Surgical Resection for Lymph Node Metastasis After Liver Transplantation for Hepatocellular Carcinoma

Results

Among the patients who underwent LDLT for HCC (n=212), 28 patients showed recurrent HCC in the lung (n=9), LNs (n=6), bone (n=5), liver (n=4), peritoneum (n=3) and adrenal gland (n=1). The mean period from LDLT to recurrence was 1.7±1.3 years. The 5- and 10-year cumulative patient survival rates were 89.3% and 85.5% in those without recurrence (n=184) and 38.8% and 30.7% in those with recurrence, respectively (p<0.01).

Six patients (three male, three female, average age=58.5±5.1 years) presented with recurrent disease in the LNs (Figure 1, Table I). Only one patient received a right lobe graft, the others had left lobe grafts. In terms of primary HCC, the initial two patients (patients 1 and 2) were outside the Milan criteria and others were within the criteria. Poorly differentiated components were observed in two patients patients 3 and 6) by microscopic examination of the explanted liver. The mean time from LDLT to LN recurrence was 2.0±1.3 years. The mean size of the recurrent tumor was 2.4±0.8 cm and all tumors were solitary except those in patient 3. The locations of the recurrences were the phrenic (n=2), common hepatic artery (CHA) (n=2), inferior vena cava (IVC) (n=1) and gastric (n=1) LNs.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1.

Lymph node (LN) metastasis after living donor liver transplantation in patient 1 at the gastric LN (A), patient 2 at the vena cava LN (B), patients 3 (C) and 4 (D) at the hepatic artery LN, and patients 5 (E) and 6 (F) at the phrenic LN.

Treatments were surgery alone in three patients, surgery followed by chemoradiation in one, radiation followed by chemotherapy in one, and chemotherapy, radiation and sorafenib in one (Table I).

Patient 1 initially underwent laparotomy and surgical resection for HCC recurrence in a gastric LN at the lesser curvature (Figure 1A), 4.9 years after LDLT. Three months after the LN removal, he developed two 3-cm HCC recurrences at the root of the middle hepatic vein in the transplanted liver, and received chemotherapy comprising 5-fluorouracil (500 mg/day) and cisplatin (5 mg/day) with local radiation therapy (30 Gy). However, his disease progressed systemically and he died 7 months after the initial recurrence.

Patient 2 developed HCC recurrence in a LN adjacent to the hepatic IVC (Figure 1B) and received radiation (50 Gy) resulting in progressive disease, followed by chemotherapy comprising 5-fluorouracil (250 mg/day) and cisplatin (5 mg/day). However, he had multiple lung metastases and died 1.2 years after the recurrence.

Patient 3 developed HCC recurrence in LNs at the CHA (Figure 1C). He received gemcitabine (1400 mg/body), 5-fluorouracil (250 mg/day) and cisplatin (5mg/day) resulting in progressive disease, followed by radiation (50G) and sorafenib. He developed multiple bone metastases and died 6 months later.

Patient 4 developed recurrent HCC in a LN at the CHA (Figure 1D), and both patient 5 (Figure 1E) and patient 6 (Figure 1F) developed recurrence in LNs on the diaphragm. Because we recognized at that time that nonsurgical treatment does not offer sufficient outcomes, we performed surgical resection despite the fact that the surgical approach to the lesions was not expected to be easy. Nevertheless, the operative time and blood loss for patients 4, 5, and 6 were 140 min and 60 g, 141 min and 129 g, and 144 min and 60 g, respectively, with uneventful post-surgical courses. In Patient 6, the recurrent nodule was identified just behind the junction of the hepatic and cardiac IVC on the diaphragm, and we performed a thoracolaparotomy (Figure 2A) to divide and follow the diaphragm to reach the target LN safely and effectively, avoiding injury to the middle hepatic vein on the surface of the extended left lobe graft and the IVC. By placement of the surgeon's fingers behind the diaphragm and IVC to identify and hold the targeted tumor, surgical resection of the recurrent mass was safely performed (Figure 2B). The postoperative survival period for patients 4, 5, and 6 was 11.2 years, 4.5 years and 0.8 years, respectively without any signs of re-recurrence.