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ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 10  |  Page : 628-633

Liver abscess following transarterial chemoembolization for the treatment of hepatocellular carcinoma: A retrospective analysis of 23 cases


1 Department of Interventional Radiology, No. 2 People's Hospital of Changzhou, Nanjing Medical University, Changzhou 213003; Department of Interventional Radiology, People's 10th Hospital Affiliated to Nanjing Medical University, Shanghai 200072, China
2 Department of Radiology and Interventional Radiology, Lishui Central Hospital, Lishui, Zhejiang 325000, China
3 Department of Interventional Radiology, People's 10th Hospital Affiliated to Nanjing Medical University, Shanghai 200072, China
4 Department of Radiology, Mayo Clinic, Jacksonville, Florida 32224, USA
5 Department of Interventional Radiology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China

Date of Web Publication24-Sep-2018

Correspondence Address:
Maoquan Li
Department of Interventional Radiology, People's 10th Hospital Affiliated to Nanjing Medical University, Shanghai 200072
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.199385

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 > Abstract 


Objective: To investigate the incidence, management, and outcome of a liver abscess after transarterial embolization/chemoembolization (TAE/TACE) therapy for hepatocellular carcinoma (HCC).
Materials and Methods: From May 2007 to May 2014, all patients complicated with liver abscess following TAE/TACE for HCC were identified and analyzed at four medical centers.
Results: During the study period, a total of 6984 TAE/TACE procedures were performed among 3129 patients, and a total of 23 patients developed liver abscess with the incidence of 0.33% (23/6984) per procedure. There were 21 males and 2 females, and mean age of 52.1 ± 12.1 years. The mean interval from last TAE/TACE procedure to the diagnosis of liver abscess was 12.9 ± 6.6 days. All the patients received intravenous antibiotics, with ten patients had a percutaneous drain, one each for percutaneous aspiration and surgery. Complications related to the liver abscess were hepatorrhexis and pleural effusion (n = 1), pleural effusion (n = 1), and obstructive jaundice (n = 1), all of which were resolved after conservative treatments. The serum alpha-fetoprotein (AFP) levels were significantly reduced at 6 months after treatment (P < 0.01) in 15 patients whose AFP > 400 ng/mL preprocedure. Complete or partial tumor response at 6 months after TAE/TACE was achieved in three and twenty patients, respectively; and 6 months survival was 100%.
Conclusions: The incidence of a liver abscess after TAE/TACE is low; antibiotics therapy along was successful in about half patients, and percutaneous abscess aspiration/drainage were necessary in large size abscess and severely symptomatic patients; the outcomes are benign without worsening of the progression of underlying HCC.

Keywords: Abscess, complications, hepatocellular carcinoma, transarterial chemoembolization


How to cite this article:
Jia Z, Tu J, Cao C, Wang W, Zhou W, Ji J, Li M. Liver abscess following transarterial chemoembolization for the treatment of hepatocellular carcinoma: A retrospective analysis of 23 cases. J Can Res Ther 2018;14, Suppl S3:628-33

How to cite this URL:
Jia Z, Tu J, Cao C, Wang W, Zhou W, Ji J, Li M. Liver abscess following transarterial chemoembolization for the treatment of hepatocellular carcinoma: A retrospective analysis of 23 cases. J Can Res Ther [serial online] 2018 [cited 2020 Oct 28];14:628-33. Available from: https://www.cancerjournal.net/text.asp?2018/14/10/628/199385




 > Introduction Top


Transcatheter arterial embolization/chemoembolization (TAE/TACE) has been widely accepted as a choice of treatment for unresectable hepatocellular carcinoma (HCC)[1] and has been considered as an effective treatment modality.[2] However, severe complications can occur, which include but not limit to hepatic failure, renal failure, liver abscess, biliary tract injury, necrotizing pancreatitis, and cerebral lipiodol embolism.[3],[4],[5],[6]

Liver abscess is an uncommon complication and can cause a prolonged hospital course and significantly morbidity.[6],[7] The early diagnosis and therapeutic strategies for liver abscess after TACE have been reported differently due to individual patients' critical pathophysiological status, such as advanced tumors, hepatic dysfunction, ascites, and dyscrasia.[7] The effective treatment and outcome along with the underlying progress of malignancy are largely unknown. The aim of this study was to investigate the incidence, diagnosis, treatment, and outcome of liver abscess after TAE/TACE in patients with HCC.


