Treating early stage bile duct cancer with chemoradiation, liver transplant

By Becky Kraenow

Perihilar cholangiocarcinoma is a small tumor that can cause big problems. These tumors form in the bile ducts leading out of the liver ― high-stakes real estate, according to Julie Heimbach, M.D., a transplant surgeon at Mayo Clinic.

"An artery, portal vein and the bile duct run through this area," says Dr. Heimbach. "So even though these tumors can be very small, they might block key structures, making their removal difficult without affecting how blood flows into the liver and how bile flows out."

Cholangiocarcinoma is a cancer of the bile ducts, and it's classified according to the location of the tumor. "Perihilar," or "hilar," refers to tumors that start in the bile ducts just outside the liver. Perihilar cholangiocarcinoma is the most common form of bile duct cancer. In many cases, these tumors can't be removed with surgery.

At first, health care professionals tried liver transplant to improve the chance of surgically removing the bile duct tumors. But many patients' tumors returned.

Health care professionals also noticed that some patients who had radiation therapy had longer-term, disease-free survival. Many of these people, however, had worsening liver damage from the radiation treatment.

In 1993, the liver transplant team at Mayo Clinic in Rochester, Minnesota, partnered with their colleagues in Radiation Oncology and Medical Oncology to combine radiation and liver transplant for certain patients with early stage perihilar cholangiocarcinoma that could not be removed with surgery. They began using chemoradiation followed by liver transplant.

Health care professionals at Mayo Clinic have now performed more than 200 liver transplants following chemoradiation to treat perihilar cholangiocarcinoma at Mayo Clinic in Arizona, Florida and Minnesota.

"We have developed quite an experience with this," says Dr. Heimbach. "It's definitely a challenging tumor to manage on many levels. We keep pushing to move the field forward."

Patients must meet strict criteria to receive this treatment

To be eligible to receive chemoradiation and liver transplant for perihilar cholangiocarcinoma at Mayo Clinic, patients must have an X-ray of their bile ducts called a cholangiography, according to a 2020 article published in the Journal of Gastrointestinal Surgery. During this exam, a health care professional looks for narrowing of the bile ducts that appears to be cancer, and specific markers that the patient is a good fit for this treatment.

People cannot receive this treatment if:

• Their cancer has spread to other parts of the body.
• They have had previous radiation treatment in the abdomen that would make further radiation in the area ill-advised.
• They have had a previous attempt at surgical removal of their bile duct tumor.

If selected for this treatment, a patient starts chemoradiation therapy. After chemoradiation, all patients then have their tumors assessed in an operation that happens as close to the time of transplant as possible. This helps health care professionals be sure the tumor hasn't spread beyond the bile duct.

There is a sweet spot in the timing of transplant following chemoradiation, but researchers are still learning exactly what that window is. If a patient receives a transplant too early, a patient might still have inflammation from chemoradiation, and aggressive tumors might be missed. This puts the patient at greater risk for a tumor to return following surgery. On the other hand, if a patient waits too long for a transplant, the cancer or any underlying liver disease may progress and the patient can suffer complications from the therapy.

Health care professionals are learning more about this ideal time frame as they treat more patients with this procedure.

More experience means more positive outcomes

Chemoradiation followed by liver transplant is being used more widely around the world to treat perihilar cholangiocarcinoma, but it's a technically difficult procedure that requires a large team working together toward success. For the best possible outcome, Dr. Heimbach recommends patients seek treatment at a cancer center with experience performing this procedure. A 2020 study published in the Annals of Surgical Oncology found that outcomes after transplant were better at centers that had performed more than six liver transplants for these tumors than at centers that had performed fewer of these transplants.

Learn more

Learn more about bile duct cancer and find a bile duct cancer clinical trial at Mayo Clinic.