Michitami Yano

Interferon Therapy Reduces the Risk for Hepatocellular Carcinoma: National Surveillance Program of Cirrhotic and Noncirrhotic Patients with Chronic Hepatitis C in Japan

Hepatitis C virus (HCV) infection rarely resolves spontaneously once it becomes chronic (1). Most patients remain asymptomatic for a long period, with liver cirrhosis developing after approximately 30 years (2, 3). Chronic hepatitis C with cirrhosis is a major risk factor for hepatocellular carcinoma (4-7). It has been previously shown that the risk increases with the degree of liver fibrosis (5). Interferon is the only agent known to be effective against HCV infection (8-10). It induces a sustained virologic response in 15% to 30% of patients (11-14). Responders usually show biochemical and histologic improvement (9, 11, 15). Recently, interferon therapy in patients with chronic hepatitis C and cirrhosis was shown to be associated with a reduced incidence of hepatocellular carcinoma (16). Because most patients treated with interferon do not have cirrhosis, we included noncirrhotic as well as cirrhotic patients in our analysis of the effect of interferon therapy on the incidence and prevention of hepatocellular carcinoma. A national surveillance program, the Inhibition of Hepatocarcinogenesis by Interferon Therapy (IHIT) Study, was begun in 1994 as a multicenter, large-scale, retrospective cohort study supported by the Japan Ministry of Health and Welfare as one of the Comprehensive 10-Year Strategy for Cancer Control Projects (17). In this program, patients with chronic hepatitis C who have undergone liver biopsy at one of eight participating institutions are enrolled and followed periodically for development of hepatocellular carcinoma by using several imaging techniques. We analyzed the incidence of hepatocellular carcinoma as of February 1998 by using multivariate proportional hazards regression. Methods Patients The IHIT Study Group approved the design of this study on 21 September 1994. All patients who were positive by a second-generation HCV antibody assay and who had undergone liver biopsy since 1986 at one of the eight participating institutions were enrolled. Patients who were participants in interferon trials for non-A, non-B chronic hepatitis (18-21) and in whom anti-HCV seropositivity was confirmed by using stored sera were also included; these patients had undergone liver biopsy in 1986 or later. Patients were excluded if at the time of liver biopsy they presented with hepatocellular carcinoma or other liver diseases, such as chronic hepatitis B, alcoholic liver disease,autoimmune hepatitis, or primary biliary cirrhosis. The minimum follow-up was established as 1 year for two reasons. First, if hepatocellular carcinoma is detected within 1 year after liver biopsy, the possibility that the cancer was present at the time of liver biopsy cannot be ruled out. Second, interferon therapy must be started within 1year after liver biopsy according to Japanese health insurance rules. By February 1998, 3223 patients who fulfilled the inclusion criteria were registered. Of these patients, 333 were excluded from the analysis: 161 patients (5.0%) transferred to other hospitals without follow-up, and the follow-up period after liver biopsy was less than 1 year for172 patients (5.3%). Thus, 2890 patients were included in the present analysis. Figure 1 shows the schema for patient selection. Figure 1. Schema for patient selection. Interferon therapy was given to 2400 patients; 490patients did not receive treatment (control group). Interferon therapy was initiated within 1 year after liver biopsy (within 6 months in 93% of patients); 84% of patients received interferon-, 14% received interferon-, and 2% received a combination of interferon- and interferon-. The median total dose was 480 MU (first quartile, 324 MU; third quartile, 702 MU), and the median duration of administration was 160 days(first quartile, 94 days; third quartile, 168 days). Once interferon therapy was started, a patient was included in the interferon treatment group even if therapy was discontinued because of adverse events or other reasons. The 490patients who did not receive interferon chose this course of action voluntarily on the basis of concerns about adverse effects; lack of time for therapy; or physician recommendation, which took into account depression, severe diabetes mellitus, or other medical conditions. Serum HCV load was quantitatively determined at the timeof liver biopsy by using various commercial and in-house assays. Because it is difficult to correlate the results of different assay methods, only data obtained with two widely used assays, the branched-DNA probe assay (22) and competitive reverse-transcription polymerase chain reaction (RT-PCR) (23), were used. HCV RNA genotype was determined by RT-PCR using genotype-specific primers (24) or by serologic grouping of serum antibody (25), assuming that genotypes 1a and 1b correspond to serologic group 1 (genotype 1) and genotypes 2a and 2b correspond to serologic group 2 (genotype 