Hilar Cholangiocarcinoma: Resection or Transplantation?

Abstract

This is a review of the current status of surgical resection and liver transplantation in the treatment of hilar cholangiocarcinoma (CCA). For patients with hilar CCA and underlying parenchymal disease, specifically those with primary sclerosing cholangitis, liver transplantation is generally favored as there is risk of hepatic insufficiency and multicentric disease with extended resection. For de novo patients with no underlying liver disease, the decision between resection and transplantation proves to be more difficult. Results have shown that when margin- and node-negative resections are achieved, survival outcomes between patients undergoing resection and liver transplantation are comparable, though at baseline the patients selected for transplant were unresectable and, thus, had no other curative option and potentially more advanced disease than those selected for resection. Difficulty lies, however, in accurately predicting which patients are resectable as commitment to surgical resection precludes liver transplantation and vice versa. Recent work has focused on improving surgical resection outcomes as liver transplantation continues to be limited by the extreme organ shortage. Hilar lesions previously considered unresectable as a result of vascular involvement are now being resected using en bloc surgical techniques with vascular reconstruction. Additionally, the application of portal vein embolization to CCA has allowed for safer extended hepatic resections in a select group of patients. At present, surgical resection and liver transplantation remain as the only potentially curative treatment options for perihilar CCA. The presence of underlying parenchymal liver disease, ability to obtain margin- and node-negative resection, and overall candidacy for transplantation should guide decision making.