Oral (pre-recorded)
OB01 Biliary: Cholangiocarcinoma 
Selection of Presentations from Abstract Submissions

OB01-01 Proposed Modification of Staging for Distal Cholangioncarcinoma on the Basis of the 8th Edition of the American Joint Committee on Cancer Staging System
Younghun You, Korea, Republic of

Y. You1, Y.C. Shin2, I.W. Han3, D.W. Choi3, J.S. Heo3, K.-T. Jang3, N. Kim3, H. Kim4, C.-S. Lim5, Samsung Medical Center
1Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, Republic of, 2Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Korea, Republic of, 3Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, Republic of, 4Seoul National University College of Medicine, Korea, Republic of, 5Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Korea, Republic of

Introduction: We validated 7th and 8th AJCC staging system. Second, we tried to find the optimal value for T category, total lymph node count (TLNC), positive lymph node count (PLNC) and lymph node ratio (LNR). Finally, comparison of performance by various staging models was performed.
Method: We retrospectively reviewed 251 patients who underwent surgery for DCC at 4 centers. To determine optimal cutoff value, univariate and multivariate Cox regression analyses were used and χ2 score of each values were compared. To compare the predictive superiority of various staging models, Akaike information criterion (AIC), Bayesian information criterion (BIC), AIC correction (AICc), and Harrells C-statistic were calculated.
Results: When applying the optimal cut off value for T category, the categories are classified as follows and referred to as 'revised T category': T1 (< 5mm), T2 (5-10mm) and T3(>10mm). As to N category, PLNC is divided into N (0), N (1-2) and N (≥ 3). LNR were divided into 3 groups
(0, >0 to < 0.1 and ≥0.1). In multivariate analysis, age (P = 0.003), TLNC (P = 0.033), revised T(LNR)M staging (P < 0.001) were identified as independent factor for OSR. The predictive performance of revised T (LNR) M staging (AIC:1288.925, BIC 1303.377, AICc 1291.52 and Harrell's C statics 0.667) was superior to other staging system.
Conclusions: A modified staging system consisting of revised T category and LNR predicted better overall survival of DCC than AJCC 7th and AJCC 8th editions.
OB01-02 Evaluation of Clinicopathological Features of Intraductal Biliay Neoplesm of the Bile Duct Based on New Classification: A Japan-Korea Collaborative Study
Keiichi Kubota, Japan

K. Kubota1, J.-Y. Jang2, Y. Nakanuma3, K.-T. Jang4, N. Fukushima5, T. Furukawa6, S.-M. Hong7, Y. Sakuraoka1, H. Kim8
1Second Department of Surgery, Dokkyo Medical University, Japan, 2Department of Surgery, Seooul National University Hospital, Korea, Republic of, 3Division of Pathology, Fukui Saiseikai Hospital, Japan, 4Department of Pathology and Translational Genomics, Samsung Medical Center, Korea, Republic of, 5Department of Pathology, Jichi Medical University, Japan, 6Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Japan, 7Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Korea, Republic of, 8Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Korea, Republic of

Introduction: The prevalent location and incidence of intraductal papillary neoplasm of the bile duct (IPNB) and invasive carcinoma associated with them have varied markedly among studies due to differences in diagnostic criteria and tumor location. To clarify the clinicopathological features of IPNB, a collaborative study of IPNB based on the new classification was performed by the Japan Biliary Association and the Korean Association of Hepato-Biliary-Pancreatic Surgery.
Methods: IPNBs were classified into two types: Type 1 IPNB, being histologically similar to intraductal papillary-mucinous neoplasm of the pancreas, and Type 2 IPNB, having a more complex histological architecture with irregular papillary branching or foci of solid-tubular components. Medical data, pathological findings and long-term outcomes for the two types were evaluated.
Results: Among 694 IPNB patients, 520 and 174 had Type 1 and Type 2, respectively. The levels of AST, ALT, ALP, γ-GTP, T. Bil, CEA and CA19-9 were significantly higher in patients with Type 2 than in those with Type 1. Type 1 IPNB was more frequently located in the intrahepatic bile duct than Type 2, whereas Type 2 was more frequently located in the distal bile duct than Type 1 IPNB (P< 0.001). There were significant differences in 5-year cumulative survival rates (75.2% vs 50.9%; P < 0.0001) and 5-year cumulative disease-free survival rates (64.1% vs 35.3%; P < 0.0001) between the two groups.
Conclusion: Type 1 and Type 2 IPNBs differ in their clinicopathological features and prognosis. IPNB should not be discussed as a single-entity disease but as heterogeneous disease.
[Cumulative survival rates of patients with Type 1 and 2 IPNB (n=694).]
OB01-03 Clinical Significance of Novel Item-Based Pathological Report for Hilar Cholangiocarcinoma
XiangDe Shi, China

