#These authors contributed equally to this article as co-first authors
Metastatic spread of hepatocellular carcinoma (HCC) to the spleen is uncommon, only occurring in approximately 1% of cases. Atraumatic splenic rupture due to HCC metastasis is extremely rare and affects patient prognosis, clinical management, and mortality. We report a case of a 65-year-old man with a history of chronic hepatitis B infection who presented with left-sided abdominal pain and fatigue. Clinical examination showed acute anemia with elevated levels of serum alpha-fetoprotein (AFP) and protein induced by vitamin K absence (PIVKA-II). On ultrasound and computed tomography imaging, hemoperitoneum caused by a ruptured splenic tumor was revealed. In addition to multiple hepatic lesions, enlarged abdominal lymph nodes and osteolytic lesions in the thoracic vertebral bodies were detected. The patient underwent total splenectomy and was diagnosed histopathologically with splenic rupture secondary to Grade 2 HCC metastasis. Atraumatic, pathological splenic rupture due to HCC metastasis should be considered in patients with chronic hepatitis B or C infection and increasing serum AFP and PIVKA-II levels, even though splenic metastasis is uncommon.
Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer that occurs in adults and is associated with a poor prognosis. Extrahepatic metastatic spread confers a worse prognosis. The spleen is an uncommon site of extrahepatic metastatic HCC, accounting for approximately 1% of metastatic cases [
A 65-year-old man was admitted to our hospital complaining of fatigue and mild left-side abdominal pain without any history of recent trauma. He had a history of chronic hepatitis B infection for the past 6 years. Physical examination revealed a palpable mass below the left costal margin, which was defined as an enlarged spleen on abdominal ultrasound. Additionally, multiple nodules and masses were detected in the spleen and liver on ultrasonography. The patient was transferred to the oncology department with suspicion of metastatic disease with an unknown primary. Two days after admission, the patient developed severe acute abdominal pain, hypotension (80/50 mmHg), and tachycardia (105 beats per minute). Laboratory tests revealed a low hemoglobin (85 mg/dL), elevated alpha-fetoprotein (AFP; 8757 ng/mL), and elevated protein induced by vitamin K antagonist II (PIVKA-II; 23043.11 AU/mL). Bedside ultrasonography detected free intraperitoneal fluid with mixed internal echogenicity, suggesting hemoperitoneum. Therefore, urgent CECT was performed, which revealed a large quantity of hyperdense, free fluid in the pelvis and surrounding the inferior splenic pole, most consistent with hemoperitoneum (
HCC is a common complication of hepatitis B infection or liver cirrhosis from any cause [
Melanoma, as well as malignancies of the breast, lung, ovary, colon, stomach, and pancreas, are the most frequent cancers to spread to the spleen. The spleen is one of the most well-vascularized organs, yet it is only very infrequently implicated in metastasis. The splenic artery and the coeliac axis form a steep angle, making it troublesome for tumor cells to reach the spleen. Because the splenic parenchyma lacks afferent lymphatic capillaries and the splenic capsule only has a few restricted lymphatics, most metastic tumors are found in the subcapsular area. The splenic sinusoids’ rhythmic contractions may prevent tumor cells from implanting on vascular endothelial cells. The spleen capsule also acts as a physical barrier, preventing tumor cells from entering the spleen. Another protective factor against metastasis is thought to be the spleen’s immunological properties. The spleen, in reality, is a big reticuloendothelial organ with a significant number of lymphocytes and macrophages that generate a variety of chemical compounds that can kill tumor cells [2.3]. Patients presenting with splenic metastasis are often asymptomatic, and metastases are incidentally detected on imaging [
Splenic metastasis is a rare cause of the atraumatic, pathological splenic rupture, accounting for 3.8% of cases [
Patients with spontaneous splenic ruptures due to metastases should undergo immediate total splenectomy or transcatheter arterial embolization to stop the bleeding [
In our case, urgent CECT facilitated the diagnosis of hemoperitoneum due to splenic lesion rupture. However, the presence of multiple lesions in the liver, spleen, and bone, including abdominal lymphadenopathy, provided a challenge to the diagnosis of the primary tumor. Splenectomy was both therapeutic and diagnostic, leading to the diagnosis of metastatic HCC.
Metastatic HCC that results in atraumatic splenic rupture is a rare phenomenon. Atraumatic splenic rupture can be clinically considered when a patient with known HCC or known chronic liver disease has an acute onset of abdominal pain and signs of hypovolemia. CECT readily provides diagnosis and can expedite ensuing urgent management and reduce patient mortality.