Epidemiology and prevention of hepatocellular carcinoma. Cancer Lett. 2009;286:5-8. [PMID: 19070421 DOI: 10.1016/j.canlet.2008.10.046]

Tribbles homolog 2 promotes hepatic fibrosis and hepatocarcinogenesis through phosphatase 1A-Mediated stabilization of yes-associated protein

BACKGROUND & AIMS

Hepatic stellate cells (HSCs) play critical roles in liver fibrosis and hepatocellular carcinoma (HCC). Tribbles homolog 2 (TRIB2) is an oncogene implicated in a variety of cancers, including liver cancer. However, the biological function and regulatory mechanism of TRIB2 in HSCs are poorly understood. In addition, little is known about its role in liver fibrosis progression to HCC. Here, we revealed the clinical significance of TRIB2 in liver fibrosis and HCC development.

METHODS

We investigated TRIB2 promoting liver fibrosis in vitro and in vivo. In mouse model of liver fibrosis and HCC, we measured hepatic fibrosis and HCC level through knockdown TRIB2 with shRNA. In addition, we performed western blotting, real-time quantitative PCR, immunofluorescence and co-immunoprecipitation assay to study TRIB2 function in LX-2 cells.

RESULTS

TRIB2 expression was strongly upregulated in human fibrotic liver tissues and HCC tissues. TRIB2 colocalized with α-smooth muscle actin (α-SMA) in fibrotic and HCC liver tissues. Knockdown of TRIB2 inhibited HSC activation and liver fibrosis in vitro and in vivo. TRIB2 promoted Yes-associated protein (YAP) stabilization, nuclear localization, and subsequent fibrotic gene expression independent of the MST-LATS phosphorylation cascade in HSCs. TRIB2 interacted with YAP to recruit phosphatase 1A (PP1A), promoting PP1A-mediated YAP dephosphorylation. TRIB2 knockdown potently attenuated the development of fibrosis-associated liver cancer.

CONCLUSIONS

TRIB2 is an attractive target for hepatic fibrosis and fibrosis-associated liver cancer treatment.

A comprehensive genome-wide profiling comparison between HBV and HCV infected hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, especially in East Asia. Even with the progress in therapy, 5-year survival rates remain unsatisfied. Chronic infection with the hepatitis B virus (HBV) or hepatitis C virus (HCV) has been epidemiologically associated with HCC and is the major etiology in the East Asian population. The detailed mechanism, especially the changes of DNA methylation and gene expression between the two types of virus-related HCC, and their contributions to the HCC development, metastasis, and recurrence remain largely unknown.

METHODS

In this integrated analysis, we characterized genome-scale profiles of HBV and HCV infected HCC by comparing their gene expression pattern, methylation profiles, and copy number variations from the publicly accessible data of The Cancer Genome Atlas Program (TCGA).

RESULTS

The HLA-A, STAT1, and OAS2 genes were highly enriched and up-regulated discovered in the HCV-infected HCC. Hypomethylation but not copy number variations might be the major factor for the up-regulation of these immune-related genes in HCV-infected HCC.

CONCLUSIONS

The results indicated the different epigenetic changes of HBV/HCV related hepatocarcinogenesis. The top up-regulated genes in HCV group were significantly clustered in the immune-related and defense response pathways. These findings will help us to understand the pathogenesis of HBV/HCV associated hepatocellular carcinoma.

Predictors of 5 year survival rate in hepatocellular carcinoma patients

Background

Hepatocellular carcinoma (HCC) is one of the most common primary hepatic malignancies and growing challenges of global health. In this study, for the first time in Iran, we investigated the 5-year survival rate and prognostic factors in patients with HCC.

Materials and Methods

In this historical cohort study, we examined the medical records of 227 HCC patients who were registered in the central tumor registry of our institution from September 2007 to September 2017. Demographic data, clinical parameters, received treatments, and survival curves from time of diagnosis were evaluated. Kaplan-Meier was used for univariate analysis, and multivariable analysis was performed by Cox regression.

Results

A total of 208 (91.63%) patients were dead. The 5-year survival rate was estimated 19 (8.37%). The average follow-up in this study was 14.3 months. Overall median survival rate was 12.1 months. Univariate analysis showed that tumor size, metastasis, number of involved lymph node, hepatitis type, and treatment were significantly related to the survival rate, and Cox regression analysis revealed that the tumor size >3 cm (hazard ratio [HR] = 3.06, 95% confidence interval [CI] = 1.68-4.97; P = 0.027), involved lymph nodes >2 (HR = 4.12, 95% CI = 2.66-6.38; P = 0.001), metastasis (HR = 3.87, 95% CI = 3.13-6.54; P = 0.011), combination therapy with surgery and chemotherapy (HR = 0.4, 95% CI = 0.15-0.79; P = 0.023), and coinfection with hepatitis B virus and hepatitis C virus (HR = 2.11, 95% CI = 1.81-4.6; P = 0.036) are the most relevant prognostic factors with 5-year survival rate in patients with HCC.

Conclusion

Results of this study will help estimate survival rates for patients with HCC according to their clinical status.

Cancer prevention and control: hepatocellular carcinoma

Liver cancer (mostly hepatocellular carcinoma, HCC) is both common and highly lethal throughout Africa, in particular in western and middle Africa where HCC is the first cause of cancer death in men and the third in women. In these high-incidence areas, HCC develops mostly early (<50 years), with an aggressive clinical course and frequently without prior diagnosis of liver cirrhosis. The dynamics of African populations predict that the burden of liver cancers will be multiplied by three to four in the next decades unless effective prevention and therapy is achieved. This article outlines a path for significantly curbing the mortality of liver cancer in Africa by combining primary prevention, improved early detection and introduction of innovative and appropriate management strategies.

Antiviral Therapy for AECHB and Severe Hepatitis B (Liver Failure)

This chapter describes the principles of antiviral therapy, treatment strategies, medications and recommendations for AECHB, HBV-ACLF, HBV-related liver cirrhosis, HBV-related HCC, and liver transplantation.

