HCV-associated hepatocellular carcinoma without cirrhosis

Etiologic fractions in patients of hepatocellular carcinoma in India with and without a background of cirrhosis: a multi-centric study

BACKGROUND

Hepatocellular cancer (HCC) typically arises in the background of cirrhosis. The epidemiology of HCC has changed in recent years due to availability of newer antivirals, changing life-styles and greater possibility for early detection. We undertook a multicentric national sentinel surveillance for liver cirrhosis and HCC to assess the attributable risk factors for the development of HCC, both with and without a background of cirrhosis.

METHODS

Data from January 2017 till August 2022 from hospital-based records of eleven participating centers were included. Diagnosed cases of cirrhosis [radiological (multiphase and/or histopathological] and HCC [as per AASLD 2018] were included. History of significant alcohol intake was elicited by AUDIT-C questionnaire.

RESULTS

Altogether 5798 enrolled patients were assessed, of which 2664 patients had HCC. The mean age was 58.2 ± 11.7 years and 84.3% (n = 2247) were males. Diabetes was found in over a third of those with HCC (n = 1032;39.5%). The most common etiology of HCC was NAFLD (n = 927;35.5%) followed by viral hepatitis B and C and harmful levels of alcohol. Among those with HCC, 27.9% (n = 744) had no cirrhosis. Higher proportion of cirrhotic HCC patients had alcohol as an etiological factor as compared to non-cirrhotic (17.5 vs. 4.7%, p ≤ 0.001). NAFLD was an etiological factor for a higher proportion of non-cirrhotic HCC patients as compared to cirrhotic HCC (48.2 vs. 30.6%, p ≤0.001). Diabetics more commonly had non-cirrhotic HCC (50.5 vs. 35.2%). The following factors were associated with an occurrence of cirrhotic HCC: male gender (OR 1.372 and 95% CI 1.070-1.759), age above 60 years (OR 1.409 and 95% CI 1.176-1.689), HBV (OR 1.164 and 95% CI 0.928-1.460), HCV (OR 1.228 and 95 CI 0.964-1.565) and harmful consumption of alcohol (OR 3.472 and 95% CI 2.388-5.047). The adjusted odds of non-cirrhotic patients having NAFLD was 1.553 (95% CI 1.290-1.869).

CONCLUSION

This large multi-centric study demonstrates that NAFLD is the most important risk factor for development of both cirrhotic and non-cirrhotic HCC in India and has overtaken viral hepatitis. Awareness campaigns and large-scale screening are required to reduce the high burden of NAFLD-related HCC in India.

Computed Tomography-Measured Liver Volume Predicts the Risk of Hepatocellular Carcinoma Development in Chronic Hepatitis C Patients

AIM

In this retrospective cohort study, we evaluated the significance of liver volume in the prediction of hepatocellular carcinoma (HCC) in 277 chronic hepatitis C (CHC) patients who received dynamic computed tomography (CT) during surveillance.

METHODS

Liver volumes were measured on portal venous phase of CT images by using ImageJ software. Liver volume index, a ratio of the standard liver volume expected by weight and height to the measured liver volume, was calculated to adjust for normal variations. The cohort was randomly divided to derivation (n = 100) and validation sets (n = 177) for the generation of a liver volume-based Cox prediction model and validation of a liver volume-based nomogram, respectively.

RESULTS

The liver volume index was independent of weight or height, and it predicted further development of HCC (hazard ratio [HR] 16.30, 95% CI 6.70-39.62; p < 0.001). Liver cirrhosis, gamma-glutamyl transferase, and liver volume index were independent predictors of HCC, and nomogram-based prediction score from these three parameters identified high-risk patients at the cutoff of 110 in both derivation (p < 0.001) and validation cohort (p < 0.001).

CONCLUSION

Liver volume-based prediction model stratifies the risk of developing HCC in CHC patients whose initial dynamic CT study gave negative results.

Nondegradable Collagen Increases Liver Fibrosis but Not Hepatocellular Carcinoma in Mice

Although hepatocellular cancer (HCC) usually occurs in the setting of liver fibrosis, the causal relationship between liver fibrosis and HCC is unclear. in vivo and in vitro models of HCC involving Colr/r mice (that produce a collagenase-resistant type I collagen) or wild-type (WT) mice were used to assess the relationship between type I collagen, liver fibrosis, and experimental HCC. HCC was either chemically induced in WT and Colr/r mice or Hepa 1-6 cells were engrafted into WT and Colr/r livers. The effect of hepatic stellate cells (HSCs) from WT and Colr/r mice on the growth of Hepa 1-6 cells was studied by using multicellular tumor spheroids and xenografts. Collagen type I deposition and fibrosis were increased in Colr/r mice, but they developed fewer and smaller tumors. Hepa 1-6 cells had reduced tumor growth in the livers of Colr/r mice. Although Colr/r HSCs exhibited a more activated phenotype, Hepa 1-6 growth and malignancy were suppressed in multicellular tumor spheroids and in xenografts containing Colr/r HSCs. Treatment with vitronectin, which mimics the presence of degraded collagen fragments, converted the Colr/r phenotype into a WT phenotype. Although Colr/r mice have increased liver fibrosis, they exhibited decreased HCC in several models. Thus, increased liver type I collagen does not produce increased experimental HCC.

Different Performance of Liver Stiffness Measurement According to Etiology and Outcome for the Prediction of Liver-Related Events

BACKGROUND/AIMS

Liver stiffness measurement (LSM) by transient elastography (TE) has shown promising results for prediction of hepatocellular carcinoma (HCC) and hepatic decompensation in patients with chronic liver disease (CLD). However, whether prognostic performance of TE differs according to etiology or type of outcome remains further clarification.

METHODS

Performance of LSM for the prediction of HCC and hepatic decompensation was analyzed in a cohort of 4026 patients with asymptomatic CLD.

RESULTS

During median 4.5 years of follow-up (range 3.0-6.2 years), liver-related events (LRE) were observed in 196 patients (166 with HCC, 45 with hepatic decompensation, and 15 with both). In the multivariate analysis, LSM was independent factor associated with LRE and showed high AUROC (0.78). When stratified by type of outcome and etiology of liver disease, LSM showed high AUROC for the prediction of HCC for patients with non-viral hepatitis (0.89), while it showed relatively low AUROC for the prediction of HCC for patients with viral hepatitis (0.75). For the prediction of hepatic decompensation, LSM showed high AUROC for patients with both viral- and non-viral hepatitis (0.90, 0.90, respectively).

CONCLUSIONS

LSM showed powerful prognostic role for the prediction of LRE in patients with CLD. Notably, HCC risk was not negligible in patients with viral hepatitis who showed LSM value < 10 kPa, indicating watchful attention for HCC is still needed for viral hepatitis patients with low LSM.

Outcomes Following Resection of Hepatocellular Carcinoma in the Absence of Cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) occasionally occurs in non-cirrhotic patients; however, outcomes for these patients are not extensively documented.

