touchONCOLOGY touchONCOLOGY
Gastrointestinal Cancers
Read Time: 2 mins

Liver Transplantation for Cholangiocarcinoma

Copy Link
Published Online: May 15th 2012 European Oncology & Haematology, 2012;8(3):173-8 DOI: https://doi.org/10.17925/EOH.2012.08.3.173
Authors: Armin Thelen, Christoph Benckert, Sven Jonas
Quick Links:
Abstract
Article
Article Information
Abstract:
Overview

The treatment of intra- and extrahepatic cholangiocarcinomas remains a medical challenge. Due to the poor efficacy of conventional chemotherapy, surgical treatment modalities represent the only chance of attaining long-term survival and cure. The introduction of new procedures, in particular extended liver resections – which were enabled by increasing surgical expertise and the implementation of multimodal treatment protocols – led to an increasing number of curatively treated patients and significant improvements in long-term results after curative resection. However, numerous patients are not suitable for radical resection because of local tumour growth, intrahepatic metastases, infiltration of main vascular and biliary structures or insufficient remnant liver function. In unresectable tumours, liver transplantation is a curative treatment option for many patients and represents the only chance to achieve long-term survival and cure. Yet, cholangiocarcinomas are not currently a standard indication for liver transplantation, because of the organ shortage and the resulting necessity to allocate available organs to patients with the best prognosis. In recent years, the results of liver transplantation for the different types of cholangiocarcinoma have improved following the application of new treatment protocols. The most promising long-term results were achieved in hilar cholangiocarcinoma by using neoadjuvant radiochemotherapy prior to transplantation. Long-term survival rates were not inferior to those seen in patients receiving a transplantation for benign liver diseases or early-stage hepatocellular carcinoma. The improved long-term outcomes of transplantation for intra- and extrahepatic cholangiocarcinomas have led to a renewed interest for liver transplantation as a treatment for these tumour entities.

Keywords

Hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, liver transplantation, results, indications

Article:

Over the past two decades, liver transplantation for cholangiocarcinomas has been controversial. In the early era of transplantation, intrahepatic and hilar cholangiocarcinomas were considered to be ideal indications for liver transplantation. The tumours tend to remain localised within the liver and the liver hilum, respectively, until late in the course of the disease and can often be completely removed by hepatectomy and replacement of a homograft, even if curative resection is not feasible.1,2 Therefore, liver transplantation represents a curative treatment option in patients with cholangiocarcinomas. However, despite cure obtained in a considerable proportion of patients, the long-term results of the procedure were found to be inferior to those of liver transplantation performed on patients with benign diseases or early-stage hepatocellular carcinoma.1–4 In the early 1990s, because of the upcoming organ shortage and the resulting necessity to allocate available organs to patients with the best prospects of success in the long term, cholangiocarcinomas started to be refused as an indication for liver transplantation.5,6

However, numerous patients with cholangiocarcinomas are not suitable for resection due to local tumour extension or insufficient remnant liver function (see Figure 1). In particular, patients with an underlying liver disease, such as primary sclerosing cholangitis (PSC), frequently have unresectable cholangiocarcinomas (see Figure 2). A number of these patients develop cholangiocarcinoma at a younger age, which underlines the need for a curative treatment option in tumours that are not suitable for resection.7 In this group of patients, liver transplantation remains the only chance of long-term survival and cure. Therefore, liver transplantation remains an important tool in the treatment of patients with cholangiocarcinomas.

In recent years, new treatment approaches have markedly improved patient outcomes. However, liver transplantation used in the treatment of cholangiocarcinomas remains complex and the indication needs to take into account the different biological behaviours, the availability of effective alternative treatment modalities, the current transplant allocation criteria and theindividual prognosis.

To view the full article in PDF or eBook formats, please click on the icons above.

Article Information:
Disclosure

The authors have no conflicts of interest to declare.

