The role of hepatic arterial embolization in the treatment of spontaneous rupture of hepatocellular carcinoma

Comprehensive review of clinical presentation, diagnosis, management, and prognosis of ruptured hepatocellular carcinoma

BACKGROUND

Spontaneous rupture of hepatocellular carcinoma (rHCC) is a life-threatening complication that occurs in 3 % to 15 % of patients with hepatocellular carcinoma (HCC). This review aimed to discuss the most recent updates in the epidemiology, pathophysiology, risk factors, diagnosis as well as presentation, management, and prognostic factors of rHCC.

METHODS

A comprehensive systematic review was conducted using Medline/PubMed and Web of Science databases with the end of search date being December 1, 2023 regarding rHCC diagnosis, imaging, and management.

RESULTS

Achieving adequate hemostasis and stabilization of the patient remains the primary objective in the management of patients with rHCC. In earlier studies, the mortality rate in the acute phase of rHCC was reported to be 25 % to 75 %. However, more recent studies have demonstrated that transcatheter arterial embolization (TAE)/transcatheter arterial chemoembolization (TACE) followed by elective hepatectomy in select patients may offer improved survival benefits and decrease perioperative complications compared with TAE/TACE alone or emergent/1-stage hepatectomy.

CONCLUSION

Although the prognosis for rHCC remains the worst among causes of death related to HCC, more recent studies have demonstrated that improved short- and long-term patient outcomes may be achieved through active surveillance efforts for HCC combined with advanced multimodal diagnostic tools and multidisciplinary management strategies.

Research progress of spontaneous ruptured hepatocellular carcinoma: Systematic review and meta-analysis

Background

Spontaneously ruptured hepatocellular carcinoma (rHCC) with hemorrhage is characterized by rapid onset and progression. The aim of this systematic review was to explore the current studies on rHCC with hemorrhage and determine the optimum treatment strategy.

Method

The PubMed, Web of Science, Embase, and the Cochrane Library databases were searched for studies reporting survival outcomes with comparison between emergency resection (ER) and transarterial embolization following staged hepatectomy (SH) were included by inclusion and exclusion criteria, the perioperative and survival data were statistically summarized using Review Manager 5.3 software.

Result

A total of 8 retrospective studies were included, with a total sample size of 556, including 285 (51.3%) in the ER group and 271 (48.7%) in the SH group. The perioperative blood loss and blood transfusion volume in the SH group were less than those in the ER group, and there were no significant differences in the operative time, incidence of complications, mortality and recurrence rate of tumors between the two groups. The 1-, 2-, 3-year overall survival and 1-, 2-, 3-, 5-year disease-free survival of the ER group were not significantly different from those of the SH group, and the 5-year overall survival rate of ER group was lower than that of the SH group (hazard ratios=1.52; 95% confidence intervals: 1.14-2.03, P=0.005).

Conclusion

There was no significant difference in the short-term efficacy of ER or SH in the treatment of ruptured HCC, and SH was superior to ER in the long-term survival.

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.

Outcome of conventional transarterial chemoembolization (cTACE) in the management of spontaneously ruptured hepatocellular carcinoma

Background and Objectives:

Hepatocellular carcinoma (HCC) is a highly vascular tumor and mortality after spontaneous rupture of HCC remains considerably high. There are no definitive guidelines for the management of ruptured HCC and no fixed protocol has been proposed in the literature. We evaluated the outcome of conventional transarterial chemoembolization (cTACE) in the management of spontaneously ruptured HCC and factors affecting the outcome of cTACE.

Materials and Methods:

This is a single center retrospective study analyzing the outcome of patients presenting with spontaneous rupture of HCC who received cTACE from January 2014 to June 2017. These patients were followed up periodically for clinical and imaging findings to ascertain the technical effectiveness along with survival.