METHODS

We performed an institutional review of patients without cirrhosis who underwent resection for HCC. Clinical data were evaluated to identify factors impacting recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Forty-two patients underwent hepatectomy for HCC in the absence of cirrhosis over a 10-year period. Median follow-up was 22 months. For the entire cohort, 1-, 3-, and 5-year RFS was 62%, 42%, and 38% and 1-, 3-, and 5-year OS was 78%, 60%, and 49%, respectively. On univariate analysis, RFS was significantly worse for patients with a disrupted/absent tumor capsule (p = 0.027), vascular invasion (p = 0.030), elevated alkaline phosphatase (p = 0.004), and tumor size > 10 cm (p = 0.016). OS was significantly worse for patients with a disrupted/absent tumor capsule (p = 0.044), obesity (p = 0.036), and elevated alkaline phosphatase (p = 0.007) with a trend towards decreased OS for tumor size > 10 cm (p = 0.07).

CONCLUSIONS

Patients undergoing resection for HCC in the absence of cirrhosis have fairly high recurrence and modest survival rates. Pre-operative alkaline phosphatase, tumor size, tumor encapsulation, and vascular invasion are important prognostic factors.

Hepatocellular carcinoma in non-cirrhotic liver: A comprehensive review

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, which in turns accounts for the sixth most common cancer worldwide. Despite being the 6^th most common cancer it is the second leading cause of cancer related deaths. HCC typically arises in the background of cirrhosis, however, about 20% of cases can develop in a non-cirrhotic liver. This particular subgroup of HCC generally presents at an advanced stage as surveillance is not performed in a non-cirrhotic liver. HCC in non-cirrhotic patients is clinically silent in its early stages because of lack of symptoms and surveillance imaging; and higher hepatic reserve in this population. Interestingly, F3 fibrosis in non-alcoholic fatty liver disease, hepatitis B virus and hepatitis C virus infections are associated with high risk of developing HCC. Even though considerable progress has been made in the management of this entity, there is a dire need for implementation of surveillance strategies in the patient population at risk, to decrease the disease burden at presentation and improve the prognosis of these patients. This comprehensive review details the epidemiology, risk factors, clinical features, diagnosis and management of HCC in non-cirrhotic patients and provides future directions for research.

Primary malignant tumours in the non-cirrhotic liver

Intrahepatic chlangiocarcinomas (CCs), the second most common primary malignant liver tumours, usually occur in non-cirrhotic liver, and can be classified into three types based on gross morphology: mass-forming; periductal infiltrating; and intraductal growing. Among them, mass-forming intrahepatic CCs are the most common type and characterized by homogeneous mass with an irregular but well-defined margin with peripheral enhancement on late arterial phase and delayed enhancement in central portion of tumours corresponding to the fibrous stroma. Several imaging features such as enhancement pattern and degree of diffusion restriction have been suggested as prognostic markers for mass-forming CCs. Hepatocellular carcinomas (HCCs) are the most common primary malignant liver tumors, and usually arise from the cirrhotic liver. However, approximately 20% of HCCs involve the non-cirrhotic liver (hereafter, non-cirrhotic HCC), and non-cirrhotic HCCs are often detected at an advanced stage due to the lack of surveillance for patients with non-cirrhotic liver. Other primary malignant liver tumours other than CCs and HCCs including angiosarcoma, undifferentiated embryonal sarcoma are quite rare, and imaging diagnosis is often difficult. This review offers a brief overview of epidemiology, risk factors and imaging features of primary malignant tumours in non-cirrhotic liver. Understanding of radiologic appearance and predisposing clinical features as well as differentials of primary malignant tumour in non-cirrhotic liver can be helpful for radiologists to adequately assess these tumours, and subsequently to make optimal management plan.

Multifucosylated Alpha-1-acid Glycoprotein as a Novel Marker for Hepatocellular Carcinoma

High-sensitivity and -specificity diagnostic techniques to detect early-stage hepatocellular carcinoma (HCC) are in high demand. Screening with serum HCC markers, such as alpha-fetoprotein, is not practical because they possess poor sensitivity and specificity. As such, we focused on glycan alterations of glycoproteins found in patient sera in an attempt to discover novel HCC markers that are more specific and sensitive than current HCC markers. Sera from 42 HCC patients and 80 controls, composed of 27 chronic hepatitis B patients, 26 chronic hepatitis C patients, and 27 healthy volunteers, were analyzed in this study. Glycopeptides obtained from serum proteins by trypsin digestion were enriched by ultrafiltration and Aleuria aurantia lectin-based affinity chromatography, followed by analysis using liquid chromatography time-of-flight mass spectrometry. The data were analyzed by our newly developed software, which calculates peak intensities and positions (m/z and elution time), aligns all sample peaks, and integrates all data into a single table. HCC markers were extracted from more than 30 000 detected glycopeptide peaks by t test, mean-fold change, and ROC analyses. As a result, we revealed that alpha-1-acid glycoprotein with multifucosylated tetraantennary N-glycans was significantly elevated in HCC patients, whereas the single fucosylated derivative was not.

Oncogenic viruses and hepatocellular carcinoma

About 80% of hepatocellular carcinoma (HCC) is caused by hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infections especially in the setting of established cirrhosis or advanced fibrosis, making HCC prevention a major goal of antiviral therapy. HCC tumors are highly complex and heterogeneous resulting from the aberrant function of multiple molecular pathways. The roles of HCV or HBV in promoting HCC development are still either directly or indirectly are still speculative, but the evidence for both effects is compelling. In patients with chronic hepatitis viral infection, cirrhosis is not a prerequisite for tumorigenesis.

Hepatocellular carcinoma in chronic hepatitis C in the absence of advanced fibrosis or cirrhosis

OBJECTIVE

The objective of our study was to describe the cross-sectional imaging appearance of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C virus (HCV) infection in the absence of advanced fibrosis and cirrhosis.

MATERIALS AND METHODS

This study is a retrospective review of our surgical database to identify patients with chronic HCV infection and HCC who underwent hepatectomy and who had undergone preoperative CT or MRI. Only patients with a Metavir fibrosis score of F0, F1, or F2 on pathology were included. Patients with hepatitis B virus coinfection or other causes of chronic liver disease and patients with histopathologic evidence of advanced fibrosis or cirrhosis (Metavir scores F3 and F4) were excluded. Contrast-enhanced CT or MRI examinations performed within 2 months before surgery were reviewed for the number, size, and location of tumors; tumor enhancement characteristics; and presence of macrovascular invasion.

