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Liver manifestation in Wilson Disease: Role of the HFE genotype
W1416
days), 25(66%) of the patients who rebkd had repeat TIPSS performed, 72 (62%) patients have died over the tallow up period. Survival as per the Childs Pugh classification is shown in Ihe table. Of the patients who died, recurrent bleeding was the cause of death in 16 (22%) whilst multiorgan failure was the most conmmn mode of death (70%), CONCLUSION TIPSS is an etiective procedure in controlling variceal bleeding. Muhiorgan failure is the most common cause of death in this mainly akohol related patient group. Mortality rates remain high in Child C patients
A New Multitumoral Syndrome induding Cholangiocarcinoma as a Part of The
Syndrome?. Cetta F., Cariati a., MazzareUa L, Bon G., Nounga H., Zuckermann M. Institute of Surgical Clinic, University of Siena, Italy Francesco Cetta pentz-Jegbers syndrome (PJS) is a dominantly inherited disease characterized by hamartomatuus gastrointestinal polyps and mucocntaneons pigmentatinn of the lips and buccosal mucosa, associated with germ-fine mutations in the STKll/LKB1 gene (19p13.3), that encodes a multilunctional serine-threonine kinase. Art increased risk of gastrointestinal, gynecologic, breast, thyroid and pancreatic carcinomas has been detected. Several reports have shown LOH on 19p in breast, colorectal and pancreatic cancer. However, since the STK11/LKB1 gene has been cloned, evidence for biallelic somatic inactivation of STK11 in colorectal and breast cancer is lacking Recent reports have shown evidence for genetic heterogeneity in PJS. Interestingly, about 30% of patients with acfiincal pathologic diagnosis of PJS failed to show a gema-fine mutation of the STK11/LKB1 gene. A second candidate gene, possibly located at 19p14 has been hypothesized in particular, a very high incidence of cholangiocarcinoma, (40%), possibly located at 19p14 has been oobserved in PJS patients not showing germ-hue mutations of STK11/LKB1 geue. A kindred with 11 patients spanning 4 generations is here reported, with the proband showing non malignant thyroid tumor (at age 22), breast ductal cancer at age 40, cholangwcarcinoma of the hepatic convergence at age 62 and colon cancer not associated with FAP or multiple amartomatous polyps at age 66~ Initial genetic screening showed no germ-fine nrutation of STKll/I.KBI APC gene, responsible for FAP and PTEN-MMAC1FfEP1, responsible for Cowden disease and STK11/ LKB1, search for a new candidate gene at 19p14 is in progress.
FNE YEARSURVIVALAS PER CHILDSPUGHSCORINGSYSTEM CHILDS SCORE A B C
30 day surviwl 88% 86% 70%
6 month survival 82% 79% 63%
t2 month survival 75% 80% 48%
24 month sundval 63% 60% 39%
60 month survival 't9% 25% 8%
W1414 Wnt- Beta Catenin Signaling and Microsatellite Instability in Liver Carcinogenesis Cetta F, Zuckermann M, *Curia Mc, Mariani Costantini R, Bon G, Mazzarella L Institute of Snrgical Clinics, University of Siena,ltaly *Dpt of Pathology, University of Chieti, Italy' Fran~.esco Cetta Background: Hepatobfastoma (HB) is an embryonic rumor, usually" consisting of epithelial and meseuchymal compor~ents, which usually occurs before age 2. Most of hepatceellular carcinomas (lqCCs) develop in cirrhotic livers and are trequemly virns-related. Interestingly, 10%-20% ot HCCs occur in the absence oi HBV-HC..%~ int;ection and cirrhosis, Beta-Catenin and APC ate part ot the WNT~Wingless pathway Beta-Catenin gene mutation and its nuclear overexpression seems to be involved in tumorigenesis and cell differentiation Patients and Methods: We report a muhicentric study concerning 20 sporadic HBs and 11 non viresrelated HCCs In the HB group the mean age of the patients was 19 months (range: 3 months - 4 years and 8 months); in the HCC group all patients were less than 40-years and had tumor occurrence in the absence of overt cirrhosis. Mutational analysis of the exon 3 (fiom nucleotide 214 to nucleotide 364) ot the beta-Catenin gene and research of microsatellite instabdily were performed in all patients with HBs and HCCs Results: SSCP altalysis and sequencing of genomic DNA showed mutation of the beta-Catenin gene in 2 HBs (10%) and 2 HCCs (18%). A missei~se mutation at codons 32 and 38 was discovered in 2 ttBs, whereas is a nonsense mutation at codon 27 and a missense mutation at codon 32 were fbund in 2 H ( C s Interestingly, rnicrosatelfite instability was present in 11 HBs (55%), but m none of HCCs, Conclusion: Present data conhrm the previously" suggested involvment of beta-Catenin in bver carcinogenesis. Interestingly, HBs showed a high percentage (55%) of rm~ rosatellite n~stability This could suggest a possible role for both deregulation of the WNT beta-Catenin sigualing and microsatdlite instability, in fiver carcinogenesis, even if in ditterem types of tumors.
