et al.

Relationship between HCV Viral Load and 

HCC 

Thesis 

Submitted in Partial Fulfillment of Master Degree 

In 

Internal Medicine 

By 

Yasser Abosaud Mohammed Hamouda 

M.B.B.CH. 

Under Supervision of 

Prof. Dr. 

Mohammed El-Semary 

Professor of Internal Medicine 

Faculty of Medicine 

Zagazig University 

Dr. 

Saad El-Aosh 

Professor of Clinical Pathology 



Prof. Dr. 

Mahmoud El-Shafay 

Professor of Internal Medicine 




Zagazig University

2009 

ﺪﺒﻜﻟا نﺎﻃﺮﺳو مﺪﻟا ﻰﻓ ﻰﺳ سوﺮﻴﻓ ﺔﻴﻤآ ﻦﻴﺑ 

ﻦﻣ ﺔﻣﺪﻘﻣ ﺔﻟﺎﺳر 

ةدﻮﻤﺣ ﺪﻤﺤﻣ دﻮﻌﺴﻟا ﻮﺑأ ﺮﺳﺎﻳ 

/ ﺐﻴﺒﻄﻟا 

ﺮﻴﺘﺴﺟﺎﻤﻟا ﺔﺟرد ﻰﻠﻋ لﻮﺼﺤﻠﻟ ﺔﺌﻃﻮﺗ 

ﻰــــــــــــﻓ 

ﺔــــﻣﺎﻌﻟا 

ﺔــــﻨﻃﺎﺒﻟا 

فاﺮﺷإ ﺖﺤﺗ 

ىﺮـﻤﺴﻟا ﺪــﻤﺤﻣ 

/ د. 

أ 

ﺔـﻨﻃﺎﺒﻟا 

ضاﺮـﻣأ 

ذﺎـﺘﺳأ 

ﺐـﻄﻟا 

ﺔـﻴﻠآ 

ﻖـﻳزﺎﻗﺰﻟا 

ﺔـﻌﻣﺎﺟ 

ﺶــــﻌﻟا ﺪﻌﺳ / د. 

أ 

ﺔـﻴﻜﻴﻨﻴﻠآﻹا ﺎـﻴﺟﻮﻟﻮﺛﺎﺒﻟا ذﺎـﺘﺳأ 

ﺐـﻄﻟا 

ﺔـﻴﻠآ 



ﻰـﻌﻓﺎﺸﻟا دﻮـــﻤﺤﻣ / د. 

أ 

ﺔـﻨﻃﺎﺒﻟا 

ضاﺮـﻣأ 

ذﺎـﺘﺳأ 

ﺐـﻄﻟا 

ﺔـﻴﻠآ 



م2009 

ﺔﻗﻼﻌﻟا

ﻢﻴﺣﺮﻟﺍ ﻦﲪﺮﻟﺍ ﷲﺍ ﻢﺴﺑ 

ﺎﻤﻠﻋ ﻰﻧﺩﺯ ﻰﺑﺭ ﻞﻗﻭ 

ﻢﻴﻈﻌﻟﺍ ﷲﺍ ﻕﺪﺻ 

( 

ﻪﻃ ةرﻮﺳ -114 

ﺔﻳﻻا)

Abstract 

Hepatitis C virus is carried by about 0.01-2% of blood 

donors world wide. The problem in Egypt resides in high 

prevalence of positive anti-HCV in healthy subjects who are 

considered as possible reservoirs of infection for the population. 

The results of HCV seropositivity widely ranged from 5.2 to 

24.4%. The prevalence of anti-HCV in blood donors in Sharkia 

Governorate was 17.6%. 

Eighty percent of patients will develop chronic hepatitis 

and 20% will go into cirrhosis. Liver cell failure develops often 

after 10 or more years of disease. Bleeding from esophageal 

varices is unusual until late, the first episode of variceal 

bleeding is one of' the most frequent causes of death in patients 

with liver cirrhosis. 

Hepatocellular carcinoma (HCC) is a common malignancy 

worldwide. It is the fifth most common cancer and the third 

leading cause of cancer death in the world. 

HCC is the most common terminal complication of 

chronic inflammatory and fibrotic liver disease.

Acknowledgment 

First of all, thanks for AllA. 

I would like to express my deep gratitude to Prof. Dr. 

Mahmoud El-Shafay, Professor of Internal Medicine, 

Faculty of Medicine, Zagazig University, for his kind 

supervision, sincere help and expert advice. 

I am deeply indebted to Prof. Dr. Mohammed El- 

Semary, Professor of Internal Medicine, Faculty of Medicine, 

Zagazig University, for his great effort . 

I am deeply indebted to Dr. Saad El-Aosh, Professor 

of Clinical Pathology, Faculty of Medicine, Zagazig University, 

for his kind continuous support throughout this work. 

Lastly, I would like to thank all patients whom included 

in this study for their help and cooperation. 

Yasser Abosaud

Dedicated 

To My Parents, My Wife 

Who gives me very much 

and I give them nothing

LIST OF ABBREVIATIONS 

ADCC Complement mediated antibody dependent cellular 

cytotoxicity 

AFP Alpha-Fetoprotein 

ALT Serum Alanine Aminotransferase 

AST Asprtate aminotransferase 

ATE Transcatheter Arterial Embolization 

CLD Chronic liver diseases 

CD4 Cytokin Derivative 4 

CD8 Cytokin Derivative 8 

CT Computed Tomography 

CTAP Ct Arterioportography 

CTL Cytotoxic T Lymphocyte 

CTP Child-Turcotte-Pugh 

ETR End of Treatment Response 

FDA Food and Drug Administration 

FLC Fibrolamellar Carcinoma 

FNA Fine Needle Aspirations 

HAI Histology Activity Index 

HBs Ag Hepatitis B Surface Antigen 

HBV Hepatitis B Virus 

HCC Hepatocellular Carcinoma 

HCV Hepatitis C Virus 

HIFU High Intensity Focused Ultrasound 

HVR Hypervariable Region 

IgG Immunoglobulin G 

ILP Interstitial Laser Photocoagulation 

IL-1 Interleukin 1

IL-10 Interleukin 10 



INF Interferon 

INR International Normalized Ratio 

IOM Institute of Medicine 

ITP Idiopathic Thrombocytopenic Purpura 

L-LUS Laparoscopy with Laparoscopic Ultrasound 

LP Lichen Planus 

MALT Mucosal Associated Lymphatic Tissue 

MDCT Multidetector-Row computerized tomography 

MPGN Membranoproliferative Glomerulonephritis 

MRI Magnetic Resonance Imaging. 

PAI Percoetaneous Acetic Acid Injection 

PEI Percoetaneous Ethanol Injection 

PET Position Emission Tomography 

PHEIT Percoetaneous Hot Ethanol Injection Therapy 

PMC Percoetaneous Microwave Coagulation 

RFA Radiofrequency Ablation 

SCT Spiral computerized tomography 

STAT1 Signal Transducer and activator of transcription 1 

STAT 2 Signal Transducer and activator of transcription 2 

TACE Transarterial Chemoembolization 

US Ultrasound

List of tables. 

List of figures. 

List of abbreviations. 

LIST OF CONTENTS 

Introduction. 1 

Aim of the Work. 2 

Review of Literature . 3 

- HCV. 3 

- HCC. 41 

Subjects and Methods. 94 

Results. 96 

Page 

Discussion. 102 

Summary and Conclusion. 105 

Recommendations. 107 

References. 108 

Arabic Summary.

LIST OF TABLES 

Table Title Page 

1 Modified Child's Grade. 24 

2 Comparison of demographic date. 95 

3 Grading of hepatic encephalopathy. 95 

4 

5 

6 

7 

8 

9 

Descriptive statistics of laboratory data of hepatocellular 

carcinoma patients included in the study. 

Descriptive statistics of laboratory data of chronic 

hepatitis C virus patients included in the study. 

Comparison between demographic data of HCC and 

HCV patients included in the study. 

Comparison between age and laboratory data of HCC 

and HCV patients included in the study. 

Comparison between viral load, demographic and 

laboratory data of HCC patients included in the study. 

Comparison between viral load, demographic and 

laboratory data of HCV patients included in the study. 

96 

97 

98 

99 

100 

101

ﻲـــــــﺑﺮﻌﻟا ﺺـــﺨﻠﻤﻟا 

ﺐﻴﺼﻳ ﺚﻴﺣ ،ﻢﻟﺎﻌﻟا ﻰﻓ ارﺎﺸﺘﻧا ماروﻷا ﺮﺜآأ ﻦﻣ ﻰﻧﺎﻃﺮﺴﻟا ﺪﺒﻜﻟا مرو 

ﺮﺒﺘﻌﻳ 

ﺪﻳﺪﺤﺗ ﻦﻜﻤﻳ ﻰﺘﻟا ﺔﻠﻴﻠﻘﻟا ماروﻷا ﻦﻣ ﻮهو . ﺎﻳﻮﻨﺳ ﻢﻟﺎﻌﻟا ﻰﻓ ﺾﻳﺮﻣ نﻮﻴﻠﻣ ﻰﻟاﻮﺣ 

( ﻰﺳ) 

ﻰﺋﺎﺑﻮﻟا ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا ﻞﺜﻤﻳو . تﻻﺎﺤﻟا ﻦﻣ ﺮﻴﺜآ ﻰﻓ مرﻮﻟا اﺬه رﻮﻬﻇ ﺐﺒﺳ 

ﻰﻓ ماروﻷا ﻩﺬه ثوﺪﺣ لﺪﻌﻣ دادﺰﻳو ،ﻰﻧﺎﻃﺮﺴﻟا ﺪﺒﻜﻟا مرو رﻮﻬﻈﻟ 

ﺮﻴﻄﺧ ﻞﻣﺎﻋ 

.( ﻰﺳ) 

ﻰﺋﺎﺑﻮﻟا ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا ثوﺪﺣ لﺪﻌﻣ ةدﺎﻳز ﺔﺠﻴﺘﻧ لوﺪﻟا ﻦﻣ ﺮﻴﺜآ 

لﺎﺼﺌﺘﺳﻻ ءاﻮﺳ ﻊﻳﺮﺴﻟا ﻰﺣاﺮﺠﻟا ﻞﺧﺪﺘﻟاو مرﻮﻟا اﺬﻬﻟ ﺮﻜﺒﻤﻟا ﺺﻴﺨﺸﺘﻟا نإ 

. ضﺮﻤﻟا اﺬﻬﻟ ﻞﺜﻣﻷا جﻼﻌﻟا ﺮﺒﺘﻌﻳ ﺾﻳﺮﻤﻠﻟ ﺪﺒآ عرﺰﻟ وأ مرﻮﻟا اﺬه 

ﺾﻤﺣ ﻦﻣ نﻮﻜﻣ ىوﺮآ سوﺮﻴﻓ ﻮه ( ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا سوﺮﻴﻓ 

نإ 

. م1988 

مﺎﻋ ةﺮﻣ لوﻷ ﻪﻔﺻو ﻢﺗ ىﺬﻟاو ( ﻪﻳإ. 

نإ. 

رﺁ) 

ىوﻮﻧ 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا سوﺮﻴﻓ ىوﺪﻋ نأ ﺪﺟو ﺪﻘﻟو ﺔﻴﻤﻟﺎﻋ ﺔﻴﺤﺻ ﺔﻠﻜﺸﻣ ﻞﺜﻤﻳ ﻮهو 

بﺎﺒﺳأ ﻢهأ ﻦﻣ ﺮﺒﺘﻌﻳ ﺚﻴﺣ ﻢﻟﺎﻌﻟا ىﻮﺘﺴﻣ ﻰﻠﻋ ارﺎﺸﺘﻧا ﺮﺜآﻷا ﻰه ﺮﺼﻣ ﻰﻓ ( ﻰﺳ) 

ﻦﻘﺤﻟﺎﺑ ﺎﻴﺳرﺎﻬﻠﺒﻟا ضﺮﻤﻟ ﺔﻴﻋﺎﻤﺠﻟا ﺔﺠﻟﺎﻌﻤﻟا ﺐﺒﺴﺑ ﻚﻟذو ﺎﻬﻴﻓ 

ﺔﻨﻣﺰﻤﻟا ﺪﺒﻜﻟا ضاﺮﻣأ 

ﻦﻋ ﺎﻀﻳأ ﻮﻬﻓ مﺪﻟا ﻖﻳﺮﻃ ﻦﻋ ﻪﻟﺎﻘﺘﻧا ﺐﻧﺎﺟ ﻰﻟإو ،ﺮﻴﻃﺮﻄﻟا تﺎﺒآﺮﻤﻟ ىﺪﻳرﻮﻟا 

. ﺔﻴﻟﺰﻨﻤﻟا ﺔﻴﻣﻮﻴﻟا تﺎﺳرﺎﻤﻤﻟاو ﺎﻬﻨﻴﻨﺠﻟ مﻷا ﻦﻣو ﺲﻨﺠﻟا ﻖﻳﺮﻃ 

ﺔﻋﻮﻤﺠﻤﻟا ﻦﻴﺘﻋﻮﻤﺠﻣ ﻰﻟإ ﺖﻤﺴﻗ ﺔﻟﺎﺣ 100 ﻰﻠﻋ ﺔﺳارﺪﻟا ﻩﺬه ﺖﻳﺮﺟأ 

ﻦﻣ ﺔﻟﺎﺣ 50 ﺔﻴﻧﺎﺜﻟا ﺔﻋﻮﻤﺠﻤﻟا ،( 

ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻﺎﺑ ﺔﺑﺎﺼﻣ ﺔﻟﺎﺣ 50 ﻰﻟوﻷا 

ﻦﻴﺑ ﻦﻣ ﻢهرﺎﻴﺘﺧا ﻢﺗ ،( 

ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻼﻟ ﺐﺣﺎﺼﻤﻟا ﻰﻧﺎﻃﺮﺴﻟا ﺪﺒﻜﻟا مرو تﻻﺎﺣ 

. ﻖﻳزﺎﻗﺰﻟا ﺔﻌﻣﺎﺟ تﺎﻴﻔﺸﺘﺴﻤﺑ ﺔﻨﻃﺎﺒﻟا ضاﺮﻣأ ﻢﺴﻘﻟ ﻰﻠﺧاﺪﻟا ﻢﺴﻘﻟا ﻰﺿﺮﻣ 

ﻰﺒﻄﻟا ﻒﺸﻜﻟاو 

ﻰﺿﺮﻤﻟا ﺦﻳرﺎﺘﻠﻟ ﻞﻣﺎآ ءﺎﻔﻴﺘﺳﻻ تﻻﺎﺤﻟا ﻞآ ﺖﻌﻀﺧ ﺪﻗو 

ﺰﻴآﺮﺗو ﻦﻣز ﺔﻠﻣﺎﺷ ﺪﺒآ ﻒﺋﺎﻇو ﻞﻤﻋ ﻞﺜﻣ ﺔﻴﻠﻤﻌﻤﻟا تﺎﺻﻮﺤﻔﻟا ﻚﻟﺬآو ﻰﻜﻴﻨﻴﻠآﻹا 

.( ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا ﺺﻴﺨﺸﺘﻟ رﺁ ﻰﺳ ﻰﺑ – ﻦﻴﺗوﺮﺑﺮﺘﻴﻓ ﺎﻔﻟأ ،ﻦﻴﺒﻣوﺮﺛوﺮﺒﻟا 

ﺔﻌﺷأ ﻞﻤﻋ ﻢﺗ ﺎﻤآ ،ﻰﺿﺮﻤﻟا ﻞﻜﻟ ﺪﺒﻜﻟا ﻰﻠﻋ ﺔﻴﺗﻮﺼﻟا قﻮﻓ تﺎﺟﻮﻣ ﻞﻤﻋ ﻢﺗ ﻚﻟﺬآ 

. 

ﻢﻬﻟ دﺎﻌﺑﻷا ﺔﻴﺛﻼﺛ ﺔﻴﻌﻄﻘﻣ

. ﻰﻤﻜﻟا رﺁ ﻰﺳ ﻰﺑ ماﺪﺨﺘﺳﺎﺑ ﻦﻴﺘﻋﻮﻤﺠﻤﻟا ﻦﻴﺑ رﺁ سإ ﻰﺑ ﺔﻧرﺎﻘﻣ ﻢﺗ 

ﺔﻴﻤآ عﺎﻔﺗرا ﻦﻴﺑ ةﺮﺷﺎﺒﻣ ﺔﻗﻼﻋ دﻮﺟو مﺪﻋ ﺔﺳارﺪﻟا ﺞﺋﺎﺘﻧ تﺮﻬﻇأ ﺪﻗو 

. ﺪﺒﻜﻟا نﺎﻃﺮﺳو مﺪﻟا ﻰﻓ ( ﻰﺳ) 

سوﺮﻴﻓ 

جﻼﻋ ﻰﻓ ﻰﻤﻠﻋ سﺎﺳأ مﺪﻘﺗ نأ ﻦﻜﻤﻳ ﺔﻴﻠﻤﻌﻤﻟا ﺔﺳارﺪﻟا ﻩﺬه نأ ﺺﻠﺨﺘﺴﻧ ﻚﻟذ ﻦﻣ 

. 

ﺪﺒﻜﻟا نﺎﻃﺮﺳو ( ﻰﺳ) 

سوﺮﻴﻓ

Introduction 

& 

Aim of the Work

INTRODUCTION 

Introduction & Aim of the Work 


donors world wide (Sherlock & Doolley, 2002). The problem in 

Egypt resides in high prevalence of positive anti-HCV in 

healthy subjects who are considered as possible reservoirs of 

infection for the population. The results of HCV seropositivity 

widely ranged from 5.2 to 24.4% (E1-Zayadi, 2001). The 

prevalence of anti-HCV in blood donors in Sharkia Governorate 

was 17.6% (Mahmoud and Abd El-Naeem, 1994). 

Eighty percent of patients will develop chronic hepatitis 

and 20% will go into cirrhosis. Liver cell failure develops often 

after 10 or more years of disease. Bleeding from esophageal 

varices is unusual until late, the first episode of variceal 

bleeding is one of' the most frequent causes of death in patients 

with liver cirrhosis (Koretz et al., 1993 and Chalasani et al., 

2001). 

Hepatocellular carcinoma (HCC) is a common malignancy 

worldwide (Blum and Hopt, 2003). It is the fifth most common 

cancer and the third leading cause of cancer death in the world 

(Mas et al., 2004). 

HCC is the most common terminal complication of 

chronic inflammatory and fibrotic liver disease (Daniel and 

Micheal, 1999). 

-1-

-2- 

Introduction & Aim of the Work 

In Egypt there is an apparent increase in the number of 

HCC patients attending the hepatology and oncology centers 

(Esmat et al., 2002). Strong correlations exist between the 

prevalence of the viral hepatitis B and viral hepatitis C viruses 

and HCC incidence (Dsjardians, 2002). 

HCC incidence rate in Egypt was estimated to be between 

5 and 7 per 100000 population per year (Jones, 1999). 

AIM OF THE WORK 

The aim of this work is to evaluate relationship between 

viral load HCV and HCC.

Review 

of 

Literature

HCV 

Review of Literature 

HCV is a single stranded enveloped RNA virus of 

approximately 50 nm size and is known to posses an RNA 

genome of approximately 9033 nucleotides. The sequence 

includes a single long open reading frame coding for a 

polyprotein of about 3011 amine acids (Choo et al., 1991). 

The gene product is a viral polyprotein precursor of amino 

acids which undergoes proteolytic posttranslational cleavage to 

yield structural (core and envelope) and nonstructural 

(proteases, helicases, RNA-dependent RNA polymerase) 

proteins (Dusheiko, 1992). 

The structural proteins are derived from the 5' third of the 

genome and the non-structural proteins from 3' (NS1 to NS5) 

two-thirds regions. The 5' end begins with a non-coding region 

of at least 341 bases (Fig. 1). This sequence of HCV appears to 

be highly conserved with a high degree of sequence homology 

among most isolates so far sequenced (Han et al., 1991). 

-3-

Fig. (1) 


The structure of HCV includes a core that encapsidates the 

RNA genome. A host derived bilipid membrane surrounds the 

core and through this are inserted two proteins, a glycoprotein 

called E for envelope and a pre-M protein that is further 

processed to yield the M-protein found in the extra cellular 

mature form of the virus. Mature viron proteins are processed by 

a series of enzymatic reaction, some of which performed by the 

host protease (NS3) while others occur within cellular 

membranes. The viral proteins include the already mentioned 

structural proteins C, pre-M and E which is glycosylated. The 

non-structural proteins (NS1, NS2, NS3, NS4 and NS5) include 

a protease helicase (NS3) and the viral RNA-dependent RNA 

polymerase (NS5). No function has been assigned to NS1, NS2 

or NS4 (Stephen, 1991) (Fig. 2). 

