Antibody to hepatitis-B core antigen in patients with primary hepatic carcinoma

Beasley's 1981 paper: The power of a well-designed cohort study to drive liver cancer research and prevention

The 1981 Lancet paper by Beasley et al., "Hepatocellular carcinoma and hepatitis B virus. A prospective study of 22707 men in Taiwan" is a seminal publication that clearly demonstrated that chronic infection with hepatitis B virus (HBV), as measured by seropositivity for the hepatitis B surface antigen (HBsAg), preceded the development of hepatocellular carcinoma (HCC). In doing so, this study paved the way for liver cancer prevention efforts through the implementation of hepatitis B vaccination programs. In this commentary, we will describe the discovery of HBV, which led to the study by Beasley et al.; summarize the major findings of the Beasley paper and its implications; discuss the importance of well-designed cohort studies for prevention activities; and consider the ramifications of the Beasley study and the work that has followed since.

Possible origins and evolution of the hepatitis B virus (HBV)

All members of the family Hepadnaviridae are primarily viruses which contain double-stranded DNA genomes that are replicated via reverse transcription of a pregenomic RNA template. There are two subgroups within this family: mammalian and avian. The avian member's include the duck hepatitis B virus (DHBV), heron hepatitis B virus, Ross goose hepatitis B virus, stork hepatitis B virus and the recently identified parrot hepatitis B virus. More recently, the detection of endogenous avian hepadnavirus DNA integrated into the genomes of zebra finches has revealed a deep evolutionary origin of hepadnaviruses that was not previously recognised, dating back over 40 million years ago. The non-primate mammalian members of the Hepadnaviridae include the woodchuck hepatitis virus (WHV), the ground squirrel hepatitis virus and arctic squirrel virus, as well as the recently described bat hepatitis virus. The identification of hepatitis B virus (HBV) in higher primates such as chimpanzee, gorilla, orangutan, and gibbons that cluster with the human genotypes further implies a more complex origin of this virus. By studying the molecular epidemiology of HBV in indigenous and relict populations in Asia-Pacific we propose a model for the origin and evolution of HBV that involves multiple cross-species transmissions and subsequent recombination events on a background of genotype C HBV infection.

Hepatitis B-related hepatocellular carcinoma: epidemiological characteristics and disease burden

Worldwide, 350 million people are chronically infected with hepatitis B virus (HBV) who are at greater risk of hepatocellular carcinoma (HCC) compared with uninfected people. The relative risks of HCC among people infected with HBV ranges from 5 to 49 in case-control studies and from 7 to 98 in cohort studies. More than 50% of HCC cases worldwide and 70-80% of HCC cases in highly HBV endemic regions are attributable to HBV. Incidence of HCC (per 100,000 person/year) among people with chronic HBV infection ranges from 400 to 800 in male and from 120 to 180 in female. Factors associated with increased risk of HCC include demographic characteristics (male sex and older age), lifestyles (heavy alcohol consumption and smoking), viral factors (genotype C, D F, high level of HBV DNA, core/precore mutation) and clinical factors (cirrhosis, elevated alpha-fetoprotein (AFP) and alanine aminotransferase (ALT)). HBV-related HCC has extremely poor prognosis with median survival less than 16 months. Survival rates of HBV-related HCC ranged from 36% to 67% after 1 year and from 15% to 26% after 5 year of diagnosis. Older age, liver function impairment, vascular invasion, tumour aggressiveness and elevated AFP are associated with HCC survival. Global burden of HBV-related liver disease is still a major challenge for public health in the 21st century. While decreases in incidence of HBV infection have been observed in birth cohorts following the introduction of universal infant HBV vaccination programme, HBV-related HCC incidence in is projected to increase for at least two decades because of the high prevalence of chronic HBV infection and prolonged latency to HCC development. To reduce HBV-related HCC continued expansion of universal infant HBV vaccination is required along with antiviral therapy targeted to those individuals at highest risk of HCC. Broad public health strategies should include routine testing to identify chronic HBV infection, improved health infrastructures including human resource to provide diagnosis and treatment assessment.

The woodchuck model of hepatitis B virus infection

The woodchuck hepatitis virus (WHV) was the first of the mammalian and avian hepadnaviruses described after discovery of the virus of hepatitis B (HBV). Woodchucks chronically infected with WHV develop progressively severe hepatitis and hepatocellular carcinoma, which present as lesions that are remarkably similar to those associated with HBV infection in humans. The initial virological studies and studies of pathogenesis utilized woodchucks that had been trapped in the wild and had acquired WHV infection naturally. Research with wild woodchucks was complicated by lack of knowledge of their backgrounds (e.g., dietary history, exposure to parasites or environmental toxins, and source and duration of WHV infection). Breeding colonies of woodchucks have been established and maintained in laboratory animal facilities, and laboratory-reared woodchucks are superior for experimental studies of pathogenesis or hepatocarcinogenesis. It is possible to infect neonatal woodchucks born in the laboratory with standardized inocula and produce a high rate of chronic WHV carriers that are useful for controlled investigations. WHV has been shown experimentally to cause hepatocellular carcinoma, supporting conclusions based on epidemiological and molecular virological studies that HBV is an important etiological factor in human hepatocarcinogenesis. Chronic WHV carrier woodchucks have become a valuable animal model for the preclinical evaluation of antiviral therapy for HBV infection, providing useful pharmacokinetic and pharmacodynamic results in a relevant animal disease model. It also has been shown that the pattern of toxicity and hepatic injury observed in woodchucks treated with certain fluorinated pyrimidines is remarkably similar to that observed in humans that were treated with the same drugs, suggesting the woodchuck has significant potential for the preclincial assessment of antiviral drug toxicity.