Results:

Sixteen patients were identified who received cTACE for ruptured HCC. Majority of the patients (81.3%) had abdominal pain, while 25% had hypovolemic shock at initial presentation. Complete response and partial response were seen in 35.7% and 57.1% of patients, respectively. One patient (7.1%) showed progressive disease in form of peritoneal spread along the liver surface. The overall cumulative survival rates at 30 days, 180 days, and at 1 year were 87.5%, 72.2%, and 54.1%, respectively.

Conclusion:

cTACE is safe in patients with spontaneous HCC rupture and it leads to immediate hemostasis along with overall survival advantage. Achieving quick hemostasis may be a key to better outcome.

Hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma in noncirrhotic liver. A case report and systematic review

INTRODUCTION

Hepatocellular carcinoma (HCC) is the sixth most common cancer. Spontaneous rupture of HCC is an acute complication with a high mortality rate. The HCC principally arises in the background of chronic liver disease and cirrhosis of the liver. In the last few years, the rising incidence of HCC in noncirrhotic liver suggests the presence of other factors that may play a role in liver carcinogenesis.

METHODS

We reviewed all cases treated at the University Surgical Department of Ospedali Riuniti of Foggia from 2009 to 2018. Only a single case of hemoperitoneum caused by spontaneous rupture of HCC in noncirrhotic liver was found. An extensive search of the relevant literature was carried out using MEDLINE, and a total of 58 published studies were screened from the sources listed.

CONCLUSIONS

The management of this devastating emergency should be carefully analyzed, with stabilization of vital signs as soon as possible. Patient with ruptured HCC and hemoperitoneum without a prior history of cirrhosis and viral infections benefited from the role of transcatheter arterial embolization (TAE) as the preliminary treatment in order to have a more precise diagnosis and an optimal stabilization of the patient. Delayed or staged hepatectomy after TAE represents the definitive treatment.

Intraoperative radiofrequency ablation and distilled water peritoneal lavage for spontaneously ruptured hepatocellular carcinoma

Purpose

Spontaneously ruptured hepatocellular carcinoma (srHCC) is known to be a life-threatening complication with poor prognosis. Although there are various treatment modalities, there is no definite treatment guideline. The purpose of this study was to review the surgical outcome and prognosis of srHCC treated with intraoperative radiofrequency ablation (RFA) and distilled water peritoneal lavage (DWPL).

Methods

From March 2012 to October 2018, 9 patients with srHCC who underwent emergent surgery were reviewed. After hematoma removal, intraoperative RFA and DWPL were applied to all patients. Hepatectomy was performed if necessary. Patients with multiple tumors, distant metastasis, and vascular tumor involvement in radiologic imaging were excluded.

Results

Six of 9 patients with diameters less than 7 cm were able to obtain hemostasis using RFA alone (RFA group). However, 3 patients with a tumor size of more than 10 cm underwent liver resection because they could not obtain hemostasis with RFA (hepatectomy only group). The RFA group had shorter operation time (148.3 ± 31.7 minutes vs. 251.7 ± 20.2 minutes, P < 0.05) and less red blood cell transfusion (5.8 ± 2.5 packs vs. 24.0 ± 11.5 packs, P < 0.05) than the hepatectomy only group. There was no peritoneal metastasis at long-term follow-up in the RFA group. Five-year recurrence-free survival rate was 0% in both groups. However, 5-year overall survival rate was better in the RFA group (83.3% vs. 0%, P < 0.05).

Conclusion

Intraoperative RFA and DWPL are easy to perform and theoretically the best methods for managing relatively small srHCC.

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.

