Acoustic radiation force impulse predicts long-term outcomes in a large-scale cohort: High liver cancer, low comorbidity in hepatitis B virus.

BACKGROUND: Acoustic radiation force impulse (ARFI) is used to measure liver fibrosis and predict outcomes. The performance of elastography in assessment of fibrosis is poorer in hepatitis B virus (HBV) than in other etiologies of chronic liver disease. AIM: To evaluate the performance of ARFI in long-term outcome prediction among different etiologies of chronic liver disease. METHODS: Consecutive patients who received an ARFI study between 2011 and 2018 were enrolled. After excluding dual infection, alcoholism, autoimmune hepatitis, and others with incomplete data, this retrospective cohort were divided into hepatitis B (HBV, n = 1064), hepatitis C (HCV, n = 507), and non-HBV, non-HCV (NBNC, n = 391) groups. The indexed cases were linked to cancer registration (1987-2020) and national mortality databases. The differences in morbidity and mortality among the groups were analyzed. RESULTS: At the enrollment, the HBV group showed more males (77.5%), a higher prevalence of pre-diagnosed hepatocellular carcinoma (HCC), and a lower prevalence of comorbidities than the other groups (P < 0.001). The HCV group was older and had a lower platelet count and higher ARFI score than the other groups (P < 0.001). The NBNC group showed a higher body mass index and platelet count, a higher prevalence of pre-diagnosed non-HCC cancers (P < 0.001), especially breast cancer, and a lower prevalence of cirrhosis. Male gender, ARFI score, and HBV were independent predictors of HCC. The 5-year risk of HCC was 5.9% and 9.8% for those ARFI-graded with severe fibrosis and cirrhosis. ARFI alone had an area under the receiver operating characteristic curve (AUROC) of 0.742 for prediction of HCC in 5 years. AUROC increased to 0.828 after adding etiology, gender, age, and platelet score. No difference was found in mortality rate among the groups. CONCLUSION: The HBV group showed a higher prevalence of HCC but lower comorbidity that made mortality similar among the groups. Those patients with ARFI-graded severe fibrosis or cirrhosis should receive regular surveillance.

Comparing Predictability of Non-invasive Tools for Hepatocellular Carcinoma in Treated Chronic Hepatitis C Patients.

BACKGROUND: Non-invasive tools including liver stiffness measurement (LSM) or FIB-4, assessed before or after direct acting antivirals (DAA), have been suggested to predict hepatocellular carcinoma (HCC). AIMS: This study aims to compare predictability of HCC by these methods at different time points, to validate the HCC surveillance suggestion by guidelines, and to propose personalized strategy. METHODS: Chronic hepatitis C whose LSM and FIB-4 were available at pretherapy and after sustained virological response (SVR) were enrolled. Advanced chronic liver disease (ACLD) was defined as pretherapy LSM ≥ 10 kPa or FIB-4 index ≥ 3.25 or ultrasound signs of cirrhosis plus platelet count < 150,000/µL. The predictabilities were compared by area under ROC. The cumulative HCC incidences were calculated by Kaplan-Meier analysis. RESULTS: Among 466 ACLD patients, 40 patients developed HCC during a follow-up duration of 26.8 months. Comparable predictive performances for HCC between LSM and FIB-4 at pretherapy and SVR were noted. By guidelines suggestion using pretherapy LSM = 10 kPa (advanced fibrosis) and 13 kPa (cirrhosis) for risk stratification, the annual HCC incidences of those with LSM of < 10, 10-12.9 and ≥ 13 kPa were 1.1, 3.6, and 5.0%, respectively. Combination of baseline LSM < 12 kPa and SVR FIB-4 < 3.7 could further stratify relatively low risk of HCC in ACLD patients of annal incidence of 1.2%. CONCLUSIONS: ACLD patients who met advanced fibrosis but not cirrhosis by guidelines' cut-offs still posed high risk of HCC. Baseline LSM with SVR FIB-4 can be applied to stratify low, intermediate, and high risk of HCC for personalizing surveillance strategies after SVR.

Hepatitis B Co-Infection Has Limited Impact on Liver Stiffness Regression in Chronic Hepatitis C Patients Treated with Direct-Acting Antivirals.

