Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study

Epidemiology of hepatitis B virus infection among the tribes of Andaman and Nicobar Islands, India

The Andaman and Nicobar Islands, Union Territory of India, are home to six primitive tribes, namely the Great Andamanese, Onges, Jarawas and Sentinelese (Negrito race), and the Shompens and Nicobarese (Mongoloid race). These tribes account for about 8% of the island's population and the Nicobarese constitute >95% of the tribal population. Hepatitis B virus (HBV) infection is highly endemic among them with the prevalence of hepatitis B surface antigen (HBsAg) ranging from 23% among the Nicobarese to 66% among the Jarawas. The high HBsAg prevalence among pregnant mothers (20.5%), a linear increase in the age-specific rates of HBV exposure and the presence of HBsAg-positive individuals in every family suggested a combination of perinatal and horizontal transmission among the Nicobarese. Molecular studies of HBV isolates from the Onges, Nicobarese and Great Andamanese indicated a predominance of genotype D and there was a close similarity between these isolates and isolates from mainland India, suggesting that HBV may have been introduced from mainland India. In contrast, genotype C predominated among the Jarawas, with isolates similar to strains from Southeast Asian countries. Due to its high prevalence, hepatitis B vaccine is included in the childhood vaccination programme in these islands. It might be worth considering a pilot screening programme for chronic HBV patients to detect hepatocellular carcinoma.

Hepatitis C infection in patients with chronic kidney disease

The management of hepatitis C virus (HCV)-infected patients with chronic kidney disease (CKD) is complex and represents a particular concern since numerous issues, such as antiviral therapy in dialysis patients and post renal transplant, and prevention of HCV spread within dialysis units, remain unresolved. An enormous body of literature has been published on HCV in the CKD population; however, clinical evidence on important issues is mostly based on uncontrolled clinical trials or retrospective surveys. The aim of this paper is to provide a systematic review of the literature. Responses to the critical issues have been developed by a consensus of experts, endorsed by the Italian Association for the Study of the Liver (AISF) and some clinical recommendations have been added.

Hepatocarcinoma in viral and metabolic liver disease

It is becoming increasingly evident that children, like adults, with chronic viral or metabolic liver diseases are at risk for the development of hepatocarcinoma. The aims of this article are to review the risk factors for hepatocarcinoma in chronic viral or metabolic liver disease, outline potential pathogenic mechanisms of hepatocarcinoma, and describe surveillance strategies, clinical evaluation, and management of hepatocarcinoma in children.

Diagnostic accuracy of tumor markers for hepatocellular carcinoma: a systematic review

Background and aims The role of alphafetoprotein (AFP) in the diagnosis and surveillance of hepatocellular carcinoma (HCC) is getting smaller owing to the advances in imaging modalities. The aims of this study were to assess the diagnostic accuracy of tumor markers in small HCC and to find the optimal cutoff value of each tumor marker for efficient surveillance. Methods Studies in all languages were identified by searching MEDLINE from 1982 to 2002. Studies were included when they showed sensitivity and specificity for HCCs 5 cm or smaller and recruited only patients with chronic hepatitis or liver cirrhosis as control. We assessed diagnostic odds ratios (DORs) for the evaluation of diagnostic accuracy of tumor markers and positive likelihood ratios (LRs+) to find the optimal cutoff value. DORs and LRs+ were combined according to the random effect model. The summary receiver operating characteristics (ROC) curve was also assessed. Results Seventeen articles on three tumor markers-AFP, des-gamma-carboxyprothrombin (DCP), and Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3)-were enrolled after full-text evaluation. AFP was inferior to DCP and AFP-L3 in both DOR (4.50 vs. 8.16 and 10.50) and area under the ROC curve (0.647 vs. 0.688 and 0.695). Optimal cutoff values that provide the best LR+ were 200 ng/ml for AFP, 40 mAU/ml for DCP, and 15% for AFP-L3. Conclusions Diagnostic accuracy of AFP in small HCC was substantially limited. Surveillance including other tumor markers with optimal cutoff value should be conducted to confirm the efficacy of the policy.

The progression of hepatitis B- and C-infections to chronic liver disease and hepatocellular carcinoma: presentation, diagnosis, screening, prevention, and treatment of hepatocellular carcinoma

Much information has been gained in the diagnosis and treatment of HCC during the last 15 years. Ever improving imaging technology has made nonhistologic diagnostic criteria possible, albeit controversial. Liver transplantation, resection, and RFA are considered curative options. Yet,HCC incidence is steadily rising because of limited progress on disease prevention. Accurate and cost-effective screening is necessary. Presently, only 10% to 15% of HCC patients present with a curative stage of disease. Because the field of HCC is rapidly changing, patients with HCC should be referred to liver centers with a full array of services, from surgical to oncologic. The prognosis for HCC patients will surely improve with a multidisciplinary approach to care and further clinical research. Better screening and prevention of recurrence should eventually improve survival. It is hoped that antiviral treatment studies will lower the risk of HCC, and that these changes will occur soon enough to help the many patients at risk for or diagnosed with HCC over the next several years.

Natural history of chronic hepatitis B: special emphasis on disease progression and prognostic factors

The natural history of chronic hepatitis B virus (HBV) infection and disease is complex and highly variable. We review the natural history of chronic hepatitis B with emphasis on the rates of disease progression and factors influencing the course of the liver disease. Chronic hepatitis B is characterized by an early replicative phase (HBeAg positive chronic hepatitis) and a late low or non-replication phase with HBeAg seroconversion and liver disease remission (inactive carrier state). Most patients become inactive carriers after spontaneous HBeAg seroconversion with good prognosis, but progression to HBeAg negative chronic hepatitis due to HBV variants not expressing HBeAg occurs at a rate of 1-3 per 100 person years following HBeAg seroconversion. The incidence of cirrhosis appears to be about 2-fold higher in HBeAg negative compared to HBeAg positive chronic hepatitis. In the cirrhotic patient the 5-year cumulative risk of developing hepatocellular carcinoma is 17% in East Asia and 10% in the Western Europe and the United States and the 5-year liver related death rate is 15% in Europe and 14% in East Asia. There is a growing understanding of viral, host and environmental factors influencing disease progression, which ultimately could improve the management of chronic hepatitis B.

High viral load and hepatitis B virus subgenotype ce are associated with increased risk of hepatocellular carcinoma

PURPOSE

We aimed to investigate the impact of hepatitis B virus (HBV) DNA and HBV genotypes/subgenotypes on the risk of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

A prospective cohort of patients infected with chronic HBV in a surveillance program for HCC since 1997 was studied. Ultrasound and alpha-fetoprotein evaluation were regularly performed to detect HCC. Risk factors for HCC and the relationship between HBV DNA and HBV genotypes were determined.

RESULTS

Among 1,006 patients with a median follow-up of 7.7 years, 86 patients (8.5%) developed HCC. With reference to the low HBV DNA stratum (log HBV DNA 4.5 to 6.5 copies/mL) was 1.62 (95% CI, 1.05 to 2.48; P = .027) and that of the high HBV DNA stratum (log HBV DNA > 6.5 copies/mL) was 2.73 (95% CI, 1.76 to 4.25; P < .001). Among patients with genotyping results, 330 patients had HBV genotype B and 439 patients had HBV genotype C (94 subgenotype Ce and 345 subgenotype Cs). With reference to HBV genotype B, HBV subgenotype Ce has the highest risk of HCC (hazard ratio = 2.75; 95% CI, 1.66 to 4.56; P < .0001) and HBV subgenotype Cs has intermediate risk (hazard ratio = 1.70; 95% CI, 1.09 to 2.64; P = .020). On multivariate analysis, HBV DNA, HBV genotypes, liver cirrhosis, male sex, older age, and lower serum albumin were independent risk factors of HCC.

