[Radioimmunoimaging with monoclonal antibody to HBV X protein in nude mice bearing human hepatocellular carcinoma]

A mouse monoclonal antibody directed against the protein of hepatitis B virus X open reading frame was prepared. After radiolabeled with sodium 131I-iodine and administration, imaging was performed with gamma camera and radioactivity of the tumor, organs, and blood were counted in a mini-gamma counter at day 1, 3, 5, 7 in nude mice bearing HCC xenografts, and the biodistribution and T: NT ratio was calculated. Selective accumulation was observed in tumor sites on day 3 and a clear image of tumor was shown in gamma camera on day 7. The image of tumor in the irrelevant IgG group was not obtained at any time. The tumor:blood ratio was 0.48 and tumor:liver was 1.2 on day 1, then increased to 1.5 and 4.5 on day 7 in experimental group, respectively. Specific mAb uptake by tumor was significantly greater than nonspecific IgG(P < 0.05) on day 7. The results were encouraging. The finding of this study indicates the possibility of using 131I-anti-HBx mAb to target cytostatic drugs to 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.

Evolution of surgery in the treatment of hepatocellular carcinoma from the 1950s to the 1990s

In the 1950s, hepatic lobectomy for huge hepatocellular carcinoma (HCC) has benefited 5-10% of HCC patients; in the 1970s, limited resection for small HCC and reresection for recurrence have benefited another 5-10% HCC patients. Cytoreduction and sequential resection for unresectable HCC might be of benefit to a further 5-10% HCC patients in the 1990s. Analysis of 1,642 patients with pathologically proven HCC in 1959-1991 demonstrated that the series 5-year survival has increased from 3.0% (n = 136) in the 1960s, to 12.2% (n = 440) in the 1970s, to 40.2% (n = 1,066) in the 1980s, which was correlated to the increasing number of limited resections for small HCC, reresections for subclinical recurrence, and cytoreductions and sequential resections for portions of unresectable HCC. With the advances in early detection, multimodality treatment, and changing concepts in surgical oncology, the role of surgery in the treatment of HCC has increased.

Microwave surgery in the treatment of hepatocellular carcinoma

Microwave surgery was employed for the treatment of 50 patients with hepatocellular carcinoma (HCC) and liver cirrhosis, including hepatectomy in 46 patients and in situ coagulation of tumor in 4 patients. In the study, 2,450 MHz microwaves were generated and transmitted to a monopolar needle electrode. For hepatectomy, the needle electrode was inserted into the liver parenchyma to coagulate the liver tissue and this was repeated at 1 cm intervals along the line where incision is anticipated. For unresectable HCC, the needle electrode was directly inserted into HCC to coagulate the cancer in situ. The average amounts of blood loss and blood transfusion for 46 hepatectomies using microwave were 215 +/- 189 ml and 274 +/- 261 ml, respectively. Eighteen patients (39.1%) did not need blood transfusion. A significant lower volume of blood loss and blood transfusion was observed in comparison with 46 matched conventional hepatectomies, 652 +/- 1,008 ml and 841 +/- 878 ml, respectively, all being P < 0.01. There were no operative mortality and complications, such as delayed bleeding, bile leakage, and abdominal infection. These results indicate that microwave surgery can be utilized safely and effectively in the field of liver surgery.

Experience with resection of segment VIII of liver for hepatocellular carcinoma

Hepatic segment VIII is located at the dome of the right liver lobe, next to the intrahepatic inferior vena cava (IVC) and is situated between the right and the middle hepatic veins. Its close relation to the IVC inferior medially makes liver cancer resection in this particular segment extremely difficult and hazardous. A personal series of 32 cases of segment VIII resection for hepatocellular carcinoma performed during the period January 1970-May 1992 is being presented. Most resections could be performed with occlusion of the porta hepatis only but some cases required total hepatic vascular exclusion. Since segment VIII is surrounded by major vessels, the extent of resection is limited in this region. Furthermore, tumor cells are easily disseminated along the vascular route. The long-term results are far from ideal. One-, 3-, and 5-year survival rates were 93.33%, 57.14%, and 28.5%, respectively. However, eight patients in this series have survived 180, 168, 104, 78, 53, 43, 43, and 36 months, respectively, and some of them have returned to work. Therefore, despite the technical difficulties involved in segment VIII resection, it is still worthwhile adopting an aggressive operative approach to this group of patients.

