Risk factors and prevention of hepatocellular carcinoma in HCV infection

Difference in incidence of developing hepatocellular carcinoma between hepatitis B virus-and hepatitis C virus-infected patients

BACKGROUND

It is generally accepted that the incidence of hepatocellular carcinoma (HCC) in hepatitis C virus (HCV)-associated patients is higher than that in hepatitis B virus (HBV)-associated patients. The reason why this difference in the incidence of HCC occurs in patients with HBV and HCV infections remains unclear. We report the possibility that the contributing power of inflammation, which is the main risk factor for developing HCC, may be different with HBV and HCV infections.

AIM

To investigate this, we surveyed the hazard ratio of inflammation for HCC development which was identified by serum alanine aminotransferase (ALT) levels between patients with HBV and HCV infections.

METHODS

The PubMed database was searched (2001-2021) for studies published in English regarding the incidence of HCC identifying 8924 HBV-and 7376 HCV- infected patients. From these studies, interferon-treated patients with both HBV and HCV infections were excluded. Furthermore, in HBV patients, those administered nucleos(t)ide analogues were excluded, and in HCV patients, those administered direct acting antivirals were also excluded. Studies citing hazard ratios of HCC regarding inflammation (serum elevated alanine aminotransferase levels) were selected. Finally, there were 14 studies of HBV- infected patients and 8 studies of HCV-infected patients. We calculated the hazard ratio in patients in an inflammatory state (serum ALT levels were above the normal range).

RESULTS

In the 14 studies of HBV patients, the average hazard ratio (HR) of elevated ALT for developing HCC was 2.74 [1.98-3.77] and that in the 8 studies of HCV-infected patients was 5.51 [3.08-9.83]. The HR of inflammation for HCC development in HCV-associated liver diseases is about twice that in HBV-associated liver diseases. HR in HCV-infected patients was significantly (P = 0.0391) higher than that in HBV-infected patients. In hepatitis B patients, the abnormal range adopted was 28-45 IU/L, and in hepatitis C patients, it was 20-50 IU/L. It was demonstrated that the abnormal ALT levels adopted in hepatitis B and C patients were very similar in this series.

CONCLUSION

The difference in the incidence of HCC development between HBV and HCV patients may depend on the difference in the hazard risk of ALT between HBV and HCV infections.

Prevention of hepatocellular carcinoma: Focusing on antioxidant therapy

Oxidative stress has been investigated in the context of alcoholic liver injury for many years and shown to be a causal factor of chronic hepatitis C (CHC), nonalcoholic steatohepatitis (NASH), drug-induced liver injury, Wilson’s disease, and hemochromatosis. In CHC, it has been demonstrated that oxidative stress plays an important role in hepatocarcinogenesis. In cases with persistent hepatitis due to failure of hepatitis C virus eradication, or chronic liver disease, such as NASH, the treatment of which remains unestablished, it is important to reduce serum alanine aminotransferase levels and prevent liver fibrosis and development of hepatocellular carcinoma. This also suggests the importance of antioxidant therapy. Among treatment options where it would be expected that anti-inflammatory activity plays a role in their confirmed efficacy for chronic hepatitis, iron depletion therapy, glycyrrhizin, ursodeoxycholic acid, Sho-Saiko-To, and vitamin E can all be considered antioxidant therapies. To date, however, the ability of these treatments to prevent cancer has been confirmed only in CHC. Nevertheless, anti-inflammatory and anti-fibrotic effects have been demonstrated in other liver diseases and these therapies may potentially be effective for cancer prevention.

Impact of immunogenetic IL28B polymorphism on natural outcome of HCV infection

With the aim of investigating whether interleukin 28B gene (IL28B) rs1297860 polymorphism is associated with different hepatitis C (HCV) infection statuses, we compared IL28B allelic distribution in an Italian case series of 1050 patients with chronic infection and different outcomes, 47 individuals who spontaneously cleared HCV, and 178 blood donors. Furthermore, we compared IL28B variants among 3882 Caucasian patients with chronic infection, 397 with spontaneous clearance, and 1366 blood donors reported in PubMed. Overall data confirmed a relation between IL28B C allele and HCV spontaneous clearance. Furthermore, we found that IL28B T allele had a weak relation with chronic HCV progression to hepatocellular carcinoma. Study findings are in accordance with the hepatocellular carcinogenic model where IL28B TT genotype, by promoting a persistent chronic hepatitis which leads to both hepatocyte injury and chronic inflammation, could facilitate HCC development. Conversely, patients with lymphoproliferative disorders had not any significantly different IL28B rs1297860 allelic distribution than those with chronic HCV, but, like all chronic HCV-related diseases, they showed a lower CC frequency than patients who spontaneously cleared HCV. Study results confirmed the model of persistent HCV infection as a risk factor for the pathogenesis of both liver and lymphoproliferative disorders.

