il trattamento chirurgico del colangiocarcinoma - gastrolearning®

Gian Luca GraziHepato-Biliary-Pancreatic Surgery

National Cancer Institute Regina Elena

Rome

CholangiocarcinomaTreatment

Cholangiocarcinoma - Treatment

Bridgewater J et al., J Hepatol 2014, in press

Cholangiocarcinoma - Treatment

Bridgewater J et al., J Hepatol 2014, in press

Cholangiocarcinoma - Treatment

Bridgewater J et al., J Hepatol 2014, in press

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Razumilava N, Lancet. 2014 Feb 25.

Cholangiocarcinoma - Treatment

Assenza di problemi medici maggioriAnamnesi e visita medicaEsami di laboratorio e di funzionalità

Assenza di metastasi a distanzaStudio del torace e dell’addome

Altre indagini volte allo studio di sintomi

Periferico – stadiazione locale

Valutazione dei peduncoli glissonianiValutazione delle vene sovraepaticheCoinvolgimento del parenchimaStudio della via biliare

Distale – stadiazione locale

Valutazione della vena portaValutazione della v. mesenterica superioreValutazione delle vene sovraepaticheValutazione dell’arteria epatica

Studio della via biliare

TAC conricostruzionevascolare (laparoscopia?)

TAC conricostruzionevascolare ± Colangio RM(laparoscopia?)

Colangio RMERCPPTC

TAC total body ± PET / laparoscopia

Cholangiocarcinoma - Treatment

The major determinants of resectability are

•the extent of tumor within the biliary tree,

•the amount of hepatic parenchyma involved,

•vascular invasion,

•hepatic lobar atrophy, and

•metastatic disease.

Assessment of resectability

Cholangiocarcinoma - Treatment

Patient to be resected

•Non cirrhotic•No pre-op CHT

Major resection planned

Minor resection planned

•Cirrhotic•Pre-op CHT

Major resection planned

Minor resection planned

Maybe nothingIGR ??

VolumetryIGR ??

MELDIGR Useful

MELDIGRVolumetryBiopsy ??

Cholangiocarcinoma - Treatment

• Normal underlying liverFLR should be 20-25% of total liver volume

(TLV)

• Chemotherapy induced liver injuryFLR should be >30% of TLV

• Chronic liver disease (cirrhosis or severe fibrosis)

FLR should be >40%

Future Remnant Liver

Cholangiocarcinoma - Treatment

Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Ercolani G, Ann Surg 2010, 252: 107-113

Cholangiocarcinoma - Treatment

de Jong MC, J Clin Oncol 2011, 29: 3140-3145

• Although tumor size provides no prognostic information, tumor number, vascular invasion, and LN metastasis are associated with survival.

• N1 status adversely affected overall survival and also influenced the relative effect of tumor number and vascular invasion on prognosis.

• Lymphadenectomy should be strongly considered for ICC, because up to 30% of patients will have LN metastasis.

Cholangiocarcinoma - Treatment

de Jong MC, J Clin Oncol 2011, 29: 3140-3145

Cholangiocarcinoma - Treatment

de Jong MC, J Clin Oncol 2011, 29: 3140-3145

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

• The preoperative clinical T staging system as proposed by Jarnagin

and Blumgart defines both the radial and longitudinal extension of

hilar cholangiocarcinoma, which are critical factors in the

determination of resectability.

• This Memorial Sloan-Kettering Cancer Center (MSKCC) staging system

incorporates 3 factors based on preoperative imaging studies:

(1) location and extent of ductal involvement;

(2) presence or absence of portal vein invasion, and;

(3) presence or absence of hepatic lobar atrophy.

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

440 patients from 17 centers(From January 1, 1992, through December 31, 2007)

16 years

5/17 centers (29.4%) reported 40 or more patients who underwent resection and accounted for 317 patients (72.0%)

5 High volume centers317 procedures63.4 procedures/center3.9 procedures/year

12 Low volume centers123 procedures10.2 procedures/center0.6 procedures/year

Nuzzo G, Arch Surg 2012; 147: 26-34

Cholangiocarcinoma - Treatment

Razumilava N, Lancet. 2014 Feb 25.

