0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review Article |

Spontaneous Rupture of Hepatocellular Carcinoma:  A Systematic Review FREE

Eric C. H. Lai, MB, ChB, MRCSEd; W. Y. Lau, MD, FRCS, FRACS(Hons)
[+] Author Affiliations

Author Affiliations: Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong.


Arch Surg. 2006;141(2):191-198. doi:10.1001/archsurg.141.2.191.
Text Size: A A A
Published online

Objectives  To review the management of spontaneous ruptured hepatocellular carcinoma in the acute phase, the definitive treatment after hemostasis, and the prognosis.

Data Sources  A MEDLINE search was undertaken to identify articles in English from 1970 to 2004 using the key words “hepatocellular carcinoma,” “spontaneous rupture,” “therapeutic embolization,” and “laparoscopy.” Additional articles were identified by a manual search of the references from the key articles.

Study Selection  There were no exclusion criteria for published information on the topics.

Data Extraction  All studies that contained material applicable to the topic were considered.

Data Synthesis  In the acute phase, transarterial embolization for hemostasis has a high success rate (53%-100%). It has a lower 30-day mortality rate than open surgical methods (0%-37% vs 28%-75%). For the definitive treatment, staged liver resection has a higher resection rate (21%-56% vs 13%-31%) and a lower in-hospital mortality rate (0%-9% vs 17%-100%) than 1-stage emergency liver resection. Staged liver resection has a good survival rate (1-year survival, 54.2%-100%; 3-year survival, 21.2%-48%; 5-year survival, 15%-21.2%).

Conclusions  Transarterial embolization is effective in controlling bleeding from ruptured hepatocellular carcinoma in the acute phase. The serum bilirubin level, shock on hospital admission, and prerupture disease state are important prognostic factors to predict survival in the acute phase. For definitive treatment, staged liver resection after attaining hemostasis is better than 1-stage emergency liver resection. Laparoscopy and laparoscopic ultrasonography may decrease unnecessary exploratory laparotomy, thus increasing the resection rate of previously ruptured hepatocellular carcinoma. Prolonged survival can be achieved in select patients with definitive treatment. It is still uncertain whether the long-term outcome of liver resection is the same for hepatocellular carcinoma with and without rupture when patients with the same tumor stage and liver functional state are compared.

Figures in this Article

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world.1 The number of new cases is estimated to be 564 000 per year.2 It is common in areas with endemic viral hepatitis B or C. More than 80% of HCC develops in cirrhotic livers.14 Liver resection and liver transplantation offer the best chance of cure.1,3,4 One of the life-threatening complications of HCC is rupture of the tumor with intraperitoneal hemorrhage. Ruptured HCC occurs in 3% to 15% of patients with HCC.513 With earlier detection of HCC, the incidence of ruptured HCC is decreasing. However, the mortality rate of ruptured HCC in the acute phase remains high (25%-75%) .6,1419 Liver failure occurs in 12% to 42% of patients during the acute phase.12,16,1925

This article reviews the management of spontaneous ruptured HCC in the acute phase, the definitive treatment after hemostasis, and the prognosis.

A MEDLINE search was undertaken to identify articles in English from 1970 to 2004 using the key words “hepatocellular carcinoma,” “spontaneous rupture,” “therapeutic embolization,” and “laparoscopy.” Additional articles were identified by a manual search of the references from the key articles. All studies, even case reports, that contained materials related to the topic were considered. This review covered about 1500 patients with spontaneous ruptured HCC.

MECHANISM

The mechanism of spontaneous rupture is still not exactly known.26 Hypotheses include rapid growth of the tumor and necrosis,26 rupture by splitting the overlying nontumorous liver parenchyma or erosion of a vessel,7,27,28 increased intratumor pressure with the occlusion of hepatic veins by tumor thrombi or invasion,5,6,8 and coagulopathy.8 Recently, Zhu et al29,30 postulated that spontaneous rupture of HCC may be related to vascular dysfunction. The vascular dysfunction results from degeneration of elastin and degradation of type IV collagen, rendering the blood vessels stiff and weak and causing them to split easily when the vascular load increases from hypertension or minor trauma. Large and peripherally located tumors are more prone to rupture.5,17,27,31

DIAGNOSIS

Diagnosing ruptured HCC can be difficult, particularly in patients without a history of cirrhosis or HCC.32,33 The development of imaging studies improved the rate of preoperative diagnosis. However, 20% to 33% of the diagnoses are still made only during an emergency exploratory laparotomy.13,19

A sudden onset of abdominal pain (66%-100%) is the most common symptom.6,11,12,16,18 Shock is present in 33% to 90% of patients.4,6,11,12,16,18,34 Ultrasonography (USG) and computed tomography of the abdomen are useful in demonstrating the presence of hemoperitoneum and liver tumor.23,27,31,35 Computed tomography also has the advantage of showing the patency of the portal vein. However, the site of active bleeding can seldom be demonstrated. Hepatic angiography can demonstrate extravasation of contrast from the tumor in 13.2% to 35.7% of patients.22,24,36 Abdominal paracentesis is reliable to confirm the diagnosis.6,8,20,36

MANAGEMENT OF RUPTURED HCC IN THE ACUTE PHASE

The primary aim of management is to attain hemostasis and to preserve as much functioning liver parenchyma as possible. From the 1960s to the 1980s, the open surgical method was the mainstay of treatment for hemostasis. Various surgical procedures, including perihepatic packing, suture plication of bleeding tumors, injection of absolute alcohol, hepatic artery ligation (HAL), and liver resection were reported to be effective in hemostasis. Open surgical procedures achieve a high rate of hemostasis but are associated with a high in-hospital mortality rate (Table 1). With the introduction of transarterial embolization (TAE) and transarterial chemoembolization (TACE) as palliative treatments for patients with unresectable HCC, TAE has been increasingly used for hemostasis in ruptured HCC. Open surgical hemostasis becomes a second-line treatment when TAE fails or is not available. To our knowledge, until now, there has been no prospective randomized controlled trial or well-designed comparative study to find out which is the best method of hemostasis. Most evidence comes from cohort series. The Figure illustrates a logical strategy for the management of spontaneous ruptured HCC.

Place holder to copy figure label and caption
Figure.

Treatment of patients with spontaneous ruptured hepatocellular carcinoma (HCC). HAL indicates hepatic artery ligation; TAE, transarterial embolization.

