Pulmonary Complication following Drug-Eluting Bead Hepatic Chemoembolization

Abstract

A 70-year-old man with a history of essential hypertension presented to his gastroenterologist with a 6-month history of unintentional weight loss. After an unremarkable colonoscopy, a computed tomographic (CT) scan of the abdomen was performed demonstrating a 6.2-cm arterially enhancing hepatic mass with delayed washout and extension into the hepatic vein ([Fig. 1a], [b]). The patient was found to have no associated liver disease or serologic evidence of viral hepatitis. A biopsy of the mass was performed demonstrating poorly differentiated hepatocellular carcinoma (HCC), and the patient was referred to interventional radiology for locoregional therapy. Prior to liver-directed therapy, imaging demonstrated a small pleural effusion felt to be related to venous invasion and narrowing of inferior vena cava (IVC). The drug-eluting beads transarterial chemoembolization (DEB-TACE) was performed with 100- to 300-µm drug-eluting beads loaded with 75 mg of doxorubicin (LC Beads, BTG, West Conshohocken, PA) followed by 300 to 500 µm “bland” particle (Embosphere; Merit Medical, Salt Lake City, UT) embolization. An angiographic endpoint of 5-beat stasis was reported. No angiographic images were stored demonstrating arteriovenous shunting; however, in retrospect, shunting could have been suspected based on attenuation of caval blood surrounding the tumor on arterial phase imaging on both CT and angiography ([Fig. 1c], [d]). Approximately 48 hours after discharge, the patient presented to his primary care physician with fevers and mild dyspnea. This was attributed to an increased right pleural effusion following DEB-TACE, which was managed conservatively without thoracentesis. The patient's oxygen saturation was incidentally noted to be decreased at 92%; however, patient was judged not to be symptomatic enough to require treatment and as such was discharged from medical care with instructions to follow up if symptoms worsened. The patient improved over the course of the next month, but follow-up imaging demonstrated a minimal response of the treated HCC. After discussion with the patient, repeat DEB-TACE was performed.