Basic Programme: FEBRUARY Clinical Programme: MOLECULAR PATHOGENESIS

Transcription

Basic Programme:
MOLECULAR PATHOGENESIS
& TRANSLATIONAL RESEARCH
IN LIVER CANCER
FEBRUARY 13 -14, 2014
Clinical Programme:
LIVER CANCER MANAGEMENT
FEBRUARY 15 -16, 2014
GENEVA . SWITZERLAND
PROGRAMME
AND ABSTRACTS
www.easl.eu/hccsummit2014
www.easl.eu
LIVER
KIDNEY
LUNG
THYROID
Pioneering. Powerful. Proven.
6 years of delivering unsurpassed survival in your unresectable
LIVER
hepatocellular
carcinoma
for LRT*
KIDNEY (HCC) patients
LUNG not eligible
THYROID
• Nexavar® is the first proven systemic therapy to consistently
demonstrate an overall survival (OS) benefit vs placebo in
unresectable HCC patients among approximately 100 trials in
over 30 years1
– 44% to 47% improvement in OS vs placebo in
2 phase III trials of Western and Asian patients1,2
• Nexavar is the recommended standard for advanced
HCC and in patients not eligible/refractory to
earlier treatments3
Basic Programme:
MOLECULAR PATHOGENESIS
& TRANSLATIONAL RESEARCH
IN LIVER CANCER
FEBRUARY 13-14, 2014
®
With Nexavar® you can optimize
outcomes for your patients with HCC
Clinical Programme:
LIVER CANCER MANAGEMENT
FEBRUARY 15-16, 2014
GENEVA . SWITZERLAND
*LRT=Locoregional therapies
Essential Information
C: sorafenib tosylate. I: treatment of patients with hepatocellular carcinoma and treatment of advanced renal cell cancer after
nephrectomy and palliative or adjuvant prior therapy with cytokines (IL-2, IFN). P/A: 400 mg (= 2 tablets of 200 mg) twice a day
until progression or unacceptable toxicity. CI: hypersensitivity reaction to active or to any of the excipients. P: hand-foot syndrome,
rash, hypertension, hemorrhage, warfarine or neomycin co-administration, unstable coronary heart disease, long QT interval, severe
hepatic impairment, impairment of fertility. UE: very common: lymphopenia, hypophosphatemia, hemorrhage, hypertension, diarrhea,
nausea, vomiting, hand-foot syndrome, rash, erythema, pruritus, alopecia, fatigue, pain, increased lipase, increased amylase. Common:
leucopenia, anemia, neutropenia, thrombocytopenia, weight loss, anorexia, hypocalcemia, hypokaliaemia, depression, peripheral
sensory neuropathy, tinnitus, congestive heart failure, myocardial ischaemia, myocardial infarction, flushing, hoarseness, dyspnea,
cough, dyspepsia, dysphagia, constipation, pain and disorders of the mouth, renal insufficiency, proteinuria, dry skin, acne, dermatitis
exfoliative, desquamation, mayalgia, arthralgia, erectile dysfunction, influenza like illness, asthenia, fever, edema of the lower leg, increase
in transaminases. I: with substrates UGT 1A1 and UGT 1A9 (i.e. barbiturates, irinotecan, paclitaxel, estradiol, propofol), inducers of
CYP3A4 (rifampicin, St. John’s wort, phenytoin, carbamazepine, phenobarbital, dexaméthasone), coumarin preparations, docetaxel,
neomycin. D: Bayer (Schweiz) AG, 8045 Zurich. List A. Reimbursed (L). Status January 2013. For further information please consult the
professional information on www.swissmedicinfo.ch.
References: 1. Llovet JM, Ricci S, Mazzaferro V, et al; for the SHARP Investigators Study
Group. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008;359:378390. 2. Cheng A-L, Kang Y-K, Chen Z, et al. Efficacy and safety of sorafenib in patients
in the Asia-Pacific region with advanced hepatocellular carcinoma: a phase III
randomised, double-blind, placebo-controlled trial. Lancet Oncol. 2009;10(1):25-34.
3. Bruix J, Sherman M; American Association for the Study of Liver Diseases. Management of
hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020-1022.
Bayer (Schweiz) AG
Grubenstrasse 6
CH-8045 Zürich
www.bayer.ch
L.CH.ONC.01.2014.0115-EN
PROGRAMME
AND ABSTRACTS
The EASL Building
HOME OF EUROPEAN HEPATOLOGY
7 rue Daubin
CH-1203 Geneva
Tel. +41 22 807 03 60
Fax: +41 22 328 07 24
[email protected]
www.easl.eu
www.easl.eu/hccsummit2014
2
PROGRAMME AND ABSTRACTS
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
CONTENTS
WELCOME MESSAGE
04
COMMITTEES
06
ACKNOWLEDGEMENTS & SPONSORS
07
GENERAL INFORMATION
09
TECHNICAL INFORMATION
12
SCIENTIFIC PROGRAMME
13
POSTER BOARDS
21
BASIC PROGRAMME ABSTRACTS
SPEAKERS’ ABSTRACTS
41
POSTER ABSTRACTS
89
CLINICAL PROGRAMME ABSTRACTS
SPEAKERS’ ABSTRACTS
161
POSTER ABSTRACTS
195
INDEX
341
EASL HCC SUMMIT
3
4
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
5
WELCOME MESSAGE
Dear colleagues,
CLINICAL PROGRAMME
The European Association for the Study of the Liver (EASL) is pleased to inform you of a
broader and enhanced programme on the topic of Liver Cancer that has developed into
a new concept in the form of the 2014 EASL HCC Summit.
The objectives of this segment is to provide an in-depth review on the different
management issues related to early detection, diagnosis, and treatment of HCC, and
also, to highlight the ways of dealing with such an important and rapidly involving field:
Liver Cancer Management. Over two days, we will cover a broad range of topics relevant
to the management of HCC, starting with screening, through diagnosis and elaborating
on stage specific treatment of this most important liver disease.
Taking place in Geneva, Switzerland from February 13-16, 2014, the programme will
offer two sub-components. A Basic Science programme on Molecular Pathogenesis and
Translational Research in Liver Cancer, immediately followed by a Clinical programme
on Liver Cancer Management. This will result in a considerably broader scope of HCC
topics aimed at a wider audience. Participants will be offered the option to attend either
programmes or both.
We anticipate that this combination of high quality presentations together with the strong
reputation of the invited speakers and the relevance of the topics will bring together
leading researchers, academics, clinicians and scientists involved in HCC for what will
be a memorable meeting.
BASIC SCIENCE PROGRAMME
The invited speakers will be the most prominent investigators and contributors in the
field, and consequently opinion leaders in HCC. A State Of The Art lecture will form part
of the complete scientific programme, and time and space will be reserved for poster
presentations of original work on latest HCC research and management.
We anticipate that this combination of high quality presentations together with the strong
reputation of the invited speakers and the relevance of the topics will bring together
leading researchers, academics, clinicians and scientists involved in HCC for what will
be a memorable meeting.
We look forward to welcoming you in Geneva for this major event.
The interest in HCC has risen dramatically over the past years and many conferences
address this topic. While most of them center around aspects of clinical application,
there is a definitive lack of meetings that address more basic biomedical research
aspects of liver cancer. Since there is no tomorrow´s clinical application without today´s
basic research, we have taken the task to devote the first part of this conference mainly
to basic research in liver cancer and bring together the leading basic scientists with
junior researchers, and also clinical researchers interested in novel research concepts.
This concept requires sufficient time for discussion and communication, something
frequently missing in large scale meetings. Liver cancer is the paradigm for infectionand inflammation-induced cancer and one of the mainstays of animal and cell culture
cancer models; there is much to learn from it even for other tumour entities and many
new mechanisms need to be tested for their applicability.
SCIENTIFIC ORGANISING COMMITTEE: BASIC PROGRAMME
Michael Manns
Peter Schirmacher
Jessica Zucman-Rossi
SCIENTIFIC ORGANISING COMMITTEE: CLINICAL PROGRAMME
Jean-François Dufour
Markus Peck-Radosavljevic
Jean-Luc Raoul
6
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
SCIENTIFIC ORGANISING COMMITTEE
ACKNOWLEDGEMENTS
BASIC PROGRAMME
Michael Manns, Hannover, Germany
Peter Schirmacher, Heidelberg, Germany
Jessica Zucman-Rossi, Paris, France
PREMIUM SPONSORS
7
EASL thanks its Premium Sponsors for their generous contributions and support of all
the 2014 EASL educational activities with an unrestricted educational grant.
CLINICAL PROGRAMME
Jean-François Dufour, Bern, Switzerland
Markus Peck-Radosavljevic, Vienna, Austria
Jean-Luc Raoul, Marseille, France
EASL GOVERNING BOARD
SECRETARY GENERAL
CONFERENCE SPONSOR
EASL acknowledges the following companies dedication and generous support for the
HCC Summit.
Gold Sponsor
VICE-SECRETARY
Laurent Castera, Paris, France
TREASURER
Mauro Bernardi, Bologna, Italy
SCIENTIFIC COMMITTEEE MEMBERS
Alessio Aghemo, Milan, Italy
Matías A. Avila, Pamplona, Spain
Frank Lammert, Homburg, Germany
Helen Louise Reeves, Newcastle-upon-Tyne, UK
Cecília Rodrigues, Lisbon, Portugal
EDUCATIONAL COUNCILLORS
Cihan Yurdaydin, Ankara, Turkey
EU POLICY COUNCILLOR
Patrizia Burra, Padua, Italy
Bronze Sponsor
OTHERS
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
MANY WAYS
ONE AIM
THE CONQUEST
OF ALL LIVER
DISEASE
MEMBER BENEFITS:
• Free monthly online subscription to the
Journal of Hepatology
• Reduced fees at The International Liver
Congress™ and to all EASL Meetings
• Free access to the Liver TreeTM e-learning
portal of EASL including; webcasts, podcasts,
BECOME PART
OF OUR VISION…
SUPPORT EASL!
MISSION:
Provide professional
leadership in the liver
disease arena
Reduce the prevalence
of liver disease in our
community and worldwide
Minimize the suffering
of patients and prevent
liver- related deaths
Promote clinical, basic and
translational research
quizzes, E-Series and E-Posters
• Possibility to host fellows as part of the EASL Fellowship Programme
• Opportunity to organise EASL
Monothematic and Special Conferences
Foster international
scientific exchange
• Possibility to host one of the EASL
Schools of Hepatology
• EASL Newsletter
• Application support for the EU Research
Framework Programme
• EASL funding for Registry Grant applications
• Application for Mentorship programme
Membership is valid from January 1st to December 31st
Advise european health
authorities concerning
liver diseases, the provision
of clinical services, and the
need for research funding
Raise public awareness
of liver diseases and
their management
Throughout its history,
EASL has attracted an ever growing
number of experts and sponsors
concerned with the health and wellbeing of individuals all over the world.
We invite all who wish to take up a challenge to
join EASL and become a part of our vision.
Please visit www.easl.eu for full conditions.
www.easl.eu/_membership
GENERAL
INFORMATION
9
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
11
GENERAL INFORMATION
VENUE
Starling Geneva Hotel and Conference
Center
Route François-Peyrot 34
1218 Grand-Saconnex
Switzerland
http://www.shgeneva.ch/
INFORMATION ABOUT GENEVA
City website: http://www.geneve.ch/
welcome_en.html
LANGUAGE
The official language of the conference
is English.
CLIMATE
Due to the tempering effects of the lake
and surrounding mountains, Geneva is
pleasant almost year round. January and
February are the coldest months but rarely
drop below freezing. For more information,
go to: www.free-weather.com/
Geneva-Switzerland.php
NAME BADGES
All participants are kindly requested to
wear their name badges throughout the
EASL HCC Summit in order to be admitted
to the lecture halls and other scheduled
activities.
REGISTRATION DESK
The onsite registration desk at the
conference venue, will be opened:
Thursday, 13 February
11:00- 19:30
Friday, 14 February
7:30 - 19:30
Saturday, 15 February
7:30 - 20:00
Sunday, 16 February
7:30 - 20:00
OFFICIAL LETTER OF INVITATION
Official letters of invitation designed to
help overcome administrative difficulties
in certain countries may be requested. It
must be understood that such letters do
not represent a commitment on the part of
the Organising Committee or conference to
provide any financial assistance.
CME ACCREDITATION
EASL has applied to the European
Accreditation Council for Continuing
Medical Education (EACCME) to provide
CME accreditation for medical specialists
attending the EASL HCC Summit. The
EACCME is an institution of the European
Union of Medical Specialists (UEMS) www.
uems.net. Each medical specialist should
claim only those hours of credit that he/she
actually spent in the educational activity.
EACCME credits are recognized by the
American Medical Association towards
the Physician Recognition Award (PRA).
To convert EACCME credit to AMA PRA
category 1 credit, contact the AMA. Vice
versa, all CME activities approved by the
American Medical Association (AMA) are
recognized by the EACCME. The American
Medical Association is an Accredited
Provider of the Accreditation Council for
Continuing Medical Education (ACCME)
USA. Updated information regarding
CME accreditation will be available on the
conference website.
EVALUATION FORMS & CERTIFICATES
Session Evaluation Forms - will be available
online. A link will be sent to you by e-mail
after the conference. You are requested to
kindly complete the forms for each session
that you attend.
CME Events Evaluation Form - will also be
available online. A link will be sent to you
by e-mail after the conference. In order
to receive a Certificate of Attendance, a
CME Events Evaluation Form must be
completed online.
Certificate of Attendance - Please note
that a completed CME Events Evaluation
Form is a pre-requisite in order to receive a
Certificate of Attendance. Upon completion
of all mandatory online evaluations, the
EASL Office will send you an electronic
version of your certificate by e-mail.
TRANSPORT TO VENUE
Easily accessible, the Starling Geneva
Hotel & Conference Center is located just
3 minutes from Geneva Airport with free
transfers from the first to the last flight. The
city center and the Lake are 10 minutes
away and the Palexpo exhibition center is
only 1 minute by foot.
Access from the airport
Please use the complementary Starling
Geneva Hotel Shuttle which is located at
gate F4 at the arrivals level. The shuttle leaves
every 15 minutes from 5:10 am to 11:45 pm
Access by train
From the Geneva Central Railway Station
(Gare Cornavin) take bus n°5 towards
“Aeroport/Palexpo” get off at “GrandSaconnex “ cross the road and go towards
the hotel restaurant “La Colombière”.
Access by public transport (bus)
From the city centre, take bus n°5 towards
“Aeroport/Palexpo” get off at “GrandSaconnex “ cross the road and go towards
the hotel restaurant “La Colombière”. LIST OF PARTICIPANTS
To be displayed on the notice board located
in the registration area.
DRESS CODE
Informal for all occasions.
SMOKING POLICY
This is a non-smoking event.
BANKING & CURRENCY EXCHANGE
The official currency in Switzerland is the
Swiss Franc (CHF).
Foreign currency can be exchanged at
banks, bureau de change and automatic
currency exchange machines.
SAFETY AND SECURITY
Please do not leave bags or suitcases
unattended at any time, whether inside or
outside the session halls. Hotels strongly
recommend that you use their safety
deposit boxes for all valuables.
LIABILITY AND INSURANCE
The EASL Office cannot accept liability for
personal accidents or loss of or damage to
private property of participants. Participants
are advised to take out their own personal
travel and health insurance for their trip.
GENERAL INFORMATION
GENERAL INFORMATION
10
12
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
TECHNICAL INFORMATION
ORAL PRESENTATION
If using a Powerpoint (or any other
computer) presentation, the content
should be brought on a CD, a DVD or a
memory stick/USB key (using the USB port
in the computer) and loaded on to one of
the conference computers in the Speakers’
Ready Room located near the plenary hall
(follow “Speakers Ready Room” signs) at
least 1 hour before the start of the session.
If combining video films with PowerPoint,
please check the content in the session hall
where your lecture is taking place during a
coffee or lunch break prior to your session,
at least 30 minutes before the start of
the session - even after checking it in the
Speakers’ Ready Room.
Conference computers in the session halls
are being supplied with Windows 7 and
Office 2010.
Important note for Macintosh users:
In order to use MAC presentations on a PC
compatible computer you need to prepare
according to the instructions below, before
bringing presentations to the Speakers’
Ready Room:
1.
Use a common font, such as Arial,
Times New Roman, Verdana etc.
(Special fonts might convert
to a default font when using a
PowerPoint based PC).
2.
Insert pictures as JPG files (not TIF,
PNG or PICT - these images will not
be visible on a PowerPoint based PC).
3.
Use a common movie format, such
as AVI, MPG and WMV (MOV files
from QuickTime will not be visible
on a PowerPoint based PC).
You may use your own Macintosh laptop
computer as a back-up. In such cases
please confirm that it has a VGA socket
for external signal and come to check
it first in the Speakers’ Ready Room as
soon as you arrive and then later in the
session hall where your lecture is taking
place (during the coffee or lunch break
prior to your session), at least 30 minutes
before the start of the session.
VHS Video projection, 35 mm’ slide
projection and overhead projection
(projection of transparencies) will not be
available.
IMPORTANT NOTE:
It is mandatory that all oral
presenters prepare a disclosure slide
as the first slide in their presentation.
If you have nothing to disclose, this
slide must be included and indicate
“nothing to disclose”.
POSTER PRESENTATION
Poster presenters are requested to
stand next to their poster during coffee
breaks and lunch breaks as indicated in
the programme for informal discussions/
questions regarding their work.
Basic Programme
Posters should be set up before 13:50
on Thursday, February 13, 2014 and
must be taken down at the end of the
Basic Programme on Friday, February
14, 2014.
Clinical Programme
Posters should be set up before 11:00
on Saturday, February 15, 2014, and
removed at the end of the sessions on
Sunday February 16, 2014.
