[Varicella gastritis under immunosuppression : Case report of a woman after lung transplantation due to granulomatosis with polyangiitis]

A 35-year-old woman who had previously undergone a lung transplantation presented with severe abdominal pain and vomiting. The gastroscopy showed diffuse ulcerative gastric lesions. Tests for varicella zoster virus and Epstein-Barr virus via polymerase chain reactions (PCR) on endoscopically obtained gastric biopsies were found to be positive and confirmed varicella gastritis. Intravenous antiviral therapy with acyclovir was administered resulting in a normalization of all clinical symptoms, especially of abdominal pain and inflammation parameters.

AFP-producing adenocarcinoma of the esophagogastric junction: report of a case with atypical immunohistochemical findings responding to palliative chemotherapy with 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT regime)

AFP-producing adenocarcinoma of the esophagus and esophagogastric junction are rare tumor diseases. These tumors show an aggressive behavior characterized by early occurrence of liver metastases and mimic hepatocellular carcinoma (HCC). A general recommendation for palliative therapy is not established for these special tumors.Here we report about a 61-year-old man with multiple liver metastases and high serum alpha-fetoprotein (AFP) level. First, HCC was suspected, but further evaluation showed an AFP-producing adenocarcinoma of the esophagogastric junction with unusual findings on further immunohistochemical analysis. Palliative chemotherapy with FLOT (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel) regime showed a 9 month duration of partial response.

Recurrent pyogenic cholangitis as a differential diagnosis in biliary tract diseases

Recurrent Pyogenic Cholangitis (RPC) or Primary Hepatolithiasis is a common disease of the biliary tract in Asia, whereas it is usually not seen in Europeans. With increasing global mobility, the disease will be encountered in Europe more frequently, too. It should therefore be considered as a differential diagnosis in patients from endemic countries with recurrent symptoms of cholestasis/cholangitis and bile duct dilations, strictures and hepatolithiasis. In this case report, we present the history of a 37-year old patient from Sri Lanka and describe typical aspects of RPC. The patient presented at our hospital with scleral jaundice and pruritus. In the past she had been treated for septic cholangitis. Diagnosis in our patient was made after laboratory tests, MRT/MRCP and ERC. She was treated interventionally by ERC and is now monitored on a regular basis.

[Primary perivascular epitheloid cell tumour (PEComa) of the liver - is a new entity of the liver tumors?]

Perivascular epitheloid cell tumor (PEComa) is a rare tumor, characterized by dual Expression of smooth muscle and melanocytic markers. Due to the development of diagnostic procedures, we now diagnose PEComa more often. We report about a case of PEComa of the liver as an accidental finding. We analyze the clinical and morphological characteristics of this tumor and compare it with the data of the literature. Management of patients with PEComa is not yet standardized; therefore biopsy with immunhistochemical staining is necessary for the diagnosis. In case of liver tumors which cannot be classified by their morphology on imaging modalities, it is important to think about this rare entity.

[Guideline compliant diagnostics of hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third most common cause of cancer death worldwide. The incidence continues to rise and only a detailed surveillance of patients with chronic liver disease can allow an early assessment. Diagnosis is made by imaging techniques, such as contrast-enhanced ultrasound (CEUS), computed tomography (CT), magnetic resonance imaging (MRI) and also histopathological examination of biopsy material. The determination of the tumor marker alpha fetoprotein (AFP) is no longer established for early detection but can be used as a supplement in addition in HCC history progressio.

[OTSC-assisted resection of a duodenal neuroendocrine tumor: a case report]

The over the scope clip (OTSC) is mainly used for closure of gastrointestinal endoluminal defects and treatment of gastrointestinal bleeding. Its use for resection of subepithelial tumors or full-thickness resection is still under investigation. Duodenal neuroendocrine tumors (NET) are rare neoplasms. Endoscopic resection is appropriate up to a size of 20  mm, however positive deep margins are a frequent challenge in these subepithelial tumors. We report on a 60-year-old male patient who had undergone endoscopic mucosal resection with R1 deep margins of a NET (G1) in the duodenal bulb. To avoid local surgical resection in this multimorbid patient, we performed OTSC-assisted deep resection. Complete resection (R0) was achieved, and no complications occurred. Our report suggests that OTSC-assisted resection of subepithelial tumors is a possible and safe option, especially for patient's and in locations with a high perioperative risk.

