Prognostic assessment of resected colorectal liver metastases integrating pathological features, RAS mutation and Immunoscore.

Surgical resection of colorectal liver metastases combined with systemic treatment aims to maximize patient survival. However, recurrence rates are very high postsurgery. In order to assess patient prognosis after metastasis resection, we evaluated the main patho-molecular and immune parameters of all surgical specimens. Two hundred twenty-one patients who underwent, after different preoperative treatment, curative resection of 582 metastases were analyzed. Clinicopathological parameters, RAS tumor mutation, and the consensus Immunoscore (I) were assessed for all patients. Overall survival (OS) and time to relapse (TTR) were estimated using the Kaplan-Meier method and compared by log-rank tests. Cox proportional hazard models were used for uni- and multivariate analysis. Immunoscore and clinicopathological parameters (number of metastases, surgical margin, histopathological growth pattern, and steatohepatitis) were associated with relapse in multivariate analysis. Overall, pathological score (PS) that combines relevant clinicopathological factors for relapse, and I, were prognostic for TTR (2-year TTR rate PS 0-1: 49.8.% (95% CI: 42.2-58.8) versus PS 2-4: 20.9% (95% CI: 13.4-32.8), hazard ratio (HR) = 2.54 (95% CI: 1.82-3.53), p < 0.0000; and 2-year TTR rate I 0: 25.7% (95% CI: 16.3-40.5) versus I 3-4: 60% (95% CI: 47.2-76.3), HR = 2.87 (95% CI: 1.73-4.75), p = 0.0000). Immunoscore was also prognostic for OS (HR [I 3-4 versus I 0] = 4.25, 95% CI: 1.95-9.23; p = 0.0001). Immunoscore (HR [I 3-4 versus I 0] = 0.27, 95% CI: 0.12-0.58; p = 0.0009) and RAS mutation (HR [mutated versus WT] = 1.66, 95% CI: 1.06-2.58; p = 0.0265) were significant for OS. In conclusion, PS including relevant clinicopathological parameters and Immunoscore permit stratification of stage IV colorectal cancer patient prognosis in terms of TTR and identify patients with higher risk of recurrence. Immunoscore remains the major prognostic factor for OS.

Long-term natural history of liver disease in patients with chronic hepatitis B virus infection: an analysis using the Markov chain model.

BACKGROUND: The relationship between the hepatitis B e antigen (HBeAg) seroconversion and the long-term natural history of liver disease has not been sufficiently investigated. METHODS: A total of 408 [4352 person-year (PY) units] patients with chronic hepatitis B virus (HBV) without antiviral therapy were enrolled. The study patients were divided into three groups, as follows: Group A (2666 PY units), seroconverted of HBeAg at age < 40; Group B (413 PY units), seroconverted of HBeAg at age ≥ 40; Group C (1273 PY units), persistently HBeAg positive. Yearly transition probabilities from each liver state [chronic HBV infection, chronic hepatitis B, cirrhosis, hepatocellular carcinoma (HCC), and hepatitis B surface antigen (HBsAg) negativity] were calculated using the Markov chain model. RESULTS: In the analysis of 1 year liver disease state transition probabilities, the liver states remained almost the same in Group A. In Groups B and C, each liver state tended to progress to a worse state. Assuming a chronic hepatitis B state at age 40 as the starting condition for simulation over the next 40 years, the chronic hepatitis B state accounted for approximately 60% of males aged ≥ 50 and approximately 40% of females aged ≥ 60 in Group A, and the HBsAg-negative state accounted for approximately 30-40% of males and females aged ≥ 60. In Groups B and C, the probabilities of patients with cirrhosis and HCC gradually increased with age. CONCLUSIONS: Not only patients with persistent HBeAg positive, but also patients with delayed HBeAg seroconversion showed poor prognosis of liver-related natural history.

Neutrophil-to-lymphocyte ratio for the prognostic assessment of hepatocellular carcinoma: A systematic review and meta-analysis of observational studies.