CONCLUSION

High HBV DNA level and HBV genotype C, particularly subgenotype Ce, increased the risk of HCC in chronic hepatitis B.

Surveillance for hepatocellular carcinoma and early diagnosis

Good management of patients at risk for the development of hepatocellular carcinoma includes regular ultrasound surveillance, and aggressive management of lesions detected at ultrasound. Good radiology and good pathology are essential to the appropriate management of these small lesions. With good quality testing it is possible to cure the majority of HCCs using minimally invasive techniques such as radiofrequency ablation. Such an approach has the potential to convert HCC from a disease in which incidence more or less equaled mortality to one in which cure is frequently possible.

Antiviral prophylaxis for chemotherapy-induced reactivation of chronic hepatitis B virus infection

Chronic hepatitis B virus (HBV) carriers are at considerable risk of reactivation of HBV infection when undergoing chemotherapy or immunosuppressive therapy. Complications of HBV reactivation, including asymptomatic elevation of HBV DNA levels, acute hepatitis, acute liver failure, and delays or dose reductions in chemotherapy, are avoidable with appropriate prophylactic oral antiviral therapy. This article reviews evidence for and presents a grade A recommendation supporting primary prophylaxis among HBV carriers with lamivudine. The dose and duration of prophylaxis, risk of lamivudine resistance, and future directions of prophylactic therapy for HBV reactivation during chemotherapy are discussed. Recommendations are suggested based on expert opinion for prophylaxis with the combination of lamivudine plus adefovir or with entecavir as alternative antiviral strategies that substantially reduce or avoid the risk of HBV antiviral drug resistance.

Hepatocellular carcinoma: epidemiology and clinical aspects

Liver cancer is one of the most frequent solid cancers that kills more than 650,000 people around the world each year. Though great improvements have been done in last 10 years on the understanding the molecular mechanisms involved in liver oncogenesis, the prognosis of patients affected by liver cancer is still poor for most of them. Even in those where a relatively early diagnosis is done, the course of the disease is often fatal due to the underlying liver cirrhosis. In this review authors report the most recent findings on the pathogenesis of liver cancer and on therapeutic approaches, included those emerging from the most recent literature.

Screening for hepatocellular carcinoma

This article reviews methodological issues around screening for hepatocellular carcinoma, and discusses selection of the at-risk group, which screening test to use, and how frequently it should be applied. Screening of patients at risk for hepatocellular carcinoma should be undertaken using ultrasonography applied at six-month intervals. Patients at risk include all those with cirrhosis, and certain non-cirrhotic patients withchronic hepatitis B. In this population, screening has been shown to reduce disease-specific mortality. Although data do not exist for other populations, screening is nonetheless advised because small cancers can be cured with appreciable frequency.

Do young hepatocellular carcinoma patients with relatively good liver function have poorer outcomes than elderly patients?

BACKGROUND AND AIM

The risk of hepatocellular carcinoma (HCC) is known to be age dependent; the influence of age on prognosis is, however, controversial. The aim of this study was to compare the tumor characteristics and survival rates of young and old HCC patients, with respect to tumor stage.

METHODS

We reviewed the clinical data and survival times of 71 young HCC patients from 1987 to 2003 and compared these with those of their older counterparts (n = 239). Patients were categorized into three age groups: group A, age <30 years (n = 71); group B, age >/=30 to <61 years (n = 168); and group C, age >/=61 years (n = 81). Kaplan-Meier methods and Cox proportional hazards regression were used to analyze survival.

RESULTS

The overall survival time of group A was shorter than groups B or C (P = 0.0071). Survival was not different in the three groups in subgroup analysis according to several tumor staging systems (e.g. Japan Integrated Staging score, Cancer of the Liver Italian Program scoring system and Barcelona Clinic Liver Cancer staging classification). The multivariate hazard ratio of group B was 0.840 (95% confidence interval [CI] 0.490-1.440) and that of group C was 0.770 (95% CI 0.410-1.446) in reference to group A.

CONCLUSIONS

Young HCC patients showed a poorer prognosis than older HCC patients because they have a more advanced tumor stage at diagnosis. However, age was not an independent prognostic factor when stages were matched. Therefore, we suggest that periodic surveillance in young chronic hepatitis B virus carriers would improve outcomes.

Hepatocellular carcinoma in Sydney South West: late symptomatic presentation and poor outcome for most

BACKGROUND

Hepatocellular cancer (HCC) is a serious complication of cirrhosis and chronic hepatitis B infection. The aim of the study was to determine the characteristics of patients with HCC presenting within the South West Sydney area, including an analysis of the rates and benefits of hepatocellular surveillance.

METHODS

Data from patients with HCC presenting to Liverpool and Bankstown Hospitals from July 1993 to June 2003 were analysed retrospectively, predominantly from hospital records.

RESULTS

Of the 151 HCC patients, 41% were Asian born. Most of the patients required an interpreter. Chronic viral hepatitis infection was present in 91 patients, of whom only 7% had previously received antiviral therapy. Alcohol alone was considered responsible in 31 patients. Cirrhosis could be documented in 58% of patients. Most of the patients (75%) presented symptomatically. The median survival was 5.1 months. When HCC was detected by surveillance, the tumours were slightly but not significantly more likely to be operable and the patients tended to be offered some form of active treatment more frequently. Multivariate analysis identified detection by surveillance, lower Child-Pugh score, smaller tumour size and eligibility for some form of treatment to be associated with a more favourable outcome.

CONCLUSION

We observed low rates of surveillance for HCC, low recognition of cirrhosis before development of HCC and low rates of prior treatment of viral hepatitis. The poor outcome of HCC in the small group who had some sort of community surveillance is also a concern requiring further investigation.

Factors influencing physicians' screening behavior for liver cancer among high-risk patients

BACKGROUND

Little is known about physicians' screening patterns for liver cancer despite its rising incidence.

OBJECTIVE

Describe physician factors associated with liver cancer screening.

DESIGN

Mailed survey.

PARTICIPANTS

Physicians practicing in family practice, internal medicine, gastroenterology, or nephrology in 3 northern California counties in 2004.

MEASUREMENTS

Sociodemographic and practice measures, liver cancer knowledge, attitudes, and self-reported screening behaviors.

RESULTS

The response rate was 61.8% (N = 459). Gastroenterologists (100%) were more likely than Internists (88.4%), family practitioners (84.2%), or nephrologists (75.0%) to screen for liver cancer in high-risk patients (p = 0.016). In multivariate analysis, screeners were more likely than nonscreeners to think that screening for liver cancer reduced mortality (odds ratio [OR] 1.60, CI 1.09-2.34) and that not screening was a malpractice risk (OR 1.88, CI 1.29-2.75). Screeners were more likely than nonscreeners to order any screening test if it was a quality of care measure (OR 4.39, CI 1.79-10.81).

CONCLUSIONS

Despite debate about screening efficacy, many physicians screen for liver cancer. Their screening behavior is influenced by malpractice and quality control concerns. More research is needed to develop better screening tests for liver cancer, to evaluate their effectiveness, and to understand how physicians behave when there is insufficient evidence.

