Expanding indications for liver transplantation in the era of liver transplant oncology

Abstract

Despite numerous advances and emerging data, liver transplantation in the setting of gastrointestinal malignancies remains controversial outside of certain accepted indications. In an era of persistent organ shortage and increasing organ demand, allocation of liver grafts must be considered carefully. While hepatocellular carcinoma and hilar cholangiocarcinoma have become accepted indications for transplantation, tumor size and standardized multi-disciplinary treatment protocols are necessary to ensure optimal patient outcomes. As more studies seeking to expand the oncologic indications for liver transplantation are emerging, it is becoming increasingly clear that tumor biology and response to therapy are key factors for optimal oncologic outcomes. In addition, time from diagnosis to transplantation appears to correlate with survival, as stable disease over time portends better outcomes post-operatively. Identifying aggressive disease pre-transplant remains difficult with current imaging and tissue sampling techniques. While tumor size and stage are important prognostic predictors for most malignancies, patient and tumor selection protocols are necessary. As the fields of medical and surgical oncology continue to evolve, it is clear that a protocolized interdisciplinary treatment approach is necessary for combatting any cancer effectively. Disease stability over time and response to neoadjuvant therapy may be the best predictors for successful patient outcomes and can be easily incorporated in our treatment paradigms. Current data evaluating liver transplantation for expanded oncologic indications such as: expanded criteria hepatocellular carcinoma, intrahepatic cholangiocarcinoma, mixed tumors, and liver limited metastatic colorectal carcinomas, incorporate multi-modal therapies and evaluation of tumor treatment response. While further investigation is necessary, initial results suggest there is an expanded role for transplant surgery in malignancy in a new era of liver transplant oncology.

Keywords: Liver transplantation; Transplant oncology; Intrahepatic cholangiocarcinoma; Hepatocellular carcinoma; Colorectal metastases; Mixed hepatocholangiocarcinoma

Core Tip: Liver transplantation in the setting of malignancy is currently limited to patients with hepatocellular carcinoma and hilar cholangiocarcinoma who meet specific criteria. While more expanded indications remain controversial, data that a wider spectrum of gastrointestinal malignancies may be amenable to liver transplant is emerging. Pre-transplant tumor characteristics and peri-transplant multi-modal treatment protocols can be combined to successfully refine patient selection and dramatically improve patient outcomes. Here we review the current literature for liver transplantation in the setting of select hepatic and nonhepatocellular liver-limited gastrointestinal malignancies.