Hepatitis B antigen in black patients with hepatocellular carcinoma: correlation between orcein stained liver sections and serology

Hepatocellular carcinoma. A worldwide problem and the major risk factors

Male sex, age, cirrhosis, and HBsAg are the major risk factors for hepatocellular carcinoma (HCC). The geographic distribution of HCC is highly uneven, such that three distinct incidence areas are recognized. To clarify the reason(s) for this geographic variability of HCC, the risk factors in each incidence area were assessed. In parallel with the geographic distribution of HCC, HBsAg prevalence was highest in both HCC patients and in general population in Africa and Asia, where mothers of HCC patients are frequently HBsAg-positive, suggesting that hepatitis B virus hyperendemicity and perinatal infection account for the high HCC incidence in these areas. Cirrhosis, which is found on autopsy in 80% of the cases of HCC patients worldwide, is the most prevalent risk factor for HCC in areas where hepatitis B virus infection is less common. However, HBsAg carriage adds to the HCC risk carried by cirrhosis and explains the higher incidence of HCC in cirrhotics from Africa and Asia as well as elsewhere. Available data suggest that chronic HCV infection is a risk factor for cirrhosis and HCC. HBV vaccination should decrease HCC incidence rates worldwide; however, HCC prevention in regions where HBsAg carriage is infrequent may also require prevention of the other causes of cirrhosis in order for HCC rates to decline.

Immunohistochemical characterization of 130 cases of primary hepatic carcinomas

Primary liver carcinoma (PLC) may express a certain number of markers. Here we communicate results of an analysis of five such markers (alpha-1-antitrypsin--AAT--, carcino-embryonic antigen --CEA--, alpha-fetoprotein --AFP--, and superficial --HBsAg-- and core --HBcAg-- antigens of hepatitis B virus) by means of PAP techniques in 130 cases of PLC, comparing the neoplastic tissue and the non-tumorous liver. Three variants of PLC are distinguished: hepatocarcinoma (HC) (108 cases); cholangiocarcinoma (CC) (19 cases); and three cases of hepatocholangiocarcinoma (HCC). AAT was positive in 29 HC, 2 HCC, and negative in all 19 CC. CEA appeared positive in 16 HC, 16 CC and only one HCC. AFP was positive in two HC, and negative in all CC and HCC. HBsAg displayed positivity in 15 HC and one HCC, being negative in all 19 CC. HBcAg was positive in 4 HC, and negative in all CC and HCC. HBsAg was also positive in two neoplastic emboli associated with HC. On the non-tumorous liver tissue the immunohistochemical results showed positivity for AAT and CEA, but not for AFP. Therefore the present results confirm that in the geographical area from which these tumors proceed, PLC is closely correlated with HBsAg positivity and with cirrhosis.

The epidemiology of primary liver cancer in a West German population: the Saarland

The present study is based on the data of 321 cases of primary liver cancer (PLC); 225 hepatocellular carcinomas (HCC), 54 cholangiocellular carcinomas (CCC) and 35 unclassified carcinomas autopsied between 1963 and 1982 or reported to the Saarland Cancer Registry between 1967 and 1981. The age standardized incidence rate for the Saarland was determined as 1.1. We noticed an increase in incidence for both HCC and CCC. The HCC rise was based on a significant (p less than 0.05) increase for women. The incidence maximum in the successive birth cohorts is shifting into younger age groups. The highest rates were observed in men and women born between 1900 and 1909. The regional distribution of PLC in the Saarland shows an accumulation in the urban areas. The mean survival time from diagnosis to death was 3.1 months. Prognosis was only influenced by the grade of differentiation. 88.3% of the HCC, but only 28.6% of CCC occurred in cirrhotic livers. Orcein staining of 55 liver specimens showed evidence of previous HBV infection in 12 out of 38 cases of HCC (31.6%) and no evidence of HBVB in the 17 cases of CCC studied.