2) (11). Histologic Evaluation Liver biopsy specimens were evaluated by a representative pathologist at each institution (a total of eight pathologists were involved) and were scored for the stage of liver fibrosis and grade of inflammatory activity according to the classification of Desmet and colleagues (26). Stage of fibrosis was assessed from stage F0 (no fibrosis) to stage F4 (cirrhosis), and grade of inflammatory activity was scored from grade A1 (mild) to grade A3 (severe). To confirm interobserver concordance in scoring, a subsequent blind and independent examination of 350randomly selected liver biopsy specimens was conducted by two of the eight pathologists. Definition of Interferon Response Virologic and biochemical criteria were used to define response to interferon therapy. Hepatitis C virus RNA was used as a marker of virologic response and was determined by RT-PCR. A virologic sustained response was defined as HCV RNA negativity more than 6 months after termination of interferon therapy; positivity at the same time point was considered a nonsustained response (27). Patients with nonsustained response included those who had temporary disappearance of viremia followed by relapse. In patients treated before the availability of RT-PCR, virologicresponse was determined by using sera stored at 30 C or collected afterward. The serum alanine aminotransferase (ALT) level was used as a marker of biochemical response to interferon therapy. Sustained biochemical response was defined as persistently normal serum ALT levels more than 6 months after termination of interferon therapy; nonsustained response was defined as elevated serum ALT levels at the same time point. Nonsustained response was subdivided into two categories: mildly elevated for a serum ALT level less than two times the upper limit of normal and highly elevated for a serum ALT level two or more times the upper limit of normal. Screening for Hepatocellular Carcinoma Patients were examined for hepatocellular carcinoma by abdominal ultrasonography at least every 6 months. If hepatocellular carcinoma was suspected on the basis of ultrasonographic results, additional procedures, such as computed tomography, magnetic resonance imaging, abdominal angiography, and ultrasonography-guided tumor biopsy, were used to confirm the diagnosis. Statistical Analysis Statistical analysis was performed by using SAS software, version 6.12 (SAS Institute, Inc., Cary, North Carolina). Interobserver concordance of histologic scoring was evaluated by using the Spearman correlation coefficient. Differences between two groups were evaluated by using the unpaired Student t-test or the Mann-Whitney U-test. Categorical data were compared by using the chi-square test or the Fisher exact probability test. Cumulative incidence curves were determined with the Kaplan-Meier method, and the differences between groups were assessed by using the log-rank test. We used the Cox proportional-hazards regression analysis to examine the effect of interferon therapy on the incidence of hepatocellular carcinoma. Because virologic and biochemical responses were mutually dependent, the risk ratio for hepatocellular carcinoma was calculated separately for these factors. The risk ratio attributable to categorical data, such as stage of liver fibrosis and serum ALT level, was calculated by using dummy variables. A P value less than 0.05 was considered statistically significant. Results Patient Characteristics The demographic and clinical features of patients at the time of their enrollment are summarized in Table 1. The frequency distribution of the stages of liver fibrosis differed between interferon-treated patients and untreated patients. Most laboratory values also differed between the two groups. However, differences in laboratory values between treated patients and untreated patients were not significant at the same stage of fibrosis. This indicated the need to adjust for stage of liver fibrosis, which was done in the following analyses. Table 1. Demographic and Clinical Characteristics Histologic Evaluation The concordance in scores for stage of fibrosis and grade of inflammatory activity determined at each institution and by the two representative pathologists was strong, with Spearman coefficients ranging from 0.897 to 0.918 for stage of fibrosis and from 0.878 to 0.849 for grade of inflammatory activity. The original score was sustained by at least one of the two pathologists in 319 of 350 cases for fibrosis staging and in 320 of 350cases for grading inflammatory activity. Response to Interferon Therapy Response to interferon therapy was determined in 2357(98.2%) of the 2400 interferon-treated patients. Response was not determined in43 patients because of insufficient follow-up (<6 months) after termination of therapy. A sustained virologic response was achieved in 789 patients(33.5%). The response rate was similar regardless of the type of interferon used (32.3%, 34.5%, and 25.6% for interferon-, interferon-, and the combination of the two, respectively). A sustained bioch