W1417 Liver Manifestation in wilson Disease: Role of the FIFE Genotype Jainne Genschel, Anna Czlonkowska, Marta Deguti, Bettina Bochow, Lkhagvasuren Sodnomtsogt, Eduardo L Cancado, Herbert Lochs, Hartmnt H. Sehmidt The clinical symptoms in Wilson Disease (WD) are quite variable. One of the major organ involvemem in WD represents the liver. Oxidative stress has been discussed in the context of copper accumulation in WD resulting in organ damage. A similar pathomechanism for liver disease is hypothesized in patients with iron overload. Hereditary hemochromatosis represents a severe form of iron overload in humans and results most commonly from the C282Y mutation within the HFE gene, to a lesser extent from the H63D and presumably also from the 865C variant within HFE Since the prevalence of these FIFE genotypes are relatively common, we studied them in genetically characterized WD subjects to determine the role of the HFE gene as potential candidate for hver disease in WD. We identified 123 WD snbjects due to clinical, biochemical, and histochemieal characteristics. In 76/123 patients (62%) we identified mutations within the ATP7B gene on both alleles, in 23/123 (19%) on one allele Single neurological involvement was observed in 41/123 patients (33%), primary liver involvement in 22/123 (18%) patients. Subsequently', we compared these two pattern groups for the presence of the C282Y, H63D, and $65C mutation within FIFE. None of the studied patients were homozygous or compound heterozygous for the evaluated FIFE genotypes. The frequencies of the C282Y, H63D, and $65C mutation were 0/22 (0%), 7/ 22 (32%), and 0/22 (0%), respectively, for the WD patients with primarily liver involvement. In contrast, the frequencies of the C282Y, H63D, and $65C mutation were 3/41 (7%), 8/ 41 (20%), and 1/41 (2%), respectively, in WD patients with single neurological disease. Therefore, the studied genotypes occurred also in patients with neurological disease. There was no pronounced tendency of HIE mutations within the WD patients presenting primarily with liver disease. Despite this limited number of studied patients, the HIE genotype seems to be not of significant importance in the manifestation of liver disease in WD. in concfusion, the occurrence of the C282Y, H63D, and $65C mutation within HIE in this studied cohort of WD subjects was detectable in both patients with single neurological manifestation and in patients with primarily hepatic disease. Therefore, these data incline that other factors than the HFE gene may play a role in determiinng the disease phenotype in WD.
