EPIDEMIOLOGICAL STUDIES OF a-FETOPROTEIN AND HEPATITIS B ANTIGEN IN T O M E TOWN, NAGASAKI, JAPAN Toshihiko Koji, Tatsuo Munehisa, Kunitaro Yamaguchi, Yukio Kusumoto, and Susumu Nakamura The First Department of Internal Medicine Nagasaki University School of Medicine Nagasaki. Japan
Introduction
A high incidence of liver cirrhosis is generally seen in southern and western parts of Japan. Nagasaki prefecture in particular shows one of the highest incidences of the disease in Japan.' The high rate of hepatoma combined with liver cirrhosis is worthy of note. The type B cirrhosis classified by Miyake' is involved in a majority of these cases. With this point in mind, we have surveyed the people living in one of the towns in Nagasaki prefecture for several years. Tomik Town was selected as the town where the above-mentioned features are most dominant. Annual mass physical examination of the residents was carried out, and the following results were revealed: ( 1 ) Hepatitis B antigen (HB-Ag) and Hepatitis B antibody (HB-Ab) were significantly prevalent among the people. The study does not prove, but suggests the relation between HB-Ag and chronic liver disease. (2) Most of the cirrhotic patients and the one patient with hepatoma and cirrhosis had a positive HB-Ag. It is, however, not clear at present how HB-Ag is related to development of hepatoma. ( 3 ) Incidentally, one clinically latent hepatoma patient was detected by the a-fetoprotein (AFP) assay and underwent a successful operation. Subjects and Methods
All subjects participating in the course of study were living in Tomik Town (FIGURE 1) in Nagasaki prefecture, and its population was about 11,000. Most of the residents were engaged in fishing and farming. The mortality rate from liver cirrhosis in this area was as high as about 25 per 100,000 from 1942 through 1968. A team of physicians from the First Department of Internal Medicine, Nagasaki University School of Medicine, with the collaboration of Prof. T. Miyaji, Department of Pathology, Osaka University, established clinics in Tomik, during the summers of 1968-1973 in order to screen the residents over age 30 for clinical evaluation of liver diseases. The subjects who participated included 1,582 individuals, 6 I3 males and 969 females, ranging from 30 to 84 years old (TABLE1 ) . All of them felt themselves to be well. The clinical protocol involved a medical history, a physical examination and five laboratory tests, including serum glutamic oxaloacetic transaminase (GOT, measured by Reitman-Frankel method, R F unit), glutamic PYrUViC transaminase (GPT, measured by Reitman-Frankel method, R F unit), thymol
239
Annals New York Academy of Sciences
240
turbidity test (TTT, measured by Maclagan method, M unit), zinc sulfate turbidity test (ZST, measured by Kunkel method, K unit) and alkaline phosphatase (Al-Pase, measured by the Bodansky method, Bod unit). Further examinations were carried out on the individuals in whom hepatomegaly was detected or who showed abnormal findings in these five tests. In addition to those examinations. 8 1 individuals from this group underwent liver biopsy via Vim-Silverman needle. The biopsy materials were fixed in 10% paraldehyde and examined after staining with hematoxylin and eosin, Malloryazan, VanGieson, Laid low’s silver impregnation for reticulin, and with Sudan 111. Among 668 adult subjects (246 male 422 female), the HB-Ag and HB-Ab levels were measured by the immune adherence hemagglutination method (IAHA) and the passive hemagglutination method (PHA), respectively in 1973. Serum AFP levels were estimated by the hemagglutination method, in collaboration with Prof. H. Hirai, Department of Biochemistry, Hokkaido University. Two of 668 subjects were estimated quantitatively by the radioimmunoassay method (a-Feto.Riakit. Dainabot) . A detailed description of the community, the methods of study and the preliminary findings have been reported el~ewhere.~ TABLE 1 SUBJECTS Sex
Male Female Total
Population
Subjects
2,067 2,606
613 969
4,613
1,582
Results
Among the subjects we noted 484 cases (30.6%) of hepatomegaly of more than one finger breadth in the right costal margin and 208 cases (13.1%) showed abnormal liver function. The number of the individuals who had both hepatomegaly and abnormal liver function tests was 101 (6.4%). Among the subjects who underwent liver biopsy, 7 cases of liver cirrhosis were observed and one of them revealed hepatoma. Ten cases of chronic hepatitis and 40 cases of nonspecific liver fibrosis were seen. Other than those, fatty liver ( 6 cases), cholangitis ( 6 cases), nonspecific reactive hepatitis ( 5 cases), liver cyst ( 1 case), congestive liver ( 1 case) and Dubin-Johnson Syndrome ( 2 cases) were found. Three cases showed no abnormal histology (TABLE2 ) . The incidences of the positive HB-Ag and HB-Ab in the serum level measured in 1973 are as high as 5.7% and 25.4%, respectively. As shown in TABLE3, these values are very high compared to those surveyed in the Gifu and Mi6 districts. A relationship between HB-Ag and HB-Ab and liver diseases confirmed by biopsy is shown in TABLE2. Of 5 cases of liver cirrhosis or hepatoma, 4 cases, one of hepatoma with cirrhosis and 3 of liver cirrhosis, showed the positive HB-Ag.