Efficacy and safety of telaprevir (TVR) triple therapy in a 'real-life' cohort of 102 patients with HCV genotype 1: interim analysis after 24 weeks of treatment

Since 2011, telaprevir (TVR)-based triple therapy is the new treatment standard for hepatitis C genotype 1 virus infection. The aim of our retrospective interim analysis encompassing the first 24 weeks on TVR-based triple therapy was to assess 'real-life' antiviral efficacy and side effects in a large single-centre cohort, both in comparison with the data obtained in large prospective clinical trials. In total, we treated 102 patients: 24 treatment-naïve patients, 58 patients pretreated with PEG-IFN/RBV (thereof: 28 with nonresponse, 25 with relapse, five unknown) and 20 patients who previously had received nonpegylated interferon. 74 of 102 patients were assigned with HCV genotype 1b; 34 of 102 patients were treated in the context of liver cirrhosis. 72 of 102 patients have reached treatment week 24 (mean treatment duration 31 weeks). In the ITT analysis, overall response rates were at: week 4: 66%; week 12: 85%; and week 24: 78%. So far, 24 patients discontinued treatment prematurely, of those, 10 patients were due to virological failure. Haematological side effects were frequent (40% anaemia), as were 'flu-like' symptoms (94%), rash (65%) and pruritus (79%). According to our interim ITT analysis encompassing up to 24 weeks of TVR-based triple therapy, our 'real-life' antiviral effects are comparable to the results of large multicentric clinical trials. However, TVR-based triple therapy exhibited a high frequency of side effects requiring multiple therapeutic interventions. Notably, in our 'real-life' cohort, no lethal case was observed so far.

FOLFIRINOX as first-line treatment for unresectable acinar cell carcinoma of the pancreas: a case report

Pancreatic acinar cell carcinoma (ACC) is a rare, aggressive variant of pancreatic ductal adenocarcinoma. Surgery is the only curative treatment option and protocols for palliative chemotherapies in this context are not standardized yet. We reported a 63-year-old white male patient who had painless jaundice, weight loss, elevated bilirubin, and a mass of the pancreatic head as well as liver metastasis. Core biopsy revealed the diagnosis of ACC. Therapy with FOLFIRINOX resulted in a significant decrease of the primary tumor and regressiveness of a liver metastasis after chemotherapy. Our report suggests that pancreatic ACC treated by FOLFIRINOX is well tolerated and might be superior to other single chemotherapies in this rare tumor disease.

Treatment of recurrent genotype 1 hepatitis C post-liver transplantation: single center experience with telaprevir-based triple therapy

Recurrent HCV infection post-liver transplantation (post-LT) is still a major challenge in the treatment of hepatitis C virus (HCV) infection. In this retrospective analysis we gathered data about treatment response and safety of all 14 post-LT patients who were treated between 2011 and 2013 at our centre with a telaprevir (TVR)-based triple therapy. Seven out of 14 patients completed the full treatment course of 48 weeks. Five patients achieved a SVR 24, while 3 additional HCV RNA-negative patients are still in follow-up (end of treatment, SVR 12 and 22). Four patients discontinued treatment prematurely due to side effects. A virological non-response at TW 4 was seen in 1 patient. Virological breakthrough was observed in 2 patients at TW 16 and 28, respectively; 1 patient displayed a virological relapse after the end of treatment (EOT). Patients with a complicated course post-LT accumulated most of the severe side effects, largely infections. One patient with cholestatic hepatitis died 11 weeks after discontinuation of treatment due to progressive graft failure. In conclusion, TVR-based triple therapy in post-LT patients reveals an acceptable antiviral efficacy. Unfortunately, severe side effects are frequent and often require therapeutic interventions. Therefore, with the approval of less straining DAA like sofosbuvir in sight, TVR-based triple therapy in post-LT patients should be, if possible avoided.

[Diagnosis of and therapy for hepatocellular carcinoma]

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

Molecular therapy for the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Conventional cytotoxic chemotherapy has failed to show a substantial benefit for patients with HCC. Recently, a number of new drugs targeting molecular mechanisms involved in liver cell transformation have entered into clinical trials and led to encouraging results. In this review we summarise this data and point to a number of new compounds, which are currently being tested and can potentially broaden our therapeutic arsenal even further.

