Hilar cholangiocarcinoma: Outcomes in a Northern Tertiary Referral Centre


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Abdullah Malik1,Stuart Robinson2,Jeremy French2,Gourab Sen2,Colin Wilson2,John Hammond2,Steven White2,Derek Manas2
1University of Liverpool,2Newcastle upon Tyne Hospitals NHS Foundation Trust

Abstract

Background

Hilar cholangiocarcinoma (HCCA) is a malignant tumour arising from the bifurcation of the common hepatic duct and has a poor prognosis. Most patients present with unresectable disease. If resectable, an extended hemihepatectomy plus caudate lobe resection is usually required to provide oncological clearance. Developments in patient selection, pre-operative assessment, biliary drainage and liver optimisation via ipsilateral portal vein embolisation (PVE) have improved outcomes. We reviewed outcomes for patients with HCCA managed at our centre.

Method

A retrospective review of patients referred with HCCA over a ten-year period (2007-2017) was undertaken using peri-operative records, pathology reports, discharge notes and clinic letters. The Kaplan-Meier method was used to estimate survival with the log rank test used for significance (p<0.05). Patients were censored for follow-up. Statistical analysis was performed using SPSS version 22.

Results

156 patients with HCCA were identified, confirmed on radiological imaging correlated with CA 19-9. 44 patients underwent resection (extended left n=14, extended right n=28, extra-hepatic bile duct resection n=1, trial dissection n=1). 112 were determined to have unresectable disease. Overall survival (OS) was increased in resected patients compared with non-resected (39.3 ±21.0 versus 9.8 ±3.8months, p<0.001). In patients undergoing resection, margin status (R0 n=11), need for vascular resection (n=11), caudate resection (n=36), PVE (n=11), lymph node positivity (n=19), post-operative bile leak (n=23), microvascular (n=28) and microlymphatic invasion (n=21) did not impact OS (p>0.05). Perineural invasion (n=33) was associated with significantly shorter OS (24.4 versus 55.7 months, p=0.032). The 30-day mortality rate after resection for HCCA was 11.4% (n=5).

Conclusion

The majority of patients with HCCA had unresectable disease at presentation. Surgery provided superior outcome compared to non-surgical treatment of HCCA, with vascular resection and resection margin having no impact on survival. Therefore in patients with resectable disease we continue to advocate an aggressive approach for surgically treating HCCA.