Liver Abscess Formation Following Transarterial Chemoembolization: Clinical Features, Risk Factors, Bacteria Spectrum, and Percutaneous Catheter Drainage

Risk factors of liver abscess and biloma formation after drug-eluting bead transarterial chemoembolization for unresectable intrahepatic cholangiocarcinoma

BACKGROUND AND STUDY AIMS

Drug-eluting bead transarterial chemoembolization (DEB-TACE) causes serious complications, including liver abscess and biloma formation. This study aimed to investigate the frequency and risk factors of liver abscess and biloma formation after dug-eluting bead transarterial chemoembolization for unresectable intrahepatic cholangiocarcinoma (ICC).

PATIENTS AND METHODS

152 unresectable ICC patients received 241 DEB-TACE procedures from February 2018 to November 2022 were studied retrospectively. Patients were evaluated for the presence of liver abscess and biloma formation after DEB-TACE. The medical records, including baseline demographic data, preoperative imaging data, DEB-TACE details, and postoperative management, were reviewed to search for risk factors of liver abscess and biloma formation.

RESULTS

Liver abscesses developed in 11 cases, with an incidence rate of 7.2 % (11/152) per patient and 4.6 % (11/241) per procedure. In the 11 patients with abscesses, the incidence of biloma formation was 36.4 % (n = 4). The binary logistic regression analysis showed that diabetes mellitus (OR 7.967, 95 % CI 1.491-42.571, p = 0.015), bilioenterostomy or biliary stent implantation (OR 18.716, 95 % CI 1.006-348.049, p = 0.049) and grade 1 arterial occlusion (OR 9.712, 95 % CI 1.054-89.484, p = 0.045) were independent risk factors for liver abscess and biloma formation.

CONCLUSION

Liver abscesses and biloma formation induced by DEB-TACE are associated with various factors. Diabetes mellitus, bilioenterostomy or biliary stent implantation, and grade 1 artery occlusion were all associated with liver abscess and biloma formation after DEB-TACE for unresectable ICC. In patients with these risk factors, the DEB-TACE procedure should be finely designed and manipulated with more caution.

Spectrum of Imaging Findings and Complications After Hepatic Transarterial Chemoembolization for Liver Tumors

ABSTRACT

This study reviews the spectrum of imaging findings and complications after transarterial chemoembolization (TACE) for the treatment of primary liver tumors (hepatocellular carcinoma, cholangiocarcinoma) and liver metastases. The review encompasses a spectrum of imaging criteria for assessing treatment response, including the modified Response Evaluation Criteria in Solid Tumors guidelines, tumor enhancement, and apparent diffusion coefficient alterations.We discuss the expected posttreatment changes and imaging responses to TACE, describing favorable and poor responses. Moreover, we present cases that demonstrate potential complications post-TACE, including biloma formation, acute cholecystitis, abscesses, duodenal perforation, arterial injury, and nontarget embolization. Each complication is described in detail, considering its causes, risk factors, clinical presentation, and imaging characteristics.To illustrate these findings, a series of clinical cases is presented, featuring diverse imaging modalities including computed tomography, magnetic resonance imaging, and digital subtraction angiography.

Liver abscess after drug-eluting bead transarterial chemoembolization for hepatic malignant tumors: Clinical features, pathogenesis, and management

AIM

The study aimed to investigate the clinical features, incidence, pathogenesis, and management of liver abscess after drug-eluting bead transarterial chemoembolization (DEB-TACE) for primary and metastatic hepatic malignant tumors.

METHODS

From June 2019 to June 2021, patients with liver abscess after DEB-TACE for primary and metastatic hepatic malignant tumors were reviewed and evaluated at our hospital. Demographic and clinical data, radiological findings, management approaches, and prognosis were retrospectively analyzed.

RESULTS

In total, 419 DEB-TACE procedures were carried out in 314 patients with primary and metastatic liver tumors at our medical center. Twelve patients were confirmed to have liver abscesses after DEB-TACE through clinical manifestations, laboratory investigations, and imaging. In this study, the incidence of liver abscess was 3.82% per patient and 2.86% per DEB-TACE procedure. After percutaneous drainage and anti-inflammatory treatments, 10 patients recovered, and the remaining 2 patients died due to direct complications of liver abscess, such as sepsis and multiple organ failure. The mortality rate of liver abscesses after DEB-TACE was 16.7% (2/12).

CONCLUSION

The incidence of liver abscess after DEB-TACE is relatively high and can have serious consequences, including death. Potential risk factors could include large tumor size, history of bile duct or tumor resection, history of diabetes, small DEB size (100-300 μm). Sensitive antibiotics therapy and percutaneous abscess aspiration/drainage are effective treatments for liver abscess after DEB-TACE.

