Expanding the therapeutic Frontier: Liver transplantation for unresectable colorectal liver metastases

A substantial proportion of patients with colorectal cancer present with or ultimately develop metastatic disease confined to the liver. The management of colorectal liver metastases remains one of the most complex and debated areas in oncological practice, with curative resection feasible in only a minority of cases. However, emerging evidence, most notably from the TransMet study, has reshaped the therapeutic landscape. The demonstration of a clear survival advantage in carefully selected patients with unresectable hepatic disease undergoing liver transplantation represents a transformative advance and challenges longstanding treatment paradigms. This narrative review critically appraises the epidemiological burden of colorectal liver metastases and delineates the key biological and clinical determinants underpinning their development. We synthesise the pivotal clinical trial data establishing the rationale for liver transplantation in this population and define the parameters for appropriate patient selection. The evolving perioperative integration of systemic therapies and the optimisation of postoperative surveillance strategies are examined in detail. Finally, we evaluate the emerging role of liquid biopsy as a precision tool to refine risk stratification and guide management, while addressing the ethical, logistical, and immunological considerations inherent to expanding transplant indications in this setting.