Masahiko Yanagi

The usefulness of determining des‐γ‐carboxy prothrombin by sensitive enzyme immunoassay in the early diagnosis of patients with hepatocellular carcinoma

Measurements of serum concentrations of des‐γ‐carboxy prothrombin (DCP) are widely used for diagnosing hepatocellular carcinoma (HCC). However, the DCP is not always sensitive enough to detect small HCCs. In the current study, the authors investigated the usefulness of DCP in the early diagnosis of HCC, using a more sensitive enzyme immunoassay than is conventionally employed.

Clinical significance of simultaneous determinations of alpha-fetoprotein and des-gamma-carboxy prothrombin in monitoring recurrence in patients with hepatocellular carcinoma

Measurements of serum alpha‐fetoprotein (AFP) concentration and plasma concentration of des‐gamma‐carboxy prothrombin (DCP) have been widely used for the early diagnosis of hepatocellular carcinoma (HCC). The two markers generally run parallel to each other. However, in our study, they sometimes fluctuated independently in response to tumor regression or recurrence.

Plasma Cells and the Chronic Nonsuppurative Destructive Cholangitis of Primary Biliary Cirrhosis

There has been increased interest in the role of B cells in the pathogenesis of primary biliary cirrhosis (PBC). Although the vast majority of patients with this disease have anti‐mitochondrial antibodies, there is no correlation of anti‐mitochondrial antibody titer and/or presence with disease severity. Furthermore, in murine models of PBC, it has been suggested that depletion of B cells may exacerbate biliary pathology. To address this issue, we focused on a detailed phenotypic characterization of mononuclear cell infiltrates surrounding the intrahepatic bile ducts of patients with PBC, primary sclerosing cholangitis, autoimmune hepatitis, chronic hepatitis C, and graft‐versus‐host disease, including CD3, CD4, CD8, CD20, CD38, and immunoglobulin classes, as well as double immunohistochemical staining for CD38 and IgM. Interestingly, CD20 B lymphocytes, which are a precursor of plasma cells, were found in scattered locations or occasionally forming follicle‐like aggregations but were not noted at the proximal location of chronic nonsuppurative destructive cholangitis. In contrast, there was a unique and distinct coronal arrangement of CD38 cells around the intrahepatic ducts in PBC but not controls; the majority of such cells were considered plasma cells based on their expression of intracellular immunoglobulins, including IgM and IgG, but not IgA. Patients with PBC who manifest this unique coronal arrangement were those with significantly higher titers of anti‐mitochondrial antibodies. Conclusion: These data collectively suggest a role for plasma cells in the specific destruction of intrahepatic bile ducts in PBC and confirm the increasing interest in plasma cells and autoimmunity. (HEPATOLOGY 2012)

N‐Acetylglucosaminyltransferase V as a possible aid for the evaluation of tumor invasiveness in patients with hepatocellular carcinoma

A close relationship has been shown to exist between the metastatic potential and β1–6 branched oligosaccharides in human and rodent cells. N‐acetylglucosaminyltransferase V (GnT‐V) catalyzes this process. Although this phenomenon has been reported, little is known about the clinical usefulness of the determination of GnT‐V in the evaluations of tumor invasiveness in hepatocellular carcinoma (HCC). In this study, we measured the GnT‐V activity in serum of patients with HCC, together with its activity and gene expression in HCC tissues, and elucidated the clinical usefulness of the GnT‐V level in evaluating tumor invasiveness.

