ruptured hcc: an update marco wong cheuk yi united christian hospital

RUPTURED HCC: AN UPDATE

Marco Wong Cheuk YiUnited Christian Hospital

© 2008 IBM Corporation2

What is included today

Case report in UCH

Compare different modalities

New management options


The case

77/F

Hep B carrier

Strong family history of HCC

Epigastric pain and anaemia


CT taken on the day of admission


Case in UCH (2)

Urgent CT:

– S8/4a 6cm tumour, bleeding caudate tumour

– TAE to right hepatic artery with gelfoam

2 days after TAE

– Hb drop again with increasing pain

Open RFA for bleeding control


Operative photos


Background Information

Hepatocellular carcinoma is the 5th most common cancer in the world

Prevalent among Asian countries (hepatitis B and C endemic areas)

Common presentations:

– hepatomegaly

– detected during surveillance

3-15% of all HCC patients presented with rupture

Locally most common cause of spontaneous haemoperitoneum !

Llovet JM et al.. Lancet. 2003 Dec 6;362(9399):1907-17.


Ruptured HCC

Common symptoms:

– shock 67%

– abdominal pain 66%

– abdominal distension 16%

Main cause of death:

– hypovolaemia

– liver failure

Management

– Evolving trend

– Advances in treatment modalities, improving technique

Miyamoto M et al. Am J Gastroenterol 1991; 16: 334-6


Prognostic factors

Bilirubin

Portal vein invasion

Shock upon presentation

AFP level

Child’s status

Ngan H et al. Clin Radiol. 1998 May;53(5):338-41. Leung CS et al. J R Coll Surg Edinb. 2002 Oct;47(5):685-8.

Tan FL et al. ANZ J Surg. 2006 Jun;76(6):448-52.


Treatments available

Conservative

Open haemostatic surgery

Emergency liver resection

TAE (transcatheter arterial embolization)

New treatment

– Radiofrequency ablation


Conservative Management

Supportive

– Correct hypovolaemia

– Correction of coagulopathy

– close monitoring

conservative management indicated in:

– Stable patient with radiological evidence of rupture

– Poor premorbid

– Advanced tumour stage

high mortality 90-100%

Leung KL et al. Arch Surg. 1999 Oct;134(10):1103-7.


Open haemostatic surgery

Options

– Perihepatic packing

– Suture plication

– Hepatic artery ligation

– Alcohol injection

No larges scale studies comparing different modalities of treatment

High mortality up to 70% 3 months

Yoshida H et al. J Hepatobiliary Pancreat Surg. 2008;15(2):178-82. Epub 2008 Apr 6.


Emergency Hepatectomy

Benefits Both curative and bleeding control

high mortality (operative mortality 28.5-54.5%)

But elective hepatectomy: 0-10%

Tan FL et al. ANZ J Surg. 2006 Jun;76(6):448-52. Yoshida H et al. J Hepatobiliary Pancreat Surg. 2008;15(2):178-82. Epub 2008 Apr 6. Lai EC et al. Ann Surg. 1989 Jul;210(1):24-8.


Emergency Hepatectomy (2)

Pros

– Single procedure with curative intent

– No delay

Cons

– Unstable patient

– Coagulopathies

– Unknown liver function reserve

– Unknown tumour load

– Compromised margins

Only considered in selective cases


The current treatment philosophy is…

Effective means of bleeding control

Selective

Less collateral damage

– preserving as much liver function as possible

Not aiming at cure in the emergency setting

Minimal invasive

Would not hinder subsequent definitive treatment


How to achieve these goal?

Effective means of bleeding control

Selective

Less collateral damage

– preserving as much liver function as possible

Not aiming at cure in the emergency setting

Minimal invasive

Would not hinder subsequent definitive treatment


Transcatheter Arterial Embolization

First reported in early 80s

Treatment of choice since early 90s

Effective in bleeding control in >70% cases

In-hospital mortality 0-30%

Compared with hepatic artery ligation

– similar haemostasis success rate

– mortality ~ 70%

Availability of expert interventional radiologists !

Yoshida H et al. J Hepatobiliary Pancreat Surg. 2008;15(2):178-82. Epub 2008 Apr 6. Leung CS et al. J R Coll Surg Edinb. 2002 Oct;47(5):685-8. Shimada R et al. Surgery. 1998 Sep;124(3):526-35. Yang Y et al. Zhonghua Zhong Liu Za Zhi. 2002 May;24(3):285-7. (article in Chinese)


Contraindications

Decrease portal blood flow

– Main portal vein occlusion

– Marked cirrhosis with diminished portal blood flow

Severe hepatic dysfunction

– Bilirubin cutoff: 50 micromol/l

– encephalopathy

Ngan H et al. Clin Radiol. 1998 May;53(5):338-41.


New Option: RFA

Introduced in late 90s

Proven to be effective in tumour ablation

– size <= 5cm

– up to 3 nodules with size <=3cm

Less morbidity especially with percutaneous approach

Chen MS et al. Ann Surg. 2006 Mar;243(3):321-8. Shiina S et al. Oncology. 2002;62 Suppl 1:64-8. Lu MD et al. Zhonghua Yi Xue Za Zhi. 2006 Mar 28;86(12):801-5. (article in Chinese)


RFA in bleeding control

Working mechanism: heat then necrosis

Proven to be effective in bleeding control

– Less blood loss in RF assisted hepatectomy compared with hepatectomy alone

– Efficient and safe method for grade III to IV hepatic traumas using dog models

Felokouras E et al. Am Surg. 2004 Nov;70(11):989-93. Mitsuo M et al. World J Surg. 2007 Nov;31(11):2208-12; discussion 2213-4.


Role of radiofrequency ablation in ruptured HCC

No large scale study for bleeding human cases yet

Only less than 5 case reports so far

– Ng KK et al. Radiofrequency ablation as a salvage procedure for ruptured hepatocellular carcinoma. Hepatogastroenterology. 2003 Sep-Oct;50(53):1641-3.

– Kobayashi et al. Successful control of ruptured hepatocellular carcinoma with radiofrequency ablation. J Gastroenterol. 2004;39(2):192-3.

– Fuchizaki U et al. Radiofrequency ablation for life-threatening ruptured hepatocellular carcinoma. J Hepatol. 2004 Feb;40(2):354-5


1 month post op


The next stage

Restage patient

Baseline liver function after recovery

Tumour load

Patient’s premorbid

Elective definitive treatment

– Hepatectomy

– Local ablative therapy


The next stage after bleeding controlled……

Ruptured = T4 disease, even if small size

Recent study comparing ruptured group with different stages of non ruptured patients, both receiving elective hepatectomy

Cumulative survival rate similar to that of stage 2/ 3 disease

Yoshida H et al. Long-term results of elective hepatectomy for the treatment of ruptured hepatocellular carcinoma. J Hepatobiliary Pancreat Surg. 2008;15(2):178-82. Epub 2008 Apr 6.


Lai EC et al. Spontaneous rupture of hepatocellular carcinoma: a systematic review. Arch Surg. 2006 Feb;141(2):191-8.


Bring home message

TAE is the choice of haemostasis

In case TAE contraindicated/ failure

– RFA as a potential new treatment modality

ruptured hcc: an update marco wong cheuk yi united christian hospital

Documents

ibm corporation

anaemia slide

bleeding control slide

operative photos slide

day of admission slide

treatment modalities

j gastroenterol

j hepatobiliary pancreat