Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide, with an incidence rate 2- to 3-fold higher in developing countries than in the industrialized world. Approximately 80% of all HCCs develop in cirrhotic livers with an annual incidence of 3% (1, 2). The most common underlying diseases are chronic viral hepatitis infection and chronic alcohol abuse. Curative treatment options are resection and liver transplantation (LT) (1, 2). LT is well established as a life-saving operation for patients with acute or chronic liver failure and is considered as the best treatment option for selected HCC patients even if extended criteria are applied (1). Imaging techniques such as computed tomography and magnetic resonance imaging have a cardinal role in the diagnosis of HCC, especially in the rare instances at which α-fetoprotein levels are negative and biopsy results are indeterminate. Despite improvements in imaging techniques, the diagnosis of small HCC (<2 or <1 cm) during the pretransplant evaluation remains difficult, resulting in a considerable rate of undetected HCC in liver explants (3). Unsuspected HCC found at the time of histologic examination of liver explants of patients transplanted for benign diseases is defined as “incidental HCC” (4). We report on an HIV-positive patient with end-stage liver disease (ESLD) who underwent LT at our Institution, with an incidental HCC found in his liver explant. The patient is a 61-year-old HIV-positive man with cirrhosis (Child-Turcotte-Pugh class-B) secondary to chronic hepatitis C viral (HCV) infection (genotype 1b). His highly active antiretroviral therapy (HAART) regimen included Lamivudin, Lopinavir, and Stavudin. Before LT, the CD4 T-cell count was 323 cells/μL and the HIV viral load less than 50 copies/mL. α-Fetoprotein levels were within the normal range. Preoperative staging was negative for tumor or metastases. The patient was listed for LT within Eurotransplant and after a waiting period of 466 days was transplanted with a deceased donor liver. The model for ESLD score at the time of LT was 13. The patient recovered uneventfully and was discharged on day 21. Immunosuppression after LT included tacrolimus and prednisone. The patient showed a stable CD4 T-cell count and undetectable HIV load under continuation of his pretransplant HAART. Histology showed two small (0.7 and 1.7 cm) moderately differentiated HCCs with no vascular invasion. Follow-up studies revealed no evidence of tumor recurrence. The patient remains in good general condition 15 months posttransplantation. More than 141 LT in HIV-positive patients, 25 cases of HIV-infected patients with concomitant viral hepatitis caused by HCV (n=19), hepatitis B viruses (HBV) (n=5) or both (n=1), and HCC are reported in the English literature (5). Morbidity resulting from chronic infection with HBV and HCV has become a leading cause of death in HIV-infected patients with synchronous chronic viral hepatitis. Since the introduction of HAART in 1996, the course of HIV-infection has changed dramatically. Therefore, HIV-positive patients are at greater risk of dying from complications of ESLD such as HCC, rather than HIV complications. Not only due to psychosocial reasons but also due to historically poorer outcomes before HAART, LT in the presence of HIV infection has been considered as contraindicated. Several series have demonstrated comparable graft and patient survival after LT between HIV-negative recipients and HIV patients with ESLD because of chronic viral hepatitis and have shown the effectiveness of LT as a therapeutic option in HIV patients affected by ESLD (6, 7). On the other hand, development of HCC especially in HBV- and HCV-related liver cirrhosis is another major indication for LT. The published results of LT in HIV-infected patients with HBV- and HCV-related HCCs using the Milan criteria are encouraging because recurrence was not observed (5, 7). LT in the HIV context requires a multidisciplinary approach and is complex and challenging. Because HAART has turned HIV infection into a chronic condition, transplant centers should accept to evaluate HIV-positive – HBV/HCV coinfected patients, for both medical and ethical reasons. The presence of HCC represents an additional reason to transplant these patients, given that tumor characteristics are within the accepted criteria. Spiridon Vernadakis1 Zoltan Mathe1 Gernot M. Kaiser1 Jürgen W. Treckmann1 Susanne Beckebaum1 Fuat H. Saner1 Andreas Paul1 Georgios C. Sotiropoulos1 1 Department of General, Visceral and Transplantation Surgery University Hospital Essen, Germany
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Jan 1, 2015
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