1. RUPTURED HCC: AN UPDATE
Marco Wong Cheuk Yi
United Christian Hospital

2. What is included today Case report in UCH Compare different modalities
New management options

3. The case 77/F Hep B carrier Strong family history of HCC
Epigastric pain and anaemia

4. CT taken on the day of admission

5. Case in UCH (2) Urgent CT: 2 days after TAE
S8/4a 6cm tumour, bleeding caudate tumour
TAE to right hepatic artery with gelfoam
2 days after TAE
Hb drop again with increasing pain
Open RFA for bleeding control
Plan further Mx of S7 lesion

6. Operative photos

7. Background Information
Hepatocellular carcinoma is the 5th most common cancer in the world
Prevalent among Asian countries (hepatitis B and C endemic areas)
Common presentations:
hepatomegaly
detected during surveillance
3-15% of all HCC patients presented with rupture
Locally most common cause of spontaneous haemoperitoneum !
Llovet JM et al.. Lancet Dec 6;362(9399):

8. Ruptured HCC Common symptoms: shock 67% abdominal pain 66%
abdominal distension 16%
Main cause of death:
hypovolaemia
liver failure
Management
Evolving trend
Advances in treatment modalities, improving technique
Miyamoto M et al. Am J Gastroenterol 1991; 16: 334-6

9. Prognostic factors Bilirubin Portal vein invasion
Shock upon presentation
AFP level
Child’s status
Ngan H et al. Clin Radiol May;53(5):
Leung CS et al. J R Coll Surg Edinb Oct;47(5):685-8.
Tan FL et al. ANZ J Surg Jun;76(6):

10. Treatments available Conservative Open haemostatic surgery
Emergency liver resection
TAE (transcatheter arterial embolization)
New treatment
Radiofrequency ablation

11. Conservative Management
Supportive
Correct hypovolaemia
Correction of coagulopathy
close monitoring
conservative management indicated in:
Stable patient with radiological evidence of rupture
Poor premorbid
Advanced tumour stage
high mortality %
Leung KL et al. Arch Surg Oct;134(10):

12. Open haemostatic surgery
Options
Perihepatic packing
Suture plication
Hepatic artery ligation
Alcohol injection
No larges scale studies comparing different modalities of treatment
High mortality up to 70% 3 months
Yoshida H et al. J Hepatobiliary Pancreat Surg. 2008;15(2): Epub 2008 Apr 6.

13. Emergency Hepatectomy
Benefits  Both curative and bleeding control
high mortality (operative mortality %)
But elective hepatectomy: 0-10%
Tan FL et al. ANZ J Surg Jun;76(6):
Yoshida H et al. J Hepatobiliary Pancreat Surg. 2008;15(2): Epub 2008 Apr 6.
Lai EC et al. Ann Surg Jul;210(1):24-8.

14. Emergency Hepatectomy (2)
Pros
Single procedure with curative intent
No delay
Cons
Unstable patient
Coagulopathies
Unknown liver function reserve
Unknown tumour load
Compromised margins
Only considered in selective cases

15. The current treatment philosophy is…
Effective means of bleeding control
Selective
Less collateral damage
preserving as much liver function as possible
Not aiming at cure in the emergency setting
Minimal invasive
Would not hinder subsequent definitive treatment

16. How to achieve these goal?
Effective means of bleeding control
Selective
Less collateral damage
preserving as much liver function as possible
Not aiming at cure in the emergency setting
Minimal invasive
Would not hinder subsequent definitive treatment
How to achieve these goal?

17. Transcatheter Arterial Embolization
First reported in early 80s
Treatment of choice since early 90s
Effective in bleeding control in >70% cases
In-hospital mortality 0-30%
Compared with hepatic artery ligation
similar haemostasis success rate
mortality ~ 70%
Availability of expert interventional radiologists !
Yoshida H et al. J Hepatobiliary Pancreat Surg. 2008;15(2): Epub 2008 Apr 6.
Leung CS et al. J R Coll Surg Edinb Oct;47(5):685-8.
Shimada R et al. Surgery Sep;124(3):
Yang Y et al. Zhonghua Zhong Liu Za Zhi May;24(3): (article in Chinese)

18. Contraindications Decrease portal blood flow
Main portal vein occlusion
Marked cirrhosis with diminished portal blood flow
Severe hepatic dysfunction
Bilirubin cutoff: 50 micromol/l
encephalopathy
Ngan H et al. Clin Radiol May;53(5):

19. New Option: RFA Introduced in late 90s
Proven to be effective in tumour ablation
size <= 5cm
up to 3 nodules with size <=3cm
Less morbidity especially with percutaneous approach
Chen MS et al. Ann Surg Mar;243(3):321-8.
Shiina S et al. Oncology. 2002;62 Suppl 1:64-8.
Lu MD et al. Zhonghua Yi Xue Za Zhi Mar 28;86(12): (article in Chinese)

20. RFA in bleeding control
Working mechanism: heat then necrosis
Proven to be effective in bleeding control
Less blood loss in RF assisted hepatectomy compared with hepatectomy alone
Efficient and safe method for grade III to IV hepatic traumas using dog models
Felokouras E et al. Am Surg Nov;70(11):
Mitsuo M et al. World J Surg Nov;31(11): ; discussion

21. Role of radiofrequency ablation in ruptured HCC
No large scale study for bleeding human cases yet
Only less than 5 case reports so far
Ng KK et al. Radiofrequency ablation as a salvage procedure for ruptured hepatocellular carcinoma. Hepatogastroenterology Sep-Oct;50(53):
Kobayashi et al. Successful control of ruptured hepatocellular carcinoma with radiofrequency ablation J Gastroenterol. 2004;39(2):192-3.
Fuchizaki U et al. Radiofrequency ablation for life-threatening ruptured hepatocellular carcinoma J Hepatol Feb;40(2):354-5

22. 1 month post op

23. The next stage Restage patient Baseline liver function after recovery
Tumour load
Patient’s premorbid
Elective definitive treatment
Hepatectomy
Local ablative therapy

24. The next stage after bleeding controlled……
Ruptured = T4 disease, even if small size
Recent study comparing ruptured group with different stages of non ruptured patients, both receiving elective hepatectomy
Cumulative survival rate similar to that of stage 2/ 3 disease
Yoshida H et al. Long-term results of elective hepatectomy for the treatment of ruptured hepatocellular carcinoma.
J Hepatobiliary Pancreat Surg. 2008;15(2): Epub 2008 Apr 6.

25. My modification?
Lai EC et al. Spontaneous rupture of hepatocellular carcinoma: a systematic review. Arch Surg Feb;141(2):191-8.

26. Bring home message TAE is the choice of haemostasis
In case TAE contraindicated/ failure
RFA as a potential new treatment modality

27. Q & A