• Cecilia G Ethun, Alexandra G Lopez-Aguiar, Douglas J Anderson, Andrew B Adams, Ryan C Fields, Maria B Doyle, William C Chapman, Bradley A Krasnick, Sharon M Weber, Joshua D Mezrich, Ahmed Salem, Timothy M Pawlik, George Poultsides, Thuy B Tran, Kamran Idrees, Chelsea A Isom, MartinRobert C GRCGDivision of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY., Charles R Scoggins, Perry Shen, Harveshp D Mogal, Carl Schmidt, Eliza Beal, Ioannis Hatzaras, Rivfka Shenoy, Kenneth Cardona, and Shishir K Maithel.
• Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
• Ann. Surg. 2018 May 1; 267 (5): 797805797-805.

ObjectiveTo investigate the influence of type of surgery (transplant vs resection) on overall survival (OS) in patients with hilar cholangiocarcinoma (H-CCA).BackgroundOutcomes after resection for H-CCA are poor, yet transplantation is currently only reserved for well-selected patients with unresectable disease.MethodsAll 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.ResultsOf 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).ConclusionsResection 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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