Are we justified in excluding combined hepatocellular-cholangiocarcinoma from transplantation?

Abstract

256 Background: Although transplantation has shown remarkable survival benefit for patients with hepatocellular carcinoma (HCC), there is limited data to support or refute the treatment of combined hepatocellular-cholangiocarcinoma (cHCC-CC) with transplantation. We hypothesized that patients with mixed histology had a lower overall survival than HCC after liver transplantation. Methods: Patients with localized HCC and cHCC-CC treated with surgical resection (SR) or transplant (TP) were identified using the Surveillance, Epidemiology, and End Results (SEER) Database (1973-2007). Survival was analyzed using the Kaplan-Meier model. Prognostic factors were examined with Cox regression analyses. Results: We identified 3378 (1447 [43%] TP and 1931 [57%] SR) patients with HCC, and 54 (19 [35%] TP and 35 [65%] SR) patients with cHCC-CC. Cohorts were similar with respect to age, gender, race, and tumor size. Median overall survival (OS) was 68 months (95% confidence interval (CI): 64-75) for HCC and 36 months (95% CI: 19-89) months for cHCC-CC (p = 0.01). Patients undergoing SR of HCC and cHCC-CC had similar 3-year OS (55% vs. 46%, p=0.4). Overall 3-year survival of patients undergoing TP was significantly longer for HCC (78%) than for cHCC-CC (48%, p=0.01). After adjusting for age at diagnosis and gender, multivariate modeling revealed an increased hazard ratio for patients undergoing TP with a mixed histology: HR 2.5 (95% CI: 1.2-5.1, p=0.01). Conclusions: Patients undergoing transplantation with localized cHCC-CC have a shorter overall survival than patients with HCC. In an era of organ shortage, this may justify excluding patients with cHCC-CC from transplantation. Our data is limited by the lack of tumor and host-specific factors, and prospective validation of this conclusion is warranted.