Interferon beta prevents recurrence of hepatocellular carcinoma after complete resection or ablation of the primary tumor-A prospective randomized study of hepatitis C virus-related liver cancer

Hepatocellular carcinoma: therapy and prevention

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. The major etiologies and risk factors for the development of HCC are well defined and some of the multiple steps involved in hepatocarcinogenesis have been elucidated in recent years. Despite these scientific advances and the implementation of measures for the early detection of HCC in patients at risk, patient survival has not improved during the last three decades. This is due to the advanced stage of the disease at the time of clinical presentation and limited therapeutic options. The therapeutic options fall into five main categories: surgical interventions including tumor resection and liver transplantation, percutaneous interventions including ethanol injection and radiofrequency thermal ablation, transarterial interventions including embolization and chemoembolization, radiation therapy and drugs as well as gene and immune therapies. These therapeutic strategies have been evaluated in part in randomized controlled clinical trials that are the basis for therapeutic recommendations. Though surgery, percutaneous and transarterial interventions are effective in patients with limited disease (1-3 lesions, <5 cm in diameter) and compensated underlying liver disease (cirrhosis Child A), at the time of diagnosis more than 80% patients present with multicentric HCC and advanced liver disease or comorbidities that restrict the therapeutic measures to best supportive care. In order to reduce the morbidity and mortality of HCC, early diagnosis and the development of novel systemic therapies for advanced disease, including drugs, gene and immune therapies as well as primary HCC prevention are of paramount importance. Furthermore, secondary HCC prevention after successful therapeutic interventions needs to be improved in order to make an impact on the survival of patients with HCC. New technologies, including gene expression profiling and proteomic analyses, should allow to further elucidate the molecular events underlying HCC development and to identify novel diagnostic markers as well as therapeutic and preventive targets.

Therapeutic effectiveness of echo-guided percutaneous radiofrequency ablation therapy with a LeVeen needle electrode in hepatocellular carcinoma

AIM: To investigate the results of radiofrequency ablation (RFA) in obtaining the necrosis of hepatocellular carcinoma (HCC) in cirrhotic patients and to assess the results of RFA in relation to recurrence of HCC and survival of the treated patients.

METHODS: Fifty-six consecutive cirrhotic patients with 63 HCCs were treated with RFA between May 2000 and May 2004. The diameter of the HCCs ranged from 1 cm to 5 cm (mean 2.8 cm). In all cases RFA was performed with percutaneous approach under ultrasound guidance using expandable needle electrode (LeVeen needle). Treatment efficacy and recurrence were evaluated with dual-phase spiral computed tomography (CT).

RESULTS: Complete necrosis after single or multiple treatment was achieved in 96.8% (61/63) tumors. We observed recurrence after complete necrosis in 23 patients (41%) during a mean follow-up of 32.3 months. The recurrences were local in 2 patients (8.6%) and in different segments in 21 (91.4%). Major complications occurred in 3 patients (4%). During follow-up period, 32 (57.1%) patients died; 15 due to progression of HCC, 11 from liver failure, 3 from esophageal varices bleeding and 3 from the causes not related to liver disease.

CONCLUSION: RFA with LeVeen needle is an effective and safe treatment for HCC < 5 cm in cirrhotic patients. It has yet to be established how far this treatment influences the survival rate of patients. It becomes important to establish treatments to prevent recurrences in different segments, such as interferon therapy.

Antiviral therapy after non-surgical tumor ablation in patients with hepatocellular carcinoma associated with hepatitis C virus

BACKGROUND

Antiviral therapy for chronic hepatitis C virus (HCV) infection has led to a reduction in the incidence of hepatocellular carcinoma (HCC). The purpose of the present paper was to assess whether antiviral therapy might suppress tumor recurrence and influence overall survival in patients with HCV-related HCC who had complete ablation of nodules by non-surgical treatments.

METHODS

Twenty patients with three or fewer nodules of HCV-related HCC who were treated with percutaneous tumor ablation and/or transcatheter arterial embolization received combined interferon (IFN; 3 or 5 million units of IFN alpha-2b thrice weekly) plus ribavirin (1000-1200 mg per day) therapy for 24-48 weeks after complete ablation of lesions. During the same period, an additional 40 age- and sex-matched control patients with similar characteristics of tumors (sizes, numbers and treatment modalities) and severity of liver disease were recruited from the HCC database. Both recurrence-free survival and actuarial survival were evaluated.

RESULTS

Of the 20 patients, 16 completed therapy and 10 showed a sustained response with normalization of alanine aminotransferase and negative HCV-RNA at 6 months after therapy completion. Due to severe side-effects experienced by Child B patients, who mostly discontinued antiviral therapy, clinical outcome was analyzed in the Child A treated (n = 16) and control (n = 33) patients. There was no significant difference in the incidence of local recurrence in sustained responders compared with non-responders or control patients (P = 0.174, 0.1284, respectively); but the second recurrence-free interval in the sustained responders was significantly longer than that of non-responders and the control group (P = 0.0141, 0.0243, respectively). Survival in sustained responders was better than in non-responders and control patients (P = 0.0691, 0.0554, respectively).

CONCLUSIONS

These results indicate that successful antiviral therapy after non-surgical tumor ablation for HCV-related HCC may lower tumor recurrence rate and prolong survival.

Rapid inhibition of MAPK signaling and anti-proliferation effect via JAK/STAT signaling by interferon-α in hepatocellular carcinoma cell lines

The potential anti-proliferation effect of interferon-alpha (IFN-alpha) against hepatocellular carcinoma (HCC) and its growth inhibitory mechanisms remain unclear. We examined four human HCC cell lines and every cell line had the anti-proliferative effect of IFN-alpha. The PLC/PRF/5 cell line, which expressed the IFN receptor most abundantly, responded most effectively to IFN-alpha stimulation. Here, we delineate the anti-proliferative effect of IFN-alpha via the MAPK pathway in human HCC cell lines. IFN-alpha retarded G1/S transition with no evidence of apoptosis and inhibited cell proliferation. IFN-alpha diminished the phosphorylation of both extracellular signal-regulated kinase (ERK) and mitogen-activated ERK-regulating kinase (MEK), but not Raf, within 5 min. Knockdown of signal transducers of activation and transcription1 (STAT1) or Janus kinase1 (JAK1) suppressed the reduction of phosphorylation both of ERK and MEK and diminished the growth inhibition by IFN-alpha. These results suggest that IFN-alpha induces anti-proliferative signaling via the JAK/STAT pathway downstream of IFN-alpha receptors and may reduce the growth stimulation signaling by cross-talk with the MEK/ERK pathway without IFN-alpha-induced transcription.

Low-dose, long-term, intermittent interferon-alpha-2b therapy after radical treatment by radiofrequency ablation delays clinical recurrence in patients with hepatitis C virus-related hepatocellular carcinoma

OBJECTIVE

To assess whether or not interferon (IFN) therapy prevents recurrence, and eventually improves the prognosis of patients with hepatocellular carcinoma (HCC) after completion of radical radiofrequency ablation (RFA) therapy.

