Hepatocellular Carcinoma In Africa Research Articles

S1458 Satellite Spatial Scaling to Assess Hepatocellular Carcinoma in Africa

S1458 Satellite Spatial Scaling to Assess Hepatocellular Carcinoma in Africa

Africa Guidelines for Hepatocellular Carcinoma Buildup Process.

Hepatocellular carcinoma (HCC), the fourth most common cancer in Africa, has a dismal overall survival of only 3 months like in sub-Saharan Africa. This is affected by the low gross domestic product and human development index, absence of coherent guidelines, and other factors. An open forum for HCC-experienced health care workers from Africa and the rest of the world was held in October 2021. Participants completed a survey to help assess the real-life access to screening, diagnoses, and treatment in the North and Southern Africa (NS), East and West Africa (EW), Central Africa (C), and the rest of the world. Of 461 participants from all relevant subspecialties, 372 were from Africa. Most African participants provided hepatitis B vaccination and treatment for hepatitis B and C. More than half of the participants use serum alpha-fetoprotein and ultrasound for surveillance. Only 20% reported using image-guided diagnostic liver biopsy. The Barcelona Clinic Liver Cancer is the most used staging system (52%). Liver transplant is available for only 28% of NS and 3% EW. C reported a significantly lower availability of resection. Availability of local therapy ranged from 94% in NS to 62% in C. Sorafenib is the most commonly used systemic therapy (66%). Only 12.9% reported access to other medications including immune checkpoint inhibitors. Besides 42% access to regorafenib in NS, second-line treatments were not provided. Similarities and differences in the care for patients with HCC in Africa are reported. This reconfirms the major gaps in access and availability especially in C and marginally less so in EW. This is a call for concerted multidisciplinary efforts to achieve and sustain a reduction in incidence and mortality from HCC in Africa.

Hepatocellular Carcinoma in Africa: Challenges and Opportunities.

Hepatocellular Carcinoma in Africa: Challenges and Opportunities.

Prognostic Value of Computed Tomography Texture Features in Patients with Hepatocellular Carcinoma Following Stereotactic Ablative Radiotherapy

Background: Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide. Cases of HCC in Africa and East Asia account for 80% of all HCC cases around the world. China is one of the countries with a high incidence rate of HCC. Objectives: This case-control study aimed to explore the prognostic value of computed tomography (CT) texture features in patients with HCC following stereotactic ablative radiotherapy (SABR). Patients and Methods: A total of 100 HCC patients, treated with SABR from January 2019 to January 2021, were divided into good prognosis (n = 57) and poor prognosis (n = 43) groups. The patients’ general data and CT texture features were then compared. Factors associated with a poor prognosis were investigated in a multivariate logistic regression analysis. A clinical feature model, a CT texture feature model, and a joint model of clinical features and CT texture features were established, and their prognostic values were evaluated by plotting the receiver operating characteristic (ROC) curves. Moreover, a nomogram prediction model was developed according to the multivariate analysis results, and its prediction efficiency was assessed. Results: Age ≤ 40 years, serum alpha-fetoprotein level > 9 ng/mL, gamma-glutamyl transpeptidase > 60 U/L, aspartate aminotransferase > 40 U/L, lesion size > 5 cm, unsmooth tumor margins, no tumor capsule or incomplete capsule, multiple tumors, portal phase CT value of cancer > 135%, and a relative washout ratio > -24% in the portal phase of cancer were risk factors for a poor prognosis in HCC patients after SABR. The area under the ROC curve and sensitivity and specificity of the joint model were 0.817 (95% confidence interval [CI]: 0.773 - 0.861, P < 0.001), 80.47%, and 91.05%, respectively, which significantly exceeded those of the other two models. The nomogram prediction model showed high accuracy and validity. Conclusion: The texture features of CT images before SABR are of a high prognostic value for HCC patients and contribute to the selection of appropriate treatment protocols.

