Hepatocellular carcinoma in Egyptians with and without a history of hepatitis B virus infection: association with hepatitis C virus (HCV) infection but not with (HCV) RNA level

The Significance of HCV Viral Load in the Incidence of HCC: a Correlation Between Mir-122 and CCL2

BACKGROUND

Hepatocellular carcinoma (HCC) is the fifth most common cancer, the third leading cause of cancer deaths worldwide with over 500,000 people affected. It is a major cause of death in patients with chronic hepatitis C virus (HCV) infection. Overwhelming lines of epidemiological evidence have indicated that persistent infection with HCV is a major risk for the development of HCC. Although a proportion of patients with a chronic hepatitis C virus infection progress to HCC, the peak incidence of HCC associated with HCV infection has not yet occurred.

AIM

This review aimed to assess the impact of hepatitis C viral load on the development of HCC as a correlation between mir-122 and, the key factor in fibrogenesis, CCL2.

CONCLUSION

According to the detailed explanation of the role of mir-122 and CCL2 in HCV and HCC and the evidence of the inverse correlation between them, it may be concluded that HCV may affect mir-122 expression level of the hepatocytes with different patterns depending on the viral genotype. Collectively, HCV viral load alone is not sufficient to predict the HCC development and progression. Besides the quantitative evaluation of the HCV, mir-122 and CCL2 determinations should also be taken into consideration.

Wide Sexual Dimorphism of Hepatocellular Carcinoma Presentation in Algeria

Hepatocellular carcinoma (HCC) represents a worrying public health problem in North Africa and particularly in Egypt. The situation is unclear in western North Africa where HCC has been rarely submitted to careful scrutiny. We decided to analyze demographic, biochemical, virological, and clinical data of a series of HCC from Algerian patients to establish the landscape of this tumor in the country. In the present work, we described 337 cases of primary liver cancer from Bologhine Hospital in Algiers, the capital of Algeria. The mean age of patients was 63.8 ± 11.4 years with a male:female sex ratio of 1.5. The most prevalent risk factors were hepatitis C, hepatitis B, and metabolic pathologies (type 2 diabetes and obesity). The mean BMI was 25.6 ± 4.7 at tumor diagnosis. A strong duality of risk factors and tumor presentation between male and female patients was apparent. Women tended to be older (mean 65.4 vs. 62.7 years, p = 0.039) and either seropositive for anti-HCV (60.0 vs. 41.6%, p = 0.0018) resulting primarily from tattoos and/or scarification (47.2 vs. 25.7%, p = 1.0 × 10^-4) or more often affected by metabolic disorders (mean BMI 26.1 ± 0.7 vs. 25.1 ± 0.5, p = 0.0248) commonly associated with personal antecedents of cholecystectomy (21.2 vs. 5.8%, p = 4.4 × 10^-5). By contrast, men were younger, poorer survivors (mean 9.3 vs. 13.3 months, p = 0.005), more frequently HBsAg carriers (27.8 vs. 10.5%, p = 4.8 × 10^-5), and more exposed to lifestyle risk factors such as smoking (39.4 vs. 3.0%, p = 3.9 × 10^-16) or alcohol use (19.1 vs. 0.7%, 1.5 × 10^-8). Finally, geographic disparities throughout Algeria were reminiscent of the situation of chronic hepatitis C in the country. A significant excess of cases originated from the region of Batna, Eastern Algeria, already known for its high rate of hepatitis C. Our results suggest that due to culture or sex-dependent biological differences, the tumor process affecting the liver is drastically different between sexes in Algeria.

Hepatocellular carcinoma in a rapidly growing community: Epidemiology, clinico-pathology and predictors of extrahepatic metastasis

BACKGROUND AND STUDY AIMS

Hepatocellular carcinoma (HCC) with extrahepatic metastasis has been studied, however, data from the Middle East remain scarce. In this study, we assess epidemiology of HCC in Qatar, and identify predictors of the metastatic behaviour.

