Jacques Carles

Osteonectin/SPARC is overexpressed in human hepatocellular carcinoma

Osteonectin (ON)/SPARC is a glycoprotein involved in extracellular matrix remodelling. ON expression by myofibroblasts has been reported in fibrotic human liver. As ON also plays a role in cell adhesion, differentiation, and proliferation, this study was designed to document its expression in human hepatocellular carcinoma (HCC). Tissues from 26 HCCs of various histological grades and architecture and from surrounding non‐tumour liver (23 cirrhotic or fibrotic, three non‐fibrotic) were tested by in situ hybridization and immunohistochemistry. Immunohistochemical detection of α‐smooth muscle actin (α‐SMA) was performed on serial sections or in combination with hybridization. Large amounts of ON mRNA and protein were detected in the tumour capsule, in the fibrous bands, and along capillaries within HCCs. The signal was located in cells suggestive of myofibroblasts, as confirmed by positive staining for α‐SMA. In HCC, ON protein was always detectable, with strong staining in high‐grade tumours, whereas it was mostly undetectable in non‐tumour tissues. A clear difference was also shown for ON transcripts, except in a few cases with chronic active hepatitis, where ON transcripts were also expressed at a high level. Overexpression of ON transcripts in HCC vs. non‐tumour liver was confirmed by RNA blot in 20/22 patients tested. In conclusion, ON is strongly expressed by the stromal myofibroblasts of human HCC, especially of high grade. This expression could play a role in tumour progression. Copyright

Increased incidence of HFE C282Y mutations in patients with iron overload and hepatocellular carcinoma developed in non-cirrhotic liver

BACKGROUND/AIMS Histological and biochemical iron overload has been reported in non-tumoral liver of most patients presenting an hepatocellular carcinoma (HCC) developed in non-cirrhotic liver (NCL). The aim of our study was to investigate HFE mutations in patients with HCC in NCL. METHODS Thirty-five patients with HCC in NCL were included either retrospectively or prospectively. Clinical data, iron and viral status, and HFE gene mutations were compared between groups with (I+, n = 19) or without histological iron overload (I-, n = 16). RESULTS Twenty per cent of patients were HBV or HCV positive. Fifty-four per cent had hepatocytic iron overload at histology. Mean hepatic iron concentration was 100.2 +/- 14.6 micromol/g in I+ versus 23.2 +/- 2.1 micromol/g in I- (p<0.001). Among the 19 I+ patients, eight mutations were found: two C282Y/C282Y, three C282Y/WT, two C282Y/H63D and one H63D/H63D. None of these mutations was found in the I- group. There was no significant difference concerning the H63D heterozygous mutation between I+ or I- patients. CONCLUSIONS In patients with HCC in NCL, HBV and HCV markers are rare (20%), and mild iron overload is frequent (54%). In patients with HCC in NCL and iron overload, C282Y mutations are frequent (36.8% of cases) and significantly increased (p<0.009) compared to HCC in NCL without iron overload; these mutations are mostly heterozygous. H63D heterozygosity is not associated with liver iron overload. Because of the small size of the series, HFE C282Y mutation should be investigated on a larger scale in patients with HCC in NCL with iron overload in order to confirm this association.

Prevalence of liver cell dysplasia and association with HCC in a series of 100 cirrhotic liver explants

BACKGROUND/AIMS Liver cell dysplasia of large (LLCD) and small (SLCD) cell types may represent a premalignant change. We sought to evaluate their prevalence, relationship with the gross type of cirrhosis, aetiology of liver disease, and the presence of hepatocellular carcinoma in a series of cirrhotic livers. METHODS The presence and pattern of SLCD and LLCD were evaluated by careful histological analysis in 100 consecutive cirrhotic livers of viral (49%) or non viral (51%) aetiology, and with or without hepatocellular carcinoma. Prevalences were compared using Chi-square or Fishers tests; relative risk for hepatocellular carcinoma was evaluated by the odds ratio. RESULTS Dysplasia was found in 82/100 of livers. Eighty-one had LLCD, with (n=49) or without (n=32) associated SLCD. SLCD alone was found in only one case. LLCD and SLCD tended to be more frequent and extensive in mixed or macronodular cirrhosis than in micronodular cirrhosis. LLCD was significantly more frequent and extensive in cirrhosis due to hepatitis B, as was SLCD in cirrhosis due to hepatitis B virus or biliary diseases, where it showed a different pattern (focal vs diffuse, respectively). LLCD and SLCD were both significantly associated with the presence of hepatocellular carcinoma, even of small size. Small foci of SLCD and widespread LLCD were the two conditions which showed the strongest association with hepatocellular carcinoma, with odds ratios of: 6.33 and 3.88, respectively. Widespread SLCD was not relevant for hepatocellular carcinoma in biliary diseases. CONCLUSIONS Liver cell dysplasia may be considered an additional risk factor for hepatocellular carcinoma in patients with cirrhosis and should be looked for in biopsies. Widespread LLCD and SLCD with a focal pattern are particularly relevant for hepatocellular carcinoma, whereas widespread small cell changes found in biliary diseases seem to have a different biological significance.

