The ILTS-SETH Consensus Conference on Extrahepatic Cancer and Liver Transplantation: Paving the Way : Transplantation

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The ILTS-SETH Consensus Conference on Extrahepatic Cancer and Liver Transplantation: Paving the Way

Colmenero, Jordi MD, PhD1; Berenguer, Marina MD, PhD2; Watt, Kymberly D. MD3

Author Information
Transplantation 106(1):p e1-e2, January 2022. | DOI: 10.1097/TP.0000000000003994
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Abstract

INTRODUCTION

Liver transplantation (LT) is the only solid organ transplantation that can be used as an oncological therapy and is indeed an excellent treatment for selected patients with primary hepatic cancer. The presence of cancer in donors and nonhepatic cancer in patients before and after LT has been increasingly recognized and the outcomes of LT recipients with recurrent or de novo cancer are poor.1 Little guidance exists that addresses the challenging selection of donors and LT candidates with a history of cancer. In addition, the preventative strategies (including screening or surveillance) for cancer development and the management of LT recipients with de novo cancer are in need of consistent, evidence-based guidance.

To address these needs covering the full spectrum of nonhepatic cancer and LT, the International Liver Transplantation Society (ILTS) convened a joint Consensus Conference with the Spanish Society of Liver Transplantation (SETH) in Valencia, Spain, January 2021. Due to the coronavirus disease 2019 pandemic, the Consensus Conference was held virtually on January 28–30, 2021.

The meeting aimed to cover the main clinical concerns related to extrahepatic cancer and LT, including the evaluation and decision making of LT candidates with prior malignancies, the risk of accepting a liver donor with a history of cancer, posttransplant surveillance of patients with either a history of cancer before LT or having received an organ from a donor with prior cancer history, the selection of cancer screening strategies, the optimal immunosuppression and oncological therapies in LT patients with recurrent or de novo malignancies, and whether the data apply to the pediatric population. For this purpose, 5 different working groups were created, of which 2 merged for a final summary document in de novo malignancies after LT:

  • 1. Nonhepatic cancer in LT candidates3
  • 2. De novo malignancies after LT4
    • a. Epidemiology, outcomes, prevention, screening
    • b. Management after LT
  • 3. Prevention and management of donor-derived malignancies after LT (deceased and living donors)5
  • 4. Nonhepatic cancer in the pediatric population6

Each working group had 2 chairs and 6 members from ILTS and SETH. All the members were experts on either transplant hepatology, transplant surgery, oncology, or organ donation. Each working group was charged to address key questions established by the ILTS governing board and consensus conference lead coordinators (J.C. and K.D.W.). Six months before the consensus conference, the working group members critically reviewed pertinent literature addressing their assigned topics focusing on the most recent literature, preferably within the last 5–10 y. This was not a formal systematic literature review using librarian support as the topics were too broad. Based on the critical review of the literature, a draft article encompassing the key studies and articles answering the focus questions as well as summary statements and recommendations were put forward by the working group to the lead consensus coordinators to minimize redundancies and inconsistencies before the consensus meeting. The preliminary recommendations were graded according to the Grading of Recommendations, Assessment, Development and Evaluation system2 by the working group members performing the literature review. According to the Grading of Recommendations, Assessment, Development and Evaluation system,2 the quality of the evidence was rated as low, moderate, or high and the strength of the recommendation was rated as strong or weak (Table 1).

TABLE 1. - Strength of recommendation and quality of evidence according to the GRADE system2
Strength of recommendation Quality of evidence
Strong recommendation
The panel is confident that the desirable effects of the intervention /recommendation outweigh its undesirable effects. A strong recommendation implies that most or all individuals will be best served by the recommended course of action.
Weak recommendation
(also known as conditional or qualified)
The desirable effects probably outweigh the undesirable effects, but appreciable uncertainty exists. Maybe not all individuals will be best served by the recommended action. Consider more carefully than usual the individual patient’s characteristics and preferences.
High
Consistent evidence from well-performed randomized, controlled trials or overwhelming evidence of some other form. Low risk of bias.
Moderate
Evidence from randomized controlled trials with relevant limitations (ie, general population or other solid organ transplantation) or strong evidence from other research designs (observational, large cohorts).
Low
Evidence from small observational studies, unsystematic clinical experience, or studies with many limitations and potential flaws.
GRADE, Grading of Recommendations, Assessment, Development and Evaluation.

The ILTS and SETH community members at large were invited to participate in the consensus conference, provided the key questions for each working group and asked to join the focus group of their interest for the first half of the conference. During the first half of the consensus conference meeting, members of each working group (including community members for a total of 20–30 individuals in each working group) reviewed the literature and discussed the questions, statements, and proposed recommendations. The second half of the conference consisted of presentations of the topic and key questions from each working group to all consensus conference attendees (>150 international attendees). The statements were discussed via the online platform and recommendations and grading were voted upon by the full congress contingent upon agreement >80% for final approval.

The final consensus conference recommendations issued from the working groups are presented in this issue of Transplantation.3-6 Given the breadth of the topics, these articles are not designed to be inclusive of detailed topic reviews but a summary of the most recent key data upon which guidance recommendations could be made. This introductory methodology applies to each of the aforementioned documents published herein. This contemporary guidance is intended primarily for healthcare professionals involved in the care of patients before and after LT. As progress is made in this area of LT, the statements and recommendations of this guidance will require ongoing reassessment and validation according to new diagnostic and therapeutic strategies.

ACKNOWLEDGMENTS

The authors greatly appreciate the efforts and excellent work for the preparation of the consensus conference by all the Kit group GmbH team (K. Schroeder, J. Mruck, N. Martinez, D. Bogdanic) and the SETH Secretariat (P. Bellés).

REFERENCES

1. Neuberger JM, Bechstein WO, Kuypers DR, et al. Practical recommendations for long-term management of modifiable risks in kidney and liver transplant recipients: a guidance report and clinical checklist by the consensus on managing modifiable risk in transplantation (COMMIT) group. Transplantation. 2017;101:S1–S56.
2. Schünemann H, Brożek J, Guyatt G, et al. GRADE handbook. 2013. Available at https://gdt.gradepro.org/app/handbook/handbook.html. Accessed January 2021.
3. Salcedo M, Vinaixa C, Javle M, et al. Evaluation and management of liver transplant candidates with prior nonhepatic cancer: guidelines from the ILTS-SETH Consensus Conference. Transplantation. 2022;106:e3–e11.
4. Colmenero J, Tabrizian P, Bhangui P, et al. De novo malignancy after liver transplantation: risk assessment, prevention and management – guidelines from the ILTS-SETH Consensus Conference. Transplantation. 2022;106:e30–e45.
5. Dominguez-Gil B, Moench K, Watson C, et al. Prevention and management of donor transmitted cancer after liver transplantation: guidelines from the ILTS-SETH Consensus Conference. Transplantation. 2022;106:e12–e29.
6. Rela M, Quintero J, Kasahara M, et al. Nonhepatic cancer in the pediatric liver transplant population: guidelines from the ILTS-SETH Consensus Conference. Transplantation. 2022;106:e46–e51.
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