A Novel Concept for Partial Liver Transplantation in Nonresectable Colorectal Liver Metastases: The RAPID Concept

New trends in surgery for colorectal liver metastasis

By presenting the most up-to-date findings and incorporating the latest evidence, this article seeks to present a comprehensive guide for navigating the complexities inherent in the management of colorectal liver metastasis. It aims to serve as a valuable resource offering clinicians and healthcare professionals an understanding of the diverse modalities and approaches available for treating this challenging and multifaceted disease. In an era of rapidly evolving medical knowledge, this article examines the latest insights to make informed decisions in the realm of colorectal liver metastasis management. The article does not only highlight the up-to-date knowledge but also provides the evidence for existing therapeutic strategies. This practical tool provides evidence-based recommendations to clinicians, thereby contributing to the ongoing advancement of effective treatment strategies for this challenging disease.

Immunosuppression in liver transplant oncology: position paper of the Italian Board of Experts in Liver Transplantation (I-BELT)

Liver transplant oncology (TO) represents an area of increasing clinical and scientific interest including a heterogeneous group of clinical-pathological settings. Immunosuppressive management after LT is a key factor relevantly impacting result. However, disease-related guidance is still lacking, and many open questions remain in the field. Based on such a substantial lack of solid evidences, the Italian Board of Experts in Liver Transplantation (I-BELT) (a working group including representatives of all national transplant centers), unprecedently promoted a methodologically sound consensus conference on the topic, based on the GRADE approach. The group final recommendations are herein presented and commented. The 18 PICOs and Statements and their levels of evidence and grades of recommendation are reported and grouped into seven areas: (1) risk stratification by histopathological and bio-molecular parameters and role of mTORi post-LT; (2) steroids and HCC recurrence; (3) management of immunosuppression when HCC recurs after LT; (4) mTORi monotherapy; (5) machine perfusion and HCC recurrence after LT; (6) physiopathology of tumor-infiltrating lymphocytes and immunosuppression, the role of inflammation; (7) immunotherapy in liver transplanted patients. The interest in mammalian targets of rapamycin inhibitors (mTORi), for steroid avoidance and the need for a reduction to CNI exposure emerged from the consensus process. A selected list of unmet needs prompting further investigations have also been developed. The so far heterogeneous and granular approach to immunosuppression in oncologic patients deserves greater efforts for a more standardized therapeutic response to the different clinical scenarios. This consensus process makes a first unprecedented step in this direction, to be developed on a larger scale.

Current role and perspectives of living donor liver transplantation for hepatocellular carcinoma: systematic review of the past 20 years

Hepatocellular carcinoma (HCC) poses a significant global health challenge, and liver transplantation (LT) remains the best curative option. Living donor liver transplantation (LDLT) emerged as a potential solution to organ scarcity, reducing waitlist times. This comprehensive review explores LDLT practices, focusing on patient selection criteria and oncologic outcomes. A systematic review following PRISMA guidelines included 50 studies (2004-2023) with 8062 patients. Data encompassed baseline characteristics, HCC features, and oncologic outcomes. Further analysis categorized results by geography and publication year. Heterogeneity in patient demographics, tumor burden, and transplant characteristics was observed. Recent LDLT series demonstrated a shift towards refined selection criteria, increased neoadjuvant treatment, and improved oncologic outcomes. Geographic disparities revealed unique challenges in Eastern and Western practices. LDLT proves effective for HCC, addressing donor shortages. Evolving practices highlight the importance of refining inclusion criteria and optimizing tumor management. While geographic differences exist, LDLT, when judiciously applied, offers promising outcomes.

Liver transplantation for intrahepatic cholangiocarcinoma: who, when and how

PURPOSE OF REVIEW

Using transplant oncology principles, selected patients with intrahepatic cholangiocarcinoma (iCCA) may achieve long-term survival after liver transplantation. Strategies for identifying and managing these patients are discussed in this review.

RECENT FINDINGS

Unlike initial reports, several modern series have reported positive outcomes after liver transplantation for iCCA. The main challenges are in identifying the appropriate candidates and graft scarcity. Tumor burden and response to neoadjuvant therapies have been successfully used to identify favorable biology in unresectable cases. New molecular biomarkers will probably predict this response in the future. Also, new technologies and better strategies have been used to increase graft availability for these patients without affecting the liver waitlist.

SUMMARY

Liver transplantation for the management of patients with unresectable iCCA is currently a reality under strict research protocols. Who is a candidate for transplantation, when to use neoadjuvant and locoregional therapies, and how to increase graft availability are the main topics of this review.

Liver Transplantation for Unresectable Colorectal Liver Metastasis: Perspective and Review of Current Literature

The treatment of unresectable colorectal liver metastasis (CRLM) has previously been limited to palliative chemotherapy. Traditionally, the role of liver transplant has not been associated with sufficient survival to justify a patient undergoing a major operation with the associated requirement for postoperative immunosuppression. With improvements in chemotherapy options, a certain subset of patients can experience stable disease for years, which has prompted investigation into the role of liver transplant in these patients. Several recent studies have shown promising results in well-selected patients, with posttransplant survival approaching that of liver transplant recipients for other diseases. Here, we present a review of the data and current protocols for liver transplant for unresectable CRLM.

