Revisiting liver transplantation for patients with hilar cholangiocarcinoma: The mayo clinic proposal

Abstract

T wo types of tumor go under the name of cholangiocarcinoma. The first type is intrahepatic or peripheral cholangiocarcinoma, sometimes called cholangiocellular carcinoma. It is a primary tumor of the liver, occurring less frequently than the other type of primary hepatocellular cancer.The second is called bile duct, ductal, or proximal cholangiocarcinoma. When situated high in the extrahepatic biliary tract, the terms hilar cholangiocarcinoma, cholangiocarcinoma at the confluence of the bile duct, or Klatskin tumor are also used, and the position and extent of the tumor has led to a treatmentoriented classification. 1 Outcomes of treatment of the 2 types of tumor are different, and it would have avoided potential confusion to have used the term hilar cholangiocarcinoma at the outset. Clear distinctions of tumor location, type, and grade are essential to the selection of appropriate literature data for assessment of the results.In the report of de Vreede et al on neoadjuvant chemoirradiation and liver transplantation for cholangiocarcinoma, the tumors are essentially hilar carcinomas. They arise in a territory broader than that of Klatskin tumors, lying above the cystic duct in the upper part of the extrahepatic biliary tract and in the ascending parts of the right and left hepatic ducts.The prognosis for hilar cholangiocarcinoma is generally regarded as poor. The only treatment that can prolong survival is surgical, either by resection or liver transplantation.The major challenge in resection is the position of the tumor close to the hilus and the hepatic pedicle. In the past 2 decades, the number of patients who can be offered resection has been increased by extending the resection to include segments 1 and 4 and by performing right or left hepatectomy according to the principal tumor location. Lymph node curage and pancreaticoduodenectomy are also used.The results of resection are variable between series. Approximately 15% of the patients survive 5 years after surgery, although in 1 series a survival rate of 41% was noted. 2 The results of resection are also different according to type of the tumor; tumor, node, metastasis stage; and presence of tumor in the resection margins. 3 Surgery can result in cure for some patients, but this is relatively infrequent.The use of liver transplantation remains controversial. Usually it is advised to resect the tumor when it is resectable, generally the case in types I, II, and III. A type IV tumor, involving both sides of the confluence, is best resected by total hepatectomy and could be considered an indication for liver transplantation. 4 In our own series of patients with Klatskin tumors, 9 patients have undergone liver transplantation: 3 patients are alive and disease free at 3 years posttransplantation, and 4 patients died of recurrence. Septic complications arising from repeated and long-term stenting were the cause of early death in 2 other patients. In many published series of liver transplantation for malignancy, it is difficult to extract the cases of hilar chol...

Extended bile duct resection liver and transplantation in patients with hilar cholangiocarcinoma: Long-term results

“…The general interest in LT for hilar cholangiocarcinoma is again increasing, as documented by several publications on that issue within the last year. The analysis of the published studies16‐32 confirmed the strong correlation between the proportion of patients without metastasis (lymph node or distant) and patient survival (Table 4 and Fig. 4), emphasizing the fundamental importance of patient selection.…”

Chirurgische Strategie beim Karzinom der Gallenblase und der extrahepatischen Gallenwege

“…Bis zu 93% der Resektionen konnten hiermit formell kurativ abgeschlossen werden wodurch eine 5-Jahres-Überle-bensrate von 38% erreicht werden konnte [9]. Der aufwendigen Patientenselektion (maximaler Aufwand zum Ausschluss von Fernmetastasen) scheint zur Erzielung verbesserter Therapieergebnisse gerade nach Transplantation entscheidende Bedeutung zuzukommen [21]. Wegen der fortbestehend großen Organknappheit stellt die Lebertransplantation, trotz der in fortgeschrittenen Stadien im Vergleich zu weniger aggressiven Verfahren teilweise günstiger erscheinenden Ergebnisse, weiterhin nur eine Therapieoption für wenige Sonderfälle dar [21].…”

“…Der aufwendigen Patientenselektion (maximaler Aufwand zum Ausschluss von Fernmetastasen) scheint zur Erzielung verbesserter Therapieergebnisse gerade nach Transplantation entscheidende Bedeutung zuzukommen [21]. Wegen der fortbestehend großen Organknappheit stellt die Lebertransplantation, trotz der in fortgeschrittenen Stadien im Vergleich zu weniger aggressiven Verfahren teilweise günstiger erscheinenden Ergebnisse, weiterhin nur eine Therapieoption für wenige Sonderfälle dar [21]. Bei Cholangiokarzinompatienten mit assoziierter fortgeschrittener Leberzirrhose stellt die Transplantation jedenfalls den einzigen chirurgischen Ansatz dar [3].…”

Liver transplantation is not indicated for cholangiocarcinoma

“…Alternatively, some have advocated complete hepatectomy and transplantation [2]; however, liver transplantation offers no improvement in survival when compared to hepatic resection, and it taxes an already inadequate donor organ supply. Table 1 summarises the results for transplantation in patients who have CCA [3][4][5][6][7][8][9][10][11]. In series that did not emphasise highly selected early stage disease and neoadjuvant or adjuvant radiation and chemotherapy, the average 1-year, 3-year and 5-year survival rates are 43%, 30% and 10%, respectively [3][4][5][6][7].…”

“…Table 1 summarises the results for transplantation in patients who have CCA [3][4][5][6][7][8][9][10][11]. In series that did not emphasise highly selected early stage disease and neoadjuvant or adjuvant radiation and chemotherapy, the average 1-year, 3-year and 5-year survival rates are 43%, 30% and 10%, respectively [3][4][5][6][7]. In the study by Goss and colleagues [8], patients with incidental CCAs treated with transplantation had a 5-year survival rate of 83% (incidental CCAs were lesions <1 cm diameter that were discovered on pathological examination of the explanted liver).…”