Characteristics and prognosis of primary liver cancer in young patients in China

To investigate the clinicopathologic characteristics of primary liver cancer (PLC) in young adults, 77 patients aged 35 or younger were compared with 603 patients older than 35 years during the same period. In the young patients, PLC showed: (1) a low incidence detected at mass survey (young 15.6% vs older 28.7%, P < 0.05); (2) a low level of history of hepatitis (young 36.8% vs older 66.3%, P < 0.01); (3) a high incidence of positivity for hepatitis B surface antigen (HBsAg) (young 79.2% vs older 67.6%, P < 0.05); (4) a relatively low incidence of associated cirrhosis (young 64.9% vs older 90.7%, P < 0.01); (5) larger tumor size (PLC > 5 cm; young 87.0% vs older 73.0%, P < 0.01); and (6) a more advanced stage of the disease according to the TNM classification (stage III; young 29.9% vs older 18.2%, P < 0.05). It is suggested that hepatitis B virus (HBV) may play an important role in the development of PLC without associated liver cirrhosis in young patients. Close periodic surveillance of young adults who are positive for HBsAg is important to detect PLC at an early stage.

Multimodality treatment in advanced primary liver cancer

This paper reports the long-term results of multimodality treatment in 1639 patients with pathologically proven primary liver cancer (PLC) over the past three decades. In this series, patients in subclinical stage constituted 23.9% (391/1639), moderate stage 63.0% (1032/1639), and late stage 13.2% (216/1639). There were 381 patients (23.2%) with small PLC (< = 5 cm). The PLC was coexistent with liver cirrhosis in 86.4% (1416/1639). The 5-year survival after resection of PLC was 45.5% for the whole series (n = 896), and 62.7% for patients with a tumor < = 5 cm (n = 345). The 5-year survival after hepatic artery ligation (HAL) and hepatic artery infusion (HAI) (n = 124) was 18.1%, while the 5-year survival after palliative resection (n = 175) was 12.5%. The 5-year survival of 40 patients receiving second-look resection after cytoreduction therapy was 68.4%. Cryosurgery was performed on 107 PLC patients, the 5-year survival being 22.0% for the whole series, and 48.8% for the 32 patients with small PLC. The 5-year recurrence rate after resection was 55.3%. The 5-year survival after reoperation for recurring tumor (n = 90) was 40.8%. It is suggested that surgery remains the modality of choice, and it plays a more important role in the treatment of PLC. The results of palliative surgery (HAL + HAI) seem better than those of palliative resection; combined multimodality treatment and second-look resection, and new surgical techniques might offer hope for unresectable advanced PLC.

Observation of changes in peripheral T-lymphocyte subsets by flow cytometry in patients with liver cancer treated with radioimmunotherapy

An analysis of lymphocyte subsets was performed in 24 patients with surgically verified unresectable hepatocellular carcinoma (HCC). In all cases, the hepatic artery was cannulated and ligated and a single dose of 131I-Hepama-1 monoclonal antibody (MAb) was infused through a hepatic artery catheter. Blood samples were obtained before infusion and 1 month post-infusion. The results indicated that the CD3+ T-cells (pan T-cells) were normal, whereas the CD4+ T-cells (T-helper/inducer cells) decreased and the CD8+ T-cells (T-suppressor/cytotoxic cells) increased significantly in comparison with the control group. So the CD4+:CD8+ ratio declined markedly. One month post-radioimmunotherapy (RIT), the T-cell subsets did not change, but CD4+, CD8+ and the CD4+:CD8+ ratio differed significantly between patients with and without sequential resection. The changes in the T-cell subsets were closely related to tumour capsule status and the human anti-murine antibody (HAMA) response, but no relationship was found between the tumour and administration of a moderate dose of radioimmunoconjugate. Therefore, determination of changes in the T-lymphocyte subsets and the CD4+:CD8+ ratio could be used as clinical and prognostic indicators in patients who have received RIT. Furthermore, RIT did not affect the distribution of T-cell subsets in patients with HCC.

