Clinicopathological Studies of Minute Hepatocellular Carcinoma

73:109-115. 1977 Copyright © 1977 by the American Gastroenterological Association

Vol. 73 , No . 1 Printed in U.S.A.

GASI'ROENTEROLOGY

LIVER PHYSIOLOGY AND DISEASE CLINICOPATHOLOGICAL STUDIES OF MINUTE HEPATOCELLULAR CARCINOMA

Analysis of 20 cases, including 4 with hepatic resection KuNia OKUDA, M.D. , TasHIRO NAKASHIMA, M.D., HIROSHI 0BATA, M.D., AND YASUHIKO KUBO, M.D. * First Department of Medicine, Chiba University S chool of Medicine, Chiba, Department of Pathology , Kurume University S chool of Medicine, Kurume, Institute of Gastroenterology , Tokyo Women's Medical College , Tokyo, and the S eco nd Department of Medicine, Kurme University S chool of Medicine, K urume, Japan

Sixteen necropsies and 4 cases of hepatic resection in which the liver had a solitary hepatocellular carcinoma smaller than 4.5 em, or a few tumor nodules smaller than 3.5 em, have been analyzed. Clinically, these patients presented with signs and symptoms compatible with cirrhosis and, of the 16 autopsy cases only 2 had been diagnosed correctly. In all but 4 cases, the noncancerous parenchyma showed advanced cirrhosis of the mixed type, with irregularly sized multilobular nodules and thin strands of stroma, different from typical alcoholic cirrhosis. The primary lesion was grossly encapsulated in the majority, suggesting a slow, expanding growth. Histologically, most primaries were relatively well differentiated. Serum a-fetoprotein was generally low, and it served as the major diagnostic clue in only 5 cases. In patients with mildly abnormal afetoprotein levels, continuous monitoring seems important in order to detect a steady rise, the first warning for tumor growth. Hepatocellular carcinoma (HCC), which constitutes the large proportion of primary liver cancer, 1- 3 continues to defy radical treatment because of the difficulty of early detection. Despite the recent addition of the afetoprotein (AFP) test4 • " to the diagnostic armamentarium, early diagnosis and surgical removal of HCC have seldom been achieved. 6 • 7 The literature lacks reports on small HCC studied in any substantial number. This is attributable in part to incomplete understanding of the etiological relationship ofHCC to chronic liver diseases, particularly cirrhosis, on which it is usually superimposed, s- 11 and of the histopathological nature of its early stages. The present communication is concerned with the study of 16 cases in which minute HCC was found at autopsy and of 4 patients in whom diagnosis of minute HCC was made clinically and hepatic resection was carried out. Received September 1, 1976. Accepted January 18, 1977. Address requests for reprints to: Dr. Kunio Okuda, Department of Medicine , Chiba University Hospital, Chiba 280, Japan. * A number of additional coinvestigators in this study are listed alphabetically: Masaharu Hashimoto, Naoaki Hayashi, Masamichi Kojiro, Yoji Motoike, Hirotake Musha, Yoshikazu Nagasaki, Yukio Nakajima, Kazuyoshi Sakamoto, Yasuhiko Sawa, and Yutaka Shimokawa.

Materials and Methods Livers containing one HCC nodule smaler than 4.5 em in its largest diameter, or a few (no more than four) nodules with the largest one smaller than 3.5 em, were selected from the autopsy materials at the Departments of Pathology, Kurume University School of Medicine and Chiba University School of Medicine, and from surgical specimens of liver resected at the Department of Surgery, Kurume University School of Medicine and Institute of Gastroenterology, Tokyo Women's Medical College. Thus, the study material consisted of 16 autopsy and 4 resected livers. For the study of tumor vasculature, postmortem angiography has been carried out at the Pathology Department, Kurume University School of Medicine, for the past 5 years. The technique involves perfusion of the liver from the hepatic artery and portal vein, injection of barium sulfate suspended in gelatin solution containing different dyes for the respective vessels, fixation in formalin, slicing of the entire liver in the frontal plane into 0.5 to 1-cm pieces and soft roentgenography. It was carried out on 71 livers with HCC, 42 livers with cirrhosis , and 96livers without HCC or cirrhosis. Thus, of the 16 livers with minute HCC, postmortem angiograms were obtained in 11, in several of which the tumor might have been missed without slicing and radiography. The histology of the tumorous and nontumorous portions of the liver was studied by hematoxylin-eosin, Azan-Mallory, and several other staining methods. Hepatitis B surface anti109

110

OKUDA ET AL .

gen CHB,Ag) in serum was determined by radioimmunoassay (Austria II, Abbott Laboratories, North Chicago, Ill.), electrosyneresis, or immune adherence hemagglutination test. 12 and AFP was determined by radioimmunoassay or micro-Ouchterlony technique.