Severe exacerbation of chronic hepatitis B is closely related to continuous HBV replication. Therefore, inhibiting HBV replication to reduce viral load may block disease progression and improve the quality of life of these patients. ETV or TDF has been recommend first-line drug for the treatment of AECHB.

A hyperactive immune response due to continuous HBV replication is the main mechanism for development of severe hepatitis B. In addition to comprehensive treatment, early administration of potent nucleoside analogs can rapidly reduce HBV DNA concentration, relieve immune injury induced by HBV, and reduce liver inflammation and patient mortality. Antiviral agents have become important in the treatment of severe exacerbation of chronic hepatitis B.

Long-term antiviral treatment with nucleoside analogs can delay or reverse the progress of liver cirrhosis. Virologic response, viral resistance and adverse drug reactions should be closely monitored during treatment. The treatment should be optimized for maximum effect based on each patient’s responses.

Effective antiviral therapy can suppress HBV replication and reduce the incidence of HBV-related HCC. Patients with HBV-related HCC should receive individualized and optimal multidisciplinary comprehensive treatment. Anti-viral drugs with high efficacy, low resistance and low adverse drug reactions should be selected to improve the patient’s quality of life and prolong survival time.

Methods to prevent HBV reinfection after liver transplantation include passive immunization (HBIG), antiviral treatment (nucleoside analogs) and active immunization (hepatitis B vaccine).

Clinical trials involving sequential combination therapy with NUC and Peg-IFN have shown statistically significant decline in HBsAg levels on treatment and high rates of sustained post-treatment serologic response. Combination therapy with novel DAA and immunotherapeutic approach may hold promise to overcome both cccDNA persistence and immune escape, representing a critical step towards HBV cure.

TR4 nuclear receptor suppresses HCC cell invasion via downregulating the EphA2 expression

Early studies indicated that testicular nuclear receptor 4 (TR4) could function as a suppressor in the transcriptional regulation of the HBV core gene expression, which might then influence the development of hepatocellular carcinoma (HCC). The direct linkage between TR4 and HCC progression, however, remained unclear. Here, via a human clinical sample survey, we found that 13 of the 18 HCC patients studied had lower TR4 expression in metastatic lesions than in matched primary HCC lesions, suggesting that TR4 may play a negative role in HCC metastasis. Results from in vitro cell migration/invasion studied confirmed that TR4 could suppress HCC cell migration/invasion. Mechanism dissection revealed that TR4 might function through downregulating ephrin type-A receptor 2 (EphA2) expression at the transcriptional level via direct binding to the TR4REs located on the 5' promoter of EphA2 to suppress HCC cell migration/invasion. Targeting the EphA2 via EphA2-siRNA partially reversed the enhanced HCC cell migration/invasion with confirmed TR4 knockdown. Notably, results from preclinical studies using in vivo mouse model with orthotopic xenograft of HCC LM3 cells also confirmed the in vitro findings. Taking these findings together, preclinical studies using multiple in vitro HCC cell lines and an in vivo mouse model all led to the conclusion that TR4 may function as a suppressor of HCC metastasis and that targeting this newly identified TR4-EphA2 signaling may improve our ability to suppress HCC metastasis.

An Ecological Study of the Association between Air Pollution and Hepatocellular Carcinoma Incidence in Texas

INTRODUCTION

Primary liver cancer is a significant cause of cancer-related death in both the United States and the world at large. Hepatocellular carcinoma comprises 90% of these primary liver cancers and has numerous known etiologies. Evaluation of these identified etiologies and other traditional risk factors cannot explain the high incidence rates of hepatocellular carcinoma in Texas. Texas is home to the second largest petrochemical industry and agricultural industry in the nation; industrial activity and exposure to pathogenic chemicals have never been assessed as potential links to the state's increased incidence rate of hepatocellular carcinoma.

METHODS

The association between the county-level concentrations of 4 air pollutants known to be linked to liver cancer, vinyl chloride, arsenic, benzene, and 1,3-butadiene, and hepatocellular carcinoma rates was evaluated using nonparametric generalized additive logistic regression and gamma regression models. Hepatocellular carcinoma incidence rates for 2000-2013 were evaluated in comparison to 1996 and 1999 pollution concentrations and hepatocellular carcinoma rates for the subset of 2006-2013 were evaluated in comparison to 2002 and 2005 pollution concentrations, respectively.

RESULTS

The analysis indicates that the relationship between the incidence of liver cancer and air pollution and risk factors is nonlinear. There is a consistent significant positive association between the incidence of liver cancer and hepatitis C prevalence rates (gamma all years, p < 0.05) and vinyl chloride concentrations (logistic 2002 and 2005, p < 0.0001; gamma 2002 and 2005, p < 0.05).

CONCLUSIONS

This study suggests that vinyl chloride is a significant contributor to the incidence of liver cancer in Texas. The relationship is notably nonlinear. Further, the study supports the association between incidence of liver cancer and prevalence of hepatitis B.

Changes in viral hepatitis B screening practices over time in West African HIV clinics

BACKGROUND

We aimed to describe changes in hepatitis B screening practices over a 3-year period among HIV-infected patients in West Africa.

METHODS

A medical chart review was conducted in urban HIV treatment centers in Ivory Coast (3 sites), Benin, Burkina Faso, Senegal, and Togo (1 site each). Among patients who started antiretroviral treatment between 2010 and 2012, 100 per year were randomly selected from each clinic. Demographic, clinical, and laboratory data was collected using a standardized questionnaire. We assessed changes in the proportion of patients screened over time and identified predictors of screening in a multivariable logistic regression.

RESULTS

A total of 2097 patients were included (median age: 37 years, 65.4% of women). Overall, 313 (14.9%) patients had been screened for hepatitis B, with an increase from 10.6% in 2010 to 18.9% in 2012 (P<0.001) and substantial differences across countries. In multivariable analysis, being aged over 45 years (adjusted odds ratio: 1.34 [1.01-1.77]) and having an income-generating activity (adjusted odds ratio: 1.82 [1.09-3.03]) were associated with screening for hepatitis B infection. Overall, 62 HIV-infected patients (19.8%, 95% confidence interval: 15.5-24.7) were HBsAg-positive and 82.3% of them received a tenofovir-containing drug regimen.

