Hepatocellular carcinoma in Hong Kong: clinical study on 340 cases

Effect of Biliary Tract Invasion with Obstructive Jaundice on the Prognosis of Patients With Unresectable Hepatocellular Carcinoma

RATIONALE AND OBJECTIVES

Biliary tract invasion (BTI) is associated with poor outcomes in patients with hepatocellular carcinoma (HCC). However, the presence of a BTI is a neglected variable for staging in the current guidelines. This study aimed to explore the effects of BTI with obstructive jaundice on the prognosis of patients with unresectable HCC.

METHODS

We retrospectively included 205 patients initially diagnosed with unresectable HCC who presented with obstructive jaundice due to BTI between January 2010 and June 2021. BTI was classified into four types according to the location of the biliary obstruction. Both clinical and treatment factors that affect median overall survival (mOS) were analyzed.

RESULTS

The mOS of patients with Barcelona Clinic Liver Cancer (BCLC) stages B, C, and D was 9.2 months, 3.4 months, and 1.8 months, respectively (p<.001). The mOS of BTI type I patients was superior to that of BTI type II patients (7.1 months vs. 3.2 months, p=.002). Patients who underwent successful biliary drainage had a longer mOS than those who underwent unsuccessful biliary drainage (10.4 months vs. 2.9 months, p<.001). In the multivariate analysis, BTI type I (p=.009), successful biliary drainage (p=.005), and HCC treatment (p<.001) were significant favorable prognostic factors that affected patient survival.

CONCLUSION

HCC patients with BTI type II may have a poorer prognosis than those with BTI type I. Effective biliary drainage and anti-cancer treatment may provide survival benefits to these patients. A more detailed staging system for HCC based on the state of BTI is needed.

Rapid progression of hepatocellular carcinoma in a pregnant woman: A case report

Hepatocellular carcinoma (HCC) in pregnant women is rare; however, a recurrence of the disease is followed by rapid lesion progression during pregnancy. We experienced a case in which HCC recurred during pregnancy and rapidly worsened. After delivery at 33 weeks, she underwent chemotherapy and made a good progress.

Recurrent hepatocellular carcinoma in pregnancy: A case report and literature review

The incidence of hepatocellular carcinoma in pregnancy is rare, and we present the first reported case of a pregnancy complicated by pre-existing advanced hepatocellular carcinoma. We describe the case of a 39-year-old woman in her second pregnancy, with a diagnosis of hepatocellular carcinoma. This was discovered in 2013 incidentally following hepato-splenectomy and pancreatectomy for a presumed hepatic adenoma in the context of multiple arterio-venous malformations. Recurrent hepatocellular carcinoma, in conjunction with co-existing pulmonary hypertension was successfully managed in a multi-disciplinary setting, resulting in a spontaneous vaginal delivery of a live female infant with maternal and neonatal survival six months following delivery.

Efficacy of 125I Versus Non-125I Combined with Transcatheter Arterial Chemoembolization for the Treatment of Unresectable Hepatocellular Carcinoma with Obstructive Jaundice

PURPOSE

To compare the therapeutic effects of ¹²⁵I versus non-¹²⁵I combined with transcatheter arterial chemoembolization (TACE) for the treatment of unresectable hepatocellular carcinoma (HCC) with obstructive jaundice.

METHODS

A retrospective analysis was conducted using the records of 54 consecutive patients who were initially diagnosed with HCC with obstructive jaundice between May 2009 and July 2016. Twenty-one cases (group A) were treated with percutaneous transhepatic biliary drainage (PTBD) followed by ¹²⁵I radioactive seed strip implantation through the PTBD tube. After the total serum bilirubin level was reduced to normal and the liver function recovered to Child-Pugh class A or early B, TACE was conducted. In 33 cases (group B) PTBD was performed in combination with TACE without applying the ¹²⁵I radioactive seeds. The duration of biliary patency and survival were analyzed.

RESULTS

The technical success rate in both groups was 100%. The median biliary patency time was 6.000 ± 0.315 months (95% CI 5.382-6.618 months) in group A and 4.000 ± 0.572 months (95% CI 2.879-5.121 months) in group B; the two groups were significantly different (P = 0.001). The median survival was 11.000 ± 0.864 months (95% CI 9.306-12.694 months) in group A and 9.000 ± 0.528 months (95% CI 7.965-10.035 months) in group B; the two groups were significantly different (P = 0.022).

CONCLUSIONS

The combination of 125I with TACE was more effective than TACE without the radioactive seeds for treating patients with unresectable HCC with obstructive jaundice. Future prospective trials with larger samples will be required to validate these results.

Epidemiology of Hepatocellular Carcinoma in the Asia-Pacific Region

Hepatocellular carcinoma (HCC) is the predominant primary liver cancer in many countries and is the third most common cause of cancer-related death in the Asia-Pacific region. The incidence of HCC is higher in men and in those over 40 years old. In the Asia-Pacific region, chronic hepatitis B virus and hepatitis C virus infections are the main etiological agents; in particular, chronic hepatitis B infection (CHB) is still the major cause in all Asia-Pacific countries except for Japan. Over the past two decades, the incidence of HCC has remained stable in countries in the region except for Singapore and Hong Kong, where the incidence for both sexes is currently decreasing. Chronic hepatitis C infection (CHC) is an important cause of HCC in Japan, representing 70% of HCCs. Over the past several decades, the prevalence of CHC has been increasing in many Asia-Pacific countries, including Australia, New Zealand, and India. Despite advancements in treatment, HCC is still an important health problem because of the associated substantial mortality. An effective surveillance program could offer early diagnosis and hence better treatment options. Antiviral treatment for both CHB and CHC is effective in reducing the incidence of HCC.

Impact of disease stage and aetiology on survival in hepatocellular carcinoma: implications for surveillance

BACKGROUND

Variation in survival in hepatocellular carcinoma (HCC) has been attributed to different aetiologies or disease stages at presentation. While international guidelines recommend surveillance of high-risk groups to permit early diagnosis and curative treatment, the evidence that surveillance decreases disease-specific mortality is weak.

METHODS

We compared HCC survival figures from Japan (n=1174) and Hong Kong (n=1675) over similar time periods (Japan 2000-2013, Hong Kong, China 2003-2014). The former has an intensive national surveillance programme, while the latter has none. We also analysed changes in survival in Japan over a 50-year period including data from before and after institution of a national HCC surveillance programme.

RESULTS

In Japan, over 75% of cases are currently detected by surveillance, whereas in Hong Kong <20% of cases are detected presymptomatically. Median survival was 52 months in Japan and 17.8 months in Hong Kong; this survival advantage persisted after allowance for lead-time bias. Sixty-two per cent of Japanese patients had early disease at diagnosis and 63% received curative treatment. The comparable figures for Hong Kong were 31.7% and 44.1%, respectively. These differences could not be accounted for by disease aetiology, and patients in Hong Kong who were detected at an early stage had a similar survival to the analogous patients in Japan.

CONCLUSIONS

The variation in survival is largely accounted for by stage at diagnosis, which in turn relates to the intensity of surveillance programmes and the consequent variation in curative therapeutic options.

Effective biliary drainage and proper treatment improve outcomes of hepatocellular carcinoma with obstructive jaundice

Background/Aims

We investigated the treatment outcomes and prognostic factors of hepatocellular carcinoma (HCC) with obstructive jaundice.

