Eligibility for Liver Transplantation in Patients with Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) has been a contraindication for liver transplantation due to frequent recurrence and poor survival. We sought to determine the true proportion of transplantation-eligible iCCA patients and their outcomes without transplantation.

Data from patients evaluated for iCCA at two academic medical centers between 2008 and 2018 were analyzed retrospectively. Overall survival was determined for patients categorized as eligible for liver transplantation based on six criteria: unresectability, no extrahepatic disease, stable disease after chemotherapy, functional status (maximum age, 72 years), no major comorbidity, and no involvement of major vasculature.

Of 1407 iCCA patients with sufficient data, 327 (23%) had advanced liver-confined disease. Most (n = 180 [55%]) progressed or died before 6 months of therapy. Others were ineligible owing to resection after pretreatment (n = 47), poor performance status (n = 8), advanced age (n = 32), comorbidity (n = 19), or extensive extrahepatic vascular involvement (n = 2). Only 39 patients (12% of 327; 2.8% of 1,407; 95% confidence interval [CI] 2-3.8%) met eligibility, with more than half (n = 22 [56%]) treated with hepatic arterial infusion pump chemotherapy. Their median survival from diagnosis was 39 months (95% CI 28-62 months); 3-year survival from estimated eligibility was 46% (95% CI 32-65%).

Patients who meet stringent eligibility criteria for liver transplantation constitute approximately 3% of patients with iCCA. The observed survival exceeds benchmarks established for systematic therapy alone and is likely attributable to favorable tumor biology and hepatic artery infusion chemotherapy.