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Butt et al. TAE for ruptured HCC in Pakistan

INTRODUCTION METHODS
Hepatocellular carcinoma (HCC) is the fifth most Study population and duration
common cancer and the third leading cause of This was a retrospective cross sectional study. Patients
[1]
cancer related mortality worldwide. Relatively ≥ 18 years of age, already diagnosed to have HCC
higher incidence rates have been reported from and admitted to Gastroenterology ward of Aga Khan
[2]
South Eastern Asia and sub-Saharan Africa. The University Hospital (AKUH) during 2006-2015 were
incidence rate of HCC in Pakistan is equivalent to 2.5 identified from our data base by using ICD code 1550.
per 100,000 persons per year which is higher than AKUH is a 563 bed, large tertiary care hospital in the
[3]
the Sub-continent and Western countries. Moreover, metropolitan city of Karachi with a population of 18
hepatitis C and B virus infection have been reported million. [15] The medical record coders at AKUH assign
to be the major attributable factors responsible for numerical codes for diseases and procedures to all
HCC in Pakistan. [4] records in accordance with standards outlined in the
International Classification of Diseases code book.
While, most of the patients remain asymptomatic, HCC Those HCC patients who presented with spontaneous
can manifest with right hypochondrial pain, weight loss, rupture of unresectable HCC were studied and
new onset jaundice and ascites. Hemoperitoneum analyzed. However, patients with hemorrhagic ascites
[5]
caused by spontaneous rupture of HCC is a rare but without HCC or where the required information was
fatal complication associated with mortality ranging incomplete were excluded.
between 25-75%. [6,7] The incidence of spontaneous
rupture of HCC ranges 3-15% in South-East Asian The information about patient’s demographics,
countries, which is higher as compared to the etiology of underlying cirrhosis, clinical, radiological
reported incidence of < 3% in Western countries. [6,8,9] characteristics, laboratory parameters, stage of
Spontaneous rupture of HCC is associated with poor HCC, treatment provided and follow up in days were
liver functional reserve, advanced stage of tumor and recorded. Child-Pugh score and Model for End Stage
high mortality rates ranging 32-62% as seen in various Liver Disease (MELD) score were used to define the
studies. [10-12] severity of liver disease.

It is not only difficult to anticipate the HCC rupture; The main outcome measure was control of bleeding.
there are few therapeutic options available to treat The other outcome measures were in-hospital
such patients. The treatment modalities that have mortality, 30-day mortality, overall duration of survival
been employed include emergency liver resection and factors associated with 30-day mortality.
in case of preserved liver function and resectable
tumor, transarterial embolization (TAE) or transarterial Diagnosis and staging of ruptured of HCC
chemoembolization (TACE) in case of advanced and cirrhosis
disease. [12,13] TAE has been found beneficial in the The diagnosis of HCC was made by combination
treatment of ruptured HCC in earlier studies by allowing of elevated alfa fetoprotein (AFP) (> 20 ng/mL)
control of bleeding and the selection of suitable patients and characteristic features of HCC on triple-phase
for later liver resection. However, the utility of available computerized tomography (CT) scan/magnetic
treatment options is limited due to the patient’s clinical resonance imaging (MRI); or in the absence of
condition and disease stage. [9,13,14] Moreover, most elevated AFP when the concurrent results were found
of the data available consists of studies with non- on CT scan/MRI along with presence of background
homogenous study population with variable disease chronic liver disease, with or without histological
stages, small sample size and limited results related verification. The diagnosis of cirrhosis was made
to prognostic factors. No data is available from either on liver biopsy or in the absence of liver
Pakistan so far. biopsy by clinical and laboratory features of portal
hypertension i.e. varices on upper gastrointestinal
Hence, in the current study, we report five years’ experience endoscopy, radiological features suggestive of
with patients who presented with spontaneous rupture of cirrhosis including irregular liver margins, dilated
unresectable HCC treated with or without TAE. The aim portal vein, spleenomegaly and ascites. [16]
is to evaluate clinicopathological characteristics and
outcomes of patients presenting with spontaneously “Spontaneous HCC rupture” was defined when it
ruptured, unresectable HCC treated with or without happened without a history of recent procedure or
TAE and to evaluate the factors associated with 30-day trauma and the “diagnosis” was established by using
mortality. contrast CT of the abdomen.
280 Hepatoma Research ¦ Volume 2 ¦ October 21, 2016