Rupture of a hepatic metastasis from renal cell carcinoma

Alpha-fetoprotein-producing gastric cancer with ruptured liver metastasis mimicking hepatocellular carcinoma

Alpha-fetoprotein (AFP)-producing gastric cancer is a rare subtype of gastric cancer known for its aggressive nature. We present an uncommon case of a 60s male with multiple liver tumors, initially suggested as hepatocellular carcinoma (HCC) by imaging. However, a subsequent gastric biopsy revealed a poorly differentiated adenocarcinoma with hepatoid features, and liver biopsy mirrored these findings. The disease progressed swiftly, with the patient representing owing to the spontaneous rupture of a metastatic liver tumor, an extremely rare occurrence, especially in metastatic liver cancers. Such ruptures in AFP-producing gastric cancer may be attributed to the tumor's rich blood flow. Distinctly differentiating this subtype from HCC is pivotal for apt management, as was evident in our case. The diagnosis was particularly challenging due to the similarities in imaging presentations between AFP-producing gastric cancer liver metastasis and HCC. This case underscores the need for vigilant diagnosis, emphasizing the importance of liver biopsy, especially in the absence of chronic liver disease. It also highlights the potential complications, like spontaneous rupture, associated with this rare form of gastric cancer.

Rupture of liver metastasis in high‐volume metastatic prostate cancer patient on androgen deprivation therapy combined with upfront docetaxel chemotherapy

Introduction

Recent studies have indicated an improvement in the survival rate of patients using docetaxel in addition to androgen deprivation therapy for high‐volume metastatic hormone‐sensitive prostate cancer. Hepatorrhexis, characterized by the rupture of the liver, is a rare complication associated with chemotherapies. We report a case of hepatic metastases rupture during androgen deprivation therapy combined with upfront docetaxel chemotherapy.

Case presentation

A 77‐year‐old man diagnosed with high‐volume metastatic hormone‐sensitive prostate cancer received an upfront docetaxel treatment combined with androgen deprivation therapy. Hepatic metastases rupture with substantial hemoperitoneum occurred on the 14th day of the fifth cycle of docetaxel chemotherapy. Transcatheter arterial embolization was performed; however, despite receiving optimal supportive care, the patient died.

Conclusion

The addition of upfront docetaxel to androgen deprivation therapy may be effective in patients with high‐volume metastatic hormone‐sensitive prostate cancer; however, strict observation is required to monitor for the occurrence of rare complications, including hepatorrhexis.

A rare case of ruptured liver metastases from a laryngeal cancer

Rupture of a metastatic liver tumor associated with laryngeal cancer is a very rare complication with no previous case in the literature. We present a case of ruptured liver metastases which was treated conservatively. Dynamic contrast-enhanced computed tomography demonstrated active extravasation and discontinuity of liver capsule. When the patient came to our hospital from the external medical center, we did not see active extravasation on control computed tomography. This case highlights the role of radiologic imaging in the diagnosis and follow-up of ruptured hepatic metastases.

Spontaneous intra-abdominal hemorrhage of a well-differentiated, grade 3 gastric neuroendocrine tumor during drug-based treatment

Grade 3, well-differentiated, gastric neuroendocrine tumors (NET G3) are extremely rare. Herein, we report the case of a 64-year-old man with a grade 3 neuroendocrine tumor of the stomach who experienced intra-abdominal bleeding during the course of drug treatment. The patient was referred to our hospital for examination of a gastric tumor that was initially diagnosed by a local medical doctor. Esophagogastroduodenoscopy revealed an elevated lesion with a central ulcer in the upper body of the stomach, and biopsy specimens confirmed the pathological diagnosis of NET G3. Abdominal contrast-enhanced computed tomography (CT) showed a 25-cm, well-defined mass lesion showing heterogeneous enhancement in the liver. A clinical diagnosis of NET G3 with multiple liver metastases was given, after which everolimus was administered in combination with a somatostatin analogue. However, the patient developed sudden-onset epigastric abdominal pain and general fatigue 2 months later, and emergency abdominal contrast-enhanced CT confirmed the presence of intra-abdominal hemorrhage. Following blood transfusion, the patient's symptoms and general condition improved. Although the patient was treated with streptozocin, abdominal CT indicated progression of the liver metastases. Unfortunately, despite receiving best supportive care, the patient died 8 months after the initial of the treatment. To the best of our knowledge, this is the first case of a patient who developed spontaneous hemoperitoneum during drug treatment for a NET G3 to be reported in the English literature. It is essential that additional data be obtained to determine the optimal treatment for this disease.