Radioimmunotherapy for unresectable hepatocellular carcinoma using 131I-Hepama-1 mAb: preliminary results

Twenty-three patients with surgically verified unresectable hepatocellular carcinoma (HCC) have been treated by intrahepatic arterial administration of 131I-labeled anti-HCC monoclonal antibody (Hepama-1) combined with hepatic artery ligation. Radioimmunoimaging demonstrated that the median tumor/liver ratio was 2.1 (1.1-3.6) at day 5. A decline in alpha-fetoprotein level and shrinkage of tumor were observed in 75% (12/16) and 78% (18/23) of patients respectively. Sequential resection was done in 11 patients (48%) after treatment. The surgical specimens revealed massive necrosis of tumor, but residual cancer cells were found at the edge of the specimens. Anti-antibody was determined in 43% (10/23) of patients 2-4 weeks after the administration of 131I-Hepama-1 mAb. No marked toxic effects were noted. It is suggested that 131I-Hepama-1 mAb might be of value as one of the multimodality treatments for unresectable HCC.

Resection of segment VIII of liver for treatment of primary liver cancer

The close relationship of hepatic segment VIII to the right and middle hepatic veins and to the inferior vena cava makes liver cancer resection in this region extremely difficult. Resection of segment VIII was performed in 25 patients with primary liver cancer between January 1970 and May 1990. Most resections were performed with just porta hepatis occlusion, but some cases required the technique of total hepatic vascular exclusion, otherwise known as "bloodless hepatic resection." It involved control of both the suprahepatic and infrahepatic inferior vena cavae in addition to control of the porta hepatis. Major modifications to the original technique were made, and the 1-, 3-, and 5-year survival rates were 90.5%, 50.0%, and 37.5%, respectively. Two patients have survived 12 and 15 years, respectively. Both of them are alive to date and have returned to work.

Experience with liver resection after hepatic arterial chemoembolization for hepatocellular carcinoma

The use of percutaneous transcatheter hepatic arterial chemotherapy and embolization in the treatment of primary liver cancer has become increasingly popular in recent years. The authors employed this method, using a combination of cisplatin, mitomycin C, 5-fluorouracil, and ethiodized oil (Lipiodol) or absorbable gelatin sponge in 30 patients with huge liver cancers (diameter range, 5.6-12.0 cm) as a preliminary treatment before liver resection. Significant tumor regression occurred after this treatment, converting these tumors into resectable lesions that were excised successfully later. Before surgery, chemoembolization was done once every 4-6 weeks. The patients underwent 1-5 treatment sessions (mean, 2.9) and then waited 1-4 months (mean, 2.4 months) before undergoing surgery. Alpha-fetoprotein levels decreased to normal in seven patients. The tumor diameters were reduced by 31.6 +/- 15.2% (2.3 +/- 1.2 cm) and the percent tumor necrotic area ranged from 40-100%. Adhesions of the tumor to the diaphragm and thickening of the hepatoduodenal ligament and gallbladder wall were the primary operative findings, but they did not significantly complicate the surgery. There was one postoperative death from acute pulmonary embolism. The 1-year, 2-year, and 3-year survival rates were 88.89%, 77.03%, and 77.03%, respectively. Although these patients still are being followed to assess their long-term survival, this treatment appears promising for patients with advanced huge liver cancers who hitherto have been denied surgery on grounds of unresectability.

The role of cryosurgery in the treatment of hepatic cancer: a report of 113 cases

From November 1973 to June 1992, cryosurgery with liquid nitrogen (-196 degrees C) was performed on 113 patients with hepatic cancer, including 107 patients with primary liver cancer (PLC) and 6 patients with secondary liver cancer (SLC). Of the 107 PLC patients, the subclinical stage constituted 30.8% (33/107), the moderate stage 61.7% (66/107), and the late stage 7.5% (8/107). There were 32 cases with small PLC (up to 5 cm). Liver cirrhosis was observed in 86.0% (92/107). We designed flat cryoprobes for freezing tumors deep within the hepatic parenchyma. Intraoperative ultrasound was used for monitoring hepatic cryolesions. There were no operative mortalities and complications, such as rupture of a tumor, delayed bleeding, or bile leakage. The 5-year and 10-year survival rates were 22.0% and 8.2%, respectively, for the 107 PLC patients and 48.8% and 17.1%, respectively, for the 32 patients with small PLC. Of the 6 SLC patients, survival ranged from 2 months to 90 months (average, 23.2 months). One SLC patient has been well for 7 years and 6 months after cryosurgery. These results indicate that cryosurgery, the in situ freezing of cancer, is a safe and effective treatment for unresectable hepatic cancer.