PATIENTS AND METHODS

All newly-diagnosed HCC patients on top of liver cirrhosis between 2011 and 2015 were included in the study.

RESULTS

A total of 180 patients met our inclusion criteria. The mean age was 58.8 ± 10.5 years with a mean follow-up of 1.0 ± 1.1 years. There were 150 male patients and HCV was the most common cause of liver cirrhosis 108 (60%), and 22 (12.2%) patients were classified as Child-Pugh class C. The overall survival of 51.1%, and 47 (26%) had at least one extrahepatic metastasis at the time of diagnosis. Single site metastasis was diagnosed in 10 patients, whereas 37 patients had multiple sites metastases. We compared patients who had metastases with patients who did not have metastasis at the time of diagnosis of HCC regarding several variables, and analysis revealed that tumour diameter larger than 5 cm (OR = 6.10, 95% CI = 1.85-20.12) (p = 0.003), and bilobar liver involvement (OR = 5.49, 95% CI = 1.10-27.30) (p = 0.037) were independent predictors of metastatic behaviour of HCC.

CONCLUSION

The incidence of HCC is rising in our population, extrahepatic metastasis is no longer rare and tumours larger than 5 cm and bilobar involvement are determinants of the extrahepatic metastasis.

Characterizing hepatitis C virus epidemiology in Egypt: systematic reviews, meta-analyses, and meta-regressions

Egypt is the most affected nation by hepatitis C virus (HCV) and needs a comprehensive characterization of HCV epidemiology to inform the scale-up of treatment and prevention programs. Systematic reviews, meta-analyses, and meta-regressions were conducted. A total of 25 incidence, 259 prevalence, and 47 genotype studies were identified. Incidence and prevalence levels were high across all populations. Genotype 4 accounted for 94.1% of infections with a relative Shannon Diversity Index of only 14.4%. Pooled mean HCV prevalence was estimated at 11.9% (95% CI = 11.1–12.6%) among the general population, 55.6% (95% CI = 49.4–61.7%) among populations at high risk, 14.3% (95% CI = 10.3–18.8%) among populations at intermediate risk, 56.0% (95% CI = 50.4–61.6%) among populations with liver-related conditions, and 35.0% (95% CI = 27.3–43.1%) among special clinical populations. Mean HCV viremic rate was estimated at 66.7% (95% CI = 61.7–71.5%). Meta-regression indicated 6% lower odds for HCV prevalence for each one-year increment in publication year (AOR = 0.94; 95% CI = 0.92–0.96). HCV prevalence is high with evidence for ongoing transmission mainly through healthcare. Genotype diversity is low with genotype 4 dominance. Two-thirds of antibody-positive Egyptians are chronically infected and need treatment. Clinical populations should be prioritized for screening. Despite the large-scale epidemic, prevalence appears to be declining rapidly consistent with a contracting epidemic.

Clinical Impact of Viral Load on the Development of Hepatocellular Carcinoma and Liver-Related Mortality in Patients with Hepatitis C Virus Infection

Aim. This study aimed to assess clinical impact of hepatitis C viral load on the development of hepatocellular carcinoma (HCC) and liver-related mortality in HCV-infected patients. Methods. A total of 111 subjects with chronic HCV infection who were available for serum quantitation of HCV RNA were recruited in this retrospective cohort. Cox-proportional hazards models were used to calculate hazard ratio (HR) of developing HCC and liver-related mortality according to serum HCV RNA titers. Results. HCC was developed in 14 patients during follow-up period. The cumulative risk of HCC development was higher in subjects with high HCV RNA titer (log HCV RNA IU/mL > 6) than subjects with low titer (log HCV RNA IU/mL ≦ 6) (HR = 4.63, P = 0.032), giving an incidence rate of 474.1 and 111.5 per 10,000 person-years, respectively. Old age (HR = 9.71, P = 0.014), accompanying cirrhosis (HR = 19.34, P = 0.004), and low platelet count (HR = 13.97, P = 0.009) were other independent risk factors for the development of HCC. Liver-related death occurred in 7 patients. Accompanying cirrhosis (HR = 6.13, P = 0.012) and low albumin level (HR = 9.17, P = 0.002), but not HCV RNA titer, were significant risk factors related to liver-related mortality. Conclusion. Serum HCV RNA titer may be considered an independent risk factor for the development of HCC but not liver-related mortality.

