Impact of spontaneous tumor rupture on prognosis of patients with T4 hepatocellular carcinoma

Machine learning models for predicting postoperative peritoneal metastasis after hepatocellular carcinoma rupture: a multicenter cohort study in China

BACKGROUND

Peritoneal metastasis (PM) after the rupture of hepatocellular carcinoma (HCC) is a critical issue that negatively affects patient prognosis. Machine learning models have shown great potential in predicting clinical outcomes; however, the optimal model for this specific problem remains unclear.

METHODS

Clinical data were collected and analyzed from 522 patients with ruptured HCC who underwent surgery at 7 different medical centers. Patients were assigned to the training, validation, and test groups in a random manner, with a distribution ratio of 7:1.5:1.5. Overall, 78 (14.9%) patients experienced postoperative PM. Five different types of models, including logistic regression, support vector machines, classification trees, random forests, and deep learning (DL) models, were trained using these data and evaluated based on their receiver operating characteristic curve and area under the curve (AUC) values and F1 scores.

RESULTS

The DL models achieved the highest AUC values (10-fold training cohort: 0.943, validation set: 0.928, and test set: 0.892) and F1 scores (10-fold training set: 0.917, validation cohort: 0.908, and test set:0.899) The results of the analysis indicate that tumor size, timing of hepatectomy, alpha-fetoprotein levels, and microvascular invasion are the most important predictive factors closely associated with the incidence of postoperative PM.

CONCLUSION

The DL model outperformed all other machine learning models in predicting postoperative PM after the rupture of HCC based on clinical data. This model provides valuable information for clinicians to formulate individualized treatment plans that can improve patient outcomes.

Comparative analysis among therapeutic modalities in ruptured hepatocellular carcinoma and identification of imaging predictors for survival

BACKGROUND

Spontaneous rupture of hepatocellular carcinoma (rHCC) poses a life-threatening complication with a mortality rate of 25-75%. Treatment aims at achieving hemostasis and includes options such as trans-arterial embolization, perihepatic packing, and hepatic resection. The optimal treatment remains a subject of debate. Our retrospective review evaluates these treatments and investigates imaging's role in prognosis for rHCC patients.

PURPOSE

We aimed to compare survival outcomes among rHCC patients who received transarterial embolization (TAE), surgery (perihepatic packing, hepatectomy), or best supportive care (BSC), while also identifying predictive imaging factors in these patients.

MATERIALS AND METHODS

All patients diagnosed with rHCC and admitted to Maharaj Nakorn Chiangmai Hospital between January 2012 and December 2021 were included. We reviewed clinical features, imaging results, treatment modalities, and outcomes. In order to balance pretreatment confounders, inverse probability treatment weighting (IPTW) was employed. Flexible parametric survival regression was utilized to compare survival outcomes and identify imaging factors predicting the survival of rHCC patients. Hazard ratios (HR) and the difference in restricted mean survival time (RMST) were reported.

RESULT

Among the 186 rHCC patients included, we observed 90-day and 1-year mortality rates of 64% and 84%, respectively. Both the TAE and surgery groups exhibited significantly lower 1-year mortality rates compared to BSC. The HR were 0.56 (95% CI 0.33-0.96) for TAE and 0.52 (95% CI 0.28-0.95) for surgery compared to BSC. Both the TAE and surgery also significantly extended the 1-yeaar life expectancy post-initial treatment when compared to BSC, with an RMST difference of + 55.40 days (95% CI 30.18-80.63) for TAE vs. BSC and + 68.43 days (95% CI 38.77-98.09) for surgery vs. BSC. The presence of active contrast extravasation and bleeding in both lobes were independent prognostic factors for 1-year survival.

CONCLUSIONS

TAE and surgical treatments provide comparable survival benefits for rHCC patients, extending survival time by approximately 2 months compared to best supportive care. We strongly recommend active management for all rHCC patients whenever possible.

Prognosis of spontaneously ruptured hepatocellular carcinoma: a propensity score matching study

PURPOSE

Spontaneous rupture is a fatal complication of hepatocellular carcinoma (HCC). This study compared the prognosis of spontaneously ruptured HCC (srHCC) with that of non-ruptured HCC (nrHCC).

