Radiation, Chemotherapy With Liver Transplant Improves Cancer Survival

The five-year survival rate for patients who received a livertransplant after radiation and chemotherapy was 82 percent,significantly higher than for those who had a conventional operation."With the combined benefits of radiation, chemotherapy and livertransplantation, our patients with bile duct cancer now have a muchbetter chance to live longer and enjoy a good quality of life," saysCharles Rosen, M.D., a Mayo Clinic transplant surgeon and co-author ofthe study.

Conventional therapy for hilar cholangiocarcinoma, a type ofbile duct cancer, is to remove (resect) the tumor, which may requireremoving part of the liver. Survival for patients with this type ofoperation is only 25 to 35 percent, and many patients cannot be treatedthis way because the tumors can involve both sides of the liver.Combination therapy with liver transplantation is possible for morepatients. Transplantation enables surgeons to remove the entire liverand obtain better tumor clearance. Patients treated withtransplantation have enjoyed a higher likelihood of prolonged survivalthan those treated with the conventional operation.

To improve results of liver transplantation for unresectablehilar cholangiocarcinoma, Mayo Clinic physicians developed a treatmentprotocol combining radiation therapy, chemotherapy and livertransplantation. Patients receive high dose external beam radiationtherapy, followed by high dose irradiation with iridium administeredthrough a catheter passing through the bile duct and tumor.Chemotherapy starts during radiation treatment and continues untiltransplantation. Prior to transplantation, patients undergo a stagingabdominal operation so surgeons can look for any spread of the tumor tolymph nodes or the abdomen that would prevent complete tumor removal.

Mayo Clinic's liver transplant team has treated over 90patients with hilar cholangiocarcinoma. Approximately one-third of thepatients have findings at the staging operation that precludesubsequent transplantation, but this number may be decreasing withearlier diagnosis and referral for treatment. Sixty patients haveundergone liver transplantation -- many recently with living donors --and results remain superb, says Dr. Rosen.

Cholangiocarcinoma is a relatively uncommon malignant tumorthat is often found in the lining of the bile duct. In the UnitedStates, the most common risk factor is sclerosing cholangitis, achronic liver disease characterized by inflammation, destruction andfibrosis of the bile ducts, often leading to cirrhosis of the liver.The cancer also is seen in patients with congenital bile duct cysts andbile duct stones. Most frequently, these tumors are located near theliver. Cholangiocarcinomas in this location are difficult to treatbecause the tumor often extends deep into the liver in a way that itcannot be completely removed with a conventional operation.

The incidence of bile duct cancer is increasing in the UnitedStates, according to Gregory Gores, M.D., Mayo Clinic liver transplantspecialist and co-author of the study. Mayo Clinic has ongoing researchinto new tests to diagnose the tumor earlier, which could lead to evenbetter results.

"The major problem is that we still don't have enough liversfor everyone who needs one," says Dr. Rosen. "We feel that patientswith cholangiocarcinoma should have equal access to donor organs,because the results are comparable to those achieved for other patientswho undergo transplantation. Without a transplant, the outlook forthese patients is fairly poor."

Other Mayo Clinic physician researchers involved with thisstudy include: David Rea, M.D., Julie Heimbach, M.D., Michael Haddock,M.D., Steven Alberts, M.D., Walter Kremers, Ph.D., and David Nagorney,M.D.

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