Hypoglycemia associated with lipid accumulation in primary hepatocellular carcinoma

Clear cell hepatocellular carcinoma: origin, metabolic traits and fate of glycogenotic clear and ground glass cells

Clear cell hepatocellular carcinoma (CCHCC) has hitherto been considered an uncommon, highly differentiated variant of hepatocellular carcinoma (HCC) with a relatively favorable prognosis. CCHCC is composed of mixtures of clear and/or acidophilic ground glass hepatocytes with excessive glycogen and/or fat and shares histology, clinical features and etiology with common HCCs. Studies in animal models of chemical, hormonal and viral hepatocarcinogenesis and observations in patients with chronic liver diseases prone to develop HCC have shown that the majority of HCCs are preceded by, or associated with, focal or diffuse excessive storage of glycogen (glycogenosis) which later may be replaced by fat (lipidosis/steatosis). In ground glass cells, the glycogenosis is accompanied by proliferation of the smooth endoplasmic reticulum, which is closely related to glycogen particles and frequently harbors the hepatitis B surface antigen (HBsAg). From the findings in animal models a sequence of changes has been established, commencing with preneoplastic glycogenotic liver lesions, often containing ground glass cells, and progressing to glycogen-poor neoplasms via various intermediate stages, including glycogenotic/lipidotic clear cell foci, clear cell hepatocellular adenomas (CCHCA) rich in glycogen and/or fat, and CCHCC. A similar process seems to take place in humans, with clear cells frequently persisting in CCHCC and steatohepatitic HCC, which presumably represent intermediate stages in the development rather than particular variants of HCC. During the progression of the preneoplastic lesions, the clear and ground glass cells transform into cells characteristic of common HCC. The sequential cellular changes are associated with metabolic aberrations, which start with an activation of the insulin signaling cascade resulting in pre-neoplastic hepatic glycogenosis. The molecular and metabolic changes underlying the glycogenosis/lipidosis are apparently responsible for the dramatic metabolic shift from gluconeogenesis to the pentose phosphate pathway and Warburg-type glycolysis, which provide precursors and energy for an ever increasing cell proliferation during progression.

Loss of insulin signaling in hepatocytes leads to severe insulin resistance and progressive hepatic dysfunction

The liver plays a central role in the control of glucose homeostasis and is subject to complex regulation by substrates, insulin, and other hormones. To investigate the effect of the loss of direct insulin action in liver, we have used the Cre-loxP system to inactivate the insulin receptor gene in hepatocytes. Liver-specific insulin receptor knockout (LIRKO) mice exhibit dramatic insulin resistance, severe glucose intolerance, and a failure of insulin to suppress hepatic glucose production and to regulate hepatic gene expression. These alterations are paralleled by marked hyperinsulinemia due to a combination of increased insulin secretion and decreased insulin clearance. With aging, the LIRKO liver exhibits morphological and functional changes, and the metabolic phenotype becomes less severe. Thus, insulin signaling in liver is critical in regulating glucose homeostasis and maintaining normal hepatic function.

Paraneoplastic syndromes in patients with hepatocellular carcinoma in Taiwan

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common malignancy in Taiwan. Some patients may manifest paraneoplastic syndromes during the clinical course of the disease. In this study, the authors evaluated the clinical significance of these paraneoplastic syndromes, compared the prevalence of these syndromes between cases of hepatitis B virus (HBV)-related and hepatitis C virus (HCV)-related HCC, and estimated significant predictors associated with the syndromes.

METHODS

Clinical data on 1197 HCC patients, including age, gender, Child-Pugh score, survival time, laboratory data (including liver biochemistry, hepatitis markers, and serum alpha-fetoprotein [AFP]), and tumor features (including tumor size, portal vein thrombosis, and histologic pictures), were retrospectively reviewed.

