Unresectable Hilar Cholangiocarcinoma Research Articles

Hepatic artery infusion chemotherapy with systemic capecitabine and camrelizumab for treating unresectable hilar cholangiocarcinoma: An initial investigation of efficacy and safety.

This study aimed to evaluate the efficacy and safety of sequential treatment of continuous transcatheter hepatic artery infusion chemotherapy (HAIC) with systemic capecitabine monotherapy and camrelizumab for treating unresectable hilar cholangiocarcinoma (HCCA). This study retrospectively analyzed patients with unresectable HCCA admitted to Linyi Cancer Hospital in Shandong Province from October 2019 to December 2021. All enrolled patients were treated with HAIC (mFOLFOX7) + camrelizumab for 2-6 cycles and administered systemic therapy with capecitabine and camrelizumab. The objective response rate (ORR), disease control rate (DCR), and adverse reactions of patients were assessed. The Kaplan-Meier method was used to describe overall survival (OS), and univariate and multivariate Cox regression models were utilized to analyze the influencing factors of OS. This study included 34 patients, ORR was 61.76% (21/34), and DCR was 97.06% (33/34) after two HAIC cycles. The median follow-up time was 17.5 months, with an average of 18.32 ± 8.06 months, and the median OS was 20.0 months. HAIC-related adverse reactions included mainly gastrointestinal symptoms and hematological toxicity caused by chemotherapy drugs, all of which were grades 1-2. Further, adverse events for camrelizumab treatment included fatigue, skin rash, and hypothyroidism, all of which were grade <3. Cox regression analysis revealed that the periductal infiltrating type of growth pattern indicated a worse OS, whereas more HAIC cycles (5 ~ 6) were a protective factor for OS. HAIC sequentially combined with systemic capecitabine chemotherapy and a programmed death-1 inhibitor displayed favorable effects for unresectable HCCA, with controllable adverse reactions.

Liver transplantation for unresectable Klatskin tumor: first long-term outcomes – a single center experience

Objective: to demonstrate the first long-term outcomes of treatment of unresectable hilar cholangiocarcinoma (HCCA) after combined neoadjuvant therapy followed by liver transplantation (LT). Materials and methods. From 2017 to 2023, at the Russian Research Center of Radiology and Surgical Technologies, 10 patients were included in the treatment protocol for unresectable HCCA. Combined neoadjuvant therapy included endobiliary photodynamic therapy (EPDT), regional chemotherapy (RCT) and systemic polychemotherapy (SPCT). Each modality was applied at least three times over a period of four to six months. Patients were placed on the LT waitlist when tumor marker CA19-9 reduced, there was no radiological evidence of disease progression, and there was no evidence of acute cholangitis. Before LT, the recipients underwent diagnostic laparoscopy to exclude carcinomatosis and also evaluation of regional lymph nodes with urgent morphologic examination. In the absence of extrahepatic tumor spread, LT from a deceased donor was performed according to the classical technique with paracaval and hepatoduodenal lymph node dissection, biliodigestive anastomosis using the Roux-en-Y procedure. The operation was performed in six patients. Patient age ranged from 40 to 55 years (mean, 46.3). The mean time from start of treatment to LT was 9.1 months (range 6 to 14). The mean CA19-9 level at the time of LT was 66.5 IU/mL (8 to 212). Results. After combined neoadjuvant treatment, the CA19-9 marker normalized in four patients and there was a 3–4-fold decrease in two patients. Radiological evaluation indicated stable disease in five patients, and a partial response in one. Disease progression was noted in four out of 10 patients. Currently, one of the 6 patients is alive with a follow-up of 34 months. Median (Me) overall survival is 28 months; Me overall survival after LT is 22.2 months; Me survival before progression is 27 months. During long-term follow-up of patients after LT, three patients out of six had disease progression: implantation metastasis (n = 2) at 25 and 27 months follow-up (metastasectomy was performed), carcinomatosis (n = 1) at 20 months follow-up. Conclusion. LT for unresectable Klatskin tumor is effective when combined neoadjuvant treatment is used and there is no acute cholangitis. However, the use of endobiliary manipulations (drainage change, EPDT) are risk factors for the development of implantation metastasis.

