High AFP Level Research Articles

Combined Hepatocellular and Cholangiocarcinoma Arising from the Retroperitoneum with Favorable Response to Systemic Chemotherapy with GemOX-B

Ectopic liver tissue (ELT) has a reported incidence of 0.24-0.47%. It is most commonly found in sites near the liver, such as hepatic ligaments, omentum, bladder, thorax and retroperitoneum. Rarely, primary liver cancer arises from ectopic liver tissue. We present a case of a combined hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) arising from retroperitoneal ectopic liver tissue in a patient previously treated for hepatitis C. 64 year-old Caucasian male with liver cirrhosis secondary to Hepatitis C successfully treated with Interferon and Ribavirin 10 year before presentation. On surveillance ultrasound, a hypoechoic mass in the porta hepatis was found and subsequently confirmed by computed tomography that demonstrated a 7.1 x 4.3 x 5.9 cm mass causing mass effect on the portal vein, inferior vena cava, duodenum and pancreatic head. Liver function tests, AFP, carcinoembryonic antigen and CA 19-9 were all within normal limits. CA 125 was elevated (839U/mL) and the hepatitis C quantitative RNA was undetectable. Exploratory laparotomy demonstrated a 15 cm mass arising from the retroperitoneum adjacent to the inferior vena cava and portal vein. The tumor did not appear to be arising from the caudate lobe. The pathology was positive for HCC (Hep Par1(+), CK19(+), CK7 focally(+), CEA focally(+), CD34(-), CK20(-), Mart1(-)). Patient received 12 cycles of systemic Gemcitabine and Oxaliplatin and restaging images demonstrated partial response to the treatment. Ectopic HCC is defined as HCC arising from hepatic tissue located outside the liver. In total, HCC has been detected in only 46 of the 110 ELT reported cases. It has been suggested that ELT is more prone to carcinogenesis than the mother liver because it lacks the complete functional architecture necessary for the clearance of viruses and carcinogenic substances. Most ectopic HCC are coincidentally detected due to high AFP levels, an abdominal mass or pain. Nowadays, there are no standard treatment modalities for unresectable combined HCC and CC, due to its mixed histology, these patients are not candidates for either HCC or CC clinical trials. GEMOX chemotherapy (Gemcitabine + Oxaliplatinum) is an active regimen used for mixed primary tumors and its use should be considered for mixed HCC and CC tumors. We herein present this unusual case of ectopic HCC/hepatoma in efforts to emphasize the importance of considering this rare entity in the differential diagnosis of an abdominal mass.

Prior Trans-arterial chemoembolization - A protective factor against rapid HCV recurrence post liver transplant in patients with HCV with HCC? - A Retrospective Cohort Study

BackgroundHCV recurrence after liver transplant is nearly universal and results in progressive fibrosis, cirrhosis, graft loss, retransplantation and mortality. There are very few studies comparing impact of pretransplant HCC therapies either as a bridge to transplant or to downstage like TACE, hepatectomy, RFA, PEI on HCV recurrence post transplant. Primary aim of the study was studying prognostic factors associated with HCV recurrence including pre transplant HCC therapies. Material and methodsAll the patients who have undergone living donor liver transplantation at Kaohsiung Chang gung memorial hospital, Taiwan for HCV related HCC between July 2002 and June 2012 were analyzed retrospectively. Severity of HCV histological recurrence was categorized according to the ISHAK hepatitis activity index score. Rapid HCV recurrence was defined ISHAK hepatitis activity index (HAI) score greater than 4 at one year. Statistical analysis was done using SPSS version 21. (IBM). ResultsOne hundred and nine patients with HCC associated with HCV undergo living donor liver transplant from July 2002 to June 2012. Median follow up time was 31 months. Forty nine patient had significant hepatitis c recurrence at the end of one year (HAI >4) and were included in study group.60 patients without significant hepatitis c recurrence were included in control group. On univariate analysis patients who did not undergo pre-transplant trans arterial chemoembolization (0.035), primary transplant (without prior hepatectomy) (p = 0.031), high meld score (p = 0.036), high viral load pretransplant (0.007), High AFP levels (0.013) were significantly associated with rapid histological recurrence of HCV (HAI greater than 4 at one year post transplant). Total 61 patient underwent prior transarterial chemoembolization, 22 of these patients developed significant HCV recurrence while 39 patient did not developed HCV recurrence. On multivariate analysis only patient who did not undergo TACE were significantly associated with rapid histological recurrence of HCV (odds ratio 3.310, p = 0.018 95% confidence interval 1.22–8.94). ConclusionPrior TACE do not increase post transplant HCV recurrence but may be beneficial for it.

