Liver transplant prolongs life in metastatic colorectal cancer

Image: PD/Colon cancer mortality rates. 

1. Patients with hepatic metastases from colorectal cancer (CRC) have similar rates of survival post-liver transplant to patients undergoing repeat liver transplantation for nonmalignant diseases. 

2. Overall survival rates for patients with colorectal liver metastases treated with a liver transplant were higher compared to those treated conventionally with chemotherapy. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Colorectal cancer is the second leading cause of cancer-related deaths in the US. Relapse rates after metastatic liver resection are high, and many patients with hepatic metastases have non-resectable lesions with poor survival rates past five years. In this study, 21 patients with non-resectable colorectal carcinoma liver metastases (CLM) underwent liver transplantation and had improved overall survival rates. Though prospective in nature and yielding intriguing results, this study was limited by its small numbers and heterogenous patient population due to the wide inclusion criteria. For example, patients had differing numbers and sizes of hepatic lesions as well as a broad range follow-up after primary resection. Some had previously undergone hepatic resection while others had not prior to transplantation. Lastly, it is important to address the issue of organ scarcity and allocation. This study was conducted in Norway, where the average time on the liver transplant waiting list is under one month. In most other parts of the world, this is not the case and many patients die waiting for a viable organ. In light of this, it is important to reiterate that this study’s results, especially given its limitations, do not support liver transplantation as a primary treatment for unresectable hepatic metastases secondary to colorectal cancer. 

Click to read the study in Annals of Surgery

Click to read an accompanying editorial in Annals of Surgery

Relevant Reading: Liver Transplantation for Neuroendocrine Tumors in Europe—Results and Trends in Patient Selection: A 213-Case European Liver Transplant Registry Study

Study Author, Dr. Aksel Foss, MD, PhD, MHA talks to 2 Minute Medicine:  Oslo University Hospital, Professor and Chair, Department of Transplantation Medicine, Transplant Surgeon

“In the SECA-study the 5-year patient survival following liver transplant for non-resectable CLM was as high as 60%. Such an outcome is superior to liver re-transplantation of any cause. The ongoing SECA2-trial has in principle two study arms. In one arm, patients with metachronous CLM, N0 at the primary resection for CRC and CEA < 100 ng/ml are offering liver transplant. These patients may have a very good prognosis after liver transplant, probably up to 80% 5 y PS (see the paper). 

In-Depth: [prospective pilot study]: This study enrolled 25 patients with non-resectable colorectal liver metastases (CLM) to undergo liver transplantation. All patients had their primary colorectal tumor removed, were healthy enough to undergo major surgery, and had been treated with at least 6 months of chemotherapy. Extrahepatic metastases were ruled out by preforming CT and PET scans prior to surgery, and perioperative lymph node frozen section analysis. No adjuvant chemotherapy was given and immunosuppression was achieved with basiliximab induction along with sirolumus, mycophenolate mofetil and corticosteroids. Patients were followed with serial CT scans and disease relapse was treated individually. Twenty-one patients underwent liver transplant, and were followed for 8-60 months. Six were deceased from disseminated cancer at the time of publication after a median of 26 months post-transplant. Statistical analysis estimated overall survival as 95%, 68%, and 60% at 1, 3, and 5 years, respectively. Disease-free survival at 1 year was only 35%. Risk factors significantly associated with decreased survival were largest liver tumor diameter over 5.5 cm, time from primary cancer resection under 2 years, CEA>80µg/L and progressive disease at time of transplant.

By Asya Ofshteyn and Allen Ho

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