Potential Role for a Panel of Immunohistochemical Markers in the Management of Endometrial Carcinoma

BACKGROUND: In order to improve the efficacy of endometrial carcinoma (EC) treatment, identifying prognostic factors for high risk patients is a high research priority. This study aimed to assess the relationships among the expression of estrogen receptors (ER), progesterone receptors (PR), human epidermal growth factor receptor 2 (HER2), Ki-67, and the different histopathological prognostic parameters in EC and to assess the value of these in the management of EC. METHODS: We examined 109 cases of EC. Immunohistochemistry for ER, PR, HER2, and Ki-67 were evaluated in relation to age, tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage and grade, depth of infiltration, cervical and ovarian involvement, lymphovascular space invasion (LVSI), and lymph node (LN) metastasis. RESULTS: The mean age of patients in this study was 59.8 ± 8.2 years. Low ER and PR expression scores and high Ki-67 expression showed highly significant associations with non-endometrioid histology (p = .007, p < .001, and p < .001, respectively) and poor differentiation (p = .007, p < .001, and p <. 001, respectively). Low PR score showed a significant association with advanced stage (p = .009). Low ER score was highly associated with LVSI (p = .006), and low PR scores were associated significantly with LN metastasis (p = .026). HER2 expression was significantly related to advanced stages (p = .04), increased depth of infiltration (p = .02), LVSI (p = .017), ovarian involvement (p = .038), and LN metastasis (p = .038). There was a close relationship between HER2 expression and uterine cervical involvement (p = .009). Higher Ki-67 values were associated with LN involvement (p = .012). CONCLUSIONS: The over-expression of HER2 and Ki-67 and low expression of ER and PR indicate a more malignant EC behavior. An immunohistochemical panel for the identification of high risk tumors can contribute significantly to prognostic assessments.

Predictors of hepatocyte proliferative activity in chronic hepatitis B and C vs. steatohepatitis as assessed by the monoclonal antibody MIB1-Ki-67Predictors of hepatocyte proliferative activity in chronic hepatitis B and C vs. steatohepatitis as assessed by the monoclonal antibody MIB1-Ki-67

Chronic hepatitis is characterised by increased regenerative cell proliferation, a process that makes cells more susceptible to gene mutations and development of hepatocellular carcinoma [HCC]. Evaluation of the proliferative index could be a useful tool for identifying patients at risk for HCC. The current study was planned to evaluate hepatocyte proliferation in predominant causes of chronic liver disease in an attempt to investigate predictors of proliferation. This study included 84 patients with chronic liver diseases, and they were classified into three groups: chronic hepatitis C [50 patients], non-alcoholic steatohepatitis [NASH] [20 patients] and chronic hepatitis B [14 patients]. All cases were investigated by liver function tests, polymerase chain reaction [PCR] hepatitis C virus [HCV] and hepatitis B virus [HBV], routine abdominal ultrasound and liver biopsy with detection of the proliferative index using the monoclonal antibody MIBI-Ki-67. The proliferative index was significantly higher in the chronic hepatitis C group than in the chronic hepatitis B group [P value = 0.007]. There were significant correlations of the Ki-67 index in both zone 1 and zones 2 and 3 with alanine aminotransferase [ALT], aspartate aminotransferase [AST] and histological activity index [HAI] score. Using the multiple regression analysis on the variables affecting proliferation, it was found that predictors of zone 1 proliferation were the following variables: ALT, age, AST and aetiological factor, in that order. HCV aetiology had significantly higher proliferation index, whereas NASH had the least. Increased HAI score is associated with higher proliferative index in either zone 1 or zones 2 and 3. Predictors of proliferation index in zone 1 were ALT, age, AST and aetiological factor

