Limits...
Delayed intratumoral hemorrhage after drug-eluting bead transarterial chemoembolization for hepatocellular carcinoma.

Shiozawa K, Watanabe M, Ikehara T, Ogino Y, Umakoshi T, Matsukiyo Y, Kogame M, Matsui T, Kikuchi Y, Igarashi Y, Sumino Y - Case Rep Oncol (2014)

Bottom Line: The cause of the symptom may have been DEB-TACE-associated intratumoral hemorrhage.Incomplete embolization might be the cause of the intratumoral hemorrhage experienced by this case presenting a few risks.To obtain the therapeutic effect of DEB-TACE while preventing the adverse events, it may be important to understand the characteristics of the beads and to apply the appropriate embolization to each individual case.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Medical Center, Omori Hospital, Tokyo, Japan.

ABSTRACT
Transarterial chemoembolization (TACE) using a drug-eluting bead (DEB-TACE) for hepatocellular carcinoma (HCC) is a new treatment method. We report on a case of delayed intratumoral hemorrhage after DEB-TACE. An 81-year-old male with hepatitis C virus-related cirrhosis was diagnosed with a HCC of 35 mm in diameter in S5 detected by dynamic computed tomography (CT) and contrast-enhanced ultrasonography (CEUS). DEB-TACE with DC Bead (®) and epirubicin hydrochloride was performed because the patient declined to undergo surgical resection. The treatment was completed, and the course after DEB-TACE was favorable. However, right hypochondriac pain suddenly developed about 1 month after DEB-TACE. Unenhanced CT showed an increase of the tumor diameter and intratumoral high-intensity area, which was not enhanced in the arterial phase. CEUS performed at the time of right hypochondriac pain (5 weeks after DEB-TACE) showed nonenhancement of almost the entire tumor in the vascular phase. The cause of the symptom may have been DEB-TACE-associated intratumoral hemorrhage. Tumor hemorrhage has been reported after DEB-TACE with tumors >5 cm in diameter, and the tumor locations were subcapsular in all previous reports. There has been no case of a tumor with a diameter <5 cm distinct from the subcapsular, as was observed in our patient. Incomplete embolization might be the cause of the intratumoral hemorrhage experienced by this case presenting a few risks. To obtain the therapeutic effect of DEB-TACE while preventing the adverse events, it may be important to understand the characteristics of the beads and to apply the appropriate embolization to each individual case.

No MeSH data available.


Related in: MedlinePlus

Left panel: CEUS (40 s after injection of Sonazoid) about 1 month after DEB-TACE (3 days before the onset of right hypochondriac pain) shows an increase of the enhancement area in the vascular phase (arrow) compared with the CEUS imaging the day after DEB-TACE. Right panel: Gray-scale US (monitor mode).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4264514&req=5

Figure 3: Left panel: CEUS (40 s after injection of Sonazoid) about 1 month after DEB-TACE (3 days before the onset of right hypochondriac pain) shows an increase of the enhancement area in the vascular phase (arrow) compared with the CEUS imaging the day after DEB-TACE. Right panel: Gray-scale US (monitor mode).

Mentions: Access for TACE was performed under sterile conditions and under local anesthesia, via the right femoral artery using a 3-Fr sheath (Medikit, Tokyo, Japan) and in a retrograde fashion. An intensely stained tumor was detected in the S5 region on celiac arterial angiography. When a microcatheter was advanced to the anterior segmental artery of the right hepatic artery and contrast imaging was applied, an intensely stained tumor was observed, with A5 as the feeding artery. A solution impregnated with 100–300 μm DC Bead and 50 mg epirubicin hydrochloride, with a DC Bead volume of 0.35 ml, was administered via the feeding artery to perform DEB-TACE. Disappearance of the intensely stained tumor image was confirmed by right hepatic arterial angiography, and the treatment was completed. The course after DEB-TACE was favorable, and no adverse events above grade 3 according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 were observed. Endoscopic submucosal dissection (ESD) of the early gastric carcinoma was performed about 1 month after DEB-TACE. Right hypochondriac pain suddenly developed 3 days after ESD, but no adverse events were assumed to be caused by ESD (i.e., free air, noted on dynamic CT). However, the tumor diameter had increased from that before DEB-TACE, and the tumor showed a high-intensity area on unenhanced CT (fig. 2a), which was not enhanced in the arterial phase on dynamic CT, suggesting intratumoral hemorrhage. The hemodynamics of the tumor were followed using CEUS over the time before and after DEB-TACE. On CEUS carried out on the day after DEB-TACE, the whole intratumoral enhancement decreased, and nonenhanced patchy regions, assumed to be necrosis, were noted in the tumor in the vascular phase. On CEUS performed 4 weeks after DEB-TACE, i.e., immediately before ESD, the tumor size was 33 × 31 mm, and the enhancement area was increased in the vascular phase (fig. 3) compared with the CEUS imaging of the day after DEB-TACE. However, the tumor had enlarged to 41 × 36 mm on CEUS when the right hypochondriac pain developed (5 weeks after DEB-TACE), and changes in the echogenicity on gray-scale US and nonenhancement of almost the entire tumor in the vascular phase on CEUS were noted (fig. 2b). Based on the above findings, the cause of right hypochondriac pain may have been DEB-TACE-associated intratumoral hemorrhage. Since the hemorrhage was limited to inside the tumor, it stopped spontaneously with rest.


