Additive effect modification of hepatitis B surface antigen and e antigen on the development of hepatocellular carcinoma

The expression of HtrA2 and its diagnostic value in patients with hepatocellular carcinoma

The purpose of this study was to detect the expression of high-temperature requirement A2 (HtrA2) and its diagnostic value in the patients with hepatocellular carcinoma (HCC).The relative serum HtrA2 expression at mRNA and protein level was severally detected by quantitative real-time polymerase chain reaction and western blot analysis in 198 HCC patients and 48 healthy controls. And its association with clinicopathological features was analyzed by chi-square test. The diagnostic value of HtrA2 expression was estimated by establishing a receiver operating characteristic (ROC) curve.Serum HtrA2 was significantly higher in patients with HCC than that in healthy controls both at mRNA and protein levels (P < .05 for both). In addition, the high HtrA2 expression was associated with large tumor size and advanced clinical stage. Furthermore, the value of the area under the ROC curve was 0.808 corresponding with a sensitivity of 65.2% and a specificity of 89.6%, revealed that HtrA2 might be a diagnostic biomarker in HCC.HtrA2 is upregulated and considered to be a potential biomarker for the diagnosis of patients with HCC.

Recognition criteria for occupational cancers in relation to hepatitis B virus and hepatitis C virus in Korea

The goal of this study was to review the scientific basis for the recognition of occupational cancer, in relation to hepatitis viral infections in Korea. Most Hepatitis B virus (HBV) infections in Korea occur as vertical infections, but these are decreasing rapidly due to vaccination. Hepatitis C virus (HCV) is known to be transmitted through parenteral routes, but the transmission route is often unclear. Most occupational infections of hepatitis virus involve accidental injuries of medical institution workers while using virus-contaminated medical devices. Many cohort studies and case-control studies have consistently reported that HBV and HCV infection increases the risk of hepatocellular carcinoma (HCC) and the strength of this association is high. Non-Hodgkin’s lymphoma appears to be associated with HCV. Cholangiocarcinoma, pancreatic cancer, leukemia, and thyroid cancer are considered to be less related or unrelated to epidemiological causation. There are no uniform international specific criteria for occupational cancer caused through occupational exposure to a hepatitis virus. In establishing appropriate standards applicable to Korea, there should be sufficient consideration of latency, virus exposure levels and frequency, and other cancers, apart from HCC.

In conclusion, we recommend keeping the current specific criteria. However, if a worker is injured at work when using a sharp medical device, and HBV and HCV viral infections are confirmed through serologic tests; if the worker is diagnosed as having a chronic HBV or HCV infection, a subsequent HCC (or Non-Hodgkin’s lymphoma following chronic HCV infection) can then be considered highly related to the worker’s occupation.

Significance of viral status on occurrence of hepatitis B-related hepatocellular carcinoma

Hepatitis B virus (HBV) infection remains a challenging global health problem, with more than 350 million people chronically infected and at risk of developing hepatocellular carcinoma (HCC). Interactions that occur among host, environmental, and viral factors determine the natural course and predict the prognosis of patients with chronic HBV infection. In the past decades, several important viral factors of predictive of HCC have been identified, such as high hepatitis B surface antigen level, seropositivity of hepatitis B e antigen, high viral load, viral genotype, and specific viral sequence mutations. Identification of certain viral risk factors for HCC development and stratification of patient risk are very important to perform future surveillance programs. In this article, we thus reviewed the risk of viral factors involved in hepatocarcinogenesis.

Coinfection of hepatitis B and C viruses and risk of hepatocellular carcinoma: systematic review and meta-analysis

A subadditive effect of hepatitis B virus (HBV) and hepatitis C virus (HCV) coinfection is possible because superinfection of one virus tends to inhibit infection of the other virus. However, studies have reported inconsistent findings, and two meta-analyses of studies from various countries (1998) and China (2005) reported a supraadditive effect for hepatocellular carcinoma (HCC) risk. Thus, we reevaluate HBV/HCV monoinfection and coinfection. Of 411 reports, we included 59 studies that assessed the association between HBV/HCV monoinfection and coinfection for HCC risk. HCC risk because of high/detectable HBV DNA and HBeAg infection was higher than HBsAg infection, whereas anti-HCV vs anti-HCV/HCV RNA was not different. Geographically, HCC risk was significantly higher in nonendemic than in HBV or HCV endemic areas. Subadditive effect for HCC risk was presented in recently published studies, cohort studies and studies conducted in HBV/HCV nonendemic areas; an additive effect was presented in studies conducted in HBV endemic areas; a supraadditive effect was presented in previously published studies, case-control studies and studies conducted in HCV endemic areas. Our results suggest HBV/HCV coinfection for HCC risk is not significantly greater than HBV/HCV monoinfection, and HCC risk due to HBV or HCV is higher in nonendemic than endemic areas. The p-heterogeneity was significant for most analyses, except HBV(+)/HCV(+) and HBV biomarker analyses. Prevention strategies targeted toward HBV or HCV monoinfected patients are needed. In addition, tailored prevention to reduce infectivity such as HBV markers (HBeAg, HBV DNA) is needed.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Independent and additive interactive effects among tumor necrosis factor-alpha polymorphisms, substance use habits, and chronic hepatitis B and hepatitis C virus infection on risk for hepatocellular carcinoma

