Main characteristics of hepatocellular carcinoma and cirrhosis and therapeutic approaches.

Between 1995 and 1997 we studied 100 patients with hepatocarcinoma (HCC) and cirrhosis. Of these 74 were males and 26 females with a mean age of 66 years. 13% patients were only HbsAg positive, 75% only anti-HCV positive, 6% HbsAg and anti-HCV and the etiology in 6% of cases was alcoholic. Alpha-foetoprotein was >400 ng/ml in only 18% of cases and portal thrombosis was present in 12%. Mononodular HCC was observed in 63% of cases (small HCC in only 38%) and in 79% was localized to the right lobe. Of the mononodular types, 70% were shown by echography to be hypoechoic, 6% hysoechoic, 6% hyperechoic and 17% mixed patterns. Histologically, 49% were well-differentiated, 45% moderately-differentiated and 6% poorly-differentiated. No correlation was found between histologic pattern and number of nodules. Well-differentiated HCC was found in 51% of mononodular types and in 46% of multinodular types. Moderately-differentiated HCC was detected in 46% and 43% respectively and poorly-differentiated HCC in 3% and 11% respectively. No correlation was found between number of nodules and the degree of Edmonson.

The immune responsiveness in hepatitis C virus infected patients: effects of interferon-alfa/ribavirin combined treatment on the lymphocyte response with special reference to B cells.

Previous data demonstrated that an elevated percentage of hepatitis C virus (HCV) infected patients are endotoxemic. Endotoxemic patients are poor responders to the interferon (IFN)- alpha/ribavirin (RIB) treatment and exhibit lower serum levels of IFN-gamma and interleukin (IL)-10 than the responder counterpart. Here we provide evidence that in endotoxemic HCV+ patients absolute numbers of CD19(+) cells (B cells) are higher than those observed in the non-endotoxemic counterpart at the end of the combined treatment. Moreover, anti lactoferrin (LF) antibodies are more elevated in non-responder HCV+ patients than in the responders. In turn, these autoantibodies may affect the antiviral activity of LF, on the one hand, and, on the other hand abrogate the LF binding to lipopolysaccharides (LPS). Such an interaction hampers the binding of LPS to LPS binding protein, thus inhibiting LPS fixation to CD14(+) cells and, ultimately, leading to a decreased release of proinflammatory cytokines.

Modifications of the immune responsiveness in patients with hepatitis C virus infection following treatment with IFN-alpha/ribavirin.

The balance between T helper (h)1 and Th2 responsiveness seems to represent a key event in the evolution of hepatitis C virus (HCV) infection. In particular, Th1 cytokines [interleukin (IL-2) and interferon (IFN-gamma)] have been demonstrated to mediate the antiviral immune response. Serum levels of Th1 cytokines (IL-2 and IFN-gamma) as well as of Th2 products (IL-4 and IL-10) were determined in a group of HCV-positive patients before and after treatment with IFN-alpha and Ribavirin (RIB). Results indicate that responder patients exhibited increased levels of IFN-gamma and IL-10, while this enhancement was not observed in non-responder patients. In this respect, the major effect exerted by the combined therapy with IFN-alpha/RIB could be represented by the attainment of a re-equilibrium between inflammatory (Th1) and antiinflammatory (Th2) mechanisms. In this framework, according to current literature, novel therapeutical approaches to treat HCV infection are represented by administration of recombinant IL-2 and IL-10.

Biological and clinical significance of endotoxemia in the course of hepatitis C virus infection.

