Effect of antimicrobial protection on tolerance to hepatic chemoembolization with a fibrous collagen carrier

Antibiotic prophylaxis in transcatheter treatment of hepatocellular carcinoma: an open randomized prospective study of oral versus intravenous administration

BACKGROUND

Transcatheter arterial chemoembolization (TACE) and transcatheter arterial infusion chemotherapy (TAI) are increasingly used to treat inoperable liver malignancies. It has not been determined whether standard oral and intravenous administration of antibiotics have different prophylactic effects against post-TACE/TAI infection. We compared the efficacy of oral levofloxacin (LVFX) and intravenous cephazolin (CEZ) in patients receiving TACE/TAI for hepatocellular carcinoma (HCC) using a prospective design.

PATIENTS AND METHODS

One hundred twenty-nine eligible subjects with HCC treated by TACE/TAI were analyzed in this study. Patients were randomly assigned by the envelope method to groups who received either intravenous infusion of CEZ at 2 g/day or oral administration of LVFX at 300 mg/day for 5 days. Laboratory data, changes in antibiotic administration from the standard ones, duration of hospital stay, side effects of antibiotics, and infectious complications were assessed.

RESULTS

There were no significant differences in the WBC counts and serum CRP levels between the groups; there were also no significant inter-group differences in the numbers of infectious and other adverse events.

CONCLUSION

Our study findings suggest that the results of peroral administration of LVFX for the prevention of post-procedure infectious complications in patients receiving TACE/TAI for HCC are not inferior to those of intravenous administration of CEZ.

Liver abscess complicating transcatheter arterial embolization: a rare but serious complication. A retrospective study after 3878 procedures

OBJECTIVES

Liver abscess is one of the complications of transcatheter arterial embolization (TAE) for hepatocellular carcinoma. We studied the clinical features and analysed the incidence, risk factors, helpful clinical clues, culture profiles and predictive factors of post-TAE liver abscess. The influence of abscess development on the evolution of the tumour process was also studied.

METHODS

We retrospectively reviewed records of 3878 TAE procedures performed over a 6 year period.

RESULTS

Ten cases of liver abscess developed in nine patients (eight males and one female). The incidence was 0.26% (10 episodes/3878 procedures). The main clinical presentations included fever (91.7%), chills (50%) and abdominal pain (33.3%). All but one febrile patient presented fever in a recurrent form. The positive culture rates were 41.7% for blood and 83.3% for pus. Gram negative bacteria were found in 80% of blood cultures and 68% of pus cultures. Polymicrobial infections were encountered in 60% of the blood cultures and 70% of pus cultures. Management included antibiotics, drainage and operation. Four patients died due to the direct complications of liver abscess. One patient experienced total tumour resolution after successful treatment for liver abscess. Patients with larger liver abscesses and patients with greater age carried higher mortality rates.

CONCLUSIONS

Liver abscess is a rare complication after TAE for hepatocellular carcinoma. Recurrent fevers after an initial symptom free interval should arouse suspicion of an abscess. The mortality is high and a large abscess and higher age predict an unfavourable outcome. Abscess formation can lead to complete tumour resolution.

Nonsurgical treatment of hepatocellular carcinoma

Given the poor prognosis of HCC and the therapeutic challenge posed by underlying liver cirrhosis, efforts and resources must be directed towards preventive strategies. Return on the investment in such research is likely to be greater than can be expected from treatment of advanced disease.

Perineal abscess after embolization for high-flow priapism

High-flow priapism is unusual and is most often due to blunt perineal trauma with resultant laceration of the cavernosal artery, creating an arteriocavernosal fistula. Although few cases have been reported, the consensus on management appears to be embolization of the fistula with autologous clot, alone or in combination with Gelfoam. We present a case of high-flow priapism treated in this manner. The embolized pseudoaneurysm evolved into an abscess that eventually spread to the perineum. The rarity of this entity and the postprocedural morbidity are reported.

Prevalence of infection following hepatic chemoembolization with cross-linked collagen with administration of prophylactic antibiotics

PURPOSE

The authors present their experience with 494 hepatic chemoembolization (HCE) procedures in 236 patients with administration of a mixture of cross-linked collagen and chemotherapeutic agents. The prevalence of infectious complications was compared in patients who did and did not receive prophylactic administration of antibiotics as part of the HCE procedure.

PATIENTS AND METHODS

Fourteen HCE procedures in nine patients were performed without prophylactic antibiotics (PA). These patients underwent embolization with cross-linked collagen alone or with low-dose cisplatinum. All of the remaining 480 procedures in 227 patients were performed with PA.

RESULTS

One of the nine patients (11%) who did not receive PA experienced fatal sepsis within 24 hours of HCE. Of the 227 patients who did receive antibiotics, six (2.6%) developed hepatic abscess and no fatal sepsis was encountered.

CONCLUSION

Use of PA decreases the prevalence of infectious complications following HCE.

[Palliative therapy of primary liver tumors]

In Europe and North America, primary liver tumors are rare. Resection is the only means of cure, but is possible in only 20-30% of the patients affected, so that in all other patients, i.e. the vast majority, only palliative treatment is possible. In a retrospective analysis we investigated the 68 patients we had treated for hepatocellular or cholangiocellular carcinoma of the liver. In 14 patients resection was possible, while 28 patients were treated by chemoembolization and 26 by intraarterial regional chemotherapy to the liver. There was no difference in tumor stage between the two groups receiving different palliative treatments. The patients in whom resection was performed, in contrast, mostly had less advanced tumors. For chemoembolization we used a mixture of Ethibloc, mitomycin, Adriamycin and cisplatin. Up to 1986, the intraarterial chemotherapy was performed with mitomycin and 5-FU. Since 1986 we have used Adriamycin and cisplatin. The overall median survival time was 8 months: after resection 17 months, after chemoembolization 6.5 months, and after intraarterial chemotherapy 6.5 months. There was a significant difference in survival between patients with tumor stage II and those with tumor stages III and IV. On comparing the survival time achieved with our treatments and that ensuing in the natural course of patients with liver tumor we found no improvement.

Considerable side effects of chemoembolization for colorectal carcinoma metastatic to the liver

The feasibility of one whole liver chemoembolization (CE) procedure with Angiostat, a vasoocclusive collagen, mitomycin, doxorubicin, and cisplatin was evaluated in eight patients with unresectable colorectal carcinoma metastatic to the liver and good performance status. One heavily pretreated patient showed a partial response in the liver lasting 188 days. Five patients had stabilization of the disease for 85-150 days. The side effects of the treatment were considerable with a fatigue syndrome lasting up to eight weeks, chemical and ischemic hepatitis, severe thrombopenia (WHO grade 4 in 2 pts) and icterus being the most disturbing toxicities. We recommend to restrict CE to patients with a life expectancy of more than 4-6 months confined to protocols, which evaluate efficacy, toxicity and influence on quality of life of CE with various cytotoxic drugs. We further suggest to perform staged unilobar CE at 4- to 6-week intervals rather than whole liver CE.