Intrahepatic cholangiocarcinoma (ICC) typically has an insidious onset, and most patients have already progressed to advanced stages by the time of initial diagnosis, missing the opportunity for radical surgery. Surgical treatment is the main approach for ICC, but the high early recurrence rate after surgery and poor prognosis remain significant challenges. In recent years, there have been continuous breakthroughs in chemotherapy, immunotherapy, targeted therapy, and combination therapies for ICC, ushering in a new era for systemic treatment. With the improvement of treatment effects, conversion therapy, and neoadjuvant therapy have emerged as prominent topics of interest. However, with the deepening of clinical diagnosis and treatment practices, complex and unresolved issues have gradually emerged, triggering extensive discussions among scholars at home and abroad. Currently, there is no clear, standardized diagnostic and therapeutic process for conversion therapy and neoadjuvant therapy in the guidelines of the National Comprehensive Cancer Network or the Chinese Society of Clinical Oncology. This article aims to comprehensively review the latest progress in neoadjuvant and conversion therapy for ICC and deeply explore the controversial focuses therein, with the expectation of providing useful references for clinical practice and promoting the further development of this field.