Importance of achieving complete necrosis during the first treatment for hepatocellular carcinoma to prevent bone metastasis: a prospective study.

BACKGROUND AND AIMS: Recent advances in the treatment of hepatocellular carcinoma (HCC) have changed the importance of bone metastasis during the follow up of such patients. In the present study, we investigated risk factors for bone metastasis after treatment for HCC. METHODS: Two hundred and two patients with HCC were diagnosed as free of bone metastasis by technecium 99m-methylene diphosphonate bone scintigraphy and were followed prospectively after treatment of the primary lesions (follow-up period 2-146 months; median 20 months). We statistically analyzed the risk factors for bone metastasis using the clinical characteristics at the time of first treatment. RESULTS: Multiple tumors (P < 0.005), main tumor size > 5 cm in diameter (P < 0.005), the presence of distant metastasis (P < 0.005), elevation of serum alpha-fetoprotein (> 100 ng/mL; P < 0.05), chemotherapy (P < 0.05) and insufficient therapeutic response (P < 0.0005) were identified as risk factors for bone metastasis by univariate analyses. Insufficient therapeutic response and main tumor size > 5 cm in diameter (both P < 0.05) were identified as independent predisposing factors for bone metastasis. CONCLUSIONS: Complete necrosis of primary HCC during the first treatment is important to prevent subsequent bone metastasis.

Experimental lupus nephritis in severe combined immunodeficient (SCID) mice: remodelling of the glomerular lesions by bystander IgM antibodies.

MRL/Mp-lpr/lpr (MRL/lpr) mice develop glomerular lesions with regular variations in their histopathological manifestations, similar to those in lupus nephritis. These lesions are mainly either cell-proliferative or wire loop-like and are associated with glomerular deposits of immunoglobulins, most frequently IgG and IgM. We previously established a nephritogenic IgG3-producing hybridoma clone, B1, from an MRL/lpr mouse, which induces only a 'wire loop-like' type of glomerular lesion when injected into SCID mice. Injection of SCID mice with an anti-trinitrophenyl IgM antibody-producing hybridoma clone, Sp6, following injection of the B1 clone, however, resulted in the development of a 'cell-proliferative' type of glomerular lesion, associated with an accumulation of both antibodies in glomeruli. This accumulation occurred even though Sp6 IgM antibodies did not react with B1 IgG3 antibodies and vice versa. A mutant clone of Sp6, T/13microE/3.1, which produces antibodies deficient in C1q binding, produced a similar effect as that of the Sp6 clone, i.e. 'cell-proliferative' lesions. Again the B1 antibodies did not react with T/13microE/3. 1-IgM antibodies and vice versa. We therefore conclude that bystander IgM antibodies contribute to the remodelling of glomerular lesions in situ, following glomerular injury by the nephritogenic antibodies.

Serum levels of soluble interferon Alfa/Beta receptor as an inhibitory factor of interferon in the patients with chronic hepatitis C.

Human serum contains a soluble form of interferon alfa/beta (sIFN alpha/beta) receptors, the functional and clinical significance of which has not been investigated in patients with chronic hepatitis C. In the present study, serum levels of sIFN alpha/beta receptor were assessed in 81 patients with chronic hepatitis C and correlated with the effectiveness of IFN therapy in these patients. Serum levels of sIFN alpha/beta receptor were significantly higher in patients with chronic hepatitis C than in healthy control patients (P <.0001). In these patients, serum levels of sIFN alpha/beta receptor were correlated with those of alanine transaminase (ALT) (P <.05), (2'-5')serum oligo(A) synthetase (2-5AS) (P <.0001), and pathological stages of liver fibrosis (P <.01). In 55 patients with chronic hepatitis C who underwent IFN therapy, there was an inverse correlation between the pretherapeutic serum levels of sIFN alpha/beta receptor and the rate of increase in serum levels of 2-5AS after the start of IFN (P <.01). Pretherapeutic serum levels of sIFN alpha/beta receptor were significantly lower in patients who showed sustained response to IFN therapy compared with those who did not respond to the therapy (P <.05). Multivariate analysis showed that low levels of serum sIFN alpha/beta receptor (

Analytical histopathological diagnosis of small hepatocellular nodules in chronic liver disease.

