Akihiro Tamori

Prevention of hepatocellular carcinoma in patients with chronic active hepatitis C and cirrhosis.

In a prospective randomised controlled study, 90 patients with chronic active hepatitis C and compensated cirrhosis were assigned symptomatic treatment or interferon alfa (IFN-alpha). We report data on decompensation, detection of hepatocellular carcinoma, and mortality rates. IFN-alpha gave a sustained response in only a small proportion of patients, but worsening of compensated cirrhosis was prevented and development of hepatocellular carcinoma was inhibited, increasing the survival rate. The risk ratio of IFN-alpha versus symptomatic treatment decreased by 0.250 for progression to Child-Pugh grade B, 0.256 for detection of hepatocellular carcinoma, and 0.135 for a fatal outcome.

Effects of Long-Term Postoperative Interferon-α Therapy on Intrahepatic Recurrence after Resection of Hepatitis C Virus–Related Hepatocellular Carcinoma: A Randomized, Controlled Trial

Hepatitis C virus (HCV) is an important cause of hepatocellular carcinoma in many areas of the world (1). The recurrence rate at 5 years after resection of HCV-related hepatocellular carcinoma has been reported as 70% to 80% (2-4). Recurrences after resection of hepatocellular carcinoma may be either metastases from the primary carcinoma or new foci of carcinomas (multicentric occurrence) (4-8). Chronic active hepatitis is a risk factor for recurrence, including multicentric carcinogenesis, after resection (4, 7, 8). In addition, the recurrence rate after the resection of HCV-related hepatocellular carcinoma is higher in patients with HCV viremia than in those without viremia (4). Interferon treatment decreases the incidence of hepatocellular carcinoma in patients with chronic hepatitis C (9-16). We conducted a randomized, controlled trial to evaluate whether postoperative therapy with interferon- would decrease the incidence of recurrence after resection of HCV-related hepatocellular carcinoma. Methods Patients and Trial Profile Between November 1993 and March 1997, 112 HCV-positive patients underwent resection for hepatocellular carcinoma at Osaka City University Hospital or Osaka City General Hospital, Osaka, Japan. Seventy-seven patients met the eligibility criteria: 1) single tumors less than 5 cm in maximum diameter on preoperative imaging; 2) detectable HCV RNA without hepatitis B surface antigen or HIV antibodies; 3) chronic hepatitis C or a ChildPugh score of A or B for compensated cirrhosis [17]; and 4) no severe thrombocytopenia (platelet count < 50 109 cells/L). Before resection, 31 of the 77 eligible patients gave written informed consent to participate in the trial; however, one patient was later excluded because resection was not curative. Forty-six patients declined to participate because they were unwilling or unable to agree to twice-weekly hospital visits for 2 years or were concerned about widely publicized side effects of interferon use. A curative operation was defined as complete resection of all macroscopically evident tumor tissue. Specifically, no tumors could be detected in the remnant liver on computed tomography performed 3 to 4 weeks after resection. In the one patient excluded from the trial after resection, a residual tumor was found on computed tomography 3 weeks after resection. In all, 30 patients were enrolled and randomly allocated to the interferon- group (n = 15) or a control group (n = 15). Randomization was done by using a random-numbers table, and patient assignments were withheld from the investigators. During the trial, no patient in the control group received any type of treatment; no patient in the interferon group received chemotherapy or any treatment other than interferon-. This study was done in accordance with the Helsinki Declaration and was approved by the ethics committees of our institutions. Interferon- Treatment Patients received 6 MIU of interferon- (human lymphoblastoid interferon, Sumiferon, Sumitomo Pharmaceuticals, Osaka, Japan) intramuscularly every day for 2 weeks, then 3 times weekly for 14 weeks, and finally twice weekly for 88 weeks (total dose, 1572 MIU). Interferon- therapy was started 5 to 15 weeks (mean, 9 weeks) after resection. In 1 of the 15 patients in the interferon- group, treatment was delayed until 7 months after resection at the patients request. Laboratory tests were done at least once monthly during interferon- therapy and at least once every 3 months thereafter for evaluation of the response to therapy and identification of side effects of interferon-. Serum HCV RNA was detected by using a method reported previously (9), and viral load was measured by using a branched-DNA probe assay (Quantiplex HCV-RNA, Chiron Corp., Emeryville, California). Response to Interferon- Therapy A complete response was defined as the absence of serum HCV RNA (virologic remission) and serum alanine aminotransferase (ALT) activity within the reference range ( 750 nkat/L [ 45 U/L]) for at least 6 months after interferon- therapy (biochemical remission) (9). A biochemical response was defined as a decrease in serum ALT activity to within the reference range but with persistently detectable serum HCV RNA. Nonresponse was defined as persistence of HCV RNA and no decrease in ALT activity. Detection of Recurrence Serum concentrations of -fetoprotein and protein induced by vitamin K absence and antagonist II were measured within 2 months of resection and every 3 months