Study of severe and rare complications of transarterial chemoembolization (TACE) for liver cancer

Missing a Lipiodol-laden hepatocellular carcinoma?: Silent iatrogenic hepatoduodenal fistula after transarterial chemoembolization: a case report

RATIONALE

Owing to the abundant collateral blood supply to the duodenum, the development of a hepatoduodenal fistula after transarterial chemoembolization (TACE) is an extremely rare complication that usually requires hospitalization and intensive medical intervention. Here, we report a case of a silent hepatoduodenal fistula following TACE.

PATIENT CONCERNS

A 74-year-old man with a history of alcoholic liver cirrhosis and type 2 diabetes. He had undergone a partial hepatectomy due to hepatocellular carcinoma (HCC) 7 years ago. In addition, he had undergone 4 TACEs for the treatment of recurrent HCCs but still had a viable tumor in S4b of the liver, which abuts the duodenal 1st portion.

DIAGNOSES

HCC.

INTERVENTIONS

The patient underwent a 5th TACE and was discharged from the hospital without major adverse events.

OUTCOMES

Follow-up computed tomography scans showed a 2 cm-sized air cavity instead of a compact Lipiodol-laden tumor in S4b, which had shrunk over time. The patient had experienced a fluctuating nonspecific mild fever for 3 months, with improvements in symptoms and laboratory findings following conservative treatment alone.

LESSONS

Hepatic fistulas may arise following TACE for HCCs near the gastrointestinal tract and may be present with nonspecific symptoms. This case suggests that increased efforts should be directed toward achieving selective embolization when treating HCC adjacent to the gastrointestinal tract, with close monitoring required after treatment.

Spectrum of Imaging Findings and Complications After Hepatic Transarterial Chemoembolization for Liver Tumors

ABSTRACT

This study reviews the spectrum of imaging findings and complications after transarterial chemoembolization (TACE) for the treatment of primary liver tumors (hepatocellular carcinoma, cholangiocarcinoma) and liver metastases. The review encompasses a spectrum of imaging criteria for assessing treatment response, including the modified Response Evaluation Criteria in Solid Tumors guidelines, tumor enhancement, and apparent diffusion coefficient alterations.We discuss the expected posttreatment changes and imaging responses to TACE, describing favorable and poor responses. Moreover, we present cases that demonstrate potential complications post-TACE, including biloma formation, acute cholecystitis, abscesses, duodenal perforation, arterial injury, and nontarget embolization. Each complication is described in detail, considering its causes, risk factors, clinical presentation, and imaging characteristics.To illustrate these findings, a series of clinical cases is presented, featuring diverse imaging modalities including computed tomography, magnetic resonance imaging, and digital subtraction angiography.

A Rare Early-Onset Fatal Complication after Transarterial Chemoembolization: A Case Report and Review of the Literature

Transarterial chemoembolization (TACE) is a minimally invasive treatment for liver cancer, often employed as a bridging therapy or destination treatment for non-operable cases. This case report discusses an 82-year-old woman with a large hepatocellular carcinoma (HCC) who underwent elective TACE due to the high surgical risk associated with her tumor size. Unexpectedly, the patient experienced liver rupture 20 h post-procedure, leading to acute surgical intervention. Despite successful hemostasis during surgery, the patient succumbed to progressive multi-organ failure. We aimed to search the PubMed database for documented cases of ruptured HCC after TACE. This study highlights risk factors for spontaneous HCC rupture and specific factors associated with TACE-induced rupture. Transarterial embolization (TAE) is currently favored as the treatment method for spontaneous ruptures, while the optimal therapy for TACE-induced ruptures remains unclear. In conclusion, this case underscores the importance of recognizing the rare complication of HCC rupture post-TACE and the need for personalized risk assessment. While TAE emerges as a primary treatment choice, the lack of consensus necessitates further studies to establish evidence-based approaches for managing this uncommon yet life-threatening complication.

Liver abscess after drug-eluting bead transarterial chemoembolization for hepatic malignant tumors: Clinical features, pathogenesis, and management

AIM

The study aimed to investigate the clinical features, incidence, pathogenesis, and management of liver abscess after drug-eluting bead transarterial chemoembolization (DEB-TACE) for primary and metastatic hepatic malignant tumors.

METHODS

From June 2019 to June 2021, patients with liver abscess after DEB-TACE for primary and metastatic hepatic malignant tumors were reviewed and evaluated at our hospital. Demographic and clinical data, radiological findings, management approaches, and prognosis were retrospectively analyzed.

RESULTS

In total, 419 DEB-TACE procedures were carried out in 314 patients with primary and metastatic liver tumors at our medical center. Twelve patients were confirmed to have liver abscesses after DEB-TACE through clinical manifestations, laboratory investigations, and imaging. In this study, the incidence of liver abscess was 3.82% per patient and 2.86% per DEB-TACE procedure. After percutaneous drainage and anti-inflammatory treatments, 10 patients recovered, and the remaining 2 patients died due to direct complications of liver abscess, such as sepsis and multiple organ failure. The mortality rate of liver abscesses after DEB-TACE was 16.7% (2/12).

CONCLUSION

The incidence of liver abscess after DEB-TACE is relatively high and can have serious consequences, including death. Potential risk factors could include large tumor size, history of bile duct or tumor resection, history of diabetes, small DEB size (100-300 μm). Sensitive antibiotics therapy and percutaneous abscess aspiration/drainage are effective treatments for liver abscess after DEB-TACE.

Imaging of hepato-pancreato-biliary emergencies in patients with cancer

Hepato-pancreato-biliary (HPB) emergencies in patients with cancer encompass an extensive array of various conditions, including primary malignancies that require prompt treatment, associated severe complications, and life-threatening consequences arising from treatment. In patients with cancer, the liver can be affected by chemotherapy-induced hepatotoxicity, veno-occlusive disease, Budd-Chiari syndrome, liver hemorrhage, and other complications arising from cancer therapy with all these complications requiring timely diagnosis and prompt treament. Cholecystitis induced by systemic anticancer therapies can result in severe conquences if not promptly identified and treated. The application of immunotherapy in cancer therapy is associated with cholangitis. Hemobilia, often caused by medical interventions, may require arterial embolization in patients with severe bleeding and hemodynamic instability. Malignant biliary obstruction in patients with biliary cancers may necessitate palliative strategies such as biliary stenting. In pancreatic cancer, patients often miss surgical treatment due to advanced disease stages or distant metastases, leading to potential emergencies at different treatment phases. This comprehensive review underscores the complexities of diagnostic and treatment roles of medical imaging in managing HPB emergencies in patients with cancer. It illustrates the crucial role of imaging techniques, including magnetic resonance imaging, computed tomography and ultrasound, in diagnosing and managing these conditions for timely intervention. It provides essential insights into the critical nature of early diagnosis and intervention in cancer-related HPB emergencies, ultimately impacting patient outcomes and survival rates.