Animal models of hepadnavirus-associated hepatocellular carcinoma

Animal models of hepatitis B virus infection have been valuable for determining the mechanisms of hepadnavirus replication, for studies of pathogenesis, and for investigations of viral hepatocarcinogenesis. The woodchuck model also seems to be useful in the discovery and development of antiviral drugs to treat HBV infection and for testing new forms of immunotherapy. In particular, the woodchuck seems to be ideal for studying the effect of antiviral treatment and immunotherapy on the outcome of hepadnavirus infection and on survival. The median life expectancy of experimentally infected, chronic WHV carriers is approximately 29 months, and almost all develop HCC. New types of prophylaxis or therapy can be evaluated under controlled experimental conditions, in a relevant animal model, and within a reasonable time frame.

Past exposure to hepatitis B virus as a risk factor for hepatocellular carcinoma in patients with chronic liver disease

The aim of the study was to determine whether past exposure to hepatitis B virus (HBV) influences the risk of the development of hepatocellular carcinoma (HCC) in Japanese patients with chronic liver disease (CLD). We conducted a hospital-based case-control study of 141 HCC patients with CLD and 151 controls with CLD but without HCC. Past exposure to HBV was assessed by antibody to hepatitis B core antigen (anti-HBc) positivity. Ninety-two patients (65%) with HCC were anti-HBc positive compared with 65 patients (43%) with CLD alone (P < 0.01). A multivariate analysis using logistic regression modelling revealed that anti-HBc positivity significantly increased the risk of the development of HCC [odds ratio (OR) 2.0, P = 0.01]. In the anti-HBc-positive patients, a significantly increased risk of HCC was seen among the patients positive for anti-HBc alone (OR, 2.6; P < 0.01). However, a significant OR was not obtained among the patients with a transient HBV infection implied by positivity for both antibody to hepatitis B surface antigen and anti-HBc (OR, 1.5; P = 0.48). These results indicate that past exposure to HBV is a risk factor for HCC in Japanese CLD patients, especially when they have no serological evidence of immunity to HBV.

Comparative study of three doses of interferon-alpha 2a in chronic active hepatitis B. The International Hepatitis Trial Group

To determine the efficacy of interferon-alpha 2a in chronic active hepatitis B, 238 patients were randomly divided, into four groups: three groups received either 2.5 MIU m-2, 5.0 MIU m-2 or 10.0 MIU m-2, three times weekly by intramuscular injection for 12-24 weeks; and a control group received no treatment. Patients were followed for up to 12 months after treatment was discontinued. There was a statistically significant difference in response [clearance of hepatitis B e antigen (HBeAg) and hepatitis B viral DNA (HBV-DNA)] between treated and untreated patients (37 vs 13%) but no statistically significant difference was seen between treatment groups (33%, 34% and 43% for the 2.5, 5.0 and 10.0 MIU m-2 groups, respectively). A transient rise in transaminases (seroconversion hepatitis) was seen in responders, but levels returned to within the normal range after response to treatment. In patients responding to interferon therapy there was a significant reduction in the severity of the hepatitis. Interferon-alpha 2a was generally well tolerated with respect to vital signs and laboratory parameters.

High prevalence of hepatitis B and C viral markers in Japanese patients with hepatocellular carcinoma

In order to assess the etiologic role of hepatitis C virus (HCV) as well as hepatitis B virus (HBV) in the etiology of HCC, we compared the prevalence of HCV-related antibodies (anti-C100-3, anti-CP9, anti-CP10) and HBV-related markers (HBsAg, anti-HBs, anti-HBc) in sera of patients with liver cirrhosis (LC) with (n = 62) and without (n = 54) hepatocellular carcinoma (HCC). In HBsAg-negative cases, at least one HCV-related marker (including HCV RNA) was detected in 92.3% (48/52) of HCC cases and in all of the 44 LC cases without HCC, with no significant difference between these two groups. In HBsAg-positive cases, the prevalence of either one of these HCV-related markers was 40.0% (4/10) both in patients with and without HCC, and there was no significant difference between these two groups. Moreover, in HBsAg-negative cases and 11 cases of positive HCV-related markers, the prevalence of anti-HBs and/or anti-HBc was significantly higher in LC patients with HCC (85.4%) than those without HCC (43.2%, P < 0.001). These results show a high prevalence of hepatitis B and C viral markers in Japanese patients with HCC and further indicate that previous HBV infection is a risk factor in the occurrence of HCC in HBsAg-negative LC and LC with positive HCV-related markers.

Prevalence of hepatitis C virus antibodies in chronic liver disease and hepatocellular carcinoma patients in India

The prevalence of antibodies to hepatitis C virus (HCV) was investigated in 129 patients with chronic liver disease (85 with chronic active hepatitis and 44 with cirrhosis) and 53 patients with hepatocellular carcinoma. The commercially available second generation anti-HCV enzyme immunoassay kit was used. Antibodies to hepatitis C virus were detected in 16.2% of the patients with chronic liver disease and in 15.1% with hepatocellular carcinoma. Of the HCV positive patients in all groups 51.7% were positive for hepatitis B virus (HBV) markers indicating present or past infection. Prevalence of HBV markers in all the three groups (CAH, cirrhosis and HCC) was higher as compared with anti-HCV prevalence. These results suggest that HCV infection may not be a major cause of chronic liver disease and hepatocellular carcinoma in India and indicate the presence of other aetiological agents.