METHODS

A total of 185 srHCC patients and 1085 nrHCC patients treated by hepatectomy between February 2005 and December 2017 at Zhongshan Hospital were retrospectively reviewed and enrolled. The overall survival (OS) and time to recurrence (TTR) were evaluated. A 1:2 propensity score matching (PSM) analysis was performed using the nearest neighbor matching with a caliper of 0.2.

RESULTS

Before PSM, patients with srHCC who underwent hepatectomy (n = 185) had a poorer prognosis than those with nrHCC (n = 1085; 5-year OS, 39.1% vs 59.2%, P < 0.001; 5-year TTR, 83.8% vs 54.9%, P < 0.001). After PSM, patients with srHCC (n = 156) had higher 5-year TTR (83.2% vs 69.0%, P < 0.001) but comparable 5-year OS with those with nrHCC (n = 312, 44.0% vs 46.0%, P = 0.600). Univariate and multivariate analyses demonstrated spontaneous rupture as an independent risk factor for TTR (hazard ratio [HR], 1.681; 95% confidence interval [CI] 1.326-2.132; P < 0.001), but not for OS (HR: 1.074; 95% CI 0.823-1.401; P = 0.600). Further analysis revealed that srHCC was not appropriate to be assigned as T4 stage in American Joint Committee on Cancer classification.

CONCLUSION

Spontaneous rupture of HCC is not a risk factor for survival. If resected eventually, srHCC may achieve comparable survival with nrHCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Comparison of the prognosis of BCLC stage A ruptured hepatocellular carcinoma patients after undergoing transarterial chemoembolization (TACE) or hepatectomy: a propensity score-matched landmark analysis

BACKGROUND

At present, the choice of treatment modalities for ruptured hepatocellular carcinoma patients in BCLC stage A remains controversial, and this study compared the overall survival of ruptured HCC patients undergoing TACE or hepatectomy.

METHODS

A total of 283 ruptured HCC patients treated at our liver surgery center were included in our study, of which 175 were treated with hepatectomy and 108 were treated with TACE. To reduce selection bias, we used a propensity score matching (PSM) model, which yielded a total of 88 pairs of patients. We used the Kaplan-Meier method to compare the long-term prognosis, and the Landmark method was used to compare the short-term and long-term prognoses of patients after PSM. Finally, we performed subgroup analysis according to whether it met the Milan criteria.

RESULTS

After PSM, in the hepatectomy group, the 1-, 3-, and 5 year OS rates were 73.4%, 45.4%, and 33.9%, respectively. In the TACE group, the 1-, 3-, and 5 year OS rates were 58.5%, 40.6%, and 23.2%, respectively. Within one year, the hepatectomy group had a better prognosis than the TACE group (P = 0.022), but there was no difference in long-term survival(P = 0.936). In the subgroup analysis, in patients who met the Milan criteria, the survival curve indicated that there was no statistically significant difference in the survival prognosis between the two groups (P = 0.294) HR = 1.56(0.68-3.59); in the patients beyond the Milan criteria, the survival time was 28.0 months (20.0-34.0) in patients who underwent hepatectomy and 18 months (9.8-26.2) in patients who underwent TACE, and the survival curve indicated a statistically significant difference (P = 0.043) HR = 1.57(1.01-2.43).

CONCLUSION

Our propensity score-matched study found that ruptured HCC patients treated by hepatectomy had a better short-term prognosis than those treated by TACE, but there was no difference in the long-term prognosis between the two treatment groups.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Early-Stage Ruptured Hepatocellular Carcinoma With Different Tumor Diameters: Small Tumors Have a Better Prognosis

Background and Aim

Ruptured hepatocellular carcinoma (rHCC) is classified as T4 according to the TNM staging system with a very poor (does not achieve expected) prognosis, which has always been controversial. This study aimed at assessing the specific impact of different tumor diameters on the posttreatment prognosis of BCLC stage 0/A rHCC patients.