P57-5 A case report of primary unresectable hilar cholangiocarcinoma eventually causing colonic obstruction due to peritoneal dissemination after chemoradiation

P57-5 A case report of primary unresectable hilar cholangiocarcinoma eventually causing colonic obstruction due to peritoneal dissemination after chemoradiation

Neoadjuvant Therapy Regimens for Hilar Cholangiocarcinoma Before Liver Transplant.

Patients with unresectable hilar cholangiocarcinoma (hCCA) may be eligible for curative treatment through liver transplantation (LT). Neoadjuvant protocols often include radiotherapy (RT), however, there is no standard RT approach. The purpose of this study is to characterize practice patterns of RT use before transplantation for hCCA. A survey was administered to radiation oncologists practicing at LT centers identified through the U.S. Organ Procurement and Transplant Network and the International Cholangiocarcinoma Research Network. The survey consisted of 13 questions regarding RT details as well as approaches to systemic therapy. For cross-regimen comparison, the cumulative RT tumor dose was standardized using the EQD2 method. Twenty-three centers utilizing neoadjuvant therapy for hCCA were identified. Most respondents (96%) use both chemotherapy and RT as part of their protocol. Elective nodal volumes commonly included the portal vein lymph nodes (91%) and celiac artery lymph nodes (70%). After an initial 45 Gy plan, a wide range of sequential boost regimens was used. The median cumulative dose including boosts to the gross disease was 58 Gy (EQD2) with a wide range of 40 to 110 Gy. Five (22%) include brachytherapy as part of their treatment plan. The majority (96%) used concurrent chemotherapy with fluoropyrimidines. These results suggest significant variability of neoadjuvant RT use for hCCA before LT. A wide range of doses and fractionation schemes are utilized with cumulative doses ranging from 40 to 110 Gy (EQD2). A further study evaluating the efficacy and toxicity of these various approaches is warranted to better inform best practices.

Excerpt from the 2022 American Association for the Study of Liver Diseases clinical practice guideline: management of primary sclerosing cholangitis and cholangiocarcinoma

What are the new contents of the guideline since 2010?A.Patients with primary and non-primary sclerosing cholangitis (PSC) are included in these guidelines for the diagnosis and management of cholangiocarcinoma.B.Define "related stricture" as any biliary or hepatic duct stricture accompanied by the signs or symptoms of obstructive cholestasis and/or bacterial cholangitis.C.Patients who have had an inconclusive report from MRI and cholangiopancreatography should be reexamined by high-quality MRI/cholangiopancreatography for diagnostic purposes. Endoscopic retrograde cholangiopancreatography should be avoided for the diagnosis of PSC.D. Patients with PSC and unknown inflammatory bowel disease (IBD) should undergo diagnostic colonoscopic histological sampling, with follow-up examination every five years until IBD is detected.E. PSC patients with IBD should begin colon cancer monitoring at 15 years of age.F. Individual incidence rates should be interpreted with caution when using the new clinical risk tool for PSC for risk stratification.G. All patients with PSC should be considered for clinical trials; however, if ursodeoxycholic acid (13-23 mg/kg/day) is well tolerated and after 12 months of treatment, alkaline phosphatase (γ- Glutamyltransferase in children) and/or symptoms are significantly improved, it can be considered to continue to be used.H. Endoscopic retrograde cholangiopancreatography with cholangiocytology brushing and fluorescence in situ hybridization analysis should be performed on all patients suspected of having hilar or distal cholangiocarcinoma.I.Patients with PSC and recurrent cholangitis are now included in the new unified network organ sharing policy for the end-stage liver disease model standard.J. Liver transplantation is recommended after neoadjuvant therapy for patients with unresectable hilar cholangiocarcinoma with diameter < 3 cm or combined with PSC and no intrahepatic (extrahepatic) metastases.