Endotoxins or lipopolysaccharides (LPS), major components of the cell wall of Gram-negative bacteria, once released from the bacterial outer membrane bind to specific receptors and, in particular, to a membrane-bound receptor, the CD14 (mCD14) and the toll-like receptor 4 present on monocytes/ macrophages. In turn, LPS-activated monocytes/ macrophages release in the host tissue an array of so-called proinflammatory cytokines and, among them, Tumor Necrosis Factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, IL-8 and IL-12 are the major mediators. Before therapy (To) and at the end of 6-month interferon (IFN)-alpha/Ribavirin (RIB) treatment (T6), circulating endotoxin levels were measured in responder and non responder HCV+ patients. At T0, 57% of the non responders were endotoxin-positive and had, on average, 54 pg/ml of plasma LPS while in 50% of the responder patients endotoxin were found with an average of 29 pg/ml. At T6, in responders LPS were no longer detectable, while in 42% of the non responders LPS were found (average levels 45 pg/ml). In terms of serum cytokine concentration, at T6 IFN-gamma levels when compared to those detected at T0 were increased in both endotoxin-positive and endotoxin-negative patients. However, at T6 IL-10 concentration was significantly increased only in the group of endotoxin-negative subjects (responder patients), in comparison to T0 values. The origin of endotoxemia in HCV+ patients seems to be multifactorial, likely depending on impaired phagocytic functions and reduced T-cell mediated antibacterial activity. In these patients, however, one cannot exclude the passage of LPS from the gut flora to the blood stream, owing a condition of altered intestinal permeability. At the same time, a less efficient detoxification of enteric bacterial antigens at the hepatic level should be taken into consideration. Finally, novel therapeutic attempts aimed to neutralize LPS in the host are discussed.

Tamoxifen in the treatment of hepatocellular carcinoma: 5-year results of the CLIP-1 multicentre randomised controlled trial.

BACKGROUND: In 1998, when data of a meta-analysis on tamoxifen in the treatment of hepatocellular carcinoma (HCC) had suggested a little advantage for this treatment, we published the results of a multicenter randomised controlled trial, that showed no survival benefit for tamoxifen vs. control. Here we report an updated analysis of the study results 4.5 years after the closure of enrollment. METHODS: The study had a planned sample size of 480 patients. Patients with any stage HCC were eligible, irrespective of locoregional treatment. Tamoxifen was given orally, 40 mg/die, from randomisation until death. RESULTS: 496 patients were randomised by 30 Institutions from January 1995 to January 1997. Information was available for 477 patients. As of July 2001, 374 deaths (78%) were recorded, and median survival times were 16 and 15 months (p=0.54), in the control and tamoxifen arm. Data were further analysed separately for advanced patients and for those eligible to potentially curative locoregional treatments: relative hazard of death for patients receiving tamoxifen was equal to 0.98 (95% CI 0.76-1.25) for the former group and 1.38 (95% CI 0.95-2.01) for the latter. The prognostic score recently devised by our group (CLIP score) was, as expected, strictly correlated (p<0.0001) to the locoregional treatment received and strongly correlated with prognosis. CONCLUSIONS: the update of the present study confirms that tamoxifen is not effective in prolonging survivals, both in advanced patients and in those potentially curable and that the CLIP score is able to predict prognosis.

Cytoplasmic localization of hepatitis B core antigen in hepatitis B virus infected livers.

Routine use of commercially available antisera against hepatitis B core antigen (HBcAg) obtained from Escherichia coli transfected with HBV-DNA, has permitted a re-evaluation of the histochemical distribution of the antigen in liver tissue. HBcAg, classically described almost exclusively in the nucleus, was found with a very high frequency in the cytoplasm of liver cells. Our data indicate, however, that formalin fixation and paraffin embedding destroy part of HBcAg antigenicity and eliminate most of its cytoplasmic expression. HBcAg was found in 6/7 (85.7%) of HBsAg/HBeAg positive subjects, and in 2/12 (16/6%) of HBsAg/anti-HBe positive subjects; in both subgroups the cytoplasmic expression of the antigen correlated with the presence of circulating hepatitis B virus-deoxyribonucleic acid (HBV-DNA).

Detection of receptors for polymerised human albumin by immunoperoxidase and immunoadherence in liver tissue of HBsAg chronic carriers.

