간동맥, 간동맥색전술, 간세포암. 간세포암 출혈, 복막종양, 복막출혈

56세/남자

Spontaneous rupture of intraperitoneal metastases of ruptured hepatocellular carcinoma

A 56 year old male was referred for evaluation of sudden onset abdominal pain. He has been diagnosed an alcoholic hepatitis before 5 years. On admission, the serumlevel of alpha-fetoprotein(AFP) was 237.9ng/ml and HBsAg was positive. Hemoglobin level was 8.1g/dL and hematocrit was 24.3. Mild hepatic dysfuction was detected. Clinically rupture of HCC was suspected. Transarterial chemoembolization(TACE) was done after confirmation of hepatoma rupture on angiography. The patient was clinically improved and discharged 2 weeks later. Seven months later, the patient was readmitted due to newly developed abdominal pain. After detection of the intraperitoneal metastatic nodules, TACE was repeated. Two months later after 2nd TACE, the patient complained of abdominal distension with pain. The patient expired two weeks later finally.

On initial abdominal CT scan, two hypervascular tumor nodules was demonstraed in the right lobe of the liver with hematoma in the perihepatic space suggestive of hepatoma rupture(Fig. 1a-c). Homogeneous lipiodol uptakes in tumor nodules were shown on follow-up CT scan after TACE(Fig. 1-d). Seven months later, three intraperitoneal metastatic nodules were detected on CT scan(Fig. 2). One of them revealed a large hematoma around the tumor nodule representing rupture. Abdominal angiography was performed to evaluate the tumor lesioins and for TACE. Selective gastroduodenal arteriography reveals three extrahetic intraeperitoneal tumor nodules compatible with the CT findings. Two of them were supplied by the distal omental branche of gastroduodenal artery. The large one with hemorrhage was supplied directly by multiple fine & small branches of the gatroduodenal and the proximal omental arteries (Fig. 3). Finally a huge enlargement of the mass, up to 23 cm in diameter, was noted on the follow -up CT scan two months later(Fig. 4).

Two tumor nodules with hemorrhage are seen on abdominal CT scan(non-enhanced, early arterial and portal phases). On follow-up CT scan after TACE, good lipiodol uptakes are shown in the tumor nodules.

Peritoneal implanted metastatic nodules are detected with hemorrhage on abdominal CT scan(7 months later)

A faint tumoral staining in the subhepatic space is shown on selective angiography of the gastroduodenal artery. The tumor is supplied by directly from multiple fine branches of both gastroduodenal and omental arteries.

Abdominal CT scan(9 months later) shows enlargement of the metastatic nodules(Fig4-a). The largest one is up to 23 cm in diamter(Fig4-b).

Initial TACE was performed for ruptured HCC in the liver. After superselection of the feeding arteries with microcatheter(Renegade, Boston-Scientific, USA), chemoinfusion, mixture of Adriamycin 30 mg and lipiodol 6 cc, with gelfoam embolization was done. Seven months later two of three peritoneal metastatic noules can be partially chemoembolized. But embolization of the large one with spontaneous rupture could not be made.

Spontaneous rupture of HCC with intraperitoneal hemorrhage is reportedin the incidence of 12-14.5%. Prognosis of ruptured HCC is generally poor. Many malignant cells are thought to disperse into the peritoneal cavity or pleural cavity during HCC rupture. A well-enhanced mass with central low -attenuation representing intratumoral necrosis and engorgement of adjacent omental vessels were reported in some patients as the imaging findings of intraperitoneal seeding from HCC by Kim et al. The omental metastases are usually supplied by omental and mesenteric arteries on angiography. Several treatment have been proposed for spontaneous rupture of HCC including surgical or radiological intervnetion. In our case, tumorswere supplied directly by fine branches of omental and gastroduodeal arteries which made complete TACE difficult or impossible. Therefore aggressive surgical intervention is the choice of treatment. Due to prolonged survival in the patients with ruptured HCC by radiologic intervention, early detection through a periodic survailllance of disseminated metastases and aggressive surgical intervention can provide the best chance for longer survival.

1. Kim TK, Han JK, Chung JW, et al. Intraperitoneal Drop Metastases from Hepatocellular Carcinoma: CT and Angiographic Findings. J Comput Assist Tomogr 1996:20(4):638-642 2. Marini P, Vilgrain V, Belghiti J, et al. Management of Spontaneous Rupture of Liver Tumors. Dia Surg 2002;19(2):109-113 3. Uneishi T, Kubo S, Hirohashi K, et al. Successful Surgical Control for Hepatocellular Carcinoma Disseminated to the Peritoneum. A Case Report. Hepatogastroenterology 2002:49(44):532-534 4. Kosaka A et al. Successful Surgical Treatment for Implanted Intraperitoneal Metastases of Ruptured Small Hepatocellular Carcinoma: Report of A Case. Surg Today 1999;2995):453-437