Decision Tree for the Performance of Intraoperative Liver Biopsy During Bariatric Surgery.

BACKGROUND AND AIMS: Bariatric surgery provides a useful opportunity to perform intraoperative liver biopsy to screen for non-alcoholic steatohepatitis (NASH). There is currently no consensus on whether intraoperative liver biopsy should be systematically performed. The aim of this study was to develop and validate a decision tree to guide that choice. APPROACH AND RESULTS: This prospective study included 102 consecutive patients from the severe obesity outcome network (SOON) cohort in whom liver biopsy was systematically performed during bariatric surgery. A classification and regression tree (CART) was created to identify the nodes that best classified patients with and without NASH. External validation was performed. Seventy-one biopsies were of sufficient quality for analysis (median body mass index 43.3 [40.7; 48.0] kg/m2). NASH was diagnosed in 32.4% of cases. None of the patients with no steatosis on ultrasound had NASH. The only CART node that differentiated between a "high-risk" and a "low-risk" of NASH was alanine aminotransferase (ALT). ALT>53IU/L predicted NASH with a positive predictive value (PPV) of 68% and a negative predictive value (NPP) of 89%, a sensitivity of 77%, and a specificity of 84%. In the external cohort (n=258), PPV was 68%, NPV was 62%, sensitivity was 27%, and specificity was 90%. CONCLUSIONS: The present work supports intraoperative liver biopsy to screen for NASH in patients with ALT>53IU/L; however, patients with no steatosis on ultrasound should not undergo biopsy. The CART failed to identify an algorithm with a good sensitivity to screen for NASH in patients with ultrasonography-proven steatosis and ALT≤53IU/L.

Diagnostic of hepatic fibrosis with the XL probe of the Fibroscan versus biopsies in patients candidates to bariatric surgery.

BACKGROUND AND AIMS: The risks of the histological evaluation for metabolic liver disease in severe obese subjects led to the development of the Fibroscan® device. The main objective of our study is to evaluate the diagnostic performance of XL probe for the measurement of hepatic fibrosis compared to histological examination, in obese subjects operated from bariatric surgery. METHODS: We included patients free from chronic liver diseases. Liver measurement and controlled attenuation parameter (CAP) were carried out using the Fibroscan®. Liver biopsies were performed during bariatric surgery and evaluated by two pathologists. Correlation between vibration-controlled transient elastography (VCTE) and fibrosis stage was assessed using the Kendall correlation coefficient. Diagnosis performance was assessed using receiver-operating-characteristic curve analysis together with its 95% confidence interval. Cut-off value maximizing the Youden index was computed together with specificity, sensitivity, positive and negative predictive values. RESULTS: The average age and body mass index were 41 years and 43 kg/m2, respectively (n = 108). Forty-one percent of patients presented fibrosis on the histological results. The Kendall correlation coefficient between fibrosis stage and liver stiffness measurement (LSM) was κ = 0.33, p<10-5. ROC analysis for the detection of fibrosis indicated the following values: 0.70 [0.60-0.79] for F≥1, 0.83 [0.72-0.92] for F≥2, 0.90 [0.83-0.97] for F≥3. Optimal cut-offs maximizing the Youden index were 7.0 kPa for F≥1, 8.1 kPa for F≥2 and 8.7 kPa for F≥3. CONCLUSION: Fibroscan® appears to be reliable for detection of significant and severe fibrosis in severe obese patients such as candidates for bariatric surgery. CLINICAL TRIAL NUMBER: NCT03548597.

Impact of controlled attenuation parameter on detecting fibrosis using liver stiffness measurement.

