LETTERS TO THE EDITOR

 

Acute necrotizing pancreatitis after transarterial chemoembolization of hepatocellular carcinoma: An usual complication

Pancreatitis aguda necrotizante posterior a quimioembolización transarterial de hepatocarcinoma: una complicación infrecuente

 

 

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Key words: Key words: Pancreatitis. Hepatocellular carcinoma. Liver cirrhosis.

Palabras clave: Pancreatitis. Hepatocarcinoma. Cirrosis hepática.

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Dear Editor,

Acute necrotizing pancreatitis following transarterial chemoembolization is an uncommon complication, its incidence being estimated in around 1.7-2% according to various studies. We report the case of a 60-year-old male patient with a diagnosis of both HBV- and alcohol-related cirrhosis. He underwent a second chemoembolization procedure for a relapsing hepatocellular carcinoma, 12.5mm in diameter, in segment VIII (he was not eligible for transplantation because of prostate adenocarcinoma). Forty-eighthours after the procedure he presented with epigastric pain radiating to the back and right hypochondrium in association with febricula at 37.8 ^oC, with lab tests showing serum amylase of 896mU/ml, C-reactive protein of 122.7mg/l, total bilirubin of 1.64mg/dl (direct bilirubin was 0.83mg/dl), GGT of 147IU/L, alkaline phosphatase of 154U/L, and mildly impaired coagulation (PT, 16.5 seconds; INR, 1.47), with normal CBC and transaminases. Abdominal, IV contrast-enhanced tomography revealed several collections: an extrapancreatic one surrounding the head of the pancreas, 50mm in size, and another one in the uncinate process, 43mm in size, associated with a complication of acute necrotizing pancreatitis (Fig. 1). Following intestinal rest, hydration, intravenous analgesia, and empiric antibiotic therapy with meropenem 1g every 8hours for 7days, the disease had a favorable evolution, and both amylase and C-reactive protein levels returned to normal. Tomographic follow-up at 3months showed that collections had shrunk by 50% in size. Similarly, no uptake was identified by the chemoembolized hepatocellular carcinoma.

 

 

Discussion

Transarterial chemoembolization is a first-line therapy for hepatocellular carcinoma. Its mechanism of action consists of compromising the tumor's arterial inflow and instilling a chemotherapy agent (usually doxorubicin) in order to bring about tumor necrosis (1). Following the procedure post-chemoembolization syndrome is commonly experienced, which is characterized by fever, abdominal pain, nausea/vomiting, and occasionally impaired liver function. Unusual complications may develop, such as noted by Xia Jinglin et al. in their study of 1,348patients, with an incidence of rare complications of 2.68% that ranged from spontaneous carcinoma rupture to hepatic artery occlusion (0.15% and 1.99%); the fact stands out that no acute necrotizing pancreatitis cases was identified in this large series (2). This is an uncommon condition, and studies estimate an incidence of 1.7-2% (clinical pancreatitis) as compared to 40% for biological pancreatitis, defined as hyperamylasemia with no clinical impact (3-5). This complication results from a retrograde injection of the chemotherapeutic, embolizing agent into pancreatic arteries, giving rise to ischemic pancreatitis (6). Amylasemia testing after chemoembolization is controversial -some authors do not recommend its routine use but in patients experiencing severe abdominal pain unrelated to post-chemoembolization syndrome (7,8).

Management in such situation is similar to that of any acute pancreatitis; prophylactic antibiotic use is indicated when severe necrosis or superinfection is present (9). In our case we used meropenem because of the presence of necrotic collections, febricula, and markedly elevated C-reactive protein levels, in addition to cirrhosis-related immune deficiency. Up to 57% of patients may have such collections progressing to pseudocysts; those located at the neck and head should be assessed for drainage or surgical resection when symptomatic (10). In our case all collections evolved satisfactorily with a significant decrease in size, and the patients remained asymptomatic after 3months of follow-up.

 

Juan Manuel Alcívar-Vásquez,Guillermo Ontanilla-Clavijo,
María Teresa Ferrer-Ríos and Juan Manuel Pascasio-Acevedo
Department of Digestive Diseases. Hospital Universitario Virgen del Rocío.
Sevilla, Spain

 

References

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