Liver Transplantation for Colorectal Liver Metastases

Colorectal cancer is one of the most common malignancies worldwide. Approximately half of the patients diagnosed will develop colorectal liver metastases (CRLM). Liver resection has a 50% 5-year survival; however, only a fourth of cases are resectable. Unresectable CRLM has poor prognosis despite improved systemic and local ablative treatments. Liver transplantation (LT) has demonstrated a survival benefit in initial prospective clinical trials. Current use of LT for CRLM is limited to several randomized trials and high-performing centers. Improving patient selection criteria and perioperative management, LT will likely become an important part of the multidisciplinary approach to managing the metastatic disease.

Post-hepatectomy liver failure: A timeline centered review

BACKGROUND

Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection.

DATA SOURCES

This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis.

RESULTS

This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade.

CONCLUSIONS

Remnant liver volume manipulation is the most consistent preventive measure against PHLF.

Long-Term Survival, Prognostic Factors, and Selection of Patients With Colorectal Cancer for Liver Transplant: A Nonrandomized Controlled Trial

Importance

Liver transplant for colorectal cancer with liver metastases was abandoned in the 1990s due to poor overall survival. From 2006, liver transplant for in nonresectable colorectal liver metastases has been reexamined through different prospective trials.

Objective

To determine predictive factors for transplant long-term survival and cure after liver transplant.

Design, Setting, and Participants

This was a prospective, nonrandomized controlled cohort study derived from different clinical trials on liver transplant for colorectal liver metastases from 2006 to 2020 at Oslo University Hospital. The trials differed in prognostic inclusion criteria, but the design was otherwise identical regarding follow-up scheme to determine disease recurrence, overall survival, and survival after relapse. Final data analysis was performed on December 31, 2021. All patients with colorectal liver metastases from comparable prospective liver transplant studies were included.

Exposure

Liver transplant.

Main outcomes and measures

Disease-free survival, overall survival, and survival time after recurrence were determined in all participants.

Results

A total of 61 patients (median [range] age, 57.8 [28.7-71.1] years; 35 male [57.4%]) underwent liver transplant at Oslo University Hospital. Posttransplant observation time ranged from 16 to 165 months, and no patient was lost to follow-up. Median disease-free period, overall survival, and survival after relapse were 11.8 (95% CI, 9.3-14.2) months, 60.3 (95% CI, 44.3-76.4) months, and 37.1 (95% CI, 4.6-69.5) months, respectively. Negative predictive factors for overall survival included the following: largest tumor size greater than 5.5 cm (median OS, 25.3 months; 95% CI, 15.8-34.8 months; P <.001), progressive disease while receiving chemotherapy (median OS, 39.8 months; 95% CI, 28.8-50.7 months; P = .02), plasma carcinoembryonic antigen values greater than 80 μg/L (median OS, 26.6 months; 95% CI, 22.7-30.6 months; P <.001), liver metabolic tumor volume on positron emission tomography of greater than 70 cm3 (26.6 months; 95% CI, 11.8-41.5 months; P <.001), primary tumor in the ascending colon (17.9 months; 95% CI, 0-37.5 months; P <.001), tumor burden score of 9 or higher (23.3 months; 95% CI, 19.2-27.4 months; P = .02), and 9 or more liver lesions (42.5 months; 95% CI, 17.2-67.8 months; P = .02). An Oslo score of 0 or Fong Clinical Risk Score of 1 yielded 10-year survival of 88.9% and 80.0%, respectively.

Conclusions and relevance

Results of this nonrandomized controlled trial suggest that selected patients with liver-only metastases and favorable pretransplant prognostic scoring had long-term survival comparable with conventional indications for liver transplant, thus providing a potential curative treatment option in patients otherwise offered only palliative care.

Updates and Expert Opinions on Liver Transplantation for Gastrointestinal Malignancies

Transplant oncology is a relatively new field in which transplantation is used to treat patients who would otherwise be unresectable. New anticancer treatment paradigms using tumor and transplant immunology and cancer immunogenomics are emerging. In turn, liver transplantation (LT) has become a potential therapy for certain patients with colorectal cancer (CRC) with liver metastasis, hepatocellular (HCC), cholangiocarcinoma (CCA), and metastatic neuroendocrine tumor (NET) of the liver. Although there are established criteria for LT in HCC, evidence regarding LT as a treatment modality for certain gastrointestinal malignancies is still debated. The aim of this review is to highlight updates in the role of LT for certain malignancies, including HCC, metastatic CRC, hilar CCA, and neuroendocrine tumor (NET), as well as contextualize LT use and discuss controversies in transplant oncology.

Transplant oncology: multivisceral transplantation for neuroendocrine tumor and liver metastasis

PURPOSE OF REVIEW

Neuroendocrine tumor (NET) liver metastatic lesions are often multiple and found to be unresectable. Rationale of multivisceral transplantation (MVT: liver-pancreas-intestine transplantation) include radical and complete resection of primary, visible and invisible metastatic tumors by removing all abdominal organs and the lymphatic system. This review aims to describe the concept of MVT for NET and neuroendocrine liver metastasis (NELM), patient selection, timing of MVT, and posttransplant outcomes and management.

RECENT FINDINGS

Although indication criteria of MVT for NET vary between transplant centers, the Milan-NET criteria for liver transplant are often applied to MVT candidates. Extra-abdominal tumors such as lung and/or bone lesions should be ruled out prior to MVT. Histology should be confirmed as low-grade (G1/G2). Ki-67 should be also checked to confirm biologic features. Timing of MVT remains controversial, whereas many experts recommend 6 months of disease stability prior to MVT.