W1415 Molecular Characterization of Familial Hypereholesterolemia in German and Greek Patients Janme Genschel Ginrgos V. Dedoussis, Bettina Bochow, Christo Pitsavos, .John Skoumas, Maganta Prassa, Lkliagvasuren Sodnomtsogt, Pavlos Toutouzas, Anja Vogt, Ursula Kassner, Herbert D~chs, Haus-Peter Thomas, Hartmut H. Schmidt Familial hypercholestemlemia ts an autosomal dominant disorder caused by mutations in the low-density lipoprotein receptor (LDLD gene afkcting approximately 1 in 500 individuals worldwide, it is characterized by a high concentration of LDL, which frequently gives rise to tendon xanthomas and premature coronary artery disease We used the denaturing gradient gel electrophoresis (DGGE) method to define mntations in the promoter region, the 18 exous, and their thnking mtrontc sequences of the LDI_Rgene, causing familial hypercholesterolemia (FE[) phenotype m 100 German and in 100 Greek hypercholesterolemic individuals In addition we tested all patients for the presence of mutations in codons 34564553 of the gene encoding apofipoprotein B-100 Twenty six aberrant DGGE patterrls were identified and subsequently diI~:ctly seqnem:ed Within the german studied cohort we detected 1 liomozygons substitution in the promoter region, 16 missense mutations (C74S, C88R, C134G, C195Y, C122Y, Q233P D245N, A370T, E387K, R395W, V408M, VS02M, G571E, A5855, V632F, C6905), 2 nonsense nmtations (W284X, E296X), 3 small ddefions and insertinns (c680-681delAC, c661insCCCCG, c680insl 2nt), and 2 splice site mutations (IVS3 + 1G/A, IVS3 + 21/C) Within tbe greek studied cohort we observed 10 missense mutations (C6W, Q233P $265R, Q363P, D365E, A370T, V408M, G528D, G571E, and R723Q), and 2 nonsense mutations (Q363X and C660X), both reported for the first time m the Greek FH population In addition ,ae identihed the splice site mutation IVS7 + 10C>G Theretore three novd missensc mutations (-63C>T homozygous, V632F, C195Y) were idemihed among German FH patients and 1 novel splice site WS7 + 10C>G among Greek FH patients. One of the German FH patients was carrier for the mutations A370T and V632F and two oi the Greek FH patients were compound heterozygntes for the mutations Q363X and D365E Two German FH patients carried tbe mutation R3500Q within the apoB gene Comparing the nmtations within the LDLR gane of the two European FH populations, the Gene;m population seems to be more heterogeneous than the Greek cohort. Future studies are in progress trying to elucidate the ditt~erent phenotypes of patients carrying the same mutation, which maybe explained by different lite-style factors and potential modiller genes
AGA
Abstracts
w1418 Long Term Experience in Wilson Disease Treatment Valentina Medici, Renata D'Inca, Michela Barollo, Carlo P. Trevisan, Lucia Zancan, Giacomo C. Stumiolo Introduction. Wilson disease (WD) is an inherited autosumal recessive disorder of copper accumulation and toxicity in the liver, brain and cornea which requires lite long anti-copper therapy. Aim: to describe the outcome of treated Wilson disease patients. Patients and methods: 27 patients (19 males) were followed at the Division of Gastroenterology, University of Padova from 1980 to 2001, mean ll years (range 1-20). The diagnosis was based on clinical symptoms (hepatic, nem'ologic or psychiatric) and laboratory testing (eerulopfasmin, urinary and hepatic copper concentrations). 47% had liver disease; 39% neurologic/psychiatric disease; 13% were diagnosed after family screening. Age at presentation was 15.5 years (range 445): 13 years for hepatic, 19 years tbr treurologic involvement. Results: All patients had been initially- treated with either penieillamine or zinc. 1) Penicillamine (600-1800 rag/ die) (17 patients): 6(35%) developed side effects (renal damage, autoimmuinty, amenorrhea) which required switching to Zinc; 5 (28%) failed to improve: Zine was effective in all but one patient with neurologic disease who gradually worsened until death after 8 yrs since diagnosis; 5(21%) patients were switched to Zinc treatment after a mean time period of 6.8 yrs: 2 pts retnraed to peincilfamine because of increasing transaminase values; one temaie patient, diagnosed after family screening, remains asymptomatic after 9 yrs since diagnosis;. 2) Zinc sulphate (660-880 mg/day)(10 patients): 8 patients improved, 1 underwent liver transplant after 8 yrs on Zinc, 2 twin brothers with both hepatic and neuropsychiatric disease, HCV positivity and poor compliance worsened and needed liver transplant after 9 and 14 yrs. One of them did not improve despite transplant and eventually died for intractabk neurologic symptoms. Zinc caused gastric discomfort in two patients, which did not require treatment withdrawl. Three pregnancies were uneventful under zinc therapy. Conclusion:
