Korean J Gastroenterol.  2014 Mar;63(3):171-175. 10.4166/kjg.2014.63.3.171.

Acute Obstructive Cholangitis Complicated by Tumor Migration after Transarterial Chemoembolization: A Case Report and Literature Review

• Park HC
• Park HB
• Chung CY
• Jung MW
• Joo YE
• Choi SK
• Cho SB

• KMID: 1730928
• DOI: http://doi.org/10.4166/kjg.2014.63.3.171

Abstract

Intraductal tumor invasion of hepatocellular carcinoma (HCC) is considered rare. Transarterial chemoembolization (TACE) is effective for tumor thrombus of HCC in the bile duct. However, a few cases of obstructive jaundice caused by migration of a tumor fragment after TACE have recently been reported. The aim of this study was to identify factors that affect tumor migration after TACE. At this writing, a review of the medical literature disclosed seven reported cases of biliary obstruction caused by migration of a necrotic tumor cast after TACE. We, herein, report on an additional case of acute obstructive cholangitis complicated by migration of a necrotic tumor cast after TACE for intrabile duct invasion of HCC, in a 71-year-old man. The tumor cast in the common bile duct was removed successfully using a basket during ERCP and was pathologically confirmed to be a completely necrotic fragment of HCC. The patient's symptoms showed dramatic improvement. In summary, physicians should be aware of acute obstructive cholangitis complicated by tumor migration in a patient undergoing TACE. We suggest that an intrabile duct invasion would be a major predisposing factor of tumor migration after TACE and drainage procedures such as ERCP or percutaneous transbiliary drainage could be effective treatment modalities in these patients.

Keyword

Hepatocellular carcinoma; Biliary obstruction; Chemoembolization; Migration; Bile duct

MeSH Terms

Acute Disease
Aged
Antineoplastic Agents/administration & dosage
Bile Ducts, Intrahepatic/pathology
Carcinoma, Hepatocellular/*diagnosis/pathology/therapy
Chemoembolization, Therapeutic/adverse effects
Cholangiopancreatography, Endoscopic Retrograde
Cholangitis/*etiology
Humans
Jaundice, Obstructive/etiology
Liver Neoplasms/*diagnosis/pathology/therapy
Male
Necrosis/pathology
Sphincterotomy, Endoscopic
Thrombosis/etiology
Tomography, X-Ray Computed
Antineoplastic Agents

Figure

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  Fig. 1. Hepatobiliary phase transverse T1-weighted MRI at the time of diagnosis shows a hepatocellular carcinoma (white arrow) measuring approximately 2.5 cm in segment IV of the liver, with invasion to the left portal vein and intrahepatic bile duct (black arrows).

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  Fig. 2. Abdominal CT scan obtained 28 days after transarterial chemoembolization. (A) Transverse section. (B) Coronoral section. It shows newly a defective lipidol uptake lesion measuring 1.8 cm in segment IV and lipidol uptake (black arrow) of tumor thrombosis in the left intrahepatic bile duct.

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  Fig. 3. Abdominal CT scan obtained 45 days after transarterial chemoembolization. Lipidol uptake of tumor thrombosis previously seen in the left intrahepatic bile duct has disappeared (A; white arrow) and migrated to the distal common bile duct (CBD) (B; black arrow). It shows acute obstructive cholangitis associated with a migrated lipiodolized tumor fragment in distal CBD.

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  Fig. 4. (A) ERCP shows an elongated filling defect (black arrow) in the lower part of the common bile duct (CBD) and a protruding mass like filling defect (white arrow) in the dilated left intrahepatic bile duct. (B) After a sphincterotomy, a dark green colored, friable material was extracted from the CBD. (C) The mass measured 2.5×1.0 cm in size, and was friable and dark green in color.

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  Fig. 5. Completely coagulative necrosis of hepatocellular carcinoma. There are no viable tumor cells and only necrotic materials with bile. Silhouettes of a few hepatocytes with nucleoli are noted in the center area (H&E, ×200).

Reference

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