Pattern of hepatocellular carcinoma recurrence following living donor liver transplantation

AimLiving donor liver transplantation (LDLT) is a promising treatment option for patients with hepatocellular carcinoma (HCC), but tumour recurrence can affect long‐term survival. The aim of the present study was to identify the pattern of HCC recurrence after LDLT for early detection and management.Patients and MethodsFrom April 2003 to October 2014, the record of 60 patients who underwent LDLT for HCC at the National Liver Institute, Menoufia University, Egypt, were retrospectively reviewed. The clinicopathological data were analysed to determine factors associated with HCC recurrence and outcome.ResultsSeven patients (11.7 per cent) had HCC recurrence after LDLT. Pretransplant α‐fetoprotein (AFP) > 1000 ng/mL, tumour grade and microvascular invasion were the incriminated risk factors for recurrence. Three patients (42.8 per cent) had intrahepatic and extrahepatic recurrence (lung and bone), two patients (28.6 per cent) had only extrahepatic recurrence in bones and two patients (28.6 per cent) had only intrahepatic recurrence. Management was as follows: two patients (28.6 per cent) had surgical excision of intrahepatic recurrence and extrahepatic metastasis, two patients (28.6 per cent) underwent radiotherapy for bone metastasis, one patient (14.2 per cent) underwent intraoperative radiofrequency ablation for liver recurrence and two patients (28.6 per cent) received sorafenib as medical treatment. The mean time of recurrence was 19.7 months, and mean survival was 29 months.ConclusionThe majority of HCC recurrences after LDLT are extrahepatic and occur mainly in the first 2 years; strict follow up is required during this period. A high level of pretransplant serum AFP and microvascular invasion are risk factors for tumour recurrence and should be taken into account when selecting candidates for LDLT.

Expression profile and prognostic value of glypican-3 in post-operative South Korean hepatocellular carcinoma patients.

Hepatocellular carcinoma (HCC) patients commonly experience poor overall survival (OS) and disease-free survival (DFS) after curative surgical resection. Glypican-3 (GPC3) has been suggested as a prognostic biomarker for post-operative survival. However, few to none of these studies have included South Korean patients. This study aimed to determine GPC3 expression rate, clinical correlation, and post-operative prognostic value in South Korean HCC patients who underwent curative surgical resection. Surgically resected tissues from 185 HCC patients were collected and assembled into tissue microarrays (TMAs), which were stained for GPC3 by immunohistochemistry. GPC3 expression rates were correlated with clinicopathological information, and survival analyses were performed to assess the prognostic value of GPC3. GPC3 expression was present in 153 patients (82.7%). GPC3-positive patients were younger with higher frequencies of microvascular invasion and higher AFP levels than GPC3-negative patients. There was no significant difference in survival between GPC3-negative and GPC3-positive patients. Based on multivariate analysis, GPC3 expression was not a prognostic marker for post-operative survival. In South Korean HCC patients, GPC3 expression was more frequent in HCCs with aggressive features, but it was not an independent prognostic biomarker.

Suppression of ATAD2 inhibits hepatocellular carcinoma progression through activation of p53- and p38-mediated apoptotic signaling.

The ATPase family, AAA domain containing 2 (ATAD2) is highly expressed in multiple cancers. We aim to understand the clinical and biological significance of ATAD2 over-expression in hepatocellular carcinoma (HCC), as a means to validate it as a therapeutic target in HCC. We demonstrated that ATAD2 was over-expressed in HCC patients, where high ATAD2 levels were significantly correlated with aggressive phenotypes such as high AFP levels, advanced tumor stages, and vascular invasion. Using RNA interference, suppression of ATAD2 in HCC cell lines decreased cell viability, migration, and invasion, and induced apoptosis in vitro. Furthermore, we identified p53 and p38 as key proteins that mediate apoptosis induced by ATAD2 suppression. In HCC cells, we demonstrated that ATAD2 directly interacted with MKK3/6, which prevented p38 activation and therefore inhibited p38-mediated apoptosis. In vivo, suppression of ATAD2 impaired the growth of HepG2 and Hep3B subcutaneous xenografts, accompanied by enhanced apoptosis and p-p53 and p-p38 levels. Our results validate that ATAD2 is an important negative regulator of apoptosis, and that neutralizing its activity has promising anti-tumor effects in HCC cells.

