Con: Liver transplantation for expanded criteria malignant diseases

Abstract

Organ shortage requires policies and guidelines to aid organ allocation along the principles of urgency or utility. Identifying patients with significant benefit and withholding liver transplantation (LT) from patients too sick for transplantation are ongoing challenges, in particular in patients with malignancies. An arbitrary threshold of >50% 5-year overall survival (OS) is broadly considered a minimum standard for LT. In patients transplanted for intrahepatic cholangiocarcinoma (iCC), this was only achieved in select cases and when the tumor had a diameter of <2 cm. In patients with extrahepatic and hilar cholangiocarcinoma (CCC), strict selection criteria and combined preoperative radiotherapy/chemotherapy according to the Mayo protocol showed that acceptable longterm results can be achieved in a single high-volume center but are difficult to repeat elsewhere. Furthermore, only rigorously selected patients with neuroendocrine tumors (NETs) meeting the NET Milan criteria adopted by United Network for Organ Sharing can also have >50% 5-year OS. A prospective study in patients with unresectable colorectal cancer metastases in the liver has shown promising OS rates, but further prospective trials are warranted. Current evidence shows that none of the proposed expanded malignant criteria justify deviation of scarce donor organs to patients with hilar CCC, iCC > 2 cm, metastatic NET beyond NET Milan criteria, or metastatic colorectal cancer (CRC) outside clinical trials.Liver Transplantation 24 104-111 2018 AASLD.Received September 1, 2017; accepted October 4, 2017. Utility of Liver Transplantation for Malignant DiseasesListing, delisting, and allocation policies aim at selecting patients with a projected 5-year survival rate of over 50% and is referred to as rationing. (1) As a result, allocation and distribution policies are not restricted to the best interest of an individual patient. To avoid ethical conflicts and litigations for physicians, treatment guidelines and allocation policies have been introduced by national transplant programs. (2) These recommendations and policies are based on empirical data with the aim to allocate donor livers to patients with the greatest need and best utility to society. (1) Recent reports suggest that selected patients with hepatobiliary malignancies despite advanced tumor stage but favorable tumor biology can have outcomes that are at least equivalent or even better than patients meeting conventional listing criteria. Expanded CriteriaIndividual candidates with tumors exceeding these criteria or with neuroendocrine tumors (NETs) or

Liver transplantation for unresectable pancreatic neuroendocrine tumors with liver metastases in an era of transplant oncology

“…The indication of the conventional technique of two-staged liver resection with portal vein embolization or the rapidly spreading new technique of associating liver partition and portal vein ligation for staged hepatectomy to expand the resectability of wide-spread metastatic liver tumors has been controversial. In an era of transplant oncology, LT should be the last resort for patients who are considered unresectable and otherwise untreatable after an exhaustive multidisciplinary team discussion with all aggressive surgical and medical options on board (29).…”

Living donor liver transplantation with two-stage hepatectomy for patients with isolated, irresectable colorectal liver—the LIVER-T(W)O-HEAL study

“…Schaefer et al did not see liver transplantation for irresectable colorectal liver metastases as standard therapy for these patients. However, despite the critical attitude of their work, the authors concede that in accordance with well-defined patient selection criteria, an expansion might be conceivable [23]. Mazzaferro et al described liver transplantation as a potential curative-oriented option in the management of patients with colorectal liver metastases if certain conditions are fulfilled.…”

Liver transplantation as a lifesaving procedure for posthepatectomy liver failure and iatrogenic liver injuries

“…Salvage LT in case of iatrogenic injuries or posthepatectomy liver failure poses not only medical considerations, but also ethical concerns in the face of organ shortage [20][21][22][23][24]. The availability of organs for transplantation is a crucial limi-tation, which directs the prioritization at each center and complicates the establishment of generally accepted indi-cations, criteria for acceptance, and allocation policies.…”