Yukihiko Matsuda

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.

Serum-manganese-superoxide dismutase: normal values and increased levels in patients with acute myocardial infarction and several malignant diseases determined by an enzyme-linked immunosorbent assay using a monoclonal antibody

An enzyme-linked immunosorbent assay (ELISA) has been developed for human manganese-superoxide dismutase (Mn-SOD), using a specific monoclonal antibody raised against the purified enzyme. The Mn-SOD molecule comprises four identical sub-units and this permitted the development of a symmetrical assay, using the same monoclonal antibody as both capture and detector. The assay offers a specific, sensitive and convenient means of measuring immunoreactive Mn-SOD in human sera. Under optimum conditions, the sensitivity of the assay permits the detection of 2-200 ng of purified Mn-SOD from human liver. The mean serum Mn-SOD levels of normal healthy males and females were 99.8 +/- 24.8 (mean +/- SD) and 88.8 +/- 20.8 (mean +/- SD), respectively. A high level of the enzyme was found in the sera of patients with acute myocardial infarction as well as malignant diseases such as acute myeloid leukemia, primary hepatoma and gastric cancer. This is the first report of an ELISA using a monoclonal antibody specific for a distinct epitope of Mn-SOD.

Inhibition of cell growth of human hepatoma cell line (HepG2) by a farnesyl protein transferase inhibitor: A preferential suppression of ras farnesylation

So far, treatment with anti‐cancer agents has failed to achieve satisfactory results in hepatocellular carcinoma. In the process of hepatocarcinogenesis, ras has been shown to play a role, ras requires a farnesyl moiety for activation. It has been found that UCFI‐C (manumycin), an antibiotic, inhibits farnesyl protein transferase, an enzyme that catalyzes farnesylation. Therefore, we investigated the effects of UCFI‐C on cell growth, prenylation of cellular proteins including ras and Rap I, MAP kinase activity, activities of 3‐hydroxy‐3‐methylglutaryl‐coenzyme A reductase, and synthesis of cholesterol in a ras‐activated human hepatoma cell line, Hep G2. Treatment with varying concentrations of UCFI‐C (10–30 μM) for 24 and 72 hr resulted in a time· and dose‐dependent inhibition of cell numbers. 3H‐Thymidine incorporation was also inhibited in a dose‐dependent manner, with 50% inhibition after 44 hr being observed at a concentration of 17 μM. UCFI‐C dose‐dependently inhibited ras farnesylation and MAP kinase activity, but did not decrease Rap I geranylgeranylation or prenylation of 21‐ to 26‐kDa proteins. Neither the activities of 3‐hydroxy‐3‐methylglutaryl‐coenzyme A reductase nor cholesterol synthesis were inhibited. These results suggest that UCFI‐C antagonizes the growth of Hep G2 via the suppression of ras farnesylation and could be a lead for the development of new anti‐cancer agents blocking the function of oncogenic ras associated with human cancer, including hepatocellular carcinoma.

Papillary-cystic neoplasm of the pancreas with multiple hepatic metastases: A case report

SummaryWe report a case of papillary-cystic neoplasm (PCN) of the pancreas in a 42-yr-old woman. Because of complication with multiple hepatic metastases, the patient could not receive radical operation, and was treated palliatively. The right hepatic tumors decreased in volume by an average of 28% (range: 13–54%) following intra-arterial infusion of doxorubicin and gelatine sponge—i.e. chemoembolization therapy. On the other hand, the left lobe tumor increased by 15% in volume following intra-arterial infusion of doxorubicin alone without selective embolization. A subsequent systemic combination chemotherapy (combinations of 5-fluorouracil, doxorubicin and mitomycin-C) was less effective for both the primary and metastatic sites of PCN of the pancreas. Intra-arterial chemoembolization proved useful—as expected—as a palliative measure.Papillary-cystic neoplasm of the pancreas accompanied by hepatic metastasis is very rare. We present herein its clinical behavior and response to the above treatment as documented by CT scan.

Manumycin and gliotoxin derivative KT7595 block Ras farnesylation and cell growth but do not disturb lamin farnesylation and localization in human tumour cells.

Recently, many inhibitors of farnesyl protein transferase (FPTase) have been identified. Some of them interrupt cell growth in addition to Ras and nuclear lamin processing of Ras-transformed cells. We have tested the effect of the FPTase inhibitors manumycin, an analogue of farnesyl diphosphate, and KT7595, a gliotoxin derivative, on Ras farnesylation, DNA synthesis and the anchorage-dependent and -independent growth of human colon carcinoma (LoVo), hepatoma (Mahlavu and PLC/PRF/5) and gastric carcinoma (KATO III). Both drugs severely inhibited DNA synthesis, cellular proliferation and Ras farnesylation in LoVo and moderately reduced them in Mahlavu and PLC/PRF/5 but not in KATO III. Complete sequencing of ras genes, however, revealed that LoVo and KATO III have activated Ki-ras and activated N-ras, respectively, whereas Mahlavu and PLC/PRF/5 have no activated ras. We next checked whether the inhibition of the cellular proliferation is due to the blocking of nuclear lamin function. Neither drug disturbed lamin farnesylation and localization, as demonstrated using metabolic labelling, immunoblotting and indirect immunofluorescence. These results indicate that manumycin and KT7595 can inhibit Ras farnesylation and cell growth without disturbing the farnesylation and localization of the lamins on human tumour cell lines.

