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Hikita H, Sato M, Endo M, Sato M, Soroida Y, Kobayashi T, Gotoh H, Iwai T, Nakagomi R, Tateishi R, Komuro T, Sone S, Koike K, Yatomi Y, Ikeda H. Disappearance of perihepatic lymph node enlargement after hepatitis C viral eradication with direct-acting antivirals. J Viral Hepat 2018; 25:329-334. [PMID: 29091333 DOI: 10.1111/jvh.12819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/19/2017] [Indexed: 12/09/2022]
Abstract
Perihepatic lymph node enlargement (PLNE) which has been shown to be negatively associated with hepatocellular carcinoma (HCC) occurrence is frequently observed in chronic liver disease; however, changes in the state of perihepatic lymph nodes after eradication of hepatitis C virus (HCV) have not been investigated yet. We aimed to evaluate this issue. We enrolled 472 patients with chronic HCV infection who achieved viral eradication with direct-acting antivirals (DAA). We investigated whether the status of perihepatic lymph nodes changed before and after HCV eradication (primary endpoint). We also evaluated the association between PLNE and clinical findings such as liver fibrosis or hepatocellular injury before HCV eradication (secondary endpoint). Perihepatic lymph node enlargement was detected in 164 of 472 (34.7%) patients before DAA treatment. Surprisingly, disappearance of PLNE was observed in 23.8% (39 patients) of all PLNE-positive patients after eradication of HCV. Disappearance of PLNE was not associated with baseline clinical parameters or changing rates of clinical findings before and after DAA treatment. At baseline, presence of PLNE was significantly associated with a lower serum HCV-RNA level (P = .03), a higher serum AST level (P = .004) and a higher ALT level (P < .001) after adjustment for sex and age. In conclusion, PLNEs became undetectable after DAA treatment in 23.8% of PLNE-positive patients. Further study with a longer follow-up period is needed to clarify the clinical importance of this phenomenon especially in relationship with the risk of HCC development.
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Affiliation(s)
- H Hikita
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - Masaya Sato
- Department of Clinical Laboratory Medicine, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Momoe Endo
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - Mamiko Sato
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - Y Soroida
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - T Kobayashi
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - H Gotoh
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - T Iwai
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - R Nakagomi
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - R Tateishi
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - T Komuro
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - S Sone
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - K Koike
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Y Yatomi
- Department of Clinical Laboratory Medicine, Tokyo, Japan
| | - H Ikeda
- Department of Clinical Laboratory Medicine, Tokyo, Japan
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Yamada Y, Matsumoto S, Mori H, Takaji R, Kiyonaga M, Hijiya N, Tanoue R, Tomonari K, Tanoue S, Hongo N, Ohta M, Seike M, Inomata M, Murakami K, Moriyama M. Periportal lymphatic system on post-hepatobiliary phase Gd-EOB-DTPA-enhanced MR imaging in normal subjects and patients with chronic hepatitis C. Abdom Radiol (NY) 2017; 42:2410-2419. [PMID: 28444420 DOI: 10.1007/s00261-017-1155-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE We sought to evaluate visualization of periportal lymphatics and lymph nodes (lymphatic system) on Gd-EOB-DTPA-enhanced magnetic resonance (MR) images using a fat-suppressed T2-weighted sequence with 3-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) at 3.0 T in normal subjects and patients with chronic hepatitis C. METHODS MR imaging was performed in 254 subjects between June 2013 and May 2016. After applying inclusion and exclusion criteria, the final population was 31 normal subjects and 34 patients with chronic hepatitis C. Images were acquired after the hepatobiliary phase following intravenous administration of Gd-EOB-DTPA, which causes signal loss in the bile ducts, to facilitate the visualization of the periportal lymphatic system. Two radiologists assessed the visualization of the periportal lymphatic system in 31 normal subjects. The axial dimensions of the main periportal lymphatic system in normal subjects were measured and compared with those of 34 patients with chronic hepatitis C using the Mann-Whitney U-test, and their correlation with a hepatic fibrosis marker, the Fibrosis-4 (FIB-4), was assessed using Spearman's rank correlation test. RESULTS The periportal lymphatic system was detected as high signal intensity areas surrounding the portal vein up to the third branches by each reader in all normal subjects. The axial dimensions of the main periportal lymphatic system in patients with chronic hepatitis C were significantly larger than those in normal subjects (p < 0.0001), and showed a significantly positive correlation with the FIB-4 score (ρ = 0.73, p < 0.001). CONCLUSIONS Fat-suppressed T2-weighted MR imaging with 3D-VISTA acquired after the hepatobiliary phase on Gd-EOB-DTPA-enhanced imaging may be a useful noninvasive method for evaluating the periportal lymphatic system and the degree of hepatic fibrosis.
