Is R1 Extended Liver Resection for Locally Advanced Intrahepatic Cholangiocarcinoma Justified? Nodal Status Not Margin Drives Prognosis

BACKGROUND AND PURPOSE: Surgery for locally advanced intrahepatic cholangiocarcinoma (LAICC) requires extended liver resections, often associated with vascular and/or biliary reconstruction. The benefits of these high-risk operations are still debated. The objective of this study was to analyze short, long-term outcomes, and futility after surgery for LAICC. METHODS: A retrospective single-center study on the 2013-2024 period was conducted. LAICC was defined as mass-forming intrahepatic tumors 5 cm or more in size with hepatic vein/IVC contact or hepatic hilum contact or both and requiring extended liver resection (five segments or more). Futility was defined as deaths within 90 days or recurrence within 6 months of surgery. RESULTS: 39 consecutive patients were analyzed, including (29) 74% women with a median age of 66 years (38-83 years). In 34 (88%) patients, a trisectionectomy (H145678 or H123458) was performed. Major vascular or biliary recontruction was required in 43.5% and 67%, respectively. Overall morbidity was 56%, with severe morbidity occurring in 8 (20%). The 90-day mortality was 5%. Median overall survival and recurrence-free survival was estimated at 58 and 23 months, respectively. Overall rate of futility was 15.4%. N+ has been shown to be the main factor affecting survival (p = 0.03 for overall survival and p = 0.01 for recurrence-free survival). R1 resection had no impact of overall or recurrence-free survival. CONCLUSIONS: Our study supports an aggressive surgical approach for LAICC. Anticipated R1 resection by necessity should not be considered a contraindication to surgery.