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

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.

Prognosis and recurrence of spontaneously ruptured hepatocellular carcinoma treated after hepatectomy: A single institution experience

Spontaneously ruptured hepatocellular carcinoma (srHCC) is a life-threatening disease. The prognosis of patients with srHCC after hepatectomy remains unclear. This study aimed to investigate the prognosis and recurrence after hepatectomy in patients with srHCC. From 2015 to 2020, a retrospective analysis of patients with srHCC who underwent hepatectomy was performed, and compared with patients with unruptured HCC. Among the 86 patients with HCC who underwent hepatectomy, 11 had srHCC. The median tumor size in the ruptured group was significantly larger than that in the unruptured group (P = .001). The incidence rate of vascular invasion and Glisson capsule invasion in the ruptured group was significantly higher than that in the unruptured group. (P = .012 and P < .001, respectively). The American Joint Committee on Cancer was significantly higher in the ruptured group than in the unruptured group (P < .001). In total, 8 (73%) patients in the ruptured group experienced recurrence, whereas the median recurrence-free survival (RFS) and overall survival (OS) periods in the ruptured group were 15 (11-32) and 23 (17-38) months, respectively. In the unruptured group, 34 (45%) patients experienced recurrence, and the median RFS and OS periods were 20 (8-37, P = .099) and 33 (12-51, P = .394) months, respectively. Patients who developed peritoneal metastases were included in the ruptured group (n = 3). Ruptured HCCs exhibit worse oncological outcomes have poorer survival and higher recurrence rates than unruptured HCCs.

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.

Comparison of post-resection survival between hepatocellular carcinoma patients in BCLC stage A or B who experience tumor rupture and patients in BCLC stage C who do not

Background and aim

Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening complication, and patients who experience it are formally assigned to stage T4 in the TNM system, while many clinicians informally assign them to stage C in the more widely used Barcelona Clinic Liver Cancer (BCLC) system. The present study explored whether these re-staging practices are appropriate for HCC patients who suffer tumor rupture.

Methods

We retrospectively reviewed the records of 1952 HCC patients who underwent hepatic resection at our hospital between January 2017 and June 2021. We compared recurrence-free and overall survival between 143 patients who had BCLC stage A or B disease at the time of spontaneous rupture and 449 patients who had BCLC stage C disease without rupture.

Results

Overall survival rate was significantly higher among the 143 patients (1, 3, 5-year survival rate was 80.3%, 60.4%, 51.4%) with rupture than among the 449 (1, 3, 5-year survival rate was 69.5%, 41.5%, 32.4%) with BCLC stage C disease (hazard ratio 1.65, 95% confidence interval 1.29 to 2.12). The two groups had similar recurrence-free survival (hazard ratio 1.19, 95% confidence interval 0.92 to 1.53), but most patients with rupture were able to receive interventional and potentially curative treatments after recurrence, whereas most patients in BCLC stage C received interventional or supportive care. Similar results were obtained after propensity score matching.

Conclusion

HCC patients who experience spontaneous rupture tumor while in BCLC stage A or B have better prognosis than patients in BCLC stage C without rupture. Our results suggest that HCC patients who suffer rupture in BCLC stage A or B should not be assigned to BCLC stage C.

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Meta-analysis of Prognostic Factors for Overall Survival Among Resected Patients with Spontaneous Ruptured Hepatocellular Carcinoma

OBJECTIVE

Our meta-analysis was performed to explore the prognostic factors for overall survival among post-hepatectomy patients with spontaneous ruptured hepatocellular carcinoma (SRHCC).

METHODS

PubMed, EMBASE, the Cochrane Library, and Web of Science were all searched up for relevant studies regarding prognostic factors with SRHCC. RevMan5.3 software and Stata 14.0 software were used for statistical analysis.

RESULTS

A total of nineteen studies with 1876 resected SRHCC patients were finally identified. Pooled results indicated that preoperative AFP (high vs low) (P = 0.003), concurrent liver cirrhosis (yes vs no) (P = 0.02), preoperative liver function (child A vs non-child A) (P = 0.0007), tumor size (large vs small) (P < 0.00001), tumor number (solitary vs multiple) (P = 0.002), satellite foci (yes vs no) (P = 0.0006), micro-vascular invasion (yes vs no) (P < 0.00001), type of hepatectomy (major or minor) (P = 0.04), surgical margin (R + vs R -) (P < 0.00001), and type of hepatectomy (emergency hepatectomy vs staged hepatectomy) (P = 0.005) were prognostic factors for overall survival among post-hepatectomy SRHCC patients.

CONCLUSION

Apart from some conventional prognostic factors identified in resected patients with SRHCC, numerous prognostic factors have also been unmasked, which might provide clinical reference to stratify patients with different therapeutic regimes.

