Updates in Surgery

, Volume 63, Issue 1, pp 25–30 | Cite as

Prognosis of patients with spontaneous rupture of hepatocellular carcinoma in cirrhosis

  • Luciano Tarantino
  • Ignazio SordelliEmail author
  • Fulvio Calise
  • Carmine Ripa
  • Michele Perrotta
  • Pasquale Sperlongano
Original Article


The treatment of cirrhotic patients with spontaneous rupture of hepatocellular carcinoma (HCC) is controversial and largely dependent on general conditions of the patients and compensation of the underlying cirrhosis. We retrospectively reviewed clinical, imaging and surgical records of 24 consecutive cirrhotic patients (17 males, 7 females; age range 52–88 years) with hemoperitoneum from spontaneous rupture of HCC observed from June 2004 to January 2010 at our Institution. When indicated, patients were referred to surgery or trans-arterial embolization (TAE). Advanced decompensated patients were conservatively treated and clinically followed up. Spontaneous rupture of HCC was assessed by aspiration of bloody ascites at paracentesis in all cases. The presence of large blood-clots over HCC and liver surface at US and/or CT was considered a specific sign of ruptured HCC in 14 cases. In two out of four patients who underwent TAE active bleeding from tumor surface could be demonstrated. In 2 cases, the active hemorrhage from the HCC surface could be assessed by contrast-enhanced ultrasonography. Four out of 24 patients underwent surgery. Three out of four of these patients died within 2 weeks, 8 months, and 20 months after operation, respectively. The remaining patient is still alive at 52 months follow-up. Four patients underwent TAE and died at 1, 2, 6 and 10 months after treatment, because of recurrent peritoneal bleeding and/or liver failure. Sixteen patients with ruptured HCC in the advanced Child C cirrhosis were treated conservatively with blood derivative transfusion and with procoagulant drugs. All patients, but one died within 2–18 days. One patient survived the acute hemorrhage from ruptured HCC and died of liver failure after 3 months. We concluded that spontaneous rupture of HCC is usually a fatal event in patients with poor liver function, even after successful TAE. In compensated patients, timely surgical treatment can result in long term and even tumor-free survival of the patient.