We conducted a case-control study to assess the roles of tumor necrosis factor (TNF)-alpha polymorphisms, substance use habits, and chronic hepatitis B virus (HBV)/hepatitis C virus (HCV) infection on the risk for hepatocellular carcinoma (HCC). We enrolled 200 pairs of sex- and age-matched patients with HCC and unrelated healthy controls. TNF-alpha polymorphisms were detected with polymerase chain reaction and direct sequencing. Serum hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCV) were detected. We used a structured questionnaire to obtain information about substance use habits.Multivariate analysis indicated that TNF308.2 allele (odds ratio [OR], 3.23; p = 0.011), habitual betel quid chewing (OR, 3.70; p = 0.011), HBsAg (OR, 23.62; p = 0.0001), and anti-HCV (OR, 38.73; p = 0.0001) were independent risk factors for HCC. Having at least 2 substance use habits was associated with risk for HCC. The more substance use habits, the higher the OR for HCC (p(for trend) = 0.0001). There were additive interactions among TNF308.2 allele, substance use habits, and chronic HBV/HCV infection. Multivariate analysis indicated that TNF308.2 allele (p = 0.001), cigarette smoking (p = 0.0001), and alcohol drinking (p = 0.0001) were independent risk factors for habitual betel quid chewing. Moreover, patients harboring the TNF308.2 allele and/or those with habits of substance use had low serum albumin concentration and platelet count (each p = 0.0001). In conclusion, there are independent and additive interactive effects among the TNF308.2 allele, substance use habits, and chronic HBV/HCV infection on the risk for HCC. Substance use habits or carrying the TNF308.2 allele correlates with disease severity and hepatic fibrosis, which may contribute to higher risks for HCC.

The preoperative positivity for serum hepatitis B e antigen did not affect overall survival after curative resection of hepatitis B virus-related hepatocellular carcinoma

BACKGROUND AND AIM

Previous studies have reported different risk factors for early and late intrahepatic recurrence after resection of hepatocellular carcinoma (HCC). However, the prognostic significance of the risk factors for early and late recurrence has not been clarified.

METHODS

A total of 190 Hepatitis B surface antigen-positive patients who received curative resection for HCC were reviewed. We investigated prognostic factors for disease-free and overall survival after resection, and further analyzed the relationship between significant prognostic factors and risk factors for early (<or=14 months) and late (>14 months) intrahepatic recurrence.

RESULTS

The 5-year disease-free and overall survival rates were 43.9% and 71.5%, respectively. In multivariate analysis, adverse prognostic factors for disease-free survival were presence of serum HBeAg, perioperative transfusion, and the presence of portal vein invasion (PVI) and/or intrahepatic metastasis (IM). Multivariate analysis revealed that overall survival was associated with ICG R15, serum albumin, Edmondson-Steiner grade, and the presence of PVI and/or IM. Independent risk factors for early intrahepatic recurrence were perioperative transfusion and PVI and/or IM, whereas positivity for HBeAg was the only risk factor for late recurrence. In addition, post-recurrence survival in patients with late intrahepatic recurrence was completely comparable to that of patients who never experienced recurrence.

CONCLUSIONS

The presence of serum HBeAg, the risk factor for late intrahepatic recurrence did not affect overall survival after resection because late recurrence was relatively well controlled by current available treatments. To further improve long-term surgical outcomes, effective treatment and preventive methods for early intrahepatic recurrence should be investigated.

Endemic hepatitis B virus infection and chronic liver disease mortality in the Republic of Palau, 1990–2002

In the Republic of Palau, a Pacific island nation, approximately 20% of the population is chronically infected with hepatitis B virus (HBV) and is at risk of developing chronic liver disease (CLD), including cirrhosis and hepatocellular carcinoma (HCC). To examine the consequences of HBV infection, we sought to quantify HBV-related CLD mortality in this population. The cause of death was abstracted from death certificates of all persons who died in Palau during 1990-2002. CLD deaths were categorised as cirrhosis or HCC. HBV serological status was determined by review of a hospital database. The cause of death was determined for 1,366 (85%) of 1,608 deaths. CLD was the fifth most common cause of death, accounting for 102 (7%) deaths with a known cause. Of deaths due to CLD, 55 (54%) were from cirrhosis and 47 (46%) were from HCC. Sixty-five percent of CLD decedents and 19% of non-CLD decedents were chronically infected with HBV (P<0.01). The attributable fraction of HBV-related CLD was 54% (58% for cirrhosis and 53% for HCC). CLD mortality rates were approximately twice the worldwide CLD rate. HBV-related CLD is a common cause of death in the Republic of Palau, highlighting the importance of routine infant hepatitis B vaccination, especially in countries with high endemicity.

