MANAGEMENT OF RUPTURED HEPATOCELLULAR CARCINOMAJoint Hospital Surgical Grand Round19th July 2014Dr. SC TamUnited Christian Hospital

Introduction• Hepatocellular carcinoma is the 5th common cause of

malignancy in the World• Hong Kong Cancer Registry 2011:

10 most common cancer 10 most common cancer death

Ruptured HCC• Occurs in 3-15% of patients with HCC• Asian > Western• Decreasing incidence• Causes:

• Spontaneous (most common)• Post-treatment• Trauma

• Mortality rate in acute phrase 25-75%• Third leading cause of HCC-related death

Liu, et al. J Clin Oncol 2001

Mechanism of ruptured• Rapid growth of tumour• Tumour necrosis• Erosion to vessels• Hepatic venous thrombosis• Coagulopathy

Risk factors

Zhu, et al: World J Gastroenterol 2012

Clinical presentation

Letchumanan, et al: Med J Malaysia 2013

Liu, et al. J Clin Oncol 2001

Diagnosis• Computed tomography/ Ultrasound• Abdominal paracentesis• Emergency laparotomy (20%)

What? Who?

When?How?

Ruptured HCC

What? Who?

When?How?

Ruptured HCC

Treatment aim• Stabilize the patient

• Resuscitation• Correct coagulopathy

• Achieve haemostasis• Minimize damage to normal liver parenchyma• Identify ways to lengthen survival• Palliation

Management strategy• Conservative • Transcatheter arterial embolization (TAE)• Surgical haemostasis

What? Who?

When?How?

Ruptured HCC

•Do something vs. do nothing?•The more we do, the better?

Do little?• 63/508 (12%) admitted for ruptured HCC• 16/63 (25%) underwent conservative management

• 100% in patient mortality

Chearanai, et al. Cancer 1983

Do more?

Lai, et al. Arch Surg 2006

Conservative management

• Period 1 vs. period 2• Intervene when:

• Unstable• Signs of continuous bleeding• Not considered “terminal”

Leung, et al. Arch Surg 1999

Conservative management• Advanced malignancy, poor pre-morbid state• Poor liver function

• Stable patient with no signs of continuous bleeding

What? Who?

When?How?

Ruptured HCC

Surgical haemostasis• Open surgical method was mainstay of treatment in 60s to

80s• Perihepatic packing• Plication of bleeder• Ligation of hepatic artery (ipsilateral/ common)• Injection of alcohol• Radiofrequency ablation• Tumour resection

• No large study comparing different technique• Surgeon’s preference depending on situation

Transcatheter arterial embolization• Gained popularity since 90s• Injection of Gelfoam (absorbable)• Achieve haemostasis >70%

• Contraindicated:• Portal vein thrombosis• Arteriovenous shunting• Technical difficulty• Bilirubin > 50umol/L

Transcatheter arterial embolization• High success rate: 4/35 (11%) failed TAE• Better survival

• 10/35 (29%) died of liver failure in 1 month• Median survival 5.6 weeks

Liu, et al. J Clin Oncol 2001

Lai, et al. Archi Surg 2006

Algorithm

Terminal, poor liver function

Cheung, et al. PLoS One 2014

Radiofrequency ablation

Cheung, et al. PLoS One 2014

Radiofrequency ablation

Cheung, et al. PLoS One 2014

Overall Had surgery

TACE Conservative

What? Who?

When?How?

Ruptured HCC

Definitive treatment of HCC• 1-stage emergency liver resection vs. staged operation

Emergency liver resection• High mortality rate 16.5%-100%• Highly controversial• Only in highly selected patients

Pros Cons

•Stop the bleeding•Definite treatment•No delay

•?Hepatic reserve•Worsening of liver function•Coagulopathy•Occult tumour nodules

Lai, et al. Archi Surg 2006

Prognosis• Prognostic factors:

• Pre-ruptured disease state• Liver function• Child-Puge score/ Bilirubin• Severity of haemorrhage (shock/ haemoglobin level)

• Median survival 8.9 weeks• 30-day mortality 38%

Liu, et al. J Clin Oncol 2001

Staged liver resection• Eligible ~21%-56% of cases

Lai, et al. Archi Surg 2006

Staged liver resectionRuptured Not ruptured

Survival 1-year 57.1% 77.1%

3-year 19.0% 59.8%

5-year 7.6% 41.2%

Disease-free survival 1-year 27.6% 57.1%

3-year 14.3% 40.6%

5-year 3.8% 32.9%

Zhu, et al. World J Gastroenterol 2012

Summary• Rupture HCC is uncommon but highly fatal• Aim of treatment:

• Stabilization and achieve haemostasis• Often definitive management to selected patients

• Treatments do not alter outcome in patients with advanced malignancy and poor liver function

• Radiofrequency ablation is new and promising• Staged liver resection > 1-stage emergency resection• Prognosis is poor

• Correct management improves survival

Definite treatment/

staged liver resection

TAE

Conservative

Surgery

UnstableContinuous bleeding

Failed Haemostasis

Summary

Reference1. Ngan H, Tso WK, Lai CL, et al: The role of hepatic arterial embolization in the treatment of spontaneous

rupture of hepatocellular carcinoma. Clin Radiol 1998;53(5):338-41

2. Liu CL, Fan ST, Lo CM, et al: Management of spontaneous rupture of hepatocellular carcinoma: single-center experience. J Clin Oncol 2001;19(17):3725-32

3. Lai EC, Lau WY: Spontaneous rupture of hepatocellular carcinoma: a systematic review. 2006;Arch Surg 141(2):191-8

4. Kirikoshi H, Saito S, Yoneda M, et al: Outcome and factors influencing survival in cirrhotic cases with spontaneous rupture of hepatocellular carcinoma: a multicenter study. BMC Gastroenterol 2009;9:29

5. Rossetto A, Adani GL, Risaliti A, et al: Combined approach for spontaneous rupture of hepatocellular carcinoma. World J Hepatol 2010;2(1):49-51

6. Bassi N, Caratozzolo E, Bonariol L, et al: Management of ruptured hepatocellular carcinoma: implications for therapy. World J Gastroenterol 2010;16(10):1221-5

7. Kim JY, Lee JS, Oh DH, et al: Transcatheter arterial chemoembolization confers survival benefit in patients with a spontaneously rupturedhepatocellular carcinoma. Eur J Gastroenterol Hepatol 2012;24(6):640-5

8. Zhu Q, Li J, Yan JJ, et al: Predictors and clinical outcomes for spontaneous rupture of hepatocellular carcinoma. World J Gastroenterol 2012;18(48):7302-7

9. Jin YJ, Lee JW, Park SW, et al: Survival outcome of patients with spontaneously ruptured hepatocellular carcinoma treated surgically or by transarterial embolization. World J Gastroenterol 2013;19(28):4537-44

10. Letchumanan VP, Lim KF, Mohamad AB: Diagnosis and management of ruptured hepatoma: single center experience over 10 years. Med J Malaysia 2013;68(5):405-9

11. Cheung TT, Poon RT, Chok KS, et al: Management of spontaneously ruptured hepatocellular carcinomas in the radiofrequency ablation era. PLoS One 2014;9(4):e94453

12. Leung KL, Lau WY, Lai PBS, et al: Spontaneous rupture of hepatocellular carcinoma: conservative management and selective intervention. Arch Surg 1999;134(10):1103-7

Supplementary information

Supplementary information