Liver transplant is an effective therapy for patients with primary liver cancer, and outcomes after transplantation are often superior to surgical resection. But the pool of potential patients is increasing, as transplantation is now emerging as an attractive option for select patients with nonresectable colorectal cancer (CRC) liver metastases, as well as those with intrahepatic cholangiocarcinoma (CCA).
Transplant is here to stay
To date, the only curative or potentially curative therapy for patients with CRC liver metastases and intrahepatic CCA has been the combination of systemic therapies and R0 resection, said Gonzalo Sapisochin Cantis, MD, associate professor, department of surgery, University of Toronto.
The new idea is that, for patients with unresectable disease, total hepatectomy followed by a liver transplant may be a promising strategy. “This is a very hot topic in transplant oncology,” he said.
Liver transplantation is already established as the best treatment option for patients with primary hepatocellular carcinoma, which has become the main indication for liver transplantation at many centers.
For patients with CRC metastases and intrahepatic CCA, liver transplantation may help cure some patients by extending the conventional margins of surgical oncology, he suggested. “This is basically going to work in patients who have exclusive liver-restricted disease and not in those with metastatic disease. The efficacy is going to be seen by objective and sustained response to some sort of neoadjuvant therapy.”
However, Dr. Sapisochin emphasized liver transplantation is not an option for every patient. “We’re going to have to have clear inclusion and exclusion criteria that need to be defined a priori.”
Intrahepatic CCA has historically been considered a contraindication for liver transplantation. Surgical resection is the preferred first-line treatment and the only one that is potentially curative, he explained. However, most patients are not candidates for surgery, and even if they do have a resection, many of these patients will experience a recurrence, usually in the liver.
There are some studies that support transplantation in this patient population, including one by Dr. Sapisochin and colleagues. That study looked at patients who were transplanted under the assumption that they had hepatocellular carcinoma but were found to actually have intrahepatic CCA. The recurrence rate at 5 years was 18%, and 5-year survival was 65%.
“We were able to show that those patients with small tumors actually can do very well after transplant, with survivals over 70%-80%, which in this population is a very good outcome,” he said.
Transplant for CRC metastases
Unresectable liver metastases from colorectal cancer can also be challenging to treat, he said. Surgical resection is the only potential cure with a combination of systemic chemotherapy, but only a minority of patients are candidates for surgery.
Data supporting transplantation for CRC metastases have been emerging. One trial was conducted by researchers in Norway, who developed the Oslo score for risk stratification. “Those with risk factors had worse outcomes, and obviously, having a large tumor diameter, a high CEA (carcinoembryonic antigen), progressing on chemotherapy, or a short interval between the primary resection and the transplant were risk factors for recurrence,” Dr. Sapisochin said.
The 10-year survival among patients with a low Oslo score was 50%. “We’re talking about patients who had no resection possibility and received a transplant after systemic chemotherapy, and they had a 10-year survival of 50%,” he emphasized.
However, Dr. Sapisochin acknowledged the biggest problem transplant surgeons face is that there are not enough donor organs.
One solution is living donor liver transplantation. “Given that this is an unlimited source, you can utilize this as extended criteria and it adds another graft to the system,” he explained.
“We have a protocol for living donor liver transplantations for patients with colorectal liver metastasis,” Dr. Sapisochin said. “We’ve done seven cases so far with pretty good outcomes. One patient, unfortunately, passed away 39 months after transplant with lung metastases, but the rest are alive with no recurrence.”*