24 1
Koji et al. : Epidemiological Studies HB-AG AND HB-AB IN
TABLE2 HISTOLOGICALLY DIAGNOSED CASES Number of
Diagnosis Hepatoma with cirrhosis Liver cirrhosis Chronic hepatitis Liver fibrosis Fatty liver Cholangitis Nonspecific reactive hepatitis Liver cyst Congestion Dubin-Johnson Syndrome Normal
Cases 1 6 10
40 6 6 5
Total
Number Tested
HB-Ag
HB-Ab
(+I
(+I
1 4
1 3 0
0 0 3
4 25
1
11
4
0
3 2
3 1
1 1 2
0
3
3
1 0 0 0 0 0
81
47
6
0 1
22
Two of 668 subjects were found to have positive AFP by the hemagglutina4A. The AFP contents of these two sera tion method as shown in TABLE estimated by the radioimmunoassay (RIA) technique were 130 and 260 ng/ml, respectively (TABLE 4B). The first subject had clinically diagnosed liver cirrhosis with hepatoma, but soon died. N o autopsy was obtained. The second is the case with hepatoma who underwent surgery and survived. In both cases, the serum HB-Ag was positive. The second case is described in brief. Case Report
The subject (cf.T.K. in TABLE 4B) had been well until 1968, when anorexia and general malaise developed. She was then admitted to the hospital for 3 months, where jaundice and slight hepatomegaly were found, and she was treated for chronic hepatitis. The course after the discharge was satisfactory. In 1970, when she first participated in our examination, slight hepatomegaly ( 1 f.b. below the right costal margin) and abnormalities of the liver function test (TTT 10.0 M units, ZST 18.8 K units, G O T 97 R F units, GPT 87 R F units, Al-Pase 6.0 Bod units) was noted but she had no complaints. In 1971, TABLE3 INCIDENCE OF POSITIVEHB-AG AND HB-AB Town Tomit Gifu M iC
Number Tested
HB-Ag Positive (IAHA, % )
HB-Ab Positive (PHA, % )
668 1,187
5.7 1.8
2,286
4.3
25.4 30.2 20.9
242
Annals New York Academy of Sciences
FIGURE 1. Location map of TomiC Town in Nagasaki prefecture in Japan.
FIGURE2. Celiac angiogram. The angiogram shows a solitary tumor stain, originating from the right posterior segmental artery lesion.
