Intraperitoneal seeding of ruptured hepatocellular carcinoma: case report

Treatment and prognosis study of spontaneous rupture hemorrhage in hepatocellular carcinoma: Recommendations for adding the A1 stage to the BCLC staging system

BACKGROUND

The Barcelona Clinic Liver Cancer (BCLC) staging system is an internationally recognized clinical staging system for hepatocellular carcinoma (HCC). However, this staging system does not address the staging and surgical treatment strategies for patients with spontaneous rupture hemorrhage in HCC. In this study, we aimed to investigate the prognosis of patients with BCLC stage A undergoing liver resection for HCC with spontaneous rupture hemorrhage and compare it with the prognosis of patients with BCLC stage A undergoing liver resection without rupture.

METHODS

Clinical data of 99 patients with HCC who underwent curative liver resection surgery were rigorously followed up and treated at Shandong Provincial Hospital from January 2013 to January 2023. A retrospective cohort study design was used to determine whether the presence of ruptured HCC (rHCC) is a risk factor for recurrence and survival after curative liver resection for HCC. Prognostic comparisons were made between patients with ruptured and non-ruptured BCLC stage A HCC (rHCC and nrHCC, respectively) who underwent curative liver resection.

RESULTS

rHCC (hazard ratio [HR] = 2.974, [p] = 0.016) and tumor diameter greater than 5 cm (HR = 2.819, p = 0.022) were identified as independent risk factors for overall survival (OS) after curative resection of BCLC stage A HCC. The postoperative OS of the spontaneous rupture in the HCC group (Group I) was shorter than that in the BCLC stage A group (Group II) (p = 0.008). Tumor invasion without penetration of the capsule was determined to be an independent risk factor for recurrence-free survival (RFS) after liver resection for HCC (HR = 2.584, p = 0.002).

CONCLUSION

HCC with concurrent spontaneous rupture hemorrhage is an independent risk factor for postoperative OS after liver resection. The BCLC stage A1 should be added to complement the current BCLC staging system to provide further guidance for the treatment of patients with spontaneous rupture of HCC.

Ruptured Hepatocellular Carcinoma: What Do Interventional Radiologists Need to Know?

Rupture of HCC (rHCC) is a life-threatening complication of hepatocellular carcinoma (HCC), and rHCC may lead to a high rate of peritoneal dissemination and affect survival negatively. Treatment for rHCC mainly includes emergency surgery, interventional therapies, and palliative treatment. However, the management of rHCC should be carefully evaluated. For patients with severe bleeding, who are not tolerant to open surgery, quick hemostatic methods such as rupture tissue ablation and TAE/TACE can be performed. We described clinical presentation, prognosis, complication, interventional management, and current evidence of rHCC from the perspective of interventional radiologists. Overall, our review summarized that interventional therapies are necessary for most patients with rHCC to achieve hemostasis, even in some patients with Child–Pugh C. Moreover, TAE/TACE followed by staged hepatectomy is a beneficial treatment for rHCC according to current clinical evidence. TAE/TACE is the first choice for most patients with rHCC, and appropriate interventional treatment may provide staged surgery opportunities for those who are not tolerant to emergency surgery to reach an ideal prognosis.

Ruptured Hepatocellular Carcinoma: What Do Interventional Radiologists Need to Know?

Rupture of HCC (rHCC) is a life-threatening complication of hepatocellular carcinoma (HCC), and rHCC may lead to a high rate of peritoneal dissemination and affect survival negatively. Treatment for rHCC mainly includes emergency surgery, interventional therapies, and palliative treatment. However, the management of rHCC should be carefully evaluated. For patients with severe bleeding, who are not tolerant to open surgery, quick hemostatic methods such as rupture tissue ablation and TAE/TACE can be performed. We described clinical presentation, prognosis, complication, interventional management, and current evidence of rHCC from the perspective of interventional radiologists. Overall, our review summarized that interventional therapies are necessary for most patients with rHCC to achieve hemostasis, even in some patients with Child–Pugh C. Moreover, TAE/TACE followed by staged hepatectomy is a beneficial treatment for rHCC according to current clinical evidence. TAE/TACE is the first choice for most patients with rHCC, and appropriate interventional treatment may provide staged surgery opportunities for those who are not tolerant to emergency surgery to reach an ideal prognosis.

