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Page 8 of 14 Hakeem et al. Hepatoma Res 2023;9:38 https://dx.doi.org/10.20517/2394-5079.2023.59

ablation or any other locoregional therapy on the waiting list. Any drop out/death on the waiting list will be
notified to the NHSBT and appropriate root cause analysis will be performed.

SURGICAL PROTOCOL
Transplant surgery will be similar to transplantation for other indications. Unlike the pCCA patients, the
FTWG did not recommend staging laparoscopy, as it is unlikely to add benefit in small iCCA tumours. The
group discussed the pros and cons of routine lymphadenectomy. It was decided that formal
lymphadenectomy is not recommended as a routine, as it is very unlikely that a ≤ 2 cm tumour will
disseminate to the nodes. The lymph nodes that are part of the explant specimen will obviously be included
for histological examination.

POST-TRANSPLANT IMMUNOSUPPRESSION AND FOLLOW-UP
The standard of care following LR for iCCA is adjuvant chemotherapy based on level 1 evidence [44,45] . For
the service evaluation on LT for iCCA, patients will be managed with no adjuvant chemotherapy. The
evidence for chemotherapy pre- and post-LT for iCCA is with tumours that were large and unresectable .
[20]
However, the published literature with good survival outcomes from very early tumours from the
multicentre study and the UK data is without adjuvant therapy [17,18,25] . The current protocol on
chemotherapy will be subject to review and these recommendations may evolve based on new evidence.

After LT for iCCA, the goal of immunosuppression is to maintain a balance between the risk of graft
rejection and the risk of disease recurrence [3,46] . The FTWG recommends that for the first 6 weeks post-LT,
the immunosuppressant protocol will be CNI-based, with either mycophenolate mofetil (MMF) or
azathioprine (AZT) as the second agent and a period of steroids for about six weeks. Sirolimus, a
mammalian target of rapamycin inhibitor (mTORi), has been found to have a positive impact on disease-
free outcomes after LT in patients with HCC [47,48] . However, there are no such data available for CCA
patients; hence, the FTWG did not feel any indication to convert CNI to mTORi. To facilitate renal sparing
in the initial period, interleukin-2 (IL-2) inhibitors such as Basiliximab may be used at the discretion of
individual units for induction and to maintain low CNI concentration. As no study has adequately
evaluated either the role of post-LT immunosuppression in reducing the risk of recurrence or the
effectiveness of adjuvant therapy in this setting, future studies should focus on identifying patients with high
[23]
risk of recurrence who may benefit from adjuvant therapy .
Patients with hepatitis B virus (HBV) related cirrhosis who undergo LT will typically receive hepatitis B
immunoglobulin (HBIG) in the peri-transplant period to prevent HBV reinfection of the transplanted liver.
Additionally, they will be prescribed oral antiviral medications to suppress the replication of HBV and
reduce the risk of post-transplant recurrence of the virus. Standard centre-based protocols will be followed
for similar indications.

There are no clear guidelines regarding the duration and frequency of follow-up for surveillance after LT for
iCCA . The post-transplant surveillance recommended by the FTWG includes assessment of tumour
[27]
marker (CA 19-9) at 3 monthly intervals for the first 3 years (to interpret the results using pre-LT values as
the baseline) and cross-sectional imaging in the form of dual-phase CT of chest, abdomen and pelvis at 6
monthly intervals for the first 2 years. After 2 years, the cross-sectional imaging is recommended on an
annual basis until the end of 5 years and the tumour markers are recommended at 6 monthly intervals,
again until the end of 5 years [Figure 2]. The FTWG recommends that although the schedule may be too
elaborate for a service evaluation, it must be adapted to have consistency in monitoring outcomes.