The far side of the moon: trans-thoracic minimally invasive resection of local recurrence of hepatocarcinoma following liver transplantation using intraoperative transdiaphragmatic ultrasound: a case report

Background: Liver transplantation (LT) is the best therapeutic strategy in patients with early-stage hepatocellular carcinoma (HCC) and end-stage liver disease. However, cancer recurrence may occur in 15–20% of cases, often configuring a poor prognosis condition. In few cases recurrence arises with a limited pattern, allowing local ablative treatments, including surgical resection, with a potentially curative effect. This is the first report of an extrahepatic nodule resection employing intraoperative ultrasonography through minimally invasive thoracoscopic surgery. Case Description: We here describe the case of a patient with a subdiaphragmatic retrohepatic HCC recurrence following LT treated with percutaneous microwave (MW) ablation and subsequent surgical resection. MW ablation of the nodule resulted in partial response and subsequent computed tomography (CT) demonstrated persistence of the nodule without further metastases development. Surgery was performed through a minimally invasive thoracoscopic approach employing intraoperative ultrasonography with partial success. Follow-up CT scan revealed an additional local recurrence. A further MW ablation procedure led to disease control with no evidence of disease at 2 years follow-up. Conclusions: Local ablative treatments may play a curative role in HCC oligorecurrence following LT. In this context, minimally invasive treatments should be preferred for their safety and lower impact on patients’ general conditions. Intraoperative transdiaphragmatic ultrasonography may be useful to correctly localize the target lesions during minimally invasive surgery.