Effects of castration and androgen replacement on tumour growth of human hepatocellular carcinoma in nude mice

Review of nonalcoholic fatty liver disease in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women. Women with PCOS frequently have metabolic complications including insulin resistance (IR), early diabetes, hypertension and dyslipidemia. Recent studies have demonstrated an association between PCOS and another metabolic complication: nonalcoholic fatty liver disease (NAFLD). NAFLD occurs as a result of abnormal lipid handling by the liver, which sensitizes the liver to injury and inflammation. It can progress to nonalcoholic steatohepatitis (NASH), which is characterized by hepatocyte injury and apoptosis. With time and further inflammation, NASH can progress to cirrhosis. Thus, given the young age at which NAFLD may occur in PCOS, these women may be at significant risk for progressive hepatic injury over the course of their lives. Many potential links between PCOS and NAFLD have been proposed, most notably IR and hyperandrogenemia. Further studies are needed to clarify the association between PCOS and NAFLD. In the interim, clinicians should be aware of this connection and consider screening for NAFLD in PCOS patients who have other metabolic risk factors. The optimal method of screening is unknown. However, measuring alanine aminotransferase and/or obtaining ultrasound on high-risk patients can be considered. First line treatment consists of lifestyle interventions and weight loss, with possible pharmacologic interventions in some cases.

Hyperandrogenemia is independently associated with elevated alanine aminotransferase activity in young women with polycystic ovary syndrome

CONTEXT

Women with polycystic ovary syndrome (PCOS) have been implicated to have higher levels of alanine aminotransferase (ALT) because of the high prevalence of obesity.

OBJECTIVE

Our aim was to investigate the relationship between elevated ALT and aspartate aminotransferase (AST) activity and characteristic hyperandrogenism in women with PCOS.

DESIGN AND SETTING

We conducted a cross-sectional case-control study in a reproductive endocrinology clinic and voluntary annual medical health check-up program of the health management center in a tertiary medical center.

PATIENTS

A total of 279 women with PCOS and 279 age-frequency-matched healthy women were studied.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

All subjects underwent anthropometric measurement, clinical history recorded by questionnaires, and biochemical tests after an overnight fast.

RESULTS

The prevalence of elevated ALT and AST levels was significantly higher in women with PCOS than healthy control subjects. Multivariate regression analysis for women revealed that the presence of PCOS was significantly associated with elevated ALT but not AST after adjustment for age, obesity, and dyslipidemia. The level of androgenicity represented by free androgen index in women with PCOS was significantly related to elevated ALT and AST levels in multivariate regression models. Women with PCOS who had the highest quartile of free androgen index level had the highest risk of elevated ALT level after adjustment for age, obesity, insulin resistance, and dyslipidemia.

CONCLUSIONS

The risk of elevated ALT level is significantly higher in women with PCOS than those without, independent of obesity. The elevated ALT levels in women with PCOS were associated with the increased androgen levels, independent of obesity, insulin resistance, and dyslipidemia.

Is human hepatocellular carcinoma a hormone-responsive tumor?

Before the positive results recently obtained with multitarget tyrosine kinase inhibitor sorafenib, there was no standard systemic treatment for patients with advanced hepatocellular carcinoma (HCC). Sex hormones receptors are expressed in a significant proportion of HCC samples. Following preclinical and epidemiological studies supporting a relationship between sex hormones and HCC tumorigenesis, several randomized controlled trials (RCTs) tested the efficacy of the anti-estrogen tamoxifen as systemic treatment. Largest among these trials showed no survival advantage from the administration of tamoxifen, and the recent Cochrane systematic review produced a completely negative result. This questions the relevance of estrogen receptor-mediated pathways in HCC. However, a possible explanation for these disappointing results is the lack of proper patients selection according to sex hormones receptors expression, but unfortunately the interaction between this expression and efficacy of tamoxifen has not been studied adequately. It has been also proposed that negative results might be explained if tamoxifen acts in HCC via an estrogen receptor-independent pathway, that requires higher doses than those usually administered, but an Asian RCT conducted to assess dose-response effect was completely negative. Interesting, preliminary results have been obtained when hormonal treatment (tamoxifen or megestrol) has been selected according to the presence of wild-type or variant estrogen receptors respectively, but no large RCTs are available to support this strategy. Negative results have been obtained also with anti-androgen therapy. In conclusion, there is no robust evidence to consider HCC a hormone-responsive tumor. Hormonal treatments should not be part of the current management of HCC.

