Liver Transplantation for Cholangiocarcinoma
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Transcript of Liver Transplantation for Cholangiocarcinoma
Is there is a place for livertransplantation in cholangiocarcinoma ?
Pr Eric Vibert
Centre Hépato-Biliaire
Hopital Paul Brousse, Villejuif, Paris
N
Survival
Recurrence
rate1 yr 3 yrs 5 yrs
Meyer 2000 IH-CC + HIL-CC 207 72% 48% 23% 51%
Shimoda 2001
EH-CC 9 86% 31% - 22%
IH-CC 16 62% 39% - 54%
Ghali 2005 Incidental 10 - 30% - 80%
Robles 2004
HIL-CC 36 82% 53% 30% 53%
IH-CC 23 77% 65% 42% 35%
Kaiser 2008 HIL-CC 47 - 31% 22% -
Rapport AFC
HIL-CC 72 78% 38% 30%
IH-CC 26 78% 44% 34% 60%
Upfront Liver Transplantation for Cholangiocarcinoma
0
,2
,4
,6
,8
1
Surv
ie C
um
.
0 1 2 3 4 5 6 7 8 9 10
Years
Graft Survival
Primary Cancers vs Non CancerMay 1968 – March 2016
Klatskin (n=358)HCC (n=22075)
CCC (n=637)84%
65%
52%
71%
37%30%
66%
30%21%CCC vs Klatskin p=0.02 CCC vs Non Cancer p<0.001
CCC vs CHC p<0.001 Klatskin vs Non Cancer p<0.001
Klatskin vs CHC p<0.00 HCC vs Non Cancer p<0.001
Non Cancer (n=87243)
75%66%
Biliary Cancer are Lymphophil
Globally 40% of operated liver cancer had lymph node invasion
Farges et al. Ann Surg 2011 Gugliemi et al. J Gastro. Surg 2013 Aoba et al. Ann Surg 2013
Bismuth Type Lymph Node Incidence
Type 1 (n=19) 21%
Type 2 (n=22) 27%
Type 3 (n=135) 41%
Type 4 (n=144) 55%
2013
Correlated with the diameterintrahepatic cholangiocarcinoma
24%
39%33%
52%
Ribeiro et al. Arch Surg 2012
Bridgewater. ILCA guidelines. J Hepatol 2014
Liver Transplantation (LT) is notrecommended for IntrahepaticCholangiocarcinoma (iCCA) orHepatocholangiocarcinoma (HCA) becauseresults are well below those published forstandard indications
Transplantation for Intra HepaticCholangiocarcinoma
Sapisochin. Am J Transpl 2014
Overall survival of patients with iCCA on native liver
Patient survivial with an iCCA≤ 2 cm « very early » versus > 2 cm
45%
71%
34%
P=0.2
Multicentric Spanish Study – 29 pts
Multicentric US Study – 32 pts including 16 iCCA and 16 HCA
Facciuto. Transplantation 2014
Overall survival
78%
32%
P=0.0457%
Disease-free survival / Milan criteria
Bridgewater. ILCA guidelines. J Hepatol 2014
Liver Transplantation (LT) is recommendedfor non resectable peri hilarcholangiocarcinoma and/or developed onsclerosing cholangitis. This assumption isbased on results of Mayo Clinic protocol
Transplantation for Peri hilarCholangiocarcinoma
11 Patients
Disease Free Survial: 45 %Mean Follow-up : 7 years !...
Transplantation for local recurrence in patient initially treated with palliative intentby external radiotherapy and curietherapy with Iridium Needle
2002
For the Scheme to Reality
Fibrotic and Infiltrative little tumor withlimits often difficult to define...
True R0 is difficult to obtain by liver surgery
Resectable Unresectable
Actual Policy in Peri Hilar CholangioK.
Extended Right Hep Extended Left Hep
RT-CT then
Liver Transplant. Palliative Chemo
Is Mayo Clinic Protocol should be used in resectable patient ?
Perihilar Cholangiocarcinoma < 3 cm and without transhepatic biliary drainage
Inclusion Criteria
• 18 to 68 year-old
• Perihilar cholangiocarcinoma inferior to 3 cm of maximal diameter in axial CT-Scan
• Resectable R0
• No pathological liver including Sclerosing Chol.
• No percutaneous drainage
2 arms : Chirurgie Vs Mayo Clinic
Exhaustive Exploration (including Laparoscopy)To exclude Intra- ou Extra Metastatic Disease
RANDOMIZATION 1:1
CapecitabineExt RT (50 grays)
LaparotomyLymph Node ?
6 Weeks
1-2 Weeks
PVE
Hepatectomy
TRANSPHIL Study : Inclusion Curve (06.09.2017)
Aim : 60 patients to have 54 randomized (27 pts x 2)
Arm RCT-LT (n=12) 9 LT
Arm Liver Res (n=13) 10 Res
Conclusion
• Upfront liver transplantation is a bad treatment of cholangiocarcinoma, excepted perhaps in unique intra-hepatic CCA < 2 cm
• Mayo Clinic Protocol had drastically changed the prognosis of non resectable peri-hilar cholangiocarcinoma, despite 25% of drop-out
• Role of Radio-Chemotherapy and transplantation in resectable peri-hilar cholangiocarcinoma will be determined by TRANSPHIL in 2021