Alpha-fetoprotein as a tumor marker in hepatocellular carcinoma: investigations in south Indian subjects with hepatotropic virus and aflatoxin etiologies

Changing Etiological Spectrum of Hepatocellular Carcinoma in India-A Systematic Review and Meta-analysis

Background

Recent studies from both India and outside India have shown a change in the etiological profile of hepatocellular carcinoma (HCC). We aimed to analyze the etiological spectrum and changing trends of HCC etiology in India using a systematic review of current literature and meta-analysis.

Methods

Electronic databases of PubMed/Medline, Scopus, and Embase were searched from inception to July 2023 for studies reporting the data on the etiology of HCC from India. The pooled proportions with 95% confidence interval were calculated using summative statistics.

Results

A total of 60 studies (n = 12,327) were included in the final analysis. The pooled proportions of HCC cases with at least one positive and negative viral marker were 56.0 (49.5-62.6) and 43.1% (36.5-49.8), respectively. The pooled proportion of HCC cases with positive hepatitis B virus (HBV) markers was 41.0 (35.8-46.1), while those with positive markers for hepatitis C virus were 20.3 (17.0-23.6). The pooled proportion of cases with HCC with significant alcohol intake was 19.0% (15.6-22.4), and those related to nonalcoholic fatty liver disease (NAFLD) were 16.9% (12.1-21.7). Around 7.9% (5.8-10.0) of the cases had HCC with multiple etiologies. Subgroup analysis showed a significant variation with the location of the study based on zone. Meta-regression analysis based on publication year (1990-2023) showed a significant reduction in the proportion of cases with HBV and an increase in cases with NAFLD. In contrast, the proportion of cases with hepatitis C virus and alcohol did not change significantly.

Conclusion

Viral hepatitis is the most common etiology of HCC in India, predominantly HBV. The proportions of cases with HCC related to NAFLD are increasing, and those related to HBV are declining.

Optimally Configured Optical Fiber Near-Field Enhanced Plasmonic Resonance Immunoprobe for the Detection of Alpha-Fetoprotein

The detection of trace biomarkers is an important supplementary approach for early screening and diagnoses of tumors. An optical fiber near-field enhanced plasmonic resonance immunoprobe is developed for the detection of the hepatocellular carcinoma biomarker, i.e., the alpha-fetoprotein. Generic principles based on dispersion models and finite element analysis (FEA) models are developed to realize the optimized configuration of spectral characteristics of the immunoprobe. Dispersion models provide theoretical guidance for the design of the multilayer sensing structure from the perspective of the ray optics theory. FEA models provide theoretical guidance for the selection of coating materials from the perspective of the self-defined dielectric constant ratio, i.e., the ratio of the real part to the imaginary part. The optimized configuration of the antibody coupling further improves the biosensing performance of the immunoprobe. The limit of detection (LOD) can reach down to 0.01 ng mL^-1 , which is one order of magnitude lower than those relevant reported works. Such a low LOD can more effectively avoid the accuracy degradation of detection results due to measurement errors. Human serum samples have also been detected, with the good precision achieved. This work shows promising prospects in applications of label-free, low-cost, rapid, and convenient early screening of tumors.

Utility of PIVKA-II and AFP in Differentiating Hepatocellular Carcinoma from Non-Malignant High-Risk Patients

Background and Objectives: We aim to compare the diagnostic performance of Protein induced by vitamin K absence-II (PIVKA-II), a biomarker for hepatocellular carcinoma (HCC), and alpha-fetoprotein (AFP) in differentiating HCC and non-malignant high-risk (NMHR) groups and to determine their cut-off values. Materials and Methods: A total of 163 patients, including 40 with HCC and 123 with NMHR (100 with liver cirrhosis and 23 with non-cirrhotic high-risk patients) were prospectively enrolled. The levels of AFP and PIVKA-II were measured, and their cut-off values were determined. We calculated and compared the areas under the receiver operating characteristic (AUROC) curves of PIVKA-II, AFP, and their combination. Results: The levels of PIVKA-II and AFP were found to be significantly higher in the HCC compared to NMHR patients (p < 0.0001). For the differentiation of HCC from NMHR, the optimal cutoff values for PIVKA-II and AFP were 36.7 mAU/mL (90% sensitivity; 82.1% specificity) and 14.2 ng/mL (75% sensitivity; 93.5% specificity), respectively. The AUROC of PIVKA-II (0.905, p < 0.0001) was higher compared to AFP (0.869, p < 0.0001), but the combination of PIVKA−II and AFP gave the highest AUROC value (0.911, p < 0.0001). However, their differences were not statistically significant (AFP vs. PIVKA; p = 0.4775, AFP vs. Combination; p = 0.3808, PIVKA vs. Combination; p = 0.2268). Conclusions: PIVKA-II and AFP showed equal performance in detecting HCC in high-risk patients. AFP as a screening marker for HCC may be adequate, and replacing or adding the PIVKA-II test in current clinical practice may be of little value.