Transcatheter arterial embolization in hepatic tumor hemorrhage

Objective: Spontaneous hepatic tumor hemorrhage is a rare but challenging emergency especially among cirrhotic patients with poor hepatic function. This study aimed at analyzing the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) in the treatment of hepatic tumor hemorrhage. Methods: This retrospective study included all patients undergoing embolization attempt for hepatic tumor hemorrhage in the Helsinki University Hospital during 2004-2017. Electronic medical records provided the study data. Outcomes included the 30-day rebleeding, complication and mortality rates, need for blood transfusions, durations of intensive care unit and hospital admissions, estimates of overall survival, and analysis of factors associated with 30-day mortality. Results: During the study period, 49 patients underwent angiography for hepatic tumor hemorrhage. TAE was technically feasible in 45 patients (92%), and controlled the bleeding with the first attempt in 84%. The 30-day complication and mortality rates were 57 and 33%, respectively. Major complications occurred in 33% of patients. In-hospital mortality was higher among cirrhotic than non-cirrhotic patients (55 versus 7%, p < .001). Patients with bleeding hepatic metastases, but no cirrhosis, had an in-hospital mortality of 0% with no major complications. Patients with benign etiology had a good prognosis and no bleeding- or tumor-related mortality. Discussion: TAE is an effective method in controlling the bleeding in spontaneous hepatic hemorrhage. Underlying pathology determines the prognosis that is poor especially in cirrhotic patients with bleeding hepatocellular carcinoma.

Development and validation of an imaging and clinical scoring system to predict early mortality in spontaneous ruptured hepatocellular carcinoma treated with transarterial embolization

PURPOSE

To develop and validate a scoring system using a combination of imaging and clinical parameters to predict 30-day mortality in ruptured HCC (rHCC) patients after transarterial embolization (TAE).

METHODS

98 consecutive patients with rHCC who underwent abdominal CT and subsequent TAE between January 2007 and December 2016 were retrospectively reviewed. The CT scans were reviewed by two radiologists blinded to the patient outcome. Clinical parameters including serum bilirubin, albumin, INR, creatinine, and hemoglobin were recorded. Independent risk factors for 30-day mortality after TAE were identified using multivariate binary logistic regression, for development of a scoring system. The scoring system was then validated in 20 patients between January 2017 and May 2018.

RESULTS

In the development cohort, bilobar tumor distribution (OR = 29.6), clinical parameters of bilirubin > 2.5 mg/dL (OR = 5.9), and albumin < 30 g/L (OR = 4.1) were independent predictors for 30-day mortality. A 6-point score was derived and yielded area-under-the-receiver-operating-characteristic-curve (AUC) of 0.904. A score ≥ 4 resulted in sensitivity of 80.5% and specificity of 91.2% for 30-day mortality. In the validation cohort, AUC for 30-day mortality was 0.939. A score ≥ 4 resulted in sensitivity of 81.2% and specificity of 88.9%. In both development and validation cohorts, the proposed scoring system was better than biochemical components of Child-Pugh score and serum bilirubin to predict 30-day mortality.

CONCLUSION

Imaging and clinical parameters can be combined into a scoring system to accurately predict 30-day mortality after TAE in rHCC patients. The score may help identify and counsel high-risk patients.

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.

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.

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.

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.

Short article: Management of ruptured hepatocellular carcinoma in a European tertiary care center

GOALS AND BACKGROUND

Spontaneous rupture is a rare complication of hepatocellular carcinoma (HCC). Treatment options consist of transcatheter arterial embolization (TAE), hepatic resection, and conservative therapy. The best approach is under debate.

STUDY

This study presents a review of clinical data of patients with a ruptured HCC admitted to a European tertiary care center.

RESULTS

Eleven patients were included; six (55%) had underlying cirrhosis. The majority of patients (73%) had no previous history of HCC. Spontaneous HCC rupture was diagnosed using abdominal computed tomography with or without a diagnostic paracentesis. Computed tomography showed one or two tumors in eight (73%) patients; the other patients had multiple tumors or diffuse infiltrative HCC. Seven (64%) patients were initially treated by TAE and one (9%) patient underwent hepatic resection. The remaining three (27%) patients, all of whom had liver cirrhosis, received conservative therapy. Two patients initially treated by TAE underwent a delayed resection and ultimately received systemic therapy. Overall, at the end of the follow-up period, three patients were still alive at 84, 991, and 1026 days after the initial presentation. Eight (73%) patients had died after a median of 88 days (range 7-417). One year after presentation, none of the conservatively treated patients was alive compared with three out of seven (43%) patients treated with TAE with or without delayed resection.

