Dr. Mohammed Omar Khalifa Epidemiological characteristics of hepatocellular carcinoma in Egypt: a retrospective analysis of 1313 cases By Dr. Mohammed Omar Khalifa Ass. Prof. of Tropical Medicine Ain Shams University, Egypt

Introduction: Hepatocellular carcinoma (HCC) is the fifth most common neoplasm, the major cause of death in patients with cirrhosis, and the third most common cause of cancer-related death in the world (Llovet et al., 2003). In most countries, HCC accounts for 70–85% of primary liver cancer cases (Ahmed et al., 2008), with the burden of disease expected to increase in coming years (Llovet, 2005).

Introduction (cont.): HCV is the most important risk factor for HCC in Western European and North American countries, as epidemiological studies have shown up to 70% of patients with HCC have anti-HCV antibody in the serum (Montalto et al., 2002).

Introduction (cont.): Egypt has the highest prevalence of HCV in the world (predominantly genotype 4), which has been attributed to previous public health eradication schemes for schistosomiasis. Even higher HCV infection rates, up to 60%, have been reported in older individuals, in rural areas such as the Nile delta, and in lower social classes (Hassan et al., 2001).

Introduction (cont.): In Egypt, HCC was reported to account for about 4.7% of chronic liver disease patients (El-Zayadi et al., 2001). Between 1993 and 2002, there was an almost two-fold increase in HCC amongst chronic liver patients in Egypt (El-Zayadi et al., 2005).

Introduction (cont.): Hospital-based studies from Egypt have reported an overall increase in the relative frequency of all liver-related cancers in Egypt (>95% as HCC), from approximately 4% in 1993 to 7.3% in 2003. Recent investigations in Egypt have shown the increasing importance of HCV infection in the aetiology of liver cancer, estimated to account for 40–50% of cases, and the declining influence of HBV and HBV/HCV co-infection (25% and 15% respectively) (El-Zayadi et al., 2005).

Aim of this study: To study the characteristics of HCC in Egypt, we comprehensively analyzed patients with HCC especially with regard to their clinical, aetiological and radiological profile.

Patients and Methods

Patients and methods: A retrospective chart review of HCC patients was done in the period from January 2009 to December 2011 for those who attended the outpatient clinic of HCC Unit, Ain Shams University Hospitals, Cairo, Egypt.

Patients and methods: HCC Unit in Ain Shams University is a specialized unit established in 2003 for the purpose of diagnosis and management of HCC patients as well as screening of CLD patients in order to detect hepatic focal lesions at early stages.

Patients and methods (Cont.): Minimum data set within the patient record was predefined before collection of data to include a record in this retrospective study. The diagnosis of HCC in those patients was done according to AASLD practice guidelines (Bruix and Sherman, 2005).

Patients and methods (Cont.): Cases were excluded if data record was incomplete to satisfactorily review the case. Records of 1456 HCC patients were screened. A total of 143 patients were excluded from this study because of incomplete records.

Patients and methods (Cont.): A total of 1313 HCC cases with full reports were enrolled in this study. The records of patients were reviewed for: Epidemiological data: age, sex, occupation, residence, special habits, risk factors and relevant medical history. Clinical data: symptoms, signs and performance status.

Patients and methods (Cont.): Laboratory data: including complete blood count, liver and kidney profiles, viral markers and AFP level. Radiological data: for complete description of tumour site, number and extension. This was done using abdominal ultrasound, triphasic spiral CT and Doppler studies for confirmation of possible vascular invasion.

Patients and methods (Cont.): Classification of patients amongst Child–Pugh classification (Pugh et al., 1973) as well as staging system of Barcelona Clinic Liver Cancer (Bruix and Sherman, 2011).

Results

Results: Baseline characteristics of patients: No. (%) Age M ± SD Median 56.2 + 8.6 years 56 years Age category 21 – 30 years 7 (0.53) 31 – 40 years 26 (1.98) 41 – 50 years 320 (24.4) 51 – 60 years 600 (45.7) 61 – 70 years 287 (21.9) 71 – 80 years 68 (5.18) > 80 years 5 (0.38) 2 1 3

Results: Baseline characteristics of patients: Gender: 78.8 % 21.2 % 4 : 1

Results: Baseline characteristics of patients: Residence: 24.5 % 1 3 75.5 %

Results: Baseline characteristics of patients: Past History: No (%) Blood transfusion 267 (20.3) Surgical operations 605 (46.1) Tartar emetic injection 878 (66.9)

Results: Clinical data of the patients: No (%) Symptoms Abdominal pain 871 (66.3) Easy fatigability 819 (62.4) Accidental discovery 657 (50) Bleeding tendency 634 (48.3) Weight loss 572 (43.6) Fever 246 (18.8) Haematemesis 184 (14)

Results: Clinical data of the patients: No (%) Signs: Lower limb edema 644 (49) Ascites 470 (35.8) Jaundice 345 (26.3) Pallor 193 (14.7) Cachexia 107 (8.2) Encephalopathy 99 (7.5)

Results: Clinical data of the patients: No (%) Performance status: 952 (72.5) 1 121 (9.2) 2 30 (2.3) 3 199 (15.2) 4 11 (0.8)

Results: AFP levels of the studied patients: No (%) AFP level (ng/ml) : < 20 433 (32.9) 20 – 100 264 (20.1) 101 – 200 83 (6.3) 201 – 400 131 (9.98) > 400 402 (30.6)

Results: Viral markers of the studied patients: No (%) Etiology: HBV alone 33 (2.51) HCV alone 1199 (91.32) Combined (HBV & HCV) 35 (2.67) Non-B, Non-C 46 (3.5)

Results: Site of lesions: 75.4 % 15.7 % 8.9 %

Results: Number of lesion: 61.5 % 17.1 % 3.4 % 18.1 %

Results: Extent of tumor within the liver:

Results: Portal vein thrombosis: By Doppler studies, malignant portal vein thrombosis was documented in 185 (14%) patients.

Results: Portal vein thrombosis: 0.5% 9.2 % 11.4 % 78.9 %

Results: Histopathological results of biopsies: Biopsies from the focal lesions were required in 205 patients to confirm the diagnosis. Pathological type (n = 205) HCC Grade I 65 (31.7) HCC Grade II 92 (44.9) HCC Grade III 38 (18.5) Dysplastic nodules 10 (4.9)

Results: Child-Pugh Classification of cases:

Results: BCLC staging: No (%) BCLC stage: A1 56 (4.3) A2 182 (13.9) A3 321 (24.4) A4 69 (5.3) B 323 (24.6) C 149 (11.3) D 213 (16.2) 47.9%

Conclusion: HCC is a major health problem in Egypt and its incidence is increasing. The high prevalence of HCV infection makes screening programs, and surveillance of patients a very important tool to early detect cases of small HCCs. Further studies focusing on risk factors other than viral infections are warranted.