Aldo‐keto reductase family 1 member B10 is associated with hepatitis B virus‐related hepatocellular carcinoma risk

Aim

Recent reports have indicated that aldo‐keto reductase family 1 member B10 (AKR1B10), a cancer‐related oxidoreductase, was upregulated in some chronic liver diseases. However, few studies have reported AKR1B10 expression in chronic hepatitis B virus (HBV)‐infected patients. The aim of the present study was to analyze AKR1B10 expression and its relevance on hepatocellular carcinoma (HCC) development in patients with chronic HBV infection.

Methods

Expression of AKR1B10 in the liver of 119 chronic HBV‐infected patients was assessed and quantified immunohistochemically. A multivariate Cox model was used to estimate the hazard ratios of AKR1B10 expression for HCC development. The cumulative incidences of HCC were evaluated using Kaplan–Meier analysis.

Results

Expression of AKR1B10 in the study cohort ranged from 0% to 84%. During the median follow‐up time (6.2 years), 13 patients developed HCC. Multivariate analysis revealed that high AKR1B10 expression (≥15%) was an independent risk factor for HCC (hazard ratio, 10.8; 95% confidence interval, 3.0–38.6; P < 0.001). The 5‐year cumulative incidences of HCC were 20.6% and 2.6% in patients with high and low AKR1B10 expression, respectively (P < 0.001). Patients with high AKR1B10 expression had significantly higher alanine aminotransferase levels during follow‐up than those with low expression, even though antiviral treatment decreased HBV‐DNA levels in both groups.

Conclusion

Chronic HBV‐infected patients with high hepatic AKR1B10 expression had an increased risk of HCC development. This suggests that AKR1B10 upregulation might play a role in the early stages of HBV‐related hepatocarcinogenesis.

     

Outcome of hepatitis B and C virus‐associated hepatocellular carcinoma occurring after renal transplantation

Kidney transplant recipients (KTR) are subjected to immunosuppressive therapy that can enhance hepatitis B and C virus replication, leading to cirrhosis and hepatocellular carcinoma (HCC). The aim of this study was to assess the prevalence and outcome of HCC in KTR. Case‐control study. Patients with chronic HBV and/or HCV infection who underwent kidney transplantation between 1976 and 2011 and subsequently developed HCC were compared to a control group of patients with chronic HBV and/or HCV infection, matched for gender and age at HCC diagnosis, who did not receive kidney transplantation. Among 2944 KTR, 330 had hepatitis B and/or C. Fourteen developed HCC, a period prevalence of 4.2%. Age at HCC diagnosis was 52.6 ± 6.5 years (53.5 ± 5.7 in controls, P=.76). Time between transplantation and HCC diagnosis was 16.7 ± 2.7 years. Six HCCs were related to HBV, six to HCV and two to co‐infection with HBV and HCV. Immunosuppressive therapy was comparable in HBV, HCV and HBV+HCV patients. At diagnosis, 71% of patients met Milan criteria (65% in the control group, P=.4). Alpha‐fetoprotein levels, tumour characteristics and treatment modalities were comparable between both groups. Patient survival 2 years after HCC diagnosis was 28% in KTR, compared to 68% in controls (P=.024). Survival after HCC diagnosis is significantly worse in KTR compared to nontransplanted patients with HBV and/or HCV. Prevention is crucial and should be based on viral eradication/suppression before or after transplantation.     

Pretreatment AKR1B10 expression predicts the risk of hepatocellular carcinoma development after hepatitis C virus eradication

