Ilva Ferretti

SUSCEPTIBILITY OF CHRONIC SYMPTOMLESS HBsAg CARRIERS TO ETHANOL-INDUCED HEPATIC DAMAGE

To investigate the susceptibility of chronic symptomless HBsAg carriers to the hepatotoxic effect of ethanol 296 such carriers were followed up for 3 1/2 years with repeated biochemical and clinical examinations. A control group of HBsAg-negative blood donors matched by age, sex, occupation, duration and type of ethanol intake, and state of nutrition were followed up for the same period. Chronic symptomless HBsAg carriers seemed to be at risk of hepatic abnormalities when drinking an amount of ethanol which was harmless for HBsAg-negative subjects (less than 80 g). It may therefore be advisable to suggest complete abstinence from ethanol for HBsAg carriers.

Hormonal therapy with megestrol in inoperable hepatocellular carcinoma characterized by variant oestrogen receptors.

Variant liver oestrogen receptor transcripts in hepatocellular carcinoma are associated with aggressive clinical course and unresponsiveness to tamoxifen. To evaluate the impact on survival and on tumour growth of megestrol (progestin drug acting at post-receptorial level) we enrolled 45 patients with HCC characterized by variant liver oestrogen receptors in a prospective, randomized study with megestrol vs. placebo. Presence of variant oestrogen receptors was determined by RT/PCR. 24 patients were randomized to no treatment and 21 to therapy with megestrol 160 mg day–1. Results were analysed by Kaplan-Meier and Cox methods. Survival of hepatocellular carcinoma characterized by variant oestrogen receptors was extremely poor (median survival 7 months); megestrol significantly improved survival (18 months) (P = 0.0090). Tumour growth at one year was significantly slowed down in megestrol-treated patients (P = 0.0212). Bilirubin levels, presence of portal thrombosis, HBV aetiology and treatment were identified at univariate analysis as factors significantly associated with survival; at multivariate analysis, only megestrol therapy (P = 0.0003), presence of HBV infection (P = 0.0009) and presence of portal vein thrombosis (P = 0.0051) were factors independently related with survival. (1) Megestrol slows down the aggressive tumour growth of patients with hepatocellular carcinoma characterized by variant estrogen receptors and (2) is also able to favourably influence the course of disease, more than doubling median survival.

High doses of alpha-interferon are required in chronic hepatitis due to coinfection with hepatitis B virus and hepatitis C virus: long term results of a prospective randomized trial.

OBJECTIVE:Coinfection with hepatitis B (HBV) and hepatitis C (HCV) viruses is associated with a more severe liver disease, increased frequency in the development of hepatocellular carcinoma, and resistance to interferon (IFN) therapy when performed with the standard dosages used in single infections. In the attempt to verify whether the outcome of IFN therapy in patients with hepatitis B and hepatitis C coinfection can be improved, we have planned a prospective, randomized trial with medium to high dosages of interferon three times a week for 6 months.METHODS:Thirty patients with HBV-HCV coinfection, and chronic hepatitis were randomized to receive either 6 or 9 MU α-interferon three times a week for 6 months. Patients were HBsAg positive, anti-HBe positive, HBV DNA negative by dot blot (6/30 positive by polymerase chain reaction), and anti-HCV-positive, HCV RNA positive. Pretreatment and posttreatment liver biopsies were performed.RESULTS:Five patients treated with 9 MU IFN consistently cleared HCV RNA and HBV DNA, whereas none of those treated with 6 MU reacted in a similar fashion (p = 0.045). Responders showed significant improvement of histological activity index in comparison with nonresponders (mean Ishak score pretreatment versus posttreatment p = 0.002). Long term follow-up showed that none of the patients treated with high doses developed cirrhosis whereas 4/14 treated with low doses did develop cirrhosis.CONCLUSION:Even though the percentage was not very high, the sustained response, the striking histological improvement, and the lack of development of cirrhosis achieved in these patients, indicate that with HBV-HCV coinfection, a trial with high doses of interferon is strongly recommended.

Estrogen Receptor Classification for Hepatocellular Carcinoma: Comparison With Clinical Staging Systems

PURPOSE Several scoring systems to evaluate patients with hepatocellular carcinoma (HCC) exist. A good scoring system should provide information on prognosis and guide therapeutic decisions. The presence of variant liver estrogen receptor (ER) transcripts in the tumor has been shown to be the strongest negative predictor of survival in HCC. The aim of this study was to compare the predictive value of the commonly applied clinical scoring systems for survival of patients with HCC with that of the evaluation of ER in patients with HCC (molecular scoring system). MATERIALS AND METHODS HCC was staged according to the Okuda classification, Barcelona Clinic Liver Cancer classification, Italian classification system (CLIP), French classification, and ER status in 96 patients. Analysis of survival was performed according to the Kaplan-Maier test and was made for each classification system and ER. A comparison between classifications was made by univariate and multivariate analysis. RESULTS Among the clinical classification systems, only the CLIP was able to identify patient populations with good, intermediate, and poor prognosis. On multivariate analysis, ER classification was shown to be the best predictive classification for survival of patients with HCC (P <.0001). This difference was the result of a better allocation of patients with ominous prognosis (variant ER) having nevertheless good clinical score. CONCLUSION The evaluation of the presence of wild-type or variant ER transcripts in the tumor is the best predictor of survival in patients with HCC. Its accuracy in discriminating patients with good or unfavorable prognosis is significantly greater than that of the commonly used scoring systems for the staging of HCC.

