Liver Transplantation for Metastatic Colorectal Cancer. Jean Botha Transplant Program Wits Donald Gordon Medical Centre
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1 ation for Metastatic Colorectal Cancer Jean Botha Transplant Program Wits Donald Gordon Medical Centre
2 Colorectal Liver Metastases (CLM) 50% pts with CRC develop CLM Most have unresectable disease Unresectable CLM has poor prognosis 10% 5 year survival LT is conceptually attractive Abandoned in mid nineties High rate of relapse Poor outcomes (18% 5 year survival) Donor shortage
3 Colorectal Liver Metastases (CLM) Contemporary LT survival > 90% Advances in systemic chemotherapy Improvements in immunosuppression mtor inhibitors have anti cancer properties Norway has a fortunate donor surplus Mean wait time for transplant is 1 month! Provided a unique opportunity to re examine the issue
4 Colorectal Liver Metastases (CLM)
5 Colorectal Liver Metastases (CLM) Inclusion Criteria: Excision of primary tumour Good performance status Absence of extra hepatic disease CT Scan Whole body PET Minimum 6 weeks of chemo Rx
6 Colorectal Liver Metastases (CLM) Exclusion Criteria: Weight loss > 10% lean body mass Standard contra indications for OLTx On admission for OLTx: Chest CT scan metastatic disease Staging laparotomy Hepatic artery or portal nodes positive on frozen section
7 Colorectal Liver Metastases (CLM) Immunosuppression Sirolimus/MMF/Steroids Target sirolimus levels 5-10 ng/ml Basiliximab induction Steroids tapered off by 3 months No adjuvant chemotherapy
8 Colorectal Liver Metastases Total 25 patients listed for transplant 1 patient removed from list lung mets 3 had positive nodes at staging laparotomy 21 patients underwent transplant No patient lost to follow up
9
10 Colorectal Liver Metastases 21 pts with unresectable CLM Median no. of mets 8 (4-40) Median size of largest met 4.5cm (2.8-13) Fong Score 3-5 (76%)
11 Colorectal Liver Metastases Overall and Disease Free survival
12 Colorectal Liver Metastases Preoperative factors affecting Survival
13
14 Colorectal Liver Metastases-Discussion Pilot study, small numbers Excellent survival Current paradigm challenged HOWEVER: Important ethical concerns Organ shortage necessitates that outcomes should approximate expected outcomes for conventional indications for liver transplantation Livers are allocated to patients with the greatest likelihood of survival
15 Colorectal Liver Metastases-Discussion Hepatocellular Carcinoma: Acceptable after multiple refinements in selection criteria Today accounts for up to 30% of transplant cases Cholangiocarcinoma Once an absolute contraindication Currently indicated in selected patients
16 Colorectal Liver Metastases-Discussion Use of extended criteria organs Older donors, Steatosis, HBV+, HIV+, donors with a previous history of cancer, ABO incompatible Patients with CRC carry a lower surgical risk No portal hypertension No coagulopathy Better renal function These patients should be able to tolerate initial graft dysfunction associated with higher risk organs
17 Colorectal Liver Metastases-Discussion
18 Colorectal Liver Metastases
19 Colorectal Liver Metastases
20 Colorectal Liver Metastases-Conclusion High risk of mortality in patients with CRC metastases justifies the use of organs with a higher risk of primary graft non-function The dogma has been challenged Survival exceeds that of chemotherapy Outcome comparable with liver resection for resectable CLM Further trials and refinement of selection criteria necessary
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