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

Table 1 Clinical characteristics and outcomes of the two patients undergoing rescue liver transplantation

Feature	Case 1: Hepatoblastoma	Case 2: Breast cancer
Age/sex at rescue LT	25-year-old male	40-year-old female
Primary tumor and year	Hepatoblastoma (2006; lung metastases at diagnosis)	HER2-positive invasive ductal carcinoma (2016; cT2N3M0; AR 7/8, 30%)
Cause of liver failure	Acute-on-chronic liver failure due to recurrent hepatic tumors and graft dysfunction	Acute hepatic failure from massive metastatic infiltration
Extrahepatic metastases at LT	Lung and bone	Lung and bone
Oncologic status at LT	Slowly progressive, unresectable recurrence	Progressive systemic metastases
Timing of rescue LT	Rapid deterioration requiring emergent DDLT (March 2022; prior LDLT 2013)	Acute liver failure with encephalopathy requiring LDLT (April 2024)
Immediate post-LT course	Graft function normalized; later rib/Lung metastasectomy + chemotherapy	Graft function normalized; systemic therapy resumed
Survival after rescue LT	17 months	9 months
Primary determinant of outcome	Aggressive tumor biology with repeated extrahepatic recurrence	Continued systemic progression
Cause of death	Multiorgan failure due to advanced malignancy	Pneumonia and cancer progression
Key point	LT prevented imminent death but did not modify tumor trajectory	LT restored hepatic function but conferred only transient benefit

LT: Liver transplantation; LDLT: Living donor liver transplantation; DDLT: Deceased donor liver transplantation; AR: Androgen receptor; HER2: Human epidermal growth factor receptor 2.