Multi-organ Early Tumor Dissemination After High Urgency Re-transplantation for Hepatocellular Carcinoma in Cirrhosis: Role of Massive Intraoperative Transfusion?

Abstract

The recurrence rate of hepatocellular carcinoma (HCC) after liver transplantation (LT) ranges between 11 and 18% [1, 2]. Although the role of post-transplant immunosuppression is still unclear [3, 4], most recurrences seem to be related to malignant cells present but not identified at the time of transplantation and/or released during the transplant procedure. Patients whose explanted liver tumors are within currently accepted criteria for transplantation have a low rate of recurrence [5]. While partial tumor necrosis after performance of bridging treatments could result in earlier tumor recurrence post-transplant [6], 100% tumor necrosis is usually associated with very good results [7]. We report on a patient with unexpected multi-organ early tumor dissemination after an initial LT for a complete necrotic HCC in the setting of cirrhosis and a subsequent high urgency re-transplantation for primary non-function. The patient is a 55-year-old man with chronic hepatitis Binduced liver cirrhosis, Child-Turcotte-Pugh class A, and a solitary recurrent HCC meeting the Milan criteria in Segments VI/VIII. The patient had undergone a partial Segment VII resection in December 2003 for a solitary HCC (pT1 G1 V0). Follow-up examinations proved a local recurrence in Segment VI/VIII in January 2005. Further diagnostic workup (abdominal and thoracic computed tomography, bone scintigraphy, positron emission tomography) excluded further tumor manifestations. The patient was evaluated for LT and listed in ‘‘Eurotransplant’’. A computed tomography (CT)-guided radiofrequency ablation was performed for the 4.8 · 3.4 cm HCC in January 2005. Further follow-up studies with CT, magnetic resonance imaging, and positron emissions tomography (PET)-CT showed complete necrosis of the lesion. After a waiting time of 127 days, the patient received a deceased donor full-size liver graft. The last imaging studies were a magnetic resonance imaging and whole-body PET-CT 2 months prior to LT, showing a necrotic area in the ablated liver segment as well as no further malignancy. Intraoperative mismanagement of inferior vena cava and central venous pressure led to excessive bleeding and corresponding transfusion of 46 units of packed red blood cells, plasma, and coagulation factors. Pathological examination of the explanted liver showed 100% necrosis of the HCC lesion as well as no viable tumor in the setting of end-staged liver cirrhosis. The patient experienced primary graft non-function leading to multiorgan failure, and was re-listed as ‘‘high-urgency’’. Three days later he underwent an uneventful re-LT. Neither of the donors had any history or physical evidence of malignancy. After discharge, the patient was followed up at our outpatient liver transplant clinic. The first HCC imaging follow-up at 4 months post-transplant with abdominal and thoracic CT showed no evidence of HCC recurrence. The second HCC follow-up at 8 months post-transplant showed multifocal bilobar intrahepatic HCC recurrence, intraabdominal involved lymph nodes, and multiple bilateral pulmonary and axillary lymph nodes metastases. Percutaneous liver biopsy confirmed the diagnosis of HCC recurrence. Immunosuppression was switched to rapamycin. The patient opted to receive palliative chemotherapy, fully aware of its limited efficacy, and he died 21 months post-transplant. Although the tumor was a well-differentiated HCC without vascular invasion, radiofrequency ablation resulted G. C. Sotiropoulos (&) S. Beckebaum E. P. Molmenti C. G. Klein V. R. Cicinnati C. E. Broelsch M. Malago Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122 Essen, Germany e-mail: georgios.sotiropoulos@uni-essen.de