Hepatocellular carcinoma: ten years experience among veterans in Puerto Rico

PURPOSE: The aim of our study is to determine the characteristics of hepatocellular carcinoma (HCC) as well as risk factors, demographics, survival rates and the use of diagnostic and therapeutic modalities among veteran patients in Puerto Rico. METHODS: A retrospective study of 114 patients with Hispanic background and biopsy-proven HCC diagnosed at the VA Caribbean Healthcare System from 1992 to 2002 was performed. Demographics data, Child-Turcotte-Pugh (CTP) score, presence of cirrhosis, viral serology, alcohol and/or other liver diseases history, diagnostic modalities, lesion size, therapy, and overall survival were examined. RESULTS: The mean age was 66.6 years old. 82% had known underlying cirrhosis. 60% had alcoholic liver disease (ALD), 33% positive serology for hepatitis C (HCV) and 21% both. 5.3% had chronic hepatitis B virus (HBV) infection. Additional causes were not present. CTP classification was: A (42%), B (44%) and C (14%). Abdominal CT scan demonstrated most of the lesions, while ultrasound only 57%. Alfa-fetoprotein was diagnostic in 32%. Mean survival was 10.3 months, better for those with CTP score A. Only 42% of the patients received any kind of therapy. CONCLUSIONS: ALD is the principal underlying liver disease in our HCC patients, closely followed by chronic HCV infection. Less than half of our patients received treatment mainly due to advanced disease for which the over survival was less than a year. HCC continues to be a dreadful disease with poor prognosis for which aggressive screening should be considered for all patients with cirrhosis and advanced liver disease regardless of the cause.

Primary duodenal signet-ring cell carcinoma presenting as gastric outlet obstruction

Small bowel tumors occur rarely. We present an unusual case of a 68 year old man with gastric outlet obstruction secondary to a non-ampullary primary duodenal signet ring cell carcinoma. A review of the literature of small bowel malignant tumors is presented along with the case.

Anaplastic T-cell lymphoma presenting as fatal acute liver failure

Acute liver failure (ALF) is an uncommon manifestation of liver disease and constitutes a medical emergency for which early identification is necessary. Hepatic involvement by hematologic malignancies although frequent, rarely causes severe hepatic dysfunction. Even more, acute hepatic failure as the first manifestation of a hematologic malignancy is extremely uncommon, although some cases have been reported in the literature. We describe the case of a 61 y/o puertorrican veteran who developed acute hepatic failure secondary to massive infiltration of the liver by a recurrent non-Hodgkin's lymphoma.

Does Silybum marianum play a role in the treatment of chronic hepatitis C?

OBJECTIVES: The recent boom in patient education on chronic hepatitis C has resulted in a worldwide increase in the diagnosis of this condition. Available treatment is expensive and associated with significant side effects; therefore, many patients seek for alternative medicine. Silybum marianum is a natural herb known to mankind for over 2,000 years that has been used as a liver-protecting agent due to its antioxidant properties. The objective of this study is to evaluate the safety profile and the effects of this herb, using a commercially available extract; in the liver chemistry and viral load of hepatitis C in chronically infected patients. METHODS: Patients aged 21-65 years old with a diagnosis of chronic hepatitis C who were not using antiviral therapy were asked to participate. Patients were randomized to treatment with S. marianum 160 mg orally three times a week for four weeks or to no-treatment (control). Blood tests for viral load and liver enzymes (ALT and AST) were done at randomization and at the end of treatment. Paired-t test was used to measure differences between baseline and week 4 values for ALT, AST and viral load. The percent change for ALT, AST and viral load of both groups was analyzed using the Mann Whitney statistical test. RESULTS: 34 patients were enrolled. Men and women were equally distributed. Mean age was 50 years old. Mean baseline measurements of AST, ALT and viral load in the treatment group were 85 +/- 12.41 IU/ml, 120 +/- 20.57 IU/ml and 8.77 +/- 4.12 copies x 10(6)/ml while for the no-treatment group were 71 +/- 9.46 IU/ml, 97 +/- 15.35 IU/ ml and 1.8 +/- 0.62 copies x 10(6)/ml respectively. For treated subjects the mean values of AST, ALT and viral load demonstrated a decrease from baseline values, but this difference was not statistically significant. For control patients the values of ALT (p= .049), AST (p = .005) and viral load (p = .005) showed a statistically significant increase at week 4. Week 4 measurement chang...

Response to combination therapy of interferon alfa-2b plus ribavirin in Hispanics with chronic hepatitis C

OBJECTIVE: To evaluate the response rate of Hispanics with chronic hepatitis C to combination therapy of interferon alfa-2b plus ribavirin and to assess its adverse events. BACKGROUND: Hepatitis C virus may lead to chronic infection and multiple complications. Response to combination therapy of interferon plus ribavirin has been studied in many populations. African Americans have been found to have a lower response rate than Caucasians. However, little data exist for Hispanics. METHODS: Hispanic patients from Puerto Rico with chronic hepatitis C were eligible for the study between November 1997 and February 2000. The Institutional Review Boards of the participating institutions approved the study. Written informed consents were obtained. Combination therapy was given for 48 weeks and patients were followed for 24 weeks after treatment. Analysis of response to therapy was performed in an intention-to-treat basis. RESULTS: The most frequent adverse event was anemia (89%), associated to ribavirin. Sustained response was 23% for naive patients, 45% for relapsers, and 8% for non-responders to previous interferon monotherapy (p < 0.001). Data to analyze response was not available in 27% of patients. Hispanic patients had a low response rate to combination therapy. CONCLUSIONS: Response rates to combination therapy for Hispanic naive and previously non-responder patients are lower than in other reported populations. This may be due to a high prevalence of genotype 1 in Puerto Rico, which is associated to poor response. The higher response rate of relapsers, similar to those reported previously, was expected since these patients showed a previous response to interferon monotherapy. Ethnic factors may play a role in the response to therapy and should be further studied to determine proper treatment strategies for this population.