Hepatitis B, C and D virus infections and risk of hepatocellular carcinoma in Africa: A meta-analysis including sensitivity analyses for studies comparable for confounders.

Africa denotes unique facies for hepatocellular carcinoma (HCC) characterized by a conjunction of low sensitization, restricted access to diagnosis and treatment and associated with the highest incidence and mortality in the world. We investigated whether hepatitis B (HBV), C (HCV) and D (VHD) viruses were etiological agents of HCC in Africa. Relevant articles were searched in PubMed, Web of Science, African Index Medicus, and African Journal Online databases, as well as manual searches in relevant reviews and included articles. Analytical studies from Africa evaluating the association between HCC development and HBV, HCV, and HDV were included. Relevant studies were selected, data extracted, and the risk of bias assessed independently by at least 2 investigators. The association was estimated using odds ratios (OR) and their 95% confidence interval (95% CI) determined by a random-effects model. Sources of heterogeneity were determined by subgroup analyses. A total of 36 case-control studies were included. With controls having non-hepatic disease, the overall results suggested a significantly increased risk of HCC in patients with HBV (HBeAg (OR = 19.9; 95% CI = [3.7-105.2]), HBsAg (OR = 9.9; 95%) CI = [6.2-15.6]) and DNA (OR = 8.9; 95% CI = [5.9-13.4]); HCV (Anti-HCV (OR = 9.4; 95% CI = [6.3-14.0]) and RNA (OR = 16.5; 95% CI = [7.8-34.6]); HDV (Anti-VHD, (OR = 25.8; 95% CI = [5.9-112.2]); and HBV/HCV coinfections (HBV DNA/HCV RNA (OR = 22.5; 95% CI = [1.3-387.8]). With apparently healthy controls, the overall results suggested a significantly increased risk of HCC in patients with HBV (HBsAg, (OR = 8.9; 95% CI = [6.0-13.0]); HCV (Anti-HCV, (OR = 7.7; 95% CI = [5.6-10.6]); and HBV/HCV coinfections (HBsAg/Anti-HCV (OR = 7.8; 95% CI = [4.4-13.6]) Substantial heterogeneity and the absence of publication bias were recorded for these results. In Africa, HBV/HCV coinfections and HBV, HCV, and HDV infections are associated with an increased risk of developing HCC. The implementation of large-scale longitudinal and prospective studies including healthy participants to search for early biomarkers of the risk of progression to HCC is urgently needed.

Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium

Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa. We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death). We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001). Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa. None.

Antiretroviral Therapy is Highly Effective Against Incident Hepatitis B Disease Acquisition Among HIV-Infected Adults in Rakai, Uganda

