Chronic viral hepatitis and hepatocellular carcinoma

Comparison of inpatient outcomes in patients with Hepatitis B, Hepatitis C, and Hepatitis B and C co-infection with Cirrhosis

BACKGROUND

Hepatitis B (HBV) and Hepatitis C (HCV) are among the most common causes of cirrhosis in the USA, with high mortality and morbidity but comparative outcomes were not well studied.

METHODS

We retrospectively analyzed cirrhosis patients with HBV, HCV, and HBV/HCV coinfection from 2016 to 2019 in National Inpatient Sample (NIS) database. Our primary outcome was the length of stay (LOS), mean hospital charge and mortality.

RESULTS

Our study included 701464 cirrhosis patients with HCV (89.7%), HBV (6.8%), and coinfection (3.5%) (P < 0.001). Male gender and white race were more common in all three cohorts (p < 0.001). The mean age for HBV, HCV, and coinfection was 55.59, 58.69, and 58.27 years. The mean LOS for HBV, HCV, and coinfection were 6.59 ± 0.1, 6.02 ± 0.03, and 6.74 ± 0.12 days respectively. The adjusted length of stay was 0.62 days longer in the HBV cohort and 0.61 days longer in the coinfection cohort, compared to the HCV cohort (P < 0.001). Adjusted hospital charges were $15112 higher in the HBV cohort and $ 6312 higher in the coinfection cohort, compared to the HCV cohort (P < 0.001). Patients with HBV had a higher risk of mortality compared to HCV infection (AOR 1.35, [1.22-1.48], P < 0.001); However, patients with coinfection had no difference in mortality compared to HCV infection.

CONCLUSION

Cirrhosis with HBV and coinfection is associated with increased duration of hospital stay and cost when compared to HCV infection. There is a higher risk of mortality in cirrhotic patients with HBV infection compared to HCV; however, no significant difference in mortality for coinfection compared to HCV.

Clinical study of lenvatinib in the treatment of hepatitis virus-related hepatocellular carcinoma and antiviral therapy

Background: Lenvatinib is recommended as a first-line tyrosine kinase inhibitor for advanced hepatocellular carcinoma (HCC) since 2017. The aim of this study was to compare the clinical action of lenvatinib in hepatitis B virus (HBV)-related HCC and hepatitis C virus (HCV)-related HCC. Methods: A continuous cohort of advanced HCC was retrospectively enrolled. And the patients were divided into HBV-related HCC and HCV-related HCC based on previous history of hepatitis virus infection. Then propensity score matching (PSM) was conducted to compare objective response rate (ORR),disease control rate (DCR),progression-free survival (PFS),overall survival (OS) and safety between the two groups. Results: A total of 203 eligible patients were included, with 72 HBV-related HCC and 36 HCV-related HCC after PSM. Both ORR (20.8% vs. 5.6%, P = .0759) and DCR (76.4% vs. 52.8%, P = .0232) were significantly higher in the HBV-related HCC than in the HCV-related HCC. Although no statistical differences in PFS (6.1 months vs. 3.3 months, P = .17) and OS (14.9 months vs. 17.7 months, P = .96) were observed between the two groups, there was a trend of difference in the PFS survival curve. On multivariate regression analysis of PFS, both HBV infection (HR, .54; 95% CI, .31-.95; P = .0332) and antiviral time >5 years (HR, .49; 95% CI, .26-.9; P = .0219) were identified as independent favorable factors, and AFP >200 ng/mL (HR, 1.88; 95% CI, 1.1-3.22; P = .0216) were found to be an independent adverse factor. In addition, compared with HCC who received the first dose of antiviral drugs less than 5 years, the patients who were administered those drugs over 5 years had a significantly favorable PFS (11.27 months vs. 3.87 months, P = .0011). Lenvatinib was well tolerated in all patients and the adverse events (AEs) were similar between the two groups. Conclusion: It seemed that lenvatinib benefited more in HBV-related advanced HCC in delaying disease progression, compared to those with HCV-related advanced HCC.

Comparison of stereotactic body radiotherapy and radiofrequency ablation for hepatocellular carcinoma: Systematic review and meta-analysis of propensity score studies

AIM

Stereotactic body radiotherapy (SBRT) is an emerging treatment for hepatocellular carcinoma (HCC) and has shown excellent local control (LC), as has radiofrequency ablation (RFA). As no randomized controlled trial has compared SBRT and RFA for HCC, data from a propensity score matched study (PSMS) are valuable. However, the results varied greatly and depended on composing factors of Barcelona Clinic Liver Cancer staging (BCLC-factors) adjusted. Therefore, we undertook a systematic review and meta-analyses of the studies focusing on BCLC-factors matching.

METHODS

We systematically searched PubMed, the Cochrane database, EMBASE, and Web of Science to identify studies comparing RFA and SBRT using propensity scores. The hazard ratios (HRs) of overall survival (OS) and LC from BCLC-factor-matched and -unmatched PSMS were pooled. Heterogeneity between the data from these studies was assessed.

RESULTS

Three BCLC-factor-matched studies were identified. Stereotactic body radiotherapy led to comparable OS (HR, 0.89; 95% CI, 0.74-1.08; p = 0.24; I²  = 0%; p for heterogeneity, 0.56) and significantly better LC (HR, 0.39; 95% CI, 0.30-0.51; p < 0.001; I²  = 0%; p for heterogeneity, 0.67). We also identified three additional BCLC-factor-unmatched studies (HR of OS, 1.41; 95% CI, 1.21-1.65; p < 0.0001; I²  = 0%; p for heterogeneity, 0.63). However, considerable heterogeneity was observed for HR of OS between BCLC-factor-matched and -unmatched studies (I²  = 92.6%; p for heterogeneity, 0.0002).

CONCLUSIONS

When BCLC-factors were properly adjusted, the results of the meta-analysis revealed equivalent OS and better LC for SBRT compared with RFA. Stereotactic body radiotherapy could be an alternative treatment option for HCC.

Hepatocellular Carcinoma in Oman: An analysis of 284 cases

Objectives

Hepatocellular carcinoma (HCC) is the most common type of primary liver tumour worldwide and is increasing in incidence. This study aimed to describe the clinical characteristics of HCC among Omani patients, along with its major risk factors, outcomes and the role of surveillance.

Methods

This retrospective case-series study was conducted between January 2008 and December 2015 at the three main tertiary care hospitals in Oman. All adult Omani patients diagnosed with HCC and visited these hospitals during the study period were included. Relevant data were collected from the patients’ electronic medical records.

Results

A total of 284 HCC patients were included in the analysis. The mean age was 61.02 ± 11.41 years and 67.6% were male. The majority had liver cirrhosis (79.9%), with the most common aetiologies being chronic hepatitis C (46.5%) and B (43.2%). Only 13.7% of cases were detected by the HCC surveillance programme. Approximately half of the patients (48.5%) had a single liver lesion and 31.9% had a liver tumour of >5 cm in size. Approximately half (49.2%) had alpha-fetoprotein levels of ≥200 ng/mL. The majority (72.5%) were diagnosed using multiphase computed tomography alone. Less than half of the patients (48.9%) were offered one or more HCC treatment modalities.

Conclusion

The majority of Omani HCC patients were male and had cirrhosis due to viral hepatitis. In addition, few patients were identified by the national surveillance programme and presented with advanced disease precluding therapeutic or even palliative treatment.

Repeated Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma

PURPOSE

In clinical practice, whether cirrhotic livers in patients with hepatocellular carcinoma (HCC) can withstand repeated stereotactic body radiation therapy (SBRT) remains unclear. This study aimed to evaluate the outcomes and toxicities in these patients.

METHODS AND MATERIALS

This retrospective study included patients with HCC who were treated with SBRT at least twice between January 2012 and June 2019. Local control and overall survival rates were calculated. Liver function before and after irradiation was evaluated using the Child-Pugh score and modified albumin-bilirubin grade. All toxicities were assessed using the Common Terminology Criteria for Adverse Events (version 4.0).

RESULTS

Fifty-two patients underwent 136 courses (148 lesions) of SBRT, which was mostly performed for out-of-field tumors but 3 in-field recurrences. The median follow-up duration from the first SBRT was 52.6 months (range, 15.7-89.3 months). The median gross tumor volume was 4.6 cm³ (range, 0.8-55.2 cm³) at the second SBRT. The 3-year local control rate was 94.5% (95% confidence interval, 88.0%-97.5%). The 3-year overall survival rate after the second course was 62.8% (95% confidence interval, 45.1%-76.2%). Although the Child-Pugh score did not deteriorate after the second course, deterioration of the modified albumin-bilirubin grade at 6, 12, and 24 months was statistically significant compared with that before the second course. One patient (1.9%) experienced grade 3 hypoalbuminemia and 2 patients (3.8%) had grade 3 thrombocytopenia 6 months after the second course. Mild fatigue and nausea were reported in 9 (17.3%) and 6 (11.5%) patients, respectively. One instance of grade 5 toxicity was observed. Two patients (1.5%) had grade 2 gastric ulcers. No other grade ≥3 gastrointestinal toxicities occurred.

