‘Substantial proportion’ of PSC patients listed for LT due to dysplasia have no neoplasia

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Key takeaways:

  • Researchers identified bile duct dysplasia or cholangiocarcinoma in 71% of explanted livers in the indication of bile duct dysplasia.
  • However, 41% with this indication had no signs of neoplasia.

Researchers identified bile duct dysplasia or cancer in most explanted livers with an indication of biliary dysplasia, although as many as 41% had no signs of neoplasia, according to a study of patients with primary sclerosing cholangitis.

“Primary sclerosing cholangitis, in short PSC, is one of the leading causes of liver transplantation in the Nordic countries with a high risk of developing cholangiocarcinoma prior to liver transplantation,” Sigurd Breder, MD, of the Norwegian PSC Research Center, said at EASL Congress. “A practice of preemptive liver transplantation in patients with bile duct dysplasia is well-established in the Nordic countries to prevent development of cholangiocarcinoma, but this remains controversial, partly because of organ supply.”

Despite a ‘substantial proportion’ of PSC patients with a primary indication of low-grade dysplasia: 41%; had no signs of neoplasia in the explanted liver.

Data derived from: Breder S, et al. Liver transplantation due to bile duct dysplasia in primary sclerosing cholangitis. Presented at: EASL Congress; June 5-8, 2024; Milan (hybrid).

Breder and colleagues evaluated the practice of preemptive LT in patients with PSC and bile duct dysplasia using the Nordic Liver Transplant Registry and identified 512 adult patients (76% men) undergoing LT from 2000 to 2021. The median age at PSC diagnosis was 33 years and the median age at first LT was 44.9 years.

Researchers retrospectively collected patient clinical and histopathological data and classified results of brush cytology and bile duct biopsies as benign, low-grade or high-grade dysplasia.

Results showed the main indication for LT was end-stage liver disease (53.1%) followed by recurrent cholangitis/cholestasis symptoms (12.5%), high-grade dysplasia (11.5%), suspected cholangiocarcinoma (7.8%), low-grade dysplasia (5.7%), hepatocellular carcinoma (4.7%) and combined indications (4.7%).

Low-grade dysplasia (65.5%), high-grade dysplasia (61%) and suspicion of cholangiocarcinoma (75%) were associated with less advanced liver disease, while all other indications were associated with cirrhosis (85.3%).

Among patients with low-grade dysplasia as the primary indication, researchers reported low-grade dysplasia in 48.3% of explants and no dysplasia in 41.4%, while for those with an indication of high-grade dysplasia, researchers identified high-grade dysplasia in 32.2% of explants and cholangiocarcinoma in 15.3%.

In patients with an indication of suspected cholangiocarcinoma, a confirmation of cholangiocarcinoma was made in 67.5% of cases, while no neoplasia was found in 27.5%. For all other indications, no neoplasia was reported in 81.7% of cases and cholangiocarcinoma was “an incidental finding” in 1.9%, Breder said.

In addition, brush cytology with low-grade dysplasia had a positive predictive value of 0.63 for neoplasia of any grade, which increased to 0.77 with high-grade dysplasia. Bile duct biopsy with high-grade dysplasia further increased the positive predictive value to 0.88 for neoplasia of any grade in the explanted liver.

Overall, researchers reported histopathology findings of bile duct neoplasia among 31.7% of all liver explants, which included low-grade dysplasia in 17% of cases, high-grade dysplasia in 5.7%, cholangiocarcinoma in 8.9% and no neoplasia in 68.3%.

“A large proportion of PSC patients are listed for liver transplantation due to primary indication of bile duct dysplasia in Oslo and Stockholm,” Breder said. “Bile duct dysplasia or cholangiocarcinoma was found in a majority of explanted livers in the indication of bile duct dysplasia. However, a substantial proportion of patients with a primary indication of low-grade dysplasia had no signs of neoplasia in the explanted liver, as many as 41%.”

He continued: “Our findings suggest that the criteria for selecting candidates for liver transplantation in the setting of bile duct dysplasia may be improved.”

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