Some clinicolaboratory predictors of nonalcoholic steatohepatitis

In nonalcoholic fatty liver disease [NAFLD], the high cost of undertaking histological assessment of all persons with asymptomatic elevations of liver enzymes cannot be justified in view of the risks and limited clinical benefits. As the clinicians cannot distinguish steatosis and nonalcoholic Steatohepatitis [NASH], the purpose of this work was to study some of the clinical and laboratory parameters that could be useful as noninvasive predictors of NASH in NAFLD patients. The demographics, clinical, radiological, laboratory, and histopathological features of 40 NAFLD patients with persistently elevated ALT were evaluated. Significant rise of serum glucose, ALT, AST, cholesterol, LDL and TG with significant decrease of HDL was found in NASH versus steatosis patients, and in patients with grade II NASH versus those with grade I. The number of NASH patients was higher among studied diabetic than non-diabetic group and in obese than non obese group. Grade II NASH was found only in diabetic and in obese patients. In NASH patients, the relative risk of hypertriglyceridemia was 17, of obesity 7.13, of diabetes 1.47, but with hypercholesterolemia it was only 1.1. In obese patients particularly those with diabetes, presence of hepatomegaly, sonographically bright liver, persistent rise of transaminases and hypertriglyceridemia are sufficient to diagnose Steatohepatitis and might prove useful in guiding selection of patients for liver biopsy and in targeting therapy

Serum transaminases and platelet count as predictive factors of fibrosis and cirrhosis in patients with chronic hepatitis C

Chronic hepatitis C is a major health problem in Egypt. Definite diagnosis of cirrhosis depends on liver biopsy. However liver biopsy had a number of limitation including, it is an invasive technique with some complications, sometimes negative results occurred and occasionally contraindicated. The aim of this work is to evaluate serum transaminases and platelets counts as non invasive, easy and simple parameters for determining the degree and stage of cirrhosis in chronic HCV infection and to applicate these parameters as a predictor of cirrhosis. This study was done on 38 patients selected as chronic hepatitis C [26 males and 12 females] aged between 19 and 49 years. All patients underwent: Full medical history, thorough clinical examination, CBC, complete liver function tests including prothrombin time and concentration, HBsAg, HCV Ab screening, HCV RNA [by PCR] abdominal U/S and finally liver biopsy to determine the degree and stage of cirrhosis. There was statistically significant negative correlation as regard WBCs, platelet, RBCs count and haemoglobin concentration with progression of cirrhosis. As regard liver function tests, there was a statistically positive significant correlation regarding ALT, AST and prothrombin time, while there was statistically significant negative correlation regarding serum albumin. However, HCV RNA [PCR] had no significant correlation with the degree and stage of cirrhosis. Also, steaosis was highly statistically significant in detection of degree and stage of cirrhosis. It can be concluded that, platelet count, serum transaminases, serum albumin and prothrombin time are non invasive valid parameters for prediction of cirrhosis in chronic HCV patients and can replace liver biopsies in many cases

Prevalence of hepatic steatosis in Egyptian patients with chronic hepatitis C [CHC] virus infection and histopathological correlation

Hepatic steatosis is a histological characteristic in patients with chronic hepatitis C [CHC] virus infection. It has been proposed that hepatic steatosis is a cytopathic effect of hepatitis C virus genotype 3a, but not other genotypes. Several studies have demonstrated that more than 90% of [CHC] patients in Egypt are infected with genotype 4. To our knowledge there is no enough data about the prevalence of steatosis in genotype 4. The aim of study was to evaluate the prevalence of hepatic steatosis in Egyptian patient with [CHC] genotype 4 and looking for possible correlation with various biochemical and histopathological variables. This study was carried out on 153 patients, with proved chronic hepatitis C [CHC] [positive HCV antibody and HCV RNA], the patients were excluded if they have concomitant hepatitis B infection, liver cell failure, severe renal, heart disease or history of alcohol abuse. Biochemical and histopathological findings were compared between patients with and without hepatic steatosis. Steatosis was found in 73 patients [47.7%], 40 of them [54.8%] had mild steatosis, 21 [28.8%] and 12 [16.4%] had moderate and severe steatosis respectively. No significant differences in level of total serum bilirubin, level of ALT, AST and serum albumin were found among patients with hepatic steatosis and patients without. Histopathological study showed that patients with hepatic steatosis had higher mean fibrotic score and higher mean necroinflammation grading than patients without hepatic steatosis [3.33 +/- 1.49 Vs 2.92 +/- 1.84], [6.96 +/- 2.26 Vs 6.04 +/- 2.64] but with no statistically significant difference. There was no significant statistical differences in the mean age, level of ALT, AST, Serum bilirubin and S. albumin with the increase of grade of steatosis. Steatosis is a feature of CHC Genotype 4 in almost 50% of patients and half of them had moderate to severe steatosis, no significant correlation were found between steatosis and necroinflammatory changes or the meanfibrotic score although steatosis was associated with higher mean necroinflammation score and high mean fibrotic score but without significant statistical difference