A phase II open-label study of cetuximab in unresectable hepatocellular carcinoma: Final results

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Background: Hepatocellular carcinoma (HCC) express the epidermal growth factor receptor (EGFR), and EGFR-targeting therapies are known to block tumor growth. We tested the activity of cetuximab (CET) in HCC and evaluated serial tumor biopsies for biomarker analyses. Methods: Patients (pts) with advanced or metastatic HCC with ECOG = 2 and adequate organ function were eligible. Prior therapy was permitted. CET was given iv weekly (400 mg/m2 loading dose, 250 mg/m2 thereafter). The primary endpoint was the rate of progression-free survival (PFS) at 24 wks. Serial tumor biopsies were performed prior to treatment, after 4 wks and at time of progression. 32 pts were enrolled. 27 pts are evaluable for tumor response. Results: Stable disease (SD) was achieved in 44.4% (12 pts) for at least 8 weeks of treatment. 55.6% failed to respond to CET (15 pts). The median time to progression (TTP) for all pts was 8.0 wks. Pts, which were stable for more than 8 wks achieved a median TTP of 22.5 wks (11–48 wks) compared to a median TTP of 6.0 wks (3–8 wks) in progressive pts. No treatment-related severe adverse events were noted throughout the study. Preliminary evaluation of surrogate markers showed no correlation with cytogenetic abnormalities based on FISH analyses for chromosome 1 and 8. Furthermore, only 5 of 21 tumor specimens were positive for EGFR expression without gene amplification, evaluated by FISH analyses. Serial tumor specimens are available in 5 responding and in 7 non-responding pts for changes of p27 and p21 expression. p27 and p21 were upregulated simultaneously in 60% (3/5 pts) of responding pts, whereas in pts with treatment failure p27 and p21 expression was detectable in 14% (1/7 pts) only. Conclusions: Cytogenetic aberrations of chromosome 1 and 8 failed to predict response to CET. In a subgroup of pts with SD >8 weeks, induction of p21 and p27 were associated with prolonged TTP >20 wks. Further evaluation of p21 and p27 as early molecular tumor response is warranted to identify pts, which benefit from anti-EGFR therapies.

[Table: see text]

No significant financial relationships to disclose.

Systemische Therapie von Leber- und Gallenwegstumoren

Hepatocellular carcinoma (HCC) is generally difficult to treat. This is primarily due to the reduced liver function of most patients and the low sensitivity of liver cancer cells to chemotherapy. This has been demonstrated in many clinical trials. Molecular therapies might represent an improvement in the systemic treatment of patients with HCC. In addition to anti-angiogenic drugs, compounds which interfere with specific signal transduction cascades have shown promising results in smaller trials. There are only limited numbers of studies about the systemic treatment options for biliary cancers. To date, the best response rates have been achieved with combination chemotherapies containing platinum analogues and gemcitabine. In the absence of larger clinical phase III trials, no standard chemotherapy for biliary cancers exists today.

A phase II open-label study of cetuximab in unresectable hepatocellular carcinoma

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Background: The majority of hepatocellular carcinomas (HCC) express the epidermal growth factor receptor (EGFR). The monoclonal anti-EGFR antibody cetuximab blocks EGFR activation. In the current study, we tested the activity of cetuximab in this disease. Methods: Pts with advanced or metastatic HCC and measurable disease with adequate renal, hematologic and hepatic function (bilirubin <2×UNL; AST/ALT <3×UNL) were eligible. Prior regional or systemic therapy was permitted. A total of 15 pts have been enrolled to date. Primary endpoint: rate of progression free survival (PFS) at 24 weeks of treatment. Secondary endpoints: overall survival (OS), objective response rate (ORR), tolerability and identification of surrogate markers. Tumor biopsies were performed prior to treatment, after 4 wks and at time of progression. Specimens were analyzed for genetic instability (FISH analyses) and cell cycle regulation (p27Kip1, skp2, EGFR) by immunohistochemistry. Cetuximab was administered 400 mg/m2 iv week 1, and 250 mg/m2 weekly thereafter until disease progression. Demographics: male 14, female 1, age 46–78 yrs (median 65), cirrhosis 13/15 pts, liver transplantion 2/15pts, Childs-Pugh class A: 14/15, B:1/15; distant metastases 6/15; risk factors: hepatitis C virus (HCV) 2/15, HBV 1/15. Contrast enhanced ultrasound examinations were performed on all pts at −2, 4, and at the time of progression to evaluate tumor blood flow. Results: At the time of the first tumor evaluation (8 wks) 2/15 pts (13%) achieved stable disease (SD). Tumor specimens showed a significant increase in copy numbers for centromeric probes against chromosome 1 and 8 in patients with progressive disease. Toxicity: all pts developed skin rash: Grade (Gr) 1 in 12/15 pts, Gr 2 in 3/15. Allergic reaction Gr 1 was seen in 1 pt. 2 pts required dose reduction for drug-related toxicity Conclusions: Cetuximab is well tolerated in pts HCC and liver cirrhosis, without additional toxicity. To date only modest activity has been detected in these unfavorably advanced pts. Accrual will continue to 35 pts total. At time of disease progression tumor specimens showed chromosomal instability with an increase in copy numbers of chr. 1 and 8. Updated results will be presented at the meeting.

