Oncologic Surgery 1 – Hepato-Gastro-Pancreatic and Liver Transplantation 

General Description 

The Unit of Oncologic Surgery 1 – Hepato-Gastro-Pancreatic and Liver Transplantation at Fondazione IRCCS Istituto Nazionale dei Tumori in Milan is an internationally renowned excellence for the treatment of hepatobiliary, pancreatic, gastric, and intestinal cancers, as well as neuroendocrine tumors and oncologic transplant medicine. 

It is globally recognized for developing the “Milan Criteria,” clinical guidelines adopted worldwide to select patients with hepatocellular carcinoma eligible for liver transplantation. This achievement laid the foundations for the discipline of Transplant Oncology, which integrates hepatic surgery, oncology, and transplant medicine in a pioneering way. 

The unit pursues a dual mission: 

• to provide excellent clinical care through personalized, high-complexity multidisciplinary treatment strategies, supported by cutting-edge technologies and the most current scientific evidence; 
• to foster innovation through translational research and clinical trials at national and international levels. 

Organization and Clinical Areas 

The unit is part of the Department of Oncologic Surgery and includes the Operative Unit for Liver Transplantation. All activities are carried out following validated internal quality protocols, which are regularly updated and integrated into shared diagnostic-therapeutic care pathways (PDTA). 

Main Conditions Treated 

• Primary liver cancers (hepatocellular carcinoma, cholangiocarcinoma) 
• Liver metastases from colorectal cancer, neuroendocrine tumors, and rare malignancies 
• Pancreatic and biliary tract tumors 
• Gastric and gastroesophageal junction cancers 
• Small intestine neoplasms 
• Gastroenteropancreatic neuroendocrine tumors 
• Oncologic diseases of the spleen 
• Chronic care for post-surgical and transplant patients 

Surgical and Transplant Activity 

The unit performs over 400 complex surgeries each year, with particular expertise in organ-sparing liver resections, major (anatomic and non-anatomic) hepatic resections, gastric resections, pancreaticoduodenectomies, total or partial pancreatectomies, and multivisceral resections. 

It is officially recognized by the Lombardia region as a Liver Unit and Pancreas Unit for the high-volume, multidisciplinary management of hepatic and pancreatic cancers. It is also an ENETS certified Center for the diagnosis and treatment of gastroenteropancreatic neuroendocrine tumors. 

Surgical procedures are tailored to the case complexity and can be performed via open surgery, laparoscopy, or with the Da Vinci robotic system. 

The Liver Transplant Program is the most active in Italy in the field of oncology and the only one within a cancer-focused hospital authorized to perform liver transplantation. To date, approximately 1,000 liver transplants have been carried out for oncologic indications, with a 5-year survival rate exceeding 80%. 

In selected cases, the team uses oxygenated hypothermic or normothermic machine perfusion to evaluate and recondition donor organs. 

Transplant indications include: 

• Hepatocellular carcinoma (with or without cirrhosis) 
• Liver metastases from neuroendocrine tumors 
• Hepatic epithelioid hemangioendothelioma and other low-grade mesenchymal tumors 
• Liver metastases from colorectal cancer (within specific protocols) 
• Mass-forming and perihilar cholangiocarcinoma (in selected protocols) 
• Other tailored indications 

Liver transplant management includes: 

• Hepatologic and oncologic evaluation of candidates with primary or secondary hepatobiliary malignancies 
• Definition of diagnostic and therapeutic pathways for patients listed for transplantation and their pre-transplant follow-up 
• Coordination of logistics related to the transplant waiting list 
• Management of the transplant procedure in collaboration with nursing staff, ensuring transport, informed consent, reassessment, and appropriate therapies 
• Inpatient post-transplant care, with focus on immunosuppression and multidisciplinary involvement 
• Long-term outpatient care with continuous monitoring and internal medicine support 
• Chronic immunosuppression management and care pathways definition 
• Management of disease recurrence (hepatic, gastrointestinal, or oncologic) 

Locoregional Therapies and Diagnostic Biopsies 

Each year, the unit manages approximately 450 hospital admissions for locoregional procedures, including transarterial chemoembolization, Y90 radioembolization, and ultrasound- or CT-guided thermal ablation for HCC and other indications. These procedures are performed in collaboration with the Interventional Radiology Unit. The team also performs liver biopsies with diagnostic purpouses for undetermined lesions. 

Research and Clinical Trials 

The unit is actively engaged in clinical and translational research in collaboration with national and international institutions such as AIRC, FIRC, NIH, AICR, and the Italian Ministry of Health. 

Key areas of research include: 

• Expanding transplant eligibility criteria for primary and secondary liver tumors 
• Integrating immunotherapy into the treatment of hepatocellular carcinoma 
• Identifying predictive and molecular biomarkers for transplant candidacy 
• Clinical trials on integrated surgical-oncologic approaches for liver metastases 
• Use of augmented reality, ICG fluorescence, and artificial intelligence in liver surgery 
• Risk-benefit analysis and quality of life in transplant recipients 
• Multicenter observational and randomized trials on pancreatic and biliary cancers 
• Integration of robotic platforms in innovative HPB surgical approaches 
• Use of hypothermic and normothermic oxygenated machine perfusion for donor organ assessment and reconditioning 

Teaching and Training 

The unit hosts a University Chair in Surgery affiliated with the University of Milan and is part of an institutional agreement for training and education programs targeting both undergraduate (medical students) and postgraduate (residency and master’s) levels. 

It is also an accredited site for: 

• Residency Programs in General Surgery and Gastroenterology, University of Milan 
• International Medical School (IMS), Faculty of Medicine and Surgery in English, University of Milan 
• National School of Liver Surgery (SIC, ACOI) 
• International fellowships and observerships 
• Continuing medical education (CME) courses and workshops on transplantation, HPB surgery, and advanced surgical oncology 

Patient Pathway and Support 

The inpatient unit consists of 12 rooms (including 2 positive-pressure rooms for immunocompromised patients), for a total of 24 beds. The care team includes 13 physicians, 18 nurses, 6 healthcare assistants, 3 administrative staff, and a transplant coordination team. 

The unit also includes a MAC (Complex Outpatient Activity) area with 2 rooms and 4 infusion chairs for administering immunomodulatory and supportive therapies. 

Patient care includes: 

• Initial or follow-up outpatient consultations 
• Weekly multidisciplinary tumor board discussions 
• Hospitalization for surgery, locoregional treatments, or outpatient therapies via the MAC 
• Clinical follow-up for at least 5 years at dedicated outpatient clinics 

Voluntary Support

The unit benefits from the support of PROMETEO, a non-profit organization composed of volunteers and former patients. PROMETEO provides logistical, emotional, and social support to patients and families, and contributes to the unit’s technical and organizational needs. 

The association also assists out-of-region patients with affordable housing solutions near the Institute via the “Casa Prometeo” initiative.