Ultrasound elastography for fibrosis surveillance is cost effective in patients with chronic hepatitis C virus in the UK

BACKGROUND

Chronic hepatitis C (HCV) is a significant risk factor for cirrhosis and subsequently hepatocellular carcinoma (HCC). HCV patients with cirrhosis are screened for HCC every 6 months. Surveillance for progression to cirrhosis and consequently access to HCC screening is not standardized. Liver biopsy, the usual test to determine cirrhosis, carries a significant risk of morbidity and associated mortality. Transient ultrasound elastography (fibroscan) is a non-invasive test for cirrhosis.

PURPOSE

This study assesses the cost effectiveness of annual surveillance for cirrhosis in patients with chronic HCV and the effect of replacing biopsy with fibroscan to diagnose cirrhosis.

METHOD

A Markov decision analytic model simulated a hypothetical cohort of 10,000 patients with chronic HCV initially without fibrosis over their lifetime. The cirrhosis surveillance strategies assessed were: no surveillance; current practice; fibroscan in current practice with biopsy to confirm cirrhosis; fibroscan completely replacing biopsy in current practice (definitive); annual biopsy; annual fibroscan with biopsy to confirm cirrhosis; annual definitive fibroscan.

RESULTS

Our results demonstrate that annual definitive fibroscan is the optimal strategy to diagnose cirrhosis. In our study, it diagnosed 20 % more cirrhosis cases than the current strategy, with 549 extra patients per 10,000 accessing screening over a lifetime and, consequently, 76 additional HCC cases diagnosed. The lifetime cost is £98.78 extra per patient compared to the current strategy for 1.72 additional unadjusted life years. Annual fibroscan surveillance of 132 patients results in the diagnosis one additional HCC case over a lifetime. The incremental cost-effectiveness ratio for an annual definitive fibroscan is £6,557.06/quality-adjusted life years gained.

CONCLUSION

Annual definitive fibroscan may be a cost-effective surveillance strategy to identify cirrhosis in patients with chronic HCV, thereby allowing access of these patients to HCC screening.

Therapeutic effects of the oriental herbal medicine Sho-saiko-to on liver cirrhosis and carcinoma

The traditional Chinese herbal medicine Sho-saiko-to is a mixture of seven herbal preparations that has long been used in the treatment of chronic liver disease. Various clinical trials have shown that Sho-saiko-to protects against the development of hepatocellular carcinoma in cirrhotic patients. However, the mechanism by which Sho-saiko-to protects hepatocytes against hepatic fibrosis and carcinoma is not yet known. Basic science studies have demonstrated that Sho-saiko-to reduces hepatocyte necrosis and enhances liver function. Sho-saiko-to significantly inhibits hepatic fibrosis by inhibiting the activation of stellate cells, the major producers of collagen in the liver, as well as by inhibiting hepatic lipid peroxidation, promoting matrix degradation, and suppressing extracellular matrix (ECM) accumulation. Furthermore, clinical trials have shown that Sho-saiko-to lowers the rate of hepatocellular carcinoma (HCC) development in patients with cirrhosis and increases the survival of patients with HCC. Unfortunately, some case reports have shown the side effects of Sho-saiko-to. Most of the side effects were interstitial pneumonia and acute respiratory failure induced by Sho-saiko-to in Japan. As a result of analyzing these case reports, the incidence and risk are increased by co-administration of interferon, duration of medication, and, high in an elderly population. This review discusses the properties of Sho-saiko-to with regards to the treatment of chronic liver diseases and suggests the side effects of Sho-saiko-to.

