Belgian protocol for indication and selection of patients with unresectable colorectal cancer liver metastases eligible for liver transplantation

Introduction: Colorectal cancer (CRC) is common in Western countries, about 50% of patients develop
liver metastases (CLM). While local CLM therapies can achieve 5-year survival up to 60%, most
patients eventually become unresectable (uCLM) and have poor outcomes with systemic treatment
alone. Prospective studies, including SECA I and II and the TransMet trial, showed that in carefully
selected patients, liver transplantation (LTx) can achieve survival outcomes comparable to standard LTx
indications.
Aim: The aim of this work was to develop a harmonized national consensus protocol for the indication
and selection of uCLM patients eligible for LTx.
Methods: Under the coordination of the Belgian Liver & Intestine Advisory Committee (Be-LIAC),
all six Belgian transplant centres delegated a transplant surgeon, an oncologist and an hepatologist
to a working group that performed a literature review and drafted preliminary criteria. Three
successive national meetings and a structured voting refined these criteria in the current protocol.
Results: Consensus was reached on inclusion and exclusion criteria for LTx in uCLM. Two key conditions
are liver-only disease and technically uCLM. Strict requirements include a six months disease stability or
response on systemic therapy and an obligatory eight-week treatment holiday. Absolute CEA levels and
specific somatic mutations are not excluded. An independent central auditing committee was established.
Conclusions: A harmonized national protocol for LTx inuCLM has been established, ensuring consistent
patient selection across all Belgian centres. Stricter criteria and an independent auditing committee aim
to optimize outcomes while maintaining ethical allocation of donor organs.