Prognosis factors of predicting survival in spontaneously ruptured hepatocellular carcinoma

Patients

One-hundred-and-twenty-seven patients with spontaneously ruptured HCC were enrolled in our institution between January 2010 and December 2020. The diagnostic criteria of HCC followed Asia–Pacific clinical practice guidelines on the management of hepatocellular carcinoma [7]. Spontaneous rupture of HCCs was diagnosed as abrupt abdominal pain; disruption of the peritumoral liver capsule with enhanced fluid collection in the perihepatic area adjacent to HCC by contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound; and hematoma around the liver as revealed by radiological examinations and/or bloody ascites by abdominal paracentesis. Patient data at the time of HCC rupture were recorded, including demographics, hemodynamic status, medical history, tumor characteristics, laboratory data, treatment modality, therapeutic strategies in the follow-up, and survival. This study was conducted in accordance with the Declaration of Helsinki and approved by our institution’s Ethics Committee.

Treatment

All patients with ruptured HCC immediately received careful conservative treatment, including anti-shock measures and patient condition assessment. Blood biochemical indices and imaging characteristics of HCC were rapidly investigated in the emergency department. Following the evaluation of key variables, including hemodynamic state, tumor status, laboratory data, Child–Pugh score, MELD score, Eastern Cooperative Oncology Group (ECOG) score, and cardiopulmonary function, therapeutic strategies were designed by surgeons, interventional physicians, and patients’ families within 48 h.

Surgical treatment

The surgical indications included a stable hemodynamic state, satisfactory hepatorenal and cardiopulmonary reservation, and tumor resection or packing. The contraindications included poor liver function (Child C), multifocal HCC, poorly controlled hepatic encephalopathy, severe coagulopathy, main portal vein or hepatic vein invasion, metastasis, and poor heart or lung function. All operations were performed by experienced hepatobiliary surgeons.

TACE/TAE

Patients contraindicated for surgery were recommended to undergo transarterial chemoembolization/transcatheter arterial embolization (TACE/TAE), and the contraindications included main portal vein thrombosis, arteriovenous fistula, Child–Pugh C cirrhosis, severe coagulopathy, and hepatic encephalopathy. Tumor blood feeding and location were observed through transcatheter hepatic arterial angiography. After a microcatheter was selectively inserted into the feeding tumor artery, embolization was performed with lipiodol, gelatin sponge, or polyvinyl alcohol particles. Common hepatic angiography was then repeated to confirm successful embolization of tumor-feeding arteries.

Conservative treatment

Patients contraindicated for surgery and TACE/TAE received careful conservative treatments, including intensive care, hemostasis treatment, antishock measures, parenteral nutrition, correction of coagulopathy, and analgesics.

Follow-up

Follow-up was performed every 1–3 months. Contrast-enhanced CT/MRI, lung CT, liver function, and alpha-fetoprotein levels were evaluated to determine further therapy for these patients. If patients failed to follow up for more than 6 months, the reason was investigated and recorded by doctors via telephone. Overall survival (OS) was defined as the interval from the date of rupture to the date of death or the last follow-up.

Statistical analysis

Continuous variables were expressed as the means ± SD, and categorical variables were expressed as a number. The survival rate was analyzed using the Kaplan–Meier method, the differences were compared using the log-rank test, and the Bonferroni method was used if more than two factors were included in the analysis. Univariate analysis and multivariate analysis were performed using a Cox proportional hazards model to identify the independent factors of overall survival. Independent factors in multivariate analysis were used to create a new survival predictive model for HCC rupture (hereafter referred to as SPHR) using a logistic regression model. To compare the accuracy of the MELD score, Child–Pugh score, and SPHR model as predictors of 30 day survival, receiver operating characteristic (ROC) curve analysis was conducted to obtain the cutoff value, sensitivity, and specificity. p < 0.05 was considered significant. Statistical analyses were performed using SPSS c21.0 software (Chicago, United States) and MedCalc 20.019 software (Los Angeles, United States).

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