Spontaneous Rupture of Hepatocellular Carcinoma With Fatal Outcome in a Patient Taking Direct-Acting Antivirals

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors globally. Many complications are attributed to it, including spontaneous rupture, which is a serious and rare complication that can be life-threatening. Managing and detecting this condition might pose challenges, especially when there is no prior history of liver cirrhosis or tumor. We report on a 57-year-old man followed as an outpatient for chronic hepatitis C who presented to the emergency department for abdominal pain with abdominal distention and jaundice, occurring two months after treatment by direct-acting antiviral (DAA). He was not known to have a liver tumor on the ultrasound performed before the start of treatment. Therefore, the diagnosis of tumor rupture was not very clear. The evolution was fatal, and death occurred quickly. Although the association between DAA treatment and hepatocarcinogenesis and its possible complications is unknown, close monitoring by high-performance imaging is probably required in patients under DAA.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Spontaneously Ruptured Hepatocellular Carcinoma: Computed Tomography-Based Assessment

Spontaneously ruptured hepatocellular carcinoma (SRHCC) is an uncommon and life-threatening complication in patients with hepatocellular carcinoma (HCC). It is usually associated with chronic liver disease and has a poor prognosis with a high mortality rate during the acute phase. SRHCC can cause a severe and urgent condition of acute abdomen disease and requires a correct diagnosis to achieve adequate treatment. Clinical presentation is related to the presence of hemoperitoneum, and abdominal pain is the most common symptom (66–100% of cases). Although the treatment approach is not unique, trans-arterial (chemo)embolization (TAE/TACE) followed by staged hepatectomy has shown better results in long-term survival. A multi-phase contrast-enhanced CT (CECT) scan is a pivotal technique in the diagnosis of SRHCC due to its diagnostic accuracy and optimal temporal resolution. The correct interpretation of the main CT findings in SRHCC, such as active contrast extravasation and the sentinel clot sign, is fundamental for a prompt and correct diagnosis. Furthermore, CT also plays a role as a post-operative control procedure, especially in patients treated with TAE/TACE. Therefore, a multi-phase CECT scan should be the diagnostic tool of choice in SRHCC since it suggests an immediate need for treatment with a consequent improvement in prognosis.

Predictors of liver failure after transarterial chemoembolization in patients with spontaneously ruptured hepatocellular carcinoma: A retrospective study

Background

Spontaneously ruptured hepatocellular carcinoma (rHCC) is a life-threatening condition. Transarterial chemoembolization (TACE) is a widely accepted treatment; however, it can lead to serious complications, especially liver failure. We sought to identify preoperative predictors of liver failure in patients with rHCC undergoing TACE.

Methods

Patients with rHCC who received TACE as the initial therapy were retrospectively studied at our institution between January 2016 and December 2021. Based on the occurrence of liver failure after TACE, the patients were divided into liver failure and no-liver failure groups. Predictors of liver failure after TACE were analyzed using univariate and multivariate regression analyses. The predictive performance was assessed using the area under the curve (AUC). Delong's test was used to compare predictive efficiency.

Results

Sixty patients (19 and 41 in the liver failure and non-liver failure groups, respectively) were included. Multivariate analysis showed that preoperative prothrombin activity (PTA) level (odds ratio [OR], 0.956; 95% confidence interval [CI], 0.920-0.994; P ​= ​0.024) and Child-Pugh grade B (OR, 6.419; 95% CI, 1.123-36.677; P ​= ​0.037) were independent predictors of liver failure after TACE in patients with rHCC. The AUCs of the preoperative PTA levels and Child-Pugh grade B for predicting liver failure after TACE in patients with rHCC were 0.783 and 0.764, respectively.

Conclusion

Preoperative PTA level and Child-Pugh grade B were significant independent risk factors for liver failure after TACE in patients with rHCC. These can be used to predict liver failure after TACE in patients with rHCC for individual decision-making regarding treatment planning.

Superstable homogeneous lipiodol-ICG formulation: initial feasibility and first-in-human clinical application for ruptured hepatocellular carcinoma

The most common treatment of spontaneous tumor rupture hemorrhage (STRH) is transcatheter arterial embolization (TAE) followed by liver resection, and surgical navigation using near-infrared fluorescence is effective method for detecting hidden lesions and ill-defined tumor boundaries. However, due to the blockage of the tumor-supplying artery after effective TAE treatment, it is difficult to deliver sufficient fluorescent probes to the tumor region. In this study, we report on the successful application of superstable homogeneous intermixed formulation technology (SHIFT) in precise conversion hepatectomy for ruptured hepatocellular carcinoma (HCC). A homogeneous lipiodol-ICG formulation obtained by SHIFT (SHIFT-ICG) was developed for clinical practice for STRH. A ruptured HCC patient received the combined protocol for embolization and fluorescence surgical navigation and exhibited excellent hemostatic effect. Lipiodol and ICG were both effectively deposited in the primary lesion, including a small metastatic lesion. In follow-up laparoscopic hepatectomy, SHIFT-ICG could clearly and precisely image the full tumor regions and boundaries in real time, and even indistinguishable satellite lesions still expressed a remarkable fluorescence intensity. In conclusion, the simple and green SHIFT-ICG formulation can be effectively used in emergency embolization hemostasis and later precise fluorescence navigation hepatectomy in patients with ruptured HCC bleeding and has high clinical application value.

Propensity score matching study of 325 patients with spontaneous rupture of hepatocellular carcinoma

Background

This study aims to find out the possible optimal therapy and assess the prognosis properly for patient with spontaneous rupture of hepatocellular carcinoma (HCC).

Methods

Propensity score matching (PSM) analysis was used to study the data from 325 patients with ruptured HCC (RHCC) and 2,291 patients with non-RHCC.

