Hepatic Abscess Development Following Locoregional Therapy for Hepatocellular Carcinoma in Patients With Decompensated Cirrhosis & Prior Biliary Manipulation: A Case Series

Introduction: The formation of hepatic abscesses (HA) after locoregional therapy (LT) for hepatocellular carcinoma (HCC) is a rare complication. It is postulated that prior bacterial seeding of peribiliary capillaries acts as a nidus for HA. We report a cohort of 4 patients with decompensated cirrhosis and HCC who developed HA after LT from 2019 to 2022. Case Description/Methods: Patient 1 is an 81-year-old man with NASH cirrhosis (Child-Pugh C) complicated by HCC with microwave ablation (MWA) and transarterial chemoembolization (TACE), ascites, esophageal varices (EV), hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), who developed biloma and strictures after right hepatectomy, requiring stenting and sphincterotomy. A 9.0 cm segment 2 and 3 HA formed 56 days after MWA growing Morganella and Pseudomonas treated with 6 weeks cefepime and drain placement for 50 days. He had two more recurrences of HA. Patient 2 is a 76-year-old man with HCV cirrhosis (Child B) complicated by HCC with MWA and transarterial radioembolization (TARE), ascites and portal vein thrombus (PVT) who developed ischemic hilar strictures and biloma after yttrium-90 TARE. A 7.3 cm segment 5 and 8 HA formed 12 days after MWA growing Klebsiella treated with 4 weeks ceftriaxone and metronidazole and drain placement for 84 days. Patient 3 is a 72-year-old man with pancreatic adenocarcinoma and HCV cirrhosis (Child A) complicated by HCC and ascites who underwent Whipple procedure and developed biliary strictures after MWA. A 6.9 cm segment 5 HA formed 20 days after MWA growing Enterococcus and Streptococcus treated with 3 weeks moxifloxacin and drain placement for 50 days. Patient 4 is a 70-year-old woman with HIV, cholangiocarcinoma and HCV cirrhosis (Child B) complicated by HCC with MWA and TACE, ascites, EV, HE, SBP and PVT who developed malignant strictures requiring stents and sphincterotomy. A 6.1 cm segment 6 HA formed 1230 days after MWA growing Klebsiella, Streptococcus and Parvinomas complicated by cholangitis and bacteremia treated with 10 weeks of antibiotics narrowed to ceftazidime-avibactam and needle aspiration. All patients received the same perioperative antibiotic prophylaxis. Discussion: This case series demonstrates the role prior biliary manipulation may play in increasing susceptibility to HA formation in HCC patients undergoing LT. Further investigation into rates of HA in patients without biliary manipulation, with other comorbidities, and those receiving alternative prophylaxis is warranted (Table 1). Table 1. - Compiled Patient Cohort Data Demographic Information Patient 1 2 3 4 Age 81 76 72 70 Race White Black White Black Comorbidities Atrial fibrillation, COPD Diabetes mellitus Pancreatic adenocarcinoma, aortic stenosis, COPD Cholangiocarcinoma, HIV, ESRD Cirrhosis Information Patient 1 2 3 4 Cirrhosis Etiology NASH HCV HCV HCV Cirrhosis Complications HCC, ascites, EV, HE, SBP HCC, ascites, PVT HCC, ascites HCC, ascites, EV, HE, SBP, PVT Reason for OLT Rejection Age Patient preference Medical comorbidities, Pancreatic adenocarcinoma Cholangiocarcinoma HCC Information Patient 1 2 3 4 Liver Segments with HCC 2, 3, 4A, 5, 6 2, 3, 4A 4A, 6 6, 7 Child-Pugh Class at Diagnosis C B A B HCC Systemic Therapy Nivolumab, Levatinib SBRT None None Locoregional Treatment Information Patient 1 2 3 4 Number TACE Procedures 2 0 0 2 Number TARE Procedures 0 1 0 0 Number MWA Procedures 4 5 2 2 Hepatic Artery Embolized Right and Left Right Right Right and Left Prophylactic Antibiotics Moxifloxacin Moxifloxacin Moxifloxacin Moxifloxacin Perioperative Antibiotics Piperacillin-tazobactam Piperacillin-tazobactam Piperacillin-tazobactam Piperacillin-tazobactam Procedural Complications None Ischemic hilar stricture Biliary stricture None Abscess and Treatment Information Patient 1 2 3 4 Bilioenteric Risk Factors Right hepatectomy with bilomaLeft hepatic duct stricture with stent, sphincterotomy Hilar stricture with stent, fistulotomyHemobilia, biloma Pancreaticoduodenectomy (Whipple procedure) CholangiocarcinomaMalignant stricture with stent, sphincterotomy Locoregional Treatment Received before Abscess MWA MWA MWA MWA Time from Locoregional Treatment to Abscess Formation 56 days 12 days 20 days 1230 days Labs on Abscess Diagnosis WBC 13.2 B/LCr 1.48 mg/dLTotal bilirubin 0.8 mg/dLAST 83 IU/LALT 69 IU/LINR 1.46 lactate 2.3 mmol/LAFP 10 mg/mL WBC 22.5 B/LCr 1.60 mg/dLTotal bilirubin 3.1 mg/dLAST 18 IU/LALT 11 IU/LINR 1.40 lactate 2.2 mmol/LAFP 2.5 mg/mL No labs collected WBC 13.0 B/LCr 1.50 mg/dLTotal bilirubin 3.3 mg/dLAST 62 IU/LALT 18 IU/LINR 2.20 lactate 3.0 mmol/LAFP 699 mg/mL MELD on Abscess Diagnosis 14 16 7 25 Liver AbscessSegment 2 and 3 5 and 8 5 6 Liver Abscess Size in Largest Dimension 9.0 cm 7.3 cm 6.9 cm 6.1 cm Organisms Isolated Morganella morganiiPseudomonas aeruginosa Klebsiella pneumoniae Enterococcus faeciumStreptococcus viridans Klebsiella pneumoniaeStreptococcus sanguinosisParvinomas micra Antibiotic Treatment Cefepime, 6 weeks Ceftriaxone and metronidazole, 4 weeks Moxifloxacin, 3 weeks Broad coverage 8 weeksCeftazidime-avibactam 2 weeks Abscess Complications Recurrence x2 None None CholangitisStreptococcus sanguinosis bacteremia Drainage Catheter Duration 28 days 84 days 50 days Needle aspiration only Days Hospitalized 4 days 10 days 1 day 72 days COPD: chronic obstructive pulmonary disease, HIV: human immunodeficiency virus, ESRD: end stage renal disease, NASH: nonalcoholic steatohepatitis, HCV: hepatitis C virus, HCC: hepatocellular carcinoma, EV: esophageal varices, HE: hepatic encephalopathy, SBP: spontaneous bacterial peritonitis, PVT: portal vein thrombus, OLT: orthotopic liver transplant, SBRT: sterotactic body radiation therapy, TACE: transarterial chemoembolization, TARE: transarterial radioembolization, MWA: microwave ablation, WBC: white blood cell, Cr: creatinine, AST: aspartate transaminase, ALT: alanine transaminase, INR: interational normalized ratio, AFP: alpha fetoprotein.