Minimizing Cutaneous Complications of Chemoembolization of Extra-Abdominal Desmoid Tumor Using Tumescent Vasoconstriction of Skin Blood Vessels

To the Editor,

Desmoid tumors (DT) are rare soft tissue tumors without metastatic potential that can aggressively infiltrate surrounding structures. Transarterial chemoembolization with doxorubicin-eluting beads (DEB-TACE) is a recently described alternative to DTs not amenable to other techniques [1]. However, its most frequent complication is the non-target embolization of cutaneous arteries [1]. This letter describes the successful prevention of non-target embolization of cutaneous branches using subcutaneous epinephrine administration during DEB-TACE of an extra-abdominal DT.

A 34-year-old woman presented to our institution in December 2021 after noticing a “golf ball-sized mass” in the lower left quadrant (LLQ). Imaging workup reported a 10 cm enhancing intramuscular mass within the left rectus abdominis muscle (LRAM) (Fig. 1). Histological study of the lesion revealed a desmoid-type fibromatosis. Given the patient’s refusal of chemotherapy, the technical impossibility of surgery and cryoablation, rapid lesion growth and sharp worsening of symptoms, treatment with DEB-TACE was proposed.

Fig. 1.

Diagnostic MRI (sagittal T1W, axial T1W fat-sat, and postcontrast T1W with subtraction) demonstrating an intra-abdominal desmoid tumor in the left rectus abdominis muscle. It presents solid mass (A-B) characteristics and homogeneous enhancement (C)

The procedure was performed in a hybrid CT-angio suite under general anesthesia. Access to the right common femoral artery and catheterization of the left common and external iliac arteries was performed using a 5F/65 cm Destination sheath (Terumo^®) and a 5F/100 cm Cobra catheter (Merit^®). Microcatheterization (Progreat^® 2.8F, Terumo^®) and digital subtraction angiography (DSA), and CT-angiography (CTA) showed tumor vascular supply from the left epigastric artery (LIEA), with prominent cutaneous vessels also arising from the LIEA (Fig. 2A-B). Considering the high risk of non-target embolization, we infiltrated the subcutaneous tissue surrounding the tumor with a prepared 1:100000 dilution of epinephrine in normal saline by mixing 1 cc of 1:1000 1 mg/ml epinephrine with 100 cc normal saline. Subsequent DSA and CTA demonstrated adequate vasoconstriction (Fig. 2C-D). Finally, we performed DEB-TACE with 100-300um beads loaded with 40 mg of doxorubicin. Final CTA and DSA confirmed total tumor devascularization (Fig. 2E-F). The patient was discharged on the same day. Minimal skin discoloration was noted during skin examination prior to discharge. Clinical and imaging follow-ups demonstrated near-total tumor necrosis, a marked decrease in size (Fig. 3) and symptoms.

Fig. 2.

CTA and DSA during extra-abdominal DT DEB-TACE. A and D demonstrate CTA and DSA, respectively, before administration of subcutaneous epinephrine. Prominent subcutaneous branches are evident (arrows). In B and E, vasoconstriction of these branches after subcutaneous epinephrine is evident. CTA and DSA after DEB-TACE, C and F, demonstrate the correct permeabilization of this branch and tumor devascularization

Fig. 3.

Follow-up MRI 6 months after treatment. The decrease in tumor size is evident (A), as well as its almost total devascularization in contrast-enhanced sequences (B). Only a slight residual peripheral uptake persists (arrow in B)

DEB-TACE is a viable treatment alternative in patients with extra-abdominal DTs not amenable to other therapies [1]. However, its skin discoloration, ulceration, or cutaneous necrosis may occur due to the inadvertent embolization of cutaneous arterial branches [1]. Therefore, special care should be given to the existence of cutaneous branches susceptible to non-target embolization.

Subcutaneous infiltration of epinephrine has been reported in surgical procedures [2]. However, only one case has reported its use during endovascular procedures [3]. Described subcutaneous epinephrine doses vary between 1:100000 and 1:1000000. Given the size of the vessel, we decided to use a dose of 1:100,000, the maximum reported for intentional vasoconstriction. In addition, accidental injections without skin necrosis with doses up to 1:1000 have been reported. Thus, necrosis at such low doses was unlikely [4].

Prophylactic topically applied ice is a widely used technique to prevent skin complications in susceptible patients during DEB-TACE. However, it has been reported that some patients may require additional intravenous sedative medications due to discomfort [5]. Furthermore, this technique does not allow direct therapy targeting of the vessel to which vasoconstriction is intended.

Subcutaneous epinephrine-induced vasoconstriction of the prominent cutaneous arteries before starting DEB-TACE proved critical in the procedure’s performance. Partial embolization of the mass to salvage these branches or even total suspension of the procedure would have been considered, given the high risk of subcutaneous necrosis. Instead, vasoconstriction of these vessels allowed to comfortably and safely perform DEB-TACE of almost the entire mass, achieving up to 90% necrosis of the mass on follow-up imaging tests, as well as complete resolution of the patient’s symptoms in a single treatment session.

Data Availability

Data sharing does not apply to this article as no datasets were generated or analyzed during the current study.