Methods

Data from 258 patients with BCLC stage 0/A HCC treated in our center from January 2008 to December 2017 were collected, including 143 rHCC patients and 115 patients with non-ruptured HCC (nrHCC). With the help of X-tile software, we determined the cutoff value of the tumor diameter in patients with rHCC. Using 8 cm as the cutoff, we divided rHCC patients into Small-rHCC (n = 96) and Large-rHCC (n = 47) groups, compared the prognoses of the S-rHCC and L-rHCC groups, as well as the prognoses of the two groups with the nrHCC group using the Kaplan–Meier method, and screened the prognostic factors of rHCC patients using the multivariate Cox risk model.

Results

The OS of the S-rHCC group was significantly higher than that of the L-rHCC group [HR = 2.41 (1.60–3.63)], and the OS of the nrHCC group was comparable to that of the S-rHCC group (P = 0.204). In patients treated with surgery only, OS and RFS were also comparable in the S-rHCC nrHCC group. Meanwhile, multivariate Cox regression analysis revealed that alpha-fetoprotein (AFP), alkaline phosphatase (ALP), and the main method of treatment were also prognostic factors for OS in patients with rHCC.

Conclusions

Ruptured HCC with a relatively small diameter (≤8 cm) can also achieve the same prognosis as nrHCC patients after aggressive treatment. It is also not recommended to include all patients with rHCC in stage T4.

Effect of Perioperative Blood Transfusion on the Postoperative Prognosis of Ruptured Hepatocellular Carcinoma Patients With Different BCLC Stages: A Propensity Score Matching Analysis

Background and Aim

The effect of perioperative blood transfusion (PBT) on the prognosis of patients with ruptured hepatocellular carcinoma (rHCC) with different Barcelona Clinic Liver Cancer (BCLC) stages is not clear. We identified the independent predictors of PBT for postoperative rHCC and investigated the effects of PBT on the prognosis of patients with rHCC at different BCLC stages.

Methods

A total of 340 patients who underwent curative hepatectomy for rHCC between January 2010 and March 2018 were abstracted from the databases of two centers. A total of 166 patients underwent PBT. The prognosis of patients who received PBT and those who did not was compared before and after propensity score matching (PSM) in different BCLC stages. Univariate and multivariate Cox regression analyses were also used to identify independent predictors of PBT.

Results

We divided the 340 patients into two groups: early tumor stage (BCLC-A) n = 196 and advanced tumor stage (BCLC-B/C) n = 144. Overall, the median survival time of the PBT group was lower than that of the nonPBT group before and after PSM. However, in the BCLC-BC group, the prognosis of patients with PBT was not statistically different from that of patients without blood transfusion. Univariate Cox analysis showed that PBT was a risk factor affecting the overall survival (OS) and recurrence-free survival (RFS) in BCLC-A, and PBT was not a risk factor for poor OS and RFS in BCLC-B/C.

Conclusion

Perioperative blood transfusion has a negative impact on the postoperative prognosis of patients with rHCC in the early stage, but has no significant impact on the postoperative prognosis of patients with rHCC in the advanced stage.

Spontaneous Rupture of Hepatocellular Carcinoma: New Insights

Background

Spontaneous rupture of hepatocellular carcinoma (HCC) is a potentially fatal complication and the third leading cause of death in patients with HCC after tumor progression and liver failure. Previous studies suggested that improved HCC surveillance has decreased the incidence of rupture. This study aims to characterize patients with ruptured HCC over time and identify predictors of rupture.

Methods

We retrospectively reviewed a prospectively collected database of 1451 HCC patients to identify cases with rupture and predictors of rupture. Data were divided into three 9-year eras to compare and trend patient/tumor characteristics and rupture.

Results

Fifty-seven patients (3.9%) presented with spontaneous HCC rupture and the following characteristics: mean age 62.6 years, 73.7% males, 41% cirrhosis, and mean tumor size of 8.0 cm. On multivariate analyses, predictors of rupture included obesity, tumor >5 cm, and single tumors, whereas the presence of cirrhosis was a negative predictor for rupture.Across three eras, there were changes in disease etiology and decreases in tumor size, and more HCCs were found with surveillance. However, more patients were noncirrhotic, and the incidence of spontaneous rupture was unchanged over time.

