Vivek Mangla1, Shailendra Lalwani1, Ajay Sharma2, Sunita Bhalla3, Samiran Nundy1, Naimish Mehta1
Departments of Surgical Gastroenterology and Liver Transplantation1,
Urology2 and Pathology3,
Sir Ganga Ram Hospital,
New Delhi, India
Dr. Vivek Mangla
Patients with cirrhosis are at a high risk of liver failure and mortality following non-transplant surgery.[1,2] The presence of co-existing extra-hepatic malignancy is generally considered a contraindication to liver transplantation thereby limiting the treatment options in such patients. There are only a few reports in the literature describing a combination of deceased donor liver transplantation with resection of extra-hepatic tumours.[3-5] We describe the evaluation and management of a case of hepatitis B virus (HBV) related cirrhosis who was incidentally detected with renal cell carcinoma (RCC) on pre-transplant imaging.
A 47-year-old lady, a known case of HBV related liver cirrhosis for 3 years, presented to us for evaluation for living related donor liver transplantation (LDLT). She had been previously treated medically for spontaneous bacterial peritonitis. She had no history of hepatic encephalopathy or variceal bleeding. The patient was taking antiviral treatment for HBV and diuretics for the last 3 years. Abdominal examination revealed the presence of ascites and splenomegaly. Her hematological and biochemical investigations were as follows: Hemoglobin 10.7 (normal, 11-15) g/dL, total leucocyte count 5100 (normal, 4000-10000) cells/ mm3, platelet count 54000 (normal, 150-450) cells/mm3, international normalized ratio (INR) 1.48, total bilirubin 1.8 (normal, 0.2-1) mg/dL, aspartate aminotransferase (AST) 57 (normal, 0-42) U/L, alanine aminotransferase (ALT) 23 (normal, 0-60) IU/L, alkaline phosphatase 155 (normal, 39-117) IU/L, gamma-glutamyl transpeptidase 42 (normal, 0-64) IU/L, total protein 6.9 (normal, 6.6-8.7) g/dL, serum albumin 2.4 (normal, 3.5-5) g/dL and serum creatinine 1.9 (normal, 0.6-1.3) mg/dL.
Renal dysfunction improved with human albumin infusion and cessation of diuretics. HBV-DNA was below detectable levels. Her Child-Turcotte-Pugh score was 10/15 (Child’s C) and MELD at admission was 19. Contrast enhanced computed tomography (CECT) scan revealed cirrhosis, ascites, dilated but patent portal vein and splenomegaly (Figure 1). There was no evidence of hepatocellular carcinoma. Incidentally, a 2 cm size lobulated hypodense cyst with heterogeneous enhancement (non FDG avid on Fludeoxyglucose Positron Emission Tomography [FDG PET-CT], was noted in the right kidney (Figure 2). A diagnosis of HBV related cirrhosis (decompensation with ascites) with right renal cyst, Bosniak category III/IV (likely malignant) was made.
DTPA scan revealed a total glomerular filtration rate (GFR) of 52.92 mL/minute. Differential GFR was 24.5 mL/minute in the left kidney (46.3%) and 28.44 mL/minute (53.7%) in the right kidney.
The patient underwent right lobe LDLT with partial right nephrectomy. During the surgical procedure, recipient hepatectomy was done first followed by a temporary portocaval shunt. Partial right nephrectomy was done next followed by disconnection of temporary portocaval shunt. Right lobe implantation was done. Graft weight was 870g. Graft Recipient Weight Ratio (GRWR) was 1.1. Frozen section for the partial nephrectomy specimen confirmed the presence of malignancy. The margins of the lesion were free of tumor. The patient was extubated on post-operative day 2. Serum creatinine during the first post-operative week ranged between 1.6-2.2 (normal, 0.6-1.3) mg/dL. Apart from steroids, rest of the immunosuppressive drugs had to be withheld (due to thrombocytopenia and abnormal serum creatinine values) till day 7 by when the creatinine normalized. Post-operative course was also marked by ascites and hyperkalemia which responded to medical management. The patient was discharged on postoperative day 21 with normal serum potassium, creatinine and liver functions.
Histopathological examination (HPE) of the explanted liver revealed mixed macro- and micro-nodular cirrhosis. HPE of the partial nephrectomy specimen revealed a well circumscribed tumour composed of small groups of large polyhedral cells with clear cytoplasm with abundant fibrovascular stroma and focal lymphomononuclear infiltrate (Figure 3). The margins were free of tumor. Tumor cells were positive for cytokeratin. The final diagnosis of the renal lesion was right renal cell carcinoma, clear cell variant, Fuhrmann grade I (Stage T1aN0M0).
Patient has been followed for 15 months with normal liver and renal functions without any evidence of recurrence of renal cell cancer on follow-up imaging.
Patients with cirrhosis and extra-hepatic malignancy present a unique challenge. The risk of bleeding and decompensation with non transplant surgery has to be balanced against the risk of tumor recurrence with immunosuppression following simultaneous liver transplantation and resection.
This patient had an incidentally detected early stage unilateral renal lesion suspected for malignancy. FDG PET-CT was done in this patient to clarify the nature of this lesion and also to rule out disseminated disease. The lesion was not FDG avid and there was no evidence of abnormal FDG uptake elsewhere. It is well known that FDG is excreted through the urine and therefore small primary lesions may be missed on FDG-PET. Therefore, accuracy of FDG-PET is less than CT for the primary tumor. However, FDG-PET is more sensitive than CT for detection of metastatic disease.
In our patient, the risk of decompensation and mortality associated with nephrectomy in the setting of cirrhosis, and a possibly higher risk of recurrence after liver transplantation (in view of the need for immunosuppression post transplant) were considered and discussed between the treating team, patient and patient’s family members following which a decision was taken to perform partial right nephrectomy with right lobe LDLT.
The authors acknowledge the help of Dr. Ethel Belho, Department of Nuclear Medicine, Sir Ganga Ram Hospital, New Delhi, India for providing the FDG PET-CT images.
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- Falkensammer CE, Bonatti H, Falkensammer J, Aranda-Michel J, Dickson RC, Norman K, et al. Combined liver transplantation together with partial/total nephrectomy in patients with renal cell cancer and nonalcoholic steatohepatitis. Transpl Int. 2007;20:471–2.
- Fayek S, Moore D, Bortecen KH, Yen H, Markmann JF, Olthoff KM, et al. Liver transplantation in the setting of extra-hepatic malignancy: two case reports. Transplant Proc. 2007;39:3512–4.
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