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BackgroundThe impact of re-resection of a positive intraoperative bile duct margin on clinical outcomes for resectable hilar cholangiocarcinoma (HCCA) remains controversial. We sought to define the impact of re-resection of an initially positive frozen-section bile duct margin on outcomes of patients undergoing surgery for HCCA.MethodsPatients who underwent curative-intent resection for HCCA between 2000 and 2014 were identified at 10 hepatobiliary centers. Short- and long-term outcomes were analyzed among patients stratified by margin status.ResultsAmong 215 (83.7%) patients who underwent frozen-section evaluation of the bile duct, 80 (37.2%) patients had a positive (R1) ductal margin, 58 (72.5%) underwent re-resection, and 29 ultimately had a secondary negative margin (secondary R0). There was no difference in morbidity, 30-day mortality, and length of stay among patients who had primary R0, secondary R0, and R1 resection (all p > 0.10). Median and 5-year survival were 22.3 months and 23.3%, respectively, among patients who had a primary R0 resection compared with 18.5 months and 7.9%, respectively, for patients with an R1 resection (p = 0.08). In contrast, among patients who had a secondary R0 margin with re-resection of the bile duct margin, median and 5-year survival were 30.6 months and 44.3%, respectively, which was comparable to patients with a primary R0 margin (p = 0.804). On multivariable analysis, R1 margin resection was associated with decreased survival (R1: hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.0–1.7; p = 0.027), but secondary R0 resection was associated with comparable long-term outcomes as primary R0 resection (HR 0.9, 95% CI 0.4–2.3; p = 0.829).ConclusionsAdditional resection of a positive frozen-section ductal margin to achieve R0 resection was associated with improved long-term outcomes following curative-intent resection of HCCA.

Background Time to tumor recurrence may be associated with outcomes following resection of hepatobiliary cancers. The objective of the current study was to investigate risk factors and prognosis among patients with early versus late recurrence of hilar cholangiocarcinoma (HCCA) after curative-intent resection. Methods A total of 225 patients who underwent curative-intent resection for HCCA were identified from 10 academic centers in the USA. Data on clinicopathologic characteristics, pre-, intra-, and postoperative details and overall survival (OS) were analyzed. The slope of the curves identified by linear regression was used to categorize recurrences as early versus late. Results With a median follow-up of 18.0 months, 99 (44.0%) patients experienced a tumor recurrence. According to the slope of the curves identified by linear regression, the functions of the two straight lines were y  = −0.465 x  + 16.99 and y  = −0.12 x  + 7.16. The intercept value of the two lines was 28.5 months, and therefore, 30 months (2.5 years) was defined as the cutoff to differentiate early from late recurrence. Among 99 patients who experienced recurrence, the majority ( n  = 80, 80.8%) occurred within the first 2.5 years (early recurrence), while 19.2% of recurrences occurred beyond 2.5 years (late recurrence). Early recurrence was more likely present as distant disease (75.1% vs. 31.6%, p  = 0.001) and was associated with a worse OS (Median OS, early 21.5 vs. late 50.4 months, p  < 0.001). On multivariable analysis, poor tumor differentiation (HR 10.3, p  = 0.021), microvascular invasion (HR 3.3, p  = 0.037), perineural invasion (HR 3.9, p  = 0.029), lymph node metastases (HR 5.0, p  = 0.004), and microscopic positive margin (HR 3.5, p  = 0.046) were independent risk factors associated with early recurrence. Conclusions Early recurrence of HCCA after curative resection was common (~35.6%). Early recurrence was strongly associated with aggressive tumor characteristics, increased risk of distant metastatic recurrence and a worse long-term survival.

