The Blumgart Preoperative Staging System for Hilar... : Journal of the American College of Surgeons (original) (raw)

Original scientific article

The Blumgart Preoperative Staging System for Hilar Cholangiocarcinoma: Analysis of Resectability and Outcomes in 380 Patients

Matsuo, Kenichi MDa,c; Rocha, Flavio G. MDa; Ito, Kaori MDa; D'Angelica, Michael I. MD, FACSa; Allen, Peter J. MD, FACSa; Fong, Yuman MD, FACSa; DeMatteo, Ronald P. MD, FACSa; Gonen, Mithat PhDb; Endo, Itaru MDc; Jarnagin, William R. MD, FACSa,*

aDepartment of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY

bDepartment of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY

cDepartment of Gastroenterological Surgery, Yokohama City University, Graduate School of Medicine, Yokohama, Japan

*Correspondence address: William R Jarnagin, MD, FACS, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065

email: [email protected]

Received March 2, 2012; Revised May 4, 2012; Accepted May 9, 2012.

CME questions for this article available athttp://jacscme.facs.org

Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose.

Abstract

BACKGROUND:

Complete resection of hilar cholangiocarcinoma (HCCA) is a critical determinant of long-term survival. This study validates a previously reported preoperative clinical T staging system for determining resectability of HCCA.

STUDY DESIGN:

Consecutive patients with confirmed HCCA treated over an 18-year period were included. Patient demographics, preoperative imaging studies, resection type, margin status, lymph node status, histopathologic findings, morbidity, and outcomes were entered prospectively and analyzed retrospectively; changes in these variables over time were assessed. All patients were placed into 1 of 3 stages based on the extent of ductal involvement by tumor, portal vein compromise, or lobar atrophy.

RESULTS:

From March 1991 through December 2008, 380 patients were evaluated. Eighty-five patients had unresectable disease; 295 patients underwent exploration with curative intent. One hundred fifty-seven patients underwent resection: 129 (82.2%) had a concomitant hepatic resection and 120 (76.4%) had an R0 resection. Of the 32 actual 5-year survivors (120 at risk), 30 patients (93.8%) had a concomitant hepatic resection. In patients who underwent an R0 resection, concomitant partial hepatectomy, well-differentiated histology, and negative lymph nodes were independent predictors of long-term survival. In the 376 patients whose disease could be staged, the preoperative clinical T staging system predicted resectability (p < 0.001), metastatic disease (p < 0.001), and R0 resection (p = 0.007).

CONCLUSIONS:

The preoperative clinical T staging system of Blumgart, defined by the radial and longitudinal tumor extent, accurately predicts resectability of HCCA. The full outcomes benefit of resection is realized only if a concomitant partial hepatectomy is performed.