Management of hepatocellular carcinoma

An analysis of the UNOS liver transplant registry: high serum alpha-fetoprotein does not justify an increase in MELD points for suspected hepatocellular carcinoma

The current United Network for Organ Sharing (UNOS) criteria for liver transplantation gives priority to patients with elevated serum alpha-fetoprotein (AFP; > or = 500 ng/mL) in the absence of radiologic evidence of a hepatic mass. Reports have shown that an elevated serum AFP is a poor diagnostic indicator for hepatocellular carcinoma (HCC) in patients with cirrhosis. Our aim was to determine if an AFP level above 500 ng/mL, in the absence of a liver mass by imaging study, correlates with the presence of HCC. Using the UNOS database we identified all patients transplanted for HCC in the United States between February 2002 and October 2005 based on these criteria. The data collected included: patient demographics, clinical information, and pathological outcomes. The data was analyzed using a chi-squared t-test and confirmed by logistic regression modeling. A total of 22 patients received a cadaveric liver transplant, while 1 received a living donor transplant during the study period. HCC was confirmed posttransplantation in only 6 patients (26%). There was no difference in race, gender, etiology of liver disease, or AFP level between patients with and without HCC but a significant difference in age (59.8 yr for HCC patients vs. 51.3 yr for the non-HCC group; P = 0.01). In conclusion, the majority of the patients who received extra Model for End-Stage Liver Disease (MELD) points based on an elevated AFP did not have HCC. Older age was a significant predictor for the presence of HCC in patients with a serum AFP greater than 500 ng/mL. These results demonstrate the poor correlation of serum AFP with the presence of HCC in patients awaiting liver transplantation.

Small hepatic nodules (< or =2 cm) in cirrhosis patients: characterization with contrast-enhanced ultrasonography

AIM

We evaluated the efficacy of contrast-enhanced ultrasonography (CEUS) for the characterization of small hepatic nodules (< or =2 cm) in cirrhosis patients.

PATIENTS AND METHODS

Thirty cirrhosis patients with 30 hepatic nodules (1-2 cm) were enrolled in this study. Eighteen hepatic nodules were hepatocellular carcinomas (HCC) and 12 were benign lesions. CEUS was performed using microbubble contrast (Levovist). With surrounding hepatic parenchyma as a reference, two characteristics of hepatic nodules, including arterial phase enhancement (AE) and the absence of delayed phase enhancement (ADE), were evaluated as criteria for the diagnosis of HCC. A radiologist independently reviewed the dynamic computed tomographies (CT) of 26 hepatic nodules.

RESULTS

CEUS showed AE in 15 nodules (13 HCC and two benign) and ADE in 17 lesions (14 HCC and three benign). For HCC, the coincidental AE of both CEUS and dynamic CT was 40%. Using both AE and ADE for HCC diagnosis, the sensitivity, specificity, accuracy, positive predictive value and negative predictive values were 55.6%, 91.7%, 70%, 90.9% and 57.9%, respectively. When using either AE or ADE for HCC diagnosis, the same parameters were 94.4%, 66.7%, 83.3%, 81% and 88.9%, respectively. One benign hepatic nodule with both AE and ADE was diagnosed as HCC 29 months after the CEUS study.

CONCLUSIONS

A combination of characteristics of AE and ADE as determined by CEUS was highly specific for small HCCs in cirrhosis patients. Concurrent delayed phase imaging is useful in the diagnosis of small hypovascular HCCs.