BACKGROUND AND AIMS: Neutrophil to lymphocyte ratio (NLR) is an inflammatory-based marker. A systematic review and meta-analysis was performed to explore the prognostic role of NLR in patients with hepatocellular carcinoma (HCC). RESULTS: Overall, 598 papers were identified, of which 90 papers including 20,475 HCC patients were finally included. Low baseline NLR was significantly associated with better overall survival (HR = 1.80, 95% CI: 1.59-2.04, p < 0.00001) and recurrence-free or disease-free survival (HR = 2.23, 95% CI: 1.80-2.76, p < 0.00001). Low post- treatment NLR was significantly associated with better overall survival (HR = 1.90, 95% CI: 1.22-2.94, p = 0.004). Decreased NLR was significantly associated with overall survival (HR = 2.23, 95%CI: 1.83-2.72, p < 0.00001) and recurrence-free or disease-free survival (HR = 2.23, 95% CI: 1.83-2.72, p < 0.00001). The findings from most of subgroup meta-analyses were consistent with those from the overall meta-analyses. MATERIALS AND METHODS: All relevant literatures were identified via PubMed, EMBASE, and Cochrane library databases. Hazard ratio (HR) with 95% confidence interval (95%CI) was calculated. Subgroup meta-analyses were performed according to the treatment options, NLR cut-off value ranges, and regions. CONCLUSIONS: NLR should be a major prognostic factor for HCC patients. NLR might be further incorporated into the prognostic model of HCC.

Biological treatment for liver tumor and new potential biomarkers.

The search for effective and efficacious therapy for liver tumor was started many years ago and is still ongoing. Despite all of the surgical advances, much work needs to be done to improve understanding of the biology of the tumor and its treatment. The rules of hepatic surgery are changing because of two recent major trends: (1) technical simplification, and (2) the endeavor to treat an increasing number of patients. T lymphocytes are potent cellular effectors of the immune system and possess a memory that responds to rechallenge by the same antigen. Being more specific and less toxic than chemotherapy, tumor infusion could be an ideal adjuvant therapy for patients with primary and secondary liver malignancies. Moreover, tumor cell vaccines have demonstrated efficacy in terms of minimal residual disease and are being investigated, but the requirement for an adequate supple of autologos tumor may limit the general applicability of these approaches. Various studies have demonstrated the aberrant expression of germ-cell proteins called cancer-testis (CT) antigens in liver neoplastic cells. Their selective normal-tissue expression makes them ideal antigens for immune targeting of malignant disease. Specific expression of CT antigens also suggests their application as tumor markers to detect circulating hepatocellular carcinoma (HCC) cells, as an adjuvant diagnostic tool, and as indicators for recurrence and prognosis. Biological therapy is now generating more clinical trials. More studies need to be performed and further experiments need to be done, although currently this seems a valid pathway for the treatment of liver cancer. Cytoreduction treatment of liver tumor and the vaccine might be the future of the treatment of primary and secondary liver tumor.

Immunohistochemical assessment and prognostic value of hepatitis B virus X protein in chronic hepatitis and primary hepatocellular carcinomas using anti-HBxAg monoclonal antibody.

Hepatitis B virus (HBV) is the most meaningful risk factor in chronic hepatitis, cirrhosis and primary hepatocellular carcinoma (PHC). The hepatitis B virus X protein (HBxAg) is a multifunctional protein with many important functions in hepatocellular carcinogenesis. A monoclonal anti-HBxAg antibody was developed in our laboratory and characterized by different methods. Using this antibody HBxAg was detected in formaldehyde fixed paraffin embedded tissue sections of 72 liver biopsies from patients with acute hepatitis, chronic hepatitis, cirrhosis and primary hepatocellular carcinoma. The co-expression of hepatitis B surface antigen (HBsAg), hepatitis B core antigen (HBcAg) and HBxAg was compared. The histological and cytological localization of the detected HBxAg showed a characteristic distribution in different stages of HBV infection. Strong and diffuse nuclear reaction was detected in PHC cases in contrast to the focal, cytoplasmic and nuclear labeling in the acute and chronic B hepatitis cases. Our antibody seems to be a suitable prognostic marker for routine pathohistological diagnosis and for comparative pathological and epidemiological research on the development of PHC.

