Several surgical approaches for the treatment of cholangiocarcinoma (CCA) were presented at the 2024 CCA Summit, including minimally invasive resection, the comparison of neoadjuvant, perioperative, and adjuvant treatments, and how to integrate adjuncts into surgery.
Hop Tran Cao, MD, FACS, presented on minimally invasive resection for hilar CCA. Dr Cao delved into the challenges of operating on perihilar CCA, laparoscopic surgery for perihilar CCA, and robotic surgery for perihilar CCA.1 Perihilar CCA is the most common biliary tract cancer (BTC) with a complex hilar anatomy. It is associated with a low rate of resection with aborted rates as high as 50%. With perihilar CCA, it is difficult to visualize and predict the true extent of disease. This cancer may only appear as a faint stricture without an associated mass. Stenting is often necessary, but it can obscure tumor evaluation and secondarily causes bile duct enhancement and inflammation. With perihilar CCA there is also a high risk for post-hepatectomy liver failure. In 113 patients with perihilar CCA, 11% had a 90-day mortality and 55% had major morbidity. The only independent predictors of post-hepatectomy liver failure–associated death was perioperative cholangitis and future liver remnant volume of less than 30%.1
There is limited data for laparoscopic surgery for perihilar CCA. One study showed that with laparoscopic surgery, intraoperative blood loss could be minimized, as well as the risk for surgical site infection, the length of stay, and perioperative blood transfusion.1 In terms of survival, there is no benefit with laparoscopic surgery compared with open surgery. Conversely, there are benefits to using the robot to improve minimally invasive surgery performance. The robot has stable visualization, it is controlled by the surgeon, and it eliminates tremors when operating, allowing for more precision and the facilitation of suturing. It can expedite the learning curve and allows surgeons to tackle cases with greater complexities. A study using robotic resection for patients with perihilar CCA involved a highly selective group of 38 patients at 3 high-volume robotic centers. As a result of using robotic resection, there were 0 hospital mortalities, a complication rate of 42%, and a 3% 90-day mortality rate.1 Another study compared robotic versus laparoscopic surgery performance. In this study 10 robotic surgeries were performed, and 36 laparoscopic surgeries were performed in patients with CCA. No difference was found between them in terms of major complications or mortality.1
Management of perihilar CCA is challenging and regardless of approach, these surgeries present a technical challenge.1 In the hands of expert surgeons, both laparoscopic and robotic surgery are safe, although the robot lowers the learning curve and will facilitate minimally invasive surgery of perihilar CCA.1
Alexander Parikh, MD, MPH, FACS, FSSO, presented on the best approach for treating resectable intrahepatic CCA (iCCA).2 He explained that iCCA is the second most common primary liver malignancy and only 15% to 20% of cases have the possibility to be resectable. iCCA is associated with a 5-year overall survival rate of 25% to 40% for localized disease and <15% for regional disease. Resectability is the ability to achieve an R0 resection with adequate future liver remnant with no extra-regional nodes, and no metastatic disease. He first discussed integrating adjuvant therapy into surgical management for patients with iCCA. The BILCAP study is the only phase 3, adjuvant trial for resected BTC. This trial compared 6 months of capecitabine versus observation with the primary endpoint of overall survival. A minority of these patients had iCCA (19%) in the capecitabine group and 18% in the observation group. This study did not reach significance for overall survival in the intent-to-treat population.2
Dr Parikh explained that high-risk disease includes regional lymph node involvement, multifocal disease (unilateral or bilateral), tumor size (T1b: >5 cm), elevated tumor markers, and major vascular invasion, in which patients may benefit from neoadjuvant therapy.2 Patients with high-risk disease may require neoadjuvant therapy. The NEO-GAP trial was a single-arm phase 2 feasibility trial of neoadjuvant gemcitabine, cisplatin, and nab-paclitaxel for resectable, high-risk iCCA. Patients received 4 cycles of neoadjuvant gemcitabine, cisplatin, and nab-paclitaxel, and the primary endpoint was completion of neoadjuvant chemotherapy and resection. A total of 22 out of 30 patients completed therapy; toxicities were manageable and there were no mortalities.2
Dr Parikh concluded that resection followed by adjuvant chemotherapy is currently the standard of care for iCCA.2 The treatment for low-risk disease is often upfront resection followed by adjuvant therapy, and the treatment for high-risk disease can include neoadjuvant therapy. Multimodality regimens including immunotherapy are standard-of-care in advanced disease.2
Ryan Fields, MD, FACS, presented on how to integrate adjuncts into surgery. He first defined adjuncts as supplementary rather than an essential part and stated that surgery plus adjunct can be greater than surgery alone. He noted that the principles of liver surgery include providing hepatic artery and portal venous inflow and outflow, biliary drainage, and adequate remaining liver, also known as functional liver remnant (FLR).3
Dr Fields explored various approaches to increase the number of patients eligible for liver resection when their FLR is not sufficient.3 These techniques include portal vein embolization (PVE), hepatic vein embolization (HVE) and when those 2 techniques are combined, there is liver venous deprivation (LVD). PVE is a procedure that blocks blood flow to the liver and increases FLR. HVE blocks blood flow from hepatic veins to the part of the liver, also thereby increasing FLR. After PVE alone, approximately 30% of patients cannot receive major liver resection because of insufficient hypertrophy and disease progression. LVD, however, can improve upon PVE alone. A meta-analysis of 10 studies looked at the differences between LVD and PVE alone for undergoing resection. LVD had a higher rate of patients undergoing liver resection than PVE, with a hazard ratio of 1.89. The time to hepatectomy also favored LVD over PVE. The kinetic growth rate (KGR) is the degree of hypertrophy divided by duration from embolization to FLR calculation after embolization. The KGR also favored LVD over PVE, with a hazard ratio of 1.37. There were no differences in post-embolization complications or postoperative complications between the 2 techniques. Post-hepatectomy liver failure decreased with LVD compared with PVE.3
Dr Fields concluded that LVD can significantly improve surgical resection rates and KGR compared with PVE alone. LVD and PVE have similar safety profiles.3 The reason most patients who undergo LVD or PVE and not liver resection is disease progression. The goal of both techniques should be shortening the length of time between embolization and resection.3
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