Hepatic artery infusion pump therapy (HAIP) delivers chemotherapy directly to the liver. It is ever more commonly used for unresectable liver tumors such as colorectal liver metastases (CRLM), since a randomized clinical study suggested an overall survival benefit.1

Recently, indications for HAIP have expanded to include advanced intrahepatic cholangiocarcinoma2 (ICC) and hepatocellular carcinoma3 (HCC). With more patients getting HAIP, the prevalence of pump-related complications has also increased. Biliary sclerosis represents a challenging situation after the long-term use of HAIP with no standard treatment.

In this issue of Annals of Surgical Oncology, Hill, Doyle, and colleagues from Washington University in St. Louis published their experience with liver transplantation (LT) for seven patients with prior HAIP since 2017.4 The indications for LT included biliary sclerosis (five patients), and unresectable CRLM and ICC (two patients). The authors describe technical considerations in performing these challenging LTs due to hepatectomies made complex by prior surgery and atypical arterial anastomoses. Although we don’t know the MELD scores of the five patients transplanted for biliary sclerosis, it is intriguing to note that all five patients had no viable tumor in their explanted liver. This raises the question of whether LT could be done before the development of biliary sclerosis and how we might identify patients with exceptional responses to systemic treatment and HAIP for LT. Furthermore, one patient with viable cancer in the explant died of metastases. This may well have been the patient with CRLM (patient 6) as this patient had lymph node metastasis, a known poor prognostic indicator.

This study from Washington University generates excitement for research in using HAIP and LT for selected patients with advanced liver malignancy. As HAIP has shown potential for locally advanced liver tumors without distant metastases, it has become a common practice in many medical centers, and HAIP is now discussed in recent AASLD guidelines.5 With the current era of organ scarcity, transplant oncology must remain focused on the development of better prognostic biomarkers to identify patients who can most benefit from LT, and better bridging treatment including effective systemic chemotherapy and HAI.

Current success in liver transplantation (LT) for HCC has attracted interest in LT for unresectable CRLM and ICC after systemic chemotherapy. Beyond chemotherapy, HAIP could be a promising bridging strategy to LT. It will be ideal for offering living donor LT (LDLT) before liver failure related to biliary sclerosis ensues. Robotic HAIP may cause less intra-abdominal adhesions, making the hepatectomy less complex during LT, and deserves further consideration. The transplant community will need to develop MELD point exception rules for these conditions. Additionally, high-volume centers will need to contribute their experiences to national or international consortia to generate meaningful data to guide MELD exceptions and utilization of LDLT. A dedicated registry with oncologic annotated variables is warranted.