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Liver Transplantation for Hepatocellular Carcinoma After Yttrium Therapy: A Case Report
Liver Transplantation for Hepatocellular Carcinoma After Yttrium Therapy: A Case Report G.C. Sotiropoulos, P. Hilgard, G. Antoch, K.M. Nowak, J. Ertl, I. Fouzas, E.P. Molmenti, G. Sgourakis, S. Beckebaum, A. Paul, C.E. Broelsch, and H. Lang ABSTRACT Yttrium-90 microspheres constitute one of the most recent treatment options for hepatocellular carcinoma (HCC) in the setting of cirrhosis. As such, their spectrum of indication is not yet fully established. Herein, we have reported the case of a patient with HCC beyond the listing criteria for liver transplantation (OLT) who was treated preoperatively with selective transarterial chemoembolization and yttrium-90 microspheres. He was subsequently transplanted with a liver from an 81-year-old donor allocated through Eurotransplant as a “rescue offer.” The posttransplant course was uneventful. Pathologic examination revealed a multifocal, well-differentiated pT2 tumor with no vascular invasion. The patient is currently alive and in good condition at 14 months posttransplant, with no evidence of tumor recurrence by a current computed tomography scan. This report provided encouraging information on the potential of yttrium-90 microspheres as a bridging option before OLT for multifocal HCC.
A
LTHOUGH THE incidence of hepatocellular carcinoma (HCC) is expected to continue to increase over the next 30 years, only a limited number of patients are eligible for surgical therapies such as resection and orthotopic liver transplantation (OLT). A variety of alternative treatment modalities have been reported, including transarterial chemoembolization (TACE), radiofrequency ablation (RFA), ethanol ablation, cryoablation, and external beam irradiation. The goal of the various therapeutic options is tumor control with minimal side effects. Yttrium-90 microspheres, a novel treatment approach, have been used in cases of primary, large HCCs. Herein, we have reported a patient with multifocal HCC beyond the listing criteria for OLT, who was treated with TACE and yttrium-90 microspheres preoperatively. CASE REPORT A 55-year-old man with multifocal HCC exceeding the Milan criteria in the setting of chronic hepatitis B infection and cirrhosis was evaluated for OLT at our institution. Downstaging of the T3 HCC was initially attempted with selective TACE, but had to be abandoned because of recanalization of the biggest lesion and inability to reach the second lesion. Yttrium-90 microspheres were delivered by hepatic intra-arterial infusion. The patient was transplanted 15 days after the treatment with an allograft from an 81-year-old donor allocated through Eurotransplant as a “rescue offer.” The posttransplant course was uneventful. Pathologic examination showed a multifocal, well0041-1345/08/$–see front matter doi:10.1016/j.transproceed.2008.09.036 3804
differentiated, 4-cm diameter pT2 tumor with extensive areas of necrosis and no vascular invasion. The patient was discharged on posttransplant day 22 on prednisone and tacrolimus immunosuppression. Rapamycin was introduced to replace tacrolimus after the month post-OLT. He is currently alive and well 14 months posttransplant, with no evidence of tumor recurrence on the current computed tomography scans of the abdomen and chest.
DISCUSSION
The extent of underlying liver damage constitutes a determining factor in the treatment of HCC. In the setting of advanced cirrhosis, nonsurgical therapies may exacerbate liver decompensation, resulting in shortened survival. Yttrium-90 microspheres are a new therapeutic alternative, employed mostly in the control of large HCCs in the setting of cirrhosis when other treatment modalities such as resection, OLT, TACE, or From the Department of General, Visceral, and Transplantation Surgery (G.C.S., K.M.N., I.F., E.P.M., G.S., S.B., A.P., C.E.B., H.L.), the Department of Gastroenterology and Hepatology (P.H., J.E.), and the Department of Diagnostic and Interventional Radiology (G.A.), University Hospital Essen, Essen; and the Department of General and Abdominal Surgery (G.C.S., H.L.), Johannes Gutenberg University Hospital, Mainz, Germany. Address reprint requests to Dr Georgios C. Sotiropoulos, MD, Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Langenbeckstraße 1, 55131 Mainz, Germany. E-mail: [email protected]
Crown Copyright © 2008 Published by Elseiver Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 40, 3804 –3805 (2008)
LIVER TRANSPLANTATION AFTER YTTRIUM THERAPY
RFA are contraindicated.1– 4 Only limited information had been available on its use in pre-OLT management.5,6 Kulik et al.6 suggested intra-arterial yttrium-90 microspheres can serve as a bridge to OLT, surgical resection, or RFA. They reported successful downstaging from T3 to T2 of 56% of HCCs.6 Eight patients (23%) in their series underwent OLT after downstaging, with a reported 1-, 2-, and 3-year survival rates of 84%, 54%, and 27%, respectively. This report provided encouraging information on the use of yttrium-90 microspheres for multifocal HCC as a bridging therapy before OLT. REFERENCES 1. Kulik LM, Carr BI, Mulcahy MF, et al: Safety and efficacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis. Hepatology 47:71, 2008
