
==== Front
Ann Surg Oncol
Ann Surg Oncol
Annals of Surgical Oncology
1068-9265
1534-4681
Springer International Publishing Cham

39012460
15830
10.1245/s10434-024-15830-8
ASO Author Reflections
ASO Author Reflections: Palliative Therapy Might be an Alternative When the Risks of Surgery for Perihilar Cholangiocarcinoma are High
Olthof Pim B. MD, PhD p.olthof@erasmusmc.nl

123
van Keulen Anne-Marleen MD, PhD 1
Buettner Stefan MD, PhD 1
Groot Koerkamp Bas MD, PhD 1
1 https://ror.org/03r4m3349 grid.508717.c 0000 0004 0637 3764 Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
2 grid.7177.6 0000000084992262 Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
3 grid.4494.d 0000 0000 9558 4598 Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
16 7 2024
16 7 2024
2024
31 10 65696570
27 6 2024
27 6 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
issue-copyright-statement© Society of Surgical Oncology 2024
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pmcPast

Surgical resection can offer long-term survival to patients with perihilar cholangiocarcinoma, with a median overall survival rate of 30 months.1 Several negative prognostic factors can influence survival. Positive resection margins are associated with median survival of 21 months, and when lymph nodes are also present, median survival is 12 months.2 In patients who underwent palliative systemic therapy, median overall survival was also 12 months.1 While surgical resection is the goal for most patients with perihilar cholangiocarcinoma, the comparable survival associated with palliative systemic therapy and surgery in high-risk patients questions the benefit of surgery for some patients.

Present

Using data from the European Network for the Study of Cholangiocarcinoma (ENS-CCA) registry, 92 patients who underwent palliative systemic therapy were compared with 146 patients who underwent resection and had postoperative positive resection margins. Median overall survival was comparable between both groups (17.1 vs. 16 months; p = 0.06), while 5-year overall survival was 20.0% with R1 resection and 2.2% with chemotherapy. Negative prognostic factors were more frequent in the chemotherapy group and type of treatment (i.e., R1 resection or palliative chemotherapy) was not an independent predictor of overall survival in multivariable analysis.3

Future

A randomized trial comparing palliative treatment with resection in patients with high-risk perihilar cholangiocarcinoma has not been performed and would be challenging. The present study shows that the benefit of surgery should be carefully weighted against the substantial risks of surgery in these patients. Major liver resection is often required and survival can be limited and even similar to palliative treatment without surgery. Surgery however can still offer long-term survival in a small proportion of patients. Surgery remains the standard for resectable perihilar cholangiocarcinoma. When the anticipated risk of positive margins is high and the risk of postoperative morbidity and mortality is considerable, palliative systemic therapy should be considered.4

Acknowledgment

This article is based upon work from European Network for the Study of Cholangiocarcinoma (ENSCCA) and COST Actions Euro-Cholangio-Net (CA18122) and Precision-BTC-network (CA22125), supported by COST (European Cooperation in Science and Technology.

This article refers to: van Keulen AM, Buettner S, Olthof PB, et al. Comparing survival of perihilar cholangiocarcinoma after R1 resection versus palliative chemotherapy for unresected localized disease. Annals Surgical Oncology. 2024. https://doi.org/10.1245/s10434-024-15582-5.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. van Keulen AM Franssen S van der Geest LG de Boer MT Coenraad M van Driel LMJW Dutch Hepatocellular & Cholangiocarcinoma Group (DHCG) : Nationwide treatment and outcomes of perihilar cholangiocarcinoma Liver Int 2021 41 8 1945 1953 10.1111/liv.14856 33641214
van Keulen AM, Franssen S, van der Geest LG, de Boer MT, Coenraad M, van Driel LMJW, Dutch Hepatocellular & Cholangiocarcinoma Group (DHCG), et al. : Nationwide treatment and outcomes of perihilar cholangiocarcinoma. Liver Int. 2021;41(8):1945–53.33641214
2. Nooijen LE Banales JM de Boer MT Braconi C Folseraas T Forner A ENSCCA Group Impact of positive lymph nodes and resection margin status on the overall survival of patients with resected perihilar cholangiocarcinoma: the ENSCCA registry Cancers 2022 14 10 2389 10.3390/cancers14102389 35625993
Nooijen LE, Banales JM, de Boer MT, Braconi C, Folseraas T, Forner A, ENSCCA Group, et al. Impact of positive lymph nodes and resection margin status on the overall survival of patients with resected perihilar cholangiocarcinoma: the ENSCCA registry. Cancers. 2022;14(10):2389.35625993
3. van Keulen AM Buettner S Olthof PB Comparing survival of perihilar cholangiocarcinoma after R1 resection versus palliative chemotherapy for unresected localized disease Ann Surg Oncol. 2024 10.1245/s10434-024-15582-5 39012460
van Keulen AM, Buettner S, Olthof PB, et al. Comparing survival of perihilar cholangiocarcinoma after R1 resection versus palliative chemotherapy for unresected localized disease. Ann Surg Oncol. 2024. 10.1245/s10434-024-15582-5.39012460
4. van Keulen AM Buettner S Erdmann JI Pratschke J Ratti F Jarnagin WR Perihilar Cholangiocarcinoma Collaboration Group Multivariable prediction model for both 90-day mortality and long-term survival for individual patients with perihilar cholangiocarcinoma: does the predicted survival justify the surgical risk? Br J Surg 2023 110 5 599 605 10.1093/bjs/znad057 36918735
van Keulen AM, Buettner S, Erdmann JI, Pratschke J, Ratti F, Jarnagin WR, Perihilar Cholangiocarcinoma Collaboration Group, et al. Multivariable prediction model for both 90-day mortality and long-term survival for individual patients with perihilar cholangiocarcinoma: does the predicted survival justify the surgical risk? Br J Surg. 2023;110(5):599–605.36918735
