Liver Transplantation for Unresectable Colorectal Liver Metastases: Evidence, Patient Selection, and Clinical Implementation

Liver transplantation (LT) has re-emerged as a potentially curative treatment for carefully selected patients with unresectable, liver-only colorectal liver metastases (CRLM). Prospective trials (SECA-I/II) demonstrated 5-year overall survival (OS) rates of 60–83% in selected patients, findings recently corroborated by the randomized TransMet trial, which showed superior 5-year OS with LT compared with chemotherapy alone. Favorable outcomes depend on rigorous patient selection integrating clinical risk stratification (Oslo Score), tumor burden assessed by metabolic tumor volume on FDG-PET-CT, and molecular profiling, while excluding high-risk features such as BRAF V600E and RAS/TP53 co-mutations. Broader implementation raises ethical challenges related to organ allocation, driving interest in alternative strategies including living-donor LT and innovative procedures such as RAPID. This narrative review summarizes evolving evidence supporting LT for CRLM, current approaches to patient selection, oncological outcomes, and practical considerations for implementing LT into contemporary HPB and transplant practice.