Viruses and hepatocellular carcinoma

Inferior Outcomes Associated with the Coexistence of Hepatocellular Carcinoma Recurrence and Hepatic Virus Reinfection After Living Donor Liver Transplantation

BACKGROUND

Chronic viral hepatitis remains a major etiology of liver cirrhosis and hepatocellular carcinoma. Liver transplantation has been considered an effective treatment for this condition. This study aims to analyze living donor liver transplantation for patients with hepatocellular carcinoma and its relationship with hepatitis virus status.

METHODS

A retrospective analysis of 268 patients who received living donor liver transplantation for hepatocellular carcinoma was performed. Patients were analyzed according to their serologic status of hepatitis virus; clinicopathologic features, operative parameters, and outcomes were also assessed and compared.

RESULTS

Twenty-three patients (8.6%) had hepatocellular carcinoma recurrence following liver transplantation; the most common pattern of recurrence was systemic spreading (n = 10). Hepatitis B virus relapse was encountered in 41 out of 188 patients (21.8%) with hepatitis B virus-positive, and hepatitis C virus reactivation was noted in 48 (60.8%) patients among 79 hepatitis C virus-positive patients. Incidence of hepatitis C virus reactivation was significantly higher than that of hepatitis B virus relapse (p < 0.0001). Hepatocellular carcinoma recurrence and overall survival were not significantly different in relation to hepatitis virus; however, patients who had hepatocellular carcinoma recurrence combined with hepatitis virus reinfection had the significantly lowest survival rate compared with other groups (p < 0.0001).

CONCLUSION

Living donor liver transplantation based on expanded hepatocellular carcinoma criteria achieved a satisfactory result, but reinfection of hepatic virus remains a great concern particularly in patient with hepatitis C. Moreover, hepatocellular carcinoma recurrence accompanied with reinfection of hepatic virus after liver transplantation is associated with inferior outcomes.

Helicobacter pylori Infection as a Risk Factor for Hepatocellular Carcinoma: A Case-Control Study in Ethiopia

Background and Aims. Hepatocellular carcinoma is a major cause of cancer death worldwide, accounting for over half a million deaths per year. Its incidence varies with geographic locations and the type of etiologic factors. In Ethiopia, unidentified causes of liver disease are of sizeable proportion. Recent studies have shown an association of H. pylori infection with different spectrums of chronic liver disease. This study was conducted at St. Paul's Hospital Millennium Medical College in Ethiopia and assesses liver cancer and the association with H. pylori infection. Method. A prospective case-control study conducted on patients with chronic liver disease presenting with a suspicious liver lesion and diagnosed to have HCC in the Gastrointestinal (GI) Clinic of St. Paul's Hospital MMC from Dec 30, 2016, to Nov 1, 2017 G.C. Descriptive surveys on clinical history and physical examination and laboratory profiles were obtained, and the clinical course of the patients including the type of treatment was followed prospectively. Control cases were taken from adult patients without evidence of liver disease in the internal medicine clinic coming for routine evaluation. After collection data were analyzed using SPSS version 23 and associations were assessed using chi-square test. Binary logistic regression was used to assess the association of HCC with different variables and H. pylori infection. All variables with p-value <0.05 were considered as statistically significant. Results. One hundred twenty patients were analyzed with equal representation of cases and controls. The majority of patients with HCC were male with a mean age of 36 years. Older age adjusted Odds Ratio (AOR) (95%CI, p-value) 1.07(1.03-1.09, <0.001), viral hepatitis B (AOR) (95%CI, p-value) 6.19 (1.92-19.93, 0.002), and H. pylori infection (AOR) (95%CI, p-value) 5.22 (2.04-13.31, <0.001) were statistically significantly associated with HCC. Conclusion. H. pylori infection is associated with HCC in this case-control study. This study supports the emerging evidence of H. pylori association with other extra-gastric manifestations.

Time trend analysis of primary liver cancer incidence in Sihui county of Guangdong Province, China (1987-2011)

BACKGROUND

Southern China is an endemic area for primary liver cancer (PLC), but it is unclear if rates have changed in recent decades. We evaluated PLC incidence and estimated the effects of age, period of diagnosis, and birth cohort in Sihui City, Guangdong Province, China.

METHODS

Age-standardized rates (ASRs) of PLC were examined for both males and females from 1987 to 2011. Joinpoint regression analysis was conducted to estimate the annual percent changes in PLC incidence. The age-period-cohort (APC) model was used to investigate the effects of age, diagnosis period, and birth cohort on the relative risk (RR) of PLC.

RESULTS

A total of 2988 PLC cases were identified in this period, with average ASRs of 51.1/100,000 for males and 11.7/100,000 for females. Joinpoint regression analysis revealed increasing PLC incidence throughout the entire period in both males (average annual change of 1.65 %) and females (0.20 %). RRs increased gradually in both sexes from the youngest age group (30-34 years) to the oldest (80-84 years). In males, the RR decreased during diagnosis period from 1987-1991 to 1997-2001 and remained stable thereafter. In females, RRs fluctuated with diagnosis period throughout the entire period. Incidence tended to increase with birth cohort from 1905-1909 to 1975-1979 in both males and females; however, female incidence plateaued in the youngest cohorts born between 1955 and 1974, while incidence in males increased sharply in the cohorts born between 1965 and 1974. According to APC analysis, the full age-period-cohort (APC) model fit the data best, and the period-cohort (PC) model would be enough to explain variability of rates in females.

CONCLUSION

The PLC incidence rate in males of Sihui City has increased more significantly than female over the last 25 years. Despite the age effect in male, this trend mainly reflects the effects of risk factors that are present in early life (birth cohort) and period change in both genders.

Th1/Th2 cytokines and their genotypes as predictors of hepatitis B virus related hepatocellular carcinoma

Hepatocellular carcinoma (HCC), the predominant type of primary liver cancer, is one of the most serious life-threatening malignancies, worldwide. In majority of the cases, HCC develops after prolonged and persistent chronic liver disease. hepatitis B virus (HBV) or HCV infection is prominent etiological factors, attributing to this condition. It has been well documented that HBV, being the inducer of chronic inflammation, is the main causative agent in causing HCC, particularly in Asian countries. The HBV infection leads to a wide range of clinical symptoms from carrier state to malignancy. Cytokines being immune-modulatory molecules, are the key mediators in the defense mechanism against viral infection. In this regard, this review will detail the substantial role of key Th1: interleukin 1 (IL-1), IL-2, IL-12, tumor necrosis factor-α, interferon-γ; Th2: IL-4, IL-10 and non Th1/Th2: IL-6, transforming growth factor-β1 cytokines genotypes in analyzing the variability in the clinical manifestations in an HBV-afflicted individual, which might finally, culminates into HCC. Since cytokine production is regulated genetically, the cytokine promoter region single-nucleotide polymorphisms induced changes, greatly affects the cytokine production, thus resulting into differential outcome of immune balance.

Golgi protein 73 as a biomarker for hepatocellular carcinoma: A diagnostic meta-analysis

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and the third leading cause of cancer-related mortality worldwide. Conflicting results have been reported regarding the use of serum Golgi protein 73 (GP73) as a promising serum marker for the diagnosis of HCC; therefore, the aim of the present study was to provide a systematic review of the diagnostic performance of GP73 for HCC. Following a systematic review of the relevant studies, a number of indices associated with the accuracy of the diagnostic performance of GP73, including the sensitivity and specificity, were pooled using Meta Disc 1.4 software. Data were presented as forest plots, and summary receiver operating characteristic (SROC) curve analysis was used to summarize the overall test performance. Eleven studies were included in this meta-analysis. The summary estimates for serum GP73 in diagnosing HCC were as follows: Sensitivity, 77% [95% confidence interval (CI), 75-79%]; specificity, 91% (95% CI, 90-92%); positive likelihood ratio, 4.34 (95% CI, 2.19-8.59); negative likelihood ratio, 0.30 (95% CI, 0.26-0.36) and diagnostic odds ratio, 15.78 (95% CI, 6.95-35.83). The area under the SROC curve was 0.8638, and the Q index was 0.7944. Significant heterogeneity was found. This meta-analysis indicates a moderate diagnostic value of GP73 in HCC; however, further studies with rigorous design, large sample size and multiregional cooperation are required.