[Functional assessment of infiltrating immunocytes in patients with primary hepatocellular carcinoma after percutaneous microwave coagulation therapy].

OBJECTIVE: To assess the function local immune cells in patients with primary hepatocellular carcinoma (HCC) after percutaneous microwave coagulation therapy (PMCT). METHODS: Thirty-eight patients with histologically proved primary HCC underwent ultrasound guided PMCT. Specimens were taken from the lesion site before and 17 days after PMCT respectively using 18-guage core needle through US-guide biopsy, embedded in paraffin, and stained by immunohistochemistry. The panel of monoclonal antibodies of CD3, CD56, CD68 and Fas-L were used to detect the CD3+, CD56+, CD68+ cells and T lymphocyte Fas-ligand. The positive cells were detected under light microscopy. Their diameter and area and the Fas-L expression rate of T lymphocytes and changes of secondary lysosomes in macrophages were measured by computer. RESULTS: Before PMCT, only a few infiltrating immunocytes were seen in the tumor specimens; the diameter of most CD3+ and CD56+ cells was less than 10 microns and the diameter of CD68+ cells was less than 18 microns. The amount and volume of CD3+, CD56+, and CD68+ cells significantly increased after PMCT (t = 3.48, P = 0.025 for CD3+ cells, t = -4.76, P = 0.000 for CD56+ cells, and t = -2.46, P = 0.028 for CD68+ cells). The percentage of CD3+ and CD56+ cells with the largest diameter > 10 microns increased from 10.4% and 20.1% respectively before PMCT to 24.9% and 30.2% respectively after PMCT. The percentage of CD68+ cells with the largest diameter > 18 microns increased from 10.2% before PMCT to 33.4% after PMCT. The Fas-l expression rate of T lymphocytes increased from 7.2% to 20.1% (t = -19.12, P = 0.000). The secondary lysosomes and cellular debris within microphages and the cellular organs in T lymphocytes significantly increased. CONCLUSION: The function of intratumaral infiltrating immunocytes is significantly enhanced after PMCT.

Intrahepatic lymphocyte analyses and assessment of the effects of levamisole in murine hepatic metastasis model.

We used hepatic metastasis models to determine the mechanism and effect of levamisole. BALB/c mice and Colon 26 cells were used. Group I was injected with tumor cells through the portal vein. Group II was primed with tumor cells before tumor cells injecting. Group III was same as Group II, but treated with levamisole. Surface antigens of intrahepatic lymphocytes and spleen cells were determined by FACScan with Anti-CD3, anti-CD4, anti-CD8, anti-CD45, anti-NK1.1 and anti-F4/80. Nodules on the liver were greatest in Group I and fewest in Group III. Concerning intrahepatic lymphocytes, Group II, when compared with Group I, had increases of CD3+, CD4+ and CD8+ cells, and decreases of CD45+ and NK1.1+ cells. Group III when compared with Group II, showed increased CD8+ cells and decreased of NK1.1+ cells. Levamisole is considered to be effective in the prevention of liver metastasis and is suggeste to enhanced CD8+ cells.

Hepatic adenoma in the pediatric age group. Clinicopathological observations and assessment of cell proliferative activity.

The clinicopathological findings of eight children with hepatic adenoma in the absence of cirrhosis are presented. The lesions ranged in diameter from 0.1 to 14.5 cm. Associated disorders were Fanconi's anemia, type I glycogen storage disease. Hurler's disease, and severe combined immunodeficiency with ADA deficiency. The remaining three children had adenoma without known associated disorders. In the children with glycogenosis and Hurler's disease the adenomas were multiple. Significant dysplasia occurred in the two children with Fanconi's anemia; however, the lesions behaved in a benign fashion--one with regression of the tumor after cessation of androgen therapy and the other with nonrecurrence after complete resection. Proliferating cell nuclear antigen (PCNA) labeling index (LI) of the adenoma arising in patients with Fanconi's anemia was significantly greater than the PCNA-LI of adenoma in the other children (mean 4.1% versus 0.9% of nuclei), approaching the lower end of the spectrum for reported hepatocellular carcinoma cases. We emphasize that the worrisome pathology that may occur in hepatic adenoma in children, particularly with Fanconi's anemia, does not necessarily predict malignant behavior. The association of hepatic adenoma with Hurler's disease or severe combined immunodeficiency has not been reported previously.

