Staging Of Cholangiocarcinoma Research Articles

Cholangiocarcinoma: Risk Factors, Diagnostic Tools, and Current Treatment Options

Cholangiocarcinoma is a disease caused by the differentiation of cells in the bile epithelium or liver parenchyma into malignant cells called cholangiocytes. This literature review presents the current risk factors, diagnostic tools, and treatment choices of cholangiocarcinoma. Publication about the current risk factors, diagnostic tools, and treatment choices of cholangiocarcinoma were collected from the Pubmed database until August 25, 2022. The keywords of the research were “cholangiocarcinoma”, “risk factor”, “diagnostic”, and “treatment”. Cholangiocarcinoma has many risk factors, from choledochal cysts, and primary sclerosing cholangitis, to asbestos exposure. The diagnosis of cholangiocarcinoma is difficult and requires the combined interpretation of different diagnostic modalities. Examinations that can be done for the diagnosis and staging of cholangiocarcinoma are MRI and CT. However, if the diagnosis remains uncertain, endoscopic examination and tissue sampling may be performed. After the diagnosis, there are several treatments, namely surgical therapy (surgical excision of bile duct tumors), endoscopic therapy (endoscopic biliary dilatation), radiological therapy (percutaneous transhepatic palliative biliary dilatation), chemotherapy and radiotherapy, and photodynamic therapy. Cholangiocarcinoma is a malignancy of cells in the biliary epithelium or liver parenchyma (cholangiocytes) that has many risk factors. The diagnosis of cholangiocarcinoma is difficult and requires a combined interpretation of the different diagnostic modalities, including MRI, CT, endoscopy, and tissue sampling. After the diagnosis, there are several treatments, namely surgical therapy, endoscopy, radiology therapy, chemotherapy and radiotherapy, and photodynamic therapy.

Challenges in Cholangiocarcinoma, Misdiagnosis with Hydatid Cyst Rupture: A Review

Cholangiocarcinoma, an adenocarcinoma arising from the epithelium of biliary ducts, is considered the second most common hepatic malignancy after hepatocellular carcinoma with increasing incidence over the past 3 decades. Many imaging modalities with correlation to clinical presentation are used for the diagnosis and staging of cholangiocarcinoma. However, the diagnosis of cholangiocarcinoma is still challenging due to the presence of some benign and malignant conditions that mimic the clinical presentation and radiological findings of this disease. One of those mimics is the condition of intrabiliary hydatid cyst rupture which can cause biliary obstructive symptoms over weeks with radiological findings that may be indistinguishable from those of cholangiocarcinoma and specifically klatskin tumor when found at the bifurcation of the common hepatic duct. In such a confusing situation, the correct preoperative diagnosis and potential treatment of the disease could both be made possible using Endoscopic Retrograde Cholangiopancreatography avoiding unrequired surgical interventions.

Advancements in cholangiocarcinoma: evolving strategies for diagnosis, treatment, and palliation over three decades.

In recent years, significant progress has been made in the diagnosis, treatment, and palliation of cholangiocarcinoma (CC). CC accounts for 15% of all primary liver neoplasms and 3% of all gastrointestinal malignancies. Despite the significant advances in the diagnosis and treatment of CC, this tumor remains a formidable challenge, accounting for 2% of all cancer-related deaths. Chronic inflammation, genetic predisposition, and congenital biliary abnormalities are the primary risk factors for CC. CC is anatomically categorized into intrahepatic CC (ICC), perihilar, and distal types, with the latter two collectively termed extrahepatic CC (ECC). Although the incidence of ICC surpasses that of ECC, both have exhibited an upward trend over the last two decades. The advancements in diagnostic techniques, including highresolution imaging modalities such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans, have improved the early detection and staging of CC. Molecular profiling and biomarker discovery have further enabled personalized treatment approaches. Endoscopic techniques have also evolved, providing minimally invasive options for biopsy and stent placement, which improve both diagnosis and palliative care. Treatment strategies have seen significant evolution, with surgical resection and liver transplantation being the only curative options. The refinement of surgical techniques and perioperative care has increased the success rates of these procedures. Additionally, neoadjuvant and adjuvant therapies, including chemoradiation, have shown promise in improving surgical outcomes and overall survival rates. Multidisciplinary teams (MDTs) play a crucial role in managing CC, ensuring that patients receive comprehensive care that includes surgical, medical, and supportive treatments. This team approach has led to the development of more effective treatment protocols and improved patient outcomes. Palliative care has also advanced, with new chemotherapeutic agents and targeted therapies providing better management of symptoms and prolongation of life. Innovations in interventional radiology, such as radiofrequency ablation and transcatheter arterial chemoembolization (TACE), offer additional palliative options that can significantly enhance quality of life. This review article outlines the progress made in diagnosing and treating individuals with CC over the last 30 years, highlighting the critical role of technological advancements and multidisciplinary care in improving patient outcomes.