thereafter. Ultrasonography, computed tomography, magnetic resonance imaging, or some combination of these tests was done within 2 months after the operation and every 3 months thereafter. These examinations were done until the detection of recurrence or until the trial end point (final examination). When tumor recurrence was suspected on the basis of tumor markers, imaging, or both, angiography, ultrasonography-guided biopsy, or both were done to establish a definitive diagnosis. The radiologists who were responsible for diagnosis of tumor recurrences had no contact with the patients and had no information about the trial. Statistical Analysis Time to recurrence was measured from the time of resection to the detection of a recurrent tumor. The recurrence rates (including data on patients who could not complete interferon- therapy) were calculated by using the KaplanMeier method, and significance of between-group differences was assessed by using the log-rank test. All analyses were done by using SAS statistical software, version 6.12 (SAS Institute, Inc., Cary, North Carolina). Role of the Funding Source The funding sources had no role in the collection, analysis, and interpretation of the data or in the decision to submit the paper for publication. Results Most baseline variables were similar in the two groups, as were the operative procedures (Table). The patients who declined participation and the patients who were enrolled were similar with regard to most variables. Table. Patient Demographic and Clinical Characteristics Interferon- could not be administered to one patient because of premature ventricular contractions. Data on this patient were included in the interferon- group for all analyses. Interferon- administration could not be completed in 3 patients because of depression (n = 1, at 17 days), severe general fatigue (n = 1, at 11 months), and renal abscess (n = 1, at 10 months; this patient also had a recurrence detected in the same month). In 4 patients with recurrence, interferon- administration was stopped prematurely to allow treatment of the tumor. In the interferon- group, 2 patients were complete responders, 6 patients were biochemical responders only, and 7 patients were nonresponders. Among the control patients, postoperative serum ALT activity (except immediately after resection) was greater than the reference range, and serum HCV RNA was detected at the follow-up appointments. The median follow-up period (from the operation to the detection of recurrence or to the study end point) was 1087 days (25th and 75th percentiles, 514 and 1376 days) for patients receiving interferon- and 897 days (25th and 75th percentiles, 439 and 1105 days) for the controls. In all patients, examinations for detection of recurrence were done according to schedule. All patients without recurrence were still alive at the end of this trial. Recurrent tumors were detected in 5 patients (including the patient who could not tolerate interferon- therapy) in the interferon- group and in 12 control patients. In the interferon- group, recurrence was definitively diagnosed in 3 patients by using angiography and in 2 patients by using angiography and biopsy. In the control group, definitive diagnoses were made in 8 patients by using angiography, in 3 patients by using biopsy, and in 1 patient by using both methods. No recurrence was detected in either of the 2 complete responders in the interferon- group. One of the 6 biochemical responders and 4 of the 7 nonresponders had recurrent tumors. The recurrence rates increased along similar curves in the two groups in the 2 years after resection; thereafter, 6 controls but no patient receiving interferon- had recurrence (Figure). The recurrence rate was significantly lower in the interferon- group than in the control group (P=0.037). Figure. Recurrence rates in the interferon- ( solid line ) and control ( dotted line ) groups. P Discussion Persistent active hepatitis is a risk factor for development of hepatocellular carcinoma, indicating that treatment of active hepatitis may be important in the management of patients with HCV-related hepatocellular carcinoma (4). In our study, absence of interferon- therapy was a risk factor for recurrence. Although for the first 2 years of follow-up the recurrence rate increased for the two groups in similar curves, the recurrence rate in the interferon- group did not increase after that time. This finding suggests that patients in the interferon- group had been truly cured. Recurrent tumors detected within 2 years of the operation were likely to be either metastases from the primary carcinoma or carcinoma that appeared before or during interferon- therapy but had gone undetected at the operation. Our findings indicate that interferon- therapy does not suppress carcinoma itself. On the other hand, recurrences that appear more than 2 years after resection are likely to have arisen because of new carcinogenesis. Recurrence was detected in 1 of 8 patients with a biochemical remission (including the 2 complete responders) and in 4 of the 7 nonresponders. Recently, several investigators have shown that hepatocellular carcinoma is less likely to develop in patients in whom interferon- decreases ALT activity to within the reference range, even if HCV is not eradicated, probably because of decreased hepatocyte necrosis and liver fibrosis (9, 11, 12, 14-16). Thus, eradication of HCV may not be necessary for reduced risk for recurrenc

