CIO 2023-9 Bowel Complication following Combined (TACE+Y90) Liver Directed Therapy

Purpose: Primary liver cancer is the sixth most diagnosed cancer and Hepatocellular carcinoma (HCC) accounts for 75-95% of all primary liver cancer cases1. Several studies have been performed on exploring the potential of combination therapies to treat advance stage HCC but there is very limited data on complications resulting from these combination therapies. We would like to present a case of advanced HCC which was treated with combination therapy involving TACE and Y90 resulting in complication of hepatic necrosis and sepsis.

Material and Methods: Initial imaging demonstrated a large infiltrative mass involving the entire right hepatic lobe with displacement of the right kidney. The tumor was near the bowel and appendix but there were no imaging features suspicious of infiltration by the tumor. Patient was deemed to be a poor surgical candidate given extent of the disease and general medical condition. Following discussion at a multidisciplinary conference, decision was made to attempt locoregional control via transarterial chemoembolization (TACE) and Y-90 radioembolization. Patient underwent two sessions of TACE and one session of Y-90 radioembolization which went uneventful.

Results: Routine imaging surveillance was performed which did not demonstrate any decrease in tumor burden. Follow up imaging, however, was concerning for infiltration/encasement of the appendix by the tumor. The patient developed sepsis with hepatic abscess for which drainage catheter was placed. His condition further deteriorated, and the family decided against any further interventions.

Conclusions: TACE and Y-90 generally have good safety profiles and to our knowledge there is limited literature on usage of combination therapies. Y-90 radioembolization is known to cause radiation pneumonitis and if not appropriately used can also cause damage to normal hepatocytes. We believe reducing the dose of Y-90 microspheres in cases where the tumor is in close proximity to bowel along with hydro-dissection may help mitigate risk of bowel complications.