The impact of liver abscess formation on prognosis of patients with malignant liver tumors after transarterial chemoembolization

Purpose

Liver abscess is a rare and serious complication after transarterial chemoembolization (TACE) for liver cancer; however, its impact on the prognosis is unclear. This retrospective study examined the outcomes of patients with liver abscess formation following TACE for malignant liver tumors to elucidate the impact of liver abscess formation on the prognosis of these patients.

Methods

From January 2017 to January 2022, 1,387 patients with malignant tumors underwent 3,341 sessions of TACE at our hospital. Clinical characteristics of patients at baseline and follow-up were examined, including treatment and outcome of liver abscess, tumor response to the TACE leading to liver abscess, and overall survival time.

Results

Of 1,387 patients, 15 (1.1%) patients with liver abscess complications after TACE resulted in a total of 16 (0.5%) cases of liver abscess after 3,341 TACE sessions (including one patient with two events). After antibiotic or percutaneous catheter drainage (PCD) treatment, all the infections associated with liver abscesses were controlled. In the PCD group, eight patients died before drainage tube removal, one retained the drainage tube until the end of follow-up, and five underwent drainage tube removal; the mean drainage tube removal time was 149.17 ± 134.19 days. The efficacy of TACE leading to liver abscess was evaluated as partial response (18.75%), stable disease (37.5%), and progressive disease (43.75%). Eleven patients died during the follow-up period owing to causes unrelated to infections caused by liver abscesses. The survival rates at 3 months, 6 months, 1 year, and 5 years were 86.7%, 50.9%, 25.5%, and 17%, respectively.

Conclusion

Patients with liver abscess formation following TACE for malignant liver tumors experienced prolonged drainage tube removal time after PCD; while this condition did not directly cause death, it indirectly contributed to a poor prognosis in these patients.

Hepatic abscess induced by gastric cancer mimicking differentiated hepatocellular carcinoma

A 58-year-old man was referred to our hospital with right abdominal pain. Contrast-enhanced computed tomography (CECT) showed a rim-enhanced lesion with a fluid collection in the right hepatic lobe. Upper gastrointestinal endoscopy revealed a Borrmann type 1 tumor on the middle gastric body, identified as an adenocarcinoma on pathology. The patient underwent percutaneous transhepatic abscess drainage and was treated with antibiotics. Two weeks after drainage, CECT revealed shrinkage of the abscess; however, the wall showed contrast enhancement. Needle biopsy was performed for the liver tumor, and it suggested the possibility of highly differentiated hepatocellular carcinoma. The patient first underwent gastrectomy, and the liver tumor was followed with CECT. Two months after surgery, CECT revealed that the liver tumor had vanished. Liver abscesses and infectious tumors can be difficult to differentiate between; therefore, careful scrutiny is essential before treatment.

Complications of Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Case Report of Bronchobiliary Fistula Development in a 68-Year-Old Man

BACKGROUND Bronchobiliary fistulas (BBFs) are abnormal communications between the biliary tract and bronchial tree. Transcatheter arterial chemoembolization (TACE) is a widely employed treatment for advanced hepatocellular carcinoma (HCC). While TACE is generally considered safe, there have been reports of severe complications. This case report is about a 68-year-old man who developed a BBF 6 months after undergoing TACE for HCC. CASE REPORT A 68-year-old man was diagnosed with HCC and underwent TACE at a local medical department. Two months after TACE, he presented with a liver abscess, which was drained and catheterized. Subsequently, the patient was transferred to our hospital. Initial MRI revealed abscesses in the right hepatic lobe extending into the lung cavity. Intrahepatic catheter replacement was performed. Six months after TACE, the patient developed cough and yellow sputum. Subsequent MRI confirmed smaller lung and liver abscesses, along with a BBF. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous catheter replacement were conducted, closing the BBF with a covered stent. Despite drainage, antibiotics, and nutritional support, the patient's condition deteriorated. Transition to hospice care was initiated, and the patient died due to sepsis and multiple organ failure. CONCLUSIONS This case highlights the importance of obtaining a comprehensive patient history when a patient has bile in the sputum, and discusses the rare but previously reported BBF as a complication of TACE for HCC. The presence of bile collections in the lungs and liver can result in tissue necrosis, potentially leading to chronic infection, emphasizing the need for early diagnosis and management.

Prevalence and Risk Factors of Post-chemoembolization Syndrome After Chemo-Embolization for Hepatocellular Carcinoma in Thailand

BACKGROUND

The data regarding the incidence of post-embolization syndrome after transarterial chemoembolization for hepatocellular carcinoma in Thailand are scarce. Therefore, this study aimed to determine the prevalence and predictors of post-embolization syndrome after transarterial chemoembolization for hepatocellular carcinoma in Thailand.

