The Study On The Risk Factors, Prognosis And Outcome Of Various Treatments For Spontaneous Rupture Of Hepatocellular Carcinoma

PART1Predictors for spontaneous rupture of hepatocellular carcinoma: a case-control study in chinaBackground and Aim:Spontaneous rupture is non-rare complication of hepatocellular carcinoma (HCC) with high mortality rate in primary liver, and its etiology remains poorly understood. It's reported that HCC incidence is increasing worldwide because of the increasing prevalence of hepatitis B and C virus infection, HCC rupture may become a more commonly encountered surgical emergency. Based on the situation, a hospital-based case-control study was conducted to examine the association of ruptured HCC with the pre-existing medical conditions.METHODS:Cases were200ruptured HCC patients referred to the Eastern Hepatobiliary Surgery Hospital from Apr2002to Nov2006in China, and compared with randomly selected202patients with no history of rupture during the same study period. Ajusted odds ratios(ORs)were calculated in logistic regression analysis.RESULTS:There were statistically significant differences (p<0.05) in the size of the tumor (p<0.0001), the presence of hepatic cirrhosis (p<0.0001), the presence of hypertension (p<0.05), a high alpha-fetoprotein level (p<0.05), positive of HBsAg (p<0.05), the presence of ascites (p<0.0001), the presence of tumor protrusion from the liver surface (p<0.05), a high serum bilirubin level (p<0.0001), a low serum albumin level (p<0.0001). In addition, the Child-Pugh's classification, platelet count levels, serum transaminase levels and clinical stage were higher, and the prothrombin times and activated partial thromboplastin times more prolonged, in the rupture group. Factors that were not statistically significant included sex, age, location of tumor, tumor thrombosis, and the presence of vascular invasion and so on. Multivariate logistic regression analysis indicated that maximum tumor size exceeding5cm, the presence of cirrhotic liver, hypertension and extrahepatic invasion, and poor liver function status (serum bilirubin, prothrombin time, albumin, ascites) correlated the best with HCC rupture (p<0.05). The adjusted odds ratio and95%CI of the five factors were4.840(2.271-10.314),5.441(2.590-11.433),19.246(3.775-98.117),3.110(1.434-6.744) and11.130(2.251-55.031) respectively.CONCLUSION:This case-control study shows that five independent predictors of spontaneously rupture of HCC were revealed:The presence of hepatic cirrhosis, the presence of hypertension, a high Child-Pugh classification (serum bilirubin, prothrombin time, albumin, ascites), the presence of extrahepatic invasion and a maximum tumor size exceeding5cm. There were not statistically significant differences (p>0.05) in the positive of HBsAg, the presence of ascites, tumor protrusion from the liver surface, platelet count, serum transaminase levels, clinical stage, location of tumor, tumor thrombosis and the presence of vascular invasion between the case group and the control group. PART2Elective one-stage hepatectomy is an independent determinant factor in patients with ruptured HCCBackground and Aim:To investigate prognostic factors that may affect survival of patients with ruptured HCC.Methods:200cases (4.8%) with ruptured HCC were studied retrospectively regarding their clinical characteristics and prognostic factors. The one-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, transarterial embolization (TAE) or surgical hepatectomy. Results of various treatments were evaluated and compared with randomly selected202patients with no history of rupture during the same study period. Clinicopathologic factors were analyzed for influence on survival by univariate and multivariate methods.Results:A multivariate analysis using the Cox hazard regression model (including all the patients; n=200) identified surgical hepatectomy as the only independent factor determining a relatively long survival period (p<0.0001).Conclusion:Elective one-stage hepatectomy in patients with ruptured HCC is the first treatment option. Prolonged survival could be achieved in selected patients with hepatic resection. PART3Effect of various treatments (hepatectomy, TAE and conservative) for spontaneous rupture of hepatocellular carcinomaBackground and Aim:The one-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, transarterial embolization (TAE) or surgical hepatectomy. There were statistically significant differences in various treatments. Previous reports have demonstrated that emergency hepatic resection for ruptured HCC may achieve long-term survival. But, one of the main limitations of previous study is the small sample size of selected patients, this small sample size has made it difficult to achieve significance in statistical analysis of the data. The aim of this study was to determine the prognostic factors of ruptured HCC and to report the management of patients with spontaneous rupture of HCC.Methods:A total of200patients with spontaneous rupture of HCC who underwent surgical treatment (105), TAE33and conservative treatment (ConT62) were retrospectively studied regarding their clinical characteristics and prognostic factors.Results:The median survival time (MST) in the ConT group was only1.0month and the survival rate was extremely poor:40.3%at3months,6.5%at6months,1.6%at1year, and none at2years. Second, the MST in the TAE group was4.0months and the survival rate was63.6%at3months,39.4%at6months,12.1%at1year,3.0%at2years, and none at3years. Last but not the least, the MST in the Surgical Treatment was12months, the survival rate was99.0%at3months,82.9%at6months,57.1%at1year,24.8%at2years,19.0%at3years and7.6%at5years. A multivariate analysis using the Cox hazard regression model (including all the patients; n=200) identified surgical hepatectomy as the only independent factor determining a relatively long survival period (p<0.0001), and size of the tumor, child-pugh classification and clinical stage were correlated the best with HCC rupture.Conclusion:Considering the high propensity to spontaneous rupture, particularly when patients present with cirrhotic liver, hypertension, poor liver function status, extrahepatic invasion and size of tumor especially>6cm, as long as preoperatively clinical evaluation meet surgery requirements, elective one-stage hepatectomy in patients with ruptured HCC is the first treatment option. Prolonged survival could be achieved in selected patients with hepatic resection.