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RUPTURED HCC: AN UPDATE

RUPTURED HCC: AN UPDATE. Marco W ong Cheuk Yi United Christian Hospital. What is included today. Case report in UCH Compare different modalities New management options. The case. 77/F Hep B carrier Strong family history of HCC Epigastric pain and anaemia.

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RUPTURED HCC: AN UPDATE

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  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: • 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

  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. 2003 Dec 6;362(9399):1907-17.

  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. 1998 May;53(5):338-41. Leung CS et al. J R Coll Surg Edinb. 2002 Oct;47(5):685-8. Tan FL et al. ANZ J Surg. 2006 Jun;76(6):448-52.

  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 90-100% Leung KL et al. Arch Surg. 1999 Oct;134(10):1103-7.

  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):178-82. Epub 2008 Apr 6.

  13. Emergency Hepatectomy • Benefits  Both curative and bleeding control • high mortality (operative mortality 28.5-54.5%) • But elective hepatectomy: 0-10% Tan FL et al. ANZ J Surg. 2006 Jun;76(6):448-52. Yoshida H et al. J Hepatobiliary Pancreat Surg. 2008;15(2):178-82. Epub 2008 Apr 6. Lai EC et al. Ann Surg. 1989 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. 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):178-82. Epub 2008 Apr 6. Leung CS et al. J R Coll Surg Edinb. 2002 Oct;47(5):685-8. Shimada R et al. Surgery. 1998 Sep;124(3):526-35. Yang Y et al. Zhonghua Zhong Liu Za Zhi. 2002 May;24(3):285-7. (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. 1998 May;53(5):338-41.

  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. 2006 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. 2006 Mar 28;86(12):801-5. (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 Eet al. Am Surg. 2004 Nov;70(11):989-93. Mitsuo M et al. World J Surg. 2007 Nov;31(11):2208-12; discussion 2213-4.

  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. 2003 Sep-Oct;50(53):1641-3. • 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. 2004 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):178-82. Epub 2008 Apr 6.

  25. Lai EC et al. Spontaneous rupture of hepatocellular carcinoma: a systematic review. Arch Surg. 2006 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

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