Hepatocellular carcinoma. Changing concepts in diagnosis and management

Contrast-enhanced sonography versus biopsy for the differential diagnosis of thrombosis in hepatocellular carcinoma patients

AIM: To clarify which method has accuracy: 2nd generation contrast-enhanced ultrasound or biopsy of portal vein thrombus in the differential diagnosis of portal vein thrombosis.

METHODS: One hundred and eighty-six patients with hepatocellular carcinoma and portal vein thrombosis underwent in blinded fashion a 2nd generation contrast-enhanced ultrasound and biopsy of portal vein thrombus; both results were examined on the basis of the follow-up of patients compared to reference-standard.

RESULTS: One hundred and eight patients completed the study. Benign thrombosis on 2nd generation contrast-enhanced ultrasound was characterised by progressive hypoenhancing of the thrombus; in malignant portal vein thrombosis there was a precocious homogeneous enhancement of the thrombus. On follow-up there were 50 of 108 patients with benign thrombosis: all were correctly diagnosed by both methods. There were 58 of 108 patients with malignant thrombosis: amongst these, 52 were correctly diagnosed by both methods, the remainder did not present malignant cells on portal vein thrombus biopsy and showed on 2nd generation contrast-enhanced ultrasound an inhomogeneous enhancement pattern. A new biopsy during the follow-up, guided to the area of thrombus that showed up on 2nd generation contrast-enhanced ultrasound, demonstrated an enhancing pattern indicating malignant cells.

CONCLUSION: In patients with hepatocellular carcinoma complicated by portal vein thrombosis, 2nd generation contrast-enhanced ultrasound of portal vein thrombus is very useful in assessing the benign or malignant nature of the thrombus. Puncture biopsy of thrombus is usually accurate but presents some sampling errors, so, when pathological results are required, 2nd generation contrast-enhanced ultrasound could guide the sampling needle to the correct area of the thrombus.

Regional over-representations on chromosomes 1q, 3q and 7q in the progression of hepatitis B virus-related hepatocellular carcinoma

Hepatocellular carcinoma is a highly malignant tumor that is prevalent in Southeast Asia and China, where hepatitis B viral infection is the main etiologic factor. Despite a high incidence of hepatocellular carcinoma developing in patients with viral hepatitis B-induced liver cirrhosis, the molecular events underlying the malignant liver progression remain largely unclear. In an effort to characterize the genetic abnormalities involved in the hepatitis B-related liver carcinogenesis, we performed genome-wide explorations by the technique of comparative genomic hybridization (CGH) on 100 hepatocellular carcinoma tumors that arose from hepatitis B-induced liver cirrhosis. According to the American Joint Committee on Cancer staging, four cases were classified as stage I, 69 as stage II, 23 as stage III and four as stage IV. CGH analysis indicated chromosomal instability in both early (stages I/II) and advanced (stages III/IV) stage tumors, with common gains on 1q, 8q and 17q23-q25, and losses on 4q22-q35, 8p21-p22, 13q14-q21, 16q and 17p identified in both groups (P>0.05). Nevertheless, preferential sites of chromosomal defects in relation to hepatocellular carcinoma progression were also identified. Statistical correlations suggested a higher incidence of regional 1q21-q22, 3q22-q28, 7q21-q22 and 7q34-q36 over-representations in association with the advanced stage tumors (P<0.05). In this study, our novel identification of specific chromosomal aberrations in relation to the advanced stage tumors may represent a first step towards mapping genes linked to the progression of hepatocellular carcinoma.

Detection of small hypervascular hepatocellular carcinomas in cirrhotic patients: comparison of superparamagnetic iron oxide-enhanced MR imaging with dual-phase spiral CT

OBJECTIVE

To compare the performance of superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) maging at 1.5T and dual-phase spiral computed tomography (CT) for the depiction of small hypervascular hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

Forty-three patients with 70 small nodular HCCs (5-20 mm; mean, 13.7 mm) were examined. Diagnosis was based on the results of surgical biopsy in 22 patients and by the combined assessment of MR imaging, lipiodol CT, alpha feto-protein levels, and angiographic findings in 21. MR imaging consisted of respiratory-triggered turbo spin-echo T2-weighted imaging, T1-weighted fast low-angle shot, and T2* -weighted fast imaging with steady-state precession imaging before and after SPIO enhancement. CT imaging was performed with 5-mm collimation and 1:1.4 pitch, and began 30 and 65 secs after the injection of 150 mL of contrast medium at a rate of 3 mL/sec. Two blinded observers reviewed all images independently on a segment-by-segment basis. Diagnostic accuracy was evaluated using receiver operating characteristics(ROC) analysis.

