Is there a role for pre-operative RT (+/-chemo) for a borderline resectable Klatskin tumor as an attempt to try to get them to surgery?

From my perspective, there is a role for preoperative chemo-radiation for borderline resectable Klatskin tumors followed by re-evaluation for surgical resection (standard resection vs liver transplant).  

Neo-adjuvant chemo-radiation followed by liver transplant has been evaluated as a treatment option at Mayo Clinic since 1992 for patients with Klatskin tumors that are not surgically resectable or occurred in patients with PSC.  This aggressive approach was an attempt to enhance results achieved with either liver transplant alone (5-yr OS 25-30%, various series) or EBRT +/- 5FU plus brachytherapy (5-yr OS 14% in published Mayo series of 24 patients). The neo-adjuvant regimen was 45Gy in 1.5Gy fractions twice daily for 3 wks plus concurrent 5FU followed by brachytherapy plus PVI 5FU.  Exploratory laparotomy or laparoscopy was performed before liver transplant to be certain lymph nodes were not involved.  In a published Mayo analysis of 215 select patients treated from 1992 to 2011, 5-yr OS was 56% in the 215 who initiated neo-adjuvant therapy and 74% in the 136 patients who proceeded to liver transplant.  In a contemporary group of 26 Mayo Clinic patients with resectable lesions treated with standard resection alone or plus postoperative chemoRT, 5-yr OS was 21%.