Liver transplantation for hepatocellular carcinoma with stem cell features in an adult patient

• Hepatocellular carcinoma (HCC) with stem cell features is an uncommon yet distinct variant of HCC. • This subtype represents a particularly aggressive form of hepatocellular carcinoma. • Early liver transplantation should be contemplated for adult patients with these highly aggressive subtypes of hepatocellular carcinoma. A 32-year-old female patient presented with a liver mass of unknown origin. The alpha-fetoprotein was markedly elevated up to 142 300 µg/L. MRI of the liver documented a bulky lobulated lesion in the right liver lobe with diameters of 11.7 × 12 × 12.6 cm with multiple satellite lesions. Staging revealed no extrahepatic metastases. Histological examination was consistent with a hepatocellular carcinoma (HCC) with stem cell features, a rare but distinct subtype of HCC with gene expression pattern similar to fetal hepatoblasts. Because of overlapping features with hepatoblastoma she was treated according to the Pediatric Hepatic Malignancy International Therapeutic Trial protocol and received induction chemotherapy with cisplatin and doxorubicin. Due to persistent involvement of the portal vein, surgical R0 resection was impossible after 6 cycles of chemotherapy, despite radiological downstaging. After multidisciplinary consultation our patient underwent a liver transplantation. Nine months after liver transplantation, a solitary pulmonary metastasis was observed necessitating wedge resection. However, >2 years after liver transplantation, the patient remains recurrence-free according to the latest available data. This is the first report of an adult patient treated for HCC with stem cell features with a liver transplant beyond the Milan criteria. This case demonstrates that early liver transplantation should be considered in adult patients with highly aggressive subtypes of HCC.