Dr Afsana Elanko
Director of Education, British Association of Surgical Oncology – The Association for Cancer Surgery
Professor Derek M Manas
Consultant Hepatobiliary and Transplant Surgeon, Clinical Director, Newcastle’s Institute of Transplantation, Associate Medical Director: Governance for NHS Blood and Transplant Trustee BASO – The Association for Cancer Surgery
Liver transplantation is providing further options for patients with unresectable liver metastases.
Over the past few decades, the outcomes following liver transplantation (LT) have improved. Five-year patient survival rates in the UK are greater than 80% for adult first-time transplants from deceased donors; hence, indications for transplantation are expanding.
New hope for patients
Since 1996, unresectable hepatocellular cancer (HCC), on the background of liver cirrhosis, has been an indication for LT. Since then, many centres have successfully extended the boundaries for transplanting HCC. As a result, there is renewed interest in liver transplantation as a treatment option for other primary and secondary unresectable liver malignancies.
Improved results from Europe and the US published over the past 15 years, coupled with the poor survival rates seen with current standard therapeutic options, have spearheaded the formation of the UK Transplant Oncology Group. This resulted in the NHS Blood and Transplant (NHSBT) Liver Advisory Group reviewing current practice. In January 2021, they recommended that unresectable liver metastases from neuroendocrine tumours (NET), hilar cholangiocarcinoma (h-CCA) in patients with primary sclerosing cholangitis (PSC), colorectal cancer (CRC) and small (less than 2cm) intra-hepatic cholangiocarcinoma (i-CCA) should be included in the UK national LT program.
Five-year patient survival rates in the UK are greater than 80% for adult first-time transplants from deceased donors.
Evidence based implementation
Based on published literature, we have a ‘road-map’ to follow which will help to facilitate the safe implementation of this transplant oncology program. Following the recommendations from several expert fixed time working groups, the Liver Advisory Group have approved transplantation for:
Hilar CCA in patients with PSC
- Strict patient selection and adherence to the ‘Mayo protocol’ is the recommendation.
- Recent data has demonstrated that survival figures for the subgroup of cirrhotic patients with unifocal tumours less than 2cm are comparable to similar patients with HCC currently being offered LT, thus allowing these patients to be considered.
Neuroendocrine liver metastases (NETLM)
- R0surgical resection is potentially the only means of achieving a cure. Around 10-20% of patients with NETLM are eligible for curative resection.
Colorectal liver metastases (CRLM)
- Based on the Norwegian (SECA-1) pilot study, patients with unresectable CRLM following resection of the colorectal primary tumour, who have completed at least six weeks of chemotherapy, have no extrahepatic disease by a staging CT scan and diagnostic laparoscopy with hilar node sampling may be considered.
Challenges and hope
There are many challenges to overcome, not least the timely ability to allocate an organ to a patient who is eligible and has completed the required neo-adjuvant treatment. With the recent research and development in the area, liver transplantation for unresectable liver metastases may provide new hope for cancer patients.