Aim: Cancer risk of cirrhotic patients seems to be increased compared to average population due to several factors such as changes in hormonal levels or impaired metabolism of carcinogens. However, major surgery and chemotherapy in subjects with liver dysfunction are associated with increased mortality and morbidity limiting special oncological therapy. Therefore, it was the aim of our present study to (1) investigate the prevalence of extrahepatic cancer, (2) the risk of postinterventional death and longterm survival after specific oncological treatment while evaluating (3) the predictors of survival in a large cirrhotic population in Southern Germany.
Methods: The study population was assembled retrospectively from a database of hospitalized patients (n=354) of our hospital who had the diagnosis of liver cirrhosis (LC) during the 4-year period from January 2005 until May 2008. The study population was divided into three subgroups: (I) patients with extrahepatic malignancies and a follow up more than 12 months [n=26, „long-term survival-group“: mean survival time: 77.3 months (24–168 months)], (II) patients with extrahepatic malignancies and a follow up shorter than 12 months [n=28, „short-term survival-group“: mean survival time: 4.2 months (0.1–12 months)], and (III) patients suffering from primary liver cancer [n=30, mean survival time: 6,6 months (0.2–24 months)].
Results: Altogether, 84 neoplasms were observed in our cirrhotic population [19.8% (70/354)]. 30 of those were hepatic [HCC 7.6% (27/354), CCC 0.8% (3/354)] and 54 were extrahepatic malignancies (15.3%). We found a relatively large proportion of colorectal carcinoma, prostate cancer and tobacco-related tumors such as lung cancer. When analysing the performed oncological treatment, a large proportion of patients with short time survival (n=13) received no specific therapy but only palliative treatment due to reduced physical performance and noncompliance even in cases of limited disease. The rate of postinterventional death after specific (mainly surgical) treatment within 30 days after procedure was relatively low (n=8) and occurred mainly in patients with advanced chronic liver disease and after surgical therapy. TNM stage was the best prognostic indicator of longterm survival when using univariate (p<0.0001) and multivariate analysis (p=0.001). The diagnostic capability of the MELD-Score in differentiation of long and short-time survival using a ROC curve analysis was good (AUC=0.873). We found a significant influence of low bilirubin (univariate analysis: p=0.01; multivariate analysis: p=0.014), normal albumin (univariate analysis: p=0.005) and the occurrence of ascites (p<0.0001), which represent parameters of Child's classification, on the survival probability. Further prognostic information was provided by comparing the mean age of both subgroups which was significantly lower in the „long-term survival-group“ (60.53yrs; p=0.032; t-test) than in the „short-term survival group“ (68.25yrs).
Conclusion: In conclusion, our data confirm that cirrhotic patients have an increased risk to develop extrahepatic cancer, especially CRC, prostate cancer and cancer related to tobacco abuse. Patients with compensated cirrhosis (low MELD score; low serum bilirubin, normal albumin, no ascites) have a significantly longer survival rate and a lower perioperative mortality. Similar to patients without liver disease, an older age and an extended TNM stage are associated with reduced longterm survival. The rate of patients who received no specific therapy due to noncompliance and reduced physical condition was relatively large emphasizing the importance of an individual decision concerning the oncological management especially for patients with LC, independent from TNM classification.
