Contribution of biomarkers and imaging in the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most frequent malignant tumour of the liver. HCC prognosis is dependent on the determination of the tumour stage by conventional imaging and early screening. However, patient survival can vary with the same tumour stage. Biomarkers thus have a role in providing an earlier diagnosis, better prognosis classification before treatment and classification prognosis during treatment. In this review article, we will provide a successive, detailed description of the serum, pathological, molecular and imaging markers of HCC.

A phase I study of AVE1642, a human monoclonal antibody–blocking insulin-like growth factor-1 receptor (IGF-1R), given as a single agent and in combination with sorafenib as first-line therapy in patients with advanced hepatocellular carcinoma (HCC)

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Background: AVE1642 blocks IGF-1R signaling. Previous phase I studies recommended AVE1642 doses ranged from 3 to 6 mg/kg in solid tumors. AVE1642 alone and in combination has shown in vitro and in vivo antitumor activity warranting further investigations in HCC.

Methods: Dose-escalation was performed using a 3+3 design in patients with advanced HCC. AVE1642 doses were 1 mg/kg (DL1) 3 mg/kg (DL2), 6 mg/kg (DL3) given IV for 30 min every 3 weeks (w). AVE1642 was given alone for 3 w and every 3 w thereafter in combination with sorafenib (400 mg bid/day). Dose-limiting toxicities (DLT) were assessed during the first two cycles. Safety, pharmacokinetic (PK), pharmacodynamic (PD), tumor response (RECIST) were evaluated.

Results: Thirteen patients (median age: 70y, M/F: 10/3, Child-Pugh A: 13/13) received 83 cycles (range 3-13) of AVE1642: 3 patients at DL1 (31 cycles), 7 patients at DL2 (38 cycles), 3 patients at DL3 (14 cycles) All patients were evaluable for safety and PK/PD. HCC was located in liver in 11 patients and was metastatic in 2. At cycle 1, exposure to AVE1642 alone led to grade 2-3 anemia in 1 patient at DL2, non febrile neutropenia in 1 at DL3. Other adverse events were grade 1-2 gastrointestinal disorders in 1 patient at DL1, in 3 at DL2 and hyperglycemia in only 1 at DL2. No liver function failure or haemorrhagic complications were observed. The frequency of sorafenib induced adverse events was not increased under combination. AVE1642 was eliminated slowly from the serum (t1/2: 5 to 6.7 days). There was no apparent effect of the dose on the systemic clearance of AVE1642, no effect of sorafenib treatment on the PK of AVE1642. IGF1 and IGFBP3 plasma concentrations (not of IGF2) were increased following AVE1642 administration. Most patients (11/13) presented tumor stabilization during a mean time of 13.3 w (ranging 6 to 27 w).

Conclusions: AVE1642 can be safely combined with active doses of sorafenib. PK of both AVE1642 and sorafenib were not modified at these relevant concentrations. Interesting long-lasting disease stabilizations were observed in these patients with progressive disease.

No significant financial relationships to disclose.

Detection of hepatocellular carcinoma with PET/CT: a prospective comparison of 18F-fluorocholine and 18F-FDG in patients with cirrhosis or chronic liver disease

This prospective study aimed to compare the diagnostic performance of (18)F-fluorocholine and (18)F-FDG for detecting and staging hepatocellular carcinoma (HCC) in patients with chronic liver disease and suspected liver nodules.

METHODS

Whole-body PET/CT was performed in a random order at 10 min after injection of 4 MBq of (18)F-fluorocholine per kilogram and at 1 h after injection of 5 MBq of (18)F-FDG per kilogram. PET/CT results were read in a masked manner by 2 specialists, and diagnostic performance was assessed from the results of consensus masked reading. Those focal lesions appearing with increased or decreased activity, compared with background, on (18)F-fluorocholine PET/CT were considered positive for malignancy. The standard of truth was determined on a per-site basis using data from a histologic examination and a follow-up period of more than 6 mo; on a per-patient basis, the Barcelona criteria were also accepted as a proof of HCC in 5 patients.

