Retiform Purpura as a Complication of Microsphere Emboli Following Transarterial Chemoembolization for Primary Hepatocellular Carcinoma: A Case Report and Literature Review

Abstract

We report an elderly man with hepatocellular carcinoma who developed a rash after undergoing transarterial chemoembolization (TACE). On examination, there was a reticulated macular pigmentation over the chest and upper abdomen. Skin biopsy revealed foreign material that occluded the small dermal cutaneous vessels. These structures were perfectly spherical, homogeneously eosinophilic, and were also nonrefractile. They had a maximum diameter of 40 μm, consistent with the size of the microspheres used in TACE. TACE is a palliative measure used to treat hepatocellular carcinoma in patients who are not surgical candidates. Vaso-occlusive manifestations of the skin are rare occurrences, with only 8 reported cases. Seven cases attributed this to nontarget embolization of the hepatic falciform artery and 1 case postulated that collateral supply of the targeted area allowed for hematogenous migration of the occluding beads via the microcirculation. Pertaining to treatment, all patients were treated with oral nonsteroidal anti-inflammatory agents to good effect, with 1 patient receiving additional laser treatment and another having local steroid injections. Prognosis is excellent, because the skin lesions tend to resolve within a year. Several methods have been suggested to prevent these vaso-occlusive skin complications, including prophylactic application of ice or placing the tip of the microcatheter distal to the origin of the hepatic falciform artery and falciform artery.

Inside out: When the skin is an unexpected target

“…It is typical for the lesions to converge into a retiform pattern. 4,5 The lesion's reticulated pattern could be explained by the vascular occlusion which leads to local ischemia and consecutive tissular damage. Most of the described cases are located on the supraumbilical area, due to the migration of the microspheres though supply from the hepatic falciform artery.…”

“…Moreover, amorphous spherical structures can be present (corresponding to the microspheres), inside the vascular lumina as well as extruded adjacent to the vessels, leading to the diagnosis. 4,5,7 Evidence for the management of this complication is limited and based on case reports. Since there is no causal treatment, symptomatic treatment is paramount, especially if the lesions are associated with pain or discomfort.…”

“…Vascular congestion and hematic extravasation are also seen, in addition to collagen thickening. Moreover, amorphous spherical structures can be present (corresponding to the microspheres), inside the vascular lumina as well as extruded adjacent to the vessels, leading to the diagnosis 4,5,7 …”

“…Preventive measures, such as placing the tip of the microcatheter distal to the origin of the hepatic falciform artery, are essential to avoid cutaneous adverse effects 5 . It has been postulated that topical ice, because of its vasoconstrictive properties, may be useful as an effective preventive measure 9,10 …”

Von innen nach außen: Die Haut ein unerwartetes Ziel

“…Diese Läsionen, die durch einen Gefäßverschluss verursacht werden, reichen von leichten asymptomatischen erythematösen Makeln bis hin zu schmerzhaften ulzerös‐nekrotischen Läsionen. Typisch ist, dass die Läsionen in einem netzförmigen Muster konvergieren 4,5 …”