Hepatocellular carcinoma in Italian patients with cirrhosis

Mutations in the HFE gene and their interaction with exogenous risk factors in hepatocellular carcinoma

The possible role of iron in facilitating the development of liver cancer is still debated. The aims of this study were to define the prevalence of the mutations 845G --> A and 187C --> G (C282Y and H63D) in the HFE gene associated with hereditary hemochromatosis in Italian patients with hepatocellular carcinoma occurring in cirrhosis and to analyze the interaction between these mutations and other established risk factors for hepatocellular carcinoma. The HFE gene mutations, performed by polymerase chain reaction, were analyzed in 81 patients (63 males, 18 females) with hepatocellular carcinoma. None of the patients had a phenotype compatible with homozygous hereditary hemochromatosis. Interaction between HFE mutations and exogenous risk factors was analyzed by collecting information on alcohol consumption, hepatitis B and C virus infections, and iron status at the time of diagnosis of chronic liver disease. This analysis was performed only in males to rule out gender influence on patients' iron status by using the case-only approach specifically designed to estimate departure from multiplicative risk ratios under the assumption of independence between genotype and environmental exposure. The prevalence of the C282Y mutation was significantly higher in patients with hepatocellular carcinoma than in normal controls (8.6% vs 1.6%, P < 0.03). At univariate analysis, iron overload was significantly associated with both HFE mutations (P < 0.0001), whereas ongoing hepatitis B virus infection was associated with the C282Y mutation (P < 0.05). By multivariate analysis, a trend for an increased risk of being positive for hepatitis virus markers (OR 2.9, CI 95% 0.9-9.5) and of having been alcohol abusers (OR 3, CI 95% 0.7-14) was observed in patients heterozygous for the HFE mutations. These data indicate that the prevalence of the main mutation associated with hereditary hemochromatosis is significantly higher in cirrhotic Italian patients with hepatocellular carcinoma compared to a normal population and suggest that heterozygotes for HFE mutations exposed to hepatitis virus infections or who had been alcohol abusers could have an increased risk of developing cirrhosis and later liver cancer than people without the mutations exposed to the same risk factors.

Primary liver tumors

Many improvements have been made in the treatment of primary liver tumors, especially in hepatocellular carcinoma. Partial hepatectomy still remains the mainstay of therapy for resectable tumors, and it offers the potential of a cure. Total hepatectomy and liver transplantation may be applicable in selected patients. Palliative resection and tumor debulking operations are beneficial for some malignant tumors. Local ablative therapy can be tried on patients with small tumors who are not suitable candidates for open resectional surgery because of serious associated medical diseases or because of poor liver function. For patients with advanced malignancy, new treatment modalities in the form of hepatic artery transcatheter treatment or systemic therapy are on the horizon. Some of these treatment options show very promising results. Properly conducted randomized studies are required to evaluate these new treatment modalities, as well as those older treatment modalities for which there is insufficient data to determine their actual role in the management of patients with liver cancer.

Screening for cancer in viral hepatitis

Early diagnosis of HCC is possible because certain risk factors for this tumor are known and because sensitive and relatively inexpensive diagnostic tools are available. Early diagnosis of HCC is also possible because of the long phase of asymptomatic tumor growth and the tumor's tendency to grow as a solitary mass in many patients. In two consensus development conferences held in Anchorage, Alaska and in Milan, Italy, chronic carriers of HBsAg, patients with cirrhosis, patients with rare metabolic liver diseases, and individuals with family histories of HCC were identified as patients at high risk for HCC and therefore as candidates for periodic screening. At the Anchorage conference, it was recommended that healthy carriers have at least yearly determinations of serum AFP and that carriers with additional risk factors (e.g., cirrhosis) be screened every 6 months by abdominal US scans and determination of serum AFP levels. No specific recommendations were released for HBsAg-negative patients with chronic liver disease. At the Milan conference, it was recommend that patients with cirrhosis or with certain congenital metabolic conditions known to be at risk for HCC should be screened by AFP determination and US scan twice a year. It was also recommended that HBsAg carriers older than 35 years or with family histories of HCC should be screened for HCC by determinations of serum AFP levels and aminotransferase levels once a year.

Nonsurgical treatment of hepatocellular carcinoma

Given the poor prognosis of HCC and the therapeutic challenge posed by underlying liver cirrhosis, efforts and resources must be directed towards preventive strategies. Return on the investment in such research is likely to be greater than can be expected from treatment of advanced disease.

Epidemiology of hepatocellular carcinoma

The epidemiology of hepatocellular carcinoma (HCC) is characterized by marked differences between genders, ethnic groups, and geographic regions. These variations are explained by the nature, frequency, and time of acquisition of the major risk factors for cirrhosis--namely hepatitis B virus, hepatitis C virus (HCV), and alcoholic cirrhosis. The incidence and mortality of HCC has been rising in the US over the last two decades and is progressively affecting younger persons. The evidence indicates that HCV infection is responsible for the current trends.

Diagnosis and monitoring of hepatic injury. II. Recommendations for use of laboratory tests in screening, diagnosis, and monitoring

Purpose: To review information on the use of laboratory tests in screening, diagnosis, and monitoring of acute and chronic hepatic injury.

Data Sources and Study Selection: A MEDLINE search was performed for key words related to hepatic diseases, including acute hepatitis, chronic hepatitis, alcoholic hepatitis, cirrhosis, hepatocellular carcinoma, and etiologic causes. Abstracts were reviewed, and articles discussing use of laboratory tests selected for review. Additional articles were selected from the references.

Guideline Preparation and Review: Drafts of the guidelines were posted on the Internet, presented at the AACC Annual Meeting in 1999, and reviewed by experts. Areas requiring further amplification or literature review were identified for further analysis. Specific recommendations were made based on analysis of published data and evaluated for strength of evidence and clinical impact.

Recommendations: Although many specific recommendations are made in the guidelines, only some summary recommendations are listed here. In acute hepatic injury, prothrombin time and, to a lesser extent, total bilirubin are the best indicators of severity of disease. Although ALT is useful for detecting acute and chronic hepatic injury, it is not related to severity of acute hepatic injury and only weakly related to severity of chronic hepatic injury. Specific tests of viral markers should be the initial differential tests in both acute and chronic hepatic injury; when positive, they are also useful for monitoring recovery from hepatitis B and C.

Prognostic features and survival of hepatocellular carcinoma in Italy: impact of stage of disease

The aim of this study was to evaluate the prognostic factors at presentation and survival in Italian patients with hepatocellular carcinoma (HCC). Clinical and demographic data of 176 patients consecutively observed from 1993 to 1997 were evaluated by univariate and multivariate analyses. Overall median survival was 18 months. At univariate analysis, low albumin, high bilirubin, high alkaline phosphatase, high alpha-fetoprotein (AFP); high platelet count, hepatitis B surface antigen (HBsAg)-positivity, the presence of ascites, of encephalopathy, of portal vein thrombosis (PVT), male sex, no treatment, poor differentiation, untreatable tumours and incidental diagnosis were each associated with shorter survival. HBsAg-positive subjects more often presented with untreatable lesions or diffuse tumours (P=0.001 and P=0.007, respectively) and had significantly worse survival (P=0.0057). By multiple regression analysis, low albumin, high bilirubin, abnormal AFP, presence of PVT and of untreatable lesions were independent risk factors for worse survival. Thus, the most important factors influencing survival are the degree of functional impairment of the liver, the presence of hepatitis B viral (HBV) infection, the type of diagnosis and the aggressiveness of the tumour.

Early diagnosis and treatment of hepatocellular carcinoma

The incidence of hepatocellular carcinoma is increasing world-wide. Although there are no randomized controlled trials showing benefits from surveillance programmes, these strategies have been widely practised by hepatologists, and most early tumours are diagnosed in the setting of such a policy. In this chapter we summarize the surveillance schedule and recall the policy applied in our Unit. Diagnosis at an early stage is crucial to allow the application of curative treatments that are the only hope for increasing the life expectancy of the patient. Surgical resection and liver transplantation are considered the first-line options for early tumours, although there is no agreement on which is the best approach. Resection is limited by the high recurrence rate, whereas the increasing waiting times have decreased the intention-to-treat outcomes of transplantation. Percutaneous treatments are reserved for patients with single non-surgical tumours. Clinical trials assessing treatments for patients with advanced tumours have not shown any survival benefits.