Space-Making Particle Therapy for Unresectable Hilar Cholangiocarcinoma

Introduction: Although the primary treatment option for hilar cholangiocarcinoma (HC) has been surgical resection, most patients present with unresectable advanced tumors at the time of diagnosis. Particle therapy (PT) holds great potential for HC, even though the anatomical proximity to the gastrointestinal tract prevents delivering a radical dose to the tumor. Space-making PT (SMPT), consisting of spacer placement surgery and subsequent PT, has been developed to minimize complications and maximize the therapeutic benefit of dose escalation for HC. This study aimed to conduct a dosimetric evaluation and examine the effectiveness of SMPT for the treatment of HC. Methods: Between 2007 and 2018, 12 patients with unresectable HC treated with SMPT were enrolled. The treatment outcomes and effectiveness of spacer placement surgery were evaluated through analyses of pre- and post-surgical parameters of dose-volume histograms. Results: All patients completed the planned SMPT protocol. The median survival time was 29.6 months, and the 1- and 3-year overall survival rates were 82.5% and 45.8%, respectively. The mean V95% value (volume irradiated with 95% of the planned treatment dose) of the gross tumor volume and clinical target volume after spacer placement surgery improved to 98.5% and 96.6% from preoperative values of 85.6% and 78.1%, respectively (p = 0.0196 and p = 0.0053, respectively). Grade 3 or higher adverse events after SMPT were seen in 6 patients. Discussion/Conclusion: SMPT led to improvements in dosimetric parameters and showed good feasibility and excellent outcomes. SMPT can be a promising novel alternative for unresectable HC.

Combined treatment of unresectable hilar cholangiocarcinoma with subsequent liver transplantation

Objective: to demonstrate the experience of unresectable hilar cholangiocarcinoma treatment using neoadjuvant therapy followed by liver transplantation (LT).Materials and methods. From 2017 to 2021, six patients were included in the treatment protocol for unresectable Klatskin tumor followed by liver transplantation at Granov Russian Scientific Center for Radiology and Surgical Technology. The neoadjuvant therapy included endobiliary photodynamic therapy (PDT), as well as regional and systemic chemotherapy. Each method was used at least three times for 4 to 5 months with radiological evaluation and measurement of CA 19-9 levels. Patients were placed on the waiting list when the tumor marker reduced, or when there were no radiological signs of disease progression and there was no acute cholangitis. The recipients underwent laparoscopic abdominal revision for carcinomatosis and assessment of lymph nodes in the hepatoduodenal ligament with urgent morphological examination. Where there was no extrahepatic spread, LT was performed according to the classical technique with paracaval, para-aortic and hepatoduodenal lymphodissection, biliodigestive anastomosis by an isolated Roux loop of small intestine. The operation was performed in three patients, all of them were men aged 40 to 55 years (mean 48). The mean time from the start of treatment to transplantation was 9.3 months (range 6 to 14). Mean CA 19-9 level at the time of intervention was 81.3 IU/mL (8 to 212).Results. In three patients, CA 19-9 levels more than doubled on average over four months despite treatment. According to data from computed tomography RECIST assessment, two of the patients showed disease progression. In one patient, carcinomatosis was detected by diagnostic laparoscopy. In three patients, CA 19-9 levels decreased more than fourfold. Two of these patients were radiologically confirmed to have the disease stabilized, and one had a partial response. One patient died from sepsis three years after transplantation as a result of secondary biliary cirrhosis and biliary abscesses without signs of progression. Two patients are still alive after 6 and 21 months without signs of tumor progression.Conclusion. LT for unresectable Klatskin tumor is effective in controlling the bioactivity of the tumor through the use of neoadjuvant therapy

Non-surgical treatment of hilar cholangiocarcinoma.

Cancer of the biliary confluence also known as hilar cholangiocarcinoma (HC) or Klatskin tumor, is a rare type of neoplastic disease constituting approximately 40%-60% of intrahepatic malignancies, and 2% of all cancers. The prognosis is extremely poor and the majority of Klatskin tumors are deemed unresectable upon diagnosis. Most patients with unresectable bile duct cancer die within the first year after diagnosis, due to hepatic failure, and/or infectious complications secondary to biliary obstruction. Curative treatments include surgical resection and liver transplantation in highly selected patients. Nevertheless, very few patients are eligible for surgery or transplant at the time of diagnosis. For patients with unresectable HC, radiotherapy, chemotherapy, photodynamic therapy, and liver-directed minimally invasive procedures such as percutaneous image-guided ablation and intra-arterial chemoembolization are recommended treatment options. This review focuses on currently available treatment options for unresectable HC and discusses future perspectives that could optimize outcomes.

