Thyroid carcinoma associated with familial adenomatous polyposis

AIMS

Thyroid carcinoma is an extracolonic manifestation that is present in about 1% to 2% of patients with familial adenomatous polyposis (FAP). Less than 100 cases have been reported in detail. We have investigated the suggestion that FAP associated thyroid carcinoma is significantly different morphologically from both papillary and follicular types and can be considered as a separate entity.

METHODS AND RESULTS

Specimens from three patients with FAP associated thyroid tumours, all but one having single nodules, have been analysed. All three patients belonged to an extended kindred (23 siblings in four generations) who had genetic analysis and intensive screening for thyroid nodules. Seven patients had the same APC mutation at codon 1061. Pathological examination revealed a typical papillary carcinoma, encapsulated variant, in all patients, with follicular areas in one case. All thyroid specimens, in addition to histological and immunohistological examinations, were also specifically studied for activation of the RET-PTC oncogene, that seems to be restricted to papillary thyroid carcinoma. Two of the three patients had RET-PTC activation (PTC1 isoform).

CONCLUSIONS

The findings suggest that the tumours were certainly papillary, at least in the present kindred. Further studies in different families are required for a better understanding of this peculiar tumour and of its biological behaviour.

Cloning and expression of the mRNA of human galectin-4, an S-type lectin down-regulated in colorectal cancer

We are interested in the characterization of genes whose expressions in the colon are modified during colorectal carcinogenesis. Our approach was to establish the phenotype of a colon tumor by partial sequencing of a large number of transcripts, then to select mRNAs of potential interest by differential screening with complex probes from normal or cancerous colon. In this paper, we report the cloning and sequencing of a mRNA strongly underexpressed in colorectal cancer. It corresponded to a protein comprising 323 amino acids, that appeared to be human galectin-4 on the basis of 76% and 79% amino acid identity to the rat and pig counterparts, respectively. Tissue distribution analysis showed that its expression was restricted to the small intestine, colon and rectum. Galectin-4 expression was compared in tumor and normal adjacent colon of 19 patients. In 18 patients, the mRNA concentration was 1.5-50-times lower in the tumor. No significant correlation was observed between decreased expression of galectin-4 and the degree of differentiation of the tumor or Duke's state. These results suggest that decreased galectin-4 mRNA expression may be an early event in colon carcinogenesis. Among five cell lines derived from colon carcinoma, only two (HT29 and LS174T) expressed galectin-4 mRNA.

Serum HCV-RNA and liver histologic findings in patients with long-term normal transaminases

In this study we aimed to correlate liver histology and the presence of hepatitis C virus (HCV) viremia, genotype, and quantity of HCV genome in 19 positive and 11 RIBA II indeterminate patients presenting persistently normal ALT values over 24 months before biopsy. In addition, after biopsy serum ALT values were monitored monthly for a mean follow-up period of 24.8 months, after which patients were reevaluated for RIBA II and the presence of viremia. Sixteen patients (53%) were serum HCV-RNA-positive; 13 of them (68%) were confirmed positive and 3 (27%) indeterminate on RIBA II. Histology of the HCV-RNA-positive patients showed eight cases of CPH (one case of genotype 1a; four cases type 1b; three cases type 2), six cases of CAH (three cases type 1b, three cases type 2), one case of CLH (type not determined), and one case of normal liver (NL) (type 1b). Histology of the HCV-RNA-negative patients showed four cases of CPH, one case of CAH, two cases of CLH, and seven cases of NL. During the follow-up period nine patients (30%) presented slight increases in ALT values (< 2 x N), and in particular, flares of ALT were observed four times in the CAH and five times in the CPH patients, who were all viremic, but never in the NL subjects. These results indicate that subjects positive on RIBA II, but with persistently normal ALT values, had a high probability of being serum HCV-RNA-positive and that almost all these viremic subjects presented histologic signs of liver disease. In contrast, RIBA II indeterminate subjects had a moderate probability of being HCV-RNA-positive, but a number of these may present signs of liver disease. In both cases there was no association with genotype or HCV-RNA serum levels. The other nonviremic cases included subjects with hepatic changes going toward resolution or with normal liver in whom hepatic biopsy can be avoided. Only one case was a true carrier since he was viremic with normal liver and persistently normal ALT values.

Circulating intercellular adhesion molecule-1 in patients with hepatocellular carcinoma

BACKGROUND

Intercellular adhesion molecule-1 (ICAM-1) is thought to play an important role in cellular immunological reactions. Expression can be induced by inflammatory cytokines in a wide variety of cells, including hepatocytes.

OBJECTIVE

To compare the behaviour of ICAM-1 in liver diseases.

PATIENTS AND METHODS

We assayed serum ICAM-1 (sICAM-1) in patients with hepatocellular carcinoma-associated liver cirrhosis, and compared them with a group of cirrhotic patients and controls. sICAM-1 values were also correlated with some biochemical parameters of liver function. Moreover, immunohistochemical localization of ICAM-1 was performed on liver tissue sections of patients with hepatocellular carcinoma, liver cirrhosis and a sample of normal liver.

RESULTS

sICAM-1 levels were significantly higher in the hepatocellular carcinoma patients than in controls (P < 0.0001) and the cirrhosis group (P < 0.001). sICAM-1 values directly correlated with alanine aminotransferase, total bilirubin, alkaline phosphatase and gamma-glutamyltranspeptidase serum values (P < 0.05), with an inverse correlation with albuminaemia values (P < 0.05). There was no correlation with alpha-fetoprotein values, but sICAM-1 values were higher in hepatocellular carcinoma patients with large tumours (> 3 cm) than in those with small tumours (< 3 cm) (P < 0.04). Immunohistochemical localization of ICAM-1 was negative in normal liver tissue; positive staining for endothelial cells was found in chronic liver disease, while in hepatocellular carcinoma tissues, positive membrane staining was observed in hepatocytes and, to a lesser extent, at the cytoplasmic level.

CONCLUSION

These results suggest that high serum levels of sICAM-1 are associated with severe liver disease, such as liver cirrhosis and hepatocellular carcinoma, and that they tend to increase with deteriorating hepatic function and tumour size.

Use of 24-hour oesophageal pH-metry for the detection of gastro-oesophageal reflux in infants: what is the ideal score and the optimal threshold? A receiver-operating-characteristic analysis

BACKGROUND

The search for the ideal score and best cut-off value to interpret the data from 24-hour continuous pH-monitoring interests both gastroenterologists with adult patients and paediatric gastroenterologists.

AIMS

To evaluate 24-hour continuous pH monitoring as a discriminatory test in the diagnosis of gastro-oesophageal reflux disease in a paediatric population, using various pH-metry scores and cut-off values.

PATIENTS

One hundred and one patients presenting gastro-oesophageal reflux disease (endoscopic diagnosis of oesophagitis or coincidence between apnoea and reflux episodes observed during pH-metry), median age 10 months, were studied, together with a control group of 84 subjects, median age 11 months.

RESULTS

After plotting the receiver operating characteristic curves and calculating the area below them, the evaluation of the total percentage reflux time proved to have a higher capacity for distinguishing between the patients and controls than the Euler score (p < 0.05). The cut-off value of 5.2% for the total percentage reflux time had a sensitivity of 75% and was 88% specific. Using higher cut-off values according to age, a 95% specificity and a 49% sensitivity were obtained. The most sensitive score was the Jolley score: 96% with a cut-off of 64 and 90% with a cut-off of 100 (a value determining the maximum diagnostic accuracy); specificity, however, was low: 39-61%. In addition, the Jolley score was the most useful parameter in detecting patients with apnoeic episodes secondary to gastro-oesophageal reflux disease and allowed a correct diagnosis in 12/13 cases.

