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Dexrazoxane prevents skin necrosis in non-target embolization of falciform artery during transcatheter arterial chemoembolization (TACE)
+Model DIII-984; No. of Pages 2
ARTICLE IN PRESS
Diagnostic and Interventional Imaging (2017) xxx, xxx—xxx
LETTER /Interventional imaging Dexrazoxane prevents skin necrosis in non-target embolization of falciform artery during transcatheter arterial chemoembolization (TACE) Keywords Chemoembolization; Complication; Doxorubicin; Hepatocellular carcinoma; Skin Dear Editor, We report a case of non-target embolization of the falciform artery during balloon transcatheter arterial chemoembolization (TACE) with drug-eluting beads (DEB) and the use of dexrazoxane to prevent skin necrosis. A 71-year-old man with a Child Pugh A5 hepatic cirrhosis due to a nonalcoholic steatohepatitis was referred to us for the treatment of hepatocellular carcinoma. Magnetic resonance imaging revealed the presence of 3 lesions (one 4.5 cm lesion in segments 6 and 7, one 2 cm lesion in segment 8 and one 7 cm lesion in segment 4). Due to the size ® and number of lesions, TACE using DEB (DC Beads , BTG London, United Kingdom) was considered. During the procedure, a balloon-occluded TACE technique was used with ® ® the Occlusafe balloon (Occlusafe , Terumo, Tokyo, Japan) to embolize the segmental artery of segment 4 to obtain a better filling of the tumor vessels of the largest lesion by DEB and to protect the branches of segments 2 and 3. Two mL of 100—300 m DEB (loaded with 37.5 mg/mL of doxorubicin ® were injected through the Occlusafe balloon inflated with 0.1 mL of mixed contrast material. Just after completion of TACE, the patient complained of severe epigastric pain. Computed tomography showed no complications. On clinical follow-up in the recovery room, the patient presented with painless supraumbilical skin rash, extending to the right chest wall along two intercostal spaces up to the axillary line, consisting of erythematous maculae without infiltration. Two days later, purple spots developed and the lesions became infiltrated (Fig. 1). Histopathological analysis of skin
biopsy revealed a dermal lymphohistiocytic infiltration with a basophilic foreign body occluding a vessel compatible with a DC bead, surrounded by fibrin and leukocytes. Meanwhile, some lesions started to slightly ulcerate. Although TACE was performed three days before, we decided to perform a treatment with dexrazoxane, a drug which is used to prevent complications from doxorubicin skin and tissue extravasation [1]. The patient was given IV perfusion of dexrazoxane at a dose of 1000 mg/m2 on days 3 and 4 and 500 mg/m2 on day 5 after TACE. During the following days, skin lesions improved with continuous improvement during subsequent follow-up visits until one month after TACE, with no skin necrosis nor need for surgery. Retrospective analysis of hepatic angiogram revealed a small patent falciform artery that was visible after TACE and not before. Although rare, non-target cutaneous embolization following TACE, including conventional TACE and DEB-TACE, has been reported [2]. It is assumed that embolic agents reach the skin via the falciform artery, which arises from the middle or the left hepatic artery, circulates in the round ligament up to the umbilic where it can vascularize the subcutaneous tissue as well as anastomosis with the superior epigastric and internal mammary arteries via the ensiform artery [3]. The frequency of a patent falciform artery on angiograms ranges from 2 to 64.5% [3]. Such a difference is explained by different methods of angiography. Indeed, blood flow through the falciform artery is very slow and the contrast medium in this vessel is better seen when late phases (capillary or venous phases) are obtained. Possible treatments of non-target embolization of the falciform artery during TACE include intralesional injection of steroids, anti-ischemic medication or surgery [2]. Our patient was treated with dexrazoxane, which is approved to treat anthracycline extravasation based on phase 2 clinical trials [1]. Although DEB remain intravascular, doxorubicin is slowly released into the tissues and dexrazoxane may lower toxicity to skin tissue. No standard of care has been established for cutaneous non-target embolization during DEB-TACE. We recommend following guidelines similar to those used for doxorubicin cutaneous extravasation.