Methods

Among 2,861 patients newly diagnosed with HCC between 2002 and 2011, a total of 63 patients who initially presented with obstructive jaundice were analyzed. Only four patients presented with resectable tumors and underwent curative resection. In the other patients who presented with unresectable tumors, 5, 8, 9, and 18 patients received transarterial chemoembolization (TACE), chemotherapy, radiotherapy, and combined treatment, respectively. Both the clinical and the treatment factors that affect overall survival (OS) were analyzed.

Results

The median OS was 4 months, and the 1-year OS rate was 23%. Patients who received treatment for HCC had a significantly improved OS rate compared with the patients who received supportive care only (1-year OS, 32% vs 0%; p<0.01). Responders to treatment showed a better OS than nonresponders (1-year OS, 52% vs 0%; p<0.01). TACE and radiotherapy resulted in relatively good treatment responses of 64% and 67%, respectively. In multivariate analyses, treatment of HCC (p=0.02) and the normalization of serum bilirubin by biliary drainage (p=0.02) were significantly favorable prognostic factors that affected the OS.

Conclusions

Unresectable HCC with obstructive jaundice has a poor prognosis. However, effective biliary drainage and treatment of HCC such as with TACE or radiotherapy improves survival.

Hepatocellular carcinoma supplied from the short gastric artery: treatment with chemoembolization

We report a case of transcatheter arterial chemoembolization (TACE) to treat hepatocellular carcinoma (HCC) that was supplied by the short gastric artery. A 67-year-old woman with two nodular HCCs underwent repeated TACE. One of the nodules was supplied by the short gastric artery.

Increased porphyrins in primary liver cancer mainly reflect a parallel liver disease

Hepatic porphyries have been associated with an increased risk of primary liver cancer (PLC), which on the other hand may cause an increased porphyrin production. To evaluate the role of an underlying liver disorder we analyzed porphyrins in patients with hepatocellular carcinoma (HCC) (n = 65), cholangiocellular carcinoma (n = 3), or suspected PLC, which turned out to be metastases (n = 18) or a benign disorder (n = 11). None of the patients had a family history of porphyry or clinical signs of porphyry. Increased aminolevulinic acid or porphyrin values were common not only in patients with PLC (43%) but also in metastatic (50%) and benign (64%) liver disorders. The corresponding proportion for HCC patients with liver cirrhosis (55%) was higher (P < .05) than in those without cirrhosis (17%). We conclude that symptomatic porphyries are unusual in PLC, whereas elevated urinary and/or faecal porphyrins are common, primarily reflecting a parallel liver disease and not the PLC.

Hepatocellular carcinoma in the Asia pacific region

Primary liver cancer, particularly hepatocellular carcinoma (HCC) remains a significant disease worldwide. It is among the top three causes of cancer death in the Asia Pacific region because of the high prevalence of its main etiological agents, chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. In this region, the incidence of HCC has been static over recent decades. Older age is a major risk factor; the incidence increasing sharply after age 40 years. There is a male predilection, with male to female ratio of 3:1, except in elderly Japanese with equal sex incidence or female predominance. In most Asia-Pacific countries, chronic HBV infection accounts for 75-80% of cases; Japan, Singapore and Australia/New Zealand are exceptions because of higher prevalence of HCV infection. In spite of advances in surgery, liver transplantation and newer pharmaco/biological therapies, the survival rate has improved only slightly over recent decades, and this could be attributable to earlier diagnosis ('lead-time bias'). The majority of patients present with advanced diseases, hence reducing the chance of curative treatment. The importance of HCC may decrease in two to three decades when the prevalence of chronic HBV infection decreases as a result of the universal HBV vaccination programs implemented in late 1980s in most Asia-Pacific countries, and because of reduced incidence of medical transmission of HCV. However, transmission of HCV by injection drug use, and rising prevalence of obesity and diabetes, both independent risk factors for HCC, may partly offset this decline.

Diabetes: one of few remarkable differences in clinicopathologic features between cirrhotic and noncirrhotic Swedes with hepatocellular carcinoma

The prognosis of hepatocellular carcinoma (HCC) is usually very poor, so increased knowledge of clinicopathologic characteristics and etiologic factors may improve the clinical handling. Because HCC in many patients is unrecognized before death, it is of particular interest to study cases from a period with a high autopsy frequency. The records and liver biopsies from all patients with a diagnosis of primary liver cancer in Göteborg, Sweden, during a 22-year period were scrutinized. Only patients with evaluable non-neoplastic liver tissue were included in the final analysis. The majority (95%) of 478 HCC cases were autopsied and cirrhosis of the liver could be established in 71%. At presentation, general paramalignant symptoms such as malaise, weight loss, anorexia, and hepatomegaly (84%) were common irrespective of cirrhosis. Alcoholism and diabetes mellitus were each significantly more common among cirrhotics (29% and 20%, respectively; P < .001), than among noncirrhotics, in which cholelithiasis was more common (54%; P < .001). The correlation between diabetes and cirrhosis was independent of reported alcoholism. In an unselected population in a low HCC incidence area, there are few differences in clinicopathologic features between cirrhotic and noncirrhotic patients. Diabetes mellitus seems to play an etiologic role in HCC in cirrhotics, and cholelithiasis in noncirrhotics.

Natural history of untreated nonsurgical hepatocellular carcinoma

OBJECTIVE

Hepatocellular carcinoma (HCC) is common in Asia, and the majority are not suitable for curative surgical treatment. We studied the natural history of untreated nonsurgical HCC to examine whether the prognosis has changed with improved supportive treatment and to identify factors affecting survival.

METHODS

One hundred and six ethnic Chinese patients with HCC not amenable to curative treatment were managed symptomatically as control-arm patients in three randomized studies conducted between January 1996 and April 2001. Seventy-six (71.7%) patients were positive for hepatitis B surface antigen (HBsAg). Prognostic variables for survival were identified by univariate analysis and were subjected to a multivariate Cox analysis to identify the independent predictors of survival.

RESULTS

All but four patients were followed until death. Common causes of death were tumor progression (63.2%) and liver failure (31.1%). The overall median survival was 3 months, and the 1-yr survival was 7.8% only. The median survival of patients of Okuda stages I, II, and III were 5.1 months, 2.7 months, and 1.0 month, respectively (p < 0.05 for comparison between any two stages). Multivariate analysis revealed four independent prognostic variables, namely, serum bilirubin, blood urea, serum alpha-fetoprotein, and Okuda stage.

CONCLUSIONS

The prognosis of untreated HCC not suitable for curative treatment in Asia is grave despite improved supportive treatment. The four prognostic variables identified in this study are important in the decision for palliative treatment, and the Okuda staging remains an important prognostic guide.

Fibrolamellar hepatocellular carcinoma in pregnancy

BACKGROUND

Hepatocellular carcinoma (HCC) is rare in pregnancy but can enlarge rapidly under these circumstances.

CASE OUTLINE

A 25-year-old woman was diagnosed with HCC of fibrolamellar type immediately post-partum. One year after liver resection the patient remains well.

DISCUSSION

This is only the second report of fibrolamellar carcinoma occurring in pregnancy. Other types of hepatocellular carcinoma in pregnancy have generally demonstrated a poor outcome, probably secondary to hormonal changes and increased liver vascularity.

Construction of the Chinese University Prognostic Index for hepatocellular carcinoma and comparison with the TNM staging system, the Okuda staging system, and the Cancer of the Liver Italian Program staging system: a study based on 926 patients

BACKGROUND

The current TNM staging system for patients with hepatocellular carcinoma (HCC) does not include liver function parameters and does not provide a precise prognosis for patients in different risk groups. The objectives of this study were to construct a new prognostic index for patients with hepatocellular carcinoma, the Chinese University Prognostic Index (CUPI), and to compare it with existing staging systems in terms of their ability to classify patients into different risk group.