Results

The incidence and hospital mortality of RHCC were 5.1% and 0.8% respectively, with a median overall survival (OS) time of 17 months. There was no difference between ruptured and non-RHCC patients undergoing conservation treatment in terms of OS. Trans-arterial embolization (TAE) was carried out in 69 (21.2%) cases with RHCC, with a median OS of 7 months, which was no difference from that of non-RHCC (pre- and post-PSM). One hundred and sixty-nine (52.0%) RHCC cases underwent one-stage hepatectomy, with a median OS and disease-free survival (DFS) of 30 and 6 months respectively, which were shorter than that of non-RHCC (post-PSM). TAE plus two-stage hepatectomy was performed in 30 RHCC cases, with a median OS and DFS of 28 and 10 months respectively; these outcomes were better than that from RHCC patients undergoing TAE alone or one-stage hepatectomy (post-PSM), which were no difference from that of non-RHCC patients undergoing hepatectomy. The risk of death for RHCC patient undergoing one-stage hepatectomy is 1.545 times higher than that of one undergoing TAE + two-stage hepatectomy.

Conclusions

TAE plus two-stage hepatectomy might be the optimal treatment for RHCC patient. Under the premise of the same pathological properties, there is no difference in prognosis between ruptured and non-RHCC patients if the therapy is appropriate.

Emergency versus delayed hepatectomy following transarterial embolization in spontaneously ruptured hepatocellular carcinoma survivors: a systematic review and meta-analysis

Background

Spontaneous rupture is a life-threatening complication of hepatocellular carcinoma (HCC). Recent trends in surgical treatments avoid emergency hepatectomy (EH) and favor emergency transarterial embolization (TAE) followed by delayed hepatectomy (DH). Still, there is debate on which is the better treatment option and whether delaying hepatectomy increases peritoneal metastasis.

Aim

To provide evidence-based references for the optimal management of patients with spontaneously ruptured HCC by comparing the outcomes of EH and DH.

Methods

Literature on postoperative outcomes of EH and DH in patients with spontaneously ruptured HCC published between the date of the database establishment and May 2022, was identified in the PubMed, EMBASE, and Cochrane Library databases. Revman 5.3 software was used for statistical analyses.

Results

Nine publications were identified, including a total of 681 patients. Of those, 304 underwent EH, and 377 underwent TAE followed by DH. The meta-analysis results indicated that the in-hospital mortality rate in the EH patient group was significantly higher than that in the DH patient group (relative risk (RR) = 2.17, 95% confidence interval (CI) 1.03–4.57, p =0.04). There was no significant differences in the rates of postoperative complications (RR = 1.21, 95% CI 0.77–1.90, p = 0.40), postoperative hospital stay (WMD = − 0.64, 95% CI − 5.61–4.34, p = 0.80), recurrence (RR = 1.09, 95% CI 0.94–1.25, p = 0.27), peritoneal metastasis (RR = 1.06, 95% CI 0.66–1.71, p = 0.80), 1-year survival (RR = 0.91, 95% CI 0.80–1.02, p = 0.11), or 3-year survival (RR = 0.81, 95% CI 0.61–1.09, p = 0.17) in survivors between the two patient groups.

Conclusion

The postoperative outcomes of the spontaneously ruptured HCC survivors who received EH were similar to those who received emergency TAE followed by DH. However, the in-hospital mortality rate was higher in EH patients. Based on the findings, DH with TAE first strategy might be considered over EH as the first line treatment modality. However, these findings await further validation by future high-quality studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02832-7.

Clinical course and role of embolization in patients with spontaneous rupture of hepatocellular carcinoma

Background

A diverse clinical course after the spontaneous rupture of hepatocellular carcinoma (HCC) renders nonstandardized treatment protocols.

Purpose

To evaluate clinical course and role of transcatheter arterial embolization (TAE) in patients with rupture of HCC.

Materials and methods

This retrospective study included 127 patients who were treated for ruptured HCC at single institution between 2005 and 2014. After multidisciplinary discussion, patients underwent medical management, TAE, emergency surgery or staged surgery. Patients were retrospectively divided into two groups based on the intent of treatment: curative and palliative. The rebleeding rate and 1-month and overall survival (OS) were compared between two groups. The incidence and survival of patients with intraperitoneal drop metastasis (IPDM) were also analyzed.

Results

The overall rebleeding rate in patients who underwent TAE was 3.1% (3/96). One-month mortality rate was 6.3% (8/127). The rebleeding and 1-month mortality rates were not significantly different between two groups. OS was significantly higher in the curative treatment group (median: 12.0 vs 2.2 months, p&lt;0.001). Among 96 patients who initially received TAE, ten patients underwent staged operation (10.4%). The median OS for medical management, TAE, emergency surgery and staged surgery was 2.8, 8.7, 19.1 and 71.1 months, respectively. Of all patients, 15.2% developed IPDM mostly within 1 year and their survival was poorer than that of patients without IPDM (median: 6.3 vs. 15.1 months, p&lt;0.001).

Conclusion

TAE provided effective immediate hemostasis with a low rebleeding rate and may serve as a bridge to elective surgery. IPDM frequently occurred within 1 year and manifested poor survival; thus, close surveillance should be considered for 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.

Recurrent umbilical varix rupture with hemoperitoneum: a case report and review of literature

Background

Non-traumatic hemoperitoneum was a rare event with the risk of sudden death. Spontaneous rupture of hepatocellular carcinoma is the most intuitive diagnosis when hemoperitoneum occurs in cirrhotic patients who are not regularly followed up. However, other etiologies of hemoperitoneum, such as intra-abdominal varix rupture, should be kept in mind.