Hepatocellular carcinoma. A study of 50 autopsy cases with detection of hepatitis B surface antigen in fixed tissues

Fifty patients who died of hepatocellular carcinoma (HCC) were autopsied at the Ciudad Sanitaria "1 degree de Octubre" and the Hospital de la Cruz Roja (Madrid) from 1974 to 1980. Formalin fixed paraffin-embedded autopsy tissue of liver and tumor from the 50 HCC and liver tissue from 50 liver cirrhosis (LC) and from 50 autopsy of non cirrhotic control cases were examined for the presence of cytoplasmic hepatitis B surface antigen (HBsAg). The study was carried out using orcein staining, immunoperoxidase technique (IP) and indirect immunofluorescence (IF). In livers with HCC the HBsAg was detected in the cytoplasm of the hepatocytes in 10 cases (20%) with the orcein staining and in 11 (22%) with the IP and IF techniques. In one case (2%) HBsAg was found in the cytoplasm of tumor cells with the three methods--In four cases (8%) of LC and 2 (4%) control cases cytoplasmic positive cells were found. In 41 patients with HCC HBsAg was studied in the serum by radio-immunoassay (RIA) (13 cases) and immunodiffussion (28 cases). 5 patients (12,1%) were positive and 36 (72%) were negative. In the 5 serum positive HBsAg HCC the staining methods for cytoplasmic HBsAg were positive (100%). In 36 serum negative HBsAg HCC the staining method were positive in 2 cases. The results let us to conclude that HBV is a probable important etiologic factor of HCC in our milieu. 54% of the patients with HCC had a previous history of alcohol abuse; however, histologic features compatible with an alcoholic etiology were found in only 5 cases. Nevertheless we consider that the described histopathologic findings do not exclude excess alcohol consumption as a possible etiologic factor for HCC in our series.

Hepatocellular carcinoma in an urbanised black community. A changing pattern

Hepatocellular carcinoma has been extensively studied in Southern Africa, and particularly its relationship to hepatitis B virus infection. Most of this work involved rural Black populations. In this study the impact of urbanization on this relationship is investigated. The material is derived from the laboratory records at Baragwanath Hospital which serves the Black urban community of Soweto, Cases autopsied during the periods 1956-1960 and 1976-1980 have been examined with regard to age, sex, underlying cirrhosis and presence of HBsAg in the non-tumour liver. In addition, all biopsies from 1955 to 1980 have been analysed with respect to age and sex. There is evidence of a significant increase in overall average age and in the proportion of female cases, while the percentage of HBsAg positive cases has fallen. Possible causes for these findings are considered.

Hepatitis B surface antigen and hepatocellular carcinoma in the People's Republic of China

Eighteen cases of heptocellular carcinoma from the People's Republic of China were investigated for the presence of hepatitis B surface antigen (HBsAg) in the cytoplasm of hepatocytes and tumor cells. The Sternberger-PAP immunoperoxidase technique utilizing monospecific antibody to HBsAg and a modified orcein method demonstrated cytoplasmic HBsAg in hepatocytes of 15 cases (83.3%) and tumor cells of 3 cases (16.7%). Thirteen of these cases were also investigated for HBs antigenemia and of these 11 were positive (84.6%). These hepatomas were often associated with macronodular cirrhosis and/or a persistent inflammatory process in the hepatic parenchyma. The high association of HBsAg and hepatoma indicates that the hepatitis B virus plays an important role in the pathogenesis of this malignancy in China. It is concluded that a major public health effort to eradicate endemic hepatitis B infection is the most reasonable way to decrease the incidence of this cancer, which is common in China.

