Liver transplantation for secondary liver tumours. BJS 2015; 102: 1589-1590.

Published: 29th September 2015

Authors: J. Lerut, A. Foss

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Kirsty McFarlane

3 years ago

We read with interest the article by Lerut and Foss (1) concerning the use of liver transplantation for hepatic metastases. The authors promote the use of liver transplantation (LT) for metastatic small-intestinal neuroendocrine tumours (SI-NETs) whilst failing to address contemporary literature on the topic.

The authors cite the ELTR study, which show a 5-year overall survival (5Y-OS) after LT of 52% for NET (2). In 2013 we published results from SI-NET patients that adhere to contemporary criteria for LT (n=78) (3) and demonstrated that optimal results can be achieved with multi-modality treatment alone. SI-NET patients under 65 years of age had an excellent 5Y-OS (84%), compared to the 20–35% found in historical series of NET (3). The adoption of stricter selection criteria (Milan Criteria) for LT appears to optimize 5Y-OS to 92% after LT of NET (4). Applying the Milan criteria on the ELTR study “improves” 5Y-OS to 79% (2). In contrast the adoption of the Milan criteria in our study of “non-transplant” patients provides a 5Y-OS of 97% and the subgroup in our study not treated by liver surgery displayed a 5Y-OS of 89% (2). The “improved outcome” shown in patients adhering to the Milan criteria is therefore almost certainly due to selection bias and not to treatment effect.

In the light of this we have concerns offering an operation with a 10% 90-day mortality rate (2) to patients with nearly 100% 5Y-OS with multi modality treatment alone (3).

Olov Norlén
Kosmas Daskalakis
Per Hellman
Kjell Öberg
Peter Stålberg

Department of Surgical Sciences, Endocrine Surgical Unit, and Department of Endocrine Oncology
Uppsala University
Uppsala University Hospital
Uppsala 753185
Sweden
olov.norlen@me.com

References:
1. Lerut J, Foss A. Liver transplantation for secondary liver tumours. Br J Surg 2015; 102: 1589-1590.
2. Le Treut YP, Grégoire E, Klempnauer J, Belghiti J, Jouve E, Lerut J et al.; for ELITA. Liver transplantation for neuroendocrine tumors in Europe – results and trends in patient selection: a 213-case European Liver Transplant Registry study. Ann Surg 2013; 257: 807–815.
3. Norlén O, Daskalakis K, Öberg K, Åkerström G, Stålberg P, Hellman P. Indication for Liver Transplantation in Young Patients with Small Intestinal NETs Is Rare? World J Surg 2014; 38: 742-747.
4. Mazzaferro V, Pulvirenti A, Coppa J. Neuroendocrine tumours metastatic to the liver: how to select patients for liver transplantation? J Hepatol 2007; 47: 460–466.