De Novo Hepatocellular Carcinoma in Recurrent Liver Cirrhosis After Liver Transplantation for Benign Hepatic Disease: Is a Deceased Donor Re-Transplantation Justified?

Abstract

Recurrence of hepatocellular carcinoma (HCC) after liver transplantation for HCC in the setting of liver cirrhosis is frequently encountered. In contrast, de novo HCCs in liver transplants with no previous history of malignacy in the explanted organ have only rarely been reported (1–3). We report on two patients with de novo hepatocellular carcinoma associated with liver cirrhosis 22 and five years posttransplantation who were treated with ablative methods. The first patient is a 61 year old woman who developed a solitary HCC associated with hepatitis C cirrhosis 22 years after liver transplantation for acute Budd-Chiari syndrome and 15 years after the initial diagnosis of hepatitis C viral infection. The patient underwent an exploratory laparotomy in January 2005. A cirrhotic liver with a 6 cm HCC in segment VII local invading the visceral peritoneum was encountered. A tumor biopsy performed intraoperatively confirmed the diagnosis. The patient underwent three sessions of super selective transarterial chemoembolization over the following six months, with very satisfactory results as documented by computed tomography imaging. The patient died in November 2005 as a result of cardiac complications from a myocardial infarction, 23 years posttransplant and 11 months after the diagnosis of the de novo HCC. The second patient is a 65 year old man who developed an HCC in the context of recurrent alcoholic cirrhosis five years after liver transplantation. The patient underwent percutaneous radiofrequency ablation for a biopsy-proven 5 cm HCC in liver segment VII in August 2000. Although follow up computed tomography scans showed necrosis of the lesion, additional tumors were detected in segments VIII and IVb. Over the following months the patient developed a pontine infarction requiring treatment at a neurological rehabilitation facility. No further tumor-specific treatment was performed. He died due to complications of brain stem ischemia in February 2004, nine years posttransplant and four years after the diagnosis of the de novo HCC. The problem of de novo HCC is a relatively new one, that is likely to become more relevant given the increasing number of long-term survivors, the rising incidence of hepatitis C induced liver cirrhosis (4) and the high rate of hepatitis C re-infection posttransplantation (5). Furthermore, management of immunosuppression in such cases should also be a topic of discussion. As deceased donor re-transplantation in such cases as “second-chance” for the patient is expected to have special ethical considerations/limitations given the organ shortage, selected cases of de novo HCC in the setting of cirrhosis could represent an additional indication for live donor liver transplantation (6). Georgios C. Sotiropoulos Andrea Frilling Ernesto P. Molmenti Eirini I. Brokalaki Susanne Beckebaum Omar S. Omar Christoph E. Broelsch Massimo Malagó Department of General, Visceral and Transplantation Surgery University Hospital Essen Essen, Germany