Transplantation Versus Resection for Hilar Cholangiocarcinoma: An Argument for Shifting Treatment Paradigms for Resectable Disease. Issue 5 (May 2018)

• Record Type: Journal Article
• Authors: Ethun, Cecilia G.; Lopez-Aguiar, Alexandra G.; Anderson, Douglas J.; Adams, Andrew B.; Fields, Ryan C.; Doyle, Maria B.; Chapman, William C.; Krasnick, Bradley A.; Weber, Sharon M.; Mezrich, Joshua D.; Salem, Ahmed; Pawlik, Timothy M.; Poultsides, George; Tran, Thuy B.; Idrees, Kamran; Isom, Chelsea A.; Martin, Robert C. G.; Scoggins, Charles R.; Shen, Perry; Mogal, Harveshp D.; Schmidt, Carl; Beal, Eliza; Hatzaras, Ioannis; Shenoy, Rivfka; Cardona, Kenneth; Maithel, Shishir K.
• Is Part Of: Annals of surgery. Volume 267:Issue 5(2018:May)
• Publication Date: 2018-05
• Subjects: Klatskin tumor -- orthotopic liver transplant -- perihilar cholangiocarcinoma; Surgery -- Periodicals; 617.005
• DOI: 10.1097/SLA.0000000000002574
• Languages: English
• ISSNs: 0003-4932

Abstract

Abstract : Objective: To investigate the influence of type of surgery (transplant vs resection) on overall survival (OS) in patients with hilar cholangiocarcinoma (H-CCA). Background: Outcomes after resection for H-CCA are poor, yet transplantation is currently only reserved for well-selected patients with unresectable disease. Methods: All patients with H-CCA who underwent resection from 2000 to 2015 at 10 institutions were included. Three institutions additionally had active H-CCA transplant protocols with similar selection criteria over similar time periods. Results: Of 304 patients with suspected H-CCA, 234 underwent attempted resection and 70 were enrolled in a transplant protocol. Excluding incomplete/R2 resections (n = 43), patients who were enrolled, but did not undergo transplant (n = 24), and transplants without confirmed H-CCA diagnoses (n = 5), 191 patients underwent curative-intent resection and 41 curative-intent transplant. Compared with resection, transplant patients were younger (52 vs 65 years; P < 0.001), and more frequently had primary sclerosing cholangitis (PSC; 61% vs 2%; P < 0.001) and received chemotherapy and/or radiation (98% vs 57%; P < 0.001). Groups were otherwise similar in demographics and comorbidities. Patients who underwent transplant for confirmed H-CCA diagnosis had improved OS compared with resection (3-year: 72% vs 33%; 5-year: 64% vs 18%; P < 0.001). Among patients who underwent resection for tumors <3 cm with lymph-node negative disease, and excluding PSC patients, transplant was still associated with improved OS (3-year: 54% vs 44%; 5-year: 54% vs 29%; P = 0.03). Transplant remained associated with improved survival on intention-to-treat analysis, even after accounting for tumor size, lymph node status, and PSC ( P = 0.049). Conclusions: Resection for hilar cholangiocarcinoma that meets criteria for transplantation (<3 cm, lymph-node negative disease) is associated with substantially decreased survival compared to transplant for the same criteria with unresectable disease. Prospective trials are needed and justified.