Diagnostic Performance of Des-γ-carboxy Prothrombin for Hepatocellular Carcinoma: A Meta-Analysis

Background. There have been many reports on des-γ-carboxy prothrombin (DCP) as a promising serum marker in the diagnosis of hepatocellular carcinoma (HCC); however, the results are inconsistent and even conflicting. Methods. This meta-analysis was performed to investigate the performance of DCP in the diagnosis of HCC. Following a systematic review of relevant studies, Meta-DiSc 1.4 software was used to extract data and to calculate the overall sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). Data are presented as forest plots and summary receiver operating characteristic curve (SROC) analysis was used to summarize the overall test performance. Results. Twelve studies were included in our meta-analysis. The overall sensitivity, specificity, PLR, and NLR of DCP for the detection of HCC in the studies included were 71% (95%CI: 68%-73%), 84% (95%CI: 83%-86%), 6.48 (95%CI: 4.22-9.93), and 0.33 (95%CI: 0.25-0.43), respectively. The area under the SROC curve was 0.8930 and the Q index was 0.8238. Significant heterogeneity was found. Conclusion. This meta-analysis indicated that DCP had moderate diagnostic accuracy in HCC. Further studies with rigorous design, large sample size, and mmultiregional cooperation are needed in the future.

Specific molecular signatures of non-tumor liver tissue may predict a risk of hepatocarcinogenesis

Hepatocellular carcinoma (HCC) is one of the most common human cancers and a major cause of cancer-related death worldwide. The bleak outcomes of HCC patients even after curative treatment have been, at least partially, attributed to its multicentric origin. Therefore, it is necessary to examine not only tumor tissue but also non-tumor liver tissue to investigate the molecular mechanisms operating during hepatocarcinogenesis based on the concept of "field cancerization". Several studies previously investigated the association of molecular alterations in non-tumor liver tissue with clinical features and prognosis in HCC patients on a genome-wide scale. In particular, specific alterations of DNA methylation profiles have been confirmed in non-tumor liver tissue. This review focuses on the possible clinical value of array-based comprehensive analyses of molecular alterations, especially aberrant DNA methylation, in non-tumor liver tissue to clarify the risk of hepatocarcinogenesis. Carcinogenetic risk estimation based on specific methylation signatures may be advantageous for close follow-up of patients who are at high risk of HCC development. Furthermore, epigenetic therapies for patients with chronic liver diseases may be helpful to reduce the risk of HCC development because epigenetic alterations are potentially reversible, and thus provide promising molecular targets for therapeutic intervention.

Specific miRNA expression profiles of non-tumor liver tissue predict a risk for recurrence of hepatocellular carcinoma

AIM

It is reasonable to investigate non-tumor liver tissues to predict a risk for development of hepatocellular carcinoma (HCC). A molecular analysis of chronically damaged liver tissues may identify specific miRNA expression profiles associated with a risk for multicentric (MC) HCC.

METHODS

Twenty HCC patients, who underwent a curative hepatectomy were classified into two groups: a non-MC group (no MC recurrence in more than 3 years, n = 10) and an MC group (MC recurrence within 3 years after hepatectomy, n = 10). An miRNA microarray (955 probes) was used to compare the miRNA expression patterns of the non-cancerous liver tissues between the two groups. This study identified the differentially expressed miRNA related to MC recurrence in the liver remnant.

RESULTS

No differences were observed between the two groups in the liver function tests and pathological variables including both tumor factors and non-tumor liver tissues. The investigation selected 20 differentially expressed miRNA related to MC recurrence. Eighteen miRNA were downregulated, while two miRNA were upregulated in the MC group. A hierarchical clustering analysis identified a cluster that may be associated with risk of the MC recurrence of HCC. The MC recurrence-related miRNA included let-7d*, miR-328 and miR18a*, which potentially regulate K-ras gene expression. A significant inverse correlation between the miR-18a* expression and the K-ras mRNA expression was confirmed by quantitative reverse transcription polymerase chain reaction.

CONCLUSION

Specific miRNA expression signatures in non-cancerous liver tissue may help to predict the risk for de novo development of HCC.

Involvement of DNA damage response pathways in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has been known as one of the most lethal human malignancies, due to the difficulty of early detection, chemoresistance, and radioresistance, and is characterized by active angiogenesis and metastasis, which account for rapid recurrence and poor survival. Its development has been closely associated with multiple risk factors, including hepatitis B and C virus infection, alcohol consumption, obesity, and diet contamination. Genetic alterations and genomic instability, probably resulted from unrepaired DNA lesions, are increasingly recognized as a common feature of human HCC. Dysregulation of DNA damage repair and signaling to cell cycle checkpoints, known as the DNA damage response (DDR), is associated with a predisposition to cancer and affects responses to DNA-damaging anticancer therapy. It has been demonstrated that various HCC-associated risk factors are able to promote DNA damages, formation of DNA adducts, and chromosomal aberrations. Hence, alterations in the DDR pathways may accumulate these lesions to trigger hepatocarcinogenesis and also to facilitate advanced HCC progression. This review collects some of the most known information about the link between HCC-associated risk factors and DDR pathways in HCC. Hopefully, the review will remind the researchers and clinicians of further characterizing and validating the roles of these DDR pathways in HCC.

Risk factors for recurrence after curative resection of hepatitis C-related hepatocellular carcinoma in patients without postoperative interferon therapy

AIM

Hepatitis C (HC)-related hepatocellular carcinoma (HCC; HC-HCC) is highly recurrent.

METHODS

From 1995-2007, 183 curative hepatic resections for primary solitary HC-HCC without postoperative interferon therapy were included in this study. The patients were divided into three groups: (i) 2 cm or less (n = 56); (ii) more than 2 cm to less than 5 cm (n = 79); and (iii) 5 cm or more (n = 48). Independent risk factors for HC-HCC recurrence for each group were determined.

RESULTS

Independent risk factors for recurrence were aspartate aminotransferase or alanine aminotransferase (AST/ALT) of 80 IU/L or more (hazard ratio [HR], 2.1; P = 0.02) in patients with HCC of 2 cm or less, des-γ-carboxy prothrombin of 100 mAU/mL or more (HR, 2.5; P = 0.02) and AST/ALT of 80 IU/L or more (HR, 2.1; P = 0.04) in patients with HCC of more than 2 cm to less than 5 cm, and the presence of macroscopic portal vein tumor thrombus (HR, 2.8; P = 0.02) and AST/ALT of 80 IU/L or more (HR, 2.1; P = 0.04) in patients with HCC of 5 cm or more. All 13 late recurrences of 1 year or more after hepatic resection (27.1%) in patients with HCC of 5 cm or more were accompanied by AST/ALT of 80 IU/L or more.

CONCLUSION

AST/ALT of 80 IU/L or more is an independent risk factor for the recurrence of primary solitary HC-HCC after curative resection irrespective of the primary HC-HCC size.

Preoperative neutrophil-to-lymphocyte ratio is a predictor of survival after hepatectomy for hepatocellular carcinoma: a retrospective analysis

OBJECTIVE

To clarify the prognostic value of the preoperative blood neutrophil-to-lymphocyte ratio (NLR) in patients undergoing hepatectomy for hepatocellular carcinoma (HCC).

BACKGROUND

Although a high NLR has been reported to be a predictor of poor survival in patients with various cancers, it has not been extensively examined in patients with HCC.

