Liver transplantation recipient with malignant transformation of hepatic adenomas

Abstract

Hepatic adenomas are uncommon benign liver neoplasms. These tumors can undergo malignant transformation into hepatocellular carcinoma (HCC). Transformations associated with anabolic steroid use are seldom reported. The ability to differentiate hepatic neoplasms is important in pre-liver transplant evaluation. Differentiating hepatic adenomas from HCC has been aided by phenotyping classification systems. We examine the case of a 39-year-old male, former athlete, with β-catenin-activated hepatic adenomas associated with anabolic steroid use that underwent malignant transformation into HCC. Ultrasonography showed an enlarged liver with multiple nodules. MRI images demonstrated multiple tumors with no invasion of biliary tract or major vessels. Biopsies of a segment 5 lesion resulted in a well-differentiated hepatocellular neoplasm (most consistent with hepatic adenoma, β-catenin phenotype negative). Specimens of a segment 7/8 lesion demonstrated a small focus on HCC positive for the β-catenin phenotype. The overall interpretation of the specimens was that the tissue represented early HCC without definite evidence of stromal invasion. Ultimately, an angiogram showed multiple hyper-vascular masses. The patient underwent liver transplantation and has been followed for 130 weeks with no evidence of further tumor progression/recurrence. This experience serves as support towards phenotyping adenomas for β-catenin in order to predict those patients with higher risk of developing HCC. Also, this case supports that adenomas with the β-catenin phenotype have a higher risk of malignant transformation. Such a finding reinforces the concept that transplantation should be recommended for the patient population that is unresectable and who is at higher risk of developing HCC. Additionally, further developments in the techniques of genotyping mutations and deletions will further enhance our ability to stratify risk for HCC transformations.