CONCLUSIONS

Repeated SBRT is feasible and produces minimal toxicity in patients with HCC and Child-Pugh scores of ≤7 and a low normal liver dose.

Hepatic Stellate Cells and Hepatocarcinogenesis

Hepatic stellate cells (HSCs) are a significant component of the hepatocellular carcinoma (HCC) tumor microenvironment (TME). Activated HSCs transform into myofibroblast-like cells to promote fibrosis in response to liver injury or chronic inflammation, leading to cirrhosis and HCC. The hepatic TME is comprised of cellular components, including activated HSCs, tumor-associated macrophages, endothelial cells, immune cells, and non-cellular components, such as growth factors, proteolytic enzymes and their inhibitors, and other extracellular matrix (ECM) proteins. Interactions between HCC cells and their microenvironment have become topics under active investigation. These interactions within the hepatic TME have the potential to drive carcinogenesis and create challenges in generating effective therapies. Current studies reveal potential mechanisms through which activated HSCs drive hepatocarcinogenesis utilizing matricellular proteins and paracrine crosstalk within the TME. Since activated HSCs are primary secretors of ECM proteins during liver injury and inflammation, they help promote fibrogenesis, infiltrate the HCC stroma, and contribute to HCC development. In this review, we examine several recent studies revealing the roles of HSCs and their clinical implications in the development of fibrosis and cirrhosis within the hepatic TME.

Role of selected criteria and preventive chemotherapy in tumor recurrence after liver transplantation

BACKGROUND

Long-term survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) patients remains poor because of tumor recurrence. To improve the prognosis of HCC patients after LT, we aimed to identify different transplantation criteria and risk factors related to tumor recurrence and evaluate the effect of preventive chemotherapy in a single center.

METHODS

In total, data on 20 variables and the survival of 199 patients with primary HCC who underwent LT between 2005 and 2015 were included for analysis. The patients were divided into the following three groups: Group 1, within the Milan and Hangzhou criteria (n = 51); Group 2, beyond the Milan but within the Hangzhou criteria (n = 36); and Group 3, beyond the Milan and Hangzhou criteria (n = 112). Survival probabilities for the three groups were calculated using multivariate Cox regression analysis. The association between preventive therapy and HCC-recurrence after LT was analyzed by multiple logistic regression analysis.

RESULTS

Child-Pugh stage C and hepatitis B virus (HBV) infection were independent risk factors for patients with tumor recurrence who did not meet the Milan criteria. The overall survival rates of the 199 patients showed statistically significant differences among the three groups (P < 0.001). Moreover, no significant difference was noted in the survival rate between Group 1 and Group 2 (P > 0.05). Multivariate logistic regression analysis showed that postoperative prophylactic chemotherapy reduced the risk of tumor recurrence in patients who did not meet the Hangzhou and Milan criteria (OR = 0.478; 95% CI: 0.308-0.741; P = 0.001).

CONCLUSIONS

Child-Pugh classification and HBV infection were the independent risk factors of tumor recurrence in HCC patients with LT. The Hangzhou criteria were effective and analogous compared with the Milan criteria. Preventive chemotherapy significantly reduced the risk of recurrence and prolonged the survival time for HCC patients beyond the Milan and Hangzhou criteria after LT.

A real-life experience of sorafenib treatment for patients with advanced hepatocellular carcinoma: a retrospective analysis at Cathay General Hospital, 2007-2015

Background

Sorafenib is an oral tyrosine kinase inhibitor that is indicated for advanced hepatocellular carcinoma (HCC). The aim of the present study was to determine the clinical outcomes of HCC patients receiving sorafenib in real-life clinical setting in comparison with formal clinical trials.

Methods

Patients diagnosed with advanced HCC between 2007 and 2015 at single institute were retrospectively enrolled and evaluated for survival and tolerability following sorafenib treatment. Overall survival (OS) and duration of treatment (TTP) were examined by different stratifications including age, gender, etiology, liver functions, and severities.

Results

A total of 67 advanced HCC patients were enrolled for analysis. Of the 67 eligible patients, 66 patients (99%) were diagnosed as Barcelona Clinic Liver Cancer stage C and 45 (67%) were Child-Pugh A. Chronic hepatitis B virus infection was the main etiology (67%), followed by hepatitis C virus infection (12%) and alcohol liver disease (8%). The median duration of treatment was 3.0 months (95% CI 2.6–3.4 months) and median OS was 8.0 months (95% CI 5.0–11.0 months). By multivariate analysis, female gender (HR =2.462, 95% CI 1.126–5.387, P=0.024), Child-Pugh C (HR =3.913, 95% CI 1.063–14.410, P=0.04), extrahepatic spread (HR =2.123, 95% CI 1.122–4.015, P=0.021), and combined other therapies (HR =0.410, 95% CI 0.117–0.949, P=0.037) were the independent predictors of OS.

Conclusion

OS of advanced HCC patients treated with sorafenib was longer than that reported in the Asia-Pacific trial study. Impaired hepatic functions are associated with the shorter survival in real-life setting.

Clinicopathologic characteristics andoutcomes of hepatocellular carcinoma associated with chronic hepatitis B versus hepatitis C infection

BACKGROUND

Hepatocellular carcinoma (HCC) is a primary liver malignancy and one of the most common cancers worldwide. Few studies in Saudi Arabia have compared the clinicopathologic characteristics of HCC caused by hepatitis B virus (HBV) versus hepatitis C virus (HCV) and their effect on patient survival and prognosis.

OBJECTIVES

Identify differences in clinicopathological characteristics and outcomes of hepatocellular carcinoma (HCC) caused by HBV versus HCV.

DESIGN

A retrospective medical records review.

SETTING

Tertiary medical center in Riyadh.

PATIENTS AND METHODS

We included all new cases of HCC with underlying HBV and HCV infection diagnosed between January 2013 and September 2017 that met inclusion criteria.

MAIN OUTCOME MEASURES

Clinical, biochemical, pathological and radiological characteristics, and survival differences were compared between HCC that developed in HBV- and HCV-infected patients.

SAMPLE SIZE

Of 253 patients evaluated, 172 patients were included in the study.

RESULTS

Of the 172 patients, 110 (64%) had HCV-associated HCC and 62 (36%) had HBV-associated HCC. More patients with HBV infection were males (P=.003) and were younger (P=.015) than HCV patients. HCV-infected patients who developed HCC had more advanced cirrhosis (P=.048). The prevalence of comorbidities and pre-existing cir.rhosis was similar in both groups. Seven patients (6.8%) with underlying HCV developed HCC in the absence of cirrhosis. Patients with HBV-associated HCC were less likely to meet Milan criteria at initial diagnosis than those with HCV-associated HCC (33.9% vs. 52.7%, respectively, P=.017). HBV-associated HCC occurred at a more advanced Barcelona Clinic Liver Cancer stage. The overall median survival and treatment outcome for each modality was comparable.

CONCLUSIONS

HBV- and HCV-associated HCC have distinct clinical and pathological characteristics, necessitating different screening policies to optimize HCC surveillance and management. However, viral etiology did not affect the treatment outcome and long-term survival.

LIMITATIONS

Conducted in a single-center, retrospective and lacks information about the use of antiviral treatment.

CONFLICT OF INTEREST

None.

Prevalence and sociodemographic disparities of Hepatitis C in Baby Boomers and the US adult population

BACKGROUND

The US Baby Boomer (BB) generation is associated with high rates of Hepatitis C virus (HCV) infection. There is limited literature detailing age-specific risk factors for HCV infection. Using a nationally representative sample, this study examines US adult HCV prevalence and age-specific risk factors for chronic HCV infection.

METHODS

We analyzed data from National Health and Nutrition Examination Survey (NHANES) for years 1999-2012. Age was divided into three categories: BB, younger than BB (YG) and older than BB (OG). HCV status was determined by the presence of a positive HCV antibody and a positive HCV RNA. Sociodemographic variables were analyzed by HCV status. Multivariable logistic regression models adjusting for sociodemographic variables were fitted to identify age-specific risk factors for HCV positivity.

RESULTS

The overall prevalence of chronic HCV was 1.19% with a US population estimate of 2,347,852 US adults. BB had the highest prevalence at 2.23%, accounting for over 74% of all chronic HCV cases. HCV prevalence was highest among all ages (1.83%) and BB (2.71%) in 2001-2002 survey cycle. Among BB, males, non-Hispanic blacks, positive blood transfusion history, current and former smoker, and living below the poverty line were significant predictors of chronic HCV positivity.