METHODS

From 1996 to 1998, 926 ethnic Chinese patients who were diagnosed with HCC (mainly hepatitis B-associated) at a single institution were recruited prospectively into this study. A multivariate analysis on 19 patient characteristics was performed using a Cox regression model to identify independent prognostic factors. Weights were derived from the regression coefficients of various factors to construct the CUPI. Patients were classified according to different staging systems. Survival curves were plotted with the Kaplan-Meier method and were compared by using a log-rank test.

RESULTS

Both the TNM staging system and the Okuda staging system had prognostic significance, but the significance was lower for the Cancer of the Liver Italian Program (CLIP) prognostic score among the patients in the study population. The CUPI was constructed by adding the following factors into the TNM staging system: total bilirubin, ascites, alkaline phosphatase, alpha fetoprotein, and asymptomatic disease on presentation. The new CUPI characterized three risk groups with highly significant differences in survival during the whole period of follow-up (P < 0.00001) and was more discriminant than the other systems.

CONCLUSIONS

In the study population of patients with mainly hepatitis B-associated HCC, the CUPI was more discriminant than the TNM staging system, the Okuda staging systems, or the CLIP prognostic score in classifying patients into different risk groups and was better at predicting survival. The CUPI needs to be validated by different cohorts of patients before it can be recommended for general use.

Selective internal radiation therapy by yttrium-90 microspheres for hepatocellular carcinoma after renal transplantation

We report a HBsAg-positive patient who developed hepatocellular carcinoma (HCC) 7 years after cadaveric kidney transplantation. The tumor was unresectable because of coexisting cirrhosis. Selective internal radiation (SIR) therapy, a novel therapy with the technique recently perfected, was used. Yttrium-90 microspheres were given via an angiographic catheter under fluoroscopy guidance. Serum alpha-fetal protein (AFP) was normalized within 2 wk. A follow-up abdominal CT scan revealed significant necrosis of the tumor and compensatory hypertrophy of non-diseased liver. The treatment was well tolerated except for transient liver function deterioration. The patient enjoyed 15 months of symptom-free survival before she died of liver failure. Practical aspects and potential applications of SIR therapy in this group of patients are discussed.

Primary liver tumors

Many improvements have been made in the treatment of primary liver tumors, especially in hepatocellular carcinoma. Partial hepatectomy still remains the mainstay of therapy for resectable tumors, and it offers the potential of a cure. Total hepatectomy and liver transplantation may be applicable in selected patients. Palliative resection and tumor debulking operations are beneficial for some malignant tumors. Local ablative therapy can be tried on patients with small tumors who are not suitable candidates for open resectional surgery because of serious associated medical diseases or because of poor liver function. For patients with advanced malignancy, new treatment modalities in the form of hepatic artery transcatheter treatment or systemic therapy are on the horizon. Some of these treatment options show very promising results. Properly conducted randomized studies are required to evaluate these new treatment modalities, as well as those older treatment modalities for which there is insufficient data to determine their actual role in the management of patients with liver cancer.

Intra-tumoural injection of 90Y microspheres into an animal model of hepatoma

BACKGROUND

Intrahepatic arterial injection of 90Y glass microspheres (90Y microspheres) is a useful therapeutic modality for inoperative liver tumour. Recently, a new concept of interstitial radiotherapy in the treatment of hepatic malignancies has been carried out with even more encouraging results. However, information regarding this technique is still very rare. The purpose of this study was to analyse the kinetics and biodistribution of 90Y microspheres in rats with hepatic tumours following intra-tumoural injection.

METHODS

Twenty male Sprague-Dawley rats with hepatoma were killed at 1 h, 24 h, 48 h and 72 h (five rats each time) after intra-tumoural injection of approximately 7.4 MBq of 90Y microspheres. Samples of various organs were obtained and used to calculate the tissue concentrations and radiation doses.

RESULTS

Our data showed that the radioactivity in the tumour was very high throughout this study. The lung was the only organ other than the tumour which showed high radioactivity. The concentrations of radioactivity in other organs, such as normal liver, muscle, spleen, bone, testis, and whole blood were quite low throughout the study.

CONCLUSION

Direct intra-tumoural injection of 90Y microspheres is extremely attractive as a clinical therapeutic alternative in hepatoma patients.

Frequency of hepatitis B virus reactivation in cancer patients undergoing cytotoxic chemotherapy: a prospective study of 626 patients with identification of risk factors

Hepatitis B virus (HBV) reactivation is a well-described complication in cancer patients who receive cytotoxic chemotherapy and may result in varying degrees of liver damage. As chemotherapy is used increasingly in cancer patients, HBV reactivation during cytotoxic treatment may become a more common problem. In lymphoma patients, the incidence of chronic HBV infection has been reported to be 26%, of whom 47% developed HBV reactivation during chemotherapy. However, corresponding data for patients with other malignancies undergoing cytotoxic chemotherapy are not known. In this prospective study, hepatitis B surface antigen (HBsAg) was determined in 626 consecutive cancer patients who received cytotoxic chemotherapy over a 12-month period. Seventy-eight patients (12%) were found to be HBsAg positive. Thirty-four (44%) developed raised alanine transaminase during their course of chemotherapy. In these 34 patients, hepatitis was attributed to HBV reactivation in 15 patients (44%), chronic active HBV infection in 1 patient (3%), hepatitis C infection in 1 patient (3%), malignant hepatic infiltration in 2 patients (6%), and the use of hepatotoxic chemotherapeutic agents in 11 patients (32%). The causes of hepatitis were unknown in 4 patients (12%). HBV reactivation was more likely to develop in patients who were male, younger age, HBeAg seropositive, and those with lymphoma. Presence of malignant hepatic infiltration, baseline pre-treatment alanine transaminase, total bilirubin, and HBV DNA levels did not correlate with the development of HBV reactivation. Of the 15 patients who developed HBV reactivation, antiviral therapy with lamivudine was available and used in 9. There was no HBV-related mortality during chemotherapy. It is concluded that in patients with chronic HBV infection under chemotherapy, HBV reactivation occurs in nearly 20% of them and accounts for 44% of hepatitis cases. The risk factors identified include male sex, younger age, HBeAg seropositive, and the diagnosis of lymphoma. In HBV endemic areas, patients with risk factors for HBV reactivation should be identified prior to receiving cytotoxic treatment and monitored closely. The potential benefit of lamivudine requires further confirmation.

The cost of palliative care for hepatocellular carcinoma in Hong Kong

BACKGROUND

Hepatocellular carcinoma (HCC) is endemic in parts of Asia and Africa and most patients are not suitable for treatment with a curative approach. Little is known about the cost of palliative care for HCC.

OBJECTIVE

To determine: (i) patient-specific costs of palliative care of HCC; and (ii) individual factors that drive patient-specific costs and to develop a model of cost per case under alternative circumstances.

METHODS

204 patients with inoperable HCC were prospectively tracked from first hospitalisation until death for health service utilisation. A societal perspective of cost was taken, including costs of formal and informal services incurred by payers, caregivers and patients. Observational data from a large Hong Kong cancer care programme were used. A regression analysis was performed using formal costs only, with the cost per observed day as the dependent variable.

