Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma

David J Rea, Julie K Heimbach, Charles B Rosen, Michael G Haddock, Steven R Alberts, Walter K Kremers, Gregory J Gores, David M Nagorney, David J Rea, Julie K Heimbach, Charles B Rosen, Michael G Haddock, Steven R Alberts, Walter K Kremers, Gregory J Gores, David M Nagorney

Abstract

Objective: Compare survival after neoadjuvant therapy and liver transplantation with survival after resection for patients with hilar CCA.

Summary background data: We developed a protocol combining neoadjuvant radiotherapy, chemosensitization, and orthotopic liver transplantation for patients with operatively confirmed stage I and II hilar CCA in 1993. Since then, patients with unresectable CCA or CCA arising in the setting of PSC have been enrolled in the transplant protocol. Patients with tumors amenable to resection have undergone excision of the extrahepatic duct with lymphadenectomy and liver resection.

Methods: We reviewed our experience between January 1993 and August 2004 and compared patient survival between the treatment groups.

Results: Seventy-one patients entered the transplant treatment protocol and 38 underwent liver transplantation. Fifty-four patients were explored for resection. Twenty-six (48%) underwent resection, and 28 (52%) had unresectable disease. One-, 3-, and 5-year patient survival were 92%, 82%, and 82% after transplantation and 82%, 48%, and 21% after resection (P = 0.022). There were fewer recurrences in the transplant patients (13% versus 27%).

Conclusions: Liver transplantation with neoadjuvant chemoradiation achieved better survival with less recurrence than conventional resection and should be considered as an alternative to resection for patients with localized, node-negative hilar CCA.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/1357753/bin/16FF1.jpg
FIGURE 1. Patient survival from start of neoadjuvant therapy (all 71 patients in transplant protocol) or resection.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/1357753/bin/16FF2.jpg
FIGURE 2. Patient survival from operation.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/1357753/bin/16FF3.jpg
FIGURE 3. Survival after operation for patients without PSC.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/1357753/bin/16FF4.jpg
FIGURE 4. Patient survival after resection.