Increasing incidence and pretransplantation screening of hepatocellular carcinoma

The incidence of hepatocellular cancer (HCC) in the United States and other traditionally "low-incidence" countries is increasing. 2. The rise in incidence of HCC is related to chronic hepatitis C. 3. Timely performance of liver transplantation is curative in patients with early-stage HCC. 4. Cirrhotic patients, especially those with viral hepatitis, should be screened for HCC. 5. The performance characteristics of current tests are suboptimal, but serial ultrasonography and alphafetaprotein are recommended. 6. Estimated medical charges related to screening and treatment suggest that $285,294 is required per "cured" case. Assuming that this cure is associated with a 75% to 85% chance for high-quality 10-year survival, the charges approximate $35,000 to $40,000/quality-adjusted life-year (QALY). This cost-benefit analysis is nearly identical to published rates for breast cancer screening ($30,000/QALY).

Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study

The benefits of screening hepatitis B surface antigen (HBsAg)-positive carriers for hepatocellular carcinoma (HCC) in terms of long-term survival have not been established. We conducted a prospective 16-year, population-based cohort study to determine the impact of screening for HCC in 1,487 HBsAg-positive Alaska native carriers with alpha-fetoprotein (AFP) determinations every 6 months. Men and nonpregnant women with an elevated AFP level were evaluated for the presence of HCC by ultrasound (US) examination. The long-term survival rate for patients whose HCC was detected by the screening program was compared with a historical control group of Alaska native patients with HCC from the same population who were clinically diagnosed with HCC between 1969 and October 1982, through a National Cancer Institute-sponsored Cancer Registry. Between October 1982 and December 1998, 26,752 AFP determinations in HBsAg carriers were performed. One or more AFP elevations were found in 61 men and 39 nonpregnant women. HCC was diagnosed in 32 patients (24 men and 8 women). HCC tumors less than 6 cm were found in 23 patients; 22 patients had resections, and 1 patient refused a resection. Compared with 12 patients with hepatitis B virus (HBV)-related HCC diagnosed from 1969 to October 1982, before this program, the 5- and 10-year survival rate for the 32 patients with HCC were 42% (P =.008) and 30% (P =.07), respectively. Five- and 10-year tumor-free survival rates for carriers who had a normal AFP level on initial screening and subsequently developed HCC were 29% (P =.004) and 24% (P =.024), respectively. Screening of HBsAg carriers with semiannual AFP was effective in detecting most HCC tumors at a resectable stage and significantly prolonged survival rates when compared with historical controls in this population.

Can large cell change and high proliferative activity predict hepatocellular carcinoma in patients with hereditary hemochromatosis?

OBJECTIVE

Patients with hereditary hemochromatosis are at high risk of developing hepatocellular carcinoma. This study was undertaken to define whether large cell change and nucleolar organizer regions proliferative index (marker of high proliferative activity) predict hepatocellular carcinoma development in hereditary hemochromatosis.

METHODS

Histological staining for large cell change and high proliferative activity were done on baseline liver biopsies of 74 patients with hereditary hemochromatosis (52 with and 22 without cirrhosis), prospectively followed-up for 83 +/- 53 months (range, 1-230 months).

RESULTS

Large cell change and high proliferative activity were found only in cirrhotic patients; 16 of 52 patients (31%) had either the large cell change or high proliferative activity. Large cell change was more frequent in patients with hepatitis B surface antigen than in those positive for hepatitis C virus (57% vs 14%, p = 0.04). Hepatocellular carcinoma developed in 7 of 16 (44%) and in 6 of 36 patients (16%) of the patients positive or negative for these morphological variables. The probability of developing hepatocellular carcinoma at 7 yr of follow-up was significantly higher in patients with large cell change or high proliferative activity than in those without. The length of follow-up from baseline histology to hepatocellular carcinoma occurrence was shorter in patients with large cell change or high proliferative activity than in those without these changes (46 +/- 36 and 109 +/- 34 months, p = 0.01). A multivariate analysis indicated that in patients with cirrhosis, large cell change or high proliferative activity (considered as a single variable), and age >55 yr were the only independent variables significantly associated with the risk of developing hepatocellular carcinoma, with a risk ratio of 4.8 (confidence interval 1.2-18.2) and 4.0 (confidence interval 1.1-15.6), respectively.

CONCLUSIONS

In hereditary hemochromatosis, the presence of large cell change or high proliferative activity in patients older than 55 yr with cirrhosis should be considered a strong predictor of hepatocellular carcinoma development, especially if hepatitis B virus infection coexists.

Transplantation for liver and biliary cancer

The early survival of patients transplanted for liver and biliary cancer is excellent, but the overall mid- to long-term survival is poor. In an era of severe donor organ shortage, it is not justified to allocate donor liver to patients with a suboptimal outcome. Patients with non-resectable hepatocellular carcinoma in a non-cirrhotic liver should not be assigned to liver transplantation. Although patients with the fibrolamellar variant have a somewhat better outlook, they are still likely to recur, and the young age of many of these patients is likely to overwhelm any rational approach. The results of transplantation for early-stage hepatocellular carcinoma in a cirrhotic liver are similar to those achieved with benign disease. The inclusion of such cases as a group is justified, but attempts should be made to resect tumors whenever possible and to not assign the entire group to transplantation as the first and only option. The value of pre- and postoperative adjuvant therapy for this group is still under debate, but the present waiting period is so long that some form of therapy to slow growth and prevent dissemination of tumor cells is probably required. The results following transplantation for cholangiocarcinoma can only be regarded as dismal, and the diagnosis of cholangiocarcinoma is a contraindication for the procedure. Liver transplantation has a definite place in the treatment of epithelioid hemangioendothelioma and unresectable chemo-responsive hepatoblastoma when confined to the liver, and in a limited number of metastatic neuroendocrine tumors.

Prevalence and prognostic value of hepatocellular carcinoma in cirrhotic patients presenting with spontaneous bacterial peritonitis

BACKGROUND/AIMS

This study examined the prognostic power of hepatocellular carcinoma in patients presenting an episode of spontaneous bacterial peritonitis treated with 3rd generation cephalosporins or quinolones, and subsequent prophylaxis with norfloxacin until death or transplantation.

METHODS

The study comprises the prospective evaluation of 168 consecutive cirrhosis patients presenting an episode of spontaneous bacterial peritonitis.

RESULTS

Hepatocellular carcinoma was diagnosed in 35 out of the 168 (20%) patients included in the study (10 single; 25 advanced tumors). Renal impairment developed in 82 patients. Resolution of infection was achieved in 90% of the cases, the hospital survival being 70%. Renal impairment, advanced tumor stage, albumin, and GGT showed independent prognostic value for hospital mortality. At the end of follow-up 101 patients had died, the 1- and 2-year survival being 36% and 31%, respectively. Four variables independently predicted survival: advanced tumor (OR: 3.9; p=0.00001), renal impairment (OR: 2.1; p=0.00001), bilirubin (OR: 1.6; p=0.02) and creatinine (OR: 1.3; p=0.03). Advanced tumor retained independent predictability in patients surviving hospitalization (OR: 7.5; p=0.0001), the 6-month survival being significantly lower in patients with advanced tumor (12% vs 57%, p<0.00001).

CONCLUSION

The prevalence of hepatocellular carcinoma in cirrhotic patients with spontaneous bacterial peritonitis is high, and its presence should be actively sought. Advanced tumor impairs both hospital and long-term survival, and should be considered in the design of future trials.

Primary liver tumors

Many improvements have been made in the treatment of primary liver tumors, especially in hepatocellular carcinoma. Partial hepatectomy still remains the mainstay of therapy for resectable tumors, and it offers the potential of a cure. Total hepatectomy and liver transplantation may be applicable in selected patients. Palliative resection and tumor debulking operations are beneficial for some malignant tumors. Local ablative therapy can be tried on patients with small tumors who are not suitable candidates for open resectional surgery because of serious associated medical diseases or because of poor liver function. For patients with advanced malignancy, new treatment modalities in the form of hepatic artery transcatheter treatment or systemic therapy are on the horizon. Some of these treatment options show very promising results. Properly conducted randomized studies are required to evaluate these new treatment modalities, as well as those older treatment modalities for which there is insufficient data to determine their actual role in the management of patients with liver cancer.