CONCLUSION

Hepatitis B screening among HIV-infected patients was low between 2010 and 2012. The increasing availability of HBsAg rapid tests and tenofovir in first-line antiretroviral regimen should improve the rates of hepatitis B screening.

Hepatitis B and Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death worldwide, and its incidence has been increasing in the last decade largely in parallel to the incidence and duration of exposure to hepatitis B and C. The widespread implementation of hepatitis B vaccine, hepatitis B antivirals, and the introduction of direct antiviral therapies for hepatitis C virus may have a substantial impact in reducing the incidence of HCC. This report reviews the risk factors and underlying mechanisms associated with the development of HCC in hepatitis B, along with advances in the diagnosis, imaging, and management of HCC.

Time trend analysis of primary liver cancer incidence in Sihui county of Guangdong Province, China (1987-2011)

BACKGROUND

Southern China is an endemic area for primary liver cancer (PLC), but it is unclear if rates have changed in recent decades. We evaluated PLC incidence and estimated the effects of age, period of diagnosis, and birth cohort in Sihui City, Guangdong Province, China.

METHODS

Age-standardized rates (ASRs) of PLC were examined for both males and females from 1987 to 2011. Joinpoint regression analysis was conducted to estimate the annual percent changes in PLC incidence. The age-period-cohort (APC) model was used to investigate the effects of age, diagnosis period, and birth cohort on the relative risk (RR) of PLC.

RESULTS

A total of 2988 PLC cases were identified in this period, with average ASRs of 51.1/100,000 for males and 11.7/100,000 for females. Joinpoint regression analysis revealed increasing PLC incidence throughout the entire period in both males (average annual change of 1.65 %) and females (0.20 %). RRs increased gradually in both sexes from the youngest age group (30-34 years) to the oldest (80-84 years). In males, the RR decreased during diagnosis period from 1987-1991 to 1997-2001 and remained stable thereafter. In females, RRs fluctuated with diagnosis period throughout the entire period. Incidence tended to increase with birth cohort from 1905-1909 to 1975-1979 in both males and females; however, female incidence plateaued in the youngest cohorts born between 1955 and 1974, while incidence in males increased sharply in the cohorts born between 1965 and 1974. According to APC analysis, the full age-period-cohort (APC) model fit the data best, and the period-cohort (PC) model would be enough to explain variability of rates in females.

CONCLUSION

The PLC incidence rate in males of Sihui City has increased more significantly than female over the last 25 years. Despite the age effect in male, this trend mainly reflects the effects of risk factors that are present in early life (birth cohort) and period change in both genders.

A pre-operative clinical model to predict microvascular invasion and long-term outcome after resection of hepatocellular cancer: The Australian experience

BACKGROUND

Hepatocellular cancer (HCC) is a leading cause of mortality worldwide. Liver resection or transplantation offer the best chance of long-term survival. The aim of this study was to perform a survival and prognostic factor analysis on patients who underwent resection of HCC at two major tertiary referral hospitals, and to investigate a pre-operative prediction model for microvascular invasion (MVI).

METHODS

Clinico-pathological and survival data were collected from all patients who underwent liver resection for HCC at two tertiary referral centres (Royal North Shore/North Shore Private Hospitals and Westmead Hospital) from 1998 to 2012. An overall and disease-free survival analysis was performed and a predictive model for MVI identified.

RESULTS

The total number of patients in this series was 125 and the 5-year overall and disease-free survival rates were 56% and 37%, respectively. MVI was the only factor to be independently associated with a poor prognosis on both overall and disease-free survival. Age ≥64 years, a serum alpha-fetoprotein (AFP) ≥400 ng/ml (×40 above normal) and tumor size ≥50 mm were independently associated with MVI. An MVI prediction model using these three pre-operative factors provides a good assessment of the risk of MVI.

CONCLUSION

MVI in the resected specimen of patients with HCC is associated with a poor prognosis. A preoperative MVI prediction model offers a useful way to identify patients at risk of relapse. However, more precise predictive models using molecular and genetic variables are needed to improve selection of patients most suitable for radical surgical treatment.

A 13-Year Retrospective Study on Primary Liver Cancer in Cambodia: A Strikingly High Hepatitis C Occurrence among Hepatocellular Carcinoma Cases

OBJECTIVES

Hepatocellular carcinoma (HCC) is the main type of primary liver cancer (PLC) worldwide, but cholangiocarcinoma (CCA) may be predominant in some specific regions of Southeast Asia. The aim of the present study was to delineate a pattern of Cambodian PLC patients attending the Calmette Hospital in the Cambodian capital Phnom Penh.

MATERIALS AND METHODS

A total of 553 medical charts diagnosing PLCs from January 2003 to May 2015 were obtained from both the Oncology and Hepato-Gastroenterology Departments of the Calmette Hospital.

RESULTS

HCC was the predominant type of PLC recorded, with 511 cases (92.4%), whereas CCA represented merely 7.6% (42 cases) of the overall series. Hepatitis B virus (HBV; 44.3%) and hepatitis C virus (HCV; 43%) infection rates were similar among the HCC patients, while small subsets of CCA patients were infected with HBV (15.4%) or HCV (11.5%). Most HCC (84%) and CCA (73.8%) patients received palliative treatment only.

CONCLUSION

The present study indicates that HCC is the main form of primary hepatic neoplasm among PLC patients attending a hospital in Cambodia. HBV and HCV infections represented equivalent burdens and major contributing factors to HCC. Therefore, the implementation of prevention programs for these infectious agents should become a priority for health policy makers in the country.