Introduction: High sustained virological response (SVR) rate (>95%) and liver stiffness regression can be achieved with direct acting antivirals treatment (DAA) in patients with chronic hepatitis C virus (CHC) infection. Reactivation of hepatitis B virus (HBV) was reported during DAA treatment in patients co-infected with HBV, although its impact on liver stiffness remains unknown. This study aims to investigate whether the liver stiffness (LSM) regression is different between HBV/HCV co-infected and mono-HCV-infected patients. Materials and Methods: CHC patients with/without HBV co-infection who received DAA treatment and achieved SVR12 between March 2015 and December 2019 in Chang Gung Memorial Hospital, Linkou branch were prospectively enrolled. LSM was assessed by transient elastography (TE, Fibroscan) at baseline and after SVR. Propensity score matching (PSM) at 3:1 ratio, adjusted for age, gender, pre-DAA alanine aminotransferase (ALT), platelet count, and LSM, between CHC with and without HBV co-infection, was performed before further analysis. Results: Among 906 CHC patients enrolled, 52 (5.7%) patients had HBV/HCV co-infection. Patients with HBV/HCV co-infection were of younger age (61.8 vs. 63.2, p = 0.31), with a higher proportion of males (53.8% vs. 38.9%, p = 0.03), and lower pretreatment LSM level (8.15 vs. 10.2 kPa, p = 0.09), while other features were comparable. After PSM, patients with HBV/HCV co-infection had insignificantly lower LSM regression compared to mono-HCV-infected patients (−0.85 kPa vs. −1.65 kPa, p = 0.250). Conclusions: The co-infection of HBV among CHC patients has limited impact on liver stiffness regression after successful DAA treatment.

Hepatitis B virus persistent infection-related single nucleotide polymorphisms in HLA regions are associated with viral load in hepatoma families.

BACKGROUND: Genome-wide association studies from Asia indicate that HLA-DP and HLA-DQ loci are important in persistent hepatitis B virus (HBV) infections. One of the key elements for HBV-related carcinogenesis is persistent viral replication and inflammation. AIM: To examine genetic and nongenetic factors with persistent HBV infection and viral load in families with hepatocellular carcinoma (HCC). METHODS: The HCC families included 301 hepatitis B surface antigen (HBsAg) carriers and 424 noncarriers born before the nationwide vaccination program was initiated in 1984. Five HBV-related single nucleotide polymorphisms (SNPs) - rs477515, rs9272105, rs9276370, rs7756516, and rs9277535 - were genotyped. Factors associated with persistent HBV infection and viral load were analyzed by a generalized estimating equation. RESULTS: In the first-stage persistent HBV study, all SNPs except rs9272105 were associated with persistent infection. A significantly higher area under the reciprocal operating characteristic curve for nongenetic factors vs genetic factors (P < 0.001) suggests that the former play a major role in persistent HBV infection. In the second-stage viral load study, we added 8 HBsAg carriers born after 1984. The 309 HBsAg carriers were divided into low (n = 162) and high viral load (n = 147) groups with an HBV DNA cutoff of 105 cps/mL. Sex, relationship to the index case, rs477515, rs9272105, and rs7756516 were associated with viral load. Based on the receiver operating characteristic curve analysis, genetic and nongenetic factors affected viral load equally in the HCC family cohort (P = 0.3117). CONCLUSION: In these east Asian adults, the mechanism of persistent HBV infection-related SNPs was a prolonged viral replication phase.

Cutoff Values of Acoustic Radiation Force Impulse Two-Location Measurements in Different Etiologies of Liver Fibrosis.