Conclusion

Despite improved early detection of HCC over time, the incidence of rupture has been unchanged. The persistent incidence of rupture may possibly be attributed to increasing proportion of fatty liver-related HCC patients who lack traditional risk factors for surveillance and may not have cirrhosis. Better identification of fatty liver disease and determining which patients need HCC surveillance may be needed in the future to prevent spontaneous rupture.

Treatment strategies and prognosis for initially unresectable ruptured hepatocellular carcinoma: a single-center experience in 94 patients

PURPOSE

To identify the treatment options and prognostic factors for patients with initially unresectable ruptured hepatocellular carcinoma (HCC).

METHODS

Between June 2012 to December 2016, 94 consecutive patients with initially unresectable ruptured HCC were analyzed retrospectively in this study. Patients were followed until December 2017. Predictors of short-term (≤30 days) and long-term (>30 days) survival were identified by using logistic regression model and Cox proportional hazard model, respectively.

RESULTS

Of the 94 patients, initial hemostasis treatment was achieved by transarterial embolization (TAE) in 59 patients, surgical hemostasis in 14, and conservative treatment in 21. Twenty-five (26.6%) patients died within 30 d after tumor rupture. In the multivariate analysis, patients treated with aggressive initial treatment strategies (TAE or surgical hemostasis) (P < 0.001) or those with better Child-Pugh class (P = 0.003) and absence of shock on admission (P = 0.001) had a better chance of short-term survival. Of the 69 patients who survived more than 30 days after initial treatment, the median survival time was 268 d. In the multivariate analysis, among the 69 who survived, early modified LCSGJ stage (P = 0.003) and staged hepatectomy as definitive treatment (P < 0.001) were significant predictors of increased long-term survival.

CONCLUSION

Short-term survival of patients with initially unresectable ruptured HCC could achieve with better Child-Pugh class, absence of shock and aggressive initial treatment strategies. After survived the emergency phase of tumor rupture, long-term survival was significantly increased with early modified LCSGJ stage and staged hepatectomy therapy.

Ruptured Massive Hepatocellular Carcinoma Cured by Transarterial Chemoembolization

Spontaneous tumor rupture is a serious but rare complication of hepatocellular carcinoma (HCC) and has a low survival rate. Here, we report a case of massive HCC that ruptured and was treated successfully with transarterial chemoembolization (TACE). A 55-year-old man with abdominal pain was diagnosed with a 12-cm-wide ruptured HCC at segment 8. The overall liver function was scored as Child-Pugh A, but the single nodule tumor had ruptured; therefore, TACE treatment was initiated. After the first TACE treatment, residual tumors were found; thus, secondary TACE was performed 5 months later. No new lesions or extrahepatic metastases were found 16 months after the first TACE treatment, so hepatic resection was performed for curative treatment. The postoperative pathology results did not reveal any cancer cells; hence, TACE alone resulted in a cure. We report this case because the cure has been maintained for more than 3 years after resection.

Outcomes and Prognostic Factors of Spontaneously Ruptured Hepatocellular Carcinoma

BACKGROUND

Spontaneous tumor rupture is a rare and life-threatening complication of hepatocellular carcinoma (HCC). The best treatment strategy remains unclear.

METHODS

The clinical data of 137 patients with spontaneously ruptured HCC from 2010 to 2015 were reviewed retrospectively. We investigated the outcome and prognostic factors of various treatment strategies.

RESULTS

Of the 137 patients, 53, 45, 3, and 36 patients underwent transcatheter arterial chemoembolization (TACE) alone, liver resection (LR) (LR alone or TACE + LR), surgical hemostasis, and conservative therapy. The patients undergoing LR had longest overall survival (OS). In the TACE alone group, independent factors affecting 30-day mortality were MELD score ≥ 12, AFP ≥ 1000 ng/ml, and largest tumor size ≥ 10 cm. AFP ≥ 1000 ng/ml, largest tumor size ≥ 10 cm, and no tumor capsule were significantly associated with poorer OS. In the LR group, largest tumor size ≥ 10 cm and no tumor capsule were the only independent prognostic factors for poorer OS and recurrence-free survival (RFS). Hypovolemic shock was an independent prognostic factor for poorer OS. The differences in OS between the TACE + LR group and LR alone group were not significant (P = 0.955). However, the RFS is significantly better in the LR alone group than those in the TACE + LR group (P = 0.031).