New advances in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the leading cause of deaths in cirrhotic patients and the third cause of cancer related deaths. Most HCC are associated with well known underlying risk factors, in fact, HCC arise in cirrhotic patients in up to 90% of cases, mainly due to chronic viral hepatitis and alcohol abuse. The worldwide prevention strategies are conducted to avoid the infection of new subjects and to minimize the risk of liver disease progression in infected patients. HCC is a condition which lends itself to surveillance as at-risk individuals can readily be identified. The American and European guidelines recommended implementation of surveillance programs with ultrasound every six months in patient at-risk for developing HCC. The diagnosis of HCC can be based on non-invasive criteria (only in cirrhotic patient) or pathology. Accurately staging patients is essential to oncology practice. The ideal tumour staging system in HCC needs to account for both tumour characteristics and liver function. Treatment allocation is based on several factors: Liver function, size and number of tumours, macrovascular invasion or extrahepatic spread. The recommendations in terms of selection for different treatment strategies must be based on evidence-based data. Resection, liver transplant and interventional radiology treatment are mainstays of HCC therapy and achieve the best outcomes in well-selected candidates. Chemoembolization is the most widely used treatment for unresectable HCC or progression after curative treatment. Finally, in patients with advanced HCC with preserved liver function, sorafenib is the only approved systemic drug that has demonstrated a survival benefit and is the standard of care in this group of patients.

Hepatocellular Carcinoma Screening and Surveillance: Practice Guidelines and Real-Life Practice

Hepatocellular carcinoma (HCC) is the seventh most common malignancy worldwide. HCC meets all the criteria established by the World Health Organization for performing surveillance on those at-risk for developing cancer. Although there are consensus guidelines in the United States, Europe, and Asia for HCC surveillance, it is unclear if these guidelines are regularly implemented in routine practice to optimize real-life clinical outcomes. We reviewed the current literature on the adherence to current HCC practice guidelines by the American Association for the Study of Liver Diseases (2009), the European Association for the Study of the Liver (2012), and the Asia Pacific Association for the Study of the Liver (2010) for screening/surveillance and outcomes of optimal versus poor adherence. We performed PubMed search for relevant articles regarding HCC surveillance and screening worldwide. Currently, HCC screening is underutilized to a large extent. In most studies, the adherence to HCC screening and surveillance is suboptimal. Various patient, provider, and health care system factors may have all contributed to such nonadherence. Strategies to improve HCC screening and surveillance are urgently needed for early HCC detection and improved survival of HCC patients. Further research is needed to elucidate the various medical and/or cultural knowledge, belief, and practice patterns that can lead to barriers to HCC screening and surveillance at both patient and provider levels. These data will help focus and target advocacy and educational efforts to improve HCC surveillance at all levels: patients, providers, and health care system/government.

Dectin-1 Regulates Hepatic Fibrosis and Hepatocarcinogenesis by Suppressing TLR4 Signaling Pathways

Dectin-1 is a C-type lectin receptor critical in anti-fungal immunity, but Dectin-1 has not been linked to regulation of sterile inflammation or oncogenesis. We found that Dectin-1 expression is upregulated in hepatic fibrosis and liver cancer. However, Dectin-1 deletion exacerbates liver fibro-inflammatory disease and accelerates hepatocarcinogenesis. Mechanistically, we found that Dectin-1 protects against chronic liver disease by suppressing TLR4 signaling in hepatic inflammatory and stellate cells. Accordingly, Dectin-1(-/-) mice exhibited augmented cytokine production and reduced survival in lipopolysaccharide (LPS)-mediated sepsis, whereas Dectin-1 activation was protective. We showed that Dectin-1 inhibits TLR4 signaling by mitigating TLR4 and CD14 expression, which are regulated by Dectin-1-dependent macrophage colony stimulating factor (M-CSF) expression. Our study suggests that Dectin-1 is an attractive target for experimental therapeutics in hepatic fibrosis and neoplastic transformation. More broadly, our work deciphers critical cross-talk between pattern recognition receptors and implicates a role for Dectin-1 in suppression of sterile inflammation, inflammation-induced oncogenesis, and LPS-mediated sepsis.

Novel metronomic chemotherapy and cancer vaccine combinatorial strategy for hepatocellular carcinoma in a mouse model

Hepatocellular carcinoma (HCC) is the most frequent primary liver cancer and represents the third and the fifth leading cause of cancer-related death worldwide in men and women, respectively. Hepatitis B virus (HBV) and hepatitis C virus (HCV) chronic infections account for pathogenesis of more than 80 % of primary HCC. HCC prognosis greatly varies according to stage at beginning of treatment, but the overall 5-year survival rate is approximately 5-6 %. Given the limited number of effective therapeutic strategies available, immunotherapies and therapeutic cancer vaccines may help in improving the clinical outcome for HCC patients. However, the few clinical trials conducted to date have shown contrasting results, indicating the need for improvements. In the present study, a novel combinatorial strategy, based on metronomic chemotherapy plus vaccine, is evaluated in a mouse model. The chemotherapy is a multi-drug cocktail including taxanes and alkylating agents, which is administered in a metronomic-like fashion. The vaccine is a multi-peptide cocktail including HCV as well as universal tumor antigen TERT epitopes. The combinatorial strategy designed and evaluated in the present study induces an enhanced specific T cell response, when compared to vaccine alone, which correlates to a reduced Treg frequency. Such results are highly promising and may pave way to relevant improvements in immunotherapeutic strategies for HCC and beyond.

Serine-arginine protein kinase 1 is associated with hepatocellular carcinoma progression and poor patient survival

The pre-mRNA splicing regulator serine-arginine protein kinase 1 (SRPK1) promotes cancer development and various pathophysiological processes. However, the clinical relevance of SRPK1 in hepatocellular carcinoma (HCC) is not clear. This study investigates the expression and prognostic value of SRPK1 in HCC. We found that SRPK1 expression was significantly upregulated at the mRNA and protein level in all HCC cell lines or HCC tissue samples compared with the hepatic cell line or matched noncancerous tissue samples, respectively. Higher SRPK1 expression significantly correlated with clinical staging (p = 0.031), survival time (p = 0.004), and gender (p = 0.011) of HCC patients. Together, our study showed that SRPK1 is overexpressed in HCC and may be a promising indicator of prognosis for HCC patients.

