Surgical Treatment of Intrahepatic Cholangiocarcinoma: Current and Emerging Principles

Abstract

Intrahepatic cholangiocarcinoma (ICC) is a rare, aggressive cancer of the biliary tract. It often presents with locally advanced or metastatic disease, but for patients with early-stage disease, surgical resection with negative margins and portahepatis lymphadenectomy is the standard of care. Recent advancements in ICC include refinement of staging, improvement in liver-directed therapies, clarification of the role of adjuvant therapy based on new randomized controlled trials, and advances in minimally invasive liver surgery. In addition, improvements in neoadjuvant strategies and surgical techniques have enabled expanded surgical indications and reduced surgical morbidity and mortality. However, recurrence rates remain high and more effective systemic therapies are still necessary to improve recurrence-free and overall survival. In this review, we focus on current and emerging surgical principals for the management of ICC including preoperative evaluation, current indications for surgery, strategies for future liver remnant augmentation, technical principles, and the role of neoadjuvant and adjuvant therapies.

The Implications of Treatment Delays In Adjuvant Therapy For Resected Cholangiocarcinoma Patients

“…23,24 Extrahepatic tumors were more likely to be treated among the rst quartile of patients, which may be a result of differences in surgical techniques and associated recovery times between tumor locations. [25][26][27] We also identi ed some predictors of delay that were less expected, including treatment with RT alone as well as black and Hispanic race. As RT alone is not a guideline-supported option for adjuvant therapy, patients treated with RT alone may represent a cohort that is unable to recover adequately from surgery to be treated with CT or CRT.…”

Recurrence after Curative Resection for Intrahepatic Cholangiocarcinoma: How to Predict the Chance of Repeat Hepatectomy?

“…As the systemic chemotherapy response is low, surgery remains the gold standard in ICC treatment and the only curative chance. However, the five-year survival rate is still low (20-40%) [4,5] with a mean survival of 12-36 months after curative surgery, versus 2-9 months for the unresectable patients [6]. The low survival rate is mainly related to the disease recurrence after surgical resection that can be as high as 50-70% [7], being mainly localized in the liver [8], followed by distant lymph node metastases.…”

Complex Liver Resections for Intrahepatic Cholangiocarcinoma

“…This might be due to improvements in diagnostic tools or increases in metabolic disorders and obesity [4]. Advances in local therapies, targeted chemotherapies and adjuvant chemotherapy are promising [5][6][7][8]; however, liver resection remains the only potential curative therapy [9,10]. At presentation, about 50% of patients have unresectable disease and another 30% will be found unresectable during surgical exploration [11].…”

“…Regarding these circumstances, non-conventional surgical techniques, such as ante situm procedures, offer a possibility for resection [17][18][19][20][21]. In addition, portal vein resection is often needed and complex constructions are described as safe for selected patients in high-volume centers [9,22,23].…”

“…In case of a non-sufficient FLR, portal vein embolization (PVE) or associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are strategies to enhance FLR [12]. Whereas PVE is considered as safe and standard technique for small FLR [9,27], the role of ALPPS is currently controversially discussed [28][29][30].…”