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March 2025 SPLITTING LIVERS EXPANDS TRANSPLANT ACCESS FOR STAGE 4 CANCER PATIENTSThe scarcity of donor organs and disadvantages within the allocation system can create a difficult pathway to transplant for patients with stage 4 colorectal cancer whose disease has spread to the liver. For the first time at Northwestern Medicine, surgeons have successfully split a deceased donor liver into two parts, transplanting one portion into the intended recipient and the other, smaller segment, into a patient with terminal colorectal cancer who could not find a suitable living donor. The treatment option is now available for select patients with advanced colorectal cancer with liver metastasis in a new clinical program at Northwestern Medicine called Colorectal Metastasis to Liver Extraction with Auxiliary Transplant and Delayed Resection (CLEAR).
Dr. Dietch, Barclay and Dr. Nadig in clinic
“The CLEAR program is exciting and unique because it serves an unmet need in a particular patient population,” says Satish Nadig, MD, PhD, transplant surgeon and director of Northwestern Medicine Comprehensive Transplant Center. “Because liver transplantation for colorectal cancer is not done at many centers around the country, the current organ allocation system does not prioritize these patients, and they end up falling lower on the waitlist. As a result, patients with colorectal cancer with liver metastasis often rely on living donors. Unfortunately, not everyone is walking around with a living donor. For many of these patients, the only alternative is palliative treatment, which we refuse to accept.”
In the fall of 2024, after being unable to find a living liver donor to treat his stage 4 colorectal cancer, 53-year-old Barclay Missen of Chicago became the first patient at Northwestern Medicine to receive a liver transplant via a surgical technique known as resection and partial liver transplantation with delayed total hepatectomy (RAPID). The two-stage procedure is for patients with cancer who might not survive the wait for a traditional transplant. First, surgeons remove a graft from a deceased donor liver that is allocated to a patient higher on the transplant waitlist. The larger portion is transplanted in the initially designated recipient, while the smaller portion is transplanted into the patient with cancer, who has half of their cancerous liver removed simultaneously. Weeks later, once the small piece has grown in size, the remaining cancerous liver is removed. 
Flowchart of RAPID liver transplant
Four months after receiving his new liver via the RAPID technique, Barclay has no signs of cancer in his body and doesn’t require any further cancer therapy.
“We are excited to offer RAPID as an option through the CLEAR program,” says Northwestern Medicine Transplant Surgeon Zachary Dietch, MD. “The entire goal of the program is to make it easier for patients with advanced colorectal cancer to get a liver transplant. We know that transplant is a lifesaving option for these patients, especially if the cancer is otherwise confined to the liver. Without it, five-year survival with chemotherapy is just 10%, but that survival can reach 80% with a liver transplant." A surprising diagnosis Colorectal cancer is the third most common cancer in both men and women worldwide, and the liver is the most common site of spread, with up to 60% of colorectal cancer patients developing liver metastasis. In December 2021, Barclay was experiencing some minor abdominal discomfort when he came to Northwestern Memorial Hospital for a colonoscopy following his 50th birthday. To his surprise, physicians found a large tumor in his colon and diagnosed him with stage 4 colorectal cancer — the disease had spread to his liver. Barclay’s medical team was able to slow the progression of the disease with chemotherapy, a colon resection, and liver ablations, but it was only a matter of time before the cancer grew resistant to treatment. By April 2024, the disease had severely damaged his liver and he learned he would need a transplant. Though friends and family volunteered as donors, none were a suitable match for Barclay. The husband and father of two was facing few options for survival when his Northwestern Medicine transplant team approached him with their innovative solution. “When I learned that RAPID was an option for me, I was elated,” says Barclay. “To go from having little hope to learning that I could become the beneficiary of so much skill, so much bravery, and so much generosity was unbelievable. Not only was I hopeful and grateful to have a chance for a cure, when I learned that this could open doors for other patients, I was all for it.” Sharing hope In October 2024, Barclay matched with a donor after cardiac death (DCD) liver that had been assigned to another Northwestern Medicine patient — then 57-year-old Kelli Podrez of Hanover Park, Illinois. Kelli, who was listed higher on the transplant waitlist due to cirrhosis, agreed to share a piece of the liver that had been allocated to her. 
Splitting liver on machine perfusion pump
“My medical team told me that the liver is like the skin; it regenerates and grows,” says Kelli. “If I could survive without the whole organ and help save someone’s life, why not share it?”
On October 23, 2024, with Kelli’s consent, surgeons worked for eight hours to remove a graft roughly the size of a human hand from the donor liver. While surgeons split the organ, a machine pumped warm, oxygenated blood through the liver to keep it healthy. The larger portion was then transplanted into Kelli. One operating room over, a separate team of surgeons removed half of Barclay’s cancerous liver to make space for the donor liver. Since the graft was too small to support Barclay on its own, half of his cancerous liver was left in place to provide enough liver function for him to survive. Once the graft was sewn in, surgeons directed blood flow to the area to encourage it to grow as quickly as possible. Within two weeks, Barclay’s new liver had nearly doubled in size — it was now large enough to sustain him on its own. 
Kelli walking the halls of Northwestern Memorial Hospital post-transplant
On November 7, 2024, Barclay went back to the operating room to have the rest of his cancerous liver removed. Four months after surgery, Kelli and Barclay’s new livers are working well. Barclay has no evidence of cancer left in his body and is looking forward to getting back to his favorite activities: woodworking, camping, painting, building guitars, and spending time with his wife and two teenage children.
“I get emotional when I think about all the things that had to happen,” says Barclay. “This donor and their family had to go through what they went through to make this possible. And on top of that, to have another person whose life is on the line be willing to share their hope with me — I can’t put into words how grateful I am for their generosity. I’m sitting here today because of that decision and my incredible Northwestern Medicine transplant team who made it happen.” “This procedure is incredibly rare and involves many moving parts,” says Dr. Nadig. “RAPID has been sparingly utilized outside of America, but by splitting a DCD liver on a machine perfusion pump, we’ve chosen to apply it in a unique way at Northwestern Medicine. On top of the skills, expertise and technology a procedure like this requires, we have to have the collaborative culture to be able to simultaneously transplant these livers, working closely with oncologists and radiologists to make sure the cancer isn’t spreading while the new liver grows. Most importantly, we need a patient who is willing to share the gift of a new liver with another, and a patient who trusts us enough to participate in a first for the health system.” About the CLEAR Research Registry The outcomes of the CLEAR program’s first 80 patients will be tracked in a research registry also called CLEAR (Colorectal Metastasis to Liver Extraction with Auxiliary Transplant and Delayed Resection), available on clinicaltrials.gov. The research registry is focused on the outcomes of the treatment intervention. Participation in the research registry is voluntary. A patient may receive a RAPID transplant as part of the CLEAR program without enrolling in the CLEAR research registry. “There is still early, but accumulated evidence that shows that certain patients with cancer who receive transplants will derive equivalent or better outcomes than patients who receive transplants for more traditional indications,” says Dr. Dietch. “Transplant oncology is a new frontier in the field of transplant, and Northwestern Medicine is at the forefront. We look forward to providing hope to more patients who are being told the alternative is palliation and death.” For more information about Northwestern Medicine’s transplant programs, visit nm.org. This article was originally published in the Northwestern Medicine Newsroom on on March 18, 2025. |
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