Prevalence of hepatitis B virus genotype D in precore mutants among chronic liver disease patients from New Delhi, India

Hepatitis B is one of the most important causes of chronic viral hepatitis world wide. Mutations in the precore region of the hepatitis B virus (HBV) genome are frequently found in hepatitis B envelope antigen-negative cases. Data from India on the HBV genotype-associated distribution of precore mutations are limited. Our objective in this study was to genotype and detect the precore mutant with a point mutation from G to A at nucleotide 1896 using ligase chain reaction (LCR) and direct sequencing. A total of 115 cases of chronic liver disease were screened. The cases were evaluated on the basis of history, clinical examination, liver function profile, and serological test for HBV infection, which includes HBsAg, anti HBcIgG, HBeAg using commercially available ELISA kits. The cases, which were HBeAg+, HBeAg-, and HBV DNA+, were subjected to LCR and confirmed by direct sequencing. Of 115 chronic liver disease cases, 50 (43.5%) cases were HBV DNA positive. All cases were subjected to LCR; 11 (22%) cases confirmed the presence of precore mutants, while the remaining 39 (78%) were classified as the wild form of the virus. HBV genotyping by direct sequencing revealed that genotype D was predominant in both wild and mutant forms of the virus. We conclude that the HBV genotype distribution was not significantly different between precore mutants and the wild form of the virus (P>0.05). North Indian patients with genotype D were more likely to have persistent HBV infection with precore mutants. HBV genotypes correlate with the clinical outcome of chronic HBV infection.

Natural course, therapeutic options and economic evaluation of therapies for chronic hepatitis B

Chronic hepatitis B virus infection afflicts 400 million people worldwide and untreated will progress to cirrhosis in 15-40% of individuals, with an associated increased risk for the development of hepatocellular carcinoma. The 'inactive carrier state' carries a benign prognosis with a very low risk of cirrhosis or hepatocellular carcinoma. However, the hepatitis B e antigen (HBeAg)-positive chronic hepatitis state is an active disease state with increased risk for progressing to cirrhosis and hepatocellular carcinoma. The HBeAg-negative mutant variety of chronic hepatitis B has been associated with a higher incidence of cirrhosis at initial presentation and more frequent progression to hepatocellular carcinoma compared with the wild-type hepatitis B. Five medications are currently approved by the US FDA for the treatment of chronic hepatitis B: interferon-alpha, lamivudine, adefovir dipivoxil, entecavir and peginterferon-alpha-2a. Interferon-alpha therapy has been shown to increase the rate of HBeAg and hepatitis B DNA loss with a small chance of hepatitis B surface antigen loss, but has significant adverse effects and is ineffective against the HBeAg-negative mutant. Lamivudine is a safely used, orally administered drug with good efficacy, but is associated with the development of a lamivudine-resistant (Lam-R) mutant in a large proportion of patients after long-term therapy. High relapse rates after lamivudine therapy make this medication less effective in the HBeAg-negative mutant also. Adefovir dipivoxil is a safely used, orally administered drug, which is effective against the Lam-R mutant. Adefovir dipivoxil is effective against the wild-type and HBeAg-negative hepatitis B and has a very low incidence of resistance development. Entecavir is a highly potent and selective new oral drug against hepatitis B. It has demonstrated no resistance development in treatment-naive patients, but a low incidence of resistance in patients infected with prior Lam-R mutants. Peginterferon-alpha-2a is administered once weekly and has improved efficacy compared with standard interferon-alpha and lamivudine. However, it has a similar adverse-effect profile to standard interferon-alpha. Pharmacoeconomic studies have demonstrated a cost benefit in treating chronic hepatitis B patients compared with no therapy. However, results have been conflicting, with earlier studies showing a cost advantage of lamivudine over interferon-alpha and a more recent, comprehensive study favouring interferon-alpha monotherapy in HBeAg-negative patients and adefovir dipivoxil 'salvage' after lamivudine resistance development in HBeAg-positive patients.

Prospective randomized comparison of minilaparoscopy and percutaneous liver biopsy: diagnosis of cirrhosis and complications

BACKGROUND AND AIMS

Liver cirrhosis represents an advanced stage of hepatic fibrosis characterized by distortion of organ architecture and formation of regenerative nodules. Retrospective series reported percutaneous liver biopsy to miss cirrhosis in about 30%. The aim of this study was to prospectively compare diagnostic sensitivity regarding the detection of cirrhosis and the complication rates of percutaneous versus minilaparoscopic liver biopsy in chronic liver disease.

METHODS

Eight hundred fifty-seven patients were randomized to percutaneous (415) or to minilaparoscopic liver biopsy (442). Macroscopic liver evaluation was documented as normal, fibrosis, or cirrhosis. Liver specimens were assessed blindly according to the modified Ishak score.

RESULTS

Demographic and clinical data of procedure groups were comparable. Histologic grading alone diagnosed cirrhosis in 22.3% (n=85) of liver specimens obtained by percutaneous route compared with 26.0% (n=98) obtained by minilaparoscopy (P=0.270). By combining macroscopy and histology, minilaparoscopic staging diagnosed a significantly higher rate of liver cirrhoses with 33.8% (n=127) compared with percutaneous route with 22.3% (n=85) (P=0.001). Analysis of minilaparoscopic data revealed that 33 of the 128 cirrhoses were diagnosed by inspection only, suggesting a 26% underestimation of cirrhosis by histology alone. Severe complications occurred in 1.0% (n=4) of percutaneous and in 0.2% (n=1) of minilaparoscopic procedures (P=0.025).

CONCLUSIONS

Minilaparoscopic evaluation based upon the combined macroscopic and histologic assessment is more sensitive with regards to the detection of cirrhosis and has a comparable safety profile.

Hepatocellular carcinoma prevention: A worldwide emergence between the opulence of developed countries and the economic constraints of developing nations

Hepatocellular carcinoma (HCC) is the fifth most common neoplasm, the major cause of death in patients with liver cirrhosis, and the third most common cause of cancer-related death in the world. The geographic distribution of HCC varies significantly and 80% of cases occur in developing countries (Far East and South Asia) where the prevalence of viral hepatitis is higher. The treatment of HCC is difficult because most patients are diagnosed when the tumour is in an advanced stage and is not amenable to potential curative therapy, thus prevention is the key to reducing HCC and its related morbidity and mortality. HCC is unique among cancers, occurring mostly in patients with a known risk factor. Ninety percent of HCCs develop in the context of chronic liver diseases and mainly in patients with cirrhosis. Viral hepatitis is the most common cause of HCC worldwide, followed by alcoholic liver disease (ALD) and other causes such as non-alcoholic fatty liver disease (NAFLD), genetic haemocromatosis (GH) and primary biliary cirrhosis in an advanced stage (III-V). In certain areas of the People’s Republic of China, exposure to aflatoxin and HBV infection are thought to be responsible for the extraordinary high risk of HCC. Substantial progresses in the prevention of virusl-related hepatitis (screening of blood units, use of disposable sanitary tools, HBV vaccination) have been achieved in developed countries, but in the same areas, alcohol- and dysmetabolism-related HCCs are emerging problems which require specific interventions in terms of public health measures. In developing countries, economic constraints limit the development of any program for the prevention of viral hepatitis transmission (including health education campaigns, healthcare politics, primary prevention and the improvement of hygienic and sanitary conditions). When viral liver disease is established, only a minority of patients are treated worldwide and benefit a possible preventive effect of medical treatment on HCC development. Thus the real contribution of medical treatment to HCC prevention in patients with chronic viral hepatitis is small. Great efforts are needed to identify more effective medical measures for primary and secondary prevention of HCC.