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days), 25(66%) of the patients who rebkd had repeat TIPSS performed, 72 (62%) patients have died over the tallow up period. Survival as per the Childs Pugh classification is shown in Ihe table. Of the patients who died, recurrent bleeding was the cause of death in 16 (22%) whilst multiorgan failure was the most conmmn mode of death (70%), CONCLUSION TIPSS is an etiective procedure in controlling variceal bleeding. Muhiorgan failure is the most common cause of death in this mainly akohol related patient group. Mortality rates remain high in Child C patients
A New Multitumoral Syndrome induding Cholangiocarcinoma as a Part of The
Syndrome?. Cetta F., Cariati a., MazzareUa L, Bon G., Nounga H., Zuckermann M. Institute of Surgical Clinic, University of Siena, Italy Francesco Cetta pentz-Jegbers syndrome (PJS) is a dominantly inherited disease characterized by hamartomatuus gastrointestinal polyps and mucocntaneons pigmentatinn of the lips and buccosal mucosa, associated with germ-fine mutations in the STKll/LKB1 gene (19p13.3), that encodes a multilunctional serine-threonine kinase. Art increased risk of gastrointestinal, gynecologic, breast, thyroid and pancreatic carcinomas has been detected. Several reports have shown LOH on 19p in breast, colorectal and pancreatic cancer. However, since the STK11/LKB1 gene has been cloned, evidence for biallelic somatic inactivation of STK11 in colorectal and breast cancer is lacking Recent reports have shown evidence for genetic heterogeneity in PJS. Interestingly, about 30% of patients with acfiincal pathologic diagnosis of PJS failed to show a gema-fine mutation of the STK11/LKB1 gene. A second candidate gene, possibly located at 19p14 has been hypothesized in particular, a very high incidence of cholangiocarcinoma, (40%), possibly located at 19p14 has been oobserved in PJS patients not showing germ-hue mutations of STK11/LKB1 geue. A kindred with 11 patients spanning 4 generations is here reported, with the proband showing non malignant thyroid tumor (at age 22), breast ductal cancer at age 40, cholangwcarcinoma of the hepatic convergence at age 62 and colon cancer not associated with FAP or multiple amartomatous polyps at age 66~ Initial genetic screening showed no germ-fine nrutation of STKll/I.KBI APC gene, responsible for FAP and PTEN-MMAC1FfEP1, responsible for Cowden disease and STK11/ LKB1, search for a new candidate gene at 19p14 is in progress.
FNE YEARSURVIVALAS PER CHILDSPUGHSCORINGSYSTEM CHILDS SCORE A B C
30 day surviwl 88% 86% 70%
6 month survival 82% 79% 63%
t2 month survival 75% 80% 48%
24 month sundval 63% 60% 39%
60 month survival 't9% 25% 8%
W1414 Wnt- Beta Catenin Signaling and Microsatellite Instability in Liver Carcinogenesis Cetta F, Zuckermann M, *Curia Mc, Mariani Costantini R, Bon G, Mazzarella L Institute of Snrgical Clinics, University of Siena,ltaly *Dpt of Pathology, University of Chieti, Italy' Fran~.esco Cetta Background: Hepatobfastoma (HB) is an embryonic rumor, usually" consisting of epithelial and meseuchymal compor~ents, which usually occurs before age 2. Most of hepatceellular carcinomas (lqCCs) develop in cirrhotic livers and are trequemly virns-related. Interestingly, 10%-20% ot HCCs occur in the absence oi HBV-HC..%~ int;ection and cirrhosis, Beta-Catenin and APC ate part ot the WNT~Wingless pathway Beta-Catenin gene mutation and its nuclear overexpression seems to be involved in tumorigenesis and cell differentiation Patients and Methods: We report a muhicentric study concerning 20 sporadic HBs and 11 non viresrelated HCCs In the HB group the mean age of the patients was 19 months (range: 3 months - 4 years and 8 months); in the HCC group all patients were less than 40-years and had tumor occurrence in the absence of overt cirrhosis. Mutational analysis of the exon 3 (fiom nucleotide 214 to nucleotide 364) ot the beta-Catenin gene and research of microsatellite instabdily were performed in all patients with HBs and HCCs Results: SSCP altalysis and sequencing of genomic DNA showed mutation of the beta-Catenin gene in 2 HBs (10%) and 2 HCCs (18%). A missei~se mutation at codons 32 and 38 was discovered in 2 ttBs, whereas is a nonsense mutation at codon 27 and a missense mutation at codon 32 were fbund in 2 H ( C s Interestingly, rnicrosatelfite instability was present in 11 HBs (55%), but m none of HCCs, Conclusion: Present data conhrm the previously" suggested involvment of beta-Catenin in bver carcinogenesis. Interestingly, HBs showed a high percentage (55%) of rm~ rosatellite n~stability This could suggest a possible role for both deregulation of the WNT beta-Catenin sigualing and microsatdlite instability, in fiver carcinogenesis, even if in ditterem types of tumors.
