Late Extrahepatic Recurrence of Hepatocellular Carcinoma after Liver Transplantation: A Rare Case Report and Literature Review

Abstract

Recurrence rate of hepatocellular carcinoma is reported below 15%, mainly within 2 years after liver transplantation. We report an original case of a 62-year-old man with HCV-related liver cirrhosis, complicated by small uninodular hepatocellular carcinoma (HCC) completely eradicated by intraoperative thermal ablation in April 2003, who underwent liver transplantation in April 2004. The histopathologic analysis of explanted liver described an occult well differentiated uninodular HCC of 7 mm in diameter, without vascular invasion. Despite a sustained virologic response to antiviral therapy for recurrence of HCV infection in the graft and alpha-fetoprotein always within the normal range, in 2014 (10 years after liver transplantation) the patient developed brain and renal lesions, resulted as undifferentiated hepatocellular carcinoma recurrences at the histopathologic analysis. After a complete surgical resection of both recurrences, we introduced therapy with Sorafenib and exchanged immunosuppressive therapy from Tacrolimus to Everolimus, but six months later alpha-fetoprotein abruptly increased and total body computer tomography shown a significant progression of disease with recurrences in liver, spleen, lung and lymph nodes. Nevertheless, to date the patient is still alive. This case illustrates the highly variable rate of HCC recurrence and progression after liver transplantation and raises interesting questions about its natural history and post-transplant surveillance.