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Page 4 of 14 Hakeem et al. Hepatoma Res 2023;9:38 https://dx.doi.org/10.20517/2394-5079.2023.59

British Association of Surgical Oncology (BASO), Great Britain & Ireland Hepato Pancreato Biliary
Association (GBIHPBA), British Society of Gastroenterology, and The British Society of Gastrointestinal
and Abdominal Radiology (BSGAR). It also had representation from the LAG, NHSBT and NHS England
(NHSE). AMMF, the largest cholangiocarcinoma charity in the UK and Europe and PSC Support (the UK
PSC patient association) provided very valuable input from the patient and public perspective. The group
also sought advice from the Medical Advisory Board of UK-PSC and the UK Digital Pathology Group.

SUMMARY OF GUIDELINES
The group met at four weekly intervals to address the objectives set out in the initial outline. The main
objectives were to conduct a literature review and provide recommendations on appropriate indications,
patient selection criteria, referral criteria, assessment prior to listing, transplant listing pathways, data
management, and overall quality assurance for the service evaluation. The group put forth the following
guidelines.

LT as an intervention in ≤ 2 cm iCCA with background chronic liver disease should be implemented as a
pilot service evaluation in all seven adult LT units in the UK.

A National Expert Review Panel (NERP) will be formed to manage this emerging indication. The panel will
help with trouble shooting any service evaluation pathway issues, provide quality assurance, overview data
collection and management and will be an access for a “second opinion” if required. The panel will be a
reassurance to patient groups and to individual centres.

Each transplant centre develops a core group of healthcare professionals interested in managing these
patients and complex pathways. This is in keeping with the already established practices seen with HCC and
LT. It is important to get support from Cancer Nurse Specialists along with the traditional support provided
by transplant coordinator teams at each centre. It is acknowledged that surgical management could be
challenging with a learning curve, and it is important that all transplant surgeons are supported to develop
their operative experience.

It is expected that over the first year, 6-8 iCCA ≤ 2 cm will be transplanted within the UK, commencing
December 2022. In order to maintain access to LT for existing indications, the UK iCCA LT protocol has
been designed to be more conservative. However, the protocol will be regularly reviewed by the NERP,
consisting of members from the FTWG, to ensure that it strikes a balance between being restrictive and
allowing enough patients to be assessed for this intervention. At the conclusion of one year, the pilot
programme will undergo a comprehensive national audit to assess safety, graft outcomes, and oncological
results.

As per the ILTS consensus, the FTWG deliberated on the potential benefits of LT for patients with advanced
[27]
iCCA undergoing downstaging using improved chemotherapeutic agents . However, currently, favourable
survival outcomes are lacking, making it an unacceptable indication [20,21,26] . As ongoing clinical trials are
exploring this possibility, the working group decided not to include it in the pilot programme. Once the
programme establishes safety and acceptable oncological outcomes, there is a definite prospect of expanding
the eligibility criteria.

PATIENT SELECTION CRITERIA
To identify patients who would benefit the most from LT, the selection process would involve finding those
with very early iCCA and cirrhosis. The group agreed with the following selection criteria: