C-erbB-2 Oncoprotein in Gastric Carcinoma: Correlation with Clinical Stage and Prognosis

The aim of this study was to investigate the expression of the oncogene c-erbB-2 in gastric tumors. Immunohistochemical study of the expression of c-erbB-2 was performed in formalin-fixed, paraffin-embedded sections from 82 gastric adenocarcinomas using polyclonal antibody. c-erbB-2-positive immunostaining was observed in 37 (45%) tumors. Positive staining was detected in 63% of well differentiated, 46% of moderately differentiated and 80% of papillary adenocarcinomas. In poorly differentiated adenocarcinomas, positivity for c-erbB-2 was observed in 21%. According to the Lauren classification, a higher frequency of c-erbB-2 positive staining was observed in intestinal type tumors (70%). During the follow-up period 43% of the patients with c-erbB-2 oncoprotein-negative tumors and 45% of the patients with c-erbB-2 oncoprotein-positive tumors died. There was no significant association between c-erbB-2 staining and sex, age, clinical stage, tumor grade, histological type or survival rates. In conclusion, almost half of the gastric cancers were positive for c-erbB-2. Nonetheless, the expression of c-erbB-2 oncoprotein did not play a role in prognosis.

Prediction of significant liver fibrosis in kidney transplant patients with chronic hepatitis C virus infection: the TX-3 index

HCV infection is highly prevalent among kidney transplant (KT) recipients. The natural history and management of these patients are controversial. We sought to assess the diagnostic value of noninvasive markers of liver fibrosis in KT HCV-infected patients. This cross-sectional study included 102 KT individuals with positive HCV-RNA. Bivariate and multivariate analyses were used to identify variables associated with significant fibrosis (METAVIR > or = F2). Significant fibrosis was observed in 20 patients (20%). Time after transplantation, AST level, and platelet count were identified as independent predictors of significant fibrosis. Based on the regression model, a simplified index was devised. The AUROC for the TX-3 model was 0.867 +/- 0.081 (0.909, when adjusted by DANA). Values < or =4.0 of TX-3 showed a NPV of 97% and scores >9.6 exhibited a PPV of 71%. If biopsy indication was restricted to scores in the intermediate range of TX-3, this could have been correctly avoided in 68% of cases. The APRI score provided a correct diagnosis in only 47 individuals (46%) and exhibited lower diagnostic indices for both cutoffs, as compared to the TX-3 index. Comparison of AUROCs showed a trend towards superior diagnostic accuracy for TX-3 over APRI, although the difference between AUROCs did not reach statistical significance (0.867 +/- 0.053 vs 0.762 +/- 0.066, respectively, P = 0.064). In conclusion, significant liver fibrosis can be reliably predicted in KT HCV-infected subjects by simple and widely available parameters. If additional studies confirm our results, this model might obviate the requirement for a liver biopsy in a significant proportion of those patients.

Serum levels of YKL-40 and hyaluronic acid as noninvasive markers of liver fibrosis in haemodialysis patients with chronic hepatitis C virus infection

Hepatitis C virus (HCV) infection is highly prevalent among end-stage renal disease (ESRD) patients undergoing haemodialysis and it is an important cause of morbidity and mortality in this population. The aim of this study was to evaluate the diagnostic value of YKL-40 and hyaluronic acid (HA) as noninvasive markers of liver fibrosis in 185 ESRD HCV-infected patients. Significant liver fibrosis was defined as METAVIR F2, F3 or F4 stages. Significant fibrosis was observed in 45 patients (24%). By univariate analysis, higher levels of YKL-40, HA, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyltransferase (GGT) as well as reduced platelet count were associated with fibrosis. However, by multivariate analysis, only AST (P = 0.001), platelet count (P = 0.004) and HA (P = 0.042) were independently associated with significant fibrosis. For the prediction of significant fibrosis, the areas under receiver operating characterictic curve (AUROC) of the regression model (0.798) was significantly higher than the AUROC of YKL-40 (0.607) and HA (0.650). No difference was noted between the AUROC of the regression model and AST to platelet ratio index (APRI) (0.787). Values <8.38 of the regression model showed a negative predictive value of 94% and scores >or=9.6 exhibited a positive predictive value of 65%. If biopsy indication was restricted to scores in the intermediate range of the regression model, it could have been correctly avoided in 61% of the cases. In conclusion, APRI and a model based on AST, platelet count and HA showed better accuracy than YKL-40 and HA (when used solely) for the prediction of significant fibrosis in ESRD HCV-infected patients.

Carcinosarcoma of the Liver: A Case Report

Primary hepatic carcinosarcoma is a rare malignant hepatic tumor containing both carcinomatous and sarcomatous elements. A 40-year-old man referred to our liver transplant team because of hepatic cirrhosis was on the waiting list, having undergone all liver tests, ultrasonography, and with normal serum alpha fetoprotein markers every 6 months to search for a tumor. He underwent a liver transplantation without complication. The pathologic findings of the original liver indicated carcinosarcoma. We have reviewed the literature on this subject.

Lack of Impact of Hepatitis C Virus Coinfection in End-Stage Renal Disease Patients With Hepatitis B Virus Infection

INTRODUCTION

Hepatitis B virus (HBV) and hepatitis C virus (HCV) coinfection results in more severe forms of liver disease in nonuremic patients; however, the impact of HCV coinfection is not clearly known in end-stage renal disease (ESRD) patients with HBV infection. We sought to determine the impact of HCV coinfection in HBV-infected ESRD patients.

PATIENTS AND METHODS

The HBsAg-positive ESRD patients evaluated between March 1999 and May 2003 were divided into two groups: group B, HBV infection alone, and group BC, HBV-HCV coinfection (anti-HCV-positive). Both groups were compared regarding epidemiological, laboratory, and histological findings. A liver biopsy was obtained in cases with evidence of viral replication and/or elevated alanine aminotransferase.

RESULTS

One hundred patients (73% men) with mean age of 42 +/- 11 years (55 patients in group B and 45 in group BC) were studied. Comparison between groups showed a difference in time on hemodialysis and duration of infection, which were higher in group BC (P < .001 and P = .001, respectively) and in history of blood transfusion, which was also more frequent in group BC (P = .04). Liver biopsies, obtained from 15 patients in group B and 28 patients in group BC, showed no difference in frequency of septal fibrosis (60% in group B vs 48% in group BC, P = .46) or interface hepatitis (73% vs 71%, P = .99).

CONCLUSIONS

HBV-HCV coinfection was related to a longer time on hemodialysis, longer duration of infection, and history of blood transfusion. Contrary to nonuremic patients, HCV coinfection was not associated with more severe forms of liver disease in ESRD patients.

Serum laminin, type IV collagen and hyaluronan as fibrosis markers in non-alcoholic fatty liver disease

Hepatic fibrosis in patients with non-alcoholic fatty liver disease is associated with progression of the disease. In the present study, we analyzed the discriminative ability of serum laminin, type IV collagen and hyaluronan levels to predict the presence of fibrosis in these patients. In this preliminary report, we studied 30 overweight patients divided into two groups according to the absence (group I, N = 19) or presence (group II, N = 11) of fibrosis in a liver biopsy. Triglycerides, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltranspeptidade, hyaluronan (noncompetitive fluoroassay), type IV collagen, and laminin (ELISA) were determined. Group II presented significantly higher mean laminin, hyaluronan, type IV collagen, and aspartate aminotransferase values, which were due to the correlation between these parameters and the stage of fibrosis in the biopsy (Spearman's correlation coefficient, rS = 0.65, 0.62, 0.53, and 0.49, respectively). Analysis of the ROC curve showed that laminin values >282 ng/ml were those with the best diagnostic performance, with 87% accuracy. Association of laminin with type IV collagen showed improvement in the positive predictive value (100%), but with reduction in diagnostic sensitivity (64%). When compared with the criteria of Ratziu et al. for the diagnosis of septal fibrosis, laminin values presented a better diagnostic accuracy (83 vs 70%). Determination of extracellular matrix components in serum, especially of laminin, may identify patients with non-alcoholic fatty liver disease and fibrosis and these components may be used as indicators for liver biopsy in these patients.

Magnetic resonance cholangiography in the diagnosis of biliary complications after orthotopic liver transplantation

OBJECTIVE

The aim of our study was to evaluate the role of magnetic resonance cholangiography (MRC) in the diagnosis of biliary tract complications (BC) after orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Among 21 OLT patients who underwent routine follow-up MRC using a breath-hold T2-weighted turbo spin-echo sequence with half-Fourier acquisition (HASTE), 5 had an elevated serum alkaline phosphatase level. Diagnostic confirmation was obtained with endoscopic retrograde cholangiography (ERC) (n = 11), surgery (n = 3), or clinical and laboratory follow-up of at least 1 year (n = 8).

RESULTS

In 13 patients, no abnormality of the biliary tract was detected using MRC. In 8 patients, anastomotic strictures were diagnosed, 7 of which were confirmed at surgery or using ERC. One patient with normal findings at MRC and abnormal liver function test results was found to have a stricture at ERC. All patients with normal MRC and liver function tests had 1 year of uneventful follow-up and were considered true-negative cases. We found that MRC had 87.5% sensitivity, 92.3% specificity, 87.5% positive predictive value, 92.3% negative predictive value, and 90.4% accuracy for the diagnosis of BC.

CONCLUSION

MRC is a valuable examination to detect BC after OLT. It provides useful information for planning interventional procedures.

A randomized double-blind study of the short-time treatment of obese patients with nonalcoholic fatty liver disease with ursodeoxycholic acid

In order to determine the effect of ursodeoxycholic acid on nonalcoholic fatty liver disease, 30 patients with body mass indices higher than 25, serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) or gamma-glutamyltransferase (gamma-GT) at least more than 1.5 times the upper limit of normality, and hepatic steatosis demonstrated by ultrasonography were randomized into two groups of 15 patients to receive placebo or 10 mg kg-1 day-1 ursodeoxycholic acid for three months. Abdominal computed tomography was performed to quantify hepatic fat content, which was significantly correlated with histological grading of steatosis (r s = -0.83, P < 0.01). Patient body mass index remained stable for both groups throughout the study, but a significant reduction in mean ( +/- SEM) serum levels of ALT, AST and gamma-GT was observed only in the treated group (ALT = 81.2 +/- 9.7, 44.8 +/- 7.7, 48.1 +/- 7.7 and 52.2 +/- 6.3 IU/l at the beginning and after the first, second and third months, respectively, N = 14, P < 0.05). For the placebo group ALT values were 66.4 +/- 9.8, 54.5 +/- 7, 60 +/- 7.6 and 43.7 5 IU/l, respectively. No alterations in hepatic lipid content were observed in these patients by computed tomography examination (50.2 +/- 4.2 Hounsfield units (HU) at the beginning versus 51.1 +/- 4.1 HU at the third month). These results show that ursodeoxycholic acid is able to reduce serum levels of hepatic enzymes in patients with nonalcoholic fatty liver disease, but this effect is not related to modifications in liver fat content.

In vitro-induced antibody production in chronic hepatitis C virus infection

The objectives of the present study were to assess the in vitro-induced anti-hepatitis C virus (HCV) antibody production (IVIAP) in relation to the clinical, biochemical, virologic and histologic variables of patients with HCV infection. The study included 57 patients (60% males) with HCV infection (anti-HCV and HCV-RNA positive). Alanine aminotransferase (ALT) was elevated in 89% of the patients. Mean viral load was 542,241 copies/ml and histology of the liver showed chronic hepatitis in 27/52 (52%) and cirrhosis in 11/52 (21%) patients. IVIAP levels were determined by immunoenzymatic assay at median absorbance of 0.781 at 450 nm. IVIAP was negative in 14% of the patients. When groups with IVIAP levels above and below the median were compared, high IVIAP levels were associated with the male sex, elevated ALT levels and more advanced disease stage. After logistic regression analysis, advanced histologic damage to the liver remained as the only independent variable associated with elevated IVIAP levels. Using a receiver operator characteristic curve, the best cut-off level for IVIAP was established (= 1.540), with 71% sensitivity and 94% specificity for the detection of more advanced disease stages (grades 3 and 4). These findings are consistent with the participation of immunological mechanisms in the genesis of the hepatic lesions induced by HCV and indicate that the IVIAP test may be useful as a noninvasive marker of liver damage either alone or in combination with other markers.

Malignant melanoma with liver and spleen metastases: case report

CONTEXT

The diagnosis of primary melanoma is easily confirmed after histological analysis of the lesion, whereas it is rarely diagnosed when the patient even has distant metastases.

DESIGN

Case report

CASE REPORT

Malignant melanoma is responsible for about 1% of all deaths caused by cancer in the USA and only 3% of all malignant skin diseases. Malignant melanoma is a rare disease, although it corresponds to 65% of all deaths caused by skin cancer. The liver and spleen are rarely the first sites of melanoma metastases. This paper reports on the clinical picture of a patient with fatal malignant melanoma and hepatic and spleen metastases. As this was an un-usual presentation, the melanoma diagnosis could only be made after pathological analysis of the skin and hepatic lesions.

[Hypoinsulinemia in alcoholics with minimal liver disease]

The chronic pancreatitis (CP) may evolve with low insulin levels and develop clinical picture of diabetes mellitus. Low seric levels of insulin and C peptide after stimulus has also been described in asymptomatic alcoholics even with normal glycemic curves. It is known that the chronic alcoholism is the main etiological factor of CP and hepatic diseases, and that the insulin produced by the pancreas is metabolized mainly by the liver. High levels of periferic insulin are described in hepatic cirrhosis due to decrease of hepatic metabolization alone or associated to increase of periferic resistance.

AIM

In alcoholics with minimal hepatic lesions to evaluate the seric insulin and glucose levels after stimulus with intravenous glucose.

METHODS

In 8 alcoholic patients with minimal hepatic lesions characterized by hepatic biopsy, and 26 non-alcoholics, healthy controls, it was studied the serum glucose and insulin levels in basal time, 1, 3, 5, and 10 minutes after stimulus with intravenous glucose (0.5 g/kg).

RESULTS

The insulin means in time 1, 3 minutes and total integrated response after stimulus were lower (p < 0.05) in alcoholic group than in control, even with normal glucose curves.

CONCLUSION

Alcoholics with minimal hepatic lesions showed low seric insulin levels after glucose stimulus, similar to former observations in asymptomatic alcoholics, indicating hypofunction of pancreatic B cells.

Asymptomatic hepatopathy is frequent in chronic alcoholic pancreatitis

BACKGROUND

Chronic ethanol abuse is a common cause of chronic hepatic and pancreatic diseases in Western countries. The objectives of the present study were to determine the occurrence and the clinical evolution during follow-up of asymptomatic hepatic disease in Brazilian alcoholics with chronic pancreatitis whose most important beverage is cachaça, a beverage distilled from sugar cane.

PATIENTS-METHODS

Thirty-two patients, mean age 35 years, with a mean daily ethanol intake of 204 g during a mean period of 16 years, presenting with chronic pancreatitis without clinical and laboratory features of hepatocellular failure, were followed up during 34 +/- 8 months after undergoing a percutaneous biopsy of the liver and histological examination.

RESULTS

Hepatic injury was observed in 50% of the cases. During the follow-up, only one patient showed clinical or biochemical evidence of hepatic deterioration or complication.

CONCLUSIONS

In subjects with a chronic intake of cachaça, the association between asymptomatic alcoholic hepatopathy and chronic alcoholic pancreatitis is frequent (50%). In chronic alcoholic pancreatitis, associated hepatic disease may remain asymptomatic in the majority of the cases and has little influence on the outcome of the patients, at least in a short-term follow-up.

Significance of the presence of antibodies against hepatitis C virus in asymptomatic blood donors

In order to determine the significance of anti-hepatitis C virus (anti-HCV) antibodies in blood donors, 46 consecutive asymptomatic individuals were recruited at the blood bank of Hospital São Paulo, São Paulo, Brazil. They were submitted to an interview to collect epidemiological data and to clinical examination and blood samples were obtained for biochemical, serological and virological analysis. All patients were followed for a minimum period of six months and those with abnormal mean alanine aminotransferase (ALT) levels were submitted to a liver biopsy after giving informed consent. Hepatitis C virus RNA (HCVRNA) was detected by the polymerase chain reaction (PCR) in 22/47 (47.8%) patients and this finding was associated with parenteral risk factors (P = 0.03) and ethanol abuse (P = 0.03). HCVRNA positivity was also associated with abnormal levels of ALT (P < 0.001) and gamma-glutamyl transpeptidase (gamma-GT) (P = 0.01). Abnormal ALT levels were good marker of viremia, with 86.4% sensitivity and 79.2% specificity. Twenty-three patients with elevated mean ALT levels were submitted to a liver biopsy and histopathological changes were observed in 17 of them (73.9%). HCVRNA positivity was associated with severe forms of hepatic disease (chronic hepatitis and cirrhosis). These results indicate the need for a judicious evaluation of all anti-HCV-positive blood donors, including clinical examination, biochemical tests and liver histology when ALT is persistently elevated.

[Plasma kallikrein clearance by the liver in experimental cirrhosis]

AIM

To study the hepatic clearance of a glycoprotein (rat plasma kallikrein) by the liver of rats with experimental decompensated cirrhosis.

MATERIAL AND METHODS

Cirrhosis was induced by intragastrically administration of carbon tetrachloride 520 mg/kg/week, during 16-19 weeks. After this period, each liver was isolated, exsanguinated and perfused at 37 degrees C with 10nM rat plasma kallikrein (RPK).

RESULTS

58% of the animals died during the treatment and the remaining developed prostration, ascites, jaundice and bleeding; at the end of the treatment period serum aminotransferases were not altered and serum albumin decreased. The liver histology showed cirrhosis. RPK clearance rate of the cirrhosis group (5.4 +/- 0.9 pmol/g liver/10 min) was significantly lower (p < 0.05) than that of the control group (13.5 +/- 2.7 pmol/g liver/10 min).

CONCLUSION

The development of cirrhosis is associated with a decreased hepatic clearance of a glycoprotein which endocytosis is mediated by a receptor.

[Esophageal squamous cell papilloma. Report of 3 cases. Diagnostic aspects]

Dysphagia is not always present in patients with esophageal squamous cell papilloma, and it can be an incidental finding during gastrointestinal endoscopy of an asymptomatic patient.

PURPOSE

Three cases of squamous cell papilloma of the esophagus and aspects regarding diagnosis and association with human papillomavirus are presented. CASUISTIC: Two cases are male and one female what is consistent with a higher incidence showed in the literature in males. The three patients were submitted to upper gastrointestinal endoscopy: in one case the tumor was unusually large and in all patients it was located in the mid and lower esophagus. Chromoscopy was performed in one case and the lesion was not stained. We were unable to identify human papillomavirus using DNA-hybridization techniques. Our results are similar to those reported in the review of the literature.

RESULTS

There is no other case published in the Brazilian literature and this is the first report on the use of chromoscopy.

CONCLUSION

We were not able to show an association between esophageal squamous papilloma and human papillomavirus.

Plasma kallikrein clearance by the liver of chronic carbon tetrachloride-treated rats

