Over the past two decades, liver transplantation for cholangiocarcinomas has been controversial. In the early era of transplantation, intrahepatic and hilar cholangiocarcinomas were considered to be ideal indications for liver transplantation. The tumours tend to remain localised within the liver and the liver hilum, respectively, until late in the course of the disease and can often be completely removed by hepatectomy and replacement of a homograft, even if curative resection is not feasible.1,2 Therefore, liver transplantation represents a curative treatment option in patients with cholangiocarcinomas. However, despite cure obtained in a considerable proportion of patients, the long-term results of the procedure were found to be inferior to those of liver transplantation performed on patients with benign diseases or early-stage hepatocellular carcinoma.1–4 In the early 1990s, because of the upcoming organ shortage and the resulting necessity to allocate available organs to patients with the best prospects of success in the long term, cholangiocarcinomas started to be refused as an indication for liver transplantation.5,6
However, numerous patients with cholangiocarcinomas are not suitable for resection due to local tumour extension or insufficient remnant liver function (see Figure 1). In particular, patients with an underlying liver disease, such as primary sclerosing cholangitis (PSC), frequently have unresectable cholangiocarcinomas (see Figure 2). A number of these patients develop cholangiocarcinoma at a younger age, which underlines the need for a curative treatment option in tumours that are not suitable for resection.7 In this group of patients, liver transplantation remains the only chance of long-term survival and cure. Therefore, liver transplantation remains an important tool in the treatment of patients with cholangiocarcinomas.
In recent years, new treatment approaches have markedly improved patient outcomes. However, liver transplantation used in the treatment of cholangiocarcinomas remains complex and the indication needs to take into account the different biological behaviours, the availability of effective alternative treatment modalities, the current transplant allocation criteria and theindividual prognosis.
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