The document discusses liver transplantation as a treatment for hilar cholangiocarcinoma (CCA). It notes that liver transplantation (LT), after neoadjuvant chemoradiation therapy, provides superior outcomes for unresectable hilar CCA compared to resection alone. The University of Utah and Huntsman Cancer Institute program began in 2006 and has successfully transplanted 9 of 9 eligible patients, with an 89% overall survival rate. The program follows a strict protocol for patient selection, pre-transplant chemoradiation therapy, and post-transplant surveillance.

1. Liver Transplantation for
Hilar Cholangiocarcinoma
Robin D Kim, MD
Executive Medical Director, Transplant Service Line
Director, Hepatobiliary Cancer Program
Huntsman Cancer Institute and the University of Utah
The Cholangiocarcinoma Foundation
February 27 to 28, 2014

2. Surgical Options for Cholangiocarcinoma
- R0 resection or LT currently the only
curative treatments for CCA
- 20% of patients who present with CCA are
candidates for R0 surgery
- Distribution: Upper Extrahepatic/Hilar
(UEH) 40-60%, Lower Extrahepatic (LEH)
30%, Intrahepatic (IH) 10%
- Location determines the operation required
- UEH/Hilar requires liver/bile duct
resection or liver transplantation
- LEH requires
pancreaticoduodenectomy
- IH requires liver resection
- R0 candidacy is ascertained at a
comprehensive Hepatobiliary/LT Center
IH
UEH/Hilar
LEH

3. LT for Hilar CCA
- Early results for LT alone for CCA were uniformly poor due to a high incidence of recurrence and
mortality
- Meyer CG, Penn I, James L. Liver transplantation for cholangiocarcinoma: results in 207 patients. Transplantation 2000
- Protocol for neoadjuvant chemoXRT for unresectable hilar CCA then LT began at the Mayo Clinic
- From 1993 – 2002, 38 pts receiving neoadjuvant tx then LT for unresectable hilar CCA were
compared to pts who were resected. LT provided superior outcomes, with 5-yr survival for LT
vs resection of 82% vs 21%.
- Rea D, Heimbach JK, Rosen CB, et al. Liver transplantation with neoadjuvant chemoradiation is more effective than
resection for hilar cholangiocarcinoma. Ann Surg 2005; 3:451–461.
- Follow up data on from 2006 showed that in 65 pts undergoing neoadjuvant tx then LT with
mean follow-up of 32 months, 1 yr and 5 yr survival of 91% and 76%, respectively. These
results are similar to those achieved for other standard indications for LT such as HCC and HCV
cirrhosis.
- Heimbach JK, Gores GJ, Haddock MG, et al. Predictors of disease recurrence following neoadjuvant chemoradiotherapy
and liver transplantation for unresectable perihilar cholangiocarcinoma. Transplantation 2006; 12:1703–1707.
- A similar protocol employing higher dose brachytherapy without EBRT was undertaken at the
University of Nebraska.
- Hassoun Z, Gores GJ, Rosen CB, et al. Preliminary experience with liver transplantation in selected patients with
unresectable hilar cholangiocarcinoma. Surg Oncol Clin N Am 2002; 11:909–921.

4. Patients with hilar CCA Stage I or II (AJCC 5th Ed) may be considered for neoadjuvant chemoradiation
followed by LT if the following criteria are met.
I. Inclusion Criteria (A, B, C must all be met)
A) Patients with unresectable CCA (per experienced HPB surgeon) and/or CCA in PSC
B) Dx of CCA established by (1 and 2 must be met)
1) CT, MRI/MRCP demonstrating an malignant-looking mass < or = 3 cm or a dominant stricture at the
extrahepatic hilar bile duct and above the cystic duct
2) CCA confirmed by a) an intraluminal brush cytology or intraluminal biopsy showing cancer or suspicious
cells, or b) biliary aneuploidy demonstrated with fluorescent in situ hybridization (FISH). In the absence of
histologic confirmation, a Carbohydrate antigen 19-9 (CA 19-9) level greater than 100 ng/ml will be
sufficient to diagnose CCA.
II. Exclusion Criteria
1) Pre-treatment imaging demonstrating suspicious disease outside of the hilar bile duct (including skip
met into the liver parenchyma, distant nodes, chest metastases)
2) Previous chemo or XRT, uncontrolled infection, a previous malignancy other than skin or cervical cancer
within 5 years, medical conditions precluding LT, extrahepatic disease (including regional lymph node
involvement), and operative biopsy or attempted resection of the tumor.
3) Patients with hilar tumors extending below the cystic duct. Vascular encasement and tumor size are not
included in exclusion criteria.
4) Post-chemoradiation imaging or surgical staging demonstrating nodal disease, metastases, peritoneal
metastases, extent of bile duct cancer below the cystic duct.
LT for Hilar CCA at the U of U and HCI