Locoregional Therapies for Primary and Secondary Hepatic Malignancies

Management of hepatic malignancies is a multidisciplinary task with the involvement of hepatologists, medical/surgical/radiation oncologists, transplant surgeons, and interventional radiologists. Patients should be selected for a specific targeted therapy after multidisciplinary consensus. Interventional oncology, with image-guided locoregional cancer therapies, can decrease systemic toxicity without compromising tumoricidal effect.

The impact of liver abscess formation on prognosis of patients with malignant liver tumors after transarterial chemoembolization

Purpose

Liver abscess is a rare and serious complication after transarterial chemoembolization (TACE) for liver cancer; however, its impact on the prognosis is unclear. This retrospective study examined the outcomes of patients with liver abscess formation following TACE for malignant liver tumors to elucidate the impact of liver abscess formation on the prognosis of these patients.

Methods

From January 2017 to January 2022, 1,387 patients with malignant tumors underwent 3,341 sessions of TACE at our hospital. Clinical characteristics of patients at baseline and follow-up were examined, including treatment and outcome of liver abscess, tumor response to the TACE leading to liver abscess, and overall survival time.

Results

Of 1,387 patients, 15 (1.1%) patients with liver abscess complications after TACE resulted in a total of 16 (0.5%) cases of liver abscess after 3,341 TACE sessions (including one patient with two events). After antibiotic or percutaneous catheter drainage (PCD) treatment, all the infections associated with liver abscesses were controlled. In the PCD group, eight patients died before drainage tube removal, one retained the drainage tube until the end of follow-up, and five underwent drainage tube removal; the mean drainage tube removal time was 149.17 ± 134.19 days. The efficacy of TACE leading to liver abscess was evaluated as partial response (18.75%), stable disease (37.5%), and progressive disease (43.75%). Eleven patients died during the follow-up period owing to causes unrelated to infections caused by liver abscesses. The survival rates at 3 months, 6 months, 1 year, and 5 years were 86.7%, 50.9%, 25.5%, and 17%, respectively.

Conclusion

Patients with liver abscess formation following TACE for malignant liver tumors experienced prolonged drainage tube removal time after PCD; while this condition did not directly cause death, it indirectly contributed to a poor prognosis in these patients.

Spinal cord ischemia after transcatheter artery chemoembolization for hepatocellular carcinoma: A case-report

INTRODUCTION

Transarterial hepatic chemoembolization (TACE) has been used to treat unresectable hepatocellular carcinoma and has gained widespread acceptance as a treatment for both primary and secondary hepatic malignancies.

CASE REPORT

We report a case of 78-year-old male patient with chronic hepatitis B, diagnosed with HCC. He underwent the second TACE, and right after the procedure, the patient abruptly developed bilateral lower extremities motor weakness and sensory impairment below the T10 dermatome. Spinal magnetic resonance imaging showed T2-weighted scans showed increased intramedullary signal strength at the T1-T12 level. The patient received supportive care, ongoing rehabilitation, and steroid pulse therapy. The motor strength remained unchanged, but the sensory deficiencies practically disappeared.

CLINICAL DISCUSSION

The hepatic artery injury or decreased flow at the prior TACE site, which causes collateral recruitment, can explain why spinal cord injury following TACE typically happens after the second or third session. It can occasionally result from accidental embolized spinal branches originating from intercostal or lumbar collateral arteries. In our case, we hypothesize the embolism caused the infarction to the spinal cord travel through the connection between the lateral branches of the right inferior phrenic artery and the intercostal arteries, which supply the spinal cord through the anterior spinal artery.

CONCLUSIONS

TACE in rare case can have severe complications. A tailored therapeutic strategy, including consideration of a shunt and selection of the vessels utilized for the Lipiodol infusion prior to TACE, is crucial to achieving an optimal end outcome to avert these significant consequences.

Complications Related to Transarterial Treatment of Hepatocellular Carcinoma: A Comprehensive Review

Currently, various types of transarterial treatments are performed for hepatocellular carcinoma from the early to advanced stages. Its indications and efficacy have been widely investigated. However, procedure-related complications have not been updated in the literature, although new types of transarterial treatments, such as drug-eluting bead transarterial chemoembolization and transarterial radioembolization, are common in daily practice. Herein, a comprehensive literature review was carried out, and complications were organized according to the organs affected and treatment modalities.

Transarterial chemoembolization as an alternative to radioembolization is associated with earlier tumor recurrence than in radioembolization-eligible patients

Introduction

Although transarterial radioembolization (TARE) using yttrium-90 (90Y) is a treatment option for large hepatocellular carcinoma (HCC), a fraction of patients are ineligible for TARE due to high lung shunt fraction (LSF).

Methods

We evaluated if treatment with transarterial chemoembolization (TACE), owing to TARE ineligibility was associated with early HCC progression. Consecutive patients with HCC who were initially TARE candidates were included. Patients with vascular invasion or metastasis were excluded. Primary endpoints were time-to-progression (TTP) and overall survival (OS). The secondary endpoint was objective response rate.

Results

In total, 175 patients were included: 144 underwent TARE (TARE-eligible group) and 31 underwent TACE due to high LSF (TARE-ineligible group). This latter group had larger tumors (13.8 cm vs. 7.8 cm, P<0.001) and higher MoRAL scores (1,385.8 vs. 413.3, P=0.002) than the TARE-eligible group. After balancing baseline characteristics with an inverse probability of treatment weighting (IPTW), the TARE-ineligible group showed shorter TTP [adjusted hazard ratio (aHR)=2.16, 95% confidence interval (CI)=1.14-4.07, P=0.02] and OS (aHR=1.80, 95% CI=0.85-3.80, P=0.12), although the latter was not statistically significant. The TARE-ineligible group had a significantly lower objective response rate than the TARE-eligible group (9.7% vs. 56.9%, P<0.001).

Conclusion

TARE-ineligible patients had larger tumors and higher MoRAL scores than TARE-eligible patients. Treatment with TACE, owing to high LSF, was associated with a shorter TTP even after balancing tumor size and MoRAL scores.

Transradial versus transfemoral approach for TACE: a retrospective study

OBJECTIVE

Transcatheter arterial chemoembolization (TACE) has been widely applied in the treatment of hepatocellular carcinoma (HCC). Our study aimed to investigate the feasibility and efficacy of transradial access as an alternative to transfemoral access for TACE.

METHODS

Patients undergoing TACE were divided into the radial artery (RA) route group or the femoral artery (FA) route group according to the operation approach, namely, transradial or transfemoral access. We retrospectively analysed the clinical characteristics, technical outcomes, clinical efficacy and incidence of adverse events to compare the two technologies for intervention for HCC.

RESULTS

Transradial access was found to achieve superior technical outcomes and clinical efficacy, as the patients in the RA group had a lower rate of hepatic arterial spasm, a higher partial response rate and a lower progression rate than the patients in the FA group according to the mRECIST evaluations. In contrast, the liver function indices and VAS (visual analogue scale) pain scores were consistent across the two groups. Moreover, patients in the RA group had a shorter length of stay than those in the FA group, despite similar hospitalization expenses. The total adverse events were significantly reduced by transradial access for TACE (72.5% vs. 84.1%, P = 0.027).