CONCLUSION

For resectable tumor, LR is the treatment of choice for patients with spontaneous ruptured HCC and preserved liver function. The delay in LR due to preoperative TACE may account for its worse RFS compared with LR alone. In patients with an unresectable tumor, TACE therapy alone improved survival over conservative therapy.

Outcomes and Prognostic Factors of Spontaneously Ruptured Hepatocellular Carcinoma

BACKGROUND

Spontaneous tumor rupture is a rare and life-threatening complication of hepatocellular carcinoma (HCC). The best treatment strategy remains unclear.

METHODS

The clinical data of 137 patients with spontaneously ruptured HCC from 2010 to 2015 were reviewed retrospectively. We investigated the outcome and prognostic factors of various treatment strategies.

RESULTS

Of the 137 patients, 53, 45, 3, and 36 patients underwent transcatheter arterial chemoembolization (TACE) alone, liver resection (LR) (LR alone or TACE + LR), surgical hemostasis, and conservative therapy. The patients undergoing LR had longest overall survival (OS). In the TACE alone group, independent factors affecting 30-day mortality were MELD score ≥ 12, AFP ≥ 1000 ng/ml, and largest tumor size ≥ 10 cm. AFP ≥ 1000 ng/ml, largest tumor size ≥ 10 cm, and no tumor capsule were significantly associated with poorer OS. In the LR group, largest tumor size ≥ 10 cm and no tumor capsule were the only independent prognostic factors for poorer OS and recurrence-free survival (RFS). Hypovolemic shock was an independent prognostic factor for poorer OS. The differences in OS between the TACE + LR group and LR alone group were not significant (P = 0.955). However, the RFS is significantly better in the LR alone group than those in the TACE + LR group (P = 0.031).

CONCLUSION

For resectable tumor, LR is the treatment of choice for patients with spontaneous ruptured HCC and preserved liver function. The delay in LR due to preoperative TACE may account for its worse RFS compared with LR alone. In patients with an unresectable tumor, TACE therapy alone improved survival over conservative therapy.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Effect of the types of pretreatment imaging modalities on the treatment response to palliative radiation for painful bone metastases from solid cancer: a single-center retrospective analysis

Background

Determining the appropriate gross tumor volume is important for irradiation planning in addition to palliative radiation for bone metastases. While irradiation planning is commonly performed using simulation computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, and ¹⁸fluorodeoxyglucose-positron emission tomography-CT (¹⁸FDG-PET-CT) are more sensitive for detecting bone metastasis and invasion areas. Therefore, this study evaluated whether pretreatment imaging modalities influenced the response to palliative radiation therapy (i.e., the irradiation effect) for painful bone metastases from solid malignant carcinomas.

Methods

Consecutive patients with painful bone metastases treated with palliative radiation between January 2013 and December 2017 at our institution were included. We retrospectively investigated the pretreatment images from the different imaging modalities (CT, MRI, bone scintigraphy, and ¹⁸FDG-PET-CT) obtained between 1 month before and the initiation of palliative radiation and determined the primary site of carcinoma, histological type, metastatic lesion type (osteolytic, osteoblastic, or mixed), pathological fracture, and metastatic site (vertebral or not). We then evaluated the relationship between these factors and treatment response. We defined “response” as the condition in which patients achieved pain relief or reduced the use of painkiller medicines.

Results

In total, 131 patients (78 men and 53 women) were included; the median age was 66 years (range, 24–89 years). Prescribed doses were 8–50 Gy/1–25 fractions with 2–8 Gy/fraction. Among the 131 patients, 105 were responders (response rate, 80%). The imaging modalities performed before irradiation were CT in 131 patients, MRI in 54, bone scintigraphy in 56, and ¹⁸FDG-PET-CT in 14. The Welch t-test and chi-square test showed no significant association between treatment response and each factor. Multiple logistic regression analysis including the imaging modality, metastatic site, and pathological fracture also showed no significant association with each factor.

Conclusions

There was no significant relationship between the type of pretreatment imaging and treatment response for painful bone metastases. Thus, setting the appropriate radiation field according to CT images and clinical findings could help avoiding further image inspection before palliative radiation for painful bone metastases.

