THE RISK OF HEPATOCELLULAR CARCINOMA ON PATIENTS DIAGNOSED WITH HEPATITIS B AND HEPATITIS D (2012-2015)

Introduction. Hepatocellular carcinoma is the most common primary liver cancer (90%), the 5th neoplasia in terms of incidence and the 3rd mortality cause worldwide (1). This increased mortality is the consequence of diagnosis in an advanced state and of the fact that most HCC develop based on a chronic hepatic pathology. In Romania, around 7% of the population is affected by chronic hepatitis B, the incidence of this disease being increased in urban areas (2). The sooner the hepatitis B virus infection occurs in life, the higher the probability is, for this to become chronic and to lead to cirrhosis or liver cancer. Hepatitis D only occurs among people who are infected with the Hepatitis B virus because HDV is an incomplete virus that requires the helper function of HBV to replicate. Objective of the study. The main purpose of the surveillance and/or screening is to decrease mortality and morbidity by means of liver cancer for patients diagnosed with hepatitis B and hepatitis D. Matherial and methods. The study was conducted on a number of 102 patients diagnosed with viral hepatitis (HBV, HDV+HBV) admitted at the “Fundeni” Hospital, Bucharest, between 2012-2015. Two batches of patients were taken into account (patients with hepatitis B and hepatitis D). The viral load and chosen treatment were clinically, biochemically and imagistically evaluated. Results. We have noticed a significant increase in patients diagnosed with hepatitis B and D. The existence of the hepatitis D infection in patients diagnosed with hepatitis B significantly increases the occurence potential of liver cancer. The hepatic destruction degree by means of cirrhotic liver occurence respectively hepatic cirrhosisis much higher for patients diagnosed with hepatitis D. Conclusions. The close monitoring of the patients in this research program brings real benefit for the prevention of liver cancer and diagnosing it early, having a much better prognosis on the quality of life.


INTRODUCTION
Most patients diagnosed with hepatocarcinoma in Romania are admitted with tumors in an advanced state. HCC incidence is in a constant increase, whilst general survival rate of 5 years is still under 10%, which is caused by the impossibilitty of applying an efficient screening on patients with an HCC risc factor. Hepatitis B is a serious liver infection caused by the hepatitis B virus (HBV) (1,2). The infection with hepatitis B virus represents the 10 th mortality cause in the world, causing 80% of the liver cancer cases. Often these symptoms last a few weeks and rarely does the initial infection result in death. It may take 30 to 180 days for symptoms to begin. In those who get infected around the time of birth 90% develop chronic hepatitis B while less than 10% of those infected after the age of five do. Most of those with chronic disease have no symptoms; however, cirrhosis and liver cancer may eventually develop (2)(3)(4). These complications result in the death of 15 to 25% of those with chronic disease. A vaccine can prevent hepatitis B, but there's no cure if you have it. Progression to cirrhosis usually takes 5-10 years, but it can appear 2 years after onset of infection (5,6). About 60 to 70% of patients with chronic hepatitis D develop cirrhosis. A high proportion of these patients die of hepatic failure. Hepatocellular carcinoma (HCC) occurs in chronically infected HDV patients with advanced liver disease with the same frequency as in patients with ordinary hepatitis B. HCC may actually be more a secondary effect of the associated cirrhosis than a direct carcinogenic effect of the virus (7,8). The mortality rate for HDV infections lies between 2% and 20%, values that are ten times higher than for hepatitis B (9). Pathologic changes in hepatitis D are limited to the liver, the only organ in which HDV has been shown to replicate (10,11). The histologic changes consist of hepatocellular necrosis and inflammation (12). There is no vaccine for Hepatitis D, but it can be prevented in persons who are not already HBV-infected by Hepatitis B vaccination.

PURPOSE
The main purpose of the surveillance and/or screening is to decrease mortality and morbidity by means of liver cancer for patients diagnosed with hepatitis B and hepatitis D. The symptomatic development of the hepatic tumor is closely associated with the hepatic virus B. Even more, the hepatic disease is an important prognosis factor that can significantly influence the survival of the patient, moreover by limiting the therapeutical possibilities with improvement visa. Therefore, an exact diagnosis is the key to a successful HCC therapy. Even though in the past 10 years the prophylaxis of acute viral hepatitis B has been an epidemiological priority in Romania, by introduction of vaccination in the National Immunization (in 1995), high media coverage and studies on the population, there was no success in the limitation of acute HBV infections, only noticing a moderate annual decrease. The present thesis has the purpose of studying clinical forms of HBV and HDV infection in patients admitted at the "Fundeni" Hospital, Bucharest, during the time period 15.01.2012 -10.01.2015. We have tried to determine the connection between age, sex, residence of the patient and the seriousness of the infection, and also the role of the co-infection with HDV and the pathology associated with the evolution of the disease.
The main objectives of the study are: 5. Monitoring the patients diagnosed with HBV and HBD by ultrasound and periodically conducted AFP, every 6 months. 6. Establishing an epidemiology plan for the prophylaxis of the HBV infection.