Kernel-based hierarchical structural component models for pathway analysis

MOTIVATION

Pathway analyses have led to more insight into the underlying biological functions related to the phenotype of interest in various types of omics data. Pathway-based statistical approaches have been actively developed, but most of them do not consider correlations among pathways. Because it is well known that there are quite a few biomarkers that overlap between pathways, these approaches may provide misleading results. In addition, most pathway-based approaches tend to assume that biomarkers within a pathway have linear associations with the phenotype of interest, even though the relationships are more complex.

RESULTS

To model complex effects including nonlinear effects, we propose a new approach, Hierarchical structural CoMponent analysis using Kernel (HisCoM-Kernel). The proposed method models nonlinear associations between biomarkers and phenotype by extending the kernel machine regression and analyzes entire pathways simultaneously by using the biomarker-pathway hierarchical structure. HisCoM-Kernel is a flexible model that can be applied to various omics data. It was successfully applied to three omics datasets generated by different technologies. Our simulation studies showed that HisCoM-Kernel provided higher statistical power than other existing pathway-based methods in all datasets. The application of HisCoM-Kernel to three types of omics dataset showed its superior performance compared to existing methods in identifying more biologically meaningful pathways, including those reported in previous studies.

AVAILABILITY AND IMPLEMENTATION

Freely available at http://statgen.snu.ac.kr/software/HisCom-Kernel/.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Role of Cell Block Technology as an Adjunct to Fine Needle Aspiration in Evaluating as well as Differentiating Liver Lesions

BACKGROUND & OBJECTIVE

Liver lesions are difficult to diagnose and to differentiate primary from metastatic carcinoma, while Biopsy has its limitations. Cell block technology is easily accessible with high diagnostic accuracy. Our aim is 1) To find the role of cell block technology as an alternative to biopsy in identifying liver lesions; 2) To find the efficacy of cell block along with immunohistochemistry (IHC) and ancillary studies in differentiating primary from metastatic lesions; 3) To identify the site of origin of metastatic lesions. This is a descriptive study undertaken in two tertiary care hospitals over a period of three years.

METHODS

Retrospective review of adequate samples from fine needle aspirations from liver lesions under radiological coverage, converted into cell block was done. IHC was applied as needed. Usefulness of cell block preparation was evaluated, and the final diagnosis correlated with the biopsy results.

RESULTS

Analysis of 323 cases found sensitivity of 98.75% and positive predictive value of 99% for all lesions. Sensitivity for metastatic carcinomas was slightly more than hepatocellular carcinoma. However, accuracy of cell block results for individual metastatic lesions and site of origin was less. IHC and morphological pattern worked as an important adjunct in the final diagnosis. On the other hand, contribution of viral markers as a supplement in the final work up was ambiguous.

CONCLUSION

High precision of validity results of cell block technology in comparison with biopsy highlights its pivotal role in conjunction with supportive tests for diagnosing and differentiating liver lesions as well as identifying primary sites in liver metastasis.

The alpha-fetoprotein serum is still reliable as a biomarker for the surveillance of hepatocellular carcinoma in Indonesia

Background and aims

Hepatocellular carcinoma (HCC), the most common type of liver cancer, is one of the leading causes of cancer-related death worldwide with an inferior prognosis. In Indonesia, the average life expectancy is less than 5 months, with most patients being in an advanced stage wherein the survival rate is very low. Early detection through surveillance program is very crucial. HCC guidelines worldwide have provided surveillance recommendation through the examination of α-fetoprotein (AFP) and ultrasound for patients at risk in developing HCC. However, there have been some controversies regarding the usage of AFP concerning its low sensitivity and specificity in detecting HCC. Therefore, the effectiveness of AFP in the surveillance of HCC patients and identifying the parameters most associated with the increase of AFP ≥ 10 ng/ml in Indonesia should be evaluated.

Methods

We analyzed medical records of HCC patients and those at high risk of developing HCC through cross-sectional study, including patients with cirrhosis and hepatitis B and C, from 2015 to 2017 who underwent treatment at the Cipto Mangunkusumo National General Hospital and Dharmais National Cancer Hospital, Indonesia.

Results

The sensitivity and specificity of AFP in the surveillance of HCC in Indonesia with a cut-off of 10 ng/ml were 82.6 and 71.2%, respectively. The parameters most associated with the increase of AFP ≥10 ng/ml according to multivariate analysis were the etiology of hepatitis B, the stage of Barcelona Clinic Liver Cancer (BCLC) B and C, and the presence of cirrhosis, respectively.

