More available organs?
R. Mark Ghobrial, MD, PhD, director of the J.C. Walter Jr. Transplant Center at Houston Methodist Hospital, said that, 5 years ago, he was very cautious about liver transplantation for intrahepatic CCA.
He pointed out that, although transplantation for hepatocellular cancer was being done in the 1990s, the results were so poor that a moratorium was placed on the practice. “But now liver transplantation has become the definitive therapy for hepatocellular cancer, and intrahepatic cholangiocarcinoma is going the same way,” he said.
Dr. Ghobrial reiterated that one of the issues in transplantation for oncology patients is the limited supply of available organs, but he believes the landscape for liver transplantation has changed, resulting in more available organs. One factor is that hepatitis C has become curable with the advent of new therapies, and hence, the need for transplantation for patients with this disease has plummeted.
“I’ve done about maybe 800 transplants in the last 5 years. I’ve only transplanted two patients with hepatitis C,” he said. “Now we are doing more transplants for alcoholic liver disease and cancer.”
Improvements in technology are also allowing for more livers to become useable, he pointed out. One example is normothermic machine perfusion, which has entered the clinical arena in the last decade. The technique has shown promising results in improving the quality of marginal organs and increasing the pool of liver grafts.
Another factor that has increased the number of livers available for transplantation is the move to accept organs from circulatory death donors, as well as donations after brain death. “Our transplantation was about 4% of donors after cardiac death, but today this has gone up to almost 16% or 20% of the livers,” Dr. Ghobrial said. “In some centers this has gone up to about 50%.
“Liver transplantation for intrahepatic cholangiocarcinoma and colorectal cancer metastases has come of age for selected patients,” he said.
More caution needed
However, another expert urged some caution, warning that live donation carries risk. Yuman Fong, MD, a surgical oncologist with City of Hope National Medical Center, Duarte, Calif., said that around “1 in 600 live donors die from donation. That is a healthy person dying. This is not a small issue.”
He pointed out that if the criteria for transplant is greatly liberalized, the 5-year survival will not be as high as demonstrated in clinical trials.
Writing about the issue in a recent editorial, Dr. Fong pointed out that cadaveric livers for transplant remain a finite resource and that more than 1,000 patients still die every year on the waiting list for a transplant.
A more reasonable approach would be to advocate for this type of program in regions of the world where cadaveric livers are more plentiful or centers with established living donor transplant programs.
“For us to develop this resource and safeguard patients, family organ donors, and resources, we need to develop what are the best inclusion criteria,” Dr. Fong said. “We have to optimize use of all cadaveric organs and determine if we are willing to transplant borderline organs.”