RESULTS

The mean areas (Az) under the ROC curves were 0.85 for SPIOenhanced MR imaging and 0.79 for dual-phase spiral CT (p <.05). The mean sensitivity of SPIO-enhanced MR imaging was significantly higher than that of CT (p <.05), i.e. 70.6% for MR imaging and 58.1% for CT. MR imaging had higher false-positive rates than dual-phase spiral CT, but the difference was not statistically significant (3.7% vs 3.3%) (p >.05).

CONCLUSION

SPIO-enhanced MR imaging is more sensitive than dual-phase spiral CT for the depiction of small hypervascular hepatocellular carcinomas.

Assessment of genetic changes in hepatocellular carcinoma by comparative genomic hybridization analysis: relationship to disease stage, tumor size, and cirrhosis

Hepatocellular carcinoma (HCC) is a common and highly malignant tumor that is prevalent in Southeast Asia. Although the etiological factors associated are now well recognized, the interactions between individual factors and the molecular mechanisms by which they lead to cancer remain unclear. Cytogenetic analysis on HCC has been limited because of poor hepatocyte growth in vitro. The recently developed technique of comparative genomic hybridization (CGH), however, permits screening of the entire genome without the need of cell culture. CGH was applied to the study of genomic aberrations in 67 surgically resected samples of HCC, 3 of adenomatous hyperplasia (AH), and 12 of nontumorous cirrhotic liver surrounding the tumors. All samples were from patients of a racially and etiologically homogeneous population in Southern China, where chronic hepatitis B virus infection is the main etiological factor. CGH analysis of the HCC samples revealed frequent copy number gain of 1q (48/67 cases, 72%), 8q (32/67 cases, 48%), 17q (20/67 cases, 30%), and 20q (25/67 cases, 37%) and common losses on 4q (29/67 cases, 43%), 8p (25/67 cases, 37%), 13q (25/67 cases, 37%), and 16q (20/67 cases, 30%). Our finding of a high incidence of 1q gain strongly suggested this aberration was associated with the development of HCC. Genomic abnormalities were detected in 1 of the 3 AH specimens but absent in all 12 cirrhotic tissues surrounding the tumor. Clinical staging classified 3/67 HCC cases as T1, 53 cases as T2, and 11 cases as T3. No significant difference in the pattern of genomic imbalances was detected between stages T2 and T3. A significant copy number loss of 4q11-q23 was, however, identified in those tumors larger than 3 cm in diameter. Of particular interest was the identification of 8q copy number gain in all 12 cases of HCC that arose in a noncirrhotic liver, compared with only 20/55 cases in HCC arising in a cirrhotic liver. We suggest that 8q over-representation is likely associated with a growth advantage and proliferative stimulation that have encouraged malignant changes in the noncirrhotic human liver.

Case report: A hepatocellular carcinoma metastasis in the distal pancreas

Hepatocellular carcinoma is a highly malignant neoplasm. Extrahepatic metastases are found in 64% of patients with hepatocellular carcinoma. The lungs, regional lymph nodes, kidney, bone marrow and adrenals are common sites of metastases. Pancreatic metastases are not common (<5%). A case report of a hepatocellular carcinoma with a metastasis in the distal pancreas is presented. A resection of the primary tumour and metastasis was carried out with the patient still alive 16 months after resection. This case illustrates that hepatic resection for hepatocellular carcinoma with a single local metastasis can be reasonably considered although a cure has not been established.

Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma

BACKGROUND

Resection of hepatocellular carcinoma is associated with high rates of morbidity and mortality. Since intensive nutritional support can reduce the catabolic response and improve protein synthesis and liver regeneration, we performed a prospective study to investigate whether perioperative nutritional support could improve outcome in patients undergoing hepatectomy for hepatocellular carcinoma.