Natural history of inoperable hepatocellular carcinoma: estrogen receptors' status in the tumor is the strongest prognostic factor for survival

Clinical course in hepatocellular carcinoma may be very different. We prospectively evaluated 96 patients with hepatocellular carcinoma unsuitable for radical therapy to investigate factors that could influence survival. Clinical, pathologic, and molecular data of patients were analyzed by univariate and multivariate analysis. The overall actuarial probability of survival at year 1, 2, 3, 4, 5, and 6 was 72%, 41%, 38%, 24%, 20%, and 9%. At univariate analysis, alpha-fetoprotein (AFP) (P =.0082); alkaline phosphatase (P =.0281); bilirubin (P =.0076); etiology (P =.0001); increment of tumor mass at month 3 (P =.0051); type of estrogen receptor (ER) in the tumor (P =.0000); prothrombin time (P =.0003); and portal vein thrombosis (P =.0000) had prognostic significance. At multivariate analysis, only type of ER (P =.0000) and bilirubin (P =.0030) showed independent predictive value for mortality. Survival was significantly longer in patients with wild-type estrogen receptors (P =.0000). Cumulative probability of survival at year 1, 2, 3, 4, 5, and 6 was 94%, 66%, 52%, 43%, 35%, and 18% for wild-type and 51%, 21%, 16%, and 9% for variant estrogen receptors (no patients alive after 4 years). Hepatitis B surface antigen (HBsAg)-positive patients with variant ERs had a median survival of 8 months versus 45 months in anti-hepatitis C virus-positive patients with wild-type ERs (P =.0001). In conclusion, (1) the presence of variant liver ER transcripts in the tumor was the strongest negative predictor of survival in inoperable hepatocellular carcinoma; (2) their presence was associated with spontaneous survival significantly worse than in patients with wild-type estrogen receptors; and (3) HBsAg-positive patients with variant receptors were characterized by the worst survival.

The current status of liver transplantation for primary hepatic malignancy

Several advances have been achieved during the last years in the management of patients with liver cancer. The refinement of the imaging techniques and the better knowledge of the biology of this neoplasm have facilitated the establishment of useful criteria to select patients for transplantation. Following a strict selection policy (solitary tumors < or = 5 cm or up to 3 foci each one < or = 3 cm) patients with liver cancer may achieve the same survival as nonneoplastic subjects. Currently, the main problem is how to diminish the risk of tumor progression while waiting for a liver. Although at present the benefits of invasive treatments are ill-defined, the ongoing studies exploring new treatment options hopefully will succeed in preventing this complication and further improve the current results.

Prevalence of anti-hepatitis C virus antibody and chronic liver disease among atomic bomb survivors

To investigate whether exposure to atomic bomb radiation altered the prevalence of hepatitis C virus (HCV) infection or accelerated the progress toward chronic hepatitis after HCV infection, the seropositivity of antibody to hepatitis C virus (anti-HCV) was determined for 6,121 participants in the Adult Health Study of atomic bomb survivors in Hiroshima and Nagasaki. The seropositivity of anti-HCV antibody was 2.5 times higher among those with a history of blood transfusion and 1.2 times higher among those with a family history of liver disease, whereas acupuncture showed no association with anti-HCV. Although the prevalence of anti-HCV was lower for survivors with positive dose estimates than for those with 0 dose (relative prevalence 0.84, P = 0.022), there was no evidence of a smooth dose-response relationship. However, these data suggested that the radiation dose response for chronic liver disease among HCV antibody-positive survivors may be greater than that among HCV antibody-negative survivors (slope ratio 20). In conclusion, no dose-response relationship was found between anti-HCV positivity and radiation dose; a possible increase in the radiation dose response of chronic liver disease among anti-HCV-positive individuals was found. Thus radiation exposure may accelerate the progress of chronic liver disease associated with hepatitis C virus infection.

Sensitivity of commonly available screening tests in detecting hepatocellular carcinoma in cirrhotic patients undergoing liver transplantation

OBJECTIVE

Recognition of hepatocellular carcinoma (HCC) is important in the management of patients awaiting liver transplantation. HCCs >5 cm in diameter are at high risk to recur after transplant. The goal of this study was to assess the sensitivity of the diagnostic tests employed in a pretransplant screening program.

METHODS

The study is a retrospective analysis of charts of 106 consecutive adults transplanted over a 1-yr period. All patients had ultrasonography (US), computerized tomography (CT), and serum alpha fetoprotein (AFP) testing within 6 months of transplantation. Radiographic reports were subdivided into low-risk and high-risk groups, based upon level of suspicion for HCC. The results were compared to explant pathology.

RESULTS

Pathological analysis of 106 explants revealed HCC in 19 patients. High-risk US exams had a positive predictive value (PPV) of 0.69 and a negative predictive value (NPV) of 0.91 in the diagnosis of HCC. High-risk CT exams had a PPV of 0.67 and an NPV of 0.90. When patients had either a high-risk US or a high-risk CT, there was a PPV of 0.59 and an NPV of 0.83. Of the 19 patients with HCC, three had high-risk US and low-risk CT; two had high-risk CT and low-risk US. Four patients, all with HCC <4 cm, had low-risk US, CT, and serum AFP.

CONCLUSIONS

US, CT, and serum AFP, as single tests, are insensitive for detection of HCC in the cirrhotic liver. However, they are highly specific. Sensitivity and specificity for US are comparable to those for CT. Given its lower cost, US is preferable to CT for routine screening of HCC in patients with end-stage liver disease undergoing liver transplantation.

Long-term effects of interferon therapy on histology and development of hepatocellular carcinoma in hepatitis C

Chronic hepatitis C is a common disease that slowly progresses to cirrhosis and eventually to hepatocellular carcinoma (HCC). Histology offers an important insight into disease prognosis and treatment response. Biochemical and virological responses to interferon (IFN) therapy are associated with an improvement in liver histology during and shortly after treatment, but the impact of treatment on the history of a slowly progressive disease cannot be ascertained by evaluating results at the completion of treatment. Some recent studies showed that the severity of hepatic inflammation may be a major factor driving progression of chronic hepatitis C to cirrhosis, and that improving hepatic inflammation may be associated with regression or retardation of fibrosis, especially in patients with virological sustained response. Many recent studies have shown an inhibition of the development of decompensation and HCC after IFN therapy, but a randomized controlled study using a large number of subjects with a more than 5-year observation period will be required to elucidate the exact role of antiviral therapy for the delay of decompensation or suppression of HCC.

Predictors of the efficacy of interferon therapy for patients with chronic hepatitis C before and during therapy: how does this modify the treatment course?

Antiviral therapy for hepatitis C virus (HCV) infection should be based on the natural history of HCV infection; there is a sequential, but slow, progression from chronic hepatitis to cirrhosis, leading to death from either liver failure or hepatocellular carcinoma (HCC). The risk of HCC development increases in association with the advance of fibrosis, and antiviral therapy can reduce this risk. More than 30 indices have been proposed as 'predictors' of favourable response to IFN therapy: host factors (age, gender, duration of HCV-infection, alcohol intake, hepatic iron stores, platelet count, histological staging of the liver disease), viral factors (HCV RNA levels in serum, HCV subtype, diversity of the hypervariable region, mutation of non-structure 5A gene), and IFN factors (dose, duration of treatment, type, treatment regimens i.e. every day vs three times a week, escalating dose regimen). Before starting IFN therapy, HCV subtype and pretreatment HCV RNA load, as well as the fibrotic stage of the liver, should be determined. The response to IFN therapy should be monitored by the HCV RNA status in serum during therapy, and the treatment regimen modified, or discontinued as required. A sustained virological response should be checked at more than 3 months after the completion of therapy. Even though the risk of HCC is markedly reduced in sustained responders, it is possible to develop HCC several years after completion of IFN therapy.

Cost-effectiveness analysis of lamivudine for the treatment of chronic hepatitis B

OBJECTIVE

To estimate the short term and long term cost effectiveness, from a healthcare perspective, associated with the introduction of lamivudine for chronic hepatitis B.

DESIGN

The analysis used a 2-step modelling approach. A decision tree was used to estimate clinical outcomes and costs after 1 year. The 1-year results were then extrapolated to 70 years using a Markov model.

