Stadiazione intraoperatoria dei
tumori delle vie biliari
Marco Filauro
Dipartimento di chirurgia e malattie
dell’apparato digerente
SC di Chirurgia
( Dir.:M.Filauro)
E.O.Ospedali Galliera
Genova
Ann Surg. 1979 August; 190(2):
151–157
2000: CRITERIA FOR UNRESECTABILITY
Local Factors
1. Bilateral involvement of secondary biliary radicles
2. Encasement or occlusion of the main portal vein
3. Atrophy of one lobe with encasement of contralateral portal vein
branch
4. Atrophy of one lobe with contralateral involvement of secondary
biliary radicles
Distant Disease
1. Histologically proven N2 lymph node metastases
2. Liver/lung/peritoneal or other distant metastases
Ann Surg Onc 2000;
7(1). Blumgart L.
Perché stadiare ?
• Indicazione ad intervento
• Tipo di intervento
LA STADIAZIONE PREOPERATORIA
• La stadiazione preoperatoria DEVE definire
l’estensione endobiliare , extrabiliare e
linfonodale della malattia
• COME ? TC , RMN , Endo US , ERCP, ecc..
Però…. UNRESECTABLE AT PRESENTATION
= UNRESECTABLE AT LAPAROTOMY ?
All’atto dell’intervento …
Perché i tumori delle vie biliari
• possono essere multifocali (5%)
• Possono dare metastasi linfonodali (50%)
• Possono dare metastasi a distanza e/o
peritoneali ( 10-20 %)
La ristadiazione : la stadiazione
intraoperatoria ….
• Laparoscopia + LUS
• Ecografia intraoperatoria
• ..colangioscopia?
• ..ma anche: dissezione delle strutture
esame istologico intraop.
laparoscopia
ANN. SURG 2002, 235(1) :1-7. UTILY OF STAGING LAPAROSCOPY IN SUBSET OF
PERIPANCREATIC AND BILIARY MALIGNANCIES
LAPAROSCOPIA : conclusioni
• SI:per ADK TESTA PANCREAS
• NO: per tumori ampolla , vb distale
• SI : per tumori della colecisti
• I tumori dell’ilo e i tumori periferici ?
Pero’…
• Laparoscopy detected the majority (83% [33/40]) of
patients with peritoneal or liver metastases but failed to
detect all locally advanced tumors (0/19) and most nodal
metastases (2/10, P < .0001).
Ann Surg. 2002 March; 235(3): 392–399. .
Staging Laparoscopy in Patients With Extrahepatic Biliary
Carcinoma
Analysis of 100 Patients
Sharon M. Weber, MD, Ronald P. DeMatteo, MD, Yuman Fong, MD,
FACS, Leslie H. Blumgart, MD, FRCS, FACS, and William R. Jarnagin,
MD, FACS
From the Department of Surgery, Hepatobiliary Service, Memorial
Sloan-Kettering Cancer Center, New York, New York
Ecografia intraoperatoria
• The technique provides important additional, sometimes
unexpected, information to the surgeon at the time of
operation, and contributes to operative decision making and
surgical planning. Neoplasms can be staged, metastases
identified, and unexpected lesions discovered and
characterized.
Intraoperative Sonography of the Biliary System
Jonathan B. Kruskal1 and Robert A. Kane 1 Both authors: Ultrasound Division,
Department of Radiology, Beth Israel Deaconess Medical Center, West Campus 302B,
One Deaconess Rd., Boston MA 02215.
Ecografia intraoperatoria
• La conoscenza della anatomia biliare e
delle sue varianti è un prerequisito per un
corretto uso della metodica , ed è un
fattore “ critico” per la resezione chirurgica
Ecografia intraoperatoria
• La scelta della frequenza di lavoro e le
scansioni sono un altro fattore “critico”
per evidenziare lesioni superficiali
Ecografia intraoperatoria
• Le flogosi croniche possono simulare neoplasie ;
bisogna pertanto conoscere l’ecografia del
fegato e delle vie biliari compiutamente : 3°
fattore critico : lo skill ecografico
Ecografia intraoperatoria
• E’ necessario controllare che non vi siano
altre patologie associate e che queste non
modifichino il planning chirurgico
Ecografia intraoperatoria
• ..e nei casi dubbi il doppler ci può aiutare a
distinguere i dotti dai vasi e a valutare la
vascolarizzazione di pseudolesioni
I fattori prognostici post-resezione
•
•
•
•
Journal of Clinical Oncology, Vol 15, 947-954, Copyright © 1997 by American Society of Clinical
Oncology
Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic
factors
J Klempnauer, GJ Ridder, R von Wasielewski, M Werner, A Weimann and R Pichlmayr
Department of Pathology, Hanover Medical School, Germany.