RESULTS

Eighty-one patients were recruited; standard of truth was determined in 59 cases. HCC was diagnosed in 34 patients. Therefore, sensitivity was 88% for (18)F-fluorocholine and 68% for (18)F-FDG (P = 0.07), and in 70 sites, sensitivity was 84% for (18)F-fluorocholine, significantly better than the 67% for (18)F-FDG (P = 0.01). Of the 11 patients with well-differentiated HCC, 6 had a positive result with (18)F-fluorocholine alone, whereas (18)F-FDG was never positive alone; corresponding site-based sensitivity was 94% for (18)F-fluorocholine and 59% for (18)F-FDG (P = 0.001). The detection rate of 18 sites corresponding to other malignancies was 78% for (18)F-fluorocholine and 89% for (18)F-FDG. In nonmalignant sites, (18)F-fluorocholine appeared less specific than (18)F-FDG (62% vs. 91% P < 0.01) because of uptake by focal nodular hyperplasia.

CONCLUSION

(18)F-fluorocholine was significantly more sensitive than (18)F-FDG at detecting HCC, in particular in well-differentiated forms. In contrast, (18)F-FDG appeared somewhat more sensitive at detecting other malignancies and was negative in focal nodular hyperplasia. Thus (18)F-fluorocholine appears to be a useful PET/CT tracer for the detection and surveillance of HCC; however, performing PET/CT with both radiopharmaceuticals seems to be the best option.

The diffusion-weighted imaging perfusion fraction f is a potential marker of sorafenib treatment in advanced hepatocellular carcinoma: a pilot study

OBJECTIVE

To determine the total Apparent Diffusion Coefficient (ADC), the pure Diffusion coefficient (D) and the perfusion fraction (f) in advanced hepatocellular carcinoma (HCC) under sorafenib treatment.

MATERIALS AND METHODS

Two target tumors were prospectively analyzed in 12 patients at baseline, 2-weeks and 2-months treatment using b values of 0, 200, 400, 800 s/mm. Repeatability error was estimated on a healthy volunteer.

RESULTS

Lesion sizes, ADC and D values did not significantly change during treatment (overall mean values, respectively, 47.8 ± 31.0 mm, 1.34 ± 0.14 × 10⁻³ mm² s and 1.18 ± 0.22 × 10⁻³ mm²/s). However, f values significantly increased in seven responder patients (+38.39% at 2-weeks, +50.94% at 2-months, P = 0.005) while they decreased in five non responder patients (-41.93% at 2-weeks, P = 0.006). Furthermore, f was inversely correlated with αFP levels (P = 0.032) and responder patients had a higher mean overall survival (OS) than non responder patients (12.29 ± 4.46 vs. 7.80 ± 4.9 months). The % variation of f relative to baseline at 2-months was correlated with OS (P = 0.038) and symptomatic time to progression (P = 0.022).

CONCLUSION

Contrary to ADC and D, the perfusion fraction f is a valuable marker of sorafenib treatment in advanced HCC.

Insulin-like growth factor-1 receptor inhibition induces a resistance mechanism via the epidermal growth factor receptor/HER3/AKT signaling pathway: rational basis for cotargeting insulin-like growth factor-1 receptor and epidermal growth factor receptor in hepatocellular carcinoma

PURPOSE

The insulin-like growth factor (IGF) signaling axis is frequently dysregulated in hepatocellular carcinoma (HCC). Therefore, we investigated whether the specific targeting of the IGF type 1 receptor (IGF-1R) might represent a new therapeutic approach for this tumor.

EXPERIMENTAL DESIGN

Total and phosphorylated levels of IGF-1R were measured in 21 paired samples of human HCCs and adjacent nontumoral livers using ELISA. The antineoplastic potency of a novel anti-IGF-1R antibody, AVE1642, was examined in five human hepatoma cell lines.

RESULTS

Overexpression of IGF-1R was detected in 33% of HCCs and increased activation of IGF-1R was observed in 52% of tumors. AVE1642 alone had moderate inhibitory effects on cell viability. However, its combination with gefitinib, an epidermal growth factor receptor (EGFR) inhibitor, induced supra-additive effects in all cell lines that were associated with cell cycle blockage and inhibition of AKT phosphorylation. The combination of AVE1642 with rapamycin also induced a synergistic reduction of viability and of AKT phosphorylation. Of marked interest, AVE1642 alone up-regulated the phosphorylated and total levels of HER3, the main partner of EGFR, and AVE1642-induced phosphorylation of HER3 was prevented by gefitinib. Moreover, the down-regulation of HER3 expression with siRNA reduced AKT phosphorylation and increased cell sensitivity to AVE1642.

