Management of Intrahepatic bile duct cancer - Key considerations

In this video, Dr. Gunjan Desai, a liver surgeon in Mumbai, provides a comprehensive discussion on the management of resectable intrahepatic bile duct cancer (iCCA). Intrahepatic cholangiocarcinoma is a rare but aggressive malignancy arising from the bile ducts within the liver. Surgical resection remains the only potentially curative treatment, but successful management requires a multidisciplinary approach involving oncologists, hepatobiliary surgeons, and interventional radiologists.

Defining Resectable Intrahepatic Bile Duct Cancer
Dr. Desai begins by explaining the criteria for resectability in intrahepatic cholangiocarcinoma, which is determined by:

Absence of distant metastases (no spread to lungs, peritoneum, or lymph nodes beyond the hepatoduodenal ligament)
Adequate future liver remnant (FLR) to sustain post-resection liver function
No extensive vascular involvement that prevents reconstruction
No invasion of both hepatic lobes or bile ducts leading to widespread biliary obstruction
Preoperative Evaluation and Staging
A thorough preoperative assessment is essential to determine the feasibility of surgery. Imaging modalities such as contrast-enhanced CT, MRI with MRCP, and PET-CT are crucial for staging and surgical planning. Key factors assessed include:

Tumor size, location, and proximity to vascular structures
Liver function tests (bilirubin, albumin, and prothrombin time)
Assessment of underlying liver disease (e.g., cirrhosis or fibrosis) using FibroScan or liver biopsy
CA 19-9 and CEA tumor markers to support diagnosis and monitor response to therapy
Surgical Approach for Resectable iCCA
Dr. Desai elaborates on the surgical techniques used in iCCA resection, emphasizing the need for an R0 resection (negative margins) to achieve the best survival outcomes. Common procedures include:

Anatomical liver resection (segmentectomy, lobectomy, or extended hepatectomy) based on tumor location
Portal vein embolization (PVE) in cases where FLR volume is inadequate, allowing hypertrophy before major hepatectomy
En bloc resection of involved structures, including major vascular resections with reconstruction when necessary
Lymphadenectomy, as per recent guidelines recommending regional lymph node dissection for accurate staging and prognostication
The Role of Adjuvant Therapy
While surgery is the primary curative modality, the risk of recurrence remains high, making adjuvant therapy an essential component of treatment. Dr. Desai reviews key clinical trials supporting adjuvant therapy, including:

The BILCAP Trial, which demonstrated improved survival with adjuvant capecitabine in resected cholangiocarcinoma
The potential role of gemcitabine-based chemotherapy in select cases
Emerging data on targeted therapies and immunotherapy, especially in patients with FGFR2 fusions or IDH1 mutations
Postoperative Surveillance and Follow-up
Dr. Desai stresses the importance of regular follow-up to detect recurrence early. Postoperative surveillance includes:

CT or MRI every 3–6 months in the first 2 years, then annually
Tumor marker monitoring (CA 19-9, CEA) to track disease progression
Lifestyle modifications and liver health optimization to prevent post-resection liver failure
The Future of iCCA Management
The management of intrahepatic bile duct cancer is evolving with advancements in systemic therapy, minimally invasive surgery, and liver transplantation for select cases. Dr. Desai highlights ongoing clinical trials exploring neoadjuvant strategies, novel chemotherapeutic agents, and personalized medicine approaches that may revolutionize treatment in the coming years.

Conclusion
This video provides valuable insights into the latest surgical and oncological strategies for managing resectable intrahepatic cholangiocarcinoma (iCCA). Whether you are a surgeon, oncologist, radiologist, or medical professional, this discussion will enhance your understanding of current best practices and future directions in iCCA management. Be sure to watch until the end for expert recommendations on optimizing patient outcomes.

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