High Concentration of Glucose Increases Mitogenic Responsiveness to Heparin-Binding Epidermal Growth Factor–like Growth Factor in Rat Vascular Smooth Muscle Cells

The effect of a high extracellular glucose concentration on the mitogenic response of rat vascular smooth muscle cells (SMCs) to heparin-binding epidermal growth factor-like growth factor (HB-EGF) was investigated. The mitogenic effect of HB-EGF was significantly greater in SMCs cultured in high glucose (25 mmol/L) than in cells cultured in low glucose (5.5 mmol/L) or at high osmolarity (5.5 mmol/L glucose plus 19.5 mmol/L mannitol). The mitogenic effect of epidermal growth factor (EGF), which shares the EGF receptor with HB-EGF, was not affected by glucose concentration. The mitogenic effect of HB-EGF was greater when incubated with heparan sulfate (HS) isolated from SMCs cultured in high glucose than with HS from cells cultured in low glucose. HS synthesized by cells in high glucose was of smaller molecular size and less sulfated than HS synthesized by cells in low glucose. The abundance of mRNA encoding HS-N-deacetylase/N-sulfotransferase (HS-NdAc/NST), a regulatory enzyme in the biosynthesis of HS, was decreased by high glucose in a protein kinase C-independent manner. These observations suggest that the enhanced mitogenic response to HB-EGF in SMCs cultured in high glucose may be attributable to changes in cell-associated HS. Downregulation of HS-NdAc/NST gene expression by high glucose may be related to the altered HS biosynthesis.

Interleukin‐6 in transcatheter arterial embolization for patients with hepatocellular carcinoma. Effects of serine protease inhibitor

Background. Modulation of serum levels of circulating cytokines and inflammatory responses with a serine protease inhibitor was studied in 34 patients with hepatocellular carcinoma (HCC) after transcatheter arterial embolization (TAE).

Increased Mitogenic Response to Heparin-Binding Epidermal Growth Factor–like Growth Factor in Vascular Smooth Muscle Cells of Diabetic Rats

We investigated the mitogenic effects of heparin-binding epidermal growth factor-like growth factor (HB-EGF) in vascular smooth muscle cells (SMCs) obtained from rats with streptozotocin (STZ)-induced diabetes and evaluated the role of heparan sulfate proteoglycan (HSPG) in inducing these effects. HB-EGF significantly increased DNA synthesis in the SMCs of diabetic rats (STZ-SMCs) compared with control rats (control SMCs). However, the mitogenic effects of EGF, which shares EGF receptors with HB-EGF, and basic fibroblast growth factor, another heparin-binding growth factor, were similar in STZ-SMCs and control SMCs. The mitogenic response to HB-EGF in SMCs of insulin-treated diabetic rats was similar to the response in control SMCs. HB-EGF-induced autophosphorylation of EGF receptors was increased in STZ-SMCs compared with control SMCs, although the number of EGF receptors in STZ-SMCs was 40% of that in controls. This increased mitogenic response to HB-EGF in STZ-SMCs was completely inhibited by treatment with heparitinase, chlorate, and a synthetic peptide corresponding to the heparin-binding domain of HB-EGF. Compared with heparan sulfate isolated from control SMCs, heparan sulfate isolated from STZ-SMCs was of smaller molecular size and caused a greater mitogenic effect of HB-EGF. These findings suggest that the mitogenic response to HB-EGF is increased in SMCs of diabetic rats. Changes in cell-associated heparan sulfate in STZ-SMCs may be related to the increased mitogenic response to HB-EGF.

Transforming growth factor-β1-induced degradation of activated Src tyrosine kinase in rat fibroblasts

Transforming growth factors-beta (TGF-βs) play pivotal roles in the regulation of cell growth and differentiation, although little is known regarding the regulation of cytoplasmic components by TGF-βs. Src tyrosine kinase is required for signal transduction of various cytokine receptors, including epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and G-protein coupled receptors. Moreover, Src tyrosine kinase is important in signal cross-talk between these receptors. To determine whether Src kinase is also involved in TGF-β signaling, we examined the effects of TGF-β1 on Src in the rat fibroblast cell line 3Y1 and in v-Src-transformed 3Y1 (SR-3Y1). TGF-β1 inhibited mitogen-activated protein kinase activity and inhibited growth in SR-3Y1 cells, while it did not affect the growth of 3Y1 cells. TGF-β1 significantly decreased v-Src kinase activity and protein abundance in SR-3Y1 cells, mainly by accelerating the degradation of v-Src. In contrast, in 3Y1 cells, TGF-β1 did not affect c-Src abundance or kinase activity. However, upon activation of c-Src in 3Y1 cells by PDGF, TGF-β1 decreased Src abundance. Additionally, in 3Y1 cells transfected with an activated c-Src mutant which lacks the SH3 domain, its level was decreased by TGF-β1 treatment. These findings suggest that TGF-β1 specifically induces degradation of activated Src kinase. This may be a novel mechanism for cross-talk between growth factors and TGF-β.