CONCLUSION

Patients with a spontaneously ruptured HCC have a poor prognosis. In selected patients, however, prolonged survival is possible using TAE as initial therapy with or without a delayed resection and systemic therapy.

Spontaneous ruptured hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is rising worldwide. Spontaneous rupture of HCC occasionally occurs, and ruptured HCC with intraperitoneal hemorrhage is potentially life-threatening. The most common symptom of ruptured HCC is acute abdominal pain. The tumor size in ruptured HCC is significantly greater than that in non-ruptured HCC, and HCC protrudes beyond the original liver margin. In the acute phase, hemostasis is the primary concern and tumor treatment is secondary. Transcatheter arterial embolization (TAE) can effectively induce hemostasis. The hemostatic success rate of TAE ranges 53-100%. A one-stage surgical operation is a treatment modality for selected patients. Conservative treatment is usually given to patients in a moribund state with inoperable tumors and thus has poor outcomes. Patients with severe ruptures of advanced HCC and poor liver function have high mortality rates. Liver failure occurs in 12-42% of patients during the acute phase. In the stable phase, tumor treatment, such as transarterial chemoembolization or hepatic resection should be concerned. The combination of acute hemorrhage and cancer in patients with ruptured HCC requires a two-step therapeutic approach. TAE followed by elective hepatectomy is considered an effective strategy for patients with ruptured HCC.

Clear visualization of extravasation on angiography using carbon dioxide in a case of hepatocellular carcinoma rupture with unclear visualization using iodine contrast agent

A 62-year-old woman with hepatocellular carcinoma (HCC) and asthma presented with acute abdominal pain and a decreased hemoglobin level. Peritoneal fluid was detected around the lesion, and rupture was suspected based on the findings of computed tomography. Extravasation of the HCC tumor was not detected on angiography with iodine contrast agent; however, such extravasation was clearly observed on angiography with carbon dioxide (CO2). CO2 angiography is sometimes utilized in patients with arterial bleeding. This modality be more effective and safe than angiography with iodine contrast agent for assessing potential ruptured HCC lesions.

Management of bleeding liver tumors

Liver tumors bleed rarely; management has changed radically during the last 20years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.

Non-bleeding Spontaneous Rupture of Hepatocellular Carcinoma

Rupture of hepatocellular carcinoma (HCC) is not uncommon and most ruptured HCC present with hemoperitoneum and hemorrhagic shock. Management of ruptured HCC is different than non-ruptured one. Short- and long-term mortality increases following rupture of HCC with increasing chances of tumor dissemination. We describe a case with non-bleeding spontaneous rupture of HCC. A 62-year-old male patient was admitted to our institute hospital with mild to moderate pain in the right upper part of the abdomen. He lost appetite and weight. Ultrasonography of the abdomen was performed and it suggested HCC and ascites. Triple phase computer tomography revealed HCC in segments 6 and 7 of liver with typical radiological characteristics. Portal vein was thrombosed. No extravasation of dye was seen. Ruptured of tumor through liver capsule was seen with necrosis and hemorrhage in the center of the tumor. Non-bleeding ruptured HCC has not been reported in the literature to the best of our knowledge. We herein describe this rare case.

Survival outcome of patients with spontaneously ruptured hepatocellular carcinoma treated surgically or by transarterial embolization

AIM: To evaluate clinical outcomes of patients that underwent surgery, transarterial embolization (TAE), or supportive care for spontaneously ruptured hepatocellular carcinoma (HCC).