METHODS

We studied 124 patients undergoing resection of hepatocellular carcinoma. Sixty-four patients (39 with cirrhosis, 18 with chronic active hepatitis, and 7 with no associated liver disease) were randomly assigned to receive perioperative intravenous nutritional support in addition to their oral diet, and 60 patients (33 with cirrhosis, 12 with chronic active hepatitis, and 15 with no associated liver disease) were randomly assigned to a control group. The perioperative nutritional therapy consisted of a solution enriched with 35 percent branched-chain amino acids, dextrose, and lipid emulsion (50 percent medium-chain triglycerides) given intravenously for 14 days perioperatively.

RESULTS

There was a reduction in the overall postoperative morbidity rate in the perioperative-nutrition group as compared with the control group (34 percent vs. 55 percent; relative risk, 0.66; 95 percent confidence interval, 0.45 to 0.96), predominantly because of fewer septic complications (17 percent vs. 37 percent; relative risk, 0.57; 95 percent confidence interval, 0.34 to 0.96). There were also a reduction in the requirement for diuretic agents to control ascites (25 percent vs. 50 percent; relative risk, 0.57; 95 percent confidence interval, 0.37 to 0.87), less weight loss after hepatectomy (median loss, 0 kg vs. 1.4 kg, P = 0.01), and less deterioration of liver function as measured by the change in the rate of clearance of indocyanine green (-2.8 percent vs. -4.8 percent at 20 minutes, P = 0.05). These benefits were seen predominantly in the patients with underlying cirrhosis who underwent major hepatectomy. There were five deaths during hospitalization in the perioperative-nutrition group, and nine in the control group (P not significant).

CONCLUSIONS

Perioperative nutritional support can reduce complications after major hepatectomy for hepatocellular carcinoma associated with cirrhosis.

Hepatic resections for primary liver cancer

The medical records of 399 patients who underwent hepatic resection between January 1981 and December 1990 were reviewed. Information regarding the results of the hepatic resection in terms of the operative indication, operative procedure, operative morbidity, and mortality was abstracted. As of the end of 1990, a total of 402 hepatic resections had been completed, including those of 319 primary malignancies, 4 secondary malignancies, 2 gallbladder carcinomas, 42 cases of intrahepatic cholelithiasis, and 35 benign masses. Major hepatic resections were performed on 117 patients (29%), of whom 60 (51%) had histologically proven liver cirrhosis. Minor hepatic resections were performed on the remaining 285 patients (71%). Sepsis was the most frequent complication, which manifested primarily as wound infection (71 cases) or intra-abdominal infection (25 cases). Nonfatal hepatic failure occurred in nine patients with cirrhosis and one patient without cirrhosis. There were 38 operative deaths among the 402 hepatic resections, for an overall operative mortality of 9.4%; 25 of those deaths were due to hepatic failure after the operation, accounting for 66% of the total operative mortality. There was an increasing frequency of hepatic resection during the last 5 years. The indication for resection due to hepatocellular carcinoma increased from 87 to 195 cases. The cumulative data show a decrease in the incidence of complications and the operative mortality rate. In the most recent period, nonlethal postoperative complications occurred in 135 of 286 patients (47%). The overall 1-, 3-, and 5-year survival rates for 172 patients, excluding cases of operative mortality, palliative resection, and re-resection, were 71.0%, 39.8%, and 28.3%, respectively.

[Liver resections for primary liver malignancies. Personal results and analysis of the literature]

In a retrospective study we analysed 50 resections for primary liver tumors performed between 1 July 1979 and 31 December 1991 at the Department of Surgery of the University of Cologne. The mean resectability rate was 28%. Hospital mortality after resection was 22% and could be reduced to 4% during the last 4 years. The overall survival rates after 1, 3 and 5 years were 55%, 30% and 24% respectively. The surgical radicality is the most important prognostic factor. In a review of the literature the results of 8,725 resections for primary liver malignancies published between 1980 and 1992 were analyzed. The mean resectability rate was 32 +/- 17%. The hospital mortality after resection could be reduced from 15 +/- 5% (resections before 1970) to 6 +/- 2% (resections after 1980). The overall survival rates after 1, 3 and 5 years were 66 +/- 17%, 39 +/- 15% and 27 +/- 10%, respectively. Apart from a lower hospital mortality in Asian studies (4% vs. 7%) the resection rates and long-term results of Asian, American and European studies were similar. Long-term prognosis predominantly depended on the surgical radicality and on the size and extension of the tumor at the point of resection. The effectivity of an adjuvant tumor therapy is not analyzed sufficiently.