RESULTS

The median survival was 95 days and the mean observation period was 153 days. The mean value per person for formal healthcare cost was 30 983 Hong Kong dollars [$HK] ($US3872, 1998 values). The distribution of cost values were positively skewed. The regression analysis showed that age, days of observation and survival were negatively related to cost per observed day, and the Child-Pugh grading of severity of liver cirrhosis was positively related to cost per observed day. A sensitivity analysis based on the regression equation indicated that nonsurvivorship doubles the cost per case, increased severity as measured by the Child-Pugh Index adds about 50% to the cost, and chemotherapy increases cost 2-fold.

CONCLUSIONS

The relatively modest average cost per patient with HCC in Hong Kong reflects the short median survival and subsequently the limited use of inpatient care and chemotherapy.

Frequency of hepatitis B virus reactivation in cancer patients undergoing cytotoxic chemotherapy: a prospective study of 626 patients with identification of risk factors

Hepatitis B virus (HBV) reactivation is a well-described complication in cancer patients who receive cytotoxic chemotherapy and may result in varying degrees of liver damage. As chemotherapy is used increasingly in cancer patients, HBV reactivation during cytotoxic treatment may become a more common problem. In lymphoma patients, the incidence of chronic HBV infection has been reported to be 26%, of whom 47% developed HBV reactivation during chemotherapy. However, corresponding data for patients with other malignancies undergoing cytotoxic chemotherapy are not known. In this prospective study, hepatitis B surface antigen (HBsAg) was determined in 626 consecutive cancer patients who received cytotoxic chemotherapy over a 12-month period. Seventy-eight patients (12%) were found to be HBsAg positive. Thirty-four (44%) developed raised alanine transaminase during their course of chemotherapy. In these 34 patients, hepatitis was attributed to HBV reactivation in 15 patients (44%), chronic active HBV infection in 1 patient (3%), hepatitis C infection in 1 patient (3%), malignant hepatic infiltration in 2 patients (6%), and the use of hepatotoxic chemotherapeutic agents in 11 patients (32%). The causes of hepatitis were unknown in 4 patients (12%). HBV reactivation was more likely to develop in patients who were male, younger age, HBeAg seropositive, and those with lymphoma. Presence of malignant hepatic infiltration, baseline pre-treatment alanine transaminase, total bilirubin, and HBV DNA levels did not correlate with the development of HBV reactivation. Of the 15 patients who developed HBV reactivation, antiviral therapy with lamivudine was available and used in 9. There was no HBV-related mortality during chemotherapy. It is concluded that in patients with chronic HBV infection under chemotherapy, HBV reactivation occurs in nearly 20% of them and accounts for 44% of hepatitis cases. The risk factors identified include male sex, younger age, HBeAg seropositive, and the diagnosis of lymphoma. In HBV endemic areas, patients with risk factors for HBV reactivation should be identified prior to receiving cytotoxic treatment and monitored closely. The potential benefit of lamivudine requires further confirmation.

Primary liver tumors

Many improvements have been made in the treatment of primary liver tumors, especially in hepatocellular carcinoma. Partial hepatectomy still remains the mainstay of therapy for resectable tumors, and it offers the potential of a cure. Total hepatectomy and liver transplantation may be applicable in selected patients. Palliative resection and tumor debulking operations are beneficial for some malignant tumors. Local ablative therapy can be tried on patients with small tumors who are not suitable candidates for open resectional surgery because of serious associated medical diseases or because of poor liver function. For patients with advanced malignancy, new treatment modalities in the form of hepatic artery transcatheter treatment or systemic therapy are on the horizon. Some of these treatment options show very promising results. Properly conducted randomized studies are required to evaluate these new treatment modalities, as well as those older treatment modalities for which there is insufficient data to determine their actual role in the management of patients with liver cancer.

Staged hepatectomy after emergency transcatheter arterial embolization for ruptured hepatocellular carcinoma

BACKGROUND

Staged hepatectomy after emergency transcatheter arterial embolization (TAE) has been advocated in ruptured hepatocellular carcinoma (HCC). However, there have been no reports of clinical series of this strategy. The purpose of this study was to evaluate the protocol of this therapeutic strategy.

METHODS

Sixteen patients with suspected rupture of HCC were included in the study. After emergency TAE, tumor resectability was assessed, followed by staged hepatectomy or repeated TAE. The patients were reevaluated with regard to rupture of HCCs.

RESULTS

Primary hemostasis was achieved successfully in all patients. Eleven patients were finally judged to have experienced HCC rupture. Seven of them underwent staged hepatectomy; the other four underwent repeated TAE because their tumors were considered unresectable. Survival time tended to be longer, but not to a significant extent, in patients who underwent hepatectomy (range, 139 to 1527 days; median, 375 days) than in those treated by TAE alone (range, 43 to 1317 days; median, 158 days).

CONCLUSIONS

Staged hepatectomy after TAE is a rational treatment for patients with ruptured HCC. Although TAE is highly effective for initial hemostasis, hepatectomy appears to provide better long-term survival.

Injection sclerotherapy for variceal bleeding in patients with hepatocellular carcinoma: cyanoacrylate versus sodium tetradecyl sulphate

BACKGROUND

Patients with hepatocellular carcinoma complicated by variceal bleeding have a very limited life span. Recurrent bleeding after endoscopic injection sclerotherapy is common. Our aim was to compare the efficacy of endoscopic injection of cyanoacrylate versus sodium tetradecyl sulphate in the control of variceal bleeding in patients with hepatocellular carcinoma.

METHODS

Patients known to be suffering from inoperable hepatocellular carcinoma who presented with upper gastrointestinal bleeding underwent endoscopy within 24 hours of admission. After bleeding from esophageal varices was confirmed, they were randomized to receive endoscopic injections of either cyanoacrylate (1:1 mixture with Lipoidol) or sodium tetradecyl sulphate (1.5%). Injection were given intravariceally into each visible column for up to four injections for cyanoacrylate and up to 30 mL for sodium tetradecyl sulphate.

RESULTS

A total of 50 patients were recruited for this study with 25 cases randomized to each endoscopic treatment group. Control of acute bleeding failed in four patients (16%) in both treatment groups, and two patients in each group died during the index episode of bleeding. Six patients (24%) in the cyanoacrylate group and four patients (16%) in the sodium tetradecyl sulphate group developed recurrent bleeding during their hospital stay (p = 0.48). Recurrent bleeding within 30 days after the index episode of bleeding was documented in seven patients (28%) who received cyanoacrylate injection and five patients (20%) who received sodium tetradecyl sulphate injection (p = 0.51). Median survival in the cyanoacrylate group was 16 days (range 1 to 485 days) and that of the sodium tetradecyl sulphate group was 13 days (range 1 to 407 days). There was no difference in cumulative survival between the two groups as analyzed by the Kaplan-Meier method. Patients with portal vein thrombosis had a higher risk of recurrent hemorrhage. Patients with Child's C liver disease had a significantly higher mortality.

CONCLUSIONS

Cyanoacrylate did not improve the outcome of hepatocellular carcinoma patients with variceal hemorrhage.