Ruptured Hepatocellular Carcinoma: Current Status of Research

Background

Ruptured hepatocellular carcinoma (rHCC) is considered a rare and life-threatening manifestation; when it happens, it often requires acute and positive intervention. At present, the mechanism of rHCC development is gradually being understood while there are many kinds of rHCC treatment. From our clinical observation, the prognosis of rHCC patients is not as poor as it is currently believed. It may not be appropriate to include all patients with rHCC in T4.

Main Body

The incidence of ruptured hepatocellular carcinoma is now rising. Especially in the Asian region, it can even reach 10% – 15%. The most common symptom of HCC rupture is abdominal pain, and there are now a variety of treatments for hepatocellular carcinoma rupture. With aggressive treatment, rHCC patients can also achieve a better prognosis. The patient’s condition varies on admission, so the treatment methods will also be different. It is critical to identify prognostic factors simultaneously, and rHCC can be effectively managed by focusing on important prognostic factors.

Conclusion

A review was carried out to analyze diagnosis, mechanism, treatment, and prognostic risk factors on this disease condition during the current situation; it is hoped that it will provide better guidance for clinicians. Moreover, patients with rHCC were managed hierarchically to prolong their prognosis.

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.

Hepatectomy for spontaneous rupture of hepatocellular carcinoma without portal triad clamping

Hepatectomy without portal triad clamping may decrease the incidence of liver injury; however, the effects of hepatectomy without portal triad clamping in the treatment of spontaneous rupture of hepatocellular carcinoma (SRHCC) remain unclear. The aims of the present study were to evaluate the therapeutic value of hepatectomy without portal triad clamping in the treatment of patients with SRHCC. The present study retrospectively reviewed patients with SRHCC who received hepatectomy without portal triad clamping (non-clamping group) and the therapeutic efficacy was compared with that of 20 patients with SRHCC undergoing the same surgery in the presence of portal triad clamping (clamping group). Following hepatectomy, the non-clamping group exhibited a significantly lower incidence of acute liver failure compared with the clamping group (P<0.05). No significant differences in operative time, intra-operative blood loss, disease-free or overall survival times between the two groups were identified (all P>0.05). At 1 week and 2 weeks after surgery, the non-clamping group exhibited significantly lower alanine aminotransferase, aspartate aminotransferase and total bilirubin serum levels compared with the clamping group (all P<0.05). Hepatectomy without portal triad clamping may decrease the incidence of liver injury and liver failure in patients with SRHCC, suggesting that it may be a safe and effective therapeutic strategy.

Partial hepatectomy for ruptured hepatocellular carcinoma

BACKGROUND

Improvements in surgical technique and perioperative care have made partial hepatectomy a safe and effective treatment for hepatocellular carcinoma (HCC), even in the event of spontaneous HCC rupture.

METHODS

A consecutive cohort of patients who underwent partial hepatectomy for HCC between 2000 and 2009 was divided into a ruptured group and a non-ruptured group. Patients with ruptured HCC were further divided into emergency and staged hepatectomy subgroups. Mortality and morbidity, overall survival and recurrence-free survival (RFS) were compared. Prognostic factors for overall survival and RFS were identified by univariable and multivariable analyses.