METHODS

This retrospective study collected data from patients undergoing transarterial chemoembolization for five years. Post-embolization syndrome was defined as fever and/or abdominal pain, and/or nausea or vomiting that occurred within three days after the transarterial chemoembolization procedure for hepatocellular carcinoma or hospital discharge. Pre-defined predictors for post-embolization syndrome were explored using Poisson regression analysis.

RESULTS

Of the 298 patients and 739 transarterial chemoembolization procedures, the incidence of post-embolization syndrome was 68.1% (203/298) and the incidence density was 53.9% (398/739). Tumor size, Barcelona Clinic Liver Cancer stages, and dose of chemotherapy showed no association with the occurrence of PES. However, a model for end-stage liver disease score was the only predictor for post-embolization syndrome [adjusted IRR 0.91 (0.84-0.98); p = 0.01]. There were three patients developing fever after transarterial chemoembolization due to infection.

CONCLUSION

Post-embolization syndrome was common in patients undergoing transarterial chemoembolization for hepatocellular carcinoma. Patients with a lower model for end-stage liver disease scores were at increased risk of post-embolization syndrome. This study highlights the burden of post-embolization syndrome among patients with hepatocellular carcinoma receiving transarterial chemoembolization.

Transarterial Chemoembolization for Hepatocellular Carcinoma: 2023 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post-procedural patient care.

Complications Related to Transarterial Treatment of Hepatocellular Carcinoma: A Comprehensive Review

Currently, various types of transarterial treatments are performed for hepatocellular carcinoma from the early to advanced stages. Its indications and efficacy have been widely investigated. However, procedure-related complications have not been updated in the literature, although new types of transarterial treatments, such as drug-eluting bead transarterial chemoembolization and transarterial radioembolization, are common in daily practice. Herein, a comprehensive literature review was carried out, and complications were organized according to the organs affected and treatment modalities.

Pyogenic liver abscess in non-liver cancer patients and liver cancer patients treated with TACE: Etiological characteristics, treatment, and outcome analysis

Clinical, laboratory, and microbiological features, clinical outcomes, and pyogenic liver abscess (PLA) prognosis evaluation in non-liver cancer (Non-LC) and liver cancer patients treated with transarterial chemoembolization (TACE, LC-TACE). Clinical data of 48 consecutive PLA patients from January 2016 to December 2020 were retrospectively analyzed. Mortality between two PLA patient groups were compared, and mortality risk factors were evaluated. A total of 48 PLA patients (31 males and 17 females) from January 2016 to December 2020 met the study's inclusion criteria. There were 32 and 16 patients in the Non-LC and LC-TACE groups, respectively. Positive pus culture rate in the Non-LC group was 87.5% and positive pus culture rate in LC-TACE group was 81.3%. In the Non-LC group, 28 patients improved after treatment, 1 patient did not improve, and 3 patients died during hospitalization, with a 9.4% mortality rate. In the LC-TACE group, nine patients improved after treatment, three patients did not improve, and four patients died during hospitalization, with a 25% mortality rate. The Non-LC group cure time was 37.4 ± 23.1 days, while the LC-TACE group was 91.5 ± 49.7 days. PLA of the Non-LC group and the LC-TACE group were different in terms of pathogenic bacteria and cure time, and so on. A more comprehensive treatment should be considered for PLA after TACE.

Emerging curative-intent minimally-invasive therapies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common cause of liver malignancy and the fourth leading cause of cancer deaths universally. Cure can be achieved for early stage HCC, which is defined as 3 or fewer lesions less than or equal to 3 cm in the setting of Child-Pugh A or B and an ECOG of 0. Patients outside of these criteria who can be down-staged with loco-regional therapies to resection or liver transplantation (LT) also achieve curative outcomes. Traditionally, surgical resection, LT, and ablation are considered curative therapies for early HCC. However, results from recently conducted LEGACY study and DOSISPHERE trial demonstrate that transarterial radio-embolization has curative outcomes for early HCC, leading to its recent incorporation into the Barcelona clinic liver criteria guidelines for early HCC. This review is based on current evidence for curative-intent loco-regional therapies including radioembolization for early-stage HCC.

Drug-eluting bead transarterial chemoembolization followed by apatinib is effective and safe in treating hepatocellular carcinoma patients with BCLC stage C

BACKGROUND

The present study aimed to evaluate the efficacy and safety of drug-eluting beads transarterial chemoembolization (DEB-TACE) followed by apatinib in treating hepatocellular carcinoma (HCC) patients with Barcelona Clinic Liver Cancer (BCLC) stage C.

