The difficult detection of a diffuse tumor growing in a liver transplanted patient.

A 71-year-old woman was transplanted for primary biliary cholangitis (PBC) in 2006, with graft function that was persistently normal during follow-up, as well as normal liver stiffness (FibroscanⓇ) and abdominal doppler ultrasound. Immunosuppression was CNI-based (tacrolimus, blood level=4 µg/L) and everolimus (blood level 2.3 µg/L) added-on in 2014 (diagnosis of PTLD TCD8+, CD 30-, BOM negative). In December 2019, the patient presented with the appearance of a diffuse arthro-myalgia; pancytopenia; abnormal alkaline phosphatase and Gamma-glutamyl-transferase (364/231 IU/L). Thus, a liver biopsy was performed in January 2020. Histology revealed a diffuse hepatic infiltration of high-grade neuroendocrine carcinoma (NEC) showing high proliferation-index (Ki-67 80%) (Fig. 1) [ [1] Colmenero J Tabrizian P Bhangui P Pinato DJ Rodríguez-Perálvarez ML Sapisochin G Bhoori S Pascual S Senzolo M Al-Adra D Herrero JI Petrowsky H Dawson LA Hosni A Kutzke JL Gastaca M Watt KD. De Novo malignancy after liver transplantation: risk assessment, prevention, and management-guidelines from the ILTS-SETH consensus conference. Transplantation. 2022 Jan 1; 106: e30-e45https://doi.org/10.1097/TP.0000000000003998 Crossref PubMed Scopus (16) Google Scholar ]. A disease staging by imaging included: 1-TC-scan showing thoracic-axillary-abdominal adenopathies; an inhomogeneous colliquated lesion (6 cm) in mediastinal region; an inhomogeneous liver graft with multiple hypodense areas and lumpy margins; 2- A PET-TC revealed the presence of high glucose metabolic activity of hetero-productive significance of the mediastinal lesion; multiple lymphadenopathies; diffuse similar activity in the liver and at the medullary level (Fig. 2); 3- EGD: microfoci of neoplastic infiltration of the gastric lamina propria; 4- A Bone marrow aspirate/biopsy showed massive infiltration of NEC, as also was shown by fine-needle aspiration of the mediastinal lesion and axillary lymph node, with probable pulmonary primitivity. The oncological program including mutational characteristics of the neoplasm was started but not concluded after hospital discharge. In fact, at the end of March 2020 the patient developed a severe respiratory failure and died from Covid-19 infection. Fig. 2A. CT Scan showing solid lesion in the upper right paramediastinal region of 6 cm, inhomogeneous, adhering to the mediastinal pleura with hetero-productive appearance. B. PET showing intense and inhomogeneous accumulation of tracer in the liver site of known hetero-productive disease, with more intense and confluent areas, particularly in the II, IV and V segment (SUV max 9.8). C. CT scan with enlarged liver, lumpy outlines, inhomogeneous parenchyma, due to the presence of hypodense areas with blurred edges in the IV-V segment. View Large Image Figure Viewer Download Hi-res image