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PERIHILAR CHOLANGIOCARCINOMA
New Classification and
Treatment JM.TUBIANA
Hôpital Saint-Antoine [email protected]
PERIHILAR CHOLANGIOCARCINOMA
• In the past two decades , with the advances in diagnostic ,interventional imaging and surgical techniques , many surgeons have adopted an agressive approch to perihilar CC as surgical resection is the only way to cure this intractable disease .
• So the surgical outcomes and survival rates have gradually improved .
PERIHILAR CHOLANGIOCARCINOMA
• Tumors located in the extra-hepatic biliiary tract proximal to the origine of the cystic duct.
• Potentially include 2 types of tumors : one arising from the large hilar bile duct and the other with intrahepatic component and secondary invasion of the porta hepatis.
INTRA-HEPATIQUE
EXTRA-HEPATIQUE DISTAL
EXTRA-HEPATIQUE PROXIMAL
AJCC 7EME EDITION 2011
60 %
10 %
30 %
30%
Mass-forming CC 12%
Periductal infiltra.ng CC 84% sub-mucosal extension
Intraductal 4% Mucosal extension
The Liver Cancer Study Group of Japan
PERIHILAR CHOLANGIOCARCINOMA Role of Imaging
• Imaging US ,CT, MRI , IR, is mandatory for :
• - Diagnostic • - Tumor extent • - Before surgery
PERIHILAR CHOLANGIOCARCINOMA Role of Imaging
• Imaging US ,CT, MRI , IR, is mandatory for :
• - Diagnostic • - Tumor extent • - Before surgery
Frequently the initial Imaging modality performed
CT / MRI
• The accuracy of CT and MRI with MRCP for prediction of the extent of ductal involvement ( 84-91 % ) , hepatic artery and portal invasion (86 – 98 % ) ,hepatic volumetry , lymph nodes and metastasis ( 74 – 84 % ) .
INFILTRATING
INTRADUCTAL
CCH INFILTRANT
DETECTION ADC
ADC
PERIHILAR CHOLANGIOCARCINOMA Role of Imaging
• Imaging US ,CT, MRI , IR, is mandatory for :
• - Diagnostic • - Tumor extent • - Before surgery
Longitudinal Extension : Bismuth /Corlette classification
Mucosal extension :
intraductal ,nodular, mean length 10-20mm ,surgical margin >2 cm for negative margins
Submucosal extension :
infiltrative form,length 6-10mm , surgical for negative margin>10 mm
Direct infiltration along lymphatic and perineural tissues
CCH B / C I
• Reverchon
CCH II B / C
CCH B / C III b
CCH B / C IV
VERTICAL EXTENSION
• Direct invasion of the surrounding structures : • - Pancreas , Duodenum . • - Hepatoduodenal ligament including
adjacent hepatic artery and portal vein . • - Hepatic parenchyma .
• Distant metastasis and lymph nodes .
INVOLVEMENT HA / PV
INVOLVEMENT HA / PV
INVOLVEMENT LPV
INVOLVEMENT MAIN PV
HEPATIC INVOLVEMENT
STAGING N
METASTASIS MALIGNANT ASCITIS
PERIHILAR CHOLANGIOCARCINOMA Role of Imaging
• Imaging US ,CT, MRI , IR, is mandatory for :
• - Diagnostic • - Tumor extent • - Before surgery
PORTAL VEIN EMBOLIZATION
• Now widely used in the presurgical treatmentof patients undergoing an extended hepatectomy to minimize the post-operative liver dysfunction .
PORTAL VEIN EMBOLIZATION
• Can benefit patients requiring a future liver remnant of 25 % of the total liver volume if liver function is normal and 40 % if liver function is compromised .
BILIARY DRAINAGE
• Remain controversial • Has provred to be beneficial in case of
cholangitis , severe malnutrion and coagulation abnormalities .
• Absolutely indicated for patients requiring major hepatic resection .
• Unilateral BD for future remnant lobe is recommanded in B / C III and IV tumors .
B.Guiu. Cardiovasc Intervent Radiol 2013
STAGING / CLASSIFICATION
• Staging should ideally be performed before and after surgery to include all inta-operative informations and results from macroscopic and microscopis examinations
STAGING / CLASSIFICATION
Systems most commonly used to evaluate PCH
• - Bismuth / Corlette • - MSKCC ( Memorial Sloan-Kettering Cancer Center ) • - AJCC ( American Joint Commission on Cancer
Staging 7 th edition ) : TNM • - EHPBA (European Hepato-Pancreato-Biliary
Association )
SURGERY
SURGERY
• Resectional procedures depend on the location of the primary tumor.
• - Rigth hepatectomy is applied to B/C I ,II and III a tumor.
• - Left hepatectomy to B/C IIIb .
SURGERY
• In B / C IV , the type of hepatectomy is determined by considering the predominant tumor location , the presence or absence of portal vein or hepatic artery invasion and liver function.
SURGERY
• In B / C IV
• - Right predominant tumor : right trisectionectomy ( trisegmentectomy or hight extensive hepatectomy ) 4,5,6,7,8+ 1
• - Left predominant : left trisectionectomy : 2,3,4,5,8 + 1
OTHERS THERAPIES
• Neo-adjuvant / Adjuvant therapy . • Photodynamics therapy . • Intra-luminal brachytherary . • External radiation . • Liver transplantation .
REPORT
• Tumor morphology : localisation ,size , form . • Vascular anatomy : PV , HA , Arcuate ligament • Longitudinal extension : B / C . • Vertical extension : PV , HA ,Liver . • Liver remnant volume . • Underlying liver disease . • Lymph nodes . • Metastasis . • IR necessary .