Treatment of unresectable primary liver cancer: with reference to cytoreduction and sequential resection

Unquestionably, progress has been made in the early detection and early treatment of primary liver cancers (PLCs), although most remain unresectable, mainly because the cancer is advanced and coexists with liver cirrhosis, particularly in Oriental patients. Thanks to the progress of regional cancer therapy, a multidisciplinary approach, and changing concepts about surgical oncology, it has been proved that some unresectable but not far advanced PLCs are potentially convertible to being resectable, particularly those cancers confined to the right lobe of a cirrhotic liver. A retrospective analysis of 571 unresectable PLCs revealed the following: (1) There was an increase in 5-year survivals in the series, from 0% during the 1960s (n = 61), to 4.8% during the 1970s (n = 163), to 21.2% during the 1980s (n = 347). It might be a result of the increase in double- or triple-modality treatments in these series (from 9.8%, to 19.6%, to 70.3%, respectively) and in the sequential resection rate after cytoreduction (from 0%, to 2.5%, to 14.7%). (2) The combination of hepatic artery ligation, hepatic artery cannulation and infusion, and intrahepatic arterial radioimmunotherapy has resulted in better shrinkage of the tumor, a higher sequential resection rate, and a higher 5-year survival (28.2%). (3) Of the 55 patients who had initially unresectable PLCs and yielded "cytoreduction and sequential resection," the 5-year survival was 58.5%. It is concluded that cytoreduction and sequential resection might be an important approach to improving the prognosis of patients with unresectable PLCs.

Recurrence after resection of alpha-fetoprotein-positive hepatocellular carcinoma

The long-term prognosis of surgery for hepatocellular carcinoma (HCC) is not yet satisfactory, the main reason being the high recurrence rate. The authors report the results of a long-term follow-up of 308 patients with HCC who became alpha-fetoprotein-(AFP)-negative after resection between 1975 and 1991. By March 1992, there was recurrence in 134 patients (43.5%). The 1-, 3-, 5- and 10-year recurrence rates were 9.2%, 38.8%, 54.9% and 85.0%, respectively. The 5-year survival rate was 49.7% for patients who had undergone a second hepatic resection (n = 48). Analysis of factors influencing postoperative recurrence indicated that patients subjected to mass survey, with a lower gamma-glutamyltransferase level, at an early stage of TNM classification, with a tumour of less than 5 cm, without tumour embolus, and with postoperative immunotherapy had a lower incidence of recurrence. It is concluded that the earlier the disease is diagnosed, the less the recurrence rate; adjuvant immunotherapy may reduce postoperative recurrence, and the early detection and resection of a recurrent tumour are important to prolonging survival further after curative resection of HCC.

Surgical treatment of recurrent hepatocellular carcinoma

During the last 16 years, radical resection was performed in 392 patients with hepatocellular carcinoma (HCC). Eight patients died within 30 days after resection. The other 384 patients were discharged from hospital and closely followed for 6 to 195 months. By December 1991, 185 patients had developed a recurrent tumor, the 1-, 3-, and 5-year recurrence rates being 15.0%, 45.4%, and 55.3%, respectively. Ninety of the 185 patients underwent reoperation, including second hepatic resection (65 cases), cryosurgery (8 cases), resection of lung metastasis (6 cases), hepatic artery ligation and infusion chemotherapy (2 cases), intratumor ethanol injection (3 cases), microwave coagulation plus intratumor ethanol injection (2 cases), and exploration (4 cases). The survival rate of these 90 patients was significantly better than that of 95 patients who were treated by other palliative methods, the 5-year survival rate being 63.4% as compared with 28.6% after the first resection (P < 0.01), and 40.8% vs. 2.2% after recurrence (P < 0.01), respectively. These results suggest that reoperation for recurrent HCC might be an important approach to prolonging survival further after hepatic resection.

Subclinical hepatocellular carcinoma: an analysis of 391 patients

Subclinical hepatocellular carcinoma (SCHCC) is defined as HCC without obvious HCC symptoms and signs. During 1958-1991, 391 patients with SCHCC were analyzed. In the entire series, 1) 67.3% was detected by natural population screening using alpha-fetoprotein (AFP) serosurvey, while the others were discovered by high-risk population screening or regular health checkup using AFP and/or ultrasonography (US); 2) AFP > 20 micrograms/L was found in 77.6% of patients; 3) serum hepatitis B surface antigen (HBsAg) was positive in 68.9%; 4) associated liver cirrhosis occurred in 89.1%; 5) the median tumor size was 5 cm, and small HCC (< or = 5 cm) amounted to 61.1%; 6) resection was done in 81.4%, and limited resection was performed in the majority (71.3%); 7) re-resection for subclinical recurrence was done in 44 patients; and 8) cytoreduction and sequential resection was carried out in 13 patients with unresectable SCHCC. Comparison between SCHCC and clinical HCC (n = 1,251) revealed higher resectability (81.4% vs. 46.8%), lower operative mortality (1.9% vs. 6.0%), and higher 5-year survival (entire series: 50.7% vs. 20.6%; resection: 60.5% vs. 36.8%). It is concluded that the study of SCHCC has resulted in marked improvement of ultimate outcome of HCC; screening in high-risk populations using AFP and/or US, limited resection, and re-resection for subclinical recurrence are some of the key features.

