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

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. (Korean J Gastroenterol 2014;63:171-175)

Systematic review comparing the safety and efficacy of conventional and drug‐eluting bead transarterial chemoembolization for inoperable hepatocellular carcinoma

“…42 Spontaneous liver rupture after DEB-TACE has also been reported. 43 These ADE do not appear to be specific to DEB-TACE, because they have also been reported after cTACE, [44][45][46][47] and the affected patients are usually older and experience multiple preoperative complications.…”

Intraductal migration of necrotic hepatocellular carcinoma: A possible cause of obstructive cholangitis after chemoembolization

“…[10][11][12] However, there has been no study of their long-term clinical outcomes. In addition, according to Kim et al, 10 asymptomatic patients whose tumors spontaneously pass into the gastrointestinal tract can be kept under observation.…”

“…10 Ductal invasion with intraductal tumor ingrowth in HCC is one of the main reasons for obstructive jaundice in HCC patients. In almost all cases with intraductal tumor fragment migration after TACE, CT scans performed before TACE show evidence of bile duct invasion, such as irregularly dilated ducts passing through the tumor or intraductal protrusion of the tumor, 12 and Park et al 12 suggested that intraductal invasion would be a major predisposing factor to tumor migration after TACE. Rarely, it may also occur in patients without bile duct invasion because TACE induces marked ischemia in the tumor vascular bed and adjacent biliary tree.…”

“…Acute obstructive cholangitis due to the migration of necrotized tumor fragment(s) has been rarely reported after TACE, [3][4][5][6][7][8][9] and knowledge of its treatment is even more limited. [10][11][12] Here, we report a case of obstructive cholangitis due to detachment of a necrotic tumor fragment and its migration into the common bile duct (CBD) after TACE for HCC with suspicious bile duct invasion, with its detailed clinical course and imaging findings.…”

Sloughing of biliary tumour ingrowth of hepatocellular carcinoma after chemoembolization

“…Migration of intraductal tumour ingrowth to the distal common bile duct, causing obstructive jaundice, rarely occurs following chemoembolization of HCCs with bile duct invasion, which is the so-called 'sloughing' of an intraductal tumour ingrowth [9][10][11][12][13][14][15][16][17][18]. The clinical course of this event remains poorly documented.…”