Resection for intrahepatic cholangiocellular cancer: new advances

Abstract

Intrahepatic cholangiocarcinoma (ICC) is the second most prevalent primary liver neoplasm after hepatocellular carcinoma (HCC), corresponding to 10% to 15% of cases. Pathologies that cause chronic biliary inflammation and bile stasis are known predisposing factors for development of ICC. The incidence and cancer-related mortality of ICC is increasing worldwide. Most patients remain asymptomatic until advance stage, commonly presenting with a liver mass incidentally diagnosed. The only potentially curative treatment available for ICC is surgical resection. The prognosis is dismal for unresectable cases. The principle of the surgical approach is a margin negative hepatic resection with preservation of adequate liver remnant. Regional lymphadenectomy is recommended at time of hepatectomy due to the massive impact on outcomes caused by lymph node (LN) metastasis. Multicentric disease, tumor size, margin status and tumor differentiation are also important prognostic factors. Staging laparoscopy is warranted in high-risk patients to avoid unnecessary laparotomy. Exceedingly complex surgical procedures, such as major vascular, extrahepatic bile ducts and visceral resections, ex vivo hepatectomy and autotransplantation, should be implemented in properly selected patients to achieve negative margins. Neoadjuvant therapy may be used in initially unresectable lesions in order to downstage and allow resection. Despite optimal surgical management, recurrence is frustratingly high. Adjuvant chemotherapy with radiation associated with locoregional treatments should be considered in cases with unfavorable prognostic factors. Selected patients may undergo re-resection of tumor recurrence. Despite the historically poor outcomes of liver transplantation for ICC, highly selected patients with unresectable disease, especially those with adequate response to neoadjuvant therapy, may be offered transplant. In this article, we reviewed the current literature in order to highlight the most recent advances and recommendations for the surgical treatment of this aggressive malignancy.

Keywords: Cholangiocarcinoma; biliary tract cancer; intrahepatic; liver transplantation; resection; surgery.

Figure 1

Liver autotransplantation for cholangiocarcinoma. (A) Arterial phase of computed tomography scan showing large hypervascular lesion of 6.5 cm × 4.5 cm on hepatic veins confluence, infiltrating segments I, II, IV and VIII. (B) Coronal cut showing the invasion on right hepatic vein (red arrow). Anterior branch of the right portal vein (green arrow) is preserved. (C) Ex vivo left hepatectomy was performed, with partial removal of inferior vena cava and right hepatic vein. A deceased donor iliac vein graft was used for reconstruction on back table. (D) Final aspect of the reimplanted right lobe after venous reconstruction.