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Affiliation(s)
- Yasunari Yamada
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Shunro Matsumoto
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan.
| | - Hiromu Mori
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Ryo Takaji
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Maki Kiyonaga
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Naoki Hijiya
- Department of Molecular Pathology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Rika Tanoue
- Oita Diagnostic Imaging Center, Beppu, Oita, 874-0023, Japan
| | | | - Shuichi Tanoue
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Norio Hongo
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masayuki Ohta
- Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masataka Seike
- Gastroenterology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masafumi Inomata
- Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Kazunari Murakami
- Gastroenterology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masatsugu Moriyama
- Department of Molecular Pathology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
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Tian F, Wu JX, Yu WB. Prognostic Factors and Clinical Characteristics for Hepatocellular Carcinoma Patients with Benign Enlarged Perihepatic Lymph Nodes: a Single-Center Experience from China. J Gastrointest Surg 2015; 19:1822-32. [PMID: 26259664 DOI: 10.1007/s11605-015-2900-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The clinical and prognostic significance of benign perihepatic lymph nodes enlargement (PLNE) from patients with hepatocellular carcinoma (HCC) remains unclear. The objective of this study is to evaluate the relative frequency, incidence and locations of benign PLNE, and the impact on long-term survival of the patients. METHODS A total of 219 consecutive patients who underwent curative resection of HCC between July 2006 and March 2012 in our single institution were divided into two groups according to the presence of PLNE: PLNE group (n = 76), and control group (n = 143). The long-term outcomes were evaluated and compared between the two groups. RESULTS The 1-, 3-, and 5-year recurrence-free survival rates were 77.2, 60.0, and 38.1 % in the PLNE group and 71.3, 42.5, and 25.0 % in the control group (p = 0.080). Corresponding overall survival rates were 96.0, 84.8, 67.1 % and 93.5, 72.4, 46.9 % respectively (p = 0.041). Patients with benign PLNE were associated with a higher rate of centrally located HCCs or tumors adjacent to the major branch of vascular vessels. Multivariate analysis revealed that benign PLNE was an independent positive prognostic factor affecting the overall survival. CONCLUSIONS According to our analysis, patients of HCC with benign PLNE after curative resection can be expected to have better long-term survival. It is also associated with a lower risk of tumor recurrence, but not significant. This finding may provide new insights into daily clinical practice and the pathophysiological characteristics of HCC development.
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Affiliation(s)
- Fei Tian
- Abdominal Surgery Department, Cancer Institute and Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Jian-Xiong Wu
- Abdominal Surgery Department, Cancer Institute and Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China.
