240 Is meld score better than child-turcotte-pugh score in predicting mortality of cirrhotic patients with hepatocellular carcinoma?

Posters

92

•

PROSPECTIVE INTERVENTIONAL STUDY TO EVALUATE THE EFFICACY AND SAFETY OF PERCUTANEOUS ETHANOL INJECTION AS NEOADJUVANT T H E R A P Y OF HEPATOCELLULAR C A R C I N O M A ON WAITING LIST FOR LIVER TRANSPLANTATION

J.F. Castroagudin 1, M.B. Delgado 1, S.M. Martinez 1, I. Abdulkader 2, F. Gude I , S. Tom+1, E. Otero 1, J. Forteza 2, E. Varo 1. 1Liver

Transplantation Unit, Unioersity Hospital of Santiago, Santiago de Compostela, Spain," 2Department of Pathology, University Hospital of Santiago, Santiago de Compostela, Spain Background: Progressive increase o f the length of waiting time in list for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) may allow tumor progression. Safe arid effective means of delaying tile progression of HCC in LT candidates are needed. Ahn: To assess the efficacy and safety of percutaneous ethanol injection (PEI) as adjuvant therapy of HCC listed for LT. Methods: 33 patients (26 male, mean age 58.7--7.1 years) with HCC listed for LT were included. Etiology of cirrhosis was alcoholic (12), viral infection (16), haemochromatosis (2), and cryptogenic (3). Pre-treatment Child-Pugh score was 6.54-1.7. CHC was single in 29 patients (87.9%). Mean tumor diameter was 314-12mm. Basal AFP was 5.24-194ng/ml (range 1-1042). Ultrasonography-gnided PEI by means of 20-22G needles was performed in 38 nodules. A mean of 3±1.8 sessions arid injected volume of 37.74-28.2ml of ethanol by lesion were applied. After LT, the explanted liver was examinated throughout 0.5 cm wide cross-sections. Response was determined as percentage of necrosis with respect to tumor maximal diameter. Additional analysed variables were presence of viable satellite arid distant nodules, vascular invasion, capsule, arid grade o f differe'atiati on. Results: Five patients dropped-out the waiting list due to turnor progression (2), death secondary to complications of cirrhosis (2), arid PST deterioration (1). Of the remaining 28 patients, 24 were transplanted. Median interval PEI-TH was 173 day's. Examination of liver showed complete necrosis (>90%) in 16 nodules (61.5%), arid partial necrosis (30 89%) in the remaining 10 nodules. Small size nodules (<30mm)presented higher rates of complete response (p < 0.05). No evidence of turnor seeding on needle track was observed at transplantation, or in the explant. Three patients (12.5%) died during the post-transplantation follow-up, due to sepsis, chronic rejection, arid early recurrence of HCC, respectively. The remaining 21 patients are alive and recurrence-free after a median followup of 485 days. Conclusions: PEI is a useful arid safe procedure as therapy of HCC in waiting list for LT. The achievement of high volumes of necrosis may stop or slow the HCC progression, but more studies to evaluate its influence over post-trarisplantation survival and recurrence are needed.

•

CT-GUIDED HIGH-DOSE PERCUTANEOUS ETHANOL INJECTION T H E R A P Y FOR HEPATOCELLULAR C A R C I N O M A NOT DETECTED WITH US-GUIDED METHOD

W.J. Jung I . "KS. Hong I , K.M. Kwon 1, B.K. Jang 1, K.S. Park ~, K.B. Cho ~, J.S. Hwang I , S.H. Ahn I , J.H. Kwon2 . 2Department of Internal Medicine,

