Pulmonary Metastasectomy After Liver Transplantation: Indications, Timing, and Surgical Decision-Making Across Primary Tumor Histologies

Liver transplantation (LT) has evolved from a treatment for end-stage benign liver disease into a therapeutic strategy for selected oncological indications, including hepatocellular carcinoma (HCC), unresectable colorectal liver metastases (CRLM), hepatoblastoma, neuroendocrine tumor hepatic metastases, and hepatic epithelioid hemangioendothelioma. As the indications for LT expand and post-transplant survival improves, pulmonary recurrence has emerged as the predominant pattern of extrahepatic relapse across histologies. Yet no standardized surgical guidelines exist for managing lung metastases in the post-transplant patient. This narrative review synthesizes the available evidence on pulmonary metastasectomy following LT, addressing the incidence and tumor-specific patterns of pulmonary recurrence, the influence of immunosuppression on metastatic biology, surgical indications and contraindications, approach and timing considerations, and patient selection across primary histologies. We propose a practical decision-making framework integrating primary tumor biology, disease-free interval, lesion characteristics, immunosuppression regimen, and systemic therapy response. With the recent regulatory recognition of CRLM as a standard transplant indication and the ongoing SECA-III randomized trial, the downstream surgical management of pulmonary recurrence in LT recipients requires urgent evidence-based codification.