Fig. (2) 

-4-


HCV is a very heterogenous virus with only about 70% 

homology among all known isolates, a level of variability 

similar to that of other flaviviruses (Chambers et al., 1990). 

The striking genetic heterogeneity of HCV suggested that 

the virus might have different genotypes. There is at least six 

known genotypes and more than 80 subtypes, but other HCV 

genotypes 7, 8 and 9 were proposed based on isolates from 

Southeast Asia (Simmonds, 1995). 

Nucleotide substitution over time will result in the 

evolution of a single isolate of HCV to a highly related but 

heterogenous population of isolates known as quasispecies 

(Moribe et al., 1995). The same isolate may evolve into 

different populations of quasispecies in different patients (Ni et 

al., 1997). This probably reflects both some degree of 

randomness in nucleotide substitution as well as selective 

immune pressure. Furthermore, the diversity of the quasispecies 

probably reflects duration of infection and the level of 

replication (Gonzalez-Peralta et al., 1996). 

Epidemiology of HCV: 


donors world wide (Sherlock & Dooley, 2002). The problem in 

Egypt resides in high prevalence of positive anti-HCV in 

healthy subjects who are considered as possible reservoirs of 

infection for the population. The results of HCV seropositivity 

widely ranged from 5.2 to 24.4% (El-Zayadi, 2001). The 

prevalence of anti-HCV in blood donors in Sharkia Governorate 

was 17.6% (Mahmoud and Abd EL-Nacem, 1994). 

-5-


In Egypt, a high prevalence of antibodies to hepatitis C 

virus (anti-HCV) has been found among apparently healthy 

Egyptian populations, such as expatriate workers in Gulf region 

(31%) (Mohamed et al., 1996), blood donors (10%-28%) 

(Arthur et al., 1997), military recruits (22%-33%), (Abdel- 

Wahab et al., 1994), rural primary-school children (12%) and 

rural village inhabitants (16%-18%) (Kamel et al., 1994). In the 

largest published study, anti hepatitis C virus (anti-HCV) was 

assessed in 5071 Egyptians undergoing pre-employment 

examination, and the prevalence increased with age, peaking at 

55% among those 45 to 49 years old (Mohamed et al., 1996). 

Methods of transmission and risk groups: 

HCV is a blood borne virus that generally circulates in low 

titers infected sera. Epidemiological studies show that the most 

efficient transmission of HCV is through the transfusion of 

blood or blood products or through the transplantation of organs 

from infected donors and through the sharing of contaminated 

needles among injection drug of abuses However, less than half 

of patient with acute hepatitis C report a history such exposure. 

A small number of epidemiological studies demonstrate the 

perinatal, sexual, household, and occupational transmission 

could occur (Alter, 1994). HCV causes more than 90 % of cases 

of post-transfusion hepatitis as it is mainly a blood borne virus 

(Lai et al., 1993). The risk acquiring HCV infection increased 

with the duration of haemodialysis, but it was independent of 

the volume of transfused blood (Selim et al., 1991). 

About 64 to 80% of intravenous drug abusers were found 

HCV antibody positive because of repeated exposure to carriers 

-6-


of through shared contaminated needles (Esteban et al., 1989). 

Accident exposure from a needle contaminated by blood from a 

known hepatitis, carriers occur in health care workers 

(Kiyosawa et al., 1991). Given low prevalence of HCV in 

homosexuals and western heterosexuals, absence of 

transmission in chimpanzee colonies and the undetectability 

HCV in sexual body secretions, it can be concluded that sexual 

transmission occurs extremely rare or not at all (Bader,1995). 

Maternal infant transmission appears low. Also the 

intrafamilial transmission appears very low or not present. It is 

clear that HCV is no transmitted through the fecal oral route 

since there are no reports of food associated epidemics as in 

case of hepatitis A. there is no evidence that sneezing coughing 

or casual transmits HCV. All HCV negative recipient of solid 

organs (e.g., hearts, kidney, liver) from HCV positive donors 

become infected with hepatitis C virus (Pereina et al., 1992), 

Habib et al. (2001) told about the risk factors for hepatitis 

C virus (HCV) infection in a rural village in the Nile Delta, with 

a high prevalence of antibodies to HCV (anti-HCV), history of 

active infection with Schistosoma and using parenteral tartar 

emetic, circumcisions and shaving by community barbers, blood 

transfusion, dental treatment and invasive hospital procedures 

are the important risk factors for HCV transmission. 

Immunopathogenesis of hepatitis C virus: 

The host immune response to HCV infection consists of 

both nonspecific immune response, including interferon (IFN) 

production and natural killer (NK) cell activity, and a virus- 

-7-


specific immune response, including humoral and cellular 

components: 

(1) Humoral immune response: 

The humoral arm of the immune response in HCV 

infection suggested by the presence of hepatic lymphoid 

aggregates containing activated B cells (Desmet et al., 1994), 

elevated levels of the B-cell activated B cells (Desmet et al., 

1994), elevated levels of the B-cell-activating interleukin-4 (IL- 

4), (Reiser et al., 1997) and a B-cell mediated response with 

production of antibodies to several structural and nonstructural 

polypeptides (Ray et al., 1994). 

Antibodies have two effects that might play role in the 

immunopathogenesis of hepatitis C. These are viral 

neutralization an antibody-dependent cellular cytotoxicity 

(ADCC). Antibodies against envelope proteins often have 

neutralizing ability. Antibodies against conserved epitopes of 

the HCV envelope proteins (El, E2) are found in more 90% of 

patients with chronic HCV infection (Ray et al., 1994). 

However, the persistence of infection in most patients with anti- 

E1/anti-E2 suggests that either the antibodies do not have 

neutralization capability or that the target is not relevant to viral 

persistence, also chimpanzee studies have demonstrated that 

neutralizing antibodies can be raised by repeated immunization 

with envelope proteins (Choo et al., 1994), it appears that while 

neutralizing antibodies are formed, evolution of the virus may 

-8-


allow escape from this humoral response. This is not unexpected 

because the envelope proteins are not highly conserved. E2 

contains two hypervariable regions (HVR) in which nucleotide 

substitutions are largely unconstrained and wide genetic 

differences evolve. Antibodies against the variable part of E1 

and the hypervariable region 1(HVR1) of E2 are present in 44% 

an 60% to 70% of patients, respectively, it has been suggested 

that antibodies to these regions (especially HVR1) neutralize 

existing strains of the virus and drive genetic drift (Kato et al., 

1993). 

Antibodies may also direct destruction of its bound target 

through activation of other mechanisms, specifically the 

complement mediated antibody-dependent cellular cytotoxicity 

(ADCC). However, for these antibodies to contribute to cell 

injury, they must recognize HCV antigens on the hepatocyte cell 

membrane. Although HCV antigens (Core, El, E2, NS3 and 

NS4) have been detected in the cytoplasm of infected 

hepatocytes, membranous antigen have not been observed 

(Selby et al., 1994). 

Although evidence to suggest a pathogenic role of the 

humoral response in the liver diseases associated with HCV 

infection is still lacking, the response may be associated with 

other manifestations of infection, also patients with chronic 

HCV infection commonly develop autoantibodies (MacFariane 

et al., 1994). 

However, humoral activation is not limited to antibody 

production, more than half of the patients with chronic HCV 

infection show expansion of CD5-positive B lymphocytes in 

-9-


peripheral blood (Pozzato et al., 1994). Activation of this subset 

has been associated with autoimmune diseases such as 

rheumatoid arthritis, (Jarvis et al., 1992), and it is possible that 

a similar mechanism plays a role in the development of B-cell 

lymphomas in patients with HCV infection (Ferri et al., 1994)., 

HCV is associated with the development of mixed essential 

cryoglobulinemia, in which deposition of immune complexes 

composed of IgG and rheumatoid factor precipitate in small 

blood vessels (Agnello, 1999). 

Finally ,the antibody response to HCV may provide clues 

to the clinical course of infection. Anti-NS4 may decline or even 

disappear in patients who recover from acute hepatitis or 

respond to IFN therapy, core-specific IgG may also decline with 

successful IEN therapy, and some have suggested that the 

antibody titer may correlate with disease activity, although this 

is controversial (Lau et al., 1994). 

(2) Cellular immune response: 

The cellular immune response to viral infection involves 

nonspecific mechanisms and antigen-specific mechanisms 

including cytotoxic T lymphocytes and inflammatory cytokine 

release. The cellular immune response including the following: 

(A) CD4 + T-lymphocyte: 

The CD4 + T-cell response to viral proteins is critical for 

host protection because it occurs relatively early, helps antibody 

production by B cells, and stimulates CD8 + T cells, including 

those that are specific for virus infected cells (Kita et al., 1995). 

No one viral antigen is responsible for this CD4 + response, 

-10-


although peptide derived from core and NS4 result in the 

greatest proliferative responses (Ferrari et al., 1994), which are 

most in persons who resolve acute infection (Lechman et al., 

1996) 

There are studies explaining that HCV specific 

proliferative responses tend to home to the liver once chronic 

infection is established and although studies of intrahepatic CD4 

+ responses have been limited, proliferative responses to core, 

E1 and NS4 have been reported, however several striking 

differences from peripheral CD4 + responses have been 

reported, the first is the reactive CD4 + clones which do not 

always react to the same HCV peptides that are recognized 

peripherally (Minutello et al., 1993), and the second is 

proliferative response appears to correlate with more active liver 

disease (Lohr et al., 1994). Intrahepatic CD4 + T cells 

differentiate into both T-helper cell 1 (IL-1) (IFN-) and Th2 

(IL-4) population but the former predominate (Betoletti et al., 

1997). 

(B) CD8 + T-lymphocyte: 

There is several lines of evidence suggest that the CD8+ 

T-lymphocytes play an important role in HCV infection, firstly 

immunophenotyping studies have demonstrated that a significant 

proportion of the activated cells in the livers of patients with 

chronic hepatitis C are CD8 + lymphocytes (Onji et al., 1992). 

Secondary, expression of adhesion molecules, one pathway for 

recruitment and priming of T cells, is upregulated in the hepatic 

portal tracts (Garcia-Monzon et al., 1995). Thirdly and most 

important, HCV-specific cytotoxic CD8 + T-lymphocytes have 

-11-


been isolated from both liver or peripheral blood in a significant 

proportion of patients with chronic HCV infection (Koziel et 

al., 1993). The target epitopes from within both structural and 

nonstructural regions have been identified (Cerny et al., 1995) 

and the immunodominant cytotoxic T-lymphopcyte (CTL) 

epitopes are most commonly located within the HCV structural 

antigens; CTL responses to nonstructural regions occur in a 

smaller subset of patients. However, multiple epitopes may be 

targeted by the same patient, and the magnitude of the CTL is 

variable both within the same patient and between different 

patients (Koziel and Walker, 1999). 

(C) Cytokine response: 

Cytokines are regulatory molecules that play an important role 

in control infection and representing several physiologic and 

pathologic processes. Cytokines responses are referred to as 

Th1-like and Th2-like after the original description of the 

cytokine profiles produced by subsets of the CD4+Th cells 

(Mosmann and Coffinan, 1989). Th1-like responses include 

IL-2, TNF-, and IFN- secretion and are required for CTL 

generation and NK cell activation during the host's antiviral 

immune response and Th2-like responses produce IL-4 and IL- 

10, which help augment antibody production and inhibit the 

development of Th1 response (Florentino et al., 1991). 

Although patients with chronic HCV infection have an 

activated T-cell response pattern and have been reported to have 

elevated levels of serum IL-2, TNF-, IFN-, IL-4, IL-10 and 

transforming growth factor (TGF). Stimulation of either 

peripheral blood and liver-derived HCV-specific T-cell clones 

-12-


results in a Th1-like cytokine response with release of IFN- and 

TNF- (Diepolder et al., 1994). Furthermore, IFN- and IL-2 

mRNA are increased in the livers of patients with chronic 

hepatitis suggesting that these cytokines are produced locally by 

resident CD4 + cells (Napoli et al., 1996). 

The levels of IFN- and IL-2 mRNA correlated with 

fibrosis and portal inflammation suggesting that Th1 cytokines 

might play a role in mediating hepatocellular damage and to 

further support this hypothesis, elevated plasma levels of TNF- 

appear to be associated with more severe hepatocellular damage 

(Lim et al., 1994). Th1 also has a role in control HCV 

replication as patients without viraemia after HCV infection 

frequently have strong Th lymphocyte responses of Th1 type to 

multiple HCV antigens many years after the onset of infection 

whereas antibody responses are less marked (Cramp et al., 

1999). However, other have reported a predominantly Th-2-like 

profile with elevated serum IL-4 and IL-10 levels and some Th2 

cell markers in hepatic inflammatory infiltrates, and this can be 

used in management of HCV infection as IFN treatment seems 

to decrease this Th2 cytokine response in parallel to the 

reduction in viral levels (Cacciarelli et al., 1996). 

Direct viral cytopathogenicity: 

It has been difficult to determine whether HCV is directly 

cytopathic or not, however several lines. of evidence support a 

cytopathic role for HCV, firstly, the presence of direct 

cytopathic injury to infected cells in other members of the 

flavivirdae family, such as the yellow fever virus (Major and 

Feinstone, 1997). Secondly, the histological examination of 

-13-


HCV-infected livers occasionally reveals dying hepatocytes 

without adjacent inflammation (Dienes et al., 1982). Thirdly, 

there is serum aminotransferase levels and hepatic inflammation 

decline in relative parallel to viral levels during IFN treatment 

(Davis et al., 1989). Fourthly, some studies have found a 

correlation between serum HCV RNA level and the degree of 

hepatocellular damage (Jeffers et al., 1993), really, high level 

of cellular expression of HCV has been seen in some patients 

with severe hepatic injury and this was first reported in an 

immunosuppressed heart transplant recipient who acquired acute 

HCV infection from the donor organ (Lim et al., 1994), but a 

similar picture has been reported in other immunosuppressed 

patients (Dickson et al., 1996). In these cases, an unusually high 

proportion of the liver cells contains HCV, and liver biopsies 

reveal an atypical histological picture of pericellular fibrosis, 

marked intracellular cholestasis, and only mild inflammation, 

which similar to the fibrosing cholestatic hepatitis sometimes 

seen in immunosuppressed patients with chronic hepatitis B 

(Lau et al., 1992). Evidence supporting the hypothesis of direct 

cytopathicity of HCV was provided in cell lines expressing high 

levels of HCV structural proteins so these cells showed 

mitochondrial and endoplasmic reticulum proliferation, 

distention of the endoplasmic reticulum, and hepatocellular 

ballooning similar to that seen in the infected transplant 

recipient described before (Wu et al., 1996). However, there is 

also considerable evidence to suggest that HCV is not directly 

cytopathic as in the overwhelming majority of patients, 

particularly immunocompetent patients, biochemical or 

histological markers of disease activity do not correlate with 

-14-


serum viral levels or the amount of HCV RNA or antigen in the 

liver (Lau et al., 1996). In fact, many patients with HCV 

infection have persistently normal serum ALT levels and 

minimal liver injury despite the presence of detectable HCV 

RNA in serum (Shindo et al., 1995). Furthermore, a transgenic 

mouse model with high-level expression of HCV structural 

proteins does not demonstrate cytopathic changes in the liver 

(Kawamura et al., 1997). 

Liver Histopathology: 

Histological evaluation of a liver biopsy specimen remains 

the gold standard for determining the activity of HCV-related 

liver disease and histological staging remains the only reliable 

predictor of prognosis and the likelihood of disease progression 

(Yano et al., 1996). A biopsy may also help to rule out other, 

concurrent causes of liver disease. Therefore, biopsy is generally 

recommended for the initial assessment of persons with chronic 

HCV infection (EASL, 1999). However, a liver biopsy is not 

considered mandatory before the initiation of treatment, and 

some recommend a biopsy only if treatment does not result in 

sustained remission (Lauer and Walker, 2001). 

The lesions found in the liver of acutely and chronically 

infected patients are not pathognomonic for HCV infection, 

consisting essentially of inflammation, and hepatocellular 

necrosis. The major usefulness of biopsy findings is in the 

staging of liver damage severity and in evaluating how lesions 

progress with time or respond to therapy (Perrillo, 1997). 

Histologically, a large proportion of acute hepatitis infections do 

not resolve but evolve with time into a chronic hepatitis of 

-15-


increasing severity that can progress to cirrhosis and HCC. The 

severity of liver damage may be graded with Knodell's 

"histological activity index" which considers the following four 

types of lesions: periportal necrosis (score from 1 to 10), 

intralobular degeneration and focal necrosis, portal 

inflammation, and fibrosis (each one with a score from 1 to 4). 

The summation of the individual component scores provides a 

total histology activity index (HAI) with, values ranging from 0 

to 22. The HAI grading system has been extensively used to 

quantify histopathologic changes because it has the advantage of 

being fairly simple and providing a numerical result that can be 

useful in comparing different biopsy specimens from the same 

patient over time as well as in making cross-comparisons 

between biopsy specimens from different patients. Using this 

system, it is also possible to evaluate chronic hepatitis as mild, 

moderate, and severe (Knodell et al., 1981). 

Features that are frequently observed in chronic hepatitis C 

include lymphoid aggregates or follicles in the portal areas 

(present in approx 80% of biopsies), biliary duct lesions, and 

steatosis (present in more than 50% of biopsies). Biliary duct 

lesions consist of infiltration of inflammatory cells in the basal 

membrane, stratification and loss of polarity of epithelial cells, 

nuclear picnosis, degeneration, and mitotic activity or a 

combination of these findings, and may lead to disappearance of 

the biliary ducts (Bach et al., 1992). Even in the presence of 

cirrhosis or HCC, there are no histopathological features 

specific of an underlying HCV infection, except for the possible 

-16-


observation of sporadic lymphoid aggregates (Scheuer et al., 

1992). 

-17-

Clinical Course of HCV Infection 


In study by Alter (1992) the clinical course of hepatitis C 

infection was identical regardless of the mean by which the 

patient acquired the infection. He noted the course of 100 HCV 

infected individuals and reported that, about 15% of patients 

might have spontaneous resolution of infection, 85% would 

probably experience chronic HCV infection, 20% of this 

patients with chronic HCV would progress to cirrhosis, the 

remainder would have chronic disease perhaps with only mild or 

moderate symptoms that might have evaded diagnosis for 

several decades, the over all mortality of HCV infection patients 

related to liver disease is approximately 4%. 

HCV disease was previously assumed to have a relatively 

benign course, however Khan et al. (1995) reported that this 

infection often progressed from chronic active stage through 

bridging necrosis and cirrhosis and occasionally to 

hepatocellular carcinoma (HCC in 2% to 70% of cases). HCC 

may even develop without the intermediate development of 

cirrhosis. 

I- Acute hepatitis C: 

The disease has an incubation period of 6-12 weeks 

however, with moculum such as following administration of 

factor VIII the incubation period is reduced (Lim et al., 1991). 

The acute phase of HCV in most patients is clinically mild, 

with ALT levels occasionally exceeding 600 IU/l. Seventy five 

-18-


percent off cases are anicteric and relatively asymptomatic (Ach 


ALT values usually remain lower in acute HCV disease 

than in acute hepatitis from HAV or BBV, infrequently 

exceeding 1000 M. Peak ALT levels are seen between 8 and 12 

weeks from initiation of infection and fluctuate considerably or 

show a polyphasic behavior through single peaks or plateau 

patterns are also observed (Koretz et al., 1993). 

In a large proportion of patients, symptoms of acute 

hepatitis graciously resolve spontaneously within a few months. 

Resolution of symptoms and ALT normalization, however, do 

not mean that the virus has been cleared, since persistent or 

intermittent viraemia is the most frequent occurrence (Vento et 

al., 1996). 

In transfusion recipients, the time lag between the patients 

exposure to HCV and development of hepatitis 2-26 weeks, with 

a peak of onset between 6 to 12 weeks Using ELISA assays that 

detect serum antibodies against both structural and non 

structural components of HCV, the mean time between exposure 

and zero conversion is much shorter approximately 2 weeks 

(Altar et al., 1997 and Ach et al., 1991). 

The time between exposure to HCV and onset of virus 

replication detected by serum HCV-RNA may be as short as one 

week (Farci et al., 1991). Thus a constant feature of HCV 

infection is that viral replication can be detected very soon after 

exposure and that the appearance of antibodies to multiple 

epitopes does not coincide with the first ALT peak (Colombo, 

1991). 

