Computed tomography and angiographic interventional features of ruptured hepatocellular carcinoma: pictorial essay
Peter T W Kim1, Jenny C Su, Andrzej K Buczkowski
1Department of Surgery, University of British Columbia, Vancouver, BC.
Insights
Spontaneous rupture of hepatocellular carcinoma (HCC) is a rare but serious complication. Computed tomography (CT) is the preferred imaging method for diagnosing ruptured HCC and guiding treatment strategies.
Area of Science:
- Hepatobiliary Surgery
- Diagnostic Radiology
- Oncology
Background:
- Spontaneous rupture of hepatocellular carcinoma (HCC) is an uncommon yet potentially fatal complication.
- Prognosis is poor, especially with coexisting cirrhosis and coagulopathy.
Purpose of the Study:
- To review the radiologic features of spontaneously ruptured HCC on CT imaging.
- To discuss treatment options for ruptured HCC.
Main Methods:
- Computed tomography (CT) is the first-line imaging modality, superior to angiography for detecting rupture.
- Optimal CT protocol involves triphasic imaging: precontrast, arterial, and portal venous phases.
- Angiography has limitations in detecting slow bleeding rates and contrast extravasation.
Main Results:
- CT confirms ruptured HCC diagnosis and assesses liver status, portal vein involvement, and suitability for embolization or resection.
- Triphasic CT protocol evaluates lipiodol uptake, mass enhancement, and portal vein patency.
- Treatment options include transarterial catheter embolization (TACE), emergency resection, and delayed resection.
Conclusions:
- Multidisciplinary management, often starting with TACE followed by delayed resection, is the preferred approach.
- CT imaging is crucial for diagnosis and treatment planning of ruptured HCC.
- Rupture is frequently associated with diffuse intrahepatic tumor spread and underlying cirrhosis.
Abstract:
Spontaneous rupture is an uncommon and potentially fatal complication of hepatocellular carcinoma (HCC), occurring in approximately 15% of patients with HCC in Asia and 3% in the United Kingdom.3 The prognosis for hemorrhage of HCC is poor, particularly in those patients with underlying cirrhosis and severe coagulopathy. Computed tomography (CT) rather than angiography is the first-line modality for the detection of rupture. CT can confirm the diagnosis of ruptured HCC and can also help in assessing other organs if the diagnosis is not clear prior to imaging. It allows for an assessment of the entire liver, including the portal vein, which aids in determining the feasibility of embolization and resection. Since the rate of bleeding must normally exceed 1 mL/min before it can be detected on angiography and the extravasation of contrast is present in less than 20% of cases, CT is a more helpful modality. The optimal CT protocol for this condition is triphasic: the precontrast phase allows for assessment of ethiodized oil (lipiodol) uptake, the arterial phase demonstrates enhancement of the mass, and the portal venous phase allows for assessment of the portal veins. Various treatment options have been proposed: transarterial catheter embolization (TACE), emergency liver resection, and delayed resection. Surgical treatment is difficult, if not impossible. In most cases, rupture is a result of diffuse intrahepatic spread of the tumour and underlying liver cirrhosis. Many authors have concluded that a multidisciplinary management that includes TACE as the primary procedure followed by a delayed resection is the preferred treatment. This pictorial essay reviews the radiologic features of spontaneously ruptured HCC on CT imaging and of treatment by angiography.
