The choices are very small. Depending of the extension of the tumor, in some cases should be preferible observation alone and in others may be short adjuvant radiotherapy

Its have been more than 8 months after surgery and without clinical evidence of the disease. However, If the patient is in a good clinical condition, I would repeat surgery, take new frozen sections of both distal and proximal bile duct. If positive margins, i would performed hepatectomy oncludong segment I, lynfadenectomy and re hepaticojejunostomy...

I think that if residual disease is present, resection would offer the only curative option

i assume that the Adjuvant chemo is now completed. If so, I would not do anything except image. I would consider doing a baseline PET scan since post surgical changes should have resolved. If there is a mass or uptake on PET, you can consider Brachytherapy with intrabiliary radiotherapy as an option for treatment

This was MRI before the operation. It seems like Bismuth I or maybe Bismuth II.

I think we should do reintervention, extended lympadenectomy and hepatectomy.

This patient has only one chance to survival :to performe a reoperation with hepatectomy,frozen sections of proximal and distal biliary tree and extended lymphadenectomy

The issue is now that the bile duct margin is positive, the route of recurrence is not just lymphovascular and neural, but also at the anastomosis and freely into the peritoneum. For this reason, transperitoneal biopsy of cholangiocarcinomas in the Mayo Clinic protocol for liver transplantation for Klatskin's tumors contraindicate transplantation. I suspect that reoperation now will not alter the high risk of recurrence, not the eventual outcome. In any case, there is no correct answer. Good luck.

Thank you Emilio for your interesting input. However the patient came to see me after operation so it was not possible anymore to do Spyglass examination. Of course if it would be done before initial operation the Klatskin tumor would not be mistaken for benign stricture and none of this would happen.

I suggest only follow-up of Clinical signs & Symptoms to exclude any necessity for other intervention, else Observe....

Thanks Dr Vukovic and Machado. I also think that reoperation is a great idea but I understand the point of view from Dr Fung regarding the probably route of recurrence.

The last PET-CT is negative.

Please me let me know If the patient doesnt go to surgery, and have no recurrence... if so, we should stop operating klatskin, and just give them radiochemotherapy

Reoperation combined with radiotherapy would be a good election

Dear Agustin, Rodrigo and Dai. I agree with you but both oncologist and patient are reticent to go to surgery because there is no evidence of disease at the moment. I know this is an unusual situation that would not be present if he was initially treated by an HPB expert surgeon. Anyway it may occur and we dont have the correct answer, at least in the literature. Thats what this discussion with you is all about.

I think the evidence that there is disease at the present moment is the positive margin and what we know about the pathophysiology of the disease.

There is no evidence in the literature that chemotherapy may achieve a complete pathological response on this tumor

Totally agree with you both (Dai and Agustin) that patient has residual disease and chemotherapy may not be enough to achieve long-term pathological response. Patient returned and he refused surgery. I am not sure that he totally understood the implication of positive margins and incomplete resection. Anyone suppport the use or radiotherapy now?

I think that if.the patient refusses surgery that is an.absolut contraindication to do it.

Radiotherapy may produced local complications like biliary stricture, but tumor progresion will do the same for sure...

In my opinion chemotherapy is the best option to try to control disease progession.

In the case the tumor progesses and obstruct the biliar anastomosis, radiotherapy could be an option after percutaneus biliary drainage and stenting.

However i doubt this may help the patient.

Coming into this conversation late, but there are some relatively new alternatives. A significant portion of cholangiocarcinoma is responsive to PD-1/PD-1L blockade, and this can be investigated on the explanted tissue. There are trials ongoing but off-label in the US as of now. Intraductal RFA has also been shown in EU and China to significantly increase survival and ductal patency, and the catheter (Habib HPB RFA cath) is available in US and around the world. Access to the anastamosis by retrograde ERC for intraductal therapy can usually be accomplished by advanced endoscopists using a device-assisted enteroscope, colonoscope or duodenoscope, depending somewhat on the jej-jej anast orientation and length of the hepaticojejunal limb. External radiotherpy/systemic chemotherapy is the 'std' of care for positive margins, and intraductal or periductal brachytherapy has not shown a benefit over beam. Conformational intensity-modulated radiotherapy may have some benefits from narrower fields. Once obstruction occurs, this all becomes very difficult and requires biliary drainage by some route. External drainage is great for us, but painful and difficult for patients. I agree with Dr. Fung that redo surgery is unlikely to be curative once the primary tumor has been disrupted into the peritoneum, and a combination of local and field treatment will provide the longest recurrence-free survival.

Thank you Geoffrey by this nice input. I will certainly forward your suggestions to the medical oncologist in charge and see if we have these alternatives available for this patient.

Dear Marcel Autran,

I think that with positive margins at the time of 1st surgery, tumor extension into second order biliary radicles and/or into surrounding adipose tissue and/or hepatic parenchyma could have been already established at time of that surgery. Moreover, portal vein and/or hepatic artery could have been involved instead of only lymph node metastases. How about the histopathological grade? We are aware that tumor behavior could be more agressive depending on this finding. How about the tumor markers?

Although patient has come to ask you for the 2nd opinion and he has stated that he wish not to be operated on, I agree with Prof Marcel C Machado's suggestion. However, I would try to perform a laparoscopic approach to observe peritoneal implants and local invasion.

Radiotherapy is another dilemma: most of patients present biliary stricture. But, I have some patients who answer positively to the treatment.

Best wishes!