Etiologic factors and clinical presentation of hepatocellular carcinoma: Differences between cirrhotic and noncirrhotic Italian patients

Background. It is not known whether the prevalence of hepatocarcinogenic factors differs between cirrhotic and noncirrhotic patients with hepatocellular carcinoma (HCC) or whether the clinical presentation of HCC in these two groups differs. Methods. The prevalence of the putative etiologic factors of HCC and its clinical presentation in 373 patients with cirrhosis and 102 without cirrhosis seen from 1981 to 1992 were evaluated. Results. Hepatitis C virus infection (76 vs. 48%, P = 0.003) and both current (22.5 vs. 10%, P = 0.007) and past (50.5 vs. 34.5%, P = 0.045) hepatitis B virus infections were more common in cirrhotic than in noncirrhotic patients with HCC. The absence of exposure to both viruses was much less frequent in the former (7 vs. 40%, P <0.001). Heavy alcohol intake prevailed in patients with cirrhosis (30 vs. 16.5%, P = 0.01). Alpha-fetoprotein elevation was more common in cirrhotic patients (63% vs. 31%, P <0.001); however, the prevalence of diagnostic (>400 ng/ml) levels did not differ significantly (24 vs. 17%) between the two groups. Extrahepatic extension of HCC was more common in noncirrhotic patients (20.5 vs. 6.5%, P <0.001) and its independent predictors were poor cancer differentiation and absence of cirrhosis. 'Asymptomatic' cancers were more frequently encountered with cirrhosis. Abdominal pain was the most common presenting symptom in both groups. Signs of hepatic decompensation prevailed in cirrhotic patients, whereas a 'toxic syndrome' dominated the clinical picture of the noncirrhotic patients. Conclusions. Hepatitis viruses are associated more with carcinogenesis of the cirrhotic than of the noncirrhotic liver. Alpha- fetoprotein is not a sensitive neoplastic marker, particularly in noncirrhotic patients. In the latter, HCC appears more advanced at diagnosis and symptoms of neoplastic toxicity are prominent.