The Human Homolog of Drosophila Headcase Acts as a Tumor Suppressor through Its Blocking Effect on the Cell Cycle in Hepatocellular Carcinoma.

The molecular pathogenesis of hepatocellular carcinoma (HCC) is heterogeneous and extremely complex. Thus, for individual molecular targeted therapy, novel molecular markers are needed. The abnormal expression of the human homolog of Drosophila headcase (HECA homo) has been found in pancreatic, colorectal, and oral squamous cell carcinoma. Studies of oral squamous cell carcinoma have also demonstrated that the HECA homo protein can be negatively controlled by the Wnt-pathway and transcription factor 4 (TCF4) and can slow cell division by interacting with cyclins and CDKs. However, the role of HECA in HCC has not been reported elsewhere. Here, immunohistochemical analysis revealed that the downregulation of HECA homo protein occurred in 71.0% (66/93) of HCC cases and was positively correlated with a poorly differentiated grade, high serum AFP level, liver cirrhosis and large tumor size. The expression of HECA homo was detected in five live cell lines. In vitro, the overexpression of HECA homo in HepG2, Huh-7 and MHCC-97H cells could inhibit cell proliferation and colony formation and induce G1 phase arrest. In contrast, the downregulation of HECA homo could promote cell proliferation, colony formation and the cell cycle process. However, neither the overexpression nor downregulation of HECA homo in the three cell lines could affect cell migration or invasion. Collectively, HECA homo is regularly expressed in normal live cells, and the HECA homo protein level is heterogeneously altered in HCC, but the downregulation of HECA homo is more common and positively correlated with several malignant phenotypes. The HECA homo protein can slow cell proliferation to some extent primarily through its blocking effect on the cell cycle. Hence, the HECA homo protein may act as a tumor suppressor in HCC and might be a potential molecular marker for diagnostic classification and targeted therapy in HCC.

Hepatobiliary Quiz (Answers)—15 (2015)

Hepatobiliary Quiz (Answers)—15 (2015)

MicroRNA-212 inhibits hepatocellular carcinoma cell proliferation and induces apoptosis by targeting FOXA1.

MircroRNA-212 (miR-212) is proposed as a novel tumor-related miRNA and has been found to be significantly deregulated in human cancers. In this study, the miR-212 expression was found to be obviously downregulated in hepatocellular carcinoma (HCC) tissues as compared with adjacent nontumor tissues. Clinical association analysis indicated that low expression of miR-212 was prominently correlated with poor prognostic features of HCC, including high AFP level, large tumor size, high Edmondson-Steiner grading, and advanced tumor-node-metastasis tumor stage. Furthermore, the miR-212 expression was an independent prognostic marker for predicting both 5-year overall survival and disease-free survival of HCC patients. Our in vitro studies showed that upregulation of miR-212 inhibited cell proliferation and induced apoptosis in HepG2 cells. On the contrary, downregulation of miR-212 promoted cell proliferation and suppressed apoptosis in Huh7 cells. Interestingly, we found that upregulation of miR-212 decreased FOXA1 expression in HepG2 cells. Significantly, FOXA1 was identified as a direct target of miR-212 in HCC. FOXA1 was downregulated in HCC tissues as compared with noncancerous tissues. An inverse correlation between FOXA1 and miR-212 expression was observed in HCC tissues. Notably, FOXA1 knockdown inhibited cell proliferation and induced apoptosis in HepG2 cells. In conclusion, miR-212 is a potent prognostic marker and may suppress HCC tumor growth by inhibiting FOXA1 expression.

Tumour antigen expression in hepatocellular carcinoma in a low-endemic western area.

