Hepatocellular carcinoma in Italian patients with cirrhosis

Clinical predictors for hepatocellular carcinoma in patients with primary biliary cirrhosis

BACKGROUND & AIMS

Although hepatocellular carcinoma (HCC) occurs with increased frequency in patients with primary biliary cirrhosis (PBC), the exact frequency is relatively low. Optimal selection of PBC patients for HCC screening needs to be determined for effective screening. In this study, we aimed to explore clinical predictors of HCC in PBC patients.

METHODS

We performed a case-control study using 17 PBC patients with HCC identified from 1976 to 2002 at the Mayo Clinic. Control PBC patients who had no evidence of HCC were selected for each case by matching the first year of their visit to the Mayo Clinic. All medical information was collected within 2 years from when the cases were diagnosed with HCC. Logistic regression models were used for the analyses.

RESULTS

Age, sex, history of blood transfusion, current smoking, histologic stage at PBC diagnosis, any signs of portal hypertension, Mayo score, hemoglobin level, platelet count, aspartate aminotransferase level, and albumin level were associated with the presence of HCC (P < .05 for each). In multivariable analysis, older age (OR, 1.7; 95% confidence interval [CI], 1.1-2.5 for 5 years), male sex (OR, 9.7; 95% CI, 1.4-68.3), history of blood transfusion (OR, 5.0; 95% CI, 1.0-24.3), and any signs of portal hypertension (OR, 22.9; 95% CI, 3.4-155.3) were associated significantly with increased odds of HCC and yielded an excellent diagnostic performance (area under the receiver operating characteristics curve rate, 0.91).

CONCLUSIONS

Older age, male sex, history of blood transfusion, and any signs of portal hypertension or cirrhosis indicate higher likelihood of HCC and should be considered for HCC screening. Further studies in larger patient cohorts are required to verify the diagnostic model.

Clinical and pathological factors associated with the development of hepatocellular carcinoma in patients with hepatitis virus-related cirrhosis: a long-term follow-up study

AIMS

Hepatocellular carcinoma (HCC) represents >90% of primary liver neoplasms and develops mainly in patients with liver cirrhosis. Risk factor identification for the development of HCC in patients with cirrhosis possesses great clinical relevance due to its high incidence and poor prognosis when detected at advanced stages. The aim of this study was to identify HCC development-associated risk factors in a cohort of patients with hepatitis virus-related chronic liver disease and cirrhosis.

MATERIALS AND METHODS

Patients with a diagnosis of hepatitis virus-related cirrhosis between January 1980 and January 2000 were included. Patients were followed with an abdominal ultrasound and the determination of alpha-fetoprotein levels, a physical examination, and routine biochemical tests every 3-6 months. The end point of the study was defined as the development of HCC. Liver histology was evaluated according to the French METAVIR Cooperative Study Group (METAVIR) score.

RESULTS

Two hundred and eighty-two patients met the inclusion criteria; most of these (86%) had a serologic diagnosis of hepatitis C virus, and only 14% had hepatitis B virus at the time of the diagnosis of cirrhosis, whereas 56 and 37% were classified as Child A and B, respectively, and only 7% as Child C. Histological activity was mild in 59% of patients, and moderate and severe in 41%. The mean annual incidence was 1.87%, and 22 and 35% of patients developed HCC at 10 and 15 years of follow-up, respectively. The diagnosis of HCC was made by histopathology in 37% and by tumoural lesion-associated alpha-fetoprotein elevation confirmed by imaging studies in 63%. In multivariate analysis, we found three variables associated with HCC: moderate to severe histological activity; a platelet count <105x10(3)/mm(3), and alpha-fetoprotein >5 ng/ml. The patients were divided into two groups according to regression coefficient: low and high risk; patients assigned to the low-risk group showed 5-, 10- and 15-year HCC incidences of 3.4, 6.4 and 6.4%, respectively, in contrast to patients from the high-risk group, who showed incidences of 17.8, 33.5 and 56.8%, respectively.

CONCLUSIONS

We found three HCC-associated variables: histological activity, platelet count and alpha-fetoprotein levels. Patients considered as high risk for developing HCC must be considered candidates for closer follow-up.

Evaluation of the prognostic value of Okuda, Cancer of the Liver Italian Program, and Japan Integrated Staging systems for hepatocellular carcinoma patients undergoing radiotherapy

PURPOSE

The purpose of this study was to compare the validity of staging systems, as well as to identify the staging system with the best prognostic value, in hepatocellular carcinoma (HCC) patients treated with radiotherapy.

METHODS AND MATERIALS

From 1992 to 2003, a total of 305 patients undergoing radiotherapy for HCC were evaluated retrospectively. All patients were classified before radiation therapy by the following systems: tumor-node-metastasis (TNM), Okuda, Cancer of the Liver Italian Program (CLIP), and Japan Integrated Staging (JIS) score. Cumulative survival rates were obtained using the Kaplan-Meier method, and were statistically compared using the log-rank test.

RESULTS

Median survival time was 11 months. The 1-, 2-, 3-, 4-, and 5-year survival rates were 45.1%, 24.5%, 14.7%, 10.3%, and 6.4%, respectively. Significant differences in survival were observed between all TNM stages, between CLIP scores 2, 3 and 5, 6, as well as between JIS scores 1, 2, and 2, 3.

CONCLUSIONS

Among the systems studied, the TNM staging approach appeared to be the best predictor of prognosis. Staging systems that reflect liver disease status (Okuda stage, CLIP, and JIS score) showed limitations in stratifying patients undergoing radiotherapy into different prognostic groups.

No evidence of hepatitis C virus infection in Serbian patients with oral leukoplakia

BACKGROUND

A review of the literature reveals controversy regarding the relationship between hepatitis C virus (HCV) infection and oral leukoplakia (OL). The aim of this study was to determine the frequency of HCV antibodies in patients with OL and control subjects resident in Serbia.

METHODS

In this cross-sectional study 73 consecutive patients with histologically proven OL and 90 control subjects, whose age and gender were matched, were examined for the presence of serological evidence of chronic hepatic disease, hepatitis B surface antigen (HBsAg) and anti-HCV seropositivity.

RESULTS

None of the patients with OL or control subjects had antibodies to HCV or HBsAg. All patients with OL and control subjects had normal liver function.

CONCLUSION

The present data indicate that patients with OL resident in Serbia do not have evidence of HCV or HBV infection.

Non-invasive diagnosis of cirrhosis and the natural history of its complications

Several methods have been studied in the attempt to reach a diagnosis of cirrhosis by non-invasive means. Although abdominal ultrasound can detect the hepatic and extra-hepatic changes consistent with cirrhosis, its ability to distinguish chronic hepatitis from compensated cirrhosis is limited. Serum markers can rule in or rule out fibrosis in up to 35% of patients but, in individual patients, cannot differentiate the stages of fibrosis reliably. Transient elastography (Fibroscan) might be of value for the non-invasive diagnosis of cirrhosis; however, its reproducibility needs to be further validated. Cirrhosis can be divided into 4 stages: stage 1, no varices, no ascites; stage 2, varices without ascites and without bleeding; stage 3, ascites+/-varices; stage 4, bleeding+/-ascites. Yearly mortality ranges from 1% in stage 1 to 57% in stage 4. The yearly incidence of oesophageal varices is 5-7%; their rate of enlargement is 10-12% per year. The incidence of variceal bleeding is about 25% at 2 years. Bleeding stops spontaneously in about 50% of cases but early rebleeding occurs in 30-40% of patients. Bleeding-related mortality has declined over time and is now around 20% at 6 weeks.

