European Journal of Radiology, 15 ( 1992) 68-70 0 1992 Elsevier Science Publishers
68
B.V. All rights reserved. 0720-048X/92/$05.00
EURRAD 0028 1
Intraperitoneal hemorrhage due to rupture of hepatocellular carcinoma after transcatheter arterial embolization with Lipiodol. A case report JosC I. Bilbao, Manuel Ruza, Jestis M. Longo and Francisco Department of Radiology, Clinica Universitan’a, Facultad de Medicina, Give&dad
J. Lecumberri
de Navarra. Pamplona, Spain
(Received 29 November 1991; accepted after revision 21 January 1992)
Key words: Liver, neoplasm; Contrast media, Lipiodol; Interventional
radiology
Introduction Transcatheter hepatic arterial embolization (TAE) with Lipiodol is commonly performed for the detection of small hepatocellular carcinomas (HCC) due to Lipiodol’s affinity for hepatic tumoral cells and peritumoral vessels [ 11. This technique can also be used for therapeutic purposes since Lipiodol can serve as a medium to transport chemotherapeutic agents [ 21. Although TAE is an effective technique and has low morbidity, some complications, like acute cholecystitis [ 31 and significant increase in serum amylase [4], have been reported. We present a case of a patient who suffered a rupture of HCC after TAE with Lipiodol.
Fig. 1. Non-contrast
CT scan shows a well-defined tumor in the left lobe of the liver.
Case report A 59-year-old male presented with a history of arterial hypertension, obesity and hypertransaminasemia. During a routine medical check-up, a solid hypoechoic hepatic lesion was detected by abdominal ultrasound. Abdominal computerized tomography (CT) showed a mass suggestive of hepatocarcinoma (Fig. 1). A hepatic arteriogram revealed a hypervascular mass in the left lobe of the liver (Fig. 2). The portal venous system was normal, with a good hepatopetal flow. Five ml of Lipiodol were injected into the right hepatic artery and 5 ml into the common hepatic artery . Immediately after the arteriographic study, the pa-
Correspondence to: J.I. Bilbao. Department of Radiology. Clinica Universitaria de Navarra. Avda. Pio XII s/n. Pamplona 31008. Navarra, Spain.
Fig. 2. Highly hypervascular tumor in the left lobe of the liver.
69
Fig. 3. a. CT-scan performed seven days after the intraarterial injection of Lipiodol. High tumoral uptake of Lipiodol and residual homogeneous opacification of the rest of the liver. b. Hematoma around the tumoral area.
tient experienced epigastric pain, that could have been due to the entry of Lipiodol into the gastroduodenalpancreatic arteries. However, subsequent serum amylase controls remained within normal limits. Pain was attenuated with analgesics but did not disappear completely in the following days. A CT-scan of the liver was performed 7 days after the embolization (Fig. 3). High uptake of Lipiodol was observed within the tumor, and a zone of increased density in the mesocolic area compatible with hematoma was also detected. No other tumor implants were detected in the liver, and a left hepatic lobectomy was subsequently performed. At laparotomy, a hematoma at the subhepatic peritumoral area and extending into the transverse mesocolon was evacuated. Histologic study showed hepatocarcinoma and liver cirrhosis. Complete thrombosis of the left hepatic artery was also noted. The post-operative course was uneventful. Two years later the patient remained asymptomatic, without any evidence of tumor recurrence. Discussion Lipiodol selectively accumulates in neoplastic cells and in peritumoral vessels [ 11. This selective accumulation has been attributed to the leaky character of tumor neovasculature and the lack of lymphatic clearance of the agent from the tumor [5]; likewise, the decreased number of Kupffer cells in HCC may affect the clearance of Lipiodol [ 11. This feature permits the diagnosis of small nodules that can be overlooked by CT scan [5,6]. Hepatic intraarterial injection of Lipiodol is usually a safe technique. However, some complications have been reported, such as significant increase in serum
amylase due to the reflux of embolic material into the pancreatico-duodenal artery [4] and acute cholecystitis related to the embolization of the cystic artery [ 31. In our patient, hepatic intraarterial injection of Lipiodol was followed by rupture of the HCC. CT-scan showed tumor irregularity with an adjacent hematoma, findings that are similar to those described by Cates [ 71 and Siskind [8]. The incidence of spontaneous rupture and bleeding of HCC may be as high as 15% [9] and accounts for a 10% mortality of HCC patients in Japan [lo]. Clinical features of ruptured hepatocellular carcinoma are severe abdominal pain, shock and hemoperitoneum [ 91. In our patient the bleeding was not massive probably due to the left hepatic artery thrombosis. Several theories have been proposed to explain parenchymal and peritoneal hemorrhage in patients with liver tumors: vessel invasion by tumor, increase in intraabdominal pressure induced by coughing or by direct palpation of the liver, sequelae of needle biopsy, etc. Lipiodol leaks out of the vascular spaces and attaches itself to cancer cell membranes, compromising membrane transport of tumor cells and altering the intracellular environment [ 11. This should play a role in the development of tumor edema, which increases the intratumoral pressure, and may eventually lead to rupture of the hepatocarcinoma.