5. A) Pre-treatment workup:
CT abdomen/pelvis dual phase or MRI with contrast and MRCP, 2) CT Chest, 3) Bone Scan, 4) ERCP with
brushings and or biopsy with FISH, 5) CA 19-9, CEA, 6) EUS with biopsy of suspicious lymph nodes.
B) Neoadjuvant chemo-radiation
PTC guided flexible catheter will be inserted and remain for the entire protocol. EBRT administered to a
target dose of 4500 cGy in 25 fractions with IV 5-FU at 500 mg / m2 as a daily bolus for the first 3 days of
radiation. Two to 3 weeks after EBRT, a transluminal boost of radiation delivered using a transcatheter
Iridium-192 brachytherapy wire, with a target dose of 2000cGy, given in 4 treatments over 2 days. A total
of 4 radiation treatments, 500 cGy each, will be delivered over two days, with each treatment at least 6
hours apart. Total max boost dose of 14.4 Gy in 8 fractions. Following brachytherapy, patients will be
treated with oral capecitabine (2000 mg/m2 per day in 2 divided doses, 2 out of every 3 weeks) until LT.
C) Pre-listing assessment (4 to 6 weeks after chemoXRT and before listing):
CT chest, abdomen and pelvis with IV contrast, 2) CA 19-9, CEA, 3) EUS with biopsy of any suspicious
nodes. If EUS is not possible, then operative lymph node biopsy is required. 4) Operative staging 6 weeks
after completion of chemoXRT and before listing.
D) Follow-up while on the liver transplant list:
Submission of recertification and upgrade per UNOS. This would include a CA 19-9, CEA and MRCP q 4
months, 2) Presentation of such recertification studies at Liver Tumor Planning Conference at the HCI.
E) Liver Transplant
Ref: Rea DJ, Heimbach JK, Rosen CB, et al. Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar
cholangiocarcinoma. Ann Surg. 2005; 242: 451-461.
LT for Hilar CCA at the U of U and HCI

6. • LT for Hilar CCA Program began as a clinical trial in 2006
• Program approved by UNOS for exception point accrual in 2012
• 9 of 9 patients successfully transplanted since official
designation
• 89% overall survival to date
• All survivors in excellent health
LT for Hilar CCA at the U of U and HCI

7. Selected CCA-related Publications
from the U of U and HCI
Darwish MS, Kim WR, Harnois DM, et al. Efficacy of neoadjuvant chemoradiation, followed by liver
transplantation, for perihilar cholangiocarcinoma at 12 US centers. Gastroenterology. 2012
Jul;143(1):88-98.e3
Schwartz JJ, Thiesset HF, Clayton F, et al. Using the modern Silverhawk™ atherectomy catheter to
characterize biliary structures that appear malignant: review of initial experience. HPB (Oxford).
2011 Nov;13(11):823-9. doi: 10.1111/j.1477-2574.2011.00376.x.
Schwartz JJ, Sorensen JB, Kim RD (2013). Selection of Patients for Resection and Liver
Transplantation. In Lau, WY (Eds.), Hilar Cholangiocarcinoma. New York: Springer.
Schwartz JJ, Thiesset HF, Hutson W, et al. Complete Resolution of a Malignant Biliary Stricture using
Combined Neoadjuvant Chemoradiation and Brachytherapy Boost Prior to Orthotopic Liver
Transplantation. Journal of Liver: Disease & Transplantation (Accepted for publication).

9. Hepatobiliary Cancer Research Program
at the U of U and HCI
• Hepatobiliary Cancer group May 2013 was officially recognized as a Disease
Oriented Team at the HCI to cific funding received for Hepatobiliary cancer
research.
• Hepatobiliary cancer investigators are currently looking:
• at a variety of conditions predisposing patients to cancer and genetic analysis
of molecular components in tissue and blood. Our staff currently consents
patients and collects samples to ensure we can work to provide answers to all
of the questions that cancer provides.

10. • We are currently looking at
inflammatory bowel disease
blood and tissue samples to
potentially identify common
molecular signatures with
Cholangiocarcinoma.
• Furthermore, we are conducting
epidemiological studies to
determine pre-cursing diseases
to Cholangiocarcinoma.
Hepatobiliary Research Program continued…

11. Hepatobiliary Patient Advocacy
Annual patient advocacy support meetings held in
September
Annual newsletters and education flyers highlighting
patients and research
Advocacy walks as part of the Huntsman Cancer Institute
to raise funds for Hepatobiliary Cancers

12. Clinical program
The University of Utah and Huntsman Cancer Institute have
been able to attract a robust Cholangiocarcinoma patient
population due to the combined specialties found at an
academic center.
We are able to offer our patients first line defense against
hepatobiliary cancer with liver transplantation and
resection. Furthermore, we are also able to provide
chemoembolizations and radiation therapy.

13. Hepatobiliary Cancer Program
Surgeons, Medical Oncologists, Hepatologists, Radiologists,
Radiation Oncologists, Gastroenterologists, Interventional
Radiologists, Social Workers, Nurses, Coordinators, and other
clinical staff work together to ensure patients get the best care
possible.