RESULTS

A total of 1233 patients underwent partial hepatectomy for HCC, of whom 143 had a ruptured tumour. The morbidity and mortality rates were similar in the ruptured and non-ruptured groups, as well as in the emergency and staged subgroups. In univariable analyses, overall survival and RFS were lower in the ruptured group than in the non-ruptured group (both P < 0·001), and also in the emergency subgroup compared with the staged subgroup (P = 0·016 and P = 0·025 respectively). In multivariable analysis, spontaneous rupture independently predicted poor overall survival after hepatectomy (hazard ratio 1·54, 95 per cent confidence interval 1·24 to 1·93) and RFS (HR 1·75, 1·39 to 2·22). Overall survival and RFS after hepatectomy for ruptured HCC in the emergency and staged subgroups were not significantly different in multivariable analyses.

CONCLUSION

Spontaneous rupture predicted poor long-term survival after hepatectomy for HCC, but surgical treatment seems possible, safe and appropriate in selected patients.

Spontaneous tumor rupture and surgical prognosis of patients with hepatocellular carcinoma

BACKGROUND

Spontaneous rupture is an uncommon but the most fatal complication of hepatocellular carcinoma (HCC) and is recognized as a risk factor for tumor recurrence. The present study is to investigate the short- and long-term survival of the patients with HCC rupture and evaluate the influence of tumor rupture on patient's survival after hepatic resection.

PATIENTS AND METHODS

The clinical data of 101 patients with HCC rupture from 2000 to 2010 were reviewed retrospectively. The management of tumor rupture and clinicopathological parameters affecting 30-day mortality of the patients were recorded and evaluated. Long-term survival of the 41 patients undergoing hepatic resection was compared with 446 patients with non-ruptured HCC at the same time period.

RESULTS

The 30-day mortality rate of the 101 patients with HCC rupture was 35.6% and median survival was 79 days. The independent risk factors affecting 30-day mortality were tumor size and blood transfusion quantity. Compared with 446 non-ruptured HCC patients, 41 patients with ruptured HCC undergoing hepatic resection had a similar overall and disease-free survival to 446 without rupture (Log-rank test, p = 0.704 and 0.084, respectively). Multivariate analysis revealed that age, gender, and tumor size were independently significant factors in differentiating tumor rupture from non-rupture.

CONCLUSION

Early mortality of spontaneous rupture of HCC was dependent on preoperational liver function, tumor status, and severity of bleeding. Prolonged survival can be achieved in patients with ruptured HCC after hepatic resection as those without the complication.

Risk factors, clinical features, and prognosis of the hepatocellular carcinoma with peritoneal metastasis

BACKGROUND

The clinical features and prognosis of hepatocellular carcinoma (HCC) with peritoneal metastasis have not been fully evaluated.

AIMS

This study aimed to investigate the risk factors, clinical features, and prognosis of HCC with peritoneal metastasis.

METHODS

Patients who were diagnosed as HCC with peritoneal metastasis and the same number of randomly selected, risk factor-matched HCC controls without peritoneal metastasis were included. The risk factors and overall survival were compared between peritoneal metastasis-positive and -negative groups after adjustment of other variables.

RESULTS

HCC rupture was an independent risk factor for peritoneal metastasis in HCC patients (P = 0.008). When the risk factors (age, sex, Child-Pugh score, and intrahepatic tumor stage) were matched, peritoneal metastasis failed to independently affect overall survival (P = 0.511). In the peritoneal metastasis-positive group, advanced Child-Pugh class [hazard ratio (HR), 1.99; 95% confidence interval (CI), 1.07-3.72; P = 0.030] and progressive intrahepatic HCC status (HR, 19.04; 95% CI, 2.55-142.13; P = 0.004) were independent risk factors for early death. Complications such as ileus, bleeding, and hydronephrosis due to rectovesical mass were reported in 1.5-7.4% in the peritoneal metastasis-positive group.

CONCLUSIONS

Peritoneal metastasis was not found to be an independent prognostic factor of HCC, and among HCC patients with peritoneal metastasis, those with advanced Child-Pugh class and with uncontrolled intrahepatic HCC showed poor survival. Therefore, the maintenance of favorable hepatic function and control of intrahepatic HCC should still be emphasized in HCC patients with peritoneal metastasis.

