Prevention of hepatocellular carcinoma and its recurrence with anti-hepatitis B viral therapy.

The ultimate goal of antiviral therapy for chronic hepatitis B (CHB) should be prevention of Hepatocellular carcinoma (HCC). The discovery of the hepatitis B virus (HBV) in 1965 and eventual development of antiviral drugs during the past decades, has led us to observe a remarkable success in arresting the disease progression. More importantly, we have been able to prevent secondary HCC formation with antiviral therapy. Currently HCC is the second most common cause of cancer-related death, worldwide, accounting for more than 700,000 deaths each year. Most of the burden of disease (85%) is observed in the HBV endemic regions. It is thought that HBV contributes to HCC by directly modulating pathways that promote the malignant transformation of hepatocytes. Primary prevention of HBV infection by vaccination has been effective in reducing the incidence of HCC. On the other hand in people already infected with HBV, there is abundant evidence that antiviral therapies with the aim to suppress or eliminate HBV replication, can slow progression or even reverse liver damage, therefore, preventing HCC formation. Antiviral therapies also play an important role in preventing tumor recurrence in patients who undergo chemotherapy, ablative therapy, local resection, liver transplant or palliative treatment for HCC. This review will evaluate the mechanisms of HBV induction of HCC and the role of antivirals in both primary and secondary prevention of HCC.

Serum ferritin as a predictor of host response to hepatitis B virus infection.

With hemodialysis patients, a high serum ferritin before there was serological evidence of hepatitis B virus infection increased the likelihood that the infection would be persistent. This finding suggested that hepatitis B virus is likely to infect and actively replicate in liver cells with the propensity for increased ferritin synthesis. The virus itself could stimulate the synthesis of ferritin in a cyclic positive feedback mechanism that increases intracellular ferritin concentration and, eventually, intracellular iron. Transformed liver cells have low iron content, do not replicate hepatitis B virus, and require iron for growth. Infected, nonmalignant liver cells could supply iron to the transformed cells and nourish their expansion.

Active antiviral therapy for chronic hepatitis B and hepatocellular carcinoma.

The ultimate goal of treatment for chronic hepatitis B (CHB) is to prevent hepatocellular carcinoma (HCC). During the last decade, great strides have been made in the treatment of hepatitis B virus (HBV) infections. Six highly effective anti-HBV agents are currently available and more agents are on the horizon. Prospective and retrospective studies of large numbers of CHB patients with advanced liver disease, including cirrhosis, have demonstrated that the treatment with lamivudine not only delays the disease progression but also reduces the incidence of HCC. In a large prospective study of 3,653 HBV carriers in Taiwan, 164 persons developed HCC in a 12-year follow-up period; an extensive analysis of their condition led to the conclusion that the most important risk factor for HCC is an increased serum level of HBV DNA >10,000 copies/mL regardless of the HBeAg status, alanine aminotransferase levels or presence of cirrhosis. The incidence of HCC correlated with serum HBV DNA level at entry in a dose-response relationship. These pivotal studies re-emphasize the need for an active anti-HBV therapy for CHB patients with viral replication as the ultimate prevention and/or delay for the development of HCC.

An expert consensus for the management of chronic hepatitis B in Asian Americans.