SCIENTIFIC
PROGRAMME
13
14
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
15
BASIC PROGRAMME
THURSDAY, FEBRUARY 13, 2014
9:00-12:00
WORKING GROUP MEETING: MOLECULAR CLASSIFICATION
OF HCC
14:50 – 15:05
OPPOSING PPARG AND ROSIGLITAZONE PATHWAYS CONVERGE
ON RUVBL1 IN HCC CELL LINES
Tommaso Mello, Italy
15:05 – 15:20
NOTCH1 DRIVES SECRETOME SWITCHING IN RAS-INDUCED
SENESCENCE
Matthew Hoare, United Kingdom
15:20 – 15:50
CELL CYCLE, METABOLISM AND HCC
Lluis Fajas, Switzerland
15:50 – 16:20
COFFEE BREAK
16:20 – 18:20
SESSION 3: TUMOUR STEM CELLS
Chair: Thomas Lüdde, Germany, Peter Galle, Germany
16:20 – 16:50
MIXED LIVER TUMOUR DIFFERENTIATION
Tania Roskams, Belgium
16:50 – 17:20
PROFILING, CANCER STEM CELLS
Snorri Thorgeirsson, USA
17:20 – 17:35
SPECIFIC TARGETING OF STEM-LIKE CELLS IN LIVER CANCER BY
NF-KB MEDIATED INHIBITON OF HISTONE DEACETYLASES
Jens Marquardt, Germany
17:35 – 17:50
SIDE POPULATION ANALYSIS IDENTIFIES A ROLE FOR LAMININ IN
MODULATING THE HUMAN HEPATIC CANCER STEM CELL NICHE
Olivier Govaere, Belgium
17:50 – 18:05
RAGE SIGNALING IN OVAL CELL ACTIVATION DURING
LIVER DAMAGE
Aurora De Ponti, Germany
18:05 - 18:20
RESECTABLE TRANSGENIC TUMOUR MODEL IN MICE FOR
INTRAHEPATIC CHOLANGIOCARCINOMA
Engin Gürlevik, Germany
18:30
COCKTAIL RECEPTION FOR ALL PARTICIPANTS AND POSTER
SESSION
BASIC RESEARCH PROGRAMME
Molecular Pathogenesis and Translational Research in Liver Cancer
February 13 – 14, 2014 – Geneva
Organisers:
Michael Manns, Hannover, Germany
Peter Schirmacher, Heidelberg, Germany
Jessica Zucman-Rossi, Paris, France
THURSDAY, FEBRUARY 13, 2014
12:15
12:20 – 13:20
WELCOME AND INTRODUCTION
Michael Manns, Germany
Peter Schirmacher, Germany
SESSION 1: HCC EPIDEMIOLOGY AND PREDISPOSITION
Chair: Michael Manns, Germany, Ansgar Lohse, Germany
12:20 – 12:50
GENETIC PREDISPOSITION TO HCC
Pierre Nahon, France
12:50 – 13:20
POLYPLOIDY
Chantal Desdouet, France
13:20 – 13:50
COFFEE BREAK
13:50 –15:50
SESSION 2: METABOLIC AND ENDOCRINE MECHANISMS
Chair: Nisar Malek, Germany, Tania Roskams, Belgium
13:50 – 14:20
METABOLIC MECHANISMS
Stephan Herzig, Germany
14:20 – 14:50
ENDOCRINE HEPATOCARCINOGENESIS
Frank Dombrowski, Germany
BASIC PROGRAMME
16
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
17
FRIDAY, FEBRUARY 14, 2014
BASIC PROGRAMME
8:30 – 11:00
8:30 – 9:00
SESSION 4: INFLAMMATION, INFECTION AND
HCC DEVELOPMENT
Chair: Ralf Bartenschlager, Germany, Massimo Colombo, Italy
HCV AND HCC
Thomas Pietschmann, Germany
9:00 – 9:30
INFLAMMATORY CYTOKINES AND HCC DEVELOPMENT
Michael Karin, USA
9:30 – 9:45
NEUTROPHILS PROMOTE ROS-MEDIATED TELOMERE DAMAGE
AND HEPATOCELLULAR CARCINOMA THAT IS NEGATIVELY
REGULATED BY HOMODIMERS OF THE NF-KB P50 SUBUNIT
Caroline Wilson, United Kingdom
12:45 – 13:00
INTEGRATIVE GENOMIC AND TRANSCRIPTOMIC ANALYSIS TO
SEARCH FOR METASTASIS DRIVER GENES
Stephanie Roessler, Germany
13:00 – 13:30
HIGH THROUGHPUT IN VIVO MODELS
Lars Zender, Germany
13:30 – 14:45
POSTER SESSION & LUNCH BREAK
14:45 – 16:30
TOPIC 6: GENOMIC AND EPIGENETIC MECHANISMS
Chair: Augusto Villanueva, Spain, Lars Zender, Germany
14:45 – 15:15
CENTROSOMES AND F-BOX PROTEINS
Nisar Malek, Germany
15:15 – 15:45
METHYLOME IN HCC
Thomas Longerich, Germany
15:45 – 16:00
A PROOF OF CONCEPT STUDY FOR THE TUMOUR SUPPRESSOR
EFFECT OF A THERAPEUTIC STRATEGY AGAINST MIR-34A IN
MOUSE TUMOURS MUTATED FOR BETA-CATENIN
Angélique Gougelet, France
16:00 – 16:30
MIRNAS
Laura Gramantieri, Italy
9:45 – 10:00
TRANSARTERIAL CHEMOEMBOLISATION FOR HEPATOCELLULAR
CARCINOMA CAN MODULATE REGULATORY CD4+T-CELLS
Ka-Kit Li, United Kingdom
10:00 – 10:15
GENERATION OF RAPID AND POTENT ANTI-TUMOR IMMUNITY
USING MICROSPHERE-BASED PRIME BOOST T CELL VACCINES
Thomas Wirth, Germany
10:15- 10:30
THERAPY WITH T CELL RECEPTOR GENE MODIFIED T CELLS
TARGETING HCC WITH HBV-DNA INTEGRATION
Antonio Bertoletti, Singapore
16:30 – 17:00
COFFEE BREAK
17:00 – 19:45
SESSION 7: FUNCTIONAL MECHANISMS
Chair: Snorri Thorgeirsson, USA, Michael Karin, USA
10:30 – 11:00
PREMALIGNANT LESIONS IN HBV-CARCINOGENESIS
Young Nyun Park, South Korea
17:00 – 17:30
WNT/-CATENIN AND METABOLISM IN HCC
Sabine Colnot, France
11:00 – 11:30
COFFEE BREAK
17:30 – 18:00
11:30 – 13:30
SESSION 5: PROFILING/HIGH THROUGHPUT ANALYSES
Chair: Peter Schirmacher, Germany, Josep Llovet, Spain/USA
ONCOGENIC TRANSCRIPTIONAL REGULATORS
Kai Breuhahn, Germany
18:00 – 18:15
11:30 – 12:00
NGS AND HCC PROFILING
Jessica Zucman-Rossi, France
THE FUNCTION OF FOS AND FOS~JUN DIMERS IN LIVER CANCER
Rainer Hamacher, Spain
18:15 – 18:45
PHOSPHOPROTEOME IN HCC
Augusto Villanueva, Spain
MYC
Arndt Vogel, Germany
18:45 – 19:45
JOINT TRANSLATIONAL KEY NOTE LECTURE
“TODAY’S MAJOR CHALLENGES IN MANAGING A PATIENT
WITH HCC”
Jordi Bruix, Spain
20:00
JOINT FACULTY DINNER
12:00 – 12:30
12:30 – 12:45
SPECIFIC GENOMIC AND TRANSCRIPTOMIC ABERRATIONS IN
HCC INDUCED BY PARTIAL HEPATECTOMY
Daniel Goldenberg, Israel
BASIC PROGRAMME
11:20 – 14:00
SESSION 2: DIAGNOSIS OF HCC
Chairs: Jordi Bruix, Spain, Jens Ricke, Germany
11:20 – 11:40
EPIDEMIOLOGY OF HCC
Shiv Kumar Sarin, India
11:40 – 12:10
SCREENING FOR HCC: WHOM, HOW, AND HOW OFTEN
Massimo Colombo, Italy
12:10 – 12:30
COST EFFECTIVENESS OF SCREENING
Morris Sherman, Canada
12:30 – 13:00
STANDARD DIAGNOSTIC ALGORITHM FOR HCC: CT AND MRI
Ahmed Ba-Ssalamah, Austria
13:00 – 13:30
OTHER DIAGNOSTIC TOOLS: CEUS, PET-CT AND OTHERS
Fabio Piscaglia, Italy
13:30 – 14:00
HISTOLOGIC CLASSIFICATION OF HCC: OLD-FASHIONED OR
STILL HOT?
Mike Torbensen, USA
14:00 – 15:00
LUNCH BREAK AND POSTER VIEWING
15:00 – 17:00
SESSION 3: CURATIVE TREATMENTS I
Chairs: Jean-François Dufour, Switzerland, Bruno Sangro, Spain
15:00 – 15:30
RESECTION FOR HCC, CURRENT DATA
Christian Toso, Switzerland
15:30 – 16:00
RESECTION OR RFA AS FIRST LINE TREATMENT FOR EARLY
STAGE HCC ?
Alejandro Forner, Spain
16:00 – 16:30
RESECTION FOR LARGE AND MULTIFOCAL HCC
Chinburen Jigjidsuren, Mongolia
16:30 – 17:00
PROGRESS IN PERCUTANEOUS TREATMENT
Jens Ricke, Germany
17:00 – 17:15
COFFEE BREAK AND POSTER VIEWING
17:15 – 19:15
TRANSLATIONAL DIAGNOSTICS IN HCC
Peter Schirmacher, Germany
SESSION 4: CURATIVE TREATMENTS II
Chairs: Jean-Luc Raoul, France, Didier Samuel, France
17:15 – 17:45
10:10 – 10:35
WNT/ß-CATENIN AND PERSONALIZED TREATMENT
Paul Monga, USA
ADJUVANT AND NEOADJUVANT TREATMENT WITH RESECTION
Francis Yao, USA
17:45 – 18:15
10:35 – 11:00
GENE SIGNATURES AND PCR-ARRAYS: ARE THEY OF PRACTICAL
USE TODAY?
Andreas Teufel, Germany
OLT FOR HCC, TODAY’S STANDARD
Vincenzo Mazzaferro, Italy
18:15 – 18:45
OLT FOR HCC-EXTENDING THE INDICATION
Yaman Tokat, Turkey
18:45 – 19:15
11:00 – 11:20
COFFEE BREAK
MANAGEMENT OF HCC ON THE OLT WAITING LIST
Chris Verslype, Belgium
SATURDAY, FEBRUARY 15, 2014
CLINICAL PROGRAMME
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
CLINICAL PROGRAMME
Liver Cancer Management
February 15 – 16, 2014 – Geneva
Organisers:
Jean-Luc Raoul, Marseille, France
8:20 – 8:30
OPENING ADDRESS
Markus Peck-Radosavljevic, EASL, Secretary General
Nurdan Tozun, TASL, President
8:30 – 11:00
JOINT SESSION 8/1 ON TRANSLATION AND NOVEL
THERAPEUTIC APPROACHES (JOINT ILCA-EASL MODULE)
Chair: Markus Peck, Austria, Jessica Zucman-Rossi, France
8:30 – 8:55
STATUS OF JOINT MOLECULAR CLASSIFICATION EFFORT OF HCC
Josep Llovet, Spain/USA
8:55 – 9:20
INTEGRATION WITH A MOLECULAR CLASSIFICATION
OF CIRRHOSIS
Yujin Hoshida, USA
9:20 – 9:45
9:45 – 10:10
INTEGRATION OF METABOLOMIC AND MIRNA CLASSIFICATION
Xin W. Wang, USA
19
CLINICAL PROGRAMME
18
20
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
CLINICAL PROGRAMME
SUNDAY, FEBRUARY 16, 2014
8:30-10:30
SESSION 5: TRANSARTERIAL TREATMENTS
Chairs: Markus Peck-Radosavljevic, Austria, Andrew Ann-Lii Cheng,
Taiwan
8:30 - 9:00
PATIENT SELECTION FOR TACE IN INTERMEDIATE STAGE HCC
Wolfgang Sieghart, Austria
9:00 - 9:30
TACE: MONOTHERAPY OR COMBINATION TREATMENT?
Jean-Francois Dufour, Switzerland
9:30 - 10:00
RADIOEMBOLIZATION
Bruno Sangro, Spain
10:00 - 10:30
THE MULTIDISCIPLINARY APPROACH: HOW TO SET UP
AN EFFICIENT TUMOUR BOARD
Frederik Nevens, Belgium
10:30 - 11:00
COFFEE BREAK
11:00 - 13:00
SESSION 6: SYSTEMIC TREATMENTS AND BEYOND IN HCC
Chairs: Michael Manns, Germany, Nurdan Tozun, Turkey
11:00 - 11:30
SORAFENIB AND NEW DRUGS IN FIRST LINE
Andrew X. Zhu, USA
11:30 - 12:00
SECOND-LINE DRUG TREATMENT FOR HCC
Markus Peck-Radosavljevic, Austria
12:00 - 12:30
RADIOLOGY IN ASSESSING RESPONSE OR AS PREDICTIVE TOOL
Rita Golfieri, Italy
12:30 - 13:00
BEST SUPPORTIVE CARE FOR HCC
Jean-Luc Raoul, France
13:00
END OF THE CONFERENCE
POSTER BOARDS
21
22
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
23
POSTER BOARDS
#
Title
Last name
First Name
B01
CONNECTING METABOLISM AND HCC
DEVELOPMENT THROUGH THYROID
HORMONE INTERACTING PROTEIN (TRIP)
FUNCTION
Berriel Diaz
Mauricio
B02
EFFECT OF EXTRACELLULAR MATRIX
PROTEINS ON PROGENITOR CELL
DIFFERENTIATION
Heindryckx
Femke
B03
THE ROLE OF HYPOXIA ON LIVER
PROGENITOR CELL ACTIVATION IN A MOUSE
MODEL FOR HEPATOCELLULAR CARCINOMA.
Bogaerts
Eliene
B04
SEQUENTIAL EXPRESSION OF LIPID
DROPLET-ASSOCIATED PROTEINS OF THE
PERILIPIN FAMILY DURING STEATOGENESIS:
IMPLICATIONS FOR STEATOHEPATITIS AND
MALIGNANT PROGRESSION
Straub
Beate K.
B05
HARNESSING THE THERAPEUTIC
POTENTIAL OF MICRORNAS INVOLVED IN
THE PROGRESSION AND REGRESSION OF
HEPATOCELLULAR CARCINOMA.
Balakrishnan
B06
VARIATION IN HEPATITIS B VIRUS GENOME IN
PATIENTS OF HEPATOCELLULAR CARCINOMA
FROM NORTHERN, SOUTHERN AND NORTH
EAST INDIA
Sarma
B07
CLINICAL IMPLICATIONS OF GST GENE
POLYMORPHISM, HEPATITIS B AND C
VIRUS INFECTION AND AFLATOXIN B1
AS THE PREDISPOSING FACTORS OF
HEPATOCELLULAR CARCINOMA
Asim
#
Title
Last name
First Name
B08
ASSOCIATION OF
METHYLENETETRAHYDROFOLATE
REDUCTASE (MTHFR) A1298C & C667T GENE
POLYMORPHISM IN HEPATOCELLULAR
CARCINOMA PATIENTS FROM INDIA
Bharali
Dipu
B09
NUP155 IS REQUIRED FOR FULL INDUCTION
OF A SUBSET OF P53 TARGET GENES IN HCC
Holzer
Kerstin
B10
HYPOXIA INDUCES AN INCREASED NUMBER
OF PROGENITOR CELLS IN LATE BUT NOT
IN EARLY STAGES OF HEPATOCELLULAR
CARCINOMA.
Bogaerts
Eliene
B11
HUMAN AMNIOTIC MEMBRANE-DERIVED
PROTEINS DISPLAY ANTICANCER ACTIVITY IN
Mamede
Ana C.
B12
NEW INSIGHTS IN HOXA13 AND HOTTIP
ROLE AS PROGNOSTIC FACTORS IN
Quagliata
Luca
B13
CIRCULATING MICRORNAS PROFILES
IDENTIFY CIRRHOTIC PATIENTS WITH HCC
Fornari
Francesca
B14
CASPASE-3 TARGETING: A FURTHER TILE
SUSTAINING THE ANTI-APOPTOTIC ROLE OF
MIR-221 IN HEPATOCELLULAR CARCINOMA
Fornari
Francesca
B15
FUNCTIONAL CONSEQUENCES OF
EPIGENETIC REGULATED TUMOUR
SUPPRESSOR MIRNA-449-FAMILY IN
Sandbothe
Maria
Asha
Manash P.
Mohammad
POSTER BOARDS
BASIC PROGRAMME POSTERS
POSTER BOARDS
#
Title
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Last name
B16
UNSHIELDING IGF-II MRNA BY TARGETING
IGF2BP-2 AND 3 THROUGH DEMETHYLATING
THE MICRO-RNA LET-7A-3 GENE IN
HEPATOCELLULAR CARCINOMA CELL LINES
Waly
B17
UPREGULATION OF SMAD7 EXPRESSION
IN HEPATOCELLULAR CARCINOMA AS A
POTENTIAL MECHANISM FOR LOSS OF
CYTOSTATIC TGF-BETA EFFECTS
Feng
B18
CONTROL OF HEPATIC STELLATE CELLS OF
LIVER HEALTH AND DISEASE
Mogler
B19
EPIGENETIC REPROGRAMMING MODULATES
MALIGNANT PROPERTIES OF HUMAN LIVER
CANCER CELLS
Raggi
B20
INVESTIGATING HEPATITIS C VIRUSASSOCIATED PATHOGENESIS
AND CARCINOGENESIS IN AN
IMMUNOCOMPETENT SMALL ANIMAL MODEL
B21
QUANTITATIVE PHOSPHOPROTEOME
ANALYSIS OF HUMAN HEPATOCELLULAR
CARCINOMAS DEVELOPED ON NON-FIBROTIC
LIVER
Rosenbaum
LONG-TERM IMPROVEMENT OF MORTALITY
WITH REDUCED HEPATOCELLULAR
CARCINOMA (HCC) INCIDENCE IN PATIENTS
WITH CHRONIC HEPATITIS B VIRUS (HBV)
INFECTION TREATED WITH NUCLEOTIDE
ANALOGUES
Matsumura
GLYCOMIC ANALYSIS OF SAFFRON-BASED
PROTECTION AGAINST HEPATOCELLULAR
CARCINOMA
Amin
B22
B23
Rupp
First Name
Amr
#
Title
Last name
First Name
B24
HUMAN BILE CONTAIN MICRORNA-LADEN
EXOSOMES THAT CAN BE USED FOR CANCER
DIAGNOSIS
Tomuleasa
Ciprian
B25
MICRORNA-21 STIMULATES CANCER
GROWTH AND INVASION BY INHIBITING THE
TUMOR SUPPRESSOR EFFECTS OF SERPINI-1,
PDCD4 AND PTEN
Timis
Tanase
B26
B-CELL LYMPHOMA 3 PROTEIN MODULATES
LIVER INJURY AND REGENRATION IN VIVO
Nagel
Michael
B27
ASOCCIATION BETWEEN ANGIOPOEITIN-1
AND ANGIOPOEITIN-2 WITH STAGES OF LIVER
FIBROSIS AND GRADES OF INFLAMMATION IN
CHRONIC HEPATITIS C PATIENTS
HernándezBartolomé
Ángel
B28
ANGIOPOIETIN 2 EXPRESION IS ASSOCIATED
WITH PROGRESSION OF INFLAMMATION
AND FIBROSIS IN TISSUE LIVER OF CHRONIC
HEPATITIS C PATIENTS
HernándezBartolomé
Ángel
B29
TGF B1 AS SERUM BIOMARKER OF
Mehmedovic
Amila
B30
EVALUATION OF ANNEXIN-II AND FOLLISTATIN
AS POTENTIAL SERUM MARKERS FOR
Elabd
Nevine E.
B31
IMMUNOLEVELS OF TRANSCRIPTION
FACTOR FOXM1 AND GLYCOLYTIC ENZYME
HKII CORRELATE WITH CD90+ AND CD133+
CANCER STEM CELLS, OXIDATIVE AND
NITROSATIVE STRESS, AND DISEASE
PROGRESSION IN HEPATOCELLULAR
CARCINOMA
Mei
Lily
Teng
Carolin
Chiara
Daniel
Jean
Yuki
Amr
EASL HCC SUMMIT
25
POSTER BOARDS
24
POSTER BOARDS
#
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Title
Last name
First Name
#
B32
IMMUNOHISTOCHEMICAL FEATURES OF
HEPATIC ADENOMAS IN MEN
Dhanasekaran
Renumathy
B33
IMPACT OF GLUTATHIONE PEROXIDASE 4
OVEREXPRESSION ON HEPATOCELLULAR
CARCINOMA: AN IN VITRO AND IN VIVO
STUDY
B34
SOLUBLE MIC PROTEINS IN HEPATITIS
B VIRUS INDUCED HEPATOCELLULAR
CARCINOMA
Tong Hoang
B35
GLUTAMINE PROTECTS AGAINST BETACATENIN-DEPENDENT TUMOR DEVELOPMENT
IN LIVER
Godard
Cécile
B36
MITOTIC KINESIN-LIKE PROTEIN 2
DEREGULATION IN HEPATOCELLULAR
CARCINOMA
Bourgain
Florence
B37
MICRORNA EXPRESSION PATTERN IN
PBMCS FROM PATIENTS WITH HCV-RELATED
MALIGNANCIES
Piluso
Alessia
B38
EXPRESSION OF TH1/TH2 CYTOKINES IN
HEPATITIS B MEDIATED HEPATOCELLULAR
CARCINOMA IN PATIENTS FROM NORTH EAST
INDIA
Deka
Manab
B39
STUDY OF HNF4ALFA ROLE IN MOUSE LIVER
Sartor
Chiara
B40
THE ROLE OF GROWTH HORMONE RECEPTOR
IN LIVER FIBROSIS AND CANCER
Stiedl
Patricia
B41
CELL CYCLE DEREGULATION BY HCV
PROTEIN EXPRESSION, A POTENTIAL
HEPATOCARCINOGENIC TRIGGER
Florimond
Alexandre
Rohr-Udilova
Nataliya
EASL HCC SUMMIT
27
Title
Last name
First Name
B42
PI3K/AKT PATHWAY ACTIVATION BY HCV AND
ITS ROLE IN LIVER CARCINOGENESIS
Lerat
Herve
B43
MICRORNA-125B MODULATES CELL GROWTH,
METABOLISM AND HBV REPLICATION VIA
LIN28B/LET7 AXIS
Deng
Wanyu
B44
ANALYSIS OF DLC 1 GENE POLYMORPHISM
AMONG HEPATOCELLULAR CARCINOMA
PATIENTS IN INDIA
Vellingiri
Balachandar
B45
MUTATIONS IN TP53, CTNNB1 AND PIK3CA
GENES IN HEPATOCELLULAR CARCINOMA
ASSOCIATED WITH HEPATITIS B AND
HEPATITIS C VIRUS INFECTIONS
Buonaguro
Franco M.
B46
LONGITUDINAL MRI-BASED RESPONSE
MONITORING OF SORAFENIB TREATMENT
IN TRANSPLANTED VERSUS CHEMICALLY
INDUCED RAT HCC
Gross
Claudia M.
