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1266 Progenitor cell features in hepatocellular carcinoma
770A
AASLD ABSTRACTS
1265
SERUM AND BILIARY CYTOKERATIN FRAGMENT CYFRA 21-1, CEA, AND CA 19.9 AS TUMOR MARKERS FOR CHOLANGIOCARCINOMA. Gamal Badra, National Liver
Institute, Shebeen~ l-Kom, ~ gypt; Hosam Ghanem, Mansoura University School of Medicine, Mansoura, ~ gypt; Hosam Taha, National Liver Institute, Shebeen ~ l-Kom, ~ gypt; Seham Self, Mansoura University School of Medicine, Mansoura, ~ gypt; Imam Waked, National Liver Institute, Shebeen~ l-Kom, ~ gypt Serum levels of CEA and CA 19.9 are occasionally elevated in cases of cholangiocarcinoma (CC). They, however, have low sensitivity and specificity, which makes the diagnosis of CC difficult, and better tumor markers are needed. CYFRA 21-1 is a cytokeratin fragment that is being evaluated as a tumor marker with diagnostic potential for small cell lung carcinoma. This study aimed at evaluating the role of measuring serum and bile CYFRA 21-1 as a tumor marker in patients with CC, comparing it to CEA and CA19.9. Patients and Methods: Twenty consenting patients (15 males, mean age 55.7 years) with histologically proven CC (7 patients were Bismuth stage I, 4 patients stage II, 3 patients stage III, and 6 patients stage W) were included. Patients were studied preoperatively using ultrasound, helical CT, ERCP and brush cytology, and percutaneous transhepatic biliary drainage (PTD) if ERCP failed. Serum and bile samples were obtained at time of biliary drainage and stent placement (18 during ERCP and 2 during Pro). The diagnosis of CC was confirmed by histopathology in 11 patients who underwent surgery, by bile cytology in 8 patients and by fine needle biopsy in one patient. In addition, 20 consenting patients with calcular obstructive jaundice had serum and bile samples obtained during endoscopic removal of stones to control for the effect of biliary obstruction on CYFRA 21-1 levels. CEA and CA 19.9 were measured using enzyme immunoassay (EIA), and CYFRA 21-1 level was measured using electrochemiluminescece immunoassay (ECLIA) in serum and bile of the CC patients and the gall stone controls. Results: Patients with CC had significantly higher serum levels of CEA (24.5 ± 6 vs 4.3 ± 1.3 ng/ml, p<0.01), CA 19.9 (118.9 ± 25.4 vs 31.2 ± 8.4 U/ml, p < 0.01) and CYFRA 21-1 (8.3 ± 2.7 vs 2.1 ± 0.5 ng/ml, p<0.01) than patients with benign biliary obstruction. Bile levels of the 3 markers were significantly higher in CC than benign obstruction (CEA: 376 ± 82 vs 7.6 ± 1.9 ng/ml p<0.001; CA 19.9:169 ± 30.5 vs 56.3 ± 12.6 U/ml, p < 0.01; CYFRA 21-1:29.3 ± 7.8 vs 5.9 ± 1.6 ng/ml, p<0.001). All bile concentrations were significantly higher than serum concentrations of all 3 markers in both benign and malignant obstruction. A serum cut off value for CYFRA 21-1 of 4.5 ng/ml had a 73% sensitivity and a 96% specificity for diagnosing CC, and the sensitivity, specificity and diagnostic accuracy of serum and bile CYFRA 21-1 were all higher than those for CEA and CA 19-9. Patients with Bismuth stages III and IV CC had significantly higher levels of the 3 markers than stage I and II patients. Conclusion: CYFRA 21-1, CEA, and CA 19.9 levels increase in serum and bile of CC patients, and the level is related to the tumor stage. Their measurement in bile is important for the supplementary diagnosis of CC, especially w h e n brush cytologies are negative. Serum and bile concentrations of CYFRA 21-1 appear superior as tumor markers than CEA and CA 19-9 in diagnosis of CC, and their clinical validity requires further studies. Disclosures: Gamal Badra - No relationships to disclose Hosam Ghanem - No relationships to disclose Seham Self - No relationships to disclose Hosam Taha - No relationships to disclose Imam Waked - No relationships to disclose
1266
PROGENITOR CELL FEATURES IN HEPATOCELLULAR CARCINOMA. Anne M T Durnez, Chris Verslype, Raymond Aerts,
Jacques lh'renne, Tania Roskams, KUL Leuven, Leuven, Belgium We previously described a hepatocellular carcinoma (HCC) with progenitor cell features showing a rapid clinical deterioration.
