Shuzo Noda

Relation of Interferon Therapy and Hepatocellular Carcinoma in Patients with Chronic Hepatitis C

Hepatocellular carcinoma, a major cause of death in patients with cirrhosis, is one of the most prevalent malignant tumors worldwide, and its incidence is increasing [1-5]. After isolation of hepatitis C virus (HCV), most patients with chronic hepatitis and those with cirrhosis of unknown origin were found to be positive for anti-HCV [6-8]. Evidence suggests that HCV-related chronic liver disease plays a role in the development of hepatocellular carcinoma [9-13]. A high proportion of patients with hepatocellular carcinoma have anti-HCV, although the prevalence varies geographically. The highest rate of anti-HCV is in southern Europe and Japan, where about 70% of patients with hepatocellular carcinoma are positive for anti-HCV [5]. Interferon has been widely used to treat chronic HCV infection. A series of clinical trials showed that some patients who received interferon had sustained normalization of serum aminotransferase levels and elimination of serum HCV RNA [14-17]. Histologic improvement was also seen in patients who received interferon [14, 18-20]. It is important to determine whether interferon treatment also lowers the incidence of hepatocellular carcinoma in patients with chronic hepatitis C, but the recognized benefits of interferon make a randomized, controlled trial to address this question unethical. We did a retrospective study to compare the incidence of hepatocellular carcinoma in interferon-treated patients with HCV infection and histologically proven chronic hepatitis or cirrhosis with that in historical controls who did not receive interferon. We also examined the relation between response to interferon therapy and incidence of hepatocellular carcinoma. Methods Patients The interferon group comprised 419 consecutive patients with chronic hepatitis C who had undergone liver biopsy 1 to 2 weeks before interferon therapy and had started treatment between January 1992 and December 1993. The control group consisted of 144 consecutive patients with chronic hepatitis or cirrhosis who had undergone liver biopsy between January 1986 and December 1989. All patients had histologically proven chronic hepatitis or cirrhosis (Child-Pugh class A) and were positive for anti-HCV. Interferon Treatment In the interferon group, 176 patients received human lymphoblastoid interferon, 149 received recombinant interferon- 2a, and 94 received recombinant interferon- 2b for 6 months. The median total interferon dose was 480 mU (range, 282 to 800 mU). No patient had received interferon therapy before study entry. Contraindications to interferon treatment included pregnancy, presence of hepatitis B surface antigen, other types of liver disease, autoimmune disease, and any other serious illness. Efficacy of interferon therapy was categorized as follows. Patients with persistent normalization of alanine aminotransferase (ALT) levels during interferon therapy and follow-up were considered to have sustained response. Patients whose serum ALT level was normal at the end of the treatment but increased to an abnormal level after cessation of treatment were considered to have relapse. All other patients were classified as nonresponders. Follow-up Abdominal ultrasonography or computed tomography was performed every 4 to 8 months, and serum -fetoprotein was measured every 2 to 6 months. The diagnosis of hepatocellular carcinoma was confirmed by needle biopsy, by surgically resected tumor specimens, or by typical radiologic findings on hepatic angiography. The starting date of follow-up for patients in the interferon and control groups was defined as the date of liver biopsy. For both groups, the end of follow-up was the development of hepatocellular carcinoma or December 1991 in the control group and the time of the latest abdominal imaging in the interferon group. To detect hepatocellular carcinoma, follow-up examinations were done in 85.4% of controls and 90.7% of patients in the interferon group. The Osaka Cancer Registry was used [21, 22] to determine whether hepatocellular carcinoma had occurred in patients lost to follow-up. This population-based cancer registry has been operating since December 1962 with the cooperation of the Osaka Medical Association, the Department of Health of Osaka Prefecture, and Osaka Medical Center for Cancer and Cardiovascular Diseases. It covers all of Osaka Prefecture, which had a population of 8.6 million in 1995, and registers cases of cancer by using reports from hospitals and clinics and death certificates collected from health centers. One patient in each group who had been lost to follow-up was listed as having hepatocellular carcinoma in the Osaka Cancer Registry. Determination of the Presence of Hepatitis C Virus Antibody and Hepatitis C Virus RNA Hepatitis C virus antibody was measured by first-, second-, or third-generation enzyme-linked immunosorbent assays (Ortho Diagnostics, Tokyo, Japan). Serum HCV RNA was measured by reverse