Prognostic influence of spontaneous tumor rupture on hepatocellular carcinoma after interval hepatectomy

Background. Spontaneous tumor rupture (STR) is a life-threatening complication of hepatocellular carcinoma (HCC). Yet, interval partial hepatectomy (PH) is feasible in selected patients after hemostasis for the rupture event. Little is known, however, about the extent of negative prognostic impact STR had on these patients after resection. Our aim was to determine the impact of STR on the oncologic outcome of interval PH for ruptured HCC, and the prognostic value of STR on the current tumor node metastasis (TNM) classification. Study design. From 1989 to 2010, 84 of 364 patients (23%) with STR received staged PH. Clinicopathologic variables associated with STR were identified by logistic regression analysis and ruptured tumor size with prognostic impact was determined by receiver operating characteristic analysis. Comparison of survival curves was performed after stratification by the American Joint Committee on Cancer/TNM, 7th edition. Results. Ruptured HCC had substantially worse survival than nonruptured tumor (5-year overall survival: 22.3% vs 53.4% P <.001). Anti-HCV status (hazard ratio [HR]: 3.225 confidence interval [95% CI]: 1.175-8.847, P =.023), platelet count (HR. 1.003, CI 1.0001-1.006, P =.042), tumor size (HR: 1.089, CI 1.025-1.156, P =.006) and microvascular invasion (HR 2.377, Cl 1.255-4.502, P =.008) were independently associated with STR. When stratified by the TNM system after excluding STR as a component of T-staging, ruptured HCC had worse survival outcomes than nonruptured HCC in T1-T2 disease and tumors <= 10 cm only. A receiver operating characteristic analysis confirmed that STR had no additional adverse prognostic impact over other tumor features when size > 10 cm (area under curve 0.65, P <.001). Conclusion. STR affects the outcome of PH for T1-T2 disease or tumor <= 10 cm only. Assigning all resectable ruptured tumors to T4 may overestimate the severity of disease.