Novel Prognostic Scoring System after Surgery for Klatskin Tumor

ArticleinThe American surgeon 79(1):90-5 · January 2013with15 Reads
Source: PubMed
Klatskin tumor is a rare hepatobiliary malignancy whose outcome and prognostic factors are not clearly documented. Between April 1998 and January 2007, 96 patients with hilar cholangiocarcinoma underwent resection. Data were collected prospectively. Thirty-one variables were evaluated for prognostic significance. There were 40 trisectionectomies, 40 hemihepatectomies, five central hepatectomies, and 11 biliary hilar resections. Thirty-seven (n = 37) patients required vascular reconstruction. There were 68 R0, 26 R1, and two R2 resections. Age (P = 0.048), pT status (P = 0.046), R class (P = 0.034), and adjuvant chemoradiation (P = 0.045) showed predictive significance by multivariate Cox proportional hazard regression analysis. A point scoring system was determined as follows: age younger than 62 years:age 62 years or older = 1:2 points; pT1:pT2 to 4 = 1:2 points; R0:R1/2 = 1:2 points; and chemoradiation yes:no = 1:2 points. The only model that reached statistical significance (P = 0.0332) described the following three groups: score 6 or less; score = 7; and score = 8. Median survival for score 6 or less, score = 7, and score = 8 was 26.5, 12, and 2.2 months, respectively (P = 0.032). The corresponding 1- and 3-year survival rates were 73 to 56 per cent, 52 to 38 per cent, and 17 to 0 per cent, respectively. We propose a scoring system predictive of long-term surgical outcome that could potentially improve patient selection for further postoperative oncologic treatment for Klatskin tumors.
    • "Surgical resection of PHC, using a combined extrahepatic bile duct resection and partial liver resection, offers the best chance for long-term survival with a reported median survival of 19–39 months in large series [2]. However, liver surgery in cholestatic patients with PHC is associated with high risks of postoperative morbidity and mortality, as reported up to 68% and 18%, respectively [3,4]. Preoperative biliary drainage is used to create a safer environment for liver surgery in PHC [5]. "
    [Show abstract] [Hide abstract] ABSTRACT: Liver surgery in perihilar cholangiocarcinoma (PHC) is associated with high postoperative morbidity because the tumor typically causes biliary obstruction. Preoperative biliary drainage is used to create a safer environment prior to liver surgery, but biliary drainage may be harmful when severe drainage-related complications deteriorate the patients' condition or increase the risk of postoperative morbidity. Biliary drainage can cause cholangitis/cholecystitis, pancreatitis, hemorrhage, portal vein thrombosis, bowel wall perforation, or dehydration. Two methods of preoperative biliary drainage are mostly applied: endoscopic biliary drainage, which is currently used in most regional centers before referring patients for surgical treatment, and percutaneous transhepatic biliary drainage. Both methods are associated with severe drainage-related complications, but two small retrospective series found a lower incidence in the number of preoperative complications after percutaneous drainage compared to endoscopic drainage (18-25% versus 38-60%, respectively). The present study randomizes patients with potentially resectable PHC and biliary obstruction between preoperative endoscopic or percutaneous transhepatic biliary drainage. The study is a multi-center trial with an "all-comers" design, randomizing patients between endoscopic or percutaneous transhepatic biliary drainage. All patients selected to potentially undergo a major liver resection for presumed PHC are eligible for inclusion in the study provided that the biliary system in the future liver remnant is obstructed (even if they underwent previous inadequate endoscopic drainage). Primary outcome measure is the total number of severe preoperative complications between randomization and exploratory laparotomy. The study is designed to detect superiority of percutaneous drainage: a provisional sample size of 106 patients is required to detect a relative decrease of 50% in the number of severe preoperative complications (alpha = 0.95; beta = 0.8). Interim analysis after inclusion of 53 patients (50%) will provide the definitive sample size. Secondary outcome measures encompass the success of biliary drainage, quality of life, and postoperative morbidity and mortality. The DRAINAGE trial is designed to identify a difference in the number of severe drainage-related complications after endoscopic and percutaneous transhepatic biliary drainage in patients selected to undergo a major liver resection for perihilar cholangiocarcinoma. Netherlands Trial Register [ NTR4243 , 11 October 2013].