Keimyung University, College of Medicine, Daegu, South Korea," 2Department of Diagnostic Radiology, Keimyung University, College of Medicine, Daegu, South Korea Background: Hepatocellular carcinoma (HCC) is usually treated by hepatic resection, local ablation therapy, transcatheter arterial chemoembolization (TACE), or hepatic arterial infusion chemotherapy. Among local therapies, radiofrequency thermal ablation (RFA) and percutaneous ethanol injection therapy (PEIT) are commonly performed. But instead of a higher ablation rate, RFA has some limitations arid more common

complications, which can be overcome by CT-guided PEIT These situations include technically difficult masses, which are not detected with ultrasonogram (US), are located in the subcapsular area or exophytically located or are surrounded by large vessels. Aim: Standard percutaneous ablation therapy is performed with real-time US guidance. Some nodules cannot be detected with US, which are located at the hepatic dome, in the deep r e , on of the liver, and on the surface. We discuss advantages and extended indications of CT-guided high dose PEIT (>10 till) over US-guided method. Methods: Between January 2003 and September 2004, 149 patients with 233 HCCs or 2 adenomatous hyperplasias underwent CT-guided high-dose PEIT and were checked follow up CT 3 and 6 months later. Results: 1. Among total cases, 129 HCCs (55.3%) were not detected with US. 2. Male was 72 patients (82.8%) and female was 15 patients (17.2%). HCCs are caused by chronic hepatitis B (58.6%), chronic hepatitis C (13.8%), alcohol ingestion (20.7%) and unidentified causes (6.9%) 3. 234 PEI sessions were performed and average PEIT number was 1.8 sessions (from 1 to 5 sessions). 4. 129 HCCs included 20 exophytical located, 54 subcapsular located, and 21 HCCs abutting on great vessels. 5. The numbers of mass according to size are 82.2% (<3 cm), 14.7% (3-5 cm), and 3.1% (>5 cm). 6. 10 HCCs were included in ChildPugh C Class. 7. We experienced 9 cases of pneumothomx and 1 case of hemoperiteneum. 8. When evaluate complete ablation arid margin free as successful response of treatment by follow-up CT, successful response rates were 82% (89 among 109 cases) at 3 months after PEIT, and 72.5% (55 among 74 cases) at 6 months after PEIT. Conclusion: In the cases of HCCs not detected by US-guided method, CT-guided high-dose PEIT seems to be a safe and effective for the treatment of HCC. ~ O ] I S MELD SCORE BETTER THAN C H I L D - T U R C O T T E PUGH SCORE IN PREDICTING MORTALITY OF CIRRHOTIC PATIENTS WITH HEPATOCELLULAR CARCINOMA.'? G.G. Di Costanzo, M. De Luca, F.P. Picdotte, A. Galeota Lanza, G. Trirro, F. Lampasi, M.T. Tartaglione, L. Addario, A. Ascione. Unita di

Epatologia - Ospedale A Cardarelli, Napoli, Italy Background: Prognosis of cirrhotics with hepatocellular carcinoma (HCC) is difficult to assess. Tile Model for End-Stage Liver Disease (MELD) is useful in predicting short-term prognosis of advanced-stage cirrhotics and seems to be more precise than Child-Turcotte-Pugh (CTP) score. However, CTP score is currently used to categorize HCC patients and is incorporated in prognostic scores. Aim: To compare MELD, both original (MELD-O) and UNOS formula (MELD-U), vs CTP score in predicting prognosis in a large cohort of 465 HCC patients followed-up for/>12 months (27.5±20.8 months). Patients: Males 74%, age 66±8y, viral etiology 92%; CTP A=57%, B = 32%, C = 11%; median MELD-O = 9 (-3 to 29), MELD-U = 11 (6-29); monofocal HCC 59%, multifocal 37%. Methods: ROC curves were plotted to evaluate MELD and CTP score performance and to select the cut-off values (IvIELD = 9, CTP = 6; sensitivity/specificity: 67%/52%, 75%/52%, respectively). Linear trend chisquare, likelihood ratio test, Kaplan-Meier method and stepwise survival analysis (Cox regression) were used. MELD and CTP both as continous and categorical score were tested; 3-month, 6-month, 12-month and endof-follow up mortality were evaluated. Results: 275 patients died (59%). At univariate analysis, MELD and CTP score were significantly associated with mortality. The ROC curve c-statistics for the scores in predicting 3-month arid 6-month mortality were CTP 0.78 arid 0.73, MELD-O 0.72 and 0.67, MELD-U 0.71 and 0.63 respectively; the c-statistic was <0.70 for any other time-point. At multivariate analysis, all scores resulted independently related to mortality; the odds ratio of CTP was slightly higher than MELD for all time-points (OR: 3-month: CTP = 1.49, CI 1.07-2.09; MELD-O = 1.40, CI 0.90-2.04;