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.

Experience with liver resection after hepatic arterial chemoembolization for hepatocellular carcinoma

The use of percutaneous transcatheter hepatic arterial chemotherapy and embolization in the treatment of primary liver cancer has become increasingly popular in recent years. The authors employed this method, using a combination of cisplatin, mitomycin C, 5-fluorouracil, and ethiodized oil (Lipiodol) or absorbable gelatin sponge in 30 patients with huge liver cancers (diameter range, 5.6-12.0 cm) as a preliminary treatment before liver resection. Significant tumor regression occurred after this treatment, converting these tumors into resectable lesions that were excised successfully later. Before surgery, chemoembolization was done once every 4-6 weeks. The patients underwent 1-5 treatment sessions (mean, 2.9) and then waited 1-4 months (mean, 2.4 months) before undergoing surgery. Alpha-fetoprotein levels decreased to normal in seven patients. The tumor diameters were reduced by 31.6 +/- 15.2% (2.3 +/- 1.2 cm) and the percent tumor necrotic area ranged from 40-100%. Adhesions of the tumor to the diaphragm and thickening of the hepatoduodenal ligament and gallbladder wall were the primary operative findings, but they did not significantly complicate the surgery. There was one postoperative death from acute pulmonary embolism. The 1-year, 2-year, and 3-year survival rates were 88.89%, 77.03%, and 77.03%, respectively. Although these patients still are being followed to assess their long-term survival, this treatment appears promising for patients with advanced huge liver cancers who hitherto have been denied surgery on grounds of unresectability.

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)

[Surgical treatment of 1450 patients with hepatocellular carcinoma]

An analysis of 1450 patients with pathologically and surgically proved hepatocellular carcinoma (HCC) revealed a steadily increased 5-year survival rate of 2.8% (1958-1968), 10.5% (1969-1979), and 36.6% (1980-1990), owing to increased number of cases with small HCC (0.9%, 9.9%, 25.2%, respectively), more and more patients undergoing tumor resection (0, 14, 59) and preoperative tumor bulk reduction for otherwise unresectable HCC (0, 1, 33 cases). Small HCC resection (n = 250) resulted in a high 5-year survival rate as compared to non-small HCC resection (n = 491) (66.3% versus 31.2%). The 5-year survival of 73 patients undergoing tumor re-resection was 40.6%, and the 5-year survival of 34 patients having second stage resection was as high as that of those having small HCC resection (62.0%). 125 patients survived more than 5 years; of these 65 underwent small HCC resection, and 43 non-small HCC resection. Thus, early resection, re-resection for subclinical recurrence, and second stage resection for originally unresectable HCC play an important role in improving prognosis of HCC.

Mutations on free and integrated hepatitis B virus DNA in a hepatocellular carcinoma: footprints of homologous recombination

Hepatitis B virus nucleotide sequences derived from a hepatocellular carcinoma with free and multiply integrated viral DNAs were determined. Based on a comparison within the X-gene region, cloned free viral DNA previously had been attributed to two distinct groups of preC minus genomes. The comparison of the complete sequence identified one of the genome equivalents as a recombinant between members of these groups. Four different integrated viral DNA elements were cloned and analysed. Similarity to either one of two DNAs representing the two groups of free viral DNA on one hand and the presence of certain mutations only on integrated DNA on the other hand, allowed to recognize distinct segments within the integrants. The data suggest a contribution of different but related genotypes to contiguous stretches of integrated viral DNA via homologous recombination. On this basis an evolutionary relationship between free and integrated DNAs of the preC and the preC minus genotype could be recognized when short sequence segments were compared. The observed coexistence on a given integrated DNA of segments homologous to free viral DNA and of segments homologous to another integrated DNA is consistent with (1) a long lasting association of individual genotypes with dividing cells and (2) multiple integration events being the result of a series of steps not separated by a long time span.