Receptors for polymerised human albumin (pHSA-Rs) were detected in unfixed cryostat sections from HBsAg chronic carriers using direct immunoperoxidase and immunoadherence methods. Although pHSA-Rs were detected by both methods, the receptors detected by immunoperoxidase were associated with HBV and showed properties different from the receptors detected by immunoadherence. The double immunocytochemical staining which detected contemporaneously pHSA-Rs and HBsAg in the same cell showed that there are two types of infected hepatocytes: one capable of synthesizing pHSA-Rs and HBsAg and the other capable of synthesizing only HBsAg. The intrahepatocyte synthesis of pHSA-Rs does not correlate with the severity of chronic liver disease or with the presence of tissue HB core antigen.

An enzyme-linked immunosorbent assay for the detection of autoantibodies to albumin.

The development of an enzyme-linked immunosorbent assay (ELISA) for anti-albumin autoantibodies (AAA), using immobilized monomeric or glutaraldehyde-polymerized human, bovine or egg albumin, is described. Major problems in detection by the ELISA of AA against human albumin (HSA) were due to high 'non-specific' binding with the commercial anti-human immunoglobulin antisera used and to interference by IgM/HBs circulating complexes. However, it was found that AAA are not species-specific and that these problems may be overcome using immobilized bovine (BSA) or egg (EggA) albumin. AAA were found to have a similar affinity for BSA as for HSA but slightly lower for EggA, while AAA affinities for the monomeric forms were lower than for the corresponding polymeric albumins. All sera from the 28 normal subjects tested were found to contain both IgM- and IgG-AAA. Patients with acute hepatitis B (n = 23) had significantly lower titres of IgM-AAA than normal subjects, as did chronic HBV carriers with (n = 33) or without (= 17) underlying liver disease, while IgG-AAA titres were reduced only in the acute hepatitis patients. These findings support the concept that AAA have a normal physiological function (probably for removal of effete albumin molecules) and that, in HBV infection, there is a decrement in titres that may be related to the clearance of the virus.

Combination therapy with ribavirin and alpha interferon for the treatment of chronic hepatitis C refractory to interferon.

BACKGROUND: Up to 80% of hepatitis C patients are refractory to treatment with interferon-alpha. These patients are not likely to benefit from higher dosages or longer duration of interferon alone. The addition of ribavirin has been shown to improve the response rate in patients resistant to a previous course of interferon-alpha alone. AIM: To evaluate whether a sustained hepatitis C virus (HCV) RNA response could be obtained with combination therapy of interferon-alpha and ribavirin in patients who did not respond to or relapsed after a standard interferon-alpha treatment. METHODS: A total of 73 patients, 59 non-responders and 14 relapsers after interferon-alpha alone, were treated with a combination of ribavirin (1000-1200 mg/day) and interferon-alpha (3 MU three times a week) for 24 weeks. Alanine aminotransferase levels and HCV RNA were checked for 24 weeks after completion of therapy. RESULTS: At the end of the combination therapy, 36 patients (49%) showed alanine aminotransferase normalization and in 20 patients (27%), HCV RNA was undetectable in serum. At the end of the 24 weeks follow-up period, only 12 patients (16%) had a sustained response with serum negativity of HCV RNA. This response was significantly higher in relapsers than in non-responders: five (36%) vs. seven (12%) patients (P=0.03), respectively. Adverse effects were restricted to flu-like symptoms and moderate haemolytic anaemia. CONCLUSIONS: Combination of interferon-alpha and ribavirin is quite limited, both in scope and efficacy, in HCV patients who had a non-response to monotherapy with interferon. Better results may be expected in relapsers, but larger studies are necessary.

Demonstration of HBsAg as the antigen component in circulating immune complexes detected by peg-solid phase test.

