Hepatobiliary and Pancreatic: Hepatocellular carcinoma supplied by portal blood after repeated transcatheter arterial chemoembolization

Abstract

Hepatocellular carcinoma is the fifth most common cancer worldwide and the most common malignant tumor of the liver. Transarterial chemoembolization (TACE) is widely used in the treatment of liver tumors and has become the preferred treatment for patients with hepatocellular cancer who are not suitable for surgical or ablative therapies. The technique is based on the observation that most hepatocellular carcinomas are very vascular tumors with a blood supply that is largely or solely derived from the hepatic artery. The procedure permits the local administration of relatively high concentrations of chemotherapeutic drugs and, in addition, impairs the viability of the tumor by reducing its blood supply. Although TACE can decrease the size of the tumor in up to 70% of patients, there is debate as to the optimal chemotherapeutic drug, the method of embolization and the use of newer products such as drug-eluting beads. Although TACE can be repeated on a number of occasions, a potential issue is that occlusion of the arterial blood supply may lead to nourishment of the tumor by portal blood. An example of this phenomenon is illustrated below. A male, aged 69, was admitted to our hospital because of refractory ascites. He was known to have hepatitis B and had been diagnosed with hepatocellular carcinoma 4 years previously. At the time of diagnosis, hepatic arteriography showed that the tumor was supplied by a branch of the right hepatic artery (Figure 1). He was subsequently treated by TACE and had repeat procedures on five occasions. Prior to admission, ascites had increased in severity with a poor response to diuretics and salt restriction. Blood tests revealed a hemoglobin of 76 g/l with minor changes in liver function tests and a normal serum level of alpha fetoprotein. Peritoneal fluid was a transudate (serum-fluid albumin gradient >1.1 g/dl; 11 g/l) and was repeatedly negative for malignant cells. Arterial portography using a computed tomography scan showed signs of portal hypertension and blood flow to the tumor that contained iodized oil (Figure 2 left). Subsequently, the patient had hepatic arteriography and was treated with a transjugular intrahepatic portosystemic shunt (TIPS). Hepatic angiography was entirely normal but direct portal venography prior to insertion of the shunt revealed tumor staining and a prominent gastric coronary vein (Figure 2 right). The TIPS procedure was associated with improvement in ascites.