PATIENTS

The study population comprised hypothetical cohorts of patients with chronic hepatitis B, representative of those likely to receive treatment in clinical practice in Australia.

MAIN OUTCOME MEASURES AND RESULTS

In the short term, more patients sero-converted when lamivudine was available, with an incremental cost-effectiveness ratio of 3341 Australian dollars ($A) per additional seroconversion. In the long term, the introduction of lamivudine increased life expectancy by 3.9 years [3.2 quality-adjusted life-years (QALYs)] compared with when interferon-alpha was the only treatment, or 4.6 years (3.8 QALYs) compared with no treatment. There were reductions in lifetime risk of developing compensated cirrhosis, decompensated cirrhosis and hepatocellular carcinoma of 5, 11 and 11%, respectively, when lamivudine was available. The incremental cost of having lamivudine available, as opposed to interferon-alpha only, was $A633 per year of life saved or $A735 per QALY.

CONCLUSION

The introduction of lamivudine is expected to reduce and delay the progression of chronic hepatitis B, increasing the life expectancy and quality of life of patients for a small overall increase in healthcare costs.

Interferon Therapy in Liver Cirrhosis Type C

Objective:

To review current information on the role of interferon (IFN) therapy in patients with liver cirrhosis type C.

Data Sources:

All relevant articles from 1989 to December 1998 were identified by a MEDLINE search using the terms interferon treatment and liver cirrhosis. Some studies were identified from bibliographies of selected articles.

Study Selection:

More than 97 articles were identified. Reports were included if they contained new or relevant information on the hepatitis C virus (HCV), IFN therapy in liver fibrosis and cirrhosis, outcome of cirrhosis, hepatocellular carcinoma (HCC), or adverse effects related to IFN. Abstracts were included only when they added information not otherwise available in the literature.

Data Synthesis:

Response to IFN is unfavorably influenced by the presence of cirrhosis; there are several other predictors of response. IFN therapy can decrease the risk of development of HCC in some patients. In patients with compensated cirrhosis type C, a higher dosage of IFN-alfa and longer duration of therapy are associated with a better response. Combined therapy with IFN-alfa 2b and ribavirin is more effective than therapy with IFN-alfa alone. Therapy with human lymphoblastoid IFN (L-IFN) produces sustained response rates equivalent to those of recombinant IFN-alfa. Consensus IFN (CIFN) is more effective than IFN-alfa 2b. Larger dosages of CIFN are associated with better results. Normal alanine transaminase concentration and the absence of serum HCV RNA after treatment and again after 24 weeks of observation indicate a successful end point of IFN therapy. Adverse effects related to IFN treatment are usually minor.

Conclusions:

Although the presence of cirrhosis predicts a poor response to IFN treatment, some patients benefit from this therapy. Reasonable treatment regimens for patients with compensated HCV cirrhosis include IFN-alfa therapy, 6 MU subcutaneously three times weekly for 12 months, L-IFN 3 MU intramuscularly three times weekly for six months, or CIFN 9 or 12 μg subcutaneously three times weekly for six months. Patients receiving IFN should be seen every two to four weeks, with frequent monitoring of complete blood count and serum transaminase concentrations.

Histologic improvement of fibrosis in patients with hepatitis C who have sustained response to interferon therapy

BACKGROUND

Short-term histologic improvement in hepatitis C-related hepatic fibrosis has been noted in studies with more than 2 years of follow-up, but the long-term effects of interferon therapy on hepatic fibrosis remain unclear.

OBJECTIVE

To assess changes in hepatic fibrosis after interferon therapy in patients with chronic hepatitis C.

DESIGN

Retrospective cohort study.

SETTING

7 university hospitals and 1 national hospital in Japan.

PATIENTS

593 patients with chronic hepatitis C who underwent a paired liver biopsy from 1987 to 1997. Of these, 487 patients received interferon therapy and 106 patients were untreated.

INTERVENTION

Patients in the treatment group received a 2- to 6-month course of interferon within 6 months after the initial biopsy.

MEASUREMENTS

Fibrosis and inflammatory activity in paired biopsy samples obtained a median of 3.7 years apart (range, 1 to 10 years) were graded by using the criteria of Desmet and colleagues (F0 to F4) and those of the French METAVIR Cooperative Study Group (A0 to A3), respectively. Changes in fibrosis staging and activity scores and yearly rates of fibrosis progression and regression were calculated.

RESULTS

183 of the 487 interferon-treated patients showed a sustained virologic response. Activity grade was unchanged in most of the untreated patients and improved in 89% (CI, 83% to 93%) of patients with a sustained virologic response. A sustained response to interferon was associated with a mean (+/-SE) reduction in fibrosis score of -0.60+/-0.07 at less than 3 years of follow-up and -0.88+/-0.08 at 3 years or more of follow-up. The rate of fibrosis progression was -0.28+/-0.03 unit/y (regression) in patients with sustained response, 0.02+/-0.02 unit/y in patients with nonsustained response (P< 0.001), and 0.10+/-0.02 unit/y in untreated patients.

CONCLUSION

Although the time between biopsies partly affected the patient's clinical course, the differences observed here suggest that in patients with chronic hepatitis C, regression of fibrosis is associated with sustained virologic response to interferon therapy.

Hepatocellular carcinoma in patients with HCV

In most Western countries hepatitis C virus (HCV) is a common risk factor for hepatocellular carcinoma (HCC). Many HCCs are multifocal in origin, but HCC may also grow as a single hepatic nodule for years before generating satellite or distant tumours. HCV may promote cancer through cirrhosis, which is often associated with HCV-related HCC, but it might also have oncogenic properties by interacting with cellular genes that regulate cell growth and differentiation. Treatment of patients with chronic hepatitis C using interferon might attenuate HCC risk, particularly in those who respond to therapy. Many patients whose cancer is detected early have been successfully treated by liver transplantation and have shown significantly prolonged survival. This is less often achieved with hepatic resection or regional therapies, which may indeed destroy small tumours, without affecting the complications of portal hypertension. Screening remains the only realistic approach for improving the treatment of HCC patients, but its cost-effectiveness is uncertain.

[Hepatocellular carcinoma. Part 2. Treatment]

Recent improvements on the therapeutical management of hepatocellular carcinoma are revised with special attention to evaluate the role of surgery for the disease. Considering that definitive surgical intervention is not feasible in most cases because of extreme tumor extension, multiplicity of tumor foci, and associated advanced liver cirrhosis at the time of diagnosis, others forms of treatment are listed, such as transcatheterarterial chemoembolization, percutaneous ethanol and acetic acid injections, and chemotherapy only to a small portion of patients with no indication for standard treatments. The emerging role of retinoic acid metabolism blocking agents, was examined and may offer a significant new potential treatment for cancer, inclusive the possibility of combining other anticancer drugs with exogenous retinoids or modulation of endogenous retinoids as a real opportunity to advance our ability to treat or prevent human cancer effectively Octreotide, nitrosamine and other drugs are analyzed and is concluded that improves survival and is a valuable alternative in the treatment of inoperable hepatocellular carcinoma. The potential role of intersticial laser coagulation for patients with irresectable hepatic tumors was investigated, and in terms of experience, it has now been developed sufficiently to study its effect on these patients survival. The homeostatic control of angiogenesis and its influences on the tumor growth and for migration of metastatic cells, was focused in this concise review, given that hepatocytes are the source of much of the precursor pool, regulation of angiogenesis may be regarded as a new liver function with important consequences for tissue repair and cancer. Early hepatocellular carcinoma and its recognition in routine clinical practice contributes to improved patients survival. Recombinant-Interferon-alpha therapy surely prevents, the development of cirrhosis or hepatocellular carcinoma in about one-third of patients, with chronic hepatitis C, with sustained response. Finally, in individuals with life-threatening liver disease, such as those with cirrhosis and hepatocellular carcinoma, the liver transplantation, must be considered, besides controversial, however, with increasing experience the results of the procedure in these patients have improved, and may offer a better long-term survival than liver resection.

