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Page 6 of 9 Akabane et al. Hepatoma Res 2023;9:29 https://dx.doi.org/10.20517/2394-5079.2023.45

[56]
survival rates in patients with iCCA . Consequently, given the considerable resources and the requirement
for chronic immunosuppression associated with transplantation, the option of liver resection should be
given serious consideration, particularly in cirrhotic patients with well-preserved liver function. Living
donor liver transplantation (LDLT) is an alternative to deceased donor liver transplantation that can help
alleviate the organ shortage. In LDLT, a healthy living donor donates a portion of their liver to the recipient,
[57]
allowing both the donor’s and recipient’s livers to regenerate to near-normal size and function . Although
LDLT has been successfully utilized in patients with HCC, its application in iCCA patients remains limited
and warrants further investigation. A 2021 meta-analysis by Ziogas et al. indicated that merely 6.6% of all
liver transplantations for iCCA were performed with LDLT . LDLT should only be considered when the
[40]
potential risk to the donor can be justified by a reasonable outcome for the recipient. As the outcome for the
donor improves, even after right-sided hepatectomy, an ideal 5-year OS post-liver transplantation of 83.3%,
as reported by Lunsford et al., can be justified . Given the low median OS of 10.3 months for patients with
[9]
advanced cholangiocarcinoma, LDLT could be a valuable option for tumors otherwise deemed non-
resectable . Strategies to expand the donor pool include the utilization of marginal donors, such as
[58]
donation after circulatory death (DCD) livers, aged donors, or donors initially discarded but subsequently
recovered using machine perfusion techniques . Additionally, donors with a history of cancer and
[59]
moderate/high transmission risks, such as neuroblastoma, breast cancer, and colon cancer, could be
considered in select cases .
[60]
Xenotransplantation, the transplantation of organs from animals to humans, is an emerging field with the
potential to address the shortage of donor livers. Preclinical studies have demonstrated the feasibility of
employing pig livers for transplantation; however, significant immunological and ethical challenges must be
overcome before implementing this approach in clinical practice .
[61]

Patients with iCCA face unique challenges within the context of liver transplantation, as they often fail to
meet traditional criteria for transplantation based on tumor size and number. The use of exception points,
which grant additional priority on the waiting list to patients with specific medical conditions, could help to
[62]
address these challenges and ensure that iCCA patients have access to transplantation when appropriate .
CONCLUSION
The prognosis of iCCA remains challenging due to the complexity and aggressiveness of the disease. While
liver transplantation provides a potentially curative option for a select group of patients with early-stage
iCCA, particularly those with liver cirrhosis, its application in advanced iCCA lacks robust evidence.
Notably, studies suggest that integrating neoadjuvant and adjuvant therapies may improve post-transplant
outcomes, opening avenues for further research. However, in the context of donor scarcity, careful
evaluation and balance of risk and benefit become paramount. The evolving understanding of iCCA and the
continual development of novel treatment strategies promise to refine and enhance the current therapeutic
landscape.

DECLARATIONS
Authors’ Contributions
Participated in research design; Akabane M, Sasaki K
Participated in the writing of the paper; Akabane M, Sasaki K
Participated in the critical review: Akabane M, Imaoka Y, Sasaki K