Increased liver pathology in hepatitis C virus transgenic mice expressing the hepatitis B virus X protein

Transgenic mice expressing the full-length HCV coding sequence were crossed with mice that express the HBV X gene-encoded regulatory protein HBx (ATX mice) to test the hypothesis that HBx expression accelerates HCV-induced liver pathogenesis. At 16 months (mo) of age, hepatocellular carcinoma was identified in 21% of HCV/ATX mice, but in none of the single transgenic animals. Analysis of 8-mo animals revealed that, relative to HCV/WT mice, HCV/ATX mice had more severe steatosis, greater liver-to-body weight ratios, and a significant increase in the percentage of hepatocytes staining for proliferating cell nuclear antigen. Furthermore, primary hepatocytes from HCV, ATX, and HCV/ATX transgenic mice were more resistant to fas-mediated apoptosis than hepatocytes from nontransgenic littermates. These results indicate that HBx expression contributes to increased liver pathogenesis in HCV transgenic mice by a mechanism that involves an imbalance in hepatocyte death and regeneration within the context of severe steatosis.

Interaction between hepatitis B and C viruses in hepatocellular carcinogenesis

Although hepatitis B (HBV) and C viruses (HCV) are, individually, major causes of hepatocellular carcinoma, the interaction, if any, between the carcinogenic effects of the two viruses is uncertain. Equal numbers of published studies have reported no risk interaction or a synergistic risk interaction. These conflicting results are explained by the rarity of concurrent infection with HBV and HCV in individuals without clinically evident liver disease, which severely limits the ability to accurately estimate the hepatocarcinogenic risk of dual infection compared with that of either infection alone. In an attempt to circumvent this difficulty, two meta-analyses have been performed, one based on studies published from a number of countries and the other on studies confined to Chinese patients. Both analyses concluded that a synergistic carcinogenic interaction existed between the two viruses and that the increased risk was super-additive but not multiplicative. If confirmed, this risk interaction will occur against a background of negative confounding effects on viral replication between HBV and HCV, which may be reciprocal. The mechanisms responsible for the carcinogenic interaction between the viruses are unknown. One possibility is that the increased incidence of cirrhosis with concurrent HBV and HCV infections acts as an even more potent tumour promoter than occurs with either virus alone. Synergism between the direct hepatocarcinogenic effects of the two viruses is another possible mechanism, but proof will have to await a fuller understanding of the pathogenetic mechanisms involved with the individual viruses.

A mathematical model to estimate global hepatitis B disease burden and vaccination impact

BACKGROUND

Limited data are available regarding global hepatitis B virus (HBV)-related morbidity and mortality and potential reduction in disease burden from hepatitis B vaccination.

METHODS

A model was developed to calculate the age-specific risk of acquiring HBV infection, acute hepatitis B (illness and death), and progression to chronic HBV infection. HBV-related deaths among chronically infected persons were determined from HBV-related cirrhosis and hepatocellular carcinoma (HCC) mortality curves, adjusted for background mortality. The effect of hepatitis B vaccination was calculated from vaccine efficacy and vaccination series coverage, with and without administration of the first dose of vaccine within 24 h of birth (i.e. birth dose) to prevent perinatal HBV infection.

RESULTS

For the year 2000, the model estimated 620,000 persons died worldwide from HBV-related causes: 580,000 (94%) from chronic infection-related cirrhosis and HCC and 40,000 (6%) from acute hepatitis B. In the surviving birth cohort for the year 2000, the model estimated that without vaccination, 64.8 million would become HBV-infected and 1.4 million would die from HBV-related disease. Infections acquired during the perinatal period, in early childhood (<5 years old), and > or = 5 years of age accounted for 21, 48, and 31% of deaths, respectively. Routine infant hepatitis B vaccination, with 90% coverage and the first dose administered at birth would prevent 84% of global HBV-related deaths.

CONCLUSION

Globally, most HBV-related deaths result from the chronic sequelae of infection acquired in the perinatal and early childhood periods. Inclusion of hepatitis B vaccine into national infant immunization programs could prevent >80% of HBV-related deaths.

