title: Is Liver Transplantation Appropriate for Patients with Potentially Resectable De Novo Hilar Cholangiocarcinoma?
abstract: BACKGROUND
  Liver transplantation (LTX) is curative for selected patients with hilar cholangiocarcinoma (HC) in the setting of sclerosing cholangitis. However, the outcome of LTX vs liver resection (RTX) for patients with de novo HC remains unclear.
  
  
  METHODS
  Patients with de novo HC treated by protocol LTX (n = 90) or RTX (n = 124) between 1993 and 2013 were reviewed. Based on preoperative imaging, RTX was pursued for Bismuth type III HC and LTX for unresectable Bismuth type IV.
  
  
  RESULTS
  Unadjusted analysis showed that overall survival after operation was greater for LTX than RTX (p = 0.003). One-, 3-, and 5-year overall survival rates, respectively, were 90%, 71%, and 59% for LTX and 81%, 53%, and 36% for RTX. Survival was not different between LTX and RTX after adjusting for patient age, lymph node metastases, and tumor size. After postoperative pathologic review, HC after RTX was reclassified as Bismuth-Corlette (B-C) IV, based on the necessity of multiple biliary anastomoses in 40 patients to more accurately compare treatment outcomes. Overall survival was greater after LTX than RTX (p = 0.039) for patients with Bismuth-Corlette IV HC.
  
  
  CONCLUSIONS
  Patients with clearly resectable de novo HC should be treated with resection because there is no evidence that they would fare better with LTX. Patients with locally unresectable de novo HC, meeting criteria for our protocol, should be treated with LTX. The decision to proceed with RTX or LTX for patients with borderline resectable de novo HC remains difficult, but our results suggest that patients with B-C type IV HC might be best treated with transplantation, if they are excellent transplant candidates.
authors: Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL; Division of Subspecialty General Surgery, Mayo Clinic College of Medicine, Rochester, MN.
authors: Kristopher P
authors: KP
authors: Croome
authors: Division of Transplantation Surgery and Mayo Clinic William J von Liebig Transplant Center, Mayo Clinic College of Medicine, Rochester, MN.
authors: Charles B
authors: CB
authors: Rosen
authors: Division of Transplantation Surgery and Mayo Clinic William J von Liebig Transplant Center, Mayo Clinic College of Medicine, Rochester, MN.
authors: Julie K
authors: JK
authors: Heimbach
authors: Division of Subspecialty General Surgery, Mayo Clinic College of Medicine, Rochester, MN; Division of Transplantation Surgery and Mayo Clinic William J von Liebig Transplant Center, Mayo Clinic College of Medicine, Rochester, MN. Electronic address: nagorney.david@mayo.edu.
authors: David M
authors: DM
authors: Nagorney
mesh_terms: D000328:Adult; D000368:Aged; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy; D006801:Humans; D016031:Liver Transplantation / Q000401:mortality; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D016019:Survival Analysis; D016896:Treatment Outcome