Surgical Volume Alone Does Not Determine Outcome Following Liver Transplant for Perihilar Cholangiocarcinoma
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LETTER – HEPATOBILIARY TUMORS
Surgical Volume Alone Does Not Determine Outcome Following Liver Transplant for Perihilar Cholangiocarcinoma Fiona Hand, and Emir Hoti Department of Hepatobiliary and Liver Transplant Surgery, St. Vincent’s University Hospital, Dublin 4, Ireland
To the Editor We read with interest the findings of Kitajima et al. recently published in Annals of Surgical Oncology.1 Perihilar cholangiocarcinoma (pCCA) is a rare malignancy, and those who meet the stringent criteria for orthotopic liver transplantation (OLT) are rarer still. As OLT becomes more widely incorporated into the treatment algorithm for pCCA, this present analysis makes the argument to centralize transplant services for this challenging patient cohort. In reviewing the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) database, the authors identified 155 patients who received model for end-stage liver disease (MELD) exception points for pCCA, transplanted across 30 centers.1 Seven centers were deemed ‘well-experienced’ and were found to have significantly better 5-year survival rates than patients transplanted in ‘less-experienced’ centers (45.8% vs. 26.0%; p = 0.026). Similarly, a significantly higher 1-year mortality rate associated with disease recurrence was noted among those transplanted in ‘less-experienced’ centers. However, a wide variation in volume among ‘well-experienced’ centers is present, with one unit performing in excess of four times the number of transplants as that performed in the other units. As the Mayo Clinic remains the forerunner in OLT for pCCA, a similar spread of data is frequently encountered in studies of this nature. Nonetheless, a recent meta-analysis of OLT
Ó Society of Surgical Oncology 2020 First Received: 24 June 2020 Accepted: 15 July 2020 F. Hand e-mail: [email protected]
for pCCA failed to demonstrate any relationship between center volume and outcomes, with similar 5-year survival between the Mayo Clinic and non-Mayo centers.2 While we applaud the premise of this study, it is reductive to simply attribute outcomes following transplantation to volume alone. In reality, careful selection of appropriate patients combined with comprehensive preoperative management and effective neoadjuvant chemoradiotherapy are essential to optimize outcomes following OLT for pCCA. Patient selection is fundamentally important and difficult to standardize among the multiple centers included in this study. Decision making is undoubtedly influenced by the multidisciplinary team available; isolated transplant units will approach patients differently to those that provide both a resectional hepatobiliary service in addition to transplantation. Indeed, resectional units performing regular trisectionectomy or extended hepatectomy with vascular resection are less likely to refer patients onwards for consideration of OLT.3 Careful preoperative management of this patient cohort is imperative. Expertise in accessing the biliary tree is needed not only to diagnose but also to dra
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