Characteristics and long-term prognosis of the autoimmune hepatitis/primary sclerosing cholangitis overlap syndrome.

GOALS/BACKGROUND: Diagnosis, treatment, and prognosis of the overlap syndrome of autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC) are controversial. Our aim was to assess the clinical characteristics and long-term prognosis of the AIH/PSC overlap syndrome. STUDY: We reviewed the data of 16 patients seen in our center who fulfilled the diagnostic criteria of both diseases at some stage of their medical history. RESULTS: All patients had initially presented with laboratory markers of both, cholestasis and definite AIH. Histologic reexamination of initial biopsies, available from 11 of 16 patients, revealed features of both AIH and PSC in all biopsies. Cholangiography was performed at initial presentation in 9 of 16 patients and appeared normal in 6 of 9 patients. During follow-up cholangiography, an additional 11 patients developed pathologic characteristics of PSC. The age and sex distribution was typical for PSC. Immunosuppressive therapy improved biochemical markers; however, fibrosis was observed to progress in all patients during a median observation period of 12 years. Three patients initially presented with cirrhosis, 12 of 16 patients developed cirrhosis at the end of the observation period, and 3 developed complications of cirrhosis. CONCLUSIONS: Overlap of AIH and PSC was detected most reliably on grounds of serologic markers and histology; early bile duct changes were often missed by endoscopic retrograde cholangiography. Immunosuppression combined with ursodeoxycholic acid seems to be beneficial, but cannot prevent long-term progression toward cirrhosis in the majority of patients.

Liver biopsy in primary biliary cirrhosis: clinicopathological data and stage.

The purpose of the present study was to characterize histopathological lesions in primary biliary cirrhosis (PBC) and to assess the relationship between histopathological lesions and biochemistry. Liver biopsies of 252 patients with PBC were investigated. A laboratory database was established. Histopathological characterization was performed. Relationships between detailed histopathological features and biochemistry were calculated statistically. Combining the data, a PBC group, consisting of an anti-mitochondrial antibody (AMA)-positive and -negative subgroup, and an overlap group were defined, with a female preponderance of >90% and higher activity of aspartate aminotransferase (AST) in the overlap group. Histopathological changes were characteristic in >80%. Periductal concentric fibrosis, lobular granuloma formation and steatosis were frequently remarkable. Correlations were found between alanine aminotransferase activity and modified hepatitis activity index in the overlap group and the AMA-positive group. A positive significant relationship was demonstrated between mean AST activity and portal fibrosis for the AMA-positive group. A highly significant positive link was seen between mean concentration of bilirubin and stage of fibrosis. Biochemistry reflects only in part the degree of severity of histopathological lesions in PBC. Histopathology indicates comorbidity in a high percentage of patients.

Portal vein arterialization increases hepatocellular apoptosis and inhibits liver regeneration.

BACKGROUND: Portal vein arterialization is performed in particular situations to guarantee sufficient blood flow in the portal vein. In addition, some authors have postulated a proliferation-promoting influence of portal vein arterialization on the liver tissue. However, portal vein arterialization is an unphysiological procedure: It increases portal blood flow and blood pressure as well as oxygenation of the liver tissue. On the other hand, it reduces the influx of hepatotrophic factors from the portal venous blood. The aim of these experiments was to investigate apoptosis and proliferation of hepatocytes during various conditions of the portal perfusion. MATERIALS AND METHODS: After 70% liver resection in Lewis rats, the following four experimental groups were formed differing in portal perfusion: (I) hyperperfused, nonarterialized; (II) flow-regulated, nonarterialized; (III) hyperperfused, arterialized; (IV) flow-regulated, arterialized. A warm ischemia of 30 min was kept in all groups. RESULTS: Portal vein arterialization of 70% reduced rat livers significantly reduced liver regeneration as shown by a significant reduction in liver weight, body weight, and liver function after 6 wk, in contrast to the group with 70% liver mass reduction and portal venous inflow of the portal vein. Furthermore, we found a significantly elevated number of apoptotic hepatocytes after portal vein arterialization. These results were independent from blood flow regulation of the arterialized portal vein, which caused no improvement of the results. CONCLUSIONS: Portal vein arterialization should be performed only temporarily and is clinically not recommended as a permanent option, because of the increased hepatocellular apoptosis and the very distinctive, negative long-term effects on liver weight.

Severe chronic diarrhea and weight loss in cholesteryl ester storage disease: a case report.