AIM To clarify the association between aldo-keto reductase family 1 member B10(AKR1B10) expression and hepatocarcinogenesis after hepatitis C virus eradication.METHODS In this study,we enrolled 303 chronic hepatitis C patients who had achieved sustained virological response(SVR) through interferon-based antiviral therapy. Pretreatment AKR1B10 expression in the liver was immunohistochemically assessed and quantified as a percentage of positive staining area by using image-analysis software. A multivariate Cox analysis was used to estimate the hazard ratios(HRs) of AKR1B10 expression for hepatocellular carcinoma(HCC) development after achieving SVR. The cumulative incidences of HCC development were evaluated using Kaplan-Meier analysis and the log-rank test.RESULTS Of the 303 chronic hepatitis C patients,153(50.5%) showed scarce hepatic AKR1B10 expression,quantified as 0%,which was similar to the expression in control normal liver tissues. However,the remaining 150 patients(49.5%) exhibited various degrees of AKR1B10 expression in the liver,with a maximal AKR1B10 expression of 73%. During the median follow-up time of 3.6 years(range 1.0-10.0 years),8/303 patients developed HCC. Multivariate analysis revealed that only high AKR1B10 expression(≥ 8%) was an independent risk factor for HCC development(HR = 15.4,95%CI: 1. 8- 1 3 2. 5,P = 0. 0 1 2). T h e 5- y e a r c u m u l a t i v e incidences of HCC development were 13.7% and 0.5% in patients with high and low AKR1B10 expression,respectively(P 0.001). During the follow-up period after viral eradication,patients expressing high levels of AKR1B10 expressed markedly higher levels of alanine aminotransferase and α-fetoprotein than did patients exhibiting low AKR1B10 expression.CONCLUSION Chronic hepatitis C patients expressing high levels of hepatic AKR1B10 had an increased risk of HCC development even after SVR.     

Efficacy of lamivudine on hepatitis B viral status and liver function in patients with hepatitis B virus‐related hepatocellular carcinoma

Background/Aims: Treatment of patients with hepatocellular carcinoma (HCC) depends on the tumour extent and underlying liver function. Antiviral therapy with nucleoside/nucleotide analogues has been shown to be effective in improving the liver function of chronic hepatitis B (CHB) patients. We assessed whether lamivudine could induce biochemical and virological improvements in patients with hepatitis B virus‐related HCC. Patients/Methods: Of 148 CHB patients treated with 100 mg/day lamivudine for at least 6 months, 80 had HCC (CHB/HCC group) and 68 did not (CHB group). Biochemical and virological parameters were serially monitored. Results: Compared with the CHB group, the CHB/HCC group was older, had higher male predominance, bilirubin levels and liver cirrhosis rate, and lower albumin and hepatitis B virus (HBV) DNA levels and hepatitis B e antigen (HBeAg) positivity (P<0.05 each). The two groups showed similar cumulative rates of alanine aminotransferase normalization, HBV DNA seroconversion, HBeAg loss and viral breakthrough during 12 months of lamivudine treatment. After 12 months, the CHB/HCC group showed, relative to baseline, increased albumin levels (3.51±0.5 vs. 3.72±0.5 mg/ml) and decreased ascites scores (1.63±0.7 vs. 1.45±0.6) and Child–Pugh scores (6.92±1.9 vs. 6.02±1.38) (P<0.05 each). Conclusion: Lamivudine had comparable antiviral effects both in patients with CHB and CHB/HCC, and improved underlying liver function in the latter group. Treatment of HBV may increase the chance of curative treatments in patients with HBV‐related HCC.     

Diabetes mellitus not an unfavorable factor on the prognosis of hepatitis C virus‐related hepatocellular carcinoma

Aim

Diabetes mellitus (DM) is a potential risk factor for hepatocarcinogenesis, especially in patients with hepatitis C virus (HCV) infection. We aimed to elucidate whether DM influences the surgical outcomes of patients with hepatocellular carcinoma (HCC).

Methods

Our patients were routinely controlled to keep urinary glucose excretion to less than 3.0 g/day before surgery, and the serum glucose level under 200 mg/dL after surgery. The surgical outcomes and postoperative complications of 112 patients with HCV‐related HCC with DM (DM group) were compared to those of 112 propensity‐matched patients without DM (non‐DM group).

