Liver transplantation, once considered incompatible with a cancer diagnosis, has emerged as a viable treatment for select patients. While the presence of cancer might seem to automatically disqualify someone, specific circumstances allow for this complex procedure. This approach offers a chance at long-term survival for individuals whose cancer is confined to the liver and meets stringent criteria.
When a Liver Transplant for Cancer is Considered
Liver transplantation is most commonly considered for hepatocellular carcinoma (HCC), the most prevalent type of primary liver cancer. Selection is based on strict guidelines, such as the Milan criteria, which typically allow for a single tumor no larger than 5 centimeters or up to three tumors, each not exceeding 3 centimeters, without evidence of vascular invasion or spread beyond the liver. Patients meeting these criteria often achieve 5-year survival rates ranging from 70% to 80% after transplant, comparable to those receiving transplants for non-cancer conditions.
The University of California San Francisco (UCSF) criteria represent a slightly expanded set, considering solitary tumors up to 6.5 centimeters or up to three nodules, each 4.5 centimeters or less, with a total diameter not exceeding 8 centimeters. These expanded criteria have also shown favorable outcomes, with 5-year survival rates around 75.2%. These criteria help ensure the donated organ is used effectively, maximizing long-term survival and minimizing cancer recurrence risk. In some cases, patients whose tumors initially exceed these limits may undergo “downstaging” therapies, such as local-regional treatments, to reduce tumor size and number, making them eligible for transplant.
Beyond HCC, liver transplantation is rarely considered for other types of cancer, primarily for certain neuroendocrine tumors (NETs) that have spread only to the liver. For these patients, the primary tumor must typically be resected, and there should be no extrahepatic disease. Five-year survival rates for well-selected NET patients can range from 47% to 71% after transplant, although recurrence rates can be high, often between 31% and 57%.
Liver transplantation for colorectal liver metastases (CRLM) is generally considered experimental and is often performed within clinical trials due to historically high recurrence rates. However, highly selected cases meeting strict criteria, such as the primary tumor being removed, no extrahepatic disease, and a favorable response to chemotherapy, have shown promising 5-year survival rates, sometimes reaching 73% to 83% in specialized programs.
Similarly, perihilar cholangiocarcinoma (pCCA), a bile duct cancer, is rarely treated with transplant, usually only in specific circumstances involving small tumors (less than 3 centimeters) that are unresectable and have undergone neoadjuvant chemoradiation.
The Pre-Transplant Evaluation Process
Becoming a candidate for a liver transplant in the context of cancer involves a comprehensive and rigorous evaluation. This process begins with a referral to a transplant center, where a multidisciplinary team assesses the patient’s overall health and suitability. This team typically includes transplant hepatologists, surgeons, oncologists, social workers, psychiatrists, dietitians, and nurse coordinators, all collaborating to make an informed decision.
Diagnostic tests provide detailed information about the cancer and the patient’s general health. These tests often include advanced imaging such as CT scans and MRIs to precisely map the liver tumors and confirm the absence of spread elsewhere in the body. Biopsies may be performed to understand tumor characteristics, and blood tests assess liver function, kidney function, and tumor markers like alpha-fetoprotein.
Assessment of overall health is crucial, including evaluations of cardiac and pulmonary function to ensure the patient can withstand the demands of major surgery and long-term recovery. Psychosocial factors involve evaluations by social workers and psychiatrists to understand the patient’s support system, mental health, and ability to adhere to a post-transplant medical regimen. The team assesses the cancer’s stage, its response to prior treatments, and the patient’s capacity to manage lifelong immunosuppression.
Life After Liver Transplant for Cancer
Patients who receive a liver transplant for cancer require lifelong immunosuppression to prevent their body from rejecting the new organ. While essential for graft survival, these medications impact long-term health. They can increase the risk of infections, particularly in the initial months following transplantation, and community-acquired infections later on.
Lifelong immunosuppression increases the risk of developing new cancers. Skin cancers are more common, and there is an elevated risk of lymphomas and other cancers. Additionally, immunosuppressive drugs can lead to metabolic complications such as diabetes, which may affect up to 30% of recipients, hypertension in up to 70% of patients, dyslipidemia, and osteoporosis. Kidney dysfunction is another potential side effect, with chronic kidney disease occurring in up to 40% of patients, particularly due to certain types of immunosuppressants.
Despite strict selection criteria, cancer recurrence remains a risk after liver transplantation, occurring in an estimated 8% to 20% of HCC cases. Most recurrences typically happen within the first two years following the transplant, and the prognosis for recurrent cancer can be poor. Therefore, ongoing surveillance with the transplant team, including regular imaging and blood tests, is essential to monitor for recurrence and manage medication side effects.
Despite these challenges, quality of life for most patients improves after liver transplantation, particularly after the initial three to six-month recovery period. Many individuals are able to return to work, engage in physical activities, and resume their social lives. Patients can live for decades following a liver transplant, demonstrating its potential for a renewed and active life.