RESULTS

Two hundred forty-five resections of HCC in patients with HCV were performed in our institution from 1987 to 2012. Of this group, 26 patients (10.6%) had a Metavir fibrosis score of F0, F1, or F2; of those patients, 19 (18 men and one woman; 18 non-Asian patients and one Asian patient; mean age, 64 years) had imaging studies available for review. Twenty-one HCCs (mean size, 4.5 cm; range, 0.9-14.8 cm) were evaluated at imaging. Typical wash-in and washout characteristics were seen in 16 of 19 viable lesions (84.2%). The remaining two HCCs were completely necrotic after transarterial chemoembolization. Eighteen patients had a solitary tumor. Most tumors (15/21, 71.4%) developed in the right hepatic lobe.

CONCLUSION

HCC can develop in patients with chronic HCV without advanced fibrosis or cirrhosis, most frequently in older non-Asian men, and usually appears as a large solitary tumor with a typical wash-in-washout enhancement pattern.

Long-term results of liver resection for hepatocellular carcinoma in noncirrhotic liver

BACKGROUND

Hepatocellular carcinoma (HCC) is among the most common malignant neoplasms worldwide. Only few data on HCC in noncirrhotic livers without viral hepatitis in Western countries are available. The purpose of this study was to define the outcomes and potential prognostic factors associated with survival after hepatic resection in patients with HCC in the absence of liver cirrhosis and hepatitis B or C infection.

PATIENTS AND METHODS

From January 2000 to September 2010, 148 patients without liver cirrhosis and without extrahepatic metastases underwent curative hepatic resection for HCC at the Surgical Department of the Charité, Campus Virchow Klinikum. The outcomes of these patients were retrospectively reviewed. Patients with cirrhosis or severe fibrosis, fibrolamellar HCC, and those positive for hepatitis B or C were excluded.

RESULTS

The cumulative 1-, 3-, 5-, and 7-year survival rates were 75.4%, 54.7%, 38.9%, and 31.8%, respectively. The 1-, 3-, 5-, and 7-year disease-free survival rates were 60.3%, 38.0%, 29.1%, and 18.1%, respectively. In the multivariate analysis, cumulative survival was decreased by patient age, increased operative time, increased preoperative serum gamma-glutamyl transferase (GGT), and tumor stage. In the subgroup with unifocal neoplasms, N0 and R0 status, tumor size >10 cm, and tumor differentiation were highly predictive of lesser survival. Unfavorable survival was observed in patients with multifocal neoplasms, tumor size >10 cm, and/or poor tumor differentiation.

CONCLUSION

The current TNM staging system is stratified for survival and recurrence. Extension of the current TNM staging system by grading and more exact differentiation of tumor size may increase its prognostic accuracy for predicting outcome. Preoperative increased serum GGT level could be a new poor prognostic factor.

Long-term survival after resection of hepatocellular carcinoma

BACKGROUNDS/AIMS

Although recent advances in surgical techniques and alternative treatment, the long-term survival >5 years after liver resection for hepatocellular carcinoma (HCC) is still unsatisfactory due to the high recurrence rate compared with other solid organ cancers. This study was conducted to analyze long-term survival after HCC resection and to develop an optimal strategy to achieve long-term survival.

METHODS

A retrospective review was performed for HCC patients who underwent liver resection between 1996 and 2006. The survival rates and prognostic factors were assessed. The clinical and pathological factors of patients who survived more than 5 years were compared with those of patients whose survival was less than 5 years. The clinicopathological features characterizing long-term survivors were also reviewed.

RESULTS

The overall and disease-free 5-year survival rates of 87 cases were 38.5% and 29.4%, respectively. Twenty-seven of 87 patients survived longer than 5 years after liver resection. The univariate analysis revealed that hepatitis C, the serum aspartate sminotransferase (AST) level, liver cirrhosis, Edmondson-Steiner grade, AJCC stage, and vascular invasion were significant factors for overall survival, and serum AST level, liver cirrhosis, Edmondson-Steiner grade, AJCC stage, and vascular invasion were the affecting factors for disease-free survival. In multivariate analysis, serum AST level, hepatitis C and vascular invasion were related with the overall survival, liver cirrhosis and vascular invasion which were associated with disease-free survival. Vascular invasion, AJCC stage, and the Edmondson-Steiner grade were significant factors in long-term survivors.

CONCLUSIONS

Patients without liver cirrhosis, vascular invasion and normal liver function, good differentiation and an early stage may be expected to have a long-term survival.

Cancer-associated carbohydrate antigens as potential biomarkers for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common human malignancies. Therefore, developing the early, high-sensitivity diagnostic biomarkers to prevent HCC is urgently needed. Serum a-fetoprotein (AFP), the clinical biomarker in current use, is elevated in only ∼60% of patients with HCC; therefore, identification of additional biomarkers is expected to have a significant impact on public health. In this study, we used glycan microarray analysis to explore the potential diagnostic value of several cancer-associated carbohydrate antigens (CACAs) as biomarkers for HCC. We used glycan microarray analysis with 58 different glycan analogs for quantitative comparison of 593 human serum samples (293 HCC samples; 133 chronic hepatitis B virus (HBV) infection samples, 134 chronic hepatitis C virus (HCV) infection samples, and 33 healthy donor samples) to explore the diagnostic possibility of serum antibody changes as biomarkers for HCC. Serum concentrations of anti-disialosyl galactosyl globoside (DSGG), anti-fucosyl GM1 and anti-Gb2 were significantly higher in patients with HCC than in chronic HBV infection individuals not in chronic HCV infection patients. Overall, in our study population, the biomarker candidates DSGG, fucosyl GM1 and Gb2 of CACAs achieved better predictive sensitivity than AFP. We identified potential biomarkers suitable for early detection of HCC. Glycan microarray analysis provides a powerful tool for high-sensitivity and high-throughput detection of serum antibodies against CACAs, which may be valuable serum biomarkers for the early detection of persons at high risk for HCC.

[Hepatitis C virus infection and hepatocarcinogenesis]

It is evidenced that both HBV and HCV infections may cause chronic hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC). HCV is considered as an oncogen virus. The mechanism of carcinogenesis in case of the two distinct viruses shows a number of common and different features. HCC usually develops in stage of liver cirrhosis caused by chronic inflammation of many years or decades. In contrast to HBC, HCV will not be incorporated into the genome of hepatocytes. It induces throughout different mechanisms the development of cancer cells, which will proliferate out of control. Before the discovery of HCV, the connection of non-A non-B (NANB) hepatitis and liver cancer has yet been observed. The subsequent epidemiological studies confirmed this association. A number of publications prove that HCC may develop without cirrhosis in HCV infected patients. The exact mechanism is not known, but data indicate that some proteins of the virus may induce oncogenic process. Differences were found in HCV core gene between HCC patients with and without cirrhosis. It is postulated that the virus evolves its oncogenic effect via endoplasmic and oxidative stress, further on by activation of different oncogenic signal pathways. Recent publications indicate the role of virus induced insulin resistance. Besides the virus determined factors, the host reaction, the deficient tumor cell eliminating capacity may also have a role in the development of liver carcinoma. Monitoring of HCV infected patients for HCC is an important clinical issue. Most relevant is the regular ultrasound cheek up. Serum alpha fetoprotein level is elevated only in a smaller proportion of the patients. The treatment protocol of HCV induced HCC does not differ from the others developed in non-HCV liver diseases.

