Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 5/2018

01-05-2018 | Hepatobiliary Tumors

The Impact of Intraoperative Re-Resection of a Positive Bile Duct Margin on Clinical Outcomes for Hilar Cholangiocarcinoma

Authors: Xu-Feng Zhang, MD, PhD, Malcolm H. Squires III, MD, MS, Fabio Bagante, MD, Cecilia G. Ethun, MD, Ahmed Salem, MD, Sharon M. Weber, MD, Thuy Tran, MD, George Poultsides, MD, Andre Y. Son, MD, Ioannis Hatzaras, MD, Linda Jin, MD, Ryan C. Fields, MD, Matthew Weiss, MD, Charles Scoggins, MD, Robert C. G. Martin, MD, Chelsea A. Isom, MD, Kamron Idrees, MD, Harveshp D. Mogal, MD, Perry Shen, MD, Shishir K. Maithel, MD, Carl R. Schmidt, MD, Timothy M. Pawlik, MD, MPH, PhD, FACS, FRACS (Hon.)

Published in: Annals of Surgical Oncology | Issue 5/2018

Login to get access

Abstract

Background

The impact of re-resection of a positive intraoperative bile duct margin on clinical outcomes for resectable hilar cholangiocarcinoma (HCCA) remains controversial. We sought to define the impact of re-resection of an initially positive frozen-section bile duct margin on outcomes of patients undergoing surgery for HCCA.

Methods

Patients who underwent curative-intent resection for HCCA between 2000 and 2014 were identified at 10 hepatobiliary centers. Short- and long-term outcomes were analyzed among patients stratified by margin status.

Results

Among 215 (83.7%) patients who underwent frozen-section evaluation of the bile duct, 80 (37.2%) patients had a positive (R1) ductal margin, 58 (72.5%) underwent re-resection, and 29 ultimately had a secondary negative margin (secondary R0). There was no difference in morbidity, 30-day mortality, and length of stay among patients who had primary R0, secondary R0, and R1 resection (all p > 0.10). Median and 5-year survival were 22.3 months and 23.3%, respectively, among patients who had a primary R0 resection compared with 18.5 months and 7.9%, respectively, for patients with an R1 resection (p = 0.08). In contrast, among patients who had a secondary R0 margin with re-resection of the bile duct margin, median and 5-year survival were 30.6 months and 44.3%, respectively, which was comparable to patients with a primary R0 margin (p = 0.804). On multivariable analysis, R1 margin resection was associated with decreased survival (R1: hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.0–1.7; p = 0.027), but secondary R0 resection was associated with comparable long-term outcomes as primary R0 resection (HR 0.9, 95% CI 0.4–2.3; p = 0.829).