Colchicine delays the development of hepatocellular carcinoma in patients with hepatitis virus-related liver cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) is a malignant neoplasm associated with liver cirrhosis, with an annual incidence of 3% to 9%, which is one of the main causes of death in patients with cirrhosis. Viral hepatitis is associated with an increased risk of HCC, probably due to an inflammatory reaction. Colchicine is an antiinflammatory agent that inhibits the formation of intracellular microtubules, affecting mitosis and fibrogenesis. Diverse clinical studies have failed to demonstrate the benefit of colchicine over the progression of fibrosis in patients with liver cirrhosis; nevertheless, to the authors' knowledge there are no studies that evaluate its effect in the development of HCC.

METHODS

The effect of the administration of colchicine on the development of HCC was evaluated in 186 patients with hepatitis virus-related liver cirrhosis in a retrospective cohort study. The minimum follow-up time was 3 years (median, 84 months +/- 2.8 months). One hundred sixteen patients received treatment with colchicine. The characteristics of both groups were similar.

RESULTS

The percentage of patients who developed HCC was significantly smaller in the colchicine group when compared with the noncolchicine group (9% vs. 29%; P = .001). On multivariate analysis, an alpha-fetoprotein level > or = 5 ng/dL (P = .03), a platelet count < 100,000 at diagnosis (P = .05), alanine aminotransferase > or = 52 IU (P = .006), and a lack of treatment with colchicine (P = .0001) were found to be associated with an earlier development of HCC. The average time for the development of HCC was 222 months +/- 15 months and 150 months +/- 12 months in the patients who received and who did not receive colchicine, respectively.

CONCLUSIONS

The results suggest that treatment with colchicine prevents and delays the development of HCC in patients with hepatitis virus-related cirrhosis. The protective mechanisms of colchicine over the development of HCC could be related to antiinflammatory properties and inhibition of mitosis. Prospective studies to confirm this observation with a greater number of patients and long-term follow-up may be indicated.

Cost-effectiveness of hematologic growth factors for anemia occurring during hepatitis C combination therapy

In hepatitis C virus (HCV)-infected patients who develop anemia during combination therapy, erythropoietic growth factors maintain higher drug treatment levels compared to ribavirin dose reduction, which may lead to an increase in treatment response rates. This study estimated the cost-effectiveness of growth factor therapy in maintaining anemic HCV-infected patients on target drug levels during combination therapy. A decision analysis using a Markov model was developed with 7 health states: Sustained viral response, chronic HCV, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, and death. Data sources included population-based studies of growth factor therapy, previously published estimates of costs and natural history of hepatitis C, and recent prospective studies. Our reference case was a 45-year-old Caucasian man with HCV infection (genotype 1, 2, or 3) who developed anemia while undergoing combination therapy with ribavirin and pegylated interferon. We compared growth factor injections (darbepoetin alpha or epoetin alpha) during combination therapy with standard ribavirin dose reduction. Compared to a ribavirin dose reduction strategy, the cost of darbepoetin per additional quality-adjusted life-year was 34,793 dollars for genotype 1 and 33,832 dollars for genotypes 2 or 3 versus 60,600 dollars and 64,311 dollars for epoetin. For all genotypes, the results were sensitive to changes in the cure rates of HCV therapy, the utility of chronic HCV, the costs of growth factors, and the age at which therapy is begun. In conclusion, use of erythropoietic growth factors, specifically darbepoetin, for patients with anemia occurring during HCV combination therapy appears to be cost-effective for genotypes 1, 2, or 3.

Surveillance program for early detection of hepatocellular carcinoma in Japan: results of specialized department of liver disease

OBJECTIVE

Surveillance of cirrhotic patients enables early detection of hepatocellular carcinoma (HCC) and possibly prolongs survival. The aim of this study was to explore whether early-stage HCC can be detected earlier at a specialized department of liver disease than in other institutions.

METHODS

The study subjects were 574 patients with HCC. Patients were subdivided into 3 groups according to the manner of HCC detection: group A, HCC was detected in 91 patients during periodic examination at Kurume University School of Medicine; group B, HCC was detected in 301 patients during periodic examination at other institutions; group C, HCC was detected incidentally or because of symptoms in 182 patients.

RESULTS

The HCC detected in group A was significantly of smaller size (20.4 mm) compared with groups B (27.1 mm, P<0.0001) and C (57.8 mm, P<0.0001). The frequency of receiving treatment (surgery or local ablation therapy) was significantly higher in group A (73%) than in groups B (52%, P=0.002) and C (26%, P<0.0001). The 5-year survival rates were 52% for group A, 40% for group B, and 23% for group C, respectively. The survival of group A was significantly better than that of groups B (P=0.0157) and C (P<0.0001).

CONCLUSIONS

Surveillance for HCC at specialized Department of Liver Disease can detect early-stage HCC, resulting in a higher chance of receiving promising treatment.

Preclinical and post-treatment changes in the HCC-associated serum proteome

SELDI-based proteomic profiling of body fluids is currently in widespread use for cancer biomarker discovery. We have successfully used this technology for the diagnosis of hepatocellular carcinoma (HCC) in hepatitis C patients and now report its application to serial serum samples from 37 hepatitis C patients before development of HCC, with HCC and following radiofrequency ablation of the tumour. As with alpha-fetoprotein, an accepted biomarker for HCC, we hypothesised that HCC-associated proteomic features would 'return to normal' following successful treatment and the primary aim of our study was to test this hypothesis. Several SELDI peaks that changed significantly during HCC development were detected but they did not reverse following treatment. These data may be interpreted to suggest that the characteristic SELDI profile is not linearly related to tumour burden but may result from the progression of underlying liver disease or from the emergence of precancerous lesions. beta2-Microglobulin, a protein previously reported to be markedly elevated in patients with HCV related HCC, was also the most significantly HCC associated proteomic feature (m/z 11720) in this study.

Epidemiology and natural history of hepatitis C virus infection in injection drug users: implications for treatment

Effective methods to diminish the burden of hepatitis C virus (HCV) infection among injection drug users (IDUs) require consideration of the epidemiology and natural history of both hepatitis C and drug use. Most HCV infections are due to injection drug use, and most IDUs have HCV infection. In addition, HCV infection often occurs with other medical problems, such as human immunodeficiency virus infection and depression, which may complicate its recognition and management. Infection with HCV can be fatal, but usually not until years later, and persons may be unaware of the infection, allowing an individual to infect many others. Effective treatment is available for HCV infection; however, the therapy is prolonged, involving both weekly injections and daily oral medication, and is typically associated with significant adverse effects, such as fatigue, depression, and, rarely, life-threatening complications. Although clearly some IDUs want their HCV infection to be treated, many are unwilling or unable to initiate or sustain treatment with currently available therapies, and IDUs who are treated require considerable, multidimensional support. Solutions to the problem of HCV infection among IDUs must account for these facts.

Efficacy of ultrasonography and alpha-fetoprotein on early detection of hepatocellular carcinoma

AIM: To evaluate the effectiveness of ultrasonographic screening for early detection of hepatocellular carcinoma (HCC).

METHODS: The data of 14 968 patients who had ultrasonography (US) for chronic liver diseases were collected into a database program from June 1995 to June 2005. The risk factors for HCC were also studied. A total of 6089 patients who had repeated US were enrolled, 264 patients were diagnosed with HCC during follow-up (mean, 39 mo).

RESULTS: The detection rate of small HCC (≤ 3 cm in diameter) was 67.7%. The tumor size detected by screening at the intervals of 6 mo was significantly smaller than that at longer intervals. Only 29.3% of HCC patients had an elevated serum alpha fetoprotein (AFP) level above 400 ng/mL. The risk of HCC development during follow-up was higher in patients with liver cirrhosis (10.9%) and hepatitis C (9.0%) than in patients with chronic hepatitis (4.2%), hepatitis B (4.9%) and non-B, non-C hepatitis (NBNC, 3.9%).

CONCLUSION: US screening at a interval of 6 mo is beneficial to high-risk patients over 40 years old and the early detection of HCC prolongs survival.