Results

After a median follow‐up of 3.2 years (range, 0.2–11.3 years), the median overall (5.2 years; 95% confidence interval, 3.8–6.5 years) and recurrence‐free survival (2.2 years; 1.7–2.9 years) in the DM group were not significantly different from those (6.3 years; 5.4–7.1 years, P = 0.337; and 2.2 years; 1.7–3.6 years, P = 0.613) in the non‐DM group. The independent factors related to overall survival were the background liver (hazard ratio, 2.06; 95% confidence interval, 1.27–3.39, P = 0.014) and tumor differentiation grade (2.07; 1.14–4.05, P = 0.015). Thirty‐two patients (28.5%) in the DM group and 32 patients (28.5%) in the non‐DM group had morbidities after operation, with no significant difference between the groups (P = 1.000). Furthermore, postoperative control status of DM did not affect the prognostic outcome.

Conclusion

Diabetes mellitus does not affect the surgical outcomes of patients with HCV‐related HCC, and it is not an unfavorable factor when selecting candidates for liver resection of HCC.     

Clinical significance of antibody against hepatitis B virus core antigen in patients with hepatitis C virus‐related hepatocellular carcinoma

Purpose: We investigated the unsettled issue of whether seropositivity for antibody to hepatitis B core antigen (anti‐HBc) affects characteristics of hepatitis C virus (HCV)‐related hepatocellular carcinoma (HCC). Methods: Antibody status was determined by enzyme immunoassay in 243 patients with this cancer, and associations with clinicopathologic characteristics and outcome were analysed. Serum hepatitis B virus (HBV) DNA was determined by real‐time polymerase chain reaction. Results: Of 235 patients with unequivocal serologic status, 142 were seropositive and 93 were seronegative. Clinicopathologic characteristics and overall cumulative survival rates were comparable between the two groups. However, seropositivity tended to predict poor outcome for patients in Child class B or C (P=0.068), those in tumour‐nodes‐metastasis‐based stage 3 or 4 (P=0.081), those with tumours exceeding 25 mm (P=0.068), and those with a past history of clinical liver disease (P=0.088). Multivariate analysis identified serum albumin, portal vein tumour thrombosis, and tumour size as independent determinants of survival. Serum HBV DNA was below 1.7 log copies/ml in all 40 patients tested. Conclusions: Overall, the clinical features of HCV‐HCC were unaffected by seropositivity for anti‐HBc. Seropositivity tended to worsen prognosis for subgroup with poor hepatic reserve or advanced tumours.     

The risk of hepatocellular carcinoma among chronic hepatitis B virus‐infected patients outside current treatment criteria

We assessed the incidence of hepatocellular carcinoma (HCC) in those outside of current treatment recommendations and risk factors associated with HCC development. A multi‐centre, retrospective cohort of 3624 patients who were monitored without antiviral treatment was analysed. Incident HCC risk according to the Asian Pacific Association for the study of the Liver (APASL), the American Association for the Study of Liver Disease (AASLD) and the European Association for the Study of the Liver (EASL) treatment recommendations was assessed. A risk score was developed using independent factors associated with HCC development among patients who were outside current treatment criteria. During a median follow‐up of 4.6 years, incident HCC was diagnosed in 161 (4.4%) patients. The proportions of patients who developed HCC outside treatment recommendation according to APASL, AASLD and EASL criteria were 64.0%, 46.0% and 33.5%, respectively. The 5‐year cumulative HCC incidence rate was 13.9% for cirrhotic patients with low‐level viremia and 6.1 ~ 7.3% for chronic hepatitis patients with elevated HBV DNA levels plus mildly elevated alanine aminotransferase levels. Among patients who were outside treatment recommendation, age, sex, hepatitis B e antigen, cirrhosis, alanine aminotransferase and platelet levels were independent factors associated with HCC development. When these factors were used to calculate the risk score for each patient, those with a score ≥8 had a higher HCC incidence rate (14.3% at 5‐year), although they were currently outside treatment recommendations. Thus, HCC was observed among patients who were outside current treatment criteria indicating that careful monitoring for HCC and efforts to identify patients at risk are required.     