-19-


Serum HCV-RNA usually lasts less than four months in 

patients with acute self limited hepatitis C, but may persists for 

decades in patients with chronic disease. The acute disease may 

resolve completely with clearance of HCV RNA from serum 

(Farci et al., 1991). 

II- Chronic hepatitis and its sequalae: 

Chronic hepatitis C is defined as having abnormal liver 

enzyme for greater than 6 months and the patients tests positive 

for HCV antibody. About 85% of those infected with HCV will 

not clear the virus and will develop chronic hepatitis of varying 

severity (Marcellin, 1999). Viral load fluctuates and in many 

patients declines with time (Fanning et al., 2000). 

Cases of chronic hepatitis C with normal ALT seen in 

approximately one-third of patients despite detectable HCV 

RNA in serum. There is general consensus now that chronic 

infection occurs in at least 80% of cases after acute disease 

(Muller, 1996). Using serum HCV-RNA to detect persistent 

infection the rates of chronicity raise to 82-100% (Barreca et 


In cases of chronic hepatitis C with elevated ALT, the 

severity of the liver disease varies considerably as mild chronic 

hepatitis affect (50%) (Marcellin, 1999). The main symptom is 

fatigue associated with musculoskeletal pain (Barkhuizen et 


Moderate or sever chronic hepatitis is seen in about 50% 

of newly diagnosed patients with a raised ALT and there are no 

abnormal physical signs and the ALT is usually 2-10 times the 

-20-


upper limit of normal, but this is a poor marker of disease 

activity (Healy et al., 1995). 

Although the mechanisms underlying persistence of virus 

in patient with hepatitis C are largely unknown, a faulty immune 

reaction to HCV is likely candidate. Perhaps persistence of HCV 

is due to immune escape of neutralizing antibodies and/or lack 

of cytotoxic T cell activity in situ or to extrahepatic replication 

of the virus. Clearly, chronicity is not related to viral integration 

into the host genome because there are no DNA intermediates in 

the viral life cycle (Colombo, 1991). 

Serum aminotransferases decline from the peak values 

encountered in the acute phase of the disease but typically 

remain two to eight fold abnormal. In some cases, the enzyme 

levels fluctuate markedly with sudden elevation following 

month of normal measurements. The cause of these fluctuations 

is unclear. but reinfection with another HCV variant is a 

considerable explanation for fluctuation in enzyme levels. 

Another possibility is that regeneration of the damaged liver 

presents a new population of cells for infection (Alter et al., 

1992). 

Neither the source of initial HCV infection nor the severity 

of the acute illness seems to predict chronicity, and the 

chronically infected individual may have symptoms of hepatitis 

(Farci et al., 1991). 

Anti-HCV persist for years and even decades in chronic 

hepatitis C but may decline in titre or disappear with resolution. 

A small percentage of patients appear to eradicate HCV-RNA 

-21-


permanently after chronic infection but this is usually less than 

5-19% (Tanaka et al., 1992). 

During the course of chronic infection, episodes of acute 

hepatitis (flare-ups) can be observed and may be caused by 

reactivation of the underlying infection or to reinfections. The 

latter occurrence has been described not only in repeatedly 

exposed chimpanzees but also in hemophiliacs and other 

patients who require frequent infusion of blood derivatives 

(Jarvis et al., 1994). 

The natural history of HCV infection has been very 

difficult to assess, because of the usually silent onset of the 

acute phase as well as the frequent paucity of symptoms during 

the early stages of chronic infection (Seeff et al., 2000). 

Among 248 asymptomatic blood donors positive for anti- 

HCV enrolled in a long term prospective study, 86% who had 

chronic HCV infection appeared to have recovered as assessed 

by serial serum ALT levels and HCV RNA by PCR (Alter, 

1997). 

HCV-RNA usually persists in patients with abnormal 

serum amino transferase and anti-HCV. Although most patients 

with raised serum ALT are HCV-RNA. positive, the reverse is 

not always true. Isolation of HCV in individual patients may 

show nucleotide substitution with time, suggesting that the 

HCV-RNA mutates at rate similar to those of other RNA viruses 

(Ogata et al., 1991). 

In chronic infection there is usually an indolent course but 

there can a variety of histological lesions. It is important to note 

-22-


that HCV is not a progressive disease in all infected patients. 

The spectrum of histological lesions ranges from minimal 

hepatic inflammation to severe active cirrhosis and 

hepatocellular carcinoma (HCC) (Lee et al., 1991). 

Chronic hepatitis C virus induces haemostatic abnormalities 

through hepatocellualr impairment, auto antibodies against 

platelets and cryoglobulinemia. The cryoglobulinemia induce 

haemostatic changes through deposition of cryoprecipitable 

immune complexes in the blood vessel walls (Willems et al., 

1994). 

III- Liver cirrhosis: 

Irrespective of the source of infection, cirrhosis has been 

found to develop in 10-20% of chronic hepatitis C patients 

followed for 5 to 20 years and some of those go on to develop 

(HCC). In two retrospective studies of post transfusion hepatitis 

C the mean time interval from exposure to clinical presentation 

of chronic hepatitis, cirrhosis and HCC was estimated to be 10, 

21 and 29 years respectively. 

The probability of developing decompensate cirrhosis is 

12% at 3 years, 18% at 5 years. and 29% at 10 years, and the 

risk of developing hepatocellular carcinoma is 4% at 3 years, 

7% at 5% years and 14% at 10 years (Fattovich et al., 1997). 

Once cirrhosis develops, symptoms of end stage liver 

disease can appear such as marked fatigue, fluid retention, upper 

intestinal hemorrhage, jaundice and itching (Merican et al., 

1993). Once end stage liver disease has developed, the only 

-23-


practical means of restoring health is liver transplantation 

(Detre et al., 1996). 

All forms of cirrhosis lead to portal hypertension 

(McIndoe, 1928). Chronic portal hypertension may not only be 

associated with discrete varices but with a spectrum of intestinal 

mucosal changes due to abnormalities in the microcirculation 

(Vianna et al., 1987). Portal hypertensive gastropathy, this is 

almost always associated with cirrhosis and is seen in the fundus 

and body of the stomach (Payen et al., 1995). These gastric 

changes may be increased after sclerotherapy. They are relieved 

only by reducing the portal pressure (Panes et al., 1994). 

Gastric antral vascular ectasia not directly related portal 

hypertension, but is influenced by liver dysfunction (Spahr et 

al., 1999). Congestive jejunopathy and colonopathy are seen 

(Nagral et al., 1993). 

About 50% of patients with liver cirrhosis have varices at 

the time of diagnosis of liver disease (Sauerbrush, 1994), only 

about 30% of cirrhotic patients will actually have a bleeding 

episode (Weber et al., 1991). Portal hypertension is the main 

factor responsible for varix formation in intrahepatic portal 

obstruction but it can't be the only factor (Palmer, 1995).. 

Child and Tureotte (1964) classified cirrhotic patients 

into three categories; A, B and C according to the increasing 

abnormality in the five parameters: serum bilirubin, ascites, 

encephalopathy, albumin and the nutritional state. Pugh et al. 

(1973) modified child's grading scheme into a numerical scoring 

system. They also included prolongation of the prothrombin 

time instead of the nutritional state (Table 1). 

-24-

Table (l): Modified Child's Grade (Pugh et al., 1973). 


Clinical and biochemical Points scored for increasing abnormality 

measurements 1 point 2 point 3 point 

Encephalopathy grade 

Ascites 

Bilirubin (mg/100ml) 

Albumin (gm/100m) 

Prothrombin time sec. 

prolonged 

Non 

Absent 

1.2 

>3.5 

3 

6 

Grade (A): 5-6 point (B): 7-9 point (C): 10-15 point 

N.B.: The clinical grades of hepatic encephalopathy. 

I Mild confusion, euphoria, anxiety or depression 

Shortened attention span 

Slowing of ability to perform mental tasks (addition/subtraction) 

Reversal of sleep rhythm 

II Drowsiness, lethargy, gross deficits in ability to perform mental tasks 

Obvious personality changes 

Inappropriate behavior 

Intermittent disorientation of time (and place) 

Lack of sphincter control 

III Somnolent but rousable 

Persistent disorientation of time and place 

Pronounced confusion 

Unable to perform mental tasks 

IV Coma with (IVa) or without (IVb) response to painful stimuli 

IV- Hepatocellular carcinoma (HCC): 

(Sherlock and Dooley, 2002) 

HCV infection is major risk factor for HCC (Bruix et al., 

1989 and Colombo et al., 1989). Several factors have been 

evaluated as possible toward cirrhosis and HCC including HCV 

-25-


predictive markers of evolution genotype, viraemia load, 

duration of infection, age and immunological situation at the 

time of infection, ALT behavior, coinfection with hepatitis B 

virus and alcoholism, but no firm conclusions are yet possible 

(Benvegnu et al., 1997). 

In a study by Khan et al. (1995) to evaluate the 

relationship between HCV infection and HCC in a population of 

patients referred for liver transplant, a review of all HCC cases 

revealed that 38% of patients were infected with HCV alone, 

12% of patients with HBV alon, while in 17% of cases there 

was an association of HCV and a history of alcohol use. 

In addition Miyamura et al. (1990) reported finding of 

HCV-RNA by PCR in hepatocallular cancer tissue as well as in 

surrounding cirrhotic tissues. In patients with HCC due to HCV 

infection HCV-Ib was the most common subtype (57%) 

followed by HCV-Id (19%) and HCV-2a (5%). Subtype 

prevalence was not significantly different between HCC patients 

with advanced liver cirrhosis and those without advanced 

cirrhosis. 

It seem that the risk of HCC become consistent only when 

cirrhosis developed (Di Bisceglie, 1995). Recently, however, 

HCV related HCC has been reported to occur in a small number 

of virtually normal livers (Ballardini et al., 1996 and Romeo et 


In Egypt, Darwish et al. (1993) suggested a possible link 

between HCV and HBV and the development of HCC. Abd El 

Wahab et al. (1994) stated that 54% of HCC patients were sero 

positive for anti-HCV. 

-26-


V- Hepatitis C virus carrier with normal liver enzymes: 

Rarely a carrier state may exist i.e. the enzymes of the 

liver persistently not raised, the liver biopsy is almost normal 

and HCV-RNA is positive (Alter et al., 1992, Prieto et al., 

1995 and Wang et al., 1996). 

It is controversial whether or not there are HCV carrier 

with no liver histology (Alberti and Realdi, 1991). Unlike 

hepatitis B, there is clear cut evidence that there are carriers with 

entirely normal liver histology. A few patients with serum anti- 

HCV and normal liver histology have been reported, but they 

were consistently serum negative for HCV-RNA. By contrast, 

there also seem to be carrier with normal hepatic histology with 

detectable circulating levels of HCV-RNA (Prieto et al., 1995 

and Shindo et al., 1995). 

Extrahepatic manifestations of HCV: 

There are several extrahepatic diseases that have been 

associated with HCV infection, mostly by immune-mediated 

mechanisms. 

(A) Immunoglobulin production and deposition: 

1) Mixed cryoglobulinemia: 

Mixed cryoglobulinernia is a lymphoproliferative disorder 

that often occurs in association with a variety of infectious and 

systemic diseases, and may lead to deposition of immune 

complexes in small to medium sized blood vessels, which lead 

also to clinical triad of palpable purpura, arthralgia and 

weakness. Cases of pulmonary fibrosis have been also described 

(Ferri et al., 1997). There is suggestion of a strong relationship 

-27-


between HCV infection and mixed cryoglobulinemia, also anti 

HCV is found in 42 to 54% and HCV RNA in up to 84% of 

patients with essential mixed type II cryoglobulinemia which 

consist of mixtures of polyclonal IgG and a monoclonal 

immunoglobulin, usually IgM with anti-IgG activity (Lunel et 

al., 1994), furthermore, cryoglobulins are found in 19 to 54% of 

patients with hepatitis C, especially those with cirrhosis, 

although symptoms occur in only 25% of these, and 

cryoglobulin may be common in patients with high levels of 

virus, but viral genotype does not appear to be important 

(Zignego et al., 1996). 

Interferon (FN) treatment may result in a decrease or loss 

of cryoglobulins, improvement in skin lesions and symptoms, 

and reduction in viral RNA (Schirren et al., 1995). 

2) Autoantibodies: 

Autoantibodies are common in patients with chronic 

hepatitis C, such as antinuclear antibody, smooth muscle 

antibody, or antithyroid antibodies are detected in 40 to 65% of 

patients with chronic hepatitis C (Clifford et al., 1995). 

However, the presence of these autoantibodies does not appear 

to influence the clinical presentation, course of the disease or 

response to treatment (Lenzi et al., 1991). 

3) Membranous glowerulonephritis: 

HCV has increasingly been associated with 

membranoproliferative glomerulonephritis (MPGN) and 

nephrotic syndrome. Anti-HCV and HCV RNA have found in 

-28-


both circulating antigen/antibody complexes and the 

cryoprecipitate of patients with MPGN and nephrotic syndrome 

and in addition, immune complex deposition, cryoglobulin-like 

structures, and HCV core protein have been detected in the 

glomeruli of these patients (Okada et al., 1996). In the presence 

of cryoglobulinemia 98 to, 100% of patients with MPGN are 

anti-HCV-positive (Pasquariello et al., 1993). 

4) Lymphoma: 

A high prevalence of anti-HCV ranging from 20 to 40% 

has been described in patients with B-cell non-Hodgkin's 

lymphoma (NEL) but not in other blood malignancies (Mazzaro 

et al., 1996). HCV also has been described in association with 

Mucosal-associated lymphatic tissue lymphomas (MALT 

lymphomas) (Luppi et al., 1996). Furthermore, in one study, 

bone marrow biopsy documented low-grade NHL and reactive 

non monoclonal bone marrow infiltration in 11 (36%) and 12 

(29%) respectively of 31 patients with HCV infection and 

cryoglobulinemia (Pozzato et al., 1994). The mechanism by 

which HCV is related to the development of cryoglobulinemia 

and NHL is unknown, although there is suggestion that 

complexes of virus and lipid might result in antigen-driven Bcell 

proliferation (Agnello, 1999). IFN treatment appears to be 

an effective treatment for some patients with HCV-associated. 

lymphomas (Mazzaro et al., 1996). 

-29-

(B) Autoimmune disorders: 

1) Thyroid disease: 


Thyroid disorders are the most common autoimmune 

diseases in patients with chronic hepatitis C, antithyroid 

antibodies are present in 5.2 to 12.5% of patients with hepatitis 

C, also thyroid disease, primarily hypothyroidism, is present in 

3.1 to 5.5% of patients, and the highest prevalence of both 

thyroid antibodies and thyroid disease was found in older 

women (Marazuela et al., 1996). 

2) Sjogren syndrome: 

Sjogren syndrome consists of chronic lymphocytic 

infiltration of salivary and lacrimal glands by activated T-cells 

and some B-cells, also there is an associated oligoclonal B-cell 

activation that may result in hypergammaglobulinemia and 

immune complex deposition. However, the syndrome of dry 

eyes and dry mouth (sicca syndrome) results from a progressive 

destruction of exocrine glands, but extraglandular tissues can 

also be involved, but HCV infection is not associated with 

primary Sjogren syndrome (King et al., 1994). Also, 

lymphocytic sialadenitis, similar of Sjogren syndrome, was 

described in 57% of patients with chronic hepatitis C in one 

series (Haddad et al., 1992). 

3) Autoimmune idiopathic thrombocytopenic purpura: 

Anti-HCV has been found in 10 to 19% of patients with 

autoimmune idiopathic thrombocytopenia purpura (ITP) 

(Pawlotsky et al., 1995). In addition, there is cases of hepatitis 

C developed or exacerbated ITP during IF'N therapy (Bacq et 


-30-

4) Lichen planus: 


Lichen planus (LP) is an uncommon skin rash that presents 

as flattopped, violatious, pruritic papules in a generalized 

distribution. There is high incidence of mucosal involvement, 

and also it can affect hair and nails and anti-HCV is present in 

10% to 38% of patients of LP (Sanchez-perez et al., 1996). 

There are numerous reports of development or exacerbation of 

LP during IFN treatment (Barreca et al., 1995). 

(C) Unknown mechanism: 

Porphyria cutanea tarda: (PCT) 

HCV have been reported in 62 to 91% of patients with 

PCT, suggesting that HCV may be a critical factors in the 

development of the disease (Navas et al., 1995). 

Diagnostis of HCV infection: 

(A) Screening and supplemental antibody test: 

Screening diagnostic test include highly sensitive tests for 

anti-HCV and a supplemental assay to resolve false positive 

results in the screening test, the screening antibody test is a 

unique enzyme immunoassay in which antibodies to several 

different viral antigens, this tests are simple too perform, 

reproducible, and relatively inexpensive, however three versions 

of the anti-HCV EIA test (enzyme immunoassay) have been 

developed, the first one discovered immediately after HCV had 

been known (Kuo et al., 1989) and it was used for screening of 

blood donors to reduce posttransfusion hepatitis (Esteban et al., 

1990). However, because the assay used only a single target 

antigen, it lacked sensitivity and in fact, only 80% of infected 

-31-


patients were antibody positive by this test. Because of the low 

sensitivity, false positive results were common in low 

prevalence populations, thus it was important to develop a 

supplemental test to resolve the specificity of EIA results. The 

importance of the supplemental RIBA test (recombinant 

immunoblot assay) is evident in a low HCV prevalence setting, 

such as with screening healthy blood donors and in this situation 

50 to 70% of the positive EIA-1 results were subsequently 

shown to have false positive test results when tested by 

supplemental assays, it is important to recognize that RIBA 

assay is not as sensitive as the EIA test and so it should not be 

used for screening purposes (Gretch et al., 1992). 

The first generation anti-HCV test was replaced in 1992 by 

a multiantigen test, EIA-2, which is a screening test available to 

use in the United States until 1998, this EIA-2 contains HCV 

antigens from the core and third and fourth nonstructural regions 

(NS3 and NS4), this provided greater sensitivity and specificity, 

so this test is capable of identifying new infections at an earlier 

time (Alter, 1992). EIA-2 detects anti-HCV in at least 95% of 

infected patients, which is a great advantage over EIA-1 

(Gretch et al., 1992). ELISA is satisfactory for routine 

screening, particularly of blood donors, it is positive as early as 

11 weeks after infection and always within 20 weeks of the 

onset (Sherlock and Dooley, 2002). 

The latest version of the anti-HCV screening test (EIA-3) 

was approved for screening blood products in the United State 

in 1997 and has been introduced to replace EIA-2 for diagnostic 

testing at some centers. Although the EIA-3 test contains 

reconfigured core and NS3, the changes was not sufficiently 

-32-


great as to allow designation by the Food and Drug 

Administration (FDA) as a third-generation assay and so EIA-3 

has not led to a significant improvement in sensitivity or 

specificity in most settings (Vrielink et al., 1999). However, 

EIA is able to detect antibody earlier after infection and 

therefore offers an advantage in identifying acute infections that 

would have been missed (Uyttendaele et al., 1999). 

A third-generation supplemental test is Radioimmunoblot 

assay (RIBA-3), now it adds HCV NS5 peptide to the antigens 

already present in RIBA-2, RIBA-3 is more specific, correlates 

better with HCV-PCR results and has fewer indeterminate 

results (Pawalotsky et al., 1996). The sensitivity of anti HCV 

antibodies in detecting HCV infection was 85.7% while the 

specificity was 85.18% (Okasha et al., 2000). 

(B) Measurement of viral RNA: 

Detection of HCV RNA in patient serum by highly 

sensitive assays has become increasingly important for 

confirming the diagnosis of hepatitis C and for assessing the 

antiviral response to IFN therapy, from a diagnostic standpoint, 

HCV-RNA testing has been particularly useful in seronegative 

patients with chronic hepatitis, especially immuncompromised 

individuals who may lack serologic evidence of HCV infection 

despite clinical and molecular evidence of hepatitis C (Lau et 


1) Polymerase chain reaction: 

Reverse transcription-PCR (RT- PCR) involves separation 

of nucleic acid from the specimen, reverse transcribing the 

-33-


RNA, to DNA, and repeatedly amplifying the DNA by specific 

primers until the amount of product reaches a level that can be 

detected by autoradiography, ethidium bromide staining, or 

colorimetric testing, most PCR assays for HCV RNA have been 

designed by individual laboratories and are often referred to as 

"home-brew" test (Polyak and Gretch, 1999). Some 

commercial PCR based tests had begun to appear, the first of 

these (AMPLICOR, Roche Diagnostics) has several potential 

advantages over home-brew assays, including a microtiter test 

format, a standarized methodology and controls for assay 

sensitivity and specificity (Young et al., 1995). The sensitivity 

of the assay is about 700 copies/ml (Nolte and Thurniond, 

1995) in compared to 1.000 viral copies/ml in "home-brew" 

tests, although many investigators claim that their tests are 

capable of measuring for less that this amount of nucleic acid 

(Gretch et al., 1993). 