We have previously reported that the endocytosis of rat plasma kallikrein (RPK) by hepatocytes is a calcium-independent and beta-galactoside-dependent mechanism. We now report the clearance of RPK by the liver of four groups of rats: normal, inflamed (48 h ex-turpentine) and two groups chronically treated with CCl4 (52 mg/kg per week, intragastrically, for 9-12 weeks). Each liver was isolated, exsanguinated and perfused at 37 degrees C with 30 mL of BSA-Krebs-Henseleit-bicarbonate medium containing 10 nmol/L RPK. Although all rats received the same mild CCl4 treatment, the liver histology showed that they evolved either to severe hepatitis (serum alanine aminotransferase [ALT] 4852 +/- 885 U/L, parenchymatous necrosis in the perivenous region) or to compensated cirrhosis (serum ALT 209 +/- 42 U/L, vigorous fibrous encircling regeneration nodules); neither jaundice nor ascites was noted. The results show that serum albumin was not altered among the groups and that: the acute-phase response by itself (inflamed group) increased RPK clearance rate (3.01 +/- 0.59 mL/min) as compared with the normal group (1.85 +/- 0.14 mL/min); the CCl4 treatment, although induced an acute-phase response, decreased (P < 0.01) RPK clearance rates (0.80 +/- 0.11 mL/min hepatitis group and 0.98 +/- 0.10 mL/min cirrhosis group). These findings suggest that the hepatic clearance rate of plasma kallikrein is an early indicator of liver injury.

[Peutz-Jeghers syndrome and adenocarcinoma. Report of a case]

Peutz-Jeghers syndrome is a rare disease, characterized by autosomic inheritance, presenting skin stain and hamartomatous polyps. We report one case of Peutz-Jeghers syndrome and duodenal adenocarcinoma in a young male who presented with liver metastasis and pancreatic invasion. Such association is reported to be presented in 5% of patients with the syndrome. The reasons of such association are unknown, being possible that: 1) there is malignant degeneration of a adenomatous polyp; 2) malignant degeneration of a hamartomatous polyp, or 3) adenomatous portion of a hamartomatous polyp could undergo malignant transformation.

Iron, copper and alpha 1-antitrypsin deficiency in the liver of cirrhotic and schistosomotic patients

While a number of studies investigated iron and copper storage or alpha 1-antitrypsin (A1AT) deficiency in the liver of patients with cirrhosis, we did not find any similar study in schistosomotic patients reported in literature. We investigated the storage of both metals and the A1AT deficiency in the liver of 72 cirrhotic and 27 schistosomotic patients (5 with the hepatointestinal and 22 with the hepatoesplenic form of the disease). Forty-four patients with cirrhosis were also alcoholic, and 28 were not. Iron storage was detected in 23 patients with cirrhosis (31.9%); among these 16 (36.3%) were alcoholic and 7 (25.0%) non-alcoholic (the difference was not statistically significant). Thirteen (56.5%), 5 (21.7%) and 5 (21.7%) patients presented I-grade, II-grade, and III-grade iron storage, respectively. Copperstorage was detected in 24 cirrhotic patients (33.3%), 15 being alcoholic (34.0%) in contrast with 9 non-alcoholic patients (32.1%), a statistically non-significant difference. A1AT deficiency was observed in 2 patients with cirrhosis (2.8%), one with history of alcoholism. HBsAg and HBcAg in hepatic tissue were detected in 5 cirrhotic patients (6.9%), three of them with a history of alcoholism. Iron and copper storage and A1AT deficiency were observed in 3 patients with cirrhosis (12.5%), while iron storage and A1AT deficiency were found in 2 additional patients with cirrhosis (2.8%). The authors underline that neither iron nor copper storage nor A1AT deficiency was found in any schistosomotic patient. The authors discuss the possible importance of these data.

[Relation of hepatitis B virus markers in the serum and hepatic tissue in chronic carriers of HBsAg]

The authors studied 23 chronic carriers of HBsAg, to classify them in terms of serology, histopathologic findings and behaviour of markers HBsAg and HBcAg in hepatic tissue. Immunohistochemical techniques were used to establish possible relations between these parameters. Among patients with positive HBeAg found all exhibited HBcAg in hepatic tissue, but in 16 patients in which HBeAg was negative, liver HBcAg was positive in 3 cases (18.7%). No correlation was found between the HBeAg system/anti-HBe and histopathologic findings because chronic active hepatitis was observed in 6/8 anti-HBe positive patients (75%). These findings suggest that, the evaluation of chronic carriers of HBsAg, requires a histologic analysis of the liver, including a tissue research for the virus in addition to a complete serologic study of HBV.