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The aim of the present study was to investigate the background characteriscs of ruptured hepatocellular carcinoma (HCC) and to clarify the true impact of tumor rupture on patient prognosis in a large patient cohort.Spontaneous tumor rupture of HCC has been associated with a very poor patient prognosis and the current TNM staging systems classify ruptured HCC as T4 based on insufficient evidence.In total, 1106 patients with ruptured HCC were extracted from the database of a nationwide survey conducted in Japan from 2000 to 2005. The clinicopathological parameters associated with HCC rupture were investigated using univariate and multivariate logistic regression models. The survival curves for ruptured and nonruptured HCC were generated and compared to evaluate the impact of the event (rupture) itself on patient prognosis and the TNM staging systems.The multivariate analyses showed that tumor rupture was associated with both a poor liver functional reserve and an advanced tumor status. Analyses of the survival curves stratified according to the baseline TNM staging showed that tumor rupture had an additional impact on the baseline survival curves without rupture, and the impact corresponded to the addition of 0.5 to 2 stages to the baseline tumor staging.The present study suggested that tumor rupture itself had a negative impact on patient survival. However, its impact was not strong enough to cancel the effects of the other tumor-related parameters. Therefore, it may be appropriate to give additional stages to the baseline tumor staging in cases of ruptured HCC.