Steatosis as a predictive factor for treatment response in patients with chronic hepatitis C

BACKGROUND: Hepatic steatosis has been described in 31-72% of chronic hepatitis C virus (HCV) liver biopsies. Steatosis has been related to disease progression and suggested as a predictor of treatment response in chronic HCV. This study aims to evaluate the presence and degree of steatosis in liver histology of patients with chronic HCV prior to combination therapy with interferon (INF) and ribavirin (RBV), and how it influences treatment response. METHODS: The medical charts of patients with chronic HCV who received treatment at the San Juan Veterans Affairs (VA) Medical Center from 1998 to 2002 were reviewed. Selected patients completed therapy, had a pre-treatment liver biopsy, genotype determination, and pre and post treatment HCV-RNA levels. Patient's age, sex and body mass index (BMI) were determined. Pre-treatment liver biopsy slides were reviewed and graded for steatosis by a hepatopathologist blinded to the treatment outcome. Steatosis was graded by the presence of fat in total biopsy area as: mild (<33%), moderate (33-66%), severe (>66%) or absent. Treatment response was defined as virological clearance measured by HCV RNA at the end of treatment and 24 weeks after completion of treatment. The presence of steatosis was compared to BMI, HCV genotype and treatment response. RESULTS: 46 patients met the inclusion criteria. All patients were male of Hispanic origin. Mean age: 52.7 years (range: 40-68). Mean BMI: 27.5 kg/m2 (range: 21.1-35.9). HCV genotype 1 was present in 67% of patients. 82.6% (38/46) of the patients had hepatic steatosis: 29 (63%) mild, 7 (15%) moderate and 2(4%) severe. 16.6% (8/46) of the biopsies did not show steatosis. Overall, the response rate for those with steatosis was 31.6% (12/38): 10/29 (34.5%) mild, 1/7 (14.3%) moderate and 1/2 (50%) of severe. 75% (6/8) of those without steatosis responded to treatment. This difference (31.6% vs. 75%) was statistically significant (p=.042). The mean BMI of both groups was similar (27.7)...

Prevalence of chronic hepatitis C virus genotypes among patients between 21 to 65 years old in Puerto Rico

OBJECTIVES: This is the first study done in Puerto Rico to estimate the prevalence of hepatitis C virus (HCV) genotype distribution in patients with chronic infection and to determine the statistical association between the genotype and variables such as age, sex, HCV risk factors, and viral load. METHODS: Chronic HCV infected patients diagnosed with ELISA, RIBA or PCR from 1990 to 2002 who were under follow up with members of the Puerto Rico Gastroenterological Association were asked to participate. Eligible patients were those without evidence of HIV or other viral hepatic infection; had no previous antiviral treatment or if previously treated, therapy ended at least six months prior to their participation in the study; had no history of organ transplant and were willing to participate. All study subjects completed a study questionnaire and had blood samples taken to determine HCV genotype and viral load. RESULTS: 500 patients were recruited. Most of the study subjects were males (68%); 70% were 45 to 65 years old. The principal reported risk factors were: surgeries (75.5%), drug use (46.8%), sexual relationships with intravenous/intranasal drug users (30.3%), blood transfusions (30.2%), multiple sex partners (28.9%), tattoos (22.0%), needle accidents (12.7%), and sexual relationships with an HCV infected partner (9.0%). Most patients had multiple risks factors for infection, only 3.4% (17/500) reported a single risk factor whereas 2.0% (10/500) reported none. 33% of the patients were previously treated (non-responders or relapsers) while 67% were naive. In general, 82% of the HCV patients had genotype 1, while 18% had non-1 genotypes. Among genotype 1 subtypes, genotype la (39.8 %) was more common than 1b (27%). The most common non-1 genotype was genotype 2 of which 2b represented 9.8% of the study population. Similar distribution was observed within the categories of the HCV risk factors, with the exception of those who reported sex with an infected partn...

Pseudomyxoma peritonei: case report and review of the literature.

Pseudomyxoma peritonei is a rare entity manifested by implants of a mucinous gelatinous material arising from either the appendix or ovary and involves the peritoneal cavity, peritoneum and omentum. Preoperative diagnosis is feasible by means of radiographic studies. The main step in the treatment is debulking surgery with appendectomy, bilateral oophorectomy and omentectomy. Adjuvant radiotherapy and chemotherapy has been used. Long term survival is around 54% at five years. Here we present a case of a ruptured mucocele of the appendix and pseudomyxoma who presents as massive increase in the abdominal girth of two years evolution.

Gastric campylobacter-like organisms and active antral gastritis in Puerto Rico.

We attempted to verify if the reported association of gastric campylobacter like organisms (GCLO) with active antral gastritis holds true in our population. All patients undergoing elective upper endoscopy were eligible for the study unless they had a history of gastric cancer or previous antrectomy. Biopsy specimens from 100 consecutive patients were examined blindly for the presence of inflammatory activity and/or intestinal metaplasia. The presence of GCLO was determined by the acridine orange fluorescence technique. A total of 131 antral biopsies examined were classified as either normal, active gastritis, chronic gastritis with activity and chronic gastritis without activity. GCLO were identified in 84% of the biopsies with inflammatory activity (active gastritis and chronic gastritis with activity). However, GCLO were found only in 11% of those biopsies with chronic gastritis without activity. It is therefore our conclusion that the previously reported association of GCLO with active gastritis holds true for our population.