Alcohol--a major risk factor for hepatocellular carcinoma?

Increased porphyrins in primary liver cancer mainly reflect a parallel liver disease

Hepatic porphyries have been associated with an increased risk of primary liver cancer (PLC), which on the other hand may cause an increased porphyrin production. To evaluate the role of an underlying liver disorder we analyzed porphyrins in patients with hepatocellular carcinoma (HCC) (n = 65), cholangiocellular carcinoma (n = 3), or suspected PLC, which turned out to be metastases (n = 18) or a benign disorder (n = 11). None of the patients had a family history of porphyry or clinical signs of porphyry. Increased aminolevulinic acid or porphyrin values were common not only in patients with PLC (43%) but also in metastatic (50%) and benign (64%) liver disorders. The corresponding proportion for HCC patients with liver cirrhosis (55%) was higher (P < .05) than in those without cirrhosis (17%). We conclude that symptomatic porphyries are unusual in PLC, whereas elevated urinary and/or faecal porphyrins are common, primarily reflecting a parallel liver disease and not the PLC.

Diabetes: one of few remarkable differences in clinicopathologic features between cirrhotic and noncirrhotic Swedes with hepatocellular carcinoma

The prognosis of hepatocellular carcinoma (HCC) is usually very poor, so increased knowledge of clinicopathologic characteristics and etiologic factors may improve the clinical handling. Because HCC in many patients is unrecognized before death, it is of particular interest to study cases from a period with a high autopsy frequency. The records and liver biopsies from all patients with a diagnosis of primary liver cancer in Göteborg, Sweden, during a 22-year period were scrutinized. Only patients with evaluable non-neoplastic liver tissue were included in the final analysis. The majority (95%) of 478 HCC cases were autopsied and cirrhosis of the liver could be established in 71%. At presentation, general paramalignant symptoms such as malaise, weight loss, anorexia, and hepatomegaly (84%) were common irrespective of cirrhosis. Alcoholism and diabetes mellitus were each significantly more common among cirrhotics (29% and 20%, respectively; P < .001), than among noncirrhotics, in which cholelithiasis was more common (54%; P < .001). The correlation between diabetes and cirrhosis was independent of reported alcoholism. In an unselected population in a low HCC incidence area, there are few differences in clinicopathologic features between cirrhotic and noncirrhotic patients. Diabetes mellitus seems to play an etiologic role in HCC in cirrhotics, and cholelithiasis in noncirrhotics.

Incidence of primary liver cancer and aetiological aspects: a study of a defined population from a low-endemicity area

The prevalence of primary liver cancer (PLC) varies throughout the world. It has been attributed to variations in incidence of the predominant histological type, hepatocellular carcinoma (HCC). The incidence of PLC types other than HCC such as cholangiocellular carcinoma (CCC) is far less known, especially in low-incidence areas. The aetiology of HCC and other PLC types is obscure, with the exception of the association between HCC and cirrhosis as well as chronic viral hepatitis. The present retrospective incidence and aetiology study concerns a well-defined population from a period with a high autopsy frequency. Preserved biopsy specimens were re-evaluated histopathologically and patient records were studied. Among 590 histologically verified cases of PLC, HCC constituted 90%, CCC 8% and a mixed form of these types 1%. At the end of the study period the annual age-standardised incidence rate of HCC was 3.6 cases per 100,000 inhabitants. Other PLC types were hepatoblastoma (n = 3), fibrolamellar carcinoma (n = 2), angiosarcoma (n = 1) and infantile haemangioendothelioma (n = 1), each constituting less than 1% of the PLC cases. Comparing HCC with CCC we found that cirrhosis (70%) and alcoholism (21%) was significantly more frequent in HCC, and cholelithiasis was significantly more common (60%) in patients with CCC. In the majority of the PLC cases with liver cirrhosis this disorder was unknown before diagnosis of the tumour.

Erythrocyte porphobilinogen deaminase activity and primary liver cancer

OBJECTIVES

To study whether primary liver cancer (PLC) could be associated with acute intermittent porphyria (AIP) carriership and whether the activity of erythrocyte porphobilinogen deaminase (PBGD) could be used as a tumour marker for PLC.

DESIGN

Prospective study.

SETTING

Medical and surgical wards in two general hospitals in Göteborg, Sweden.

SUBJECTS

All patients with a strong suspicion of PLC (n = 109) who came to the authors' attention.

MAIN OUTCOME MEASURES

Measurement of PBGD activity in erythrocytes. Comparison of the PBGD activity in groups with various final diagnoses-hepatocellular carcinoma (n = 58), cholangiocellular carcinoma (n = 2), malignancy other than PLC (n = 18), benign liver disorders (n = 11)--and according to presence of cirrhosis.

