Advanced Cholangiocarcinoma: Criteria for Resection

John L. Marshall, MD: Sameek, let’s go back to talking about curative therapy for these cancers. How do we stage these people, and how do we make decisions about who should go to surgery or get chemotherapy first?

Sameek Roychowdhury, MD, PhD: After we’ve made that tissue or clinical diagnosis, it’s back to the anatomy. Whether the tumor is intrahepatic, involving a hilar or a distal duct, that will help us understand what is a surgically resectable tumor. CT scans from chest to pelvis to help look for distant metastasis is a first step. Then, nodal involvement and the tumor’s involvement in the structures of the liver, ducts, and important blood vessels that are in the center of the liver are important considerations to see if we can adequately remove the tumor with good surgical margins. Nodal involvement away from the liver is typically seen as a problem. Nodal involvement of the porta hepatis is also typically seen as a problem, but in different circumstances, maybe after therapy that’s systemic, that can be addressed.

Again, the goals are to identify a tumor with 1 set of ducts clear from blood vessels that can be safely removed and make sure we’ve ruled out nodal involvement. Depending on the anatomy, what’s resected may depend on the location. An intrahepatic duct will involve a significant hepatectomy vs a hilar or a distal tumor, which may involve removal of parts of the pancreas and parts of certain blood vessels, as well as certain kinds of reconstruction of the bowel. You need someone with expertise, such as hepatobiliary surgeons. A surgeon who doesn’t do many of these operations is not going to have the experience to think about the reconstruction or blood vessels involved and may not be as aggressive. Those are the key elements: Thinking about surgical resectability and working closely with our colleagues in surgical oncology or hepatobiliary surgery.

John L. Marshall, MD: Katie, let me ask you this. Is there a role for PET [positron emission tomography] scanning or bone scanning at staging? Do we do CEAs [carcinoembryonic antigen tests] or 19-9s [cancer antigen 19-9 tests]? What do you like to see in your portfolio of initial work-up on a patient like this who might be curable?

R. Kate Kelley, MD: There are 2 separate goals. One is the metastatic staging and making sure we’re not missing a different primary tumor, and that’s what the oncologist is always thinking about. Then there’s the surgical planning question. From the oncologist’s perspective, I definitely always will want a multiphasic or triphasic scan of the liver and then also chest and pelvis. We don’t routinely get PETs or bone scans unless there’s an equivocal finding on the other scans or a symptom that needs additional work-up, at least at the current time.

To the point we talked about earlier concerning cancer of unknown primary, if it’s an intrahepatic tumor that has an appearance that could be compatible with metastatic disease, in general, we should think about getting upper and lower endoscopies, EGG [electrogastrogram], and colonoscopy to make sure we’re not missing a different primary.

In patients who have recently had scopes, good imaging, and no other signs, I won’t necessarily repeat a set of scopes if there is no index of suspicion, but if it’s an intrahepatic and there are multifocal metastatic-appearing lesions, that should be considered. From a surgical planning standpoint, our surgeons will want either an MRCP [magnetic resonance cholangiopancreatography] and/or a hepatic angiogram to look at the fine details of the arterial anatomy. There can be a lot of intrapatient variability about where that hepatic artery takes off and whether there’s an accessory artery that allows for a more extended resection that wasn’t otherwise possible. The vascular anatomy is very important from a surgical perspective.

Transcript Edited for Clarity