MASSIMO MALAGO 2

Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen

Massimo MalagóThe Ilse Bagel Professor of Surgery and The Ilse Bagel Professor of Surgery and

TransplantationTransplantationUniversity of Duisburg-EssenUniversity of Duisburg-Essen

Liver transplantation in liver tumors other than HCC


Therapy of liver tumorsHistory

Liver transplantation: a reality in the ’70-‘80

Resection AND / ORTransplantation

Radicality Organ preservation, I/RPreserved function Immunology

Multidisciplinarity Cooperation

Oncology, RT, nutrition Hepatology, ICU, virology

No Competition but

Sinergy!!!!


Rudolf Pichlmayr, Christoph Broelsch

Med.Kln. 78 (1983) 744-752

Therapy of liver tumorsHistory - Liver transplantation

Radicality, locoregional controlVs

Immunosuppression related recurrence


Therapy of liver tumorsHistory - Liver transplantation

Oncological rationale

Radicality, locoregional controlVs

Occult - „dormant“ metastases

In advanced secondary and primary tumors


General SurveyIndications - ResultsOrgan allocationImmunosuppression



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Up to date sul trapianto di fegatoHepatobiliary Tumors

www.eltr.org/publi/results.



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Metabolic diseases : 3592

6%

Cholestatic diseases : 6256

11%

Acute hepatic failure : 5166

9%

Cancers : 7318

13%

* Others : 1779

3%

Cirrhosis : 33845

58%

* Others : Budd Chiari : 567 Benign liver tumors or Polycystic diseases : 635Parasitic diseases : 54 Other liver diseases : 523

Primary Diseases leading to Liver Transplantion in Europe

01/1988 - 12/2005

ELTR12/2005


Primary Diseases leading to Liver Transplantion by Country

01/1988 - 12/2005

0% 20% 40% 60% 80% 100%

YUGOSLAVIA

TURKEY

SWITZERLAND

SWEDEN

SPAIN

SLOVENIA

ROMANIA

PORTUGAL

POLAND

NORWAY

NETHERLANDS

MONACO

ITALY

IRELAND

HUNGARY

GREAT BRITAIN

GERMANY

FRANCE

FINLAND

DENMARK

CZECH REP.

BELGIUM

AUSTRIA

Cirrhosis : 33845

Cancers : 7318

Acute hepatic failure : 5166

Others : 7166


Organ pool „independent“ from allocationOptimal timing: no waiting timePre-selected organ quality

Donor risks!!Recipients: suboptimal results in

- advanced tumors- severe cirrhosis

Liver Transpl. 2001 7:921-7Liver Transpl. 2001 7:921-7

LDLT for HCC


Organ allocation

Maximal gain concept: The sickest patients (High Meld) benefit more!!!



Evolution of Primary Diseases leading to Liver Transplantation in Europe

05/1968 - 12/2005

Cirrhosis : 34684 Cancers : 7824Acute hepatic failure : 5313 Others : 12088

ELTR12/2005

0%

20%

40%

60%

80%

100%

68-

80

83 86 89 92 95 98 2001 2004




Hepatobiliary Tumors




NHBDNHBD

Organ shortageLiver

Optimal use of the organ resources

Marginal Marginal SPLIT SPLIT Living Donor Living Donordonorsdonors

DominoDomino

ECDECD


Live donor LTLive donor LTfor HCC - Adultsfor HCC - Adults

Extended criteria but not open end


Liver transplantation

Vs

Liver resection

Extension of radicality - resectability

Primary liver tumors


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HCC: Liver resection Restricted function



benötigt.


benötigt.

HCC: Liver resection


Leberresektionen Essen Apr. 1998 - 2006

___________

Leberresektionen gesamt 2710

Hemihepatektomie

Erweiterte Hemihepatektomie

Anatomische Leberresektionen

Nicht-anatomische Leberresektionen

Hepatikusgabelresektionen

Leberlebendspender

892

308

341

937

58

174


Klatskin tumorsKlatskin tumors


Avoiding unnecessary transplantationsR Trisegmentectomy + Whipple for Kltaskin

Avoiding unnecessary transplantationsR Trisegmentectomy + Whipple for Kltaskin

Radical surgery for Hilar CCCRadical surgery for Hilar CCC


LTX for Hepatobiliary Tumors

(HCC)Hepatoblastoma

CCC

Stroma Tumors - Mesenchymal (Liver sarcoma)Epitheliod Hemangioendithelioma

neuroendocrine (NE)Metastatic tumors

non NE Colorectal



LTX ESSEN April 1998 – October 2006 n = 881

Split (115)