Early detection of hepatocellular carcinoma increases the chance of treatment: Hong Kong experience

The prognosis for patients with hepatocellular carcinoma (HCC) is poor because of the low chance of curative treatment. To increase the chance of intervention and to improve survival, early detection of subclinical HCC (SCHCC) by alpha-fetoprotein (AFP) and/or ultrasonography (USG) screening is implemented in many countries. Three hundred six Chinese patients with HCC diagnosed between January 1995 and December 1997 were recruited. They were categorized into two groups: 142 patients (group 1) had SCHCC diagnosed by screening (AFP and/or USG), and 164 patients (group 2) presented with symptomatic HCC. The tumor size was significantly smaller in group 1 compared with that of group 2 (3.5 cm vs. 8.1 cm; P <.0001). A significantly higher proportion of patients had bilobar involvement, multifocal HCC, diffuse-type HCC, portal vein infiltration, and distant metastasis in group 2 when compared with group 1. Operability and feasibility of treatment by transcatheter intra-arterial chemoembolization (TACE) in group 1 patients (26.8% and 45.1%, respectively) were significantly better than in group 2 patients (7.9% and 32.3%, P <.0001 and P =.03, respectively). The cumulative survival rate was significantly higher in group 1 than in group 2 (P <.0001). For those who had surgical resection and those who had TACE, group 1 patients had a higher cumulative survival rate compared with that of group 2 patients (P =.04 and P =.0003, respectively). Screening for HCC by AFP and/or USG can identify tumors at an early stage, resulting in a higher chance of receiving treatment. Whether it can improve survival requires a further prospective, randomized study.

Hemochromatosis

The recent cloning of the hemochromatosis gene (HFE) and the demonstration that a single missense mutation is responsible for 90% or more of patients with the disease, have stimulated renewed interest in all aspects of this common disease. The molecular tests for identifying mutations in HFE provide improved means for diagnosis, family screening, and population screening. Moreover, the elucidation of the role of the HFE gene product will provide new insights into the regulation of normal iron absorption and iron metabolism. In addition, it is now apparent that iron, even in the modest tissue concentrations, can act as a co-factor in potentiating cell injury in other liver diseases.

Cost effectiveness analysis of different strategies of management of chronic hepatitis C infection in children

BACKGROUND

Chronic hepatitis C virus infection in the pediatric patients is commonly encountered by clinicians, and although interferon-based therapy has been shown to be reasonably effective in children no formal economic analysis of such treatment strategies is available.

METHODS

With a Markov cycle tree simulation model, a cost effectiveness analysis was done to compare interferon-based treatment strategies for chronic HCV infection in children with a strategy of no treatment in a cohort of 10-year-old otherwise healthy children. Clinical probabilities used in the model was obtained from available literature, and cost estimates were obtained from two teaching hospitals. Cost per patient, quality-adjusted life years gained in each strategy and incremental cost-effective ratio were the primary outcome measures compared.

RESULTS

In the baseline analysis the treatment strategies dominated the strategy of no treatment. A 12-month treatment strategy was better than the 6-month treatment strategy. Combination therapy for 6 months with interferon and ribavirin was at least equally if not more effective than 12-month monotherapy. All treatment strategies decreased the number of patients developing decompensated cirrhosis, hepatocellular carcinoma and also number of orthotopic liver transplants in the lifetime of the model cohort.

CONCLUSIONS

Interferon-based treatment strategies were more effective in terms of quality-adjusted life years saved and at the same time cheaper when compared with the strategy of no treatment. Combination therapy may be more cost-effective than interferon monotherapy, and clinical trials of combination therapy in pediatric patients are needed.

Is surgery for large hepatocellular carcinoma justified?

BACKGROUND/AIMS

Most hepatocellular carcinomas are still discovered at an advanced stage and are left untreated as large hepatocellular carcinomas are contraindications to liver transplantation and percutaneous ethanol injection and are usually considered as poor indications for liver resection. The aim of this study was to reassess the results of surgery in these patients.

METHODS

Between 1984 and 1996, 256 patients underwent resection of biopsy-proven, non-fibrolamellar hepatocellular carcinoma. Of these, 121 had a tumour diameter of less than 5 cm (small hepatocellular carcinomas) and 94 a tumour diameter of more than 8 cm (large hepatocellular carcinomas). The short- and long-term outcome of patients with small and large hepatocellular carcinomas were compared.

RESULTS

The in-hospital mortality rate following resection of small and large hepatocellular carcinomas was comparable (11.5 vs. 10.6%), even after stratifying for the presence and severity of an underlying liver disease. In patients with a chronic liver disease, large hepatocellular carcinomas were associated with a greater risk of death and recurrence during the first 2 operative years. In the long term, however (3-5 years), survival and disease-free survival following resection of small and large hepatocellular carcinomas were comparable (34 vs. 31% and 25 vs. 21% at 5 years). Similarly, treatment of and survival after the onset of recurrence were not influenced by the size of the initial tumour.

CONCLUSIONS

Patients with large hepatocellular carcinomas should not be abandoned and should be considered for liver resection as this treatment may be associated with an in-hospital mortality rate and a long-term survival comparable to that observed after resection of small hepatocellular carcinomas.

Hepatitis C virus and hepatocellular carcinoma

The sequential development of cirrhosis and hepatocellular carcinoma (HCC) in patients with transfusion-associated hepatitis was a clue leading to the identification of hepatitis C virus (HCV) as a risk factor for HCC. The incidence of HCV-related liver cancer is increasing in many developed countries: tumours arise in older patients, are almost invariably associated with cirrhosis and often have a less aggressive course than is seen in HCC related to other aetiological factors. Most HCCs grow as a single hepatic nodule for several years before generating satellite or distant tumour nodules. Tumour progression and hepatic failure are the leading causes of death. HCV might promote cancer through cirrhosis, which is per se an important risk factor for this tumour. HCV might also have oncogenic properties by interacting with cellular genes that regulate cell growth and differentiation. The primary prevention of HCC through vaccination against HCV is not yet available. The treatment of patients with chronic hepatitis C with interferon might attenuate the risk of HCC.

Cost effectiveness of interferon alpha2b combined with ribavirin for the treatment of chronic hepatitis C

Treatment of chronic hepatitis C with Interferon (IFN) alpha2b monotherapy results in 10% to 15% sustained virological response (SVR). Combining IFN with ribavirin increases this response. In this analysis, using the Markov model, 6 treatment strategies for chronic hepatitis C (previously untreated) were compared on the basis of incremental cost per additional quality-adjusted life years ($/QALY). Our results showed that the no treatment strategy was associated with a cost of $38,747 and 13.10 QALYs. The strategy using IFN alone for 48 weeks was associated with a cost of $35,642 and 14.05 QALYs. The strategy using IFN monotherapy followed by combination therapy for nonresponders and relapsers was associated with a cost of $34, 561 and 15.53 QALYs. A similar strategy, but limiting combination to relapsers only, was associated with a cost of $34,758 and 14.40 QALYs. The strategy using IFN with ribavirin as the initial therapy for all patients was associated with a cost of $34,792 and 15.31 QALYs. Finally, the strategy using viral genotyping first and then adjusting the duration of combination therapy based on genotype was associated with a cost of $37,263 and 15.89 QALYs. The strategy using genotyping to guide duration of combination therapy was the most cost-effective approach with an incremental cost-effectiveness ratio of $7,500 per QALY. Sensitivity analyses confirmed the robustness of these results. We conclude that combination of IFN and ribavirin with duration of therapy based on the viral genotype, is a cost-effective approach in treating patients with chronic hepatitis C.

The rebleeding course and long-term outcome of esophageal variceal hemorrhage after ligation: comparison with sclerotherapy

BACKGROUND

Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation and compare it with that after sclerotherapy.

METHODS

One hundred and eighty-five liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were randomized to undergo endoscopic variceal sclerotherapy or ligation. These patients received regular follow-up and detailed clinical assessment.

RESULTS

Two patients developed hepatoma within 6 months of entry in each group and were excluded. Another six patients in the sclerotherapy group and seven patients in the ligation group were excluded because of poor compliance or lost to follow-up. Therefore, 84 patients in each group were analyzed. In this long-term follow-up (55.3 +/- 12.5 months) the rebleeding rate for ligation was lower than that for sclerotherapy, regardless of whether the rebleeding was analyzed by patient number or Kaplan-Meier analysis. With regard to the rebleeding risk of various periods, the sclerotherapy risk was higher than that of ligation within 4 weeks of the initial endoscopic treatment or before variceal eradication. Multifactorial analysis showed hematemesis, poor hepatic function, and sclerotherapy were the risk factors determining rebleeding. The annual hepatocellular carcinoma incidence was 4.9%. There was no difference in survival between sclerotherapy and ligation. Multifactorial analysis showed that poor hepatic function was the only factor determining survival.