Case no.

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Results Frequency of minute HCC. During the 6-year period from 1970 through 1975, there were 154 necropsies of HCC cases at our departments of pathology, of which 16

TABLE 1. Tw enty ca ses of minute hepatocellular carcinoma - 16 necropsies and 4 resections- pathological findings • Tumor nodule Liver wt Age Sex Noncancerous portion • HBsAg' (g) Size and number pigCapsule Bile (largest, em) ment 56

M

600

2 3 4 5 6 7 8

56 67 43 57 72 73 74

M M M M M M M

720 1340 820 530 1180 990 1000

4 X 2 1.1 X 2.5 x 2.5 X 3.5 X 0.7 X 1.5 x

1 2.5, few 2.5 3.5 0.5 1.5, few

+ + + + +

9

54

M

1400

2.2 x 2.2, few

+

10 11 12 13 14 15

73 44 51 67 61 64

M M M M M

810 980 510 720 1200 1890

2 X 2 2.5 X 2.5 0.8 x 0.8, few 2 x 2, few 1.4 X 1.3 1.8 X 1.3

+ + + + +

16 17

49 57

M

860

3.5 x 3, few 2.1 X 1.5

+

18

46

:

4.5

4

+

19 20

53 60

M M

2.5 x 1.2, few 2.8 x 2.4, few

+ +

F

}

Hopatio resection

2

X

1.5

X

+

+

+ +

Cirrhosis and schistosomiasis Cirrhosis Cirrhosis Cirrhosis and clonorchiasis Cirrhosis Cirrhosis Clonorchiasis Cirrhosis and schistosomiasis Cirrhosis and schistosomiasis Cirrhosis Cirrhosis Cirrhosis Cirrhosis Cirrhosis Cirrhosis and tumor thrombi Cirrhosis Cirrhosis

±

Fibrosis and chronic active hepatitis Cirrhosis Cirrhosis

+

±

±

+

±

+

ND

ND ND

ND

+ -CES)

+ -CIA)

+ +

0 +, positive; -, negative; ±, thin indistinct capsule, or pigmented only in part; ND, not done; ES, electrosyneresis; IA, immune adherence hemagglutination test. • All cases of cirrhosis were mixed micro- and macronodular type . ,. HBsAg was determined by radioassay unless specified.

FIG. 1. A minute encapsulated hepatocellular carcinoma (HCC) measuring 1.3 by 1.2 em. The reference scale at the left bottom is 1.0 em. The tumor is dark greenish brown indicating production of bilirubin (case 8).

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MINUTE HEPATOCELLULAR CARCINOMA

(10.4%) were minute HCC. Hepatic resection was carried out on 24 patients with HCC at the two institutes during the same period, and the tumor was so small as to meet the criteria for minute HCC in only 4. Pathological features . As shown in table 1, a single tumor nodule was found 12 cases, the size ranging from 0.7 by 0.5 em to 4.5 by 4 em on the cut surface; two to four tumors were found in 8 cases, with the largest one measuring 3.5 by 3 em. Grossly, the tumor was brownish yellow to green, tuming deep green upon formalin fixation-evidence for bilirubin production-in 8 cases. The primary or the largest lesion was bounded by a distinct fibrous capsule in the majority (fig. 1). It was lacking in two (cases 3 and 15), and was not distinct in another (fig. 2). Most tumors were hypervascular on postmortem angiography, even though the size was very small, and presented a distinct pattem different from the vasculature of the noncancerous portion. Often, there were one or two feeding arteries which, unlike normal dichotomous division, divided into many branches (fig. 3). Those with early necrosis were hypovascular, however. The tumor cells were generally well differentiated. They were arranged more or less in a trabecular pattem, with endothelium-lined blood spaces in all but two, in which a solid pattem of growth was seen in

?

