Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
391
Original Article
SMJ
Walailak Chaiyasoot, M.D.*, Jirawadee Yodying, M.D.*, Trongtum Tongdee, M.D.*, Panjit Jittungboonya, M.D.**
*Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand, **Diagnostic Imaging Division,
Buengkan Hospital, Buengkan 38000, ailand.
Spontaneously Ruptured Hepatocellular Carcinoma
Treated by Transarterial Embolization Compared
with Conservative Treatment: Survival Outcome
and Prognostic Factors
ABSTRACT
Objective: To report the survival outcome and prognostic factors in the patients with spontaneously ruptured
hepatocellular carcinoma treated by transarterial embolization compared with conservative treatment.
Materials and Methods: A retrospective review of 89 patients who had spontaneous rupture of hepatocellular
carcinoma (HCC) at Siriraj Hospital between January 2011 and February 2017 were enrolled. Ruptured HCC patients
are diagnosed by clinical presentations of abdominal pain/distension, anemia/shock with dynamic liver computed
tomography ndings as: hemoperitoneum, focal discontinuity or tumor protrusion of the hepatic surface and/or
active contrast material extravasation. We compared the survival outcome and prognostic factors of the ruptured
HCC patients who received two treatment methods; conservative treatment and transarterial embolization (TAE).
Results: e cumulative median survival time of the ruptured HCC patients was signicantly higher in the TAE
group (81 days) than in the conservative treatment group (29 days) with p-value = 0.006. ere were two signicant
predictors for post-treatment mortality. First, treatment modality in the TAE group showed a signicantly lower
mortality rate than in the conservative treatment group with a hazard ratio (HR) 0.454 (p-value = 0.003). Second,
a pre-treatment high hematocrit level was a signicant predictive factor for lower mortality than a low hematocrit
level with a hazard ratio (HR) 0.946 (p-value = 0.016).
Conclusion: TAE results in a good clinical outcome and increased survival rate in the patients with ruptured HCC.
A pre-treatment high hematocrit level was a good prognostic factor for the survival in ruptured HCC patients.
Keywords: Prognostic factors; survival outcome; ruptured hepatocellular carcinoma; transarterial embolization
(Siriraj Med J 2021; 73: 391-398)
Corresponding author: Jirawadee Yodying
E-mail: jijirid@gmail.com
Received 23 February 2021 Revised 16 March 2021 Accepted 23 March 2021
ORCID ID: http://orcid.org/0000-0002-2369-9008
http://dx.doi.org/10.33192/Smj.2021.52
INTRODUCTION
Hepatocellular carcinoma (HCC) is the sixth most
common malignant hepatic tumor and the second most
common cause of cancer-related death in the world.
1
In
ailand, it occurs as one of the most common cancers
in men and the third most common cancer in women.
2
Previous ai studies have reported that spontaneous
tumor rupture is the most common complication found
in 16% of cases
2,3
and approximately 10% of patients
with HCC die from this severe complication.
4
Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
392
e mechanisms of ruptured HCC have not yet been
fully elucidated. Some authors believe that it depends
on multifactorial factors
5
, including disruption of the
feeding artery or a tear at the tumor surface. Others
believe that bleeding is likely due to a laceration of
a tumor located supercially resulted from a minor
trauma. Some hypothesize that increased pressure in
the tumor from a sudden occlusion of hepatic vessels
causes venous congestion, in conjunction with central
necrosis within the tumor and coagulopathy, leading to
bleeding or rupture.
In this study, the diagnosis of HCC was based on
the ailand Guideline for Management Hepatocellular
Carcinoma 2019
6
by the ai Association for the Study of
the Liver (THASL). e most common clinical presentation
of ruptured HCC patients is acute abdominal pain with
or without shock. However, a denite diagnosis of the
ruptured HCC needs to be conrmed by dynamic contrast-
enhanced computed tomography (CT).
7,8
e advantages
of CT imaging is its ability to demonstrate the tumor
location, size, number, degree of hemoperitoneum, portal
vein tumor thrombus, and extrahepatic lesions. From
a literature review, we found that almost all previous
ai studies reported the treatment outcome in patients
with unruptured HCC.
9
ere are only two ai studies
concerning the treatment of ruptured HCC patients.