Treatment of unresectable hepatocellular carcinoma with a combination of human recombinant alpha-2b interferon and doxorubicin: results of a pilot study

Based on the in vitro and in vivo potentiation of the cytotoxic activity of chemotherapeutic agents by the interferons, a pilot study combining human recombinant alpha-2b interferon (IFN) and doxorubicin was conducted for the treatment of unresectable, histologically proven hepatocellular carcinoma. Between March 1988 and May 1990, 21 patients (median age: 60 years, range: 29-76) entered the study. The dose of doxorubicin was fixed at 35 mg/m2, every 3 weeks. The dose of alpha-2b IFN was 6 million U/m2 per day, 5 days a week. 3 patients (14%) obtained a partial response lasting 11, 16 and 30 months, and 1 had a stable disease during 8 months. The other 17 patients died within a median survival time of 4 months. All patients experienced flu-like symptoms. 7 patients experienced WHO grade III-IV haematological toxicity. We conclude that the association of alpha-2b IFN and doxorubicin is feasible, with respect to the use of doxorubicin at an inferior dose level than the same agent used without IFN. The response rate is comparable to that observed with doxorubicin used alone. Further phase I studies and randomised trials are required to confirm the role of this regimen in the treatment of unresectable hepatocellular carcinoma.

Hepatocellular carcinoma. Prognostic factors and survival analysis in 135 Italian patients

This is a retrospective study to evaluate the history of hepatocellular carcinoma and find the relationship between clinical, biochemical and ultrasonographic features and survival in Italian patients. In 135 consecutive patients median follow-up was 16 months (range 1-66 months) and median survival from the time of diagnosis was 12 months. Univariate analysis showed that individual variables associated with significantly decreased survival included: absence of therapy, Okuda's Stage III, Child-Pugh's Class C, alpha-fetoprotein greater than 400 ng/ml, presence of symptoms, moderate or severe ascites, tumor involving both lobes, mixed internal echo pattern, and multinodular or massive type. Multiple regression analysis (Cox model) revealed that the mixed internal echo pattern of hepatocellular carcinoma, the presence of moderate or severe ascites and Okuda's Stage III were independent predictors of high risk of death. These data can help in selecting patients whose probability of survival is considered high enough to undergo treatment and may be useful for stratifying patients in randomized controlled trials.

Impaired energy metabolism of lymphocytes in cirrhotics after hepatectomy

To clarify the mechanism of high susceptibility to infection in cirrhotics, the changes in adenylate energy charge and MTT assay in peripheral blood lymphocytes were studied in cirrhotic and noncirrhotic patients in the early postoperative period after hepatectomy. The adenylate energy charge measured by radioactive labeling of the lymphocyte adenine nucleotide pool showed no significant difference preoperatively between cirrhotics and noncirrhotics, but a significant difference was observed in the pre- and postoperative distribution of adenine nucleotide metabolites (P less than 0.01). In the cirrhotic group, the adenylate energy charge of lymphocytes decreased significantly to 0.807 +/- 0.011 on the third postoperative day compared with preoperative value (0.891 +/- 0.006, P less than 0.01) and was restored to the normal range on the fifth and tenth postoperative days (0.886 +/- 0.006, 0.899 +/- 0.014), while no significant decrease was observed in the noncirrhotic group. MTT assay revealed that lymphocyte cell function decreased significantly in cirrhotics after hepatectomy. These results indicate that, in cirrhotic patients, the energy metabolism of lymphocytes is already impaired to some extent preoperatively, and that it undergoes further deterioration when surgical stress is applied. It is suggested that the decreased energy metabolism in the lymphocyte may be responsible for the increased susceptibility to infection in postoperative cirrhotics.