BACKGROUND: Acoustic radiation force impulse (ARFI) imaging is a popular modality to measure liver fibrosis. ARFI selects optimal locations for measurement under imaging guiding. However, there are concerns on study locations and observers bias. To decrease the variations, ARFI at two locations was measured with standardized protocol. This study attempted to establish its cutoff values according to Metavir fibrosis score in different etiologies. METHODS: A consecutive series of patients who received liver histology study were prospectively enrolled. All cases had hemogram, liver biochemistry, viral markers, and ARFI two-location measurements within 4 weeks of histology study. A standardized protocol was performed by single technologist. We excluded patients with alanine aminotransferase >5x upper limit normal. RESULTS: Five hundred and ten patients that included 153 seronegative for both HBsAg and anti-HCV Non-B non-C (NBNC), 33 autoimmune liver diseases (AILD), 261 chronic hepatitis B (CHB), and 63 chronic hepatitis C (CHC) were enrolled. About 83% of NBNC patients had fat cell >5%. For diagnosis of liver cirrhosis, the area under receiver operating characteristic curve of NBNC, AILD, CHB, and CHC groups was 0.937, 0.929, 0.784, and 0.937; the cutoff values for mean ARFI were 1.788, 2.095, 1.455, and 1.710 m/s, respectively. The sensitivity and specificity are both over 0.818 for patients with nonalcoholic fatty liver diseases, CHC, and AILD, but the corresponding data are only 0.727-0.756 in CHB. The Fibrosis-4 Score is as good as ARFI on fibrosis assessment in NBNC. CONCLUSION: The performance of ARFI two-location measurement is excellent in NBNC, AILD, and CHC, but is only satisfactory in CHB.

Hepatic steatosis assessment using ultrasound homodyned-K parametric imaging: the effects of estimators.

BACKGROUND: The homodyned-K (HK) distribution is an important statistical model for describing ultrasound backscatter envelope statistics. HK parametric imaging has shown potential for characterizing hepatic steatosis. However, the feasibility of HK parametric imaging in assessing human hepatic steatosis in vivo remains unclear. METHODS: In this paper, ultrasound HK µ parametric imaging was proposed for assessing human hepatic steatosis in vivo. Two recent estimators for the HK model, RSK (the level-curve method that uses the signal-to-noise ratio (SNR), skewness, and kurtosis based on the fractional moments of the envelope) and XU (the estimation method based on the first moment of the intensity and two log-moments, namely X- and U-statistics), were investigated. Liver donors (n=72) and patients (n=204) were recruited to evaluate hepatic fat fractions (HFFs) using magnetic resonance spectroscopy and to evaluate the stages of fatty liver disease (normal, mild, moderate, and severe) using liver biopsy with histopathology. Livers were scanned using a 3-MHz ultrasound to construct µ RSK and µ XU images to correlate with HFF analyses and fatty liver stages. The µ RSK and µ XU parametric images were constructed using the sliding window technique with the window side length (WSL) =1-9 pulse lengths (PLs). The diagnostic values of the µ RSK and µ XU parametric imaging methods were evaluated using receiver operating characteristic (ROC) curves. RESULTS: For the 72 participants in Group A, the µ RSK parametric imaging with WSL =2-9 PLs exhibited similar correlation with log10(HFF), and the µ RSK parametric imaging with WSL = 3 PLs had the highest correlation with log10(HFF) (r=0.592); the µ XU parametric imaging with WSL =1-9 PLs exhibited similar correlation with log10(HFF), and the µ XU parametric imaging with WSL =1 PL had the highest correlation with log10(HFF) (r=0.628). For the 204 patients in Group B, the areas under the ROC (AUROCs) obtained using µ RSK for fatty stages ≥ mild (AUROC1), ≥ moderate (AUROC2), and ≥ severe (AUROC3) were (AUROC1, AUROC2, AUROC3) = (0.56, 0.57, 0.53), (0.68, 0.72, 0.75), (0.73, 0.78, 0.80), (0.74, 0.77, 0.79), (0.74, 0.78, 0.79), (0.75, 0.80, 0.82), (0.74, 0.77, 0.83), (0.74, 0.78, 0.84) and (0.73, 0.76, 0.83) for WSL =1, 2, 3, 4, 5, 6, 7, 8 and 9 PLs, respectively. The AUROCs obtained using µ XU for fatty stages ≥ mild, ≥ moderate, and ≥ severe were (AUROC1, AUROC2, AUROC3) = (0.75, 0.83, 0.81), (0.74, 0.80, 0.80), (0.76, 0.82, 0.82), (0.74, 0.80, 0.84), (0.76, 0.80, 0.83), (0.75, 0.80, 0.84), (0.75, 0.79, 0.85), (0.75, 0.80, 0.85) and (0.73, 0.77, 0.83) for WSL = 1, 2, 3, 4, 5, 6, 7, 8 and 9 PLs, respectively. CONCLUSIONS: Both the µ RSK and µ XU parametric images are feasible for evaluating human hepatic steatosis. The WSL exhibits little impact on the diagnosing performance of the µ RSK and µ XU parametric imaging. The µ XU parametric imaging provided improved performance compared to the µ RSK parametric imaging in characterizing human hepatic steatosis in vivo.