10,11
Also, a study by Kerdsuknirun et al.
12
stated about the
overall survival of ruptured HCC patients compared to
non-ruptured cases, but the report did not mention the
specic treatment.
Consequently, the objective of this study aimed to
report the survival outcome and prognostic factors of
patients with spontaneously ruptured HCC treated by
TAE compared with conservative treatment in ailand.
MATERIALS AND METHODS
e study was approved by the Ethics Committee of
Siriraj Hospital, protocol number 844/2016 (EC3). e
research involved a retrospective study of the ruptured
HCC patients treated at the Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok, ailand from
January 2011 to February 2017. Inclusion criteria was
ruptured HCC patients who were 15 years old or older
and treated with TAE or conservative treatment whose
CT imaging and clinical data were available. Exclusion
criteria was patients who were missing data.
A CT scan of the abdomen (120 kVp; 400 mA;
slice thickness, 1.25 mm) was performed for diagnosis
in all patients using a 64-slice CT scanner, General
Electric (GE) Light speed volumetric CT (VCT), and GE
Discovery CT 750HD instruments with an intravenous
non-ionic iodinate contrast media (350 mg I/ml) at a
dose of 2 ml/kg. We dened ruptured HCC according
to dynamic contrast enhanced CT
7,8
demonstrating an
arterial enhancing tumor with delayed phase washout
associated with hemoperitoneum, focal disruption of
the liver capsule, protruding tumor from the hepatic
surface area, and/or active contrast extravasation.
A total of
89 patients who met the inclusion criteria of
ruptured HCC were reviewed. Demographic data included
age, gender, date of diagnosis, and date of death. e
laboratory tests: complete blood count (CBC: hematocrit
and platelet count), coagulogram (prothrombin time or
PT, international normalized ratio or INR), liver function
test (LFT: total bilirubin, direct bilirubin, albumin), and
types of viral hepatitis were collected. We did not obtain
the clinical encephalopathy because it was not recorded
in all patients.
For the CT ndings, we evaluated the size of the
ruptured tumor (measured as the longest diameter in one
dimension), number of tumors, location of the ruptured
tumor (capsular region or protrusion from the hepatic
capsule), ascites, surrounding perihepatic hematoma,
portal vein thrombosis, extrahepatic metastasis, and
contrast extravasation from the CT scan or angiogram.
Aer ruptured HCC was diagnosed, the patient
underwent immediate resuscitation, including intravenous
uid and blood transfusion with or without abdominal
paracentesis. Of the 89 patients, 45 (50.6%) patients
received conservative management and 44 (49.4%) patients
underwent TAE for emergency hemostatic treatment.
TAE group: In hemodynamic instability patients or
patients with continuous bleeding, TAE was chose if the
patient’s liver function was preserved. e procedures
were performed by four experienced interventional
radiologists. e tumor location, neovascularization,
and active bleeding area were determined by angiogram.
Selective arterial embolization was performed in all patients
using a 5Fr angiographic catheter (Radiofocus®, Terumo®,
Tokyo, Japan) followed by super-selective catheterization
using a 2.7Fr microcatheter (Progreat®, Terumo®, Tokyo,
Japan). For embolic materials, our center typically uses
a temporary occlusive particle, Gelfoam® (Spongostan
TM
Absorbable Gelatin Sponge, Denmark), which is cut into
a small cube approximately 1 mm in size. Seven patients
received additional Ethiodized Oil (Lipiodol® UltraFluide,
Guerbet, France), an oil-based radio-opaque contrast
agent which has a specic characteristic for transient
embolization at the hepatic sinusoid level. One patient
received additional polyvinyl alcohol, PVA® (Contour®,
Boston Scientic, Ireland), which is a permanent embolic
particle. Successful control of the bleeding was dened
Chaiyasoot et al.
Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
393
Original Article
SMJ
as stabilization of the hemodynamic and hematocrit
level without further pack red cell (PRC) transfusion.
Conservative group: The patients who had hemodynamic
stability received the best conservative treatment, such as
replacement of the blood component, albumin, diuretic,
and/or analgesic drugs with the correction of coagulopathy.
