Ann Liver Transplant.  2021 Nov;1(2):194-201. 10.52604/alt.21.0017.

Fifteen-year-long journey with hepatocellular carcinoma from diagnosis during pregnancy to recurrence after liver transplantation: A case report of intractable tumor recurrence

• Hwang S
• Jung DH
• Ha TY

• KMID: 2560872
• DOI: http://doi.org/10.52604/alt.21.0017

Abstract

Hepatocellular carcinoma (HCC) during pregnancy is very rare and reported to be associated with inferior prognosis. We herein present a case of a patient who was diagnosed with HCC at the age of 26 years during pregnancy. The patient was infected with hepatitis B virus through vertical transmission. After full-term vaginal delivery, the patient underwent transarterial chemoembolization (TACE) twice and right hepatectomy consecutively. One year later, TACE was repeated and second hepatectomy was performed. Four years later, TACE was repeated and third hepatectomy was performed. Two years later, TACE was repeated and fourth hepatectomy was performed. Two years later, HCC recurred around the left hepatic duct and external beam radiotherapy was performed. Subsequently, biliary stenosis occurred, thus endoscopic retrograde biliary drainage tube was inserted. One year later, her liver function deteriorated with tumor progression and portal vein occlusion. The patient underwent deceased donor liver transplantation using an HBsAg-positive whole liver graft. At posttransplant 6 months, pulmonary metastasis occurred, which was managed with pulmonary metastasectomy twice and radiotherapy. The patient passed away 20 months after transplantation because of HCC progression. The patient had suffered from HCC for 15 years, in which she underwent hepatectomy four times, TACE 10 times, liver transplantation, pulmonary metastasectomy twice, and radiotherapy three times. The patient demonstrated unusual long-term intractable course of HCC recurrence refractory to various locoregional treatments.

Keyword

Pregnancy; Locoregional treatment; Repeat hepatectomy; Liver transplantation; Metastasectomy

Figure

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  Figure 1 Intraoperative finding of the second hepatectomy. (A) Two masses (circles) are visible before partial hepatectomy of segment IV. (B) The recurrent masses are visible at the resected liver specimen.

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  Figure 2 Computed tomography finding of the hepatocellular carcinoma after the initial two sessions of transarterial chemoembolization.

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  Figure 3 Sequences of treatment with transarterial chemoembolization after the third hepatectomy. Two recurrent masses (A) were treated with transarterial chemoembolization twice (B, C), resulting in control of the recurrent masses (D).

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  Figure 4 Perioperative finding of the fourth hepatectomy. (A, B) The remnant segment IV and some of segment III parenchyma including the recurrent mass were resected. (C, D) Intraoperative cholangiography is taken to check the anatomy of the remnant left hepatic duct using a segment III bile duct branch.

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  Figure 5 Endoscopic management of the radiation therapy-induced bile duct stenosis. (A) Biliary stenosis is identified on endoscopic retrograde cholangiography. (B) An endoscopic retrograde biliary drainage tube is inserted.

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  Figure 6 Computed tomography taken after internal biliary drainage. (A) Recurrent mass occurred around the left hepatic duct. (B) The left portal vein is completely occluded (arrow).

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  Figure 7 Gross photograph of the explant liver showing overt liver cirrhosis and cholestasis.

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  Figure 8 Sequences of treatment for graft outflow vein stenosis. (A, B) Early posttransplant computed tomography shows focal stenosis (arrow) at the suprahepatic inferior vena cava area, which was dilated by a wall stent. (C, D) A wall stent is inserted to relieve the stenosis (arrow) at the inferior vena cava.

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  Figure 9 Sequences of treatment for lung metastasis. (A) Multiple lung metastases are identified. (B) A resected lung specimen is visible after the second pulmonary metastasectomy. (C) Fluorodeoxyglucose positron emission tomography shows multiple lung metastases. (D) External beam radiotherapy is planned with simulation.

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