Background:Identification of tumour antigens is crucial for the development of vaccination strategies against hepatocellular carcinoma (HCC). Most studies come from eastern-Asia, where hepatitis-B is the main cause of HCC. However, tumour antigen expression is poorly studied in low-endemic, western areas where the aetiology of HCC differs.Methods:We constructed tissue microarrays from resected HCC tissue of 133 patients. Expression of a comprehensive panel of cancer-testis (MAGE-A1, MAGE-A3/4, MAGE-A10, MAGE-C1, MAGE-C2, NY-ESO-1, SSX-2, sperm protein 17), onco-fetal (AFP, Glypican-3) and overexpressed tumour antigens (Annexin-A2, Wilms tumor-1, Survivin, Midkine, MUC-1) was determined by immunohistochemistry.Results:A higher prevalence of MAGE antigens was observed in patients with hepatitis-B. Patients with expression of more tumour antigens in general had better HCC-specific survival (P=0.022). The four tumour antigens with high expression in HCC and no, or weak, expression in surrounding tumour-free-liver tissue, were Annexin-A2, GPC-3, MAGE-C1 and MAGE-C2, expressed in 90, 39, 17 and 20% of HCCs, respectively. Ninety-five percent of HCCs expressed at least one of these four tumour antigens. Interestingly, GPC-3 was associated with SALL-4 expression (P=0.001), an oncofetal transcription factor highly expressed in embryonal stem cells. SALL-4 and GPC-3 expression levels were correlated with vascular invasion, poor differentiation and higher AFP levels before surgery. Moreover, patients who co-expressed higher levels of both GPC-3 and SALL-4 had worse HCC-specific survival (P=0.018).Conclusions:We describe a panel of four tumour antigens with excellent coverage and good tumour specificity in a western area, low-endemic for hepatitis-B. The association between GPC-3 and SALL-4 is a novel finding and suggests that GPC-3 targeting may specifically attack the tumour stem-cell compartment.

Alpha fetoprotein mediates HBx induced carcinogenesis in the hepatocyte cytoplasm.

Although tumor-associated fetal protein AFP has demonstrated utility as a clinical tumor marker, the significance of intracellular AFP is still unclear. The aim of this study was to explore the role of cytoplasmic AFP during HBx induced carcinogenesis, which had not previously been recognized; 614 HCC patients were analyzed for correlation of HBV infection with AFP level, and much higher AFP levels were found in HBsAg positive patients. Tumor tissue specimens from 20 HCC patients were used for analysis of AFP and GADD45α. Analysis of HCC specimens showed that upregulation of cytoplasmic AFP is associated with down-regulation of GADD45α in neoplastic tissue. Transfected HBx promotes transcription of AFP by acting on the elements in the AFP gene regulatory region. HBx itself did not directly impact transcription of GADD45α. However, the obstruction of RAR signaling by HBx induced elevation of AFP, which led to down-regulation of GADD45α. Cytoplasmic AFP was able to interact with RAR, disrupting its entrance into the nucleus and binding to the elements in the regulatory region of the GADD45α gene. Knockdown of AFP in siRNA-transfected AFP positive cell lines was synchronously associated with an incremental increase of RAR binding to DNA, as well as upregulation of GADD45α and it was contrary in AFP gene-transfected AFP negative cell lines. These results indicate cytoplasmic AFP is not only a histochemical tumor biomarker for human hepatoma but is also an intracellular signal molecule and potential participant in HBx induced hepatocarcinogenesis.

Polymorphisms in genes of the de novo lipogenesis pathway and overall survival of hepatocellular carcinoma patients undergoing transarterial chemoembolization.

Aberrant expression of genes in de novo lipogenesis (DNL) pathway were associated with various cancers, including hepatocellular carcinoma (HCC). Single nucleotide polymorphisms (SNPs) of DNL genes have been reported to be associated with prognosis of some malignancies. However, the effects of SNPs in DNL genes on overall survival of HCC patients receiving transarterial chemoembolization (TACE) treatment are still unknown. In present study, nine SNPs in three genes (ACLY, ACACA and FASN) in DNL pathway were genotyped using the Sequenom iPLEX genotyping system in a hospital-based cohort with 419 HCC patients treated with TACE, and their associations with HCC overall survival were evaluated by Cox proportional hazard regression analysis under three genetic models (additive, dominant and recessive). Although we did not find any significant results in total analysis (all p>0.05), our stratified data showed that SNP rs9912300 in ACLY gene was significantly associated with overall survival of HCC patients with lower AFP level and SNP rs11871275 in ACACA gene was significantly associated with overall survival of HCC patients with higher AFP level. We further identified the significant interactions between AFP level and SNP rs9912300 or rs11871275 in the joint analysis. Conclusively, our data suggest that genetic variations in genes of DNL pathway may be a potential biomarker for predicting clinical outcome of HCC patients treated with TACE.

