Liver transplantation for unresectable colorectal liver metastases in patients and donors with extended criteria (SECA-II arm D study).

BACKGROUND: Patients with metastatic colorectal cancer receiving palliative chemotherapy have a 5-year survival rate of approximately 10 per cent. Liver transplantation using strict selection criteria in patients with colorectal cancer and unresectable liver-only disease will result in a 5-year survival rate of 56-83 per cent. The aim of this study was to evaluate survival of patients with colorectal liver metastases (CRLM) after liver transplantation using extended criteria for both patients and donors. METHODS: This was a prospective single-arm study. Patients with synchronous unresectable CRLM who were not suitable for arms A, B or C of the SEcondary CAncer (SECA) II study who had undergone radical resection of the primary tumour and received chemotherapy were included; they underwent liver transplantation with extended criteria donor grafts. Patients who had resectable pulmonary metastases were eligible for inclusion. The main exclusion criteria were BMI above 30 kg/m2 and liver metastases larger than 10 cm. Survival was estimated using Kaplan-Meier analysis. RESULTS: Ten patients (median age 54 years; 3 women) were included. They had an extensive liver tumour load with a median of 20 (range 1-45) lesions; the median size of the largest lesion was 59 (range 15-94) mm. Eight patients had (y)pN2 disease, six had poorly differentiated or signet ring cell-differentiated primary tumours, and five had primary tumour in the ascending colon. The median Fong clinical risk score was 3 (range 2-5) and the median Oslo score was 1 (range 1-4). The median plasma carcinoembryonic antigen level was 4·3 (range 2-4346) µg/l. Median disease-free and overall survival was 4 and 18 months respectively. CONCLUSION: Patients with unresectable liver-only CRLM undergoing liver transplantation with extended patient and donor criteria have relatively short overall survival.

ANTECEDENTES: Los pacientes con cáncer colorrectal metastásico (metastatic colorectal c¡ncer, CRC) que reciben quimioterapia paliativa presentan aproximadamente una supervivencia a los 5 años del 10%. El trasplante de hígado utilizando criterios de selección estrictos en pacientes con CRC y enfermedad localizada hepática no resecable presenta una supervivencia a los 5 años del 56-83%. El objetivo de este estudio fue evaluar la supervivencia de pacientes con metástasis hepáticas CRC no resecables (non-resectable CRC liver metastases, CRLM) después del trasplante hepático utilizando criterios extendidos para pacientes y donantes. MÉTODOS: Se ha realizado un estudio prospectivo de un solo brazo. A los pacientes con CRLM sincrónicas no resecables que no eran adecuados para ser incluidos en los brazos A, B o C del estudio SECA-II, con resección quirúrgica radical previa del tumor primario y que recibieron quimioterapia, se les realizó un trasplante de hígado con injerto de donante con criterios extendidos. Los pacientes con metástasis pulmonares resecables también podían ser incluidos. Los principales criterios de exclusión principales fueron el índice de masa corporal > 30 y metástasis hepáticas > 10 cm. La supervivencia se estimó utilizando el método de Kaplan-Meier. RESULTADOS: Diez pacientes (mediana de edad de 54 años, 3 varones) incluidos en el estudio tenían una carga tumoral hepática extensa con una mediana de 20 lesiones (rango 1-45) y un tamaño mediano de la lesión más grande de 59 mm (rango 15-94 mm). Ocho pacientes tenían (y) pN2, seis tenían tumores primarios pobremente diferenciados/células de anillo de sello y cinco tenían tumor primario en colon ascendente. La mediana del Fong Clinical Risk Score fue 3 (rango 2-5). La mediana del Oslo Score fue 1 (rango 1-4). La mediana del nivel de CEA en plasma fue 4 µg/L (rango 2-4346). La mediana de supervivencia libre de enfermedad y supervivencia global fue de 4 y 18 meses, respectivamente. CONCLUSIÓN: Los pacientes con CRLM no resecables localizadas en el hígado que se someten a un trasplante de hígado con criterios extendidos de pacientes y donantes tienen una supervivencia global relativamente corta.

Long-term quality of life after liver transplantation for non-resectable colorectal metastases confined to the liver.

Background: Liver transplantation for patients with non-resectable colorectal liver metastases offers increased survival, with median overall survival of more than 5 years. The aim of this study was to compare quality of life before and up to 3 years after liver transplantation for colorectal liver metastases. Methods: Quality of life was assessed using the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire version 3.0. The patients received the questionnaire before and up to 3 years after liver transplantation. Results: Some 23 patients were included in the analysis. Three months after liver transplantation they reported reduced quality of life (global health status scale), physical function and role function, and increased dyspnoea. At 6 months, global health status, physical function and role function had returned to pretransplant values. Three years after liver transplantation all symptom and function scores were comparable to baseline values. Patients with high scores for fatigue, pain and appetite loss at baseline had reduced 3-year overall survival. Conclusion: Patients with non-resectable colorectal liver-only metastases receiving liver transplantation had good long-term quality of life. Patients with high symptom scores before transplantation had reduced 3-year overall survival.