Feasibility of magnetic resonance imaging-based radiomics features for preoperative prediction of extrahepatic cholangiocarcinoma stage

AimThe aim of this study is to develop and test radiomics models based on magnetic resonance imaging (MRI) to preoperatively and respectively predict the T stage, perineural invasion, and microvascular invasion of extrahepatic cholangiocarcinoma (eCCA) through a non-invasive approach. MethodsThis research included 101 eCCA patients (29–83 years; 45 females and 56 males) between August 2011 and December 2019. Radiomics features were retrospectively extracted from T1-weighted imaging, T2-weighted imaging, diffusion-weighted imaging, and apparent diffusion coefficient map using MaZda software. The region of interest was manually delineated in the largest section on four MRI images as ground truth while keeping 1–2 mm margin to tumor border, respectively. Pretreatment, dimension reduction method, and classifiers were used to establish radiomics signatures for assessing three pathological characteristics of eCCA. Finally, independent training and testing datasets were used to assess radiomics signature performance based on receiver operating characteristic curve analysis, accuracy, precision, sensitivity, and specificity. ResultsThis study extracted 1208 radiomics features from four MRI images of each patient. The best performing radiomics signatures for assessing the T stage, perineural invasion, and microvascular invasion were respectively produced by L1_normalization + linear discriminant analysis (LDA) + logistic regression, Box_Cox transformer + LDA + K-nearest neighbor, and L2_normalization + LDA + AdaBoost. The area under the curve values of the radiomics signatures for predicting the training and testing cohorts in each subgroup were respectively 1 and 0.962 (T stage), 1 and 1 (both perineural invasion and microvascular invasion). ConclusionThese proposed radiomic models based on MR images had powerful performance and high potential in predicting T stage, perineural, and microvascular invasion of eCCA. Reporting guidelines/Research designPrognostic study.

Clinical implication of tumor location in intrahepatic cholangiocarcinoma and assessment of the current staging system

Intrahepatic cholangiocarcinoma (ICC) exhibits a variety of morphologic and histologic growth pattern, and its treatment and prognosis are known to vary depending on the location and extent of tumor. This study aims to compare the clinical data according to the tumor location in ICC and to verify the current staging system used in ICC. 302 patients who underwent curative resection were reviewed. Central type ICC (C-ICC) was defined when the tumor had an invasion of intrahepatic secondary confluence or segmental branches of the bile duct and peripheral type ICC (P-ICC) when the tumor was located more peripherally. Clinicopathologic characteristics, oncological outcomes, and prognostic stratification of the AJCC 8th staging system were assessed. Among 302 patients, 123 were classified as C-ICC and 179 as P-ICC. Bigger tumor size, higher rate of elevated CA19-9 level, vascular invasion, periductal invasion type, R1 rate, and advanced T stage was found in C-ICC. Five-year overall survival rates were 34.0% for C-ICC and 47.5% for P-ICC (p = 0.005). A significant difference in disease-free survival was seen as well (p = 0.036). The prognostic utility of ICC T stage was assessed in N0 C-ICC but failed to stratify T2, T3, and T4 tumors (median survival; T2: 37 m. T3: 34 m. T4: 33 m. p = 0.591). When applying the perihilar cholangiocarcinoma staging system (p < 0.001), stratification was improved and similar results were also seen in the overall staging. C-ICC has a worse aggressive clinical course compared to P-ICC. The perihilar cholangiocarcinoma cancer staging system is better than ICC staging to stratify the prognosis of C-ICC.

High expression of tissue O-linked glycans is associated with a malignant phenotype of cholangiocarcinoma.

