Partial hepatectomy for spontaneous tumor rupture in patients with hepatocellular carcinoma: a retrospective cohort study

Risk Factors and Survival Analysis of Spontaneously Ruptured Hepatocellular Carcinoma: A Retrospective Cohort Study in Bilateral Centers

BACKGROUND

This study aimed to analyze risk factors for spontaneously ruptured hepatocellular carcinoma (HCC) and investigate the impact of spontaneous tumor rupture (STR) on the long-term survival of HCC patients treated by transcatheter arterial chemoembolization (TACE).

METHODS

A retrospective cohort of patients with a diagnosis of HCC was divided into the ruptured group and the non-ruptured group. Uni- and multivariate logistic regression analyses were performed for risk factors. The survival outcomes for the patients treated with hepatectomy, TACE, or best supportive care (BSC) in ruptured group were compared. The prognosis of HCC patients treated with TACE were compared using propensity score-matching (PSM).

RESULTS

The study enrolled 1103 HCC patients for risk factors analysis. Logistic regression analysis showed that male sex, liver cirrhosis, tumor protrusion, tumor diameter greater than 5 cm, macrovascular invasion, alpha fetoprotein (AFP) of 400 ng/mL or higher, and ascites were independent risk factors for STR. A COX regression analysis indicated that tumor diameter greater than 5 cm, AFP of 400 ng/mL or higher, and STR were independent prognostic factors for overall survival (OS). Furthermore, tumor diameter greater than 5 cm and macrovascular invasion were independent prognostic factors for progress-free survival (PFS). In ruptured group, treatment with hepatectomy indicated the best prognosis, followed by treatment with TACE and BSC. Also, in TACE group, the non-ruptured HCC patients had significant longer OS than the ruptured HCC patients, whereas PFS showed no statistical difference before or after PSM.

CONCLUSIONS

Male sex, liver cirrhosis, tumor protrusion, tumor diameter greater than 5 cm, macrovascular invasion, AFP of 400 ng/mL or higher, and ascites are independent risk factors for STR. In ruptured group, treatment with hepatectomy indicated the best prognosis, followed by treatment with TACE and BSC. For the HCC patients treated with TACE, STR was independent prognostic factor for OS but not PFS.

Prognosis and recurrence of spontaneously ruptured hepatocellular carcinoma treated after hepatectomy: A single institution experience

Spontaneously ruptured hepatocellular carcinoma (srHCC) is a life-threatening disease. The prognosis of patients with srHCC after hepatectomy remains unclear. This study aimed to investigate the prognosis and recurrence after hepatectomy in patients with srHCC. From 2015 to 2020, a retrospective analysis of patients with srHCC who underwent hepatectomy was performed, and compared with patients with unruptured HCC. Among the 86 patients with HCC who underwent hepatectomy, 11 had srHCC. The median tumor size in the ruptured group was significantly larger than that in the unruptured group (P = .001). The incidence rate of vascular invasion and Glisson capsule invasion in the ruptured group was significantly higher than that in the unruptured group. (P = .012 and P < .001, respectively). The American Joint Committee on Cancer was significantly higher in the ruptured group than in the unruptured group (P < .001). In total, 8 (73%) patients in the ruptured group experienced recurrence, whereas the median recurrence-free survival (RFS) and overall survival (OS) periods in the ruptured group were 15 (11-32) and 23 (17-38) months, respectively. In the unruptured group, 34 (45%) patients experienced recurrence, and the median RFS and OS periods were 20 (8-37, P = .099) and 33 (12-51, P = .394) months, respectively. Patients who developed peritoneal metastases were included in the ruptured group (n = 3). Ruptured HCCs exhibit worse oncological outcomes have poorer survival and higher recurrence rates than unruptured HCCs.

Comparison of post-resection survival between hepatocellular carcinoma patients in BCLC stage A or B who experience tumor rupture and patients in BCLC stage C who do not

BACKGROUND AND AIM

Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening complication, and patients who experience it are formally assigned to stage T4 in the TNM system, while many clinicians informally assign them to stage C in the more widely used Barcelona Clinic Liver Cancer (BCLC) system. The present study explored whether these re-staging practices are appropriate for HCC patients who suffer tumor rupture.

METHODS

We retrospectively reviewed the records of 1952 HCC patients who underwent hepatic resection at our hospital between January 2017 and June 2021. We compared recurrence-free and overall survival between 143 patients who had BCLC stage A or B disease at the time of spontaneous rupture and 449 patients who had BCLC stage C disease without rupture.