transcription polymerase chain reaction or complementary DNA assay, as reported elsewhere [23, 24]. Assessment of Liver Histologic Findings The histologic findings in liver biopsy specimens were scored by three of the authors in a blinded manner by using two scoring methods. For assessment of histologic staging, fibrosis score (F1 to F3 for chronic hepatitis and F4 for cirrhosis) was used; F1 indicated portal fibrous expansion, F2 indicated portal-portal septa without architectural distortion, F3 indicated portocentral septa with architectural distortion, and F4 indicated cirrhosis [25]. For assessment of histologic grading, a total score of histologic activity (components 1 to 3) of the Knodell histologic activity index was used [26]. Statistical Analysis Patients who did not complete the treatment protocol were included for analysis on an intention-to-treat basis. The chi-square test was used to compare the baseline characteristics of both groups. The Wilcoxon rank-sum test was used to assess a significant difference between tumor sizes in the two groups. The Kaplan-Meier method was used to calculate the cumulative incidence of hepatocellular carcinoma, and the log-rank test was used to compare the cumulative incidence of hepatocellular carcinoma between the groups. To estimate independent risk factors for the development of hepatocellular carcinoma, Cox proportional-hazards regression analysis was used. For analysis, interferon therapy, age, sex, serum ALT level, serum -fetoprotein level, platelet count, histologic staging, and activity scores were used as variables. A P value less than 0.05 was considered statistically significant. Data are expressed as medians and ranges and as risk ratios and 95% CIs. Results Table 1 shows the baseline characteristics of the interferon and control groups. The groups did not differ for age, sex, serum ALT level, or platelet count. In the interferon group, 387 patients (92%) had chronic hepatitis (128 had F1 disease, 138 had F2 disease, and 121 had F3 disease) and 32 (8%) had cirrhosis. In the control group, 124 patients (86%) had chronic hepatitis (30 had F1 disease, 38 had F2 disease, and 56 had F3 disease) and 20 (14%) had cirrhosis (P = 0.005). The proportion of patients with serum -fetoprotein levels greater than 20 ng/mL was higher in the control group (24%) than in the interferon group (15%) (P = 0.011). Table 1. Baseline Characteristics of Interferon-Treated Patients and Historical Controls with Chronic Hepatitis C In the interferon group, 151 patients (36%) had sustained response, 120 (29%) had relapse, and 148 (35%) were nonresponders. In the 143 patients with sustained response, serum HCV RNA was measured during follow-up. Sustained absence of serum HCV RNA was noted in 120 (84%) of these patients. Twenty-one patients could not complete the 6-month treatment protocol because of depression (5 patients), severe general fatigue (4 patients), skin eruptions (2 patients), severe reduction of serum platelet count (1 patient), pulmonary tuberculosis (1 patient), interstitial pneumonia (1 patient), severe nausea (1 patient), ischemic colitis (1 patient), cardiomyopathy (1 patient), hyperthyroidism (1 patient), and hypermenorrhea (1 patient). One patient stopped treatment because of his business, and one patient discontinued treatment after 3 months because hepatocellular carcinoma was diagnosed. Only 1 of the 21 patients who did not complete treatment showed sustained response; all others were nonresponders. Median follow-up was 47.6 months (range, 3.3 to 65.2 months) in the interferon group and 46.8 months (range, 6.9 to 71.6 months) in the control group. During follow-up, hepatocellular carcinoma was found in 19 controls (4 with F2 disease, 8 with F3 disease, and 7 with F4 disease). In the interferon group, 28 patients developed hepatocellular carcinoma during follow-up (2 patients with F1 disease, 5 with F2 disease, 13 with F3 disease, and 8 with F4 disease). A final diagnosis of hepatocellular carcinoma was made histologically in 17 patients in the interferon group (61%) and 11 controls (58%). In 11 patients (39%) in the interferon group and 8 controls (42%), a final diagnosis was made on the basis of typical angiographic findings. The maximum tumor sizes of hepatocellular carcinoma in the interferon and control groups at the time of discovery on ultrasonography or computed tomography were 20 mm (range, 10 to 52 mm) and 24 mm (range, 10 to 50 mm), respectively (P > 0.2). Figure 1 shows the cumulative incidence of hepatocellular carcinoma in the interferon and control groups, estimated by using the Kaplan-Meier method. The 4-year rate of hepatocellular carcinoma incidence was 6.6% in the interferon group and 12.2% in the control group (log-rank test, P = 0.040). Figure 1. Cumulative incidence of hepatocellular carcinoma (HCC) in interferon-treated patients (dotted line) and historical controls (solid line) with chronic hepatitis C. P Cox proportional-hazards regression analysis was performed to identify factors co

