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Selvakumar et al. Multikinase inhibitors as neo-adjuvants in HCC

A B C

Figure 2: The final istopathology results of case 1. (A) AFP stain showing necrotic tumor, ×4; (B) back ground cirrhosis (HE, ×4);
(C) necrotic tumor (HE, ×10)

POD 6. He tolerated immunosuppression well. He was liver. They are the fifth most common cancers with 4th
discharged in a stable condition on POD 13. commonest malignancy. There are multiple etiologies
for HCCs. In general, cirrhotic livers have higher
The final histopathology of the explant specimen did incidence of HCC as compared to non cirrhotics.
not show any tumor at all. There was complete tumor The duration of cirrhosis is directly proportional to
response to hepatic artery ligation and sorafenib the cumulative incidence of malignancy. HCC has
therapy [Figure 2]. peculiar tumor biology. Curative treatment options for
HCC are RFA, resection and liver transplantation. [1]
At 14 months post transplantation, he has been switched Of these three, primary liver transplantation has better
over to everolimus based immunosuppression. Also he survival in patients with cirrhosis and HCC. The
[2]
is on adjuvant sorafenib treatment. At 13 months post indications for liver transplantation in CLD with HCC
transplantation his serum AFP is normal and PET-CT has been gradually expanding since the publication
is normal. Graft functions are normal. of Milan criteria. It started from Milan criteria and has
reached to any size any number without vascular
Case 2 invasion criteria. Even in cases of vascular
[3]
A 48-year-old gentleman from Sindh Pakistan was invasion there are case series to prove the efficacy
a case of HCV related chronic liver disease. He was of neoadjuvant radiotherapy (branchy/EBRT) with
[4]
diagnosed in 2012 with HCV. He received interferon reasonable recurrence free survival rate. In case 1
therapy and achieved SVR. In June 2013 he was where the intention was purely palliative but later on
diagnosed with HCC and PVT along with elevated patient ended up with successful liver transplantation.
AFP. He was given sorafenib treatment. Subsequent Initial look up of the case was suggestive of hopeless
follow up revealed normalization of AFP, clearance situation. Hence we abandoned the resection
of PVTT and decrease in the tumor size. Sorafenib attempt after ligation of the hepatic artery. There was
therapy was discontinued after 4 months owing to no decompensation in the post-operative period.
intolerance. He was on regular follow up with 3 monthly He received sorafenib as palliative chemotherapy
AFP and CT scan. The AFP was normal and the protocol. Decision making for liver transplantation was
tumor was more or less constant size of 4.5 cm with crucial in this case. However, we went by basic tumor
no evidence of new lesions elsewhere. In view of the assessment methods like serum AFP, PET avidity and
PVTT in previous scans, transplantation was deferred contrast enhancement of tumor and thrombus. Since
by various transplantation centers. However, in June all three parameters were negative he was taken up
2015 he developed severe encephalopathy followed for transplantation. There are trials which showed
by recurrent episodes of minor encephalopathies. In improved survival in HCC patients who had received
view of hepatic decompensation, he underwent liver TACE+ sorafenib instead of either one alone. However,
transplantation in October 2015. Post transplantation there is no case report so far in the literature where a
explant biopsy revealed low grade HCC in Milan patient with massive portal vein tumor thrombus has
with no capsular or vascular invasion. He had had complete tumor response after hepatic artery
uneventful post-operative course. At 14 months post blockage and sorafenib therapy. We do not know
transplantation, patient survival and graft survival are
good with no tumor recurrence. whether the response was purely to Hepatic artery
ligation or it is cumulative response to sorafenib also.
[5]
DISCUSSION
The case 2 we described received sorafenib with
HCCs are the commonest primary neoplasms of the palliative intent. But follow-up evaluation with CT

20 Hepatoma Research ¦ Volume 3 ¦ January 12, 2017