SUMMARY

Although MVT would not be a standard therapy because of limited access to MVT centers, benefit of MVT should be recognized, which includes its potential ability to better achieve curative resection of disseminated tumors in the abdominal cavity. Early referral of difficult cases to MVT centers should be considered before palliative best supportive cares.

Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go?

Colorectal cancer is the third most common cancer worldwide, and up to 50% of all patients diagnosed will develop metastatic disease. Management of colorectal liver metastases (CRLM) has been constantly improving, aided by newer and more effective chemotherapy agents and the use of multidisciplinary teams. However, the only curative treatment remains surgical resection of the CRLM. Although survival for surgically resected patients has shown modest improvement, this is mostly because of the fact that what is constantly evolving is the indication for resection. Surgeons are constantly pushing the limits of what is considered resectable or not, thus enhancing and enlarging the pool of patients who can be potentially benefited and even cured with aggressive surgical procedures. There are a variety of procedures that have been developed, which range from procedures to stimulate hepatic growth, such as portal vein embolization, two-staged hepatectomy, or the association of both, to technically challenging procedures such as simultaneous approaches for synchronous metastasis, ex-vivo or in-situ perfusion with total vascular exclusion, or even liver transplant. This article reviewed the major breakthroughs in liver surgery for CRLM, showing how much has changed and what has been achieved in the field of CRLM.

New Insights in the Setting of Transplant Oncology

Background and Objectives: Liver transplantation (LT) is the best strategy for curing several primary and secondary hepatic malignancies. In recent years, growing interest has been observed in the enlargement of the transplant oncology indications. This paper aims to review the most recent developments in the setting of LT oncology, with particular attention to LT for unresectable colorectal liver metastases (CRLM) and cholangiocellular carcinoma (CCA). Materials and Methods: A review of the recently published literature was conducted. Results: Growing evidence exists on the efficacy of LT in curing CRLM and peri-hilar and intrahepatic CCA in well-selected patients when integrating this strategy with (neo)-adjuvant chemotherapy, radiotherapy, or locoregional treatments. Conclusion: For unresectable CCA and CRLM management, several prospective protocols are forthcoming to elucidate LT’s impact relative to alternative therapies. Advances in diagnosis, treatment protocols, and donor-to-recipient matching are needed to better define the oncological indications for transplantation. Prospective, multicenter trials studying these advances and their impact on outcomes are still required.

Liver transplantation for isolated unresectable colorectal liver metastases - Protocol for a service evaluation in the United Kingdom - UKCoMET study

BACKGROUND

Liver transplantation (LT) for unresectable colorectal liver metastases (CRCLM) demonstrates good overall survival for selected patients in contemporary studies, with 5-year survival of 80%. A Fixed Term Working Group (FTWG), set up by NHS Blood and Transplant (NHSBT) Liver Advisory Group (LAG), advised whether CRCLM should be considered for LT in United Kingdom. Their recommendation was that LT may be undertaken for isolated and unresectable CRCLM using strict selection criteria as a national clinical service evaluation.

METHODS

Opinions were sought from colorectal cancer/LT patient representatives, experts in colorectal cancer surgery/oncology, LT surgery, hepatology, hepatobiliary radiology, pathology, and nuclear medicine, and appropriate patient selection criteria, referral and transplant listing pathways were identified.

RESULTS

This paper summarises selection criteria for LT in United Kingdom for isolated and unresectable CRCLM patients, and highlights referral framework and pre-transplant assessment criteria. Finally, oncology-specific outcome measures to be utilised for assessing applicability of LT are described.

CONCLUSION

This service evaluation represents a significant development for colorectal cancer patients in United Kingdom and a meaningful step forward in the field of transplant oncology. This paper details the protocol for the pilot study, scheduled to begin in the fourth quarter of 2022 in United Kingdom.

Auxilliary Liver Transplantation According to the RAPID Procedure in Noncirrhotic Patients: Technical Aspects and Early Outcomes

OBJECTIVE

To present technical details and short-term experiences of liver transplantation as a 2-stage procedure using small for size grafts in a multicenter cohort study.

BACKGROUND

Two-stage liver transplantation using small for size grafts should be a feasible procedure with lower morbidity and mortality rates. Retrospective cohort study between 2015 and 2022 with multicenter experience. Twenty-three resection and partial liver transplantation with delayed total hepatectomy procedures for noncirrhotic indications were performed in 6 European centers (20 with grafts from living donors and 3 after deceased donation). Procedure's feasibility, graft volumetric changes, morbidity, and mortality of donor and recipient were explored.

RESULTS

There was a low donor morbidity (4.3%) in our cohort. Hypertrophy of the graft was rapid (mean graft volume increases 107% between both stages) and offered the opportunity for remnant hepatectomy after a median of 14 days. In all cases, portomesenteric flow was routed to the graft by right remnant portal vein ligation. Portal vein inflow modulation to alleviate transient harmful portal hypertension was not needed in any case. Early postoperative mortality (4.3%) of the recipients were low. Ten patients suffered from complications ≥IIIb according to the Clavien-Dindo classification.

CONCLUSIONS

Two-stage liver transplantation is a feasible option for noncirrhotic patients allowing the safe use of small for size grafts and could possibly be extended with caution to liver diseases with portal hypertension and cirrhosis. The resection and partial liver transplantation with delayed total hepatectomy technique might be a viable option for expanding the donor pool given the current organ shortage especially for low-model of end stage liver disease patients.