METHODS

This retrospective study enrolled 958 patients who underwent hepatectomy without preoperative therapy for HCC from 1996 to 2009. Clinicopathological parameters, including NLR, were evaluated to identify predictors of overall and recurrence-free survival after hepatectomy. Univariate and multivariate analyses were performed, using the Cox proportional hazards model. The best cutoff was determined with time-dependent receiver operating characteristic curve. To determine the mechanism of NLR elevation, immunohistological examination using CD163 staining was performed in 150 patients.

RESULTS

Univariate and multivariate analyses showed that NLR was an independent prognostic factor in overall and recurrence-free survival. The best cutoff of NLR was 2.81, and 238 of 958 patients (24.8%) had NLR of more than 2.81. The 5-year survival rate after hepatectomy was 72.9% in patients with NLR less than 2.81 and 51.5% in those with NLR 2.81 or more (P < 0.0001). CD163-positive cell counts were significantly higher in tumors in the group with NLR 2.81 or more than in the group with NLR less than 2.81 (P = 0.0004).

CONCLUSIONS

Our results show that NLR is an independent predictor of survival after hepatectomy in patients with HCC. Accumulation of tumor-associated macrophages in the tumor is associated with a high NLR.

New serum markers of hepatocellular carcinoma

Hepatocellular carcinoma (HCC), one of the most common cancers worldwide, usually develops in a liver already suffering from chronic damages, often cirrhosis. There has been marked progress in the treatment of HCC. However, effective treatments are limited to patients with less advanced HCC. The detection of HCC at an early stage is still a prerequisite for improved prognosis. To address this problem, a variety of screening modalities are used, including measurement of alpha-fetoprotein (AFP) and ultrasonography (US) at regular intervals in high-risk populations. Unfortunately, poor sensitivity and specificity of AFP and the operator-dependency of US limit the value of either test to diagnose early-stage lesions. Other tests, including Lens culinaris agglutinin-reactive AFP and des-gamma carboxyprothrombin (DCP), are currently being evaluated and may be superior to current tests. Recent developments in gene-expressing microarrays and proteomics promise even more potential diagnostic options. The strict application of the Early Detection Research Network methodology will aid in the assessment of their diagnostic utility, and provide an objective basis for the assessment of their clinical utility.

International trends in liver cancer incidence rates

BACKGROUND

Several previous studies have documented region or country-specific liver cancer incidence trends around the world. However, no study has systematically examined the international pattern using the most recently updated incidence data from the International Agency for Research on Cancer.

METHODS

We examined recent trends in liver cancer incidence rates from 1993 to 2002 by joinpoint analysis for 32 cancer registries worldwide, using Cancer Incidence in Five Continents. We also examined the male to female rate ratios for these and four additional registries, based on the 1998-2002 incidence data.

RESULTS

Liver cancer incidence rates for both men and women statistically significantly increased from 1993 to 2002 for 8 of 32 cancer registries considered in the analysis. Increases were largely confined to economically developed countries of Western Europe, North America, and Oceania. In contrast, rates decreased in both men and women in 5 registries including 3 in Asia. Despite this, the incidence rates in Asian countries are twice as high as those in Africa and more than four times as high as rates in North America. Male to female rate ratios varied from 0.9 in sub-Saharan African and South American registries to 5.0 in France and Egypt.

CONCLUSIONS

Liver cancer incidence rates continue to increase in some low-risk parts of the world whereas they are decreasing in some of the highest risk countries in Asia. Etiologic studies are required to further elucidate factors contributing to the divergent liver cancer incidence trends worldwide.

IMPACT

Our description of international liver cancer incidence trends may stimulate further etiologic studies.

Molecular characteristics of non-cancerous liver tissue in non-B non-C hepatocellular carcinoma

Although chronic infection with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) are the most important risk factors for the development of hepatocellular carcinoma (HCC) worldwide, the proportion of HCC patients negative for the hepatitis B surface antigen and hepatitis C antibody, so-called "non-B non-C HCC", is rapidly increasing, especially in Japan. The background liver diseases of non-B non-C HCC patients can be multifactorial, including occult HBV infection and non-alcoholic steatohepatitis. It is reasonable to investigate the non-cancerous liver tissues to identify the potential molecular mechanisms responsible for the processes of hepatocarcinogenesis of non-B non-C HCC. However, to date, only a few studies have focused on this research concept based on the idea of "field cancerization". This review highlights the potential importance of the molecular analysis of non-cancerous liver tissues to clarify the molecular characteristics in patients with non-B non-C HCC. A better understanding of the molecular mechanisms underlying the individual predisposition to non-B non-C HCC will lead to improvements in the prevention, early diagnosis and treatment of this neoplastic disease.

Epidemiology of primary and secondary liver cancers

Primary liver cancer is the sixth most common cancer worldwide with a wide geographic distribution. The incidence of primary liver cancer is increasing and there is still a higher prevalence in developing countries. Early recognition remains an obstacle and lack of it results in poor outcomes for hepatocellular carcinoma (HCC), the most prevalent primary liver cancer, and cholangiocarcinoma. The most common risk factors associated with HCC are hepatitis B and chronic hepatitis C infections, alcohol use, smoking, and aflatoxin exposure. Emerging risk factors such as obesity might play an important role in the future because of the increasing prevalence of this condition.

Tumor-infiltrating lymphocytes and hepatocellular carcinoma: pathology and clinical management

The presence of tumor-infiltrating lymphocytes (TILs) in hepatocellular carcinoma (HCC) is relatively rare. The prognosis of patients with HCC and marked TILs is better than that of patients with HCC without TILs. TILs in HCC tissues are mainly T cells, and previous reports suggested that TILs might be important antitumor effector cells. TILs have been extensively analyzed, and subpopulations of CD3(+), CD4(+), and CD8(+) T cells are often present in HCC. Some studies have reported that the percentage of CD8(+) T cells, which might have cytotoxic activity, is decreased in tumors with TILs, as compared with noncancerous tissues. Although the antitumor effects of TILs seem to be impaired in HCCs, the underlying mechanism has remained unclear until quite recently. Pathological and in vitro studies have now shown that regulatory T cells play important roles in the deterioration of the antitumor effects of TILs. The aim of this review is to introduce recent pathological findings for TILs in HCC and to evaluate new therapeutic strategies in this field.

Molecular signatures of noncancerous liver tissue can predict the risk for late recurrence of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an aggressive malignancy mainly due to tumor metastases or recurrence even after undergoing potentially curative treatment. There are two types of HCC recurrence. The early and late tumor recurrences appear in distinct biological contexts, and their clinical courses are quite different. Therefore, it is important to precisely and distinctly discriminate the risk of each type of HCC recurrence. Many researchers have used DNA microarray technology to reclassify HCC with respect to its malignant potential. Some of these studies successfully identified specific gene-expression signatures derived from the cancerous tissues of HCC for predicting the early recurrence due to intrahepatic metastasis. However, there are no well-defined predictors for late recurrence. Recently, a few studies have focused on the nontumorous portion of liver tissues to predict late recurrence, possibly due to de novo hepatocarcinogenesis based on the idea of "field cancerization." This study reviewed the possible value of a gene-expression analysis of noncancerous liver tissue to clarify the risk for multicentric late recurrence of HCC. These findings may have important implications for chemopreventive strategies and tailored surveillance programs. Furthermore, this approach may also be applicable to other multifocal tumors, such as head and neck carcinoma.