Selective internal radiation therapy for nonresectable hepatocellular carcinoma with intraarterial infusion of 90yttrium microspheres

PURPOSE

To evaluate the efficacy of intraarterial 90yttrium (90Y) microspheres in nonresectable hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

Patients with nonresectable HCC, but without extrahepatic disease, who also had lung shunting < 15% and tumor-to-normal ratio > or =2, as determined by simulation using (99m)technetium macroaggregated albumin, were entered into the study. The radiation dose delivered to the lungs, tumor, and normal liver was estimated by a partition model. 90Y microspheres were infused into the hepatic artery at the time of hepatic angiography or through an implanted arterial portacatheter under fluoroscopy. Repeated treatments were given for residual or recurrent tumor. Response to treatment was monitored by serum alpha-fetoprotein or ferritin levels, together with serial computed tomography.

RESULTS

Seventy-one patients, including 20 patients with postoperative recurrence, were initially treated with an activity of 0.8 to 5.0 Giga-Becquerel (GBq) (21.6-135.1 mCi) (median 3.0 GBq or 81.1 mCi) of 90Y microspheres. There was a 50% reduction in tumor volume in 19 (26.7%) patients after the first treatment. However, the overall objective response in terms of changes in alpha-fetoprotein levels was 89% [partial response (PR) 67%, complete response (CR) 22%] among the 46 patients with raised pretreatment levels. The serum ferritin level in the other 25 patients dropped by 34 to 99% after treatment. Treatment was repeated in 15 patients. The maximum number of treatments was 5 and the maximum total activity was 13.0 GBq (351.4 mCi), given in 3 treatments. The estimated radiation doses to the nontumorous liver ranged from 25 to 136 Gy (median 52 Gy) in the first treatment and the highest total radiation dose was estimated to be 324 Gy. For the tumors, the estimated radiation doses ranged from 83 to 748 Gy (median 225 Gy) in the initial treatment and the highest cumulative dose reached was 1580 Gy. The residual tumors were resected in 4 patients. Two of these had complete histological remission, but only occasional viable tumor cells were found in the necrotic centers of the tumors resected from the other 2 patients. The median survival of the 71 patients was 9.4 months (range 1.8 to 46.4 months). Treatment was well tolerated and there was no bone-marrow toxicity, or clinical evidence of radiation hepatitis or pneumonitis.

CONCLUSIONS

Selective internal radiation therapy using 90Y microspheres is effective for selected cases of nonresectable HCC and is well tolerated. The objective response rate in terms of drop in tumor marker levels is higher than that based on reduction in tumor volume shown by computed tomography. The nontumorous liver appears more tolerant to internal radiation than external beam radiation. Selective internal radiation treatment may convert nonresectable tumors to resectable ones.

Gastrointestinal bleeding in cirrhotic patients with hepatocellular carcinoma undergoing intrahepatic artery chemotherapy

BACKGROUND

Hepatocellular carcinoma in cirrhotic patients increases the risk of variceal bleeding. We sought to characterize bleeding in a cirrhotic patient population undergoing intrahepatic artery chemotherapy for hepatocellular carcinoma and to determine the possible influence of this treatment on gastrointestinal bleeding.

METHODS

We retrospectively reviewed 179 patients with hepatocellular carcinoma who underwent intrahepatic artery doxorubicin and cis-platinum chemotherapy to determine the incidence of gastrointestinal bleeding and compared them with 434 hepatocellular carcinoma historic controls not undergoing regional chemotherapy.

RESULTS

Of the 179 patients, 27 patients (15.1%) developed upper gastrointestinal bleeding over a mean follow-up of 15.2 months; 18 of the 27 (66.7%) bled from a variceal source and 9 (33.3%) bled from a nonvariceal source: ulcer (n = 6), gastropathy (n = 1), Mallory-Weiss (n = 1), erosive gastritis (n = 1). Twenty-one patients developed bleeding after initiation of chemotherapy (14 variceal and 7 nonvariceal). The number of chemotherapy sessions among patients with variceal and nonvariceal bleeding was similar (2.1 +/- 0.4 and 4.0 +/- 1.2; p = Not significant). Patients with variceal and nonvariceal bleeding were comparable with respect to Child-Pugh classification, pTNM stage, age, time to bleeding, and gender.

CONCLUSIONS

Regional intra-arterial chemotherapy for hepatocellular carcinoma is associated with a low risk of variceal bleeding. Nonvariceal sources of upper gastrointestinal bleeding in this population account for a significant component of bleeding episodes.

MRI and CT of metastatic hepatocellular carcinoma causing spinal cord compression

We report the imaging features in five patients with metastatic hepatocellular carcinoma causing spinal cord compression, three of which were biopsy proven and two were in patients with known diagnosis of hepatocellular carcinoma. The radiographic, magnetic resonance imaging (MRI) and computed tomography (CT) features are highlighted. Although the occurrence of metastatic disease in hepatocellular carcinoma is exceedingly rare, it may be increasingly encountered as survival of patients is improved with advancing methods of therapy, both surgical and palliative. It often accompanies local recurrence, and invariably signals a grave prognosis with extremely short life expectancy. Unusually, two of the five patients in this series presented initially with skeletal metastases which led to the diagnosis of hepatocellular carcinoma.

A logical approach to hepatocellular carcinoma presenting with jaundice

OBJECTIVE

This prospective cohort study on patients with hepatocellular carcinoma (HCC) presenting with jaundice emphasized the importance of differentiating patients with hepatic insufficiency from patients with obstructive jaundice caused by tumor.

SUMMARY BACKGROUND DATA

There are little data in the medical literature on the management of patients with HCC presenting with jaundice. Experience has accumulated mainly from case reports and retrospective studies.

METHODS

Data were collected prospectively on 2095 patients with HCC seen over a 12-year period. All patients were investigated with blood tests, abdominal ultrasound, and chest radiography. Endoscopic retrograde cholangiopancreatography-percutaneous transhepatic cholangiography, computed tomography and hepatic angiography were carried out in selected patients.

RESULTS

Of the 530 patients who had clinically detectable jaundice, 481 had jaundice due to hepatic insufficiency and 49 patients had obstructive jaundice. Patients with hepatic insufficiency had extremely poor prognosis, and 90% of them died within 10 weeks of first presentation. "Curative" resection, however, was possible in 9 of 49 patients with obstructive jaundice, and histologic analysis showed resectional margin involvement by tumor in 1 patient. In addition, 35 patients were treated with biliary stents to relieve the obstructive jaundice. Supportive treatment only was given to five patients who were considered too terminally ill. The overall survival of patients with HCC with obstructive jaundice was similar to those patients who presented with no clinical detectable jaundice and was much better than those with jaundice due to hepatic insufficiency (log-rank test, p < 0.001).

CONCLUSIONS

The prognosis of patients with HCC who presented with jaundice due to hepatic insufficiency was dismal. It is important to identify the patients who had obstructive jaundice because with proper treatment, good palliation and occasional cure are possible.

Surgery for biliary obstruction by tumour thrombus in primary liver cancer

Five patients with primary liver cancer presented with obstructive jaundice due to extension of tumour thrombus into the biliary ducts. Three patients had hepatocellular carcinoma, two of whom had alcoholic cirrhosis, and the other two had a peripheral cholangiocarcinoma. Preoperative diagnosis of biliary thrombus was best achieved by ultrasonography and computed tomography which showed peripheral hepatic tumour with dilated bile ducts containing dense material. All patients underwent liver resection associated with biliary exploration, clearance and T-tube drainage. Major hepatectomy was required in four cases. There were no postoperative deaths; one patient developed a subphrenic collection of bile which was drained percutaneously. All patients survived more than a year; median survival was 29 months. There are two long-term survivors without recurrence at 29 and 80 months. Patients with primary liver cancer and jaundice due to migrated tumour fragments in the common bile duct may benefit from surgical resection which can result in long-term resolution of symptoms and occasional cure.

