Regional Expansion of Transplant Oncology: The First Case of Liver Transplantation for Unresectable Colorectal Liver Metastasis in the Gulf Region.

INTRODUCTION

Liver transplantation for colorectal liver metastases (CRLM) has emerged as a potential curative option for highly selected patients with unresectable liver-only disease, with recent trials demonstrating 5-year overall survival rates of 55% to 83%. Surgical resection remains the only curative treatment for colorectal liver metastases (CRLM), but its applicability is limited, with only 25% of patients eligible. However, this approach remains investigational with limited global experience and has never been implemented in the Middle East region. Recently, liver transplantation (LT) has emerged as a potential curative option for select patients with unresectable liver-only metastases. This report highlights the potential for liver transplantation to serve as a curative modality in highly selected patients with CRLM and demonstrates its feasibility in a new geographic region.

CASE REPORT: We report the first case in the Gulf Cooperation Council (GCC) region of a 41-year-old male with unresectable CRLM who underwent LT following an aggressive multimodal pretransplant protocol. The patient was initially treated at an outside facility for synchronous left-sided colorectal cancer with liver metastases, achieving complete remission after FOLFOX chemotherapy. He subsequently developed 2 liver recurrences: the first in July 2023, with 17 metastases managed at the outside facility by surgical resection and chemotherapy; and the second in October 2023, with 40 metastases, treated with systemic chemotherapy and trans arterial radioembolization (TARE-Y90). He received additional treatment with ablative liver-directed therapies consistent with the "Cleveland Protocol." The patient subsequently underwent orthotopic liver transplantation. His postoperative course was complicated with moderate acute cellular rejection, which was successfully treated, and he was discharged on post-operative day 16.

CONCLUSION

This case demonstrates the successful implementation of liver transplantation for CRLM in the Gulf region, achieving disease-free survival at 4-month follow-up despite high-risk biological features typically associated with poor prognosis. It illustrates the feasibility and potential benefit of LT for unresectable CRLM in carefully selected patients, following an aggressive pretransplant locoregional therapy protocol modeled after the Cleveland Clinic approach. Key success factors included rigorous patient selection using established criteria (Oslo score 0, low Fong score, low PET-MTV), intensive pretransplant optimization with multimodal therapy, and experienced multidisciplinary management of post-transplant complications. With careful patient selection and integration of systemic and liver-directed therapies to achieve maximal disease control, this strategy may help expand transplant eligibility, possibly offering a curative approach. This case provides valuable regional data for the evolving role of transplant oncology in colorectal cancer management in a resource-limited setting.