Statistical analysis
e patients’ baseline characteristics are shown as
medians (ranges) and frequencies. We used the Student’s
t test and Mann-Whitney U test for the differences
between categories or continuous variables. e post-
treatment cumulative mortality rate between the two
groups (conservative and TAE groups) was analyzed
using the chi-square test or Fisher’s exact test. Survival
time was dened from the diagnosis of ruptured HCC to
the patient’s date of death. For the multivariate analysis,
a COX regression hazard model to demonstrated the
predictive factors of post-treatment mortality was performed.
A two-tailed p-value of less than 0.05 was considered
statistically signicant in all the analyses with the SPSS
Statistics 23.
RESULTS
In total, 89 patients with ruptured HCC were
categorized into two groups according to the treatment
modality: group 1, consisting of 45 patients who received
conservative treatment, and group 2, consisting of 44
patients who received TAE treatment.
e baseline characteristics of all the patients as
well as the clinical variables of the two treatment groups,
including the unit of PRC transfusion, laboratory results,
and CT ndings, are shown in Table 1. Most of the patients
with ruptured HCC had evidence of anemia which were
evaluated by low hematocrit level and the number of
PRC transfusion. e univariate analysis showed that
the hematocrit level and total bilirubin were signicantly
higher in the conservative group compared with in the
TAE group (p-value = 0.035 and 0.027, respectively).
Portal vein thrombosis and surrounding hematoma
were signicantly more evidence in the conservative
group than in the TAE group (p-value < 0.001 and 0.04,
respectively). e other clinical parameters showed no
signicant dierence between the conservative treatment
group and the TAE group.
e data of the ruptured HCC patients who received
TAE treatment showed contrast extravasation from angiogram
in 6 patients (13.6%) and tumoral neovascularization in
44 patients (100%). e embolic material used for TAE
were Gelfoam® in 37 patients (84.1%), Gelfoam® with
PVA® in 1 patient (2.3%), and Gelfoam® with Lipiodol®
in 6 patients (13.6%).
e cumulative median survival time of the ruptured
HCC patients was signicantly higher in the TAE group
(81 days) compared to the conservative treatment group
(29 days) (p-value = 0.006). e cumulative survival rates
at 1, 3, and 6 months were 46.7%, 28.9%, and 17.8% in
the conservative treatment group, and 70.5%, 50%, and
38.6% in the TAE group, respectively (Fig 1).
e results from the multivariate analysis of the
signicant predictive factors for post-treatment mortality
in the patients with ruptured HCC are summarized in
Table 2. ere were only two signicant predictors: the
treatment modality in the TAE group, which showed a
signicantly lower mortality rate than for the conservative
treatment group with a hazard ratio (HR) of
0.454 (p-value
= 0.003), and the pre-treatment high hematocrit level,
which was a signicant predictive factor for lower mortality
than a low hematocrit level with a hazard ratio (HR) of
0.946 (p-value = 0.016).
DISCUSSION
Spontaneous rupture of hepatocellular carcinoma
(HCC) is a serious complication of HCC. It occurs in
approximately 3-15% of cases, resulting a high mortality
rate between 25%-75%.
13-14
e previous study reported
that TAE was an eective treatment modality for ruptured
HCC patients, which showed a better survival rate than
those in the supportive treatment group.
15-16
Moreover,
TAE is less invasive than surgical treatment. erefore,
currently, TAE is the rst-line hemostasis in cases of
ruptured HCC whereas conservative treatment can be
considered in the patients who have stable hemodynamics
and no demonstrated active contrast extravasation from
CT imaging.
One study from ailand (2012)
10
involving 94
patients with spontaneous rupture of HCC during 1997-
2011, found the median survival of embolized and non-
embolized patients were 34 vs. 9 days (p-value = 0.005).
Our study showed that the cumulative overall survival rates
at 1, 3, and 6 months of the patients with ruptured HCC
were higher in the group treated with TAE than those in
the conservative treatment group. However, there might
be signicant factors in two groups that may lead to the
dierent overall survival, as the patients in TAE group
had better LFT and the patients in conservative group
had more portal vein thrombosis. e median survival
rate of the ruptured HCC patients was 29 days in the
conservative group and 81 days in the TAE group, with
p-value = 0.006, which was longer than in that previous
report. It was also probably be due to the development
of new technique and better equipment used in the
interventional radiology eld.
Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
394
Variable Conservative group TAE group p-value
(n = 45) (n = 44)
Age (year) 60 (41- 88) 62 (37- 88) 0.51
Gender (male) 38 (84.4%) 35 (79.5%) 0.55
PRC transfusion (unit) 3.4 4.4 0.58
Hct, g/dL 27 24 0.035
Platelet, 1,000/mm
3
204 193 0.65
Prothrombin time 20 18 0.68
Albumin, mg/dL 2.8 3.0 0.198
Total bilirubin, mg/dL 4.7 2.5 0.027
Direct bilirubin, mg/dL 3.5 1.7 0.062
Multiple tumors 42 (93.3%) 40 (81.9%) 0.240
Ruptured tumor size, cm 11.8 10.7 0.28
Viral hepatitis (A/B/C/None) 0 (0%) / 22 (48.9%) 1 (2.3%) / 23 (52.3%) 0.73
/ 10 (22.2%) / 13 (28.9%) / 8 (18.2%) / 12 (27.3%) 0.181
Ascites (mild/moderate/severe) 7 (15.6%) / 21 (46.7%) 5 (13.5%) / 29 (56.2%)
/ 17 (37.8%) / 10 (22.7%)
Protrusion from hepatic capsule 44 (97.8%) 44 (100.0%) 1.000
Capsular region of ruptured tumor 45 (100.0%) 44 (100.0%) NA
Disruption of hepatic capsule 45 (100.0%) 44 (100.0%) NA
Portal vein thrombosis 38 (84.0%) 21 (47.7) <0.001
Extrahepatic metastasis 26 (58.8%) 12 (28.3) 0.068
Hemoperitoneum 45 (100.0%) 44 (100.0%) NA
Surrounding hematoma 32 (71.1%) 39 (88.6%) 0.040
Active contrast 8 (17.8%) 11 (25.0%) 0.406
extravasation from CT scan
TABLE 1. Baseline clinical data of the 89 patients enrolled in the study and according to two treatment modalities:
a conservative treatment group and a transarterial embolization (TAE) group.
Abbreviations: NA = Not applicable, PRC = pack red cell, Hct = hematocrit, CT = computed tomography
Chaiyasoot et al.
Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
395
Original Article
SMJ
Fig 1. Cumulative median survival rate in the
patients with ruptured HCC, showing that the
survival rate in the transarterial embolization
(TAE) group was signicantly higher than in the
conservative group (p-value = 0.006).
TABLE 2. Multivariate analysis of the signicant predictive factors for post-treatment mortality in ruptured
hepatocellular carcinoma patients.
Multivariate analysis
95.0% CI for Exp (B)
Variable HR Lower Upper p-value
1. Treatment modality (conservative or TAE) 0.454 0.271 0.761 0.003
2. Portal vein thrombosis 1.518 0.912 2.525 0.108
3. Surrounding hematoma 1.561 0.853 2.857 0.148
4. Extrahepatic metastasis 0.789 0.480 1.296 0.349
5. Hct 0.946 0.904 0.989 0.016
6. TB 0.889 0.609 1.296 0.540
7. DB 1.161 0.756 1.782 0.494
Abbreviations: CI = Condence Interval, HR = Hazard Ratio, TAE = transarterial embolization,
Hct = hematocrit, TB = total bilirubin, DB = direct bilirubin
A recent study from India
17
reported the outcome of
conventional transarterial chemoembolization (cTACE)
in 16 patients with spontaneously ruptured HCC. ey
found that the overall cumulative survival rates at 30
days, 180 days, and at 1 year were 87.5%, 72.2%, and
54.1%, respectively. However, in our hospital, we usually
perform TAE without additional chemo-infusion in the
ruptured HCC cases because these patients mostly have
unstable hemodynamics. e primary treatment end
point is to achieve hemostasis and save life rst. en,
we may schedule for TACE in the next session both
via hepatic or extrahepatic collateral arteries supplying
HCC.
18
Another recent study reported that TAE was eective
for initial treatment in patients with spontaneously
ruptured HCC.