B47
SURFACE MARKER PROFILING OF HUMAN
HEPATOCELLULAR CARCINOMA CELLS USING
HIGH THROUGHPUT FLOW CYTOMETRY
SCREENING
Ghanekar
Anand
B48
THE CROSS TALK BETWEEN HEPATIC
STELLATE CELLS AND HCC CELLS OFFSETTS
SORAFENIB EFFECTIVENESS VIA LAMININ-5
INTEGRINS ENGAGEMENT
Giannelli
Gianluigi
Van
POSTER BOARDS
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28
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
29
POSTER BOARDS
#
Title
Last name
First Name
C01
FINAL ANALYSIS OF EFFICACY AND SAFETY
IN EUROPEAN PATIENTS TREATED WITH
SORAFENIB FOR LESS THAN OR GREATER
THAN 28 WEEKS IN THE GIDEON STUDY
Criotoru
Adina E.
C02
STUDY OF FACTORS ASSOCIATED WITH
POOR SURVIVAL IN PATIENTS WITH
NONRESECTABLE HEPATOCELLULAR
CARCINOMA
Taha
Alaa A.
C03
ROLE OF DIETARY SUPPLEMENT AND
SORAFINEB IN THE MANAGEMENT OF ENDSTAGE HCC PATIENTS
Mahtab
Mamun A.
C04
EVALUATION OF COMBINED
RADIOFREQUENCY ABLATION FOLLOWED
BY CHEMOEMBOLIZATION VERSUS
CHEMOEMBOLIZATION IN MANAGEMENT OF
HEPATOCELLULAR CARCINOMA PATIENTS
AbdElMoez
Amal T.
SORAFENIB FOR ADVANCED
HEPATOCELLULAR CARCINOMA IN
PATIENTS WITH ALCOHOLIC CIRRHOSIS
AND COMORBIDITIES. EFFICACY AND
TOLERABILITY IN REAL-LIFE SETTING
Giovanis
INFLUENCE OF SARCOPENIA IN SORAFENIB
DISCONTINUATION DURING ADVANCED
HEPATOCARCINOMA TREATMENT
Gigante
EXPERIENCES WITH LARGE
HEPATOCELLULAR CARCINOMA: JAKARTA
PERSPECTIVE
Nugroho
C05
C06
C07
#
Title
Last name
First Name
C08
SEVERE 25-HYDROXYVITAMIN D
DEFICIENCY IDENTIFIES HEPATOCELLULAR
CARCINOMA PATIENTS WITH A POOR
PROGNOSIS
Waidmann
Oliver
C09
PERSONALIZED SORAFENIB THERAPY FOR
Maida
Marcello
C10
PROSPECTIVE EVALUATION OF THE
CORRELATION BETWEEN HEMOSTATIC
STATUS AND INCIDENCE OF PORTAL
VEIN THROMBOSIS IN PATIENTS WITH
LIVER CIRRHOSIS AND HEPATOCELLULAR
CARCINOMA
Zanetto
Alberto
C11
LAPAROSCOPIC RADIOFREQUENCY
ABLATION VERSUS HEPATIC RESECTION
IN THE TREATMENT OF VERY EARLY
CIRRHOTIC CARCINOMA: A COHORT STUDY
Costa
Mara
C12
SORAFENIB FOR THE TREATMENT
OF RECURRENT HEPATOCELLULAR
CARCINOMA AFTER LIVER
TRANSPLANTATION. TWO CASES WITH
FATAL OUTCOME
Perricone
Giovanni
C13
PRETREATMENT NEUTROPHIL - TO LYMPHOCYTE RATIO IN CIRRHOTIC
PATIENTS WITH HCC
Shabana
Hany R.
C14
THE INDIAN NATIONAL ASSOCIATION FOR
STUDY OF THE LIVER (INASL) CONSENSUS
ON PREVENTION, DIAGNOSIS AND
MANAGEMENT OF HEPATOCELLULAR
CARCINOMA IN INDIA
Kumar
Ashish
Petros
Elia
Adianto
POSTER BOARDS
CLINICAL PROGRAMME POSTERS
#
Title
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Last name
First Name
PERCUTANEOUS LOCAL INJECTION
OF ETHANOL AND MITOXANTRONE
IN TREATMENT OF HEPATOCELLULAR
CARCINOMA
Bihery
C16
SORAFENIB AFTER RFA IN HCC PATIENTS:
A PILOT STUDY
De Stefano
Giorgio
C17
SUBSEGMENTECTOMY TREATMENT FOR
WITH PORTAL HYPERTENSION
Zhang
Keming
C18
ITALY GIDEON FINAL ANALYSIS SORAFENIBTREATED PATIENTS: PROGNOSTIC VALUE OF
BASELINE CHARACTERISTICS AND STAGING
SYSTEMS
D'Angelo
Salvatore
C19
LOW MIR-125B EXPRESSION IN
PREDICTS RECURRENCE AFTER LIVER
TRANSPLANTATION
De Vito
Claudio
C20
CIRRHOSIS: PROGNOSTIC FACTORS AND
SURVIVAL
Said
C21
URINARY PROTON NUCLEAR MAGNETIC
RESONANCE SPECTROSCOPY IDENTIFIES
ALTERED METABOLIC PATHWAYS IN
Ladep
Nimzing G.
C22
INDEPENDENCE OF SERUM AUTOTAXIN
LEVELS FROM THE STATUS OF
Kondo
Mayuko
BILE DUCT INJURY AFTER TACE
Wen
C15
POSTER BOARDS
C23
#
Title
Last name
First Name
C24
EPIDEMIOLOGY OF HEPATOCARCINOMA IN
TRANSILVANIA
Rezi
Elena C.
C25
ALPHA-FETOPROTEIN CHANGES
AS SURVEILLANCE TEST FOR
HEPATOCELLULAR CARCINOMA: RESULTS
OF A CASE-CONTROL STUDY
Conti
Fabio
C26
PIVKA-II : A TISSUE BIOMARKER
OF MICROVASCULAR INVASION IN
HEPATOCELLULAR CARCINOMAS
Poté
Nicolas
C27
IS FIB-4 INDEX USEFULL FOR PREDICTING
OCCURENCE OF HEPATOCELLULAR
CARCINOMA IN PATIENTS WITH HEPATITIS
C VIRUS HAS GOT NORMAL ALANINE
AMINOTRANSFERASE LEVELS
Sirin
Goktug
C28
LIVER STIFFNESS (LS) ASSESSED WITH
ACOUSTIC RADIATION FORCE IMPULSE
(ARFI) CAN IDENTIFY PATIENTS AFFECTED
BY CHRONIC LIVER DISEASE (CLD) AT
HIGHER RISK OF HEPATOCELLULAR
CARCINOMA (HCC)
Bassanelli
Chiara
C29
RS4374383 SINGLE NUCLEOTIDE
POLYMORPHISM OF MERTK GENE IS
ASSOCIATED WITH HEPATOCELLULAR
CARCINOMA (HCC) IN PATIENTS WITH HCV
CIRRHOSIS
Calvaruso
Vincenza
C30
(ARFI) AS PREDICTOR OF ASCITES IN
CIRRHOTICS UNDERGOING RESECTION FOR
HEPATOCELLULAR CARCINOMA (HCC):
A NEW FRIEND FOR THE PHYSICIAN?
Gallusi
Giulia
Ahmed
Yosra
Xiaoyu
EASL HCC SUMMIT
31
POSTER BOARDS
30
#
Title
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Last name
MAXIMUM ONCOLOGICAL EFFECT INDUCED
BY NEOADJUVANT TRANSARTERIAL
CATHETER EMBOLIZATION HAS NO IMPACT
ON DISEASE-FREE SURVIVAL OF LIVER
TRANSPLANT RECIPIENTS WITH A SINGLE
HEPATOCELLULAR CARCINOMA WITHIN THE
MILAN CRITERIA
Felga
C32
COMPARISON OF SURVIVAL OF
IN STAGE BCLC C BEFORE AND AFTER
APPROVAL OF SORAFENIB
Weinmann
C33
CORRELATION BETWEEN LDH LEVELS AND
RESPONSE TO SORAFENIB IN HCC PATIENTS
Sacco
C34
IDENTIFICATION OF RESPONDERS
TO SORAFENIB IN HEPATOCELLULAR
CARCINOMA: IS TUMOUR VOLUME
MEASUREMENT THE WAY FORWARD?
Sacco
ACOUSTIC RADIATION FORCE IMPULSE (ARFI)
IN PREDICTING POST-RADIOEMBOLIZATION
(TARE) LIVER FAILURE IN PATIENTS
WITH INTERMEDIATE AND ADVANCED
HEPATOCELLULAR CARCINOMA (HCC)
Lupo
C31
POSTER BOARDS
C35
C36
COMPLETE CAUDATE LOBECTOMY VIA
ANTERIOR APPROACH FOR TUMORS IN
OR INVOLVING THE PARACAVAL PORTION:
A SINGLE CENTER EXPERIENCE WITH 63
CASES
Zhou
C37
SELF-EFFICACY IN COPING WITH CANCER
AFFECTING THE MENTAL RELATED QUALITY
OF LIFE IN LIVER CANCER PATIENTS AFTER
RECEIVING TREATMENTS
Shun
First Name
#
Title
Last name
First Name
C38
A RCT TO COMPARE PRINGLE MANOEUVRE
WITH HEMI-HEPATIC VASCULAR INFLOW
OCCLUSION IN LIVER RESECTION FOR
HEPATOCELLULAR CARCINOMA WITH
CIRRHOSIS
Ni
Junsheng
C39
ALCOHOL, OBESITY AND TOBACCO AS
RISK FACTORS FOR HEPATOCELLULAR
CARCINOMA
Babameto
Adriana
C40
HCC MANAGEMENT WITH SORAFENIB
AND TACE: ITALIAN EXPERIENCE FROM
GIDEON (GLOBAL INVESTIGATIONAL OF
THERAPEUTIC DECISIONS IN HCC AND OF
ITS TREATMENT WITH SORAFENIB)
Lorusso
Vito
C41
ONE YEAR DISEASE-FREE FOLLOW
UP AFTER ORTHOTOPIC LIVER
TRANSPLANTATION IN A MULTICENTRIC
HEPATOCELLULAR CARCINOMA PATIENT
SUBMITTED TO SYSTEMIC CHEMOTHERAPY
WITH SORAFENIBE
Boin
Ilka
C42
INTRAOPERATIVE BLOOD SALVAGE DURING
LIVER TRANSPLANTATION IN PATIENTS WITH
Boin
Ilka
C43
IMPACT OF THE IMMUNOSUPPRESSION IN THE
LATE RECURRENCE OF HEPATOCELLULAR
CARCINOMA AFTER SEQUENTIAL
TRANSPLANTATION LIVER-KIDNEY
Da Silva
Renato F.
C44
GAMMA GLUTAMYL TRANSPEPTIDASE
(GGT): IS THERE ANY CORRELATION
BETWEEN GGT AND ALPHA-FETOPROTEIN
(AFP) LEVELS IN CIRRHOTIC PATIENTS WITH
HEPATOCELULAR CARCINOMA?
Da Silva
Renato F.
Guilherme
Arndt
Rodolfo
Rodolfo
Marinella
Weiping
Shiow-Ching
EASL HCC SUMMIT
33
POSTER BOARDS
32
POSTER BOARDS
#
Title
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Last name
First Name
C45
MOLECULAR ANALYSIS OF THE GENE GSTP1
ALA114VAL POLYMORPHISM IN PATIENTS
WITH CIRRHOSIS AND HEPATOCELLULAR
CARCINOMA (HCC)
Da Silva
C46
VASCULAR ENDOTHELIAL GROWTH FACTOR
GENETIC VARIANTS RELATED TO GENDER
IN HEPATOCELLULAR CARCINOMA AND
CIRRHOSIS: PRELIMINARY RESULTS
Da Silva
C47
CURATIVE TREATMENT IN
THE MANAGEMENT OF SMALL
Hefaiedh
C48
RADIOEMBOLIZATION WITH YTTRIUM-90
MICROSPHERES IN TREATMENT OF
ADVANCED HEPATOCELLULAR CARCINOMA
WITH VASCULAR INVASION; FIRST EGYPTIAN
PILOT STUDY
C49
CHUBBY IS BEATIFUL: SUBCUTANEOUS FAT
AREA AS PREDICTOR OF BETTER SURVIVAL
IN PATIENTS WITH HCC TREATED WITH
SORAFENIB
Iegri
C50
MICRO –RNA SIGNATURE IN EGYPTIAN
PATIENTS WITH CHRONIC HEPATITIS C
RELATED HEPATOCELLULAR CARCINOMA
Omar
Heba
C51
HEPATOCELLULAR CARCINOMA IN POST
VIRAL HEPATITIS CIRRHOTIC PATIENTS: A
STUDY FROM PAKISTAN
Asad
Muhammad
TREATMENT OF HEPATOCELLULAR
CARCINOMA: A MONOCENTRIC TUNISIAN
STUDY
Romdhane
C52
El Fouly
Renato F.
#
Last name
First Name
C53
PREDICTORS OF HCC RECURRENCE
FOLLOWING LIVER TRANSPLANTATION: THE
SIGNIFICANCE OF ALPHA-FETOPROTEIN
Fatourou
Evangelia
C54
PROGENITOR CELL MARKERS IN
HEPATOCELLULAR CARCINOMA: CLINICOPATHOLOGICAL CORRELATIONS AND
PROGNOSTIC VALUE
Fatourou
Evangelia
C55
ROLE OF 1H MR SPECTROSCOPY
IN EVALUATING RESPONSE OF
HEPATOCELLULAR CARCINOMA TO
RADIOFREQUENCY ABLATION"
Ziada
Dina H.
C56
RISK OF HCC AND ITS PREDICTORS IN
VIRAL HEPATITIS COINFECTED PATIENTS
Yesmembetov
Kakharman I.
C57
DEVELOPMENT OF HEPATOCELLULAR
CARCINOMA IN A HBEAG-NEGATIVE
CHRONIC HEPATITIS B PATIENT WITHOUT
CIRRHOSIS UNDER THE LONG-TERM
VIROLOGICAL SUPPRESSION WITH
LAMIVUDINE PLUS ADEFOVIR THERAPY
Günal
Emine
C58
HEPATOCELLULAR CARCINOMA IN A
LONG-TERM SUSTAINED VIROLOGICAL
RESPONDER FOLLOWING PEGYLATED
INTERFERON PLUS RIBAVIRIN
COMBINATION THERAPY FOR CHRONIC
HEPATITIS C
Günal
Emine
C59
HIGH LEVELS OF CIRCULATING
ENDOTHELIAL CELLS AND RISK OF
PROGRESSION IN PATIENTS WITH
LOCALLY ADVANCED OR METASTATIC
HEPATOCELLULAR CARCINOMA RECEIVING
SORAFENIB
Giovanis
Petros
Amr
Claudia
Hayfa
35
Title
Renato F.
Rania
EASL HCC SUMMIT
POSTER BOARDS
34
POSTER BOARDS
#
Title
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Last name
C60
THE APPLICATION OF DATA MINING
TECHNIQUES TO EXPLORE PREDICTORS
OF HCC BASED ON THE NON-INVASIVE
ROUTINE WORKUP IN EGYPTIAN PATIENTS
WITH CHRONIC HEPATITIS
Awad
C61
ASSESSMENT OF PIVKA II AS A MARKER
IN RECURRENT HEPATOCELLULAR
CARCINOMA AFTER RADIOFREQUENCY
ABLATION THERAPY
Ibrahim
C62
LOCOREGIONAL TREATMENTS FOR
CIRRHOTIC PATIENTS: ASSESSMENT OF
LIVER FUNCTION BY 13C-AMINOPYRINE
BREATH TEST
C63
SINGLE CENTER EXPERIENCE OVER
A DECADE IN LIVING DONOR LIVER
TRANSPLANTATION FOR EGYPTIAN
PATIENTS WITH HEPATOCELLULAR
CARCINOMA: STRETCHING THE LIMITS
Montasser
C64
ANATOMO-CLINICAL ASPECTS OF
HEPATOCELLULAR CARCINOMA IN ALGERIA
: MONOCENTRIC STUDY OF 280 CASES
Chikhi
C65
DELTA HEPATITIS-RELATED
HEPATOCELLULAR CARCINOMA: NEW
MESSAGES FROM EASTERN FRONT
C66
HEPATOCELLULAR CARCINOMA: A
RETROSPECTIVE STUDY FROM EASTERN
PART OF TURKEY
Guarracino
Dulger
Dulger
First Name
Abubakr
Wesam A.
Marco
#
Ahmet C.
Ahmet C.
37
Title
Last name
First Name
C67
ANTIVIRAL THERAPY FOR PREVENTION
OF HEPATOCELLULAR CARCINOMA AND
MORTALITY IN CHRONIC HEPATITIS B:
SYSTEMATIC REVIEW AND META-ANALYSIS
Thiele
Maja
C68
HCC EPIDEMIOLOGY
Romana
Francesca
C69
HCC TREATMENT AND PVT
Romana
Francesca
C70
ASSOCIATION OF TNF-ALPHA
Farag
Raghda E.S.
C71
CHARACTER OF NBNC-HCC
Taura
Naota
C72
DIAGNOSIS OF PRIMARY LIVER
TUMORS THE ROLE OF 18F-FDG AND
18F-FLUOROCHOLINE
Brito
Ana F.
C73
GOSSYPOL: AN OPTION IN
HEPATOCELLULAR CARCINOMA THERAPY?
Brito
Ana F.
C74
STUDY OF MULTIDRUG RESISTANCE IN
HEPATOCELLULAR CARCINOMA: THE ROLE
OF NUCLEAR MEDICINE
Brito
Ana F.
C75
HEPATOCELLULAR CARCINOMA AND
QUERCETIN: A CURIOUS RELATIONSHIP
Brito
Ana F.
C76
MULTIMODALITY TREATMENT OF
HEPATOCELLULAR CARCINOMA IN A SINGLE
TERTIARY REFERRAL CENTRE
Sangiovanni
Angelo
C77
CONTRAST ENHANCED ULTRASOUND
(CEUS) IN THE DIAGNOSIS AND IN THE
FOLLOW UP OF HEPATOCELLULAR
CARCINOMA (HCC)
Santovito
Daniela
Iman
Yazid
EASL HCC SUMMIT
POSTER BOARDS
36
POSTER BOARDS
#
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Title
Last name
First Name
C78
PREDICTIVE BIOMARKER FOR SORAFENIB
THERAPY IN HEPATOCELLULAR CARCINOMA
Honda
Takuya
C79
ROLE OF THE ERK5 SIGNALLING IN THE
HUMAN HEPATOCELLULAR CARCINOMA
Di Maira
C80
GENETIC AND EPIGENETIC ALTERATIONS OF
P16 & RASSF1A GENE IN HEPATOCELLULAR
CARCINOMA FROM NORTH INDIA
Polipalli
Sunil K.
C81
HBV DNA INTEGRATION IN PATIENTS
WITH OCCULT HBV INFECTION AND
Saitta
Carlo
C82
Skladany
C83
CARCINOVIC STUDY: CLINICAL COURSE
AND RADIOLOGICAL FEATURES OF
HEPATOCELLULAR CARCINOMA IN HIV/HCV
CO-INFECTED PATIENTS
Gelu-Simeon
C84
HEPATOCELLULAR CARCINOMA SCREENING
IS INDICATED EVEN AFTER SUSTAINED
VIROLOGICAL RESPONSE:-MOROCCAN
UNIVERSITY HOSPITAL EXPERIENCE-
Cherradi
C85
INTRATUMORAL INJECTION OF
S-NITROSO-N-ACETYLCYSTEINE (SNAC)
IN A RODENT MODEL OF NON-ALCOHOLIC
STEATOHEPATITIS (NASH)-RELATED
Oliveira
SPLENOSIS MIMICKING HEPATIC TUMOR: A
CASE REPORT
Battista Levi
Sandri
Giovanni
SURGERY IN LIVER HAEMANGIOMA
Battista Levi
Sandri
Giovanni
C87
Title
Last name
First Name
C88
MANAGEMENT OF INTERMEDIATE STAGE
OF HCC: A COMPARISON BETWEEN
CONVENTIONAL AND DRUG-ELUTING
BEADS TACE
Patti
Riccardo
C89
STRATEGY TREATMENT OF SURGICAL
RESECTION INCREASES THE SURVIVAL
RATE OF SELECTED HEPATOCELLULAR
CARCINOMA PATIENTS IN BARCELONA
CLINIC LIVER CANCER STAGE C
Lin
Chih-Wen
C90
NAFLD-ASSOCIATED HEPATOCELLULAR
CARCINOMA IN CIRRHOTIC AND NONCIRRHOTIC PATIENTS IN BRAZIL
Oliveira
Claudia P.