X. Shi, R. Zhang, H. Li, J. Sun, Q. Tang, C. Liu
Biliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, China

Introduction: The en bloc cancer resection was performed using no touch, vascular resection and reconstruction techniques, which preserves the anatomical integrity of the hilar tumor and peripheral vessels and tissues.
Methods: Novel item-based pathological reports for 10 patients with en bloc resection of hilar cholangiocarcinoma were adopted. The longitudinal bile duct margin, ventral bile duct margin(hilar plate) and dorsal bile duct margin(portal bifurcation and RHA) were analyzed by three dimensional pathology.
Results: The longitudinal evaluation of bile duct margin showed that only 10% positive rate of distal CBD margin was found, and then hepatopancreaticoduodenectomy was performed. The infiltration rate of Calot's triangle was 30% , the positive margin rate of right/left hepatic duct was 10%, without infiltration of adjacent liver parenchyma over 10mm and without intrahepatic metastases. The hilar plate (ventral margin of bile duct confluence) in 90% cases showed cancer infiltration. The distance from tumor to visceral peritoneum of hilar plate was only 0.1mm to 5mm depending on the Bismuth-Corlette type. By analyzing the tissue around the dorsal margin of bile duct confluence, it was found that if no variation in HA, infiltration of RHA adventitia/intima was 22%, and distance between cancer and adventitia of RHA was 0.15-2mm. The adventitia of portal bifurcation had no cancer infiltration, but it was closely related to RHA, which made it difficult to separate.
Conclusions: The item-based pathological report can evaluate the degree of cancer invasion in three-dimension and evaluate the margins of vessels and bile duct sufficiently.
OB01-05 Clinical Significance of Biliary Intraepithelial Neoplasia-3 (BilIN-3) in Resection Margin of Bile Duct for Perihilar Cholangiocarcinom
Dakyum Shin, Korea, Republic of

D. Shin
Division of Hepatobiliary and Pancreas Surgery, Asan Medical Center/University of Ulsan College of Medicine, Seoul, Korea, Republic of

Introduction: As R0 resection is the most critical concern for the surgery of perihilar cholangiocarcinoma (PHCC), it is still controversial as to whether additional resection of the bile duct is needed on biliary intraepithelial neoplasia-3 (BilIN-3) margin. We aimed to investigate the clinical significance of BilIN-3.
Methods: Patients who underwent surgery for PHCC with curative intent between 2000 and 2015 were included in the study and were analyzed retrospectively. We stratified the patients by resection margin status (R0, BilIN-3, R1) and compared the clinical outcomes
Results: Overall survival rates for each group at 5 years were 34.5% in the R0 group, 44.4% in the BilIN-3 group, and 21.0% in R1 group, whereas the rates at 10 years were 18.0%, 15.2%, and 11.4% respectively. The recurrence rates at 5 years were 76.4% in the R0 group, 51.7% in the BilIN-3 group, and 88.0% in the R1 group, respectively, while those at 10 years were 83.7%, 83.9%, and 92.8%.
Conclusions: The BilIN-3 group showed more similar survival and recurrence patternpatterns to those of the R0 group thanin comparison with the R1 group, but, considering itsthe malignant potential in the late period, BilIN-3 marginmargins should be avoided if technically possible during perihilar cholangiocarcinomaPHCC surgery.
OB01-07 Prognostic Predictability of American Joint Committee on Cancer 8th Staging System for Perihilar Cholangiocarcinoma: Limited Improvement Compared with the 7th Staging System
Jong Woo Lee, Korea, Republic of

J.W. Lee1, J.H. Lee2, Y. Park2, W. Lee2, J. Kwon2, K.B. Song2, D.W. Hwang2, S.C. Kim2
1Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Korea, Republic of, 2Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea, Republic of