Liver Transplantation for Hepatic Metastases from Colorectal Cancer: Current Knowledge and Open Issues

More than 40% of patients with colorectal cancer present liver metastases (CRLM) during the course of their disease and up to 50% present with unresectable disease. Without surgical interventions, survival for patients treated with systemic therapies alone is dismal. In the past, liver transplantation (LT) for patients with unresectable CRLM failed to show any survival benefit due to poor selection, ineffective chemotherapeutic regimens, unbalanced immunosuppression and high perioperative mortality. Since then and for many years LT for CRLM was abandoned. The turning point occurred in 2013, when the results from the Secondary Cancer (SECA I) pilot study performed at Oslo University were published reporting a 60% 5-year overall survival after LT in patients with unresectable CRLM. These results effectively reignited the interest in LT as a potential therapy for CRLM, and several trials are undergoing. The aims of this article are to give a comprehensive overview of the available evidence on LT for CRLM, discuss the open issues in this rapidly evolving field, and highlight possible ways to address the future of this fascinating therapeutic alternative for selected patients with CRLM.

Non-colorectal liver metastases: A review of interventional and surgical treatment modalities

Liver metastases (LM) occur in up to 90% either simultaneously with the diagnosis of the primary tumor or at a later time-point. While resection of colorectal LM and resection or transplantation of neuroendocrine LM is part of a standard therapy with a 5-year patient survival of up to 80%, resection of non-colorectal and non-neuroendocrine LM is still discussed controversially. The reason for it is the significantly lower survival benefit of all different tumor entities depending on the biological aggressiveness of the tumor. Randomized controlled trials are lacking. However, reviews of case series with ≥100 liver resections are available. They show a 5-year patient survival of up to 42% compared to only <5% in patients without treatment. Risk factors for poor survival include the type of primary tumor, a short interval between resection of the primary tumor and liver resection, extrahepatic manifestation of the tumor, number and size of the LM, and extent of liver resection. Overall, it has recently been shown that a good patient selection, the technical advances in surgical therapy and the use of a risk score to predict the prognosis lead to a significantly better outcome so that it is no longer justified not to offer liver resection to patients with non-colorectal, non- endocrine LM. Since modern therapy of LM is multimodal, the optimal therapeutic approach is decided individually by a multidisciplinary team consisting of visceral surgeons, oncologists, interventional radiologists and radiologists as part of a tumor board.

Liver transplantation for colorectal secondaries: on the way to validation

PURPOSE OF REVIEW

Liver transplantation for nonresectable colorectal liver metastases (CRLMs) is an emerging field within transplant oncology. This review summarizes recent developments within this field.

RECENT FINDINGS

More stringent selection criteria can yield 5-year survival rates that are similar to conventional indications for liver transplantation. Response to chemotherapy, low carcinoembryonic antigen levels, limited tumor volume and stable disease with observation time exceeding 12 months are fundamental requirements in this context. Radiomic analysis of pre transplant PET/computed tomography scans to determine metabolic tumor volume (MTV) in the liver seems particularly promising with regards to prediction of a favorable tumor biology. MTV values below 70 cm3 are associated with excellent long-term survival after transplantation, whereas the MTV threshold for liver resection seem far smaller. Recent studies put into question whether technical nonresectability per se is a valid inclusion criterion for liver transplantation. In patients with high hepatic tumor burden, but otherwise favorable prognostic features as assessed by the Oslo score, liver transplantation could possibly give a clinically relevant survival benefit compared with liver resection.

SUMMARY

Liver transplantation is feasible treatment option in highly selected patients with nonresectable CRLMs. Robust and stringent selection criteria should be applied according to international consensus guidelines.

Surgical Therapy in Patients with Colorectal Liver Metastases

BACKGROUND

Liver metastases (LM) occur in about 50% of patients with colorectal cancer. Besides the multimodal treatment of the primary tumor, the only way to cure patients with colorectal LM (CRLM) is complete resection. Different surgical procedures for this purpose are available depending on location, size, and number of LM. Additional concepts for patients with primary unresectable LM exist, ranging from Chemotherapy to induction of liver hypertrophy and even liver transplantation. This review intends to provide an overview of the surgical approach.

SUMMARY

Surgical options in the treatment of CRLM are defined and limited by their intraparenchymal location and their proximity to major vessels and intrahepatic bile ducts. Lesions located in the periphery can be excised in a parenchymal sparing fashion with a small tumor-surrounding resection margin of healthy liver parenchyma. If this is not possible, anatomical resections based on segmental boundaries are performed. In these cases, a sufficient functional volume of liver parenchyma after resection (future liver remnant volume [FLRV]) has to be preserved. This FLRV depends on various factors such as bodyweight and possible preexisting liver damage, such as cirrhosis, fibrosis, or chemotherapy-induced liver impairment. Liver hypertrophy via partial occlusion of the portal venous system is a standard procedure for patients with primary unresectable LM to increase FLRV. Furthermore, discussion of liver transplantation in cases of unresectable LM is gaining importance again. A combination of surgery and adjuvant and/or neoadjuvant chemotherapy may be indicated in individual cases, but general evidence-based recommendations cannot be given without further studies.

KEY MESSAGES

Surgical removal of all metastases represents the only option of a potentially curative treatment of UICC stage IV colorectal carcinoma with liver involvement. An interdisciplinary approach consisting of chemotherapeutical downsizing and hypertrophy of the FLRV offers potential curative treatment for patients with initially unresectable metastases. For all others, liver transplantation is seeing a revival showing promising results in overall survival compared to chemotherapy alone.

