Published online Aug 24, 2022. doi: 10.5306/wjco.v13.i8.688
Peer-review started: April 8, 2022
First decision: May 12, 2022
Revised: June 14, 2022
Accepted: July 11, 2022
Article in press: July 11, 2022
Published online: August 24, 2022
Processing time: 136 Days and 17.1 Hours
Cholangiocarcinoma (CC) is a rare tumor that arises from the epithelium of the bile ducts. It is classified according to anatomic location as intrahepatic, perihilar, or distal. Intrahepatic cholangiocarcinoma (ICC) is rare in patients with cirrhosis due to causes other than primary sclerosing cholangitis. Mixed hepatocellular-cholangiocarcinoma (HCC-CC) is a rare neoplasm with histologic findings of both hepatocellular carcinoma (HCC) and ICC within the same tumor mass.
Because of difficulties in reaching the correct diagnosis, patients eventually undergo liver transplantation (LT) with a presumptive diagnosis of HCC on imaging when, in fact, they have ICC or HCC-CC.
To determine the prevalence of ICC or HCC-CC confirmed by explant pathology in patients who underwent LT with the presumptive diagnosis of HCC and to compare tumor recurrence (TR), recurrence-free survival (RFS), and overall mortality (OM) rates between these patients and LT recipients with HCC.
This retrospective cohort study included patients aged ≥ 18 years with liver cirrhosis and imaging findings suggestive of HCC within the Milan criteria who underwent LT between June 1997 and July 2019. Patients were divided into three groups according to the diagnosis on explant pathology: (1) Patients with HCC; (2) Patients with ICC; and (3) Patients with mixed HCC-CC. The analyzed outcomes were TR, RFS, and OM. Propensity score matching was used to assess whether TR, OM, and RFS rates in patients with ICC or HCC-CC differed from those in patients with HCC. Additionally, hazard ratios (HRs) and their confidence intervals were calculated. Progression-free survival and OM rates were computed with the Kaplan-Meier method using Cox regression for comparison.
Over a 22-year period, 475 patients with the presumptive diagnosis of HCC underwent LT, and 15 (3.1%) were found to have either ICC (n = 8) or HCC-CC (n = 7) detected in the pathological examination of the explant. LT recipients with ICC had higher TR (46% vs 11%; P = 0.006), higher OM (63% vs 23%; P = 0.002), and lower RFS (38% vs 89%; P = 0.002) than those with HCC when matched for pretransplant tumor characteristics, as well as higher TR (46% vs 23%; P = 0.083), higher OM (63% vs 35%; P = 0.026), and lower RFS (38% vs 59%; P = 0.037) when matched for posttransplant tumor characteristics. Two pairings were performed to compare the outcomes of LT recipients with HCC-CC vs HCC. There was no significant difference between the outcomes in either pairing.
Patients with ICC had worse outcomes than patients with HCC undergoing LT. Preoperative diagnosis of HCC-CC should not prompt the exclusion of these patients from transplant options.
This study reinforces the need for more accurate criteria: (1) To identify these rare tumors in pretransplant evaluation; and (2) To select patients who may benefit from LT.