TACE of Metastatic HCC to the Pleura Gabriel Howles, MD, PhD Nishita Kothary MD Department of Radiology Division of Interventional Radiology Stanford University School of Medicine

Disclosures Gabriel Howles, MD, PhD None Nishita Kothary, MD Scientific Advisor, Siemens Healthcare Penn IR

History in Brief 68 Y Male hepatitis B and C negative Prior partial hepatectomy for a 4cm HCC (path: well differentiated HCC, no vascular invasion). On Sorafenib (400mg BID) Triphasic CT showed numerous hypervascular nodules with washout with the dominant burden in Couinaud segment VI, VII Pleural metastasis with chronic right pleural effusion seen on CT. Acc 8479365

Arterial phase of a triphasic CT, demonstrating multiple hypervascular foci in segment VI and VII that washed out on the portal venous and delayed phase (not shown), consistent with HCC

A B Axial and coronal images of the chest (A and B), demonstrate a 2.5cm x 2.5cm x 5cm pleural based, hypervascular nodule on the right, consistent with pleural metastatic disease

Laboratory Data AFP –Pre hepatectomy: 57, post-hepatectomy 28. At presentation:1137 LFT: Total Bilirubin 0.8mg/dL, AST 37 U/L, ALT 38 U/L, Albumin 3.7g/dL, INR 1.2 Creatinine 1.3mg/dL, Platelet count 78,000/µL

A B Early and delayed DSA imaging (A and B) of the thoracic aorta demonstrates arterial supply of pleural mets supplied by the intercostal arteries

A B Catheterization of the right 6th intercostal artery (A) and further selection and placement of a 1.9Fr microcatheter in the distal portion of the 6th intercostal artery (B), redemonstrates the hypervascular pleural met.

Pleural met treated with 31. 3mg of Doxrubicin and 0 Pleural met treated with 31.3mg of Doxrubicin and 0.625mL of Lipiodol (A). Prophylactic topical Ice was placed to prevent cutaneous complications of non-target chemoembolization. Unenhanced CBCT (B) demonstrates lipiodol staining in pleural met

A B Supply to pleural mets by 5th intercostal artery, treated in a similar superselective fashion.

MIP images reconstructed from a contrast enhanced CBCT obtained for radioembolization planning demonstrates multifocal HCC.

Clinical Course Patient returned for Y90 administration on Day 10. Erythema noted along the right posterior chest without ulceration. Asymptomatic, no treatment for chest wall. Uneventful administration of Y90. Skin erythema resolved, without consequences.

Discussion Lung is the most commonly affected organ of extrahepatic metastases from HCC 1 year survival is approximately 30% after diagnosis of pulmonary mets1 Prognostic factors that predict survival after diagnosis of pulmonary mets include oligometastasis, absence of pleural effusion and treatment of pulmonary metastases1

Discussion For intra- or extra-hepatic tumors supplied by extra-hepatic arteries (intercostal arteries or internal mammary arteries), cutaneous complications can occur when therapeutic agents are delivered due to the inadvertent deposition in the terminal cutaneous branches. Topical ice can be used to vasoconstrict cutaneous vasculature and prevent non-target deposition2.

Questions The commonest organ for extrahepatic metastatic disease from HCC is the: Brain Bone Lungs Mediastinal lymph nodes

Questions The commonest organ for extrahepatic metastatic disease from HCC is the: Brain Bone Lungs Mediastinal lymph nodes Answer B

Questions In patients with HCC metastatic to the lung, predictors of improved survival include Oligometastasis Absence of pleural effusion Treatment targeted to the pulmonary mets Resection of primary tumor All of the above

Questions In patients with HCC metastatic to the lung, predictors of improved survival include Oligometastasis Absence of pleural effusion Treatment targeted to the pulmonary mets Resection of primary tumor All of the above Answer E

References 1.Zhang SM et al: Prognostic analysis of pulmonary metastases from hepatocellular carcinoma: Hepatol Int 2008 Jun; 2(2): 237-243. 2. Wang DS et al: Prophylactic Topically Applied Ice to Prevent Cutaneous Complications of Nontarget Chemoembolization and Radioembolization. JVIR 2013 Apr, 24(4): 596-600