A canine case of Ehrlichia canis infection without a history of being in an endemic area in Japan.

A mixed-breed, 8-year-old male dog developed neutropenia, thrombocytopenia, and hyperglobulinemia. Bone marrow hyperplasia and splenic plasmacytosis were cytologically observed. The dog had never been outside of Tokyo or Shizuoka Prefecture. Splenectomy was performed to confirm and remove the cause of splenic plasmacytosis. A histopathological diagnosis of splenic plasmacytoma was made; however, serum protein electrophoresis showed polyclonal gammopathy. Further screening was performed, and Ehrlichia canis infection was confirmed. The dog was treated with doxycycline for 5 weeks. After the antibiotic therapy, no relapse of neutropenia, thrombocytopenia, hyperglobulinemia, or positive polymerase chain reaction result of E. canis infection was observed for 3 years. Careful attention should be given to ehrlichiosis when exploring the cause of pancytopenia or hyperglobulinemia, regardless of the travel history.

Large granular lymphocyte lymphoma in the skin and urinary bladder of a dog.

A 10-year-old female Cavalier King Charles Spaniel presented with hematuria, pollakiuria and skin rash. Based on the histopathological and cytological examination of the skin and bladder mucosa, the dog was diagnosed with large granular lymphocytic (LGL) lymphoma of the bladder and skin. The dog responded well to the initial chemotherapy with nimustine for 3 months. Since recurrence of skin erosion and bladder wall thickening were observed, the dog was subsequently administered chemotherapy with other anticancer drugs, including chlorambucil, vincristine, doxorubicin, L-asparaginase, cytosine arabinoside, and cyclophosphamide. The dog survived for 11 months and died due to tumor-related disseminated intravascular coagulation. This is the first report of a canine case of LGL lymphoma in the skin and bladder.

Case Report: 1-Year Follow-Up of Vagus Nerve Stimulation in a Dog With Drug-Resistant Epilepsy.

A vagus nerve stimulation (VNS) system was surgically implanted to treat drug-resistant epilepsy in a 5-year-old male Shetland Sheepdog. At regular visits during a 1-year follow-up, treatment efficacy and adverse effects were assessed, and programmable stimulation parameters were adjusted to optimize stimulation intensity while avoiding adverse effects. The frequency of generalized tonic-clonic seizures was reduced by 87% after the initiation of VNS. The owner reported that the dog regained his personality, and the quality of life of both the dog and owner improved. The only adverse effect of VNS was a cough that was controlled by adjusting stimulation parameters. There were no surgical complications or other issues with the VNS device. This is the first long-term evaluation of VNS therapy in a dog, and the results obtained suggest that gradual adjustments of VNS parameters facilitate optimum VNS dosing.

Three-dimensional spheroid culture of canine hepatocyte-like cells derived from bone marrow mesenchymal stem cells.

INTRODUCTION: Primary cultured hepatocytes are an important model for early safety evaluations of newly developed drugs. Many factors, however, hinder the wider applications of this technology, especially the difficulty to maintain these cells in long-term culture. To date, creating a stable supply of human or animal hepatocytes with proper hepatic function in vitro has not been achieved. Furthermore, frequently harvesting hepatocytes from living donors for use in culture is highly invasive and simply not feasible. We have previously reported that canine bone marrow-derived mesenchymal stem cells (cBMSCs) can be effectively converted into induced hepatocyte-like cells (iHep cells); however, these cells had reduced function in comparison to mature hepatocytes. In recent studies, spheroid formation-based three-dimensional (3D) culture has been noted to greatly increase hepatocyte function; nevertheless, no reports have described the use of this technology for culturing canine hepatocytes. Therefore, in this study, we aimed to establish a 3D spheroid culture using converted canine iHep cells to investigate their function as hepatocytes. METHODS: The iHep cells were prepared by introducing two genes, namely, the Forkhead box A1 (Foxa1) and hepatocyte nuclear factor 4 homeobox alpha (Hnf4α), into cBMSCs seeded onto an ultra-low attachment microplate to induce spheroid formation. Thereafter, the hepatic functions of these spheroids were evaluated using immunocytochemistry, as well as qualitative and quantitative PCR. RESULTS: Notably, albumin was observed in the iHep spheroids and the expression of hepatic genes, such as albumin and drug metabolism CYP genes, could also be detected. Another interesting finding was evident upon further comparing the quantified albumin gene and CYP2E1 gene expressions in the two-dimensional and three-dimensional culture systems; notably, a 100- to 200-fold increase in gene expression levels was observed in the three-dimensional spheroids when compared to those in conventional monolayers. CONCLUSIONS: Upon incorporating three-dimensional technology, we managed to achieve iHep spheroids that are closer in gene expression to living liver tissue compared to conventional monolayer cultures. Thus, we are one step closer to creating a sustainable in vitro hepatocyte model. Furthermore, we believe that this system is capable of maintaining the stable drug metabolizing capacity of canine hepatocytes in vitro, which might be useful in improving current drug assessment studies.

