New guidelines provide framework for safe liver transplantation for non-resectable colorectal liver metastases
NEW YORK 17/09 - Growing interest in liver transplantation to treat non-resectable colorectal liver metastases prompted an international working group to develop consensus guidelines.
"Trials evaluating liver transplantation for non-resectable colorectal liver metastases have shown good outcomes in well-selected patients, and this has sparked an exponential increase in the number of patients transplanted for this indication worldwide," the group writes in The Lancet Gastroenterology and Hepatology.
The working group was commissioned by the International Hepato-Pancreato-Biliary Association and included international leaders in the areas of hepatobiliary surgery, colorectal oncology, liver transplantation, hepatology and bioethics.
The group focused on five key domains: patient selection, evaluation of biological behavior, graft selection, recipient considerations and outcomes.
Following a three-step Delphi consensus process, the group reached final consensus on 44 statements, standardized nomenclature, and developed a practical management algorithm.
The aim of the selection process is to identify patients with non-resectable colorectal liver metastases with favorable tumor biology who would derive the greatest survival benefit from liver transplantation, the group says.
They identified prognostic factors from an array of clinicopathological and molecular features to establish biologically based criteria for patient selection. Specific criteria for clinico-patho-radiological assessments with molecular profiling is "crucial" in this setting, they write.
After the patient-selection process, "the careful evaluation of biological behavior with bridging therapy to transplantation with an appropriate assessment of the response is required," the group says. "The sequencing of treatment in synchronous metastatic disease requires special consideration."
The group discusses the ethical dilemmas within organ allocation for malignant indications. "The standard-of-care for patients with non-resectable colorectal liver metastases at present is palliative systemic therapy, and liver transplantation should improve on this survival to be ethically justifiable," the group says.
The group also reviews the role for extended-criteria grafts, living-donor transplantation, and machine-perfusion technologies for non-resectable colorectal liver metastases.
Finally, the group proposes appropriate immunosuppressive regimens and strategies for the follow-up and treatment of recurrent disease.
These consensus guidelines provide "a framework by which liver transplantation for non-resectable colorectal liver metastases might be safely instituted and is a meaningful step towards future evidenced-based practice for better patient selection and organ allocation to improve the survival for patients with this disease," the group concludes.
They recognize the "stimulating" ongoing work in this field and the importance of international registries and future prospective trials in elucidating biological prognostic factors to improve the stratification of risk.
"As survival outcomes for liver transplantation in well selected patients with non-resectable colorectal liver metastases improve, it is foreseeable that non-resectable colorectal liver metastases might become a standard indication for liver transplantation in the future, and strategies for prioritizing these patients against those with other malignant and non-malignant indications for liver transplantation must be devised," they write.
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