Transarterial chemoembolization for the treatment of hepatocellular carcinoma: a single center experience including 221 patients

BACKGROUND

Hepatocelluar carcinoma (HCC) is a major health problem in Egypt as well as in many countries. Transarterial chemoemoblization (TACE) is a treatment modality applicable to locally advanced HCC beyond surgery or ablative therapies and is associated with survival improvements. The aim of this study was to assess the outcomes of TACE in our center over the past four years.

METHODS

This is a retrospective cohort study that included 221 patients with locally advanced HCC treated with TACE in a single center between the years 2007 and 2010. The median age was 57 years with male predominance. Liver cirrhosis, viral hepatitis and Bilharziasis were encountered in 64%, 31% and 8% of patients, respectively. Abdominal pain was the most common presenting symptom (67%). Most cases were diagnosed based on radiology (57%) with a TNM stage I or II (73%) and a median AFP value of 150 ng/mL.

RESULTS

221 patients received 440 cycles of TACE with a median of 2 cycles per patient. Cisplatin and doxorubicin (50mg per cycle, each) were the most commonly used drugs. Impaired liver function was the most common toxicity. Liver cell failure occurred in 17% of patients. An objective tumor response was achieved in 44% of cases. The median overall survival (OS) was 16 months (95% CI, 13-19 months) and the median progression free survival (PFS) was 6 months (95% CI, 4.3-7.8 months). Responding patients, Child-Pugh class A and patients receiving standard doses of chemotherapy had a significantly better OS than their counterparts. Only Child-Pugh class A was associated with significantly longer PFS (p < 0.001).

CONCLUSION

TACE produces reasonable responses and fair survival rates in locally advanced HCC but with noticeable toxicities. Proper patients' selection and prompt liver support are mandates for improving TACE outcomes.

Hepatitis C virus seromarkers and subsequent risk of hepatocellular carcinoma: long-term predictors from a community-based cohort study

PURPOSE

Hepatitis C virus (HCV) contributes to one third of hepatocellular carcinoma cases worldwide. Long-term predictors for HCV-related hepatocellular carcinoma are essential for early intervention. Serum HCV RNA and ALT levels and HCV genotype were assessed for their predictability of hepatocellular carcinoma risk.

METHODS

A prospective cohort of 925 participants positive for antibodies against HCV and age 30 to 65 years was recruited and followed from 1991 to 2006. Serum HCV RNA and ALT levels and HCV genotypes at enrollment and during follow-up were examined. Newly developed hepatocellular carcinoma was identified by health examination and computerized linkage with national cancer registration and death certification profiles. Multivariate adjusted hazard ratios with 95% CIs were estimated using Cox regression models.

RESULTS

Fifty-five participants newly developed hepatocellular carcinoma during 8,476 person-years of follow-up, giving an incidence rate of 648.9 per 100,000 person-years. The cumulative hepatocellular carcinoma risk increased from 1.1% for HCV RNA seronegative status to 6.4% for low HCV RNA levels and to 14.7% for high HCV RNA levels (P < .001). The cumulative risk also increased with elevated serum ALT levels from 1.7% for persistently ≤ 15 U/L to 4.2% for ever more than 15 U/L but never more than 45 U/L and to 13.8% for ALT ever ≥ 45 U/L (P < .001). Having HCV genotype 1 was associated with a higher cumulative hepatocellular carcinoma risk (12.6%) than not having HCV genotype 1 (4.5%; P < .001).