METHODS

Included as the IFN group in this study were 24 patients in total, who received radical RFA therapy first, followed by medication with IFN-alpha2b at such a low dose of 3 MIU x 2/week for as long as possible. On the other hand, the control group comprised 33 patients in total, who received radical RFA therapy without subsequent treatment with IFN. The control group was matched to the IFN group in age, platelet counts and size of nodules.

RESULTS

Of the 24 patients treated with IFN, only one patient showed sustained virologic response. The median tumor-free period until the first recurrence after radical RFA therapy was 3.4 years in the IFN group and 1.4 years in the control group (p = 0.02). During the first 3 years after commencement of IFN administration, the cumulative recurrence rate in the IFN group was found to be lower than in the control group (p = 0.01); however, with the lapse of time over 3 years, the recurrence rate in the IFN group increased. There was no difference in the cumulative survival rates between the IFN group and the control group (p = 0.25).

CONCLUSION

Subsequently after radical RFA therapy, long-term, low-dose, intermittent IFN therapy successfully delayed clinical recurrence of HCC.

Differential effects of interferon alpha-2b and beta on the signaling pathways in human liver cancer cells

BACKGROUND

Interferon (IFN) has been reported to reduce the incidence of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C and the recurrence of HCC after effective treatment. We examined the effect of IFNs on the proliferation and the signaling pathways of human HCC cells.

METHODS

Cellular proliferation was examined by a modified 3-(4,5-dimethylthiazol-2-yl)-2,5 diphenyltetrazolium bromide (MTT) assay. Activities of signaling molecules were evaluated by Western blot analysis.

RESULTS

Cellular growth was not significantly modulated by IFNalpha-2b or by IFN-beta, even though the HCC cells expressed the IFN receptors. However, extracellular signal-regulated kinase (ERK)1/2 was activated by treatment with IFNalpha-2b, and both ERK1/2 and AKT were activated by treatment with IFN-beta, implying a possible role in resistance to IFNs. Contrary to our expectations, inhibition of mitogen-activated ERK-regulating kinase (MEK) or phosphatidylinositol-3-OH kinase (PI3K) did not modulate the proliferation of HCC cells. Also, abrogation of the ERK1/2 and AKT signaling pathways did not affect cell-cycle arrest at the G1/S phase caused by IFNalpha-2b.

CONCLUSIONS

IFNalpha-2b and IFN-beta activated ERK1/2 and/or AKT independently of modulating the proliferation of HCC cells and the cell-cycle machinery. A signal transduction-based approach for HCC treatment needs to focus on other possible signaling molecules besides ERK1/2 and AKT when challenged with IFNs.

Viral hepatitis and hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in the world. The incidence of HCC varies considerably with the geographic area because of differences in the major causative factors. Chronic hepatitis B and C, mostly in the cirrhotic stage, are responsible for the great majority of cases of HCC worldwide. The geographic areas at the highest risk are South-East Asia and sub-Saharan Africa, here hepatitis B is highly endemic and is the main cause of HCC. In areas with an intermediate rate of HCC such as Southern Europe and Japan, hepatitis C is the predominant cause, whereas in low rate areas such as Northern Europe and the USA, HCC is often related to other factors as alcoholic liver disease. There is a rising incidence in HCC in developed countries during the last two decades, due to the increasing rate of hepatitis C infection and improvement of the clinical management of cirrhosis.

METHODS

This article reviews the literature on hepatitis and hepatocellular carcinoma. The Medline search was carried out using these key words and articles were selected on epidemiology, risk factors, screening, and prevention of hepatocellular carcinoma.

RESULTS

Screening of patients with advanced chronic hepatitis B and C with hepatic ultrasound and determination of serum alfa-fetoprotein may improve the detection of HCC, but further studies are needed whether screening improves clinical outcome. Hepatitis B and C viruses (HBV/HCV) can be implicated in the development of HCC in an indirect way, through induction of chronic inflammation, or directly by means of viral proteins or, in the case of HBV, by creation of mutations by integration into the genome of the hepatocyte.

CONCLUSION

The most effective tool to prevent HCC is avoidance of the risk factors such as viral infection. For HBV, a very effective vaccine is available. Preliminary data from Taiwan indicate a protective effect of universal vaccination on the development of HCC. Vaccination against HBV should therefore be a health priority. In patients with chronic hepatitis B or C, interferon-alfa treatment in a noncirrhotic stage is protective for HCC development in responders, probably by prevention of cirrhosis development. When cirrhosis is already present, the protective effect is less clear. For cirrhosis due to hepatitis B, a protective effect was demonstrated in Oriental, but not in European patients. For cirrhosis due to hepatitis C, interferon-alfa treatment showed to be protective in some studies, especially in Japan with a high incidence of HCC in untreated patients. Virological, but also merely biochemical response, seems to be associated with a lower risk of development of HCC. As most studies are not randomized controlled trials, no definitive conclusions on the long-term effects of interferon-alfa in HBV or HCV cirrhosis can be established. Especially in hepatitis C, prospective studies should be performed using the more potent reference treatments for cirrhotics, namely the combination of peginterferon and ribavirin.

Prevention of hepatocellular carcinoma

The accuracy and the reliability of well-recognized clinical, virologic, histologic, and molecular risk factors for hepatocellular carcinoma are still insufficient; thus, accurate risk prediction of developing cancer in individual patients remains an elusive goal.

Pharmacotherapy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the more common causes of cancer death worldwide. It occurs on a background of chronic liver disease or viral hepatitis in the vast majority of cases, with hepatitis C being mostly responsible for its continuing rise in western countries. With the screening of at-risk groups, up to 70% of HCC lesions will be detected at a treatable stage but at best, only 20-30% will benefit from potentially curative hepatic resection or transplantation. How best to treat the remaining nonsurgical patients is an area of much debate and no ideal treatment is yet available. This review summarises some of the therapeutic modalities used for HCC, with an emphasis on pharmacological therapies.

Treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumours worldwide. The major etiologies and risk factors for HCC development are well defined and some of the multiple steps involved in hepatocarcinogenesis have been elucidated in recent years. Despite these scientific advances and the implementation of measures for early HCC detection in patients at risk, patient survival has not improved during the last three decades. This is due in part to the advanced stage of the disease at the time of clinical presentation, in part due to the limited therapeutic options. These fall into four main categories: (1) surgical interventions, including tumour resection and liver transplantation, (2) percutaneous interventions, including ethanol injection and radiofrequency thermal ablation, (3) transarterial interventions, including embolisation and chemoembolisation and (4) drugs as well as gene and immune therapies. These therapeutic strategies have been evaluated in part in randomised controlled clinical trials that are the basis for therapeutic recommendations. While surgery and percutaneous as well as transarterial interventions are effective in patients with limited disease (1-3 lesions, < 5 cm in diameter) and compensated underlying liver disease (cirrhosis Child A), at the time of diagnosis more than 80% patients present with multicentric HCC and advanced liver disease or comorbidities that restrict the therapeutic measures to best supportive care. In order to reduce morbidity and mortality from HCC, therefore, early diagnosis and the development of novel systemic therapies for advanced disease, including drugs, gene and immune therapies as well as primary HCC prevention are of paramount importance. Further, secondary HCC prevention after successful therapeutic interventions needs to be improved in order to make an impact on the survival of patients with HCC. New technologies, including gene expression profiling and proteomic analyses, should further elucidate the molecular events underlying HCC development and identify novel diagnostic markers as well as therapeutic and preventive targets.

