What is the recommended management approach for a patient with ruptured hepatocellular carcinoma (HCC) after drug-eluting bead transarterial chemoembolization (DSM TACE)?

Management of Ruptured Hepatocellular Carcinoma After DSM-TACE

Emergency arterial embolization is the recommended first-line treatment for ruptured hepatocellular carcinoma following drug-eluting bead transarterial chemoembolization (DSM-TACE). 1, 2

Initial Assessment and Management

• Immediate hemodynamic assessment and stabilization should be performed for all patients with suspected HCC rupture after DSM-TACE 2
• Cross-sectional imaging (CT or MRI) should be performed if the patient is hemodynamically stable to confirm rupture and assess the extent of intraperitoneal bleeding 3
• Laboratory tests including complete blood count, liver function tests, and coagulation profile should be obtained to assess the severity of bleeding and baseline liver function 4

Definitive Management

• Emergency selective arterial embolization is the treatment of choice for hemodynamically unstable patients with ruptured HCC following TACE 1, 2
• Selective catheterization of the tumor-feeding arteries should be performed using 1.5-2.0 F microcatheters for optimal targeting 5
• Even when angiography does not reveal active extravasation, embolization of feeding arteries should still be performed to achieve hemostasis 1
• Superselective embolization technique should be employed to minimize damage to non-tumoral liver tissue 5

Technical Considerations

• Cone-beam CT (CBCT) should be utilized during the embolization procedure to enhance therapeutic efficacy and safety 5
• Complete occlusion of the tumor feeding artery is necessary to achieve hemostasis, but caution should be exercised as this is also a risk factor for rupture in subsequent TACE procedures 4
• For patients who are hemodynamically stable but have evidence of HCC rupture, a staged approach with initial TAE followed by delayed definitive treatment may be considered 2, 6

Post-Embolization Care

• Close monitoring in an intensive care setting with serial hemoglobin measurements is essential in the first 48 hours after embolization 1
• Antibiotic prophylaxis should be administered, especially in patients with biliary abnormalities or previous biliary interventions 5
• Management of post-embolization syndrome (pain, fever, nausea) with appropriate supportive care is recommended 3

Risk Factors and Prevention

• Large tumor size, peripheral location adjacent to the liver capsule, and complete occlusion of feeding arteries are risk factors for HCC rupture after TACE 4
• For high-risk tumors (large, subcapsular), consider less aggressive embolization or alternative treatment modalities 4
• Superselective TACE should be performed whenever possible to minimize ischemic damage to non-tumoral tissue 5

Follow-up and Subsequent Management

• Follow-up imaging (CT or MRI) should be performed within 4-6 weeks to assess treatment response 3
• After successful management of ruptured HCC, multidisciplinary tumor board discussion is recommended to determine optimal subsequent treatment strategy 3
• For patients who survive the acute rupture, consider staged hepatectomy if liver function and performance status permit 2

Prognosis

• Mortality after HCC rupture is high, with liver failure being the major cause of early death 6
• Patients with bilirubin levels below 50 μmol/L and those presenting with shock have poorer outcomes 6
• Successful emergency embolization can improve short-term survival and provide an opportunity for subsequent definitive treatment 1, 2