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Generally, short- and long-term survival rates after ruptured The two-stage therapeutic approach to manage ruptured
HCC are worse compared to non-ruptured HCC patients. HCC consists of initial management by conservative
Spontaneous rupture is considered the third leading cause method, hemostasis by TAE or surgical means, and
of HCC-related death after tumor progression and liver followed by second-stage hepatic resection or TACE. [7,9]
failure, with an associated mortality that is even higher than Previous studies suggested that multidisciplinary
ruptured esophageal varices. [4] management with TAE and postponed surgery in selected
patients improve the short-term mortality. If the patient’s
[7]
The exact mechanism of spontaneous rupture of HCC is not conditions allow, a two-staged approach involving TAE for
clearly known at this time, but it is believed to be related to hemostasis followed by staged hepatectomy is preferred
[5]
a tear in the tumor surface or rupture of a feeding artery. over emergency hepatectomy. This approach permits to
Risk factors that could be responsible for HCC rupture stabilize the patient, assess the liver function, and stage
include subcapsular location, rapid growth of the tumor with cancer to better plan the surgical resection. Emergency
necrosis, and erosion of vessels and blunt abdominal trauma, liver resection can achieve hemostasis and provide a
especially with superficial tumors. [6,7] definitive treatment in a single operation. However, one-
stage hepatectomy is only recommended for patients with
The usual symptoms of spontaneous rupture are right preserved liver function (Child-Pugh Classes A and B) and
upper quadrant or epigastric pain, and when the lesion is resectable tumors. [12-14]
more peripheral and located on the free surface of the liver,
it might be associated with signs of shock and peritoneal Conser vative treatment is recommended for patients who
irritation due to hemoperitoneum. Peritoneal irritation are hemodynamically stable at initial presentation. TAE
due to bleeding is not as common in cases of rupture of a is the first choice of treatment for unstable patients with
deeper lesion, which does not interrupt the liver capsule. continuous intra-abdominal hemorrhage, TAE is thought
In addition to pain and hemorrhagic shock, there is also to be the ideal treatment because it is simple and effective
[10]
a risk of peritoneal seeding of cancer cells, which worsen with a success rate of about 90%. Definitive treatment of
the prognosis. The diagnosis can be confirmed by the HCC should follow the initial recovery from ruptured HCC.
presence of hemoperitoneum on abdominal paracentesis. Patients with preser ved liver function and resectable tumors
Ultrasonography may demonstrate a hepatic tumor and should be considered for curative hepatic resection if a low-
ascites, the rupture site appears as a hyperechoic area risk curative resection is possible for patients with Child-Pugh
[10-13]
around the tumor, CT is valuable in showing the tumor Classes A and B. TAE as a palliative procedure is indicated
with a high attenuation close to it, which represents acute when the liver function is compromised or in the case of
blood clotting. Conventional angiography may reveal multifocal bilobar HCC. Long-term sur vival is correlated with
extravasations of contrast from the tumor. Zhu et al. the stage of the disease, its local spread after rupture, and
[8]
[9-12]
reported that the positive rate of correct diagnosis was the residual hepatic function.
86% with paracentesis, 66% by ultrasonography, 100% by In summary, HCC has a tendency to rupture spontaneously,
CT, and 20% by angiography.
which may lead to a life-threatening condition. Though
recently TAE followed by a second-stage resection has been the
Treatment of spontaneous rupture of HCC is dependent on first choice of treatment, laparotomy is still a reliable method
the pre-ruptured liver function and severity of bleeding, liver for hemostasis and permits consideration for resection of the
resection is the only curative option for ruptured HCC and tumor at the same time. In the presented case, the two-stage
the first step of treatment is resuscitation and stabilization therapeutic approach was used, utilizing a multidisciplinary
of the patients. [9-11] team approach consisting of gastroenterology, hepatobiliary
surgery, and IR consultants. Our patient was first managed
The open surgical method was the mainstay of treatment with TAE to achieve hemodynamic stability and after that she
for hemostasis in the period from the 1960s to the 1980s. underwent resection of the tumor with excellent outcomes.
Various surgical procedures, including perihepatic packing,
suture plication of bleeding tumors, hepatic artery To our knowledge, until now, there has been no prospective
ligation, and liver resection, were reported to be effective randomized controlled trial or well-designed comparative
in hemostasis. [10-13] Open surgical procedures achieved a study to find out which is the best method of hemostasis.
high rate of hemostasis but were associated with a high Most evidence comes from cohort series; therefore, more
in-hospital mortality rate. With the introduction of TAE research is needed in this field.
and transarterial chemoembolization (TACE), TAE has been
increasingly used for hemostasis in ruptured HCC. Now, open Financial support and sponsorship
surgical hemostasis becomes a second-line treatment when Nil.
TAE fails or it is not available. However, it is still regarded as
a reliable method for hemostasis, and permits consideration Conflicts of interest
for resection of the tumor at the same time. [4] There are no conflicts of interest.

Hepatoma Research | Volume 2 | April 1, 2016 105