City of Hope National Medical Center, Duarte, CA.
City of Hope National Medical Center, Duarte, CA.
Surgery. 2023 Jul;174(1):113-115. doi: 10.1016/j.surg.2023.01.019. Epub 2023 Mar 9.
Intrahepatic cholangiocarcinoma is an aggressive tumor that commonly presents at an advanced stage requiring multimodal treatment. Surgical resection remains the only curative option; however, only 20% to 30% of patients present with resectable disease as these tumors remain asymptomatic at an early stage. Diagnostic workup for intrahepatic cholangiocarcinoma includes contrast-enhanced cross-sectional imaging (eg, computed tomography, magnetic resonance imaging) to determine resectability and percutaneous biopsy for patients receiving neoadjuvant therapy or with unresectable disease. Surgical treatment of resectable intrahepatic cholangiocarcinoma is centered on complete resection of the mass with negative (R0) margins while preserving sufficient future liver remnant. Intraoperative measures that aid in ensuring resectability include diagnostic laparoscopy to rule out peritoneal disease or distant metastases and ultrasound to evaluate for vascular invasion or intrahepatic metastases. Predictors of survival after surgery for intrahepatic cholangiocarcinoma include margin status, vascular invasion, nodal disease, and tumor size and multifocality. Patients with resectable intrahepatic cholangiocarcinoma may also benefit from systemic chemotherapy in either the neoadjuvant or adjuvant setting; however, guidelines do not presently support the use of neoadjuvant chemotherapy outside of ongoing clinical trials. For unresectable intrahepatic cholangiocarcinoma, the combination of gemcitabine and cisplatin has been the first-line chemotherapeutic option, but recent advancements in triplet regimens and immunotherapies may offer novel strategies. Hepatic artery infusion presents an efficacious adjunct to systemic chemotherapy as it takes advantage of the hepatic arterial blood supply that feeds intrahepatic cholangiocarcinomas to deliver high-dose chemotherapy to the liver through a subcutaneous pump. Thus, hepatic artery infusion takes advantage of first-pass hepatic metabolism and provides liver-directed therapy while minimizing systemic exposure. In unresectable intrahepatic cholangiocarcinoma, using hepatic artery infusion therapy in conjunction with systemic chemotherapy has been associated with better overall survival and response rates when compared to systemic chemotherapy alone or other liver-directed therapies, such as transarterial chemoembolization and transarterial radioembolization. This review focuses on surgical intervention for resectable intrahepatic cholangiocarcinoma and the utility of hepatic artery infusion for patients with unresectable disease.
肝内胆管癌是一种侵袭性肿瘤，通常在晚期出现，需要采用多模式治疗。手术切除仍然是唯一的治愈方法；然而，只有 20%到 30%的患者具有可切除的疾病，因为这些肿瘤在早期没有症状。肝内胆管癌的诊断工作包括对比增强的横断面成像（例如，计算机断层扫描、磁共振成像），以确定可切除性，并对接受新辅助治疗或不可切除疾病的患者进行经皮活检。可切除肝内胆管癌的手术治疗以完整切除肿瘤并获得阴性（R0）切缘为中心，同时保留足够的未来肝残留量。术中有助于确保可切除性的措施包括诊断性腹腔镜检查以排除腹膜疾病或远处转移，以及超声检查以评估血管侵犯或肝内转移。肝内胆管癌手术后的生存预测因素包括切缘状态、血管侵犯、淋巴结疾病以及肿瘤大小和多灶性。可切除肝内胆管癌患者也可能受益于新辅助或辅助全身化疗；然而，目前指南不支持在正在进行的临床试验之外使用新辅助化疗。对于不可切除的肝内胆管癌，吉西他滨和顺铂的联合治疗一直是一线化疗选择，但最近三联方案和免疫疗法的进展可能提供新的策略。肝动脉灌注作为一种有效的辅助全身化疗方法，因为它利用了供应肝内胆管癌的肝动脉血液供应，通过皮下泵将高剂量化疗药物输送到肝脏。因此，肝动脉灌注利用了肝脏的首过代谢，并提供了肝定向治疗，同时最小化了全身暴露。在不可切除的肝内胆管癌中，与单独使用全身化疗或其他肝定向治疗（如经动脉化疗栓塞和经动脉放射性栓塞）相比，联合使用肝动脉灌注治疗和全身化疗与更好的总生存率和反应率相关。本综述重点介绍了可切除肝内胆管癌的手术干预措施以及肝动脉灌注在不可切除疾病患者中的应用。