Hepatocellular carcinoma in non-cirrhotic liver: a reappraisal

Although not frequently, hepatocellular carcinoma (HCC) can ensue in a non-cirrhotic liver. As compared to cirrhotic HCC, this kind of tumour has some peculiarities, such as: (a) a lower male preponderance and a bimodal age distribution; (b) a lower prevalence of the three main risk factors (hepatitis B and C virus infections and alcohol abuse), with an increased prevalence of other etiologic factors, such as exposure to genotoxic substances and sex hormones, inherited diseases, genetic mutations; (c) a more advanced tumour stage at the time of diagnosis, as it is usually detected due to the occurrence of cancer-related symptoms, outside any scheduled surveillance program; (d) a much higher amenability to hepatic resection, due to the low risk of liver failure even after extended parenchymal mutilation; (e) overall and disease-free survivals after resection of non-advanced tumours (meeting the Milano criteria) comparable to that obtained with liver transplantation in cirrhotic patients carrying an early tumour; (f) overall survival strictly dependent on tumour burden (and its recurrence) and barely influenced by liver function.

[Prognostic factors after resection of hepatocellular carcinoma in the non-cirrhotic liver: presentation of 51 cases]

BACKGROUND

Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients.

OBJECTIVE

To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival.

MATERIAL AND METHODS

Between 1990 and 2006, 51 patients were operated on. Data were retrospectively analysed from a prospectively collected database. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival.

RESULTS

Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75% and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41% and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis.

CONCLUSIONS

Major hepatic resection is a safe treatment for hepatocellular carcinoma in non-cirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable.

Lectin-based glycoproteomics to explore and analyze hepatocellular carcinoma-related glycoprotein markers

More and more new diagnostic biomarkers of hepatocellular carcinoma (HCC) have been found in association with advances in the standardization of 2-DE coupled with MS analysis. However, the diagnosis of HCC is still detected in the late stages of the disease, when treatment options are limited and prognosis is poor. The glycosylation of proteins is known to change in tumor cells during the development of HCC as the result of alterations in the levels of glycosyltransferases, such as increased fucosylation of Golgi Protein 73 and alpha-fetoprotein. These structural changes can influence the function or physiochemical properties of a protein, resulting in abnormal cancer cell behavior. Therefore, identification of HCC-related glycoprotein markers and analysis of glycan structural alterations might assist in the early detection of HCC. Here, we summarize lectin-based glycoproteomic strategies for the discovery of relevant biomarkers of HCC. The carbohydrate-binding specificities of different lectins offer a biological affinity approach that complements existing MS capabilities. These strategies involve the enrichment of glycoproteins or glycopeptides by lectins, followed by releasing carbohydrates with peptide-N-glycosidase F or reductive beta-elimination. The obtained glycopeptides are then identified by automated MS/MS and structural analysis of glycans is performed through modern methods such as quadrupole IT-TOF, MALDI-TOF/TOF and lectin microarray. These strategies will lead to faster and more clinically adaptable tests with greater sensitivity and specificity.

Experimental mouse models for hepatocellular carcinoma research

Every year almost 500,000 new patients are diagnosed with hepatocellular carcinoma (HCC), a primary malignancy of the liver that is associated with a poor prognosis. Numerous experimental models have been developed to define the pathogenesis of HCC and to test novel drug candidates. This review analyses several mouse models useful for HCC research and points out their advantages and weaknesses. Chemically induced HCC mice models mimic the injury-fibrosis-malignancy cycle by administration of a genotoxic compound alone or, if necessary, followed by a promoting agent. Xenograft models develop HCC by implanting hepatoma cell lines in mice, either ectopically or orthotopically; these models are suitable for drug screening, although extrapolation should be considered with caution as multiple cell lines must always be used. The hollow fibre assay offers a solution for limiting the number of test animals in xenograft research because of the ability for implanting multiple cell lines in one mouse. There is also a broad range of genetically modified mice engineered to investigate the pathophysiology of HCC. Transgenic mice expressing viral genes, oncogenes and/or growth factors allow the identification of pathways involved in hepatocarcinogenesis.

Capn4 overexpression underlies tumor invasion and metastasis after liver transplantation for hepatocellular carcinoma

Liver transplantation (LT) is one of the best therapeutic options for nonresectable hepatocellular carcinoma (HCC). Unfortunately, some HCC patients succumb to the disease after LT, which reduces long- and medium-term survival. To identify the proteins associated with HCC invasion and metastasis, HCC patients undergoing LT with complete follow-up data were included in this study and were categorized into recurrence and nonrecurrence groups. We extracted the total protein from the acquired homogeneous tumor cells and applied a cleavable isotope-coded affinity tag technology to quantitate relative changes in protein levels between the two groups. We identified a total of 149 proteins with two-dimensional liquid chromatography coupled with tandem mass spectrometry, including 52 differentially expressed proteins by at least two-fold. Among them, calpain small subunit 1 (Capn4), a protein with relevant interactions with many migration-invasion-related proteins, has attracted more attention. First, Capn4 overexpression in the recurrence group was confirmed via real-time polymerase chain reaction and western blotting in another cohort of 40 HCC patients undergoing LT. Second, Capn4 was associated with enhanced invasiveness in vitro. The small interfering RNA-mediated knockdown expression of Capn4 in HCC cell lines significantly inhibited its mobile and invasive ability. Tissue microarray in a further 192 cases revealed that Capn4 significantly correlated with invasive phenotype of HCC, and univariate and multivariate analyses indicated that Capn4 is an independent prognostic factor for recurrence and survival of HCC patients.

CONCLUSION

Our study revealed that Capn4 overexpression underlies invasion and metastasis after LT for HCC and might be a candidate biomarker for future diagnosis and a target for therapy.

Hepatocellular carcinoma: epidemiology, risk factors and pathogenesis

Hepatocellular carcinoma (HCC) is the commonest primary malignant cancer of the liver in the world. Given that the burden of chronic liver disease is expected to rise owing to increasing rates of alcoholism, hepatitis B and C prevalence and obesity-related fatty liver disease, it is expected that the incidence of HCC will also increase in the foreseeable future. This article summarizes the international epidemiology, the risk factors and the pathogenesis of HCC, including the roles of viral hepatitis, toxins, such as alcohol and aflatoxin, and insulin resistance.

Hepatocellular carcinoma: Epidemiology, risk factors and pathogenesis

Hepatocellular carcinoma (HCC) is the commonest primary malignant cancer of the liver in the world. Given that the burden of chronic liver disease is expected to rise owing to increasing rates of alcoholism, hepatitis B and C prevalence and obesity-related fatty liver disease, it is expected that the incidence of HCC will also increase in the foreseeable future. This article summarizes the international epidemiology, the risk factors and the pathogenesis of HCC, including the roles of viral hepatitis, toxins, such as alcohol and aflatoxin, and insulin resistance.