W1417 Liver Manifestation in wilson Disease: Role of the FIFE Genotype Jainne Genschel, Anna Czlonkowska, Marta Deguti, Bettina Bochow, Lkhagvasuren Sodnomtsogt, Eduardo L Cancado, Herbert Lochs, Hartmnt H. Sehmidt The clinical symptoms in Wilson Disease (WD) are quite variable. One of the major organ involvemem in WD represents the liver. Oxidative stress has been discussed in the context of copper accumulation in WD resulting in organ damage. A similar pathomechanism for liver disease is hypothesized in patients with iron overload. Hereditary hemochromatosis represents a severe form of iron overload in humans and results most commonly from the C282Y mutation within the HFE gene, to a lesser extent from the H63D and presumably also from the 865C variant within HFE Since the prevalence of these FIFE genotypes are relatively common, we studied them in genetically characterized WD subjects to determine the role of the HFE gene as potential candidate for hver disease in WD. We identified 123 WD snbjects due to clinical, biochemical, and histochemieal characteristics. In 76/123 patients (62%) we identified mutations within the ATP7B gene on both alleles, in 23/123 (19%) on one allele Single neurological involvement was observed in 41/123 patients (33%), primary liver involvement in 22/123 (18%) patients. Subsequently', we compared these two pattern groups for the presence of the C282Y, H63D, and $65C mutation within FIFE. None of the studied patients were homozygous or compound heterozygous for the evaluated FIFE genotypes. The frequencies of the C282Y, H63D, and $65C mutation were 0/22 (0%), 7/ 22 (32%), and 0/22 (0%), respectively, for the WD patients with primarily liver involvement. In contrast, the frequencies of the C282Y, H63D, and $65C mutation were 3/41 (7%), 8/ 41 (20%), and 1/41 (2%), respectively, in WD patients with single neurological disease. Therefore, the studied genotypes occurred also in patients with neurological disease. There was no pronounced tendency of HIE mutations within the WD patients presenting primarily with liver disease. Despite this limited number of studied patients, the HIE genotype seems to be not of significant importance in the manifestation of liver disease in WD. in concfusion, the occurrence of the C282Y, H63D, and $65C mutation within HIE in this studied cohort of WD subjects was detectable in both patients with single neurological manifestation and in patients with primarily hepatic disease. Therefore, these data incline that other factors than the HFE gene may play a role in determiinng the disease phenotype in WD.