BACKGROUND: Liver fibrosis is often accompanied by steatosis, particularly in patients with non-alcoholic fatty liver disease (NAFLD), and its non-invasive characterisation is of utmost importance. Vibration-controlled transient elastography is the non-invasive method of choice; however, recent research suggests that steatosis may influence its diagnostic performance. Controlled Attenuation Parameter (CAP) added to transient elastography enables simultaneous assessment of steatosis and fibrosis. AIM: To determine how to use CAP in interpreting liver stiffness measurements. METHODS: This is a secondary analysis of data from an individual patient data meta-analysis on CAP. The main exclusion criteria for the current analysis were unknown aetiology, unreliable elastography measurement and data already used for the same research question. Aetiology-specific liver stiffness measurement cut-offs were determined and used to estimate positive and negative predictive values (PPV/NPV) with logistic regression as functions of CAP. RESULTS: Two thousand and fifty eight patients fulfilled the inclusion criteria (37% women, 18% NAFLD/NASH, 42% HBV, 40% HCV, 51% significant fibrosis ≥ F2). Youden optimised cut-offs were only sufficient for ruling out cirrhosis (NPV of 98%). With sensitivity and specificity-optimised cut-offs, NPV for ruling out significant fibrosis was moderate (70%) and could be improved slightly through consideration of CAP. PPV for significant fibrosis and cirrhosis were 68% and 55% respectively, despite specificity-optimised cut-offs for cirrhosis. CONCLUSIONS: Liver stiffness measurement values below aetiology-specific cut-offs are very useful for ruling out cirrhosis, and to a lesser extent for ruling out significant fibrosis. In the case of the latter, Controlled Attenuation Parameter can improve interpretation slightly. Even if cut-offs are very high, liver stiffness measurements are not very reliable for ruling in fibrosis or cirrhosis.

Circumferential margin involvement after total mesorectal excision for mid or low rectal cancer: are all R1 resections equal?

AIM: Our aim was to assess the prognostic influence of the circumferential resection margin (CRM) exact value after total mesorectal excision for mid or low rectal cancer. METHODS: All patients (n = 321) who underwent total mesorectal excision from 2005 to 2013 were identified from a prospective database, including 49 (15%) who presented with a CRM ≤ 1 mm. Four groups were defined: group 1, CRM = 0 mm (n = 21); group 2, 0 < CRM ≤ 0.4 mm (n = 13); group 3, 0.4 < CRM ≤ 1 mm (n = 15); group 4, CRM > 1 mm (n = 272). RESULTS: After a mean follow-up of 42 ± 26 months, locoregional recurrence rates were 8/21 (38%) in group 1, 3/13 (23%) in group 2, 0/12 (0%) in group 3 and 26/272 (10%) in group 4 (P < 0.001), leading to significantly impaired 3-year locoregional recurrence-free survival in group 1 (57% ± 13%) and group 2 (56% ± 15%) compared to group 3 (85% ± 10%, vs group 1, P = 0.021, vs group 2, P = 0.049) and to group 4 (89% ± 2%, vs group 1, P < 0.001, vs group 2, P < 0.001). In multivariate Cox analysis, a CRM ≤ 0.4 mm was identified as an independent factor impairing both locoregional recurrence-free survival (OR 3.14, 95% CI 1.53-6.46; P = 0.002) and disease-free survival (OR 2.15, 95% CI 1.28-3.63; P = 0.004). CONCLUSION: Our study suggests that the prognosis after mid or low rectal cancer surgery was worse with a CRM ≤ 0.4 mm. The prognosis was similar in patients with a CRM > 0.4 mm or ≤ 1 mm and patients with an R0 resection.

Diagnostic performance of FibroTest, SteatoTest and ActiTest in patients with NAFLD using the SAF score as histological reference.

BACKGROUND: Blood tests of liver injury are less well validated in non-alcoholic fatty liver disease (NAFLD) than in patients with chronic viral hepatitis. AIMS: To improve the validation of three blood tests used in NAFLD patients, FibroTest for fibrosis staging, SteatoTest for steatosis grading and ActiTest for inflammation activity grading. METHODS: We pre-included new NAFLD patients with biopsy and blood tests from a single-centre cohort (FibroFrance) and from the multicentre FLIP consortium. Contemporaneous biopsies were blindly assessed using the new steatosis, activity and fibrosis (SAF) score, which provides a reliable and reproducible diagnosis and grading/staging of the three elementary features of NAFLD (steatosis, inflammatory activity) and fibrosis with reduced interobserver variability. We used nonbinary-ROC (NonBinAUROC) as the main endpoint to prevent spectrum effect and multiple testing. RESULTS: A total of 600 patients with reliable tests and biopsies were included. The mean NonBinAUROCs (95% CI) of tests were all significant (P < 0.0001): 0.878 (0.864-0.892) for FibroTest and fibrosis stages, 0.846 (0.830-0.862) for ActiTest and activity grades, and 0.822 (0.804-0.840) for SteatoTest and steatosis grades. FibroTest had a higher NonBinAUROC than BARD (0.836; 0.820-0.852; P = 0.0001), FIB4 (0.845; 0.829-0.861; P = 0.007) but not significantly different than the NAFLD score (0.866; 0.850-0.882; P = 0.26). FibroTest had a significant difference in median values between adjacent stage F2 and stage F1 contrarily to BARD, FIB4 and NAFLD scores (Bonferroni test P < 0.05). CONCLUSIONS: In patients with NAFLD, SteatoTest, ActiTest and FibroTest are non-invasive tests that offer an alternative to biopsy, and they correlate with the simple grading/staging of the SAF scoring system across the three elementary features of NAFLD: steatosis, inflammatory activity and fibrosis.