Epidemiology and Prevention of Hepatitis B Virus Infection

Hepatitis B is one of the most common infectious diseases globally. It has been estimated that there are 350 million chronic hepatitis B virus (HBV) carriers worldwide. The prevalence of chronic HBV infection varies geographically, from high (>8%), intermediate (2-7%) to low (<2%) prevalence. HBeAg-negative chronic hepatitis B (e-CHB) and occult HBV infection are two special clinical entities, and the prevalence and clinical implications remain to be explored. The predominant routes of transmission vary according to the endemicity of the HBV infection. In areas with high HBV endemicity, perinatal transmission is the main route of transmission, whereas in areas with low HBV endemicity, sexual contact amongst high-risk adults is the predominant route. HBV has been classified into 7 genotypes, i.e. A to G, based on the divergence of entire genome sequence and HBV genotypes have distinct geographical distributions. Three main strategies have been approved to be effective in preventing HBV infection. They are behavior modification, passive immunoprophylaxis, and active immunization. The implement of mass HBV immunization program is recommended by the WHO since 1991, and has dramatically decreased the prevalence of HBV infection and HCC in many countries.

Habitual betel quid chewing and risk for hepatocellular carcinoma complicating cirrhosis

This case-control study aimed to assess the independent and interactive role of habitual betel quid chewing and known risk factors for hepatocellular carcinoma (HCC). Subjects enrolled included 210 pairs of sex- and age-matched cirrhotic patients with HCC, patients with cirrhosis alone, and healthy controls. Information on risk factors was obtained through serologic examination of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis C virus (anti-HCV), and a standardized personal interview with a structured questionnaire. Multivariate analysis indicated that betel quid chewing (odds ratio [OR], 5.81; 95% confidence interval [CI], 2.26-14.94); HBsAg (OR, 37.98; 95% CI, 19.65-73.42); and anti-HCV (OR, 47.23; 95% CI, 18.86-118.25) were independent risk factors for HCC when HCC patients were compared with healthy controls. Using patients with cirrhosis alone as a reference group, multivariate analysis indicated that only betel quid chewing (OR, 1.69; 95% CI, 1.04-2.76) and HBsAg (OR, 1.54; 95% CI, l.01-2.37) were independent risk factors for HCC. There was an additive interaction between betel quid chewing and the presence of either HBsAg (synergy index, 5.22) or anti-HCV (synergy index, 1.35). Moreover, a higher risk of HCC was associated with a longer duration of betel quid chewing and a larger amount of betel quid consumed (each p(for trend) < 0.0001). In conclusion, betel quid chewing is an independent risk factor for cirrhotic HCC. There is an additive interaction between betel quid chewing and chronic hepatitis B and/or hepatitis C virus infection.

Seropositivity of hepatitis B e antigen and hepatocellular carcinoma

Chronic infection with hepatitis B virus (HBV) is an important clinical problem due to its worldwide distribution and potential of adverse sequelae including hepatocellular carcinoma (HCC). Hepatitis B e antigen (HBeAg) is a biomarker of active viral proliferation in hepatocytes and infectivity. The prevalence of HBeAg among subjects chronically infected with HBV decreases with the increase in age. Case series studies have found a lowest seroprevalence of HBeAg in HCC patients compared with patients affected with chronic hepatitis B and liver cirrhosis. Case-control studies have shown a significantly higher seroprevalence of HBeAg in HCC cases than matched controls. A recent long-term follow-up study has shown a significantly elevated HCC risk for seropositives of both hepatitis B surface antigen (HBsAg) and HBeAg compared with seropositives of HBsAg only and seronegatives. The biological gradient remained in further stratification analyses by serum level of alanine transaminase and status of liver cirrhosis detected by ultrasonography. The cumulative HCC risk from age 30 to 70 years has been estimated to be 87% for those who were persistently seropositive on HBsAg and HBeAg, 12% for those with persistent seropositivity of HBsAg only, and 1% for those who were seronegative on HBsAg and HBeAg.

The Gambia Liver Cancer Study: Infection with hepatitis B and C and the risk of hepatocellular carcinoma in West Africa

Hepatocellular carcinoma (HCC) is the most common cancer in The Gambia. Hepatitis B virus (HBV) infection is endemic, with 15% to 20% of the population being chronic carriers, whereas hepatitis C virus (HCV) prevalence is low. We recruited 216 incident cases of HCC and 408 controls from three sites. HBV carriage was present in 61% (129/211) of HCC patients and 16% (64/402) of controls, whereas 19% (36/191) of HCC patients were HCV seropositive compared with 3% (11/382) of controls. HCC patients with HCV were notably older and were more likely to be female than those with HBV. Increased HCC risk was strongly associated with chronic HBV (odds ratio, 16.7; 95% CI, 9.7-28.7), HCV (16.7; 6.9-40.1), and dual infection (35.3; 3.9-323). We interpret the additive nature of risk with coinfection as representative of HBV and HCV acting primarily through shared steps in the multistage process of hepatocarcinogenesis. HCV infection was not observed among younger participants, suggesting a possible cohort effect. Reasons for the striking age and gender differences in HCC associated with HBV compared with HCV are unclear, but transmission patterns and age at exposure may be factors. In conclusion, in a standardized evaluation of well-characterized study participants from The Gambia, most cases of HCC are attributable to HBV (57%), but HCV adds a significant fraction (20%), especially among older patients and females. If HCV transmission is not perpetuated in future cohorts, focusing available resources on HB vaccination efforts could greatly ameliorate a major cause of cancer death in sub-Saharan Africa.