2) Quantitative tests for HCV RNA: 

Two different technologies have evolved to quantitate 

HCV-RNA levels and these include target amplification 

methods that use PCR-base technology and signal amplification 

technologies such as branched DNA assay (bDNA) (Gretch et 


Target amplification methods typically spike the initial 

reaction mixture with a known amount of a tag that is amplified 

along with the sample and the ratio of the initial tag to the 

amount in the final reaction mixture can then be used to estimate 

the original amount of sample RNA, although several 

laboratories have developed these PCR-based quantitative 

-34-


methods, their usefulness is limited by a lack of standardization 

(Polyak and Gretch, 1999). Lately, there is only one 

standardized and commercially available quantitative PCR assay 

(Monitor, Roche Molecular laboratories), it is reported to have 

high assay variability and a limited ability to measure samples 

with more than 1 million RNA copies/ml (Hawkins et al., 

1997). 

Several problems with PCR-based assays currently limit 

their clinical usefulness, the first lack of standardization and 

high laboratory-to-laboratory variability, many laboratories in 

Europe demonstrated that only 16% correctly identified all 

samples in the coded test panel (Zaijer et al., 1993). A similar 

series of laboratory surveys in the United States found accurate 

identification ranging from 12 to 95% (Gretch, 1997). Several 

factors may explain inaccuracies in HCV-RNA assay. Delayed 

serum separation, inadequate storage conditions, and specimen 

contamination can reduce the amount of nucleic acid in the 

specimen (Davis et al., 1995). Using synthetic RNA transcripts 

as a standard for a quantitative enzyme-linked PCR, quantitation 

of HCV RNA derived from HCV type 1 is typically accurate 

(Hawkins et al., 1997), but genotypes 2 and 3 HCV RNA are 

underestimated by up to one log (Fang et al., 1997). 

(C) HCV genotyping: 

As HCV is a remarkably heterogenous family of viruses 

with at least six distinct genotypes and multiple subtypes of 

HCV identified throughout the world. Currently, the reverse 

hybridization line probe assay is the most commonly used 

genotyping method in practice (Stuyver et al., 1993). 

-35-

Treatment 


The success of treatment can be measured now by the 

assessment of a virologic response (as defined by negative result 

on a qualitative PCR assay for HCV RNA). Also assessment of 

the histologic response, but in clinical practice there is little 

indication of post-treatment biopsy. Since responses to therapy 

may not be maintained after treatment is stopped, the success of 

clinical trials has been evaluated in terms of the response at the 

end of therapy (end-of treatment response, ETR) and six months 

after the cessation of treatment (sustained treatment response, 

STR). Persons with a sustained virologic response have a high 

probability of having a durable biochemical, virologic and 

histologic response (Reichard et al., 1999). 

Interferons (IFNs): 

IFNs are a group of naturally occurring cytokines that are 

secreted by cells of the mammalian immune system when they 

are stimulated by viral, bacterial and other antigens. There are 3 

types of IFN, designated alpha, beta and gamma. Each has antiproliferative, 

anti-viral and immunomodulatory effects. The 

binding of IFN to cell surface receptors stimulates the 

production of specific gene products within the cell within 15 

minutes. These catalyze the phosphorylation of an IFNstimulated 

gene factor and two other proteins called STAT1 and 

STAT2. The gene products enhance antigen presentation by the. 

This allows once-weekly injections to be administered with 

continues elevated concentration of INF. Two such preparations 

are available: PEG IFN-2a (40 Kds) size and PEG IFN-2b 

(12 Kds). The larger molecule has a longer half-life and may 

-36-


achieve more sustained levels of IFN but the side effects are 

similar (Zeuzem, 2000). 

The side effects of INFs either, early which is usually 

temporary occur 4-8 hour after injection during the 1 st weak in 

the form of flue like, myalgia, headaches, nausea or later in the 

form of fatigue, muscle aches irritability, anxiety, depression, 

weight loss, diarrhea, alopecia, bone marrow suppression, 

bacterial infections, autoimmune auto antibodies and optic tract 

neuropathy (Sherlock & Dooley, 2002). 

Acute infection: 

Data regarding the efficacy of the treatment of acute HCV 

infection are very limited, since the infection is seldom 

diagnosed during the acute phase. Given the high rate of 

progress to chronic infection and the relatively limited efficacy 

of therapy for chronic infection, the treatment of acute infection 

has been advocated (EASL, 1999), but it has not yet proved to 

be beneficial. Furthermore, somepatients with acute 

symptomatic HCV infection have high rates of spontaneous 

clearance and would therefore be treated unnecessarily 

(Gerlach et al., 1999). 

However, the preliminary results of more recent studies suggest 

that early treatment, even with interferon alone, has a high rate 

of efficacy. In view of these data early therapy may be 

advisable, but the optimal therapeutic regimen and the best point 

at which to intervene have not been defined. Since the study of 

persons with acute HCV infection may also provide valuable 

information about the pathogenesis of HCV infection in general, 

it would be ideal to follow such patients in controlled clinical 

-37-


trials. Another unanswered question is whether post-exposure 

prophylaxis, for example, after a needle-stick injury is 

beneficial, as is the case for HIV-infection. Currently, no 

prophylactic regimen has been shown to be effective and 

efficient and only monitoring is recommended (Hoey, 2001). 

Chronic infection: 

Interferon monotherapy for HCV infection with IFN was 

associated with initial rates of response as high as 40 percent. 

but the rates of, sustained response are less than half this 

(Poynard et al., 1998 and McHutchison et al., 1998). 

IFN/Ribavirin combination: Ribavirin therapy is a 

nucleoside analogue that is well absorbed orally and has broad 

antiviral activity against a variety of DNA and RNA viruses. It 

is administered in a doses of 1000-1200mg/day depending on 

body weight (below/above/75kgm). When, ribavirin is used 

alone in chronic hepatitis C, it gives significant biochemical 

response without any virological response (Di Biseeglie et al., 

1994). The IFN/Ribavirin combination increases the percentage 

of previously untreated patients who have a sustained virologic 

response, from 16% to 40%. The studies showed that in patients 

infected with HCV genotype 2 or 3 and in those with two viral 

load before treatment, the response was maximal after 24 weeks 

of treatment, whereas patients infected with genotype 1 and 

those with a high viral load before treatment required a course 

of 48 weeks for an optimal outcome (Poynard et al., 1998 and 

McHuchison et al., 1998). This finding led to the 

recommendation that the duration of treatment should be based 

on the HCV genotype and the pretreatment viral load. However, 

-38-


since tests for the quantification of HCV RNA are still not 

standardized, and since the viral load naturally fluctuates over 

time, the viral load is currently not routinely used for 

determining the treatment regimen. The virologic response to 

combination therapy should be assessed at week 24, since 

elimination of the virus can occur late with this approach. 

Persons with a positive PCR assay for HCV RNA at week 24 

should be considered to have had no response to treatment, and 

therapy should be discontinued. Those infected with HCV 

genotype 2 or 3 who have a negative PCR assay for HCV RNA 

can also usually stop therapy at this time, but an additional 24 

weeks of treatment is suggested for patients with other 

genotypes and a negative PCR assay (EASL, 1999). 

Peg-interferon alfa-2a in combination with ribavirin 

for hepatitis C: The FDA approved peg-interferon alfa-2a for 

chronic hepatitis C therapy. In one study, more than one 

thousand patients were randomized to receive either peginterferon 

alfa-2a (once a week) with ribavirin (daily), peginterferon 

alfa-2a alone (once a week), or standard interferon 

alfa-2b (three times per week) with ribavirin (daily). Patients 

were treated for 48 weeks. The authors reported that "sustained 

virologic response" (undetectable virus at 24 weeks after 

cessation of therapy) was noted in 56% of patients treated with 

standerd peg-interferon alfa-2a alone and 44% of patients 

treated with interferon alfa-2b and ribavirin. As has already been 

reported in prior studies, patients with particular strains of 

hepatitis C (known as "nongenotype 1" virus) continue to fare 

much better than those with the more common strain (known as 

-39-


"genotype 1"). 76% of patients with genotype 2 and 3 had a 

sustained response to treatment, but only 46% of patients with 

genotype 1 responded (Heathcote et al., 2000 and Fried et al., 

2002). 

A new indicator of successful treatment, known as the 

"early treatment response". Currently, patients receive treatment 

for six months before undergoing an initial evaluation of 

whether the virus has been eradicated, and whether the treatment 

has been successful. However, the investigators found that after 

only 12 weeks of treatment with pegylated interferon and 

ribavirin, they could predict who would ultimately succeed. 

'After twelve weeks, 86% of patients (390 of 453) had at least a 

one hundred-fold reduction in viral levels. And of this group, 

65%, ultimately had a "sustained virologic response", the 

marker of success, more than one year later. In contrast, 63 

patients did not have a significant decrease in viral level after 12 

weeks of treatment, and only 3% (2 out of 63) ultimately 

eradicated the virus when evaluated a year later. Because of the 

cost and the side effects associated with peg-interferon and 

ribavirin therapy, it is worthwhile to determine the success of 

treatment as early as possible-after three months of therapy, 

rather than six. This may spare potential "nonresponders" those 

patients in whom treatment fails to work so the additional three 

months of therapy is unnecessary (Fried et al., 2002). 

Amantidine has been used in combination with interferon- 

. There is conflicting evidence of efficacy and at present there 

is no clear role for this combination (Zeuzem et al., 2000). New 

antiviral agents. knowledge of molecular biology of HCV has 

-40-


led to identification of specific functions associated with 

particular regions of the virus. Treatments may be targeted to 

inhibit specifically encoded functions. These include antisense 

oligunucleotides targeted against the ribosomal binding site of 

the 5' non-translated region of HCV genome. Protease and 

helicase inhibitors are under development. Unfortunately, they 

have not reached the stage of clinical trials. Inosine 

monophosphate dehydrogenase (MDH) inhibitory is being 

tested (Sherlock and Dooley, 2002). 

-41-

Introduction: 

HCC 


The development of hepatocellular carcinoma (HCC) is a 

major global health problem (Bosch et al., 1999 and Parkin et 

al., 2001). Its incidence has increased worldwide and nowadays 

it constitutes the 5th most frequent cancer representing around 

5% of all cancers worldwide. More than 500.000 new cases are 

diagnosed per year and it represents the third cause of cancerrelated 

death and the first cause of death among cirrhotic 

patients (Fattovich et al., 1995 and Bolondi et al., 2001). 

HCC incidence has striking geographical differences. In 

North America, Europe and Australia the age-adjusted incidence 

is less than 2/100.000 per year. This increases in the South 

European and Mediterranean countries and, reaches the highest 

scores (>50/100.000) in Sub-Saharan Africa and South East 

Asia (Bosch et al., 1999). 

This geographic pattern overlaps with the distribution of 

risk factors and probably also reflects genetic characteristics 

inherited or acquired through oncogenic agents. While in some 

high risk areas the incidence has decreased as a result of a better 

health care of the population, the HCC incidence in several 

areas such as USA and South Europe has increased. This may be 

due both to increased disease awareness with a higher diagnostic 

capability, and also to the emergence of risk factors which up till 

now would have had a minor dissemination and thus, no impact. 

This is probably the case for HCV related HCC that should 

represent the final step of the HCV epidemic that spread in some 

-42-


Western countries after the second world war, while in Asia it 

could have appeared decades before (Bruix et al., 2003). 

North America and Western Europe are generally 

considered to be low-incidence regions (incidence 2.6 to 9.8 per 

100.000 population), but in these regions the incidence of HCC 

is rising (Fertay et al., 2000 and WHO, 2001). 

The incidence of HCC appears to be rising in Australia as 

well. Most cases in Melbourne are attributed to viral hepatitis B, 

HCV infection, and alcohol abuse (Roberts et al., 1999).). 

In Egypt, hepatocellular carcinoma had become a common 

malignancy which usually develops on top of cirrhosis of viral 

origin (Abd-El Wahab et al., 2000). 

In Egypt the incidence of HCC is expected to increase 

significantly in the next decade mainly because of high 

prevalence of HCV in the population, it accounts for most of 

cirrhosis and HCC (Hassan, et al., 2001), 

In 2005; E1-Zayadi and co-workers conducted a study to 

identify the trend, possible risk factors and any pattern of 

change of hepatocellular carcinoma (HCC) in Egypt over a 

decade and they found that over a decade, there was nearly a 

two fold increase of the proportion of HCC among CLD patients 

with a significant decline of HBV and slight increase of HCV as 

risk factors. 

I – INCIDENCE(Age, Race and Sex): 

The incidence of HCC is age related, but the age 

distribution differs in different local regions of the world. The 

pattern suggests that with urbanization the median age of onset 

-43-


is shifted to older age groups. In less well developed countries it 

is not rare to find HCC in people younger than 45. However, in 

developed countries the incidence. of HCC only really starts to 

increase over about age 45 and continues to increase until the 

70s. These differences may reflect a difference in the age of 

exposure to hepatitis viruses, exposure occurring at younger 

ages in high-incidence countries (Sherman, 2005). 

Researchers from the United States have found HCC to be 

more common than expected among children; however, the 

trend shows the number of new cases to be declining over time, 

perhaps as a consequence of widespread vaccination against 

hepatitis B virus (Darbari and Schwarz, 1999). 

The relationship of race to HCC was also examined. 

Population-based databases reveal that rates of HCC in blacks 

are more than twice that in whites (Jemal et al., 2003). 

Yu and colleagues in 2003 presented an analysis of 

hospital admissions for HCC and showed that black patients 

with HCC were significantly younger in age than white patients 

and that HCC may have a more important impact on the lifespan 

of blacks with chronic liver disease. 

Men develop HCC more often than women in all 

populations; male-to-female ratios are reported from 2:1 to 8:1. 

This may be due to androgen receptors on HCC or an increased 

prevalence of viral hepatitis and/or alcoholic cirrhosis in men 

(El Serag, 2001). Countries that lie on the Mediterranean Sea 

have a HCC incidence of 10 to 25 per 100,000 for males and 2 

to 9 per 100,000 for females (Wilson, 2005). 

-44-

II- Risk factors of hepatocellular carcinoma: 


One of the keys to effective early detection is an 

understanding of the epidemiologic risk factors for HCC; this 

will permit the medical community to focus its limited resources 

on those individuals at highest risk for disease. Currently, the 

best understood risk factors for HCC include cirrhosis related to 

hepatitis B and C (Befeler, 2003). 

Major risk factors: 

HBV. 

HCV. 

Cirrhosis. 

Haemochromatosis and other metabolic liver disease. 

Aflatoxin exposure. 

Minor risk factors. 

Primary biliary cirrhosis. 

Thorotrast exposure. 

Vinyl chloride exposure. 

Oestrogens. 

Androgens. 

Cigarette smoking. 

(Kew, 1998 and Baily & Brunt, 2002) 

Chronic viral hepatitis B and C and liver cirrhosis: 

Hepatitis B and C will remain for some time, major health 

problems in Egypt and the entire continent of Africa. Both 

infections can lead to HCC in a 20-30 years period. In addition, 

hepatitis B and C infection rates differ in different settings, and 

prognosis may be worse in conjunction with malaria in Sudan 

-45-


and human immunodeficiency virus (HIV) in other African 

populations (Attia, 1998). 

A study conducted by EL-Zayadi and co-workers in 

2001 in Egypt, revealed that HCC is showing an increasing 

trend among patients. Its development is mainly due to high 

rates of HCV Ab and HBsAg positivity. HBsAg positive 

patients were at double risk to develop HCC and HCV Ab 

positive patients were at 1.6 more risk. The high prevalence-of 

HCV Ab positivity renders its contribution to the development 

of HCC over seven-fold higher than HBsAg positivity. 

Darwish et al. (1993) studied the frequency of HCV and 

HBV infection on 70 patients with HCC, and they found that the 

total positivity for anti-HCV and for HBsAg was 70% and 

61.4% respectively, so they suggested a possible link between 

HCV and HBV infection and the development of HCC in Egypt 

Badawi and Michael in (1999) found that HBV infection was 

the major risk factor in the development of HCC. However, 

other factors associated with an increased risk of HCC in Egypt 

were age over 60 years-old, farming, cigarette smoking and 

occupational exposure to chemicals such as pesticides. 

The highest incidence of HCC is seen in China (-100 per 

100.000 population), where the major component of the 

attributable risk is related to chronic hepatitis B (range 40 to 

90%) (Ferlay et al., 2000; WHO, 2001 and Bosch et al., 

2004). Similarly, in Africa, where the HCC incidence is also 

very high, the major component of the attributable risk is 

chronic hepatitis B. In contrast, in Europe hepatitis C accounts 

for 63% of the attributable risk (Bosch et al., 2004). 

-46-


In the United States the increase, from 1.4 to 2.4 per 

100,000 per year, has been seen in all races and is mainly due to 

an increase in the incidence of HCC related to hepatitis C, with 

much smaller increases in the incidence of HCC associated with 

alcohol and hepatitis B (El Serag and Manson, 1999; Hassan 

et al., 2002 and El Serag et al., 2003). 

In many countries immigration from areas of high hepatitis 

prevalence will also result in an increase in HCC related to both 

hepatitis B and hepatitis C (Sherman, 2005). Studies in 

immigrant populations have clearly shown that first-generation 

immigrants carry with them the high incidence of HCC that is 

present in their native countries. However, in the second and 

subsequent generations the incidence decreases (Rosenblatt et 

al., 1996 and Me Credie et al., 1999). This is probably a 

reflection of improved sanitation, improved health care, and 

improved health in general, resulting in a lower prevalence of 

underlying liver disease (Sherman, 2005). 

A major risk factor for the development of HCC is liver 

cirrhosis. Epidemiological studies showed that over 80% of 

HCC worldwide occur in a cirrhotic liver (Simonetti et al., 

1997). 

Community-based autopsy studies have shown the 

prevalence of cintiosis to be between 2.95% to 9.5% and that 

cirrhosis is associated with HCC, because the rate of HCC was 

between 7.4% and 23.0% in all patients with cirrhosis, 

compared with a rate between 0.11 to 0.28% in non cirrhotic 

patients (Burnett et al., 1978 and Bartoloni et al., 1984). 

Altogether approximately 75% of HCCs were detected in 

-47-


cirrhotic individuals and 25% occurred in non cirrhotic 

individuals. The second important finding from these studies is 

that male cirrhotic patients seem three to four times more likely 

to develop HCC than female cirrhotic patients (Bethke and 

Schubert, 1984). The risk of developing HCC seems similar for 

non cirrhotic men and women (McDonald, 2001). 

III- Mortality of HCC: 

Hepatocellular carcinoma (HCC) is usually diagnosed in 

the background of chronic liver disease with cirrhosis, and has 

been estimated to result in up to 1 million deaths per year 

worldwide (Better and Di Besceglie, 2002). Hepatitis C-related 

cirrhosis is thought to be the main cause of the recent increase in 

incidence and mortality due to HCC (El-Serag and Mason, 

1999). 

Unlike many other cancers in the United States, the 

incidence and mortality of HCC are growing. After analyzing 

several national databases, El-Serag and Mason in 1999 

reported a 41% increase in mortality when comparing the period 

1976-1980 with 1991-1995. Further analysis from the late 1990s 

shows continuing increases in age-adjusted mortality rates 

(Jemal et al., 2003). 

Studies from cancer registries have shown a rising trend in 

HCC death in France, Japan, Scotland, Australia, and Italy (Me 

Glynn et al., 2001 and Levi et al., 2004). Mortality rates have 

increased in several European regions, but some of these 

increases may be the results of improved detection (Stewart, 

2003). 

-48-


Mohammed et al. (1999) and Hassan et al. (2001) 

reported a tripling of HCC mortality in Egypt over the past 12- 

15 years and this was associated primarily with HCV infection 

and also to a lesser extent with HCV infection and exposure to 

aflatoxin. 

Hepatitis infection and Hepatocarcinogenesis: 

HCV lb was the most prevalent type among the patients 

reported with HCV associated HCC in the absence of cirrhosis 

(De Mitri et al., 1995 and Mohamed & Al-Karawi, 1997). 