ObjectiveThis study aimed to investigate the expression of O-linked glycoprotein glycans in tissue of patients with cholangiocarcinoma compared with adjacent normal tissue.MethodsSixty patients with cholangiocarcinoma were included in the study. Permethylated O-linked glycans from intrahepatic cholangiocarcinoma tissue and adjacent normal tissue were analyzed using nano-spray ionization-linear ion trap mass spectrometry. Histochemistry of peanut agglutinin lectin was used for detection and localization of galactose (Gal) 1, N-acetyl-galactosamine (GalNAc) 1.ResultsO-linked glycans from patients with cholangiocarcinoma were composed of di- to hexa-saccharides with a terminal galactose and sialic acids (N-acetylneuraminic acid [NeuAc]). A total of eight O-linked glycan structures were detected. Gal1GalNAc1 and Gal2 N-acetyl-glucosamine 1 GalNAc1 expression was significantly higher in tissue from patients with cholangiocarcinoma compared with adjacent normal tissue, while NeuAc1Gal1GalNAc1 expression was significantly lower. High Gal1GalNAc1 expression was significantly associated with the late stage of cholangiocarcinoma (stages II–IV), lymphatic invasion, and vascular invasion.ConclusionOur study shows expression of O-linked glycans in progression of cholangiocarcinoma and highlights the association of Gal1GalNAc1 with lymphatic and vascular invasion of cholangiocarcinoma.

Gadoxetic acid magnetic-enhanced resonance imaging in the diagnosis of cholangiocarcinoma.

The use of liver magnetic resonance imaging is increasing thanks to its multiparametric sequences that allow a better tissue characterization, and the use of hepatobiliary contrast agents. This review aims to evaluate gadoxetic acid enhanced magnetic resonance imaging in the diagnosis and staging of cholangiocarcinoma and its different clinical and radiological classifications proposed in the literature. We also analyze the epidemiology, risk factors in correlation with clinical findings and laboratory data.

Progress on biomarkers for bile duct carcinoma

There were no obvious symptoms, no specific biochemical diagnostic indicators, and early detection and diagnosis were difficult in the early stage of cholangiocarcinoma. With the development of molecular biology, more and more biomarkers have been found in cholangiocarcinoma. It is of great significance for the early detection of cholangiocarcinoma if specific biomarkers or highly specific biomarkers can be found. Key words: Bile duct neoplasms; Biomarkers, tumor; Clinical laboratory techniques

Pathogenesis, diagnosis and treatment of premalignant and malignant stages of cholangiocarcinoma in primary sclerosing cholangitis.

Patients with primary sclerosing cholangitis (PSC) confer a high risk of cholangiocarcinoma (CCA). The molecular mechanisms of CCA development in PSC are incompletely understood, but pro-oncogenic processes resulting from chronic biliary inflammation are presumably of central importance. Distinguishing benign from malignant biliary strictures in PSC patients is challenging and accurately diagnosing CCA in PSC often requires a multifaceted approach involving imaging, serological testing, biliary brush cytology and fluorescence in situ hybridization (FISH). Lack of early detection tools leads to a late diagnosis in the majority of cases. Surgical resection or liver transplantation represent the only curative intent treatments in PSC-CCA, but is only an option for the small subset of patients where CCA is detected at an early stage. Current palliative treatment modalities result in only a modest increase in survival. Overall, PSC-CCA carries a dismal prognosis with a 5-year survival less than 20%. Advances aiming at improving strategies for early detection, treatment and surveillance of CCA will be essential to provide better future patient care for PSC patients. Herein, we review the pathogenetic mechanisms for PSC-CCA as well as strategies for diagnosing and managing premalignant and malignant stages of CCA in PSC.