CONCLUSION

This study highlights the elevated prevalence of chronic HCV among BB and identifies age-specific risk factors for chronic HCV infection. As the BB population ages, it is important to use these generation-specific risk factors that can guide health professionals in targeted screening and public health prevention efforts.

Hepatitis C Infection and Periodontal Disease: Is there a Common Immunological Link?

Hepatitis C virus (HCV) infections could have an important impact on the oral health status of patients, favoring conditions such as periodontal disease and oral cancer. The review of the existing scientific literature written in English was performed, searching for oral and periodontal manifestations of HCV infection and its impact on the oral fluids. HCV infection can determine direct extrahepatic manifestations at the oral and periodontal level including oral lichen planus, Sjögren-like sialadenitis, and oral cancer. The changes caused by the infection in the subjects' immune system, diet, and lifestyle can facilitate the development of oral conditions such as periodontal disease. Important changes also occur in the composition of the infected patients' saliva and gingival fluid. HCV-infected patients need to be carefully monitored in terms of oral health since the infection with the virus can result in oral complications. The cellular and molecular particularities of the gingival fluid of HCV-infected patients can answer some questions regarding its impact upon periodontium impairment and whether this refers to a possible bidirectional relationship, with hepatic biomarker adjustments being induced by the periodontal patients' inflammatory status.

Predictors and Barriers to Hepatitis B Screening in a Midwest Suburban Asian Population

Despite guidelines recommending hepatitis B virus (HBV) screening among the Asian population, not all Asians are screened. We assessed barriers to and factors predicting HBV screening in Michigan. Adults residing in Southeast Michigan self-identifying as Asian were surveyed at Asian grocery stores, restaurants, churches, and community events. 404 persons participated in the survey, 54 % were women, median age was 51 years, 63 % were Chinese, and 93.8 % were born outside the U.S. 181 (44.8 %) had not or could not recall having been screened for HBV. Of these, 89 % said their primary care physicians (PCP) had never brought up screening. Unscreened participants were more likely to think HBV is genetically inherited and cannot be treated than those who had been screened. They were also more likely to think they should avoid close contact with others, would bring shame to their families, and lose their job, if found to be infected with HBV. Among 223 (55.2 %) who had been screened, 48 % said their PCP had the greatest influence in their decision to be screened and 70.9 % said they were screened at a doctor's visit. Screened participants were more likely to know someone with HBV, have a PCP, and have health insurance. Logistic regression analysis showed knowing someone with HBV was the only predictor for screening. Despite guidelines for HBV screening, only half of the Asian Americans surveyed had been screened. Increasing awareness among PCPs is needed to increase HBV screening in this population.

Targeting blockage of STAT3 inhibits hepatitis B virus-related hepatocellular carcinoma

Hepatitis B virus (HBV) infection is a significant cause of liver disease pathogenesis, which results in the development of hepatic dysfunction, cirrhosis and hepatocellular carcinoma (HCC). Our previous studies showed that oncogene STAT3 might be an ideal target for HCC therapy. Here, we investigated whether targeting blockage of STAT3 signaling is efficient for HBV-related HCC. Based on the refractory of HCC and the persistence of HBV, in this study, we designed shRNAs targeting STAT3. The results showed that blocking STAT3 signaling by shRNAs could promote HBV positive HCC cell apoptosis and induce cell cycle arrest, resulting in HCC cell growth inhibition in vitro. Importantly, STAT3-shRNAs efficiently suppressed HBV replication, which would reduce HBV-derived stimulation to STAT3 signaling and augment STAT3-shRNAs-mediated anti-HCC effect. Finally, STAT3-shRNAs-mediated anti-HBV positive HCC effect was confirmed in xenograft nude mice. This study suggested that targeting STAT3 therapies such as STAT3-shRNAs may be an efficacious strategy for HBV-related HCC.

Hepatocellular Carcinoma and Viral Hepatitis in New York City

BACKGROUND

 The incidence and mortality rate of hepatocellular carcinoma (HCC) are increasing in the United States. Viral hepatitis infection is a primary risk factor for HCC. This study describes the relationship between viral hepatitis and HCC in New York City (NYC).

METHODS

 Viral hepatitis cases reported to the NYC Department of Health from 1999-2012 were matched to HCC cases diagnosed from 2001 to 2012 and reported to the New York State Cancer Registry. HCC cases were stratified by the presence or absence of viral hepatitis. Demographic characteristics, factors associated with specific causes of death, and survival time were analyzed for all HCC cases.

RESULTS

 From 2001-2012, a total of 8827 NYC residents had HCC diagnosed; 38.4% had hepatitis C virus (HCV) infection, 17.9% had hepatitis B virus (HBV) infection, and 2.2% had both. Patients with HCC were predominantly men (74.8%), with equal proportions of white non-Hispanic (28.6%) and Hispanic (28.9%) patients. Those with HBV infection were primarily Asian/Pacific Islanders (63.2%). The median survival time after HCC diagnosis for persons with HBV infection was 22.3 months, compared with 13.1 months for persons with HCV infection, and 6.9 months for noninfected persons. The 5-year survival rate was 37.5% for those with HBV infection, 20.0% for those with HCV infection, 29.5% among coinfected individuals, and 16.1% for those with neither infection reported.

CONCLUSIONS

 In NYC, most persons with HCC have viral hepatitis; the majority of viral hepatitis infections are due to HCV. Survival for persons with HCC differs widely by viral hepatitis status. This study highlights the importance of viral hepatitis prevention and treatment and HCC screening.

Comparison of MRI features of pathologically proven hepatocellular carcinoma between patients with hepatitis B and hepatitis C infection

PURPOSE

To compare MRI features of pathologically-proven hepatocellular carcinoma (HCC) between patients with hepatitis B (HBV) and hepatitis C (HCV) infection.

METHODS

Two radiologists assessed 51 confirmed HCCs on MRI in HBV (n=18) or HCV (n=33) patients; a third, more experienced, radiologist resolved discrepancies.

RESULTS

Arterial hyperenhancement occurred more frequently in HCV (90.9% vs. 66.7%; P=.032), DWI/T2WI hyperintensity more frequently in HBV [(DWI: 78.6% vs. 45.8%, T2WI: 77.8% vs. 48.5%; P=.073-0.088)]. Tumors were larger in HBV (P≤.016). Washout, pseudocapsule, homogeneity, circumscribed margins, lipid, iron, and visually low ADC were not different.

CONCLUSION

Larger studies are required to confirm these preliminary findings.

Dynamic tumor-tracking radiotherapy with real-time monitoring for liver tumors using a gimbal mounted linac

PURPOSE

Dynamic tumor-tracking stereotactic body radiotherapy (DTT-SBRT) for liver tumors with real-time monitoring was carried out using a gimbal-mounted linear accelerator and the efficacy of the system was determined. In addition, four-dimensional (4D) dose distribution, tumor-tracking accuracy, and tumor-marker positional variations were evaluated.

MATERIALS AND METHODS

A fiducial marker was implanted near the tumor prior to treatment planning. The prescription dose at the isocenter was 48-60 Gy, delivered in four or eight fractions. The 4D dose distributions were calculated with a Monte Carlo method and compared to the static SBRT plan. The intrafractional errors between the predicted target positions and the actual target positions were calculated.

RESULTS

Eleven lesions from ten patients were treated successfully. DTT-SBRT allowed an average 16% reduction in the mean liver dose compared to static SBRT, without altering the target dose. The average 95th percentiles of the intrafractional prediction errors were 1.1, 2.3, and 1.7 mm in the left-right, cranio-caudal, and anterior-posterior directions, respectively. After a median follow-up of 11 months, the local control rate was 90%.

CONCLUSIONS

Our early experience demonstrated the dose reductions in normal tissues and high accuracy in tumor tracking, with good local control using DTT-SBRT with real-time monitoring in the treatment of liver tumors.

