S5471 Ruptured Hepatocellular Carcinoma Presenting as Hemothorax

Introduction: Hepatocellular carcinoma (HCC) is a known complication of cirrhosis and can rupture due to its vascularity. Although hemoperitoneum due to ruptured HCC has been well described, ruptured HCC presenting as hemothorax has been infrequently reported. Among the limited literature that is available, most cases involve bleeding from metastatic lesions in the thoracic cavity, and only a few reports of hemothorax from a ruptured HCC liver lesion exist. We describe the rare case of a newly identified ruptured HCC lesion presenting as hemothorax. Case Description/Methods: The patient is a 70-year-old man with past medical history of decompensated alcohol-related cirrhosis who presented with progressive shortness of breath and acute on chronic anemia. Upon presentation, vital signs were stable, and physical exam was notable for decreased breath sounds in the right lower lung field. Initial laboratory studies were notable for hemoglobin of 6.6 g/dL, platelets of 84 K/µL, creatinine of 2.5 mg/dL, international normalized ratio of 1.5, and elevated alpha-fetoprotein of 481 ng/mL, with Model for End-Stage Liver Disease score of 29. Chest x-ray identified a right-sided pleural effusion. A chest tube was placed with significant bloody output. The patient was subsequently upgraded to the intensive care unit for hemorrhagic shock, requiring multiple blood transfusions. Computed tomography angiogram identified active extravasation from a right hepatic lobe mass and multiple liver lesions concerning for HCC, with no active extravasation or lesions noted in the intrathoracic cavity. The patient underwent successful embolization of arteries feeding the bleeding hepatic mass. Although triple-phase magnetic resonance imaging described LI-RADS M lesions, the hepatology and oncology teams determined that the lesion was most consistent with a ruptured HCC. Liver biopsy was not pursued due to high bleeding risk. He was determined not to be a transplant candidate given the extent of disease and was referred to outpatient oncology upon discharge. Discussion: This unique case describes the rare presentation of hemothorax caused by a newly identified ruptured HCC lesion. As very few cases have been reported, we aim to add to the limited literature and increase clinician awareness of this presentation. Moreover, our patient’s rapid decompensation highlights the morbidity of this presentation and importance of prompt intervention. Finally, this case demonstrates the importance of HCC screening for earlier detection and increased likelihood of candidacy for curative therapies.