Hormonal treatment of human hepatocellular carcinoma

Animal models of experimental liver carcinogenesis and epidemiological studies in humans suggest a relationship between sex hormones and hepatocellular carcinoma (HCC). In 1997, a systematic review of the existing, small randomized trials evaluating the antiestrogen tamoxifen yielded a positive result, but the large randomized CLIP-1 trial showed no survival advantage from the addition of tamoxifen to best supportive care. A possible explanation for the negative results is the lack of patient selection, but the expression of estrogen (ER) and progesterone (PgR) receptors in HCC does not clearly affect the survival outcome of the patients treated with tamoxifen. In the last years, it has been proposed that negative results might be due to the fact that tamoxifen in HCC could act via an ER-independent pathway, which requires much higher doses than those usually administered, but a double-blind Asian randomized trial conducted to assess possible dose-response effect showed no efficacy for tamoxifen, with an inversely negative impact with increasing dose. According to the results of large trials and of the Cochrane systematic review, neither further trials are warranted with tamoxifen in HCC, nor should any use in clinical practice be considered. Interesting results have been obtained when the type of hormonal treatment (tamoxifen or megestrol) has been chosen according to the presence of wild-type or variant ER, but these results should be confirmed in large randomized trials. Negative results have been obtained with antiandrogen therapy. In conclusion, hormonal treatment should not be a part of the current management of HCC patients.

Better survival in female patients with hepatocellular carcinoma: oral contraceptive pills related?

BACKGROUND

Hepatocellular carcinoma (HCC) has an indisputable male predominance. "Gender" as an independent prognostic factor for survival is, however, controversial.

GOALS

Determine the influence of gender on survival in HCC patients, and identify factors that may account for the difference.

METHODS

A retrospective analysis on a prospectively collected database in a 15-year period, from 1989 to 2003.

RESULTS

A total of 3,171 HCC patients were managed in our institution (946 with curative treatment, 1,388 with palliative treatment, and 837 with supportive treatment) and studied. Female patients (n = 520) were 4.3 years older (P = 0.000), had a lower proportion of smokers and drinkers (P = 0.000), and were less likely to be hepatitis B carriers (P = 0.000). There was no difference in Child-Pugh status, tumor size, and the use of different treatments between genders. The overall median survival was 25.7 months longer in females after curative treatment (73.6 vs. 47.9 months; P = 0.012). The survival benefit in female patients was observed in early-stage diseases and persisted when only hepatitis B surface antigen-positive patients were analyzed (96.4 vs. 47.9 months; P = 0.044). With multivariate analysis, gender, indocyanine green test value at 15 minutes, number of tumor nodules, size of tumor, major vascular invasion, invasion of adjacent organs, and tumor rupture were the independent variables for survival. More importantly, in female patients, history of using oral contraceptive was an independent factor with survival benefit (P = 0.004).

CONCLUSION

Gender is an independent variable for survival after curative treatment of HCC. A survival benefit was observed in females. History of using oral contraceptive is associated with a better long-term survival in female patients.

Randomized trial of leuprorelin and flutamide in male patients with hepatocellular carcinoma treated with tamoxifen