Case presentation

A 44-year-old man with alcoholic liver cirrhosis, Child–Pugh B was sent to our emergency department (ED) because of recurrent abdominal pain and hypovolemic shock. He had similar symptoms one month ago and was diagnosed as hepatocellular carcinoma (HCC) rupture with hemoperitoneum, therefore he underwent trans-arterial embolization (TAE). However, the follow-up magnetic resonance imaging (MRI) showed less possibility of hepatocellular carcinoma. Contrast enhanced abdominal computed tomography (CT) showed possible umbilical vein contrast agent extravasation. Exploratory laparotomy confirmed the diagnosis of rupture umbilical varix with hemoperitoneum.

Conclusion

Although umbilical varix rupture is a rare cause of hemoperitoneum, it should be kept in mind in cirrhotic patients with unexplained hemoperitoneum.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02167-3.

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.

Predictors of Spontaneous Rupture of Hepatocellular Carcinoma and Clinical Outcomes Following Hepatectomy

OBJECTIVE

To explore the independent predictive factors of spontaneous tumor rupture (STR) in patients undergoing curative resection of hepatocellular carcinoma (HCC), and to evaluate the impact of STRHCC on long-term survival after hepatectomy.

METHODS

The clinicopathological parameters of 106 patients with STRHCC and 201 patients with non-ruptured HCC who underwent hepatectomy from January 2007 to November 2011 at the Eastern Hepatobiliary Surgery Hospital and Zhongnan Hospital of Wuhan University were analyzed using propensity score matching (PSM) and a logistic regression model.

RESULTS

Factors including hypertension, cirrhosis, total bilirubin (TB), tumor size, and ascites were independent predictors of STR. For all 307 HCC patients, the 1-, 3- and 5-year overall survival (OS) rates were 54.0%, 37.3% and 33.8%, respectively. After PSM, the 1-, 3-, and 5-year OS rates in the ruptured group remained significantly lower at 41.5%, 23.5%, and 17.5% when compared with the non-ruptured group at 70.8%, 47.1%, and 37.6%, respectively, while the 1-, 3-, and 5-year disease-free survival (DFS) rates between the groups did not differ significantly (50.4%, 35.1%, 27.1% vs 55.4%, 38.2%, 27.4%). STRHCC was significantly associated with increased risk of OS, but not of shorter DFS. No significant difference in postoperative morbidity or hospital death was observed between the groups.

CONCLUSION

Factors including hypertension, liver cirrhosis, higher TB levels, tumor size > 5cm, and ascites are significant predictors of STR. The recurrence rate of patients in the ruptured group was significantly higher than that of patients in the non-ruptured group. STR results in poorer OS but not DFS in patients undergoing curative resection for HCC. STRHCC has no impact on postoperative morbidity and mortality after hepatectomy.

Relevance of miR-223 as Potential Diagnostic and Prognostic Markers in Cancer

In 1993, the discovery of microRNAs in Caenorhabditis elegans (C. elegans) altered the paradigmatic view of RNA biology and post-transcriptional gene regulation. Further study revealed the role of microRNAs in disease development and progression. In particular, this review highlights microRNA-223 (miR-223 or miRNA-223) expression in malignant neoplastic disorders. miR-223 expression controls aspects of hematopoiesis and apoptosis, and cell proliferation, migration, and invasion. miR-223 regulates a number of gene targets, including cytoplasmic activation/proliferation-associated protein-1 (Caprin-1), insulin-like growth factor-1 receptor (IGF-1R), and other cell proliferation- and cell cycle-associated genes. Several studies have proposed miR-223 as a novel biomarker for early cancer diagnosis. Here, we emphasize miR-223′s role in the development and progression of cancer.

The treatment strategy and outcome for spontaneously ruptured hepatocellular carcinoma: a single-center experience in 239 patients

PURPOSE

There exist no treatment guidelines for spontaneously ruptured hepatocellular carcinoma (srHCC) and its prognosis remains controversial.

METHODS

Patients were retrospectively enrolled and grouped based on hemodynamics and tumor resectability. The 30-day mortality, 5-year overall survival (OS), progression-free survival (PFS), peritoneal metastasis (PM) and intrahepatic metastasis (IM) rates were compared.

RESULTS

In general, 239 patients were classified into four groups: patients with stable hemodynamics underwent semi-elective hepatectomy (n = 119), and those with unstable hemodynamics received emergent hepatectomy (n = 17), sequential hemostatic-transcatheter arterial chemoembolization (TACE)/-laparotomy with late hepatectomy (n = 49), or TACE only (n = 54). Hepatectomy was safer and provided better OS and PFS than TACE both before and after propensity score matching. Emergent hepatectomy was associated with higher 30-day mortality (6.2%, P < 0.05) and poorer prognosis whereas semi-elective hepatectomy and sequential treatment had comparable mortality (both 0%) and survival (36.3% vs 45.2%, P > 0.05). Compared with hemostatic TACE in the sequential treatment group, early surgical intervention (semi-elective hepatectomy, emergent hepatectomy, and sequential laparotomy with late hepatectomy) decreased PM (13.6% vs 34.2%, P = 0.003) whereas had higher IM (68.0% vs 50.0%, P = 0.039), but neither procedure had affected OS. In srHCC patients with high risk of recurrence (multiple tumors, micro- and macro-vascular invasion), postoperative adjuvant TACE improved OS.

CONCLUSION

Hepatectomy could provide better prognosis than TACE for srHCC patients while semi-elective hepatectomy and sequential hemostatic-TACE with staged hepatectomy are viable options for srHCCs with stable and unstable hemodynamics, respectively.

