Current Perspectives in Liver Transplantation for Perihilar Cholangiocarcinoma

Abstract

Cholangiocarcinoma (CCA) encompasses all malignant neoplasms arising from the epithelial cells of the biliary tree. About 40% of CCAs are perihilar, involving the bile ducts distal to the second-order biliary branches and proximal to the cystic duct implant. About two-thirds of pCCAs are considered unresectable at the time of diagnosis or exploration. When resective surgery is deemed unfeasible, liver transplantation (LT) could be an effective alternative. The overall survival rates after LT at 1 and 3 years are 91% and 81%, respectively. The overall five-year survival rate after transplantation is 73% (79% for patients with underlying PSC and 63% for de novo pCCA). Multicenter case series reported a 5-year disease-free survival rate of ~65%. However, different protocols, including neoadjuvant therapy, have been proposed. The scarcity of organ availability represents a crucial limiting factor in recommending LT preferentially in treating pCCA. Living donor transplantations and marginal cadaveric allografts have proven to be exciting options to overcome organ shortage. Management of jaundice and cholangitis is still challenging for these patients and could impact LT listing. Whether to adopt surgical resection or LT as standard-of-care in pCCA is still a matter of debate, and more prospective studies are needed.

Keywords: bile duct neoplasm; biliary tumour; cholangiocarcinoma; liver transplantation; review.

Figure 1

Graphic representation of the Bismuth–Corlette classification.

Figure 2

Blumgart T-staging system for hilar cholangiocarcinoma. T1 corresponds to a tumour involving biliary confluence with unilateral extension to second-order biliary radicles. T2 corresponds to a tumour involving biliary confluence with unilateral extension to second-order biliary radicles and ipsilateral portal vein involvement or ipsilateral hepatic atrophy. T3 corresponds to tumours involving biliary confluence with bilateral extension to second-order biliary radicles, unilateral extension to second-order biliary radicles with contralateral portal vein involvement, unilateral extension to second-order biliary radicles with contralateral hepatic lobar atrophy, or main or bilateral portal venous involvement.

Figure 3

Mayo Clinic neoadjuvant protocol. EBRT: external beam radiotherapy; BT: brachytherapy; SL: staging laparotomy; LT: a liver transplant. * with biopsies of at least common hepatic artery and distal bile duct lymph nodes.

Figure 4

Toronto neoadjuvant protocol. Hf-EBRT: hyperfractionated external beam radiotherapy; mCT: maintenance chemotherapy; SS: staging surgery (either laparotomy or laparoscopic); LT: liver transplant; BID: twice a day. * with biopsies of hepatic artery and hepatoduodenal lymph nodes.

Figure 5

University of Michigan neoadjuvant protocol. SBRT: stereotactic body radiotherapy; SS: staging surgery; LT: liver transplant; BID: twice a day. * with lymph nodes biopsies.