Relapsed hepatocellular carcinoma in transplanted liver. Local involvement and spread through the abdominal wall

A. Segura Huerta, L. Palomar Abad, J. Molina Saera, A. Guerrero Zotano and L. Pellín Ariño

Service of Oncology. University Hospital La Fe. Valencia. Spain

 

A 67-year old woman without previous diseases was diagnosed in March 1999 with a liver lesion. She had pain in the upper right abdomen and altered hepatic tests. An image consistent with adenoma was found in the liver. An orthotopic liver transplantation was performed in May 1999. A histologic diagnosis of hepatocellular carcinoma was made (30 cm in diameter).

In June 2002, while remaining asymptomatic, increased serum levels of alpha-fetoprotein were observed (87 mg/ml). A chest CT scan showed bilateral lung nodes. The patient was informed about her diagnosis and prognosis, and she refused any kind of treatment. Hepatic and pulmonary lesions developed in July 2003. The patient started treatment with oral fluoropirimidines. Here we present CT images (August 2003). Figure 1 shows a hepatic tumor progression to the chest. Figure 2 shows pulmonary lesions.

Hepatocellular carcinoma is the most frequent primary hepatic tumor (1). Surgery is considered the treatment of choice but only a little proportion of patients are amenable to radical surgery at diagnosis (2). Nearly 80% of patients have also liver cirrhosis, which may contribute to poor prognosis (3). Orthotopic liver trasplantation is a therapeutic option for those patients with a primary tumor smaller than 5 cm in size without vascular invasion. This therapeutic approach can resolve both diseases (liver cirrhosis and hepatocellular carcinoma). Chemotherapy is scarcely effective, and usual drugs elicit overall responses in about 20% (4). Adriamycine and 5-fluorouracil are the most commonly used drugs in the treatment of hepatocellular carcinoma. Median survival of non-resectable patients is about 14 weeks (5).

Our patient has a non-resectable hepatocellular carcinoma and, because of the liver transplantation, is being treated with immunosuppressors. Due to the low efficacy of chemotherapy and the toxicity of these treatments in immunosuppressed patients, these must be extensively informed and contribute to decision making regarding their treatment. Oral fluoropirimidines are a feasible option in this group of patients.

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