MATHERIALS AND METHODS
HCC is mostly an asymptomatic disease. Given the fact that this neoplasis develops on a hepatic pathology, a series of prophylaxis methods have been applied to HBV and HBV+ HDV patients, survaillance by means of abdominal ultrasound, fibroscan, biochemical parametres and by monitoring the αFP is still the basis of an exact diagnosis. The current study is based on a number of 102 patients admitted at the "Fundeni" Hospital, diagnosed with HBV and HDV during the time period 15.01.2012 -10.01.2015. The study is a retrospective statistical one of the patients admitted with a B and D hepatic virus, using all personal documents presented by them at admission and those obtained from the moment of admission specialty clinicalparaclinical conjunction, taking into account data obtained from other specialists ( from gastroenterological, medical, anathomical-pathological services). The evolution of hepatic infections is done by periodically monitoring the ultrasound, αFP, the biochemical parameters and in some cases the carcinoembryonic antigen (CAE) and the carbohydrate antigen CA-125. By determining the oncofetal antigen, respectively the carcinoembryonic antigen (CAE) and the carbohydrate antigen CA-125, we have found significantly increased values only in hepatic methastasis cases, therefore any liver structure modification as well as biochemical modification of the hepatic marker (αFP) is alarming.
The close monitoring of the patients in this research program brings real benefit for the prevention of liver cancer and diagnosing it early, having a much better prognosis on the quality of life.

RESULTS
The study has taken into account 102 patients with viral hepatitis B and D. The componence of the batches is presented in the following table:  The most consistent batch is the "HB" batch, in which more than half the cases are included. What is worrying is the very high increase (38%) of patients diagnosed with Hepatitis D and Hepatitis B. An HDV infection absolutely requires an associated HBV infection. Infection with both HBV and HDV is associated with more severe liver injury than HBV infection alone. The outcome of disease largely depends on whether the two viruses infect simultaneously (coinfection), or whether the newly HDV-infected person is a chronically infected HBV carrier (superinfection). Overinfection can worsen the hepatic lesions and, over the course of a few decades, it can lead to cirrhosis and hepatocellulary carcinoma. Coinfections of HBV and HDV are usually acute, self-limited infections. The chronic form of hepatitis D is seen in less than 5% of HBV-HDV coinfected patient. Out of all the patients diagnosed with hepatits B and hepatitis B+ Hepatitis D, 68 males and 34 females have been identified. The incidence was higher for male patients, which can be seen in Fig. 2. In our study, the M:F comparison was 2,7:1, whilst worldwide it is 3,7:1. Although the cause of incidence difference is unknown, the working environment and also ethanol abuse can be blamed. The high occurrence of hepatocellulary carcinoma in male patients can be based on hormonal profile, working environment or life style.  The structural evolution of the liver is very important. According to Table 2, 76% of the patients diagnosed with hepatitis B have a cirrhotic liver. The study shows that the overinfection of co-infection with hepatitis D is close to that, with a very high percentage (74% of the total). Therefore, patients with hepatitis D develop the cirrhotic syndrome much faster.