General management

Hepatocellular carcinoma is one of the most common malignancies worldwide. The general management of hepatocellular carcinoma begins with an accurate diagnosis. With advances in imaging studies, noninvasive diagnosis has become an accepted standard of care for hepatocellular carcinoma, though pathologic examination is still required in selected cases. Following diagnosis, accurate staging is the next most important step in selecting the most appropriate treatment modality. Patients with localised tumor and compensated liver disease should be considered for partial hepatectomy, and patients with poor hepatic function but early tumor stage are candidates for liver transplantation. Patients who do not qualify for either of these curative treatments may be evaluated for palliative therapy, of which transarterial chemoembolisation is most widely used. This review will discuss the role of biopsy, the pros and cons of noninvasive and pathologic tissue diagnosis as well as the general approach to choose the most appropriate treatment for patients with hepatocellular carcinoma.

The prognostic factor for outcome following second resection for intrahepatic recurrence of hepatocellular carcinoma with a hepatitis B virus infection background

PURPOSE

Second resection has been proved to be a safe and effective treatment for patients with intrahepatic recurrent HCC after primary resection; however, preoperative prognostic factors for outcome following second resection in patients with a hepatitis B virus (HBV) infection background remains to be clarified.

METHODS

Fifty-seven patients with intrahepatic recurrent an HCC and HBV infection background received second resection from 1997 to 2003 in our institute. All of them were negative for anti-hepatitis C virus (HCV) and positive regarding HBV profile. Patient and tumor factors were analyzed.

RESULTS

At the time of preparing this paper, 31 had re-recurrence and 21 patients had died. No postoperative mortality was noted. The 1-, 3-, and 5-year overall survival after second resection were 69.9%, 61.2%, and 30.6%, respectively. Univariate and multivariate analysis showed that vascular invasion and time to recurrence were the independent prognostic factors for overall survival following second resection. The 3- and 4-year overall survival after second resection were 57.7% and 46.6% in patients with the presence of any of two risk factors (n = 46), and 100% and 100% in those with absence of both risk factors (n = 11, P = 0.008).

CONCLUSIONS

Vascular invasion and time to recurrence were the prognostic factors for overall survival following second resection of intrahepatic recurrent HCC.

Naturally Acquired MAGE-A10- and SSX-2-Specific CD8+ T Cell Responses in Patients with Hepatocellular Carcinoma

Immunotherapy is being proposed to treat patients with hepatocellular carcinoma (HCC). However, more detailed knowledge on tumor Ag expression and specific immune cells is required for the preparation of highly targeted vaccines. HCC express a variety of tumor-specific Ags, raising the question whether CTL specific for such Ags exist in HCC patients. Indeed, a recent study revealed CTLs specific for two cancer-testis (CT) Ags (MAGE-A1 and MAGE-A3) in tumor infiltrating lymphocytes of HCC patients. Here we assessed the presence of T cells specific for additional CT Ags: MAGE-A10, SSX-2, NY-ESO-1, and LAGE-1, which are naturally immunogenic as demonstrated in HLA-A2(+) melanoma patients. In two of six HLA-A2(+) HCC patients, we found that MAGE-A10- and/or SSX-2-specific CD8(+) T cells naturally responded to the disease, because they were enriched in tumor lesions but not in nontumoral liver. Isolated T cells specifically and strongly killed tumor cells in vitro, providing evidence that these CTL were selected in vivo for high avidity Ag recognition. Therefore, besides melanoma, HCC is the second solid human tumor with clear evidence for in vivo tumor recognition by T cells, providing the rational for specific immunotherapy, based on immunization with CT Ags such as MAGE-A10 and SSX-2.

Effect of long-term postoperative interferon therapy on intrahepatic recurrence and survival rate after resection of hepatitis C virus-related hepatocellular carcinoma

OBJECTIVE

This study was aimed at evaluating the effects of interferon (IFN)-alpha on survival rate after resection of hepatocellular carcinoma.

METHODS

In a randomized, controlled trial by the University Hospital, Medical Center and affiliated hospital in Osaka, Japan, 30 men were after surgery randomly allocated to an IFN-alpha group (15 patients) and to a control group. Patients in the IFN group received 6 MIU of IFN-alpha intramuscularly daily for 2 weeks, then three times a week for 14 weeks, and finally twice a week for 88 weeks. The incidence of recurrence and survival rate were then studied.

RESULTS

The response to IFN was sustained viral response (SVR) in 2 patients, biochemical response (BR) in 6, partial response (PR) in 5, and no response (NR) in 2. In the control, 8 of the 15 patients demonstrated continuous abnormally high levels of ALT. At the end point of the study, intrahepatic recurrence was detected in 9 of the IFN group and in 13 of the control (p = 0.065, log-rank test). The cumulative survival rate was higher in the IFN group than in the controls (p = 0.041).

CONCLUSION

Postoperative IFN therapy improves the outcome after resection of hepatitis C virus-related hepatocellular carcinoma.

Interferon Therapy for 2 Years or Longer Reduces the Incidence of Hepatocarcinogenesis in Patients with Chronic Hepatitis C Viral Infection

OBJECTIVE

The purpose of this clinical study was to determine the effect of long-term interferon (IFN) administration on the incidence of hepatocellular carcinomas (HCC) in chronic hepatitis C patients, without eradication of hepatitis C virus (HCV) by IFN therapy.

METHODS

The number of patients with biopsy-proven chronic hepatitis with moderate or severe staging, HCV genotype 1b, a high viral load exceeding 1 MEq/ml (mega equivalents per milliliter), who received 6 MU of natural IFN-alpha daily for 2-8 weeks, followed by three times/week for 16-22 weeks, as initial IFN therapy, and positivity for HCV RNA during IFN administration was 131. 47 of the 131 patients continued to be treated with IFN (long-term IFN group, dose 3 or 6 MU twice or three times weekly for 1.5-10.5 years, median 4.0 years) after initial IFN therapy, while 84 patients did not receive any IFN therapy apart from the initial 6-month course (no-add-IFN group). The patients were prospectively monitored, and the cumulative incidence of HCC and risk factors for HCC were examined.

RESULTS

The 5- and 10-year cumulative rates of HCC were 1.9 and 6.4% and 1.9 and 26.8% for long-term IFN and no-add-IFN groups, respectively. Cox regression analysis indicated that the relative risk of HCC in the patients of the no-add-IFN group was 8.72 times of that in patients of the long-term IFN group.

CONCLUSION

Long-term IFN therapy in patients with chronic HCV infection is effective in preventing hepatocarcinogenesis.