CONCLUSION

Elevated serum levels of HCV RNA and ALT and HCV genotype 1 infection are independent risk predictors of hepatocellular carcinoma. These findings have strong implications for the management of chronic HCV.

Epidemiologic risk factors of hepatocellular carcinoma in a rural region of Egypt

BACKGROUND

Hepatocellular carcinoma (HCC) is a major health problem worldwide, including Egypt. In the recent past, HCC has become the second most prevalent cancer among men in Egypt. Since HCC has not been well studied in the rural population of Egypt, this case-control study was conducted to investigate the epidemiologic risk factors of HCC in the predominantly rural region of Gharbiah, Egypt.

METHODS

A total of 150 cases and 150 controls matched to cases on age (±5 years) and sex were recruited from the Gharbiah Cancer Society and Tanta Cancer Center. Exposure data were collected by an interviewer-administered standardized questionnaire about epidemiologic, occupational, medical and family history of HCC. Conditional logistic regression was utilized to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CI). The effect modification of HCC risk between viral infection and environmental risk factors was also assessed.

RESULTS

Being an industrial worker was an independent risk for developing HCC (OR 3.54, 95% CI 1.18, 10.63) after adjusting for viral infection, schistosomiasis and tobacco smoking. High relative risk of HCC was observed among HCV-infected individuals who were farmers (OR 9.60, 95% CI 3.72, 24.76), industrial workers (OR 12.90, 95% CI 4.33, 38.43) or active smokers (OR 5.95, 95% CI 2.20, 16.08).

CONCLUSION

Occupational exposure may play an important role in the development of HCC. Farming, industrial exposures and cigarette smoking may increase the risk of HCC among HCV-seropositive individuals. Future research focusing on mechanisms of occupational exposures among HCV patients in this population is needed.

Epidemiology of hepatitis viruses among hepatocellular carcinoma cases and healthy people in Egypt: a systematic review and meta-analysis

Liver cancers are strongly linked to hepatitis B virus (HBV) and hepatitis C virus (HCV). Egypt has the highest prevalence of HCV worldwide and has rising rates of hepatocellular carcinoma (HCC). Egypt's unique nature of liver disease presents questions regarding the distribution of HBV and HCV in the etiology of HCC. Accordingly, a systematic search of MEDLINE, ISI Web of Science, ScienceDirect and World Health Organisation databases was undertaken for relevant articles regarding HBV and HCV prevalence in Egypt among healthy populations and HCC cases. We calculated weighted mean prevalences for HBV and HCV among the populations of interest and examined differences in prevalence by descriptive features, including age, year and geographic region. Prevalences for HBV and HCV were 6.7% and 13.9% among healthy populations, and 25.9% and 78.5% among HCC cases. Adults had higher prevalences of both infections (Adult HBV=8.0%, Child HBV=1.6%; Adult HCV=15.7%, Child HCV=4.0%). Geographically, HBV was higher in the south, whereas HCV was greater in the north (North HBV=4.6%, South HBV=11.7%; North HCV=15.8%, South HCV=6.7%). Among HCC cases, HBV significantly decreased over time (p=0.001) while HCV did not, suggesting a shift in the relative influences of these viruses in HCC etiology in Egypt. Our results highlight large amounts of heterogeneity among the epidemiological factors associated with liver disease in Egypt and underscore the necessity of an integrated strategy for the successful prevention of viral hepatitis infections and chronic liver disease.

Patterns of hepatocellular carcinoma incidence in Egypt from a population-based cancer registry

AIM

Hepatocellular carcinoma (HCC) is increasing worldwide, and is frequently attributed to rising rates of hepatitis C virus infection and interactions between viral and environmental risk factors. Because of Egypt's unique risk factor profile, we analyzed data from the Gharbiah Population-Based Cancer Registry for the period 1999-2003 to characterize demographic and geographic patterns of cases in this province.