Hepatocellular carcinoma-derived exosomal miRNA-761 regulates the tumor microenvironment by targeting the SOCS2/JAK2/STAT3 pathway

BACKGROUND

Exosomes and exosomal microRNAs have been implicated in tumor occurrence and metastasis. Our previous study showed that microRNA-761 (miR-761) is overexpressed in hepatocellular carcinoma (HCC) tissues and that its inhibition affects mitochondrial function and inhibits HCC metastasis. The mechanism by which exosomal miR-761 modulates the tumor microenvironment has not been elucidated.

METHODS

Exosomal miR-761 was detected in six cell lines. Cell counting kit-8 (CCK-8) and transwell migration assays were performed to determine the function of exosomal miR-761 in HCC cells. The luciferase reporter assay was used to analyze miR-761 target genes in normal fibroblasts (NFs). The inhibitors AZD1480 and C188-9 were employed to determine the role of the Janus kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) signaling pathway in the transformation of cancer-associated fibroblasts (CAFs).

RESULTS

In this study, we characterized the mechanism by which miR-761 reprogrammed the tumor microenvironment. We found that HCC-derived exosomal miR-761 was taken up by NFs. Moreover, HCC exosomes affected the tumor microenvironment by activating NFs via suppressor of cytokine signaling 2 (SOCS2) and the JAK2/STAT3 signaling pathway.

CONCLUSIONS

These results demonstrated that exosomal miR-761 modulated the tumor microenvironment via SOCS2/JAK2/STAT3 pathway-dependent activation of CAFs. Our findings may inspire new strategies for HCC prevention and therapy.

Prognostic Influence of Spontaneous Tumor Rupture in Patients With Hepatocellular Carcinoma After Hepatectomy: A Meta-Analysis of Observational Studies

Objective: This study aims to comprehensively analyze the influence of spontaneous tumor rupture on the prognosis of hepatocellular carcinoma patients following hepatic resection.

Methods: We systematically searched four online electronic databases, including PubMed, Embase, Web of Science, and Cochrane Library, for eligible studies published from inception to March 2021. The main endpoints were overall survival (OS) and disease-free survival (DFS).

Results: This meta-analysis included 21 observational articles with 57,241 cases. The results revealed that spontaneous tumor rupture was associated with worse OS (hazard ratio (HR), 1.65; 95% confidence interval (CI), 1.33–2.05) and DFS (HR, 1.42; 95% CI, 1.12–1.80) in resectable hepatocellular carcinoma patients. This phenomenon was observed in most subgroups, which were classified by recorded survival time, age, country, alpha-fetoprotein (AFP) concentration, liver cirrhosis, and microvascular invasion. However, in subgroups of macrovascular invasion positive, spontaneous tumor rupture was not a risk factor for OS (HR, 1.55; 95% CI, 0.99–2.42) and DFS (HR, 1.23; 95% CI, 0.91–1.65) in hepatocellular carcinoma patients after hepatectomy. For macrovascular invasion negative, compared with non-ruptured hepatocellular carcinoma patients, ruptured hepatocellular carcinoma patients exhibited worse prognosis for OS (HR, 1.55; 95% CI, 0.99–2.42) and DFS (HR, 1.23; 95% CI, 0.91–1.65) following hepatectomy.

Conclusions: Spontaneous tumor rupture was a prognostic risk factor for hepatocellular carcinoma patients after hepatic resection. However, in macrovascular invasion patients, spontaneous tumor rupture was not a prognostic risk factor.

Development and Validation of Artificial Neural Networks for Survival Prediction Model for Patients with Spontaneous Hepatocellular Carcinoma Rupture After Transcatheter Arterial Embolization

Background

Spontaneous rupture bleeding is a fatal hepatocellular carcinoma (HCC) complication and a significant determinant of survival outcomes. This study aimed to develop and validate a novel artificial neural network (ANN)-based survival prediction model for patients with spontaneous HCC rupture after transcatheter arterial embolization (TAE).

Methods

Patients with spontaneous HCC rupture bleeding who underwent TAE at our hospital between January 2010 and December 2018 were included in our study. The least absolute shrinkage and selection operator (LASSO) Cox regression model was used to screen clinical variables related to prognosis. We incorporated the above clinical variables identified by LASSO Cox regression into the ANNs model. Multilayer perceptron ANNs were used to develop the 1-year overall survival (OS) prediction model for patients with spontaneous HCC ruptured bleeding in the training set. The area under the receiver operating characteristic curve and decision curve analysis were used to compare the predictive capability of the ANNs model with that of existing conventional prediction models.

Results

The median survival time for the whole set was 11.8 months, and the 1-year OS rate was 47.5%. LASSO Cox regression revealed that sex, extrahepatic metastasis, macroscopic vascular invasion, tumor number, hepatitis B surface antigen, hepatitis B e antigen, tumor size, alpha-fetoprotein, fibrinogen, direct bilirubin, red blood cell, and γ-glutamyltransferase were risk factors for OS. An ANNs model with 12 input nodes, seven hidden nodes, and two corresponding prognostic outcomes was constructed. In the training set and the validation set, AUCs for the ability of the ANNs model to predict the 1-year OS of patients with spontaneous HCC rupture bleeding were 0.923 (95% CI, 0.890–0.956) and 0.930 (95% CI, 0.875–0.985), respectively, which were higher than that of the existing conventional models (all P < 0.0001).

Conclusion

The ANNs model that we established has better survival prediction performance.