Chronic hepatitis C and screening for hepatocellular carcinoma

It is now at least theoretically possible to prevent patients with hepatocellular carcinoma (HCC) from dying of HCC. Screening identifies small potentially curable lesions, and the diagnostic algorithm allows for efficient investigation and diagnosis. Radiofrequency ablation completely ablates more than 05% of lesions smaller than 2 cm. Second primary cancers can be dealt with in the same manner as the initial primary. If the management of HCC is so efficient and effective, liver transplantation may come to be used as a last resort, rather than the treatment of choice. This benefits patients with hepatitis C and other liver diseases because more organs become available for treatment of other liver diseases.

Preclinical and post-treatment changes in the HCC-associated serum proteome

SELDI-based proteomic profiling of body fluids is currently in widespread use for cancer biomarker discovery. We have successfully used this technology for the diagnosis of hepatocellular carcinoma (HCC) in hepatitis C patients and now report its application to serial serum samples from 37 hepatitis C patients before development of HCC, with HCC and following radiofrequency ablation of the tumour. As with alpha-fetoprotein, an accepted biomarker for HCC, we hypothesised that HCC-associated proteomic features would 'return to normal' following successful treatment and the primary aim of our study was to test this hypothesis. Several SELDI peaks that changed significantly during HCC development were detected but they did not reverse following treatment. These data may be interpreted to suggest that the characteristic SELDI profile is not linearly related to tumour burden but may result from the progression of underlying liver disease or from the emergence of precancerous lesions. beta2-Microglobulin, a protein previously reported to be markedly elevated in patients with HCV related HCC, was also the most significantly HCC associated proteomic feature (m/z 11720) in this study.

Systematic review: lamivudine prophylaxis for chemotherapy-induced reactivation of chronic hepatitis B virus infection

BACKGROUND

Reactivation of hepatitis B virus infection in asymptomatic hepatitis B surface antigen carriers undergoing chemotherapy or immunosuppressive therapy is a well-documented and potentially fatal complication. Data supporting the use of lamivudine for primary prophylaxis have emerged, but its use remains controversial and is not standardized.

AIM

To review current randomized-controlled trials, randomized trials and prospective case series to provide a clinically applicable, evidence-based recommendation.

METHODS

The published literature was identified using a MEDLINE/PubMed search with secondary review of cited publications, and inclusion of all prospective studies.

RESULTS

In nine prospective trials and one randomized-controlled trial, the rate of hepatitis among subjects receiving lamivudine prophylaxis ranged from 0% to 20% (16 of 173, 9.2%), compared with 33-67% among controls. Of patients receiving prophylaxis, 0-24% (15 of 173, 8.7%) developed hepatitis B virus reactivation, compared with 29-56% of controls. Three reactivation-related mortalities were reported (one receiving prophylaxis, two controls). No patients withdrew secondary to toxicity or development of lamivudine-resistant mutations.

CONCLUSIONS

The available data show a four- to sevenfold decrease in the rate of hepatitis and hepatitis B virus reactivation in patients who receive lamivudine prophylaxis. It is thus recommended that all hepatitis B surface antigen carriers receive lamivudine, or a comparable anti-viral agent, as prophylaxis from the initiation of chemotherapy until at least 1 year following its completion.

Cofactors associated with liver disease mortality in an HBsAg-positive Mediterranean cohort: 20 years of follow-up

The risk of developing liver cancer in hepatitis B virus (HBV) carriers differs across geographical areas, suggesting that exposure to other risk factors may contribute to HBV-linked cancer risk. Our study estimates the mortality due to liver disease and the role of other risk factors in a Spanish HBV cohort. 2,352 hepatitis B surface antigen (HBsAg)-positive and 15,504 HBsAg-negative subjects were identified among blood donors during 1972-1985 and were followed until December 2000 through the Mortality Registry. Clinical examination and an epidemiological questionnaire were performed on 1,000 HBsAg-positive survivors during 1994-1996. In subjects deceased from liver disease, medical records were revised and relatives were interviewed. A nested case-control analysis was conducted comparing both groups. In HBsAg-positive men, an excess mortality from liver cancer [standardized mortality ratio (SMR): 14.1; 7.7-23.6], cirrhosis (SMR: 10.5; 7.0-15.1), haematological neoplasms (SMR: 3.2; 1.2-6.9) and AIDS was detected (SMR: 5.5; 2.2-11.4). In women, an excess was found for cirrhosis (SMR: 7.2; 1.4-21.1). Progression factors to liver disease were alcohol intake [odds ratio (OR): 6.3; 3.1-12.8], diabetes (OR: 3.6; 1.3-9.6), HBV replication (OR: 50.0; 14.9-167.3) and hepatitis C virus (HCV) infection (OR: 27.4; 7.1-107.7). In conclusion, in Spain after 20 years of follow-up, chronic HBV exposure appears as a major risk factor for liver cancer among men and for cirrhosis in both sexes. The risk of death from liver disease among HBV carriers with the presence of HBV replication, HCV, alcohol consumption and diabetes was significantly increased and suggests synergism among these exposures and HBV. Mortality from haematological neoplasms was detected and could be associated to HIV coinfection. These results support screening and adequate follow-up among HBsAg-positive subjects at high risk to develop liver disease, particularly when these risk cofactors are present.

Surveillance of hepatocellular carcinoma in patients with hepatitis C virus infection may improve patient survival

BACKGROUND

The benefit of surveillance of hepatocellular carcinoma (HCC) for patients with hepatitis C virus (HCV) infection, in terms of long-term survival, has not yet been established.

METHODS

A total of 384 consecutive anti-HCV-positive HCC patients admitted to our hospital between January 1991 and October 2003 were enrolled. Patients were categorized into two groups, a surveillance group (182 patients) and a non-surveillance group (202 patients), according to tumor detection in a surveillance program based on periodical examination via ultrasound sonography and alpha fetoprotein determination at 6-month intervals, and their survival rates were compared.

RESULTS

Although there were no significant differences in age and Child-Pugh classes between the two groups, the surveillance group exhibited a smaller tumor size (19 vs. 35 mm) and a higher incidence of single HCC (67% vs. 46%), compared with the non-surveillance group (each, P < 0.001). The cumulative survival rate in the surveillance group was higher than that in the non-surveillance group (5 years survival, 46% vs. 32%, P < 0.001). When the survival after correction of the lead-time bias in the surveillance group was analyzed according to the Child-Pugh classification, the surveillance program was found to have had a favorable outcome in Child-Pugh class A patients, but not in Child-Pugh class B/C patients.

CONCLUSIONS

HCC surveillance for patients with HCV infection can lead to discovery of tumors at an early stage, especially in Child-Pugh class A, resulting in a favorable outcome.

Impact of age on screening and surveillance for primary liver cancer

OBJECTIVES

Although screening and surveillance for liver cancers have become established practices, the impact of age on these practices is unknown. The age at which these could be stopped, if any, is unclear. Our aims were to assess the impact of age on developing or dying from liver cancer, and to define the relative impact of prematurely stopping screening.

METHODS

Actuarial life-table analyses were performed using age-stratified mortality rates for primary liver cancers, and for all other causes combined, obtained from population-based databases from the United States. The impact of prematurely stopping screening at a given age was expressed as days of life lost compared to the maximal benefit expected from lifelong screening.

RESULTS

Mortality from primary liver cancers increases with age and peaks at 37 per 100,000 persons at ages 85-90 yr. However, mortality from other causes increases even more with age. Consequently, the relative proportion of deaths from primary liver cancer is maximal at 1.34% of all deaths at age 50 yr, and gradually decreases thereafter. Eighty percent of the maximal potential benefit of lifetime screening from age 45 yr is achieved by age 77 yr, and 90% by age 82 yr.