CONCLUSIONS

The rebleeding risk was higher in sclerotherapy than in ligation before variceal eradication, especially within 4 weeks of the initial endoscopic treatment. Long-term survival was dependent on hepatic reserve regardless of the treatment method.

Correlation of serum hepatitis C virus RNA titre with aminotransferases and liver histopathological findings in HCV-seropositive cases with end-stage chronic liver disease

The quantity of circulating hepatitis C virus (HCV) RNA, aminotransferases and the degree of liver cell injury in relation to HCV serotype have not been fully studied. In this work, we estimated the HCV RNA titre in serum and correlated the findings with levels of aminotransferases, gamma glutamyltransferase (GGT), and liver histopathological changes and with HCV serotype. HCV RNA was found in 22 out of 30 HCV-seropositive cases included in this study (73. 3%) and serotype 4 represented 90.9% (20/22). Levels of aminotransferases and GGT correlated with the levels of serum HCV RNA. Noticeably, GGT showed the highest positive correlation with the level of HCV RNA. Liver histopathological findings of 15 patients showed that eight had hepatocellular carcinoma and seven had cirrhosis. There was no significant difference between these two groups regarding levels of enzymes or serum HCV RNA titre.

Screening for hepatocellular carcinoma in patients with advanced cirrhosis

OBJECTIVE

Most available data on screening for hepatocellular carcinoma (HCC) in patients with cirrhosis originate from Asia and Europe. These data may not be applicable to patients from the United States because of geographic variation in the underlying etiology and other factors. Our aim was to assess the risk of HCC in U.S. patients with cirrhosis undergoing standardized screening.

METHODS

All cirrhotic patients evaluated for liver transplantation at our institution from January 1, 1994-December 31, 1997 were included in this study. The screening strategy included initial screening, which was offered to all patients and consisted of alpha-fetoprotein (AFP), abdominal ultrasound, and computed tomography (CT) scan, and extended screening, which was performed only on transplant-eligible patients and consisted of semiannual AFP and ultrasound.

RESULTS

During the study period, 285 patients with cirrhosis were evaluated for transplantation and underwent initial screening. Of these, 166 were eligible for transplantation and underwent extended screening during a median follow-up of 15 months (range 6-42 months). Twenty-seven HCC were found, 22 during initial screening and five during extended screening. The cancer-free proportions of the cohort who underwent extended screening at 1, 2, and 3.5 yr were 98.6% +/- 1.4%, 96.4 +/- 1.8%, and 77.1% +/- 1.7%, respectively (mean +/- SE). Hepatitis C, either alone or in part, was the etiology in 63% of patients with HCC. The sensitivity of CT scan (88%) was significantly higher than AFP >20 ng/ml (62%) and ultrasound (59%) for detecting HCC (p < 0.001).

CONCLUSIONS

In patients with established cirrhosis, the risk of detecting HCC is maximal at the baseline screening (7%). Hepatitis C was the most common etiology for cirrhosis in study. In U.S. patients with established cirrhosis, CT scan exhibited higher sensitivity for detecting HCC than ultrasound or AFP.

Long-term treatment of chronic hepatitis C with ursodeoxycholic acid: influence of HCV genotypes and severity of liver disease

AIMS/BACKGROUND

Current therapy for chronic hepatitis C virus (HCV) infection is based on the administration of interferon alpha (IFN) alone or in combination with other anti-viral agents. However, such therapy is effective in only a minority of selected patients. Long-term ursodeoxycholic acid (UDCA) treatment has been reported to improve liver function and structure especially in cholestatic disorders. We investigated the effect of long-term UDCA treatment on liver function in respect to the severity of chronic liver disease and HCV genotypes.

METHODS

Forty-five patients with non-cholestatic laparoscopy-biopsy proven HCV-associated chronic hepatitis (n=16) or cirrhosis (n=29) who had not responded to, or were unsuitable for IFN, were randomly assigned to receive UDCA (600 mg/day; n=23) or no therapy (n=22) for 12 months. At entry, all patients were evaluated by means of conventional and quantitative liver function tests (LFTs), including galactose elimination capacity and antipyrine clearance, HCV antibodies, HCV-RNA and HCV genotypes. LFTs were measured at 6 and at 12 months, whereas HCV-RNA was determined again after treatment.

RESULTS

Baseline characteristics were comparable in the two study groups. Long-term UDCA therapy was well tolerated. Based on the analysis of variance, there was a significant decrease in serum transaminase, LDH and GGT levels in UDCA treated patients. By contrast, the activities of these enzymes increased in untreated patients, with AST levels reaching statistical significance only. Statistical analysis also showed that the improvement in biochemical markers was more pronounced in UDCA treated patients with liver cirrhosis than in those with chronic hepatitis but was similar in patients with HCV genotype 1b and non-1b. However, HCV-RNA was positive in all patients after treatment. Quantitative LFTs remained, on average, stable over the 12 months of the trial in all groups.

CONCLUSIONS

Long-term UDCA treatment is well tolerated in patients with HCV-associated chronic liver disease. The effect appears to be greater in cirrhotics than in patients with chronic hepatitis but is independent of HCV genotypes. Thus, long-term UDCA treatment, despite the absence of an anti-viral effect, seems beneficial in reducing disease activity in patients with chronic hepatitis or cirrhosis who are unsuitable for IFN therapy.

Parenchymal echo patterns of cirrhotic liver analysed with a neural network for risk of hepatocellular carcinoma

BACKGROUND

To objectively evaluate the parenchymal echo patterns of the liver in cirrhosis, an image analysing system in which a neural network is used has been found capable of numerically calculating coarse score (CS). Using this system, we analysed whether or not CS can serve as a predictive factor for the development of hepatocellular carcinoma (HCC).

METHODS

The risk factors for HCC were evaluated in 95 patients with liver cirrhosis with an average follow-up period of 2041 +/- 823 days. We used a three-layer feed-forward neural network and a back-propagation algorithm to calculate CS.

RESULTS

There were strong correlations between CS, alanine aminotransferase (ALT) and alpha-fetoprotein (AFP) and the average cumulative incidence rate of HCC evaluated by the Cox's proportional hazards model. The adjusted rate ratios were estimated to be 3.00, 2.80 and 2.01, respectively. The cumulative risks of HCC were significantly higher with an initial CS > or = 1.5 than with an initial CS < 1.5, with ALT > or = 80 IU/L than with initial ALT < 80 IU/L and with AFP > or = 20 ng/mL than with initial AFP < 20 ng/mL, all analysed by the log-rank test.

CONCLUSIONS

Coarse score is a useful predictor for development of HCC.

Presence of alpha-fetoprotein mRNA in blood correlates with outcome in patients with hepatocellular carcinoma

BACKGROUND/AIMS

Since hematogenous spread of tumor cells may adversely affect the prognosis of patients with hepatocellular carcinoma, we prospectively analyzed whether the presence of alpha-fetoprotein (AFP) messenger RNA (mRNA) in blood, used as a marker of circulating hepatocellular carcinoma cells, correlates with outcome.

METHODS

Eighty-eight patients were enrolled between December 1993 and August 1995, and 81 were followed until the end of 1997. All patients were treated with percutaneous ethanol injection therapy and/or transarterial embolization during follow-up. The status of AFP mRNA in blood was serially determined. Cumulative metastasis-free survival and overall survival were analyzed in relation to AFP mRNA and other clinical and laboratory variables.

RESULTS

Among 81 patients followed, 54 were positive for AFP mRNA at entry and 27 were negative. Extrahepatic metastasis developed more frequently among the AFP mRNA-positive patients (13 of 54) than among the AFP mRNA-negative patients (2 of 27) (p=0.0296). After treatment, AFP mRNA became negative in 24 of 54 patients (44%). Cumulative metastasis-free survival and overall survival were significantly better in the 24 patients whose AFP mRNA became negative after treatment than in the 30 patients with persistently positive AFP mRNA (p= 0.0001 and p<0.0001, respectively).

CONCLUSIONS

The presence or absence of AFP mRNA in blood is a predictor of outcome in patients with hepatocellular carcinoma.