LDLT (185)

Standard-Tx (573)

Reduced Liver (8)


37

467

53

Lebendspende OLTx reduzierte Leber Split

Pediatric n = 143

148

528

1 61

Lebendspende OLTx reduzierte Leber Split

Adults n = 738

LTX ESSEN April 1998 – October 2006 n = 881

140

8

Right Left

ALDLT n =148


42

7

73

hccother tumorsother disease

ALDLT n=121ALDLT n=121

HCC 34%HCC 34%

54 1

475

hccother tumorsother disease

Cadaver LTx n=530Cadaver LTx n=530

HCC 10,1%HCC 10,1%

LTx for HCC - AdultsLTx for HCC - Adults

Essen 1998 - 2005Essen 1998 - 2005

Mean F-up 28 mo.Mean F-up 28 mo.


Living Donor LTx Indications

1

50

152123

2

Non TumorNon Tumor

AdenoCaAdenoCaHCCHCC

NeuroEndocrineNeuroEndocrine

MesenchymalMesenchymal

Pseudo-TumorPseudo-Tumor

HepatoblastomaHepatoblastoma


Living Donor: 4.8%


Cadaveric LTx Indications

4 56 14

632Non TumorNon Tumor

AdenoCaAdenoCaHCCHCC

NeuroEndocrineNeuroEndocrine

MesenchymalMesenchymal


Deceased Donor: 1.3%


HepatoblastomaomaLiver transplantation - SIOPEL Protocol

Otte et al Ped Transpl 2005


HepatoblastomaomaLiver transplantation - SIOPEL Protocol

Patients referred n = 6

Not transplantable n = 1

Liver resection n = 4

LDLT n = 1


Cholangiocarcinoma

[ Gallbladder (GBC) ]

Intrahepatic (ICC or peripheral CC)

without cirrhosis, without PSC*

with Caroli´s disease *with cirrhosis (secondary biliary cirrhosis)

with PSC

Hilar (Klatskin-Tumor)

without cirrhosis, without PSC *with PSC *normal liver functional reserve


Extended Liver Resections

Cholangiocarcinoma- without cirrhosis, without PSC


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Scenario 5 - Extended L Hepatectomy


Left Trisectionectomy


Extended - R trisectionectomy


Author/year n 1y 3y 5y median (mon.)

Berdah/1996 19 67 40 32 15

Chu/1997 39 57 24 16 12

Harrison/1998 32 76 56 42 59

Madariaga/1998 34 67 40 35 19

Roayaie/1998 16 86 64 21 43

Weimann/ 2000 95 64 31 21 18

Weber/ 2001 33 83 55 31 37

Lang/ 2005 27 65/88* 53/77% 46*

* R0 only

Intrahepatic CholangiocarcinomaLiver Resection


Intrahepatic Cholangiocarcinoma- without cirrhosis, without PSC


Intrahepatic Cholangiocarcinoma- without cirrhosis, without PSC Liver Resection

Lang et al.,

Ann Surg 2005, 241-


Intrahepatic Cholangiocarcinoma - without cirrhosis, without PSCLiver Transplantation

Weimann et al,

Br J Surg 2000


CholangiocarcinomaLiver transplantation

Shimoda et al, Liver Transplantation 2001


Hilar Cholangiocarcinoma- without cirrhosis, without PSCTransplantation

Treatment optionsLTx alone

LTx plus Whipple

LTx plus cluster resection-transplantation

LTx plus neoadjuvant therapy



Concept: LTx alone

Pichlmayr et al,Ann Surg 1996



Concept: Whipple plus cluster Tx

n = 12

3-months mortality 2/12 (17%)

Survival: 3 pts. alive at time of report52, 54, 59 months

Alessiani et al., J Am Coll Surg

1995


Hilar Cholangiocarcinoma- with/ without PSCTransplantation

Concept: LTx plus neoadjuvant therapy

Heimbach JK et al, Seminars in Liver Disease 2004


Hilar CholangiocarcinomaAuthor Year LTx operative neo-/

adjuvantHospital Survival

(n) extension treatment mortality (months)

(n) (n) (n)

Alessiani 1995 12 (12) Cluster-Tx - - -

Cherqui 1995 2 (2) Whipple (2) RTx 0 23 med.