Irradiation-induced localization of IL-12-expressing mesenchymal stem cells to enhance the curative effect in murine metastatic hepatoma

Irradiation in conjunction with gene therapy is considered for efficient cancer treatment. Mesenchymal stem cells (MSCs), due to their irradiation-promotable tumor tropism, are ideal delivery vehicles for gene therapy. In this study, we investigated whether treatment with radiation and interleukin (IL)-12-expressing MSCs (MSCs/IL-12) exerts improved antitumor effects on murine metastatic hepatoma. HCa-I and Hepa 1-6 cells were utilized to generate heterotopic murine hepatoma models. Tumor-bearing mice were treated with irradiation or MSCs/IL-12 alone, or a combination. Monocyte chemoattractant protein-1 (MCP-1/CCL2) expression was assessed in irradiated hepatoma tissues to confirm a chemotactic effect. Combination treatment strategies were established and their therapeutic efficacies were evaluated by monitoring tumor growth, metastasis and survival rate. IL-12 expression was assessed and the apoptotic activity and immunological alterations in the tumor microenvironment were examined. MCP-1/CCL2 expression and localization of MSCs/IL-12 increased in the irradiated murine hepatoma cells. The antitumor effects, including suppression of pulmonary metastasis and survival rate improvements, were increased by the combination treatment with irradiation and MSCs/IL-12. IL-12 expression was increased in tumor cells, causing proliferation of cluster of differentiation 8(+) T-lymphocytes and natural killer cells. The apoptotic activity increased, indicating that the cytotoxicity of immune cells was involved in the antitumor effect of the combined treatment. Treatment with irradiation and MSCs/IL-12 showed effectiveness in treating murine metastatic hepatoma. IL-12-induced proliferation of immune cells played an important role in apoptosis of tumor cells. Our results suggest that treatment with irradiation and MSCs/IL-12 may be a useful strategy for enhancing antitumor activity in metastatic hepatoma.

Hepatocellular carcinoma treatment over sorafenib: epigenetics, microRNAs and microenvironment. Is there a light at the end of the tunnel?

INTRODUCTION

Sorafenib is currently the only approved therapy in hepatocellular carcinoma (HCC). Alternative first- and second-line treatments are a significant unmet medical need, and several biologic agents have been tested in recent years, with poor results. Therefore, angiogenic pathways and the cytokine cascade remain possible targets in HCC. Recent studies suggest a role of epigenetic processes, associated with the initiation and development of HCC. In this field, DNA methylation, micro-RNAs (miRNAs) and tumor microenvironment cells became a possible new target for HCC treatment.

AREAS COVERED

This review explains the possible role of DNA methylation and histone deacetylase inhibitors as predictive biomarkers and target therapy, the extensive world of the promising miRNA blockade strategy, and the recent strong evidence of correlation between HCC tumors and peritumoral stroma cells. The literature and preclinic/clinic data were obtained through an electronic search.

EXPERT OPINION

Future research should aim to understand how best to identify patient groups that would benefit most from the prescribed therapy. To overcome the 'therapeutic stranding' of HCC, a possible way out from the current therapeutic tunnel might be to evaluate the major epigenetic and genetic processes involved in HCC carcinogenesis, not underestimating the tumor microenvironment and its 'actors' (angiogenesis, immune system, platelets). We are only at the start of a long journey towards the elucidation of HCC molecular pathways as therapeutic targets. Yet, currently this path appears to be the only one to cast some light at the end of the tunnel.

Evaluation of total hepatocellular cancer lifespan, including both clinically evident and preclinical development, using combined network phenotyping strategy and fisher information analysis

We previously showed that for hepatocellular cancer (HCC) prognostication, disease parameters need to be considered within a total personal clinical context. This requires preserving the coherence of data values, observed simultaneously for each patient during baseline diagnostic evaluation. Application of the Network Phenotyping Strategy (NPS) provided quantitative descriptors of these patient coherences. Combination of these descriptors with Fisher information about the patient tumor mass and the histogram of the tumor masses in the whole cohort permitted estimation of the time from disease onset until clinical diagnosis (t(baseline)). We found faster growth of smaller tumors having total masses<70 (80% of cohort) which involved about three times more interacting cellular processes than were observed for slower growing larger tumors (20% of cohort) with total masses>70. Combining the clinical survival and t(baseline) normalized all HCC patients to a common 1,045 days of mean total disease duration (t(baseline) plus post diagnosis survival). We also found a simple relationship between the baseline clinical status, t(baseline), and survival. Every difference between individual patient baseline clinical profiles and special coherent clinical status (HL1) reduced the above common overall survival (OVS) by 65 days. In summary, we showed that HCC patients with any given tumor can best have their tumor biology understood, when account is taken of the total clinical and liver contexts, and with knowing the point in the tumor history when an HCC diagnosis is made. This ability to compute the t(baseline) from standard clinical data brings us closer to calculating survival from diagnosis of individual HCC patients.

A comparison of patients with hepatitis B- or hepatitis C-based advanced-stage hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer death and has characteristic causes, epidemiology and clinical features. The leading causes include hepatitis B virus (HBV), hepatitis C virus (HCV), alcoholism, and aflatoxin B1 dietary exposure, as well as combinations of these factors. Few cancers offer the opportunity to study the clinical and cancer phenotype that results from different causes, quite like HCC. Advantage was taken of a large cohort of advanced, unresectable and untransplantable HCCs to compare the phenotypes resulting from HBV-based compared with HCV-based HCC. The main findings were that HBV-based HCC patients were statistically significantly younger, had a higher percent of males, had larger maximum tumor sizes, and had higher blood alpha-fetoprotein (AFP) and albumin levels and platelet counts than HCV-based HCC patients. These differences partly reflect an earlier age of HBV infection and a lesser degree of cirrhosis-associated liver damage, as a result of the different biological consequences of chronic HBV compared with chronic HCV infection.

Combination of macrophage inflammatory protein 1 alpha with existing therapies to enhance the antitumor effects on murine hepatoma

Existing therapies such as irradiation or sorafenib have limited success in the treatment of hepatocellular carcinoma (HCC) due to tumor recurrence and metastasis. Therefore, combination with other therapeutics is often considered. Macrophage inflammatory protein-1 alpha (MIP-1α) is a member of a family of chemoattractant cytokines that can induce the migration of monocytes, which in turn can play a role in fighting tumors. This study investigated whether intravenous injection of MIP-1α in conjunction with irradiation or sorafenib could enhance the antitumor effects on murine hepatoma. An HCa-I tumor was grown on the right thigh of each C3H/HeN mouse. Mice were then treated with 10 Gy of irradiation, sorafenib, or a combination of MIP-1α with either irradiation or sorafenib, and antitumor and antimetastatic effects were then investigated. To understand the mechanisms, changes in the level of immunological markers were also evaluated. Combination treatment of MIP-1α with irradiation or sorafenib resulted in a significant enhancement of antitumor effects, prevention of lung metastasis and increase in host survival. This was achieved by significantly increasing the levels of the immunological markers: Cluster Differentiation (CD) 8, CD107A and CD11C. We conclude that a combination treatment of MIP-1α with irradiation or sorafenib would be a useful strategy for management of hepatoma.

Aberrant DNA methylation in hepatocellular carcinoma tumor suppression (Review)

Aberrant DNA methylation leads to altered gene expression, resulting in cancerous features. Numerous tumor suppressor genes are silenced by DNA methylation during hepatocarcinogenesis. Promoter CpG island hypermethylation is an important mechanism for inactivating tumor suppressor genes in hepatocellular carcinoma (HCC). Hypermethylation of CpG islands in the p16 (INK4a) and p15 (INK4b) promoters may increase the risk of developing HCC, particularly hepatitis B virus-related HCC. Environmental factors can lead to geographic variations in the methylation status of CpG islands. Aberrant DNA methylation of CpG islands is catalyzed by DNA methyltransferases (DNMTs). Thus, abnormal variations of DNMTs can contribute to hepatocarcinogenesis. In hepatitis-related HCC, microRNAs participate in hepatocarcinogenesis by directly targeting DNMTs, during which hepatitis B virus X acts as a regulator. DNA methylation may also contribute to HCC tumorigenesis by regulating the cell cycle. Based on the importance of DNA methylation in tumor suppression of HCC, certain DNA methylations may predict the risk of tumor development, tumor staging, patient survival and HCC recurrence.

Treatment of spontaneous ruptured hepatocellular carcinoma: A single-center study

Objectives: Spontaneous rupture of hepatocarcinoma (HCC) is a fatal complication of advanced HCC and is associated with poor prognosis. However, there is no consensus on the best approach to treat hemoperitoneum due to ruptured HCC. In this paper, we evaluate and discuss the outcomes of different treatment methods employed at our center for ruptured HCC.

Methods: We reviewed the medical records of 132 patients diagnosed with ruptured HCC at our hospital from January 2003 to December 2012 and evaluated and compared the outcomes of five treatment methods for ruptured HCC: conservative treatment, surgical hemostasis, transarterial embolization (TAE), and one- and two-stage resections.

Results: There was no significant difference in the median survival time between the conservative treatment and surgical hemostasis groups. Patients in the TAE alone group had a better prognosis than those in the conservative treatment and surgical hemostasis groups. The survival time of the tumor resection group was obviously better than that of the conservative treatment, surgical hemostasis, and TAE alone groups, but no significant difference was observed between the one-stage and two-stage resection groups.