CONCLUSIONS

The relative benefits from screening for primary liver cancer are reduced in the elderly due to competing risks for death despite an increasing incidence of primary liver cancer with age. The majority of societal benefit is gained from screening at younger ages, when the relative proportions of death attributable to liver cancer are the greatest.

Efficacy and tolerability of pegylated-interferon alpha-2a in hemodialysis patients with chronic hepatitis C

BACKGROUND AND AIM

Hepatitis C virus (HCV) is prevalent in hemodialysis (HD) patients. These patients experience more side-effects with antiviral treatment. The aim of the present study was to evaluate the efficacy and tolerability of pegylated interferon (PEG-IFN) alpha-2a in chronic hemodialysis patients with chronic hepatitis C.

METHODS

Twenty-five patients were included into the study. All of the patients were interferon naive, anti-HCV antibodies positive and polymerase chain reaction HCV-RNA positive. Twelve of the patients received PEG-IFN alpha-2a at a dose of 135 microg weekly for 48 weeks (Group 1). The remaining 13 patients who received no specific treatment were used as controls (Group 2). The patients were prospectively followed up for a period of 18 months. Biochemical and virological responses were evaluated at the end of the study period (end-of-treatment response) and 6 months after the completion of therapy (sustained response).

RESULTS

Virological end-of-treatment response was observed in 10 patients (83.4%) in Group 1 and one patient (7.7%) in Group 2 (P < 0.001). Sustained virological response was observed in nine patients (75%) in Group 1 and one patient (7.7%) in Group 2 (P < 0.001). Alanine aminotransferase (ALT) levels were initially increased in seven patients in Group 1 and normalized in five of these patients at the end of the treatment and sustained biochemical response was 71.4%. In contrast, ALT levels in Group 2 were initially high in five patients and normalized in two of them (40%) at the end of the 48 weeks. Even if most of the patients experienced several side-effects (anemia 75%, fatigue 58.3%, thrombocytopenia 33.3% and leukopenia 33.3%), they did not impose the discontinuation of the treatment.

CONCLUSION

The present study showed that PEG-IFN alpha-2a for 48 weeks is efficacious and well tolerated in hemodialysis patients with HCV.

Assessment and Management of Chronic Hepatitis B

An understanding of the natural history of CHB is critical for the management of the liver disease. Three clinical patterns with different clinical outcomes are recognized: HBeAg-positive CHB, HBeAg-negative CHB,and inactive CHB. Patients with elevated aminotransferase levels and HBV DNA greater than 105 viral copies per mL in serum and with features of chronic hepatitis on liver biopsy are candidates for therapy regardless of HBeAg status. Multiple host and viral factors and safety profiles of current therapies need to be considered carefully before recommending therapy. There appears to be no role for HBV genotyping in the management of patients. Three antiviral agents are approved for use against CHB infection:IFN-a, lamivudine, and adefovir. Efficacy is moderate at best and is limited by the poor tolerability of IFN and the development of resistance, coupled with concerns regarding the long-term safety with nucleoside analogs. Several new nucleoside and nucleotide analogs and novel agents are at various stages of development as potential therapies for CHB. The ideal compound would be one that is active against all replicative intermediates of the virus and has a low toxicity profile. Despite current shortcomings, the future of therapy for HBV is promising, as newer therapeutic options are being developed based on an understanding of the HBV life cycle.

Clinical features and prognosis of hepatocellular carcinoma in young patients from a hepatitis B-endemic area

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. However, the clinical features of young HCC patients have not been fully studied. In the present study, we investigated the prevalence, clinical characteristics and prognosis of young HCC patients.

METHODS

A retrospective analysis was performed for HCC patients in our center using Korean cancer registry data. Among 4234 patients enrolled, there were 38 patients younger than 30 years of age (0.9%). We compared clinical characteristics and survival data of these patients (group I) with those of sex-matched, randomly selected HCC patients aged 30-59 years (group II; n = 231) and 60 years or older (group III; n = 147).

RESULTS

Group I showed distinct features compared with groups II and III as follows: low frequency of smoking history, high positive rate of hepatitis B s antigen, no association with anti-hepatitis C virus antibody, high frequency of alpha-fetoprotein > or = 400 ng/mL, well-preserved liver function, larger tumor size, more advanced tumor-node-metastasis (TNM) stage and Cancer of the Liver Italian Program (CLIP) score and more frequent application of surgical resection and chemotherapy as initial treatment. The overall survival of group I was worse than that of group II, but similar to that of group III. Multivariate analysis showed that TNM stage and CLIP score, not age itself, were independent predictive factors for survival.

CONCLUSIONS

The results suggest that young HCC patients tend to have a poor prognosis owing to advanced tumor stage, despite well-preserved liver function and aggressive treatment. Further studies regarding the role of HCC screening in young people may be useful, especially in hepatitis B virus carriers from high endemic areas.

Optimizing management strategies in special patient populations

Chronic hepatitis B infection presents a number of challenges to clinicians. There are additional considerations when defining management strategies for individuals with advanced liver disease, or coinfection, or those at high risk of developing hepatocellular carcinoma (HCC). Treatment of decompensated cirrhosis is particularly important. Evidence suggests that suppression of viral replication through nucleos(t)ide analog therapy leads to longer time to transplantation, improved liver function, and improved survival times. The use of interferon in patients with decompensated hepatitis B is associated with serious complications and is currently contraindicated for these patients by the AASLD Practice Guidelines. Hepatitis B coinfection is often associated with more extensive disease. In patients with HBV/HCV coinfection, one disease is usually dominant and consequently should be the focus of therapy. HIV/HBV coinfection increases the risk of progressive liver disease. Therapeutic agents active against both viruses should be utilized at the correct dose to limit the development of resistance. Agents specific for HBV, e.g., entecavir, enable hepatitis to be treated while avoiding the risk of HIV resistance developing. Dual infection with HBV and HDV is particularly challenging. Nucleos(t)ide analogs are ineffective in treating HDV infection, and there is limited data concerning the efficacy of interferon in this setting. The association between chronic hepatitis B infection and hepatocellular carcinoma (HCC) is well established. In patients at high risk of HCC, screening regimes may be effective. Furthermore, there is an increasing body of evidence indicating that effective suppression of viral replication may be associated with a reduced risk of HCC.

Thrombocytopenia as a surrogate for cirrhosis and a marker for the identification of patients at high-risk for hepatocellular carcinoma

BACKGROUND

The objective of this study was to examine the usefulness of platelet counts in the diagnosis of cirrhosis and for identifying high-risk individuals in a community-based hepatocellular carcinoma (HCC) screening program.

METHODS

Pilot Study 1 determined the correlation between platelet counts and pathologic hepatic fibrosis scores among individuals with chronic hepatitis B virus (HBV) infection (n = 122 patients) and hepatitis C virus (HCV) infection (n = 244 patients). Pilot Study 2 investigated proportions of individuals with thrombocytopenia (<150 x 10(3)/mm(3)) among patients with HCC (n = 4042 patients). Pilot Study 3 demonstrated the correlation between platelet counts and ultrasonographic (US) parenchyma scores among anti-HCV-positive individuals (n = 75 patients). The core study was a 2-stage, community-based screening for HCC among residents age 40 years or older in townships with a high prevalence of anti-HCV (n = 4616 individuals) and in townships with a low prevalence of anti-HCV (n = 1694 individuals). Patients with thrombocytopenia were identified for US and alpha-fetoprotein screening.