CONCLUSION

Our study suggested that transradial access is an effective and feasible alternative to transfemoral access for TACE. Large-scale prospective randomized controlled studies are expected.

Pyogenic liver abscess in non-liver cancer patients and liver cancer patients treated with TACE: Etiological characteristics, treatment, and outcome analysis

Clinical, laboratory, and microbiological features, clinical outcomes, and pyogenic liver abscess (PLA) prognosis evaluation in non-liver cancer (Non-LC) and liver cancer patients treated with transarterial chemoembolization (TACE, LC-TACE). Clinical data of 48 consecutive PLA patients from January 2016 to December 2020 were retrospectively analyzed. Mortality between two PLA patient groups were compared, and mortality risk factors were evaluated. A total of 48 PLA patients (31 males and 17 females) from January 2016 to December 2020 met the study's inclusion criteria. There were 32 and 16 patients in the Non-LC and LC-TACE groups, respectively. Positive pus culture rate in the Non-LC group was 87.5% and positive pus culture rate in LC-TACE group was 81.3%. In the Non-LC group, 28 patients improved after treatment, 1 patient did not improve, and 3 patients died during hospitalization, with a 9.4% mortality rate. In the LC-TACE group, nine patients improved after treatment, three patients did not improve, and four patients died during hospitalization, with a 25% mortality rate. The Non-LC group cure time was 37.4 ± 23.1 days, while the LC-TACE group was 91.5 ± 49.7 days. PLA of the Non-LC group and the LC-TACE group were different in terms of pathogenic bacteria and cure time, and so on. A more comprehensive treatment should be considered for PLA after TACE.

Fasudil inhibits hepatic artery spasm by repressing the YAP/ERK/ ETA/ETB signaling pathway via inhibiting ROCK activation

OBJECTIVE

To explore the effect of Fasudil on HA spasm and its underlying mechanism.

METHODS

Rabbits were divided into Sham, Fasudil, and Model groups for experiments. Fasudil was injected into the left medial lobe of the rabbit liver using a 16G lumbar puncture needle through the laparotomic route. The spasm model was established by inserting the catheter sheath into the femoral arteries of rabbits, followed by celiac artery angiography and left HA catheterization with a micro-catheter. Next, the GSE60887 and GSE37924 datasets concerning Fasudil treatment were analyzed. Moreover, immunofluorescence staining was conducted for YAP1 and α-SMA. Finally, Western blotting was performed to examine the expressions of YAP1, ROCK, ERK1/2, ETA, and ETB.

RESULTS

Fasudil could relieve HA spasm. The Go and KEGG pathway analyses revealed that the MAPK signaling pathway and the Hippo signaling pathway were enriched in vasospasm. Besides, GSEA revealed that ROCK was functionally enriched in the MAPK and Hippo signaling pathways. Co-expression analysis revealed that MAPK1 was significantly correlated with YAP1 and MYC, and YAP1 was significantly correlated with ETA and ETB. It was manifested in the results of immunofluorescence staining that the YAP1-positive fluorescence area was significantly decreased after Fasudil treatment. Moreover, Western blotting results showed that Fasudil decreased the expressions of YAP1, RhoA, ROCK, ETA, ETB, and p-ERK1/2. In addition, in-vitro Western blotting revealed that Fasudil suppressed the YAP/ERK/ETA/ETB signaling pathway in the case of HA spasm by inhibiting ROCK activation.

CONCLUSIONS

Fasudil ameliorates HA spasm through suppressing the YAP/ERK/ETA/ETB signaling pathway and the ROCK activation.

Practical utility of liver segmentation methods in clinical surgeries and interventions

Clinical imaging (e.g., magnetic resonance imaging and computed tomography) is a crucial adjunct for clinicians, aiding in the diagnosis of diseases and planning of appropriate interventions. This is especially true in malignant conditions such as hepatocellular carcinoma (HCC), where image segmentation (such as accurate delineation of liver and tumor) is the preliminary step taken by the clinicians to optimize diagnosis, staging, and treatment planning and intervention (e.g., transplantation, surgical resection, radiotherapy, PVE, embolization, etc). Thus, segmentation methods could potentially impact the diagnosis and treatment outcomes. This paper comprehensively reviews the literature (during the year 2012-2021) for relevant segmentation methods and proposes a broad categorization based on their clinical utility (i.e., surgical and radiological interventions) in HCC. The categorization is based on the parameters such as precision, accuracy, and automation.

Recent Trends and In-Hospital Mortality of Transarterial Chemoembolization (TACE) in Germany: A Systematic Analysis of Hospital Discharge Data between 2010 and 2019

(1) Background: Transarterial chemoembolization (TACE) is a minimally invasive procedure, characterized by the selective occlusion of tumor-feeding hepatic arteries, via injection of an embolizing agent and an anticancer drug. It represents a standard of care for intermediate-stage hepatocellular carcinoma (HCC), and it is also increasingly performed in cholangiocarcinoma (CCA), as well as in liver metastases. Apart from the original method, based on intra-arterial infusion of a liquid drug followed by embolization, newer particle-based TACE procedures have been introduced recently. As yet, comprehensive data on current trends of TACE, as well as its in-hospital mortality in Germany, which could help to further improve outcome following TACE, are missing. (2) Methods: Based on standardized hospital discharge data, provided by the German Federal Statistical Office from 2010 to 2019, we aimed at systematically evaluating current clinical developments and in-hospital mortality related to TACE in Germany. (3) Results: A total of 49,595 individual cases undergoing TACE were identified within the observation period. The overall in-hospital mortality was 1.00% and significantly higher in females compared to males (1.12 vs. 0.93%; p < 0.001). We identified several post-interventional complications, such as liver failure (51.49%), sepsis (33.87%), renal failure (23.9%), and liver abscess (15.87%), which were associated with a significantly increased in-hospital mortality. Moreover, in-hospital mortality significantly differed between the underlying indications for TACE (HCC: 0.83%, liver metastases: 1.22%, and CCA: 1.40%), as well as between different embolization agents (liquid embolization: 0.80%, loaded microspheres: 0.92%, spherical particles: 1.54%, and non-spherical particles: 2.84%), for which we observed large geographic differences in their frequency of use. Finally, in-hospital mortality was significantly increased in centers with a low annual TACE case volume (<15 TACE/year: 2.08% vs. >275 TACE/year: 0.45%). (4) Conclusion: Our data provide a systematic overview of indications and embolization methods for TACE in Germany. We identified a variety of factors, such as post-interventional complications, the embolization method used, and the hospitals’ annual case volume, which are associated with an increased in-hospital mortality following TACE. These data might help to further reduce the mortality of this routinely performed local-ablative procedure in the future.

Local Treatments in the Unresectable Patient with Colorectal Cancer Metastasis: A Review from the Point of View of the Medical Oncologist

For patients with isolated liver metastases from colorectal cancer who are not candidates for potentially curative resections, non-surgical local treatments may be useful. Non-surgical local treatments are classified according to how the treatment is administered. Local treatments are applied directly on hepatic parenchyma, such as radiofrequency, microwave hyperthermia and cryotherapy. Locoregional therapies are delivered through the hepatic artery, such as chemoinfusion, chemoembolization or selective internal radiation with Yttrium 90 radioembolization. The purpose of this review is to describe the different interventional therapies that are available for these patients in routine clinical practice, the most important clinical trials that have tried to demonstrate the effectiveness of each therapy and recommendations from principal medical oncologic societies.