Screening for hepatocellular carcinoma in patients with cirrhosis in the United States: results of a national survey

OBJECTIVE

Hepatocellular carcinoma (HCC) is one of the dreaded complications of cirrhosis. Although there are no randomized controlled studies showing improved survival with screening, patients with cirrhosis are screened for HCC. Little is known about the practice of HCC screening in the United States. Our aim was to describe the practice of HCC screening in patients with cirrhosis in the United States.

METHODS

In March 1998, we mailed a standard questionnaire to 1021 physician members of the American Association of Study for Liver Diseases and the same questionnaire was re-sent to nonrespondents 4 weeks later.

RESULTS

We received a response from 554 members (54%). After excluding those not involved in active adult patient care, 473 responses were eligible for analysis. Eighty-four percent of the respondents routinely screened patients with cirrhosis for HCC (screening respondents). Nearly half of the screening respondents limited the HCC screening to patients with high-risk etiologies such as hepatitis B or C or hemochromatosis. Although alpha-fetoprotein (99.7%) and ultrasound (93%) were the two most frequently used screening methods, a sizable proportion of the screening respondents (25%) used abdominal computed tomography for routine screening. On multivariate analysis, the following variables predicted screening for HCC by the respondents: seeing more than one new cirrhotic per week (odds ratio [OR]: 5.4, 95% confidence interval [CI]: 2.5-11.7); practicing for < 10 yr (OR: 4.0, 95% CI: 1.2-13.4); an opinion that screening is cost-effective (OR: 6.4, 95% CI: 1.6-25); an opinion that screening prolongs survival (OR: 5.7, 95% CI: 1.8-17.9); and an opinion that not screening poses malpractice liability (OR: 9.3, 95% CI: 4.2-20.8).

CONCLUSIONS

The majority of respondents routinely screen patients with cirrhosis for HCC. Approximately half of the screening respondents limit their screening to only patients with high-risk etiologies. On multivariate analysis, several variables predicted screening for HCC by the respondents.

A new prognostic classification for predicting survival in patients with hepatocellular carcinoma. Groupe d'Etude et de Traitement du Carcinome Hépatocellulaire

BACKGROUND/AIMS

In patients with hepatocellular carcinoma, prediction of survival is difficult. The aim of this prospective study was to provide a simple classification for predicting survival of patients with hepatocellular carcinoma, based on a multivariable Cox model.

METHODS

Seven hundred and sixty-one patients who presented with hepatocellular carcinoma from 24 Western medical centers were enrolled over a 30-month period. Patients were randomly assigned to either a training sample (n=506, with 418 deaths) from which a classification system was established, or a test sample (n=255, with 200 deaths) for validating its prognostic significance.

RESULTS

Five prognostic factors were selected at the 0.0001 level: Karnofsky index <80% (relative risk of death=2.2, 95% confidence interval: 1.7-2.7), serum bilirubin >50 micromol/l (relative risk=2.1, 95% confidence interval: 1.7-2.6), serum alkaline phosphatase at least twice the upper limit of normal range (relative risk=1.6, 95% confidence interval: 1.3-2.0), serum alpha-fetoprotein >35 microg/l (relative risk=1.7, 95% confidence interval: 1.4-2.1), and ultrasonographic portal obstruction (relative risk=1.3, 95% confidence interval: 1.1-1.7). Three risk groups with different 1-year survival rates (72%, 34%, 7%) were derived, and independently validated in the test sample (79%, 31%, 4%).

CONCLUSION

This classification could be useful in the assessment of prognosis from homogeneous groups of patients with respect to their expected outcome.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with Child's grade A or B cirrhosis: a multivariate analysis of prognostic factors

We evaluated factors affecting long-term survival after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) complicating cirrhosis. One hundred eighty-two patients with Child's class A or B cirrhosis and an HCC, not amenable to surgery or percutaneous ethanol injection, underwent 346 TACEs (mean 1.9) with epirubicin, iodized oil, and gelatin sponge. Many prognostic factors were subjected to univariate analysis and thereafter, when significant, to the Cox's hazard proportional model. Finally, the significant indices in the Cox's model were used to estimate the accuracy of the probability of death with computation of the area under the receiving operative characteristic (ROC) curve. The cumulative survival rates at 1, 2, 3, and 5 years were 0.83, 0.52, 0.40, and 0.16, respectively. According to Cox's model, the factors associated with significantly worse survival were the presence of ascites (p = 0.0027), elevated bilirubin levels (p = 0.0163), elevated alpha-fetoprotein (alphaFP) values (p = 0.0067), a tumor greater than 5 cm in diameter (p = 0.0001), and the absence of a tumor capsule-like rim (p = 0.0278). According to these parameters, the accuracy of the probability of death estimated with ROC analysis was 0.63. Minor and major complications occurred in 82 patients (45%) and caused death in 2 patients. Long-term prognosis after TACE for HCCs in patients with Child's class A or B cirrhosis depends on the presence of ascites, the bilirubin level, the alphaFP value, the diameter of the tumor, and the presence of a tumor capsule-like rim. However, when considered altogether, these variables are poor predictors to evaluate survival, and other factors should be investigated to identify subjects more responsive to TACE. Complications occur in a high percentage of patients, but they do not affect long-term prognosis.

Risk factors for development of hepatocellular carcinoma among Australians with hepatitis C: a case-control study

BACKGROUND

Older patients with cirrhosis due to hepatitis C are at risk of developing hepatocellular carcinoma (HCC), but additional risk factors may vary between countries.

AIM

In the present study, we sought to identify additional risk factors for HCC among a cohort of Australian patients with chronic hepatitis C.

METHODS

Case-control study of patients with advanced fibrosis stage hepatitis C who developed HCC during five-year follow up at a referral liver clinic. Cases were compared to twice the number of age-matched patients with chronic hepatitis C of similar fibrotic severity who did not develop HCC over a similar interval, using conditional logistic regression analysis (CLRA) and multivariate analysis. The main outcome measures were demographic and disease-related variables at first presentation in relation to the development of HCC.

RESULTS

HCC developed in 17 cases, an annual incidence among those considered to be at risk of 2%. The duration of follow up since first assessment was comparable among the cases and 34 selected age-matched controls (4.1 and 5.2 years respectively, p=0.5). Cases were more often male (p=0.03), born in Asia (p=0.05), and had poorer liver function as indicated by serum albumin concentration (p=0.02). Anti-hepatitis B core-antibody (anti-HBc) was detected in 59% (ten/17) of cases, compared to 21% (seven/34) of the controls (p=0.01). No patient with a sustained response to interferon developed HCC during follow up. There were no significant differences in the mode of HCV transmission, HCV genotype, alcohol exposure, serum bilirubin level or prothrombin time between the cases and the controls. Although the data set was small, multivariate CLR analysis identified serum albumin < or = 35 g/L and anti-HBc positivity to be independent risk factors for development of HCC.

CONCLUSIONS

Among older Australian patients (over the age of 40 years) with advanced fibrosis stage hepatitis C, the annual incidence of HCC is about 2%. Those who have low serum albumin and evidence of previous exposure to hepatitis B virus (anti-HBc positivity) appear to have the highest risk of developing HCC during follow up, but males and those born in Asia could also be at increased risk.

High prevalence of multinodular hepatocellular carcinoma in patients with cirrhosis attributable to multiple risk factors

To see whether or not there is an association between the cause of cirrhosis and the number of hepatocellular carcinoma (HCC) nodules, we analyzed 178 consecutive patients in whom HCC was detected during a prospective screening by abdominal ultrasound (US). The relevant information was obtained from the database of the screening programs operating at four hospitals in the Milan area. One hundred twenty-nine (72%) patients had a single tumor nodule detected by US and 49 (28%) patients had multinodular disease. Ninety-eight (55%) patients had normal serum values of alpha-fetoprotein (AFP). Tumor staging with biphasic computed tomography (CT) scan or hepatic arteriography with lipiodol revealed that 101 (57%) patients had single tumor nodules and 77 (43%) patients had more than one HCC nodule. After staging, multinodular HCC was more common in patients with multiple risk factors than in the hepatitis C virus (HCV) carriers (56% vs. 38%, P =.05). Interestingly, single tumors were as common in the 126 patients undergoing 6-month interval screening as in the 52 patients who were studied at yearly intervals. The former patients, however, had more small tumors than the latter ones (91% vs. 74%, P =.04). The 22 patients who were alcohol abusers had normal levels of serum AFP more often than the hepatitis B virus (HBV) or HCV carriers or those with multiple risk factors (86% vs. 57%, P <.04; vs. 47%, P <.002; vs. 52%, P <.006, respectively). We concluded that multinodular HCC was underdetected by real time US; it prevailed among patients with multiple risk factors. In these patients, screening with US exams every 6 months may be inadequate for early detection of liver cancer.