Conclusions: One-stage hepatectomy is a better option for patients with preserved liver function, whereas TAE is a better option for those with poorly preserved liver function.

Reversible phospho-Smad3 signalling between tumour suppression and fibrocarcinogenesis in chronic hepatitis B infection

Transforming growth factor (TGF)-β, type I receptor (TβRI) and c-Jun N-terminal kinases (JNK) phosphorylate Smad3 differentially to create 2 isoforms phosphorylated (p) at the COOH-terminus (C) or at the linker region (L) and regulate hepatocytic fibrocarcinogenesis. This study aimed to compare the differences between how hepatitis B virus (HBV) infection affected hepatocytic Smad3 phosphorylated isoforms before and after anti-viral therapy. To clarify the relationship between Smad3 phosphorylation and liver disease progression, we studied 10 random patients in each stage of HBV-related fibrotic liver disease (F1-4) and also 10 patients with HBV-associated HCC. To examine changes in phosphorylated Smad3 signalling before and after anti-HBV therapies, we chose 27 patients with chronic hepatitis B who underwent baseline and follow-up biopsies at 52 weeks from the start of nucleoside analogue treatments (Lamivudine 100 mg daily or Telbivudine 600 mg daily). Fibrosis stage, inflammatory activity and phosphorylated Smad3 positivity in the paired biopsy samples were compared. Hepatocytic pSmad3C signalling shifted to fibrocarcinogenic pSmad3L signalling as the livers progressed from chronic hepatitis B infection to HCC. After nucleoside analogue treatment, serum alanine aminotransferase (ALT) and HBV-DNA levels in 27 patients with HBV-related chronic liver diseases were decreased dramatically. Decrease in HBV-DNA restored pSmad3C signalling in hepatocytes, while eliminating prior fibrocarcinogenic pSmad3L signalling. Oral nucleoside analogue therapies can suppress fibrosis and reduce HCC incidence by successfully reversing phosphorylated Smad3 signalling; even liver disease progressed to cirrhosis in chronic hepatitis B patients.

Influence of hepatitis viruses on clinicopathological profiles and long-term outcome in patients undergoing surgery for hepatocellular carcinoma

BACKGROUND

The global risk of hepatocellular carcinoma (HCC) is largely due to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. In recent years, however, an increased prevalence of non-viral HCC has been noted. The clinical impact of the presence/absence of viral infections in HCC remains controversial. The present study aimed to assess the effect of hepatitis viruses on demographics, clinical and pathological features and long-term outcome in a large cohort of Romanian patients who underwent surgery for HCC.

METHODS

The study included 404 patients with HCC who had undergone resection, transplantation or radiofrequency ablation at a single institution between 2001 and 2010. The patients were divided into four groups: 85 patients with hepatitis B virus infection (HBV group), 164 patients with hepatitis C virus infection (HCV group), 39 patients with hepatitis B and C virus co-infection (HBCV group), and 116 patients without viral infection (non-BC group).

RESULTS

The patients of both HBV (56.0+/-11.3 years) and HBCV groups (56.0+/-9.9 years) were significantly younger than those of the HCV (61.0+/-8.5 years, P=0.001) and non-BC groups (61.0+/-13.0 years, P=0.002). Interestingly, the prevalence of liver cirrhosis was significantly lower in the non-BC group (47%) than in any other subsets (72%-90%, P<0.002). Furthermore, the non-BC patients were more advanced according to the Barcelona Clinic Liver Cancer stages than the patients of the HCV or HBCV groups (P<0.020); accordingly, they were more frequently assessed beyond the Milan criteria than any other groups (P=0.001). No significant differences in the disease-free or overall survival rates were observed among these groups.

CONCLUSIONS

Patients with non-viral HCC are diagnosed at advanced ages and stages, a situation plausibly due to the poor effectiveness of cancer surveillance in community practice. The presence of viral infections does not appear to impair the long-term prognosis after surgical treatment in patients with HCC; however, there is a trend for worse disease-free survival rates in HBCV patients, though statistical significance was not reached.

Prospective screening increases the detection of potentially curable hepatocellular carcinoma: results in 8,900 high-risk patients

OBJECTIVES

Historically, only 10% of patients with hepatocellular carcinoma (HCC) are diagnosed with early-stage, potentially curable disease. In this study, chronic hepatitis virus-infected patients were prospectively screened to determine: (i) the proportion of patients diagnosed with potentially curable HCC, and (ii) survival following curative therapy.

METHODS

The study included 8900 chronic hepatitis virus-infected patients enrolled in a prospective screening programme, of whom 1335 (15.0%) were infected with hepatitis B virus (HBV), 7120 (80.0%) with hepatitis C virus (HCV), and 445 (5.0%) with both HBV and HCV. Screening was conducted every 6 months and included serum alpha-fetoprotein (AFP) measurement and ultrasonography. Curative treatments included liver transplantation, resection, radiofrequency ablation and/or ethanol injection.

RESULTS

Hepatocellular carcinoma was diagnosed in 765 (8.6%) patients. Of 1602 patients with cirrhosis, 758 (47.3%) developed HCC. Curative treatment was possible in 523 (68.4%) of the 765 HCC patients. Two- and 5-year rates of overall survival in the curative treatment group were 65% and 28%, respectively, compared with 10% and 0% in the advanced disease group (P < 0.001).

CONCLUSIONS

Prospective screening of patients at high risk for the development of HCC increases the proportion of patients diagnosed with potentially curable disease. This may result in an increase in the number of longterm survivors. Screening strategies should focus on patients with chronic HBV or HCV infection who have progressed to cirrhosis because more than 40% of these patients will develop HCC.

Oridonin induces the apoptosis of metastatic hepatocellular carcinoma cells via a mitochondrial pathway

The selective induction of apoptosis is a promising strategy for cancer therapy. The antitumor effects of oridonin have been reported in several types of malignant tumors. However, the effects of oridonin on MHCC97-H cells, a highly metastatic human hepatocellular carcinoma cell line, have not been reported. The present study aimed to determine the effect of oridonin on the apoptosis of MHCC97-H cells and to identify the underlying molecular mechanisms that are involved. Compared with the untreated control cells, oridonin significantly decreased (P<0.05) cell proliferation in a concentration- and time-dependent manner. Oridonin at concentrations of 12.5, 25, 50 and 100 μM resulted in increased apoptotic Annexin V-positive and propidium iodide-negative cells by 9.5, 15.6, 22.2 and 31.7%, respectively, compared with the control groups (P<0.05). The mitochondrial membrane potential was significantly decreased by 6.0, 12.9, 18.9 and 27.1% in the MHCC97-H cells that were treated with oridonin at concentrations of 12.5, 25, 50 and 100 μM, respectively, for 24 h compared with the control groups (P<0.05). Oridonin increased the activity of caspase-3 and the expression of cleaved caspase-9 and cytochrome c in the cytoplasm and decreased the Bcl-2:Bax ratio in a concentration-dependent manner. The data indicate that oridonin inhibited the proliferation of the MHCC97-H cells by inducing apoptosis via a mitochondrial pathway. This mitochondrial pathway of apoptosis involved a reduction in the mitochondrial membrane potential and the subsequent release of cytochrome c and activation of caspase-3 and -9.

Bevacizumab and erlotinib in previously untreated inoperable and metastatic hepatocellular carcinoma

PURPOSE

To evaluate the combination of erlotinib and bevacizumab in subjects with hepatocellular carcinoma (HCC) who are not candidates for local therapy.

PATIENTS AND METHODS

Twenty-one subjects with metastatic or inoperable HCC who had not received local or systemic therapy were treated with 15 mg/kg bevacizumab every 3 weeks and a daily dose of 150 mg oral erlotinib. The primary endpoint was progression-free survival (PFS) at 27 weeks. The secondary endpoints were median time to progression and median overall survival.

RESULTS

Twenty-one subjects were enrolled. Eighteen were evaluable for the primary endpoint; all subjects were evaluable for toxicity. The median age was 60 years (range, 33 to 81 y). Five subjects (28%) were progression free at 27 weeks (90% confidence interval (CI), 12%-50%). Median time to progression was 2.57 months (95% CI, 2.13-4.20 mo). Median overall survival was 8.33 months (95% CI, 5.73-13.97 mo). Two subjects withdrew consent, and 1 subject did not have adequate baseline scans.

CONCLUSIONS

The 28% progression-free survival rate at 27 weeks was not significantly higher than the recent historical control rate of 20% observed on the placebo arm of the Sorafenib Hepatocellular Carcinoma Assessment Randomized Protocol trial (P=0.28). The combination of bevacizumab and erlotinib does not appear to have sufficient efficacy in patients with unresectable and metastatic HCC not amenable to local therapy, and may not warrant further investigation. However, this could be evaluated as an alternative to those intolerant to sorafenib therapy.