Background The surgical approach to treat Bismuth type I and II hilar cholangiocarcinoma (HCCA) has been a topic of debate. We sought to characterize whether bile duct resection (BDR) with or without concomitant hepatic resection (HR) was associated with R0 margin status, as well as define the impact of HR+BDR versus BDR alone on long-term survival. Methods Patients who underwent curative-intent HR+BDR for HCCA between 2000 and 2014 were identified from a multi-institutional database. Perioperative and long-term outcomes were compared among patients who underwent BDR only, BDR+left hepatic resection (LHR), and BDR+right hepatic resection (RHR) for Bismuth type I and II HCCA. Results Among 257 patients with HCCA, 61 (23.7%) patients had a Bismuth type I (n=25, 41.0%) or II (n=36, 59.0%) lesion. The incidence of R0 resection after BDR only was the same as among patients after LHR and RHR (BDR 70.0% vs. BDR+LHR 71.4% vs. BDR+RHR 76.5%, p =0.891). In contrast, severe complications were more likely after LHR and RHR than BDR only (BDR 21.4% vs. BDR+LHR 60.0% and BDR+RHR 50.0%, p =0.041). Overall (median: BDR 20.9 vs. BDR+LHR 23.2 and BDR+RHR 25.0 months, p =0.213) and recurrence-free (median: BDR 13.4 vs. BDR+LHR 15.3 and BDR+RHR 25.0, p = 0.109) survival were comparable. On multivariable analysis, while CA19-9>37.0U/ml (Ref. CA19-9≤37.0U/ml, HR 3.2, 95% CI 1.1–9.4, p =0.035) and AJCC T3-T4 disease (Ref. T1-T2, HR 4.6, 95% CI 1.5–13.7, p =0.007) were associated with long-term survival, surgical approach was not (BDR+LHR: HR 1.0, 95% CI 0.5–2.2, p =0.937; BDR+RHR: HR 0.6, 95% CI 0.3–1.3, p =0.197). Conclusion R0 resection, overall survival, and recurrence-free survival were comparable among well-selected patients who had BDR versus BDR+HR for Bismuth type I and II HCCA.

Objectives To characterize the prognostic implication of jaundice and preoperative biliary drainage on postoperative outcomes among patients with gallbladder cancer (GBC) undergoing surgical resection. Methods Patients who underwent surgical resection of GBC identified from a multicenter database between January 2000 and December 2019 were retrospectively analyzed. Data on clinical and pathological details, as well as short- and long-term overall survival (OS), were obtained and compared among patients with and without preoperative jaundice and biliary drainage. Results Among 449 patients with GBC, median and 1‐, 3‐, and 5‐year OS were 17.4 months, 63.7%, 28.4%, and 22.1%, respectively. Patients who presented with preoperative jaundice ( n  = 100, 22.3%) were more likely to have advanced disease, a lower incidence of R0 resection (29.0% vs. 69.1%, p  < 0.001), as well as a higher incidence of postoperative liver failure (4% vs. 0, p  = 0.002), and worse long-term survival versus patients without jaundice (median OS, 10.4 vs. 27.1 months, p  < 0.001). Preoperative biliary drainage was performed for the majority of jaundiced patients (77.0%) and was associated with decreased risk of postoperative liver failure (1.3% vs. 13.0%, p  = 0.041); preoperative biliary drainage failed to improve long-term survival (median OS, 10.2 months vs. 12.0 months, p  = 0.679). On multivariable analysis, R0 resection (17.5 vs. 7.6 months, p  < 0.001) and adjuvant therapy (15.6 vs. 6.6 months, p  = 0.027) were associated with improved long-term survival among jaundiced patients. Conclusions While preoperative biliary drainage of jaundiced GBC patients decreased the risk of postoperative liver failure, it did not impact long-term outcomes. Rather, preoperative jaundice was associated with a lower chance at R0 resection and worse long-term survival.

The purpose of the accumulated earnings tax is to prevent shareholders from avoiding income tax on dividends by allowing earnings and profits to accumulate within the corporate entity beyond the reasonable needs of the business instead of receiving taxable dividends. Currently, there is a split between the Ninth and Fifth Circuit Courts of Appeal over the timing of the adjustment allowed for accrued federal income taxes when determining a corporation's accumulated taxable income. Resolving this controversy over the timing of accrued taxes would greatly affect the calculation of corporate earnings ultimately subject to the penalty tax. In Metro Leasing and Development Corporation v. Commissioner, the Ninth Circuit did not allow a tax deficiency that had already been paid to be deducted in calculating accumulated taxable income, because the taxpayer continued to contest the deficiency.