Hepatocellular carcinoma: current surgical management

Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world, responsible for 500,000 deaths globally every year. Although HCC is a slow-growing tumor, it is often rapidly fatal because it is usually not discovered until the disease is advanced. HCC occurs primarily in individuals with cirrhosis, a condition that increases the risk of performing potentially curative surgical therapy. Over the last 2 decades, however, the safety of surgical resections has greatly improved because of advances in radiologic assessment, patient selection, and perioperative care. As such, the operative mortality rate for hepatectomy has decreased from the 10%-20% level seen in the 1980s to less than 5% today. The ultimate goal of treatment of HCC is to prolong the quality of life by eradicating the malignancy while preserving hepatic function. For treatment with a curative intent, the gold standard remains surgical resection, by either partial hepatectomy or total hepatectomy followed by liver transplantation. Resectability and choice of procedure depend on many factors, including baseline liver function, absence of extrahepatic metastases, size of residual liver, availability of resources including liver graft, and expertise of the surgical team. Patients without cirrhosis can tolerate extensive resections, and partial hepatectomy should be considered first. For Child class B and C patients with a small HCC, liver transplantation offers the best results, whereas partial liver resection is indicated in patients with well-compensated cirrhosis. Living donor liver transplantation should be considered using the same criteria as that used for cadaveric transplantation.

Prevention of hepatitis C virus-related hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing in North America, Europe, and Japan, caused largely by the high rates of chronic hepatitis C virus (HCV) infection. In such individuals, the risk factors for developing HCC are advancing age, male gender, worsening hepatic fibrosis (particularly cirrhosis), and greater degrees of hepatic inflammation. Additional, potentially modifiable risk factors include coinfection with hepatitis B, excessive alcohol use, iron overload, and diabetes/obesity. Thus, approaches to preventing HCC should focus on eradicating HCV infection, responsible for the inflammation and fibrosis, and also on treating or reducing the modifiable risks, such as through hepatitis B vaccination, decreasing alcohol use, phlebotomy for iron overload, and weight control and diabetes prevention. These approaches have yet to be proven effective. Meta-analyses of standard interferon monotherapy trials in patients with HCV-related cirrhosis suggest that interferon has a small but significant effect on reducing HCC risk, particularly in those who achieve a sustained response. Other studies indicate that the reduction in HCC is greatest if a response is achieved before cirrhosis develops. Secondary prevention when HCC has been ablated or resected may be partially effected with interferon treatment or oral polyprenoic acid. No long-term studies of the effect of the currently recommended regimen of peginterferon and ribavirin have been reported, and no current trials include untreated control groups. Studies of maintenance peginterferon therapy in virological nonresponders are under way in the hope of proving that this approach is effective in decreasing the risk of HCC.

High pathological risk of recurrence after surgical resection for hepatocellular carcinoma: an indication for salvage liver transplantation

Surgical resection and liver transplantation offer a 5-year survival greater than 70% in patients with hepatocellular carcinoma, but the high recurrence rate impairs long-term outcome after resection. Pathological data such as vascular invasion and detection of additional nodules predict recurrence and divide patients into high and low risk profile. Based on this, we proposed salvage liver transplant to resected patients in whom pathology evidenced high recurrence risk even in the absence of proven residual disease. From January 1995 to August 2003 we have evaluated 1,638 patients. Resection was indicated in 77 patients, but only 17 (22%) (all cirrhotics, 14 hepatitis C virus+) were optimal candidates for both resection and transplantation. Of them, 8 exhibited a high risk profile at pathology and were offered transplantation. Among the 8 high risk patients, 7 presented recurrence, compared with only 2 of the 9 at low risk (P = .012). Two of the high risk patients refused transplant and developed multifocal disease during follow-up. The other 6 were enlisted and all but 1 had tumor foci in the explant. Only 1 presented extrahepatic dissemination early after transplant and died 4 months later. The others are free of disease after a median follow-up of 45 months. Two recurrences were detected in low risk patients, 1 of them being transplanted 18 months after surgery. These data in a small series of patients confirm that pathological parameters identify patients at higher risk of recurrence, which allow them to be listed for liver transplantation without proven malignant disease. In conclusion, this policy is clinically effective and could further improve the outcome of resected patients.

Antiviral therapy in patients with chronic hepatitis B and cirrhosis

Chronic hepatitis B virus infection (HBV) may result in significant morbidity, including cirrhosis, end-stage liver disease, and hepatocellular carcinoma. The management of chronic HBV cirrhosis is advancing rapidly. Current treatment options for patients with HBV-related cirrhosis include interferon-alpha (IFN-alpha), lamivudine and adefovir dipivoxil. IFN-a is used less commonly today because of its toxicity, difficulty with administration, and the availability of safer drugs. Lamivudine, an oral nucleoside analog, has proven to be at least as effective, and is safer, than IFN-a in the treatment of HBV-related cirrhosis. It is plagued by the development of resistant viral mutants, however. The newest oral nucleotide analog, adefovir dipivoxil, has shown excellent efficacy in treatment-naïve and lamivudine-resistant HBV patients and has lower rates of resistance in the short-term.

Systemic therapy for advanced hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is a common cause of cancer mortality worldwide. Whilst local treatments are useful in selected patients, they are not suitable for many with advanced disease. Here, we review phase II and III trials for systemic therapy of advanced disease, finding no strong evidence that any chemotherapy, hormonal therapy, or immunotherapy regimen trialled to date benefits survival in this setting. Many trials were inadequately powered, single centre, and enrolled highly selected patients. From this review, we cannot recommend any therapeutic approach in these patients outside of a clinical trial setting. Including an untreated control arm in clinical trials in HCC is still justified. Every effort should be made to enroll these patients into adequately powered trials, and promising phase II results must be tested in a multicentre phase III setting, preferably against a placebo control arm. Prevention of hepatitis B and C remains vital to decrease deaths from HCC.

Biologic therapy of liver tumors

Nonresectable primary and metastatic liver tumors are common malignancies that lack therapies allowing substantial prolongation of survival. Recent progress in molecular and cell biology has opened the way to novel therapies based on biological modifiers, gene transfer, and autologous stem cells. It is now possible to transfer therapeutic genes to the tumor or pericancerous tissue, and to control their expression for long periods of time. It is also feasible to generate autologous endothelial progenitor cells that can be recruited by tumoral vessels acting as vehicles to convey therapeutic genes to the interior of the tumor mass. Combination of biological modifiers, gene therapy, and cell therapy will hopefully provide efficient means to combat inoperable neoplasms in a not-very-distant future.

Favorable surgical outcomes in patients with early hepatocellular carcinoma

BACKGROUND

Early hepatocellular carcinoma (HCC) is defined as well-differentiated HCC with an obscure tumor margin in the classification of the Liver Cancer Study Group of Japan. However, the surgical outcomes in patients with early HCC have not yet been clarified.

METHODS

From 1985 to 1994, 186 patients with HCC 2 cm or less in greatest dimension underwent curative hepatectomy. Of the 186 cases, 37 were early HCC and 149 were small advanced HCC. The relationship between clinicopathological findings and surgical outcomes was examined.