 > Materials and Methods Top


Patients

This study was approved by all participating institutional review boards. Retrospective reviewing of liver abscess was conducted in four different medical centers for all HCC patients who received TAE/TACE therapy during the period of May 2007 and May 2014. Cases were identified through the departmental procedural logs. Patient demographics, clinical information, and procedural data were gathered from patients' medical records.

TAE/TACE procedure

Transarterial embolization/chemoembolization (TAE/TACE) was performed according to the current practice guideline.[8] No single institution was required to prescribe routine prophylactic antibiotic prior to TACE. All patients were admitted after the TAE/TACE procedures for postprocedure supportive treatment and observing potential complications. Routine managements include hydration, antiemetic, pain control, and monitoring liver function changes.

According to the follow-up protocol established at four different hospitals, a routine survey of procedure-related complications was carried out on postdischarged from day 5 to 9 with telephone contact, and additional telephone calls or clinic visits as needed. Immediate clinical follow-up was required if there was suspicious for any severe complication of TAE/TACE treatment.

Diagnosis of liver abscess

The patient presented with fever, chills, leukocytosis, and right upper quadrant pain underwent further imaging evaluation, including contrast-enhanced computed tomography (CT) scan, magnetic resonance imaging (MRI), or ultrasound examines. The liver abscess was defined as a hypoattenuating lesion with peripheral rim enhancement on CT images; MRI showed typical hyperintense signal on T2 and central hypointense on T1; ultrasound revealed dominantly hypoechoic (still with some internal echoes however) to hyperechoic or gas bubbles within the lesion. In addition, any of the three following conditions should be met: (1) blood culture was positive for bacteria, (2) aspirate showed typical purulent material or culture positive, and (3) temperature higher than 38.5°C lasted more than 5 days with leukocyte count >12 × 109/L without another cause.[7],[9]

Treatment of liver abscess

Once the diagnosis of liver abscess established, intravenous antibiotic therapy was routinely initiated in all patients; choice of antibiotic was based on the availabilities and treatment of protocol in different hospitals but generally include Gram-negative enteric organisms.[10] Imaging-guided percutaneous abscess aspiration was performed if liver abscess <5 cm in diameter or drain placement for the abscess >5 cm in diameter without improvement of clinical symptoms after intravenous antibiotic treatment; surgical debridement or segmentectomy was performed in patients whom considered suitable candidates.

The resolution of liver abscess was defined as disappearing of associated clinical symptoms and/or signs, and no longer percutaneous drain or need intravenous antibiotics.

Clinical follow-up

Clinical follow-up was scheduled on the 1st, 2nd, and 3rd months after resolution of liver abscess, and every 3 months thereafter. During follow-up, contrast-enhanced CT or MRI was performed, and routine laboratory workup was obtained, including complete blood count, liver enzymes and bilirubin, and serum alpha-fetoprotein (AFP). The modified Response Evaluation Criteria in Solid Tumors was used to assess the tumor response.[11] Survival was calculated from the date of diagnosis of the liver abscess to the date of death or last follow-up.


 > Results Top


Patients

From May 2007 to May 2014, a total of 3650 patients with HCC underwent TAE/TACE procedures among four participant hospitals. Among the 3650 patients, 521 patients were excluded due to lost to follow-up, and the remaining 3129 patients with clinical follow-up were reviewed. Of the 3129 patients, a total of 6984 TACE procedures were performed, and a total of 23 patients were diagnosed of a liver abscess after TAE/TACE therapy and included in this study [Figure 1]. The incidence of liver abscess was 0.33% (23/6984) per TAE/TACE procedure.
Figure 1: Selection of the patients