Correlation between enhancement pattern of hepatocellular carcinoma on real-time contrast-enhanced ultrasound and tumour cellular differentiation on histopathology

The objective of this study was to evaluate the correlation between the enhancement pattern of hepatocellular carcinoma (HCC) on contrast-enhanced ultrasound (CEUS) and tumour cellular differentiation on histopathology. 189 HCC lesions in 189 patients were retrospectively evaluated with CEUS and histopathological examination. CEUS was performed with SonoVue and contrast pulse sequencing. Histopathological diagnoses were made according to the Edmonson grading system. Significant differences were shown between the time that the HCC became hypoenhancing or remained echogenic in late phase and tumour cellular differentiation (p = 0.006; p = 0.036), but not with the time of commencement of hyperenhancing or commencement of isoenhancing in arterial phase and portal phase (p = 0.164, p = 0.113; p = 0.186, p = 0.070). The timing of HCC becoming hypoenhancing on CEUS is correlated with tumour cellular differentiation; well differentiated tumours wash out more slowly than poorly differentiated ones.

Hepatic changes in the failing Fontan circulation

BACKGROUND

The failing Fontan circulation is associated with hepatic impairment. The nature of this liver injury is poorly defined.

OBJECTIVE

To establish the gross and histological liver changes of patients with Fontan circulation relative to clinical, biochemical and haemodynamic findings.

METHODS

Patients were retrospectively assessed for extracardiac Fontan conversion between September 2003 and June 2005, according to an established clinical protocol. Twelve patients, mean age 24.6 (range 15.8-43.4) years were identified. The mean duration since the initial Fontan procedure was 14.1 (range 6.9-26.4) years.

RESULTS

Zonal enhancement of the liver (4/12) on CT was more common in patients with lower hepatic vein pressures (p = 0.007), and in those with absent cardiac cirrhosis on histological examination (p = 0.033). Gastro-oesophageal varices (4/12) were more common in patients with higher hepatic vein pressure (21 (6.3) vs 12.2 (2.2) mm Hg, p = 0.013) and associated with more advanced cirrhosis (p = 0.037). The extent of cirrhosis (7/12) was positively correlated with the hepatic vein pressure (r = 0.83, p = 0.003). A significant positive correlation was found between the Fontan duration and the degree of hepatic fibrosis (r = 0.75, p = 0.013), as well as presence of broad scars (r = 0.71, p = 0.021). Protein-losing enteropathy (5/12) occurred more frequently in patients with longer Fontan duration (11.7 (3.2) vs 17.9 (6.1) years, p = 0.038).

CONCLUSIONS

Liver injury, which can be extensive in this patient group, is related to Fontan duration and hepatic vein pressures. CT scan assists non-invasive assessment. Cardiac cirrhosis with the risk of developing gastro-oesophageal varices and regenerative liver nodules, a precursor to hepatocellular carcinoma, is common in this patient group.

Technology insight: Image-guided therapies for hepatocellular carcinoma--intra-arterial and ablative techniques

Locoregional techniques have become the mainstay of therapy for patients with unresectable hepatocellular carcinoma (HCC). Such image-guided interventions include catheter-based approaches (transarterial chemoembolization and yttrium-90 radiotherapy) and locoregional ablative techniques, either chemical (percutaneous ethanol injection), or thermal (radiofrequency ablation, laser ablation, microwave ablation and cryoablation). These therapies are mainly utilized for palliation, but have also been used with curative intent. In selected cases, percutaneous interventional treatments have shown good results (5-year survival 40-50%), but, even when chosen as first-line treatment, have not been able to achieve the response rates and outcomes achieved by surgical options (resection or transplantation). New promising image-guided therapies are continuously emerging, as we attempt to improve tumor targeting, minimize hepatic toxicity and ultimately improve quality of life and survival of patients with HCC. With new technologies in imaging and drug delivery becoming available, it is likely that, in the future, patients with HCC will be best treated by a multidisciplinary team approach, utilizing a combination of techniques to improve patient survival. This review outlines the current status of the most commonly used image-guided locoregional interventions in the treatment of patients with HCC, and describes recent research and advances related to image-guided interventions for liver cancer.