Zekri et al. (2001) examined the distribution of HCV 

genotypes among Egyptian patients positive for anti HCV and 

their influence when combined with new-oncoprotein over 

expression, on the development of HCC and they concluded that 

infection with subtype la and 4 HCV may be considered a rise 

factor for the induction of new-oncuprotein over expression and 

subsequent development of HCC. 

Cirrhosis develops in 20% of patients chronically infected 

with hepatitis C (Fattovich et al., 1997), and hepatocellular 

carcinoma (HCC) develops in 4% of those with established 

HCV related cirrhosis (Resnick and Koff, 1993). 

HCV associated hepatocarcinogenesis is poorly understood 

and may possibly be isolated to the long-standing necroinflammatory 

effect of HCV in the liver. However, the existence 

of patients with chronic HCV infection without cirrhosis who 

developed HCC. as well as experimental data suggest that HCV 

may be directly involved in hepatocarcinogenesis, with the 

products of the virus being involved in regulating liver cell 

-49-


proliferation. Evidence of a direct mechanism of HCV in tumor 

development is supported by the detection minus strand HCV 

RNA in patients with HCC and With HCV infection (Niu et al., 

1995). 

-50-

DIAGNOSIS OF HCC 

CLINICAL DIAGNOSIS OF HCC: 

Symptoms: 


Forty percent of patients are asymptomatic at the time of 

diagnosis (Chen et al., 1997). 

Pain is the most frequent symptom (91%), appearing at 

advanced stages and when Glisson's capsule is affected. Pain is 

typically located in the upper quadrant of the abdomen. Acute 

onset pain may indicate bleeding into the peritoneal cavity 

resulting from rupture of the tumor and is the first symptom of 

HCC in 5%of cases. Most patients have underlying hepatic 

cirrhosis and present with such signs and symptoms of liver 

failure as malaise (31%), weight loss (35%), anorexia (27%), 

and jaundice (7%). Jaundice may be caused by functional 

impairment of the liver tissue or may be obstructive, resulting 

from tumor compression and blood clotting. Nausea and 

vomiting are observed in 85 of cases. Physical signs include 

hepatomegaly (89%), hepatic bruit (28%), ascites (52%), and 

splenomegaly (65%), jaundice (41 %) wasting (15%) and fever 

(38%) (Okuda et al., 1984). 

As many as 15% of patients admitted to the hospital with 

variceal bleeding are diagnosed with HCC, and as many as 20% 

of patients who present with spontaneous bacterial peritonitis 

have underlying HCC. Hemorrhagic ascites may reflect minor 

or major bleeding of the tumor. In a necropsy series, 50% of 

patients with HCC were found to have hemorrhagic ascites, a 

feature that is seldom seen in cirrhotic patients. In a few patients 

-51-


the symptoms of metastatic spreading of the disease are the first 

symptoms of HCC, especially when metastatic disease has 

spread to the hilar nodes, bones, lungs and adrenal glands 

(Abeloff et al., 2000). 

Diarrhea which is probably caused by the production of 

vasoactive substances (vasoactive intestinal polypeptide, gastrin 

and prostaglandins) by the tumor, occurs in as many as 50 % of 

patients at an average of 3 months before the diagnosis. 

Erythrocytosis is seen in 10% of patients. Other findings in HCC 

include hypercaicaemia, sexual precocity and gonadotropin 

production (Can et al., 1997). 

Signs: 

Careful physical examination can suffice to diagnose an 

advanced FICC when a large hepatic mass with a vascular 

murmur is found in a patient from a highly endemic area The 

physical findings associated with HCC depend on the stage of 

the disease when the patient is first seen by a physician. 

Hepatomegaly is the most frequent physical finding in both 

high-and low-incidence areas. Liver tenderness is frequent and 

may be severe. Hepatomegaiy is present at the time of diagnosis 

in over 90 percent of African and Asian HCC patients, 

compared to 50 to 75 Dercent of American and European 

patients. An arterial bruit is detectable over the liver in 5 to 25 

percent of patients. The presence of a bruit reflects the highly 

vascular nature of HCC and may be attributable to turbulence in 

dilated tumor vessels or indicative of arteriovenous 

communications (Abeloff et al., 2000). 

-52-


Physical examination reveals the presence of ascites in up 

to 60 percent of Western patients and in 35 to 50 percent of 

African and Oriental patients. The higher incidence of ascites in 

Western populations reflects the greater prevalence of cirrhosis 

and older age of HCC patients with longstanding liver disease. 

Ascites is related most frequently to portal hypertension 

secondary to coexisting cirrhosis, or to tumor invasion of the 

portal vein. Two less frequent causes of ascites are peritoneal 

carcinomatosis and the Budd-Chiari syndrome caused by 

malignant invasion of the hepatic veins. Tumor invasion of 

hepatic veins is found in 14 percent of HCC patients at 

necropsy. Splenomegaly is another physical finding related to 

portal hypertension, a palpable spleen in HCC patients has been 

reported in 15 to 48 percent of cases (Ryder, 2003). 

Muscle wasting related to anorexia and weight loss is 

noted in up to 25 percent of patients. The presence of a 

persistent temperature elevation of 37.5 to 38.5C is noted in 

10 to 40 percent of patients. Fever is more prevalent in highincidence 

populations, which correlates with the increased 

proportion of patients with large, necrotic HCC. Fever is 

presumably related to the tumor necrosis and release of 

pyrogenic compounds (Ryder, 2003). 

Complications: 

Spontaneous rupture of HCC: 

A catastrophic presentation of HCC is acute, severe 

abdominal pain and hypovolaemia caused by spontaneous 

rupture of the tumor. Spontaneous rupture of HCC is reported in 

only 1 percent of Western patients and, because of the relative 

-53-


rarity of the tumor in these geographic regions, the diagnosis 

rarely is made prior to operation or autopsy. However, in highincidence 

regions of the world, spontaneous rupture occurs in 10 

to 20 percent of patients. In high incidence areas, spontaneous 

rupture is the cause of death in 10 percent of HCC patients. In 

patients with long-standing hepatitis or cirrhosis who present 

with an acute abdominal catastrophe, the diagnosis of a ruptured 

HCC must be entertained. Over 90 percent of patients who 

present with rupture of their HCC have significant underlying 

cirrhosis. Almost all complain of vim sudden, severe upper 

abdominal pain and distension, and two thirds present in 

hemorrhagic shock. Emergency resection of the ruptured HCC 

is possible in a minority of patients because of the large size of 

most ruptured tumors and the coexistent cirrhosis. One- or twostage 

hepatic resection provides the highest 3-month survival 

(59.5 percent and 89.4 percent, respectively) and 12-month 

survival (45 percent and 76 percent, respectively) following 

spontaneous rupture of HCC. Other treatment, including 

packing, hepatic a very ligation, and hepatic artery embolization 

have been used to control acute hemorrhage, but are associated 

with 30 day mortality rates in excess of 70 percent (Miyamoto 


Paraneoplastic Syndromes: 

A variety of para neoplastic manifestations may occur in 

patients with HCC. Occasionally symptoms related to para 

neoplastic phenomena may antedate the more common 

abdominal symptoms related to tumor growth (Abeloff et al., 

2000). Hypoglycemia forms the most common of the para 

-54-


neoplastic syndromes associated with HCC. HCC-related 

hypoglycemia occurs in 10 to 25 percent of African and Asian 

patients. The type of hypoglycemia specifically associated with 

HCC occurs early in the course of the disease, and frequently 

produces symptoms of neurologic or psychiatric disorders, 

seizures, mental status changes, or coma, which ultimately leads 

to a diagnosis of HCC. This type of hypoglycemia is difficult to 

control even with infusion of high concentrations of glucose and 

may require urgent treatment of the HCC in attempts to 

ameliorate the symptoms. It appears that this tumor-related 

hypoglycemia is caused by the inappropriate production and 

secretion of high molecular weight insulin-like growth factor II 

(IGF-II). Further investigation in HCC patients with high serum 

levels of IGF-II has revealed insertion of HBV genomic DNA 

near the promoter for the IGF-II gene. Thus, inappropriate 

translation and transcription of this gene in otherwise 

asymptomatic HCCs may produce life-threatening hypoglycemia 

(Yonei et al., 1992). 

Erythrocytosis is the second most common para neoplastic 

syndrome in HCC, with an incidence ranging from 3 percent to 

12 percent. Since Cirrhosis frequently is associated with anemia, 

the appearance of erythrocytosis in a cirrhotic patient should 

suggest the diagnosis of HCC. The pathogenesis of 

erythrocytosis in HCC patients is related to ectopic production 

of erythropoietin by the tumor. Serum erythropoietin levels are 

increased in HCC patients with inappropriately high hemoglobin 

and packed cell volume, and studies of human hepatocellular 

carcinoma cell lines and tumors have demonstrated increased 

-55-


erythropoietin messenger RNA (mRNA) and protein. 

(Funakoshi et al., 1993). 

In HCC patients who do not have detectable osseous 

metastases, hypercalcaemia has been reported occasionally. 

Increased osteoclastic activity in these patients may be related to 

inappropriate secretion of osteoclastic hormones or prosiaglandins 

by the tumor cells. Hypercholesterolemia also has been noted in 

patients with HCC. Increased cholesterol synthesis has been 

demonstrated in human HCCs. Malignant hepatocytes have been 

shown to lack cell surface receptors for chylomicron remnants. 

Thus, cholesterol is prevented from entering the malignant 

hepatocytes to exert negative feedback inhibition on cholesterol 

biosynthesis (Abeloff et al., 2000). 

Feminization attributed to trophoblastic activity of the 

tumor resulting in high serum estrogen levels has been noted in 

several adult HCC patients, although this syndrome is more 

common in children with hepatoblastoma. An HCC secreting 

high levels of serotonin produced severe diarrhea and syncope 

because of carcinoid syndrome. An HCC secreting large 

quantities of angiotensinogen caused severe, poorly controlled 

hypertension. Several cases of patients with hyperthyroidism 

have been described with HCC secreting thyroid-stimulating 

hormone (TSH). Inappropriate secretion of adrenocorticotropic 

hormone, cortisol, gastrin, and glueagon has been described. 

While fibrolamellar HCC rarely has been associated with 

paraneoplastic syndromes, these tumors also have the potential 

for inappropriate hormone secretion with the discovery of five 

-56-


patients whose tumors were secreting neurotensin (Abeloff et 


Methods of Tumor Detection: 

The definitive diagnosis of HCC depends on histologic 

examination of a biopsy or FNA specimen. However, in highincidence 

regions of the world, the diagnosis of HCC can be 

made with a high degree of accuracy based on diagnostic 

studies. In a cirrhotic patient with a serum AFP greater than 

1000ng/ml or a serum AFP value that is rising steadily, and a 

hypervascular hepatic mass lesion on radiographic imaging 

studies, the diagnosis is unequivocally HCC. A variety of 

imaging studies has been used to identify and define the extent 

of disease in patients with HCC. These include plain chest and 

abdominal films, radionuclide scintigraphy, angiography, realtime 

ultrasonography, computed tomography, and magnetic 

resonance imaging. Diagnostic studies also are important for 

screening high-risk patients in regions of the world with a high 

incidence of HCC (Abeloff et al., 2000). 

Blood chemistry: 

Liver cancer is not diagnosed by routine blood tests, 

including a standard panel of liver tests. Since most patients 

with HCC have associated liver disease (cirrhosis), their liver 

blood tests may not be normal. If these blood tests become 

abnormal or worsen due to HCC, this usually signifies extensive 

cancerous involvement of the' liver. Sometimes, however, other 

abnormal blood tests can indicate the presence of HCC. When 

cells become cancerous, certain of the cell's genes that were 

turned off may become turned on. Thus, in HCC, the cancerous 

-57-


liver cells may take on the characteristics of other types of cells. 

For example, HCC cells sometimes can produce hormones that 

are ordinarily produced in other body systems. These hormones 

then can cause certain abnormal blood tests, such as 

erythrocytosis, hypoglycemia and hypercalcaemia. Another 

abnormal blood test, hypercholesterolemia, is seen in up to 10% 

of patients from Africa with HCC. The high cholesterol occurs 

because the liver cancer cells are not able to turn off (inhibit) 

their production of cholesterol. (Normal cells are able to turn off 

their production of cholesterol) (Fong and Schoenfield, 2002). 

Assay of serum alkaline phosphatase (ALP) is widely used 

as a biochemical screening test and is frequently elevated when 

hepatic parenchyma is displaced by a tumor. This elevation may 

occur even when the serum billirubin level remains normal 

(Tietz, 1987). 

Elevation of transaminases (AST and ALT), lactic acid 

dehydrogenase (LDH) occurs in advanced HCC in addition to 

alkaline phosphatase (ALP) (McIntyre et al., 1991). 

Also with progression of the disease the difference 

between aspartate transaminase (AST) and alanine transaminase 

(ALT) becomes invariably higher (Mclntyre et al., 1991). 

Serological tumor markers: 

Alpha-fetoprotein (AFP), the major protein component of 

fetal serum, is synthesized by the visceral endoderm of the yolk 

sack during early fetal life and subsequently by the fetal liver. 

AFP concentration in the serum decreases gradually after birth 

to


it reappears in maternal serum during pregnancy and only when 

certain pathologic conditions develop it rises again. It has been 

known for almost 40 years that are expression of AFP 

consistently occurs in patients with hepatocellular carcinoma 

(HCC), and on this basis AFP became one of the first clinically 

useful tumor markers (Johnson, 2001). 

The only serological marker widely used for the screening 

and diagnosis of HCC is AM Increased circulating AFP has 

been associated with HCC, gastric carcinoma, lung cancer, 

pancreatic cancer, biliary tract cancer, and testicular carcinoma 

(Chan and Dell, 1999). AFP is the most accurate diagnostic 

marker of HCC at a cut off value of 500ng/ml with 100% 

sensitivity but specificity was not acceptable (30%) while at 

1000ng/ml, specificity was 100% and sensitivity was 70%, the 

lentil lection reactive fraction of AFP proved to be the most 

sensitive and specific in diagnosing HCC (100%) (Abdel 

Rahim et al., 1988; Abou Raya, 1988 and El-Gharib, 1992). 

A systematic review of the published literature shows that 

at a cutoff value of 20ng/ml AFP displays between 41-65% 

sensitivity and 80-94% specificity (HCC vs CLD) for the 

diagnosis of HCC (Gupta et al., 2003); for small tumors, 

sensitivity is around 40% (Taketa, 1990 and Levy et al., 2001). 

AFP can also be moderately elevated in some patients with 

benign liver disease (Johnson, 2001). If a higher cut-off value is 

used, the specificity of the test will increase but, obviously, the 

sensitivity will be reduced (Gupta et al., 2003). Due to the 

limited sensitivity, particularly for small tumors, the usefulness 

of AFP measurement as a diagnostic test and surveillance tool 

-59-


for patients at risk for HCC has been questioned. It has been 

proposed that the only circumstance in which the measurement 

of AFP is justified is for the confirmation of an initial diagnosis 

based on an imaging technique (Sherman, 2001). 

In chronic hepatitis B and cirrhosis the frequency and 

extent of AFP rises especially if HBsAg is positive, so AFP 

monitoring in patients with HBV infection is the most 

satisfactory tool in the early detection of HCC (Chu et al., 

2001). 

In Egypt, EL-Zayadi, (1989), Shamaa, (1990) and 

Abdel-Wahab et al. (1994b) reported significantly raised AFP 

in HCC cases. 

In high-HCC-incidence regions of the world, a single 

elevated AFP level less than 500ng/ml is not as predictive for 

HCC as are persistently elevated levels or progressively rising 

levels. In general, serum AFP levels at the time of HCC 

diagnosis have some prognostic value; patients with lower 

serum levels live longer. As noted, this is a general and not 

specific observation because AFP levels in untreated and treated 

patients can fluctuate significantly (Abeloff et al., 2000). 

Iso-electric focusing (IEF) has been used to identify 

isoforms of AFP directly (Burditt et al., 1994 and Johnson et 

al., 1997). Of the three main bands observed, the AFPII band 

and AFPIII band seem relatively specific for HCC and 

nonseminomatous germ cell tumors (NSGCT), respectively. A 

further band (I) is found in the AFP that arises in patients with 

chronic liver disease without any evidence of malignancy. A 

preliminary study that followed a large cohort of patients with 

-60-


chronic liver disease for the development of FICC showed that 

the band II hepatoma-specific AFP could often be detected 

several months' before ultrasound scanning could find the tumor 

(Johnson et al., 1997). 

A simple qualitative assessment of the tumor-specific band 

led to an increase in positive predictive value from 41.5% with 

the conventional assay for total AFP to 73.1% with the specific 

isoform. The sensitivity and specificity were 86% and 77%, 

respectively (Johnson et al., 1997). 

Given the limitations of the AFP test, the search for more 

sensitive serological markers for HCC has continued. Other 

molecules have been investigated as potential markers, 

including des-gamma carboxy-prothrombin (DGCP, also called 

protein induced by vitamin K absence or antagonist-U [PIVKA- 

II] and the AFP variant AFP-L3 (Nomura et al., 1999, Ishii et 

al., 2000 and Li et al., 2001). None of these markers have been 

conclusively shown to be more sensitive than AFR. DGCP is 

currently being used in Japan, but has not been recommended by 

the European Association for Study of the Liver (EASL) (Bruix 


DCP is induced by the absence of vitamin K and cannot 

interact with other coagulation factors (Weitz and Liebman, 

1993). The protein is increased in as many as 91% of patients 

with HCC but may be elevated in patients with vitamin K 

deficiency, cirrhosis, obstructive jaundice, intrahepatic 

cholestasis, chronic active hepatitis of metastatic carcinoma. Its 

sensitivity in detecting lesions smaller than 3cm in diameter 

ranges from 19% to 48% (Tanabe et al., 1988). Although the 

-61-


specificity of DCP for HCC is similar or higher than that of 

AFP, it is not as sensitive as AM DCP disappears from the 

plasma if the patient is given vitamin K. DCP alone is not 

sensitive enough to detect early small liver cancers, the use of 

both DCP and alpha fetoprotein in addition to imaging in the 

follow-up of patient with liver cirrhosis might be beneficial 

(Izuno et al., 1995). 

Tang et al. (2005) found that DCP expression, even if it 

was observed only in non-cancer tissues, was related to poorer 

prognosis. Univariate and multivariate analyses showed that 

DCP expression in cancer and/or non-cancer tissues was a 

significant prognostic factor. Furthermore, the combined 

evaluation of tissue DCP expression and serum DCP levels 

showed that prognosis was poorest for patients showing positive 

tissue DCP expression and high levels of serum DCP. 

HCCs are very heterogeneous tumors, therefore the 

difficulties in finding good tumor markers are not surprising 

(Thorgeirsson and Grisham, 2002). In fact, as the evidence for 

HCC heterogeneity accumulates, it is increasingly evident that it 

is unlikely that a single marker will be found to display both 

very high sensitivity and specificity. Thus, it is reasonable to 

propose that an optimal serological test for HCC will be based 

on the simultaneous measurement of two or three highly specific 

serological markers (Jorge and Mariana, 2004). 

In 1997 Hsu et al. reported the identification of a 

transcript that was up-regulated in HCC. This transcript, which 

had been previously named MXR7, was later called glypican-3 

(GPC3) (Lage & Dletel, 1997). These investigators found that 

-62-


serum GPC3 messenger RNA (mRNA) was expressed in 143 of 

191 (75%) primary and recurrent HM, but in only 5 of 154 (3%) 

normal livers. In addition, no GPC3 expression was detected in 

three hepatocellular adenomas or in six cholangiosarcomas (Hsu 


Three others reports confirming the over-expression of 

GPC3 mRNA in HCC nave been published more recently (Zhu 

et al., 2001 and Huang et al., 2004). In one of these studies the 

authors compared the levels of GPC3 mRNA in HCC versus 

normal liver, focal nodular hyperplasia (a benign lesion), and 

liver cirrhosis. They found that GPC3 mRNA values in focal 

nodular hyperplasia and liver cirrhosis were similar to those of 

normal liver, and that levels of GPC3 in HCCs were above the 

mean value of the nonmalignant groups in 25 of 30 (83%) 

patients. Based on these results the investigators proposed that 

GPC3 could be a useful marker to differentiate between benign 

and malignant liver tissue (Zhu et al., 2001). 

