# Perioperative and Oncological Outcome in Patients Undergoing Curative-Intent Liver Resection for Cholangiocarcinoma in the Context of Osteopenia

## TL;DR

This study found that low bone density does not predict worse outcomes in liver cancer surgery patients, contrary to expectations.

## Contribution

The study reveals that osteopenia is not a reliable predictor of poor outcomes in cholangiocarcinoma surgery, unlike in other cancers.

## Key findings

- Osteopenia was common in patients with cholangiocarcinoma but did not correlate with higher surgical complications.
- Patients with low bone density had similar survival rates as those with normal bone density.
- Age was significantly higher in patients with osteopenia, but it did not affect clinical outcomes.

## Abstract

Cholangiocarcinoma is a rare but aggressive form of liver cancer that starts in the bile ducts. Surgery is currently the only chance for a cure, but it carries high risks, especially in older or physically weaker patients. This study explores whether measuring bone mineral density using routine CT scans before surgery could help predict who is at greater risk of complications or poor outcomes as osteopenia is often linked to aging and frailty. We studied over 202 patients who underwent surgery with curative intent and compared the outcomes between those with and without osteopenia. Surprisingly, we found that having low bone density did not lead to worse surgical outcomes or survival rates. These findings suggest that, unlike in other cancer types, osteopenia may not be a reliable prognostic factor for patients undergoing surgery for cholangiocarcinoma. Further research is needed to confirm these results.

Background: Cholangiocarcinoma (CCA) of the liver is a highly aggressive cancer that arises from malignant cells in the bile ducts. Radical surgery remains the only curative option, but major liver resection carries high perioperative risks. This study investigates the predictive value of preoperative bone mineral density (BMD), measured via CT, for perioperative complications, mortality, and long-term outcomes. Methods: The analysis included 202 patients who underwent curative-intent surgery for intrahepatic cholangiocarcinoma (iCCA; n = 97) or perihilar cholangiocarcinoma (pCCA; n = 105) between 2010 and 2019. Preoperative bone mineral density (BMD) was assessed using computed tomography segmentation at the level of the 12th thoracic vertebra. Osteopenia was defined according to established cutoffs. Results: Osteopenia was highly prevalent in both iCCA (53/97, 54%) and pCCA (54/105, 51%) subcohorts. Patients suffering from osteopenia were significantly older than those without (71.1 [62–76.6] years vs. 61.3 [52.9–69.2] years; p < 0.001). Alteration in BMD did not demonstrate a significant prognostic effect in terms of perioperative morbidity (Mann–Whitney U; comprehensive complication index—CCI: 34 [9–56] vs. 40 [21–72] p = 0.185; iCCA: p = 0.803; pCCA: p = 0.165). The median overall survival in our cohort was 19 [14–25] months. Patients with osteopenia did not exhibit a significantly different overall survival compared to those with normal bone mineral density (log-rank p = 0.234). Conclusions: In contrast to our previous observations in other oncological patient cohorts, osteopenia alone had no significant negative impact on clinical outcomes in our large European cohort of patients undergoing curative-intent surgery for CCA. To validate these findings, further prospective studies are warranted.