Rising incidence of hepatocellular carcinoma: the role of hepatitis B and C; the impact on transplantation and outcomes

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.

Latin American Association for the Study of the Liver (LAASL) clinical practice guidelines: management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third most common cause of cancer death, and accounts for 5.6% of all cancers. Nearly 82% of the approximately 550,000 liver cancer deaths each year occur in Asia. In some regions, cancer-related death from HCC is second only to lung cancer. The incidence and mortality of HCC are increasing in America countries as a result of an ageing cohort infected with chronic hepatitis C, and are expected to continue to rise as a consequence of the obesity epidemic. Clinical care and survival for patients with HCC has advanced considerably during the last two decades, thanks to improvements in patient stratification, an enhanced understanding of the pathophysiology of the disease, and because of developments in diagnostic procedures and the introduction of novel therapies and strategies in prevention. Nevertheless, HCC remains the third most common cause of cancer-related deaths worldwide. These LAASL recommendations on treatment of hepatocellular carcinoma are intended to assist physicians and other healthcare providers, as well as patients and other interested individuals, in the clinical decision-making process by describing the optimal management of patients with liver cancer.

Viral status at the time of liver transplantation for hepatocellular carcinoma: a modern predictor of longterm survival

OBJECTIVES

The impact of pre-transplant hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection in patients with hepatocellular carcinoma (HCC) is not well described. This study was conducted to test the hypothesis that viral status is an independent predictor of retransplantation rates, graft survival (GS) and overall survival (OS) in patients undergoing liver transplantation for HCC.

METHODS

Patients with HCC were identified from the Organ Procurement and Transplantation Network database (2005-2012), and categorized by viral status according to these categories: HBV-/HCV-; HBV+/HCV-; HBV-/HCV+, and HBV+/HCV+.

RESULTS

Of 7742 patients transplanted for HCC, 7060 had known HBV and HCV status. Five-year GS and OS were highest in recipients who were HBV+/HCV-, at 75% and 78%, respectively, compared with patients who were HBV-/HCV- (GS = 63%, OS = 66%), HBV-/HCV+ (GS = 64%, OS = 60%) or HBV+/HCV+ (GS = 60%, OS = 62%). In multivariable analyses, HBV-/HCV+ patients were more likely than HBV+/HCV- patients to undergo repeat transplantation. Patients who were HBV-/HCV+ also had poorer GS and OS than both HBV-/HCV- and HBV+/HCV- patients. Other independent predictors of poorer OS included older age, higher Model for End-stage Liver Disease score, African-American race, and diabetes. The few HBV+/HCV+ patients (n = 138) showed trends toward fewer retransplantations, prolonged GS and prolonged OS compared with HBV-/HCV+ patients. In adjusted models, antiviral medications did not impact GS or OS.

CONCLUSIONS

In the era of modern selection criteria, viral status is an independent predictor of outcome following liver transplantation for HCC. Both HBV-/HCV- and HBV+/HCV- patients have superior GS and OS compared with HBV-/HCV+ patients.

Circulating microRNA-122a as a diagnostic marker for hepatocellular carcinoma

BACKGROUND

The purpose of this study was to evaluate the potential value of circulating miRNA-122a and miRNA-221 in the diagnosis of hepatocellular carcinoma.

METHODS

Serum samples were obtained from 85 patients with hepatocellular carcinoma and 85 age-matched and sex-matched healthy volunteers. miRNAs were isolated from the serum samples, and alfa-fetoprotein levels were determined. Expression of miRNA-122a and miRNA-221 in cases and controls was quantified using U6 sn RNA as the internal control. The diagnostic value of miRNA-122a, miRNA-221, and alfa-fetoprotein was compared by receiver operating characteristic analysis.

RESULTS

The serum miRNA-122a level in patients with hepatocellular carcinoma was significantly reduced in comparison with healthy controls and correlated with known risk factors for hepatocellular carcinoma. Circulating miRNA-221 in patients with hepatocellular carcinoma was higher compared with the control group, but the difference was not statistically significant. Receiver operating characteristic analysis revealed that the diagnostic power of miRNA-122a was suboptimal compared with serum alfa-fetoprotein. Further, the serum alfa-fetoprotein and miRNA-122a combined classifier resulted in performance similar to that of alfa-fetoprotein alone.

CONCLUSION

The serum miRNA-122a level correlates with risk factors for hepatocellular carcinoma. However, use of miRNA-122a as a diagnostic tool for hepatocellular carcinoma is not superior to alfa-fetoprotein. Further analysis is needed to evaluate the diagnostic power of plasma miRNA-122a for hepatocellular carcinoma.