[Table: see text]

Molekulare Therapie in der Gastroenterologie und Hepatologie

During recent years, molecular techniques have significantly impacted our understanding and therapeutic concepts in gastrointestinal and liver disease. In a number of diseases, diagnostic work-up includes molecular data that supplements the phenotypical evaluation. This includes monogenic diseases as well as the identification of genetic risk factors (e. g. NOD2/CARD15 mutation in Crohn's disease) and viral disease. Attempts to replace liver transplantation in hereditary liver disease by targeted molecular interventions (e. g. via viral vectors) are still experimental, but the associated techniques have improved considerably. The molecular identification of therapeutic targets was followed by the development of specifically tailored therapeutics. These agents are mainly used in the treatment of chronic inflammatory bowel disease and gastrointestinal tumors.

A mouse knock-in model exposes sequential proteolytic pathways that regulate p27Kip1 in G1 and S phase

The protein p27Kip1 is an inhibitor of cell division. An increase in p27 causes proliferating cells to exit from the cell cycle, and a decrease in p27 is necessary for quiescent cells to resume division. Abnormally low amounts of p27 are associated with pathological states of excessive cell proliferation, especially cancers. In normal and tumour cells, p27 is regulated primarily at the level of translation and protein turnover. Phosphorylation of p27 on threonine 187 (T187) by cyclin-dependent kinase 2 (Cdk2) is thought to initiate the major pathway for p27 proteolysis. To critically test the importance of this pathway in vivo, we replaced the murine p27 gene with one that encoded alanine instead of threonine at position 187 (p27T187A). Here we show that cells expressing p27T187A were unable to downregulate p27 during the S and G2 phases of the cell cycle, but that this had a surprisingly modest effect on cell proliferation both in vitro and in vivo. Our efforts to explain this unexpected result led to the discovery of a second proteolytic pathway for controlling p27, one that is activated by mitogens and degrades p27 exclusively during G1.

The enhancer I core region contributes to the replication level of hepatitis B virus in vivo and in vitro

Chronic hepatitis B virus (HBV) infection can lead to liver cirrhosis and hepatocellular carcinoma. Long-term interaction of the immune system with the virus results in the selection of escape mutants and viral persistence. In this work we characterize mutations in the enhancer I region isolated prior to liver transplantation from the HBV genomes of 10 patients with chronic HBV infection. The HBV-genomes were sequenced, and the enhancer I region was cloned into luciferase reporter constructs to determine the transcriptional activity. Functional studies were performed by transfecting HBV replication-competent plasmids into hepatoma cells. Analyses of the replication fitness of the mutant strains were conducted by biochemical analysis. In all HBV genomes the enhancer I region was mutated. Most of these mutations resulted in decreased transcriptional activity. The strongest effects were detectable in strains with mutations in the hepatocyte nuclear factor 3 and 4 (HNF3 and HNF4) binding sites of the enhancer I core domain. Replication-competent HBV constructs containing these mutations demonstrated up to 10-fold-reduced levels of virus replication. Before liver transplantation, when the mutant strains were detected in the patients' sera, low HBV DNA levels were found. After transplantation and reinfection with a wild-type virus, the levels of replication were up to 240-fold higher. Our results show that mutations in the enhancer I region of HBV have a major impact on HBV replication. These mutations may also determine the switch from high to low levels of viral replication which is frequently observed during chronic HBV infection.

NF-kappaB determines between apoptosis and proliferation in hepatocytes during liver regeneration

Tumor necrosis factor (TNF)-alpha is a potent inducer of apoptotic cell death in various tissues, whereas the transcription factor nuclear factor (NF)-kappaB is essential to protect against TNF-alpha-induced apoptosis. Human hepatoma cell lines were used to investigate the effectiveness and specificity of the fungal metabolite gliotoxin in inhibiting TNF-alpha-induced NF-kappaB activation in transformed cells. Gliotoxin-TNF-alpha cotreatment induced massive apoptosis in these otherwise TNF-alpha-resistant cell lines. With the use of the mouse partial hepatectomy model, we were also able to demonstrate in vivo the capacity of gliotoxin to act as inhibitor of NF-kappaB activation. Bromodeoxyuridine staining of liver sections showed that the lack of NF-kappaB activation correlated with 80% reduction of DNA synthesis 48 h after hepatectomy compared with untreated controls. Additionally, animals treated with gliotoxin showed nuclear condensation and DNA laddering of hepatocytes indicative of apoptosis 24 h after hepatectomy. In summary, our results demonstrate that NF-kappaB is essential in defining the fate of liver cells in response to TNF-alpha in vivo and furthermore implicate gliotoxin as a potential new response modifier for TNF-alpha-based therapy.