Data reported by several laboratories indicate that GPC3 is 

specifically over expressed in a majority of patients with HCCs, 

and that GPC3 could be used as a histological and serological 

marker for HCC. Furthermore, results published to date suggest 

that, although the sensitivity of the serological GPC3 test is 

limited, the combined used of AFP and GPC3 could provide a 

highly specific and sensitive diagnostic test for HCC. It is also 

possible that the combined use of GPC3 and AFP would provide 

an improved test to screen the large number of cirrhotic patients 

that are at risk of developing HCC. Certainly, further studies are 

required to test this hypothesis (Jorge and Mariana, 2004). 

-63-


Other assays such as fucosylated AFP and serum alpha L- 

Fucosidase (AFU) have been developed (Taketa, 1990). The 

serum fundamental frequency signal. Thus. THI has several 

advantages, such as increase of resolution and contrast 

resolution capability. THI is more useful in the detection of liver 

tumors (Kudo, 1999). 

Coded phase inversion harmonic imaging is a novel grey 

scale imaging type of contrast ultrasound. This procedure is 

based on a combination of phase-inversion harmonic imaging 

and coded technology, which increases both tissue and contrast 

harmonic signals. Detailed vascularization can be imaged in 

various hepatic tumors by contrast-enhanced ultrasound using 

harmonic based techniques. Coded phase inversion harmonic 

imaging can depict fine vascular images in hepatic tumors in the 

early phase of contrast enhanced ultrasound (Furuse et al., 

2003). 

Three Dimensional Ultrasound Technology and Doppler: 

The use of transparent rotating scans, comparable to a 

block of glass, generates a 3D effect (Zoller et al., 1993). The 

major advantage of 3D ultrasonography is the ability to obtain 

ultrasound sections which are impossible to see on a routine 

scan and the ability to perform accurate volume measurements. 

In addition, it allows interactive manipulation of volume data 

using rendering, rotation and zooming on localized features, 

displaying images of anatomy and organs in a straightforward, 

manner (Thomas & Dolores, 1997). 

Three dimensional US appeared to be very important in 

volume calculation and in shape tomography visualization of the 

-64-


liver. It gives the opportunity to the spatial definition of the 

lesions and contiguous structures e.g., between liver lesions and 

vessels. It also permits the correct evaluation of surgical 

intervention; as well as more accurate ultrasound guided 

biopsies (Candiai et al., 2000 and Esmat, 2001). 

Liess and Colleagues in (1994) showed that 3D 

ultrasound provided more accurate and repeatable measurements 

of focal liver lesions than either 2D ultrasound or CT in 

sequential studies. 

This is an extremely important finding, as it is crucial to 

have an accurate measurement of the volume of the liver lesions 

that are to be treated with minimally invasive therapies, and the 

amount of therapy given to the patient during the procedures For 

example, with alcohol ablation of HCC in cirrhotic patients, the 

dose of alcohol injected into the lesion is directly proportional to 

the volume of the tumor (Alexander et al., 1996). 

Zakaria in (2003) studied the value of 3D ultrasound on 

the different hepatic focal lesions in 24 patients and he 

concluded that, 3D is a non-invasive diagnostic technique that 

has the ability to obtain US sections which are impossible to see 

on routine scan and it can also give accurate volume and 

vascular study. 

Long and Colleagues in (1999), showed that volume 

measurement using 3D ultrasound provided comparable results 

to those of CT. Clinically, 3D ultrasound could be helpful in the 

follow up of patients of non resectable tumors or in planning for 

liver resection, by assessing the volume of the liver tissue 

-65-


remaining after resection or by better visualization of the 

topography of the liver tumor or the major hepatic structures. 

Three dimensional power Doppler has been developed to 

visualize the intra-tumoral structures by processing of the power 

Doppler images, it is useful in the differential diagnosis of 

hepatic tumors, especially HCC and FNH (Hirai et al., 1998). 

In an Egyptian study done by Abdel Hameed, (2005), 

they found that 3DUS was very valuable in estimation of the 

lesion volume before and after local ablation techniques and in 

proper positioning of the needle inside the HCC lesion. 

Four Dimensional US: 

Esmat, (2000) reported that four dimensional US 

(upgraded 3D) is useful in providing guidance for interventional 

procedures in the liver, including taking biopsies, aspiration or 

injection of therapeutic materials. 

Four dimensional ultrasonography marks a new dimension 

in ultrasound imaging. It features advanced signal processing, 

which produces higher quality image. 4D US takes threedimensional 

US images and adds the element of time to the 

process. This results in live action images of any internal 

anatomy, thus, increasing the accuracy in US guided biopsies as 

the needle can be visualized moving in real time in all three 

planes. So physicians can detect or rule out vascular anomalies 

and genetic syndromes. In addition displaying the entire volume 

of an object that is being examined makes it possible to analyze 

the tissue concerned (Philip et al., 2001). 

-66-


Ultrasound Guided Fine Needle biopsy and Fine Needle 

Aspiration of Hepatic Focal Lesions: 

Fine Needle Biopsy: 

The biopsy should be done under imaging control US or 

CT (Di Bisceglie, 1998). The accuracy of US guided biopsy is 

about 95% (Benvengsew et al., 1992 and Bolondi et al., 2001). 

Ultrasound-guided FNC is accurate in the diagnosis of 

HCC in 90% of patients with small nodules, where more than 

60% turn out to be malignant. This is more accurate than other 

approaches, for which rates of 50-80%, depending on the degree 

of differentiation and the size of the tumor, hgve been reported 

(Scholmerich, 2004). In addition, biopsy is not needed in all 

patients because AFP levels >400ng/ml and typical features in 

larger nodules have a high predictive value for the presence of 

HCC (Scholmerich, 2005). 

Although mortality as a result of FNB is low. bleeding 

occurs in 0.5-2.5% of patients and sometimes surgical treatment 

is needed. Needle tract seeding of malignant cells has been 

suggested as an important risk of FNB for HCC. This risk has, 

however, to be weighed against a 2.5% rate of unnecessary 

surgery when biopsy is not done (Torzilli, 1999). 

Needle-tract seeding is very rare and the risk does not 

outweigh the chances of a delayed diagnosis tendering curative 

treatment approaches much less possible. So, if the result of 

FNB will influence treatment choices the risks should not 

preclude biopsy (Scholmerich, 2005). 

-67-


There are only few contraindications for performing liver 

biopsy, and most of them are only relative contraindications. 

The presence of a major or uncontrolled bleeding diathesis 

and this is considered the main contraindication for this 

procedure, as most of HCCs are hyper-vascular and patents may 

have some degree of coagulopathy (Spitz et al., 1999). 

Correction by administration of the appropriate clotting 

elements (vitamin K, platelets, and/or fresh frozen plasma 

depending on the type of coagulopathy) is necessary prior to the 

procedure (McGahan and Goldberg, 1997). 

EL-Dorry in (2001) considered, a focal hepatic lesion in a 

cirrhotic liver with elevated alpha-fetoprotein levels >200ng/dl; 

HCC without performing biopsy. Spiral CT examination was 

performed for patients having alpha-fetoprotein levels 


A sensitivity and specificity >95% had been reported. 

Haemangiomas, FNH and HCC appear to be more difficult to 

diagnose, accurately by FNN, sensitivity ranges between 60% 

and 70% in many series (Ros and Davis, 1998). 

Another controversy about the use of FNA in HCC is the 

risk of needle tract seeding and tumor spread into the 

circulation, a risk that may be as high as 5% (Takamori et al., 

2000). 

Computed tomography (CT): 

Although ultrasound has been widely used for the 

detection of HCC, US examination of an entire liver is 

occasionally difficult because of intervening bones, air in the 

intestine or lung and the presence of fatty tissue, this does not 

affect the liver in CT (Okazaki et al., 1990). 

Evaluation of the liver is one of the most common 

indications for abdominal computed tomography examinations. 

Within the past 10 years there has been tremendous 

improvement in the technical performance of the scanners 

themselves, allowing very rapid high-resolution scans of even 

the most challenging patients. The rapid scan times coupled with 

mechanical injectors for rapid administration of IV contrast 

media have led to development of specific CT protocols that 

optimize the use and timing of the vascular contrast agents to 

diagnose and characterize various hepatic lesions (Federle, 

1998). 

-69-

Applications for CT: 

1. Non-contrast enhanced CT 

2. Contrast enhanced CT (CECT) 

Single- phase CECT 

Dual phase (Biphasic) CECT (spiral CT) 

3. Three-dimensional CT 

4. Angiography assisted CT 

CT hepatic antgiography (CTHA) 

CT angioportography (CTAP) 

Iodized oil CT scan. 

1- Non-contrast enhanced CT scan: 


CT demonstrates focal hepatic lesions and some diffuse 

hepatic conditions. On un-enhanced CT scans the solitary or 

multi-nodular form of HCC appears as a solitary mass or 

multiple masses that are hypo-dense relative to the normal liver, 

while in fatty liver, focal lesions appear denser (Ferris et al., 

1996 and Palbo & Ros, 1998). Fibro lamellar carcinoma in CT 

appears, as a well demarcated, iobulated, hypo-dense lesion with 

stellate areas of increased hypo-density centrally that represent 

the fibrous scar. Calcification also may be detected, while 

cholangiocarcinoma appears as rounded or oval mass of low 

attenuation value with irregular margins (Baron et al., 1996). 

Because of low inherent difference between the 

attenuation of normal liver parenchyma and tumors, the use of 

intravenous contrast is usually desired. Indications for noncontrast 

enhanced CT scan are diffuse liver diseases, such as 

hemochromatosis and cirrhosis (Palbo and Ros, 1998). Certain 

tumors are characterized by focal hemorrhage, fat or 

-70-


calcification, all of which are more easily recognized before 

contrast enhancement of the liver. NCECT scans are always 

obtained in CT evaluation of the cirrhotic liver because 

regeneration nodules are easier to recognize and to distinguish 

from other focal hepatic masses with the added information 

provided by non-contrast images (Palbo and Ros, 1998). 

The evaluation of hypervascular liver tumors is no longer 

considered an indication of NCECT (Patten et al., 1993). 

2- Contrast enhanced CT: 

a) Single-phase CECT: 

Because about 75% to 80% of hepatic parenchymal blood 

flow is supplied by the portal venous system, while hepatic 

neoplasms receive all of their blood supply from the hepatic 

artery, following intravenous contrast and scanning during 

portal venous phase. (60 sec after the start of bolus injection), 

HCC is usually seen as a hypodense lesion relative to the normal 

enhanced liver parenchyma (Palbo and Ros, 1998). 

Due to their hypervascularity, some HCCs become 

isodense to normal liver during the portal venous phase. 

Because of this, it is not surprising that dual-phase CT scan 

obtained during both the arterial phase and portal venous phase, 

has shown to detect a greater number of HCCs than portal 

venous phase imaging alone (Palbo and Ros, 1998). 

b) Dual-phase CECT (Spiral CT): 

Helical (or spinal) CT scanners were introduced in 1991 

and represent a fundamental improvement over earlier 

conventional axis CT scanners. Helical CT scanners combine a 

-71-


continuous pattent-table motion with continuous rotation of the 

CT gantry containing the X-ray tube and detectors. Prior to this 

innovation, a delay of 7 to 20 sec was required between each CT 

slice to allow for cooling of the X-ray tube and repositioning of 

electrical cables. The absence of this interscan delay in helical 

CT allows for a rapid acquisition of a volume data (e.g., the 

entire liver) within a single breath hola, eliminating 

misregistration artifacts due to variation in the depth of 

inspiration. Equady importantar are decreased scan speed allows 

the eadiologist a greater flexibility in the administration of IV 

contrast material (Michael et al., 2001). 

Spiral imaging has dramatically increased the diagnostic 

capabilities of CT in the evaluation of small HM (

- Hepatic arterial phase: 


During the first 20 to 30 sec of injection, during the 

arterial phase, tumors appear enhanced against the relatively 

unenhanced liver parenchyma (Palbo and Ros, 1998). 

Although sensitive, arterial phase images can be falsely 

positive and detect benign lesions such as focal nodular 

hyperplasia (Jang et al., 2000). Further, dysplastic nodules may 

be difficult to detect on CT with arterial portography or hepatic 

arteriography because many of these lesions are iso-attenuating 

due to the fact that their blood supply is equivalent to that of the 

surrounding liver parenchyma (Lim et al., 2000). 

- Portal venous phase: 

Between 30 and 50 sec, the large load of contrast via the 

portal circulation causes the lesions to appear hypodense relative 

to liver parenchyma (Palbo and Ros, 1998). 

- Delayed (equilibrium) phase: 

Delayed CT images of the liver may be obtained 10 to 15 

min after the initiation of contrast injection and are useful for 

specific indications. Tumors with a large component of fibrosis 

demonstrate prolonged hyperdense enhancement of stroma. This 

feature has proved to be particularly characteristic of chotangio 

carcinoma (Lacomis et al., 1997). 

Delayed images are very helpful in hepatic masses felt to 

possibly represent cavernous hemangioma, where progressive 

centripetal ennancement of the hemangioma is one of its 

characteristic features (Lacomis et al., 1997). 

-73-


This physiology is particularly important in imaging of 

hypervascular liver tumors. These tumors have an unusually rich 

arterial blood supply. They are often not seen on portal venousphase 

imaging because they enhance to a similar degree as the 

surrounding liver parenchyma, rather appearing relatively 

hypodense (Palbo and Ros, 1998). 

3-Angiography assisted CT: 

Curative partial liver' resection in patients with metastases 

and occasionally primary malignant tumors requires an accurate 

preoperative imaging technique in order to decrease the false 

positive rate of resectability (Bluemke et al., 1995a,b). 

Angiography assisted CT is very helpful in determination 

of the exact number, extent, relation to vascular structures and 

estimation of the tumor-free margin in the pre-surgical settings 

in order to avoid inadequate and unnecessary surgical 

procedures (Bluemke et al., 1995a,b). 

In CT angiography (or CT arteriography), a contrast agent 

is selectively injected into the hepatic artery during the study 

(Spitz et al., 1999). Selective intra-arterial digital subtraction 

angiography (DSA) in which the contrast is given by selective 

arterial injection with immediate subtraction of images can 

detect tumors of 2cm or less which change from iso-vascular to 

hyper-vascular with time (Ikeda et al., 1993). 

CT with arterial portography (CT arterioportography, 

CTAP) has proved to be the best method to study mass lesions 

in the liver. Because it is invasive, it is generally reserved for 

operable cases (Spitz et al., 1999). 

-74-


The contrast agent is injected in superior mesenteric artery 

and the splenic artery via the femoral artery. Lesions smaller 

than 2cms in diameter are easily detected, and the sensitivity of 

CTAP in identifying liver mass lesions is reported to be as high 

as 97% (Spitz et al., 1999). 

The modality of iodized oil CT scan appears to be the most 

sensitive technique for detection of small HCCs. The ethiodized 

oil emulsion (LipiodoV) is injected into the hepatic artery and a 

CT is performed 7 to 14 days later (Lencioni et al., 1994). 

The nonmalignant liver parenchyma clears the ethiodized 

oil emulsion, but the HCC cells are unable to clear this 

compound. Thus, deposits of HCC are recognized clearly as 

dense lesions. Iodized oil CT scan has a detection sensitivity of 

greater than 90%, which includes HCCs less than 1cm in 

diameter. Although the HCC detection sensitivities for the three 

arterial enhanced CT techniques are improved compared to 

standard CT, all are associated with the increased risks 

associated with placement of an arterial catheter. The time and 

cost to perform the procedures also is markedly increased 

(Merine et al., 1990). 

-75-

PATHOLOGICAL DIAGNOSIS 

Pathology of Hepatocellular carcinoma: 

Gross pathology: 


Grossly, the cut surface of an HCC may be tan to yellow in 

color frontfatty infiltration. Welldifferentiated HCC that 

produces bile may, have a yellowy or green color, while areas of 

hemorrhage or necrosis may cause foci of red, purple, brown, or 

black coloration. Tumor thrombi in intrahepatic branches of the 

portal vein or hepatic vein radicles may be visible on cut 

sections through the liver and tumor. The tumor tissue tends to 

be soft and friable. However, some tumors can be densely 

sclerotic with an appearance and consistency that is difficult to 

distinguish from metastatic tumor (Abeloff et al., 2000). 

A classification system with five types of tumor has been 

suggested and may correlate with clinical, histologic, and 

prognostic patterns. 

Table (2): A Classification system of HCC: 

Farley type HCC Type I Type II Type III Type IV 

- Small tumors 


In general, early HCC and types I and II are small, 

histologically better less frequently HBsAg-positive, produce 

lower levels of differentiated, serum AFP, show fewer portal 

venous tumor thrombi, have fewer intrahepatic metastases, 

occur in non-cirrhotic or minimally cirrhotic livers, and have a 

better prognosis. Types III and IV usually are larger and less 

well differentiated tumors tend to be HBsAg-positive, have 

higher AFP levels, have frequent hepatic vascular tumor 

thrombi and intrahepatic metastases, and have a worse 

prognosis. (Abeloff et al., 2000). 

Microscopic Pathology: 

The malignant hepatocytes that comprise HCC most 

commonly have a plate like or trabecular growth pattern, other 

histologic patterns (pseudoglandular, compact or Schirrhous) 

may be present. HCC has a tendency to invade and grow along 

blood vessels and bile ducts (Ishak et al.,1994). 

Microscopically, polyhedral shaped neoplastic cells that 

resemble hepatocytes are commonly identified. The presence of 

bile in neoplastic cells obtained on FNA is pathognomonic of 

HCC, but only occurs in one third of aspirates. An analysis that 

compared the cytologic characteristics of FNA specimens from 

35 patients with HCC and 75 patients with metastatic liver 

tumors indicated that a finding of polygonal cells with centrally 

located nuclei was the criterion most suggestive of HCC. These 

characteristics were observed in 94 % of the HCCs, but in only 

15% of metastatic liver tumors The two other cytologic features 

important in diagnosing HCC were clusters of malignant cells 

separated by capillary vessels and the presence of bile pigment 

-77-


in the tumor cells. More than 95% of the HCCs exhibited at 

least two of the three criteria noted above, while none of the 

metastatic tumors had more than one of these criteria (Okuda, 

1990). 

Histologic Pattern of HCC: 

Based on the structural organization of tumor cells, the 

World Health Organization (WHO) proposed the following 

histologic classification of HCC (Gibson, 1978). 

Trabecular type (Sinusoidal): The tumor cells are 

arranged in cords of variable cell thickness separated by 

sinusoids lined by flat endothelial cells. 

Fibrous connective tissue is absent between the tumor 

cords and cells, but few collagen fibers may sometimes be 

detected in the sinusoidal walls. 

Pseudoglandular type (Acinar): Tumor cells form glandlike 

structures. Canaliculi with or without bile are common. 

Gland-like spaces may derive from central degeneration and are 

filled with cellular debris, exudates and macrophages. The 

contents may be Periodic Acid Schiff (PAS) positive remains 

detectable. 

Compact type: The tumor cells grow in solid masses of 

cells, sinusoids are inconspicuous by compression. 

Scirrhous type: There is significant fibrous stroma 

separating cords of tumor cells. This appearance should be 

distinguished from those of cholangiocarcinoma and metastatic 

tumors. 

-78-

Cytological Variations: 


Clear cell type: Clear cell HCC is a pathologic variant 

comprising less than 10 percent of HCCs. Thirty to 50 percent 

of the cells are water-clear because of large amounts of 

glycogen as shown by periodic acid-Schiff (PAS) staining. 

Biopsy of clear cell HCC may be misinterpreted as metastatic 

adrenal carcinoma or clear cell carcinoma of the kidney or clear 

cell adenoma of the ovaries. The presence of bile droplets or a 

trabecular pattern of the neoplastic cells indicates the hepatic 

origin of the tumor in these cases. HCC of the clear cell variant 

was thought to have a favorable prognosis compared with that of 

other variants but this has not been proven (Abeloff et al., 

2000). 

Pleomorphic cell type: bizarre pleomorphic cells 

characterize it. It is common in poorly differentiated HCC 

(Nakashima et al., 1987). 

Sarcomatoid (spindle cell type): Occasionally, 

sarcomatoid I-ICC; consisting of spindle shaped or pleomorphic 

anaplastic, tumor cells, are found in part or most of the tumor 

with or without a transitional feature between trabecular HCC 

and the sarcomatoid area. This may be a sarcomatoid variant 

rather than the combination of true sarcoma and HCC. Among 

more than 62 surgically resected HCCs, less than 2cm in 

diameter none had a sarcomatoid appearance, whereas about 4% 

of advanced HCCs had a sarcomatoid appearance. Thus, the 

sardomatoid cytologic variant of HCC may be caused by 

phenotypic changes of cancer cells that occur during the course 

of the disease (Maeda et al., 1995). 

