Rapid Intra-Hepatic Dissemination of Hepatocellular Carcinoma with Pulmonary Metastases Following Combined Loco-Regional Therapy
An 83-year-old man with alcoholic liver cirrhosis was treated with microwave ablation of a solitary HCC in segment 4A (2.8 cm in size), and developed tumor recurrence at the ablation site 5 months later (, white arrow), with the recurrent tumor measuring 3.5 cm in size. Given the early recurrence with microwave ablation, the decision was made to perform combination therapy, using TACE and RFA. TACE was performed using a single vial of 100-300 um of DC Beads (Biocompatibles, Surrey, England, UK) loaded with 50 mg of doxorubicin. During arteriography, variant hepatic arterial anatomy was noted. The right lobe was supplied by a replaced right hepatic artery arising from the superior mesenteric artery, a replaced left hepatic artery arising from the gastrohepatic trunk to supply the segment II and III and the middle hepatic artery arising from the gastroduodenal artery supplied only segment 4 and the tumor. No other hypervascular tumors were detected on angiography in the rest of the liver. Cone-beam CT was performed following infusion of the DC beads from the middle hepatic artery (segmental TACE), showing good tumoral uptake of the DC beads (, white arrow). While RFA was scheduled for the next day, it was delayed for 2 weeks for the patient to recover from a urinary tract infection following TACE.\nRadiofrequency ablation was performed with Cool-tip RF system (Valleylab, Boulder, CO, USA), utilizing a switch-box with three active electrodes. Probe placement was performed under combined US and cone-beam CT guidance with no transgression of vascular structures. Active ablation was performed for a total of 16 minutes per device protocol, achieving tip temperature of 70-82 degrees Celsius in the electrodes. Track ablation was performed on completion of the ablation cycle and the patient tolerated the procedure well. The immediate post ablation contrast enhanced CT confirmed adequate ablation margins, with no evidence of disease in the lung bases and rest of the liver ().\nFour weeks after ablation, the patient complained of mild epigastric discomfort and on examination was found to have hepatomegaly. This was associated with close to 10 times elevation of serum alpha-fetoprotein levels from the pre-TACE/RFA level of 2662 ng/L to 24734 ng/L. Contrast enhanced MRI showed multiple (> 15), new 1-1.5 cm rim enhancing nodules around the ablation site and scattered in the left lobe (segment IV, II and III) (). Additionally, tumor thrombus was also present in the inferior vena cava (, curved white arrow) and the left portal vein (, curved white arrow). Several new pulmonary nodules had developed, consistent with pulmonary metastases (). The patient declined systemic therapy, received symptomatic treatment, and died 3 months later from diffuse metastatic disease.