CONCLUSIONS

a) The simple determination of total percentage reflux time, according to the methodology used, has a higher predictive capacity than the more complex pH-monitoring scores; b) the best cut-off value for total percentage reflux time is 5.2% as it combines a good specificity and sensitivity which are necessary for this test; c) age-dependent cut-off values are highly specific but sensitivity is much too low; d) the Jolley score is very sensitive and this was maintained even when the cut-off was raised to a value of 100; it is the best predictive score for episodes of gastro-oesophageal reflux-dependent apparent life-threatening events.

Prospective study on thyroid autoimmunity and dysfunction related to chronic hepatitis C and interferon therapy

This study was designed to assess patients with chronic hepatitis C (CHC) for the presence of thyroid autoimmunity and dysfunction, to evaluate the risk of thyroid disorders associated with interferon (IFN) therapy, and to survey the outcome of possible treatment-related thyroid injury. Out of 104 consecutive untreated patients (30 women and 74 men; mean age, 52.7 years), 8 (7.7%) were found seropositive for thyroid autoantibodies (ThyAb), whereas seropositivity in healthy controls was 1/98 (1.3%). The relative increase in risk of developing thyroid autoimmunity associated with CHC was 760% (95% CI, 220-1300%). No patients had abnormalities of thyroid function tests, but on IFN treatment, 3/3 patients showed a rapid over-range rise in circulating thyrotropin, which returned to normal after therapy discontinuation. In the other 5 seropositive patients who refused treatment, thyroid function remained normal. Out of the 58 initially seronegative patients who consented to IFN treatment, 9 (15.5%) developed thyroid autoimmunity. Seven of them (77.7%) had thyroid dysfunction: hypothyroidism in 4 cases, transient thyrotoxicosis in 2 cases. The last patient developed TSH-receptor antibodies and Graves' disease, requiring methimazole therapy. Thyroid function recovered in the former 6 cases following IFN discontinuation. In the 28 initially seronegative patients who refused IFN and participated in a preliminary tauroursodeoxycholic acid trial, antithyroglobulin antibodies alone appeared in one case, but no thyroid dysfunction was observed. The relative risk of thyroid autoimmune disorder associated with IFN therapy was 342% (28-636%). The patients with CHC were unlikely to develop thyroid dysfunction in the absence of IFN therapy, in spite of being ThyAb seropositive. Moreover, a considerable proportion of seronegative patients, when IFN-treated, developed thyroid autoimmunity and then thyroid dysfunction. Both in seropositive and seronegative patients immediate IFN discontinuation normalized thyroid function and hormone replacement therapy was not necessary.

[Levels of scientific evidence and strength of clinical recommendations. From trials to guidelines. The Italian Group on Medicine Based on Evidence--(GIMBE)]

Evidence-based medicine is a new paradigm of clinical practice that promotes the collection, interpretation and integration of valid, important and applicable to patients research-derived evidence, and it can improve the efficiency and the effectiveness of health care. Nevertheless research often fails to get in clinical practice, also because the traditional tools used by physicians to solve clinical problems are less reliable as the volume/complexity of medical information and biomedical technology have grown exponentially. New tools are emerging to help physicians: the systematic reviews of randomized controlled trials and the clinical practice guidelines that summarize a great volume of medical knowledge to improve health care. Practice guidelines, with a systematic review or meta-analysis pertaining to a definite health problem, summarize the evidence of clinical trials in clinical recommendation. These combine the strength and heterogeneity of the primary studies with magnitude and precision of the treatment effects as it relates to the minimal clinical benefit. The recommendation may suggest therapeutic intervention when the baseline risk is high or otherwise when the baseline risk is low. The Authors discuss principles of evidence-based medicine, measures of treatment effectiveness, systematic reviews and methods used by experts to graduate the strength of clinical recommendations in producing practice guidelines.

Role of pancreatic impairment in growth recovery during gluten-free diet in childhood celiac disease

BACKGROUND & AIMS

Clinical significance and duration of insufficient release of pancreatic enzymes in childhood celiac disease have not been clarified. The aim of this study was to evaluate the role that pancreatic impairment plays in growth recovery and the duration of this impairment.