Conclusion

AFP can still be used in the surveillance of HCC in Indonesia for its high sensitivity value.

Prognostic impact of toll-like receptors 2 and 4 expression on monocytes in Egyptian patients with hepatocellular carcinoma

Toll-like receptors (TLRs) have a role in chronic inflammation. Still, little is known about the expression of TLRs in hepatocellular carcinoma (HCC). Herein, we tried to assess the prognostic value of TLR2 and TLR4 expression on circulating monocytes in HCC patients and correlate their levels with some clinical, laboratory data, and treatment outcomes. Forty patients with hepatic focal lesions diagnosed radiologically as HCC by triphasic multislice CT pelviabdominal and chest, and in some patients MRI diffusion and 38 age and sex matching healthy controls were enrolled in the study. Subjects were evaluated for liver functions, alpha-fetoprotein (AFP), imaging, response to different treatments, and overall survival. TLR2 and TLR4 expression by monocytes was detected by flow cytometry. The expression of both TLR2 and TLR4 on monocytes was significantly increased in HCC patients than the controls, in patients with more progressive HCC than those with lower progression and in patients with poor response to treatment than patients with better treatment response. Moreover, their levels showed positive correlations with ALT, AST, and AFP and inverse correlations with the overall survival of HCC patients. The results of the current study suggest that increased expression ofTLR2 and TLR4 on peripheral monocytes might reflect the development and progression of HCC and can be used to indicate poor prognosis. In addition, high expression of TLR2 correlated significantly with poor response to treatment, while high expression of both TLR2 and TLR4 were associated with poor survival. Our findings will help to design more studies on the role of TLRs in HCC pathogenesis and prognosis which may provide new therapeutic targets for HCC.

TIM-3 as a marker of exhaustion in CD8+ T cells of active chronic hepatitis B patients

BACKGROUND

Chronic HBV infection presents weak or no virus-specific T-cell responses, implying to an exhausted phenotype, characterized by overexpression of several inhibitory receptors. In the present study, it was aimed to characterize the panel of inhibitory molecules on the CD8⁺ T cells in patients with active chronic HBV infection.

METHODS

In this study, 31 active and 32 inactive individuals with chronic HBV infection were recruited. Peripheral blood mononuclear cells were isolated and a multicolor flow cytometry was applied to evaluate the surface inhibitory molecules of TIM3, PD-1, and CD39.

RESULTS

CD8⁺ T cells expressing TIM3 were significantly higher in cases with active chronic HBV infection compared to inactive chronic HBV group (8.43 ± 1.4 vs. 5.15 ± 1.43; P < 0.0001). CD8⁺TIM3⁺PD-1⁺ T cells were significantly higher in active chronic HBV cases in comparison to the inactive chronic HBV subjects (4.26 ± 1.04 vs. 3.41 ± 0.74; P < 0.001). Different subpopulations of the CD8⁺ T cells were correlated with the duration of infection and HBV DNA load in the cases with active chronic HBV infection.

CONCLUSION

It appears that CD8⁺ TIM3⁺ T cells are the major exhausted phenotype of T cells during the active state of HBV infection.

Evaluation of Diagnostic Efficiency of Alpha-Fetoprotein in Patients with Liver Cirrhosis and Hepatocellular Carcinoma: Single-Center Experience

BACKGROUND

AFP serum levels are considered as diagnostic and specific for hepatocellular carcinoma (HCC) in patients with liver cirrhosis (LC).

AIM

This study aimed to examine the diagnostic value of AFP in the distinguishing of patients with HCC from patients with LC, and to analyse the potential correlation between AFP levels and liver disease stages.

MATERIAL AND METHODS

Fifty patients with LC and fifty patients with HCC were included in this study. The majority of the patients were males, while the HBV aetiology was dominant.

RESULTS

Significant differences between LC and HCC patients were detected for AST, ALT, GGT, bilirubin, AFP and AP. Patients with HCC had higher AFP values compared to LC. There was no significant correlation between the size of the tumour lesion and serum AFP levels. A positive correlation between AFP concentration and GGT activity was determined, as was the negative correlation between AFP and age of the subjects. The AFP value of 23.34 ng/m showed high sensitivity (84%) and specificity (82%).

CONCLUSION

The size of the surface below the ROC curve (AUC) was 0.877 (0.80-0.95), which makes AFP a good biomarker and this diagnostic test is sufficient to separate patients with HCC and LC.

