Recurrence Of Hepatocellular Carcinoma At The Porta-Hepatis Following Liver Transplantation: It Can Happen!

Hepatocellular carcinoma (HCC) is a potentially fatal complication of chronic liver disease. Liver transplantation is now the preferred treatment due to good outcomes. We present a unique case of recurrence of HCC at the porta hepatis four years after orthotopic liver transplantation (OLT). A 57-year-old male with a past history of OLT four years prior due to decompensated cirrhosis and HCC presented after a lesion was found at the porta hepatis during routine imaging. The patient had received OLT for a history of HCC and decompensated hepatitis C virus (HCV) four years prior to current presentation. The patient did well post OLT and was maintained on tacrolimus and mycophenolate acid. Unfortunately, the patient was lost to follow-up for 1.5 years and presented again to the hepatology clinic. Four years after his OLT, a surveillance computed tomography (CT) scan of the liver showed a well-circumscribed enhancing mass in the porta hepatis measuring 4.6 x 5.6 x 6.4 cm [Figure 1]. His previous CT scan two years ago was unremarkable, except for post-surgical changes. An endoscopic ultrasound (EUS) along with a fine needle aspiration (FNA) of the mass and peripancreatic lymph nodes was performed. Histopathology showed morphological features consistent with well-differentiated HCC [Figure 2]. Subsequently, the patient underwent resection of HCC and lymphadenectomy. Surgical pathology confirmed well-differentiated HCC. The patient tolerated the procedure well and continues to follow up with hepatology. A CT scan of the liver performed 3 months post resection was unremarkable, except several liver imaging reporting and data system (LI-RADS) 3 lesions.OLT provides excellent long-term outcomes in patients with HCC and has become the preferred treatment modality. The most common sites of recurrence are extrahepatic, including the lung, bone, abdominal lymph nodes, adrenal glands, and peritoneum. Our case is unique in several ways. Recurrence of HCC post OLT is mostly extra-hepatic and our patient developed recurrence of HCC at the porta-hepatis. In addition, the diagnosis of HCC is exceedingly rare with the use of EUS-FNA. Our patient had classic features of HCC on FNA-cytology obtained during EUS. Our report also highlights that intrahepatic recurrence of HCC can be surgically treated. However, further studies are needed to develop treatment algorithms for intra-hepatic recurrence of HCC post liver transplantation.2317_A Figure 1. a well-circumscribed enhancing mass in the porta hepatis measuring 4.6 x 5.6 x 6.4 cm2317_B Figure 2. Well-differentiated HCC