RESULTS

None of the patients had a clinical or family history of AIP. Four cases with low PBGD activity, suggesting AIP gene carriership, were found, which is more than expected. However, the cases were evenly distributed amongst the groups. The mean activity of PBGD was higher in cirrhotic patients, irrespective of the presence of PLC, than in others.

CONCLUSIONS

(i) Acute intermittent porphyria gene carriership might be associated with an increased risk not only for PLC but also for secondary malignancies and benign tumours in the liver. (ii) High activity of PBGD is not unusual in liver cirrhosis and the reason for this needs to be elucidated, but it seems to be of no clinical value as a tumour marker for PLC.

Hepatocellular carcinoma in liver cirrhosis. A prospective study

From January 1984 to December 1991 we carried out a prospective surveillance of the development of hepatocellular carcinoma (HCC) in 200 cirrhotic patients, monitored from the first histologic diagnosis of cirrhosis. Real-time ultrasonography (US) and serum alpha-fetoprotein (AFP) assays were performed every 3-6 months. During this period we detected HCC in 38 patients. The overall cumulative incidence of HCC in the 8 years was 41%, with a yearly incidence of 5.1%. Eighteen of 38 patients (48%) had a tumor < 5 cm in diameter. AFP reached diagnostic levels (> 500 ng/ml) in eight cases only (21%). Patients with initial AFP values > 20 ng/ml developed HCC more frequently than patients with values < or = 20 ng/ml; the percentage of HCC was statistically higher (p < 0.01) in patients in Child's B and C than in Child's A class. A periodic follow-up, using US and AFP, is suggested for the early diagnosis of HCC in cirrhotic patients.

Anti-HCV positive hepatocellular carcinoma in cirrhosis. Prevalence, risk factors and clinical features

Recent reports indicate that hepatitis C virus (HCV) may play a role in the pathogenesis of hepatocellular carcinoma in cirrhotics. Using an ELISA test, we evaluated the prevalence of anti-HCV antibodies in 97 patients with hepatocellular carcinoma (HCC) in cirrhosis and in a group of 223 patients, including: 49 patients with HBsAg-positive chronic liver disease (CLD), 42 with alcoholic CLD, 110 with cryptogenic CLD and 22 with post-transfusional HBsAg-negative CLD. All diagnoses were histologically confirmed. Overall, anti-HCV-positive HCC were 64% of the total, with no statistically significant difference with respect to CLD (60.9%). The prevalence of anti-HCV was higher in cryptogenic HCC (80%) than in HBsAg-positive (60%) or alcoholic HCC (42.8%) (p less than 0.005). When HCC and cirrhosis of similar putative etiology were considered, anti-HCV prevalence was significantly higher in HCC than in cirrhosis only in the groups of patients with alcoholic liver damage (60% in HCC vs. 38% in cirrhosis, p less than 0.005). In HBsAg-positive patients, anti-HCV prevalence was twice as high in HCC than in CLD, but the difference was not statistically significant. Overall, anti-HCV prevalence in HCC was significantly higher than in alcoholic or HBsAg-positive CLD (p less than 0.001 and p less than 0.01, respectively) but lower than in cryptogenic CLD (p less than 0.001). Association between anti-HCV and anti-HBc was significantly more prevalent in patients with CLD than in those with HCC.(ABSTRACT TRUNCATED AT 250 WORDS)

Natural history of hepatocellular carcinoma in Spain. Five year's experience in 249 cases

In this study we attempted to define the clinical pattern and prognosis of hepatocellular carcinoma (HCC) patients in Spain. Two hundred and forty-nine patients were included in the study. One hundred and eighty-seven were male and 62 female, with their mean age being 62.5 +/- 0.6 years. The majority of patients (92.8%) had an underlying cirrhosis. In most of the patients, the disease appeared as decompensated liver disease. Only 18.5% of the HCC cases were asymptomatic. Only 8.2% of the cases were HBsAg positive. alpha-Fetoprotein reached diagnostic values in only 37.2% of the patients. Surgical treatment was successfully performed in 14 patients: one underwent orthotopic liver transplantation and the 13 others complete tumor resection. Chemotherapy was administered to 38 subjects, while percutaneous ethanol injection was applied in seven cases. Patients receiving only symptomatic treatment, comprised 76.7%. Survival was related to tumor size and liver function. While the median survival of the whole series was 3.3 +/- 0.4 months, it was 14.5 +/- 2.2 months in patients with preserved liver function and small tumors. These results reflect that in Spain HCC patients are diagnosed at a moderately advanced phase. Since early diagnosis is the only way to increase the proportion of patients suitable for curative treatment, early detection plans are mandatory in the population at risk.