C91
CHALLENGES FACING BCLC THERAPEUTIC
ALGORITHM IN TREATMENT OF 1437
EGYPTIAN HEPATOCELLULAR CARCINOMA
PATIENTS
El Fouly
Amr
C92
NEUTROPHIL-TO-LYMPHOCYTE RATIO:
A GOOD PREDICTOR OF DROP OUT IN
HEPATOCELLULAR CANCER PATIENTS
WAITING FOR LIVER TRANSPLANTATION
Lai
Quirino
C93
EFFECT OF LEPTIN ADMINISTRATION
ON ETHANOL INDUCED APOPTOSIS
AND FIBROGENESIS IN THE MOUSE
Vairappan
C94
FINAL ANALYSIS OF EUROPEAN SUBSET
OF GIDEON (GLOBAL INVESTIGATION
OF THERAPEUTIC DECISIONS IN
HEPATOCELLULAR CARCINOMA AND OF
ITS TREATMENT WITH SORAFENIB [SOR])
IN SOR-TREATED PATIENTS (PTS): CLINICAL
FINDINGS IN PTS WITH LIVER DYSFUNCTION
Bronowicki
Giovanni
SURVEILLANCE OF HEPATOCELLULAR
CARCINOMA: HOW IT WORKS IN CENTRAL
SLOVAKIA
C86
#
EASL HCC SUMMIT
Lubomir
Moana
Younès
Claudia P.
39
Balasubramaniyan
Jean-Pierre
POSTER BOARDS
38
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
MILAN. ITALY
BASIC ORAL
ABSTRACTS
MAY 23 - 24 / 2014
PRIMARY BILIARY
CIRRHOSIS (PBC)
www.easl.eu
Abstract submission deadline:
February 22, 2014
SCIENTIFIC ORGANISING COMMITTEE:
U. Beuers, P. Invernizzi, A. Pares
Sponsored by
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EASL HCC SUMMIT
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41
DISCOVER NOW THE…
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
43
GENETIC PREDISPOSITION TO
1
Pierre Nahon 1 2
Liver Unit, Jean Verdier Hospital and University Paris 13, Bondy, 2Inserm U674,
Université Paris 5, Paris, France
ble
Av a i l a
EASL
for all
ers
memb
The LiverTree™ offers a wide range of educational content,
including educational webcasts, accredited courses,
eSeries, case studies, learning quizzes, video podcasts,
documents, congress materials and much more to discover.
www.easl.eu
Liver carcinogenesis is a complex and multi-factorial process, in which both environmental
and genetic features interfere and contribute to malignant transformation. Patients with
cirrhosis are particularly exposed and justify periodical screening in order to detect the
early development of hepatocellular carcinoma (HCC). The risk of HCC is, however, not
identical from one patient to another. This observation suggests the implication of host
genetic factors that might not only predispose to a higher risk of HCC emergence in specific
sub-groups, but also to differences in tumour aggressiveness. The identification of these
host factors may improve our understanding of the implications of the various biological
pathways involved in liver carcinogenesis; such progress may as well help to refine the
selection of patients who could benefit from specific preventative measures or could
be given adapted screening policies. Numerous candidate-gene studies have reported
associations between single nucleotide polymorphisms (SNPs) and the presence of HCC.
Some of these publications unfortunately suffer from major methodological drawbacks
because of their case-control, retrospective and mono-centric aspect. Prospective cohort
studies conducted in large homogeneous populations and comprising a sufficient number
of events during follow-up may overcome these pitfalls, but require a long time to be
conducted and are still scarce. More recently, the first Genome Wide Association studies
(GWAs) have enabled the identification of unsuspected loci that may be involved in various
steps implicated in liver tumourigenesis, but have been so far restricted to Asian patients
chronically infected by HBV or HCV. Taken together, these studies highlight variants that
modulate oxidative stress, iron metabolism, inflammatory and immune responses, DNArepair mechanisms or systems involved in cell-cycle regulation as genetic traits susceptible
to influence the risk of HCC occurrence. Research in this field will continue to benefit
from both progress in genomics technology and coordinated work for the establishment
of large cohorts of well-defined patients. The incorporation of numerous variants in riskassessment models to predict HCC occurrence in prospective cohorts of cirrhotic patients
should enable to highlight gene–gene interactions, assess polygenic predictive scores
and may allow implementation of genetic-based screening or preventative strategies.
BASIC SPEAKERS’ ABSTRACTS
Corresponding author’s e-mail: [email protected]
OXIDATIVE STRESS PROMOTES PATHOLOGICAL
LIVER POLYPLOIDIZATION IN NAFLD
Géraldine Gentric 1, Dominique Couton 1, Valérie Paradis 2, Bernard Fromenty 3,
Séverine Celton-Morizur 1, Chantal Desdouets 1
1
Development Reproduction and Cancer, Institut Cochin Inserm U1016, Paris 75014,
2
Pathology Department, Beaujon Hospital, Clichy, 3Université de Rennes, Inserm U991,
Rennes, France
Introduction: Polyploidization is one of the most dramatic changes that occur in the
genome. Physiological polyploidization events have been observed both during liver
development and throughout adult life. We now show that pathological polyploidization
takes place in nonalcoholic fatty liver disease (NAFLD), a widespread hepatic metabolic
disorder that is nowadays suspected as being an emerging menace for hepatocellular
carcinoma (HCC) development.
Results: Using NAFLD murine models, we demonstrate that fatty liver parenchyma
shows altered polyploidization process, with a specific increase in the highly mononuclear
polyploid population, rarely observed in normal hepatic parenchyma. Significantly, this
hepatocyte ploidy alteration is also observed in patients with nonalcoholic steatohepatitis
(NASH). We also found that NAFLD polyploidization occurs in response to a G2/M DNA
damage signal, preventing activation of the Cyclin B1/Cdk1 complex and thus inducing
endoreplication cycles. Oxidative stress during NAFLD induces this DNA damage
response. Upon antioxidant treatment, NAFLD hepatocytes resume normal cell division
cycles leading to the restoration of physiological polyploidy.
Conclusions: Collectively, these findings indicate that oxidative stress promotes
pathological polyploidization, which represents an early event in NAFLD and might have
a pathogenic role in HCC.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
45
TRANSCRIPTIONAL PATHWAYS IN METABOLISM
AND HEPATOCELLULAR CARCINOMA
1
Stephan Herzig 1
Joint Department Molecular Metabolic Control, German Cancer Research Center and
Center for Molecular Biology Heidelberg, Heidelberg, Germany
Cancer development and progression are influenced by genetic, epigenetic, and
environmental factors. Large-scale epidemiological studies have demonstrated that
the Metabolic Syndrome and its components obesity, insulin resistance, and type 2
diabetes are associated with a substantial increase in cancer risk, particularly including
hepatocellular carcinoma (HCC). Consequently, the American Cancer Society has named
obesity as one of the most important risk factors for a broad range of cancer entities, being
responsible for up to 20% of all cancer deaths in the United States.
While a plethora of data confirms increased cancer risk in obese and diabetic patients,
common pathways in metabolism and cancer development and the mechanistic links
between the Metabolic Syndrome and HCC remain elusive.
In this respect, major components of the Metabolic Syndrome, including insulin resistance,
dyslipidemia, and chronic inflammation are triggered by the de-regulation of specific
molecular checkpoints in energy homeostasis. A metabolic checkpoint function can in
many cases be attributed to the activity of transcription factors, integrating and translating
dietary, hormonal, and inflammatory signals into alterations of genetic and metabolic
programs in corresponding target tissues.
This presentation will discuss if and how aberrations in normal transcription factor functions
are causally linked not only to the pathogenesis of obesity-related type 2 diabetes but also
to metabolic aberrations in the tumor-bearing state as well as the risk for HCC.
44
46
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
47
OPPOSING PPARG AND ROSIGLITAZONE
PATHWAYS CONVERGE ON RUVBL1 IN HCC
CELL LINES
1
Biomedical, Clinical and Experimental Sciences, University of Florence,
2
Gastroenterology Unit, Careggi University Hospital, Florence, Italy
Introduction: Ruvbl1 is an AAA+helicase involved in many cellular processes including
cell growth and oncogenic transformation. Ruvbl1 is overexpressed in several human
cancers including HCC, where its expression correlate with a poor prognosis. We
previously identified Ruvbl1 as a gene downregulated by Rosiglitazone (RGZ) in a
transgenic PPARg-conditional knock-out mice prone to HCC. However, the role of PPARg
and RGZ in the regulation of Ruvbl1 are currently unknown.
Aims: To investigate the RGZ-PPARg axis in the regulation of Ruvbl1 and its biological
relevance to HCC cell growth.
Methodology: Cell lines: Hepa1-6 and HepG2. Ruvbl1 expression was evaluated by
qPCR, western blot and IHC. Ruvbl1 promoter analysis was performed by CHIP and
reporter assays. mRNA stability was evaluated by 3’-UTR reporter assay. Modulation of
Ruvbl1 and PPARg was performed by RNAi and overexpression. HCC cell growth was
evaluated in vitro by thymidine incorporation and ATP measurement, and in vivo through
a syngenic-orthotopic mice model.
Results: RGZ reduces Ruvbl-1 expression in HCC cell lines. Surprisingly, also
PPARg silencing significantly reduces both Ruvbl1 expression and promoter activity.
Overexpression of PPARg activates Ruvbl1 promoter and increases Ruvbl1 mRNA and
protein levels. In silico analysis identified several putative PPAR Response Elements
on the Ruvbl1 promoter. By progressive deletions we show that funcional PPREs are
localized in two distinct promoter regions, consistent with the in silico prediction. PPARg
binding on Ruvbl1 promoter was confirmed by CHIP in HepG2 cells.
Despite its ability to activate PPARg transcriptional activity in Hepa1-6 and HepG2
cells, RGZ had negligible effects on Ruvbl-1 promoter activity. Moreover, RGZ does not
destabilize Ruvbl1 mRNA, as tested by the 3’-UTR reporter assay. Analysis of Ruvbl1
pre-mRNA suggests that RGZ may impair Ruvbl1 mRNA maturation thereby reducing its
expression.
Both PPARg or Ruvbl1 silencing impair HCC cell growth in vitro and reduce the number
and size of tumors in the orthotopic mice model. PPARg downregulation reduced HCC cell
viabilty, which was recovered through the overexpression of Ruvbl1.
Conclusions: RGZ and PPARg antagonize each other in the regulation of Ruvbl1
expression. Knockdown of Ruvbl-1 or PPARgamma effectively reduces HCC cell growth
in vitro and in vivo. Since Ruvbl1 regulates several cellular processes crucial for cancer,
the net outcome of PPARg and RGZ antagonism may potentially elicit either pro- or anticancer effects.
Tommaso Mello 1, 2, Mirko Tarocchi 1, Fabio Perini 1, Francesca Buccoliero 1,
Giada Marroncini 1, Ceni Elisabetta 1, Simone Polvani 1, Sara Tempesti 1,
Stefano Milani 1 2, Andrea Galli 1, 2
48
NOTCH1 DRIVES SECRETOME SWITCHING IN
RAS-INDUCED SENESCENCE
Matthew Hoare 1, Michael Weekes 2, Yoko Ito 1, Nicholas Matheson 2, Suraj Menon 1,
Rafik Salama 1, Robin Antrobus 2, Paul Lehner 2, Masashi Narita 1
1
Cambridge Institute, Cancer Research UK, 2Cambridge Institte for Medical Research,
University of Cambridge, Cambridge, United Kingdom
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
49
CELL CYCLE, METABOLISM AND HCC
1
Pierre-Damien Denechaud 1, Lluis Fajas 1
Department of Physiology, University of Lausanne, Lausanne, Switzerland
Introduction: Oncogene-induced senescence (OIS) is a tumour suppressor mechanism
leading to stable cell-cycle arrest in response to unrestricted oncogene activation. OIS is
a heterogeneous phenotype involving multiple effector mechanisms, including secretion
of multiple factors such as IL-6 and TGF-β, that have pleiotropic context-dependent
effects. The secretome of senescent cells has been demonstrated to be important in
hepatocarcinogenesis.
Methodology: We utilised SILAC-based plasma membrane proteomics (PMP) to identify
the cell surface phenotype of Ras-induced senescence (RIS) in an HDF model. 1504
proteins were identified from 4 independent replicates. From GO annotation, 59% were
present at the cell surface. The correlation between PMP and transcriptomic changes was
significant (r2=0.63). Ingenuity-based network enrichment analysis incorporating PMP
and transcriptomics identified Notch1 in the top enriched networks during RIS.
Results: Notch1, a highly conserved transmembrane receptor that determines cell fate,
was significantly up-regulated in RIS compared to control cells (3.1 – 3.4 fold, adj p=0.03,
FDR=0.1). Upon activation, the cleaved Notch1 intracellular domain (N1ICD) translocates
to the nucleus, binds to cofactors including MAML1 and regulates transcription of target
genes, such as HES1 and HEYL. The up-regulation of plasma membrane Notch1 was
confirmed in both RIS and DNA damage senescence. Up-regulation of Notch1 was
dependent upon p53. However, in contrast to cell surface Notch1, the levels of its
activated form, N1ICD and downstream target genes were transiently up-regulated at an
early phase of RIS, but down-regulated at full senescence.
Inhibition of Notch1 signaling through expression of a dominant-negative MAML1 led to
a reduction in TGF-β, but increased RIS-associated expression of IL-1, IL-6 and IL-8. Overexpression of N1ICD drove reciprocal secretome changes with reduced IL-1, IL-6
and IL-8 and increased TGF-β. Transcriptional profiling of Notch1- and Ras-expressing
HDFs confirmed the TGF-β-rich Notch1-driven secretome in distinction to the RIS-driven
secretome.
Conclusions: In conclusion, PMP has identified a cell-surface phenotype of RIS. Notch1
cell surface expression is up-regulated, but downstream signaling is dynamically regulated
in RIS. The transition to RIS is correlated with a switch from Notch1-driven TGF-β-rich
secretome to Ras-driven IL-1, -6 and -8 rich secretome. Appropriate regulation of Notch1
signaling is crucial to secretome composition in senescence.
Introduction: Abnormal metabolic changes are a feature of tumour development and
cancer. This was already reported early in the last century. Otto Warburg (1928) observed
that tumours have a higher rate of glucose metabolism than normal tissues. De novo
fatty acid biosynthesis is another hallmark of tumour cells, including liver cancer cells. We
show here new therapeutic targets in the lipid synthesis pathway in cancer cells, and we
elucidate the molecular mechanisms implicated in the metabolic switch observed during
cancer development and progression. In this context, we show that cell cycle regulators
are responsible for triggering the metabolic changes directly regulating the expression
and/or activity of key proteins implicated in these processes. We prove that cancer cells
change their lipid metabolism. Our data indicates that the cdk4-pRB-E2F1 axis is a
major regulator of lipid synthesis in cancer cells. Furthermore E2F1 directly regulates the
expression of genes involved in glycolysis and in lipid synthesis pathways. We use models
of liver cancer and mice deficient for some of these cell cycle regulators to prove that
inhibition of lipid synthesis results in the abrogation of the ability of these factors and other
oncogenes to sustain tumour growth.
MIXED LIVER TUMOUR DIFFERENTIATION
1
According to the cancer stem cell (CSC) concept, hepatic carcinoma consists of a hierarchy
of cell populations, of which the very small cancer stem cell population is the one that has
the growth and metastatic potential of the tumour. The other neoplastic cells are offspring
of the cancer stem cells and each can differentiate a little differently, according to the local
microenvironment in each part of the tumor, hence explaining the enormous phenotypic
heterogeneity of a neoplasm. Current therapeutic strategies mostly target rapidly growing
differentiated tumour cells. However the results are often unsatisfactory because of the
chemoresistance of hepatic carcinomas. New therapies targeting cancer stem cells
should therefore be developed. A prerequisite is a good understanding of the mechanisms
of activation and differentiation of normal stem/progenitor cells in normal and diseased
liver. Hepatocytes and cholangiocytes have stem cell features, but also progenitor
cells, located in the smallest branches of the biliary tree. Since hepatic progenitor cells
(HPCs) are activated in most chronic liver diseases which are known risk factors for the
development of hepatocellular carcinoma (HCC) as well as cholangiocellular carcinoma
(CC), progenitor cells are potential target cells for carcinogenesis. We previously
described subsets of primary liver carcinomas with stem/progenitor cell features and also
with mixed hepatocellular and cholangiocellular features, supporting the concept of HPCs
being the cell of origin of these types of tumours. Although the concept of cancer stem
cells is intriguing and a large number of experimental studies support the cancer stem cell
hypothesis, there are still open questions and room for caution. One debate concerns the
origin of cancer stem cells. Does the cancer stem cell derive initially from a normal stem
cell or from a dedifferentiated cell during tumour progression? Their functional similarities
with normal stem cells and the observation that they often share specific surface markers
at least argue for mutated stem cells as their origin.
EASL HCC SUMMIT
51
STEM CELL-LIKE SIGNATURES IN THE
CLASSIFICATION OF HCC
Tania Roskams 1
University Hospitals Leuven, Leuven, Belgium
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
1
Snorri Thorgeirsson 1
Laboratory of Experimental Carcinogenesis, Center for Cancer Research, National
Cancer Institute, NIH, MD, United States
Hepatocellular carcinoma (HCC) is the most common and deadly cause of primary
liver cancer. Although the incidence of HCC is highest in Asia and sub-Saharan Africa
the steadily increasing incidence of HCC in traditionally low incidence regions such
as Northern Europe and the United States constitutes a significant public health care
problem. Cells with “stemness,” or stem-cell properties, are referred to as cancer stem
cells or cancer-initiating cells. The concept that these cells rest at the apex of the cancer
hierarchy is an evolving theme in cancer research. These cells are by definition primarily
responsible for initiation and propagation of tumors as well as relapse after therapy, and
they are therefore of major scientific interest. Several studies indicate that hepatocellular
carcinomas that harbor phenotypic features of stem cells and progenitor cells constitute a
subclass of therapeutically challenging cancers that are associated with a particularly poor
prognosis. Recent studies will be discussed in the presentation.
50
52
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
53
Jens U. Marquardt 1 2, Luis Gomez-Quirez 3, Lucrecia O. Arreguin Camacho 1, Frederico
Pinna 4, Yun-Han Lee 2, Jesper B. Andersen 2, Kai Breuhahn 4, Peter R. Galle 1, Valentina
M. Factor 2, Snorri S. Thorgeirsson 2
1
University of Mainz, Department of Medicine I, Mainz, Germany, 2Laboratory of
Experimental Carcinogenesis, CCR/NCI/NIH, Bethesda, United States, 3Universidad
Autónoma Metropolitana-Iztapalapa, Departamento de Ciencias de la Salud, Mexico,
Mexico, 4Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
Introduction: The cancer stem cells (CSCs) hypothesis possesses important therapeutic
implications for multi-resistant cancers such as hepatocellular carcinoma. We have
recently reported that activation of NF-kB signaling is consistently observed in stem-like
cells in human liver cancer.
Aims: Based on these data, we hypothesized that NF-kB may be a specific therapeutic
target against hepatic CSCs.
Methodology: Inhibition of NF-kB signaling was performed using curcumin, an effective IKK
inhibitor, siRNA against p65 and by the specific inhibitory peptide SN50. Anti-proliferative
and pro-apoptotic capacity of the drug was evaluated in different liver cancer cells. The
effect on CSC was assessed by the Side Population (SP) approach, and expression levels
of selected targets determined by RT-qPCR, gene expression microarray, EMSA, and
Western blotting.
Results: Curcumin treatment caused anti-proliferative and pro-apoptotic responses
directly related to the extent of NF-kB inhibition. In curcumin-sensitive cell lines, the
treatment led to a selective depletion of CSC reflected by a significant reduction in the SP
population, sphere formation and tumorigenicity as well as subsequent down-regulation of
selected CSC markers, such as CD133, EpCAM, NANOG and c-Kit. In contrast, curcuminresistant cells exhibited a paradoxical increase in proliferation and activation of the CSC
markers in response to the treatment.
Specific inhibition of NF-kB signaling by SN50 and siRNA led to general suppression
of cell growth accompanied by a drastic reduction in the size of SP fraction confirming
that the response to curcumin was dependent on effective disruption of the NF-kB
pathway. Mechanistically, CSC-depleting activity was exerted by NF-kB mediated histone
deacetylase (HDAC) inhibition leading to down-regulation of c-MYC and other key
oncogenic targets. Co-administration of a class I and II HDAC inhibitor sensitized resistant
cells to curcumin treatment. Further, integration of a predictive signature with our HCC
database indicated that with patients with poor prognosis and progenitor features are most
likely to benefit from NF-kB inhibition. Conclusions: Together, these data demonstrate that NF-kB inhibtion can specifically
target CSC populations, providing an important step towards CSC-directed HCC therapy.