Comparison of initial tumor responses to transarterial bland embolization and drug-eluting beads-transarterial chemoembolization in the management of hepatocellular carcinoma: a propensity-score matching analysis

Background

Transarterial bland embolization (TABE) is widely used to treat the spontaneous rupture of hepatocellular carcinoma (HCC), and can lead to ischemic necrosis of the tumor. In this study, we used the propensity-score matching (PSM) method to compare the initial responses of treatment-naïve HCC patients to TABE and drug-eluting beads-transarterial chemoembolization (DEB-TACE), and the safety of these treatments.

Methods

Patients with treatment-naïve HCC, who had been admitted to 2 medical centers from January 2016 to December 2020, were enrolled as the research subjects. The data of 26 patients treated with TABE for ruptured HCC and 52 patients treated with DEB-TACE for primary HCC were collected according to our inclusion and exclusion criteria, and a PSM analysis was conducted to assess the safety and effectiveness of these two interventional techniques 1 month postoperatively.

Results

In relation to ruptured HCC, TABE had a hemostatic success rate of 97.0%. Before PSM, the TABE group had a larger maximum tumor diameter (P<0.05), a higher proportion of multiple tumors (P<0.05), a higher proportion of Child-Pugh class B (P<0.05), and a higher proportion of Barcelona Clinic Liver Cancer (BCLC) stage B (P<0.05) than the DEB-TACE group. After PSM, the baseline characteristics of these two groups were well balanced, and there was no significant difference in patients' initial therapeutic responses and tumor recurrence rates (both P>0.05). The multivariate regression analysis showed that tumor size was an independent predictor of the objective response rate (ORR) [odds ratio (OR): 3.312; 95% CI: 0.152-5.944; P<0.05]. Tumor number and BCLC stage also affected ORR; however, ORR was not significantly correlated with the interventional technique (TABE vs. DEB-TACE; P>0.05). The incidences of post-embolization syndrome (PES) and 48-h hepatotoxicity were significantly lower in the TABE group than the DEB-TACE group (both P<0.05), but there was no significant difference in hepatotoxicity after 1 month (P>0.05).

Conclusions

TABE is highly effective at managing hemorrhage from ruptured HCC. The initial therapeutic response of HCC to TABE is similar to that to DEB-TACE; however, TABE is associated with lower hepatotoxicity and fewer adverse effects, which paves the way for subsequent treatments and systemic therapies.

Surgical Outcomes of Spontaneously Ruptured Hepatocellular Carcinoma

BACKGROUND

Surgical and oncological outcomes in ruptured hepatocellular carcinoma (HCC) are not well known. The objective of this study was to review and compare survival outcomes and recurrence rates between ruptured and unruptured HCC.

METHODS

Data of patients with ruptured HCC who underwent curative surgical resection between January 2000 and December 2016 were retrospectively reviewed. To compare survival outcomes between ruptured and unruptured HCC, 1:2 individual matching was conducted.

RESULTS

The 1-, 3-, and 5-year overall survival (OS) rates were 88.8%, 67.0%, and 51.9%, respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 51.7%, 32.8%, and 25.0%, respectively. OS and DFS rates were significantly lower in the ruptured HCC group than the matched unruptured HCC group. HCC recurred in 63 patients (70.8%), 33 (52.4%) of whom presented with both intrahepatic and extrahepatic recurrences. Mean recurrence interval was 12.6 ± 13.8 months. The 1-, 3-, and 5-year survival rates after recurrence were 61.6%, 40.2%, and 33.6%, respectively. Mean survival time after recurrence was 26.4 ± 29.5 months. Incidence of peritoneal seeding (PS) was 18.0%, and eight of them demonstrated solitary lesion. Mean recurrence interval was 5.9 ± 8.2 months. The 1-, 3-, and 5-year OS rates after recurrence were significantly lower in patients with PS (49.7%, 18.7%, and 9.3%, respectively) than in patients without PS.

CONCLUSIONS

Hepatectomy in ruptured HCC did show worse survival outcome compared with unruptured HCC and bear a high risk of PS. However, surgical resection combined with transcatheter arterial chemoembolization could help in achieving acceptable oncological outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment of spontaneously ruptured hepatocellular carcinoma: use of laparoscopic microwave ablation and washout

BACKGROUND

Ruptured, or bleeding, hepatocellular carcinoma (rHCC) is a relatively rare disease presentation associated with high acute mortality rates. This study sought to evaluate outcomes following laparoscopic microwave ablation (MWA) and washout in rHCC.

METHODS

A retrospective single-center review was performed to identify patients with rHCC (2008-2018). The treatment algorithm consisted of transarterial embolization (TAE) or trans-arterial chemoembolization (TACE) followed by laparoscopic MWA and washout.

RESULTS

Fifteen patients with rHCC were identified (n = 5 single lesion, n = 5 multifocal disease, n = 5 extrahepatic metastatic disease). Median tumor size was 83 mm (range 5-228 mm), and 10 of 15 underwent TAE or TACE followed by laparoscopic MWA/washout. One patient required additional treatment for bleeding after MWA with repeat TAE. Thirty-day mortality was 6/15. For those patients discharged (n = 9), additional treatments included chemotherapy (n = 5), TACE (n = 3), and/or partial lobectomy (n = 2). Median follow-up was 18.2 months and median survival was 431 days (range 103-832) (one-year survival n = 7; two-year survival n = 4; three-year survival n = 3). Six patients had post-operative imaging from which one patient demonstrated recurrence.

