Is there a place for Liver Transplantation for “non HCC” tumors?☆
Article Outline
Abbreviations: HCC, hepatocellular carcinoma, OLT, orthotopic liver transplantation
A persistent controversy among the transplant community is the role of orthotopic liver transplantation (OLT) in patients with cancer, and particularly whether this procedure should be offered to patients with tumors other than hepatocellular carcinoma (HCC). A number of issues related to cancer and OLT have been well covered in previous issues of Forum on Liver Transplantation. The fourth Forum on Liver Transplantation focused on controversies related to the role of OLT in patients with HCC [1]. Arguments, for example, were provided in favour [2] or against [3] the use of OLT in patients with advanced HCC extending beyond the Milan criteria. The fifth Forum on Liver Transplantation focused entirely on the risk of developing cancer after transplantation [4] including a provocative article entitled “Will all liver transplantation patients eventually die from cancer?” [5]. In this ninth forum, we address the issue of whether OLT is indicated in patients with “non HCC” primary and metastatic tumors.
In the first article of this forum, Gregory Gores, David Nagorney and Charles Rosen present their unique experience at the Mayo Clinic with the use of OLT in patients with limited stage cholangiocarcinoma. They challenge previous frustrating experiences of others with this disease [6], [7] by reporting a 70% 5-year survival using a strict, although cumbersome, “neoadjuvant” protocol in highly selected patients presenting with tumors <3
cm, and in the absence of extrahepatic metastasis, including negative node involvement. The so-called neoadjuvant “Mayo” protocol includes a multi-disciplinary commitment beginning with external beam radiation plus 5-FU, followed by brachytherapy via an endoscopic approach. After a negative surgical exploration, particularly to exclude those with positive lymph node involvement, patients receive capecitabine until OLT. While these results are the best so far reported in patients with unresectable diseases, the question whether this should also be considered in patients with a resectable disease remains wide open. In the second article of this forum, Vincenzo Mazzaferro, Andrea Pulvirenti and Jorgelina Coppa critically review the indications and results of OLT in patients with metastatic neuroendocrine tumors. In an appealing and didactic manner they review the neuroendocrine tumors of the GI tract, and demonstrate that the results of OLT in this population, like HCC and cholangiocarcinoma, are closely linked to the selection criteria. They propose new “Milan” criteria to select patients with neuroendocrine tumors for OLT. A strong emphasis is given to considering only patients with symptomatic disease and a portal drainage of the primary tumor. Interestingly, they suggest considering OLT only in patients with relatively limited liver involvement (<50%). The last article in this Forum by Jan Lerut, Markus Weber, Giuseppe Orlando and Philip Dutkowski looks at the highly controversial topic of transplanting patients with vascular or other rare primary or metastatic tumors. The literature provides scarce and often contradictory data. Large databases, however, such as the ELITA-ELTR database, have enabled us to convincingly validate OLT in larger series of patients, for example showing an excellent survival rate (approximately 80% survival at 5 years) in patients with hepatic epitheloid haemangioendothelioma, and a very poor outcome in those with haemangiosarcoma. The authors also discuss rare indications for OLT, such as hepatic schwannoma, lymphoma, and GIST tumors, as well as benign conditions including Echinococcus granulosus, polycystic liver diseases and adenoma.
Due to rapid changes in immunosuppression, chemotherapeutic agents, and surgical techniques, indications of OLT for liver tumors are likely to change. But, at this point the question of whether we will perform more or fewer transplantations for a specific condition remains widely open. This series of articles, however, highlights the need to prospectively and systematically gather long-term data in patients undergoing OLT for “non HCC” tumors, as randomized studies are unlikely to appear. I hope that this forum will provide a timely overview and help the clinicians to better evaluate this difficult population of patients for OLT.
References
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- . Should we expand the criteria for liver transplantation for hepatocellular carcinoma – Yes, of course! Fourth Forum on Liver Transplantation. J Hepatol. 2005;43:569–573
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- . The role of liver transplantation in hepatobiliary malignancy. A retrospective analysis of 95 patients with particular regard to tumor stage and recurrence 209. Ann Surg. 1989;1:88–98
- De novo tumors after liver transplantation: a single-institution experience. Liver Transpl. 2002;8:285–291
☆ The author declares that he does not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.
PII: S0168-8278(07)00397-2
doi:10.1016/j.jhep.2007.07.002
© 2007 Published by Elsevier Inc.