Proteomics of viruses

Proteomics is a promising approach for the study of viruses allowing a better understanding of disease processes and the development of new biomarkers for diagnosis and early detection of disease, thus accelerating drug development. Viral proteomics has included the analysis of viral particles to determine all proteins that compose the infectious virus, the examination of cellular proteins associated with a single viral protein in the hopes of determining all the functions of that viral protein, or the determination of cellular proteins induced or altered during a particular disease state. Viral particles of human cytomegalovirus (HCMV) and Kaposi's sarcoma-associated herpesvirus/human herpesvirus 8 (KSHV/HHV-8) have been recently examined. During the herpesviral replicative cycle, different viral particles are formed. For HCMV, this includes mature, infectious virions, noninfectious enveloped particles, and dense bodies. A proteome database of B-lymphoblastoid cell lines (LCLs), before and after transformation, has been developed to identify the cellular mechanisms of virus-induced immortalization. 2DE is used to first separate proteins based on their relative charge (pI) and then based on their molecular weight. Proteomic analysis has provided a unique tool for the identification of diagnostic biomarkers, evaluation of disease progression, and drug development. It is also an important approach for clinical diagnostics.

Telomerase reverse transcriptase mRNA expression in peripheral lymphocytes of patients with chronic HBV and HCV infections

Telomerase activity is present at low levels in peripheral lymphocytes (PL) and is upregulated upon activation, possibly protecting PL from telomere shortening. As decreased telomere length is considered a sign of cellular senescence, telomerase may, therefore, play an important role on immune function, organ regeneration and carcinogenesis. So far, quantification of human telomerase reverse transcriptase levels (hTERT) in PL, has not been reported. We determined hTERT mRNA levels in PL of hepatitis B virus (HBV) and hepatitis C virus (HCV) patients, in an attempt to address whether hTERT transcripts in PL are altered in these viral diseases, which are characterized by immune dysfunction and increased incidence of hepatocarcinogenesis. hTERT mRNA levels in PL of HBV (n = 17), HCV (n = 24) patients and healthy controls (n = 22) were quantified by real-time polymerase chain reaction. We observed significantly lower hTERT mRNA levels in HBV and HCV patients compared with healthy individuals (P < 0.05). hTERT mRNA levels were not associated with the patients' clinical status (inactive, hepatitis and cirrhosis). Also no correlation was observed between hTERT mRNA expression, and HBV and HCV replicative activity. In the inactive group (n = 18) we observed a negative correlation between hTERT mRNA expression and disease duration (rs = -0.52, P < 0.03). We performed for the first time an accurate quantification of hTERT mRNA expression in PL of HBV and HCV patients. The observed low levels of hTERT mRNA expression in the above patients may suggest its involvement in the immunopathogenesis of chronic viral hepatitis.

Prognostic factors and longterm survival after hepatic resection for hepatocellular carcinoma originating from noncirrhotic liver

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) in cirrhotic and noncirrhotic liver is increasing in the world, probably because of the high prevalence of infections by hepatitis B and C viruses. Despite numerous publications on hepatic resection, prognostic factors for intrahepatic recurrence and survival are not well known for patients with HCC without cirrhosis.

STUDY DESIGN

One hundred eight consecutive patients with HCC in noncirrhotic liver have been treated by hepatic resection in the past 18 years in our center. Clinical, biologic, and histopathologic parameters of these patients were collected. Risk factors for intrahepatic recurrence and prognostic factors for survival were evaluated by univariate and multivariate analyses.

RESULTS

Postoperative morbidity and mortality rates were 23% and 6.5%, respectively. The 3- and 5-year disease-free and overall survival rates were 55% and 43%, and 43% and 29%, respectively. Blood transfusion, absence of tumor capsule, and daughter nodules were independently associated with overall survival. But the only risk factors for recurrence were blood transfusion, absence of tumor capsule, daughter nodules, and margin resection < 10 mm.

CONCLUSIONS

In the treatment of HCC without cirrhosis, hepatectomy remains a safe and legitimate treatment, but longterm results are impaired by a high rate of early recurrence likely related to metastatic dissemination. Only histopathologic factors related to the tumor are predictive of recurrence and overall survival.

Gene expression in HCV-associated hepatocellular carcinoma--upregulation of a gene encoding a protein related to the ubiquitin-conjugating enzyme

BACKGROUND/AIMS

To investigate gene expression in HCV-associated human hepatocellular carcinomas (HCC) by identifying up- and down-regulated genes.

METHODS

Differential display RT-PCR was used to compare levels of gene expression in tumorous and non-tumorous tissues from the same livers. Differential expression was confirmed using a ribonuclease protection assay (RPA). The relative expression levels of one candidate gene were studied in various normal tissues and malignant cell lines using a multiple tissue expression (MTE) array. Further characterisation of this gene was carried out using nucleotide sequence analysis programmes and Northern hybridisation.

RESULTS

Fifty-two differentially expressed cDNA fragments were identified and 29 were cloned, sequenced and compared with the nucleotide sequence database. RPA confirmed reproducibly that one particular cDNA was upregulated in the tumour cells. Analysis using the MTE array revealed that this selected candidate gene is expressed at high levels in various human tumour cell lines. The expression levels in HCV-associated HCC were higher than in other tumours. Investigation revealed that this novel gene lies on chromosome 17. The transcript is approximately 2.5 kb in size and encodes a protein similar to the ubiquitin-conjugating enzyme.

CONCLUSIONS

The ubiquitin system may be involved in HCV-related hepatocarcinogenesis and in the development of other cancers.

Epidemiology, risk factors, and natural history of hepatocellular carcinoma

The incidence of hepatocellular carcinoma is increasing in many countries. The estimated number of new cases annually is over 500,000, and the yearly incidence comprises between 2.5 and 7% of patients with liver cirrhosis. The incidence varies between different geographic areas, being higher in developing areas; males are predominantly affected, with a 2:3 male/female ratio. The heterogeneous geographic distribution reflects the epidemiologic impact of the main etiologic factors and environmental risk, which are the hepatitis B (HBV) and hepatitis C (HCV) viruses. The percentage of cases of hepatocellular carcinoma attributable to HBV worldwide is 52.3% and is higher in Asia where the seroprevalence of HBsAg in the population is high. However, the vaccination campaign against this virus in some eastern countries has tended to lower the incidence of new cases of hepatocellular carcinoma. The percentage of cases of hepatocellular carcinoma attributable to HCV is 25%, and it is more prevalent in Japan, Spain, and Italy where the association between hepatocellular carcinoma and antibodies to HCV ranges between 50 and 70%. In most cases hepatocellular carcinoma develops in cirrhotic livers, where the persistent proliferation of liver cells represents the key factor of progression to hepatocellular carcinoma independent of the etiology. Another minor risk factor is aflatoxin B1 consumption, which is responsible for most cases of hepatocellular carcinoma in Africa, where the consumption of contaminated foods is common. Other known risk factors are some hereditary diseases, such as hemochromatosis, porphyria cutanea tarda, hereditary tyrosinemia, and alpha1 anti-trypsin deficiency. The natural history of hepatocellular carcinoma is heterogeneous and is influenced by nodule dimension, the mono- or plurifocality of lesions at diagnosis, the growth rate of the tumor, and the stage of the underlying cirrhosis. Available data to date suggest that tumor growth in a cirrhotic liver is variable and that the time in which a lesion in undetectable until it becomes 2 cm is between 4 and 12 months. Therefore, the suggested interval for surveillance screening with ultrasound in patients with liver cirrhosis has been set at 6 months. Patients who should benefit from screening programs are those who would be treated with curative therapy if diagnosed with hepatocellular carcinoma. Thus, the ideal target population should be limited to Child-Pugh's class A cirrhotic patients without significant comorbidity.

