Innovative surgery ‘changes the game’ for colorectal cancer that metastasizes to liver
Key takeaways:
- Surgeons successfully split a deceased donor’s liver to give to two transplant recipients.
- One recipient, a man who had stage IV colorectal cancer with liver metastases, has been cancer free since the procedure.
Barclay Missen had resigned himself to hospice care.
Missen, a 53-year-old from Chicago, got diagnosed with stage IV colorectal cancer in 2021.
Chemotherapy and surgery rid Missen of his primary malignancy, but the disease had spread to his liver and had caused significant damage by April 2024. The husband and father of two needed a liver transplant, but he could not find a living donor.
“His only other option was hospice,” Satish N. Nadig, MD, PhD, transplant surgeon and director of the Northwestern Medicine Comprehensive Transplant Center, told Healio. “That wasn’t acceptable to us.”
Instead, Nadig and colleagues attempted a procedure — never tried in the United States — called resection and partial liver transplantation with delayed total hepatectomy (RAPID).
After getting consent from a woman receiving a transplant from a deceased donor, surgeons took a small part of that liver and attached it next to a portion of Missen’s remaining cancerous liver.
Over the next 2 weeks, the donor section more than doubled in size in Missen’s body. Once the healthy portion became large enough to support Missen, surgeons removed the last of the malignant part.
Missen remains cancer free 5 months later.
“With this case, the United States and Northwestern have moved the needle in cancer care,” Nadig said.
Background
Colorectal cancer incidence has continued to rise in the U.S. A projected 154,270 cases will occur and 52,900 people in the country will die of the disease this year, according to American Cancer Society’s Cancer Statistics 2025 report.
Colorectal cancer metastasizes to the liver in up to 60% of cases, according to a Northwestern Medicine press release.
Individuals whose cancer spreads to the liver have a 5-year survival rate of only 10%, but survival increases to between 60% and 80% if they receive a liver transplant.
However, most institutions around the country do not perform transplantation for patients with colorectal cancer.
“The current organ allocation system does not prioritize these patients, and they end up falling lower on the waitlist,” Nadig said in the release. “As a result, patients with colorectal cancer with liver metastasis often rely on living donors. Unfortunately, not everyone is walking around with a living donor. For many of these patients, the only alternative is palliative treatment.”
‘Why not share it?’
The inspiration for RAPID came from Europe, Nadig told Healio.
Nadig’s colleague, Zachary C. Dietch, MD, transplant surgeon and assistant professor of surgery (organ transplantation) at Northwestern University Feinberg School of Medicine, had traveled for a medical conference and came back with an idea.
“He came to me [and said] there’s a way we can adapt this to the United States,” Nadig said. “Right now, machine perfusion for liver transplant is becoming more mainstream. We take a liver, we put it on a machine and we pump blood through it, and it’s living outside of the body. We could actually split that, take a piece of it [as it is] on the machine. No one had done that in the United States on this particular type of pump.”
In October 2024, an opportunity to attempt RAPID presented itself.
Kelli Podrez, a then-57-year-old from Hanover Park, Illinois, had been matched for a deceased liver donor to treat her cirrhosis.
Northwestern approached Podrez about sharing the liver with Missen, a procedure Nadig said did not significantly add risk for Podrez.
“[There is] very low likelihood [the liver] will fail,” he explained. “It’s the same amount of likelihood as if she was getting a whole organ and it fails just because it’s so much liver. That’s really not something that we worry about in this particular instance.”
Podrez had “no hesitation,” Nadig said.
“My medical team told me that the liver is like the skin; it regenerates and grows,” Podrez said in the release. “If I could survive without the whole organ and help save someone’s life, why not share it?”
The procedure
Nadig and colleagues performed a couple practice surgeries on discarded livers before the big day.
The procedure required two operating rooms and two surgical teams working together at the same time.
The first surgical group spent 8 hours cutting off approximately a 15% section of the donor liver as a machine pumped blood through it.
In another operating room, the second surgical team removed half of Missen’s malignant liver.
The larger portion of the donor liver went to Podrez, and Missen received the smaller end.
The remaining half of Missen’s cancerous liver stayed attached to the vena cava, and surgeons attached the small section of donor liver to the other half of the vein.
“The healthy organ is not connected to the cancerous organ. The cancerous organ is very separate from the healthy organ,” Nadig said.
The blood flow helped the donor liver grow from approximately 360 mL of volume to around 860 mL in about 2 weeks, Nadig said.
At that point, the healthy donor liver had gotten big enough to function on its own. Surgeons then removed the remaining section of malignant liver.
“I get emotional when I think about all the things that had to happen,” Missen said in the release. “This donor and their family had to go through what they went through to make this possible. And on top of that, to have another person whose life is on the line be willing to share their hope with me — I can’t put into words how grateful I am for their generosity. I’m sitting here today because of that decision and my incredible Northwestern Medicine transplant team who made it happen.”
Next steps
Northwestern Medicine has started the Colorectal Metastasis to Liver Extraction with Auxiliary Transplant and Delayed Resection (CLEAR) program for patients like Missen.
The first 80 patients of CLEAR will be monitored as part of a clinical trial, with their outcomes serving as the primary endpoint.
However, participation is voluntary and not required for individuals who receive RAPID.
“[RAPID] completely changes the game of the treatment of colorectal cancer in today’s current medical therapies,” Nadig told Healio.
Nadig estimates that RAPID could save anywhere from 5,000 to 10,000 individuals with colorectal cancer and liver metastases every year.
It requires “a lot of coordination, strong oncology, strong transplant [and] strong hepatology,” Nadig said. “But the actual technical aspects of it can be done at any high-volume transplant program in the country.
“We entered a new therapy into the armamentarium of the United States treatment of colorectal cancer metastasis to the liver,” he added.
The procedure’s success also has Nadig and colleagues wondering whether living donor transplants could be affected.
Currently, living donors give 50% of their liver for a transplant. RAPID could allow donors to give less.
“It puts the living donor at less risk,” Nadig said. “It’s less of a tricky operation. It’s a less intense operation to take a smaller piece of the liver. That’s definitely a possibility.”
References:
- Northwestern Medicine launches clinical program to make liver transplants more accessible for patients with stage 4 colorectal cancer. https://news.nm.org/northwestern-medicine-launches-clinical-program-to-make-liver-transplants-more-accessible-for-patients-with-stage-4-colorectal-cancer. Published March 18, 2025. Accessed March 18, 2025.
For more information:
Satish N. Nadig, MD, PhD, can be reached at satish.nadig@northwestern.edu.
Perspective
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We need to see the results of the CLEAR program to determine if this approach is safe and effective when used in more patients. If successful, the RAPID approach could make liver transplant more accessible to patients with colorectal cancer with liver metastases.
My word of caution is that we need more data regarding safety and efficacy in the patients receiving RAPID and participating in the CLEAR registry before this is widely adopted in the US. Participation in the registry is voluntary, but I hope that most patients will choose to participate.
If this approach is shown to be safe and effective, this unique approach should be performed at high-volume transplant centers and will require much coordination. Some patients might be reluctant to share the liver; however, Ms. Podrez reportedly had “no hesitation” to share, and I anticipate that many patients will feel the same.
It also will be important to look at the CLEAR data — when available — to determine if there are certain factors that may help us understand which patients might benefit the most from RAPID.
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