Ll

places (cases 11 and 20). A typical tumor with a thin capsule is shown in figure 4. The noncancerous parenchyma was cirrhotic in 18 cases, 16 of which demonstrated advanced cirrhosis; it was not cirrhotic in 2. The cirrhosis was of the mixed type, with varying sizes of nodules partitioned by thin stromas (fig. 2). None exhibited the typical features of alcoholic cirrhosis, which is characterized by micronodules and steatosis. One liver had numerous Clonorchis sinensis in the markedly dilated intrahepatic bile ducts, exhibiting a secondary biliary cirrhosis. The 2 patients in which no cirrhosis was seen had mild fibrosis with chronic inflammation in the portal area. It is to be noted that none of these patients had extrahepatic metastasis. In the 2 patients who died postoperatively, cirrhosis was probably too advanced to warrant hemihepatectomy. There has been no sign of tumor recurrence or development as of the writing of this paper in cases 18 and 19, suggesting that there had been no lesion other than the removed tumors in which transformation to carcinoma was occurring. In other words, tumorigenesis was not multicentric in these patients. In case 15, in which the tumor was not encapsulated, there had already been a number of gross tumor thrombi in the portal branches, although the solitary HCC measured only 1.8 by 1.3 em. Histologically, there were varying degrees ofinflamma-

5

7i;-841J

FIG. 2. Relatively well demarcated minute hepatocellular carcinoma (HCC) arising in a cirrhotic liver. It was greenish yellow, producing bilirubin. The cirrhosis is a mixed micro- and macronodular type with thin stroma (case 17).

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OKUDA ET AL.

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FIG. 3. Two feeding arteries are apparent in this 1.3- by 1.3-cm hepatocellular carcinoma (HCC). They divide in a peculiar but characteristic fashion, producing a typical vascular pattern often seen in a large solitary HCC (case 4).

FIG. 4. Relatively well differentiated hepatocellular carcinoma (HCC) of the trabecular and acinar pattern. Note the fibrous boundary being formed between tumor and parenchyma (to the right) (H & E , x 50).

tory reactions in the stroma. The dysplastic changes8 • 13 of the hepatocytes were occasionally seen in livers with advanced cirrhosis; the details of this are described elsewhere. Clinical and laboratory findings. Four of our patients were heavy drinkers, 6 drank moderately, and 10 were nondrinkers. Only 2 of the autopsy cases were diagnosed antemortem as "cirrhosis with HCC," based on increased AFP (Case 1) and percutaneous portography 14 (case 16). In cases 14 and 15 (table 2), minute HCC was an unexpected discovery at autopsy. In the remainder, "cirrhosis" with the possibility of silent HCC was the diagnosis. In the 4 resected cases, HCC was first sus-

pected from increasing AFP levels during a regular checkup at the Outpatient Clinic and the diagnosis was established with celiac angiography (fig. 5) and laparoscopy. In 1 patient (case 9), angiographic abnormalities were recognized only retrospectively because of the low grade vascularity. Clinical manifestations were not different from those of chronic liver disease, particularly of cirrhosis. Abdominal pain, the most common complaint in massive HCC, was noted in only 1 patient (case 6), who also had had gallstones. The physical signs of cirrhosis, such as spider nevi and stigmata of portal hypertension, were common, but severe hepatic encephalopathy was not

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MINUTE HEPATOCELLULAR CARCINOMA

encountered. Blood chemistry was similarly compatible with cirrhosis. The SGOT:SGPT ratio, which increases in advanced HCC, 1" was relatively low (2.39 ± 0.32) and was less than 1:1 in 4 cases. HBsAg in serum was positive in only 1 of 12 autopsy cases studied. Serum AFP was negative by the microOuchterlony method in 4; the highest value during the clinical course was less than 100 ng per ml in 7, between 100 and 1000 ng per ml in 3, and above 1000 ng per ml in 4. It rose rather sharply in case 18, and slowly but steadily in cases 17, 19, and 20. When survival was calculated from the time when the patient was first told of liver disease or of cirrhosis, it ranged from 4 months to 7 years. The direct cause of death was hepatic failure or gastrointestinal bleeding in the majority. Of the 4 patients in whom the liver was resected, 1 is still living 2.5 years after operation and another has survived almost 1 year. The other 2 died from hepatic failure postoperatively. Discussion Although incidental discovery of small HCC in the liver at autopsy or during laparoscopy may not be surprising in areas where HCC is not uncommon, little

