Sloughing of Intraductal Tumor Thrombus of Hepatocellular Carcinoma after Transcatheter Chemoembolization Causing Obstructive Jaundice and Acute Pancreatitis

Editor: A 69-year-old man with liver cirrhosis as a result of hepatitis C virus was admitted to our department. He had a history of surgical resection of hepatocellular carcinoma (HCC) 6 years earlier. Thereafter, two new foci of HCC developed and each was treated with a combination of transcatheter chemoembolization (TACE) and radiofrequency (RF) ablation. At the current admission, another tumor with a diameter of 1.7 cm had developed in the periphery of the medial segment. The patient was admitted in anticipation of RF ablation of this tumor under computed tomographic (CT) fluoroscopic guidance. Our institution does not require an institutional review board approval for retrospective reports such as this. Plain CT images for targeting immediately before RF ablation showed dilation of the intrahepatic bile duct in the left lobe and soft tissue density within the expanded left hepatic duct as the causes of biliary dilation. Because we speculated that cholangitis may possibly develop after RF ablation of the liver with biliary dilation, the scheduled RF ablation was cancelled. Laboratory data obtained the same day showed serum total bilirubin level of 2.18 mg/dL (normal range, 0.33–1.28 mg/dL). Dynamic CT and magnetic resonance imaging were subsequently performed to evaluate the mass within the left hepatic duct. In addition to the tumor in the medial segment, a hypervascular tumor 3.2 cm in diameter directly adjacent to the left hepatic duct was demonstrated in the lateral segment. The mass within the left hepatic duct did not enhance after contrast medium administration, likely indicating hemobilia caused by hemorrhage from the tumor in the lateral segment invading into the left hepatic duct. Six days later, the serum total bilirubin level returned to the previous level and repeat CT images showed that biliary dilation substantially improved, accompanied by spontaneous resolution of hemobilia. Because of limited hepatic function, the patient was not a suitable candidate for surgical resection. RF ablation was also inappropriate because the tumor in the lateral segment involved the left hepatic duct. Therefore, it was selected to perform TACE. On hepatic arteriography, the tumor in the medial segment was supplied by the medial segmental artery and the tumor in the lateral segment was supplied mainly by a branch of the lateral segmental artery. To reduce the possible risk of hepatic failure, hepatic abscess, and biloma after TACE, we performed superselective embolization of each tumor. A microcatheter (Renegade; Boston Scientific, Natick, MA) was selectively introduced into the arteries supplying each tumor, and TACE was performed with injection of a mixture of 1.2 mL iodized oil (Lipiodol; Laboratoire Andre Guerbet, Aulnay-sous-Bois, France) and 12 mg epirubicin (Kyowa-Hakko, Tokyo, Japan), followed by gelatin sponge particles, for the tumor in the medial segment. The tumor in the lateral segment was then treated in the same fashion, but with 0.8 mL iodized oil and 8 mg epirubicin before administration of gelatin sponge particles. On plain CT images immediately after TACE, part of the iodized oil accumulation in the tumor in the lateral segment seemed to protrude into the left hepatic duct (Figure, part a) and dense iodized oil accumulation was seen in the entire tumor in the medial segment (Figure, part a). No immediate complications occurred and the patient was discharged 10 days after TACE. Eighteen days after TACE, the patient returned to our department because with jaundice and severe back pain. Laboratory data on admission showed markedly increased serum total bilirubin and amylase levels of 8.03 mg/dL and 1,000 IU/L (normal range, 38–125 IU/L), respectively. On dynamic CT images, marked dilation of the intrahepatic and common bile duct was demonstrated. Iodized oil accumulation within the left hepatic duct was no longer visible (Figure, part b), and at the bottom of the common bile duct was a high-density deposit (Figure, part c), which was believed to represent sloughed tumor with iodized oil accumulation and the cause of biliary obstruction. Subsequent endoscopic examination revealed the oral protrusion markedly expanding and the sloughed tumor obstructing the ampulla of Vater and protruding into the lumen of the duodenum (Figure, part d). Endoscopic sphincterotomy was then performed and two pieces of tumor migrated into the duodenum. Immediately after the endoscopic therapy, the patient’s back pain resolved. The serum amylase level decreased promptly and returned to normal level 2 days later. The serum total bilirubin level gradually decreased and returned to baseline level 1 month after the endoscopic therapy. Although tumor thrombus into the portal vein is a common feature in the development of HCC, intraductal tumor involvement is not as widely recognized. Kojiro et al (1) reported 24 cases of HCC with prominent tumor growth in the bile duct among 259 autopsy and surgical cases, with a prevalence of approximately 9%. Intraductal tumor is usually associated with large HCC with volumes of more than 40% of the whole liver (1) and associated with varying degree of jaundice at admission or during the course of the disease (1–3). HCC with intraductal tumor involvement is DOI: 10.1097/01.RVI.0000200055.74822.ED Letters to the Editor