A high prevalence of antibody to the hepatitis C virus in patients with hepatocellular carcinoma in Japan

In Japan, hepatocellular carcinoma (HCC) is one of the most prevalent cancers, with a reported fatality rate showing a consistent and significant increase in the last decade. At most, only 25% of HCC cases are positive for the hepatitis B surface antigen (HBsAg). To investigate a potential role for hepatitis C virus (HCV) in the development of HCC, sera from 105 HBsAg-negative HCC patients were collected from five districts of Japan and assayed for antibody to HCV antigen (HCVAb). A large number of these patients (76.2%) were found to be positive for the HCVAb in comparison with the reported prevalence in sera from blood donors (1.1%). A history of blood transfusion was found in 39.6% of the cases positive for HCVAb, which was significantly different to the lower rate (4.7%) observed in HCC patients who were both positive for HBsAg and negative for HCVAb (P less than 0.001).

Clustering of hepatocellular carcinoma in Alaska Native families

Alaska Natives have a high incidence of hepatocellular carcinoma (HCC), with regional, ethnic, village, and familial clustering. During 1969-1988, 15 of the 45 incident cases of HCC in Alaska Natives occurred in 5 families. This report presents epidemiologic, virologic, and immunogenetic data on these 5 families. The results of hepatitis B virus (HBV) serologic testing indicates that HBV infection was an important factor in 4 of the 5 families. Human lymphocyte antigen (HLA) testing was performed in 3 families. The HLA results are reviewed in relationship to the familial clustering of HCC.

The pattern of childhood malignancy in eastern Nigeria

The pattern of childhood malignancies in the developing countries of Africa is characterized by a high incidence of lymphoma and a low incidence of leukaemia. The converse is the case in the developed countries of Europe and North America. A high incidence of lymphoma with low incidence of leukaemia has been associated with poor living standards. The clinical records of 257 children admitted with malignant disease to the University of Nigeria Teaching Hospital, Enugu between January 1978 and December 1982 were studied retrospectively to determine the pattern of malignant diseases amongst these children. The lymphomas were the commonest tumours, constituting nearly 40% of the total, followed by Wilm's tumour (14.0%), leukaemia (12.9%) and CNS tumours (9.7%). However, the incidence of lymphoma was lower while the incidence of leukaemia was higher than in previous reports from other parts of Nigeria and Africa. The rarity of Ewing's tumour, histocytosis-X and testicular tumours in African children is confirmed in the present study.

Constitutive heterochromatin polymorphism and chromosome damage in viral hepatitis

The frequencies of chromosomal aberrations and sister-chromatid exchanges (SCEs) were scored in relation to constitutive heterochromatin in 100 patients with viral hepatitis B, 100 patients with viral hepatitis A and 100 age- and sex-matched normal controls. 23.4%, 15% and 4% of the cells showed chromosomal aberrations in patients with hepatitis B, hepatitis A and normal controls respectively. Non-random involvement of chromosomal aberrations were also noted in chromosome 1 of patients with hepatitis B and A as compared to normal controls. The frequencies of SCEs (mean +/- S.D.) were found to be 10.40 +/- 2.83 in hepatitis B and 8.70 +/- 2.34 in hepatitis A. These values were significantly higher than the SCE frequency (mean +/- S.D.) of 5.88 +/- 2.25 observed in normal controls (P less than 0.001). The intra-chromosomal distribution of SCEs revealed a relatively increased incidence of SCEs in chromosome 1 of patients with hepatitis B and A as compared to normal controls. Analysis of constitutive heterochromatin polymorphism showed chromosome 1 qh+ to be the most frequent variant in patients with hepatitis B and A as compared to normal controls. The increased involvement of C-band variant 1 qh+ in patients with hepatitis B and A as compared to normal controls may indicate that extra heterochromatin offers additional sites for viral integration.

Fibrolamellar carcinoma of the liver: an immunohistochemical study of nineteen cases and a review of the literature

Hepatocellular carcinoma (HCC) is a rapidly fatal neoplasm of high worldwide prevalence. Fibromellar carcinoma (FLC), a variant of HCC, lacks the dismal prognosis of "ordinary" HCC (O-HCC) and is characterized by a diagnostic histologic appearance. The current study analyzes the clinical characteristics, immunohistochemistry, and treatment of nineteen cases of FLC. These data, together with a detailed review of the literature, further characterize this unique variant. FLC affects younger patients and lacks the male predominance of O-HCC. Also, FLC lacks specific association with cirrhosis, hepatitis B virus infection, use of oral contraceptives, and alcohol abuse, all of which are implicated in other hepatic tumors. This, along with differences in serum tumor marker prevalence (AFP, B12 binding protein) suggests that its pathogenesis differs from that of O-HCC. Despite these differences, FLC shares a common differentiation with O-HCC. The increased amounts in FLC of stainable alpha-1-antitrypsin, fibrinogen, and C-reactive protein, all of which are acute phase reactants and normal hepatocyte products, implies better differentiation of FLC cells. Finally, the better prognosis of FLC is supported by this study, since only two of the 19 patients died because of tumor. This contrasts with the reported survival of patients with O-HCC, usually measured in weeks. Hepatic transplantation may hold promise for future patients with "surgically unresectable" FLC as procedure-related complications are overcome.

Immunohistochemical characterization of 130 cases of primary hepatic carcinomas

Primary liver carcinoma (PLC) may express a certain number of markers. Here we communicate results of an analysis of five such markers (alpha-1-antitrypsin--AAT--, carcino-embryonic antigen --CEA--, alpha-fetoprotein --AFP--, and superficial --HBsAg-- and core --HBcAg-- antigens of hepatitis B virus) by means of PAP techniques in 130 cases of PLC, comparing the neoplastic tissue and the non-tumorous liver. Three variants of PLC are distinguished: hepatocarcinoma (HC) (108 cases); cholangiocarcinoma (CC) (19 cases); and three cases of hepatocholangiocarcinoma (HCC). AAT was positive in 29 HC, 2 HCC, and negative in all 19 CC. CEA appeared positive in 16 HC, 16 CC and only one HCC. AFP was positive in two HC, and negative in all CC and HCC. HBsAg displayed positivity in 15 HC and one HCC, being negative in all 19 CC. HBcAg was positive in 4 HC, and negative in all CC and HCC. HBsAg was also positive in two neoplastic emboli associated with HC. On the non-tumorous liver tissue the immunohistochemical results showed positivity for AAT and CEA, but not for AFP. Therefore the present results confirm that in the geographical area from which these tumors proceed, PLC is closely correlated with HBsAg positivity and with cirrhosis.

