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Percutaneous Ablation of Colorectal Liver Metastasis in a Patient With Hereditary Hemorrhagic Telangiectasia
Introduction
Ashwin Mahendra discusses his CIO2023 abstract, "CIO 2023-35 Percutaneous Ablation of Colorectal Liver Metastasis in a Patient With Hereditary Hemorrhagic Telangiectasia."
Transcript
Hi, my name is Ashwin Mahendra. I'm a third-year medical student at the Florida Atlantic University College of Medicine. I'm presenting a case done by Dr. Govindarajan Narayanan at MCVI of microwave ablation of colorectal liver metastases in a patient with hereditary hemorrhagic telangiectasia. So the patient was a 48-year-old male. We presented to our service for pre-radioembolization mapping of 4 colorectal liver metastases, all located in the right hepatic lobe.
His last imaging had shown that the patient had pulmonary and hepatic arteriovenous malformations concerning for Osler-Weber-Rendu syndrome. And on interview with the patient, it was clear that the patient met the Curaçao criteria for a diagnosis of HHT, 4 out of 4. We were a little skeptical at this point about whether pre-radioembolization mapping would show a high lung shunt. And kind of unsurprisingly, the patient had a lung shunt fraction of around 95%.
Current guidelines for the treatment of serious liver conditions in patients with HHT recommend going straight to liver transplant, given the high bleeding risk in these patients. However, the patient had very good liver performance status, and we were hoping to do a local regional therapy on him. There have been about five case reports discussing the treatment of liver tumors in patients with HHT. They've discussed systemic therapy, liver transplant, surgery, and vascular therapy. None of them have discussed ablation.
We felt, given the small size of these metastases and the location of these metastases, that the patient would be a great candidate for a minimally invasive technique like ablation, and that this might be preferred over something that has a slightly higher complication profile like surgery. So we prepped the patients for ablation. Prior to actually getting them into the room for the ablation, we embolized the pulmonary AVM, just as a prophylactic measure to prevent any strokes from any embolus thrown during the ablation. During the microwave ablation, we ablated the visible colorectal liver metastases. The patient had a small, stable pleural effusion that kind of went away with time. And at about 2 weeks follow-up, the patient had a pseudo-aneurysm seen along one of the ablation tracks. In that 2-week interval period, the patient describes feeling some persistent abdominal pain, no shortness of breath, no fevers, no other complications of any other kind.
So the next day, we took him in, we embolized the pseudo-aneurysm using coils, and the patient noted an immediate resolution of that abdominal pain. Since then, the patient has not had any other interventions done. He's on maintenance therapy with capecitabine and Avastin. And about a year later, the patient achieved a complete metabolic response on PET-CT and a negative response for any circulating tumor DNA on Signatera. The patient continues maintenance regimen and is doing fine now. Big learning points from this case include that ablation is a safe procedure or can be done safely in patients with HHT and liver tumors.
Any operators attempting this procedure should be aware of the risks of bleeding and should be very cautious for other risks such as pseudoaneurysm or any other vascular issues that may occur given the high number of AVMs seen in these patients. And finally, this is the first case report discussing the treatment of colorectal liver metastases with local regional techniques in patients with HHT. So far, the evidence that we're kind of showing proves that it can be done.
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