METHODS

Forty-six patients with celiac disease who had a median age of 2.5 years were enrolled. Fecal chymotrypsin level was determined at diagnosis and then every 15 days after the beginning of a gluten-free diet in all patients.

RESULTS

At diagnosis, 17 of 46 patients with celiac disease had subnormal fecal chymotrypsin values. During the gluten-free diet, a progressive reduction in the percentage of patients with subnormal fecal chymotrypsin values was observed: 12 of 46 patients after 30 days and 2 of 46 patients after 60 days. Weight increase after 2 months of gluten-free diet was significantly greater in patients with normal fecal chymotrypsin values at diagnosis than in patients with subnormal values, and a positive correlation was found between fecal chymotrypsin at diagnosis and weight increase (r = 0.56).

CONCLUSIONS

A small percentage of patients with celiac disease still had subnormal chymotrypsin concentrations after 60 days of gluten-free diet. Fecal chymotrypsin is a predictive index of weight recovery in the first months after diagnosis of celiac disease; it could be used to select patients for enzyme supplementation therapy.

Secondary impairment of pancreatic function as a cause of severe malabsorption in intestinal giardiasis: a case report

We report the case of a 54-year-old male patient hospitalized for diarrhea and weight loss (8 kg over the previous three months). At admission, we observed pale oral and conjunctival mucosa and peripheral edema of the lower limbs. Stool frequency was 8-10 per day. Laboratory data were as follows: hemoglobin, 11 g/dL; total proteins, 4.3 g/dL; albumin, 2 g/dL; pseudocholinesterase, 1248 U/L; triglycerides, 54 mg/dL; serum cholesterol, 102 mg/dL; calcium, 7.9 mg/dL. Fecal fat was 8.2 g/24 hr. Fecal chymotrypsin (FCT) was 2.3 U/g. A duodenal probe was performed after administration of intravenous secretin and cerulein stimulation, and a contemporaneous mucosal biopsy was taken at the ligament of Treitz. Microscopic examination showed numerous Giardia lamblia in the fluid collected. Pancreatic enzyme activity in the duodenal fluid showed a severe reduction in lipase: 120 U/ml/min (normal value = 600 U/ml/min). Small bowel bacterial overgrowth was excluded by microbiologic examination of intestinal fluid. The patient was treated with metronidazole, leading to a complete remission of symptoms. Immediately after stopping treatment, the FCT was 15.2 U/g. Four months after hospitalization, the patient's weight had increased by 11 kg and he was asymptomatic; total proteins were 6.7 g/dL; albumin, 3.8 g/dL; triglycerides, 104 mg/dL; cholesterol, 152 mg/dL; pseudocholinesterase, 3,567 mg/dL; calcium, 10 mg/dL; steatorrhea was 3.6 g/24 hr and fecal chymotrypsin was 88 U/g. This case describes a severe, reversible impairment in pancreatic function leading to clinical malabsorption in the presence of Giardia infection.

Evaluation of pancreatic function development after hydrolyzed protein-based and soy-based formulas in unweaned infants

AIMS

Different protein sources could determine differences in the maturation of the exocrine pancreas in humans during the first months after birth; however, no studies have been carried out in man to evaluate the effect of a hydrolyzed protein diet on exopancreatic function. Our aim was therefore to determine the effect of two different milk formulas on pancreatic secretion in patients with cow's milk protein allergy (CMPA).

METHODS

We selected 12 infants (median age, 3.0 months), fed for 6 weeks with a hydrolyzed casein-based formula, and 14 infants (median age, 3.0 months) who received a soy-protein based formula over the same period. As controls, two groups of age-matched infants with no gastrointestinal disease and receiving a free diet were studied. In the patients with CMPA a secretin-cerulein test was performed at the commencement of the diet and after 6 weeks; in the controls the same test was performed only once. Enzyme concentrations and outputs of trypsin, chymotrypsin, lipase, and phospholipase were assayed.

