Liver Transplantation May Be An Option For Select Patients With Metastatic Colorectal Cancer

Certain patients with colorectal cancer that has spread to the liver have a higher five-year survival rate with a liver transplant than with portal vein embolization and resection, a new study suggests.

An analysis of data from 50 patients who received a transplant and 53 who had resections revealed that five-year survival among those who received a transplant was significantly higher, whether their tumor burden was low or high, according to the results published in JAMA Surgery.

"Liver transplantation may be the best medical treatment option for colorectal cancer patients with extensive liver metastases," said the study's lead author, Dr. Svein Dueland, a senior consultant in oncology at the Experimental Transplantation and Malignancy Research Group at the Oslo University Hospital in Norway. "The problem is the world-wide scarcity of donor grafts necessary for the treatment."

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Transplantation makes sense when patients are carefully selected, Dr. Dueland said in an email.

"Highly selected colorectal cancer patients receiving a liver transplant may obtain overall survival of more than 10 years after a liver transplant," he added. "The standard treatment option for these patients with non-resectable liver metastases is palliative chemotherapy with median overall survival of about two years."

Only a minority of colorectal cancer patients with liver metastases will be candidates for this treatment, Dr. Dueland noted. "Patients with metastatic lesions in other organs in addition to liver will be excluded from liver transplantation."

To explore whether outcomes would be better for patients if they had a liver transplant rather than a resection following portal vein embolization (PVE) to expand the volume of the future remnant liver, Dr. Dueland and his colleagues compared the results of liver transplant in 50 patients to resection in 53.

Among the 21 patients who had a low tumor burden (less than 10 lesions and no tumor measuring more than 5.5 cm or greater), five-year survival was 72.4% in transplant recipients as compared to 53.1% among 23 patients who received PVE and resection.

Among patients with a high tumor load (greater than nine tumors or the largest tumor measuring more than 5.5 cm), five-year survival was 33.4% with liver transplant, as compared to 6.7% with PVE and resection. With high tumor load and left-sided primary tumors, overall five-year survival was 45.3% with liver allograft and 12.5% with PVE and resection, the authors note.

For patients with a high tumor burden, median overall survival in transplant recipients was 40.5 months, as compared to 19.2 months in the PVE group.

"The main takeaway point of this article is that liver transplantation is an option in highly selected patients with colorectal metastatic disease to the liver," said Dr. James P Celebrezze, an assistant professor of surgery in the division of colon and rectal surgery at the University of Pittsburgh School of Medicine.

"To expound, liver metastasis is a common cause of colorectal cancer death as up to half of patients will present with or develop metastatic disease in their course, with the most common site being liver," Dr. Celebrezze said in an email. "Very often, these patients are treated with chemotherapy with varying results (vastly improved over the previous three decades) but few are found to be candidates for resection of all their metastatic burden. Other modalities of liver-directed treatment are available and techniques to improve the number of resectable patients are being investigated. Liver transplantation therefore represents yet another tool to be potentially utilized in highly selected patients that have no other options."

Even though livers for transplant are scarce, transplants could be an option for some patients with colorectal cancer that has spread to the liver, he noted.

"I believe that liver transplantation in metastatic colorectal cancer to the liver can make sense even when organs are limited," said Dr. Celebrezze, who was not involved in the new research. "If proper selection criteria are utilized and considered in a multi-disciplinary team approach, highly skilled transplant surgical teams are available, and careful analysis of results either via clinical trials or registries is done, then liver transplantation is a viable option. The indications for liver transplantation have certainly evolved since its early days and transplantation for otherwise incurable metastatic disease is a possible evolutionary step."

—Linda Carroll

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