RESULTS

A total of 232 of 1197 patients (19.4%) had paraneoplastic syndromes. HCC patients with paraneoplastic syndromes had significantly higher serum AFP; higher rates of initial main portal vein thrombosis, metastasis, and bilobal tumor involvement; larger tumor volume; and shorter survival than those without these syndromes. Patients with HBV-related HCC had a significantly higher prevalence of paraneoplastic syndromes than patients with HCV-related HCC (20.1% vs. 11.2%, P = 0.005). In a stepwise multivariate logistic regression analysis, AFP >50,000 ng/mL and tumor volume >30% were significant predictive variables associated with the presence of paraneoplastic syndromes in HCC patients.

CONCLUSIONS

HCC patients with paraneoplastic syndromes usually had higher levels of serum AFP and larger tumor volumes than those without. Patients with HBV-related HCC had a significantly higher prevalence of paraneoplastic syndromes than those with HCV-related HCC.

Humoral Hypercalcemia of Hepatocellular Carcinoma Associated with Elevated Levels of Parathyroid-Hormone-Related-Peptide

Parathyroid-hormone-related-peptide (PTHrP) has been shown to be important in the pathogenesis of hypercalcemia of malignancy. The malignancies most commonly associated with hypersecretion of PTHrP include squamous cell carcinoma and breast cancer. The pathogenesis of hypercalcemia associated with hepatocellular carcinoma was evaluated in this study. Two male patients with hepatocellular carcinoma were found to have severe hypercalcemia at initial presentation. PTHrP was measured with radioimmunoassay in these two patients before treatment as well as in nine other patients with hepatocellular carcinoma but without hypercalcemia. The levels were markedly elevated in the two patients with hypercalcemia (29.3 and 32.1 pM), but were less than 5 pM in the nine patients without hypercalcemia. These results suggest that PTHrP was important in the pathogenesis of hypercalcemia associated with hepatocellular carcinoma in these men.

Hypercholesterolaemia in patients with hepatocellular carcinoma

Ninety-one (11.4%) subjects with hypercholesterolaemia (serum cholesterol level more than 250 mg/dL) of 792 Chinese patients with hepatocellular carcinoma (HCC) were studied in Taiwan. All 91 patients had large tumours greater than 7 cm in diameter and a tumour volume greater than 50%; 56 (61%) of these patients manifested tumour involvement in both lobes of the liver. The HCC patients with hypercholesterolaemia had significantly higher mean serum levels of albumin, triglyceride and alpha-fetoprotein (AFP) compared with age-sex-tumour volume matched HCC patients without hypercholesterolaemia. The associated incidence of hypoglycaemia in hypercholesterolaemic HCC patients was significantly higher than in HCC patients without hypercholesterolaemia (15/90 vs 4/90; P = 0.01). There was no significant difference in the survival analysis between HCC patients with and without hypercholesterolaemia. Eight and 11 of hypercholesterolaemic HCC patients had their tumours surgically resected and received transcatheter hepatic arterial chemoembolization (TAE), respectively. Serum cholesterol levels fell to the normal range after treatment and rose to abnormal levels again when tumours recurred after surgery or progressively enlarged after TAE. The change in pattern of serum cholesterol was parallel to the change in serum AFP. Serum cholesterol levels may serve as another marker in identifying tumour recurrence and the presence of a viable tumour mass in hypercholesterolaemic HCC patients who have received surgical resection or TAE.

C-peptide in non-alcoholic cirrhosis and hepatocellular carcinoma

Fourteen normal controls, eleven patients with non-alcoholic cirrhosis, twenty-nine with hepatocellular carcinoma (HCC) and six with HCC and hypoglycemia were studied. The tests performed include iv glucose tolerance test (25 g) and glucagon challenge test (2 mg). In cirrhosis, glucose intolerance and insulin resistance were demonstrated. The fasting hyperinsulinemia in cirrhosis is the result of decreased degradation as shown by the normal fasting C-peptide. The increased insulin responses to glucose, despite a normal C-peptide response, further supports the importance of impaired degradation in the pathogenesis of hyperinsulinemia after challenge. Despite a strong etiological association between cirrhosis and HCC, patients with HCC do not have significant hyperinsulinemia or glucose intolerance. This provides metabolic evidence to support the clinico-pathological observation that HCC occurred when cirrhosis was not advanced or in a precirrhotic stage. In HCC patients with clinically overt hypoglycemia, the fasting glucose, insulin and C-peptide were very low. The C-peptide responses to glucose and glucagon challenges were suppressed despite pharmacologic stimulation. This can be explained by the suppression of insulin secretion by a circulating substance secreted by hepatoma. The results support the pathogenetic importance of insulin-like activities recently detected in HCC patients with hypoglycemia.

