HILAR CHOLANGIOCARCINOMA - PATTERNS OF SPREAD, THE IMPORTANCE OF HEPATIC RESECTION FOR CURATIVE OPERATION, AND A PRESURGICAL CLINICAL STAGING SYSTEM

Objectives To determine the resectability rate for hilar cholangiocarc inoma, to analyze reasons for unresectability, and to devise a presurg ical clinical T-staging system. Methods Ninety patients with hilar cho langiocarcinomas seen between March 1, 1991, and April 1, 1997, were e valuated. Accurate patterns of disease progression and therapy were ev aluable. Disease was staged in 89 patients using extent of ductal tumo r involvement, portal vein compromise, and liver atrophy. Results In 2 1 patients, disease was deemed unresectable for cure at presentation. in 39 patients, disease was found to be unresectable at laparotomy, 23 secondary to nodal (N2) or distant metastases. Unresectability was th e result of metastases in 52% and of locally advanced disease in 28%. Thirty patients (33%) had resection of all gross disease, and 25 of th ese (83%) had negative histologic margins. Twenty-two patients underwe nt partial hepatectomy. The 30-day mortality rate was 7%. Projected su rvival is greater than 60 months in those with a negative histologic m argin, with a median follow-up of 26 months. A presurgical T-staging s ystem allows presurgical selection for therapy, predicts partial hepat ectomy, and offers an index of prognosis. Conclusions In half the pati ents, unresectability is mainly the result of intraabdominal metastase s. Presurgical imaging predicts unresectability based on local extensi on but is poor for assessing nodal metastases. in one third of patient s, disease can be resected for cure with a long median survival. Curat ive resection depends on negative margins, and hepatic resection is ne cessary to achieve this. The T-staging system correlates with resectab ility, the need for hepatectomy, and overall survival.