management of ruptured hepatocellular carcinoma joint hospital surgical grand round 19 th july 2014...
TRANSCRIPT
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MANAGEMENT OF RUPTURED HEPATOCELLULAR CARCINOMAJoint Hospital Surgical Grand Round19th July 2014Dr. SC TamUnited Christian Hospital
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Introduction• Hepatocellular carcinoma is the 5th common cause of
malignancy in the World• Hong Kong Cancer Registry 2011:
10 most common cancer 10 most common cancer death
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Ruptured HCC• Occurs in 3-15% of patients with HCC• Asian > Western• Decreasing incidence• Causes:
• Spontaneous (most common)• Post-treatment• Trauma
• Mortality rate in acute phrase 25-75%• Third leading cause of HCC-related death
Liu, et al. J Clin Oncol 2001
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Mechanism of ruptured• Rapid growth of tumour• Tumour necrosis• Erosion to vessels• Hepatic venous thrombosis• Coagulopathy
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Risk factors
Zhu, et al: World J Gastroenterol 2012
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Clinical presentation
Letchumanan, et al: Med J Malaysia 2013
Liu, et al. J Clin Oncol 2001
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Diagnosis• Computed tomography/ Ultrasound• Abdominal paracentesis• Emergency laparotomy (20%)
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What? Who?
When?How?
Ruptured HCC
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What? Who?
When?How?
Ruptured HCC
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Treatment aim• Stabilize the patient
• Resuscitation• Correct coagulopathy
• Achieve haemostasis• Minimize damage to normal liver parenchyma• Identify ways to lengthen survival• Palliation
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Management strategy• Conservative • Transcatheter arterial embolization (TAE)• Surgical haemostasis
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What? Who?
When?How?
Ruptured HCC
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•Do something vs. do nothing?•The more we do, the better?
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Do little?• 63/508 (12%) admitted for ruptured HCC• 16/63 (25%) underwent conservative management
• 100% in patient mortality
Chearanai, et al. Cancer 1983
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Do more?
Lai, et al. Arch Surg 2006
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Conservative management
• Period 1 vs. period 2• Intervene when:
• Unstable• Signs of continuous bleeding• Not considered “terminal”
Leung, et al. Arch Surg 1999
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Conservative management• Advanced malignancy, poor pre-morbid state• Poor liver function
• Stable patient with no signs of continuous bleeding
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What? Who?
When?How?
Ruptured HCC
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Surgical haemostasis• Open surgical method was mainstay of treatment in 60s to
80s• Perihepatic packing• Plication of bleeder• Ligation of hepatic artery (ipsilateral/ common)• Injection of alcohol• Radiofrequency ablation• Tumour resection
• No large study comparing different technique• Surgeon’s preference depending on situation
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Transcatheter arterial embolization• Gained popularity since 90s• Injection of Gelfoam (absorbable)• Achieve haemostasis >70%
• Contraindicated:• Portal vein thrombosis• Arteriovenous shunting• Technical difficulty• Bilirubin > 50umol/L
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Transcatheter arterial embolization• High success rate: 4/35 (11%) failed TAE• Better survival
• 10/35 (29%) died of liver failure in 1 month• Median survival 5.6 weeks
Liu, et al. J Clin Oncol 2001
Lai, et al. Archi Surg 2006
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Algorithm
Terminal, poor liver function
Cheung, et al. PLoS One 2014
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Radiofrequency ablation
Cheung, et al. PLoS One 2014
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Radiofrequency ablation
Cheung, et al. PLoS One 2014
Overall Had surgery
TACE Conservative
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What? Who?
When?How?
Ruptured HCC
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Definitive treatment of HCC• 1-stage emergency liver resection vs. staged operation
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Emergency liver resection• High mortality rate 16.5%-100%• Highly controversial• Only in highly selected patients
Pros Cons
•Stop the bleeding•Definite treatment•No delay
•?Hepatic reserve•Worsening of liver function•Coagulopathy•Occult tumour nodules
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Lai, et al. Archi Surg 2006
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Prognosis• Prognostic factors:
• Pre-ruptured disease state• Liver function• Child-Puge score/ Bilirubin• Severity of haemorrhage (shock/ haemoglobin level)
• Median survival 8.9 weeks• 30-day mortality 38%
Liu, et al. J Clin Oncol 2001
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Staged liver resection• Eligible ~21%-56% of cases
Lai, et al. Archi Surg 2006
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Staged liver resectionRuptured Not ruptured
Survival 1-year 57.1% 77.1%
3-year 19.0% 59.8%
5-year 7.6% 41.2%
Disease-free survival 1-year 27.6% 57.1%
3-year 14.3% 40.6%
5-year 3.8% 32.9%
Zhu, et al. World J Gastroenterol 2012
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Summary• Rupture HCC is uncommon but highly fatal• Aim of treatment:
• Stabilization and achieve haemostasis• Often definitive management to selected patients
• Treatments do not alter outcome in patients with advanced malignancy and poor liver function
• Radiofrequency ablation is new and promising• Staged liver resection > 1-stage emergency resection• Prognosis is poor
• Correct management improves survival
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Definite treatment/
staged liver resection
TAE
Conservative
Surgery
UnstableContinuous bleeding
Failed Haemostasis
Summary
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Reference1. Ngan H, Tso WK, Lai CL, et al: The role of hepatic arterial embolization in the treatment of spontaneous
rupture of hepatocellular carcinoma. Clin Radiol 1998;53(5):338-41
2. Liu CL, Fan ST, Lo CM, et al: Management of spontaneous rupture of hepatocellular carcinoma: single-center experience. J Clin Oncol 2001;19(17):3725-32
3. Lai EC, Lau WY: Spontaneous rupture of hepatocellular carcinoma: a systematic review. 2006;Arch Surg 141(2):191-8
4. Kirikoshi H, Saito S, Yoneda M, et al: Outcome and factors influencing survival in cirrhotic cases with spontaneous rupture of hepatocellular carcinoma: a multicenter study. BMC Gastroenterol 2009;9:29
5. Rossetto A, Adani GL, Risaliti A, et al: Combined approach for spontaneous rupture of hepatocellular carcinoma. World J Hepatol 2010;2(1):49-51
6. Bassi N, Caratozzolo E, Bonariol L, et al: Management of ruptured hepatocellular carcinoma: implications for therapy. World J Gastroenterol 2010;16(10):1221-5
7. Kim JY, Lee JS, Oh DH, et al: Transcatheter arterial chemoembolization confers survival benefit in patients with a spontaneously rupturedhepatocellular carcinoma. Eur J Gastroenterol Hepatol 2012;24(6):640-5
8. Zhu Q, Li J, Yan JJ, et al: Predictors and clinical outcomes for spontaneous rupture of hepatocellular carcinoma. World J Gastroenterol 2012;18(48):7302-7
9. Jin YJ, Lee JW, Park SW, et al: Survival outcome of patients with spontaneously ruptured hepatocellular carcinoma treated surgically or by transarterial embolization. World J Gastroenterol 2013;19(28):4537-44
10. Letchumanan VP, Lim KF, Mohamad AB: Diagnosis and management of ruptured hepatoma: single center experience over 10 years. Med J Malaysia 2013;68(5):405-9
11. Cheung TT, Poon RT, Chok KS, et al: Management of spontaneously ruptured hepatocellular carcinomas in the radiofrequency ablation era. PLoS One 2014;9(4):e94453
12. Leung KL, Lau WY, Lai PBS, et al: Spontaneous rupture of hepatocellular carcinoma: conservative management and selective intervention. Arch Surg 1999;134(10):1103-7
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Supplementary information
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Supplementary information
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