Contrast harmonic sonographically guided radio frequency ablation for spontaneous ruptured hepatocellular carcinoma

Intraperitoneal bleeding due to a ruptured tumor is a serious complication in patients with hepatocellular carcinoma (HCC). According to data compiled by the Liver Cancer Study Group of Japan, ruptured HCC accounts for around 10% of deaths in these patients. Clinical features include the sudden onset of abdominal pain and distension and, if bleeding is massive, the presence of shock. Other causes of an acute abdominal emergency must be ruled out. Diagnostic imaging generally includes sonography, contrast computed tomography (CT), and angiography. In patients with ruptured HCC, prompt diagnosis and treatment is essential to avoid hepatocyte necrosis and secondary hepatic failure associated with shock and decreased hepatic perfusion due to bleeding. The underlying liver disease varies in such patients with ruptured HCC. Chronic hepatitis, cirrhosis, or both may be present, and the severity of hepatic dysfunction as well as the size, number, and progression of the neoplastic lesions present varies from case to case. A common feature is the presence of a responsible lesion on or protruding from the surface of the liver. If hemostasis can be achieved early after HCC rupture, then overall prognosis depends on the patient's liver function and degree of tumor progression. Although there is a risk of intraperitoneal seeding, long-term survival is possible if the tumor can be completely resected by hepatectomy. One study has already reported a good 5-year survival rate after resection of ruptured and nonruptured HCC. In another study, rather than performing emergency surgery, Marini et al used transcatheter arterial embolization (TAE) to control bleeding; in those patients who could then undergo surgery, elective hepatectomy was associated with long-term survival. Treatment of ruptured HCC involves more than just hemostasis. Subsequent therapy is important, and, whenever possible, complete resection should be performed after bleeding has been controlled. Nevertheless, in a series of 172 patients with ruptured HCC in Japan, Miyamoto et al reported that subsequent hepatectomy was possible in only 12% of cases; in most cases, the presence of multiple lesions or underlying cirrhosis made surgery difficult. In patients in whom hepatectomy cannot be performed, relatively radical yet less invasive treatment with percutaneous radio frequency ablation (RFA) may lead to an improved prognosis. Transcatheter arterial embolization is now widely used as first-line treatment to achieve safe and reliable hemostasis in ruptured HCC. However, extensive TAE may worsen liver function and lead to post-TAE hepatic failure. In addition, angiographic localization of the bleeding site in ruptured HCC is difficult and is successful in 20% of cases at most. Accurate localization of the bleeding site allows for hemostasis with superselective TAE and local ablative therapy that can minimize injury to nontumor tissue and reduce the risk of posttreatment hepatic failure. In the case of ruptured HCC reported here, we identified the site of bleeding by contrast harmonic sonography and performed RFA under sonographic guidance to achieve hemostasis. This case shows the successful application of percutaneous ablative therapy guided by contrast harmonic sonography.