Hepatocellular carcinoma in southern Germany: epidemiological and clinicopathological characteristics and risk factors

The aetiology of chronic liver disease leading to hepatocellular carcinoma (HCC) and the clinical characteristics of patients with HCC vary considerably internationally and intranationally. This study analyses the characteristics of HCC patients in southern Germany, a low endemic area of HCC.

METHODS

The files of 118 consecutive patients with HCC observed in a single tertiary care hospital between 1994 and 2000 have been reviewed. Epidemiological and clinicopathological characteristics such as age at presentation, ethanol consumption, serological hepatitis virus markers, and fibrosis were studied. Additionally, serum levels of alpha-fetoprotein (AFP) were analysed at the time of diagnosis in 77 patients.

RESULTS

The male:female ratio was 4:1 and the mean age at presentation was 61.8 years. Alcohol abuse (49.2%) and chronic hepatitis C infection (17.8%) were the most frequent risk factors. Histologically proven liver cirrhosis in the surrounding non-tumorous tissue was present in only 59.0% of cases. AFP levels were elevated in 78% of cases, but only 34% reached >500 ng/ml, a value considered to be significant for the diagnosis of HCC. AFP levels correlated with the stage of fibrosis.

SUMMARY AND CONCLUSIONS

The sensitivity of AFP serum levels as a tumour marker is poor but might help to detect at least a minority of cases. As in other populations within Europe, chronic alcohol abuse is frequently associated with HCC in southern Germany, confirming that alcohol is still the most important risk factor for hepatocarcinogenesis in areas with low hepatitis virus prevalence. Considering the poor prognosis of HCC, prevention is of pivotal importance, particularly for patients with chronic liver disease and other risk factors for the development of HCC.

Hepatocellular carcinoma: an overview

Hepatocellular carcinoma remains widely prevalent in tropical Africa and south-east Asia and is largely related to chronic hepatitis B virus (HBV) infection. Primary prevention by vaccination of infants at or near birth is effective but any reduction in tumour incidence cannot be expected for decades to come yet, even in those countries in which the necessary resources exist, as millions of adults remain chronically infected. Meanwhile, the incidence is rising in Japan, Mediterranean countries of Europe, Middle East and North Africa and in the USA, largely due to chronic hepatitis C virus (HCV) infection introduced by the indiscriminate use of unscreened blood and blood products in the recent past. Much has been learned from molecular biological studies on hepatocarcinogenesis incriminating the HBX gene of HBV, the core protein of HCV and a unique guanine to thymine transversion at codon 249 has been observed in cases due to aflatoxin exposure. The subject of precancerous lesions, notably adenomatous/dysplastic nodules and large-cell/small-cell change continues to be a source of much debate and the distinction of nodular lesions in cirrhosis from early carcinoma remains uncertain. Spontaneous regression of hepatocellular carcinoma is rare but it is probably immunologically mediated and treatment by activated T-lymphocytes may reduce recurrence rates after surgery. The positive identification of hepatocellular carcinoma by a liver-specific antibody has greatly facilitated the diagnosis in difficult cases.

Octreotide for cancer of the liver and biliary tree

Inoperable liver tumors have an unfavorable natural course despite various therapeutic modalities. Octreotide, a somatostatin analog, has shown considerable antitumor activity on animal models of various hepatic tumors and on isolated cell culture lines. In this paper, a review of the experimental evidence is presented. Moreover clinical papers of case reports of uncontrolled studies of patients are also reviewed. The majority of clinical studies provide evidence of a clinical and biochemical response of liver endocrine tumors while regression of tumor size is a rare event. A randomized controlled trial of octreotide in the treatment of advanced hepatocellular carcinoma has shown a significant survival benefit in the treated patients. Literature reports indicate a stimulatory effect of octreotide on Kupffer cells as a possible antitumor mechanism, but other antiproliferative actions of octreotide have been suggested but not proved. Finally the question of the presence and affinity of somatostatin receptors on liver tumor tissue is discussed. In conclusion, according to our experience, octreotide administration is the best available treatment for advanced inoperable hepatocellular carcinoma and future better patient selection, based on receptor subtypes, might further improve the results.

Prognostic factors and survival after hepatic resection for hepatocellular carcinoma without cirrhosis

BACKGROUND

Detailed follow-up of patients with chronic hepatitis has resulted in increased diagnosis of hepatocellular carcinoma (HCC) in patients without cirrhosis. Despite numerous studies on hepatic resection, the prognostic factors for intrahepatic recurrence and survival are not well known for patients with HCC without cirrhosis.

METHODS

Among 349 patients with HCC treated in the past 13 years, cirrhosis was absent in 126 patients (36 per cent). Curative hepatic resection was carried out in 100 (79 per cent) of these patients. Risk factors for intrahepatic recurrence and prognostic factors for survival were evaluated by univariate and multivariate analyses.

RESULTS

Postoperative morbidity and mortality rates were 22 and 3 per cent respectively. The 5- and 10-year disease-free and overall survival rates were 31 and 50 per cent, and 22 and 47 per cent respectively. Blood loss, surgical resection margin, intrahepatic metastasis, portal vein invasion and extent of hepatic resection were independently associated with overall survival. However, the only risk factors for intrahepatic recurrence were portal vein invasion and hepatitis C virus (HCV) infection. The former was related to early recurrence while the latter was related to later recurrence. The 5-year disease-free survival rate was 58 per cent in patients with hepatitis B virus infection while it was 6 per cent in patients with HCV infection (P < 0.001).

CONCLUSION

In the treatment of HCC without cirrhosis, major hepatectomy is advocated to prevent early recurrence. Liver transplantation may be required for patients with HCV infection.

The importance of hepatic resection for hepatocellular carcinoma originating from nonfibrotic liver

BACKGROUND

Our study aimed to clarify the characteristics of hepatocellular carcinoma (HCC) in patients with a nonfibrotic liver and the role of surgical resection for HCC in nonfibrotic liver compared with patients with HCC in fibrotic or cirrhotic livers.