Anthuber 1996 10 (4) Whipple - 2 25 med.

Pichlmayr 1996 25 - - 3 15.5 med.

Beckurts 1997 5 - (5) IORT - 12 med.

Iwatsuki 1998 38 (11) Cluster-Tx (18) RTx±5FU

8 12.7 cum.

Robles 1999 6 - - - 29 mean

De Vreede 2000 11 - (11) RTx±5FU

- 44 med.

Figueras 2000 8 - (8) RTx+5FU - -

Shimoda 2001 5 - - - -

Sudan 2002 11 - (11) BB+5FU 3 17 med.

Robles 2004 36 - - 3 55 cum.

Zheng 2005 5 - - 1 30 med.


Sex: 11 male/ 8 female

Age: Mean 47 ± 2 (28-64 years)

Follow up: Mean 24,3 ± 0,92 (0,1-140,5 months)

ICC n=6

Klatskin n=9

CCC in PSC n=4

LT for CholangiocarcinomaUniversity of Essen: 1987-2006 Liver Transplantation n=19 Recipients


0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Sur

vivi

ng

0 12 24 36 48 60 72 84 96 108 120

Time (months)

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Sur

vivi

ng

0 12 24 36 48 60 72 84 96 108 120

Time without hospital mortality (months)

CholangiocarcinomaUniversity of Essen: 1987-2006Liver Transplantation n = 19Overall survival


Early series: 1987 - 1998 n= 13/321( 4%)

Primary LTx: 1 stage procedure

CCC in PSC= 2/18

Late series: 1998 - 2006 n= 6/881 (0,68%)

Rescue LTx post resection: 2 stage procedure

LDLT for intention to treat cases

CCC in PSC=2/36

CholangiocarcinomaUniversity of Essen: 1987-2006 Liver Transplantation n= 13 + 6 =192 series in 1: Early and Late


after 01.04.1998before 01.04.1998

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Sur

vivi

ng

0 12 24 36 48 60 72 84 96 108 120

tumor free time without hospital mortality [months]

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Sur

vivi

ng

0 12 24 36 48 60 72 84 96 108 120

tumor free time (months)

CholangiocarcinomaLiver Transplantation n= 13 + 6 =19University of Essen: 1987-2006


p=0,234 p=0,357

CCCKlatskinPSC; CCC

n=6

n=9

n=4

CholangiocarcinomaUniversity of Essen: 1987-2004Liver Transplantation n = 19Survival according to tumor type

0,00,10,20,30,40,50,60,70,80,91,0

Sur

vivi

ng

0 12 24 36 48 60 72 84 96 108 120Time (months)

0,00,10,20,30,40,50,60,70,80,91,0

Su

rviv

ing

0 12 24 36 48 60 72 84 96 108 120Time without hospital mortality (months


CholangiocarcinomaEarly diagnosis: Tumor Markers

Ca19-9 Cutoff value 129 U/lSensitivity 78,6 %

Specificity 98,5 %

Pos. Pred. Value 78,6 %

Change over time 63,2 U/l p=0,0001

Levy C et al, Dig Dis & Sci 2005

Other Markers:ERBB-2, COX-2K-rasINK4a/ADP ARF…..??

Endo K et al, Hepatology 2002

Kubicka S et al, Gut 2005

Klump B et al, Clin Cancer Res 2003


- High recurrence rate also in T1-2 N0

- Low survival rates

- 1 year : 21% - 70%

- 2 years : 4% - 21 %

- 5 years : 0% - 18%

- Casavilla, J Am Coll Surg 1997

- Weimann, Br J Surg 2000

CCC and LTx



(HCC)Hepatoblastoma

CCC

Stroma Tumors - Mesenchymal (Liver sarcoma)Epitheliod Hemangioendithelioma

neuroendocrine (NE)Metastatic tumors

non NE Colorectal



Epitheliod Hemangioendothelioma

Transplantation

Intermediate malignancy

Survival 2y 5y

80% 40%

Transplant also in presence of “limited” metastatic disease

Lafler et al Cancer 1996


Neoplasia non HCC: Stroma tumors Neoplasia non HCC: Stroma tumors ALDLT - Essen n= 4ALDLT - Essen n= 4