Conclusions

Additional resection of a positive frozen-section ductal margin to achieve R0 resection was associated with improved long-term outcomes following curative-intent resection of HCCA.
Literature
1.
2.
Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg. 2001;234(4):507–17; discussion 517–509.
3.
Nakeeb A, Pitt HA, Sohn TA, et al. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors. Ann Surg. 1996;224(4):463–73; discussion 473-465.
4.
Weiss MJ, Cosgrove D, Herman JM, Rastegar N, Kamel I, Pawlik TM. Multimodal treatment strategies for advanced hilar cholangiocarcinoma. Langenbeck’s Arch Surg. 2014;399(6):679–92.CrossRef
5.
Cho MS, Kim SH, Park SW, et al. Surgical outcomes and predicting factors of curative resection in patients with hilar cholangiocarcinoma: 10-year single-institution experience. J Gastrointest Surg. 2012;16(9):1672–9.CrossRefPubMed
6.
Nuzzo G, Giuliante F, Ardito F, et al. Improvement in perioperative and long-term outcome after surgical treatment of hilar cholangiocarcinoma: results of an Italian multicenter analysis of 440 patients. Arch Surg. 2012;147(1):26–34.CrossRefPubMed
7.
Zheng-Rong L, Hai-Bo Y, Xin C, et al. Resection and drainage of hilar cholangiocarcinoma: an 11-year experience of a single center in mainland China. Am Surgeon. 2011;77(5):627–33.PubMed
8.
de Jong MC, Marques H, Clary BM, et al. The impact of portal vein resection on outcomes for hilar cholangiocarcinoma: a multi-institutional analysis of 305 cases. Cancer. 2012;118(19):4737–47.CrossRefPubMed
9.
Ebata T, Nagino M, Kamiya J, Uesaka K, Nagasaka T, Nimura Y. Hepatectomy with portal vein resection for hilar cholangiocarcinoma: audit of 52 consecutive cases. Ann Surg. 2003;238(5):720–7.CrossRefPubMedPubMedCentral
10.
Miyagawa S, Makuuchi M, Kawasaki S, et al. Outcome of major hepatectomy with pancreatoduodenectomy for advanced biliary malignancies. World J Surg. 1996;20(1):77–80.CrossRefPubMed
11.
Ribero D, Amisano M, Lo Tesoriere R, Rosso S, Ferrero A, Capussotti L. Additional resection of an intraoperative margin-positive proximal bile duct improves survival in patients with hilar cholangiocarcinoma. Ann Surg. 2011;254(5):776–81; discussion 781–773.
12.
Oguro S, Esaki M, Kishi Y, et al. Optimal indications for additional resection of the invasive cancer-positive proximal bile duct margin in cases of advanced perihilar cholangiocarcinoma. Ann Surg Oncol. 2015;22(6):1915–24.CrossRefPubMed
13.
Konishi M, Iwasaki M, Ochiai A, Hasebe T, Ojima H, Yanagisawa A. Clinical impact of intraoperative histological examination of the ductal resection margin in extrahepatic cholangiocarcinoma. Br J Surg. 2010;97(9):1363–8.CrossRefPubMed
14.
Endo I, House MG, Klimstra DS, et al. Clinical significance of intraoperative bile duct margin assessment for hilar cholangiocarcinoma. Ann Surg Oncol. 2008;15(8):2104–12.CrossRefPubMed
15.
Tsao JI, Nimura Y, Kamiya J, et al. Management of hilar cholangiocarcinoma: comparison of an American and a Japanese experience. Ann Surg. 2000;232(2):166–74.CrossRefPubMedPubMedCentral
16.
Kawasaki S, Imamura H, Kobayashi A, Noike T, Miwa S, Miyagawa S. Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization. Ann Surg. 2003;238(1):84–92.PubMedPubMedCentral
17.
Buettner S, Margonis GA, Kim Y, et al. Conditional probability of long-term survival after resection of hilar cholangiocarcinoma. HPB (Oxford). 2016;18(6):510–7.CrossRefPubMedPubMedCentral
18.
19.
Shingu Y, Ebata T, Nishio H, Igami T, Shimoyama Y, Nagino M. Clinical value of additional resection of a margin-positive proximal bile duct in hilar cholangiocarcinoma. Surgery. 2010;147(1):49–56.CrossRefPubMed
20.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.CrossRefPubMedPubMedCentral
21.
22.
Edge S BD, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC cancer staging manual. 7th ed. New York: Springer;2010.
23.
Ribero D, Pinna AD, Guglielmi A, et al. Surgical approach for long-term survival of patients with intrahepatic cholangiocarcinoma: a multi-institutional analysis of 434 patients. Arch Surg. 2012;147(12):1107–13.CrossRefPubMed
24.
Nagino M, Ebata T, Yokoyama Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg. 2013;258(1):129–40.CrossRefPubMed
25.
Soares KC, Kamel I, Cosgrove DP, Herman JM, Pawlik TM. Hilar cholangiocarcinoma: diagnosis, treatment options, and management. Hepatobiliary Surg Nutr. 2014;3(1):18–34.PubMedPubMedCentral
26.
Hemming AW, Reed AI, Fujita S, Foley DP, Howard RJ. Surgical management of hilar cholangiocarcinoma. Ann Surg. 2005;241(5):693–9; discussion 699–702.
27.