243
Koji et af.: Epidemiological Studies
she underwent a liver biopsy for the further evaluation and a diagnosis of postnecrotic liver cirrhosis was made. The serum HB-Ag was positive at that time. On routine mass physical examination made in 1973, the liver was enlarged to 2 f.b. below the right costal margin. The serum A F P level revealed 260 ng/ml, and HB-Ag was positive again. She was admitted to our hospital for further evaluation, although she had no complaints. On admission, the physical examination revealed no abnormality except for hepatomegaly. The GOT value was 56 R F units, G P T 44 R F units, LDH 420 units, and Al-Pase 14.3 King-Armstrong units. Serum albumin content was 4.3 g/dl and y-globulin 2.2 g/dl. The TlT value was 10.0 M units and ZST was 15.7 K units. Bromsulphalein retention was 9.2% (45 minutes) and bilirubin content was 0.2 mg/dl (direct) and 0.9 mg/dl (total). A HB-Ag determination was positive and the serum AFP level showed 680 ng/ml. A hepatic scintigram showed no
TABLE4 NUMBER(A) AND CHARACTERISTICS (B) OF PATIENTS FOUND BY MASS PHYSICAL EXAMINATION (A) AFP-Positive Number Tested
( Hemagglutination)
668
2
(B)
AFP
Name
Age
Sex
K.N.
66
M
130ng/ml
(IAHA) 5 12 x
T. K.
52
F
260 ng/ml
4096
x
Diagnosis Hepatoma with liver cirrhosis? Hepatoma with liver cirrhosis
cold area. Laparoscopic procedure and histological findings by the needle biopsy 2 ) showed a revealed only liver cirrhosis. Finally, celiac angiogram (FIGURE solitary tumor stain, originating from the right posterior segmental artery lesion. On December 5, 1973, the partial hepatectomy of the right lobe was carried out at the Second Department of Surgery, Nagasaki University, and a mass about 3.5 cm in diameter was excised (FIGURE 3). The histological examination revealed hepatocellular carcinoma and liver cirrhosis of type A’ (FIGURES 4 and 5 ) . The pre- and postoperative changes of the serum level of AFP were shown in FIGURE 6. The level of AFP was 260 ng/ml at the time of detection, and thereafter increased to 680 ng/ml on admission. After the operation its values went down to 280 ng/ml on the 6th day and to 14 ng/ml on the 55th day. Although a transient rise to 128 ng/ml was found three months later, the level determined 9 months after the operation remains low at 38 ng/ml. She has no complaints at present and is enjoying ordinary daily life in good health.
244
Annals New York Academy of Sciences
FIGURE3. Excised tumor from the right lobe of the liver. The mass is about 3.5 cm in diameter.
FIGURE4. Area of postnecrotic liver cirrhosis. Photograph shows broad and narrow fibrous bands with round cell infiltration dividing the nodular parenchymal tissue. Fatty degeneration is a prominent feature in the lower pseudolobule. (Azan-Mallory, x 600).
Koji et al. : Epidemiological Studies
245
FIGURE 5. Area of trabecular liver cell carcinoma. The alveolar pattern is obvious in this tumor. The nests of the tumor cells are surrounded by well developed capillary spaces. (H&E, x 600).
FIGURE 6. Pre- and postoperative changes in serum AFP levels.
Annals New York Academy of Sciences
246
Discussion
In TomiC Town, the mortality rate of cirrhosis was as high as 25 per 100,000 during 1942 through 1968, and was one of the highest in Nagasaki prefecture, while the mortality rate of liver cirrhosis in Japan in 1968 was 11 per 100,000. In the analysis of 6285 autopsy cases in Nagasaki University for the last 20 years, liver cirrhosis with hepatoma was found in 2.9% of them, which is 3 times greater than the average in Japan (cf. TABLE 5). A close rela-
tionship between liver cirrhosis and hepatoma, in the Nagasaki district, was suggested by the fact that 85.8% of hepatoma cases were associated with liver cirrhosis. From the clinical point of view, the hepatoma patients rarely complain of the accompanying cirrhosis. So, 50% of the patients who were found to have hepatoma with liver cirrhosis visited clinics not for the symptoms of TABLE5 INCIDENCE OF LIVER~ ~ W ~ O S AND I S HEPATOMA (A) AND THEIR COMPLICATION RATIO(B)
(A) Disease
Japan
Nagasaki
