Lesion is located on the surface of segment II, so repeat resection is still feasible. Previous surgery includes right hepatectomy and segment IVa resection with margin of cava. Previous histology confirms HCC on both occaisions and completely normal background liver. I can only find one article by Hess et al (Clin Translant 2002) describing this.
This is recurrence in a different segment than the original tumor. Would this indicate probable additional recurrence lesions in other liver segments and possible metastatic lesions elsewhere (e.g. lung) too small to detect by CT or MRI?
I wonder if more data are available about this case;
the time for both recurrences and vascular invasion (micro- and macro-) and grade of HCC in the previous resections.
Also, AFP level in the currennt recurrence, the tumor size and number and the future remnant liver volume
I hesitate to venture outside my own field of colorectal surgery, but I am a bit concerned about the use of the word "recurrence".
Is this a true recurrence of a micro-deposit of the orginal tumour that has now activated or is it a second different new tumour in a condition known to be multifocal?
The risk factors now affecting the patient's prognosis may not be the same for these; if they are thgought to differ, perhaps DNA analyses of the original tunour and the present one might be helpful?
Timing of recurrence in relation to firs resection as well as signs of microvascular invasion and AFP level are crucial information in order to make an optimal assessment. If the time frame is less than 12 months, it may well be that this is not recurrence but a staging error due to the fact that microscopic tumors will not be possible to diagnose on the original imaging. If no vascular invasion, and a short interval, salvage transplantation is a viable option
Thanks for the input:
2001: original resection demonstrating HCC with possible vascular invasion, AFP negative, areas of necrosis and normal background liver. R0
2012: re-resection, mostly necrotic tumour, some abnormal hepatic cells yes consistent with HCC. R0
background liver normal on both resections. Given the time frame probably not a staging error. I take the point that other micro mets may exist but with the spacing between the recurrences and primary re
May be you should refer the case to your regional liver transplant center and see what opinion they give?
With the liver being normal and assuming the tumour is resectable then resection may still be the best option. However the better longer term option would be for the patient to undergo liver transplant (to prevent further tumour development in the remnant liver).
Given the long time interval for recurrence in both settings, the normal background liver, the low AFP and the peripheral location of the tumor, re-resection appears to be the best option. Refering the patient to salvage liver transplantation may be too much for that case.
Only if the patient is above 60 years, SLT should be considered, because if further re-recurrence occures, the patient may have then exceeded the age limit for transplantation.
Re-resection can be attempted when possible to gain as much of transplant free survival. Salvage LT might be a good option as it will offer the best long term survival provided there are no distant metastasis. Age by itself should not be a contraindication. Marginal grafts with high DRI can be directed towards these patients who often have a low MELD and do reasonably well.
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