Progression from idiopathic portal hypertension to incomplete septal cirrhosis with liver failure requiring liver transplantation

We report the case of a 30-year-old male patient suffering from what was initially thought to be end-stage cryptogenic cirrhosis with portal hypertension and liver failure, who underwent liver transplantation. Histological examination of the surgical specimen showed incomplete septal cirrhosis. At the age of 17 this patient had presented pancytopenia and splenomegaly, which were treated by splenectomy. The surgeon discovered portal hypertension. Re-examination of the wedge liver biopsy taken at this time revealed features of idiopathic portal hypertension. This case clearly shows that incomplete septal cirrhosis may be a late manifestation of idiopathic portal hypertension. The presence of sinusoidal dilatation and peliosis as well as early evidence of fibrosis which are already visible on the initial biopsy and are still present on the late specimen, are indirect evidence of a continuous process which ultimately led to incomplete cirrhosis with liver failure.

Heterozygous protein C deficiency and dysfibrinogenemia acquired by liver transplantation

Orthotopic liver transplantation is now a successful treatment for end-stage liver diseases. Since most components of the coagulation system are synthesized by liver parenchymal cells, there is always a risk of genetic defects of hemostasis being transmitting by liver transplantation. Some coagulation factor defects, such as protein C deficiency, do not induce abnormalities in routine coagulation tests and, thus, go undetected before organ procurement. We report the first case, to our knowledge, of the transmission of heterozygous protein C deficiency, an autosomal recessive genetic defect, associated with dysfibrinogenemia, an autosomal dominant trait, by liver transplantation. Both the recipient and the donor presented with severe thrombotic complications. This case shows that potentially morbid genetic defects can be transmitted by organ transplantation, and it emphasizes the difficulty associated with organ procurement criteria, particularly for liver transplantation, in which routine blood tests appear insufficient for determining whether or not organs can or should be procured from a given donor.

Multiple black hepatocellular adenomas in a male patient.

A 65-year-old man presented with multiple liver tumours. Imaging techniques could not differentiate between adenomas and hepatocellular carcinomas. He had no relevant past medical history. Liver function tests were normal except for a 1.5-fold rise in GGT. AFP was normal. Viral markers were negative. During laparoscopy, numerous black tumours of different sizes were seen. These tumours were adenomas without malignant transformation. Tumoral hepatocytes contained a brown pigment in the canalicular area without evidence of cholestasis. This pigment was Fontana positive and looked like Dubin-Johnson pigment by electron microscopy. The expression of the canalicular multispecific organic anion transporter (cMOAT) was decreased in the tumours but normal in the non-tumoral liver ruling out the diagnosis of Dubin-Johnson syndrome. There was mild iron deposition possibly related to an homozygous H63D mutation in the HFE gene. Three years after their discovery, the size of the tumours remained stable. It is concluded that this male patient with multiple adenomas and mild iron overload is at risk of developing an hepatocellular carcinoma and that the black colour of adenomas is probably due to a partial defect in excretion of organic anions.

CASE REPORT: Incomplete septal cirrhosis with liver cell dysplasia

A 60‐year‐old woman was transplanted for end‐stage alcoholic cirrhosis. The diagnosis of cirrhosis was made 13 years earlier on the basis of features of portal hypertension and a wedge liver biopsy. Liver function tests were subnormal except for a low prothrombin time. Unproven possible alcohol abuse was the only aetiological factor. Her condition remained unchanged until transplantation, despite complete abstinence. Histological examination of the explant showed incomplete septal cirrhosis associated with distal obstructive portal venopathy, cirrhotic nodules predominantly in the subcapsular areas and nodular regenerative hyperplasia with septal fibrosis elsewhere. In addition, there were areas of large and small liver cell dysplasia. This observation shows the difficulty in making a diagnosis of incomplete septal cirrhosis and the hypothetical link between liver cell dysplasia (which has never been reported in incomplete septal cirrhosis but is well known to be associated with hepatocellular carcinoma in cirrhosis) and rare cases of liver adenomas and carcinomas reported in patients presenting with liver vascular disorders.