Liver Transplantation for a Giant Hepatic Neuroendocrine Tumour in the Liver

Abstract

Address for Correspondence/Yazisma Adresi: Dr. Tonguc Utku Yilmaz, Transplantation Unit, Gazi University, Ankara, Turkey Phone: +90 312 202 52 78 E-mail: tutku@gazi.edu.tr ©Telif Hakki 2012 Gazi Universitesi Tip Fakultesi Makale metnine www.gazimedicaljournal.org web sayfasindan ulasilabilir. ©Copyright 2012 by Gazi University Medical Faculty Available on-line at www.gazimedicaljournal.org doi:10.5152/gmj.2012.09 A 45-year-old woman from another country was suffering from dyspepsia, weight loss and early satiety. Her GGT and ALP levels were 1172 U/L and 369 U/L, respectively. Computed tomography (CT) of the abdomen revealed a 12x18 cm solid lesion in the right lobe and a 6x8 cm lesion in the left lobe of the liver (Figure 1a). The intrahepatic bile ducts were dilated. The biopsy results were consistent with a neuroendocrine tumor type I; the Ki67 proliferation index was 1%. Histology revealed a trabecular pattern coexisting with PGP 9.5, cytokeratin-19, chromogranin and CD56 positivity. CEA, HCC, insulin, gastrin, TTF-1 and CDX-2 staining was negative. It was suspected to be a primary liver neuroendocrine tumor. Positron emission tomography revealed pathological activity only in the liver. The tumor was subsequently deemed to be unresectable because of the inadequate remnant liver volume and liver transplantation (LT) was planned. Until the LT, long-acting somatostatin analogues were given to the patient. As one lesion was wrapped around the inferior vena cava (IVC), cadaveric LT with an IVC was the ideal approach, as a cadaveric LT would permit us to explant the liver with the IVC. However, according to the laws of Turkey, foreign patients cannot be listed in the National Organ Sharing Network. This situation made a living related LT the only choice. Her brother was evaluated as a living donor. We prepared a vascular graft before the operation in preparation for the possibility that the liver could not be resected from the IVC. Recipient hepatectomy was performed without the need for an IVC graft (Figure 1b, c). Living related LT was performed with a right lobe graft. Handling the liver and manipulating it into place over the inferior vena cava was difficult. In order to ease the operation, a transient portacaval vascular shunt was performed after portal vein division. We managed to explant the liver without any damage to the IVC, and portal vein re-anastomosis was performed. The neuroendocrine tumours were 24 cm and 9 cm in diameter (Figure 1d). There were infiltrative areas in other parts of the liver. The hilar lymph nodes were free of metastases. The patient has been followed for one year with thoracoabdominal CT and blood chromogranin levels without recurrence.