Effect of pravastatin on survival in patients with advanced hepatocellular carcinoma. A randomized controlled trial

Chemotherapy is not effective for hepatocellular carcinoma (HCC). HMG-CoA redutase inhibitors have cytostatic activity for cancer cells, but their clinical usefulness is unknown. To investigate whether pravastatin, a potent HMG-CoA reductase inhibitor, prolongs survival in patients with advanced HCC, this randomized controlled trial was conducted between February 1990 and February 1998 at Osaka University Hospital. 91 consecutive patients <71 years old (mean age 62) with unresectable HCC were enroled in this study. 8 patients were withdrawn because of progressive liver dysfunction; 83 patients were randomized to standard treatment with or without pravastatin. All patients underwent transcatheter arterial embolization (TAE) followed by oral 5-FU 200 mg–1d for 2 months. Patients were then randomly assigned to control (n = 42) and pravastatin (n = 41) groups. Pravastatin was administered at a daily dose of 40 mg. The effect of pravastatin on tumour growth was assessed by ultrasonography. Primary endpoint was death due to progression of HCC. The duration of pravastatin administration was 16.5 ± 9.8 months (mean ± SD). No patients in either group were lost to follow-up. Median survival was 18 months in the pravastatin group versus 9 months in controls (P = 0.006). The Cox proportional hazards model showed that pravastatin was a significant factor contributing to survival. Pravastatin prolonged the survival of patients with advanced HCC, suggesting its value for adjuvant treatment.

Changes in hepatic functional reserve after transcatheter embolization of hepatocellular carcinoma Assessment by maximal removal rate of indocyanine green

To clarify the influence of transcatheter arterial embolization (TAE) on hepatic function, the maximal removal rate of indocyanine green (ICG-Rmax), which represents the hepatic functional reserve, and the plasma disappearance rate of indocyanine green (k-ICG) were measured serially before and after 15 TAE procedures performed on 13 hepatocellular carcinoma (HCC) patients with underlying hepatic diseases. Compared to the values before TAE, ICG-Rmax values did not change or gradually decreased during 4 weeks in seven of the 13 patients but markedly decreased in the remaining six by as much as 50% during the first week. k-ICG values remained almost unchanged at any time after TAE. Albumin and prothrombin time were serially measured before and after 24 TAE procedures performed on 21 HCC patients with underlying hepatic diseases in whom no plasma products had been used for therapy. Albumin decreased by up to 75% in one of the 21 patients during the first week but did not change or gradually decreased in 20 of the 21 patients. Prothrombin time showed no obvious changes. This study showed that prominent changes occurred in ICG-Rmax, i.e., in the hepatic functional reserve, after TAE.

Hepatic conversion of 1-(tetrahydro-2-furanyl)-5-fluorouracil into 5-fluorouracil in patients with hepatocellular carcinoma

