\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[greek,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Hepatic cirrhosis in two patients with neuroblastoma receiving
hematopoietic stem cell transplantation}



\author[1]{Daiki Hori}%
\author[1]{Ryoji Kobayashi}%
\author[2]{Daisuke Suzuki}%
\author[2]{Hirozumi Sano}%
\author[2]{Masato Yanagi}%
\author[2]{Satoru Matsushima}%
\author[2]{Kunihiko Kobayashi}%
\affil[1]{Sapporo Hokuyu hospital}%
\affil[2]{Sapporo Hokuyu Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Hepatic cirrhosis is a very rare complication of hematopoietic stem cell
transplantation (SCT) and of neuroblastoma. We encountered two patients
developing cirrhosis after SCT against neuroblastoma. A 6-year-old boy
who had received allogeneic bone marrow transplantation developed
cirrhosis 10 years after the SCT with the massive upper gastrointestinal
hemorrhage. A 27-year-old man receiving allogeneic cord blood
transplantation against recurrence of neuroblastoma, died of liver
failure due to histological cirrhosis 1 year after the SCT. We could not
detect the definite etiologic candidates of cirrhosis; however, careful
monitoring appears warranted to avoid overlooking the onset and
progression of cirrhosis after SCT.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Hepatic cirrhosis is a very rare complication of hematopoietic stem cell
transplantation (SCT), with estimated cumulative incidences of 0.6\% by
10 years and 3.8\% by 20 years after SCT \textsuperscript{1)}.
Similarly, the complication of cirrhosis with neuroblastoma is rare and
only one report is available that describes hepatic cirrhosis in two
patients with neuroblastoma \textsuperscript{2)}. No previous reports
appear to have described the development of cirrhosis after SCT in
patients with neuroblastoma.

\textbf{Case Descriptions}

Case 1

A 6-year-old boy with no prior history of note presented with a mass
under the right costal margin. Computed tomography (CT) demonstrated a
tumor with huge cysts and partial calcification between the right lobe
of the liver and kidney, arising from the right retroperitoneum (Figure
1A). No evidence of bone marrow infiltration or other metastases was
seen. Open biopsy demonstrated amplified \emph{MYCN} gene and revealed
neuroblastoma of round cell type, poor prognosis group. The tumor was
classified as high-risk group with stage L2 disease based on the
International Neuroblastoma Risk Group Staging System
(INRGSS)\textsuperscript{3)}. He received three courses of chemotherapy
including cyclophosphamide (CPM), vincristine (VCR), pirarubicin (THP),
cisplatin (CDDP), etoposide (VP-16), and ifosfamide. Then he underwent
right segmental liver resection, right nephrectomy, and partial
diaphragm resection due to direct tumor invasion, followed by two
courses of chemotherapy and irradiation with 15 Gy to the entire abdomen
and 30 Gy to the left supraclavicular fossa and posterior mediastinum
under the shielding of the liver and the kidneys. Allogeneic bone marrow
transplantation (BMT) from a sibling was then performed after
myeloablative conditioning with total body irradiation (TBI), VP-16 and
cyclophosphamide (CY). Methotrexate was used for graft-versus-host
disease (GVHD) prophylaxis. Grade I acute GVHD manifested as exanthema
but resolved spontaneously. After BMT, he received additional
chemotherapy with CPM, dacarbazine and VCR. Treatment was completed in 2
years when he was 8 years old. Ten years after that, the patient was
hospitalized due to massive gastrointestinal hemorrhage. Upper
gastrointestinal endoscopy revealed ruptured esophageal varices, and CT
demonstrated portal vein aneurysm with extensive collateral vein
formation (Figure 1B). He met the clinical criteria for hepatic
cirrhosis and portal hypertension, although liver enzymes remained
within normal limits. His severe condition settled and he was
discharged, but the patient committed suicide 1 year after this event at
19 years old, 11 years after BMT.