Hepatocellular carcinoma in Asia: Prevention strategy and planning

AIM: To review all of epidemiological and etiological aspects of hepatocellular carcinoma (HCC) and examined the prevention of this disease in Asia.

METHODS: We conducted a systematic review according to the PRISMA guidelines. We were chosen articles that published previously, from PubMed (MEDLINE), the Cochrane database and Scopus. The key words used in this research were as follows: HCC in Asia and the way of prevention of this disease, with no language limitations. We selected those papers published before 2014 that we considered to be most important and appropriate. All relevant articles were accessed in full text and all relevant materials was evaluated and reviewed.

RESULTS: More than 70% of all new cases of liver cancer were diagnosed in Asia, a region that 75% of all those chronically infected with hepatitis B virus (HBV) in the world. Chronic HBV infection is the main cause of HCC in Asia, where the virus is endemic and vertical transmission is common. Japan, Saudi Arabia, Egypt and Pakistan are exception because of high prevalence of HCV infection in these regions. The prevalence of this cancer is high in Eastern and South-Eastern Asia, But Middle Eastern countries are characterized as moderate prevalence rate of HCC region and Central Asia and some part of Middle Eastern countries are known as low prevalence rate of HCC. In addition of HBV and HCV the other factors such as aflatoxin, alcohol, obesity, diabetes and non-alcoholic fatty liver disease (NAFLD) might be responsible for a low prevalence of HCC in Asian countries. Currently available HCC therapies, chemotherapy, surgical are inefficient, mainly due to usually late diagnosis and high recurrence rates after surgical resection, and usually end with treatment failure. Liver transplantation also remains as a difficult strategy in patients with HCC. Thus prevention of HCC by treating and prevention HBV and HCV infection, the major causative agents of HCC, and the other risk factors such as aflatoxin, alcohol, obesity, diabetes and NAFLD is of a great medical importance.

CONCLUSION: The main challenge which still present in Asia, is the high prevalence of chronic hepatitis. So, prevention of HBV and HCV is the key strategy to reduce the incidence of HCC in Asia.

Inhibitory Effect of Genistein on PLC/PRF5 Hepatocellular Carcinoma Cell Line

BACKGROUND

Natural compounds including flavonoids like genistein (GE) are able to inhibit cell proliferation and induce apoptosis. GE is the main representative of these groups. GE inhibits carcinogenic tumors such as colon, stomach, lung, and pancreas tumors. The aim of the present study was to analyze the apoptotic effect of GE in the hepatocellular carcinoma (HCC) PLC/PRF5 cell line.

METHODS

Cells were treated with various doses of GE (1, 5, 10, 25, 50, 75, and 100 μM/L) at different times (24, 48, and 72 h) and the MTT assay was commonly used. Furthermore, cells were treated with single dose of GE (25 μM) at different times and flow cytometry was performed.

RESULTS

GE inhibited the growth of liver cancer cells significantly with a time- and dose-dependent manner. The percentage of living cells in GE treatment groups with a concentration of 25 μM at different times were 53, 48 and 47%, respectively (P < 0.001). Result of flow cytometry demonstrated that GE at a 25 μM concentration induces apoptosis significantly in a time-dependent manner. The percentage of apoptotic cells at different times were 44, 56, and 60%, respectively (P < 0.001).

CONCLUSIONS

GE can significantly inhibit the growth of HCC cells and plays a significant role in apoptosis of this cell line.

Hepatocellular carcinoma epidemiology

Primary liver cancer (namely hepatocellular carcinoma, HCC) is worldwide the fifth most common cancer in men and the seventh one in women, and it represents the third most frequent cause of cancer death. HCC rates are particularly high in eastern/south-eastern Asia and in Africa, intermediate in Southern Europe, and low in most high-income countries. Persistent infections by HBV or HCV are the main recognized risk factors for HCC. Aflatoxin exposure is also an important risk factor for HCC development in Africa and eastern Asia. In high-income countries heavy alcohol drinking, tobacco smoking, overweight, diabetes, familial/genetic factors, and selected dietary aspects, have a relevant role. Updated geographic patterns and time trends in mortality from HCC in Europe, USA, Japan, and Australia are provided in the present review, together with an overview of relevant etiologic factors for HCC and main measures for the prevention of this neoplasm.

Could metabolic syndrome lead to hepatocarcinoma via non-alcoholic fatty liver disease?

It was estimated that from 2002 to 2008 the risk of developing cancer increased a quarter-fold in men and two-fold in women due to excessive BMI. Obesity, metabolic syndrome and type 2 diabetes mellitus are strictly related and are key pathogenetic factors of non-alcoholic fatty liver disease (NAFLD), the most frequent liver disease worldwide. The most important consequence of the “metabolic epidemics” is the probable rise in the incidence of hepatocarcinoma (HCC), and NAFLD is the major causative factor. Adipose tissue is not merely a storage organ where lipids are preserved as an energy source. It is an active organ with important endocrine, paracrine, and autocrine actions in addition to immune functions. Adipocytes produce a wide range of hormones, cytokines, and growth factors that can act locally in the adipose tissue microenvironment and systemically. In this article, the main roles of insulin growth factor (IGF)-1 and IGF-2 are discussed. The role of IGF-2 is not only confined to HCC, but it may also act in early hepato-carcinogenesis, as pre-neoplastic lesions express IGF-2 mRNA. IGF-1 and IGF-2 interact with specific receptors (IGF-1R and IGF-2R). IGF-1R is over-expressed in in vitro and in animal models of HCC and it was demonstrated that IGF ligands exerted their effects on HCC cells through IGF-1R and that it was involved in the degeneration of pre-neoplastic lesions via an increase in their mitotic activity. Both IGF-2R and TGF β, a growth inhibitor, levels are reduced in human HCC compared with adjacent normal liver tissues. Another key mechanism involves peroxisome proliferator-activated receptor (PPAR)γ. In in vitro studies, PPARγ inhibited various carcinomas including HCC, most probably by regulating apoptosis via the p21, p53 and p27 pathways. Finally, as a clinical consequence, to improve survival, efforts to achieve a “healthier diet” should be promoted by physicians and politicians.

