Case Report Highlights Malignancy Challenges Post Liver Transplant

Despite significant advances in liver transplantation in recent years, posttransplant de novo or recurrent malignancies remain a significant problem in this patient population.

In a new case report published in the Experimental & Clinical Transplantation, investigators describe a patient who received a liver transplant due to hepatitis B–related end-stage liver disease and subsequently developed de novo intrahepatic cholangiocarcinoma. The authors said this is believed to be the first such case reported in the scientific literature.

In this case, a 48-year-old man with hepatitis B–related liver cirrhosis and end-stage liver disease with several complicating factors sought care. His Model for End-Stage Liver Disease score was 26, prompting physicians to list him as a candidate for a transplant. Pretransplant imaging indicated no evidence of any malignancy, the authors noted.

He eventually received a whole-organ transplant from a deceased 72-year-old man who was confirmed to be negative for the hepatitis B surface antigen and hepatitis C virus antibody. There also was no evidence of malignancy, the authors said.

The recipient was given induction Simulect (basiliximab), and Prograf (tacrolimus), CellCept (mycophenolate mofetil), and prednisolone as maintenance therapy for immunosuppression. Tacrolimus was maintained at a level of 10 ng/mL for the first year after the transplant.

The patient was discharged from the hospital 20 days following the transplant, with no report of complications. However, after 2 months, he patient experienced a fever, abdominal pain, and a skin rash, prompting a trip to the emergency department (ED). Imaging identified what appeared to be a benign biliary stricture in the right hepatic duct. It was repaired using a biliary drainage catheter and the patient was discharged.

The following day, he returned to the ED with a fever and skin rash and a series of laboratory tests was administered. A cytomegalovirus real-time polymerase chain reaction test came back at 565 IU/mL. The patient was administered simultaneous antiviral and antibacterial medication. His symptoms improved, but then recurred, prompting repeated hospitalization and discharge.

At 10 months post transplant, the patient returned to the hospital with symptoms described as anorexia and generalized pain. This time, a scan showed intrahepatic bile duct dilation and a new contrast-enhancing mass around the hilum, the authors said. A biopsy confirmed it to be cholangiocarcinoma and chemotherapy was initiated, but the patient died 8 months later.

The investigators said the case was rare in part due to the type of cancer the patient experienced after his transplant. In Western populations, nearly half of de novo malignancies following liver transplant are skin cancers. In Korean populations, stomach and colon cancer in men and breast cancer in women are among the most common de novo cancer types, they said.

The authors added that it can be difficult to ever know for sure whether a posttransplant malignancy is due to cancer transmitted from the donor, the development of cancer in donor cells after transplant, a new cancer resulting from long-term transplant consequences, or a recurrence of cancer for which the recipient had already been treated. They said a determination in this particular patient was likewise difficult.

“Both a donor-derived cancer and newly developed cancer in the recipient were thought to be possibilities,” they wrote. “These issues may also be related to grafts from older donors.”

Liver transplant remains the gold standard treatment for patients with end-stage liver disease, the authors said, noting that the use of older donors has increased as liver transplant wait lists have grown longer. One study found no significant differences in patient or graft survival in cases where the donor was older than 70 years vs cases with younger donors.

In this case, in the absence of a living or younger donor, the investigators decided to use the liver from the older donor due to the lack of fatty change and a satisfactory visual inspection of the liver. They noted that the recipient’s liver function following surgery recovered without problems.

Still, the investigators said there may be more to understand about the use of transplants from elderly donors

“Caution should be taken when using grafts from elderly donors, as additional donor risk factors, such as steatosis or long-term ischemia, may increase the incidence of organ dysfunction,” they concluded.

The investigators added that tumor marking tests and CT scans, in addition to other tests, could be leveraged to better evaluate grafts from older donors.

Reference

Moon HH, Shin DH, Choi YI. De novo intrahepatic cholangiocarcinoma after deceased donor liver transplant in an adult patient. Exp Clin Transplant. 2022;20(3):316-320. doi:10.6002/ect.2021.0437