A liver nodule in a patient transplanted for primary sclerosing cholangitis: an interdisciplinary diagnostic approach

Abstract

We report the case of a 53-year-old female patient who was transplanted with the liver of a 71-year-old male donor for advanced primary sclerosing cholangitis (PSC) and who additionally was diagnosed with a histologically non-classifiable colitis shortly before transplantation. Upon follow-up abdominal ultrasound 4 months after transplantation, a liver lesion measuring 16 × 23 mm was detected in the transplanted liver. This lesion had not been noticed immediately after transplantation and showed a pattern suspicious for malignancy in contrast-enhanced ultrasound. In line, a biopsy revealed the presence of a metastasis of an adenocarcinoma of colorectal origin, suggesting that a colitis- and PSC-associated colorectal cancer of the recipient might have been overseen upon the initial diagnostic workup. Despite two negative follow-up colonoscopies, this hypothesis was further supported by a strong positive signal in projection to the cecum in a subsequently performed PET/CT-scan. However, surgical resection of the right colon that was performed simultaneously with the atypical resection of the liver metastasis only revealed an inflamed diverticulum but no malignancy in the resected colon segment. Moreover, cytogenetic and molecular genetic testing on the resected specimens clearly attributed the metastasis to the male donor. On the one hand, this case underlines the necessity of endoscopic surveillance of patients with PSC and/or inflammatory bowel disease as well as the challenges in diagnosis of colitis-associated cancer. On the other hand, it shows that the acceptance of organs from elderly donors in times of organ shortage might be linked to an increased risk of donor transmitted malignancies.

Zusammenfassung

Wir berichten den Fall einer 53-jährigen Patientin, die aufgrund einer fortgeschrittenen primär sklerosierenden Cholangitis (PSC) sowie einer begleitenden histologisch nicht klassifizierbaren Kolitis mit der Leber eines 71-jährigen Spenders transplantiert wurde. Im Rahmen einer sonografischen Kontrolle 4 Monate nach Lebertransplantation fiel eine 16 × 23 mm große intrahepatische Raumforderung auf, die unmittelbar nach Transplantation nicht vorhanden war und sich in der Kontrastmittelsonografie als malignitätsverdächtig darstellte. Die Punktion ergab die Diagnose einer Metastase eines Adenokarzinoms vom kolorektalen Bautyp, sodass der dringende Verdacht auf ein Colitis ulcerosa- und PSC-assoziiertes kolorektales Karzinom (KRK) der Empfängerin mit Metastasierung in die Transplantatleber vorlag, welches in der initialen Diagnostik übersehen wurde. Dieser Verdacht erhärtete sich trotz 2 negativer Follow-up-Koloskopien durch eine PET-/CT-Untersuchung mit starker Tracer-Anreicherung im ileozökalen Übergang. Es wurde der interdisziplinäre Entschluss zur Lebermetastasenresektion sowie zusätzlich zur Resektion des entsprechenden Kolonbereichs gefasst, welcher allerdings den Befund eines entzündeten Divertikels als Korrelat des PET-/CT-Befunds erbrachte. Letztendlich konnte mittels zytogenetischer und molekulargenetischer Verfahren der einzelnen Resektate die Lebermetastase eindeutig dem männlichen Spender zugeordnet werden. Zum einen unterstreicht dieser Fall die Notwendigkeit und die Besonderheiten der endoskopischen Überwachung und KRK-Diagnostik bei Patienten mit PSC und/oder chronisch entzündlichen Darmerkrankungen. Zum anderen zeigt dieser Fall, dass in Zeiten der Organknappheit und der damit verbundenen zunehmenden Verwendung von Organen älterer Spender die Möglichkeit einer Transmission unerkannter maligner Erkrankungen an den Empfänger zu bedenken ist.

Schlüsselwörter

Kontrastmittelsonografie - Lebertransplantation - erweiterter Organspenderkreis - primär sklerosierende Cholangitis (PSC) - Colitis ulcerosa (CU) - FISH-Analyse

Key words

contrast-enhanced ultrasound - liver transplantation - marginal donors - primary sclerosing cholangitis (PSC) - ulcerative colitis (UC) - FISH

^* These authors contributed equally to this work.

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