Hepatocellular carcinoma (HCC) is a common health problem worldwide. It usually parallels the prevalence of a viral hepatitis. In what follows with development of advanced surgical techniques and technology, the option of a resection procedure has remained the first line of treatment to achieve a cure for HCC in patients with satisfactory liver function reserve and who are the status of being satisfactory anatomically resectable candidates for the procedure.12 However the prognosis of post-hepatectomy patients still remains unsatisfactory with a documented recurrence of 50–80% at 5 years.1 The recurrence can generally be divided in to intrahepatic recurrence (IHR) only and extrahepatic recurrence (EHR) cases or patient groups. In this sense, the EHR is less common than IHR; 16%, and patients with EHR have a much poorer prognosis.3 This is probably as a result of the fact that these tumors are usually multiple, aggressive and therefore not always amenable to the use of a curative resection, and there are no established systemic therapies to recommend for an EHR of HCC.

We herein present a patient with a bleeding EHR occurring within 1 year after curative right hemihepatectomy. A 51-year-old female, with a background history of hepatitis B carrier for which she is on oral tenofovir, presented with a 5-month history of dull right hypochondriac pain. On examination, no abdominal mass was found at that time. Additionally, the blood investigation results revealed an alpha-fetoprotein (AFP) of 8334 ng/ml. A multiphase computed tomography (CT) of the liver showed a segment V & VI mass with peripheral enhancement, with a much smaller satellite nodule in the segment 6, for which the patient underwent a right hemihepatectomy on 7th April 2016. Besides superficial surgical site infection, the patient recovered well and was discharged on postsurgery day 13. Subsequently, the histopathological examination showed a moderately differentiated HCC Grade II, with the nearest resection margin measured at 1.5 cm, as well as the focal capsular involvement, venous invasion and background of steatosis.

During follow-up, AFP reduced to 65 ng/ml, and a multiphase CT liver showed no enhancing liver lesion. During the 6th month follow-up, it was noted that AFP was 3284 ng/ml. A repeat CT multiphase on 5th December 2016 (8 months post-surgery) showed no enhancing liver lesions, but did note an irregular heterogeneous mass with characteristic surrounding fat streakiness in the pelvis thus measuring 6.6 cm×6.5 cm×6.5 cm.

The patient was scheduled for a diagnostic laparoscopy with the intention of localizing and assessing the option of resectability. On the night before the surgery, the patient started experiencing vague abdominal pain (retrospective) for which the patient ignored. Her vital signs were recorded as stable overnight. The laparoscopy found that the the omentum was adhered to the pelvic region, and it was found that there were blood and clots located in the peritoneal cavity. An immediate decision was made to convert the surgery to a midline laparotomy. The finding was an omental mass measuring 10 cm, which was loosely adhered to the dome of the bladder, which was freed easily with the use of a blunt dissection. The tumor was resected en-bloc with omentum. The patient recovered well and was discharged on post-surgery day 5. The associated histopathology report showed a metastatic HCC. A repeat CT a month after the surgery showed no recurrence and AFP level dropped to 108.2 ng/ml.

In patients with HCC, it is noted that bleeding or presence of ruptured HCC is not a common occurrence. A single center in Hong Kong documented a 9% incidence of bleeding HCC from the total number of cases of HCC seen over a 10 year period.3 The diagnosis may be difficult, as this condition may mimic other forms of intraabdominal pathologies, and requires a high index of suspicion. As of now there are no standard algorithms of related treatment approaches to be utilized in dealing with recurrent HCC. The definitive management usually ranges from conservative, the use of minimally invasive approaches via endovascular embolization to surgery with plication, hepatic artery ligation, alcohol injection, double stage procedure (packing then definitive) or definitive procedure in a single setting.4 In these cases, the 30-day mortality was measured to be 38%.3

The pattern of extrahepatic recurrence can then further be grouped into 3 patterns. Pattern I represented patients whose first recurrence was noted in the liver and in whom an extrahepatic metastasis developed later after repetitive locoregional treatments; pattern II included patients in whom both intrahepatic and extrahepatic recurrences were evident when recurrence was identified; and pattern III included patients who had only extrahepatic metastasis without intrahepatic metastases at the time of diagnosis of metastasis. Out of these groups, it is noted that the group 3 is considered the rarest group.5

The incidence of bleeding in a metastatic HCC is uncommon. Not many recent case reports are available discussing the incidence of a ruptured bleeding metastatic/recurrent HCC. One case shows a post mortem report of a ruptured peri-pancreatic lymph node; along with a histopathological examination of which returned as conclusively reported metastatic HCC.6 Another article discussed two patients being treated with HCC who were originally presenting with an acute abdomen.7 In these cases, with the CT imaging showing peritoneal tumor seeding and hematoma, the patients were operated to achieve hemostasis. The nodules which were sent for histopathological examination also confirmed the presence of a metastatic HCC.7

These bring us to understand that the route of extrahepatic HCC spread has been postulated from travel through tumor cells via lymphatics, vessels, direct extension or seedling.8 In this case report, the possibility of existing tumor deposit during the first operation cannot be ruled out, although the serum AFP did show a drastic drop post-surgery.

In conclusion, a bleeding metastatic HCC can be equally difficult to diagnose and as difficult to treat. A high index of suspicion is required in these cases, and an intervention should be recommended after a full review as on a timely basis. There are no protocols for this type of treatment, therefore treatment should be tailored to each patient and patient situation.