Cost-effectiveness of Chronic Hepatitis C Treatment with Thymosin Alpha-1

BACKGROUND

More than one million individuals in Mexico are infected with hepatitis C virus (HCV), and 80% are at risk for developing a chronic infection that could lead to hepatic cirrhosis and other complications that impact quality of life and institutional costs. The objective of the study was to determine the most cost-effective treatment against HCV among the following: peginterferon, peginterferon plus ribavirin, peginterferon plus ribavirin plus thymosin, and no treatment.

METHODS

We carried out cost-effectiveness analysis using the institutional perspective, including a 45-year time frame and a 3% discount rate for costs and effectiveness. We employed a Bayesian-focused decision tree and a Markov model. One- and two-way sensitivity analyses were performed, as well as threshold-oriented and probabilistic analyses, and we obtained acceptability curves and net health benefits.

RESULTS

Triple therapy (peginterferon plus ribavirin plus thymosin alpha-1) was dominant with lower cost and higher utility in relationship with peginterferon + ribavirin option, peginterferon alone and no-treatment option. In triple therapy the cost per unit of success was of 1,908 [USD/quality-adjusted life years (QALY)] compared with peginterferon plus ribavirin 2,277/QALY, peginterferon alone 2,929/QALY, and no treatment 4,204/QALY. Sensitivity analyses confirmed the robustness of the base case.

CONCLUSIONS

Peginterferon plus ribavirin plus thymosin alpha-1 option was dominant (lowest cost and highest effectiveness). Using no drug was the most expensive and least effective option.

The natural history of compensated cirrhosis due to hepatitis C virus: A 17-year cohort study of 214 patients

Large databases of consecutive patients followed for sufficiently long periods are needed to establish the rates, chronology, and hierarchy of complications of cirrhosis as well as the importance of other potential causes of liver disease. In accordance with this goal, a cohort of patients with compensated cirrhosis due to hepatitis C virus (HCV) was followed for 17 years. Two hundred and fourteen HCV RNA-seropositive patients with Child-Pugh class A cirrhosis who had no previous clinical decompensation were prospectively recruited and followed up with periodic clinical and abdominal ultrasound examinations. During 114 months (range 1-199), hepatocellular carcinoma (HCC) developed in 68 (32%), ascites in 50 (23%), jaundice in 36 (17%), upper gastrointestinal bleeding in 13 (6%), and encephalopathy in 2 (1%), with annual incidence rates of 3.9%, 2.9%, 2.0%, 0.7%, and 0.1%, respectively. Clinical status remained unchanged in 154 (72%) and progressed to Child-Pugh class B in 45 (21%) and class C in 15 (7%). HCC was the main cause of death (44%) and the first complication to develop in 58 (27%) patients, followed by ascites in 29 (14%), jaundice in 20 (9%), and upper gastrointestinal bleeding in 3 (1%). The annual mortality rate was 4.0% per year and was higher in patients with other potential causes of liver disease than in those without them (5.7% vs. 3.6%; P = .04). In conclusion, hepatitis C-related cirrhosis is a slowly progressive disease that may be accelerated by other potential causes of liver disease. HCC was the first complication to develop and the dominant cause for increased mortality.

Treatment of small hepatocellular carcinoma: a comparison of techniques and long-term results

OBJECTIVE

The aim of this study was to compare the results over time of transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), laser thermal ablation (LTA) and combined therapy in the treatment of small hepatocellular carcinoma.

METHODS

Between 1998 and 2004, 131 cirrhosis patients (99 Child-Pugh class A, 32 Child-Pugh class B) with a small hepatocellular carcinoma were included in the study; 34 were treated with PEI, 46 with LTA, 18 with TACE and 33 with combined therapy.

RESULTS

No major complication occurred during any procedure. Computed tomography scan showed that complete necrosis was achieved in 81% of treated nodules (120 out of 148); as a whole, the disease relapsed in 42 (32.0%) patients (with a disease-free interval of 17.0+/-13.7 months). The cumulative survival rates were 81.9, 35.7 and 20.8% at 12, 36 and 60 months respectively. A univariate analysis of survival showed statistically significant differences in the comparison between Child-Pugh class A with respect to Child-Pugh class B (P<0.0001) and between nodules with a diameter of 20 mm or less as opposed to larger than 20 mm (P=0.001). Patients subjected to LTA showed a statistically significant longer survival than those treated with TACE and PEI.

CONCLUSIONS

LTA proves to be the most effective treatment, affording reduced invasiveness, a limited number of sessions, complete necrosis in almost all cases and better total survival in the treated patients.

Outpatient Management of Cirrhosis: A Narrative Review

Cirrhosis is the 12th leading cause of death in the United States. Individuals with cirrhosis are at risk for many potential complications. Complications can be managed or detected early with proper outpatient management. The most lethal of these complications is bleeding esophageal varices. All patients with cirrhosis should be screened for the presence of varices and treated when indicated. The most common complication seen in these patients is ascites. Ascites can be treated with dietary modifications and a diuretic regimen. Other potential complications include spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatic encephalopathy, hepatorenal syndrome, and hepatopulmonary syndrome. The outpatient management of these complications will be discussed in this paper, along with the use of vaccinations, educating patients about the avoidance of hepatotoxic drugs, and when to refer a patient for liver transplant.

Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review

BACKGROUND AND AIM

In patients with chronic liver disease, the accuracy of ultrasound scan (US), spiral computed tomography (CT), magnetic resonance imaging (MRI), and alpha-fetoprotein (AFP) in diagnosing hepatocellular carcinoma (HCC) has never been systematically assessed, and present systematic review was aimed at this issue.

METHODS

Pertinent cross-sectional studies having as a reference standard pathological examinations of the explanted liver or resected segment(s), biopsies of focal lesion(s), and/or a period of follow-up, were identified using MEDLINE, EMBASE, Cochrane Library, and CancerLit. Pooled sensitivity, specificity, and likelihood ratios (LR) were calculated using the random effect model. Summary receiver operating characteristic (SROC) curve and predefined subgroup analyses were made when indicated.

RESULTS

The pooled estimates of the 14 US studies were 60% (95% CI 44-76) for sensitivity, 97% (95% CI 95-98) for specificity, 18 (95% CI 8-37) for LR+, and 0.5 (95% CI 0.4-0.6) for LR-; for the 10 CT studies sensitivity was 68% (95% CI 55-80), specificity 93% (95% CI 89-96), LR+ 6 (95% CI 3-12),and LR- 0.4 (95% CI 0.3-0.6); for the nine MRI studies sensitivity was 81% (95% CI 70-91), specificity 85% (95%CI 77-93), LR+ 3.9 (95%CI 2-7), and LR- 0.3 (95% CI 0.2-0.5). The sensitivity and specificity of AFP varied widely, and this could not be entirely attributed to the threshold effect of the different cutoff levels used.

CONCLUSIONS

US is highly specific but insufficiently sensitive to detect HCC in many cirrhotics or to support an effective surveillance program. The operative characteristics of CT are comparable, whereas MRI is more sensitive. High-quality prospective studies are needed to define the actual diagnostic role of AFP.

Hepatocellular carcinoma in patients undergoing orthotopic liver transplantation: radiological findings with anatomopathological correlation in Brazil

BACKGROUND: Hepatocellular carcinoma is one of the most common malignant tumors worldwide. Imaging techniques, specially computed tomography and ultrasound, are among the most useful diagnostic tools, although the accuracy of these methods may have a significant variability. AIMS: To determine the prevalence of hepatocellular carcinoma in cirrhotic patients undergoing orthotopic liver transplantation at "Santa Casa de Misericórdia" of Porto Alegre, RS, Brazil; to estimate the sensitivity of computed tomography and ultrasound in pretransplantation detection of hepatocellular carcinoma in this population; to correlate the radiological characteristics with anatomopathological findings. MATERIALS AND METHODS: Retrospective prevalence study. Population: adult, cirrhotic patients undergoing orthotopic liver transplantation from January 1990 to July 2003. Among the 292 transplanted patients, 31 cases of hepatocellular carcinoma were diagnosed, of which 29 were included in the study. Tumor characteristics in both ultrasound and computed tomography were compared to those observed in anatomopathological examination. RESULTS: Prevalence of hepatitis C virus infection among patients with diagnosis of hepatocellular carcinoma was 93.5%, and the prevalence of hepatocellular carcinoma among transplanted patients was 10.6%. The overall sensitivity of the imaging techniques was 70.3% for computed tomography and 72% for ultrasound. CONCLUSION: The prevalence of hepatocellular carcinoma at our institution, as well as the sensitivity of both ultrasound and computed tomography to detect such tumors at pretransplantation screening were similar to those found by other authors, while the prevalence of hepatitis C virus infection, the most common etiological agent for liver disease in our patients, is one of the highest ever reported in literature. Factors influencing hepatocellular carcinoma detection rates were: time from examination to liver transplantation; acquisition of computed tomography images during arterial phase; lesion size. Arterial phase proved to be the most useful part of computed tomography examination in this study.

