Prolonged disease-free survival after orthotopic liver transplantation plus adjuvant chemoirradiation for cholangiocarcinoma

Orthotopic liver transplantation (OLT) alone for unresectable cholangiocarc inoma is often associated with early disease relapse and limited survival, Because of these discouraging results, most programs have abandoned OLT for cholangiocarcinoma, However, a small percentage of patients have achieved prolonged survival after OLT, suggesting that adjuvant approaches could per haps improve the survival outcome. Based on these concepts, a protocol was developed at the Mayo Clinic using preoperative irradiation and chemotherap y for patients with cholangiocarcinoma. We report our initial results with this pilot experience. Patients with unresectable cholangiocarcinoma above the cystic duct without intrahepatic or extrahepatic metastases were eligib le. Patients initially received external-beam irradiation plus bolus fluoro uracil (5-FU), followed by brachytherapy with iridium and concomitant protr acted venous infusion of 5-FU. 5-FU was then administered continuously thro ugh an ambulatory infusion pump until OLT. After irradiation, patients unde rwent an exploratory laparotomy to exclude metastatic disease. To date, 19 patients have been enrolled onto the study and have been treated with irrad iation. Eight patients did not go on to OLT because of the presence of meta stasis at the time of exploratory laparotomy (n = 6), subsequent developmen t of malignant ascites (n = 1), or death from intrahepatic biliary sepsis ( n = 1). Eleven patients completed the protocol with successful OLT. Except for 1 patient, all had early-stage disease (stages I and II) in the explant ed liver. All patients who underwent OLT are alive, 3 patients are at risk at 12 months or less, and the remaining 8 patients have a median follow-up of 44 months (range, 17 to 83 months; 7 of 9 patients > 36 months). Only 1 patient developed tumor relapse, OLT in combination with preoperative irrad iation acid chemotherapy is associated with prolonged disease-free and over all survival in highly selected patients with early-stage cholangiocarcinom a.