| | - Wei-Bo Yu
- Abdominal Surgery Department, Cancer Institute and Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
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Sato M, Hikita H, Hagiwara S, Sato M, Soroida Y, Suzuki A, Gotoh H, Iwai T, Kojima S, Matsuura T, Yotsuyanagi H, Koike K, Yatomi Y, Ikeda H. Potential associations between perihepatic lymph node enlargement and liver fibrosis, hepatocellular injury or hepatocarcinogenesis in chronic hepatitis B virus infection. Hepatol Res 2015; 45:397-404. [PMID: 24849617 DOI: 10.1111/hepr.12361] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 04/03/2014] [Accepted: 05/15/2014] [Indexed: 02/08/2023]
Abstract
AIM Although perihepatic lymph node enlargement (PLNE) is frequently observed in chronic liver disease, little is known about PLNE in chronic hepatitis B virus (HBV) infection. We aimed to evaluate this issue. METHODS We originally enrolled a consecutive 502 patients with chronic HBV infection. Among them, 288 patients without history of interferon-based or nucleoside analog treatment and hepatocellular carcinoma (HCC) were primarily analyzed. RESULTS PLNE was detected in 27 of 288 (9.4%) patients, which was fewer than that in chronic hepatitis C patients but more than that in subjects undertaking a general health examination as previously reported. The presence of PLNE was significantly associated with a higher probability of having an aspartate aminotransferase (AST) platelet ratio index of more than 1.5 (11.1% vs 1.5%, P = 0.01), a higher AST level (38.0 vs 26.8 U/L, P = 0.001), a higher alanine aminotransferase level (50.1 vs 28.0 U/L, P < 0.0001), and a lower platelet count (18.6 vs 20.6 × 10(4) /μL, P = 0.048) after adjustment for sex and age. However, in our original sample (n = 502), PLNE was observed in 1.4% of the patients with HCC and/or its history whereas 9.2% of the patients without HCC, and the proportion was significantly lower in patients with HCC and/or its history (P = 0.03). CONCLUSION PLNE was associated with liver fibrosis and hepatocellular injury, but was negatively associated with HCC in chronic HBV infection.
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Affiliation(s)
- Masaya Sato
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Hikita H, Enooku K, Satoh Y, Yoshida H, Nakagawa H, Masuzaki R, Tateishi R, Soroida Y, Sato M, Suzuki A, Gotoh H, Iwai T, Yokota H, Koike K, Yatomi Y, Ikeda H. Perihepatic lymph node enlargement is a negative predictor for sustained responses to pegylated interferon-α and ribavirin therapy for Japanese patients infected with hepatitis C virus genotype 1. Hepatol Res 2013; 43:1005-12. [PMID: 23356977 DOI: 10.1111/hepr.12061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 12/10/2012] [Accepted: 12/25/2012] [Indexed: 02/01/2023]
Abstract
AIM Although perihepatic lymph node enlargement (PLNE) is reportedly associated with the negative outcome of interferon therapy for chronic hepatitis C, there were limitations in that the results were obtained in patients with various genotypes, viral loads and treatment regimens. We aimed to precisely clarify the significance of PLNE in interferon therapy for chronic hepatitis C. METHODS Between December 2004 and June 2005, 112 patients with hepatitis C virus (HCV) genotype 1 and HCV RNA of more than 100 KIU/mL were enrolled, who underwent pegylated interferon-α plus ribavirin therapy thereafter. PLNE was defined as a perihepatic lymph node of more than 1 cm in the longest axis by ultrasonography. RESULTS The sustained virological response (SVR) rate was lower in patients with PLNE (4/22, 18.2%) than in those without (37/90, 41.1%; P = 0.045) and viral load decline was smaller in patients with PLNE than in those without (P = 0.028). The proportion of PLNE positive patients was the smallest in the SVR group (P = 0.033) among the patient groups divided by the treatment outcome. PLNE was retained as a negative predictor for SVR by multivariate logistic regression analysis (P = 0.012). Furthermore, PLNE was not significantly associated with the mutations at HCV core protein and at interferon sensitivity-determining region, or interleukin-28B polymorphism in 45 patients with HCV genotype 1, enrolled between December 2011 and March 2012. CONCLUSION PLNE is a negative predictor for SVR in patients with HCV genotype 1 and HCV RNA of more than 100 KIU/mL treated with pegylated interferon-α plus ribavirin, independent of other known predictors for SVR.