1265 Endoscopic Ultrasound an Excellent Tool for Diagnosis of Early Stages of Cholangiocarcinoma

INTRODUCTION: Cholangiocarcinoma (CC) is a biliary tract malignancy with a poor prognosis and 3-year survival rate of 95%.1 Due to late onset of symptoms, patients often present with metastatic disease. Data suggest that endoscopic ultrasound (EUS) is an excellent tool to diagnose cholangiocarcinoma with a sensitivity varying from 60 to 89%.2–5 CASE DESCRIPTION/METHODS: Case 1 An 80-year-old man with a 3-week history of weight loss, jaundice, and generalized pruritus underwent both ultrasound and abdominopelvic CT scan which demonstrated dilatation of the intra and extrahepatic ducts and no masses. MR with MRCP revealed a common bile duct (CBD) measuring 18 mm and a biliary stricture at the head of the pancreas; masses were not noted in the pancreas or bile duct. He subsequently underwent EUS-guided fine needle aspiration (FNA) that revealed a 9 × 6 mm hypoechoic distal CBD lesion and normal pancreatic head; FNA cytology revealed adenocarcinoma consistent with biliary origin. Based on the EUS impression and cytology, the patient was diagnosed with T1N0M0 extrahepatic cholangiocarcinoma. Case 2 A 69-year-old male with history of weight loss, jaundice, and acholic stools was found to have several pancreatic cysts clustered together, 18 mm in conglomerate with a dilated CBD to 11 mm and no masses on MR of the abdomen. A subsequent EUS showed a normal pancreas, a 1 × 1.2 cm distal CBD lesion without evidence of invasion into the pancreatic head and a 1.2 cm peripancreatic lymph node with equivocal EUS features for malignancy. FNA cytology of lymph nodes was negative for malignancy. ERCP showed a distal CBD stricture of 2 cm suspicious for malignancy; brushings showed adenocarcinoma. EUS findings were consistent with T1N0M0 extrahepatic cholangiocarcinoma. DISCUSSION: EUS-FNA is an established, minimally invasive diagnostic modality for pancreatico-biliary tumors with high sensitivity to diagnose tumors less than 3 cm.6 EUS has demonstrated benefit in the diagnosis and staging of extrahepatic cholangiocarcinoma, as compared to other modalities such as MRI.7 While ERCP is primarily a therapeutic modality, it can also be used for diagnosis of CC via ERCP guided forceps biopsy, brush cytology or cholangioscopic biopsy.7 Our cases highlights the utility of EUS in diagnosing early stage cholangiocarcinoma, while other imaging modalities are indeterminate. The second case also illustrates how ERCP guided brush cytology complements EUS imaging in the diagnosis of T1 extrahepatic cholangiocarcinoma.

Diagnostic-therapeutic management of bile duct cancer.

Biliary tract cancer, or cholangiocarcinoma, comprises a heterogeneous group of malignant tumors that can emerge at any part of the biliary tree. This group is the second most common type of primary liver cancer. Diagnosis is usually based on symptoms, which may be heterogeneous, and nonspecific biomarkers in serum and biopsy specimens, as well as on imaging techniques. Endoscopy-based diagnosis is essential, since it enables biopsy specimens to be taken. In addition, it can help with locoregional staging of distal tumors. Endoscopic retrograde cholangiopancreatography is a key technique for the evaluation and treatment of malignant biliary tumors. Correct staging of cholangiocarcinoma is essential in order to be able to determine the degree of resectability and assess the results of treatment. The tumor is staged based on the TNM classification of the American Joint Committee on Cancer. The approach will depend on the classification of the tumor. Thus, some patients with early-stage disease could benefit from surgery; complete surgical resection is the cornerstone of cure. However, only a minority of patients are diagnosed in the early stages and are suitable candidates for resection. In the subset of patients diagnosed with locally advanced or metastatic disease, chemotherapy has been used to improve outcome and to delay tumor progression. The approach to biliary tract tumors should be multidisciplinary, involving experienced endoscopists, oncologists, radiologists, and surgeons.

Indications for Single-Operator Cholangioscopy and Pancreatoscopy: an Expert Review.

Direct endoscopic visualization of the biliary and pancreatic ducts by single-operator cholangioscopy (SOC) and pancreatoscopy (SOP) is an expanding technique with an increasing number of indications. This review provides technical tips and tricks and a literature update on the usefulness of SOC and SOP in clinical practice. SOC has shown a 91.3% and 87.3% diagnostic procedural success in indeterminate strictures and difficult stones respectively, with a 9.4%-16.4% complication rate. Although the interpretation of the images suspected for malignancy can be challenging, new classifications based in mucosal and vascular patterns as well as better devices are in development. A higher sensitivity has been associated to targeted biopsies, compared to brushing and blinded biopsies. Indeed, SOC has recently demonstrated a decrease in the number of procedures and costs when compared with endoscopic retrograde cholangiopancreatography. This technique has also been reported for many other diagnostic and therapeutic indications, such as cholangiocarcinoma staging and foreign body extraction. Similarly, diagnostic and therapeutic SOP in indeterminate strictures or pancreatic stones, and intraductal papillary mucinous neoplasms, has been successfully reported. Research to date supports the use of cholangioscopy as a complementary examination in patients with indeterminate strictures, difficult stones and specific situations. In a near future, there will probably be new established indications, a better understanding of the imaging findings and a place of SOC/SOP as first line in selected scenarios.

