上段の図４〜図６で肝臓と脾臓周囲に腹水があり（※），△と，図８と図９の△はやや高濃度を呈し血腫の可能性が高い．図８〜図１３の白矢印は不整な内部構造を示し血腫であろう．図５〜図７で内部構造不整な円形の病変が肝左葉に認められ（↑）そこから図１２まで広がる▲は大動脈と同濃度を呈するのでextravasation（造影剤の血管外漏出）であり，HCV抗体が陽性なことも考慮し肝臓癌の破裂と診断する．図７ではIVCが虚脱し強い脱水状態を意味する．図Aと図Bの血管造影で不整に造影される腫瘤（↓）とextravasation（▲）を示し，lipiodol と抗癌剤を注入し（図C），止血に成功した．

参考症例（肝細胞癌破裂）：70歳男性．上腹部痛で発症し，立ち上がろうとして転倒し救急搬送された．早期相（Early）と後期相（Late）のDouble phase 造影CTである．

早期相のCTで図１〜図１０の白矢印はdensityが高く，やや不整で血腫を含む血性腹水を示唆する．造影される病変があり（図２〜図４：↑），図４〜図７の▲はextravasationを示している．後期相では不整に造影された腫瘍性病変が明瞭となり，extravasation（▲）は上下に広がりさらに明白となる．早期相の図５の△と後期相の図１５の△は形と大きさに変化を認めないから出血源となっている異常血管（動脈瘤？）と解釈する．図Aと図Bが血管造影で，不整に造影される多発性の巨大腫瘍を示し（↑），△が動脈瘤様の異常血管で，▲がextravasation．ゼラチンスポンジで塞栓し止血に成功した．

文献考察１）：肝細胞癌破裂のCT所見：肝表面近くに存在する腫瘍，肝表面から突出する腫瘍，肝表面の断裂像（discontinuity）と周辺の血腫．
Br J Radiol. 2001 Feb;74(878):142-6.
The findings of ruptured hepatocellular carcinoma on helical CT.
Choi BG, Park SH, Byun JY, Jung SE, Choi KH, Han JY.

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.PMID: 11718385（full text）



文献考察２）：肝細胞癌破裂154例（全肝細胞癌の9％）．死亡率は38％，予後不良因子は来院時ショック，貧血，黄疸と進行性手術不可能例．
J Clin Oncol. 2001 Sep 1;19(17):3725-32.
Management of spontaneous rupture of hepatocellular carcinoma: single-center experience.
Liu CL, Fan ST, Lo CM, Tso WK, Poon RT, Lam CM, Wong J.

PURPOSE: To report the management of patients with spontaneous rupture of hepatocellular carcinoma (HCC) in a single center over a 10-year period and to evaluate a two-stage therapeutic approach. PATIENTS AND METHODS: A retrospective study was performed on all 1,716 patients with HCC who presented from 1989 to 1998. The two-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, hemostasis by transarterial embolization (TAE) or surgical means, followed by second-stage hepatic resection or transarterial oily chemoembolization (TOCE). Results of definitive treatment were compared with patients with no history of rupture during the same study period. RESULTS: During the study period, 154 patients (9%) had spontaneous HCC rupture. Initial intervention to control bleeding included TAE in 42 patients, surgical hemostasis in 35 patients, and conservative management only in 53 patients. The 30-day mortality rate was 38%. Independent factors on presentation affecting 30-day mortality were shock on admission, hemoglobin, serum total bilirubin, and known diagnosis of inoperable tumor. After initial stabilization and clinical evaluation, 33 patients underwent hepatic resection and 30 patients received TOCE. Median survival of the hepatectomy patients was 25.7 months; that of the TOCE patients was 9.7 months. Compared with patients with no rupture, survival after hepatectomy (25.7 months v 49.2 months, P =.003) was inferior but still substantially long, whereas survival after TOCE was comparable (9.7 months v 8.7 months, P =.904). CONCLUSION: Early mortality of spontaneous rupture of HCC was dependent on prerupture disease state, liver function, and severity of bleeding. Although it was a catastrophic presentation, prolonged survival could be achieved in selected patients with second-stage hepatic resection or TOCE.PMID: 11533094