Milind Javle, MD: Anjana, we don’t have a lot of time to discuss transplant, but you are our transplant expert here. Could you briefly describe in just a few lines, what are the indications for transplant in biliary tract cancer?

Anjana Pillai, MD: Of course. I think that depends, again, on the location of the tumor. What’s tried and true is the Mayo [Clinic] protocol for hilar cholangiocarcinoma, the class of tumors we’re talking about. For those patients, there are very specific inclusion/exclusion criteria that centers that do it often follow. It could even be a modified version, but the inclusion criteria are always the same. You have to have a tumor radial size under 3 cm. You need ideally pathologic confirmed hilar cholangio, but as you stated, that’s not always easy, even with cholangioscopy and FISH [fluorescence in situ hybridization]. But in that case, you need a CA19-9 [serum marker] of at least greater than 100 U/mL and the presence of a radiographically malignant stricture. You can have metastasis and you can have positive nodes. Those patients undergo lead-in chemoradiation for 6 weeks and then maintenance chemotherapy to transplant, ideally with staging every 2 to 3 months. That’s where living donation is ideal because then you can schedule that surgery.

Now, back to what Flavio was talking about as far as peripheral lesions, there are multicenter and international data for, incidentally found most of the time, smaller peripheral cholangiocarcinomas that have excellent survival, though very early. We have also adopted what you all do ... with intrahepatic cholangio. We follow the same inclusion criteria there as well. These are patients with intrahepatic cholangio who are unresectable without metastases who have at least 6 months of stability on chemotherapy. Then we offer them a transplant. I do feel like we have a relatively high rate of dropout, probably not as much as you see in metastatic colorectal [cancer] for transplant. This is another aspect of it; we’re are sometimes seeing them too late, and so when is the right time is also something we struggle with. But the ones who have undergone that protocol, right now we have 9 patients for whom we’ve done that in the last 5 years, and hopefully, we too will get those data out there soon. I think that more and more centers are thinking about absolutes and overall survival. As you all showed at Methodist, yes, your 1-, 3-, and 5-year survival rates in these patients who get transplants versus who don’t are significantly higher, and maybe not necessarily the metrics that the transplant community likes to hold onto. That’s a point of debate too, but it is an option that patients do quite well with.

Transcript edited for clarity.