Neoadjuvant Therapy Regimens for Hilar Cholangiocarcinoma Before Liver Transplant

Patients with unresectable hilar cholangiocarcinoma (hCCA) may be eligible for curative treatment through liver transplantation. Neoadjuvant protocols often include radiotherapy (RT), however there is no standard approach. The purpose of this study is to characterize practice patterns of RT use prior to transplantation for hilar cholangiocarcinoma.A survey was administered to radiation oncologists practicing at liver transplantation centers identified through the U.S. Organ Procurement and Transplant Network and the International Cholangiocarcinoma Research Network. The survey was distributed via SurveyMonkey and consisted of 13 questions regarding RT details including technique, brachytherapy use, target volumes, dose/fractionation, as well as approaches to systemic therapy. The cumulative tumor dose was standardized using the EQD2 method for cross comparison of regimens RESULTS: Twenty-three unique centers utilizing neoadjuvant therapy for hCCA were identified from an initial cohort of 124 radiation oncologists contacted. Most respondents (96%) integrate both systemic and RT as part of their protocol. SBRT to the primary alone without elective nodal coverage was utilized in 3 (13%) centers while most did include elective nodal regions in the RT fields. Elective nodal volumes commonly included the portal lymph nodes (91%), celiac artery lymph nodes (70%), and hepatic artery lymph nodes (61%). In total, 18 centers report using a boost with total EQD2 outlined in Table 1. Two centers used integrated boosts to 60 or 54 Gy in 25 fractions (fx). After an initial 45 Gy plan, a wide range of sequential boost regimens are used including 9 Gy (1.5 Gy BID n = 3, 1.8 Gy daily n = 2), 20 Gy (4-5 fx N = 3), 15Gy (10 fx n = 1), 16 Gy (4 fx n = 1), 30 Gy (1.5 Gy BID n = 1). The median cumulative dose including boosts to the gross disease was 58 Gy (EQD2) with a range of 40 -110 Gy. Concurrent chemotherapy with a fluoropyrimidine was utilized in most (96%). Chemotherapy after the RT was most common (78%), including Capecitabine in 10(43%) and Gemcitabine/Cisplatin in 6(26%) centers. Neoadjuvant chemotherapy was used in two centers (9%).These results suggest significant variability of neoadjuvant RT use for unresectable hilar cholangiocarcinoma prior to transplant. A wide range of doses and fractionation schemes are utilized with cumulative doses ranging from 40 -110 Gy (EQD2). Further study evaluating the efficacy and toxicity of these various approaches is warranted to better inform best practices.

O37: SYSTEMATIC REVIEW AND PROPORTIONAL META-ANALYSIS OF SURVIVAL FOLLOWING NEOADJUVANT CHEMORADIATION AND LIVER TRANSPLANTATION IN UNRESECTABLE HILAR CHOLANGIOCARCINOMA

Abstract Introduction Despite improvements in survival for other tumour types, the prognosis of hilar cholangiocarcinoma (CC) continues to be extremely poor. Since publication of the Mayo protocol in 2000, an increasing number of case series around the world have reported excellent outcomes after neoadjuvant chemoradiation followed by liver transplantation (NCR-LT) in unresectable hilar CC. Method MEDLINE, EMBASE, Scopus and Web of Science databases were searched and data extracted from relevant studies. A proportional meta-analysis was conducted to pool 1, 3- and 5-year survival and disease recurrence rates following NCR-LT. Result Twenty studies comprising 428 patients were eligible for final analysis. The pooled 1, 3- and 5-year overall survival rates following LT without neoadjuvant therapy were 71.2% (95% CI 62.2 - 79.4), 48.0% (95% CI 35.0 - 60.9) and 31.6% (95% CI 23.1 - 40.7). These rates improved to 82.8% (95% CI 73.0 - 90.8), 65.5% (95% CI 48.7 - 80.5) and 65.1% (95% CI 55.1 - 74.5) following administration of a neoadjuvant chemoradiation protocol. The pooled recurrence rate was 51.7% (95% CI 33.8 - 69.4) in patients who did not undergo neoadjuvant treatment and 24.1% (95% CI 17.9 - 30.9) in those who did. Conclusion In unresectable hilar CC, NCR-LT confers long-term survival in selected patients able to complete neoadjuvant chemoradiation followed by transplantation. Patients with primary sclerosing cholangitis have the most favourable survival outcomes. A high disease recurrence rate is of concern when considering extending national graft allocation schemes. CC - Cholangiocarcinoma, NCR-LT - Neoadjuvant Chemoradiation &amp; Liver Transplantation Take-home message In selected patients, the treatment of unresectable hilar cholangiocarcinoma with neoadjuvant chemoradiation and liver transplantation results in 5-year overall survival rates greater than 50%. Patients with hilar cholangiocarcinoma and concomitant primary sclerosing cholangitis have the most favourable outcomes post-transplantation.