Hepatocellular carcinoma Hemoperitoneum Liver resection 


  1. 1.
    Llovet JM, Burroughs A, Bruix J (2003) Hepatocellular carcinoma. Lancet 362:1907–1917PubMedCrossRefGoogle Scholar
  2. 2.
    Bosch FX, Ribes J, Diaz M, Cleries R (2004) Primary liver cancer: worldwide incidence and trends. Gastroenterology 127(Suppl):S5–S16PubMedCrossRefGoogle Scholar
  3. 3.
    Ong GB, Chu EPH, Yu FYK, Lee TC (1965) Spontaneous rupture of hepatocellular carcinoma. Br J Surg 52:123–129PubMedCrossRefGoogle Scholar
  4. 4.
    Ong GB, Taw JL (1972) Spontaneous rupture of hepatocellular carcinoma. BMJ 4:146–149PubMedCrossRefGoogle Scholar
  5. 5.
    Nagasue N, Inokuchi K (1979) Spontaneous and traumatic rupture of hepatoma. Br J Surg 66:248–250PubMedCrossRefGoogle Scholar
  6. 6.
    Chearanai O, Plengvanit U, Asavanich C, Damrongsak D, Sindhvananda K, Boonyapisit S (1983) Spontaneous rupture of primary hepatoma: report of 63 cases with particular reference to the pathogenesis and rationale of treatment by hepatic artery ligation. Cancer 51:1532–1536PubMedCrossRefGoogle Scholar
  7. 7.
    Chen MF, Hwang TL, Jeng LB, Jan YY, Wang CS (1988) Surgical treatment for spontaneous rupture of hepatocellular carcinoma. Surg Gynecol Obstet 167:99–102PubMedGoogle Scholar
  8. 8.
    Lai ECS, Wu KM, Choi TK, Fan ST, Wong J (1989) Spontaneous ruptured hepatocellular carcinoma: an appraisal of surgical treatment. Ann Surg 210:24–28PubMedCrossRefGoogle Scholar
  9. 9.
    Dewar GA, Griffin SM, Ku KW, Lau WY, Li AKC (1991) Management of bleeding liver tumours in Hong Kong. Br J Surg 78:463–466PubMedCrossRefGoogle Scholar
  10. 10.
    Miyamoto M, Sudo T, Kuyama T (1991) Spontaneous rupture of hepatocellular carcinoma: a review of 172 Japanese cases. Am J Gastroenterol 86:67–71PubMedGoogle Scholar
  11. 11.
    Vergara V, Muratore A, Bouzari H et al (2000) Spontaneous rupture of hepatocellular carcinoma: surgical resection and long-term survival. Eur J Surg Oncol 26:770–772PubMedCrossRefGoogle Scholar
  12. 12.
    Nouchi T, Nishimura M, Maeda M, Funatsu T, Hasumura Y, Takeuchi J (1984) Transcatheter arterial embolization of ruptured hepatocellular carcinoma associated with liver cirrhosis. Dig Dis Sci 29:1137–1141PubMedCrossRefGoogle Scholar
  13. 13.
    Cherqui D, Panis Y, Rotman N, Fagniez PL (1993) Emergency liver resection for spontaneous rupture of hepatocellular carcinoma complicating cirrhosis. Br J Surg 80:747–749PubMedCrossRefGoogle Scholar
  14. 14.
    Pombo F, Arrojo L, Perez-Fontan J (1991) Hemoperitoneum secondary to spontaneous rupture of hepatocellular carcinoma: CT diagnosis. Clin Radiol 43:321–322PubMedCrossRefGoogle Scholar
  15. 15.
    Baer PA, Meagher T, Pal JM, Viloria J (1984) Severe weight loss and fatal intra-abdominal hemorrhage in an elderly man. Can Med Assoc J 131:319–324PubMedGoogle Scholar
  16. 16.
    Reso A, Ball CG, Sutherland FR, Bathe O, Dixon E (2009) Rupture and intra-peritoneal bleeding of a hepatocellular carcinoma after a transarterial chemoembolization procedure: a case report. Cases J 2(1):68PubMedCrossRefGoogle Scholar
  17. 17.
    Chen CY, Lin XZ, Shin JS et al (1995) Spontaneous rupture of hepatocellular carcinoma: a review of 141 Taiwanese cases and comparison with nonrupture cases. J Clin Gastroenterol 21:238–242PubMedCrossRefGoogle Scholar
  18. 18.
    Leung KL, Lau WY, Lai PBS, Yiu RYC, Meng WCS, Leow CK (1999) Spontaneous rupture of hepatocellular carcinoma. Arch Surg 134:1103–1107PubMedCrossRefGoogle Scholar
  19. 19.
    Xu HS, Yan JB (1994) Conservative management of spontaneous ruptured hepatocellular carcinoma. Am Surg 60:629–633PubMedGoogle Scholar
  20. 20.
    Liu CL, Fan ST, Lo CM et al (2001) Management of spontaneous rupture of hepatocellular carcinoma: single-center experience. J Clin Oncol 19:3725–3732PubMedGoogle Scholar
  21. 21.
    Llovet JM, Brù C, Bruix J (1999) Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis 19(3):329–338PubMedCrossRefGoogle Scholar