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Of the 23 patients, there were 21 males and 2 females, with a mean age of 52.1 ± 12.1 years (range: 23–74 years). [Table 1] summarizes the demographic information, managements, and outcomes of the 23 patients. The mean tumor diameter was 7.2 ± 2.5 cm (range: 2–17 cm), and lipiodol as an embolic agent was used in 22 patients (mean 11.4 ± 5.2 ml, range, 5–30 ml) and polyvinyl alcohol was in 1 patient. A total of 48 TAE/TACE procedures were performed among 23 patients with liver abscess, with mean 2.1 ± 0.9 (range: 1–7) procedures for each patient. The most frequently reported symptom was fever (87.0%, 20/23), followed by chills (34.8%, 8/23) and abdominal pain (26.1%, 6/23). Imaging findings showed peripheral rim enhancement on contrast-enhanced CT or MRI in all 23 patients, and gas contained lesion was seen in 69.6% (16/23) patients. The interval between TAE/TACE procedure and diagnosis of liver abscess was 12.9 ± 6.6 days (range: 2–36 days)
Table 1: The demographic information, managements, and outcomes of the 23 liver abscess patients

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Treatments and outcomes

All the patients received intravenous antibiotics, with ten patients had a percutaneous drain, one each for percutaneous aspiration and surgery. The mean antibiotic therapy was 10.8 ± 4.5 days (range: 4–25 days) of the 11 patients who received antibiotic therapy only, and the mean percutaneous drainage therapy was 28.1 ± 9.1 days (range: 15–42 days) of the ten patients who received percutaneous drainage. The serum AFP levels was significantly reduced (1124.0 ± 210.4 vs. 124.8 ± 63.5 ng/mL, P < 0.01) at 6 months posttreatment in 15 patients whose AFP >400 ng/mL preprocedure. Complete or partial tumor response at 6 months after TAE/TACE treatment was achieved in three and twenty patients, respectively, and 6 months survival was 100% [Figure 2], [Figure 3], [Figure 4].
Figure 2: A 37-year-old male presented with fever, chills, and abdominal pain 11 days after transarterial chemoembolization treatment for approximately 8 days. (a-d) Contrast-enhanced computed tomography scan showed large gas (arrow) contained cavity within the liver, near the residual lipiodol area. There were associated hepatorrhexis and pleural effusion due to liver abscess (arrowhead)

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Figure 3: These patients received percutaneous drainage, and an 8-Fr pigtail catheter was inserted into the cavity of liver abscess (same patient)

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Figure 4: Liver abscess and hepatocellular carcinoma were all resolutions by magnetic resonance imaging 1.5 years later (a-d), these patients have been followed up for 3 years and no hepatocellular carcinoma recurrence (same patient)

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Complications related to the liver abscess were hepatorrhexis and pleural effusion (n = 1) [Figure 2], pleural effusion (n = 1), and obstructive jaundice (n = 1). The hepatorrhexis, pleural effusion, and pleural effusion were healed after conservative treatment, and obstructive jaundice in one patient was resolved after percutaneous drainage of a liver abscess. At the completion of the treatment, all above abscess-related complications were disappeared and all the 23 patients were recovered clinically without further consequence.


 > Discussion Top


This study demonstrated: (1) the incidence of liver abscess was 0.33% (23/6984) per TAE/TACE procedure, (2) the most frequently reported symptom was fever (87.0%, 20/23), followed by chills (34.8%, 8/23) and pain (26.1%, 6/23), (3) intravenous antibiotics therapy can be applied successfully in about half patients, and percutaneous abscess aspiration/drainage applied successfully in about half patients, and (4) the outcomes were benign and all patients were recovered without worsening of the progression of underlying HCC.

TAE/TACE is a widely accepted treatment option for inoperable HCC.[12] With the advancement of TAE/TACE technologies, therapeutic effects have improved, whereas adverse effects have decreased.[13],[14] However, TAE/TACE may still cause a liver abscess.[15],[16],[17] The incidence of a liver abscess after TAE/TACE therapy is uncommon. A recent study, including 3613 patients (2832 HCC patients and 781 metastatic hepatic tumor patients) reported the incidence of liver abscess was 0.19% per TAE/TACE procedure.[7] However, the incidence of liver abscess after TAE/TACE therapy was 0.33% of this study, which was slightly higher. The reasons for the higher incidence in this study was not clear; it may be related to the only HCC patients who were included in this study.[7]