Due to the recent progress in radiology and increased clinical and pathological interest, small hepatocellular nodules about 1 cm in size are frequently being detected in patients with chronic liver disease, particularly liver cirrhosis. Two new types of small hepatocellular nodules are now known: low-grade hepatocellular carcinomas (HCC) and dysplastic nodules, in addition to the previously known HCC (classical) and regenerative nodules. Ultrasound-guided needle biopsies from these nodules are routinely used for the differential diagnosis. For comparison, a simultaneous needle biopsy from the liver remote from the nodule is strongly recommended. Low-grade HCC, which are different from classical HCC in their morphological atypia and also biological behaviors, show local invasion into the portal tracts and surrounding hepatic parenchyma, but not intrahepatic or extrahepatic metastasis. Dysplastic nodules show mild cellular and structural atypia, a finding which is not sufficient for making a diagnosis of malignancy. An increased nuclear/cytoplasmic (N/C) ratio and nuclear crowding, small cell-dysplasia, increased cytoplasmic staining, clear cell change, pseudogland formation, and fatty change of hepatocytes are variably seen in these nodules. Nuclear changes, local invasion to the portal tract and surrounding liver, and loss of the reticulum fibers along the hepatocytes are useful markers favoring low-grade HCC rather than dysplastic nodules. These low-grade HCC and dysplastic nodules should also be distinguished from classical HCC as well as large-sized regenerative nodules. A comparative analysis of the histological findings observed in individual nodules is a reasonable approach to differential diagnosis at present. The recognition and analysis of these two new hepatocellular nodules may augur a new horizon in the study of hepatocellular neoplasm.

Histological features predicting malignant transformation of nonmalignant hepatocellular nodules: a prospective study.

BACKGROUND & AIMS: Recent advances in imaging modalities allow the identification of borderline hepatocellular nodules that have the potential for malignant transformation. The aim of this study was to elucidate histological predictive features of borderline nodules by needle biopsy for the evolution to hepatocellular carcinoma (HCC). METHODS: Thirty-four hepatocellular nodules diagnosed by needle biopsy were followed up for more than 6 months. Several histological parameters of these nodules that were related to malignant transformation were evaluated. RESULTS: During the follow-up periods (median, 35 months), 5 of 34 nodules evolved to HCC during a follow-up of 6-15 months. Significant prognostic features of malignant transformation were an increased ratio of nuclear density of >1.5, clear cell change, small cell dysplasia, and fatty change of the hepatocytes. In multivariate analysis, an increased ratio of nuclear density of >1.5 and clear cell change were independent. CONCLUSIONS: A nodule with an increased ratio of nuclear density, clear cell change, small cell dysplasia, and fatty change should be recognized to be a high risk for evolution to HCC. Particularly, the former two were independent prognostic factors for malignant transformation.

Expression of interferon alpha/beta receptor in the liver of chronic hepatitis C patients.

Interferon (IFN) demonstrates antiviral activity by binding to receptors on the cell surface. Expression of the IFN receptor in hepatocytes may be directly associated with a hepatitis C virus (HCV) infection and the response to IFN therapy. A competitive PCR method was developed to measure IFN alpha/beta (alphabeta) receptor mRNA in liver samples obtained by needle biopsy. Thirty-one patients with chronic hepatitis C (21 without cirrhosis, 10 with cirrhosis) and six normal subjects were used. Eighteen of the 21 patients without cirrhosis received the IFN therapy. Competitive PCR was carried out using IFN alphabeta receptor gene-specific primers and a specific competitor. Expression of the receptor was detected in all liver samples. There was no association between the expression level and serum alanine aminotransferase level, serum (2'-5') oligo (A) synthetase level, amount of serum HCV RNA, or HCV genotype. The expression level in patients with chronic hepatitis was significantly higher than that in normal livers (P < 0.05) and in cirrhotic livers (P< 0.01). Seven of the 18 patients treated with IFN demonstrated a sustained response to IFN (sustained responders), and the remaining 11 did not (nonsustained responders). The expression level of IFN alphabeta receptor mRNA in the sustained responders was significantly higher than that in the nonsustained responders (P< 0.01). Thus, the expression of IFN alphabeta receptor mRNA may be one of the host factors influencing the response to IFN therapy.

Gastrointestinal amyloidosis secondary to hypersensitivity vasculitis presenting with intestinal pseudoobstruction.

A 22-year-old woman developed sudden hepatic encephalopathy and severe intestinal bleeding. She was diagnosed with acute fatty liver and hypersensitivity vasculitis and was successfully treated with whole plasma exchange, methylprednisolone pulse therapy, and transcatheter arterial embolization. Twenty-seven months later, she began complaining of lower abdominal fullness, tenderness, and nausea and vomiting. Histologic examination showed that she had developed gastrointestinal and renal amyloidosis with intestinal pseudoobstruction and proteinuria. The immunohistochemical study of the stomach, rectum, and kidney with anti-amyloid A fluorescent antibody showed that the systemic amyloid deposit was secondary to her underlying disease. This is the first report of amyloidosis occurring secondary to hypersensitivity vasculitis.

