Liver transplantation (LT) for colorectal liver metastases (CRLM) seems to be nowadays an established treatment, not only of unresectable CRLM (uCRLM) (1) but also for borderline resectable ones (2,3). For these patients, the benefit of LT vs standard modern advanced palliative therapies ranges between 40–80% (1). Notwithstanding the high rates of recurrence, LT can definitely be considered as a curative option, in particular considering the excellent long-term results recently published by the Oslo group (4).
Most of data available up to now are mainly results of standard whole LT from deceased donors (DD). Unfortunately, in times of DD paucity, the huge discrepancy between offer and demand already for standard indications still persists. The extension of the spectrum of indications of LT to CRLM may represent an additional medical and ethical problem in the context of graft sharing. The actual excellent long-term results of LT for CRLM (4), which are similar or even better than standard indications (5), would justify the extension of indication to ultra-selected patients (i.e., less than 5% of all potential candidates) (6). Therefore, there is an urgent need of alternatives to standard DD-LT. At this regard, the use of extended criteria donor (ECD) livers and the 2-staged auxiliary LT according to the RAPID concept have been proposed (7-10).
The use of ECD livers for uCRLM (particularly in times of machine perfusion) has been justified by the fact that in these patients the risk of complications by using marginal grafts is definitely lower than dying without LT. In other words, the poor prognosis with conventional treatment and the possible advantages of improved survival are considered to outweigh the risks taken by using marginal grafts (11). Actually, two running trials are facing this topic, i.e., the SOULMATE study (Sweden, NCT04161092) and the COLT Study (Italy, NCT03803436). In their recent study, Villard et al. (12) showed that the use of ECDs could increase today’s donor pool by 6–18%. This donor pool would be sufficient to cover the need of LT for ultra-selected patients with uCRLM (6,12).
In this context, the recent consensus guidelines (1) proposed the use of ECD in patients affected of uCRLM. On the contrary, the Oslo group in SECA II Arm D Study showed that these patients undergoing LTs with extended patient and donor criteria have relatively short overall survival (13).
In summary, given that the number of potentially eligible cases of LT for uCRLM is not a real competition to the standard indications, especially considering the excellent long-term results, the use of ECD livers in this context may represent an opportunity but should be considered very carefully.
Supplementary
The article’s supplementary files as
Acknowledgments
Funding: None.
Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Footnotes
Provenance and Peer Review: This article was commissioned by the editorial office, Hepatobiliary Surgery and Nutrition. The article did not undergo external peer review.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-22-576/coif). The author has no conflicts of interest to declare.
References
- 1.Bonney GK, Chew CA, Lodge P, et al. Liver transplantation for non-resectable colorectal liver metastases: the International Hepato-Pancreato-Biliary Association consensus guidelines. Lancet Gastroenterol Hepatol 2021;6:933-46. 10.1016/S2468-1253(21)00219-3 [DOI] [PubMed] [Google Scholar]
- 2.Lanari J, Hagness M, Sartori A, et al. Liver transplantation versus liver resection for colorectal liver metastasis: a survival benefit analysis in patients stratified according to tumor burden score. Transpl Int 2021;34:1722-32. 10.1111/tri.13981 [DOI] [PubMed] [Google Scholar]
- 3.Dueland S, Yaqub S, Syversveen T, et al. Survival Outcomes After Portal Vein Embolization and Liver Resection Compared With Liver Transplant for Patients With Extensive Colorectal Cancer Liver Metastases. JAMA Surg 2021;156:550-7. 10.1001/jamasurg.2021.0267 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Solheim JM, Dueland S, Line PD, et al. Transplantation for Nonresectable Colorectal Liver Metastases - Long Term follow- up of the First Prospective Pilot Study. Ann Surg 2022. [Epub ahead of print]. doi: . 10.1097/SLA.0000000000005703 [DOI] [PubMed] [Google Scholar]
- 5.Houben P, Schimmack S, Unterrainer C, et al. Rare Malignant Indications for Liver Transplantation: A Collaborative Transplant Study Report. Front Surg 2021;8:678392. 10.3389/fsurg.2021.678392 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Dueland S, Grut H, Syversveen T, et al. Selection criteria related to long-term survival following liver transplantation for colorectal liver metastasis. Am J Transplant 2020;20:530-7. 10.1111/ajt.15682 [DOI] [PubMed] [Google Scholar]
- 7.Line PD, Hagness M, Berstad AE, et al. A Novel Concept for Partial Liver Transplantation in Nonresectable Colorectal Liver Metastases: The RAPID Concept. Ann Surg 2015;262:e5-9. 10.1097/SLA.0000000000001165 [DOI] [PubMed] [Google Scholar]
- 8.Königsrainer A, Templin S, Capobianco I, et al. Paradigm Shift in the Management of Irresectable Colorectal Liver Metastases: Living Donor Auxiliary Partial Orthotopic Liver Transplantation in Combination With Two-stage Hepatectomy (LD-RAPID). Ann Surg 2019;270:327-32. 10.1097/SLA.0000000000002861 [DOI] [PubMed] [Google Scholar]
- 9.Nadalin S, Settmacher U, Rauchfuß F, et al. RAPID procedure for colorectal cancer liver metastasis. Int J Surg 2020;82S:93-6. 10.1016/j.ijsu.2020.03.078 [DOI] [PubMed] [Google Scholar]
- 10.Settmacher U, Ali-Deeb A, Coubeau L, et al. Auxilliary Liver Transplantation According to the RAPID Procedure in Non-cirrhotic Patients - Technical Aspects and Early Outcomes. Ann Surg 2023;277:305-12. . 10.1097/SLA.0000000000005726 [DOI] [PubMed] [Google Scholar]
- 11.Reivell V, Hagman H, Haux J, et al. SOULMATE: the Swedish study of liver transplantation for isolated colorectal cancer liver metastases not suitable for operation or ablation, compared to best established treatment-a randomized controlled multicenter trial. Trials 2022;23:831. 10.1186/s13063-022-06778-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Villard C, Westman J, Frank J, et al. The potential use of extended criteria donors and eligible recipients in liver transplantation for unresectable colorectal liver metastases in Central Sweden. Hepatobiliary Surg Nutr 2021;10:476-85. 10.21037/hbsn.2020.03.10 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Smedman TM, Line PD, Hagness M, et al. Liver transplantation for unresectable colorectal liver metastases in patients and donors with extended criteria (SECA-II arm D study). BJS Open 2020;4:467-77. 10.1002/bjs5.50278 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The article’s supplementary files as