Rescue liver transplantation for liver failure with extrahepatic metastases: An ethical and clinical framework informed by two cases

Abstract

BACKGROUND

Liver transplantation (LT) is traditionally contraindicated in patients with active extrahepatic metastases due to concerns regarding futility, donor risk, organ allocation fairness, and limited post-transplant survival. However, in rare and extreme situations, acute hepatic failure becomes immediately life-threatening and no alternative life-saving therapy exists.

AIM

To report two rescue LT cases undertaken for end-stage hepatic failure despite persistent extrahepatic metastases, and to construct an ethical-clinical decision framework applicable to similar exceptional scenarios.

METHODS

We conducted a retrospective review of two patients who underwent rescue LT for hepatic failure with extrahepatic metastases. Clinical course, decision-making processes, donor consent procedures, and post-transplant outcomes were examined. Integrating these cases with existing literature, we developed a structured ethical and clinical decision framework.

RESULTS

One patient received a living donor graft after undergoing an enhanced informed-consent process that emphasized voluntariness, proportionality of risk, and understanding of the non-curative intent. The other patient received a deceased-donor graft, which proceeded after institutional review and confirmation that transplantation represented the only life-saving option. Postoperatively, both patients recovered normal liver function and were discharged with improved quality of life. The hepatoblastoma patient survived for 17 months post-LT, and the breast cancer patient for 9 months, with stable graft function but progressive extrahepatic disease. Both families expressed deep gratitude and satisfaction with the decision to pursue LT.

CONCLUSION

Although survival was limited, rescue LT allowed meaningful additional life in selected patients and was consistent with ethically defensible decision-making grounded in autonomy, beneficence, and compassion. However, such interventions must remain exceptional and require rigorous donor safeguards and transparent deliberation. Our proposed decision framework may support clinicians facing similar extreme scenarios and inform future discussions on exceptional indications for LT.

Keywords: Liver transplantation; Extrahepatic metastases; Hepatic failure; Contraindications; Surgical ethics

Core Tip: Rescue liver transplantation (LT) is generally considered futile in patients with extrahepatic metastases, yet in rare situations acute liver failure not tumor progression poses the true immediate threat to life. This study describes two such exceptional cases and proposes a structured ethical-clinical decision framework integrating futility assessment, donor safety, allocation fairness, and values-aligned consent. Our model outlines when rescue LT may be ethically and clinically defensible, emphasizing that its value lies in restoring hepatic function and providing meaningful time not oncologic cure.