I. de Sio

Ultrasound guided fine needle biopsy of early hepatocellular carcinoma complicating liver cirrhosis: a multicentre study

Background: Because hepatic cirrhosis is a major risk factor for hepatocellular carcinoma, recent guidelines by the European Association for the Study of the Liver (EASL) on clinical management of hepatocellular carcinoma recommend periodic ultrasound surveillance of cirrhotic patients with immediate workup for nodules >1 cm; an increase in the frequency of screening is considered sufficient for smaller lesions. Aims: To determine the actual risk of hepatocellular carcinoma associated with the latter lesions and to assess the role of ultrasound guided-fine needle biopsy in their diagnosis Patients and methods: Data were analysed for 294 new nodular lesions <20 mm, including 48 that were <10 mm, detected during a prospective multicentre study involving ultrasound surveillance of 4375 patients with hepatic cirrhosis. In the absence of α fetoprotein (AFP) levels diagnostic of hepatocellular carcinoma, ultrasound guided-fine needle biopsy was performed (n = 274). AFP and fine needle biopsy diagnoses of malignancies (hepatocellular carcinoma and lymphoma) were considered definitive. Non-malignant fine needle biopsy diagnoses (dysplastic or regenerative nodule) were verified by a second imaging study. Diagnoses of hepatocellular carcinoma based on this study were considered definitive; non-malignant imaging diagnoses were considered definitive after at least one year of clinical and ultrasound follow up. Results: Overall, 258/294 (87.6%) nodules proved to be hepatocellular carcinoma, including 33/48 (68.7%) of those ⩽10 mm. Overall typing accuracy of ultrasound guided-fine needle biopsy was 89.4%, and 88.6% for lesions ⩽10 mm. Conclusions: In a screening population, well over half of very small nodules arising in cirrhotic livers may prove to be hepatocellular carcinoma, and approximately 90% of these malignancies can be reliably identified with ultrasound guided-fine needle biopsy.

Hepatitis C virus infection is an additive risk factor for development of hepatocellular carcinoma in patients with cirrhosis.

The aim of the present study was to evaluate whether hepatitis C virus plays any role in the development of hepatocellular carcinoma in cirrhotic patients. The role of age, sex, alcohol abuse, and infection by other hepatitic viruses, such as hepatitis B and Delta viruses, was also assessed. We found that mean age and male/female ratio were significantly higher in patients with HCC plus liver cirrhosis than in those with liver cirrhosis alone. Also, the prevalence of HCV infection was found to be higher in HCC patients compared to cirrhotics. Further, by means of multiple logistic regression, we evaluated the independent role of each variable in the development of HCC. Age, male sex, and to a lesser degree, HCV infection, as assessed by anti-HCV positivity, were the only risk factors which significantly correlated with the development of HCC. Moreover, when age and sex were excluded from the statistical model, HCV infection, but not HBV, HDV, and alcohol abuse, appeared to be associated with HCC. In conclusion, based on these data, age and male sex are the most important factors for the development of hepatocellular carcinoma in cirrhotic patients. Hepatitis C virus, at least in the Mediterranean area, may play a role as an additive risk factor of HCC in patients suffering from liver cirrhosis.

A new silybin-vitamin E-phospholipid complex improves insulin resistance and liver damage in patients with non-alcoholic fatty liver disease: preliminary observations

Non-alcoholic fatty liver disease (NAFLD) may occur as an expression of a metabolic syndrome or in association with hepatitis C virus (HCV) chronic infection. The contemporaneous presence of NAFLD in this later group of patients may negatively affect the progression of fibrosis and the response to antiviral treatment.1,2 It has been suggested that in the future a therapeutic approach to chronic liver disease would consist of a number of complementary approaches considering the multitude of pathogenic mechanisms.3 Silybin is a natural flavonoid that has been conjugated to vitamin E and phospholipids to improve its bioavailability, and antioxidant and antifibrotic activity.4 After approval of the ethics committee and informed consent, 85 outpatients were consecutively enrolled in the study: 59 were affected by primitive NAFLD (group A) …

Tamoxifen in the Treatment of Hepatocellular Carcinoma: 5-Year Results of the CLIP-1 Multicentre Randomised Controlled Trial