A 5-year experience of lipiodolization: selective regional chemotherapy for 200 patients with hepatocellular carcinoma

Between 1982 and 1987, selective regional cancer chemotherapy using Lipiodol plus an anticancer drug (lipiodolization) was prescribed for 200 patients with hepatocellular carcinoma. One hundred forty-nine patients were given lipiodolization alone, and the remaining 51 underwent hepatic resection following lipiodolization. The grades of deposits of the oily contrast medium in the neoplastic tissue seen on the plain X-ray correlated well with the antitumor effect. In the resected specimens of 17 patients treated with lipiodolization prior to surgery, concentrations of adriamycin in the malignant liver tissues were 13.2 +/- 18.2 micrograms per gm, whereas the adjacent liver parenchyma contained 1.4 +/- 2.0 micrograms per gm of adriamycin; the difference was statistically significant (p less than 0.05). In the 149 patients treated with lipiodolization, 1-, 2-, 3- and 4-year survival rates were 56.1, 28.9, 17.3 and 7.4%, respectively. Thus, lipiodolization was considerably more effective, compared to the results achieved by hepatic artery ligation and cannulation into the hepatic artery for patients in Stages I and II. In this sequential nonrandomized study, the survival rates for patients undergoing hepatic resection were superior to those for patients in Stage I and treated with lipiodolization. The significant difference appeared to depend on incomplete killing of tumor cells, which are most often present in the fibrous capsule, by lipiodolization. We conclude from these data that lipiodolization is an effective treatment for hepatocellular carcinoma when the tumor is not curatively resectable. When the clinical status is good, then surgery is warranted.

Spontaneous rupture of hepatocellular carcinoma in a child: report of a survival

A 10-year-old girl presented in shock with symptoms and signs of an acute abdomen. Spontaneous rupture of a hepatocellular carcinoma was diagnosed by ultrasonography in the emergency room and confirmed by a computed tomography scan. Despite contamination of the peritoneal cavity, aggressive resection of the involved hepatic lobe and the contiguous tissues, without chemotherapy or radiotherapy, has thus far achieved a 3 1/2-year disease-free survival.

Hepatocellular carcinoma imaging

Radionuclide scintigraphy can give a specific diagnosis when a hypervascular "cold" defect on colloid scans "fills in" with gallium scanning. The majority of hepatocellular carcinomas will also accumulate hepatobiliary agents especially in delayed images. Magnetic resonance imaging is superior to other modalities in providing anatomic detail, such as location and relation to vessels, needed by the surgeon in operative planning.

Review: the treatment of hepatocellular carcinoma

Surgical resection offers the only realistic hope of cure in hepatocellular carcinoma (HCC) but is usually not possible, either because the tumour is widespread throughout the liver at diagnosis, or because liver function is adversely affected by concomitant cirrhosis. The results of operation in early asymptomatic disease are, however, encouraging and efforts should be made to screen regularly the cirrhotic population at risk of HCC development. The prognosis for inoperable patients remains gloomy, though exciting new treatment methods exist which require extensive evaluation. An anthracycline given as single agent intravenous therapy is probably the current treatment of choice for inoperable patients, though only 20-30% will show a response. Intra-arterial therapy has not yet been convincingly shown to have any advantages over intravenous therapy. The evaluation of clinical trials in HCC would be made easier if response criteria were standardized and universally adopted, and if trials were properly controlled and of sufficient sample size to test adequately the hypothesis in question. This review deals only with the specific treatment of HCC. HCC prevention, the early diagnosis of HCC, and the relief of symptoms in HCC, though areas of obvious importance, are outside the scope of this review.

Primary liver cancer in a referral hospital in Hawaii

This is a retrospective review of 43 patients who had primary liver cancer diagnosed during 1974-1983. Patients' ages ranged from 27 to 84 years (median 52.5). Nine of 39 patients with hepatoma were females, while two of the four patients with cholangiocarcinoma were women. Hepatitis surface antigen was positive in 90% tested, and 62% had cirrhosis. Also, 60-65% were heavy users of alcohol and cigarettes. Alpha-fetoprotein was elevated in one of four white patients, and in six of eight patients of other races (75%). Tissue diagnosis was obtained by peritoneoscopy in 16, by percutaneous biopsy in 7, by laparotomy in 9, and at autopsy in 11. Only one of 11 patients who were explored has his lesion resected. About half of the cases diagnosed antemortem died 1 month or less after diagnosis. The median survival of hepatoma patients who had no specific treatment or systemic chemotherapy was 2 months. Two patients who received chemotherapy in conjunction with occlusion of the hepatic artery lived 16 to 19 months.