Graphic Jump Location
Table Graphic Jump LocationTable 1. Results of Open Surgical Hemostasis for Ruptured Hepatocellular Carcinoma in the Acute Phase
Conservative Treatment

Conservative treatment for ruptured HCC includes correction of coagulopathy, close monitoring, and urgent medical imaging to confirm the diagnosis after initial resuscitation. It is most commonly used in patients in a moribund state and with inoperable tumor.5,10,15,37 It is therefore not surprising that conservative treatment had poor results in some studies.8,12,36 Chearanai et al8 reported a 100% mortality for 16 patients who received conservative treatment. Miyamoto et al12 reported a 3-month survival rate of 10% and a mean survival of 19.2 days for 14 patients who received conservative treatment.

On the other hand, conservative treatment has been used in some centers on stable patients who have no signs of continuous bleeding.16,18,19,38 In patients who show signs of continuous bleeding but with good liver function, a hemostatic procedure is carried out. The hemostatic procedure can either be an open surgical approach or TAE. Xu and Yan16 used conservative treatment in this way, and the 1-week and 1-month mortality rates were 26.5% and 48.5%, respectively. These results were comparable with those obtained with emergent open surgery, HAL, and TAE. Unfortunately, in the Xu and Yan study, there was a lack of information on the patients' background and liver function status. Leung et al18 reported a retrospective study on 112 patients with ruptured HCC. In this study, the outcome of patients treated by a conservative approach was compared with an aggressive approach. In the conservative approach, conservative treatment was used initially with all the patients. A hemostatic procedure was used only when the patients showed signs of continuous bleeding. In the aggressive approach, a hemostatic procedure was used unless the patient's condition was moribund. The differences between the aggressive and the conservative approaches in the overall in-hospital mortality rate (62% vs 51%) and the median survival time (7 days vs 12 days) were not significant. They concluded that the conservative approach gave similar results to the aggressive approach. However, the conservative approach had the advantage of a lower intervention rate; thus, it was more cost-effective. In the subgroup analysis in which patients with terminal disease were excluded, the in-hospital mortality rate and survival for the conservative approach were significantly better than for the aggressive approach.

Perihepatic Packing

Packing of a bleeding tumor achieves hemostasis by the tamponade effect. It is effective especially for oozing tumors situated near the diaphragm. There was a lack of data on the additional effects of topical hemostatic agents to be combined with perihepatic packing for ruptured HCC. Ong and Taw6 suggested that the pack should only be left in situ for 24 to 48 hours and if the pack was left longer, infection would invariably take place. To our knowledge, there was no well-planned study to find out how long the perihepatic packing should be left in situ for ruptured HCC in the literature. Most of the clinical evidence was derived from perihepatic packing for liver trauma. The rate of intra-abdominal abscess and sepsis following packing within 72 hours was 23% to 32%.39,40 If the pack was left in place longer than 72 hours, the infection rate would significantly increase.41,42 Thus, the packs should be removed within 72 hours after perihepatic packing. The role of prophylactic antibiotics for perihepatic packing is unclear. Removal of packs also carries the risk of rebleeding.6,40 Perihepatic packing is a good procedure in hemodynamically unstable patients who require a quick damage-control laparotomy for further resuscitation and stabilization.

Suture Plication

Suture plication is only applicable when the bleeding site is small and easily accessible. Its use is limited by the friable tumor tissue.43 Miyamoto et al12 described 30 patients who underwent packing and/or suture plication. The 3-month survival rate was 26.9%, and the mean survival was 81.5 days.

Absolute Alcohol Injection

Sunderland et al44 reported successful hemostasis in 8 of 9 patients with ruptured HCC using laparotomy and absolute alcohol injection. Bleeding was controlled by a combination of factors including an increase in tissue tension, fixation of tissue, and thrombosis of blood vessels. However, there have been no further studies to validate the results.

Hepatic Artery Ligation

The liver has a dual blood supply from the hepatic artery and the portal vein. In the normal liver, the portal vein supplies 70% of the total hepatic perfusion, and the hepatic artery supplies the rest. However, HCC derives its blood supply almost exclusively from the hepatic artery. In ruptured HCC, HAL has a hemostatic success rate of 68% to 100%.6,8,10 It also reduces blood flow to the tumor and results in tumor regression. However, the effect is only temporary because the arterial collateral circulations from any of the nearby arteries develop rapidly to supply the tumor from 1 to 4 weeks.45 Hepatic artery ligation can either be selective or common. Selective HAL is preferable to common HAL because it results in a lower risk of postoperative liver failure. In addition, the preservation of the contralateral arterial supply allows the possibility of future definitive liver resection or TACE. The use of HAL is limited by its high in-hospital mortality rate of 50% to 77%.5,8,10

Transarterial Embolization

The role of TAE in the management of ruptured HCC has increased rapidly in the last 20 years. It has been shown to be highly effective in achieving immediate hemostasis, even in patients with massive hemoperitoneum. With the use of angiographic techniques, the location of tumor, the active bleeding site, and the patency of the portal vein can be assessed. The agents used for embolization are sterile absorbable gelatin sponge (Gelfoam), stainless steel coils, or polyvinyl alcohol sponge (Ivalon).3 The choice of the embolization agents depends on the size of the artery being embolized. Stainless steel coils and Ivalon particles can produce permanent occlusion of the hepatic artery, while Gelfoam can only produce temporary occlusion. Gelfoam has the advantage of recannalization of the embolized artery and provides an opportunity of further TACE. Transarterial embolization is generally considered a contraindication in patients with complete occlusion of the main portal vein by tumor thrombus because of the high risk of hepatic infarction. However, partial occlusion of the portal vein should not be regarded as an absolute contraindication to TAE.26 Corr et al23 reported successful TAE without complications in 3 patients with partial portal vein occlusion. The advantage of TAE over surgery is that hemostasis can be achieved better by occluding the feeding vessels more distally and a major surgery can be avoided in a poor-risk patient. Transarterial embolization for hemostasis has a high success rate of 53% to 100% (Table 2). It has a lower 30-day mortality rate (0%-37%) than open surgical hemostasis.14,1925,46,47 The tumor rerupture rate after TAE, which has an extremely poor prognosis, is 0% to 35%.22,23,25,47,48 The most common complication of TAE is postembolization syndrome (26%-85%), which consists of fever, abdominal pain, nausea, and liver enzyme elevation.23,47 The syndrome usually resolves within 1 to 2 weeks. The major life-threatening complication is liver failure (11.8%-33.3%),1925 which is the most common cause of death after TAE. The selection criteria for TAE in ruptured HCC are not well studied. In the presence of continuous bleeding from the ruptured HCC, TAE should be used for hemostasis in patients with reasonable liver function but without complete portal vein thrombosis. Four retrospective studies showed that TAE was rarely effective in prolonging survival in patients with a serum bilirubin level higher than 2.92 mg/dL (50 μmol/L).2225 It is unclear whether routine TAE will benefit patients with stable hemodynamic parameters in the prevention of tumor rerupture and survival.

