Rupture of Hepatocellular Carcinoma: A Review of Literature

Abstract

Approximately 700,000 people die of Hepatocellular Carcinoma (HCC) each year worldwide, making it the third leading cause of cancer related deaths. Rupture is a potentially life-threatening complication of HCC. The incidence of HCC rupture is higher in Asia and Africa than in Europe. In Asia approximately 10% of patients with a diagnosis of HCC die due to rupture each year. Spontaneous rupture is the third most common cause of death due to HCC after tumor progression and liver failure. The diagnosis of rupture in patients without history of cirrhosis or HCC may be difficult. The most common symptom of ruptured HCC is abdominal pain (66-100%). Shock at presentation can be seen in 33-90% of cases; abdominal distension is reported in 33%. Abdominal paracentesis documenting hemoperitoneum is a reliable test to provisionally diagnose rupture of HCC, it can be seen in up to 86% of clinically suspected cases. The diagnoses can be confirmed by computed tomography scan or ultrasonography, or both in 75% of cases. Careful pre-treatment evaluation is essential to decide the best treatment option. Management of ruptured HCC involves multidisciplinary care where hemostasis remains a primary concern. Earlier studies have reported a mortality rate of 25-75% in the acute phase of ruptured HCC. However, recent studies have reported a significant decrease in the incidence of mortality. There is also a decrease in the incidence of ruptured HCC due to improved surveillance and early detection of HCC. Transarterial Embolization is the least invasive method to effectively induce hemostasis in the acute stage with a success rate of 53-100%. Hepatic resection in the other hand has the advantage of achieving hemostasis and in the same go offers a potentially curative resection in selected patients. (J CLIN EXP HEPATOL 2019;9:245-256) INCIDENCE The reported incidence of HCC rupture shows a distinct global variation. In the West, the incidence of HCC is increasing but HCC ruptures are relatively uncommon, with an incidence of less than 3%. 12-14 However, in Asia and Africa, the incidence is considerably higher, ranging between 3% and 26%. 14,15 The incidences of ruptured HCC reported from around the globe are 10% from Japan, 12.4% from Thailand, 12.7% from southern Africa, 14.5% from

Development and validation of risk score for predicting spontaneous rupture of hepatocellular carcinoma

“…A number of factors that are independently related to rHCC have been identified by previous studies, further strengthening the confidence with which APAS score might be applied in clinical practice. Consistent associations were shown for PFLS and tumor size of >5 cm [ 2 12 ]. Tumor size has been recognized as an important risk factor for spontaneous rupture, although this may be due to other related variables, such as vascular invasion and tumor grade, rather than the absolute maximum tumor size [ 12 13 ].…”

“…HCC patients with PFLS had an increased risk of rHCC, as compared with other tumor locations [ 7 14 ]. These indicated that normal parenchyma surrounding liver cancer can protect tumors from rupture; thus, protruded tumors without surrounding parenchyma may easily rupture due to compression or friction with adjacent organs [ 2 15 ]. Interestingly, ascites remained predictive for rHCC.…”

“…Spontaneous liver rupture is a potentially serious complication of liver cancer and occurs in about 3%–26% of hepatocellular carcinoma (HCC) patients [ 1 ]. Mortality from spontaneously ruptured HCC (rHCC) remains high in the acute phase, ranging from 25% to 75%, and the median survival is short, about 7–21 weeks, making it the third common cause of death of liver cancer excepting cancer progression and liver failure [ 2 3 ]. Either nonsurgical or surgical treatment aiming at long-term survival is often considered as futile in treating rHCC [ 4 ].…”

Survival of patients with ruptured and non‐ruptured hepatocellular carcinoma

“…Hepatocellular carcinoma (HCC) is causing an increasing number of deaths in Australia; the 5‐year survival rate from diagnosis is about 16% . Tumour rupture is a life‐threatening complication and the third most common cause of death (after tumour progression and liver failure) for people with HCC; mortality caused by rupture during the acute phase has been reported to be 25–75% in Asian countries . The poor prognosis is related to intraperitoneal haemorrhage and the potential for intraperitoneal metastases.…”

“…Hypotheses about the cause of spontaneous rupture include rapid growth and necrosis, splitting of the overlying parenchyma or vessel erosion, increased intratumoral pressure with hepatic vein occlusion, and coagulopathy . Tumour size exceeding 50 mm and superficial location are risk factors for rupture …”