Redefining resection margins and dissection planes in perihilar cholangiocarcinoma\u2014radical resection is a rare event

Melroy A D’Souza,Olof Danielsson,Ernesto Sparrelid,Carlos Fernández Moro,Christian Sturesson,Hasan Ahmad Al-Saffar,Sonia Shtembari

doi:10.1007/s00428-021-03231-1

Abstract

Radical tumor resection (pR0) is prognostic for disease-free and overall survival after resection of perihilar cholangiocarcinoma (pCCA). However, no universal agreement exists on the definition of radical resection and histopathological reporting. The aim of this study was to provide a standardized protocol for histopathological assessment and reporting of the surgical specimen obtained after resection for pCCA. All consecutive patients operated for pCCA with curative intent at the Karolinska University Hospital, Stockholm, Sweden between 2012 and 2021 were included. A standardized protocol for histopathological assessment and reporting of the surgical specimen after liver resection for pCCA is presented. A detailed mapping of the transection margins and dissection planes was performed. The results of applying different existing pR0 definitions were compared. Sixty-eight patients with pCCA were included. Five transection margins and two dissection planes were defined. By defining pR0 as cancer-free margins and planes tolerating distances <1mm, the pR0 rate was 66%. However, when pR0 was set as >1mm from invasive cancer to all resection margins and dissection planes, the pR0 rate fell to 16%. This study supports the use of thorough and standardized pathological handling, assessment and reporting of resection margins and dissection planes of surgical specimens of pCCA.

Highlights

Perihilar cholangiocarcinoma arises from the biliary epithelium of the hepatic hilum and even when treated with curative intent is generally associated with poor outcomes [1,2,3]
Five transection margins and two dissection planes are used to evaluate surgical radicality of the specimen in the pathological examination of resected perihilar cholangiocarcinoma (pCCA) and take into consideration the surgical procedure performed for pCCA as the conceptual basis for their use in reporting
These features make it comparable to the posterior retroperitoneal dissection plane in pancreatoduodenectomy specimens. These two dissection planes have recently been included in the definition of circumferential or radial margins after resection of pCCA in a study by Shinohara et al [5]

Summary

Introduction

Perihilar cholangiocarcinoma (pCCA) arises from the biliary epithelium of the hepatic hilum and even when treated with curative intent is generally associated with poor outcomes [1,2,3]. There is no universal agreement on the definition of what constitutes a ‘pR0’ resection in pCCA and how wide the tumor-free margin should be [11]. Differing definitions have been described with 1 mm as the usual cutoff value for a tumor-free margin [7, 11]. As the concept of pR0 resection carries profound prognostic value, it is of importance to have a common universal definition of ‘pR0’ when comparing results from different institutions and when designing studies factoring in the surgical treatment of pCCA. A detailed mapping of the transection margins and dissection planes was performed Based on this investigation on the surgical specimens from a single center, the results of applying different existing R0 definitions are compared

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