    Full-text · Article · Dec 2015
    • "However, perineural invasion and papillary tumors were strong prognostic factors in the derivation cohort, but not independent prognostic factors due to correlation with other factors. The only published prognostic model for PHC is a risk score based on 96 patients and calculated with age, T stage, margin status, and adjuvant chemoradiation [19] . Two prognostic models have been developed for extrahepatic cholangiocarcinoma , which included both patients with perihilar and distal cholangiocarcinoma. "
    [Show abstract] [Hide abstract] ABSTRACT: The objective of this study was to derive and validate a prognostic nomogram to predict disease specific survival (DSS) after a curative intent resection of perihilar cholangiocarcinoma (PHC). A nomogram was developed from 173 patients treated at Memorial Sloan Kettering Cancer Center (MSKCC), New York, USA. The nomogram was externally validated in 133 patients treated at the Academic Medical Center (AMC), Amsterdam, The Netherlands. Prognostic accuracy was assessed with concordance estimates and calibration, and compared with the American Joint Committee on Cancer (AJCC) staging system. The nomogram is available as web-based calculator (after peer review) at For all 306 patients, the median overall survival (OS) was 40 months and the median DSS 41 months. Median follow-up for patients alive at last follow-up was 48 months. Lymph node involvement, resection margin status, and tumor differentiation were independent prognostic factors in the derivation cohort (MSKCC). A nomogram with these prognostic factors had a concordance index of 0.73 compared to 0.66 for the AJCC staging system. In the validation cohort (AMC) the concordance index was 0.72, compared to 0.60 for the AJCC staging system. Calibration was good in the derivation cohort; in the validation cohort patients had a better median DSS than predicted by the model. The proposed nomogram to predict DSS after curative intent resection of PHC had a better prognostic accuracy than the AJCC staging system. Calibration was suboptimal because DSS differed between the two institutions. The nomogram can inform patients and physicians, guide shared decision-making for adjuvant therapy, and stratify patients in future randomized controlled trials. © The Author 2015. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email:
    Article · Jun 2015
  • [Show abstract] [Hide abstract] ABSTRACT: Background.Hilarcholangiocarcinomais the most common biliary tract malignancy. Aim.Analysis of long-term results after R0 and R1 resections in patients with hilarcholangiocarcinoma.Materialandmethods.Proximalbileductresectionswithorwithoutmajorliverresectionswereperformed in 132 patients. Ninety five percent of isolated bile duct resections were performed before 2003. Long-term results of bile duct resections with or without major liver resections were assessed. One hundred and four patients (79%) were followed up from 0,5 till 12,5 years. Hospital mortality was included in calculation of survival. Results.Overall 5-year survival after R0 and R1 resections was 23%. There was no difference in survival before and after 2003 (19% and 37% respectively). Three factors discovered independent significant impact on survival in multivariate analysis: 1) age > 60; 2) R0 vs R1; 3) stage TNM, 2010 (I, II vs III, IV). There was no difference in survival after bile duct resections with and without major liver resections. Five-yearsurvivalwas 22% and 34% respectively. MajorliverresectionswereappliedmorefrequentlyinpatientswithIII, IVstagesTNM in comparison with minor liver resections and isolated bile duct resections(73% and 49% respectively). Five-yearsurvivalafter bileductresectionswithandwithoutmajorliverresectionswas75% and 46% respectively in patients of <60 years old age with I, IIstages TNM. Caudate lobe resection combined with major liver resection was performed in 44% of patients. Five-yearsurvivalof patients with R0 resections after caudate lobectomy was 60%, without caudate lobectomy – 42%. Conclusion. The crucial point in improvement of survival in patients with hilarcholangiocarcinoma is R0 resection. The most restrictive factor for survival was III, IV stage of disease according TNM classification. Aggressive surgery is justified if R0 resection is achievable.
    Full-text · Article · Jan 2013 · Annals of Oncology
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