Prognostic value of HER-2/NEU expression in breast carcinoma

Although axillary lymph node status is still the most powerful prognostic indicator, 15 to 45% of patients whose lymph nodes do not contain metastases still experience a recurrence and die. Conversely, up to 15% of patients with >10 positive lymph nodes treated only with surgery and radiotherapy survive without recurrence or metastases. Because of this, other prognostic markers have been developed to improve prognostic accuracy, particularly in the group of patients with node-negative tumors. To study the expression and prognostic value of HER-2/neu in breast cancer patients, to determine its role in defining high risk patients in cases with a relatively good prognosis [e.g. node negative cases and progesterone receptor [PR] positive cases]. This study included 90 patients with invasive breast cancer [44 patients node positive and 46 patients node negative]. Study for histopathologic prognostic factors was done and immunohistochemical study for HER-2/neu, oestrogen receptors [ER] and pogestrone receptors. HER-2/neu was positive in 26.1% of lymph node negative cases, positive in 31.8% of lymph node positive cases and positive in 28.9% of all patients.HER-2/neu overexpression, by itself, possessed a highly significant prognostic value for shorter overall survival [O.S] and disease free survival [D.F.S] for the whole patients group and for progesterone receptor positive cases. However, in the lymph node negative group it has significant prognostic value for shorter overall survival, by itself, but it lost its effect on steroid receptors. HER-2/neu overexpression seemed to identify patients with poor outcome from those subgroups known to have good prognosis e.g. progesterone receptor positive cases [regarding both disease free survival and overall survival] and node-negative patients [regarding overall survival]

Why total thyroidectomy for benignthyroid disease ?

Aim :The aim of this study was to evaluate Total Thyroidectomy asa an option for clinically benign Thyroid Disease as multimodular goiter,Grave's disease and thyroiditis.Since the re operation for the recurrentgoiter after surgery less than total Thyroidectomy.Or incidental cancermay be associated with increased complication rate many times thanthat due to total Thyroidectomy from the start

Patients and Methods: This prospective study included 45 patientswho underwent total thyroidectomy for benign thyroid disease. It included 32 women and 13 men with mean age 42.3 years. Indications of sur-gery were simple multimodular goiter 28 [ 62.2 % ] ,Toxic nodular goiter 8[17.8 %] Graves disease 6 [ 13.3 %] Hashimoto's thyroiditis 3 [6.7]

Results :Transient recurrent laryngeal nerve injury occurred in 1 patient [2.2 %].Permenant new injury in 1 patient [ 2.2 %].Transient hypocal-cemia in 2 [4.4%] Permenant hypocalcemia in 1 [2.2 %] hematoma indicat-ing reoperation in 1 [ 2.2 ] incidental thyroid cancer in 4 [8.9]

Conclusion :For patients with bilateral involvement of thyroid glandby clinically Benign disease , Total Thyroidectomy is a preferred optionbecause it decreased the future redo for recurrent diseases or incidentalcarcinoma

Association of serum vascular endothelial growth factor level with estrogen receptors status in breast cancer patients

