ASO Author Reflections: Intrahepatic Cholangiocarcinoma: Downstaging Strategies Open the Gate to Surgery and Cure
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Intrahepatic Cholangiocarcinoma: Downstaging Strategies Open the Gate to Surgery and Cure Karim Boudjema, MD, PhD1, and Julien Edeline, MD, PhD2 1 2
Department of Hepatobiliary and Digestive Surgery, Hoˆpital Pontchaillou, Universite´ de Rennes 1, Rennes, France; Medical Oncology, Centre Euge`ne Marquis, Rennes, France
PAST Intrahepatic cholangiocarcinoma (ICC) was an uncommon primary liver cancer. Until 10 years ago, this tumor received little attention from surgeons. One of the reasons for this disinterest was that most patients were diagnosed at an advanced stage. Resection was reserved for the few patients in good general condition with tumors limited in size. Positive margins were frequent, and 5-year survival was dismal, only reaching 30% in the best series. Recurrences were frequent, and early and multiple lesions, positive nodes, or surgical margins were strong predictive factors of poor progression-free survival.1 The results of chemotherapy in unresectable disease were limited with a low response rate (20–25%), and very few patients were downstaged to surgery, the only curative option.2 PRESENT The incidence of ICC has risen, and both the increase in liver disease risk factors (such as obesity-associated steatohepatitis) and better recognition may explain this trend. The best indications for resection have been refined, and as is the case for hepatocellular carcinoma (HCC), the smaller the tumor, the better the prognosis.3 Apart from systemic chemotherapy, other medical treatment approaches have been studied. After the publication of retrospective cohorts, a few prospective studies testing locoregional strategies such as intraarterial hepatic
Ó Society of Surgical Oncology 2020 First Received: 4 April 2020 K. Boudjema, MD, PhD e-mail: [email protected]
chemotherapy and selective internal radiation therapy (SIRT) have reported improved results in terms of response and promising results in terms of survival.4 Of note, SIRT showed that, in very selected cases, huge tumors that could not be resected immediately could be downstaged to complete resection.5 This finding has introduced the concept of downsizing to resection. To achieve this objective, chemoembolization, intraarterial chemotherapy, external radiotherapy, and eventually SIRT have all been tested with encouraging results. Compared with other pretreatments, SIRT offers the major advantage of being associated with rapid and significant hypertrophy of the hemiliver contralateral to the tumor. This providential and still unexplained phenomenon drastically facilitates radical surgery. We reported in this journal that cisplatin-based chemotherapy alone, or even better combined with SIRT, could bring initially unresectable tumors to secondary resectability with prognosis similar to upfront surgery.6 This is an important addition to the literature, confirming that initially unresectable tumors should not always be considered only in a palliative approach, but that a combination strategy could br
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