Transplantation for Metastases

Transplant Indications for Secondary Malignancies in the Past

Liver transplantation for secondary malignancies has a long history; many programs included this indication in their pioneer phase in cases where the primary tumor was successfully removed and metastatic disease was confined to the liver. Metastases from cancers of the colon, tail of the pancreas, hypernephroma, meningioma, and duodenal leiomyosarcoma have been reported by Calne. The Denver-Cincinnati Registry reported procedures for liver metastases arising from the colon, carcinoid of the small bowel or bronchial tree, leiomyosarcoma of the small bowel, breast carcinoma, gastrinomas, glucagonomas, meningiomas, neuroblastomas, renal cell carcinoma, cystosarcoma of the pancreas, hemangiopericytoma, seminoma, VIPoma, melanoma, acute myeloid leukemia, and unknown primaries. For current standards the outcome was unfavorable; 59% died of tumor recurrence or suffered surgical complications.

Purely Surgical Approach to Colorectal Liver Metastases

The selection of transplant candidates was based upon histological freedom of central aortic lymph nodes at primary surgery (N2) and a radiologically assessed confinement of the tumor to the liver. No adjuvant chemotherapy was applied. A larger single-center series of patients with colon carcinoma metastases was reported by the group in Vienna, with an actuarial 1-year tumor-free survival rate of 68%; however, with the larger experience of 19 patients, median survival did not exceed 13.1 months. Neither surgery nor chemotherapy was considered if tumor recurrence was detected. This group terminated the “surgery only” program after 28 cases, the longest survivor reaching 30 years after surgery (alive in 2013) ( Fig. 18-1 ). This patient was free of lymphatic micrometastases, as determined by a special genetic screening method. The authors proposed freedom of lymphatic involvement as a selection criterion.