Applicability and results of liver transplant combined with neoadjuvant chemo-radiotherapy in the treatment of unresectable hilar cholangiocarcinoma

BackgroundIn 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA). AimTo analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat. MethodsObservational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found. ResultsBetween 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5–192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years. ConclusionThe suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.

Chemotherapy plus concurrent irreversible electroporation improved local tumor control in unresectable hilar cholangiocarcinoma compared with chemotherapy alone

Introduction Unresectable hilar cholangiocarcinoma (UHC) is a malignant tumor and has a poor prognosis. IRE is a novel non-thermal ablative therapy that causes cellular apoptosis via electrical impulses. To compare the curative effect for UHC, chemotherapy plus concurrent IRE and chemotherapy alone were set up. Materials and methods From July 2015 to May 2019, 47 patients with UHC were analyzed to chemotherapy + IRE group (n = 23) or chemotherapy alone group (n = 24) in this study. Treatment response was assessed with computed tomography (CT) or magnetic resonance imaging (MRI) 1 month after treatment and every 3 months thereafter. Local tumor progression (LTP), time to LTP, overall survival (OS) and procedure-related complications were compared between the two groups. Results Chemotherapy plus concurrent IRE group showed a tendency toward a decreased rate of LTP (16.7% vs. 39.5%; p = 0.039) and an increased complete response rate (52.2% vs. 12.5%; p = 0.011) compared with chemotherapy alone group. Time to LTP was significantly longer in the chemotherapy plus concurrent IRE group compared to chemotherapy alone group (11.2 months vs. 4.2 months; p = 0.001). Median OS was significantly longer in the chemotherapy plus concurrent IRE group compared to chemotherapy alone group (19.6 months vs. 10.2 months; p = 0.001). Conclusions Chemotherapy plus concurrent IRE improved local control and prolonged time to LTP and OS in patients with UHC.

Long-term results of ERCP- or PTCS-directed photodynamic therapy for unresectable hilar cholangiocarcinoma

BackgroundPhotodynamic therapy (PDT) can be performed as palliative therapy for cholangiocarcinoma, while there is currently insufficient evidence for the efficacy. The aim of this study was to explore the clinical efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP)- or percutaneous transhepatic cholangioscopy (PTCS)-directed PDT combined with stent placement for unresectable hilar cholangiocarcinoma.MethodsA retrospective analysis was conducted on 62 patients with unresectable hilar cholangiocarcinoma. Thirty patients received PDT using hematoporphyrin combined with biliary stent placement (PDT+stent group), including 22 receiving ERCP-directed PDT and 8 receiving PTCS-directed PDT. Survival time, quality of life, and postoperative adverse events were compared to 32 patients receiving biliary stent placement alone (Stent-only group).ResultsAfter 42 months of follow-up, median survival time was significantly longer in the PDT+stent group than the Stent-only group (14.2 vs. 9.8 months, P = 0.003). In the PDT+stent group, the median survival time was longer in the 6 patients with recurrence after surgical resection than the 24 patients without prior surgical resection (20.0 vs. 13.0 months, P = 0.017). The QOL total scores was significantly higher in the PDT+stent group than the Stent-only group at postoperative 6, 9, and 12 months (P<0.05). There was no significant difference in the incidence of postoperative adverse events between the two groups (24 [38.7%] vs. 20 [29.0%], P = 0.239).ConclusionERCP- or PTCS-directed PDT + stent placement can prolong the survival of patients with unresectable hilar cholangiocarcinoma, especially those with recurrence and improve quality of life without increasing adverse events.

