Increased expression of proliferating cell nuclear antigen in autoimmune hepatitis in a patient with raised serum concentration of CA19-9

Elevated tumor markers for monitoring tumor response to immunotherapy

BACKGROUND

As the immune-related response evaluation criteria in solid tumors (irRECIST) by imaging greatly underestimated the objective response to immunotherapy, we established the response evaluation criteria in solid tumors based on tumor markers (RecistTM) to explore whether RecistTM can compensate for the deficiencies of the irRECIST criteria.

METHODS

This was an observational study, which consisted of two parts. The first part (Group A) was a retrospective study including the patients with malignant solid tumors. The second part (Group B) was a prospective study, which were EGFR-negative and ALK-negative patients with stage IIIB-IV non-small cell lung cancer receiving first-line treatment. From January 2017 to September 2020, one hundred and ten patients with a three-time increase in tumor markers receiving immunotherapy were recruited. The treatment response to immunotherapy was evaluated by irRECIST and RecistTM. Efficacy, overall survival (OS), first evaluation time and earliest response time under the different evaluation criteria were compared by statistics.

FINDINGS

The treatment response evaluated by the RecistTM criteria was not consistent with that evaluated by the irRECIST criteria (Kappa = 0.386, p < 0.001). RecistTM had a higher completed response (CR) rate compared to irRECIST criteria (20.9% vs 1.8%, p < 0.001). The earliest response time under the RecistTM criteria was 3.42 weeks earlier than that under the irRECIST criteria (u = -5.233, p < 0.001). There were significant differences in median OS between tumor marker-related complete response (tmCR) and tumor marker-related partial response (tmPR), as well as between tmPR and tumor marker-related stable disease (tmSD) (χ² = 15.572, p < 0.001; χ² = 7.720, p = 0.005), but not between tmSD and tumor marker-related progressive disease (tmPD) (χ² = 1.596, p = 0.206). When applying both criteria together, for patients with immune-related CR / immune-related PR (irCR/irPR) (n = 54) under irRECIST criteria, there was a significant difference in median OS between achieving tmCR (n = 22) and tmPR (n = 32) (χ² = 14.011, p < 0.001). RecistTM criteria can predict 1-year and 2-year OS more accurately than irRECIST criteria (AUCs:0.862 vs 0.552, 0.649 vs 0.521, respectively;both p < 0.001). In RecistTM, 4 patients had been observed with pseudoprogression in tumor markers.

INTERPRETATION

The RecistTM criteria could effectively distinguish CR, PR, and SD, which may help resolve the shortcomings of the RECIST criteria in evaluating the treatment response to immunotherapy, especially in assessing whether patients can achieve deep or even complete response as soon as possible.

FUNDING

This work was supported by the Key projects of Chongqing Health and Family Planning Commission (to Xueqin Yang, 2019ZDXM011).

Carbohydrate antigen 19-9 elevation without evidence of malignant or pancreatobiliary diseases

Although carbohydrate antigen 19-9 (CA 19-9) may be elevated in benign diseases, elevated CA 19-9 may cause a fear of cancer and unnecessary follow-up studies. Research on how to approach systematically in this case is very limited. The purpose of this study was to analyze the clinical features and the causes of CA 19-9 elevation without evidence of malignant or pancreatobiliary diseases. We retrospectively reviewed the medical records of patients who had CA 19-9 elevation (≥80 U/mL) and were found to be unrelated to cancer after follow-up. After exclusion, 192 patients were included in this study. The median level of CA 19-9 was 136.5 U/mL. The causes of CA 19-9 elevation were determined in 147 (76.6%) patients, and that was unknown in 45 (23.4%). The estimated causative diseases were hepatic diseases in 63 patients, pulmonary diseases in 32, gynecologic diseases in 38, endocrine diseases in 13, and spleen disease in 1. Of 45 patients with unknown cause, 35 had normalization of CA 19-9 and 10 had persistently elevated CA 19-9. In conclusion, CA 19-9 elevation without malignancies or pancreatobiliary diseases should be systematically evaluated and followed up. We suggest an algorithm to investigate the causes and follow up these patients.

Liver transplantation for autoimmune hepatitis: a single-center experience

OBJECTIVE

To present our experience with deceased donor liver transplantation (DDLT) and living-donor liver transplantation (LDLT) for autoimmune hepatitis (AIH).

PATIENTS AND METHOD

Between April 2001 and November 2006, a total of 116 LT procedures were performed (73 DDLTs and 43 LDLTs) in 112 patients (4 retransplants). Of the 112 recipients, 16 patients (14.3%) were transplanted for AIH (15 DDLTs and 1 LDLT). All recipients received FK506- and steroid-based immunosuppressive regimens.

RESULTS

The male/female ratio was 3/13, median age was 22 years (range, 15 to 35), and the median MELD score was 25 (range, 11 to 40). Arterial reconstruction was needed in four DDLTs due to severe steroid-induced angiopathy. After a median follow-up period of 530 days (range, 11 to 2016), the overall patient and graft survival rates were 93.8%. Only one patient died following LDLT due to primary graft nonfunction. Histopathologic recurrence was seen in three patients (18.7%) and was successfully treated by optimizing immunosuppression. Markedly elevated serum CA19-9 levels (median, 1069; range, 217 to 2855) was seen in four patients (28%), malignancy was ruled out and all patients normalized serum CA19-9 levels within the first 3 months posttransplant. Steroids withdrawal failed in all recipients and was always accompanied with almost immediate elevation of liver enzymes.

