Resection versus transplantation for intrahepatic and hilar cholangiocarcinoma

Cholangiocarcinoma is divided into; intrahepatic (iCCA), hilar (hCCA) and distal (dCCA). We will focus on the surgical management of iCCA and hCCA (resection vs. transplantation). Resection for hCCA is the standard of care in patients with resectable disease and no background liver disease such as primary sclerosing cholangitis (PSC). However liver transplantation provides significant advantage in PSC, locally unresectable or borderline resectable disease (Bismuth IV) if performed under transplant protocol and in selected patients. Liver resection remains the standard of care for resectable iCCA. In small subset of patients with unresectable disease, neoadjuvant therapy can provide downstaging opportunity to resectable disease. Liver transplantation should be considered in unresectable disease with stability on neoadjuvant therapy under strict protocol such as Methodist-MD Anderson Joint Cholangiocarcinoma Collaborative Committee. For now, liver transplant for ICC should remain designated as experimental until further experience in selection, preoperative therapy and comparison to other modalities is achieved.