-79-


Also immunohistochemically, the sarcomatous tumor cells 

were frequently positive for keratin, albumin, alpha-feto protein 

and/or fibrinogen. These results are strongly suggesting that the 

sarcomatous appearance seen in HCC is due to morphological 

changes in the tumor cells (Nagamine et al., 1978). 

Degree of Differentiation and Grading of HCC: 

(A) Edmondson and Steiner's classification of HCC (1954): 

Grade I: This type is the most differentiated and consists of 

tumor cells with a thin trabecular pattern. 

Grade II: Although the tumor cells show some resemblance to 

normal liver cells, their nuclei are large and more 

hyperchromatic and their cytoplasm is abundant and 

acidophilic. Mitoses are present although scanty. Acinar 

and glandular structures are frequently associated with the 

trabecular pattern which is a basic structure. 

Grade III: In this type the nuclei are usually larger and more 

hyper chromatic than those of grade II. Giant tumor cells 

are very numerous in this type. Mitosis is frequent. 

Grade IV: Here the cancer cells are at least differentiated. The 

nuclei are intensely hyperchromatic and occupy a greater 

part of the cell, Mitosis is frequent and often irregular. The 

cytoplasm is often scanty. The growth in the liver is more 

medullary. The trabecular pattern is uncommon. and tumor 

cells often lack cohesiveness. 

(B) Suqihare et al., (1992) classification: 

Well-differentiated HCC: This carcinoma is characterized 

by the increased cell density with an irregular their, trebzcular 

-80-


pattern with frequent areas of pseudo glandular patterns and 

fatty change. The HCC cells lack distinct cellular and nuclear 

atypia. It is common among HCCs


The nucleus/cytoplasm ratio is almost equal to that of the nontumors 

hepatocyte. This carcinoma corresponds to grade II to III 

carcinoma of the Edmondson-Steiner classification and is most 

common among advanced HCCs. 

Poorly differentiated HCC: Cancer cells in poorly 

differentiated HCCs show a compact (solid) growth pattern 

without showing a trabecular pattern. A slit-like blood vessel is 

sporadically observed in the tumor. Cancer cells show an 

increased nucleus/cytoplasm ratio and frequently show 

pleomorphism, including mononucleated and/or multinucleated 

giant cells. These large, pleomorphic multinucleated cells may 

dominate certain areas of the tumor. This carcinoma 

corresponds to grade III to IV carcinoma of the Edmondson- 

Steiner classification. 

Undifferentiated carcinoma: Cancer cells in undifferentiated 

HCC have scanty cytoplasm with short spindle shaped and/or 

round nuclei. They proliferate in a solid or modularly pattern. It 

is often difficult to diagnose this carcinoma only by histological 

findings. This carcinoma corresponds to grade IV carcinoma of 

the Edmondson-Steiner classification. 

A variant of HCC is fibrolamellar HCC, which is known 

also as eosinophilic HCC with lamellar fibrosis. Fibrolamellar 

HCC comprises less than 10 percent of all cases of HCC. When 

compared to more common forms of HCC, fibrolamellar HCC 

tends to occur in younger patients (mean age of onset


infection is much less common in fibrolamellar HCC than in 

other HCCs. However, HBV DNA insertion into host genomic 

DNA has been described in fibrolamellar HCC, and the 

chromosomal insertion sites were unique when compared to 

other HBV related HCCs (Davison et al., 1990). 

Serum AFP levels usually are elevated in fibro lamellar 

HCC but rarely exceed 250ng/ml. Patients with fibro lamellar 

HCC more frequently have resectable lesions than other patients 

with HCC and seem to have a higher cure rate after resection. 

However, it is not clear that prognosis after resectiction of a 

fibro lamellar HCC is better than non-fibro lamellar HCC, 

because it has been pointed out that the survival rates for 

resected HCC of any histoldgic type may be similar. The higher 

resectability rate of the slow-growing fibro lamellar HCCs may 

skew the data to suggest an improved survival (Abeloff et al., 

2000). 

Grossly, fibro lamellar HCC usually presents as a large, 

solitary tumor arising in a non-cirrhotic liver. The cut edge of 

the tumor is white to and extremely firm. Areas of the tumor 

may be hard, which correlates with the calcium deposition 

within the tumor noted in radiographs. Rarely multiple satellite 

nodules may be present (Abeloff et al., 2000). 

Microscopically, there are three characteristic features in 

fibro lamellar HCC. First, the neoplastic cells have deeply 

eosinophilic cytoplasm due to the abundance of mitochondria 

and perioxisomes. As in the more common types of HCC, 

histologic heterogeneity frequently is present with areas that are 

less intensely eosinophilic. Second, mitoses and multinucleated 

-83-


giant cells are uncommon. Third, giving the tumor its name, 

abundant fibrous stroma composed of parallel bundles of 

collagen fibers produces a laminated composition. The fibrous 

bands divide the tumor into thin columns of hepatocytes or into 

nodules. Rarely, the fibrous bands in fibro lamellar HCC form 

thick regions that grossly resemble the central scars of focal 

nodular hyperplasia (Wood et al, 1988). 

Staging and scoring of HCC: 

Staging of HCC is an important step because the different 

treatment modalities are dependent on staging (Kane & 

Ganger, 1997). A prerequisite to treatment is thorough 

radiological assessment using the variety of radiologic 

techniques available (Shima and Ba-Salmach, 1999). 

The current American Joint Committee on Cancer 

(MJCC), TNM (Tumor, nodes, metastases) staging system for 

HCC has been challenged by a new T staging system which was 

proposed to correlate the staging group with patient outcome 

after curative liver resection. The new T staging system 

proposed T1 as no vascular invasion, tumor size 5cms, vascular invasion or multiple 

tumors; T3 as the presence of two of the above' three factors; 

and T4 as the presence of all three (Lui et al., 1999). 

Another staging system based on prognostic indices, was 

also proposed, the Barcelona Clinic Liver Cancer (BCLC) 

staging classification. This staging system comprises four stages 

that select the best candidates for the best therapies currently 

available. 

-84-


Early stage (A): includes patients with asymptomatic early 

single tumor masses suitable for radical therapies resection, 

transplantation or percutaneous treatment. 

Intermediate stage (B): comprises patients with 

asymptomatic multinodular HCC. 

Advanced stage (C): includes patients with symptomatic 

tumors and/or an invasive tumor pattern (vascular invasion / 

extra hepatic spread). Stage (B) and (C) patients may receive 

palliative treatments. 

End stage disease (D): contains patients with extremely 

grim prognosis that should merely receive symptomatic 

treatment (Liovet et al., 1999). 

AJCC Staging System for HCC: 

Primary tumor (T): 

Tx: primary tumor can not be assessed. 

T0: no evidence of tumor. 

T1: solitary turnor


Regional lymph nodes (N): 

Nx: regional lymph nodes can not be assessed. 

N0: no regional lymph node metastasis. 

N1: regional lymph node metastasis. 

Distant metastasis (M): 

Mx: presence of distant metastasis can not be assessed. 

M0: no distant metastasis. 

M1: distant Metastasis. 

Stage grouping: 

Stage I -> T1 N0 

Stage II -> T2 N0 

Stage III -> T3 N0 

T1-3 N1 

Stage IVa -> T4 Any N 

Stage IVb -> Any T Any N 

(Beahrs, 1997) 

The Okuda staging system: 

* Tumor size >50% (+)------ 3mg/dl(+) -------


Treatment of Hepatocellular Carcinoma 

Among various solid malignant tumors, HCC is the most 

difficult to treat for various reasons. It is deeply seated and the 

background liver is usually cirrhotic. A liver with advanced 

cirrhosis cannot tolerate major surgery. Cirrhosis itself is a 

precancerous condition and even when the primary lesion is 

removed successfully, some of the nodules may soon turn 

malignant. Hepatocytes are radioresistant and an ailing cirrhotic 

liver cannot tolerate high dose of chemotherapy. 

Absolute cure can be achieved only by replacing a cirrhotic liver 

with a new healthy one before extrahepatic spread occurs. 

However, donors are far outnumbered countries where HCC is 

endemic (Okuda, 1998). 

I- Surgical Therapy: 

Surgery, resection or transplantation remains the definitive 

treatment for HCC. Other modalities may have a role when 

surgery is not feasible (Spitz et al., 1999). 

For decision of adequate surgical therapy and comparison 

of results, differentiation of HCC in cirrhotic and non-cirrhotic 

fivers is important. Liver resection is the treatment of choice for 

HCC in non-cirrhotic liver. While liver transplantation is the 

treatment of choice in small (


Principles of Surgical Resection and Transplantation: 

Although hepatic resection for tumors arising within the 

liver has been performed since 1886, it has only been in the last 

30 years with improvement in understanding of hepatic anatomy 

and physiology as well as advances in surgical technique, 

anesthesia, and blood replacement that safe hepatic resection has 

been frequently performed. As much as 80% to 90% of the liver 

can be removed during surgical resection either with a formal 

lobectomy or alternatively with segmentectomies or wedge 

resection of lesions. The underlying function of the remaining 

liver and in particular the presence of cirrhosis dictates the 

ability of such lesions to be surgically excised (Tamori, 1993). 

Preoperative work-up is designed to assess the local extent 

of the disease and to demonstrate any evidence of intrahepatic or 

extrahepatic metastatic disease. An arteriogram is obtained by 

many, surgeons demonstrate the highly variable hepatic 

arterialaratomy although operative dissection is often sufficient 

for this purpose (Saiton et al., 1994). 

1- Hepatic Resection: 

A normal liver can tolerate removal of up to 75% of the 

parenchyma and will return to normal size within several 

months (Okuda, 1998). 

2- Hepatic Transplantation: 

Liver transplantation became popular throughout the world 

after the 1983 NIH consensus Development Conference on 

Liver Transplantation, and increasing numbers of orthotropic 

-88-


liver transplantation (OLTs) have since been earned out for 

HCC and other malignant liver tumors (Okuda, 1998). 

Better outcomes of the patients receiving liver 

transplantation for viral hepatitis and HCC are achieved by 

improved patient selection and preoperative treatment with 

antiviral agents including lamivudine, ribavirin and interferon. 

Patient selection is accomplished by high-quality imaging as 

well as exclusion of patients with large tumors, obvious 

extrahepatic disease or macroscopic vascular invasion. Using 

such criteria, a 5-year survival of 92% has been reached in the 

Queensland Liver Transplant Service on a small number of 

highly selected patients with HCC (Matsunami et al., 2002). 

II- Invasive Techniques: 

1- Intra Lesional Injection Techniques: 

A. Percutaneous Ethanol Injection (PEI): 

PEI is a common procedure for the treatment of malignant 

liver neoplasms (Zuo et al., 2004). PEI was first described by 

Suguria and colleagues in 1983 for treatment of HCC (Suguria 

et al., 1983). Since that time, PEI has been used extensively for 

treatment of unresectable HCC (Livraghi el al., 1995). 

The only absolute contraindications to therapy are 

uncontrollable coagulapathy uncontrollable ascites, extrahepatic 

metastases and portal vein thrombosis (Lee et at., 1995). 

Absence of ascites most be confirmed by sonography and the 

prothrombin time and platelet count must be checked before 

therapy. The procedure is performed only in patients whose 

-89-


prothrombin concentration time is more than 35% and platelet 

count is more than 40000/mm 3 (Shiina et al., 1990). 

B. Percutaneous Acetic Acid Injection (PAI): 

PAI is a potential alternative to percutaneous alcohol 

injection for therapy of small (less them or equal to 3cm) HCC. 

It causes necrosis by dehydration and protein denaturation (Lin 

and Lin, 2003). The most common adverse effects are pain 

locally during injection and transient fever to as 38C for up to 3 

days, mild elevations of serum transaminase levels, bilirubin, or 

creatinine could be observed (Ohnishi et al., 1994). PAI has the 

advantage of fewer treatment sessions in each treatment course 

(Huo et al., 2003). 

C. Percutaneous Hot Saline Injections (PSI): 

PSI therapy, like PAI injection has been proposed as an 

alternative to PE1 for percutaneous HCC ablation by lesional 

injection, PS1 causes target destruction via heat induced 

coagulation necrosis rather than protein denaturation (Honda et 

al., 1994). In a study of 20 patients with 23 HCCs 

less than 3 em in diameter and a total of 59 treatment 

sessions, there were no major complications requiring-specifictherapy, 

burning pain of moderate severity was reported 

in the majority, transient fever in 20 % of sessions, and small 

right pleural effusions in 5% of sessions (Honda et al., 1994)~ 

2- Lesional Heating Techniques: 

Tumor local hyperthermia has been shown to cause almost 

immediate coagulation necrosis at temperatures of 60C or 

greater, and to have a preferential cytotoxic effect on tumor cells 

-90-


at temperatures between 41C and 45C, the time required to 

achieve a cytotoxic effect ranges from 15 min at 45C to 24 min 

at 41C (Waldow et al., 1988). During the last 10 years, 

considerable interest has developed in the thermal ablation 

techniques that produce heat. Methods that are being 

investigated include microwave, laser, high intensity focused 

ultrasound and radiofrequency ablation. 

A. Interstitial Laser Photocoagulation (ILP): 

Steger et al. (1989) first described this technique for the 

treatment of unresectable liver metastasis such as CRC and 

endocrine neoplasm. ILP is also useful in treatment of 

hepatomas; however, PE1 is technically easier, more available, 

less expensive and more effective in treatment of HCC (Vogle 


B. Percutaneous Microwave Coagulation (PMC): 

PMC has been applied to achieve hernostasis along 

incision plane to reduce blood loss during hepatic resection. 

Particularly for high-risk patients, with HCC and cirrhosis but 

also fir benign lesions (Lau et al., 1992). This technique has 

been performed intraoperatively and during laparoscopy as an 

alternative to hepatectomy in patients with unresectable HCC 

(Sato et al., 1996). 

C. High intensity focused ultrasound (HIFU): 

HIFU is a unique method among percutaneous techniques 

of hepatic tumor ablation in being an extracorporeal method, 

offering the potential for tumor destruction without intervening 

tissues (Yang et al., 1992). 

-91-


This method uses sharply focused high energy US 

transducers of different focal lengths to induce local temperature 

elevation during a short exposure time (1-20 seconds). Targeting 

is carried out using MR1 and as the IRFUS is applied; 

temperature sensitive phase difference sequences are used to 

provide instantaneous thermal maps of the target area. By 

moving the HIFUS probe, adjacent small lesions can be 

produced, amounting to a significant area of ablation. 

Movement of the transducer within the magnetic is controlled 

by a hydraulic potsitioning device. Power monitoring circuitry is 

included for patient safety. The target volume to be ablated is 

outlined with cress sectional MR1. The US focus moves to 

ablate the defined volume. After an initial low dose test heat 

pulse, without tissue damage short high intensity pulses are 

applied to produce non-hemorrhagic sharply demarcated lesions 

(Jolesz and Silverman, 1995). 

D. Radiofrequency Ablation (RFA): 

RFA is an important alternative/complementary tool in the 

treatment of metastatic disease to the liver (Koike and Omata, 

2003) and can lead to palliation as well as increased survival in 

selected patients. RFA has been shown to be safer and better 

tolerated than other ablative techniques and has been associated 

with a low rate of local recurrence when performed properly 

(Rai and Manas, 2003). RFA also has shown some promise in 

combination with surgical resection and other therapies. Patients 

who undergo RFA still suffer from progressive metastatic 

disease. reinforcing the premise that local therapies have little 

impact on the natural history of aggressive cancers. Trials 

-92-


combining RFA with surgical resection and regional and 

systemic chemotherapy are ongoing and it is the hope that RFA 

combined with multimodality adjuvant therapy will reduce the 

development of both local disease and progressive metastatic 

disease, leading to improved overall survival (Parikh et al., 

2002). Hepatic KFA is effective in treating patients with 

unresectable hepatic malignancies (Iannitti et at., 2002). 

III- Non-Invasive Techniques: 

1- Chemotherapy: 

Systemic treatment for HCC is indicated in locally 

advanced or metastatic disease. Monochemotherapies have 

yielded unsatisfactory results with response rates of around 20% 

but survival is often not improved. Polychemotherapies may 

induce complete responses but have substantial toxicity and are 

limited to selected patients with presented liver function 

(Treffier, 2001). Systemic chemotherapy for HCC has been of 

limited value because only a small fraction of patients obtain 

meaningful palliation and because the toxicity of chemotherapy 

often outweighs the benefits (Okuda, 1998). 

2- Radiation Therapy: 

Palliation of metastatic disease to liver has generally not 

included the use of external-beam radiotherapy because of 

restricted liver tolerance to radiotherapy. However, more 

recently, treatment policies have evolved to more generous use 

of palliative radiotherapy with utilization of tumor boos doses to 

partial liver volumes. This has resulted in improvement in 

palliation and a suggestion of improved survival with higher 

-93-


radiotherapy doses, which have been well tolerated by, small 

volumes of liver (Malik and Mobiuddin, 2002). 

3- Immunotherapy: 

With the development of recombinant interleukin-2, 

systemic administration of autologous lymphokine-activated 

killer (LAK) cells has become possible. LAK cells have been 

shown to lyse human HCC cell (Hsich et al., 1987). The first 

carried out adoptive immunotherapy using LAK cells generated 

from the autelogous spleen in one patient with advanced HCC 

was by Okuno et al. (1986). 

4- Hormonal Therapy: 

A prospective study was performed to test the hypothesis 

that tamoxifen might improve the survival of patients with 

advanced HCC and to correlate the response of treatment with 

the expression of hormone receptors. The study concluded that 

tamoxifen has no efficacy in the treatment of patients with 

advanced HCC and response to treatment was not affected by 

the expression hormone receptors (Lia et al., 2000). Tamoxifen 

combined with octretide exerts reliable therapeutic effects 

patients with HCC (Pan et al., 2003). 

5- Gene Therapy: 

Although resection is currently the only curative approach 

for metastatic liver cancer, only a small number of cases are 

suitable for this procedure. In the past few years, gene therapy 

has emerged as an appealing treatment option for liver cancer. 

Phase I and II clinical trials have been conducted in patients 

with either primary or secondary liver cancer using a variety of 

-94-

-95- 


genes including tumor-suppressor gene p53, suicide genes, 

immune genes, and replication-competent oncolytic adenoviruses. 

The results have shown that, although gene therapy has been 

well tolerated and toxicity has been low, the clinical benefit has 

so far been marginal. Gene therapy as a definitive treatment for 

liver metastases remains limited, at least for the time being, but 

it may be useful as an adjuvant treatment in combination with 

radiotherapy, chemotherapy, and/or surgery to achieve diseasefree 

survival (Havlik et al., 2002). 

IV- Combined Modalities: 

Trans-Arterial Ablation Therapy: Targeted Chemotherapy 

Arterial Embolization And Chemoembolization: 

Because systemic chemotherapy has little activity against 

HCC, numerous studies have been performed using intra-arterial 

infusion of single and multiple chemotherapeutic agents. This 

targeted chemotherapy allows the delivery of high 

concentrations of cytotoxic drugs directly to the tumor. In 

addition, their systemic side effects can be minimized. Intraarterial 

doxorubicin, alone or in combination with other agents, 

has produced the best response rates in this technique (Spitz et 

at., 1999).

Patients 

And 

Methods

Patients: 

PATIENTS AND METHODS 

Patients and Methods 

This works has been conducted in Internal Medicine 

Department, Zagazig University Hospitals from February 2008 

to February 2009. 

It comprised 100 patients with HCV-related liver cirrhosis. 

They were classified into: 

Group A: 50 patients had HCV-related liver cirrhosis at 

different stages of hepatic dysfunction. 

It comprised 43 male and 7 female with a mean age 

of 50.06.3. 

Group B: 50 patients had HCV-related liver cirrhosis with 

HCC on top. 

Methods: 


of 59.98.5. 

Patients were enrolled at the study after the following 

work up to choose and classify patients. 

Thorough history and clinical examination. 

Laboratory investigations: 

- Liver function tests. 

-94-

- Prothrombin time. 

- Quantitative PCR for HCV, RNA. 


- HBs Ag and HBc Ab to exclude HBV infection. 

- Alfa feto protein. 

Abdominal ultrasonography. 

Triphasic C.T abdomen, to patients with hepatic focal 

lesions. 

Table (3): Demographic date: 

Age 

Sex: 

♂ : ♀ 

Group A Group B 

50.06.3 

43 : 7 

59.58.5 

36 : 14 

Table (4): Grading of hepatic encephalopathy. 

