Spontaneous rupture of HCC Ruptured HCC following TACE Department of Gastroenterology R4 Woo Yong-Sik

Ruptured hepatoma with hemoperitoneum Hemoperitoneum to non-traumatic hepatic rupture rare but potentially fatal condition caused by different neoplastic & nonneoplastic dz. Malignant Hepatocellular carcinoma metastatic carcinoma Benign Cirrhosis Hepatic angioma Hepatic adenoma Etc peliosis hepatis polyarteritis nodosa SLE, pre-eclampsia

Ruptured hepatoma with hemoperitoneum Incidence - 3~15% of pts with HCC 12.4% in Thailand, 14.5% in Hong Kong cause of death in 10% of all pt.with HCC in japan In western, incidence <3% in UK mortality rate in acute phase – high, 25~75% Clinical manifestations: sudden onset of abdominal pain (66~100%) hypovolemic shock (30~90%)

Ruptured hepatoma with hemoperitoneum - Mechanisms rapid growth of tumor and necrosis rupture by splitting overlying normal parenchyma or erosion of vessel occlusion of hepatic v. by tumor thrombi coagulopathy due to underlying cirrhosis vascular dysfunction resulting degeneration of elastin and degradation of type IV collagen → rendering blood vessels stiff and weak

Ruptured hepatoma with hemoperitoneum - Diagnosis History of hepatoma Typical clinical symptoms – sudden onset of abdominal pain, peritoneal sign, shock…. Abdominal CT scan Hepatic angiography – extravasation of contrast from t tumor in 13.2~35.7% paracentesis – reliable test to confirm diagnosis positive in 86% of pt

J Clin Oncol 2001:19:3725~3732

Management of ruptured hepatoma with hemoperitoneum Initial hemostasis Definite treatment Arch Surg. 2006;141:191-198

Management of ruptured hepatoma -Conservative treatment 3-month survival rate of 10% and mean survival of 19.2 days most commonly pts in moribund state and with inoperable tumor differences between aggressive & conservative approaches : not significant conservative treatment was used initially →hemostatic procedure on signs of continuous bleeding overall inhospital mortality rate (62% vs 51%) median survival time (7 days vs 12 days) Am J Gastroenterol. 1991;86:67-71. Arch Surg. 1999;134:1103-1107..

Management of ruptured hepatoma -Transcatheter arterial embolization (TAE) Total 53~100% 0~37% Arch Surg. 2006;141:191-198 1 mo. survival rate: 62% (vs 50% & 29% in patients underwent emergency operation & conservative treatment) Am J Emer Med 2005; 23: 730-736 major life-threatening complication - liver failure (12%-33.%), M/C cause of death after TAE

Management of ruptured hepatoma -surgical mangement Perihepatic Packing hemostasis by tamponade effect effective especially situated near diaphragm. intra-abdominal abscess and sepsis following packing within 72 hrs - 23% to 32% Suture Plication limited by friable tumor tissue 3-mo survival rate and mean survival - 26.9%, and 81.5 days Hepatic Artery Ligation HCC supply almost exclusively from hepatic artery hemostatic success rate - 68~100% limited by high in-hospital mortality rate - 50~ 77% Ann Surg. 1992;215:467-474. Am J Gastroenterol. 1991;86:67-71. Ann Surg. 1989;210:24-28.

Definite treatment of ruptured hepatoma -One stage Emergency Liver Resection vs Staged Liver Resection- Total 12.5~31% 16.5~100% Total 21~56% 0~9% 54.2~100% 21.2~48% 15~21% Arch Surg. 2006;141:191-198

Ruptured hepatoma with hemoperitoneum - Prognostic factors In multivariate analysis, independent factors on 30-day mortality (1) shock on admission (2) hemoglobin level, (3) serum total bilirubin level (4) known diagnosis of HCC before rupture J Clin Oncol 2001:19:3725~3732

Ruptured HCC following TACE Eur J Radiol 2006;59:407~412

Incidence of spontaneous hepatoma rupture following TACE : rare searching for article reporting spontaneous hepatoma rupture following TACE in past 10 yrs by MEDLINE SEARCH Two articles each reported six cases and three cases from asia Liu CL British j surg 1998;85:512-514 Xia Jinglin Eur J Radiol 2006;59:407–412 One article reported two cases in western Narendra Battula Hepatobiliary Pancreat Dis int 2007;6:49-51

1443 sessions of TAOE among 391 pt. predominantly in men after first session of TOCE for large irresectable HCC of the right lobe. British j surg 1998;85:512-514

530 sessions of TACE among 294 pt. Large tumor size, male sex and exophytic growth of tumor may be predisposing factors for rupture. Hepatobiliary Pancreat Dis int 2007;6:49-51

Huge tumor measuring 14x12cm-size in Rt. lobe Developed rupture at 3rd post-TACE Huge tumor in Rt. lobe Developed rupture at 45th post-TACE 3x3cm superficially in Rt. lobe Developed rupture at same day-TACE Eur J Radiol 2006;59:407~412

Predisposing factor for rupture Spontaneous rupture of HCC Ruptured HCC following TACE Large sized tumor more advanced disease (worse clotting profile higher serum AFP) lower hemoglobin less ass. with alcoholism Large sized tumor Rt. Lobe Male sex Exophytic growth of tumor (=superficially located) First session of TACE