Proximal bile duct cancer: high resectability rate and 5-year survival

Abstract

Objective: To review and update the authors' experience with resectional surgery for proximal bile duct carcinoma (Klatskin tumor) and assess the role of liver resection over the past 25 years.

Background: Until recently, resection of proximal bile duct carcinoma was uncommon, with most patients undergoing palliative procedures. The authors adopted a radical surgical approach aimed at definitive cure in 1974. Recent reports suggest that resection improves outcome.

Methods: The records of 40 of 94 patients (23 men, 17 women, age range 34-81 years) diagnosed with proximal bile duct carcinoma who underwent resection between 1968 and 1993 were reviewed. According to the Bismuth classification, there were five type I, four type II, 25 type III, and six type IV lesions; 11 patients underwent tumor resection alone, and 25 patients had combined tumor and liver resection (seven of these also underwent an associated regional vascular resection). In 3 patients, venous allografts were harvested from cadaveric donors and used to reconstruct the portal vein. Four patients underwent liver transplantation; in two, organ cluster-type resections including the liver with porta hepatitis and pancreas were performed.

Results: The resectability rate in the more recent period of the study was 49.4%. Most type I, three (of four) type II, T in situ, T1a, T1b, and all stage 0 tumors were resected without hepatectomy. In the other subgroups of tumors, the main surgical procedure was hepatectomy. Thirty-day mortality was 12.5%. After tumor resection alone, survival at 1, 3, and 5 years was 81.8%, 45.5%, and 27.3%, respectively. After tumor resection and hepatectomy without vascular resection, 1-, 3-, and 5-year survival was 66.7%, 16.7%, and 6%, respectively. With vascular resection, survival rates were similar: 64%, 20%, and 4%, respectively.

Conclusion: The type of surgery required to achieve cure is closely related to tumor location, TNM classification, and staging. Increasing resectability through the use of hepatectomy improves survival and offers a chance of cure in patients with more advanced disease.

Figure 1. Posterior intrahepatic approach of the hilum. Glissonian sheath covering left bile duct tumor is shown separated from parenchyma. When the tumor extends into parenchyma, only the opposite sheath is dissected.

Figure 10. Survival according to TNM staging.

Figure 11. Survival according to age.

Figure 12. Survival according to histology.

Figure 13. Relationship between resectability rate and hepatectomy in selected studies. 1, Tsuzuki (52%, 52%); 2, Blumgart (13%, 19%); 3, Gazzaniga (9%, 21%); 4, Iwasaki (19.5%, 61%); 5, Mizumoto (50%, 92%); 6, Pinson (6%, 18%); 7, Launois (34%, 61%); 8, Pichlmayr (25%, 48.1%); 9, Nimura (77%, 83.3%); 10, Bismuth (9.6%, 16.9%); 11, present study (33%, 49.4%).

Figure 2. Bile duct in Glissonian sheaths. (From: Launois B, Jamieson GG. Modern operative techniques in liver surgery. Edinburgh: Churchill Livingston; 1993. With permission.)

Figure 3. Type of surgical procedures according to (A) tumor location, (B) TNM classification, and (C) staging.

Figure 4. Overall actuarial survival.

Figure 5. Survival according to the type of surgery.

Figure 6. Survival according to tumor location.

Figure 7. Survival according to TNM classification.

Figure 8. Survival according to lymph node involvement.

Figure 9. Survival according to liver metastases.