METHODS

Totally, 110 HCC patients with BCLC stage C treated with DEB-TACE followed by apatinib were consecutively enrolled. Treatment response (including complete response rate (CR), objective response rate (ORR) and disease control rate (DCR)), survival data (progression-free survival (PFS), overall survival (OS)), and adverse events were documented during the follow-up.

RESULTS

CR, ORR and DCR were 25.5%, 77.2% and 79.1% at 3 months, then were 29.1%, 59.1% and 71.0% at 6 months, respectively. Regarding survival, median PFS (95%CI) was 6.3 (5.0-7.7) months, meanwhile 1-year and 2-year PFS were 19.8% and 3.3%, respectively; median OS (95%CI) was 16.9 (10.2-23.7) months, then 1-year, 2-year and 3-year OS were 66.5%, 34.7% and 14.2%, respectively. Further subgroup analysis indicated that nodule size, Child-Pugh stage, Eastern Cooperative Oncology Group performance status score and level of portal vein invasion were negatively correlated with PFS or OS, which were further validated by univariate and multivariate Cox's regression analysis. Most adverse events by DEB-TACE and apatinib treatment were mild and well-tolerable.

CONCLUSION

DEB-TACE followed by apatinib is effective and safe in treating BCLC stage C HCC patients, indicating its role as an acceptable option in HCC management.

Liver abscess after drug-eluting bead chemoembolization in patients with metastatic hepatic tumors

OBJECTIVE

To investigate the incidence and risk factors for liver abscess formation after treatment with drug-eluting bead chemoembolization (DEB-TACE) in patients with metastatic hepatic tumors (MHT).

METHODS

The current study is a retrospective analysis of the clinical data of 137 patients with metastatic hepatic tumors who received DEB-TACE treatment in our institute (Union Hospital, Tongji Medical College, Huazhong University of Science and Technology) between June 2015 and September 2020. Patients were evaluated for the presence or absence of post-DEB-TACE liver abscess. Univariate and multivariate analyses were used to identify risk factors for liver abscess formation.

RESULTS

The incidence of liver abscess formation after the DEB-TACE procedure was 8.76% per patient and 5.53% per procedure. Univariate analysis showed that larger maximum tumor diameter (p = 0.004), Grade 1 artery occlusion (p < 0.001) and systemic chemotherapy within 3 months before the DEB-TACE procedure (p < 0.001) were all associated with liver abscess formation. However, only systemic chemotherapy within 3 months before the DEB-TACE procedure (OR 5.49; 95% CI 0.34-13.54; p < 0.001) was identified by multivariate analysis to be an independent risk factor.

CONCLUSIONS

Tumor size, Grade 1 artery occlusion and recent systemic chemotherapy may all be associated with increased risk of liver abscess formation following DEB-TACE treatment in patients with metastatic hepatic tumors.

ADVANCES IN KNOWLEDGE

Identification of risk factors for liver abscess formation following DEB-TACE in patients with MHT. These findings suggest the need for caution and consideration of the aforementioned risk factors on the part of interventional radiologists when designing DEB-TACE strategies and performing post-procedure patient management.

Antibiotic prophylaxis in patients with cirrhosis: Current evidence for clinical practice

Patients with cirrhosis show an increased susceptibility to infection due to disease-related immune-dysfunction. Bacterial infection therefore represents a common, often detrimental event in patients with advanced liver disease, since it can worsen portal hypertension and impair the function of hepatic and extra-hepatic organs. Among pharmacological strategies to prevent infection, antibiotic prophylaxis remains the first-choice, especially in high-risk groups, such as patients with acute variceal bleeding, low ascitic fluid proteins, and prior episodes of spontaneous bacterial peritonitis. Nevertheless, antibiotic prophylaxis has to deal with the changing bacterial epidemiology in cirrhosis, with increased rates of gram-positive bacteria and multidrug resistant rods, warnings about quinolones-related side effects, and low prescription adherence. Short-term antibiotic prophylaxis is applied in many other settings during hospitalization, such as before interventional or surgical procedures, but often without knowledge of local bacterial epidemiology and without strict adherence to antimicrobial stewardship. This paper offers a detailed overview on the application of antibiotic prophylaxis in cirrhosis, according to the current evidence.

Investigation of the Physical Properties and Clinical Application of Embosphere Microspheres

BACKGROUND

The aim of this study was to understand physical characteristics of Embosphere microspheres for the clinical use of microsphere chemotherapy embolization of liver cancer.

