tumoral invasion of the biliary ducts. Five patients did not undergo either diagnostic modality. Excluding the patients who underwent OLT, no significant differences were found in surgical mortality (1 v 2 patients) or postoperative morbidity (100% v 66%) for patients with and without preoperative biliary drainage. The postoperative mortality rate was 11% (3 of 28 patients). The overall resectability rate was 37%. Mean survival in the surgical and palliative groups was 35 and 6 months, respectively (P < .0001). Patients who underwent OLT had a better 5-year survival rate than those treated by tumor resection (36% v 21%; P ‫؍‬ .02). Combined chemotherapy and radiotherapy apparently did not provide a significant survival benefit. Helical CT and magnetic resonance cholangiography are useful techniques to delineate tumor extent and rule out vascular invasion and lymph node or liver metastases. No clear conclusions regarding preoperative drainage can be drawn from this study. A high resectability rate (37%) is feasible with major hepatectomy. (Liver Transpl 2000;6:786-794.)

CT Evaluation of Disease Pattern in Hilar Cholangiocarcinoma

“…Therefore, imaging also plays an important role in determining whether a patient is a candidate for curative resection and in planning management [16]. Helical CT and MRCP are the best imaging techniques to diagnose the disease, delineate the extent of the tumor and rule out liver metastasis and enlarged lymph nodes [17]. MDCT allows for faster scanning with thinner collimation and can result in an improved diagnosis and evaluation of hilar cholangiocarcinoma [15].…”

Radiotherapy combined with transarterial infusion chemotherapy and concurrent infusion of a vasoconstrictor agent for nonresectable advanced hepatic hilar duct carcinoma

“…The survival rates after surgical resection are better than those after palliative treatment and were reported to be 45-87% at 1 year, 21-30% at 3 years, and 11-21% at 5 years. [2][3][4][5] However, curative surgical resection can be performed in only 30 -40% of patients with hilar duct carcinoma, even in recent reports. 2,5 Patients with unresectable hilar duct carcinomas often are treated by biliary drainage with or without radiotherapy.…”

“…[1][2][3][4][5][6][7] Despite recent advances in diagnostic and therapeutic technologies, patients with carcinoma of the hepatic hilar duct are often diagnosed in the advanced stage and the majority (approximately 58 -83%) of patients can only be treated palliatively. [1][2][3][4][5][6][7] The reported median survival time for patients with unresectable hilar duct carcinoma ranges from 3 to 11 months. nal beam radiotherapy (EBRT) alone or in combination with brachytherapy, 10 -12 but others reported that EBRT had no apparent effect on either survival or late toxicity.…”

Surgical Palliative Drainage in Un-resectable Malignant Biliary Obstruction

“…Studies revealed that patients receiving surgical treatment have a longer survival and better quality of life compared to the patients underwent nonsurgical palliative therapies [12,13]. Despite main advantages of surgical bypass, high early postoperative morbidity and mortality and complications due to external biliary drainage such as fluid and electrolyte imbalance, loss of bile, dislocation and obstruction of external catheter have to be considered [14,15].…”