Mutations in NOTCH1 and nucleotide excision repair genes are correlated with prognosis of hepatitis B virus-associated hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer-related mortality because of its poor prognosis. Therefore, identifying targetable genetic mutations and mutational signatures associated with prognosis and treatment strategies are needed. Ultra-deep sequencing of 409 cancer genes using formalin-fixed paraffin-embedded tissue from 33 male patients with hepatitis B virus-associated HCC was performed to identify mutational signatures associated with the prognosis of HCC. A total of 47 genes were found to be mutated in more than 10% of patients. Chromatin remodeling genes were overrepresented in the mutation profile. We found patient survival was associated with mutations in NOTCH1 and the nucleotide excision repair genes which have not been described previously in HCC. From the mutation profile, six patients were eligible for Sorafenib treatment. Among the remaining patients, 7 patients had mutations in genes that are targets for other cancer drugs and 16 patients had mutations in potentially targetable genes. Only one patient carried no potential drug target. We identified mutational signatures associated with the patient survival of HCC. The findings may facilitate identifying subgroups of patients with a poor prognosis as well as potential drug targets for use in personalized strategies for HCC treatment.

Hepatic Steatosis Assessment with Ultrasound Small-Window Entropy Imaging.

Nonalcoholic fatty liver disease is a type of hepatic steatosis that is not only associated with critical metabolic risk factors but can also result in advanced liver diseases. Ultrasound parametric imaging, which is based on statistical models, assesses fatty liver changes, using quantitative visualization of hepatic-steatosis-caused variations in the statistical properties of backscattered signals. One constraint with using statistical models in ultrasound imaging is that ultrasound data must conform to the distribution employed. Small-window entropy imaging was recently proposed as a non-model-based parametric imaging technique with physical meanings of backscattered statistics. In this study, we explored the feasibility of using small-window entropy imaging in the assessment of fatty liver disease and evaluated its performance through comparisons with parametric imaging based on the Nakagami distribution model (currently the most frequently used statistical model). Liver donors (n = 53) and patients (n = 142) were recruited to evaluate hepatic fat fractions (HFFs), using magnetic resonance spectroscopy and to evaluate the stages of fatty liver disease (normal, mild, moderate and severe), using liver biopsy with histopathology. Livers were scanned using a 3-MHz ultrasound to construct B-mode, small-window entropy and Nakagami images to correlate with HFF analyses and fatty liver stages. The diagnostic values of the imaging methods were evaluated using receiver operating characteristic curves. The results demonstrated that the entropy value obtained using small-window entropy imaging correlated well with log10(HFF), with a correlation coefficient r = 0.74, which was higher than those obtained for the B-scan and Nakagami images. Moreover, small-window entropy imaging also resulted in the highest area under the receiver operating characteristic curve (0.80 for stages equal to or more severe than mild; 0.90 for equal to or more severe than moderate; 0.89 for severe), which indicated that non-model-based entropy imaging-using the small-window technique-performs more favorably than other techniques in fatty liver assessment.

Effects of sex and generation on hepatitis B viral load in families with hepatocellular carcinoma.

AIM: To explore factors associated with persistent hepatitis B virus (HBV) infection in a cohort of hepatocellular carcinoma (HCC)-affected families and then investigate factors that correlate with individual viral load among hepatitis B surface antigen (HBsAg)-positive relatives. METHODS: We evaluated non-genetic factors associated with HBV replication in relatives of patients with HCC. Relatives of 355 HCC cases were interviewed using a structured questionnaire. Demographics, relationship to index case, HBsAg status of mothers and index cases were evaluated for association with the HBV persistent infection or viral load by generalized estimating equation analysis. RESULTS: Among 729 relatives enrolled, parent generation (P = 0.0076), index generation (P = 0.0044), mothers positive for HBsAg (P = 0.0007), and HBsAg-positive index cases (P = 5.98 × 10-8) were associated with persistent HBV infection. Factors associated with HBV viral load were evaluated among 303 HBsAg-positive relatives. Parent generation (P = 0.0359) and sex (P = 0.0007) were independent factors associated with HBV viral load. The intra-family HBV viral load was evaluated in families clustered with HBsAg-positive siblings. An intra-family trend of similar HBV viral load was found for 27 of 46 (58.7%) families. Male offspring of HBsAg-positive mothers (P = 0.024) and older siblings were associated with high viral load. CONCLUSION: Sex and generation play important roles on HBV viral load. Maternal birth age and nutritional changes could be the reasons of viral load difference between generations.