Hepatitis C: a review for primary care physicians

Primary care physicians see many of the estimated 250 000 Canadians chronically infected with the hepatitis C virus (HCV). Of this number, about one-third are unaware they are infected, which constitutes a large hidden epidemic. They continue to spread HCV unknowingly and cannot benefit from advances in antiviral therapy that may clear them of the virus. Many HCV-infected people remain asymptomatic, which means it is important to assess for risk factors and test patients accordingly. The third-generation enzyme immunoassay for HCV antibodies is a sensitive and specific test, although the presence of the virus can be confirmed by polymerase chain reaction testing for HCV RNA in some circumstances. Pegylated interferon-alpha and ribavirin combination therapy clears the virus in about 45%-80% of patients, depending on viral genotype. Preventive strategies and counselling recommendations are also reviewed.

Probability of liver cancer and survival in HCV-related or alcoholic-decompensated cirrhosis. A study of 377 patients

BACKGROUND

Although chronic alcohol intake and chronic hepatitis C may progress to cirrhosis and hepatocellular carcinoma (HCC), few data are available about survival and probability of developing HCC in decompensated cirrhosis of both aetiologies.

METHODS

This study identified factors related with probability of developing HCC and survival in a cohort of 377 consecutive patients with decompensated HCV-related cirrhosis (200 cases) or alcoholic cirrhosis (177 cases) without known HCC, hospitalized for their first hepatic decompensation, as well as to evaluate differences between both aetiologies. Patients were followed for a mean period of 39 +/- 2 months.

RESULTS

During follow-up, 42 patients (11.1%) developed HCC (16.5% vs 5.1%) in groups HCV and alcohol, respectively; p = 0.0008), and 131 patients (34.7%) died (42% vs 26.6% in groups HCV and alcohol, respectively; p = 0.002). Age and HCV-cirrhosis were independently related to HCC development, while baseline age and Child-Turcotte-Pugh score were independently correlated with survival.

CONCLUSION

Survival in decompensated HCV-related or alcoholic cirrhosis is influenced by age and baseline Child-Turcotte-Pugh score, without differences in cirrhosis aetiology. The risk of developing HCC is greater in HCV-related cirrhosis than in alcoholic cirrhosis.

[Early diagnosis of liver cancer]

Hepatocellular carcinoma is a frequent neoplasm that usually develops in patients with liver cirrhosis. Because it is the main cause of death in these patients, they should be included in a surveillance program in order to identify these tumors at an early stage and be able to indicate curative treatment (liver transplantation, surgical resection or percutaneous ablation therapy) and to reduce mortality. Surveillance should include determination of alpha-fetoprotein and abdominal ultrasound every 6 months. This strategy should only be applied to patients suitable to receive curative treatment if diagnosed of hepatocellular carcinoma. Using this approach, 40-80% of tumors identified are solitary at diagnosis, although only half of these patients can benefit from curative treatment.

An intensive surveillance program detected a high incidence of hepatocellular carcinoma among hepatitis B virus carriers with abnormal alpha-fetoprotein levels or abdominal ultrasonography results

PURPOSE

To study the incidence and treatment outcomes of hepatocellular carcinoma (HCC) detected in an intensive surveillance program (ISP) of hepatitis B virus (HBV) carriers.

PATIENTS AND METHODS

We screened 1,018 HBV carriers by serum alpha-fetoprotein (AFP) measurement and abdominal ultrasonography (AUS). Patients with an abnormal AFP level or AUS result were enrolled in an ISP that included Lipiodol computed tomography followed by AFP measurement/AUS every 3 months for 2 years and then every 6 months thereafter. The rest were on routine surveillance for 2 years.

RESULTS

A total of 9,849 serum AFP measurements and 3,053 AUSs were performed. After a median follow-up of 4.12 years, we diagnosed 24 HCCs among 78 patients with abnormal screening test results at enrollment (group A); 23 HCCs among 93 patients with only abnormal surveillance test results during follow-up (group B); and nine HCCs among 847 patients with 2 years of normal surveillance (group C). Annual incidence of HCC in the ISP was 760.2 (95% CI, 538.4 to 1,073.7) per 100,000. Mean tumor sizes were 3.02, 2.91, and 4.82 cm in groups A, B, and C, respectively (P = .01). Tumor resection rate of the ISP was 36.2%, although another 29.8% of the patients were eligible for locoregional ablative therapy.

CONCLUSION

This study illustrated that a high incidence of relatively small HCCs may be detected by using intensive surveillance of high-risk HBV carriers. However, the surgical resection rate was low, and we were not able to demonstrate clinical benefit with the early detection. Future surveillance studies should consider incorporation of therapy aimed at long-term control of small-sized tumors.

Predictors of long-term survival after liver transplantation for hepatocellular carcinoma

AIMS

The aim of this study was to identify predictors of both survival and tumor-free survival of a cohort of 155 patients, with hepatocellular carcinoma (HCC) and cirrhosis, who were treated by orthotopic liver transplantation (OLT).

METHODS

From January 1989 to December 2002, 603 OLTs were performed in 549 patients. HCC was diagnosed in 116 patients before OLT and in 39 at histological examination of the explanted livers. Eighty-four percent of the patients met "Milan" criteria at histology. Ninety-four patients received anticancer therapies preoperatively.

RESULTS

The median follow-up was 49 months (range, 0-178). Overall, 1-, 3-, 5-, and 10-yr survival were 84%, 75%, 72%, and 62%, respectively. Survival was not affected by the patient's age or sex, etiology of liver disease, Child score at transplantation, rejection episodes, tumor number, total tumor burden, bilobar tumor, and pathologic Tumor, Nodes, Metastasis (pTNM) stages. There was no statistically significant difference in survival when patients were grouped according to the recently proposed simplified pTNM staging (5-yr survival, 80% in stage I, 69% in stage II, 50% in stage III, p= 0.3) or the United Network for Organ Sharing (UNOS) staging system for HCC. Encapsulation of the tumor and alpha-fetoprotein levels significantly affect patient survival. Five-year survival of patients with poorly differentiated (G3) HCC was significantly worse than that of patients with moderately (G2) or well-differentiated (G1) HCC (respectively, G3 44%, G2 67%, and G1 97%, p= 0.0015). Patients with micro- or macro-vascular invasion had a worse 5-yr survival than patients without vascular invasion (49%vs 77%, p= 0.04). Multivariate analysis showed that histological grade of differentiation and macroscopic vascular invasion are independent predictors of survival (HR 2.4, 95% CI 1.4-4.1, p= 0.0009 and HR 2.8, 95% CI 1.2-6.8, p= 0.022).

CONCLUSION

Histological grade of differentiation and macroscopic vascular invasion, as assessed on the explanted livers, are strong predictors of both survival and tumor recurrence in patients with cirrhosis who received transplants for HCC.

Finding evidence-based answers to practical questions in radiology: which patients with inoperable hepatocellular carcinoma will survive longer after transarterial chemoembolization?

