Y90 Treatment in Pregnant Woman With Fibrolamellar Hepatocellular Carcinoma

Abstract

Introduction: Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare primary malignancy of the liver. There are only case reports of FLHCC occurring in pregnancy. This case report describes management of FLHCC patient to include treatment of FLHCC during pregnancy with yttrium-90 microspheres (Y90). Case Report: 23y/o female at 17 weeks gestation presented for evaluation of upper abdominal pain, elevated liver associated enzymes, and thrombocytopenia found to have multiple intrahepatic lesions and enlarged spleen on ultrasound of the abdomen. Non-contrast MRI revealed multiple hepatic lesions with largest measuring 8.3x10.9cm in the left hepatic lobe with extension into portal vein. EGD revealed grade II esophageal varices and portal hypertensive gastropathy. FNA of hepatic lesions was performed during EUS revealed fibrolamellar hepatocellular carcinoma. Perigastric, splenic, esophageal and pancreatic varices was noted during EUS and patient was placed on beta blocker therapy. Serum AFP was 30. Multidisciplinary tumor meeting held and decision for interventional radiology (IR) consultation for treatment of FLHCC with Y90. Surgery determined patient not a surgical candidate given involvement of hepatic vasculature. Patient received two doses of Y90 to both hepatic lobes during her pregnancy and tolerated without significant issues. Subsequent imaging did not reveal significant change to tumor burden and plan was for possible repeat Y90 nine months after last dose. Management of baby was performed by OB services and was taken to emergent cesarean at 32 weeks gestation of healthy child. Post-delivery patient discussion regarding Sorafenib for treatment of FLHCC however patient declined in order to breast feed which she was did for 3 weeks. Patient agreed to trial with Sorafenib however stopped due to side effects after only doses. Decision was made for patient to move closer to family and her husband was relocated to duty station near family. Discussion: Care of this young patient involved difficult decisions much of which has no formal guidelines. Portal hypertension secondary to large hepatic tumor burden was managed expectantly; however treatment of her FLHCC in the setting of pregnancy with Y90 was a novel approach. Throughout, patient ultimately made decisions to ensure the safety and well-being of her child over her own survivability. Conclusion: FLHCC in pregnancy have no formal guidelines for treatment. Treatment of FLHCC with Y90 during pregnancy can led to viable child delivery and prolonged maternal survival. However, limited data in this setting exist.Figure 1Figure 2Figure 3