IMAGES IN LIVER TRANSPLANTATION
Liver Transplantation for Giant Hepatic
Parsia A. Vagefi,1,2Helge Eilers,3Annie Hiniker,3and Chris E. Freise1,2
Departments of1Surgery (Division of Transplant Surgery),2Anesthesia, and3Anatomic Pathology,
University of California San Francisco, San Francisco, CA
Received March 16, 2011; accepted March, 24 2011.
A 57-year-old gentleman with a past medical history
significant for Hodgkin’s lymphoma in 1977 (which
required splenectomy, radiation therapy, and chemo-
therapy) was incidentally found to have a large left
lobe liver mass in July 2008 while he was undergoing
computed tomography imaging for presumed nephro-
lithiasis. The mass was approximately 20 cm in its
maximum dimension and proved to be a complex,
heterogeneous mass replacing the entire left lobe of
the liver and encroaching
(Fig. 1A). Biopsy was performed, and the sample was
consistent with an angiomyolipoma (AML) of the liver.
The patient was evaluated for resection, and the
tumor was subsequently deemed to be unresectable
because of the complete involvement of the left and
middle hepatic veins and the partial involvement of
the right hepatic vein. The patient was referred for
transcatheter arterial chemoembolization, which was
unsuccessful in shrinking the mass.
One year later, the patient presented with weight
loss and dyspepsia attributable to his enlarged he-
patic mass causing significant gastric compression,
A photograph shows the explanted liver at the time of transplantation oriented in the same position (ruler 5 15 cm). (C) Hematoxylin
and eosin staining (magnification 340) of the explanted liver shows the normal liver parenchyma next to the AML.
(A) A computed tomography coronal image shows a large left hepatic AML causing caudal displacement of the right lobe. (B)
Abbreviation: AML, angiomyolipoma.
Address reprint requests to Parsia A. Vagefi, M.D., Division of Transplant Surgery, University of California San Francisco, 505 Parnassus
Avenue, Moffitt M-896, Box 0780, San Francisco, CA 94143. Telephone: 415-353-1888; FAX: 415-353-2102;
View this article online at wileyonlinelibrary.com.
LIVER TRANSPLANTATION.DOI 10.1002/lt.22310 Published on behalf of the American Association for the Study of Liver Diseases
LIVER TRANSPLANTATION 17:985-986, 2011
C 2011 American Association for the Study of Liver Diseases.
and he was referred for a liver transplant evaluation.
The United Network for Organ Sharing was petitioned,
and exception points were granted. During his liver
transplant evaluation, the patient was found to have
coronary artery disease requiring the placement of
drug-eluting stents and the initiation of antiplatelet
therapy; thus, his transplant candidacy was post-
poned for approximately 1 year. After cardiac clear-
ance, the patient was placed on the transplant wait
list and accrued exception points for a Model for End-
Stage Liver Disease score of 28; at this point, a liver
from a 50-year-old deceased donor became available.
The patient underwent uncomplicated liver transplan-
tation without the need for venovenous bypass, and
he was discharged home on postoperative day 5. The
liver explant demonstrated a 4.35-kg liver measuring
34.5 cm ? 29 cm ? 8 cm (Fig. 1B). The hepatic mass
measured 24 cm ? 26 cm ? 6 cm. Histological exami-
nation found mature adipose tissue, thick-walled, tor-
tuous vessels without elastic lamina, smooth muscle
arising from the thick-walled vessels, and epithelioid
perivascular cells; all were consistent with a benign
hepatic AML (Fig. 1C). Immunohistochemical staining
for human melanoma black 45 and melan-A con-
firmed the diagnosis.
Hepatic AMLs are rare hepatic mesenchymal neo-
plasms with a demonstrated female predominance.1
Although most remain benign neoplasms, there are
reports of the malignant degeneration of hepatic
AMLs.2Serial imaging can be used to observe patients
with small (<5 cm), asymptomatic tumors that are
biopsy-proven benign AMLs. Surgical management
is recommendedfor symptomatic
Although resection alone allows for the surgical man-
agement of these lesions in the absence of concomitant
liver disease, patients with lesions not amenable to
resection should be referred for liver transplantation.
This case report did not require IRB review by UCSF
1. Petrolla AA, Xin W. Hepatic angiomyolipoma. Arch Pathol
Lab Med 2008;132:1679-1682.
2. Nguyen TT, Gorman B, Shields D, Goodman Z. Malignant
hepatic angiomyolipoma: report of a case and review of
literature. Am J Surg Pathol 2008;32:793-798.
986 VAGEFI ET AL.LIVER TRANSPLANTATION, August 2011