CONCLUSIONS

These findings indicate that hepatoma cells overcome IGF-1R inhibition through HER3 activation in an EGFR-dependent mechanism, and that HER3 represents a critical mediator in acquired resistance to anti-IGF-1R therapy. These results provide a strong rational for targeting simultaneously EGFR and IGF-1R in clinical trials for HCC].

A multicenter, randomized phase II trial of gemcitabine and oxaliplatin (GEMOX) alone or in combination with biweekly cetuximab in the first-line treatment of advanced biliary cancer: Interim analysis of the BINGO trial

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Background: There is no standard regimen for palliative chemotherapy of advanced biliary cancers. The GEMOX regimen is an option (BJC 2008). EGFR over-expression has been observed in advanced biliary cancers suggesting that the combination with anti-EGFR monoclonal antibodies may be appropriate. Methods: Patients with advanced biliary cancer, WHO performance status 0–1, and without prior palliative chemotherapy were eligible for this international, open-label, two-stage, randomized phase II trial. Patients received GEMOX (gemcitabine, 1000 mg/m2 [10 mg/m2/min] at day [D]1; oxaliplatin, 100 mg/m2 at D2) alone (arm A) or with cetuximab (500 mg/m2 at D1 or 2, arm B), every 2 weeks. Randomization was stratified according to tumor stage and location, center, and prior treatments. The primary endpoint was 4-month crude progression-free survival (PFS) rate (H0 hypothesis, < 40%; H1, ≥ 60%; planned sample size, 50 patients per arm). Secondary endpoints were response rate, PFS, overall survival, toxicity, early response assessment by PET, and blood/tumor EGFR signalling pathway member analyses. A data safety monitoring board-approved interim analysis was performed at the end of the first stage (18 patients per arm, minimal follow- up 4 months). Results: From October 2007 to October 2008, we enrolled 101 patients (median age, 62 yrs; male, 60%; metastatic, 86%; non-gallbladder, 76%). Among the 36 patients at the time of the interim analysis, the median number of treatment cycles was 6 and 8 in arms A and B, respectively. 76% (arm A) and 67% (arm B) had NCI-CTC grade 3–4 toxicity, mainly cytopenia (41%/39%), peripheral neuropathy (modified Levi's scale grade 2–3: 29%/33%), fatigue (6%/22%), gastrointestinal toxicity (12%/17%), and rash/hypersensitivity (0%/17%). The 4-month PFS rate was 44% (95% CI, 20–70) and 61% (95% CI, 36–83) in arms A and B, respectively. Conclusions: The GEMOX-cetuximab regimen seems well tolerated in patients with advanced biliary cancer. Adding cetuximab to GEMOX showed promising activity and therefore the trial was continued. Updated results on the whole population for primary and secondary endpoints will be available at the meeting.

[Table: see text]

Gemcitabine plus oxaliplatin (GEMOX) combined with cetuximab in patients with progressive advanced stage hepatocellular carcinoma: results of a multicenter phase 2 study

BACKGROUND

The authors conducted a phase 2 trial of the antiepidermal growth factor receptor (EGFR) monoclonal antibody cetuximab in combination with the gemcitabine plus oxaliplatin (GEMOX) regimen in patients with documented progressive hepatocellular carcinoma (HCC).

METHODS

Forty-five untreated patients with advanced-stage progressive HCC were prospectively enrolled. Treatment consisted of cetuximab at a dose of 400 mg/m2 initially then 250 mg/m2 weekly, plus gemcitabine at a dose of 1000 mg/m2 on Day 1 and oxaliplatin at a dose of 100 mg/m2 on Day 2, every 2 weeks. Treatment was continued until disease progression, unacceptable toxicity, or patient refusal.