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Seyama S, World J Gastroenterol 2007;13(10):1505-1515

Cholangiocarcinoma - Treatment

Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54

Cholangiocarcinoma - Treatment

Pro ConsPTBD provides precise preoperative staging of the disease

Increases the risk of cholangitis

Contributes to improved surgical outcome

Possibly increases tumor seeding

Definitive role when portal veinembolization is needed

Could be omitted:•recent onset jaundice (<2-3 weeks), total bilirubin <200 μmol/l,•absence of sepsis,•future liver remnant 40%.

It should not be performed systematically and specialized surgical evaluation should be performed before any type of direct cholangiography or PBD is performed.

Consensus Conference on Cholangiocarcinoma, HPB, 2008; 10

Biliary stenting

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Aljiffry M,J Am Coll Surg 2009; 208, 134-147

Schulick RD,HPB, 2008; 10: 122-125

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Definition of Surgical Strategy

Definition of the extention of the tumor in the left and in the right ducts

Volumetryleft lobe – S2+S3left hemiliver – S2+S3+S4right lobe – S5+S6+S7+S8caudate lobe

Cholangiocarcinoma - Treatment

The Bismuth classification takes into account tumour

extension into the right and left biliary system; but, tumour

extension anteriorly to the quadrate lobe (segment 4) and

posteriorly to the caudate lobe (segment 1) is equally

important.

Surgical treatment, therefore, should include resection of

segments 4 and 1 which in the case of right-sided tumours

(type IIIa) comes down to extended right hemihepatectomy

en bloc with segment 1.

In conjunction with any resection, complete

lymphadenectomy of the hepatoduodenal ligament is carried

out.Van Gulik TM, 2007; 26 (Suppl 2), 127–132

Cholangiocarcinoma - Treatment

Changes in pre-, intra-, and postoperative management over the course of the study period. ENBD indicates endoscopic naso-biliary drainage; MDCT,multidetector-row computed tomography; PTBD, percutaneous transhepatic biliary drainage; PTCS, percutaneous transhepatic cholangioscopy.

Nagino M, Ann Surg 2013;258: 129–140

Cholangiocarcinoma - Treatment

Nagino M, Ann Surg 2013;258: 129–140

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Left Hepatectomy +caudate lobe

Right Hepatectomy +caudate lobe

Pro Cons Pro Cons

Smaller procedure Greater procedure

Greater liver remnant volume

Smaller liver remnant volume

No need for PVE Needs PVE

Right duct shorter Left duct longer(usually available)

Often double (triple) duct anastomosis

Often one single duct anastomosis

Quickly available Longer “evaluation to surgery” time

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

Cholangiocarcinoma - Treatment

The role of Portal Vein Embolization

colangiocarcinomacolangiocarcinoma:

3 % tumori dell’apparato digerenteetà > 65 anni 2/3 dei casi> frequenza nei paesi asiatici

COLECISTI 2/315% VB intraepatiche

VB 1/3 60 % ilari (tumori di Klatskin)

25 % VB extraepatica

The role of Portal Vein Embolization

- fattori di rischio: 2 volte più frequente nella donnacorrelazione con litiasi colecisti non dimostrata

- stadio iniziale: reperto fortuito dopo colecistectomia per calcoli- stadio avanzato: massa epatica del IV-V segm, ittero, cattiva prognosi

COLECISTI 2/315% VB intraepatiche

VB 1/3 60 % ilari (tumori di Klatskin)

25 % VB extraepatica

The role of Portal Vein Embolization

- fattori di rischio: leggera prevalenza nel maschioetà > 50 anni, colangite sclerosante primitiva

- clinica: ittero ostruttivoittero ostruttivo con epatomegalia, urine ipercromiche, feci ipocoliche, prurito, colecisti distesa (se tumore del coledoco), colangite (rara), calo PT (malassorbimento vit. K)

COLECISTI 2/315% VB intraepatiche

VB 1/3 60 % ilari (tumori di Klatskin)

25 % VB extraepatica

The role of Portal Vein Embolization

Gian Luca GraziHepato Biliary Pancreatic Surgery

National Cancer Institute “Regina Elena”, Rome, Italy

grazi@ifo.it

www.chirurgiadelfegato.it

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The role of Portal Vein Embolization