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Affiliation(s)
- Hiromi Hikita
- Department of Clinical Laboratory Medicine, The University of Tokyo, Tokyo, Japan
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Gotoh H, Enooku K, Soroida Y, Sato M, Hikita H, Suzuki A, Iwai T, Yokota H, Yamazaki T, Koike K, Yatomi Y, Ikeda H. Perihepatic lymph node enlargement observed at a general health examination: A cross-sectional study. Hepatol Res 2013; 43:906-10. [PMID: 23279215 DOI: 10.1111/hepr.12029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/16/2012] [Accepted: 11/20/2012] [Indexed: 02/08/2023]
Abstract
AIM Although perihepatic lymph node enlargement (PLNE) is known as a common finding in chronic liver disease, it can be found occasionally at a general health examination. We aimed to clarify the clinical significance of PLNE in general. METHODS Between January 2008 and December 2011, 4234 subjects were enrolled, who underwent a general health examination at the University of Tokyo Hospital. RESULTS PLNE was observed in 69 (1.6%) subjects, among whom 17 (0.4%) had liver disorders and 13 (0.3%) had malignancy, one of whom had both. No disorders were determined in the remaining 40 subjects (0.9%). Among 17 subjects with liver disorder-associated PLNE, anti-hepatitis C virus (HCV) antibody was determined in 11 and serum alanine aminotransferase levels were less than 40 U/L in eight. Among 13 subjects with malignancy-associated PLNE, para-aortic lymph nodes were also enlarged in eight. Among 40 subjects with PLNE of unknown etiology, 27 could be followed up for the mean period of 2.08 years, where no underlying disorders were newly determined with largely unaltered size of PLNE. CONCLUSION The incidence of PLNE in the general population may vary with the prevalence of chronic liver disease, especially HCV infection. When PLNE is observed, liver disorders should be first surveyed including HCV infection even with normal serum alanine aminotransferase levels. PLNE with para-aortic lymph node enlargement may be suggestive of a malignant lesion. The incidence of PLNE of unknown etiology may be approximately 1% in the general population, which may be just followed up without further change.
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Affiliation(s)
- Hiroaki Gotoh
- Department of Clinical Laboratory Medicine, The University of Tokyo, Tokyo, Japan
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Hikita H, Nakagawa H, Tateishi R, Masuzaki R, Enooku K, Yoshida H, Omata M, Soroida Y, Sato M, Gotoh H, Suzuki A, Iwai T, Yokota H, Koike K, Yatomi Y, Ikeda H. Perihepatic lymph node enlargement is a negative predictor of liver cancer development in chronic hepatitis C patients. J Gastroenterol 2013; 48:366-73. [PMID: 22790352 DOI: 10.1007/s00535-012-0635-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 06/19/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perihepatic lymph node enlargement (PLNE) is a common ultrasound finding in chronic hepatitis C patients. Although PLNE is considered to reflect the inflammatory response to hepatitis C virus (HCV), its clinical significance remains unclear. METHODS Between December 2004 and June 2005, we enrolled 846 chronic hepatitis C patients in whom adequate ultrasound examinations had been performed. PLNE was defined as a perihepatic lymph node that was at least 1 cm in the longest axis by ultrasonography. We analyzed the clinical features of patients with PLNE and prospectively investigated the association between PLNE and hepatocellular carcinoma (HCC) development. RESULTS We detected PLNE in 169 (20.0%) patients. Female sex, lower body mass index (BMI), and HCV serotype 1 were independently associated with the presence of PLNE. However, there were no significant differences in liver function tests, liver stiffness, and hepatitis C viral loads between patients with and without PLNE. During the follow-up period (mean 4.8 years), HCC developed in 121 patients. Unexpectedly, patients with PLNE revealed a significantly lower risk of HCC development than those without PLNE (p = 0.019, log rank test). Multivariate analysis revealed that the presence of PLNE was an independent negative predictor of HCC development (hazard ratio 0.551, p = 0.042). In addition, the sustained viral response rate in patients who received interferon (IFN) therapy was significantly lower in patients with PLNE than in patients without PLNE. CONCLUSIONS Patients with PLNE had a lower risk of HCC development than those without PLNE. This study may provide new insights into daily clinical practice and the pathophysiology of HCV-induced hepatitis and hepatocarcinogenesis.