Case 2

A 24-year-old man with no prior history of note presented with pain in
the lower back and pancytopenia. Bone biopsy revealed neuroblastoma
cells, and CT showed an abdominal mass arising from the right adrenal
gland. Infiltrations into bone marrow and bone throughout the body were
identified. INRGSS high-risk \emph{MYCN} -non-amplified stage M
neuroblastoma was diagnosed. He received 5 courses of chemotherapy with
VCR, CPM, THP and CDDP and underwent autologous peripheral blood SCT
(PBSCT) with myeloablative conditioning comprising busulfan (BU) and CY.
He then underwent tumor resection and irradiation to the whole spine and
right adrenal gland (19.8 Gy), and to the skull, pelvis and femur (5.4
Gy). Secondary aplastic anemia was developed, and oral administration of
cyclosporine (CsA) was initiated. Due to the frequent blood
transfusions, iron overload gradually progressed but rapidly improved by
administration of deferasirox. He was discharged 10 months after the
PBSCT. One and a half years after discharge, bone marrow and bone
recurrence occurred. He received 4 cycles of chemotherapy with
irinotecan, VP-16 and carboplatin, followed by allogeneic cord blood
transplantation (CBT) with myeloablative conditioning of BU, VP-16 and
CY. CsA and methylprednisolone were used for GVHD prophylaxis. Moderate
veno-occlusive disease (VOD)/sinusoidal obstruction syndrome (SOS) was
treated with danaparoid sodium and ursodeoxycholic achieving rapid
improvement. Grade II acute GVHD manifesting as diarrhea was controlled
with additional prednisolone. Cytomegalovirus (CMV) antigenemia was also
well controlled by administration of ganciclovir. From around 50 days
after transplantation, pleural effusion and ascites retention gradually
worsened along with deterioration of renal function. Relapse of
neuroblastoma was negative, but his condition had gradually worsened.
Ten months after CBT, CT showed liver atrophy and marked ascites
retention. Blood Mac-2-binding protein glycosylation isomer index and
the 15-min retention rate of indocyanine green was elevated, both
suggesting development of cirrhosis. Upper gastrointestinal endoscopy
showed no esophageal varices. His general condition continued to worsen,
and he died of liver failure 1 year after CBT, at 29 years old.
Histological examination of needle liver autopsy demonstrated
characteristics of bridging and pericellular fibrosis with architectural
distortion and spotty necrosis, consistent with cirrhotic changes, and
severe hepatocyte damage with slight infiltration of inflammatory cells
(Figure 2A, B). Fibrotic hyperplasia and mild infiltration of
inflammatory cells were also evident around the portal vein. No
histological evidence of GVHD or sinusoidal obstruction was seen. A
definitive histological diagnosis of cirrhosis was made.

\textbf{Discussion}

In our institution, we have over 120 patients receiving SCT against
hematological malignancies and solid tumors in childhood, adolescence or
young adulthood so far. However, we have encountered only two patients
that developed hepatic cirrhosis after SCT, and both suffered from
neuroblastoma. Neither case showed evidence of hepatitis virus infection
including hepatitis C virus (HCV), which has been accepted as the most
frequent cause of cirrhosis \textsuperscript{1)4)}. Treatment,
conditioning before SCT and other characteristics of our two cases
differed markedly from each other except for the underlying disease,
neuroblastoma. Speculation on the involvement of the underlying disease
in the onset of cirrhosis is thus natural. The liver is known as an
organ to which neuroblastoma frequently metastasizes, and a previous
report showed that the frequency of neuroblastoma metastasis to the
liver at the time of diagnosis was 29.6\% \textsuperscript{5)}. However,
since very few patients undergo liver biopsy at diagnosis or during
treatment, and evaluation is usually made only by imaging, the exact
frequency of liver involvement remains unclear. Another speculation
regarding underlying condition is that some congenital predisposition
(such as DNA repair defects, telomere disorders and so on) and
autoimmunity had some impact on massive hepatic damage. Both our cases
had no medical history, family history or congenital malformations that
suspected them. Other possible causes of cirrhosis would be TBI,
VOD/SOS, GVHD, CMV infection and iron overload. Regarding TBI, a
previous report showed that radiation-induced liver disease is unlikely
to occur after a mean liver dose around 30 Gy in conventional
fractionation \textsuperscript{6)}. Neither case was exposed to 30 Gy at
the liver in our patients. Liver damage associated with
VOD/SOS\textsuperscript{1)}, GVHD \textsuperscript{7)}, CMV
infection\textsuperscript{8)} and iron overload \textsuperscript{9)}
could conceivably have contributed to the onset of cirrhosis. In our
cases, however, these conditions would not play a direct inducer of
hepatic cirrhosis since these were properly handled by medications and
achieved clinical improvement. We have made a number of considerations
on the causes or mechanisms that induced hepatic cirrhosis in our two
patients but could not get any definitive conclusion.