RESULTS

Among the individuals who were positive for anti-HCV, platelet counts decreased according to increased pathologic fibrosis scores or US scores for liver parenchyma disease: The best cutoff platelet count was 150 x 10(3)/mm(3) for a diagnosis of cirrhosis. The sensitivity and specificity were 68.2% and 76.4%, respectively, for pathologic cirrhosis and 76.2% and 87.8%, respectively, for US cirrhosis. Forty-eight percent of patients with HCC were thrombocytopenic. The proportion of thrombocytopenia was significantly greater in patients with HCV-related HCC (63%) than in patients with HBV-related HCC (42%). In the townships with high and low anti-HCV prevalence, the prevalence of thrombocytopenia was 17.9% and 6.1%, respectively, (P < .001), respectively. Twenty-five patients were diagnosed with HCC, and all of those patients resided in the high-prevalence township.

CONCLUSIONS

Thrombocytopenia was a valid surrogate of cirrhosis and a valid marker for the identification of individuals at high-risk for HCC, especially in areas that had a high prevalence of HCV.

Hepatitis B surface antigenaemia and alpha-foetoprotein detection from dried blood spots: applications to field-based studies and to clinical care in hepatitis B virus endemic areas

In many resource-limited regions with endemic hepatitis B virus (HBV), there is limited infrastructure to collect, process, transport, and store blood samples for identification of persons with chronic HBV infection or with hepatocellular carcinoma (HCC). We describe the application of a simple technique using commercially available kits for detection of HBV surface antigen (HBsAg) and alpha-foetoprotein (AFP) in dried blood spots (DBS) collected on filter paper. Study participants included subjects with and without chronic HBV infection and subjects with HCC or cirrhosis. Three to five blood drops were dried on filter paper. Dried blood (equivalent to 20 muL) was eluted and tested for HBsAg by Determine(TM) HBsAg and for AFP by counter-current immuno-electrophoresis and radio-immunoassay (RIA). The primary analysis focused on comparison of DBS results to serum testing results as the gold standard. The sensitivity of DBS for detecting chronic HBV infection was 96% (98-98) with specificity of 100% (CI 99-100). Sensitivity of DBS in detecting AFP compared with serum RIA was 73% (60-86) with specificity of 90% (81-98). Both HBsAg and AFP recovery were unaffected when DBS were left at room temperature (30-33 degrees C) and under humid conditions for up to 28 days prior to elution. We conclude that DBS can be reliably used as an economical and logical alternative for detection of HBsAg in chronically infected patients and for AFP-based diagnosis of HCC in clinical situations which preclude adequate collection and processing of blood samples. Both research-oriented field studies and routine clinical care may benefit from application of these techniques in resource-limited settings.

An intensive surveillance program detected a high incidence of hepatocellular carcinoma among hepatitis B virus carriers with abnormal alpha-fetoprotein levels or abdominal ultrasonography results

PURPOSE

To study the incidence and treatment outcomes of hepatocellular carcinoma (HCC) detected in an intensive surveillance program (ISP) of hepatitis B virus (HBV) carriers.

PATIENTS AND METHODS

We screened 1,018 HBV carriers by serum alpha-fetoprotein (AFP) measurement and abdominal ultrasonography (AUS). Patients with an abnormal AFP level or AUS result were enrolled in an ISP that included Lipiodol computed tomography followed by AFP measurement/AUS every 3 months for 2 years and then every 6 months thereafter. The rest were on routine surveillance for 2 years.

RESULTS

A total of 9,849 serum AFP measurements and 3,053 AUSs were performed. After a median follow-up of 4.12 years, we diagnosed 24 HCCs among 78 patients with abnormal screening test results at enrollment (group A); 23 HCCs among 93 patients with only abnormal surveillance test results during follow-up (group B); and nine HCCs among 847 patients with 2 years of normal surveillance (group C). Annual incidence of HCC in the ISP was 760.2 (95% CI, 538.4 to 1,073.7) per 100,000. Mean tumor sizes were 3.02, 2.91, and 4.82 cm in groups A, B, and C, respectively (P = .01). Tumor resection rate of the ISP was 36.2%, although another 29.8% of the patients were eligible for locoregional ablative therapy.

CONCLUSION

This study illustrated that a high incidence of relatively small HCCs may be detected by using intensive surveillance of high-risk HBV carriers. However, the surgical resection rate was low, and we were not able to demonstrate clinical benefit with the early detection. Future surveillance studies should consider incorporation of therapy aimed at long-term control of small-sized tumors.

Hepatitis B in children: complexities in management

Chronic hepatitis B virus (HBV) infection by definition is persistence of hepatitis B surface antigen (HBsAg) in the serum for > or =6 months. The risk of developing chronic HBV infection ranges from 90% in neonates to <5% in immunocompetent adults. HBV acquired by perinatal infection has a prolonged immune-tolerant phase, characterized by the presence of hepatitis Be antigen (HBeAg), high HBV-DNA and normal alanine aminotransferase (ALT) levels. Efficient and multi-specific helper and cytotoxic T-cell response is essential for controlling HBV infection. Chronic HBV infection is characterized by a state of HBV-specific T-cell hyporesponsiveness. The goal of therapy in chronic HBV infection is to eliminate or significantly suppress HBV replication and prevent the progression of liver disease to cirrhosis with the potential development of liver failure or hepatocellular carcinoma (HCC). In adults, drugs currently licensed for treatment of HBV infection: are interferon-alpha (IFN-alpha), lamivudine (LMV) and adefovir dipivoxil (ADV), the first two are also licensed to use in children. IFN-alpha has the advantage of having a more durable response, fixed duration of treatment and lack of resistant mutants. The disadvantages of IFN-alpha include need for thrice-weekly injections, higher cost and more side-effects compared with the nucleoside analogues. Nucleoside analogues can be given orally and used in decompensated cirrhosis and transplant recipients. ADV and newer drugs like tenefovir can successfully treat mutants produced after prolonged LMV therapy. Current protocols exclude children with immunotolerant HBV. Periodic screening with liver ultrasound scan and alpha-fetoprotein (AFP) in all children with chronic HBV infection is recommended. The severe shortage of cadaveric donor organs has led to the use of marginal (including anti-HBc-positive) cadaveric donor livers in selected transplant candidates with high medical urgency; 5-10% of all liver transplants are because of HBV. Using hepatitis B immunoglobulin and nucleoside analogues has made the outcome following liver transplantation for hepatitis B, comparable with, if not slightly better, than that in patients with other diagnoses. Future treatments should be based on the restoration of HBV-specific T-cell responses to levels similar to that seen in subjects controlling HBV.

Misperceptions among patients with chronic hepatitis B in Singapore

AIM: To identify the misperceptions among CHB patients, as well as to determine the factors associated with better knowledge.

METHODS: A telephone interview was conducted on 192 adult CHB patients, who earlier responded to an advertisement for free screening. The questionnaire included items about socio-demographic factors and a 14-item quiz on knowledge of general aspects, transmission, and management of HBV infection.

RESULTS: The mean knowledge score on HBV was 10.4/14. Common misperceptions included availability of treatment for HBV infection and early liver cancer, as well as on transmission. Having completed tertiary education was the only independent factor associated with a high knowledge score, after controlling other demographic factors.

CONCLUSION: More educational efforts should be focused on patients misperceptions and target the less educated HBV carriers.