Lipid droplets may lay a spacial foundation for vasculogenic mimicry formation in hepatocellular carcinoma

Vasculogenic mimicry is a highly patterned vascular channel distinguished from the endothelium-dependent blood vessel. Vasculogenic mimicry is lined by highly aggressive tumor cells, and is associated with tumor grade, invasion and metastasis, and poor clinical prognosis. Much attention has been focused on the signaling pathways and the tumor microenvironment needed for vasculogenic mimicry formation, however, the studies on the spacial foundation for vasculogenic mimicry formation are limited. There are many lipid droplets in hepatocellular carcinoma due to steatosis, while increased numbers of lipid droplets also have been reported in many other neoplastic processes. The role of lipid droplets in tumor is still unclear. Based on the similar structural and morphological characteristics between vasculogenic mimicry and lipid droplet, we speculate that the lipid droplets may lay a spacial foundation for vasculogenic mimicry formation by a way of "space placeholder" in HCC. Experimental data and limited clinical literatures support the hypothesis to a certain degree. This hypothesis may provide a new idea for the study of vasculogenic mimicry and also provide a new direction for the functional study of lipid droplets in tumor.

Universal hepatitis B vaccination in Belgium: impact on serological markers 3 and 7 years after implementation

Hepatitis B virus (HBV) can be eliminated by effective universal vaccination. In Belgium, a free-of-charge HBV vaccination programme in infants with catch-up in adolescents was introduced in 1999. To evaluate the effects in <20-year-olds, seroprotection (anti-HBs >11 mIU/ml, according to the assay) and markers of infection (anti-HBc, HBsAg) were assessed in 2443 residual sera collected 7-8 years after implementation of the programme. The maximal prevalence of a solely anti-HBs seroprotective ('vaccinated') serostatus was 82·9% at age 1 year and 60·5% at age 13 years. A clear increase was found in age cohorts targeted by the campaign after a similar serosurvey conducted 4 years earlier. The prevalence of HBV infection remained unchanged at a low level (1·8% in 2006) similar to pre-vaccination data (1993-1994). We conclude that universal HBV vaccination has achieved overall high levels of vaccine-induced immunity, despite regional variations, which may give rise to pockets of susceptible young adults in the future.

Reduced aflatoxin exposure presages decline in liver cancer mortality in an endemic region of China

Primary liver cancer (PLC) is the third leading cause of cancer mortality globally. In endemic areas of sub-Saharan Africa and Asia, PLC largely arises from chronic infection with hepatitis B virus (HBV) and ingestion of aflatoxins. Although synergistic interactions between these two risk factors have been observed in cohort studies in China, here we determined the impact of agricultural reforms in the 1980s leading to diminished maize consumption and implementation of subsidized universal vaccination against HBV in the 2000s on PLC primary prevention. A population-based cancer registry was used to track PLC mortality in Qidong, China and was compared with the timeline of HBV immunization. Randomly selected serum samples from archived cohort collections from the 1980s to present were analyzed for aflatoxin biomarkers. More than 50% reductions in PLC mortality rates occurred across birth cohorts from the 1960s to the 1980s for Qidongese less than 35 years of age although all were born before universal vaccination of newborns. Median levels of the aflatoxin biomarker decreased from 19.3 pg/mg albumin in 1989 to undetectable (<0.5 pg/mg) by 2009. A population attributable benefit of 65% for reduced PLC mortality was estimated from a government-facilitated switch of dietary staple from maize to rice; 83% of this benefit was in those infected with HBV. Food policy reforms in China resulted in a dramatic decrease in aflatoxin exposure, which, independent of HBV vaccination, reduced liver cancer risk. The extensive HBV vaccine coverage now in place augurs even greater risk reductions in the future.

Etiologic and epidemiologic study of hepatocellular carcinoma in West Azarbaijan of Iran (2006-2011)

Background:

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Epidemiologic and etiologic studies help in the prevention of disease and improve surveillance of affected patients. The aim of this study was to study the etiology and epidemiology of HCC in West Azarbaijan of Iran.

Materials and Methods:

In this cross-sectional, retrospective study, medical records of 60 patients with HCC who were diagnosed between 2006 and 2011 in West Azarbaijan of Iran were analyzed for age, sex, location, presence of liver cirrhosis and/or well-known risk factors of HCC. Data were analyzed by SPSS 17 software.

Results:

From 60 patients with HCC, 75% were male and 25% were female. Mean age of the patients was 63.47 years. 51.66% were from rural areas and 48.33% were from urban areas. 43.33% of HCC patients were cirrhotic while 56.66% patients were non-cirrhotic. Of the 26 cirrhotic patients, 57.69% were seropositive for hepatitis B surface antigen (HBsAg), 15.38% not only had history of excess alcohol intake but were also HBsAg positive, 3.84% had history of alcoholism, 3.84% had history of Wilson disease and the rest (19.24%) had cryptogenic cirrhosis. Of the 34 non-cirrhotic patients, 35.29% were positive for HBsAg. None of the 60 patients with HCC had positive serology for hepatitis C virus (HCV) or history of hepatitis C infection.

Conclusion:

In our study, most of the patients (>50%) with HCC did not have underlying liver cirrhosis. In the cirrhotic patients, hepatitis B infection was the most common predisposing factor, followed by hepatitis B infection concomitant with alcoholism, alcoholism alone and Wilson disease. In the remaining cirrhotic patients, we could not find any predisposing factor for cirrhosis. Infection with HCV was not found in our studied group. We concluded that etiology of HCC in our province is different from that in the western countries.