To some, evidence-based practice (EBP) means the identification of centers that produce evidence reports and technology assessments to support guideline development. To others, EBP is the best research evidence integrated with clinical expertise and patient values. Inherent in the first approach is the implication that only central academic organizations can produce valid, reliable analyses of existing literature, which will then be distributed to ordinary practitioners. The second approach implies that ordinary practitioners can learn to use a stepwise approach and a preprepared set of rules and tools to effectively find the best current literature, appraise it, and then apply local circumstances to these rules and tools in their hospital. Paul Glasziou, director of the Centre for Evidence-based Practice in Oxford, England, has coined the phrases top-down EBP and bottom-up EBP to describe these approaches. In this article, the authors describe how knowledge gaps in an ordinary radiology practice can be addressed by using stepwise bottom-up EBP techniques. The following clinical scenario is used: Your hospital's recently appointed chief hepatobiliary surgeon questions the use of transarterial chemoembolization for inoperable hepatocellular carcinoma because of his concerns after reading a recent review article suggesting that there is no clear survival benefit to using this procedure. What would you do? Here is how the authors would do it.

Influence of recent advances in medical management on clinical outcomes of cirrhosis

Cirrhosis and its disease-related complications are the 12th leading cause of mortality among U.S. adults and are the 5th leading cause of death for individuals aged 45 to 54 years. Hospitalization costs for disease-related complications are estimated at 18,000 dollars per episode of care, and 10% of admitted patients die. Despite these ominous findings, the survival rate of patients with cirrhosis has improved during the past 2 decades. This observation coincides with the conducting and reporting of high-quality randomized controlled trials and observational studies. Therefore, the improved prognosis in cirrhosis may be related to the effective translation of research findings to clinical practice for this patient population. Although explicit data to support this claim are not available, this article reviews the reported trends in clinical outcomes for patients with cirrhosis and the existence of evidence-based medical information that is available to care for these chronically ill patients.

Hepatocellular carcinoma in Egypt: A single center study over a decade

AIM: To identify the trend, possible risk factors and any pattern change of hepatocellular carcinoma (HCC) in Egypt over a decade.

METHODS: All HCC patients attending Cairo Liver Center between January 1993 and December 2002, were enrolled in the study. Diagnosis of HCC was based on histopathological examination and/or detection of hepatic focal lesions by two imaging techniques plus α-fetoprotein level above 200 ng/mL. The duration of the study was divided into two periods of 5 years each; period I (1993-1997) and period II (1998-2002). Trend, demographic features of patients (age, gender, and residence), risk factors (HBsAg, HCV-Ab, schistosomiasis and others) and pattern of the focal lesions were compared between the two periods. Logistic regression model was fitted to calculate the adjusted odds ratios for the potential risk factors. The population attributable risk percentage was calculated to estimate the proportion of HCC attributed to hepatitis B and C viral infections.

RESULTS: Over a decade, 1 328 HCC patients out of 22 450 chronic liver disease (CLD) patients were diagnosed with an overall proportion of 5.9%. The annual proportion of HCC showed a significant rising trend from 4.0% in 1993 to 7.2% in 2002 (P = 0.000). A significant increase in male proportion from 82.5% to 87.6% (P = 0.009); M/F from 5:1 to 7:1 and a slight increase of the predominant age group (40-59 years) from 62.6% to 66.8% (P = 0.387) in periods I and II respectively, reflecting a shift to younger age group. In the bivariate analysis, HCC was significantly higher in rural residents, patients with history of schistoso-miasis and/or blood transfusion. Yet, after adjustment, these variables did not have a significant risk for development of HCC. There was a significant decline of HBsAg from 38.6% to 20.5% (P = 0.000), and a slight increase of HCV-Ab from 85.6% to 87.9% in periods I and II respectively. HBV conferred a higher risk to develop HCC more than HCV in period I (OR 1.9 vs 1.6) and period II (OR 2.7 vs 2.0), but the relative contribution of HBV for development of HCC declined in period II compared to period I (PAR% 4.2%, 21.32%). At presentation, diagnostic α-fetoprotein level (≥200 ng/mL) was demonstrated in 15.6% vs 28.9% and small HCC (≤3 cm) represented 14.9% vs 22.7% (P = 0.0002) in periods I and II respectively.

CONCLUSION: Over a decade, there was nearly a twofold increase of the proportion of HCC among CLD patients in Egypt with a significant decline of HBV and slight increase of HCV as risk factors. α-Fetoprotein played a limited role in diagnosis of HCC, compared to imaging techniques. Increased detection of small lesions at presentation reflects increased awareness of the condition.

Growth rate of hepatocellular carcinoma: evaluation with serial computed tomography or magnetic resonance imaging

OBJECTIVE

To evaluate the growth rate of untreated hepatocellular carcinoma (HCC) by calculating tumor volume doubling time (TVDT) on serial computed tomography (CT) or magnetic resonance imaging (MRI) and to predict TVDT based on initial tumor size.

METHODS

Sixteen untreated HCCs in 11 patients with cirrhosis who underwent serial CT or MRI at our institution were retrospectively identified. Two independent readers recorded bidimensional measurements for all tumors, which were used to determine tumor volume (TV). Growth rate was expressed as TVDT. A mathematic model was used to predict TVDT based on baseline tumor size.

RESULTS

Mean baseline and follow-up TVs were 10.5 cm3 (range: 0.7-243.6 cm3) and 22.0 cm3 (range: 2.5-870.8 cm3), respectively. Mean duration of follow-up was 176 days (range: 76-472 days). Mean TVDT was 127 days (95% confidence interval: 80, 203; range: 17.5-541.4 days). Expected TVDT could be expressed as TVDT = 114 x (baseline volume)0.14 (P < 0.002).

CONCLUSION

The results of this study suggest a preferred interval follow-up of approximately 4.5 months (127 days) for HCC screening. Small HCCs show a tendency toward faster growth and may require shorter follow-up to demonstrate progression.

Natural history of hepatitis C

Fifteen years after the discovery of the hepatitis C virus, a substantial amount of information has been learned about the natural history of infection. Testing for viral nucleic acid made it possible to accurately diagnose chronic infection and provided a more precise estimate of the overall frequency of viral persistence. Although cirrhosis and hepatocellular carcinoma can arise in persons with chronic hepatitis C, these outcomes do not always occur. The cirrhosis risk is greater in those who are infected at older ages, those who drink >50 g of alcohol each day, and persons coinfected with HIV. However, much of the person-to-person variability in progression of chronic hepatitis C remains unexplained. The ability to detect persons at highest risk of progression remains incomplete and represents an important future challenge in the understanding of the natural history of hepatitis C.

Bi-allelic presence of the interleukin-10 receptor 1 G330R allele is associated with cirrhosis in chronic HCV-1 infection

Immune response to viral infection is an important determinant of liver injury in chronic hepatitis C (CHC). Experimental and clinical data suggest a protective role of interleukin-10 (IL-10) in hepatic fibrogenesis. The significance of two SNPs of the interleukin-10 receptor 1 (IL-10R1), S138G (SNP3) and G330R (SNP4) was investigated on (i) susceptibility to CHC, (ii) progression of hepatic fibrosis and (iii) response to interferon/ribavirin therapy. DNA and liver biopsies were obtained from 212 patients with HCV (hepatitis C virus)-genotype-1 infection. The allele frequencies were 0.17 for SNP3 and 0.33 for SNP4, both of which were indifferent from healthy controls (0.17 and 0.32, respectively). Stage 1 liver fibrosis was found in 22 cases (10.4%), stage 2 in 108 (50.9%), stage 3 in 27 (12.8%), and stage 4 (cirrhosis) in 55 (25.9%). An association was found between the SNP4 allele and the presence of cirrhosis (P=0.01). Homozygous SNP4 individual variants segregated within the cirrhosis group (P=0.03). We found neither an association with SNP3 nor with the necroinflammatory disease activity (as measured by ALT levels) nor with the response to antiviral therapy. Our work implies that IL-10R1 SNP4 is a recessively inherited risk factor for hepatic cirrhosis in HCV genotype-1 infection.