Introduction: This study was conducted to evaluate the prognostic values of the 7th and 8th American Joint Committee on Cancer (AJCC) staging systems for patients with curative intent resected perihilar cholangiocarcinoma (PHCC).
Methods: A total of 348 patients who underwent major hepatectomy for PHCC between 2008 and 2015 were identified from a single center. Overall survival (OS) was estimated using the Kaplan-Meier method and compared across stage groups with the log-rank test. The concordance index was used to evaluate the prognostic predictability of the 8th AJCC staging system compared with that of the 7th.
Results: In the 8th edition, the stratification of each group of T classification improved compared to that in the 7th, as the survival rate of T4 decreased (T2, 31.2%; T3, 13.9%; T4, 15.1%; T1-T2, p=0.260; T2-T3, p=0.001; T3-T4, p=0.996). Both editions showed significant survival differences between each N stage, except between N1 and N2 (p=0.063) in 7thedition. Differences of point estimates between the 8th and 7th T and N classification and overall stages were +0.026, +0.006 and +0.039, respectively (T, p=0.010; N, p=0.115; overall stage, p=0.008). In multivariable analysis, posthepatectomy liver failure, T stage, N stage, distant metastasis, histologic differentiation, intraoperative transfusion, and resection margin status were associated with OS.
Conclusions: The prognostic predictability of 8th AJCC staging for PHCC improved, with statistical significance, compared to the 7th edition, but its overall performance is still unsatisfactory.
OB01-06 Preoperative C-Reactive Protein-Albumin Ratio Is Predicting Prognostic Long-Term Outcomes But Cannot Predict Lymph Node Metastasis and CA19-9 Can Predict in Patients with Extrahepatic Cholangiocarcinoma
Koji Kubota, Japan

K. Kubota, A. Shimizu, T. Motoyama, T. Notake, T. Ikehara, K. Yasukawa, H. Hayashi, A. Kobayashi, Y. Soejima
Division of Gastroenterological, Hepato-Billiary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Japan

Background: Systemic inflammation has prognostic value in some malignancies and could related to the lymph node metastasis. The aims of this study was to evaluate the impact of systematic inflammatory biomarkers on long-term and oncological outcomes and to assess the association of serum markers with lymph node metastasis.
Method: We enrolled 355 consecutive patients who underwent surgical resection for extrahepatic cholangiocarcinoma. Poor prognostic factors including systematic inflammatory biomarkers were compared to identify the biomarker most associated with overall survival (OS) and disease free survival (DFS) using receiver operating characteristic (ROC) curves and multivariable analysis. Furthermore, we evaluated the relationship between biomarkers including tumor markers and lymph node metastasis.
Results: Six and three biomarkers were predictive for OS and DFS, respectively, among which C-reactive protein-to-albumin ratio (CAR) was the highest area under the curve value (OS: 0.598; DFS: 0.605). In Multivariable analysis, high CAR status was independent prognostic factor for both OS and DFS (P = 0.002, P = 0.007, respectively). Although high CAR was not significant correlation with lymph node metastasis (P = 0.645), CA19-9 was significant correlation (P < 0.001).
Conclusion: Preoperative CAR is the most predicting factor for OS and DFS in patients with extrahepatic cholangiocarcinoma, however it cannot predict the lymph node metastasis. CA19-9 value may predict preoperative lymph node metastasis.
OB01-09 Outcome after Resection for Perihilar Cholangiocarcinoma in Primary Sclerosing Cholangitis - an International Multicenter Study from the Perihilar Cholangiocarcinoma Collaboration Group
Hannes Jansson, Sweden

H. Jansson1, P.B. Olthof2, A. Bergquist3, T.M. van Gulik2, E. Sparrelid1, The Perihilar Cholangiocarcinoma Collaboration Group
1Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Sweden, 2Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Netherlands, 3Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, Sweden