Transarterial chemoembolization of hepatocellular carcinoma before liver transplantation and risk of post-transplant vascular complications: a multicentre observational cohort and propensity score-matched analysis

BACKGROUND

Transarterial chemoembolization (TACE) in patients with hepatocellular cancer (HCC) on the waiting list for liver transplantation may be associated with an increased risk for hepatic artery complications. The present study aims to assess the risk for, primarily, intraoperative technical hepatic artery problems and, secondarily, postoperative hepatic artery complications encountered in patients who received TACE before liver transplantation.

METHODS

Available data from HCC liver transplantation recipients across six European centres from January 2007 to December 2018 were analysed in a 1 : 1 propensity score-matched cohort (TACE versus no TACE). Incidences of intraoperative hepatic artery interventions and postoperative hepatic artery complications were compared.

RESULTS

Data on postoperative hepatic artery complications were available in all 876 patients (425 patients with TACE and 451 patients without TACE). Fifty-eight (6.6 per cent) patients experienced postoperative hepatic artery complications. In total 253 patients who had undergone TACE could be matched to controls. In the matched cohort TACE was not associated with a composite of hepatic artery complications (OR 1.73, 95 per cent c.i. 0.82 to 3.63, P = 0.149). Data on intraoperative hepatic artery interventions were available in 825 patients (422 patients with TACE and 403 without TACE). Intraoperative hepatic artery interventions were necessary in 69 (8.4 per cent) patients. In the matched cohort TACE was not associated with an increased incidence of intraoperative hepatic artery interventions (OR 0.94, 95 per cent c.i. 0.49 to 1.83, P = 0.870).

CONCLUSION

In otherwise matched patients with HCC intended for liver transplantation, TACE treatment before transplantation was not associated with higher risk of technical vascular issues or hepatic artery complications.

The role of muscle depletion and visceral adiposity in HCC patients aged 65 and over undergoing TACE

Background

The incidence of hepatocellular carcinoma (HCC) has been increasing among the elderly populations. Trans-arterial chemoembolization (TACE), a widely used first-line non-curative therapy for HCCs is an issue in geriatrics. We investigated the prognosis of elderly HCC patients treated with TACE and determined the factors that affect the overall survival.

Methods

We included 266 patients who were older than 65 years and had received TACE as initial treatment for HCC. We analyzed the skeletal muscle index (SMI) and visceral-to-subcutaneous fat ratio (VSR) around the third lumbar vertebrae using computed tomography scans. Muscle depletion with visceral adiposity (MDVA) was defined by falling below the median SMI and above the median VSR value sex-specifically. We evaluated the overall survival in association with MDVA and other clinical factors.

Results

The mean age was 69.9 ± 4.5 years, and 70.3% of the patients were men. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, 29, 136, and 101 patients were classified as BCLC 0, A, and B stages, respectively, and 79 (29.7%) had MDVA. During the median follow-up of 4.1 years, patients with MDVA had a shorter life expectancy than those without MDVA (P = 0.007) even though MDVA group had a higher objective response rate after the first TACE (82.3% vs. 75.9%, P = 0.035). Multivariate analysis revealed that MDVA (Hazard ratio [HR] 1.515) age (HR 1.057), liver function (HR 1.078), tumor size (HR 1.083), serum albumin level (HR 0.523), platelet count (HR 0.996), tumor stage (stage A, HR 1.711; stage B, HR 2.003), and treatment response after the first TACE treatment (HR 0.680) were associated with overall survival.

Conclusions

MDVA is a critical prognostic factor for predicting survival in the elderly patients with HCC who have undergone TACE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08905-2.

Imaging of acute abdomen in cancer patients

The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.

Transarterial chemoembolization for pulmonary or mediastinal metastases from hepatocellular carcinoma

OBJECTIVE

To evaluate the feasibility, efficacy and safety of transcatheter arterial chemoembolization (TACE) with HepaSphere for patients with pulmonary or mediastinal metastases from hepatocellular carcinoma (HCC).

METHODS

Between June 2009 and January 2018, 14 patients with pulmonary or mediastinal metastases from HCC were treated with TACE with a combination of 1-3 chemotherapeutic drugs followed by HepaSphere embolization. As first end point, local tumor response and adverse events were evaluated after the first session of TACE, with Response Evaluation Criteria In Solid Tumors v. 1.1 and Common Terminology Criteria for Adverse Events v. 4 criteria, respectively. Overall survival was evaluated as secondary end point. TACE was repeated on-demand.

RESULTS

TACE with HepaSphere was well tolerated with acceptable safety profile and no 30 day mortality. 1 month objective response and disease control rate were calculated to be 7.1 and 100%, respectively. Mean tumor size reduction rate was 15.6±9.5% at the first month. Two Grade 3 cytopenia events were seen (14.3 %), however none of the Grade 2 or more post-embolization syndrome was observed. The median overall survival time was 15.0 months and the 1 year, 3 year and 5 year survival rate were, 57.1%, 28.6%, 19.1%, respectively.

CONCLUSION

Early experience showed that the transarterial treatment with HepaSphere is safe and effective treatment for patients with pulmonary or mediastinal metastases from HCC.

ADVANCES IN KNOWLEDGE

Currently, the effects of molecular targeted drugs on HCC metastases are limited and side-effects are relatively frequent. In the present study, transarterial treatment might be a promising treatment for HCC metastasis.

Post-transarterial Chemoembolization Tumor Rupture in a Patient with Autoimmune Hepatitis Cirrhosis and Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) is a generally well-tolerated and safe procedure that is increasingly being used in the management of intermediate-stage hepatocellular carcinoma (HCC). Tumor rupture is a rare major complication of TACE. Predisposing factors for tumor rupture include large tumor size and peripherally located tumors; in cases of HCC in cirrhosis secondary to autoimmune hepatitis (AIH), tumor rupture may occur more frequently because of the phenomenon of peliosis that occurs in AIH leading to higher propensity to rupture. Management of tumor rupture can be surgical or conservative depending on the individual case. We describe the first documented case of tumor rupture post-TACE in a patient with AIH cirrhosis and HCC.

