# Transplant Oncology in Evolution: Emerging Roles for Liver Transplant Beyond Hepatocellular Carcinoma

## TL;DR

Liver transplants are now being used to treat certain liver cancers beyond hepatocellular carcinoma, offering new hope for patients with specific types of advanced liver tumors.

## Contribution

The paper highlights liver transplantation as a curative option for selected patients with unresectable hepatic malignancies beyond hepatocellular carcinoma.

## Key findings

- Liver transplantation for colorectal liver metastases achieves 5-year OS rates of 60–83% in highly selected patients.
- Perihilar cholangiocarcinoma patients treated with strict selection and neoadjuvant therapy achieve 5-year OS rates of 50–68%.
- Intrahepatic cholangiocarcinoma patients with sustained response to neoadjuvant therapy can achieve 79.5% 5-year OS.

## Abstract

Historically, liver transplantation was indicated for patients with cirrhosis and hepatocellular carcinoma. Over the last decade, carefully selected patients with colorectal liver metastases, perihilar cholangiocarcinoma, and intrahepatic cholangiocarcinoma have achieved long-term survival after liver transplantation that approaches outcomes of traditional indications. In this narrative review we discuss the key data including the Oslo SECA I–II series, the randomized TransMet trial for colorectal liver metastases, the Mayo Clinic protocol for perihilar cholangiocarcinoma, and prospective work from the Houston Methodist–MD Anderson collaborative group in intrahepatic cholangiocarcinoma into practical selection criteria, peri-transplant therapy strategies, and post liver transplantation management considerations to guide clinicians and researchers.

Liver transplantation has emerged as a curative treatment option for selected patients with unresectable hepatic malignancies beyond hepatocellular carcinoma, marking a paradigm shift in transplant oncology. For colorectal cancer liver metastases (CRLM), prospective trials have demonstrated that highly selected patients achieve 5-year OS rates of 60–83%, with the Oslo score identifying optimal candidates for transplantation. Perihilar cholangiocarcinoma (pCCA) has been successfully treated using strict patient selection criteria combined with neoadjuvant therapy, achieving 5-year OS rates of 50–68%, though emerging data suggests chemotherapy-based approaches may be preferable to radiation in selected cases. Intrahepatic cholangiocarcinoma (iCCA), previously considered a contraindication to transplantation, can now achieve excellent long-term outcomes (79.5% 5-year OS) in patients demonstrating sustained response to neoadjuvant chemotherapy and radioembolization, with metabolic tumor volume < 70 cm3 serving as an objective prognostic marker. Across these three emerging indications, successful outcomes depend on strict patient selection based on tumor biology, intensive multimodal neoadjuvant therapy, multidisciplinary evaluation in high-volume centers, and careful observation during treatment to exclude patients with aggressive disease. This evolution in transplant practice offers curative intent therapy to patients that previously only had palliative therapeutic options, fundamentally transforming hepatobiliary and oncologic surgery.