Future investigations will determine the potential of combined targeting NF-kB signaling as
well as HDAC for the treatment of liver cancer patients with poor prognosis.
SPECIFIC TARGETING OF STEM-LIKE CELLS IN
LIVER CANCER BY NF-KB MEDIATED INHIBITON
OF HISTONE DEACETYLASES
54
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
55
Olivier Govaere 1, Jasper Wouters 1, Michaela Petz 2, Kathleen van den Eynde 1,
Anke Van den broeck 3, Christophe Empsen 4, Lies Gremeaux 5, An Ceulemans 1,
Raymond Aerts 3, Frederik Nevens 6, Jacques Pirenne 7, Leo van Grunsven4, Baki Topal 3,
Hugo Vankelecom 5, Wolfgang Mikulits 2, Mina Komuta 1, Tania Roskams 1
1
Department of Imaging and Pathology, KULeuven, Leuven, Belgium, 2Department of
Medicine I, Medical University of Vienna, Vienna, Austria, 3Department of Abdominal
Surgery, KU Leuven and University Hospitals Leuve, Leuven, 4Department of Cell
Biology, Vrije Universiteit Brussel, Brussels, 5Department of Development and
Regeneration, KULeuven, 6Department of Hepatology, 7Department of Abdominal
Transplant Surgery, KU Leuven and University Hospitals Leuve, Leuven, Belgium
Introduction: Cancer stem cells (CSCs) are thought to be persistent in tumors due to their
chemoresistance and are thought to be the cause for relapse and metastasis. Intrahepatic
carcinomas displaying hepatic progenitor cell (HPC) features have been associated with
a poor prognosis, although it still remains unclear how CSCs relate to these different
histological subtypes.
Aims: In this study we aim to characterize the CSC fraction in different histopathological
subtypes of intrahepatic carcinomas, reflecting their possible cell of origin. Moreover, we
focus on the influence of particular members of the specialized CSC niche in vitro.
Methodology: Candidate CSCs were isolated from clinical primary tissue samples
diagnosed as keratin(K)19 negative/positive hepatocellular carcinoma (HCC) or mixed
hepatocellular/cholangiocarcinoma (mixed phenotype), using the Side Population
technique. Isolated populations were processed for gene expression analysis and target
genes were validated using immunohistochemistry. HepG2 cells were grown in laminin
coated and non-coated conditions, and further analyzed for HPC/quiescence markers and
cytotoxicity sensitivity.
Results: Flow cytometric analysis showed that the CSC fraction in intrahepatic carcinomas
differs from 3.43% (±2.27) in K19-negative HCCs (n=7) to 9.29% (±4.42) in K19-positive
HCCs (n=7) and 15.43% (±13.98) in the mixed phenotype (n=4); gradually increasing
with the degree of HPC features found in these carcinomas. Although certain markers
(e.g. CXCR4, CD133, TWEAKR) identified the CSCs of specific histological subtypes, all CSC
fractions showed elevated expression of KRT19, KRT7, TACSTD2, LAMC2 and MDR1.
LAMC2 immunoreactivity was mainly found in the cytoplasm and in the surrounding of
small HPC-like tumor cells. In the neighboring tissue, LAMC2 was seen as part of the
extracellular matrix surrounding the HPCs. In vitro, laminin significantly induced K19
expressionin HepG2 cells and reduced the number of phosphor-histone H3-positive cells,
indicating that fewer cells underwent mitosis. Moreover, after 72h laminin coated HepG2
cells proved to be more resilient to doxorubicin treatment when compared to the noncoated condition.
Conclusions: In this study we identified a role for laminin as part of the specialized CSC
niche in maintaining and supporting ‘stemness’, e.g. quiescence and chemoresistance.
SIDE POPULATION ANALYSIS IDENTIFIES A
ROLE FOR LAMININ IN MODULATING THE
HUMAN HEPATIC CANCER STEM CELL NICHE
RAGE SIGNALING IN OVAL CELL ACTIVATION
DURING LIVER DAMAGE
Aurora M. De Ponti 1, Tobias Pusterla 1, Ilan Stein 2, David Knigin 2,
Eli Pikarsky 2, Jochen Hess 3, Peter Angel 1
1
Signal Transduction and Growth Control, German Cancer Research Center- Dkfz,
Heidelberg, Germany, 2Department of Pathology and the Lautenberg Center for
Immunology, Hebrew University - Hadassah Medical School, Jerusalem, Israel,
3
Department of Otolaryngology, Head and Neck Surgery, University Hospital Heidelberg,
Heidelberg, Germany
Introduction: The Receptor for Advanced Glycation End-products (RAGE) is a patternrecognition receptor, able to bind different types of damage- associated molecular pattern
(DAMP) molecules, such as HMGB1 and several calcium-binding S100 proteins, which
are released during tissue damage and inflammation. Rage engagement in inflammatory
conditions and in cancer i) upregulates the receptor itself, ii) activates different proinflammatory responses and iii) promotes tumor development. We previously demonstrated
that in Mdr2 knockout mice, a model of inflammation-associated HCC development,
Rage ablation impairs tumor development and causes a delay in the onset of chronic
liver damage and fibrosis. This phenotype is associated with a reduced activation of oval
cells, the hepatic progenitor cells involved in liver regeneration. We found that primary
oval cells and BMOL cells (an oval cell line) express Rage. In BMOL cells stimulation by
HMGB1 promotes cell proliferation. In accordance, Rage knock-down reduces BMOL cell
proliferation, and in vivo blockade of the receptor signaling by means of injection of the
decoy receptor sRAGE reduces oval cell activation (Pusterla et al., 2013).
Aims: The project aims to establish a protocol to isolate and cultivate primary liver
progenitor cells, and to demonstrate the involvement of RAGE in oval cell proliferation,
migration and differentiation, as well as to investigate the role of RAGE-dependent
signaling and gene regulatory networks in these processes.
Methodology: In order to compare the biological processes occurring in control or Ragedeleted ex vivo isolated oval cells, we ablated Rage by adding 4-OH tamoxifen to the
culture medium, which posttranslationally activates the Cre recombinase enzyme. Ragepositive and Rage-deficient oval cells are currently used to characterize cellular responses
(proliferation, migration, apoptosis, differentiation and cytokines release) and signalling
pathways promoted by RAGE ligands.
Results: We are able to isolate and cultivate primary oval cells, which express several
indicative markers of liver progenitor cells but are negative for hepatocyte specific gene
expression. Importantly, these cells migrate towards a HMGB1 gradient strongly implying
that this DAMP molecule controls oval cell chemotaxis.
Conclusions: Our data strongly suggest that stimulation of RAGE by HMGB1 during liver
damage plays a decisive role in oval cell activation.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
57
RESECTABLE TRANSGENIC TUMOR
MODEL IN MICE FOR INTRAHEPATIC
CHOLANGIOCARCINOMA
Engin Gürlevik 1, Bettina Fleischmann-Mundt 1, Norman Woller 1, Jennifer Brooks 1,
Michael Manns 1, Stefan Kubicka 1, Florian Kühnel 1
1
Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
Introduction: Surgical complete resection (R0) of the primary tumor is the only potential
curative treatment option for many tumor entities. Despite surgical resection, patients with
intrahepatic cholangiocarcinoma (ICC) have poor prognosis, because of frequent tumor
recurrence and outgrowth of metastases after surgery. Unfortunately, the current animal
tumor models do not reflect the aspect of resectability, though surgery and adjuvant
therapy is still the most important and potentially curative therapeutic intervention for
cancer patients.
Aims: To address the aspect of tumor resection in murine tumor models, we established a
corresponding model for ICC in mice by facilitating endogenous induction of a single tumor
in situ that is suitable for surgical resection.
Methodology: Intratissue injection of Sleeping Beauty-based, oncogenic transposon
plasmids followed by subsequent local electroporation leads to formation of a locally
restricted, resectable primary tumor. The injected DNA includes a transposon vector for
expression of mutated KRas-G12V and a plasmid for expression of Cre-recombinase.
In p53-fl/fl-mice, the Cre recombinase induces the knockout of p53 and simultaneous
transformation by genomic insertion and expression of the RasG12V transposon.
Results: According to our aims, mice developed a single tumor lesion at the electroporated
tissue locus. Formation of ICC was verified by histological analysis. Molecular analysis
after electroporation provided evidence for hepatocytes as origin of tumor formation.
Metastases in the lung and peritoneum could be detected. By R0-resection of the
primary tumor, we were able to prolong median survival with the observation of local
disease recurrence, peritoneal carcinomatosis, and metastases in liver and lung. Using
gemcitabine as therapeutic standard for biliary cancer, we could observe a survival benefit
only in the adjuvant approach. Palliative gemcitabine application did not improve survival.
These results indicate different mode of action of gemcitabine in the adjuvant or palliative
situation, respectively.
Conclusions: Our resection models reflect the clinical situation in humans and holds great
promise for preclinical evaluation of novel multimodal and adjuvant therapies in genetically
defined biliary cancers to prevent recurrence and outgrowth of metastases. Furthermore,
the results suggest that therapies have to be evaluated separately for palliative or adjuvant
approaches, respectively.
56
MODELS AND PATHWAYS OF HEPATITIS C VIRUS
ASSOCIATED LIVER CANCER
1
Thomas Pietschman 1
Division Experimental Virology, TWINCORE - Centre for Experimental and Clinical
Infection Research, Hannover, Germany
Chronic hepatitis C virus infection (HCV) is associated with liver disease including
development of hepatocellular carcinoma (HCC). In fact, HCV infection is one of the prime
reasons for development of liver cancer and in turn a key indication for liver transplantation.
Despite of intensive research, the pathways leading to HCV-driven hepatocellular
carcinoma are still incompletely understood. This is certainly in part due to lack of robust
model systems to dissect molecular pathways of HCV-associated liver cancer. While the
Chimpanzee model in many ways recapitulates key features of HCV infection in humans,
these animals do not develop HCC. Moreover, ethical concerns clearly limit utility of this
model. Nevertheless, important in vitro and in vivo model systems have been developed
and contributed important pieces to our current understanding of HCV-induced HCC.
These models include transgenic mice ectopically expressing various viral proteins and
cultured cells transfected or infected with replicons or fully infectious HCV. Accumulated
evidence derived from these models indicates that HCV elicits indirect effects including an
inflammatory and profibrotic host response thus contributing to carcinogenesis. However,
in addition mounting data support the notion that HCV also exerts direct effects on infected
cells that may promote their malignant transformation. In that regard viral factors have been
reported to modulate cellular signaling cascades crucial for regulation of cell proliferation
and survival including the p53 and retinoblastoma pathways. Moreover, some host factors
utilized by HCV have been implicated as tumor suppressors including miRNA-122 and
Claudins. Therefore, dysregulation of the function of these cellular factors may in addition
contribute to development of liver cancer. Future research into these pathways may
ultimately reveal new targets for intervention with HCV-dependent liver disease.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
59
LIVER INFLAMMATION, OBESITY AND CANCER
Michael Karin 1, Hayato Nakagama 1, Atusushi Yumemura 1, Debanjan Dhar 1,
Joan Font Burjada 1, Eek Jun Park 1
1
Laboratory of Gene Regulation and Signal Transduction, Departments of Pharmacology
and Pathology, UCSD School of Medicine, San Diego, United States
Obesity increases cancer risk and its effect is most notable on liver cancer, whose risk
is 4.5-fold higher in men with BMI > 35. In fact, obesity is one of the major drivers of
hepatocellucar carcinoma (HCC) in the US. We have shown that feeding with high fat
diet (HFD) or genetic obesity strongly potentiate the induction of HCC in male mice given
the chemical pro-carcinogen diethyl nitrosamine (DEN). Part of this increase is due to
TNF driven inflammatory signaling in hepatocytes that leads to upregulation of IL-6 and
STAT3 activation. In addition, consumption of HFD results in activation of mTORC1 and
phosphorylation of its downstream targets. We used rapamycin to interrogate the role of
mTORC1 and found that although it inhibited hepatic steatosis it led to enhanced IL-6
production and STAT3 activation. Although this effect may be due to mTORC1 inhibition
in macrophages, we found that hepatocyte specific deletion of Raptor (an essential
scaffold of mTORC1) strongly potentiated the induction of HCC by DEN in both lean and
obese animals. To further understand the mechanism of hepatocarcinogenesis and how
it is affected by HFD we developed new procedures for isolation of HCC projection cells
(HcPC ) from pre-malignant lesions. These cells can give rise to HCC after transplantation
into MUP-uPA transgenic mice, whose livers suffer transient liver damage due to ER
stress. The progression of HcPC to HCC depends on autocrine production of IL-6 and is
strongly stimulated by feeding the MUP-uPA recipients with HFD. Interestingly, MUP-uPA
mice given HFD develop classical non-alcoholic steatohepatitis (NASH) accompanied by
massive leukocyte and lymphocyte infiltration into the liver. In this model, obesity-promoted
HcPC to HCC progression and NASH development are highly dependent on TNF receptor
1 (TNFR1) signaling activated by TNF produced by infiltrating macrophages that are
activated by DAMPs that are released by hepatocytes that undergo lipotoxic stress due to
fatty acid exposure and ER stress. Anti-TNF drugs can attenuate tumor progression and
clinical evidence suggests that TNF also has a role in the pathogenesis of human NASH
and its progression to HCC.
58
60
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
61
Caroline L. Wilson 1, Saimir Luli 1, Diana Jurk 2, Paul Banks 1, Nicola Fullard 1,
Jelena Mann 1, Fiona Oakley 1, Derek A. Mann 1
1
Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne,
2
Institute for Ageing & Health, Newcastle University, Newcastle upon Tyne,
United Kingdom
Introduction: High neutrophil/lymphocyte ratio is a poor prognostic indicator for HCC.
The functional contribution of neutrophils to HCC is poorly defined. The role of neutrophils
in HCC was established in that their depletion was a successful therapeutic strategy in a
mouse model. Mechanistic work to be presented supports (i) NF-κB p50:p50 homodimer
as a tumor suppressor that limits neutrophil-mediated hepatocellular genotoxic damage
by suppressing hepatic neutrophil chemokine expression and (ii) the neutrophil as a
stimulator of ROS-induced telomere damage.
Aims: To discover the regulation of neutrophil-driven tumorogenesis in HCC.
Methodology: nfκb1-/-, nfκb1S340A+/+ and wt mice challenged with diethylnitrosamine
(DEN) to induce HCC. Hepatic neutrophils and telomere DNA damage determined by
IHC and FISH. in vivo imaging (IVIS) used to track neutrophil recruitment. To determine
the contribution of neutrophil recruitment on DEN induced liver damage and tumour
development, animals were treated with anti-CXCL1 and 2 or LY6G neutrophil depleting
antibodies. Results: DEN-induced liver cancer and human HCC is associated with striking neutrophil
accumulation and telomere damage. The nfkb1-/- mouse which lacks p50 spontaneously
develops HCC at 20 months and displays accelerated DEN-induced HCC; both models are
associated with elevated hepatic neutrophils and ROS-associated cellular and telomere
DNA damage.
Neutrophil depleting antibody LY6G dramatically decreased tumor number and telomere
damage even when used late in disease with both wt and nfkb1-/- DEN mice. Absence
of hepatic p50 was associated with over-expression of CXCL1 and CXCL2 and failure to
recruit transcriptional repressor HDAC1 to their genes. In vivo imaging of transfused labeled
wt neutrophils confirmed that DEN-injured p50-deficient liver attracts neutrophils more
efficiently than wt liver. Antibody-mediated depletion of CXCL1 and CXCL-2 suppressed
DEN-induced neutrophil recruitment. HDAC1-mediated transcriptional repression of NFκB target genes is thought to be regulated by p50:p50:HDAC1 complexes. A specific
amino acid residue (Ser340) was identified as absolutely required for p50 homodimers
(but not for RelA:p50). This mutation was engineered into a mouse (nfκb1S340A+/+), which
following DEN injury was phenotypically almost identical to nfkb1-/-. Conclusions: Hence, p50:p50:HDAC1 suppression of hepatic neutrophil chemokine
expression is an important homeostatic mechanism preventing neutrophil-mediated
genotoxic damage and HCC.
NEUTROPHILS PROMOTE ROS-MEDIATED
TELOMERE DAMAGE AND HEPATOCELLULAR
CARCINOMA THAT IS NEGATIVELY REGULATED
BY HOMODIMERS OF THE NF-KB P50 SUBUNIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
63
GENERATION OF RAPID AND POTENT ANTITUMOR IMMUNITY USING MICROSPHEREBASED PRIME BOOST T CELL VACCINES
TRANSARTERIAL CHEMOEMBOLISATION
FOR HEPATOCELLULAR CARCINOMA CAN
MODULATE REGULATORY CD4+T-CELLS
Ka-Kit Li 1, Yazid J. Resheq 1, Stuart M. Curbishley 1, Tony Bruns 1 2,
Henning W. Zimmermann 1 3, Palak J. Trivedi 1, Christopher J. Weston 4, David H. Adams 1
1
University of Birmingham, NIHR Biomedical Research Unit & Centre for Liver Research,
Birmingham, United Kingdom, 2University of Jena, Integrated Research and Treatment
Center for Sepsis Control and Care, Jena, 3University of Aachen, Department of
Medicine III, Aachen, Germany, 4NIHR Biomedical Research Unit & Centre for Liver
Research, University of Birmingham, Birmingham, United Kingdom
EASL HCC SUMMIT
Introduction: Transarterial chemoembolisation (TACE) delivers local-regional
chemotherapy for patients with hepatocellular carcinoma (HCC) and evidence suggests
TACE may enhance anti-tumour immune-response. CD4+regulatory T-cells (CD4+Treg)
are immunosuppressive T-cells crucial for the maintenance of immune-homeostasis
which, in the context of cancer, inhibit effective anti-tumour immunity.
Aims: The aims of this study were to investigate whether TACE alters the number and
function of CD4+Treg in patients with HCC.
Methodology: Blood was collected from patients with HCC (n=50) before, 3 days and
42 days after TACE. The frequency of CD4+Treg was determined by flow-cytometry, and
direct suppressive-capacity assessed through co-culture proliferation assays with effector
T-cells. Patients were assessed for response to TACE according to the mRECIST criteria
by cross-sectional imaging.
Results: The proportion of Treg within the total CD4+T-cell population was significantly
reduced by day 3 in patients following TACE (baseline; 7.9%+4.8%, day 3; 6.4%+4.2%,
day 42; 6.1%+3.9%, P<0.05). When patients were stratified according to treatment effect;
Treg frequencies were significantly reduced following TACE in treatment-responders/
stable disease (n=40; baseline; 8.4%+4.9%, day 42; 5.8%+4.0%, P<0.05). When
compared to patients with progressive disease, Treg frequencies were significantly
increased following TACE (n=10; baseline; 5.0%+3.1%, day 42; 7.7%+2.7%, P>0.05).
CD4+Treg from HCC patients suppressed effector T-cell proliferation and this suppressive
ability was comparable before and after TACE irrespective of treatment-response.
Conclusions: Treatment response to TACE was correlated with a reduction in CD4 Treg
in patients with HCC. This may be used as a predictor of TACE treatment-response and
might represent the basis to support the use of TACE as an adjuvant to immunotherapy.
+
1
Thomas C. Wirth 1, Dmitrij Ostroumov 1, Michael P. Manns 1
Gastroenterology, Hepatology and Endocrinology, Medical School Hannover,
30625 Hannover, Germany
Introduction: Due to disadvantages and limitations of current dendritic cell vaccinations,
immunotherapeutic cancer treatment requires novel, innovative vaccination strategies
that are able to rapidly generate high numbers of cancer-specific CD8 T cells. Current
vaccinations, however, fail to generate potent immune responses that allow for long-term
tracking and phenotyping of cancer-specific CD8 T cells.
Aims: The aim of our study was to establish a novel vaccination method that allows for
the induction of potent immune responses in vivo. Our primary goal was a rapid induction
of fully functional and cytotoxic CD8 T cells and to test them in a model system of
autochthonous murine liver cancers. Methodology: We established an in vivo model of hepatocellular carcinoma using
hydrodynamic tail vein injection of transposon-flanked plasmids in conjunction with a
transiently expressed transposase. Using this flexible plasmid-based system, we were
able to establish orthotopic liver cancers and to incorporate model antigens and in vivo
monitoring genes. In parallel, we tested various immunization protocols that employed
injection of antigen coupled to PLGA microspheres and different bacterial and viral
vaccination vectors to identify the optimal combination for prime-boost vaccinations.