Do young hepatocellular carcinoma patients have worse prognosis? The paradox of age as a prognostic factor in the survival of hepatocellular carcinoma patients

BACKGROUND/AIMS

Our previous study showed that male hepatocellular carcinoma (HCC) patients below 40 years of age had the worst survival in the initial several years, but had the best prognosis thereafter. Thus, it seems that age has a paradoxical influence on the prognosis. To further clarify the issue of age on HCC prognosis, we initiated this study.

METHODS

A total of 11,312 HCC cases from seven medical centers from 1986 to 2002 were included. We analyzed the 1-year survival and survival after 1 year.

RESULTS

Male gender, age younger than 40 years old and hepatitis B virus (HBV) were associated with worse 1-year survival. In contrast, male gender, age younger than 40 years old and HBV were associated with better survival after 1 year. Higher percentage of the young HCC patients had a tumor size larger than 3 cm. 83.7% of HCC patients below 40 years of age were male and 89.8% of them were HBV carriers.

CONCLUSIONS

If we encountered a young HCC patient, the patient will probably be a male HBV carrier. He would probably have larger tumor and is more likely to expire within 1 year than the older HCC patients. However, if the young HCC patient can survive for more than 1 year, he would probably have better survival in the following years than the older patients.

Elevated plasma osteopontin levels in patients with hepatocellular carcinoma

OBJECTIVES

Osteopontin (OPN) is a secreted glycoprotein, frequently associated with various tumors. We investigated the usefulness of plasma OPN level as a biomarker for hepatocellular carcinoma (HCC).

METHODS

We determined plasma levels of OPN, alpha-fetoprotein (AFP), and prothrombin induced by vitamin K absence II (PIVKA II) in a group of 62 HCC patients, in 60 patients with chronic liver diseases, and in 60 healthy control individuals using a standardized ELISA kit. To determine the source of elevated plasma level of OPN, immunohistochemical analysis of 285 HCC samples on tissue microarray was performed.

RESULTS

Plasma OPN levels in the HCC patients (median 954 ng/mL, range 168-5,742) were significantly higher (p-value < 0.001) than those patients with chronic liver diseases (381 ng/mL, 29-1,688) or of a healthy control group (155 ng/mL, 10-766). Within the HCC patient group, plasma OPN level increased significantly with advancing degree of Child-Pugh class and of tumor stage. Diagnostic sensitivity and specificity of OPN for HCC was 87% and 82%, respectively (cut-off value: 617.6 ng/mL). OPN had a greater area under curve value (0.898) than AFP (0.745) or PIVKA II (0.578), suggesting superior diagnostic accuracy of OPN. Immunohistochemistry of 285 samples of HCC showed that OPN was expressed in 92 of 285 tumors (32.3%). OPN expression was found in the malignant hepatocytes and cancer-infiltrating macrophages, not in the noncancerous hepatocytes or Kupffer cells.

CONCLUSIONS

These data propose elevated plasma OPN levels as a potential biomarker for HCC.

The AST/ALT ratio as an indicator of cirrhosis in patients with PBC

OBJECTIVES

A non-invasive, simple and non-expensive test to predict cirrhosis would be highly desirable. The aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio has been proven to be such an indicator of cirrhosis in alcoholic liver disease, hepatitis C.

AIM

To test whether the AST/ALT ratio is a marker of cirrhosis also in patients with primary biliary cirrhosis (PBC).

METHODS

The study consisted of 160 patients. In 126 patients, we had clinical and laboratory data at the time of diagnosis and follow-up with outcome: liver-related death, liver transplantation and survival. In 121 patients, we had laboratory data and liver histology.

RESULTS

We found that the AST/ALT ratio was significantly higher in cirrhotic patients than in non-cirrhotic patients. A high AST/ALT ratio was significantly associated with esophageal varices and ascites. In a multivariate analysis, bilirubin and ALP were predictors of poor prognosis.

CONCLUSION

The AST/ALT ratio seems to be of clinical value as a hint to the diagnosis of cirrhosis in patients with PBC but not as a prognostic factor.