METHODS

The morphology of Embosphere microspheres in different states, including static, oscillating, and in a magnetic field was observed with the naked eye. Ninety-five patients diagnosed with primary hepatocellular carcinoma (HCC) were separated into 3 groups based on the types of embolic material as follows: 32 cases of sole microspheres, 34 cases of iodinated oil (17 cases with additional application of gelatin sponge particle), and 29 cases of iodinated oil + Embosphere microspheres.

RESULTS

The diameter of the microspheres ranged from 100 to 300 μm, with a sedimentation rate υ = 0.0375 cm/s in physiological saline. The diameter of microspheres ranged from 300 to 500 μm, with a sedimentation rate υ = 0.1875 cm/s. The swelling rate of microspheres was 90%. Microspheres showed nondirectional movement in a 1.5- or 3.0-T magnetic field during magnetic resonance imaging. A volumetric ratio of 1:1.4-1:1.5 between microspheres and contrast agent resulted in optimal suspension properties. Microspheres appeared circular with a smooth surface upon water adsorption. Microsphere embolism was observable in blood vessels of pathological sections. The surface of microspheres can adsorb 5-fluorouracil and arsenic trioxide. There are statistically significant differences in local-regional tumor control conditions among patients treated with sole microspheres, iodinated oil, and iodinated oil + microspheres during transarterial chemoembolization.

CONCLUSIONS

Embosphere microspheres can be used to embolize patients with rupture and hemorrhage of HCC. Embosphere microsphere embolization is superior to iodinated oil and iodinated oil + microsphere for HCC.

Progress toward improving outcomes in patients with cholangiocarcinoma

Purpose of review:

To provide an update on latest advances in treatment of cholangiocarcinoma.

Recent findings:

Incidence of cholangiocarcinoma has been increasing over the past decade. A better understanding of the genetic landscape of cholangiocarcinoma and its risk factors resulted in earlier diagnosis and treatment option expansion to targeted therapy with FGFR inhibitors, and liver transplantation for early perihilar cholangiocarcinoma and early intrahepatic cholangiocarcinoma. IDH1/2 inhibition for intrahepatic cholangiocarcinoma is an emerging targeted therapy approach. Data supports benefits of adjuvant therapy for a subset of patients undergoing surgical resection. Approaches combining different treatment modalities such as chemotherapy, surgery, radiation therapy appear promising.

Summary:

Earlier diagnosis and genetic characterization provided additional treatment options for patients with previously incurable cholangiocarcinoma. A precision medicine approach with a focus on actionable genetic alterations and combination of treatment modalities are actively being explored and will further improve outcomes in our patients with cholangiocarcinoma.

Association between prophylactic antibiotic use for transarterial chemoembolization and occurrence of liver abscess: a retrospective cohort study

OBJECTIVES

Clinical evidence on prophylactic antibiotics for transarterial chemoembolization (TACE) to prevent liver abscess is limited because liver abscess is a rare event. This study aimed to analyse the association between prophylactic antibiotic use for TACE and the occurrence of liver abscess after TACE.

METHODS

Using the nationwide Diagnosis Procedure Combination database in Japan, we retrospectively identified patients who underwent TACE for hepatic cancer between July 2010 and March 2017. The primary outcome was liver abscess requiring procedural intervention within 30 days of TACE. Secondary outcomes included 30-day in-hospital mortality and length of stay. Propensity score matching was performed to adjust for potential confounding factors and compare outcomes between patients with and without prophylactic antibiotics.

RESULTS

Among 167 544 eligible patients, 134 712 received antibiotics and 32 832 did not. In the matched cohort of 29 211 pairs, the proportion of patients with liver abscess requiring procedural intervention was significantly lower in the antibiotics group than in the no-antibiotics group (0.08% vs. 0.22%, p 0.001; relative risk (95% confidence interval), 0.35 (0.22-0.57); absolute risk reduction, 0.0014 (0.0008-0.0021); and number needed to treat, 696 (476-1223)). There was no significant difference in 30-day in-hospital mortality between the groups. The length of stay was longer in the antibiotics group than in the no-antibiotics group (median, 10 vs. 9 days, p < 0.001).

CONCLUSIONS

Prophylactic antibiotic use in patients undergoing TACE was associated with a reduced occurrence of liver abscess requiring procedural intervention.