19
ey found that large sized tumors, a
Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
396
poor Child-Pugh classication, and shock were signicantly
associated with poorer prognosis. Our study did not
evaluate the Child-Pugh score because we had incomplete
data of clinical encephalopathy to calculate the score in all
patients and some patients presenting with shock which
could not evaluate the encephalopathy. e multivariate
analysis of this study showed two signicant predictive
factors for lower post-treatment mortality; TAE treatment
and pre-treatment high hematocrit level. is meant
that the patients who had TAE and pre-treatment high
hematocrit would have less mortality than the patients
who had conservative treatment and low hematocrit
level. However, the amount of PRC transfusion was not a
signicant variable for indicating the bleeding severity in
our study, which may be due to unavailable information
regarding blood transfusion unit the patients received
before transferring to our hospital.
In the conservative treatment group, 8 (17.8%) of 45
patients showed evidence of active contrast extravasation on
their CT ndings but the clinician still chose conservative
management instead of TAE. is might imply that these
patients were not suitable for TAE.
In the TAE group, the CT ndings showed active
extravasation in 11 (25 %) of 44 patients (Fig 2A, B), but
showed no signicant impact factor for post-treatment
mortality. However, the angiographic ndings showed
active contrast extravasation in only 6 (13.6%) of 44
patients (Fig 2D), which may explain by spontaneous
hemostasis of the bleeding from the time of the CT scan
to the angiogram.
e CT appearances in all 89 cases of ruptured HCC
were hemoperitoneum (Fig 3A), tumor located at the
capsular region and disruption of the hepatic capsule
(Fig 3B, C). Protrusion of the tumor from the hepatic
capsule was demonstrated in nearly almost patients.
Most of the ruptured tumors’ size was large, with a mean
size of 11.7 cm in the conservative group and 10 cm in
the TAE group. is indicated that tumors with large
size tend to experience spontaneous rupture more than
small size.
Fig 2. A 55-year-old female with hepatitis B cirrhosis and HCC presented with syncope and hypotension. A. Axial and B. Coronal contrast
enhanced portal phase CT scan shows a well encapsulated mass with portal washout at segment 8 of the right hepatic lobe (arrowheads)
with ascites and active contrast extravasation (white arrows). C. Scout lm angiogram showed a microcatheter placing at superior right
hepatic lobe (arrow) D. Selective right hepatic angiography shows a hypervascular lesion with active contrast extravasation from the A8
branch of the right hepatic artery (arrow). E. Post-embolization angiography shows disappearance of the contrast extravasation.
Chaiyasoot et al.
Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
397
Original Article
SMJ
Fig 3. A 81-year-old male with anemia (Hct 22.9%), epigastric distension and tenderness. A. Non-contrast phase CT scan shows hyperattenuating
hematoma at the lateral aspect of the right hepatic lobe (long arrow). B. Arterial and C. Delayed phase CT scans show a well-dened arterial
enhancing mass at hepatic segment 7, which demonstrated hepatic capsular disruption of the HCC (dark arrows) with active contrast
extravasation (short arrows).
ere are some limitations in this study. Firstly,
this is a small sample size, retrospective study which the
treatment modality was decided by the patient’s condition
and their physicians which can lead to selection bias.
Secondly, the previous data of blood transfusion unit
from the rst referring hospitals was mostly unavailable,
so we could not evaluate this signicant predictive factor.
Lastly, there are some signicant dierent of baseline
characteristic associated with outcome and mortality such
as LFT and portal vein thrombosis between two groups.
Future study with propensity matching such as exclude
all the patients who had contraindication for TAE in the
conservative treatment group would make the analysis
result more reliable in the ruptured HCC patients.
CONCLUSION
TAE results in a good clinical outcome and increased
survival rate in the patients with ruptured HCC. A pre-
treatment high hematocrit level was a good prognostic
factor for the survival in ruptured HCC patients.
ACKNOWLEDGEMENTS
e authors would like to thanks all the interventional
radiologists at Siriraj Center of Interventional Radiology
and the referring clinicians who take good care of our
patients.
Conicts of interest: No potential conicts of interest
relevant to this article is reported.
REFERENCES
1. Torre LA, Bray F, Siegel RL, Ferley J, Lortet-Tieulent J, Jemal
A. Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87-
108.
