A 78 year-old male with Child-Pugh B cirrhosis and chronic hepatitis C treated with sofosbuvir and velpatasvir underwent his annual follow-up at our Center. Two years prior, the patient successfully underwent radiofrequency ablation (RFA) for an HCC nodule located in segment 5. Contrast-enhanced CT demonstrated no signs of disease recurrence at the site of the previous treatment and the absence of significant ascites. However, it revealed two nodular lesions of 13 mm and 10 mm within segment 6. These lesions exhibited arterial hypervascularization and portal-venous washout consistent with HCC. In addition, a 5 mm nodular lesion was detected in the peritoneum along the right lateroconal fascia, raising suspicion of extrahepatic HCC metastasis, possibly secondary to tumor spillage following the prior percutaneous therapeutic procedure. Laboratory results indicated elevated levels of both total bilirubin (2.6 mg/dL) and albumin (3.0 g/dL), with an international normalized ratio (INR) of 1.5 and alpha-fetoprotein (AFP) levels of 16.5 ng/mL.

Both intrahepatic nodules were not suitable for ablation, and surgical resection was deemed high risk. Therefore, TACE was proposed as an alternative treatment after multidisciplinary deliberation. The treatment of the suspected extrahepatic metastasis was postponed, pending the outcome of the intra-arterial procedure.

Under fluoroscopic guidance, TACE was performed by selectively catheterizing the hepatic arteries feeding the lesions using a highly flexible coaxial microcatheter (2.7–2.8 Fr ProgreatTM, Terumo®), passed through a 4 Fr catheter previously placed in the hepatic artery. Subsequently, a mixture of Epirubicin (Farmorubicin; Pfizer®, Latina, Italy) and iodized oil (Lipiodol; Guerbet®, Milan, Italy) was injected, followed by embolizing Spongel particles (Gelitaspongel®). Follow-up CT at 3 months post-TACE demonstrated a complete radiological response of both nodules, with homogeneous Lipiodol uptake and the disappearance of intra-tumoral enhancement (Fig. 1). However, the extrahepatic nodule exhibited notable growth (10 mm vs. 5 mm) (Fig. 2).

Contrast-enhanced computed tomography (CT) imaging shows the two nodular lesions of 13 mm and 10 mm within segment 6 of the liver, exhibiting arterial hypervascularization (arrows in a) and portal-venous washout (arrows in b), consistent with hepatocellular carcinoma (HCC). The angiographic study, in the parenchymal phase, confirms the two hypervascular nodules (arrows in c). After transarterial chemoembolization (TACE), the occlusion of the tumor-feeding vessels is demonstrated together with the patency of the remaining hepatic arteries (d). Contrast-enhanced CT performed 3 months post-TACE demonstrates the homogeneous accumulation of the Lipiodol in both lesions, with no signs of relapse in the arterial and portal-venous phases (arrows in e and f)

Contrast-enhanced computed tomography (CT) imaging shows a 5 mm peritoneal nodular lesion along the right lateroconal fascia in both the arterial (arrow in a) and portal-venous (arrow in b) phases. The nodule may represent an extrahepatic HCC metastasis possibly secondary to tumor seeding following a prior radiofrequency ablation (RFA). Contrast-enhanced CT performed 3 months after the transarterial chemoembolization of the two intrahepatic nodules demonstrates a notable growth of the extrahepatic deposition (10 mm vs. 5 mm) (arrows in c and d)

Considering the excellent response achieved with TACE for the two intrahepatic HCC nodules, alongside the persistent contraindications to surgical intervention, multidisciplinary consensus favored attempting TACE treatment for the extrahepatic nodule. Preliminary evaluation of maximum intensity projection (MIP) of CT images allowed accurate delineation of the tumor-feeding vessel, which originated from a thin branch of the right renal artery. Under fluoroscopic guidance, superselective catheterization of the feeding artery was performed and confirmed by cone-bean CT. In addition, the artery’s limited supply to the abdominal parenchyma and intestine was demonstrated. Finally, a mixture of epirubicin (Farmorubicin; Pfizer®, Latina, Italy; 50 mg) and iodized oil (Lipiodol; Guerbet®, Milan, Italy; 10 ml) was injected, followed by embolization using Glubran II particles (GEM Italy®) until complete blockage of the vessel was demonstrated. The patient tolerated the procedure well without any immediate complications.

Follow-up imaging at 1 month post-TACE revealed successful therapeutic agent delivery and the disappearance of arterial enhancement. The Lipiodol deposition was reduced at the 12 month follow-up, and the lesion demonstrated a significant dimensional regression (Fig. 3).

Preliminary evaluation of maximum intensity projection (MIP) of computed tomography (CT) images allowed accurate delineation of the tumor-feeding vessel of the peritoneal metastasis from hepatocellular carcinoma (HCC), which originated from a thin branch of the right renal artery (arrow in a). The angiographic study confirmed the blood supply of the extrahepatic metastasis and its rich blood supply similar to its counterparts in the liver (arrow in b and c). The cone-beam computed tomography (CT) also demonstrated the superselective catheterization of this thin tumor-feeding artery and its limited supply to the abdominal parenchyma and intestine (arrow in d). After transarterial chemoembolization (TACE), the occlusion of the tumor-feeding vessel is demonstrated together with the patency of the remaining hepatic arteries (e). Contrast-enhanced CT performed 1-month post-TACE revealed successful therapeutic agent delivery and the disappearance of arterial enhancement (arrow in f). The Lipiodol deposition was reduced at the 12-month follow-up, and the lesion demonstrated a significant dimensional regression (arrow in g)