HemangioendotheliomaHemangioendothelioma( Hemangioendothelioma ) -> Stroma T. G1( Hemangioendothelioma ) -> Stroma T. G1Liver Stroma Tumor (angiosarcoma)Liver Stroma Tumor (angiosarcoma)**

Met. Stroma Tumor - rectovaginal spaceMet. Stroma Tumor - rectovaginal space

Follow-up 32,2 mos (11 mos - 4,4 yr) Follow-up 32,2 mos (11 mos - 4,4 yr) Actual 1 yr survival 2/3 Overall 3/6Actual 1 yr survival 2/3 Overall 3/6

Quality of life: excellent!!Quality of life: excellent!!Cave pre-LT DiagnosisCave pre-LT Diagnosis

Wrong Pre-LTx *Wrong Pre-LTx *diagnosisdiagnosis

**


Neoplasia non HCC: Stroma tumors Neoplasia non HCC: Stroma tumors ALDLT - Essen n= 4ALDLT - Essen n= 4

HemangioendotheliomaHemangioendothelioma AW AW 63 mo63 mo

( Hemangioendothelioma ) -> Stroma T. G1( Hemangioendothelioma ) -> Stroma T. G1** AW AW 6 mo6 mo

Liver Stroma Tumor (angiosarcoma)Liver Stroma Tumor (angiosarcoma)** DWDDWD 9 mo9 mo

Met. Stroma Tumor - rectovaginal spaceMet. Stroma Tumor - rectovaginal space AWDAWD 74 mo74 mo

Wrong Pre-LTx *Wrong Pre-LTx *diagnosisdiagnosis


Liver Transplantation for Non-Resectable Metastatic Liver Disease

Gastrointestinal Stromal Tumors

GIST

Favourable biological behaviour

Prognostc parameters-C-KIT mutations

Liver metastases frequent

Imatinib (Glivec) – adjuvant treatment

One patient -12 years tumor history - 6 years after LDLT


A Surgeon, A Surgeon,

when confronted with a problemwhen confronted with a problemhe cannot solve,he cannot solve,

performs the operation he knows bestperforms the operation he knows best

David B. Skinner MDDavid B. Skinner MDThe Phemister Dallas Professor of SurgeryThe Phemister Dallas Professor of Surgery


Colrectal Liver MetastasesTransplantation

Total 24 (30?) casesTotal 24 (30?) cases

Is orthotopic liver transplantation a feasible treatment for Is orthotopic liver transplantation a feasible treatment for secondary liver cancer of the liver ?secondary liver cancer of the liver ?MMühlbacher F, Huck I, Steininger R et al.ühlbacher F, Huck I, Steininger R et al.

Transplant. Proc. 1991, 23:1567 Transplant. Proc. 1991, 23:1567 University Of ViennaUniversity Of Vienna 21 cases 21 cases

High Recurrence/Mortality rateHigh Recurrence/Mortality rate



Hepatic Transplantation for Metastatic CancerInitial Experience

Autors Year Histology Number Survival

Muehlbacher 1987 Metastases-Colorectal

16/60 1-year 68%, 2-year 10%

O´Grady 1987 MetastasesNET

9/932/93

Median 3 Mo.7 Mo., 12 Mo.

Pichlmayer/ELTR 1988 Metastases 41/1218 2-year 14%

Ringe 1988 Metastases 9/95 Median 1.5 Mo.

Alsina 1990 NET 2 2-year 50%

Penn 1991 MetastasesNET

32/6379/637

2-year 38%



**

*


Indication :

Symptomatic Metastases

(neuroendrocrinological symptoms, pain, liver failure)

not responsive to conservative and surgical therapy

LTx for irresectable neuroendocrine (NE) liver

metastases


Good symptomatic therapy

Long term palliation (5 yrs survival 82%*)

Often tumor recurrence (up to 80%)

Sometime curative

* Lang H et al., Ann Surg 1997

LTx for irresectable neuroendocrine liver

metastases


LT for metastatic neuroendocrine tumors

Published single-center experiences with transplantation for metastatic neuroendocrine tumors

Reference Year No. of patients

MedianFollow-up

(mo)

1-yr survival

(%)

5-yr survival

(%)

