32. Liver Transplantation With Neoadjuvant Chemoradiation Is More Effective Than Resection For Hilar Cholangiocarcinoma
David J. Rea, MD*, Julie K. Heimbach, MD*, Charles B. Rosen, MD*, Gregory J. Gores, MD*, Michael G. Haddock, MD*, Steven R. Alberts, MD*, Walter K. Kremers, PhD*, David M. Nagorney, MD
Mayo Clinic College of Medicine, Rochester, MN

Objective: To compare patient survival after neoadjuvant chemoradiation followed by orthotopic liver transplantation (OLT) with major hepatic resection (MHR) for hilar cholangiocarcinoma (CCA).
Methods: Since 1993, we have treated unresectable CCA or CCA arising in primary sclerosing cholangitis (PSC) with neoadjuvant therapy and OLT. Treatment includes external beam radiotherapy with 5-FU, Iridium-192 brachytherapy, and maintenance 5-FU or capecitabine until OLT. Staging laparotomy is performed prior to OLT to exclude extrahepatic disease. We have continued to treat potentially resectable CCA with MHR. We reviewed our experience between January 1993 and August 2004.
Results: Seventy-one patients entered the transplant treatment protocol and 38 underwent OLT. Twenty-two (31%) had disease progression or lymph node metastasis at staging, and 11 were awaiting OLT. Fifty-four patients were explored for resection. Twenty-six underwent MHR and 28 (52 %) had unresectable disease.

Table 1. Patient Characteristics

	N	Age † (mean ± SD)	Gender (M:F)	PSC † (No. (%))	Positive Nodes (No. (%))	Positive Margins (No. (%))
MHR	26	62 ± 14	14:12	2 (6%)	8 (31%)	3 (12%)
OLT	38	48 ± 10	28:10	29 (76%)	0	0

Table 2. Survival & Recurrence

	N	1-Year (%)	3-Year (%)	5-Year (%)	Recurrences
MHR ‡	26	84 ± 7	48 ± 12	20 ± 12	8 (33%)
MHR -Negative Nodes & Negative Margins *	15	87 ± 9	53 ± 15	18 ± 15	4 (27%)
OLT	38	91 ± 5	87 ± 6	87 ± 6	5 (13%)

^† p<0.001 (Student’s t-test) & ^‡ p=0.002 and ^* p=0.022 vs. OLT (log-rank test)
Conclusions: Neoadjuvant therapy and liver transplantation achieved excellent survival for selected patients with hilar cholangiocarcinoma and should be considered as an alternative to resection for patients with localized, node-negative disease.

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