Hepatitis-B surface antigen in tumour tissue and non-tumorous liver in black patients with hepatocellular carcinoma

Formalin-fixed, paraffin-embedded sections of liver and tumour tissue obtained at necropsy from 44 southern African Blacks with hepatocellular carcinoma were stained for hepatitis-B virus surface antigen by immunofluorescence, immunoperoxidase and orcein techniques. The antigen was present in the serum of 68% of the patients. Staining for tissue antigen was positive in 45% of the patients. Non-tumorous hepatocytes alone stained positively in 22.5% of patients, tumour cells alone in 12.5% and both in 10%. Antigen was present in relatively few tumour cells and the amounts detected were small; it was more readily detectable in moderately differentiated than in poorly differentiated malignant cells. Identical results were obtained with immunofluorescence and immunoperoxidase staining, but the orcein stain failed to demonstrate the antigen in tumour cells. Cirrhosis was present in the non-tumorous liver in 70% of the patients. Antigen was detected in cirrhotic tissue in 43% of the patients with cirrhosis, and in non-tumorous liver tissue in 8% of those without cirrhosis, but this difference was not significant. The antigen frequency in tumour tissue was the same in patients with and without cirrhosis. No correlation was found between the presence of liver-cell dysplasia and the presence or absence of either the antigen or cirrhosis in the non-tumorous liver tissue. Ground-glass hepatocytes were seen in non-tumorous liver tissue of 5 patients, but not in tumour tissue. While 54% of the patients with antigenaemia had demonstrable tissue antigen, 10% of patients with tissue antigen had no detectable antigenaemia.

Hepatitis B surface antigen and hepatocellular carcinoma in Southern Africa

Most series in Africa show a high percentage of hepatitis B surface antigen in hepatocellular carcinoma. Two groups of cases were investigated in this study. The one was derived from the autopsy material at Baragwanath hospital from subjects who had lived in Soweto, a large Black urban town. The second group consisted of male Black mineworkers generally originating from rural areas. A combination of the aldehydefuchsin stain and immunoperoxidase technique was used. The two groups showed totally different results. The Baragwanath series consisted of 24 hepatocellular carcinomas of which only 4 (17%) were HBsAg positive. Of the 24 cases, 14 had cirrhosis of which 9 were macronodular and 5 micronodular. Ten of these cases showed heavy iron overload. The series of male Black mineworkers comprised 22 cases of which 16 (72%) were HBsAg positive. Twelve of the 22 cases showed a macronodular cirrhosis and there were no micronodular cirrhoses. Only one case showed severe iron overload. These findings delineate two different populations of hepatocellular carcinoma in Southern Africa.

An appraisal of the relationship between primary hepatocellular carcinoma and hepatitis B virus

The association between hepatitis B virus infection and primary hepatocellular carcinoma is reviewed. On the basis of serological and tissue examination there is a close link between virus infection and the tumour. While there is evidence to favour an oncogenic role for virus this is not conclusive, and other possible explanations for the relationship are discussed.

Hepatitis B virus antigens in human primary hepatocellular carcinoma tissues

The presence of hepatitis B virus (HBV) antigens was examined in specimens of liver tissue obtained at necropsy from black Senegalese patients suffering from primary hepatocellular carcinoma (PHC). The results were correlated with markers of hepatitis B infection in serum. Hepatitis B surface antigen (HBsAg) and core antigen (HBcAg) were sought for in 15 liver extracts. HBsAg was found in the liver in 10 of 12 cases with HBsAg-positive serum. HBcAg was detected in three livers. The HBsAg was detected in seven of eight livers by immunofluorescence and orcein staining. HBsAg-positive cells were mainly located in the peri-tumoral cirrhotic tissue, although positive hepatocytes were also found in tumour nodules in liver from one of the patients. HBcAg was found in five of seven cases by immunofluorescence in hepatocytes of the cirrhotic areas. HBcAg fluorescence was primarily nuclear but, in some lobules, a patchy cytoplasmic fluorescence was observed. This suggests a cytoplasm-nucleus pathway in the synthesis of the HBV core antigen. Electron microscopy was performed on two HBsAg- and HBcAg-positive cases. Fibrillar and crystalline cytoplasmic inclusions were observed in tumour cells. In the same cells, 20-25 nm virus-like particles were present in swollen cisternae of the endoplasmic reticulum.