BACKGROUND: Hepatitis B virus (HBV) infection is common with major clinical consequences. In Asian Americans, the HBsAg carrier rate ranges from 2% to 16% which approximates the rates from their countries of origin. Similarly, HBV is the most important cause of cirrhosis, hepatocellular carcinoma (HCC) and liver related deaths in HBsAg positive Asians worldwide. AIM: To generate recommendations for the management of Asian Americans infected with HBV. METHODS: These guidelines are based on relevant data derived from medical reports on HBV from Asian countries as well as from studies in the HBsAg positive Asian Americans. The guidelines herein differ from other recommendations in the treatment of both HBeAg positive and negative chronic hepatitis B (CHB), in the approach to HCC surveillance, and in the management of HBV in pregnant women. RESULTS: Asian American patients, HBeAg positive or negative, with HBV DNA levels >2000 IU/mL (>104 copies/mL) and ALT values above normal are candidates for anti-viral therapy. HBeAg negative patients with HBV DNA >2000 IU/mL and normal ALT levels but who have either serum albumin <3.5 g/dL or platelet count <130 000 mm3 , basal core promoter (BCP) mutations, or who have first-degree relatives with HCC should be offered treatment. Patients with cirrhosis and detectable HBV DNA must receive life-long anti-viral therapy. Indications for treatment include pregnant women with high viraemia, coinfected patients, and those requiring immunosuppressive therapy. In HBsAg positive patients with risk factors, life-long surveillance for HCC with alpha-fetoprotein (AFP) testing and abdominal ultrasound examination at 6-month intervals is required. In CHB patients receiving HCC treatments, repeat imaging with contrast CT scan or MRI at 3-month intervals is strongly recommended. These guidelines have been assigned to a Class (reflecting benefit vs. risk) and a Level (assessing strength or certainty) of evidence. CONCLUSIONS: Application of the recommendations made based on a review of the relevant literature and the opinion of a panel of Asian American physicians with expertise in HBV treatment will inform physicians and improve patient outcomes.

Source of increased ferritin in neuroblastoma: studies with concanavalin A-sepharose binding.

Serum ferritin is present in two forms--a glycosylated form that results from active secretion by cells and a nonglycosylated form that is directly released by damaged cells. Glycosylated ferritin binds to concanavalin A (Con A) through the glucose and/or mannose residues of the molecule. Patients with neuroblastoma frequently present at diagnosis with abnormally elevated levels of serum ferritin. The ferritin levels will, however, return to normal with clinical remission, suggesting that the tumor is the origin of the elevated ferritin. With the use of a Con A binding assay, an investigation was made as to whether the increased levels of serum ferritin at diagnosis in neuroblastoma patients resulted from active secretion by the tumor or were the consequence of direct release of ferritin from damaged tissue. Serum samples were collected at diagnosis from 36 children with neuroblastoma and from 16 normal healthy subjects. Tissue ferritins were purified from normal human liver, placenta, HeLa cells, human neuroblastoma, and hepatoma cells grown in culture. Serum and tissue ferritins were measured before and after binding with Con A. Sixty-three percent of serum ferritin from neuroblastoma patients and 66% of serum ferritin from normal subjects were bound to Con A, suggesting that they were glycosylated and were likely to have been secreted. On the other hand, only 28% of tissue ferritin were bound to Con A. Furthermore, most patients showed abnormally elevated levels of serum ferritin, and 63% of these ferritins were bound to Con A. These results are compatible with the hypothesis that much of the elevated ferritin in sera of patients with neuroblastoma seen at diagnosis is the result of secretion of ferritin by the tumor.

Changes in clonal expression during the course of acute leukemia: possible subsets in childhood leukemia.

We studied cell surface markers and chromosomes in the leukemia cells of a boy with the initial diagnosis of acute lymphocytic leukemia during 18 months from diagnosis to demise. During this time he received induction therapy, underwent bone marrow transplantation, and relapsed. The leukemia cells expressed three membrane phenotypes during different stages of disease: T-cell at diagnosis; T-cell, B-cell, and monocyte during the induction period; T-cell in the first relapse after bone marrow transplantation; and T-cell and B-cell during the terminal stage. Some cells expressed markers of two cell types, indicating a common origin of these cells. Cytogenetic studies during post-transplantation relapse showed abnormal marker chromosomes that indicated two major sublines. However, there was enough sharing of other aberrant chromosomes to suggest that these two populations presented sublines within the same neoplastic clone. We suggest that these leukemia cells were derived from a pluripotential cell prior to differentiation into cells of the lymphoid and monocytic series. This particular case may represent a subset of acute leukemia and may account for the resistance to conventional therapy.

Childhood lymphoblastic cancer: subgroups defined by nonhuman primate antisera to human lymphatic leukemia cell antigens.

