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MANAGEMENT OF RUPTURED HEPATOCELLULAR CARCINOMA

This presentation discusses the management of ruptured hepatocellular carcinoma (HCC), a serious complication with high mortality rates. It covers the causes, diagnosis, treatment options including surgical and conservative approaches, and prognosis factors. The focus is on stabilizing patients, achieving hemostasis, and improving survival rates through appropriate interventions. The role of transcatheter arterial embolization (TAE), surgical haemostasis, and radiofrequency ablation is highlighted, along with the importance of selecting appropriate treatment based on patient condition. The presentation concludes with a summary that emphasizes the need for tailored management strategies and the impact on patient outcomes.

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MANAGEMENT OF RUPTURED HEPATOCELLULAR CARCINOMA

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  1. MANAGEMENT OF RUPTURED HEPATOCELLULAR CARCINOMA Joint Hospital Surgical Grand Round 19th July 2014 Dr. SC Tam United Christian Hospital

  2. Introduction • Hepatocellular carcinomais the 5th common cause of malignancy in the World • Hong Kong Cancer Registry 2011: 10 most common cancer 10 most common cancer death

  3. 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

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

  5. Risk factors Zhu, et al: World J Gastroenterol 2012

  6. Clinical presentation Letchumanan, et al: Med J Malaysia 2013 Liu, et al. J Clin Oncol 2001

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

  8. What? Who? Ruptured HCC How? When?

  9. What? Who? Ruptured HCC How? When?

  10. Treatment aim • Stabilize the patient • Resuscitation • Correct coagulopathy • Achieve haemostasis • Minimize damage to normal liver parenchyma • Identify ways to lengthen survival • Palliation

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

  12. What? Who? Ruptured HCC How? When?

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

  14. Do little? • 63/508 (12%) admitted for ruptured HCC • 16/63 (25%) underwent conservative management • 100% in patient mortality Chearanai, et al. Cancer 1983

  15. Do more? Lai, et al. Arch Surg 2006

  16. Conservative management • Period 1 vs. period 2 • Intervene when: • Unstable • Signs of continuous bleeding • Not considered “terminal” Leung, et al. Arch Surg 1999

  17. Conservative management • Advanced malignancy, poor pre-morbid state • Poor liver function • Stable patient with no signs of continuous bleeding

  18. What? Who? Ruptured HCC How? When?

  19. 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

  20. 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

  21. 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

  22. Algorithm Terminal, poor liver function Cheung, et al. PLoS One 2014

  23. Radiofrequency ablation Cheung, et al. PLoS One 2014

  24. Radiofrequency ablation Overall Had surgery TACE Conservative Cheung, et al. PLoS One 2014

  25. What? Who? Ruptured HCC How? When?

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

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

  28. Lai, et al. Archi Surg 2006

  29. 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

  30. Staged liver resection • Eligible ~21%-56% of cases Lai, et al. Archi Surg 2006

  31. Staged liver resection Zhu, et al. World J Gastroenterol 2012

  32. 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

  33. Summary Definite treatment/ staged liver resection Conservative Unstable Continuous bleeding TAE Failed Haemostasis Surgery

  34. Reference • 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 • 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 • Lai EC, Lau WY: Spontaneous rupture of hepatocellular carcinoma: a systematic review. 2006;Arch Surg 141(2):191-8 • 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 • Rossetto A, Adani GL, Risaliti A, et al: Combined approach for spontaneous rupture of hepatocellular carcinoma. World J Hepatol 2010;2(1):49-51 • Bassi N, Caratozzolo E, Bonariol L, et al: Management of ruptured hepatocellular carcinoma: implications for therapy. World J Gastroenterol 2010;16(10):1221-5 • 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 • 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 • 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 • 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 • 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 • 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

  35. Supplementary information

  36. Supplementary information

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