Impact of Definitive Chemoradiation on Clinical Outcomes in Unresectable Hilar or Extrahepatic Cholangiocarcinoma: A Multi-campus, Single-institutional Experience

Impact of Definitive Chemoradiation on Clinical Outcomes in Unresectable Hilar or Extrahepatic Cholangiocarcinoma: A Multi-campus, Single-institutional Experience

Aplicabilidad y resultados del trasplante hepático combinado con quimiorradioterapia neoadyuvante en el tratamiento del colangiocarcinoma perihiliar irresecable

BackgroundIn 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA). AimTo analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat. MethodsObservational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found. ResultsBetween 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5-192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years. ConclusionThe suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.

Clinical impact of irreversible electroporation ablation for unresectable hilar cholangiocarcinoma

Irreversible electroporation (IRE) is a non-thermal ablation modality that has been shown to be safe and effective in its application to tumors that are close to risky areas. This study aims to assess the safety and efficacy of IRE for unresectable hilar cholangiocarcinoma. Nine patients from two medical centers in Asia received IRE treatment between June 2015 and July 2017. Before IRE treatment, percutaneous biliary decompressions had been performed on eight patients, and internal stenting had been performed on one patient. All patients tolerated the procedure well without high-grade complications. The ablated tumors had constant size without contrast enhancement for more than three months in eight patients and the level of CA19-9 decreased significantly in all patients. The percutaneous biliary drainage tube was removed from two patients with recanalization of the bile duct. The internal stent in one patient was removed without further stenting. The median overall survival period was 26 months, and the progression-free survival was 18 months. Bile ducts remained narrow in the majority (2/3) of the treated patients. Nevertheless, IRE ablation of unresectable hilar cholangiocarcinoma involving vital structures is a safe and feasible primary treatment for local tumor control and is effective in prolonging survival.

Selection for Liver Transplantation: Indications and Evaluation.

Purpose of ReviewLiver transplantation is an important therapeutic option for patients with life-limiting liver disease, which may present in the form of acute liver failure, end-stage chronic liver disease, primary hepatic cancers, or inborn metabolic disorders. While significant strides have been made with respect to liver transplantation outcomes, the practice is constrained by an organ supply/demand mismatch. The purpose of this review, therefore, is to review the general indications and contraindication to liver transplantation, and to provide an overview of the transplant evaluation process. These considerations ultimately shape the specific criteria for patient selection, which will continue to evolve as means are developed to expand the donor pool, improve surgical techniques, broaden indications for safe transplant, and extend the lifetime of a graft.Recent FindingsSelected patients with unresectable hilar cholangiocarcinoma may be candidates for liver transplantation. Patients over 65 years may be transplant candidates if they possess a favorable comorbidity profile. Patients at body mass index extremes (≥ 40 or < 18.5) have increased post-transplant mortality and require nutritional evaluation.SummaryLiver transplantation may be life saving for patients with acute liver failure or end-stage liver disease. It is therefore critical for healthcare providers caring for patients with liver disease to be familiar with the general indications for transplantation and to know when it is appropriate or inappropriate to refer for transplant evaluation.

Vascular resection and reconstruction in hilar cholangiocarcinoma.

