ANNALS OF SURGERY
Vol. 226, No. 1, 107-114
© 1997 Lippincott-Raven Publishers
July 19, 1996
The article by Su et al. about prognostic factors in hilar
cholangiocarcinoma is an excellent study. However, I would
like to discuss the term "hilar cholangiocarcinoma," which
they used in their study and referred to Nimura et al.' I disagree
with the authors about including "intrahepatic bile duct cancer
invading the hepatic hilus" in hilar cholangiocarcinoma group.
Intrahepatic cholangiocarcinoma is associated with a differ-
ent clinical, laboratory, and radiographic presentation. Intrahe-
patic cholangiocarcinoma is surgically approached in a fashion
similar to hepatocellular carcinoma, and the prognosis for re-
sectable intrahepatic cholangiocarcinoma is more favorable than
for hilar cholangiocarcinoma.2 The tumors can be divided into
hilar or intrahepatic bile duct tumor categories primarily by
their macroscopic location and extent. In patients whose tumors
are located above the intrahepatic duct bifurcation, the biliary
tree may be obstructed initially on only the left or right side.
These patients usually present with abdominal pain, unilobular
hepatic enlargement, and elevations of the serum alkaline phos-
phatase or gamma glutamyltransferase without elevations of
serum bilirubin and without clinical jaundice.3'4 Such a presenta-
tion necessitates complete investigation with computed tomog-
raphy and cholangiography, so the diagnosis of intrahepatic
cholangiocarcinoma can be made early in the course of the
disease. With the extent of this tumor to the intrahepatic duct
bifurcation, this can be misclassified as hilar cholanciocarci-
I recommend to define "hilar cholangiocarcinoma" as the
tumors arising in the common hepatic duct and its first and
second bifurcations and "intrahepatic cholangiocarcinoma" as
the tumors arising in the small intrahepatic bile ducts beyond
the second bifurcation. The hilar cholangiocarcinoma and intra-
hepatic cholangiocarcinoma are often impossible to differenti-
ate, because the level of origin can not be determined even at
the time of autopsy.3-6 In cases in which the classification is
uncertain or ambiguous, histologic classification is needed.7'8
Although the term you have used for hilar cholangiocarci-
noma includes intrahepatic cholangiocarcinoma invading he-
patic hilum, as shown in Figure 1 in the article, it is obvious
that you have no patient that corresponds to this type of tumor.
Again, I would like to thank the authors for their presentation
of a large series of hilar cholangiocarcinoma.
1. Nimura Y, Hayakawa N, Kamiya J, et al. Hepatic segmentectomy
with caudate lobe resection for bile duct carcinoma of the hepatic
hilus. World J Surg 1990; 14:535-544.
2. Pitt HA, Dooley WC, Yeo CJ, Cameron JL. Malignancies of the
biliary tree. Curr Probl Surg 1995; 32:36-70.
3. Edmondson HA, Steiner PE. Primary carcinoma of the liver. A study
of 100 cases among 48900 necropsies. Cancer 1954; 51:462-503.
4. Okuda K, Kubo Y, Okazaki N, et al. Clinical aspects of intrahepatic
bile duct carcinoma including hilar carcinoma: a study of 57 autopsy
proven cases. Cancer 1977; 39:232-246.
5. Altemeier WA, Gall EA, Zinniger MM, Hoxworth LH. Sclerosing
carcinoma of the major intrahepatic ducts. Arch Surg 1957; 75:450-
6. Chen MF, Jan YY, Wang CS, et al. Clinical experience in 20 hepatic
7. Kurashina M, Kozuka S, Nakasima N, et al. Relationship of intrahe-
patic bile duct hyperplasia to cholangiocellular carcinoma. Cancer
8. Suzuki M, Takahashi T, Ouchi K, Matsuno S. The development and
extension of hepatohilar bile duct carcinoma. A three-dimensional
tumor mapping in the intrahepatic biliary tree visualized with the aid
of a graphics computer system. Cancer 1989; 64:658-666.
MUSTAFA SAHIN, M.D.
September 17, 1996
The bile duct cancer is usually classified into intrahepatic,
perihilar, and extrahepatic lesions; the extrahepatic tumors are
recategorized into upper, middle, and lower third according to
their location; their distribution shows a predilection for the
upper third lesions in most series.1'2 The intrahepatic or periph-
eral cholangiocarcinoma is usually well documented if the le-
sion is confined to the periphery of the liver without involve-
ment of the hepatic hilum. The main controversy remained with
the hilar tumor. Klatskin3 defined it as tumor arise in the hepatic
duct and its bifurcation within the porta hepatis and it is well
adopted by most surgeons. Bismuth and Corlette4 reclassified
it according to its extent and tumor involvement on the right
or left hepatic duct. Pitt et al.5 suggested a new classification to
include the major intrahepatic and extrahepatic ductal segments.
It is well demonstrated that intrahepatic or peripheral cholan-
giocarcinoma is associated with a different presentation, radio-
logic findings, and operative treatment than that of hilar or distal
bile duct cholangiocarcinoma. Intrahepatic cholangiocarcinoma
is surgically approached in a fashion similar to hepatocellular
carcinoma, and hepatic lobectomy is performed with standard
resection technique without the necessity of cholangiojejunos-
tomy provided the lesion is peripherally located. A better 5-
year survival in the resectable cases also is well presented.67
However, when the tumor involved the hepatic hilum, its
presentation will be just like a hilar cholangiocarcinoma with