METHODS: A consecutive 54 patients who diagnosed as spontaneously ruptured HCC at our institution between 2003 and 2012 were retrospectively enrolled. HCC was diagnosed based on the diagnostic guidelines issued by the 2005 American Association for the Study of Liver Diseases. HCC rupture was defined as disruption of the peritumoral liver capsule with enhanced fluid collection in the perihepatic area adjacent to the HCC by dynamic liver computed tomography, and when abdominal paracentesis showed an ascitic red blood cell count of > 50000 mm³/mL in bloody fluid.

RESULTS: Of the 54 patients, 6 (11.1%) underwent surgery, 25 (46.3%) TAE, and 23 (42.6%) supportive care. The 2-, 4- and 6-mo cumulative survival rates at 2, 4 and 6 mo were significantly higher in the surgery (60%, 60% and 60%) or TAE (36%, 20% and 20%) groups than in the supportive care group (8.7%, 0% and 0%), respectively (each, P < 0.01), and tended to be higher in the surgical group than in the TAE group. Multivariate analysis showed that serum bilirubin (HR = 1.09, P < 0.01), creatinine (HR = 1.46, P = 0.04), and vasopressor requirement (HR = 2.37, P = 0.02) were significantly associated with post-treatment mortality, whereas surgery (HR = 0.41, P < 0.01), and TAE (HR = 0.13, P = 0.01) were inversely associated with post-treatment mortality.

CONCLUSION: Post-treatment survival after surgery or TAE was found to be better than after supportive care, and surgery tended to provide better survival benefit than TAE.

Transcatheter arterial chemoembolization confers survival benefit in patients with a spontaneously ruptured hepatocellular carcinoma

OBJECTIVE

Spontaneous rupture causing a hemoperitoneum is a life-threatening complication of hepatocellular carcinoma (HCC). The aim of this study was to document clinical features and prognostic factors in patients with a ruptured HCC.

METHODS

The medical records of 1412 patients with HCC admitted to a single tertiary medical center from January 2000 to August 2010 were reviewed. The clinical features, treatment modalities, and outcomes were collected. Univariate and multivariate analyses were carried out to analyze the factors affecting survival.

RESULTS

Thirty-five of 1412 patients diagnosed with a ruptured HCC were included. The median survival time was 59 days. Transcatheter arterial chemoembolization (TACE) was performed in 24 patients and 11 patients were managed conservatively. The 24 patients who received TACE achieved hemostasis without complications. The 30-day survival was related to better Child-Pugh class, higher hemoglobin level, lower creatinine level, and TACE in patients with a ruptured HCC. Multivariate analysis showed that patients who received TACE [odds ratio (OR), 0.076; P=0.020] or those with higher hemoglobin level (OR, 0.626; P=0.011) had a better chance of survival. The 30-day survival rate in a patient who received TACE was 83.3%. In the TACE group, the 30-day survival was independently associated with a higher hemoglobin level (OR, 0.609; P=0.036).

CONCLUSION

TACE is a minimally invasive treatment that has a high success rate for hemostasis. TACE increased the 30-day survival in patients with a ruptured HCC. However, survival rates in patients with lower hemoglobin levels, resulting in a large amount of bleeding, remained poor regardless of successful TACE.

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.

Spontaneous hepatic rupture: 13-year experience of a single center

BACKGROUND

Spontaneous hepatic rupture is a rare clinical event associated with various pathologies of the liver. Most series to date reported the incidence and characteristics of a single etiology.

METHODS

Data were collected for all patients admitted with spontaneous hepatic rupture from 1995 to 2007.

RESULTS

Ten patients met the study criteria. Hepatocellular adenoma was the cause of the rupture in six female patients, in their second to fourth decade. In the remaining patients, the ruptures were because of hepatocellular carcinoma in two, metastatic gastrointestinal stromal tumor in one, and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) in one. Nine out of 10 patients were treated surgically.

CONCLUSION

Spontaneous hepatic rupture requires a high index of suspicion for a correct and timely diagnosis. Outcome is potentially grave and greatly depends on the underlying condition.