Aim: angiogenesis is essential for tumour growth and metastasis. Vascular endothelial growth factor [VEGF] has been suggested as the major angiogenic factor in breast carcinoma. The aim of the present study was to analyze the relationship between the serum of vascular endothelial growth factor [VEGF] in breast cancer patients and its relationship to various prognostic indices and estrogen receptor status

Methods: VEGF levels was determined in 45 breast cancer patients a d 15 healthy women, using enzyme-linked immunoassay technique

Results: serum vascular endothelial growth factor [VEGF] levels were detected in 45 patients with breast cancer before surgery and at 3 weeks after surgery. The serum VEGF levels of the cancer patients as a group were significantly elevated compared with those of the controls [P < 0.0005]. VEGF levels were elevated in patients with invasive cancer of duct carcinoma, and estrogen receptor [ER]-positive tumors. Post-operatively, VEGF level decreased significantly

Conclusions: preoperative senln2 VEGF detects breast cancer with a sensitivity of 62.2%. The relationship to cancer type and EX status may have future therapeutic implications which deserves more extensive study

Surgical treatment of bronchial carcinoid tumors analysis of factors affecting outcome

Background: Bronchial carcinoid tumors are relatively rare tumors. These tumors were wrongly considered as bronchial adenomas till 3 decades ago. Now these tumors are classified as neuroendocrine bronchopulmonary tumors of lower grade of malignancy that arise from Kulchitsky cells

Aim: to study the spectrum of pulmonary carcinoids presented from our locality, demonstrating its clinicopathological profile. Also to analyze our results of surgery for these tumors and compare it with those of other centers to define the influence of the site of the tumor, carcinoid histological category , and lymph node involvement on the outcome of surgery

Patients and methods: Forty three patients with pulmonary carcinoid tumors were surgically treated at the Department of Cardiothoracie Surgery, Mansoura University Hospitals, through a period of 10 years ending December 2003. The files of all the patients were retrospectively revised for the demographic profile, clinical data, and findings of both rigid and fiberoptic bronchoscopy done to the patients. Also data extracted from CT scans and virtual CT bronchoscopy were collected and tabulated. All the patients had pulmonary resection varying from pneumonectomy till segmentectomy , according to the location and extent of the tumors. All the resectd pulmonary specimens, along with its hilar and mediastial lymph nodes were examined histopathologically, and reviewed according to the current WHO/IASLC criteria for neuroendocrine tumors. Patients were followed up from 1 to 10 years for recurrence and long term survival in relation to both typical and atypical carcinoid categories, LN affection , central and peripheral location. Results were recorded and tabulated for deduction of statistical significance

Results: The patients had a mean age of 39.35 +/- 8.55 years [range 21-64 years], 27 were females [62.79%] and 16 were males [37.3%]. Thirty five patients were symptomatic [79.1%]. Haemoptysis was the most common presenting symptom, occurring in 22 patients [51.1%]. Only 9 patients were asymptomatic [20.9 %]. Data from CT scan and bronchoscopy revealed that 29 patients [67.4%] had central tumors while 14 cases had peripheral ones. Preoperative tissue diagnosis was obtained in 22 patients [51%]. The 43 patients has 43 Operative; 21 had lobectomies, 19 had bilobectomies, one formal and one completion pneumonectomy and one segmentectomy. Typical carcinoid type was found in 35 patients [[81.3%] and eight cases had atypical carcinoid [18.7%]. Of the 35 patients with typical carcinoid. 5 had lymph node involvement [14.2%], while 3 out of 8 cases of atypical carcinoid [37.5%] showed lymph node involvement. We had one hospital mortality [2.3%] due to pulmonary embolism in an obese male aged 61 years, W. had 10 postoperative complications in 6 patients [13.9%] . We found no statistically significant correlation between the incidence of morbidity and hospital mortality and the carcinoid tissue type , place of the tumor or LN affection. Follow up: Out of the typical carcinoid group [34 surviving patients]. 29 Patients who had no LN involvement had 5 year disease free Survival of 96.55%. Out of the 5 cases with LN involvement had 5 year disease free survival 80%. Out of the atypical carcinoid group [8 surviving cases] , 5 cases who had no LN involvement had 5 year disease free survival 60%. Three cases with LN involvement, got 5 year disease free survival of 33% at the end of 5 years of follow up. By comparing results of different groups, significant predictors of 5 year disease free survival are typical carcinoid histology, absent mediastial LN involvement , and peripheral type of carcinoid