Correspondence

Armin Thelen, Department of Visceral, Transplantation, Vascular and Thoracic Surgery, Leipzig University, Liebigstrasse 20, 04103 Leipzig, Germany. E: armin.thelen@medizin.uni-leipzig.de

Received

2012-07-02T00:00:00

References

  1. Iwatsuki S, Gordon RD, Shaw BW Jr, Starzl TE, Role of liver transplantation in cancer therapy, Ann Surg, 1985;202:401–7.
  2. Ringe B, Wittekind C, Bechstein WO, et al., The role of liver transplantation in hepatobiliary malignancy. A retrospective analysis of 95 patients with particular regard to tumor stage and recurrence, Ann Surg, 1989;209:88–98.
  3. European Liver Transplant Registry (ELTR), Data Analysis Booklet 05/1968-12/2004, Paris: ELTR, 2004.
  4. Penn I, Hepatic transplantation for primary and metastatic cancers of the liver. Surgery, 1991;110:726–34.
  5. Bismuth H, Chiche L, Adam R, et al., Liver resection versus transplantation for hepatocellular carcinoma in cirrhotic patients, Ann Surg, 1993;218:145–51.
  6. Pichlmayr R, Weimann A, Oldhafer KJ, et al., Role of liver transplantation in the treatment of unresectable liver cancer, World J Surg, 1995;19:807–13.
  7. Razumilava N, Gores GJ, Lindor KD, Cancer surveillance in patients with primary sclerosing cholangitis, Hepatology, 2011;54:1842–52.
  8. Rosen CB, Heimbach JK, Gores GJ, Liver transplantation for cholangiocarcinoma, Transpl Int, 2010;23:692–7.
  9. Rea DJ, Heimbach JK, Rosen CB, et al., Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma, Ann Surg, 2005;242:451–8.
  10. Åberg F, Isoniemi H, Höckerstedt K, Long-term results of liver transplantation, Scand J Surg, 2011;100:14–21.
  11. Heimbach JK, Gores GJ, Nagorney DM, Rosen CB, Liver transplantation for perihilar cholangiocarcinoma after aggressive neoadjuvant therapy: a new paradigm for liver and biliary malignancies? Surgery, 2006;140:331–4.
  12. Heimbach JK, Successful liver transplantation for hilar cholangiocarcinoma, Curr Opin Gastroenterol, 2008;24:384–8.
  13. Mantel HT, Rosen CB, Heimbach JK, et al., Vascular complications after orthotopic liver transplantation after neoadjuvant therapy for hilar cholangiocarcinoma, Liver Transpl, 2007;13:1372–81.
  14. Raby N, Karani J, Thomas S, et al., Stenoses of vascular anastomoses after hepatic transplantation: treatment with balloon angioplasty, AJR Am J Roentgenol, 1991;157:167–71.
  15. Funaki B, Rosenblum JD, Leef JA, et al., Percutaneous treatment of portal venous stenosis in children and adolescents with segmental hepatic transplants: long-term results, Radiology, 2000;215:147–51.
  16. Zajko AB, Sheng R, Bron K, et al., Percutaneous transluminal angioplasty of venous anastomotic stenoses complicating liver transplantation: intermediate-term results, J Vasc Interv Radiol, 1994;5:121–6.
  17. Shibata T, Itoh K, Kubo T, et al., Percutaneous transhepatic balloon dilation of portal venous stenosis in patients with living donor liver transplantation, Radiology, 2005;235:1078–83.
  18. Kaiser GM, Sotiropoulos GC, Jauch KW, et al., Liver transplantation for hilar cholangiocarcinoma: a German survey, Transplant Proc, 2008;40:3191–3.
  19. Robles R, Figueras J, Turrión VS, et al., Spanish experience in liver transplantation for hilar and peripheral cholangiocarcinoma, Ann Surg, 2004;239:265-71.
  20. Jonas S, Benckert C, Thelen A, et al., Radical surgery for hilar cholangiocarcinoma, Eur J Surg Oncol, 2008;34:263–71.
