A 66-year-old man with pancreatic acinar cell carcinoma developed a hepatic metastasis that enlarged to 6.6 cm despite neoadjuvant FOLFIRINOX, pancreaticoduodenectomy, adjuvant chemoradiotherapy, and gemcitabine plus cisplatin. CT showed a heterogeneously hypoenhancing mass in the periphery of segment VI, an enhancement pattern predicting insufficient coverage by conventional chemoembolization alone. In a single session, 15 mL of an ethanol–doxorubicin–ethiodized oil mixture (1:2) was infused into the segment VI hepatic artery, and the resulting ethiodized oil deposition served as a fluoroscopic target for MWA guided by ultrasonography and fluoroscopy. A purulent perihepatic collection with pneumoperitoneum developed and resolved after percutaneous drainage. Complete response was sustained on follow-up CT, indicating that combined transarterial and thermal ablation can eradicate a large chemotherapy-refractory metastasis.

Variant right inferior adrenal arterial supply to caudate lobe HCC is rare and may be overlooked. We report a 53-year-old man with recurrent caudate lobe HCC after 12 TACE sessions. During the 13th TACE, cone-beam CT of the common hepatic artery did not reveal tumor vascularity. At the 14th TACE, performed 3 days later, the right inferior phrenic artery, the most common extrahepatic collateral feeder to caudate lobe HCC, showed no tumor supply. Angiography and cone-beam CT from a small aortic common trunk giving rise to a variant right inferior adrenal artery and the right renal capsular artery revealed predominant supply from the variant right inferior adrenal artery. Embolization through these branches achieved compact iodized oil uptake without immediate complications.