AKR1B10基因沉默对肝癌细胞增殖和凋亡的影响

目的探索肝细胞癌(HCC)中醛酮还原酶家族1成员B10(AKR1B10)的生物学功能和相关的病理机制。方法通过CCLE数据库分析正常肝细胞与HCC细胞系中AKR1B10 mRNA的表达,UALCAN以及Oncomine数据库分析癌旁组织与HCC组织中AKR1B10 mRNA的表达,Western Blot法验证HCC患者癌组织与癌旁组织中AKR1B10蛋白表达差异。使用慢病毒分别敲减HepG2及Huh7细胞中的AKR1B10,分为对照组和AKR1B10敲减组(shAKR1B101#、shAKR1B102#)。采用AnnexinV-APC/PI双染法、细胞克隆实验、皮下移植肿瘤的方法检测敲减AKR1B10后HCC细胞凋亡、克隆形成、皮下成瘤体积的变化。过氧化物敏感性荧光探针DCFH-DA以及Western Blot检测敲减AKR1B10后HCC细胞内活性氧(ROS)以及p-ATMser1981、γ-H2AX、c-Caspase-3和c-RARP等蛋白的变化。计量资料多组间比较采用单因素方差分析,进一步两两比较采用SNK-q检验。结果CCLE数据库提示AKR1B10 mRNA在HCC细胞中的表达明显高于正常肝细胞;Oncomine数据库显示,与癌旁组织相比,HCC组织中AKR1B10 mRNA的表达增加了10倍以上;UALCAN数据库提示AKR1B10基因在HCC组织中高表达;本研究的6例HCC患者中AKR1B10在HCC组织中的表达高于癌旁组织。与对照组相比,AKR1B10敲减组中HCC细胞的克隆形成能力明显下降(P值均<0.001),细胞凋亡率明显增加(P值均<0.001)。与对照组相比,AKR1B10敲减组ROS的水平升高,DNA损伤指标p-ATMser1981、γ-H2AX蛋白,细胞凋亡指标c-Caspase-3和c-RARP蛋白增加。此外,在BALB-c/Nude小鼠模型中,从异体移植后第13天开始,与对照组相比,AKR1B10敲减组肿瘤体积明显缩小(P值均<0.05)。结论AKR1B10可能是治疗HCC的有效治疗靶标。     

乙型及丙型肝炎患者发生肝细胞癌的风险预测：REVEAL-HBV/HCV研究的回顾

乙型肝炎病毒（HBV）及丙型肝炎病毒（HCV）的慢性感染是肝细胞癌（HCC）的主要致病原因。全球约有3亿5千万人为HBV的慢性感染者;HCV慢性感染者则有2亿人。全球每年约有50万人死于乙型肝炎引起的HCC,另有25万人死于丙型肝炎引起的HCC。乙型肝炎慢性感染者,其血中HBV DNA及ALT持续处于高水平是HCC最重要的预测因子。其他的危险因子还包括HBV C基因型、HBV基础核心促进子A1762T/G1764A双突变、男性、老年、肝癌家族史、酗酒习惯、以及与HCV或人类免疫不全病毒的合并感染等。根据REVEAL-HBV研究的资料,我们发展出简单易用的列线图,可利用非侵入性的临床特征准确地预测慢性乙型肝炎患者发生HCC的风险。丙型肝炎慢性感染患者发生HCC最重要的预测因子包括高血中HCV RNA水平、高ALT水平、HCV基因型以及老年等。REVEAL-HCV研究案例中,与HCV RNA水平低于检测范围且低ALT水平者相比,HCV RNA可测得、高ALT水平且感染第一型病毒的案例具有最高的HCC发生风险,其多变项调整后的风险比值（95%CI）为21.87（5.09～93.95）,这些发现对于慢性丙型肝炎的临床处置具有重要的意义。     

HBsAg-negative hepatitis B virus infections in hepatitis C virus-associated hepatocellular carcinoma

