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Special Feature
Oct 2012

Image of the Month—Diagnosis

Author Affiliations


Arch Surg. 2012;147(10):974-974. doi:10.1001/archsurg.147.10.974
Answer: Recurrent Metastatic HCC

Slides of pathologic samples from the initial biopsy specimen confirmed the diagnosis of metastatic HCC. Immunohistochemical staining for HepPar-1, pancytokeratin, and PIN4 was positive, while staining for PSA, PSMA, P50IS, S-100 protein, and HMB-45 expression was negative. Given the patient's poor performance status and the location of the metastatic disease, surgery was not considered an option. The patient was started on a regimen of sorafenib, 400 mg twice daily, but failed to tolerate this therapy because of hand-foot syndrome. The patient was treated with palliative external beam radiotherapy of 4 Gy (to convert gray to rad, multiply by 100) for 5 fractions, followed by 2 Gy for 15 fractions, for a total of 50 Gy to the pelvic mass. Unfortunately, the patient died 3 months after the conclusion of radiotherapy.

Liver transplant is the preferred treatment for patients with small HCC and established liver cirrhosis. Disease recurrence in the setting of immunosuppression is, however, a major problem and remains the rate-limiting factor for long-term survival. The most common sites of recurrence include the liver graft, lung, and bone. Other possible sites include the abdominal lymph nodes, adrenal glands, and peritoneum.1,2 The patient we describe likely had a “drop” peritoneal recurrence in the cul-de-sac between the prostate and rectum, which subsequently invaded both structures.

Although most patients experience recurrence of HCC in the first 2 years after transplant, late recurrences are possible even years following transplant. In a series of 57 patients with recurrent HCC after liver transplant, 6 patients (11%) experienced recurrence of HCC after 4 or more years.1 Tumor factors associated with late recurrence were small tumor size, well to moderate differentiation, and a history of hepatitis C or alcoholism rather than hepatitis B or cryptogenic cirrhosis. A separate study reported that 69% of recurrences were within the first 2 years and 21% after 3 years.2 Similarly, late recurrence was more common among patients who received a transplant when they had low-stage disease and well-differentiated tumors. Intrahepatic and extrahepatic late recurrences have been documented equally.

Management of recurrent HCC can be difficult and therefore is most appropriately handled in a multidisciplinary setting. Surgical salvage, when feasible, can offer a chance for long-term survival ranging between 27% and 88%.14 Surgical management of intrahepatic recurrence can include resection, ablation, or a second transplant in appropriately selected patients. Other therapeutic options for intrahepatic recurrence include percutaneous ablation or intra-arterial therapy, such as transarterial chemoembolization. Molecular targeted therapy with sorafenib is a systemic option for patients with advanced disease. Finally, radiotherapy—as in the current case—may be helpful to palliate symptoms and retard progression of disease, but its ability to prolong survival in patients with extrahepatic HCC recurrence remains ill defined.

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Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgery has temporarily discontinued accepting submissions for this feature. Requests for submissions will resume in April 2013. Thank you.

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Article Information

Correspondence: Timothy M. Pawlik, MD, MPH, PhD, Department of Surgery, The Johns Hopkins Hospital, 600 N Wolfe St, Blalock 288, Baltimore, MD 21287 (

Accepted for Publication: October 5, 2011.

Author Contributions:Study concept and design: Kneuertz, Malla, Cosgrove, Kamel, Cameron, and Pawlik. Acquisition of data: Kneuertz, Malla, Kamel, Geschwind, and Pawlik. Analysis and interpretation of data: Malla, Herman, Kamel, and Geschwind. Drafting of the manuscript: Kneuertz, Malla, Herman, Kamel, Cameron, and Pawlik. Critical revision of the manuscript for important intellectual content: Kneuertz, Cosgrove, Herman, Kamel, Geschwind, and Pawlik. Statistical analysis: Malla, Kamel, and Geschwind. Obtained funding: Geschwind. Administrative, technical, and material support: Kneuertz and Pawlik. Study supervision: Kamel, Cameron, and Pawlik.

Financial Disclosure: None reported.

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