Clinical features, biochemical parameters, and virological profiles of patients with hepatocellular carcinoma in Hong Kong

BACKGROUND

Clinical features of hepatocellular carcinoma patients are changing because of screening.

AIM

To examine the clinical features of hepatocellular carcinoma patients in Hong Kong and validity of different staging systems.

METHODS

A total of 223 Chinese patients with hepatocellular carcinoma were studied.

RESULTS

Seventy-eight percent of hepatocellular carcinoma patients had chronic hepatitis B (43% diagnosed by screening). Hepatitis B positivity, weight loss, jaundice, encephalopathy, alpha-fetoprotein level, portal vein thrombosis, extrahepatic metastasis, and treatment were shown to be independent factors affecting survival. Of chronic hepatitis B patients, hepatitis B virus DNA levels (P = 0.001) and portal vein thrombosis (P = 0.008) were independent factors affecting survival. Seventy-six percent of chronic hepatitis B patients with hepatocellular carcinoma were hepatitis B e antigen negative. Screening patients had hepatocellular carcinoma detected at an earlier stage and better survival (median survival: 21 vs. 4 months, P < 0.0001). All staging systems had good stratification of survival. Prognosis and median survival generated were different when compared with the US data.

CONCLUSIONS

Chronic hepatitis B was the most common cause of hepatocellular carcinoma in Hong Kong. High-risk chronic hepatitis B patients should be followed irrespective of the hepatitis B e antigen status. Hepatitis B virus DNA levels at the time of diagnosis are an important survival predictor. Screening detected hepatocellular carcinoma at an earlier stage and prolonged survival. Staging systems should be validated in different populations.

New aspects of diagnosis and therapy of hepatocellular carcinoma

Hepatocellular carcinoma is one of the major cancer killers. It affects patients with chronic liver disease who have established cirrhosis, and currently is the most frequent cause of death in these patients. The main risk factors for its development are hepatitis B and C virus infection, alcoholism and aflatoxin intake. If acquistion of risk factors is not prevented and cirrhosis is established, the sole option to improve survival is to detect the tumor at an early stage when effective therapy may be indicated. Early detection plans should be based on hepatic ultrasonography every 6 months, whereas determination of tumor markers is not efficient. Upon detection of a hepatic nodule, there is a need to establish unequivocal diagnosis, either through biopsy or through the application of non-invasive criteria based on the specific radiology appearance of the tumor: fast arterial uptake of contrast followed by venous washout. Effective treatment for liver cancer includes surgical resection, liver transplantation and percutaneous ablation. These options provide a high rate of complete responses and are assumed to improve survival that should exceed 50% at 5 years. If the tumor is diagnosed at an advanced stage, the sole option that improves survival is transarterial chemoembolization. Ongoing research should further advance the time at diagnosis and identify new and effective options targeting molecular pathways governing tumor progression.

PET/CT in patients with hepatocellular carcinoma using [(18)F]fluorocholine: preliminary comparison with [(18)F]FDG PET/CT

PURPOSE

The diagnostic accuracy of [(18)F]fluorodeoxyglucose (FDG) PET is insufficient to characterise hepatocellular carcinoma (HCC) in liver masses and to diagnose all cases of recurrent HCC. HCC has been reported to take up [(11)C]acetate, but routine use of this tracer is difficult. Choline is another tracer of lipid metabolism, present in large amounts in HCC. In a proof-of-concept study, we evaluated [(18)F]fluorocholine (FCH) uptake by HCC and compared FCH PET/CT with FDG PET/CT.

METHODS

Twelve patients with newly diagnosed (n=8) or recurrent HCC (n=4) were prospectively enrolled. HCC was assessed by histology in eight cases and by American Association for the Study of Liver Diseases (AASLD) criteria in four cases. All patients underwent whole-body PET/CT 10 min after injection of 4 MBq/kg FCH. Within 1 week, 9 of the 12 patients also underwent whole-body FDG PET/CT 1 h after injection of 5 MBq/kg FDG.