Outcome and prognostic factors of spontaneous ruptured hepatocellular carcinoma treated with transarterial embolization

BACKGROUND

Rupture of hepatocellular carcinoma (HCC) is a life-threatening condition accompanied by hemorrhage. Transarterial embolization/chemoembolization (TAE/TACE) can be used as the first-line treatment to achieve initial homeostasis.

PURPOSE

To investigate the outcome of TAE/TACE for spontaneous ruptured HCC and to determine the prognostic factors affecting survival.

MATERIAL AND METHODS

We retrospectively reviewed the clinicoradiologic data of 47 patients (8 women, 39 men; median age 64.4 years) with serum bilirubin levels <3.0 mg/dL that underwent TAE/TACE for ruptured HCC between January 2004 and June 2010. Survival rates were estimated using the Kaplan-Meier method and prognostic factors of poor survival were obtained by univariate and multivariate analyses.

RESULTS

The clinical success rate of TAE/TACE was 94% (44/47). The median survival time was 179.6 days. The 1-month, 3-month, 6-month, and 12-month survival rates were 75%, 54%, 48%, and 43%, respectively. Old age, a previous history of TACE for HCC, low initial hemoglobin level, higher blood transfusion requirement, Child-Pugh class C, high serum bilirubin level, low serum albumin level, prolonged prothrombin time, high serum creatinine level on admission, presence of encephalopathy, severe ascites, lobar TAE/TACE, presence of portal vein thrombosis, and tumors involving both lobes were associated with poor survival. Multivariate analysis revealed that higher blood transfusion requirement, Child-Pugh class C, presence of portal vein thrombosis, and tumors involving both lobes were significant predictors of poor survival.

CONCLUSION

TAE/TACE is effective for achieving initial hemostasis, which is critical to survival. Regardless of successful TAE/TACE, the survival rate in patients with Child-Pugh class C remains poor. Portal vein thrombosis and tumor extent are significant image parameters for predicting survival after TAE/TACE for ruptured HCC.

Exploring the role of resection of extrahepatic metastases from hepatocellular carcinoma

The role of hepatic resection, taking into consideration the functional status of the liver, for localized hepatocellular carcinoma (HCC) is an established curative treatment. In advance disease, a variety of interventional-based liver-directed therapies and more recently systemic therapy with sorafenib are available to treat unresectable tumors. Extrahepatic Metastasis (EHM) of HCC may occur at initial diagnosis or during recurrence following treatment. This may occur with or without concurrent intrahepatic disease. We reviewed the published works on surgical metastasectomy for common sites of EHM of HCC metastases. It appears from the studies reported in the literature that from selected cases reported, long-term survival may be achieved from resecting metastasis at sites of the abdominal lymph node, adrenal gland, lung, and peritoneum. The encouraging results presented demonstrate that highly selected fit patients may be suitable candidates for these radical curative pursuits. It is likely that indications for resection of EHM HCC may benefit patients with limited isolated metastasis, who have a preserved liver function, and whose primary tumor has been adequately controlled. A registry study to pull the results of case reports and institutional experiences may be useful in cumulating evidence of this practice.

Hepatocellular Carcinoma Peritoneal Metastases: Report of Three Cases and Collective Review of the Literature

Introduction: Patients with peritoneal metastases (PM) from hepatocellular carcinoma (HCC) often experience a rapid demise even after a complete removal of intrahepatic tumour. Localised PM may now be adequately controlled and managed with cytoreductive surgery (CRS). Treatment: Three patients underwent CRS for HCC PM. Outcome: The first patient survived 21 months from the time of CRS and is alive with the disease. The second patient died 4 months after CRS. The third patient survived 10 months since CRS and is also alive with the disease. Collectively, the survival of 24 patients with HCC PM extracted through a collective literature review who were treated with cytoreductive surgery had 1- and 2-year survival percentages of 83% and 71%, respectively. Conclusion: Careful selection of patients with localised disease to the peritoneal cavity for CRS, taking into consideration the performance status, liver function and tumour biology may lead to a successful outcome in patients with HCC PM. Key words: Cytoreductive surgery, Peritoneal dissemination

Clinical manifestations and survival of hepatocellular carcinoma patients with peritoneal metastasis

BACKGROUND AND AIM

Peritoneal metastasis is an uncommon manifestation of hepatocellular carcinoma (HCC). The aim of the present paper was to investigate the characteristics and survival of HCC patients with peritoneal metastases.