Table Graphic Jump LocationTable 2. Results of Transarterial Embolization for Ruptured Hepatocellular Carcinoma in the Acute Phase
DEFINITIVE TREATMENT OF RUPTURED HCC
One-Stage Emergency Liver Resection vs Staged Liver Resection

Liver resection provides the only hope of cure for patients with ruptured HCC. Emergency liver resection has been advocated to achieve both hemostasis and to provide a definitive treatment in a single operation.6,9,13,15,49 Ong and Taw6 suggest that a delay in liver resection after initial hemostasis might compromise the resection rate. Their rationale is that ruptured HCC is due to the sudden obstruction of the outflow of blood from the tumor growth. Once HCC invades the venous drainage system, the spread of the tumor will be very rapid. The resection rate during emergency is between 12.5% to 31%. One-stage emergency liver resection carries an in-hospital mortality of 16.5% to 100% (Table 3). Emergency liver resection is associated with a poor outcome because the tumor stage and the liver functional reserve are unclear. Furthermore, the presence of hemorrhagic shock renders the liver function poorer than usual. The presence of coagulopathy in a patient with compromised liver function further increases the surgical risk.

Table Graphic Jump LocationTable 3. Results of 1-Stage Emergency Liver Resection for Definitive Treatment of Ruptured Hepatocellular Carcinoma

Nowadays, most authors advocate staged liver resection as the preferred definitive treatment after the patients and the liver have recovered from the rupture episode.12,18,19,5057 In the medical literature, there is no study, to our knowledge, on the optimal time to carry out staged liver resection. The time ranged from 10 to 126 days. After adequate workup, staged liver resection has a resection rate of 21% to 56%, which is comparable with the resection rate of nonruptured HCC. When compared with 1-stage emergency liver resection, staged liver resection has a much lower in-hospital mortality rate (0%-9%) and a better survival rate (1-year survival rate, 54.2%-100%; 3-year survival rate, 21.2%-48%; 5-year survival rate, 15%-21.2%) (Table 4). One-stage emergency liver resection should be reserved for patients with a small and easily accessible tumor and a noncirrhotic liver.

Table Graphic Jump LocationTable 4. Results of Staged Liver Resection for Definitive Treatment of Ruptured Hepatocellular Carcinoma
Role of Laparoscopy and Laparoscopic USG in the Definitive Treatment of Ruptured HCC

Laparoscopy and laparoscopic USG have been found to be useful in staging hepatobiliary malignancy.58,59 With their use, unnecessary laparotomy can be avoided with the detection of peritoneal secondary tumors, liver secondary tumors, or major vessel invasion. Patients with unresectable tumors can benefit from a shorter hospital stay, a lower operative morbidity, and an earlier intervention with another procedure, such as local ablative therapy, internal radiation, TACE, or chemotherapy.6063 A small proportion of patients with unresectable HCC can benefit from salvage surgery after tumor downstaging with these treatments.6468 In patients with a previous ruptured HCC, the tumor stage can be more advanced than in those without rupture. The tumor may progress during the recovery phase from the acute bleeding episode. Furthermore, there is a chance of peritoneal implantation during the tumor rupture.69,70 Therefore, laparoscopy and laparoscopic USG may have a role in preventing unnecessary laparotomy, thus improving the resectability in ruptured HCC.

Two prospective studies showed that laparoscopy and laparoscopic USG reduced the rate of unnecessary laparotomy and increased the resection rate in patients with nonruptured HCC.71,72 Lo et al71 and Weitz et al72 showed that laparoscopy and laparoscopic USG prevented exploratory laparotomy in 63% and 30% of patients with unresectable disease, respectively, and increased the resection rate during laparotomy from 74% to 88% and from 68% to 89%, respectively. Lang et al73 reported a retrospective comparative study on 33 patients with ruptured HCC. Laparoscopy and laparoscopic USG prevented unnecessary exploratory laparotomy in 12 of 13 patients with unresectable HCC. In 21 patients who had laparoscopy followed by laparotomy, liver resection was carried out in 20. This compares favorably with 26 patients who underwent laparotomy without laparoscopy, with liver resection carried out in 18 patients. Lang et al also suggested that laparoscopy did not have any adverse effect on tumor recurrence or survival in patients after liver resection. More prospective studies are necessary to further validate these findings. Laparoscopy and laparoscopic USG may have a role in the definitive treatment of ruptured HCC.

RADIOFREQUENCY ABLATION

Radiofrequency ablation is increasingly used in patients with small nonruptured HCC confined to the liver, especially when the tumors are unresectable because of poor general condition of the patient or because of compromised liver function.74 However, the role of radiofrequency ablation in the management of spontaneous ruptured HCC is still unknown. The data on this treatment for ruptured HCC are very limited in the medical literature.75

PROGNOSIS AND SURVIVAL

Ruptured HCC is associated with a high in-hospital mortality rate of 25% to 75%.6,1419 The serum bilirubin level, shock on hospital admission, and prerupture disease state are important prognostic factors.19,2225,48 Evidence from retrospective studies showed that a serum total bilirubin level higher than 2.92 mg/dL (50 μmol/L) was a critical level in predicting the outcome. In the series of patients treated with TAE reported by Ngan et al,24 none of the patients with serum total bilirubin levels higher than 2.92 mg/dL (50 μmol/L) survived longer than 9 weeks (median survival of 1 week), while patients with a serum total bilirubin level of 2.92 mg/dL (50 μmol/L) or lower survived 15 weeks. In the series of patients treated with TAE reported by Leung et al,25 the mean survival of patients with a serum total bilirubin level higher than 2.92 mg/dL (50 μmol/L) was only 34 days while that of patients with a serum total bilirubin level lower than 2.92 mg/dL (50 μmol/L) was 165 days.

After curative liver resection for patients with previous ruptured HCC, the 1-year survival rate was 50% to 100%, the 3-year survival rate was 21% to 50%, and the 5-year survival rate was 15% to 33%.13,15,19,4957 In the medical literature, to our knowledge, there are no prospective studies to compare the outcome of surgical treatment of ruptured and nonruptured HCC. The results from retrospective cohort studies are presented in Table 5. Liu et al19 reported that the survival of patients with ruptured HCC was significantly worse than those with nonruptured HCC. However, Yeh et al55 reported that patients with nonruptured HCC had a similar overall survival as those with ruptured HCC but the disease-free survival rate was significantly better. Mizuno et al57 tried to compare the survival rates of patients with ruptured and nonruptured HCC based on the same background factors, such as disease stage and liver function. They found no significant difference in the 2 groups of patients in the overall survival and disease-free survival. Based on the limited data available in the medical literature, it is difficult to draw a definitive conclusion on the long-term outcome after definitive surgical resection in patients with ruptured HCC when compared with patients with nonruptured HCC. One clear message is that prolonged survival is achievable in select patients with ruptured HCC with liver resection.

