Hilar cholangiocarcinoma (Klatskin tumor) – current treatment options
Authors:
F. Bělina
Authors‘ workplace:
Chirurgická klinika 2. LF UK a ÚVN Praha, přednosta: prof. MUDr. M. Ryska, CSc.
Published in:
Rozhl. Chir., 2013, roč. 92, č. 1, s. 4-15.
Category:
Review
Overview
Hilar cholangiocarcinoma is a rare tumor with a rather poor prognosis, and thus remains a challenge for diagnosis and treatment. The sole potentionally curative treatment is the complete resection of the tumor. A negative surgical margin is one of the most important factors in achieving prolonged survival. A preoperative evaluation of the tumor is important for the evaluation of resectability and the extent of surgery. Unfortunately, only a small number of patients with hilar cholangiocarcinoma is indicated for the radical procedure. Liver transplantation is not a standard method in the treatment of the Klatskin tumor and it is reserved only for carefully selected patients in a few transplant centres. The main aim of the palliative treatment is biliary drainage, reduction of the pain and pruritus and overall improvement of the quality of life. Adjuvant chemotherapy and radiotherapy are the important parts of the complex therapy, however, no definite regimen has been established to date. Further evidence is needed to define the role of liver transplantation and (neo)adjuvant new therapeutic modalities.
Key words:
hilar cholangiocarcinoma – radical surgery – palliative treatment – liver transplantation – (neo) adjuvant chemotherapy – radiotherapy
Sources
1. Altemeier WA, Gall EA, Zinninger MM, Hoxworth PI. Sclerosing carcinoma of the major intrahepatic bile ducts. AMA Arch Surg 1957; 75(3):450–461.
2. Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. An unusual tumour with distinctive clinical and pathological features. Am J Med 1965;38:241–256.
3. Dušek L, et al. Czech Cancer Care in Numbers 2008–2009, Praha, Grada Publishing 2009.
4. Blechacz B, Gores JG. Cholangiocarcinoma: Advances in Pathogenesis, Diagnosis, and Treatment. Hepatology 2008; 48 (1): 308–321.
5. Olnes MJ, Erlich R. A review and update on cholangiocarcinoma. Oncology 2004;66:167–179.
6. Ebata T, Watanabe H, Ajioka Y, Oda K, Nimura Y. Pathological appraisal of lines of resection for bile duct carcinoma. Br J Surg 2002;89:1260–1267.
7. Gerhards MF, Vos, P, van Gulik TM, Rauws EA, Bosma A, Gouma DJ. Incidence of benign lesions in patients resected for suspicious hilar obstruction. Br J Surg 2001;88:48–51.
8. Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg. Gynecol. Obstet 1975;140:170-178.
9. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL. III A Perihilar Bile Ducts. In: AJCC Cancer Staging Handbook. 7th ed. Chicago, IL: Springer 2010:718.
10. Jarnagin WR, Fong Y, DeMatteo RP, Gonen M, Burke EC, Bodniewicz BJ, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001;234: 507–517.
11. DeOliveira ML, Richard L, Schulick D, Nimura Y, Rosen Ch, Gores G. New Staging System and a Registry for Perihilar Cholangiocarcinoma. Hepatology 2011;53:1363–1371.
12. Kubota K, Makuuchi M, Kusaka K, Kobayashi T, Miki K, Hasegawa K, et al. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology 1997;26:1176–81.
13. Miyagawa S, Makuuchi M, Kawasaki S, Kakazu T. Criteria for safe hepatic resection. Am J Surg 1995;169:589–94.
14. Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunvén P, Yamazaki S, Hasegawa H, Ozaki H. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 1990;107: 521–527.
15. Nagino M, Kamiya J, Nishio H, Ebata T, Arai T, Nimura Y. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Ann Surg 2006; 243:364–372.
16. Kodama Y, Shimizu T, Endo H, Miyamoto N, Miyasaka K. Complications of percutaneous transhepatic portal vein embolization. J Vasc Interv Radiol 2002;13:1233–7.
17. van Gulik TM, van den Esschert JW, de Graaf W, van Lienden KP, Busch OR, Heger M, van Delden OM, Lameris JS, Gouma DJ. Controversies in the use of portal vein embolization. Dig Surg 2008;25:436–444.
18. van Gulik TM, Ruys AT, Busch ORC, Rauws EAJ, Gouma DJ. Extent of Liver Resection for Hilar Cholangiocarcinoma (Klatskin Tumor): How Much Is Enough? Dig Surg 2011;28:141–147.
19. Hochwald SN, Burke EC, Jarnagin WR, Fong Y, Blumgart LH. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg 1999;134:261–266.
20. Sewnath ME, Karsten TM, Prins MH, Rauws EJ, Obertop H, Gouma DJ. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002;236:17–27.
21. Young AL, Igami T, Senda Y, Adair R, Farid S, Toogood GJ, K. Rajendra Prasad KR, Lodge JPA. 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 2011;13,483–493.
22. Kloek JJ, van der Gaag NA, Aziz Y, Rauws EA, van Delden OM, Lameris JS, Busch OR, Gouma DJ, van Gulik TM. Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg 2010; 14:119–125.
23. Qian-Feng Shi, Ting-Bo Liang, Yun-Sheng Qin, Wei-Lin Wang, Yan Shen Min Zhang and Shu-Sen Zheng. Evaluation of surgical approach for extrahepatic cholangiocarcinoma Hepatobiliary Pancreat Dis Int 2007;6:622–626.
24. Ikeyama T, Nagino M, Oda K, Ebata T, Nishio H, Nimura Y. Surgical approach to Bismuth type I and II hilar cholangiocarcinomas: audit of 54 consecutive cases. Ann Surg 2007;246:1052–7.