STUDY DESIGN

A total of 516 patients who underwent hepatectomy between April 1985 and June 1999 were classified into two groups: a nonfibrotic liver group (n=65) and a fibrotic liver group (n=451), which included fibrotic or cirrhotic livers. Clinicopathologic variables were then compared between the groups, including disease-free survival rate and patient survival rate.

RESULTS

Only 8 of 65 patients (12.3%) with a nonfibrotic liver showed a histologically completely normal liver. The numbers of men and patients with alcohol abuse in the nonfibrotic liver group were higher than in the fibrotic liver group. The numbers of patients with positive hepatitis B antigen and positive hepatitis C antibody in the nonfibrotic liver group were lower than in the fibrotic liver group. Results of liver function tests in the nonfibrotic liver group were better than those in the fibrotic liver group. The rates of both portal vein and hepatic vein invasion of cancer cells in the nonfibrotic liver group were higher than in the fibrotic liver group. The tumor size in the nonfibrotic liver group was larger than in the fibrotic liver group. The patient survival and disease-free survival rates in the nonfibrotic liver group were better than in the fibrotic liver group.

CONCLUSIONS

Hepatic resection can be beneficial for patients with HCC originating from a nonfibrotic liver when compared with fibrotic or cirrhotic patients with HCC.

Hepatocellular carcinoma occurring in nonfibrotic liver: epidemiologic and histopathologic analysis of 80 French cases

Hepatocellular carcinoma (HCC) occurring in nonfibrotic liver represents a rare, ill-defined subgroup of HCC without cirrhosis in which mechanisms of hepatocarcinogenesis remain unclear. The aim of our study was to assess epidemiological factors and detailed histopathologic changes in the nontumoral liver of patients developing such tumors. Of 330 HCCs resected in our institution between 1985 and 1998, we retrospectively analyzed 80 cases (53 men, 27 women; mean age, 51 +/- 16 years) in which the nontumoral liver showed no (n = 28) or minimal (n = 52) portal fibrosis without any septal fibrosis. In the group with no portal fibrosis there was no male predominance, and patients were significantly younger (44 +/- 19 years vs. 54 +/- 14 years) than those with minimal portal fibrosis. Sixty-seven tumors were typical HCCs, 8 were of fibrolamellar type, and 5 were hepatocholangiocarcinomas. Mean tumor size was 10 +/- 5 cm. Risk factors for HCC development were found in 30 patients: hepatitis B (n = 17) or C (n = 2) virus infections, alcohol consumption (n = 11), and hemochromatosis (n = 1). In the nontumoral liver, periportal and lobular necrosis, mild portal inflammation, steatosis, and iron overload were present in 15%, 57%, 52%, and 54% of cases, respectively. Liver cell changes were noted in 6%. This study emphasizes the need for strict criteria to classify HCC without cirrhosis. HCC in nonfibrotic liver is a distinct subgroup in which nontumoral liver shows nonspecific minimal changes without regeneration or premalignant lesion. Etiologic factors are often unidentified, although presence of HBV infection in 21% suggests a direct oncogenic role of this virus.

Incidence of primary cholangiocellular carcinoma of the liver in japanese patients with hepatitis C virus-related cirrhosis

BACKGROUND

Hepatitis C virus (HCV) infection is a major risk factor for the development of hepatocellular carcinoma. However, the risk factors for primary cholangiocellular carcinoma of the liver (PCC-L) have not been fully investigated. The authors determined the incidence of PCC-L in patients with HCV-related cirrhosis.

METHODS

Between 1980 and 1997, the authors prospectively studied 600 consecutive patients for the appearance of PCC-L; these patients were positive for HCV and later developed cirrhosis. The follow-up period ranged from 0 to 18.5 years (median, 7.2 years).

RESULTS

During the observation period, PCC-L developed in 14 patients (2.3%). Among these, 11 (1.8%) had cholangiocellular carcinomas and the other 3 (0.5%) had a combined type of hepatocellular and cholangiocellular carcinoma. Within the same period, hepatocellular carcinoma (HCC) developed in 206 patients (34.3%). The cumulative rates of newly diagnosed PCC-L were 1.6% at 5 years and 3.5% at 10 years, which was about 1000 times higher than the estimated incidence of PCC-L in the general population of Japan. PCC-L was treated by surgical resection in 3 patients who survived for > 3 years. However, the other 11 patients received palliative therapy or chemotherapy. The survival rates among PCC-L patients were 39.3%, 23. 6%, and 16.5% at the end of 1, 3, and 5 years, respectively, and were significantly lower than those of HCC (P = 0.0001).

CONCLUSIONS

The results of this study show a relatively high incidence of PCC-L in patients with HCV-related cirrhosis, and also show that this type of liver cancer is associated with a relatively poor prognosis. These results indicate that HCV-related cirrhosis is a major risk factor for PCC-L in Japanese patients.

Increased incidence of HFE C282Y mutations in patients with iron overload and hepatocellular carcinoma developed in non-cirrhotic liver

BACKGROUND/AIMS

Histological and biochemical iron overload has been reported in non-tumoral liver of most patients presenting an hepatocellular carcinoma (HCC) developed in non-cirrhotic liver (NCL). The aim of our study was to investigate HFE mutations in patients with HCC in NCL.

METHODS

Thirty-five patients with HCC in NCL were included either retrospectively or prospectively. Clinical data, iron and viral status, and HFE gene mutations were compared between groups with (I+, n = 19) or without histological iron overload (I-, n = 16).

RESULTS

Twenty per cent of patients were HBV or HCV positive. Fifty-four per cent had hepatocytic iron overload at histology. Mean hepatic iron concentration was 100.2 +/- 14.6 micromol/g in I+ versus 23.2 +/- 2.1 micromol/g in I- (p<0.001). Among the 19 I+ patients, eight mutations were found: two C282Y/C282Y, three C282Y/WT, two C282Y/H63D and one H63D/H63D. None of these mutations was found in the I- group. There was no significant difference concerning the H63D heterozygous mutation between I+ or I- patients.

CONCLUSIONS

In patients with HCC in NCL, HBV and HCV markers are rare (20%), and mild iron overload is frequent (54%). In patients with HCC in NCL and iron overload, C282Y mutations are frequent (36.8% of cases) and significantly increased (p<0.009) compared to HCC in NCL without iron overload; these mutations are mostly heterozygous. H63D heterozygosity is not associated with liver iron overload. Because of the small size of the series, HFE C282Y mutation should be investigated on a larger scale in patients with HCC in NCL with iron overload in order to confirm this association.

