In the article by Ruelas-Villavicencio et al1 that evaluates a hepatocellular carcinoma (HCC) surveillance program the authors concluded that male predominance was not observed for this neoplasm in their series (male:female ratio was 1.2:1) and that only 42% of thier patients showed “signs of cirrhosis”, which is not far from the 56% found by Mondragón et al in their Mexican series of HCC patients.2
The difference between the findings in this paper and those described in the literature is due to the methods used in diagnosing hepatic cirrhosis (fine needle aspiration biopsy, or clinical presentation and laboratory abnormalities associated to endoscopic and or imaging findings) and the inclusion criteria for the cases.
Fine needle aspiration biopsy is not an useful method in the diagnosis of hepatic cirrhosis,3 and a conclusion cannot be supported with the diagnosis of “findings compatible with cirrhosis” (it was the diagnosis in 30% of the patients with liver biopsy).
Tumors were classified as well differentiated HCC, intermediately differentiated HCC, poorly differentiated HCC, compatible with HCC, fibrolamellar carcinoma, mixed carcinoma, and in 76 cases histological findings were not described. Again, a conclusion cannot be supported in cases diagnosed as “compatible with HCC” or in cases with unknown histological changes (76 cases). On the other hand, fibrolamellar carcinoma is a different disease than “ordinary” or “common” liver cell carcinoma; these tumors have. different etiology, pre-cancerous lesions, clinical presentation and biological behaviour, although both are of liver-cell origin and are malignant. Also mixed carcinoma is a different tumor than ordinary HCC.
Mondragón et al2 reported that cirrhosis was demonstrated in 52% of the patients with HCC (not 56%), but they included common liver cell carcinoma, fibrolamellar carcinoma, cholangiocarcinoma and “cystic tumors”.
In an autopsy series published by Ramos-Martínez et al in México, in 19824 (from a third health care center), there were 88 cases of common liver cell carcinoma. The male:female ratio was 3:1, the average age was 64 years, and in 81 cases (92%) the liver showed cirrhosis. These findings are in agreement with what has been pointed out by Anthony: “constant risk factors in all parts of the world are male sex, age, and cirrhosis”.5