Habitual betel quid chewing as a risk factor for cirrhosis: a case-control study

Betel quid chewing, part of traditional Taiwanese culture, is common in 10%-20% of the human population worldwide. In this case-control study we assessed the independent and interactive role of habitual betel quid chewing and chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection on risk of cirrhosis. Subjects enrolled included 210 pairs of sex- and age-matched cirrhotic patients and healthy controls. Information on risk factors was obtained through serologic examination of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis C virus (anti-HCV), and a standardized personal interview with a structured questionnaire. Univariate analysis indicated that betel quid chewing, HBsAg+, anti-HCV+, alcohol drinking, and smoking are significant risk factors for cirrhosis. Multivariate analysis indicated that betel quid chewing (odds ratio [OR], 3.56), HBsAg (OR 20.37), and anti-HCV (OR 31.43) are independent risk factors for cirrhosis. Most betel quid chewers habitually drink alcohol. Although our analysis indicates that betel quid chewing acts independently from alcohol as a risk factor for cirrhosis, the confounding effect of alcohol cannot be excluded entirely by our study. There was an additive effect of the interaction between betel quid chewing and the presence of either HBsAg or anti-HCV. Moreover, a higher risk of cirrhosis was associated with longer duration of betel quid chewing and greater amount of betel quid consumed (each p for trend <0.0001). In conclusion, betel quid chewing appears to be an independent risk factor for cirrhosis. There is an additive interaction between betel quid chewing and chronic HBV/HCV infection.

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

Hepatocellular carcinoma caused by hepatitis B and hepatitis C are global scourges but are likely to peak in incidence in the next 2 decades and then decline. Universal vaccination has been effective in stemming the incidence of chronic hepatitis B and early-onset HCC in regions of high endemicity where implemented, but preventive measures in HCV are not yet available. After the attrition of older affected generations, the incidence of HCC will likely decline rapidly. While no vaccine is currently available for hepatitis C, cases are projected to peak and decline because of a marked reduction in transmission as a result of behavioral modification and safeguarding of blood supplies. Until these epidemiologic projections come to pass, management of hepatocellular carcinoma will continue to become a progressively more frequently encountered clinical challenge. Therapy for chronic hepatitis may ameliorate but will not eliminate the development of tumors. The demand for orthotopic liver transplantation will continue to climb, and palliative therapies for non-resectable cases will require studies aimed at optimization of benefit. LDLT may remain an option for high-risk patients affording tumor-free survival for some otherwise terminal patients.

Hepatitis B e antigen and the risk of hepatocellular carcinoma

BACKGROUND

The presence of hepatitis B e antigen (HBeAg) in serum indicates active viral replication in hepatocytes. HBeAg is thus a surrogate marker for the presence of hepatitis B virus DNA. We conducted a prospective study to determine the relation between positivity for hepatitis B surface antigen (HBsAg) and HBeAg and the development of hepatocellular carcinoma.

METHODS

In 1991 and 1992, we enrolled 11,893 men without evidence of hepatocellular carcinoma (age range, 30 to 65 years) from seven townships in Taiwan. Serum samples obtained at the time of enrollment were tested for HBsAg and HBeAg by radioimmunoassay. The diagnosis of hepatocellular carcinoma was ascertained through data linkage with the computerized National Cancer Registry in Taiwan and with death certificates. We performed a multiple regression analysis to determine the relative risk of hepatocellular carcinoma among men who were positive for HBsAg alone or for HBsAg and HBeAg, as compared with those who were negative for both.

RESULTS

There were 111 cases of newly diagnosed hepatocellular carcinoma during 92,359 person-years of follow-up. The incidence rate of hepatocellular carcinoma was 1169 cases per 100,000 person-years among men who were positive for both HBsAg and HBeAg, 324 per 100,000 person-years for those who were positive for HBsAg only, and 39 per 100,000 person-years for those who were negative for both. After adjustment for age, sex, the presence or absence of antibodies against hepatitis C virus, cigarette-smoking status, and use or nonuse of alcohol, the relative risk of hepatocellular carcinoma was 9.6 (95 percent confidence interval, 6.0 to 15.2) among men who were positive for HBsAg alone and 60.2 (95 percent confidence interval, 35.5 to 102.1) among those who were positive for both HBsAg and HBeAg, as compared with men who were negative for both.

CONCLUSIONS

Positivity for HBeAg is associated with an increased risk of hepatocellular carcinoma.