-509C>T polymorphism in the TGF-beta1 gene promoter, impact on the hepatocellular carcinoma risk in Chinese patients with chronic hepatitis B virus infection

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. The risk for developing HCC increases with severity of inflammation and fibrosis. Transforming growth factor-beta1 (TGF-beta1) is most frequently upregulated in tumor cells. The most studied -509C>T polymorphism of TGF-beta1 gene has been associated with colorectal, gynecologic, and lung cancers. To assess whether this polymorphism in TGF-beta1 gene is associated with susceptibility to and/or clinicopathologic characteristics of HBV-related HCC, a total of 575 patients with chronic HBV infection and 299 healthy volunteers with no evidence of recent or remote HBV infection were prospectively enrolled. The patients were divided into two groups: those without (n = 196) and those with HCC (n = 379). These 379 HCC patients with chronic HBV infection were designated as cases, the remaining 196 patients without HCC and 299 healthy volunteers served as disease and healthy controls, respectively. -509C>T polymorphism in the TGF-beta1 gene promoter was studied using restriction fragment-length polymorphism. In addition, tumor tissues of liver (n = 60) were obtained from the studied HCC patients for measurement of TGF-beta1 mRNA expression levels. We also assessed the plasma TGF-beta1 levels of HBV patients without (n = 94) or with HCC (n = 136) and healthy subjects (n = 120). In our study group, the risk of HCC in Chinese patients with HBV infection was significantly lower with the TT genotypes than in those with the CC genotypes at position -509 of TGF-beta1 gene (P = 0.01). In addition, in the case group, patients with the CC genotype had a statistically significant higher median plasma TGF-beta1 or liver tumor tissue TGF-beta1 mRNA level compared with the individuals with the TT genotype. However, in a subsequent analysis of the association between this polymorphism and clinicopathological characteristics including tumor number, size, grade, stage, and invasiveness, there was no significant difference in both the distribution of genotype or allelic frequency within HCC patients, indicating that -509C>T exchange in TGF-beta1 gene may play an important role in the occurrence, not the progression of HBV-related HCC through influencing plasma concentrations of TGF-beta1 or TGF-beta1 mRNA expression of liver tumor tissue.

Hepatocellular carcinoma in viral hepatitis: improving standard therapy

Hepatocellular carcinoma (HCC) is a common malignancy worldwide, and its incidence is increasing in the United States and elsewhere. The prognosis of HCC patients depends not only on tumour stage but also on the background liver function reservoir. Current options for the treatment of HCC are surgical resection, liver transplantation, transcatheter arterial embolization, chemotherapy, and percutaneous ablation therapy. The choice of optimal treatment for individual patients, especially those at an earlier cancer stage, is sometimes controversial. Short-term prognosis of HCC patients has been much improved recently due to advances in early diagnosis and treatment, although long-term prognosis is as yet far from satisfactory as indicated by the overall survival at 10 years after apparently curative treatment of only 22-35%. Prevention of HCC recurrence, or tertiary prevention, is one of the most challenging tasks in current hepatology.

Response to interferon therapy affects risk factors for postoperative recurrence of hepatitis C virus-related hepatocellular carcinoma

BACKGROUND

Interferon therapy might reduce recurrence after resection of hepatitis C virus-related hepatocellular carcinoma, especially among sustained virologic or biochemical responders.

METHODS

Of 209 patients who underwent curative resection for early-stage hepatitis C virus related hepatocellular carcinoma, 70 patients underwent interferon therapy. A sustained virologic or biochemical response was achieved in 40 patients (SVR/BR group). Thirty no responders and 139 patients who had not received interferon therapy were classified as the NR/non-IFN group. Risk factors for postoperative recurrence in each group were analyzed.

RESULTS

The tumor-free survival rates in the SVR/BR group were significantly higher than those in the NR/non-IFN group. By multivariate analysis, the presence of multiple tumors was independently associated with recurrence after resection in both groups, while histologic evidence of cirrhosis was another independent risk factor for postoperative recurrence in the NR/non-IFN group.

CONCLUSIONS

Newly multicentric carcinogenesis after resection could be suppressed when active hepatitis is controlled by interferon therapy. Patients with single hepatitis C virus related hepatocellular carcinoma detected after successful interferon therapy are good candidates for surgical resection. Adjuvant interferon therapy might be indicated for patients who undergo curative resection for single hepatocellular carcinoma associated with hepatitis C.

Successful treatment with lamivudine may correlate with reduction of serum ferritin levels in the patients with chronic hepatitis and liver cirrhosis type B

PURPOSE

To study the changes in serum ferritin levels in lamivudine (LAM)-treated patients with chronic hepatitis and liver cirrhosis type B and determine whether successful treatment with LAM results in a reduction of serum ferritin levels.

METHODS

Thirty patients with chronic hepatitis B virus (HBV) infection were followed prospectively during their treatment with LAM for 12 months. Serum HBV DNA, ferritin levels, and emergence of YMDD mutants were monitored. A case of severe liver cirrhosis with hepatic hemosiderosis that was treated successfully with LAM also is shown as a representative case.

RESULTS

Serum alanine aminotransferase and ferritin levels decreased significantly more in the patients treated with LAM without YMDD mutants (n = 23) than those with mutants (n = 7). Hepatic hemosiderosis along with serum iron markers improved greatly in the representative patient.

CONCLUSION

Successful treatment with LAM may reduce serum ferritin levels and improve hepatic siderosis in a subset of patients with chronic HBV infection.

Clinical characteristics and surgical outcome in hepatocellular carcinoma without hepatitis B virus surface antigen or hepatitis C virus antibody

OBJECTIVE

We investigated clinical characteristics and surgical outcome of hepatocellular carcinoma in association with hepatitis viral status. No consensus exists concerning differences in surgical outcome in patients with hepatocellular carcinoma according to viral hepatitis status, especially those negative for hepatitis B virus surface antigen and antibody to hepatitis C virus.

METHODS

Clinicopathologic data were available for 39 hepatectomy patients with hepatocellular carcinoma who were negative for hepatitis B virus surface antigen and hepatitis C virus antibody. Clinical characteristics and surgical outcome were analyzed retrospectively and compared to those patients with positive hepatitis viral markers.

RESULTS

Patients negative for viral hepatitis markers were more likely to have large, advanced-stages tumors with relatively well-preserved liver function and had a lower incidence of intrahepatic recurrences (P = 0.009). The intrahepatic recurrence rate reached a plateau at approximately 3 years after resection in patients with negative viral markers, while it continued to increase steadily in patients positive for viral hepatitis markers. By multivariable analysis, the absence of viral hepatitis markers predicted a decreased rate of intrahepatic recurrence (relative risk, 0.222; P = 0.001).

CONCLUSIONS

Adequate surgical resection in hepatocellular carcinoma patients negative for viral markers offers a good survival benefit, regardless of the etiology of the hepatocellular carcinoma.

Risk of recurrence in a long-term follow-up after surgery in 417 patients with hepatitis B- or hepatitis C-related hepatocellular carcinoma

OBJECTIVE

The aim of this study is to clarify the difference of risk of recurrence after hepatic resection between patients with hepatitis B- and hepatitis C-related hepatocellular carcinoma (HCC).

SUMMARY AND BACKGROUND DATA

HCC is a highly recurrent carcinoma. However, consensus has not yet been reached about the relationship between hepatitis virus types and risk of recurrence in a long-term follow-up for HCC patients who underwent hepatic resection.

PATIENTS AND METHODS

From the beginning of January 1990 to the end of December 1999, of 469 HCC patients who underwent curative hepatic resection, 66 (14%) patients with positive hepatitis B virus surface antigen (HBs-Ag) and negative hepatitis C virus antibody (HCV-Ab) were regarded to have B-type hepatitis (HB)-related HCC (HB-HCC) and 351 (75%) with negative HBs-Ag and positive HCV-Ab were regarded to have C-type hepatitis (HC)-related HCC (HC-HCC). A clinical follow-up was performed to assess the existence of recurrence with the median follow-up periods of 11.0 and 10.1 years for HB- and HC-HCC patients, respectively.

RESULTS

The 3-, 5-, and 10-year disease-free survival (DFS) rates of HC-HCC (40%, 24%, and 12%, respectively) were significantly shorter than those of HB-HCC (57%, 54%, and 28%, respectively) (P = 0.0001). In multivariate Cox proportional hazard analysis, viral type, TNM stage, surgical margin, and Edmondson's grade were significantly associated with risk of recurrence. The risk of recurrence from the initial HCC increased to 1.93 times (95% confidence interval, 1.27-2.93) greater in HC-HCC patients than in HB-HCC patients.