Infection with hepatitis C virus is an adverse prognostic factor after liver resection for early-stage hepatocellular carcinoma: implications for the management of hepatocellular carcinoma eligible for liver transplantation

INTRODUCTION

Recent data support liver resection (LR) as first-line approach in patients with preserved liver function who have resectable/transplantable hepatocellular carcinoma (HCC). This study was designed to evaluate the outcome of LR in patients with transplantable HCC.

METHODS

Between 1998 and 2009, 75 patients (65 men, mean age 61 ± 11 years) with HCC eligible for liver transplantation (LT) underwent LR. The underlying hepatic disease was related to hepatitis C (HCV) in 30 (40 %) patients, hepatitis B (HBV) in 15 (20 %) patients, alcohol abuse in 26 patients (36 %) and other in 10 patients (13 %). Fifty-five (73 %) patients had cirrhosis. Intermittent clamping of the hepatic pedicle was used in 41 (55 %) patients. Treatment of recurrence by salvage LT was performed in 6 (8 %) patients.

RESULTS

Operative morbidity and mortality rates were 37 and 5 % respectively. At 1, 3, and 5 years, overall (OS) and disease-free (DFS) survival rates were 81, 69,55 and 56, 31, and 21 %, respectively. On multivariate analysis, HCV infection was the only independent factor associated with decreased OS (p = 0.02). On multivariate analysis, HCV infection (p = 0.05) and intermittent hepatic pedicle clamping (p = 0.003) were associated with decreased DFS. The 1-, 3-, and 5-year OS and DFS rates in patients with HCV-related HCC were 69, 53, 38 and 50, 18, and 9% respectively.

CONCLUSIONS

Overall and disease-free survival after liver resection in patients with HCV-related HCC and preserved liver function is poor. Primary LT should be offered to these patients.

Primary pleomorphic liposarcoma of liver: a case report and review of the literature

Primary liver liposarcoma is a rare disease. The knowledge of the clinical course, management, and prognosis of primary liver liposarcoma are all limited because of its rarity. Twelve cases of primary liposarcoma of the liver have been previously reported. We present the thirteenth case, which occurred in an adult male patient. A 42-year-old male patient came to our outpatient department with complaints of pain abdomen, mass per abdomen, and weight loss. Ultrasonography showed a mass arising from the the left lobe of liver. CT abdomen showed a heterogenous enhancing mass from left lobe of liver with multiple cystic and necrotic areas compressing the stomach and spleen with no evidence of metastasis. Differential diagnosis included adenoma and primary malignancy. Exploratory laparotomy and resection were done. HPE was found to be pleomorphic liposarcoma of liver.

Inverse relationship between cirrhosis and massive tumours in hepatocellular carcinoma

BACKGROUND

A subset of patients with hepatocellular carcinoma (HCC) present with massive tumours. It is unknown why certain patients develop these massive tumours, and whether this presentation is specific to the underlying viral aetiology or patient demographics such as gender, race and age.

METHODS

All patients with HCC at Bellevue Hospital Center, New York from 1998 to 2012 were identified and relevant demographic and clinical information was collected. Computed tomography/magnetic resonance imaging (CT/MRI) images were reviewed and the maximal tumour diameter on axial sections was recorded. Cirrhosis was defined histologically or by radiographical criteria. The two cohorts of massive and non-massive HCC were compared.

RESULTS

A total of 361 patients with HCC were identified, of which 58 were categorized as having a massive HCC using a 13 cm size cut-off. Univariate and multivariate analysis demonstrated a significant association of massive HCC with age <40 years; hepatitis B or Asian ethnicity; and a lack of cirrhosis or platelet count >100.

DISCUSSION

Massive HCC represents a tumour subtype that is associated with young, chronic hepatitis B carriers with non-cirrhotic livers. The clinical implications of this finding are that patients with massive HCC are typically excellent resection candidates barring the presence of gross vascular invasion or distant metastases.

Experimental studies and clinical experiences on treatment of secondary hypersplenism with extracorporeal high-intensity focused ultrasound

The aim of this study is to investigate the efficacy and safety of extracorporeal high-intensity focused ultrasound (HIFU) in treatment of hypersplenism. Fifteen adult dogs, weighing 13-18 kg were divided into three groups: sham group, SVL group undergoing splenic vein ligation (SVL) after laparotomy, and SVL + HIFU group receiving SVL followed by extracorporeal HIFU. Pathologic and hematologic analyses were performed. We also reviewed the clinical data of 19 patients with secondary hypersplenism caused by liver cirrhosis or hepatocellular carcinoma who underwent extracorporeal HIFU. Extracorporeal HIFU significantly diminished the volume of the spleen of animals, coupled with occurrence of coagulation necrosis and fibrosis in the target area. Both platelet and red blood cell counts were significantly restored by HIFU intervention. Similarly, HIFU treatment improved the hematologic parameters in patients with hypersplenism, and no major complications were encountered. Extracorporeal HIFU intervention is effective and safe in managing secondary hypersplenism.

Acceptable toxicity after stereotactic body radiation therapy for liver tumors adjacent to the central biliary system

PURPOSE

To evaluate biliary toxicity after stereotactic body radiation therapy (SBRT) for liver tumors.

METHODS AND MATERIALS

Among 297 consecutive patients with liver tumors treated with SBRT of 35 to 50 Gy in 5 fractions, patients who were irradiated with >20 Gy to the central biliary system (CBS), including the gallbladder, and had follow-up times >6 months were retrospectively analyzed. Toxicity profiles, such as clinical symptoms and laboratory and radiologic data especially for obstructive jaundice and biliary infection, were investigated in relation to the dose volume and length relationship for each biliary organ.

RESULTS

Fifty patients with 55 tumors were irradiated with >20 Gy to the CBS. The median follow-up period was 18.2 months (range, 6.0-80.5 months). In the dose length analysis, 39, 34, 14, and 2 patients were irradiated with >20 Gy, >30 Gy, >40 Gy, and >50 Gy, respectively, to >1 cm of the biliary tract. Seven patients were irradiated with >20 Gy to >20% of the gallbladder. Only 2 patients experienced asymptomatic bile duct stenosis. One patient, metachronously treated twice with SBRT for tumors adjacent to each other, had a transient increase in hepatic and biliary enzymes 12 months after the second treatment. The high-dose area >80 Gy corresponded to the biliary stenosis region. The other patient experienced biliary stenosis 5 months after SBRT and had no laboratory changes. The biliary tract irradiated with >20 Gy was 7 mm and did not correspond to the bile duct stenosis region. No obstructive jaundice or biliary infection was found in any patient.

CONCLUSIONS

SBRT for liver tumors adjacent to the CBS was feasible with minimal biliary toxicity. Only 1 patient had exceptional radiation-induced bile duct stenosis. For liver tumors adjacent to the CBS without other effective treatment options, SBRT at a dose of 40 Gy in 5 fractions is a safe treatment with regard to biliary toxicity.

Hepatitis B virus X protein upregulates mTOR signaling through IKKβ to increase cell proliferation and VEGF production in hepatocellular carcinoma

Hepatocellular carcinoma (HCC), a major cause of cancer-related death in Southeast Asia, is frequently associated with hepatitis B virus (HBV) infection. HBV X protein (HBx), encoded by a viral non-structural gene, is a multifunctional regulator in HBV-associated tumor development. We investigated novel signaling pathways underlying HBx-induced liver tumorigenesis and found that the signaling pathway involving IκB kinase β (IKKβ), tuberous sclerosis complex 1 (TSC1), and mammalian target of rapamycin (mTOR) downstream effector S6 kinase (S6K1), was upregulated when HBx was overexpressed in hepatoma cells. HBx-induced S6K1 activation was reversed by IKKβ inhibitor Bay 11-7082 or silencing IKKβ expression using siRNA. HBx upregulated cell proliferation and vascular endothelial growth factor (VEGF) production, and these HBx-upregulated phenotypes were abolished by treatment with IKKβ inhibitor Bay 11-7082 or mTOR inhibitor rapamycin. The association of HBx-modulated IKKβ/mTOR/S6K1 signaling with liver tumorigenesis was verified in a HBx transgenic mouse model in which pIKKβ, pS6K1, and VEGF expression was found to be higher in cancerous than non-cancerous liver tissues. Furthermore, we also found that pIKKβ levels were strongly correlated with pTSC1 and pS6K1 levels in HBV-associated hepatoma tissue specimens taken from 95 patients, and that higher pIKKβ, pTSC1, and pS6K1 levels were correlated with a poor prognosis in these patients. Taken together, our findings demonstrate that HBx deregulates TSC1/mTOR signaling through IKKβ, which is crucially linked to HBV-associated HCC development.