The development of an enzyme-linked immunosorbent assay to identify HBsAg as the antigen component within circulating immune complexes using immobilized polyethylene glycol (PEG) is described. The method utilizes, on one hand, the ability of PEG to bind stably to plastic supports and, on the other, to precipitate circulating macromolecules. This method is easily performed, very cheap, quick and, above all, it helps define the biological nature of the immune complexes. HBsAg can be revealed as the antigen component of HBsAg/anti-HBs soluble immune complexes at concentrations of at least 20 ng/ml and either in antigen or antibody excess. Our results indicate that HBsAg circulates in a complexed form in 47% of HBsAg chronic carriers and in 10.7% of patients with liver disease who are positive for serum antibody to hepatitis B surface antigen (anti-HBs) and to core antigen (anti-HBc). None of the other groups of patients in the study had circulating HBsAg in the complexed form.

Serum 90K/MAC-2BP glycoprotein levels in hepatocellular carcinoma and cirrhosis.

90K/MAC-2BP glycoprotein is a serum tumour marker, member of the scavenger receptor cysteine rich (SRCR) protein superfamily, involved in different immunological mechanisms. In the present study, we determined 90K serum levels by a sandwich enzyme immunoassay using the same monoclonal antibody in 11 chronic active hepatitis (CAH), 48 liver cirrhosis and 36 hepatocellular carcinoma (HCC). In comparison, the same samples were also tested for AFP. According to a cut-off point of 14 micrograms/mL for the 90K, established as 100% of specificity in 50 controls, we observed increasing positivities from CAH to cirrhosis and then to HCC (27%, 50% and 78%, respectively). In cirrhotic patients 90K levels were associated with the presence of anti-HCV antibodies, but not with the degree of liver compromise. Finally, 90K sensitivity was higher than AIFP in all groups of hepatic patients. However, further investigations are needed before proposing 90K as a clinical useful tumour marker in the progression from cirrhosis to HCC.

Are 90K/MAC-2BP serum levels correlated with poor prognosis in HCC patients? Preliminary results.

In this study we assessed the prognostic significance of 90K/MAC-2BP serum levels in a group of 40 hepatocellular carcinoma patients. This glycoprotein is a new, interesting serum marker that reflects the immune reaction of the host against certain viral infections and tumors such as breast, ovarian and pancreatic cancer. Hepatocellular carcinoma (HCC) is one of the most widespread tumors in the world. AFP is currently the most useful marker for HCC, in spite of its poor diagnostic sensitivity. In this study 40 cirrhotic HCC patients were enrolled. The prevalence of viral hepatic infections in this group was 73% for HCV, 8% for HBV, and 8% for both viruses. Thirteen percent of the patients showed non-virus-related liver damage. 90K serum levels were assayed by an ELISA kit and AFP levels by a chemiluminescent enzyme immunometric system. The overall survival curves were estimated by the Kaplan-Meier method, taking into account age, sex, 90K and AFP serum levels. Statistical analysis showed a highly significant influence on overall survival of age below 70 years and 90K serum levels below the cutoff of 14 ng/mL. Serum AFP (< or = 20 ng/mL) had positive prognostic value only when it was associated with 90K levels (p < 0.02, log-rank).

The serum tissue polypeptide antigen in the detection of hepatocellular carcinoma in cirrhotic patients.

The aim of our work was to assess the performance of tissue polypeptide antigen in detecting hepatocellular carcinoma in cirrhotic patients, while also checking for any influence of liver dysfunction on the serum level of the marker. One hundred and twenty-five consecutive cirrhotic patients, 35 with and 90 without, hepatocellular carcinoma were studied. Tissue polypeptide antigen had a different distribution in the two groups and the best diagnostic accuracy with 48.6% sensitivity and 85.6% specificity was found at the cut-off value of 240 UL-1. In cirrhotic patients significant linear correlations were found between tissue polypeptide antigen and alanine-transaminase, aspartate-transaminase, G-glutamyl-transpeptidase and alkaline phosphatase; there was no correlation with bilirubin or pseudo-cholinesterase. In patients with hepatocellular carcinoma a significant linear correlation was found only with alanine and aspartate transaminase and G-glutamyl-transpeptidase. The analysis of covariance still showed a significant difference between mean tissue polypeptide antigen levels in the two groups also accounting for covariates. These results suggest that: a) the liver dysfunction may be involved in increasing tissue polypeptide antigen values; b) tissue polypeptide antigen has a different distribution in cirrhotic patients with and without hepatocellular carcinoma also accounting for covariates; these findings further support the specificity of tissue polypeptide antigen.