Hepatocellular carcinoma: molecular biology of its growth and relationship to hepatitis B virus infection

Hepatocellular carcinoma is a very common tumor worldwide and is associated with high mortality rates. Evidence that the development of hepatocellular carcinoma is related to chronic HBV infection has accumulated from epidemiologic studies, information from animal and cell culture models, and molecular biologic evidence that HBV components can be found within hepatocellular carcinoma tissue. Integration of HBV DNA within host liver cell chromosomes may be a crucial step in the development of hepatocellular carcinoma. Integration is associated with disruption of both structure and function of DNA at the site of integration. The study of individual examples of HBV DNA integration in hepatocellular carcinoma tissue illustrates possible mechanisms of hepatocarcinogenesis by HBV. In many cases, activation of various growth factors has been found in association with HBV DNA integration including IGF II, oncogenes such as c-myc, and novel growth factors such as the retinoic acid receptor. A clearer understanding of the mechanisms involved may allow for possible therapeutic interventions in the future, or perhaps even the prevention of hepatocellular carcinoma.

HBV-DNA hybridization in hepatocellular carcinoma associated with alcohol in Japan

To clarify the role of the hepatitis B virus (HBV) in hepatocellular carcinoma (HCC) associated with alcohol consumption, HBV-DNA in the liver of 19 patients with HCC were investigated. HBV-DNA was examined by Southern blot hybridization. HBV-DNA was integrated into tumor cells from five out of six (83%) patients with HCC associated with HBs antigen (HBsAg)-positive post-hepatitic liver cirrhosis (LC), but this was not related to the history of alcohol intake. In 13 HCC patients of HBsAg-negative alcoholic LC, HBV-DNA integration was not detected in any patient. These findings suggest that HBV does not play a major role in the pathogenesis of HCC in HBsAg-negative alcoholics in Japan.

Viral versus chemical hepatocarcinogenesis

Almost all experimental studies on hepatocarcinogenesis have been performed on models induced by chemicals. The human hepatocellular carcinoma (HCC), a highly malignant tumor, particularly frequent in the Far East and in Africa, is overwhelmingly associated with hepatitis B virus (HBV) infections and only very rarely is it caused by chemicals. This raises the question as to what degree observations on the preferentially studied chemical carcinogenesis apply to human HCC. This question is timely, since a woodchuck model has been developed in which laboratory infection with a hepadna virus, biologically and genomically similar to HBV, regularly produces HCC in prolonged surface antigen carrier woodchucks. Permanent surface antigen carriage by itself may also be a risk factor. A comparison, based on available observations of chemical and hepadna viral carcinogenesis, was attempted on four aspects: (1) histologic features, (2) growth patterns, (3) growth factors, and (4) molecular biological observations. At this time, only few conclusions can be drawn, mainly on a morphological and molecular biological basis. In the initial stage, chemicals cause mutations of very few bases, while in hepadna viral infections long sequences are inserted into both strands of chromosomal DNA. Additional studies appear to be indicated, to the greatest degree with existing methods and primarily on hepadna viral carcinogenesis. A key question is whether the active necroinflammation, preceding or observed at the time the HCC is recognized, in woodchuck and also in human chronic HBV infections is a promoting event or a secondary reaction. Additional therapeutic strategies, specific for hepadna viral carcinogenesis, can be considered, particularly elimination of hepatocytes carrying integrated viral sequences and prevention or suppression of the promoting necroinflammation. Success in HCC may be applicable to cancers related to papilloma virus in other organs, for instance, the female genital tract.

Aetiological factors in hepatocellular cancer

The major risk factors for HCC are outlined in Table 2. Each factor may contribute to the multistep process of hepatocarcinogenesis. Hepatitis B virus and aflatoxins are the principal aetiological candidates and may be considered as initiators of the malignant state (see Figure 1). The majority of HCC arises via the cirrhotic pathway; the associated changes in the hormonal milieu may alter the handling of environmental carcinogens and the rounds of cell proliferation may increase sensitivity to sub-threshold doses of carcinogens. Exogenous androgens and oestrogens may operate through a similar mechanism to promote clonal expansion of preneoplastic cells. The importance of identifying the major aetiological factors lies in the possibility of prevention. The prognosis of HCC is dismal and it represents a major scourge in developing Third World countries. It is encouraging to think that the majority of cases could be prevented by the widespread use of hepatitis B vaccines and the development of intervention programmes against aflatoxin contamination of foodstuffs.