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Hakeem et al. Hepatoma Res 2023;9:38 https://dx.doi.org/10.20517/2394-5079.2023.59 Page 5 of 14

Inclusion criteria

≤ 2 cm tumours with background chronic liver disease.

Resection is precluded because of underlying liver function or the location of the tumour.

Biopsy-proven and to exclude patients with mixed hepatocellular/cholangiocellular carcinoma (cHCC-
CCA).

No signs of extrahepatic metastatic disease on imaging.

Good performance status; The Eastern Cooperative Oncology Group (ECOG) 0 or 1.

Signed, informed consent.

Exclusion criteria

Patients with extrahepatic disease or multiple tumours or satellite lesions.

Patients with previous liver resection for intrahepatic cholangiocarcinoma.

Patients not fit for LT due to other surgical or anaesthetic reasons.

Contraindications to liver resection

The FTWG recognised the importance of providing clear guidelines regarding the contraindications to liver
resection, which include:

Patients with advanced liver cirrhosis.

Patient with inadequate functional liver remnant.

Inability to obtain a curative intent (R0) resection.

Presence of extrahepatic disease, lymph node metastases, or multicentric tumours.

The FTWG expressed concern that the number of patients diagnosed with biopsy-proven iCCA measuring
≤ 2 cm would be limited, owing to the difficulties in radiologically diagnosing nodules smaller than 2 cm in
cirrhotic patients [31-34] . Solitary iCCA > 2-5 cm was discussed as a potential inclusion criterion. In fact, the
French multicentre study showed that the outcomes in the > 2-5 cm group are comparable to the outcomes
of tumours ≤ 2 cm very early iCCA, but this included patients with both iCCA (49%) and
cHCC-CCA (51%), the latter has shown to have better overall survival outcomes [19,35,36] . According to the
authors, the use of magnetic resonance imaging (MRI) and increased vigilance in cases where radiographic
findings are atypical for HCC, combined with advancements in radiological techniques, could lead to a
[37]
higher rate of preoperative diagnosis of iCCA and cHCC-CCA . However, this remains easier for tumours
up to 5 cm in size and very challenging for tumours smaller than 2 cm. The FTWG concluded that we