t(11;14)(q23;q24) generates an MLL-human gephyrin fusion gene along with a de facto truncated MLL in acute monoblastic leukemia

More than 20 different partner genes with MLL have been cloned from leukemia cells with translocations involving chromosome 11 band q23 (11q23). All reported partner genes fused in-frame to MLL and the fusion cDNA encode chimeric MLL proteins with a significant portion derived from the partner genes. We analyzed one patient with de novo acute monoblastic leukemia with t(11;14)(q23;q24) and identified that a human homologue of gephyrin (human gephyrin) fused with MLL. Gephyrin is a rat glycine receptor-associated protein, which forms submembranous complexes and anchor glycine or gamma-aminobutyric acidA receptors to microtubules. Alternative splicing of human gephyrin gene created two different forms of fusion cDNA. In one form, human gephyrin gene fused in-frame to MLL exon 9, and the chimeric product had COOH terminus of human gephyrin protein, including the tubulin binding site. In the other, the reading frame terminated shortly after the fusion point. As a result, only seven amino acids with no known function were attached to the NH2 terminus of MLL protein. The functional significance of this de facto truncated MLL gene product is not clear.

Changes of esophageal varices in hepatitis C patients after achievement of a sustained viral response by direct-acting antivirals

OBJECTIVES

The changes in portal hypertension after achieving a sustained viral response (SVR) by direct-acting antivirals (DAAs) have not been fully elucidated. Consequently, noninvasive and inexpensive predictors need to be investigated. We therefore explored factors associated with the progression of EVs after the achievement of an SVR with DAAs in patients with chronic hepatitis C.

METHODS

Eighty-nine patients, who had achieved an SVR with DAAs and could have their esophagogastroduodenoscopy (EGD) findings compared between before DAAs administration and after achieving an SVR achievement were enrolled in this study. We compared the patients with and without EVs progression. Furthermore, the cumulative progression rates of EVs were also analyzed.

RESULTS

The fibrosis-4 index (FIB-4) before DAAs administration was the only significant factor for the progression of EVs after an SVR (odds ratios: 1.2, 95% confidence intervals: 1.05-1.38, p = 0.01). In a receiver operating characteristics analysis, the cut-off of FIB-4 for the progression of EVs was 8.41 (sensitivity: 0.63, specificity: 0.86, positive predictive value: 0.31, negative predictive value: 0.96), namely EVs of those with more than 8.41 of FIB-4 progressed and those with less than 8.41 of FIB-4 did not.

CONCLUSIONS

As patients with FIB-4 ≥ 8.41 may have progressions of EVs, periodic surveillance by EGD should be continued in such cases, even after an SVR is achieved.

Sero‐epidemiological survey of hepatitis virus infection in Taiwan: A study in 6863 subjects from the general population

Abstract A sero‐epidemiological study was made of 6863 apparently healthy randomly selected volunteers from various parts of Taiwan. It revealed an 18% incidence of hepatitis B surface antigen (HBsAg) carriers amongst the general population, the prevalence being significantly higher in males than females (21.7% vs 14.1%). The Takasago natives showed the highest HBsAg carrier rate (27.0%). Those who are primarily derived from Ming Nan had a significantly higher prevalence (19.0%) than those from Hakka (14.7%) and recent immigrants from Mainland China (14.6%). About one‐third of female carriers of child‐bearing age in southern Taiwan were positive for e antigen (HBeAg) in a limited study; they may be an important source of HB virus (HBV) infection. The positivity rate for HBeAg was significantly higher in subjects below 40 years of age (36.7%) than those above 40 years (7.5%). There was a significant association between HBsAg positivity and elevated serum transaminase levels, especially in males; 20.3% of carriers had elevated transaminase in comparison with 11.1% of female carriers. Among HBsAg seronegative individuals, the frequency of abnormal transaminase increased with age with an overall abnormality rate of 10.6% in males and 5.0% in females, suggesting that factors other than HBV may also contribute to liver disease in Taiwan. Altogether, 9.3% had elevated transaminase. Out of 82 randomly selected HBsAg carriers who were evenly distributed in geography, serum antidelta antibody was positive in only five men (6.1%), of whom four had a mild elevation of transaminase levels (< 100 KU). The overall positivity rate for anti‐hepatitis A (HA) antibody was 93.0% in southern Taiwan, indicating poor sanitation. These findings indicate that HB and HA virus infections are highly endemic in Taiwan and that delta infection is infrequent despite a high prevalence of HB virus infection.