A global perspective on hepatitis B-related single nucleotide polymorphisms and evolution during human migration.

Genome-wide association studies have indicated that human leukocyte antigen (HLA)-DP and HLA-DQ play roles in persistent hepatitis B virus (HBV) infection in Asia. To understand the evolution of HBV-related single nucleotide polymorphisms (SNPs) and to correlate these SNPs with chronic HBV infection among different populations, we conducted a global perspective study on hepatitis-related SNPs. We selected 12 HBV-related SNPs on the HLA locus and two HBV and three hepatitis C virus immune-related SNPs for analysis. Five nasopharyngeal carcinoma-related SNPs served as controls. All SNP data worldwide from 26 populations were downloaded from 1,000 genomes. We found a dramatic difference in the allele frequency in most of the HBV- and HLA-related SNPs in East Asia compared to the other continents. A sharp change in allele frequency in 8 of 12 SNPs was found between Bengali populations in Bangladesh and Chinese Dai populations in Xishuangbanna, China (P < 0.001); these areas represent the junction of South and East Asia. For the immune-related SNPs, significant changes were found after leaving Africa. Most of these genes shifted from higher expression genotypes in Africa to lower expression genotypes in either Europe or South Asia (P < 0.001). During this two-stage adaptation, immunity adjusted toward a weak immune response, which could have been a survival strategy during human migration to East Asia. The prevalence of chronic HBV infection in Africa is as high as in Asia; however, the HBV-related SNP genotypes are not present in Africa, and so the genetic mechanism of chronic HBV infection in Africa needs further exploration. Conclusion: Two stages of genetic changes toward a weak immune response occurred when humans migrated out of Africa. These changes could be a survival strategy for avoiding cytokine storms and surviving in new environments. (Hepatology Communications 2017;1:1005-1013).

Acoustic structure quantification by using ultrasound Nakagami imaging for assessing liver fibrosis.

Acoustic structure quantification (ASQ) is a recently developed technique widely used for detecting liver fibrosis. Ultrasound Nakagami parametric imaging based on the Nakagami distribution has been widely used to model echo amplitude distribution for tissue characterization. We explored the feasibility of using ultrasound Nakagami imaging as a model-based ASQ technique for assessing liver fibrosis. Standard ultrasound examinations were performed on 19 healthy volunteers and 91 patients with chronic hepatitis B and C (n = 110). Liver biopsy and ultrasound Nakagami imaging analysis were conducted to compare the METAVIR score and Nakagami parameter. The diagnostic value of ultrasound Nakagami imaging was evaluated using receiver operating characteristic (ROC) curves. The Nakagami parameter obtained through ultrasound Nakagami imaging decreased with an increase in the METAVIR score (p < 0.0001), representing an increase in the extent of pre-Rayleigh statistics for echo amplitude distribution. The area under the ROC curve (AUROC) was 0.88 for the diagnosis of any degree of fibrosis (≥F1), whereas it was 0.84, 0.69, and 0.67 for ≥F2, ≥F3, and ≥F4, respectively. Ultrasound Nakagami imaging is a model-based ASQ technique that can be beneficial for the clinical diagnosis of early liver fibrosis.

Differences in liver fibrosis between patients with chronic hepatitis B and C: evaluation by acoustic radiation force impulse measurements at 2 locations.