Outcomes and factors influencing survival in cirrhotic cases with spontaneous rupture of hepatocellular carcinoma: a multicenter study

BACKGROUND

Spontaneous rupture is rare complication of hepatocellular carcinoma (HCC) with high mortality rate in cirrhotic cases. The aim of this study was to determine the factors influencing prognosis in cases of spontaneously ruptured HCC and to investigate the outcomes of the treatments employed, especially transcatheter arterial embolization (TAE).

METHODS

A retrospective multicenter study was conducted in 48 cirrhotic patients with spontaneous rupture of HCC. Conservative treatment was employed in 32 patients (ConT group) and TAE was performed in 16 patients (TAE group).

RESULTS

The median survival time (MST) in the ConT group was only 13.1 days and the survival rate was extremely poor: 59.4% at 7 days, 37.5% at 14 days, and 6.3% at 30 days. On the other hand, the MST in the TAE group was 244.8 days and the survival rate was 87.5% at 1 month, 56.3% at 3 months, 23.4% at 12 months, and 15.6% at 24 months. According to the results of univariate analyses, factors associated with poor hepatic function and poor suitability for TAE was important determinants of short-term death (less than 3 weeks) among the patients (p < 0.05). On the other hand, among the patients in whom initial TAE was successfully performed (n = 15), a multivariate analysis showed that a maximum tumor size not exceeding 7 cm was the only independent factor determining long-term survival (p = 0.0130).

CONCLUSION

Despite the inherent limitations of this retrospective study, TAE appears to be a useful treatment strategy for cirrhotic patients with spontaneous HCC rupture, as it yielded a longer survival period compared with conservative treatment in patients with ruptured HCC. Among the patients with ruptured HCC in whom initial TAE was successfully performed, the maximum tumor size was an important factor influencing survival.

The various manifestations of ruptured hepatocellular carcinoma: CT imaging findings

Hepatocellular carcinoma (HCC) has a tendency to rupture spontaneously which leads to a life-threatening condition. Disruption of the tumor surface or a tear in a parasitic feeding artery can cause HCC rupture leading to hemoperitoneum. When evaluating patients with a ruptured HCC, CT can detect tumors, determine tumor extent, define the presence of tumor bleeding, and show serial hematoma density changes. Thus, familiarity with the various CT findings of ruptured HCCs is essential to ensure proper diagnosis and treatment. In this pictorial essay, the authors illustrate the usual and unusual manifestations of ruptured HCCs, as visualized by CT, and include some angiographic correlations. CT findings predictive of HCC rupture are also discussed.

Transcatheter arterial embolization in the emergency department for hemodynamic instability due to ruptured hepatocellular carcinoma: analysis of 167 cases

OBJECTIVE

The purpose of this study was to analyze the prognostic factors associated with emergency transcatheter arterial embolization in the treatment of patients in hemodynamically unstable condition caused by rupture of hepatocellular carcinoma.

MATERIALS AND METHODS

An 8-year retrospective cohort study was conducted to evaluate emergency transcatheter arterial embolization in the treatment of 167 patients in unstable hemodynamic condition (systolic blood pressure < 90 mm Hg at presentation) due to rupture of hepatocellular carcinoma. The clinical, laboratory, and imaging findings of a group who died (survival period, < or = 30 days) were compared with those of a group who survived more than 30 days.