Hepatocellular carcinoma, hepatic cirrhosis, and hepatitis B virus infection in Nigeria

A total of 200 consecutive patients bearing histologically confirmed primary hepatocellular carcinoma (PHC) were studied at University of Calabar Teaching Hospital (CTH), Calabar, Nigeria in 5 years and compared with 150 patients with metastatic hepatic carcinoma (MHC). Four hundred symptomless non-icteric nontumor-bearing individuals were noncontemporaneous controls. Sera (a total of 750) were assayed for markers of hepatitis B virus (HBV) infection; hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and hepatitis B surface antibody (anti-HBs). Specimens which were positive for HBsAg also were examined for hepatitis E antigen (HBeAg) and antibody (anti-HBe). The results show that PHC was associated with HBV seropositivity in 80% of patients, and postnecrotic (macronodular) cirrhosis of the liver in 90% clearly indicating a strong association between primary liver cancer and HBV infections and liver cirrhosis. The main factor associated with seropositivity among normal controls was a large number of therapeutic injections. Seropositives received over twice as many injections as seronegatives. Public health measures are urgently required to prevent parenteral transmission of HBV in Nigeria.

Relative incidence of primary liver cancer in cirrhosis in Austria. Etiological considerations

The incidence of primary liver cancer (PLC) was assessed in 652 patients (429 male, 223 female) with liver cirrhosis. By the end of the study 416 (64%) of all patients had died. The autopsy rate was 65%. PLC developed in 73 patients. Histologically, 67 cases were classified as hepatocellular (HCC), one as mixed hepatocellular-cholangiocellular and five as cholangiocellular carcinoma. In 30 cases, HCC was confirmed within a year of diagnosis of cirrhosis, and in the remaining 37 cases HCC developed 2-13 years later. At autopsy, the frequency of HCC was almost twice as high in males (27%) as in females (15%) (p less than 0.025). This difference occurred in alcoholic and posthepatitic cirrhosis but not in cryptogenetic cirrhosis. HBsAg was detected in 19.0% of male and 9.2% of female patients (p less than 0.01). Comparison of patients with and without HCC revealed no significant differences in the prevalence of HBsAg. These data indicate that HCC is common in Austrian patients with cirrhosis, representing 60% of all malignant tumors in this group. In view of the high HBsAg carrier rate and the prevalence of chronic alcoholism in patients with cirrhosis, it is suggested that the two factors together lead to an increased risk of cirrhosis followed by an increased incidence of HCC.

Hepatocellular carcinoma. A study of 50 autopsy cases with detection of hepatitis B surface antigen in fixed tissues

Fifty patients who died of hepatocellular carcinoma (HCC) were autopsied at the Ciudad Sanitaria "1 degree de Octubre" and the Hospital de la Cruz Roja (Madrid) from 1974 to 1980. Formalin fixed paraffin-embedded autopsy tissue of liver and tumor from the 50 HCC and liver tissue from 50 liver cirrhosis (LC) and from 50 autopsy of non cirrhotic control cases were examined for the presence of cytoplasmic hepatitis B surface antigen (HBsAg). The study was carried out using orcein staining, immunoperoxidase technique (IP) and indirect immunofluorescence (IF). In livers with HCC the HBsAg was detected in the cytoplasm of the hepatocytes in 10 cases (20%) with the orcein staining and in 11 (22%) with the IP and IF techniques. In one case (2%) HBsAg was found in the cytoplasm of tumor cells with the three methods--In four cases (8%) of LC and 2 (4%) control cases cytoplasmic positive cells were found. In 41 patients with HCC HBsAg was studied in the serum by radio-immunoassay (RIA) (13 cases) and immunodiffussion (28 cases). 5 patients (12,1%) were positive and 36 (72%) were negative. In the 5 serum positive HBsAg HCC the staining methods for cytoplasmic HBsAg were positive (100%). In 36 serum negative HBsAg HCC the staining method were positive in 2 cases. The results let us to conclude that HBV is a probable important etiologic factor of HCC in our milieu. 54% of the patients with HCC had a previous history of alcohol abuse; however, histologic features compatible with an alcoholic etiology were found in only 5 cases. Nevertheless we consider that the described histopathologic findings do not exclude excess alcohol consumption as a possible etiologic factor for HCC in our series.

Hepatitis B virus antigens in liver tissue in hepatocellular carcinoma and advanced chronic liver disease-relationship to liver cell dysplasia

Hepatitis B surface (HBs) and core (HBc) antigens (Ag) were studied in liver tissue in HBsAg seropositive patients with chronic liver disease complicated (n = 32) and not complicated (n = 36) by hepatocellular carcinoma. Both groups were matched by age, sex and underlying disease. There was no qualitative and quantitative difference in tissue HBsAg between the two groups. However, HBcAg was significantly less in quantity in hepatocytes of patients with hepatocellular carcinoma compared to chronic liver disease without cancer. Serum hepatitis B e antigen tested by radioimmunoassay was also less frequently positive in patients with hepatocellular carcinoma. These findings seem to suggest that hepatitis B virus replication becomes less active in the process of hepatocarcinogenesis. The relationship between intrahepatic hepatitis B antigens and liver cell dysplasia was also studied. In hepatocellular carcinoma, tissue hepatitis B antigens often coexisted in the same liver having liver cell dysplasia, but no such association was observed in chronic liver disease without cancer. However, no indication was obtained that the dysplastic cells harbor HBsAg more frequently than non-dysplastic cells.

