Liver Transplantation After Chemotherapy and SIRT for Unresectable Intrahepatic Cholangiocarcinoma: Journal of Hepatology | July 2026

Introduction:

Liver transplantation (LT) has traditionally not been recommended for unresectable intrahepatic cholangiocarcinoma (iCCA) because of historically poor outcomes. This study evaluated whether neoadjuvant chemotherapy combined with selective internal radiation therapy (SIRT) could identify a highly selected group of patients suitable for curative liver transplantation.

Why was this study needed?

• Most patients with iCCA present with unresectable disease and have limited curative treatment options.
• Historical liver transplantation outcomes for iCCA have been poor, leading to exclusion from transplant guidelines.
• Chemotherapy plus SIRT can achieve prolonged disease control and tumor downstaging in selected patients.
• Better selection criteria are needed to identify patients who may benefit from transplantation.
• Prospective evidence supporting response-based transplantation strategies is lacking.

Results:

• Highly selected patients with stable, liver-only unresectable iCCA who underwent neoadjuvant chemotherapy plus SIRT followed by liver transplantation achieved an outstanding 100% five-year overall survival.
• Five-year progression-free survival was 44%, with recurrence occurring in a minority of patients, yet no patient died from tumor progression during follow-up.
• Only about 5% of the entire unresectable iCCA cohort qualified for transplantation, emphasizing the importance of strict patient selection and prolonged disease stability before LT.

Clinical Impact:

This study challenges the traditional view that unresectable iCCA is an absolute contraindication to liver transplantation. It supports a multidisciplinary, response-based "test-of-time" strategy, where sustained disease control after chemotherapy and SIRT—not tumor size alone—determines transplant eligibility. Larger prospective studies are needed before this approach can be widely adopted.

Bottom Line:

Liver transplantation may become a curative option for a carefully selected subgroup of patients with unresectable liver-limited iCCA who achieve durable disease control after chemotherapy and SIRT. Treatment response appears to be a more important predictor of post-transplant success than initial tumor size.