Patients with cirrhosis are at significant risk for hepatocellular carcinoma (HCC). The aim of the present study was to evaluate the relationship between the percentage of hepatocytes showing nucleolar hypertrophy and the development of HCC in cirrhosis of different causes. A total of 111 cirrhotic patients were studied, with a mean follow-up period of 83.3 months. Histologic sections from liver biopsy specimens were silver stained for selective visualization of the nucleolus; the nucleolar area was measured by image cytometry. Nucleoli with a size of 7 m 2 or greater were considered to be hypertrophic. The nucleolar index was obtained by calculating the percentage of hepatocytes disclosing a nucleolar area of 7 m 2 or greater. During the observation time, HCC was diagnosed in 39 of 111 patients. The incidence rate of HCC was greater in patients with nucleolar indexes of 2.5 or greater than in patients with nucleolar indexes of less than 2.5 (16.49%/y vs. 3.41%/y, respectively; P < .0001). The capacity of the nucleolar index to predict HCC development was separately tested in groups of patients divided by etiology, and it was found to be particularly relevant in hepatitis B virus (HBV)-related cirrhosis (P ؍ .0006). Among patients with hepatitis C virus (HCV) infection, high nucleolar-index values were associated with a greater risk for HCC development, but the difference in the incidence rate of HCC between groups with a nucleolar index of 2.5 or greater and less than 2.5 was not statistically significant (P ؍ .0944). In conclusion, our results have shown that high percentages of hepatocytes showing nucleolar hypertrophy significantly predict HCC development in patients with HBV infection, whereas their predictive value in HCV-related cirrhosis seems to be lower. (HEPATOLOGY 2003;37:72-78.) H epatocellular carcinoma (HCC) is one of the most prevalent tumors in humans. It is particularly common in certain regions of Asia and sub-Saharan Africa, but over the past decades its incidence has been increasing also in Western countries. 1 The prognosis of HCC is poor, and the application of various screening and treatment protocols during the past 25 years does not appear to have significantly improved the chances of survival of HCC patients. 2 Most HCCs occur in association with underlying chronic liver disease and, in more than 80% of cases, arise in cirrhotic liver. 3 The major risk factors affecting HCC development in cirrhotic patients are reported to be male sex, old age (over 60 years), alcohol abuse, and viral infection caused by hepatitis B virus (HBV) and hepatitis C virus (HCV). In addition to these well-established factors, hepatocyte proliferation rate 4-7 and the presence of large cell changes (LCC) 8,9 have been suggested as predictors of HCC occurrence in cirrhosis.Nucleolar hypertrophy or prominence, as frequently referred by pathologists, represents a morphologic feature that characterizes both proliferating and dysplastic hepatocytes. It is well known that after hematoxylin-eosin staining, nucleo...