RESULTS

Overall, 306 cycles were administered. Grade 3 to 4 hematologic toxicity consisted of thrombocytopenia (24%), neutropenia (20%), and anemia (4%). Grade 3 oxaliplatin-induced neurotoxicity occurred in 5 patients (11%) and grade 3 cutaneous toxicity in 7 patients (16%). There were no treatment-related deaths. The confirmed response rate was 20% and disease stabilization was obtained in 40% of patients. The median progression-free and overall survival times were 4.7 months and 9.5 months, respectively. The 1-year survival rate was 40%.

CONCLUSIONS

In poor-prognosis patients with progressive advanced-stage HCC, the GEMOX-cetuximab combination appears to be active and to have manageable toxicity. A comparative randomized trial is now being planned.

[Therapeutic advances in hepatocellular carcinoma]

Liver cancer is the sixth most common cancer, killing 600,000 people each year worldwide. Hepatocellular carcinoma (HCC) is the most common form of liver cancer. HCC has several specific features. In particular, the risk factors and causes are well known, thereby permitting - in theory - primary prevention and early detection surveillance programs. Also, HCC is a vascular solid tumor with a high degree of drug resistance (the so-called angiogenic and MDR phenotype). These features should be targeted primarily, if not exclusively, by future biological therapies. In this review, the authors report the most recent therapeutic developments, including emerging targeted strategies.

Gemcitabine, oxaliplatin (GEMOX) and cetuximab for treatment of hepatocellular carcinoma (HCC): Results of the phase II study ERGO

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Background: A promising efficacy of the GEMOX combination was previously reported in HCC. Moreover, the EGFR signalling pathway is involved in hepatic carcinogenesis and tumor progression. This phase II study of GEMOX plus cetuximab was therefore undertaken in patients with unresectable HCC. Methods: 44 patients were included in the study between November 2005 and October 2006. All patients received cetuximab (initial dose 400 mg/m2 BSA then 250 mg/m2 weekly) combined with GEMOX (gemcitabine 1000 mg/m2, Day 1 and oxaliplatin 100 mg/m2, Day 2), repeated every 14 days until disease progression or limiting toxicity. Inclusion criteria were: histologically proven HCC or morphologically typical hepatic tumor with alpha-feto protein (AFP) level >250 ng/mL, ECOG performance status (PS) 0–2, age =18, measurable lesion, platelets >100.109 G/L, PNN >1.5.109 G/L, creatinine <120 μmol/L, non decompensated Child A or B cirrhosis, documented tumor progression (RECIST), informed consent. Results: 43 patients, including 22 with baseline AFP >400, were evaluable for safety and 35 for efficacy. Patients’ characteristics, toxicity and efficacy are summarized in the table below; 26% of patients received prior intra-arterial chemotherapy. Only one grade 4 toxicity was reported (thrombocytopenia). Grade 3 toxicities were: thrombocytopenia (21%) neutropenia (19%), acneiform rash (19%), asthenia (7%). Grade 2 and 3 neurotoxicity (specific scale) occurred in 16% and 5% of patients, respectively. No toxic death or other severe toxicity was reported. Conclusion: GEMOX plus cetuximab was well tolerated and induced a satisfactory control of disease in progressive HCC. Final results will be presented at the meeting.

[Table: see text]

No significant financial relationships to disclose.

The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids

Early identification of patients with severe (discriminant function > or = 32) alcoholic hepatitis (AH) not responding to corticosteroids is crucial. We generated a specific prognostic model (Lille model) to identify candidates early on for alternative therapies. Three hundred twenty patients with AH prospectively treated by corticosteroids were included in the development cohort and 118 in its validation. Baseline data and a change in bilirubin at day 7 were tested. The model was generated by logistic regression. The model combining six reproducible variables (age, renal insufficiency, albumin, prothrombin time, bilirubin, and evolution of bilirubin at day 7) was highly predictive of death at 6 months (P < 0.000001). The area under the receiver operating characteristic (AUROC) curve of the Lille model was 0.89 +/- 0.02, higher than the Child-Pugh (0.62 +/- 0.04, P < 0.00001) or Maddrey scores (0.66 +/- 0.04, P < 0.00001). In the validation cohort, its AUROC was 0.85 +/- 0.04, still higher than the other models, including MELD (0.72 +/- 0.05, P = 0.01) and Glasgow scores (0.67 +/- 0.05, P = 0.0008). Patients above the ideal cutoff of 0.45 showed a marked decrease in 6-month survival as compared with others: 25% +/- 3.8% versus 85% +/- 2.5%, P < 0.0001. This cutoff was able to identify approximately 75% of the observed deaths.