W1415 Molecular Characterization of Familial Hypereholesterolemia in German and Greek Patients Janme Genschel Ginrgos V. Dedoussis, Bettina Bochow, Christo Pitsavos, .John Skoumas, Maganta Prassa, Lkliagvasuren Sodnomtsogt, Pavlos Toutouzas, Anja Vogt, Ursula Kassner, Herbert D~chs, Haus-Peter Thomas, Hartmut H. Schmidt Familial hypercholestemlemia ts an autosomal dominant disorder caused by mutations in the low-density lipoprotein receptor (LDLD gene afkcting approximately 1 in 500 individuals worldwide, it is characterized by a high concentration of LDL, which frequently gives rise to tendon xanthomas and premature coronary artery disease We used the denaturing gradient gel electrophoresis (DGGE) method to define mntations in the promoter region, the 18 exous, and their thnking mtrontc sequences of the LDI_Rgene, causing familial hypercholesterolemia (FE[) phenotype m 100 German and in 100 Greek hypercholesterolemic individuals In addition we tested all patients for the presence of mutations in codons 34564553 of the gene encoding apofipoprotein B-100 Twenty six aberrant DGGE patterrls were identified and subsequently diI~:ctly seqnem:ed Within the german studied cohort we detected 1 liomozygons substitution in the promoter region, 16 missense mutations (C74S, C88R, C134G, C195Y, C122Y, Q233P D245N, A370T, E387K, R395W, V408M, VS02M, G571E, A5855, V632F, C6905), 2 nonsense nmtations (W284X, E296X), 3 small ddefions and insertinns (c680-681delAC, c661insCCCCG, c680insl 2nt), and 2 splice site mutations (IVS3 + 1G/A, IVS3 + 21/C) Within tbe greek studied cohort we observed 10 missense mutations (C6W, Q233P $265R, Q363P, D365E, A370T, V408M, G528D, G571E, and R723Q), and 2 nonsense mutations (Q363X and C660X), both reported for the first time m the Greek FH population In addition ,ae identihed the splice site mutation IVS7 + 10C>G Theretore three novd missensc mutations (-63C>T homozygous, V632F, C195Y) were idemihed among German FH patients and 1 novel splice site WS7 + 10C>G among Greek FH patients. One of the German FH patients was carrier for the mutations A370T and V632F and two oi the Greek FH patients were compound heterozygntes for the mutations Q363X and D365E Two German FH patients carried tbe mutation R3500Q within the apoB gene Comparing the nmtations within the LDLR gane of the two European FH populations, the Gene;m population seems to be more heterogeneous than the Greek cohort. Future studies are in progress trying to elucidate the ditt~erent phenotypes of patients carrying the same mutation, which maybe explained by different lite-style factors and potential modiller genes
AGA
Abstracts
w1418 Long Term Experience in Wilson Disease Treatment Valentina Medici, Renata D'Inca, Michela Barollo, Carlo P. Trevisan, Lucia Zancan, Giacomo C. Stumiolo Introduction. Wilson disease (WD) is an inherited autosumal recessive disorder of copper accumulation and toxicity in the liver, brain and cornea which requires lite long anti-copper therapy. Aim: to describe the outcome of treated Wilson disease patients. Patients and methods: 27 patients (19 males) were followed at the Division of Gastroenterology, University of Padova from 1980 to 2001, mean ll years (range 1-20). The diagnosis was based on clinical symptoms (hepatic, nem'ologic or psychiatric) and laboratory testing (eerulopfasmin, urinary and hepatic copper concentrations). 47% had liver disease; 39% neurologic/psychiatric disease; 13% were diagnosed after family screening. Age at presentation was 15.5 years (range 445): 13 years for hepatic, 19 years tbr treurologic involvement. Results: All patients had been initially- treated with either penieillamine or zinc. 1) Penicillamine (600-1800 rag/ die) (17 patients): 6(35%) developed side effects (renal damage, autoimmuinty, amenorrhea) which required switching to Zinc; 5 (28%) failed to improve: Zine was effective in all but one patient with neurologic disease who gradually worsened until death after 8 yrs since diagnosis; 5(21%) patients were switched to Zinc treatment after a mean time period of 6.8 yrs: 2 pts retnraed to peincilfamine because of increasing transaminase values; one temaie patient, diagnosed after family screening, remains asymptomatic after 9 yrs since diagnosis;. 2) Zinc sulphate (660-880 mg/day)(10 patients): 8 patients improved, 1 underwent liver transplant after 8 yrs on Zinc, 2 twin brothers with both hepatic and neuropsychiatric disease, HCV positivity and poor compliance worsened and needed liver transplant after 9 and 14 yrs. One of them did not improve despite transplant and eventually died for intractabk neurologic symptoms. Zinc caused gastric discomfort in two patients, which did not require treatment withdrawl. Three pregnancies were uneventful under zinc therapy. Conclusion:
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