METHODS

We calculated age- and sex-specific and age- and sex-standardized HCC incidence rates for the eight districts in Gharbiah. We also compared rates from Gharbiah with the USA (US Surveillance Epidemiology and End RESULTS [SEER] database).

RESULTS

The analysis revealed a higher incidence in males than in females, significant geographic variations among districts, and a higher incidence in Gharbiah than that reported by SEER.

CONCLUSION

The findings of this study document the heterogeneous distribution of HCC at regional and international levels. This population-based registry offers the opportunity for careful representative studies of various etiologies, particularly infectious and/or environmental factors that may contribute to risk.

Necrolytic acral erythema in Egyptian patients with hepatitis C virus infection

BACKGROUND

Necrolytic acral erythema (NAE) is a distinctive skin lesion that was first described in 1996 with only few cases being reported, mostly from Egypt. It is unique in its acral distribution and exclusive association with hepatitis C virus (HCV) infection.

METHODS

Twenty-three patients (mean age 41.7 +/- 11.5 years; M:F 10:13) with clinical features consistent with NAE were enrolled in a 3-year period. Five of those were known HCV-infected individuals and 18 were referred by the dermatologist for evaluation and HCV screening. Liver function tests, serum zinc, hepatitis B markers, HCV antibodies and HCV-RNA were tested. All patients were subjected to skin biopsy examination; five lesional biopsies were selected for electron microscopic examination and capillary endothelium was scanned for hepatitis C viral particles. An additional five patients were subjected to detection of HCV-RNA in their skin biopsies by polymerase chain reaction. All patients received oral zinc sulfate supplementation while interferon-alpha therapy combined with ribavirin was available for four patients.

RESULTS

Most NAE patients were adults (91.3%) and the skin lesions were predominantly chronic (78.3%), with affection of the dorsa of toes and/or feet in all cases. Skin biopsies showed hyperkeratosis, psoriasiform epidermis and upper epidermal necrosis. Electron microscope examination demonstrated clumped tonofilaments in the keratinocytes, yet HCV-RNA could not be detected in the skin lesions of examined cases. Interferon-alpha combined with ribavirin caused regression of skin lesions in three patients and complete clearance in one patient. Some improvement was induced by oral zinc administration.

CONCLUSION

Necrolytic acral erythema is considered to be a cutaneous marker for HCV infection. The majority of patients are diagnosed by dermatologists. Therefore, improved awareness of this cutaneous lesion should prompt early diagnosis and treatment of HCV, which should in turn cure the lesion and prevent progression of liver disease.

Expected increase in hepatitis C-related mortality in Egypt due to pre-2000 infections

BACKGROUND/AIMS

Egypt has the highest prevalence of Hepatitis C Virus (HCV) in the world, apparently due to mass parenteral antischistosomal therapy. Estimating the future burden of HCV in Egypt is important to support health policies to combat the epidemic.

METHODS

A previous back calculation model was adapted to the situation in Egypt. It combines a model of the natural history of HCV infections with available epidemiological data to back calculate the past HCV incidence from observed 1980-1999 hepatocellular carcinoma (HCC) mortality. In turn, the HCV-related mortality burden is projected in the future due to pre-2000 infections.

RESULTS

Compared with the observed number of HCC deaths in 1999, the model predicts a 3.5-fold increase in this mortality in the next 20 years. Globally, the model predicts a 2.4-fold increase in the HCV-related mortality. These predictions do not take into account the new infections that may occur after 2000, which would still increase the estimated future mortality burden.

CONCLUSIONS

HCV-related mortality is expected at least to double in the next 20 years. The use of antiviral therapies can lower these predictions. Efficient prevention policies are needed to avoid these predictions being exceeded.