RESULTS

The rate of hepatitis C antibody or number of tumors was significantly higher in patients with early HCC than in patients with small advanced HCC. Liver function test showed no differences between patients with early HCC and patients with small advanced HCC. The 5-and 10-year survival rates were 85% and 61%, respectively, in patients with early HCC, which was significantly better than in patients with small advanced HCC (P = 0.0137). Univariate and multivariate analysis showed Child-Pugh class, intrahepatic metastasis, and early HCC to be significant prognostic factors.

CONCLUSIONS

Patients with early HCC had a different clinical background and good surgical outcomes; therefore, it should be recognized that early HCC is a distinct clinicopathological entity.

[Best supportive care of hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in some areas of the world. The major etiologic risk factors include toxins (alcohol, aflatoxin B(1)), hepatitis B and C virus infection as well as various inherited metabolic disorders. The prognosis of HCC patients is generally very poor with a 5-year survival rate of less than 5%. The diagnosis is based on biochemical and imaging tests as well as histology. Therapeutic strategies include surgery (resection or liver transplantation) and non-surgical interventions, such as percutaneous ethanol injection or radiofrequency thermal ablation as well as transarterial embolization or chemoembolization. Radio- or chemotherapy are mostly ineffective. Therefore, the development and evaluation of novel HCC treatment strategies as well as the implementation of existing and the development of new measures to prevent HCC are of utmost importance. The better understanding of the clinical and molecular pathogenesis of HCC should lead to improved diagnostic, therapeutic and preventive strategies with the aim to reduce the incidence of HCC, one of the most devastating malignancies worldwide.

Neither hepatitis C virus genotype nor virus load affects survival of patients with hepatocellular carcinoma

OBJECTIVE

Hepatitis C virus (HCV) genotype and virus load, the strongest determinants of the efficacy of interferon therapy, have been presumed to be associated with risk for hepatocellular carcinoma (HCC). This study was conducted to elucidate whether these two factors are capable of predicting the prognosis of patients with HCC.

METHODS

A total of 371 patients with HCV infection (258 men and 113 women; median age, 66 years; range, 37-88 years) who developed HCC between January 1993 and December 1999 were enrolled. Overall survival and recurrence-free survival were analysed with the Cox proportional hazard regression according to HCV genotype (type 1 versus type 2) and virus load (above versus below 100 kIU/ml).

RESULTS

Of the 371 patients, 346 received locoregional treatments (ethanol injection, microwave, radiofrequency, or surgery), and 307 achieved complete response as determined by subsequent imaging studies. The remaining 25 patients underwent arterial embolization or chemotherapy. Cox proportional hazard regression showed that neither genotype (P = 0.814) nor virus load (P = 0.958) were significant predictors for survival (P = 0.814 and 0.958, respectively) and recurrence (P = 0.505 and 0.736, respectively).

CONCLUSIONS

Neither genotype nor virus load of HCV affected prognosis of HCC patients.

Angiogenesis in hepatocellular carcinoma: the retrospectives and perspectives

Hepatocellular carcinoma (HCC) is a typical hypervascular tumor. Many angiogenic factors have been studied in HCC, and several anti-angiogenic therapies have been tested in animal models and patients. This paper summarizes the latest findings, especially regarding the clinical significance of endothelial cell markers and angiogenic factors in HCC, and experimental and clinical anti-angiogenesis therapies. Further developments in this area, such as endothelial cell-oriented research and better experimental and clinical designs in the evaluation of anti-angiogenic therapies are discussed.

A prospective comparison of the effect of interferon-alpha and interferon-beta treatment in patients with chronic hepatitis C on the incidence of hepatocellular carcinoma development

To investigate differences in the effect of interferon (IFN) -alpha and IFN-beta treatment for hepatitis C on hepatocellular carcinoma (HCC) development, we prospectively followed 351 consecutive patients (median age, 56.6 years; mean follow-up, 5.7 +/- 2.6 years) with chronic hepatitis C virus (HCV) viremia. Of 260 IFN-alpha and 91 IFN-beta treated patients, 17 (6.5%) and 4 (4.4%), respectively, developed HCC. Virological response (VR) was defined as persistent HCV RNA disappearance from serum, and biochemical response (BR) as persistent alanine aminotransferase (ALT) normalization after treatment. No significant between-group differences in HCC development were found between those with and without VR. Although the HCC development rate in patients without BR was significantly higher than that in patients with BR in the IFN-alpha group (11.4% and 0.8%; P << 0.05), no significant difference was found in the IFN-beta group (6.3% and 2.3%). Similar rates of HCC development were found in patients with chronic HCV viremia treated with either IFN-alpha or IFN-beta.

Prospective randomized controlled study of interferon-alpha in preventing hepatocellular carcinoma recurrence after medical ablation therapy for primary tumors

BACKGROUND

Hepatocellular carcinoma (HCC) recurrence after ablation therapy for primary tumors is common.

METHODS

To evaluate the effectiveness of interferon-alpha (IFN-alpha) in preventing HCC recurrence, 30 eligible patients were randomized into three groups: 11 patients treated with three mega units (MU) of IFN-alpha three times weekly for 24 months (IFN-alpha-continuous group), 9 patients treated with 3 MU of IFN-alpha daily for 10 days every month for 6 months followed by 3 MU of IFN-alpha daily for 10 days every 3 months for a further 18 months (IFN-alpha-intermittent group), and 10 patients who received no IFN-alpha therapy (control group). The three groups were comparable in terms of etiology, demographics, and laboratory data at entry and HCC characteristics.

RESULTS

After a median follow-up of 27 months (range 4-53 months), 9 patients (90%) in the control group and 9 patients (45%) in 2 treatment groups (6 patients in the IFN-alpha-continuous group and 3 patients in the IFN-alpha-intermittent group) developed an HCC recurrence (P = 0.021). Cumulative HCC recurrence rates in the IFN-alpha-intermittent, IFN-alpha-continuous, and control groups were 22.2%, 27.3%, and 40% at the end of 1 year and 33.3%, 54.6%, and 90% at the end of 4 years (P = 0.0375), respectively (control vs. IFN-alpha-intermittent group, P = 0.0123; vs. IFN-alpha-continuous group, P = 0.0822). If both IFN-alpha groups were combined, the cumulative HCC recurrence rate of the patients treated with IFN-alpha and the control group was 25% and 40% at the end of 1 year and 47% and 90% at the end of 4 years, respectively (P = 0.0135).

CONCLUSIONS

The data suggested that IFN-alpha therapy may reduce HCC recurrence after medical ablation therapy for primary tumors.

