RUPTURED HCC: AN UPDATE Marco Wong Cheuk Yi United Christian Hospital

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: 2 days after TAE 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 Plan further Mx of S7 lesion

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 How to achieve these goal?

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.

My modification? 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

Q & A