Results: Our results show that administration of the model antigen ovalbumin coupled
to biodegradable PLGA microspheres induces tumor-specific CD8 T cell populations that
can rapidly be boosted to high numbers in vivo when followed by booster vaccination with
a Listeria monocytogenes vector. This novel vaccination regime resulted in fully functional
and oncolytic CD8 T cell populations within 14 days. In our newly established in vivo
model of hepatocellular carcinoma, the novel vaccination regime resulted in eradication
of autochthonous liver cancers and in significantly improved overall survival of the treated
mice compared to a conventional dendritic cell vaccine.
Conclusions: Tumor vaccines based on a prime-boost protocols employing PLGA
microsphere administration and subsequent Listeria vector vaccination holds promise as
a novel immunotherapy for hepatocellular carcinoma.
62
64
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
65
Waseem Qasim 1, Maurizia Brunetto 2, Adam Gehring 3 4, Shao-An Xue 5, Atefeh Khakpoor
6
, Hong Zhan 1, Pietro Ciccorossi 2, Kimberly Gilmour 1, Daniela Cavallone 2, Francesco
Moriconi 2, Farzin Farzhenah 7, Alessandro Mazzoni 2, Lucas Chan 7, Emma Morris 5,
Adrian Thrasher 1, Mala Maini 5, Ferruccio Bonino 8, Hans Stauss 5, Antonio Bertoletti 6 3
1
Institute of Child Health & Great Ormond Street Hospital, London, United Kingdom,
2
Hepatology Unit, University Hospital of Pisa, Pisa, Italy, 3Singapore Institute for Clinical
Sciences, A*STAR, Singapore, Singapore, 4Molecular Microbiology and Immunology
Department, Saint Louis University School of Medicine, St. Louis, United States,
5
Department of Immunology, Royal Free Hospital, London, United Kingdom, 6Emerging
Viral Diseases, Duke-NUS Medical School, Singapore, Singapore, 7Rayne Institute,
Kings College, London, United Kingdom, 8General Medicine, Liver – Digestive Division ,
University Hospital of Pisa, Pisa, Italy
Introduction: HBV-DNA integration frequently occurs in HBV-related HCC, but whether
HBV antigens are expressed in HCC cells and can be targeted by immune therapeutic
strategies remains controversial
Aims: We characterized HBV antigen expression in HCC metastasis occurring in a patient
who underwent liver transplantation for HBV-related HCC. We then used HBsAg-specific
T cell receptor redirected T cells to treat the chemoresistant extrahepatic metastases
present in the patient. Methodology: Biopsies of the primary HCC, lymphonodes metastasis and transplanted
liver were analyzed for HBV antigen expression with immune-histology methods and for
HBV-DNA integration. T cell receptors specific for the HLA-A201/HBs183-91 complex were
utilized to redirect the T cell specificity of the patient lymphocytes using retroviral vector
produced under GMP conditions. The redirected T cells were administered as a single
dose at 10,000 HBs183-91 specific T cells/kg and the patient underwent serial virological,
biochemical and radiological monitoring assessments.
Results: Cytoplasmic HBsAg was detected in explanted HCC and recurrent metastases
but not in the transplanted liver. Infusion of TCR-redirected lymphocytes was well tolerated
without significant adverse events. Transaminase levels showed a steady (but clinically
non-significant) increase (19, 70, 81, 106 IU/L) at day 0, 3, 10, 30 after T cell transfer,
while serum HBsAg decreased over the same time period (3561, 3150, 2631, 554 IU/ml).
AFP levels dropped after infusion (4569 to 2949 ng/ml at day 10) but then increased at
day 30 (6389 ng/ml). TCR-redirected cells were detected at a frequency of 6%> of total
CD8 T cells after 30 days indicating notable in vivo expansion. Imaging analysis performed
40 days after therapy did not detect any measurable reduction in the size of pre-existing
metastasis and progressive CNS lesions resulted in death at day 60. Conclusions: HBV antigens was expressed in HCC relapses occurring in a liver
transplanted patient and were recognized in vivo by lymphocytes engineered to express
HBV-specific T cell receptors. These T cells were able to survive, expand and mediate
a reduction in HBsAg without exacerbation of liver inflammation. Whilst clinical benefit
was not demonstrated in this patient who was treated on a compassionate basis in the
context of end-stage metastatic disease, these data show that gene –modified T cells can
constitute a new therapeutic opportunity in the early treatment of HCC relapses in liver
transplant patients.
THERAPY WITH T CELL RECEPTOR GENE
MODIFIED T CELLS TARGETING HCC WITH
HBV-DNA INTEGRATION
66
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
67
PREMALIGNANT LESIONS IN
HBV-CARCINOGENESIS
1
Young Nyun Park 1
Pathology, BK21 PLUS Project for Medical Science Yonsei University College of
Medicine, Seoul, Korea, South
Introduction: Accumulating evidence strongly favors the existence of a multistep process
in hepatocarcinogenesis. In the liver, dysplastic cells may form clusters (dysplastic foci,
< 0.1 cm in diameter), which are detectable only upon microscopic examination, or nodules
(dysplastic nodules, DNs, usually 1cm in diameter), which are detectable macroscopically.
Dysplastic foci consist of two types of hepatocellular changes: small liver cell change
(SLCC) and large liver cell change (LLCC). DNs can be classified into low-grade DNs or
high-grade DNs on the basis of cytological and architectural atypia.
Aims: The aim of this study was to characterize the premalignant nature of DNs and
dysplastic foci in HBV-carcinogenesis.
Methodology: The molecular and pathological features of DNs and dysplastic foci were
investigated in HBV-carcinogenesis. Results: In HBV-multistep hepatocarcinogenesis, gradual increases in the molecular
pathological characteristics of angiogenesis, telomere shortening, telomere dysfunction,
TERT activation, inactivation of cell cycle checkpoints, DNA damage, chromosomal
instability, etc., were seen as the disease progressed from cirrhosis to low grade DN, high
grade DN, and finally, hepatocellular carcinoma (HCC). The molecular pathological features
of high grade DNs were similar to those of HCC. The frequency of methylated genes,
including APC, RASSF1A, and SOCS1, increased in a stepwise fashion, progressing
from cirrhosis to low grade DN and high grade DN, and peaked in early HCCs. However,
progressed HCCs exhibited relatively less gene methylation than early HCCs, suggesting
that epigenetic changes occur predominantly in early stages of hepatocarcinogenesis. The
expression of liver stem/progenitor cell markers showed low levels in DNs and gradually
increased during multistep hepatocarcinogenesis, with the highest levels recorded in
progressed HCCs.
And it was higher in HBV- than HCV-related hepatocarcinogenesis. Neoplastic cells
expressing liver stem/progenitor cell markers appeared to be more involved in late rather
than earlier stage of hepatocarcinogenesis. Concerning dysplastic foci, there was a
progressive decrease in telomere length and progressive increase in proliferative activity
from normal looking cirrhotic hepatocytes to LLCC, SLCC, and HCC. Cell cycle checkpoint
markers including p21, p27, and p16, decreased in SLCC and were absent in HCC,
whereas γH2AX-DNA damage foci were present in SLCC and HCC. These data suggest
the precancerous nature of SLCC, whereas LLCC is rather heterogeneous in nature,
depending on the biological setting. HBV-related LLCC showed significantly high Tp53
labeling index, γ-H2AX labeling index, and micronuclei index; shorter telomere length;
decreased SA-β-Gal activity; and increased net cellular gain compared to cholestatic
LLCC. The characteristics of HBV-related LLCC were more consistent with dysplastic
rather than merely reactive hepatocytes, whereas those of cholestatic LLCC were more
likely to represent a reactive change with more stringent cell cycle checkpoint control.
Conclusions: Precancerous lesions of HCC include DNs and dysplastic foci. DNs,
especially high grade DNs are considered as precancerous lesions of HCC. In regards to
dysplastic foci, SLCC exhibits pathological characteristics of precancerous lesion, whereas
the nature of LLCC is rather heterogeneous depending on the biological setting. HBVrelated LLCC is considered as premalignant lesion rather than merely reactive change.
68
PHOSPHOPROTEOME IN HEPATOCELLULAR
CARCINOMA
1
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
69
NOTES
Augusto Villanueva 1
King’s College London, London, United Kingdom
Current mainstream trends in systemic therapy for solid tumors mostly rely in the selective
blockade of tyrosine kinases. The main biochemical mechanism of kinase activation is
constitutive phosphorylation, generally due to an activating mutation. Ideally, identification
of the dominant aberrant activated kinase would allow tailoring treatment on an individual
basis. This has proved effective in different solid tumours such as in patients with lung
cancer, ALK rearrangements and response to crizotinib, or in those with BRAF mutated
melanoma and vemurafenib. In hepatocellular carcinoma (HCC), solid preclinical and
clinical evidence indicates that blocking tyrosine kinases provides enough antitumor
effect to increase patient’s survival. However, successful results of sorafenib haven’t been
reproduced with other tyrosine kinase inhibitors, either due to futility or toxicity. Indeed,
it is unclear which is the precise mechanism by which sorafenib induce its antitumoral
effects. Extensive mapping of the de-regulated kinases in HCC could provide additional
clues of potential new therapeutic pathways, or suggest mechanisms behind resistance
to sorafenib.
70
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
71
Ezra Ella 1, Evgeniy Stoyanov 1, Orit Pappo 2, Denise Heim 3, Temima Schnitzer Perlman 1,
Nathalie Nachmansson 1, Rona Steinfeld 1, Israel Steinfeld 4, Ludmila Rivkin 1, Deborah
Olam 1, Henning Wege 3, Rinat Abramovitch 1 5, Eithan Galun 1, Daniel Goldenberg 1
1
Goldyne Savad Institute of Gene Therapy, 2Department of Pathology, HadassahHebrew University Medical Center, Jerusalem, Israel, 3Department of Gastroenterology
and Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,
4
Computer Science Department, Technion-Israel Institute of Technology, Haifa, 5Magnetic
Resonance Imaging/Magnetic Resonance Spectroscopy Laboratory, Hadassah-Hebrew
University Medical Center, Jerusalem, Israel
Introduction: The Mdr2-KO mouse is a model for inflammation-mediated hepatocellular
carcinoma (HCC). Previously, we demonstrated that partial hepatectomy (PHx) promotes
hepatocarcinogenesis in this model (PNAS 2010, 107:2207-12).
Aims: To explore the molecular mechanisms underlying the tumor-promoting effect of
PHx, we compared genomic and transcriptomic profiles of the HCC tumors induced by
70% PHx with spontaneous tumors developing in the Mdr2-KO mice.
Methodology: Six tumors from each experimental group were compared with their
matched non-tumorous liver tissue samples using microarray-based comparative genomic
hybridization and genome-scale gene expression profiling. HCC tumors subjected to
genomic analysis in both groups were similar in size and morphology.
Results: In hepatectomized mice, HCC developed three months earlier than in untreated
mice. Among PHx-induced tumors, 5/6 had major chromosomal aberrations: all of them
were amplifications affecting multiple chromosomes, and most of them were located near
the acrocentric centromeres. Four different chromosomal regions were amplified each
in at least four tumors. All six tumors of untreated mice had chromosomal aberrations,
including both deletions and amplifications.
Amplifications in spontaneous tumors affected fewer chromosomes and were not located
preferentially at chromosomal edges. PHx-induced and spontaneous tumors shared
the same frequently amplified region at chromosome 18. One of the regulatory genes
encoded by this amplified region, Crem, was up-regulated in many published human
HCC datasets. Here, we demonstrated its nuclear expression in human HCC, and its
pro-proliferative activity in human HCC cell lines in vitro. Comparison of gene expression
profiles revealed very limited numbers of common up- and down-regulated genes in the
post-PHx and spontaneous tumors. Post-PHx tumors were significantly enriched with
expression signatures of oncogenes, chromosomal instability markers and E2F1 targets.
Both tumors and non-tumor liver tissues of the post-PHx mice were enriched with the “poor
prognosis” HCC-specific gene expression signatures.
Conclusions: PHx of the chronically inflamed liver directed tumor development to a
discrete pathway characterized by amplification of specific chromosomal regions and
expression of specific tumor-promoting genes. Liver PHx in Mdr2-KO mice may serve
as a model for HCC recurrence in patients. Crem is a candidate oncogene frequently
amplified in this model.
SPECIFIC GENOMIC AND TRANSCRIPTOMIC
ABERRATIONS IN HCC INDUCED BY PARTIAL
HEPATECTOMY OF A CHRONICALLY INFLAMED
LIVER
72
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
73
Stephanie Roessler 1, Guoling Lin 2, Marshonna Forgues 2, Anuradha Budhu 2, Shelley
Hoover 3, R. Mark Simpson 3, Xiaolin Wu 4, Ping He 5, Lun-Xiu Qin 6, Zhao-You Tang 6,
Qing-Hai Ye 6, Xin Wei Wang 2
1
Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany, 2Laboratory
of Human Carcinogenesis, 3Laboratory of Cancer Biology and Genetics, NCI, Bethesda,
MD, USA, 4Laboratory of Molecular Technology, NCI, Frederick, 5FDA, Bethesda, MD,
United States, 6Liver Cancer Institute, Fudan University, Shanghai, China
Introduction: Metastasis is the main cause of cancer mortality but its process remains
poorly understood and thus hampers more effective treatment and improved cancer
prognosis. Thus, it is expected that there is a significant difference in tumor biology
between primary tumor cells and their metastasized progenies.
Aims: Identification of metastasis-related and organ site-specific metastasis genes.
Methodology: Here, we recruited a comprehensive set of paired primary tumor and
distant metastatic clinical specimens of liver and colorectal cancer patients with the goal
of identifying metastasis-related genes. We performed gene expression profiling of laser
capture microdissected tumor and paired metastasis samples to ensure that the identified
genes are tumor-specific. In addition, we analyzed genome-wide somatic copy number
alteration (SCNA) profiling of paired primary tumors and distant metastasis of the same
patient. We also globally integrated gene expression and SCNA to identify key metastasis
genes.
Results: Analysis of the gene expression and SCNA profiles revealed that primary
tumor and paired metastatic tissues of liver and colorectal carcinoma are very similar.
However, class comparison of non-metastatic liver cancer to lung metastases, lymph node
metastases and colorectal liver metastases resulted in 280, 730 and 1387 differential
genes, respectively (p<0.001). The identified differential gene sets exhibited a small
overlap of only 14 genes, suggesting that most genes are tumor type and organ sitespecific. Further analyses of SCNAs showed that the gene expression profiles of primary
tumors and metastasis are more stable than SCNA. Interestingly, the number of genomic
aberrations of primary versus metastatic tissue was significantly higher in liver cancer
than in colorectal cancer. The correlation of gene expression and SCNA showed that
29% of genes exhibit significant correlation. Pathway analysis showed that lymph node
metastasis genes are involved in the HMG-CoA pathway, whereas, lung metastasis genes
are enriched in cell-cell signaling and colon metastasis in stearate/fatty acid activation.
Despite distinct pathway enrichment, different metastasis gene sets shared common
prognostic capacity and were predictive of patient outcome in an independent HCC cohort
(N=242).
Conclusions: The minimum difference between paired primary tumors and metastasis
implies that metastasis does not necessitate the cancer cells to acquire additional
mutations beyond those needed for primary tumor formation.
INTEGRATIVE GENOMIC AND TRANSCRIPTOMIC
ANALYSIS TO SEARCH FOR METASTASIS
DRIVER GENES
CENTROSOMES AND F BOX PROTEINS
1
Nisar P. Malek 1, Uta Kossatz 2, Benita Wolf1
University Hospital Tübingen, University Hospital Tuebingen, Tübingen, Germany
2
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
75
METHYLOME IN HCC
1
Thomas Longerich 1
Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
Introduction: HCC is a genetically highly unstable tumor. In the past we have shown that
the dysregulation of ubiquitin ligases can result in the formation of liver cancer stem cells
and in the induction of genetic instability.
Introduction: Human hepatocarcinogenesis is considered a step-wise process in which
genetic and epigenetic alterations result in the activation of oncogenes and the inactivation
of tumor suppressor genes. Epigenetic alterations include aberrant methylation and histone
modifications, which do not alter the genetic information per se, but affect its transcription.
Aims: We have used mouse strains in which components of the Cul3 system were deleted
to study the effects of dysregulated ubiquitylation in vitro and in vivo. We were particularly
interested in the mechanisms which promoted the formation of liver cancer stem cells and
in processes which dysregulated centrosome duplication.
Methodology: For our studies we used inducible cul3 knockout mice and transposon
driven gene transfer technologies.
Results: Our current research shows that loss of cul3 in the liver leads to the formation
of cancer stem cells which produce high levels of Il8/KC. This factor results in a block to
stem cell differentiation and which again results in treatment resistance. As Il8 leads to an
activation of the mTOR signalling pathway we showed that treating cul3 deficient cancer
stem cells with mTOR inhibitors induces stem cell differentiation and overcomes treatment
resistance in vitro and in vivo. Interestingly the number of circulating tumor stem cells in
HCC patients correlated significantly with the levels of Il8 in vivo. Conclusions: We present evidence that liver cancer stem cells produce IL8 to maintain
their stem cell state and at the same time protect themselves against cytotoxic drugs.
mTOR inhibition presents a way to overcome this block and sensitize these cells to
treament. Aims: While overall tumor DNA is hypomethylated, which may promote genomic instability,
aberrant hypermethylation of promoter-associated CpG islands has been observed in
human HCC and may result in the inactivation of tumor suppressor genes.
Methodology: In the past DNA methylation analyses have been carried out mainly by
locus specific techniques following bisulfite conversion of unmethylated cytosines, while
nowadays array- and next generation sequencing-based techniques are used for highresolution genome-wide analysis.
Results: In human HCC, hypermethylation is frequently observed in genes known to be
inactivated by the polycomb repressive complex 2, while hypomethylation is associated
with loss of imprinting. Vertical integration of genome-wide methylation analysis with other
levels of genetic and expression profiling has allowed for the identification of new tumor
suppressor gene candidates in human HCC.
Conclusions: In addition, significantly higher methylation has been demonstrated in the
group of CTNNB1-mutated HCCs suggesting that methylation profiling may significantly
contribute to a comprehensive molecular classification of human hepatocarcinogenesis.
74
76
A PROOF OF CONCEPT STUDY FOR THE
TUMOUR SUPPRESSOR EFFECT OF A
THERAPEUTIC STRATEGY AGAINST MIR-34A
IN MOUSE TUMOURS MUTATED FOR
BETA-CATENIN
Angelique Gougelet 1, Laura Bachelot 1, Cecile Godard 1,
Chiara Sartor 1, Benoit Terris 1, Christine Perret 1, Sabine Colnot 1
1
U1016, INSERM, Paris, France
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
77
Our second approach consists to isolate bipotent mouse embryonic liver cells from E14.5
ApcKO embryos and treat them with LNA-34a before injection in the liver of control mice.
The tumour development will be followed as previously. Conclusions: Our work highlights the crucial oncogenic role of miR-34a in tumours
mutated for β-cat. By a LNA strategy, we expect to highlight miR-34a as the first oncogenic
actor in β-cat-mutated HCC, which could be easily targeted. The great potential of this
strategy lies on the modulation of HNF-4α activity, which results in the restoration of the
metabolic program and the control of cell cycle through cyclin D1 targeting.
Introduction: microRNAs (miRNAs) are small non-coding RNAs involved in the
development and the progression of a great variety of tumours, in particular of
hepatocellular carcinoma (HCC). Our team focuses in particular on the role of β-catenin
(β-cat) in liver tumour development. By ChIPseq and RNAseq experiments, we recently
showed a functional antagonism between β-cat and HNF-4α, which is described as a
tumour suppressor in HCC. Aims: Our objective is to identify candidate miRNAs by miRNAseq, which could be
regulated by β-cat and involved in liver tumourigenesis. Methodology: This project is realized on transgenic mice exhibiting an overactivation
of β-cat following the deletion of its inhibitor Apc (ApcKO). This model is liver-specific and
inducible by tamoxifen injection. It is a pretumoural model since lower dose of tamoxifen
results in the apparition of tumours mutated for β-cat, which mimic human HCC. Results: miR-34a is significantly induced following β-cat activation in correlation with a
loss of its target HNF-4α. miR-34a is also significantly increased in the mouse tumours
obtained following Apc depletion and in HCC patients mutated for β-cat, as compared to
normal liver. We thus decided to test the effect of a locked nucleic acid approach against
miR-34a (LNA-34a) in the progression of tumours mutated for β-cat. The LNA-34a exerts
an anti-proliferative activity on primary hepatocytes isolated from ApcKO model, while it
has no effect on wild-type hepatocytes. This inhibition of proliferation is associated to a
decrease of cyclin D1 protein level, a negative target of HNF-4α. We currently initiate the
in vivo study with LNA-34a injection in tumoural ApcKO mice. As soon as liver tumours
are detectable by echography, we intraperitoneally inject the LNA-34a (10mg/kg, once a
week). Tumour development is bimonthly followed by 3D-echography.