Hepatocellular carcinoma in patients with chronic hepatitis C virus infection without cirrhosis

AIM: To investigate and characterise patients with chronic hepatitis C virus (HCV) infection presenting with hepatocellular carcinoma (HCC) in the absence of cirrhosis.

METHODS: Patients with chronic hepatitis C infection without cirrhosis presenting with HCC over a 2-year period were identified. The clinical case notes, blood test results and histological specimens were reviewed to identify whether additional risk factors for the development of HCC were present.

RESULTS: Six patients (five male, one female) with chronic hepatitis C infection without cirrhosis presented to a single centre with HCC over a 2-year period. Five patients were treated by surgical resection and one patient underwent liver transplantation. Evaluation of generous histological specimens confirmed the presence of HCC and the absence of cirrhosis in all cases. The degree of fibrosis of the background liver was staged as mild (n = 1), moderate (n = 4) or bridging fibrosis (n = 1). Review of the clinical case notes revealed that all cases had an additional risk factor for the development of HCC (four had evidence of past hepatitis B virus infection; two had a history of excessive alcohol consumption; a further patient had prolonged exposure to immune suppression).

CONCLUSION: HCC does occur in patients with non-cirrhotic HCV infection who have other risk factors for hepatocarcinogenesis.

Circulating interleukin-6 as a tumor marker for hepatocellular carcinoma

BACKGROUND

A large amount of evidence suggests a possible role of interleukin-6 (IL-6) in the pathogenesis of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We studied both IL-6 and A(1)FP in patients with HCC, non-neoplastic liver disease or in healthy controls.

RESULTS

IL-6 titers were four-fold higher in cancer than in cirrhotic patients and 25-fold higher than in healthy controls. As for alpha1-fetoprotein (A(1)FP) titers, the highest levels were observed in cancer patients. Receiver operating characteristic (ROC) curves analysis demonstrated that IL-6 is significantly more discriminant than A(1)FP, with 'optimal' cut-off values of 7.9 pg/ml (sensitivity = 0.83, specificity = 0.83, efficiency = 0.83). The ROC curves used to distinguish HCC from cirrhotic patients only, showed higher discriminant power of IL-6 versus A(1)FP titers, with a new cut-off value of 12 pg/ml (sensitivity = 0.73, specificity = 0.87, efficiency = 0.8). Discriminant analysis on HCC and non-HCC subjects yielded sensitivity, specificity and efficiency rates of 77%, 93% and 88%, respectively. The overall efficiency of the two tests combined was 82%.

CONCLUSIONS

IL-6 could be considered a promising tumor marker for HCC. In particular, the diagnostic value of the test is significantly increased when combined with A(1)FP.

Yttrium-90 microspheres for the treatment of hepatocellular carcinoma: a review

To present a critical review of yttrium-90 (TheraSphere) for the treatment of hepatocellular carcinoma (HCC). Medical literature databases (Medline, Cochrane Library, and CANCERLIT) were searched for available literature concerning the treatment of HCC with TheraSphere. These publications were reviewed for scientific and clinical validity. Studies pertaining to the use of yttrium-90 for HCC date back to the 1960s. The results from the early animal safety studies established a radiation exposure range of 50-100 Gy to be used in human studies. Phase I dose escalation studies followed, which were instrumental in delineating radiation dosimetry and safety parameters in humans. These early studies emphasized the importance of differential arteriolar density between hypervascular HCC and surrounding liver parenchyma. Current trends in research have focused on advancing techniques to safely implement this technology as an alternative to traditional methods of treating unresectable HCC, such as external beam radiotherapy, conformal beam radiotherapy, ethanol ablation, trans-arterial chemoembolization, and radiofrequency ablation. Yttrium-90 (TheraSphere) is an outpatient treatment option for HCC. Current and future research should focus on implementing multicenter phase II and III trials comparing TheraSphere with other therapies for HCC.

Repair and regeneration: opportunities for carcinogenesis from tissue stem cells

This review will discuss the mechanisms of repair and regeneration in various tissue types and how dysregulation of these mechaisms may lead to cancer. Normal homeostasis involves a careful balance between cell loss and cell renewal. Stem and progenitor cells perform these biologic processes as the functional units of regeneration during both tissue homeostasis and repair. The concept of tissue stem cells capable of giving rise to all differentiated cells within a given tissue led to the concept of a cellulr hierarchy in tissues and in tumors. Thus, only a few cells may be necessary and sufficient for tissue repair or tumor regeneration. This is known as the hierarchical model of tumorigenesis. This report will compare this model with the stochastic model of tumorigenesis. Under normal circumstances, the processes of tissue regeneration or homeostasis are tightly regulated by several morphogen pathways to prevent excessive or inappropriate cell growth. This review presents the recent evidence that dysregulation of these processes may provide opportunities for carcinogenesis for the long-lived, highly proliferative tissue stem cell population. New findings of cancer initiating tissue stem cells identified in several solid and circulating cancers including breast, brain hematopoietic tumors will also be reviewed. Finally, this report reviews the cellular biology of cancer and its relevance to the development of more effective cancer treatment protocols.