Cytokine profile in Egyptian hepatitis C virus genotype-4 in relation to liver disease progression

AIM: To observe the imbalance between T helper cell Th1 and Th2 cytokines in several chronic hepatitis disease at different stages of disease progression.

METHODS: We measured the cytokine levels of Th1 (IL-2 and IL-2R), Th2 (IL-10) and the pro-inflammatory cytokines (IL-6 and IL-6R and TNF and TNF-RI and II) by the ELISA technique in the sera of 33 hepatocellular carcinoma (HCC) patients and 20 chronic liver disease (CLD) patients. In addition, 20 asymptomatic hepatitis C virus carriers and 20 healthy subjects negative for hepatitis C virus(HCV) markers served as controls.

RESULTS: Anti-HCV antibodies were found to be positive in 94% of HCC cases and 75% of CLD cases. On the other hand, HCV viremia was detected using RT-PCR in 67% of HCC cases and 65% of CLD cases. HBsAg was positive in 9% of HCC cases and 30% of CLD cases. Also bilharzial-Ab was positive in 55% of HCC cases, 65% of CLD cases and in 70% of asymptomatic carriers (ASC). HCC patients had significantly higher values of IL-2R, TNF-RII (P<0.001), and TNF-RI (P>0.05), but lower TNFα (P<0.001) and IL-6 (P = 0.032) in comparison to ASC. But, in comparison to non-cancer controls, HCC patients had higher values of IL-2R, IL-6R, TNF-RI and TNF-RII, but lower TNF-α (P<0.001). CLD patients had higher IL-2R, TNF-RI, and TNF-RII (P<0.001) than ASC. But, in comparison to non-cancer controls, CLD patients had higher values of IL-2R, TNF-RI and TNF-RII, but lower TNF-α (P<0.001). IL-10 was higher (though not significantly) in HCC and CLD patients than in symptomatic carriers and non-cancer controls.

CONCLUSION: Liver disease progression from CLD to HCC due to HCV genotype-4 infection is associated with an imbalance between Th1 and Th2 cytokines. IL-2R, TNF-RI, and TNF-RII could be used as potential markers.

Alterations of p53, Bcl-2, and hMSH2 protein expression in the cirrhotic, macroregenerative, dysplastic nodules and hepatocellular carcinomas in Upper Egypt

BACKGROUND

Hepatocarcinogenesis involves alterations in p53, Bcl-2 and human Mut S homologue-2 (hMSH2) genes. In Upper Egypt, the clinicopathologic and genetic changes during hepatocarcinogensis (cirrhotic nodules (CN); macroregenerative nodules (MRN) and dysplastic nodules (DN) are unknown.

METHODS

To examine these issues, 48 hepatic resection specimens entailing 25 CN, 16 MRN, 23 DN and 48 hepatocellular carcinoma (HCC) were immunohistochemically evaluated for p53, Bcl-2 and hMSH2 protein expression.

RESULTS

HCC was common in males than in females (2.6:1, P<0.05) and with hepatitis C virus than hepatitis B virus infection (77.1% vs. 18.7%, P=0.001). p53 expression was found in DN (3/23) and HCC (12/48). Its average weighted scores were high in DN/HCC as compared with CN (1.60+/-0.40 and 7.20+/-1.20, P=0.0001). Bcl-2 expression was seen in CN, MRN, DN and HCC (7/48). Its average weighted scores were high in DN (7.60+/-1.60), HCC (6.86+/-0.85) as compared with CN (6.14+/-0.42) and MRN (6.50+/-0.50, P=0.22). hMSH2 average weighted scores were reduced in HCC (7.94+/-1.06) as compared with CN (8.47+/-0.52), MRN (8.00+/-1.00) and DN (8.20+/-0.80, P>0.05).

CONCLUSION

In Upper Egypt: (1) HCC had similar clinicopathologic features to those in the high-risk regions, and (2) alterations of the p53, Bcl-2 and hMSH2 proteins occur during hepatocarcinogensis.