Role for Liver Transplant in Biliary Tract Cancers

Transcript:

Milind M. Javle, MD: Dr Rocha, the ultimate local therapy, liver transplant, is an accepted modality for the other liver cancer, HCC [hepatocellular carcinoma]. But I recall the original Milan criteria in NEJM [New England Journal of Medicine], which reflected on the fact that HCC used to be a contraindication for liver transplants sometime ago. There has been a sea change in cholangiocarcinoma as well. Could you comment on hilar cholangiocarcinoma and your experience there?

Flavio G. Rocha, MD, FACS, FSSO: The only disclosure is that I’m a hepatic biliary surgeon and not a transplant surgeon. I have many colleagues, and we work together as a group. But you’re right: the field of transplant oncology, at least in this space, started in HCC. It has really moved on to the cholangiocarcinoma space, mainly because what was learned over time is that some of these explant tumors had cholangiocarcinomas and not HCC. For hilar cholangiocarcinoma, what limits us surgically is the extent of resection and obtaining negative margins. Transplant takes that out of the picture.

Imagine you’re taking out the whole liver and putting in a new liver. Margins become inconsequential. However, disease biology still plays a role. This is where it’s very important to stage these patients appropriately and make sure they have no extrahepatic disease before they’re enrolled in a protocol. The 1 leading the way was the Mayo Clinic protocol. It’s a critical feature that’s important in determining the good outcomes that they’ve had. One is that you didn’t necessarily need a diagnosis of cancer. We talked about the challenge in hilar cholangiocarcinoma of getting a diagnosis. They were able to pioneer things like FISH [fluorescence in situ hybridization scale] and look for antipode as a suggestion for therapy.

The other important piece about transplant is that because the patients are getting immunosuppression, you don’t want to violate any of the tissues during the work-up. This is something we highlight with our gastroenterology colleagues. With some of their biopsy techniques, as long as they stay within the bile duct and they’re not traversing any plane. That would make patients ineligible. This may be frustrating to some, but we have to stick to those criteria to duplicate those outcomes. For perihilar cholangiocarcinoma, liver transplant is an accepted modality. There’s no randomized trial compared with resection. We have enough of natural history in centers of excellence that do this well.

The exciting space is in intrahepatic cholangiocarcinoma and transplantation. You and your colleagues in Houston, Texas, have been leading that charge. It’s all about selection. We don’t have livers that grow off the shelf. We can’t just pull them when we have them. We have to be judicious about how organs and graphs are allocated. We had a nice transplant oncology debate at ASCO GI [American Society of Clinical Oncology Gastrointestinal Cancers Symposium]. What we’re learning, as we get mutational profiles and our therapies get better, is that we can enroll patients on these transplant protocols. We can select that handful of patients who will benefit from the ultimate local therapy, which is transplantation. You and your colleagues have led the way in that effort.

Milind M. Javle, MD: Thank you. The skepticism in intrahepatic cholangiocarcinoma was based on data from the 1980s and ’90s, showing that intrahepatic cholangiocarcinoma had a long-term survival. Long-term survival is very limited by systemic metastases. It was a contraindication for transplantation. Even today, it’s not on the UNOS [United Network for Organ Sharing] list for approved diseases. We’ve been using extended criteria and looking at patients who have good biology, to identify those patients. It was a debate, but it looked like pro positions on both sides. Clearly, this is an area of development, and few patients qualify. We shouldn’t forget this modality.

Transcript edited for clarity.