Serum N-acetylglucosaminyltransferase III activities in hepatocellular carcinoma

N‐Acetylglucosaminyltransferase III (GnT III) catalyses the addition of N‐acetylglucosamine through a β 1–4 linkage to the mannose of the trimannosyl core, resulting in conversion of the concanavalin A (Con A)‐reactive glycan into a non‐reactive state. In this study, we measured GnT III activity to evaluate its diagnostic efficacy and its therapeutic effect on hepatocellular carcinoma (HCC). Concanavalin A‐non‐reactive fraction of serum transferrin (Tf) was also determined since the sugar chains of Tf are one of the possible candidates for the product of GnT III. Serum samples (159) were used from patients with HCC (89), liver cirrhosis (30), chronic hepatitis (19), alpha‐fetoprotein (AFP) producing gastric carcinoma metastatic to the liver (five) and healthy controls (16). N‐Acetyl‐glucosaminyltransferase III activity was determined by high performance liquid chromatography. The reactivity of serum Tf to Con A was also analysed in 21 paired HCC samples before and after treatment by crossed immuno‐affinoelectrophoresis. N‐Acetylglucosaminyltransferase III activity from the HCC group (153 ± 72 pmol/mL/h) was significantly higher than that from liver cirrhosis (99 ± 67 pmol/mL per h), chronic hepatitis (84 ± 39pmol/mL per h) and the normal controls (62 ± 16pmol/mL per h). N‐Acetylgiucosaminyltransferase III activity of 21 patients with HCC was significantly reduced after treatment such as transcatheter arterial chemoembolization and/or percutaneous ethanol infection therapy, (123 ± 77 to 100 ± 60pmol/mL per h). Commensurate decreases of AFP and des‐γ‐carboxy prothrombin with GnT III activity were also observed after treatment. The Con A‐non‐reactive fraction (n= 21; 6.4 ± 2.3%) in patients with HCC after treatment was significantly lower than before (8.2 ± 2.4%). The present study suggests that GnT III activity is a possible and in the diagnosis and evaluation of HCC, especially when other tumour markers are negative.

Microheterogeneity of serum transferrin in the diagnosis of hepatocellular carcinoma

Heterogeneous reactivity of human serum transferrin (Tf) with lectins was analysed using patient sera to determine whether it can be used to distinguish patients with hepatocellular carcinoma (HCC) from those with liver cirrhosis (LC). Microheterogeneity of Tf was analysed by crossed immunoaffinity electrophoresis (CIAE) with concanavalin A (Con A) and Lens culinaris agglutinin (LCA). Sample sera from 58 patients with HCC, 43 patients with LC and 10 normal controls were used in this study and the results were evaluated statistically. The increments of Con A‐non‐reactive (C1) and ‐weakly reactive (C2) species of Tf were observed in HCC compared with those of LC and Norm. Significant increase in the combined percentage of Con A‐ C1 + C2 species was also revealed in HCC (35.5 ± 8.5%, mean ± s.d.) compared with those of LC (29.1 ± 6.8%; P < 0.001) and normal controls (17.1 ± 2.3%; P < 0.001). The elevation of LCA‐reactive (L2) species of Tf was recognized in HCC (8.2 ± 3.8%) in comparison with those of LC (4.8 ± 3.1%; P<0.001) and normal controls (1.3 ± 1.7%; P < 0.001). The increment of C1+C2 species and/or L2 species of Tf was observed in 78% (sensitivity) of patients with HCC. The specificity, the positive predictive value and the overall accuracy were 81, 88 and 72%, respectively. Positive ratio of C1+C2 and/or L2 species was 77 and 70% in alpha‐fetoprotein low and ‐high producing HCC patients, respectively. These results indicate that the microheterogeneity analysis of human serum Tf is useful for distinguishing patients with HCC from those with LC and normal controls.

Alpha-fetoprotein-producing renal cell carcinoma with increased activity of N-acetylglucosaminyl-transferase III.