Total Cases of Autopsy Liver Cirrhosis (LC) Hepatoma (Hep) Hepatoma with Cirrhosis
85.568 2,302 (2.70%) 646 (0.75%) 876 (1.02%)
6,285 256 (4.10%) 31 (0.49%) 187 (2.97%)
(B) Hep with LC LC only
+ Hep with LC
(%I
28.0
42.2
(%I
57.3
85.8
Hep with LC Hep only + Hep with LS
cirrhosis, but for those of hepatoma, that is, abdominal mass or abdominal ache. This fact suggests a possibility that cirrhosis or chronic hepatitis are hidden in the people who seemed healthy. Actually, in our mass physical examination 1 case of hepatoma with cirrhosis, 6 cases of latent liver cirrhosis, and 10 cases of chronic hepatitis were found. In adult subjects living in TomiC Town, 5.7% were found positive for HB-Ag and 25.4 for HB-Ab. These values were the highest compared with those in the other districts in Japan (cf. TABLE 3). In Japan, the regional incidence of positive HB-Ag varied widely, and is, in general, higher in the southern and western parts of Japan. Of 1,187 subjects living in a district in the Gifu prefecture, which is located in the central part of Japan, 1.9% were found positive for HB-Ag and 30.2% for HB-Ab. The values shown at the bottom of TABLE 3 were quoted from the study in a town of a remote island in Mi6
Koji et al. : Epidemiological Studies
247
prefecture like Tomi6 Town. The positive HB-Ag and HB-Ab were, respectively, 4.3% and 20.9%. A high incidence of positive HB-Ag may be explained on the basis of its tendency to familial clustering, which had been uncovered by our mass physical examination in the past. A further study may ascertain whether this high incidence rests on a horizontal or vertical mode of infection. 2, HB-Ag was positive in one case of hepatoma with As shown in TABLE cirrhosis, three of liver cirrhosis, and one of liver fibrosis. The HB-Ab was also positive in 3 cases of chronir: hepatitis and 11 cases of liver fibrosis. These data suggest a possible role for HB-Ag as one of the etiological factors in liver disease. In 1973, we first carried out the survey of serum AFP of 668 cases by the hemagglutination method. Two cases showed positive AFP. The first was diagnosed clinically as hepatoma with liver cirrhosis, and developed ascites and marked hepatomegaly, but died soon. No autopsy was obtained. The second with hepatoma was operated on and survived. In this second case, three months after partial hepatectomy, a transient rise of AFP to 126 ng/ml was observed. This fact may imply a reflection of the regenerative process of partial hepatectomy. Nine months after the operation. no clinical signs of relapse were found. In 1970, Vogel et al:' reported a high incidence of positive HB-Ag (40%) in Ugandan patients with hepatocellular carcinoma. In Japan, Nishioka et alas also demonstrated a high correlation of HB-Ag with primary hepatocellular carcinoma in an ethnic group in Asia and Africa. In our two cases of hepatoma with liver cirrhosis HB-Ag was detected to be positive as early as two years before. This may suggest that HB-Ag cannot be disregarded as a cause of hepatoma. A relationship between HB-Ag and AFP is controversial. In our second case, AFP level came down definitely, whereas the HB-Ag level was unchanged. With regard to the second case, this is the first one among the reports that we searched in the past in which hepatoma was found by the mass screening test and was treated successfully by surgery. This verifies the validity of the AFP assay for the early finding of hepatoma. References 1. YUNOKI, K. 1957. The corrected mortality from liver cirrhosis of the prefecture (ken) of Japan. J. Public Health (Japan) 21: 31-36. 2. MIYAKE,H. 1960. Pathology of liver-studies on the classification of liver cirrhosis. Trans. SOC.Pathol. Japan 49: 589-632. 3. TAKAOKA, Y., T. KOJI, H. KURATSUNE, T. MUNEHISA, K. YAMAGUCHI, Y. KusuMOTO, H. KONDO, S. ~ U R & U S. KAMURA. 1971. Jpn. I. Clin. Exp. Med. 48: 2177-2185. 4. VOGEL, C. L., P. P. ANTHONY, N. MODY& L. F. BARKER. 1970. Hepatitis-associated antigen in Ugandan patients with hepatocellular carcinoma. Lancet 2: 62 1-624. 5. NISHIOKA, K. 1973. Australia antigen and hepatocellular carcinoma. Gann Mongr. Cancer Res. 14: 167-175.
