LAUSR

Figure 1. --Q2 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 Dear Editors: Recurrence rates in hepatocellular carcinoma (HCC) patients selected for liver transplantation have drastically improved after the Milan criteria were established. However, about 10% of these patients still experience a recurrence within 5 years. For these patients, systemic therapy with sorafenib often remains the only option available. However, sorafenib treatment is associated with only a modest improvement of survival and its employment is limited by untoward effects often determining treatment discontinuation (see the recently published paper by Bruix et al for review). Recently, immune checkpoint modulators, such as the PD1 inhibitor nivolumab, have been investigated with encouraging results for the therapy of HCC. Nevertheless, fear of organ rejection upon treatment with this immunostimulatory drug has prevented thus far its use after liver transplantation. Here, we report the case of a 41-year-old male liver transplant recipient who, upon HCC recurrence, received 15 cycles of nivolumab without signs of organ rejection or treatment-related liver failure. This patient, with iatrogenic chronic hepatitis C virus and human immunodeficiency virus infections and liver cirrhosis, was diagnosed with HCC and underwent liver transplantation 16 months thereafter. Recurrence of HCC was diagnosed and confirmed histologically 11 months after transplantation. Intrahepatic lesions were initially treated by transarterial chemoembolization and microwave ablation. An adrenal gland metastasis was resected surgically. However, follow-up imaging showed several new intrahepatic and mesenterial metastatic lesions not amenable to further local treatment. Nevertheless, the patient’s overall performance status and liver function remained excellent. Sorafenib treatment, which before transplantation had been poorly tolerated and had not prevented disease progression, was declined by the patient. By that time, the interim results of the phase I/II study of nivolumab in patients with advanced HCC had been published, showing promising response rates (19%) and, in a few patients (5%), a complete remission. Thus, rescue treatment with nivolumab was considered. The patient and his family were thoroughly informed about the potential risks of an off-label treatment with an immunostimulator, including transplant rejection and fatal liver failure.