Survival after liver resection and liver transplantation for colorectal liver metastases: a comparative analysis stratified by metabolic tumor volume assessed by 18F-FDG PET/CT

BACKGROUND

Many patients undergoing resection for colorectal liver metastases (CRLM) recur with poor survival. Overall survival (OS) following liver transplantation (LT) for CRLM is reported to be about 80% at 5 years. In this study, survival following resection versus transplantation for CRLM in patients with moderate (6-70 cm³) metabolic tumor volume (MTV) from the preoperative positron emission tomography (PET) was compared.

METHODS

Disease-free survival (DFS), OS and post recurrence survival (PRS) following resection (n = 18) and LT (n = 12) was compared by using the Kaplan Meier method and log rank test for patients with moderate MTV.

RESULTS

Patients undergoing LT had unresectable metastases, significantly lower age, higher tumor burden score and number of liver metastases, longer time from diagnosis to surgery, and more patients received neoadjuvant chemotherapy. OS at 5 years was 39% in the resection group and 83% in the LT group (P = 0.012). PRS was significantly improved in patients treated with LT compared to resection with 71% alive at 5 years from recurrence compared to 17% in the resection group (P = 0.017).

CONCLUSION

LT for selected patients seems to be superior to resection as treatment for CRLM for patients with moderate MTV.

A contemporary systematic review on liver transplantation for unresectable liver metastases of colorectal cancer

The 5-year overall survival rate of a patient with unresectable metastatic colorectal cancer is poor at approximately 14%. Similarly, historical data on liver transplantation (LT) in those with colorectal liver metastases (CRLM) showed poor outcomes, with 5-year survival rates between 12% and 21%. More recently, limited data have shown improved outcomes in select patients with 5-year overall survival rates of approximately 60%. Despite these reported survival improvements, there is no significant improvement in disease-free survival. Given the uncertain benefit with this therapeutic approach and a renewed investigational interest, we aimed to conduct a contemporary systematic review on LT for CRLM. A systematic review of the literature was performed according to the preferred reporting items for systematic reviews and meta-analysis statement. English articles reporting on data regarding LT for CRLM were identified through the MEDLINE (via PubMed), Cochrane Library, and ClinicalTrials.gov databases (last search date: December 16th, 2021) by 2 researchers independently. A total of 58 studies (45 published and 13 ongoing) were included. Although early retrospective studies suggest the possibility that some carefully selected patients may benefit from LT, there is minimal prospective data on the topic and LT remains exploratory in the setting of CRLM. Additionally, several other challenges, such as the limited availability of deceased donor organs and defining appropriate selection criteria, remain when considering the implementation of LT for these patients. Further evidence from ongoing prospective trials is needed to determine if and to what extent there is a role for LT in patients with surgically unresectable CRLM.

Liver Transplant Oncology: Towards Dynamic Tumor-Biology-Oriented Patient Selection

While liver transplantation was initially considered as a curative treatment modality only for hepatocellular carcinoma, the indication has been increasingly extended to other tumor entities over recent years, most recently to the treatment of non-resectable colorectal liver metastases. Although oncologic outcomes after liver transplantation (LT) are consistently good, organ shortage forces stringent selection of suitable candidates. Dynamic criteria based on tumor biology fulfill the prerequisite of an individual oncological prediction better than traditional morphometric criteria based on tumor burden. The availability of specific (neo-)adjuvant therapies and customized modern immunosuppression may further contribute to favorable post-transplantation outcomes on the one hand and simultaneously open the path to LT as a curative option for advanced stages of tumor patients. Herein, we provide an overview of the oncological LT indications, the selection process, and expected oncological outcome after LT.

[Colorectal cancer liver metastases: current state of the problem, priority treatment approaches]

The review is devoted to the world trends in epidemiology of colorectal cancer and treatment of colorectal cancer liver metastases. The authors analyze the effectiveness of traditional (resection) and modern minimally invasive methods of local destruction (radiofrequency thermoablation, microwave ablation, cryoablation), stereotactic radiotherapy, radiosurgery, targeted therapy and endovascular techniques (chemoinfusion, chemoembolization, radioembolization). It was emphasized that searching for new chemotherapeutic and targeted drugs is one of the reserve ways to improve treatment outcomes in patients with potentially resectable colorectal cancer liver metastases. The possibilities and prospects of liver transplantation as a priority treatment strategy for patients with unresectable bilobar colorectal cancer liver metastases are highlighted.

Liver Transplantation as a Curative Approach for Patients With Nonresectable Colorectal Liver Metastases

OBJECTIVES

Liver transplant is emerging as a potential treatment option for patients with isolated colorectal liver metastasis. In this review article, we analyzed the published literature on liver transplant outcomes in such patients.

MATERIALS AND METHODS

Four prospective studies documenting the clinical outcomes in patients with colorectal liver metastasis who underwent liver transplant were analyzed to study the feasibility of liver transplant in such patients.

RESULTS

The SECA-II trial demonstrated the highest overall survival of 100%, 83%, and 83% at 1, 3, and 5 years, respectively, and disease-free survival of 53%, 44%, and 35%, respectively, with a narrow inclusion criterion. Conversely, extended criteria for selection and donors in arm D of the same trial resulted in median overall survival and disease-free survival of 18 and 4 months, respectively.