Introduction
A high incidence of liver cirrhosis is generally seen in southern and western parts of Japan. Nagasaki prefecture in particular shows one of the highest incidences of the disease in Japan.' The high rate of hepatoma combined with liver cirrhosis is worthy of note. The type B cirrhosis classified by Miyake' is involved in a majority of these cases. With this point in mind, we have surveyed the people living in one of the towns in Nagasaki prefecture for several years. Tomik Town was selected as the town where the above-mentioned features are most dominant. Annual mass physical examination of the residents was carried out, and the following results were revealed: ( 1 ) Hepatitis B antigen (HB-Ag) and Hepatitis B antibody (HB-Ab) were significantly prevalent among the people. The study does not prove, but suggests the relation between HB-Ag and chronic liver disease. (2) Most of the cirrhotic patients and the one patient with hepatoma and cirrhosis had a positive HB-Ag. It is, however, not clear at present how HB-Ag is related to development of hepatoma. ( 3 ) Incidentally, one clinically latent hepatoma patient was detected by the a-fetoprotein (AFP) assay and underwent a successful operation. Subjects and Methods
All subjects participating in the course of study were living in Tomik Town (FIGURE 1) in Nagasaki prefecture, and its population was about 11,000. Most of the residents were engaged in fishing and farming. The mortality rate from liver cirrhosis in this area was as high as about 25 per 100,000 from 1942 through 1968. A team of physicians from the First Department of Internal Medicine, Nagasaki University School of Medicine, with the collaboration of Prof. T. Miyaji, Department of Pathology, Osaka University, established clinics in Tomik, during the summers of 1968-1973 in order to screen the residents over age 30 for clinical evaluation of liver diseases. The subjects who participated included 1,582 individuals, 6 I3 males and 969 females, ranging from 30 to 84 years old (TABLE1 ) . All of them felt themselves to be well. The clinical protocol involved a medical history, a physical examination and five laboratory tests, including serum glutamic oxaloacetic transaminase (GOT, measured by Reitman-Frankel method, R F unit), glutamic PYrUViC transaminase (GPT, measured by Reitman-Frankel method, R F unit), thymol
239
Annals New York Academy of Sciences
240
turbidity test (TTT, measured by Maclagan method, M unit), zinc sulfate turbidity test (ZST, measured by Kunkel method, K unit) and alkaline phosphatase (Al-Pase, measured by the Bodansky method, Bod unit). Further examinations were carried out on the individuals in whom hepatomegaly was detected or who showed abnormal findings in these five tests. In addition to those examinations. 8 1 individuals from this group underwent liver biopsy via Vim-Silverman needle. The biopsy materials were fixed in 10% paraldehyde and examined after staining with hematoxylin and eosin, Malloryazan, VanGieson, Laid low’s silver impregnation for reticulin, and with Sudan 111. Among 668 adult subjects (246 male 422 female), the HB-Ag and HB-Ab levels were measured by the immune adherence hemagglutination method (IAHA) and the passive hemagglutination method (PHA), respectively in 1973. Serum AFP levels were estimated by the hemagglutination method, in collaboration with Prof. H. Hirai, Department of Biochemistry, Hokkaido University. Two of 668 subjects were estimated quantitatively by the radioimmunoassay method (a-Feto.Riakit. Dainabot) . A detailed description of the community, the methods of study and the preliminary findings have been reported el~ewhere.~ TABLE 1 SUBJECTS Sex
Male Female Total
Population
Subjects
2,067 2,606
613 969
4,613
1,582
Results
Among the subjects we noted 484 cases (30.6%) of hepatomegaly of more than one finger breadth in the right costal margin and 208 cases (13.1%) showed abnormal liver function. The number of the individuals who had both hepatomegaly and abnormal liver function tests was 101 (6.4%). Among the subjects who underwent liver biopsy, 7 cases of liver cirrhosis were observed and one of them revealed hepatoma. Ten cases of chronic hepatitis and 40 cases of nonspecific liver fibrosis were seen. Other than those, fatty liver ( 6 cases), cholangitis ( 6 cases), nonspecific reactive hepatitis ( 5 cases), liver cyst ( 1 case), congestive liver ( 1 case) and Dubin-Johnson Syndrome ( 2 cases) were found. Three cases showed no abnormal histology (TABLE2 ) . The incidences of the positive HB-Ag and HB-Ab in the serum level measured in 1973 are as high as 5.7% and 25.4%, respectively. As shown in TABLE3, these values are very high compared to those surveyed in the Gifu and Mi6 districts. A relationship between HB-Ag and HB-Ab and liver diseases confirmed by biopsy is shown in TABLE2. Of 5 cases of liver cirrhosis or hepatoma, 4 cases, one of hepatoma with cirrhosis and 3 of liver cirrhosis, showed the positive HB-Ag.
