Hepatocellular carcinoma: a clinicopathological study of 64 cases

Hepatocellular carcinoma (HCC) is the most common of all liver cancers and is a major worldwide public health problem. The aim of this study was to provide an updated overview on clinicopathological features, treatment and outcome of HCC. In our retrospective study, we reviewed 64 cases of HCC that were diagnosed at the pathology department of Mongi Slim hospital over a fifteen-year period (2000- 2014). Relevant clinical information and microscopic slides were retrospectively reviewed. Our study group included 38 men and 26 women (sex ratio M/F = 1,26) aged between 8 and 83 years (mean = 56,64 years). The presenting clinical symptoms were dominated by abdominal pain (n=34), followed by altered general health (n=25) and jaundice (n=4). Fifty-five patients underwent surgical treatment. Liver transplantation was performed in two cases and transarterial chemoembolization was achieved in seven cases. Histopathological examination of the surgical or biopsy specimen established the diagnosis of conventional HCC in 55 cases, fibrolamellar carcinoma in 6 cases and clear cell HCC in 3 cases. Seven patients with HCC died postoperatively. Local recurrence of the tumour occurred in three cases and two patients had distant metastases postoperatively. The other patients are still being followed-up. Hepatocellular carcinoma is associated with a high rate of mortality because of early invasion, widespread metastasis and lack of effective therapeutic modalities. Accurate diagnosis and staging of these tumours is critical for optimal treatment planning and for determining prognosis.


Introduction
Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third cause of cancer-related deaths in the world. It is the most common cause of death in patients with cirrhosis [1,2]. In this paper, we report our experience with HCC over the past 15 years.
Our aim was to analyze epidemiological characteristics, clinical symptoms, radiological features, treatment and outcomes of 64 patients who were surgically treated at our institution. Our results are analyzed in comparison to a review of the literature.

Methods
We undertook a retrospective study of 64 patients who were operated on for HCC at the General Surgery Department of Mongi Slim hospital of Tunis between February 2000 and November 2014.
The cases were retrieved from the files of the registry of surgery of the same hospital. Medical records were scrutinized for epidemiological characteristics, predisposing factors, initial manifestations of the disease, methods of diagnosis, laboratory findings, surgical or palliative therapy and overall morbidity and mortality. Diagnosis of HCC was based upon clinical, imaging and histopathological findings. All patients underwent imaging evaluation during the preoperative period. All specimens were surgically obtained. Tissues were fixed in 10% phosphate buffered formaldehyde, embedded in paraffin and sections were prepared for routine light microscopy after staining with haematoxylin and eosin.
For clear cell HCC, immunohistochemical analysis was performed using the avidin-biotin complex technique with antibodies against Hepatocyte Specific Antigen (HepPar1). Patient confidentiality was maintained.

Biological tests:
Preoperative serum alpha-fetoprotein levels were performed in 50 cases. They were elevated in 40 cases and within normal range in 10 cases. Preoperative serum carbohydrate antigen CA 19-9 levels were performed in eight cases. They were elevated in four cases (> 100 U/ml) and within normal range in four cases.
Preoperative serum CEA levels were performed in fourteen cases.
They were slightly elevated (> 5ng /ml) in three cases and within normal range in four cases. Hepatitis B and C serology were

Discussion
The incidence of HCC varies in different countries, depending on the prevalence of major causes, namely chronic viral hepatitis (hepatitis B and C) or other chronic liver diseases (fatty liver disease, alcohol, hemochromatosis, and α-1-antitrypsin deficiency). Hepatocellular carcinoma occurs more frequently in older than in young individuals and affects men more often than women at a ratio of 2:1 to 4:1 [3].
In our series, mean age at presentation was 56 years with a male predominance (sex-ratio M/F = 1,26). The presenting signs and symptoms in patients with HCC may be caused by the tumour itself or by the advanced stage of chronic liver disease predisposing to malignancy. Thus symptoms include abdominal pain, general malaise, anorexia or weight loss and nausea or vomiting [4]. oncologists, radiologists as well as surgeons, is necessary to provide the most up-to-date care and to ensure the best outcomes. Surgical resection and orthotopic liver transplantation are the only potentially curative treatments for HCC. However, the coexistence of chronic liver diseases and the insidious nature of HCC make it unresectable in most patients. In these cases, treatment normally consists of local ablation therapies using ethanol injection or radiofrequency irradiation as well as transarterial chemoembolization [7].
At gross examination, HCC may display a nodular, infiltrative, or diffuse macroscopic pattern. The nodular (expanding) pattern is the most common type. It is typically seen in association with cirrhosis.
Tumor nodules may be solitary or multiple across the liver. The infiltrative (massive) pattern is usually characterized by a single large mass that occupies a substantial portion of the liver. The lesion is poorly circumscribed with ill-defined, invasive borders. The diffuse pattern is the least common and represents widespread infiltration by numerous small nodules that virtually replace the entire liver. Pedunculation is noted in rare instances, presumably reflecting origin from an accessory hepatic lobe [8]. to only a few months in untreated patients [12]. Spontaneous regression of HCC is exceedingly rare with only 47 cases reported in literature previously [13].

Conclusion
In

Competing interests
The author declare no competing interests.

Authors' contributions
Dr Faten Limaiem was the principle investigator who prepared,