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Akbulut S, Yilmaz S. Liver transplantation for intrahepatic cholangiocarcinoma: From contraindication to biology-driven selection. World J Gastroenterol 2027; 33(3): 124080 [DOI: 10.3748/wjg.124080]
World J Gastroenterol. Jan 21, 2027; 33(3): 124080 Published online Jan 21, 2027. doi: 10.3748/wjg.124080
Liver transplantation for intrahepatic cholangiocarcinoma: From contraindication to biology-driven selection
Sami Akbulut, Sezai Yilmaz
Sami Akbulut, Sezai Yilmaz, Department of Surgery and Liver Transplantation, Inonu University Faculty of Medicine, Malatya 44280, Türkiye
Author contributions: Akbulut S conceived the review, performed the literature search, analyzed and interpreted the relevant literature, and drafted the manuscript; Yilmaz S critically revised the manuscript for important intellectual content and supervised the review; both authors read and approved the final version of the manuscript.
AI contribution statement: ChatGPT (GPT-5.6 Thinking; OpenAI, San Francisco, CA, USA) was used as an assistive tool during manuscript revision for English-language polishing, grammar correction, sentence restructuring, readability improvement, and consistency checking. It was not used to generate data, perform statistical analyses, or independently formulate scientific conclusions. Final literature selection, scientific interpretation, and all editorial decisions remained the responsibility of the authors. All AI-assisted suggestions, factual statements, and references were critically reviewed and verified against the original sources by the authors. No figures or images were generated using AI. The authors take full responsibility for the accuracy, integrity, originality, and final content of the manuscript.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
Corresponding author: Sami Akbulut, MD, PhD, FACS, Professor, Department of Surgery and Liver Transplantation, Inonu University Faculty of Medicine, Elazig Yolu 10 Kilometers, Malatya 44280, Türkiye. akbulutsami@gmail.com
Received: June 5, 2026 Revised: July 12, 2026 Accepted: August 20, 2026 Published online: January 21, 2027 Processing time: 162 Days and 2.7 Hours
Abstract
Intrahepatic cholangiocarcinoma (iCCA) has historically been considered a contraindication to liver transplantation (LT) because early outcomes in unselected patients were marked by high recurrence and poor survival. Liver resection remains the standard curative-intent treatment when technically feasible and oncologically appropriate. Contemporary evidence challenges this binary view, suggesting that transplant benefit depends less on diagnosis or anatomy alone than on careful candidate selection and disease behavior over time. This narrative review examines LT for iCCA within current transplant oncology practice. Current evidence supports cautious consideration of LT in two distinct settings. The first is very early iCCA in cirrhotic patients, particularly solitary tumors ≤ 2 cm, for which explant-based retrospective studies have shown better outcomes than those observed in larger or multifocal disease. Evidence for this setting derives mainly from incidental or explant-based series. Selected solitary tumors ≤ 3 cm may be considered within consensus-based, guidance-based, trial-based, or registry-based frameworks after documented stability and exclusion of nodal or extrahepatic disease, although this threshold is less well validated than the 2-cm threshold. The second is unresectable, liver-limited iCCA controlled by neoadjuvant systemic therapy with or without locoregional therapy, where durable radiologic response or stability, usually for at least 6 months, serves as a dynamic test of disease behavior. Evidence for this setting derives from highly selected neoadjuvant cohorts and remains investigational. In both settings, histological confirmation when feasible, careful staging, and exclusion of nodal or extrahepatic spread are essential. LT should be framed not as routine indication expansion, but as a highly selective treatment strategy for patients with liver-limited disease and sustained disease control.
Core Tip: Liver transplantation (LT) should not be regarded as a routine treatment for intrahepatic cholangiocarcinoma, but as a highly selective option for carefully chosen patients. The most established evidence concerns cirrhotic patients with very early solitary tumors, whereas LT for selected patients with unresectable, liver-limited disease controlled after neoadjuvant therapy remains promising but investigational. In both settings, appropriate candidate selection requires durable disease stability, accurate staging, histological confirmation when feasible, and reliable exclusion of nodal and extrahepatic spread. Multidisciplinary assessment is essential, and LT should be considered only within strict selection protocols rather than as an alternative to resection in patients with safely resectable disease.