CONCLUSIONS

Liver transplant provided more prolonged overall survival compared with other therapeutic modalities. Patients with isolated colorectal liver metastasis of less aggressive biology, good performance status, at least 6 weeks of chemotherapy, low clinical risk scores, and negative nodal disease should be considered for patient selection. Moreover, exclusion criteria consisting of patients with the right-sided primary tumor, less than 3 years to liver transplant after diagnosis, and elevation of carbohydrate antigen (CA19-9) in the presence of BRAF mutation should be explored.

Living Donor Liver Transplantation for Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma is in most transplant regions a contraindication for liver transplantation, even ruling out an active waiting list registration. However, recent studies showed that well-selected patients after a neo-adjuvant treatment benefit from liver transplantation with good long-term outcomes. The role of living donor liver transplantation is unclear for this indication. The current study focuses on LDLT for intrahepatic cholangiocarcinoma.

Successful Simultaneous Subtotal Splenectomy During Left Lobe Auxiliary Liver Transplantation for Portal Inflow Modulation and Severe Hypersplenism Correction: A Case Report

Adult-to-adult living donor liver transplantation with small partial liver grafts often requires intraoperative portal inflow modulation to prevent portal hyperperfusion and subsequent small-for-size syndrome (SFSS). However, there are concerns about the specific morbidity of these modulation techniques. This study aims to lower post-perfusion portal venous pressure and correct severe hypersplenism in a patient with end-stage liver cirrhosis by simultaneous subtotal splenectomy during auxiliary partial orthotopic liver transplantation (APOLT). A 29-year-old man was diagnosed with cryptogenic cirrhosis and severe portal hypertension suffered recurrent acute variceal bleeding, severe thrombocytopenia, and massive ascites before admission to our hospital. After the recipient's left liver was resected, we performed APOLT using his 51-year-old father's left lobe graft with a graft-to-recipient weight ratio of 0.55%. Intraoperatively, simultaneous subtotal splenectomy was performed to lower graft post-perfusion portal vein pressure below 15 mmHg and correct severe hypersplenism-related pancytopenia. The recipient's postoperative hospital course was uneventful with no occurrence of SFSS and procedure-related complications. Platelet and leukocyte counts remained in the normal ranges postoperatively. The living donor was discharged 6 days after the operation and recovered well-with no complications. After a follow-up period of 35.3 months, both the recipient and donor live with good liver function and overall condition. This is the first case report of simultaneous subtotal splenectomy during APOLT using small-for-size living-donated left liver lobes, which is demonstrated to be a viable procedure for modulating portal inflow and correcting severe hypersplenism in selected adult patients with end-stage liver cirrhosis. APOLT using a small-for-size liver graft may be a safe and feasible treatment option for selected adult patients with end-stage liver cirrhosis.

Shifting concepts in the management of colorectal liver metastases

Management of patients with colorectal liver metastases has evolved considerably due to a better understanding of the biology of the disease with concurrent improvements in surgical techniques, oncological strategies and radiological interventions. This review article examines the factors that have contributed to this radical change. Management will be discussed in relation to chemotherapy, surgery and interventional radiology. The addition of chemotherapy and biological agents has greatly extended the reach and scope of surgery. Parenchymal sparing resections, repeat resections, two stage hepatectomy and Associating Liver Partition and Portal Vein ligation are all available to the hepatobiliary surgeon who deals with colorectal liver metastases. Interventional radiology techniques like liver venous deprivation may also replace established surgical practice. Whilst traditionally it was thought that only a few liver metastases could be treated effectively, nowadays tumour number is no longer a limiting factor provided enough functioning liver can be spared and the patient can tolerate the operation.

Advances in liver transplantation for unresectable colon cancer liver metastasis

It is estimated that 50% of patients with colorectal cancer will develop liver metastasis. Surgical resection significantly improves survival and provides a chance of cure for patients with colorectal cancer liver metastasis (CRLM). Increasing the resectability of primary unresectable liver metastasis provides more survival benefit for those patients. Considerable surgical innovations have been made to increase the resection rate and decrease the potential risk of hepatic failure postoperation. Liver transplantation (LT) has been explored as a potential curative treatment for unresectable CRLM. However, candidate selection criteria, chemotherapy strategies, refined immunity regimens and resolution for the shortage of grafts are lacking. This manuscript discusses views on surgical indication, peritransplantation anti-tumor and anti-immunity therapy and updated advances in LT for unresectable CRLM. A literature review of published articles and registered clinical trials in PubMed, Google Scholar, and Clinicaltrials.gov was performed to identify studies related to LT for CRLM. Some research topics were identified, including indications for LT for CRLM, oncological risk, antitumor regimens, graft loss, administration of anti-immunity drugs and solutions for graft deficiency. The main candidate selection criteria are good patient performance, good tumor biological behavior and chemosensitivity. Chemotherapy should be administered before transplantation but is not commonly administered posttransplantation for preventive purposes. Mammalian target of rapamycin regimens are recommended for their potential oncological benefit, although there are limited cases. In addition to extended criterion grafts, living donor grafts and small grafts combined with two-stage hepatectomy are efficient means to resolve organ deficiency. LT has been proven to be an effective treatment for selected patients with liver-only CRLM. Due to limited donor grafts, high cost and poorly clarified oncological risks, LT for unresectable CRLM should be strictly performed under a well-organized study plan in selected patients. Some vital factors, like LT indication and anti-tumor and anti-immune treatment, remain to be confirmed. Ongoing clinical trials are expected to delineate these topics.

Auxiliary Liver Transplantation for Cirrhosis: From APOLT to RAPID: A Scoping Review

OBJECTIVE

To survey the available literature regarding the use of auxiliary liver transplantation (ALT) in the setting of cirrhosis.