Pre-treatment alphafeto protein in hepatocellular carcinoma with non-viral aetiology - a prospective study

Background

Alpha-fetoprotein (AFP) is a biomarker for hepatocellular carcinoma (HCC). The significance of pre-treatment AFP (pt-AFP) in non-viral HCC (nvHCC) is not clear.

Methods

Patients with nvHCC, referred to a Hepatobiliary Clinic from September 2011–2015 were screened. HCC was diagnosed using American Association for the Study of Liver Disease guidelines, and TNM staged. nvHCC was diagnosed when HBsAg and anti-HCVAb was negative. Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease (MELD) scores were calculated. AFP level was evaluated against patient characteristics, tumour characteristics and survival.

Results

Three hundred eighty-nine patients with nvHCC [age 64(12–88) years; 344(88.4%) males] were screened. Median AFP was 25.46 ng/ml (1.16–100,000). 41.2% (n = 160) Of patients had normal AFP level. 22.9% (n = 89) had AFP over 400 ng/ml. Female gender (P < 0.05), vascular invasion (P < 0.001), tumours over 5 cm (P < 0.05), late TNM stage (P < 0.001) and non-surgical candidates had higher AFP levels. Diffuse type (P < 0.001), macro vascular invasion (P < 0.001) and late stage tumours (P < 0.001) had AFP over 400 ng/ml. Having AFP below 400 ng/ml was associated with longer survival (16 vs. 7 months, P < 0.001).

Conclusion

Pre treatment AFP has a limited value In diagnosing nvHCC, Having a AFP value over 400 ng/ml was associated with aggressive tumour behaviour and poor prognosis.

Dendritic cell-derived exosomes elicit tumor regression in autochthonous hepatocellular carcinoma mouse models

BACKGROUND & AIMS

Dendritic cell (DC)-derived exosomes (DEXs) form a new class of vaccines for cancer immunotherapy. However, their potency in hepatocellular carcinoma (HCC), a life-threatening malignancy with limited treatment options in the clinic that responds poorly to immunotherapy, remains to be investigated.

METHODS

Exosomes derived from α-fetoprotein (AFP)-expressing DCs (DEX_AFP) were investigated in three different HCC mouse models systemically. Tumor growth and microenvironment were monitored.

RESULTS

DEX_AFP elicited strong antigen-specific immune responses and resulted in significant tumor growth retardation and prolonged survival rates in mice with ectopic, orthotopic and carcinogen-induced HCC tumors that displayed antigenic and pathological heterogeneity. The tumor microenvironment was improved in DEX_AFP-treated HCC mice, demonstrated by significantly more γ-interferon (IFN-γ)-expressing CD8⁺ T lymphocytes, elevated levels of IFN-γ and interleukin-2, and fewer CD25⁺Foxp3⁺ regulatory T (Treg) cells and decreased levels of interleukin-10 and transforming growth factor-β in tumor sites. Lack of efficacy in athymic nude mice and CD8⁺ T cell-depleted mice showed that T cells contribute to DEX_AFP-mediated antitumor function. Dynamic examination of the antitumor efficacy and the immune microenvironment in DEX_AFP-treated orthotopic HCC mice at different time-points revealed a positive correlation between tumor suppression and immune microenvironment.

CONCLUSIONS

Our findings provide evidence that AFP-enriched DEXs can trigger potent antigen-specific antitumor immune responses and reshape the tumor microenvironment in HCC mice and thus provide a cell-free vaccine option for HCC immunotherapy. Lay summary: Dendritic cell (DC)-derived exosomes (DEXs) form a new class of vaccines for cancer immunotherapy. However, their potency in hepatocellular carcinoma (HCC) remains unknown. Here, we investigated exosomes from HCC antigen-expressing DCs in three different HCC mouse models and proved their feasibility and capability of treating HCC, and thus provide a cell-free vaccine for HCC immunotherapy.

Enhanced Hepatic Functions of Genetically Modified Mouse Hepatoma Cells by Spheroid Culture for Drug Toxicity Screening

While hepatic cell lines are mainly used for in vitro drug induced toxicity studies, they exhibit limited functionalities. To overcome this, the authors have employed genetically engineered mouse hepatoma cells, Hepa/8F5, wherein expression of liver enriched transcription factors is induced by doxycycline leading to increased functionality. Further enhancement in functionality is achieved by spheroid culture in a previously developed 3D cell culture platform. Cells are seeded in presence of temperature-responsive poly(N-isopropylacrylamide) on poly(N-isopropylacrylamide--co-gelatin) cryogel scaffold based high throughput platform. Cells seeded in presence of poly(N-isopropylacrylamide) and induced with doxycycline exhibited highest functionalities. There is an increase of ≈26, 36, and 39% in albumin secretion, ammonia removal, and CYP3A4 activity, respectively. Morphological analysis showed arrest in cell proliferation and enlarged nucleus in presence of doxycyline and spheroid formation in presence of poly(N-isopropylacrylamide). Drug induced liver toxicity studies revealed that cells induced with doxycycline are resistive to tamoxifen but sensitive to acetaminophen whereas, cultures initiated in presence of poly(N-isopropylacrylamide) are resistive to both the drugs which is indicative of diffusional barrier of the spheroids. The authors conclude that Hepa/8F5 cells show enhanced functionality in cryogel based spheroid culture platform which can be successfully used for high throughput screening of hepatic toxicity in vitro.

