Analysis of Liver Resection Versus Liver Transplantation on Outcome of Small Intrahepatic Cholangiocarcinoma and Combined Hepatocellular‐Cholangiocarcinoma in the Setting of Cirrhosis

Abstract

Background The role of liver transplantation (LT) for small intrahepatic cholangiocarcinoma (iCCA) or combined hepatocellular‐cholangiocarcinoma (cHCC‐CCA) in patients with cirrhosis, is controversial. Objective The aim of this multicenter study was to compare the outcomes of transplanted cirrhotic patients with iCCA or cHCC‐CCA found incidentally in the native liver, versus those of patients with the same tumors undergoing liver resection (LR). Methods Patients with histologically confirmed iCCA/cHCC‐CCA ≤5 cm in the setting of cirrhosis who underwent LR or LT in three tertiary centers between 2002 and July 2015 were analyzed retrospectively. Results Forty‐nine LT patients (65%) were compared to twenty‐six LR patients (35%). Tumor recurrence was significantly lower among LT patients (18% vs 46%; p=0.01), Independent predictive factors for tumor recurrence were the median diameter of the largest nodule (HR 1.07 [95%Cl 1.02‐1.12]; p=0.006) and tumor differentiation (HR 3.74 [95%CI 1.71‐8.17]; p=0.001). Five‐year recurrence‐free survival (RFS) was significantly higher in the LT group (75% vs 36%; p=0.004). In the subgroup of patients with tumors larger than 2 cm but less than 5 cm, the recurrence rate was lower in the LT group (21% vs 48%; p=0.06). Independent risk factors for recurrence were: LT (protective) (HR 0.23 [95%CI 0.07‐0.82]; p=0.02), the median diameter of the largest nodule (HR 1.097 [95%CI 1.02‐1.73]; p=0.007) and tumor differentiation (HR 4.16 [95%CI 1.37‐12.66]; p=0.01). Five‐year RFS was higher in LT patients (74% vs 40%; p=0.06). In the LT group, 5‐year survival reached 69% and 65% (p=0.40) in patients with tumors ≤2 cm and >2‐5 cm, while survival was also comparable between iCCA and cHCC‐CCA patients (p=0.29). Conclusions LT may offer a curative strategy for highly selected patients with unresectable iCCA/cHCC‐CCA in the setting of cirrhosis and tumors smaller than 5 cm. Efforts should be made to evaluate tumor differentiation, and these results need to be confirmed prospectively in a larger population.