Imaging findings:
In our experience a ruptured HCC typically presents itself as a large inhomogeneous subcapsular mass with surrouding and intra-abdominal hematoma [Figs.
1,2,
5-12].
Frank extravasation of contrast is not always noted,
but risk of rebleeding is high.
Extravasation of contrast in our patient series was noted in only 48 % of patients.
As stated before risk of rebleeding is high and pre-emptive embolization should always be considered.
Figures on the right are CT,
MR and angiogram images of the same patient with a large HCC.
On the hepatic arterial phase CT a large inhomogeneous hypervascular subcapsular mass is noted [Fig.
5].
There is frank hemoperitoneum.
The portal venous phase CT shows necrosis and wash-out [Fig.
6].
The T1 contrast enhanced MR image accurately shows the arterial hypervascular nature of the HCC with wash-out in the portal venous and later phases [Fig.
7].
The DWI and ADC images show markedly resctricted diffusion.
All CT and MR imaging findings are characteristic and typical for hepatocellular carcinoma [6,7].
Patient-Lesion characteristics:
We retrospectively identified twenty-three patients with HCC and acute hemorrhage.
All patients where admitted to our hospital from 1999 to 2011.
Patient demographics were as listed below [Table 1.]:
Fifteen patients were male,
8 were female.
Mean age was 62 years (range 42-87).
Liver cirrhosis was present in 15 of 23 (65 %) patients.
Signs of portal hypertension was relatively uncommon and present in 9 of 23 patients (39 %). Six (26 %) patients had partial or complete portal vein thrombosis.
No.
of patients (N) |
23 |
Mean Age (y) |
62 |
Gender M/F |
15/8 |
Cirrhosis |
15/23 (65 %) |
Signs of portal hypertension |
9/23 (39 %) |
Partial or complete portal vein occlusion |
6/23 (23 %) |
Table 1.
Patient demographics.
Lesion characteristics [Table 2.]:
Most patients had only one HCC lesion (16/23),
whereas two patients had 2 to 4 lesions and 5 patients had 5 lesions or more. All lesions were located in a subcapsular position and had an equal distribution over the right and left liver lobes; twelve in the left liver lobe,
and 11 in the right lobe.
Mean diameter of the lesion with hemorrhage was 10,0 cm (range 3,8-22,4).
Active extravasation was noted in 11 out of 23 patients ( 48 %).
Number of lesions (N) |
|
1 |
16/23 (70 %) |
2-4 |
2/23 |
>5 |
5/23 |
Subcapsular/superficial position |
23/23 (100 %) |
Distribution R/L |
11/12 |
Mean diameter of ruptured HCC (cm) |
10,0 cm |
Active extravasation on arterial fase CT |
11/23 (48 %) |
Table 2.
Lesion characteristics.
Treatment/follow-up [Table 3.]:
Transarterial (chemo)embolisation was performed in 8 patients.
Primary resection in 10/23.
Expectative/palliative therapy was given in 6 patients.
During follow-up 11 patients died within 6 months to a year.
Six patients developed metastasis,
all in less than 1 year after bleeding: peritoneal metastasis in 3,
lung metastasis in 2,
and bone metastasis in 1.
Transarterial embolization |
Resection |
Palliative/expectative |
8/23 |
9/23 |
6/23 |
Table 3.
Treatments performed.