mention has been made of it in the studies oflarge series of HCC. 1- 3 • &-Jo, HHH In Berman's autopsy material in Africa, the smallest liver weighed 1900 g. IH When Miyaji and his associates studied 380 cases in Japan in 1960, all livers weighed above 1 kg.w In the present series, in which the livers averaged 905 g in weight, the smallest was 530 g. In 1954, Edmonson and Steiner observed that of their 29 cases of mature cell type, 9 had livers of normal or less than normal weight, and most of them had advanced cirrhosis. 1 Our observations have been similar. SteinerH mentioned in his analysis of nearly 1000 cases of HCC that "cancerous livers that were of less than normal weight were usually found either in cases in which a small tumor was present in a highly cirrhotic organ or in those in which a small tumor near the surface had ruptured through the hepatic capsule." Management of hepatic tumors has improved in recent years, 19 and the survey conducted by the Japan Liver Cancer Study Group in 1975 disclosed that as of the end of 1974, there were 25 patients living more than 5 years of 297 hepatectomized, with the longest surviving more than 17 years. 20 These statistics are encouraging. The observation that the primary lesion usually had a distinct fibrous caspule suggests that in that stage

TABLE 2. Clinical feature of 20 cases of minute hepatocellular carcinoma (HCCJ Blood chemistry' Case no.

b

c

AFP" (ng/mi)

Alkaline phosphatase (KAU)

SGOT

(KUl

SGOT/ SGPT

1 2 3 4 5 6

Cirrhosis and HCC Cirrhosis Cirrhosis Cirrhosis Cirrhosis Cirrhosis and gallstone

11600 ND 1 -(MO) 55 -(MO)

34.1 15.7 17.1 9.2 6.6 56 .0

85 94 660 59 32 40

2.1 3.6 2.4 0.9 2.0 2.9

7 8

Cirrhosis Cirrhosis

-(MO) 1

31.4 9.7

320 550

5.4 6.0

9

Cirrhosis

16.8

108

3.3

10

Cirrhosis

ND

20.1

53

3.8

11

1400

17

87

2.4

12 13 14

Menetrier's disease and cirrhosis Cirrhosis Cirrhosis Apoplexy

-(MO) 12 96

16 6.3 6.5

61 41 48

1.5 1.5

15 16

Diabetes Cirrhosis and HCC

60 0-40

19.5 14

89 82

0.9 0.9

17

Cirrhosis and HCC

288-4100

10.4

48

1.7

18

Chronic active hepatitis and HCC Cirrhosis and HCC Cirrhosis and HCC

5.6

115

0.9

20.6 10.5

17 42

2.4 2.0

19 20 a

Clinical diagnosis

200-400

3-10800 1-660 26-536

1.1

Cause of death

Survival (from time of diagnosis of chronic liver disease)

Hepatic failure Hematemesis Hepatic failure Ruptured varix Hepatic failure Postoperative hepatic failure Pneumonia Gastrointestinal bleeding Postsplenectomy death Gastrointestinal bleeding Hepatic failure

8 mo. 11 mo. 6.5 mo. 10 mo. 18 mo. 3.5 yr.

Hepatic failure Hepatic failure Gastrointestinal bleeding Diabetic coma Postlaparotomy hepatic failure Postoperative failure Living

14 mo. 5.5 yr. 4 yr.

Living Postoperative hepatic failure

AFP, a-fetoprotein; ND, not done; MO, micro-Ouchterlony method. Two weeks before death, or shortly before hepatectomy; KAU, King-Armstrong U; KU, Karmen U. Still living.

4 yr. 4 mo. 2 yr. 7.5 yr. 6 yr.