Liver transplantation for malignancy

Liver transplantation for hepatic malignancies has emerged from an exotic and desperate approach to a well-documented and proven treatment modality for these unfortunate patients. However, early unsatisfactory results emphasized that only a highly selected patient population would benefit from transplantation. Currently, <10% of all liver transplants performed are for hepatocellular cancer (HCC). There is no controversy that hepatoblastoma is an excellent indication in pediatric patients with unresectable tumors. Similarly, liver transplantation for HCC in the adult population yields good results for patients whose tumor masses do not exceed the Milan criteria. It remains to be determined whether patients with more extensive tumors can be reliably selected to benefit from the procedure. Adjunctive procedures like radiofrequency ablation, chemoembolization, or cryotherapy might be indicated to limit tumor progression for patients on waiting lists. Epitheloid hemangioendothelioma is also an appropriate indication for liver transplantation, unlike angiosarcoma. Metastatic liver disease is not an indication for liver transplantation, with the exception of cases in which the primary is a neuroendocrine tumor, for which liver transplantation can result in long-term survival and even cure in a number of patients. And finally, while gallbladder cancers are never an indication for liver transplantation, rare cases of cholangiocellular cancer might qualify if aggressive combination therapies, including chemotherapy and radiotherapy followed by OLT, are carried through. Survival in these selected patients can approach that for patients with cholestatic liver disease.

Natural history of hepatocellular carcinoma

The natural history of hepatocellular carcinoma is variable. In many patients the tumor has a long-lasting subclinical incubation period and often grows as a solitary mass to a size at which it can be detected by ultrasound. In other patients, however, the onset of the tumor is multinodal with great variations in the growth rates. Prognostication of patients with hepatocellular carcinoma takes into account the size and number of tumor nodes and their relation to the portal veins, and the degree of liver impairment.

Viral hepatitis and hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in the world. The incidence of HCC varies considerably with the geographic area because of differences in the major causative factors. Chronic hepatitis B and C, mostly in the cirrhotic stage, are responsible for the great majority of cases of HCC worldwide. The geographic areas at the highest risk are South-East Asia and sub-Saharan Africa, here hepatitis B is highly endemic and is the main cause of HCC. In areas with an intermediate rate of HCC such as Southern Europe and Japan, hepatitis C is the predominant cause, whereas in low rate areas such as Northern Europe and the USA, HCC is often related to other factors as alcoholic liver disease. There is a rising incidence in HCC in developed countries during the last two decades, due to the increasing rate of hepatitis C infection and improvement of the clinical management of cirrhosis.

METHODS

This article reviews the literature on hepatitis and hepatocellular carcinoma. The Medline search was carried out using these key words and articles were selected on epidemiology, risk factors, screening, and prevention of hepatocellular carcinoma.

RESULTS

Screening of patients with advanced chronic hepatitis B and C with hepatic ultrasound and determination of serum alfa-fetoprotein may improve the detection of HCC, but further studies are needed whether screening improves clinical outcome. Hepatitis B and C viruses (HBV/HCV) can be implicated in the development of HCC in an indirect way, through induction of chronic inflammation, or directly by means of viral proteins or, in the case of HBV, by creation of mutations by integration into the genome of the hepatocyte.

CONCLUSION

The most effective tool to prevent HCC is avoidance of the risk factors such as viral infection. For HBV, a very effective vaccine is available. Preliminary data from Taiwan indicate a protective effect of universal vaccination on the development of HCC. Vaccination against HBV should therefore be a health priority. In patients with chronic hepatitis B or C, interferon-alfa treatment in a noncirrhotic stage is protective for HCC development in responders, probably by prevention of cirrhosis development. When cirrhosis is already present, the protective effect is less clear. For cirrhosis due to hepatitis B, a protective effect was demonstrated in Oriental, but not in European patients. For cirrhosis due to hepatitis C, interferon-alfa treatment showed to be protective in some studies, especially in Japan with a high incidence of HCC in untreated patients. Virological, but also merely biochemical response, seems to be associated with a lower risk of development of HCC. As most studies are not randomized controlled trials, no definitive conclusions on the long-term effects of interferon-alfa in HBV or HCV cirrhosis can be established. Especially in hepatitis C, prospective studies should be performed using the more potent reference treatments for cirrhotics, namely the combination of peginterferon and ribavirin.

[Hepatitis B and C virus infection and the hepatocellular carcinoma in the East Amazon, Brazil]

In order to contribute to a better understanding of the possible role of hepatits B and C in the etiopathogenis of HCC in the East Amazon, there were studied 36 patients in Belém/PA. Serological hepatitis markers were evaluated and polymerase chain reaction assays were used to detect HBV-DNA and HCV-RNA. Alcohol abuse was observed in 33.3% and cirrhosis in 83.3%. In 88.9% of the sample, one or more hepatitis B markers were positive. Also, 8.3% those patients had anti-HCV simultaneously positive. The HBsAg serological test was positive in 58.3%; anti-HBc in 86%; anti-HBe in 85.7%; anti-HBe in 9.5%; IgM anti-HBc in 57.1%. The HBV DNA was found in 37.7% and in 65% of the HBsAg positive. The HCV RNA was detected in 8.5% and in 100% of the patients positive to anti-HCV. The AFP was above the normal value in 88.9% of patients, with levels up to 400ng/ml in 75% of them. In conclusion, hepatitis B virus infection seems to be important in the etiology of HCC and improving measures such immunization and screening in the risk population should be emphasyzed.

Interferon-gamma-mediated hepatocarcinogenesis in mice treated with diethylnitrosamine

Hepatocarcinogenesis is a complex multifactorial process in which continuous intrahepatic inflammation plays a major role. Although inflammatory cell infiltration is observed in the process of chemical-induced hepatocarcinogenesis, the pathophysiological role of the inflammatory response is not well defined. To approach this question, molecular and cellular responses were monitored during the development of liver tumors in mice exposed to a chemical hepatocarcinogen, diethylnitrosamine (DEN), in drinking water (50 microg/l). Intrahepatic type I and type II interferon (IFN-beta and IFN-gamma, respectively) mRNA expression was found to be induced 2 months before the appearance of hepatocellular carcinomas. The pathogenetic importance of IFNs was determined by monitoring tumor development in mice genetically deficient in the IFN-alpha/beta receptor (IFN-alpha/betaR KO) or the IFN-gamma receptor (IFN-gammaR KO). IFN-gammaR KO mice developed fewer tumors than IFN-alpha/betaR KO and wild-type (wt) mice, although the tumor diameters did not differ significantly among the three lineages. Interestingly, immunohistochemical studies demonstrated that the percentage of monocytes/macrophages in infiltrating mononuclear cells was reduced greatly in the livers of IFN-gammaR KO mice, which is consistent with the facts that intrahepatic cytokine expression was diminished and oxidative DNA damage was induced to a lesser extent. In conclusion, type II IFN, but not type I IFNs, may be involved critically in the initiation stage, but not the promotion stage, of DEN-induced hepatocarcinogenesis by enhancing monocytes/macrophages activation and eventual hepatocyte DNA damage.

Cytokine gene polymorphisms in Japanese patients with hepatitis B virus infection--association between TGF-beta1 polymorphisms and hepatocellular carcinoma

BACKGROUND/AIMS

In this study, we determined the frequencies of the genotypes associated with the polymorphism of the cytokines genes, and investigated their association with the risk of hepatocellular carcinoma (HCC) in hepatitis B virus (HBV) carriers.

METHODS

Genetic polymorphism in the cytokines TNF-alpha, IFN-gamma, TGF-beta1, IL-6, and IL-10 were studied in 236 Japanese patients with HBV infection. The genetic polymorphisms of these cytokines were analyzed by polymerase chain reaction-sequence-specific primer (SSP).

