Immunodeficiency to hepatitis B virus infection and genetic susceptibility to development of hepatocellular carcinoma

Hepatocellular carcinoma, hepatic cirrhosis, and hepatitis B virus infection in Nigeria

A total of 200 consecutive patients bearing histologically confirmed primary hepatocellular carcinoma (PHC) were studied at University of Calabar Teaching Hospital (CTH), Calabar, Nigeria in 5 years and compared with 150 patients with metastatic hepatic carcinoma (MHC). Four hundred symptomless non-icteric nontumor-bearing individuals were noncontemporaneous controls. Sera (a total of 750) were assayed for markers of hepatitis B virus (HBV) infection; hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and hepatitis B surface antibody (anti-HBs). Specimens which were positive for HBsAg also were examined for hepatitis E antigen (HBeAg) and antibody (anti-HBe). The results show that PHC was associated with HBV seropositivity in 80% of patients, and postnecrotic (macronodular) cirrhosis of the liver in 90% clearly indicating a strong association between primary liver cancer and HBV infections and liver cirrhosis. The main factor associated with seropositivity among normal controls was a large number of therapeutic injections. Seropositives received over twice as many injections as seronegatives. Public health measures are urgently required to prevent parenteral transmission of HBV in Nigeria.

Maternal transmission of hepatocellular carcinoma

A family in which four members have died of hepatocellular carcinoma is presented. Hepatitis B surface antigen was present in both cases in which it was sought and also present in nine of ten surviving siblings in the second generation. Maternal transmission of hepatitis B surface antigen and susceptibility to hepatocellular carcinoma is postulated.

Hepatitis B virus profile of hepatocellular carcinoma in the Philippines

The hepatitis B virus (HBV) profile was investigated in 104 age-grouped hepatocellular carcinoma (HCC) patients and 84 controls from the Philippines. The HCC-control percent positivities of the HBV parameters are: HBsAg: 70-18; anti-HBs: 25-37; anti-HBs: 25-37; anti-HBc: 94-35; HBeAg: 5-2; anti-HBe: 60-30; HBV exposure rate: 97-57; current infection: 80-31. Male HCC anti-HBs positivity is significantly lower than in controls. Female HCC patients' anti-HBs are also lower than controls, but this difference is not statistically significant. Simultaneous presence of HBsAg and anti-HBs was found only in male HCC patients. The mean anti-HBc titer of anti-HBs-positive HCC is higher than that of controls. That of HCC patients negative for both HBsAg and anti-HBs is also higher than the corresponding controls. Anti-HBe positivities of infected and noninfected but previously exposed HCC patients are not significantly different, in contrast to noninfected previously exposed controls whose anti-HBe is lower than those with current infection. The exposure rate prevalence of current infection, and the antibody responses to HBV of HCC patients suggested a close relationship between the two conditions in the Philippines.

A prospective study on the development of hepatocellular carcinoma from liver cirrhosis with persistent hepatitis B virus infection

We made a prospective study on the development of hepatocellular carcinoma (HCC) in patients with liver cirrhosis with hepatitis B virus infection from April, 1973 to December, 1977. Seven out of 30 patients (23%) with hepatitis B surface antigen (HBsAg)-positive cirrhosis developed HCC. On the other hand, only 5.9% of the patients with HBsAg-negative liver cirrhosis developed HCC. These patients were classified into three groups according to their anti-HB core (anti-HBc) titers. When the anti-HBc titer, expressed as a dilution of serum, was 2(10) or more (Group I), 20-24% of the liver cirrhosis patients developed HCC either with or without a detectable amount of HBs Ag present in the sera. When the anti-HBc titer was 2(9) or less (Group II), only 0-5.7% developed HCC. There was no significant difference between this and the anti-HBc and HBsAg-negative group (Group III), which was 4.4%. In five individual cases from group I, HBsAg was detected in serum, and in biopsies of liver cells, before HCC could be detected by angiography and/or rising levels of alphafetoprotein (AFP). In all of these cases, the anti-HBc titer was higher than 2(10) throughout the observation period, even before the development of HCC. These findings indicate that active virus proliferation in chronic hepatitis B virus infection precedes the development of HCC as indicated by a higher anti-HBc titer. Therefore we have prepared these studies to show the pathogenic role of hepatitis B virus in the development of hepatocellular carcinoma.

Hepatitis B surface antigen and antibody status in biopsy proven chronic hepatitis in Singapore

During the period between January 1975 and August 1976, 203 liver biopsies were received at the Singapore General Hospital from patients with a variety of liver diseases. A histological diagnosis of chronic hepatitis was made in 29 patients: 13 cases of Chronic Aggressive Hepatitis (C.A.H.). 10 cases Chronic Persistent Hepatitis (C.P.H.) and 6 of Chronic Lobular Hepatitis (C.L.H.). C.P.H. and C.L.H. were found mainly in the third and fourth decades. C.A.H. was more common in the fifth to seventh decades and occurred principally in females. Hepatitis B antigenaemia was detected in 48.3% of these cases using the immunoelectroosmophoresis (EOP) technique and showed an even scatter in all histological sub-types. Using the reverse passive haemagglutination (rPHA) method for detection by HBs antigen and the radioelectrocomplexing (REC) method for anti-HBs, an immune sub-group (HBs Ag+/anti-HBs+) was identified in greater proportions in C.A.H. and C.P.H. compared to normal controls. This was interpreted to mean that these patients suffered from a primary immunodeficiency characterized by failure of production of high avidity anti-HBs with resulting failure to clear HBsAg leading to perpetuation of liver damage due to circulating immune complexes. It is also suggested that patients with C.P.H. belonging to this immune sub-group may progress to C.A.H. with its more ominous prognosis.