RESULTS

The per-patient analysis showed a detection rate of 12/12 using FCH PET/CT for both newly diagnosed and recurrent HCC. The median signal to noise ratio was 1.5+/-0.38. There was a trend towards a higher FCH SUV(max) in well-differentiated HCC (15.6+/-7.9 vs 11.9+/-0.9, NS). Of the nine patients who underwent FCH and FDG PET/CT, all nine were positive with FCH whereas only five were positive with FDG.

CONCLUSION

FCH provides a high detection rate for HCC, making it potentially useful in the initial evaluation of HCC or in the detection of recurrent disease. The favourable result of this proof-of-concept study opens the way to a phase III prospective study.

Systematic review: evidence-based management of hepatocellular carcinoma--an updated analysis of randomized controlled trials

The treatment strategy of hepatocellular carcinoma applied following scientific guidelines is only supported by 77 randomized controlled trials published so far, a figure that clearly pinpoints hepatocellular carcinoma as an 'orphan' cancer in terms of clinical research when compared with other high-prevalent cancers worldwide. A systematic review analysing 61 randomized controlled trials (1978-2002) showed a modest survival benefit from chemoembolization in patients with intermediate tumours, and the lack of an effective first-line treatment option for patients with advanced disease. These conclusions have been endorsed by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. The present updated evidence-based approach includes 16 randomized controlled trials published from 2002 to 2005 assessing percutaneous ablation (seven), other loco-regional therapies (three) and systemic therapies (six). Eight showed high-quality methodological profiles. Four randomized controlled trials demonstrated a better local hepatocellular carcinoma control in tumours larger than 2 cm treated by radiofrequency ablation compared with ethanol injection. No survival advantages were obtained from systemic treatments in patients with advanced hepatocellular carcinoma, an area that is an unmet need. Therefore, there is an urgent request to conduct well-designed phase III investigations in hepatocellular carcinoma patients.

Hepatocellular carcinoma

The number of patients who have hepatocellular carcinoma (HCC) is expected to more than double over the next 1 to 2 decades. Patients who have cirrhosis, regardless of cause, are at the highest risk for developing HCC. This article discusses surveillance of these patients for HCC by alpha-fetoprotein and ultrasound, evaluation using imaging, classification of HCC using the Barcelona staging classification, and treatment. Resection, transplantation, and percutaneous ablation are considered curative interventions and are applied to about 30% of all patients who have HCC. Currently, there is no standard therapy for advanced HCC.

Analysis of factors predicting survival in patients with hepatocellular carcinoma treated with percutaneous laser ablation

BACKGROUND/AIMS

The factors which predict the long-term outcome in patients with hepatocellular carcinoma who are treated with percutaneous laser ablation (PLA) are not well established.

METHODS

We prospectively analyzed treatment and survival parameters of 148 cirrhotic patients with nonsurgical hepatocellular carcinoma who had undergone PLA at a single institution during an 11-year period.

RESULTS

Single tumors were seen in 129 of 148 (87%) patients, and 2-3 nodules were seen in 19 (13%) patients, for a total of 169 tumors. The median overall time survival was 39 months (95% confidence interval [CI], 30-47 months). The 1-, 2-, 3-, 4-, and 5-year cumulative survival rates were 89, 75, 52, 43, and 27%, respectively. From multiple regression analysis, the independent predictors of survival were found to be tumor grading (P=0.002; risk ratio [RR] 0.37, 95% CI 0.20-0.70), bilirubin levels < or =2.5mg/dl (P=0.014; RR 1.58, 95% CI 1.09-2.28), and the achievement of complete tumor ablation (P=0.020; RR 0.53, 95% CI 0.31-0.90). An initial complete tumor ablation was the only factor associated with longer survival in patients with Child-Turcotte-Pugh class A cirrhosis (P=0.012; hazard ratio [HR] 0.48, 95% CI 0.23-1.03).