Enzymes of collagen synthesis and type III procollagen amino-propeptide in serum from Nigerians with hepato-cellular carcinoma and other malignant diseases

Serum immunoreactive prolyl hydroxylase protein (S-IRPH), galactosylhydroxylysyl glucosyltransferase activity (S-GGT) and the amino-terminal propeptide of type III procollagen [S-Pro(III)-N-P] were studied in 24 patients with primary hepatocellular carcinoma, 18 with secondary liver neoplasms and 35 with other malignant diseases but no evidence of liver involvement; this latter group included 13 patients with Burkitt's lymphoma, 11 with breast cancer and 11 with other neoplasms. Control values were determined for 60 apparently healthy Nigerians, S-IRPH and S-GGT were above the upper normal limit, defined as the mean + 2 SD of the controls, in all the patients with primary hepatocellular carcinoma and all but one with secondary liver neoplasms, whereas only one S-IRPH value and three S-GGT values exceeded this limit in the patients with other malignant diseases. The mean S-Pro(III)-N-P was even more elevated than S-IRPH and S-GGT in the primary and secondary liver neoplasm cases, but was also elevated in other malignant neoplasms; about one third of the patients with no evidence of liver involvement had a concentration exceeding the upper normal limit. A high correlation was found between the values for the three assays both in primary hepatocellular carcinoma and in the whole series of malignant diseases. The data suggest that primary and secondary malignant neoplasms of the liver have a high rate of collagen synthesis. The three assays may be of some value in the diagnosis of primary hepatocellular carcinoma and secondary liver involvement in other malignant diseases, and in monitoring the treatment provided.

The effect of chronic habitual alcohol intake on the development of liver cirrhosis and hepatocellular carcinoma: relation to hepatitis B surface antigen carriage

To study the effects of habitual alcohol intake on the latency period for the development of liver cirrhosis and hepatocellular carcinoma (HCC), 158 patients with cirrhosis and 79 with HCC were analyzed with respect to age at the time of diagnosis. They were classified into four groups based on hepatitis B surface antigen (HBsAg) in serum, and the history of intake of more than one small bottle of Japanese "sake" or an equivalent per day for more than 10 years. The average age of HBsAg positive male cirrhotics with a drinking habit (n = 10) was 38.8 years, 10.5 years younger than that of those without a drinking habit (n = 8) (P less than 0.05). The average age of HBsAg negative cirrhotics with a drinking habit (n = 97) was 47.9 years, eight years younger than that of those not drinking (n = 36) (P less than 0.001). There was no significant difference in the laboratory data between these groups. The average age of the HBsAg positive HCC patients with a drinking habit (n = 20) was 48.9 years, nine years younger than that of those without a drinking habit (n = 12) (P less than 0.05). The average age of HBsAg negative male HCC cases with habitual intake of more than 126 ml of ethanol per day was 51.0 years (n = 8), ten years younger than that of nondrinking male HCC cases (n = 11) (P less than 0.05). These data suggest that habitual alcohol intake may promote the development of liver cirrhosis and HCC, especially in HBsAg carriers.

A serological study on primary hepatocellular carcinoma in Zambia

The enzyme linked immunosorbent assay (ELISA) was used to measure alpha-foetoprotein (AFP) levels and to detect Hepatitis B surface antigen (HBsAg) and antibody to Hepatitis B surface antigen (anti-HBs) in patients with primary hepatocellular carcinoma and in controls free of the disease in Zambia. Virtually all the patients with primary hepatocellular carcinoma had grossly elevated AFP levels and about two thirds of them were positive for HBsAg. All the controls had much lower AFP levels and one sixth were positive for HBsAg.

Hepatitis B virus profile of hepatocellular carcinoma in the Philippines

The hepatitis B virus (HBV) profile was investigated in 104 age-grouped hepatocellular carcinoma (HCC) patients and 84 controls from the Philippines. The HCC-control percent positivities of the HBV parameters are: HBsAg: 70-18; anti-HBs: 25-37; anti-HBs: 25-37; anti-HBc: 94-35; HBeAg: 5-2; anti-HBe: 60-30; HBV exposure rate: 97-57; current infection: 80-31. Male HCC anti-HBs positivity is significantly lower than in controls. Female HCC patients' anti-HBs are also lower than controls, but this difference is not statistically significant. Simultaneous presence of HBsAg and anti-HBs was found only in male HCC patients. The mean anti-HBc titer of anti-HBs-positive HCC is higher than that of controls. That of HCC patients negative for both HBsAg and anti-HBs is also higher than the corresponding controls. Anti-HBe positivities of infected and noninfected but previously exposed HCC patients are not significantly different, in contrast to noninfected previously exposed controls whose anti-HBe is lower than those with current infection. The exposure rate prevalence of current infection, and the antibody responses to HBV of HCC patients suggested a close relationship between the two conditions in the Philippines.

Primary hepatocellular carcinoma in Alaskan natives, 1969-1979

The records of 20 Alaskan Native patients with primary hepatocellular carcinoma (PHC) diagnosed in the 11-year period 1969-1979 were reviewed. The annual incidence of PHC was found to be high among Alaskan Native males and especially high among Alaskan Eskimo males (7.6 and 11.2 per 100,000 respectively) in comparison to Greenland and Canadian Eskimos and US white males. Familial and geographic clustering of PHC patients was noted in areas known to be hyperendemic for hepatitis B virus (HBV) infection. A bimodal age distribution among PHC patients occurred with peaks at 15-25 years and 40-65 years. A high prevalence of hepatitis B surface antigen (HBsAg) in serum of patients in the younger age group suggests that HBV infection might be a factor associated with the development of PHC in young Eskimos. PHC in Alaskan Natives is apparently not closely associated with alcoholic cirrhosis.