Current management of hepatocellular carcinoma

After a long, hopeless period in the management of hepatocellular carcinoma (HCC), the diagnosis and treatment of HCC have progressed remarkably in the past decade. In particular the discovery of asymptomatic HCC in the early 1970s opened up a new era in clinical research of HCC. With the progress in the diagnostic imaging of liver tumors, a 1 cm hepatic mass can now be detected. It is especially worth noting that a 5-year survival rate of 72.9% has been achieved after the resection of the tumor in asymptomatic HCC patients. The role of surgery in the treatment of HCC has become more important. Various modalities of medical treatment and combination therapy have been recommended and used. Despite the progress in the early diagnosis and treatment of HCC, a complete cure is very rare. Problems to be studied include new tumor markers for the early detection of alpha-fetoprotein (AFP)-negative HCC, the development of more specific treatments for unresectable HCC with uncompensated cirrhosis, and an effective approach to preventing recurrence and metastasis after radical resection.

Hepatic artery ligation and infusion chemotherapy for unresectable primary liver cancer

During the period of 1958-1989, 356 patients with pathologically proven primary liver cancer (PLC) were determined by laparotomy to be unresectable. Of the 356 patients, 51 (14.3%) were of subclinical stage, 287 (80.6%) of moderate stage and 18 (5.1%) of late stage. The association of liver cirrhosis was present in 310 patients (87.1%). Treatment modalities in 356 patients were divided into 4 groups: hepatic artery ligation (HAL) (51), hepatic artery infusion (HAI) of chemotherapeutic agents (114), HAL + HAI (117), and HAL + HAI + radiotherapy (74). The 5-year survival rate was zero in the 4 groups in the period of 1958-1977. During 1978-1989, however, the 5-year survival rate was zero in HAL, 7.9% in HAI, 24.4% in HAL + HAI (with second look resection in 10 patients), and 36.5% in HAL + HAI + radiotherapy (with second look resection in 19). The marked improvement in survival in later period was attributable to the accurate site of hepatic artery catheter, longer infusion chemotherapy, and combination treatment, particularly second look resection in some of the patients. These results indicate that HAL + HAI + combination treatment might provide a possible prolongation of survival or even resection in some patients with original unresectable PLC.

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.

Preliminary result of mixed bacterial vaccine as adjuvant treatment of hepatocellular carcinoma

Mixed bacterial vaccine (MBV) was employed in the multi-modality treatment of hepatocellular carcinoma (HCC) during 1985-1988. Thirty eight patients undergoing palliative resection and cisplatin therapy (Series 1) and 48 patients with unresectable HCC who received hepatic artery ligation + intraarterial cisplatin infusion + radiotherapy (Series 2) were randomized to receive MBV or not. In series 1, the 1- and 2-year survival rates of MBV group and control were 75% vs 58% (P = 0.19) and 45% vs 39% (P = 0.23). In series 2, the 1-, 2- and 3-year survival rates were 59%, 41% and 41% for MBV group and 39%, 25% and 20% for the control, respectively (P1 = 0.07, P2 = 0.09, P3 = 0.07). In addition, MBV improved the "second look" resection rate to 40% as compared to 17% in the control (P greater than 0.05). MBV could also prevent such immunosuppression as decrease of macrophage activity caused by radiotherapy. We consider MBV a potential nonspecific immunostimulant in the multimodality treatment of HCC.

