Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Nov 27, 2020; 12(11): 1089-1097
Published online Nov 27, 2020. doi: 10.4254/wjh.v12.i11.1089
Occurrence of seeding metastases in resectable perihilar cholangiocarcinoma and the role of low-dose radiotherapy to prevent this
Lotte C Franken, Eva Roos, Job Saris, Jeanin E van Hooft, Otto M van Delden, Joanne Verheij, Joris I Erdmann, Marc G Besselink, Olivier R Busch, Geertjan van Tienhoven, Thomas M van Gulik
Lotte C Franken, Eva Roos, Joris I Erdmann, Marc G Besselink, Olivier R Busch, Thomas M van Gulik, Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, Netherlands
Eva Roos, Joanne Verheij, Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, Netherlands
Job Saris, Jeanin E van Hooft, Department of Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, Netherlands
Otto M van Delden, Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, Netherlands
Geertjan van Tienhoven, Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, Netherlands
Author contributions: Franken L, Saris J, van Gulik TM designed the research study; Franken LC, Saris J performed the research. van Hooft JE, Roos E, van Delden OM, Verheij J, Besselink MG, Erdmann JI, Busch OR, van Gulik TM contributed essential reagents or tools; van Tienhoven G contributed essential reagents or tools, interpretation of the data, revised work for important intellectual content; Franken L, Saris J analyzed the data; Roos E, van Gulik TM, van Delden OM, Erdmann JI, Busch OR, van Gulik TM interpretation of data; Franken L, van Gulik TM, Roos E and van Gulik TM wrote the paper; Van Hooft J, Roos E, van Delden OM, Verheij J, Besselink MG, Erdmann JI, Busch OR and van Gulik TM revised work for important intellectual content.
Institutional review board statement: The need for ethical approval was waived by the Medical Ethics Review Committee of the Amsterdam UMC, location AMC (W19_155).
Informed consent statement: The need for individual informed consent was waived by the Medical Ethics Review Committee of the Amsterdam UMC, location AMC (W19_155).
Conflict-of-interest statement: The authors declare no conflict of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Lotte C Franken, MD, PhD, Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, Netherlands. l.c.franken@amsterdamumc.nl
Received: April 13, 2020
Peer-review started: April 13, 2020
First decision: June 18, 2020
Revised: August 11, 2020
Accepted: September 3, 2020
Article in press: September 3, 2020
Published online: November 27, 2020
Abstract
BACKGROUND

Preoperative biliary drainage in patients with presumed resectable perihilar cholangiocarcinoma (PHC) is hypothesized to promote the occurrence of seeding metastases. Seeding metastases can occur at the surgical scars or at the site of postoperative drains, and in case of percutaneous biliary drainage, at the catheter port-site. To prevent seeding metastases after resection, we routinely treated PHC patients with preoperative radiotherapy (RT) for over 25 years until January 2018.

AIM

To investigate the incidence of seeding metastases following resection of PHC.

METHODS

All patients who underwent resection for pathology proven PHC between January 2000 and March 2019 were included in this retrospective study. Between 2000-January 2018, patients received preoperative RT (3 × 3.5 Gray). RT was omitted in patients treated after January 2018.

RESULTS

A total of 171 patients underwent resection for PHC between January 2000 and March 2019. Of 171 patients undergoing resection, 111 patients (65%) were treated with preoperative RT. Intraoperative bile cytology showed no difference in the presence of viable tumor cells in bile of patients undergoing preoperative RT or not. Overall, two patients (1.2%) with seeding metastases were identified, both in the laparotomy scar and both after preoperative RT (one patient with endoscopic and the other with percutaneous and endoscopic biliary drainage).

CONCLUSION

The incidence of seeding metastases in patients with resected PHC in our series was low (1.2%). This low incidence and the inability of providing evidence that preoperative low-dose RT prevents seeding metastases, has led us to discontinue preoperative RT in patients with resectable PHC in our center.

Keywords: Perihilar cholangiocarcinoma, Seeding metastases, Preventive radiotherapy

Core Tip: Routine preoperative radiotherapy (3 times 3.5 Gray) to prevent the occurrence of seeding metastases was used in our tertiary center for 28 years in patients undergoing resection for perihilar cholangiocarcinoma. Seeding metastases occurred in 2 out of 171 patients (1.2%) undergoing resection between 2000 and 2019. Intraoperative bile cytology showed no significant difference in the presence of tumor cells in the bile of patients undergoing preoperative radiotherapy or not. Due to the current low incidence of seeding metastases, preoperative radiotherapy to prevent seeding metastases is now abandoned in our institution.