Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma

Objective To analyze resectability and survival in patients with hilar cholangiocarci noma according to a proposed preoperative staging scheme that fully integra tes local, tumor-related factors. Summary Background Data In patients with hilar cholangiocarcinoma, long-term survival depends criti cally on complete tumor resection. The current staging systems ignore facto rs related to local tumor extent, preclude accurate preoperative disease as sessment, and correlate poorly with resectability and survival. Methods Demographics, results of imaging studies, surgical findings, pathology, and survival were analyzed prospectively in consecutive patients. Using data f rom imaging studies, all patients were placed into one of three stages base d on the extent of ductal involvement by tumor, the presence or absence of portal vein compromise, and the presence or absence of hepatic lobar atroph y. Results From March 1991 through December 2000, 225 patients were evaluated, 77% of whom were seen and treated within the last 6 years. Sixty-five patients had unresectable disease; 160 patients underwent exploration with curative int ent. Eighty patients underwent resection: 62 (78%) had a concomitant hepati c resection and 62 (78%) had an RO resection (negative histologic margins). Negative histologic margins, concomitant partial hepatectomy, and well-dif ferentiated tumor histology were associated with improved outcome after all resections. However, in patients who underwent an RO resection, concomitan t partial hepatectomy was the only independent predictor of long-term survi val. Of the 9 actual 5-year survivors (of 30 at risk), all had a concomitan t hepatic resection and none had tumor-involved margins; 3 of these 9 patie nts remained free of disease at a median follow-up of 88 months. The rates of complications and death after resection were 64% and 10%, respectively. In the 219 patients whose disease could be staged, the proposed system pred icted resectability and the likelihood of an RO resection and correlated wi th metastatic disease and survival. Conclusion By taking full account of local tumor extent, the proposed staging system f or hilar cholangiocarcinoma accurately predicts resectability, the likeliho od of metastatic disease, and survival. Complete resection remains the only therapy that offers the possibility of long-term survival, and hepatic res ection is a critical component of the surgical approach.