Grade Level of 

consciousness 

1 Lack of 

awareness 

Personality 

change 

Day/night 

reversal 

2 Lethargic 

Inappropriate 

behavior 

3 Asleep 

Rousable 

Intellectual 

function 

Neurological 

findings 

Short attention Incoordination 

Mild asterixis 

Disoriented Asterixis 

Abnormal 

reflexes 

Loss of 

meaningful 

communication 

-95- 

Asterixis 

Abnormal 

reflex 

EEG 

Slowing 

(5-6 cps) 

Triphasic 

Slowing 

Triphasic 

Slowing 

Triphasic

-96- 


4 Unrousable Absent Decerebrate Very slow (2- 

3 cps), delta 

(Sherkock and Dooley, 2002)

Results

Descriptive statistics: 

1- Group B (Table 5): 

RESULTS 

Results 

Patients of group B showed a mean albumin level of 

3.00.6, mean prothrombin time of 15.03.1, a mean of total 

billirubin of 2.31.6, a mean of SGOT of 611.6, a mean of 

SGPT of 51.818.1, a mean of AFP of 1216.13750.0, a mean 

of viral load of 1674355.04940150.0. 

Table (5): Descriptive statistics of laboratory data of hepatocellular 

carcinoma patients included in the study: 

Variables Range MeanSD 

Albumin (g/dl) 

pT (sec) 

Total billirubin (mg/dl) 

SGOT (U/L) 

SGPT (U/L) 

AFP 

Viral load 

PT : Prothrombin time. 

AFP : Alpha feto protein. 

1.2-4.0 

10.0-25.0 

0.6-6.2 

17.0-123.0 

22.0-90.0 

4.9-17565.0 

343.0-250000000 

-96- 

3.00.6 

15.03.1 

2.31.6 

61.025.7 

51.8181 

1216.13750.0 

1674355.04940150.0

2- Group A (Table 6): 

Results 

Patients of group A showed a mean albumin level of 

3.30.5, mean prothrombin time of 13.62.4, a mean of total 

billirubin of 2.53.2, a mean of SGOT of 57.941.0, a mean of 

SGPT of 60.159.8, a mean of viral load of 1454004.0 

2731874.0. 

Table (6): Descriptive statistics of laboratory data of chronic 

hepatitis C virus patients included in the study: 

Variables Range MeanSD 

Albumin (g/dl) 2.0-4.2 

pT (sec) 

10.0-20.0 

Total billirubin (mg/dl) 0.1-20.6 

SGOT (U/L) 

16.0-249.0 

SGPT (U/L) 

9.0-368.0 


361.0-170000000 


AFP : Alpha feto protein. 

-97- 

3.30.5 

13.62.4 

2.53.2 

57.941.0 

60.159.8 

1454004.0 2731874.0

Results 

Comparison between demographic data of HCC and HCV patients 

included in the study (Table 7): 

Patients of group B showed 0% score A of child score, 

16.7% score B, 83.3% score C, patients group A showed 54% 

score A, 20% score B, 26% score C, group B showed 8% 

patients with no ascites, 92% with ascites, group A showed 64% 

with no ascites, 36% with ascites, group A showed 74% pt with 

conscious, 12% pt with grade I enceph, 10% grade II enceph, 

4% grade III, group B showed 8.3% pt with conscious, 41.7% pt 

with grade I enceph, 33.3% grade II enceph, 16.7% grade III. 

Table (7): Comparison between demographic data of HCC and 

Variables 

Child score: 

Score A 

Score B 

Score C 

Ascites: 

- ve 

+ve 

Encephalopathy: 

Conscious 

Grade I 

Grade II 

Grade III 

HCV patients included in the study: 

27 

10 

13 

32 

18 

37 

6 

5 

2 

HCV HCC 

N % N % 

54 

20 

26 

64 

36 

74 

12 

10 

4 

-98- 

0 

8 

40 

4 

46 

4 

20 

16 

10 

0 

16.7 

83.3 

8 

92 

8.3 

41.7 

33.3 

16.7 

P-value 

0.0001* 

0.0001* 

0.0001*

Results 

Comparison between age and laboratory data of HCC and HCV 

patients included in the study Table (8): 

Showed comparison of age and laboratory data in HCC 

and HCV patients included in the study. We found statistically 

groups significant difference between age, albumin and PT of 

both while non significant difference in viral load, total 

bilirubin, SGOT and SGPT. 

Table (8): Comparison between age and laboratory data of HCC 

and HCV patients included in the study: 

Variables 

Age (yr) 


PT (sec) 


SGOT (U/L) 

SGPT (U/L) 


HCC 

MeanSD 

N=50 

59.58.5 

3.00.6 

15.03.1 

2.31.6 

61.025.7 

51.818.1 

1674355.0 

4940150.0 

-99- 

HCV 

MeanSD 

N=50 

50.06.3 

3.30.5 

13.62.4 

2.53.2 

57.941.0 

60.159.8 

1454004.0 

2731874.0 

P-value 

0.0001* 

0.01* 

0.02* 

0.4 

0.1 

0.4 

0.3

Results 

Correlation between viral load, demographic and laboratory data of 

HCC patients included in the study Table (9): 

Showed correlation between viral load, demographic and 

laboratory data of HCC patients included in the study. We found 

a significant positive correlation between viral load and PT 

while non significant correlation between viral load, age, AFP, 

albumin, total bilirubin, SGOT, SGPT and child score. 

Table (9): Correlation between viral load, demographic and 

laboratory data of HCC patients included in the study: 

Variables 

Age (yr) 

AFP 


PT (sec) 


SGOT (U/L) 

SGPT (U/L) 

Child score 


0.2 

0.1 

-0.1 

0.3 

0.1 

0.1 

0.2 

0.1 

-100- 


r P-value 

0.1 

0.6 

0.7 

0.02* 

0.7 

0.7 

0.1 

0.6

-101- 

Results 

Correlation between viral load, demographic and laboratory data of 

HCV patients included in the study Table (10): 

Showed correlation between viral load, demographic and 

laboratory data of HCV patients included in the study, we found 

non significant positive correlation between viral load, 

demographic and laboratory data of HCV patients included in 

the study. 

Table (10): Correlation between viral load, demographic and 

laboratory data of HCV patients included in the study: 

Variables 

Age (yr) 


PT (sec) 


SGOT (U/L) 

SGPT (U/L) 

Child score 

0.2 

0.1 

0.1 

0.3 

0.1 

0.1 

0.2 


r P-value 

0.2 

0.7 

0.7 

0.07 

0.7 

0.6 

0.1

Discussion

DISCUSSION 

Discussion 

Hepatocellular carcinoma (HCC) accounts for 85% to 90% 

cases of primary liver cancer. HCC is unique in that it occurs 

within an established background of chronic liver disease and 

cirrhosis (approximately 70% to 90% of all of cases)4. Major 

causes of cirrhosis in patients with HCC include hepatitis B 

virus (HBV) infection, hepatitis C virus (HCV) infection, 

alcoholic liver disease, and possibly non-alcoholic liver disease 

(Hashem, 2007). 

Viral load is a risk factor foe HCC in patients with chronic 

HBV infection. Patients with a high HBV viral load should be 

carefully monitored for HCC (Kazuyuki Ohata, et al., 2004). 

Infection with a specific subtype of hepatitis B virus 

(HBV) and a high viral load are associated both independently 

and additively with an increase risk of a type of live cancer 

(Zielnski, 2005). 

Concerning HCV, viral load is a well-recognized predictor 

of treatment outcome, viral load

Discussion 

We conducted this study to test if there is a relationship 

between the viral load of HCV and the development of HCC. 

Our study include 100 patients (50 patients of HCC with a mean 

age of 59.58.5 and 50 patients of HCV with a mean age of 

50.06.3) who are positive for HCV Ab and never treated with 

anti-HCV therapy (IFN + RBV). 

We could not trace the duration of HCV infection among 

our patients because of the lack of health records and the long 

asymptomatic course known for HCV infection. 

Our results showed no relation between the viral load and 

the presence or absence of HCC as there was no statistically 

significant difference between the viral load in patient with and 

without HCC (1674355.04940150.0 for HCC patients vs. 

1454004.02731874.0 for HCV patients without HCC). The 

design of our study is not the best for its purpose and a Cohort 

study would be better albeit time consuming. 

This relation, whether positive or negative was not met 

clearly in the literature. Romeo et al. (1996) reported no direct 

correlation between the viral load of HCV and the severity of 

HCV-related liver damage. 

This is similar to our study which showed that there is no 

significant correlation between viral load and albumin, SGOT, 

total bilirubin, PT and child score in patents with HCC Also 

there no significant relation between viral load and albumin, 

SGOT, Total bilirubin, PT and child score, in patients with 

chronic HCV. 

-103-

-104- 

Discussion 

It was noticed that the two groups of the study are will 

mached except for P, T. bilirubion, Albumin which denoted 

more deterioration of liver functions in patients with HCC 

compared to patients with HCV only which is expected. 

As regards age of patient with HCC are older than patients 

with HCV 

However, Ishikawa et al. (2001) reported high-titer of 

HCV-RNA (more than 1.0meg/ml) as a predictive factor for the 

development of HCC from viral compensated liver cirrhosis in 

related issue, Akamatsu et al. (2004) found that neither the 

genotype nor the viral load of HCV affect the prognosis of 

HCC. Young et al. (2002) found that HCV-RNA level in serum 

and non-cancerous liver tissue were markedly higher for HCV 

genotype 1 than genotype non-1-More, HCV-RNA levels were 

markedly higher in non-cancerous liver tissue than in HCC in a 

genotype independent manner. 

So, the determination of HCV viral load is beneficial only 

as a predictor of response to treatment. The lower the HCV 

RNA (viral load) the better the chance of eradicating the 

hepatitis C virus.

Summary & 

Conclusion

SUMMARY 

Summary and Conclusion 

Recent study indicate that there is lack of association 

between type of hepatitis C virus, serum load and severity of 

liver diseases. 

The present study was planned to evaluate the relationship 

between HCV viral load and HCC. 

This study include 100 patients were classified into two 

groups: 

Group A: 50 patients had HCV-related liver cirrhosis at 

different stages of hepatic dysfunction. 


of 50.06.3. 

Group B: 50 patients had HCV-related liver cirrhosis with 

HCC on top. 


of 59.98.5. 

All patients were enrolled at the study after the following 

work up to choose and classify patients. 

Thorough history and clinical examination. 

Laboratory investigations: 

- Liver function tests. 

- Prothrombin time. 

- Quantitative PCR for HCV, RNA. 

-105-


- HBs Ag and HBc Ab to exclude HBV infection. 

- Alfa feto protein. 

Abdominal ultrasonography. 

Triphasic C.T abdomen, to patients with hepatic focal 

lesions. 

We could not trace the duration of HCV infection among 

our patients because of the lack of health records and the long a 

symptomatic course known for HCV infection. 

Conclusion 

Therefore our study showed no relation between HCV 

viral load and the presence or absence of HCC as there was no 

statistically significant difference between the viral load in 

patients with and without HCC (1674355.04940150.0 for HCC 

patients vs. 1454004.02731874.0 for HCV patients without 

HCC). 

-106-

RECOMMENDATIONS 

-107- 


Application of Cohart study to evaluate relationship 

between HCV viral load and HCC. 

Screening decrease of occurrence of HCC in patients with 

high viral load HCV on (INF+RBV).

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ﻲـــــــﺑﺮﻌﻟا ﺺـــﺨﻠﻤﻟا 

ﺐﻴﺼﻳ ﺚﻴﺣ ،ﻢﻟﺎﻌﻟا ﻰﻓ ارﺎﺸﺘﻧا ماروﻷا ﺮﺜآأ ﻦﻣ ﻰﻧﺎﻃﺮﺴﻟا ﺪﺒﻜﻟا مرو 

ﺮﺒﺘﻌﻳ 

ﺪﻳﺪﺤﺗ ﻦﻜﻤﻳ ﻰﺘﻟا ﺔﻠﻴﻠﻘﻟا ماروﻷا ﻦﻣ ﻮهو . ﺎﻳﻮﻨﺳ ﻢﻟﺎﻌﻟا ﻰﻓ ﺾﻳﺮﻣ نﻮﻴﻠﻣ ﻰﻟاﻮﺣ 

( ﻰﺳ) 

ﻰﺋﺎﺑﻮﻟا ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا ﻞﺜﻤﻳو . تﻻﺎﺤﻟا ﻦﻣ ﺮﻴﺜآ ﻰﻓ مرﻮﻟا اﺬه رﻮﻬﻇ ﺐﺒﺳ 

ﻰﻓ ماروﻷا ﻩﺬه ثوﺪﺣ لﺪﻌﻣ دادﺰﻳو ،ﻰﻧﺎﻃﺮﺴﻟا ﺪﺒﻜﻟا مرو رﻮﻬﻈﻟ 

ﺮﻴﻄﺧ ﻞﻣﺎﻋ 

.( ﻰﺳ) 

ﻰﺋﺎﺑﻮﻟا ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا ثوﺪﺣ لﺪﻌﻣ ةدﺎﻳز ﺔﺠﻴﺘﻧ لوﺪﻟا ﻦﻣ ﺮﻴﺜآ 

لﺎﺼﺌﺘﺳﻻ ءاﻮﺳ ﻊﻳﺮﺴﻟا ﻰﺣاﺮﺠﻟا ﻞﺧﺪﺘﻟاو مرﻮﻟا اﺬﻬﻟ ﺮﻜﺒﻤﻟا ﺺﻴﺨﺸﺘﻟا نإ 

. ضﺮﻤﻟا اﺬﻬﻟ ﻞﺜﻣﻷا جﻼﻌﻟا ﺮﺒﺘﻌﻳ ﺾﻳﺮﻤﻠﻟ ﺪﺒآ عرﺰﻟ وأ مرﻮﻟا اﺬه 

ﺾﻤﺣ ﻦﻣ نﻮﻜﻣ ىوﺮآ سوﺮﻴﻓ ﻮه ( ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا سوﺮﻴﻓ 

نإ 

. م1988 

مﺎﻋ ةﺮﻣ لوﻷ ﻪﻔﺻو ﻢﺗ ىﺬﻟاو ( ﻪﻳإ. 

نإ. 

رﺁ) 

ىوﻮﻧ 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا سوﺮﻴﻓ ىوﺪﻋ نأ ﺪﺟو ﺪﻘﻟو ﺔﻴﻤﻟﺎﻋ ﺔﻴﺤﺻ ﺔﻠﻜﺸﻣ ﻞﺜﻤﻳ ﻮهو 

بﺎﺒﺳأ ﻢهأ ﻦﻣ ﺮﺒﺘﻌﻳ ﺚﻴﺣ ﻢﻟﺎﻌﻟا ىﻮﺘﺴﻣ ﻰﻠﻋ ارﺎﺸﺘﻧا ﺮﺜآﻷا ﻰه ﺮﺼﻣ ﻰﻓ ( ﻰﺳ) 

ﻦﻘﺤﻟﺎﺑ ﺎﻴﺳرﺎﻬﻠﺒﻟا ضﺮﻤﻟ ﺔﻴﻋﺎﻤﺠﻟا ﺔﺠﻟﺎﻌﻤﻟا ﺐﺒﺴﺑ ﻚﻟذو ﺎﻬﻴﻓ 

ﺔﻨﻣﺰﻤﻟا ﺪﺒﻜﻟا ضاﺮﻣأ 

ﻦﻋ ﺎﻀﻳأ ﻮﻬﻓ مﺪﻟا ﻖﻳﺮﻃ ﻦﻋ ﻪﻟﺎﻘﺘﻧا ﺐﻧﺎﺟ ﻰﻟإو ،ﺮﻴﻃﺮﻄﻟا تﺎﺒآﺮﻤﻟ ىﺪﻳرﻮﻟا 

. ﺔﻴﻟﺰﻨﻤﻟا ﺔﻴﻣﻮﻴﻟا تﺎﺳرﺎﻤﻤﻟاو ﺎﻬﻨﻴﻨﺠﻟ مﻷا ﻦﻣو ﺲﻨﺠﻟا ﻖﻳﺮﻃ 

ﺔﻋﻮﻤﺠﻤﻟا ﻦﻴﺘﻋﻮﻤﺠﻣ ﻰﻟإ ﺖﻤﺴﻗ ﺔﻟﺎﺣ 100 ﻰﻠﻋ ﺔﺳارﺪﻟا ﻩﺬه ﺖﻳﺮﺟأ 

ﻦﻣ ﺔﻟﺎﺣ 50 ﺔﻴﻧﺎﺜﻟا ﺔﻋﻮﻤﺠﻤﻟا ،( 

ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻﺎﺑ ﺔﺑﺎﺼﻣ ﺔﻟﺎﺣ 50 ﻰﻟوﻷا 

ﻦﻴﺑ ﻦﻣ ﻢهرﺎﻴﺘﺧا ﻢﺗ ،( 

ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻼﻟ ﺐﺣﺎﺼﻤﻟا ﻰﻧﺎﻃﺮﺴﻟا ﺪﺒﻜﻟا مرو تﻻﺎﺣ 

. ﻖﻳزﺎﻗﺰﻟا ﺔﻌﻣﺎﺟ تﺎﻴﻔﺸﺘﺴﻤﺑ ﺔﻨﻃﺎﺒﻟا ضاﺮﻣأ ﻢﺴﻘﻟ ﻰﻠﺧاﺪﻟا ﻢﺴﻘﻟا ﻰﺿﺮﻣ 

ﻰﺒﻄﻟا ﻒﺸﻜﻟاو 

ﻰﺿﺮﻤﻟا ﺦﻳرﺎﺘﻠﻟ ﻞﻣﺎآ ءﺎﻔﻴﺘﺳﻻ تﻻﺎﺤﻟا ﻞآ ﺖﻌﻀﺧ ﺪﻗو 

ﺰﻴآﺮﺗو ﻦﻣز ﺔﻠﻣﺎﺷ ﺪﺒآ ﻒﺋﺎﻇو ﻞﻤﻋ ﻞﺜﻣ ﺔﻴﻠﻤﻌﻤﻟا تﺎﺻﻮﺤﻔﻟا ﻚﻟﺬآو ﻰﻜﻴﻨﻴﻠآﻹا 

.( ﻰﺳ) 

ىﺪﺒﻜﻟا بﺎﻬﺘﻟﻻا ﺺﻴﺨﺸﺘﻟ رﺁ ﻰﺳ ﻰﺑ – ﻦﻴﺗوﺮﺑﺮﺘﻴﻓ ﺎﻔﻟأ ،ﻦﻴﺒﻣوﺮﺛوﺮﺒﻟا 

ﺔﻌﺷأ ﻞﻤﻋ ﻢﺗ ﺎﻤآ ،ﻰﺿﺮﻤﻟا ﻞﻜﻟ ﺪﺒﻜﻟا ﻰﻠﻋ ﺔﻴﺗﻮﺼﻟا قﻮﻓ تﺎﺟﻮﻣ ﻞﻤﻋ ﻢﺗ ﻚﻟﺬآ 

. 

ﻢﻬﻟ دﺎﻌﺑﻷا ﺔﻴﺛﻼﺛ ﺔﻴﻌﻄﻘﻣ

. ﻰﻤﻜﻟا رﺁ ﻰﺳ ﻰﺑ ماﺪﺨﺘﺳﺎﺑ ﻦﻴﺘﻋﻮﻤﺠﻤﻟا ﻦﻴﺑ رﺁ سإ ﻰﺑ ﺔﻧرﺎﻘﻣ ﻢﺗ 

ﺔﻴﻤآ عﺎﻔﺗرا ﻦﻴﺑ ةﺮﺷﺎﺒﻣ ﺔﻗﻼﻋ دﻮﺟو مﺪﻋ ﺔﺳارﺪﻟا ﺞﺋﺎﺘﻧ تﺮﻬﻇأ ﺪﻗو 

. ﺪﺒﻜﻟا نﺎﻃﺮﺳو مﺪﻟا ﻰﻓ ( ﻰﺳ) 

سوﺮﻴﻓ 

جﻼﻋ ﻰﻓ ﻰﻤﻠﻋ سﺎﺳأ مﺪﻘﺗ نأ ﻦﻜﻤﻳ ﺔﻴﻠﻤﻌﻤﻟا ﺔﺳارﺪﻟا ﻩﺬه نأ ﺺﻠﺨﺘﺴﻧ ﻚﻟذ ﻦﻣ 

. 

ﺪﺒﻜﻟا نﺎﻃﺮﺳو ( ﻰﺳ) 

سوﺮﻴﻓ

et al.

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