Then the patient��s abdomen was closed. The frozen section selleck chemical revealed a tumor mainly composed by atypical epithelioid cells. Mitotic figures were absent. Postoperative contrast-enhanced CT, revealed a large oval-shaped hepatic mass, which measured 86��72 mm, involving the left liver lobe. Following the injection of contrast, the lesion showed heterogeneous enhancement in all arterial, portal, and late phases. The internal structure was inhomogeneous with both soft- and fat-tissue density areas (Figs. 1 and and2).2). After 48 hours of Intensive Care Unit (ICU) staying, the patient underwent again to surgery for a left-liver lobectomy (Fig. 3). Fig. 1 Plain CT: large hypo-attenuating lesion completely takes up the left liver. Fig. 2 Contrast-enhanced CT: peripheral enhancement in arterial phase with hypodense areas.

Fig. 3 Surgical specimen of liver left-lobectomy for a 9 cm epithelioid angiomyolipoma. The postoperative period was uneventful and the dimission of the patient took place 9 days later. Histology of the surgery specimen revealed a well-circumscribed nodular mass of 9 cm. The cut surface showed a yellow-colored mass. The tumor consisted of adult fat cells, smooth-muscle cells, and vasculature (epithelioid angiomyolipoma). The mitotic index was < 1/50 high-power fields and necrotic areas were present. Immunohistochemically epithelioid cells were positive for HMB-45 and MelanA but negative for S100 protein, Actin, CK(PAN), CK7, Desmin and MIB 1 2%. Discussion Spontaneously rupture is a rare and dangerous complication which may occur in fibrolamellar HCC and more rarely in hepatic AML.

A tumor rupture followed by hemodynamic instability, is a surgical emergency and its treatment should be based on trauma principles. In this case we followed the damage control principles. The concept of damage control was introduced by Stone et al. in the 1980s and promulgated by Burch et al. in 1992 (10). The damage control surgery includes the first phase of control of hemorrhage, the second phase of resuscitation and stabilization in the intensive care unit for 24 h to 48 h and the third phase of re-exploration and definitive surgery. In the early 1990��s the concept of damage control surgery revolutionized the world of trauma and dramatically changed how trauma surgeons operate.

The concept focuses on abbreviated initial surgery, placing more Brefeldin_A emphasis on the body��s metabolic responses and less on restoring anatomy to the pre-injury state. These concepts include minimizing time in the operating room, leaving the abdomen open and covered (laparostomy), and early re-warming and resuscitation in the ICU. This method is associated with significantly survival advantages because it is directed toward the avoidance of hypothermia, coagulopathy, and acidosis that interact to produce a deteriorating metabolic situation and high mortality.