AIM: An inherited deficiency of human lysosomal acid lipase (LAL) results in the rare conditions of Wolman disease and cholesteryl ester storage disease (CESD). We want to present the rare case of CESD in an adult. METHODS: We report about an adult female patient with severe chronic diarrhea and weight loss as a consequence of CESD. Clinical examination revealed signs of malabsorption and slightly elevated liver enzymes. RESULTS: Histopathologic changes in the liver tissue and DNA sequence analysis confirmed the diagnosis of CESD due to homozygosity for the most common CESD mutation, a G934A splice site defect encoded by exon 8 of the lysosomal acid lipase (LIPA) gene. CONCLUSION: It is the first case in the literature with diarrhea as a putative symptom of CESD in adult patients.

Expression of inducible nitric oxide synthase and cyclooxygenase-2 in pancreatic adenocarcinoma: correlation with microvessel density.

AIM: Cyclooxygenases (COX) are key enzymes for conversion of arachidonic acid to prostaglandins. Nitric oxide synthase (NOS) is the enzyme responsible for formation of nitric oxide. Both have constitutive and inducible isoforms. The inducible isoforms (iNOS and COX-2) are of great interest as regulators of tumor angiogenesis, tumorigenesis and inflammatory processes. This study was to clarify their role in pancreatic adenocarcinomas. METHODS: We investigated the immunohistochemical iNOS and COX-2 expression in 40 pancreatic ductal adenocarcinomas of different grade and stage. The results were compared with microvessel density and clinicopathological data. RESULTS: Twenty-one (52.5%) of the cases showed iNOS expression, 15 (37.5%) of the cases were positive for COX-2. The immunoreaction was heterogeneously distributed within the tumors. Staining intensity was different between the tumors. No correlation between iNOS and COX-2 expression was seen. There was no relationship with microvessel density. However, iNOS positive tumors developed more often distant metastases and the more malignant tumors showed a higher COX-2 expression. There was no correlation with other clinicopathological data. CONCLUSION: Approximately half of the cases expressed iNOS and COX-2. These two enzymes do not seem to be the key step in angiogenesis or carcinogenesis of pancreatic adenocarcinomas. Due to a low prevalence of COX-2 expression, chemoprevention of pancreatic carcinomas by COX-2 inhibitors can only achieve a limited success.

Conspicuity of zones of ablation after radiofrequency ablation in porcine livers: comparison of an extracellular and an SPIO contrast agent.

PURPOSE: To compare conspicuity of zones of ablation on nonenhanced, gadopentetate dimeglumine-(Gd-DTPA) and ferucarbotran-(SPIO)-enhanced magnetic resonance (MR) images. MATERIALS AND METHODS: In all, 33 radiofrequency ablations (RFA) were performed in 17 healthy porcine livers at 1.5T MR imaging 1 day and 2 and 4 weeks after RFA: T2-weighted (w) ultra turbo spin echo (UTSE), proton density (PD)-w UTSE, T1-w gradient echo (GRE) pre- and 5 minutes postcontrast administration, dynamic T1-w GRE during Gd-DTPA (Magnevist) or SPIO (Resovist) administration, T2-w UTSE, and PD-w UTSE sequences 10 minutes after SPIO administration. Regions of interest (ROIs) for contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were drawn in consensus by two radiologists. RESULTS: PD-w SPIO-enhanced images (23.5 +/- 5.5) showed higher liver-to-lesion CNR than T1-w GRE Gd-DTPA-enhanced images (13.5 +/- 6.1) 1 day after RFA (P < or = 0.05). At all other timepoints, liver-to-lesion CNR of PD-w and T2-w SPIO-enhanced images did not differ significantly from T1-w GRE Gd-DTPA-enhanced images (P > or = 0.05). Nonenhanced T2-w images revealed lower liver-to-lesion CNR (7.0 +/- 7.5/6.5 +/- 5.9/6.8 +/- 5.0, 1 day/2 weeks/4 weeks, respectively) than T2-w SPIO-enhanced (17.4 +/- 4.8/15.3 +/- 4.5/14.2 +/- 5.7), PD-w SPIO-enhanced (23.5 +/- 5.5/16.9 +/- 3.6, 1 day/2 weeks), and T1-w Gd-DTPA-enhanced (15.3 +/- 3.6/12.7 +/- 3.5, 2/4 weeks) images (P < or = 0.05). Liver-to-lesion CNR of SPIO-enhanced dynamic T1-w GRE images after 30, 80, 150, and 240 seconds did not change significantly over time (P > or = 0.05). CONCLUSION: One day after RFA lesion conspicuity on PD-w ferucarbotran-enhanced images is better than on T1-w GRE Gd-DTPA-enhanced images. At all other timepoints, ferucarbotran is not superior to gadolinium. Ferucarbotran- and gadolinium-enhanced images improve lesion conspicuity compared with nonenhanced T2-w images at all timepoints.

