Outcomes After Liver Transplantation With Incidental Cholangiocarcinoma

Abstract

Cholangiocarcinoma (CCA) is currently a contraindication to liver transplantation (LT) in the United Kingdom (UK). Incidental CCA occurs rarely in some patients undergoing LT. We report on retrospective outcomes of patients with incidental CCA from six UK LT centres. Cases were identified from pathology records. Data regarding tumour characteristics and post-transplant survival were collected. CCA was classified by TNM staging and anatomical location. 95 patients who underwent LT between 1988–2020 were identified. Median follow-up after LT was 2.1 years (14 days-18.6 years). Most patients were male (68.4%), median age at LT was 53 (IQR 46-62), and the majority had underlying PSC (61%). Overall median survival after LT was 4.4 years. Survival differed by tumour site: 1-, 3-, and 5-year estimated survival was 82.1%, 68.7%, and 57.1%, respectively, in intrahepatic CCA (n = 40) and 58.5%, 42.6%, and 30.2% in perihilar CCA (n = 42; p = 0.06). 1-, 3-, and 5-year estimated survival was 95.8%, 86.5%, and 80.6%, respectively, in pT1 tumours (28.2% of cohort), and 65.8%, 44.7%, and 31.1%, respectively, in pT2-4 (p = 0.018). Survival after LT for recipients with incidental CCA is inferior compared to usual outcomes for LT in the United Kingdom. LT for earlier stage CCA has similar survival to LT for hepatocellular cancer, and intrahepatic CCAs have better survival compared to perihilar CCAs. These observations may support LT for CCA in selected cases.

Transplant oncology – Current indications and strategies to advance the field

“… 74 These findings were confirmed in two other retrospective multicentre follow-up studies where comparison of incidentally found “very early” vs. advanced iCCA and pT1 vs. pT2-T4 resulted in significantly different 5-year survival rates (65% vs. 45%, p = 0.02 and 80% vs. 31%, p = 0.018). 75 , 76 In line with these observations, the recently published EASL-ILCA Clinical Practice Guidelines on the management of iCCA propose the inclusion of LT as a potential treatment option for patients with very early iCCA in cirrhotic livers. 77 …”

Liver transplantation for tumor entities

“…This suggests that the definition of “early stage” could extend up to 5 cm, with tumor differentiation being a main factor associated with recurrence. In contrast, two recent retrospective analyses on national databases in the UK ( n = 40) [28 ▪ ] and USA ( n = 66) [41 ▪ ] revealed 57% vs 36% 5 year-OS rates, respectively, highlighting limitations of previous studies based on explant pathology [28 ▪ ,41 ▪ ,42–44] (Table 2). The Toronto group is conducting a prospective study on LT in cirrhotic patients with early (≤2 cm) iCCA (NCT02878473) not amenable to resection due to poor functional reserve, which will shed more light on this controversial topic.…”

“…ICCAs (10–20% of all CCAs) originate above the second-order bile ducts, while pCCA (50–60%) and dCCA (20–30%) are located proximally and distally to the insertion of the cystic duct, respectively. LT is an emerging option for selected cases of iCCA and pCCA [28 ▪ ].…”