Inhibition of spontaneous development of liver tumors by inoculation with dendritic cells loaded with hepatocellular carcinoma cells in C3H/HeNCRJ mice

We attempted to prevent spontaneous development of liver tumors by s.c. inoculation with DCs loaded with syngeneic HCC cells in C3H/HeNCrj mice. A new cell line, MIH-2, was established from an HCC that had developed spontaneously in a C3H/HeNCrj mouse. Bone marrow-derived DCs were loaded with irradiated MIH-2 cells by treatment with PEG. Fluorescence microscopy and flow-cytometric analysis showed that about 45% of PEG-treated DCs and MIH-2 cells (DC/MIH-2) were DCs loaded with MIH-2 cells. Thirteen-month-old mice received inoculations of DC/MIH-2 (9 x 10(5)/mouse) 4 times at 6-day intervals and were killed at 16 months of age to assess liver tumors. The incidence of liver tumors in these mice was significantly lower than that in mice not receiving inoculations (p < 0.05) but similar to that in 13-month-old mice (the age at which inoculation started), indicating that inoculation inhibited the development of new tumors. Splenocytes from inoculated mice, but not those from uninoculated mice, showed cytotoxic activity against MIH-2 cells. Cytotoxic activity was not elicited by CD4(+) T cells, CD8(+) T cells, or DX5(+) cells isolated from splenocytes but was elicited by adherent cells, identified as CD11b(+) macrophages. CD4(+) T cells, but not CD8(+) T cells, from inoculated mice produced IFN-gamma by incubation with DC/MIH-2. Cytotoxicity by splenocytes was attenuated by anti-IFN-gamma antibody. Immunization with DCs loaded with syngeneic HCC cells induces CD4(+) T cells that produce IFN-gamma by response to antigen of HCC, which would lead to macrophage activation to kill liver tumor cells at an early stage.

A decade's studies on metastasis of hepatocellular carcinoma

Metastasis remains one of the major challenges before hepatocellular carcinoma (HCC) is finally conquered. This paper summarized a decade's studies on HCC metastasis at the Liver Cancer Institute of Fudan University. We have established a stepwise metastatic human HCC model system, which included a metastatic HCC model in nude mice (LCI-D20), a HCC cell line with high metastatic potential (MHCC97), a relatively low metastatic potential cell clone (MHCC97L) and several stepwise high metastatic potential cell clones (MHCC97H, HCCLM3, and HCCLM6) from their parent MHCC97 cell. Endeavors have been made for searching human HCC metastasis-related chromosomes/proteins/genes. Monogene-based studies revealed that HCC invasion/metastasis was similar to that of other solid tumors, and the biological characteristics of small HCC were only slightly better than that of large HCC. Using comparative genomic hybridization (CGH), fluorescence in situ hybridization (FISH), genotyping, cDNA microarray, and 2-dimensional gel electrophoresis, we obtained some interesting results. In particular, in collaboration with the National Institute of Health (NIH) in the United States, we generated a molecular signature that can classify metastatic HCC patients, identified osteopontin as a lead gene in the signature, and found that genes favoring metastasis progression were initiated in the primary tumors. We also found that chromosome 8p deletion, particularly in the region of 8p23, was associated with HCC metastasis. Cytokeratin 19 was identified as one of the proteins, which was found in MHCC97H, but not in MHCC97L cells. Experimental interventions using the high metastatic nude mice model have provided clues for the prevention of HCC metastasis. Translation from workbench to bedside demonstrated that serum VEGF, microvessel density, and p53 scoring may be of value for the prediction of postoperative metastatic recurrence. Interferon alpha proved effective for the prevention of recurrence both experimentally and clinically. In conclusion, HCC metastasis that probably initiated in the primary tumor is a multigene-involved, multistep, and changing process. The further elucidation of the mechanism underlying HCC metastasis will provide a more solid basis for the prediction and prevention of the metastatic recurrence of HCC.

Inhibitory effect of MUC1 gene immunization on H22 hepatocellular carcinoma growth

AIM

To investigate the special anti-H22 hepatocellular carcinoma growth effect of the MUC1 gene immunization.

METHODS

Balb/c mice were immunized intramuscularly with 100 mg MUC1 cDNA 3 times at 3-weekly intervals. Three weeks after the last immunization, tumor challenge experiments were performed by using MUC1 expressing tumor cell line H22. Tumor growth inhibition and body protection were observed two weeks later. After 43d of challenge experiments, all mice were killed and tumors were weighed. Histological analysis of tumor tissue was carried out with HE staining.

RESULTS

After 43 d of challenge experiments, the volumes of H22 hepatocellular carcinoma in MUC1cDNA, pcDNA3.1(+) and NS groups were 547±59 mm³, 1 185±84 mm³ and 1 220±95 mm³ (P <0.01), respectively. The average mass of H22 hepatocellular carcinoma in the three groups was 1.87±0.96 g, 4.19±1.34 g and 4.23±1.32 g (P <0.01), respectively . Tumorigenic rate was only 50 % in MUC1cDNA group, and was 100 % in pcDNA3.1(+) and NS group. H22 hepatocellular carcinoma growth in mice of MUC1cDNA group was significantly suppressed (P <0.01), and a significant body protective effect was found in mice of MUC1cDNA group (P <0.05), compared with control group. Histological analysis showed that the H22 hepatocellular carcinoma tissues were markedly necrosed in mice of MUC1cDNA group compared with that in control group.

CONCLUSION

MUC1 gene immunization can significantly suppress H22 hepatocellular carcinoma growth.

Rising incidence of hepatocellular carcinoma: the role of hepatitis B and C; the impact on transplantation and outcomes

Hepatocellular carcinoma caused by hepatitis B and hepatitis C are global scourges but are likely to peak in incidence in the next 2 decades and then decline. Universal vaccination has been effective in stemming the incidence of chronic hepatitis B and early-onset HCC in regions of high endemicity where implemented, but preventive measures in HCV are not yet available. After the attrition of older affected generations, the incidence of HCC will likely decline rapidly. While no vaccine is currently available for hepatitis C, cases are projected to peak and decline because of a marked reduction in transmission as a result of behavioral modification and safeguarding of blood supplies. Until these epidemiologic projections come to pass, management of hepatocellular carcinoma will continue to become a progressively more frequently encountered clinical challenge. Therapy for chronic hepatitis may ameliorate but will not eliminate the development of tumors. The demand for orthotopic liver transplantation will continue to climb, and palliative therapies for non-resectable cases will require studies aimed at optimization of benefit. LDLT may remain an option for high-risk patients affording tumor-free survival for some otherwise terminal patients.

Hepatocellular carcinoma: surgical indications and results

Hepatocellular carcinoma (HCC) is a tumour of increasing incidence that usually arises in cirrhotic liver. Untreated, the prognosis is grim and the only curative treatment is surgical resection. The practical application of segmental surgery to the liver together with the use of ultrasound and other imaging techniques, patient selection criteria and improvements in perioperative technique and postoperative care have contributed to better results in hepatic surgery. Today, less than 10% mortality for resection of cirrhotic livers, with up to 50% 5-year survival rates are to be expected. However, the limits of resection for cure: intrahepatic recurrence makes stringent follow-up necessary. In this way the available modalities of treatment can be applied so as to improve survival. Herein, a current 'state-of-the-art' of surgical indications and results for HCC is given.