Transarterial chemoembolization with medium-sized doxorubicin-eluting Callisphere is safe and effective for patients with hepatocellular carcinoma

The study aimed to compare the tumor response to and complications of doxorubicin-eluting CalliSphere bead-transarterial chemoembolization (DEB-TACE) using small- and medium-sized beads in patients with hepatocellular carcinoma (HCC) who underwent multiple rounds of oncology therapies. Sixty patients with intermediate stage HCC who had previously received multiple oncology therapies underwent DEB-TACE with CalliSpheres of 100-300 μm (small bead group, n = 34) or 300-500 μm (medium bead group, n = 26) in diameter between October 2016 and December 2018. Adverse events and the response rate of the index tumor based on the modified Response Evaluation Criteria in Solid Tumors at 3 months post-TACE were compared between the groups. The rates of complete response, partial response, stable disease, and progressive disease were 35.4%, 29.4%, 17.6%, and 17.6%, respectively, for the small bead group and 33.1%, 23.1%, 20.8%, and 23.0%, respectively, for the medium bead group, showing no significant between-group differences (P > 0.05). Common Terminology Criteria for Adverse Events version 4.0 grade 3/4 adverse events were reported in 8 patients in the small bead group and in no patients in the medium bead group, showing a significant group difference (P < 0.01). Major complications included 8 events of ischemic hepatitis, 2 of biloma, and 2 of severe liver abscess. DEB-TACE using CalliSpheres of 300-500 μm was associated with a comparable rate of tumor response but lower rate of complications compared with that using CalliSpheres of 100-300 μm for HCC treatment in patients who had already undergone multiple rounds of oncology therapies.

Lipiodol Pneumonitis Following Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

Transcatheter arterial chemoembolization (TACE) is a useful palliative therapeutic modality for hepatocellular carcinoma (HCC). Postembolization syndromes, such as fever, abdominal pain, and elevated liver enzyme levels are commonly known complications of TACE. One post-TACE pulmonary complication, lipiodol pneumonitis, is rarely reported. Lipiodol pneumonitis after TACE appears to be associated with chemical injury due to accidental perfusion of lipiodol to the lung vasculature, promoted by arteriovenous shunts within the hypervascular HCC. Here, we report a 42-year-old man with unresectable HCC and hepatic vein thrombosis. The patient was initially treated with TACE. The following day after TACE, acute respiratory symptoms such as dyspnea and cough developed with decreased oxygen saturation. Chest X-ray and computed tomography showed multiple patches and diffuse ground-glass opacities in both lung fields, suggesting of lipiodol pneumonitis. The patient's condition and radiologic abnormalities subsequently improved after 2 weeks of conservative treatment alone.

Bloodstream Infection and Its Clinical Characteristics and Relevant Factors Associated with Interventional Therapy in a Large Tertiary Hospital: A Six Years Surveillance Study

Background

Interventional therapy has been widely used in the medical field as its advantages of minimally invasive, safe and quick recovery. Bloodstream infection (BSI) is the most common healthcare-associated infections (HAIs) after interventional therapy, but there are few reports about it. This study intends to analyze the clinical characteristics and relevant factors of BSI after six years of interventional therapy in a large tertiary teaching hospital, in order to provide guidances for the prevention and control of BSI after interventional operations.

Methods

The case information of patients with BSI after interventional therapy from 2013 to 2018 were collected through the "real-time monitoring system of healthcare-associated infections". All BSI was determined by the infection control full-time staff and clinicians. Questionnaires were designed to review case by case and register the relevant patient information into a database. A total of 18 relevant factors were counted. Statistical software was used for analysis.

Results

174 cases of BSI occurred in 25401 patients, the incidence was 0.69%, and BSI accounted for 50% of all infected sites. Gram-positive bacteria accounted for 56.05%, coagulase-negative Staphylococcus was the main infectious bacteria. Relevant risk factor analysis showed that hepatocellular carcinoma, had undergone surgery, biliary complications, prophylactic antibiotic, replacement of antibiotics, number of interventional operations, days of prophylactic antibiotic use were the related risk factors associated with BSI (P < 0.05). Multivariate analysis showed that days of prophylactic antibiotic use (OR = 1.586, P < 0.05) and replacement of antibiotics (OR = 13.349, P < 0.05) were the main risk factors associated with the development of BSI.

Conclusions

BSI is the main infection site after interventional surgery. For patients with the risk factors as hepatocellular carcinoma/biliary complications/had undergone surgery etc., the time of prophylactic antibiotic use can be prolonged properly before interventional surgery, and selection of single antibiotic appropriate for use could significantly aid preventive measures to avoid occurrence of BSI.

Angiographic Findings in Patients with Hepatocellular Carcinoma Previously Treated Using Proton Beam Therapy

Given the growing interest in using proton beam therapy (PBT) for hepatocellular carcinoma (HCC), it is possible that transarterial chemoembolization (TACE) could be used for selected patients who have previously undergone PBT. However, these cases can be technically challenging to treat and require appropriate preparation. Thus, we aimed to identify angiographic findings in this setting. We retrospectively identified 31 patients (28 men and 3 women, mean age: 69 years, range: 43–84 years) who underwent hepatic angiography plus TACE or transarterial infusion chemotherapy (TAI) for HCC that recurred after PBT (July 2007 to June 2018). We discovered four angiographic findings, which we speculate were related to the previous PBT. 18 patients experienced recurrence in the irradiated field, and 13 patients experienced recurrence outside the irradiated field. 29 patients underwent TACE and only 2 patients underwent TAI. The mean number of previous PBT treatments was 1.3 ± 0.6 (range: 1–4). The median interval from the earliest PBT treatment to hepatic angiography was 559 days (range: 34–5,383 days), and the median interval from the latest PBT treatment to hepatic angiography was 464 days (range: 34–5,383 days). Abnormal staining of the irradiated liver parenchyma was observed in 22 patients, which obscured the angiographic tumor staining in 4 patients. Development of a tortuous tumor feeder vessel was observed in 13 patients. Development of an extrahepatic collateral pathway was observed in 7 patients. Development of an arterioportal or arteriovenous shunt was observed in 4 patients. Based on these findings, we conclude that PBT was associated with various angiographic findings during subsequent transarterial chemotherapy for recurrent HCC, and familiarity with these findings will be important in developing appropriate treatment plans.

Diffuse biliary peritonitis secondary to rupture of metastatic liver adenocarcinomas after drug-eluting bead transcatheter arterial chemoembolization: a case report

Transcatheter arterial chemoembolization (TACE) has become one of the first-line standard treatments for intermediate-advanced hepatocellular carcinoma, as well as an effective treatment for metastatic hepatic carcinoma. The majority of TACE-related complications are mild and acceptable to patients. Compared with conventional (C)-TACE, drug-eluting bead (DEB)-TACE allows permanent embolization of blood vessels, a slow continuous release of anti-tumour drugs in a locally targeted manner, and reduction of the systemic release of anti-tumour drugs, so that their adverse effects are significantly reduced. The general consensus is that DEB-TACE is safer and better tolerated by patients than C-TACE because serious complications after DEB-TACE are rarely reported. This current case report describes a rare case of diffuse biliary peritonitis secondary to rupture of a hepatic tumour after DEB-TACE. After the procedure, the patient presented with progressively worsening upper abdominal pain. As conventional management methods for the suspected tumour rupture failed, an emergency laparotomy was performed to remove the metastatic mass of differentiated hepatic adenocarcinoma. The patient remains under surveillance with no further complications. In our opinion, although DEB-TACE is safe and rarely has serious complications, caution should be exercised when this method is used to treat tumours that are located close to the liver surface.