Analysis of one hundred and twenty five patients with primary liver cancer surviving more than five years

During the period of 1958-1986, a series of 125 patients with pathologically proven hepatocellular carcinoma (HCC) surviving more than 5 years was collected in authors' institute. Thirty seven of them survived more than 10 years, the longest being 30 years. Of the entire series, 55.2% of patients was discovered by screening, 48.0% of patients was subclinical HCC, 80.0% of patients had solitary tumor, and 53.6% of patients had tumor size smaller than 5 cm. Pathological findings revealed that 90.2% of tumor was grade I and II (Edmondson grading) and 81.6% of patients associated with cirrhosis. The serum HBsAg was positive in 63% and anti-HBc in 80% of the patients who had checked the HBV markers. Of the 125 patients, 108 patients received resection, 67 patients were small HCC resection, 41 patients were non-small HCC resection, re-resection for subclinical recurrence or solitary lung metastasis was done in 26 patients with resection. Limited resection amounted to 54.6% of patients with resection. Of the 125 patients, 17 patients received palliative surgery other than resection, including hepatic artery ligation, cannulation, or their combination, etc. Eight out of the 17 patients received second stage resection due to marked shrinkage of tumor. It is concluded that early resection remained the major approach to get a long-term survivor, re-resection for subclinical recurrence is also of proved merit. Resection of huge tumor is still useful but less effective. Cyto-reduction and sequential resection is a new trend. Primary liver cancer (PLC) has long been recognized as incurable malignancy with extremely low 5-year survival rate. According to the cancer statistics in the United States, the relative 5-year survival rates for patients with PLC was 2% in 1960-1963, 3% in 1970-1973, 4% in 1974-1976, 3% in 1977-1980 and 5% in 1981-1986. Patients with PLC survived more than 5 years were rarely reported in the literature. In 1971, Curutchet collected worldwide data from 45 authors covering the period for 65 years (1905-1970), only 45 patients with PLC were found to be 5-year survivors. Thanks to the progress in tumor markers, particularly alpha fetoprotin (AFP) and new localization measurements, diagnosis and treatment are possible in subclinical stage. Based on combined strategies to the treatment of PLC including resection of small liver cancer, re-resection of subclinical recurrence after curative resection, multimodality treatment, and sequential resection after shrinkage of tumor, the 5-year survival of PLC has gradually increased.(ABSTRACT TRUNCATED AT 400 WORDS)

Solitary minute hepatocellular carcinoma. A study of 14 patients

Fourteen patients with clinical Stage I hepatocellular carcinoma (T1N0M0) were studied. All patients were asymptomatic, and their conditions were detected by alpha-fetoprotein (AFP) serosurvey and/or ultrasonography (US) either in the natural population in the early years of the study or in the high-risk population in the later years of the study. Cirrhosis was present in all patients. Radical resection was performed in all patients. There were no operative deaths or hospital deaths in this series. The 5-year survival rate after resection was 100%. There were seven long-term survivors in this series (14.2 years (alive), 11.3 years (alive), 8.8 years (alive), 8.8 years, 7.9 years, 7.6 years (alive), and 7.2 years after resection). The authors discuss aspects concerning early diagnosis, treatment, and prognosis of hepatocellular carcinoma (HCC).

Cytoreduction and sequential resection: a hope for unresectable primary liver cancer

For decades, unresectable primary liver cancer (PLC) determined by operation was incurable. However, a retrospective study of 24 years' materials with unresectable PLC indicated that 5-year survival of unresectable PLC has increased from 0% in 1966-1977 (n = 137) to 16.9% in 1978-1989 (n = 345). This encouraging improvement was mainly a result of cytoreduction therapy followed by sequential resection. Multimodality combination treatment with hepatic artery ligation, plus hepatic artery infusion with chemotherapy, plus radioimmunotherapy (or radiotherapy) yielded the highest sequential resection rate (30.6%) and 5-year survival (28.0%) as compared with double combination and single modality treatment. The 5-year survival of 33 patients receiving sequential resection after cytoreduction therapy was 63.2%. It is suggested that cytoreduction and sequential resection might offer a hope for surgically verified unresectable PLC.