Detection of HBsAg containing cells in liver biopsies by different stains and classification of positively reacting ground-glass hepatocytes

The diagnostic significance of orcein, aldehydthionine, and chromotrope anilinblue stains for the demonstration of HBsAg containing hepatocytes was investigated in 602 unselected liver biopsies. Five types of specifically stained ground-glass hepatocytes (GGH) were distinguished: Type I showed a positive staining reaction of the cytoplasmic periphery (marginal GGH), type II a diffuse staining of the total cytoplasm (diffuse GGH). Type III contained round or oval globular positive cytoplasmic masses (globular GGH). Type IV showed only very small round, drop-like or sickle-shaped positive structures (spotty GGH). The GGH with fatty changes were designated as type V. In all carriers and patients with minimal hepatitis GGH, mostly type I and II, appeared in extensive clusters within the lobules. In chronic persistent hepatitis, there were moderately numerous, partly grouped, partly disseminated ground-glass hepatocytes of type II and III. In chronic active hepatitis there were only a few GGH of type IV. In acute viral hepatitis, there were no typical GGH, however, positively stained phagocytes were seen. The intracellular antigen localization and the intralobular distribution of GGH are considered to be the result of an immune reaction. Single so-called 'metabolic' GGH sometimes showed similar pictures. However, they could usually be distinguished from virus containing GGH because of their granular cytoplasmic structure and a lower staining intensity in the applied stains. Among the three stains the orcein stain yielded the best results. In some cases with HBsAg-positive chronic active hepatitis virus infection could not be proved by means of staining.

Detection of hepatitis B surface antigen in fixed tissues of patients with cirrhosis and hepatoma

HBsAg has been sought by light microscopy in liver specimens from patients with cirrhosis (79 cases) and hepatoma (99 cases). The study was carried out on fixed material using orcein staining, immunoperoxidase technique and indirect immunofluorescence. HBsAg was detected in the serum by radio-immunoassay (RIA) using Ausria II-125 in 38 patients with cirrhosis and in 36 with hepatoma. In the 38 seropositive cases of cirrhosis HBsAg-positive cells were observed in 31 (81.6%) by the orcein staining and in 32 (84.2%) by the peroxidase and immunofluorescence staining. Among the 36 seropositive patients with hepatoma, HBsAg was detected in the surrounding non-neoplastic part of the liver, cirrhotic or not, in 30 (83.3%) by orcein staining and in 34 (94.4%) by the immunoperoxidase method and immunofluorescence. Positive solitary-cells were seen occasionally in the tumor tissue in 16 cases using orcein, in 9 using peroxidase and in 7 by fluorescence, out of the 36 seropositive patients with hepatoma. The results of this study do not support the hypothesis of a direct oncogenic effect of HBsAg on the liver cells, since this antigen was detected mainly in the non-neoplastic part of the liver tissue and only occasionally in the tumor cells. Of the 63 cases of seronegative hepatoma, 3 showed some round orcein-positive inclusion bodies in the cytoplasm of the neoplastic and the non-neoplastic cells; these bodies were not stained by the two immunological methods.

Orcein-positive material in hepatocytes in viral hepatitis and other liver diseases

Liver biopsy samples from 110 patients with various liver diseases were stained by orcein according to the method of Shikata et al. Orcein-positive hepatocellular material was observed in only the 31.7% of HBsAg seropositive cases. A positive orcein reaction was frequently found in protracted and chronic viral hepatitis and occasionally in other liver diseases, such as alcoholic and cholestatic hepatitis, as well as in cryptogenetic cirrhosis and in liver metastases. The results obtained suggest a more cautious evaluation of the diagnostic and prognostic significance of orcein-positive hepatocellular material.