25. Nimura Y, Hayakawa N, Kamiya J, Kondo S, Shionoya S. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J Surg 1990;14:535–43.
26. Kamiya J, Nimura Y, Hayakawa N, Kondo S, Nagino M, Kanai M. Preoperative cholangiography of the caudate lobe: surgical anatomy and staging for biliary carcinoma. J Hepatobiliary Pancreat Surg 1994;4:385–9.
27. Jonas S, Benckert C, Thelen A, Lopez-Hänninen E, Rösch T, Neuhaus P. Radical surgery for hilar cholangiocarcinoma. Eur J Surg Oncol 2008;34:263–271.
28. Nagino M, Kamiya J, Arai T, Nishio H, Ebata T, Nimura Y. Anatomic right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma. Ann Surg 2006;243:28–32.
29. Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Staging laparoscopy in patients with extrahepatic biliary carcinoma: analysis of 100 patients. Ann Surg 2002;235:392–9.
30. Kitagawa Y, Nagino M, Kamiya J, Uesaka K, Sano T, Yamamoto H, Hayakawa N, Nimura Y. Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection. Ann Surg 2001;233:385–392.
31. 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: 720–727.
32. Neuhaus P, Jonas S, Settmacher U, Thelen A, Benckert C, Lopez-Hanninen E, et al. Surgical management of proximal bile duct cancer: extended right lobe resectionin creases resectability and radicality. Langenbecks Arch Surg 2003;388:194–200.
33. Hirano S, Kondo S, Tanaka E, Shichinohe T, Tsuchikawa T, Kato K. No-touch resection of hilar malignancies with right hepatectomy and routine portal reconstruction. J Hepatobiliary Pancreat Surg 2009;16:502–507.
34. Miyazaki M, Kato A, Ito H, Kimura F, Shimizu H, Ohtsuka M, Yoshidome H, Yoshitomi H, Furukawa K, Nozawa S. Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? Surgery 2007;141:581-588.
35. Hemming AW, Reed AI, Fujita S, Foley DP, Howard RJ. Surgical management of hilar cholangiocarcinoma. Ann Surg 2005;241: 693–702.
36. Meyer CG, Penn I, James L. Liver transplantation for cholangiocarcinoma: results in 207 patients. Transplantation 2000;69:1633.
37. Alessiani M, Tzakis A, Todo S, et al. Assessment of 5-year experience with abdominal organ cluster transplantation. J Am Coll Surg 1995;180:1.
38. Seehofer D, Thelen A, Neumann U, et al. Extended bile duct resection and liver transplantation in patients with hilar cholangiocarcinoma: long-term results. Liver Transpl 2009;15:1499.
39. De Vreede I, Steers JL, Burch PA, Rosen CB, Gunderson LL, Haddock MG, et al. Prolonged disease-free survival after orthotopic liver transplantation plus adjuvant chemoirradiation for cholangiocarcinoma. Liver Transpl 2000;6:309–316.
40. Lo CM, Fan ST, Liu CL, Yong BH, Wong Y, Lau GK, et al. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004;240:151–158.
41. Kloek JJ, Ten Kate FJ, Busch ORC, Gouma D J, van Gulik TM. Surgery for extrahepatic cholangiocarcinoma: predictors of survival. HPB, 2008;10:190–195.
42. Launois B, Reding R, Lebeau G, Buard J. Surgery for hilar cholangiocarcinoma: French experience in a collective survey of 552 extrahepatic bile duct cancers. J Hepatobiliary Pancreat Surg 2000;7:128–34.
43. Singhal D, van Gulik TM, Gouma DJ. Palliative management of hilar cholangiocarcinoma. Surg Oncol 2005;14:59–74.
44. Deviere N, Baize M, De Toeuf S, Cremer M. Long-term follow-up of patients with hilar malignant stricture treated by endoscopic biliary stenting. Gastrointest Endosc 1988;34:95–101.
45. Kaassis M, Boyer J, Dumas R, Ponchon T, Coumaros D, Delcenserie R, et al. Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endosc 2003;57:178–182. [PubMed: 12556780].
46. Sang HL, Park JK, Yoon WJ, et al. Optimal biliary drainage for inoperable Klatskin tumor based on Bismuth type. World J Gastroenterol 2007;7:3948–55.
47. Madoff D, Wallace M. Palliative treatment of unresectable bile duct cancer. Which stent? Which approach? Surg Oncol Clin N Am 2002;11:923–39.
48. Cowling M, Adam A. Internal stenting in malignant biliary obstruction. World J Surg 2001;25:355–61.
49. Válek V, Kysela P, Kala Z, Tomášek J, Petera J. Brachytherapy and percutaneous stenting in the treatment of cholangiocarcinoma: A prospective randomised study. European J Radiology 2007;62,2:175–179.
50. Czito BG, Anscher MS, Willett CG. Radiation therapy in the treatment of cholangiocarcinoma. Oncology (Williston Park) 2006;20:873–884 [discussion: 886-878,893–875].
51. Morganti AG, Trodella L, Valentini V, et al. Combined modality treatment in unresectable extrahepatic biliary carcinoma. International Journal of Radiation Oncology Biology Physics 2000; 46(4):913–9.
52. Ortner ME, Caca K, Berr F, Liebetruth J, Mansmann U, Huster D, et al. Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study. Gastroenterology 2003;125:1355–1363.
53. Kiba T, Nishimura T, Matsumoto S, Hatano E, Mori A, Yasumi S, et al. Single-agent gemcitabine for biliary tract cancers. Study outcomes and systematic review of the literature. Oncology 2006;70:358–365.
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2013 Issue 1
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