Table Graphic Jump LocationTable 5. Results of Liver Resection for Ruptured HCC (Staged) and Nonruptured HCC

Transarterial embolization is effective in controlling bleeding for ruptured HCC in the acute phase. The serum bilirubin level, shock on hospital admission, and prerupture disease state are important prognostic factors to predict survival in the acute phase. Staged liver resection after attaining hemostasis is better than 1-stage emergency liver resection. Laparoscopy and laparoscopic USG may prevent unnecessary exploratory laparotomy, thus increasing the resection rate of previously ruptured HCC. Prolonged survival can be achieved in select patients with ruptured HCC after liver resection. It is still unclear whether the long-term outcome of curative liver resection for HCC with previous rupture is inferior to that for HCC without rupture, if the same tumor stage and liver functional state are comparable in the 2 groups.

Correspondence: W. Y. Lau, MD, FRCS, FRACS(Hons), Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China (josephlau@cuhk.edu.hk).

Accepted for Publication: March 7, 2005.

Llovet  JMBurroughs  ABruix  J Hepatocellular carcinoma. Lancet 2003;3621907- 1917
PubMed Link to Article
Bosch  FXRibes  JDiaz  MCleries  R Primary liver cancer: worldwide incidence and trends. Gastroenterology 2004;127 ((suppl)) S5- S16
PubMed Link to Article
Lau  WY Primary hepatocellular carcinoma. Blumgart  LHFong  YDisease of the Liver and Biliary Tract 3rd ed. London, England WB Saunders Co Ltd2000;1423- 1450
Lau  WY Management of hepatocellular carcinoma. J R Coll Surg Edinb 2002;47389- 399
PubMed
Ong  GBChu  EPHYu  FYKLee  TC Spontaneous rupture of hepatocellular carcinoma. Br J Surg 1965;52123- 129
PubMed Link to Article
Ong  GBTaw  JL Spontaneous rupture of hepatocellular carcinoma. BMJ 1972;4146- 149
PubMed Link to Article
Nagasue  NInokuchi  K Spontaneous and traumatic rupture of hepatoma. Br J Surg 1979;66248- 250
PubMed Link to Article
Chearanai  OPlengvanit  UAsavanich  CDamrongsak  DSindhvananda  KBoonyapisit  S Spontaneous rupture of primary hepatoma: report of 63 cases with particular reference to the pathogenesis and rationale of treatment by hepatic artery ligation. Cancer 1983;511532- 1536
PubMed Link to Article
Chen  MFHwang  TLJeng  LBJan  YYWang  CS Surgical treatment for spontaneous rupture of hepatocellular carcinoma. Surg Gynecol Obstet 1988;16799- 102
PubMed
Lai  ECSWu  KMChoi  TKFan  STWong  J Spontaneous ruptured hepatocellular carcinoma: an appraisal of surgical treatment. Ann Surg 1989;21024- 28
PubMed Link to Article
Dewar  GAGriffin  SMKu  KWLau  WYLi  AKC Management of bleeding liver tumours in Hong Kong. Br J Surg 1991;78463- 466
PubMed Link to Article
Miyamoto  MSudo  TKuyama  T Spontaneous rupture of hepatocellular carcinoma: a review of 172 Japanese cases. Am J Gastroenterol 1991;8667- 71
PubMed
Vergara  VMuratore  ABouzari  H  et al.  Spontaneous rupture of hepatocellular carcinoma: surgical resection and long-term survival. Eur J Surg Oncol 2000;26770- 772
PubMed Link to Article
Nouchi  TNishimura  MMaeda  MFunatsu  THasumura  YTakeuchi  J Transcatheter arterial embolization of ruptured hepatocellular carcinoma associated with liver cirrhosis. Dig Dis Sci 1984;291137- 1141
PubMed Link to Article
Cherqui  DPanis  YRotman  NFagniez  PL Emergency liver resection for spontaneous rupture of hepatocellular carcinoma complicating cirrhosis. Br J Surg 1993;80747- 749
PubMed Link to Article
Xu  HSYan  JB Conservative management of spontaneous ruptured hepatocellular carcinoma. Am Surg 1994;60629- 633
PubMed
Chen  CYLin  XZShin  JS  et al.  Spontaneous rupture of hepatocellular carcinoma: a review of 141 Taiwanese cases and comparison with nonrupture cases. J Clin Gastroenterol 1995;21238- 242
PubMed Link to Article
Leung  KLLau  WYLai  PBSYiu  RYCMeng  WCSLeow  CK Spontaneous rupture of hepatocellular carcinoma. Arch Surg 1999;1341103- 1107
PubMed Link to Article
Liu  CLFan  STLo  CM  et al.  Management of spontaneous rupture of hepatocellular carcinoma: single-center experience. J Clin Oncol 2001;193725- 3732
PubMed
Sato  YFujiwara  KFurui  S  et al.  Benefit of transcatheter arterial embolization for ruptured hepatocellular carcinoma complicating liver cirrhosis. Gastroenterology 1985;89157- 159
PubMed
Hsieh  JSHuang  CJHuang  YSSheen  PCHuang  TJ Intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma: treatment by hepatic artery embolization. AJR Am J Roentgenol 1987;149715- 717
PubMed Link to Article
Okazaki  MHigashihara  HKoganemaru  F  et al.  Intraperitoneal hemorrhage from hepatocellular carcinoma: emergency chemoembolization or embolization. Radiology 1991;180647- 651
PubMed Link to Article
Corr  PChan  MLau  WYMetreweli  C The role of hepatic arterial embolization in the management of ruptured hepatocellular carcinoma. Clin Radiol 1993;48163- 165
PubMed Link to Article
Ngan  HTso  WKLai  CLFan  ST The role of hepatic arterial embolization in the treatment of spontaneous rupture of hepatocellular carcinoma. Clin Radiol 1998;53338- 341
PubMed Link to Article
Leung  CSTang  CNFung  KHLi  MKW A retrospective review of transcatheter hepatic arterial embolization for ruptured hepatocellular carcinoma. J R Coll Surg Edinb 2002;47685- 688
PubMed
Zhu  LXWang  GSFan  ST Spontaneous rupture of hepatocellular carcinoma. Br J Surg 1996;83602- 607
PubMed Link to Article
Kanematsu  MImeda  TYamawaki  Y  et al.  Rupture of hepatocellular carcinoma: predictive value of CT findings. AJR Am J Roentgenol 1992;1581247- 1250
PubMed Link to Article
Hermann  REDavid  TE Spontaneous rupture of the liver caused by hepatomas. Surgery 1973;74715- 719
PubMed
Zhu  LXGeng  XPFan  ST Spontaneous rupture of hepatocellular carcinoma and vascular injury. Arch Surg 2001;136682- 687
PubMed Link to Article
Zhu  LXLiu  YFan  ST Ultrastructural study of the vascular endothelium of patients with spontaneous rupture of hepatocellular carcinoma. Asian J Surg 2002;25157- 162
PubMed Link to Article
Choi  BGPark  SHByun  JYJung  SEChoi  KHHan  JY The findings of ruptured hepatocellular carcinoma on helical CT. Br J Radiol 2001;74142- 146
PubMed Link to Article
Vivarelli  MCavallari  ABellusci  RDe Raffaele  ENardo  BGozzetti  G Ruptured hepatocellular carcinoma: an important cause of spontaneous haemoperitoneum in Italy. Eur J Surg 1995;161881- 886
PubMed
Okezie  ODeAngelis  G Spontaneous rupture of hepatoma: a misdiagnosed surgical emergency. Ann Surg 1974;179133- 135
PubMed Link to Article
Muhammad  IMabogunje  O Spontaneous rupture of primary hepatocellular carcinoma in Zaria, Nigeria. J R Coll Surg Edinb 1991;36117- 120
PubMed
Pombo  FArrojo  LPerez Fontan  J Hemoperitoneum secondary to spontaneous rupture of hepatocellular carcinoma: CT diagnosis. Clin Radiol 1991;43321- 322
PubMed Link to Article
Hirai  KKawazoe  YYamashita  K  et al.  Transcatheter arterial embolization for spontaneous rupture of hepatocellular carcinoma. Am J Gastroenterol 1986;81275- 279
PubMed
Tanaka  ATakeda  RMukaihara  S  et al.  Treatment of ruptured hepatocellular carcinoma. Int J Clin Oncol 2001;6291- 295
