Liver transplantation for patients with colorectal liver metastases

December 3, 2024

The American Cancer Society estimates that more than 150,000 people will be diagnosed with colorectal cancer in the U.S. this year, and about 50% of them will develop metastases.

Surgical resection to remove colorectal liver metastases can extend the 5-year survival rate to 40% to 60% in patients who are suitable candidates. Although advances in systemic therapy and interventional radiology can turn patients who are otherwise ineligible for surgical resection into candidates for surgery, the vast majority of patients have disease that is too advanced for resection. I am suffering.

Studies supporting liver transplantation for colorectal liver metastases

In highly selective cases, liver transplantation can significantly improve the outcome of patients with colorectal liver metastases and is an important option when other treatments are not possible.

Liver transplantation is an effective treatment for primary liver malignancies, such as hepatocellular carcinoma and hilar cholangiocarcinoma, with better outcomes than surgical resection. Patients with metastatic neuroendocrine tumors treated with liver transplantation have also demonstrated improved long-term survival when compared to systemic therapy alone.

The 2024 TransMet study, published in The Lancet, is the first randomized controlled trial to show improved survival for patients who received chemotherapy plus a liver transplant compared to patients who received chemotherapy alone. This is facility research.

The study's authors believe that increased survival is due to three key factors, including strict patient selection criteria, implementation of an expert panel to evaluate liver transplant candidates, and rapid follow-up of transplant patients to limit tumor progression. We believe that this is likely due to several factors.

The results of the TransMet study support that unresectable colorectal liver metastases are the criterion for transplantation. The 5-year overall survival rate of 73% is comparable to survival rates seen in other patients recommended for liver transplantation. The results may also signal a change in how liver transplantation is viewed as a treatment or cure for patients with metastatic dissemination.

Prior research laid the foundation for innovative treatments

The Norwegian SECA-1 study showed a 60% survival rate after 5 years. In the study, published in Annals of Surgery in 2015, 21 patients received neoadjuvant chemotherapy and then underwent liver transplantation. Although overall survival was acceptable, recurrence rates remained high, with only 33% of patients having no evidence of disease at maximum follow-up.

Results from an additional study by the same group, using more stringent inclusion criteria, were published in Annals of Surgery in 2020. Eligible patients had at least a 10% radiographic response rate to chemotherapy and an interval of at least 1 year between diagnosis and transplantation. In this study, the 5-year survival rate was 83%.

Further studies attempt to compare these results with current treatments for colorectal liver metastases. The results show positive trends in improved survival when compared to chemotherapy, lower tumor burden when compared to portal vein embolization and metastasectomy, as well as a clear increase in the effectiveness of the same treatment with higher tumor burden. demonstrated the benefits. This data has influenced the adoption of aggressive transplant protocols for patients with colorectal liver metastases at several centers in the United States.

“The results of these studies support liver transplantation as a viable treatment for patients who may not be candidates for other curative therapies,” said Dennis M. Harnois, M.D., a transplant hepatologist at the Mayo Clinic in Florida. It continues,” he said. “Our transplant team has been implementing this innovative treatment since 2023, adding it to a powerful suite of therapies designed to treat metastatic colorectal cancer.”

Mayo Clinic Treatment Options

Mayo Clinic pioneered transplant surgery for the treatment of colorectal liver metastases and is one of the few centers in the United States offering this highly complex procedure.

To be eligible for transplantation, patients must have surgically unresectable colorectal liver metastases and the primary colorectal tumor must have been removed. Patients must be 70 years of age or younger at the time of publication or must be candidates for liver transplantation.

Oncological criteria for consideration of transplantation are:

• Stage T4a or below in primary tumor pathology.
• There is no extrahepatic disease.
• Carcinoembryonic antigen (CEA) less than 80 micrograms/liter or more than 50% reduction from maximum CEA.
• After the presence of liver metastases, six months of chemotherapy was completed.
• No evidence of tumor progression.
• There are no BRAF v600E variants.
• There is no microsatellite high instability (MSI-H) or Lynch syndrome.

Candidates will undergo a standard workup for transplantation, as well as an MRI and PET-CT scan of the abdomen and pelvis to rule out extrahepatic disease. If approved by the transplant committee, patients will be switched from their current chemotherapy to capecitabine alone before being placed on the transplant list.

For more information

Dueland S, etc. Chemotherapy or liver transplant for unresectable liver metastases due to colorectal cancer? Surgical records. 2015;261:956.

Dueland S, etc. Survival after liver transplantation for patients with unresectable liver-only colorectal metastases. Surgical records. 2020;271:212.

Dueland S, etc. Survival outcomes after portal vein embolization and liver resection compared with liver transplantation for patients with extensive colorectal cancer liver metastases. JAMA surgery. 2021;156:550.

Adam R et al. Liver transplantation plus chemotherapy versus chemotherapy alone (TransMet) in patients with permanently unresectable colorectal liver metastases: Results of a multicenter, open-label, prospective, randomized controlled trial. Lancet. 2024;404:1107.

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