Category 3: Liver Tumors (Epidemiology, Diagnosis, Management) MELD-U=0.74, CI 0.47-1.16. 6-month: CTP=l.72, CI 1.35-2.19; MELD-O = 1.50, CI 1.14-1.97; MELD-U = 0.59, CI 0.43-0.82. 12-month: CTP = 1.41, CI 1.2-1.67; MELD-O = 1.36, CI 1.16-1.62; MELD-U= 0.69, CI 0.56-0.84). Subgroup analyses were done: in patients with multifocal HCC, CTP and MELD score performance in predicting 6-month mortaliW were better than in the whole group (CTP=0.81; MELD-O=0.74; MELD-U = 0.71). Conclusions: In patients with viral cirrhosis and HCC, CTP and MELD score performance in predicting 6-month and long-term mortality was unsatist:actory. Only in multifocal HCC subgroup, the performance of both CTP and MELD to assess 6-month prognosis was good. In HCC setting, MELD score is not better than CTE

I•

CONTRIBUTION OF LASER CAPTURE MICRODISSECTION TO PROTEOMIC ANALYSIS OF HEPATITIS C VIRUS (HCV)ASSOCIATED HEPATOCELLULAR C A R C I N O M A (HCC)

A. Dos Santosl, N. Bensalem2, S. Sat 1, E Brouillard 2, M.R Bralet 3, E Demaugrel , A. Edelman 2, V Thiers 4, C. Brechot 1 . IINSERM U370,

Facultd de Mddecine Necker Enfants Malades, Paris, France," 2INSERM U467, Facultd de Mddecine Necker Enfants Malades, Paris, France," 3Service d'Anatomie Pathologique, H@ital Paul Brousse, Villejuif France," 4 CNR Hepatites Virales B e t C, Institut Pasteur, Paris, France Identification of specifically deregulated proteins in HCC is an important goal. Tissue heterogeneity" observed in HCC developed on cirrhosis, such as most HCC related to HCV infection, impedes accurate determination of proteome modifications between tumor (T) and non-tumor (NT) hepatocytes when studied on total liver tissue. The laser capture microdissection (LCM), enabling to pick up groups ofhepatocytes from liver sections, should allow tile identification of specifically deregulated proteins in HCC. Aim: To demonstrate the profit of LCM for proteins identification whose expression is specifically deregulated in the HCC. Patients anti Methods: Three patients with HCV-aasociated HCC were included in this study. Comparative proteomic analysis of the T and tile adjacent NT counterparts was performed using 2D-PAGE realised either with total liver extracts or with microdissected hepatocytes from the T and paired NT tissues. 2D-PAGE was performed with 120 ~tg of pooled protein extracts (40 [xg of protein from each patient). Isoelectrofocalisation was performed on immobilised pH 5 to 8 IPG strips. Each experiment was performed in triplicates. Proteins stained with silver nitrate were analysed with Image Master 2D Software. Proteins of interest were identified by mass spectrometry (MALDI-TOF). Results: We have analysed the relative variations of expression of 35 proteins separated on 2D-PAGE either from LCM samples or from total liver sections. These proteins were differentially expressed (unpaired Student's t-test; p < 0.05) with an expression ratio ?2 in LCM samples. In total liver extracts only 12/35 proteins were deregulated as observedin LCM samples with an expression ratio >2. Among them, T-complex protein 1 and elongation factor 1 ¥ were identified in the two conditions. Moreover, we observed that 5/35 proteins varied in different ways in total liver extracts: two proteins were not modified and the three others varied in an opposite way (SNAP-a was identified in this group). Conclusion: As compared to studies performed with total liver extracts, selection of hepatocytes using LCM allows a more accurate identification of deregulated proteins in HCC developed on cirrhosis. Thus, LCM is a slfitable tool to define new potential biomarkers.

