Liver transplantation is now an acceptable treatment for small hepatocellular carcinomas in the setting of cirrhosis. Larger tumors in cirrhotic livers and unresectable tumors in noncirrhotic livers (including fibrolamellar hepatocellular carcinomas) may also be indications for transplantation. With the limited number of cadaver grafts available, living donor liver transplant is becoming an option for some of these patients. We describe a method of reconstruction of the recipient inferior vena cava with deceased donor graft in right lobe living donation for fibrolamellar hepatocellular carcinoma. (Liver Transpl 2004;10:555–556.)
Liver transplantation for patients with hepatocellular carcinoma (HCC) and cirrhosis is becoming more commonplace. In fact, recent changes in the United Network of Organ Sharing (UNOS) allocation of cadaver livers has given priority to patients with small HCCs.1 Patients with larger tumors or noncirrhotic patients with large unresectable tumors are not prioritized, as their prognosis is not felt to be favorable enough to warrant the use of a scarce cadaver graft. Living donor liver transplant (LDLT) can be a solution for selected patients who are not candidates for upgrading on the deceased donor list.
Adult to adult living donor liver transplant using the right hepatic lobe was first performed successfully in the United States in 1997.2 Since then, the number of LDLT has increased each year with success rates comparable to deceased donor transplantation.
LDLT using a right lobe does not allow for resection of the recipient vena cava. There has been a report, however, of LDLT with total hepatectomy including the retrohepatic vena cava with reconstruction using a deceased donor graft for hepatoblastoma in children.3 We report a case of right lobe LDLT to an adult recipient for fibrolamellar hepatocellular carcinoma (FL-HCC) without cirrhosis, encasing the inferior vena cava, utilizing a deceased donor graft to reconstruct the cava.
A 53-year old male presented with sudden onset of upper abdominal pain. CT scan revealed a mass in both right and left lobes of the liver encasing the intrahepatic inferior vena cava. (Fig. 1) Percutaneous biopsy of the mass demonstrated a fibrolamellar hepatocellular carcinoma.
The patient had no risk factors, nor was there any CT evidence of cirrhosis. CT scan of chest and abdomen showed no evidence of extrahepatic disease. His hepatitis B and C serologies were negative. Aside from mild renal impairment (creatinine 1.6mg/dl) secondary to renal artery stenosis, he was in good health.
The mass was unsuitable for partial hepatectomy. It was felt that transplantation, with complete excision of tumor and retrohepatic vena cava, was the patient's only option for a curative procedure. The patient's 27-year old son volunteered himself as willing to undergo right hepatectomy for living donation and was medically suitable.
Using a living donor right lobe, necessitated reconstruction of the recipient inferior vena cava with deceased donor vena caval graft. The case was scheduled to follow the day after a compatible blood-type cadaver donor procurement, in which an appropriate length of infra-renal vena cava was obtained.
The recipient was explored prior to commencement of the donor surgery. A large, centrally located liver mass involving the caudate lobe and completely encasing the retrohepatic vena cava was found. Frozen section of hilar lymph nodes was negative for tumor.
After the liver and vena cava were completely removed from the recipient, the deceased donor caval graft was interposed between the two caval segments. (Fig. 2) Caval flow was then reinstituted to check for patency and hemostasis. The graft was performed within 25 minutes and the patient tolerated clamping of the inferior vena cava well.
The caval graft was reclamped and a venotomy was made for the anastomosis of the donor right hepatic vein. The portal venous anastomosis was then completed and the liver was reperfused. The hepatic artery was completed with a spatulated end-to-end technique and a Roux-en-Y hepaticojejunostomy was created for the biliary anastomosis.
Immunosuppression consisted of tacrolimus, mycophenolate mofetil, and a three-day course of methylprednisolone.
Histology of the explant showed a 12 × 9 × 7.5 cm moderately differentiated fibrolamellar HCC surrounding the inferior vena cava. The tumor infiltrated the adventitia of the cava but not the wall. All lymph nodes were negative.
The patient recovered without complication. Notably, there was no deterioration in renal function. He was discharged from the hospital on day 8. The donor was discharged on day 7 with a small amount of bile in his drain. This resolved spontaneously with no further intervention.
The recipient is now one year post transplant with normal liver function and no evidence of recurrent tumor on CT scan of chest and abdomen.
FL-HCC has been recognized as a distinct histological subtype. These tumors are often bulky and involve adjacent structures when first diagnosed. They often follow a more indolent course than regular hepatomas and the patient usually does not have cirrhosis. An aggressive approach toward surgical resection of these tumors and contiguous structures or transplantation for nonresectable tumors can yield acceptable results.4, 5 LDLT offers a means of treatment for FL-HCC without cirrhosis, when partial hepatectomy is not possible. We offer a technique that demonstrates a possible application of LDLT in highly selected cases of this type of malignancy.