Bland Liver Tumor Embolization Complicated by Hepatic Abscess
18 August 2015 (online)
A 64-year-old man with metastatic pancreatic acinar cell carcinoma featuring BRCA2 mutation was referred to the authors' Interventional Oncology (IO) section to discuss treatment options for an enlarging left hepatic mass. In 2008, he underwent resection of locally advanced disease including Whipple procedure with total pancreatectomy, splenectomy, and partial left colectomy. He was placed on adjuvant therapy starting with FOLFOX until he developed dose-limiting toxicity. He then received gemcitabine as monotherapy followed by the addition of Abraxane until 2011. He developed liver metastases in 2012 and was placed on FOLFIRI prior to right hepatectomy with Roux-en-Y hepaticojejunostomy. In 2013, additional metastatic disease developed in his liver remnant and did not respond to carboplatin/taxol, or irinotecan/panitumumab. At the time of consultation, he was receiving irinotecan and panitumumab infusions and PO temozolomide.
In clinic, he was appearing healthy and fully participating in work and activities of daily living (ECOG 0). His postpancreatectomy diabetes was well controlled. He denied hypertension, shortness of breath, chest pain, or other signs/symptoms. Review of imaging demonstrated a single large hypervascular left hepatic lobe mass measuring 12 cm × 10 cm. There were postsurgical changes from the patient's prior right hepatectomy including pneumobilia. The portal vein was patent ([Fig. 1]).
Treatment options including radioembolization and bland embolization were discussed with the patient, as were the potential complications. The consult included a focused discussion on the increased risk of liver abscess in the setting of the patient's bilioenteric anastomosis. Radioembolization was ultimately selected, as the patient preferred the outpatient recovery and lesser potential postembolization syndrome.
Planning mesenteric angiogram with technetium-99m macroaggregated albumin (Tc99m-MAA) was performed. This demonstrated postsurgical changes from prior right hepatectomy, with otherwise standard arterial anatomy. Both mapping angiography and cone–beam computed tomography (CT) confirmed a hypervascular tumor blush in the left lateral lobe, supplied by the segment 3 hepatic artery ([Fig. 2]). The microcatheter tip was positioned in the segment 3 hepatic artery, no arterial supply to extrahepatic structures was identified, and 4 mCi of Tc99m-MAA was administered from this location. SPECT/CT was then performed that demonstrated uptake in the hepatic metastasis. Unfortunately, there was a hepatic to pulmonary shunt fraction of 37.3% ([Fig. 3]). Given the large pulmonary shunt fraction, radioembolization was deferred in favor of bland embolization.
The authors' routine prophylactic antibiotic protocol for patients with bilioenteric anastomoses was prescribed, which included 400 mg moxifloxacin (Avelox, Bayer HealthCare, Seattle, WA) for 3 days prior to the procedure, followed by an additional 17 days post-procedure. This prophylaxis is used for all patients with a disrupted sphincter of Oddi undergoing any arterial or ablative procedure for hepatic malignancy.
Two weeks following mapping angiography, the patient returned for a percutaneous biopsy and bland tumor embolization. Immediately prior to bland embolization, a CT-guided biopsy of the hepatic mass was performed to bank tissue for future molecular testing ([Fig. 4]). Five 18-gauge core samples were acquired. Bland embolization was then performed under fluoroscopic guidance with moderate sedation. As with the mapping, a microcatheter was advanced into the segment 3 hepatic artery supplying the tumor, and embolization was performed with one vial of 100 to 300 µm microspheres and one vial of 300 to 500 µm microspheres (Embosphere, Merit Medical, South Jordan, UT). Postembolization angiography demonstrated elimination of tumor blush ([Fig. 5]). The patient was discharged the following day in good condition with instructions to complete his moxifloxacin course, and plans for a 1-month follow-up CT.
After the embolization, the patient experienced typical symptoms of postembolization syndrome including several days of nausea, vomiting, and low-grade fevers. However, on postprocedure day 9, the patient was admitted to an outside hospital for worsening symptoms and disorientation. The patient was diagnosed with Escherichia coli–related sepsis, and was transferred to the authors' institution. Upon admission his white blood cell (WBC) count was more than 50,000, and a noncontrast CT showed interval development of gas throughout the tumor, with an associated air–fluid level ([Fig. 6]). No other fluid collections or other imaging findings to explain his septicemia were identified. CT-guided drainage was performed with placement of an 8F pigtail drain. Culture of the abscess fluid grew E. coli (a gram-negative facultative anaerobic rod) and Veillonella species (a gram-negative anaerobic cocci), both resistant to ciprofloxacin and levofloxacin. The patient clinically improved after drainage of the abscess and was ultimately discharged with a 14-day course of intravenous piperacillin/tazobactam.
