Page 50 - Read Online

Hewitt et al. Hepatoma Res 2021;7:75 https://dx.doi.org/10.20517/2394-5079.2021.83 Page 13 of 19

Table 2. Inclusion and exclusion criteria for liver transplantation for hilar-cholangiocarcinoma
Liver transplantation for hilar-cholangiocarcinoma
Inclusion criteria Exclusion criteria
Diagnosis of cholangiocarcinoma Uncontrolled infection
Transcatheter biopsy or brush cytology Prior radiation or chemotherapy
CA19-9 > 100 mg/mL with mass or malignant appearing stricture Prior or attempted biliary resection
Biliary ploidy by FISH with mass or malignant appearing stricture Intrahepatic metastasis
Unresectable tumor above cystic duct Extrahepatic disease
Radial tumor diameter < 3 cm History of other malignancy within 5 years
Absence of intra and extrahepatic metastasis Transperitoneal biopsy
Medically fit for transplantation

CA19-9: Carbohydrate antigen 19-9.

20% of patients may harbor occult disease . It is recommended that at least one lymph node along the
[137]
proper hepatic artery and common bile duct are excised and pathologically evaluated even if it appears
normal as nodal disease would prohibit LT . Additionally, percutaneous or endoscopic ultrasound
[145]
directed transperitoneal biopsy has been observed to cause peritoneal seeding, these interventions preclude
[145]
transplant . Indication and contraindications for LT for PCCA are outlined in Table 2 . After
[145]
neoadjuvant therapy and in highly selected patients, 5-year OS was found to be 75% and 5 year RFS of
[145]
65% .
[146]
MINIMALLY INVASIVE SURGERY
Minimally invasive surgery has been used in the treatment of multiple hepato-pancreatico-biliary
malignancies, including CCA. Over the past decade, multiple consensus statements have been written
stating that minimally invasive liver surgery is safe in the hands of experienced surgeons [147-149] . In a study
performed to evaluate laparoscopic versus open liver resection in patients with ICCA, the authors found
that the Pringle Maneuver was used less frequently, and blood loss was less in the laparoscopic group.
Additionally, there was no difference in complication rates between open and laparoscopic surgery.
Importantly, there was no difference in oncologic outcomes . Conversely, a recent retrospective study of
[150]
149 patients with PCCA who underwent laparoscopic or open resection reported that while most short-
term surgical outcomes were similar, patients who underwent open surgical resection compared with
laparoscopic resection had better OS and DFS . In another study, a review of the National Cancer
[151]
Database stratified patients by laparoscopic liver resection vs. open liver resection. In total, 2309 patients
with ICCA underwent liver resection between 2010 and 2015. During that time, laparoscopic liver resection
increased from 12% to 16% and was more common for wedge and segmental resections. However, nodal
evaluation was only performed in 58% of all patients with ICCA. The use of laparoscopic surgery was found
to exacerbate the lack of lymph node dissection, where patients who underwent laparoscopic surgery had
significantly worse nodal evaluation than patients who underwent open surgery . Recent meta-analyses
[152]
demonstrated laparoscopic surgery for ICCA is safe and may provide improved short-term outcomes with
no difference in long-term oncologic results [153,154] . Additionally, although very technically demanding even
in the open setting with high morbidity , surgeons have performed robotic resections and associated
[155]
reconstruction of PCCA . Overall, data comparing minimally invasive vs. open hepatic resection among
[156]
patients with CCA has been limited to retrospective reviews. Randomized controlled trials are needed to
clarify the role of minimally invasive surgery in this patient population. Although minimally invasive
surgery can be performed, the first priority is to perform safe surgery followed by achieving good oncologic
outcomes.