Successful prolonged treatment with sofosbuvir/velpatasvir for a hepatitis C patient with decompensated cirrhosis and treatment failure after 12-week therapy

There is no established rescue therapy for hepatitis C patients with decompensated cirrhosis who experience treatment failure on 12-week sofosbuvir (SOF)/velpatasvir (VEL) therapy that is the only approved regimen for decompensated cirrhosis in Japan. We experienced a patient with decompensated cirrhosis who showed virologic relapse at post-treatment week 7 following 12-week SOF/VEL therapy. She had resistance-associated substitutions (RASs) against VEL before therapy but did not achieve new RASs against VEL or SOF after therapy. We considered rescue therapy following strong demand from her and her family. The drug adherence of therapy was 100%, and the treatment was well tolerated. Because we prioritized the safety and drug adherence of the regimen, we performed prolonged 24-week SOF/VEL therapy without ribavirin at her own expense with the approval of the ethics board in the hospital where the first author belongs. Fortunately, a sustained virologic response 24 was achieved without any adverse events. Hepatocellular carcinoma that had developed after 12-week SOF/VEL therapy recurred and was treated near the end of rescue therapy, but hepatic functional reserve improved. Although this was a single case report and was assumed to be very rare, the same regimen might be effective for treatment failure with 12-week SOF/VEL therapy.

[A case of malignant lymphoma mimicking a seminal vesicle tumor]

A 76-year-old man was admitted to our hospital with severe diarrhea and syncope. Abdominal computed tomography (CT) showed a mass 7 cm in diameter mimicking a seminal vesicle tumor and magnetic resonance imaging showed a heterogeneously enhanced mass with an unclear borderline to the rectum. The differential diagnosis of the lesion included a tumor arising from a seminal vesicle, a local recurrence of rectal cancer, a rectal GIST, and a mesenchymal tumor. Transrectal needle biopsy revealed non-Hodgkin's malignant lymphoma (diffuse large B cell lymphoma). Chest and abdominal CT showed no specific findings except the lesion for the seminal vesicle lesion, but positron emission tomography showed accumulations in the gastrointestinal tract, pleura, and lymph nodes. The patient was thus determined to have stage IV malignant lymphoma and was given two courses of combination chemotherapy including RCHOP. The tumor responded to one course, but the patient died of neutropenic sepsis during the second course.

Emerging therapeutic strategies for hepatitis C virus infection

The universal prevalence of hepatitis C virus (HCV) infection, which causes chronic hepatitis, cirrhosis, liver failure, and hepatocellular carcinoma, has become a significant health problem worldwide. Interferon-based therapies, the current standard, IFN-based therapies have limited efficacy and undesirable adverse effects. In addition, neither vaccination against HCV nor specific antiviral reagents for HCV are yet available. Thus, a major medical need still exists for novel and more efficacious anti-HCV reagents showing broad-spectrum clinical efficacy with enhanced tolerability. With the progress in our current understanding of the function and regulation of HCV gene products, the three-dimensional structures of virally encoded enzymes and the recent establishment of the HCV-replicon system, several pharmacological targets are being studied for HCV therapy, including cellular receptors mediating HCV entry, factors facilitating HCV replication and assembly, and intracellular pathways. Recently developed mouse models will be very helpful in evaluating the in vivo efficacy of novel antiviral reagents. Currently many novel antiviral drugs are under evaluation in clinical trials. This review will comprehensively discuss the current treatment options and various novel antiviral reagents available. Ongoing clinical studies of promising lead drugs are also reviewed.

Tec protein-tyrosine kinase directly associates with Lyn protein-tyrosine kinase through its N-terminal unique domain

Most of non-receptor-type protein-tyrosine kinases share common structures, such as N-terminal unique domains, Src homology region (SH)-2 domains, SH-3 domains and kinase domains. Although vast effort has brought some information about the in vivo roles of SH-2, -3 and kinase domains, little is still understood about the function of N-terminal unique domain. By utilizing the glutathione S-transferase (GST)-fusion system, we have investigated the role of N-terminal unique domain of the Tec protein-tyrosine kinase in a mouse IL-3-dependent myeloid cell line. We could reveal that the C-terminal half of the Tec N-terminal unique domain (NTec2 region) can bind to a set of tyrosine-phosphorylated cellular proteins in vitro in an IL-3-dependent manner. Surprisingly, p56/53Lyn constitutively binds to the NTec2 region. Among the NTec2-bound Lyn proteins, only the p56 form seems to be inducibly tyrosine-phosphorylated in response to IL-3. Binding domain of Lyn to the NTec2 region was localized to its SH-3 domain. Tec was also shown to make a stable complex with Lyn in vivo. This is the first report demonstrating the direct association between distinct cytoplasmic protein-tyrosine kinases, especially through N-terminal unique domain.

