Bismuth-Corlette Classification Research Articles

Long-term outcome and prognostic factors of patients with hilar cholangiocarcinoma

To evaluate the long-term outcome and prognostic factors of patients with hilar cholangiocarinoma. Ninety-six consecutive patients underwent treatment for malignant hilar bile duct tumors during 1995-2005. Of the 96 patients, 20 were initially treated with surgery (n = 2 R0 / n = 18 R1). In non-operated patients, data analysis was performed retrospectively. Among the 96 patients, 76 were treated with endoscopic transpapillary (ERC, n = 45) and/or percutaneous transhepatic biliary drainage (PTBD, n = 31). The mean survival time of these 76 patients undergoing palliative endoscopic and/or percutaneous drainage was 359 +/- 296 d. The mean survival time of patients with initial bilirubin levels > 10 mg/dL was significantly lower (P < 0.001) than patients with bilirubin levels < 10 mg/dL. The mean survival time of patients with Bismuth stage II (n = 8), III (n = 28) and IV (n = 40) was 496 +/- 300 d, 441 +/- 385 d and 274 +/- 218 d, respectively. Thus, patients with advanced Bismuth stage showed a reduced mean survival time, but the difference was not significant. The type of biliary drainage had no significant beneficial effect on the mean survival time (ERC vs PTBD, P = 0.806). Initial bilirubin level is a significant prognostic factor for survival of patients. In contrast, age, tumor stage according to the Bismuth-Corlette classification, and types of intervention are not significant prognostic parameters for survival. Palliative treatment with endoscopic or percutaneous biliary drainage is still suboptimal, new diagnostic and therapeutic tools need to be evaluated.

C-reactive protein is a prognostic indicator in patients with perihilar cholangiocarcinoma

To evaluate prognostic indicators for the outcome of patients with perihilar extrahepatic cholangiocarcinoma in an unselected cohort. We retrospectively analyzed 98 patients with perihilar cholangiocarcinoma. Twenty-three patients (23.5%) underwent tumor resection. Patients with non-resectable tumors underwent either transpapillary or percutaneous transhepatic biliary drainage. Additionally, 32 patients (32.7%) received photodynamic therapy (PDT) and 18 patients (18.4%) systemic chemotherapy. Predefined variables at the time of diagnosis and characteristics considering the mode of treatment were entered into a Cox's proportional hazards model. Included in the analysis were age, tumor stage following the modified Bismuth-Corlette classification, bilirubin, prothrombin time (PT), C-reactive protein (CRP), carbohydrate antigen 19-9 (CA19-9), history of weight loss, surgical resection, chemotherapy and PDT. The Kaplan-Meier estimate of overall median survival was 10.5 (95%CI: 8.4-12.6) mo. In the univariate analysis, low Bismuth stage, low CRP and surgical resection correlated significantly with better survival. In the multivariate analysis, only CRP (P = 0.005) and surgical resection (P = 0.029) were found to be independently predictive of survival in the cohort. Receiver operating characteristic (ROC) analysis identified a CRP level of 11.75 mg/L as the value associated with the highest sensitivity and specificity predicting a survival > 5 mo. Applying Kaplan-Meier analysis, patients with a CRP < 12 mg/L at the time of diagnosis had a significantly longer median survival than patients with higher values (16.2 vs 7.6 mo; P = 0.009). This retrospective analysis identified CRP level at the time of diagnosis as a novel indicator for the prognosis of patients with perihilar cholangiocarcinoma. It should be evaluated in future prospective trials on this entity.

Hepatic Sarcoidosis Mimicking Klatskin Cholangiocarcinoma

A 57-year-old African-American man presented with progressive obstructive jaundice, pruritus, and weight loss. Investigations were notable for elevated liver canalicular enzymes with negative serologies for viral hepatitis, autoimmune, and metabolic liver diseases. Serum CA 19–9, CEA, and AFP were within normal limits. ERCP demonstrated a complex stricture of common hepatic duct (CHD) at the confluence with proximal extension into both intrahepatic ducts (Bismuth-Corlette classification IV) (Figure 1). Intraductal brushings across the stricture were negative for malignancy. MRI revealed a lesion measuring 2.5 × 2.5 × 2.8 cm encasing the CHD (Figure 1). At EUS, a 2.4-cm lesion was identified surrounding the CHD (Figure 3). Cytology from FNA of the lesion was negative for malignancy. Liver biopsy revealed mild lobular hepatitis without granuloma or fibrosis. CT scan of the chest showed a normal lung parenchyma without mediastinal lymphadenopathy. Given a lesion that was highly suspicious for Klatskin cholangiocarcinoma without evidence of metastasis, he underwent an exploratory laparotomy with right hepatic lobe resection and Roux-en-Y left hepaticojejunostomy. Final pathology revealed non-caseating granulomatous inflammation forming a 3.5 cm mass in the hilar soft tissue adjacent to CHD without any evidence of malignancy or infection, consistent with sarcoidosis. In this report, we describe a unique case of hepatic sarcoidosis presenting as obstructive jaundice due to the isolated involvement of CHD and bilateral intrahepatic ducts, mimicking Klatskin cholangiocarcinoma. No involvement of other organs was identified. To our knowledge, this is the first such case report in the literature. It highlights the great difficulty in establishing a definitive diagnosis for the etiology of a biliary stricture without performing an exploratory laparotomy despite the application of multiple pre-operative radiographic modalities and tissue sampling techniques. If hepatic sarcoidosis had been diagnosed pre-operatively, a therapeutic trial of corticosteroids might have been attempted initially.[figure 1]Figure

Cholangiocarcinoma

Cholangiocarcinoma

Imaging of extrahepatic cholangiocarcinoma.

