From the Guidelines
Emergency department treatment for a suspected bleeding hepatocellular carcinoma (HCC) or metastatic tumor with active bleed involves immediate stabilization and referral to a multidisciplinary team.
Initial Assessment and Stabilization
- The first step in managing a patient with a suspected bleeding HCC or metastatic tumor is to ensure hemodynamic stability, which may involve fluid resuscitation and blood transfusions as needed 1.
- Initial assessment should also include imaging studies, such as CT scans, to confirm the diagnosis and evaluate the extent of the bleed.
Treatment Options
- For patients with bleeding HCC, transarterial embolization (TAE) is a recommended treatment option to control the bleed 1.
- Transcatheter arterial chemoembolization (TACE) may also be considered for patients with bleeding HCC, although its use is more commonly associated with palliative treatment of non-bleeding HCC 1.
- In some cases, percutaneous ablation or radiofrequency ablation (RFA) may be used to treat bleeding HCC, although these options are typically reserved for smaller tumors 1.
Multidisciplinary Approach
- Given the complexity of HCC and the need for individualized treatment plans, referral to a multidisciplinary team involving hepatologists, radiologists, surgeons, and oncologists is essential for optimal management 1.
- This team can help determine the best course of treatment, taking into account the patient's overall health, tumor characteristics, and other relevant factors.
Real-Life Practice Considerations
- In real-life practice, treatment decisions must be made on a case-by-case basis, considering factors such as the patient's performance status, underlying liver disease, and presence of comorbidities 1.
- The Barcelona Clinic Liver Cancer (BCLC) staging system is a useful tool for determining treatment options, but it should be adapted to individual patient needs and circumstances 1.
From the Research
Emergency Department Treatment for Suspected Bleeding Hepatocellular Carcinoma (HCC) or Metastatic Tumor
- The treatment for a suspected bleeding HCC or metastatic tumor with active bleed in the emergency department (ER) involves a multidisciplinary approach, including diagnosis, control of bleeding, and treatment of the underlying tumor 2.
- The first step is to perform an abdominopelvic CT scan as soon as the patient's hemodynamics allow, to diagnose and control the bleeding 2.
- If active bleeding is visualized, arterial embolization is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology 2.
- In cases where surgery is unavoidable, an abbreviated laparotomy (damage control) with perihepatic packing is recommended 2.
- Radiofrequency ablation has also been shown to be effective in controlling bleeding from ruptured HCC, especially in cases where angiographic control is difficult or contraindicated 3.
- Emergency embolization has been found to be effective in stopping intraperitoneal bleeding from HCC, with no severe complications reported 4.
Treatment of Underlying Tumor
- The treatment of the underlying tumor depends on the etiology and diagnosis, with prompt resection indicated for HCC, atypical adenoma, or lesions at risk for degeneration to HCC 2.
- For adenoma with no suspicion of malignancy, it is recommended to wait for the hematoma to resorb completely before undertaking appropriate therapy 2.
- In cases of metastatic tumors, treatment may involve a combination of therapies, including surgery, embolization, and radiation therapy, depending on the location and extent of the tumor 5.
Multidisciplinary Approach
- A multidisciplinary approach to the treatment of HCC and metastatic tumors is essential, involving a team of healthcare professionals, including radiologists, surgeons, oncologists, and other specialists 6.
- This approach has been associated with increased survival and improved outcomes for patients with HCC and metastatic tumors 6.