Isoelectric focusing of alphafetoprotein in patients with hepatocellular carcinoma--frequency of specific banding patterns at non-diagnostic serum levels

Serum levels of alphafetoprotein are raised in 60-80% of patients with hepatocellular carcinoma. Although widely used as a serum marker, frequent false-positive results in patients with benign liver disease, result in poor specificity. This occurs particularly when levels of alphafetoprotein fall between 50-500 ng ml-1, the so-called 'grey area'. Recent reports suggest that isoelectric focusing of alphafetoprotein demonstrates certain bands that are more specific for hepatocellular carcinoma. Our aim was to determine whether the apparent specificity of this new approach is gained at the expense of decreased sensitivity. Sera from 110 patients with a 'non-diagnostic' serum alphafetoprotein level (50-500 ng ml-1) were examined by isoelectric focusing and quantified by densitometric scanning. Ten patients with chronic liver disease and a raised serum alphafetoprotein level (50-500 ng ml-1), but with no evidence of hepatocellular carcinoma, were also studied. Isoelectric focusing revealed characteristic hepatocellular carcinoma bands (bands +II and +III) in 96% patients overall, and 100% of those with levels of total alphafetoprotein greater than 100 ng ml-1. No such bands were seen among ten subjects with cirrhosis but without hepatocellular carcinoma. Bands that are characteristic of hepatocellular carcinoma (bands +II or +III) are seen in the great majority of hepatocellular carcinoma patients; their absence makes a diagnosis of hepatocellular carcinoma extremely unlikely.

A prospective study of upper gastrointestinal hemorrhage in patients with hepatocellular carcinoma

Our purpose was to determine, in a prospective study, the causes of gastrointestinal hemorrhage in patients with hepatocellular carcinoma, and the relationship of portal vein invasion with variceal hemorrhage in these patients. During an 11-month period, 55 patients presented with hepatocellular carcinoma presented with signs and/or symptoms of upper gastrointestinal hemorrhage. Forty-seven percent had bleeding from varices, whereas the majority, 53%, had a nonvariceal bleeding source. Among those with nonvariceal bleeding, duodenal ulceration was the commonest cause. Direct tumor invasion into the gastrointestinal tract was found in three patients. Tumor invasion of the portal venous system was detected by ultrasound examination in 76% of the variceal bleeders, compared to only 45% of the nonvariceal bleeders. Despite the very high frequency of cirrhosis among patients with hepatocellular carcinoma, the source of bleeding was variceal in less than half of the patients. Portal vein invasion is a risk factor for subsequent variceal bleed.

Obstructive jaundice secondary to hepatocellular carcinoma

This prospective study aimed to identify different groups of patients with the rare pathology of biliary obstruction caused by hepatocellular carcinoma (HCC). Patients were evaluated with blood tests, chest radiography, ultrasound of the liver and endoscopic retrograde cholangiopancreatography/percutaneous transhepatic cholangiography. Patients who were potentially operable were further assessed with selective hepatic angiography and computed tomography (CT). Of the 38 patients with obstructive jaundice secondary to HCC, the levels of obstruction were extrahepatic in 19 patients and intrahepatic in 19 patients. The clinical presentations and blood biochemistry were similar in these two groups of patients. "Curative' resection was significantly more common in extrahepatic obstruction (8/19) than in intrahepatic obstruction (0/19) (chi 2 with Yates correction P = 0.001). All non-resectable tumours, except in four patients with terminally ill disease, were palliated with stents. Survival in patients who had "curative' liver resection was significantly better than in those who had no resection (median survival 25.3 vs. 2.1 months, log-rank test P = 0.004). Patients with extrahepatic biliary obstruction secondary to HCC had a better chance of being treated by liver resection, which resulted in a significantly improved survival rate compared to patients with intrahepatic obstruction.

Aggressive primary hepatic lymphoma in Chinese patients. Presentation, pathologic features, and outcome

BACKGROUND

Primary non-Hodgkin's lymphoma of the liver is rare. In this study, the presentation, pathologic features, and outcome of seven Chinese patients with primary hepatic lymphoma are described.

METHODS

From 1984 to 1994, the clinical records of 14 Chinese patients with non-Hodgkin's lymphoma and histologically proven liver involvement were reviewed. Seven (four males, three females; median age, 54 years) were considered to have primary hepatic lymphoma. Histologic and immunohistochemical studies were performed on paraffin embedded liver tissue.

RESULTS

"B" symptoms including fever (86%) and weight loss (57%) were the most striking presenting features. Hepatomegaly was present in all patients, splenomegaly in three (43%), and thrombocytopenia in six (86%). Only one patient was hepatitis B surface antigen-seropositive. None had preexisting liver disease. Histologic subtypes, though heterogeneous, were mostly unfavorable and consisted of diffuse large cell lymphoma (two patients), small lymphocytic lymphoma (one patient), lymphoblastic lymphoma (one case), mantle cell lymphoma (one patient), anaplastic large cell Ki-1 lymphoma (one patient), and hepatosplenic T-cell lymphoma (one patient). Three patients expressed B-cell and 2 expressed T-cell phenotypes. Six patients received cytotoxic chemotherapy. One had resection and one had splenectomy, but none achieved complete remission, and only one remained alive as of this writing. The median survival was 3.7 months (range, 8 days to 47.7 months).

CONCLUSION

Chinese patients with primary non-Hodgkin's lymphoma of the liver have prominent "B" symptoms, disease with a highly aggressive course, a poor response to local and systemic treatment, and short survival. Hepatitis B virus infection is not a major etiologic factor for these patients.

Molecular genetics of major histocompatibility complex class II genes in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common malignant tumor of the liver with a possible genetic predisposition. We have studied the HLA-DQ and -DR regions of 57 unrelated HCC patients of southern Chinese origin using molecular DNA techniques and compared them with 104 normal controls. Seventy-six hepatitis B carriers (HBsAg) were also studied. Restriction fragment length polymorphism (RFLP) was used to genotype the MHC class II DR beta, DQ alpha and DQ beta loci of the subjects. Polymerase chain reaction (PCR) using sequence primer for DQ beta genes was also performed. No significant difference was found in the HLA-DQ and -DR loci between HCC patients and normal controls, HCC patients and HBsAg carriers, or HBsAg carriers and normal controls respectively. Forty-one HCC patients were HBsAg positive, and no difference was found in the HLA-DQ and -DR genotype between this group of patients compared with the group of normal controls or HBsAg carriers. Thirty-six HCC patients had elevated alpha-fetoprotein levels, and 15 HCC patients had normal levels. No difference in the HLA-DQ and -DR loci was detected between these two groups and the controls. The results suggest that HLA-DQ and -DR genotypes are not associated with hepatocellular carcinoma in southern Chinese.

Hepatocellular carcinoma during pregnancy and its comparison with other pregnancy-associated malignancies

BACKGROUND

Cancer in pregnancy is rare and hepatocellular carcinoma (HCC) in pregnancy even rarer. The impact of pregnancy on the prognosis of patients with different types of cancer remains controversial. Reported cases of HCC in pregnancy are largely isolated and highly scattered. Thus, the effect of pregnancy on the prognosis of patients with HCC and the risk factors of developing HCC in pregnancy are not well documented.