References

    1. Launois B, Campion JP, Brissot P, et al. Carcinoma of the hepatic hilus. surgical management and the case for resection. Ann Surg. 1979;190:151–157.
    1. Rea DJ, Munoz-Juarez M, Farnell MB, et al. Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients. Arch Surg. 2004;139:514–523; discussion 523–525.
    1. Kondo S, Hirano S, Ambo Y, et al. Forty consecutive resections of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins: results of a prospective study. Ann Surg. 2004;240:95–101.
    1. Pichlmayr R, Weimann A, Klempnauer J, et al. Surgical treatment in Proximal Bile Duct Canter. Ann Surg. 1996;224:628–638.
    1. Kosuge T, Yamamoto J, Shimada K, et al. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg. 1999;230:663–671.
    1. Iwatsuki S, Todo S, Marsh JW, et al. Treatment of hilar cholangiocarcinoma (Klatskin tumors) with hepatic resection or transplantation. J Am Coll Surg. 1998;187:358–364.
    1. Jang J, Kim S, Park D, et al. Actual long-term outcome of extrahepatic bile duct cancer after surgical resection. Ann Surg. 2005;241:77–84.
    1. Todoroki T, Kawamoto T, Koike N, et al. Radical resection of hilar bile duct carcinoma and predictors or survival. Br J Surg. 2000;87:306–313.
    1. Jarnagin W, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg. 2001;234:507–519.
    1. Washburn WK, Lewis WD, Jenkins RL. Aggressive surgical resection for cholangiocarcinoma. Arch Surg. 1995;130:270–276.
    1. Rosen CB, Nagorney DM, Wiesner RH, et al. Cholangiocarcinoma complicating primary sclerosing cholangitis. Ann Surg. 1991;213:21–25.
    1. Meyer CG, Penn I, James L. Liver transplantation for cholangiocarcinoma: results in 207 patients. Transplantation. 2000;69:1633–1637.
    1. Robles R, Figueras J, Turrion VS, et al. Spanish experience in liver transplantation for hilar and peripheral cholangiocarcinoma. Ann Surg. 2004;239:265–271.
    1. Alessiani M, Tzakis A, Todo S, et al. Assessment of 5-year experience with abdominal organ cluster transplantation. J Am Coll Surg. 1995;180:1–9.
    1. Goldstein RM, Stone M, Tillery GW, et al. Is liver transplantation indicated for cholangiocarcinoma? Am J Surg. 1993;166:768–771; discussion 771–772.
    1. Shimoda M, Farmer DG, Colquhoun SD, et al. Liver transplantation for cholangiocellular carcinoma: analysis of a single-center experience and review of the literature. Liver Transpl. 2001;7:1023–1033.
    1. Foo ML, Gunderson LL, Bender CE, et al. External radiation therapy and transcatheter iridium in the treatment of extrahepatic bile duct carcinoma. Int J Radiat Oncol Biol Phys. 1997;39:929–935.
    1. De Vreede I, Steers JL, Burch PA, et al. Prolonged disease-free survival after orthotopic liver transplantation plus adjuvant chemoirradiation for cholangiocarcinoma. Liver Transpl. 2000;6:309–316.
    1. Heimbach JK, Gores GJ, Haddock MG, et al. Liver transplantation for unresectable perihilar cholangiocarcinoma. Semin Liver Dis. 2004;24:201–207.
    1. Hassoun Z, Gores GJ, Rosen CB. Preliminary experience with liver transplantation in selected patients with unresectable hilar cholangiocarcinoma. Surg Oncol Clin N Am. 2002;11:909–921.
    1. Baron TH, Harewood GC, Rumalla A, et al. A prospective comparison of digital image and analysis and routine cytology for the identification of malignancy in biliary tract strictures. Clin Gastroenterol Hepatol. 2004;2:214–219.
    1. Kipp BR, Stadheim LM, Halling SA, et al. A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures. Am J Gastroenterol. 2004;99:1675–1681.
    1. Fleitas MG, Casanova D, Martino E, et al. Could the piggyback operation in liver transplantation be routinely used? Arch Surg. 1994;129:842–845.
    1. Jarnagin WR, Shoup M. Surgical management of cholangiocarcinoma. Sem Liver Dis. 2004;24:189–199.
    1. Jarnagin WR, Ruo L, Little SA, et al. Patterns of initial disease recurrence after resection of gallbladder carcinoma and hilar cholangiocarcinoma. Cancer. 2003;98:1689–1700.
    1. Goss JA, Shackleton CR, Farmer DG, et al. Orthotopic liver transplantation for primary sclerosing cholangitis. a 12-year single center experience. Ann Surg. 1997;225:472–481.
    1. Deschenes M, Marotta P, Marleau D, et al. Liver transplantation for incidental cholangiocarcinoma: analysis of a Canadian multicenter experience. Hepatology. 2002;36:228A.
    1. Kamada T, Saitou H, Takamura A, et al. The role of radiotherapy in the management of extrahepatic bile duct cancer: an analysis of 145 consecutive patients treated with intraluminal and/or external beam radiotherapy. Int J Rad Oncol Biol Phys. 1996;34:767–774.
    1. Heron DE, Stein DE, Eschelman DJ, et al. Cholangiocarcinoma: the impact of tumor location and treatment strategy on outcome. Am J Clin Oncol. 2003;26:422–428.
    1. Gerhards MF, van Gulik TM, Gonzalez D, et al. Results of postoperative radiotherapy for resectable hilar cholangiocarcinoma. World J Surg. 2003;27:173–179.
    1. McMasters KM, Tuttle TM, Leach SD, et al. Neoadjuvant chemoradiation for extrahepatic cholangiocarcinoma. Am J Surg. 1997;174:605–609.
    1. Neuhaus P, Jonas S, Settmacher U, et al. Surgical management of proximal bile duct cancer: extended right lobe resection increases resectability and radicality. Langenbecks Arch Surg. Jul 2003;388:194–200.
    1. Sudan D, DeRoover A, ChinnaKotla S, et al. Radiochemotherapy and transplantation allow long-term survival for non-metastatic hilar cholangiocarcinoma. Am J Transplantation. 2002;2:774–779.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever