Living Donor Liver Re-Transplantation for Recurrent Hepatoblastoma in the Liver Graft following Complete Eradication of Peritoneal Metastases under Indocyanine Green Fluorescence Imaging

Abstract

The curability of chemotherapy-resistant hepatoblastoma (HB) largely depends on the achievement of radical surgical resection. Navigation techniques utilizing indocyanine green (ICG) are a powerful tool for detecting small metastatic lesions. We herein report a patient who underwent a second living donor liver transplantation (LDLTx) for multiple recurrent HBs in the liver graft following metastasectomy for peritoneal dissemination with ICG navigation. The patient initially presented with ruptured HB at 6 years of age and underwent 3 liver resections followed by the first LDLTx with multiple sessions of chemotherapy at 11 years of age. His alpha-fetoprotein (AFP) level increased above the normal limit, and metastases were noted in the transplanted liver and peritoneum four years after the first LDLTx. The patient underwent metastasectomy of the peritoneally disseminated HBs with ICG navigation followed by the second LDLTx for multiple metastases in the transplanted liver. The patient has been recurrence-free with a normal AFP for 30 months since the second LDLTx. To our knowledge, this report is the first successful case of re-LDLTx for recurrent HBs. Re-LDLTx for recurrent HB can be performed in highly select patients, and ICG navigation is a powerful surgical tool for achieving tumor clearance.

Keywords: hepatoblastoma; indocyanine green; living donor liver transplantation; transplant oncology.

Figure 1

The clinical course of the patient. The years after the initial presentation are plotted on the horizontal axis, and the values of alpha-fetoprotein (AFP) are plotted on the vertical axis. Blue arrowheads indicate laparotomies other than living donor liver transplantation (LDLTx). Bars on the bottom represent the chemotherapeutic regimen. CITA: cisplatin 80 mg/m² and tetrahydropyranyl adriamycin (THP-ADR) 30 mg/m², C5V: cisplatin 90 mg/m², 5-fluorouracil 600 mg/m² and vincristine 1.5 mg/m², CPT-11: Irinotecan 20 mg/m².

Figure 2

(A,B,C) The pathological findings of the metastatic nodule in the liver, which were compatible with wholly epithelial-type (fetal subtype) hepatoblastoma (HB) with vascular invasion. (A,B; H.E. stain, A; 100×, B; 200×, C; Elastica van Gieson (EVG) stain, 200×). (D) The arrowhead represents the peritoneal nodule adjacent to the transplanted liver, which was noted in the first laparotomy after the first LDLTx procedure. (E) The pathological findings of the peritoneal nodule is shown in Figure (H.E. stain, 100×).

Figure 3

White-light mode (A,C) and corresponding near-infrared mode (B,D) findings in the peritoneal cavity at the time of the second laparotomy after the first LDLTx procedure are shown, macroscopic image.

Figure 4

(A) The sliced explanted liver in white-light mode and (B) near-infrared mode. The hot spots in near-infrared mode were compatible with hepatoblastomas in histology, macroscopic image.

Figure 5

A schematic illustration of the hypothesized mechanism of recurrence in this patient. Multiple metastases in the liver graft are assumed to be derived from disseminated nodules through the portal vein.