Combined analysis of HPV-DNA, p16 and EGFR expression to predict prognosis in oropharyngeal cancer.

Molecular prognostic indicators for oropharyngeal squamous cell carcinoma (OSCC), including HPV-DNA detection, epidermal growth factor receptor (EGFR) and p16 expression, have been suggested in the literature, but none of these are currently used in clinical practice. To compare these predictors, 106 newly diagnosed OSCC for the presence of HPV-DNA and expression of p16 and EGFR were analyzed. The 5-year disease-free survival (DFS) and overall survival (OS) were calculated in relation to these markers and a multivariate Cox analysis was performed. Twenty-eight percent of the cases contained oncogenic HPV-DNA and 30% were positive for p16. The p16 expression was highly correlated with the presence of HPV-DNA (p < 0.001). Univariate analysis of the 5-year DFS revealed a significantly better outcome for patients with p16-positive tumors (84% vs. 49%, p = 0.009). EGFR-negative tumors showed a tendency toward a better prognosis in DFS (74% vs. 47%, p = 0.084) and OS (70% vs. 45%, p = 0.100). Remarkable and highly significant was the combination of p16 and EGFR expression status, leading to 5-year DFS of 93% for p16+/EGFR- tumors vs. 39% for p16-/EGFR+ tumors (p = 0.003) and to a 5-year OS of 79% vs. 38%, respectively (p = 0.010). In multivariate analysis p16 remained a highly significant prognostic marker for DFS (p = 0.030) showing a 7.5-fold increased risk for relapse in patients with p16-negative tumors. Our data indicate that p16 expression is the most reliable prognostic marker for OSCC and further might be a surrogate marker for HPV-positive OSCC. HPV+/p16+ tumors tended to have decreased EGFR expression, but using both immunohistological markers has significant prognostic implications.

Experimental radiofrequency ablation near the portal and the hepatic veins in pigs: differences in efficacy of a monopolar ablation system.

BACKGROUND: We sought to compare the efficacy of a monopolar radiofrequency ablation system in vivo near the portal vein and the hepatic veins in porcine liver. MATERIALS AND METHODS: Radiofrequency ablation of healthy livers near the portal vein and the hepatic veins was performed in 10 pigs with a multitined expandable electrode. Volumes and diameters of zones of ablation were assessed by magnetic resonance imaging. RESULTS: Volumes (16.0 +/- 5.5 mL, P = 0.001) and diameters (4.0 +/- 0.7 cm, 3.3 +/- 0.7 cm, 3.0 +/- 0.6 cm, P

Physiologic microcirculation of the heterotopically transplanted rat liver with portal vein arterialization depending on optimal stent diameter.

BACKGROUND: Clinical experience with portal vein arterialization (PVA) in liver transplantation is controversial. One reason for this is the lack of standardized flow regulation. The present experiments aimed to establish flow regulation in the arterialized portal vein for heterotopic auxiliary liver transplantation (HALT), to obtain physiological portal blood flow, and to compare this technique with orthotopic liver transplantation. MATERIAL/METHODS: Lewis rats were divided into 7 groups (n = 8 transplantations/group). Group: A I-IV: In HALT, the portal vein was anastomosed to the right renal artery using stents with different diameters (0.2, 0.3, 0.4, 0.5 mm). Afterwards, HALT with PVA using the stent diameter that had achieved the most physiological portal blood flow (group B II) was compared with orthotopic liver transplantation with porto-portal anastomosis (group B III) and to the sham group (B I). RESULTS: After reperfusion, only the 0.3 mm stent resulted in an average blood flow in the arterialized portal vein in HALT which was within the normal range (1.7+/-0.4 ml/min/g liver weight). The parameters of microcirculation and early graft function were significantly better in group B II than in group B III (functional sinusoidal density: 335+/-48 vs. 224+/-31/cm, diameter of sinusoids: 6.4+/-0.6 vs. 5.2+/-0.6 microm, diameter of postsinusoidal venules: 31.1+/-3.3 vs. 25.5+/-2.0 microm, bile-production: 27+/-8 vs. 19+/-5 microl/h/g liver weight). CONCLUSIONS: Using an optimal stent diameter in HALT with portal vein arterialization, an adequate flow-regulation can be achieved. Avoiding portal hyper- and hypoperfusion, good results for microcirculation and early graft function can be obtained.

Ex vivo analysis of antineoplastic agents in precision-cut tissue slices of human origin: effects of cyclooxygenase-2 inhibition in hepatocellular carcinoma.