Brush cytology of herpes simplex virus infection in oral mucosa: use of the ThinPrep processor.

Evaluation was made of oral scraping specimen using Cytobrush from 11 patients with clinical suspicious lesions for herpes simplex virus (HSV) infection. In this study, oral brush cytology prepared using an automated smear apparatus (ThinPrep method) has been applied. The smears prepared by ThinPrep are equally well suited for screening purposes, producing highly cellular specimens with well-preserved cytoplasm and nuclei. The results obtained on the 11 patients, four cytologic specimens, showed pathognomonic viral cellular changes of HSV infection. Viral isolation studies were performed on 10 of the 11 patients and ten specimens tested positive for HSV by culture. Of the ten HSV positive isolates, six were positive by either cytology or immunocytochemical staining. Of the two smears showing HSV positive cells, both smears were also confirmed by in situ hybridization (ISH) with a biotinylated clone DNA probe. Using the ICC technique, detection of HSV antigen in oral scraping smears was of great value in the diagnosis of oral HSV infection, especially in cases of equivocal lesions. Oral cytology by means of ThinPrep method obviously deserves additional trials as an adjunct in the cytology of HSV-suspected lesions.

Involvement of peribiliary glands in primary sclerosing cholangitis: a histopathologic study.

We examined the histological changes of the peribiliary glands (PBGs), a hitherto pooly recognized anatomical element around the biliary tree, in 7 cases of primary sclerosing cholangitis (PSC). These glands showed proliferation, and nonspecific inflammation with lymphoplasmacytic infiltration, fibrosis, and destruction. In addition, there were cystic lesions around the bile ducts, and they were considered to reflect dilatation of the PBGs. These changes were found around the intrahepatic and extrahepatic bile ducts in the cases examined. It is of interest that changes in the PBGs tended to correlate with the inflammatory changes of the bile duct wall itself, though 2 cases showed changes in the duct walls and PBGs unrelated to their distribution along the biliary tree. These findings suggest that the PBGs are also a target structure in addition to the bile ducts themselves in PSC.

Rheumatic diseases in an MRL strain of mice with a deficit in the functional Fas ligand.

OBJECTIVE: To characterize Fas antigen expression on the cell surface, and to determine the effect of this expression in rheumatic diseases using a newly established gld-congenic MRL strain of mice (MRL/gld), which is defective in its functional Fas ligand (Fas-L). METHODS: Flow cytometric analyses of lymphoid cells and macrophages were performed using anti-Fas and other cell surface markers. Histopathologic manifestations were examined using immunochemistry and light and electron microscopy. Serum levels of IgG and anti-DNA antibodies were measured by single radial immunodiffusion and enzyme-linked immunosorbent assay, respectively. RESULTS: MRL/gld mice developed systemic lymphadenopathy with an accumulation of Thy1.2+, B220+ and CD4-, CD8- T cells, which both express the Fas antigen. Splenic B cells positive for surface IgM and/or surface IgD, and resident peritoneal macrophages exhibited up-regulated expression of the Fas antigen, at much higher levels than those observed in MRL/MpJ-+/+ (MRL/+) mice. Forms of rheumatic disease were observed in these mice, although not in C3H/HeJ-gld/gld mice. These forms included diffuse glomerulonephritis, granulomatous arteritis, and arthritis, and were associated with the infiltration of mononuclear cells expressing the Fas antigen. Serum levels of IgG and anti-DNA antibodies were significantly increased in MRL/gld mice compared with MRL/+ mice. CONCLUSION: Rheumatic disease was generated by the gld gene in mice with an MRL background, as it is by the lpr gene, which is a Fas deletion mutant, associated with autoimmune traits. Rheumatic disease in this MRL strain was initiated by an incapacity for Fas/Fas-L-induced apoptosis, resulting in the development of autoimmunity and allowing for a persistent immune response in the affected lesions.

A case of zoster in the 2nd and 3rd branches of the trigeminal nerve associated with simultaneous herpes labialis infection--a case report.

A patient with herpes zoster infection affecting the second and third branches of the trigeminal nerve is reported. This case demonstrates the occurrence of a simultaneous VZV and HSV infection. Isolation of these viruses from exudates of the blisters was required to prove coexistence of the two viruses within the same blister. Relevant literature is discussed.

Clinicopathological study of primary biliary cirrhosis negative for antimitochondrial antibodies.