I•

93

LEPTIN'S S U P P R E S S I O N OF HEPATOCELLULAR C A R C I N O M A BY ACTIVATION OF NK LYMPHOCYTES AND INHIBITION OF TUMOR PROLIFERATION IS ASSCOCIATED WITH ALTERED EXPRESSION OF STAT2, SOCS1, & CIS

E. Elinav 1. A. Abd E1 Nabi 1, O. Pappo 2, D. Engelhardt3, E. Rabbani 3,

Y. Ilan I . 1Liver Unit, Department of Medicine, Hadassah-Hebmw University Medical Center, Jerusalem, Israel," 2Pathology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel, SENZO Biochem, New York NY, USA Baekgrouuti: Leptin possesses potent immune modulatory properties, but its in-vivo effects on tumor growth have not been studied. Aims: To determine leptin's anti-tumor effect in a murine model of hepatocellular carcinoma (HCC). Methods: In vitro, leptin's effects on tumor cell proliferation & natural killer cell (NK) proliferation and cytotoxicity were determined. In addition, leptin receptor mRNA expression and leptin-induced expression of several signal transduction molecules (STATs, SOCSs & CIS)were determined in human HEPA-3B HCC cells. In-vivo, leptin's effect on tumor growth was studied using HCC implantation in T cell deficient (nude) mice, T&B cell deficient (SCID) mice, and T,B,&NK-deficient (SCID-Beige) mice, with or without administration of two daily intraperitoneal doses of 0.5 mg/g leptin for 6 weeks. To determine the mechanism of anti-tumor effect, splenic lyrnphocytes were analyzed by FACS for N K markers. STAT 1-6, SOCS 1~4 & CIS expression in splenic lymphocytes was tested by RTPCR. Serum leptin, IFN-g, ILl0, ILl2 levels were measured by ELISA. Results: Human HCC cells expressed leptin receptor mRNA. In-vitro leptin administration in doses of 0.5, 5 and 50 ng/ml resulted in increased mRNA expression of both STAT2 and SOCS1 in HCC cells. Leptin induced a dose-dependent reduction in HCC proliferation, and a dosedependent enhancement of NK cell proliferation and cytotoxicity. In vivo, leptin a&ninistration was associated with suppression of turnor growth and increased survival in nude and SCID mice, but not in NK-deficient SCID-beige mice (P < 0.001). Histologically, leptin-administered nude and SCID mice featured increased inflammation within tumors, while leptinadministered NK-deficient mice featured no fitflammation following leptin administration. Splenocytes from leptin-treated mice featured decreased expression of CIS mRNA. Leptin-induced tumor suppression was associated with NK cell expansion (6.16--2.19% vs. 3.25±0.67%, in leptin and saline administered groups, respectively, P 0.03). Conclusions: Leptin administration is associated with a significant suppression of hepatocellular carcinoma. The leptin-induced anti-tumor effect is mediated via: (A) N K cell activation and expansion leading to an antitumor fikflammatory response through decreased lymphocyte expression of the anti-fifflammatory CIS protein, (B) direct inhibition of tumor growth through increased tumor expression of the anti-proliferative STAT2 and SOCS 1 proteins. Leptin holds promise as a novel anti HCC therapy.

I•

CONTRAST-ENHANCED S O N O G R A P H Y IN THE CHARACTERIZATION OF SMALL HEPATOCELLULAR C A R C I N O M A S IN CIRRHOTIC PATIENTS: COMPARISON WITH CONTRAST-ENHANCED ULTRAFAST MAGNETIC R E S O N A N C E IMAGING

A. Giorgio ~, G. Ferraioli 1. G. de Stefano I , C. Coppola I , A. Di Sarno I , L. Del Viscovo 2. l Interventional Ultrasound Service - 'D. Cotugno'

Hospital, Naples, Italy," 2Department of Clinical and Experimental Medicine - Section of Diagnostic Imaging - 2nd University of Naples, Naples, Italy Purpose: Aim of this study was to evaluate the role o f low mechanical index contrast-enhanced sonogrephy (CEUS) for the characterization of small hepatocellular carcinomas (HCC) in cirrhotic patients, by comparing