Liver transplantation plus chemotherapy significantly improves overall survival in carefully selected patients with unresectable colorectal liver metastases compared with chemotherapy alone, according to the results of the TRANSMET trial.
The combined approach led to a 5-year overall survival rate of 73% compared with 9% among those who received only chemotherapy.
“Liver transplantation plus chemotherapy offers a potential cure to patients with cancer with otherwise poor long-term outcomes,” principal investigator Rene Adam, MD, PhD, said when presenting the latest findings at the American Society of Clinical Oncology (ASCO) 2024 annual meeting.
However, careful patient selection will be critical, cautioned ASCO discussant, Major K. Lee, MD, PhD, associate professor of surgery, Penn Medicine in Philadelphia.
Chemotherapy remains the standard of care for patients with definitively unresectable colorectal liver metastases, but historically these patients have poor long-term outcomes.
Liver transplantation has shown promise in this population but requires “strong evidence” of clinical benefit, Adam said, given the scarcity of organs and the perception that there is “no role for local treatment in an advanced metastatic disease.”
TRANSMET is the first randomized trial evaluating the efficacy of liver transplantation plus chemotherapy in this patient population and the eligibility criteria were “very, very strict,” Adam explained.
Eligibility was restricted to patients who were aged no more than 65 years and had good performance status (ECOG 0 or 1). Patients had surgeon-confirmed unresectable colorectal liver metastases and had undergone gold standard resection of the primary tumor. Patients also had no extrahepatic disease, a partial response or stability with chemotherapy, no BRAF mutation, low carcinoembryonic antigen levels, and adequate platelet and white blood cell count.
A total of 94 patients were randomized to continue chemotherapy or undergo liver transplantation plus chemotherapy. Patients put on the transplant waiting list were prioritized for timely access to an organ so liver transplantation could be performed within 2 months after the last chemotherapy treatment.
In the intent-to-treat analysis of all patients (47 per group), overall survival at 5 years was 57% in the transplant plus chemotherapy group vs 13% in the chemotherapy only group (hazard ratio [HR], 0.37; P =.0003).
However, nine patients in the intent-to-treat transplant group progressed and did not receive a liver transplant; two others were excluded from the per protocol analysis including one patient who had a liver transplant more than 3 months after the last chemotherapy treatment.
The per protocol analysis included 74 patients — 36 in the liver transplant group and 38 in the chemotherapy only group. In this analysis, 5-year overall survival was 73% in the transplant group and 9% in the chemotherapy only group (HR, 0.16; P <.0001>
Among the 36 patients in the liver transplant arm, 26 (72%) experienced disease recurrence — 14 patients had recurrence in the lungs, three in the lymph nodes, one in the liver, and eight at other or multiple sites. Among those with disease recurrence, 12 patients (46%) underwent surgery or ablation, leaving 15 of the 36 patients (42%) with no evidence of disease.
In contrast, in the chemotherapy per protocol group, all but one patient (97%) experienced disease progression. After switching to a new chemotherapy regimen, only one patient had no evidence of disease (3%).
In the per protocol analysis, progression-free survival at 3- and 5-years was 33% and 20%, respectively, in the liver transplant group vs 4% and 0%, respectively, in the chemotherapy group (HR, 0.34; P <.0001>
These data suggest that “transplanted patients with colorectal liver metastases have similar survival as those transplanted for established liver transplantation indications,” said Adam, chief, Department of Hepato-Biliary Surgery, Cancer, and Transplantation, Paul Brousse Hospital, Villejuif, France.
“These results support liver transplantation as a new standard option that could change practice,” Adam added.
Lee, the discussant during the session, agreed that the trial shows that liver transplant carries the potential for extended survival in patients with unresectable colorectal liver metastases.
However, Lee noted, “identifying candidates can be challenging.” Overall, 40% of submitted patients were deemed ineligible, and 19% of patients (nine of 47) randomized to transplant did not receive one due to progressive or intraoperative findings.
This data also show “how difficult it is to pick the right patients” for a transplant, said Lee, who wondered whether it is “even possible to develop standard algorithms to get patients to transplant when we have such a heterogeneous population.”
The study had no commercial funding. Adam and Lee had no relevant disclosures.
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