This study was conducted to evaluate reports that hepatitis B virus (HBV) DNA sequences can be found in the serum and/or tumour tissue from some hepatocellular carcinoma (HCC) patients who have no detectable hepatitis B surface antigen (HBsAg) in their sera. Such HBV infections would be highly atypical, because prospective studies have shown a clear succession of specific serologic markers during and after most HBV infections. As most HBsAg-negative HCC patients in Japan have hepatitis C virus (HCV) infections, the present study was conducted to determine whether some of these patients actually have unrecognized HBV infections. Thirty newly diagnosed HCC patients from Kurume, Japan, with antibody to the hepatitis C virus (anti-HCV) were studied. None of the 30 had HBsAg detectable in their serum. Of 22 for whom test results for antibodies to the hepatitis B core antigen (anti-HBc) and antibodies to HBsAg (anti-HBs) were available, 14 (64%) had anti-HBc and anti-HBs, four (18%) had anti-HBc alone, and four (18%) had no HBV markers. Nested polymerase chain reaction was used to detect the HBV surface (S), core (C), polymerase (P) and core promoter gene sequences in the HCC tissues and in the adjacent nontumorous liver tissues. HBV DNA was detected in HCC and/or adjacent nontumorous liver in 22 of 30 (73%) patients [detected in both HCC and nontumorous liver in 19/30 patients (63%)]. Among the 22 patients with detectable HBV DNA, more than one HBV gene was detected in 10 (46%). Among the four patients whose sera were negative for all HBV markers, three had HBV DNA in either HCC and nontumorous liver (two cases) or only in the nontumorous liver (one case); HBV DNA could not be detected in tissues from the fourth patient. In 18 of 21 (86%) patients with detectable HBV core promoter sequences, mutations at both nucleotides 1762 (A-GT) and 1764 (G-A) in the core promoter region were found. No deletions were detected in the core promoter gene region of the type reported to be associated with some cases of HBsAg-negative HBV infection. Thus, HBV DNA was detectable in 22 (73%) HBsAg-negative, anti-HCV-positive HCCs, including three (10%) who were also negative for anti-HBc and anti-HBs. HBV mutations at both nucleotides 1762 (A-GT) and 1764 (G-A) in the core promoter region were found in the majority of cases, mutations that have previously been reported in HBV that is integrated in HCC DNA. In serologic surveys to determine etiologic associations of HCC, patients such as those in this study would have been incorrectly designated as having 'HCV-associated HCC,' whereas the data in this study suggest that HBV could have played a role in the development of their HCCs.     

Hepatic steatosis and the risk of hepatocellular carcinoma in chronic hepatitis C

BACKGROUND AND AIM: Obesity associated hepatic steatosis has been suggested to have a premalignant potential. We determined whether hepatic steatosis predisposes to liver cancer in persons with chronic hepatitis C virus (HCV) infection. METHODS: We compared the histological severity of steatosis in the index liver biopsies of 25 patients with chronic hepatitis C who subsequently developed hepatocellular carcinoma (HCC) with matched controls who did not. Cases were aged (mean) 54.7 years, 84% males, 76% genotype 1, and 64% fibrosis stage 4; and controls were matched for these characteristics. Those with a sustained virologic response to antiviral therapy were excluded. RESULTS: Duration of HCV infection, concomitant alcohol intake, body mass index and indices of past hepatitis B virus (HBV) infection were comparable between the groups. Controls were followed for a longer period after the index liver biopsy than were cases (113 months vs 55 months, P < 0.001). As determined by percentage area of biopsy core occupied by steatosis on computer assisted morphometric evaluation, and graded by semiquantitative histological assessment, steatosis was comparable among cases and controls. The odds of developing HCC among those with steatosis grades 1 and 2 did not differ significantly from those without steatosis. There was no association between increasing morphometric percentage area occupied by steatosis and the subsequent development of HCC. Neither steatosis grade or percent area of steatosis on biopsy were selected in multivariate regression analysis as independent predictors for the development of HCC. CONCLUSIONS: Hepatic steatosis does not augment the risk of hepatocarcinogenesis in patients with chronic HCV infection.     