RESULTS

On arrival in the emergency department, the group who died (n = 52) were in significantly worse condition than the group who survived (n = 115). The group who died had a poorer Child-Pugh class, lower hemoglobin and serum albumin levels, higher demand for blood transfusion, higher incidence of acute respiratory failure, worse neurologic status (Glasgow Coma Scale score, < or = 12), greater prevalence of portal vein thrombosis, and higher serum total bilirubin and creatinine levels (p < 0.05, two-sample Student's t test and Fisher's exact or chi-square test). Multivariate logistic regression analysis showed that patients who did not have portal venous thrombosis (odds ratio, 0.241; p = 0.012) or a lower creatinine level (odds ratio, 0.458; p = 0.003) had better probability of survival. Successful hemostasis with transcatheter arterial embolization was achieved in 99% of patients (30-day mortality rate, 31%). Patients with coexistent acute respiratory failure or impaired neurologic status and marked hyperbilirubinemia (> 2.7 mg/dL) had exceptionally high mortality rate (> 70%).

CONCLUSION

Emergency transcatheter arterial embolization is effective for hemostasis of ruptured hepatocellular carcinoma in patients in hemodynamically unstable condition being treated in the emergency department. However, patients with portal venous thrombosis, a high serum creatinine level, acute respiratory failure, impaired neurologic status, and a high serum total bilirubin level continue to be at high risk of death.

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.

Selective transcatheter arterial embolization for treatment of bleeding complications or reduction of tumor mass of hepatocellular adenomas

Hepatocellular adenomas (HCAs) are benign liver lesions which may be complicated by spontaneous intratumoral bleeding, with or without rupture into the abdominal cavity, or malignant degeneration. Recent advances in radiological interventional techniques now offer selective transcatheter arterial embolization (TAE) as an alternative approach to surgery as the initial treatment to stop the bleeding or as an elective treatment to reduce the tumor mass of the HCA. Herein, we report our initial experience using TAE in the management of HCA. Five female patients and one male patient presented with spontaneous hemorrhage of HCA. Four patients were initially treated with selective TAE to stop the bleeding. In two patients in whom the bleeding stopped spontaneously, TAE was electively undertaken 1 year after presentation to reduce the tumor mass of HCAs >5 cm. Selective TAE as initial treatment in patients with spontaneous bleeding of HCA with or without rupture is effective and will change the need for urgent laparotomy to control bleeding. Selective TAE may also be used as an elective treatment to reduce the tumor mass of larger HCAs.

Outcomes of emergency treatment in ruptured hepatocellular carcinoma in the ED

The choice of emergency treatment of ruptured hepatocellular carcinoma (HCC) remains controversial. This study analyzed the prognostic factors for ruptured HCC seen in an ED. Patients were retrospectively classified into survival and mortality groups. Fifty-five patients were enrolled into this study, and the hospital mortality rate was 38.2%. There were no associations of clinical presentation, tumor characteristics, and emergency treatment method with patients' prognoses. Significantly higher mortality rate was noted in patients with poor liver function. The time between admission and emergency chemoembolization was significantly shorter in the mortality group than in the survival group (mean, 255 vs 394 minutes). The 1-month survival rate was 69% in patients who received conservative treatment and 59% in patients who underwent emergency chemoembolization. Routine emergency chemoembolization did not improve outcome and was associated with higher mortality and complication rates, especially in patients with poor liver function. Conservative therapy may be a preferable option for patients with ruptured HCC if they have baseline poor liver function.

Emergency embolization of spontaneous ruptured hepatocellular carcinoma: correlation between survival and Child-Pugh classification

From February 1994 to April 2000, 29 emergency gelfoam embolizations for spontaneous ruptured hepatocellular carcinoma (HCC) performed in 28 patients were retrospectively reviewed. There were 11 patients in Child's A, 11 in Child's B and six in Child's C classification of cirrhosis. The duration of the procedure, artery embolized and complications were reviewed, and the Child-Pugh classification of each patient was correlated with their mean survival period. Embolization was done in 12 right hepatic arteries, two left hepatic arteries and 15 proper hepatic arteries. In one patient, the left hepatic artery was embolized initially but the proper hepatic artery was also embolized because another subcapsular liver tumour was found after reviewing the preangiogram CT scan. The entire procedure took 40-170 min (mean = 86 min) with no periprocedural complication. Following embolization, the mean survival period for Child's A class was 218.3 days, Child's B class was 83.4 days and Child's C class was 11.0 days. Transcatheter embolization is an effective treatment to arrest bleeding in spontaneous ruptured HCC. Patients with Child's A class cirrhosis have the longest survival. Selective embolization of either the right or the left hepatic artery alone carries the potential risk of missing multifocal HCC that might not be easily appreciated during angiography.