CONCLUSION

Using laparoscopic MWA with washout may offer advantage in the treatment of ruptured HCC. It not only achieves hemostasis but also could have oncologic benefit by targeting local tumor and decreasing peritoneal carcinomatosis risk.

Complete Response for Advanced Hepatocellular Carcinoma by Conversion Surgery Therapy Following a Good Response of Regorafenib Despite Rapid Progressive Disease with Sorafenib

A 68-year-old man with hepatocellular carcinoma (HCC) visited his previous hospital due to abdominal pain and was diagnosed with ruptured HCC. Before visiting our hospital, he underwent HCC treatment at his previous hospital, but his tumors did not improve. Although he started treatment with sorafenib, the tumors rapidly grew. Subsequently, regorafenib was given, and the tumors shrank. After 22 months being treated with regorafenib, HCC reoccurred, with a new lung metastasis and a contrast-enhanced nodule on the peritoneal dissemination appearing. He underwent conversion surgery and survived for 4.5 years after his HCC was diagnosed.

Policeman to the Rescue; A Case of Ruptured Hepatocellular Carcinoma

Spontaneous rupture of hepatocellular carcinoma (HCC) are rare. Most cases present with acute abdominal pain and hemorrhagic shock. Various modalities of treatment are available which range from conservative treatment to surgical excision of the tumour. Various factors have to be considered when deciding on the treatment, but patient prognostic factors is the key in decision making. In this case we decided on an early laparotomy and surgical excision of the tumor since the patient was hemodynamically stable and as the omentum adhered to the site of rupture. Treatment in these cases requires a multidisciplinary approach to decide on the best possible procedure for each case.

The prognostic value of aspartate aminotransferase-to-lymphocyte ratio index in early-stage hepatocellular carcinoma after hepatectomy: A propensity-score matched analysis

BACKGROUND

An elevated preoperative aspartate aminotransferase-to-lymphocyte ratio index (ALRI) may predict poor survival in various cancers. However, the prognostic value of aminotransferase-to-lymphocyte ratio index (ALRI) in patients with hepatocellular carcinoma (HCC) remains to be determined.

MATERIALS AND METHODS

A retrospective cohort study was conducted among 983 patients with HCC in our hospital from February 2007 to March 2016. A propensity-score matching (PSM) was performed to correct the selection bias and confounding factors. The risk of death and recurrence was plotted over aminotransferase-to-lymphocyte ratio index (ALRI) using the locally weighted scatterplot smoothing (LOWESS)-smoothed fit curve. Time-dependent receiver operating characteristic (ROC) and Kaplan-Meier method analysis was utilized to the role of aminotransferase-to-lymphocyte ratio index (ALRI) in HCC. Multivariate analysis was conducted to identify independent prognostic factors associated with overall survival (OS) and recurrence-free survival (RFS).

RESULTS

With the increase of aminotransferase-to-lymphocyte ratio index (ALRI), the risk of recurrence and death in HCC patients increases. In time-dependent ROC analysis, the AUC of aminotransferase-to-lymphocyte ratio index (ALRI) for predicting 1-, 3- and 5-year OS were 0.668 (95% CI: 0.596-0.740), 0.605 (95% CI: 0.560-0.649) and 0.613 (95% CI: 0.570-0.656), respective. The AUC of aminotransferase-to-lymphocyte ratio index (ALRI) for predicting 1-, 3- and 5-year RFS were 0.598 (95% CI: 0.555-0.641), 0.590 (95% CI: 0.552-0.628) and 0.604 (95% CI: 0.562-0.646), respectively. HCC patients with high aminotransferase-to-lymphocyte ratio index (ALRI) had a poor overall survival. Moreover, cox regression analysis revealed that aminotransferase-to-lymphocyte ratio index (ALRI) was an independent factor affecting the prognosis of HCC patients.

CONCLUSIONS

Elevated preoperative aminotransferase-to-lymphocyte ratio index (ALRI) is a noninvasive, simple, and effective predictor in the prognosis of patients with HCC.

The role of hyperthermic intraperitoneal chemotherapy in the treatment of spontaneously ruptured hepatocellular carcinoma: a pilot study

Background

Spontaneous tumor rupture is a distinctive disease pattern in patients with hepatocellular carcinoma (HCC). The application of hyperthermic intraperitoneal chemotherapy (HIPEC) in spontaneously ruptured hepatocellular carcinoma (srHCC) is debatable. Our study aimed to compare the long-term outcomes of srHCC vs. nrHCC and to test the role of postoperative HIPEC in patients with srHCC after hepatectomy.

Methods

From 2014 to 2018, PSM was performed to compare 57 patients who performed liver resection for srHCC and met the research criteria with 57 nrHCC patients selected from 446 consecutive patients. Then patients with srHCC were divided into two groups according to whether they underwent HIPEC after hepatectomy.

Results

After 1:1 PSM, the clinical characteristics of the patients with srHCC and nrHCC were comparable. In terms of long-term outcomes, the nrHCC group had significantly longer OS (P=0.026) and DFS (P<0.001) than the srHCC group. Of the 57 srHCC patients, the HIPEC group showed added complications compared to the non-HIPEC group, including an increased length of hospital stay and higher in-hospital costs. However, there were no significant differences in the metastatic patterns of these recurrent patients, and there was no statistically significant difference in DFS (P=0.28) or OS (P=0.56) between the two groups.

Conclusions

The prognosis of ruptured HCC patients were worse than those of non-ruptured HCC patients. HIPEC may not be a robust treatment for srHCC now.