OBJECTIVES: The purpose of this study was to evaluate liver fibrosis by acoustic radiation force impulse (ARFI) measurements at 2 locations in patients with chronic hepatitis B and C. METHODS: A total of 204 consecutive patients (146 male and 58 female) with chronic hepatitis B (n = 121) and C (n = 83) who underwent liver biopsy were enrolled. All patients received ARFI measurements at 2 locations in the right intercostal space on the same day as biopsy. RESULTS: There was no difference in median ARFI values between detection locations. However, a significant difference was found for low and high values between locations (median ± SD, 1.38 ± 0.43 versus 1.56 ± 0.55 m/s; P < .001). By receiver operating characteristic (ROC) curve analysis for a METAVIR fibrosis score of F4 (cirrhosis), the lower value of 2 measurements had the highest area under the ROC curve (0.750), followed by the mean value (0.744) and the higher value (0.730). Patients with hepatitis C had a higher area under the ROC curve than patients with hepatitis B (0.824 versus 0.707) for predicting liver cirrhosis. By logistic regression analysis, ARFI was the best modality for predicting liver cirrhosis in hepatitis C, and conventional sonography was the best modality in hepatitis B (P < .001). The ARFI value in patients with hepatitis B was significantly influenced by liver inflammation (P = .019). CONCLUSIONS: Acoustic radiation force impulse imaging is the modality of choice for predicting liver cirrhosis in chronic hepatitis C, whereas conventional sonography is still the modality of choice in chronic hepatitis B.

Thyroid hormone enhanced human hepatoma cell motility involves brain-specific serine protease 4 activation via ERK signaling.

BACKGROUND: The thyroid hormone, 3, 3', 5-triiodo-L-thyronine (T3), has been shown to modulate cellular processes via interactions with thyroid hormone receptors (TRs), but the secretory proteins that are regulated to exert these effects remain to be characterized. Brain-specific serine protease 4 (BSSP4), a member of the human serine protease family, participates in extracellular matrix remodeling. However, the physiological role and underlying mechanism of T3-mediated regulation of BSSP4 in hepatocellular carcinogenesis are yet to be established. METHODS: The thyroid hormone response element was identified by reporter and chromatin immunoprecipitation assays. The cell motility was analyzed via transwell and SCID mice. The BSSP4 expression in clinical specimens was examined by Western blot and quantitative reverse transcription polymerase chain reaction. RESULTS: Upregulation of BSSP4 at mRNA and protein levels after T3 stimulation is a time- and dose-dependent manner in hepatoma cell lines. Additionally, the regulatory region of the BSSP4 promoter stimulated by T3 was identified at positions -609/-594. BSSP4 overexpression enhanced tumor cell migration and invasion, both in vitro and in vivo. Subsequently, BSSP4-induced migration occurs through the ERK 1/2-C/EBPß-VEGF cascade, similar to that observed in HepG2-TRα1 and J7-TRα1 cells. BSSP4 was overexpressed in clinical hepatocellular carcinoma (HCC) patients, compared with normal subjects, and positively associated with TRα1 and VEGF to a significant extent. Importantly, a mild association between BSSP4 expression and distant metastasis was observed. CONCLUSIONS: Our findings collectively support a potential role of T3 in cancer cell progression through regulation of the BSSP4 protease via the ERK 1/2-C/EBPß-VEGF cascade. BSSP4 may thus be effectively utilized as a novel marker and anti-cancer therapeutic target in HCC.

New sarcomatoid cancer cell line SAR-HCV established from a hepatitis C virus-related liver tumour lesion.

A sarcomatoid carcinoma cell line (SAR-HCV) was established from a malignant liver lesion of a patient infected with hepatitis C virus. SAR-HCV cells were successfully xenografted in SCID mice. Vimentin was strongly positive in cultured SAR-HCV cells, the primary tumour lesion and the xenografts. Hepatocyte paraffin 1 protein and certain cytokeratin markers, CK8, CK18 and AE1/AE3 were not detected in cultured cells, but were focally positive in the tumour lesion and xenografts, suggesting that this cancer cell line preserves some features of hepatocyte differentiation when grown in vivo. HLA class I, N-cadherin, vascular endothelial growth factor, CD44, and heat-shock protein 70 were moderately expressed in this cell line. Spectral karyotyping analysis revealed a nearly triploid karyotype, 34-63<3n>, XXY[12] with complicated genetic abnormalities of chromosomal structure in all metaphases examined. This cell line will be useful in further studying hepato-sarcomatoid carcinoma cells and in understanding carcinogenesis and epithelial-mesenchymal transition in hepatitis C virus-related liver tumour.

