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Image of the Month—Diagnosis
Arch Surg. 2009;144(3):286.
Answer: Gastrohepatic Fistula Following TACE for HCC
Transarterial chemoembolization is a commonly used treatment modality for unresectable HCC. It involves the use of transarterial catheters to deliver local high doses of chemotherapy to the tumor. Often, particulate embolic agents are also administered with the chemotherapy to eliminate the arterial vascular supply of the lesion. Transarterial chemoembolization therapy can be quite effective in treating HCC, resulting in tumor response in 16% to 61% of patients.1 Data on whether TACE offers a survival benefit to patients with HCC remains somewhat controversial.2 Two randomized trials3-4 have suggested that there is no survival benefit, while 2 other randomized studies have reported an improvement in survival following TACE.5-6 Although TACE can usually be performed safely, it can be associated with complications. The most common complication is acute liver failure secondary to hepatic necrosis. Other complications include acute renal failure, encephalopathy, and gastrointestinal bleeding. More rare ischemic complications have also been reported, including hepatic and splenic abscess, gastric and duodenal ulcerations, and biliary stricturing. Often, these complications are attributed to leaking of chemoembolic agents into collateral vessels that supply other organs outside of the tumor bed with blood.7 To our knowledge, this is the first reporting of a hepatogastric fistula following TACE therapy.
This patient was discussed at the multidisciplinary tumor board with interventional radiologists, hepatobiliary surgeons, and oncologists to determine the best course of action to address the fistula. The technical details of the embolization were also reviewed. There was no concern that the chemoembolization agents had inadvertently entered the gastric vessels at the time of the initial TACE. Evaluation of the fistula defect on computed tomography (Figure 2) demonstrated that the liver was well drained into the stomach without any extravasation of enteric contents. Since the patient was clinically well with a contained fistula, it was felt that no further intervention was warranted. After discussion with the patient, surgical intervention was not recommended given the patient’s extensive medical comorbidities and his baseline poor prognosis related to his underlying cirrhosis and advanced HCC. As such, the patient was treated with palliative supportive care.
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Figure 2. Computed tomography of the abdomen in a patient with hepatocellular carcinoma.
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AUTHOR INFORMATION
Correspondence: Timothy M. Pawlik, MD, MPH, Department of Surgery, Johns Hopkins, 600 N Wolfe St, Halsted Bldg, Room 614, Baltimore, MD 22187-6681 (tpawlik1{at}jhmi.edu).
Accepted for Publication: June 18, 2007.
Author Contributions: Study concept and design: Jain, Smith, and Pawlik. Acquisition of data: Jain, Smith, and Geschwind. Analysis and interpretation of data: Jain. Drafting of the manuscript: Jain, Smith, Geschwind, and Pawlik. Critical revision of the manuscript for important intellectual content: Jain and Pawlik. Administrative, technical, and material support: Smith and Geschwind. Study supervision: Pawlik.
Financial Disclosure: None reported.
REFERENCES
1. Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology. 2003;37(2):429-442.
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2. Cormier JN, Thomas KT, Chari RS, Pinson CW. Management of hepatocellular carcinoma. J Gastrointest Surg. 2006;10(5):761-780.
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3. Pelletier G, Roche A, Ink O; et al. A randomized trial of hepatic arterial chemoembolization in patients with unresectable hepatocellular carcinoma J Hepatol. 1990;11(2):181-184.
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4. Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire. A comparison of lipiodol chemoembolization and conservative treatment for unresectable hepatocellular carcinoma. N Engl J Med. 1995;332(19):1256-1261.
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5. Llovet JM, Real MI, Montana X; et al, Barcelona Liver Cancer Group. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial Lancet. 2002;359(9319):1734-1739.
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6. Lo CM, Ngan H, Tso WK; et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma Hepatology. 2002;35(5):1164-1171.
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7. Marelli L, Stigliano R, Triantos C; et al. Transarterial therapy for hepatocellular carcinoma: which technique is more effective? a systematic review of cohort and randomized studies. Cardiovasc Intervent Radiol. 2007;30(1):6-25.
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SECTION EDITOR: CARL E. BREDENBERG, MD
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Image of the Month—Quiz Case
Ajay Jain, Christopher Smith, Jean-Francois H. Geschwind, and Timothy M. Pawlik
Arch Surg. 2009;144(3):285.
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