CONCLUSION

Hepatitis viral type is an independent factor for recurrence of HCC in a long-term clinical follow-up. This finding suggests that we may need a different strategy to control postoperative recurrence by the viral types in HCC patients.

Specific gene-expression profiles of noncancerous liver tissue predict the risk for multicentric occurrence of hepatocellular carcinoma in hepatitis C virus-positive patients

BACKGROUND

Hepatitis C virus (HCV) infection produces chronic hepatitis, cirrhosis, and, ultimately, hepatocellular carcinoma (HCC). A molecular analysis of the damaged liver tissues infected with HCV may identify specific gene-expression profiles associated with a risk for liver carcinogenesis.

METHODS

Forty patients with HCV-positive HCC were classified into two groups: single nodular HCC group (n = 28) and multicentric HCC group (n = 12). Using a complementary DNA microarray, we compared the gene-expression patterns of the noncancerous liver tissue specimens between the two groups. We also identified the differentially expressed genes related to multicentric recurrence in the liver remnant. We then evaluated whether a specific gene-expression profile can accurately estimate the risk for multicentric hepatocarcinogenesis.

RESULTS

We selected the 230 differentially expressed genes in the multicentric HCC group. A hierarchical clustering analysis identified a cluster that might be closely associated with the multicentric occurrence of HCC. On the basis of the gene-expression profiling of the 36 genes commonly associated with both multicentric HCC and multicentric recurrence, we created a scoring system to estimate the risk for multicentric hepatocarcinogenesis. The prediction score of patients in the multicentric HCC group with multicentric recurrence (19.9 +/- 9.2) was significantly higher (P < .05) than that in the single nodular HCC group without multicentric recurrence (-1.8 +/- 12.7).

CONCLUSIONS

Specific gene-expression signatures in noncancerous liver tissue may help to accurately predict the risk for developing HCC.

Possible contribution of prior hepatitis B virus infection to the development of hepatocellular carcinoma

BACKGROUND

The prevalence of prior hepatitis B virus (HBV) infection in hepatocellular carcinoma (HCC) patients and its role in hepatocarcinogenesis are not clear. The aim of the present study is to clarify the importance of prior HBV infection in development of HCC.

METHODS

Of 1288 consecutive HCC patients between January 1999 and October 2002, 1008 patients were enrolled. To determine the influence of prior HBV infection in hepatitis B surface antigen (HBsAg)-negative HCC, the prevalence of antibody to hepatitis B core antigen (anti-HBc) was examined according to age, and the clinical features were compared between the anti-HBc positive and the negative groups.

RESULTS

The proportion of HBsAg-negative HCC patients, HCC patients with antibody to hepatitis C virus (anti-HCV; C-HCC) and HCC patients negative for both HBsAg and anti-HCV (nBnC-HCC), increased with age. The anti-HBc-positive rates in C-HCC patients also increased with age. Those rates in nBnC-HCC patients were >50% in all age groups. Furthermore, it was found that the anti-HBc-positive rates of these patients were higher than those of corresponding control patients. Tumor size and a positive rate for vessel involvement both in C-HCC and nBnC-HCC patients were larger and higher, respectively, in anti-HBc-positive patients compared with anti-HBc-negative patients, although the difference in nBnC-HCC did not reach statistical significance because of the small numbers. These tumor characteristics were similar to those of B-HCC patients.

CONCLUSION

A possible contribution of prior HBV infection to the development of HCC is indicated.

Cytokine gene polymorphisms in Japanese patients with hepatitis B virus infection--association between TGF-beta1 polymorphisms and hepatocellular carcinoma

BACKGROUND/AIMS

In this study, we determined the frequencies of the genotypes associated with the polymorphism of the cytokines genes, and investigated their association with the risk of hepatocellular carcinoma (HCC) in hepatitis B virus (HBV) carriers.

METHODS

Genetic polymorphism in the cytokines TNF-alpha, IFN-gamma, TGF-beta1, IL-6, and IL-10 were studied in 236 Japanese patients with HBV infection. The genetic polymorphisms of these cytokines were analyzed by polymerase chain reaction-sequence-specific primer (SSP).

RESULTS

There was no statistically significant difference in the genetic polymorphisms of TNF-alpha, IFN-gamma, and IL-10 genes between HBV carriers with HCC and those without HCC. However, the TGF-beta1+29 (codon 10) C/C genotype was lower in HBV carriers with HCC than in those without HCC (HCC 14.6% vs non-HCC 31.9%). The association of HCC was significantly lower in HBV carriers with C/C genotype than in those with T/C or T/T genotype in position +29 of the TGF-beta1 gene.

CONCLUSIONS

Our findings suggest that the genetic polymorphism in codon 10 of the TGF-beta1 gene may play a role in HCC development in patients with chronic HBV infection.

The impact of immigration on the increasing incidence of hepatocellular carcinoma in the United States

AIMS

To assess if the rising incidence of hepatocellular carcinoma in the United States can be accounted for by immigration and an ageing population, or is a true increase among the USA-born residents.

METHODS

Design--A retrospective chart review. Setting--Urban, multiethnic hospital and specialty clinics in a large indigent health system in Houston, Texas. Subjects--Approximately 23,000 admissions and 143,000 out-patient clinic visits each year from 1992 through 2001 were assessed. A total of 494 patient records were selected and reviewed because of suspicion of hepatocellular carcinoma. Analysis- Hepatocellular carcinoma was confirmed by histopathology, alpha-fetoprotein level >400 ng/mL, and suggestive imaging studies. The age-adjusted incidence was determined and causative factors were identified.

RESULTS

About 111 cases of confirmed hepatocellular carcinoma were found. The age-adjusted incidence rose from 3.44 per 100,000 hospital admissions during 1992-1996 (95% confidence interval: 2.86-4.02) to 5.19 during 1997-2001 (95% confidence interval: 4.41-5.97). The proportion of patients of non-USA place of birth decreased between 1992-1996 and 1997-2001 (46-24%, respectively, P = 0.03). Fifty-two per cent and 68% were hepatitis C virus-positive respectively; 37% and 34% were hepatitis B surface antigen-positive respectively; 46% and 59% had a history of alcohol abuse; and 22% and 11% had no identifiable risk factors.

CONCLUSIONS

The incidence of hepatocellular carcinoma within the greater Houston area has increased during the past decade, rising by 51% from 1992-1996 to 1997-2001. This increase is not from immigration or population ageing but represents a true rise among the native born population. Hepatitis C and alcoholic cirrhosis are associated with a majority of cases, particularly in the latter half of the decade.

Hepatocellular carcinomas <2 cm in diameter complicating cirrhosis: ultrasound and clinical features in 153 consecutive patients

PURPOSE

To determine the frequencies of various echogenicity patterns in 153 consecutive unifocal hepatocellular carcinomas (HCCs) <2 cm detected in cirrhotic livers and to identify their relationships with clinical, laboratory, and microscopic features.

PATIENTS AND METHODS

The tumors were classified as hypoechoic, hyperechoic, isoechoic, or nodule-in-nodule. Correlation was evaluated between hypoechoic and hyperechoic patterns and the following variables: age, gender, serum alphafetoprotein (AFP), tumor size, ultrasound features of liver parenchyma, cirrhosis etiology, and cyto/histological tumor grading.

RESULTS

One hundred and seventeen tumors (76.4%) were hypoechoic, 26 (17.0%) were hyperechoic, 5 (3.3%) were isoechoic, and 5 (3.3%) had nodule-in-nodule patterns. The hyperechoic pattern was more common in patients under 69 years (25.0% vs. 11.3% in those under 69 years or older, P=0.033). Patients with a hyperechoic pattern displayed a trend towards lower AFP levels and higher prevalence of hepatitis C-related cirrhosis. The prevalence of well-differentiated tumors was identical (56.6% and 56.5%) in the hypoechoic and hyperechoic subgroups. AFP was higher than 400 ng/ml in only 11/153 cases (7.2%).