Liver resection in malignant disease

As more surgeons become familiar with the techniques of hepatic resection and the mortality and morbidity decrease, the indications for resection of malignant disease within the liver broadens. The preoperative assessment of malignant liver lesions, as well as the definition of resectability, are outlined. Indications for operative intervention as well as the results obtained are covered. The personal experience of the authors at the Royal Postgraduate Medical School Hepatobiliary Unit, Hammersmith Hospital, in dealing with malignant lesions of the liver is detailed with respect to procedures performed and postoperative morbidity and mortality. Hepatocellular carcinoma, hilar cholangiocarcinoma, and metastatic colon carcinoma are discussed in detail. The authors' experience with each of these diseases is presented.

Characteristics of fibrolamellar hepatocellular carcinoma. A study of nine cases and a review of the literature

Clinical and laboratory data for nine patients with hepatocellular fibrolamellar carcinoma treated at our institution have been summarized with emphasis on the relevance of plasma neurotensin levels as a tumor marker. The mean age of the patients was 22 years. Seven underwent hepatic resection, and two of these had later surgical removal of recurrent disease. Plasma neurotensin levels were initially elevated in five of the seven patients in whom it was measured. Neurotensin levels were within normal limits in three of four patients with recurrent disease, but were elevated in one patient who also had elevated plasma neurotensin levels preoperatively. In addition, a review of 80 patients reported since 1980 was performed. The mean age of these patients was 23 years, and only 6 percent were older than 50. The male to female ratio was 3:4. Eight percent were positive for hepatitis B antigen and 11 percent had elevated alpha-fetoprotein levels. Four percent had cirrhosis of the liver. The resectability rate was 58 percent. Five year survival for patients who underwent hepatic resection was 56 percent. Patients treated nonsurgically had a median survival of 13 months, and none of these patients lived for 5 years. Fibrolamellar hepatoma seems to be a distinct clinical entity that mainly occurs in young patients. The prognosis in patients treated with a curative resection is good. Plasma neurotensin levels may be of value as a tumor marker, but further studies are necessary to substantiate this theory.

Diagnosis of primary hepatic neoplasms by fine-needle aspiration cytology

This article describes the cytologic features of various primary hepatic neoplasms as seen in fine-needle aspirates. Hepatocellular carcinoma can be differentiated from metastatic carcinoma by its tendency to recapitulate the characteristics of normal hepatocytes, namely, resemblance of the neoplastic cells to liver cells, growth in trabeculae, and bile production. Fibrolamellar hepatocellular carcinoma is characterized by larger, polygonal tumor cells with clearly defined cell outline, deeply eosinophilic granular cytoplasm, and extremely large solitary nucleoli. Lamellae of fibrocytes are seen dividing the tumor cells into small groups. Hepatocellular adenoma and focal nodular hyperplasia exhibit cells that are benign-appearing or minimally atypical. Cholangiocarcinoma is an adenocarcinoma and cannot be differentiated from metastatic adenocarcinoma on purely morphologic grounds. Primary hepatic sarcoma is exceptionally rare and shows malignant spindle cells. Some inflammatory conditions such as abscess, cysts, and tuberculoma often present as space-occupying lesions and should be included in the differential diagnosis of hepatic neoplasm.

Large hepatocellular cancers: hepatic resection or liver transplantation?

Thirteen patients with primary hepatocellular cancer were studied to outline criteria for resectability in patients with large liver tumours. The mean age was 34 and the mean tumour diameter 13 cm (range 7-18 cm). Five of the tumours had a diameter of 15 cm or more. Extensive radiological investigations showed that seven of the patients had tumours of both right and left lobes of the liver, 10 had evidence of vascular invasion, and three had evidence of extrahepatic spread. Only two of the patients underwent a classically described formal hepatic resection, the rest having extensive resections crossing major anatomical planes. In no instance did the vascular invasion preclude resection, and extrahepatic spread could be verified in only one patient. The traditional criteria of resectability--that is, tumours located to one main lobe of the liver without vascular invasion and extrahepatic spread--can and should be extended. Resection may be preferable to transplantation even in patients with large primary liver tumours.