Reappraising Liver Transplantation for Combined Hepatocellular-cholangiocarcinoma
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Published on: March 10, 2023
Sadhana Shankar1, Ashwin Rammohan, Vasanthakumar Gunasekaran
1The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chromepet, Chennai, India.
Objective:
To determine whether liver transplantation (LT) confers durable oncologic benefit in combined hepatocellular-cholangiocarcinoma (cHCC-CCA) and to identify predictors of recurrence that may guide transplant candidacy.
Background:
cHCC-CCA is a rare primary liver malignancy with aggressive biological behavior. LT has traditionally been contraindicated due to concerns regarding recurrence. We evaluated long-term outcomes of LT versus liver resection (LR) and compared LT outcomes for cHCC-CCA with those for hepatocellular carcinoma (HCC).
Methods:
Patients with cHCC-CCA who underwent LT or LR between 2010 and 2024 were identified from a prospective database. Survival outcomes, recurrence patterns, and risk factors for recurrence were analyzed. Outcomes of LT for cHCC-CCA were additionally compared with HCC.
Results:
A total of 79 patients underwent LT (diagnosed on explant) and 32 underwent LR for cHCC-CCA. 5-year overall survival (OS) and recurrence-free survival (RFS) were superior following LT compared with LR (OS: 89.9% vs. 65.6%, P=0.007; RFS: 84.8% vs. 53.1%, P=0.001). This benefit was maintained for tumors within UCSF criteria [overall survival (88.7% LT vs. 65.6% LR, log rank P 0.014) and RFS (89.8% LT vs. 51.6% LR, P<0.001)]. Among LT recipients, OS for cHCC-CCA was comparable to HCC (89.9% vs. 86%, P=0.721). Within the LT cohort, macrovascular invasion (HR 25.01, P=0.003) and poor tumor differentiation (HR 7.29, P=0.004) independently predicted recurrence.
Conclusion:
In carefully selected patients, cHCC-CCA within UCSF criteria can achieve transplant outcomes comparable to HCC. Macrovascular invasion and poor tumor differentiation are major predictors of recurrence and may inform candidate selection for LT.