Nathalie Ganne

Prospective study of screening for hepatocellular carcinoma in Caucasian patients with cirrhosis

Screening is widely used to detect early hepatocellular carcinoma in Asian patients with cirrhosis. Its effectiveness in Caucasian patients has been suggested, but remains to be proven. Therefore we prospectively studied 118 French patients (68 males, 50 females, age 55 +/- 12) with Child-Pugh A or B cirrhosis (alcoholic in 82) and without detectable hepatocellular carcinoma. The screening program consisted of ultrasound examination of the liver and determination of blood alpha-fetoprotein and des-gamma-carboxyprothrombin levels every 6 months. The median follow up was 36 months (range 4-48). Only four patients were lost to follow up. Fourteen hepatocellular carcinomas were detected, in six cases by ultrasonography alone, in four by alpha-fetoprotein alone, in three by ultrasonography and alpha-fetoprotein and in one case by ultrasonography and des-gamma-carboxyprothrombin, but never by des-gamma-carboxyprothrombin alone. The tumor presented as a unique nodule in nine patients. The tumor was less than 3 cm in diameter without portal thrombosis or metastasis in three cases. Surgery was performed in only one case. In this study, the annual incidence of hepatocellular carcinoma was high (5.8%), but the screening methods used did not effectively identify potentially resectable tumors in Caucasian patients with cirrhosis.

Clinical and biological relevance of hepatocyte apoptosis in alcoholic hepatitis.

BACKGROUND/AIMS Although human and experimental studies have shown that apoptosis plays a role in hepatocyte death in alcoholic liver disease, its clinical and biological significance has not been investigated in alcoholic hepatitis (AH). The aim of this study was to quantify hepatocyte apoptosis in AH and to attempt to relate it to the clinical and biological severity of the disease. METHODS The hepatocyte apoptotic index was determined using a double in situ transferase-mediated dUTP nick end (TUNEL) and CD15 (neutrophils) labelling on 35 liver biopsies from patients with AH lesions of different severities. The specificity of TUNEL labelling for apoptosis was monitored both by morphology and fractin (a caspase actin cleavage site) immunostaining. RESULTS The hepatocyte apoptotic index ranged from 0.3 to 28% and was related to the severity of alcoholic hepatitis as measured by the Maddrey score (P < 0.05; Mann-Whitney test) while ballooning (which reflects hepatocytes potentially undergoing necrosis) and neutrophil indexes were not. CONCLUSIONS This suggests that hepatocyte apoptosis could be a therapeutic target to treat or to prevent alcoholic hepatitis in cirrhotic patients. Co-localization of apoptotic hepatocytes with neutrophils and the strong quantitative correlation would suggest an apoptosis dependent transmigration of neutrophils.

Large (≥5.0-cm) HCCs: Multipolar RF Ablation with Three Internally Cooled Bipolar Electrodes—Initial Experience in 26 Patients

