Pro (With Caution): Extended oncologic indications in liver transplantation

Abstract

The success of liver transplantation (LT) in curing cancer (particularly hepatocellular carcinoma and hepatic metastases from neuroendocrine tumors) is based on the augmented oncologic potentials of the total hepatectomy and on restrictive criteria applied to patient selection. Consensus on the grade of expansion of conventional limits and implementation of alternative indications to LT (cholangiocarcinoma and metastases from colorectal cancer) has not been reached. On top of regional/local conditions for wait-list dynamics and organ availability, expanded cancer indications for LT should be explored with caution. Prospective investigations should rely on staging protocols predicting the exclusive hepatic location of cancer; restrictions on clinical conditions, tumor biology, and molecular profile, including the response to neoadjuvant therapies; confirmed tumor nonresectability with curative intent; sufficient life span of the transplant candidates to assess survival and transplant benefit; and use of marginal and extended criteria donors. In conclusion, the arguments supporting moderately loosened criteria for cancer seem more valid today than in the past. Transplant oncology is likely to represent a leading field in the near future, also because comorbidities and transplant-related causes of death are better managed and often eliminated.Liver Transplantation 24 98-103 2018 AASLD.

EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma

“…Hepatocellular carcinoma (HCC) is the only generally accepted indication for solid organ transplantation in cancer and yet, liver transplantation (LT) for HCC represents a prototype for other transplant indications in various cancer conditions affecting the liver. 395,396 Four areas have been addressed by the panel in the context of LT for patients with HCC: i) Patient selection; ii) Organ allocation and priority for patients with HCC with respect to non-HCC candidates; iii) Neoadjuvant therapies and their impact on LT for HCC; (4) Living donor LT for HCC.…”

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

“…These terms are the use of up-to-date staging protocols, restrictions on clinical conditions and tumor presentation known to affect prognosis, nonresectability has to be confirmed in centers with experience in both (liver resection and liver transplantation), sufficient life span of the transplant candidates to assess survival and life-gain achieved with liver transplantation, and priority given to the use of marginal donors. Interestingly, the authors reflected in the discussion of the last mentioned point, among others, to the use of living liver donors [24].…”

Microvascular Invasion in HCC: The Molecular Imaging Perspective

“…Nonetheless, more recently, MC have been criticized because they appear over conservative, thus refraining a significant number of patients from a possible curative treatment [ 7 ]. In this sense, nowadays, it is generally accepted that MC cutoffs have to be extended in order to increase the number of HCC patients eligible for LT [ 8 ]. However, it is still unclear how far the selection limits may be pushed without excessively increasing the risk of tumor relapse.…”