The toll-like receptor 2 (TLR2) -196 to -174 del/ins polymorphism affects viral loads and susceptibility to hepatocellular carcinoma in chronic hepatitis C

Chronic hepatitis C virus (HCV) infection is a major risk factor for hepatocellular carcinoma (HCC). HCV proteins core and NS3 can bind to toll-like receptor 2 (TLR2) and trigger inflammatory responses. Polymorphisms in the TLR2 gene predispose to various forms of malignancy but have not been studied in HCV-associated HCC. Here, we investigated whether single nucleotide polymorphisms (SNPs), rs4696480, rs5743708, rs5743704 and the -196 to -174 del/ins polymorphism of the TLR2 gene affect the risk for HCC in chronic hepatitis C. The study involved 189 and 192 HCV genotype 1 infected patients with and without HCC, respectively, as well as 347 healthy controls. TLR2 alleles were determined by hybridization probe assays and allele-specific short fragment polymerase chain reaction on a LightCycler system. All TLR2 polymorphisms matched the Hardy-Weinberg equilibrium in each study group. Although TLR2 SNPs showed no effect, the frequency of the TLR2 -196 to -174 del allele was significantly higher in patients with HCV-associated HCC (22.5%) than in HCV-infected patients without HCC (15.6%, p = 0.016) and healthy controls (15.3%, p = 0.003). HCV-infected carriers of a TLR2 -196 to -174 del allele had significantly higher HCV viral loads than TLR2 -196 to -174 ins/ins homozygous patients (p = 0.031). Finally, in carriers of the TLR2 -196 to -174 del allele, stimulation of monocytes resulted in significantly lower TLR2 expression levels and interleukin-8 (IL-8) induction than in individuals with the TLR2 -196 to -174 ins/ins genotype (p < 0.05). Our data suggest the TLR2 -196 to -174 del allele to affect HCV viral loads and to increase the risk for HCC in HCV genotype1-infected patients.

Long-term phlebotomy with low-iron diet therapy lowers risk of development of hepatocellular carcinoma from chronic hepatitis C

BACKGROUND

We have previously demonstrated that in patients with chronic hepatitis C (CHC), iron depletion improves serum alanine aminotransferase (ALT) levels as well as hepatic oxidative DNA damage. However, it has not been determined whether continuation of iron depletion therapy for CHC favorably influences its progression to hepatocellular carcinoma (HCC).

METHODS

We conducted a cohort study on biopsy-proven CHC patients with moderate or severe liver fibrosis who failed to respond to previous interferon (IFN) therapy or had conditions for which IFN is contradicted. Patients were divided into two groups: subjects in group A (n = 35) underwent weekly phlebotomy (200 g) until they reached a state of mild iron deficiency, followed by monthly maintenance phlebotomy for 44-144 months (median, 107 months), and they were advised to consume a low-iron diet (5-7 mg iron/day); group B (n = 40) comprised CHC patients who declined to receive iron depletion therapy.

RESULTS

In group A, during the maintenance phase, serum ALT levels decreased to less than 60 IU/l in all patients and normalized (<40 IU/l) in 24 patients (69%), whereas in group B no spontaneous decrease in serum ALT occurred. Hepatocarcinogenesis rates in groups A and B were 5.7% and 17.5% at the end of the fifth year, and 8.6% and 39% in the tenth year, respectively. Multivariate analysis revealed that iron depletion therapy significantly lowered the risk of HCC (odds ratio, 0.57) compared with that of untreated patients (P = 0.0337).

CONCLUSIONS

Long-term iron depletion for CHC patients is a promising modality for lowering the risk of progression to HCC.

Hepatic steatosis and the risk of hepatocellular carcinoma in chronic hepatitis C

BACKGROUND AND AIM

Obesity associated hepatic steatosis has been suggested to have a premalignant potential. We determined whether hepatic steatosis predisposes to liver cancer in persons with chronic hepatitis C virus (HCV) infection.

METHODS

We compared the histological severity of steatosis in the index liver biopsies of 25 patients with chronic hepatitis C who subsequently developed hepatocellular carcinoma (HCC) with matched controls who did not. Cases were aged (mean) 54.7 years, 84% males, 76% genotype 1, and 64% fibrosis stage 4; and controls were matched for these characteristics. Those with a sustained virologic response to antiviral therapy were excluded.

RESULTS

Duration of HCV infection, concomitant alcohol intake, body mass index and indices of past hepatitis B virus (HBV) infection were comparable between the groups. Controls were followed for a longer period after the index liver biopsy than were cases (113 months vs 55 months, P < 0.001). As determined by percentage area of biopsy core occupied by steatosis on computer assisted morphometric evaluation, and graded by semiquantitative histological assessment, steatosis was comparable among cases and controls. The odds of developing HCC among those with steatosis grades 1 and 2 did not differ significantly from those without steatosis. There was no association between increasing morphometric percentage area occupied by steatosis and the subsequent development of HCC. Neither steatosis grade or percent area of steatosis on biopsy were selected in multivariate regression analysis as independent predictors for the development of HCC.