Conclusions: Carcinoid tumor is not uncommon bronchial tumor that affects females more than males. Long term survival is favorable in typical carcinoid with no LN affection, prognosis is better in peripheral type. atypical carcinoids have worse long term survival rates and recurrence Patterns, a wide surgical resection with LN clearance is essential for successful long term disease free Survival

Detection of chlamydia pneumoniae in diseased aortic and mitral valves diagnostic dilemma

Chlamydia Pneumoniae [CP] is a common pathogen that has been linked to coronary artery disease. Also, CP antigen has been demonstrated in valve biopsy specimens from patients with acquired aortic valve stenosis and in patients with culture negative endocarditis. The aim of this paper is to study the presence of CP in both aortic and mitral valves by using polymerase chain reaction [PCR] and its relation to the pathology of the valve. 27 patients [16 males] who underwent aortic and mitral valve replacement were studied. Key demographic and clinical data were collected including age , gender , past history of rheumatic fever . NYHA class, preoperative 12 leads ECG. Chest X-ray and Echocardiography. One portion of the valve leaflet was sent for pathologic examination to detect the nature of valve disease e.g. rheumatic or non-rheumatic and the other portion was sent for PCR study. The age ranged from 19 to 55 years with mean valve 36.48 +/- 11.46. 5 patients had isolated aortic valve stenosis , 12 had mitral valve disease and 10 had double valve disease . Aschotf body and cells were seem in 11 patients and 5 patients had non-rheumatic degenerative aortic stenosis . 7 out of 27 cases [25.9%] were PCR positive. 5 of them were isolated non-rheumatic aortic stenosis and represent [33. %] of aortic cases. The remaining 2 PCR positive cases were rheumatic mitral valve disease one of them was severe isolated mitral regurgitation due to native valve endocardifis . CP infection was common with nonrheumatic aortic valves [P=0.045] and also with stenotic lesions than regurgitant ones [P=0.045]. Culture negative endocarditis maybe due to CP infection and also CP maybe present in rheumatic mitral valve most probably as passengers

Influence of tumor grade and CD95 expression on progression-free survival following surgery and irradiation for localized intracranial ependymoma

This study was conducted to evaluate the impact of extent of tumor resection, histological grade and CD95 expression on the progression-free survival [PFS] after surgical excision and irradiation [RT] for patients with localized intracranial ependymomas. This study includes thirty four patients with localized intracranial ependymomas with median age of 23.5 [range 2-65] at the time of surgical excision. All patients underwent microsurgical resection followed by RT with or without chemotherapy during the period between January 2000 and June 2003. Ten patients were histologically identified as anaplastic ependymoma [AEP]. Immunohistochemical staining for CD95 was applied as a marker for apoptosis for all specimens of the studied group. The extent of surgical resection was estimated as gross total resection in 21 patients [61.8%], near total resection in 4 patients [11.8%] and subtotal resection in 9 patients [26.5%]. The median dose of RT to the primary site was 55Gy. Only 8 patients received pre RT chemotherapy [CTh]. At a median follow up period of 24.5 months [range 6-51 months], 25 patients were alive, while, at a median follow up of 22 months [range 8-49 months], progression occurred in 15 patients [12 local and 3 local and distant], with a median time to failure after RT of 18 months [range 5-37 months]. There was a significant influence of gross total resection [p=0.003] and tumor grade [p=0.009] on the PFS after RT. The two years PFS rate was 26% +/- 13% for patients with AEP compared with 82% +/- 7% for patients with EP. When correlating these findings with the extent of surgical resection, age less than 4 years, pre-RT CTh and CD95 expression, they remained significant. AEP was more frequent in the supratentorial ependymomas. Five of 9 patients with supratentorial tumors developed recurrence and all were anaplastic type [AEP] and CD95-stained tumors. Progression-free survival was found to be significantly influenced by the extent of surgical resection. Tumor grade and apoptosis have an impact upon the outcome of patients with ependymoma treated with surgery and RT. CTh before RT had a worse effect on the PFS and overall survival.