  22. 22.
    Piscaglia F, Lencioni R, Sagrini E, Pina CD, Cioni D, Vidili G, Bolondi L (2010) Characterization of focal liver lesions with contrast-enhanced ultrasound. Ultrasound Med Biol 36(4):531–550 (Review)PubMedCrossRefGoogle Scholar
  23. 23.
    Torzilli G et al (2008) Systematic extended right posterior sectionectomy: a safe and effective alternative to right hepatectomy. Ann Surg 247(4):603–611PubMedCrossRefGoogle Scholar
  24. 24.
    Mittleman RE (1987) Hepatic rupture due to metastatic lung carcinoma. Am J Clin Pathol 88:506–509PubMedGoogle Scholar
  25. 25.
    Schoedel KE, Dekker A (1992) Hemoperitoneum in the setting of metastatic cancer to the liver. Dig Dis Sci 37:153–154PubMedCrossRefGoogle Scholar
  26. 26.
    Fidas-Kamini A, Busuttil A (1987) Fatal hemoperitoneum from ruptured hepatic metastases from testicular teratomas. Br J Urol 60:80–81PubMedCrossRefGoogle Scholar
  27. 27.
    Alavi AH (1985) Massive hemoperitoneum following rupture of hepatoma: report of three autopsy cases. East Afr Med J 62(6):415–419PubMedGoogle Scholar
  28. 28.
    Cooperman AM, Weiland LH, Welch JS (1976) Massive bleeding from a ruptured metastatic hepatic melanoma treated by hepatic lobectomy. Mayo Clin Proc 51:167–170PubMedGoogle Scholar
  29. 29.
    Muhammad I, Mabogunje O (1991) Spontaneous rupture of primary hepatocellular carcinoma in Zaria, Nigeria. J R Coll Surg Edinb 36:117–120PubMedGoogle Scholar
  30. 30.
    Corr P, Chan M, Lau WY, Metreweli C (1993) The role of hepatic arterial embolization in the management of ruptured hepatocellular carcinoma. Clin Radiol 48:163–165PubMedCrossRefGoogle Scholar
  31. 31.
    Kanematsu M, Imeda T, Yamawaki Y et al (1992) Rupture of hepatocellular carcinoma: predictive value of CT findings. AJR Am J Roentgenol 158:1247–1250PubMedGoogle Scholar
  32. 32.
    Choi BG, Park SH, Byun JY, Jung SE, Choi KH, Han JY (2001) The findings of ruptured hepatocellular carcinoma on helical CT. Br J Radiol 74:142–146PubMedGoogle Scholar
  33. 33.
    Recordare A et al (2002) Management of spontaneous bleeding due to hepatocellular carcinoma. Minerva Chir 57:347–356PubMedGoogle Scholar
  34. 34.
    Bassi N et al (2010) Management of ruptured hepatocellular carcinoma: Implications for therapy. World J Gastroenterol 16(10):1221–1225PubMedCrossRefGoogle Scholar
  35. 35.
    Tanaka A, Takeda R, Mukaihara S, Hayakawa K, Shibata T, Itoh K, Nishida N, Nakao K, Fukuda Y, Chiba T, Yamaoka Y (2001) Treatment of ruptured hepatocellular carcinoma. Int J Clin Oncol 6:291–295PubMedCrossRefGoogle Scholar
  36. 36.
    Ngan H, Tso WK, Lai CL, Fan ST (1998) The role of hepatic arterial embolization in the treatment of spontaneous rupture of hepatocellular carcinoma. Clin Radiol 53:338–341PubMedCrossRefGoogle Scholar
  37. 37.
    Tan FL, Tan YM, Chung AY, Cheow PC, Chow PK, Ooi LL (2006) Factors affecting early mortality in spontaneous rupture of hepatocellular carcinoma. ANZ J Surg 76:448–452PubMedCrossRefGoogle Scholar
  38. 38.
    Al-Mashat FM, Sibiany AM, Kashgari RH, Maimani AA, Al-Radi AO, Balawy IA, Ahmad JE (2002) Spontaneous rupture of hepatocellular carcinoma. Saudi Med J 23:866–870PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Luciano Tarantino
    • 1
  • Ignazio Sordelli
    • 2
    Email author
  • Fulvio Calise
    • 3
  • Carmine Ripa
    • 4
  • Michele Perrotta
    • 4
  • Pasquale Sperlongano
    • 5
  1. 1.Hepatology and Interventional Ultrasound DepartmentSan Giovanni di Dio HospitalFrattamaggiore (NA)Italy
  2. 2.V Division of SurgerySecond University of NaplesNaples (NA)Italy
  3. 3.Hepatobiliary and Transplantation DepartmentCardarelli HospialNaplesItaly
  4. 4.Department of SurgerySan Giovanni di Dio Hospital FrattamaggioreFrattamaggiore (NA)Italy
  5. 5.V Division of SurgerySecond University of NaplesNaplesItaly

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