RESULTS

No significant difference was observed between the two groups of patients with CMPA for any of the enzymes studied, either at base line or after 6 weeks of diet. No difference was recorded between CMPA patients and age-matched controls on a free diet either. In both CMPA groups there was a significant increase over basal values in trypsin, chymotrypsin, and lipase concentrations after 6 weeks. Furthermore, there was a significant positive correlation between the age of the patients and enzyme concentrations. Mean daily weight gain was 27.4 +/- 3.9 g with hydrolyzed casein and 27.2 +/- 3.5 g in soyfed patients.

CONCLUSIONS

It is suggested that the diets with different protein content used in subjects with CMPA did not determine any difference in the stimulation of proteolytic and lipolytic pancreatic enzymes.

Influence of haemodialysis on lipase activity

Our aim was to determine whether the increase in serum pancreatic lipase values, reported in patients with chronic renal failure maintained on haemodialysis, is the result of haemoconcentration by fluid removal during dialysis, or whether it is due to lipase stimulation by endothelial lipoprotein lipase, induced by the heparin used as an anticoagulant. We therefore compared the increases in serum lipase, when heparin was used, with those observed when this was replaced by the antithrombotic agent, defibrotide, which has no effect on lipoprotein lipase. In addition, in order to determine the effects of haemoconcentration, variations in total protein concentration and haematocrit values were determined on the same samples, both before and after dialysis. The results showed a statistically significant post-dialysis increase in lipase only when heparin was used (p < 0.03). There was also a mean percentage post-dialysis increase of 16.2% in total protein (p < 0.0001) and 15.5% in haematocrit (p < 0.0001), due to fluid removal. No significant correlation in percentage increases was found between lipase vs total protein or haematocrit values. These findings suggest that heparin-induced lipoprotein lipase stimulation is the principal cause of the post-dialysis increase in pancreatic lipase, and that fluid removal during dialysis makes only a minor contribution to this increase.

[Serum variations of 2 markers of fibrogenesis in chronic hepatitis C treated with alpha interferon]

We evaluated variations in serum levels of N-terminal peptide of type III procollagen (PIIIP) and laminin (Lam-P1) in 36 anti-HCV positive patients, confirmed by RIBA II, with chronic hepatitis treated with alpha interferon (IFN) at a dose of 6 million units (MU) three times for week for 6 months, followed by 3 MU three times for week for a further 6 months. We consider responders (R) those patients who after one year of therapy had normalized ALT levels, and non-responders (NR) the remaining subjects. Serum PIIIP and Lam-P1 were determined by RIA on entry to the study and at 12 months. Ten patients underwent a percutaneous liver biopsy also at the end of the therapy for the histological evaluation of the necroinflammatory activity and fibrosis according to the Knodell score system. Overall, at the end of therapy, the mean levels of both markers were lower than at entry to the study, with a statistically significance only for the Lam-P1 values (p < 0.05). When, however, we divided the patients into R (n = 15) and NR (n = 21) subgroups, the mean baseline values of both markers were significantly higher in NR vs controls and after therapy there was a significantly reduction only for PIIIP values (p < 0.01). In the group of R there is a slight, but not significantly reduction of both markers. The comparison of the Knodell's score before and after IFN treatment showed an improvement of the necroinflammatory activity, but not of fibrosis. In conclusion patients R to IFN therapy have lower baseline values of PIIIP and Lam-P1 than NR and therapy with IFN improves the serum values of PIIIP as well as the score of the necroinflammatory activity.