CONCLUSION

In the largest cohort to date of patients with severe AH, we demonstrate that the term "nonresponder" can now be extended to patients with a Lille score above 0.45, which corresponds to 40% of cases. Early identification of subjects with substantial risk of death according to the Lille model will improve management of patients suffering from severe AH and will aid in the design of future studies for alternative therapies.

Effect of prolonged interferon therapy on the outcome of hepatitis C virus-related cirrhosis: a randomized trial

BACKGROUND & AIMS

The impact of interferon (IFN) treatment on the occurrence of complications related to hepatitis C virus (HCV)-related cirrhosis is debated because the majority of studies are retrospective. We designed a randomized controlled trial comparing the efficacy of prolonged IFN alfa-2a treatment vs nontreatment on complication-free survival in patients with compensated HCV cirrhosis.

METHODS

A total of 102 patients (mean age, 60.5 +/- 9.5 y; male/female ratio, .82) with biopsy examination-proven HCV cirrhosis, Child-Pugh score A, who were hepatocellular carcinoma (HCC) free, and had at least 1 risk factor of complications were randomized to receive IFN or no therapy for 24 months.

RESULTS

During the follow-up evaluation, the complication rate was 24.5%: HCC occurred in 12 and decompensation unrelated to HCC occurred in 13 patients. The number of HCC patients was similar in both groups. The probability of complication-free survival was not significantly different between treated and untreated patients (98% and 72.3% vs 90% and 70.7% at 12 and 24 mo, respectively, P = .59). The median time until complication occurrence was 17.1 months in the treated group vs 13.6 months in the untreated group (P = .2).

CONCLUSIONS

This randomized controlled trial showed that a 2-year course of IFN has little or no impact on complication-free survival in patients with high-risk compensated HCV cirrhosis.

Impact of IGF-1R/EGFR cross-talks on hepatoma cell sensitivity to gefitinib

Epidermal growth factor receptor (EGFR)- and type 1 insulin-like growth factor receptor (IGF-1R)-dependent pathways are up-regulated in hepatocellular carcinoma (HCC), and cross-talks between both pathways have been described in other systems. Gefitinib, a specific EGFR inhibitor, has shown to reduce significantly, although not completely, HCC formation in rat cirrhotic liver. Here, we investigated whether IGF-1R-dependent pathways may interfere with EGFR signalling in hepatoma cells and, if so, whether such cross-talks may affect the antitumoral effect of gefitinib in these cells. We show that the proliferative action of IGF2 in HepG2 and Hep3B cells requires EGFR activation through the autocrine/paracrine release of amphiregulin. Thus, IGF2-induced extracellular signal-regulated kinase activity and DNA synthesis were inhibited by neutralizing antibodies against either EGFR or amphiregulin and by TAPI-1, a pharmalogical inhibitor of tumor necrosis factor-alpha converting enzyme, a sheddase of amphiregulin. Accordingly, IGF2 and EGF stimulating effects on cell proliferation were both strongly repressed by gefitinib. However, while gefitinib blocked Akt activation by EGF, it had no effect on Akt activation by IGF2 and did not cause apoptosis by its own. AG1024, a selective IGF-1R inhibitor, induced apoptosis and this effect was potentiated by gefitinib. In conclusion, we show that in HCC cells IGF2/IGF-1R activation triggers proliferative and survival signals through EGFR-dependent and -independent mechanisms, respectively. The IGF2/IGF-1R survival pathway may contribute to gefitinib resistance in these cells. Therefore, the inhibition of IGF2/IGF-1R signalling could potentiate the anti-tumoral effect of gefinitib in HCC.

PET/CT in patients with hepatocellular carcinoma using [(18)F]fluorocholine: preliminary comparison with [(18)F]FDG PET/CT

PURPOSE

The diagnostic accuracy of [(18)F]fluorodeoxyglucose (FDG) PET is insufficient to characterise hepatocellular carcinoma (HCC) in liver masses and to diagnose all cases of recurrent HCC. HCC has been reported to take up [(11)C]acetate, but routine use of this tracer is difficult. Choline is another tracer of lipid metabolism, present in large amounts in HCC. In a proof-of-concept study, we evaluated [(18)F]fluorocholine (FCH) uptake by HCC and compared FCH PET/CT with FDG PET/CT.