The patient required four additional drain-related procedures including revisions, upsizing, and repositioning, during which communication between the abscess and biliary tree was noted ([Fig. 7]). Prolonged antibiotics and multiple changes in regimen were required to manage recurrent fevers and bacteremia. Final imaging demonstrated an increasing size of the left lobe tumor, with a small residual central fluid collection ([Fig. 8]). Ultimately the drain was removed after 4 months, and the patient was referred to hospice shortly thereafter. Repeat drainage was not required and he died several weeks later.
- 1 Brown DB, Nikolic B, Covey AM , et al; Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for transhepatic arterial chemoembolization, embolization, and chemotherapeutic infusion for hepatic malignancy. J Vasc Interv Radiol 2012; 23 (3) 287-294
- 2 Kim W, Clark TW, Baum RA, Soulen MC. Risk factors for liver abscess formation after hepatic chemoembolization. J Vasc Interv Radiol 2001; 12 (8) 965-968
- 3 Mezhir JJ, Fong Y, Fleischer D , et al. Pyogenic abscess after hepatic artery embolization: a rare but potentially lethal complication. J Vasc Interv Radiol 2011; 22 (2) 177-182
- 4 Song SY, Chung JW, Han JK , et al. Liver abscess after transcatheter oily chemoembolization for hepatic tumors: incidence, predisposing factors, and clinical outcome. J Vasc Interv Radiol 2001; 12 (3) 313-320
- 5 de Baère T, Roche A, Amenabar JM , et al. Liver abscess formation after local treatment of liver tumors. Hepatology 1996; 23 (6) 1436-1440
- 6 Woo S, Chung JW, Hur S , et al. Liver abscess after transarterial chemoembolization in patients with bilioenteric anastomosis: frequency and risk factors. AJR Am J Roentgenol 2013; 200 (6) 1370-1377
- 7 Patel S, Tuite CM, Mondschein JI, Soulen MC. Effectiveness of an aggressive antibiotic regimen for chemoembolization in patients with previous biliary intervention. J Vasc Interv Radiol 2006; 17 (12) 1931-1934
- 8 Geschwind JF, Kaushik S, Ramsey DE, Choti MA, Fishman EK, Kobeiter H. Influence of a new prophylactic antibiotic therapy on the incidence of liver abscesses after chemoembolization treatment of liver tumors. J Vasc Interv Radiol 2002; 13 (11) 1163-1166
- 9 Khan W, Sullivan KL, McCann JW , et al. Moxifloxacin prophylaxis for chemoembolization or embolization in patients with previous biliary interventions: a pilot study. AJR Am J Roentgenol 2011; 197 (2) W343-5
- 10 Spies JB, Rosen RJ, Lebowitz AS. Antibiotic prophylaxis in vascular and interventional radiology: a rational approach. Radiology 1988; 166 (2) 381-387
- 11 Sato K, Lewandowski RJ, Bui JT , et al. Treatment of unresectable primary and metastatic liver cancer with yttrium-90 microspheres (TheraSphere): assessment of hepatic arterial embolization. Cardiovasc Intervent Radiol 2006; 29 (4) 522-529
- 12 Piana PM, Bar V, Doyle L , et al. Early arterial stasis during resin-based yttrium-90 radioembolization: incidence and preliminary outcomes. HPB (Oxford) 2014; 16 (4) 336-341
- 13 Cholapranee A, van Houten D, Deitrick G , et al. Risk of liver abscess formation in patients with prior biliary intervention following yttrium-90 radioembolization. Cardiovasc Intervent Radiol 2015; 38 (2) 397-400
- 14 Geisel D, Powerski MJ, Schnapauff D , et al. No infectious hepatic complications following radioembolization with 90Y microspheres in patients with biliodigestive anastomosis. Anticancer Res 2014; 34 (8) 4315-4321
- 15 Bester L, Salem R. Reduction of arteriohepatovenous shunting by temporary balloon occlusion in patients undergoing radioembolization. J Vasc Interv Radiol 2007; 18 (10) 1310-1314