Effects of TACE combined with precise RT on p53 gene expression and prognosis of HCC patients

To investigate the effects of transcatheter arterial chemoembolization (TACE) combined with precise radiation therapy (RT) on p53 gene expression and prognosis of patients with hepatocellular carcinoma (HCC). A total of 80 patients with unresectable HCC treated in the First People's Hospital of Qinhuangdao from March 2009 to March 2015 were randomly divided into TACE group (n=40) and TACE + RT group (n=40). Enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of p53 in both groups before and after treatment. The biochemical indexes of liver function [α-fetoprotein (AFP), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT)] were detected. Moreover, adverse reactions were compared between the two groups of patients, the short-term therapeutic effect was evaluated, and effects of two treatment methods on progression-free survival (PFS) and overall survival (OS) of patients were detected. There were no statistically significant differences in clinical data between the two groups of patients (P>0.05). The p53 protein levels were significantly downregulated in both treatment methods, and it was decreased more significantly in TACE + RT group than that in TACE group (P<0.05). Compared with those before treatment, AFP and GGT levels in both groups of patients after treatment were decreased, but the levels of ALT were increased (P<0.05), and TACE + RT group had a better curative effect than TACE group (P<0.05). Besides, the incidence rate of adverse reactions in TACE + RT group (37.5%) was obviously lower than that in TACE group (65%) (P<0.05). The number of patients with stable disease (SD) and progressive disease (PD) and disease control rate (DCR) in TACE + RT group were superior to those in TACE group (P<0.05). The 2-year survival rate and median PFS of patients in TACE + RT group were also significantly better than those in TACE group (P<0.05). In conclusion, TACE combined with RT has a better clinical effect than TACE alone in the treatment of HCC.

The efficacy and safety of long- versus short-interval transarterial chemoembolization in unresectable hepatocellular carcinoma

Background: To compare the efficacy and safety of long- versus short-interval of transarterial chemoembolization (TACE) in unresectable hepatocellular carcinoma (HCC) patients.

Methods: This retrospective analysis enrolled 574 patients with unresectable HCC who underwent at least two sessions of TACE between January 2007 and December 2014. The patients were divided into a short-interval group (SIG) and a long-interval group (LIG) based on the median TACE interval of the first two sessions. Propensity score matching (PSM) identified 476 patients for a comparison of overall survival (OS) and safety.

Results: Before matching, the LIG had a longer OS than the SIG (Median: 12.1 vs. 8.7 months; P = 0.003). After matching, median OS in the SIG and LIG were 9.1 and 14.2 months (P < 0.001). The 1-, 2-, and 3-year survival rates were 37.5%, 17.1%, and 9.9% for SIG and 50.1%, 19.3%, and 11.6% for LIG, respectively. The TACE interval was an independent prognostic factor for OS. The LIG had a longer OS than the SIG in Barcelona Clinic liver cancer (BCLC) stage C patients (Median: 10.2 vs. 5.8 months; P < 0.001), but not in BCLC-A or B. The postoperative adverse rates were similar in matched SIG and LIG patients (29.4% vs. 33.6%, P = 0.324).

Conclusions: A long interval between the first two sessions of TACE resulted in a better OS than a short interval in patients with unresectable BCLC C-stage HCC.

Transcatheter arterial chemoembolization combined with radiofrequency or microwave ablation for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the sixth most common type of malignancy. Several therapies are available for HCC and are determined by stage of presentation, patient clinical status and liver function. Local–regional treatment options, including transcatheter arterial chemoembolization, radiofrequency ablation or microwave ablation, are safe and effective for HCC but are accompanied by limitations. The synergistic effects of combined transcatheter arterial chemoembolization and radiofrequency ablation/microwave ablation may overcome these limitations and improve the therapeutic outcome. The purpose of this article is to review the current literature on these combined therapies and examine their efficacy, safety and influence on the overall and recurrence-free survival in patients with HCC.

Systematic Review and Meta-Analysis of Posttransplant Hepatic Artery and Biliary Complications in Patients Treated With Transarterial Chemoembolization Before Liver Transplantation

BACKGROUND

Hepatic artery complications are feared complications after liver transplantation and may compromise the biliary tract, graft, and patient survival. The objective of this systematic review and meta-analysis was to compare risk of hepatic artery and biliary complications after liver transplantation in patients who underwent neoadjuvant transarterial chemoembolization (TACE) versus no TACE.

METHODS

Comprehensive searches were performed in Embase, MEDLINE OvidSP, Web of Science, Google Scholar, and Cochrane databases to identify studies concerning hepatocellular cancer patients undergoing preliver transplantation TACE. Quality assessment of studies was done by the validated checklist of Downs and Black. Meta-analyses were performed to evaluate the incidence of all hepatic artery complications, hepatic artery thrombosis, and biliary tract complications, using binary random-effect models.

RESULTS

Fourteen retrospective studies, representing 1122 TACE patients, met the inclusion criteria. Postoperative hepatic artery complications consisted of hepatic artery thrombosis, stenosis, and (pseudo)-aneurysms. Preliver transplantation TACE was significantly associated with occurrence of posttransplant hepatic artery complications (odds ratio, 1.57; 95% confidence interval, 1.09-2.26; P = 0.02). No significant association between neoadjuvant TACE and hepatic artery thrombosis alone or biliary tract complications was found.

CONCLUSIONS

Patients treated with TACE before liver transplantation may be at increased risk for development of hepatic artery complications after liver transplantation.

Ischemic Duodenal Ulceration after Transarterial Chemoembolization for Hepatocellular Carcinoma: A Case Report

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a well-established, minimally invasive interventional treatment for nonresectable hepatocellular carcinoma (HCC). Generally, TACE is regarded as safe and effective with a low complication rate. However, remote gastrointestinal ischemia due to the carryover of embolic material into visceral arteries is a rare but serious complication of TACE. In this report, we present a case of duodenal ulceration with contained perforation and severe necrotizing pancreatitis after TACE in a patient with nonresectable HCC and underlying hepatitis C virus associated with Child-Pugh stage B liver cirrhosis. This patient showed, for the first time, complete endoscopic and clinical recovery within 2 months of conservative treatment. Considering the high mortality rate from surgical intervention in all previously reported patients, the significant recovery potential demonstrated by our case suggests conservative treatment with antibiotics and parenteral nutrition combined with close clinical, radiological, and endoscopic monitoring should be considered in all clinically stable patients without signs of peritonism or septic sequelae.

Rupture of Hepatocellular Carcinoma after Transarterial Chemoembolization followed by Massive Gastric Bleeding

Introduction

Transarterial chemoembolization (TACE) is the first-line therapy for patient with unresectable hepatocellular carcinoma (HCC). Although TACE is a generally safe procedure, major complications can be occurred. We describe a patient with rupture of HCC after TACE followed by gastric bleeding.

Case Presentation

An 81-year-old man presented with worsening epigastric pain. He had been diagnosed with multiple HCC with nonalcoholic steatohepatitis and underwent TACE 19 days previously. A contrast enhanced computed tomography (CT) scan of the abdomen showed rupture of an HCC. He was treated nonoperatively and discharged on hospital day 18. Five weeks after TACE, he was emergently admitted with massive hematochezia and shock. A contrast enhanced CT scan demonstrated extrinsic gastric compression by an HCC lesion with extravasation of contrast into the stomach. Emergent upper gastrointestinal endoscopy showed a bleeding gastric ulcer with extraluminal compression which was successfully controlled by hypertonic saline-epinephrine injection. Due to tumor progression, he was discharged for palliative care and died six weeks after TACE.