MGMT expression predicts response to temozolomide in pancreatic neuroendocrine tumors.

Temozolomide (TEM) showed encouraging results in well-differentiated pancreatic neuroendocrine tumors (WDPNETs). Low O(6)-methylguanine-DNA methyltransferase (MGMT) expression and MGMT promoter methylation within tumors correlate with a better outcome under TEM-based chemotherapy in glioblastoma. We aimed to assess whether MGMT expression and MGMT promoter methylation could help predict the efficacy of TEM-based chemotherapy in patients with WDPNET. Consecutive patients with progressive WDPNET and/or liver involvement over 50% who received TEM between 2006 and 2012 were retrospectively studied. Tumor response was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 guidelines. Nuclear expression of MGMT was assessed by immunochemistry (H-score, 0-300) and MGMT promoter methylation by pyrosequencing. Forty-three patients (21 men, 58years (27-84)) with grade 1 WDPNET (n=6) or 2 (n=36) were analyzed. Objective response, stable disease, and progression rates were seen in 17 patients (39.5%), 18 patients (41.9%), and 8 patients (18.6%), respectively. Low MGMT expression (≤50) was associated with radiological objective response (P=0.04) and better progression-free survival (PFS) (HR=0.35 (0.15-0.81), P=0.01). Disease control rate at 18months of treatment remained satisfying with an MGMT score up to 100 (74%) but dropped with a higher expression. High MGMT promoter methylation was associated with a low MGMT expression and longer PFS (HR=0.37 (0.29-1.08), P=0.05). Low MGMT score (≤50) appears to predict an objective tumor response, whereas an intermediate MGMT score (50-100) seems to be associated with prolonged stable disease.

Comparison of liver biopsy and noninvasive techniques for liver fibrosis assessment in patients infected with HCV-genotype 4 in Egypt.

In Egypt, as elsewhere, liver biopsy (LB) remains the gold standard to assess liver fibrosis in chronic hepatitis C (CHC) and is required to decide whether a treatment should be proposed. Many of its disadvantages have led to develop noninvasive methods to replace LB. These new methods should be evaluated in Egypt, where circulating virus genotype 4 (G4), increased body mass index and co-infection with schistosomiasis may interfere with liver fibrosis assessment. Egyptian CHC-infected patients with G4 underwent a LB, an elastometry measurement (Fibroscan(©)), and serum markers (APRI, Fib4 and Fibrotest(©)). Patients had to have a LB ≥15 mm length or ≥10 portal tracts with two pathologists blinded readings to be included in the analysis. Patients with hepatitis B virus co-infection were excluded. Three hundred and twelve patients are reported. The performance of each technique for distinguishing F0F1 vs F2F3F4 was compared. The area under receiver operating characteristic curves was 0.70, 0.76, 0.71 and 0.75 for APRI, Fib-4, Fibrotest© and Fibroscan©, respectively (no influence of schistosomiasis was noticed). An algorithm using the Fib4 for identifying patients with F2 stage or more reduced by nearly 90% the number of liver biopsies. Our results demonstrated that noninvasive techniques were feasible in Egypt, for CHC G4-infected patients. Because of its validity and its easiness to perform, we believe that Fib4 may be used to assess the F2 threshold, which decides whether treatment should be proposed or delayed.

[Fundamental and translational research on hepatocellular carcinoma in 2008: forces and priorities]. / Recherche fondamentale et translationnelle sur le carcinome hépatocellulaire en 2008 : avancées récentes et perspectives.

Hepatocellular carcinogenesis is usually the result of a muti-step process. It begins with an exposure to various risk factors; followed by the development of a chronic hepatitis and cirrhosis that is a pre-neoplastic step; and finally after the occurrence of an hepatocellular carcinoma (HCC), different molecular events control aggressiveness of the tumors. The aim of this work was to identify in the international context, forces and priorities of the fundamental and translational HCC research.

[Epidemiology, prevention, screening and diagnosis of hepatocellular carcinoma]. / Epidémiologie, prévention, dépistage et diagnostic du carcinome hépatocellulaire.