The aggressive approach of vascular resection plus reconstruction in curative resection of hilar cholangiocarcinoma (HC) remains controversial. This retrospective study investigated its short- and long-term outcomes. Data of HC patients from 1989 to 2016 were reviewed. Operated patients were divided into two groups (with and without vascular resection) and compared in terms of perioperative results. Patients who had unresectable HC were also compared with patients who had been operated. Ninety patients underwent curative HC resection. They were divided into group A (without aggressive approach, n = 68) and group B (with aggressive approach, n = 22). The groups were comparable in all parameters including rates of overall and major complication and in-hospital, 30-day and 90-day mortality except that group B had more patients with more advanced disease (P = 0.008), more patients with tumour invasion of the vasculature (40.9% versus 7.4%, P = 0.001), and fewer patients with blood transfusion (27.3% versus 52.9%, P = 0.036). The groups had similar disease-free survival (group A: median, 17.9 months, 5 years, 27.4%; group B: median, 11.7 months, 5 years, 14.3%; P = 0.427) and overall survival (group A: median, 22.0 months, 5 years, 26.5%; group B: median, 26.5 months, 5 years, 14.7%; P = 0.90). Two hundred patients with unresectable HC were compared with patients who had received operation and found to have worse survival outcomes (P < 0.001). Vascular resection plus reconstruction in HC resection was feasible and safe and might improve the long-term survival of patients with advanced HC. This aggressive approach should be adopted if the expertise is available and the patient's condition allows.

Gemcitabine Plus Cisplatin Chemotherapy Prolongs the Survival in Advanced Hilar Cholangiocarcinoma: A Large Multicenter Study.

Gemcitabine plus cisplatin (GC) is recommended as first-line treatment for advanced cholangiocarcinoma. We investigated the impact of GC in patients with unresectable hilar cholangiocarcinoma (HC) based on the time taken for effective biliary drainage (EBD). We retrospectively enrolled 113 patients with unresectable HC. Thirty-nine and 74 patients received GC chemotherapy and best supportive care (BSC), respectively. EBD was defined as a reduction in total bilirubin >50% or to a value <2 mg/dL after the drainage procedure. Early EBD (eEBD) and delayed EBD (dEBD) were separated by 2 weeks. Overall survival (OS) was estimated. The GC group showed a significantly longer median OS than the BSC group (12.8 vs. 6.1 mo; P<0.001). Moreover, the eEBD group experienced a significantly longer OS than the dEBD group (8.2 vs. 4.3 mo; P<0.001). GC led to improved OS in the eEBD (12.8 vs. 6.8 mo; P=0.003) and dEBD (12.2 vs. 3.4 mo; P=0.009) groups. In multivariate analysis, dEBD (adjusted hazard ratio [aHR], 1.785; 95% confidence interval [CI], 1.183-2.691; P=0.006), BSC (aHR, 2.409; 95% CI, 1.579-3.675; P<0.001), and an ECOG status ≥2 (aHR, 3.721; 95% CI, 2.093-6.615; P<0.001) were associated with poor prognosis. In GC group, the older (70 y and above) patients did not have a higher risk of death than younger patients. GC prolongs the survival of patients with unresectable HC, even those with dEBD or elderly.

Percutaneous transhepatic cholangiography and drainage and endoscopic retrograde cholangiopancreatograph for hilar cholangiocarcinoma: which one is preferred?

both percutaneous transhepatic cholangiography and drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) with SEMS implantation have been used for unresectable hilar cholangiocarcinoma (HC) in the clinic for many years. However, which one is preferred is still unknown. to study the effects of biliary drainage of self-expanding metal stents (SEMS) implantation under PTCD or ERCP to treat HC. the clinical data of 82 patients with HC from January 2006 to January 2015 were recorded retrospectively. Patients were treated with biliary implantation of self-expanding metal stents (SEMS) under PTCD (PTCD group, 40 patients) or ERCP (ERCP group, 42 patients). Clinical data, including total bilirubin concentrations, complications and survival time were analyzed. the remission of jaundice was similar in both groups (p > 0.05). The median survival time of the ERCP group and PTCD group were 237 d and 252 d respectively, with no significant differences (p > 0.05). The biliary infection rates under ERCP and PTCD procedure were 52.4 % and 20.0 % respectively, with a significant statistical difference (p < 0.05). For those HC patients of Bismuth III/IV, the infection rates under ERCP and PTCD procedure were 58.3 % and 14.3 %, respectively (p < 0.05). both PTCD and ERCP with SEMS implantation were effective to prolong the survival time of HC patients. The biliary infection rates were higher in the ERCP group, especially for Bismuth III/IV HC patients.