Usefulness of positron emission tomography with fluorine-18-fluorodeoxyglucose for predicting outcome in patients with hepatocellular carcinoma

OBJECTIVES:The present study was designed to assess the usefulness of positron emission tomography with fluorine-18-fluorodeoxyglucose (FDG-PET) for predicting outcome in patients with hepatocellular carcinoma.METHODS:FDG-PET was performed in 48 patients with hepatocellular carcinoma. For quantitative evaluation, a region of interest (ROI) was placed over the area of maximum activity within the lesion. A background ROI was then placed over the nontumor region of the liver. The average activity within each ROI was subsequently corrected for radioactive decay, and the standardized uptake value (SUV) was calculated by dividing the tissue activity by the injected dose of radioactivity per unit body weight. SUV ratio was expressed as the tumor-to-nontumor ratio of the SUV.RESULTS:The tumor-volume doubling time, as index of the growth rate of hepatocellular carcinoma, correlated significantly with SUV ratio but did not correlate with SUV. On the basis of the SUV ratio, the patients were divided into two groups of similar size: group A, SUV ratio of ≤1.5; and group B, SUV ratio >1.5. The cumulative survival rate was significantly lower in group B than in group A. On the basis of the SUV, the patients were divided into two groups of roughly equal size: group C, ≤SUV 2.6; and group D, >SUV 2.6. The cumulative survival rate was similar in these groups. On regression analysis with the Cox proportional hazards model, the SUV ratio and tumor number were significantly related to survival.CONCLUSIONS:These results suggest that FDG-PET is useful not only for the evaluation of the malignancy of hepatocellular carcinoma but also for the prediction of outcome in patients with hepatocellular carcinoma.

Effects of lamivudine on outcome after liver resection for hepatocellular carcinoma in patients with active replication of hepatitis B virus

Aim:  Patients with high serum hepatitis B virus (HBV) DNA concentrations are at high risk of tumor recurrence after liver resection for HBV‐related hepatocellular carcinoma (HCC).

Development of hepatocellular carcinoma in patients with chronic hepatitis C who had a sustained virological response to interferon therapy: a multicenter, retrospective cohort study of 1124 patients

Background: Interferon (IFN) improves hepatic inflammation/fibrosis and reduces the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C (CH‐C). However, HCC develops in some patients who have a sustained virological response (SVR) to IFN therapy. We designed this study to establish a follow‐up protocol for patients with CH‐C who have SVR to IFN therapy.

Alteration of gene expression in human hepatocellular carcinoma with integrated hepatitis B virus DNA.

Purpose: Integration of hepatitis B virus (HBV) DNA into the human genome is one of the most important steps in HBV-related carcinogenesis. This study attempted to find the link between HBV DNA, the adjoining cellular sequence, and altered gene expression in hepatocellular carcinoma (HCC) with integrated HBV DNA. Experimental Design: We examined 15 cases of HCC infected with HBV by cassette ligation–mediated PCR. The human DNA adjacent to the integrated HBV DNA was sequenced. Protein coding sequences were searched for in the human sequence. In five cases with HBV DNA integration, from which good quality RNA was extracted, gene expression was examined by cDNA microarray analysis. Results: The human DNA sequence successive to integrated HBV DNA was determined in the 15 HCCs. Eight protein-coding regions were involved: ras-responsive element binding protein 1, calmodulin 1, mixed lineage leukemia 2 (MLL2), FLJ333655, LOC220272, LOC255345, LOC220220, and LOC168991. The MLL2 gene was expressed in three cases with HBV DNA integrated into exon 3 of MLL2 and in one case with HBV DNA integrated into intron 3 of MLL2. Gene expression analysis suggested that two HCCs with HBV integrated into MLL2 had similar patterns of gene expression compared with three HCCs with HBV integrated into other loci of human chromosomes. Conclusions: HBV DNA was integrated at random sites of human DNA, and the MLL2 gene was one of the targets for integration. Our results suggest that HBV DNA might modulate human genes near integration sites, followed by integration site–specific expression of such genes during hepatocarcinogenesis.

p16 Promoter Hypermethylation in Human Hepatocellular Carcinoma with or without Hepatitis Virus Infection

