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Zhang et al. Late recurrence of hepatocellular carcinoma

the patient underwent LT. Explanted liver demonstrated He underwent surgical resection and pathology
2 well differentiated HCC in the right lobe (1.5 cm and showed a 5.3 cm HCC.
1.0 cm) with 60% necrosis and 3 non-necrotic satellite
nodules measuring 0.2 to 0.3 cm. No microvascular Post-operatively, his immunosuppression was
invasion was noted. changed to very low dose tacrolimus and sirolimus.
Sorafenib was also added. His AFP continued to
Four years after LT, the patient was found to have 1.1 cm increase and he also developed skeletal metastases.
solid nodule in the right chest wall at the 8th rib. He expired 18 months after recurrence of HCC.
Needle biopsy showed necrosis and fibroinflammatory
tissue reaction with a focus of metastatic HCC. Case 4
Complete wide excision of this mass showed no The next case is a 66-year-old Puerto-Rican male
additional HCC. Long-term immunosuppression with hepatitis C cirrhosis and a 2.3 cm mass adjacent
consisted of low dose tacrolimus. to the inferior vena cava. AFP was 46 ng/mL. Liver
biopsy demonstrated HCC and he underwent
Six years post-LT, he developed another 2.4 cm soft TACE followed by LT 4 months later. The explanted
tissue mass in the right lateral chest wall. This was liver showed a 2.0 cm moderately differentiated
thought to be a needle tract seeding of tumor related HCC with 20% necrosis and no vascular invasion.
to a previous biopsy and RFA. Wide surgical resection Immunosuppression consisted of basiliximab,
was performed and revealed metastatic HCC with steroids, mycophenolate, and tacrolimus; he was
necrosis. gradually weaned to tacrolimus monotherapy.

Seven years post-LT, he developed a persistent Six years after transplant, AFP was noted to be
cough and CT scan showed a 1.8 cm mass in the 216 ng/mL. CT scan showed a nonspecific 1.0 cm
left lower lung and AFP was 3 ng/mL. He underwent hypovascular lesion in the left lobe which increased to
a left thoracotomy and wedge excision of a 1.7 cm 2.2 cm on subsequent imaging. Immunosuppression
moderately differentiated squamous cell lung cancer was changed to very low dose tacrolimus and
(node negative). No additional therapy was given for everolimus 0.5 mg bid. Sorafenib was also added.
his lung cancer. He underwent RFA and subsequent CT scan showed
no new lesions, but AFP increased to 10,385 ng/mL
He was disease free from both lung cancer and HCC 1 month later. MRI scan showed a suspicious 5.4 cm
up until 9 years post-LT when he began to complain of mass in the left lobe. Stereotactic body radiation
right rib pain. AFP was 140 ng/mL. CT scan showed (SBRT) was planned and AFP decreased to 8,243 ng/mL.
a multilobulated mass in the right chest wall involving When he arrived for SBRT simulation, the lesion
the 8th and 9th ribs and adjacent diaphragm, which could not be found. AFP decreased to 2.1 ng/mL. CT
was separate from the liver. He underwent radiation scan now showed no liver lesion and resolution of the
and refused sorafenib. He eventually expired from this previously seen liver mass. All subsequent AFP tests
1 year later. have been normal. His hepatitis C was successfully
treated with sofosbuvir and simepravir. He is currently
Case 3 on everolimus and sorafenib and has no evidence of
The third case is a 59-year-old Japanese male liver disease on imaging 44 months after diagnosis of
with non-alcoholic steatohepatitis with variceal recurrent HCC.
bleeding episode. He was found to have a 3 cm
liver mass and biopsy showed poorly differentiated Case 5
HCC. Within 4 months of diagnosis, he received LT. The final case is a 59-year-old Korean male with
His explanted liver showed a 3.8 cm moderately end stage liver disease due to hepatitis B. During
differentiated HCC with lymphovascular invasion. the LT evaluation, he was found to have a 2.2 cm
Immunosuppression consisted of basiliximab, steroids, hypervascular mass. AFP was 10.2 ng/mL. He
mycophenolate mofetil and tacrolimus. Maintenance underwent LT without any locoregional therapy
immunosuppression was with low dose tacrolimus. preoperatively. The explanted liver showed a multifocal
HCC with at least 7 lesions. Immunosuppression
Five years after transplant, a routine AFP was noted consisted of tacrolimus and steroids.
to be 70 ng/mL. His AFP continued to increase but
multiple imaging tests were negative. A few months Post-LT, he had no episodes of rejection, infection,
later, repeat CT scan showed a 3 cm mass in the or liver dysfunction. His hepatitis B was well-
pelvis between the internal and external iliac arteries. controlled with lamivudine and hepatitis B immune

62 Hepatoma Research ¦ Volume 3 ¦ April 10, 2017