HEPATOLOGY, October 2003
Therefore we studied the prevalence of progenitor cell features in a consecutive series of 45 HCCs. We used immunohistochemistry for cytokeratin (CK) 7, OV-6, Alpha-foetoprotein (AFP), CK18, polyCEA and Hepar-1. Of the 45 HCCs of different etiologies (viral hepatitis, alcoholic liver disease, hemochromatosis, non alcoholic fatty liver disease, Wilson disease), 18/45 originated in a cirrhotic liver, 17/45 showed a normal architecture or periportal, centrolobular and/or perisinusoidal fibrosis, 10/45 were in a septal stage. CK18 was reactive throughout the tumor in 73% of cases. Focal loss of CK18 was seen in 27%. PolyCEA canalicular staining was positive throughout the tumor in 44% and only in areas of the tumor in 56% of cases. Hepar-1 was reactive in 72% of cases. CK7 staining showed a massive positivity with majority of cells positive in 4% of cases, a partial positivity in 69%. Part of the CK7 positive cells presented as hepatic progenitor cells (HPCs), defined as small epithelial cells, with an oval nucleus and a narrow rim of cytoplasm. They showed strong cytoplasmic reactivity and occurred as single cells in the tumor or in strands. Submembranous CK7 reactivity was seen in polygonal cells with an intermediate size between that of HPCs and hepatocytes. They occurred in groups, acinar structures, or scattered in the tumor, mostly in the vicinity of HPCs. OV-6 staining was positive in 67% of cases, with a majority of positive cells in one third of these cases. The pattern of staining was similar to CK7, showing both HPCs and intermediate hepatocytes. AFP showed positivity in 47% of cases, with a majority of positive cells in one third of these cases. This series of HCCs shows the presence of some progenitor cell features in 2/3 of tumors. Progenitor cell features in HCC could be the result of dedifferentiation of tumoral, mature hepatocytes or from maturation arrest of progenitor cells during the carcinogenic process. In the latter possibility, the earliest presursor lesions of HCC, small cell dysplastic foci, should contain HPCs. We previously indeed showed that 55% of small cell dysplastic foci in chronic hepatitis patients consist of HPCs and intermediate hepatocytes. This suggests the possibility of h u m a n hepatocarcinogenesis from HPCs, concordant with several animal models of carcinogenesis. 2/45 (4%) HCCs in this series consist of small immature cells, expressing progenitor markers CK7 and OV-6 in the majority of cells. This subtype has been described in several case reports as 'progenitor cell tumor' or 'small cell HCC' having a rapid clinical evolution and suggesting the need to consider them as a separate entity with poor prognosis. 12/45 (27%) of HCCs in the series consist of mature hepatocytes, showing no progenitor cell features, while 31/45 (69%) of HCCs show some progenitor cell features.The correlation of our phenotypic study with genetic expression profiles and clinical outcome is in progress. We hope that this correlation can lead to a pathological classification with clinical and therapeutical relevance. Disclosures: Raymond Aerts - No relationships to disclose Anne M T D u r n e z - No relationships to disclose Jacques Pirenne - No relationships to disclose Tania Roskams - No relationships to disclose Chris Verslype - No relationships to disclose
1267
PREDICTING POST-TRANSPLANT SURVIVAL WITH HEPATOCELLULAR CARCINOMA: AN ASSESSMENT OF CURRENT STAGING SYSTEMS AND INDIVIDUAL PARAMETERS. ~ manuel Cavazzoni, Melissa D Meehan,
Christopher Shackleton, Cedars-Sinai Medical Center, Los Angeles, CA; Linda Sher, University of Southern California, Los Angeles, CA; Nicholas Nissen, John Vierling, Paul Martin, Fred Poordad, Tram Tran, Walid Ayoub, Steven Colquhoun, Cedars-Sinai Medical Center, Los Angeles, CA Background: The development of an adequate staging system for patients with Hepatocellular carcinoma (HCC) remains an area of great interest and need. Especially in the transplant setting, the ability to accurately stage patients with some sense of post-transplant prognosis is critical to the appropriate utilization of limited