N-acetylglucosaminyltransferase (GnT) III catalyzes the addition of N-acetylglucosamine through a beta 1-4 linkage to the mannose of the trimannosyl core, resulting in conversion of the concanavalin-A-(ConA)-reactive glycan into the ConA-nonreactive one. In this study, we measured GnT III levels in serum, tumor, and surrounding normal tissues together with a glucosaminylation index of alpha-fetoprotein (AFP), which is defined as the percentage of the ConA-nonreactive species in total AFP, in a case of AFP-producing renal cell carcinoma. The glucosaminylation index was determined by affinoelectrophoresis in the presence of ConA. GnT III was measured by using a pyridylaminated asialoagalactobiantennary sugar chain as a substrate by high-performance liquid chromatography. The glucosaminylation index of serum AFP, the concentration of which was 68 ng/ml, was 60%. This value is much higher than observed in hepatocellular carcinomas. The tumor tissue level of GnT III was 55.34 pmol/mg/h which was about six fold higher (9.50 pmol/mg/h) than in normal surrounding tissues. The serum level of this enzyme before surgery was 27.65 pmol/ml/h and decreased to 5.38 pmol/ml/h thereafter in association with a depression of serum AFP from 68 to 5.4 ng/ml. Thus, an increased level of GnT III in tumor tissues could account for the elevated conversion of a biantennary complex type sugar chain of AFP into a bisecting glucosaminylated biantennary one resulting from the addition of an N-acetylglucosamine residue at the trimannosyl core. This is, to our knowledge, the first report explaining the change in the carbohydrate structure of AFP with different affinity to ConA on the enzymatic basis in a renal cell carcinoma.

A Fatal Aortoesophageal Fistula Caused by Critical Combination of Double Aortic Arch and Nasogastric Tube Insertion for Superior Mesenteric Artery Syndrome.

Double aortic arch (DAA) is a rare vascular congenital abnormality. Since a vascular ring surrounds bronchus and esophagus, any oral or nasal intubation can physically cause fatal aortoesophageal fistula (AEF). We report herein the first case of association of DAA and superior mesenteric artery (SMA) syndrome and the second case of AEF caused by nasogastric intubation in an adult with DAA. A 19-year-old woman visited our hospital for nausea and vomiting. She was diagnosed with SMA syndrome by computed tomography (CT). Nasogastric intubation relieved her symptoms in 4 days. Extramural compression with top ulceration was found in esophagogastroduodenoscopy on the 5th hospital day. She suddenly showed massive hematemesis on the 12th hospital day. AEF was found by CT. Soon, she died despite of intensive care. Retrospective interview disclosed the fact that DAA was pointed out in her childhood. We conclude that intubation must be avoided in DAA and a detailed clinical interview about DAA is mandatory to avoid AEF.

Hepatocellular carcinoma, with portal thrombus after viral eradication, disappeared by 5-fluorouracil and interferon.

Hepatocarcinogenesis after a sustained virological response (SVR) in type C chronic hepatitis and cirrhosis is an important issue in endemic areas; hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) therapy is especially very hard. We herein report a first case in which combination therapy with interferon-α and continuous intra-arterial infusion of 5-fluorouracil (designated as FAIT) provided a complete response in HCC with PVTT after SVR. Therefore, we think that FAIT is a good option to treat HCC with or without PVTT, even after SVR.

Laparoscopic peritoneal biopsy can be crucial for diagnosis of tuberculous peritonitis

A 28-year-old woman was admitted to a nearby hospital because of low-grade fever and lower abdominal pain, where ascites and slightly elevated serum CA125 level were found. Both acid-fast stain (AFS) and polymerase chain reaction (PCR) failed to detect Mycobacterium tuberculosis in her ascitic fluid, sputum, and gastric juice. She was referred to our division under suspicion of tuberculous peritonitis or ovarian carcinoma. Finally, diagnostic laparoscopy was carried out, showing yellowish-white small nodules disseminated on her whole peritoneum with thin fibrous adhesions. Peritoneal biopsy of these nodules showed epithelioid cell granulomas without caseous necrosis. AFS and PCR again failed to show any evidence of Mycobacterium tuberculosis in these biopsied samples. Based on the laparoscopic findings, however, we thought that she suffered from tuberculous peritonitis. Antituberculous therapy was started and she improved soon. Later, Mycobacterium tuberculosis was demonstrated in the 4-week culture of a peritoneal biopsy specimen. We conclude that laparoscopy may be the only way to detect Mycobacterium tuberculosis in tuberculous peritonitis whenever doubtful but no direct evidence is obtained.