Tumor-derived exosomes elicit tumor suppression in murine hepatocellular carcinoma models and humans in vitro

Hepatocellular carcinoma (HCC) remains a global challenge due to high morbidity and mortality rates and poor response to treatment. Immunotherapy, based on introduction of dendritic cells (DCs) activated by tumor cell lysates as antigens ex vivo, shows limited response rates in HCC patients. Here, we demonstrate that tumor cell-derived exosomes (TEXs), displaying an array of HCC antigens, can elicit a stronger immune response than cell lysates in vitro and in vivo. Significant tumor growth inhibition was achieved in ectopic and orthotopic HCC mice treated with TEX-pulsed DCs. Importantly, the tumor immune microenvironment was significantly improved in orthotopic HCC mice treated by TEX-pulsed DCs, demonstrated by increased numbers of T lymphocytes, elevated levels of interferon-γ, and decreased levels of interleukin-10 and tumor growth factor-β in tumor sites. As expected, T cells played an essential role in the TEX-pulsed DC-mediated immune response. Notably, exosomes from HCC cells not only promoted HCC-specific cytolysis but also provided cross-protective effects against pancreatic cancer cells. Moreover, HCC-specific cytolysis, elicited by DCs pulsed with human HepG2 cell-derived exosomes, was observed across different human HCC cells irrespective of human leukocyte antigen types.

CONCLUSION

HCC TEXs can potently carry HCC antigens, trigger a strong DC-mediated immune response, and improve the HCC tumor microenvironment. (Hepatology 2016;64:456-472).

Crosstalk-eliminated quantitative determination of aflatoxin B1-induced hepatocellular cancer stem cells based on concurrent monitoring of CD133, CD44, and aldehyde dehydrogenase1

Cancer stem cells (CSCs), known as tumor initiating cells, have become a critically important issue for cancer therapy. Although much research has demonstrated the induction of hepato cellular carcinoma by aflatoxin B1, the formation of hepatocellular CSCs and their quantitative determination is hardly reported. In this work, it was found that hepatocellular CSCs were produced from HepG2 cells by aflatoxin B1-induced mutation, and their amount was quantitatively determined using crosstalk-eliminated multicolor cellular imaging based on quantum dot (Qdot) nanoprobes and an acousto-optical tunable filter (AOTF). Hepatocellular CSCs were acquired via magnetic bead-based sorting and observed using concurrent detection of three different markers: CD133, CD44, and aldehyde dehydrogenase1 (ALDH1). The DNA mutation of HepG2 cells caused by aflatoxin B1 was quantitatively observed via absorbance spectra of aflatoxin B1-8, 9-epoxide-DNA adducts. The percentages of hepatocellular CSCs formed in the entire HepG2 cells were determined to be 9.77±0.65%, 10.9±1.39%, 11.4±1.32%, and 12.8±0.7%, respectively, at 0 μM, 5 μM, 10 μM, and 20 μM of aflatoxin B1. The results matched well with those obtained utilizing flow cytometry. This study demonstrates that aflatoxin mediated mutation induced the conversion of hepatic cancer cell to hepatic CSCs by using a Qdot based constructed multicolor cellular imaging system.

Primary liver cancer deaths and related years of life lost attributable to hepatitis B and C viruses in India

BACKGROUND AND AIMS

More than 25,000 people die of liver cancer annually in India. There is little information about the contribution of hepatitis B virus (HBV) and hepatitis C virus (HCV) to these deaths. We conducted a systematic review of published studies on HBV or HCV infection and liver cancer in India and estimated the population attributable fraction (PAF) of liver cancer deaths caused by these infections and the corresponding annual number of deaths and years of life lost (YLL) in the country.

METHODS

We searched the PubMed and Scopus databases, as well as the reference list of relevant articles in the systematic review. For calculation of the number of liver cancer deaths attributable to HBV and HCV, we used two sources of outcome data and two relative risks for the association between HCV and liver cancer.

