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Recent research suggests liver transplant may benefit patients with an expanding range of primary or secondary hepatic malignancies.

Patients with an expanding range of primary or secondary hepatic malignancies may be eligible for liver transplants, a recent review article suggests.

“Liver malignancies that start in the liver and those that start elsewhere and go to the liver are very common, have high mortality rates, and are increasing globally,” explains senior author Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA. “Liver transplant is an established treatment for hepatocellular carcinoma and for select cases of perihilar cholangiocarcinoma. Transplant is increasingly being used for patients with intrahepatic cholangiocarcinoma, colorectal liver metastases, and metastatic neuroendocrine tumors. In the past, these patients were not eligible for transplant due to underlying liver disease or tumor burden.”

Dr. Pawlik talked with Physician’s Weekly about the review of outcomes of liver transplants for hepatic malignancies that he and his colleagues recently published in JAMA Surgery.

PW: Why was it important to publish this review now?

Dr. Pawlik: We lay out the role transplantation may play for providers’ patients who have various cancers. The field of transplant oncology is evolving as we attempt to define specific guidelines and specifications we can use to select appropriate patients. Including both primary and secondary liver neoplasms as indications for transplant is a burgeoning field.

Traditionally, transplants have been used for people with cirrhosis due to alcohol, hepatitis, or fatty liver disease. In contrast, transplants for cancer have been limited to neoplasms arising from the liver itself. But over the last 5 to 7 years, research interest has broadened to include transplantation for other types of cancers, including colon cancer and neuroendocrine tumors that have spread to the liver and bile duct cancer in the liver. Evidence-based on prospective research suggests that for well-selected patients, transplants can indeed provide a survival benefit.

PW: How could this information affect patient care?

Physicians need to be aware of the criteria and the role of transplantation for patients with these cancers and should consider referring them to high-volume transplant centers with protocols for evaluating and treating qualified patients.

Using transplantation to treat some of these cancers, like metastatic colorectal cancer or metastatic neuroendocrine tumor to the liver, is not a “standard of care” at this point. It is typically done on a protocol basis in specialized centers that collect and monitor the outcomes in a prescribed manner, analyze the data, and further refine the selection criteria to identify which patients can benefit the most from transplantation. The selection criteria are strict but should be considered, especially in patients who are otherwise healthy, have very good performance status, and perhaps are young.

PW: What questions are researchers asking?

We have many unanswered questions. Guidelines exist but need to be refined. We need more research to define the optimal selection criteria for these expanded indications. We must continue defining patient-specific factors, including tumor size, number, and location. We also need to understand molecular signatures, specific mutations in certain genes, and other factors that suggest better or worse outcomes.

We need to identify the role of living donation. Deceased donors provide a limited number of livers, but increasing the use of living donors makes more livers available for a broader range of indications.

PW: What ethical issues require examination?

The ethics around organ allocation to individuals who may benefit from prolonged survival after transplant must be further defined. Who will benefit most? How can we use these limited resources wisely?

Some of the ethics around transplantation for a cancer indication involve whether the patient will be cured of their cancer or whether a transplant will prolong their survival in the setting of recurrence. How do we weigh that benefit relative to the benefit of using a limited resource for a non-cancer indication?

We need to weigh the allocation of scarce resources and the benefits versus the risks for donors and recipients. We need to define these factors further to better understand the true benefit we’re providing our transplantation patients.