Please cite this article in press as: Stalder G, et al. Dexrazoxane prevents skin necrosis in non-target embolization of falciform artery during transcatheter arterial chemoembolization (TACE). Diagnostic and Interventional Imaging (2017), http://dx.doi.org/10.1016/j.diii.2017.09.005
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ARTICLE IN PRESS
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Letter Consent Signed informed consent was obtained from the patient included in this work. The patient also gave us the consent to use his photographs in scientific publications. Acknowledgments We thank Dr Angela Neub and Dr Julie Di Lucca who performed the skin biopsy, Dr Alexandra Miles who provided the picture for Fig. 1c, Dr Oumama El Ezzi for following up the evolution of skin lesions. Disclosure of interest Alban Denys: consultant BTG and Terumo. The other authors declare that they have no competing interest. References [1] Pérez Fidalgo JA, García Fabregat L, Cervantes A, Margulies A, Vidall C, Roila F, et al. Management of chemotherapy extravasation: ESMO-EONS Clinical Practice Guidelines. Ann Oncol 2012;23:vii167—73. [2] Kim HY, Bae SH, Park C-H, Song MJ, Choi JY, Yoon SK, et al. Supraumbilical subcutaneous fat necrosis after transcatheter arterial chemoembolization with drug-eluting beads: case report and review of the literature. Cardiovasc Intervent Radiol 2013;36:276—9. [3] Song S-Y, Chung JW, Lim HG, Park JH. Nonhepatic arteries originating from the hepatic arteries: angiographic analysis in 250 patients. J Vasc Interv Radiol 2006;17:461—9.
G. Stalder a,∗ , G. Deplanque a , K. Shabafrouz a , A. Orcurto a , P. Bize b , R. Duran b , A. Denys b a
Service of Medical Oncology, centre hospitalier universitaire Vaudois and University of Lausanne, 46, rue du Bugnon, 1011 Lausanne, Switzerland b Service of Radiodiagnostic and Interventional Radiology, centre hospitalier universitaire Vaudois and University of Lausanne, 46, rue du Bugnon, 1011 Lausanne, Switzerland ∗ Corresponding
author.
E-mail address: [email protected] (G. Stalder) http://dx.doi.org/10.1016/j.diii.2017.09.005 2211-5684/© 2017 Editions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved. Figure 1. Photographs of the patient’s skin lesions at day 3 (a) and 35 (b) after the procedure; c: skin biopsy from the axilla showing a dermal lymphohistiocytic infiltration with a basophile foreign body in a vessel lumen (star), surrounded by fibrin and leucocytes (hematoxylin & eosin, × 10); d: celiac angiogram showing the hepatic falciform artery (arrows) arising from the left hepatic artery; e: schematic representation of anastomoses between liver and skin vascularization. Falciform artery (A) arises from left or middle hepatic artery, has anastomoses (B) through cutaneous branches or via ensiform artery with superior epigastric and internal mammary arteries. Anterior intercostal arteries (C) arise from internal mammary artery.
Please cite this article in press as: Stalder G, et al. Dexrazoxane prevents skin necrosis in non-target embolization of falciform artery during transcatheter arterial chemoembolization (TACE). Diagnostic and Interventional Imaging (2017), http://dx.doi.org/10.1016/j.diii.2017.09.005
ARTICLE IN PRESS
Diagnostic and Interventional Imaging (2017) xxx, xxx—xxx
LETTER /Interventional imaging Dexrazoxane prevents skin necrosis in non-target embolization of falciform artery during transcatheter arterial chemoembolization (TACE) Keywords Chemoembolization; Complication; Doxorubicin; Hepatocellular carcinoma; Skin Dear Editor, We report a case of non-target embolization of the falciform artery during balloon transcatheter arterial chemoembolization (TACE) with drug-eluting beads (DEB) and the use of dexrazoxane to prevent skin necrosis. A 71-year-old man with a Child Pugh A5 hepatic cirrhosis due to a nonalcoholic steatohepatitis was referred to us for the treatment of hepatocellular carcinoma. Magnetic resonance imaging revealed the presence of 3 lesions (one 4.5 cm lesion in segments 6 and 7, one 2 cm lesion in segment 8 and one 7 cm lesion in segment 4). Due to the size ® and number of lesions, TACE using DEB (DC Beads , BTG London, United Kingdom) was considered. During the procedure, a balloon-occluded TACE technique was used with ® ® the Occlusafe balloon (Occlusafe , Terumo, Tokyo, Japan) to embolize the segmental artery of segment 4 to obtain a better filling of the tumor vessels of the largest lesion by DEB and to protect the branches of segments 2 and 3. Two mL of 100—300 m DEB (loaded with 37.5 mg/mL of doxorubicin ® were injected through the Occlusafe balloon inflated with 0.1 mL of mixed contrast material. Just after completion of TACE, the patient complained of severe epigastric pain. Computed tomography showed no complications. On clinical follow-up in the recovery room, the patient presented with painless supraumbilical skin rash, extending to the right chest wall along two intercostal spaces up to the axillary line, consisting of erythematous maculae without infiltration. Two days later, purple spots developed and the lesions became infiltrated (Fig. 1). Histopathological analysis of skin