Case Report: Complete Necrosis of a Large Adrenocortical Cancer and Liver Metastases Achieved by Selective Arterial Embolization: A Case Study and Review of Literature

There is very limited experience regarding the interventional radiological treatment of adrenocortical cancer (ACC). We present the case of a 57-year-old female patient with a large, potentially unresectable left-sided ACC and two hepatic metastases. Both liver tumors were effectively treated by trans-arterial embolization (TAE), followed by TAE of the bulky primary tumor as a life-saving intervention necessitated by severe intratumoral bleeding. Surgical removal of the primary tumor revealed complete necrosis. The patient is considered tumor free after 3.5 years. To the best of our knowledge, this is the first report to show that even a primary ACC may be completely ablated by selective embolization, and the fourth to prove the curative potential of liver TAE for ACC metastases. This case highlights the potential of selective embolization in ACC treatment.

Procalcitonin Levels in Post TACE Infection

Purpose

This study aimed to evaluate the value of serum procalcitonin (PCT) levels in the diagnosis of abscess and sepsis following transarterial chemoembolization (TACE) therapy among patients with hepatocellular carcinoma (HCC).

Patients and Methods

In this study, a retrospective review of patient charts was performed in 2221 patients who suffered from hepatocellular carcinoma and had undergone 8656 TACE procedures from January 2012 to January 2018. According to the diagnosis of infection and abscess after TACE, these participants were divided into infection group (group A, n=48) and abscess group (group B, n=35). Group B included subgroup B1 (suffered from liver abscess but no sepsis, n=16) and subgroup B2 (suffered from liver abscess and sepsis, n=19). The main observational indexes included sociodemographic characteristics and laboratory and clinical parameters.

Results

The results showed that the mean PCT and C-reactive protein (CRP) levels were higher in group B, but receiver-operating characteristic (ROC) analysis showed low sensitivity and specificity. Only the mean PCT level was higher in subgroup B2 than in subgroup B1 (P<0.001); the ROC analysis had high sensitivity and specificity. However, all other data such as NEUT (neutrophil count) and NEUTP (neutrophil percentage) showed no significant differences.

Conclusion

Serum PCT level was a promising inexpensive marker for the diagnosis of liver abscess and sepsis following TACE therapy among patients with primary liver cancer. A cutoff level of 5.1 ng/mL for PCT had high sensitivity and specificity in predicting liver abscess with sepsis.

Multi-modal and sequential treatment of liver cancer and its impact on the gastrointestinal tract

Hepatic tumors include hepatocellular cancer (HCC) and cholangiocarcinoma (CC), a small subgroup of tumors (approx. 1%) are classified as combined hepatocellularcholangiocellular carcinomas. Different stage-dependent therapeutic approaches comprise resection, local ablative techniques, locoregional therapies, systemic treatment, liver transplantation in selected cases and possible combination of these treatment modalities. This review summarizes current knowledge on multi-modal treatment strategies for liver cancer focusing on gastrointestinal side effects.

Cured giant hepatocellular carcinoma after transarterial embolization complicated with liver abscess formation

Many patients with hepatocellular carcinoma cannot be treated surgically because of the advanced stage of the tumor and/or coexisting cirrhosis. Transcatheter arterial embolization (TAE) represents an alternative therapeutic approach for some of these patients. However, it is not a curative measure, and an additional therapy is required to eradicate the residual disease. In this communication, we report a case of 55-year-old man with giant hepatocellular carcinoma located in the right lobe of the liver that was successfully treated with TAE. TAE completely devascularized the tumor in one session. Despite of postembolization antibiotic therapy, complete tumor necrosis led to abscess formation. After 57 days of abscess drainage, necrotic tumor tissue was completely evacuated from the drained cavity; no viable tumor tissue was identified by computed tomography/magnetic resonance imaging scan on a 5 year follow-up. TAE procedure can be suggested as a modulator of antitumor immune response, by exposing tumor antigens after necrosis leading to inflammation. In addition to necrosis caused by TAE, an antimicrobial acute inflammatory reaction in the treated area led to the complete destruction of the giant tumor.

Bloodstream Infection and Its Clinical Characteristics and Relevant Factors Associated with Interventional Therapy in a Large Tertiary Hospital: A Six Years Surveillance Study

Background

Interventional therapy has been widely used in the medical field as its advantages of minimally invasive, safe and quick recovery. Bloodstream infection (BSI) is the most common healthcare-associated infections (HAIs) after interventional therapy, but there are few reports about it. This study intends to analyze the clinical characteristics and relevant factors of BSI after six years of interventional therapy in a large tertiary teaching hospital, in order to provide guidances for the prevention and control of BSI after interventional operations.

Methods

The case information of patients with BSI after interventional therapy from 2013 to 2018 were collected through the "real-time monitoring system of healthcare-associated infections". All BSI was determined by the infection control full-time staff and clinicians. Questionnaires were designed to review case by case and register the relevant patient information into a database. A total of 18 relevant factors were counted. Statistical software was used for analysis.

