Inclusion criteria for liver transplantation in patients with colorectal liver metastases: How to make the best selection?

The selection of patients with colorectal cancer liver metastases (CRLM) for liver transplantation (LT) represents a significant challenge, requiring a balance between oncological outcomes and organ scarcity. Recent advancements in transplantation outcomes for CRLM have prompted the establishment of rigorous selection criteria to optimize patient survival and graft utilization. This review examines the key criteria used to select candidates for LT in this setting, with a focus on oncological factors, patient characteristics, and response to therapy. Eligible candidates are typically those with non-resectable liver-only CRLM, demonstrating controlled primary tumor disease. Tumor biology is a critical determinant, excluding patients exhibiting high-risk molecular features such as BRAF or RAS mutations. Furthermore, candidates must show a favorable response to systemic chemotherapy, with either tumor stability or reduction in size and no extrahepatic progression during a defined treatment period. Specific tumor burden scores, such as the Oslo score or criteria based on the number and size of lesions, aid in stratifying candidates with acceptable recurrence risks. Other factors, including age, performance status, and absence of significant comorbidities, are also pivotal. Long-term follow-up data highlight the importance of stringent patient selection, showing superior 5-year survival in patients meeting these criteria compared to those who do not. In conclusion, strict selection criteria based on tumor biology, systemic disease control, and patient-specific factors ensure optimized outcomes for LT in CRLM patients, marking a pivotal step toward broader clinical acceptance of this novel approach.