Intrahepatic and Perihilar Cholangiocarcinoma: Presentation, Staging and the Case for Surgery

Intent comes first. Even in India, transplant is offered at only a handful of government centres, with growth coming mainly from the private sector. Beyond intent, a new programme needs mentorship from teams already trained in transplant so that skills transfer gradually, buy-in across radiology, anaesthesia, critical care and hepatology rather than a purely surgeon-driven effort, and infrastructure including a strong interventional radiology service, phasic CT and MRI, and an apheresis machine for ABO-incompatible transplants. Management has to be fully behind the programme, because it takes far more time and effort than routine GI or hepatobiliary surgery.

Dr. George asked to review the actual scan before a specific recommendation, but for a resectable tumour around 3 to 3.5 centimetres, his general advice was not to force a diagnosis upfront: resect with a clear margin and send the specimen for histopathology. At that size, liver function or parenchymal loss is unlikely to be a concern, so surgery can proceed before, rather than after, a biopsy.

Hepatocellular carcinomas develop on a cirrhotic liver, which is like a fertile field: removing one tumour by resection or ablation does not remove the underlying tendency of that liver to produce another. Because the diseased liver stays in place after resection or ablation, these patients carry a higher ongoing risk of new tumours. A transplant removes the whole diseased liver and replaces it with one that does not carry that risk, which is why upfront transplant can be the better option even when a tumour looks resectable.

The first check is whether the background liver is cirrhotic or, from vertical hepatitis B or C transmission, essentially normal; a normal liver allows extended resection with portal vein embolisation to grow the future remnant. On a cirrhotic background, the priority is ruling out disease outside the liver, then grading any portal vein invasion from VP1 (a segmental branch) to VP4 (the main portal vein). Patients with VP1 or VP2 involvement and no extrahepatic disease can still be offered transplant, upfront or after downstaging with TACE, sometimes combined with SBRT for a portal vein tumour thrombus, aiming for 12 weeks of stable disease.

Non-cirrhotic HCC is uncommon in Dr. George's own caseload, around 5 patients in every 100 he sees, but for exactly this group his unit is far more aggressive: extended resections, portal vein embolisation, and even ALPPS, a staged hepatectomy, are all options, because a normal liver can lose as much as 80 percent of its volume and still regenerate enough function from what remains.

Cholangiocarcinoma accounts for around 10 to 15 percent of primary liver cancers, considerably smaller than hepatocellular carcinoma.

It grows peripherally as a mass forming lesion without early symptoms and can spread through the lymph nodes. Because it is picked up later than perihilar tumours, which cause early jaundice, it carries a somewhat poorer prognosis.

R0 resection means the tumour is removed with histologically negative margins, confirmed under the microscope. Along with lymphadenectomy of the perihepatic nodes, it is the only curative approach for either intrahepatic or perihilar cholangiocarcinoma.

These peripherally placed tumours can show capsular retraction, where the liver's edge pulls inward, along with peripheral and progressive delayed enhancement on imaging.