24 1
Koji et al. : Epidemiological Studies HB-AG AND HB-AB IN
TABLE2 HISTOLOGICALLY DIAGNOSED CASES Number of
Diagnosis Hepatoma with cirrhosis Liver cirrhosis Chronic hepatitis Liver fibrosis Fatty liver Cholangitis Nonspecific reactive hepatitis Liver cyst Congestion Dubin-Johnson Syndrome Normal
Cases 1 6 10
40 6 6 5
Total
Number Tested
HB-Ag
HB-Ab
(+I
(+I
1 4
1 3 0
0 0 3
4 25
1
11
4
0
3 2
3 1
1 1 2
0
3
3
1 0 0 0 0 0
81
47
6
0 1
22
Two of 668 subjects were found to have positive AFP by the hemagglutina4A. The AFP contents of these two sera tion method as shown in TABLE estimated by the radioimmunoassay (RIA) technique were 130 and 260 ng/ml, respectively (TABLE 4B). The first subject had clinically diagnosed liver cirrhosis with hepatoma, but soon died. N o autopsy was obtained. The second is the case with hepatoma who underwent surgery and survived. In both cases, the serum HB-Ag was positive. The second case is described in brief. Case Report
The subject (cf.T.K. in TABLE 4B) had been well until 1968, when anorexia and general malaise developed. She was then admitted to the hospital for 3 months, where jaundice and slight hepatomegaly were found, and she was treated for chronic hepatitis. The course after the discharge was satisfactory. In 1970, when she first participated in our examination, slight hepatomegaly ( 1 f.b. below the right costal margin) and abnormalities of the liver function test (TTT 10.0 M units, ZST 18.8 K units, G O T 97 R F units, GPT 87 R F units, Al-Pase 6.0 Bod units) was noted but she had no complaints. In 1971, TABLE3 INCIDENCE OF POSITIVEHB-AG AND HB-AB Town Tomit Gifu M iC
Number Tested
HB-Ag Positive (IAHA, % )
HB-Ab Positive (PHA, % )
668 1,187
5.7 1.8
2,286
4.3
25.4 30.2 20.9
242
Annals New York Academy of Sciences
FIGURE 1. Location map of TomiC Town in Nagasaki prefecture in Japan.
FIGURE2. Celiac angiogram. The angiogram shows a solitary tumor stain, originating from the right posterior segmental artery lesion.
243
Koji et af.: Epidemiological Studies
she underwent a liver biopsy for the further evaluation and a diagnosis of postnecrotic liver cirrhosis was made. The serum HB-Ag was positive at that time. On routine mass physical examination made in 1973, the liver was enlarged to 2 f.b. below the right costal margin. The serum A F P level revealed 260 ng/ml, and HB-Ag was positive again. She was admitted to our hospital for further evaluation, although she had no complaints. On admission, the physical examination revealed no abnormality except for hepatomegaly. The GOT value was 56 R F units, G P T 44 R F units, LDH 420 units, and Al-Pase 14.3 King-Armstrong units. Serum albumin content was 4.3 g/dl and y-globulin 2.2 g/dl. The TlT value was 10.0 M units and ZST was 15.7 K units. Bromsulphalein retention was 9.2% (45 minutes) and bilirubin content was 0.2 mg/dl (direct) and 0.9 mg/dl (total). A HB-Ag determination was positive and the serum AFP level showed 680 ng/ml. A hepatic scintigram showed no
TABLE4 NUMBER(A) AND CHARACTERISTICS (B) OF PATIENTS FOUND BY MASS PHYSICAL EXAMINATION (A) AFP-Positive Number Tested
( Hemagglutination)
668
2
(B)
AFP
Name
Age
Sex
K.N.