CONCLUSIONS

Hepatic steatosis does not augment the risk of hepatocarcinogenesis in patients with chronic HCV infection.

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.

Screening for hepatocellular carcinoma in patients with hepatitis C cirrhosis: a cost-utility analysis

OBJECTIVES

Screening for hepatocellular carcinoma (HCC) is advocated in cirrhotic patients to optimize early detection and treatment. However, the cost-effectiveness is not well defined. Our objective was to perform a cost-utility analysis from a third-party payer's perspective of no screening, alpha-fetoprotein (AFP) concentration measurement alone, abdominal ultrasound (US) and AFP, abdominal three-phase CT and AFP, and abdominal magnetic resonance imaging (MRI) and AFP.

METHODS

A Markov model was constructed simulating the natural history of hepatitis C-related cirrhosis in a cohort of patients age 50 yr over a time horizon of their remaining life expectancy. Transition probabilities were obtained from published data and U.S. vital statistics. Costs represented Medicare reimbursement data. Costs and health effects were discounted at a 3% annual rate.

RESULTS

Screening with ultrasonography and AFP concentration measurement was associated with an incremental cost-utility ratio of 26,689 US dollars per quality-adjusted life year, whereas screening with abdominal three-phase CT and AFP concentration measurement was associated with an incremental cost-utility ratio of 25,232 US dollars per quality-adjusted life year compared with no screening. Compared with three-phase CT and AFP, magnetic resonance and AFP imaging costs 118,000 US dollars per quality-adjusted life year. Sensitivity analysis demonstrated that the results are most sensitive to the annual incidence of HCC, proportion of tumors amenable to treatment, and to transplant candidacy, whereas the choice of screening strategy is most sensitive to the test characteristics and cost.

CONCLUSIONS

Screening for HCC with CT is a cost-effective strategy in transplant-eligible patients with cirrhosis secondary to chronic hepatitis C viral (HCV) infection, comparable with other commonly accepted screening interventions such as mammography and colonoscopy.

Results of surgical resection for hepatocellular carcinoma

The overall prognosis of HCC is very poor because most patients are unresectable at the time of initial evaluation. Surgical resection is the only potentially curative treatment for HCC, however the recurrence rate after resection remains high as well. Utilizing screening protocols which incorporates the use of hepatic ultrasound and biochemical markers, HCC can be identified earlier and enable the patient to withstand surgical resection. Morbidity and mortality after resection is multifactorial and relates to HCC itself, underlying liver disease and comorbid conditions. Utilizing tests such as ICG R15, Redox Tolerance Index and Tc-GSA to define the functional status of the liver and staging systems helps define who will tolerate hepatic resection. Morbidity and mortality from hepatic resections has also improved with minimizing intraoperative blood loss and minimizing the amount of functional tissue resected. The use of maneuvers such as total vascular exclusion with or without venovenous bypass has expanded the indications for surgery. Utilizing therapeutic combinations, including TAE, portal vein embolization or ablative therapies widens the indications for resection of HCC. Since there are no chemotherapeutic regimens that have been found to prolong survival, surgical resection remains the procedure of choice for treating HCC.

Patterns of hepatocellular carcinoma development in hepatitis B virus and hepatitis C virus related cirrhosis