BACKGROUND In 1998, when data of a meta-analysis on tamoxifen in the treatment of hepatocellular carcinoma (HCC) had suggested a little advantage for this treatment, we published the results of a multicenter randomised controlled trial, that showed no survival benefit for tamoxifen vs. control. Here we report an updated analysis of the study results 4.5 years after the closure of enrollment. METHODS The study had a planned sample size of 480 patients. Patients with any stage HCC were eligible, irrespective of locoregional treatment. Tamoxifen was given orally, 40 mg/die, from randomisation until death. RESULTS 496 patients were randomised by 30 Institutions from January 1995 to January 1997. Information was available for 477 patients. As of July 2001, 374 deaths (78%) were recorded, and median survival times were 16 and 15 months (p=0.54), in the control and tamoxifen arm. Data were further analysed separately for advanced patients and for those eligible to potentially curative locoregional treatments: relative hazard of death for patients receiving tamoxifen was equal to 0.98 (95% CI 0.76-1.25) for the former group and 1.38 (95% CI 0.95-2.01) for the latter. The prognostic score recently devised by our group (CLIP score) was, as expected, strictly correlated (p<0.0001) to the locoregional treatment received and strongly correlated with prognosis. CONCLUSIONS the update of the present study confirms that tamoxifen is not effective in prolonging survivals, both in advanced patients and in those potentially curable and that the CLIP score is able to predict prognosis.

Helicobacter pylori infection but not small intestinal bacterial overgrowth may play a pathogenic role in rosacea

Background and aims Recent studies suggest a potential relationship between rosacea and Helicobacter pylori (H. pylori) infection or small intestinal bacterial overgrowth (SIBO), but there is no firm evidence of an association between rosacea and H. pylori infection or SIBO. We performed a prospective study to assess the prevalence of H. pylori infection and/or SIBO in patients with rosacea and evaluated the effect of H. pylori or SIBO eradication on rosacea. Methods We enrolled 90 patients with rosacea from January 2012 to January 2013 and a control group consisting of 90 patients referred to us because of mapping of nevi during the same period. We used the 13C Urea Breath Test and H. pylori stool antigen (HpSA) test to assess H. pylori infection and the glucose breath test to assess SIBO. Patients infected by H. pylori were treated with clarithromycin-containing sequential therapy. Patients positive for SIBO were treated with rifaximin. Results We found that 44/90 (48.9%) patients with rosacea and 24/90 (26.7%) control subjects were infected with H. pylori (p = 0.003). Moreover, 9/90 (10%) patients with rosacea and 7/90 (7.8%) subjects in the control group had SIBO (p = 0.6). Within 10 weeks from the end of antibiotic therapy, the skin lesions of rosacea disappeared or decreased markedly in 35/36 (97.2%) patients after eradication of H. pylori and in 3/8 (37.5%) patients who did not eradicate the infection (p < 0.0001). Rosacea skin lesions decreased markedly in 6/7 (85.7%) after eradication of SIBO whereas of the two patients who did not eradicate SIBO, one (50%) showed an improvement in rosacea (p = 0.284). Conclusions Prevalence of H. pylori infection was significantly higher in patients with rosacea than control group, whereas SIBO prevalence was comparable between the two groups. Eradication of H. pylori infection led to a significant improvement of skin symptoms in rosacea patients.

Ultrasound-guided percutaneous ethanol injection: first choice for treatment of hepatocellular carcinoma in the elderly

Percutaneous ethanol injection (PEI) under ultrasound guidance has recently been proposed as a new therapeutic approach for patients with liver cirrhosis (LC) and hepatocellular carcinoma (HCC). HCC is more frequently observed in elderly subjects. We treated 59 patients (44 males and 15 females, mean age 66 years, age-range 54-77 years). Forty-six patients were in Child A, 12 in Child B and 1 in Child C class. Thirty-nine patients had a single lesion up to 5 cm size; 2 had a single lesion larger than 5 cm, and 18 had 2 or 3 lesions, each smaller than 4 cm. The survival rates after 1, 2, 3 and 4 years for all patients were 92, 73, 54 and 54%, respectively; while for those with only a single lesion amounted to 94, 85, 63, and 63%, for the same years. In this latter group, the survival rates at 1 and 2 years were significantly higher in subjects in the Child A class, than in those who were in Child B and C classes (100 and 95%, against 79 and 63%, respectively, p < 0.05). In the group of patients with multiple lesions the survival rates were 89, 57 and 42% at 1, 2 and 3 years, respectively. We did not have any lethal complications during the procedure of PEI, and only minor complications occurred in 6 patients. During the follow-up, 21 patients developed new lesions, and 6 patients had small local recurrences which were possibly retreated. In conclusion, PEI is a safe and efficient alternative therapy for the management of HCC in LC in elderly subjects.