METHODS

Twelve patients with newly diagnosed (n=8) or recurrent HCC (n=4) were prospectively enrolled. HCC was assessed by histology in eight cases and by American Association for the Study of Liver Diseases (AASLD) criteria in four cases. All patients underwent whole-body PET/CT 10 min after injection of 4 MBq/kg FCH. Within 1 week, 9 of the 12 patients also underwent whole-body FDG PET/CT 1 h after injection of 5 MBq/kg FDG.

RESULTS

The per-patient analysis showed a detection rate of 12/12 using FCH PET/CT for both newly diagnosed and recurrent HCC. The median signal to noise ratio was 1.5+/-0.38. There was a trend towards a higher FCH SUV(max) in well-differentiated HCC (15.6+/-7.9 vs 11.9+/-0.9, NS). Of the nine patients who underwent FCH and FDG PET/CT, all nine were positive with FCH whereas only five were positive with FDG.

CONCLUSION

FCH provides a high detection rate for HCC, making it potentially useful in the initial evaluation of HCC or in the detection of recurrent disease. The favourable result of this proof-of-concept study opens the way to a phase III prospective study.

EXIBIT: An international multicenter phase II trial of gemcitabine and oxaliplatin (GEMOX) in patients with advanced biliary tract cancer

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Background: Biliary tract carcinomas (BTC) are often diagnosed at an advanced/metastatic stage and have a poor prognosis. The combination of gemcitabine and oxaliplatin (GEMOX) showed promising activity in a French Phase II study (4 centers) in advanced BTC (André. Ann Oncol 2004;15:1339–1343). The objective of this study is to further evaluate the efficacy and safety of GEMOX as first-line therapy in patients (pts) with advanced BTC. Methods: Eligible pts were >18 years of age with histologically proven and measurable, locally advanced or metastatic BTC, had an ECOG PS ≤ 2, adequate renal and hematologic functions, bilirubin < 2.5 × upper limit of normal, and no prior malignancy or brain metastases. Gemcitabine 1000 mg/m2 (Day 1) and oxaliplatin 100 mg/m2 (Day 2) were administered every 2 weeks. The primary objective was response rate (RR) by RECIST (one dimension); secondary objectives were progression-free survival (PFS), overall survival (OS), and safety. Here we report an interim analysis of OS and safety. Results: A total of 70 pts were enrolled between April 2003 and April 2005. The median age was 62 years (range 30–83), 40.0% of pts were male, 94.3% had ECOG PS 0–1. Tumor sites were intrahepatic bile ducts (37.1%), gallbladder (31.4%), extrahepatic bile ducts (12.9%), ampulla of Vater (1.4%), intra/extrahepatic bile ducts (1.4%), missing data (15.7%); 98.6% of pts had no prior radiotherapy and 50% had no prior surgery for BTC. Median OS is 8.25 months (68% of pts are dead and 32% have censored data). Sixty-seven pts were evaluable for safety. Grade 3/4 (NCI-CTC v. 2) hematologic toxicities (% of pts) included thrombocytopenia 10.4%, anemia 9.0%, and neutropenia 9.0%. One pt had febrile neutropenia. Grade 3/4 nonhematologic toxicities included pain 10.4%, ALT elevation 9.0%, fatigue 9.0%, infection 10.4%, vomiting 9.0%, sensory neuropathy 4.5%, nausea 4.5%, and diarrhea 3.0%. One patient died during treatment (cause unknown). Conclusions: GEMOX has acceptable toxicity in pts with BTC. Updated efficacy data (RR, PFS, and OS for the entire population and also by tumor sites) will be presented at the meeting.

[Table: see text]

Treatment of small hepatocellular carcinoma with acetic acid percutaneous injection

Percutaneous ablation using acetic acid is an attractive method because of its low morbidity and low number of sessions required to induce complete tumor necrosis. Moreover, the real-time fluoroscopy CT scan could improve the technique by improving distribution of the necrotizing agent within the tumor.