Abstract 30 Background and objective: Co-infection with Hepatitis B (HBV) and HIV is common in sub-Saharan Africa (SSA) and accelerates progression of liver disease to cirrhosis, hepatocellular carcinoma (HCC) and other complications. About 60% of HCC in Africa is attributed to HBV. In Uganda, 80% of HCC patients have HBV and 20% have HIV/HBV coinfection. HCC is the 4th commonest cancer among Ugandan males and the 6th commonest in females. It is almost always a fatal malignancy in SSA. Prevention of HBV is best achieved through vaccination. Vaccination of HIV-infected adults for HBV is standard of care in developed countries but not in SSA where HBV is believed to be acquired in childhood and where there is lack of HBV incidence data. We investigated the incidence and risk factors associated with HBV among HIV-infected adults in Rakai, Uganda. Methods: We screened stored sera from 944 HIV infected adults enrolled in the Rakai Community Cohort Study between September 2003 and March 2015 for evidence of HBV exposure using the anti-HBc marker. Serum from participants who tested anti-HBc negative (497) at the baseline round was tested over 3-7 consecutive survey rounds for either anti-HBc or HBsAg sero-conversion. The time of HBV incidence was defined as the median date between the last anti-Hbc or HBsAg negative sample and the first positive anti-HBc or HBsAg serum sample. Almost all ART treatment regimens contained at least one HBV active medication. Exact poisson incidence methods were used to estimate the incidence of HBV with 95% confidence intervals while the Cox proportional regression methods were used to estimate adjusted hazard ratios of ART use and other confounders. Results: Thirty nine infections occurred (8 positive for both HBsAg and anti-HBc, 3 for HBsAg only, and 28 for anti-HBc only) over 3,342 person-years (pys), incidence 1.17/100 person-years. HBV incidence was significantly lower with ART use: 0.48 /100 person-years with ART use and 2.34/100 person-years without ART (p&lt;0.001) and with HIVRNA suppression: 0.6/100pys with HIVRNA ≤400 copies/mL 6.0/100pys with &gt;400copies/mL (p&lt;0.001). It also decreased significantly with age: 2.60/100 pys if aged 15-29 years, 1.32/100 pys if aged 30-39 years and 0.48/100 pys if aged 40-50 years (p&lt;0.001). The adjusted hazard ratios of HBV incidence significantly differed by ART use: non ART use versus ART use, aHR=0.24 (95% CI, 0.1-0.5), lamivudine (3TC) use: no ART versus 3TC-based ART, aHR= 0.24(0.1-0.5), p=&lt;0.001), HIVRNA suppression ≤400 versus &gt;400copies/mL, aHR= 6.4(2.2-19.0) and by age: 40-50 years versus 15-29 years, aHR= 3.66 (1.3-10.2); 40-50 years versus 30-39 years, aHR=2.18(0.9-5.4). No new HBV infections occurred among participants on a tenofovir-based regimen and there was no statistical significant differences by gender, occupation, marital status or number of sex partners, duration on ART or baseline CD4 count. Conclusion: The protective effects of HBV-active ART medications underscores additional benefits of earlier initiation of ART. Ongoing HBV transmission demonstrated by this study represents an opportunity for vaccine preventive strategies which could ultimately significantly reduce the burden of HCC in SSA. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Emmanuel Seremba No relationship to disclose Victor Ssempijja No relationship to disclose Sarah Kalibbala No relationship to disclose Ronald Gray No relationship to disclose Maria Wawer No relationship to disclose Fred Nalugoda No relationship to disclose Corey Casper Consulting or Advisory Role: Temptime Corporation, GlaxoSmithKline Research Funding: Janssen Pharmaceuticals Travel, Accommodations, Expenses: GlaxoSmithKline, TempTime Warren T. Phipps No relationship to disclose Ponsiano Ocama No relationship to disclose David L. Thomas No relationship to disclose Steven J. Reynolds No relationship to disclose