SUMMARY BACKGROUND

ALT is a type of LT procedure in which part of the cirrhotic liver is resected and part of the liver graft is transplanted. The cirrhotic liver left in situ acts as an auxiliary liver until the graft has reached sufficient volume. Recently, a two-stage concept named RAPID (Resection And Partial LIver segment 2/3 transplantation with Delayed total hepatectomy) was developed, which combines hypertrophy of the small graft followed by delayed removal of the native liver.

METHODS

A scoping review of the literature on ALT for cirrhosis was performed, focusing on the historical background of RAPID and the status of RAPID for this indication. The new comprehensive nomenclature for hepatectomy ("New World" terminology) was used in this review.

RESULTS

A total of 72 cirrhotic patients underwent ALT [heterotopic (n = 34), orthotopic (APOLT, n = 34 including 5 followed by resection of the native liver at the second stage) and RAPID (n = 4)]. Among the 9 two-stage LTs (APOLT, n = 5; RAPID, n = 4), portal blood flow modulation was performed in 6 patients by deportalization of the native liver (n = 4), portosystemic shunt creation (n = 1), splenic artery ligation (n = 3) or splenectomy (n = 1). The delay between the first and second stages ranged from 18 to 90 days. This procedure led to an increase in the graft-to-recipient weight ratio between 33% and 156%. Eight patients were alive at the last follow-up.

CONCLUSIONS

Two-stage LT and, more recently, the RAPID procedure are viable options for increasing the number of transplantations for cirrhotic patients by using small grafts.

Can Living Donor Liver Transplantation in the United States Reach Its Potential?

Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.

New Indications for Liver Transplantation

Liver transplantation (LT) is an important therapeutic option for the treatment of several liver diseases. Modern LT is characterized by remarkable improvements in post-transplant patient survival, graft survival, and quality of life. Thanks to these great improvements, indications for LT are expanding. Nowadays, clinical conditions historically considered exclusion criteria for LT, have been considered new indications for LT, showing survival advantages for patients. In this review, we provide an updated overview of the principal newer indications for LT, with particular attention to alcoholic hepatitis, acute-on-chronic liver failure (ACLF), cholangiocarcinoma and colorectal cancer metastases.

Liver transplantation versus liver resection for colorectal liver metastasis: a survival benefit analysis in patients stratified according to tumor burden score

Liver transplantation (LT) for colorectal liver metastasis (CRLM) may provide excellent survival rates in patients with unresectable disease. High tumor load is a risk factor for recurrence and low overall survival (OS) after liver resection (LR). We tested the hypothesis that LT could offer better survival than LR in patients with high tumor load. LR performed at Padua University Hospital for CRLM was compared with LT for unresectable CRLM performed both at Oslo and Padua. High tumor load was defined as tumor burden score (TBS) ≥ 9, and inclusion criteria were as in the SECA-I transplant study. 184 patients were eligible: 128 LRs and 56 LTs. 5-year OS after LR and LT was 40.5% and 54.7% (P = 0.102). In the high TBS cohort, 5-year OS after LR and LT was 22.7% and 52.2% (P = 0.055). In patients with Oslo score ≤ 2 and TBS ≥ 9 (13 LR; 24 LT) the 5-year OS after LR and LT was 14.6% and 69.1% (P = 0.002). The corresponding disease-free survival (DFS) was 0% and 22.9% (P = 0.005). Selected CRLM patients with low Oslo score and high TBS could benefit from LT with survival outcomes that are far better than what is achieved by LR.

Long-Term Normothermic Machine Preservation of Partial Livers: First Experience With 21 Human Hemi-Livers

OBJECTIVE

The aim of this study was to maintain long-term full function and viability of partial livers perfused ex situ for sufficient duration to enable ex situ treatment, repair, and regeneration.

BACKGROUND

Organ shortage remains the single most important factor limiting the success of transplantation. Autotransplantation in patients with nonresectable liver tumors is rarely feasible due to insufficient tumor-free remnant tissue. This limitation could be solved by the availability of long-term preservation of partial livers that enables functional regeneration and subsequent transplantation.

METHODS

Partial swine livers were perfused with autologous blood after being procured from healthy pigs following 70% in-vivo resection, leaving only the right lateral lobe. Partial human livers were recovered from patients undergoing anatomic right or left hepatectomies and perfused with a blood based perfusate together with various medical additives. Assessment of physiologic function during perfusion was based on markers of hepatocyte, cholangiocyte, vascular and immune compartments,, as well as histology.

RESULTS

Following the development phase with partial swine livers, 21 partial human livers (14 right and 7 left hemi-livers) were perfused, eventually reaching the targeted perfusion duration of 1 week with the final protocol. These partial livers disclosed a stable perfusion with normal hepatic function including bile production (5-10 mL/h), lactate clearance, and maintenance of energy exhibited by normal of adenosine triphosphate (ATP) and glycogen levels, and preserved liver architecture for up to 1 week.

CONCLUSION

This pioneering research presents the inaugural evidence for long-term machine perfusion of partial livers and provides a pathway for innovative and relevant clinical applications to increase the availability of organs and provide novel approaches in hepatic oncology.