The growth of hepatocellular carcinoma (HCC) is thought to be dependent on androgens, as androgen receptors are present in most of these tumors. The aim of this multicenter trial was to assess the effect of antiandrogens in patients who have advanced HCC. Male patients with advanced HCC were randomized into 2 groups treated with (1) leuprorelin (3.75 mg/mo subcutaneously), flutamide (750 mg/d orally), and tamoxifen (30 mg/d orally) or (2) tamoxifen alone (30 mg/d orally) administered until death. Survival was the main end point (log-rank test). The required sample size was 375 patients (alpha, 5%; beta, 10%; 1-year survival, 45% in treated group and 30% in controls). Between February 1994 and January 1998, 376 male patients (mean age, 66 years; treated group, n = 192; control group, n = 184) were included. No baseline imbalance was found between the groups. At the reference date (January 1, 2003), 183 deaths (95.3%) were observed in the treated group and 177 deaths (96.2%) were observed in controls. Thirteen patients were lost to follow-up. Median survival time was estimated to be 135.5 days (95% CI, 112-189) and 176 days (95% CI, 141-227) in treated and control groups, respectively (P = .21). Crude and adjusted relative risks of death in the treated group were estimated at 1.14 (95% CI, 0.93-1.40) and 1.08 (95% CI, 0.87-1.33; P = .48) respectively. Premature interruption of treatment was more frequent in the treated group (n = 45) than in controls (n = 22; P = .0045), mainly because of digestive side effects. In conclusion, no benefit in survival was found with antiandrogenic treatment in male patients with advanced HCC.

Marked inhibition of testosterone biosynthesis by the hepatotoxin nodularin due to apoptosis of Leydig cells

We previously observed that the serum testosterone level was greatly reduced in the course of diethylnitrosamine-nodularin-induced hepatocarcinogenesis in Fischer 344 male rats (Lim et al., Gastroenterological Carcinogenesis, 1999). As an extension of this observation, this study was undertaken to investigate the molecular mechanism of downregulation of testosterone and its effect on target organs in Fischer 344 male rats treated with the hepatotoxin nodularin. After treating the rats with nodularin, a marked reduction of the testosterone level was noted in both serum and testis, with an accompanying accumulation of cholesterol in serum. Reduction of serum testosterone was not due to increased degradation of testosterone in the liver but to impaired biosynthesis in the testes, reduced activities of the cholesterol side chain cleavage enzyme and 17alpha-hydroxylase, and decreased expression of the steroidogenic acute regulatory protein gene, all of which constitute rate-limiting steps for testosterone biosynthesis in the testes. Intraperitoneal injection of nodularin into rats induced cuboidal changes of glandular epithelium in ventral prostates and apoptotic changes of spermatogonium, for example, nuclear chromatin condensation, shrinkage, and detachment from Sertoli cells, which included many lysosomal granules. Leydig cells also showed evidence of chromatin condensation and significant induction of peroxisome proliferation. In conclusion, the potential causes of impaired testosterone biosynthesis might have been apoptosis of Leydig cells induced by direct toxicity of the hepatotoxin on testes or hypothalamopituitary dysfunction.

Sex hormone dependency of diethylnitrosamine-induced liver tumors in mice and chemoprevention by leuprorelin

The prevalence of liver tumors throughout the world makes it imperative to seek chemopreventive agents. This tumor appears to be hormone-responsive and hormonal manipulations may therefore be beneficial. On this basis, both sexes of 12-day-old B6C3F(1) mice were injected i.p. with diethylnitrosamine (DEN) at the dose of 2.5 mg / g body weight and observed for 32 weeks (males) or 36 weeks (females). In 100% of male mice, liver tumors were observed with an average diameter of 2.72 mm and multiplicity of 60.8. Orchidectomy at 6 weeks of age in these mice inhibited the incidence, multiplicity and size to 63%, 5.6 and 1.54 mm, respectively. By further implantation with an E(2) pellet at monthly intervals, these parameters were reduced to 26%, 0.6 and 0.61 mm, respectively. Administration of a gonadotropin-blocking chemical, leuprorelin, to DEN-treated male mice significantly reduced the multiplicity and size of tumors to 18.3 and 2.54 mm (P < 0.01 compared to those of DEN only). In female mice, the incidence of liver tumor was significantly smaller than that of males. However, ovariectomy and / or testosterone supplement significantly increased the occurrence of liver tumor. An anti-estrogen, toremifene, caused a marked further decrease of liver tumors. Mitotic indices with bromodeoxyuridine in tumor tissues paralleled the occurrence of liver tumors. Serum testosterone levels were significantly reduced by orchidectomy or by leuprorelin administration. These results further confirm that liver tumor is testosterone-responsive and hormonal manipulation by surgical orchidectomy or by chemical orchidectomy i.e. by leuprorelin, could substantially prevent the appearance of liver tumors.