Liver Transplantation in Patient With Suspected Hepatoma
Liver Transplantation in Patient With Suspected Hepatoma
A 63-year-old white male with cirrhosis secondary to chronic hepatitis C virus infection had an intra-abdominal hemorrhage due to rupture of a 5 X 6 cm hypervascular lesion in the right lobe suspected to be a hepatoma. He was treated with embolization of the feeding artery. Another 4-cm lesion is seen in the same lobe. His alpha-fetoprotein level is within normal limits. Would you consider this patient a candidate for liver transplantation? How would you estimate his risk of recurrence? Does he need adjunctive therapy?
Marius Braun, MD
The issue of the natural history of a ruptured hepatocellular carcinoma (HCC) has not been fully defined. Several groups have suggested that HCCs that spontaneously rupture are associated with the same overall survival (not transplanted) as those that do not rupture. In both studies, it was noted that the disease-free survival rate after liver resection was better in the nonruptured HCC, but this may have been due to differences in size of the tumors; ruptured HCCs tend to be larger. However, the University of Hong Kong group did show that preoperative tumor rupture was an independent risk factor for early recurrence after liver resection.
In this case, the presence of 2 lesions, one that exceeds the Milan criteria and the other at risk for being an intrahepatic metastasis, should be considered high risk for HCC recurrence. Since adjuvant chemotherapy still has not been shown to impact the incidence of recurrence, you should not depend on adjuvant therapy to control recurrence after liver transplantation.
Supported by an independent educational grant from Fujisawa Healthcare.
A 63-year-old white male with cirrhosis secondary to chronic hepatitis C virus infection had an intra-abdominal hemorrhage due to rupture of a 5 X 6 cm hypervascular lesion in the right lobe suspected to be a hepatoma. He was treated with embolization of the feeding artery. Another 4-cm lesion is seen in the same lobe. His alpha-fetoprotein level is within normal limits. Would you consider this patient a candidate for liver transplantation? How would you estimate his risk of recurrence? Does he need adjunctive therapy?
Marius Braun, MD
The issue of the natural history of a ruptured hepatocellular carcinoma (HCC) has not been fully defined. Several groups have suggested that HCCs that spontaneously rupture are associated with the same overall survival (not transplanted) as those that do not rupture. In both studies, it was noted that the disease-free survival rate after liver resection was better in the nonruptured HCC, but this may have been due to differences in size of the tumors; ruptured HCCs tend to be larger. However, the University of Hong Kong group did show that preoperative tumor rupture was an independent risk factor for early recurrence after liver resection.
In this case, the presence of 2 lesions, one that exceeds the Milan criteria and the other at risk for being an intrahepatic metastasis, should be considered high risk for HCC recurrence. Since adjuvant chemotherapy still has not been shown to impact the incidence of recurrence, you should not depend on adjuvant therapy to control recurrence after liver transplantation.
Supported by an independent educational grant from Fujisawa Healthcare.
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