Perihepatic caudate lobe haematoma originating from a pancreatic pseudoaneurysm: a diagnostic dilemma.

Despite advances in diagnostic imaging and interventional techniques, pancreatic pseudoaneurysms remain a life-threatening complication of pancreatitis. Presentation varies among patients and may include intra-abdominal, retroperitoneal, or gastrointestinal bleeding and bleeding into the pancreatic or common bile duct. We present a unique case of a 74-year-old man with a history of heavy alcohol consumption who presented with a haematoma surrounding the caudate lobe of the liver. Initially, alcoholic cirrhosis and a ruptured hepatocellular carcinoma were suspected. Therefore, transarterial embolization (TAE) of the caudate branch of the hepatic artery was performed. However, 3 months later, the patient experienced abdominal pain with a lesser sac haematoma and a seemingly interconnected pancreatic cyst. One month later, a pseudoaneurysm appeared in the pancreatic cyst. TAE was successfully performed for the pseudoaneurysm, and the patient showed no signs of recurrence during the 1-year follow-up.

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.

A pathologic scoring system for predicting postoperative prognosis in patients with ruptured hepatocellular carcinoma.

BACKGROUND: The accuracy of pathological factors to predict the prognosis of patients with ruptured hepatocellular carcinoma (rHCC) is unclear. We aimed to develop and validate a novel scoring system based on pathological factors to predict the postoperative survival of patients with rHCC. METHOD: Patients with rHCC who underwent hepatectomy were recruited from three hospitals and allocated to the training (n = 221) and validation (n = 194) cohorts. A new scoring system, namely the MSE (microvascular invasion-satellite foci-Edmondson Steiner) score, was established based on three pathological factors using univariate and multivariate Cox proportional hazards regression analyses, including microvascular invasion, satellite foci, and differentiation grade. Finally, patients were stratified into three groups based on their risk of prognosis (low, intermediate, or high) according to their MSE score. We also constructed MSE score-based nomograms. The performance of the nomograms was assessed by receiver operating characteristic and calibration curve analyses and validated using the validation cohort. RESULTS: Three pathological factors were significantly correlated with overall survival (OS) and recurrence-free survival (RFS), three of which were included in the MSE score. The score can clearly stratify rHCC patients after hepatectomy (P < 0.05). And we established nomograms based on the MSE score (MSE score, Barcelona Clinic Liver Cancer stage, and alpha-fetoprotein concentration) to predict postoperative OS and RFS in patients with rHCC. The nomograms showed good discrimination, with C-indices over 0.760 for OS and RFS at 1, 3, and 5 years, respectively. The calibration curve showed excellent nomogram calibration, which was also verified in the validation cohort. CONCLUSION: The clinical MSE score were accurate in predicting OS and RFS in patients with rHCC with resectable lesions after hepatectomy.

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.

Robotic emergency liver resection of ruptured hepatocellular carcinoma.

BACKGROUND: The spontaneous rupture of hepatocellular carcinoma (HCC) is a rare complication. The management of this complication needs a stepwise, multidisciplinary approach which considers first of all clinical conditions of the patient and also the possibility of the best curative treatment. METHODS: We report our experience of an emergency robotic liver resection for a ruptured HCC in an elderly patient. Minimally invasive liver resection is currently recognised as a safe and feasible approach to the treatment of HCC in elderly patients. RESULTS: Our patient presented haemodynamic stability, which allows us to perform a robotic resection of segment 3. To our knowledge, this is the first report of the application of a robotic platform in an emergency setting for liver resection. CONCLUSIONS: Rupture of HCC is an uncommon complication, burdened by a high rate of mortality. Its management still remains controversial. Treatment should be individualised taking into consideration the clinical status of the patient, tumour features and possibility of centre therapeutic strategy.

Delayed gastric perforation following transarterial chemoembolization: Case report.