66
M
130ng/ml
(IAHA) 5 12 x
T. K.
52
F
260 ng/ml
4096
x
Diagnosis Hepatoma with liver cirrhosis? Hepatoma with liver cirrhosis
cold area. Laparoscopic procedure and histological findings by the needle biopsy 2 ) showed a revealed only liver cirrhosis. Finally, celiac angiogram (FIGURE solitary tumor stain, originating from the right posterior segmental artery lesion. On December 5, 1973, the partial hepatectomy of the right lobe was carried out at the Second Department of Surgery, Nagasaki University, and a mass about 3.5 cm in diameter was excised (FIGURE 3). The histological examination revealed hepatocellular carcinoma and liver cirrhosis of type A’ (FIGURES 4 and 5 ) . The pre- and postoperative changes of the serum level of AFP were shown in FIGURE 6. The level of AFP was 260 ng/ml at the time of detection, and thereafter increased to 680 ng/ml on admission. After the operation its values went down to 280 ng/ml on the 6th day and to 14 ng/ml on the 55th day. Although a transient rise to 128 ng/ml was found three months later, the level determined 9 months after the operation remains low at 38 ng/ml. She has no complaints at present and is enjoying ordinary daily life in good health.
244
Annals New York Academy of Sciences
FIGURE3. Excised tumor from the right lobe of the liver. The mass is about 3.5 cm in diameter.
FIGURE4. Area of postnecrotic liver cirrhosis. Photograph shows broad and narrow fibrous bands with round cell infiltration dividing the nodular parenchymal tissue. Fatty degeneration is a prominent feature in the lower pseudolobule. (Azan-Mallory, x 600).
Koji et al. : Epidemiological Studies
245
FIGURE 5. Area of trabecular liver cell carcinoma. The alveolar pattern is obvious in this tumor. The nests of the tumor cells are surrounded by well developed capillary spaces. (H&E, x 600).
FIGURE 6. Pre- and postoperative changes in serum AFP levels.
Annals New York Academy of Sciences
246
Discussion
In TomiC Town, the mortality rate of cirrhosis was as high as 25 per 100,000 during 1942 through 1968, and was one of the highest in Nagasaki prefecture, while the mortality rate of liver cirrhosis in Japan in 1968 was 11 per 100,000. In the analysis of 6285 autopsy cases in Nagasaki University for the last 20 years, liver cirrhosis with hepatoma was found in 2.9% of them, which is 3 times greater than the average in Japan (cf. TABLE 5). A close rela-
tionship between liver cirrhosis and hepatoma, in the Nagasaki district, was suggested by the fact that 85.8% of hepatoma cases were associated with liver cirrhosis. From the clinical point of view, the hepatoma patients rarely complain of the accompanying cirrhosis. So, 50% of the patients who were found to have hepatoma with liver cirrhosis visited clinics not for the symptoms of TABLE5 INCIDENCE OF LIVER~ ~ W ~ O S AND I S HEPATOMA (A) AND THEIR COMPLICATION RATIO(B)
(A) Disease
Japan
Nagasaki
Total Cases of Autopsy Liver Cirrhosis (LC) Hepatoma (Hep) Hepatoma with Cirrhosis
85.568 2,302 (2.70%) 646 (0.75%) 876 (1.02%)
6,285 256 (4.10%) 31 (0.49%) 187 (2.97%)
(B) Hep with LC LC only
+ Hep with LC
(%I
28.0
42.2
(%I
57.3
85.8
Hep with LC Hep only + Hep with LS
