Colorectal cancer is a prevalent disease worldwide, with more than 50% of patients developing metastases to the liver. Despite advances in improving resectability, most patients present with non-resectable colorectal liver metastases requiring palliative systemic therapy and locoregional disease control strategies. There is a growing interest in the use of liver transplantation to treat non-resectable colorectal liver metastases in well selected patients, leading to a surge in the number of studies and prospective trials worldwide, thereby fuelling the emerging field of transplant oncology. The interdisciplinary nature of this field requires domain-specific evidence and expertise to be drawn from multiple clinical specialities and the basic sciences. Importantly, the wider societal implication of liver transplantation for non-resectable colorectal liver metastases, such as the effect on the allocation of resources and national transplant waitlists, should be considered. To address the urgent need for a consensus approach, the International Hepato-Pancreato-Biliary Association commissioned the Liver Transplantation for Colorectal liver Metastases 2021 working group, consisting of international leaders in the areas of hepatobiliary surgery, colorectal oncology, liver transplantation, hepatology, and bioethics. The aim of this study was to standardise nomenclature and define management principles in five key domains: patient selection, evaluation of biological behaviour, graft selection, recipient considerations, and outcomes. An extensive literature review was done within the five domains identified. Between November, 2020, and January, 2021, a three-step modified Delphi consensus process was undertaken by the workgroup, who were further subgrouped into the Scientific Committee, Expert Panel, and Transplant Centre Representatives. A final consensus of 44 statements, standardised nomenclature, and a practical management algorithm is presented. Specific criteria for clinico-patho-radiological assessments with molecular profiling is crucial in this setting. After this, the careful evaluation of biological behaviour with bridging therapy to transplantation with an appropriate assessment of the response is required. The sequencing of treatment in synchronous metastatic disease requires special consideration and is highlighted here. Some ethical dilemmas within organ allocation for malignant indications are discussed and the role for extended criteria grafts, living donor transplantation, and machine perfusion technologies for non-resectable colorectal liver metastases are reviewed. Appropriate immunosuppressive regimens and strategies for the follow-up and treatment of recurrent disease are proposed. This consensus guideline provides a framework by which liver transplantation for non-resectable colorectal liver metastases might be safely instituted and is a meaningful step towards future evidenced-based practice for better patient selection and organ allocation to improve the survival for patients with this disease.

Abdominal Transplant and Hepato Pancreato Biliary Surgical Oncology Multi Organ Transplant Program Division of General Surgery University of Toronto Toronto ON Canada

Department of Gastroenterology and Hepatology Institute for Clinical and Experimental Medicine Prague Czech Republic

Department of Haematology Oncology National University Cancer Institute Singapore

Department of Hepatobiliary Surgery Careggi University Hospital Florence Italy

Department of Medical Oncology Mayo Clinic Rochester MN USA

Department of Medical Oncology West Cancer Center and Research Institute Germantown TN USA

Department of Medicine Royal Marsden Hospital London UK

Department of Surgery Case Western Reserve University School of Medicine Cleveland OH USA

Department of Surgery Liver Transplantation Centre Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan

Department of Transplantation and Hepatobiliary Surgery Leeds Teaching Hospital NHS Trust Leeds UK

Department of Transplantation Medicine Oslo University Hospital Oslo Norway

Department of Transplantation Medicine Oslo University Hospital Oslo Norway; Institute of Clinical Medicine University of Oslo Oslo Norway

Division of Gastroenterology and Hepatology National University Hospital Singapore

Division of Hepato Pancreato Biliary Surgery and Transplantation Department of Surgery Saint Eloi Hospital Montpellier University Hospital School of Medicine Montpellier France

Division of Hepatobiliary and Pancreatic Surgery National University Hospital Singapore

Division of Liver Transplantation and Hepato Pancreato Biliary Surgery Department of Surgery Weill Cornell Medicine New York City NY USA

Division of Liver Transplantation Hepatobiliary and Pancreatic Surgery Queen Mary Hospital Hong Kong

Hepato Biliary Surgery Cancer and Transplantation Unit AP HP Paul Brousse Hospital University Paris Saclay Villejuif France

Institute of Liver Studies King's College Hospital London UK

Liver Unit Queen Elizabeth Hospital University Hospitals Birmingham NHS Foundation Trust Birmingham UK

The Centre of Medical Ethics and Law Department of Medicine Stellenbosch University Stellenbosch South Africa

Lancet Gastroenterol Hepatol. 2021 Nov;6(11):e7. doi: 10.1016/S2468-1253(21)00345-9. PubMed

Hepatobiliary Surg Nutr. 2023 Jun 1;12(3):424-427. doi: 10.21037/hbsn-23-200. PubMed

Hepatobiliary Surg Nutr. 2023 Aug 1;12(4):595-597. doi: 10.21037/hbsn-23-270. PubMed

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