INTRODUCTION AND IMPORTANCE: Transarterial chemoembolization (TACE) is widely employed to control acute bleeding in ruptured hepatocellular carcinoma (rHCC). Ischemia leading to perforation of the gastrointestinal tract (GIT) after TACE is a rare complication. We report a patient who presented with rHCC and who suffered gastric perforation post-TACE. CASE REPORT: A 70-year-old woman presented with rHCC. Emergency TACE was undertaken to control bleeding, and was successful. The patient was discharged 5 days post TACE. Two weeks after TACE, she presented with acute abdominal pain. Computed tomography of the abdomen showed perforation at the lesser curvature of the stomach. The angiogram from TACE was reviewed: the small vessels from an accessory branch of the left gastric artery originating from the left hepatic artery that had been embolized were likely responsible for gastric ischemia and subsequent perforation. The patient underwent operation with simple closure and omental patch repair. Postoperative gastric leak was not observed. Unfortunately, the patient died due to severe decompensated liver disease ∼4 weeks after TACE. CLINICAL DISCUSSION: Gastrointestinal tract (GIT) perforation after TACE is a rare complication. We suspected that perforation of the lesser curve of the stomach was secondary to ischemia due to non-target embolization to the accessory branch of the left gastric artery from the left hepatic artery, combined with stress and hemodynamic instability from rHCC. CONCLUSIONS: rHCC is a life-threatening condition. Variation in vascular structures must be clarified carefully. Significant adverse events in the GIT post-TACE are rare, but high-risk patients must be cautiously monitored.

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

BACKGROUND: At present, the choice of treatment modalities for ruptured hepatocellular carcinoma patients in BCLC stage A remains controversial, and this study compared the overall survival of ruptured HCC patients undergoing TACE or hepatectomy. METHODS: A total of 283 ruptured HCC patients treated at our liver surgery center were included in our study, of which 175 were treated with hepatectomy and 108 were treated with TACE. To reduce selection bias, we used a propensity score matching (PSM) model, which yielded a total of 88 pairs of patients. We used the Kaplan-Meier method to compare the long-term prognosis, and the Landmark method was used to compare the short-term and long-term prognoses of patients after PSM. Finally, we performed subgroup analysis according to whether it met the Milan criteria. RESULTS: After PSM, in the hepatectomy group, the 1-, 3-, and 5 year OS rates were 73.4%, 45.4%, and 33.9%, respectively. In the TACE group, the 1-, 3-, and 5 year OS rates were 58.5%, 40.6%, and 23.2%, respectively. Within one year, the hepatectomy group had a better prognosis than the TACE group (P = 0.022), but there was no difference in long-term survival(P = 0.936). In the subgroup analysis, in patients who met the Milan criteria, the survival curve indicated that there was no statistically significant difference in the survival prognosis between the two groups (P = 0.294) HR = 1.56(0.68-3.59); in the patients beyond the Milan criteria, the survival time was 28.0 months (20.0-34.0) in patients who underwent hepatectomy and 18 months (9.8-26.2) in patients who underwent TACE, and the survival curve indicated a statistically significant difference (P = 0.043) HR = 1.57(1.01-2.43). CONCLUSION: Our propensity score-matched study found that ruptured HCC patients treated by hepatectomy had a better short-term prognosis than those treated by TACE, but there was no difference in the long-term prognosis between the two treatment groups.

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

Background and Aim: Ruptured hepatocellular carcinoma (rHCC) is classified as T4 according to the TNM staging system with a very poor (does not achieve expected) prognosis, which has always been controversial. This study aimed at assessing the specific impact of different tumor diameters on the posttreatment prognosis of BCLC stage 0/A rHCC patients. Methods: Data from 258 patients with BCLC stage 0/A HCC treated in our center from January 2008 to December 2017 were collected, including 143 rHCC patients and 115 patients with non-ruptured HCC (nrHCC). With the help of X-tile software, we determined the cutoff value of the tumor diameter in patients with rHCC. Using 8 cm as the cutoff, we divided rHCC patients into Small-rHCC (n = 96) and Large-rHCC (n = 47) groups, compared the prognoses of the S-rHCC and L-rHCC groups, as well as the prognoses of the two groups with the nrHCC group using the Kaplan-Meier method, and screened the prognostic factors of rHCC patients using the multivariate Cox risk model. Results: The OS of the S-rHCC group was significantly higher than that of the L-rHCC group [HR = 2.41 (1.60-3.63)], and the OS of the nrHCC group was comparable to that of the S-rHCC group (P = 0.204). In patients treated with surgery only, OS and RFS were also comparable in the S-rHCC nrHCC group. Meanwhile, multivariate Cox regression analysis revealed that alpha-fetoprotein (AFP), alkaline phosphatase (ALP), and the main method of treatment were also prognostic factors for OS in patients with rHCC. Conclusions: Ruptured HCC with a relatively small diameter (≤8 cm) can also achieve the same prognosis as nrHCC patients after aggressive treatment. It is also not recommended to include all patients with rHCC in stage T4.

