Outcome of living donor liver transplantation in patients of hepatic malignancy with metachronous adrenal gland metastasis: Can we achieve long term survival?

Abstract

Hepatocellular carcinoma (HCC) is third most frequent cause of cancer-related deaths worldwide. Liver transplantation (LT) is a potentially curative treatment and is the best treatment option for patients with decompensated cirrhosis. Although advanced HCCs are considered as contraindication for LT due to dismal prognosis, certain patients of HCCs with solitary metastasis in adrenal gland without any other extra-hepatic disease can still be managed by local resection of the adrenal gland metastasis and sequential LT. Herein we present our experience of sequential 4 cases of HCC solitary metastasis to adrenal gland that were treated by local resection followed by LT. Materials and Methods: Database of 937 patients that underwent LT at china medical university hospital was retrospectively analyzed. Four HCC patients that had solitary adrenal metastasis were evaluated for the outcome after living donor liver transplantation (LDLT). Three patients were diagnosed to have HCC whereas one patient was diagnosed with unresectable cholangiocarcinoma on explant pathology. All the four patients had underlying cirrhosis with solitary adrenal metastasis without any extrahepatic spread of primary disease. The adrenal gland metastasis was confirmed by pre-LT PET scan. Results: Four patients (mean age, 53 years; M:F, 2:2) underwent LDLT for HCC with single adrenal metastasis (right adrenal gland=2 patients; and left adrenal gland=2 patients) . In three patients the adrenalectomy was performed during the recipient surgery whereas one patient underwent LDLT six months after the adrenal metastasis resection (Table 1). Follow up period ranged from 9 months to 59 months. Survival in first two patients was 52 and 59 months, respectively. The first patient developed lung metastatic and expired due to overwhelming sepsis at 52nd post-LT month. The second patient in this series continue to have recurrence free survival at 59 months post-LT. The survival in third and fourth patients was 28 months and 9 months, respectively. The fourth patient in addition had mixed HCC-cholangiocarcinoma on histopathological analysis. Conclusion: Limited extrahepatic metastasis due to HCC can still be resected and LT can be performed if liver resection not possible with a good overall survival. The adrenalectomy can be done as a single stage procedure during LT surgery without increasing the risk.