References Park Ch, Choi SI, Kin H, Yoo HS, Lee YO. Distribution of Lipiodol in hepatocellular carcinoma. Liver 1990; 10: 72-78. Takayasu K, Shima Y, Muramatsu Y. Moriyama N, Yamada T’. Makuuchi M, Hasegawa H, Hirohashi S. Hepatocellular carcinoma: treatment with intraarterial iodized oil with and without chemotherapeutic agents. Radiology 1987; 162: 345-351.
IO 3 Young E, Jackson J, Finn JP, Thomas HG, Benjamin IS, Adam
A. Acalculous cholecystitis complicating hepatic intraarterial Lipiodol. Case Report. Cardiovasc Interv Radio1 1989; 12: 8092. 4 Kishimoto W, Nakao A, Takagi H, Hayakawa T. Acute pancreatitis after transcatheter arterial embolization (TAE) for hepatocellular carcinoma. Am J Gastroenterol 1989; 84: 13961399. 5 Iwai K, Maeda H, Konno T. Use of oily contrast medium for selective drug targeting to tumor: enhanced therapeutic effect and x-ray image. Cancer Res 1984; 44: 2115-2121. 6 Bruneton JN, Kerboul P, Grimaldi CH, Norman01 F, BaluMaestro C, Rampal P, Delmont J. Hepatic intraarterial Lipiodol:
7
8
9 10
technique, semiologic patterns, and value for hepatic tumors. Gastrointest Radio1 1988; 13: 45-51. Cates JD, Thorsen HK, Feley WD, Lawson TL. CT diagnosis of massive hemorrhage from hepatocellular carcinoma. J Comput Assist Tomogr 1987; 11: 81-82. !&kind BN, Malat J, Hammers L, Rigsby CM, Taylor C, Radin DR, Rosenfield AT. CT features of hemorrhagic malignant liver tumors. J Comput Assist Tomogr 1987; 11: 766-770. Ong GB, Chu EPH, Yu FYK, Lee TC. Spontaneous rupture of hepatocellular carcinoma. Brit J Surg 1965; 27: 123-129. Miyamoto M, Sudo T, Kuyama T. Spontaneous rupture of hepatocellular carcinoma: a review of 172 Japanese cases. Am J Gastroenterol 1991; 86: 67-71.
68
B.V. All rights reserved. 0720-048X/92/$05.00
EURRAD 0028 1
Intraperitoneal hemorrhage due to rupture of hepatocellular carcinoma after transcatheter arterial embolization with Lipiodol. A case report JosC I. Bilbao, Manuel Ruza, Jestis M. Longo and Francisco Department of Radiology, Clinica Universitan’a, Facultad de Medicina, Give&dad
J. Lecumberri
de Navarra. Pamplona, Spain
(Received 29 November 1991; accepted after revision 21 January 1992)
Key words: Liver, neoplasm; Contrast media, Lipiodol; Interventional
radiology
Introduction Transcatheter hepatic arterial embolization (TAE) with Lipiodol is commonly performed for the detection of small hepatocellular carcinomas (HCC) due to Lipiodol’s affinity for hepatic tumoral cells and peritumoral vessels [ 11. This technique can also be used for therapeutic purposes since Lipiodol can serve as a medium to transport chemotherapeutic agents [ 21. Although TAE is an effective technique and has low morbidity, some complications, like acute cholecystitis [ 31 and significant increase in serum amylase [4], have been reported. We present a case of a patient who suffered a rupture of HCC after TAE with Lipiodol.
Fig. 1. Non-contrast
CT scan shows a well-defined tumor in the left lobe of the liver.
Case report A 59-year-old male presented with a history of arterial hypertension, obesity and hypertransaminasemia. During a routine medical check-up, a solid hypoechoic hepatic lesion was detected by abdominal ultrasound. Abdominal computerized tomography (CT) showed a mass suggestive of hepatocarcinoma (Fig. 1). A hepatic arteriogram revealed a hypervascular mass in the left lobe of the liver (Fig. 2). The portal venous system was normal, with a good hepatopetal flow. Five ml of Lipiodol were injected into the right hepatic artery and 5 ml into the common hepatic artery . Immediately after the arteriographic study, the pa-
Correspondence to: J.I. Bilbao. Department of Radiology. Clinica Universitaria de Navarra. Avda. Pio XII s/n. Pamplona 31008. Navarra, Spain.
Fig. 2. Highly hypervascular tumor in the left lobe of the liver.