Influence of interleukin-10 gene promoter polymorphisms on disease progression in patients chronically infected with hepatitis B virus

OBJECTIVES:The role of host genetic factors in chronic hepatitis B virus (HBV) infection is not fully understood. We studied the influence of tumor necrosis factor-α (TNF-α) and interleukin-10 (IL-10) gene promoter polymorphisms on disease progression in HBV carriers.METHODS:The sample population included 213 Japanese HBV carriers and 52 healthy volunteers. Of 213 HBV carriers, 66 were considered to be asymptomatic carriers based on the sustained normalization of serum ALT together with seropositivity for the antibody to hepatitis B e antigen (anti-HBe), and 147 were found to have chronic progressive liver disease including cirrhosis. Five biallelic polymorphisms in the TNF-α gene promoter and three biallelic polymorphisms in the IL-10 gene promoter were analyzed by polymerase chain reaction in combination with direct sequencing or restriction fragment length polymorphism assay.RESULTS:Allelic distributions of both gene promoters were not significantly different between HBV carriers and healthy volunteers. In HBV carriers, the TNF-α gene promoter polymorphisms were not linked to disease progression. In contrast, allelic frequencies of T and A at positions −819 and −592, respectively, in the IL-10 gene promoter, as well as the frequencies of ATA haplotype at positions −1082/− 819/− 592 (which is characterized with low capacity for IL-10 production), were significantly higher in asymptomatic carriers than in patients with chronic progressive liver disease. Even after adjusting for individuals positive for anti-HBe, such a relationship could be found between the two groups.CONCLUSION:In chronic HBV infection, inheritance of the IL-10 gene promoter polymorphisms is involved in a host genetic factor that is relevant to disease progression.

Influence of Human Immunodeficiency Virus Type 1 Infection on Acute Hepatitis A Virus Infection

To assess the possible influence of human immunodeficiency virus type 1 (HIV-1) infection on the clinical course of acute hepatitis A virus (HAV) infection, 15 HIV-1-infected homosexual men and 15 non-HIV-infected age-matched subjects were compared. HAV load was higher in HIV-1-infected than in non-HIV-infected patients (P<.001). Duration of viremia in HIV-1-infected patients (median, 53 days) was significantly (P<.05) longer than in non-HIV-infected patients (median, 22 days). HIV-1-infected patients had lower elevations in alanine aminotransferase levels than did non-HIV-infected patients (P<.01) but had higher elevations in alkaline phosphatase levels than did non-HIV-infected patients (P<.001). Some HIV-1-infected patients still had HAV viremia when clinical symptoms had disappeared and alanine aminotransferase levels had returned to normal (60-90 days after the onset of symptoms). HIV-1 infection was associated with prolongation of HAV viremia, which might cause a long-lasting outbreak of HAV infection in HIV-1-infected homosexual men.

Impact of aging on the development of hepatocellular carcinoma in patients with posttransfusion chronic hepatitis C

Hepatitis C virus (HCV) infection is a heterogeneous disease, the natural history of which remains controversial. There is solid evidence that chronic HCV infection is responsible for the occurrence of hepatocellular carcinoma (HCC). The aim of the current cohort study was to determine the rate of the development of HCC from the time of primary HCV infection and to assess the risk factors for the development of HCC in chronic posttransfusion hepatitis C patients.

Clinicopathological study of nonalcoholic fatty liver disease in Japan: the risk factors for fibrosis.

Background/Aims: We evaluated patients with nonalcoholic fatty liver disease (NAFLD) and compared the clinical and pathological features to identify the risk factors for NAFLD with severe fibrosis.

The des-γ-carboxy prothrombin index is a new prognostic indicator for hepatocellular carcinoma

Des‐γ‐carboxy prothrombin (DCP) has been reported to be an important prognostic factor in patients with hepatocellular carcinoma (HCC). Recently, a monoclonal antibody, 19B7, which recognizes the Gla domain of DCP, has been identified. The 19B7 antibody recognizes an epitope different from that recognized by MU‐3, which is another antibody against DCP. In this study, the authors investigated the measurement of DCP using the antibodies MU‐3 and 19B7, respectively, as a prognostic factor for patients with HCC who had solitary, small tumors and or Child Stage A HCC.