Effect of the presence of hepatitis B e antigen on prognosis after liver resection for hepatocellular carcinoma in patients with chronic hepatitis B

We examineded the clinical effects of serum hepatitis B e antigen (HBeAg) positivity on clinicopathologic findings and prognosis after liver resection for hepatocellular carcinoma (HCC) in patients with chronic hepatitis B. A series of 56 patients who underwent curative resection were divided into two groups: 25 HBeAg-positive patients (group 1) and 31 HBeAg-negative patients (group 2). The mean age was significantly lower in group 1 than in group 2 (p = 0.0021), and the proportion of patients with symptoms was significantly higher in group 1 than in group 2 (p = 0.037). There were no significant differences in other clinical findings between the two groups, including laboratory test results, coexisting medical conditions, and operative methods. Although tumor size, degree of differentiation of the main tumor, and the prevalence of vascular invasion did not differ between the groups, the prevalence of intrahepatic metastasis and the proportion of patients with active hepatitis were significantly higher in group 1 than in group 2 (p = 0.009 and p = 0.043, respectively). Tumor-free and cumulative survival rates were significantly lower in group 1 than in group 2 (p = 0.022 and p = 0.0001, respectively). Multivariate analysis of various possible risk factors demonstrated serum HBeAg positivity to be an independent risk factor for recurrence [risk ratio (RR) 2.49; 95% confidence interval (CI) 1.12-5.49; p = 0.032] and an independent unfavorable factor for the survival time (RR 7.58; 95% CI 2.10-27.8; p = 0.0020). We concluded that the prognosis after liver resection for HCC is worse for HBeAg-positive patients than for HBeAg-negative patients.

Betel quid chewing as a risk factor for hepatocellular carcinoma: a case-control study

The role of betel quid chewing in the aetiology of hepatocellular carcinoma (HCC) was evaluated in a case-control study including 263 pairs of age- and sex-matched HCC patients and healthy controls. Serum hepatitis B surface antigen (HBsAg), and antibodies to hepatitis C virus (anti-HCV) were determined, and standardized personal interview conducted using a structured questionnaire. Multivariate analysis indicated that betel quid chewing (odds ratio (OR), 3.49; 95% confidence interval (CI), 1.74-6.96), HBsAg (OR, 16.69; 95% CI, 9.92-28.07), anti-HCV (OR, 38.57; 95% CI, 18.15-81.96), and educational duration of less than 10 years (OR, 1.71; 95% CI, 1.05-2.78) are independent risk factors of HCC. In addition, there was an additive interaction between betel quid chewing and chronic infection with either hepatitis B virus (synergy index, 5.37) or hepatitis C virus (synergy index, 1.66). Moreover, risk on HCC increased as duration of betel quid chewing increased, or amount of betel quid consumed (each P for trend < 0.0001).

A meta-analysis of epidemiological studies on the combined effect of hepatitis B and C virus infections in causing hepatocellular carcinoma

The aim of the study was to assess whether co-infection by hepatitis-B virus (HBV) and hepatitis-C virus (HCV) is associated with a higher risk of developing hepatocellular carcinoma (HCC) than each infection alone. A meta-analysis of data published up to June 1997 was performed. HBsAg and anti-HCV antibodies or HCV RNA (anti-HCV/HCV RNA) were considered as serological markers of current HBV and HCV infection respectively. A total of 32 case-control studies were suitable for a quantitative overview. The summary odds ratios (OR) were 13.7 for HBsAg positivity and 11.5 for anti-HCV/HCV RNA positivity. The OR for anti-HCV was lower among studies using second- or third-generation anti-HCV or HCV RNA (OR, 8.2) with respect to studies with first-generation anti-HCV test (OR, 19.1). When combining data from the studies with second- or third-generation anti-HCV or HCV RNA, the OR for HBsAg positivity and anti-HCV/HCV RNA negativity was 22.5 (95% confidence interval (CI), 19.5-26.0), the OR for anti-HCV/HCV RNA positivity and HBsAg negativity was 17.3 (95% CI, 13.9-21.6), and the OR for both markers positivity was 165 (95% CI: 81.2-374, based on 191 cases and 8 controls exposed). A synergism was found between HBV and HCV infections, the OR for co-infection being greater than the sum and lower than the product of those for each infection alone. The interaction was therefore negative according to the multiplicative model, providing epidemiological evidence both of an independent effect and of interference between the 2 viruses in the carcinogenic process.

