Vol. 25, No. 1 Printed in Japan

Gastroenterologia Japonica Copyright 9 1990 by The Japanese Society of Gastroenterology

- Original Article --

Clinicopathological studies and operative results of hepatocellular carcinoma with liver cirrhosis, comparing HB-associated cirrhosis to alcoholic and post-transfusion cirrhosis Takazumi IMAI, Viccente M. CARRILLO, Hajime YOKOI, Takashi NOGUCHI, Yoshifumi KAWARADA, and Ryuji MIZUMOTO

First Department of Surgery, Mie University School of Medicine, Mie 514, Japan Summary: The present study was undertaken to elucidate clinicopathological findings and operative results of HCC with HB-associated cirrhosis, compared with those in HCC patients with alcoholic and post-transfusion cirrhosis. The number of the HBV group was 26 cases, consisting of 17 in sAg(+), 4 in eAg(+) and 5 in eAb(+) subgroups. The number of the post-transfusion group was 7 and that of alcoholic group was 12. A high incidence of hypersplenism and esophageal varix in the eAg(+) subgroup was found. ICG R15 was the highest, KICGand ICG Rma x w e r e the lowest in the eAg(+) subgroup. The mean diameter of tumors was the largest, 6.6+3.9 cm, in the sAg(+) subgroup and was the smallest, 2.2+1.7 cm, in the eAg(+) subgroup. The incidence of postoperative jaundice, hyperammoninemia and live dysfunction were the highest in the sAg(+) and eAg(+) subgroup. One and three-year survival rate were 76.9% and 48.1% in the sAg(+) subgroup, 60.0% and 30.0% in the eAb(+) subgroup, and the oneyear survival rate in the eAg(+) subgroup was 50.0%. The three-year survival rate could not be calculated because 3 years had not passed since the operation. The prognosis was the poorest in the HBV group among all groups. This study suggests that in HBV-associated cirrhosis, hepatectomy might induce "acute on chronic" changes (acute hepatitis and fulminant hepatitis). Therefore we should select operative procedures by considering surgical risk and the etiology of liver cirrhosis in hepatectomy.

Gastroenterol Jpn 1990;25:54-60 Key words: HBV; hepatocellular carcinoma; liver cirrhosis; non-A non-B hepatitis; post-transfusion

Introduction Primary hepatocellular carcinoma is the s e c o n d m o s t frequent next to gastric cancer a m o n g digestive tract m a l i g n a n t n e o p l a s m s in Japan. It is well k n o w n that hepatocellular carcinoma (HCC) occurs m o s t frquently in cirrhotic liver, a n d it seems that the process causing cirrhosis is associated with an increasing risk of HCC. H o w e v e r , this risk differs significantly according to etiology of cirrhosis. Alcoholic cirrhosis is a major p r e d i s p o s i n g lesion of H C C in the U n i t e d States a n d in s o m e E u r o p e a n countries,

although the percentage of cirrhotic patients d e v e l o p i n g H C C is low, being 5 to 10% 1. O n the contrary, cirrhosis associated w i t h hepatitis B virus (HBV) infection is far m o r e responsible for the d e v e l o p m e n t of H C C in South Africa a n d South East Asia with 40 to 50% incidence 2. The distribution of non-A, non-B hepatitis appears to be similar w o r l d w i d e . Non-A, non-B hepatitis is frequently transmitted by blood transfusion, a n d m a y cause liver cirrhosis and HCC. In Japan, viral hepatitis, especially HBV infection, is the m o s t i m p o r t a n t factor in the dev e l o p m e n t of liver cirrhosis. H o w e v e r , both

Received May 8, 1989. Accepted September 22, 1989. Address for correspondence: Takazumi Imai, M.D., The First Department of Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie 514, Japan.

February1990

Clinicopathology and operative results of HCC on etiology of cirrhosis

general and per capita consumption of alcohol and liver disease associated with excess alcohol intake have conspicuously increased recently in Japan 3. There is increasing incidence of liver cirrhosis caused by chronic alcoholism and its consequent HCC. There have been only a few studies on the results of surgical treatment for cirrhotic patients with HCC, concerned with the different etiologies of cirrhosis. The present study was undertaken to elucidate clinicopathological findings and operative results of hepatocellular carcinoma with HB-associated cirrhosis, compared with those in HCC patients with alcoholic and post-transfusion cirrhosis. Materials and Methods

Among 130 patients with hepatocellular carcinoma operated in the First Department of Surgery of Mie University from September 1976 to August 1988, 106 patiens (81.5%) have liver cirrhosis. Of 106 patients with both HCC and liver cirrhosis, 88 patients who underwent hepatectomy, were classified as follows, by the etiology of their cirrhosis, from the past history and measurement of serum HB associated antigen and antibody with radioimmunoassay. HBV group: patients with positive HBV marker positive HB surface antigen and negative HBe antigen (sAg) positive HB surface antigen and positive HBe antigen (eAg) positive HBe antibody and positive HBc antibody (eAb) Post-transfusion group: patients with a history of blood transfusion and/or post-transfusion hepatitis. Alcoholic group: patients with a history of ethanol intake of more than 143ml every day for more than ten years. A single etiology of liver cirrhosis was found in 45 cases; 26 cases in the HBV group including 17 in the sAg subgroup, 4 in the eAg subgroup, 5 in the eAb subgroup, 7 cases in the post-trans-

55

Table 1 Clinical findings on admission Age

Sex (M:F)

Duration (year)

(26) (17) (4) (5)

53.1 +9.4 54.2+_9.0 47.8_+3.7 58.6+5.2

17:9 10:7 3:1 4:1

7.3• 9.3+_4.3 8.0+_2.2 7.5_+3.0

Posttransfusion ( 7 )

59.3+_8.0

7:0

8.3+_2.6

Alcohol

58.4_+9.6

12:0

4.2_+3.1

HBV sAg eAg eAb

(12)

Table 2 Preoperative complication Gall stone HBV sAg eAg eAb

(26) (17) (4) (5)

Hypersplenism Esophageal varix

4 (15.4%) 1 (5.9%) 0 3 (60.0%)

7 5 1 1

Posttransfusion (7)

1 (14.3%)

2 (28.6%)

Alcohol

2 (16.7%)

6 (50.0%)

(12)

(26.9%) (29.4%) (25.0%) (20.0%)

9 5 2 2

(34.6%) (29.4%) (50.0%) (40.0%)

3 (25.0%)

fusion group, and 12 cases in the alcoholic group. Two or three etiologies were observed in 17 cases and I case, respectively, and unknown etiology in 25 cases. In the present study, 45 cases with a single etiology of liver cirrhosis, all of which were posthepatitic cirrhosis histologically except for one nutritional cirrhosis in the alcoholic group, were investigated, and the clinicopathological findings and operative results were compared among the three groups. Statistical analyses were performed by Student's t test, P