Resection of the primary liver cancer of the hepatic hilus

Primary liver cancer (PLC) of the hepatic hilus was designated as a tumor situated at the main branch of the portal vein or pedicle of the hepatic veins in contact with the intrahepatic vena cava. That is, the main tumor located at segment I, IV, V, or VIII and concentrating on the central part of the liver was called "the central type of PLC," which differed from a tumor located at segment II, III, VI, or VII; the latter was called "the peripheral type of PLC." Surgical treatment of the PLC has been significantly improved in the past two decades, but the resection of the central type of PLC is difficult and hazardous. This institution admitted 903 PLC from January 1970 to April 1988, of which 118 cases were the central type; 65 cases were resected successfully, a resectability of 55.1%. One patient died from sepsis within 1 month of operation (mortality 1.53%). The modes of operation for the different segments are described, and suggestions for improvements are presented. The survival rates were compared with a similar number of patients with the peripheral type of tumor in the same period and treated by the same surgeons. The results show noticeable differences. The one-year, three-year, and five-year survival rates after resection were 70.9%, 43.2%, and 39.2% in the central type of PLC; they were 98.3%, 85.0%, and 76.4% in the peripheral type of PLC (P less than 0.001). Further discussion of improvements in surgical techniques and mental awareness are suggested.

Resection of hepatocellular carcinoma: oligocentric origin of recurrent and multinodular tumours

The structure of integrated hepatitis B virus (HBV) DNA was analysed to determine the origin of recurrent and multinodular hepatocellular carcinoma (HCC). In 5 cases, recurrent tumours were compared with the respective primary tumours, all of which had chromosomally integrated viral DNA. In only one of these cases, an identical HBV DNA integration pattern was found, indicating a monocentric origin of primary and secondary tumour. In all other cases a polycentric origin was deduced. Particular features observed were: (i) the apparent absence of integrated viral DNA in a recurrent tumour; and (ii) an integration pattern identical to that of the primary tumour and a distinct new pattern in two different foci of multinodular recurrent HCC. For multinodular primary HCC one case was analysed and found to be of independent origin.

Radioimmunotherapy in the multimodality treatment of hepatocellular carcinoma with reference to second-look resection

Experimental study using nude mice human hepatocellular carcinoma (HCC) xenograft indicated that the combination treatment with iodine 131 (131I)-anti-human HCC isoferritin (131I-isoFtAb), cisplatin, and mixed bacterial vaccine (MBV) yielded better inhibition rate as compared with double combination or 131I-isoFtAb alone. Based on these findings, 25 patients with surgically proven nonresectable and pathologically proven HCC have been treated by radioimmunotherapy using 131I-isoFtAb intrahepatic arterial infusion as a part of multimodality treatment. Of the 25 patients, seven (28.0%) received second-look resection after marked shrinkage of tumor. The 1-year survival was 52.5% (12/23) and 2-year survival 27.7% (five of 18) in the entire series. Of the five patients with 2-year survival, four were in the second-look resection group. Patients with tumor less than or equal to 8 cm showed higher second-look resection rate (62.5% versus 11.8%) and 1-year survival (85.7% versus 37.5%) as compared with tumor greater than 8 cm. Mixed bacterial vaccine as adjuvant immunotherapy seemed effective to prolong survival. The 2-year survival was higher in patients with second-look resection as compared with those without (75.0% versus 14.3%). Thus, radioimmunotherapy using 131I-isoFtAb might be one of the modalities of choice, particularly in the conversion of nonresectable to resectable HCC in a well-designed multimodality treatment regimen.

[Multimodality treatment and two-stage resection for unresectable hepatocellular carcinoma--experimental and clinical studies]

During the period 1978-1987, 255 patients with pathologically proven hepatocellular carcinoma (HCC) were assessed to be unresectable by laparotomy. Of them 155 had their tumors chiefly confined in the right or left lobe. Second stage resection was performed in 26 (16.8%) after marked reduction of the tumor by combination treatment with hepatic artery ligation (HAL) + hepatic artery infusion chemotherapy (HAI) + multifractionated radiotherapy (MFD) with linear accelerator, or radioimmunotherapy using 131I-anti human HCC ferritin antibody (131I-FtAb), which yielded the highest second stage resection rate (29.8%, 14/47) as compared to HAL + HAI or HAL + cryosurgery (16.9%, 12/71), HAL or HAI (0%, 0/37) alone. The 3 year survival rate of the 26 patients with second stage resection was 74.3%, comparable with those of small HCC resection (82.7%, n = 111) and radical resection of large HCC (56.1%, n = 122) in the same period. Experimental study using nude mice bearing human HCC also showed the superiority of triple (MFD or 131I-FtAb + Cisplatin PDD + mixed bacterial vaccine MBV) versus double (MFD or 131I-FtAb + PDD, or MFD or 131I-FtAb + MBV) and double versus single treatment modality. Both experimental and clinical data indicated that immunosuppression after radiotherapy was prevented by adjuvant immunotherapy (MBV). Thus, this treatment model provides an opportunity for resection or even cure in a part of patients with unresectable HCC confined in one lobe.