Figure 1 : miR-34a oncogenic role in liver
miR-34a is upregulated in tumors from Apc null mice (A) and human β-catenin mutated
HCC (B). miR-34a level was measured by qPCR with a taqman miRNA assay (Applied
biosystems). C : a locked nucleic acid (LNA) against miR-34a efficiently restores HNF4α and cyclin D1 level in western-blot. 100nM LNA was transfected for 48h in primary
hepatocytes isolated from Apc KO mice by lipofectamine. D : the LNA against miR-34a
inhibits hepatocyte proliferation. 100nM LNA was transfected into primary hepatocytes
isolated from ApcKO and control (Ctrl) mice by lipofectamine. E : hypothetized model for
miR-34a action.
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GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
79
MICRO RNA
1
Laura Gramantieri 1
S.Orsola-Malpighi University Hospital, Bologna, Italy
The critical role of microRNAs (miRNAs) in tumorigenesis has been widely investigated
and ascertained in the last decade, confirming their important regulatory action in several
biological processes involved in cancer development and progression. MiRNAs constitute
a large class of genes that encode short RNAs (19-24 nucleotides long), which play key
roles in development and differentiation, by the post-transcriptional regulation of protein
coding genes. At present, miRNAs have a widely recognized role in human carcinogenesis,
including hepatocarcinogenesis, and many experimental evidences indicate that they may
act as oncogenes or tumor suppressor genes regulating the expression of crucial proteincoding genes. By binding to complementary sequences in the 3’UTR of target genes,
miRNAs can promote their degradation or impair their translation. Interestingly, miRNAs
display their effects also on mRNAs with a partial sequence complementarity. Therefore,
one miRNA may modulate the expression of a wide range of mRNAs at one time, thus
regulating more pathways or one pathway at more levels. Thus, a fine modulation on
single mRNAs may produce relevant final effects. MiRNA-based molecular signatures
characterize different tumor types, including HCC and, despite some discrepancies
can be found through the different series reported in the literature, a panel of miRNAs
commonly deregulated in HCC can be identified. Among these commonly deregulated
miRNAs in HCC tissue, miR-21, miR-199, miR-221 and miR-122, are recurrent and seem
to characterize HCC tissue regardless of etiology of the underlying liver disease. Yet,
deregulated miRNAs signatures may also help to identify HCCs with different etiology,
genetic background and prognosis. Interestingly, miRNA signatures have been proposed
to complement transcriptomic signatures in several malignant diseases including HCC.
Molecular events driving miRNAs expression are still poorly understood, however
evidences are accumulating on the role of transcription factors and epigenetic changes.
In addition, miRNA mutations have also been described in neoplastic tissues, possibly
associated with their abnormal expression and function. Regulatory feed-back or feedforward loops have also been identified, contributing to the deregulated expression of
miRNAs in several malignancies.The understanding of miRNAs contribute to the malignant
phenotype has been attempted by the identification of their target genes. Several gene
products playing relevant roles in the malignant phenotype have been identified as miRNA
targets, mainly by using in vitro approaches.
Proteins regulating cell cycle progression, apoptosis, senescence, EMT, cell migration and
invasion capability were identified among the targets of deregulated miRNAs. Remarkably,
in vitro findings should be interpreted keeping in mind that such experimental conditions
are very outstretched, and that cell and tissue context play a fundamental role in the
determination of miRNA functions. In addition, the microenvironment surrounding tumor
tissue was demonstrated to play an important role as well. From a translational point of
view, miRNAs have been proposed as possible novel biomarkers for cancer diagnosis,
prognostic assessment and assessment of susceptibility to different treatments. However
these findings still need an adequate validation. Since miRNAs are biomarkers with
beknown potential in molecular classification and prognostication in HCC tissue, they
are being the more and more addressed as possible biomarkers to be assayed also in
body fluids, such as serum, plasma and urine. Despite several studies appeared in the
literature in the last years, still no common pattern has been found on circulating miRNAs
deregulated in HCC. The wide heterogeneity of such studies should be ascribed to several
reasons, including different study designs, analytical approaches, heterogeneous internal
and exogenous standards, different populations enrolled as controls. The understanding
of HCC pathogenesis could be an opportunity to develop new targeted strategies and
therapeutic approaches against HCC. MiRNAs modulation represents an appealing
treatment modality for liver diseases, due to the high uptake of these kind of molecules by
the liver itself, after peripheral vein injection. In addition, no relevant adverse event was
reported after miRNA-based therapeutic approach against HCV infection. We have recently
reported that anti-miR-221 has a significant antitumor activity in a TG-221 transgenic
mouse model over-expressing miR-221 in the liver. Histo-pathological analyses showed a
significant reduction in the number and size of tumors of treated mice in comparison with
untreated animals and at the molecular level a significant down-regulation of miR-221 in
liver of anti-miR-221 treated mice was displayed, confirming the ability of these molecules
to inhibit the endogenous miR-221. While pre-clinical studies in in vivo models of HCC
seem to confirm the great potential of miRNAs as therapeutic targets, yet we should keep
in mind the context-dependent role of miRNAs as well as their possible action at distant
sites and off target effects.
BETA-CATENIN SIGNALLING AND HCC
METABOLISM
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Introduction: β-catenin signaling can be both a physiological and an oncogenic pathway
in the liver. It controls compartmentalized gene expression, allowing the liver to ensure its
essential metabolic function. It is activated by mutations in 20 to 40% of hepatocellular
carcinomas with specific metabolic features.
Aims: β-catenin forms a transcriptional complex together with its nuclear partner Tcf4.
We aimed at identifying at which extent this complex is involved in the genetic metabolic
programme of the zonal liver, and if this has consequences in the pathogenesis of
β-catenin-mutated HCC in humans.
Methodology: We deciphered the molecular determinants of β-catenin-dependent
zonal transcription using mice with β-catenin-activated or -inactivated hepatocytes,
characterizing in vivo their chromatin occupancy by Tcf4 and β-catenin (ChIP-Seq), their
transcriptome (mRNA-Seq) and their metabolome (nHPLC/ms-ms).
Results: We found that Tcf4 DNA-bindings depend on β-catenin. Tcf4/β-catenin binds
Wnt-responsive elements preferentially around β-catenin-induced genes. In contrast,
genes repressed by β-catenin bind Tcf4 on Hnf4-responsive elements. β-catenin, Tcf4
and Hnf4α interact, dictating β-catenin transcription which is antagonistic to that elicited
by Hnf4α. Finally, we find the drug/bile metabolism pathway to be the one most heavily
targeted by β-catenin, partly through xenobiotic nuclear receptors.
Conclusions: We conclude that β-catenin patterns the zonal liver together with Tcf4,
Hnf4α and xenobiotic nuclear receptors. This network represses lipid metabolism, and
exacerbates glutamine, drug and bile metabolism, mirroring hepatocellular carcinomas
with β-catenin mutational activation.
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ONCOGENIC TRANSCRIPTIONAL REGULATORS
1
Sabine Colnot 1, Angélique Gougelet 1, Cyril Torre 1, Philippe Veber 1, Chiara Sartor 1,
Cécile Godard 1, Christine Perret 1
1
Cochin Institute U1016, INSERM, Paris, France
EASL HCC SUMMIT
Kai Breuhahn 1
Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
Transcriptional regulators (transcription factors and co-factors) integrate and process input
signals of different (oncogenic) pathways and therefore represent cellular bottlenecks
that regulate tumor cell biology. Genomic and transcriptomic data of primary human liver
cancer revealed that many of these factors were dysregulated in subgroups of HCCs
with a more aggressive phenotype, suggesting that transcriptional regulators collect input
information in order to promote tumor initiation and progression.
Recent studies demonstrate that dysregulation of the Hippo signaling pathway is critically
involved in hepatocarcinogenesis. Deletion of essential Hippo-pathway constituents or
overexpression of the transcriptional co-activator yes-associated protein (YAP) leads
to the development of liver cancer. However, the underlying molecular mechanisms in
hepatocarcinogenesis have not been defined so far. Nuclear accumulation of YAP in
almost 70% of human HCCs is significantly correlated with tumor cell proliferation and
dedifferentiation. By using cross-species analysis of expression data, the Notch ligand
Jagged-1 (Jag-1) was identified as a downstream target of YAP in primary hepatocytes and
HCC cells. TEAD4 was identified as the transcription factor required for YAP-dependent
regulation of Jag-1. YAP-induced activation of the Jag-1/Notch pathway significantly
correlated with poor prognosis of HCC patients. Transgenic mice with inducible expression
of constitutively active YAPS127A showed hepatomegaly (after 4 weeks) and eventually tumor
formation (after 10 weeks). The additional knock-out of Jag-1 reduced hepatomegaly on
the basis of diminished proliferation; however, tumor formation was not affected.
Although transcriptional regulators are believed to be nondruggable owing to large and
stable DNA/protein surface interactions, recent results suggest that disruption of the YAP/
TEAD interaction through specific small compounds may provide promising approaches
for the treatment of HCCs with increased YAP levels.
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82
THE FUNCTION OF FOS AND FOS~JUN DIMERS
IN LIVER CANCER
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
83
NOTES
Rainer Hamacher 1, Osvaldo Graña 2, Latifa Bakiri 1, Erwin F. Wagner 1
Genes, Development and Disease Group, F-BBVA - CNIO Cancer Cell Biology
Programme, 2Structural Biology and Biocomputing Programme, Bioinformatics Unit,
Spanish National Cancer Research Centre (CNIO), Madrid, Spain
1
Introduction: Hepatocellular carcinomas (HCC) are tumours associated with chronic
inflammation. The crosstalk between hepatocytes and non-parenchymal liver cells (NPCs)
is well established and involves important signalling molecules like MAPKs, NF-κB, AP-1,
Myc and STAT3. The proto-oncogene c-Jun, a component of the dimeric AP-1 transcription
factor, is required for mouse liver tumourigenesis (Eferl et al., Cell, 2003). Moreover, c-Jun
promotes cell survival during tumour initiation by controlling c-Fos/SIRT6-dependent
expression of the anti-apoptotic protein Survivin (Min et al., Nat Cell Biol, 2012). The c-Jun
partner c-Fos is frequently over-expressed in HCC, however, the in vivo function of c-Fos
in liver cancer remains to be defined.
Methodology: The chemical carcinogenesis (DEN) protocol was applied to genetically
engineered mouse models (GEMMs). We generated mice carrying novel tetracycline (tet)switchable hepatocyte-specific c-fos and forced jun~fos alleles (gain-of-function). We also
analyzed mice with conditional hepatocyte-specific deletion (loss-of-function) using AlfpCre and conditional deletion of c-fos in hepatocytes and NPCs using Mx-Cre.
Results: Hepatocyte-specific ectopic expression of c-Fos in adult mice led to spontaneous
hyperproliferative dysplasia and promoted DEN-induced liver carcinogenesis. Interestingly,
when c-Fos dimerization was restricted to a single Jun partner, the resulting c-Jun~cFos and JunD~c-Fos expressing mice displayed as well hyperproliferative dysplasia,
unlike JunB~c-Fos expressing mice. Deletion of c-Fos in hepatocytes protects from DENinduced liver carcinogenesis. Interestingly, deletion of c-Fos in NPCs and hepatocytes
abrogates this protective effect. Using whole transcriptome sequencing (RNA-Seq) the
steroid biosynthesis pathway was identified as being altered in a Fos- and cell-typedependent manner.
Conclusions: These results emphasize the cell-type-specific and dimer-dependent role
of c-Fos/AP-1 in liver disease. c-Fos is oncogenic in hepatocytes through dimerization
with c-Jun or JunD but not JunB, whereas c-Fos acts as a tumour suppressor in NPCs.
Mechanistically, c-Fos seems to inhibit the biosynthesis of steroids in a cell-type-specific
manner. Defining how c-Fos controls development of liver tumours and influences the
tumour microenvironment will help to identify new prognostic biomarkers and therapeutical
targets.
84
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
85
THE ROLE OF C-MYC IN CHRONIC LIVER INJURY
AND HEPATOCARCINOGENESIS
1
Arndt Vogel 1
Gastroenterology, Medical School Hannover, Hannover, Germany
Elevated and/or deregulated expression of c-myc has been detected in many human
cancers, including hepatocellular carcinomas. Given the fact that most tumors are detected
at an advanced stage, it is difficult to ascertain whether c-myc plays a more important role
in tumor initiation or in tumor progression. In embryonic and neonatal murine livers, c-myc
overexpression induces marked cell proliferation and the immediate onset of neoplasia. In
contrast, c-myc overexpression in adult livers failed to induce hepatocyte proliferation and
mice develop tumors only after a prolonged latency suggesting context-specific effects of
c-myc in hepatocytes. Co-expression of c-myc with other oncogenes such as transforming
growth factor alpha (TGFα) results in a tremendous acceleration of neoplastic development
in the liver. The importance of c-myc for tumor maintenance has been shown in mouse
models with conditional transgene expression systems. Hepatocellular carcinomas usually
arise within the context of chronic liver injury. Most previous studies have continuously
overexpressed c-myc as a transgene in otherwise healthy mice to analyze the role of c-myc
in tumorigenesis. This approach precludes the investigation of the specific consequences
of c-myc activation during chronic liver injury. C-myc regulates cellular processes through
positive and negative regulation of multiple target genes by distinct mechanisms, which
include direct binding to DNA, interacting with other transcription factors and recruiting
histone acetylases and DNA methyltransferases. Another layer of complexity has emerged
from the binding of Myc – Max heterodimers, thereby disrupting the functions of other
transcription factors. Finally, c-myc regulates a broad set of miRNAs. Multiple studies have
documented the deregulation of miRNAs in cancer cells. Although altered expression of
specific miRNAs has been shown to promote tumorigenesis, downregulation of global
miRNA abundance seems to contribute to neoplastic transformation due to an increased
expression of proteins with oncogenic potential. There is increasing evidence that c-myc
not only activates specific miRNA clusters, but also leads to a widespread repression of
miRNA by directly binding to their promoter.
One of the key functions of c-myc is its ability to regulate the expression of genes that are
required for somatic cell cycle progression and most in vitro and in vivo studies suggest that
inducing uncontrolled proliferation is one of the most important oncogenic consequences
of deregulated c-myc expression. In addition to its function in driving the cell cycle and
cell differentiation, c-myc was also shown to participate in the apoptotic response. In the
absence of survival factors or if cell cycle progression is blocked, c-myc can either induce
or sensitize cells to apoptosis. Finally, it has become increasingly clear that metabolic
changes that accompany transformation are intimately related to the growth abnormalities
of malignant cells and that these metabolic changes are necessary to provide the energy
required for rapid cell division. Studies in cancer cells that overexpress c-myc revealed
that c-myc gene could serve as a “master regulator” of cellular metabolism and that c-myc
is involved in glycolyis, glutamine metabolism and mitochondrial biogenesis.The central
role of c-myc as master regulator of tumor growth suggests that this transcription factor
is an intriguing target for cancer therapies. Moreover, there is evidence for a certain
threshold level of c-myc expression, which is required to maintain a tumor phenotype.
Down regulating c-myc below a critical level reduced its ability to maintain tumorigenesis
and induced a shift in gene expression that re-established cell cycle checkpoints, halted
protein translation, and promoted apoptosis. Very recently, specific DsiRNA have been
developed, which specifically targets c-myc in tumor cells. These DsiRNAs are currently
evaluated for their anti-tumor efficacy in different preclinical models.
86
TODAY’S MAJOR CHALLENGES IN MANAGING A
PATIENT WITH HEPATOCELLULAR CARCINOMA
1
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
87
NOTES
Jordi Bruix 1
BCLC group. Liver Unit., Hospital Clínic. University of Barcelona, IDIBAPS.
CIBEREHD., Barcelona, Spain
The diagnosis and treatment of patients with hepatocellular carcinoma has significantly
improved in the last two decades. Joint efforts by experts from different fields and
geographical origin have taken advantage of imaging technologies and treatment options
to elaborate a structured set of definitions to be used for the management of these
patients. This knowledge according to robust scientific evidence has been exposed in
clinical practice guidelines developed by several scientific associations and consortia,
so that current clinical management of HCC patients is shared by practicing physicians
and investigators. This allows further research to build on top of this clinical ground.
The current challenges affect from molecular profiling to diagnosis, prognosis prediction
and treatment. It is expected that the novel “omics” technologies will ultimately lead to a
molecular classification that is linked to treatment decision. However, biopsy sampling
has to face the heterogeneous nature of the tumor within the nodule, across nodules and
also, along its evolution. Hence, major effort should be place in the fruits of the so-called
“liquid biopsy” from peripheral blood. Indeed, this peripheral blood research may also
prime an earlier diagnosis or the recognition of the disease even prior to overt malignant
transformation. Until then, imaging techniques will be instrumental to improve the current
detection rate as well as the diagnostic confirmation capacity. Improved performance
and applicability of screening ultrasound are needed to reach an optimal effectiveness
of surveillance. Imaging techniques will gain accuracy for staging and molecular imaging
may become instrumental for diagnosis and prognostic prediction.The better knowledge
of molecular pathobiology and improved capacity to predict and influence tumor evolution
should change the current selection of the first line treatment approach that is mostly
based in rough assessment of tumor size and number. Criteria for liver transplantation
and surgery may be modified by such information that will include the assessment of the
risk of recurrence and the potential to reduce/eliminate it by molecular targeted agents.
Locoregional approaches based in physical damage may benefit from combination with
systemic agents or even be slowly replaced by biology-based treatments acting selectively
against tumor cells or the surrounding stromal population. Sorafenib has been the first
agent to show that tumor progression may be halted with a significant survival increase,
but there is need for major improvement to finally transform cancer into a chronic condition.
As known, generous combination of laboratory research with clinical research with critical
insight from all sides is the sole way to advance in all these fronts, while not forgetting that
the optimal approach would be to be able to prevent HCC development.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
ATHENS. GREECE
SEPTEMBER 25 - 27 / 2014
BASIC POSTER
ABSTRACTS
OPTIMAL MANAGEMENT OF
HEPATITIS B VIRUS INFECTION
Co-organised by APASL
Abstract submission deadline:
June 27, 2014
SCIENTIFIC ORGANISING COMMITTEE:
P. Lampertico, M. Maini, G. Papatheodoridis
Sponsored by
www.easl.eu
89
91
Poster Board Number B1
CONNECTING METABOLISM AND HCC
DEVELOPMENT THROUGH THYROID HORMONE
INTERACTING PROTEIN (TRIP) FUNCTION
EFFECT OF EXTRACELLULAR MATRIX PROTEINS
ON PROGENITOR CELL DIFFERENTIATION
1
Bettina Meissburger 1, Mauricio Berriel Diaz 1, Ashley Eheim 1, Stephan Herzig 1 2 3
Molecular Metabolic Control, German Cancer Research Center (DKFZ), 2Heidelberg
University Hospital, Heidelberg, 3Center for Molecular Biology (ZMBH),
69120 Heidelberg, Germany
Introduction: Obesity and associated metabolic disorders are recognized risk factors for
the development of liver cancer. Many chronically obese people develop non-alcoholic
fatty liver disease (NAFLD), which can progress to steatohepatitis (NASH) and liver
cirrhosis, which may promote malignant transformation of liver cells. However, detailed
molecular mechanisms linking metabolic disorders to hepatocellular carcinoma (HCC) are
largely unknown.
BASIC POSTER ABSTRACTS
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Aims: We aimed to identify and functionally characterize distinct transcriptional regulator
complexes in the metabolic etiology of HCC.
Methodology: To characterize oncogenic pathways in HCC, which specifically arise in
the setting of metabolic dysfunction, we employed DEN-induced liver carcinogenesis in a
model of diet-induced obesity/NAFLD. Expression profiling of tumor and non-tumor tissue
from mice fed low-fat diet (LFD) or high-fat diet (HFD) was performed. This data-set was
compared to hepatic gene expression from both genetic and diet-induced obesity as well
as models of NASH. Upon confirmation in human data-sets, selected candidates were
functionally characterized in vitro, utilizing proliferation assays and analyses of cellular
metabolism.
Results: HCC development was significantly accelerated in metabolically challenged
animals. We identified thyroid hormone interacting protein (TRIP) to be consistently induced
in liver tumors, with the same induction observed in human HCC. Additionally, we found
hepatic TRIP expression to be upregulated in genetic and diet-induced obesity mouse
models as well as in NASH. Notably, TRIP knockdown markedly reduced proliferation of
hepatoma cells. Supporting the pro-proliferative function of TRIP, reduced cellular glucose
consumption was evident post-knockdown, suggesting a more oxidative metabolic state.
Conclusions: Overall, our results strongly indicate TRIP is a novel oncogenic factor,
which may integrate metabolic control and HCC development. Further functional
characterization will provide valuable clues for the exploitation of the TRIP pathway in
future metabolocentric approaches of liver cancer prevention and treatment.