PubMed Link to Article
Leow  CKLau  JWY Management of specific tumour complications. Leong  ASYLiew  CTLau  JWYJohnson  PJHepatocellular Carcinoma. Diagnosis, Investigation and Management London, England Arnold1999;193- 203
Sharp  KWLocicero  RJ Abdominal packing for surgically uncontrollable hemorrhage. Ann Surg 1992;215467- 474
PubMed Link to Article
Caruso  DMBattistella  FDOwings  JTLee  SLSamaco  RC Perihepatic packing of major liver injuries: complications and mortality. Arch Surg 1999;134958- 962
PubMed Link to Article
Saifi  JFortune  JBGraca  LShah  DM Benefits of intra-abdominal pack placement for the management of nonmechanical hemorrhage. Arch Surg 1990;125119- 122
PubMed Link to Article
Abikhaled  JAGranchi  TSWall  MJHirshberg  AMattox  KL Prolonged abdominal packing for trauma is associated with increased morbidity and mortality. Am Surg 1997;631109- 1112
PubMed
Balasegaram  M Spontaneous intraperitoneal rupture of primary liver-cell carcinoma. Aust N Z J Surg 1968;37332- 337
PubMed Link to Article
Sunderland  GTChisholm  EMLau  WYChung  SCLi  AKC Alcohol injection: a treatment for ruptured hepatocellular carcinoma. Surg Oncol 1992;161- 63
PubMed Link to Article
Plengvanit  UChearanai  OSindhvananda  KDamrongsak  DTuchinda  SViranuvatti  V Collateral arterial blood supply of the liver after hepatic artery ligation: angiographic study of twenty patients. Ann Surg 1972;175105- 110
PubMed Link to Article
Chen  MFJan  YYLee  TY Transcatheter hepatic arterial embolization followed by hepatic resection for the spontaneous rupture of hepatocellular carcinoma. Cancer 1986;58332- 335
PubMed Link to Article
Castells  LMoreiras  MQuiroga  S  et al.  Hemoperitoneum as a first manifestation of hepatocellular carcinoma in western patients with liver cirrhosis: effectiveness of emergency treatment with transcatheter arterial embolization. Dig Dis Sci 2001;46555- 562
PubMed Link to Article
Ohtomo  KFurui  SKokubo  T  et al.  Transcatheter arterial embolization for spontaneous rupture of hepatocellular carcinoma. Radiat Med 1988;6150- 156
PubMed
Chiappa  AZbar  AAudisio  RAPaties  CBertani  EStaudacher  C Emergencyliver resection for ruptured hepatocellular carcinoma complicating cirrhosis. Hepatogastroenterology 1999;461145- 1150
PubMed
Yoshida  HOnda  MTajiri  T  et al.  Treatment of spontaneous ruptured hepatocellular carcinoma. Hepatogastroenterology 1999;462451- 2453
PubMed
Inoue  SNagao  TWakabayashi  T  et al.  Spontaneous rupture of hepatocellular carcinoma: an approach with delayed hepatectomy. Surg Today 1992;22474- 480
PubMed Link to Article
Shimada  RImamura  HMakuuchi  M  et al.  Staged hepatectomy after emergency transcatheter arterial embolization for ruptured hepatocellular carcinoma. Surgery 1998;124526- 535
PubMed Link to Article
Shuto  THirohashi  KKubo  S  et al.  Delayed hepatic resection for ruptured hepatocellular carcinoma. Surgery 1998;12433- 37
PubMed Link to Article
Takebayashi  TKonbo  SAmbo  Y  et al.  Staged hepatectomy following arterial embolization for ruptured hepatocellular carcinoma. Hepatogastroenterology 2002;491074- 1076
PubMed
Yeh  CNLee  WCJeng  LBChen  MFYu  MC Spontaneous tumour rupture and prognosis in patients with hepatocellular carcinoma. Br J Surg 2002;891125- 1129
PubMed Link to Article
Marini  PVilgrain  VBelghiti  J Management of spontaneous rupture of liver tumours. Dig Surg 2002;19109- 113
PubMed Link to Article
Mizuno  SYamagiwa  KOgawa  T  et al.  Are the results of surgical treatment of hepatocellular carcinoma poor if the tumor has spontaneously ruptured? Scand J Gastroenterol 2004;39567- 570
PubMed Link to Article
John  TGGreig  JDCarter  DCGarden  OJ Carcinoma of the pancreatic head and periampullary region: tumor staging with laparoscopy and laparoscopic ultrasonography. Ann Surg 1995;221156- 164
PubMed Link to Article
D’Angelica  MFong  YWeber  S  et al.  The role of staging laparoscopy in hepatobiliary malignancy: prospective analysis of 401 cases. Ann Surg Oncol 2003;10183- 189
PubMed Link to Article
Shijo  HOkazaki  MHigashihara  H  et al.  Hepatocellular carcinoma: a multivariate analysis of prognostic features in patients treated with hepatic arterial embolization. Am J Gastroenterol 1992;871154- 1159
PubMed
Mondazzi  LBottelli  RBrambilla  G  et al.  Transarterial oily chemoembolization for the treatment of hepatocellular carcinoma: a multivariate analysis of prognostic factors. Hepatology 1994;191115- 1123
PubMed Link to Article
Lau  WYHo  SKWLeung  TWT  et al.  Selective internal radiation therapy for nonresectable hepatocellular carcinoma with intraarterial infusion of 90 yttrium microspheres. Int J Radiat Oncol Biol Phys 1998;40583- 592
PubMed Link to Article
Lau  WYLeung  TWTYu  SCHHo  SKW Percutaneous local ablative therapy for hepatocellular carcinoma: a review and look into the future. Ann Surg 2003;237171- 179
PubMed
Meric  FPatt  YZCurley  SA  et al.  Surgery after downstaging of unresectable hepatic tumours with intra-arterial chemotherapy. Ann Surg Oncol 2000;7490- 495
PubMed Link to Article
Lau  WYLeung  TWTLai  PBS  et al.  Preoperative systematic chemoimmunotherapy and sequential resection for unresectable hepatocellular carcinoma. Ann Surg 2001;233236- 241
PubMed Link to Article
Lau  WYHo  SKWYu  SCHLai  ECHLiew  CTLeung  TWT Salvage surgery following downstaging of unresectable hepatocellular carcinoma. Ann Surg 2004;240299- 305
PubMed Link to Article
Ku  YIwasaki  TTominaga  M  et al.  Reductive surgery plus percutaneous isolated hepatic perfusion for multiple advanced hepatocellular carcinoma. Ann Surg 2004;23953- 60
PubMed Link to Article
Clavien  PASelzner  NMorse  MSelzner  MPaulson  E Downstaging of hepatocellular carcinoma and liver metastases from colorectal cancer by selective intra-arterial chemotherapy. Surgery 2002;131433- 442
PubMed Link to Article
Sonoda  TKanematsu  TTakenaka  KSugimachi  K Ruptured hepatocellular carcinoma evokes risk of implanted metastases. J Surg Oncol 1989;41183- 186
PubMed Link to Article
Kosaka  AHayakawa  HKusagawa  M  et al.  Successful surgical treatment for implanted intraperitoneal metastases of ruptured small hepatocellular carcinoma: report of a case. Surg Today 1999;29453- 457
PubMed Link to Article
Lo  CMLai  ECLiu  CLFan  STWong  J Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma. Ann Surg 1998;227527- 532
PubMed Link to Article
Weitz  JD’Angelica  MJarnagin  W  et al.  Selective use of diagnostic laparoscopy prior to planned hepatectomy for patients with hepatocellular carcinoma. Surgery 2004;135273- 281
PubMed Link to Article
Lang  BHHPoon  RTPFan  STWong  J Influence of laparoscopy on postoperative recurrence and survival in patients with ruptured hepatocellular carcinoma undergoing hepatic resection. Br J Surg 2004;91444- 449
PubMed Link to Article
Lai  ECLau  WY The continuing challenge of hepatic cancer in Asia. Surgeon 2005;3210- 215
PubMed Link to Article
Ng  KKLam  CMPoon  RT  et al.  Radiofrequency ablation as a salvage procedure for ruptured hepatocellular carcinoma. Hepatogastroenterology 2003;501641- 1643
PubMed