METHODS

From January 1985 to December 2004, we retrospectively reviewed the records of 53 Taiwanese HCC patients with peritoneal metastases.

RESULTS

Peritoneal metastases were detected at the time of HCC diagnosis (synchronously) in 10 patients and after the initial therapy for the primary tumors (metachronously) in 43 patients. The mean time for development of the metachronous peritoneal metastases was similar whether the primary cancer was treated with surgery (24 months) or transarterial chemoembolization (22.2 months). The single patient whose primary cancer was treated with supportive care alone developed peritoneal metastasis only 7.5 months after detection of the primary cancer. Surgical resection of the peritoneal metastases was possible in two-thirds of the 43 metachronous patients. The median survival for those who received surgery for these metastases was 12.5 months vs. 2.1 months for those without surgery (P = 0.0013). However, there was no difference in survival if patients were stratified to Child-Pugh grade.

CONCLUSIONS

Peritoneal metastases of HCC are rare and can occur synchronously or metachronously. Though increased long-term survival was found in patients who had surgical removal of peritoneal metastases, the main determinant of better survival is Child-Pugh grade.

Intraperitoneal metastasis of hepatocellular carcinoma after spontaneous rupture: a case report

Rupture of hepatocellular carcinoma (HCC) is a life-threatening complication. Peritoneal metastasis of HCC after spontaneous rupture was seldom noted. We report a case of intraperitoneal metastasis of HCC after spontaneous rupture. A previously asymptomatic 72-year-old man was admitted due to dull abdominal pain with abdominal fullness. He had a history of HCC rupture 10 mo ago and transarterial embolization was performed at that time. Abdominal computer tomography (CT) scan showed a huge peritoneal mass over the right upper quadrant area. Surgical resection was arranged and subsequent microscopic examination confirmed a diagnosis of moderately-differentiated HCC.

Intraperitoneal metastasis of hepatocellular carcinoma after spontaneous rupture: A case report

Rupture of hepatocellular carcinoma (HCC) is a life-threatening complication. Peritoneal metastasis of HCC after spontaneous rupture was seldom noted. We report a case of intraperitoneal metastasis of HCC after spontaneous rupture. A previously asymptomatic 72-year-old man was admitted due to dull abdominal pain with abdominal fullness. He had a history of HCC rupture 10 mo ago and transarterial embolization was performed at that time. Abdominal computer tomography (CT) scan showed a huge peritoneal mass over the right upper quadrant area. Surgical resection was arranged and subsequent microscopic examination confirmed a diagnosis of moderately-differentiated HCC.

Diffuse intraperitoneal metastasis after spontaneous rupture of hepatocellular carcinoma

Rupture of hepatocellular carcinoma (HCC) is a fatal complication. Intraperitoneal metastasis after rupture of HCC is rare. We report a case of diffuse intraperitoneal metastases after rupture of HCC. A previously asymptomatic 32-year-old man was admitted because of massive ascites due to ruptured HCC. Poor liver reserve limited the therapeutic options. Transarterial chemoembolization was performed to stop tumor bleeding. Abdominal computed tomography demonstrated multiple large peritoneal metastases 3 months after the rupture episode. Echo-guided fine needle aspiration from the suprapubic area was performed. Cytology was positive for HCC. It is rare for HCC to develop intraperitoneal metastases in as short as 3 months.

