HCC is strongly associated with liver cirrhosis.
Frequent causes of liver cirrhosis are the abuse of alcohol,
chronic infection with hepatitis B and C virus and haemochromatosis.
HCC,
although relatively uncommon in western and northern Europe,
is a common abdominal carcinoma worldwide.
Incidence ranges from 3/100.000 in most of Europe to 35.5/100.000 in Eastern Asia [1].
Male to female ratio is 8:1 in high incidence areas and 2.5:1 in low incidence areas.
Hemorrhage of HCC,
is a rare but potentially life-threatening complication and a surgical or interventional emergency.
Shock is present in 59-90 % of patients,
and signs of peritonitis and abdominal distention in 60-100% [2].
In high prevalence areas in Africa and Asia HCC rupture is reported to occur in 6.9-14 % of cases [2].
It represents the most frequent etiology for non-traumatic acute hemoperitoneum in men.
Rupture of HCC is associated with a subcapsular location,
where the tumor protrudes into the abdominal cavity without any overlying normal liverparenchyma [3].
The proposed mechanisms for rupture are the following (2):
1.
A hypertrophic artery or vein ruptures.
Because HCC is a hypervascular tumor,
arteries can be large,
especially in large masses.
2.
Minor (repetitive) trauma causes a feeding artery to rupture.
For example repetitive breathing motion can cause a large extracapsular tumor to rupture.
3.
Occlusion of a hepatic vein branch increases intratumoral pressure,
which can cause rupture and bleeding.
Current treatment options for (ruptured) HCC are the following (4,5):
1.
Surgical: Resection and transplantation.
This gives the best chance for cure,
although frequently not possible because of extensive disease or poor functional reserve (cirrhosis).
Indicated in early stage HCC.
2.
Radiofrequency Ablation (RFA).
According to the Barcelona Clinic Liver Cancer Staging system (BLCL system),
image guided tumor ablation is recommended in patients with early stage HCC without any surgical options.
3.
Transarterial Chemoembolization (TACE) with doxorubicine (loaded on beads or mixed with embolization particles) and Selective Internal Radiation therapy (Yttrium-90).
According to the BLCL system,
transarterial chemoembolization is the standard of care for multinodular HCC and intermediate stage HCC.
The development of hypertrophic arteries in HCC is used to selectively embolize the tumor with either doxorubicine chemotherapy beads or Beta-emitting Yttrium-90 particles.
4.
Systemic therapy/chemotherapy. Indicated in advanced HCC.
When a liver tumor has signs of acute hemorrhage,
it is not always clear that the underlying tumor is a HCC.
A therapy is instituted for acute control of intraperitoneal bleeding and hemodynamic status of the patient.
The ruptured tumor is often already very large and in an advanced stage.
This precludes any surgical and RFA procedures.
In such cases transarterial embolization [Fig.
3,4] is nowadays the standard of care.
After local control of the bleeding and stabilization of the patient a definite work-up can be done.
For control of bleeding we prefer not to use coils because this precludes a future TACE when the tumor turns out to be a large HCC.