Survival in hepatocellular carcinoma: impact of screening and etiology of liver disease

BACKGROUND AND AIMS

As the merits of screening at-risk populations for hepatocellular carcinoma (HCC) remain unclear, we compared the clinico-pathologic features and survival of patients with cirrhosis and HCC detected by screening (Group A) to that in non-screened cases (Group B).

METHODS

We studied cirrhotics who developed HCC between 1994 and 2002. During this period, cirrhotics managed by the Gastroenterology Unit were regularly screened at 6-12 monthly intervals while those managed by other hospital units were not. Demographic data, tumor details, treatment received and survival were recorded and compared according to screening status.

RESULTS

There were 96 cases identified; 41 by screening (group A) and 55 by non-screening methods (Group B). HCC in Group A were smaller (P < 0.01), more likely unilobar (P < 0.01), at an early stage (P < 0.0005) and before vascular invasion (P < 0.005) than Group B cases. The frequency of hepatic surgery and/or local ablation was higher in Group A than Group B (P = 0.001). Overall median survival of Group A was 882 days versus 99 days in Group B (P < 0.0001). One- and 3-year probabilities of survival in Group A were 89% and 38%, versus 33% and 19% in Group B (P < 0.001). Independent predictors of survival included screening, Child-Pugh score, creatinine, tumor stage and absence of alcohol as the etiology.

CONCLUSIONS

Screening for HCC in cirrhosis identifies tumors at an earlier stage, results in a higher chance of receiving curative treatment and possibly improves patient survival. The absence of alcoholic liver disease impacts favorably on survival.

Utility of the Health Belief Model in predicting compliance of screening in patients with chronic hepatitis B

BACKGROUND

Regular surveillance is recommended for patients with chronic hepatitis B, to select candidates for anti-viral therapy and detect early complications. However, factors that determine compliance are not well studied.

AIM

To determine the utility of the Health Belief Model in explaining non-compliance, among a group of chronic hepatitis B patients for screening.

METHODS

A total of 192 chronic hepatitis B patients who responded to advertisement for free screening took part in a telephonic interview study. Subjects were asked about the five constructs of the Health Belief Model, and factors associated with recent screening were analysed.

RESULTS

The mean age of the subjects was 42.1 +/- 0.7 years; 77% white male, and 97% Chinese. About 108 patients (56%) had recent screening. At multivariate analysis, only the ability to remember date of follow-up (OR: 4.37; 95% CI: 2.07-9.17) and the perception of having to wait a long time for venepuncture (OR: 0.38; 95% CI: 0.19-0.79) were significantly associated with recent screening.

CONCLUSION

Future public health measures should include improving the logistics of follow-up procedures and providing reminders for screening to improve compliance.

Liver cell lines for the study of hepatocyte functions and immunological response

BACKGROUND

Liver cell lines closely resembling primary hepatocyte are essential for research on hepatitis viruses and hepatocyte function. Currently used cell lines are derived from hepatic tumours and have altered gene expression.

AIMS

The generation and characterisation of novel human hepatocyte lines (HHLs) derived from healthy human liver, retaining the primary hepatocyte phenotype.

RESULTS

Primary hepatocytes were immortalised with Moloney's mouse leukaemia virus expressing E6 and E7 proteins of human papillomavirus, and cultures propagated long-term. All HHLs contained markers of hepatocyte and biliary phenotype (cytokeratins 7, 8, 18 and 19), Cytochrome P450 and albumin. The HHLs did not express high levels of p53 or alpha-fetoprotein. When grown in a collagen sandwich culture, or at the air-liquid interface, HHLs were maintained as monolayer whereas Huh-7 and HepG2 formed thick layers. All HHLs showed increased capacity to bind recombinant hepatitis C virus-like particles in comparison with Huh-7 and HepG2. We also demonstrate that HHLs contained active gap junctions, and that the cells respond to stimulation with IFN-alpha by upregulation of major histocompatibility complex (MHC)-I and -II.

CONCLUSIONS

These HHLs retain primary hepatocyte phenotype and should be useful for investigating mechanisms of entry and replication of hepatotropic viruses, and should also be valuable in the study of hepatocyte biology and pathology.

Viral hepatitis in the Arctic

OBJECTIVES

Summarize research on viral hepatitis in indigenous populations in the Arctic.

STUDY DESIGN

Literature review.

METHODS

Medline search from 1966-2003.

RESULTS

High prevalence rates of total hepatitis A antibody of > 50% and of hepatitis B of between 22% in Alaska and 42% in Greenland for total infection and between 3% in Canada and 12% in Siberia for chronic infection have been reported. Universal childhood vaccination with hepatitis A vaccine beginning at age 2 have stopped epidemics of HAV in Alaska and newborn hepatitis B immunization programs in Alaska and Canada have reduced new infections. However, in all Arctic countries several thousand persons chronically infected with HBV remain at risk for the development of cirrhosis and hepatocellular carcinoma. Prevalence rates of hepatitis C (HCV) reported are <1.4% in the Arctic. Hepatitis D virus, which co-infects with HBV, has been found in 40% of persons with HBV in Greenland.

CONCLUSIONS

High rates of viral hepatitis A, B, C, and D are found in the Arctic. Effective vaccines against HAV, HBV and HDV can prevent transmission of these viruses. In addition, new antiviral therapies for HBV and HCV can be used effectively to treat many chronically infected patients.

Does screening or surveillance for primary hepatocellular carcinoma with ultrasonography improve the prognosis of patients?

PURPOSE

The purpose of this paper is to evaluate the efficacy of ultrasonographic screening for primary hepatocellular carcinoma.

PATIENTS AND METHODS

A total of 680 eligible cases were classified into three groups (surveillance, opportunistic, and symptomatic groups) according to their initial exposure. We used survival time, tumor morphology, and T staging as prognostic outcomes. The outcomes of screened/unscreened and sur veillance/nonsur veillance were compared with the use of the logistic regression model.

RESULTS

The adjusted odds ratios for the screened group versus the unscreened group, with 1-, 2-, and 3-year survival time being used as outcomes, were 0.33 (95% confidence interval [CI], 0.21-0.52), 0.33 (95% CI, 0.21-0.53), and 0.37 (95% CI, 0.23-0.61), respectively. The adjusted odds ratios for surveillance versus nonsurveillance were 0.58 (95% CI, 0.35-0.97), 0.45 (95% CI, 0.27-0.74), and 0.44 (95% CI, 0.26-0.73). The odds ratios were even smaller when tumor morphology or T stage was taken as the main outcome. All these results were statistically significant. There were significant gradient relationships between prognostic outcomes and extent of screening history.

CONCLUSION

The significant impact of ultrasonographic screening on mortality reduction was demonstrated. These findings strongly suggest that early detection of hepatocellular carcinoma by ultrasound may improve the prognosis of patients with hepatocellular carcinoma.

The progression of hepatitis B- and C-infections to chronic liver disease and hepatocellular carcinoma: presentation, diagnosis, screening, prevention, and treatment of hepatocellular carcinoma

Much information has been gained in the diagnosis and treatment of HCC during the last 15 years. Ever improving imaging technology has made nonhistologic diagnostic criteria possible, albeit controversial. Liver transplantation, resection, and RFA are considered curative options. Yet, HCC incidence is steadily rising because of limited progress on disease prevention. Accurate and cost-effective screening is necessary. Presently, only 10% to 15% of HCC patients present with a curative stage of disease. Because the field of HCC is rapidly changing, patients with HCC should be referred to liver centers with a full array of services, from surgical to oncologic. The prognosis for HCC patients will surely improve with a multi-disciplinary approach to care and further clinical research. Better screening and prevention of recurrence should eventually improve survival. It is hoped that antiviral treatment studies will lower the risk of HCC, and that these changes will occur soon enough to help the many patients at risk for or diagnosed with HCC over the next several years.

