A rare case of ruptured liver metastases from a laryngeal ca
A 68-year-old man who had a very heavy history of smoking and alcohol consumption (2 packs/day / 40 years of cigarette and 1 small bottle /day / 40 years of alcohol) diagnosed with SCC of the larynx in February 2016 and had partial laryngectomy operation. Four months later in June 2016, a control computed tomography (CT) image detected 2 new nodules smaller than 1 cm on the bilateral lungs. Biopsy couldn't be done because of the smaller size of the lesions. Therefore he underwent stereotactic radiotherapy with 54 Gy in 18 fractions for both lesions separately in August 2016. He did well for 3 years until June 2019 when a new recurrent laryngeal lesion was detected during routine imaging.

He had a total laryngectomy operation and bilateral lymph node dissection. The pathological result of the resected lesion was compatible with intermediate differentiated SCC. Due to recurrent disease, he received chemotherapy and radiotherapy between August 2019 and September 2019. In August 2020, a routine biochemical test showed increased liver function tests and alpha feta protein . He had ultrasonography (USG) which showed multiple metastatic hypoechoic lesions in the liver. Later a contrast-enhanced magnetic resonance imaging (MRI) was obtained to rule out primary HCC. But MRI was not suggestive for HCC. He had a liver biopsy which revealed SCC. He received 3 cycles of gemcitabine and carboplatin. After 2 days of his last chemotherapy, he showed up in the emergency clinic with acute abdominal pain. His physical examination revealed rebound tenderness at the right upper abdomen with muscular defense, tachycardia (120 beats/minute) with low blood pressure (80/50 mm Hg). Laboratory findings were as follows: white blood cell count 20,100/mm3, hemoglobin 9.8 g/dL, hematocrit 28.8 %, platelet cell count 438,000/mm3, prothrombin time (PT): 14.3 s; INR: 1.09; activated partial thromboplastin time: 28.1 s. No coagulation abnormalities were found, 20 days before this emergent presentation, his Hb and Hct levels were 12.1 g/dL and 36.5%, respectively emphasizing rapid onset of anemia. Emergency abdominal USG showed mult?ple liver metastases and ascites in the perihepatic area.

Dynamic contrast-enhanced CT was performed and revealed perihepatic hyperdense hematoma and multiple liver metastases. A subcapsular metastatic lesion that showed rapid growth compared to the previous imaging in the caudate lobe was detected. Protrusion of this lesion and discontinuity of the liver surface was observed with active contrast extravasation on the arterial phase of CT. Author diagnosed hemoperitoneum secondary to the rupture of a caudate lobe metastasis with these radiologic findings. Control contrast-enhanced CT showed no active extravasation. Considering the general condition and vital signs being normal values, the medical team including a general surgeon, interventional radiologist, and oncologist compromised on managing the patient conservatively. The patient was given palliative therapies such as blood transfusion and analgesic treatments; Hb and Hct were monitored serially and anemia improved during subsequent days and he was discharged by the improved condition. Medical oncology continued a new chemotherapy regimen. Control contrast-enhanced MRI showed no progression of the ruptured metastases..