When Dr. Sudha Kodali arrived at Houston Methodist seven years ago, she did not come with a mandate to disrupt transplant oncology. The liver cancer program was already established, and the charge was straightforward: provide leadership.

She has served as Medical Director of the Liver Tumor Program for the past six years. Under her leadership, the program has advanced a transplant oncology model that integrates hepatology, transplant surgery and medical oncology to optimize selection and timing for curative-intent interventions.

What followed has been a steady, data-driven expansion of transplant eligibility, now reshaping national and international thinking about liver cancer.

A hepatologist at the helm

Trained in internal medicine, gastroenterology and hepatology, Dr. Kodali practices as a transplant hepatologist with a focused research and clinical interest in cancer. She describes transplant oncology as “a hybrid of hepatology, surgery and oncology trying to take care of patients who have cancer and get them the best outcomes.”

That framing informs the structure of the liver tumor program she leads. While many liver cancer programs are oncology-driven, Houston Methodist’s program is led by hepatology — a distinction that remains relatively rare.

“Typically, the cancer programs are run by oncologists, but the majority of patients who have liver cancer have liver disease. Cirrhosis is a major risk factor for liver cancer,” she says.

From her perspective, the model is not ideological — it is practical. “Maybe I’m biased because I’m here,” she says, “but I think it only makes sense that hepatology is integral in leading the whole process.”

A fully integrated, multidisciplinary model

At Houston Methodist, patients with liver tumors are reviewed in a multidisciplinary tumor board before they ever step into the clinic. Imaging is evaluated across specialties, and when patients are seen, they are evaluated by hepatology, transplant surgery and oncology, often on the same day.

“At our transplant oncology clinic, it’s completely multidisciplinary,” Dr. Kodali explains. “There are three specialties seeing the patient at the same time.”

For clinicians, this model reduces delays and ambiguity. For patients, it eliminates the burden of navigating fragmented care. “When they leave the clinic that day, they actually leave with a plan in place,” she says, whether that plan includes surgery, systemic therapy, locoregional treatment, transplant listing or a staged approach combining several modalities.

Transplanting beyond conventional criteria

Perhaps the most defining feature of how the program is pushing the envelope is willingness to transplant patients who have been declined at other centers.

Many centers continue to rely strictly on size based criteria, selecting patients with hepatocellular carcinoma based on tumor size and number. At Houston Methodist, those criteria are a reference point, not a hard stop.

“We do transplant ‘out of criteria,’” Dr. Kodali says plainly. “Very large hepatocellular carcinomas.”

Through center-specific protocols and close collaborations, patients rejected elsewhere are downstaged, carefully evaluated and, when appropriate, transplanted.

"Our 10-year outcomes for patients with extremely large liver cancers that were declined at other centers are fantastic,” she says. “These patients do as well as patients who have smaller tumors.”

The implication is clear: tumor biology, response to therapy and careful selection matter more than size alone.

“We’ve shown that over years, these patients actually do very well if you carefully select them and put them through treatments pre-transplant.”

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Sudha Kodali, MD

Intrahepatic cholangiocarcinoma: from contraindication to programmatic strength

The program’s most significant challenge may be its work in intrahepatic cholangiocarcinoma (iCCA), historically viewed as an absolute contraindication due to high recurrence rates.

“Those patients are not felt to be transplantable because of the high risk of recurrence and poor prognosis,” Dr. Kodali says. Yet over the past decade, Houston Methodist has transplanted about 50 carefully selected patients with iCCA following intensive pre-transplant treatment.

“We are number one in the country when it comes to just that specific kind of cancer and transplant,” she notes. “And we’ve shown that over years, these patients actually do very well if you carefully select them pre-transplant.”

The impact is extending beyond U.S. borders. International collaborators are now seeking to form a global registry, with the goal of replicating the approach elsewhere.

Expanding indications: colorectal liver metastases

The program has also developed protocols for transplanting select patients with colorectal cancer metastatic to the liver, another population long excluded from transplant consideration.

“We do have a protocol for those patients, and we’ve been doing this for many years now,” Dr. Kodali says, noting that only recently have other centers begun to adopt similar strategies.

Volume, access and outcomes

Houston Methodist is the largest transplant center for liver transplant in the country, performing 340 last year. “A third of those transplants are now for cancer patients,” Dr. Kodali emphasizes. “That’s a big, big deal.”

That scale enables innovation: expanding donor utilization through machine perfusion technologies, a growing robotic surgery platform and a forward-leaning living donor program that includes cancer patients.

“Living donation will offer increased access to patients with cancer and help us transplant more patients,” she says. While still early, the effort places the program among a small minority of U.S. centers willing to explore this option.

Moving the needle on survival

For Dr. Kodali, the ultimate metric is survival — measured in years, not months.

“The main point is that what we’re doing here is saving the lives of these people that probably don’t have a life-saving option otherwise,” she says.

She puts the numbers in stark terms: “Five-year survival for large cholangiocarcinomas is less than 20%, versus what we see here in our multidisciplinary transplant oncology program — with a 60% five-year survival for the same patients."

Meeting the need where it exists

Beyond the tertiary-care center, the program invests heavily in outreach. South Texas carries one of the highest liver cancer burdens in the country. Dr. Kodali and her colleagues regularly travel to the Rio Grande Valley to educate gastroenterologists and primary care physicians on surveillance and referral.

“Patients who were initially just being sent home on hospice — now the providers know that they need to refer them so that we can help them,” she says.

A program defined by responsibility

What distinguishes Houston Methodist’s liver tumor program is not a single protocol or technique, but a willingness to assume responsibility for patients deemed “too high risk” elsewhere and a very supportive leadership. As Dr. Kodali puts it, the work is about “improving outcomes, improving long-term survival and offering better outcomes for patients who otherwise are felt to be just too high risk.”

For physicians across hepatology, oncology and surgery, the message is clear: with rigorous selection, multidisciplinary care and institutional commitment, transplant oncology can — and should — push beyond historical limits.