Unusually high alanine aminotransferase to aspartate aminotransferase ratio in a patient with cyproterone-induced icteric hepatitis.

A 70-year-old man with prostatic adenocarcinoma received cyproterone acetate 200 mg per day. Three months later, mild fatigue and anorexia with elevation of the alanine aminotransferase (ALT) level to 1311 U/L, total bilirubin level to 14 mg/dL and prothrombin time of 15/11.9 seconds developed. At that time the aspartate aminotransferase (AST) level was only 82 U/L. Viral hepatitis and autoimmune markers were all negative. This hepatitis resolved quickly after cyproterone therapy was discontinued. One and a half years later, the patient was prescribed cyproterone 100 mg daily at another hospital where staff were unaware of his previous history. General malaise, upper abdominal pain and jaundice developed two months later. Laboratory studies at emergency room revealed an AST of 245 U/L, ALT of 255 U/L, total bilirubin of 8.2 mg/dL, amylase of 6055 U/L, prothrombin time of 15.2/11.1 seconds and platelet count of 68000 cells/mL. Although cyproterone was discontinued, the patient died of multiple organ failure 20 days after admission. This case report presents a rare situation with marked elevation of the ALT level without AST level elevation. This finding suggests that cyproterone may induce specific damage to the plasma membrane, and the mitochondria are not involved in the initial stage.

Relative roles of HBsAg seroclearance and mortality in the decline of HBsAg prevalence with increasing age.

OBJECTIVES: Mortality and hepatitis B surface antigen (HBsAg) seroclearance are the two extremes of prognostic destination of chronic hepatitis B virus (HBV) infection. Their relative roles in the decline of HBsAg prevalence with increasing age are unknown. METHODS: HBsAg-seropositive subjects with near normal alanine aminotransferase (ALT) were followed up every 3 to 12 months for >1 year. Serum HBsAg was assayed at entry and re-assayed at 3- to 5-year intervals. The morbidity and mortality data were obtained from hospital records, cancer registration, and the national mortality database. The mortality and HBsAg-seroclearance rates were examined by survival analysis. RESULTS: At entry, 1,386 subjects (20.9%) were hepatitis B e antigen (HBeAg) seropositive and 5,235 were HBeAg seronegative. The mean follow-up period was 13.6+/-5.4 years (median 13.2; range 1-29.1). HBsAg seroclearance occurred more frequently (555 cases, 8.4%) than mortality (97 cases, 1.5%; P<0.001; overall HBsAg seroclearance/mortality ratio: 5.6), of which only 40% were liver-related cases. Cox regression analysis revealed that male sex, HBeAg negativity, older age, low maximal ALT level, and hepatic steatosis were factors associated with HBsAg seroclearance. The estimated annual HBsAg seroclearance rate was around 1.05-1.61% after the age of 50 years, whereas the estimated mortality rate was quite low before the age of 60 and increased from 0.41% per year at ages 60-64 to 1.19% per year at ages 70-74 years. CONCLUSIONS: The HBsAg seroclearance over mortality rate was 5.6 in this cohort. This suggests that HBsAg seroclearance is the main reason for decreasing HBsAg prevalence with increasing age in the population.

Candidate serological biomarkers for cancer identified from the secretomes of 23 cancer cell lines and the human protein atlas.

Although cancer cell secretome profiling is a promising strategy used to identify potential body fluid-accessible cancer biomarkers, questions remain regarding the depth to which the cancer cell secretome can be mined and the efficiency with which researchers can select useful candidates from the growing list of identified proteins. Therefore, we analyzed the secretomes of 23 human cancer cell lines derived from 11 cancer types using one-dimensional SDS-PAGE and nano-LC-MS/MS performed on an LTQ-Orbitrap mass spectrometer to generate a more comprehensive cancer cell secretome. A total of 31,180 proteins was detected, accounting for 4,584 non-redundant proteins, with an average of 1,300 proteins identified per cell line. Using protein secretion-predictive algorithms, 55.8% of the proteins appeared to be released or shed from cells. The identified proteins were selected as potential marker candidates according to three strategies: (i) proteins apparently secreted by one cancer type but not by others (cancer type-specific marker candidates), (ii) proteins released by most cancer cell lines (pan-cancer marker candidates), and (iii) proteins putatively linked to cancer-relevant pathways. We then examined protein expression profiles in the Human Protein Atlas to identify biomarker candidates that were simultaneously detected in the secretomes and highly expressed in cancer tissues. This analysis yielded 6-137 marker candidates selective for each tumor type and 94 potential pan-cancer markers. Among these, we selectively validated monocyte differentiation antigen CD14 (for liver cancer), stromal cell-derived factor 1 (for lung cancer), and cathepsin L1 and interferon-induced 17-kDa protein (for nasopharyngeal carcinoma) as potential serological cancer markers. In summary, the proteins identified from the secretomes of 23 cancer cell lines and the Human Protein Atlas represent a focused reservoir of potential cancer biomarkers.