RESULTS

Overall survival rate was significantly higher among the 143 patients (1, 3, 5-year survival rate was 80.3%, 60.4%, 51.4%) with rupture than among the 449 (1, 3, 5-year survival rate was 69.5%, 41.5%, 32.4%) with BCLC stage C disease (hazard ratio 1.65, 95% confidence interval 1.29 to 2.12). The two groups had similar recurrence-free survival (hazard ratio 1.19, 95% confidence interval 0.92 to 1.53), but most patients with rupture were able to receive interventional and potentially curative treatments after recurrence, whereas most patients in BCLC stage C received interventional or supportive care. Similar results were obtained after propensity score matching.

CONCLUSION

HCC patients who experience spontaneous rupture tumor while in BCLC stage A or B have better prognosis than patients in BCLC stage C without rupture. Our results suggest that HCC patients who suffer rupture in BCLC stage A or B should not be assigned to BCLC stage C.

Transarterial Chemoembolization Plus Tyrosinkinase Inhibitors and PD-1 Inhibitors for Spontaneously Ruptured Hepatocellular Carcinoma

PURPOSE

To compare the efficacy and safety of transcatheter arterial chemoembolization (TACE) in combination with tyrosinkinase inhibitors (TKI) and PD-1 inhibitors, versus TACE monotherapy for the treatment of ruptured hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This study included 104 patients with ruptured HCC receiving either combination therapy or TACE monotherapy at two centers between June 2015 and June 2022. Propensity score matching (PSM) analysis was used at a 1:2 ratio to reduce bias between the two groups. The primary outcome measures were overall survival (OS) and progression-free survival (PFS), and the secondary outcome measures were the occurrence of adverse events (AEs, Common Terminology Criteria for AEs, version 5.0.) and the peritoneal metastasis rate.

RESULTS

A total of 69 patients were enrolled after PSM, including 23 patients in the combination group and 46 patients in the monotherapy group. The combination group exhibited a significantly longer median OS (553 days, 95% confidence interval [CI] 222.6-883.9) compared to the monotherapy group (105 days, 95% CI 81.2-128.7; P < 0.001). Similarly, the combination group showed a better median PFS (356 days, 95% CI 299.5-412.4) compared to the monotherapy group (97 days, 95% CI 75.9-118.1; P < 0.001). Moreover, there was no significant difference in the peritoneal metastasis rate (combination group: 8.6% vs. monotherapy group: 26.1%, P = 0.119). Grade 3 AEs occurred at a rate of 21.7% and 13% in combination and monotherapy groups, respectively. No Grade 4/5 AEs were observed in either group.

CONCLUSIONS

Our study demonstrated that the combination of TACE with TKI and PD-1 inhibitors significantly enhances OS and PFS compared to TACE monotherapy in ruptured HCC patients. Furthermore, this combined approach exhibited an acceptable safety profile.

Nomogram-based development and evaluation for predictions of 30-day and 1-year survival in patients with spontaneously ruptured hepatocellular carcinoma

Background

Accurately predicting the prognosis of patients with spontaneously ruptured hepatocellular carcinoma (HCC) is crucial for effective clinical management. The aim of the present study was to establish and evaluate prediction models for 30-day and 1-year survival in patients with spontaneously ruptured HCC.

Methods

A total of 118 patients with spontaneous rupture HCC were enrolled. Univariate and multivariate analyses were performed using logistic-regression model and Cox proportional-hazard model. The identified indicators were used to establish prediction models, the performance of which we compared with those of commonly used liver disease scoring models. The survival possibilities of different risk categories were calculated using the newly developed models.

Results

Largest tumor size (LTS), serum albumin (ALB), total bilirubin (TBil), and serum creatinine were identified as independent predictors, which were used to establish a 30-day survival prediction model. LTS, BCLC staging, ALB, TBil, hepatectomy at rupture, and TACE during follow-up were identified as independent predictors of 1-year survival model. The 30-day survival model had sensitivity of 79.3%, specificity of 87.1%, and an AUC of 0.879, exhibiting better predictive performance than scores for Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) and Model for End-stage Liver Disease (MELD). The 1-year survival model had sensitivity of 66.7%, specificity of 94.6%, and an AUC of 0.835, showing better predictive performance than Albumin–Bilirubin (ALBI), Child–Pugh, CLIF-C ADs, and MELD. After stratification, survival possibilities were 90.9 and 21.1% in low- and high-risk groups within 30 days, respectively, and 43.90, 4.35%, and 0 in low-, intermediate-, and high-risk groups at 1 year, respectively.