Hepatitis B virus X protein upregulates mTOR signaling through IKKβ to increase cell proliferation and VEGF production in hepatocellular carcinoma

Hepatocellular carcinoma (HCC), a major cause of cancer-related death in Southeast Asia, is frequently associated with hepatitis B virus (HBV) infection. HBV X protein (HBx), encoded by a viral non-structural gene, is a multifunctional regulator in HBV-associated tumor development. We investigated novel signaling pathways underlying HBx-induced liver tumorigenesis and found that the signaling pathway involving IκB kinase β (IKKβ), tuberous sclerosis complex 1 (TSC1), and mammalian target of rapamycin (mTOR) downstream effector S6 kinase (S6K1), was upregulated when HBx was overexpressed in hepatoma cells. HBx-induced S6K1 activation was reversed by IKKβ inhibitor Bay 11-7082 or silencing IKKβ expression using siRNA. HBx upregulated cell proliferation and vascular endothelial growth factor (VEGF) production, and these HBx-upregulated phenotypes were abolished by treatment with IKKβ inhibitor Bay 11-7082 or mTOR inhibitor rapamycin. The association of HBx-modulated IKKβ/mTOR/S6K1 signaling with liver tumorigenesis was verified in a HBx transgenic mouse model in which pIKKβ, pS6K1, and VEGF expression was found to be higher in cancerous than non-cancerous liver tissues. Furthermore, we also found that pIKKβ levels were strongly correlated with pTSC1 and pS6K1 levels in HBV-associated hepatoma tissue specimens taken from 95 patients, and that higher pIKKβ, pTSC1, and pS6K1 levels were correlated with a poor prognosis in these patients. Taken together, our findings demonstrate that HBx deregulates TSC1/mTOR signaling through IKKβ, which is crucially linked to HBV-associated HCC development.

SERPINB3 expression on B-cell surface in autoimmune diseases and hepatitis C virus-related chronic liver infection

SERPINB3 is a serine protease inhibitor with pleiotropic functions. It is involved in several physiological and pathological processes, where it appears to exert antiapoptotic effects. Little is known about its expression on immune system cells, the major players in mechanisms of viral defense and autoimmune disorders. The aim of this study was to characterize the expression of SERPINB3 on the surface of peripheral blood mononuclear cell subsets in both normal subjects and in patients with chronic viral infections and autoimmune diseases. Sixty-two patients were analyzed by flow cytometric analysis, including 45 with hepatitis C virus (HCV)-related chronic liver disease and 17 with systemic lupus erythematosus (SLE). SERPINB3 was expressed on B lymphocytes in 79% of the controls, in 32% of the HCV-infected patients and in none of the SLE patients. Surface localization of SERPINB3 was confirmed by confocal microscopy. SERPINB3 positivity was associated with CD27 reactivity (r = 0.98), but not to other activation molecules (CD69, CD71, CD86 and CXCR3). SERPINB3 is physiologically expressed on the surface of CD27(+) B lymphocytes, but its expression is reduced in HCV viral infection and not detectable in SLE patients. These results may suggest a role for SERPINB3 in B-cell defects typically found in viral infections and autoimmune disorders.

Effect of mosapride citrate on gastric emptying in interferon-induced gastroparesis

BACKGROUND AND OBJECTIVES

Gastroparesis, a gastrointestinal autonomic neuropathy, is a common adverse reaction in chronic hepatitis C (CHC) patients receiving interferon therapy. Current therapeutic options are limited. We evaluated the efficacy of mosapride for IFN-induced gastroparesis.

METHODS

Twenty-four consecutive CHC patients were randomly assigned to either the control group, which received pegylated interferon α-2b at 1.5 μg/kg/week and ribavirin at 600-1,000 mg/day, depending on body weight (PegIFN/RBV), or the mosapride group, which received PegIFN/RBV plus mosapride at 15 mg/person/day. The solid-phase gastric emptying half-times (T1/2) of the total, proximal, and distal stomach (scintigraphy) and digestive symptoms (questionnaire) were measured within one week before and four weeks after initiation of the assigned therapy. The test meal comprised a 200-g pancake containing Tc-99m diethylenetriamine pentaacetic acid.

RESULTS

In the control group, after PegIFN/RBV initiation, a significant increase was observed in the total T1/2 (before: 84.0 ± 22.1 min versus after: 100.8 ± 28.9 min, P = 0.03), the distal T1/2 (before: 95.3 ± 32.2 min versus after: 115.3 ± 41.4 min, P = 0.03), and digestive symptom score (before: 3.2 ± 1.4 versus after: 8.1 ± 4.8, P = 0.02); proximal T1/2 change was not significant. In the mosapride group, no significant delays were observed in the total, proximal, and distal T1/2 values; the change in symptom scores was not significant.

CONCLUSIONS

Mosapride improved total and distal gastric motility in IFN-induced gastroparesis, and consequently relieved symptoms.

Incidence and risk factors for hepatocellular carcinoma in Texas Latinos: implications for prevention research

Background

Hepatocellular carcinoma (HCC) is increasing in the U.S. despite a decline in cancer overall. Latinos have higher rates of HCC than the general population according to the Surveillance, Epidemiology, and End Results (SEER) Program. Not included in SEER, Texas Latinos make up one-fifth of the U.S. Latino population. To determine whether HCC incidence differs among U.S. and Texas Latinos, this descriptive study compares HCC incidence from 1995 through 2006 among three Latino populations: U.S. SEER, Texas overall and a South Texas subset. To identify lines of prevention research, we compare prevalence of known HCC risk factors among these Latino groups.

Methods

Data were collected from the U.S. SEER Program, Texas Cancer Registry and Texas Department of State Health Services (TDSHS). Annual age-specific and age-adjusted HCC incidence rates, annual percent changes (APCs) and 95% confidence intervals were calculated as well as prevalence of obesity, diabetes, heavy alcohol use and cigarette smoking.

Results

Of the three Latino groups compared, South Texas Latinos had the highest age-adjusted HCC incidence rates and SEER Latinos had the lowest (10.6/100,000 (10.1–11.1) and 7.5/100,000 (7.2–7.7), respectively). HCC incidence significantly increased over time (APCs>0) among Latinos in all three geographic groups. Between 1995 and 2006, there was an increase in obesity among all three populations, and obesity was highest among South Texas Latinos. Diabetes increased among U.S. Latinos, and Latino women in South Texas had significantly higher diabetes prevalence than U.S. Latino women. Cigarette smoking and heavy alcohol use were similar among groups.

Conclusions

The incidence of HCC among Latinos in South Texas is higher than elsewhere in the United States. Higher rates of HCC among Texas and South Texas Latinos may be associated with greater prevalence of obesity and diabetes, risk factors for HCC that are amenable to intervention.

Declining rates of hepatocellular carcinoma in urban Shanghai: incidence trends in 1976-2005

In China, hepatocellular carcinoma (HCC) incidence rates in several registry catchment populations are amongst the highest worldwide. The incidence rates in urban Shanghai were analyzed between 1976 and 2005 to describe and interpret the time trends. Age-specific and age-standardized rates were calculated and graphically presented. An age-period-cohort model was fitted to assess the effects of age at diagnosis, calendar period, and birth cohort on the changing HCC incidence rates. In total, 35,241 and 13,931 men and women were diagnosed with HCC during 1976-2005 in urban Shanghai. The age-standardized incidence rates in urban Shanghai were 33.9 per 10(5) among men and 11.4 per 10(5) among women in 1976-1980, but decreased in both sexes to 25.8 per 10(5) and 8.5 per 10(5), respectively by 2001-2005. Accelerating rates in birth cohorts born in the early-1930s and decelerating rates circa 1945 were observed in both sexes, with further accelerations noted in the late-1950s (in women) and early-1960s (in men). Given the parameterization, increases in risk of HCC were seen in successive male and female generations between 1900 and 1935, followed by a further increase among successive cohorts born around 1960, with a reduction in risk in the most recent generations. The incidence rates of HCC in urban Shanghai from 1976 to 2005 have declined in both sexes, with the complex but similar patterns observed in successive generations suggestive of a shared changing prevalence in risk factors in men and women, with a role possibly for HBV interventions reducing risk of HCC in cohorts born after 1960.

Risk factors for hepatocellular carcinoma in a cohort infected with hepatitis B or C

BACKGROUND AND AIM

The incidence of hepatocellular carcinoma (HCC) has increased in Australia in recent decades, a large and growing proportion of which occurs among a population chronically infected with hepatitis B virus (HBV) or hepatitis C virus (HCV). However, risk factors for HCC among these high-risk groups require further characterization.

