Liver transplantation for intestinal malignancies

Liver transplantation (LT) is increasingly recognised as a valuable treatment option in carefully selected cases of metastatic intestinal cancers. While traditionally reserved for primary liver tumours such as hepatocellular carcinoma (HCC), recent evidence has broadened the transplant oncology paradigm to include colorectal liver metastases (CRLM) and neuroendocrine liver metastases (NELM). This review explores the evolving indications, patient selection criteria, and clinical outcomes of LT in these contexts, emphasising the need for a conceptual and methodological reassessment. We distinguish between prognostic factors, which are variables independently linked with clinical outcomes, and selection criteria, which determine patient eligibility and transplant prioritisation. This distinction is vital for proper candidate stratification. It emphasises the importance of using overall survival as the primary endpoint in transplant oncology rather than recurrence-free survival, which can be misleading due to early detection bias and competing risks. The idea of "transplant benefit," defined as the survival gain attributable to LT compared to non-transplant strategies, is proposed as a fair and informative measure for ethical allocation. Data from prospective studies, such as SECA I-II and the TransMet trial, offer estimates of benefit in different indications, showing significant variation, from 22.5 months in per-protocol CRLM to around 12 months in NELM. We also examine intention-to-treat versus per-protocol analyses, the impact of dropout and waiting list mortality, and the implications for allocation policy. Finally, we outline future directions, including expansion to unresectable tumours beyond the criteria and borderline resectable tumours within the criteria. In the era of personalised medicine, LT for intestinal malignancies requires careful patient selection, transplant ethics, and collaborative oncologic governance.