Transplantation Versus Resection for Hilar Cholangiocarcinoma: An Argument for Shifting Treatment Paradigms for Resectable Disease
Open accessAbstract
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.
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Liver transplantation is associated with better long-term outcomes than resection for hilar CCA.
“However, liver transplantation is a potentially curative treatment option and has been reported to be associated with better long-term outcomes than resection for hilar CCA.334,335”
From EASL Clinical Practice Guidelines on sclerosing cholangitis (2022) · cites this paper as [335]
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- Authors
- Ethun, C. G., Lopez-Aguiar, A. G., Anderson, D. J., Adams, A. B., Fields, R. C., Doyle, M. B., Chapman, W. C., Krasnick, B. A., Weber, S. M., Mezrich, J. D., Salem, A., Pawlik, T. M., Poultsides, G., Tran, T. B., Idrees, K., Isom, C. A., Martin, R. C. G., Scoggins, C. R., Shen, P., Mogal, H. D., Schmidt, C., Beal, E., Hatzaras, I., Shenoy, R., Cardona, K., & Maithel, S. K.
- Affiliations
- Emory University (US)
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
- Washington University in St. Louis (US)
- University of Wisconsin–Madison (US)
- Johns Hopkins University (US)
- University of Louisville (US)
- The Ohio State University (US)
- Corresponding author
- Ethun, Cecilia G.
- Pawlik, Timothy M.
- Hatzaras, Ioannis
- Shenoy, Rivfka
- Cardona, Kenneth
- Maithel, Shishir K.
- ORCID
- Ethun, Cecilia G.
- Anderson, Douglas J.
- Adams, Andrew B.
- Fields, Ryan C.
- 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.
- Shen, Perry
- Mogal, Harveshp D.
- Schmidt, Carl
- Beal, Eliza
- Shenoy, Rivfka
- Cardona, Kenneth
- Maithel, Shishir K.
- Venue
- Annals of Surgery
- Published
- 2018-05
- Volume
- 267
- Issue
- 5
- Pages
- 797-805
- ISSN
- 0003-4932 (ISSN-L)
- 1528-1140
- PMC
- PMC6002861
- OpenAlex
- W2766326448
- Cited by
- 191
- References
- 28
- Citations by year
- 2026: 10 · 2025: 25 · 2024: 25 · 2023: 22 · 2022: 21 · 2021: 27 · 2020: 30 · 2019: 20 · 2018: 9 · 2017: 1
- FWCI
- 16.80
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Annals of Surgery (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Cancer Institute (K12CA090625, T32CA009621, T32CA106183, P30CA016058, P30CA091842)
- Topics
- Health Sciences › Medicine › Surgery › Cholangiocarcinoma and Gallbladder Cancer Studies
- Health Sciences › Medicine › Surgery › Pediatric Hepatobiliary Diseases and Treatments
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Gallbladder and Bile Duct Disorders
- Keywords
- hilar cholangiocarcinoma, liver transplantation, hepatectomy, surgical resection, overall survival, primary sclerosing cholangitis, unresectable disease, lymph node status, tumor size, curative-intent surgery
- MeSH terms
- Adult, Aged, Bile Duct Neoplasms, Bile Ducts, Intrahepatic, Female, Follow-Up Studies, Hepatectomy, Humans, Male, Middle Aged, Retrospective Studies, United States, Survival Rate, Liver Transplantation, Klatskin Tumor, Patient Selection
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