Distribution of regulatory T cells in inflammatory colorectal polyps of miniature dachshunds.

Inflammatory colorectal polyp (ICRP) is an emerging disease in Miniature Dachshunds (MDs). Animals with this disease exhibit multiple polyps with severe neutrophil infiltration that respond to immunosuppressive therapy. Macrophages in polypoid lesions have been described to play an important role in neutrophil infiltration in the lesion by producing IL-8. In contrast, IL-10, an anti-inflammatory cytokine, was also reported to be upregulated in polypoid lesions, but its significance in the pathogenesis of ICRP has not been clarified. Regulatory T cells (Tregs) are the main source of IL-10 production and contribute to the maintenance of intestinal homeostasis. Therefore, the objective of this research was to compare the distribution of Tregs in polypoid lesions of ICRPs and the association between the distribution and expression of pro- or anti-inflammatory cytokines. Tissue biopsy specimens of polypoid lesions were collected from 28 MDs with ICRP. Those of macroscopically non-polypoid colonic mucosa from 24 MDs with ICRPs and 21 control dogs were further included as controls. Real-time quantitative polymerase chain reaction was used to quantify gene expression of IL-1ß, IL-4, IL-6, IL-8, IL-10, IL-17, IL-22, IFN-γ, TNF-α, TGF-ß, and forkhead box protein P3 (Foxp3) in each tissue sample. The numbers of Foxp3-positive cells (Tregs) and ionized calcium binding adapter molecule 1 (Iba-1)-positive cells (macrophages) were determined by immunohistochemistry. The gene expression of IL-1ß, IL-6, IL-8, TNF-α, IFN-γ, IL-17, IL-10, TGF-ß, and Foxp3 was significantly upregulated in polypoid lesions relative to control levels. The numbers of Foxp3-positive Tregs and Iba-1-positive macrophages were significantly increased in polypoid lesions compared to those in the non-polypoid colonic mucosa of MDs with ICRPs and control dogs. The upregulation of IL-10 was moderately correlated with the distribution of Tregs in polypoid lesions from MDs with ICRPs. In addition, the relative upregulation of IL-1ß, IL-6, and IL-8 in polypoid lesions, compared to expression in non-polypoid colonic mucosa of MDs with ICRPs, was significantly greater than that of IL-10. These results indicate that increases in Treg numbers and anti-inflammatory cytokines in polypoid lesions comprise reactive changes in response to the inflammation, which warrants further investigation.

Fecal microbiome in dogs with inflammatory bowel disease and intestinal lymphoma.

Although alteration of commensal microbiota is associated with chronic gastrointestinal (GI) diseases such as inflammatory bowel disease (IBD) in dogs, the microbiota composition in intestinal lymphoma, an important differential diagnosis of canine IBD, has not been investigated. The objective of this study was to compare the fecal microbiota in dogs with IBD, dogs with intestinal lymphoma, and healthy dogs. Eight dogs with IBD, eight dogs with intestinal lymphoma, and fifteen healthy dogs were included in the study. Fecal samples were analyzed by 16S rRNA gene next-generation sequencing. Rarefaction analysis failed to reveal any difference in bacterial diversity among healthy dogs and diseased dogs. Based on PCoA plots of unweighted UniFrac distances, the bacterial composition in dogs with intestinal lymphoma was different from those observed in dogs with IBD and healthy dogs. When compared with healthy dogs, intestinal lymphoma subjects showed significant increases in organisms belonging to the Eubacteriaceae family. The proportion of the family Paraprevotellaceae and the genus Porphyromonas was significantly higher in dogs with IBD compared to healthy dogs. These observations suggest that dysbiosis is associated with intestinal lymphoma as well as IBD in dogs.

Analysis of fecal short chain fatty acid concentration in miniature dachshunds with inflammatory colorectal polyps.