METHODS

A series of five patients with HCC in pregnancy seen at two different centers is reported. A Medlar search for articles between 1957 and 1993 with the key words "Hepatocellular Carcinoma" and "Pregnancy" was conducted. All reported cases were combined and analyzed in terms of race, age, parity, hepatitis B surface antigen status, cirrhosis, serum alpha-fetoprotein (AFP) levels at presentation, history of taking oral contraceptive pills and fetal and maternal outcome. The impact of pregnancy on 12 other malignancies as reported in the medical literature also was reviewed.

RESULTS

To the authors' knowledge, The five cases reported here constitute the largest series of HCC in pregnancy. A literature search revealed 23 additional cases. Analysis of the 28 cases suggests that the rarity of HCC in pregnancy results from a combination of three factors: the male predominance of HCC, the late age at which the tumor usually presents in women, and decreased fertility in women with advanced cirrhosis (hepatitis is a predisposing factor for HCC development). Long term use of oral contraceptives and high parity enhance the risk. Elevated AFP level is useful for diagnosis. The median survival is shorter than for patients who are not pregnant. There is no significant difference in survival between pregnant and not pregnant women matched by tumor stage, age, and other clinical parameters in most malignancies except in some tumors like lymphoma, thyroid cancer, and nasopharyngeal carcinoma.

CONCLUSION

Pregnancy has an adverse effect on the prognosis of patients with HCC, lymphoma, thyroid cancer, and nasopharyngeal carcinoma but not of most other malignancies. Measurement of AFP level is recommended for screening HCC in pregnant women at high risk.

Resection of hepatocellular carcinoma with diaphragmatic invasion

Fourteen consecutive patients with hepatocellular carcinoma (HCC) and diaphragmatic invasion found during operation and confirmed histopathologically were studied. They were treated by resection of the liver tumour en bloc with part of the diaphragm. Eight of the 14 patients had a diaphragmatic hump on chest radiography. Preoperative ultrasonography, computed tomography and hepatic angiography were unable to diagnose diaphragmatic invasion in these patients. A control group of 14 closely matched patients were selected from 98 undergoing curative resection for HCC during the period of the study. No evidence of a diaphragmatic hump was found in the control patients (P < 0.001). There was no significant difference in survival, operative morbidity or mortality rates between the two groups. In patients with HCC situated in the dome of the liver, the presence of a diaphragmatic hump on chest radiography strongly suggests invasion of the diaphragm. There was no difference in outcome in patients with or without diaphragmatic invasion; the tumour should be resected if the patient is fit for operation.

Treatment of inoperable hepatocellular carcinoma with intrahepatic arterial yttrium-90 microspheres: a phase I and II study

Eighteen patients with inoperable hepatocellular carcinoma (HCC) were treated with intrahepatic arterial yttrium-90 microspheres. All these patients showed a lung shunting below 15% and a tumour-to-normal ratio higher than 2 as determined by diagnostic technetium-99m macroaggregated albumin (Tc-MAA) gamma scintigraphy. The treatment was given through an arterial port placed during laparotomy. The radiation doses to the liver and tumour were determined intraoperatively with a beta probe and liquid scintillation counting of multiple liver biopsies. The treatment was well tolerated without major complications. In all patients the tumour marker fell to a level which ranged from 41% to 0.2% of the pretreatment level. Tumour regression was found to be dose related. Progressive or static disease occurred in a higher proportion of patients whose tumours received < 120 Gy (P = 0.005). Survival was better in those whose tumours received > 120 Gy (median survival = 55.9 weeks) than those whose tumours received lower doses (median survival = 26.2 weeks). This difference is statistically significant with P = 0.005. We conclude that yttrium-90 microsphere therapy is safe and that tumour response is dose related. A tumour dose of > 120 Gy is recommended.

Cytoreductive surgery for hepatocellular carcinoma

A prospective study was conducted on 26 patients for cytoreductive surgery of inoperable hepatocellular carcinoma. These patients underwent cytoreduction with liver resection, cryosurgery, microwave tissue coagulation and/or absolute alcohol injection. In-hospital mortality was 7.7%. The symptomatic relief and quality of survival were excellent. The median survival of patients after cytoreduction was 10.0 months and the survival was much better than those of 26 patients matched by sex, age, tumour size, Child-Pugh grading and Karnofsky scores who received systemic chemotherapy during the same period of the study (log rank test, P = 0.0001). There was no statistical difference between the survival curves of those patients who received (19 patients) and those who did not receive (7 patients) additional treatment by chemotherapy or selective internal radiation therapy after cytoreduction. This suggests that the gained survival benefit could have been derived mainly from the cytoreductive surgery rather than the additional treatments.

Hepatitis B virus DNA in peripheral blood leukocytes. A comparison between hepatocellular carcinoma and other hepatitis B virus-related chronic liver diseases

BACKGROUND

Hepatitis B virus (HBV) DNA has been detected in the peripheral blood leukocytes (PBL) during acute and chronic HBV infection. Possible pathobiologic significance includes infectivity and altered immunity. There are few data relating PBL HBV-DNA with severity of the liver disease, in particular with hepatocellular carcinoma (HCC).

METHODS

HBV-DNA was detected by dot-spot hybridization technique in PBL separated from venous blood samples of 209 hepatitis B surface antigen-positive patients (28 healthy carriers and 95 chronic hepatitis, 29 cirrhotic, and 57 HCC patients). Serum HBV-DNA and hepatitis B e-antigen (HBeAg) were also measured.

RESULTS

Thirty percent of HCC patients were hepatitis e-antigen-positive compared to 50%, 84% (P < 0.0001), and 69% (P < 0.00001) of healthy carriers and chronic hepatitis and cirrhotic patients, respectively. Furthermore, only 11% of HCC patients had detectable serum HBV-DNA compared to 39% (P < 0.001), 58% (P < 0.001), and 31% (P < 0.05) of these respective patient groups. despite low viral replication among HCC patients, 58% had PBL HBV-DNA. Corresponding figures for healthy carriers and for chronic hepatitis and cirrhotic patients were 39%, 58%, and 56%. Fifty-two percent of HCC patients had positive PBL HBV-DNA in the absence of serum HBV-DNA, compared with 25% in healthy carriers (P < 0.05) and 22% in chronic hepatitis (P < 0.001) and 35% in cirrhotic patients (P = NS).

CONCLUSION

The high detection rate of PBL HBV-DNA among HCC patients may reflect certain pathogenetic processes of HBV infection and indicate a higher risk of development of HCC.

The role of hepatic arterial embolization in the management of ruptured hepatocellular carcinoma

Fifteen patients with ruptured hepatocellular carcinomas and intraperitoneal bleeding were considered for hepatic arterial embolization. Embolization was attempted in nine patients (60%) with patent or partially patent portal veins. Successful occlusion of the feeding tumour vessels was achieved in eight patients (53%) with six patients (40%) surviving more than 3 months compared to three survivors in the non-embolized group, all of whom had total occluded portal veins. Prognosis depends on the underlying liver function with total serum bilirubin levels of survivors significantly lower than those patients who died (P < 0.01). Embolization was tolerated well in those patients with partial portal vein occlusion. Selective tumour embolization should be the initial treatment of choice in these severely ill patients who have reasonable hepatic function.