Figures

Place holder to copy figure label and caption
Figure.

Treatment of patients with spontaneous ruptured hepatocellular carcinoma (HCC). HAL indicates hepatic artery ligation; TAE, transarterial embolization.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Results of Open Surgical Hemostasis for Ruptured Hepatocellular Carcinoma in the Acute Phase
Table Graphic Jump LocationTable 2. Results of Transarterial Embolization for Ruptured Hepatocellular Carcinoma in the Acute Phase
Table Graphic Jump LocationTable 3. Results of 1-Stage Emergency Liver Resection for Definitive Treatment of Ruptured Hepatocellular Carcinoma
Table Graphic Jump LocationTable 4. Results of Staged Liver Resection for Definitive Treatment of Ruptured Hepatocellular Carcinoma
Table Graphic Jump LocationTable 5. Results of Liver Resection for Ruptured HCC (Staged) and Nonruptured HCC

References

Llovet  JMBurroughs  ABruix  J Hepatocellular carcinoma. Lancet 2003;3621907- 1917
PubMed Link to Article
Bosch  FXRibes  JDiaz  MCleries  R Primary liver cancer: worldwide incidence and trends. Gastroenterology 2004;127 ((suppl)) S5- S16
PubMed Link to Article
Lau  WY Primary hepatocellular carcinoma. Blumgart  LHFong  YDisease of the Liver and Biliary Tract 3rd ed. London, England WB Saunders Co Ltd2000;1423- 1450
Lau  WY Management of hepatocellular carcinoma. J R Coll Surg Edinb 2002;47389- 399
PubMed
Ong  GBChu  EPHYu  FYKLee  TC Spontaneous rupture of hepatocellular carcinoma. Br J Surg 1965;52123- 129
PubMed Link to Article
Ong  GBTaw  JL Spontaneous rupture of hepatocellular carcinoma. BMJ 1972;4146- 149
PubMed Link to Article
Nagasue  NInokuchi  K Spontaneous and traumatic rupture of hepatoma. Br J Surg 1979;66248- 250
PubMed Link to Article
Chearanai  OPlengvanit  UAsavanich  CDamrongsak  DSindhvananda  KBoonyapisit  S Spontaneous rupture of primary hepatoma: report of 63 cases with particular reference to the pathogenesis and rationale of treatment by hepatic artery ligation. Cancer 1983;511532- 1536
PubMed Link to Article
Chen  MFHwang  TLJeng  LBJan  YYWang  CS Surgical treatment for spontaneous rupture of hepatocellular carcinoma. Surg Gynecol Obstet 1988;16799- 102
PubMed
Lai  ECSWu  KMChoi  TKFan  STWong  J Spontaneous ruptured hepatocellular carcinoma: an appraisal of surgical treatment. Ann Surg 1989;21024- 28
PubMed Link to Article
Dewar  GAGriffin  SMKu  KWLau  WYLi  AKC Management of bleeding liver tumours in Hong Kong. Br J Surg 1991;78463- 466
PubMed Link to Article
Miyamoto  MSudo  TKuyama  T Spontaneous rupture of hepatocellular carcinoma: a review of 172 Japanese cases. Am J Gastroenterol 1991;8667- 71
PubMed
Vergara  VMuratore  ABouzari  H  et al.  Spontaneous rupture of hepatocellular carcinoma: surgical resection and long-term survival. Eur J Surg Oncol 2000;26770- 772
PubMed Link to Article
Nouchi  TNishimura  MMaeda  MFunatsu  THasumura  YTakeuchi  J Transcatheter arterial embolization of ruptured hepatocellular carcinoma associated with liver cirrhosis. Dig Dis Sci 1984;291137- 1141
PubMed Link to Article
Cherqui  DPanis  YRotman  NFagniez  PL Emergency liver resection for spontaneous rupture of hepatocellular carcinoma complicating cirrhosis. Br J Surg 1993;80747- 749
PubMed Link to Article
Xu  HSYan  JB Conservative management of spontaneous ruptured hepatocellular carcinoma. Am Surg 1994;60629- 633
PubMed
Chen  CYLin  XZShin  JS  et al.  Spontaneous rupture of hepatocellular carcinoma: a review of 141 Taiwanese cases and comparison with nonrupture cases. J Clin Gastroenterol 1995;21238- 242
PubMed Link to Article
Leung  KLLau  WYLai  PBSYiu  RYCMeng  WCSLeow  CK Spontaneous rupture of hepatocellular carcinoma. Arch Surg 1999;1341103- 1107
PubMed Link to Article
Liu  CLFan  STLo  CM  et al.  Management of spontaneous rupture of hepatocellular carcinoma: single-center experience. J Clin Oncol 2001;193725- 3732
PubMed
Sato  YFujiwara  KFurui  S  et al.  Benefit of transcatheter arterial embolization for ruptured hepatocellular carcinoma complicating liver cirrhosis. Gastroenterology 1985;89157- 159
PubMed
Hsieh  JSHuang  CJHuang  YSSheen  PCHuang  TJ Intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma: treatment by hepatic artery embolization. AJR Am J Roentgenol 1987;149715- 717
PubMed Link to Article
Okazaki  MHigashihara  HKoganemaru  F  et al.  Intraperitoneal hemorrhage from hepatocellular carcinoma: emergency chemoembolization or embolization. Radiology 1991;180647- 651
PubMed Link to Article
Corr  PChan  MLau  WYMetreweli  C The role of hepatic arterial embolization in the management of ruptured hepatocellular carcinoma. Clin Radiol 1993;48163- 165
PubMed Link to Article
