Colorectal Carcinoma in the Post-liver-transplant Setting – A Short Overview
Table 3: Studies Reporting on the Yield of Pre-liver-transplant Evaluation in Liver Transplant Candidates Study, Year,
Investigation Reference
Rabinovitz, 199039 Selingo, 199741
Weller, 199842 Zaman, 199938 Parikshak, 200243 Gravante, 200840 Ishikawa, 200944
Colonoscopy Colonoscopy
Colonoscopy
Sigmoidoscopy Colonoscopy
Colonoscopy Colonoscopy Albright, 201034 Sint Nicolaas, 201035 Colonoscopy Colonoscopy or sigmo-barium enema
Cohort Adenoma AA n
412 86
56 71 229 80 67
152 288
n (%) 20 (5)
10 (12) 24 (43) 15 (21) 19.6 (45) 7(9) 28(42)
n (%) 12 (3) 1 (1)
6 (11) 4 (6) 13 (6) 4 (5) 8(12)
22 (15) NR 36 (13)
Age Pre-LT Comments (Years)
NR NR
49
52 49
54 52 6 (2)
54 46
AA defined as adenoma with villous component
19% colonic polyps; AA defined as CRC; colonoscopy in patients >45 years
Symptomatic patients were included; colonoscopy in patients >50 years; AA defined as size >1cm AA defined as >1cm
Cohort, adenoma and AA is mentioned for overall transplants (i.e. kidney, lung, heart, liver); AA defined as size >1cm
AA defined as TVA and HGD; no difference with control population (defined as non-cirrhotic)
Living Donor LT; 3 CRC were detected during pre-LT evaluation; AA defined as >25% villous component, >1cm or HGD or CRC
Symptomatic and screening patients AA defined as >25% villous component, >1cm or HGD
AA = advanced adenomas; CRC = colorectal carcinoma; HGD = high-grade dysplasia; LT = liver transplant; NR = not reported; TVA = tubulovillous adenoma.
Table 4: Overview of Studies Reporting on the Yield of Post-liver-transplant Colonoscopy Surveillance Study, Year,
Reference Parikshak, 200243
Screened FU LT-colonoscopy AA Cohort n
Years
74 versus 75 2.7 controls
Atassi, 200349 Koornstra, 200748
25 versus 25 3.4 controls 92
Rurdrajaju, 200850
82 versus 82 6.2 controls
Albright, 201034 Herrero, 200911 186 NR 1.2* 7–10 *Median follow-up (FU) interval liver transplant (LT) colonoscopy.
AA = advanced adenoma; CRC = colorectal carcinoma; HGD = high-grade dysplasia; IBD = inflammatory bowel disease; NA = not applicable; NR = not reported; OR = odds ratio; RR = relative risk; VA = villous component.
malignancy or its precursor lesions may have an accelerated progression while patients receive immune suppressive therapy after LT and therefore the diagnosis of pre-existing extra-hepatic malignancy at LT work-up is a contraindication for transplantation.46,47
Based on the available literature, no recommendation for a pre-LT screening colonoscopy protocol can be given for LT candidates. Further studies must determine whether colonoscopy as an integral part of pre-LT screening work-up would be cost-effective. Screening for CRC in liver transplant candidates should not be more often or earlier performed than in the general population until survival benefit in post-LT patients or cost-effectiveness can be provided for the pre-LT colonoscopy screening approach.
Post-liver-transplant Colonoscopy Screening/Surveillance
Evaluating the current evidence, the place for screening and/or surveillance colonoscopy for non-PSC post-LT patients is still
EUROPEAN ONCOLOGY
questionable. Studies that investigated post-LT surveillance are provided in Table 4.11,34,43,48–50
As noted before, none of them were
prospective and applied a systematic screening strategy in all patients at fixed surveillance intervals. The time interval between LT and post-LT colonoscopy in patients is important. A reasonable interval between LT and post-LT colonoscopy is necessary to observe an increased adenoma prevalence compared with asymptomatic non-LT cohorts (general population) that can be attributed to post- transplant influences. This principle also applies in the case of pre-transplant adenoma findings, where the appropriate control values should be derived from surveillance colonoscopy studies stratified for baseline characteristics in the general population. Some of the studies provided in Table 4 suggest that there may be a trend towards increased potential in the post-transplant period for (advanced) adenomas. In a Dutch study, the RR for adenomas in LT recipients
33 CRC by n (%)
12(13) cases versus
7 (9) controls NA
11* 8 (8.7)
6 (7.3) cases versus
1 (1.2) controls NR
NR
Screening n NR
0 0 1 3 1 Design
Case–control setting
Case–control setting
Retrospective cohort
Case–control setting
Retrospective cohort
Retrospective cohort
Comments
Overall transplant (not specified for LT); >50 years and pre-LT colonoscopy as inclusion; AA defined as size >1cm; Adenoma cases versus control: 28 versus 8%; OR = 4.5 (95% CI 1–21.1)
Inclusion >5 years post-LT FU; exclusion history of adenoma; 21.7% adenomas
>45 years; IBD and family history; history of adenoma excluded; AA defined as villous component, >1cm or HGD
>1 year post-LT FU; 39 adenomas found in 186 patients (18.3%)
Three symptomatic cancers, one detected by screening
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