Hepatic intra-arterial lipiodol ultrasound guided biopsy in the management of hepatocellular carcinoma

One hundred and fifty-one consecutive new patients with suspected hepatocellular carcinoma (HCC) were investigated from 1989 to 1990. Ultrasound showed the tumours to be inoperable in 111 patients. Selective hepatic angiography revealed 17 more patients with inoperable HCC. Hepatic intra-arterial lipiodol (HIAL) was injected in the remaining 23 patients. In 16 of them, a clinical decision could be reached basing on the radiological findings. Hepatic intra-arterial lipiodol ultrasound (HIAL/USG) guided biopsy was done in seven patients with suspicious lesions. Histology obtained with this method revealed hyperplastic cirrhotic nodules in four patients (two with suspected HCC and two with suspected secondaries). In another two patients, the suspected lesions were confirmed to be malignant. In the last patient who had received chemotherapy for extensive HCC, HIAL/USG guided biopsy revealed necrotic tissue only. At laparotomy, diffuse infiltrative abnormality was found and repeated biopsy confirmed residual malignancy in the necrotic tumour. We conclude that when there is radiological uncertainty as to the nature and extent of the HCC, HIAL/USG guided biopsy can help the clinician to make important decisions.

Microwave tissue coagulator in liver resection for cirrhotic patients

The use of the microwave tissue coagulator was studied on 20 consecutive elective hepatic resections carried out for symptomatic hepatocellular carcinoma with liver cirrhosis. The mean operative blood loss (excluding one patient with hepatic vein injury) was 1132 mL. Five patients required no blood transfusion. The average time taken to coagulate the anticipated liver transection plane was less than 15 min. Apart from the complications similar to those occurring in hepatic resections for cirrhotic patients, higher incidences of intra-abdominal sepsis (20%), sympathetic pleural effusion in the absence of chest or intra-abdominal sepsis (20%), and persistent fever lasting more than 1 week (40%) were encountered. It was considered that these complications were related to the coagulated tissue present in the liver remnants (mean depth of tissue coagulation = 3.8 mm) and concluded that although the hospital mortality rate of 10% and the mean operative blood loss of 1132 mL were acceptably low, microwave liver surgery carried a high morbidity rate which is a drawback in major hepatic resectional surgery.

Does hepatitis C virus infection contribute to hepatocellular carcinoma in Hong Kong?

BACKGROUND

Hong Kong has a high incidence of hepatocellular carcinoma (HCC) and, because it is an endemic area for hepatitis B virus (HBV) infection, the etiologic association between HCC and HBV infection is reported to be as high as 80%. Hepatitis C virus (HCV) recently was shown to be a possible pathogenetic agent for HCC in a number of countries.

METHODS

To assess the relative importance of these two viruses in HCC in Hong Kong, a retrospective study of 424 Chinese patients with HCC was performed.

RESULTS

Three hundred forty-one (80.3%) patients were found to be carriers of hepatitis B surface antigen (HBsAg). Hepatitis C antibodies (anti-HCV) were detected in 31 patients (7.3%). Fifteen patients with positive findings for anti-HCV had concurrent HBV infection, 11 had serologic evidence of previous HBV infection, and only 5 patients had anti-HCV marker alone. Patients with positive findings for anti-HCV were older than those with HBsAg (mean ages, 60 and 53 years, respectively). A higher preponderance of male patients was found in the HBsAg-positive group; the male to female ratio was 11:1, compared with 7:1 among patients with anti-HCV. Anti-HCV was detected in 0.64% of 175 age-matched and sex-matched controls.

CONCLUSIONS

These data indicate a possible causal role of HCV infection in HCC, but it is of relatively minor epidemiologic significance in Hong Kong, where HBV infection is overwhelming.

Treatment of inoperable hepatocellular carcinoma by intra-arterial lipiodol and 4'-epidoxorubicin

A total of 30 patients presenting with inoperable hepatocellular carcinoma (HCC) were treated with intrahepatic arterial Lipiodol (5 ml) and 4'-epidoxorubicin (90 mg/m2) once every 4 weeks. The treatment results included no complete response, 2 partial responses, 6 cases of static disease and 19 cases of progressive disease. The median survival was 18.9 weeks. All patients had died by the time of this writing, with survival duration ranging from 4.1 to 87.3 weeks. Toxicities were minimal and included anaemia and alopecia. As compared with a historic control group that had received the same dose of intravenous 4'-epidoxorubicin, the treatment group showed similar response rates but developed fewer toxicities. There was no significant survival benefit over the control group. We concluded that although this form of treatment had comparable activity and produced fewer side effects, it provided no survival benefit over intravenous treatment. The slight prolongation of survival achieved in the treatment group as compared with the control arm might have been due to case selection.

Nephrogenous cyclic AMP in primary hepatocellular carcinoma patients with or without hypercalcaemia

OBJECTIVE

To study the relationship between the excretion of nephrogenous cyclic AMP (NcAMP) and other blood and urine parameters as an index of PTH-like activity in patients with primary hepatocellular carcinoma.

DESIGN

After overnight fast, a double voided urine and a blood sample were collected from each subject for determination of various analytes and results compared between various groups.

PATIENTS

Fifty-five consecutive untreated patients with primary hepatocellular carcinoma, 14 healthy controls and eight patients with cirrhosis only.

MEASUREMENTS

Serum calcium, phosphate, alkaline phosphatase, albumin, creatinine and urinary calcium, creatinine and hydroxyproline were measured by routine methods. cAMP was measured in plasma and urine by a radioimmunoassay (Diagnostic Products Corporation) and PTH measured in serum by an immunoradiometric assay (Nichols Institute). TmP/GFR, NcAMP etc. were calculated according to various published methods.

RESULTS

Four out of 55 patients (7%) with primary hepatocellular carcinoma had hypercalcaemia. These four patients had significantly lower (P less than 0.05) phosphate, PTH and TmP/GFR and elevated NcAMP (P less than 0.001) compared with normocalcaemic hepatocellular carcinoma and cirrhotic patients, and healthy controls. The excretion of hydroxyproline and calcium was significantly elevated (P less than 0.001) in the hypercalcaemic patients. Bone resorption was found to be the major cause of hypercalcaemia in three of the four hypercalcaemic patients. Fifteen hepatocellular carcinoma patients (29%) with normocalcaemia had suppressed PTH.

CONCLUSION

We conclude that a PTH-like humoral factor such as PTH related peptide is the cause of hypercalcaemia in patients with primary hepatocellular carcinoma, and that in some normocalcaemic patients with this tumour PTH is suppressed.

Management of bleeding liver tumours in Hong Kong

A retrospective study was undertaken of 41 patients diagnosed as having suffered spontaneous liver rupture over a 4-year period to identify the clinical features, treatment and outcome of this complication in an area in which hepatocellular carcinoma is endemic. Two patients were excluded with a revised diagnosis of haemorrhagic malignant ascites. Of the remaining 39 patients, 37 bled from ruptured hepatocellular carcinoma, one from peliosis hepatis and multiple liver cell adenomas, and one from a malignant hepatic epithelioid haemangioendothelioma. Analysis showed that 59 per cent of patients were in shock on admission and that all but two of the 37 patients with ruptured hepatocellular carcinoma were men with cirrhosis. The association with cirrhosis was significantly higher than in a series of 45 patients with hepatocellular carcinoma undergoing elective resection during the same period (P less than 0.05). Treatment consisted of supportive care only in two patients, angiographic embolization in four, emergency liver resection in 11 of whom six died, hepatic artery ligation in 12 of whom eight died, and suture and/or packing in eight of whom six died. One patient died at laparotomy and in another patient bleeding was successfully arrested by intratumoural injection of absolute alcohol. Because of the high operative mortality of emergency surgery in these poor risk patients, prospective evaluation of emergency angiographic embolization is required.