To compare incidence, risk factors and morphologic pattern of hepatocellular carcinoma (HCC) development in hepatitis B virus (HBV) and hepatitis C virus (HCV) related cirrhosis, 401 patients were followed prospectively by periodic ultrasound examination for 14-189 months (mean: 84.8+/-36.7). During follow-up, 77 (19.2%) patients developed HCC, with 5 and 10 year cumulative incidence of 10 and 27.5%, respectively. The risk of HCC was significantly higher in HBV and HCV co-infected patients (P=0.014) compared to those with single HBsAg or anti-HCV (antibodies to hepatitis C virus) positivity. In anti-HCV positive cases the annual risk of HCC increased from 2% in the first 5 year period to 4% in the third 5 year period, while it decreased from 2 to 0% in the same time periods in the HBsAg positive group. By Cox's regression, age above 59 years (P=0.001), male sex (P=0.09), longer duration (P=0.04) and more advanced stage (P=0.01) of cirrhosis, lower platelets count (P=0.001) and higher ALT levels were significant risk factors for HCC in anti-HCV positive patients, while only high alpha-fetoprotein (AFP) levels during follow-up (P=0.04) was a significant risk factor for HCC in HBsAg positive cases. The pattern of HCC was nodular in 63 (81.8%) patients and infiltrating in 14 (18.2%), and the former type was associated with older age (P=0.0001), longer duration (P=0.002) and more advanced stage (P=0.0001) of cirrhosis but not with the viral etiology of disease. In contrast, development of infiltrating HCC was unrelated to age and disease duration and stage, and was associated with male sex (P=0.01), HBV infection (P=0.06) and HBV and HCV co-infection (P=0.0001). Our results indicate different incidence profile, risk factors and patterns of morphogenesis of HCC development in HBV and HCV associated cirrhosis, suggesting different mechanisms of carcinogenesis.

Effect of interferon therapy on the development of hepatocellular carcinoma in patients with hepatitis C virus-related cirrhosis: a meta-analysis

BACKGROUND

The role of interferon in the prevention of hepatocellular carcinoma remains controversial.

AIM

In this meta-analysis we evaluated the hepatocellular carcinoma incidence in interferon-treated and -untreated patients with hepatitis C virus-related cirrhosis.

METHODS

Eleven studies with 2178 patients were found to fulfil our inclusion criteria. The pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated from the raw study data.

RESULTS

Hepatocellular carcinoma development was significantly more frequent in untreated (21.5%) than in interferon-treated patients (8.2%; OR: 3.0, 95% CI: 2.3-3.9). In the five studies reporting hepatocellular carcinoma incidence in patients with and without sustained response to interferon, hepatocellular carcinoma was detected at a much higher rate in patients without (9%) than with a sustained response (0.9%; OR: 3.7, 95% CI: 1.7-7.8). Moreover, hepatocellular carcinoma developed significantly more frequently in the untreated patients than in the non-sustained responders (OR: 2.7, 95% CI: 1.9-3.9). The benefit from interferon on hepatocellular carcinoma incidence was not influenced by the study type (prospective or retrospective), the follow-up duration, or the study origin.

CONCLUSIONS

Interferon therapy significantly reduces the hepatocellular carcinoma risk in patients with hepatitis C virus cirrhosis. Hepatocellular carcinoma development becomes almost negligible among sustained responders, but a reduction in hepatocellular carcinoma incidence is also achieved even in the non-sustained responders.

Analysis of factors affecting the appearance of hepatocellular carcinoma in patients with chronic hepatitis C. A long term follow-up study after histologic diagnosis

BACKGROUND

Hepatocellular carcinoma (HCC) occurs more frequently in patients with hepatitis C virus (HCV)-related chronic liver disease than those with hepatitis B virus-related disease. It is important to assess the factors affecting the development of HCC.

METHODS

A long term follow-up study involving patients with chronic HCV was performed retrospectively. A total of 153 patients diagnosed between June 1981 and November 1990 with chronic HCV with or without cirrhosis by liver biopsy were enrolled in a long term follow-up study (average, 99.4 months) and the cumulative incidence rate of HCC and factors affecting the appearance of HCC were examined.

RESULTS

The 5-year cumulative incidence rate was 9%, the 10-year cumulative incidence rate was 23%, and the 15-year cumulative incidence rate was 42%. The annual rate of incidence increased as the follow-up period progressed. The authors selected ten variables and investigated their effect on the incidence rate of HCC, including age, gender, habitual heavy drinking, positivity of antibody against hepatitis B virus surface antigen, treatment with interferon (IFN) during the follow-up period, maximum and minimum serum alanine aminotransferase levels during the follow-up period, histologic staging, grading, and irregular regeneration of hepatocytes. Of the 10 variables, age (> 50 years), habitual heavy drinking, and histologic staging were determined to be independent risk factors according to multivariate Cox proportional hazards regression analysis. IFN therapy by itself was not found to be an independent factor affecting the appearance of HCC.

CONCLUSIONS

In patients with chronic HCV, the annual incidence rate of HCC appeared to increase as the follow-up period progressed. According to the results of the current study, the factors that independently affected the development of HCC were age, habitual heavy drinking, and histologic staging.