Correlation of clinicopathologic features of resected hepatocellular carcinoma with hepatitis C virus genotype

Clinicopathologic findings in patients with hepatocellular carcinoma complicating hepatitis C virus and outcomes after liver resection were compared between different viral genotypes. One hundred and forty-seven patients with both anti-hepatitis C virus antibody and hepatitis C virus RNA in their sera underwent curative resection for hepatocellular carcinoma in our department between 1991 and 1997. Of these patients, 115 were infected with hepatitis C virus genotype 1b (group 1), and 32 were infected with 2a or 2b (group 2). Clinicopathologic findings and outcomes after operation were compared between the two groups. Alanine aminotransferase activity was significantly higher in group 2 than in group 1. Genotypes did not differ concomitantly with histopathologic features of the carcinoma or adjacent hepatic tissue. Although the tumor-free survival rate did not differ significantly between the two groups, recurrence was not detected during the period beyond 3 years following operation in group 2, while recurrences arose during that period in 16 group 1 patients, most of whom continued to manifest active hepatitis. In 7 of these 16 patients, the recurrent tumors were histologically multicentric in origin. The cumulative survival rate was significantly lower in group 1 than 2. Multivariate analysis indicated that genotype 1b was an independent risk factor for short survival. Patients infected with genotype 1b may have a relatively high risk of ongoing hepatocarcinogenesis and more aggressive progression of associated liver dysfunction, resulting in a poorer outcome than with other genotypes.

Hepatitis viruses: their role in human cancer

Hepatitis B virus (HBV) has been shown to be linked causally to the development of hepatocellular carcinoma (HCC) in humans. One of the HBV gene products, the "X" protein, has been specifically implicated in the malignant transformation of hepatocytes; mutations in one or more of the HBV structural proteins have also been linked to HCC. HBV DNA may act as an insertional mutagen in the myc family of genes. Mutations within the pre-core and core promoter regions of HBV-DNA have also been associated with the development of HCC. Patients chronically infected with hepatitis C virus (HCV) often develop cirrhosis; a significant proportion of these patients progress to HCC. Although numerous genotypes of HCV exist, type 1b is most often associated with the eventual development of HCC in chronically infected patients. The molecular mechanisms for the malignant transformation of hepatocytes by HCV have not been elucidated.

Broadsheet number 47: Chronic hepatitis: an update with guidelines for histopathological assessment of liver biopsies. Board of Education of The Royal College of Pathologists of Australasia

The liver biopsy remains the 'gold standard' for the diagnosis of chronic hepatitis, particularly since it is the only investigation that permits assessment of the severity (grade of histological activity and stage of fibrosis) of liver injury. As outlined below, the liver biopsy is invaluable for both diagnosis and the monitoring of therapy. To optimise the value of the liver biopsy, a standardised approach for assessment and reporting of chronic hepatitis is recommended.

Impact of HBV, HCV and GBV-C/HGV on hepatocellular carcinomas in Europe: results of a European concerted action

BACKGROUND/AIMS

To investigate the impact of hepatitis B (HBV) and C (HCV) infections on hepatocellular carcinoma (HCC) in Europe.

METHODS

Five hundred and three patients with HCC, from six liver centers, were included. All 503 sera and 80 liver samples were tested for HBV DNA and HCV RNA by polymerase chain reaction. GBV-C/HGV RNA was also tested in 57 sera.

RESULTS

HBsAg and anti-HCV were detected in 19% and 40.1% of the patients, respectively. Serum and liver HBV DNA were detected in 82% and 91% of the HBsAg positive subjects. HBV DNA was also detected in the serum and liver of 33% and 47% of HBsAg negative patients. In this group, serum HBV DNA was more prevalent in anti-HBs and/or anti-HBc patients (47.9%), compared to those without any HBV marker (25.1%). HCV RNA was detected in 89% and 7% of anti-HCV positive and negative cases, respectively, HCV 1b being the most prevalent genotype (80%). Coinfection with HBV and HCV was shown in 20.4% of patients, while only 29% had neither HBV nor HCV GBV-C/HGV RNA was detected in only 4/57 sera.

CONCLUSIONS

This study offers the first large analysis of HCC in Europe, based on both serology and molecular tests. It demonstrates the major impact of HBV and HCV, but not of GBV-C/HGV, in liver carcinogenesis in Northern as well as Southern Europe. It also stresses the need to use viral genome detection in epidemiological studies when serological tests are negative.

Primary hepatocellular carcinoma in workers exposed to vinyl chloride: a report of two cases

BACKGROUND

Vinyl chloride (VC), an industrial toxic gas, has a dose-dependent carcinogenicity in rodents and has been responsible for multiple cases of liver angiosarcoma in humans. The aim of this study was to describe histopathologic liver alterations and to evaluate risk factors for hepatocellular carcinoma in two workers from the same plant, both of whom had primary nonangiosarcoma liver tumors and were exposed to VC.

METHODS

Clinical, biochemical, serologic, and pathologic data were reviewed at the time of hepatic resection. Clinical and biologic follow-up were available for several years before the diagnosis of hepatocellular carcinoma.

RESULTS

Liver alterations distant from the tumor site were compatible with ongoing exposure to VC in both cases. Several areas containing dysplastic hepatocytes were present in nontumoral liver in one patient. Both patients are alive after partial liver resection, and 1 has had 5 years of follow-up without recurrence.

CONCLUSIONS

Exclusion of classic risk factors for noncirrhotic hepatocellular carcinoma of the liver in both patients suggests a relationship between VC exposure and observed tumors. Systematic long term follow-up with biology and ultrasonography for workers exposed to VC may result in relatively early diagnoses of liver tumors and long term survival in some cases.

Hepatitis C virus infection and extrahepatic malignancies

An association between chronic hepatitis C (HCV) infection and non-Hodgkin's lymphoma has been reported. We carried out this study to evaluate the possibility of an association between HCV infection and other extrahepatic malignancies. The medical records of 103 unselected, consecutively chosen, anti HCV-positive and 105 hepatitis B surface antigen (HBsAg)-positive patients attending the liver clinic or hospitalized in the Department of Medicine were reviewed. Patients in whom anti-HCV positivity was detected after the malignancy was diagnosed were excluded. Malignancy rates in the general Israeli population were obtained from the Israeli cancer registry. The ages of anti-HCV-positive and HBsAg-positive patients were 54 +/- 16 (+/-SD) (range, 15-84) and 45 +/- 12 (range, 20-78) years, respectively; the male/female ratios were 50/53 and 73/32, respectively. Extrahepatic malignancies were found in 15 (14.6%) of the anti-HCV and in three (2.9%) of the HBsAg-positive patients. Thirteen of the malignancies were found among the 60 anti-HCV-positive patients aged > or =55 years old. Only one malignancy was found among the 28 HBsAg-positive patients of the same age group (p < 0.01). The rate of extrahepatic malignancies in these HCV-infected patients was significantly higher (p < 0.01) than expected in the general population. An association between HCV infection and extrahepatic malignancy may exist, but further prospective studies, including a large number of patients with HCV infection, will be necessary to define this observation.