Liver Transplant For Cancer

A new liver when the cancer cannot be cut out. For carefully selected patients.

In the TransMet trial, five-year survival with unresectable bowel cancer liver metastases was 73.3 percent after transplant plus chemotherapy, against 9.3 percent with chemotherapy alone.

Why a transplant can cure liver cancer

Removing the whole liver

Removing part of the liver works when the tumor can be cut out with a margin and enough healthy liver remains. A transplant goes further. It removes every part of the liver, including tumors too small to see on scans, and in hepatocellular carcinoma it also removes the cirrhotic liver in which new cancers keep forming. The limit is the cancer outside the liver. Tumor cells that have already reached the lungs, bones or lymph nodes are not removed by a transplant, and the drugs that stop the body rejecting the new liver also weaken its defense against cancer, so a cancer that has spread can grow faster afterward. Selection therefore decides everything. Teams use size, number, blood markers, response to treatment and time to pick the patients in whom the cancer is most likely confined to the liver, and they set those limits so that the donated liver gives a result comparable to transplants for other diseases.

Selection decides whether a transplant cures.

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Liver cancer and the Milan criteria

The Milan criteria require

1. one tumor up to 5 centimeters, or up to three tumors none over 3 centimeters,
2. no invasion of the main blood vessels,
3. and no spread outside the liver.

Where the criteria came from

In 1996, a team in Milan reported 48 patients with cirrhosis and small hepatocellular carcinomas who had a transplant. Patients qualified with a single tumor up to 5 centimeters, or up to three tumors none larger than 3 centimeters, and no spread. At four years, survival was 75 percent overall, and among the 35 whose tumors were confirmed within those limits on the removed liver, it was 85 percent, with 92 percent free of recurrence. These Milan criteria remain the reference point, and wider criteria based on size, number and the alpha-fetoprotein blood level are used by many programs.

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Bowel cancer that has spread to the liver

Metastases from colorectal cancer were long thought unsuitable for transplant. A pilot study in Oslo changed that in 2013. Among 21 patients with liver-only metastases that could not be resected, survival was 95 percent at one year and 60 percent at five years, far beyond what chemotherapy alone achieved.

Next, the European TransMet trial randomized 94 patients aged 18 to 65 with permanently unresectable, liver-only metastases that had responded to chemotherapy, from bowel cancers without a BRAF mutation, to transplant plus chemotherapy or chemotherapy alone. Five-year survival was 56.6 percent against 12.6 percent counting everyone randomized, and 73.3 against 9.3 percent among those treated as planned.

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TransMet also recorded

• serious adverse events in 80 percent of transplanted patients,
• three repeat transplants,
• and one death after a repeat transplant.

Bile duct cancer

For small perihilar cholangiocarcinomas that cannot be removed, a protocol of radiotherapy and chemotherapy followed by transplantation has been used across 12 American centers in 287 patients. Results were encouraging. Five-year survival was 53 percent counting everyone who started, and 65 percent of those transplanted were free of recurrence at five years.

Living donor transplantation

In Turkey, most liver transplants use part of a liver from a living donor, usually a close relative, which avoids long waits on a deceased donor list. Timing can then follow the cancer. Turkish rules allow donation by relatives up to the fourth degree and spouses, with other donors reviewed by an ethics committee.

Risks and how they are managed

In the first weeks

Early problems include

• bleeding,
• clots in the liver vessels,
• and slow function of the new liver.

The recovery

Recipients spend the first days in intensive care and two to three weeks in hospital, while the donor goes home after a week. Walking starts early. For the first three months, blood tests run several times a week to set the medicine doses, because the levels of tacrolimus and similar drugs must sit in a narrow range, high enough to prevent rejection and low enough to spare the kidneys and limit infections, and crowds, sick contacts and undercooked food are avoided while immunity is lowest. A transplant nurse teaches the medicine schedule before discharge. Pills are taken at the same times every day, with a written plan for missed doses. Donors recover faster, returning to desk work in four to six weeks and to full activity in about three months as their own liver regrows. Recipients return to normal activity within three to six months, and many go back to work.

How long to stay in Istanbul

Plan for two to three months for the recipient.

A published Istanbul living donor package lists fifteen days in hospital for the recipient, with up to three days of intensive care, and seven days for the donor, and includes preoperative tests for both, three follow-up consultations, transfers, accommodation for companions, a translator and English medical reports. Assessment before surgery takes one to two weeks. After discharge, staying near the hospital for several weeks allows close blood tests and medicine adjustments before the flight home.

What decides the cost

Living or deceased donor, assessment of the donor and recipient, bridging treatment, intensive care nights, the hospital stay and the first months of medicines set most of the figure.

A quote you can compare names both operations and the stay, and that figure comes only after the transplant team reviews your scans, tumor markers and the donor's details. The review costs nothing.

Arranging the trip

Your scans, tumor markers, pathology and a note about a possible donor, sent on WhatsApp, open the review, and the coordinator who replies stays with you and your donor through assessment, surgery and the months after you return. The team speaks English, Arabic, French, Russian, Serbian, Romanian and Spanish, and interpreters cover other languages. A companion sleeps on the companion bed in the room. The international office books hotels for the family, sends visa invitation letters ten days before travel and arranges transfers, and halal, vegetarian and diabetic meals, a prayer room and a female physician on request are available.

Once you are back home

Lifelong immunosuppression continues with blood tests, and scans every three to six months watch for recurrence in the first years. Your local hepatologist works with the Istanbul transplant team through the coordinator.

Fever, yellowing of the eyes, dark urine, abdominal pain, confusion, or missed medicine doses because of vomiting. Each needs a doctor the same day.

Liver transplant for cancer FAQ