Short chain fatty acids (SCFAs) play an important role in the maintenance of colonic homeostasis, and their depletion has been reported in various gastrointestinal disorders. Inflammatory colorectal polyps (ICRPs) are a recently recognized disease specific to miniature dachshunds (MDs), and fecal dysbiosis with a reduction of SCFA-producing bacteria has been reported with this disease. Therefore, this study was performed based on the hypothesis that a reduced SCFA concentration associates with the development of ICRPs. We recruited 11 ICRP-affected MDs and 25 control MDs. Their fecal SCFA concentrations and bacterial proportions were quantified using high performance liquid chromatography and quantitative real-time PCR, respectively. The feces of ICRP-affected MDs contained lower amounts of propionic acid and lower proportions of Bifidobacterium than the feces of control MDs. Furthermore, fecal proportions of Bifidobacterium, Firmicutes and Lactobacillus exhibited significant positive correlations with fecal concentrations of total SCFAs and/or propionic acid; fecal Escherichia coli proportions correlated negatively with fecal concentrations of total SCFAs, as well as acetic, propionic and butyric acid. This result indicates an association between fecal dysbiosis and fecal SCFA concentrations; these phenomena may contribute to ICRP pathogenesis in MDs. Potential therapeutic targeting of the reduced propionic acid concentration using probiotics, prebiotics or SCFA enemas merits further study.

Fecal dysbiosis in miniature dachshunds with inflammatory colorectal polyps.

Chronic gastrointestinal disease is associated with the alteration of gastrointestinal microbiota. Inflammatory colorectal polyps (ICRPs) are commonly observed in miniature dachshunds (MDs) in Japan and are characterized by multiple polyps that are restricted in the colorectal mucosa with severe neutrophil infiltration. This study was aimed to compare the fecal microbiota of ICRP-affected MDs with that of healthy MDs. High-throughput sequencing of amplicons derived from the V3-V4 region of the 16S rRNA gene was applied using the Illumina MiSeq system. Principal coordinates analysis revealed that fecal microbiota of ICRP-affected MDs was significantly altered compared with that of healthy MDs. Proportions of Fusobacteriaceae, Helicobacteraceae, Porphyromonadaceae, and Turicibacteraceae were significantly more abundant in ICRP-affected MDs, while those of Lachnospiraceae were significantly less abundant in ICRP-affected MDs compared with healthy MDs. These results suggest that the dysbiosis is associated with ICRPs and is a potential therapeutic target, though further investigations are needed.

Regulation of p16 gene expression by histone H3 acetylation in canine lymphoid tumor cell lines.

In order to investigate whether suppression of the p16 gene is mediated by histone H3 acetylation in 4 canine lymphoid tumor cell lines, the gene's acetylation status was examined. In 2 canine lymphoid tumor cell lines with low p16 mRNA expression (GL-1 and UL-1), the acetylation level was lower than that in CL-1 cells with high p16 mRNA expression. The expression of the p16 gene in these 2 cell lines was markedly restored after culture in the presence of a histone deacetylase inhibitors trichostatin A, indicating that p16 was inactivated by hypoacetylation. Findings obtained this study will add new insights and lead to the better understanding of the disease pathogenesis and future development of epigenetic therapeutic strategies.

Efficacy of leflunomide for treatment of refractory inflammatory colorectal polyps in 15 Miniature Dachshunds.

Inflammatory colorectal polyp (ICRP), common in miniature dachshunds, presents with hematochezia, tenesmus and mucoid feces. Although an 80% response rate has been reported when treated with prednisolone and cyclosporine, effective treatment is needed for the remaining 20% of ICRP dogs. Leflunomide is an immunosuppressive drug reported as effective in several immune-mediated diseases. In the present study, we retrospectively evaluated the efficacy and adverse effects of leflunomide in 15 ICRP dogs that were refractory to treatment with prednisolone and cyclosporine. Treatment efficacy was assessed by endoscopy, clinical symptoms and rectal palpation. Adverse effects were determined by clinical symptoms and blood testing during follow-up. The leflunomide treatment response rate was 93.3%. The median dosage of leflunomide and the median response time were 3 mg/kg (range: 1.7-4.0 mg/kg) and 35 days (range: 20-119 days), respectively. Adverse effects observed included lethargy (3 dogs), anorexia (1 dog), respiratory symptoms (1 dog), leukocytopenia (2 dogs), thrombocytopenia (1 dog), anemia (1 dog) and liver enzyme elevation (8 dogs). Most of the adverse effects improved with symptomatic treatment and leflunomide discontinuation or dosage reduction. In conclusion, leflunomide treatment is effective in ICRP dogs refractory to treatment with prednisolone and cyclosporine. Because several adverse effects were observed, close monitoring is needed during leflunomide treatment follow-up.

