48 The Risk of Fresh Frozen Specimen-Dependent R0 Resection for Hilar Cholangiocarcinoma

Abstract

Background: Most institutes use intraoperative bile ductal fresh frozen specimens (FFS) for achieving an R0 resection. However, this approach has the possibility to influence the local recurrence because of manipulating cancer lesion. METHODS: From September 1996 through September 2008, 40 patients with HCCA underwent a finally R0 resection in the department of gastroenterological surgery of Hirosaki University. Three patients were excluded because they did not have bile duct margins submitted for intraoperative frozen section analysis. We selected the positivity of invasive carcinoma at the first cut margin submitted for FFS (the first FFS) as the marker for manipulating cancer lesion. Medical records and pathological findings were reviewed to assess the other potential local recurrent risk factors (age, gender, operative type, portal vein resection, narrow bile ductal margin, narrow radial margin, Bismuth classification, and other tumor pathological factors). The local recurrent rates were analyzed using a logistic regression model. RESULTS: Total number of submitted FFS was 128. As compared to final histopathology, FFS had 75% positive predictive value and 100% negative predictive value. Six patients had invasive carcinoma at the first cut margin in final histopathology. According to the results of FFS, 4 patients underwent additional bile duct resection, 1 patient panceratoduodenectomy, and 1 patient right hepatectomy. The positivity of the first FFS had significant higher rate of the local recurrence as compared to no invasive carcinoma at the first FFS, respectively 67% and 20% (p=0.039). Multivariate analysis revealed the first FFS was the only risk factor with odds ratio of 8.00 (p=0.034). The survival is shorter in the local recurrent group compared to no local recurrent group with a 5 year survival of 11% and 65%, respectively (p=0.039). The positivity of the first FFS had the worse survival compared to no invasive carcinoma at the first FFS with a 5 year survival of 33% and 51%, respectively, but this difference did not show statistical significance (p=0.332). Conclusion: The positivity of the first FFS is the more important risk factor of the local recurrence than the narrow margin. This results show that the manipulation of cancer lesion might cause the spread of cancer to result in the local recurrence, so we should perform FFS-independent R0 resection for the better local control of HCCA.