Cecilia G Ethun1, Alexandra G Lopez-Aguiar1, Douglas J Anderson2, Andrew B Adams2, Ryan C Fields3, Maria B Doyle4, William C Chapman4, Bradley A Krasnick3, Sharon M Weber5, Joshua D Mezrich6, Ahmed Salem5, Timothy M Pawlik7, George Poultsides8, Thuy B Tran8, Kamran Idrees9, Chelsea A Isom9, Robert C G Martin10, Charles R Scoggins10, Perry Shen11, Harveshp D Mogal11, Carl Schmidt12, Eliza Beal12, Ioannis Hatzaras13, Rivfka Shenoy13, Kenneth Cardona1, Shishir K Maithel1. 1. Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA. 2. Division of Transplantation, Department of Surgery, Emory University, Atlanta, GA. 3. Department of Surgery, Section of Hepatobiliary, Pancreatic and Gastrointestinal Surgery, Washington University School of Medicine, St Louis, MO. 4. Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO. 5. Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. 6. Division of Transplant, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. 7. Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD. 8. Department of Surgery, Stanford University Medical Center, Stanford, CA. 9. Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN. 10. Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY. 11. Department of Surgery, Wake Forest University, Winston-Salem, NC. 12. Division of Surgical Oncology, The Ohio State University, Columbus, OH. 13. Department of Surgery, New York University, New York, NY.
Abstract
OBJECTIVE: To investigate the influence of type of surgery (transplant vs resection) on overall survival (OS) in patients with hilar cholangiocarcinoma (H-CCA). BACKGROUND: Outcomes after resection for H-CCA are poor, yet transplantation is currently only reserved for well-selected patients with unresectable disease. METHODS: All patients with H-CCA who underwent resection from 2000 to 2015 at 10 institutions were included. Three institutions additionally had active H-CCA transplant protocols with similar selection criteria over similar time periods. RESULTS: Of 304 patients with suspected H-CCA, 234 underwent attempted resection and 70 were enrolled in a transplant protocol. Excluding incomplete/R2 resections (n = 43), patients who were enrolled, but did not undergo transplant (n = 24), and transplants without confirmed H-CCA diagnoses (n = 5), 191 patients underwent curative-intent resection and 41 curative-intent transplant. Compared with resection, transplant patients were younger (52 vs 65 years; P < 0.001), and more frequently had primary sclerosing cholangitis (PSC; 61% vs 2%; P < 0.001) and received chemotherapy and/or radiation (98% vs 57%; P < 0.001). Groups were otherwise similar in demographics and comorbidities. Patients who underwent transplant for confirmed H-CCA diagnosis had improved OS compared with resection (3-year: 72% vs 33%; 5-year: 64% vs 18%; P < 0.001). Among patients who underwent resection for tumors <3 cm with lymph-node negative disease, and excluding PSC patients, transplant was still associated with improved OS (3-year: 54% vs 44%; 5-year: 54% vs 29%; P = 0.03). Transplant remained associated with improved survival on intention-to-treat analysis, even after accounting for tumor size, lymph node status, and PSC (P = 0.049). CONCLUSIONS: Resection for hilar cholangiocarcinoma that meets criteria for transplantation (<3 cm, lymph-node negative disease) is associated with substantially decreased survival compared to transplant for the same criteria with unresectable disease. Prospective trials are needed and justified.
OBJECTIVE: To investigate the influence of type of surgery (transplant vs resection) on overall survival (OS) in patients with hilar cholangiocarcinoma (H-CCA). BACKGROUND: Outcomes after resection for H-CCA are poor, yet transplantation is currently only reserved for well-selected patients with unresectable disease. METHODS: All patients with H-CCA who underwent resection from 2000 to 2015 at 10 institutions were included. Three institutions additionally had active H-CCA transplant protocols with similar selection criteria over similar time periods. RESULTS: Of 304 patients with suspected H-CCA, 234 underwent attempted resection and 70 were enrolled in a transplant protocol. Excluding incomplete/R2 resections (n = 43), patients who were enrolled, but did not undergo transplant (n = 24), and transplants without confirmed H-CCA diagnoses (n = 5), 191 patients underwent curative-intent resection and 41 curative-intent transplant. Compared with resection, transplant patients were younger (52 vs 65 years; P < 0.001), and more frequently had primary sclerosing cholangitis (PSC; 61% vs 2%; P < 0.001) and received chemotherapy and/or radiation (98% vs 57%; P < 0.001). Groups were otherwise similar in demographics and comorbidities. Patients who underwent transplant for confirmed H-CCA diagnosis had improved OS compared with resection (3-year: 72% vs 33%; 5-year: 64% vs 18%; P < 0.001). Among patients who underwent resection for tumors <3 cm with lymph-node negative disease, and excluding PSCpatients, transplant was still associated with improved OS (3-year: 54% vs 44%; 5-year: 54% vs 29%; P = 0.03). Transplant remained associated with improved survival on intention-to-treat analysis, even after accounting for tumor size, lymph node status, and PSC (P = 0.049). CONCLUSIONS: Resection for hilar cholangiocarcinoma that meets criteria for transplantation (<3 cm, lymph-node negative disease) is associated with substantially decreased survival compared to transplant for the same criteria with unresectable disease. Prospective trials are needed and justified.
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