Results

174 cases of BSI occurred in 25401 patients, the incidence was 0.69%, and BSI accounted for 50% of all infected sites. Gram-positive bacteria accounted for 56.05%, coagulase-negative Staphylococcus was the main infectious bacteria. Relevant risk factor analysis showed that hepatocellular carcinoma, had undergone surgery, biliary complications, prophylactic antibiotic, replacement of antibiotics, number of interventional operations, days of prophylactic antibiotic use were the related risk factors associated with BSI (P < 0.05). Multivariate analysis showed that days of prophylactic antibiotic use (OR = 1.586, P < 0.05) and replacement of antibiotics (OR = 13.349, P < 0.05) were the main risk factors associated with the development of BSI.

Conclusions

BSI is the main infection site after interventional surgery. For patients with the risk factors as hepatocellular carcinoma/biliary complications/had undergone surgery etc., the time of prophylactic antibiotic use can be prolonged properly before interventional surgery, and selection of single antibiotic appropriate for use could significantly aid preventive measures to avoid occurrence of BSI.

Liver abscesses after transcatheter arterial embolization

Objective

This study aimed to evaluate the clinical features, radiological findings, risk factors, and management of liver abscesses following transcatheter arterial chemoembolization (TACE) therapy in patients with primary and metastatic liver cancer.

Methods

The medical records of 163 patients who were treated with TACE in our hospital for a total of 313 times between January 2012 and January 2018 were reviewed. The incidence rate of patients who developed liver abscesses after undergoing treatment, the computed tomography findings of the abscesses, predisposing risk factors, and the method of treatment were evaluated.

Results

Formation of liver abscesses was observed after treatment in four of the 163 (2.4%) patients and in four (1.3%) of the 313 chemoembolization procedures. Additionally, bilioenteric anastomosis was found in two patients and diabetes mellitus in two patients.

Conclusion

Formation of liver abscesses after TACE is a rare, but serious, complication. Physicians should be aware of the predisposing risk factors of TACE because of the possibility of death.

Update on Transarterial Chemoembolization with Drug-Eluting Microspheres for Hepatocellular Carcinoma

Conventional transcatheter arterial chemoembolization (c-TACE) is a widely used first-line palliative treatment for patients with unresectable hepatocellular carcinoma (HCC). Despite the effectiveness of c-TACE, to date, technique and procedure scheduling has not yet been standardized. Drug-eluting microspheres (DEMs) were therefore introduced to ensure more sustained and tumor-selective drug delivery for permanent embolization. These DEMs can load various drugs and release them in a sustained manner over a prolonged period. This approach ensures the delivery of high concentrations of chemotherapeutic agents to tumors, without increasing systemic concentrations, and promote tumor ischemia and necrosis. This review summarizes the recent advances in the use of DEM-TACE to treat HCC.

Complications of transarterial chemoembolization (TACE) in the treatment of liver tumors

INTRODUCTION

Transarterial chemoembolization (TACE) is considered a therapeutic option. It is mostly used in hepatocellular carcinoma or liver colorectal, neuroendocrine or melanoma metastases. Although it is considered a safe procedure, TACE presents complications, such as acute cholecystitis, which is the most common. Other procedure-related complications include pulmonary embolism, hepatic abscess, bile duct injury, gastric mucosa injury and, less frequently, acute pancreatitis. The aim of this study is to review the complications following TACE for liver tumors.

METHODS

We performed a retrospective study including all the TACE procedures performed in a single center during the period between January 2013 and December 2016.

RESULTS

Out of the 196 patients with liver tumors who had undergone 322 TACE, 258 (80%) were male and 64 (20%) were female. Mean patient age was 66.5years. Major complications after chemoembolization included: decompensation with edema/ascites (6patients), acute cholecystitis (4), acute pancreatitis (3), liver rupture (1), liver abscess (1) and renal failure (1). Postembolization syndrome appeared in 71 (20%) patients. On multivariate analysis, it was observed that concomitant cardiovascular disease (OR: 4.5; 95%CI: 1.2-17; P=.025) is a risk factor for the development of complications.

CONCLUSIONS

TACE is a safe and effective procedure for liver tumor treatment. The majority of the complications are rare and present a low incidence of mortality.

Liver abscess caused by Clostridium haemolyticum infection after transarterial chemoembolization for hepatocellular carcinoma: A case report

RATIONALE

Liver abscesses caused by Clostridium species infection are extremely rare.

PATIENT CONCERNS

The authors report the first case of a liver abscess due to Clostridium haemolyticum, which occurred after transarterial chemoembolization (TACE) for hepatocellular carcinoma, in a 76-year-old woman who presented with right upper quadrant pain and fever.

