The findings of ruptured hepatocellular carcinoma on helical CT

Abstract

To evaluate the helical CT findings of ruptured hepatocellular carcinoma (HCC), 12 patients with ruptured HCC were reviewed with regard to the tumour's location, size and contour protrusion, the appearance of the mass, the enhancement pattern, multiplicity and secondary changes. All ruptured tumours were located at the periphery of the liver and had a protruding contour. The maximum diameter of tumours ranged from 2 cm to 16 cm. Discontinuity of the hepatic surface was seen in 11 cases. In eight cases, CT images during the arterial phase showed a non-enhancing low attenuating lesion with focal discontinuity and peripheral rim enhancement. Seven cases showed separation of tumour content from the peripheral enhancing rim and intraperitoneal rupture of tumour content into the perihepatic space. Because of the similar appearance to an enucleated orbital globe with remaining sclera, this was termed the "enucleation sign". As well as ruptured masses, 10 cases with non-ruptured masses also showed a non-enhancing low attenuating pattern. Seven cases showed a haematoma with high attenuation around the ruptured mass. The peripheral location, protruding contour, discontinuity of the hepatic surface and surrounding haematoma are helpful signs in the diagnosis of ruptured HCC. The "enucleation sign" may be a characteristic finding in ruptured HCC.

Enucleation Sign: A Computed Tomographic Appearance of Ruptured Hepatocellular Carcinoma

“…Other factors include large tumor size, peripheral location, and the extent of extrahepatic protrusion. 2,5 The exophytic tumor projecting beyond the original liver contour is more likely to rupture than one surrounded by normal parenchyma. The protruded tumor without surrounding normal parenchyma may easily rupture due to compression or friction to the adjacent diaphragmatic muscle, abdominal wall, and gastrointestinal tracts.…”

“…Peripheral rim enhancement is due to compressed normal parenchyma and does not represent true lesion. 5 mortality due to hypovolemic shock and renal failure; moreover, this is usually fatal in patients with underlying liver cirrhosis due to severe coagulation defects. Owing to high mortality, prompt and accurate diagnosis is desirable, which is possible by CT scanning.…”

“…Though no large series are reported as to the percentage of ruptured HCC demonstrating ''enucleation sign'' on CT scan, nevertheless it is the imaging of choice and is very specific. 5,10,12,13 On CT scan, a ruptured HCC manifests as ''enucleation sign,'' which appears as a peripheral mass, showing central necrosis, protruding contour, and discontinuity on hepatic surface. These findings if associated with a surrounding hematoma and/or extravasation of contrast material as a sign of active bleeding are highly specific for ruptured HCC.…”

“…These findings if associated with a surrounding hematoma and/or extravasation of contrast material as a sign of active bleeding are highly specific for ruptured HCC. 5,[11][12][13] …”

Hepatocellular carcinoma – diagnostic dilemmas

“…Nagły, ostry ból umiejscowiony w nadbrzuszu i śród-brzuszu, któremu towarzyszą objawy otrzewnowe, zmniejszenie hematokrytu i spadek ciśnienia tętnicze-go, przemawia za samoistnym krwotokiem z guza do jamy otrzewnej [13]. W przypadku obecności wodobrzusza objawy krwawienia mogą być słabiej wyrażone, a kolor płynu puchlinowego zmienia się ze słomkowego w krwisty.…”