Introduction: Resection remains the only therapeutic option for PSC patients that present with resectable perihilar cholangiocarcinoma (PHCC) in stages where transplantation is precluded.
Data on PSC-specific outcomes after resection for PHCC is sparse. The aim of this study was to compare outcomes after resection for PSC-PHCC and non-PSC PHCC in a large international multicenter cohort.
Method: Retrospective multicenter cohort of patients resected for PHCC from 20 European and American centers (1996-2018). Primary outcome was overall survival (OS), secondary outcome complications Clavien-Dindo grade 3 and higher. PSC patients and non-PSC controls were matched 1:3 by propensity score (PS) including covariates age, ASA-class, T-stage and N-status. Covariate balance of matching was evaluated by standardized mean difference < 0.1. Kaplan-Meier survival analysis was performed.
Results: 1054 patients were included for analysis, with PHCC verified by pathology and known PSC-status (all PHCC n=1461). 28 patients (2.7%) had PSC-PHCC, 1026 (97.3%) non-PSC PHCC.
3- and 5-year OS (95% CI) was 48% (25-71%) and 24% (7-49%) in PSC-PHCC, compared to 42% (30-54%) and 29% (17-42%) in matched controls (Fig. 1), and 42% (38-46%) and 26% (23-30%) in unmatched controls. Frequency of complications CD≥3 was 68% in PSC-PHCC compared to 37% in matched controls (p=0.004), and 40% in unmatched controls (p=0.003).
Conclusions: Although postoperative complications were significantly increased after resection for PSC-PHCC, 3-year OS was similar compared to controls matched with age, ASA-class, T-stage and N-status. Survival data for 5 years and over was limited, and PSC-specific survival ≥ 5 years could be decreased (Fig. 1).
[Figure 1]
OB01-10 Perihilar Cholangiocarcimoma: Are We Ready to Step Towards Minimally-invasiveness?
Francesca Ratti, Italy

F. Ratti, G. Fiorentini, F. Cipriani, M. Catena, M. Paganelli, L. Aldrighetti
Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy

Introduction: The endpoint of this study isis to evaluate the potential advantages of laparoscopic approach over the open counterpart in a comparative study within an analysis based on the propensity score matching.
Materials and methods: From January 2004 to June 2019, 261 procedures with curative intent for PHC were performed. From March 2018 a Mils program for PHC was undertaken: 16 patients constituted the study group that was compared with a group of patients operated by open technique (control group) from 2014 to march 2018 through a propensity score matching with a 1: 2 ratio.
Results: There were no statistically significant differences in terms of preoperative characteristics between the two groups. Laparoscopic resections resulted in statistically significant longer procedures (360 vs 275 minutes, p=0.048). Conversion rate was 18.8%, being oncological concerns the most frequent reason for conversion (3/3 cases). Laparoscopic series resulted in a statistically significant lower blood loss (380 vs 470, p=0.048) and minor intraoperative blood transfusions (12.5% vs 21.9%, p=0.032). Number of retrieved nodes was 9 vs 8 (p=ns) and the rate of R0 resections was similar between the two groups. Patients in the MILS group had a significantly shorter length of postoperative stay (median 10; range: 7-15) compared with the open group (median: 14; range:12-29), p=0.048.
Conclusion: The laparoscopic approach in phc, so far maintained in an exploratory phase, demonstrates adequate feasibility and safety standards when conducted in carefully selected patients and in centers with expertise.
OB01-11 Outcomes in Hilar Cholangiocarcinoma Management through a Clinical Pathway Implementation: A 30-year Single Centre Experience
Francesco Giovinazzo, United Kingdom

F. Giovinazzo, A. Schlegel, B. Dasary, N. Chatzizacharias, K. Roberts, R. Marudanayagam, D. Mirza, J. Isaac, P. Muiesan
Queen Elizabeth Hospital Birmingham, United Kingdom

Introduction: Multidisciplinary team assessment and clinical pathways improve the outcomes of cancer treatments. Perihilar-cholangiocarcinoma is a rare disease, and surgical resection remains the only possibility of curative treatment. The present study aimed to investigate patient outcomes after the introduction of an institutional Perihilar cholangiocarcinoma clinical pathway.
Methods: All patients with a diagnosis of Perihilar-cholangiocarcinoma, between 1988 and 2018 were identified from a prospectively collected database. Outcomes from a historical control group of 508 (83%) patients were compared with patients after the implementation of the Perihilar-cholangiocarcinoma clinical pathway (n=107; 17%).
Results: Median Charlson Comorbidities Index (CCI) was 5 (IQ 4-6) in the Perihilar-cholangiocarcinoma clinical pathway and 4 (IQ 3-5) before the Clinical pathway (p< 0.0001). The overall number of patient defined as localized without vascular involvement, vascular involvement, and with metastatic diseases were 28% (n=28), 49% (n=50), and 24% (n=24) within the Perihilar-cholangiocarcinoma clinical pathway and 42% (n=101), 40% (n=94), and 17% (n=41) before introduction of the Clinical Pathway (p=0.02). The non-surgical candidates were 369 (73%) and 60 (58%), and the exploratory laparotomies without resections were 49 (10%) and 15 (14%), respectively (p=0.01). One-year survival was 61% vs. 67% (HR: 2.664 CI: 1.056 to 6.639, p=0.032) in the no clinical pathway and in the Perihilar-cholangiocarcinoma clinical pathway.
Conclusion: The introduction of the Perihilar-cholangiocarcinoma clinical pathway significantly increased the resection rate trough a significant number of patients with vascular involvement deemed resectable within the pathway. Such results are consistent with the standard approach of other high volume international centres.
OB01-12 Resection or HAIP Chemotherapy for Multifocal Intrahepatic Cholangiocarcinoma
Stijn Franssen, Netherlands

