Oncology/endocrine
Empiric Antibiotics for Transarterial Embolization in Hepatocellular Carcinoma: Indicated?

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Background

Transarterial embolization (TAE) remains a common treatment option in unresectable patients with hepatocellular cancer (HCC); however there are no standard protocols for post procedure care in these patients who often have extensive disease, marginal liver function, and multiple comorbidities. The aim of this study was to examine antibiotics use in HCC undergoing TAE.

Methods

A prospective review of our center's 1109 hepato-pancreatico-biliary patients, from 1/99 to 7/07, was performed to identify all HCC patients.

Results

Two hundred one patients with HCC, of whom 59 (29.4%) underwent bland, TAE, or Yttrium-90 therapy. All embolizations were performed by experienced interventional radiologists and were admitted to the surgical oncology service for post-procedure care. There were 46 men and 13 women, with a median age of 61 y. The mean MELD score was 10.9 (8.5–17) with 25 of 59 having <25% liver involvement. The lesion size ranged from 2 to 12 cm with a mean of 4.88 cm; 24 patients (41%) received a single pre-procedural dose of an antibiotic, 7 (12%) a dose of an antibiotic pre- and post-procedurally, and 28 (47%) did not receive any form of antibiotic. The mean length of stay was 1 (0–5) d depending on adjuvant procedures performed during the same hospital admission. No immediate or long term infectious complications were noted, including liver abscess, cholangitis, pneumonia, or sepsis with a median follow up of 28 mo.

Conclusion

The current practice of pre- or post-procedure antibiotics is variable and no evidence can support giving or not giving antibiotics for hepatic arterial therapy. The uses are not indicated as prophylaxis against hepatic infectious complications in patients undergoing transarterial embolization for the treatment of hepatocellular cancer.

Introduction

Hepatocellular carcinoma (HCC) continues to be one of the most rapidly rising cancers in the world with over 500,000 deaths attributed to this disease annually. From 1973 to 1998, there has been a 114% increase in the incidence of the disease in the United States alone, with 10 to 15,000 new cases diagnosed annually. It is estimated that by 2019, the yearly incidence will increase 2-fold [1]. Although resection, transplantation, and local ablative techniques (radio frequency ablation) remain the only potential curative modalities, only 30% of patients are considered suitable candidates. In addition, systemic chemotherapy has failed to demonstrate a survival benefit and has generally had a poor response rate [2].

Transarterial embolization (TAE) and transarterial chemoembolization (TACE) have become a common treatment option for patients with unresectable HCC for the purpose of palliation. This procedure has been widely performed for the past 20 years and the technique has evolved and has been well described in the literature. It has been used alone and in conjunction with radiofrequency ablation (RFA) with the theory that multimodality treatment will allow for increased tumor destruction and decreased local recurrence rates. One possible mechanism that may explain this is that tumor devascularization with transarterial embolization may decrease the heat sink effect by blood causing an increased zone of necrosis during RFA [3].

The rationale for using TAE to treat patients with HCC is as follows: the portal vein normally supplies 75% to 80% of the blood to hepatic parenchyma. In patients with HCC, however, the dominant blood supply is the hepatic artery. This anatomical reconfiguration by the tumor helps explain the efficacy of TAE. It also allows for tumor necrosis while preserving normal hepatic parenchyma.

Multiple meta-analyses have been performed demonstrating a survival benefit for patients receiving TAE versus symptomatic treatment [4]. In addition, a randomized control trial performed by Llovet and colleagues also showed a survival benefit in favor of the TAE treatment arm [5]. Due to these favorable results, it can be reasonable to expect that this modality will continue to be increasingly used.

Although techniques describing the procedure have been well documented, no standard protocols for pre- and post-procedure care have been devised. Specifically, the role of antibiotic prophylaxis against infection has not been evaluated. Generally, the use of antibiotics has been left to the discretion of the proceduralist, with the use hypothesized to reduce TAE associated liver abscess, but no supporting data exists for this practice. The objective of our study was to evaluate and examine the use of antibiotics in HCC patients undergoing TAE.

Section snippets

Methods

An institutional review board approved retrospective review of a prospectively created database of 1109 hepato-pancreatico-biliary patients from 1999 to 2007 was performed. All patients who underwent TAE, TACE, or Yttrium-90 were identified. Only patients who had histological or serological evidence of HCC were included in the study. All other lesions, including metastatic liver tumors, neuroendocrine, and other histological malignancies were excluded. We examined numerous endpoints including

Results

Two hundred and one patients were identified in the database who had hepatocellular cancer; 59 of those patients who underwent transarterial embolization were selected and reviewed. There were 46 men and 13 women (Table 1). The median length of stay was 1 d (0–5) depending on whether RFA was performed during the same hospitalization period. The median size of the largest lesion treated was 4 cm (2–11). The average number of lesions treated was 1 (1–4). The median AFP score was 18 (1.3–12,000).

Discussion

The findings of our study demonstrate that the routine use of antibiotics for post-procedure care in patients undergoing TAE, TACE, or Yttrium-90 as a treatment of HCC is unwarranted. No patient in our review developed infectious complications, including cholangitis, generalized sepsis, liver abscess, or pneumonia.

Historically, much emphasis has been places on antibiotic therapy before and after surgical procedures. However, a thorough search in the literature demonstrates a paucity of articles

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