Background: Epigenetic alteration through methylation is one of the most important steps in carcinogenesis. However, the relation between hepatitis virus infection and epigenetic alterations is poorly understood. Methods: Sixteen patients without hepatitis B virus (HBV) and hepatitis C virus (HCV) and 35 patients with HBV or HCV who underwent liver resection for hepatocellular carcinoma (HCC) were studied. Mutation of p53 was detected by direct sequencing. Methylation status of p16 was evaluated in tumor and noncancerous liver tissues by methylation-specific polymerase chain reaction. Results: In HCC without HBV and HCV, p53 mutations were detected in 5 (31%) of 16 HCCs. Methylation of p16 promoter was detected in 2 (25%) of 8 moderately differentiated HCCs, 6 (75%) of 8 poorly differentiated HCCs, and none of 16 noncancerous tissue specimens. In HCC with HBV or HCV, p53 mutations were detected in 8 (23%) of 35 HCCs. Methylation of p16 promoter was detected in 2 (100%) of 2 well-differentiated HCCs, 13 (76%) of 17 moderately differentiated HCCs, 12 (75%) of 16 poorly differentiated HCCs, and 9 (26%) of 35 noncancerous liver tissue specimens. Conclusions: Our results suggest that hepatitis viruses might induce methylation of p16 promoter in liver with chronic inflammation, before appearance of HCC.

Association of IL28B variants with response to pegylated-interferon alpha plus ribavirin combination therapy reveals intersubgenotypic differences between genotypes 2a and 2b†

Genetic polymorphisms of the interleukin 28B (IL28B) locus are associated closely with outcomes of pegylated‐interferon (PEG‐IFN) plus ribavirin (RBV) combination therapy. The aim of this study was to investigate the relationship between IL28B polymorphism and responses to therapy in patients infected with genotype 2. One hundred twenty‐nine chronic hepatitis C patients infected with genotype 2, 77 patients with genotype 2a and 52 patients with genotype 2b, were analyzed. Clinical and laboratory parameters, including genetic variation near the IL28B gene (rs8099917), were assessed. Drug adherence was monitored in each patient. Univariate and multivariate statistical analyses of these parameters and clinical responses were carried out. Univariate analyses showed that a sustained virological response was correlated significantly with IL28B polymorphism, as well as age, white blood cell and neutrophil counts, adherence to RBV, and rapid virological response. Subgroup analysis revealed that patients infected with genotype 2b achieved significantly lower rapid virological response rates than those with genotype 2a. Patients with the IL28B‐major allele showed higher virus clearance rates at each time point than those with the IL28B‐minor allele, and the differences were more profound in patients infected with genotype 2b than those with genotype 2a. Furthermore, both rapid and sustained virological responses were associated significantly with IL28B alleles in patients with genotype 2b. IL28B polymorphism was predictive of PEG‐IFN plus RBV combination treatment outcomes in patients infected with genotype 2 and, especially, with genotype 2b. In conclusion, IL‐28B polymorphism affects responses to PEG‐IFN‐based treatment in difficult‐to‐treat HCV patients. J. Med. Virol. 83:871–878, 2011.

Usefulness of transient elastography for assessment of liver fibrosis in chronic hepatitis B: Regression of liver stiffness during entecavir therapy.

Aim:  The usefulness of transient elastography remains to be validated in chronic hepatitis B, particularly as a tool for monitoring the degree of liver fibrosis during treatment.

Effect of Long-Term Postoperative Interferon Therapy on Intrahepatic Recurrence and Survival Rate after Resection of Hepatitis C Virus-Related Hepatocellular Carcinoma

Objective: This study was aimed at evaluating the effects of interferon (IFN)-α on survival rate after resection of hepatocellular carcinoma. Methods: In a randomized, controlled trial by the University Hospital, Medical Center and affiliated hospital in Osaka, Japan, 30 men were after surgery randomly allocated to an IFN-α group (15 patients) and to a control group. Patients in the IFN group received 6 MIU of IFN-α intramuscularly daily for 2 weeks, then three times a week for 14 weeks, and finally twice a week for 88 weeks. The incidence of recurrence and survival rate were then studied. Results: The response to IFN was sustained viral response (SVR) in 2 patients, biochemical response (BR) in 6, partial response (PR) in 5, and no response (NR) in 2. In the control, 8 of the 15 patients demonstrated continuous abnormally high levels of ALT. At the end point of the study, intrahepatic recurrence was detected in 9 of the IFN group and in 13 of the control (p = 0.065, log-rank test). The cumulative survival rate was higher in the IFN group than in the controls (p = 0.041). Conclusion: Postoperative IFN therapy improves the outcome after resection of hepatitis C virus-related hepatocellular carcinoma.