Ngan  HTso  WKLai  CLFan  ST The role of hepatic arterial embolization in the treatment of spontaneous rupture of hepatocellular carcinoma. Clin Radiol 1998;53338- 341
PubMed Link to Article
Leung  CSTang  CNFung  KHLi  MKW A retrospective review of transcatheter hepatic arterial embolization for ruptured hepatocellular carcinoma. J R Coll Surg Edinb 2002;47685- 688
PubMed
Zhu  LXWang  GSFan  ST Spontaneous rupture of hepatocellular carcinoma. Br J Surg 1996;83602- 607
PubMed Link to Article
Kanematsu  MImeda  TYamawaki  Y  et al.  Rupture of hepatocellular carcinoma: predictive value of CT findings. AJR Am J Roentgenol 1992;1581247- 1250
PubMed Link to Article
Hermann  REDavid  TE Spontaneous rupture of the liver caused by hepatomas. Surgery 1973;74715- 719
PubMed
Zhu  LXGeng  XPFan  ST Spontaneous rupture of hepatocellular carcinoma and vascular injury. Arch Surg 2001;136682- 687
PubMed Link to Article
Zhu  LXLiu  YFan  ST Ultrastructural study of the vascular endothelium of patients with spontaneous rupture of hepatocellular carcinoma. Asian J Surg 2002;25157- 162
PubMed Link to Article
Choi  BGPark  SHByun  JYJung  SEChoi  KHHan  JY The findings of ruptured hepatocellular carcinoma on helical CT. Br J Radiol 2001;74142- 146
PubMed Link to Article
Vivarelli  MCavallari  ABellusci  RDe Raffaele  ENardo  BGozzetti  G Ruptured hepatocellular carcinoma: an important cause of spontaneous haemoperitoneum in Italy. Eur J Surg 1995;161881- 886
PubMed
Okezie  ODeAngelis  G Spontaneous rupture of hepatoma: a misdiagnosed surgical emergency. Ann Surg 1974;179133- 135
PubMed Link to Article
Muhammad  IMabogunje  O Spontaneous rupture of primary hepatocellular carcinoma in Zaria, Nigeria. J R Coll Surg Edinb 1991;36117- 120
PubMed
Pombo  FArrojo  LPerez Fontan  J Hemoperitoneum secondary to spontaneous rupture of hepatocellular carcinoma: CT diagnosis. Clin Radiol 1991;43321- 322
PubMed Link to Article
Hirai  KKawazoe  YYamashita  K  et al.  Transcatheter arterial embolization for spontaneous rupture of hepatocellular carcinoma. Am J Gastroenterol 1986;81275- 279
PubMed
Tanaka  ATakeda  RMukaihara  S  et al.  Treatment of ruptured hepatocellular carcinoma. Int J Clin Oncol 2001;6291- 295
PubMed Link to Article
Leow  CKLau  JWY Management of specific tumour complications. Leong  ASYLiew  CTLau  JWYJohnson  PJHepatocellular Carcinoma. Diagnosis, Investigation and Management London, England Arnold1999;193- 203
Sharp  KWLocicero  RJ Abdominal packing for surgically uncontrollable hemorrhage. Ann Surg 1992;215467- 474
PubMed Link to Article
Caruso  DMBattistella  FDOwings  JTLee  SLSamaco  RC Perihepatic packing of major liver injuries: complications and mortality. Arch Surg 1999;134958- 962
PubMed Link to Article
Saifi  JFortune  JBGraca  LShah  DM Benefits of intra-abdominal pack placement for the management of nonmechanical hemorrhage. Arch Surg 1990;125119- 122
PubMed Link to Article
Abikhaled  JAGranchi  TSWall  MJHirshberg  AMattox  KL Prolonged abdominal packing for trauma is associated with increased morbidity and mortality. Am Surg 1997;631109- 1112
PubMed
Balasegaram  M Spontaneous intraperitoneal rupture of primary liver-cell carcinoma. Aust N Z J Surg 1968;37332- 337
PubMed Link to Article
Sunderland  GTChisholm  EMLau  WYChung  SCLi  AKC Alcohol injection: a treatment for ruptured hepatocellular carcinoma. Surg Oncol 1992;161- 63
PubMed Link to Article
Plengvanit  UChearanai  OSindhvananda  KDamrongsak  DTuchinda  SViranuvatti  V Collateral arterial blood supply of the liver after hepatic artery ligation: angiographic study of twenty patients. Ann Surg 1972;175105- 110
PubMed Link to Article
Chen  MFJan  YYLee  TY Transcatheter hepatic arterial embolization followed by hepatic resection for the spontaneous rupture of hepatocellular carcinoma. Cancer 1986;58332- 335
PubMed Link to Article
Castells  LMoreiras  MQuiroga  S  et al.  Hemoperitoneum as a first manifestation of hepatocellular carcinoma in western patients with liver cirrhosis: effectiveness of emergency treatment with transcatheter arterial embolization. Dig Dis Sci 2001;46555- 562
PubMed Link to Article
Ohtomo  KFurui  SKokubo  T  et al.  Transcatheter arterial embolization for spontaneous rupture of hepatocellular carcinoma. Radiat Med 1988;6150- 156
PubMed
Chiappa  AZbar  AAudisio  RAPaties  CBertani  EStaudacher  C Emergencyliver resection for ruptured hepatocellular carcinoma complicating cirrhosis. Hepatogastroenterology 1999;461145- 1150
PubMed
Yoshida  HOnda  MTajiri  T  et al.  Treatment of spontaneous ruptured hepatocellular carcinoma. Hepatogastroenterology 1999;462451- 2453
PubMed
Inoue  SNagao  TWakabayashi  T  et al.  Spontaneous rupture of hepatocellular carcinoma: an approach with delayed hepatectomy. Surg Today 1992;22474- 480