Hepatitis C and alcohol

A close relationship and possible interaction has been noted between alcohol intake and hepatitis C virus infection, since the discovery of HCV markers. It is not understood whether these are additive or synergistic effects in causing liver injury. Interactions between alcohol and HCV may be studied at several levels, including epidemiology, virology (including viral load), histology (effect on the severity of liver lesions), carcinogenesis (the role of alcohol in the occurrence of hepatocellular carcinoma), and the effect on the extrahepatic manifestations or severity of HCV infection. At the epidemiological level, a high prevalence of HCV infection was noted in patients with alcoholic liver diseases (14-37%), also characterized by a high rate of viral replication as detected by PCR, which was present in over 90% of patients tested. Moreover, the prevalence of anti-HCV antibodies increased proportionally with the severity of liver lesions. Virological analysis based on the determination of HCV RNA levels in the serum showed variations of HCV RNA levels with diet, and a clear relationship between self reported alcohol consumption and the levels of serum HCV RNA (r = .26, p = .001). At the histologic level the role of alcohol may be evaluated either through the development of fibrosis or by determination of the incidence of cirrhosis. A study on the effect of alcohol intake below or over 40 g per day on the histologic progression of liver lesions has confirmed a more rapid increase in fibrosis and a doubling in the incidence of cirrhosis in patients admitting to alcohol consumption >40 g per day. The role of alcohol in the occurrence of hepatocellular carcinoma in patients with cirrhosis due to HCV infection has been extensively studied with controversial results. A recent case control study performed in Italy showed that the relative risk of HCC in patients with HCV infection and heavy alcohol consumption doubled. Finally, alcohol consumption potentially worsens the evolution of dermatological diseases associated with HCV infection such as porphyria cutanea tarda. All of the above are strong arguments which should be used to advise HCV patients against alcohol consumption, regardless of the degree of liver injury. However, the deleterious effect of the occasional intake of small amounts of alcohol has not been demonstrated and therefore an occasional drink may be allowed in some cases.

Effect of interferon therapy on the natural history of hepatitis C virus-related cirrhosis and hepatocellular carcinoma

In patients with chronic hepatitis C who have a sustained virologic response to IFN therapy, there is a dramatic effect on the natural history of the disease, with ALT levels becoming normal, histologic activity improving or disappearing, and the progression of fibrosis slowing. A sustained virologic response 6 months after the end of treatment is predictive of a sustained remission 4 years later. From these results, a long-term survival benefit is expected from IFN treatment in patients with an intermediate or rapid rate of fibrosis. For patients with chronic hepatitis C who do not experience a sustained eradication of virus, there is evidence that IFN treatment significantly reduces the viral load and serum ALT level, improves histologic activity, and blocks fibrosis progression, in comparison with the natural history of this disease. Therefore, patients who still have a detectable level of HCV RNA should no longer be considered nonresponders to IFN therapy. Although the number of randomized trials is [figure: see text] small, cumulative data suggest that IFN therapy can reduce the incidence of and the mortality from hepatocellular carcinoma in patients with cirrhosis.

Expression of interferon receptor genes in the liver as a predictor of interferon response in patients with chronic hepatitis C

Interferon (IFN) receptor mRNA expression patterns in the liver have been shown to correlate with the effectiveness of IFN therapy in patients with hepatitis C virus (HCV) infection. However, it is not clear to what extent this factor contributes to the short (primary)- and long (sustained)-term results of IFN treatment with respect to biochemical and virological remission. Eighty-two patients who subsequently received lymphoblastoid IFN-alpha therapy underwent liver biopsies before IFN therapy. Possible factors that might correlate with IFN response were chosen and analyzed. The primary biochemical and virological responses at the end to treatment (24 weeks) were 63% and 43% vs. 46% and 32% for sustained biochemical and virological remission at the end of follow-up (48 weeks), respectively. In univariate analysis, the absence of HCV genotype 1b, a low titer of HCV RNA, and the expression of IFN receptor mRNA were significantly correlated with sustained biochemical and virological responses to IFN therapy. Multiple logistic regression analysis showed that IFN receptor mRNA expression and the absence of genotype 1b were significant predictors of the sustained biochemical and virological effectiveness of IFN therapy. IFN receptor mRNA expression predicted a sustained virological response to IFN therapy with a positive predictive value of 100% with genotype non-1b and had a negative predictive value of 97% with genotype 1b. It is concluded that expression of IFN receptor genes in the liver is a useful index for predicting the short- and long-term efficacy of IFN therapy in patients with chronic HCV infection.

