International survey on the use of preoperative chemotherapy in the setting of multimodality management of intrahepatic cholangiocarcinoma

Background: Indication to neoadjuvant chemotherapy and resectability of intrahepatic cholangiocarcinoma (iCCA) are not clearly defined. Aim of this survey was to assess practice patterns of iCCA treatment. Methods: Data were collected from an online survey approved by the International Hepato-Pancreato-Biliary Association consisting of 33 questions. Results: Of 167 surgeons surveyed from 44 countries, 83 % work at academic centers and 74.8 % routinely discuss iCCA cases in a multidisciplinary setting. Criteria of unresectability in absence of distant metastases included: insufficient future liver remnant volume (82.0 %), inability to obtain negative margins (71.3 %), contralateral nodules (62.9 %), contact with future remaining portal pedicles (49.1 %) and hepatic veins (44.3 %), multiple unilateral/satellite nodules (31.3 %), and positive regional lymph nodes (19.8 %). The most common indications for preoperative chemotherapy were initially unresectable disease (91.6 %) and radiologically enlarged regional lymph nodes (40.1 %). When planning hepatectomy for iCCA, 74.8 % of surgeons surveyed would consider administering neoadjuvant chemotherapy to increase the likelihood of achieving R0 resection (80.0 %), shrink tumor (81.6 %), and select patients with favorable tumor biology (73.6 %). Conclusion: While expert consensus would help define unresectability for iCCA, preoperative chemotherapy is considered a suitable tool to help downstage disease and select patients with favorable tumor characteristics to increase R0 resection rates.