Spontaneous rupture of hepatocellular carcinoma: a case report and review of literature

Hepatocellular carcinoma (HCC) has a tendency for fatal spontaneous rupture leading to massive haemorrhage. A 64-year-old man presented with sudden, severe epigastric pain for 6 h. Systolic blood pressure was 80/50 mmHg, and pulse rate was 100/min. The patient's history did not reveal any operation or disease up to date. Contrast enhancement-axial computed tomography (CT) scan showed a tumoral lesion with a necrotic centre measuring 6 x 5 cm within 6th segment of the liver and a fluid collection (haemoperitoneum) at the periphery of the liver. At exploratory laparotomy, the liver was found to be cirrhotic, and an actively bleeding tumour confirmed in 6th segment of the liver. The tumour was resected. Post-operative recovery was unremarkable, and the patient was discharged on the 14th post-operative day. Ruptured HCC should be included in the differential diagnosis of non-traumatic intra-abdominal haemorrhage.

Resection of peritoneal implantation from hepatocellular carcinoma

BACKGROUND

Peritoneal implantation is a rare presentation of hepatocellular carcinoma (HCC). This article presents the clinical features and surgical outcomes of 16 patients with HCC in whom isolated peritoneal implantation from HCC was found and who underwent surgical resection.

METHODS

From 1988 to 2000, 16 patients with HCC after hepatic resection who underwent resection of peritoneal implantation of HCC were retrospectively reviewed.

RESULTS

Four hundred sixty-five of 749 patients (62.1%) had recurrence of HCC after hepatic resection. Sixteen (3.4%) developed isolated peritoneal implantation and underwent resection. During the detection of the peritoneal implantation, the alfa fetoprotein level was increased in 13 of these 16 patients. Five of 15 patients had a peritoneal mass discovered by ultrasonography, and 14 of 15 patients had a mass discovered by computed tomography. The follow-up period ranged from 2.1 to 81.6 months (median, 16 months). The median disease-free and overall survivals of the 16 patients were 7.89 and 15.98 months, respectively.

CONCLUSIONS

Peritoneal implantation occurs infrequently in posthepatectomy patients. Increased alfa fetoprotein values after hepatic resection should suggest recurrence of HCC. Computed tomography is superior to ultrasonography in detection of peritoneal implantation from HCC. Surgical resection of peritoneal implantation from HCC might prolong survival in selected patients.

Management of spontaneous rupture of hepatocellular carcinoma: single-center experience

PURPOSE

To report the management of patients with spontaneous rupture of hepatocellular carcinoma (HCC) in a single center over a 10-year period and to evaluate a two-stage therapeutic approach.

PATIENTS AND METHODS

A retrospective study was performed on all 1,716 patients with HCC who presented from 1989 to 1998. The two-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, hemostasis by transarterial embolization (TAE) or surgical means, followed by second-stage hepatic resection or transarterial oily chemoembolization (TOCE). Results of definitive treatment were compared with patients with no history of rupture during the same study period.

RESULTS

During the study period, 154 patients (9%) had spontaneous HCC rupture. Initial intervention to control bleeding included TAE in 42 patients, surgical hemostasis in 35 patients, and conservative management only in 53 patients. The 30-day mortality rate was 38%. Independent factors on presentation affecting 30-day mortality were shock on admission, hemoglobin, serum total bilirubin, and known diagnosis of inoperable tumor. After initial stabilization and clinical evaluation, 33 patients underwent hepatic resection and 30 patients received TOCE. Median survival of the hepatectomy patients was 25.7 months; that of the TOCE patients was 9.7 months. Compared with patients with no rupture, survival after hepatectomy (25.7 months v 49.2 months, P =.003) was inferior but still substantially long, whereas survival after TOCE was comparable (9.7 months v 8.7 months, P =.904).

CONCLUSION

Early mortality of spontaneous rupture of HCC was dependent on prerupture disease state, liver function, and severity of bleeding. Although it was a catastrophic presentation, prolonged survival could be achieved in selected patients with second-stage hepatic resection or TOCE.