Delayed intratumoral hemorrhage after drug-eluting bead transarterial chemoembolization for hepatocellular carcinoma.

Shiozawa K, Watanabe M, Ikehara T, Ogino Y, Umakoshi T, Matsukiyo Y, Kogame M, Matsui T, Kikuchi Y, Igarashi Y, Sumino Y - Case Rep Oncol (2014)

Left panel: CEUS (40 s after injection of Sonazoid) about 1 month after DEB-TACE (3 days before the onset of right hypochondriac pain) shows an increase of the enhancement area in the vascular phase (arrow) compared with the CEUS imaging the day after DEB-TACE. Right panel: Gray-scale US (monitor mode).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4264514&req=5

Figure 3: Left panel: CEUS (40 s after injection of Sonazoid) about 1 month after DEB-TACE (3 days before the onset of right hypochondriac pain) shows an increase of the enhancement area in the vascular phase (arrow) compared with the CEUS imaging the day after DEB-TACE. Right panel: Gray-scale US (monitor mode).
Mentions: Access for TACE was performed under sterile conditions and under local anesthesia, via the right femoral artery using a 3-Fr sheath (Medikit, Tokyo, Japan) and in a retrograde fashion. An intensely stained tumor was detected in the S5 region on celiac arterial angiography. When a microcatheter was advanced to the anterior segmental artery of the right hepatic artery and contrast imaging was applied, an intensely stained tumor was observed, with A5 as the feeding artery. A solution impregnated with 100–300 μm DC Bead and 50 mg epirubicin hydrochloride, with a DC Bead volume of 0.35 ml, was administered via the feeding artery to perform DEB-TACE. Disappearance of the intensely stained tumor image was confirmed by right hepatic arterial angiography, and the treatment was completed. The course after DEB-TACE was favorable, and no adverse events above grade 3 according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 were observed. Endoscopic submucosal dissection (ESD) of the early gastric carcinoma was performed about 1 month after DEB-TACE. Right hypochondriac pain suddenly developed 3 days after ESD, but no adverse events were assumed to be caused by ESD (i.e., free air, noted on dynamic CT). However, the tumor diameter had increased from that before DEB-TACE, and the tumor showed a high-intensity area on unenhanced CT (fig. 2a), which was not enhanced in the arterial phase on dynamic CT, suggesting intratumoral hemorrhage. The hemodynamics of the tumor were followed using CEUS over the time before and after DEB-TACE. On CEUS carried out on the day after DEB-TACE, the whole intratumoral enhancement decreased, and nonenhanced patchy regions, assumed to be necrosis, were noted in the tumor in the vascular phase. On CEUS performed 4 weeks after DEB-TACE, i.e., immediately before ESD, the tumor size was 33 × 31 mm, and the enhancement area was increased in the vascular phase (fig. 3) compared with the CEUS imaging of the day after DEB-TACE. However, the tumor had enlarged to 41 × 36 mm on CEUS when the right hypochondriac pain developed (5 weeks after DEB-TACE), and changes in the echogenicity on gray-scale US and nonenhancement of almost the entire tumor in the vascular phase on CEUS were noted (fig. 2b). Based on the above findings, the cause of right hypochondriac pain may have been DEB-TACE-associated intratumoral hemorrhage. Since the hemorrhage was limited to inside the tumor, it stopped spontaneously with rest.

Bottom Line: The cause of the symptom may have been DEB-TACE-associated intratumoral hemorrhage.Incomplete embolization might be the cause of the intratumoral hemorrhage experienced by this case presenting a few risks.To obtain the therapeutic effect of DEB-TACE while preventing the adverse events, it may be important to understand the characteristics of the beads and to apply the appropriate embolization to each individual case.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Medical Center, Omori Hospital, Tokyo, Japan.

ABSTRACT
Transarterial chemoembolization (TACE) using a drug-eluting bead (DEB-TACE) for hepatocellular carcinoma (HCC) is a new treatment method. We report on a case of delayed intratumoral hemorrhage after DEB-TACE. An 81-year-old male with hepatitis C virus-related cirrhosis was diagnosed with a HCC of 35 mm in diameter in S5 detected by dynamic computed tomography (CT) and contrast-enhanced ultrasonography (CEUS). DEB-TACE with DC Bead (®) and epirubicin hydrochloride was performed because the patient declined to undergo surgical resection. The treatment was completed, and the course after DEB-TACE was favorable. However, right hypochondriac pain suddenly developed about 1 month after DEB-TACE. Unenhanced CT showed an increase of the tumor diameter and intratumoral high-intensity area, which was not enhanced in the arterial phase. CEUS performed at the time of right hypochondriac pain (5 weeks after DEB-TACE) showed nonenhancement of almost the entire tumor in the vascular phase. The cause of the symptom may have been DEB-TACE-associated intratumoral hemorrhage. Tumor hemorrhage has been reported after DEB-TACE with tumors >5 cm in diameter, and the tumor locations were subcapsular in all previous reports. There has been no case of a tumor with a diameter <5 cm distinct from the subcapsular, as was observed in our patient. Incomplete embolization might be the cause of the intratumoral hemorrhage experienced by this case presenting a few risks. To obtain the therapeutic effect of DEB-TACE while preventing the adverse events, it may be important to understand the characteristics of the beads and to apply the appropriate embolization to each individual case.

No MeSH data available.


Related in: MedlinePlus