Liver abscess after TAE/TACE therapy has been reported in the literature.[18],[19],[20] However, the underlying risks are still unclear.[18],[19],[20],[21] The possible cause may be multiple:[7] (1) Bacterial infection superimposed upon liver embolization and necrosis, (2) infection during the TAE/TACE procedure, (3) the immunosuppressant effect of chemotherapeutic agents leading to decreased immunity, and (4) patients who with diabetes mellitus. Liver abscess is also reported to relate to be associated with cholelithiasis, intra-abdominal surgery, malignancy, biliary tract disease, liver cirrhosis, and diabetes mellitus.[7],[18] Although 23 patients were included in this study, statistical analysis of risk factors was not possible because of the small sample.

Fever is the most commonly observed symptom in patients developing liver abscess after TAE/TACE therapy, however, which were also frequently encountered in patients without complicating liver abscess after TAE/TACE therapy. Contrast-enhanced CT, MRI, or abdominal ultrasonography may not be able to differentiate liver abscess formation from tumor necrosis syndrome immediate after TAE/TACE therapy. Delayed recognition of liver abscess and subsequently can cause significant morbidity and mortality.[7] Nonetheless, if fever, chills, and abdominal pain were present concomitantly after TAE/TACE, and liver abscess should be suspected if the symptoms persist more than a week, especially in patients whose tumor was large (>5 cm) with profound tumor necrosis on imaging studies.[22] Gas containing focal lesion found on CT and ultrasonogram is the most valuable clue leading to the suspicion and early diagnosis of a liver abscess after TAE/TACE therapy.[23] This study demonstrated 87.0% patients present with fever, 34.8% patients present with chills, and 26.1% patients present with abdominal pain, with the mean interval between TAE/TACE procedure and the diagnosis of liver abscess of 13.4 ± 7.0 days, and gas containing focal lesion was found in 69.6% patients, which suggested fever and chill are common symptoms of liver abscess patients, and a gas containing focal lesion on CT may be the most valuable clue leading to the early diagnosis of liver abscess after TAE/TACE therapy.

When the liver abscess is suspected, prompt treatment is important due to liver abscess is uniformly fatal.[7] Antibiotics therapy should be given immediately after the diagnosis of liver abscess. For the small liver abscess (<5 cm), it could be managed by conservative treatment if the patients' symptoms are mild. Antibiotics therapy is mandatory in assisted with intravenous fluid and nutritional support. Percutaneous aspiration/drainage should be carried out when the patients are clinically ill, large size liquefied abscess or necrosis mixed with the gas component. Combining treatment of the liver abscess with antibiotics therapy and percutaneous aspiration/drainage was effective, and surgery is rarely required.[7],[10] Our study showed antibiotics therapy applied successfully in about half of the patients, and percutaneous abscess aspiration/drainage applied successfully in about half patients; which proved antibiotics therapy or antibiotics therapy plus percutaneous abscess aspiration/drainage were useful to liver abscess patients.

Our study showed all patients were recovered after proper treatments. Interestingly, the serum AFP levels was significantly reduced (P < 0.01) at 6 months in this group of patients after the diagnosis of liver abscess, and complete or partial response at 6 months after TAE/TACE treatment was achieved in three and twenty patients, respectively. The findings may indicate that the abscess formation could be associated with a complete devascularization of the large tumor, which may therefore be of benefit to the HCC patients. However, the prospective, randomized, clinical trials with a large sample size and long-term follow-up are needed to validate this hypothesis.

Study limitations

The major limitation of this retrospective study is that its retrospective nature; the risk factors of a liver abscess after TAE/TACE cannot be analysis due to the amount of patients was small; also, the observation time was short.


 > Conclusions Top


The incidence of liver abscess after TAE/TACE therapy is low; antibiotics therapy along was successful in about half patients, and percutaneous abscess aspiration/drainage was necessary in large size abscess and severely symptomatic patients; the outcomes are benign without worsening of the progression of underlying HCC.

Acknowledgment

The authors would like to thank Arvin Bagherpour, MD, for his help with revising the manuscript.

Financial support and sponsorship

This study was supported by the Natural Science Foundation of China (NO. 81401498) and High-level Medical Talents Training Project of Changzhou (No. 2016CZBJ009). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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