Variant estrogen receptors and their role in liver disease

The liver presents estrogen receptors alpha and beta. As for breast cancer, a variant form of estrogen receptor alpha transcript (ER) has been described in hepatocellular carcinoma (HCC). It is derived by an exon 5-deleted transcript (vER), which lacks the hormone-binding domain of the receptor but, being intact in the DNA-binding domain, maintains constitutive transcriptional activity. HCCs presenting vER have an extremely aggressive clinical course and are unresponsive to the antiestrogen tamoxifen. On the other hand, megestrol, a drug able to block both the wild type and the variant form of ER, influence the clinical course of HCC presenting vER. The presence of vER is associated with elevated cancer cell proliferation rate.

Effect of ursodeoxycholic acid treatment on alanine aminotransferase and γ-glutamyltranspeptidase serum levels in patients with hypertransaminasemia: Results from a double-blind controlled trial

The ability of ursodeoxycholic acid (UDCA, 600 mg/day) to lower alanine aminotransferase (ALT) blood levels in blood donors rejected for donation because of fluctuating hypertransaminasemia was evaluated in a randomized, controlled, double-blind clinical trial vs. placebo. All subjects with ALT values at least twice the normal upper limit in at least two out of three previous checks (the last one not more than 1 month previously) were admitted to the study. Checks were carried out 1, 2 and 3 months after the admission. 59 out of 65 patients completed the study. Although all patients were asked to abstain from alcohol, more than 50% of them in both groups had basal gamma-glutamyltransferase (gamma-GT) values higher than normal. After 1 month of treatment and throughout its duration, UDCA was effective in lowering ALT in all patients (30% decrease with respect to the basal value) and, especially, in lowering gamma-GT in those patients with elevated levels (50% decrease with respect to the basal value). This decrease was significantly different from the spontaneous 10% decrease of the ALT and gamma-GT levels observed in the placebo group. 3 months after suspension of therapy a rebound of both ALT and gamma-GT to values comparable to the basal ones or even higher was found only in UDCA-treated patients. We conclude that the short-term administration of UDCA is free of hepatotoxic effects and could be useful in lowering ALT and gamma-GT serum levels. The real significance of UDCA treatment in the natural history of chronic liver diseases deserves further investigation.

HCV RNA in serum of asymptomatic blood donors involved in post-transfusion hepatitis (PTH)

A group of blood donors involved in post-transfusion hepatitis was investigated for the presence of the anti-HCV antibody and of HCV RNA as a more direct infection marker. RNA was extracted from serum, reverse transcribed and amplified using primers which belonged to the non structural region. The amplified product of the PCR reaction was 582 base pairs. Seven (25.9%) of the 27 blood donors examined were found anti-HCV-positive by ELISA; five (71.4%) of these were HCV RNA positive. Among the 20 anti-HCV-negative blood donors, four (20.0%) were HCV RNA positive. ALT levels were below 45 UI/l in 18 donors, while the other nine had ALTs over the limit accepted for transfusion. The anti-HCV-negative HCV RNA-positive blood donors had normal ALTs. Our study offers a direct explanation for the substantial proportion of residual cases of anti-HCV-positive post-transfusion hepatitis and suggests the necessity of creating a register of blood donors who have at some time presented blood enzyme abnormalities and for whom second level investigations such as HCV RNA should be used.

Estrogen receptor α mRNA variant lacking exon 5 is co-expressed with the wild-type in endometrial adenocarcinoma

BACKGROUND Endometrial adenocarcinoma is a typical estrogen-dependent neoplasia. The molecular mechanisms underlying carcinogenesis in the endometrium are still largely unknown. Recently, estrogen receptor (ER) mRNA splicing variants have been investigated in several normal and neoplastic human tissues. It has been suggested that the variant receptors compete with the wild-type receptors and thereby modulate the effects of estrogens and related steroids. OBJECTIVE To investigate the possible expression of the ER alpha mRNA variant-type lacking exon 5 (ERDelta5) in endometrial adenocarcinoma and peritumoral tissues, non-neoplastic endometrium of healthy women served as control. STUDY DESIGN The study included 16 patients divided in two groups. The first group (n=6) was submitted to hysteroscopy and endometrial biopsy for metrorrhage, showing normal proliferative (n=2) or secretory (n=4) endometrium, the second group (n=10) included patients submitted to hysterectomy for endometrial adenocarcinoma (stages Ib-IIIb). In this latter group, specimens from peritumoral tissues were also analyzed (n=3). Characterization of the variant and wild-type alpha estrogen receptor transcripts was performed by RT-PCR with primers located in exons 4 and 6, followed by southern hybridization with probes directed to a specific 29 nucleotide sequence of exon 6, internal to the amplified fragments. RESULTS The ER alpha mRNA variant was co-expressed with the wild-type ER in five or six samples of non-neoplastic endometrium and in 10/10 cases of adenocarcinoma, with a more intense hybridization signal corresponding to the wild-type 439bp band compared to the variant-type 300bp band. Specimens from peritumoral tissue also expressed the variant ERDelta5 along with wild-type ER. CONCLUSION The presence of alpha mRNA variant lacking exon 5 in both normal and endometrial adenocarcinoma do not support a major role of variant estrogens receptors in the biology of endometrial cancer.

