Transplantation Versus Resection for Hilar Cholangiocarcinoma An Argument for Shifting Treatment Paradigms for Resectable Disease

• Authors: Cecelia G. Ethun, Emory University; Alexandra G. Lopez-Aguiar, Emory University; Douglas J. Anderson, Emory University; Andrew B. Adams, Emory University; Ryan C. Fields, Washington University; Maria B. Doyle, Washington University; William C. Chapman, Washington University; Bradley A. Krasnick, Washington University; Sharon M. Weber, University of Wisconsin; Joshua D. Mezrich, University of Wisconsin; Ahmed Salem, University of Wisconsin; Timothty M. Pawlik, Johns Hopkins University Hospital; George Poultsides, Stanford University; Thuy B. Tran, Stanford University; Kamran Idrees, Vanderbilt University; Chelsea A. Isom, Vanderbilt University; Robert C.G. Martin, University of Louisville; Charles R. Scoggins, University of Louisville; Kenneth Cardona, Emory University; Shishir Kumar Maithel, Emory University
• Journal Title: Annals of Surgery
• Volume: Volume 267, Number 5
• Publisher: Lippincott, Williams & Wilkins | 2018-05-01, Pages 797-805
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1097/SLA.0000000000002574
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Oncology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Surgery; Klatskin tumor; orthotopic liver transplant; perihilar cholangiocarcinoma; LIVER-TRANSPLANTATION; PERIHILAR CHOLANGIOCARCINOMA; NEOADJUVANT CHEMORADIATION; SURGICAL-TREATMENT; RISK-FACTORS; EXPERIENCE; OUTCOMES; CANCER

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.