Lysosomal aspartic and cysteine proteinases serum levels in patients with pancreatic cancer or pancreatitis

Lysosomal cathepsins D (CD), B (CB), and L (CL) serum levels were determined by immunoassays in patients with chronic (CHP) or acute (AP) pancreatitis and in patients with ductal pancreatic carcinoma (DPC) and correlated with some biological and clinical parameters of this tumor. CB serum concentrations significantly higher than those measured in healthy subjects (NS) were observed in CHP, AP, and DPC patients (p < 0.01). However, no significant difference was noted among these groups. Increased CL serum levels were evident only in cancer patients compared to NS, AP, or CHP groups (p < 0.05), while no difference was observed among these groups. Elevated CD serum values were observed in CHP and AP patients compared to healthy subjects or cancer patients (p < 0.01). In cancer patients no correlation between CD, CB, and CL and clinical stage or tumor size was found. However, significant correlations were observed only between serum CD and CA50 (p < 0.02) and between CD and CL (p < 0.05). No further relationship among the biochemical parameters examined was observed. The present data suggest that the different serum patterns of CD, CB, and CL in patients with pancreatitis and pancreatic cancer may be of clinical interest as additional biochemical parameters for the differential diagnosis of these diseases. However, further prospective clinical studies are needed to assess better their potential value as prognostic parameters to identify patients with pancreatitis at increased risk to develop pancreatic cancer.

Lysosomal cathepsins B and L and Stefin A blood levels in patients with hepatocellular carcinoma and/or liver cirrhosis: potential clinical implications

The serum levels of lysosomal cathepsin B and L and Stefin A, an intracellular inhibitor of these proteolytic enzymes, were determined in patients with hepatocellular carcinoma (HCC) and/or liver cirrhosis (LC) and correlated with some clinical and biochemical parameters of these diseases. Cathepsin B serum levels were increased in HCC and in LC patients as compared to normal subjects (p < 0.001). However no difference was observed between HCC and LC groups. Interestingly, a significant relationship was evidenced between cathepsin B serum content and the grade of severity of cirrhosis (r = 0.41; p < 0.001). Cathepsin L was significantly elevated only in sera of cancer patients as compared to normal subjects or LC patients (p < 0.001) and significantly correlated with the number of malignant lesions (r = 0.49; p = 0.001). Stefin A serum levels were increased in HCC and LC patients as compared to healthy subjects (p < 0.02). However, these levels were significantly higher in the LC group as compared to the HCC group (p < 0.05). In cancer patients, a significant relationship was observed between Stefin A serum content and tumor size (r = 0.35; p < 0.05), number of neoplastic lesions (r = 0.556; p < 0.001) and serum alpha-fetoprotein (r = 0.38; p < 0.01). These data suggest that cathepsin B and L and Stefin A may be potentially useful as additional biochemical parameters to monitor the therapeutic response of these diseases to clinical treatments and to identify patients with cirrhosis developing precancerous lesions.

Pancreatitis-associated protein in patients with celiac disease: serum levels and immunocytochemical localization in small intestine

Since PAP is a stress protein expressed in human pancreas during pancreatitis but also constitutively synthesized in the small intestine, we looked whether its expression would be altered in patients with celiac disease. Serum PAP concentrations were determined consecutively in 54 patients with celiac disease on a free diet (group A), in 47 patients with celiac disease on a gluten-free diet (group B), in 22 patients with other intestinal pathologies but with normal intestinal mucosa (group C), in 14 patients with retarded growth, no gastrointestinal disease and normal intestinal mucosa (group D), and in 17 controls (group E). Serum PAP levels (ng/ml) were significantly higher in group A (127.3 +/- 56.8) than in the other groups (B: 47.2 +/- 20.5; C: 51.5 +/- 32.2; D: 47 +/- 22.8; E: 27.6 +/- 9.0), which were not different from each other. In group A, a positive correlation was observed between serum PAP values and antigluten antibody levels (vs. AGA IgG r = 0.58, p < 0.001; vs. AGA IgA r = 0.66, p < 0.001). Furthermore, 12 patients from group A were evaluated after 10-12 months of gluten-free diet and in all of them PAP serum concentration had decreased (mean +/- SE before the diet 122.5 +/- 36.4, after the diet 48.7 +/- 13.7, p < 0.0001). In addition, we performed an immunocytochemical study to localize PAP in the intestinal mucosa of patients from all groups except E. PAP was localized to the Paneth cells and to some globet cells, in patients with mucosal atrophy as well as in those with normal mucosa with no obvious quantitative difference. We concluded that in patients with celiac disease the active phase of the disease was accompanied by an increased serum concentration of PAP. Further studies are necessary to understand the mechanism leading to PAP elevation in the serum of patients with celiac disease.