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.

Intratumoral Hemorrhage of Liver Metastasis from a Rectal Neuroendocrine Tumor

A 56-year-old healthy woman was referred to our hospital for abdominal pain. Contrast-enhanced computed tomography (CT) showed a 14-cm-diameter liver tumor with intratumoral hemorrhage. We performed emergent transcatheter arterial embolization. She was referred to hepatic surgeon (M.M.) for resection. Preoperative colonoscopy showed an elevated lesion measuring 2 cm in diameter that was pathologically diagnosed as a rectal neuroendocrine tumor (NET). We performed low anterior resection of the rectum, followed by extended right hepatectomy for all hepatic lesions. Intratumoral hematoma was observed in the largest hepatic lesion (size: 150 mm×100 mm). Microscopy also indicated NET G2. We pathologically diagnosed a liver tumor from a rectal NET that bled spontaneously.

Hemoperitoneum Secondary to Rupture of a Hepatic Metastasis from Small Cell Lung Cancer during Chemotherapy: A Case with a Literature Review

A 65-year-old man was diagnosed with small cell lung cancer with multiple liver metastases. Three days after initiating chemotherapy, he experienced abdominal discomfort with hypotension. Computed tomography revealed a ruptured liver metastasis and the presence of hemorrhagic ascites. Transcatheter arterial embolization to the appropriate hepatic artery in concomitant with supportive therapies successfully stabilized his condition. Unlike with hepatocellular carcinoma, the rupture of a liver metastasis and associated hemoperitoneum is very rare in patients with lung cancer. We comprehensively reviewed the literature and found 10 similar cases with this serious condition. Physicians should therefore be aware of the risk of hemoperitoneum caused by ruptured liver metastases in patients with lung cancer.

Spontaneous hepatic haemorrhage: a review of pathogenesis, aetiology and treatment

BACKGROUND

A spontaneous hepatic haemorrhage (SHH) is a rare condition that presents acutely to both hepatobiliary and general surgeons. Management of the condition is challenging because of the emergent presentation requiring immediate intervention, the presence of underlying chronic liver disease and the multiple potential underlying aetiological conditions.

METHODS

A literature search on a spontaneous hepatic haemorrhage was instituted on Medline (1966-2014), Cochrane Register of Controlled Trials, EMBASE (1947-2014), PubMed, Web of Science and Google Scholar. The specific topics of interest were causes - including rare causes, pathophysiological mechanisms and management options. A narrative review was planned from the outset.

RESULTS

After 1546 abstracts were reviewed, 74 studies were chosen for inclusion. Hepatocellular carcinoma (HCC) is the commonest cause of a spontaneous haemorrhage with 10% of HCC presenting with bleeding. Other causes are benign hepatic lesions (hemangioma, adenoma, focal nodular hyperplasia, nodular regenerative hyperplasia, biliary cystadenoma and angiomyelolipoma), malignant hepatic tumours (angiosarcoma, haemangioendothelioma, hepatoblastoma and rhabdoid sarcoma), peliosis hepatis, amyloid, systemic lupus erythematosis, polyarteritis nodosa, HELLP syndrome and acute fatty liver of pregnancy. Treatment practice emphasizes arterial embolization to obtain haemostasis with a hepatectomy reserved for tumour-bearing patients after staging and assessment of liver function.

CONCLUSION

A spontaneous hepatic haemorrhage is an acute presentation of a spectrum of conditions that requires early diagnosis and multidisciplinary management.

Ruptured hepatic metastases of cutaneous melanoma during treatment with vemurafenib: an autopsy case report

BACKGROUND

The spontaneous rupture of hepatic metastases is rare compared to that of primary hepatic tumors. In addition, vemurafenib, a selective inhibitor of the mutant BRAF protein or gene product, has been reported to be extremely effective in patients with metastatic melanoma who harbor a BRAF V600E mutation.

CASE PRESENTATION

A 44-year-old female had previously undergone surgery for resection of a malignant melanoma in the lower right leg. Four years later, hepatic metastases became apparent, and transcatheter arterial embolization (TAE) was performed. Then she underwent treatment with vemurafenib. The size of the hepatic metastases markedly decreased. Two months later, they enlarged rapidly and ruptured, requiring emergency TAE. However, the patient developed hemorrhagic shock and died of renewed intra-abdominal bleeding on the 26th postoperative day.