The epidemiology and morphology of primary malignant liver tumors

The ubiquitous problem of cirrhosis may be complicated by the development of primary liver cell carcinoma, with rates of incidence so high in certain parts of the world as to make it a candidate for the most common cancer in humans. When cirrhosis reaches the macronodular stage, the risk of developing liver cell carcinoma increases, and at this point liver cell dysplasia may be seen in biopsy. Alcoholics, who classically have a micronodular cirrhosis, may attain the macronodular pattern through better clinical management, abstinence, and longer survival. Hepatitis B-related cirrhosis, on the other hand, is most often macronodular. Recent DNA hybridization studies strongly favor a viral role in oncogenesis, and this possibility is supported by the serologic and epidemiologic evidence complied in the last decade. Liver cell malignant tumors tend to recapitulate the characteristics of normal liver, namely, growth in cords, uniformity of cytologic appearances, and bile production, but also present distinctive histologic and immunohistochemical patterns that are unique to a malignant liver cell population. The other primary malignant tumors of the liver, arising in bile ducts, blood vessels, and mesenchymal elements, all carry their individual epidemiology and morphology, but in general invoke, as does liver cell carcinoma, the concept of a series of step by step cell-carcinogen and cell-carcinogen interactions by which normal cells give rise to malignant populations.

Association of hepatitis B virus infection with hepatocellular carcinoma in American patients

Thirty-four patients from the Philadelphia area with hepatocellular carcinoma (HCC) were matched with colon cancer patients, lung cancer patients and blood donors according to age and sex. Sera from the four groups were tested to determine the prevalence of hepatitis B surface antigen (HBsAg), antibody to HBsAg (anti-HBs), and antibody to hepatitis B core antigen (anti-HBc). Five of the HCC patients (14.7%) and none of the controls were positive for HBsAg. At least one of the three serologic markers of hepatitis B virus (HBV) infection was found in 51.5% of the HCC patients, 5.3% of the colon cancer patients, 11.1% of the lung cancer patients, and 10.7% of the blood donors. Twelve of the seventeen seropositive HCC patients (70.6%) were positive for anti-HBc alone, while all of the seropositive lung cancer patients and donors were positive for anti-HBs alone. Sera positive for any HBV marker were also tested for e antigen (HBeAg) and its antibody (anti-HBe). Four of the HCC patients (23.5% of the seropositives) had anti-HBe, while none of the sera tested had HBeAg. A history of alcoholism did not appear to influence HBV seropositivity in the HCC patients. This study supports the hypothesis that HBV infection is closely associated with HCC even in areas where both conditions are uncommon. The wide disparity between seropositivity for HBsAg and anti-HBc in the HCC patients is an unusual feature, for which an age effect may be the best explanation.

Hepatitis B virus antigens in human primary hepatocellular carcinoma tissues

The presence of hepatitis B virus (HBV) antigens was examined in specimens of liver tissue obtained at necropsy from black Senegalese patients suffering from primary hepatocellular carcinoma (PHC). The results were correlated with markers of hepatitis B infection in serum. Hepatitis B surface antigen (HBsAg) and core antigen (HBcAg) were sought for in 15 liver extracts. HBsAg was found in the liver in 10 of 12 cases with HBsAg-positive serum. HBcAg was detected in three livers. The HBsAg was detected in seven of eight livers by immunofluorescence and orcein staining. HBsAg-positive cells were mainly located in the peri-tumoral cirrhotic tissue, although positive hepatocytes were also found in tumour nodules in liver from one of the patients. HBcAg was found in five of seven cases by immunofluorescence in hepatocytes of the cirrhotic areas. HBcAg fluorescence was primarily nuclear but, in some lobules, a patchy cytoplasmic fluorescence was observed. This suggests a cytoplasm-nucleus pathway in the synthesis of the HBV core antigen. Electron microscopy was performed on two HBsAg- and HBcAg-positive cases. Fibrillar and crystalline cytoplasmic inclusions were observed in tumour cells. In the same cells, 20-25 nm virus-like particles were present in swollen cisternae of the endoplasmic reticulum.

Relation between aflatoxin, hepatitis-B virus, and hepatocellular carcinoma

A new role is postulated for aflatoxin in the production of hepatocellular carcinoma. Rather than acting as a primary carcinogen, as it seems to do in animals, it is suggested that aflatoxin suppresses cell-mediated immunity. This effect on the immune system would allow the hepatitis-B virus, highly endemic in certain populations, to maintain itself more easily in the liver, to produce more chronic infection and cirrhosis, and in the long term to lead to a high incidence of hepatocellular carcinoma.

Histology and ultrastructural aspects of virus-induced primary liver cancer and transplantable hepatomas of viral origin in chickens

The macroscopic, light microscopic and electron microscopic features and biological properties of MC-29 virus-induced hepatocellular carcinomas in chickens are described. The tumors developed in noncirrhotic livers within a very short time and formed metastases. Virus production was also evidenced in the tumors. There were also indications of virus production in the transplantable tumors. The tumors grew equally well after sc, ip, or im inoculation. In about 25% of the tumor-bearing animals, tumorous nodules developed in the liver. It could not be established whether they were metastases or primary liver cancers induced by viruses released from the transplantable tumors.

Role of hepatitis B virus in primary liver cancer

There is an excess prevalence of markers of active infection with hepatitis B virus in patients with primary liver cancer in many parts of the world. Early age of infection with hepatitis B virus is likely to be an important factor, resulting in persistent infection that may progress to chronic liver damage. Results of recent experimental studies are consistent with integration of hepatitis B viral DNA with host cell DNA molecules. It is likely that primary liver cancer is the cumulative result of several cofactors including infection with hepatitis B virus; genetic, immunologic, hormonal, and nutritional factors; and environmental factors including mycotoxins and chemical carcinogens.