Treatment of intermediate-to-advanced unresectable hepatocellular carcinoma is shifting toward a multidisciplinary strategy that includes multiple modalities as needed

In the recent issue of the World Journal of Gastroenterology, Han et al compared the efficacy of and adverse reactions to bevacizumab versus lenvatinib as molecularly targeted agents in combination with interventional therapy and immunotherapy (IMT) to treat intermediate-to-advanced unresectable hepatocellular carcinoma. No significant differences in efficacy or adverse reactions were observed between bevacizumab and lenvatinib. This study is highly promising because in some regions, e.g., Japan, the combination of molecularly targeted therapy with IMT is fixed because of insurance restrictions, and some molecularly targeted agents cannot be combined with IMT. Further studies using these three modalities are expected to be conducted in the future. Additionally, because advanced radiotherapy modalities have recently been established, the number of combinations continues to increase, and further evidence regarding combination therapy, which is the cornerstone of personalized medicine, needs to be accumulated.

[Hepatocarcinogenesis in NASH]

With the increase of lifestyle-related diseases, metabolic syndrome has clearly increased in recent years. Fatty liver, which is the manifestation of metabolic syndrome in the liver, has received little attention because it is not the actual cause of death. However, with the developing increase of metabolic syndrome, non-alcoholic fatty liver disease(NAFLD), especially nonalcoholic steatohepatits(NASH), has increased, and has received much attention. In chronic liver disease, liver cirrhosis develops, finally leading to liver failure. The most serious chronic liver disease is progression to liver cancer. Once hepatic fibrosis develops, the hepatic carcinogenic rate has been increased. Hepatic carcinogenic rate has been reported to reach 8%per year in hepatitis type C-related liver cirrhosis. Although little has been reported about NASH-related liver cancer, NASH-related hepatic carcinogenic rate reached to about 2. 6%per year. In this review, we will describe the epidemiology, gender differences, risk factors and pathogenesis of NASH-related liver cancer.

Usefulness of radiofrequency ablation with micro-convex probe for hepatocellular carcinoma

BACKGROUND/AIMS

It was aimed to assess whether a micro-convex probe is superior to the present conventional probe for ultrasonography from the points of safety and efficacy during percutaneous radiofrequency ablation therapy for hepatocellular carcinoma.

METHODOLOGY

Twenty-one patients with 23 hepatocellular carcinoma lesions who had one or 2 lesions, each 4 cm or less in diameter, and liver function of Child-Pugh class A or B were enrolled. All the patients except for 2 patients were seropositive for hepatitis C virus. Radiofrequency ablation was carried out under a real-time US guidance. The cooled-tip electrodes used were single and clustered.

RESULTS

It was possible to perform safe and accurate percutaneous radiofrequency ablation procedure using micro-convex probes for the treatment of all hepatocellular carcinoma nodules. It was also possible to treat hepatocellular carcinoma located in the right subphrenic region without artificial pleural effusion under intercostal ultrasonography guide. Improved clustered needles were successfully applied to treat the nodules more than 3 cm in diameter with less resistance for penetration compared with the conventional needle. The findings of advanced dynamic flow image on ultrasonography to assess the therapeutic efficacy indicated the consistency with those of dynamic CT which was done 3 to 5 days later radiofrequency ablation. Major complication of radiofrequency ablation procedure was noted in none.

CONCLUSIONS

These results suggest that micro-convex probe with clustered tips is superior to conventional probe for ultrasonography from the points of safety and efficacy during radiofrequency ablation for hepatocellular carcinoma nodule located in the right subphrenic region and for larger sized nodule more than 3 cm.

The first reported case of Noonan syndrome complicated with hepatocellular carcinoma

Noonan syndrome is a genetic multisystem disorder and is associated with mutation of genes encoding the proteins in the RAS-MAPK pathway. We reported the first case of Noonan syndrome complicated with hepatocellular carcinoma.

Augmentation of antitumor immunity using genetically M-CSF-expressing L1210 cells

Macrophage colony-stimulating factor (M-CSF) enhances tumoricidal activities of macrophages. We transduced human M-CSF cDNA into the mouse lymphoid cell line, L1210, and examined the antitumor effect of the locally expressed M-CSF. Mice injected with the M-CSF-producing subline showed improved survival in comparison with the mock-transfected cell line or parental cell line plus M-CSF administration (20 microg/kg for 3 days) at inoculated cell numbers of 10(2) or 5 x 10(3). The survival rate at 50 days after injection of 10(6) high M-CSF-expressing cells was 80%, significantly higher than that after injection of the mock-transfected cells, which killed all the mice by day 23. The survival rate appeared to depend on the amount of M-CSF produced. Moreover, all surviving mice after intravenous injection of the M-CSF-expressing sublines were rechallenged with 10(6) parental L1210 cells at day 50, and all survived up to day 100, demonstrating that M-CSF-expressing cells induced immune protection against the parental cells. The same improvement of survival was observed in mouse M-CSF-expressing cell lines. These observations imply that M-CSF cDNA is a candidate gene for use in gene therapy in leukemia.