RESULTS

The PAF was 67% for HBV, 17-19% for HCV, and 71-72% for HBV and/or HCV. The annual attributable number of liver cancer deaths was approximately 17,000 for HBV; 4500 for HCV; and 18,500 for HBV and/or HCV, corresponding to approximately 297,000, 75,000, and 315,000 YLL, respectively. There was little difference in these numbers using the two sources of outcome data or the two risk estimates for HCV.

CONCLUSIONS

Our findings underscore the importance of primary prevention of HBV and HCV by appropriate measures, including vaccination (HBV only), prevention of transfusion-related infections, and increased awareness of the routes of transmission and long-term health outcomes.

Conceptual models for the initiation of hepatitis B virus-associated hepatocellular carcinoma

Although chronic hepatitis B virus (HBV) infection is a known risk factor for the development of hepatocellular carcinoma (HCC), the steps involved in the progression from normal liver to HCC are poorly understood. In this review, we apply five conceptual models, previously proposed by Vineis et al. to explain carcinogenesis in general, to explore the possible steps involved in the initiation and evolution of HBV-associated HCC. Available data suggest that the most suitable and inclusive model is based on evolution of hepatocyte subpopulations. In this evolutionary model, HCC-associated changes are driven by selection and subsequent clonal expansion of phenotypically altered hepatocyte subpopulations in the microenvironment of the HBV-infected liver. This model can incorporate the wide range of mechanisms proposed to play a role in the initiation of HCC including oncogenic HBV proteins, integration of HBV DNA and chronic inflammation of the liver. The model may assist in the early prevention, detection and treatment of HCC and may guide future studies of the initiation of HBV-associated HCC.

Carcinogenic effects of aflatoxin B1 among wheat handlers

BACKGROUND

Epidemiological studies have demonstrated that serum aflatoxin B1 (AFB1) is a hepatocarcinogenic mycotoxin and contributor to the high rate of hepatocellular carcinoma (HCC). The prevalence of liver cancer in Egypt is particularly worrisome. In a registry-based analysis of occupational risk for HCC, significant excesses were observed especially for grain mill workers.

OBJECTIVE

The aim of this study was to assess the hepatic carcinogenicity of AFB1 in wheat handlers.

METHODS

Serum AFB1/albumin (AFB1/Alb), alpha-fetoprotein (AFP), alpha-l-fucosidase (AFU), and arginase were estimated in exposed wheat handlers including millers and bakers. The control group was composed of non-occupationally exposed workers.

RESULTS

AFB1/Alb and AFU were significantly higher among workers employed as bakers compared to mill workers and controls. Mill workers had higher levels of AFB1/Alb than the controls. AFB1/Alb, AFP, and AFU were all significantly higher and arginase was significantly lower among HCC cases compared to the other groups. There was a significant correlation between AFU and AFB1/Alb in bakers and between AFP and AFB1/Alb in HCC cases. Arginase was inversely correlated with AFB1/Alb in HCC cases. AFB1/Alb was significantly correlated with the duration of exposure in bakers.

CONCLUSION

Wheat handlers exposed to Aspergillus flavus have a high risk of elevated serum AFB1/Alb levels and AFU.

The Indian National Association for Study of the Liver (INASL) Consensus on Prevention, Diagnosis and Management of Hepatocellular Carcinoma in India: The Puri Recommendations

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality and healthcare expenditure in patients with chronic liver disease. There are no consensus guidelines on diagnosis and management of HCC in India. The Indian National Association for Study of the Liver (INASL) set up a Task-Force on HCC in 2011, with a mandate to develop consensus guidelines for diagnosis and management of HCC, relevant to disease patterns and clinical practices in India. The Task-Force first identified various contentious issues on various aspects of HCC and these issues were allotted to individual members of the Task-Force who reviewed them in detail. The Task-Force used the Oxford Center for Evidence Based Medicine-Levels of Evidence of 2009 for developing an evidence-based approach. A 2-day round table discussion was held on 9th and 10th February, 2013 at Puri, Odisha, to discuss, debate, and finalize the consensus statements. The members of the Task-Force reviewed and discussed the existing literature at this meeting and formulated the INASL consensus statements for each of the issues. We present here the INASL consensus guidelines (The Puri Recommendations) on prevention, diagnosis and management of HCC in India.

Carcinogenic effects of aflatoxin B1 among wheat handlers

BACKGROUND

Epidemiological studies have demonstrated that serum aflatoxin B1 (AFB1) is a hepatocarcinogenic mycotoxin and contributor to the high rate of hepatocellular carcinoma (HCC). The prevalence of liver cancer in Egypt is particularly worrisome. In a registry-based analysis of occupational risk for HCC, significant excesses were observed especially for grain mill workers.