Hepatectomy for ruptured hepatocellular carcinoma classified as Barcelona Clinic Liver Cancer stage 0/A: The optimal treatment.

BACKGROUND AND AIMS: Ruptured hepatocellular carcinoma (rHCC) generally has a very poor prognosis and is currently classified as T4 in the tumor-node-metastasis (TNM) staging system. In this study, we aimed to demonstrate the actual impact of rHCC, as well as the positive effect of hepatectomy in patients with Barcelona Clinic Liver Cancer (BCLC) stage 0/A rHCC. METHODS: We enrolled 86 patients with rHCC after surgery and 526 patients with non-rHCC after surgery or transcatheter arterial chemoembolization (TACE). Survival curves were plotted using the Kaplan-Meier method to compare the postoperative prognosis of patients with rHCC with that of patients with non-rHCC. Univariate and multivariate Cox regression analyses were used to identify the risk factors affecting patient survival. RESULTS: BCLC stage 0/A rHCC treated with surgery had a worse prognosis than BCLC stage 0/A non-rHCC treated with surgery (overall survival [OS]: hazard ratio [HR] = 3.12 [2.24-4.34], P < 0.001; recurrence-free survival [RFS]: HR = 2.26 [1.65-3.09], P < 0.001). Rupture was an independent prognostic factor in patients with BCLC stage 0/A rHCC (OS: HR = 1.685 [1.416-2.006], P < 0.001; RFS: HR = 1.484 [1.267-1.737], P < 0.001), and patients with BCLC stage 0/A rHCC who underwent surgery had a comparable prognosis to patients with BCLC stage B HCC who underwent surgery or TACE (OS: P = 0.78). CONCLUSIONS: Patients classified as having BCLC stage 0/A rHCC can achieve comparable outcomes to patients with BCLC stage B HCC after hepatectomy. However, not all patients with rHCC should be classified as T4 in the TNM staging system.

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

Background and Aim: The effect of perioperative blood transfusion (PBT) on the prognosis of patients with ruptured hepatocellular carcinoma (rHCC) with different Barcelona Clinic Liver Cancer (BCLC) stages is not clear. We identified the independent predictors of PBT for postoperative rHCC and investigated the effects of PBT on the prognosis of patients with rHCC at different BCLC stages. Methods: A total of 340 patients who underwent curative hepatectomy for rHCC between January 2010 and March 2018 were abstracted from the databases of two centers. A total of 166 patients underwent PBT. The prognosis of patients who received PBT and those who did not was compared before and after propensity score matching (PSM) in different BCLC stages. Univariate and multivariate Cox regression analyses were also used to identify independent predictors of PBT. Results: We divided the 340 patients into two groups: early tumor stage (BCLC-A) n = 196 and advanced tumor stage (BCLC-B/C) n = 144. Overall, the median survival time of the PBT group was lower than that of the nonPBT group before and after PSM. However, in the BCLC-BC group, the prognosis of patients with PBT was not statistically different from that of patients without blood transfusion. Univariate Cox analysis showed that PBT was a risk factor affecting the overall survival (OS) and recurrence-free survival (RFS) in BCLC-A, and PBT was not a risk factor for poor OS and RFS in BCLC-B/C. Conclusion: Perioperative blood transfusion has a negative impact on the postoperative prognosis of patients with rHCC in the early stage, but has no significant impact on the postoperative prognosis of patients with rHCC in the advanced stage.

The effect of the number of hepatic inflow occlusion times on the prognosis of ruptured hepatocellular carcinoma patients after hepatectomy.