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Affiliation(s)
- Hiromi Hikita
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Clinical significance of perihepatic lymphadenopathy in patients with chronic hepatitis C infection. Dig Dis Sci 2011; 56:2137-44. [PMID: 21259074 DOI: 10.1007/s10620-010-1555-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 12/30/2010] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients with chronic hepatitis C (HCV) infection commonly have perihepatic lymph node enlargement (PLNE). We investigated the prognostic value of PLNE in the development of complicated cirrhosis and death, as well as the clinical and laboratory factors associated with the presence of PLNE in a cohort of HCV-infected veterans. METHODS Using a retrospective cohort design, we compared the rate of development of decompensated cirrhosis and/or death in a group of HCV-infected patients who did not have evidence of decompensated cirrhosis stratified by the presence or absence of PLNE. We used Kaplan-Meier survival curves. We then evaluated which factors were predictive of detection of PLNE using logistic regression. RESULTS A total of 131 patients were included in the study. Fifty-nine patients had PLNE and 72 patients did not. After a mean follow-up of 42 months, survival in the absence of progression to decompensated cirrhosis and/or death was not significantly different between the two groups (log-rank test, p = 0.27). The only factor predictive of progression to decompensated cirrhosis and/or death was the presence of cirrhosis at baseline (HR 13.13, 95% CI 2.21-79.41). In addition, cirrhosis was the only factor predictive of the detection of PLNE on CT scan (OR 3.09: CI 2.1-25.9). CONCLUSIONS Presence of PLNE in patients with chronic HCV infection is strongly associated with subclinical cirrhosis. However, PLNE does not independently predict the progression of liver disease to decompensated cirrhosis and/or death in HCV-infected patients.
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Friedrich-Rust M, Forestier N, Sarrazin C, Reesink HW, Herrmann E, Zeuzem S. Ultrasound evaluation of perihepatic lymph nodes during antiviral therapy with the protease inhibitor telaprevir (VX-950) in patients with chronic hepatitis C infection. ULTRASOUND IN MEDICINE & BIOLOGY 2007; 33:1362-7. [PMID: 17467151 DOI: 10.1016/j.ultrasmedbio.2007.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 02/01/2007] [Accepted: 02/25/2007] [Indexed: 05/15/2023]
Abstract
Previous studies have shown that the total perihepatic lymph node (PLN) volume is (1) associated with the extent of inflammatory activity in the liver and (2) changes according to the antiviral response in patients receiving interferon-based therapy for chronic hepatitis C (HCV) infection. The aim of this prospective pilot study was to examine whether the total PLN volume similarly changes in patients receiving antiviral monotherapy with the protease inhibitor telaprevir (VX-950). The present study was conducted in a subgroup of 19 patients with chronic hepatitis C genotype-1 infection treated with the protease inhibitor telaprevir (VX-950) or placebo in a phase Ib clinical trial. The total perihepatic lymph node volume was assessed using sonography before the initiation of antiviral therapy, at the end of 14 d of treatment, and at follow-up. Treatment with telaprevir resulted in a significant reduction of plasma HCV-RNA in all patients at the end of 14 d of treatment. In patients receiving telaprevir, the total PLN volume decreased significantly at the end of 14 d of treatment compared with pretreatment volume (1.26 mL to 0.76 mL, p=0.01). In contrast, no significant difference was seen in patients receiving placebo (1.00 mL to 1.06 mL, p=0.26). These results suggest that the perihepatic lymph node volume can be used as an indicator for viral and histologic response not only as previously reported in patients receiving interferon-based therapy, but also in patients receiving therapy with direct antivirals.
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Affiliation(s)
- Mireen Friedrich-Rust
- Department of Internal Medicine, Saarland University Hospital, Homburg/Saar, Germany
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