An appraisal of the efficacy and cost effectiveness of antenatal screening for hepatitis B

In this review published data are used to determine the benefits and costs of antenatal screening for hepatitis B carriers to prevent the later occurrence of hepatoma and chronic liver disease in their offspring. In Britain, babies born to carrier mothers have a 25% risk of perinatal infection and of becoming carriers themselves (the risk is 82% if their mothers are positive for the e antigen and 10% if negative). The carrier state increases the risk of hepatoma an estimated 86 times and the risk of chronic liver disease 20 times. Life table analysis showed that there is an 11% lifetime risk in carriers in Britain of dying from hepatoma (which results in seven years of life lost on average) and a 7% risk of chronic liver disease (14 years of life lost). Neonatal vaccination reduces the risk of the infant becoming a carrier by about 90%. Perinatal transmission occurs in 38 of every 100,000 neonates in Britain. Antenatal screening of all women and vaccinating babies of carrier mothers would prevent perinatal transmission in 34 of the 38 children (90%), or 255 per year in Britain. Of these 34, 8.4 children would be Chinese in ethnic origin, 4.2 African, 11.5 South Asian (from the Indian subcontinent), 2.0 Caribbean, and 7.3 would be white. Six deaths in the 34 from hepatoma or chronic liver disease caused by hepatitis B would then be prevented. The direct cost in Britain of screening all women, irrespective of ethnicity, at their first pregnancy only, would be 1300 pounds for each year of life saved (undiscounted) or 2500 pounds if screening at every pregnancy. Screening just Chinese, Africans, and South Asians, at first pregnancy only, would cost 330 pounds for each year of life saved but would prevent only 64% of these deaths. Vaccinating the infants of carrier mothers is likely also to prevent horizontal transmission of hepatitis B in early childhood and prevent the carrier state developing in an estimated three extra children for each child protected from vertical transmission. When this is taken into account the number of deaths prevented increases fourfold, reducing the cost for each year of life saved by 75%. Screening all women at first pregnancy only is an acceptably cost effective policy in Britain (1300 pounds for each year of life saved), actually preventing 45 deaths a year from hepatoma and chronic liver disease (or about 180 deaths if those horizontally infected are included), at a total cost of 540,000 pounds a year. It has the advantage of being comprehensive, equitable, and easier to implement than a policy based on screening of high risk ethnic groups.

Clinical relevance of transforming growth factor-beta 1 in the urine of patients with hepatocellular carcinoma

To assess the clinical relevance of transforming growth factor-beta 1 (TGF-beta 1) in the urine of patients with hepatocellular carcinoma (HCC), TGF-beta 1 was measured, by radioimmunoassay, in 140 patients with HCC, 50 cirrhotic patients, 30 patients with chronic active hepatitis, and 50 healthy controls. The results indicate that there were significantly increased urinary TGF-beta 1 levels in patients with HCC. Raised TGF-beta 1 levels were associated, in a dose-related fashion, with increased risk for development of HCC (odds ratio, 1.05, 95% confidence interval, 1.03-1.07). HCC patients with raised TGF-beta 1 levels had shorter survival than those with normal TGF-beta 1 levels (p = 0.038). TGF-beta 1 levels decreased after successful anticancer therapy (p < 0.0001). There was an inverse correlation between TGF-beta 1 and serum alpha-fetoprotein (AFP) (r = -0.199, p < 0.04). Receiver operating characteristics (ROC) curve analysis indicated that parallel determination of TGF-beta 1 and AFP significantly increased the sensitivity and diagnostic accuracy, with a high specificity. In conclusion, raised urinary TGF-beta 1 was associated with HCC development. It is a predictor of poor prognosis, and a tumor marker for diagnosis and therapeutic follow-up of HCC.

Urinary transforming growth factor-beta 1 in relation to serum alpha-fetoprotein in hepatocellular carcinoma

BACKGROUND

Our aim was to assess the relationship between transforming growth factor beta 1 (TGF-beta 1) and alpha-fetoprotein (AFP) levels in hepatocellular carcinoma (HCC).

METHODS

Urinary TGF-beta 1 and serum AFP were determined in 123 HCC patients, 50 patients with chronic liver disease (CLD), and 50 healthy controls.

RESULTS

Both TGF-beta 1 and AFP levels were higher in HCC patients than in CLD patients or controls (each, P = 0.0001). There was a negative correlation between TGF-beta 1 and logAFP (r = -0.196, P = 0.029). Multivariate analysis indicated that TGF-beta 1 and AFP were associated with an increased risk of HCC development. By receiver-operating characteristic curve analysis, determination of AFP and TGF-beta 1 in parallel significantly increased the sensitivity and diagnostic accuracy in detecting HCC.

CONCLUSION

Increased urinary TGF-beta 1 level can be used as a complementary marker to AFP for detection of HCC with low AFP production.