Conclusions

The established models exhibited good performance in predicting both 30-day and 1-year survival in patients with spontaneously ruptured HCC.

Development of a prognostic score for recommended transarterial chemoembolization candidates with spontaneous rupture of hepatocellular carcinoma

BACKGROUND

Although transarterial chemoembolization (TACE) has been widely used for treating the spontaneous rupture of hepatocellular carcinoma (HCC), no existing model exists for predicting survival. The aim of this study was thus to develop and validate a nomogram for estimating the prognosis in patients with ruptured HCC upon undergoing TACE treatment.

METHODS

This study included 55 patients with spontaneously ruptured HCC who underwent TACE treatment between January 2015 and April 2019. The diagnosis of spontaneous HCC rupture was based on the disruption of the peritumoral liver capsule with surrounding fluid in the perihepatic region. The prognostic nomogram was constructed using the independent predictors assessed by the multivariate Cox proportional hazards model.

RESULTS

The median overall survival (OS) was 6.4 months, with 6-month and 1-year survival rates of 52.7% and 41.8%, respectively. In the univariate analysis, the size of the largest tumor, total bilirubin (TBIL) levels, and aspartate aminotransferase (AST) levels were associated with the OS of patients. Multivariate analysis suggested that TBIL levels (HR =0.358, P=0.036) and diameter of the largest tumor (HR =1.012, P=0.044) were independent prognostic factors for predicting the OS. Based on these variables, we developed and validated a nomogram for the risk stratification of HCC rupture after TACE treatment for individual patients. According to the nomogram risk assessment, we were able to evaluate the approximate 1- and 2-year survival rates based on patients' tumor diameter and TBIL level after TACE treatment of ruptured HCC. The concordance index for the OS prediction was 0.748 (95% CI: 0.691-0.805). This newly developed nomogram represents an intuitive tool for predicting the OS of patients with ruptured HCC.

CONCLUSIONS

This study indicated that TBIL levels and diameter of the largest tumor were independent prognostic factors for predicting the OS of ruptured HCC. This study may help maximize favorable TACE treatment outcomes.

Ruptured Hepatocellular Carcinoma: Current Status of Research

Background

Ruptured hepatocellular carcinoma (rHCC) is considered a rare and life-threatening manifestation; when it happens, it often requires acute and positive intervention. At present, the mechanism of rHCC development is gradually being understood while there are many kinds of rHCC treatment. From our clinical observation, the prognosis of rHCC patients is not as poor as it is currently believed. It may not be appropriate to include all patients with rHCC in T4.

Main Body

The incidence of ruptured hepatocellular carcinoma is now rising. Especially in the Asian region, it can even reach 10% – 15%. The most common symptom of HCC rupture is abdominal pain, and there are now a variety of treatments for hepatocellular carcinoma rupture. With aggressive treatment, rHCC patients can also achieve a better prognosis. The patient’s condition varies on admission, so the treatment methods will also be different. It is critical to identify prognostic factors simultaneously, and rHCC can be effectively managed by focusing on important prognostic factors.

Conclusion

A review was carried out to analyze diagnosis, mechanism, treatment, and prognostic risk factors on this disease condition during the current situation; it is hoped that it will provide better guidance for clinicians. Moreover, patients with rHCC were managed hierarchically to prolong their prognosis.

Surgical Outcomes of Spontaneously Ruptured Hepatocellular Carcinoma

BACKGROUND

Surgical and oncological outcomes in ruptured hepatocellular carcinoma (HCC) are not well known. The objective of this study was to review and compare survival outcomes and recurrence rates between ruptured and unruptured HCC.

METHODS

Data of patients with ruptured HCC who underwent curative surgical resection between January 2000 and December 2016 were retrospectively reviewed. To compare survival outcomes between ruptured and unruptured HCC, 1:2 individual matching was conducted.

RESULTS

The 1-, 3-, and 5-year overall survival (OS) rates were 88.8%, 67.0%, and 51.9%, respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 51.7%, 32.8%, and 25.0%, respectively. OS and DFS rates were significantly lower in the ruptured HCC group than the matched unruptured HCC group. HCC recurred in 63 patients (70.8%), 33 (52.4%) of whom presented with both intrahepatic and extrahepatic recurrences. Mean recurrence interval was 12.6 ± 13.8 months. The 1-, 3-, and 5-year survival rates after recurrence were 61.6%, 40.2%, and 33.6%, respectively. Mean survival time after recurrence was 26.4 ± 29.5 months. Incidence of peritoneal seeding (PS) was 18.0%, and eight of them demonstrated solitary lesion. Mean recurrence interval was 5.9 ± 8.2 months. The 1-, 3-, and 5-year OS rates after recurrence were significantly lower in patients with PS (49.7%, 18.7%, and 9.3%, respectively) than in patients without PS.