BACKGROUND AND AIM: It has been previously reported that inflow occlusion does not affect postoperative outcomes in hepatocellular carcinoma patients. However, for patients with ruptured hepatocellular carcinoma(rHCC), the effect of hepatic inflow occlusion and the number of occlusion times on the prognosis is unknown. METHODS: 203 patients with ruptured hepatocellular carcinoma were enrolled in this study. They were first divided into the non-hepatic inflow occlusion (non-HIO) group and the hepatic inflow occlusion (HIO) group. The Kaplan-Meier method was used to compare the recurrence-free survival and overall survival between the two groups. Patients in the HIO group were further divided into one-time HIO and two times HIO groups. KM method was also used to compare the two groups. Finally, independent risk factors affecting RFS and OS were determined by multivariate Cox regression analysis. RESULT: In the non-HIO group, 1-,3- and 5-year OS rates were 67.0%, 41.0%, and 22.0%respectively, and RFS rates were 45.0%, 31.0%, and 20.0% respectively; In the one-HIO group, the 1-,3-, and 5-year OS rates were 55.1%, 32.1%, and 19.2% respectively, and RFS rates were 33.3%, 16.7%, and 7.7% respectively; In the two-HIO group, 1-,3-, and 5-year OS rates were 24.0%, 0.0%, and 0.0% respectively, and RFS rates were 8.0%, 0.0%, and 0.0% respectively. By Cox regression analysis, HIO was an independent risk factor for a poor prognosis in rHCC patients. CONCLUSION: One time hepatic inflow occlusion did not affect postoperative OS, but negatively affected the RFS of rHCC patients; two times hepatic inflow occlusion negatively affected the postoperative OS and RFS in patients with rHCC.

Alpha-Fetoprotein in Predicting Survival of Patients with Ruptured Hepatocellular Carcinoma after Resection.

Background/Aim: Alpha-fetoprotein (AFP) had been used as a prognostic factor in hepatocellular carcinoma but it was unknown what level of AFP could predict the survival of patients with ruptured hepatocellular carcinoma (rHCC) after resection. This retrospective study was to identify the best cutoff value of AFP for this prediction.Methods: Data of patients having hepatectomy for rHCC from 1989 to 2015 were reviewed. The receiver operating characteristic curve and Youden's index were used to identify the cutoff value of AFP affecting survival. The patients were then divided into two groups by the cutoff for comparison.Results: Totally 114 patients were included. An AFP level of 256 ng/ml was found to affect survival (area under curve 63.1%, 95% confidence interval 0.514-0.748, p = 0.027; sensitivity 0.6, specificity 0.706). The 114 patients were divided into Group A (AFP < 256 ng/ml, n = 56) and Group B (AFP ≥ 256 ng/ml, n = 58). The median AFP level was 13.0 ng/ml (range, 2-253 ng/ml) in Group A and 11206.5 ng/ml (range, 259-481,000 ng/ml) in Group B (p < 0.001). Group A had a larger proportion of patients receiving transarterial embolization at the time of rupture, and the time to hepatectomy was longer in this group. Patients in Group B had more blood loss, more complications, larger tumors, and more cases of macrovascular/microvascular invasion. Overall survival (p = 0.013) and disease-free survival (p = 0.024) were significantly better in Group A. On multivariate analysis, AFP ≥ 256 ng/ml was an independent risk factor for overall survival.Conclusion: AFP ≥ 256 ng/ml had an adverse impact on the survival of patients with rHCC after resection.

Outcomes of Living Donor Liver Transplantation in Patients With a History of Ruptured Hepatocellular Carcinoma.

Background: Liver transplantation (LT) is considered a contraindication in patients with a history of hepatocellular carcinoma (HCC) rupture because ruptured HCCs are classified as T4 in the current American Joint Committee on Cancer TNM system. This study aimed to assess living donor liver transplantation (LDLT) in these patients and elucidate the factors that may have affected their outcomes. Methods: Data of patients with a history of ruptured HCC who underwent LDLT between January 1999 and December 2019 were retrospectively reviewed. Results: Among 789 patients who underwent LDLT for HCC, five (0.64%) had a history of HCC rupture. Three patients (60%) were treated with transarterial chemoembolization (TACE) or transarterial embolization (TAE) for hemostasis, and two patients (40%) achieved spontaneous hemostasis. One of two patients who achieved spontaneous hemostasis underwent surgical resection and LT at 1 week and 6 years after the rupture, respectively. The other patient underwent LT 2 days after the rupture. Four patients (80%) survived for >5 years, while two patients (40%) experienced recurrence and succumbed during the median follow-up duration of 85.3 months (range, 12.4-182.7). The recurrence first developed at 4.3 and 17.0 months after LT; these patients were managed well using surgical resection for peritoneal seeding and TACE for intrahepatic HCC. Conclusion: LDLT can be considered a treatment method even in patients with a history of HCC rupture after full evaluation of tumor biology and risk of recurrence.