CONCLUSIONS

The hyperechoic pattern of HCC is by no means uncommon, particularly in patients under 70. Hyperechogenicity is not related to an increased frequency of well-differentiated tumors. AFP shows limited value as a confirmatory test of small HCC.

Sequential changes of serum ferritin levels and their clinical significance in lamivudine-treated patients with chronic viral hepatitis B

AIM

To study the sequential changes of serum ferritin levels in lamivudine-treated patients with chronic viral hepatitis B and the clinical implications.

METHODS

Thirty-eight patients with chronic viral hepatitis B were prospectively studied during their treatment with lamivudine. Each patient received 100 mg oral lamivudine daily for 12 mo, and was observed and tested for blood biochemistry and hepatitis B virus (HBV) DNA levels and serum ferritin levels at baseline and at 3, 6 and 12 mo during the treatment. Serum HBV DNA levels were quantitatively determined using fluorescent quantitative polymerase chain reaction (FQ-PCR), and serum ferritin levels were measured by radioimmunoassay. The sequential changes of serum ferritin levels and their relationships with virological, serological and biochemical responses in the patients were analyzed.

RESULTS

All the patients had a baseline HBV DNA level higher than 1 x 10(7) copies/L as determined by FQ-PCR and positive HBsAg and HBeAg and abnormal ALT levels. At the end of the 12-mo treatment, 19 of the 38(50.00%) patients had undetectable serum HBV DNA levels by FQ-PCR, and 12(31.58%) became negative for serum HBeAg and 10(26.32%) had seroconversion from HBeAg to HBeAb. Nineteen out of the 38(50.00%) patients had biochemically normal ALT levels after 12-mo lamivudine treatment. Sequential determination showed that lamivudine treatment significantly reduced ferritin levels in chronic hepatitis B patients. When the patients were divided into different groups according to their post-treatment virological, serological and biochemical responses for analysis of the sequential changes of ferritin levels, it was found that the decrease of ferritin levels in HBV DNA-negative group was significantly more obvious than that in HBV DNA-positive group at 6 mo during the treatment (P=0.013). Consecutive comparisons showed that ferritin levels at 3 mo of treatment were obviously decreased as compared with the baseline levels (P<0.05) in HBeAg-negative group, and the decrease of serum ferritin levels in patients with normalized ALT was more significant than that in patients with abnormal ALT at the end of the 12-mo treatment (P=0.048).

CONCLUSION

Lamivudine treatment can reduce the serum ferritin levels in chronic viral hepatitis B patients and decreases of ferritin levels can be more significant in patients exhibiting virological, serological and biochemical responses, indicating that dynamic observation of serum ferritin levels in patients with chronic viral hepatitis B during lamivudine treatment might be helpful for monitoring and predicting patients' responses to the therapy.

Treatment of centrally located hepatocellular carcinoma with central hepatectomy

BACKGROUND

For treatment of centrally located hepatocellular carcinoma (HCC), central hepatectomy (including central trisegmentectomy [Couinaud's segments 4, 5, and 8] and anterior segmentectomy [Couinaud's segments 5 and 8]) may have an important advantage (ie, preservation of nontumorous parenchyma) over conventional lobectomy or extended lobectomy. For determination of the efficacy of this technique, we compared the outcomes of patients with HCC who underwent treatment with the central and conventional methods.

PATIENTS AND METHODS

In our institute, 52 patients with HCC underwent treatment with central hepatectomy (group 1) and 63 patients with comparable tumor size underwent treatment with conventional major hepatectomy (group 2) from November 1993 to April 1999. Overall patient survival and disease-free survival rates were calculated and analyzed. The possible prognostic risk factors for patient and disease-free survival in group 1 were analyzed.

RESULTS

Group 1 had comparable overall patient and disease-free survival rates with those of group 2. Vascular invasion, higher pathology grading, and resection margin less than 1 cm appeared to be the prognostic factors for overall patient survival, and vascular invasion was the only risk factor for disease-free survival.

CONCLUSION

Central hepatectomy is a safe and effective operative procedure for the treatment of centrally located HCC. The patient and disease-free survival rates were the same as those of conventional major hepatectomy. Although it is technically more demanding, central hepatectomy preserves more nontumor liver parenchyma, which is important for the survival of those patients with liver cirrhosis.

Phase II study of the efficacy and safety of cisplatin-epinephrine injectable gel administered to patients with unresectable hepatocellular carcinoma

PURPOSE

To study the efficacy and safety of percutaneous cisplatin-epinephrine (CDDP-EPI) injectable gel in patients with localized unresectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Eligible patients had histologically proven HCC, no prior treatment except for surgery, and no more than three tumors (each measured < or = 7 cm, total tumor volume < or = 200 cm(3)). They were treated percutaneously under ultrasound or computed tomography (CT) guidance, with up to 10 mL of CDDP-EPI gel (1 mL contains 4 mg of CDDP and 0.1 mg of EPI) per treatment and four treatments in 6 weeks to a maximum of eight treatments. The primary end points were tumor response, defined by change of percentage of tumor necrosis according to CT criteria, and safety. Survival parameters were secondary end points.

RESULTS

From June 1997 to April 2000, 58 patients (median age, 65 years) entered the study. All patients were assessable for safety, and 51 were assessable for efficacy. The median number of treatments was four (range, one to eight treatments). Objective response rate was 53% (27 of 51 patients), including 16 complete and 11 partial responses. Of the 27 responders, 14 (52%) subsequently developed progressive disease, but in most of them (93%), a new tumor arose at untreated liver sites. Median survival was 27 months (range, 18.4 to 35.7 months). The 1-, 2-, and 3-year survival rates were 79%, 56%, and 14% respectively. The procedure was well tolerated with only minor side effects.

CONCLUSION

Percutaneous local ablation with CDDP-EPI injectable gel can induce significant tumor necrosis and local control for localized unresectable HCC, and the treatment is well tolerated.

Delayed gastrointestinal transit in patients with hepatocellular carcinoma

BACKGROUND AND AIM

Disturbed gastrointestinal (GI) motility exists in cirrhotic patients; however, less is known about the character of GI transit in hepatocellular carcinoma (HCC) patients. It is interesting to study the GI transit in HCC patients and to explore the patient factors modulating GI transit.

METHODS

A non-invasive hydrogen breath test, which measured the orocecal transit time (OCTT), was used to study GI transit in 40 HCC patients, 20 cirrhotics and 40 age- and sex-matched healthy volunteers with normal bowel habits. Meanwhile, their clinical manifestations and various blood parameters, such as platelet count, prothrombin time, erythrocyte sedimentation rate etc. were collected. The plasma endothelin-1 and nitrate/nitrite levels were also measured.

RESULTS

The OCTT were delayed in HCC and cirrhotic patients compared with controls (116.3 +/- 7.8 and 104.5 +/- 10.6 vs 75.3 +/- 5.1 min, P < 0.05). Neither the severity of liver damage, presence of ascites, tumor size, portal hypertension, nor various blood parameters, such as nitrate/nitrite, endothelin-1, platelet count etc., had any influence on GI transit. Only serum alpha-fetoprotein levels exhibited a trend toward positive correlation with the OCTT (r = 0.271, P = 0.091).

CONCLUSIONS

Hepatocellular carcinoma patients have delayed GI transit. The confounding factor responsible for the disturbance of GI transit in HCC patients needs further exploration.

