Liver Transplantation for Hepatic Malignancies: Identifying Inaccurate Statements About Drawbacks
Direct Answer
The statement that would NOT be accurate regarding drawbacks of liver transplantation for hepatic malignancies is any claim suggesting that transplantation is contraindicated for ALL metastatic liver disease, as select metastatic neuroendocrine tumors can achieve long-term survival and even cure with transplantation in carefully selected patients. 1, 2, 3
Key Accurate Drawbacks of Liver Transplantation for Malignancies
Organ Scarcity and Waitlist Mortality
The lack of sufficient liver donation is the major limitation for liver transplantation, with waiting periods between listing and transplantation varying among programs. 1
The dropout rate from the waiting list may be as high as 25% if the waiting list exceeds 12 months, as tumors grow and develop major contraindications (vascular invasion, extrahepatic spread) during the waiting period. 1
If the dropout rate due to advancing disease reaches 25% at 1 year, this translates into only a 60% survival rate for transplantation based on intention-to-treat analysis of patients listed for transplant. 1
High Recurrence Risk in Certain Malignancies
For hepatocellular carcinoma (HCC), early unsatisfactory results with broad selection criteria led to recurrence rates of 32-54% at 5 years and 5-year survival below 40%. 1
Most recurrences, especially those appearing early during follow-up, are due to tumor dissemination and have a more aggressive biological pattern compared to primary tumors. 1
The most powerful predictor of recurrence in the absence of extrahepatic spread is macro- or microscopic vascular invasion, with likelihood running parallel to tumor size and number. 1
For cholangiocarcinoma, overall results are discouraging with 44% recurrence rate (52% within 12 months, 70% within two years) and 5-year patient survival of only 17%. 1
Poor Outcomes in Specific Tumor Types
For primary cholangiocarcinoma, early recurrence is common with most patients dying of recurrent disease within the first few years after operation. 1
Angiosarcoma is associated with very poor survival and is considered a contraindication to transplantation. 2, 3
Retransplantation for liver failure from recurrent hepatitis C has been associated with particularly poor survival. 1
The Exception: Metastatic Neuroendocrine Tumors
Why This Represents an Inaccurate Drawback Statement
While most metastatic liver disease is a contraindication to transplantation, metastatic neuroendocrine tumors represent a specific exception where transplantation can result in long-term survival and even cure in well-selected patients. 2, 3
The AASLD guidelines acknowledge that liver transplantation for metastatic neuroendocrine tumors should be confined to highly selected patients who are not candidates for surgical resection in whom symptoms have persisted despite optimal medical therapy. 1
Although most patients with metastatic neuroendocrine tumors have died of recurrent disease within the first few years, there have been occasional long-term disease-free survivors. 1
Patients with low tumor activity index can achieve excellent posttransplant survival despite tumor recurrence. 3
Selection Criteria for Metastatic Neuroendocrine Tumors
Primary indications include: (1) tumors not accessible to curative surgery or major tumor reduction; (2) tumors not responding to medical or interventional treatment; and (3) tumors causing life-threatening hormonal symptoms. 1
Metastases from neuroendocrine tumors are often slow growing and can be confined to the liver for long periods. 1
Additional Accurate Drawbacks
Immunosuppression-Related Issues
Long-term immunosuppression carries inherent risks and complications that must be weighed against benefits. 2
Patients with polycystic disease seem unusually susceptible to infection after transplantation. 1
Ethical and Allocation Concerns
The ethics of organ allocation to individuals who may benefit from prolonged survival after transplant yet have a high incidence of recurrence remains a significant concern. 4
Expanding listing criteria increases dropout rates and translates into poor survival figures on intention-to-treat analysis. 1
Perioperative Risks
Mortality is increased postoperatively in cirrhotic compared with non-cirrhotic patients, with risk of complications aggravated by portal hypertension, high Child-Pugh score, and number of liver segments resected. 1
Perioperative mortality for patients meeting Milan criteria is around 3%, with 1-year mortality of ≤10%. 1