RESULTS

There was no statistically significant difference in the genetic polymorphisms of TNF-alpha, IFN-gamma, and IL-10 genes between HBV carriers with HCC and those without HCC. However, the TGF-beta1+29 (codon 10) C/C genotype was lower in HBV carriers with HCC than in those without HCC (HCC 14.6% vs non-HCC 31.9%). The association of HCC was significantly lower in HBV carriers with C/C genotype than in those with T/C or T/T genotype in position +29 of the TGF-beta1 gene.

CONCLUSIONS

Our findings suggest that the genetic polymorphism in codon 10 of the TGF-beta1 gene may play a role in HCC development in patients with chronic HBV infection.

SELDI-TOF MS profiling of serum for detection of the progression of chronic hepatitis C to hepatocellular carcinoma

Proteomic profiling of serum is an emerging technique to identify new biomarkers indicative of disease severity and progression. The objective of our study was to assess the use of surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS) to identify multiple serum protein biomarkers for detection of liver disease progression to hepatocellular carcinoma (HCC). A cohort of 170 serum samples obtained from subjects in the United States with no liver disease (n = 39), liver diseases not associated with cirrhosis (n = 36), cirrhosis (n = 38), or HCC (n = 57) were applied to metal affinity protein chips for protein profiling by SELDI-TOF MS. Across the four test groups, 38 differentially expressed proteins were used to generate multiple decision classification trees to distinguish the known disease states. Analysis of a subset of samples with only hepatitis C virus (HCV)-related disease was emphasized. The serum protein profiles of control patients were readily distinguished from each HCV-associated disease state. Two-way comparisons of chronic hepatitis C, HCV cirrhosis, or HCV-HCC versus healthy had a sensitivity/specificity range of 74% to 95%. For distinguishing chronic HCV from HCV-HCC, a sensitivity of 61% and a specificity of 76% were obtained. However, when the values of known serum markers alpha fetoprotein, des-gamma carboxyprothrombin, and GP73 were combined with the SELDI peak values, the sensitivity and specifity improved to 75% and 92%, respectively. In conclusion, SELDI-TOF MS serum profiling is able to distinguish HCC from liver disease before cirrhosis as well as cirrhosis, especially in patients with HCV infection compared with other etiologies.

Comparing the outcomes of radiofrequency ablation and surgery in patients with a single small hepatocellular carcinoma and well-preserved hepatic function

GOALS

To compare the efficacy of radiofrequency ablation (RFA) and surgical resection in a group of patients with a Child-Pugh score of 5 and a single HCC less than 4 cm in diameter.

BACKGROUND

Radiofrequency ablation (RFA) has become a popular method for treatment of hepatocellular carcinoma (HCC) and has been applied as an alternative primary therapy to surgical resection.

STUDY

We compared outcomes for 148 patients treated with RFA (n = 55) and those treated surgically (n = 93).

RESULTS

The rate of local recurrence among patients in the RFA group was significantly higher than in the surgery group (P = 0.005), while the incidence of remote recurrence was similar between the two groups (P = 0.30). The cumulative 1- and 3-year overall survival rates (P = 0.24) and the cumulative 1- and 3-year recurrence-free survival rates (P = 0.54) were not significantly different between the two groups.

CONCLUSIONS

Despite a higher rate of local recurrence, RFA was found to be as effective as surgical resection for the treatment of single small HCC in patients with well-preserved liver function, in terms of the incidence of remote recurrence and the patients' likelihood of achieving overall and/or recurrence-free survival.

Alcohol in hepatocellular cancer

Hepatocellular cancer accounts for almost half a million cancer deaths a year, with an escalating incidence in the Western world. Alcohol has long been recognized as a major risk factor for cancer of the liver and of other organs including oropharynx, larynx, esophagus, and possibly the breast and colon. There is compelling epidemiologic data confirming the increased risk of cancer associated with alcohol consumption, which is supported by animal experiments. Cancer of the liver associated with alcohol usually occurs in the setting of cirrhosis. Alcohol may act as a cocarcinogen, and has strong synergistic effects with other carcinogens including hepatitis B and C, aflatoxin, vinyl chloride, obesity, and diabetes mellitus. Acetaldehyde, the main metabolite of alcohol, causes hepatocellular injury, and is an important factor in causing increased oxidant stress, which damages DNA. Alcohol affects nutrition and vitamin metabolism, causing abnormalities of DNA methylation. Abnormalities of DNA methylation, a key pathway of epigenetic gene control, lead to cancer. Other nutritional and metabolic effects, for example on vitamin A metabolism, also play a key role in hepatocarcinogenesis. Alcohol enhances the effects of environmental carcinogens directly and by contributing to nutritional deficiency and impairing immunological tumor surveillance. This review summarizes the epidemiologic evidence for the role of alcohol in hepatocellular cancer, and discusses the mechanisms involved in the promotion of cancer.

A novel display of reconstruction computed tomography for the detection of small hepatocellular carcinoma

PURPOSE

To evaluate the usefulness of the alternate display of arterial and equilibrium phase images (ADAEI) of 2 mm-pitch reconstruction computed tomography (CT) in the detection of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

One hundred and eleven nodules in 72 patients were confirmed as HCC by radiology, histology, or clinical course. Blinded to the outcome, we retrospectively reviewed the CT images obtained with dual-phase spiral CT (Radix Prima, Hitachi Medical, Tokyo, Japan) by ADAEI and by conventional display on cut films. Scanning for the arterial and equilibrium phases was initiated at 33 and 120 s, respectively, after starting the injection of contrast medium (iopamidol 3 ml/s) with a section thickness of 5 mm and a table feed speed of 5-7 mm/s. In ADAEI, all images were reconstructed with a 2-mm interval, and displayed on the monitor in an alternating fashion so that an image in the arterial phase was followed by the corresponding image in the equilibrium phase, and then by the next pair of images in the craniocaudal direction.

RESULTS

All 20 HCC nodules larger than 20 mm in diameter were detected by both ADAEI and the conventional display (NS). On the other hand, detectability of smaller HCC nodules was 91/91 (100%) and 72/91 (79%), respectively (P<0.0001 by McNemar' test). False-positively identified HCC nodules, including those diagnosed as possible HCC, were 11 by ADAEI and eight by conventional display.

CONCLUSION

The novel, alternate display, ADAEI of 2 mm-pitch reconstruction CT images was useful in detecting small HCC nodules while not requiring additional equipment or expense.

Alpha-fetoprotein and ultrasonography screening for hepatocellular carcinoma

Although there is no definitive evidence that hepatocellular carcinoma (HCC) screening in high-risk groups improves survival, many physicians screen high-risk populations with various strategies. alpha-fetoprotein (AFP) and liver ultrasonography (US) are the most widely used tools. AFP sensitivity and specificity depend on the cut-off value chosen. In cirrhotic patients, using a cut-off level of 20 ng/mL, sensitivity is only around 60% and positive predictive value ranges from 9% to 50%, depending on HCC prevalence. Sensitivity and specificity are much higher (94.1% and 99.9%, respectively) in hepatitis B carriers, but positive predictive value is only 5%. The performance of US as a screening tool varies widely depending on the experience of the examiner and the technology used. Recent studies generally indicate a 60% sensitivity or higher, a specificity greater than 90%, and a positive predictive value of 70%. The cost effectiveness of screening strategies using AFP, US, or both have been estimated retrospectively or using decision models. In general, HCC screening using both AFP and US appears to be of borderline cost effectiveness or not cost effective at all. Based on the estimated HCC doubling time, the recommended screening interval is 6 months, although a 1-year interval seems as effective. Currently, HCC screening with AFP only is not recommended except when US is either not available or of poor quality. US seems more efficient as a screening tool. Pathology assessment of liver explants in living-donor transplantation programs will provide more precise and reliable information regarding the value of AFP and US as HCC screening tools.

