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    Resection for hilar cholangiocarcinoma

    Background

    Resections of liver may be undertaken to excise a range of lesions in the hepatobiliary system.1-4

    Hilar cholangiocarcinomas are defined anatomically as tumours located in the extrahepatic biliary tree proximal to the origin of the cystic duct, up to and including the second branches of the right and left hepatic ducts.4 Specific staging information required for these tumours should be considered.5

    Liver specimens usually require a range of special and immunohistochemical stains.

    This protocol includes liver and/or bile duct resection for hilar cholangiocarcinoma. Separate protocols are provided for intrahepatic tumours (hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastatic tumours) and transplant hepatectomy specimens.


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen.

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Photograph the intact specimen.

    Describe the following features of the specimen:

    Procedure

    ​Record as stated by the clinician.

    • Partial hepatectomy
    • Perihilar (hilar) and hepatic resection
    • Segmental bile duct resection

    Specimen integrity

    • Intact
    • Opened

    Anatomical components included (more than one may apply) and dimensions (mm)

    Describe and measure the anatomical components present.

    Record three dimensions of:

    • Liver (antero-posterior x medio-lateral x supero-inferior)
    • Gallbladder see also gallbladder protocol

    Record length x diameter of:

    • Common bile duct
    • Right hepatic duct
    • Left hepatic duct
    • Common hepatic duct
    • Cystic duct

    Specimen weight (g)

    • Record

    Liver capsule

    • Normal
    • Abnormal
      • Breached by tumour
      • Evidence of previous biopsy or surgery, e.g. scar or sutures
      • Nodular

    Dissection

    Paint the relevant surgical margin(s) with ink and record the colours applied:

    • Biliary resection margins; proximal (if applicable) and distal
    • Liver parenchymal resection margin (if applicable)

    Two methods of dissection are possible:1

    1. Serial section the common bile duct from the pancreatic aspect including common hepatic duct with right and left hepatic duct and shave margins of all duct margins.
    2. Open the ducts longitudinally, describe the tumour (as below) before serial sectioning as in method 1.

    Internal Inspection

    Describe the cut surface appearance including the following items:

    Tumour

    • Absent
    • Present
      • Number; if more than one tumour, designate and describe each tumour separately

    Tumour site

    • Describe

    Check carefully for the presence of tumour at the circumferential surface of the tissue surrounding the biliary tree (peritoneal surface right and anteriorly; surgical plane left and posteriorly). 1,5

    Tumour size (mm)

    • Maximum dimension
    • Other dimensions

    Tumour description

    • Extent of invasion into the biliary tree
    • Depth of invasion beyond the biliary tree
    • Involvement of liver (if present)
    • Distance from closest resection margin (mm) including hepatic resection margin (if applicable)

    Macroscopic involvement of vessels

    • No
    • Yes, specify vessel if possible

    Vascular invasion is an important prognostic factor.6,7

    Background parenchyma

    • Normal
    • Abnormal, describe

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of grossly identified lymph nodes submitted
    • Maximum diameter of each (mm)

    Lymph nodes are not commonly included in liver resection specimens except for the cystic lymph node.


    Processing

    Dissect the specimen further and submit sections for processing as provided in the following block key.1,8

    Submit all lymph nodes and identify the site of each.

    Record details of each cassette.

    An illustrated block key similar to the one below may be useful.

    Block allocation key

    Cassette id
    Site
    No. of pieces
    A
    Distal margin of the biliary tree
     
    B
    Proximal margin left hepatic duct (if segmental resection)
     
    C
    Proximal margin right hepatic duct (if segmental resection)
     
    D
    Cystic duct margin if present
     
    E
    Left/right portal veins and or hepatic artery margins should be sampled if included
     
    F-H
    Serial sections along common bile duct from pancreatic to hepatic aspect
     
    I-K
    Serial sections along common hepatic duct from pancreatic to hepatic aspect
     
    L-M
    Left hepatic serial sections from bifurcation proximally
     
    N-O
    Right hepatic serial sections from bifurcation proximally
     
     

    Acknowledgements

    A/Prof Bastiaan de Boer for his contribution in reviewing and editing this protocol.


    References

    1. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    2. Goodman ZD, Terracciano LM and Wee A. Tumours and tumour-like lesions of the liver. In: MacSween’s Pathology of the Liver, Burt AD, Portmann BC and Ferrell LD (eds), Churchill Livingstone Elsevier, 2012;761–852.
    3. Ishak KG, Goodman ZD and Stocker JT. Atlas of Tumour Pathology. Tumours of the Liver and Intrahepatic Bile Ducts. 3rd series, Fascicle 31. Armed Forces Institute of Pathology, Washington, 2001.
    4. Deoliveira ML, Schulick RD, Nimura Y, Rosen C, Gores G, Neuhaus P and Clavien PA. New staging system and a registry for perihilar cholangiocarcinoma. Hepatology 2011;53(4):1363-1371.
    5. John AR, Khan S, Mirza DF, Mayer AD, Buckels JA and Bramhall SR. Multivariate and univariate analysis of prognostic factors following resection in HCC: the Birmingham experience. Dig Surg 2006;23(1-2):103-109.
    6. Shah SA, Tan JC, McGilvray ID, Cattral MS, Cleary SP, Levy GA, Greig PD and Grant DR. Accuracy of staging as a predictor for recurrence after liver transplantation for hepatocellular carcinoma. Transplantation 2006;81(12):1633-1639.
    7. Sakamoto E, Nimura Y, Hayakawa N, Kamiya J, Kondo S, Nagino M, Kanai M, Miyachi M and Uesaka K. The pattern of infiltration at the proximal border of hilar bile duct carcinoma: a histologic analysis of 62 resected cases. Ann Surg 1998;227(3):405-411.

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    22-Mar-2019
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