Hepatocellular carcinoma and hepatitis C in the United States

Chronic infection with hepatitis C virus (HCV) is a major risk factor for development of hepatocellular carcinoma (HCC). In general, HCC develops only after 2 or more decades of HCV infection and the increased risk is restricted largely to patients with cirrhosis or advanced fibrosis. Factors that predispose to HCC among HCV-infected persons include male sex, older age, hepatitis B virus (HBV) coinfection, heavy alcohol intake, and possibly diabetes and a transfusion-related source of HCV infection. Viral factors play a minor role. The likelihood of development of HCC among HCV-infected persons is difficult to determine because of the paucity of adequate long-term cohort studies; the best estimate is 1% to 3% after 30 years. Once cirrhosis is established, however, HCC develops at an annual rate of 1% to 4%. Successful antiviral therapy of patients with HCV-related cirrhosis may reduce the future risk for HCC. The incidence of and mortality caused by all HCC has doubled in the United States over the past 25 years, an increase that has affected all ethnic groups, both sexes, and younger age groups. Given the current prevalence of HCV infection among persons 30 to 50 years of age, the incidence and mortality rates of HCC are likely to double in the United States over the next 10 to 20 years. Future research should focus on improving understanding of the incidence and risk factors for HCC, causes of HCV-related carcinogenesis, means of early detection, and better treatment for HCC.

Hepatocellular carcinoma and hepatitis C in the United States

Chronic infection with hepatitis C virus (HCV) is a major risk factor for development of hepatocellular carcinoma (HCC). In general, HCC develops only after 2 or more decades of HCV infection and the increased risk is restricted largely to patients with cirrhosis or advanced fibrosis. Factors that predispose to HCC among HCV-infected persons include male sex, older age, hepatitis B virus (HBV) coinfection, heavy alcohol intake, and possibly diabetes and a transfusion-related source of HCV infection. Viral factors play a minor role. The likelihood of development of HCC among HCV-infected persons is difficult to determine because of the paucity of adequate long-term cohort studies; the best estimate is 1% to 3% after 30 years. Once cirrhosis is established, however, HCC develops at an annual rate of 1% to 4%. Successful antiviral therapy of patients with HCV-related cirrhosis may reduce the future risk for HCC. The incidence of and mortality caused by all HCC has doubled in the United States over the past 25 years, an increase that has affected all ethnic groups, both sexes, and younger age groups. Given the current prevalence of HCV infection among persons 30 to 50 years of age, the incidence and mortality rates of HCC are likely to double in the United States over the next 10 to 20 years. Future research should focus on improving understanding of the incidence and risk factors for HCC, causes of HCV-related carcinogenesis, means of early detection, and better treatment for HCC.

Lamivudine does not increase the efficacy of interferon in the treatment of mutant type chronic viral heaptitis B

AIM: To study the role of lamivudine in improving the efficiency of interferon for the treatment of mutant type chronic hepatitis B.

METHODS: Fifteen patients with mutant type chronic hepatitis B were prospectively studied. All patients had liver histology and serology to prove the diagnosis of chronic hepatitis B. Each patient received 4.5 millionunits of interferon alpha-2a thrice weekly and 100 mg of oral lamivudine daily for 24 wk. Patients were observed and tested for blood chemistry every week for the initial 4 wk and every 2 wk thereafter during the treatment until 24 wk. After the end of treatment, patients were followed up at 4-week intervals for an additional 6 mo. Serum HBV DNA levels were tested using the liquid phase molecular hybridization assay. Those with non-detectable HBV DNA were also tested using the real-time polymerase chain reaction. One patient, who did not finish treatment due to depression, was excluded.

RESULTS: At the end of treatment, 7 (50%) patients had serum ALT levels within normal limits; 12 (86%) patients had serum HBV DNA levels < 5 pg/mL using the liquid phase molecular hybridization assay, but only 8 (67%) were < 20 copies/dL using the real-time polymerase chain reaction. Six months after treatment, only two (14%) patients had a sustained complete response to the combination therapy with serum ALT level < 35 iu/L and undetectable serum HBV DNA levels.

CONCLUSION: These pilot data showed that lamivudine did not increase the efficacy of interferon in the treatment of mutant type chronic hepatitis B. The liquid phase molecular hybridization assay was not sensitive enough to detect the low HBV DNA levels during combined interferon and lamivudine therapy.

Surgical results in patients with hepatitis virus-related hepatocellular carcinoma in Taiwan

To investigate the surgical results of hepatectomy for hepatocellular carcinoma in relation to hepatitis virus status in Taiwan, 252 patients (196 men and 56 women; March 1992 to August 1998) were reviewed. The patients were divided into four groups: 30 patients (11.9%) seronegative for both hepatitis B surface antigen (HBsAg) and antihepatitis C antibody (HCVAb) (N-HCC group); 133 patients (52.8%) seropositive for HBsAg and seronegative for HCVAb (B-HCC group); 66 patients (26.2%) seronegative for HBsAg and seropositive for HCVAb (C-HCC group); and 23 patients (9.1%) seropositive for both HBsAg and HCVAb (BC-HCC group). Patients in group C-HCC were older (p = 0.001) and had a higher incidence of diabetes mellitus (p = 0.004). Also, they had a higher indocyanine green retention rate at 15 minutes (p = 0.021), longer international normalization ratio for the prothrombin time (p = 0.049), and smaller tumor (p = 0.006). Postoperative complications and hospital mortality were significantly higher in patients in the C-HCC and BC-HCC groups (p = 0.046, 0.021). All patients were followed 12 to 76 months after hepatectomy (mean 23.5 +/- 16.3 months). The 1-, 3-, and 5-year overall cumulative survival rates of the 252 patients in this series were 80%, 54.3%, and 34.2%, respectively. The cumulative intrahepatic recurrence rates were 46.5%, 64.9%, and 72.9% at 1, 3, and 5 years, respectively. The mean disease-free survival time was longest in group C-HCC and shortest in group BC-HCC (p = 0.020). The overall survival time and cumulative survival rates in the four groups were not significantly different (p = 0.146).

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common malignancy worldwide and is a disease of multifactorial etiology. Strong correlations exist between the prevalence of the hepatitis B and C viruses and HCC incidence. HCC treatment may involve surgical resection, liver transplantation, locoregional treatments, and chemotherapy. Prevention of virus-related HCC is contingent upon control of hepatitis types B and C. Universal vaccination against hepatitis B could eliminate hepatitis B-related HCC; however, hepatitis C-related HCC still could occur because a vaccine for hepatitis C currently is not available. Individuals at risk for HCC should be screened for the disease. Early detection could result in improved prognosis and survival.

Previous or occult hepatitis B virus infection in hepatitis C virus-associated hepatocellular carcinoma without hepatic fibrosis

We investigated the role of hepatitis B virus infection in development of hepatocellular carcinoma in hepatitis C virus-infected patients without hepatic fibrosis. Of 253 patients, 8 lacked hepatic fibrosis (group 1); group 2 included the remaining 245 patients. Clinicopathologic findings were compared between the groups. Hepatitis B x gene was sought in cancers and adjoining noncancerous liver. Group 1 showed better liver function parameters and milder active hepatitis than group 2. The proportion of patients with anti-hepatitis B virus antibody tended to be higher in group 1 than in group 2. The proportion of patients with hepatitis B x RNA in cancers was significantly higher in group 1 than in group 2. All group 1 patients had previous or occult hepatitis B virus infection. Previous or occult hepatitis B virus infection may be critical in development of hepatocellular carcinomas in hepatitis C virus-infected patients without hepatic fibrosis.