CONCLUSIONS

Hepatectomy in ruptured HCC did show worse survival outcome compared with unruptured HCC and bear a high risk of PS. However, surgical resection combined with transcatheter arterial chemoembolization could help in achieving acceptable oncological outcomes.

Treatment strategies and prognosis for initially unresectable ruptured hepatocellular carcinoma: a single-center experience in 94 patients

PURPOSE

To identify the treatment options and prognostic factors for patients with initially unresectable ruptured hepatocellular carcinoma (HCC).

METHODS

Between June 2012 to December 2016, 94 consecutive patients with initially unresectable ruptured HCC were analyzed retrospectively in this study. Patients were followed until December 2017. Predictors of short-term (≤30 days) and long-term (>30 days) survival were identified by using logistic regression model and Cox proportional hazard model, respectively.

RESULTS

Of the 94 patients, initial hemostasis treatment was achieved by transarterial embolization (TAE) in 59 patients, surgical hemostasis in 14, and conservative treatment in 21. Twenty-five (26.6%) patients died within 30 d after tumor rupture. In the multivariate analysis, patients treated with aggressive initial treatment strategies (TAE or surgical hemostasis) (P < 0.001) or those with better Child-Pugh class (P = 0.003) and absence of shock on admission (P = 0.001) had a better chance of short-term survival. Of the 69 patients who survived more than 30 days after initial treatment, the median survival time was 268 d. In the multivariate analysis, among the 69 who survived, early modified LCSGJ stage (P = 0.003) and staged hepatectomy as definitive treatment (P < 0.001) were significant predictors of increased long-term survival.

CONCLUSION

Short-term survival of patients with initially unresectable ruptured HCC could achieve with better Child-Pugh class, absence of shock and aggressive initial treatment strategies. After survived the emergency phase of tumor rupture, long-term survival was significantly increased with early modified LCSGJ stage and staged hepatectomy therapy.

Early versus Delayed Hepatectomy for Spontaneously Ruptured Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

Here, we aimed to compare early hepatectomy (EH) with delayed hepatectomy (DH) as a treatment for spontaneously ruptured hepatocellular carcinoma (HCC).

METHODS

Several databases were systematically searched for eligible studies that compared DH with EH for spontaneously ruptured HCC treatment. Studies that met the inclusion criteria were reviewed systematically, and the reported data were aggregated statistically, using the RevMan v5.3 software.

RESULTS

Seven studies were included, with a total of 385 patients, comprising of 224 EH cases and 161 DH cases. Compared with the EH group, incidence of intraoperative bleeding [mean difference (MD), 353.93; 95% CI, 230.04-447.83; P < 0.00001], volume of intraoperative blood transfusion (MD, 420.61; 95% CI, 354.40-486.81, P < 0.00001), and 30-day mortality rate (OR, 14.94; 95% CI, 1.76-126.66; P = 0.01) were significantly lower in the DH group. Furthermore, the 1-, 2-, and 3-year survival rates were significantly higher in the DH group [1-year：hazard ratio (HR), 1.76; 95% CI, 1.06-2.94; P = 0.03; 2-year：HR, 1.52; 95% CI, 1.02-2.25; P = 0.04; 3-year: HR, 1.53; 95% CI, 1.06-2.21; P = 0.02]. There was no difference between the groups in the 5-year survival rate (HR, 1.40; 95% CI, 0.92-2.11; P = 0.11).

CONCLUSION

For resectable spontaneously ruptured HCC, DH could reduce intraoperative bleeding, intraoperative blood transfusion volume, and 30-day mortality rate and increase the 1-, 2-, and 3-year survival rates, endowing the patients with greater short- and long-term benefits during and following the surgery.