Replication of hepatitis B virus in a hepatocellular carcinoma

Hepatitis B virus transcripts and DNA from paired samples of neoplastic and nonneoplastic liver tissue of HBsAg seropositive patients were analyzed. The data obtained support the view that transcription of integrated DNA is frequent, both in neoplastic as well as in nonneoplastic liver tissue. In the case of one patient, integrated and free forms of hepatitis B virus DNA were detected in the tumor. Complete cycles of viral replication in this tumor were suggested by the following markers: (i) DNA and RNA intermediates expected to occur during replication of the viral genome, (ii) HBcAg and HBsAg, (iii) core and Dane particles. Viral DNA cloned from tumor tissue was proven to be replication competent in a transient replication assay. Five independent clones of viral DNA were established and found to be closely related at the nucleotide level. A preX open reading frame and a stop codon within preC were common features. In tissue surrounding the tumor, a nonreplicative state of virus infection prevailed, characterized by free viral DNA exclusively of the covalently closed, circular form. The replication of the viral DNA appeared to be blocked at the level of transcription.

[Diagnosis of congenital CMV infection by specific CMV IgM antibody in cord serum with ELISA]

Cytomegalovirus IgM (CMV IgM) antibodies of 582 cord sera from 6 hospitals in Chengdu were detected by direct ELISA and indirect ELISA. Twenty-seven cases with CMV IgM antibody positive were detected from 582 cord sera. Twenty-five and 15 cases were found to have CMV IgM antibody by direct ELISA and indirect ELISA, respectively (P greater than 0.05). Indirect ELISA for detection CMV IgM antibody was only interfered by high concentration of CMV IgG and rheumatoid factor. Children with CMV IgM antibody positive were followed-up to 5-6 months. Hearing loss was detected by impedance audiology in only 2 cases. But the other physical and mental examinations were normal. The result showed that the prevalence of congenital CMV infection is 4.6% in our study and direct ELISA method is more specific and sensitive than indirect ELISA method to detect CMV IgM antibody in cord serum.

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.

Acquired cytomegalovirus infection of breast milk in infancy

A cross-sectional study was conducted to examine the rate of cytomegalovirus (CMV) shedding through breast feeding and the rate of acquired infection by the infants. Among the 104 seropositive breast-feeding mothers, CMV was recovered in the milk in 19 cases, with a milk shedding rate of 18.3%. Isolation of CMV from the urine of the infants of the 188 seropositive mothers found 36 positive cases. Of the 36 cases, 15 of 19 fed on CMV-positive milk were infected through breast-feeding, with an infection rate of 78.9%; 11 of the 85 fed on CMV-negative milk were infected, the infection rate being 12.9%; and 10 (11.9%) of 84 fed on cow's milk were infected. These demonstrate that the rate of infection in infants fed on virus-positive milk was significantly higher than those fed on virus-negative milk or cow's milk (P less than 0.005).

Radioimmunotherapy for hepatocellular carcinoma (HCC) using 131I-anti HCC isoferritin IgG: preliminary results of experimental and clinical studies

Based on radioimmunoimaging for HCC using 131I-anti HCC isoferritin IgG, the experimental and clinical studies on radioimmunotherapy for HCC were reported. Thirty-six nude mice bearing human HCC were used for the study of labeled IgG, pure 131NaI and pure IgG. In the labeled IgG group, the tumor inhibition rate was significantly higher than that in other groups (81%, 60%, and 18%, respectively, p less than 0.05). The tumor cell DNA analysis showed the tumor cell was inhibited in the S stage of the cell cycle. Twenty pathologically proven unresectable HCC patient were treated by 131I-antihuman HCC isoferritin IgG 20-55mCi monthly for 1-3 times (via hepatic arterial catheter or intravenously). The short-term response was promising, a decline in AFP level and shrinkage of tumor were observed in 80% (12/15) and 65% (13/20) of patients respectively. Sequence resection was successful in five patients (5/20) after radioimmunotherapy. No marked toxic effects were noted in our limited experience, but some problems remain to be discussed.