Sano T, Kamiya J, Nagino M, et al. Macroscopic classification and preoperative diagnosis of intrahepatic cholangiocarcinoma in Japan. J Hepatobiliary Pancreat Surg. 1999;6(2):101–7.CrossRefPubMed
28.
Isaji S, Kawarada Y, Taoka H, Tabata M, Suzuki H, Yokoi H. Clinicopathological features and outcome of hepatic resection for intrahepatic cholangiocarcinoma in Japan. J Hepatobiliary Pancreat Surg. 1999;6(2):108–16.CrossRefPubMed
29.
Yamamoto M, Takasaki K, Yoshikawa T. Extended resection for intrahepatic cholangiocarcinoma in Japan. J Hepatobiliary Pancreat Surg. 1999;6(2):117–21.CrossRefPubMed
30.
Valverde A, Bonhomme N, Farges O, Sauvanet A, Flejou JF, Belghiti J. Resection of intrahepatic cholangiocarcinoma: a Western experience. J Hepatobiliary Pancreat Surg. 1999;6(2):122–7.CrossRefPubMed
31.
Lee SG, Song GW, Hwang S, et al. Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience. J Hepatobiliary Pancreat Sci. 2010;17(4):476–89.CrossRefPubMed
32.
Young AL, Igami T, Senda Y, et al. Evolution of the surgical management of perihilar cholangiocarcinoma in a Western centre demonstrates improved survival with endoscopic biliary drainage and reduced use of blood transfusion. HPB (Oxford). 2011;13(7):483–93.CrossRefPubMedPubMedCentral
33.
Govil S, Reddy MS, Rela M. Surgical resection techniques for locally advanced hilar cholangiocarcinoma. Langenbeck’s Arch Surg. 2014;399(6):707–16.CrossRef
34.
35.
36.
Tamada K, Ushio J, Sugano K. Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations. World J Clin Oncol. 2011;2(5):203–16.CrossRefPubMedPubMedCentral
37.
Valero V, 3rd, Cosgrove D, Herman JM, Pawlik TM. Management of perihilar cholangiocarcinoma in the era of multimodal therapy. Expert Rev Gastroenterol Hepatol. 2012;6(4):481–95.CrossRefPubMedPubMedCentral
38.
Nguyen K, Sing JT, Jr. Review of endoscopic techniques in the diagnosis and management of cholangiocarcinoma. World J Gastroenterol. 2008;14(19):2995–9.CrossRefPubMedPubMedCentral
39.
Komaya K, Ebata T, Yokoyama Y, et al. Verification of the oncologic inferiority of percutaneous biliary drainage to endoscopic drainage: a propensity score matching analysis of resectable perihilar cholangiocarcinoma. Surgery. 2017;161(2):394–404.CrossRefPubMed
40.
Komaya K, Ebata T, Fukami Y, et al. Percutaneous biliary drainage is oncologically inferior to endoscopic drainage: a propensity score matching analysis in resectable distal cholangiocarcinoma. J Gastroenterol. 2016;51(6):608–19.CrossRefPubMed
41.
Kim KM, Park JW, Lee JK, Lee KH, Lee KT, Shim SG. A comparison of preoperative biliary drainage methods for perihilar cholangiocarcinoma: endoscopic versus percutaneous transhepatic biliary drainage. Gut Liver. 2015;9(6):791–9.CrossRefPubMedPubMedCentral
42.
Ogawa T, Ito K, Koshita S, et al. Usefulness of cholangioscopic guided mapping biopsy using spyglass ds for preoperative evaluation of extrahepatic cholangiocarcinoma: a pilot study. Gastrointest Endosc. 2017;85(5):Ab624.CrossRef
Metadata
Title
The Impact of Intraoperative Re-Resection of a Positive Bile Duct Margin on Clinical Outcomes for Hilar Cholangiocarcinoma
Authors
Xu-Feng Zhang, MD, PhD
Malcolm H. Squires III, MD, MS
Fabio Bagante, MD
Cecilia G. Ethun, MD
Ahmed Salem, MD
Sharon M. Weber, MD
Thuy Tran, MD
George Poultsides, MD
Andre Y. Son, MD
Ioannis Hatzaras, MD
Linda Jin, MD
Ryan C. Fields, MD
Matthew Weiss, MD
Charles Scoggins, MD
Robert C. G. Martin, MD
Chelsea A. Isom, MD
Kamron Idrees, MD
Harveshp D. Mogal, MD
Perry Shen, MD
Shishir K. Maithel, MD
Carl R. Schmidt, MD
Timothy M. Pawlik, MD, MPH, PhD, FACS, FRACS (Hon.)
Publication date
01-05-2018
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 5/2018
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-018-6382-0

Other articles of this Issue 5/2018

Annals of Surgical Oncology 5/2018 Go to the issue

Gastrointestinal Oncology

Sarcopenia and Comorbidity in Gastric Cancer Surgery as a Useful Combined Factor to Predict Eventual Death from Other Causes

Thoracic Oncology

Risk Stratification According to the Prognostic Nutritional Index for Predicting Postoperative Complications After Lung Cancer Surgery

Hepatobiliary Tumors

Minimally Invasive Liver Surgery: Has it Achieved the Standard of Care?

Breast Oncology

Internal Mammary Lymph Node Biopsy During Free-Flap Breast Reconstruction: Optimizing Adjuvant Breast Cancer Treatment Through Comprehensive Staging

Thoracic Oncology

Survival Impact of Stations of Pathological Lymph Nodes in N2 Non-small Cell Lung Cancer in a French Hospital

Gastrointestinal Oncology

Elucidation of the Anatomical Mechanism of Nodal Skip Metastasis in Superficial Thoracic Esophageal Squamous Cell Carcinoma