The impact of portal vein resection on outcomes for hilar cholangiocarcinoma

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. Cancer 2012. © 2012 American Cancer Society.

Curative-intent Surgery for Perihilar Cholangiocarcinoma with and without Portal Vein Resection - A Comparative Analysis of Early and Late Outcomes

“…No differences in morbidity rates were observed in most of the published studies (17)(18)(19)(20)(21)(22)25,(27)(28)(29)46), as it was the case in the present series. Only one study showed significantly increased morbidity rates when a PVR is performed (23).…”

“…Regarding the early outcomes, some studies associated a PVR with trends towards increased mortality rates (15,24,27,49) while others did not (6,11,(18)(19)(20)(21)(22)(23)25,28), as it was the case in the present series. No differences in morbidity rates were observed in most of the published studies (17)(18)(19)(20)(21)(22)25,(27)(28)(29)46), as it was the case in the present series.…”

“…Other studies did not identify the portal vein invasion as a significant prognostic factor (18,19,45,51). The reported incidence of V1 rates in the previous studies varies between 22% and 80% (5,7,11,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)45) (Table 4). A recent study has shown that histopathological tumor invasion of the portal vein is associated with an aggressive tumor biology (55).…”

“…Some studies identified a PVR as negative prognostic factor for long-term survival (6,11,19,27), while others did not (5,15,18,(21)(22)(23)(24)(25)(26)28,43,(51)(52)(53) (Table 4). It is worth to mention that there are several studies that associated a PVR with significantly improved survivals in PHC (7,20).…”

“…Although challenging, the safety of a portal vein resection (PVR) during curative-intent surgery for PHC has been demonstrated in several studies (6,7,11,(18)(19)(20). However, the impact of a PVR in PHC surgery remains controversial and previous comparative studies reached conflicting results (5,7,11,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29), none including patients from Eastern Europe. Furthermore, meta-analyses comparing the outcomes of patients with and without a PVR for PHC did not reach the same conclusions (29)(30)(31)(32)(33).…”