Abdominal Skin Injury due to Non-Target Embolization of Hepatocellular Carcinoma Vascularized by the Internal Mammary Artery

Abstract

Transarterial chemoembolization (TACE) is considered the first-line treatment for hepatocellular carcinoma (HCC) in patients who are not candidates for curative treatments [1]. HCC is usually a hypervascular tumor with numerous arterial feeders that could lead to non-target embolization injuries [2]. We report a 71-year-old man with a compensated cirrhosis and HCC. A magnetic resonance imaging (MRI) of April 9, 2020, identified a 7 cm lesion at segment IV-A. On April 24, a left lobar TACE was performed through the left hepatic artery (Fig. 1). A 4-week follow-up contrast enhanced CT showed an incomplete response. The internal mammary artery (IMA) was identified as a probable tumoral feeder on cross-sectional imaging. On June 30, the patient was readmitted for a second treatment. Micro-catheterization of the IMA confirmed that indeed, this vessel was responsible for residual tumor vascularization. This was corroborated by Dyna-CT imaging. After unsuccessful attempts to selectively catheterize the tumoral feeding branch, a selective coil embolization (3–5 mm Concerto coils-Medtronic USA) of the IMA artery beyond the feeding tumoral arteries (musculo-phrenic artery) was performed to prevent non-target embolization injury. A doxorubicin–lipiodol emulsion (100 mg/8 ml 1:1 volume) was then injected followed by Gelfoam slurry to near arterial stasis (Fig. 2). Non-enhanced CT obtained immediately after the second embolization showed lipiodol retention in the targeted residual tumor, within the rectus abdominis and internal oblique muscles, as well as on the skin. Unfortunately, one week later the patient presented with an abdominal skin injury (Fig. 3). Initial observation revealed multiple coalescing erythematous, slightly indurated, polycyclic and branching plaques forming a broad reticulated pattern, consistent with altered blood flow in the cutaneous microvasculature, on his right upper quadrant. He was prescribed topical nitroglycerin 2% ointment (Nitrol ) and warm compresses in an attempt to prevent ulceration. However, a one-week follow-up visit showed persistent and painful dusky red indurated plaques with central scarring and focal ulceration. He was given regular paracetamol and hydromorphone for pain control as well as Mupirocin (Bactroban ong ) for the ulcers. Isaac Ruiz, Nadine S. Maalouf and Ahmed Bentridi shares co-first authorship.