Changing concept of hepatitis B virus

Hepatitis B virus (HBV) infection is currently one of the most common chronic viral infections worldwide. Two billion people are estimated to be exposed to HBV infection once in their whole life. HBV infection causes a wide spectrum of liver disease, including acute or fulminant hepatitis, inactive carrier state, reactivation, chronic hepatitis, cirrhosis and hepatocellular carcinoma (HCC). More than 420 million individuals in the world are estimated to have chronic HBV infections; 15–40% of them are at risk to die due to liver failure, or HCC. Hepatitis B virus have been classified into four serotypes by mutually exclusive point mutation in the S region of HBV DNA. Recent studies showed eight genotypes, A–H, of HBV are distinguished by a divergence > 8% and molecular evolutionary analysis in the entire genomic sequence and associated with anthropologic and human migration. One of the most important findings in HBV genotypes has distinct geographic distributions and the different clinical manifestations in each area. Genotype A is associated with chronic liver disease more frequently than genotype D which is most prevalent in the world. Genotype A is classified into three subgenotypes, A1–A3, and A1 is reported to be associated with highly prevalence of HCC in Africa with specific mutation in the precore region. Genotype E is reported by the association with progression to HBV carrier during the childhood in East Africa and genotype F and H are localized in the New World. Recent identified genotype G always co-infected with genotype A and is incapable of the processing of HBeAg. HBV genotype B and C are common in Asia and genotype C has higher disease-inducing capacity than genotype B with high positivity of HBeAg and basic core promoter mutation in Eastern countries. Moreover, genotype B is classified into two major subgenotypes, Bj and Ba. Ba is located in Asian countries except Japan and recombinated with genotype C in the core region. Interestingly, Ba is strongly associated with HCC among young generation, < 35 years. Genotype A and D are prevalent in the Middle-East and Central and South Asian countries. These data indicate that clinical differences among HBV genotypes would be attributable by infecting genome structure of HBV genotypes. To investigate these differences, we developed HBV transfection system using 1·24-fold HBV genome constructs belonging to HBV genotypes, Aa, Ae, Ba, Bj, C and D for in vitro and used SCID transgenic mice for urokinase-type plasminogen activator with human hepatocyte (chimeric mice) for in vivo. HBV DNA levels in cell lysates of Huh 7 cells were the highest for C followed by Bj and Ba, by D and Ae (P < 0·01) and the lowest by Aa (P < 0·01), whereas in culture media, they were the highest for Bj, distantly followed by Ba, C and D (P < 0·01), and further by Ae and Aa (P < 0·01). HBV Core protein was about threefold higher for D than Ae and Aa. Cellular retention in Huh 7 cells was higher for C and Ba to other genotypes. HBsAg was most abundant for Ae followed by Aa, Ba, Bj, and C and remotely by D, which was consistent with mRNA levels. The HBV DNA levels expressed in the chimeric mice were higher for C than Ae by 2 logs at 4–7 weeks postinoculation. In conclusion, virological differences in HBV genotypes were demonstrated both in tissue culture and the chimeric mice. These differences explained the different clinical manifestation of HBV infections with distinct genotypes in the host and also indicated that provision against HBV infection through blood transfusion should be considered on specific HBV genotype in each area of the world depending on the diffident clinical and virological characteristics of HBV genotypes.

20 Years into the Gambia Hepatitis Intervention Study: Assessment of Initial Hypotheses and Prospects for Evaluation of Protective Effectiveness Against Liver Cancer

Primary hepatocellular carcinoma is the commonest cancer in The Gambia. The Gambia Hepatitis Intervention Study (GHIS) was established in 1986 to evaluate the protective effectiveness of infant hepatitis B immunization in the prevention of chronic liver disease, particularly, hepatocellular carcinoma and cirrhosis later in adult life. This program was designed based on a series of assumptions. Here, we used data from observational and epidemiologic studies developed since 1986 to examine the validity of these assumptions. We found that (a) hepatitis B vaccine coverage was 15% more than originally assumed, (b) protection against hepatitis B virus (HBV) infection was not dependent on the number of vaccine doses received, (c) perinatal infection with HBV was of negligible importance, and (d) the HBV attributable risk of hepatocellular carcinoma at age < 50 was 70% to 80%, lower than initially assumed. Based on these data, the final outcome of the GHIS should be measurable from 2017, sooner than originally assumed. The GHIS strategy takes into account-specific patterns of virus epidemiology and natural history of hepatocellular carcinoma in Africa and provides a model for integrating and evaluating new vaccines into the Expanded Programme of Immunization of sub-Saharan African countries.

