Hepatic Necrosis after Trans-Arterial Embolization of Metastatic Neuroendocrine Tumour

Liver metastases from neuroendocrine tumours (NETs) are usually seen on cross-sectional imaging at presentation. In such cases, curative surgical resection is usually not possible given that most patients have bilobar disease. Various locoregional approaches are now widely available that enable local control of disease and management of systemic symptoms. These include trans-arterial embolization (TAE), trans-arterial chemoembolization (TACE), selective internal radiotherapy and thermal ablation. We describe a rare case of hepatic necrosis after TAE in a 61-year-old woman with a metastatic NET. Cross-sectional imaging showed extensive necrosis affecting segments VII and VIII of the liver. This occurred secondary to thrombosis in the portal vein branches to these segments, confirmed on a Doppler ultrasound scan. The mechanism of portal vein thrombosis after TAE could be due to the presence of occult arterioportal anastomoses. These allow transit of the embolizing agents into the portal vein branches supplying the treated segments and subsequent thrombosis. LEARNING POINTS: Hepatic necrosis is a very rare but significant complication of TAE. The incidence of this complication after TAE has not yet been reported. Hepatic necrosis may be mimicked by the more commonly encountered post-embolization syndrome (PES). Hepatic necrosis should be suspected when symptoms are prolonged, or if the patient exhibits any form of deterioration. Prompt cross-sectional imaging is crucial in establishing diagnosis. Thorough supportive management is key in the setting of liver injury or failure. Sepsis should be treated aggressively with regular blood cultures and specialist input should be sought for optimization of antibiotic regimes.