Randomized controlled trial of screening for hepatocellular carcinoma

PURPOSE

Screening for hepatocellular carcinoma (HCC) has been conducted for over 20 years, but there is no conclusive evidence that screening may reduce HCC mortality. The aim of this study was to assess the effect of screening on HCC mortality in people at increased risk.

METHODS

This study included 18,816 people, aged 35-59 years with hepatitis B virus infection or a history of chronic hepatitis in urban Shanghai, China. Participants were randomly allocated to a screening (9,373) or control (9,443) group. Controls received no screening and continued to use health-care facilities. Screening group participants were invited to have an AFP test and ultrasonography examination every 6 months. Screening was stopped in December 1997; by that time screening group participants had been offered five to ten times. All participants were followed up until December 1998. The primary outcome measure was HCC mortality.

RESULTS

The screened group completed 58.2 percent of the screening offered. When the screening group was compared to the control group, the number of HCC was 86 versus 67; subclinical HCC being 52 (60.5%) versus 0; small HCC 39 (45.3%) versus 0; resection achieved 40 (46.5%) versus 5 (7.5%); 1-, 3,-, and 5-year survival rate 65.9%, 52.6%, 46.4% versus 31.2%, 7.2%, 0, respectively. Thirty-two people died from HCC in the screened group versus 54 in the control group, and the HCC mortality rate was significantly lower in the screened group than in controls, being 83.2/100,000 and 131.5/100,000, respectively, with a mortality rate ratio of 0.63 (95%CI 0.41-0.98).

CONCLUSIONS

Our finding indicated that biannual screening reduced HCC mortality by 37%.

Screening for hepatocellular carcinoma

There is currently no evidence that screening patients at risk for hepatocellular carcinoma reduces mortality from the disease. Nonetheless, screening is widely practiced. Screening is a process that includes selecting patients, applying screening tests, deciding on recall policies, and subsequently proving or disproving the presence of cancer. The literature on screening for hepatocellular carcinoma is confusing at best, and does not adequately consider the many biases that result from uncontrolled and retrospective studies. Nonetheless, screening can be justified because it is likely that mortality is decreased by adequate treatment of small cancers, particularly in the era of liver transplantation. False-positive screening test results are common. Once an abnormal screening result is obtained there is little guidance from the literature as to how patients should be investigated further, nor about how to determine whether the screening test result was a false-positive. This should at minimum include short interval follow-up with CT scans and MRI's.

Diagnosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is responsible for a large proportion of cancer deaths worldwide. HCC is frequently diagnosed after the development of clinical deterioration at which time survival is measured in months. Long-term survival requires detection of small tumors, often present in asymptomatic individuals, which may be more amenable to invasive therapeutic options. Surveillance of high-risk individuals for HCC is commonly performed using the serum marker alpha-fetoprotein (AFP) often in combination with ultrasonography. Various other serologic markers are currently being tested to help improve surveillance accuracy. Diagnosis of HCC often requires more sophisticated imaging modalities such as CT scan and MRI, which have multiphasic contrast enhancement capabilities. Serum AFP used alone can be helpful if levels are markedly elevated, which occurs in fewer than half of cases at time of diagnosis. Confirmation by liver biopsy can be performed under circumstances when the diagnosis of HCC remains unclear.

Serum insulin-like growth factor-II as a serologic marker of small hepatocellular carcinoma

OBJECTIVE

Alpha-fetoprotein (AFP) is not a useful tumor marker for diagnosis of small hepatocellular carcinoma (HCC). There is over-expression of insulin-like growth factor (IGF)-II in HCC tissue. This study investigates the diagnostic application of IGF-II in small HCC.

MATERIAL AND METHODS

Serum levels of IGF-II and AFP were determined in 41 patients with small cirrhotic HCC (< or = 3 cm), 41 sex- and age-matched patients with cirrhosis alone (LC), and 41 healthy adults. The optimal cut-off values for diagnosing HCC were determined with receiver operating characteristics (ROC) curve.

RESULTS

Both IGF-II and AFP levels in HCC were higher than those in LC patients or controls (each p = 0.0001). The IGF-II levels in LC patients were lower than those in controls (p = 0.001). In HCC patients, multivariate analysis indicated that that both IGF-II (odds ratio, 4.54; 95% confidence interval, 2.15-9.55; p = 0.0001) and AFP (odds ratio, 1.05; 95% confidence interval, 1.01-1.08; p = 0.003) were found to be associated with an increased risk of presence of HCC. The optimal cut-off values of IGF-II (4.1 mg/g prealbumin) and AFP (50 ng/ml) were determined with ROC curves. The sensitivity, specificity, and diagnostic accuracy values for IGF-II were 63%, 90%, and 70%, respectively. Those for AFP were 44%, 95%, and 70%, respectively. Determination of both markers in parallel significantly increase the diagnostic accuracy (88%) and sensitivity (80%), with a high specificity (90%).

CONCLUSIONS

Serum IGF-II level can be used as an independent serologic marker or a complementary tumor marker to AFP for diagnosis of small HCC.

Chronic hepatitis B

Interferon alpha, lamivudine, and adefovir are the three drugs currently approved for the treatment of chronic hepatitis B virus (HBV). There are pros and cons associated with the use of each drug. Individualization of therapy, based upon factors such as patient comorbidities, response to prior therapies, and stage of disease, is recommended. Patients with abnormal liver enzymes, indices of active viral replication (HBV DNA positive hepatitis B early antigen positive) or evidence of necroinflammatory activity on liver biopsy, and compensated liver disease are potential candidates for treatment with interferon, lamivudine, or adefovir. Patients with abnormal liver enzymes, indices of active viral replication (HBV DNA positive HB(e)Ag positive), and decompensated liver disease are candidates for treatment with lamivudine or adefovir. Consideration of liver transplantation should occur concurrently. Interferon alpha treatment results in hepatitis B surface antigen loss and sustained suppression of HBV DNA replication in 30% to 40% of treated patients. Loss of HBsAg occurs in nearly 10% of patients and a higher than expected frequency of HBsAg loss occurs long-term. The main limitation of therapy is the side effects and the need for parenteral administration. Additionally, interferon therapy is not applicable to all patient groups. Lamivudine achieves HB(e)Ag seroconversion in 15% to 20% of patients treated for 12 months, but (HBsAg) loss is rare. Reduction in HBV DNA to undetectable levels (by hybridization assay) during treatment is nearly universal, and histologic improvement is seen in about 55% of patients. The main limitation of lamivudine therapy is the development of drug resistance, which occurs in 20% of patients after 12 months and increases with duration of therapy (55% at 3 years). Adefovir achieves HB(e)Ag seroconversion in 12% of patients treated for 12 months, but HBsAg loss is rare. An average 3.5 log reduction in HBV DNA levels is and histologic improvement occurs in 50% to 60% of patients. It is effective against both wild-type and lamivudine-resistant HBV. The risk of drug resistance is low and estimated to be approximately 2% to 3% after 2 years of treatment. Several new antiviral agents are currently under evaluation in clinical trials. In addition, there are two drugs (tenofovir and emtricitabine) that have been approved for HIV infection and that have anti-HBV activity. In the future, combination therapy for chronic HBV infection can be anticipated. Utilization of two or more anti-HBV drugs would be predicted to enhance efficacy and reduce the likelihood of emergence of drug resistance.