The Blumgart Preoperative Staging System for Hilar Cholangiocarcinoma: Analysis of Resectability and Outcomes in 380 Patients

• Published in: Journal of the American College of Surgeons Vol. 215; no. 3; pp. 343 - 355
• Main Authors: Matsuo, Kenichi, MD, Rocha, Flavio G., MD, Ito, Kaori, MD, D'Angelica, Michael I., MD, FACS, Allen, Peter J., MD, FACS, Fong, Yuman, MD, FACS, DeMatteo, Ronald P., MD, FACS, Gonen, Mithat, PhD, Endo, Itaru, MD, Jarnagin, William R., MD, FACS
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.09.2012; Elsevier
• Subjects: Adult; Aged; Aged, 80 and over; Bile Duct Neoplasms - mortality; Bile Duct Neoplasms - pathology; Bile Duct Neoplasms - surgery; Bile Ducts, Extrahepatic - pathology; Bile Ducts, Extrahepatic - surgery; Biological and medical sciences; Blood Loss, Surgical - statistics & numerical data; Cholangiocarcinoma - mortality; Cholangiocarcinoma - pathology; Cholangiocarcinoma - surgery; Female; Gastroenterology. Liver. Pancreas. Abdomen; General aspects; Hepatectomy; Humans; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Lymph Node Excision; Male; Medical sciences; Middle Aged; Neoplasm Staging - methods; Postoperative Complications - epidemiology; Preoperative Care - methods; Retrospective Studies; Surgery; Survival Analysis; Treatment Outcome; Tumors; FDG-PET; DSS; MSKCC; Memorial Sloan-Kettering Cancer Center; MDCT; multidetector-row computed tomography; American Joint Committee on Cancer; disease-specific survival; positron emission tomography with [ F] fluoro-2-deoxy-D-glucose; hilar cholangiocarcinoma; MRCP; AJCC; HCCA; magnetic resonance cholangiopancreatography; Human; Prognosis; Hilar cholangiocarcinoma; Bile duct cancer; Hepatic disease; Patient; Malignant tumor; Biliary tract disease; Medicine; Treatment; Surgery; Classification; Digestive diseases; Evolution; Preoperative; Cancer
• ISSN: 1072-7515; 1879-1190; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2012.05.025

Background Complete resection of hilar cholangiocarcinoma (HCCA) is a critical determinant of long-term survival. This study validates a previously reported preoperative clinical T staging system for determining resectability of HCCA. Study Design Consecutive patients with confirmed HCCA treated over an 18-year period were included. Patient demographics, preoperative imaging studies, resection type, margin status, lymph node status, histopathologic findings, morbidity, and outcomes were entered prospectively and analyzed retrospectively; changes in these variables over time were assessed. All patients were placed into 1 of 3 stages based on the extent of ductal involvement by tumor, portal vein compromise, or lobar atrophy. Results From March 1991 through December 2008, 380 patients were evaluated. Eighty-five patients had unresectable disease; 295 patients underwent exploration with curative intent. One hundred fifty-seven patients underwent resection: 129 (82.2%) had a concomitant hepatic resection and 120 (76.4%) had an R0 resection. Of the 32 actual 5-year survivors (120 at risk), 30 patients (93.8%) had a concomitant hepatic resection. In patients who underwent an R0 resection, concomitant partial hepatectomy, well-differentiated histology, and negative lymph nodes were independent predictors of long-term survival. In the 376 patients whose disease could be staged, the preoperative clinical T staging system predicted resectability (p < 0.001), metastatic disease (p < 0.001), and R0 resection (p = 0.007). Conclusions The preoperative clinical T staging system of Blumgart, defined by the radial and longitudinal tumor extent, accurately predicts resectability of HCCA. The full outcomes benefit of resection is realized only if a concomitant partial hepatectomy is performed.