AASLD ABSTRACTS
1265
SERUM AND BILIARY CYTOKERATIN FRAGMENT CYFRA 21-1, CEA, AND CA 19.9 AS TUMOR MARKERS FOR CHOLANGIOCARCINOMA. Gamal Badra, National Liver
Institute, Shebeen~ l-Kom, ~ gypt; Hosam Ghanem, Mansoura University School of Medicine, Mansoura, ~ gypt; Hosam Taha, National Liver Institute, Shebeen ~ l-Kom, ~ gypt; Seham Self, Mansoura University School of Medicine, Mansoura, ~ gypt; Imam Waked, National Liver Institute, Shebeen~ l-Kom, ~ gypt Serum levels of CEA and CA 19.9 are occasionally elevated in cases of cholangiocarcinoma (CC). They, however, have low sensitivity and specificity, which makes the diagnosis of CC difficult, and better tumor markers are needed. CYFRA 21-1 is a cytokeratin fragment that is being evaluated as a tumor marker with diagnostic potential for small cell lung carcinoma. This study aimed at evaluating the role of measuring serum and bile CYFRA 21-1 as a tumor marker in patients with CC, comparing it to CEA and CA19.9. Patients and Methods: Twenty consenting patients (15 males, mean age 55.7 years) with histologically proven CC (7 patients were Bismuth stage I, 4 patients stage II, 3 patients stage III, and 6 patients stage W) were included. Patients were studied preoperatively using ultrasound, helical CT, ERCP and brush cytology, and percutaneous transhepatic biliary drainage (PTD) if ERCP failed. Serum and bile samples were obtained at time of biliary drainage and stent placement (18 during ERCP and 2 during Pro). The diagnosis of CC was confirmed by histopathology in 11 patients who underwent surgery, by bile cytology in 8 patients and by fine needle biopsy in one patient. In addition, 20 consenting patients with calcular obstructive jaundice had serum and bile samples obtained during endoscopic removal of stones to control for the effect of biliary obstruction on CYFRA 21-1 levels. CEA and CA 19.9 were measured using enzyme immunoassay (EIA), and CYFRA 21-1 level was measured using electrochemiluminescece immunoassay (ECLIA) in serum and bile of the CC patients and the gall stone controls. Results: Patients with CC had significantly higher serum levels of CEA (24.5 ± 6 vs 4.3 ± 1.3 ng/ml, p<0.01), CA 19.9 (118.9 ± 25.4 vs 31.2 ± 8.4 U/ml, p < 0.01) and CYFRA 21-1 (8.3 ± 2.7 vs 2.1 ± 0.5 ng/ml, p<0.01) than patients with benign biliary obstruction. Bile levels of the 3 markers were significantly higher in CC than benign obstruction (CEA: 376 ± 82 vs 7.6 ± 1.9 ng/ml p<0.001; CA 19.9:169 ± 30.5 vs 56.3 ± 12.6 U/ml, p < 0.01; CYFRA 21-1:29.3 ± 7.8 vs 5.9 ± 1.6 ng/ml, p<0.001). All bile concentrations were significantly higher than serum concentrations of all 3 markers in both benign and malignant obstruction. A serum cut off value for CYFRA 21-1 of 4.5 ng/ml had a 73% sensitivity and a 96% specificity for diagnosing CC, and the sensitivity, specificity and diagnostic accuracy of serum and bile CYFRA 21-1 were all higher than those for CEA and CA 19-9. Patients with Bismuth stages III and IV CC had significantly higher levels of the 3 markers than stage I and II patients. Conclusion: CYFRA 21-1, CEA, and CA 19.9 levels increase in serum and bile of CC patients, and the level is related to the tumor stage. Their measurement in bile is important for the supplementary diagnosis of CC, especially w h e n brush cytologies are negative. Serum and bile concentrations of CYFRA 21-1 appear superior as tumor markers than CEA and CA 19-9 in diagnosis of CC, and their clinical validity requires further studies. Disclosures: Gamal Badra - No relationships to disclose Hosam Ghanem - No relationships to disclose Seham Self - No relationships to disclose Hosam Taha - No relationships to disclose Imam Waked - No relationships to disclose
1266
PROGENITOR CELL FEATURES IN HEPATOCELLULAR CARCINOMA. Anne M T Durnez, Chris Verslype, Raymond Aerts,
Jacques lh'renne, Tania Roskams, KUL Leuven, Leuven, Belgium We previously described a hepatocellular carcinoma (HCC) with progenitor cell features showing a rapid clinical deterioration.