CONCLUSIONS

A complete tumor ablation results in improved survival in all patients with nonsurgical hepatocellular carcinoma. Ideal candidates for PLA are those with a well-differentiated histology, and normal bilirubin levels.

Hepatocellular carcinoma

PURPOSE OF REVIEW

Our aim is to review the latest information regarding the risk factors, markers for early detection, diagnosis, and therapy for this tumor type.

RECENT FINDINGS

Alcohol, tobacco, and obesity interact together to increase the risk of hepatocellular carcinoma, which may allow us to identify a high-risk group for hepatocellular carcinoma among patients with cirrhosis. For the first time, a randomized controlled trial of surveillance for hepatocellular carcinoma showed improved survival for those patients who underwent surveillance compared with no surveillance. Another study showed that washout of contrast of an arterially enhancing lesion is sensitive and specific for hepatocellular carcinoma. The Barcelona Clinic Liver Cancer staging classification is the best at stratifying prognosis and treatment strategy for patients with hepatocellular carcinoma. Three randomized trials showed that radiofrequency ablation improves survival when compared to percutaneous ethanol injection for early hepatocellular carcinoma.

SUMMARY

Not all patients with cirrhosis have an equal risk for developing hepatocellular carcinoma. Further studies should stratify the risk of hepatocellular carcinoma so surveillance is tailored to those at the highest risk. Washout of contrast of arterially enhancing mass is regarded as the typical appearance of hepatocellular carcinoma in triple-phase imaging. Radiofrequency ablation is the best ablative technique for the treatment of small hepatocellular carcinoma.

Prospective validation of the Barcelona Clinic Liver Cancer staging system

BACKGROUND/AIMS

The Barcelona Clinic Liver Cancer (BCLC) classification offers a prognostic stratification of patients with hepatocellular carcinoma (HCC). We recently demonstrated the BCLC's peculiar prognostic ability in a retrospective cohort of HCC patients. The aim of this study was to evaluate the BCLC system prospectively in a subsequent separate group of HCC patients enrolled at the same surgically oriented liver unit.

METHODS

One hundred and ninety-five consecutive HCC patients were prospectively enrolled and their liver disease was staged before therapy. Unlike the BCLC treatment protocol, nodule size and number were not used as absolute exclusion criteria for radical treatment. Predictors of survival were identified using the Cox model.

RESULTS

The median survival time was 23 months overall, and 53, 16, 7 and 3 months, respectively, for BCLC categories A, B, C, and D. In our cohort, BCLC had the best independent predictive power for survival when compared with the Okuda, CLIP, UNOS-TNM, and JIS prognostic systems (linear trend chi(2)=43.01, likelihood chi(2)=57.94, AIC 885.98). Moreover, the BCLC classification showed a better prognostic ability than the AJCC-TNM 2002 system in surgical patients.

CONCLUSIONS

The discriminating power of BCLC staging was prospectively assessed in an Italian cohort of HCC patients treated mainly with radical therapies.

Thrombocytopenia as a surrogate for cirrhosis and a marker for the identification of patients at high-risk for hepatocellular carcinoma

BACKGROUND

The objective of this study was to examine the usefulness of platelet counts in the diagnosis of cirrhosis and for identifying high-risk individuals in a community-based hepatocellular carcinoma (HCC) screening program.

METHODS

Pilot Study 1 determined the correlation between platelet counts and pathologic hepatic fibrosis scores among individuals with chronic hepatitis B virus (HBV) infection (n = 122 patients) and hepatitis C virus (HCV) infection (n = 244 patients). Pilot Study 2 investigated proportions of individuals with thrombocytopenia (<150 x 10(3)/mm(3)) among patients with HCC (n = 4042 patients). Pilot Study 3 demonstrated the correlation between platelet counts and ultrasonographic (US) parenchyma scores among anti-HCV-positive individuals (n = 75 patients). The core study was a 2-stage, community-based screening for HCC among residents age 40 years or older in townships with a high prevalence of anti-HCV (n = 4616 individuals) and in townships with a low prevalence of anti-HCV (n = 1694 individuals). Patients with thrombocytopenia were identified for US and alpha-fetoprotein screening.