Prognostic value of matrix metalloprotinease2 [MMP-2] and p53 expression in colorectal carcinoma patients with lymph node metastasis

P53 gene mutation occurs in about 50-60% of colorectal carcinoma [CRC] patients. The key enzymes responsible for extracellular matrix breakdown are matrix metalloproteinases [MMPs]. These have been reported to plug an important role in tumor cell invasion and metastasis, which are major factors in the morbidity and mortality of CRC. The study included 46 patients with CRC who were diagnosed and treated in Mansoura University Hospital d w the period between January 1999 to January 2001. They were treated with left or right hemicolectomy, anterior resection or total mesolectal excision. These included 24 males and 22 females with age ranged from 22-70 year with median age of 46 years [+/- 1 4] Immunohistochemically staining of both tumor and positive lymph nodes was performed on paraffin sections for p53 and MMP2. Twenty one patients were stage C with lymph node metastasis. P53 diffuse positive staining of the tumor cell nuclei was identified in 16 out of 46 [3596] tumor cases and 10 out of 21 [48%] of metastatic tumors. Cytoplasmic MMP-2 expression was positive in 20 out of 46 [43%] tumors, where its expression in the stroma was positive in 17[37%] In lymph node metastasis, cytoplasmic MMP-2 was positive in 11 out of 21 [52%] of tumors. There was a statistical correlation between p53 and MMP-2 expression in lymph node metastatic tumors [p<0.05]M. MP-2 was seen more in tumor cells invading the muscular is with little staining in more superficial areas. Poor survival was associated with MMP2, p53 expression in patients with 1ymph node metastasis. Lymph node metastatic tumors have higher incidence of p53 and MMP2 staining. These data suggest a role for MMP-2 in colorectal cancer with lymph node metastasis. These results confirm the prognostic value of MMP-2 and p53 on survival of CRC

postcholecystectomy syndrome. A prospective study of 46 patients

Although cholecystectomy is one of the most frequently and successfully performed operation for treatment of symptomatic gall stones, the development of postoperative symptoms is embrassing to the surgeon and may represent a source of discomfort to the patient. The aim of this study is to evaluate the possible etiological factors that may be implicated in development of postcholecystectomy dyspepsia, including helicobacter pylori [H. pylori] colonization, gastric electrical and mucosal changes. This prospective study has been carried out on 46 patients [20 males and 26 females] with mean age of 41.7 +/- 0.2 years. All patients had symptomatic gall stones and were subjected to cholecystectomy. These patients were carefully evaluated before surgery and one year after. The workup included thourough history and clinical examination, upper gastrointestinal endoscopy, histopathological examination of the antral mucosa, H. pylori detection and electrogastrography [EGG]. The number of patients presenting with symptoms suggestive of reflux gastritis increased after surgery. Patients experiencing epigastric pain increased from 17.4% [8 cases] to 23.4% [11 cases], nausea increased from 13% [6 cases] to 26.1% [12 cases] and bilious vomiting increased from 6.5% [3 cases] to 23.9% [11 cases]. Mild antral gastritis increased from 43.5% [20 cases] to 58.7% [27 cases]. Moderate antral gastritis were detected in 17.4% [8 cases], whereas severe antral gastritis with erosions were detected only in 4.3% [2 patients] after cholecystectomy. The incidence of chronic superficial gastritis decreased from 50% to 28.2% while the inactive form increased from 32.6% to 50%. Chronic atrophic gastritis with intestinal metaplasia or dysplasia were only detected in 4.3% of patients. H. pylori infection decreased from 69.6% to 41.3% of patients. EGG abnormal frequencies decreased from 26.1% to 8.7% in the fasting state and form 16.9% to 4.3% in the postprandial state. The number of patients with decreased EGG amplitude after meal increased from 4.3% to 28.3%. Postcholecystectomy dyspepsia is considered one of the controversial issues as regard both the etiology and management. In this study we found that duodenogastric reflux [DGR] is significantly increased after cholecystectomy, whereas H. pylori colonization is considerably decreased. If reflux gastritis should conclusively be shown to cause dyspepsia, then these observations and findings would be helpful in management of residual or new dyspepeptic manifestations after cholecystectomy. Finally EGG may be used as an objective mean for detection and evaluation of these postoperative changes