Risk Factors of Hepatocellular Carcinoma Recurrence After Liver Transplantation: Accuracy of the Alpha-Fetoprotein Model in a Single-Center Experience

BackgroundRecurrence of hepatocellular carcinoma (HCC) and cirrhosis after a liver transplantation (LT) is a major concern, and a strict Milan criteria selection of candidates does not accurately discriminate the relapse rate after LT. PurposeThis study sought to analyze the risk factors affecting tumor recurrence after LT for related cirrhosis HCC and the application of the French prognostic model (preLT alpha-fetoprotein [AFP], size, number) in a single center. MethodsIn a retrospective observational study of LT for HCC and cirrhosis, clinicopathological features were analyzed. Also, the preoperative and postoperative AFP model score was calculated with a cutoff of 2. ResultsOf 480, 109 patients underwent cadaveric LT for HCC. Eight of them had a relapse (7%). High AFP level, AFP model score >2, high pathological tumor-node-metastasis (pTNM) stage, poor differentiation, macrovascular-microvascular invasion, infiltration, and R1 margin were statistically significant (P < .05) for recurrence. Also, in the preoperative model, AFP score >2 was a predictor of worse survival (1-, 3-, 5-, 10-year survival of 81%, 51%, 30%, 30% vs 90%, 76%, 73%, 69% in ≤2, with P = .005). Regarding the postoperative model, similar results were found (1-, 3-, 5-, 10-year survival of 84%, 47%, 37%, 37% vs 90%, 78%, 73%, 52%, P = .028) between AFP model score >2 and ≤2, respectively. However, Milan and up-to-7 criteria were not accurate in recurrence nor in survival. ConclusionsThe French AFP model has proven to be a more discerning prognostic tool than other established criteria in the prediction of recurrence and survival. Also, in postoperative prognosis, pathological risk factors for relapse such as pTNM, differentiation grade, macrovascular-microvascular invasion, infiltration, and R1 margin have been predictors of recurrence.

2D DIGE proteomic analysis highlights delayed postnatal repression of α-fetoprotein expression in homocystinuria model mice

Cystathionine β-synthase-deficient (Cbs−/−) mice, an animal model for homocystinuria, exhibit hepatic steatosis and juvenile semilethality via as yet unknown mechanisms. The plasma protein profile of Cbs−/− mice was investigated by proteomic analysis using two-dimensional difference gel electrophoresis and matrix-assisted laser desorption/ionization-time of flight/mass spectrometry. We found hyperaccumulation of α-fetoprotein (AFP) and downregulation of most other plasma proteins. AFP was highly expressed in fetal liver, but its expression declined dramatically via transcriptional repression after birth in both wild-type and Cbs−/− mice. However, the repression was delayed in Cbs−/− mice, causing high postnatal AFP levels, which may relate to transcriptional repression of most plasma proteins originating from liver and the observed hepatic dysfunction.

HULC and H19 Played Different Roles in Overall and Disease-Free Survival from Hepatocellular Carcinoma after Curative Hepatectomy: A Preliminary Analysis from Gene Expression Omnibus.

Objective. This study aimed to evaluate the relationships between long noncoding RNAs (lncRNAs) in tumor tissues and hepatocellular carcinoma (HCC) aggressiveness and survival. Methods. We correlated the lncRNAs in tumor tissues with HCC survival and clinicopathological features based on Gene Expression Omnibus expression profile GSE36376. Results. Eight lncRNAs and 240 HCC patients were included. Cox regression analysis indicated that HULC was a positive factor for HCC overall survival (HR = 0.885, 95% CI = 0.797–0.983, and P = 0.023) and disease-free survival time (HR = 0.913, 95% CI = 0.835–0.998, and P = 0.045). H19 and UCA1 were both demonstrated to be risk factors of HCC disease-free survival in multivariate Cox model (HR = 1.071, 95% CI = 1.01–1.137, and P = 0.022 and HR = 2.4, 95% CI = 1.092–5.273, and P = 0.029, resp.). But Kaplan-Meier method showed no significant association between UCA1 and HCC disease-free survival (log rank P = 0.616). Logistic regression demonstrated that H19 was overexpressed in HBV-infected patients (OR = 1.14, 95% CI = 1.008–1.29, and P = 0.037). HULC had a significant association with vascular invasion (OR = 0.648, 95% CI = 0.523–0.803, and P < 0.001). H19 and MEG3 were both considered to be risk factors for high AFP level (OR = 1.45, 95% CI = 1.277–1.646, and P < 0.001 and OR = 1.613, 95% CI = 1.1–2.365, and P = 0.014, resp.). Conclusions. Contributing to decreased susceptibility to vascular invasion, upregulation of HULC in tumor tissues was positively associated with HCC survival. In contrast, H19 overexpression might be risk factor for HCC aggressiveness and poor outcomes.