Sofosbuvir/Ribavirin therapy for patients experiencing failure of ombitasvir/paritaprevir/ritonavir + ribavirin therapy: Two cases report and review of literature

BACKGROUND

The effectiveness of sofosbuvir/ribavirin (SOF/RBV) combination therapy, which is one of the 1st-choice therapeutic options for patients with hepatitis C virus (HCV) genotype 2 (HCV-G2) in Japan according to the most recent version of the Japan Society of Hepatology guideline, for patients who experienced failure of the ombitasvir/paritaprevir/ritonavir plus ribavirin (OBV/PTV/r+RBV) combination therapy, which was another option for patients with HCV-G2, is unknown.

CASE SUMMARY

We evaluated the effects of SOF/RBV combination therapy in two patients with genotype 2a who could not achieve a sustained virological response (SVR) by OBV/PTV/r+RBV combination therapy. One patient was complicated with Vogt-Koyanagi-Harada (VKH) disease. Resistance-associated variations before SOF/RBV combination therapy were not detected in two patients. Both patients had an SVR at 12 wk after the treatment (SVR12). Regarding adverse events (AEs), itching, chill, a dull feeling in the throat and cough as well as increase of alanine transaminase level were shown in one patient, while a headache and deterioration of light aversion probably due to the recurrence of VKH disease were shown in the other patients. In addition, the latter patient developed arthralgia and morning stiffness approximately 7 wk after the therapy and turned out to be diagnosed with rheumatoid arthralgia.

CONCLUSION

SOF/RBV therapy might be effective for patients experiencing failure of OBV/PTV/r+RBV therapy, but caution should be taken regarding the AEs.

Significant association between HLA-B*35:01 and onset of drug-induced liver injury caused by Kampo medicines in Japanese patients

AIM

Drug-induced liver injury (DILI) is a severe and life-threatening immune-mediated adverse effect, occurring rarely among treated patients. We examined genomic biomarkers in the Japanese population that predict the onset of DILI after using a certain class of drugs, such as Kampo products (Japanese traditional medicines).

METHODS

A total of 287 patients diagnosed as DILI by hepatology specialists were recruited after written informed consent was obtained. A genome-wide association analysis and human leukocyte antigen (HLA) typing in four digits were performed.

RESULTS

We found a significant association (p = 9.41 × 10-10 ) of rs146644517 (G > A) with Kampo product-related DILI. As this polymorphism is located in the HLA region, we evaluated the association of HLA types and found that 12 (63.2%) of 19 Kampo-DILI patients contained HLA-B*35:01, whereas only 15.2% were positive for this HLA among healthy volunteers. The odds ratio was 9.56 (95% confidence interval 3.75-24.46; p = 2.98 × 10-6 , corrected p = 4.17 × 10-5 ), and it increased to 13.55 compared with the DILI patients not exposed to Kampo products. The individual crude drug components in the Kampo products, including Scutellaria root (ougon in Japanese), rhubarb (daiou), Gardenia fruit (sanshishi), and Glycyrrhiza (kanzou), were significantly associated with HLA-B*35:01.

CONCLUSIONS

HLA-B*35:01 is a genetic risk factor and a potential predictive biomarker for Kampo-induced DILI in the Japanese population.

Four-dimensional ultrasonography for therapeutic radiofrequency ablation for hepatocellular carcinoma

BACKGROUND/AIMS

We examined whether four-dimensional real-time flow imaging on ultrasonography (US) is valuable to display the accurate position of percutaneous radiofrequency ablation (RFA) needle in the nodule of hepatocellular carcinoma (HCC).

METHODOLOGY

Ten patients with 12 HCC nodules were studied; nine were infected with hepatitis C virus (HCV) and one was diagnosed as non-B non-C. Diagnosis was done by helical dynamic CT and/or celiac angiography. Tumor vascularities in the early arterial and post-vascular phases after injection of a microbubble contrast agent were assessed by real-time US scanning of coded harmonic imaging and intermittent interval-delay scanning with a wide-band power Doppler technology. Percutaneous RFA was performed with four-dimensional real-time flow imaging under US to display the accurate position of cool-tip needle.

RESULTS

It was possible to obtain accurate position of the needle during RFA procedure in all 12 nodules. The needle was confirmed to be inserted into the center of the tumor nodule by various angles. The simultaneous study before RFA therapy showed the inflow of arterial blood and tumor staining in all nodules at early arterial phase of coded harmonic angio on contrast-enhanced US scan. Posttreatment study to evaluate the therapeutic efficacy showed no blood flow at both early vascular and post-vascular phases. No residual blood flow was noted on early phase of CT scan with adequate safety margin. There was no discrepancy in the finding at early phase between contrast-enhanced US and dynamic CT.

CONCLUSIONS

It appeared that four-dimensional real-time US provided more perceptible information on the spatial relationship between RFA needle and the target lesion, and resulted in accurate therapeutic efficacy for percutaneous RFA procedure.