Binding and receptors for human albumin polymers and IgM/HBs circulating complex in HBsAg chronic carriers.

Binding activity for polymerized human serum albumin (pHSA-binding), studied in passive haemoagglutination, receptors for polymerized human serum albumin (pHSA-receptors), studied in ELISA, as well as the circulating IgM/HBs complex were tested in 71 chronic carriers of HBsAg with and without liver pathology. We found that 73.2% of the sera were reactive for pHSA-binding while 45% were reactive for pHSA-receptors and 42.2% for the circulating IgM/HBs complex. The distribution and mode of association of these 3 markers showed a close correlation with the e-antigen in circulation (HBeAg) and with liver disease (p less than 0.05). We further observed that pHSA-binding can be present in the absence of pHSA-receptors, suggesting the possible existence of further reactants in the serum-pHSA reaction. We did not observe any correlations between the circulating IgM/HBs complexes, pHSA-binding and pHSA-receptors. Blocking experiments, in fact, confirmed the non-involvement of polymerized human serum albumin in the formation of the circulating IgM/HBs complex. Elution experiments showed that, in addition to HBsAg, class-G immunoglobulins are also directly involved in the serum-pHSA reaction.

Autoantibody to albumin of type G and M in acute and chronic viral hepatitis.

Autoantibodies to albumin (AAA) were tested by an ELISA method in patients with A, B and NANB acute and chronic hepatitis, and in a control group. AAA-IgM had a different behaviour in acute hepatitis type A, in which we observed a high average titre as compared with B, and NANB hepatitis, in which we observed a decrease in the average titre. In the chronic phase, we noted a decrement of the average titre in all the types of hepatitis. For AAA-IgG, in the acute phase the average titre in hepatitis A, B and NANB was lower than in the control group. In the chronic stage, only NANB hepatitis showed a decrement of the average titre of the antibody. On the base of these results, we can say that the involvement of AAA seems to be different in hepatitis A from the other two types, in which the decrement of average titre may be explained by the formation of immunocomplexes which are not detected by this test.

Serum binding activity for human albumin polymers in acute and chronic virus hepatitis.

We considered the serum binding activity for human albumin polymerized with glutaraldehyde in 346 serum samples of 205 subjects with acute and chronic type A, B and non-A, non-B virus hepatitis. We showed that the binding activity for pHSA in the control groups did not have a titer higher than 2(-6). All sera from patients with HAV and HBV acute infection showed a high binding titer that returned to below the threshold in the former after the peak of hepatocytolysis, and in the latter after the seroconversion of HBsAg to anti-HBs. In the subjects who became HBsAg chronic carriers after the acute episode of HBV infection, the pHSA binding activity showed a decrement of the titer in relation to the seroconversion of HBeAg to anti-HBe. Furthermore, 92% of HBsAg chronic carriers who were HBeAg positive had a high titer of pHSA binding, while only 14.3% of the anti-HBe positives showed a high titer. Acute and chronic hepatitis non-A, non-B virus showed a pHSA binding titer similar to that of the control group. The results indicate that the non-A, non-B virus does not seem to be correlated to pHSA or related factors.

[Histomorphological study of the relation between mast cells and liver disease]. / Studio istomorfologico sul rapporto tra "mastzellen ed epatopatia".

In order to report the eventual role of mastzellen in hepatic pathology, we recorded the histological count on 75 sections of transcutaneous hepatic biopsies. We observed that there is no difference between the number and the localization of the mastzellen of normal subjects and those of nonevolving pathologies (Chronic Persistent Hepatitis, Portal Fibrosis, Steatosis). We saw consisent increase in number in the evolving pathologies and in particular near the collagenopoietic cytolitic foci, indicating a possible role of these elements in inflammation and in the production of collagen in liver diseases.

