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Additional Resection of the Cancer Positive Proximal or Distal Duct Margin for Wide-Spread Perihilar Cholangiocarcinoma
Minoru Esaki*, Satoshi Nara, Yoji Kishi, Yoichi Miyata, Kazuaki Shimada
Hepato-biliary pancreatic surgery, National Cancer Center Hospital, Tokyo, Japan
Background: The survival benefits of additional resection of the cancer positive proximal and distal ductal margin in cases of perihilar cholangiocarcinoma remain to be elucidated. The aim of this retrospective study was to clarify the efficacy of additional resection for the cancer positive proximal ductal margin (PM) and distal ductal margin (DM).
Methods: All patients who underwent major hepatectomy and extrahepatic bile duct resection for perihilar cholangiocarcinoma between 2000 and 2013 were analyzed. Surgical variables, the status of the PM and DM, prognostic factors and survival were evaluated.
Results: A total 258 patients were enrolled. Additional resection was performed in 59 of 86 invasive cancer positive PMs, resulting in 48 negative PMs (69%) (Fig.1). The survival of patients with a negative PM treated with additional resection (n=48) was significantly worse than that of the patients with a negative PM without additional resection (n=171) and did not significantly differ from positive PM cases (n=38). Only in the subgroups of serum carbohydrate antigen 19-9 (CA19-9) level less than 64, the survival of the patients with a negative PM treated with additional resection was significantly better than that of positive PM cases (Fig.2).
Additional resection was performed in 47 of 61 cancer positive DMs, resulting in 28 negative DMs (58%). Procedures of additional resection were 44 with intra-pancreatic bile duct resection and 3 with pancreaticoduodenectomy (Fig.1). The survival of patients with a cancer positive initial DM treated with additional resection (n=35) tended to be worse, but were not significantly worse than that of the other patients (P=0.10). DM was not prognostic factors independently. Only two cases developed recurrence at lower part of bile duct in all positive DM cases (one in invasive cancer positive DM case, 1 year after resection and one with cancer-in-situ positive DM case, 6 year after resection).
A multivariate analysis demonstrated that CA19-9 level, combined vascular resection, pN, pM, the histological grade, perineural invasion and R status were independent prognostic factors. PM and DM were not prognostic factors independently.
Conclusions: Additional resection of cancer positive PMs may improve survival in limited patients with a lower level of CA19-9. Additional resection of intra-pancreatic bile duct may provide good outcome for cancer positive DM in the most perihilar cholangiocarinoma cases.
Overview of the relationship between initial and final proximal ductal margin (PM) and distal ductal margin (DM) status
  Overview of the relationship between initial and final proximal ductal margin (PM) and distal ductal margin (DM) status
Overall survival according to the final proximal ductal margin (PM) status - subgroup analysis according to serum CA19-9 level -
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