[Assessment of the proliferative activity of hepatocellular carcinoma with the monoclonal antibody Ki-67 using flow cytometry].

This study examined whether the monoclonal antibody Ki-67 is an indicator of hepatocellular carcinoma proliferation and whether it represents a new parameter for determining the diagnosis and prognosis. The subjects were 22 patients who were not treated preoperatively among the patients undergoing hepatectomy at our department. Fresh specimens of the cancer tissue and the noncancerous regions were stained with PI after processing them with FITC-labeled Ki-67. Then 20,000 cells were analyzed by two-color flow cytometry. A significant difference was observed between the well differentiated group and the moderately and poorly differentiated groups. However, no significant difference was observed with respect to any other factor. The average Ki-67 labeling of the cancers in the patients with and without cirrhosis was 17.0 +/- 10.5% and 5.3 +/- 3.5%, respectively (p < 0.05). The cancers showed high Ki-67 labeling rates compared with the noncancerous areas and a positive correlation was observed between the two. These findings suggested that coexistent hepatic lesions have some influence on the proliferative activity of cancer. A significant correlation was confirmed by flow cytometry after immunostaining using the antibody MIB-1. Analysis by this method was considered to be useful for assessing the proliferating activity of hepatocellular carcinoma.

Assessment of lymphokine-activated killer activity and gamma-interferon production in patients with small hepatocellular carcinomas.

We have previously reported depressed gamma-interferon production and depressed lymphokine-activated killer and natural killer activity in patients with relatively large hepatocellular carcinomas. These parameters were normal in cirrhosis. Some evidence had suggested a gamma-interferon production defect as the main cause of depressed lymphokine-activated killer activity in hepatocellular carcinoma, (i.e., gamma-interferon enhances lymphokine-activated killer and natural killer activity and gamma-interferon antibody inhibits lymphokine-activated killer induction). However, we were unable to clinically define the precise mechanism operating here because gamma-interferon production and lymphokine-activated killer activity were both defective in advanced hepatocellular carcinoma. In recent years, it has become possible to detect even small hepatocellular carcinomas on ultrasonography and to confirm them by fine-needle biopsy. In this study, we assessed those immune parameters in 48 patients with hepatocellular carcinomas less than 2 cm in diameter to confirm depressed immune function and to clarify the mechanism of these defects. Lymphokine-activated killer activity was defective in 31 patients (64.6%), whereas gamma-interferon production was defective in only 1 of these patients (2.1%). This observation argues against the hypothesis that defective gamma-interferon production is the primary defect and provides new insight into the mechanism of progression of defective immune function in hepatocellular carcinoma. Thirty-one of the 48 hepatocellular carcinoma patients were treated surgically, and these immune parameters were followed for 6 mo. The recovery of lymphokine-activated killer activity in all hepatocellular carcinoma patients with low lymphokine-activated killer activity suggests the tumor burden as the cause of defective lymphokine-activated killer activity.

Detection of hepatitis C virus antibodies with new recombinant antigens: assessment in chronic liver diseases.

A new serological assay to detect antibodies against hepatitis C, based on a recombinant protein (BHC10) which incorporates structural and non-structural viral antigens, was tested in 67 healthy subjects and 409 patients with various forms of liver disease. Results were compared with the current assay based on the recombinant non-structural viral antigen c100 and with the recently introduced second-generation assay, Ortho2. None of the healthy subjects was positive by any of the assays. In patients with chronic non-A, non-B hepatitis the prevalence of anti-BHC10 was 96.8%, higher than anti-c100 (83.3%, p less than 0.001) and similar to Ortho2 (94.3%). False-positive results were less frequently found when BHC10 was used. These findings show that assays incorporating structural and non-structural antigens provide higher sensitivity to detect hepatitis C virus infection and they define an almost exclusive role of hepatitis C virus in the genesis of chronic non-A, non-B hepatitis.