Cellular pharmacology and anti-HIV activity of 2',3'-dideoxyguanosine

The antiviral activity, uptake, and metabolism of 2',3'-dideoxyguanosine was investigated in human immunodeficiency virus- (HIV) infected and noninfected human cells. 2',3'-Dideoxyguanosine had anti-HIV activity (effective dose 50%: 0.1-1.0 microM) in H-9 and MT-2 cells. The addition of excess (greater than or equal to 30 microM) guanosine, deoxyguanosine, or 8-aminoguanosine had no effect on the anti-HIV activity of 2',3'-dideoxyguanosine. In [8-3H]2',3'-dideoxyguanosine-exposed cells, the intracellular radioactivity was twofold higher than the extracellular. When guanosine, deoxyguanosine, or 8-aminoguanosine was preincubated or added simultaneously to 2',3'-dideoxyguanosine, uptake of 2',3'-dideoxyguanosine was reduced by 28 to 34%, whereas addition of p-nitrobenzylmercaptopurine riboside (20 microM) had no effect. In metabolism studies using H-9 cells, dideoxyguanosine triphosphate could not be detected despite a 24-h incubation of 2',3'-dideoxyguanosine at effective anti-HIV concentrations. The addition of excess (greater than or equal to 30 microM) guanosine, deoxyguanosine, and 8-aminoguanosine, while inhibiting the catabolism of 2',3'-dideoxyguanosine, did not enhance the anabolic conversion of 2',3'-dideoxyguanosine to dideoxyguanosine triphosphate. Our failure to detect the formation of dideoxyguanosine triphosphate and the lack of reversal of antiviral effects by natural purine nucleosides raises questions on the role of this metabolite in the anti-HIV activity of 2',3'-dideoxyguanosine.

[Study of thromboangiitis obliterans treated with "vascular no. 3" using Doppler ultrasound]

A clinical study was carried out in 31 patients (39 limbs) with thromboangiitis obliterans (TAO, Buerger's Disease) by Chinese herbs "Vascular No.3". Doppler ultrasound flow velocity tracing at the femoral, popliteal, posterior tibial and dorsalis pedis levels and blood pressure at the ankle level were measured. The results showed that TAO patients treated with "Vascular No.3" had a total effective rate of 92.3% and a distinct improvement of 76.9%. The results of Doppler ultrasound proved that "Vascular No.3" significantly decreased arterial lumen stenosis level, increased blood velocity and local flow, promoted developing arterial collaterals and improved vaso-functional conditions.

Hepatocellular carcinoma: some aspects to improve long-term survival

Sixty-six patients surviving over 5 years after resection of hepatocellular carcinoma (HCC) are investigated. Of them, subclinical stage amounted to 56.1% (37/66) and moderate stage to 43.9% (29/66). There were 35 cases with small HCC (less than or equal to 5 cm). Cirrhosis was present in 81.1% (54/66). Radical resection was performed in 98.5% (65/66) and palliative resection in 1.5% (1/66). Reoperation for subclinical recurrence and solitary pulmonary metastasis was done in 14 patients, and sequential resection of huge tumors, in three patients. By the end of June 1988, follow-up varied from 60 to 319 months (mean, 115 months); 80.3% of the patients (53/66) are still alive and free of disease; 19.7% (13/66) died with disease. The majority of long-term survivors have returned to their original work; some young patients got married after resection of small HCC 10 years ago, and some can even play football again. Some aspects to improve long-term survival are discussed.

Surgery of small hepatocellular carcinoma. Analysis of 144 cases

A long-term follow-up study of 144 cases with surgically and pathologically proved small hepatocellular carcinoma (less than or equal to 5 cm) from 1967 to 1987 is reported. One hundred eight cases (75.0%) were detected by alpha-fetoprotein serosurvey and/or ultrasonography mainly in a high-risk population; 129 cases (89.6%) coexisted with cirrhosis. Resection was done in 132 cases (91.7%) with three (2.3%) operative deaths; cryosurgery, laser vaporization, and hepatic arterial chemotherapy were used in the rest. Limited resection was done in 67.4% of resections. Reresection of subclinical recurrence or solitary pulmonary metastasis was done in 21 cases. The 5-year and 10-year survival rates were 67.9% and 53.4% in the resection group but zero in the nonresection group. Survival was correlated negatively with tumor size, 5-year survival after resection was 84.6% in tumors less than or equal to 2 cm but 59.5% in tumors of 4.1 to 5 cm. The increase of resectability and reresection resulted in marked improved of 5-year survival from 43.5% in 1973 to 1977 to 63.3% in 1978 to 1982 in the entire series. No significant difference was found between survival of limited resection and lobectomy. Resection may be the modality of choice for treatment of small hepatocellular carcinomas with compensated liver function. Limited resection instead of lobectomy was the key to increased resectability and decreased operative mortality in cirrhotic livers. Reresection of subclinical recurrence was important to prolong survival further.