Conclusion

Rupture of HCC is a life-threatening complication after TACE with mortality rates up to 50%. After treatment of a ruptured HCC, extragastric compression and bleeding can occur due to direct compression by a primary lesion or intraperitoneal dissemination.

Transarterial chemoembolization for unresectable hepatocellular carcinoma: A comparison of the efficacy and safety of 2 embolic agents

The aim of this study was to compare the efficacy and safety of 2 different embolic agents, namely gelatin sponge particle (GSP) and Lipiodol, for transarterial chemoembolization (TACE) of unresectable hepatocellular carcinoma (HCC).We retrospectively reviewed 87 consecutive patients with unresectable HCC who underwent Lipiodol TACE with lobaplatin and 87 consecutive patients with unresectable HCC who underwent GSP TACE with lobaplatin between January 2013 and June 2017 in our institution as the initial treatment. Both groups were compared considering the clinical and laboratory outcomes and imaging findings before and after TACE. Tumor response and adverse events were also evaluated.There was significant difference in the rate of complete and overall response between the groups (P = .029 and .001, respectively), specifically when the tumor size was >5 cm (P = .001). The disease control rate was significantly better in the GSP group than in the Lipiodol group (94.3% vs. 86.4%, P = .011). The response differences in higher stages were significant between the 2 groups (P = .035 and .007, respectively). The grades of adverse events were also significantly different between the groups (P = .000).GSP-as an embolic agent in TACE for HCC-could significantly increase the rate of tumor response 1 month after treatment, especially in large tumors, without any significant increase in severe adverse events, when compared to Lipiodol.

The impact of transarterial chemoembolization induced complications on outcomes after liver transplantation: A propensity-matched study

BACKGROUND

Loco-regional complications of transarterial chemoembolization (TACE) may adversely affect technical aspects of the liver transplantation (LT). This study reviewed the impact of those complications on postoperative outcomes encompassing implications on graft selection.

METHODS

A retrospective, propensity score matching (1:1) analysis accounting for donor and recipient confounders was performed on a dataset of patients undergoing LT for hepatocellular carcinoma. Outcomes of patients who had TACE (TACE-group) were compared with those who did not (NoTACE-group).

RESULTS

A total of 57 matched pairs were analyzed. TACE achieved effective tumor control (Pre-TACE vs Post-TACE; Median: 44 mm [interquartile range: 43-50] vs 17 mm [0-36]; P = .002) on imaging follow-up. TACE group had, at the hepatectomy, higher incidence of ischemia-related complications (adhesions of the necrotic tumor, cholecystitis, and/or bile duct necrosis) (40.4% vs 10.5%; P = .001). Overall major post-LT complications rate (Dindo-Clavien ≥3) were similar (P = .134). Those in the TACE group with donors after circulatory death (DCD) had 4.6% 90-day mortality and 54.3% major complication rate compared to 6.9% and 77.3% (P = .380 and P = .112, respectively).

CONCLUSION

TACE was an effective bridging procedure that may complicate LT inducing ischemic-related complications; nevertheless, it has not shown repercussions on mortality or morbidity after the procedure, even using donors after circulatory death.

Liver abscess caused by Clostridium haemolyticum infection after transarterial chemoembolization for hepatocellular carcinoma: A case report

RATIONALE

Liver abscesses caused by Clostridium species infection are extremely rare.

PATIENT CONCERNS

The authors report the first case of a liver abscess due to Clostridium haemolyticum, which occurred after transarterial chemoembolization (TACE) for hepatocellular carcinoma, in a 76-year-old woman who presented with right upper quadrant pain and fever.

DIAGNOSES

Computed tomography of the abdomen after the second TACE showed an air-filled abscess around a compact, lipiodolized lesion in the right hepatic lobe. Pus culture showed the growth of C haemolyticum.

INTERVENTIONS

Broad-spectrum antibiotics, including piperacillin/tazobactam and metronidazole, were administered, and a percutaneous 10-French pigtail catheter for pus drainage and culture was inserted in the liver abscess.

OUTCOMES

Despite administering intensive treatments, she presented with rapid deterioration in mental status, liver function, and infection markers. She was transferred to the local hospital for palliative conservative treatment.

LESSONS

Clostridia infections, including those involving C haemolyticum, are extremely rare, but should be considered as one of the causative organisms of liver abscess formation after TACE because of its rapid and fatal clinical course.

A Case Series of Liver Abscess Formation after Transcatheter Arterial Chemoembolization for Hepatic Tumors

Background:

Liver abscess is a serious complication following transcatheter arterial chemoembolization (TACE). Much attention has been paid to this condition as it may interfere with the treatment process and result in a poor prognosis of the patient. This study aimed to analyze the causes of liver abscess, a complication, after TACE for hepatic tumors and to summarize management approaches.

Methods:

From June 2012 to June 2014, of 1480 consecutive patients who underwent TACE at our hospital, five patients developed liver abscess after TACE procedures for hepatic tumors. Of the five patients, each receiving conventional TACE, one underwent three sessions, two underwent two sessions, and the remaining two underwent one session of TACE. Demographic and clinical characteristics, together with management approaches and prognosis, were collected through a review of medical records.

Results:

These five patients were confirmed to have post-TACE liver abscess through clinical manifestations, laboratory, and imaging tests. After percutaneous drainage and anti-inflammatory treatments, the symptoms present in four patients with liver abscess significantly improved as evidenced by shrinkage or disappearance of the abscess cavity, and the patients recovered completely after sufficient drainage. The remaining patient experienced recurrent symptoms and abdominal abscess, achieved no significant improvement after treatment, and eventually died of severe infection and multiple organ failures.

Conclusions:

TACE must be implemented with extreme caution to avoid liver abscess. An effective management relies on an early diagnosis, prompt use of sufficient doses of appropriate antibiotics, and active implementation of abscess incision, drainage, and aspiration.

Intraperitoneal metastases after transarterial embolization of hepatocellular carcinoma: An observational study

PURPOSE

Transarterial embolization is frequently used to treat local hepatocellular carcinoma (HCC). While various complications are known to occur following transarterial embolization, only one prior case of peritoneal spread of HCC occurring shortly after transarterial chemoembolization has been reported. We present five cases of peritoneal spread of HCC following transarterial embolization (including bland embolization, conventional transarterial chemoembolization (TACE), and doxorubicin-eluting beads TACE) and identify features common among those cases.

METHODS

Search of electronic radiology reports and images identified five patients with imaging before and after treatment of HCC with transarterial embolization and with newly developed peritoneal metastases after treatment. Various patient demographics and tumor characteristics were noted.

