Painful Groin Mass in a Liver Transplant Recipient

Authors


American Journal of Transplantation Images in Transplantation—Continuing Medical Education (CME)

Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace.

This month's feature article is titled: “Painful Groin Mass in a Liver Transplant Recipient.”

Accreditation and Designation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Blackwell Futura Media Services, the American Society of Transplant Surgeons, and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians, and fulfills the requirements for the American Board of Surgery (ABS) for Maintenance of Certification (MOC).

Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Need

Transplant recipients are at increased risk for a variety of malignancies, making the differential diagnosis for a new mass lesion broad. The evaluation and management of neoplasms in transplant recipients continues to be challenging for transplant physicians.

Purpose of Activity

This activity was designed to improve the competence and performance of transplant physicians in approaching neoplastic lesions in transplant recipients.

Identification of Practice Gap

In the context of the wide spectrum of malignancies affecting transplant recipients, physicians may not be well versed in the development of a comprehensive differential diagnosis and/or the execution of a streamlined work-up. Diagnostic inefficiency can potentially increase patient morbidity by delaying treatment. This activity will illustrate the diagnostic and therapeutic approach in a patient with a new mass lesion.

Learning Objectives

Upon completion of this educational activity, participants will be able to:

  • Develop a comprehensive but rational differential diagnosis for malignancy in a liver transplant recipient.
  • Analyze results from a diagnostic work-up and make appropriate treatment recommendations.
  • Apply the strategies learned from this activity to the work-up of future patients presenting with possible posttransplant malignancy.

Target Audience

This activity has been designed to meet the education needs of physicians, surgeons, and advanced health care providers in the field of transplantation.

Disclosures

No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable.

Editor-in-Chief

Allan D. Kirk, MD, PhD, FACS, has no relevant financial relationships to disclose.

Editors

Sandy Feng, MD, PhD, discloses stock ownership or equity in Abbott, Amgen, Charles River Labs, Eli Lily, Glaxo-Smith Klein, Hospira, Johnson and Johnson, Express Scripts, Medco, Merck, Pfizer, and Stryker; and research support from Novartis and Quark.

Matthew H. Levine, MD, PhD, discloses research support from Pfizer.

CME Manager, ASTS

Nerissa Legge, MSIMC, has no relevant financial relationships to disclose.

Education Assistant, ASTS

Ellie Proffitt, CHES, has no relevant financial relationships to disclose.

Authors

Andrew S. Barbas, MD, Maryam Elmi, MD, Sandra Fischer, MD, and Gonzalo Sapisochin, MD, PhD, have no relevant financial relationships to disclose.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Instructions on Receiving CME Credit

This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for 12 months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional 12 months.

Physicians must correctly answer 75% or more of the post-test items to claim MOC credit.

Follow these steps to participate, answer the questions and claim your CME credit:

  • Log on to https://www.wileyhealthlearning.com/ajt.
  • Read the learning objectives, target audience, and activity disclosures.
  • Read the article in print or online format.
  • Reflect on the article.
  • Access the CME Exam, and choose the best answer to each question.
  • Complete the required evaluation and print your CME certificate.

A 74-year-old man presented with a 3-mo history of a painful left groin bulge and sought outpatient surgical evaluation for a possible inguinal hernia. His medical history was notable for liver transplantation 12 years earlier for hepatitis B liver disease complicated by multifocal hepatocellular carcinoma (HCC) based on University of California, San Francisco (UCSF) criteria. Preoperative therapy included radiofrequency ablation of a segment 5 lesion, and the α-fetoprotein (AFP) level at transplant was 318 ng/mL. Explant pathology was beyond UCSF criteria, with 4 HCC lesions (maximal diameter of 4.5, 3, 2.5, and 2.4 cm) and evidence of microvascular invasion. His posttransplant course was largely unremarkable, with no episodes of rejection and good compliance with transplant medications and antiviral therapy (tenofovir). The initial immunosuppression regimen consisted of tacrolimus, mycophenolic acid, and prednisone, which was ultimately narrowed to tacrolimus alone. Posttransplant follow-up included routine computed tomography (CT) surveillance of the chest, abdomen, and pelvis, which never demonstrated any evidence of recurrent disease. He had no other significant medical conditions. Health maintenance screening was up to date, with an up-to-date colonoscopy with normal findings. At the time of his presentation, physical examination demonstrated a firm mass in the left inguinal region. In addition, he had an enlarged left testicle, which appeared consistent with a hydrocele. A CT scan of the abdomen and pelvis with intravenous contrast was obtained and showed a 5.1 × 3.4 × 3.2-cm heterogeneously hyperattenuating complex mass in the left inguinal canal (Figure 1). No intra-abdominal masses were identified, and the transplanted liver was normal in appearance. A 10-cm testicular cyst was noted, consistent with physical examination findings. Additional work-up at this point included measurement of serum AFP, which was 28 ng/mL. A CT scan of the chest was also obtained and showed no evidence of any malignancy.

Figure 1.

Computed tomography of the abdomen and pelvis demonstrating a hyperattenuating mass in the left inguinal canal.

Figure 2.

Cross-section of the inguinal mass invading the spermatic cord with associated photomicrograph.

Figure 3.

Resected specimen, including the inguinal mass, the spermatic cord, and the testicle (with cyst).

Questions

  1. What is the most appropriate diagnostic test to perform during the initial presentation of a groin mass in a transplant patient?
    1. Ultrasound
    2. Computed tomography scan
    3. Fine-needle aspirate
    4. Stereotactic core biopsy
    5. Serum α-fetoprotein levels
  2. A picture of the gross tumor specimen and photomicrograph are included in Figure 2. Histological examination demonstrates a moderately differentiated tumor with trabecular architecture formed by large polygonal cells separated by thin-walled vascular channels and scant tumor stroma. In the context of the clinical vignette, what is the most likely diagnosis?
    1. Posttransplant lymphoproliferative disease
    2. Metastatic recurrent hepatocellular carcinoma
    3. Inguinal lymph node metastasis from anal cancer
    4. Metastatic melanoma
    5. Inguinal lymph node metastasis from testicular tumor
  3. What is the most common malignancy in patients following liver transplantation?
    1. Nonmelanoma skin cancer
    2. Melanoma
    3. Non-Hodgkin's lymphoma
    4. Lung cancer
    5. Anal cancer
  4. What is the optimal treatment?
    1. Reduction in immunosuppression
    2. Change primary immunosuppression to everolimus
    3. Systemic chemotherapy
    4. Surgical resection
    5. Radiofrequency ablation

To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt

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