  21. Neuhaus P, Blumhardt G, Extended bile duct resection – a new oncological approach to the treatment of central bile duct carcinomas? Description of method and early results, Langenbecks Arch Chir, 1994;379:123–8.
  22. Jonas S, Kling N, Guckelberger O, et al., Orthotopic liver transplantation after extended bile duct resection as treatment of hilar cholangiocarcinoma. First long-term results, Transpl Int, 1998;11(Suppl. 1):S206–8.
  23. Seehofer D, Thelen A, Neumann UP, et al., Extended bile duct resection and [corrected] liver and transplantation in patients with hilar cholangiocarcinoma: long-term results, Liver Transpl, 2009;15:1499–507.
  24. Patel T, Increasing incidence and mortality of primary intrahepatic cholangiocarcinoma in the United States, Hepatology, 2001;33:1353–7.
  25. Alvaro D, Bragazzi MC, Benedetti A, et al., Cholangiocarcinoma in Italy: A national survey on clinical characteristics, diagnostic modalities and treatment. Results from the “Cholangiocarcinoma” committee of the Association for the Study of Liver disease, Dig Liver Dis, 2011;43:60–5.
  26. Von Hahn T, Ciesek S, Wegener G, et al., Epidemiological trends in incidence and mortality of hepatobiliary cancers in Germany, Scand J Gastroenterol, 2011;46:1092–8.
  27. Rossi RL, Heiss FW, Beckmann CF, Braasch JW, Management of cancer of the bile duct, Surg Clin North Am, 1985;65:59–78.
  28. Jonas S, Thelen A, Benckert C, et al., Extended liver resection for intrahepatic cholangiocarcinoma: A comparison of the prognostic accuracy of the fifth and sixth editions of the TNM classification, Ann Surg, 2009;249:303–9.
  29. Endo I, Gonen M, Yopp AC, et al., Intrahepatic cholangiocarcinoma: rising frequency, improved survival, and determinants of outcome after resection, Ann Surg, 2008;248:84–96.
  30. Uenishi T, Kubo S, Yamazaki O, et al., Indications for surgical treatment of intrahepatic cholangiocarcinoma with lymph node metastases, J Hepatobiliary Pancreat Surg, 2008;15:417–22.
  31. Patel T, Medscape, Cholangiocarcinoma – controversies and challenges, Nat Rev Gastroenterol Hepatol, 2011;8:189–200.
  32. Lazaridis KN, Gores GJ, Primary sclerosing cholangitis and cholangiocarcinoma, Semin Liver Dis, 2006;26:42–51.
  33. Friman S, Cholangiocarcinoma – current treatment options, Scand J Surg, 2011;100:30–4.
  34. Starzl TE, Koep LJ, Surgical approaches for primary and metastatic liver neoplasms, including total hepatectomy with orthotopic liver transplantation, Prog Clin Cancer, 1978;7:181–93.
  35. Meyer CG, Penn I, James L, Liver transplantation for cholangiocarcinoma: results in 207 patients, Transplantation, 2000;69:1633–7.
  36. Friman S, Foss A, Isoniemi H, et al., Liver transplantation for cholangiocarcinoma: selection is essential for acceptable results, Scand J Gastroenterol, 2011;46:370–5.
  37. Sotiropoulos GC, Kaiser GM, Lang H, et al., Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience, Transplant Proc, 2008;40:3194–5.
  38. Weimann A, Varnholt H, Schlitt HJ, et al., Retrospective analysis of prognostic factors after liver resection and transplantation for cholangiocellular carcinoma, Br J Surg 2000; 87:1182–7.
  39. 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;7:1023–33.
  40. Casavilla FA, Marsh JW, Iwatsuki S, Hepatic resection and transplantation for peripheral cholangiocarcinoma, J Am Coll Surg, 1997;185:429–36.

Further Resources

Share this Article
Related Content In Gastrointestinal Cancers
  • Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72