Saudi Journal of Gastroenterology
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Year : 1996  |  Volume : 2  |  Issue : 2  |  Page : 87-90
Hepatic tumors in a Saudi patients population


Department of Medicine, Liver Transplant Unit, King Faisal Specialist Hospital and Research Center, Saudi Arabia

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   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

How to cite this URL:
Fashir B, Sivasubramaniam V, Al-Momen S, Assaf H. Hepatic tumors in a Saudi patients population. Saudi J Gastroenterol [serial online] 1996 [cited 2020 Nov 25];2:87-90. Available from: https://www.saudijgastro.com/text.asp?1996/2/2/87/34032


Primary hepatocellular carcinoma (HCC) is considered to be the most common malignant tumor in Africa, Asia including the Kingdom of Saudi Arabia (KSA) [1],[2],[3],[4],[5] . This is explained by the high prevalence of viral hepatitis in these areas. [1],[2],[3],[6],[7],[8],[9] . 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 [10] . FNA cytology is emerging as an important tool for the minimally-invasive emerging documentation of suspected lesions through guidance of ultrasound or CT scan [11] . Mortality from FNA of liver has been reported [12] . AFP of 200 ng/ml or more was diagnostic of HCC in patients with a liver mass [3] . 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 Top


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 Top


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 Top


Our study showed the majority of liver masses were malignant. This was explained by the high prevalence of HBV and HCV in this region [6],[9] . HCV antibodies and HBsAg were positive in 62 and 46 percent of patients with HCC, respectively. Studies from Italy [13],[14] and Spain [15] 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 [3] . The peak age of patients with HCC was 55 years, which is consistent with reports from China and Hong Kong [4],[5] . 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 [11] . Lungquest et al, reported only one serious complication among 2,611 FNA biopsies [16] . Riska et al reported a case fatality (this was a single case report) after FNA biopsy of a liver in a patient with HCC [12] . Benkejtok et al reported a case of severe bile peritonitis following FNA of the liver that required laparotomy [17] . FNA of the liver is a safe procedure but unexpected serious complications can arise [12],[18] . 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 [18],[19],[20],[21],[22] . 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 [3] . 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[28].

