**8. Liver transplantation for colorectal cancer metastases**

Liver transplantation is indicated for end-stage chronic liver disease and acute liver failure. In addition, transplantation has certain indications regarding malignant tumours. The classic indications include hepatocellular carcinoma on the background of liver cirrhosis if the patient corresponds to the Milan criteria; fibrolamellar hepatocellular carcinoma, hepatoblastoma and epithelioid haemangioendothelioma. Transplantation is researched in patients having hepatocellular carcinoma with tumour burden exceeding the Milan criteria, hepatocellular carcinoma in noncirrhotic liver, cholangiocellular cancer and liver metastases from neuroen‐ docrine tumours. Hepatocellular carcinoma with extrahepatic spread or portal vein invasion, hepatoblastoma with uncontrolled extrahepatic spread and other malignancies are regarded as contraindications for liver transplantation. Thus, until recently, colorectal cancer metastases to the liver also were considered a contraindication for liver transplantation [100] due to allocation justice in the background of organ shortage and due to the risk of tumour recurrence on the background of immunosuppression.

A revolutionary approach has been undertaken in Norway by Hagness et al. offering liver transplantation to patients with unresectable liver metastases of colorectal cancer. The resulting life quality was good. The 5-year survival was 60%, that exceeds the survival

obtained by chemotherapy and is comparable to the survival after liver resection in suitable cases [9].

cycles. Thus, the inclusion of bevacizumab in the chemotherapy schedule in addition to

The planning of liver surgery can be challenging in patients presenting with colorectal cancer and synchronous liver metastases. Simultaneous resection of primary tumours and liver metastases can be performed in selected patients. Liver resection can safely be performed as the first operation followed by the large bowel operation [93]. The safety of liver-first approach

The risk factors of cancer recurrence include the presence of lymph node or extrahepatic metastases, high CEA (above 200 ng/mL), multiple and large (above 5 cm) metastases, short disease-free survival [18], high tumour grade and positive resection lines [4]. Regarding the resection line, the minimal requirements are under discussion regarding R0 resection with distance between tumour and resection line less than 1 cm. In the recent literature, lack of 1 cm margin is not considered a contraindication for liver resection [80], and generally the requirement for tumour-free tissue border has decreased from 10 to 2 mm or even 0 mm [95– 98]. The presence of hilar lymph node metastases is an adverse prognostic factor in comparison to metastases affecting only liver but can be less hazardous in prognostic terms than metastases

After resection, MRI or CT should be used for surveillance. The examinations must be repeated every 3–6 months for 2 years after resection and every 6 months for 3–5 years after the surgery [1]. Perioperative chemotherapy, including adjuvant treatment, increases recurrence-free

Liver transplantation is indicated for end-stage chronic liver disease and acute liver failure. In addition, transplantation has certain indications regarding malignant tumours. The classic indications include hepatocellular carcinoma on the background of liver cirrhosis if the patient corresponds to the Milan criteria; fibrolamellar hepatocellular carcinoma, hepatoblastoma and epithelioid haemangioendothelioma. Transplantation is researched in patients having hepatocellular carcinoma with tumour burden exceeding the Milan criteria, hepatocellular carcinoma in noncirrhotic liver, cholangiocellular cancer and liver metastases from neuroen‐ docrine tumours. Hepatocellular carcinoma with extrahepatic spread or portal vein invasion, hepatoblastoma with uncontrolled extrahepatic spread and other malignancies are regarded as contraindications for liver transplantation. Thus, until recently, colorectal cancer metastases to the liver also were considered a contraindication for liver transplantation [100] due to allocation justice in the background of organ shortage and due to the risk of tumour recurrence

A revolutionary approach has been undertaken in Norway by Hagness et al. offering liver transplantation to patients with unresectable liver metastases of colorectal cancer. The resulting life quality was good. The 5-year survival was 60%, that exceeds the survival

FOLFOX improves the outcome in terms of achieving resectability [91].

has been confirmed in a recent review [94].

184 Recent Advances in Liver Diseases and Surgery

on the background of immunosuppression.

survival [99].

in lymph nodes adjacent to truncus coeliacus or aorta [4].

**8. Liver transplantation for colorectal cancer metastases**

Interestingly, the recurrence patterns after liver transplantation differ from those after liver resection. The most frequent event is single-site recurrence in the lungs, followed by recurrence in multiple sites. In the present group of patients, no single-site recurrences in liver were observed, although the liver was involved by tumour metastases in patients having recurrence in multiple sites. Regarding the outcome, the pulmonary metastases followed indolent course, but metastases to the transplanted liver were prognostically adverse. The immunosuppressive treatment did not enhance the growth of those pulmonary metastases that were present at the time of transplantation [9]. The m-TOR inhibitors used for immunosuppression can have beneficial influence as they block angiogenesis and proliferation [9, 100].