RESULTS

Among the individuals who were positive for anti-HCV, platelet counts decreased according to increased pathologic fibrosis scores or US scores for liver parenchyma disease: The best cutoff platelet count was 150 x 10(3)/mm(3) for a diagnosis of cirrhosis. The sensitivity and specificity were 68.2% and 76.4%, respectively, for pathologic cirrhosis and 76.2% and 87.8%, respectively, for US cirrhosis. Forty-eight percent of patients with HCC were thrombocytopenic. The proportion of thrombocytopenia was significantly greater in patients with HCV-related HCC (63%) than in patients with HBV-related HCC (42%). In the townships with high and low anti-HCV prevalence, the prevalence of thrombocytopenia was 17.9% and 6.1%, respectively, (P < .001), respectively. Twenty-five patients were diagnosed with HCC, and all of those patients resided in the high-prevalence township.

CONCLUSIONS

Thrombocytopenia was a valid surrogate of cirrhosis and a valid marker for the identification of individuals at high-risk for HCC, especially in areas that had a high prevalence of HCV.

Comparison of the clinical characteristics among hepatocellular carcinoma of hepatitis B, hepatitis C and non-B non-C patients

BACKGROUND/AIMS

The present study was undertaken to compare the clinical characteristics, availability of initial treatment options and prognostic features of patients with hepatocellular carcinoma in relation to hepatitis B or C viral infection.

METHODOLOGY

Six hundred and ninety-two patients with hepatocellular carcinoma treated during the 12-year-period from Jan 1989 to Dec 2000 were categorized into three groups as follows: 1) 59 were classified as the HBV group: positive for hepatitis B surface antigen (HBsAg) and negative for antibody to hepatitis C (HCVAb), 2) 594 were placed in the HCV group: negative for HBsAg and positive for HCVAb, and 3) 39 were put into the Non-B, Non-C (NBNC) group: negative for both HBsAg and HCVAb. The age distribution, gender ratio, serum alpha-fetoprotein level, the presence of underlying cirrhosis, tumor size, the number of hepatocellular carcinoma tumors at the initial detection, the types of follow-up until the initial detection of hepatocellular carcinoma, the initial treatments chosen, and the survival were analyzed and compared among the three groups.

RESULTS

Regarding age, the HBV group showed a younger age (56.3 +/- 12.2 years old) than the other two groups (the HCV group: 66.3 +/- 8.3, the NBNC group: 67.9 +/- 8.5 years old), however, no difference was observed in the male-to-female ratio of the three groups. The serum alpha-fetoprotein level, the prevalence of hepatocellular carcinoma measuring more than 3 cm in diameter, non-solitary hepatocellular carcinoma and portal thrombosis were strongly demonstrated at the initial detection in the HBV group, which was most likely due to the poor follow-up until detection. Consequently, the 1-, 3-, 5- and 7-year survivals of the patients in the HBV group were 40.4, 25.1, 18.8 and 5.2%, and were significantly shorter than both the HCV group which were 72.6, 44.9, 25.0 and 10.0%, and the NBNC group which were 71.2, 41.4, 31.1 and 31.1%, respectively. As for the NBNC group, in spite of the lack of a careful follow-up a longer survival was observed probably because they had a better preserved liver condition.

CONCLUSIONS

Regarding the hepatocellular carcinoma patients, those infected with HBV presented at the advanced stage due to the lack of a careful follow-up, thus resulting in a shorter survival. As a result, hepatocellular carcinoma patients infected with HBV need to be strictly followed up.