Serum anti-P53 antibodies and alpha-fetoprotein in patients with non-B non-C hepatocellular carcinoma

The rate of hepatocellular carcinoma (HCC) is increasing worldwide including Egypt. Non-B non-C HCC was reported in some countries. We aimed to investigate P53 antibodies and alpha-fetoprotein in patients with non-B non-C HCC in our region. In a case series study, included 281 patients with HCC and 20 patients with liver cirrhosis of matched age, sex and social factors were received for management at Tanta University Hospitals. Sera were tested for HCV and HBV markers by ELISA/PCR, alpha-fetoprotein (AFP) level and anti-p53 antibody were evaluated by ELISA. Antinuclear antibody, serum copper and iron were assessed in non-viral HCC. Liver scanning and biopsy were evaluated. Non-B non-C HCC patients were 13.87% of total. P53 antibody serum level in non-B non-C HCC patients showed insignificant difference (p>0.05) as compared to viral-associated HCC, while significant as compared to cirrhosis. They had significant decrease in serum AFP level (p<0.001) as compared to viral-associated HCC. Their tumors were mainly solitary, and have smaller-sizes. Sensitivity, specificity, PPV, NPV and accuracy test of anti P53 antibody positive patients were 91.52%, 84.63%, 90.34%, 80.2% and 74.8% respectively. It correlates positively with AFP, tumor size and staging, MELD score and Child-Pugh score. Non-B non-C HCC showed high serum prevalence of anti-p53 as viral-associated HCC suggesting an evidence of high onchogenecity. It appears of much benefit in diagnosis, follow up and differentiation from cirrhosis in presence of low levels of alpha-fetoprotein.

Hepatitis C virus and other risk factors in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) increased in Egypt in the past years, becoming the most common cancer among men. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the known primary risk factors for HCC. This study describes the viral profile of HCC in a predominantly rural area in Egypt. We included 148 HCC cases and 148 controls from the Tanta Cancer Center and the Gharbiah Cancer Society in the Nile delta region. Serological (ELISA) and molecular (PCR) analysis for HBV and HCV infection were performed on plasma samples from each subject. Epidemiologic, environmental, and medical histories were collected by interviewing of subjects. Around 90.5% of cases and controls were from rural areas. HCV infection was high in both cases and controls (89.2% and 49.3%, for cases and controls respectively by serology). HCV was the most important HCC risk factor [OR 9.7 (95% CI: 3.3-28.0, P <0.01)], and HBV infection showed marginal tendency of increased risk [OR 5.4 (95% CI: 0.9-31.8, P <0.06)]. Ever worked in farming [OR 2.8 (95% CI: 1.1-7.2, P <0.03)] and history of cirrhosis [OR 3.6 (95% CI: 1.6-8.1, P <0.01)] or blood transfusion [OR 4.2 (95% CI: 0.99-17.8, P <0.05)] were also associated with increased HCC risk. This study in a predominantly rural area in Egypt supports previous reports from other parts of Egypt that HCV infection is the primary HCC risk factor in Egypt. Further understanding of the relationship between infection and other risk factors in the development of HCC could lead to targeted interventions for at-risk individuals.

KEYWORDS

hepatocellular carcinoma; hepatitis; rural; risk factors; Egypt.

Global geographical overlap of aflatoxin and hepatitis C: controlling risk factors for liver cancer worldwide

About 85% of hepatocellular carcinoma (HCC, liver cancer) cases occur in low-income countries, where the risk factors of dietary aflatoxin exposure and chronic hepatitis B and C (HBV and HCV) viral infection are common. While studies have shown synergism between aflatoxin and HBV in causing HCC, much less is known about whether aflatoxin and HCV synergise similarly. From an exposure perspective, it was examined whether there is a geographical overlap in populations worldwide exposed to high dietary aflatoxin levels and with high HCV prevalence. While HCV is one of the most important risk factors for HCC in high-income nations (where aflatoxin exposure is low), it is found that HCV prevalence is much higher in Africa and Asia, where aflatoxin exposure is also high. However, within a given world region, there are some inconsistencies regarding exposure and cancer risk. Therefore, there is a need to control risk factors such as aflatoxin and hepatitis viruses in a cost-effective manner to prevent global HCC, while continuing to evaluate biological mechanisms by which these risk factors interact to increase HCC risk.

Quality improvement in gastroenterology clinical practice

An emphasis on quality improvement (QI) is vital to the cost-effective provision of evidence-based health care. QI projects in gastroenterology have typically focused on endoscopy to minimize or eliminate procedure-related complications or errors. However, a significant component of gastroenterology care is based on the management of chronic disease. Patients with chronic diseases are seen in many different outpatient practices in the community and academia. In an attempt to ensure that every patient receives high-quality care, major gastrointestinal societies have published guidelines on the management of common gastrointestinal complaints. However, adherence to these guidelines varies. We discuss common outpatient gastrointestinal illnesses with established guidelines for management that could benefit from active QI projects; these would ensure a consistently high standard of care for every patient.

Interferon regulatory factor (IRF)-1 and IRF-2 are associated with prognosis and tumor invasion in HCC

BACKGROUND

Interferon regulatory factor (IRF)-1 and IRF-2 are transcriptional factors that mediate interferons functions; the loss of IRF-1 expression and gain of IRF-2 expression were associated with malignant phenotype in multiple cancers. However, their roles in the progression of hepatocellular carcinoma (HCC) remain poorly described.

METHODS

Immunohistochemistry was used to analyze the nuclear expression of IRF-1/2 in a cohort of 332 HCC patients. The expression of IRF-1/2 in HCC cell lines with stepwise metastasis potential was determined by immunoblotting. Downregulation of IRF-1 or IRF-2 expression was mediated by shRNAs; a series of experiments were conducted to determine the changes of invasion ability and downstream molecular events.

RESULTS

High expression of IRF-1 was associated with good outcome (p<.001 for OS/TTR), while high expression of IRF-2 was relevant to increased recurrence probability (p=.049) in HCC patients. The combination of the 2 IRFs showed better predictive power than either factor alone. Immunoblotting analysis revealed that IRF-2/IRF-1 ratio was positively correlated with the metastatic potential in human HCC cell lines. Downregulation of IRF-2 led to sharply attenuated invasion ability, paralleled with a decreased expression of STAT3, p-STAT3(Ser727), and MMP9. While downregulation of IRF-1 caused a concurrent decrease in IRF-2, little or no change was displayed in IRF-2/IRF-1 ratio, invasion ability, and MMP9 expression.

