November 2001, Volume 51, Issue 11

Short Reports

Multi Locular Presentation of Hepatocellular Carcinoma

N. Khokhar  ( Department of Medicine, Shifa International Hospital and Shifa College of Medicine, Islamabad. )


Hepatocellular carcinoma (HCC) is among the commonest malignancies world wide and is increasing in prevalence in many part of the world1,2. Recent trends have shown that chronic hepatitis has become a more common cause of the hepatocellular carcinoma and more people are developing it at a relatively younger age3. South East Asia, including our country and certain parts of Africa and China are becoming areas of major occurrence of this type of cancer4. We describe our experience of hepatocellular carcinoma, during the last 4 years period, at Shifa International Hospital, which is a tertiary referral center.

Materials, Methods and Results

All the liver biopsies performed at Shifa International Hospital from 1995-1999 were reviewed. Patients with solitary lesions on either sonography or CTscan were biopsied under ultrasonic guidance and those with multiple lesions without radiologic guidance. Liver biopsies were performed using standard technique with Menghini needle.
The medical record of hepatocellular carcinoma as histological diagnosis, were further reviewed for age, sex, serology, aiphafeto protein, ultrasound and CT appearances, presenting features and ultimate outcome, if known.
A total of 301 liver biopsies were performed. Out of these 27 patients were diagnosed with hepatocellular carcinoma. Seventeen (63%) patients had single lesions and 10 (37%) had multiple lesions. Their age ranged from 3 5-84 years and there were 19 males and 8 females. Hepatitis “B” surface antigen was positive in 4 (l5%) and Anti-HCV in 7 (26%) patients. Alpha fetoprotein ranged from 43 to over 6300 ng/ml. Twenty two patients (8 1%) had cirrhosis (Table).
Eighty five percent patients presented with epigastric or right upper quadrant pain. Most of them (52%) had a palpable liver or a mass in the right upper quadrant or epigastrium. Four patients came with jaundice and one with fever.
The management of these patients was also reviewed. Most of the cases came from long distances and were either unwilling or unfit for surgery or palliative treatment. Most of the patients who were available for follow up had died within 4-6 months of the initial diagnosis.


Ten (37%) patients with HCC in this study had multi locular lesions on ultrasonography. US/CT guided liver biopsy was the only way to differentiate HCC from metastatic lesions. Right upper quadrant mass and hepatomegaly observed in this series have also been reported from Karachi5. Alpha fetoprotein ranged from 43-6300 ng!ml in this study. More than 200 ng/ml titers were found in nearly 60% cases in previous studies from Pakistan5,6.
In Pakistan, hepatitis B positivity ranged from 10 to 70% in cases of hepatocellular carcinoma7,8. An earlier study from Karachi showed 60% of patients with HCC had a HBV marker5. After the discovery of hepatitis C virus, more cases of HCC are being attributed to HCV9. Fifty percent cases of HCC were found to be positive for HCV in a recent study from Karachi10. In our study hepatitis B surface antigen was positive in 15% and Anti-HCV in 26% patients. Relationship of Aflatoxin with HCC has also been reported in some studies6,11 but this issue was not addressed in the present study.
In summary, this study showed that a significant percent of patients with HCC had HCV or HBV in their sera. Eighty percent had cirrhosis before developing HCC. A significant proportion of these patients presented with multilocular appearance on US/CT-scan mimicking metastatic disease of the liver.


1.Bismuth H. Hepatocellular carcinoma in elderly: results of surgical and non-surgical management. Am. J. Gastroenterol., 1999, 94: 2336-7.
2.Poon RIP, Fan ST, Loc M, et al. Hepatocellular carcinoma in elderly: results of surgical and non-surgical management. Am. J. Gastroenterol., 1999; 94: 2460-6.
3.Choudhry AM, Roberts 1, Gupta TI Changing patterns of hepatocellular carcinoma. Am. J. Gastroenterol., 1999; 94: 257 1-2.
4.Tang ZY. Treatment of hepatocellular carcinoma. Digestion, 1998; 59: 556-62.
5.Qureshi H, Zuberi Si, Jafarey NA, et al. Hepatocellular carcinoma in Karachi. i Gastroenterol Hepatol., 1990; 5:1-6.
6.Zuberi Si. Immunological studies in primary liver cancer in Karachi. Ann Acad Med Singapore., 1980; 9:203-5.
7.Mujeeb A, Jamal Q, Khanani R, et al. Prevalence of hepatitis “B” surface antigen and HCV antibodies in hepatocellular carcinoma cases in Karachi, Pakistan. Trop. Doct., 1997; 27: 45-6.
8.Zuberi Si, Lodi TZ, Samad F. Prevalence of hepatitis “B” surface antigen and antibody in healthy subjects and patients with liver disease. J. Pak. Med. Assoc., 1978; 28: 2-3.
9.Tong CY, Khan R, Beeching NJ, et al, The occurrence of hepatitis “B” and “C” viruses in Pakistani patients with chronic liver disease and hepatocellular carcinoma. Epidemiol. infect., 1996; 117:327-32.
10.Shah HA, Jafri W, Malik 1, et al. Hepatitis C virus (HCV) genotypes and chronic liver disease in Pakistan. J. Gastroenterol. Hepatol., 1997; 12:758-61.
11.Nizami HM, Zuberi Si. Aulatoxins and liver cancer in Karachi, a preliminary survey. J. Pak. Med. Assoc., 1977; 27: 35 1-2.

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