Hepatocellular carcinoma (HCC) with osteoclast-like giant cells (OGC) developed in the cirrhotic liver of a 42-year-old male. Serum protein induced by vitamin K absence or antagonist II was elevated preoperatively. The patient died of the disease on the 28th postoperative day. Histologically, the tumor consisted of OGC and mononuclear cells (MC). The OGC were characterized by benign-appearing nuclei, whereas the MC had atypical nuclei with a considerable number of mitoses. A vaguely trabecular pattern was observed in the focal area of the tumor, but no evidence of overt HCC was found. Immunohistochemical analysis revealed that both OGC and MC were diffusely positive for histiocytic and mesenchymal markers. Some MC were focally positive for cytokeratins 7, 8 and 19, and for albumin. Our clinical, histological and immunohistochemical findings suggest that the MC were derived from hepatocytes, with some mesenchymal features, but the OGC were non-neoplastic and reactive histiocytes.

To evaluate the tolerance of the cirrhotic liver to extended warm ischaemia, 47 patients with cirrhosis who underwent liver resection over a 4-year period were studied retrospectively. Three groups of patients were identified. In group 1 (14 patients) liver resection was performed under conditions of portal triad occlusion ranging from 50 to 75 (mean 57.1) min. Group 2 (12 patients) was treated with portal occlusion for a period ranging from 30 to 42 (mean 33.1) min. Group 3 comprised 21 patients who underwent hepatectomy using conventional techniques. Mean blood loss was significantly reduced by portal triad occlusion (819 ml in group 1, 523 ml in group 2) compared with the conventional technique (1652 ml in group 3) (P < 0.05, group 1 versus group 3; P < 0.01, group 2 versus group 3). Hospital death occurred in three of the 21 patients in group 3 but in no patient who underwent portal triad occlusion. The morbidity rate was lower in the two occlusion groups (four of 26 patients) than in group 3 (six of 21). Bilirubin metabolism was substantially better after surgery in the occlusion groups (P < 0.05, groups 1 and 2 versus group 3 at day 14). Although the serum levels of transaminases were significantly raised until day 3 in patients undergoing long-term occlusion, the cirrhotic liver withstood the ischaemia-reperfusion insult, as assessed by changes in hepatic microcirculation, lipid peroxidation and the morphology of hepatic sinusoids. It is concluded that prolonged ischaemia during liver resection can be sustained in patients with cirrhosis and without high-risk factors.