METHODS

We conducted a population-based cohort study using HBV and HCV cases notified to the New South Wales Health Department between 2000 and 2007. These were linked to cause of death data, HIV/AIDS notifications, and hospital records. Proportional hazards regression was used to identify significant risk factors for developing HCC.

RESULTS

A total of 242 and 339 HCC cases were linked to HBV (n = 43 892) and HCV (n = 83 817) notifications, respectively. For both HBV and HCV groups, being male and increasing age were significantly associated with risk of HCC. Increasing comorbidity score indicated high risk, while living outside urban areas was associated with lower risk. Hazard ratios for males were two to three times those of females. For both HBV and HCV groups, cirrhosis, alcoholic liver disease, and the interaction between the two were associated with significantly and considerably elevated risk.

CONCLUSION

This large population-based study confirms known risk factors for HCC. The association with older age highlights the potential impact of HBV and HCV screening of at-risk groups and early clinical assessment. Additional research is required to evaluate the impact of improving antiviral therapy on HCC risk.

Prevalence of hepatitis B in the southeast of China: a population-based study with a large sample size

OBJECTIVE

Hepatitis B is a major public health problem in China. However, in the past 10 years, estimates of the prevalence of hepatitis B virus (HBV) have been sparse, with results that do not always agree. The purpose of this study was to investigate the epidemiology of HBV in adults and to provide the most recent baseline data for planning and monitoring of health.

METHODS

The prevalence of HBV was determined in a community-based, cross-sectional, age-stratified sample of adults (aged 20 years or older). The study population was selected using random multistage cluster sampling. Demographic information and serological samples were obtained from 19 933 participants.

RESULTS

The prevalence of anti-HBV core antibody, HBV surface antigen (HBsAg), and anti-HBV surface antibody was 38.6, 7.9, and 44.9%, respectively. We found statistically significant differences in hepatitis B infection between men and women (P<0.001). The prevalence of HBV infection increased with age. The rates of HBsAg positivity and HBV infection in individuals living on an island were higher than those of individuals living in plains. The alanine aminotransferase level was elevated (≥38 IU/l) in 15.7 and 7.2% of HBsAg-positive and HBsAg-negative patients; the proportion of elevated alanine aminotransferase was markedly higher in men (12.7%) than in women (4.7%) (P<0.001). The α-fetoprotein-positive rate was 2% in HBsAg-positive individuals who were aged 30 years or older.

CONCLUSION

Borderline intermediate/high endemicity was found among adults in the northern region of Zhejiang Province. The vaccination program has contributed to a reduction in infection over the last 20 years, although further efforts are required to turn the region into a 'low-endemicity' area.

Rising incidence and demographics of hepatocellular carcinoma in the USA: what does it mean?

The incidence of hepatocellular carcinoma (HCC) is increasing in the USA. Traditional factors, such as hepatitis C and hepatitis B, along with new emerging trends suggest that the incidence is not only increasing, but is also likely to be under-represented in the current literature. Emerging knowledge of its incidence and epidemiology reflects an increased incidence in younger patients and certain ethnic groups. Without a clear treatment algorithm for this complex cancer, therapy and its utilization remain unclear.

Inhibition of hepatitis C virus 3a genotype entry through Glanthus Nivalis Agglutinin

Background

Hepatitis C Virus (HCV) has two envelop proteins E1 and E2 which is highly glycosylated and play an important role in cell entry. Inhibition of virus at entry step is an important target to find antiviral drugs against HCV. Glanthus Nivalis Agglutinin (GNA) is a mannose binding lectin which has tendency for specific recognition and reversible binding to the sugar moieties of a wide variety of glycoproteins of enveloped viruses.

Results

In the present study, HCV pseudoparticles (HCVpp) for genotype 3a were produced to investigate the ability of GNA to block the HCV entry. The results demonstrated that GNA inhibit the infectivity of HCVpp and HCV infected serum in a dose-dependent manner and resulted in 50% reduction of virus at 1 ± 2 μg concentration. Molecular docking of GNA and HCV glycoproteins (E1 and E2) showed that GNA inhibit HCV entry by binding N-linked glycans.

Conclusion

These results demonstrated that targeting the HCV glycans is a new approach to develop antiviral drugs against HCV.

Inhibition of HCV 3a core gene through Silymarin and its fractions

Hepatitis C is a major health problem affecting 270 million individuals in world including Pakistan. Current treatment regimen, interferon alpha and ribavirin only cure half of patients due to side effects and high cost.

RESULTS

In the present study Silybum marianum (Milk thistle) seeds were collected, extracted and analyzed against HCV 3a core gene by transiently transfecting the liver cells with HCV core plasmid. Our results demonstrated that Silymarin (SM) dose dependently inhibit the expression or function of HCV core gene at a non toxic concentration while the GAPDH remained constant. To identify the active ingredient, SM was fractioned by thin layer chromatography (TLC), column chromatography and HPLC. Purified fractions were tested for HCV core gene and western blotting results showed that two factions of SM (S1 and S2) inhibit HCV 3a core expression or function in liver cells

CONCLUSION

Our results suggest SM and its fractions (S1 and S2) inhibit HCV core gene of 3a genotype and combination of SM and its fractions with interferon will be a better option to treat HCV infection.

Liver cancer: Targeted future options

Hepatocellular carcinoma (HCC) has a poor prognosis and systemic chemotherapies have disappointing results. The increasing knowledge of the molecular biology of HCC has resulted in novel targets, with the vascular endothelial growth factor and epidermal growth factor receptor (EGFR)-related pathways being of special interest. New blood vessel formation (angiogenesis) is essential for the growth of solid tumors. Anti-angiogenic strategies have become an important therapeutic modality for solid tumors. Several agents targeting angiogenesis-related pathways have entered clinical trials or have been already approved for the treatment of solid tumors. These include monoclonal antibodies, receptor tyrosine kinase inhibitors and immunomodulatory drugs. HCC is a highly vascular tumor, and angiogenesis is believed to play an important role in its development and progression. This review summarizes recent advances in the basic understanding of the role of angiogenesis in HCC as well as clinical trials with novel therapeutic approaches targeting angiogenesis and EGFR-related pathways.

A simulation shows that early treatment of chronic hepatitis B infection can cut deaths and be cost-effective

Chronic hepatitis B affects between 800,000 and two million people in the United States and causes 4,000 deaths each year. Yet the costs and benefits of treatment have not been fully evaluated. Using a model that simulates disease progression, we compare treatment programs for hepatitis B that start at an early stage of the disease to treatment that begins at a late stage. Our analysis concludes that early hepatitis B care can improve health, reduce premature deaths, and prevent expensive complications, making it highly cost-effective in the long term. Our results demonstrate the importance of screening for hepatitis B among at-risk groups and then linking screening to treatment. They also illustrate how predictive models can be used to evaluate strategies for improving access to care.

Disparities in hepatocellular carcinoma survival among Californians of Asian ancestry, 1988 to 2007

BACKGROUND

Hepatocellular carcinoma (HCC) represents a significant health disparity affecting Asian Americans, a population comprised of distinct ethnic groups. The purpose of this article is to analyze Californians of Asian ancestry with HCC with respect to socioeconomic status, demographic factors, stage of disease, treatment received, and survival.

METHODS

To investigate ethnic differences in survival, we analyzed ethnically disaggregated data from 6,068 Californians of Asian ancestry with HCC diagnosed in 1988 to 2007 and reported to the California Cancer Registry.

RESULTS

Compared with the average of all ethnic groups, cause-specific mortality was significantly higher among Laotian/Hmong [hazard ratio, 2.08; 95% confidence interval (95% CI), 1.78-2.44] and Cambodian patients (hazard ratio, 1.26; 95% CI, 1.06-1.51), groups with higher proportions of their populations at low levels of socioeconomic status; in addition, Laotian/Hmong patients disproportionately presented at later stages of disease, with only 3% receiving local surgical treatment, resection, or liver transplantation. After adjustment for time of diagnosis, age at diagnosis, gender, geographic region, stage at diagnosis, type of surgery, and socioeconomic status, survival disparities remained for both groups (Laotian/Hmong hazard ratio, 1.51; 95% CI, 1.28-1.79; Cambodian hazard ratio, 1.24; 95% CI, 1.03-1.48).

CONCLUSIONS

Our hypothesis that survival outcomes would differ by ethnicity was verified.

IMPACT

Research is needed not only to develop more effective treatments for HCC but also to develop community-based interventions to recruit Asian Americans, particularly Laotian/Hmong and Cambodians, for hepatitis B screening and into medical management to prevent or detect this tumor at an early stage.