2. Somboon K, Siramolpiwat S, Vilaichone RK. Epidemiology
and survival of hepatocellular carcinoma in the central region
of ailand. Asian Pac J Cancer Prev 2014;15(8):3567-70.
3. Chonprasertsuk S, Vilaichone RK. Epidemiology and treatment
of hepatocellular carcinoma in ailand. Japanese Journal of
Clinical Oncology JJCO 2017;47(4)294-7.
4. Miyamoto M, Sudo T, Kuyama T. Spontaneous rupture of
hepatocellular carcinoma: A review of 172 Japanese cases. Am
J Gastroenterol 1991;86(1):67-71.
Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
398
5. Yoshida H, Mamada Y, Taniai N, Uchida E. Spontaneous
ruptured hepatocellular carcinoma: Hepatol Res 2016;46(1);
13-21.
6. e ai Association for the study of the liver. ailand Guideline
for Hepatocellular Carcinoma 2019:28.
7. e ai Association for the study of the liver. ailand Guideline
for Hepatocellular Carcinoma 2016:3-10.
8. Kim HC, Yang DM, Jin W, Park SJ. e various manifestations
of ruptured hepatocellular carcinoma: CT imaging ndings.
Abdom imaging 2008;33(6):633-42.
9. Eurvilaichit C, Kanjanapitak A. Hepatocellular carcinoma:
treated with hepatic arterial embolization, an analysis of
prognostic features in 150 cases. J Med Assoc ai 2000;83:983-
91.
10. Kaewwichian W, Munkong W, Lao-paiboon V, Pugkhem A,
Bhudhisawasdi A. Clinical features, treatment outcomes and
factors inuencing survival of spontaneous ruptured hepatocellular
carcinoma: A Srinagarind hospital-based study, 1997-2011
(abstract). Department of surgery, Faculty of Medicine Khonkaen
university. Medical Library Collection 2012:1-10.
11. Charoenkajonchai S. Management and outcome of ruptured
hepatocellular carcinoma. e ai Journal of Surgery 2015;
36(2):47-51.
12. Kerdsuknirun J, Vilaichone V, Vilaichone RK. Risk factors
and prognosis of spontaneously ruptured hepatocellular carcinoma
in ailand. Asian Pac J Cancer Prev 2018;19(12):3629-34.
13. Aoki T, Kokudo N, Matsuyama Y, Izumi N, Ichida T, Kudo M,
et al. Prognosis impact of spontaneous tumor rupture in the
patients with hepatocellular carcinoma: an analysis of 1160
cases from a nationwide survey. Ann Surg 2014;259(3):532-42.
14. Leung KL, Lau WY, Lai PB, Yiu RY, Meng WC, Leow CK.
Spontaneous rupture of hepatocellular carcinoma: conservative
management and selective intervention: Single -center experience.
Arch Surg 1999;134(10):1103-7.
15. Monroe EJ, Kogut MJ, Ingraham CR, Kwan SW, Hippe DS, Padia
SA. Outcomes of emergent embolization of ruptured hepatocellular
carcinoma in a western population. Clin Radiol 2015;70(7):
730-5.
16. Butt AS, Hamid S, Butt N, Sharif F, Hag TUI, Jafri W. Is
transarterial embolization a valuable treatment option for
spontaneous rupture of hepatocellular carcinoma: experience
from a tertiary care hospital of South-Asia. Hapatoma Res 2016;
2:279-86.
17. Palidar Y, Khisti R, Yadav A, Mukund A, Sarin S. Outcome
of conventional transarterial chemoembolization (cTACE) in
the management of spontaneously ruptured hepatocellular
carcinoma. Indian J Radiol Imaging 2019;29(2):177-81.
18. Ngamsombat C, Chaiyasoot W. Analysis of extrahepatic collateral
arteries in transcatheter arterial chemoembolization of
hepatocellular carcinoma. Siriraj Med J 2018;70(3):247-53.
19. Zhou C, Zu QQ, Wang B, Zhou CG, Shi HB, Liu S. Ecacy and
prognostic factors of transarterial embolization as initial treatment
of spontaneously ruptured hepatocellular carcinoma: a single-
center retrospective analysis in 57 patients. Jpn J Radiol 2019;
37(3):255-63.
Chaiyasoot et al.
