Predictors and clinical outcomes for spontaneous rupture of hepatocellular carcinoma

AIM:To determine the risk factors for hepatocellular carcinoma(HCC) rupture,and report the management and long-term survival results of patients with spontaneous rupture of HCC.METHODS:Among 4209 patients with HCC who were diagnosed at Eastern Hepatobiliary Surgery Hospital from April 2002 to November 2006,200(4.8%) patients with ruptured HCC(case group) were studied retrospectively in term of their clinical characteristics and prognostic factors.The one-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative treatment,transarterial embolization(TACE) or hepatic resection.Results of various treatments in the case group were evaluated and compared with the control group(202 patients) without ruptured HCC during the same study period.Continuous data were expressed as mean ± SD or me-dian(range) where appropriate and compared using the unpaired t test.Categorical variables were compared using the Chi-square test with Yates correction or the Fisher exact test where appropriate.The overall survival rate in each group was determined using the Kaplan-Meier method and a log-rank test.RESULTS:Compared with the control group,more patients in the case group had underlying diseases of hypertension(7.5% vs 3.0%,P =0.041) and liver cirrhosis(87.5% vs 56.4%,P < 0.001),tumor size >5 cm(83.0% vs 57.4%,P < 0.001),tumor protrusion from the liver surface(66.0% vs 44.6%,P < 0.001),vascular thrombus(30.5% vs 8.9%,P < 0.001) and extrahepatic invasion(36.5% vs 12.4%,P < 0.001).On multivariate logistic regression analysis,underlying diseases of hypertension(P = 0.002) and liver cirrhosis(P < 0.001),tumor size > 5 cm(P < 0.001),vascular thrombus(P = 0.002) and extrahepatic invasion(P < 0.001) were predictive for spontaneous rupture of HCC.Among the 200 patients with spontaneous rupture of HCC,105 patients underwent hepatic resection,33 received TACE,and 62 were managed with conservative treatment.The median survival time(MST) of all patients with spontaneous rupture of HCC was 6 mo(range,1-72 mo),and the overall survival at 1,3 and 5 years were 32.5%,10% and 4%,respectively.The MST was 12 mo(range,1-72 mo) in the surgical group,4 mo(range,1-30 mo) in the TACE group and 1 mo(range,1-19 mo) in the conservative group.Ninety-eight patients in the control group underwent hepatic resection,and the MST and median diseasefree survival time were 46 mo(range,6-93 mo) and 23 mo(range,3-39 mo) respectively,which were much longer than that of patients with spontaneous rupture of HCC undergoing hepatic resection(P < 0.001).The 1-,3-,and 5-year overall survival rates and the 1-,3-and 5-year disease-free survival rates in patients with ruptured HCC undergoing hepatectomy were 57.1%,19.0% and 7.6%,27.6%,14.3% and 3.8%,respectively,compared with those of 77.1%,59.8% and 41.2%,57.1%,40.6% and 32.9% in 98 patients with-CONCLUSION:Prolonged survival can be achieved in selected patients undergoing one-stage hepatectomy,although the survival results were inferior to those of the patients without ruptured HCC.

Precautions in caudate lobe resection: Report of 11 cases

AIM: To find the precautions against the safety in caudate lobe resection. METHODS: The clinical data obtained from 11 cases of primary liver cancer in caudate lobe who received hepatectomy successfully were retrospectively analyzed. Four safe procedures were used in resection of primary liver cancer in caudate lobe: (1) selection of appropriate skin incision to obtain excellent exposure of operative field; (2) adequate mobilization of the liver to allow the liver to be displaced upwards to the left or to the right; (3) preparatory placement of tapes for total hepatic vascular exclusion, so that this procedure could be used to control the fatal bleeding of the liver when necessary; (4) selection of the ideal route for hepatectomy based on the condition of the tumor and the combined removal of multiple lobes if necessary. Among the 11 cases, simple occlusion of vessels of porta hepatis was used in caudate lobectomy for 6 cases, while in the other cases, the vessels were intermittently occluded several times or total hepatic vascular isolation was used in the caudate lobectomy. Combined partial right hepatectomy was done for 3 cases, combined left lateral lobectomy for 2 cases and caudate lobectomy alone for 6 cases. RESULTS: Operation was successful for all the 11 cases. Intermittent inflow occlusion was performed for all patients for 15 min at 5-min intervals. Blockade was performed twice in 3 patients and total hepatic vascular exclusion was performed in one of the three patients. Blockade was performed three times in one patient, including a total hepatic vascular exclusion. Total hepatic vascular exclusion was performed only in one patient. The mean blood loss was 300 mL. Ascites and pleural effusion occurred in 4 patients, jaundice in 1 patient. Sixpatients died of tumor recurrence in 6, 11, 12, 13, 15, 19 mo after operation, respectively. The other 5 patients have survived more than 16 mo since the operation. CONCLUSION: Caudate lobectomy for liver cancer in candate lobe can be safely performed with the above procedures.