Retrospective analysis of transcatheter arterial chemoembolization treatment for spontaneously ruptured hepatocellular carcinoma

Spontaneous rupture is one of the complications of hepatocellular carcinoma (HCC) associated with a high mortality rate. Transcatheter arterial chemoembolization (TACE) has been widely used in patients with ruptured liver tumors. The aim of the present study was to evaluate the benefits and safety of conventional TACE and the disease prognosis following TACE and surgery with regard to the progression of spontaneously ruptured HCC. The clinical data of 70 patients diagnosed with spontaneous rupture of HCC were retrospectively reviewed. The majority of adverse reactions that occurred following treatment were Grade 2 or below. Grade 3/4 events occurred in 20 patients (14.3%), which included gastrointestinal hemorrhage, cardiac failure, pulmonary embolism, shock and recurrent tumor rupture. All of these patients recovered and were discharged following symptomatic and supportive treatment, with the exception of two cases of severe hemorrhagic shock and hepatic failure prior to TACE treatment. These patients did not survive during the period of hospitalization. Multivariate analysis identified that a maximum tumor size >10 cm and a high serum total bilirubin level >30 µmol/l were independent factors for determining overall patient survival rate. Additionally, the overall survival rates at 1, 6 and 12 months were 92.3, 53.8 and 46.2% in the TACE group and 100, 87.1 and 54.8% in the surgery group, respectively. The overall survival rates at 1 and 6 months following TACE were lower than those of the surgery group (P<0.05). However, the overall survival rates at 12 months were similar (P>0.05). Patients in the TACE group had a shorter hospital admission compared with those in the resection group (median 7 vs. 13 days; P<0.01). Therefore, the data demonstrated that conventional TACE therapy was safe and effective for the treatment of spontaneously ruptured HCC. In addition, this type of therapy conferred a similar long-term survival rate with that of open surgery.

Hemoperitoneum in cirrhotic patients in the absence of abdominal trauma

Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management. Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed. Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).

Prognostic Factors and Survival Outcomes of Surgical Resection of Huge Hepatocellular Carcinomas

INTRODUCTION

The aim of the study was to analyze the various prognostic factors that influence survival and clinical outcomes in patients undergoing liver resection for huge hepatocellular carcinomas.

MATERIALS AND METHODS

The records of patients who underwent curative surgery between 1991 and 2011 for huge hepatocellular carcinoma were analyzed. Various prognostic factors that influenced the survival were studied. The patients were followed up till November 2016.

RESULTS

The number of patients who underwent liver resection with huge hepatocellular carcinoma during the study period was 17; this included 14 males and 3 females. The median age of the study population was 52 years. The median serum AFP in the study population was 132.3 ng/ml (range 2 to 187,000 ng/ml). 41.2% of the patients were hepatitis B positive. The overall morbidity was 6%. The mortality rate was nil. The mean size of the resected specimen was 13.9 cm ± 3.6 cm. The overall recurrence rate was 76.5%. The local recurrence rate was 29.4%. The median time to recurrence was 8 months. The 5-year disease-free survival and overall survival of the study group were 26% and 32%, respectively. The factors that predicted an adverse survival outcome after the log-rank test for univariate analysis using life-table method were presence of lymphovascular invasion (p = 0.047), age ≤ 55 years (p = 0.021), and raised serum AFP (p = 0.041).

CONCLUSION

The factors that predict an adverse outcome after surgery in patients with huge hepatocellular carcinomas were the presence of lymphovascular invasion, raised serum AFP, and age ≤ 55 years.

Liver Transplantation After Downstagings of Ruptured Advanced Hepatocellular Carcinoma in Cirrhotic Liver: Is It Advisable? A Case Report

Spontaneous rupture of hepatocellular carcinoma (HCC), defined as T4 in TNM stage by the American Joint Committee on Cancer (eighth edition), is a serious life-threatening complication. Effective treatment remains challenging because of a high 1-month mortality, a short median survival, and the potential of peritoneal metastasis. We reported on a case that received a living related donor liver transplantation (LDLT) after successful consecutive downstaging therapies. A 63-year-old man with alcohol-related liver cirrhosis and multiple HCC developed spontaneous rupture and hemoperitoneum. He received 3 sessions of transcatheter hepatic arterial chemoembolization and target therapy with sorafenib. Computed tomography scans and magnetic resonance imaging after 11 months of treatment showed that the patient's HCCs fulfilled the Milan criteria and the University of California San Francisco criteria prior to LDLT. The perioperative course was rather smooth. After discharge, interval follow-up computed tomography studies of chest and liver and a whole-body bone scan showed no tumor recurrence or metastasis up to 20 months post-operation. Successful downstaging therapies of ruptured HCC to fulfill Milan criteria to receive liver transplantation is advisable in highly selected patients.