Liver transplantation for non-resectable colorectal liver metastases

Abstract

Patients with non-resectable colo-rectal metastases (NRCRM) receiving palliative chemotherapy have a poor prognosis. Overall survival rates vary between 5-15%. Until recently NRCRM have been considered an absolute contraindication for liver transplantation. The SECA-I study from Oslo, Norway (n=21) demonstrated a 5 year overall survival of 60% after liver transplantation for NRCRM. Objective(s)To determine the overall and recurrence free survival in selected patients with NRCRM undergoing liver transplantation at Wits Transplant Program in Johannesburg. Method(s): After obtaining authorization from our IRB, we enrolled patients with NRCRM (n=5). Main inclusion criteria were; hepatic only metastases confirmed by MRI/CT scan and FDG PET scan, prior resection of primary tumour and having completed at least first-line chemotherapy. Patients were only offered expanded criteria organs that had been declined for recipients on the regular waiting list. These included; older donors, donors with large droplet steatosis >40% and ABO incompatible donors (ABOi). Primary outcome was patient survival and disease free survival. Secondary outcomes were survival after recurrence. Result(s): At median follow-up of 36 months (range 10-52 months), 4/5 (80%) of the patients are alive. Recurrence occurred in all patients at a median time to recurrence of 6 months (range 3-13). Oslo score ranged from 1-3. One patient had progressive disease on chemotherapy pre-transplant and developed rapid recurrence and progression to death, also being the only patient who was KRAS mutant. Pulmonary recurrence occurred in 3 patients, 2 have undergone pulmonary resections and are currently disease free. Discussion(s): Liver transplantation, using marginal organs that would otherwise be discarded, potentially provides acceptable survival in patients with NRCRM. In this small 'proof of concept' case series, survival exceeded that of palliative chemotherapy. It is hoped that more rigorous selection strategies may provide long-term survival comparable to standard indications for liver transplantation.