OBJECTIVE

The aim of this study was to assess the hepatic carcinogenicity of AFB1 in wheat handlers.

METHODS

Serum AFB1/albumin (AFB1/Alb), alpha-fetoprotein (AFP), alpha-l-fucosidase (AFU), and arginase were estimated in exposed wheat handlers including millers and bakers. The control group was composed of non-occupationally exposed workers.

RESULTS

AFB1/Alb and AFU were significantly higher among workers employed as bakers compared to mill workers and controls. Mill workers had higher levels of AFB1/Alb than the controls. AFB1/Alb, AFP, and AFU were all significantly higher and arginase was significantly lower among HCC cases compared to the other groups. There was a significant correlation between AFU and AFB1/Alb in bakers and between AFP and AFB1/Alb in HCC cases. Arginase was inversely correlated with AFB1/Alb in HCC cases. AFB1/Alb was significantly correlated with the duration of exposure in bakers.

CONCLUSION

Wheat handlers exposed to Aspergillus flavus have a high risk of elevated serum AFB1/Alb levels and AFU.

Detection of circulating tumor cells in patients with hepatocellular carcinoma using an improved asialoglycoprotein receptor-based separation method

AIM: To introduce a novel magnetic cell separation system which allows for immunomorphological identification and enumeration of circulating tumor cells (CTCs) in patients with hepatocellular carcinoma (HCC).

METHODS: The asialoglycoprotein receptor (ASGPR) is a transmembrane protein expressed exclusively on the surface of hepatocytes. We have recently developed a sensitive and specific system mediated by the interaction of the ASGPR with its ligand to magnetically separate CTCs in HCC patients. In the system, HCC cells were bound by biotinylated asialofetuin, an ASGPR ligand, and subsequently labeled by anti-biotin antibody-coated magnetic beads, followed by magnetic separation. The separated HCC cells were then identified by immunofluorescence staining using the hepatocyte-specific antibody Hep Par 1. In this study, we used EDTA instead of heparin for anticoagulation because heparin could cause the presence of gels in cell suspension, which affected the passage of cells through the separation column and reduced the separation efficiency. The recovery, specificity and sensitivity of the HCC CTC separation and detection system were determined by performing Hep3B cell spiking experiments.

RESULTS: Calcium chelating agent EDTA was used for anticoagulation instead of heparin in some steps of the original method and gel phenomenon no longer appeared in the cell suspension. The cell spiking experiments showed that when there were 10, 30, 90, 270 and 810 Hep3B cells spiked into five milliliters of peripheral blood from healthy volunteers, the average recovery was ≥ 70% at each spiking level and the recovery of the modified method was higher than that of the original method (P < 0.05).

CONCLUSION: We have developed a new tool that allows for highly sensitive and specific separation and detection of CTCs in HCC patients. It may be clinically useful for diagnosis and monitoring of HCC. The cell spiking experiments showed that the recovery of the modified method was higher than that of the original method.

Monitoring of the generation of circulating tumor cells in central venous blood of patients undergoing right hepatectomy using anterior liver hanging maneuver

AIM: To monitor the generation of circulating tumor cells in central venous blood of patients undergoing right hepatectomy using anterior liver hanging (ALH) maneuver.

METHODS: From January 2008 to June 2011, 40 patients undergoing right hepatectomy were randomly allocated to ALH and conventional approach (CA) groups. Blood samples were collected from all patients through a central venous catheter, just before skin incision, just before parenchymal transection (after hilar dissection in the ALH group and after mobilization of the liver in the CA group), and after delivery of the tumor. All samples were detected for CTCs using an asialoglycoprotein receptor-based isolation strategy. The proportions of CTC-positive patients at various stages of surgery were compared between the two groups.

RESULTS: The proportion of CTC-positive patients showed no significant difference before surgery between the two groups (2/18 vs 1/19, P > 0.05) but was significantly lower in the ALH group than in the CA group before parenchymal transection and at the end of surgery after delivery of the tumor (20% vs 55%, 40% vs 80%, P = 0.022, 0.010).

CONCLUSION: Right hepatectomy using anterior liver hanging maneuver can reduce intraoperative blood-borne spread of tumor cells compared with the conventional method.

Reference intervals for serum alpha-fetoprotein and carcinoembryonic antigen in Chinese Han ethnic males from the Fangchenggang Area Male Health and Examination Survey

OBJECTIVES

We calculated upper 95% reference limits for serum alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) according to the CLSI/NCCLS C28-A3 guideline.

