Intrahepatic cholangiocarcinoma arising from HBV infection may be a highly selected population for liver transplantation

Potential conflict of interest: Nothing to report. Author names in bold designate shared co‐first authorship. TO THE EDITOR: In a recent study in Hepatology, Sapisochin et al.1 introduced prognostic outcomes of liver transplantation (LT) for cirrhotic liver with incidental and misdiagnosed intrahepatic cholangiocarcinoma (iCCA) and concluded that patients with very early iCCA (single tumor ≤2 cm) with cirrhosis might be suitable candidates for LT. In Western countries, a majority of iCCAs develop on the basis of cirrhotic liver, such as primary sclerosing cholangitis, which requires routine serological and imaging examinations, thus providing an opportunity for very early iCCA to be detected. In Eastern countries, a newly identified major risk factor of iCCA is viral hepatitis infection, making early diagnosis of iCCA difficult and rarely transplanted in the Model for End‐Stage Liver Disease (MELD) era. A few recent works have revealed that hepatitis B virus (HBV)‐associated iCCA is a malignancy with distinctive characteristics between hepatocellular carcinoma and iCCA with younger age, a predominance of male patients, frequent elevation of alpha‐fetoprotein, and infrequent lymph node metastasis.2 In addition, survival outcomes of patients with HBV‐associated iCCA have been found to be significantly better than those without HBV infection after hepatic resection.3 Most importantly, the representative hallmark of iCCA, lymph node metastasis, which significantly worsens prognosis and critically contributes to the tumor recurrence after surgical resection, has been found to be significantly more infrequent in HBV‐associated iCCA.4 Therefore, apart from the number and the size of iCCA, HBV infection should also be considered when establishing inclusion criteria of LT for iCCA. In addition, as suggested by Gupta and Gupta,5 the role of antiviral therapy on the outcomes of iCCA upon LT also needs to be evaluated. Because patients with hilar cholangiocarcinoma who have received neoadjuvant therapies have been awarded with a MELD exception score by the United Network for Organ Sharing, the assessment on safety and efficacy of neoadjuvant radiochemotherapy for highly selected iCCA followed by LT should be implemented.