Clinical presentation, diagnosis and staging of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a heterogeneous group of tumours, derived from cells of the biliary tree, which represent the second most frequent primary liver tumour. According to the most recent classifications, CCA can be subdivided into intrahepatic (iCCA) and extrahepatic (eCCA) which include perihilar (pCCA) and distal (dCCA) CCA. CCA are usually identified at advanced stages, when the primary tumour grows enough to produce a large liver mass or when jaundice has developed because of biliary tree obstruction. The ongoing challenges in the identification of risk factors and definition of a specific population at higher risk of developing CCA are the main challenges for the development of screening programs. Therefore, late diagnosis remains an unresolved issue in CCA. Imaging plays an important role in the detection and characterization of CCA, helping with radiological diagnosis, guiding biopsy procedures and allowing staging of the tumour. This review focuses on clinical presentations and diagnosis and staging techniques of CCA.

Role of digital single-operator cholangioscopy in the diagnosis and treatment of biliary disorders.

Due to the need for improvement in the diagnosis and minimally invasive therapy of the bile duct disorders new technologies for cholangioscopy have been recently developed. Per-oral cholangioscopy has become an important diagnostic and therapeutic tool leading to avoidance of aggressive and unnecessary surgery in many clinical scenarios. This paper focuses on the newly developed SpyGlass DS technology, its advantages, and the technique of single-operator cholangioscopy (SOC), biliary indications and possible adverse events. We also review the available literature; discuss the limitations and future expectations. Digital SOC (D-SOC) is a useful technique, which provides endoscopic imaging of the biliary tree, optical diagnosis, biopsy under direct vision and therapeutic interventions. The implementations are diagnostic and therapeutic. Diagnostic indications are indeterminate biliary strictures, unclear filling defects, staging of cholangiocarcinoma, staging of ampullary tumors (extension into the common bile duct), unclear bile duct dilation, exploring cystic lesions of the biliary tree, unexplained hemobilia, posttransplant biliary complications. Therapeutic indications are lithotripsy of difficult stones, retrieval of migrated stents, foreign body removal, guide wire placement, transpapillary gallbladder drainage and endoscopic tumor ablative therapy. Most studied and established indications are the diagnosis of indeterminate biliary stricture and intraductal lithotripsy of difficult stones. The adverse events are not different and more common compared to those of Endoscopic retrograde cholangiopancreatography (ERCP) alone. D-SOC is a safe and effective procedure, adjunct to the standard ERCP and the newly available digital technology overcomes many of the limitations of the previous generations of cholangioscopes.

Cholangiocarcinoma: classification and staging

The main classifications of cholangiocarcinoma (CC) are currently the TNM classification, as well as the Bismuth–Corlette and MSKCC classifications. The criteria of T, N and M categories and characteristics of the stages of cholangiocarcinoma of the proximal and distal bile ducts, which are specified in the modern 8th edition of the international TNM classification, are presented. TNM classification is the most common for the development of treatment methods and the determination of disease prognosis. The Bismuth–Corlette classification, which characterizes the CC of the bile ducts in the region of the gate of the liver, is used to determine the type and volume of surgery. MSKCC classification of the CC of proximal bile ducts is designed to assess the prognosis of resectability, the risk of metastases and long-term survival of patients.

Proposal for a new T-stage classification system for distal cholangiocarcinoma: a 10-institution study from the U.S. Extrahepatic Biliary Malignancy Consortium

BackgroundSeventh AJCC distal cholangiocarcinoma T-stage classification inadequately separates patients by survival. This retrospective study aimed to define a novel T-stage system to better stratify patients after resection. MethodsCurative-intent pancreaticoduodenectomies for distal cholangiocarcinoma (1/2000-5/2015) at 10 US institutions were included. Relationships between tumor characteristics and overall survival (OS) were assessed and incorporated into a novel T-stage classification. Results176 patients (median follow-up: 24mo) were included. Current AJCC T-stage was not associated with OS (T1: 23mo, T2: 20mo, T3: 25mo, T4: 12mo; p = 0.355). Tumor size ≥3 cm and presence of lymphovascular invasion (LVI) were associated with decreased OS on univariate and multivariable analyses. Patients were stratified into 3 groups [T1: size <3 cm and (−)LVI (n = 69; 39.2%); T2: size ≥3 cm and (−)LVI or size <3 cm and (+)LVI (n = 82; 46.6%); and T3: size ≥3 cm and (+)LVI (n = 25; 14.2%)]. Each progressive proposed T-stage was associated with decreased median OS (T1: 35mo; T2: 20mo; T3: 8mo; p = 0.002). ConclusionCurrent AJCC distal cholangiocarcinoma T-stage does not adequately stratify patients by survival. This proposed T-stage classification, based on tumor size and LVI, better differentiates patient outcomes after resection and could be considered for incorporation into the next AJCC distal cholangiocarcinoma staging system.