Liver Transplant After Normothermic Regional Perfusion From Controlled Donors After Circulatory Death: The Norwegian Experience.

BACKGROUND: In order to meet the increasing demand for donor organs, the concept of donation after circulatory death (DCD) was reintroduced in Norway, first as a pilot study, followed by the use of DCD as institutional practice. We report the current Norwegian experience with liver transplant after DCD. METHODS: After acceptance from next of kin, life support was withdrawn from patients with devastating brain injury and cardiac arrest observed. After a 5-minute "no-touch" period, extracorporeal membrane oxygenation for post mortem normothermic regional perfusion (NRP) by extracorporeal membrane oxygenator circuit was established. Data from all liver transplant recipients receiving controlled DCD (cDCD) livers in Oslo were analyzed. RESULTS: From 2015 to 2017, a total of 8 patients underwent liver transplant with cDCD and NRP liver grafts in Norway. Median Model for End-Stage Liver Disease score was 26 (range, 6-40). There were no cases of delayed graft function or graft loss. Seven patients have reached 1 year of follow-up, and 1 patient has reached 6 months. Two patients have recurrence of primary disease (primary sclerosing cholangitis and steatohepatitis). All patients had normalized liver function at last follow-up. Two patients underwent procedures for biliary complications. In 1 patient, leakage from the cystic duct was successfully handled endoscopically by stenting. In the other patient, a suspected stricture on magnetic resonance imaging led to an endoscopic retrograde cholangiopancreatography, which did not confirm signs of biliary stenosis. There was 1 instance of hepatic artery stenosis, which was managed with endovascular technique. CONCLUSION: The results after liver transplant using cDCD with NRP are good. The rate of complications seems to be within the same range as when using conventional donation after brain death grafts.

Survival following liver transplantation for liver-only colorectal metastases compared with hepatocellular carcinoma.

BACKGROUND: Liver transplantation is considered the standard of care for patients with hepatocellular carcinoma (HCC) within the Milan criteria. Liver transplantation in patients with unresectable colorectal cancer with liver-only disease has been shown to be associated with a 5-year overall survival rate of 56 per cent, compared with 9 per cent in patients receiving standard palliative chemotherapy. The aim of the present study was to compare disease-free (DFS) and overall (OS) survival after liver transplantation in patients with HCC and those with colorectal metastases. METHODS: Data were collected from the SEcondary CAncer (SECA) study database and an institutional (national) database of patients undergoing liver transplantation for HCC; all liver-transplanted patients were included. Patients with colorectal metastases treated by liver transplantation were divided into high- and low-risk groups for mortality based on carcinoembryonic antigen levels, response to chemotherapy, largest lesion at time of transplantation and time from primary surgery to transplantation. RESULTS: Patients with colorectal metastases had a median of 8 lesions, compared with 1 in patients with HCC within the Milan criteria. DFS was shorter in both the high-risk and the low-risk colorectal cancer groups compared with that in patients with HCC. The 5-year OS rate in the low-risk colorectal cancer group was 75 per cent, compared with 76 per cent in patients with HCC within the Milan criteria. The 5-year OS rate in patients with HCC beyond the Milan criteria was 56 per cent. CONCLUSION: The low-risk group of patients with colorectal cancer and unresectable liver-only disease had a 5-year OS rate following liver transplantation similar to that of patients with HCC with lesions within the Milan criteria.

Single transplanted kidneys from a 90-year-old deceased donor perform acceptably at 1 year.

Most centers are reluctant to accept expanded criteria donors above 70 to 75 years of age. We accepted kidneys from a 90-year-old male and report the 1-year outcome. The kidneys were used as single transplants and both had immediate graft function. Recipient A was a 71-year-old male, with cold ischemia time of 4 hours 49 minutes. One rejection was successfully treated with intravenous methylprednisolone. At 1 year, serum creatinine was 146 µmol/L with estimated glomerular filtration rate (eGFR) 41 mL/min. Recipient B was a 79-year-old male with known panel-reactive antibody positivity prior to transplantation. Cold ischemia time was 10 hours 4 minutes. He experienced no rejections. At 1 year serum-creatinine was 99 µmol/L with eGFR 63 mL/min. Both recipients performed a surveillance biopsy at 1 year with identical findings: interstitial fibrosis and tubular atrophy grade 1 with moderate to severe arteriolosclerosis. We conclude that both kidneys performed acceptably 1 year after engraftment. The use of old kidneys in old recipients gives them a properly functioning kidney and improves quality of life. Longer observation is needed.