Meta-analysis: evaluation of adjuvant therapy after curative liver resection for hepatocellular carcinoma

AIM

To evaluate adjuvant modalities after curative resection for hepatocellular carcinoma using a meta-analysis of randomized and non-randomized controlled trials.

METHODS

In a first step, a meta-analysis of randomized controlled trials was carried out. Sensitivity analyses after inclusion of non-randomized controlled trials were performed. Four therapeutic modalities were evaluated: pre-operative transarterial chemotherapy, post-operative transarterial chemotherapy, systemic chemotherapy and a combination of systemic and transarterial chemotherapy.

RESULTS

Only post-operative transarterial chemotherapy improved survival significantly at 2 years [difference, 22.8%; confidence interval (CI), 8.6-36.9%; P = 0.002] and 3 years (difference, 27.6%; CI, 8.2-47.1%; P = 0.005), and decreased the probability of no recurrence at 1 year (difference, 28.8%; CI, 16.7-40.8%; P < 0.001), 2 years (difference, 27.6%; CI, 8.2-47.1%; P = 0.005) and 3 years (difference, 28%; CI, 8.2-47.9%; P = 0.006). In a sensitivity analysis after inclusion of non-randomized controlled trials, post-operative transarterial chemotherapy still improved survival at 1 year (difference, 9.6%; CI, 0.8-18.3%; P = 0.03), 2 years (difference, 13.5%; CI, 0.9-26%, P = 0.04) and 3 years (difference, 18%; CI, 7-28.9%; P < 0.001), and decreased the probability of no recurrence at 1 year (difference, 20.3%; CI, 7.7-33%; P = 0.002), 2 years (difference, 35%; CI, 21.4-46.3%; P < 0.001) and 3 years (difference, 34.5%; CI, 18.7-50.3%; P < 0.001).

CONCLUSION

Post-operative transarterial chemotherapy improved survival and decreased the cumulative probability of no recurrence. New randomized controlled trials evaluating this modality are required.

Interferon for preventing and treating hepatocellular carcinoma associated with the hepatitis B and C viruses

The possibility that interferon-alpha might be effective for the prevention or treatment of hepatocellular carcinoma is suggested by its efficacy against the associated hepatitis B and C viruses, by its efficacy in the treatment of some other human tumours, and by evidence that interferon-alpha may inhibit the growth of human hepatocellular carcinoma cell lines and their production of hepatitis B surface antigen. Few studies support the use of interferon-alpha for preventing hepatitis B virus-associated hepatocellular carcinoma. In contrast, benefit from the use of interferon-alpha to prevent hepatitis C virus-associated hepatocellular carcinoma is suggested in a large number of studies, but most of these studies have weaknesses of study design that preclude definitive conclusions. Nevertheless, most of these studies suggest that the incidence of hepatocellular carcinoma is lower in hepatitis C virus-infected patients receiving interferon-alpha, particularly in patients with a sustained response to interferon-alpha, compared to nonresponders. As a treatment for hepatocellular carcinoma, interferon-alpha was only evaluated in a small number of patients with advanced disease; 'partial responses' and prolongation of survival times in a few of these studies suggest that additional studies should be done in patients with less advanced disease.

Preventive treatments for recurrence after curative resection of hepatocellular carcinoma - A literature review of randomized control trials

To review the inhibitory effect of preventive approaches on recurrence after operation in patients with hepatocellular carcinoma (HCC), we summarized all available publications reporting randomized control trial indexed in PubMed. The treatment approaches presented above included pre-operative transcatheter arterial chemoembolization (TACE), post-operative TACE, systemic or locoregional chemotherapy, immunotherapy, Interferons and acyclic retinoic acid. Although no standard treatment has been established, several approaches presented promising results, which were both effective and tolerable in post-operative patients. Pre-operative TACE was not effective on prolonging survivals, while post-operative TACE was shown with both disease-free survival and overall survival benefits in some papers, however, it was also questioned by others. Systemic chemotherapy was generally not effective on prolonging survival but also poorly tolerated for its significant toxicities. Adoptive immunotherapy using LAK cells was proved to be beneficial to patients’ survival in a recent paper. Interferon α and Interferon β can inhibit recurrence in HCC patients with HCV infection background, though the mechanism is not fully understood. Acyclic retinoic acid was shown to decrease multi-centric recurrence after operation, which was reported by only one group. In conclusion, several adjuvant approaches have been studied for their efficacy on recurrence in HCC patients in randomized control trials; however, multi-centric randomized control trial is still needed for further evaluation on their efficacy and systemic or local toxicities; in addition, new adjuvant treatment should be investigated to provide more effective and tolerable methods for the patients with HCC after operation.

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What surgeons should know about viral hepatitis and hepatocellular carcinoma

Most patients with hepatocellular carcinoma (HCC) have viral hepatitis, either hepatitis C (HCV) or hepatitis B (HBV). HCV is an RNA virus that does not integrate into the host genome but likely induces HCC through viral protein: for example, host protein interactions or via the inflammatory response to the virus. Eradication of HCV with interferon plus riboviron therapy may help prevent cancer recurrence in selected patients. In contrast to HCV, HBV is an DNA virus that integrates into the host genome, and this integration is believed, in part, to be carcinogenic. HBV is usually classified as replicative (DNA-positive in the serum) or nonreplicative (DNA-negative in the serum). Treatment with nucleoside analogs is indicated in most patients with cirrhotic-stage replicating HBV. Nonreplicative stages of this virus do not merit therapy with these agents.

Cost-effectiveness of adjuvant interferon therapy after surgical resection of Hepatitis C-related hepatocellular carcinoma

BACKGROUND

To evaluate cost-effectiveness of adjuvant interferon therapy used with surgical resection of hepatitis C-related primary hepatocellular carcinoma.

DESIGN

We constructed a Markov model that simulated adjuvant interferon therapy after resection of hepatitis C-related hepatocellular carcinoma, and evaluated life expectancy, costs, and cancer recurrence. The reference case is a 60-year-old man with hepatitis C-related compensated cirrhosis.

RESULTS

At the baseline, adjuvant interferon therapy yielded 6.1 life years with a cost of dollars 77000, and an incremental cost-effectiveness ratios of dollars 15700/life year compared with no interferon therapy. The proportion of patients who experienced recurrence of hepatocellular carcinoma until death was reduced from 87.6% to 62.9% using adjuvant interferon therapy. The incidence of recurrent hepatocellular carcinoma after interferon influenced the cost-effectiveness of adjuvant interferon therapy. A threshold analysis showed that adjuvant interferon therapy was not cost-effective (ICER = dollars 27000/year) if the annual incidence of recurrent hepatocellular carcinoma after interferon is 16% (baseline 8.9%). The proportions of patients with recurrent hepatocellular carcinoma were 74.4% and 86.9% at the annual recurrence rates after interferon of 16% and 35%, respectively.

CONCLUSIONS

Adjuvant interferon therapy after surgical resection of primary hepatitis C-related hepatocellular carcinoma improves life expectancy through suppression of recurrent cancer with acceptable cost-effectiveness.