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 in cirrhotic patients in the absence of abdominal trauma.

Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management. Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed. Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).

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.

Spontaneous Rupture of Hepatocellular Carcinoma in a Young Patient with Fatal Outcome.

Spontaneous rupture of hepatocellular carcinoma (HCC) is a potentially life-threatening complication. Diagnosis may be difficult, particularly in the absence of known liver cirrhosis or tumor. A 20-year-old male patient presented with progressive abdominal pain and shock. His past medical history was uneventful. Anemia, acute renal failure, and abnormal liver function test were demonstrated. Mild hepatomegaly, perihepatic and flank fluid, and multiple hypodense liver lesions suggestive of intrahepatic metastases or multifocal HCC were revealed by computed tomography. Two actively bleeding liver tumors and multiple tumors in a noncirrhotic liver were found. Hemostatic suture and perihepatic packing were performed. The patient remained in critical condition, with a fatal outcome 48 h later. Histopathologic analysis reported HCC and absence of cirrhotic changes. HCC spontaneous rupture incidence is reported between 2.3 and 26%. Median age is 65 years. No liver cirrhosis is found in one-third of patients, with a median age of 51 years. Sudden onset of abdominal pain and shock is observed in the majority of cases. An accurate preoperative diagnosis improves to 75% with ultrasound and computed tomography. Besides hemodynamic stabilization, there is no general agreement on the best treatment option. Transarterial embolization, surgical perihepatic packing, suture plication, and hepatic artery ligation are useful methods of hemostasis in unstable patients. Mortality has been reported from 16.5 to 100%. The histopathologic finding of HCC in a noncirrhotic liver represents a less frequent presentation. A case of spontaneous rupture of HCC carcinoma and a noncirrhotic liver in a young patient is herein reported.

Outcomes of Surgical Resection for Ruptured Hepatocellular Carcinoma

BACKGROUND/AIMS: Many recent studies have shown excellent outcomes of surgical resection for ruptured hepatocellular carcinoma (HCC). In addition, there are several reports suggesting that a ruptured HCC did not increase the risk for peritoneal dissemination of a tumor after surgical resection. However, the impact of HCC rupture on recurrence and patient survival has not yet been clarified. METHODS: The medical data of patients who underwent surgical resection for ruptured HCC in our center between January 2011 and December 2015 were retrospectively reviewed. The outcomes of the patients were investigated. RESULTS: Among 128 patients who underwent surgical resection for HCC, 5 patients (3.9%) had a ruptured HCC. All patients underwent elective operation in a stable condition. Transarterial chemoembolization (TACE) was performed for achieving hemostasis in four patients except one who achieved spontaneous hemostasis. Two patients had tumor recurrence and one patient died due to HCC recurrence during the median follow-up duration of 28.3 months (range, 24.3–62.3 months). One patient who developed late intrahepatic recurrence at 40.0 months after resection was managed well by means of radiofrequency ablation and TACE and is now alive for 5 years without any evidence of viable tumor. However, the other patient who showed early peritoneal seeding at 1.9 months after resection finally died despite aggressive treatments. CONCLUSIONS: Rupture of HCC might result in peritoneal seeding of the tumor in the early postoperative stage, which could lead to a poor result. Nonetheless, surgical resection may be the best treatment option yielding good survival, even for a ruptured HCC.

Metabolic imaging for guidance of curative treatment of isolated pelvic implantation metastasis after resection of spontaneously ruptured hepatocellular carcinoma: A case report.

Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening complication and its prognosis is significantly poor because of the high recurrence rate after initial hepatectomy. Resection of isolated extrahepatic metastasis of HCC has been advocated to obtain a possibility of long-term survival. However, it is a challenge for clinicians to detect implantation metastasis of spontaneously ruptured HCC. Accurate re-staging plays the most important role in making a decision on isolated metastasis resection. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) is useful in detecting intra-abdominal implantation metastasis from a variety of malignancies and shows superior accuracy to conventional imaging modalities in determining the location of metastasis. We present one patient with a new isolated pelvic implantation metastasis detected by 18F-FDG PET/CT and pathologically confirmed by PET/CT-guided percutaneous biopsy, who had a history of resection of spontaneously ruptured HCC two years ago. The patient's condition was stable at the 6-mo follow-up after resection of the isolated pelvic metastasis.