Lymphoblasts from 23 children with acute lymphocytic leukemia (ALL) and 10 with lymphoblastic lymphoma (LBL) were studied by complement-dependent microcytoxicity tests with two nonhuman primate antisera defining leukemia-associated and lymphoma-associated antigens. Cells form 15 patients with ALL and 1 with LBL reacted only with antiserum to chronic lymphatic leukemia (CLL). These group-I patients were predominantly female. Most were pancytopenic and lacked mediastinal widening and T-cell markers; lymphoblasts from 15 were periodic acid-Schiff-positive. Cells from 8 male patients reacted only with antiserum to converted lymphosarcoma (LS). All these group-II patients expressed T-cell markers; 5 had mediastinal enlargement and 2, an abdominal mass. Six of the 8 were PAS-negative. Cells from 9 patients reacted with both antisera. The group-III patients demonstrated some characteristics of each of the above groups. Patients whose lymphoblasts reacted with CLL antiserum presented with clinical and laboratory features indicative of a good prognosis, i.e., ALL with PAS positivity and no T-cell markers or localized mass. Patients whose cells reacted with LS antiserum often had bad prognostic features: mediastinal or abdominal mass, expression of T-cell markers, and PAS negativity. These antisera appear able to differentiate childhood ALL from LBL. The distinction is important prognostically and perhaps therapeutically.

Studies of parents of children with acute leukemia.

In a case-control study, 70 mothers and 24 fathers of children with acute leukemia (AL) were compared with 70 mothers and 24 fathers of normal children. Three significant differences (p smaller than 0.05) were found when 35 factors were compared among the mother pairs and one difference among the father pairs. Mothers of children with AL, though alike in most respects to their matched controls, had a significantly lower number of monocytes than their controls. This was a new observation. The mothers of the children with AL also had higher levels of gamma-globulin, IgA, and IgG (Philadelphia only), which confirmed previous observations. The fathers and mothers had higher levels of basophils. These findings direct attention to the immune systems, particularly the mononuclear cells, of the parents of children with AL, as a focus for further studies on the etiology and pathogenesis of childhood leukemia.

Lack of influence of T-cell marker and importance of mediastinal mass on the prognosis of acute lymphocytic leukemias of childhood.

One hundred consecutive new cases of acute lymphocytic leukemia (ALL) were studied in patients that were 4 months to 16 years of age when admitted to The Children's Hospital of Philadelphia. Various prognostic factors were examined and related to the duration of the first remission. These factors included lymphoblast surface markers, age at diagnosis, sex, race, initial white blood counts (WBC), presence of mediastinal mass, degree of hepatosplenomegaly, and lymph node size. Classification by lymphoblast surface markers showed 22 T-cell, 71 null cell, and 3 B-cell leukemias; 3 cases were unclassifiable and 1 had both T- and B-cell markers. Statistical analysis indicated that stratification by presence or absence of mediastinal mass was necessary. Most patients with mediastinal masses, 5 of thymus and 4 of the non-thymus type, fared poorly with a median duration of continuous complete remission of less than 12 months as compared with greater than 48 months for those without such masses. The most satisfactory model to estimate remission duration in children without mediastinal masses was dependent upon initial WBC, sex, race, and surface markers. Low WBC, white race, female sex, and T-cell markers in patients without mediastinal masses were associated with a favorable prognosis. The findings suggest that patients with mediastinal masses need special therapy and that T-cell ALL without a mediastinal masses need special therapy and that T-cell ALL without a mediastinal mass does not carry a poorer prognosis than does null cell ALL.

Iron nutrition and tumor growth: decreased tumor growth in iron-deficient mice.