Expression profile of circulating serum microRNAs in dogs with lymphoma.

Serum microRNAs (miRNAs) are mediators of cell-to-cell communication and alter the cellular microenvironment; they are stable for hours under certain conditions in body fluids despite the presence of RNases. Certain miRNAs have been found to be altered in the serum or plasma of humans with various cancers and may represent promising, non-invasive biomarkers for various diseases in humans and animals. The objective of this study was to determine the expression profile of circulating miRNAs in the serum of dogs with lymphoma. Serum samples were obtained from 61 dogs with lymphoma and 40 control dogs, and real-time reverse transcription-polymerase chain reaction was used for miRNA measurement. In order to select candidate genes, a comprehensive expression analysis was undertaken prior to validation of several candidate miRNAs. Of 277 miRNAs, five (let-7b, miR-223, miR-25, miR-92a, and miR-423a) were selected as candidates. The expression levels of four miRNAs (let-7b, miR-223, miR-25, miR-92a) were significantly reduced in the lymphoma group, whereas miR-423a levels were significantly increased compared to the controls. When the lymphoma cases were categorized into high- or low-grade as well as into their anatomic form, miR-25 levels were lower in the serum samples from the lymphoma group compared to those from the control group. Although the biological function of serum miRNAs still remains unclear, determining their functional roles in serum and tissues will contribute not only to the identification of potential biomarkers but also to the elucidation of the pathogenesis of canine lymphoma.

Polymorphisms of nucleotide-binding oligomerization domain 2 (NOD2) gene in miniature dachshunds with inflammatory colorectal polyps.

Inflammatory colorectal polyps (ICRPs) frequently occur in miniature dachshunds (MDs) in Japan, typically form multiple polyps with severe neutrophil infiltration. ICRPs are speculated as a novel, breed-specific canine inflammatory bowel disease. Pattern recognition receptors (PRRs) play an important role in the differentiation of pathogens from commensal bacteria and food antigens, and polymorphisms of various PRRs have been shown to be associated with human and canine IBD. We recently reported that the reactivity of nucleotide-binding oligomerization domain 2 (NOD2), toll-like receptor (TLR) 1/2, TLR2, and TLR2/6 are greater in ICRP-affected MDs than that in controls. Therefore, this study was aimed to investigate single nucleotide polymorphisms (SNPs) of PRRs associated with ICRPs in MDs. Mutational analysis of canine NOD2, TLR1, TLR2, and TLR6 genes was performed with six ICRP-affected MDs, five control MDs, and five healthy beagles. The mutational analysis identified 13 non-synonymous SNPs in NOD2, TLR1, TLR2, and TLR6 genes, of which six SNPs in NOD2 exon 3 were further analyzed in an association study using 63 ICRP-affected MDs, 82 control MDs, and 237 control dogs of various breeds. Four of the SNPs (A1532G, T1573C, C1688G, and G1880A of the NOD2 gene) were in Hardy-Weinberg equilibrium and in complete linkage disequilibrium in MDs, and their minor allele frequencies were significantly lower in ICRP-affected MDs than in control MDs (0.016 vs. 0.140, P=0.0002). The calculated inheritance model was an additive model (odds ratio=0.10, 95% confidence interval=0.02-0.45, P=0.0001), which indicates that the haplotype with minor alleles in these SNPs (A, T, C, and G in A1532G, T1573C, C1688G, and G1880A) possess a protective effect regarding the development of ICRPs. However, these SNPs were not specific for MDs, although the minor allele frequencies of these SNPs in control MDs were significantly lower than in other breed dogs. These results suggest that the identified four SNPs (A1532G, T1573C, C1688G, and G1880A in the NOD2 gene) may play a role in the pathogenesis of ICRPs in MDs. Because the majority of MDs and other breed dogs do not have the protective alleles, their absence may not be a specific cause of ICRPs in MDs but rather contribute to the development of inflammation.

Functional analysis of pattern recognition receptors in miniature dachshunds with inflammatory colorectal polyps.

