Atypical Late Presentations of Metastatic Hepatocellular Carcinoma After Liver Transplant

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Liver transplantation (LT) is the primary curative option for hepatocellular carcinoma (HCC). Two cases here exemplify late and atypical metastatic HCC post-LT Case Description/Methods: Case 1: A 67-year-old woman with a history of hepatitis C (HCV) cirrhosis complicated by HCC underwent liver transplantation in 2011. She received pre-transplant treatment Pathology results of the explanted liver revealed 4.5 cm well-differentiated HCC without evidence of any invasion. Post-LT, the patient underwent routine surveillance every 6 months for 5 years. Elevated AFP was noted incidentally 12 years post-LT which led to the discovery of metastatic HCC in the right mesorectal fascia. During surgery an ovoid peritoneal metastasis was found and excised. Pathology revealed moderately differentiated HCC. Despite initiation of tyrosine kinase inhibitor (TKI) therapy, AFP levels exhibited resurgence. Continued surveillance revealed the presence of a new adnexal mass prompting bilateral salpingo-oophorectomy, which confirmed metastatic HCC. Following surgery, AFP levels demonstrated a decline. Case 2:71-year-old man with a history of HCV cirrhosis complicated by HCC underwent LT in 2006. Patient underwent pre-LT treatment. Pathology report of the explanted liver revealed a 3.5 cm moderately differentiated HCC without any invasion. Post-LT surveillance for recurrent HCC was conducted. However,15 years post-LT, AFP was noted incidentally to be elevated at 644 ng/ml. Despite negative initial imaging studies, subsequent surveillance identified 2 masses abutting the sigmoid colon. Biopsy confirmed metastatic HCC. The patient was initiated on TKI-based therapy, with plans for surgery, which revealed extensive peritoneal carcinomatosis. Biopsy confirmed metastatic HCC. Despite therapeutic interventions, AFP levels continued to rise, prompting a shift to second and subsequently third-line systemic therapy. Notably, due to disease progression, patient opted for immune checkpoint inhibitor therapy, which was discontinued due to graft rejection Discussion: These cases demonstrate the challenges with post-LT HCC recurrence. Post-LT surveillance entails imaging studies and AFP assessments up to 5 years. Elevated AFP beyond this period warrants pelvic imaging if standard scans are inconclusive. The feasibility of continued AFP monitoring beyond 5 years needs further research. In summary, late and atypical HCC recurrence post-LT calls for the need for innovative diagnostic approaches to enhance patient outcomes (see Figure 1 Table 1).

Volume

119

Issue

10

First Page

S2809

Last Page

S2810

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