SESSION TITLE: Once in a Lifetime Pleural CasesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: Transarterial chemoembolization (TACE) is an important non-surgical option in the treatment of hepatocellular carcinoma (HCC) and spontaneous HCC rupture. Pulmonary complications of TACE are typically vascular or parenchymal in etiology. We present a case with pleural involvement and empyema directly related to a TACE procedure.CASE PRESENTATION: The patient is a 70-year-old male with hepatitis C cirrhosis complicated by HCC of the right hepatic dome, who was admitted with right upper abdominal pain. Contrast-enhanced computed tomography (CT) scan showed a complex subcapsular fluid collection concerning for rupture of the HCC lesion. TACE was performed with doxorubicin-loaded embolization beads. After embolization, there was persistent patency of a subsegmental vessel with portal arterial shunting which could not embolized, but no extravasation. The patient did well and was discharged. Nine days later, he was readmitted with acute hypoxemic respiratory failure and leukocytosis of 24 k/uL. Imaging revealed a loculated right pleural effusion with the exophytic HCC abutting an intact right diaphragm. Tube thoracostomy drained grossly purulent fluid, with pleural fluid WBC > 150,000/uL, 96% polymorphonuclear neutrophils (PMNs), LDH > 1200 U/L, glucose 52 mg/dl and triglycerides of 50 mg/dl. Grossly purulent fluid continued to drain and repeat pleural fluid analysis three days later was similar with pleural fluid WBC > 150,000/uL, 97% PMNs. No organisms were isolated on either culture. Pleural fluid cytology was negative for malignancy but showed microspheres consistent with TACE beads (Image 1). He recovered with continued pleural drainage and an extended course of antimicrobials.DISCUSSION: TACE is a valuable tool for the treatment of HCC and spontaneous HCC rupture(1). Pulmonary complications occur infrequently, with symptoms in < 5%, and pulmonary oil embolism the most common event (0.05 – 9%) due to intravascular spread of the oil beads and chemotherapeutic agent to the lung vasculature via arteriovenous shunts in the tumor. Acute lung injury, inflammatory pneumonia and pleuritis are even less frequent, reported mostly in case reports. Pleural effusions related to TACE beads typically occur in the setting of lung injury and pleuritis(2). Isolated pleural effusions are exceedingly rare with only one reported case of empyema after TACE which was the result of an open diaphragmatic defect and pleural contamination, unlike our case where the diaphragm was grossly intact on imaging studies(3). The exact mechanism of TACE bead translocation to the pleura space in our case is unclear but could be through microscopic diaphragmatic defects or hematogenous spread.CONCLUSIONS: This is the first reported case of pleuritis, and empyema attributed to TACE with a grossly intact diaphragmatic border and should be one of the considerations in patients with pulmonary symptoms following TACE.Reference #1: Xu X, Chen C, Liu Q, Huang X. A Meta-analysis of TAE/TACE Versus Emergency Surgery in the Treatment of Ruptured HCC. Cardiovasc Intervent Radiol. 2020 Sep;43(9):1263-1276. doi: 10.1007/s00270-020-02514-5. Epub 2020 May 21. PMID: 32440961.Reference #2: Nhu QM, Knowles H, Pockros PJ, Frenette CT. Pulmonary complications of transcatheter arterial chemoembolization for hepatocellular carcinoma. World J Respirol. 2016;6(3):69-75. doi:10.5320/WJR.v6.i3.69Reference #3: Sur, Young & Won, Je & Wang, Hee-Jung & Kim, Jinoo. (2015). A Rare Case of Empyema Developed after Transarterial Chemoembolization for Hepatocellular Carcinoma. Journal of the Korean Society of Radiology. 72. 33. 10.3348/jksr.2015.72.1.33.DISCLOSURES: No relevant relationships by Adam BrownsteinNo relevant relationships by Jessica ChannickStock Holder relationship with Merck Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock HolderStock holder relationship with Amgen Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock HolderStock Holder relationship with GlaxoSmithKline (GSK) Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock HolderStock holder relationship with Pfizer Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock holderStock holder relationship with XOMA Please note: $1001 - $5000 by Guy Soo Hoo, value=Stock holderNo relevant relationships by Chad WilcoxNo relevant relationships by Jin Zhong