Transcatheter arterial embolization-induced bilious pleuritis in a patient with hepatocellular carcinoma

A 52-year-old man with hepatocellular carcinoma (HCC) was admitted with cough and fever. He had undergone four series of treatments, including transcatheter embolization and chemoembolization with lipiodol and anticancer drugs, over the previous 2 years. Computed tomography demonstrated dilated hepatic ducts, localized necrosis in the right hepatic lobe, and subphrenic abscess. He died of respiratory failure, because of increased effusion of the right pleura, about 3 weeks after admission. Autopsy revealed adhesions in the lower lobes of the right lung, diaphragm, and liver, with granulomas with bile pigment. A fistula was observed from the necrotic regions of the right hepatic lobe to the pleura through the diaphragm. A tumor thrombus in the portal trunk was histologically confirmed as well and moderately differentiated HCC with trabecular arrangement. Direct invasion of HCC with necrotic tissue to the pleura through the diaphragm appeared to have caused the respiratory failure. Although bilious pleuritis is a rare complication of transcatheter arterial embolization (TAE), it should be considered as an adverse effect of TAE in patients with a dilated hepatic duct.