Groups of 15 mice of three different laboratory strains (BALB/c, C3H/He, DBA/2) were fed on a low iron diet (5 mg iron/kg diet), and three similar groups of 15 mice were maintained on a normal iron diet (312 mg iron/kg diet). When the low iron diet group became iron deficient, tumor cells (5 x 10(5) cells/mouse) of CA07-A (colon adenocarcinoma), HE129 (hepatoma), and M119 (mammary adenocarcinoma) were inoculated s.c. in BALB/c, C3H/He, and DBA/2 mice, respectively. All mice developed tumors, tumors grew more slowly, and the mean tumor sizes were smaller in the low iron diet group at nearly all weekly observations in all three strains of mice. No apparent differences in the behavior, activity (e.g., movement, climbing, running, grooming, etc.), and appearance were observed between low iron diet and normal iron diet mice. The mean body weight of mice at transplantation was less in the low iron than in the normal iron groups for the BALB/c strain but higher in the low iron groups of C3H/He and DBA/2 mice, indicating that food intake of mice on a low iron diet was not impaired. These results suggest that iron nutrition of the host affects tumor growth; tumor cells grow better in an iron-rich environment. This knowledge should be considered when designing treatment for patients with cancer. Iron oversupply in cancer patients might enhance tumor growth and adversely affect cancer therapy.

Serum ferritin as a guide to therapy in neuroblastoma.

Elevated serum ferritin levels without a corresponding increase in tissue iron storage have been observed in patients with certain cancers. Increased synthesis of ferritin by cancer cells has also been reported. In order to see whether similar phenomena occurred in patients with neuroblastoma, we have screened serum ferritin levels in 58 children with neuroblastoma by counterelectrophoresis using antibody to human ferritin. Increased ferritin levels in serum, positive by counterelectrophoresis (greater than or equal to 400 ng/ml), correlated well with the presence of active disease (p less than 0.001 by Fisher's exact 2 X 2 test). A longitudinal study of serum ferritin levels in 34 of the 58 patients showed the same association of elevated serum ferritin with active disease; a return of ferritin levels to the normal ranges coincided with remission. Primary neuroblastoma tumors and cells from neuroblastoma cell lines contained ferritins with the electrophoretic characteristics different from normal liver ferritin. Supernatant fluids from six neuroblastoma cell lines grown in culture also contained ferritin. These findings suggest that the increased ferritin in the serum of patients is derived from the tumor. The serum ferritin level could be used as indicator of disease activity and as a guide to therapy.

Chromosome abnormalities in peripheral blood cells of hepatitis B virus chronic carriers.

Cytogenetic analysis of metaphase chromosome spreads from peripheral blood cells of hepatitis B virus (HBV) chronic carriers and HBV-negative individuals of the same ethnic origin revealed a significantly higher incidence of chromosome breaks and other mitotic aberrations in the HBV chronic carriers. The highest incidence of chromosome breaks was found in chronic carriers who evidenced circulating HBV. Such an association between HBV and these genetic lesions assumes importance in light of the known correlation between HBV chronic carrier status and the high risk of hepatocellular carcinogenesis, where a mutagenic effect of HBV cannot be excluded.

Prognostic importance of serum ferritin in patients with Stages III and IV neuroblastoma: the Childrens Cancer Study Group experience.

Ferritin was measured in sera obtained at diagnosis from 241 patients with neuroblastoma to determine (a) the incidence of elevated ferritin and (b) the relationship between ferritin level and outcome. Ferritin was infrequently elevated in sera from patients with Stages I and II disease but was abnormally elevated in 37 and 54% of those with Stages III and IV neuroblastoma, respectively. The mean and median levels for each stage were compared and were highest for Stages III and IV disease. Analysis of progression-free survival for children with Stages III and IV disease indicated that elevated ferritin was associated with a significantly poorer prognosis than was normal ferritin and that this correlation was independent of stage and age at diagnosis. Progression-free survival at 24 months of follow-up for patients with Stage III disease with normal ferritin was 76% and with elevated ferritin was 23%. For those with Stage IV disease, progression-free survival was 27 and 3% with normal and elevated ferritin, respectively. We conclude that determination of the level of ferritin in serum at diagnosis is useful for selecting appropriate therapy for patients with Stage III neuroblastoma. Those with normal ferritin (63% of patients) have a good outcome with current therapy, but those with elevated ferritin (37%) do poorly and require more effective therapy. Although ferritin defines subgroups with Stage IV disease, the outcome of all groups must be improved.