Surgery of small hepatocellular carcinoma. Analysis of 144 cases

A long-term follow-up study of 144 cases with surgically and pathologically proved small hepatocellular carcinoma (less than or equal to 5 cm) from 1967 to 1987 is reported. One hundred eight cases (75.0%) were detected by alpha-fetoprotein serosurvey and/or ultrasonography mainly in a high-risk population; 129 cases (89.6%) coexisted with cirrhosis. Resection was done in 132 cases (91.7%) with three (2.3%) operative deaths; cryosurgery, laser vaporization, and hepatic arterial chemotherapy were used in the rest. Limited resection was done in 67.4% of resections. Reresection of subclinical recurrence or solitary pulmonary metastasis was done in 21 cases. The 5-year and 10-year survival rates were 67.9% and 53.4% in the resection group but zero in the nonresection group. Survival was correlated negatively with tumor size, 5-year survival after resection was 84.6% in tumors less than or equal to 2 cm but 59.5% in tumors of 4.1 to 5 cm. The increase of resectability and reresection resulted in marked improved of 5-year survival from 43.5% in 1973 to 1977 to 63.3% in 1978 to 1982 in the entire series. No significant difference was found between survival of limited resection and lobectomy. Resection may be the modality of choice for treatment of small hepatocellular carcinomas with compensated liver function. Limited resection instead of lobectomy was the key to increased resectability and decreased operative mortality in cirrhotic livers. Reresection of subclinical recurrence was important to prolong survival further.

Long-term survivors after resection for primary liver cancer. Clinical analysis of 19 patients surviving more than ten years

From July 1958 to June 1978, a total of 333 cases with pathologically proven primary liver cancer (PLC) were admitted to the Zhong Shan Hospital, Shanghai Medical University, Shanghai, the people's Republic of China. Of these, 39.6% (132 of 333) were resected and 14.4% (19 of 132) survived over 10 years after resection for PLC. These 19 patients surviving over 10 years were investigated in this paper. All 19 patients underwent radical resection, including right hemihepatectomy in two cases, left hemihepatectomy in ten cases, left lateral segmentectomy in three cases, and local resection in four cases. By the end of June 1988, follow-up varied from 10 years and 1 month to 26 years and 7 months, with a mean follow-up of 15 years and 4 months. All 19 patients are still alive with free of disease. The longest survival patient had a tumor measuring 10 X 8 X 6 cm in size and underwent local resection. Upon follow-up after 26 years and 7 months, the patient was found to be still living and well. Two patients with intraperitoneal ruptured PLC have survived for 19 years and 4 months, and 16 years and 11 months, respectively, after resection of the tumors free of disease and have returned to work. Subclinical recurrence of PLC was discovered in one patient in whom reoperation with cryosurgery was carried out. The patient has been in good condition with negative alpha-fetoprotein (AFP) for 8 years and 10 months after cryosurgery. Subclinical solitary pulmonary metastasis was detected in two patients because of a secondary rise in AFP level. Reoperations were carried out and the metastatic tumors were removed. These two patients are still in good health with negative AFP 9 years and 6 months, and 10 years and 1 months, respectively, after reoperation. These results indicate that early and radical resection are the principal factors influencing long-term survival; reoperation for subclinical recurrence and solitary metastasis remains an important approach to prolong survival further; intraperitoneal rupture of PLC does not exclude the possibility of cure; new surgical techniques, such as cryosurgery and bloodless hepatectomy, have been shown to be effective in some patients.

[Randomized clinical trial of cis-platinum diamminedichloride (PDD) in the treatment of hepatocellular carcinoma (HCC)]

From Oct. 1982 to Apr. 1985, 82 patients with HCC proven by pathology were treated in our hospital. 43 treated by hepatic arterial perfusion, were randomized into PDD group: PDD 10 mg per day X 10, every 3 weeks; control group: fluorouracil (5-Fu) 250 mg per day X 4, every week and thio-tepa (TSPA) 10 mg, twice a week. The other 39 treated by intravenous chemotherapy, were also randomized into PDD group: PDD 20 mg per day X 5, every 3 weeks; control group: 5-Fu 500 mg and TSPA 10 mg, twice a week. The objective response rates were 31.8% (7/22) in PDD group and 23.8% (5/21) in control group by hepatic arterial perfusion, and 20.0% (4/20) in the former and 0% (0/19) in the latter who were treated intravenously. The median survivals were 8 months for all the patients receiving hepatic arterial perfusion, and 6 and 5 months for the intravenous PDD and its control group, respectively. The side effects and kidney toxicity of PDD were tolerable to the patients. It is observed that PDD is better than 5-Fu and TSPA in the treatment of HCC.