FIGURE 3. The presence/absence of cirrhotic liver is presented in batches in the following tables
The hepatic function was evaluated from a biochemical point of view. The mean AST value was 119 UI/L and the ALT value was 110 UI/L. The mean RBC value in the moment of admission was 11.8 g/dL and the mean hematocrit value was 38.4%. In principle, throughout the monitoring process, there were no This time, all three coefficients are significantly different from 0, indicating the existence of correlations significant hemoglobine decreases identified.
Between each variable pair there is a strong correlation Between each pair of variables exists a strong correlation (Pearson coefficient is over 0.7), also the correlation between the Alanine aminotransferase and the Aspartine aminotransferase values is very strong (Pearson coefficient is 0.914). The following diagram reflects this situation, all cases alining in the trusted reference levels of 95% on one side and the other of the regression line. In conclusion, the subscribed patients had a normal hepatic synthesis function, with no signs of cholestasis, but most of the have increased values of the hepatocellulary destruction markers. The study shows that the high viraemia viral infection B is associated with a high degree of fibrosis. Most times the degree of fibrosis is identified by imagistic evaluation, most frequently by FibroScan, Fi-broTest and abdominal ultrasound. The subscribed patients are, in an overwhelming proportion, cirrhotic. Symptoms are less severe than in acute hepatitis, and while serum ALT and AST levels are elevated, bilirubin and albumin levels and prothrombin time may be normal. In chronic hepatitis D, the HBV markers are usually suppressed. The HCC occurrence in non-cirrhotic patients, although possible through the direct viral carcinogenesis mechanism, is much less common. Most times, as our analysis shows, HCC occurs on a 84.2% cirrhotic liver, after a long evolution of the basic pathology. Alpha-fetoprotein (AFP) is used as a tumor marker to help detect and diagnose cancers of the liver. Though the test is often ordered to monitor people with chronic liver diseases such as cirrhosis, chronic hepatitis B or hepatitis C because they have an increased lifetime risk of developing liver cancer, most current guidelines do not recommend this use. The purpose of the study is to closely monitor patients with hepatitis D, because lately there has been a considerable increase in the transmission of the viral infection. The AFP level in patients with hepatitis D is much higher than in patient diagnosed only with hepatitis B. The use of the alpha feto protein (AFP) as tumor marker consists especially in the detection and monitoring of the evolution of the hepatocellulary carcinoma, which develops alongside hepatic cirrhosis and chronic hepatitis. An AFP serum increase in a patient with hepatitis B or hepatitis D would have to raise awareness that he/she has developed hepatocellulary carcinoma. It is generally accepted that the serum levels higher than 500 mcg/l (normally, in most laboratories they are between 10 and 20 mcg/l) in a high risk patient is a matter of HCC diagnosis. The survival of patients was analysed according to AFP values when they subscribed for the study and when the study ended. From our point of view, the data have no importance for initial values (Pearson coefficient=0.17) but have an importance for the final values of the study (progress, death).
Therefore we believe that AFP values don't even have a prognosis impact for the neopasis that show AFP, except a short-term prognosis. The category with the lowest patient survival rate was the one with patients with values between 100 and 500. CONCLUSIONS 1. A closer and more careful surveillance of patients entering this research program is highly beneficial for the prevention and detection of liver cancer at its early stages, allowing thus a more favorable prognosis in terms of the patient's quality of life. The most important risk factors that foster the development of liver cancers are represented in this study by the presence of viral hepatic markers.
2. Viral infections with hepatitis B and hepatitis D viruses occur more frequent in men. Consequently, the incidence of developing liver cancer is significantly higher in men than in women.
3. The occurrence of infection with hepatitis D virus in HBV patients increases considerably the potential of liver cancer development. The degree of liver damage caused by the occurrence of cirrhotic liver and cirrhosis respectively is higher in HDV patients. 4. High viraemia Hepatitis B is associated with a high degree of fibrosis, analysed imagistically and by using FibroScan. 5. In this study, the ALT level has directly influenced the carcinogenetic, evolution, its progression being more rapid than in the patients with constant ALT levels. Among all biochemical parameters we have analyzed (albuminemia, bilirubin, coagulation parameters), the reduction of the platelet count was the single variable that accurately and specifically reflected the unfavorable evolution to the worsening stage of the hepatic fibrosis. 6. AFP can temporarily increase whenever the liver is injured and regenerating, and moderate elevations can be seen with a variety of conditions. Because of this, AFP testing cannot be used solely to diagnose cancer. In addition, not every cancer will produce AFP, so a person could still have cancer even when the AFP is normal. For these reasons, the AFP test should not be used to screen the general population for cancer.
7. The AFP diagnosis-related sensibility and specificity highly depend on the admissible threshold value. There has been considered that values exceeding 400 ng/ml indicate the presence of HCC while the values varying from 100 to 400 ng/ml indicate the susceptibility of HCC 8. The biological manifestations highlighted in HCC on the cirrhotic liver have a nonspecific nature and are largely the expression of a the pre-ex-isting liver disease. The preponderant increase of AST compared to ALT and the unexplained, isolated increase of cholestasis enzymes suggest in a certain clinical context the possibility of developing a HCC. The analysis of hematologic parameters enables the identification of possible paraneoplastic syndromes 9. The importance of ultrasound for the surveillance and early detection of liver cancer and the use of AFP as adjuvant test in diagnosing the liver cancers. Ultrasound imaging is often used due to its accuracy in the early detection of liver nodules (dysplastic regenerative nodules). 10. Ultrasound imaging represents a very efficient method for screening the patients diagnosed with viral hepatitis B and D. If performed regularly, it allows the early detection of the disease in a large number of patients, improving thus the disease prognosis.
11. HCC prevention must become the main concern in Romania, given the ineffective treatment for advanced stages. Primary (vaccination) and secondary (screening) prevention measures as well as the broadening of access to antiviral therapies are necessary measures in our population.