Staged partial hepatectomy versus transarterial chemoembolization for the treatment of spontaneous hepatocellular carcinoma rupture: a multicenter analysis in Korea

Purpose

The aim of this study was to identify the prognostic factors and compare the long-term outcomes of staged hepatectomy and transarterial chemoembolization (TACE) for patients with spontaneous rupture of hepatocellular carcinoma (HCC).

Methods

This study is a multicenter, retrospective analysis of patients with newly diagnosed ruptured HCC. To compare overall survival between staged hepatectomy group and TACE alone group, we performed propensity score-matching to adjust for significant differences in patient characteristics. To identify prognostic factors, the clinical characteristics at the time of diagnosis of tumor rupture were investigated using Cox-regression analysis.

Results

From 2000 to 2014, 172 consecutive patients with newly diagnosed ruptured HCC were treated in 6 Korean centers. One hundred seventeen patients with Child-Pugh class A disease were identified; of which 112 were initially treated with transcatheter arterial embolization (TAE) for hemostasis and five underwent emergency surgery for bleeder ligation. Of the 112 patients treated with TAE, 44 underwent staged hepatectomy, 61 received TACE alone, and 7 received conservative treatment after TAE. Those that underwent staged hepatectomy had significantly higher overall survival than those that underwent TACE alone before matching (P < 0.001) and after propensity score-matching (P = 0.006). Multivariate analysis showed that type of treatment, presence of portal vein thrombosis, pretreatment transfusion >1,200 mL, and tumor size >5 cm were associated with poor overall survival.

Conclusion

Staged hepatectomy may offer better long-term survival than TACE alone for spontaneous rupture of HCC. Staged hepatectomy should be considered in spontaneous rupture of HCC with resectable tumor and preserved liver function.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Liver Transplantation After Downstagings of Ruptured Advanced Hepatocellular Carcinoma in Cirrhotic Liver: Is It Advisable? A Case Report

Spontaneous rupture of hepatocellular carcinoma (HCC), defined as T4 in TNM stage by the American Joint Committee on Cancer (eighth edition), is a serious life-threatening complication. Effective treatment remains challenging because of a high 1-month mortality, a short median survival, and the potential of peritoneal metastasis. We reported on a case that received a living related donor liver transplantation (LDLT) after successful consecutive downstaging therapies. A 63-year-old man with alcohol-related liver cirrhosis and multiple HCC developed spontaneous rupture and hemoperitoneum. He received 3 sessions of transcatheter hepatic arterial chemoembolization and target therapy with sorafenib. Computed tomography scans and magnetic resonance imaging after 11 months of treatment showed that the patient's HCCs fulfilled the Milan criteria and the University of California San Francisco criteria prior to LDLT. The perioperative course was rather smooth. After discharge, interval follow-up computed tomography studies of chest and liver and a whole-body bone scan showed no tumor recurrence or metastasis up to 20 months post-operation. Successful downstaging therapies of ruptured HCC to fulfill Milan criteria to receive liver transplantation is advisable in highly selected patients.

Abandonment of surveillance, followed by emergency surgery for a second spontaneous rupture of hepatocellular carcinoma: A case report and review of the literature

Hepatocellular carcinoma (HCC) develops in the presence of chronic liver disease, and nonalcoholic fatty liver disease is becoming a frequent cause of HCC in developed regions. Spontaneous rupture of HCC (rHCC) is a potentially life-threatening complication of a tumor. The patient's compliance with surveillance after liver resection is vital for the prevention of rHCC.

Serosal invasion is a strong prognostic factor for hepatocellular carcinoma after hepatectomy

AIM

The clinical impact of serosal invasion by hepatocellular carcinoma (HCC) remains unclear. This study aimed to clarify the significance of serosal invasion as a prognostic factor for patients who underwent hepatectomy for HCC.

METHODS

This retrospective study investigated patients who underwent hepatectomy for HCC between October 2003 and September 2016 in Ehime University Hospital (Toon, Japan). A total of 161 cases were enrolled after excluding cases of concomitant distant metastasis, macroscopic tumor remnant, mixed HCC, and rehepatectomy. We classified these 161 patients into groups with serosal invasion detected (S[+]) and serosal invasion undetected (S[-]). We compared patient characteristics, perioperative data, pathological findings, and prognosis between S(+) and S(-) groups.