PubMed Link to Article
Shimada  RImamura  HMakuuchi  M  et al.  Staged hepatectomy after emergency transcatheter arterial embolization for ruptured hepatocellular carcinoma. Surgery 1998;124526- 535
PubMed Link to Article
Shuto  THirohashi  KKubo  S  et al.  Delayed hepatic resection for ruptured hepatocellular carcinoma. Surgery 1998;12433- 37
PubMed Link to Article
Takebayashi  TKonbo  SAmbo  Y  et al.  Staged hepatectomy following arterial embolization for ruptured hepatocellular carcinoma. Hepatogastroenterology 2002;491074- 1076
PubMed
Yeh  CNLee  WCJeng  LBChen  MFYu  MC Spontaneous tumour rupture and prognosis in patients with hepatocellular carcinoma. Br J Surg 2002;891125- 1129
PubMed Link to Article
Marini  PVilgrain  VBelghiti  J Management of spontaneous rupture of liver tumours. Dig Surg 2002;19109- 113
PubMed Link to Article
Mizuno  SYamagiwa  KOgawa  T  et al.  Are the results of surgical treatment of hepatocellular carcinoma poor if the tumor has spontaneously ruptured? Scand J Gastroenterol 2004;39567- 570
PubMed Link to Article
John  TGGreig  JDCarter  DCGarden  OJ Carcinoma of the pancreatic head and periampullary region: tumor staging with laparoscopy and laparoscopic ultrasonography. Ann Surg 1995;221156- 164
PubMed Link to Article
D’Angelica  MFong  YWeber  S  et al.  The role of staging laparoscopy in hepatobiliary malignancy: prospective analysis of 401 cases. Ann Surg Oncol 2003;10183- 189
PubMed Link to Article
Shijo  HOkazaki  MHigashihara  H  et al.  Hepatocellular carcinoma: a multivariate analysis of prognostic features in patients treated with hepatic arterial embolization. Am J Gastroenterol 1992;871154- 1159
PubMed
Mondazzi  LBottelli  RBrambilla  G  et al.  Transarterial oily chemoembolization for the treatment of hepatocellular carcinoma: a multivariate analysis of prognostic factors. Hepatology 1994;191115- 1123
PubMed Link to Article
Lau  WYHo  SKWLeung  TWT  et al.  Selective internal radiation therapy for nonresectable hepatocellular carcinoma with intraarterial infusion of 90 yttrium microspheres. Int J Radiat Oncol Biol Phys 1998;40583- 592
PubMed Link to Article
Lau  WYLeung  TWTYu  SCHHo  SKW Percutaneous local ablative therapy for hepatocellular carcinoma: a review and look into the future. Ann Surg 2003;237171- 179
PubMed
Meric  FPatt  YZCurley  SA  et al.  Surgery after downstaging of unresectable hepatic tumours with intra-arterial chemotherapy. Ann Surg Oncol 2000;7490- 495
PubMed Link to Article
Lau  WYLeung  TWTLai  PBS  et al.  Preoperative systematic chemoimmunotherapy and sequential resection for unresectable hepatocellular carcinoma. Ann Surg 2001;233236- 241
PubMed Link to Article
Lau  WYHo  SKWYu  SCHLai  ECHLiew  CTLeung  TWT Salvage surgery following downstaging of unresectable hepatocellular carcinoma. Ann Surg 2004;240299- 305
PubMed Link to Article
Ku  YIwasaki  TTominaga  M  et al.  Reductive surgery plus percutaneous isolated hepatic perfusion for multiple advanced hepatocellular carcinoma. Ann Surg 2004;23953- 60
PubMed Link to Article
Clavien  PASelzner  NMorse  MSelzner  MPaulson  E Downstaging of hepatocellular carcinoma and liver metastases from colorectal cancer by selective intra-arterial chemotherapy. Surgery 2002;131433- 442
PubMed Link to Article
Sonoda  TKanematsu  TTakenaka  KSugimachi  K Ruptured hepatocellular carcinoma evokes risk of implanted metastases. J Surg Oncol 1989;41183- 186
PubMed Link to Article
Kosaka  AHayakawa  HKusagawa  M  et al.  Successful surgical treatment for implanted intraperitoneal metastases of ruptured small hepatocellular carcinoma: report of a case. Surg Today 1999;29453- 457
PubMed Link to Article
Lo  CMLai  ECLiu  CLFan  STWong  J Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma. Ann Surg 1998;227527- 532
PubMed Link to Article
Weitz  JD’Angelica  MJarnagin  W  et al.  Selective use of diagnostic laparoscopy prior to planned hepatectomy for patients with hepatocellular carcinoma. Surgery 2004;135273- 281
PubMed Link to Article
Lang  BHHPoon  RTPFan  STWong  J Influence of laparoscopy on postoperative recurrence and survival in patients with ruptured hepatocellular carcinoma undergoing hepatic resection. Br J Surg 2004;91444- 449
PubMed Link to Article
Lai  ECLau  WY The continuing challenge of hepatic cancer in Asia. Surgeon 2005;3210- 215
PubMed Link to Article
Ng  KKLam  CMPoon  RT  et al.  Radiofrequency ablation as a salvage procedure for ruptured hepatocellular carcinoma. Hepatogastroenterology 2003;501641- 1643
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 39

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Care at the Close of Life EDUCATION GUIDES
Integrating Palliative Care for Liver Transplant Candidates