Treatment decisions
This patient had undergone previous abdominal surgery in which the nonresectable liver mass was biopsied. The surgery report
described the mass as adhered to the portal vein, pancreas and bile duct, originating from the base of the liver and attaching
to the body wall, right lateral and quadrate liver lobes and gallbladder. Biopsy results at that time were consistent with
a well-differentiated hepatocellular carcinoma. Since these tumors demonstrate poor biological responses to systemic chemotherapy
and radiation of the liver is not performed, historical standard therapy involves benign neglect and supportive care until
these tumors either metastasize or, more commonly, rupture.
A CT angiogram (Figure 1) indicated that this patient was a good candidate for the drug-eluting bead TACE procedure, which
was performed the next day. A combination of 1 ml of drug-eluting beads was mixed with doxorubicin (30 mg/m2) to allow the beads to absorb the chemotherapy. A 2- to 3-cm surgical incision was made in the groin to permit the placement
of a vascular sheath within the femoral artery. A catheter was advanced under fluoroscopic guidance into the celiac artery.
Superselective access was gained by using a 2.4-Fr microcatheter in order to minimize nontarget (normal liver parenchyma)
embolization and to achieve maximal concentrations of chemotherapy and drug-eluting beads within the actual tumor.
Figure 2: Hepatic arteriograms from the first TACE procedure: 2A) A hepatic arteriogram taken before chemoembolization demonstrating
considerable vascularization of the tumor outlined by a dashed black line. 2B) A hepatic arteriogram taken after the TACE
procedure demonstrating reduced vascularity.
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Figure 2 is a digital subtraction arteriogram of the contributing right hepatic artery illustrating vascularization of the
right-sided liver tumor before (Figure 2A) and after (Figure 2B) chemoembolization. After delivery of the drug-eluting beads,
less blood supply to the tumor was seen.
The dog recovered uneventfully and was discharged from the hospital the next day with prednisone, amoxicillin-clavulanate,
tramadol, ondansetron and omeprazole. The results of repeat complete blood counts one, two and three weeks after the TACE
procedure were unremarkable.
Figure 3: Hepatic arteriograms from the second TACE procedure. 3A) A hepatic arteriogram taken before chemoembolization demonstrating
considerable vascularization of the now-diminished tumor outlined by a dashed black line. 3B) A hepatic arteriogram taken
after the TACE procedure demonstrating reduced vascularity. Note the smaller mass compared with the prior arteriogram (Figure
2).
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The procedure was repeated six weeks later. Figure 3 demonstrates the same superselection and microcatheter location before
(Figure 3A) and after (Figure 3B) the second chemoembolization procedure. Note the smaller, more consolidated liver mass on
this angiogram compared with Figure 2.
Figure 4: Abdominal CT (noncontrast-enhanced) scans taken before the second chemoembolization: 4A) Sagittal reconstruction
of the abdomen with the dashed black line outlining the smaller hepatocellular carcinoma when compared with Figure 1A. 4B)
Coronal reconstruction of the abdomen with the dashed black line outlining the smaller hepatocellular carcinoma when compared
with Figure 1B.
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At the time of the second treatment, a repeat CT angiogram demonstrated about 25 percent tumor size reduction (Figure 4),
and the animal was doing well clinically. These procedures can be repeated as needed. Follow-up phone calls each week confirmed
that the dog continued to do well. Complete blood counts at one, two and three weeks after each chemoembolization procedure
showed no evidence of white blood cell suppression.
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