SESSION TITLE: Once in a Lifetime Pleural Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Transarterial chemoembolization (TACE) is an important non-surgical option in the treatment of hepatocellular carcinoma (HCC) and spontaneous HCC rupture. Pulmonary complications of TACE are typically vascular or parenchymal in etiology. We present a case with pleural involvement and empyema directly related to a TACE procedure. CASE PRESENTATION: The patient is a 70-year-old male with hepatitis C cirrhosis complicated by HCC of the right hepatic dome, who was admitted with right upper abdominal pain. Contrast-enhanced computed tomography (CT) scan showed a complex subcapsular fluid collection concerning for rupture of the HCC lesion. TACE was performed with doxorubicin-loaded embolization beads. After embolization, there was persistent patency of a subsegmental vessel with portal arterial shunting which could not embolized, but no extravasation. The patient did well and was discharged. Nine days later, he was readmitted with acute hypoxemic respiratory failure and leukocytosis of 24 k/uL. Imaging revealed a loculated right pleural effusion with the exophytic HCC abutting an intact right diaphragm. Tube thoracostomy drained grossly purulent fluid, with pleural fluid WBC > 150,000/uL, 96% polymorphonuclear neutrophils (PMNs), LDH > 1200 U/L, glucose 52 mg/dl and triglycerides of 50 mg/dl. Grossly purulent fluid continued to drain and repeat pleural fluid analysis three days later was similar with pleural fluid WBC > 150,000/uL, 97% PMNs. No organisms were isolated on either culture. Pleural fluid cytology was negative for malignancy but showed microspheres consistent with TACE beads (Image 1). He recovered with continued pleural drainage and an extended course of antimicrobials. DISCUSSION: TACE is a valuable tool for the treatment of HCC and spontaneous HCC rupture(1). Pulmonary complications occur infrequently, with symptoms in < 5%, and pulmonary oil embolism the most common event (0.05 – 9%) due to intravascular spread of the oil beads and chemotherapeutic agent to the lung vasculature via arteriovenous shunts in the tumor. Acute lung injury, inflammatory pneumonia and pleuritis are even less frequent, reported mostly in case reports. Pleural effusions related to TACE beads typically occur in the setting of lung injury and pleuritis(2). Isolated pleural effusions are exceedingly rare with only one reported case of empyema after TACE which was the result of an open diaphragmatic defect and pleural contamination, unlike our case where the diaphragm was grossly intact on imaging studies(3). The exact mechanism of TACE bead translocation to the pleura space in our case is unclear but could be through microscopic diaphragmatic defects or hematogenous spread. CONCLUSIONS: This is the first reported case of pleuritis, and empyema attributed to TACE with a grossly intact diaphragmatic border and should be one of the considerations in patients with pulmonary symptoms following TACE. Reference #1: Xu X, Chen C, Liu Q, Huang X. A Meta-analysis of TAE/TACE Versus Emergency Surgery in the Treatment of Ruptured HCC. Cardiovasc Intervent Radiol. 2020 Sep;43(9):1263-1276. doi: 10.1007/s00270-020-02514-5. Epub 2020 May 21. PMID: 32440961. Reference #2: Nhu QM, Knowles H, Pockros PJ, Frenette CT. Pulmonary complications of transcatheter arterial chemoembolization for hepatocellular carcinoma. World J Respirol. 2016;6(3):69-75. doi:10.5320/WJR.v6.i3.69 Reference #3: Sur, Young & Won, Je & Wang, Hee-Jung & Kim, Jinoo. (2015). A Rare Case of Empyema Developed after Transarterial Chemoembolization for Hepatocellular Carcinoma. Journal of the Korean Society of Radiology. 72. 33. 10.3348/jksr.2015.72.1.33. DISCLOSURES: No relevant relationships by Adam Brownstein No relevant relationships by Jessica Channick Stock Holder relationship with Merck Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock Holder Stock holder relationship with Amgen Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock Holder Stock Holder relationship with GlaxoSmithKline (GSK) Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock Holder Stock holder relationship with Pfizer Please note: $5001 - $20000 by Guy Soo Hoo, value=Stock holder Stock holder relationship with XOMA Please note: $1001 - $5000 by Guy Soo Hoo, value=Stock holder No relevant relationships by Chad Wilcox No relevant relationships by Jin Zhong