Management of very late peritoneal metastasis of hepatocellular carcinoma 10 years after liver transplantation: Lessons from two cases

Abstract

Recurrence of hepatocellular carcinoma (HCC) 10 years after liver transplantation (LT) is very rare. Here, we present two cases of peritoneal metastasis of HCC that occurred 10 and 12 years after LT. A 77-year-old male who had undergone deceased-donor LT 10 years earlier showed slow progressive elevation of tumor marker levels over 6 months. Close observation with frequent imaging studies and monthly tumor marker analyses revealed a solitary peritoneal seeding mass. Imaging studies revealed that the mass was highly likely to be metastatic HCC. After excision of the mass, all tumor markers returned to the normal range. Over past 10 months, the patient has received everolimus monotherapy and half-dose sorafenib, and has shown no evidence of HCC recurrence. In the second case, marginally elevated tumor marker levels were detected in a 65-year-old male who had undergone living-donor LT 12 years earlier. After observation for 3 months, follow-up studies revealed a peritoneal seeding mass. Thorough imaging studies revealed that the mass was highly likely to be metastatic HCC. Two mass lesions were excised, and the patient was administered low-dose calcineruin inhibitor, sirolimus, and full-dose sorafenib. Subsequently, the tumor marker levels increased again and growth of new peritoneal seeding nodules was observed; therefore, sorafenib was stopped after 2 years of administration. During 6 years since HCC recurrence diagnosis, the patient has experienced slowly growing tumors, but has been doing well. For very late peritoneal metastasis of HCC, the therapeutic modalities include surgical resection if possible, everolimus monotherapy, and long-term use of sorafenib.

Keywords: Hepatocellular carcinoma; Metastasis; Recurrence; Resection; Sorafenib.

Fig. 1. Computed tomographic images of Case 1. (A) Pre-transplant finding. (B) Early posttransplant finding. (C) Image taken 2 months before the diagnosis of HCC recurrence. The arrow indicates the metastatic lesion. (D) Image taken at the time of diagnosis of HCC recurrence. The arrow indicates the metastatic lesion.

Fig. 2. Serial measurement of tumor marker levels in Case 1 before and after metastasectomy.

Fig. 3. Positron emission tomography analysis of Case 1 showing a mass with hypermetabolic uptake (arrow).

Fig. 4. Computed tomographic images of Case 2. (A) Pretransplant finding. (B) Early posttransplant finding. (C) Image taken 6 months before the diagnosis of HCC recurrence. (D) Image taken at the time of diagnosis of HCC recurrence. The arrow indicates the metastatic lesion.

Fig. 5. Serial measurement of tumor marker levels in Case 2 before and after metastasectomy (A) and at 4-6 years after metastasectomy (B).

Fig. 6. Positron emission tomography analysis of Case 2 showing a mass with hypermetabolic uptake (arrow).

Fig. 7. Gross image of the resected metastatic mass with equivocal tumor-negative resection margins in Case 2.

Fig. 8. Follow-up computed tomography (A) and positron emission tomography (B) images of Case 2 showing metastatic lesions at the pelvis (arrows).

Fig. 9. Magnetic resonance images showing intrahepatic metastasis (arrow) and computed tomography analyses showing multiple metastatic lesions at the pelvis (arrows).