Impact of gender, viral transmission and aging in the prevalence of hepatitis B surface antigen.

BACKGROUND: Age, gender, and perinatal infection are associated with hepatocarcinogenesis. The influence of perinatal transmission in chronic hepatitis B virus infection between genders at different ages is not well documented. METHODS: A consecutive series of individuals who had general check-ups and three groups of relatives of patients with hepatocellular carcinoma were analyzed. Siblings of index cases and children of female index cases represented groups with high perinatal transmission, while children of male index cases represented a low perinatal transmission group. RESULTS: A total of 45,035 individuals who had general check-ups and 14,513 first degree relatives of patients with hepatocellular carcinoma were included. The families of patients with hepatocellular carcinoma included 4,455 siblings of index cases, 7,111 children of male index cases, and 2,947 children of female index cases. The prevalence of hepatitis B surface antigen (HBsAg) was high in groups with high perinatal infection and in men. Gender differences in the prevalence of HBsAg diminished in children of female index cases and siblings of index cases, and in all groups after the age of 60 years. The prevalence of HBsAg declined with increasing age in all groups, with the highest decline in male siblings of index cases ( 1.37% per year) and the lowest in female children of male index cases ( 0.05% per year) in the 35-59 year-old period. Hepatitis C antibody was higher in women (5.7%) than in men (4.0%) in the general check-up group. CONCLUSIONS: Females were less susceptible to become HBsAg carriers if HBV was not transmitted during the perinatal period. The prevalence of HBsAg declined significantly in high perinatal infection groups, implying that neonatal tolerance does not endure.

Long-term outcome of hepatitis B e antigen-negative hepatitis B surface antigen carriers in relation to changes of alanine aminotransferase levels over time.

UNLABELLED: The baseline alanine aminotransferase (ALT) level was reported to have prognostic value in chronic hepatitis B virus (HBV) infection, during which ALT may change over time. Instead of baseline ALT, this study aimed to study the prognostic value of the height of ALT during the course of chronic HBV infection. A total of 4376 asymptomatic hepatitis B e antigen (HBeAg) negative, surface antigen (HBsAg) carriers with baseline ALT less than 2 times the upper limit of normal (ULN) were monitored with ALT measurement and ultrasonography every 3 to 12 month for over 3 years. Maximal ALT levels during follow-up were correlated with long-term outcomes using morbidity and mortality data from hospital records, cancer registration, and national mortality database. Baseline ALT level was normal in 3673 subjects and increased to abnormal level in 1720 (46.8%) during a mean follow-up period of 13.4 +/- 5.2 (3.0-28.7) years. The incidence of liver cirrhosis, hepatocellular carcinoma (HCC), and mortality increased with increasing maximal ALT level during follow-up, especially in those with maximal ALT of at least 2 times ULN, as compared with those who maintained normal ALT. Cox regression analysis indicated that age at entry, sex, and maximal ALT level during follow-up were significant independent factors associated with the development of cirrhosis, HCC, and mortality whereas cirrhosis was also an independent factor for HCC development and mortality. CONCLUSION: Persistently normal ALT was associated with excellent long-term prognosis, whereas increasing ALT levels of at least 2 times ULN during follow-up was associated with increasing morbidity and mortality. ALT of at least 2 times ULN is therefore an appropriate threshold for anti-HBV therapy, whereas those with ALT 1 to 2 times ULN require liver biopsy for decision.