Transplantation versus resection for hilar cholangiocarcinoma: An argument for shifting treatment paradigms for resectable disease

Cecilia G. Ethun, Alexandra G. Lopez-Aguiar, Douglas J. Anderson, Andrew B. Adams, Ryan C. Fields, Maria B. Doyle, William C. Chapman, Bradley A. Krasnick, Sharon M. Weber, Joshua D. Mezrich, Ahmed Salem, Timothy M. Pawlik, George Poultsides, Thuy B. Tran, Kamran Idrees, Chelsea A. Isom, Robert C.G. Martin, Charles R. Scoggins, Perry Shen, Harveshp D. MogalCarl Schmidt, Eliza Beal, Ioannis Hatzaras, Rivfka Shenoy, Kenneth Cardona, Shishir K. Maithel

Research output: Contribution to journalArticlepeer-review

57 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)797-805
Number of pages9
JournalAnnals of surgery
Volume267
Issue number5
DOIs
StatePublished - May 1 2018
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright:
Copyright 2019 Elsevier B.V., All rights reserved.

Keywords

  • Klatskin tumor
  • orthotopic liver transplant
  • perihilar cholangiocarcinoma

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