Molecular mechanisms of TNF receptor-mediated signaling

Tumor necrosis factor alpha (TNF alpha) is a proinflammatory cytokine involved in a variety of physiological and pathological conditions. During the past several years substantial progress has been made toward a better understanding of how a single cytokine is able to exert obviously opposing effects (e.g., apoptosis and growth). This review focuses on the recently discovered TNF-receptor (TNFR)-associated proteins involved in the activation of intracellular signal-transduction cascades. It explains which classes of proteins have been described so far and how these factors are able to mediate different biological functions after TNFR activation.

Concanavalin A-induced liver injury triggers hepatocyte proliferation

Concanavalin A (Con A) injection into mice leads to immune-mediated liver injury. We studied whether after Con A-induced liver injury, TNF- and IL-6-dependent signaling pathways known to be related to hepatocyte proliferation are activated. 2 h after Con A injection, maximum TNF-alpha, and after 4-8 h, maximum IL-6 serum levels were found. The rise in aminotransferases and DNA fragmentation started after 4 h; maximum levels were evident after 8 h. 5-Bromo-2'-deoxyuridine staining and nuclear cyclin A expression as markers of the S-phase were first detected in hepatocyte nuclei after 24 h, peaking after 48 h. An increase in TNF-dependent nuclear expression of CCAAT/enhancer-binding protein-beta (C/EBP-beta)/liver-enriched activating protein (LAP) was detected after 1 h, whereas an increase in RNA expression was evident only after 4 h. C/EBP-beta/LAP expression returned to normal values before progression into the S-phase. DNA binding of signal transducer and activator of transcription (STAT) 3/acute phase response factor (APRF) increased for up to 8 h. As found by supershift experiments, in addition to STAT3/APRF, STAT1 also binds to the same sequence. During the course of time gel shift experiments, DNA binding of the apoptosis-related STAT1 started earlier than DNA binding of STAT3/APRF, which regulates hepatocyte proliferation. However, the subsequent decrease in DNA binding of both factors was comparable. This study demonstrates that after Con A injection, TNF- and IL-6- dependent signals trigger nuclear events regulating hepatocyte apoptosis and proliferation during liver injury.

Quantification of additional short arms of chromosome 12 in germ cell tumours using the polymerase chain reaction

Male germ cell tumours are characterised by the over-representation of 12p sequences, most often in the form of isochromosome i(12p). This study describes the development of a quantitative detection system for additional copies of 12p employing the polymerase chain reaction (PCR). The validity of this method was assessed on two i(12p) containing tumour cell lines in which the number of i(12p) was determined by fluorescence in situ hybridisation. Fourteen primary male germ cell tumours were analysed using the PCR-based method. While 3/8 seminomatous germ cell cancers did not contain any additional 12p, all 6 non-seminomatous tumours did and the severity of the disease correlated with the respective copy number. The ease of the PCR-based method makes it possible for the quantification of additional 12p to become a routine diagnostic and prognostic tool for testicular germ cell tumours, thereby helping to define the role of the i(12p) anomality in larger retrospective studies.

A case of the yellow nail syndrome associated with massive chylous ascites, pleural and pericardial effusions

A 26-year-old male patient with a history of chronic peripheral lymphedema, yellowish coloured slow growing nails and pleural effusions since early childhood is described. After 23 years he developed a chylous ascites and scintigraphy with technetium-99m labeled albumin clearly demonstrated a diffuse protein loss involving the whole jejunum and ileum. Subsequent jejunal and duodenal biopsies showed the typical histological findings of intestinal lymphangiectasia thereby confirming a diffuse intestinal lymphatic damage. In addition to the gastrointestional symptoms the patient developed a pericardial effusion diagnosed by echocardiographic imaging. Dietary treatment with middle chained triglycerides and intravenous human albumin supplementation was followed by the reduction of the ascites and improvement of the peripheral lymphedema. To our knowledge this is the first description of the yellow nail syndrome associated with a diffuse lymphangiectasia involving the whole small bowel.