Meta‐analysis: interferon‐alpha prevents the recurrence after curative treatment of hepatitis C virus‐related hepatocellular carcinoma

Summary. Various clinical studies have indicated that interferon (IFN)‐alpha treatment prevents the development of hepatocellular carcinoma (HCC) in people chronically infected with hepatitis C virus. However, it has been controversial whether IFN‐alpha treatment prevents HCC recurrence. The aim of this study was to identify the preventive effect of IFN‐alpha treatment after curative therapy of primary tumours within the Milan criteria (three or fewer nodules 3 cm or less in diameter or a single nodule of 5 cm or less) on HCC recurrence. We conducted a meta‐analysis of five trials including 355 patients (167 patients received IFN‐alpha treatment after curative therapy of primary tumours) and estimated relative risks (RRs) and 95% confidence intervals (CIs) for the effect of IFN‐alpha on HCC recurrence according to the DerSimonian and Laird method. IFN‐alpha treatment after curative therapy of primary tumours significantly prevented HCC recurrence (RR 0.33; 95%CI 0.19–0.58, P < 0.0001) without a significant heterogeneity (Q = 4.52, P = 0.34). An evaluation using the Begg method suggested no evidence of publication bias. Sub‐group analyses revealed that IFN‐alpha treatment reduced HCC recurrence in two studies achieving sustained virologic response (SVR) rates >30% (RR 0.20; 95%CI 0.05–0.81, P = 0.02) and in three studies achieving SVR rates ≤30% (RR 0.44; 95%CI 0.23–0.84, P = 0.01). In conclusion, IFN‐alpha treatment after curative treatment of primary tumour within Milan criteria may be effective for the prevention of HCC recurrence, and higher SVR rate may be associated with better preventive effect of IFN‐alpha treatment on HCC recurrence.     

Conceptual models for the initiation of hepatitis B virus‐associated hepatocellular carcinoma

Although chronic hepatitis B virus (HBV) infection is a known risk factor for the development of hepatocellular carcinoma (HCC), the steps involved in the progression from normal liver to HCC are poorly understood. In this review, we apply five conceptual models, previously proposed by Vineis et al. to explain carcinogenesis in general, to explore the possible steps involved in the initiation and evolution of HBV‐associated HCC. Available data suggest that the most suitable and inclusive model is based on evolution of hepatocyte subpopulations. In this evolutionary model, HCC‐associated changes are driven by selection and subsequent clonal expansion of phenotypically altered hepatocyte subpopulations in the microenvironment of the HBV‐infected liver. This model can incorporate the wide range of mechanisms proposed to play a role in the initiation of HCC including oncogenic HBV proteins, integration of HBV DNA and chronic inflammation of the liver. The model may assist in the early prevention, detection and treatment of HCC and may guide future studies of the initiation of HBV‐associated HCC.     

Hepatitis B virus‐related hepatocellular carcinoma in the era of antiviral therapy: The emerging role of non‐viral risk factors

Hepatocellular carcinoma (HCC), one of the major malignant lethal tumours, is most prevalent in Asian patients with chronic hepatitis B virus (HBV) infection. Both viral and non‐viral factors contribute to the development of HCC. It is established that viral factors associated with HBV DNA level, HBV genotype, designated gene mutation, HBV DNA integration, HBx protein, hepatitis B surface antigen (HBsAg), hepatitis B core‐related antigen (HBcrAg) and HBV RNA are correlated with hepatocarcinogenesis. Before the introduction of antiviral therapy, viral factors once attracted more attention during the development of HCC. With the widespread use of antiviral therapy, predominantly nucleos(t)ide analogues (NAs), most patients with chronic hepatitis B (CHB) have achieved sustained viral control. The role of non‐viral factors, especially modifiable factors, is anticipated to be reinforced in the future. Herein, we reviewed the modifiable non‐viral risk factors of HBV‐related HCC, in the hope of providing substantial evidence for further development of novel precautionary measures for HCC. In addition, the therapeutic interventions for reducing the risk of HCC, like potential conventional pharmaceutical interventions and lifestyle modification are also discussed in this review. Future studies that would explore the specific mechanism of HBV‐related HCC development in patients with satisfactory viral control and related precision treatment are warranted.