The evolution of surgery for colorectal liver metastases: A persistent challenge to improve survival

Only a few decades ago, the opinion that colorectal liver metastases were a palliative diagnosis changed. In fact, previously, the prevailing view was strongly resistant against resecting colorectal liver metastases. Constant technical improvement of liver surgery and, much later, effective chemotherapy allowed for a successful wider application of surgery. The clinical use of portal vein embolization was the starting signal of regenerative liver surgery, where insufficient liver volume can be expanded to an extent where safe resection is possible. Today, a number of these techniques including portal vein ligation, associating liver partition and portal vein ligation for staged hepatectomy, and bi-embolization (portal and hepatic vein) can be successfully used to address an insufficient future liver remnant in staged resections. It turned out that the road to success is embedding surgery in a well-orchestrated oncological concept of controlling systemic disease. This concept was the prerequisite that meant liver transplantation could enter the treatment strategy for colorectal liver metastases, ending up with a 5-year overall survival of 80% in highly selected cases. In particular, techniques combining principles of 2-stage hepatectomy and liver transplantation, such as "resection and partial liver segment 2-3 transplantation with delayed total hepatectomy" (RAPID) are on the rise. These techniques enable the use of partial liver grafts with primarily insufficient liver volume. All this progress also prompted a number of innovative local therapies to address recurrences ultimately transferring colorectal liver metastases from instantly deadly into a chronic disease in some cases.

Colon Rectal Liver Metastases: The Role of the Liver Transplantation in the Era of the Transplant Oncology and Precision Medicine

The development of liver metastases in colon rectal cancer has a strong impact on the overall survival (OS) of the patient, with a 5-year survival rate of 5% with palliative treatment. Surgical resection combined with pharmacological treatment can achieve a 5-year OS rate of 31–58%. However, in only 20% of patients with colon rectal liver metastases (CRLMs), liver resection is feasible. In highly selected patients, recent trials and studies proved that liver transplantation (LT) for non-resectable CRLM is a surgical option with an excellent long-term OS. The paper aims to review the indications and outcome of LT for CRLMs, with a special focus on immunosuppressive therapy and the management of local and extrahepatic recurrence after LT.

The feasibility of medial segment graft in pediatric liver transplantation revisited by three-dimensional printing

BACKGROUND

The medial segment as a mono-segmental graft was proposed to increase the donor pool for pediatric liver transplantation, but to date, there has been no published case. This study aims to revisit the feasibility of procuring the medial segment graft (MSG) by three-dimensional (3D) printing and ex vivo procedures performed on explanted diseased livers to overcome the gap between theory and clinical implementation.

METHODS

From October 2004 to December 2016, we retrospectively analyzed preoperative computed tomography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography images of our previous live liver donors and identified the indicated anatomy for the MSG, then materialized by 3D printing models to simulate the engraftment. Furthermore, we practiced the procurement procedures on selected explanted diseased livers.

RESULTS

Among 291 analyzed livers, 96 livers (33%) met the arterial criteria for MSG, and two-thirds of them had ideal portal branches for reconstruction. The proposed right border of the MSG was the Cantlie's line, and the left edge was the right side of the umbilical fissure. The mean estimated volume of the MSG was 234 ± 54 ml. Besides, we suggest implanting the MSG as an auxiliary partial graft in an inverted vertical position or a standalone graft with right-side rotation in the right subphrenic space.

CONCLUSION

The procurement of the MSG is feasible based on our results. However, due to the novelty of the procedure, we suggest that the first attempted case of MSG should be implanted as an auxiliary partial graft to maximize patient safety.

LEVEL OF EVIDENCE

Type of study: Case series with no comparison groups EVIDENCE LEVEL: Level IV.

Auxiliary two-staged partial resection liver transplantation

A case report of two patients who underwent auxiliary liver transplantation and two staged hepatectomy was recently published in BMC Surgery. The surgical technique utilised is described as novel but has been published previously also in the setting of chronic liver disease. A new name for this surgical approach therefore seems redundant. The importance of careful hemodynamic monitoring of pressure and flow in the portal vein and artery of the auxiliary graft as well as optimizing venous outflow is paramount to ensure graft regeneration and avoid small for size syndrome. The relevant surgical considerations to ensure optimal safety has also been reported in previous literature. This brief letter to the editor of BMC Surgery gives an overview that put the article content in context with published literature on this transplant surgical technique.

Liver Living Donation for Cancer Patients: Benefits, Risks, Justification

LDLT covers all standard indications for liver transplantation, and the results are similar or even better than for standard DDLT. Due to the donor shortage and long waiting time, LDLT has become a relevant option for patients with liver tumors, provided the expected five-year survival rate is comparable to that of patients receiving a DDLT. Nowadays, LDLT offers the possibility to extend the standard morphometric selection by considering the biological parameters. In the setting of LDLT, we are not only faced with surgical morbidity in the donor, but long-term non-medical problems like psychological complications and financial burden also have to be considered. On the other hand, the benefits to the donor are mainly social and psychological. In LDLT, the donor's altruism is the fundamental ethical principle and it is based on the principles of (1) beneficence (doing good), (2) non-maleficence (avoiding harm), (3) respect for autonomy, and (4) respect for justice (promoting fairness). On top of that, the concept of double equipoise of living organ donation evaluates the relationship between the recipient's need, the donor's risk, and the recipient's outcome. It considers each donor-recipient pair as a unit, analyzing whether the specific recipient's benefit justifies the specific donor's risk in particular oncologic indications. In this light, it is essential to seek adequate informed consent focused on risk, benefits and outcome benefits of both donor and recipient supported by an independent living donor advocate. Finally, the transplant team must protect donors from donation if harm does not justify the expected benefit to the recipient.