Past
A significant proportion of patients diagnosed with intrahepatic cholangiocarcinoma (iCCA) present with localized disease but multiple hepatic lesions.1,2 While tumor multiplicity has been assessed as a contraindication to surgery,3 updated guidelines assert that resection can be considered in selected patients.4 However, the level of available evidence is low, with only limited data on outcomes after resection for multiple iCCA.4
Present
In a national population-based analysis, outcomes were assessed for all patients undergoing surgery for iCCA during the period 2010–2021.5 Patients undergoing resection for iCCA with two or three lesions had a median overall survival (OS) of 27.1 months (95% confidence interval [CI] 18.8–35.5). This outcome was dependent on selection, as patients with resection had better performance status (P = 0.007), smaller tumors (P = 0.004), and more often negative lymph nodes (P = 0.028) as compared with patients with localized multiple iCCA and nonresection.
While patients with two or three lesions achieved better outcomes with resection than after exploration (P < 0.001), patients with four or more lesions did not have better outcomes with resection (P = 0.922). When controlling for tumor number and the abovementioned selection factors in a multivariable analysis, resection was not significantly associated with OS (P = 0.090). This illustrates how long-term outcomes after resection for multiple iCCA depend on adequate selection, and that a combination with other high-risk factors such as larger size, lymph node metastasis, and poor patient condition will likely negate any benefit from surgery. Importantly, in the current cohort, most of the study period preceded the introduction of adjuvant capecitabine as standard therapy, and only less than 40% of patients received adjuvant treatment. Preoperative chemotherapy was only used for 6.5% of patients with multiple iCCA. The rate of recurrence within 6 months was 40% for patients with two or three lesions and 75% for patients with four or more lesions.
Future
While these results support consideration of resection as one option for patients with a limited number of lesions, smaller tumors, good performance status, and no clinical signs of lymph node metastasis, an elevated risk of early recurrence motivates further study of targeted and neoadjuvant systemic and locoregional oncological approaches in multiple iCCA. Future studies also need to assess whether such oncological strategies can permit resection and improve long-term outcomes for patients with a higher number of lesions or other concurrent high-risk factors.
Acknowledgement
The study was supported by grants from the Swedish Society of Medicine, the Bengt Ihre Foundation, the Royal Swedish Academy of Sciences, the Swedish Surgical Society – Swedish Association for Upper Abdominal Surgery (H.J.), and the Swedish Society for Medical Research SSMF (E.S.). The funding sources were not involved in the design or conduct of the study, the writing of the report, or the decision to submit the article for publication. The authors would like to thank Regional Cancer Center West and the Swedish quality registry for cancers of the liver and biliary tract (SweLiv) for study support.
Funding
Open access funding provided by Karolinska Institute.
Disclosure
The authors have no conflicts of interest to declare.
Footnotes
This article refers to: Jansson H, Taflin H, Björnsson B, et al. Outcomes after resection for multiple intrahepatic cholangiocarcinoma—A national population-based study. Ann Surg Oncol. 2025. (10.1245/s10434-025-18983-2).
Publisher's Note
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References
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