SummaryThe pharmacokinetics of l-(tetrahydro-2-furanyl)-5-fluorouracil (FT) and its conversion into 5-fluorouracil (FUra) in liver tissue were studied in ten patients with hepatocellular carcinoma (HCC). The plasma concentration of FT after its intravenous injection (dosage: 800 mg) was computerfitted to a biexponential function (C= Ae-αt Be-βt), indicating a two-compartment disposition. The pharmacokinetic parameters did not significantly differ between the five patients with, and the five without cirrhosis of the liver. The plasma concentrations of FUra likewise showed no significant difference between the two groups.The rates of FT degradation in the liver tissue homogenate were similar for four of the patients with cirrhosis (0.10 ± 0.05 μmol/g liver protein/30 min) and four of those without it (0.13 ±0.05). The rates of cytochrome P-450-dependent FUra formation in the microsomal fraction of liver tissue from two patients (1.1 and 1.3 nmol/mg microsomal protein/30 min) were dramatically reduced to less than half of those of two control subjects (2.4 and 2.7). The estimated rates of FUra formation in the soluble fraction (105,000 × g supernatant fraction) from the two patients (0.1 and 0.13 nmol/mg protein/30 min) were almost identical to those from the controls (0.12 and 0.14), suggesting that the rate in the soluble fraction from HCC patients may not be as strongly affected as the rate in the microsomal fraction. The soluble fraction-catalyzed rates per gram of liver protein in the two patients (58 and 67 nmol/g liver protein/30 min) were approximately twice the microsomal fraction-catalyzed rates (28.1 and 34.0), while the former rates in the controls (73 and 76) were very similar to the latter (72.5 and 84.9). These findings suggest that the soluble fraction accounts for a major portion of the capacity for converting FT to FUra in the liver of HCC patients.

Clinical evaluation of biosynthetic glucagon treatment for recovery from hypoglycemia developed in diabetic patients

Biosynthetic glucagon (GL-G) produced by recombinant DNA technology with transformed yeast strains is already available for clinical use. We studied the effects of 1 mg GL-G injection on plasma glucose level and hypoglycemic symptoms in 38 diabetic patients treated with insulin or oral hypoglycemic agents during spontaneous hypoglycemic episodes. In both intramuscularly and intravenously administered GL-G groups, plasma glucose significantly increased from 58.1 +/- 11.4 to 113.2 +/- 6.9 mg/dl (i.m., n = 17, P < 0.01) and from 76.4 +/- 4.4 to 125.7 +/- 5.9 mg/dl (i.v., n = 15, P < 0.01), respectively 20 min after the administration and the symptoms due to hypoglycemia subsided promptly after the injection of GL-G in 27 cases. The hyperglycemic effect of intramuscularly injected GL-G was more potent and long-standing than when intravenously injected, particularly in insulin-dependent diabetic (IDDM) patients. Neither significant changes of antibody levels against yeast proteins nor serious adverse effects were observed after GL-G administration. Biosynthetic glucagon is safe and useful for the treatment of hypoglycemia developing in diabetic patients.

Effect of high doses of synthetic estrogen on lipid metabolism in castrated male rats

The mechanism by which high doses of estrogen influences lipid metabolism was studied with a microtubular blocking agent. Castrated male rats received oral injection daily for 14 days of 3 mg hexestrol in olive oil, or oil alone as controls. About half of the animals in each group were injected intraperitoneally with 4 mg/100 g body weight colchicine 3 hr before they were killed. Hexestrol treatment caused an accumulation of esterified cholesterol in the liver while it decreased those in serum. Triglyceride concentrations slightly decreased in the liver but were unaffected in serum. On polyacrylamide-gel disc electrophoresis, the peaks of high density lipoproteins (HDL) and low density lipoproteins (LDL) were decreased remarkably. Electron microsopic examination of hepatocytes revealed electron-lucent lipid droplets in the cytoplasm.After a colchicine treatment of the control animals, concentrations of esterified cholesterol and triglycerides markedly increased in the liver, while those in serum decreased. Electron microscopic examination of hepatocytes revealed numerous secretory vesicles filled with nascent VLDL. In hexestrol-treated animals, the colchicine treatment was associated with marked decreases in serumesterified cholesterol and triglyceride as seen in the controls. However, there were no further increases of esterified cholesterol in the liver, and the increase of triglycerides was slight. Electron microscopic examination showed less secretory droplets than in the controls.These data suggest that very low density lipoproteins (VLDL) synthesis in the liver of hexestrol treated rats was inhibited. An accumulation of esterified cholesterol with a marked decrease in serum could not be accounted for by the inhibition of lipoproteins secretion, but rather by their enhanced entry into the liver.

