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Transcatheter hepatic arterial embolization followed by microwave ablation for hemobilia from hepatocellular carcinoma.

Bile duct invasion is rare in patients with hepatocellular carcinoma (HCC). We show the usefulness of selective transcatheter hepatic arterial embolization (TAE) followed by microwave coagulation therapy (MCT) in a case of HCC with portal and biliary tumor thrombi that ruptured into the biliary system. A 70-year-old man with HCC was admitted because of melena and postprandial abdominal pain. Four years earlier, he had undergone posterior segmentectomy of the liver for HCC. Portal venous thrombus was detected on computed tomography (CT) 3 months earlier. On admission laboratory tests revealed the following values: serum alkaline phosphatase, 760 IU/L; total serum bilirubin, 11.9 mg/dL; direct bilirubin, 9.8 mg/dL; serum hemoglobin, 7.7 g/dL; alpha-fetoprotein 103.9 ng/mL; and PIVKA-2, 52,655 mAU/mL. Serum examinations were positive for anti-hepatitis C virus antibody but negative for hepatitis B surface antigens. Ultrasonography revealed a hypoechoic mass in the right branch of the bile duct at the hepatic hilum. Doppler ultrasonography showed blood flow in the mass. CT showed diffuse tumor involvement throughout the liver parenchyma and the presence of a high-density substance in the right intrahepatic bile duct. The diagnosis was hemobilia secondary to HCC in the right hepatic lobe. The symptoms recurred, and emergency TAE was performed 5 days after the onset of hemobilia. The symptoms subsided, and liver function improved. Endoscopic retrograde cholangiography revealed obstruction of the right intrahepatic bile duct. Surgery was performed 15 days after TAE, and MCT of the right hepatic hilum was performed. After MCT, CT revealed necrosis of the right hepatic hilum. Seven months after TAE, the patient died of liver failure with no recurrence of hemobilia.