RESULTS

The mean maximal diameter of the treated HCC tumors was 3.7 cm (range 1.4-11.9 cm). Three of the patients had ascites and treated tumors in the posterior right hepatic lobe, and all patients had subcapsular tumors treated with transarterial embolization before developing peritoneal metastases. The mean time from treatment with transarterial embolization to the development of peritoneal metastases was four months.

CONCLUSIONS

Intraperitoneal metastatic disease should be considered a rare but potential complication of transarterial embolization of subcapsular HCC, particularly in patients with ascites and tumors that are in the posterior segments of the right lobe. This potential complication should perhaps be considered when planning transarterial HCC treatment, and radiologists interpreting imaging after transarterial embolization of HCC should assess for peritoneal metastases.

Transarterial chemoembolization using 40 µm drug eluting beads for hepatocellular carcinoma

AIM

To assess the safety and efficacy of transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) using a new generation of 40 μm drug eluting beads in patients not eligible for curative treatment.

METHODS

Drug eluting bead TACE (DEB-TACE) using a new generation of microspheres (embozene tandem, 40 μm) preloaded with 100 mg of doxorubicin was performed on 48 early or intermediate HCC patients with compensated cirrhosis. Response to therapy was assessed with Response Evaluation Criteria in Solid Tumors (RECIST) and modified RECIST (mRECIST) guidelines applied to computed tomography or magnetic resonance imaging. Eleven out of the 48 treated patients treated progressed on to receive liver orthotopic transplantation (OLT). This allowed for histological analysis on the treated explanted nodules.

RESULTS

DEB-TACE with 40 μm showed a good safety profile without major complications or 30-d mortality. The objective response rate of treated tumors was 72.6% and 26.7% according to mRECIST and RECIST respectively. Histological examination in 11 patients assigned to OLT showed a necrosis degree > 90% in 78.6% of cases. The overall time to progression was 13 mo (11-21).

CONCLUSION

DEB-TACE with 40 μm particles is an effective treatment for the treatment of HCC in early-intermediate patients (Barcelona Clinic Liver Cancer stage A/B) with a good safety profile and good results in term of objective response rate and necrosis.

Intrahepatic biloma following transcatheter arterial chemoembolization for hepatocellular carcinoma: Incidence, imaging features and management

Repeat transcatheter arterial chemoembolization (TACE) becomes more challenging for patients with intrahepatic biloma following TACE for hepatocellular carcinoma (HCC). The purpose of this study was to investigate the clinical course, incidence, imaging features and outcome and to explore the reasonable therapy scheme for intrahepatic biloma following TACE for HCC.A total of 4,695 TACE procedures were performed for 1,923 patients with HCC. Twenty patients with intrahepatic biloma following TACE were studied retrospectively. The incidence of intrahepatic biloma was 1.04% in this study. The 20 patients underwent 55 TACE procedures (mean, 2.75). Portal vein invasion was found in half of the patients. Eleven patients developed round solitary or multiple cystic biloma, 6 patients had branched biloma and 3 patients developed both cystic and branched biloma. Percutaneous drainage was applied for 4 patients. One patient underwent partial hepatectomy and one mortality occurred due to progressive biloma and multiple organ failure. Although severe intrahepatic biloma following TACE is rare, the procedure should be performed with caution. Timely and appropriate management, including percutaneous drainage, partial hepatectomy and antibiotic administration should be performed in the case of any signs of infection.

An Imaging and Histological Study on Intrahepatic Microvascular Passage of Contrast Materials in Rat Liver

Background. Lipiodol has been applied for decades in transarterial chemoembolization to treat liver malignancies, but its intrahepatic pathway through arterioportal shunt (APS) in the liver has not been histologically revealed. This rodent experiment was conducted to provide evidence for the pathway of Lipiodol delivered through the hepatic artery (HA) but found in the portal vein (PV) and to elucidate the observed unidirectional APS. Methods. Thirty rats were divided into 5 groups receiving systemic or local arterial infusion of red-stained iodized oil (RIO) or its hydrosoluble substitute barium sulfate suspension (BSS), or infusion of BSS via the PV, monitored by real-time digital radiography. Histomorphology of serial frozen and paraffin sections was performed and quantified. Results. After HA infusion, RIO and BSS appeared extensively in PV lumens with peribiliary vascular plexus (PVP) identified as the responsible anastomotic channel. After PV infusion, BSS appeared predominantly in the PV and surrounding sinusoids and to a much lesser extent in the PVP and HA (P < 0.001). Fluid mechanics well explains the one-way-valve phenomenon of APS. Conclusions. Intravascularly injected rat livers provide histomorphologic evidences: (1) the PVP exists in between the HA and PV, which is responsible to the APS of Lipiodol; and (2) the intrahepatic vascular inflow appears HA-PVP-PV unidirectional without a physical one-way valve, which can be postulated by the fluid mechanics.

Acute pancreatitis as a complication of trans-arterial chemoembolization of hepatocellular cancer-case report and review of literature

Transarterial chemoembolization (TACE) is a therapeutic procedure often performed for hepatocellular carcinoma (HCC). Local complications, though generally uncommon, can arise from arterial ischemia and local cytotoxicity from the chemotherapeutic delivery. We present a case of acute pancreatitis as a rare complication of the TACE procedure along with a review of literature of this uncommon adverse effect.

Role of low-molecular-weight heparins in prevention of thromboembolic complication after transarterial chemoembolization in hepatocellular carcinoma

BACKGROUND AND AIM

Portal vein thrombosis (PVT) is a common complication after transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC). This is the first clinical study to evaluate the role of low-molecular-weight heparins (LMWHs) with TACE in HCC for the prevention of thromboembolism complications (PVT).

PATIENTS AND METHODS

This study was carried out on 40 patients with HCC requiring TACE who presented to the Tropical Medicine Department, Tanta University and Interventional Radiology Department of Ain-Shams University Hospitals starting from April 2015. Patients were divided in two groups: group I included 20 patients with HCC treated by TACE only. Group II included 20 patients with HCC treated by TACE and an adjuvant dose of LMWH. Radiological assessment of efficacy of procedure and detection of PVT as a complication was performed using ultrasound abdomen and pelvis and triphasic spiral computed tomography with contrast.

RESULTS

This study was carried out on 40 patients with HCC requiring TACE who presented to the Tropical Medicine Department of Tanta University and Interventional Radiology Department of Ain-Shams University Hospitals. The incidence of PVT after TACE was higher in group I than group II, with seven cases in group I and only one case in group II.

CONCLUSION

LMWH with TACE in HCC is strongly recommended for prevention of thromboembolism complications (PVT). However, larger randomized-controlled studies are needed to confirm these obvious findings.

Intravascular Lipiodol Presenting as an Atrial Mass

A 68-year-old woman, previously treated with embolization of the thoracic duct with Lipiodol (an ethiodized oil injection) and cyanoacrylate glue (a topical tissue adhesive), was admitted with an asymptomatic mass in the inferior vena cava (IVC) and right atrium. The mass was surgically removed, and pathologic analysis revealed a Lipiodol-containing thrombus. To our knowledge, this is the first clinicopathologic report of Lipiodol-induced thrombus presenting as an intracavitary mass.