Association between HBV Pre-S mutations and the intracellular HBV DNAs in HBsAg-positive hepatocellular carcinoma in China.

This study aimed to investigate the association between HBV mutations and intrahepatic HBV status and to determine the clinical features and the contribution of HBV mutations to postoperative prognosis for hepatocellular carcinoma (HCC) patients with HBsAg (+) in China. Using TaqMan fluorescent real-time PCR, HBV covalently closed circular DNA (cccDNA) and total DNA (tDNA) were both quantified in 106 pairs of tumor tissues (TT) and adjacent non-tumor tissues (ANTT) obtained from HCC patients who received no antiviral treatment before surgical treatment. The prevalence of 19 hot spot mutations was evaluated by Sanger sequencing. HBV cccDNA and tDNA were lower in TT than in ANTT. The loads of cccDNA and tDNA in ANTT were associated with serum HBV DNA and HBeAg. Three Pre-S mutants (A2962G and C2964A in Pre-S1 and C105T in Pre-S2) were associated with higher tumor cccDNA levels (P < 0.05), and A2962G/C2964A mutants were associated with higher AFP levels. This would assist to disclose the virological features, to implement a more clinically personalized therapy and to improve the prognosis of HBV-related HCC patients.

Tumor-derived α-fetoprotein impairs the differentiation and T cell stimulatory activity of human dendritic cells.

Several tumor-derived factors have been implicated in dendritic cell (DC) dysfunction in cancer patients. α-fetoprotein (AFP) is an oncofetal Ag that is highly expressed in abnormalities of prenatal development and several epithelial cancers, including hepatocellular carcinoma (HCC). In HCC patients exhibiting high levels of serum AFP, we observed a lower ratio of myeloid/plasmacytoid circulating DCs compared with patients with low serum AFP levels and healthy donors. To test the effect of AFP on DC differentiation in vitro, peripheral blood monocytes from healthy donors were cultured in the presence of cord blood-derived normal AFP (nAFP) or HCC tumor-derived AFP (tAFP), and DC phenotype and function were assessed. Although the nAFP and tAFP isoforms only differ at one carbohydrate group, low (physiological) levels of tAFP, but not nAFP, significantly inhibited DC differentiation. tAFP-conditioned DCs expressed diminished levels of DC maturation markers, retained a monocyte-like morphology, exhibited limited production of inflammatory mediators, and failed to induce robust T cell proliferative responses. Mechanistic studies revealed that the suppressive activity of tAFP is dependent on the presence of low molecular mass (LMM) species that copurify with tAFP and function equivalently to the LMM fractions of both tumor and nontumor cell lysates. These data reveal the unique ability of tAFP to serve as a chaperone protein for LMM molecules, both endogenous and ubiquitous in nature, which function cooperatively to impair DC differentiation and function. Therefore, novel therapeutic approaches that antagonize the regulatory properties of tAFP will be critical to enhance immunity and improve clinical outcomes.

A Polymorphism in Interferon L3 Is an Independent Risk Factor for Development of Hepatocellular Carcinoma After Treatment of Hepatitis C Virus Infection

