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From the question on page 1046
Figure 1 shows a 2×4 cm lesion situated 15 cm distal to the duodenal–jejunal flexure. The H&E‐stained section (fig 2A) shows a poorly differentiated large cell neoplasm at the bottom of an ulcer. Immunochemical analysis (fig 2B) shows strong cytoplasmic positivity for hepatocyte‐specific antigen (Hepar 1) characteristic of hepatocellular carcinoma (HCC). A diagnosis of HCC recurrence within the small bowel was made. The patient subsequently underwent small bowel resection of this lesion, and remains well 1 year after surgery.
Liver transplantation is a recognised treatment for HCC occurring in cirrhotic livers. Recent British Society of Gasteroenterology guidelines (2003) recommend orthotopic liver transplant (OLT) for patients with small tumours (<5 cm in the case of a single nodule, or up to three lesions 3 cm), in whom there is a favourable outcome; however, tumour recurrence after OLT is common if lesions are >5 cm in diameter or if there is vascular invasion, especially of the portal system. When surgical treatment is not possible, percutaneous ethanol injection and chemoembolisation can be used. After OLT, HCC metastases have been described in the adrenal glands, bones and lungs. The level of immunosuppression is also known to affect tumour growth rates. Treatment involves resection of the lesion, if possible. This is the first recorded case of small bowel metastases from HCC after liver transplantation.