Pretreatment with pegylated interferon prevents emergence of lamivudine mutants in lamivudine-naive patients: a pilot study.

BACKGROUND In patients with advanced fibrosis, primary end points of long-term or possibly indefinite antiviral therapy are sustained inhibition of viral replication and avoidance of emergence of resistance. In lamivudine-treated patients, the strongest predictor of emergence of YMDD mutations is baseline hepatitis B virus (HBV) DNA viral load. We aimed to verify whether abatement of viraemia by a short course of pegylated interferon (PEG-IFN-alpha2a) treatment before lamivudine treatment could prevent the emergence of lamivudine-associated mutations during long-term therapy. METHODS A total of 14 patients with hepatitis B e antigen (HBeAg)-negative infection (3 lamivudine-experienced and 11 lamivudine-naive), with moderate/high viraemia (>10(6) copies/ml) and with Ishak stage 4-6 at liver biopsy were sequentially treated with 180 microg PEG-IFN-alpha2a for a period long enough to reach HBV DNA levels < or =10(3) copies/ml or have a decrease of 3 log(10) copies/ml from baseline. Lamivudine was then added to PEG-IFN-alpha2a treatment for 1 month and finally continued as monotherapy for 2 years or until viral breakthrough. RESULTS Baseline HBV DNA (mean +/-se 2.3 x 10(7) +/-7.2 x 10(7) copies/ml) decreased with PEG-IFN-alpha2a treatment to target value in mean +/-se 3.7 +/-1.3 months. None of the 11 lamivudine-naive patients developed genotypic resistance and were still HBV-DNA-negative after a mean +/-se observation period of 23 +/-2 months, whereas the three lamivudine-experienced patients developed YMDD mutations after 6, 9 and 12 months of lamivudine monotherapy (P=0.003, Fishers exact test). CONCLUSIONS In lamivudine-naive patients, abatement of HBV DNA<10(3) copies/ml by pretreatment with PEG-IFN-alpha2a completely prevents the emergence of YMDD mutants after 24 months of lamivudine monotherapy. This sequential schedule can optimize the use of a well tolerated, effective and inexpensive drug, such as lamivudine, in highly viraemic HBV patients.

196 PROCALCITONIN IS THE BEST DIAGNOSTIC AND PROGNOSTIC MARKER OF SEPSIS IN DECOMPENSATED CIRRHOTIC PATIENTS

Background and Aims: Almost 50% of hospitalized cirrhotics are septic. At the admission, no clear-cut clinical and biochemical features are helpful in diagnosing and prognostically stratifying ascitic patients with suspected bacterial infection. We evaluated procalcitonin (PCT) as a diagnostic and prognostic tool in decompensated cirrhotics with suspected sepsis. Patients and Methods: All cirrhotic patients admitted to our Unit for decompensation were eligible. Exclusion criteria were ongoing antibiotic therapy, recent hospitalization, and HCC out of Milan criteria. At admission signs of SIRS and blood test including PCT and C reactive protein (CRP) were recorded. In all patients, cell count of ascites, blood and urine cultures, and chest ray were performed. Sepsis was defined as the presence of 2 or more signs of SIRS plus demonstrated bacterial infection or SBP. In patients who started antibiotic treatment, all tests were repeated after 48 hours. Results: A total of 108 consecutive admission of 75 patients were analyzed (age: 60.7±13; Meld score: 18.12±7.2; Child–Pugh score: 9.7±1.9; HCC: 24%). Sepsis was present in 43 patients (39.8%; SBP: 29.6%). At univariate analysis, Meld score (21±9.52 Vs 16.7±5.6; p = 0.001), Child–Pugh score (10.5±2.1Vs 9.6±1.9; p = 0.029), CRP (5.03±4.85 Vs 2.05±1.85; p = 0.0001) and PCT levels (3.86±6.98 Vs 0.38±0.37 p=0.0001) were higher in septic patients than in non septic. Multivariate analysis identified PCT as the only variable independently related to sepsis (p = 0.0001). ROC curve for PCT showed an AUC of 0.803 (best cut-off = 0.49 ng/ml). At admission, a PCT value >0.49 ng/ml was significantly related to inpatient mortality (p = 0.005). Antibiotic treated patients (n = 48; 44%), who kept normal or normalized PCT within 48h of treatment showed significantly higher survival (p = 0.009) than remaining patients. Conclusion: PCT is both the best marker of ongoing sepsis and the strongest prognostic indicator in hospitalized cirrhotic patients with ascites.