Polymorphisms in interferon (IFN)L3 (encodes IFNλ3 or interleukin 28B) are associated with outcomes of treatment for hepatitis C virus (HCV) infection. However, there is controversy regarding how polymorphisms in IFNL3 affect the risk for development of hepatocellular carcinoma (HCC) in patients treated with pegylated interferon and ribavirin. In a retrospective study, we analyzed data from 1118 patients with HCV infection (589 men; median age, 60 y; 49.9% infected with genotype 1; 51.3% with advanced fibrosis) treated with pegylated interferon and ribavirin from March 2000 through October 2009 at the Chang Gung Memorial Hospital in Kaohsiung, Taiwan (71.64% achieved sustained virologic response [SVR]). Baseline samples were collected before therapy. Starting 24 weeks after treatment, clinical and biochemical features were assessed every 3 to 6 months and patients underwent ultrasound examinations. Lesions detected were examined by computed tomography, angiography, or fine-needle aspiration biopsy analyses. Patients were followed up from the initiation of HCV therapy until a diagnosis of HCC (based on published guidelines), death, or March 31, 2013 (median, 60 mo). DNA samples from each patient were analyzed for rs12979860 in IFNL3. Kaplan-Meier analysis was used to determine the risk for development of HCC. The percentages of patients with the IFNL3 rs12979860 CC, CT, and TT genotypes were 86.4%, 13.2%, and 0.3%, respectively. A total of 108 patients (9.66%) developed HCC. The IFNL3 rs12979860 CT and TT genotypes correlated with high baseline levels of α-fetoprotein (AFP; ≥20 ng/mL), advanced stage of fibrosis, diabetes, or lack of an SVR (all P < .05). Based on multivariate Cox regression analysis, age 60 years and older, low platelet count (<15 × 10(9) cells/L), AFP level of 20 ng/mL or greater, advanced stage fibrosis, diabetes, lack of an SVR, and the IFNL3 rs12979860 CT and TT genotypes were significant risk factors for HCC (P < .05). Age 60 years and older, low numbers of platelets or high AFP level, and advanced fibrosis were risk factors for HCC among patients with a SVR. The IFNL3 rs12979860 genotype did not have a significant effect on risk for HCC among patients with SVRs, although some of these patients (with the CT or TT genotype) did develop HCC. Among patients without SVRs, only fibrosis stage and the IFNL3 rs12979860 CT and TT genotypes (hazard ratio, 1.80; 95% confidence interval, 1.06-3.07; P = .030) were independent risk factors for HCC. Based on a retrospective study of patients treated for HCV infection, the IFNL3 rs12979860 CT and TT polymorphisms are associated with a risk for HCC, especially in patients without a SVR.

An Unusual Case of Elevated AFP in a Hepatitis C Cirrhotic Patient

Introduction: Serum α-fetoprotein (AFP) is a tumor marker used in conjunction with imaging for hepatocellular carcinoma (HCC) screening in cirrhotic patients. A high AFP level (normal<20ng/mL) in a cirrhotic patient is concerning for HCC unless proven otherwise. Other causes of an elevated AFP include hepatitis of any etiology, gonadal tumors, esophageal/gastric adenocarcinoma, hereditary tyrosinemia, and ataxia telangiectasia. We present a case of a very high AFP in a cirrhotic patient with a granular cell tumor of the esophagus. Case Report: A 55-year-old male with psoriasis and hepatitis C genotype 1a cirrhosis was referred for a markedly elevated AFP (964ng/mL) and an MRI that showed no HCC. His chronic liver disease was well compensated (Child’s A). He was previously treated for hepatitis C with telaprevir, pegylated interferon, and ribavirin, but treatment was prematurely discontinued due to adverse reactions (rash and cytopenias). Home medications included etanercept (which he had been taking for years), milk thistle, and a multivitamin. Review of systems was positive for a chronic vague sensation in his throat as well as a 20-pound intentional weight-loss over a 2-month period. There was no history of alcohol/tobacco use. Physical exam revealed a palpable spleen, but no abdominal fluid shift, and no lymphadenopathy. Laboratory results showed an AST and ALT of 145 and 138unit/L, respectively; otherwise normal metabolic panel. Repeat AFP measured 1100ng/mL; platelet count was 97,000/mcL. A repeat MRI showed splenomegaly but no discrete liver lesion. Indirect laryngoscopy and scrotal ultrasound studies were unremarkable. An esophagogastroduodenoscopy revealed a 9-mm smooth, round, yellowish submucosal mass in the distal esophagus, but otherwise normal exam. Endoscopic ultrasound was then used to remove the mass by snare resection after confirming the absence of underlying varices. Histopathologic exam determined the mass to be a granular cell tumor (GCT). The patient’s serum AFP gradually declined and 7 months later was 54ng/mL. Discussion: Granular cell tumors are rare, usually benign submucosal tumors of Schwann cell origin. They have malignant potential, especially when exceeding 4 cm. They can be found throughout the body, usually on the tongue and skin, with only 10% found in the gastrointestinal tract, most commonly the esophagus. The elevated AFP in this case appears to be related to the granular cell tumor of the esophagus. This is the first published case, to our knowledge, of a granular cell tumor causing an elevation in AFP.

