| Abstract|| |
Cytological diagnosis of one hundred and fifteen patients who had fine needle aspiration (FNA) of liver masses during the period from January 1987 to December 1993 was reviewed. Primary hepatocellular carcinoma (HCC) was the most common diagnosis in 87 patients (76%) with a male predominance of 82%, HBsAg and HCV antibodies were positive in 46 and 62% of patients, respectively. HBcAb was positive in 87% of patients. The median alphafetoprotein (AFP) level was 902 ng/ml. Sixty-two patients had AFP more than 200 ng/ml (normal range up to 8 ng/ml). Abdominal pain and liver mass were the most common clinical presentations in 88 and 90%, respectively. Raised ALT and AST were noted in 78 and 93%, respectively. Sixty-two percent of patients had low serum albumin less than 35 g/L.
In conclusion, HCC was the predominant finding in patients presenting with liver mass. HCV antibodies were frequently associated with HCC. AFP of 200 ng/ml or more was diagnostic of HCC in those patients and may negate further histological confirmation in those who are moribund or have serious coagulation disorders.
|How to cite this article:|
Fashir B, Sivasubramaniam V, Al-Momen S, Assaf H. Hepatic tumors in a Saudi patients population. Saudi J Gastroenterol 1996;2:87-90
Primary hepatocellular carcinoma (HCC) is considered to be the most common malignant tumor in Africa, Asia including the Kingdom of Saudi Arabia (KSA) ,,,, . This is explained by the high prevalence of viral hepatitis in these areas. ,,,,,, . The diagnosis of HCC has become increasingly frequent as a result of improved imaging methods. Fine needle aspiration (FNA) of the liver has proven to be an important aid in the diagnosis of malignant hepatic diseases. It is a minimally-invasive mean and a valuable diagnostic procedure for potentially resectable localized HCC  . FNA cytology is emerging as an important tool for the minimally-invasive emerging documentation of suspected lesions through guidance of ultrasound or CT scan  . Mortality from FNA of liver has been reported  . AFP of 200 ng/ml or more was diagnostic of HCC in patients with a liver mass  . This was confirmed in our study. Herein we report the outcome of 115 patients who had FNA of liver masses during a period of seven years from January 1987 to December 1993.
| Patients and Methods|| |
Patients were referred to the Security Forces Hospital, a tertiary referral hospital, from various parts of the Kingdom (KSA). At the time of referral many patients had an advanced malignancy as ultrasonography or CT scan showed large tumors more than 5 cm in a small shrunken liver, high AFP of more than 200 ng/ml and poor general condition of the patients. Those patients were beyond the scope of surgery or chemotherapy, therefore, FNA biopsy was not done. We reviewed only records of patients who have had FNA of liver masses diagnosed clinically in 90% of cases and confirmed by ultrasonography or CT scan, from January 1987 to December 1993. Only Saudi nationals were included in this study. All the necessary information such as age, sex, mode of presentation, liver function tests, AFP and viral markers for HBV and HCV were obtained. The fine needles used were those of 22-23 gauge. Specimens from FNA of all patients were reviewed by one pathologist. Wilcoxon and Chisquare Test were used for statistical analysis. P value of less than 0.05 (P<0.05) was considered to be significant.
| Results|| |
In a hundred and fifteen patients who underwent FNA for liver masses, HCC was diagnosed in 87 (76%), and metastatic liver lesions in ten (9%) patients. Other findings are summarized in [Table - 1]. HCV antibodies, HBsAg and HBcAb were found in 62, 46 and 87% of patients with HCC, respectively. Presentation with abdominal pain and liver mass were noted in 88 and 90% of patients, respectively. In our study 62% of patients with HCC had AFP of 200 ng/ml or more. Sixty percent of HCC were found in association with HBV and 52% with HCV.
The median AFP in patients with HCC was 902 ng/ml. The median AFP in patients with chronic persistent hepatitis (CPH), chronic active hepatitis (CAH)and cirrhosis was 7.2, 10.3, 23.3 ng/ml, respectively. Thirty-seven percent of patients with HCC had an AFP of less than 100 ng/ml. Nineteen percent of patients with HCC were below 50, 57% between 50 and 70. and 31 % were above 70 years of age. The peak incidence of HCC was around the age of 55 years. Two patients (1.7%) died after FNA, both had HCC. The clinical and laboratory data of patients with HCC and metastatic carcinoma of the liver are shown in [Table - 2]. The presence of HBV, HCV, high AFP and low serum albumin, significantly differentiated liver metastasis.
| Discussion|| |
Our study showed the majority of liver masses were malignant. This was explained by the high prevalence of HBV and HCV in this region , . HCV antibodies and HBsAg were positive in 62 and 46 percent of patients with HCC, respectively. Studies from Italy , and Spain  also showed higher prevalence of HCV from patients with HCC occurring in 75% and 65%, respectively. Benign liver tumors are rare in our review. It showed only one case of hepatic adenoma. About 7.8% of liver masses referred for evaluation were probably regeneration nodules in a cirrhotic liver as evidenced by radiological and cytological features and normal AFP. Primary HCC was characterized by a male predominance of 4:1 which is comparable to a previous study from Riyadh  . The peak age of patients with HCC was 55 years, which is consistent with reports from China and Hong Kong , . In contrast, younger age groups are reported from Africa (4). In our review, the youngest patient with HCC was 27 and the oldest was 85 years. We found that AFP of more that 200 ng/ml was virtually diagnostic of HCC in a patient with liver mass. None of our patients with a liver mass and AFP over 200 ng/ml proved cytologically not to have HCC.
In our series, two patients out of 115 died of hemorrhage following FNA (Mortality about 1.7%). Both patients had HCC. These tumors are vascular, friable and along with disturbed coagulopathy and thrombocytopenia associated with underlying cirrhosis, makes bleeding a real risk during biopsy. Mortality of 1.7% in our series seems to be high compared with other reports. Schwark et al reported no mortality in 60 consecutive FNA of liver masses  . Lungquest et al, reported only one serious complication among 2,611 FNA biopsies  . Riska et al reported a case fatality (this was a single case report) after FNA biopsy of a liver in a patient with HCC  . Benkejtok et al reported a case of severe bile peritonitis following FNA of the liver that required laparotomy  . FNA of the liver is a safe procedure but unexpected serious complications can arise , . These complications are related to the number of passes, presence of primary HCC and presence of more than one risk factor such as coagulopathy and thrombocytopathy ,,,, . We conclude that raised AFP of more than 200 ng/ml is diagnostic of HCC in the setting of chronic liver disease, liver mass and positive hepatitis viral markers  . In moribund patients, and in patients with serious coagulation abnormalities and/or low platelets, an AFP above 200 ng/ml may negate the need for histological confirmation. FNA or liver biopsy confirmation is only needed in liver masses with AFP less than 200 ng/ml and in those who are fit and considered for hepatic resection, transplantation or chemotherapeutic trials.
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King Faisal Specialist Hospital and Research Center, Department of Medicine, Liver Transplant Unit (MBC 53) P.O. Box 3354, Riyadh 11211
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2]