CONCLUSIONS

This is a rare case of ruptured hepatic metastases of malignant melanoma during treatment with vemurafenib. Postmortem examination and immunohistochemical analysis indicated reactivation of the mitogen-activated protein kinase pathway in the metastatic tumor, suggesting secondary resistance to vemurafenib as the possible underlying mechanism.

Spontaneous rupture of hepatic metastasis from small cell neuroendocrine carcinoma of maxillary sinus

BACKGROUND

Small cell neuroendocrine carcinoma of the maxillary sinus, a rare malignant tumor, has a poor prognosis because of its high incidence of metastasis. Moreover, metastatic cancer-induced hepatic rupture, characterized by hemoperitoneum, is infrequent, although several lines of evidences have reported that a wide variety of other neoplasms can cause this usually fatal manifestation.

CASE PRESENTATION

We now present the first case of a 49-year-old man with spontaneous rupture of hepatic metastasis from small cell neuroendocrine carcinoma of the maxillary sinus and ultimately resulted in massive intraperitoneal bleeding, which was successfully controlled by subsequent surgery (partial hepatectomy). The postoperative clinical manifestation of the patient was uneventful. He was discharged on the 16th day after operation and without any complication.

CONCLUSIONS

Small cell neuroendocrine carcinoma of the maxillary sinus is very scarce and unfortunately has a poor prognosis. It has potential to cause spontaneous metastatic rupture which can elicit fatal hemorrhage. Emergency surgery is effective, although the long-term outcome is still unsatisfactory.

Massive bleeding of ruptured metastatic hepatic melanoma treated by transarterial embolization

Although melanoma frequently metastasizes to the liver, its spontaneous rupture is rare. We report herein an unusual case of a 73-year-old man with rupture of multiple hepatic metastases from scalp melanoma and resulting massive intraperitoneal bleeding, which was successfully controlled by transarterial embolization.

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.

Rupture of liver metastasis: report of a case with an emphasis on contrast-enhanced US

We present a case of liver metastasis from an uterine leiomyosarcoma in which contrast-enhanced ultrasonography (CEUS) helped determine the bleeding point and prevented a delay in devising diagnostic and therapeutic strategies. CEUS allowed us to differentiate active from nonactive bleeding on the basis of presence or absence of contrast extravasation in the ascites. CEUS is the first examination performed when liver tumor rupture is suspected. Reference to the preangiographic CEUS results is expected to provide a road map for angiography.

Embolization for hemorrhage of liver metastases from choriocarcinoma

BACKGROUND

Because gestational trophoblastic disease (GTD) is highly sensitive to chemotherapy, life-threatening hemorrhage from metastases can occur especially early after starting therapy.

CASES

Two cases of post-term choriocarcinoma with liver metastases complicated by profuse life-threatening hemorrhage are reported. Emergency treatment with transcatheter angiographic embolization of the hepatic artery was performed to control bleeding.

DISCUSSION

Although embolization of the iliac vessels for gynecologic malignancies, including GTD, have been described, this is the first time that embolization of the hepatic artery to control bleeding from liver metastases in GTD is reported. The use and indications for embolization are expanding, and also in acute hemorrhagic complications in GTD, this intervention should be considered.

Hemoperitoneum secondary to spontaneous rupture of hepatic metastasis from lung cancer

We describe a rare case of hemoperitoneum secondary to spontaneous rupture of hepatic metastasis from lung cancer. A 72-year-old man with non-small cell lung cancer was admitted to our hospital with sudden onset of right upper abdominal pain and hypovolemic shock. Laboratory tests showed severe anemia. Abdominal contrast-enhanced computed tomography revealed massive ascites and multiple liver metastases. Rupture of a metastatic liver tumor was suspected. Only palliative therapy was performed. The patient's general condition gradually worsened, and he died 2 months after admission. Autopsy examination revealed hemoperitoneum due to a ruptured metastatic liver tumor originating from pulmonary squamous cell carcinoma.

Spontaneous intraperitoneal hemorrhage: imaging features

Spontaneous intraperitoneal bleeding can result from a vast array of etiologies. Fortunately, most are uncommon and currently available imaging modalities can be used to differentiate them in almost all cases. Meticulous imaging technique and careful observation of key imaging features are important for accurate characterization of the organ of origin of the spontaneous bleeding. CT is the single most important imaging technique in the detection and characterization of spontaneous intraperitoneal bleeding. Further development in multidetector technology, such as the introduction of new machines with 8 or 16 detectors, should improve the effectiveness of CT further. Sonography and MR imaging are complimentary to CT, especially in patients with pelvic abnormalities or equivocal CT findings.