cirrhosis, but for those of hepatoma, that is, abdominal mass or abdominal ache. This fact suggests a possibility that cirrhosis or chronic hepatitis are hidden in the people who seemed healthy. Actually, in our mass physical examination 1 case of hepatoma with cirrhosis, 6 cases of latent liver cirrhosis, and 10 cases of chronic hepatitis were found. In adult subjects living in TomiC Town, 5.7% were found positive for HB-Ag and 25.4 for HB-Ab. These values were the highest compared with those in the other districts in Japan (cf. TABLE 3). In Japan, the regional incidence of positive HB-Ag varied widely, and is, in general, higher in the southern and western parts of Japan. Of 1,187 subjects living in a district in the Gifu prefecture, which is located in the central part of Japan, 1.9% were found positive for HB-Ag and 30.2% for HB-Ab. The values shown at the bottom of TABLE 3 were quoted from the study in a town of a remote island in Mi6
Koji et al. : Epidemiological Studies
247
prefecture like Tomi6 Town. The positive HB-Ag and HB-Ab were, respectively, 4.3% and 20.9%. A high incidence of positive HB-Ag may be explained on the basis of its tendency to familial clustering, which had been uncovered by our mass physical examination in the past. A further study may ascertain whether this high incidence rests on a horizontal or vertical mode of infection. 2, HB-Ag was positive in one case of hepatoma with As shown in TABLE cirrhosis, three of liver cirrhosis, and one of liver fibrosis. The HB-Ab was also positive in 3 cases of chronir: hepatitis and 11 cases of liver fibrosis. These data suggest a possible role for HB-Ag as one of the etiological factors in liver disease. In 1973, we first carried out the survey of serum AFP of 668 cases by the hemagglutination method. Two cases showed positive AFP. The first was diagnosed clinically as hepatoma with liver cirrhosis, and developed ascites and marked hepatomegaly, but died soon. No autopsy was obtained. The second with hepatoma was operated on and survived. In this second case, three months after partial hepatectomy, a transient rise of AFP to 126 ng/ml was observed. This fact may imply a reflection of the regenerative process of partial hepatectomy. Nine months after the operation. no clinical signs of relapse were found. In 1970, Vogel et al:' reported a high incidence of positive HB-Ag (40%) in Ugandan patients with hepatocellular carcinoma. In Japan, Nishioka et alas also demonstrated a high correlation of HB-Ag with primary hepatocellular carcinoma in an ethnic group in Asia and Africa. In our two cases of hepatoma with liver cirrhosis HB-Ag was detected to be positive as early as two years before. This may suggest that HB-Ag cannot be disregarded as a cause of hepatoma. A relationship between HB-Ag and AFP is controversial. In our second case, AFP level came down definitely, whereas the HB-Ag level was unchanged. With regard to the second case, this is the first one among the reports that we searched in the past in which hepatoma was found by the mass screening test and was treated successfully by surgery. This verifies the validity of the AFP assay for the early finding of hepatoma. References 1. YUNOKI, K. 1957. The corrected mortality from liver cirrhosis of the prefecture (ken) of Japan. J. Public Health (Japan) 21: 31-36. 2. MIYAKE,H. 1960. Pathology of liver-studies on the classification of liver cirrhosis. Trans. SOC.Pathol. Japan 49: 589-632. 3. TAKAOKA, Y., T. KOJI, H. KURATSUNE, T. MUNEHISA, K. YAMAGUCHI, Y. KusuMOTO, H. KONDO, S. ~ U R & U S. KAMURA. 1971. Jpn. I. Clin. Exp. Med. 48: 2177-2185. 4. VOGEL, C. L., P. P. ANTHONY, N. MODY& L. F. BARKER. 1970. Hepatitis-associated antigen in Ugandan patients with hepatocellular carcinoma. Lancet 2: 62 1-624. 5. NISHIOKA, K. 1973. Australia antigen and hepatocellular carcinoma. Gann Mongr. Cancer Res. 14: 167-175.