DIAGNOSES

Computed tomography of the abdomen after the second TACE showed an air-filled abscess around a compact, lipiodolized lesion in the right hepatic lobe. Pus culture showed the growth of C haemolyticum.

INTERVENTIONS

Broad-spectrum antibiotics, including piperacillin/tazobactam and metronidazole, were administered, and a percutaneous 10-French pigtail catheter for pus drainage and culture was inserted in the liver abscess.

OUTCOMES

Despite administering intensive treatments, she presented with rapid deterioration in mental status, liver function, and infection markers. She was transferred to the local hospital for palliative conservative treatment.

LESSONS

Clostridia infections, including those involving C haemolyticum, are extremely rare, but should be considered as one of the causative organisms of liver abscess formation after TACE because of its rapid and fatal clinical course.

Asymptomatic pyogenic liver abscesses secondary to Fusobacterium nucleatum and Streptococcus vestibularis in an immunocompetent patient

A 66-year-old male patient presented with symptoms and signs of L4/5 radiculopathy. He was found to be anaemic with elevated inflammatory markers and deranged hepatic enzymes. Imaging revealed lumbar canal stenosis and the presence of pyogenic liver abscesses from which Fusobacterium nucleatum and Streptococcus vestibularis were isolated. The hepatic abscesses were attributed to asymptomatic diverticular perforation. Multiple coexisting incidental infections were discovered, including oesophageal candidiasis, Helicobacter pylori, stool cultures positive for Strongyloides stercoralis, and sputum cultures positive for Enterobacter cloacae, Escherichia coli and Mycobacterium avium Extensive investigations for possible underlying immunosuppression were negative.

Recurrent bacteremia and liver abscess caused by Clostridium difficile: A case report

RATIONALE

Clostridium difficile bacteremia (CDB) and liver abscess is a quite rare presentation of C. difficile infection.

PATIENTS CONCERNS

A 74-year-old male with primary biliary cirrhosis and hepatocellular carcinoma who underwent transarterial chemoembolization (TACE) developed a high fever on post-TACE day 14. Intravenous ceftriaxone and following meropenem were administered, however, his clinical response was poor. On post-TACE day 24, 2 sets of blood culture were taken due to elevation of C-reactive protein levels.

DIAGNOSIS

CDB, caused by bacterial translocation.

INTERVENTIONS

Intravenous vancomycin and oral metronidazole were administered for two weeks.

OUTCOMES

One month after recurrent CDB, the patient was re-admitted due to a liver abscess at the same site of TACE. C. difficile was isolated from the liver abscess and the patient received 6 weeks of oral metronidazole treatment. CDB and liver abscess have not recurred since completion of antibiotic treatment.

LESSONS

The spore-forming ability of C. difficile may contributed to the recurrent CDB episodes and liver abscess formation in necrotic liver tissue following TACE, and long-term metronidazole therapy was considered to be effective to C. difficile liver abscess.

The incidence and outcome of major complication following conventional TAE/TACE for hepatocellular carcinoma

To investigate the incidence and outcome of major complication following conventional transarterial embolization/chemoembolization (TAE/TACE) therapy for hepatocellular carcinoma (HCC).From May 2010 to May 2016, all patients with major complication following conventional TAE/TACE for HCC were included. Major complication was defined as admission to a hospital for therapy, an unplanned increase in the level of care, prolonged hospitalization, permanent adverse sequelae, or death after conventional TAE/TACE therapy by Society of Interventional Radiology.During the study period, a total of 2863 TAE/TACE procedures were performed among 1120 patients, and a total of 24 patients (21 male and 3 female) developed major complication with the incidence of 2.1% (24/1120) per patient and 0.84% (24/2863) per TAE/TACE procedure. The major complications were liver rupture (n = 6), liver abscess (n = 5), femoral artery pseudoaneurysm (n = 3), cholecystitis (n = 2), biloma (n = 2), pulmonary embolism (n = 2), and 1 each of the following: cerebral lipiodol embolism, tumor lysis syndrome, partial intestinal obstruction, gallbladder perforation. The mean interval from last TAE/TACE procedure to the diagnosis of major complication was 11.1 ± 7.7 days. The treatments of the complications were conservative treatment (n = 12), conservative treatment plus percutaneous drainage (n = 3), ultrasound-guided thrombin injection (n = 3), conservative treatment plus TAE (n = 2), and conservative treatment plus surgery (n = 2). Of the 24 patients, 20 patients were recovered, and remaining 4 patients were died of major complications; therefore, the mortality rate of major complication was 16.7% (4/24).Major complication following conventional TAE/TACE therapy is uncommon; the outcomes are benign of most major complications, but some are mortality.