AIM

To determine the feasibility and the long-term results of the acetic acid percutaneous injection under CT fluoroscopy guidance in a series of cirrhotic patients with small hepatocellular carcinoma in a single French center.

METHODS

One hundred and two patients with hepatocellular carcinoma were evaluated for treatment between 1999 and 2000. The selection criteria for fluoroscopy CT scan-directed percutaneous acetic acid ablation were: 1) one to three nodules<5 centimeters; 2) Child-Pugh class<13; 3) prothrombin index > 40% and platelet count > 50000 per mm(3) and 4) contraindication to both resection and liver transplantation. Post treatment follow-up included ultrasonography, magnetic resonance and alphafetoprotein levels every 3 months. Recurrence and survival rates were estimated using the Kaplan-Meier method.

RESULTS

Forty-nine patients (48%) could benefit from a curative treatment, most of them (37/49) being eligible for fluoroscopy CT scan-directed percutaneous acetic acid. The mean follow up was 24.4 +/- 2.7 months. Complete tumor necrosis was achieved in 28 patients (76%) after a mean of 1.6 sessions. In these 28 patients, the recurrence rates were 34% and 48% and survival rates were 76% and 70%, at 24 and 36 months, respectively. No serious complications occurred during or after the treatment.

CONCLUSIONS

Percutaneous ablation using acetic acid using CT fluoroscopy guidance may be considered as a short term efficient, low risk treatment and can be applied even in patients with ascites or severe hemostatic abnormalities. However, the high rate of recurrence and the early occurrence of multifocal hepatocellular carcinoma underline the limits of this method as well as of all other percutaneous strategies.

[Liver cirrhosis in adults: etiology and specific treatments]

Cirrhosis is the result of chronic inflammation and of the progressive increase of fibrosis. In France, hepatitis C infection is the second cause of cirrhosis after alcohol abuse. The other causes of cirrhosis are: hepatitis B infection, genetic haemochromatosis, autoimmune hepatitis, primary biliary cirrhosis, drug-induced cirrhosis, secondary biliary cirrhosis, Wilson's disease and al-antitrypsin deficiency. Etiological treatment is based upon: abstinence in case of alcoholic cirrhosis, the combination of pegylated interferon alpha (PEG IFN) with ribavirin in case of C viral cirrhosis, the PEG IFN and the nucleoside analogs in case of B viral cause; corticosteroids and immunosuppressive drugs in case of autoimmune cirrhosis; venesections in case of genetic haemochromatosis and stopping the drug in case of drug-induced cirrhosis. The complications of cirrhosis such as ascites, oesophageal varices, bleeding, hepatic encephalopathy and hepatocellular carcinoma mainly explain the high rate of morbidity and mortality. Liver transplantation is the established therapy for decompensated liver disease of any etiology significantly changed the outcome of patients with advanced cirrhosis.

Insulin resistance is a cause of steatosis and fibrosis progression in chronic hepatitis C

BACKGROUND

Insulin resistance is a frequent feature of chronic hepatitis C. Whether insulin resistance could be the cause or consequence of steatosis and fibrosis is unknown. The ability of HCV genotype 3 to promote steatosis by itself provides an unique opportunity to answer this question.

AIMS

The aim of the present study was to assess the relationships between insulin resistance, steatosis, and fibrosis according to genotype in 141 non-diabetic patients with biopsy proven non-cirrhotic chronic hepatitis C.

METHODS

All patients had fasting serum glycaemia and insulinaemia measurements. Insulin resistance was evaluated using the homeostasis model assessment (HOMA IR) method. Liver steatosis was determined according to hepatitis C virus genotype (1 or 3). Logistic regression and multivariate regression analysis were used to identify variables independently associated with insulin resistance, fatty liver, and fibrosis.

RESULTS

Although steatosis and fibrosis were more severe in genotype 3 patients, median HOMA IR was significantly higher in patients with genotype 1 related steatosis than in those with genotype 3 related steatosis (2.1 v 1; p = 0.001). Independent risk factors for steatosis were insulin resistance in genotype 1 patients (p = 0.001) and viral load in genotype 3 patients (p = 0.003). Among genotype 1 patients, independent parameters associated with insulin resistance were age (p = 0.04) and steatosis (p = 0.004). Steatosis was associated with more severe fibrosis whatever the genotype (p = 0.002). Among genotype 1 patients, although there was a significant relationship between circulating insulin level and fibrosis stage (p = 0.006), only steatosis and inflammatory score were independently associated with fibrosis.

