Is mandatory routine caudate lobe resection indicated in hilar cholangiocarcinoma ?

Abstract

Presenter: Lavanya Yohanathan MD | Mayo Clinic, Rochester Background: Necessity for routine resection of caudate lobe as part of liver resection in hilar cholangiocarcinoma (CCA) is controversial. The caudate lobe is an anatomic component of resectability where careful preoperative planning with assessment of imaging should factor into whether resection is indicated. We sought to evaluate if hepatectomy with caudate resection compared to those without caudate resection affected overall survival Methods: We reviewed data for all patients undergoing hilar cholangiocarcinoma (HCCA) resection between 1993-2017. Operative notes were reviewed to evaluate whether caudate lobe resection was undertaken. Extent of liver resection was recorded. Frozen section and final pathology status for was reviewed. Overall survival was the primary outcome. Progression free survival and recurrence pattern were secondary outcomes. Results: 178 patients underwent hepatic and bile duct resection with regional lymphadenectomy and Roux Y hepaticojejunostomy for HCCA. Of 178 patients, 100 (56%) patients underwent caudate resection (CR) whereas 78(44%) patients did not have their caudate lobes (NCR) resected. There was no significant difference in patient demographics or tumor characteristics. 88% of patients underwent a preoperative biopsy and the mean CA 19-9 level amongst both groups was 26.5 (17.7-38.2). Majority of these tumors were poorly differentiated (NCR:50%, CR:42.4%) followed by moderately differentiated (NCR, CR: 42.4%). Of 178 pts, 87 pts (48.9%) had a left hepatectomy, of which 81 pts had caudate lobe resection. 84 pts (47.2%) underwent a right hepatectomy ,4 pts (2.2%) had a right trisegmentectomy, of which 17 and 2 patients had their caudate lobe resected respectively. Liver margins were negative in 95% of pts in NCR group and 97% in the CR group (p=0.36). Lymph node metastases were present in 43% of pts in the NCR group and 32% in CR group (p=0.14). There was no significant difference in postoperative mortality (p=0.78). Higher rates of postoperative bile leak occurred in the NCR group 37.7% versus the CR group 21% (p=0.02) necessitating higher rates of percutaneous drain placement in the NCR group (36% vs.18%, p=0.005). Biliary fistula occurred in 17.6% of patients in NCR group compared to 7.2% in the CR group (p=0.11). Median overall survival was 28.4 and 44 months in the NCR and CR groups respectively (p=0.28). A higher proportion of patients in the NCR group received adjuvant chemotherapy (40%) and postoperative radiation (21%) when compared to CR group where 34% of pts received adjuvant chemotherapy and 13% postoperative radiation. Most frequent recurrence was within the liver and hepaticojejunostomy site. Peritoneal and extrahepatic recurrences were fewer. Intrahepatic recurrence occurred in 6/22(27%) in the NCR group and 18/35% (51%) in CR group (p=0.13). Median progression free survival was 19.8 and 33.7 months in the NCR and CR groups (p=0.34) Conclusion: Routine caudate lobe resection does not confer survival advantage in patients undergoing liver resection, regional lymphadenectomy and Roux Y reconstruction for hilar cholangiocarcinoma. Nodal status had no impact on survival related to CLR. The decision to resect caudate lobe should be based on radiological imaging, tumor characteristics, and pathologic evaluation with the ultimate goal of achieving a R0 resection.