Hepatocellular proliferation and development of hepatocellular carcinoma: a case-control study in chronic hepatitis C

Patients with hepatitis C have an increased risk of developing hepatocellular carcinoma (HCC). This is related to the stage of chronic liver disease, as characterized histologically by hepatic fibrosis and architectural distortion, but it is unclear whether histological markers can define the risk of developing HCC. We conducted a case-control immunohistochemical study of Ki-67, a marker for hepatocellular proliferation, in livers of 18 patients who had developed HCC more than 2 years after the biopsy specimen had been taken. Using conditional logistic regression analysis, the results were compared with 18 selected controls, who were age-matched patients with hepatitis C of similar histological stage who had not developed HCC. We also examined livers for cellular dysplasia, p53 mutations, and bcl-2 overexpression, and assessed whether the results could be correlated with demographic and disease-related variables, such as gender, region of birth, alcohol consumption, severity of liver disease, HCV genotype, and markers of hepatitis B virus (HBV) infection. Livers from patients who developed HCC were more often positive for Ki-67 (13 of 18 [72%] v 9 of 18 [50%]; P = .06) and tended to have higher mean Ki-67 scores (6 +/- 7.5 v 3 +/- 4.4; P = .10) compared with control cases. In the HCC-predisposed group, three livers showed large cell dysplasia, two were positive for p53 mutations, and two for bcl-2 overexpression. In contrast, in the non-HCC group, only one case had dysplasia, and none were positive for immunostaining for p53 or bcl-2 mutations. With the exception of one case, all livers with large cell dysplasia or p53 mutations and bcl-2 overexpression were also positive for Ki-67. Twelve (55%) of the 22 Ki-67-positive cases were anti-HBc-positive in the serum, in contrast to 2 of 14 (14%) patients in the Ki-67-negative group (P = .01). Patients with evidence of past infection with HBV were more often Ki-67 positive than those who had no evidence of past infection (85% [11 of 13] v 45% [10 of 22]; P = .02). There were no other associations between demographic or disease-related variables and Ki-67 expression. Increased hepatocellular proliferative activity, as assessed by Ki-67 expression, may be one factor indicative of an increased risk of developing HCC among patients with chronic hepatitis C. Furthermore, past infection with HBV appears to be an important correlate of increased hepatocellular proliferation in hepatitis C.

Retrospective analysis of the effect of interferon therapy on the clinical outcome of patients with viral cirrhosis

BACKGROUND

Recent data suggest that interferon therapy (IFN) can reduce the risk of progression to hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV)-related cirrhosis.

METHODS

A cohort of 189 patients with Child's Stage A cirrhosis of viral etiology followed prospectively were analyzed retrospectively to assess the effects of IFN on the clinical course and development of HCC.

RESULTS

During a mean follow-up of 71.5+/-23.6 months, 7.9% of 88 treated and 21.8% of 101 untreated patients showed worsening of the Child's disease stage (P < 0.01); 5.6% of treated and 26.7% of untreated patients developed HCC (P < 0.001); and 3.4% of treated and 19.8% of untreated patients died of liver disease or underwent orthotopic liver transplantation (OLT) (P < 0.005). Using Cox's regression analysis, no treatment with IFN, high bilirubin and alkaline phosphatase (ALP) levels, and low leukocyte counts and prothrombin activity (PT) were associated significantly with worsening of Child's disease stage; no treatment with IFN, long term disease, low albumin and PT, and high gamma-glutamyl transpeptidase (GGT) were related significantly to HCC development; and no treatment with IFN, low albumin and PT, and high GGT and ALP were associated significantly with reduced survival. After adjustment for independent risk factors identified by multivariate analysis, the estimated cumulative probability of worsening of cirrhosis (P < 0.05), development of HCC (P < 0.001), and death or OLT (P < 0.005) was significantly lower in IFN-treated patients compared with untreated patients. This beneficial effect of therapy was statistically evident only in HCV positive patients.

CONCLUSIONS

These results support the hypothesis that IFN improves clinical outcomes and reduces progression to HCC in patients with HCV-related cirrhosis. These conclusions, based on retrospective data, should be confirmed prospective.