Actual 5-yrDisease-free

survivors

Mount Sinai 2003 11 30 73 36 1

Olausson 2002 9 22 89 - 0

Rosenau 2002 19 38 89 80 3

Ringe 2001 5 22 80 - 0

Coppa 2001 9 39 100 70 -

Pascher 2000 4 42 100 50 1

Dousset 1996 9 29 33 33 0

Anthuber 1996 4 11 25 0 0

Alessiani 1995 14 - - - -

Routley 1995 11 - 82 57 -

Arnold 1989 4 30 50 - 0

Makowka 1989 5 32 60 - 0



Pretransplant selection - Rationale-Octreoscan-Immunohistochemical parameters / Ki67

New surgical strategies-LDLT

New immunosuppressive drugs-Antiproliferative effects

Peptide receptor radiotherapy



Endocrine Liver Metastases1992 - 2006

146 Pts.

34 Pts. evaluated for OLT



Pretransplant Evaluation

Standard pretransplant evaluation

Octreoscan

68Ga-DOTATOC-PET / CT

Cardiac evaluation / Thoracic MRI

Liver biopsy- Ki67 > 10% negative predictor of survival

Exploratory laparotomy



Octreotide Scintigraphy scan



Carcinoid heart


Pretransplant Evaluation- Results -

32 Pts.

Excluded11

Listed21

10 extrahep. tumor

1 carcinoid heart

1 died1 waiting list



Results

19 Patients transplanted

11 Deceased donor OLT

7 LDLT

1 Cluster TX

Liver weight 1.850g – 13.500g (88% tumor)




Pt.No.

Sex AgeY.

Tumor site

Clinical symptoms Primary tumorFirst degree resection

Treatment of LM before OLT

1 M 67 Bronchus Carcinoid syndrome Lung lobectomyChemotherapy

Octreotide

2 M 52 Bronchus Carcinoid syndrome Lung lobectomyChemotherapy

Octreotide

3 F 59 PancreasAdominal

discomfortDistal pancreatectomy Octreotide

4 M 37 PancreasCarcinoid syndrom

Abdominaldiscomfort

Upper abdominal exenteration

ChemotherapyOctreotide

5 F 44 Pancreas Diarrhoe Pancreatoduodenectomy Octreotide

6 M 52 ColonCarcinoid syndrome

Abdominaldiscomfort

Right hemicolectomyLeft hepatectomy

OctreotideChemotherapy

7 M 46 PancreasLiver failureAbdominal

discomfortWhipple- Procedure Chemotherapy


Liver Transplantation for non-resectable metastatic liver diseasePt.No.

SEX AgeY.

Tumor site Clinical symptoms Primary tumorFirst degree resection


8 F 42 Unknown FlushAbdominaldiscomfort

- Octreotide

9 M 53 Pancreas FlushAbdominaldiscomfort

Subtotal pancreatectomySplenectomyGastric resection

ChemotherapyOctreotideChemoembolisation DOTATOC

10 M 47 Ileum Carcinoid syndromeAbdominaldiscomfort

Ileum resection OctreotideAlpha-Interferon

11 M 48 Pancreas Carcinoid syndromeAbdominaldiscomfort

Distal pancreatectomyGastric resectionSplenectomyColon resection

ChemotherapyOctreotideChemoembolisation

12 F 51 Pancreas Carcinoid syndrome Distal pancreatectomy Octreotide

13 M 52 Lung Carcinoid syndromeAbdominaldiscomfort

Lung lobectomy Octreotide

14 M 46 Ileum Carcinoid syndrome Ileocolectomy OctreotideAlpha-Interferon

15 F 51 Ileum Carcinoid syndrome Ileum resection Octreotide


Liver Transplantation for non-resectable metastatic liver diseasePt.No.

SEX AgeY.

Tumor site

Clinical symptoms Primary tumorFirst degree resection


16 F 42 Unknown Flush Carcinoid syndrome

Abdominaldiscomfort

- Octreotide

17 F 53 Unknown Abdominal discomfortCarcinoid syndrome

Pancreatico - duodenectomy

ChemotherapyOctreotideChemoembolisation DOTATOC

18 M 47 Pancres Carcinoid syndromeAbdominal discomfort

Octreotide

19 F 48 Pancreas Carcinoid syndromeAbdominaldiscomfort

Subtotal pancreatectomySplenectomy

ChemotherapyOctreotide



Postoperative Morbidity and Mortality

Number of patients

No complications 9

Re-transplantation 1

Morbidity

THA

Lymph fistula

Bile leakage

1

1

2

Mortality

Cardiac reasons

Sepsis, rejection

Sepsis

Tumor recurrence

2

1

2

1


Liver Transplantation for Non-Resectable Metastatic Liver Disease Hamburg - Essen