Hepatocellular carcinoma (HCC) is the most frequent type of primary liver cancer and occurs mainly in patients with cirrhosis. This work aimed at reviewing the main data and trends about HCC epidemiology in France, and about prevention, screening and diagnosis in patients with chronic liver diseases. The six following research topics were considered as priorities: 1) to improve epidemiological knowledge of HCC in France; 2) to clarify the epidemiology of HCC occuring in normal liver and to identify predictive factors; 3) to prevent cancer occurrence in patients with cirrhosis; 4) to improve the knowledge of predictive factors for HCC occurrence in patients with cirrhosis; 5) to improve the diagnostic procedure of nodules below 2 cm in diameter in patients with cirrhosis; 6) to understand functioning of medical networks in order to identify the reasons for late diagnosis and treatment of HCC in patients with cirrhosis.

Serum proteomic profiling of obese patients: correlation with liver pathology and evolution after bariatric surgery.

OBJECTIVE: Chronic liver diseases, including cirrhosis, may develop in obese patients. Steatosis and non-alcoholic steatohepatitis (NASH) are risk factors for progression to fibrosis. To date, diagnosis of steatosis and NASH relies on liver biopsy. The aim of the study was to identify serum markers of steatosis and NASH in obese patients using SELDI-TOF ProteinChip. PATIENTS: Eighty obese non-alcoholic patient candidates for bariatric surgery and devoid of hepatitis B and C infection were selected. Serum samples were collected before surgery and at 6 months after surgery for 33 of these patients. Wedge liver biopsy was performed at the time of bariatric surgery. Twenty-four serum samples from healthy blood donors served as controls. The protein profiles of each serum were assessed using SELDI-TOF ProteinChip technology and were compared according to liver histological lesions. RESULTS: Twenty-four obese patients (30%) had non-significant liver lesions, 32 (40%) had significant steatosis and 24 (30%) had NASH. Comparison of serum protein profiles according to liver lesions identified three peaks (CM10-7558.4, CM10-7924.2 and Q10-7926.9) the intensity of which significantly increased according to the severity of the liver lesions (steatosis and NASH) and returned to normal after bariatric surgery. None was correlated with either liver function tests or metabolic parameters. Identification using immunoSELDI assay characterised these peaks as the double charged ions of alpha- and beta-haemoglobin subunits. CONCLUSION: The differential proteomic method demonstrated changes in serum protein profiles in obese patients according to severity of liver lesions. Free haemoglobin subunits may serve as a serum biomarker of the severity of liver damages.

Gene expression and hepatitis C virus infection.

Hepatitis C virus (HCV) is a major cause of chronic liver disease, with about 170 million people infected worldwide. Up to 70% of patients will have persistent infection after inoculation, making this disease a significant cause of morbidity and mortality. The severity of disease varies widely, from asymptomatic chronic infection to cirrhosis and hepatocellular carcinoma. Since the discovery of HCV, the treatment of hepatitis C has considerably improved. Recently, combination of pegylated interferons with ribavirin gives a response rate of about 55%. Treatment is indicated in patients with moderate or severe fibrosis. The tolerability of combination treatment is relatively poor, with a frequent flu-like syndrome and an impaired quality of life. In addition to viral and environmental behavioural factors, host genetic diversity is believed to contribute to the spectrum of clinical outcomes in HCV infection. The sequencing of the human genome, together with the development of high-throughput technologies that measure the function of the genome, have afforded unique opportunities to develop profiles that can distinguish, identify and classify discrete subsets of disease, predict the disease outcome or predict the response to treatment. This paper reviews the published literature on gene expression associated with HCV infection (HCV infection, fibrosis progression), and also according to response to treatment.

Liver biopsy.

Fibrosis, the excess deposition of extracellular matrix in the liver is a form of anatomical damage to the liver parenchyma, so that liver biopsy is the only approach for its direct assessment. Although liver biopsy has its limitations, appropriate precautions can reduce the flaws inherent in this method. The level of accuracy obtained with biopsy is particularly important for obtaining a starting point in patients with chronic liver disease who are to be followed-up over a number of years. Therefore, liver biopsy has been used as the gold standard to establish algorithm combinations of biological tests. As well as an accurate assessment of the extent of liver fibrosis, the biopsy can reveal other informations and associated features relevant to evaluation of the fibrotic process.

[Hepatitis C, cirrhosis and hepatocellular carcinoma]. / Hépatite C, cirrhose et carcinome hépatocellulaire.