Interaction of famotidine with rat liver microsomes, a study showing less inhibition of drug metabolism than with cimetidine

Interaction of famotidine with rat liver microsomes and its effect on drug metabolism in vitro were studied. Famotidine interacted with liver microsomes obtained from untreated, phenobarbital-pretreated and 3-methylcholanthrene-pretreated rats to produce characteristic type II spectral changes with peaks at 423-426 nm and troughs at 387-390 nm. The spectral dissociation constants were in the range of 0.84-0.94 mM. Famotidine inhibited aminopyrine N-demethylase activity to a much lesser extent than did cimetidine. The extent of inhibition at a concentration of 5 mM of famotidine was from 12 to 18% for the microsomes from the rats with different pretreatments. In contrast, 5 mM of cimetidine inhibited the activity 80, 59 and 80% in the microsomes from untreated, phenobarbital-pretreated and 3-methylcholanthrene-pretreated rats, respectively. Both famotidine and cimetidine inhibited aminopyrine N-demethylase in a mixed-type manner for the microsomes from phenobarbital-pretreated rats, with inhibition constants of 4.7 and 0.7 mM, respectively. These results demonstrate that famotidine is an in vitro inhibitor of microsomal drug metabolism in rats but is much less inhibitory than cimetidine.

Antipyrine clearance per unit liver volume in cirrhotics with and without hepatocellular carcinoma indicating a correlation with histological change of the liver

SummaryThe antipyrine metabolizing capacity was studied in 12 patients with cirrhosis of the liver and 12 with cirrhosis and hepatocellular carcinoma (HCC). Antipyrine clearance (Cl) and liver volume (LV) were measured and the antipyrine clearance per unit liver volume (Cl/LV) was calculated. The patients with HCC showed a significantly lower Cl value than those without HCC but there was no significant difference in Cl/LV between the two groups. This suggested that the lower Cl values in the HCC patients resulted from a decrease in residual liver mass. Cl/LV showed positive correlation with % parenchymal cell mass as an indicator of residual parenchymal cell mass per unit volume of liver. This result showed a correlation of Cl/LV with histological change of the liver in cirrhotics.

A patient with severe autoimmune hepatitis of acute onset negative for Anti-nuclear antibody but positive for anti-smooth muscle antibody.

急性重症型肝炎像にて発症した抗核抗体 (ANA) 陰性, 抗平滑筋抗体 (SMA) 陽性の自己免疫性肝炎 (AIH) の一例を経験したので報告する. 79歳女性. 平成8年1月黄疸, 肝機能異常にて入院. 輸血歴, 飲酒歴なし. 内服薬のDLSTは陰性, 肝炎ウイルスマーカーは陰性であった. 入院一週間後, T-Bil 19.6mg/dl, PT49%と悪化し腹水も出現した. ANA陰性であったがSMA陽性よりAIHを考えステロイド療法を開始した. その後肝機能及び臨床症状の著明な改善を認めた. 肝生検は慢性肝炎活動型でAIHに合致していた. 本例は従来の厚生省の診断基準では合致し得ないが, 国際診断基準と, さらにその後改訂された厚生省の診断基準ではAIHに合致した. AIHの急性発症はまれとされ, 一旦劇症化すればその予後は極めて不良である. 本例は急性重症型を呈したが早期診断により治療し得た稀な一例と考え, 文献的考察を加え報告する.

A study on the distribution of 3-methylcholanthrene-inducible cytochrome P-450 within the hepatic lobulus of rats.

メチルコラントレン誘導性ラット肝チトクロームP-450(チトクロームP-450MC)に対する抗体を作製し,蛍光抗体間接法を用いてメチルコラントレン投与をうけたラットにおけるチトクロームP-450MCの経時的な肝小葉内誘導状態を観察した.またあわせて長期エタノール投与がチトクロームP-450MCにおよぼす影響についても同様に検討した.蛍光抗体間接法におけるチトクロームP-450MCに対する特異蛍光は非誘導ラット肝において肝細胞細胞質内に弱く認められ,その小葉内分布は小葉周辺域に比し中心域および中間帯でわずかに強い傾向を示した.メチルコラントレン20mg/kg体重の1回腹腔内投与後6, 12, 24, 48時間における特異蛍光の強さおよび小葉内分布の変化を検討した.特異蛍光の強さは時間が経るにつれ増強し,その分布はすべて均一であった.長期エタノール投与ラット肝と対照ラット肝の間に特異蛍光の強さおよび分布に差を認めなかった.