Some unusual complications of malignancies: Case 1. Spontaneous rupture of hepatocellular carcinoma demonstrated by contrast-enhanced sonography

Veterans General Hospital-Taipei and School of Medicine and Institute of Biomedical Engineering, National Yang Ming University, Taipei, Taiwan.
Journal of Clinical Oncology (Impact Factor: 18.43). 11/2002; 20(19):4108-11.
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    • "Rupture of HCC is confirmed by performing abdominal paracentesis, and the fluid shows blood-stained ascites. However, an imaging study such as ultrasonography or CT can demonstrate the extent of blood loss, the severity of the liver cirrhosis, the location of the tumor and the patency of the portal vein [11]. "
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    ABSTRACT: A 57-yr-old woman previously diagnosed with chronic hepatitis B was admitted via the emergency room because she suddenly developed epigastric pain with abdominal distension. On computed tomography (CT), a round enhancing mass was found on the left hepatic lobe with ascites in the peritoneal space. Bloody ascites were found upon tapping the ascites, and this led to the diagnosis of ruptured hepatocellular carcinoma (HCC). The patient was immediately treated with transcatheter arterial chemoembolization (TACE) including 50 mg of adriamycin and 10 mL of lipiodol, and then we performed left lateral segmentectomy 20 days later. To prevent recurrence of HCC by any micrometastasis, the patient subsequently received 8 cycles of adjuvant systemic chemotherapy (a regimen of epirubicin (50 mg/m(2)), cisplatin (60 mg/m(2)) and 5-fluorouracil (200 mg/m(2))) at monthly intervals. After this, the patient has been regularly followed up and she shows no signs of tumor recurrence 7 years later. This case suggests that surgical resection and subsequent adjuvant systemic chemotherapy with using an ECF regimen may provide long-term survival for patients ruptured HCC.
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    ABSTRACT: Intraperitoneal bleeding due to a ruptured tumor is a serious complication in patients with hepatocellular carcinoma (HCC). According to data compiled by the Liver Cancer Study Group of Japan, ruptured HCC accounts for around 10% of deaths in these patients. Clinical features include the sudden onset of abdominal pain and distension and, if bleeding is massive, the presence of shock. Other causes of an acute abdominal emergency must be ruled out. Diagnostic imaging generally includes sonography, contrast computed tomography (CT), and angiography. In patients with ruptured HCC, prompt diagnosis and treatment is essential to avoid hepatocyte necrosis and secondary hepatic failure associated with shock and decreased hepatic perfusion due to bleeding. The underlying liver disease varies in such patients with ruptured HCC. Chronic hepatitis, cirrhosis, or both may be present, and the severity of hepatic dysfunction as well as the size, number, and progression of the neoplastic lesions present varies from case to case. A common feature is the presence of a responsible lesion on or protruding from the surface of the liver. If hemostasis can be achieved early after HCC rupture, then overall prognosis depends on the patient's liver function and degree of tumor progression. Although there is a risk of intraperitoneal seeding, long-term survival is possible if the tumor can be completely resected by hepatectomy. One study has already reported a good 5-year survival rate after resection of ruptured and nonruptured HCC. In another study, rather than performing emergency surgery, Marini et al used transcatheter arterial embolization (TAE) to control bleeding; in those patients who could then undergo surgery, elective hepatectomy was associated with long-term survival. Treatment of ruptured HCC involves more than just hemostasis. Subsequent therapy is important, and, whenever possible, complete resection should be performed after bleeding has been controlled. Nevertheless, in a series of 172 patients with ruptured HCC in Japan, Miyamoto et al reported that subsequent hepatectomy was possible in only 12% of cases; in most cases, the presence of multiple lesions or underlying cirrhosis made surgery difficult. In patients in whom hepatectomy cannot be performed, relatively radical yet less invasive treatment with percutaneous radio frequency ablation (RFA) may lead to an improved prognosis. Transcatheter arterial embolization is now widely used as first-line treatment to achieve safe and reliable hemostasis in ruptured HCC. However, extensive TAE may worsen liver function and lead to post-TAE hepatic failure. In addition, angiographic localization of the bleeding site in ruptured HCC is difficult and is successful in 20% of cases at most. Accurate localization of the bleeding site allows for hemostasis with superselective TAE and local ablative therapy that can minimize injury to nontumor tissue and reduce the risk of posttreatment hepatic failure. In the case of ruptured HCC reported here, we identified the site of bleeding by contrast harmonic sonography and performed RFA under sonographic guidance to achieve hemostasis. This case shows the successful application of percutaneous ablative therapy guided by contrast harmonic sonography.
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    ABSTRACT: Spontaneous rupture of liver tumor is often considered a potentially life-threatening situation. The aim of the present study was to assess re-operation after emergency repair of ruptured liver cancer. We reviewed retrospectively five patients who had been admitted within a one-year period and undergone a second operation after emergency repair of primary liver cancer rupture. Five patients (4 males and 1 female) underwent emergency repair of ruptured liver cancer in local hospitals; three of them received transarterial chemoembolization (TACE). The tumor was in the right hepatic lobe in 2 patients, middle lobe in 1, left median lobe (segment IV) in 1, and caudate lobe (segment I) in 1. Operative methods included right hemihepatectomy in 2 patients, left partial lobectomy or wedge resection in 1, caudate lobe resection in 1, and middle lobctomy+cholecystectomy+abdominal implant resection in 1. Intra-abdominal chemotherapy was given to all 5 patients. Follow-up showed that one patient died from intrahepatic metastasis and hepatic failure six months after re-operation and that two patients died from extensive intra-abdominal metastases six months later. The remaining two patients have been surviving for 28 months. Re-operation is indicated for patients with primary liver cancer rupture whose liver function is good and whose foci are localized and operable. Apart from removing the primary foci, it is necessary to clear abdominal metastatic foci, irrigate the abdomen and administer chemotherapy to prolong the patient's life.
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