Prevalence of hepatitis C infection in a population of asymptomatic people in a checkup unit in Mexico city

Hepatitis C virus (HCV) infection has an estimated prevalence of 3% around the world. Unfortunately, many persons with HCV infection are asymptomatic. The aim of this study was to determine the prevalence of hepatitis C Virus infection in asymptomatic persons. This study was carried out in a population-based cross-sectional study in the Checkup Unit of University Hospital in Mexico City. Patients with two or more HCV risk factors were studied. Serum specimens from all patients were screened for HCV RNA by qualitative polymerase chain reaction (PCR). HCV RNA-positive serum was also screened by quantitative PCR and for HCV genotype. Three hundred asymptomatic people were included, 194 men and 106 women, with a mean age of 46.8+/-11.9. Six (2%) of the 300 people were positive and viremic. The most common risk factors in positive patients were manicures or pedicures with a nonpersonal instrument and more than three sexual partners. We concluded that hepatitis C is frequent in asymptomatic people, and those people are often viremic. In addition, this study suggests that the spectrum of liver disease in asymptomatic and newly diagnosed HCV-positive persons is broad.

Epidemiology and carcinogenesis of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) shows marked variation worldwide but the magnitude of this tumor is reflected by the occurrence of at least 1 million new cases annually and the uniformly dismal outlook with median survivals of <25 months after resection and <6 months with symptomatic treatment. The strikingly uneven distribution of this tumor parallels the prevalence of hepatitis B infection with rising incidence in western countries attributed to hepatitis C infection. Chronic hepatitis and cirrhosis constitute the major preneoplastic conditions in the majority of HCCs and may be related to other etiologic agents such as environmental chemical carcinogens including nitrites, hydrocarbons, solvents, organochlorine pesticides, and the chemicals in processed foods, cleaning agents, cosmetics and pharmaceuticals, as well as plant toxins such as anatoxins produced by fungi that cause spoilage of grain and food in the tropics. Genetic diseases such as genetic hematochromatosis, Wilson's disease, alpha-1-antitrypsin deficiency, and the inborn errors of metabolism including hereditary tyrosinemia and hepatic porphyria, are known to be associated with HCC. Numerous genetic alterations and the modulation of DNA methylation are recognized in HCC and it is likely that these genetic and epigenetic changes combine with factors involved in chronic hepatocyte destruction and regeneration to result in neoplastic growth and multiple molecular pathways may be involved in the production of subsets of hepatocellular tumors.

Hepatitis C virus infection with hepatocellular carcinoma: not a controversial indication for liver transplantation

BACKGROUND

The association of hepatocellular carcinoma (HCC) and chronic hepatitis C virus (HCV) infection has been identified as a potential contraindication for orthotopic liver transplantation (LT) because of lower survival rate compared with other indications.

AIM

Evaluate the outcome of patients with and without HCC and cirrhosis with and without chronic HCV infection undergoing transplantation. Determine the postLT HCC recurrence rate and frequency of de novo postLT HCC.

PATIENTS AND METHODS

United Network for Organ Sharing (UNOS) data was collected from January 1998 to December 2002. Cohort included 17,968 patients (11,552 M; 6,416 F) with a mean age of 51 (18-87) years. Four groups were established: HCV (n = 7,079), HCC (n = 611), HCV+HCC (n = 1,078), and no HCV/no HCC (n = 9,200). The overall survival rate was calculated at 24 and 48 months postLT.

RESULTS

Patient survival at 24 months and 48 months was 84% and 75% for HCV, 84% and 68% for HCC, 78% and 72% for HCV+HCC, and 85% and 80% for no HCV/no HCC, respectively. Survival at 48 months among the two groups was not significantly different (NS). Further analysis of these groups revealed a statistically significant advantage in survival at 48 months postLT for the no HCV/no HCC group when compared with the HCV group.(P < 0.05) The reported rate of postLT HCC recurrence and de novo postLT HCC was 3.3% and 0.05%, respectively.

CONCLUSION

In this large cohort of U.S. patients, HCC does not have an impact on the survival of LT patients infected with HCV.