# The Evolving Role of Living Donor Liver Transplantation in the Management of Colorectal Liver Metastases

## TL;DR

Living donor liver transplantation is being explored as a treatment option for colorectal cancer that has spread to the liver, offering potential benefits over traditional methods.

## Contribution

The paper introduces living donor liver transplantation as a novel alternative for colorectal liver metastases, emphasizing its unique advantages and ethical considerations.

## Key findings

- Living donor liver transplantation may overcome organ shortages and improve outcomes for colorectal liver metastases.
- A patient with colorectal liver metastases remained disease-free 30 months after left lobe living donor liver transplantation.
- Molecular profiling and liquid biopsy are proposed as tools for patient selection in liver transplantation for colorectal cancer.

## Abstract

Surgical resection offers the best chance of cure for patients with advanced colorectal cancer with liver involvement. Unfortunately, surgical resection is not feasible in many patients due to the extent of liver involvement. In recent years, liver transplantation has emerged as an alternative treatment option in selected patients not suitable for resection. Early results using livers from deceased donors are encouraging but organ shortage remains the most significant challenge. Living donor liver transplantation might overcome many obstacles posed by deceased donation, but not without its own unique ethical and medical considerations. In this review, we discuss the key differences between deceased and living donor liver transplantation for colorectal cancer, summarize current global evidence, and report a successful case from out center. We also highlight novel investigations and future directions that will likely define the role of liver transplantation for colorectal cancer in the future.

Surgical resection remains the cornerstone of curative-intent therapy for colorectal liver metastases (CRLM). However, a substantial proportion of patients present with technically unresectable diseases or develop intrahepatic recurrence, despite optimal multimodal treatment. In this setting, liver transplantation (LT) has emerged as a potential strategy for durable, cancer-free survival in selected patients. Early experience with deceased donor liver transplantation (DDLT) for CRLM showed encouraging outcomes, but broader implementation has been constrained by ethical concerns and logistical barriers related to organ scarcity. Living donor liver transplantation (LDLT) offers a fundamentally different paradigm, potentially mitigating these limitations while introducing distinct technical, ethical, and logistical considerations. In this manuscript, we delineate the technical and logistic differences between DDLT and LDLT in the context of CRLM and highlight advantages unique to LDLT-based strategies. We contrast historical data with emerging contemporary evidence, with particular emphasis on LDLT outcomes. We critically examine evolving patient selection frameworks, incorporating molecular profiling and circulating tumor DNA-based liquid biopsy. In addition, we report our institutional experience with left lobe LDLT for CRLM in a patient who remains disease-free 30 months after transplantation. We conclude with a comprehensive appraisal of the current LDLT literature in CRLM and propose directions for future research.