PURPOSE To prospectively evaluate the safety and effectiveness of percutaneous multipolar radiofrequency (RF) ablation for the treatment of large (>or=5.0 cm in diameter) hepatocellular carcinomas (HCCs). MATERIALS AND METHODS Twenty-six patients (four women, 22 men; median age, 72 years) with cirrhosis (Child-Pugh class A disease, 22 patients; Child-Pugh class B disease, four patients) and at least one 5.0-9.0-cm-diameter HCC without invasion of the portal trunk or main portal branches were treated with multipolar RF ablation performed by a single operator. The procedure was performed with three separate bipolar linear internally cooled electrodes with ultrasonographic guidance. Twenty-seven of the 33 tumors treated had a diameter of 5.0 cm or greater (median diameter, 5.7 cm; range, 5.0-8.5 cm); 12 of these 27 tumors were infiltrative, and four invaded segmental portal vein branches. Ten patients had a serum alpha-fetoprotein level higher than 400 microg/L. Results were assessed by using computed tomography. Primary effectiveness, complications, tumor progression, and survival rates were recorded. Probabilities of survival were calculated by using the Kaplan-Meier method. RESULTS One to two RF ablation procedures per patient (mean, 1.15 +/- 0.43 [standard deviation]) led to the complete ablation of 22 (81%) of the 27 tumors (18 tumors after one and four tumors after two procedures), including three tumors that showed segmental portal vein invasion. All patients experienced postablation syndrome, and one experienced subcapsular hematoma and a segmental liver infarct, but no major complication occurred. After a mean follow-up of 14 months (range, 3-34 months), local and distant tumor progression and actual survival rates were 14% (three of 22), 24% (five of 21), and 65% (17 of 26), respectively. The probabilities of 1- and 2-year survival, respectively, were 68% (95% confidence interval: 49%, 86%) and 56% (95% confidence interval: 51%, 81%). CONCLUSION HCCs larger than 5.0 cm (but smaller than 9.0 cm)--even those that are infiltrative and those that involve a segmental portal vein--can be completely and safely ablated with multipolar RF ablation.

Gastrointestinal tuberculosis: 17 cases collected in 4 hospitals in the northeastern suburb of Paris

UNLABELLED Gastrointestinal tuberculosis is a rare form of extrapulmonary tuberculosis and its diagnosis can be difficult. AIMS To analyze the diagnostic and therapeutic characteristics of gastrointestinal tuberculosis. METHODS Retrospective study from 17 cases collected in 4 hospitals in Seine Saint-Denis between 1987 and 2002. RESULTS Seventeen cases and 19 localizations were collected: small intestine (N = 7), ileocecum (N = 6), colon (N = 4) and gastroduodenum (N = 2). Two patients had two localizations. Mean age was 43.9 years. Subjects from immigrant populations (76.5%) were preferentially affected. Twenty-three percent of patients (13 tested) were infected by human immunodeficiency virus. Weight-loss and general weakness (88%), abdominal pain (88%), fever (59%), nausea/vomiting (53%) were the predominant symptoms. The delay in diagnosis was 82 days (range: 7-180) and time before specific treatment 31.6 days (range: 7-90). Histological evidence of caseating granuloma was found in six patients. Mycobacterium tuberculosis was detected in six. Digestive imaging was abnormal in 15 patients. Mesenteric lymph nodes were the most common associated site of tuberculosis (N = 8, 47%). Mean duration of treatment was 8.2 months (range: 6-12). Thirteen patients were cured, three died and one was lost to follow up. CONCLUSION Gastrointestinal tuberculosis is not an uncommon diagnosis in the north-eastern Parisian area, especially among immigrant populations and immunodeficient patients. The most frequent localizations are the small intestine and ileocecum. Diagnosis can be made by pathology and/or bacteriology on endoscopic and/or surgical biopsy samples.

Reactivation of resolved hepatitis B during rituximab therapy for rheumatoid arthritis

Joint Bone Spine - In Press.Proof corrected by the author Available online since vendredi 23 septembre 2011

Radiofrequency Ablation with Internally Cooled versus Perfused Electrodes for the Treatment of Small Hepatocellular Carcinoma in Patients with Cirrhosis