11 yr. 21 mo. 11 days 918 daysc 316 daysc 65 days

114

OKUDA ET AL . ·-~

~~·Afj/r1:~

Vol. 73,No.l

mildly elevated and did not prove diagnostic. However, if followed at appropriate intervals and found slowly rising, it should arouse suspicion and angiography should be done. 28 In fact, all resected cases and 1 autopsied case were diagnosed based on AFP and celiac angiography. Hepatic resection is indicated only in patients in whom the liver function is not severely impaired, and hemihepatectomy or even extended right hepatectomy may be possible, depending upon the state of the noncancerous parenchyma.29 REFERENCES 1. Edmondson HA, Steiner PE: Primary carcinoma of the liver. A

2.

3. 4.

5. 6.

7. FIG. 5. Celiac arteriograms of case 17 made in June 3, 1973 (A) and November 29, 1974 (B ). Note the appearance in the 17-month period of a distinct hypervascular area along the posterosuperior bra nches of the right hepatic artery.

8.

9.

the tumor had been growing slowly and in an expansile, noninfiltrating fashion. 1• 8 • 21 Although the pathological issue of whether HCC arises unicentrically or multicentrically has not been settled, the relatively benign nature of the primary warrants surgery. The etiological relationship between cirrhosis and HCC is still largely unknown. Recent investigations have indicated frequent positive tests for HB5 Ag in patients with HCC in areas with a high incidence of this cancer, and etiological role for hepatitis B (HB) virus has been suggested.22- 25 In Japan, HB5Ag is positive in about 40 to 50% of HCC patients, 13 • 25 and those with antigen-positive chronic hepatitis and cirrhosis seem to develop HCC earlier than do antigen-negative patients. 26 The low positivity rate in the autopsy material in the present series may suggest slow evolution ofHCC in negative cases because the cirrhosis seen in them was advanced; however, anti-HE core, probably a more sensitive test for HB infection, 27 was not studied in these patients, and its involvement in minute HCC cannot be dismissed. Although histopathology of our material did not suggest alcoholic cirrhosis, the influences of alcoholic and viral hepatitis of a non-A, non-B type are also to be considered. Clinically, only 2 of 16 autopsy cases and 4 of the resected cases were diagnosed in the stage of minute HCC . In the remainder, AFP was either negative or

10. 11.

12.

13 . 14.

15.

16.

17. 18. 19. 20.

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21. Nakashima T: Vascular changes and hemodynamics in hepatocellular carcinoma. In Hepatocellular Carcinoma. Edited by K Okuda, RL Peters. New York, John Wiley & Sons, 1976, p 169203 22. Sherlock S, Fox RA, Niazi SP, et al: Chronic liver disease and primary liver-cell cancer with hepatitis-associated (Australia) antigen in serum. Lancet 1:1243-1247, 1970 23 . Tong MJ, Sun SC, Schaffer BT, et al: Hepatitis-associated antigen and hepatocellular carcinoma in Taiwan. Ann Intern Med 75:687-691, 1971 24. Ohbayashi A, Okochi K, Mayumi M: Familial clustering of asymptomatic carriers of Australia antigen and patients with chronic liver disease or primary liver cancer. Gastroenterology 62:618-625, 1972 25. Nishioka K, Hirayama T, Sekine T, et al: Australia antigen and

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hepatocellular carcinoma. Gann 14:167-175, 1973 26. Obata H, Hayashi N, Okuda K, et al: Continuous monitoring of HBsAg and alpha-fetoprotein in patients with cirrhosis and detection of hepatocellular carcinoma in early stage. Hepatitis Scientific Memorandum H-881, Calspan Corp, Buffalo, May 1975 27. Maupas P, Werner B, Larouze B, et al: Antibody to hepatitis-B core antigen in patients with primary hepatic carcinoma. La ncet 2:9-11, 1975 28 . Okuda K, Kubo Y, Obata H: Serum a-fetoprotein in the relatively early stages of hepatocellular carcinoma and its relationship to gross anatomical types. Ann NY Acad Sci 259:248-252 , 1975 29. Lin TY: Surgical treatment of primary liver cell carcinoma. In Hepatocellular Carcinoma. Edited by K Okuda, RL Peters. New York, John Wiley & Sons, 1976, p 449-468