Inflammatory colorectal polyps (ICRPs) frequently occur in miniature dachshunds (MDs) in Japan. MDs with ICRPs develop multiple polyps with severe neutrophil infiltration that respond to immunosuppressive therapy. Therefore, ICRPs are thought to constitute a novel, breed-specific form of canine inflammatory bowel disease (IBD). Pattern recognition receptors (PRRs) play a key role in the distinction of pathogens from commensal bacteria and food antigens. Dysfunction resulting from genetic disorders of PRRs have been linked to human and canine IBD. Therefore, we analyzed the reactivity of PRRs in MDs with ICRPs. Twenty-six MDs with ICRPs and 16 control MDs were recruited. Peripheral blood-derived monocytes were obtained from each dog and then stimulated with PRR ligands for 6 and 24 hr; subsequently, messenger RNA (mRNA) expression levels and protein secretion of IL-1ß were quantified using quantitative real-time PCR and ELISA, respectively. The levels of IL-1ß mRNA and protein secretion after stimulation with a nucleotide-binding oligomerization domain 2 (NOD2) ligand were significantly greater in monocytes from ICRP-affected MDs than in those from control MDs. In addition, IL-1ß protein secretion induced by toll-like receptor (TLR) 1/2, TLR2 and TLR2/6 stimulation was also significantly greater in ICRP-affected MDs. These results suggest that reactivity against NOD2, TLR1/2, TLR2 and TLR2/6 signals is enhanced in ICRP-affected MDs and may play a role in the pathogenesis of ICRPs in MDs. Additional studies of the genetic background of these PRRs should be performed.

Inflammatory colorectal polyps in miniature Dachshunds frequently develop ventrally in the colorectal mucosa.

This study explored the hypothesis that inflammatory colorectal polyps (ICRPs) in miniature Dachshunds are more likely to occur ventrally in the colorectum. Angle-fixed colonoscopic images were collected from 11 miniature Dachshunds with ICRPs and randomly rotated. Macroscopic severity at 12 divided angles was scored by four veterinarians blinded to the rotation angle. Mean prevalence and severity scores of ICRPs were significantly higher ventrally than dorsally (P < 0.01).

Expression profiling of pattern recognition receptors and selected cytokines in miniature dachshunds with inflammatory colorectal polyps.

Inflammatory colorectal polyps (ICRPs) are commonly seen in miniature dachshund (MD) dogs; typically, multiple polyps form with severe neutrophil infiltration. ICRP is thought to be a novel form of inflammatory bowel disease (IBD), but its etiology has not been investigated. The innate immune system is implicated in the pathogenesis of both human and canine IBD. Therefore, the aim of the current study was to evaluate the messenger RNA (mRNA) expression profiles of pattern recognition receptors (PRRs) and cytokines in ICRPs. Polyp tissues were collected by colonoscopic biopsies from 24 MDs with ICRPs. Non-polypoid colonic mucosa was collected from all MDs with ICRPs and 21 clinically healthy beagles (as the controls). The expression levels of the mRNAs encoding toll-like receptors (TLRs) 1-10; nucleotide-binding oligomerization domain (NOD)-like receptors NOD1 and NOD2; and cytokines IL-1ß, IL-6, IL-8/CXCL8, and TNF-α were evaluated by quantitative real-time RT-PCR. Three of the 10 well-known candidate reference genes were selected as housekeeper genes based on analyses from the GeNorm, NormFinder, and BestKeeper programs. Levels of TLR1, TLR2, TLR4, TLR6, TLR7, TLR8, TLR9, TLR10, NOD2, and all cytokines were significantly upregulated in the polyps relative to those in the controls. There was significant decrease in the expression levels of TLR3 and NOD1 in the polyp tissues compared to the non-polypoid colonic mucosa obtained from MDs with ICRPs. All upregulated PRR mRNAs were positively correlated with all proinflammatory cytokine mRNAs. This study demonstrated the dysregulation of PRRs and proinflammatory cytokines in ICRPs of MDs, which may play an important role in the pathogenesis of this disease.

Prognostic significance of the expression levels of the p16, p15, and p14 genes in dogs with high-grade lymphoma.