biopsy revealed a dermal lymphohistiocytic infiltration with a basophilic foreign body occluding a vessel compatible with a DC bead, surrounded by fibrin and leukocytes. Meanwhile, some lesions started to slightly ulcerate. Although TACE was performed three days before, we decided to perform a treatment with dexrazoxane, a drug which is used to prevent complications from doxorubicin skin and tissue extravasation [1]. The patient was given IV perfusion of dexrazoxane at a dose of 1000 mg/m2 on days 3 and 4 and 500 mg/m2 on day 5 after TACE. During the following days, skin lesions improved with continuous improvement during subsequent follow-up visits until one month after TACE, with no skin necrosis nor need for surgery. Retrospective analysis of hepatic angiogram revealed a small patent falciform artery that was visible after TACE and not before. Although rare, non-target cutaneous embolization following TACE, including conventional TACE and DEB-TACE, has been reported [2]. It is assumed that embolic agents reach the skin via the falciform artery, which arises from the middle or the left hepatic artery, circulates in the round ligament up to the umbilic where it can vascularize the subcutaneous tissue as well as anastomosis with the superior epigastric and internal mammary arteries via the ensiform artery [3]. The frequency of a patent falciform artery on angiograms ranges from 2 to 64.5% [3]. Such a difference is explained by different methods of angiography. Indeed, blood flow through the falciform artery is very slow and the contrast medium in this vessel is better seen when late phases (capillary or venous phases) are obtained. Possible treatments of non-target embolization of the falciform artery during TACE include intralesional injection of steroids, anti-ischemic medication or surgery [2]. Our patient was treated with dexrazoxane, which is approved to treat anthracycline extravasation based on phase 2 clinical trials [1]. Although DEB remain intravascular, doxorubicin is slowly released into the tissues and dexrazoxane may lower toxicity to skin tissue. No standard of care has been established for cutaneous non-target embolization during DEB-TACE. We recommend following guidelines similar to those used for doxorubicin cutaneous extravasation.
Please cite this article in press as: Stalder G, et al. Dexrazoxane prevents skin necrosis in non-target embolization of falciform artery during transcatheter arterial chemoembolization (TACE). Diagnostic and Interventional Imaging (2017), http://dx.doi.org/10.1016/j.diii.2017.09.005
+Model DIII-984; No. of Pages 2
ARTICLE IN PRESS
2
Letter Consent Signed informed consent was obtained from the patient included in this work. The patient also gave us the consent to use his photographs in scientific publications. Acknowledgments We thank Dr Angela Neub and Dr Julie Di Lucca who performed the skin biopsy, Dr Alexandra Miles who provided the picture for Fig. 1c, Dr Oumama El Ezzi for following up the evolution of skin lesions. Disclosure of interest Alban Denys: consultant BTG and Terumo. The other authors declare that they have no competing interest. References [1] Pérez Fidalgo JA, García Fabregat L, Cervantes A, Margulies A, Vidall C, Roila F, et al. Management of chemotherapy extravasation: ESMO-EONS Clinical Practice Guidelines. Ann Oncol 2012;23:vii167—73. [2] Kim HY, Bae SH, Park C-H, Song MJ, Choi JY, Yoon SK, et al. Supraumbilical subcutaneous fat necrosis after transcatheter arterial chemoembolization with drug-eluting beads: case report and review of the literature. Cardiovasc Intervent Radiol 2013;36:276—9. [3] Song S-Y, Chung JW, Lim HG, Park JH. Nonhepatic arteries originating from the hepatic arteries: angiographic analysis in 250 patients. J Vasc Interv Radiol 2006;17:461—9.
G. Stalder a,∗ , G. Deplanque a , K. Shabafrouz a , A. Orcurto a , P. Bize b , R. Duran b , A. Denys b a
Service of Medical Oncology, centre hospitalier universitaire Vaudois and University of Lausanne, 46, rue du Bugnon, 1011 Lausanne, Switzerland b Service of Radiodiagnostic and Interventional Radiology, centre hospitalier universitaire Vaudois and University of Lausanne, 46, rue du Bugnon, 1011 Lausanne, Switzerland ∗ Corresponding
author.
E-mail address: [email protected] (G. Stalder) http://dx.doi.org/10.1016/j.diii.2017.09.005 2211-5684/© 2017 Editions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved. Figure 1. Photographs of the patient’s skin lesions at day 3 (a) and 35 (b) after the procedure; c: skin biopsy from the axilla showing a dermal lymphohistiocytic infiltration with a basophile foreign body in a vessel lumen (star), surrounded by fibrin and leucocytes (hematoxylin & eosin, × 10); d: celiac angiogram showing the hepatic falciform artery (arrows) arising from the left hepatic artery; e: schematic representation of anastomoses between liver and skin vascularization. Falciform artery (A) arises from left or middle hepatic artery, has anastomoses (B) through cutaneous branches or via ensiform artery with superior epigastric and internal mammary arteries. Anterior intercostal arteries (C) arise from internal mammary artery.
Please cite this article in press as: Stalder G, et al. Dexrazoxane prevents skin necrosis in non-target embolization of falciform artery during transcatheter arterial chemoembolization (TACE). Diagnostic and Interventional Imaging (2017), http://dx.doi.org/10.1016/j.diii.2017.09.005