Liver Resection for Intrahepatic Cholangiocarcinoma-Single-Center Experience with 286 Patients Undergoing Surgical Exploration over a Thirteen Year Period

Abstract

Background: Intrahepatic cholangiocarcinoma (iCCA) accounts for about 10% of primary liver cancer. Surgery is the only potentially curative treatment. We report on our current series of 229 consecutive hepatic resections for iCCA, which is one of the largest Western single-center series published so far.

Methods: Between January 2008 to December 2020, a total of 286 patients underwent 307 surgical explorations for intended liver resection of iCCA at our department. Data were analyzed with regard to (1) preoperative treatment of tumor, (2) operative details, (3) perioperative morbidity and mortality, (4) histopathology, (5) outcome measured by tumor recurrence, treatment of recurrence and survival and (6) prognostic factors for overall and disease-free survival.

Results: the resectability rate was 74.6% (229/307). In total, 202 primary liver resections, 21 repeated, 5 re-repeated, and 1 re-re-repeated liver resections were performed. In primary liver resections there were 77% (155/202) major hepatectomies. In 39/202 (20%) of patients additional hepatic wedge resections and in 87/202 (43%) patients additional 119 other surgical procedures were performed next to hepatectomy. Surgical radicality in first liver resections was 166 R0-, 33 R1- and 1 R2-resection. Following the first liver resection, the calculated 1-, 3- and 5-year-survival is 80%, 39%, and 22% with a median survival of 25.8 months. Until the completion of data acquisition, tumors recurred in 123/202 (60.9%) patients after a median of 7.5 months (range 1-87.2 months) after resection. A multivariate cox regression revealed tumor size (p < 0.001), T stage (p < 0.001) and N stage (p = 0.003) as independent predictors for overall survival. N stage (p = 0.040), preoperative therapy (p = 0.005), T stage (p = 0.004), tumor size (p = 0.002) and M stage (p = 0.001) were independent predictors for recurrence-free survival.

Conclusions: For complete surgical removal, often extended liver resection in combination with complex vascular or biliary reconstruction is required. However, despite aggressive surgery, tumor recurrence is frequent and long-term oncological results are poor. This indicated that surgery alone is unlikely to make great strides in improving prognosis of patients with iCCA, instead clearly suggesting that liver resection should be incorporated in multimodal treatment concepts.

Keywords: cholangiocarcinoma; intrahepatic cholangiocarcinoma; liver resection; repeated liver resection; survival.

Figure 1

Preoperative 3D reconstruction as a PDF presentation (A) and 3D-print (B) with stained polyurethane rubber of the liver as well as CT-scan (C,D) in a 70-year-old patient with iCCA that infiltrated the right and middle hepatic vein and had contact to the left hepatic vein. Preoperative volumetric analysis of the segments 2/3 revealed a remnant volume of 563 mL. Resection was performed as an extended right-sided hemihepatectomy with hilar resection and reconstruction of the left portal vein and the medial of two branches of the left hepatic vein.

Figure 2

Flowchart of all explorations. Further subdivision in primary and repeated explorations.

Figure 3

(a) Comparison of overall survival of patients with R0 versus R1 resection; p = 0.092. Additionally, combined depiction of the complete cohort. Perioperative deaths were excluded. (b) Comparison of overall survival of patients with N0 or N1 status; p < 0.001. Perioperative deaths were excluded. (c) Comparison of overall survival of patients with solitary versus multifocal iCCA; p = 0.144. Perioperative deaths were excluded. (d) Comparison of overall survival of different UICC groups; p < 0.001. Subgroup comparison: UICC I vs. UICC II p = 0.002; UICC I vs. UICC III p < 0.001; UICC I vs. UICC IV p < 0.001; UICC II vs. UICC III p = 0.252; UICC II vs. UICC IV p = 0.014; UICC III vs. UICC IV p = 101. Perioperative deaths and patients with Nx status were excluded. (e) Comparison of overall survival of patients with visceral and/or vascular extension (VVE) versus no extension; p < 0.001. Subgroup comparison: no extension vs. VVE − infiltration p = 0.465; no extension vs. VVE + infiltration p < 0.001; VVE − infiltration vs. VVE + infiltration p = 0.007. Perioperative deaths were excluded. (f) Comparison of overall survival of patients without vascular extension (VE), VE without (−) infiltration and VE with (+) infiltration; p = 0.163. Subgroup comparison: no VE vs. VE − infiltration p = 0.746; no VE vs. VE + infiltration p = 0.058; VE − infiltration vs. VE + infiltration p = 0.125. Perioperative deaths were excluded.