Relationship between spontaneous rupture of hepatocellular carcinoma (SRHCC) and long-term survival after anatomic liver resection.

Background: Spontaneous rupture of hepatocellular carcinoma (SRHCC) is a critical complication, ranking as the third leading cause of death among HCC patients, following tumor progression and liver failure. However, the long-term survival outcomes of various interventions for SRHCC remain controversial and no authoritative standard has been established yet, highlighting the need to identify optimal treatment strategies to improve prognosis. The objective of this study is to investigate the impact of SRHCC on long-term outcomes following liver resection and to assess whether anatomic liver resection improves prognosis in these patients. Methods: This single-center, retrospective study included 2,468 HCC patients who underwent liver resection between 2009 and 2011. Patients were categorized into SRHCC (n=118) and non-SRHCC (n=2,368) groups. Cox regression was used to identify prognostic risk factors for recurrence-free survival (RFS) and overall survival (OS). Inverse probability of treatment weighting (IPTW) was applied to reduce confounding. Kaplan-Meier curves and log-rank tests were used to compare survival outcomes between groups. Subgroup analyses explored the impact of clinical characteristics, preoperative interventions, and surgical approaches on SRHCC prognosis. Results: Spontaneous rupture was identified as an independent risk factor for both RFS and OS. Patients with SRHCC exhibited significantly higher recurrence rates and poorer survival compared to non-SRHCC patients, even after IPTW adjustment. The independent risk factors for SRHCC included symptomatic presentation [odds ratio (OR) =6.30, 95% confidence interval (CI): 3.71-11.5, P<0.001], Child-Pugh classification (OR =5.15, 95% CI: 2.69-9.55, P<0.001), and tumor size >3 cm (OR =22.6, 95% CI: 4.89-401, P<0.001). Subgroup analysis showed that anatomic liver resection and the presence of a tumor capsule were associated with improved OS, while preoperative transarterial chemoembolization (TACE), anatomic liver resection, Barcelona Clinic Liver Cancer (BCLC) staging, and hepatitis B virus surface antigen (HBsAg) positivity were significant predictors of RFS. Notably, anatomic liver resection was also an independent risk factor for postoperative OS. Conclusions: Spontaneous rupture is closely associated with increased recurrence and reduced survival in HCC patients. Anatomic liver resection improves survival outcomes in SRHCC patients and should be considered a preferred surgical strategy.