Association issues guidance for LT in nonresectable colorectal liver
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The International Hepato-Pancreato-Biliary Association established consensus guidelines for liver transplantation among patients with nonresectable colorectal liver metastases.
“Collective advances in the treatment of colorectal liver metastases and immunosuppression in LT, as well as the successes in LT for hepatocellular carcinoma, have reignited interest in LT for some patients with nonresectable colorectal liver metastases,” Glenn K. Bonney, FRCS, National University Hospital in Singapore, and colleagues wrote in Lancet Gastroenterology and Hepatology. “As the number of transplants done for patients with nonresectable colorectal liver metastases worldwide increases, there is an urgent need for a consensus approach toward decision making.”
Following an extensive literature review, researchers standardized the nomenclature and defined management principles among patient selection, biologic behavior evaluation, graft selection, recipient considerations and outcomes.
Among 44 statements, key guidelines follow.
Clinicians should perform standard oncological resection of the primary tumor with clear resection margins.
Tumor histology of undifferentiated adenocarcinoma and signet ring cell carcinoma excludes patients for LT.
It is mandatory to perform analysis for BRAF and RAS mutations. While patients with BRAF V600E mutation should not be considered for transplant, RAS mutation is not a contraindication for transplant.
Researchers suggest patients should have at least one line of fluorouracil-based, oxaliplatin-based or irinotecan-based chemotherapy with an observed response for at least six months.
Evidence of progressive disease observed during bridging therapy contraindicates patients for LT.
Decision making for graft type for non-colorectal liver metastases LT should be made at the national organ allocation level or by the transplant center.
Immunosuppression should be modified for patients requiring chemotherapy during follow-up.
Systemic therapy is reserved for the management of multisite recurrence and disseminated disease.
To justify the risk, resources and cost of intervention, LT should aim for a 5-year survival of more than 50%; LT survival should be better than palliative chemotherapy survival alone.
“Trials evaluating LT for nonresectable colorectal liver metastases have shown good outcomes in well-selected patients and has sparked an exponential increase in the number of patients transplanted for this indication worldwide," Bonney and colleagues concluded. "This consensus guideline provides a framework by which LT for nonresectable colorectal liver metastases can be safely instituted and is a meaningful step toward future evidenced-based practice for better patient selection and organ allocation to improve survival for patients with this disease."
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