A case of hepatocellular carcinoma with skin injury of the upper abdominal wall after transcatheter arterial chemoembolization: a case report

Abstract

IntroductionTranscatheter arterial chemoembolization has been widely used to treat advanced hepatocellular carcinoma that cannot be treated by local ablation therapies or surgical resection. The effectiveness of transcatheter arterial chemoembolization in prolonging survival has been well established, and approximately one third of newly discovered hepatocellular carcinoma patients were repeatedly treated by transcatheter arterial chemoembolization in Japan. Various kinds of complications have been reported, and many of which are general complications such as hepatic coma, jaundice, fever-up, ascites, and bile duct injury.The hepatic falciform artery is found frequently during postmortem anatomic dissection and the incidence of hepatic falciform artery is reported to be over 60%. Hepatic falciform artery is known to be the responsible artery for supraumbilical skin rash development after arterial chemo infusion therapy; however, skin complications after transcatheter arterial chemoembolization are rare.Case presentationA 70-year-old female with chronic hepatitis C infection was diagnosed as having hepatocellular carcinoma (S4, 20 mm in diameter). Transcatheter arterial chemoembolization was performed via the left hepatic artery, which was a feeding artery of the hepatocellular carcinoma. Two days after that, supraumbilical skin rash with local tenderness and redness appeared. Retrospective analysis revealed that occlusion of the hepatic falciform artery branching from the left hepatic artery with micromaterials caused the skin lesion.ConclusionWe should keep in mind that anticancer drugs or embolic materials can flow into the HFA and may cause abdominal wall injury after transcatheter arterial chemoembolization.

Hepatic falciform ligament Tc-99m-macroaggregated albumin activity on SPECT/CT prior to Yttrium-90 microsphere radioembolization: prophylactic measures to prevent non-target microsphere localization via patent hepatic falciform arteries

“…The patient was treated with oral steroids, remained clinically stable and recovered within 5 weeks [3]. Similar complications due to patent hepatic falciform arteries have also been reported to affect transcatheter arterial chemoembolization (TACE) for unresectable HCC [7][8][9]. Prophylactic embolization of a patent hepatic falciform artery has been recommended where appropriate, to prevent radiation-induced complications to the anterior abdominal wall [2].…”

Radioembolization Complicated by Nontarget Embolization to the Falciform Artery

“…Many studies have also reported complications of supraumbilical skin rash and pain associated with chemoembolization. 11 Similarly, it has been hypothesized that these side effects might be caused by the distribution of chemotherapeutic agents through the hepatic falciform artery. 11 The presence of an angiographically identifiable falciform artery varies, and is reportedly found in 25% of cases.…”

Supraumbilical skin rash after transcatheter arterial chemoembolization: Successful treatment with pentoxifylline

“…Supraumbilical skin rash has been reported to be a relatively rare complication compared to other complications associated with TACE 2–5 . SUSR is thought to be caused by inflow of the chemotherapeutic agent into the hepatic falciform artery (HFA), 2 which branches from the left or middle hepatic artery, runs along the hepatic falciform ligament, and connects with the peripheral branch of the internal thoracic artery or the superior epigastric artery distributed around the umbilicus 3 .…”

“…The incidence of the HFA detected on angiography has been reported uncommonly, ranging from 2% to 24.5%, but was reported to be relatively high on postmortem anatomical dissection 6 . These differences for detection on hepatic angiography seem to be low velocity of arterial flow and similarity of the direction of the HFA with other arteries, including the hepatic artery and cystic artery which run close to the HFA 5 . Although hepatic angiography for our patient was also retrospectively evaluated, the HFA was not detected.…”

“…Risk factors for complication of TACE include severe portal hypertension, which causes a compensatory increase in hepatic arterial flow and collateral vessels, and damage from long‐term arterial injection of chemotherapeutic agents 5,7 . Surgical treatment such as laparoscopy may also cause enlargement of the HFA, which may likely be infused with chemotherapeutic agents 3…”