One stage transanal endorectal pull through in postanorectal myectomy hirschsprung's disease

Despite proper technique and more than 3 decades of experience, most pediatric surgeons have found that the results of anorectal myectomy as a definitive treatment of short segment Hirschsprung's disease were disappointing. In the present series 15 children [9 males and 6 females] with a mean of 4.3 years were evaluated for persistent constipation following anorectal myectomy for short segment Hirschsprung's disease. 13 children were managed by one stage transanal endorectal pull through procedure, with a follow up period of 12 to 20 months. The cosmetic results were excellent in all patients with no major complications and a bowel habit of at least once per day. Soiling was only troublesome in one child. The present series shows that anorectal myectomy is not a suitable definitive treatment of short segment Hirschsprung's disese because even if it reaches a ganglionic level the inertic dilated rectum persists with persistent constipation. It also shows that one stage transanal endorectal pull through is the best primary treatment of short segment Hirschsprung's disease and as a redo procedure for failed anorectal myectomy

Immunofluorescent detection of apoptosis in chronic viral hepatitis and other liver diseases

Chronic viral hepatitis is a common health problem in many countries including Egypt. The microscopic appearance of chronic viral hepatitis is usually associated with the appearance of eosinophilic structures called apoptotic bodies. Apoptosis is a type of programmed cell death. Abnormalities of apoptosis might contribute to many disease processes, the most important of which is neoplasia. The aim of this work is to study the frequency of apoptosis in cases of chronic viral hepatitis C [HCV], B [HB], pure Bilharzial liver affection, combined Bilharzial and chronic viral hepatitis C in addition to cases of hepatocellular carcinoma [HCC]. Liver biopsies [10 cases of HCV+ve patients, 6 cases HBs Ag +ve patients, 8 cases pure Bilharzial liver affection, 10 cases of combined Bilharzial and HCV, 10 cases of HCC and 6 cases of normal liver tissue obtained from areas adjacent to focal hepatic lesions were used as control]. A modified method of the terminal deoxynucleotidyl transferase- mediated dUTP-biotin nick end labeling [TUNEL] using immunofuorescence [FITC - dUTP] was used to detect apoptosis. Apoptotic index was determined for each case by counting apoptotic cells per 1000 cells in different fields. Apoptotic index for control cases was 0.1 +/- 0.08, cases of HCV 0.23 +/- 0.125, cases of HB 0.25 +/- 0.1, pure Bilharzial cases 0.125 +/- 0.08, combined Bilharzial and HCV cases 0.24 +/- 0.126 and for cases of HCC, it was 0.08 +/- 0.07.The difference between apoptotic index in cirrhotic and non-cirrhotic cases was statistically non significant [P = 0.896]. As a conclusion, we found that the modified TUNEL method using fluorescein isocyanate labeled dUTP was useful and sensitive for detecting apoptosis in the liver. The apoptotic index increases significantly than the control in cases of chronic viral hepatitis C [P = 0.044], B [P = 0.024] and combined HCV and Bilharzial liver affection [P = 0.033]. Apoptosis in pure Bilharzial liver affection does not significantly differ from the control [P = 0.636]. In cases of HCC, apoptosis decreases than the control in a non-significant manner [P = 0.647]. Apoptotic index does not differ significantly between cirrhotic and non- cirrhotic cases