Cholangiocarcinoma: Diagnosis and Pre-operative Evaluation

Cholangiocarcinoma is a primary malignancy of the biliary tree that comprises various anatomic and histologic subtypes. The purpose of this manuscript is to review the various imaging manifestations of cholangiocarcinoma in order to aid clinical radiologists in the diagnosis and classification of the complex malignancy, and to aid clinical colleagues in facilitating proper clinical management. Various imaging modalities may aid in the proper diagnosis and staging of cholangiocarcinoma. Recent studies have advocated the use of hepatobiliary phase magnetic resonance imaging following gadoxetic acid administration in order to improve lesion conspicuity and detection of satellite nodules and intrahepatic metastases. Accurate recognition and classification of cholangiocarcinoma is essential for proper patient management. A thorough understanding of the different anatomic classifications, morphological patterns, and the mode of metastatic spread of cholangiocarcinoma is essential for radiologists involved in the interpretation of abdominal imaging studies.

Indicaciones de las pruebas de imagen en la patología biliar y pancreática

Abdominal radiographyFor biliary and pancreatic disease, abdomen radiography provides indirect, non-diagnostic data. Abdominal ultrasoundAbdominal ultrasound is the first test to be performed for suspected biliopancreatic disease. Ultrasound contrast media has provided this technique with greater accuracy in detecting necrosis in acute pancreatitis and characterising pancreatic tumours. Computed tomographyComputed tomography, however, is the reference technique for acute pancreatitis, pancreatic cancer and the staging of cholangiocarcinoma and other bile duct tumours. Endoscopic ultrasound and magnetic cholangioresonanceEndoscopic ultrasound is the most accurate technique for detecting vesicular microlithiasis, choledocholithiasis, small pancreatic tumours and chronic pancreatitis. Only magnetic cholangioresonance, when used in biliary disease, approaches the accuracy of endoscopic ultrasound. Endoscopic retrograde cholangiopancreatographyEndoscopic ultrasound and endoscopic retrograde cholangiopancreatography enable histological sampling (by puncture or brush) and performing biliopancreatic therapy.

Suggestions for Improving Perihilar Cholangiocarcinoma Staging Based on an Evaluation of the Seventh Edition AJCC System

The first separate staging system for perihilar cholangiocarcinoma was introduced by the seventh edition American Joint Committee on Cancer (AJCC) manual. To determine whether it strengthens the prognostic value, a comparative analysis with the sixth edition was performed, through which some areas for improvements were identified. The tumor-nodes-metastasis (TNM) stage and R status of 378 operated perihilar cholangiocarcinoma patients between 1990 and 2011 were reviewed. Survival analyses were conducted. Although the stages were up-numbered from I to II and II to III, the sixth and seventh editions had intercorresponding stages providing similar classifications. Applying the seventh edition, 9.8 % were downstaged and 1.3 % upstaged. Several issues were identified. First, both editions did not discriminate node-free locally advanced resectable diseases and node-positive resectable diseases. Second, stages IVA and IVB in the seventh edition had different prognoses suggesting misclassification of stage IVA. Third, the prognosis of liver invasion (T2b) resembled that of T3 more than T2a in the seventh edition, warranting investigation into the downstaging of liver invasion. Lastly, curative resections were possible in some Bismuth type 4 tumors allowing for better survival, suggesting that classifying them as unresectable disease (T4) should be revised. A discrete staging for perihilar cholangiocarcinoma is necessary; however, some points need further clarifications.

P-0159 - Diagnosis, Staging and Treatment of Cholangiocarcinoma; a Retrospective Analysis of Our Last Decade of Experience

Introduction: Although very rare, cholangiocarcinoma is a highly lethal type of cancer that is often already locally advanced at time of diagnosis. Chemotherapy and surgery are the cornerstone of the treatment. The purpose of this study is to review our local experience with the staging and treatment of the different stages of cholangiocarcinoma.