Sloughing of biliary tumour ingrowth of hepatocellular carcinoma after chemoembolization

Abstract

• Migration of intraductal tumour ingrowth of HCC after chemoembolization occurs more commonly than reported. • The sloughed tumour is often misinterpreted as biliary calculi. • It can make cholestasis and be managed by ERCP or PTBD. • In some asymptomatic cases, a wait-and-see approach can be taken.

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

“…Most cases occur after TACE for HCC with biliary invasion or intraductal tumor ingrowth. Ductal invasion with intraductal tumor ingrowth in HCC is uncommon, with a reported incidence of 1.2%-9%, 11 and according to Kim et al, 10 the incidence of intraductal necrotic tumor migration in biliary invasive HCC patients after TACE is 10.4%, which accounts for a very small subset of HCC patients.…”

“…The time interval between TACE and the onset of symptoms may vary, but acute cholestatic symptoms such as jaundice and abdominal pain occur less than 60 days after the TACE. 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.…”

“…Because the ductal epithelium underlying the intraductal tumor ingrowth is usually preserved and the intraductal tumor does not attach tightly to the duct, 13 intraductal tumors that become necrotic after chemoembolization can easily detach from the main tumor and migrate into the bile duct. 10 CT scans can show a new soft tissue lesion with or without a radiodense portion, which suggests a migrated tumor with retained Lipiodol in the distal CBD. The CT attenuation of the lesion may vary, depending on the amount of Lipiodol accumulation.…”

“…If there is compact Lipiodol uptake, it may mimic calculous biliary stones, and if there is no or sparse Lipiodol accumulation, it may show similar attenuation to that of the surrounding soft tissue. 10 The soft tissue portion of the lesion may show no or little enhancement, reflecting tumor necrosis and no vascular supply. In addition, previously visualized tumor or Lipiodol deposits located in the bile duct lumen may no longer be seen, which would correlate with the detachment of the tumor portion.…”

“…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.…”