PURPOSE To compare the results of radiofrequency (RF) ablation with internally cooled electrodes (ICEs) versus perfused electrodes (PEs) in patients with cirrhosis with small (<or=3 cm) hepatocellular carcinoma ineligible for resection. MATERIALS AND METHODS Patients treated with RF ablation over two consecutive periods were analyzed retrospectively. From 2000 to 2002, 45 patients were treated with 17-gauge ICEs, and from 2002 to 2004, 44 patients were treated with 15-gauge PEs. The two groups were similar in age, sex, Child-Pugh stage, serum alpha-fetoprotein (AFP) level, and size and number of tumors (54 tumors in each group). Results were assessed by contrast medium-enhanced CT. RESULTS In both groups, 52 of 54 tumors (96.3%) were completely ablated. Eight of 54 tumors (14.8%) treated with ICEs and 39 of 54 tumors (72.2%) treated with PEs required multiple RF applications (P<.00005). In the respective groups, one of 54 tumors (1.8%) and seven of 54 tumors (12.9%) required multiple RF sessions (P=.03). Complication rates were similar. The 2-year probabilities of local and distant (ie, separated from the ablation zone) tumor progression in the ICE and PE groups were 11% and 15%, respectively (P=.65), and 31% and 64% (P=.01), respectively. On multivariate analysis, serum AFP level greater than 100 ng/mL (P=.006) and the use of a PE (P=.003) were risk factors for distant tumor progression. CONCLUSIONS RF ablation with the use of a PE requires more applications and sessions and is associated with a higher risk of distant tumor progression compared with the use of an ICE.

Metallothionein-1 as a biomarker of altered redox metabolism in hepatocellular carcinoma cells exposed to sorafenib

BackgroundSorafenib, a kinase inhibitor active against various solid tumours, induces oxidative stress and ferroptosis, a new form of oxidative necrosis, in some cancer cells. Clinically-applicable biomarkers that reflect the impact of sorafenib on the redox metabolism of cancer cells are lacking.MethodsWe used gene expression microarrays, real-time PCR, immunoblot, protein-specific ELISA, and gene reporter constructs encoding the enzyme luciferase to study the response of a panel of cancer cells to sorafenib. Tumour explants prepared from surgical hepatocellular carcinoma (HCC) samples and serum samples obtained from HCC patients receiving sorafenib were also used.ResultsWe observed that genes of the metallothionein-1 (MT1) family are induced in the HCC cell line Huh7 exposed to sorafenib. Sorafenib increased the expression of MT1G mRNA in a panel of human cancer cells, an effect that was not observed with eight other clinically-approved kinase inhibitors. We identified the minimal region of the MT1G promoter that confers inducibility by sorafenib to a 133 base pair region containing an Anti-oxidant Response Element (ARE) and showed the essential role of the transcription factor NRF2 (Nuclear factor erythroid 2-Related Factor 2). We examined the clinical relevance of our findings by analysing the regulation of MT1G in five tumour explants prepared from surgical HCC samples. Finally, we showed that the protein levels of MT1 increase in the serum of some HCC patients receiving sorafenib, and found an association with reduced overall survival.ConclusionThese findings indicate that MT1 constitute a biomarker adapted for exploring the impact of sorafenib on the redox metabolism of cancer cells.

Cytolytic Hepatitis Possibly Related to Levonorgestrel/Ethinylestradiol Oral Contraceptive Use: 2 Case Reports

This letter to the editor reports on two cases of biopsy-confirmed cytolytic hepatitis induced by a levonorgestrel/ethinylestradiol combination oral contraceptive pill.

Insulin-like growth factor 2 gene methylation in peripheral blood mononuclear cells of patients with hepatitis C related cirrhosis or hepatocellular carcinoma

UNLABELLED Igf2 gene specific hypomethylation has been demonstrated in hepatocellular carcinoma (HCC) cells and in non-tumoral liver samples from patients with HCV-related cirrhosis who further developed HCC. In patients with colorectal cancers, Igf2 hypomethylation is found in peripheral blood mononuclear cells (PBMC) even prior to the occurrence of cancer. AIM To compare Igf2 methylation in PBMC from healthy donors and patients with HCV-related cirrhosis without or with history of HCC. PATIENTS AND METHODS After DNA extraction from frozen PBMC samples of 52 healthy blood donors and 121 patients with HCV-related cirrhosis either without (n=59) or with past or present HCC (n=62), and sodium bisulfite treatment, unbiased PCR amplification and Denaturing High Performance Liquid Chromatography (DHPLC) analysis were used for methylation analysis at the differentially methylated region 2 of Igf2. Methylation profiles were classified in three groups (unmethylated, U; methylated, M; and intermediate, UM) according to the proportions of M and U alleles, blindly to clinical data. In addition, 677C-T mutation of Methylenetetrahydrofolate Reductase (MTHFR) was investigated by fluorescent probes. RESULTS Prevalences of U, UM and M Igf2 profiles were: 8%, 65% and 27% in blood donors, 0%, 81% and 19% in patients with HCV-related cirrhosis without HCC, 71%, 29% and 0% in patients with HCC (P<0.0001). Igf2 methylation profile was independent from gender, age, body mass index, and presence of 677C-T mutation of MTHFR. CONCLUSION These observations suggest a decrease of Igf2 methylation from cirrhosis to HCC in patients with HCV infection, which may be an additional risk factor for HCC.