Primary biliary cirrhosis (PBC) is characterized by the occurrence of antimitochondrial antibodies (AMA) and the progressive destruction of intrahepatic bile ducts, followed by biliary cirrhosis. However, there are about 5% of PBC patients who show clinicopathological features of PBC but are negative for AMA. In this study, clinicopathological features, as well as antibody reactivity against recombinant (r)-mitochondrial polypeptides, were examined in 30 AMA negative PBC patients and 38 AMA positive PBC patients, in whom the presence of AMA had been determined by indirect immunofluorescence (IF). There were few differences in the clinical and serological features between both groups. Histopathologic features, including staging, bile duct lesions and granuloma, were also similar in both groups. Among the 30 IF-tested AMA negative patients, 29 were also negative against beef heart mitochondrial proteins, but 24 reacted to one or more of the following r-polypeptides, as determined by immunoblotting: E1 alpha of pyruvate dehydrogenase complex, the E2 subunit of pyruvate dehydrogenase complex, and the branched-chain 2-oxo-acid dehydrogenase complex. The remaining six AMA-negative patients were asymptomatic, and histologically resembled having stage 1 of the disease, with relatively mild lymphocytic piecemeal necrosis. One case was positive for anti-smooth muscle antibody. The other clinicopathological features of these patients were similar to those of other AMA negative patients. The present study found that a majority of the AMA-negative patients fulfilling other clinicopathological criteria of PBC, had features similar to the AMA-positive PBC patients, and that a majority of IF AMA-negative patients were positive for r-polypeptides of the 2-oxo-acid dehydrogenase complex. It seems that nearly all the AMA negative patients possess a broad spectrum of antibody profile of AMA, in addition to clinicopathological and serological features.

Recurrent herpetic infection of the oral floor--a case report.

Recurrent herpetic infection on the mobile mucosa such as the oral floor, has not been reported previously. A case of recurrent herpetic infection of the oral floor in a 52-year-old man is presented. This case illustrates the fact that recurrent herpetic lesions can occur anywhere in the intra-oral mucosa.

Two cases of recurrent herpetic infection of the tongue.

Recently, a number of reports have been published on recurrent herpetic infection of the oral mucosa. In most of these cases, the infected tissue is the fixed intraoral mucosa, such as the gingiva or hard palate. Infection of movable mucosa such as the tongue, which is reported in the present paper, has not been reported in detail previously. In each of the two cases reported in the present paper, intraoral lesions were diagnosed as recurrent herpes-glossitis after isolation of the herpes simplex virus (HSV).

Latent multiple infections by herpes simplex virus type 1.

The presence or absence of latent multiple infections with herpes simplex virus (HSV)-1 was investigated. DNA cleavage patterns resulting from the digestion of viral DNA by restriction enzymes were studied. The DNA cleavage patterns of asymptomatically shed viruses isolated from the saliva of subjects at different time were compared to HSV-1 isolated from patients with HSV-1 infections of the oral cavity. If a patient had HSV-1 isolated from their saliva more than two times, the asymptomatically shed viruses were used in these experiments. This criterion was met by 13 patients. All patients underwent the viral isolation procedure on separate occasions. In addition, 55 viral strains from 10 patients with HSV infections were included in the experiment. The HSV-1 lesions were caused by a reactivation of the same strain of virus. The asymptomatically shed HSV-1 viruses had identical DNA cleavage patterns in only 4 of 13 patients (31%). The viruses isolated on separate occasions from the remaining 9 patients (69%) had different DNA cleavage patterns. Several investigators have reported the existence of latent HSV multiple infections.

Vascular lesions in mice with a deficit in Fas-mediated apoptosis and their transfer.

The lpr and gld genes are thought to result in an incapacity for Fas-mediated apoptosis of T and B cells and the development of subsequent autoimmune disease. A newly established gld-congenic strain of mice, MRL/MpTn-gld/gld (MRL/gld), was found to develop vascular lesions involving arteritis and glomerulonephritis (GN), which were similar to those observed in the MRL/Mp-lpr/lpr (MRL/lpr) strain. However, comparative studies with a C3H/HeJ strain bearing lpr or gld revealed that these lesions developed only in mice with an MRL background. We were successful in transferring GN to normal MHC-compatible gld/gld and irradiated +/+ mice by bone marrow cells of MRL/gld mice, but were unsuccessful using those of C3H/gld mice. Transfer of arteritis, however, was only successful in mice with an MRL background. Nephritogenic monoclonal antibodies obtained from an MRL/lpr and an MRL/gld mouse were shown to be bone marrow-derived and rich in clonal diversity, and at least two of these were capable of causing glomerular injury by different mechanisms. Development of GN and systemic arteritis in MRL/lpr and MRL/gld mice will be dependent not only on their incapacity for Fas-mediated apoptosis but also on bone marrow cells and peripheral cells with intrinsic defects.