Hepatic clear cell carcinoma associated with hypoglycemia and hypercholesterolemia

Two autopsy cases of clear cell variant of hepatocellular carcinoma were reported in which both hypoglycemia and hypercholesterolemia occurred simultaneously. The tumor consisted of lipid-laden clear cells with centrally located nuclei. Glycogen was also stored in the cytoplasm in Case 2 but not in Case 1. In reference to the literature, it was suggested that hypoglycemia and hypercholesterolemia are due to biochemically heterogeneous mechanisms that vary from patient to patient and may involve diversion, hitherto undescribed, of glucose metabolism of tumor tissue in the direction of lipogenesis and/or glycogenesis.

Hepatic gluconeogenic key enzymes in patients with hepatic cancer

Key enzymes of gluconeogenesis in the liver, phosphoenolpyruvate carboxykinase [EC 4.1.1.32] and glucose-6-phosphatase [EC 3.1.3.9], were studied in patients with primary or metastatic hepatic cancer. Liver specimens for enzyme assay were obtained by necropsy performed within four hours after death. It was confirmed that both enzyme activities in rat liver preserved at 4 degrees C remained unchanged within nine hours after the removal of the tissue. Activities of phosphoenolpyruvate carboxykinase and glucose-6-phosphatase decreased to below ten per cent of the control in neoplastic liver tissue of patients with hepatocellular carcinoma accompanied with liver cirrhosis. These two enzyme activities in cirrhotic tissue of patients with hepatocellular carcinoma were lower than those in patients merely with cirrhosis. In patients with metastatic hepatic cancer both two enzyme activities further decreased and were scarcely detected not only in neoplastic tissue but also in non-neoplastic tissue. These results show that hepatic gluconeogenesis markedly decreases in patients with primary or metastatic hepatic cancer. The biochemical analysis of the blood in hepatic cancer, decreased in blood glucose and release in immunoreactive glucagon, also suggested the suppression of gluconeogenesis.

Histologic prognostic indicators in hepatocellular carcinoma

Survival and histologic features were studied in 80 patients with proven hepatocellular carcinoma (HCC). The overall survival was 50% at 3.5 weeks with a statistically significant drop in mortality rate after 8.5 weeks. Patients with diffuse clear-cell pattern, focal clear-cell pattern, and no clear cells in their tumors had a 50% survival rate at 14 weeks, 6 weeks, and 3 weeks respectively; the differences in survival rates were statistically significant between any pair (p less than 0.001). No correlation was found between survival and (1) cytologic differentiation, (2) histologic architecture, (3) degree of pleomorphism, or (4) presence of bile production, proteinaceous secretion, giant cells, or cytoplasmic hyaline bodies. Eosinophilic HCC with lamellar fibrosis was not observed in any of our materials. We concluded that the presence of clear cells was the only histologic feature of prognostic significance in our patients.

Lipid accumulation in a hepatocellular carcinoma associated with hypoglycaemia

Four serial specimens over 18 months from a hepatocellular carcinoma associated with hypoglycaemia were studied by light microscopy. Ultrastructural study was possible for two of the specimens. Progressive fatty metamorphosis of the tumour cells was observed. The mechanism postulated was that of diversion of carbohydrate metabolism to lipogenesis due to enzyme disruption and dextrose infusion. The possibility of a defect in lipid transport was also considered.