69
Fig. 3. a. CT-scan performed seven days after the intraarterial injection of Lipiodol. High tumoral uptake of Lipiodol and residual homogeneous opacification of the rest of the liver. b. Hematoma around the tumoral area.
tient experienced epigastric pain, that could have been due to the entry of Lipiodol into the gastroduodenalpancreatic arteries. However, subsequent serum amylase controls remained within normal limits. Pain was attenuated with analgesics but did not disappear completely in the following days. A CT-scan of the liver was performed 7 days after the embolization (Fig. 3). High uptake of Lipiodol was observed within the tumor, and a zone of increased density in the mesocolic area compatible with hematoma was also detected. No other tumor implants were detected in the liver, and a left hepatic lobectomy was subsequently performed. At laparotomy, a hematoma at the subhepatic peritumoral area and extending into the transverse mesocolon was evacuated. Histologic study showed hepatocarcinoma and liver cirrhosis. Complete thrombosis of the left hepatic artery was also noted. The post-operative course was uneventful. Two years later the patient remained asymptomatic, without any evidence of tumor recurrence. Discussion Lipiodol selectively accumulates in neoplastic cells and in peritumoral vessels [ 11. This selective accumulation has been attributed to the leaky character of tumor neovasculature and the lack of lymphatic clearance of the agent from the tumor [5]; likewise, the decreased number of Kupffer cells in HCC may affect the clearance of Lipiodol [ 11. This feature permits the diagnosis of small nodules that can be overlooked by CT scan [5,6]. Hepatic intraarterial injection of Lipiodol is usually a safe technique. However, some complications have been reported, such as significant increase in serum
amylase due to the reflux of embolic material into the pancreatico-duodenal artery [4] and acute cholecystitis related to the embolization of the cystic artery [ 31. In our patient, hepatic intraarterial injection of Lipiodol was followed by rupture of the HCC. CT-scan showed tumor irregularity with an adjacent hematoma, findings that are similar to those described by Cates [ 71 and Siskind [8]. The incidence of spontaneous rupture and bleeding of HCC may be as high as 15% [9] and accounts for a 10% mortality of HCC patients in Japan [lo]. Clinical features of ruptured hepatocellular carcinoma are severe abdominal pain, shock and hemoperitoneum [ 91. In our patient the bleeding was not massive probably due to the left hepatic artery thrombosis. Several theories have been proposed to explain parenchymal and peritoneal hemorrhage in patients with liver tumors: vessel invasion by tumor, increase in intraabdominal pressure induced by coughing or by direct palpation of the liver, sequelae of needle biopsy, etc. Lipiodol leaks out of the vascular spaces and attaches itself to cancer cell membranes, compromising membrane transport of tumor cells and altering the intracellular environment [ 11. This should play a role in the development of tumor edema, which increases the intratumoral pressure, and may eventually lead to rupture of the hepatocarcinoma.
References Park Ch, Choi SI, Kin H, Yoo HS, Lee YO. Distribution of Lipiodol in hepatocellular carcinoma. Liver 1990; 10: 72-78. Takayasu K, Shima Y, Muramatsu Y. Moriyama N, Yamada T’. Makuuchi M, Hasegawa H, Hirohashi S. Hepatocellular carcinoma: treatment with intraarterial iodized oil with and without chemotherapeutic agents. Radiology 1987; 162: 345-351.
IO 3 Young E, Jackson J, Finn JP, Thomas HG, Benjamin IS, Adam
A. Acalculous cholecystitis complicating hepatic intraarterial Lipiodol. Case Report. Cardiovasc Interv Radio1 1989; 12: 8092. 4 Kishimoto W, Nakao A, Takagi H, Hayakawa T. Acute pancreatitis after transcatheter arterial embolization (TAE) for hepatocellular carcinoma. Am J Gastroenterol 1989; 84: 13961399. 5 Iwai K, Maeda H, Konno T. Use of oily contrast medium for selective drug targeting to tumor: enhanced therapeutic effect and x-ray image. Cancer Res 1984; 44: 2115-2121. 6 Bruneton JN, Kerboul P, Grimaldi CH, Norman01 F, BaluMaestro C, Rampal P, Delmont J. Hepatic intraarterial Lipiodol:
7
8
9 10
technique, semiologic patterns, and value for hepatic tumors. Gastrointest Radio1 1988; 13: 45-51. Cates JD, Thorsen HK, Feley WD, Lawson TL. CT diagnosis of massive hemorrhage from hepatocellular carcinoma. J Comput Assist Tomogr 1987; 11: 81-82. !&kind BN, Malat J, Hammers L, Rigsby CM, Taylor C, Radin DR, Rosenfield AT. CT features of hemorrhagic malignant liver tumors. J Comput Assist Tomogr 1987; 11: 766-770. Ong GB, Chu EPH, Yu FYK, Lee TC. Spontaneous rupture of hepatocellular carcinoma. Brit J Surg 1965; 27: 123-129. Miyamoto M, Sudo T, Kuyama T. Spontaneous rupture of hepatocellular carcinoma: a review of 172 Japanese cases. Am J Gastroenterol 1991; 86: 67-71.