Three cases of primary biliary cirrhosis associated with bronchial asthma.

The association of primary biliary cirrhosis (PBC) and bronchial asthma was observed in three patients. All of these patients were female (53, 54, and 41 years old, respectively), and were positive for antimitochondrial antibodies. The patients fulfilled the diagnostic criteria of both PBC and bronchial asthma. Bronchial asthma preceded PBC in two patients, and the reverse order was seen in the other. Patient the clinical symptoms were mainly due to the bronchial asthma. Two patients had asymptomatic PBC and the third patient complained of pruritus. The liver histology showed mild to moderate eosinophilic infiltration in addition to the ductal and hepatic parenchymal changes characteristic of PBC. A survey of 266 cases of PBC referred to us disclosed that, in 6 of these, the PBC was associated with bronchial asthma, while no association with bronchial asthma was the material of found in 166 patients with viral hepatitis in our liver biopsy files. The 3 present cases we experienced suggest that bronchial asthma may be included in the list of extrahepatic diseases associated with PBC. The significance of this association is unclear and may merit further study. Steroid therapy, which is known to cause adverse effects in PBC, was employed for bronchial asthma in these 3 patients. Another therapeutic approach will have to be considered in patients with bronchial asthma associated with PBC.

The role of hepatitis C virus in hepatocellular carcinoma in Japan.

Increasing numbers of patients with hepatocellular carcinoma (HCC) have been reported in Japan. In this paper, we investigated the role of hepatitis C virus (HCV) in HCC and the reason for the increase, using patients admitted to our university hospital from 1945 to 1992. 99 (73%) of 135 patients with HCC were positive for anti-HCV. Prospective studies demonstrated that 22 of 158 (14%) patients with chronic hepatitis C, and 31 of 70 (44%) cirrhotic patients with anti-HCV developed to HCC during the follow-up period (10.1 +/- 3.3 and 7.3 +/- 3.5 years, respectively). Prolonged survival of cirrhotic patients during past decades would also contribute to the increasing number of HCC cases as well as the number of HCV infections in Japan.

Induction of different types of glomerulonephritis by monoclonal antibodies derived from an MRL/lpr lupus mouse.

MRL/Mp-lpr/lpr(MRL/lpr) lupus mice develop glomerulonephritis in which the histopathological manifestations of the disease are characterized by diffuse cell-proliferative, crescentic, and/or wire loop-like lesions, resembling those of human lupus nephritis. Although these lesions are thought to be mediated by antibodies, little data is available to explain these regular variations in glomerular lesions induced by antibodies at the monoclonal level. We studied glomerular lesions of normal or severe combined immunodeficient mice injected with nephritogenic immunoglobulin G3-producing hybridoma clones (2B11.3 and 7B6.8), which we previously established from an unmanipulated MRL/lpr mouse. Both clones caused increased serum levels of immunoglobulin G3 with identical patterns over time and both induced glomerular deposits of immunoglobulin G3 and C3. However, 2B11.3 and 7B6.8 induced glomerular lesions that differed in their histopathological manifestations. The 2B11.3 clone generated cell-proliferative lesions associated with marked Mac-2-positive macrophage infiltrates, but the 7B6.8 clone induced lesions characterized by subendothelial hyaline deposits resembling wire loops. The latter was not associated with significant inflammatory cell infiltrates at any point throughout the progression of the lesion. Thus, our findings suggest that the histopathological variation in glomerulonephritis seen in MRL/lpr mice results from clonally expanded B cell clones that produce nephritogenic antibodies with different pathogenic potencies.

Mixed types of chronic active hepatitis and primary biliary cirrhosis associated with the anti-phospholipid antibody syndrome: a case report.

An understanding of the pathogenesis of mixed types of chronic active hepatitis and primary biliary cirrhosis is important for the treatment of the patients. A 40-year-old Japanese woman with antiphospholipid syndrome has been treated with prednisolone for two years since she was diagnosed as having a mixed type of chronic active hepatitis and primary biliary cirrhosis. Biochemical tests for liver function were normal during treatment. Laparoscopy revealed a white liver, and histology demonstrated disappearance of the findings of piecemeal necrosis or chronic nonsuppurative destructive cholangitis in the specimen. Steroid treatment of patients with mixed types of chronic active hepatitis and primary biliary cirrhosis is controversial, since it is contra-indicated in some. Although the clinical features of the patients varies from one to another, this case suggests that the autoimmune mechanism of some patients may resemble autoimmune hepatitis rather than primary biliary cirrhosis, and treatment with steroid is effective.