Cultures of precision-cut tissue slices allow the investigation of substance effects on human tissues under in vivo-like conditions over a limited time span. We have adapted the model for direct analyses of antineoplastic substances on tumor tissues. We have recently demonstrated that selective cyclooxygenase-2 (COX-2) inhibitors strongly suppress growth of human hepatocellular carcinoma (HCC) cells in vitro and nude mouse HCC implants by inducing apoptosis and reducing proliferation. We have now analyzed the effects of COX-2 inhibition on human tumor tissue. Three hundred micrometer slices of tumorous and non-tumorous liver tissue from three surgically resected HCCs were cultured with increasing concentrations of the selective COX-2 inhibitor Meloxicam (20-200 microM) for 6, 12, 24, and 48 h. The cultured tissue slices were analysed morphologically and by immunohistology for proliferation (Ki-67), apoptosis (M30), and COX-2 expression. COX-2 was expressed in all HCCs and in the non-tumorous liver tissue. Cytoplasmic COX-2 immunoreactivity in HCCs increased during culturing time. In two of three cases, COX-2 inhibition significantly increased tumor cell apoptosis in HCCs, whereas the low basal apoptosis rate in the non-tumorous liver parenchyma did not change. Tumor cell proliferation was mildly reduced, but the changes did not reach statistical significance. These results demonstrate that the precision-cut tissue slice culture model is a useful tool to analyze directly drug-dependent antitumorous or unwanted organ-specific effects. The analysis of COX-2 inhibition lends further support to the antineoplastic effects previously demonstrated in vitro and in animal models.

The role of Epstein-Barr virus in acute and chronic hepatitis.

BACKGROUND/AIMS: Epstein-Barr virus has a seroprevalence of more than 80% world wide and is known to be associated with hepatitis. However, little is known about the underlying pathogenesis and immunmechanisms and no standard diagnostic criteria to diagnose EBV-hepatitis are available. METHODS: We collected liver biopsies (n=21) with the tentative diagnosis of EBV induced hepatitis according to pathological changes and traceable EBV genome by PCR. Correlation with serological data revealed acute in seven cases, convalescent in two cases, past EBV infection in six cases. Viral RNA was visualised by in situ hybridisation within nuclei of lymphocytes. RESULTS: In seven of 68 liver biopsies with the diagnosis 'liver disease of unknown aetiology' EBV genome in the tissue was demonstrated indicating a possible role for EBV in the induction of hepatitis or a trapping of infected lymphocytes within the liver. In a control group of 20 EBV-seropositive patients with steatohepatitis EBV-DNA PCR of the liver tissue was negative. Immunohistochemistry identified CD3 and CD8 positive T-lymphocytes as the main lymphocytic infiltrate in EBV hepatitis. CONCLUSIONS: EBV hepatitis should be taken into consideration in case of typical histopathological changes and a positive DNA PCR of liver biopsy. Serological confirmation of the diagnosis is inevitable.

Improved microcirculation of a liver graft by controlled portal vein arterialization.

BACKGROUND: The clinical results of portal vein arterialization (PVA) in liver transplantation are controversial without a standardized portal flow regulation. The aim of these experiments was to perform a flow-regulated PVA in liver transplantation, to examine the microcirculation and early graft function after heterotopic auxiliary liver transplantation (HALT) with flow-regulated PVA, and to compare this technique with HALT with porto-portal anastomosis. Using the recently developed orthogonal polarization spectral (OPS) imaging, for the first time the microcirculation of liver grafts with PVA was visualized. MATERIALS AND METHODS: HALT was performed in Lewis rats. The portal vein was either completely arterialized via the right renal artery in a standardized splint-technique (Group I, n = 8) or anastomosed end-to-end to the recipient's portal vein (Group II, n = 8). RESULTS: After reperfusion, the average blood flow in the portal vein was within the normal range in Group I (1.7 +/- 0.4 ml/min/g liver weight) and significantly higher than in Group II (1.2 +/- 0.2 ml/min/g liver weight). The functional sinusoidal density in Group I (335 +/- 48/microm) was significantly higher than in Group II (232 +/- 58/microm), whereas the diameter of the sinusoids and the postsinusoidal venules yielded no significant differences between both groups. The bile production was comparable (27 +/- 8 versus 29 +/- 11 microl/h/g liver weight). CONCLUSIONS: In our experiments it was possible to achieve an adequate flow regulation in the arterialized portal vein with good results concerning microcirculation and early graft function. We recommend that further investigations on liver transplantation with PVA should be performed with portal flow regulation, before PVA is employed in clinical transplantation.