 
   References Top

1.Kassimi MA. Ali M, Simo M. Khan MA, Anees AM. Patterns of liver disease in the Western Region of Saudi Arabia. Ann Trop Med Parasit 1993;77(2):179-86.  Back to cited text no. 1    
2.Al-Quorain A, Satti MB, Al Harridan AR. et al. Patterns of chronic liver disease in Eastern Province of Saudi Arabia. Trop Geo. , Med 1994:46(6):358-60.  Back to cited text no. 2    
3.Kingston M, Ashraf M. Lewall D. Hepatic tumors in Saudi Arabia, Cancer 1985;55:1579-85.  Back to cited text no. 3    
4.Zakim D, Boyer TD. Hepatology: a text book of liver disease. (Second edition) Philadelphia WB Sanders Company 1990:p 1222.  Back to cited text no. 4    
5.Sherlock S. Diseases of the liver and biliary system: (ninth edition) Blackwell Scientific Publications. 1993:P 503.  Back to cited text no. 5    
6.Al Faleh F. Hepatitis B Infection in Saudi Arabia - Ann Saudi Med, 1988:8:474-9.  Back to cited text no. 6    
7.Al Mofleh I. The patterns of chronic liver disease in a hospital population in Riyadh, E Afr Med J 1988:65:514-9.  Back to cited text no. 7    
8.Jamjoom GA. Qulis Sk. Scrodiagnosis of HCV in acute and chronic liver disease in South Western Saudi Arabia. J. Trop Med Hyg 1992:61:428-31.  Back to cited text no. 8    
9.Al Saeed A. Ahmed AM, Al Karawi MA, et al. The association between Hepatitis C virus antibody and hepatocellularcarcinoma in relation to Hepatitis B viral infecion. Riyadh Armed Forced Hospital experience. Ann Saudi Med 1992;12(3):283-5.  Back to cited text no. 9    
10.Tao LC, Ho CS. McLoughlin MJ, et al. Cytologic diganosis of hepatocellular carcinoma by fine needle aspiration biopsy. Cancer 1984;53:547-52.  Back to cited text no. 10    
11.Schwerk WB. Schmitz-Moormann P. Ultasonically-guided fine needle aspiration biopsies in neoplastic liver disease. Cancer 1981;48:1469-72.  Back to cited text no. 11    
12.Riska H, Friman C. Fatality after fine needle aspiration biopsy of the liver (Letter) Br Mcd J 19722500-2.  Back to cited text no. 12    
13.Villa E. Baldiri GM. Pasquinlli C. et al. Risk factors of hepatocellular carcinoma in Italy. Cancer 1988:62:611-4.  Back to cited text no. 13    
14.Colombo M, Choo QL, Delninno E, et al. Prevalence of antibodies to hepatitis C virus in Italian patients with hepatocellular carcinoma. Lancet 1989:2:1006-8.  Back to cited text no. 14    
15.Bruix J. Clavet X. Costa J, et al. Prevalence of antibodies to hepatitis C virus in Spanish patients with hypocellular carcinoma and hepatic cirrhosis. Lancet 1989:1:126.  Back to cited text no. 15    
16.Lundquist A. Liver biopsy with a needle of 0.7 mm outer diameter, safety and quantitative yield. Acta Med Scand 1970;188:471-4.  Back to cited text no. 16    
17.Benkestok Ts. Fine needle biopsy of the liver complicated with bile peritonitis. Acta Med Scand 1976;199_141-2.  Back to cited text no. 17    
18.Bell DA. Carr CP, Szyfelbein WM. Fine needle aspiration cytology of focal liver lesions; results obstained with examination of both cytologic and histologic preparations. Acta Cytol 1986;30:397-402.  Back to cited text no. 18    
19.Sangalit G, Livraghi T. Giordano F. Fine needle biopsy of hepatocellular carcinoma, improvement in diagnosis by microhistology. Gastroenterology 1989;96:524-6.  Back to cited text no. 19    
20.Lundquist A. Fine needle aspiration and biopsy for cytodiagnosis of malignant tumor in the liver. Actn Med Scand 1970;188:465-70.  Back to cited text no. 20    
21.Tao LC, Donat EE, Ho CS, McLoughlin MJ. Percutaneous fine needle aspiration of the liver; cytologic criteria of liver cancer. Acta cyto 197923:287-91.  Back to cited text no. 21    
22.Ho CS, McLoughlin MJ, Tao LC. Blendis L, Evans WK. Guided percutaneous fine needle aspiration biopsy of the liver. Cancer 1981:47:1781-5.  Back to cited text no. 22    
23.Arya SC, Ashraf SJ, Pathak VP, et al. Serological profiles for HBV, HDV, HIV-1 and HLTV-1 in Saudi Arabian patients with malignancy. J Commun Dis 1991 Dec:23(4):270-5.  Back to cited text no. 23    
24.Dazzard MC, Meneses LV, Girad PM. et al. Hepatitis C virus antibody and hepatocellular carcinoma (letter). Lancet 1990; 1: 1216.  Back to cited text no. 24    
25.Kew MC, Houghton M. Choo QL, Kuo G. Hepatitis C virus antibodies in Southern African blacks with hepatocellular carcinoma. Lancet 1990;1:873-4.  Back to cited text no. 25    
26.Chen US. Kuo GC, et al. Hepatitis C virus infection in an area hyper endemic for hepatitis B and chronic liver disease. The Taiwan experience. Infect Dis 1990:162:817-22.  Back to cited text no. 26    
27.Hassan F, Jeflrvi L, Demedina NI, et al. Hepatitis C virus-associated hepatocellular carcinoma. Hepatology 1990;12(3):589-91.  Back to cited text no. 27    
28.Perrault J. Mcgill B, Beverly J, William Fl. Liver biopsy; compllications in 1000 inpatients and outpatients. Gastroenterology 1978;74:103-6.  Back to cited text no. 28    

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Correspondence Address:
Baroudi Fashir
King Faisal Specialist Hospital and Research Center, Department of Medicine, Liver Transplant Unit (MBC 53) P.O. Box 3354, Riyadh 11211
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864833

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