Prospective study of interferon therapy for compensated cirrhotic patients with chronic hepatitis C by monitoring serum hepatitis C RNA

Because interferon therapy exhibits low efficacy for cirrhotic patients infected with hepatitis C virus, this prospective study was conducted to determine effective interferon regimens tailored to treatment response by monitoring HCV RNA status. A total of 157 cirrhotic patients were enrolled to receive 9 million units (MU) of interferon three times a week. The HCV RNA values were drawn 8 weeks apart and the patients were randomized to a further 16 or 32 weeks of treatment after two sequential findings of negativity for HCV RNA. A total of 73 out of 157 patients (46%) proceeded to randomization to different durations of treatment, 37 short-course and 36 long-course (duration: 38 +/- 8 and 49 +/- 13 weeks; total amount of interferon: 940 +/- 240 and 1130 +/- 390 MU, respectively). The remaining 84 patients without two sequential negative serum HCV RNA determinations received 44.8 +/- 27.4 weeks of interferon (IFN) therapy with total amount of 993 +/- 633 MU. Of these 157 patients, sustained virological and biochemical response was shown in 32 (20%) and 37 patients (24%), respectively. Sustained virological and biochemical response rate in the randomized patients was significantly higher than in nonrandomized patients (41% vs. 2%, and 38% vs. 11%; each P <.01). Of the 73 randomized patients, the rate of sustained virological response in patients with long-course treatment (50%) was significantly higher than that of patients with short-course treatment (32%) (P =.026: log-rank test), and in patients with early disappearance of HCV RNA especially within 8 weeks, in patients with low virus load (</=10(6.3) copies/mL) and with HCV 2a. Multivariate analysis revealed that HCV RNA level and subtypes were the most important factors contributing to sustained virological response. Interferon is effective even in cirrhotic patients with low viral load and HCV 2a, but requires a longer course of administration.

Possible contribution to hepatocarcinogenesis of X transcript of hepatitis B virus in Japanese patients with hepatitis C virus

Serological research suggests that hepatitis B virus (HBV) and hepatitis C virus (HCV) are associated with the development of hepatocellular carcinoma (HCC). It is unclear how genes of hepatitis viruses participate in hepatocarcinogenesis in patients infected with HCV. We investigated the expression of hepatitis virus-related RNAs in resected liver from 51 patients with HCV antibodies (Ab) and without hepatitis B surface antigen (HBsAg). mRNA transcripts of the genes HBx, HBc, HBs, nonstructural (NS) region 3 of HCV, the 5'-untranslated region (UTR) of HCV, and the 5'-UTR of hepatitis G virus (HGV) were amplified by reverse-transcription polymerase chain reaction (RT-PCR) with specific primers for each gene. The HBx transcript was detected in 19 (37%) tumors and in 8 (16%) specimens of noncancerous tissues (P =.014). The NS3 gene of HCV was detected in 35 (69%) tumors and 41 (80%) noncancerous tissues. HGV RNA was detected in 3 tumors (6%). Patients with HBx transcripts were younger than patients without HBx transcripts (P =.012). HBx transcripts were detected in 3 (33%) of 9 well-differentiated HCCs, in 8 (31%) of 26 moderately differentiated HCCs, and in 8 (50%) of 16 poorly differentiated HCCs. Codon 130 (AAG) and codon 131 (GTC) of HBx were changed to ATG and ATC, respectively, in all HCCs with HBx transcripts. In conclusion, we found that the HBx gene was expressed in many HCCs; the gene might promote hepatocarcinogenesis in patients with HCVAb and without HBsAg, but HGV is not closely related to hepatocarcinogenesis in such patients.

Support for patients with hepatitis C: an exploratory qualitative study of medical specialists' perceptions

OBJECTIVE

To explore the range of meanings about the role of support for patients with hepatitis C by examining medical specialists' perceptions.

METHOD

The study employed a qualitative, open-ended interview design and was conducted in four major teaching hospitals in Adelaide, South Australia. Eight participants (three infectious disease physicians, four gastroenterologists, one hepatologist), selected through purposive sampling, were interviewed about general patient support, their role in support provision, the role of non-medical support and their reasons for not using support services.

RESULTS

Main themes included a focus on support as information provision and that patient education is best carried out by a medical specialist. The use of support services was defined as the patient's decision. Participants identified four key periods when patients would benefit from support; during diagnosis, failure to meet treatment criteria, during interferon treatment and following treatment failure.

CONCLUSIONS

It was concluded that while barriers exist to the establishment of partnerships between specialists and other support services, this study has identified clear points at which future partnerships could be established.

IMPLICATIONS

A partnership approach to developing support for patients with hepatitis C offers a systematic framework to facilitate the participation of health professionals and the community in an important area of public health.

Interferon therapy lowers the rate of progression to hepatocellular carcinoma in chronic hepatitis C but not significantly in an advanced stage: a retrospective study in 1148 patients. Viral Hepatitis Therapy Study Group

BACKGROUND/AIM

Hepatocellular carcinoma frequently develops during the advanced stages of chronic hepatitis C. We examined whether interferon prevents the development of hepatocellular carcinoma in chronic hepatitis C patients.

METHODS

Japanese patients with chronic hepatitis C (n = 1.148; 117 with portal fibrous expansion (F1), 636 with bridging fibrosis (F2), 355 with bridging fibrosis and architectural distortion (F3)) and 40 cirrhotic (F4) patients were treated with interferon. These patients were followed from 1 to 7 years after interferon therapy. Blood tests and image analysis were serially performed to assess response to interferon and to detect hepatocellular carcinoma. Fifty-five cirrhotic type C patients (control F4) not receiving interferon were enrolled in this study.

RESULTS

Sustained (SR: 27.5%) and transient (TR: 23.0%) responders totaled 50.5%, while 49.5% did not respond to interferon. SR showed an improvement in disease stage reflected by increased platelet counts. Fifty-two patients (9 F2, 36 F3, and 7 F4) developed hepatocellular carcinoma in the follow-up period; 3 SR, 8 TR, and 41 non-responders (NR). The cumulative incidence of hepatocellular carcinoma in F2 was significantly lower (p = 0.019) in SR compared with NR, but not in SR in F3 and F4 patients. However, the cumulative incidence of hepatocellular carcinoma was significantly decreased in all SR (p = 0.0001) and TR (p = 0.0397) compared with all NR.

CONCLUSION

These results indicate that interferon therapy in chronic hepatitis C patients lowered the rate of progression of hepatocellular carcinoma in sensitive cases but not in patients in an advanced stage.

Factors predicting progression to cirrhosis and hepatocellular carcinoma in patients with transfusion-associated hepatitis C virus infection

The clinical progression of chronic hepatitis C is not uniform throughout the entire period of infection and is more rapid in patients with advanced histologic disease. Our study was designed to identify factors contributing to progression to cirrhosis and hepatocellular carcinoma by taking the entire period of infection into consideration. Two hundred thirteen patients with transfusion-associated hepatitis type C chronic liver disease were included in this study. They did not have either a history of antiviral therapy or any other potential causes of chronic liver disease except for transfusion. Hepatitis C virus genotype 1b was detected in 144 (68%) patients, followed by 2a in 51 (24%), 2b in 11 (5%), 1a in 4 (2%), and coinfection with 1b and 2a in 3 (1%). The log-rank test in the Kaplan-Meier method revealed that the cumulative percentage of cirrhosis-free or hepatocellular carcinoma-free patients became significantly lower as the transfusion age went up. Patient age at the time of transfusion was the only independent factor related to disease progression in multivariate analysis using Cox's proportional hazards model. Thus age at transfusion should be taken into consideration in designing the optimal follow-up schedule and therapy in patients with posttransfusion-associated chronic hepatitis C.