CONCLUSION

This study shows that insulin resistance is the cause rather than the consequence of steatosis and fibrosis in genotype 1 patients and that increased circulating insulin is a risk factor for fibrosis through insulin resistance induced steatosis.

Impact of steatosis on progression of fibrosis in patients with mild hepatitis C

In patients with mild hepatitis C, the usefulness of antiviral therapy is subject of debate, as a low risk for progression of fibrosis is assumed. Several studies have shown that steatosis is a strong and independent predictor of the severity as well as the progression of fibrosis in chronic hepatitis C. Therefore, this study assessed the impact of steatosis on the progression of fibrosis between paired liver biopsies in untreated patients with mild hepatitis on index biopsy. One hundred thirty-five untreated patients (mean age, 38 years; M/F sex ratio, 1.43) with one known risk factor of infection (68 transfusions, 67 injecting drug use) had 2 liver biopsies after a median interval of 61 months (18-158). All had METAVIR score of A1F1 or lower at first liver biopsy. Unequivocal progression of fibrosis was considered if patients had a fibrosis score of 3 or 4 at the second liver biopsy. The probability of progression of fibrosis was estimated by using the Kaplan-Meier method. During follow-up, progression of fibrosis occurred in 21 patients (16%) after a median delay of 65 months. Cumulative probabilities of the progression of fibrosis at 4 and 6 years were 5.2% and 19.8%, respectively. In multivariate analysis, steatosis was the only independent factor predictive of progression of fibrosis (RR, 4.8; CI, 1.3-18.3). Probability of progression of fibrosis was significantly related to the percentage of hepatocytes with steatosis. In conclusion, steatosis is a major determinant of the progression of fibrosis in mild hepatitis C, regardless of the genotype. Our results argue for antiviral treatment in the subgroup of patients with mild hepatitis and steatosis.

Early change in bilirubin levels is an important prognostic factor in severe alcoholic hepatitis treated with prednisolone

Early identification of patients with severe (discriminant function >or=32) biopsy-proven alcoholic hepatitis (AH) who are not responding to corticosteroids would be clinically relevant. Our goal was to develop simple criteria that will help physicians to promptly identify nonresponders to corticosteroids. A total of 238 patients were included. We used 6 months survival as an end point because of the rule requiring 6 months for listing alcoholic patients for transplantation. Overall survival at 1 and 6 months was 85% +/- 2.3% and 64.3% +/- 3.3%, respectively. An early change in bilirubin levels (ECBL) at 7 days (defined as bilirubin level at 7 days lower than bilirubin level on the first day of treatment) was observed in 73% of patients. At 7 days, in patients with ECBL, bilirubin decreased (84 +/- 75 micromol/L [4.94 +/- 4.40 mg/dL]), whereas it increased in patients without ECBL (76.5 +/- 77 micromol/L [4.50 +/- 4.54 mg/dL], P <.0001). Ninety-five percent of patients with ECBL continued to have improved liver function during treatment. At 6 months, survival of patients with ECBL was significantly higher than that of patients without ECBL, 82.8% +/- 3.3% versus 23% +/- 5.8%, P <.0001. On multivariate analysis, ECBL, discriminant function and creatinine were independent prognostic variables, and ECBL had the most important prognostic value. In conclusion, ECBL is a very simple predictive factor for identifying nonresponders. A recommendation to discontinue corticosteroids after 7 days in patients without ECBL, suggested by our results, awaits additional confirmation.

Percutaneous acetic acid injection for hepatocellular carcinoma: using CT fluoroscopy to evaluate distribution of acetic acid mixed with an iodinated contrast agent

OBJECTIVE

The purpose of our study is to evaluate the distribution of acetic acid mixed with iodinated contrast agent during percutaneous acetic acid injection on CT fluoroscopy for hepatocellular carcinoma.

CONCLUSION

Monitoring acetic acid distribution on CT fluoroscopy can detect extratumoral diffusion and may optimize the distribution of acetic acid in hepatocellular carcinoma.