MATERIAL AND METHODS

Serum samples from 1400 healthy male subjects were collected from the Fangchenggang Area Male Health and Examination Survey (FAMHES). Serum AFP and CEA values were measured by electrochemiluminescence immunoassay on COBAS 6000 system E601 (Elecsys module) immunoassay analyzers.

RESULTS

Serum AFP and CEA values were not normally distributed but log normally distributed. The upper 95% reference limits of the reference intervals were ≤ 4.76 IU/mL (nonparametric) or ≤ 4.56 IU/mL (parametric) for AFP and ≤ 5.57 ng/mL (nonparametric) or ≤ 5.82 ng/mL (parametric) for CEA. The distribution of AFP levels was found to be consistent between the non-smoking and smoking (p=0.740) and non-drinking and drinking groups (p=0.698). The distribution of serum CEA levels was significantly higher in the smoking than the non-smoking group (p<10⁵), whereas there was no significant difference in this respect between the non-drinking and drinking groups (p=0.147). A significant increase with age was found both for serum AFP and CEA levels, and the age-dependent reference intervals were calculated.

CONCLUSIONS

The reference intervals for serum AFP and CEA show a slight deviation compared to previously reported reference levels. Distinct reference intervals of serum CEA must be established for smoking and non-smoking populations. In addition, age-dependent reference intervals should be implemented in clinical laboratories.

Hepatitis B virus-associated intrahepatic cholangiocarcinoma and hepatocellular carcinoma may hold common disease process for carcinogenesis

AIMS

To evaluate potential risk factors for intrahepatic cholangiocarcinoma (ICC) and analyse clinicopathologic characteristics of ICC patients with seropositive hepatitis B surface antigen (HBsAg).

METHODS

A retrospective case-control study was conducted. Cases were 317 ICC patients referred to the Eastern Hepatobiliary Surgery Hospital in China between 2003 and 2006. Controls were 634 healthy individuals. Adjusted odds ratios (ORs) were calculated in logistic regression analysis. Among 317 consecutively enrolled ICC patients, 154 patients were seropositive HBsAg (48.6%). We compared clinicopathologic characteristics of these patients (group I) with ICC patients seronegative for HBsAg (group II; n=163) and compared the age and sex distributions of patients in group I with randomly selected hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) (group III; n=1,140).

RESULTS

Compared with the controls, ICC patients had a high prevalence of seropositive HBsAg, cirrhosis, hepatolithiasis and hepatic schistosomiasis. Compared with seronegative-HBsAg ICC patients, seropositive-HBsAg ICC patients were younger, more frequently male and had a higher proportion of abnormal aminotransferase and serum alpha-fetoprotein (AFP) level, histological inflammation and cirrhosis, right-lobe focus, poor tumour differentiation, tumour encapsulation and microvascular invasion; had a lower proportion of abnormal serum carbohydrate antigen 19-9 (CA19-9) level and lymphatic metastasis. The age and sex distribution profiles were nearly identical between seropositive-HBsAg ICC patients and HBV-associated HCC patients.

CONCLUSIONS

The HBV infection, cirrhosis, hepatolithiasis and hepatic schistosomiasis may be potential risk factors for ICC. HBV-associated ICC shares many clinicopathological similarities with HBV-associated HCC. The result indicated HBV-associated ICC and HBV-associated HCC may hold common disease process for carcinogenesis.

Etiological and clinicopathologic characteristics of intrahepatic cholangiocarcinoma in young patients

AIM: To investigate the prevalence, risk factors, and clinicopathologic characteristics of intrahepatic cholangiocarcinoma (ICC) in young patients.

METHODS: A retrospective analysis was performed in ICC patients referred to the Eastern Hepatobiliary Surgery Hospital in Shanghai, China. Among 317 consecutively enrolled patients, 40 patients were aged ≤ 40 years (12.61%). We compared the risk factors and clinicopathologic characteristics of these patients (group I: n = 40) with those aged > 40 years (group II: n = 277).

RESULTS: Group I had distinct features compared with group II, including a low frequency of hepatolithiasis (P = 0.000); a high positive rate of serum hepatitis B surface antigen (P = 0.000) and hepatitis B virus (HBV)-associated cirrhosis (P = 0.038); a high frequency of α-fetoprotein (> 400 μg/L) (P = 0.011); a low frequency of carbohydrate antigen 19-9 (> 37 U/mL) (P = 0.017); and a high frequency of liver histological inflammation (P = 0.002). Although there was no significant difference between the two groups in regards to hepatic schistosomiasis, alcohol-associated cirrhosis and cirrhosis due to other causes (P > 0.05), they only occurred in the elderly group.

CONCLUSION: The risk factors are significantly different between young and elderly ICC patients. HBV and HBV-associated cirrhosis are the most important risk factors for young ICC patients.