Low incidence and high titers of antibodies to hepatitis B virus X-protein in sera of Chinese patients with hepatocellular carcinoma

Sera of patients from China with hepatocellular carcinoma (HCC) were tested for the presence of HBc/HBe- and HBx antibodies by immunoblotting using recombinant MS2 or beta gal fusion proteins as substrate. Antibodies against HBx were detected in four out of 68 HBsAg positive and in one out of three HBsAg negative sera, antibodies against HBc/HBe in 52 and two serum samples, respectively. Competition experiments in which sera were preincubated with individual viral proteins synthesized in E. coli were carried out to demonstrate the specificity of signals obtained in immunoblot analyses. In the five anti-HBx positive sera, the antibody titer against X fusion protein was higher than against core fusion protein and in one of these sera anti-x activity could be demonstrated even at a serum dilution of 1:50,000. These data indicate that X antibodies occur rarely in Chinese patients and are not serodiagnostic for HCC. The high titer of X antibodies in some patients shows that the X protein can be highly immunogenic in vivo. Induction of antibody formation may be triggered by X protein expressed from integrated viral DNA.

Clinical evaluation of cryosurgery in the treatment of primary liver cancer. Report of 60 cases

Cryosurgery with liquid nitrogen was employed for the treatment of 60 patients with primary liver cancer (PLC) at the Liver Cancer Research Unit, Zhong Shan Hospital, Shanghai Medical University, the People's Republic of China, from November 1973 to August 1987. Of 60 patients, subclinical stage amounted to 35% (21/60), moderate stage 55% (33/60) and late stage 10% (6/60). There were 21 cases with small PLC (less than or equal to 5 cm). The postoperative course was uneventful in all of the 60 patients. These was no operative mortality, and there was no complications such as rupture of tumor, secondary bleeding, bile leakage, or abdominal infection. The 1-year, 2-year, 3-year, 4-year, and 5-year survival rates were 51.7% (30/58), 33.9% (19/56), 20.8% (11/53), 15.6% (7/45), and 11.4% (5/44), respectively, for the whole series. Among the 21 patients with tumor nodules less than or equal to 5 cm in diameter, the 1-year, 2-year, 3-year, 4-year, and 5-year survival rates were 76.2% (16/21), 61.9% (13/21), 50.0% (9/18), 41.2% (7/17), and 37.5% (6/16), respectively. These results indicate that hepatic cryosurgery is a promising, safe, and simple treatment for neoplastic disease of liver. Cryosurgery with liquid nitrogen can be considered the surgery of choice for nonresectable PLC in patients without jaundice, ascites, and noncompensated liver function, and the whole tumor mass can be involved in the frozen area.

Clinical evaluation of cryosurgery in the treatment of primary liver cancer. Report of 60 cases

Cryosurgery with liquid nitrogen was employed for the treatment of 60 patients with primary liver cancer (PLC) at the Liver Cancer Research Unit, Zhong Shan Hospital, Shanghai Medical University, the People's Republic of China, from November 1973 to August 1987. Of 60 patients, subclinical stage amounted to 35% (21/60), moderate stage 55% (33/60) and late stage 10% (6/60). There were 21 cases with small PLC (less than or equal to 5 cm). The postoperative course was uneventful in all of the 60 patients. These was no operative mortality, and there was no complications such as rupture of tumor, secondary bleeding, bile leakage, or abdominal infection. The 1-year, 2-year, 3-year, 4-year, and 5-year survival rates were 51.7% (30/58), 33.9% (19/56), 20.8% (11/53), 15.6% (7/45), and 11.4% (5/44), respectively, for the whole series. Among the 21 patients with tumor nodules less than or equal to 5 cm in diameter, the 1-year, 2-year, 3-year, 4-year, and 5-year survival rates were 76.2% (16/21), 61.9% (13/21), 50.0% (9/18), 41.2% (7/17), and 37.5% (6/16), respectively. These results indicate that hepatic cryosurgery is a promising, safe, and simple treatment for neoplastic disease of liver. Cryosurgery with liquid nitrogen can be considered the surgery of choice for nonresectable PLC in patients without jaundice, ascites, and noncompensated liver function, and the whole tumor mass can be involved in the frozen area.