RESULTS

Serosal invasion was observed in 19 of the 161 patients (12%). The 5-year recurrence-free survival rate was lower for S(+) (13.0%) than for S(-) (28.7%, P = 0.006). The 5-year overall survival (OS) rate was lower for S(+) (24.7%) than for S(-) (63.9%, P < 0.001). Regarding OS, serosal invasion, preoperative α-fetoprotein value, presence of invasion to hepatic veins, and liver cirrhosis were independent predictors in multivariate analyses. The 3-year OS rate after recurrence was poorer in the S(+) group (22.9%) than in the S(-) group (49.7%, P = 0.001).

CONCLUSIONS

Serosal invasion was a strong predictor of worse outcomes after hepatectomy for HCC. Patients showing serosal invasion need close postoperative follow-up or consideration of adjuvant treatment.

Rupture of Hepatocellular Carcinoma: A Review of Literature

Approximately 700,000 people die of Hepatocellular Carcinoma (HCC) each year worldwide, making it the third leading cause of cancer related deaths. Rupture is a potentially life-threatening complication of HCC. The incidence of HCC rupture is higher in Asia and Africa than in Europe. In Asia approximately 10% of patients with a diagnosis of HCC die due to rupture each year. Spontaneous rupture is the third most common cause of death due to HCC after tumor progression and liver failure. The diagnosis of rupture in patients without history of cirrhosis or HCC may be difficult. The most common symptom of ruptured HCC is abdominal pain (66-100%). Shock at presentation can be seen in 33-90% of cases; abdominal distension is reported in 33%. Abdominal paracentesis documenting hemoperitoneum is a reliable test to provisionally diagnose rupture of HCC, it can be seen in up to 86% of clinically suspected cases. The diagnoses can be confirmed by computed tomography scan or ultrasonography, or both in 75% of cases. Careful pre-treatment evaluation is essential to decide the best treatment option. Management of ruptured HCC involves multi-disciplinary care where hemostasis remains a primary concern. Earlier studies have reported a mortality rate of 25-75% in the acute phase of ruptured HCC. However, recent studies have reported a significant decrease in the incidence of mortality. There is also a decrease in the incidence of ruptured HCC due to improved surveillance and early detection of HCC. Transarterial Embolization is the least invasive method to effectively induce hemostasis in the acute stage with a success rate of 53-100%. Hepatic resection in the other hand has the advantage of achieving hemostasis and in the same go offers a potentially curative resection in selected patients.

Efficacy and prognostic factors of transarterial embolization as initial treatment for spontaneously ruptured hepatocellular carcinoma: a single-center retrospective analysis in 57 patients

PURPOSE

To evaluate the efficacy and prognostic factors following transarterial embolization (TAE) as initial treatment for spontaneously ruptured hepatocellular carcinoma (HCC).

METHODS

From June 2012 to June 2016, a total of 57 spontaneously ruptured HCC patients who received TAE as initial therapy were retrospectively studied at our institution. Patients were followed until October 2016. Survival rates were estimated using the Kaplan-Meier method, and prognostic factors related to survival were evaluated using Cox regression analysis.

RESULTS

Among them, 8 (14.0%) patients died within 30 days after initial TAE. The median overall survival time was 208 days. The 6-month, 1-year, and 2-year cumulative overall survival rates were 50.3%, 35.9%, and 14.7%, respectively. Multivariate analysis indicated that tumor size [HR (hazard ratio) 1.12; 95% CI (confidence interval) 1.02-1.23, P = 0.022] Child-Pugh class (HR 1.78; 95% CI 1.13-2.80; P = 0.013), absence of shock on admission (HR 0.40; 95% CI 0.17-0.95; P = 0.039), and embolization with lipiodol and gelatin sponge particles (HR 0.33; 95% CI 0.16-0.70; P = 0.004) were independent prognostic factors for survival.

CONCLUSION

TAE appeared to be an effective initial treatment for spontaneously ruptured HCC. The results indicated that large tumors, poor Child-Pugh class, and shock on admission were associated with poor prognosis. For these patients, embolization with lipiodol and gelatin sponge particles could achieve better survival than PVA particles used.