Early versus Delayed Hepatectomy for Spontaneously Ruptured Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

Here, we aimed to compare early hepatectomy (EH) with delayed hepatectomy (DH) as a treatment for spontaneously ruptured hepatocellular carcinoma (HCC).

METHODS

Several databases were systematically searched for eligible studies that compared DH with EH for spontaneously ruptured HCC treatment. Studies that met the inclusion criteria were reviewed systematically, and the reported data were aggregated statistically, using the RevMan v5.3 software.

RESULTS

Seven studies were included, with a total of 385 patients, comprising of 224 EH cases and 161 DH cases. Compared with the EH group, incidence of intraoperative bleeding [mean difference (MD), 353.93; 95% CI, 230.04-447.83; P < 0.00001], volume of intraoperative blood transfusion (MD, 420.61; 95% CI, 354.40-486.81, P < 0.00001), and 30-day mortality rate (OR, 14.94; 95% CI, 1.76-126.66; P = 0.01) were significantly lower in the DH group. Furthermore, the 1-, 2-, and 3-year survival rates were significantly higher in the DH group [1-year：hazard ratio (HR), 1.76; 95% CI, 1.06-2.94; P = 0.03; 2-year：HR, 1.52; 95% CI, 1.02-2.25; P = 0.04; 3-year: HR, 1.53; 95% CI, 1.06-2.21; P = 0.02]. There was no difference between the groups in the 5-year survival rate (HR, 1.40; 95% CI, 0.92-2.11; P = 0.11).

CONCLUSION

For resectable spontaneously ruptured HCC, DH could reduce intraoperative bleeding, intraoperative blood transfusion volume, and 30-day mortality rate and increase the 1-, 2-, and 3-year survival rates, endowing the patients with greater short- and long-term benefits during and following the surgery.

Acute hemoperitoneum after ruptured hepatocellular carcinoma: First Moroccan SCARE-compliant case report and literature review

•

Acute hemoperitoneum after a spontaneously ruptured hepatocellular carcinoma (HCC) is a rare complication.

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In cases with stable conditions, imaging guided by computed tomography (CT) enables arterial embolisation.

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Surgery is a choice after failure of embolisation or in case of severe hemodynamic instability.

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The prognostic outcomes of ruptured HCC depend mostly on the underlying liver function.

•

Successful management by one-stage surgery allowed radical treatment of this rare entity.

Introduction

Acute hemoperitoneum with a spontaneously ruptured hepatocellular carcinoma (HCC) is a rare type of internal bleeding that requires a multidisciplinary management approach.

Presentation of case

In this case report, we describe a fortuitously ruptured peripheral and discovered HCC in an 81-years-old woman treated effectively using hepatectomy.

Discussion

The use of the computed tomography (CT) angiography to diagnose the stability of the patient’s condition allows both arterial embolization in case of active bleeding and the evaluation of the underlying hepatopathy. The place of surgery is particularly upon after both the failure of arterial embolization and while facing a severe hemodynamic instability. The surgical strategy varies between perihepatic tamponnade and a surgical resection in one or more stages. The prognosis of a ruptured HCC depends mainly on the underlying liver’s function.

Conclusion

Multidisciplinary management of spontaneously ruptured HCC results in the same survival outcome as non-ruptured HCC at the same stage of hepatopathy.

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.

Conditional survival in patients with spontaneous tumor rupture of hepatocellular carcinoma after partial hepatectomy: a propensity score matching analysis

BACKGROUND

Spontaneous tumor rupture (STR) of hepatocellular carcinoma (HCC) is a life-threatening condition. This study investigates the influences of STR on the observed survival and conditional survival of patients received hepatectomy.

METHODS

A retrospective cohort of patients who underwent hepatectomy from 2009 to 2013 was divided into tumor rupture group and non-rupture group. Propensity score matching (PSM) was used for comparison of the observed survival and conditional survival probabilities between these two groups.

RESULTS

89 pairs of patients who had comparable background and tumor characteristics were created using PSM analysis. There was significant association between STR and increased risk of OS no matter when before or after PSM (p < 0.01). STR was significantly associated with increased risks of PFS before, while not after PSM. Multivariate Cox regression analyses demonstrated that STR was an independent risk factor associated with OS. There were significant differences in two groups for conditional probabilities of OS and PFS for an additional 6 months and 1 year before PSM, while not after PSM.

CONCLUSIONS

This study identified STR but not PFS as an independent risk factor influencing OS, in patients with HCC following hepatectomy. In selected patients with STRHCC, hepatectomy should be performed with acceptable outcomes.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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.

Hemorrhagic extrahepatic recurrence of hepatocellular carcinoma: A case report

The recurrence of hepatocellular carcinoma (HCC) can mainly be divided into two phases or types: the intrahepatic recurrence (IHR) and the extrahepatic recurrence (EHR). Generally speaking, the EHR is usually referenced as being the less common of the two types or categories. In a post-hemihepatectomy patient with routine surveillance at 6 months, it was noted that the patient appeared to have an elevated alpha-fetoprotein, and also complained of vague lower abdominal pain. The accompanying computed tomography scan revealed a 6 cm-sized heterogeneous mass located at the pelvis region. Next, during a laparotomy for resection, the tumor was found to be bleeding from the omental deposition. In conclusion, a high index of suspicion and early surgical intervention can help in detecting possible bleeding extrahepatic recurrence in the background of a patient with history of HCC.

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.