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World J Gastrointest Surg. Jun 27, 2019; 11(6): 279-286
Published online Jun 27, 2019. doi: 10.4240/wjgs.v11.i6.279
Neoadjuvant therapy in the treatment of hilar cholangiocarcinoma: Review of the literature
Fabio Frosio, Federico Mocchegiani, Grazia Conte, Enrico Dalla Bona, Andrea Vecchi, Daniele Nicolini, Marco Vivarelli
Fabio Frosio, Federico Mocchegiani, Grazia Conte, Enrico Dalla Bona, Andrea Vecchi, Daniele Nicolini, Marco Vivarelli, Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
Author contributions: Frosio F collected the majority of data and wrote the paper; Mocchegiani F revised the manuscript; Conte G and Dalla Bona E helped in collecting the data about neoadjuvant therapy before resection; Vecchi A and Nicolini D finalized the research concerning the treatment prior to transplantation; Vivarelli M gave the input in realizing this review.
Conflict-of-interest statement: There is no conflict of interest associated with any of the senior authors or other coauthors who have contributed to this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Federico Mocchegiani, MD, Assistant Professor, Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Conca 71, Ancona 60126, Italy. federicomocchegiani@hotmail.com
Telephone: +39-71-5964577 Fax: +39-71-5965100
Received: March 26, 2019
Peer-review started: March 28, 2019
First decision: May 8, 2019
Revised: May 29, 2019
Accepted: June 10, 2019
Article in press: June 10, 2019
Published online: June 27, 2019
Processing time: 93 Days and 12.7 Hours
Abstract

Cholangiocarcinoma (CCA) is a malignant tumor of the biliary system and includes, according to the anatomical classification, intra hepatic CCA (iCCA), hilar CCA (hCCA) and distal CCA (dCCA). Hilar CCA is the most challenging type in terms of diagnosis, treatment and prognosis. Surgery is the only treatment possibly providing long-term survival, but only few patients are considered resectable at the time of diagnosis. In fact, tumor’s extension to segmentary or subsegmentary biliary ducts, along with large lymph node involvement or intrahepatic metastases, precludes the surgical approach. To achieve R0 margins is mandatory for the disease-free survival and overall survival. In case of unresectable locally advanced hCCA, radiochemotherapy (RCT) as neoadjuvant treatment demonstrated to be a therapeutic option before either hepatic resection or liver transplantation. Before liver surgery, RCT is believed to enhance the R0 margins rate. For patients meeting the Mayo Clinic criteria, RCT prior to orthotopic liver transplant (OLT) has proved to produce acceptable 5-years survivals. In this review, we analyze the current role of neoadjuvant RCT before resection as well as before OLT.

Keywords: Hilar cholangiocarcinoma; Klatskin tumor; Neoadjuvant treatement; Radiotherapy; Chemotherapy; Hepatic resection; Liver transplantation

Core tip: Surgery is the only potentially curative treatment for hilar cholangiorcinoma; however, most of the patients are considered not resectable because of the local extent. Neoadjuvant radiochemotherapy is supposed to increase R0 margins rate, or even to allow radical resection for locally advanced tumors, but few studies are available. Moreover, for patients with early stage tumors meeting the Mayo Clinic criteria, neoadjuvant therapy before liver transplantation has produced very good survivals, gaining worldwide acceptance. This is the first review to consider the role of neoadjuvant treatment for hilar cholangiocarcinoma, before resection as well as before liver transplantation.