Overall survival following resection versus transplant for hilar cholangiocarcinoma: systematic review and meta-analysis

Abstract

Objective: Methods: A systematic review following PRISMA guidelines was performed searching for English articles comparing OS of resection and OLT published in the last 20 years. Nine studies providing 1, 3, and 5 year OS were identified. A meta-analysis was performed in order to compare mortality and OS. The statistical analysis was conducted using RevMan software and Random Effects Model due to heterogeneity among the studies' groups. Results: Nine studies including 200 OLT and 398 resection patients were included. Five studies demonstrated favorable 5 year OS following OLT. Meta-analysis of all studies demonstrated a trend toward improved 1, 3 and 5 year survival for OLT (78% vs 72.5%, 55.5% vs 44%, 46% vs 31%), but this did not achieve statistical significance with mortality Odds Ratios (ORs) and 95%CI of 0.93 [0.59–1.47], 0.74 [0.41–1.34], and 0.72 [0.30–1.69], respectively. Only 6/9 studies reported margin status. Of these, 271/344 (79%) patients were R0. No resection patients received neoadjuvant therapy, while all OLT patients received neoadjuvant chemotherapy and radiation in 2/9 studies. These two studies demonstrated the highest OLT 5 year OS at 59% and 82%. Importantly, 28–48% of patients started on neoadjuvant never made it to OLT. Including these patients, OS dropped to approximately 35% and 44%, respectively. Conclusion: These data do not support the use of OLT over resection for de novo resectable HCCA. Patient selection via neoadjuvant therapy may account for much of the perceived improvement in OS. Future studies should explore whether neoadjuvant therapy should be administered routinely prior to resection.