[Alteration of plasma amino acid content in primary liver cancer patients]

Twenty-two plasma free amino acid contents from 22 primary liver cancer (PLC) patients were assayed by means of HPLC and compared with those from 16 normal subjects. The results showed that in PLC patients, plasma total amino acid (TAA), branched chain amino acid (BCAA), glycogenic amino acid, glutamine, histidine and arginine were lowered, while plasma aromatic amino acid (AAA) and methionine did not decrease significantly resulting in the BCAA/AAA ratio decline. Comparing 8/22 subclinical and 14/22 clinical liver cancers with healthy controls respectively, it was found that there was a decrease of plasma TAA, glutamine, arginine, histidine, BCAA and BCAA/AAA ratio, and an increase of tyrosine, in subclinical stage of PLC. It suggests that alteration of most amino acids occur in the early stage of PLC and become more obvious in the moderate and late stages. The changes of plasma amino acid contents in PLC were different from those in chronic liver diseases. The alteration of plasma amino acid contents in subclinical stage of PLC suggests that the disturbance of amino acid metabolism be resulted from malignancy. Correction of the amino acid metabolic disturbance in PLC patients may enhance the inhibition of tumor growth and improve the host metabolism and anti-cancer effect.

[Small hepatocellular carcinoma (HCC) and its remote outcome]

Comparative study of 92 cases of pathologically proven small HCC (less than or equal to 5 cm) and 787 clinical HCC treated and followed in Zhongshan Hospital from 1958 to 1984 demonstrated that: 1. Resection of small HCC is the best way for long survival, 26 of the 51 patients who survived for more than 5 years had had small HCC. 2. The increase of the 5 year survival rates from 1.7% (1958-1966) through 7.1% (1967-1975) to 22.6% (1976-1984) of the whole series is due to the increase of proportion of small HCC (0%, 7.2% and 15.1%) in the respective periods. 3. In comparison to clinical HCC, small HCC showed higher resection rate (28.7% vs 85.9%), lower operative mortality (9.7% vs 1.3%) and better 5 year survival (19.9% vs 70.3%). 4. Concepts of early detection, early diagnosis, surgical treatment, management of recurrence and metastasis, prognosis, natural history of HCC, early development of HCC, etc. may be changed basing on this study. Reoperation of subclinical recurrence after small HCC resection has improved the 5 year survival from 56.2% in 1981 to 70.3% in this study.

[Natural killer cell activity of the peripheral blood in patients with hepatocellular carcinoma]

Using 125IudR labeled K562 cells as target cells, peripheral blood of 56 patients with hepatocellular carcinoma (HCC) was studied for natural killer cell (NK cell) activity. The results show that the NK cell activity is in normal range of 53.97 +/- 4.42% and 50.85 +/- 3.55% in stages I and II of HCC but in stage III, the NK cell activity is markedly depressed, only 31.63 +/- 5.55%. The NK cell activity is much lower in HCC patients with metastasis than without metastasis (33.67 +/- 5.37% versus 50.22 +/- 2.79%). So is it in patients with high concentration than with low concentration of AFP except patients with advanced lesion and low concentration of AFP. After effective treatment, the NK cell activity increased in 10 of 11 patients treated with radical and palliative resection and in 6 of 9 after immunotherapy with BCG, mixed bacterial vaccine or interferon.

[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.

The changing role of surgery in the treatment of primary liver cancer

For decades, the role of surgery in the treatment of primary liver cancer (PLC) was important but limited. However, a comparison of pathologically proven PLC during the three periods 1958-1966, 1967-1975, and 1976-1984 revealed that as a result of alpha fetoprotein (AFP) serosurvey, changing concepts in surgical oncology, and introduction of new surgical modalities, the role of surgery has become greater. The increasing proportion of subclinical PLC (0, 7.2, and 21.2%) has favored the increasing series resection rate (16.1, 34.7, and 39.6%) and palliative surgery (13.7, 17.0, and 29.8%). The results indicated that early resection, reoperation for subclinical recurrence, resection of huge PLC in stages, and combination of palliative surgery other than resection might be responsible for the increasing 5-year survival rate (1.7, 7.1, and 19.5%) in the entire series.