HEPATOLOGY, October 2003
Therefore we studied the prevalence of progenitor cell features in a consecutive series of 45 HCCs. We used immunohistochemistry for cytokeratin (CK) 7, OV-6, Alpha-foetoprotein (AFP), CK18, polyCEA and Hepar-1. Of the 45 HCCs of different etiologies (viral hepatitis, alcoholic liver disease, hemochromatosis, non alcoholic fatty liver disease, Wilson disease), 18/45 originated in a cirrhotic liver, 17/45 showed a normal architecture or periportal, centrolobular and/or perisinusoidal fibrosis, 10/45 were in a septal stage. CK18 was reactive throughout the tumor in 73% of cases. Focal loss of CK18 was seen in 27%. PolyCEA canalicular staining was positive throughout the tumor in 44% and only in areas of the tumor in 56% of cases. Hepar-1 was reactive in 72% of cases. CK7 staining showed a massive positivity with majority of cells positive in 4% of cases, a partial positivity in 69%. Part of the CK7 positive cells presented as hepatic progenitor cells (HPCs), defined as small epithelial cells, with an oval nucleus and a narrow rim of cytoplasm. They showed strong cytoplasmic reactivity and occurred as single cells in the tumor or in strands. Submembranous CK7 reactivity was seen in polygonal cells with an intermediate size between that of HPCs and hepatocytes. They occurred in groups, acinar structures, or scattered in the tumor, mostly in the vicinity of HPCs. OV-6 staining was positive in 67% of cases, with a majority of positive cells in one third of these cases. The pattern of staining was similar to CK7, showing both HPCs and intermediate hepatocytes. AFP showed positivity in 47% of cases, with a majority of positive cells in one third of these cases. This series of HCCs shows the presence of some progenitor cell features in 2/3 of tumors. Progenitor cell features in HCC could be the result of dedifferentiation of tumoral, mature hepatocytes or from maturation arrest of progenitor cells during the carcinogenic process. In the latter possibility, the earliest presursor lesions of HCC, small cell dysplastic foci, should contain HPCs. We previously indeed showed that 55% of small cell dysplastic foci in chronic hepatitis patients consist of HPCs and intermediate hepatocytes. This suggests the possibility of h u m a n hepatocarcinogenesis from HPCs, concordant with several animal models of carcinogenesis. 2/45 (4%) HCCs in this series consist of small immature cells, expressing progenitor markers CK7 and OV-6 in the majority of cells. This subtype has been described in several case reports as 'progenitor cell tumor' or 'small cell HCC' having a rapid clinical evolution and suggesting the need to consider them as a separate entity with poor prognosis. 12/45 (27%) of HCCs in the series consist of mature hepatocytes, showing no progenitor cell features, while 31/45 (69%) of HCCs show some progenitor cell features.The correlation of our phenotypic study with genetic expression profiles and clinical outcome is in progress. We hope that this correlation can lead to a pathological classification with clinical and therapeutical relevance. Disclosures: Raymond Aerts - No relationships to disclose Anne M T D u r n e z - No relationships to disclose Jacques Pirenne - No relationships to disclose Tania Roskams - No relationships to disclose Chris Verslype - No relationships to disclose
1267
PREDICTING POST-TRANSPLANT SURVIVAL WITH HEPATOCELLULAR CARCINOMA: AN ASSESSMENT OF CURRENT STAGING SYSTEMS AND INDIVIDUAL PARAMETERS. ~ manuel Cavazzoni, Melissa D Meehan,
Christopher Shackleton, Cedars-Sinai Medical Center, Los Angeles, CA; Linda Sher, University of Southern California, Los Angeles, CA; Nicholas Nissen, John Vierling, Paul Martin, Fred Poordad, Tram Tran, Walid Ayoub, Steven Colquhoun, Cedars-Sinai Medical Center, Los Angeles, CA Background: The development of an adequate staging system for patients with Hepatocellular carcinoma (HCC) remains an area of great interest and need. Especially in the transplant setting, the ability to accurately stage patients with some sense of post-transplant prognosis is critical to the appropriate utilization of limited