Absolutely unresectable:
(1) lymph node involvement outside of the hepatic pedicle
(2) intraperitoneal tumor spread
(3) distant metastases
Patient conditions that may be relative contraindications to surgery:
(1) medically unfit for surgery
(2) cirrhosis or portal hypertension (may be a candidate for liver transplantation)
Unresectable but amenable to liver transplant:
(1) involvement of the main trunk of the portal vein or hepatic artery (proximal to bifurcation)
(2) bilateral tumor extension along intrahepatic ducts to secondary hepatic ducts
(3) parenchymal spread within 2 lobes of the liver
(4) secondary to primary sclerosing cholangitis
(5) atrophy of one lobe with encasement of the contralateral portal vein branch
(6) atrophy of one lobe with involvement of the contralateral secondary biliary radicles
where:
• While a cholangiocarcinoma related to primary sclerosing cholangitis may be resectable, the results following resection are poor (De Groen et al).
• Nagino and Nimura use metastases to N2 lymph nodes as the criteria for unresectability. N2 lymph nodes are: peripancreatic, periduodenal, periportal, celiac, superior mesenteric, posterior pancreatoduodenal
