Abstract
Summary
This report is an analysis of 231 patients with hepatocellular carcinoma (HCC) from a tertiary care hospital in India. Most of the HCCs were diagnosed in cirrhotics and at an advanced stage which limited the therapeutic options. Physician awareness of this complication of cirrhosis and regular ultrasound screening of cirrhotic patients will help in detection of early stage cancers and, thus, enhance the survival rates.
Introduction
Hepatocellular carcinoma (HCC) is one of the most common malignancies encountered in hepatology units. In Asia and Africa most of the cases are due to chronic hepatitis B. 1 As the majority of HCC cases occur in those with a background of cirrhosis, they can be easily recognized with regular surveillance with ultrasonography (USG), which has been shown to reduce tumour related mortality. 2 HCC is unique in that, in addition to the tumour stage, the status of the underlying liver disease also influences the treatment options.
Methods
Patients with HCC who had been referred to the Department of Gastroenterology and Hepatology at our hospital from December 2005 to December 2010 were reviewed retrospectively. The study was approved by the institutional ethics committee. HCC was diagnosed according to the American Association for the Study of Liver Disease (AASLD) guidelines. 3 Clinical, aetiological, radiological, histological details and the treatment received were analysed.
The diagnosis of underlying chronic liver disease was based on clinical, radiological and/or pathological findings. The aetiology was considered as ‘unknown’ if the aetiological work up was negative for any known aetiological factor such as: hepatitis B virus (HBV); hepatitis C virus (HCV); alcohol; serum ceruloplasmin ferritin; or autoantibodies. Tumour lymph node metastasis (TNM) staging was done based on the available clinical and radiological data.
Results
Three hundred and thirty-one patients were diagnosed with HCC during the study period. One hundred cases were excluded due to insufficient data; 231 (201 men, 30 women) were studied. The mean age at diagnosis was 54.4 ± 12.8 years. Three patients were younger than 20 years old. The aetiological profile of the patients is shown in Table 1. Thirty-three patients were diagnosed with HCC with no underlying liver disease and four with chronic hepatitis B developed HCC without cirrhosis. HBV related cirrhosis, was the most common cause (42%) followed by cryptogenic cirrhosis (19%). HBV DNA reports were available for 53 HBV related HCC patients and 71.7% had DNA < 105 IU/mL. Most presented late with one or more features of hepatic decompensation. A rare presentation included axillary vein thrombosis. Twenty-eight patients were diagnosed incidentally during routine investigations. Serum alpha-feto protein (AFP) was more than 200 μg in only 53.2% of the patients. Vascular invasion (portal vein thrombosis) was seen in 48.4% and distant metastasis in 40%. Tumour size of more than 5 cm was seen in 35% and multifocal lesions in 40%. Cytohistological diagnosis was obtained in only 64 patients. HCC was diagnosed radiologically, either by triple phase computed tomography [CT (n = 107)] or a magnetic resonance imaging (MRI) scan (n = 68). Fifty-five patients were diagnosed on the basis of ultrasonography, all of whom had pathology consistent with HCC. Based on the radiological investigations TNM staging (n = 221) was as shown in Figure 1.
Etiology of HCC and underlying liver disease
NCIPH, Non cirrhotic intrahepatic portal hypertension; NAFLD, Non alcoholic fatty liver disease
Tumour lymph node metastasis (TNM) stage of hepatocellular carcinoma patients (n = 211)
Only 40 of the 231 patients could be offered curative therapy such as: surgical resection (20), alone or in combination with radio frequency ablation (RFA; 3); transarterial chemoembolization (TACE; 2). RFA alone was performed in 14 cases and six patients underwent a liver transplantation.
Discussion
Our large series represents patients with HCC, mainly from the southern and eastern parts of India, from 2005–2010 – almost 15 years later than the two large series previously reported from northern India.4,5 In spite of the advances in diagnostic methods in the interim period, the majority of patients presented in an advanced stage limiting the therapeutic options. The most common aetiology for HCC was HBV chronic liver disease (CLD) which is in accordance with the other Indian studies.4–6 In 19% of the patients the cause of underlying liver disease was unknown at the time of a diagnosis of HCC. Underlying cirrhosis was present in 82% in this series. Other Indian studies have shown a presence of cirrhosis in 60%–97% of HCC patients.5,6 The mean age of patients with HBV related HCC was lower than for other aetiologies. Ninety per cent of those with HBV/HCC were younger than 60 years old.
The majority of our patients presented in advanced stage as evidenced by the child's turcotte pugh's (CTP) class and the TNM stage. Therapeutic options were limited and most patients were offered only palliative treatment.
Almost a third of those with cirrhosis will develop HCC during their lifetime. 7 Both the AASLD and the European Association for the Study of the Liver (EASL) recommend 6-monthly USG screening for HCC in patients with cirrhosis. 3,8 In addition to viral hepatitis and alcoholic cirrhosis, our study shows that patients with cryptogenic (? NAFLD) CLD also need to be on a regular USG surveillance programme for HCC.
Conclusion
Awareness of this condition and regular screening for HCC in CLD patients, including cryptogenic cases, will enable earlier detection and planning of curative therapy. Screening for HBV infection and universal vaccination would be very effective primary preventive strategy as HBV is the most common cause of HCC in India.
Footnotes
None