RUPTURED HCC: AN UPDATE
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Transcript of RUPTURED HCC: AN UPDATE
RUPTURED HCC: AN UPDATEMarco Wong Cheuk YiUnited Christian Hospital
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What is included today
Case report in UCH Compare different modalities New management options
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The case
77/F Hep B carrier Strong family history of HCC Epigastric pain and anaemia
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CT taken on the day of admission
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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
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Operative photos
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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.
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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
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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.
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Treatments available
Conservative Open haemostatic surgery Emergency liver resection TAE (transcatheter arterial embolization)
New treatment– Radiofrequency ablation
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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.
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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.
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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.
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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
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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
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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
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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)
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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.
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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)
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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.
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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
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1 month post op
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The next stage
Restage patient Baseline liver function after recovery Tumour load Patient’s premorbid
Elective definitive treatment– Hepatectomy
– Local ablative therapy
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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.
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Lai EC et al. Spontaneous rupture of hepatocellular carcinoma: a systematic review. Arch Surg. 2006 Feb;141(2):191-8.
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Bring home message
TAE is the choice of haemostasis In case TAE contraindicated/ failure
– RFA as a potential new treatment modality
Q & A