HBsAg-negative chronic active hepatitis related to hepatitis B virus

Numerous cases of chronic hepatitis have been shown to be closely associated with persistent infection with hepatitis B virus (HBV). A group of 100 patients suffering from chronic active hepatitis (CAH) was investigated for HBV serologic markers. Of these, 35 patients were HbsAg-positive; in 26 HBsAg-negative subjects, anti-HBc were detected using counterimmune electrophoresis and complement-fixation tests. These data suggest that chronic liver disease in patients who were only anti-HBc-positive might be related to persistent infection with hepatitis B virus. Epidemiological clinical and histopathological data were different when we compared CAH patients who were HBsAg-negative, but anti-HBc-positive, with HBsAg-positive CAH patients. A sequence is proposed leading from HBsAg-positive to HBsAg-negative CAH, cirrhosis, and hepatoma in temperate areas, according to a model similar to the one described in intertropical Africa.

T-lymphocytes and hepatitis B serology

The incorporation of 14C-thymidine by peripheral blood lymphocytes stimulated by phytohemagglutinin (PHA) and the proportion and absolute number of E-rosettes were determined in 28 prostitutes and the results were correlated with hepatitis B virus (HBV) serology. Women were tested for hepatitis B surface antigen (HBsAg) and its antibody (anti-HBs) as well as for antibody to the hepatitis B core antigen (anti-HBc). It was found that women who were carriers of HBsAg had significantly lower incorporation of 14C-thymidine (median value 14451 counts per minute-cpm) compared to women positive for anti-HBc but negative for the other two markers (median value 28590 cpm) as well as to women negative for all the tested markers (median value 30600 cpm). No significant difference was found among the three groups studied with respect to either the absolute number or the percentage of E-rosettes. The results indicate that the presence of anti-HBc alone, is not related to the responsiveness of lymphocytes to PHA.

Benign and malignant liver neoplasms: some new etiologic associations

Several agents have recently been implicated in the development of benign and malignant liver neoplasms. Recognition of their possible role by the primary care physician may prevent serious consequences to patients exposed to these agents, which include oral contraceptives, androgens, hepatitis virus, and vinyl chloride.

Antibody to hepatitis B core antigen in chronic active hepatitis

Antibody to hepatitis B core antigen (anti-HBc), which has been assumed to be a more sensitive indicator of hepatitis B virus replication than hepatitis B surface antigen (HBsAg), was detected in the sera of 26 of our 65 patients with HBsAg-negative chronic active hepatitis. Thus despite the absence of HBsAg the liver disease could be the consequence of chronic infection with hepatitis B virus in these patients. They differed, however, from a group of 35 patients with HBsAg-positive hepatitis in being older on average and having less active liver lesions. The two groups could represent either two stages of chronic infection with hepatitis B virus or two types of response to it.

Hepatitis B virus DNA in primary hepatocellular carcinoma tissue

Tumour, cirrhotic, and metastatic tissues from four patients with primary hepatocellular carcinoma have been investigated for the presence of hepatitis B viral DNA by nucleic acid hybridization. Tumours from two of three patients with a current HBV infection contained 1--2 genomes per cell of unintegrated viral DNA, while tumours from the third HBs antigen-positive patient contained less than one genome equivalent per ten cells. A tumour from one patient with anti-HBs contained no detectable HBV DNA. A variety of models involving HBV as an etiologic agent may be advanced to explain the statistical correlation of HBV infection with primary hepatocellular carcinoma (PHC). The data presented here argue against the model that HBV DNA integrated into every cell is required to maintain the oncogenic transformation of hepatocytes, but they do not rule out other models.

Hepatitis B antigen in black patients with hepatocellular carcinoma: correlation between orcein stained liver sections and serology

Formalin-fixed paraffin-embedded autopsy tissue of liver and tumor from 50 male black mineworkers with hepatocellular carcinoma were examined by orcein stain for the presence of cytoplasmic hepatitis B surface antigen. The results were correlated with the serum hepatitis B antigen (HBAg). In 72% serum HBAg was positive. Orcein staining of nontumor liver cell cytoplasm was present in 18 (36%). Sixteen (89%) of these orcein-positive cases were serum HBAg positive. The two false negative serum HBAg results were obtained by immunodiffusion, immunoelectrophoresis and complement fixation. Serum HBAg, measured by radio-immunoassay and hemagglutination, was positive in 14 orcein-negative cases. Six other negative orcein results appeared to be due to sampling error. Orcein staining was noted in tumor cells of three serum HBAg positive patients. Provided the limitations of the technique are realized, orcein staining of liver tissue from hepatocellular carcinoma patients may prove useful for retrospective screening surveys to assess the prevalence of HBAg positivity in these patients.

Host responses to hepatitis B infection in patients in a chronic hemodialysis unit

Host responses to hepatitis B infection were studied in 222 patients in a chronic hemodialysis unit. From 1970 to 1976, patients were monitored monthly for development of hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and serum transaminase (SGPT) elevations. Five categories of patients were identified as: 1) chronic carriers of HBsAg; 2) transiently HBsAg(+), who developed anti-HBs; 3) HBsAg(-) on admission, who developed anti-HBs without becoming HBsAg(+); 4) anti-HBs(+) on admission; 5) uninfected who remained HBsAg(-) and anti-HBs(-). For a patient who became HBsAg(+) in this clinic, the probability of becoming a chronic carrier was 62-8% and rose to 88.5% if he or she had been HBsAg(+) for five consecutive months. Males were more likely to become chronic carriers, and females were more likely to develop anti-HBs. Neither age, race, nor type of underlying kidney disease was associated with particular host responses to hepatitis B virus. No effect of hepatitis B infection on mortality was detected. Variation in host response to hepatitis B infection among renal dialysis patients may affect the usefulness of hepatitis B hyperimmune globulin and hepatitis B vaccine and be related to the outcome of kidney transplantation.