Etiology of human liver cancer: controlled prospective study in liver cirrhosis

The incidence of primary liver cell carcinoma was investigated in a prospective study over 6 yr and 5 mo in 403 clinically unselected patients derived from a homogeneous population by means of serial determination of alpha 1-fetoprotein (AFP) by radioimmunoassay. The diagnosis of liver cirrhosis was proved in 90% by laparoscopy and/or histology and/or autopsy. The incidence of primary liver cell carcinoma in liver cirrhosis in the clinically studied patients was 4.47%, significantly lower than in the autopsy material (11.03%; p less than or equal to 0.025). In the follow-up study, all patients with increasing AFP concentrations exhibited a primary liver cell carcinoma. A transitory rise of AFP (higher than 50 ng/ml) was observed in 15.1% of patients with liver cirrhosis without primary liver cell cancer. In contrast to the results of animal experiments, this transitory rise of AFP was not followed by malignant transformation of the cirrhotic tissue. Posthepatitic liver cirrhosis was observed in 21.57%, postalcoholic liver cirrhosis in 42.93%, and cryptogenic liver cirrhosis in 27.30%. Liver cirrhosis of other etiology occurred in 8.19%. The incidences of primary liver cell cancer in these 4 groups were 4.94, 4.62, 5.45, and 0%, respectively. These differences are not statistically significant, although in absolute figures postalcoholic liver cirrhosis is the main cause of primary liver cell carcinoma in this sample from West Germany. HBs antigen-positive liver cirrhosis was more often associated with primary liver cell cancer than HBs antigen-negative liver cirrhosis (6.58 versus 3.96%); this difference also is not statistically significant. Observations of larger groups of patients may show a higher risk of developing primary liver cell carcinoma in those with a combination of alcohol abuse and HBs antigenemia and/or acute hepatitis in the history. Patients without these 2 risk factors had an incidence of primary liver cell carcinoma of 2.61%; those with 1 risk factor, 5.77%; and those with both risk factors, 10.71%.

Hepatitis B and primary hepatocellular carcinoma in a European population

The prevalence of serological markers of active of past hepatitis-B virus (H.B.V.) infection was determined in 80 Greek patients with primary hepatocellular carcinoma (P.H.C.), 160 age and sex matched controls and 40 patients with metastatic liver cancer (M.L.C.). The relative risk of the various patterns of H.B.V. serological markers for P.H.C. was calculated. Active H.B.V. infection, as indicated by positive tests for hepatitis-B surface antigen (HBsAg), or antibody to hepatitis-B core antigen (anti-HBc) without antibody to HBsAg) (anti-HBs), was associated with P.H.C. (relative risk 10.4) but not with M.L.C. (relative risk 1.2). Patients without markers and those who had recovered from hepatitis B (anti-HBs-positive) had approximately the same low risk for P.H.C. (relative risk 0.8). Active infection was more common in P.H.C. patients with co-existing cirrhosis than in those without cirrhosis (67% versus 26%). Thus the relationship between active hepatitis B and P.H.C. seen in African and Asian populations is now seen in a European Caucasian population with different racial, environmental, and dietary circumstances.

Immunological abnormalities associated with liver disease: cause or effect?

Immunological abnormalities are demonstrable in patients with various types of liver damage. These may be (a) non-specific and unrelated to pathogenesis, e.g. auto-antibodies such as anti-nuclear factor; (b) specifically directed against liver antigens but not pathogenetic, e.g. cell mediated immune (CMI) reactions to liver antigen as seen in experimental carbon tetrachloride poisoning; (c) of such a nature as to modify the pathology produced by hepatotoxic agents, e.g. hepatitis B virus or alcohol; (d) primarily responsible for hepatic pathology, e.g. in idiopathic chronic active hepatitis. The latter two possibilities remain unproven although there is growing evidence that immune responses do play some role in the pathogenesis of acute and chronic hepatitis B and possibly also in the pathogenesis of alcoholic liver disease. It seems much less likely that primary abnormalities of the immune systems are responsible for any type of liver disease. In summary, therefore, the available evidence suggests that immune reactions could develop as a consequence of liver damage and only in certain circumstances do these reactions play a role in the development and continuation of hepatic pathology.

Alpha-fetoprotein

Despite all the information about AFP presented, a great deal still needs to be discovered especially in pregnancy. Geographical and racial differences remain to be elucidated. Similarly, differences in obstetric population in Helsinki and Baltimore, for example, are only now being studied. Sex differences may exist; Lardinois and associates195 cited a higher level of AFP in male than female fetuses. The important questions that need to be answered are whether AFP assays can help improve the other half of prenatal care- that directed to the fetus- and whether the AFP model can help enhance our understanding of the similarities and differences of fetal and cancer cells.