S. Franssen1, K. Soares2, J. Jolissaint2, D. Tsilimigras3, T.M. Pawlik3, W.R. Jarnagin2, B. Groot Koerkamp1
1Erasmus MC, Netherlands, 2Memorial Sloan Kettering Cancer Center, United States, 3Ohio State University, Wexner Medical Center, United States

Introduction: Intrahepatic cholangiocarcinoma (iCCA) is often multifocal (i.e. satellites or intrahepatic metastases) at presentation. We compared survival of patients with multifocal iCCA after resection and after hepatic arterial infusion pump (HAIP) chemotherapy.
Methods: The resection group consisted of consecutive patients from 12 centers who underwent a curative-intent resection of multifocal iCCA. The HAIP group consisted of consecutive patients from a single center who underwent HAIP chemotherapy for multifocal iCCA. Patients with extrahepatic metastatic disease were excluded. Overall survival (OS) was measured from the date of surgery. OS rates were compared between the two treatments using the Kaplan Meier methods and logrank test.
Results: In total, 311 patients with multifocal iCCA were included; 178 in the resection group and 133 in the HAIP group. The HAIP group was characterized by a higher percentage of bilobar disease (90.2% vs. 35.9%), higher percentage of prior systemic chemotherapy (34.6% vs. 7.9%) and larger tumors (median 9.0 vs. 7.8 cm). The median age was comparable between the two groups. The median OS for resection was 15.4 months versus 18.6 months for HAIP (p = 0.74). 5-years OS for resection was 8.4% (95% CI 5.2-13.7) versus 3.8% (95% CI 1.2-12.6) for HAIP.
Conclusion: Patients with multifocal iCCA had similar OS after resection or HAIP chemotherapy.
OB01-13 Impact of Vascular Resection on Short-term and Long-terms Outcomes during Curative Intent Hepatectomy for Intrahepatic Cholangiocarcinoma
Simone Conci, Italy

S. Conci1, L. Vigano'2, G. Ercolani3, E. Gonzales4, A. Ruzzenente1, E. De Santibanes4, D.A. Pinna3, G. Torzilli2, A. Guglielmi1
1Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Italy, 2Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center, Humanitas University, Italy, 3Department of General and Emergency Surgery and Organ Transplantation, S. Orsola-Malpighi Hospital, University of Bologna, Italy, 4Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Argentina

Background and aims: We aimed to investigated the impact of vascular resection (VR) on postoperative outcomes and survival of patients undergoing curative-intent surgery for intrahepatic cholangiocarcinoma (ICC).
Methods: A retrospective analysis of a multi-institutional series of 270 patients with resected ICC was carried out.Patients were divided in cava VR (CVR), portal VR (PVR) and no VR (NVR). Univariate and multivariate analysis were used to determine the impact of VR (CVR and PVR) on postoperative outcomes and survival.
Results: Thirty-one patients (11.5%) underwent VR: 15 (5.6%) to PVR and 16 (5.9%) to CVR. R0 resection rates were 73.6% in NVR, 73.3% of PVR and 68.8% in CVR, p=0.694. Postoperative mortality rate was 3.3% (n=9) in the entire cohort, 2.5% in NVR, 6.7% in PVR and 12.5% in CVR. The 5-years overall survival (OS) rates were 38.4% in NVR, 22.2% in PVR and 30.1% in CVR, p = 0.030. Multivariate analysis identified the following independent prognostic factors: Pattern of nodules distribution (p < 0.001), size ≥ 50 mm (p = 0.009), lymph-node metastases (N1) (p < 0.001) and R1 resections (p = 0.002). The 5-years OS rate for patients submitted to VR (CVR or PVR) associated with R0 resection and N0 was 44.4%.
Conclusion: Vascular resection (CVR and PVR) seem to be related with worse postoperative outcomes but seem to be justified by the good survival results in particular in patients without other prognostic (N0 and R0). Aggressive surgery with vascular resection should be recommended in selected ICC patients undergoing hepatectomy.