3805 2. Sotiropoulos GC, Lang H, Nadalin S, et al: Liver transplantation for hepatocellular carcinoma: University Hospital Essen experience and metaanalysis of prognostic factors. J Am Coll Surg 205:661, 2007 3. Dancey JE, Shepherd FA, Paul K, et al: Treatment of nonresectable hepatocellular carcinoma with intrahepatic 90Ymicrospheres. J Nucl Med 41:1673, 2000 4. Rowe BP, Weiner R, Foster J, et al: 90Yttrium microspheres for nonresectable liver cancer: the University of Connecticut Health Center experience. Conn Med 71:523, 2007 5. Kulik LM, Mulcahy MF, Hunter RD, et al: Use of yttrium-90 microspheres (TheraSphere) in a patient with unresectable hepatocellular carcinoma leading to liver transplantation: a case report. Liver Transpl 11:1127, 2005 6. Kulik LM, Atassi B, van Holsbeeck L, et al: Yttrium-90 microspheres (TheraSphere) treatment of unresectable hepatocellular carcinoma: downstaging to resection, RFA and bridge to transplantation. J Surg Oncol 9:572, 2006
A
LTHOUGH THE incidence of hepatocellular carcinoma (HCC) is expected to continue to increase over the next 30 years, only a limited number of patients are eligible for surgical therapies such as resection and orthotopic liver transplantation (OLT). A variety of alternative treatment modalities have been reported, including transarterial chemoembolization (TACE), radiofrequency ablation (RFA), ethanol ablation, cryoablation, and external beam irradiation. The goal of the various therapeutic options is tumor control with minimal side effects. Yttrium-90 microspheres, a novel treatment approach, have been used in cases of primary, large HCCs. Herein, we have reported a patient with multifocal HCC beyond the listing criteria for OLT, who was treated with TACE and yttrium-90 microspheres preoperatively. CASE REPORT A 55-year-old man with multifocal HCC exceeding the Milan criteria in the setting of chronic hepatitis B infection and cirrhosis was evaluated for OLT at our institution. Downstaging of the T3 HCC was initially attempted with selective TACE, but had to be abandoned because of recanalization of the biggest lesion and inability to reach the second lesion. Yttrium-90 microspheres were delivered by hepatic intra-arterial infusion. The patient was transplanted 15 days after the treatment with an allograft from an 81-year-old donor allocated through Eurotransplant as a “rescue offer.” The posttransplant course was uneventful. Pathologic examination showed a multifocal, well0041-1345/08/$–see front matter doi:10.1016/j.transproceed.2008.09.036 3804
differentiated, 4-cm diameter pT2 tumor with extensive areas of necrosis and no vascular invasion. The patient was discharged on posttransplant day 22 on prednisone and tacrolimus immunosuppression. Rapamycin was introduced to replace tacrolimus after the month post-OLT. He is currently alive and well 14 months posttransplant, with no evidence of tumor recurrence on the current computed tomography scans of the abdomen and chest.
DISCUSSION
The extent of underlying liver damage constitutes a determining factor in the treatment of HCC. In the setting of advanced cirrhosis, nonsurgical therapies may exacerbate liver decompensation, resulting in shortened survival. Yttrium-90 microspheres are a new therapeutic alternative, employed mostly in the control of large HCCs in the setting of cirrhosis when other treatment modalities such as resection, OLT, TACE, or From the Department of General, Visceral, and Transplantation Surgery (G.C.S., K.M.N., I.F., E.P.M., G.S., S.B., A.P., C.E.B., H.L.), the Department of Gastroenterology and Hepatology (P.H., J.E.), and the Department of Diagnostic and Interventional Radiology (G.A.), University Hospital Essen, Essen; and the Department of General and Abdominal Surgery (G.C.S., H.L.), Johannes Gutenberg University Hospital, Mainz, Germany. Address reprint requests to Dr Georgios C. Sotiropoulos, MD, Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Langenbeckstraße 1, 55131 Mainz, Germany. E-mail: [email protected]
Crown Copyright © 2008 Published by Elseiver Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 40, 3804 –3805 (2008)
LIVER TRANSPLANTATION AFTER YTTRIUM THERAPY
RFA are contraindicated.1– 4 Only limited information had been available on its use in pre-OLT management.5,6 Kulik et al.6 suggested intra-arterial yttrium-90 microspheres can serve as a bridge to OLT, surgical resection, or RFA. They reported successful downstaging from T3 to T2 of 56% of HCCs.6 Eight patients (23%) in their series underwent OLT after downstaging, with a reported 1-, 2-, and 3-year survival rates of 84%, 54%, and 27%, respectively. This report provided encouraging information on the use of yttrium-90 microspheres for multifocal HCC as a bridging therapy before OLT. REFERENCES 1. Kulik LM, Carr BI, Mulcahy MF, et al: Safety and efficacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis. Hepatology 47:71, 2008
3805 2. Sotiropoulos GC, Lang H, Nadalin S, et al: Liver transplantation for hepatocellular carcinoma: University Hospital Essen experience and metaanalysis of prognostic factors. J Am Coll Surg 205:661, 2007 3. Dancey JE, Shepherd FA, Paul K, et al: Treatment of nonresectable hepatocellular carcinoma with intrahepatic 90Ymicrospheres. J Nucl Med 41:1673, 2000 4. Rowe BP, Weiner R, Foster J, et al: 90Yttrium microspheres for nonresectable liver cancer: the University of Connecticut Health Center experience. Conn Med 71:523, 2007 5. Kulik LM, Mulcahy MF, Hunter RD, et al: Use of yttrium-90 microspheres (TheraSphere) in a patient with unresectable hepatocellular carcinoma leading to liver transplantation: a case report. Liver Transpl 11:1127, 2005 6. Kulik LM, Atassi B, van Holsbeeck L, et al: Yttrium-90 microspheres (TheraSphere) treatment of unresectable hepatocellular carcinoma: downstaging to resection, RFA and bridge to transplantation. J Surg Oncol 9:572, 2006