Acute Obstructive Cholangitis Complicated by Tumor Migration after Transarterial Chemoembolization: A Case Report and Literature Review

Hyung Chul Park; Hyun Bum Park; Cho Yun Chung; Min Woo Jung; Young Eun Joo; Sung Kyu Choi; Sung Bum Cho

doi:10.4166/kjg.2014.63.3.171

Journal List > Korean J Gastroenterol > v.63(3) > 1007205

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Park, Park, Chung, Jung, Joo, Choi, and Cho: Acute Obstructive Cholangitis Complicated by Tumor Migration after Transarterial Chemoembolization: A Case Report and Literature Review

Case Report

Korean J Gastroenterol 2014;63(3):171-175.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.63.3.171

Acute Obstructive Cholangitis Complicated by Tumor Migration after Transarterial Chemoembolization: A Case Report and Literature Review

Hyung Chul Park, Hyun Bum Park, Cho Yun Chung, Min Woo Jung, Young Eun Joo, Sung Kyu Choi, Sung Bum Cho

Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea

Correspondence to: Sung Bum Cho, Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, 160 Baekseo-ro, Dong-gu, Gwangju 501-746, Korea. Tel: +82-62-220-6296, Fax: +82-62-225-8578, E-mail: portalvein@naver.com

Received 28 June 2013 Revised 1 August 2013 Accepted 8 August 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Intraductal tumor invasion of hepatocellular carcinoma (HCC) is considered rare. Transarterial chemoembolization (TACE) is effective for tumor thrombus of HCC in the bile duct. However, a few cases of obstructive jaundice caused by migration of a tumor fragment after TACE have recently been reported. The aim of this study was to identify factors that affect tumor migration after TACE. At this writing, a review of the medical literature disclosed seven reported cases of biliary obstruction caused by migration of a necrotic tumor cast after TACE. We, herein, report on an additional case of acute obstructive cholangitis complicated by migration of a necrotic tumor cast after TACE for intrabile duct invasion of HCC, in a 71-year-old man. The tumor cast in the common bile duct was removed successfully using a basket during ERCP and was pathologically confirmed to be a completely necrotic fragment of HCC. The patient's symptoms showed dramatic improvement. In summary, physicians should be aware of acute obstructive cholangitis complicated by tumor migration in a patient undergoing TACE. We suggest that an intrabile duct invasion would be a major predisposing factor of tumor migration after TACE and drainage procedures such as ERCP or percutaneous transbiliary drainage could be effective treatment modalities in these patients.

Keywords: Hepatocellular carcinoma, Biliary obstruction, Chemoembolization, Migration, Bile duct

References

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Fig. 1.

Hepatobiliary phase transverse T1-weighted MRI at the time of diagnosis shows a hepatocellular carcinoma (white arrow) measuring approximately 2.5 cm in segment IV of the liver, with invasion to the left portal vein and intrahepatic bile duct (black arrows).

Fig. 2.

Abdominal CT scan obtained 28 days after transarterial chemoembolization. (A) Transverse section. (B) Coronoral section. It shows newly a defective lipidol uptake lesion measuring 1.8 cm in segment IV and lipidol uptake (black arrow) of tumor thrombosis in the left intrahepatic bile duct.

Fig. 3.

Abdominal CT scan obtained 45 days after transarterial chemoembolization. Lipidol uptake of tumor thrombosis previously seen in the left intrahepatic bile duct has disappeared (A; white arrow) and migrated to the distal common bile duct (CBD) (B; black arrow). It shows acute obstructive cholangitis associated with a migrated lipiodolized tumor fragment in distal CBD.

Fig. 4.

(A) ERCP shows an elongated filling defect (black arrow) in the lower part of the common bile duct (CBD) and a protruding mass like filling defect (white arrow) in the dilated left intrahepatic bile duct. (B) After a sphincterotomy, a dark green colored, friable material was extracted from the CBD. (C) The mass measured 2.5×1.0 cm in size, and was friable and dark green in color.

Fig. 5.

Completely coagulative necrosis of hepatocellular carcinoma. There are no viable tumor cells and only necrotic materials with bile. Silhouettes of a few hepatocytes with nucleoli are noted in the center area (H&E, ×200).

Table 1.

Summary of Reported Cases of CBD Obstruction Caused by Tumor Thrombus after TACE in HCC

Case no.	Author	Age (yr)/sex	Location (size, cm)	Bile duct dilatation	Bile duct invasion	TACE (total, n)	Days to obstruction after TACE	Treatment modalities	Outcome
1	Spahr et al.⁵	78/M	Segment IV (5)	Rt IHBD	No	1	50	ERCP	Successful
2	Hiraki et al.⁶	69/M	Medial segment (1.7)	Lt IHBD	Lt IHBD	2	18	ERCP	Successful
			Lateral segment (3.2)
3	Choi et al.⁷	62/M	Segment III, IV	Proximal CHD	Proximal CHD	1	14	PTBD	Successful
				Lt hepatic duct	Lt hepatic duct
4	Choi et al.⁸	70/M	Rt lobe	NA	NA	3	60	ERCP	Successful
5	Okuda et al.⁹	61/F	Segment IV (1.5)	Lt IHBD	Lt IHBD	3	7	ERCP	Successful
6	Okuda et al.⁹	82/F	Hilum (4)	Rt IHBD	Rt IHBD	4	10	ERCP	Successful
7	Okuda et al.⁹	71/F	Multiple, both lobes	NA	Rt hepatic duct CBD	8	7	ERCP	Successful
8	Present case	71/M	Segment IV (2)	Lt IHBD	Lt IHBD	1	45	ERCP	Successful

CBD, common bile duct; TACE, transarterial chemoembolization; HCC, hepatocellular carcinoma; Rt, right; Lt, left; NA, not available; IHBD, intrahepatic bile duct; CHD, common hepatic duct; PTBD, percutaneous transbiliary drainage.

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