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This study evaluated whether biologic burden improves recurrence stratification after curative-intent resection of pCCA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using an international, multi-institutional database, patients undergoing resection without neoadjuvant therapy for non-metastatic pCCA\u00a0were identified. Literature-based borderline resectability was defined as lymph node metastasis with portal vein\/hepatic artery involvement or Bismuth type IV disease. Using a 200-U\/mL carbohydrate antigen (CA19-9) cutoff, a three-tier anatomic-biologic borderline resectable (AB-BR) grouping (low, intermediate, high) was derived. The outcome of interest was recurrence-free survival (RFS).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 239 patients (median age, 67.0\u00a0years, interquartile range [IQR], 58.0\u201374.0 years), 38.9% (\n                      <jats:italic>n<\/jats:italic>\n                      = 93) of patients\u00a0were anatomically borderline resectable (BR). The anatomy-only BR definition did not stratify RFS or overall survival (OS) (both\n                      <jats:italic>p<\/jats:italic>\n                      &gt; 0.05), whereas CA19-9 \u2265200 U\/mL stratified 2\u00a0year RFS within both resectable (55.7% vs. 32.6%) and BR (44.5% vs. 25.3%) groups (all\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.05). Four-group analysis demonstrated overlap between resectable\/high CA19-9 and BR\/low CA19-9, supporting collapsing the categories into AB-BR tiers. The 2\u00a0year RFS was 55.7, 37.8, and 25.3% in the low-, intermediate-, and high-risk AB-BR groups, respectively (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.002). The 2\u00a0year area under the curve (AUC) value was improved by AB-BR for RFS versus anatomy alone (0.612 vs 0.537). After multivariable adjustment, high-risk AB-BR remained independently associated with higher hazards of recurrence or death (adjusted hazard ratio, 1.86; 95% confidence interval, 1.15\u20133.00).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Anatomic BR alone provided limited prognostic stratification. Incorporating CA19-9 improved recurrence prediction and identified an intermediate-risk group not captured by anatomy alone, supporting biologic resectability in pCCA. The AB-BR framework may help move surgical decision-making beyond technical resectability alone toward more oncologically informed treatment selection.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1245\/s10434-026-20223-0","type":"journal-article","created":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T14:41:50Z","timestamp":1784212910000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Anatomic-Biologic Borderline Resectability Criteria Improve Recurrence Risk Stratification in Perihilar Cholangiocarcinoma"],"prefix":"10.1245","author":[{"given":"Odysseas P.","family":"Chatzipanagiotou","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jun","family":"Kawashima","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alex B.","family":"Blair","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charalampos M.","family":"Charalampous","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kizuki","family":"Yuza","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Ruzzenente","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bas","family":"Groot Koerkamp","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federico","family":"Aucejo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hugo P","family":"Marques","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Itaru","family":"Endo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nazim","family":"Bhimani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shishir K","family":"Maithel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom","family":"Hugh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7994-9870","authenticated-orcid":false,"given":"Timothy M.","family":"Pawlik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,16]]},"reference":[{"key":"20223_CR1","doi-asserted-by":"publisher","first-page":"2393","DOI":"10.1245\/s10434-021-11206-4","volume":"29","author":"R Matsuyama","year":"2022","unstructured":"Matsuyama R, Mori R, Ota Y, et al. 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