Rana Ali

Acute lung injury following transcatheter hepatic arterial chemoembolization of doxorubicin-loaded LC beads in a patient with hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) currently is being used as an effective palliative therapy for unresectable cancers especially hepatocelluar carcinoma (HCC). Accidental lipiodol embolism to the lungs is a rare but potentially fatal complication of TACE. This procedure involves injection of drug-eluting microspheres (LC Bead) loaded with doxorubicin, followed by embolization with embozene microspheres until stasis is evident, being used in advanced HCC. We report a patient with inoperable HCC with underlying Hepatitis C and liver cirrhosis, who developed acute lung injury following targeted chemoembolization of selective feeding hepatic artery with LC beads loaded with doxorubicin. Acute lung injury as a complication of unintended lung chemoembolization with doxorubicin has not been previously reported in the literature. Interventional radiologists screen patients for potential hepatic A-V shunt and take appropriate precautions to prevent unintended pulmonary embolization. These include appropriate selection of LC bead particle size especially in patients who are embolized with radiation pellets. This report highlights the need for a screening total body scintigraphy after injection of radionuclide Tc-99 MAA in the feeding hepatic artery to identify patients with hepatic A-V shunt. In such patients, appropriate size selection of LC bead particles is critical to prevent unintended pulmonary chemoembolization and acute lung injury. Other measures include careful patient selection, low dose of chemotherapy, and transient selective hepatic vein balloon occlusion.

A 23-year old male with cough, fever and blood-streaked sputum

A 23-year-old male presented with a history of 2 weeks of cough with blood-tinged sputum, fever, chills and 10-lbs weight loss. Prior to this, he denied any complaint and had no known medical or surgical history. He emigrated 3 years ago to the United States from Mexico, smoked five cigarettes per day on average for the past 5 years and drank alcohol socially. Vitals at presentation were: BP 105/60, HR 125, RR 19, T 99.6 O2Sat 96% on room air. Examination revealed decreased air entry with dullness to percussion on the right lower lung zone. Lab results were: Hb/Hct: 6.5/20, MCV: 62, PPD (–). Initial chest X-ray is shown in Figure 1 and the patient was started on antibiotics for pneumonia. With no improvement in symptoms, and a worsening chest X-ray finding on day 3 of antibiotics, computed tomography (CT) chest was carried out (Fig. 2).