Survival from Hepatocellular Carcinoma at a Cancer Hospital in Pakistan


Objectives: To determine the tumour and general characteristics, especially survival, of patients presentingwith hepatocellular carcinoma at our tertiary care cancer hospital. Patients and methods: We retrospectivelystudied 584 charts of patients consecutively registered between 1995 and 2004 at the Shaukat Khanum MemorialCancer Hospital and Research Centre, in Lahore, Pakistan. Descriptive statistics were obtained for gender, age,tumour size and morphology, alpha fetoprotein level, means of diagnosis, Child-Pugh status, risk factors, treatmentgiven and follow-up. Survival analysis was conducted using the Kaplan-Meier method.
Results: Mean age atpresentation was 56 years. Four hundred and forty four (76%) were male. Average tumour diameter evaluablein 412 patients was 8 cm. HCC was unifocal in 194 (33%), multifocal in 303 (52%) and unevaluable in 106.Mean AFP was 4,198 u/ml (range 1 - 278,560). Methods of diagnosis were FNA in 71, biopsy in 26, imaging/AFP> 200 in 70, lipiodol angiogram in 42, combinations of two of these in 365 and biphasic CT scans in 10. InitialChild-Pugh available for 400/584 was A in 216, B in 147 and C in 37. Evidence of prior hepatitis B infection wasfound in 114, and for hepatitis C in 254. Other than the four patients who had TACE followed by surgicalresection, treatment was offered to 79/584 patients: among the 48 who had TACE, 26 experienced cancerprogression whereas 11 had stable disease ranging from 6 - 20 months; another 11 were lost to follow-up. Of the14 patients who underwent local resection, 2 were lost to follow-up, 7 developed recurrences but 5 remaineddisease free for a mean of 33 months. Following ethanol ablation in 17 patients, disease progressed in 5 butremained stable in 2 for a mean of 13 months; 10 were lost to follow-up. At the time of writing, 56 patients arealive (mean follow-up 20 months), 210 are known to have died (mean follow-up 9 months), and 318 were lost tofollow-up within 3 months. Median overall survival was 10.5 months, death being the point of interest forsurvival analysis. Child-Pugh class stratified analysis (400/584) revealed median survival of 12 months for classA, 7.7 months for class B and 4 months for class C (p < 0.001).
Conclusions: Most patients present with large,multifocal tumours, with poor liver function. Sixty one percent had evidence of prior infection with hepatitis Bor C. The advanced stage at presentation, poor background liver function in many and the absence of a nationalliver transplantation program limit treatment options. Only 14% of patients were considered suitable for definitivetreatment. Survival correlated with Child-Pugh status at presentation. Overall prognosis remains bleak. Thereis an urgent need to educate the public about the risks of hepatitis B and C and health professionals about earlydiagnosis and treatment, including possible development of a sustainable national liver transplant program.