Preoperative staging of extrahepatic cholangiocarcinoma is important in determining the best treatment plan. Several classification systems have been suggested to determine the operability and extent of surgery. Longitudinal tumor extent is especially important in extrahepatic cholangiocarcinoma because operative methods differ depending on the tumor extent. The Bismuth-Corlette classification system provides useful information when planning for surgery. However, this classification system is not adequate for selecting surgical candidates. Anatomic variation of the bile duct and gross morphology of the tumor must be considered simultaneously. Lateral spread of the tumor can be evaluated based on the TNM staging provided by American Joint Committee on Cancer (AJCC). However, there is a potential for ambiguity in the distinction of T1 and T2 cancer from one another. In addition, T stage does not necessarily mean invasiveness. Blumgart T staging is helpful for the assessment of resectability with the consideration of nodal status and distant metastasis as suggested by the AJCC cancer staging system. Computed tomography (CT) and magnetic resonance imaging (MRI) are the primary tools used in the assessment of longitudinal and lateral spread of a tumor when determining respectability. Diagnostic laparoscopy and positron emission tomography (PET) may play additional roles in this regard.

EKSTRAHEPATIC BILE DUCT CANCER

Background. Malignant strictures involving the bile ducts remain a major challenge in biliary surgery. It is an uncommon cancer. The etiology is unknown, most cases are sporadic, but several conditions confer an incrised risk of developing cholangiocarcinoma. Clinical presentation and preoperative evaluation. The early simptoms are nonspecific. In the past computed tomography, percutaneous transhepatic cholangiography and angiography were considered standard investigations, but currently magnetic resonance cholangiopancreatography is providing the same information with less risk. Evaluation of patients is principally an assessment of resectability since resection is the only effective therapy. BismuthCorlette classification and determinants of resectability are presented. Treatment. Different kinds of resections are used, according to the type of tumor based on Bismuth-Corlette classification. If resection is not possible, intrahepatic biliary-enteric bypass or percutaneous biliary drainage are performed. Currently there is no role for adjuvant radiochemotherapy. Conclusions. The treatment of hilar cholangiocarcinoma continues to evolve. Jucidious use of preoperative investigations and improvements in surgical tehnique has allowed better patient selection and performance of appropriately radical operations with an acceptable mortality.

MR cholangiography versus cholangioscopy for evaluation of longitudinal extension of hilar cholangiocarcinoma

Background: The utility of magnetic resonance cholangiography for assessment of longitudinal tumor extension of hilar cholangiocarcinoma was investigated with reference to findings by percutaneous transhepatic cholangioscopy. Methods: Ninety-nine patients with hilar cholangiocarcinoma underwent both magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy. Longitudinal tumor extension was described with the Bismuth-Corlette classification. Hilar cholangiocarcinoma was classified morphologically into stenotic, diffuse sclerosing, and polypoid types based on selective cholangiographic findings obtained during percutaneous transhepatic cholangioscopy. Agreement between percutaneous transhepatic cholangioscopy and magnetic resonance cholangiography according to the Bismuth-Corlette classification was compared. The degree of agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy according to each morphologic type was also compared in each subgroup without reference to Bismuth-Corlette type. Results: The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy with regard to Bismuth-Corlette types was 87.9% (kappa = 0.832, p < 0.01). The agreement of magnetic resonance cholangiography for each Bismuth-Corlette type with reference to percutaneous transhepatic cholangioscopy was as follows: type I (n = 18), 16/18 (88.9%); type II (n = 16), 14/16 (87.5%); type IIIa (n = 23), 19/23 (82.6%); type IIIb (n = 14), 14/14 (100%); and type IV (n = 28), 24/28 (85.7%). The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy for Bismuth-Corlette type according to selective cholangiographic findings was as follows: stenotic type, 58/61 (95.1%, kappa = 0.929, p < 0.01); diffuse sclerosing type, 12/16 (75%, kappa = 0.619, p < 0.01); and polypoid type, 17/22 (77.3%, kappa = 0.696, p < 0.01). Conclusion: There is good overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy on longitudinal extension of hilar cholangiocarcinoma. Especially for the stenotic type of hilar cholangiocarcinoma (based on selective cholangiographic findings), magnetic resonance cholangiography may replace percutaneous transhepatic cholangioscopy in the determination of longitudinal tumor extension. For polypoid or diffuse sclerosing types, however, percutaneous transhepatic cholangioscopy is required for accurate evaluation of longitudinal tumor extension. (Gastrointest Endosc 2002;56:25-32.)

CLINICOPATHOLOGICAL FEATURES OF RESECTED HILAR CARCINOMA OF THE BILE DUCT

Between 1983 and 1992, surgical intervention was attempted in 14 patients with hilar carcinoma of the bile duct. Local excision of the lesion alone was performed in four patients and hepatic resection in 10, in nine of whom resection of the caudate lobe was also undertaken. The histological free margin was observed in only five of 10 patients with hepatic resection (microscopic curative resection rate, 35.7%). The positive rate of surgical margins was 21% on the duodenal side, 36% on the resected side, 50% on the hepatic side and 21% on the paraaortic lymph-nodes. The modified Bismuth-Corlette classification was useful for selection of the type of surgical intervention in hilar carcinoma of the bile duct. It is suggested that rational resection of the bile duct including hepatectomy and extensive lymphadenectomy is necessary for widening the radical resection and to improve the surgical outcome of hilar carcinoma of the bile duct.