The prognostic significance of the inactivation of the p16, p15, and p14 genes has been reported in lymphoid malignancies in humans. To evaluate the relationship between inactivation of the p16, p15, and p14 genes and prognosis in canine high-grade lymphoma, primary tumor cell samples obtained from 71 dogs with high-grade lymphoma were examined for the expression levels of these genes. Quantitative and conventional reverse transcriptase-polymerase chain reaction (RT-PCR) analyses were used to measure the amounts of p16, p15, and p14 mRNAs. The methylation status of the CpG island of the p16 gene was evaluated using methylation-specific PCR. Overall survival (OS) was compared using the Kaplan-Meier method. The log-rank test and Cox proportional hazard model were used to evaluate factors that influenced OS. Of 62 dogs examined, p16, p15, and p14 mRNA levels were found to be undetectable in 21, 18, and 10 dogs, respectively. In 20/68 dogs analyzed, the CpG island of the p16 gene was shown to be methylated. The prognostic significance of inactivation of the p16, p15, and p14 genes as well as various conventional factors obtained from medical records was examined. p16 expression status and anatomic form/immunophenotype were found to correlate with OS in the dogs with high-grade lymphoma. p16 mRNA level over its cut-off value correlated with a poor prognosis; however, the expression levels of p15 and p14 mRNAs and p16 methylation status did not influence the prognosis in dogs with high-grade lymphoma.

Polypoid adenomas secondary to inflammatory colorectal polyps in 2 miniature dachshunds.

Two miniature dachshunds, a 7-year-old neutered male and an 8-year-old male, presented with chronic hematochezia and tenesmus. A solitary pedunculated or multiple diffuse colorectal polyps were identified by colonoscopy and resected by polypectomy. Inflammatory colorectal polyps (ICRPs) were diagnosed according to histopathological findings. Both cases were treated with immunosuppressive therapy, and the clinical signs were resolved, although the colorectal polyps remained to some extent. Several months after the initial diagnosis, both cases presented with recurrence of hematochezia and enlargement of the polyps. A second colonoscopic polypectomy was performed, and adenoma was diagnosed histopathologically in both cases. ICRPs are a nonneoplastic disease, but their long-term prognosis is unknown. Careful follow-up seems to be important, and repetitive biopsy is recommended when growth of polyps is identified in miniature dachshunds with ICRPs.

Studies on the correlation among the fucosylation index, concentration of alpha-fetoprotein and des-gamma-carboxy prothrombin as prognostic indicators in hepatocellular carcinoma.

Our previous results showed that the fucosylation index (FI) was considered to be a useful prognostic factor in patients with hepatocellular carcinoma (HCC). On the other hand, serum concentrations of alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) were regarded as prognostic indicators. However, the relationship among FI, AFP, and DCP as prognostic factors remained unknown. The aim of this study was to elucidate the correlation among these three prognostic factors. One hundred and seventy-six patients with HCC from 1990 to 1998, who showed increment of serum AFP concentrations more than 30ng/ml before treatment, were examined in the present study. FI was determined in these patients by crossed immunoaffino-electrophoresis in the presence of Lens culinaris agglutinin. FI of AFP was defined as the percentage of the L. culinaris agglutinin (LCA)-reactive species in total AFP (same as L3 fraction). Serum concentrations of DCP were also measured. Enrolled patients with HCC underwent transcatheter arterial embolization, chemoembolization, percutaneous ethanol injection, and/or percutaneous microwave coagulation therapy. The current patients status was the one which was confirmed at the end of March 2001. Analysis by the Cox's proportional hazards model showed that FI, AFP, and DCP were significant prognostic factors. When the tentative demarcation levels of FI, AFP, and DCP were set at 18%, 200ng/ml, and 0.06arbitrary units (AU)/ml, respectively, the following results for the prognostication of patients with HCC were obtained. First, the survival rates in the groups with one out of the three optional markers over the demarcation level were significantly lower than the survival rates of other groups, whose optional one marker was equal to or less than the demarcation level, respectively. Next, the survival rates in the groups in which two out of three optional markers were over the demarcation levels were lower than the survival rates of other groups, whose optional two markers were equal to or less than the demarcation levels, with high significance. On the contrary, there was absence or attenuation of statistically significant differences in the survival rates between the groups in which two of the three optional markers showed no accordant results (high FI and low AFP versus low FI and high AFP, low FI and high DCP versus high FI and low DCP, high DCP and low AFP versus low DCP and high AFP). Finally, we compared the survival rates between the HCC groups, whose optional one marker was over the demarcation level and whose remainders were equal to or less than the demarcation levels and another HCC group whose optional one marker was equal to or less than the demarcation level and whose remainders were over the demarcation levels to reconfirm the weight of each prognostic factor. These comparisons together with Cox's analysis showed that the weight of each prognostic factor in the survival rates is consecutively ordered as DCP, FI, and AFP. The present study indicates that measurements of FI, AFP, and DCP from the sera before the initial treatment improve prognostic estimates and appraisal of the therapeutic outcome in patients with HCC.