Overall survival Tumor-free survival



Tumor-free survival



Number of patients

Localization Treatment

1 Bone Resection

1 LN

Disseminated

Resection90 Y-DOTATOC

1 Bone

Disseminated

90 Y-DOTATOC

Tumor recurrence- Invasive treatment -



Conclusion

Endocrine LM suitable for OLT

High selection necessary

Tumor-free 5-year survival low

Excellent long-term palliation

Aggressive approach for tumor recurrence

Radionuclide treatment

GIST – further experience needed


Organ allocation

Fairness of allocation - Equal chance

Vs

Best utilization of (poor) resources



Organ allocation - USA

Sharma et al Liver Transplantation 2004

Freeman R Liver Transplantation 2004

No bonus for other tumors !



Organ allocation



Organ pool „independent“ from allocationOptimal timing: no waiting timePre-selected organ quality

Donor risks!!Recipients: suboptimal results in

- advanced tumors- severe cirrhosis

Liver Transpl. 2001 7:921-7Liver Transpl. 2001 7:921-7

LDLT for HCC


General SurveyIndicationsOrgan allocationImmunosuppression



What‘s New

New Molecules

Immunosuppressive Strategies




Post et al. Liver Transp. Nov 2005Post et al. Liver Transp. Nov 2005

What‘s NewImmunosuppressive drugs


Department of General Surgery and Transplantation,University Hospital Essen, Germany

Clinical Immunosuppression:What‘s New, What‘s Hot

- Optimizing longterm outcomes

- Identification of new endpoints (organ function, immune response, drug toxicity)

- Individualizing immunosuppression


Up to date sul trapianto di fegatoImmunosuppression and HCC recurrence

Vivarelli et al Liver transplantaion 2005


Immunosuppressive Drugs

* product in development ** Off-label use (mostly in USA)

Novartis

Fujisawa

Roche

Wyeth

Everolimus

Sirolimus

Genzyme

Cyclosporin

Tacrolimus

Other

MPA

MMF

Azathioprine

Basiliximab

Daclizumab

ThymoglobulinAlemtuzumab

ATGAMOKT3

FTY 720*

ISATx*

FK 778*

Proliferationsignal

inhibitors

Calcineurininhibitors

nPHD inhibitors

Antibody Other

BMS Belatacept*


Department of General Surgery and Transplantation,University Hospital Essen, Germany


- mTor inhibitor sirolimus (SRL) has antiproliferative and anti-angiogenetic properties

- Advantage: usage for HCC - Tumor recipients lower incidence of reccurrence ?

- Disadvantage: delayed wound healing, higher incidence of HAT

Individualized immunosuppression


Up to date sul trapianto di fegatoImmunosuppression and tumor recurrence

Extended Milan = single < 7.5 cm, multiple < 5 cm

Low CNI and Sirolimus - EdmontonMilano vs Extended criteria

Kneteman N. et al. Liver Transplantation 2004



SILVERA PROSPECTIVE RANDOMIZED, OPEN-LABELED TRIAL

COMPARING SIROLIMUS-CONTAINING VERSUS mTOR-INHIBITOR-FREE IMMUNOSUPPRESSION

IN PATIENTS UNDERGOING LTX FOR HEPATOCELLULAR CARCINOMA

Individualized immunosuppression

.


ConclusionsConclusions


LTX for Liver malignancies: a double edge sword

Extremely rare and selected indications

Mesenchymal tumors (grade1-2) and NE metastases

Cholangiocellular - Adenoca. Metastases contraindications

LD (ECD?) as preferred modality

New drugs - new strategies of Immunosuppression

Biology and pathologic information needed: Investigation studies needed

IMPULSE TO EXPLORE NEW WAYS IN TRANSPLANT FO R

HEPATOBILIARY MALIGNANCIES


ConclusionsConclusionsUp to date sul trapianto di fegato


HCC + ± +Hepatoblastoma + + +

CCC + - -

Liver sarcoma - - -Epitheliod Hemangioendithelioma + - ±

neuroendocrine + - ± Metastatic tumors

non neuroendocrine - - -

+

early/late overall

MASSIMO MALAGO 2

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