Early lesions and development of primary hepatocellular carcinoma in man--association with hepatitis B viral infection

It is well known that primary hepatocellular carcinoma could be derived from chronic hepatitis and liver cirrhosis in epidemiologic studies. However, it is still not clear what kinds of hepatocyte are premalignant cells. Recently we have focused on liver cell dysplasia as a possible premalignant cell, and showed localization of alpha-fetoprotein in the cytoplasma of these cells. Although the dysplastic cells were often seen in the liver of chronic active hepatitis, hepatitis B virus associated DNA polymerase activity was also significantly high in the sera from the patients with chronic active hepatitis. In this paper, we discuss the possible role of hepatitis B virus through hepatocarcinogenesis in human.

Is Burkitt's lymphoma related to perinatal infection by Epstein-Barr virus?

Burkitt's lymphoma (B.L.) is very restricted geographically, whereas the Epstein-Barr virus (E.B.V.), a very likely causal factor, exists all over the world. It is proposed that perinatal infection (either transplacental, or, more probably, neonatal) is an important risk factor for the development of B.L. This hypothesis arose when the epidemiological characteristics of E.B.V. infection were compared in different parts of the world and is supported by the preliminary results of a seroepidemiological prospective study of B.L. E.B.V. would behave in a manner similar to that of animal tumour viruses whose oncogenic potential is greatly enhanced by neonatal infection.

Age- and sex-related distribution of antibodies to hepatitis B surface and core antigens in a Swedish population

Serum samples from people born between the years 1895 and 1970 were collected and tested for antibody to hepatitis B surface antigen (anti-HBs) by passive haemagglutination (PHA) and radioimmunoassay (RIA), and for antibody to hepatitis B core antigen (anti-HBc) by immunoelectroosmophoresis (IEOP). Neither anti-HBs nor anti-HBc was detected in the serum from anyone under 15 years of age. The prevalence of anti-HBs and anti-HBc showed peaks of 9.2 and 8.3 per cent, respectively, in the age group of 40-49 years. The distribution of antibody was equal between men and women. Eighty per cent of the sera with anti-HBs were also positive for anti-HBc. All sera positive for anti-HBc also contained anti-HBs.

Host responses to hepatitis-B infection in patients with primary hepatic carcinoma and their families. A case/control study in Senegal, West Africa

A case/control study of patients with primary hepatic carcinoma (P.H.C.) and their families was carried out in Dakar, Senegal. 28 P.H.C. cases were matched by age,sex, and ethnic group with 28 controls. Serum was collected from cases, controls, parents (28 mothers, 27 fathers) of cases, parents of controls, 71 siblings of cases, and 58 siblings of controls. Assays of their sera for hepatitis-B surface antigen (HBsAg), antibody to HBsAg (anti-HBs) and antibody to hepatitis-B core antigen (anti-HBc) produced the following results. (1) Nearly all P.H.C. cases (97%) and controls (93%) had some evidence of infection with hepatitis-B virus (H.B.V.), but the cases were more likely to be anti-HBc(+) and less likely to be anti-HBs(+) than the controls. (2) Most of the mothers of the cases were HBsAg(+) (71%), whereas only 14% of the mothers of controls were HBsAg(+). Lover titres of anti-HBs were less common in the mothers of the cases. (3) None of 27 fathers of cases had detectable anti-HBs, but 13 (48%) of the fathers of controls were anti-HBs(+). (4) Siblings of the P.H.C. cases were more likely to have anti-HBs than either their sibs with P.H.C. or the sibs of the controls. However, sibs of P.H.C. cases had lower titres of anti-HBs than the sibs of the controls. These data are consistent with the hypothesis that the P.H.C. cases were infected with H.B.V. by their mothers and that there was an environmental factor which affected the immunological response of all family members to H.B.V. Infection with H.B.V. and the mode of response to that infection among members of families appear to be major factors in the aetiology of P.H.C. in West Africa.

Geographic correlation between mortality from primary hepatic carcinoma and prevalence of hepatitis B surface antigen in Greece

Average annual age-adjusted mortality rates per 100,000 from primary hepatic carcinoma (PHC) among males for 1971-1973 in the urban and rural areas of the 9 geographical regions of Greece were estimated. Hepatitis-B surface antigen (HBsAg) prevalence by region and area was evaluated in a sample of 22,844 Greek Air Force recruits from all parts of the country. Mortality from PHC was found significantly higher in urban areas (28-30 vs. 18-81) whereas prevalence of HBsAg was higher in rural areas (5-3% vs. 3-90%). Nevertheless further statistical analysis showed that there is a strong correlation between HBsAg prevalence and mortality from PHC, which is higher in rural (r = + 0-88) than in urban (+ 0-57) areas. The latter findings indicate that hepatitis B infection and PHC may be causally related.

Immunisation against hepatitis B in man

An inactivated vaccine against hepatitis B was prepared from blood-donor HBs antigen purified on immunoadsorbents. Its safety and efficacy were tested in chimpanzees. Vaccination was then applied in an attempt to protect patients and staff in a haemodialysis unit. The efficacy of the vaccine in man was assessed by observing humoral and cellular immune reactions and by comparing changes in HBs antigenaemia in vaccinated and non-vaccinated subjects. The results indicate that this vaccine protects against hepatitis B in the circumstances in which it was administered.