Belgian protocol for indication and selection of patients with unresectable colorectal cancer liver metastases eligible for liver transplantation.

Abstract

Background and study aims: Colorectal cancer (CRC) is common in Western countries, about 50% of patients develop liver metastases (CLM). While local CLM therapies can achieve 5-year survival up to 60%, most patients eventually become unresectable (uCLM) and have poor outcomes with systemic treatment alone. Prospective studies, including SECA I and II and the TransMet trial, showed that in carefully selected patients, liver transplantation (LTx) can achieve survival outcomes comparable to standard LTx indications. The aim of this work was to develop a harmonized national consensus protocol for the indication and selection of uCLM patients eligible for LTx.

Patients and methods: Under the coordination of the Belgian Liver & Intestine Advisory Committee (Be-LIAC), all six Belgian transplant centers delegated a transplant surgeon, an oncologist and an hepatologist to a working group that performed a literature review and drafted preliminary criteria. Three successive national meetings and a structured voting refined these criteria in the current protocol.

Results: Consensus was reached on inclusion and exclusion criteria for LTx in uCLM. Two key conditions are liver-only disease and technically uCLM. Strict requirements include a six months disease stability or response on systemic therapy and an obligatory eight-week treatment holiday. Absolute CEA levels and specific somatic mutations are not excluded. A national Be-LIAC governance model was established, combining local prospective decision-making with central auditing and registry-based evaluation.

Conclusions: A harmonized national protocol for LTx inuCLM has been established, ensuring consistent patient selection across all Belgian centers. Stricter criteria and a national governance model aim to optimize outcomes while maintaining ethical allocation of donor organs.