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TACE of Metastatic HCC to
the Pleura
Gabriel Howles, MD, PhD
Nishita Kothary MD
Department of Radiology
Division of Interventional Radiology
Stanford University School of Medicine
Disclosures
Gabriel Howles, MD, PhD
• None
Nishita Kothary, MD
• Scientific Advisor, Siemens Healthcare
Penn IR
History in Brief
• 68 Y Male hepatitis B and C negative
• Prior partial hepatectomy for a 4cm HCC (path:
well differentiated HCC, no vascular invasion).
• On Sorafenib (400mg BID)
• Triphasic CT showed numerous hypervascular
nodules with washout with the dominant burden
in Couinaud segment VI, VII
• Pleural metastasis with chronic right pleural
effusion seen on CT.
Arterial phase of a triphasic CT, demonstrating multiple hypervascular foci in
segment VI and VII that washed out on the portal venous and delayed phase (not
shown), consistent with HCC
A
B
Axial and coronal images of
the chest (A and B),
demonstrate a 2.5cm x
2.5cm x 5cm pleural based,
hypervascular nodule on
the right, consistent with
pleural metastatic disease
Laboratory Data
• AFP –Pre hepatectomy: 57, post-hepatectomy
28. At presentation:1137
• LFT: Total Bilirubin 0.8mg/dL, AST 37 U/L, ALT
38 U/L, Albumin 3.7g/dL, INR 1.2
• Creatinine 1.3mg/dL, Platelet count 78,000/µL
A
B
Early and delayed DSA imaging (A and B) of the thoracic aorta
demonstrates arterial supply of pleural mets supplied by the
intercostal arteries
A
B
Catheterization of the right 6th intercostal artery (A) and further selection
and placement of a 1.9Fr microcatheter in the distal portion of the 6th
intercostal artery (B), redemonstrates the hypervascular pleural met.
Pleural met treated with 31.3mg of Doxrubicin and 0.625mL of
Lipiodol (A). Prophylactic topical Ice was placed to prevent
cutaneous complications of non-target chemoembolization.
Unenhanced CBCT (B) demonstrates lipiodol staining in pleural met
A
B
Supply to pleural mets by 5th intercostal artery, treated in a
similar superselective fashion.
MIP images reconstructed from a contrast enhanced CBCT
obtained for radioembolization planning demonstrates
multifocal HCC.
Clinical Course
• Patient returned for Y90 administration on
Day 10.
• Erythema noted along the right posterior
chest without ulceration.
• Asymptomatic, no treatment for chest wall.
• Uneventful administration of Y90.
• Skin erythema resolved, without
consequences.
Discussion
• Lung is the most commonly affected organ of
extrahepatic metastases from HCC
• 1 year survival is approximately 30% after
diagnosis of pulmonary mets1
• Prognostic factors that predict survival after
diagnosis of pulmonary mets include
oligometastasis, absence of pleural effusion and
treatment of pulmonary metastases1
Discussion
• For intra- or extra-hepatic tumors supplied by extrahepatic arteries (intercostal arteries or internal mammary
arteries), cutaneous complications can occur when
therapeutic agents are delivered due to the inadvertent
deposition in the terminal cutaneous branches.
• Topical ice can be used to vasoconstrict cutaneous
vasculature and prevent non-target deposition2.
Questions
1. The commonest organ for extrahepatic
metastatic disease from HCC is the:
a)
b)
c)
d)
Brain
Bone
Lungs
Mediastinal lymph nodes
Questions
1. The commonest organ for extrahepatic
metastatic disease from HCC is the:
a) Brain
b) Bone
c) Lungs
d) Mediastinal lymph nodes
Answer B
Questions
• In patients with HCC metastatic to the lung,
predictors of improved survival include
a)
b)
c)
d)
e)
Oligometastasis
Absence of pleural effusion
Treatment targeted to the pulmonary mets
Resection of primary tumor
All of the above
Questions
• In patients with HCC metastatic to the lung,
predictors of improved survival include
a) Oligometastasis
b) Absence of pleural effusion
c) Treatment targeted to the pulmonary mets
d) Resection of primary tumor
e) All of the above
Answer E
References
1.Zhang SM et al: Prognostic analysis of pulmonary
metastases from hepatocellular carcinoma: Hepatol Int
2008 Jun; 2(2): 237-243.
2. Wang DS et al: Prophylactic Topically Applied Ice to
Prevent Cutaneous Complications of Nontarget
Chemoembolization and Radioembolization. JVIR 2013
Apr, 24(4): 596-600