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Fung et al. Hepatocellular carcinoma rupture hepatectomy

in the interval hepatectomy group (P = 0.27). The mean a retrospective analysis of patients with ruptured and
time to peritoneal recurrence was 6.4 and 6.4 months resectable HCC managed at a single tertiary referral
(P = 0.55) in the emergency and interval hepatectomy centre. The absolute number of patients was low given
groups respectively. This 11% peritoneal recurrence the rarity of rupture HCCs, although all eligible patients
rate was similar to that of hepatectomy for non-ruptured for analysis were included. There was selection bias in
HCC as reported by Jianyong et al. [36] In Chan et al. [26] determining which patients should proceed to interval
of interval hepatectomy for ruptured HCC, they found hepatectomy for ruptured HCC with the prerequisite
an intra-hepatic recurrence rate of 23.8% and extra- of satisfactory liver functional reserve and resectable
hepatic recurrence rate of 17.9% (n = 77). Additionally, HCCs with curative intent. The heterogeneous nature
peritoneal recurrence was 14.9% compared to 9.9% of patient and tumour characteristics was another
in a matched non-ruptured HCC group (P = 0.5). potential source of bias. Furthermore, the departmental
Hiraoka et al. [37] found a peritoneal recurrence rate database focussed on patients who underwent
of 7.7% in their case series. Other researchers have hepatectomy, and consequently, the data and clinical
also noted no increase in the incidence of peritoneal outcomes for patients who had ruptured HCC but were
metastases after ruptured HCC. [18,38] Moreover, there not subjected to hepatectomy (i.e. managed with TAE
are reports to suggest that patients with peritoneal only or best supportive care) cannot be retrieved for
recurrence after hepatectomy for HCC have no prior analysis.
evidence of HCC rupture. [39] These results suggested
that intra-peritoneal tumour cell implantation might not In conclusion, this study showed the feasibility of
be a common event. Although peritoneal recurrence of emergency or interval hepatectomy for highly selected
HCC can be managed by radical surgical resection, patients with ruptured and resectable HCC. Although
in the present case series, all the patients with patients in the emergency hepatectomy group had
resectable peritoneal recurrence opted for non-surgical larger tumours, worse pre-operative Child’s grading and
treatments. greater intra-operative blood loss, the recurrence-free
and overall survival rates were similar in both groups.
In this study, the median time to extrahepatic Hepatectomy should be considered for ruptured HCC
recurrence was shorter in the emergency hepatectomy provided the patient could tolerate curative resection
group, with no statistical difference in overall survival. and have surgically resectable tumours.
There were no statistical differences in the tumour
size, vascular involvement, resection margins or DECLARATIONS
degree of cirrhosis, to explain the mechanisms for
earlier extrahepatic recurrence in the emergency Authors’ contributions
hepatectomy group (data not shown). Whether there Data collection, compiling results, writing and producing
is increased haematogenous spread of HCC tumour the final manuscript: A.K.Y. Fung
cells at the time of emergency compared to interval Editing the manuscript drafts: C.C.N. Chong, K.F. Lee,
hepatectomy with subsequent extrahepatic seeding J. Wong, Y.S. Cheung, A.K.W. Fong, P.B.S. Lai
and HCC recurrence is a concept that this study Approved the final manuscript for submission: A.K.Y.
cannot answer. Fung, C.C.N. Chong, K.F. Lee, J. Wong, Y.S. Cheung,
A.K.W. Fong, P.B.S. Lai
Yang et al. [40] reported on the outcomes of 143
patients who underwent emergency (n = 28) or interval Financial support and sponsorship
hepatectomy (n = 115) for ruptured HCC. Interestingly, None.
they found that the recurrence-free survival (23%, 9%
and 9% vs. 45%, 26% and 16% at 1, 3 and 5 years, P = Conflicts of interest
0.025) and overall survival (50%, 8% and 8% vs. 70.3%,
29.2% and 19.4% at 1, 3 and 5 years, P = 0.016) were There are no conflicts of interest.
worse in the emergency group. This data suggested
that the ruptured HCC tumours were advanced at the Patient consent
time of presentation with probable micro-metastases. The data obtained through the medical record review
Although the median overall survival time was longer were managed according to the privacy policy and
in the emergency group, the absolute numbers in this ethics code of our institute.
group were small which might skew the data and give
a false survival advantage in the emergency group. Ethics approval
This was a retrospective study and did not require
There were several limitations in this study. This was Institutional Review Board approval.
202 Hepatoma Research ¦ Volume 3 ¦ September 08, 2017