Serum epoxide hydrolase (preneoplastic antigen) in human and experimental liver injury.

Reports of an increase in a serum epoxide hydrolase (sEH), immunochemically related to microsomal EH in humans and rats with hepatocellular carcinoma (HCC), suggested its use as a serum marker for this disease. We have now measured sEH levels (as either immunochemically determined content or enzyme activity) in a number of human and experimental models of liver disease. sEH was elevated above the normal range in at least 50% of individuals with HCC, including: 3 of 6 northern Californians; 4 of 7 Koreans with hepatitis B-associated HCC; hepatitis B-associated HCC in woodchucks; and male rats receiving chronic treatment with aflatoxin B1 or ciprofibrate. sEH was rarely elevated in other forms of chronic liver disease. Only 2 of 9 Koreans with hepatitis B-associated cirrhosis, 1 of 8 carriers, but none with chronic active hepatitis or infection with no apparent liver disease had elevated sEH. In addition, no elevations were found in woodchucks with noncancerous viral hepatitis. In aflatoxin B1- and M1-treated rats sEH was not elevated in those with only hyperplastic foci or hepatocellular adenomas, and in two rat initiation-promotion protocols sEH was elevated only in those rats which received the entire set of treatments. sEH was also increased during acute hepatotoxicity in rats treated with CCl4 or 1,2-dibromo-3-chloropropane. The mechanism of increase in sEH during hepatocarcinogenesis appears to be different from that of other markers of HCC, for in the Korean patients, there was no correlation between sEH concentrations and those of alpha-fetoprotein or ferritin, nor was there a correlation with alpha-fetoprotein concentrations in the aflatoxin-treated rats. Furthermore, the increase in sEH does not correlate with induction of microsomal EH in the liver of experimental animals. Studies to date indicate that sEH is selective for HCC and severe hepatonecrotic injury, and may be of some use in the diagnosis of HCC, particularly as a complement to other serum markers.

Mass-like hepatic hypertrophy: MRI findings with histologic correlation.

Hepatic parenchyma may hypertrophy following asymmetrical injury. The histologic characteristics of hypertrophic hepatic parenchyma are more similar to normal hepatic parenchyma than is the more severely damaged liver. We present four cases where large hypertrophic masses resembled neoplasm on other imaging modalities or at surgery, but had MRI signal characteristics similar to those of normal liver.

Symptomatology and health attitudes of chronic hepatitis B patients in the USA.

This study was conducted to understand the symptomatology, attitudes, and behaviours of chronic hepatitis B (CHB) patients in the USA. CHB patients enrolled in this study were recruited through multiple methods, including newspaper advertisements. Interviews were conducted in multiple languages, and all participants had a history of CHB infection for at least 6 months. Patients with documented human immunodeficiency virus or hepatitis C virus coinfection were excluded from data analyses, resulting in a total study population of 258 respondents who completed interviews between April and June 2004. The majority of monoinfected patients were male (57%) and non-Asian (92%, including 52% Caucasian, 32% African American and others). Length of diagnosis was 5.8 years for all participants (9.1-year Asian and 5.1-year non-Asian). Ninety-five per cent of CHB patients reported symptoms of differing severity in the 12 months prior to the survey. The most common symptoms included fatigue/loss of energy (90%) and loss of appetite (79%). Non-Asian patients described greater symptomatology, and were more likely than Asians to consider CHB an overriding concern in their daily activities. Patients were treated either currently or previously with interferon (IFN) described greater symptomatology than those treated without IFN. Survey results indicate that CHB patients may have greater symptomatology than recognized. Disease perceptions and treatment attitudes differ between Asian and non-Asian ethnic groups, with the former appearing to be more accepting and less concerned about the disease. Additional research about CHB symptomatology and health attitudes by ethnicity is needed to ensure that individuals with CHB are educated on the potential health risks and the availability of current treatment options.