[The effect of ursodeoxycholic acid in patients with liver cirrhosis and chronic hypertransaminasemia]. / Effetto dell'acido ursodesossicolico in pazienti con cirrosi epatica ed ipertransaminasemia cronica.

The aim of the study was to evaluate the effect of ursodeoxycholic acid (UDCA) oral administration on alanine aminotransferases (ALT) levels in cirrhotic patients with chronic hypertransaminasemia. Ninety consecutive patients with histologically proven liver cirrhosis and ALT levels higher than twice the upper limit of normal for at least six months, were admitted to the study. All the patients were treated with UDCA 10 mg/kg/day for one year. At the end of this period they were randomized to placebo or to continue UDCA therapy for three further months. ALT levels were evaluated before the beginning of UDCA therapy, at twelve and fifteen months by standard methods. After 12 months of UDCA, ALT decreased significantly (-39 UI, 95% confidence intervals -27 to -52 UI). At the 15 th month ALT did not vary with respect to its values at the 12th month in 36 patients randomized to continue UDCA, while it increased significantly in patients taking the placebo (+11 UI 95% confidence intervals +2 to +19). The results of this study suggest that UDCA is effective in controlling the biochemical activity of the liver disease in cirrhotic patients.

[Intragastric pH determination as a screening test in the diagnosis of chronic atrophic gastritis]. / Il pH intragastrico come test di screening per la diagnosi di gastrite cronica atrofica.

A simple routine endoscopic screening test has been sought for the diagnosis of chronic atrophic gastritis. An endoscopic-bioptic study was therefore carried out on 850 subjects presenting consecutively at a Digestive Endoscopy Department with dyspeptic-pain symptomatology. In a first sample of 389 patients, 2 biopsies of the gastric body and 2 of the gastric antrum were carried out, independently of the endoscopically documented macroscopic picture. Atrophic changes were in this way encountered in 65 patients (16.7%). In a second group of 461 patients, intragastric pH was determined extemporaneously during endoscopy. pH was = or greater than the chosen threshold value (3.5) in 117 patients and less than this value in 344. In all subjects with pH greater than 3.5 and, by comparison, in 130 with pH less than 3.5 biopsy was carried out on the gastric mucosa, 2 biopsies of the body and 2 of the antrum. Using this approach it was possible to determine the presence of atrophic changes in the gastric mucosa in 57 of 117 (48%) and in 25 of 130 (20%) respectively. In total, chronic atrophic gastritis was diagnosed in 83 of 461 subjects (18%). This percentage is comparable to that observed in the frequency of chronic atrophic gastritis using the more demanding and less selective test of bioptic sampling indiscriminately for all patient. So, the straight-forward determination of intragastric pH in a sample of gastric juice taken during digestive endoscopy would appear to meet the criteria demanded for a screening test and its wider use is recommended in routine endoscopic practice.

[The risk factors for hepatitis D viral infection in southern Italy]. / Fattori di rischio di infezione da virus dell'epatite delta nel Sud Italia.

The aims of this study were to evaluate the prevalence of hepatitis delta virus (HDV) infection and risk factors associated to it. Three hundred sixty-one HBsAg chronic carriers from southern Italy were studied and 13.8% of them resulted anti-delta positive. 80% of these subjects were less than 50 years old. When anti-delta positive subjects were compared with anti-delta negative ones, a lower number of healthy HDV carriers and a higher frequency of cirrhotics were noted among anti-delta positive. Of lower than 50 years, imprisonment, sexual contacts with drug abusers and male homosexuality were risk factors of HDV infection. No association was found with sex, household contacts with HBV or HDV carriers, number of family members and transfusion of blood products. These data confirm the high prevalence of HDV infection in southern Italy.