Pre-operative predictors of early recurrence/mortality including the role of inflammatory indices in patients undergoing partial hepatectomy for spontaneously ruptured hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

Spontaneous rupture of Hepatocellular Carcinoma (srHCC) is a life-threatening emergency. We sought to identify the pre-operative predictors of early tumor recurrence/mortality including the role of inflammatory indices after partial hepatectomy for srHCC.

METHODS

Between 2000-2015, 79 patients with srHCC were identified to have undergone upfront partial hepatectomy following srHCC. Clinicopathologic data were retrospectively analyzed to identify pre-operative predictors of early (<1 year) recurrence and mortality.

RESULTS

Seventy-nine patients were identified to have undergone partial hepatectomy for srHCC. The 1-year mortality and 1-year recurrence rate in our series was 30.3% and 41.8% respectively. On multivariate analyses, free tumor rupture and a tumor size > 10 cm were identified to be independent predictors of early recurrence while an alpha fetoprotein (AFP) > 200 ng/mL was an independent predictor of early mortality. Neutrophil-to-lymphocyte ratio > 3 and prognostic nutritional index < 40 were predictors of early recurrence while PLR > 180 was a predictor of early mortality on univariate analyses but not multivariate analyses.

CONCLUSIONS

Tumor size > 10 cm, free tumor rupture, and an AFP > 200 ng/mL were useful predictors in avoiding "futile surgery" in patients with srHCC undergoing a partial hepatectomy. Preoperative inflammatory markers appear to be less useful as predictors of early recurrence/mortality in this cohort of patients.

Liver radiofrequency ablation as emergency treatment for a ruptured hepatocellular carcinoma: a case report

BACKGROUND

Hemoperitoneum is a possible complication of hepatocellular carcinoma that may require emergency surgery as an alternative to radiological locoregional therapies.

CASE PRESENTATION

We present a case report of a 78-year-old white man with alcoholic-related cirrhosis and a multifocal hepatocellular carcinoma. An abdominal computed tomography scan showed multiple and bilateral foci of bleeding from broken liver cancer. He was urgently transferred from our radiology unit to our operating room for massive hemoperitoneum. A middle line laparotomy detected a massive hemoperitoneum. His liver was cirrhotic and completely subverted by a tumor; there were two spontaneous bleeding lacerations on segments II and IV, which were uncontrollable with conventional hemostatic techniques. Therefore, it was decided to carry out the coagulation of the multiple vascular afferents of each single mass by means of radiofrequency ablation cycles performed circumferentially on both nodules for a total of 40 minutes. Hemostasis was achieved; the radiofrequency ablation controlled the bleeding from his ruptured hepatocellular carcinoma. He was transferred to our intensive care unit for postoperative monitoring in terms of hemodynamic stability. On postoperative day 2 he was discharged from our intensive care unit.

CONCLUSIONS

Multifocal bleeding hepatocellular carcinoma still has an extremely high mortality. The angiographic control of multiple bilateral bleeding lesions can be extremely difficult and can be contraindicated by the location of the lesions and by the overall clinical condition of the patient. In this case, treatment with radiofrequency ablation has proven to be effective in the control of multiple and bilateral hepatic lesions. This particular technique allowed us to attack the lesion at the level of the vascular pedicle in order to control the bleeding.

Severe Anemia with Hemoperitoneum as a First Presentation for Multinodular Hepatocellular Carcinoma: A Rare Event in Western Countries

Hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma is a life-threatening and rare condition in western countries with an incidence of less than 3% because of early detection of cirrhosis and neoplasm. Here, we describe a case of a 66-year-old male patient with altered mental status with hemorrhagic shock. Computed tomography scan of abdomen revealed hemoperitoneum and mass in liver. Patient underwent resection of liver tumor and biopsy revealed multinodular hepatocellular carcinoma. A high degree of suspicion is required where severe anemia and hemoperitoneum can be a first presentation for hepatocellular carcinoma especially in patients with chronic hepatitis C infection. Early diagnosis is crucial since mortality rates remain high for untreated cases.