To the best of our knowledge, this report represents the first of
hepatic cirrhosis after SCT against neuroblastoma. Since high-risk
neuroblastoma could metastasize to various organs including the liver
and requires multidisciplinary treatment, various severe complications
can occur. Our cases demonstrated that hepatic cirrhosis could develop
at any time after treatment for neuroblastoma including SCT, and careful
life-long monitoring of the liver is warranted to detect cirrhotic
events before progression to hepatic failure.

\textbf{Conflict of Interest Statement}

The authors have no conflicts of interest or funding to disclose.

\textbf{Acknowledgments}

We express our deep appreciation to Dr. Masahiro Fujita (Department of
Clinical laboratory, Sapporo Hokuyu Hospital, Sapporo, Japan) for
valuable assistance in preparing this manuscript.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Strasser SI, Sullivan KM, Myerson D, Spurgeon CL, Storer B, Schoch HG,
  et al. Cirrhosis of the liver in long-term marrow transplant
  survivors. \emph{Blood.} 1999;93(10):3259-66.
\item
  Yule SM, Anderson J. Hepatic Cirrhosis and Portal Hypertension in
  Neuroblastoma. \emph{Pediatric Hematol Oncol} . 2000;17(6):457-61.
\item
  Monclair T, Brodeur GM, Ambros PF, Brisse HJ, Cecchetto G, Holmes K,
  et al; INRG Task Force. The International Neuroblastoma Risk Group
  (INRG) staging system: an INRG Task Force report. \emph{J Clin Oncol}
  . 2009;27(2):298-303.
\item
  Kaito S, Doki N, Hishima T, Takaki Y, Ohashi K. Progressive Hepatic
  Cirrhosis Early After Allogeneic Hematopoietic Stem Cell
  Transplantation in a Patient with Chronic Hepatitis C
  Infection.\emph{Turk J Haematol} . 2019;36(2):130-3.
\item
  Dubois SG, Kalika Y, Lukens JN, Brodeur GM, Seeger RC, Atkinson JB, et
  al. Metastatic sites in stage IV and IVS neuroblastoma correlate with
  age, tumor biology, and survival. \emph{J Pediatr Hematol
  Oncol.}1999;21(3):181-9.
\item
  Guha C, Kavanagh BD. Hepatic radiation toxicity: avoidance and
  amelioration. \emph{Semin Radiat Oncol} . 2011;21(4):256-63.
\item
  Knapp AB, Crawford JM, Rappeport JM, Gollan JL. Cirrhosis as a
  consequence of graft-versus-host disease.
  \emph{Gastroenterology.}1987;92(2):513-9.
\item
  Shimamura M, Murphy-Ullrich JE, Britt WJ. Human cytomegalovirus
  induces TGF-\selectlanguage{greek}β\selectlanguage{english}1 activation in renal tubular epithelial cells after
  epithelial-to-mesenchymal transition. \emph{PLoS Pathog} .
  2010;6(11):e1001170.
\item
  St\selectlanguage{ngerman}ål P. Iron as a hepatotoxin. \emph{Dig Dis.} 1995;13(4):205-22.
\end{enumerate}

\textbf{Figure legends}

\textbf{Figure 1.} CT of Case 1. \textbf{A)} CT on admission showing a
tumor (white arrow) with huge cysts and partial calcification between
the right lobe of the liver and the right kidney. \textbf{B)} CT at the
time of rupturing of esophageal varices revealing portal vein aneurysm
(black arrow) with extensive collateral vein formation.

\textbf{Figure 2.} Histological examination of a needle liver autopsy of
Case 2 (\textbf{A} , 40× magnification; \textbf{B} , 100×
magnification).

Masson trichrome staining of hepatocytes demonstrates characteristic
bridging and pericellular fibrosis with architectural distortion and
spotty necrosis, together with severe hepatocytic damage with slight
infiltration of inflammatory cells. Fibrotic hyperplasia and mild
infiltration of inflammatory cells are also seen around the portal vein.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