Synergistic induction of apoptosis by acyclic retinoid and interferon-beta in human hepatocellular carcinoma cells

Acyclic retinoid, a synthetic retinoid analog, as well as interferon alfa (IFN-alpha) and IFN-beta induce apoptosis in hepatocellular carcinoma (HCC) cells and are used clinically in the prevention of HCC. Here, we show that acyclic retinoid acts synergistically with IFNs in suppressing the growth and inducing apoptosis (as characterized by DNA fragmentation and chromatin condensation) in 5 human HCC cell lines (JHH7, HuH7, PLC/PRF/5, HLE, and HLF). This synergism was only observed when cells were pretreated with the acyclic retinoid, whereas natural retinoic acids (all-trans and 9-cis retinoic acid) were ineffective. This promotion may be due to up-regulation of type 1 IFN receptor (IFNR) expression by the retinoid. Accordingly, incubation with antitype 1 IFNR antibody abolished the synergy. Enhanced IFNR expression was accompanied by increased expression and DNA-binding activity of STAT1, an intracellular signal transducing molecule of IFNR, and increased induction of 2', 5'-oligoadenyl-5'-triphosphate synthetase, which is a target gene of STAT1. Acyclic retinoid did not have any effects on the growth of normal human hepatocytes (Hc) probably because of a lack of IFNR and STAT1 up-regulation. In conclusion, these results provide a rationale for combined biochemoprevention of HCC using acyclic retinoid and IFN-beta.

Hepatocellular carcinoma: systemic treatments

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with increasing incidence in Western countries. Many pharmacologic treatments have been tested against HCC; most of them belong to three categories: chemotherapy, hormone therapy, and immunotherapy. Neither single agent nor combination chemotherapy have demonstrated a clear reproducible advantage in terms of overall survival; therefore, systemic or intraarterial chemotherapy should not be considered as standard strategies for patients with HCC. Tamoxifen and antiandrogen therapy were not effective in prolonging survival when tested in randomized, controlled trials. Promising results have been obtained with octreotide in a small randomized trial, but confirmation studies are needed. Although adoptive immunotherapy was effective in the adjuvant setting, interferon should be further investigated in this setting or investigated as a preventive strategy in cirrhotic patients. On the contrary, interferon does not seem to have a role in advanced disease, where it is tolerated poorly. In the future, innovative and promising therapeutic strategies will be tested in HCC, including new biologic target-based drugs, cyclooxygenase inhibitors, and gene therapy.

[Role of interferons in the treatment of hepatitis B and hepatitis C virus infections]

BACKGROUND

Since the discovery of hepatitis C (HCV), the efficacy of treatment has significantly progressed using standard mono-therapy: with Interferon alpha (IFN) during six months we obtained approximately 10% sustained response and currently with the association of pegylated IFN and Ribavirin a 55% sustained response was achieved.

CURRENT POSITION AND MAJOR POINTS

HCV infection continues to present therapeutic problems which have not entirely been solved, mainly related to clinical and biological tolerance, and non-responders. Moreover, the care of patients with extra-hepatic localization, cirrhotic patients, as well as therapeutic problems of co-infected HIV-HCV patients. As regards hepatitis B (HBV) new effective treatments against this virus have appeared, IFN then nucleoside analogs, some of which are available in France (i.e. lamivudine, adefovir, dipovoxil). The main objective of chronic hepatitis B treatment is to obtain the complete inhibition of the HBV virus by Hbe-antigen antibody seroconversion which would therefore significantly increase patient survival. In this article the advantages and disadvantages of the different treatments are assessed.

FUTURE PERSPECTIVES

Despite the considerable and rapid progress obtained in the therapeutic treatment of infection due to HCV and HBV a number of unknown factors remain, which warrants further trials, in particular to evaluate the efficacy as well as the tolerance of the antiviral agent association.

Hepatocellular carcinoma: the high-risk patient

Hepatocellular carcinoma (HCC) is the most common hepatic malignancy worldwide. The primary risk factor for the development of HCC is cirrhosis. Even patients without cirrhosis who develop HCC are typically found to have some underlying hepatic abnormality, such as steatohepatitis or chronic viral hepatitis. Although cirrhosis of any cause increases the risk of developing HCC, cirrhosis associated with chronic hepatitis B or C virus infection or hemochromatosis carries the greatest risk. Additional factors such as patient age and sex, duration and severity of liver disease, concurrent alcohol or aflatoxin exposure, liver histology, and alpha-fetoprotein levels also contribute to the relative risk of developing HCC. Vaccination programs aimed at preventing hepatitis B virus infection have been very successful in lowering the incidence of HCC in some areas of the world. Interferon-based therapy, which may control the inflammatory activity in chronic hepatitis C, also holds promise in preventing HCC. Other novel chemopreventative agents, such as glycyrrhizin and polyprenoic acid, may also have a role in preventing HCC, but they require further study before they can be recommended for widespread use.

Advances in therapy for hepatitis C infection

The first approved therapy for chronic hepatitis C virus (HCV) infection was recombinant interferon. Subsequently, controlled studies demonstrated that the combination of interferon-alpha and ribavirin leads to significantly higher virologic sustained responses in patients with chronic hepatitis C. A novel modification of the interferon molecule resulted in the formulation of pegylated interferons, which have a longer half-life than standard interferon. Two recent trials have established the superiority of pegylated interferons compared with interferon-alpha in inducing sustained virologic responses in patients with chronic HCV infection, with or without cirrhosis. Presumably, pegylated interferons will replace standard interferon in treating HCV infection. Phase 3 trials of pegylated interferons in combination with ribavirin are currently under way. Noninterferon-based therapies for the treatment of HCV infection are also in the developmental and experimental phases. Our aims in this review are to present the currently available therapeutic options for HCV infection and the evidence supporting their use in typical patients with chronic hepatitis C or in patients with special circumstances. We also briefly review novel therapeutic approaches, including noninterferon-based therapies.

Neoadjuvant and adjuvant therapy for resectable hepatocellular carcinoma: review of the randomised clinical trials

Hepatocellular carcinoma (HCC) is common worldwide, and its incidence is increasing. Liver resection or transplantation is potentially curative, although subsequent recurrence and death are common. We reviewed randomised trials on the role of adjuvant therapy in resectable HCC. We identified 13 randomised trials with recurrence or survival endpoints reported at 3 years or longer. Three studies involved predominantly systemic adjuvant chemotherapy; four involved predominantly hepatic-artery-based chemotherapy or embolisation; and six used other therapeutic modalities including immunological, radiation, and differentiation agents. A therapeutic benefit in terms of disease-free or overall survival was noted in six trials, five of which involved modalities other than systemic or hepatic-artery chemotherapy or embolisation. We conclude that systemic and hepatic-artery chemotherapy or chemoembolisation have not been shown to improve overall or disease-free survival after resection of HCC, although there has been no definitive trial comparing adjuvant systemic chemotherapy with no treatment. Other adjuvant modalities (mostly tested in small, preliminary settings) may confer benefit after potentially curative resection of HCC.