CONCLUSIONS

In our experience, LT for AIH shows excellent long-term outcomes, patients are usually young women who present with acute deterioration and high MELD scores, and usually require long-term steroids to prevent rejection and disease recurrence. Some patients have markedly high CA19-9 in absence of malignancy. Some patients also have severe steroid-induced hepatic artery angiopathy necessitating arterial reconstruction during the transplant surgery.

Normalisation of high CA 19-9 values in autoimmune hepatitis after steroidal treatment

Carbohydrate 19-9 antigen (CA 19-9) is considered a specific marker of pancreatobiliary adenocarcinomas, but slight increase of its levels can be found in several non-malignant diseases of the liver, such as autoimmune hepatitis. We describe a case of marked CA 19-9 elevation (up to 898.0 U/ml) in a patient with autoimmune hepatitis. Laboratory and instrumental examinations excluded malignant diseases. Immunohistochemical analysis for CA 19-9 and MIB-1, performed on liver biopsy, showed reactivity in inflammatory areas, in particular in bile ductule cells and hepatocytes in ductular metaplasia, suggesting that these cells could be involved in CA 19-9 serum levels increase. After steroids, the clinical picture improved and all the laboratory parameters normalised.

Carbohydrate 19-9 antigen is not a marker of liver disease in patients with cystic fibrosis

Serum concentration of carbohydrate 19-9 antigen (CA 19-9), a sensitive marker of pancreatic cancer and cholangiocarcinoma, increases in a variety of liver diseases due to higher production and release by bile duct cells. Biliary epithelial cells are primarily affected in liver disease associated with cystic fibrosis (CF), which develops in up to 30% of CF patients. Our aim was to evaluate the usefulness of serum CA 19-9 concentration as a test of liver involvement in CF. Serum concentration of CA 19-9, liver enzymes, bile acids, and total amylase was determined in 107 CF patients (49 with and 58 without liver disease) and 56 healthy subjects. Serum CA 19-9 concentration was significantly higher in CF patients (67 U/ml, 95% CI 53.5-80.5 U/ml) than in controls (11.8 U/ml, 95% CI 2.5-44 U/ml; p < 0.001) and in CF patients with liver disease (92.3 U/ml, 95% CI 75-109.5 U/ml) compared to CF patients without liver disease (46.6 U/ml, 95% CI 27.8-65.4 U/ml; p < 0.001). In CF patients, stepwise logistic regression analysis identified alanine aminotransferase, gamma-glutamyltranspeptidase, amylase, and CA 19-9 as the most useful predictors of liver disease (p < 0.0001). Receiver-operating characteristic (ROC) curve analysis revealed gamma-glutamyltranspeptidase and CA 19-9 as the best tests for identification of liver disease in CF patients; at a CA 19-9 cut-off arbitrarily fixed at 73 U/ml, positive and negative predictive value was 70% and 78%, respectively (sensitivity 57%, specificity 81%). To increase sensitivity to 94%, the cut-off had to be fixed at 31 U/ml, which corresponds to a specificity of only 36.2% (predictive value 33%). Our study indicates that measurement of the serum CA 19-9 concentration alone cannot be proposed as a reliable test of early hepatic involvement in CF.

Overexpression of interferon gamma-inducible protein 10 in the liver of patients with type I autoimmune hepatitis identified by suppression subtractive hybridization

OBJECTIVE

To clarify gene expression profiles in the liver may elucidate the pathogenesis of type I autoimmune hepatitis (AIH). Using suppression subtractive hybridization (SSH), we identified genes overexpressed in the liver of AIH.

METHODS

A small liver biopsy sample from a patient with definite AIH was available to be analyzed in our system. By mixing cDNA synthesized from this sample as a 'tester' and cDNA from a normal liver as a 'driver,' we subtracted cDNA to enrich genes overexpressed in AIH. After polymerase chain reaction (PCR) amplification and subcloning, we identified subtracted genes by sequencing 50 randomly selected clones.

RESULTS

Only one cDNA fragment, which is identical to interferon inducible protein 10 (IP-10), was overexpressed by > 10 times in the liver of AIH, as compared with control. We confirmed IP-10 overexpression in all eight patients with AIH by reverse transcription PCR. Immunohistochemical analysis demonstrated increased IP-10 expression in hepatocytes in the liver of AIH. Reverse transcription PCR analysis of 63 liver biopsy samples with various liver diseases revealed that IP-10 expression was significantly higher in AIH (p = 0.025) and chronic hepatitis C (p = 0.0043) than in other liver diseases. Interestingly, the amount of IP-10 mRNA expression was correlated with serum ALT values in AIH (p = 0.0006), but not in chronic hepatitis C (p = 0.43).

CONCLUSION

These results indicate the IP-10 expression in the liver might be used as a preferential marker of AIH, and that IP-10 has some pathophysiological roles in the liver damage of AIH.