S2518 A Unique Case of Radio-Embolization-Induced Liver Disease (REILD)

Abstract

INTRODUCTION: Trans Arterial Radio-Embolization (TARE) is a form of selective radiation therapy used for the treatment of primary and metastatic hepatic cellular cancer (HCC) that involves delivering yttrium 90 (Y90) microspheres intra-arterially to target the tumor cells. Postradioembolization syndrome, hepatic dysfunction with deranged liver enzymes, vascular injury, etc. are the reported complications after TARE. Radio-Embolization Induced Liver Disease (REILD) characterized by ascites, weight gain, and elevated liver enzymes in the absence of tumor progression has been noticed with the incidence of 0–5% within 2 weeks to 4 months after TARE. Herein we report a unique case of REILD in a patient with abdominal distension 1 month after therapy treated with oral prednisone. CASE DESCRIPTION/METHODS: 75-year old female with a history of obesity, NAFLD presented with abdominal distension for last 1 month. She was diagnosed with HCC 3 months ago by histopathology of the right hepatic lobe lesion that was found in MRI of the abdomen (Figure#1). She had 2 sessions of TARE with Y90 one month prior. Laboratory results showed an increase in liver enzymes as shown in Table 1. CT scan of the abdomen showed slight increase in the size of right hepatic lobe lesion measuring 6 cm with the resolution of left lobe lesion (Figure 2). US of the abdomen revealed the same mass and new-onset moderate ascites. Ascitic fluid findings were consistent with portal hypertension. MRCP of the abdomen and US duplex hepatic and portal vessels were negative for biliary obstruction and veno-occlusion respectively. A provisional diagnosis of REILD was made, and oral prednisone was started. Her liver enzymes trended down over the course of five days suggestive of REILD. However, hospital course complicated by hepatorenal syndrome requiring dialysis. DISCUSSION: REILD is an uncommon side effect after RE. The absorbed dose in non-tumor parenchyma and reduced functional reserve (cirrhosis / previous treatments) are the key factors in predicting the development of liver injury. Treatment is mainly supportive, including avoidance of hepatotoxic agents and reduction of excessive extracellular volume. Medications like ursodeoxycholic acid and methylprednisolone combined together has showed to improve liver enzymes. However, no definitive treatment guidelines are formulated. It is warranted to formulate guidelines for identifying high-risk population and their treatment as RE is gaining more popularity with only increasing cases of REILD.Figure 1.: MRI of the abdomen without contrast at the time of diagnosis demonstrating right hepatic lobe mass measuring 5.6 × 5.7 × 5.0 cm.Figure 2.: CT of the abdomen and pelvis showing slight interval increase in size of right hepatic lobe mass measuring 6 cm and moderate ascites.Table 1.: Trend of Liver enzymes and creatinine during hospitalization