Emergency embolization of spontaneous ruptured hepatocellular carcinoma: correlation between survival and Child-Pugh classification

From February 1994 to April 2000, 29 emergency gelfoam embolizations for spontaneous ruptured hepatocellular carcinoma (HCC) performed in 28 patients were retrospectively reviewed. There were 11 patients in Child's A, 11 in Child's B and six in Child's C classification of cirrhosis. The duration of the procedure, artery embolized and complications were reviewed, and the Child-Pugh classification of each patient was correlated with their mean survival period. Embolization was done in 12 right hepatic arteries, two left hepatic arteries and 15 proper hepatic arteries. In one patient, the left hepatic artery was embolized initially but the proper hepatic artery was also embolized because another subcapsular liver tumour was found after reviewing the preangiogram CT scan. The entire procedure took 40-170 min (mean = 86 min) with no periprocedural complication. Following embolization, the mean survival period for Child's A class was 218.3 days, Child's B class was 83.4 days and Child's C class was 11.0 days. Transcatheter embolization is an effective treatment to arrest bleeding in spontaneous ruptured HCC. Patients with Child's A class cirrhosis have the longest survival. Selective embolization of either the right or the left hepatic artery alone carries the potential risk of missing multifocal HCC that might not be easily appreciated during angiography.

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.

Spontaneous rupture of hepatocelluar carcinoma: surgical resection and long-term survival

AIMS

Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening event, particularly in patients with associated cirrhosis. We present our experience of hepatic resection of ruptured HCC.

METHODS

We performed 199 resections of hepatocellular carcinoma between January 1984 and December 1999. Six (3%) of these patients were operated on as an emergency because of haemoperitoneum: in five the liver was cirrhotic.

RESULTS

The mean duration of the operation was 195+/-101 min; all the patients received blood transfusions. The overall morbidity was 50%, with a mortality rate of 16.5%. Three patients were alive at 50, 80 and 116 months respectively; two had an intrahepatic recurrence treated by chemoembolization.

CONCLUSIONS

Non-surgical treatment of spontaneously ruptured hepatocarcinoma should be performed only in patients with contraindication to surgery. Hepatic resection should be the treatment of choice since, according to our experience, long-term results are similar to those of elective surgery.

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has ranked second in cancer mortality in China since the 1990s and is increasing in frequency among males in many countries. Hepatitis B and C viruses, aflatoxin and algal toxin in the contaminated drinking water remain major aetiological factors and hepatitis G virus and transfusion-transmitted virus can not be excluded. A prospective randomized control trial screening for HCC in a high-risk population using alpha fetoprotein (AFP) and ultrasonography has demonstrated a decrease in HCC mortality. Rapidly progressing medical imaging has continuously contributed to the improving treatment results. Surgical resection still plays a major role in influencing prognosis of HCC. Studies on recurrence and metastasis after curative resection have become a key issue for further improvement of the surgical outcome. Regional cancer therapies are progressing rapidly, based on the advances in early diagnosis. The advantages and disadvantages of these are noted. Multimodality combination and sequential treatment has been accepted as an important approach for unresectable HCC and cytoreduction and sequential resection have attracted attention. Conformal radiotherapy has shown important potential for HCC treatment. Intra-arterial chemotherapy has been repeatedly proved effective; however, systemic chemotherapy for HCC remains disappointing. The effects of tamoxifen are questionable, whereas alpha-interferon has been shown to have significant potential, particularly in prevention of recurrence. All of these treatments have resulted in continuing improvement of HCC prognosis in some centres.