Hepatitis B or C virus serology as a prognostic factor in patients with hepatocellular carcinoma

It is not clear whether chronic hepatitis B or C virus (HBV or HCV) infection is a prognostic factor for hepatocellular carcinoma. We performed this study to determine if chronic HBV or HCV infection had any impact on postresection survival or affected patterns of failure. The records of 77 patients undergoing surgical resection for hepatocellular carcinoma between January 1990 and December 1998 were reviewed. Forty-four patients (57%) had HCV infection, 18 patients (23%) had HBV infection, and 15 patients (20%) had negative serology. There were no differences in age, sex, or tumor size among the groups, and all patients had margin-negative resections. There was a significantly higher incidence of satellitosis and vascular invasion in patients with HCV infection (32% and 41% respectively; P <0.05 vs. other groups). With a median follow-up of 30 months, a significantly decreased local disease-free survival (LDFS) was seen in HBV-positive (5-year LDFS 26%) or HCV-positive (5-year LDFS 38%) patients compared to those with negative serology (5-year LDFS 79%; P <0.05). There was also a trend toward a decreased overall survival in patients with positive hepatitis serology compared to patients with negative serology (37% vs. 79%; P = 0.12). Univariate analysis revealed that only satellitosis was related to local recurrence and overall survival. Patients with positive serology for hepatitis B or C undergoing resection for hepatocellular carcinoma have a trend toward worse overall prognosis and a significantly decreased LDFS when compared to patients with negative serology.

Management of hepatocellular carcinoma: advances in diagnosis, treatment and prevention

Since the major causes of hepatocellular carcinoma are hepatitis viruses, the difference and similarity of clinical features in relation to the causative virus may indicate that persistent inflammation of the liver is a major role in hepatocellular carcinoma development in both HBV and HCV infection. However, there is a variety of molecular products of virus-inducing mutagenesis, especially in HBV. An advance in the diagnosis of hepatocellular carcinoma is imaging modality to detect hemodynamics of hepatocellular carcinoma with noninvasive methods of ultrasonography and tumor markers. Chemoprevention using synthetic retinoid is another important issue for the prevention of hepatocellular carcinoma development, as well as viral eradication and suppression of inflammation in the liver using interferon and other drugs.

Prognostic factors for survival in patients with compensated cirrhosis and small hepatocellular carcinoma after percutaneous ethanol injection therapy

BACKGROUND

The objective of this study was to identify clinical, biochemical, ultrasound, and/or pathologic parameters capable of predicting survival in a cohort of patients with well compensated cirrhosis and small hepatocellular carcinoma (HCC) who were treated with percutaneous ethanol injection (PEI).

METHODS

The study group included 111 patients with Child--Pugh Class A cirrhosis and with one (93 patients) or two (18 patients) HCC nodules measuring < 5 cm in greatest dimension. All patients underwent multisession PEI. The prognostic values of pretreatment and post-treatment variables were analyzed using the Kaplan-Meier method.

RESULTS

The overall 3-year and 5-year survival rates of 62% and 41%, respectively, were not influenced by age, gender, duration of chronic hepatitis, serum albumin, prothrombin time ratio, total bilirubin, gamma-glutamyl transferase, hepatitis B surface antigen, antihepatitis C virus, HCC size, HCC ultrasound pattern, HCC histologic or cytologic grading, greatest spleen dimension, esophageal varices, or ascites. Levels of alpha-fetoprotein (AFP) > 14 ng/mL (P < 0.006), alanine aminotransferase > 75 IU/L (P < 0.04), and aspartate aminotransferase > 80 IU/L (P < 0.009) and platelet count < 92 x 10(9)/L (P < 0.02) before treatment were independent predictors of decreased survival. Among post-treatment parameters, AFP levels 6 months after PEI > 13.3 ng/mL (P < 0.003) and HCC recurrence in another segment of the liver (P < 0.04) were linked to decreased survival in univariate analysis.

CONCLUSIONS

Among patients with Child--Pugh Class A cirrhosis with small uninodular or binodular HCC who are treated with multisession PEI, those with elevated serum AFP and transaminase levels and low platelet count before treatment are characterized by decreased survival. During follow-up, intrahepatic recurrence of the tumor is the main factor affecting survival.

Effects of long-term postoperative interferon-alpha therapy on intrahepatic recurrence after resection of hepatitis C virus-related hepatocellular carcinoma. A randomized, controlled trial

BACKGROUND

Interferon therapy decreases the incidence of hepatocellular carcinoma in patients with chronic hepatitis C.

OBJECTIVE

To evaluate effects of interferon-alpha on recurrence after resection of hepatitis C virus-related hepatocellular carcinoma.

DESIGN

Randomized, controlled trial.

SETTING

University hospital, medical center, and affiliated hospital in Osaka, Japan.

PATIENTS

30 men were randomly allocated after resection to the interferon-alpha group (n = 15) or the control group (n = 15).

INTERVENTION

Patients in the interferon-alpha group received interferon-alpha, 6 MIU intramuscularly daily for 2 weeks, then three times weekly for 14 weeks, and finally twice weekly for 88 weeks.

MEASUREMENTS

Recurrence rates after resection.

RESULTS

Recurrent tumors were detected in 5 patients in the interferon-alpha group and in 12 control patients. The recurrence rate was significantly lower in the interferon-alpha group than in the control group (P = 0.037).

CONCLUSION

Postoperative interferon-alpha therapy appears to decrease recurrence after resection of hepatitis C virus-related hepatocellular carcinoma.

Prognostic factors after hepatic resection for hepatocellular carcinoma with hepatitis C viral infection: univariate and multivariate analysis

OBJECTIVES

Although the incidence of hepatocellular carcinoma (HCC) with hepatitis C virus (HCV) infection is higher than in patients with hepatitis B virus (HBV)-related HCC in Japan, the long-term prognosis and prognostic factors of HCV-related HCC after hepatic resection are poorly understood.

METHODS

The surgical outcome of HCV-related HCC in 172 consecutive patients who underwent hepatic resection between 1989 and 1997 was retrospectively clarified. Postresection prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model.

RESULTS

The overall incidence of postoperative complications was 23.2%, and 11 patients among that group had hospital deaths (6.4%) including 9 (5.2%) operative deaths. The mean and median overall survivals including hospital death after surgery were 41 months and 33 months, respectively. The 3-, 5-, and 7-yr overall survival rates after hepatic resection were 63%, 52%, and 47%, respectively. The 3-, 5-, and 7-yr disease-free survival rates after hepatic resection were 33%, 20%, and 15%, respectively. Multivariate analysis revealed that serum alpha-fetoprotein (AFP) of > or = 1000 ng/ml and the presence of vascular invasion were independent unfavorable prognostic factors affecting overall survival and that AFP of > or = 1000 ng/ml was an independently significant factor of poor disease-free survival.

CONCLUSIONS

We found the postresection survival of patients with HCV-related HCC should be stratified by the high value of AFP and the presence of vascular invasion. AFP may be the most powerful predictor of the long-term prognosis and recurrence in such patients.

HLA class II alleles in Chinese patients with hepatocellular carcinoma

BACKGROUND/AIMS

Recent reports of an association between human leucocyte antigens (HLA) and persistence of hepatitis B virus infection, and the familial clustering of hepatocellular carcinoma raise the question of genetic susceptibility. Previous studies have been limited to serological phenotyping of HLA B and DR antigens. The aim of this study was to use molecular genotyping to investigate HLA class II as a risk factor for the development of hepatocellular carcinoma in Hong Kong Chinese.

METHODS

We determined HLA DRB1, DQA1, DQB1 and DPB1 alleles in 123 hepatitis B surface antigen positive patients (84 with hepatocellular carcinoma and 39 without) and 124 matched controls.

RESULTS

The alleles DRB1*1501 (36% of HCC patients versus 19% of controls, odds ratio=2.44), DQA1*0102 (42% versus 26%, odds ratio=2.07), and DPB1*0501 (80% versus 63%, odds ratio=2.35) were significantly more common in patients with hepatocellular carcinoma, and DQA1*03 (36% versus 56%, odds ratio=0.53), DQB1*0302 (4.% versus 13%, odds ratio=0.25) and DPB1*0201 (14% versus 29%, odds ratio=0.4) were found at significantly lower frequencies.

CONCLUSIONS

Although none of these associations was significant after correction for multiple testing, this report suggests that further investigations are warranted.