Liver transplantation in unresectable colorectal liver metastases–Defining the optimal candidate

Approximately half of all patients with colorectal cancer develop liver metastases over the course of their disease. While 20-30% of patients with colorectal liver metastases (CRLM) are potential candidates for curative hepatic resection, those with unresectable CRLM (uCRLM) have historically been limited to systemic chemotherapy or best supportive care. Recent evidence from the randomized controlled TransMet trial has demonstrated that orthotopic liver transplantation in carefully selected patients with uCRLM results in an 8-fold higher 5-year survival compared with chemotherapy only (73% versus 9%). When patient selection is further refined using tumor biology characteristics and response to chemotherapy as key selection criteria, encouraging 5-year survival rates ranging from 50-83% after LT have been reported. Although post-transplant tumor recurrence remains a major clinical concern, recurrent disease most commonly manifests as pulmonary metastases are frequently amenable to effective local or systemic treatment. Growing clinical evidence indicates that LT for uCRLM is emerging as a viable therapeutic strategy for highly selected patients lacking otherwise curative options. Nevertheless, the field urgently requires standardized selection protocols and clear guidance on how such transplant candidates should be prioritized within national organ allocation systems.