MDR3 immunostaining on frozen liver biopsy samples is not a sensitive diagnostic tool for the detection of heterozygous MDR3/ABCB4 gene mutations.

Dear Editor, We read with great interest the recent article of Wendum et al. [1] describing histological lesions observed in the liver of 13 adult patients with heterozygous MDR3/ABCB4 gene mutations. They performed multidrug resistance Pglycoprotein 3 (MDR3) immunostaining on formalin-fixed paraffin-embedded sections of 11 patients and reported that the staining had a diffuse and strong canalicular pattern in patients and controls, except in one case who disclosed a faint staining. This finding suggested a lack of sensitivity of this technique for the diagnosis of MDR3/ABCB4 heterozygous mutations. Since we previously suggested that MDR3 immunostaining on frozen liver sections could be useful for the diagnosis of unexplained anicteric cholestasis in adult patients [2], we would like to contribute by providing our experience of MDR3 immunostaining realized on frozen liver biopsy sections of a new series of adult patients with MDR3/ABCB4 mutations. Between April 2007 and March 2011, 32 adult patients with unexplained anicteric cholestasis had ABCB4 gene sequencing, using polymerase chain reaction amplification and DNA sequencing of exons 2 to 28 and all splice junctions. Among these 32 patients, ten carried six different ABCB4 mutations. These ten patients (six females, 17– 72 years of age) displayed various clinical characteristics: three fulfilled the criteria for low phospholipid-associated cholelithiasis syndrome [3]; one had an anteriority of intrahepatic cholestasis of pregnancy; and six had an unexplained anicteric cholestasis—two of them with associated elevated aminotransferase level. Histopathological analysis using Picrosirius red and hematoxylin–eosin-stained liver biopsy sections showed that nine patients had portal fibrosis (three F1, four F2, one F3, and one F4 according to Ishak fibrosis score); six of them displaying a jigsaw pattern of biliary-type fibrosis. Bile duct lesions corresponding to mild cholangitis could be observed in four patients. Ductopenia, defined as a loss of more than 50 % of bile ducts, was seen in two patients. Lastly, six cases showed a mild to moderate ductular reaction. The clinicopathological features are detailed in Table 1. Frozen liver biopsies were available for 14 patients (five cases and nine controls). Immunohistochemistry was performed on 4-μm frozen sections by using MDR3 monoclonal antibody (clone P3II-26) and MRP2 antibody (clone M2III-6) as a control to check tissue immune reactivity. As shown in Fig. 1, we observed a diffuse and intense canalicular staining with MDR3 antibody, in the available frozen liver biopsies of the five patients with heterozygous ABCB4 mutations and in the nine controls. Positive canalicular staining was also observed with MRP2 antibody, confirming the immunoreactivity of our samples. These results are in contradiction with our previous report [2] in which no or faint MDR3 immunostaining was observed in frozen liver biopsies from four patients with A. Sannier (*) :M. Tepper :M. Ziol Service d’Anatomie Pathologique, GHU Paris-Seine-Saint-Denis, Hopital Jean Verdier, AP-HP, Avenue du 14 Juillet, 93143 Bondy Cedex, France e-mail: aureliesannier@free.fr