The screening for the detection of hepatocellular carcinoma is based on ultrasound sonography which should be realised in patients with post-hepatitis C cirrhosis with a delay between 3 and 6 months according to the most identified risk factors, in particular age and sex male. In the case of discovery of hypoechogen nodule < or = 1cm, a follow-up is mandatory because it is usually untypical by ultrasound sonography and to propose a liver biopsy in the case of an increasing in size is shown. The ultrasound guided cutting biopsy can precise the histological characteristics of the nodule, the grade, and indicate prognostic factors. The liver biopsy is also mandatory in the case of a nodule > 2 cm and when the ultrasound sonography is not contributive, especially when the nodule is between 1 and 2 cm in size.

Definition and natural history of metabolic steatosis: histology and cellular aspects.

In patients with diabetes and metabolic syndrome, liver changes may be observed on histology that are characterized as non-alcoholic fatty liver disease (NAFLD). The NAFLD spectrum covers a variety of histological features, including steatosis, necroinflammation and fibrosis. Although steatosis usually follows a benign course, steatohepatitis is prone to progress to fibrosis and cirrhosis. Establishing the degree of severity of liver lesions, the main endpoint of the disease, can identify patients at risk of disease progression. This may be achieved by liver biopsy. For that purpose, a scoring system for both activity (grade) and fibrosis (stage) is available with good reproducibility. In addition to the commonly seen histopathological patterns of lesions, additional changes are reported in patients with diabetes, including glycogenic hepatopathy and hepatic hepatosclerosis.

Diagnostic value of serum protein profiling by SELDI-TOF ProteinChip compared with a biochemical marker, FibroTest, for the diagnosis of advanced fibrosis in patients with chronic hepatitis C.

BACKGROUND: FibroTest has been validated for the diagnosis of liver fibrosis in patients with chronic hepatitis C. AIM: To compare FibroTest with a new proteome-based model for the prediction of advanced liver fibrosis. METHODS: Sera from 191 consecutive patients with simultaneous liver biopsy and FibroTest on fresh sera were used for retrospective mass spectrometry analysis. A new fibrosis index was constructed combining proteomic peaks, selected on differential expression according to fibrosis stages in logistic regression analyses. The main end point was the diagnosis of advanced fibrosis on liver biopsy. RESULTS: Eight out of 1000 peaks were selected for the construction of the proteomic index. The area under the receiver operating curve (AUROC) of the proteomic index was 0.88 (95% CI: 0.82-0.92), significantly greater than the FibroTest AUROC of 0.81 (95% CI: 0.74-0.86; P = 0.04); the AUROC of the proteomic and FibroTest combination was 0.88 (95% CI: 0.83-0.92). Seven of the eight selected peaks were highly associated with the FibroTest score, with different patterns of association with the five components of FibroTest. CONCLUSIONS: A proteomic index combining eight peaks had an excellent accuracy value for the diagnosis of advanced fibrosis in patients with chronic hepatitis C. However, despite a statistical significance, the small improvement delivered by proteomics impairs clinical applications because of its cost and its variability compared with the well validated FibroTest.

Human pancreatic mucinous cystadenoma is characterized by distinct mucin, cytokeratin and CD10 expression compared with intraductal papillary-mucinous adenoma.

AIMS: To examine cytokeratin, epithelial glycoprotein (mucin) and glycoprotein CD10 expression in benign mucinous cystdenomas (MCAs) in comparison with intraductal papillary mucinous adenomas (IPMAs). METHODS AND RESULTS: Thirty MCAs of the pancreas were analysed for immunohistochemical expression of cytokeratin (CK) 7, CK20, MUC1, MUC2, MUC5AC and CD10 and were compared with 16 IPMAs. CK7 was expressed in all neoplasms. CK20 was significantly more frequent in MCAs compared with IPMAs (56.66% versus 18.75%, P = 0.027). MUC1 was more frequent in MCAs (40% versus 12.5%, P = 0.0915), whereas MUC5AC was significantly less frequent in MCAs (33.33% versus 100%). MUC2 was expressed in goblet cells of seven MCAs. In MCAs, CD10 was observed both in epithelial cells and in the ovarian-type stromal cells (24/30). Epithelial expression of CD10 was significantly lower in IPMAs (66.66% versus 6.25%, p = 0.0001). CONCLUSIONS: MCA is characterized by a significantly greater frequency of expression of CK20 and CD10 when compared with IPMA, which preferentially expresses MUC5AC.