Serum alanine aminotransferase level in relation to hepatitis B and C virus infections among blood donors

To assess the serum alanine aminotransferase (ALT) activity in relation to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among blood donors, antibodies to HCV (anti-HCV) and hepatitis B surface antigen (HBsAg) were detected in 400 blood donors with normal ALT level (< or = 750 mumol/s per liter), and 76 blood donors with raised ALT level. The prevalence of anti-HCV (10.5%) and HBsAg (28.9%) in the latter was higher than that (2.0% and 17.5%, respectively) in the former (p < 0.001 and p < 0.03, respectively). There was a trend that indicated that the risk of anti-HCV positivity increased with increasing age (p < 0.001). Thirty of 76 (39.5%) donors with raised ALT level were positive for anti-HCV or HBsAg. Compared with HBsAg-positive donors, donors with anti-HCV had higher serum ALT levels (p < 0.01) and greater mean age (p < 0.01). Multivariate analysis indicated that both anti-HCV (odds ratio: 6.2; 95% confidence interval: 2.2-17.8) and HBsAg (odds ratio: 2.2; 95% confidence interval: 1.3-3.9) were significantly associated with raised serum ALT activity. The estimated population-attributable risk was 8.6% for anti-HCV, and 13.8% for HBsAg. In conclusion, although HBV and HCV infections are independent risk factors of raised ALT activity among blood donors, they play a minor role in the etiology of raised ALT activity.

Effect of hepatitis C and B virus infection on risk of hepatocellular carcinoma: a prospective study

To assess whether there is an additive effect between chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection on the development of hepatocellular carcinoma (HCC), 400 consecutive cirrhotic patients were followed prospectively with periodic abdominal ultrasound examination and measurement of serum alpha-fetoprotein (AFP) level every 4 months. During a follow-up of 1185 person-years, 80 (20%) patients developed HCC, with an annual incidence of 6.8%. The annual incidence was 2.0% in patients negative for hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCV), 6.6% in patients with HBsAg alone, 7.0% in patients with anti-HCV alone and 13.3% in patients co-infected with HBV and HCV. There was a positive linear trend in the annual incidence of HCC among patients without either marker, patients with single viral infection and patients with dual viral infection (P[for trend] < 0.0001). Cox's proportional hazard model indicated that HCV/HBV co-infection [hazard ratio (HR), 6.41; 95% confidence interval (CI), 1.80-22.80], anti-HCV alone (HR, 3.74; 95% CI, 1.07-13.07) and HBsAg alone (HR, 4.06; 95% CI, 1.23-13.34) were independently risk factors of HCC. In conclusion, there is an additive and independent effect modification of HCV and HBV infection on HCC development.

Elevated urinary transforming growth factor-beta1 level as a tumour marker and predictor of poor survival in cirrhotic hepatocellular carcinoma

To assess the clinical relevance of transforming growth factor-beta1 (TGF-beta1) in hepatocellular carcinoma (HCC), urinary TGF-beta1 and serum alpha-fetoprotein (AFP) were determined in 94 patients with cirrhotic HCC, 94 age- and sex-matched patients with cirrhosis alone and 50 healthy adults. TGF-beta1 level in HCC was higher than in cirrhosis alone or in healthy controls (each P = 0.0001). There is an inverse correlation between TGF-beta1 and AFP levels (r = -0.292, P = 0.004). Significantly higher TGF-beta1 level was found in HCC patients with worsening Child-Pugh stages, diffuse HCC, tumour size > 3 cm, multilobular tumour and AFP < or = 20 ng ml(-1). TGF-beta1 level decreased after complete treatment with transcatheter arterial chemoembolization (P = 0.0001). The median survival in HCC patients with raised TGF-beta1 was shorter than those with normal TGF-beta1 (P = 0.018). Multivariate analysis indicated that TGF-beta1 and AFP were significantly correlated with the presence of HCC. In addition, TGF-beta1 could be used as a diagnostic marker for HCC, particularly in tumours with low AFP production. In conclusion, elevated urinary TGF-beta1 level is a tumour marker and predictor of poor survival for cirrhotic HCC.

Clinical evaluation of urinary transforming growth factor-beta1 and serum alpha-fetoprotein as tumour markers of hepatocellular carcinoma

To evaluate the diagnostic application of urinary transforming growth factor-beta1 (TGF-beta1) and serum alpha-fetoprotein (AFP) levels in hepatocellular carcinoma (HCC), TGF-beta1 and AFP were determined in 94 patients with cirrhotic HCC and in 94 sex- and age-matched patients with cirrhosis alone. TGF-beta1 and AFP levels in HCC were higher than in cirrhosis alone (P = 0.0001). There is an inverse correlation between TGF-beta1 and log AFP (r = -0.292, P = 0.004). Multivariate analysis indicated that TGF-beta1 and AFP were closely associated, in a dose-related fashion, with the development of HCC. Receiver-operating characteristic (ROC) curves were used to determine the optimal cut-off values of TGF-beta1 (50 microg g(-1) creatinine) and AFP (100 ng ml(-1)). Both TGF-beta1 and AFP showed a high specificity (99%) and positive likelihood ratio. The sensitivity was 53.1% for TGF-beta1 and 55.3% for AFP. The determination of both markers in parallel significantly increased the diagnostic accuracy (90.1%) and sensitivity (84%), with a high specificity (98%) and positive likelihood ratio (40.0). In conclusion, TGF-beta1 and AFP are independent tumour markers of HCC and may be used as complementary tumour markers to discriminate HCC from cirrhosis.