Lecture : Liver resection for Klatskin Tumor is complicated by the proximity of the tumor to the vessels of the liver hilus, particularly the right hepatic artery. Further to this, the ingrowth into the biliary tree is often difficult to define with certainty. R0 resection can result in 5-year survival rates of 20.40%. When R0 resection is not achieved, however, the 5-year survival rate drops to almost 0%. In light of these limitation, liver transplantation for N0 Klatskin Tumors represents an interesting alternative.

Liver Transplantation for unresectable hCCC

To address the unmet need of curation of unresectable hCCC, the Mayo Clinic group in Rochester initiated an LT-specific protocol intended to treat patients with unresectable h-CCA or h-CCA (tumor size <3 cm, no evidence for metastases).
Their early experience revealed an actuarial survival of 88% at 1 year and 82% at 5 years after LT. They later published similar results after expanding the number of enrolled patients to 90. After adoption by other US Centers, Darwish et al. reported the outcomes of 287 patients treated between 1993.2010. The authors highlight a 65% rate of recurrence-free survival at 5 years after LT. All in all, the collective experience indicates that LT is an effective therapy in this select group of patients since it outperforms the alternatives by far. However, the high dropout rate during neoadjuvant treatment and the high vascular complication rates following transplantation need to be considered.

Liver Transplantation for resectable hCCC

In May 2018, Ethun et al. specifically addressed this condition by mining the US Extrahepatic Biliary Malignancy Consortium database. Building on data from 10 US academic centers, they conducted a retrospective analysis of all patients with h-CCA undergoing resection and/or exploratory laparotomy between January 2010 and March 2015. The primary endpoint of the study was patient survival following curative resection vs. neoadjuvant therapy and consecutive LT in an intention-to-treat approach. Transplantation was associated with less frequent R1 resection (10% vs. 30%), and lower percentages of lymphatic and perineural invasion. Postoperative morbidity was not significantly different in regard to major complications, postoperative liver failure and 90-day mortality while transplanted patients showed a lower overall complication rate. Importantly, the recurrence free survival rate did not differ between the two groups. Results from other group and a newly published meta analysis show the same trend albeit with a lesser advantage for transplantation.

Summary and Conclusions

The obvious limitation towards expanding this treatment to a larger group of patients is the donor organ shortage. Further to this, the retrospective nature and the imperfection of the existing studies warrants more data. Ideally, a prospective controlled trial may help to eventually answer the remaining question and provide more scientific substrate for a proper allocation towards resection vs. transplantation.
Rather than shying away from this indication, the community shall feel all the more motivated to work towards increased donor rates rather than accepting the suggested inferiority of the current standard. Recent developments in organ preservation such as hypothermic or normothermic machine perfusion may help to reduce the discard rate. Furthermore, changes in allocation policies toward a patient-oriented allocation may represent a further option to serve the need of afflicted patients.

Resch T, Esser H, Cardini B, Schaefer B, Zoller H, Schneeberger S. Liver transplantation for hilar cholangiocarcinoma (h-CCA): is it the right time? Transl Gastroenterol Hepatol. 2018 Jul 4;3:38. doi: 10.21037/tgh.2018.06.06.