Epidemiology of HBV infection and HBV‐related hepatocellular carcinoma in Africa: natural history and clinical outcome

Epidemiology of HBV infection and HBV‐related hepatocellular carcinoma in Africa: natural history and clinical outcome

Epidemiology, Risk Factors, and Natural History of Hepatocellular Carcinoma

The incidence of hepatocellular carcinoma is increasing in many countries. The estimated number of new cases annually is over 500,000, and the yearly incidence comprises between 2.5 and 7% of patients with liver cirrhosis. The incidence varies between different geographic areas, being higher in developing areas; males are predominantly affected, with a 2:3 male/female ratio. The heterogeneous geographic distribution reflects the epidemiologic impact of the main etiologic factors and environmental risk, which are the hepatitis B (HBV) and hepatitis C (HCV) viruses. The percentage of cases of hepatocellular carcinoma attributable to HBV worldwide is 52.3% and is higher in Asia where the seroprevalence of HBsAg in the population is high. However, the vaccination campaign against this virus in some eastern countries has tended to lower the incidence of new cases of hepatocellular carcinoma. The percentage of cases of hepatocellular carcinoma attributable to HCV is 25%, and it is more prevalent in Japan, Spain, and Italy where the association between hepatocellular carcinoma and antibodies to HCV ranges between 50 and 70%. In most cases hepatocellular carcinoma develops in cirrhotic livers, where the persistent proliferation of liver cells represents the key factor of progression to hepatocellular carcinoma independent of the etiology. Another minor risk factor is aflatoxin B1 consumption, which is responsible for most cases of hepatocellular carcinoma in Africa, where the consumption of contaminated foods is common. Other known risk factors are some hereditary diseases, such as hemochromatosis, porphyria cutanea tarda, hereditary tyrosinemia, and alpha1 anti-trypsin deficiency. The natural history of hepatocellular carcinoma is heterogeneous and is influenced by nodule dimension, the mono- or plurifocality of lesions at diagnosis, the growth rate of the tumor, and the stage of the underlying cirrhosis. Available data to date suggest that tumor growth in a cirrhotic liver is variable and that the time in which a lesion in undetectable until it becomes 2 cm is between 4 and 12 months. Therefore, the suggested interval for surveillance screening with ultrasound in patients with liver cirrhosis has been set at 6 months. Patients who should benefit from screening programs are those who would be treated with curative therapy if diagnosed with hepatocellular carcinoma. Thus, the ideal target population should be limited to Child-Pugh's class A cirrhotic patients without significant comorbidity.

Epidemiology of hepatocellular carcinoma.

Although rare in Canada and the United States, hepatocellular carcinoma (HCC) ranks as the eighth most common cancer in the world. High-risk regions are East and Southeast Asia, and sub-Saharan Africa. Independent of race and geography, rates in men are at least two to three times those in women; this sex ratio is more pronounced in high-risk regions. Rates of HCC in the United States have increased by 70% over the past two decades. Registry data in Canada and Western Europe show similar trends. In contrast, the incidence of HCC in Singapore and Shanghai, China, both high-risk regions, has declined steadily over the past two decades. Among white and black Americans, there is an inverse relationship between social class status and HCC incidence. Chronic infection by the hepatitis B virus (HBV) is by far the most important risk factor for HCC in humans. It is estimated that 80% of HCC worldwide is etiologically associated with HBV. In the United States, although the infection rate in the general population is low, HBV is estimated to account for one in four cases of HCC among non-Asians. Chronic infection by the hepatitis C virus is another important risk factor for HCC in the United States; however, this virus is believed to play a relatively minor role in the development of HCC in Africa and Asia. Dietary aflatoxin exposure is an important codeterminant of HCC risk in Africa and parts of Asia. In Canada and the United States, excessive alcohol intake, cigarette smoking and oral contraceptive use in women also are risk factors for HCC.

African iron overload and hepatocellular carcinoma (HA-7-0-080).