CONCLUSIONS

IRF-1 and IRF-2 expression were associated with prognosis of HCC patients with opposite predictive power. IRF-2/IRF-1 ratio was associated with tumor invasion, probably through modulation of MMP9 expression mediated by STAT3.

Cancer burden in Africa and opportunities for prevention

Cancer is an emerging public health problem in Africa. About 715,000 new cancer cases and 542,000 cancer deaths occurred in 2008 on the continent, with these numbers expected to double in the next 20 years simply because of the aging and growth of the population. Furthermore, cancers such as lung, female breast, and prostate cancers are diagnosed at much higher frequencies than in the past because of changes in lifestyle factors and detection practices associated with urbanization and economic development. Breast cancer in women and prostate cancer in men have now become the most commonly diagnosed cancers in many Sub-Saharan African countries, replacing cervical and liver cancers. In most African countries, cancer control programs and the provision of early detection and treatment services are limited despite this increasing burden. This paper reviews the current patterns of cancer in Africa and the opportunities for reducing the burden through the application of resource level interventions, including implementation of vaccinations for liver and cervical cancers, tobacco control policies for smoking-related cancers, and low-tech early detection methods for cervical cancer, as well as pain relief at the palliative stage of cancer.

The role of oncogenic viruses in the pathogenesis of hepatocellular carcinoma

HBV and HCV have major roles in hepatocarcinogenesis. More than 500 million people are infected with hepatitis viruses and, therefore, HCC is highly prevalent, especially in those countries endemic for HBV and HCV. Viral and host factors contribute to the development of HCC. The main viral factors include the circulating load of HBV DNA or HCV RNA and specific genotypes. Various mechanisms are involved in the host-viral interactions that lead to HCC development, among which are genetic instability, self-sufficiency in growth signals, insensitivity to antigrowth signals, evasion of apoptosis, limitless replicative potential, sustained angiogenesis, and tissue invasiveness. Prevention of HBV by vaccination, as well as antiviral therapy against HBV and for HCV seem able to inhibit the development of HCC.

The liver tissue bank and clinical database in China

To develop a standardized and well-rounded material available for hepatology research, the National Liver Tissue Bank (NLTB) Project began in 2008 in China to make well-characterized and optimally preserved liver tumor tissue and clinical database. From Dec 2008 to Jun 2010, over 3000 individuals have been enrolled as liver tumor donors to the NLTB, including 2317 cases of newly diagnosed hepatocellular carcinoma (HCC) and about 1000 cases of diagnosed benign or malignant liver tumors. The clinical database and sample store can be managed easily and correctly with the data management platform used. We believe that the high-quality samples with detailed information database will become the cornerstone of hepatology research especially in studies exploring the diagnosis and new treatments for HCC and other liver diseases.

Viruses and human cancer: from detection to causality

The study of cancer is incomplete without taking into consideration of tumorigenic viruses. Initially, searches for human cancer viruses were fruitless despite an expansion of our knowledge in the same period concerning acute-transforming retroviruses in animals. However, over the last 40 years, we have witnessed rapid progress in the tumor virology field. Currently, acknowledged human cancer viruses include Epstein-Barr virus, hepatitis B virus, hepatitis C virus, high-risk human papilloma viruses, human T-cell lymphotropic virus type 1 and Kaposi's sarcoma-associated herpesvirus. Extensive epidemiological and mechanistic studies have led to the development of novel preventive and therapeutic approaches for managing some of these infections and associated cancers. In addition, recent advances in molecular technologies have enabled the discovery of a new potential human tumor virus, Merkel cell polyomavirus, but its association with cancer remains to be validated. It is anticipated that in the next few decades many additional human cancer viruses will be discovered and the mechanisms underlying viral oncogenesis delineated. Thus, it can be expected that better tools for preventing and treating virus-associated cancer will be available in the near future.

Comparative analysis of promoter methylation and gene expression endpoints between tumorous and non-tumorous tissues from HCV-positive patients with hepatocellular carcinoma

Transcriptional silencing of tumor suppressor genes and other cancer-related genes induced by promoter CpG island hypermethylation is an important epigenetic mechanism of hepatocarcinogenesis. Previous studies have established methylation profiles of hepatocellular carcinomas (HCCs) and demonstrated that methylation of several candidate genes in resected tissues may be associated with time to recurrence. The goals of our study were to test whether specific promoter methylation and mRNA levels of candidate genes, as well as global changes in DNA methylation, can be linked with time to recurrence and clinicopathological variables in a homogenous study group of HCC patients. Forty-three tumorous and 45 non-tumorous liver tissue samples from the surgical margin were obtained from HCV-positive, HBV-negative HCC patients who underwent tumor resection surgery and who were monitored for tumor recurrence thereafter (median follow-up time: 16 months (range, 0-79 months)). Methylation-specific PCR was used to assess the promoter methylation status of P16(INK4a), SOCS-1, RASSF1A, APC, GSTP1, RIZ1, and MGMT genes, while the level of LINE-1 methylation was used as marker of global DNA methylation levels. Methylation frequencies in P16(INK4a), RASSF1A, APC, GSTP1, and RIZ1 genes were significantly greater in tumorous versus non-tumorous tissues. Methylation of RIZ1 in non-tumorous tissues was significantly associated with time to recurrence. Additionally, genomic DNA was significantly more hypomethylated in tumorous tissues, and this change was associated with shorter recurrence, but not with clinicopathological features. In conclusion, this study supports the role of aberrant methylation in the pathobiology of HCV-positive HCCs. The finding that RIZ1 methylation and increased levels of LINE-1 hypomethylation in non-tumorous tissues are associated with time to recurrence underscores the importance of assessing the epigenetic state of the liver remnant.