[Wilson's disease]

Wilson's disease is a rare inherited metabolic disorder usually characterized by liver and/or neurological degeneration. Unlike most genetically transmitted diseases, it rapidly responds to pharmacological treatment in case of early diagnosis and treatment. Often, however, as this disease presents with aspecific symptoms, patients are wrongly diagnosed as psychiatric cases or as having generic chronic liver disease and the true cause of symptoms is only discovered at a much later stage. The authors give a detailed review of the literature with the aim of presenting the most recent research on the main aspects of this disease and offering a practical and simple approach to early diagnosis.

Sex hormones in patients with liver cirrhosis and hepatocellular carcinoma

Sex hormones have been proposed to play an important role in promoting liver cancer transformation. The aim of our study was to evaluate changes in circulating levels of estradiol (EII), testosterone (T) and the EII/T relationship (ETR) in patients with liver cirrhosis (LC) and hepatocellular carcinoma (HCC) of viral origin compared with a group of healthy controls (C). The study population included 64 patients (41 M) mean age 62.5 years with HCC; 68 patients (41 M) mean age 61.3 years suffering from LC, while the C included 59 subjects (39 M) mean age 60.0 years recruited from voluntary blood donors. EII and T were assayed using the IEMA method; ultrasonography was performed using a Toshiba SSA 240 A scanner with a convex 3.75 MHz probe. Serum EII levels progressively increased from C to LC and HCC with statistically significant values (H=36.9, p<0.0001). Serum values of T progressively decreased from C to LC and HCC but the difference was not significant (H=3.84, p=ns). ETR values differed in the three groups, with a significant difference between C vs LC and HCC (p<0.0001). There was also a significant difference for EII, with values decreasing as the neoplasm dimension increased (p<0.04), and in particular there were differences between HCC <5 cm vs >5 cm (p<0.05). In contrast, ETR progressively increased as the diameter of neoplasm increased, but differences were significant only between <3 cm vs >5 cm (p<0.05). In conclusion, our data confirm that in LC and HCC there is an increase in serum EII levels, which can be important in the genesis of liver carcinoma. Progressive serum reduction in T may be due to increased androgen uptake and progressive accumulation within the neoplastic mass. Further studies are necessary to determine whether subjects with LC and elevated serum levels of estrogens are at higher risk of developing HCC.

Mechanism of PAP I gene induction during hepatocarcinogenesis: clinical implications

Pancreatitis-associated protein I (PAP I) is a secretory protein first described as an acute phase reactant during acute pancreatitis. Recently, induction of the PAP I gene was also described in liver during hepatocarcinogenesis. To investigate the molecular mechanisms of this induction, we used constructs carrying progressive deletions of the PAP I promoter fused to the CAT gene. We showed that the silencer conferring tissue specificity on the PAP I gene was inactive in hepatoma cells. Then, in an vitro transcription system, we compared the transcription capacity of nuclear extracts from normal liver and HepG2 cells on constructs containing the silencer. The results confirmed that a trans-acting factor interacting with the PAP I silencer was present in liver cells and absent from hepatoma cells. On the other hand, immunohistochemistry showed that PAP I was expressed in a limited number of transformed hepatocytes. It was concluded that expression of PAP I in hepatocarcinoma occurred through inactivation of its silencer element and was not concomitant in all malignant cells. On that basis, we assayed PAP I in serum from patients with chronic hepatitis, liver cirrhosis or hepatocarcinoma. PAP I levels were normal in chronic active or persistent hepatitis, significantly higher in cirrhosis and strongly elevated in hepatocarcinoma. Because those clinical entities often develop in that sequence, serum PAP I appeared as a potential marker of hepatocarcinoma development.