Epidemiology of hepatitis C virus in Japan: role in chronic liver disease and hepatocellular carcinoma.

The recent isolation by Choo et al. of the genome of hepatitis C virus (HCV), the causative agent of parenterally transmitted non-A, non-B hepatitis, has greatly advanced the characterization of the main agents that cause viral hepatitis in humans. Sero-epidemiological studies based on the detection of antibodies against C100-3, which is located in the non-structural region of the HCV polyprotein, suggest that this virus is the cause of most cases of post-transfusion non-A, non-B This review integrates what is known about HCV in Japan, its role in chronic liver disease and hepatocellular carcinoma (HCC) and the prognosis and treatment of chronic hepatitis C.

Interleukin-10 promoter polymorphisms and liver fibrosis progression in patients with chronic hepatitis C in Japan

[1] Przybylski GK, Wu H, Macon WR, Finan J, Leonard DGB, Felgar RE, et al. Hepatosplenic and subcutaneous panniculitis-like g/d T cell lymphomas are derived from different Vd subsets of g/d T lymphocytes. J Mol Diagn 2000;2:11–19. [2] Wlodarska I, Martin-Garcia N, Achten R, De Wolf-Peeters C, Pauwels P, Tulliez M, et al. Fluorescence in situ hybridisation study of chromosome 7 aberrations in hepatosplenic T-cell lymphoma: isochromosome 7q as a common abnormality accumulating in forms with features of cytologic progression. Genes Chromosomes Cancer 2002;33:243–251. [3] Khan WA, Yu L, Eisenbrey AB, Crisan D, Al Saadi A, Davis BH, et al. Hepatosplenic gamma/delta T-cell lymphoma in immunocompromised patients. Report of two cases and review of literature. Am J Clin Pathol 2001;116:41–50. [4] Iannitto E, Barbera V, Quintini G, Cirrinsione S, Leone M. Hepatosplenic gamma/delta T-cell lymphoma: complete response induced by treatment with pentostatin. Br J Haematol Jun; 2002;117: 995–996.

Therapeutic ethanol injection of hepatocellular carcinomas undetectable by angiography and lipiodol computed tomography

Seven smaller than 2 cm in diameter hepatocellular carcinomas (HCC) undetectable by hepatic arteriography and computed tomography (CT) after intraarterial injection of iodized oil (Lipiodol CT) were diagnosed by ultrasonography-guided fine-needle biopsy in 6 patients. All lesions were treated by percutaneous ethanol injection (PEI) in 1–3 weekly intervals. No recurrences have been demonstrated after 7–15 months. The treatment of HCCs undetectable by angiography and Lipiodol CT presents a problem as transcatheter arterial embolization is considered ineffective due to, poor vascularity. PEI appears to be an excellent treatment for these small HCCs.

Natural Interferon α Treatment and Interferon α Receptor 2 Levels in Acute Hepatitis C

Efficacy of interferon (IFN) therapy during the acute phase of hepatitis C infection is promising, although the optimal regimen has yet to be determined. It is not known whether the known prognostic factors for chronic hepatitis C (CHC) influence the effect of IFN in acute hepatitis C (AHC). Seventeen patients with AHC were analyzed for hepatic IFN α receptor 2 (IFNAR2) prior to IFN treatment. All patients were subsequently treated with either 168 million units (MU) or 336 MU of natural IFN α. Seventeen age-matched samples of CHC were provided as controls. The overall sustained response rate was 64.7% (11/17). In patients who received a total dose of 168 MU IFN, the sustained response rate was 28.6% (2/7), and in those who received 336 MU of IFN, the sustained response rate was 90.0% (9/10). The peaks of ALT and HCV-RNA quantity were not associated with the response to IFN. The hepatic IFNAR2 levels were 1.52±0.34 densitometry units and 0.92±0.16 in AHC and CHC, respectively (P = 0.042). There was no difference in hepatic IFNAR2 levels between sustained virological responders (SVR) and nonsustained virological responders (NR). The hepatic receptor levels were higher in AHC than in CHC patients. The levels of hepatic IFNAR2 did not differ in SVR and NR, indicating that high-dose natural IFN α treatment is effective for AHC, irrespective of the levels of hepatic IFNAR2.