図２〜図１１の肝外側の腹水（△）は高濃度を呈しているから血腫を含む腹水であり，図２〜図８の▲は肝表面でのextravasationを示しており，肝臓からの出血を意味するが，図１の出血源病変（↑）は認識できなかった．病変は不明でもCT所見で肝臓からの出血は疑う余地がないと血管造影を施行した．図Aの↑が不整に造影される病変で悪性腫瘍であろう．Extravasationを認めないが塞栓術を施行した．図Bは塞栓後で病変は造影されなくなった．図Cは塞栓後3日目のCTで，病変部は造影効果を失い低濃度となっている．AFPとPIVKA II が高値を示しHCCと診断された．後日腹腔鏡下にマイクロ波凝固術を追加した．

参考症例（肝細胞癌破裂）：76歳男性．数年前から肝硬変を，6ヶ月前にHCCを指摘されている．急激に発症した上腹部痛と嘔吐のため来院した．Dynamic 造影CTで，図１〜図１０は早期相（Early），図１１〜図２０は早期相から20秒後，図２１〜図３０は早期相から1分後のCTである．

図４の↑は1スライスだけではextravasationかどうか判断が難しいが，図１４と図１５，図２４と図２５で時間の経過とともに周囲への広がりを示しextravasationの診断が容易となる．図１１と図１２の▲，図２６〜図２８の△もextravasationである．

文献考察１）：肝細胞癌破裂例55例．死亡率は38.2%．肝機能の悪い例は予後が不良である．
Am J Emerg Med. 2005 Oct;23(6):730-6.
Outcomes of emergency treatment in ruptured hepatocellular carcinoma in the ED.
Chen WK, Chang YT, Chung YT, Yang HR.

The choice of emergency treatment of ruptured hepatocellular carcinoma (HCC) remains controversial. This study analyzed the prognostic factors for ruptured HCC seen in an ED. Patients were retrospectively classified into survival and mortality groups. Fifty-five patients were enrolled into this study, and the hospital mortality rate was 38.2%. There were no associations of clinical presentation, tumor characteristics, and emergency treatment method with patients' prognoses. Significantly higher mortality rate was noted in patients with poor liver function. The time between admission and emergency chemoembolization was significantly shorter in the mortality group than in the survival group (mean, 255 vs 394 minutes). The 1-month survival rate was 69% in patients who received conservative treatment and 59% in patients who underwent emergency chemoembolization. Routine emergency chemoembolization did not improve outcome and was associated with higher mortality and complication rates, especially in patients with poor liver function. Conservative therapy may be a preferable option for patients with ruptured HCC if they have baseline poor liver function.PMID: 16182979（full text）

文献考察２）：肝細胞癌切除例535例中破裂例は60例（11.2％），1,3,5年生存率は非破裂例で72.1，47.3，33.9%で，破裂例では54.2，35.0，21.2%であった．
Br J Surg. 2002 Sep;89(9):1125-9.
Spontaneous tumour rupture and prognosis in patients with hepatocellular carcinoma.
Yeh CN, Lee WC, Jeng LB, Chen MF, Yu MC.

BACKGROUND: Hepatocellular carcinoma (HCC) is a common disease in Taiwan. Ruptured HCC is an uncommon and potentially fatal complication of the condition. Information on the impact of ruptured HCC on hepatic resection is, however, limited. METHODS: The clinical features of 60 patients with ruptured HCC who underwent hepatic resection from 1986 to 1998 were reviewed. Clinical features and factors influencing the outcome of 475 patients with non-ruptured HCC were used for comparison. RESULTS: Of 535 surgically resected HCCs, 60 (11.2 per cent) were ruptured. Univariate analysis showed that sudden onset of abdominal pain, physical signs of haemodynamic unstability, reduced haemoglobin level and a raised aspartate aminotransferase level were more frequently found in patients with ruptured HCC than in those with non-ruptured tumours. Multivariate stepwise logistic regression analysis revealed sudden-onset abdominal pain to be the only independently significant factor in patients in the ruptured HCC group. The 1-, 3- and 5-year survival rates of patients with non-ruptured HCC were 72.1, 47.3 and 33.9 per cent, and those of patients with ruptured HCC were 54.2, 35.0 and 21.2 per cent respectively. Similar overall survival rates were found in patients with ruptured and non-ruptured HCC, although patients in the non-ruptured HCC group had a significantly better disease-free survival rate (P = 0.023). CONCLUSION: The presence of sudden-onset abdominal pain is the only independent indicator of ruptured HCC. Hepatic resection, when feasible, is the treatment of choice and can result in an overall survival rate comparable to that of patients with non-ruptured HCC.PMID: 12190677