Abstract 3865: ATOH8 depletion can reprogram noncancer stem cells into cancer stem cells

Abstract Introduction: The development of hepatocellular carcinoma (HCC), one of the most lethal of human malignancies, is caused by the accumulation of multiple genetic and epigenetic alterations. Recent advances in cancer stem cell (CSC) study have associated the poor prognosis of cancer with CSC. ATOH8 is a nucleus factor with an obvious structural similarity to the Drosophila proneural gene atonal. The aim of this study is to investigated the role of ATOH8 in CSC and its therapeutic potentials for HCC treatment. Experimental procedures: The clinical significance of ATOH8 in a cohort of 242 HCC cases was assessed by clinical correlation and Kaplan-Meier survival analyses. ATOH8-overexpressing and scliencing cell model was generated by Lentivirus system to detect its functional roles in HCC both in vivo and in vitro. iPS technology is used to analyze effects of ATOH8 on CSCs. Result: Downregulation of ATOH8 was detected in over 40% of 242 pairs primary HCC cases, which was significantly associated with disease free survival (P=0.031), high level of AFP (P=0.03) and diferentiation (P=0.01). Functional studies demonstrate the tumor suppressive role of ATOH8 in HCC, including the inhibition of cell growth, cell proliferation, tumor formation in SCID mice and cell motility when ATOH8 was introduced into HCC cells. Further study finds that ATOH8 depletion can enhance the stemness of HCC including the tumorigenicity and abilities for self-renewal, differentiation and chemo-resistance by repressing the transcription of stemness-related genes such as OCT4, NANOG, SOX2, AFP, and HCC cancer stem cell (CSC) surface markers such as CD24 and CD133. One interesting finding in this study is that knockdown of ATOH8 could increase CD133+ cell population in QSG7701 and BEL7402 cells. CD133+ cells induced by ATOH8 depletion were flow-sorted and their CSC property was characterized. The results found that flow-sorted CD133+ cells induced by ATOH8 depletion possessed most characteristics of CSC including the capacity to self-renew, differentiation, sustained proliferation and chemoresistance. In addition, ATOH8 depletion could enhance the frequency of pluripotent stem cells (iPSC) generation induced by 4 factors (OCT4, Sox2, Klf4 and cMyc). All these data strongly suggest that a non-CSC could be reprogrammed into a CSC under some circumstance such as downregulation of ATOH8. Conclusion: This study demonstrates that ATOH8 plays an important role in HCC development, and provides a potential new HCC therapeutic approach that ATOH8 could increase the chemosensitivity of HCC cells to chemotherapeutics as demonstrated in this study. Citation Format: Yangyang Song, Xin-Yuan Guan. ATOH8 depletion can reprogram noncancer stem cells into cancer stem cells. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3865. doi:10.1158/1538-7445.AM2014-3865

Prognostic value of serum α-fetoprotein in ovarian yolk sac tumors: A systematic review and meta-analysis.

This study was conducted to determine the prognostic value of serum α-fetoprotein (AFP) levels in patients with ovarian yolk sac tumor (OYST). We performed a systematic review and meta-analysis to assess the associations between serum AFP level and prognosis in OYST. A total of 12 quantitative studies met the inclusion criteria. Preoperative AFP was not found to be associated with overall survival (OS) [odds ratio (OR)=0.84, 95% confidence interval (CI): 0.43-1.62] in OYST. However, a high postoperative AFP level was associated with worse OS (OR=0.16, 95% CI: 0.05-0.48) and relapse-free survival (RFS) (OR=0.18, 95% CI: 0.08-0.43) compared to a low postoperative AFP level in patients with OYST. In addition, a postoperative AFP level of >1,000 ng/ml was associated with a decrease in OS (OR=0.16, 95% CI: 0.05-0.50) and RFS (OR=0.21, 95% CI: 0.08-0.57). In conclusion, the postoperative, but not the preoperative, AFP level was found to be a prognostic factor in patients with OYST. In particular, a postoperative AFP level of >1,000 ng/ml was an indicator of poor prognosis in patients with OYST.