Liver Transplantation in a Patient with Unresectable Colorectal Liver Metastases - A Case Report

Background: Due to the lower survival rates achieved, in theearly period of liver transplantation era, in patients withcolorectal liver metastases, and because of the organ shortage,in the last two decades colorectal liver metastases areconsidered a contraindication for liver transplantation.However, the increasing number of marginal donors, and theimprovements in posttransplant immunossuppresion, chemotherapyand methods to assess the extrahepatic disseminationof colorectal cancer, opened the perspective of liver transplantationto certain patients with malignancies (such as HCCbeyond Milan criteria, and selected patients with cholangiocarcinomaor liver metastases from neuroendocrine tumors).Since some of these patients experienced favorable outcomes,in the last years, there were authors that considered a rationalerevisitation of the benefits of liver transplantation in patientswith unresectable colorectal liver metastases. Thus, in 2006, aNorwegian group started a study which aims to assess the resultsof liver transplantation in patients with unresectable colorectalliver metastases. Their results were unexpectedly favorable, revealing that 5-year overall survival rate was 60%, and thequality of life was excellent in the first year following transplantation.However, all the patients presented relapse of thedisease in the first two years following transplantation. In thepresent paper we present the clinico-pathologic characteristics,the pre- and postoperative management and the outcome of apatient with unresectable colorectal liver metastases whounderwent liver transplantation in a very advanced state of thedisease (when he developed subacute liver failure due toinsufficient functional liver parenchyma and toxicity of chemotherapy).We consider useful to present such observations,because collecting the data presented by different centers maybe contributive to identification of a selected group of patientswho could benefit from liver transplantation.Case report: A 42-year old male patient, it was diagnosed withupper rectum cancer and multiple bilobar liver metastases inApril 2009. Chemotherapy was started (in another hospital),and because the disease was stable after 7 cycles of FOLFOXand Bevacizumab, the patient was reffered to surgery (for a “twostage”liver resection). In October 2009 it was performed primarytumor resection associated with left lateral sectionectomyand segment 4 metastasectomy. Because in November 2009 CTscan re-evaluation revealed progression of liver metastases, thesecond stage hepatectomy was precluded. Subsequent therapyconsisted in radioembolization, multiple lines of chemotherapy,and targeted therapies. After more than 2 years, the liver metastasesprogressed and the patient developed progressive cholestaticsubacute liver failure due to insufficient functional liverparenchyma and chemotherapy toxicity. In this state of thedisease, he was admitted in our hospital, being dependant byliver dialysis and plasma exchange procedures. Due to thepatients’ age, and because the MDCT scan revealed theabsence of extrahepatic disease (after almost three years ofdisease progression), and he could not benefited from any typeof antineoplastic treatment due to progressive cholestatic subacuteliver failure, liver transplantation with an organ from amarginal donor was considered and performed in January 2012.The postoperative course was uneventful, and the quality of hislife improved (being fully reinserted social and professional).The immunosuppressive regimen consisted in Sirolimus andMycophenolate mofetil, and the adjuvant chemotherapystarted two months following liver transplantation. However,the patient developed extrahepatic relapse of the disease (lungmetastases and retroperitoneal recurrence), but now, at morethan 20 months following transplantation, he is still alive in agood clinical condition.Conclusions: In patients with multiple unresectable liver onlycolorectal metastases, liver transplantation may improve overallsurvival and quality of life, by using marginal grafts whichcannot be allocated to the patients with standard indicationsfor liver transplantation. The advent of MDCT and PET CTscan and the use of m-TOR inhibitors may improve the resultsachieved by liver transplantation in patients with CLMs.Further studies could be useful in an attempt to disclosewhether a selected group of patients with unresectable liveronly colorectal metastases could become acceptable candidatesfor liver transplantation.

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