Presentation
Sudden onset of dyspnea and pain in the chest, arm, and left upper abdomen. CT pulmonary angiogram (not included here) and CT abdomen/pelvis were obtained.
Patient Data
Cirrhotic liver with a subcapsular hypodense lesion in hepatic segment 3. The left border of the lesion appears flattened and ragged, as if it has burst open, and there is active intraperitoneal hemorrhage coming from there. Also note the occlusive thrombus in the main and right portal veins and sequelae of recent Y-90 transarterial radioembolization of the right hepatic lobe.
These dynamic subtraction sequences show an observation in hepatic segment 3 measuring ≥20 mm with non-rim arterial hyperenhancement and nonperipheral washout (LI-RADS 5, definite HCC). Also noted are enhancing fibrotic changes in the right hepatic lobe, splenic varices, and patent portal veins.
The first two images are DSAs of the celiac axis showing a hypervascular, bleeding mass in the left hepatic lobe. On the third image, some of the feeding vessels have been embolized with Onyx, a liquid embolic agent; part of the mass still is receiving flow and bleeding, indicating the need for additional embolization. The fourth image is a DSA of the celiac axis after a second Onyx embolization; no extravasation or flow in the mass is seen.
Case Discussion
Spontaneous rupture of a hepatocellular carcinoma is a rare but deadly complication. In Western countries, about 3% of HCC patients will develop a spontaneous rupture with a 30-day mortality rate of approximately 25% 1,2.
The most common locations of a ruptured HCC are in hepatic segments 2, 3, and 6. One hypothesis is that the smaller dimensions of the liver in these segments makes it easier for the tumor to outgrow the parenchyma and burst through the capsule 3.
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