PURPOSE: To define the prognostic factors after surgical resection of bile duct carcinomas at the
hepatic bifurcation. PATIENTS AND METHODS: The retrospective single-center experience details
151 patients after surgical resection of central bile duct carcinoma performed between 1971 and
1995. Tumor removal was accomplished by resection of the bile duct bifurcation either alone
(group I, n = 33), in combination with hepatic resection (group II, n = 77), or combined with
hepatic and vascular resection (group III, n = 41). Survival analysis was performed by the
Kaplan-Meier method and the relationship between each of the clinicopathologic variables and
survival was assessed by the log-rank test. Multivariate results were confirmed using Cox
regression. RESULTS: The overall hospital mortality rate was 9.9% and depended on the extent of
resection (group 1, 6.1%; group II, 7.8%; group III, 17.1%). After exclusion of hospital deaths,
the overall patient survival rate was 28.4% at 5 and 15.5% at 10 years, with a median survival
duration of 2.05 +/- 0.23 years. Univariate survival analysis identified tumor size, lymph node
metastases, residual tumor stage, and tumor grading as factors with a statistically significant
prognostic impact. Survival prognosis was not influenced by the site of the tumor according to the
classification of Bismuth and Corlette, extent of resection, International Union Against Cancer
(UICC) stage, perineural and vascular invasion, age, or sex. In a multivariate Cox
analysis, only lymph node metastases and residual tumor stage
proved to be of independent prognostic significance. CONCLUSION:
Resection of central bile duct carcinoma is feasible in many patients and a favorable outcome
after resection is mainly determined by curative resection and the absence of lymph
node metastases.
Perché la stadiazione
anatomopatologica intraoperatoria
• Influence of microscopically negative
margins on survival of patients with
resected Klatskin tumors (from Nakeeb et
al, 1996).
STATUS LINFONODALE
Comparison of survival according to nodal status. Significant differences were
found between no involvement and beyond regional (p = 0.0211) and
between regional and beyond regional (p = 0.0190).
M.Makuuchi Ann Surg. 1999 November; 230(5): 663.
L’importanza di un protocollo
• It is important to evaluate all surgical margins
carefully, including an assessment of vascular and
perineural invasion. Local recurrence is often related to residual tumor
located in the proximal or distal surgical margins of the bile duct or to tumor located
along the dissected soft tissue margin in the portal area. Local recurrence (usually at
the surgical margins) is most common with carcinomas arising in the hepatic duct(s).
• In addition, malignant
tumors of the extrahepatic bile
ducts are often multifocal. Therefore, microscopic
foci of carcinoma or dysplasia may be found at
the margin(s) even though the main tumor mass
has been resected. In some cases, it may be difficult to evaluate
margins on frozen section preparations because of inflammation and reactive atypia
of the surface epithelium or within the intramural mucous glands. If surgical margins
are free of carcinoma, the distance between the closest margin and the tumor edge
should be measured.
Micrographs that compare the appearance on frozen section of a cholangiocarcinoma (A) with that of
a biliary hamartoma (B). The cholangiocarcinoma exhibits marked irregularity of the ducts, cellular
atypia, and nuclear pleomorphism and hyperchromasia. The biliary hamartoma (von Meyenburg
complex), by contrast, consists of regular, dilated ducts lined by a single layer of cells with a bland
cytologic appearance (hematoxylin-eosin, original magnification ×200)
Artifacts and pittfalls
Figure 13: specimen showing marked
cautery artifact. This creates difficulties in the recognition of
malignant structure, located at the center and on the right side (arrows) (hematoxylin-eosin, original magnification
×120). Figure 14. Photomicrograph of a margin with crush artifact, depicting the presence of a duct that exhibits
significant dysplasia (hematoxylin-eosin, original magnification ×200)
..Inoltre
2001 Digestive Disease Week
• # 2451 Peritoneal Washings are not
Predictive of Advanced Stage in Hilar
Cholangiocarcinoma
Robert C.G. Martin II, Yuman Fong,
Ronald P. Dematteo, Leslie H. Blumgart,
William R. Jarnagin, New York, NY
Per concludere:
• LA STADIAZIONE INTRAOPERATORIA DEVE ESCLUDERE
METASTASI A DISTANZA , MALATTIA MULTIFOCALE E
METASTASI LINFONODALI (N2)
• LA STADIAZIONE INTRAOPERATORIA DEVE OTTIMIZZARE
LA RESEZIONE
• LA STADIAZIONE INTRAOPERATORIA RICHIEDE QUINDI
UN TEAM “ASSOLUTAMENTE” AFFIATATO CON COMPETENZE
RADIOLOGICHE , ANATOMOPATOLOGICHE E …
OVVIAMENTE.. CHIRURGICHE