Hepatocellular carcinoma: recent trends in Japan

During the past 20 years, primary liver cancer, 95% of which is hepatocellular carcinoma (HCC), has ranked third in men and fifth in women as a cause of death from malignant neoplasm in Japan. The numbers of deaths and death rate from HCC showed a sharp increase beginning in 1975. Although both hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are important causes, HCV-related HCC has accounted for most of the recent increase and now represents 75% of all HCC in Japan. Geographically, HCC is more frequent in western than eastern Japan, and the death rate of HCC in each prefecture correlates with prevalence of anti-HCV. Among patients with HCV-related HCC, a history of blood transfusion was a relatively important source of infection in the 1990s, whereas community-acquired infections increased after 2000. There was a negative correlation between the duration from onset of infection to development of HCC and the age at onset. Interferon therapy for chronic hepatitis C has reduced the risk for HCC, indicating that early detection of HCV carriers and better treatment will contribute to improved outcomes. Nationwide screening for HCV and HBV began in 2002 in Japan, and reduction of HCC is anticipated. Further research should focus on mechanisms of carcinogenesis by HCV and HBV, development of more effective treatments, and establishment of early detection and treatment approaches. Better understanding of HCC unrelated to HCV and HBV and possibly because of steatohepatitis and diabetes should also be a major concern in future studies.

Treatment of hepatocellular carcinoma with percutaneous radiofrequency ablation: usefulness of contrast harmonic sonography for lesions poorly defined with B-mode sonography

OBJECTIVE

The purpose of this study was to assess the usefulness of contrast harmonic sonography guidance in percutaneous radiofrequency ablation of hepatocellular carcinomas that could not be adequately depicted by B-mode sonography. SUBJECTS AND METHODS. Twenty-one patients with 21 hepatocellular carcinomas prospectively underwent radiofrequency ablation treatment with contrast harmonic sonography as guidance. Twenty-five patients with 25 hepatocellular carcinomas were retrospectively selected as the historical control group under the same conditions as the study group; the control group patients were treated under B-mode sonography guidance.

RESULTS

Twenty (95.2%) of the 21 patients were successfully treated during a single treatment session, and the remaining patient (4.8%) required two treatment sessions with contrast harmonic guidance. On the other hand, only eight (32%) of the 25 control subjects were successfully treated during a single treatment session using B-mode sonographic guidance without contrast imaging. The difference between these two groups was statistically significant (p = 0.002).

CONCLUSION

Contrast harmonic sonography helps in the placement of radiofrequency ablation electrodes in hypervascular hepatocellular carcinomas that cannot be adequately depicted by B-mode sonography.

Prognostic features and survival of inoperable hepatocellular carcinoma in Turkish patients with cirrhosis

BACKGROUND

Primary hepatocellular carcinoma (HCC) is common in Turkey and its prognosis is poor. In the current study the authors analyzed the prognostic factors and survival in Turkish patients with inoperable HCC with cirrhosis.

METHODS

Clinical and demographic data of 91 patients consecutively admitted to the authors' institute from 1988 to 2000 were reviewed. A univariate analysis was performed using the Kaplan-Meier method to identify predictors of survival and were compared using the Mantel log-rank test. Independent factors correlated with survival were determined using the Cox regression analysis.

RESULTS

Cirrhosis was diagnosed in all patients. Coinfections with HCV and HBV were not observed. Overall median survival was 16.9 months. On univariate analysis, poor performance status (Eastern Cooperative Group); high alpha-fetoprotein (AFP); low albumin; high bilirubin; high alkaline phosphatase; high lactic dehydrogenase; high alanine and aspartate aminotransferase; high gamma-glutamyl transpeptidase; high platelet count; low prothrombin activity; hepatitis B surface antigen positivity; the presence of ascites, encephalopathy, and portal vein thrombosis; poor differentiation and diffuse type of tumor; and no treatment were associated with shorter survival. Multivariate analysis showed that only independent risk factors were related to performance status (Eastern Cooperative Group) at initial presentation and with pathologic characteristic of the tumor: abnormal AFP level.

CONCLUSION

HCC occurred only in patients with liver cirrhosis. Survival time can be predicted from information collected by the physician at the initial assessment.

Systematic review of radiological imaging for hepatocellular carcinoma in cirrhotic patients

We systematically reviewed the evidence for determining the best radiological imaging for characterizing hepatocellular carcinoma (HCC) in cirrhotic patients in 997 articles between 1995 and 2001. We selected only prospective and retrospective cohorts of patients, excluding both case reports and studies without separate data on HCC. Only 29 studies, comprising 918 patients, fulfilled the inclusion criteria: 10 used the explanted liver as the reference standard of diagnosis. All except one, either found no statistically significant difference between imaging modalities or had no direct comparison of sensitivity between different modalities of imaging; 16 studies evaluated HCC among cirrhotic patients and had biopsy or imaging as the reference standard for diagnosis. However, no one imaging technique was shown to be superior. In two studies, data of a HCC subgroup was derived from the studies evaluating different kinds of focal hepatic lesions. No conclusion could be drawn because of the small sample size. One study addressed the issue of therapeutic impact. The evidence for choosing the best modality of imaging for characterizing HCC in cirrhotic patients is inadequate. Large multicentre studies with defined reference standards for diagnosis, and studies evaluating therapeutic impact are needed.

Successful treatment of hepatocellular carcinoma with the tyrosine kinase inhibitor imatinib in a patient with liver cirrhosis

Several mechanisms of development of hepatocellular carcinoma (HCC) in patients with liver cirrhosis have been discussed. One hypothesis suggests that the somatic stem cells of the liver, the so-called oval cells, may undergo malignant transformation. Oval cells are derived from the biliary cells of the canal of Hering and are characterized by c-kit-positivity, the transmembrane receptor of stem cell factor. Constitutively activated tyrosine kinases have been identified as major pathogenetic mechanisms in the development of malignant diseases like gastrointestinal stromal tumors (c-kit) and chronic myelogenous leukemia (bcr-abl). The prognosis of these diseases improved enormously since the drug imatinib, a tyrosine kinase inhibitor of c-kit and bcr-abl, was introduced. Here we report the successful cure of a patient with liver cancer by this tyrosine kinase inhibitor.

Systemic therapy for advanced hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is a common cause of cancer mortality worldwide. Whilst local treatments are useful in selected patients, they are not suitable for many with advanced disease. Here, we review phase II and III trials for systemic therapy of advanced disease, finding no strong evidence that any chemotherapy, hormonal therapy, or immunotherapy regimen trialled to date benefits survival in this setting. Many trials were inadequately powered, single centre, and enrolled highly selected patients. From this review, we cannot recommend any therapeutic approach in these patients outside of a clinical trial setting. Including an untreated control arm in clinical trials in HCC is still justified. Every effort should be made to enroll these patients into adequately powered trials, and promising phase II results must be tested in a multicentre phase III setting, preferably against a placebo control arm. Prevention of hepatitis B and C remains vital to decrease deaths from HCC.

New serum biomarkers for detection of HBV-induced liver cirrhosis using SELDI protein chip technology

AIM

To find new serum biomarkers for liver cirrhosis (LC) in chronic carriers of hepatitis B virus (HBV).

METHODS

Surface enhanced laser desorption/ionization time-of-flight (SELDI-TOF) mass spectrometry was used to discover biomarkers for differentiating HBV induced LC from non-cirrhotic cohorts. A training population of 25 patients with HBV-induced LC, 20 patients with HCC, and 25 closely age-matched healthy men, was studied.

RESULTS

Two biomarkers with M(r) 7 772 and 3 933 were detected in sera of non-cirrhotic cohorts, but not in patients with HBV-induced LC. A sensitivity of 80% for all LC patients, a specificity of 81.8% for all non-cirrhotic cohorts and a positive predictive value of 75% for the study population were obtained.

CONCLUSION

These two serum biomarkers for HBV-induced LC might be used for diagnosis and assessment of disease progression.