Hepatocellular Carcinoma in a Liver Transplant Recipient?






Question
A 54-year-old patient was transplanted in April 2002 for hepatitis B virus-related cirrhosis with 6.5-cm hepatocellular carcinoma (HCC). Ten months after transplantation the HCC recurred, and 1 month later he underwent chemoembolization. He is on lamivudine, adefovir-dipivoxil, and tacrolimus 6 mg. Two months later, multiple HCC lesions presented on his liver. Should the patient's immunosuppression be decreased or even discontinued to prevent expansion of the HCC?

Themistoklis Vassiliadis, Senior Registrar

Response
from John J. Fung, MD, PhD, 08/12/2003

Experimental animal data implicate immunosuppression in the progression of hepatocellular cancers, but the data are less convincing in human subjects. A recent report by Vivarelli and colleagues suggests that the cumulative dosing of cyclosporine (CsA) in the first year after transplantation may be associated with lower recurrence rates. Calcineurin inhibitors, such as CsA and tacrolimus (TAC), can increase transforming growth factor levels, which have been implicated in increasing malignant phenotype of cancer cells in vitro. Given the overall poor prognosis of this patient, with or without immunosuppression, the decision to continue, lower, or eliminate TAC dosing is not clear and should be put into context with other medical problems. Certainly, if the patient has an elevated serum creatinine, then lower doses are warranted. However, to expect discontinuation of immunosuppression to affect the inevitable death due to metastatic HCC is unrealistic.