• Jimme K Wiggers, Bas Groot Koerkamp, David van Klaveren, Robert J Coelen, C Yung Nio, Peter J Allen, Marc G Besselink, Olivier R Busch, Michael I D'Angelica, Ronald P DeMatteo, T Peter Kingham, Thomas M van Gulik, and William R Jarnagin.
• Department of Surgery, Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY. Electronic address: Jim.wiggers@gmail.com.
• J. Am. Coll. Surg. 2018 Aug 1; 227 (2): 238246.e2238-246.e2.

BackgroundMany patients with resectable perihilar cholangiocarcinoma (PHC) on imaging are diagnosed intraoperatively with occult metastatic or locally advanced disease, precluding a curative-intent resection. This study aimed to develop and validate a preoperative risk score.Study DesignPatients with resectable PHC on imaging who underwent operations in 2 high-volume centers (US and Europe) between 2000 and 2015 were included. Multivariable logistic regression analysis was used to develop the risk score. Cross-validation was used to validate the score, alternating the 2 centers as "training" and "testing" datasets.ResultsOf 566 patients who underwent operations, 309 (55%) patients had a resection, and in 257 (45%) patients, a curative-intent resection was precluded due to distant metastasis (n = 151 [27%]) or locally advanced disease (n = 106 [19%]). Preoperative predictors included bilirubin >2 mg/dL, bile duct involvement on imaging, portal vein involvement on imaging (≥180 degrees), hepatic artery involvement on imaging (≥180 degrees), and suspicious lymph nodes on imaging. The new risk score (c-index 0.75 after cross-validation) provided significantly more accurate predictions than the Bismuth classification (c-index 0.62), Blumgart T-staging (c-index 0.67), and cTNM staging (c-index 0.68). The new risk score identified 4 risk groups for occult metastatic or locally advanced disease: low (14.7%), intermediate (29.5%), high (47.3%), and very high risk (81.3%). The preoperative score groups also predicted survival after operation, irrespective of intraoperative findings (p < 0.001).ConclusionsThe validated risk score can predict occult distant metastatic or locally advanced PHC based on 5 preoperatively available factors. The score can be useful in preoperative shared decision making and selection of patients in neoadjuvant clinical trials.Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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