Although HLA-linked hemochromatosis greatly increases the risk for hepatocellular carcinoma in people of European ancestry, iron overload in Africa is not thought to be etiologically related to this malignancy. To determine if African iron overload may be associated with hepatocellular carcinoma, we reviewed 320 consecutive diagnostic liver biopsies processed at the University of Zimbabwe from 1992 to 1994 and we selected for analysis 215 biopsies from adults that were suitable for the histological assessment of hepatocellular iron. Subjects were stratified according to hepatocellular iron grades of 0-2+ (normal levels to mild siderosis; n = 183) and grades of 3+ and 4+ (distinctly elevated levels consistent with iron overload; n = 32). Thirty-six subjects had hepatocellular carcinoma. Logistic regression modeling revealed a significant association between iron overload and hepatocellular carcinoma after adjustment for age, sex and and the presence of portal fibrosis or cirrhosis (p = 0.041). The odds of hepatocellular carcinoma in subjects with iron overload was 3.1 (95% confidence interval of 1.05-9.4) times that of subjects without iron overload. While we could not test for exposure to viral hepatitis or to aflatoxins in this study, our findings suggest that iron overload may be a risk factor for hepatocellular carcinoma in Africa.

Hepatocellular carcinoma and African iron overload.

Both hepatocellular carcinoma (HCC) and iron overload are important health problems in Africa. Chronic hepatitis B virus (HBV) infection is recognised as a major risk factor for HCC, but iron overload in Africans has not been considered in pathogenesis. Up to half the patients with HCC in Africa do not have any recognised risk factors such as preceding chronic HBV infection, and other risk factors remain unidentified. HCC is an important complication of HLA-linked haemochromatosis, an iron loading disorder found in Europeans. It is proposed that African iron overload might also be a risk factor for HCC.

HIV and HTLV in Africa

To the Editor.— In a recent letter toThe Journal, Tabor et al 1 claimed that human immunodeficiency virus type 1 (HIV-1) had not yet been introduced into two separate populations in and that human T-lymphotropic virus type 1 was absent from 1976 to 1981. Although the viruses were not present in the individuals for whom stored serum samples were available, the generalizability of the finding even to the local population of Zambia is substantially limited for two reasons. First, there is no indication of the age or sex distribution of the two groups of study subjects. The median age of hepatocellular carcinoma in Africa is about 45 years, 2,3 suggesting that the group of 123 subjects with this condition may not have been predominantly in the younger age groups that are most sexually active and presumably at highest risk of retroviral infection in Africa. Second, the 95% confidence

Histopathologic features of hepatocellular carcinoma in Zaire

The pathology of hepatocellular carcinoma (HCC) was studied based on 223 Zairian HCC cases registered from 1966 to 1985. The observations included the following: (1) hepatitis B surface antigen (HBsAg) status, (2) histologic types, (3) degree of cellular differentiation, and (4) frequency and types of the accompanying cirrhosis. Serum HBsAg was positive in 56.7% of HCC patients and 5.7% of controls (P less than 0.001). Immunohistochemical localization of HBsAg was positive in 53.3% in normal hepatocytes and in 10% in neoplastic cells. Morphologically, mixed type HCC (48.4%), trabecular (31.4%), and compact variants (13.5%) were predominant. Clear cell and pseudoglandular variants were rare (less than 1%). The majority of tumors (83%) were poorly differentiated HCC (Grades: 2-3, 3, 3-4, and 4). Well-differentiated HCC were extremely rare (0.5%). Fifty percent of HCC arose in a cirrhotic liver, predominantly of the macronodular (67.4%) inactive (55%) type. The micronodular cirrhosis was very uncommon (1.1%). These findings clearly show the excess of poorly differentiated HCC in African patients and suggest a possible link between the morphologic features of HCC in Africa and its extraordinary fast-running course.

Hepatocellular carcinoma: Presentation with vertebral metastases and radicular compression

We have recently seen two patients with hepatocellular carcinoma who presented with vertebral metastases and nerve root compression. The details of their cases are reported, and the literature concerning this presentation of hepatocellular carcinoma is reviewed. It is concluded that any patient with vertebral metastatic disease of unknown origin should be investigated for possible primary liver carcinoma. The increased awareness of this presentation of hepatocellular carcinoma in Africa probably reflects the larger overall experience with the tumor in that continent.