Bland Liver Tumor Embolization Complicated by Hepatic Abscess

Case Report

A 64-year-old man with metastatic pancreatic acinar cell carcinoma featuring BRCA2 mutation was referred to the authors' Interventional Oncology (IO) section to discuss treatment options for an enlarging left hepatic mass. In 2008, he underwent resection of locally advanced disease including Whipple procedure with total pancreatectomy, splenectomy, and partial left colectomy. He was placed on adjuvant therapy starting with FOLFOX until he developed dose-limiting toxicity. He then received gemcitabine as monotherapy followed by the addition of Abraxane until 2011. He developed liver metastases in 2012 and was placed on FOLFIRI prior to right hepatectomy with Roux-en-Y hepaticojejunostomy. In 2013, additional metastatic disease developed in his liver remnant and did not respond to carboplatin/taxol, or irinotecan/panitumumab. At the time of consultation, he was receiving irinotecan and panitumumab infusions and PO temozolomide.

In clinic, he was appearing healthy and fully participating in work and activities of daily living (ECOG 0). His postpancreatectomy diabetes was well controlled. He denied hypertension, shortness of breath, chest pain, or other signs/symptoms. Review of imaging demonstrated a single large hypervascular left hepatic lobe mass measuring 12 cm × 10 cm. There were postsurgical changes from the patient's prior right hepatectomy including pneumobilia. The portal vein was patent ([Fig. 1]).

Fig. 1 Axial contrast-enhanced CT image demonstrating a large hypervascular hepatic mass in the left lateral segment (black arrows). Pneumobilia is also present (black circle).

Treatment options including radioembolization and bland embolization were discussed with the patient, as were the potential complications. The consult included a focused discussion on the increased risk of liver abscess in the setting of the patient's bilioenteric anastomosis. Radioembolization was ultimately selected, as the patient preferred the outpatient recovery and lesser potential postembolization syndrome.

Planning mesenteric angiogram with technetium-99m macroaggregated albumin (Tc99m-MAA) was performed. This demonstrated postsurgical changes from prior right hepatectomy, with otherwise standard arterial anatomy. Both mapping angiography and cone–beam computed tomography (CT) confirmed a hypervascular tumor blush in the left lateral lobe, supplied by the segment 3 hepatic artery ([Fig. 2]). The microcatheter tip was positioned in the segment 3 hepatic artery, no arterial supply to extrahepatic structures was identified, and 4 mCi of Tc99m-MAA was administered from this location. SPECT/CT was then performed that demonstrated uptake in the hepatic metastasis. Unfortunately, there was a hepatic to pulmonary shunt fraction of 37.3% ([Fig. 3]). Given the large pulmonary shunt fraction, radioembolization was deferred in favor of bland embolization.

Fig. 2 (a) Digital subtraction angiogram and (b) axial cone-beam CT image obtained during mapping angiography by injecting contrast through a microcatheter positioned in the segment 3 hepatic artery (black arrow). The hypervascular hepatic mass in the left lateral segment is seen (white arrows and black arrowheads).

Fig. 3 Anterior planar image from Tc-99m MAA scan. Intrahepatic lung shunt fraction was calculated to be 37.3%. Note the marked uptake in the lungs (roi3).

The authors' routine prophylactic antibiotic protocol for patients with bilioenteric anastomoses was prescribed, which included 400 mg moxifloxacin (Avelox, Bayer HealthCare, Seattle, WA) for 3 days prior to the procedure, followed by an additional 17 days post-procedure. This prophylaxis is used for all patients with a disrupted sphincter of Oddi undergoing any arterial or ablative procedure for hepatic malignancy.

Two weeks following mapping angiography, the patient returned for a percutaneous biopsy and bland tumor embolization. Immediately prior to bland embolization, a CT-guided biopsy of the hepatic mass was performed to bank tissue for future molecular testing ([Fig. 4]). Five 18-gauge core samples were acquired. Bland embolization was then performed under fluoroscopic guidance with moderate sedation. As with the mapping, a microcatheter was advanced into the segment 3 hepatic artery supplying the tumor, and embolization was performed with one vial of 100 to 300 µm microspheres and one vial of 300 to 500 µm microspheres (Embosphere, Merit Medical, South Jordan, UT). Postembolization angiography demonstrated elimination of tumor blush ([Fig. 5]). The patient was discharged the following day in good condition with instructions to complete his moxifloxacin course, and plans for a 1-month follow-up CT.

Fig. 4 Axial noncontrast CT image obtained during percutaneous biopsy of the hepatic mass (white arrows). An 18-gauge core biopsy needle (white arrowheads) was placed coaxially through a 17-gauge guiding needle (black arrowheads) and five core biopsy samples were obtained with CT guidance.

Fig. 5 (a) Digital subtraction angiogram of the segment 3 branch of the left hepatic artery demonstrates a hypervascular tumor blush in the left lateral segment prior to embolization. (b) Digital subtraction angiogram after bland embolization with calibrated microspheres demonstrates no further tumor blush.

After the embolization, the patient experienced typical symptoms of postembolization syndrome including several days of nausea, vomiting, and low-grade fevers. However, on postprocedure day 9, the patient was admitted to an outside hospital for worsening symptoms and disorientation. The patient was diagnosed with Escherichia coli–related sepsis, and was transferred to the authors' institution. Upon admission his white blood cell (WBC) count was more than 50,000, and a noncontrast CT showed interval development of gas throughout the tumor, with an associated air–fluid level ([Fig. 6]). No other fluid collections or other imaging findings to explain his septicemia were identified. CT-guided drainage was performed with placement of an 8F pigtail drain. Culture of the abscess fluid grew E. coli (a gram-negative facultative anaerobic rod) and Veillonella species (a gram-negative anaerobic cocci), both resistant to ciprofloxacin and levofloxacin. The patient clinically improved after drainage of the abscess and was ultimately discharged with a 14-day course of intravenous piperacillin/tazobactam.

Fig. 6 (a) Axial noncontrast CT image obtained 10 days after bland embolization demonstrates interval development of gas throughout the tumor (white arrows). (b) A more cephalad image from the same study demonstrates an air/fluid level (white arrows).

The patient required four additional drain-related procedures including revisions, upsizing, and repositioning, during which communication between the abscess and biliary tree was noted ([Fig. 7]). Prolonged antibiotics and multiple changes in regimen were required to manage recurrent fevers and bacteremia. Final imaging demonstrated an increasing size of the left lobe tumor, with a small residual central fluid collection ([Fig. 8]). Ultimately the drain was removed after 4 months, and the patient was referred to hospice shortly thereafter. Repeat drainage was not required and he died several weeks later.

Fig. 7 Spot radiograph during an exchange of the percutaneous hepatic abscess drain demonstrates a large residual collection communicating with the biliary tree (black arrowheads) which drain into the small bowel across the bilioenteric anastomosis (black arrow).

Fig. 8 Axial contrast-enhanced CT image obtained 4 months after bland embolization demonstrates a large residual enhancing mass (black arrows), with decreased size of intratumoral fluid collection (white arrows) after removal of the percutaneous abscess drain.

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