Femke Heindryckx 1, Eliene Bogaerts 2, Hans Van Vlierberghe 2, Pär Gerwins 1
Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala,
Sweden, 2Gastroenterology & Hepatology, Ghent University Hospital, Ghent, Belgium
1
Introduction: Activated hepatic stellate cells cause an excessive deposition of extracellular
matrix (ECM) in chronically damaged livers. ECM proteins as well as their proteolytic
fragments have been implicated in playing a crucial role in tumor growth, metastasis, and
tumor neo-angiogenesis. Whereas some of the molecules in the tumor microenvironment
have an effect on vasculature, others have a direct effect on the tumor cells, altering
their behavior and phenotypic properties. While the effect of ECM on angiogenesis has
been investigated extensively, fewer research focuses on the direct effect of ECM proteins
and their degradation products on tumor growth. An interesting feature is that there is
increasing evidence that the ECM is an essential component of the stem cell niche and
that it can directly regulate stem cell differentiation, although the molecular details of how
this is achieved have only just started to emerge.
Aims: We aim to investigate the direct effect of ECM proteins on hepatocellular carcinoma
(HCC), mainly focusing on progenitor cell differentiation.
Methodology: Human immortalized hepatic stellate cells (LX2) were stimulated with
TGF-beta and/or the fibrin degradation product Fragment E (FnE) for 48hrs. Medium from
these cells was collected and used for subsequent stimulation of the human hepatoma
cell line HepG2. HepG2 cells were also grown on plates coated with ECM proteins,
including collagen 1, fibrinogen, fibrin, fragment E and fibrinogen-like-protein 1. Cells were
harvested after 48hrs and RNA was isolated for subsequent qPCR analysis on progenitor
cell markers.
Results: Exposure of the LX2 cells with FnE and TGF-beta lead to a 2-fold increase
of smooth muscle actin and collagen, compared to TGF-beta alone. Stimulating HepG2
cells with medium collected from activated hepatic stellate cells, caused a significantly
increased expression of prominin-1 and CD44 in the condition where TGF-beta and FnE
was used together to stimulate the stellate cells. Possibly, this was caused by an increased
production of collagen after stimulation with TGF-beta and FnE, since growing human HCC
cells on collagen coated plates, also caused an increased expression of progenitor cell
markers prominin-1 and CK19. Interestingly, fibrin and fibrinogen significantly increased
CD44 expression. Conclusions: ECM proteins cause a de-differentiation of HCC cells towards a more stem
cell like phenotype, which is associated with more aggressive tumors.
90
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FEBRUARY 13 - 16, 2014
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THE ROLE OF HYPOXIA ON LIVER PROGENITOR
CELL ACTIVATION IN A MOUSE MODEL FOR
Introduction: Hepatocellular carcinoma (HCC) is the 5th most common cancer worldwide
and is often detected in an advanced state. Current treatment options are mostly based
on depriving the tumor from its oxygen and nutrient supply by decreasing angiogenesis,
thus creating hypoxic conditions. This could lead to an alteration in the liver progenitor cell
(LPC)-niche, creating a more aggressive tumor phenotype. Understanding more about
the influence of oxygen deprivation on progenitor cells and their differentiation is of vast
importance when using and improving the use of hypoxia inducing therapies.
In a previous study, we have shown that weekly injections with diethylnitrosamine (DEN)
in prolyl hydroxylase domain 2, haplodeficient (PHD2+/-) mice -who have increased HIF
stabilization (mimicking hypoxic signaling)- induces a mixed cholangiohepatocellular
carcinoma, an LPC-derived tumor, while wild type (WT) mice develop only HCC.
Aims: To assess the effect of increased hypoxia inducible factor (HIF) stabilization on LPC
activation and differentiation in a DEN induced HCC mouse model, by using PHD2+/-mice.
Methodology: HCC was induced in WT and PHD2+/- mice by weekly DEN-injections and
euthanized after 20, 25 and 30 weeks. RT-qPCR analysis and Immunohistochemical
staining (IHC) for LPC markers was performed.
Results: qPCR analysis revealed an increase in cytokeratin (CK) 7, CK19 and CD44
expression after 30w in all DEN-treated groups compared to control mice (p<0,05). In
PHD2+/- mice, CK7 and CK19 mRNA concentrations increased drastically compared to
WT mice after 20 weeks (p<0,01) but dropped back to WT levels after 25 weeks. For
CD44, no significant difference between PHD2+/- and WT groups could be marked.
However, IHC for CD44 showed increased expression with longer induction and was
higher in PHD2+/- compared to WTs, significant after 30 weeks (p<0,001) and compared
to healthy controls (p<0,001).
Conclusions: During DEN-induction, LPCs are possibly in a proliferating state, as seen
by the increased levels of CK7 and CK19 and CD44 in WT and PHD+/- mice.
Increased CK7, CK19 and CD44 expression in early PHD2+/- tumors demonstrates
that activation of HIF-pathway probably influences LPC proliferation and differentiation
mostly in earlier stages of primary liver tumors, pushing them towards a more stem cell
like phenotype. This could contribute to the development of more aggressive tumors with
worse prognosis and has repercussions on patients receiving long term anti-angiogenic
treatment.
Eliene Bogaerts 1, Aurelie Comhaire 1, Femke Heindryckx 2, Annelies Paridaens 1,
Yves-Paul Vandewynckel 1, Peter Carmeliet 3, Anja Geerts 1, Hans Van Vlierberghe 1
1
Gastro-enterology and hepatology, Ghent university, Ghent, Belgium, 2Department
of Medical Biochemistry and Microbiology, uppsala university, Uppsala, Sweden,
3
Laboratory of Angiogenesis and Neurovascular link,
Vesalius Research Center VIB - KU Leuven, Leuven, Belgium
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SEQUENTIAL EXPRESSION OF LIPID
DROPLET-ASSOCIATED PROTEINS OF THE
PERILIPIN FAMILY DURING STEATOGENESIS:
IMPLICATIONS FOR STEATOHEPATITIS AND
MALIGNANT PROGRESSION
1
NOTES
Beate K. Straub 1, Lena Pawella 1, Merita Hashani 1, Peter Schirmacher 1
Institute of Pathology, University Clinic Heidelberg, 69120 Heidelberg, Germany
Aims: Aim of this study was to analyse perilipin expression in bland steatosis versus
steatohepatitis and HCCas well as in cell culture models in order to explore the diagnostic
and therapeutic potential of perilipins.
Methodology: In vitro, steatosis models were combined with stable downregulation of
perilipin 2 and/or perilipin 3 and hypoxic as well as lipolytic conditions. In parallel, immuno
histochemical analyses of perilipins were performed with over 100 liver biopsies with
steatosis, steatohepatitis and HCC.
Results: In short-term steatosis models in vitro, perilipins 3 and 5 were recruited to LDs
and in chronic steatosis, perilipin 3 and 5 were gradually replaced by perilipin 2 and finally
perilipin 1 at LDs of increasing size. In this line, in acute/toxic microvesicular steatosis
in situ, perilipins 2, 3 and 5 were detected at LDs, but perilipin 1 was virtually absent;
by contrast, perilipins 1 and 2-positive LDs were strongly increased in human chronic
macrovesicular liver disease irrespective of the underlying etiology, whereas perilipins 3
and 5 were localized cytoplasmically and not at LDs. In steatohepatitis, ballooned cells
were characterized by coexpression of perilipin 2, 3 and 5, but not perilipin 1. Also in HCC,
perilipin 2, 3 and 5, but not perilipin 1 were frequently upregulated. In steatosis models
under stable downregulation of perilipin 2 and/or 3, perilipin 1 was increased with reduced
LD number and increased LD size. Interestingly, cell vitality in cells lacking perilipin 2
and/or 3 was decreased, especially under conditions of stress as e.g. hypoxia. Under
conditions of lipolysis, perilipin 1 phophorylation controlled LD breakdown.
Conclusions: LD-maturation in hepatocytes in vivo and in vitro involves sequential
perilipin expression. Ballooned cells in steatohepatitis and hepatocellular carcinoma cells
overexpress small, newly formed LDs. Due to their central position in LD-biogenesis,
structure and break-down, perilipins may be interesting diagnostic and therapeutic targets
in steatotic liver disease.
Introduction: Hepatocellular steatosis is the most frequent liver disease in the western
world and may develop further to steatohepatitis, liver cirrhosis, and hepatocellular
carcinoma. We have previously shown that lipid droplet (LD)-associated proteins of the
perilipin family (perilipin 1-5) are differentially expressed in hepatocyte steatosis and
hepatocellular carcinoma (HCC) and that perilipin 1 is de novo expressed in chronic
steatosis, but only found in a minority of HCCs.
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HARNESSING THE THERAPEUTIC POTENTIAL OF
MICRORNAS INVOLVED IN THE PROGRESSION
AND REGRESSION OF HEPATOCELLULAR
CARCINOMA
Introduction: Hepatocellular carcinoma (HCC), the most common type of liver cancer, is
amongst the top three leading causes of cancer-related deaths worldwide with a median
survival of only six to eight months. HCCs are refractory to most existing therapeutics;
therefore, novel and more effective treatments need to be developed. The propensity of
hepatocytes to readily take-up nucleic acids raises the hope that small nucleic acid-based
drugs may have utility against liver cancer. Small non-coding microRNAs (miRNAs) are
one such class of nucleic acids that are emerging as promising therapeutic targets in
cancers. MiRNAs affect a wide range of cellular functions including growth, differentiation,
and death, and are deregulated in many human cancers including HCCs. Whether
miRNAs may affect tumor regression and the corresponding underlying mechanisms have
not been addressed.
Aims:
1. To identify novel microRNAs involved in HCC progression and regression by microRNA
expression profiling.
2. To study the effect of significantly and differentially expressed candidate miRNAs in
HCC.
Methodology: We have used liver samples collected from a conditional doxycyclineregulated c-MYC-driven liver tumor model at four specific stages – non-tumor, early
stage pre-tumor livers, full-blown liver tumors and regressing liver tumors – to carry out
miRNA profiling. This was followed by in-depth in silico analyses to identify significantly
deregulated and differentially expressed miRNAs that are altered during specific stages of
tumor progression and as tumors regress.
Results: We find that in addition to differential regulation of global miRNA pathways during
liver tumor development and regression, the four different groups analyzed also show
significantly distinct microRNA expression patterns and segregate separately. Based on
>2-fold differential regulation and a p<0.05, we identified potential tumor inhibitory or
promoting miRNAs that were differentially regulated between the full-blown tumors and
those in the regression time point.
Conclusions: Functional validation of these selected miRNAs further indicate that miRNAs
deregulated during HCC progression as well as when HCC tumors start to regress may
play significant roles in these processes. The discovery of novel miRNA-based biomarkers
and therapeutic targets is crucial for the development of novel therapeutic options for this
currently intractable disease.
Asha Balakrishnan 1 2, Andrei Goga 3 4, Michael P. Manns 1, Michael Ott 1 2
Gastroenterology, Hepatology and Endocrinology, Hannover Medical School,
2
Twincore Centre for Experimental and Clinical Infection Research, Hannover, Germany,
3
Department of Cell & Tissue Biology, 4Department of Medicine, University of California,
San Francisco, San Francisco, United States
1
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Manash P. Sarma 1, Giasuddin Ahmed 2, Subhash Medhi 1, Premashis Kar 1
1
Medicine, Maulana Azad Medical College, New Delhi,
2
Biotechnology, Gauhati University, Guwa, India
Table 1 (on page 88): Whole genome analysis of HBV genome in three different
geographical locations from HCC and asymptomatic HBV carriers (significant
mutations are tabulated).
[Salient feature of the Table : Novel mutations documented from the HCC cases in the
present study are tabulated. The are as follows: surface (132 stop), polymerase (frameshift
at codon 178), core (10 IàL, 41 SàT, 92 VàG, 96 NàT and 164 QàP) and X (33 PàS)
gene. These mutations have been reported for the first time and were found significantly
associated in HCC cases from the three regions]
(NI: North India, SI: South India, NEI: North East India, * ND: Not detected, aa: Amino acid
and NS: Not studied)
Introduction: Mutation throughout HBV genome is significantly associated with HCC and
varies with respect to its geographical location.
Aims: Study was aimed to analyse the whole genome of HBV in HCC cases from three
regions of India.
Methodology: 75 HBV related HCC cases were included. HBV DNA was amplified by six
sets of walking primers, amplicons were sequenced, submitted to http://www.ncbi.nlm.nih.
gov, translated into amino acid and aligned using BioEdit v7.0.9.
Results: 60, 15, 23 and 1 mutations were observed in PC/C, X, P and S genes respectively.
Mutations like 10IàL was significantly associated in HCC cases from NEI [(OR=5. 63) VS
SI] & [(p <0.01; OR=16.63) VS NI]. Mutations like 41SàT (p< 0.001; OR= 19.01), 92 VàG
(p< 0.001; OR= 19.01), 96NàT (p< 0.001; OR= 19.01) and 164QàP (OR= 3.085) were
significantly associated with HCC cases from NI. Widely reported 28 Wàstop mutation
was found in few HCC cases. 132àstop [(p= 0.004; OR= 5.479 VS SI) & [(p= 0.004; OR=
5.479) VS NEI] was interesting. 267IàN and 268DàT were exclusively to HCC from NEI
while 270S→F with NI. Reported drug mutants (80LàI, 236NàT, 169I→T and 181A→V)
were observed.
Conclusions: PC/C was most prone to mutation followed by P, X and S. Maximum
variation in HBV genome was observed in HCC cases from NI followed by NEI and SI.
Noval mutations in surface (132 stop), polymerase (178 frameshift), core (10 IàL, 41 SàT,
92 VàG, 96 NàT, 164 QàP) and X (33 PàS) gene needs advanced research.
VARIATION IN HEPATITIS B VIRUS GENOME IN
PATIENTS OF HEPATOCELLULAR CARCINOMA
FROM NORTHERN, SOUTHERN AND NORTH
EAST INDIA
100
Geographical Regions/
Types of patients →
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North India (25)
South India (25)
↓Genes and
Parameters(Total number
of mutation)
North East India (25)
North India (5)
HCC
(Numbers inside bracket indicate percentage of cases)
South
India (5)
101
North East
India (5)
Asymptomatic HBV carriers
(Numbers inside bracket indicate percentage of cases)
Surface Gene (1)
132 stop codon (52)
132 stop codon (16)
132 stop codon (16)
132 stop codon (20)
ND
ND
Pre S1[aa1-aa119]
ND
ND
ND
ND
ND
ND
Pre S2 [ aa119-aa174]
√ (52)
√ (16)
√ (16)
√ (20)
ND
ND
Major Surface [aa174aa400]
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
Second loop (aa139- aa
147)
√ (52)
√ (16)
√ (16)
√ (20)
ND
ND
Outside a and MHR
ND
ND
X gene (23)
31 SàA
(12)
76
AàS
(20)
78 SàC
(12)
89
LàV
(12)
135
GàS
(12)
31
SàA
(12)
33
PàS
(20)
78
SàC
(20)
89 LàV
(20)
31
SàA
(12)
33 PàS
(12)
78
SàC
(12)
89
LàV(12)
98
Làdeletion
(12)
135
GàS
(12)
31 SàA
(20)
135
GàS
(20)
113
Kàstop
(20)
139 HàE
(20)
ND
ND
Regulatory domain (aa 1aa 48)[ Strongly conserved
region]
√
√
ND
ND
ND
√
√
ND
ND
√
√
ND
ND
ND
ND
√
ND
ND
ND
ND
ND
XAP binding region (aa
61- aa 91)
ND
ND
√
√
ND
ND
√
√
ND
ND
√
√
ND
ND
ND
ND
ND
ND
ND
P 53 binding region (aa
101- aa 153)
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
√
√
√
ND
ND
178→deletion
(4)
267 IàN
(12)
268 DàT (12)
Polymerase gene (15)
ND
ND
√
178→deletion (100)
270S→F
(24)
ND
178→deletion
(20)
ND
ND
√
178→deletion
(20)
270S→F
(20)
ND
ND
Primase (aa 1-aa 178)
√
ND
√
√
ND
ND
√
ND
ND
ND
Spacer (aa 178-aa 304)
ND
√
ND
ND
√
√
ND
√
ND
ND
Catalytic determinant
(A-H)(aa 336-aa 680)
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
RNase(aa 680-aa 838)
Pre Core/Core (60)
NS
NS
10 IàL 28
(76)
WàStop
(20)
92
VàG
(88)
120
VàT
(88)
NS
96 NàT
(92)
10
IàL
(36)
NS
41 SàT 92
109
(36)
VàG(36) AàI(36)
10 IàL (16)
NS
NS
28
wàstop
(16)
148 LàS
(28)
155 IàT
(40)
NS
161 YàN
(28)
93 EàD
(100)
NS
109
AàV
(60)
120 VàT (60)
NS
ND
Inside a and MHR
First loop (aa 124-aa 137)
NS
10 IàL
(20)
30
MàR
(20)
Amino terminal (aa 1- aa
150)
√
√
√
√
√
√
√
√
√
√
√
ND
ND
ND
√
√
√
ND
√
√
Carboxyl terminal(aa 150aa 179)
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
√
√
√
ND
ND
ND
ND
ND
ND
Reliability of Phylogenetic approach to detect the HBV genotype
Based on X gene
√
√
√
√
√
√
Based on P gene
√
√
√
√
√
√
Based on C gene
√
√
√
√
√
√
Based on S gene
√
√
√
√
√
√
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CLINICAL IMPLICATIONS OF GST GENE
POLYMORPHISM, HEPATITIS B AND C VIRUS
INFECTION AND AFLATOXIN B1 AS THE
PREDISPOSING FACTORS OF HEPATOCELLULAR
CARCINOMA
1
NOTES
Mohammad Asim 1, Premashis Kar 1
Medicine, Maulana azad Medical College, Delhi, India
Aims: We aimed to evaluate whether the association of GSTM1/T1 gene polymorphisms
modifies the risk of Hepatocellular carcinoma (HCC) and what is its correlation with other
predisposing risk factors like Aflatoxin B1, alcohol intake, cigarette smoking and hepatitis
B and C infections. Methodology: It was a case-control study, included 254 HCC cases compared with
525 hospital-based age and sex matched cases of chronic liver disease without HCC as
controls from Indian population. The GSTM1 and GSTT1 genotypes were detected using
conventional multiplex PCR method. The level of aflatoxin B1 (AFB1)-N7-guanine adducts
in the urine samples collected at the recruitment of patients was examined by competitive
enzyme-linked immunosorbance assay.
Results: In this case-control study, we observed a positive correlation between age,
Aflatoxin B1, HBV and HCV infection, smoking habit of >20 packs/year, alcohol consumption
of >100 g/day and risk of liver cancer. There was a dose-response relationship between
serum levels of AFB-albumin adducts and risk of HCC. We found significantly increased
risk associated with GSTM1 null genotype (OR=3.49; 95% CI = 2.52 – 4.84) as well
as GSTT1 null genotype (OR=3.12; 95% CI=2.19 – 4.45), respectively. The biological
gradients between urinary AFB1-N7-guanine adducts level and HCC risk were observed
among HBV patients who had null genotypes of GST Ml and/or T1 but not among those
who had non-null genotypes. However, an increased risk of HCC was observed among
heavy drinkers with GSTM1 (OR=2.01; 95% CI =1.11-3.66). Further, cigarette smoking
showed a non-significant association with GSTT1 (OR=1.49; CI=0.69-3.25).
Conclusions: Our results suggest that the variants in low penetrance gene such as GSTM1
and GSTT1 are associated with an increased liver cancer risk. Further, an influence of
GSTM1/T1 null genotypes may contribute in the etiology of HCC in patients with higher
levels of AFB1-N7-guanine adducts, extensive cigarette and alcohol consumption,
respectively.
Introduction: The molecular epidemiology of Hepatocellular carcinoma (HCC) varies
among different geographic locations. Moreover, various genetic and etiological factors
might contribute to the development of HCC.
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105
1
Dipu Bharali 1, Manash P. Sarma 1, Premashis Kar 1
Medicine, Maulana Azad Medical College, New Delhi, India, New Delhi, India
Introduction: Hepatocellular carcinoma (HCC) is the third most frequent cause of
death in India. The most extensively studied risk factors for HCC are the association of
MTHFR1298A>C and 677C>T polymorphism.
Aims: This study is designed with an aim to find out the association of A1298C & C667T
polymorphism in HCC in comparison to liver diseases without cancer.
Methodology: A total of 105 cases diagnosed with HCC and 240 controls enrolled from
the Medicine and Gastroenterology OPD of Lok Nayak Hospital, Delhi and Madurai
Medical College, Tamil Nadu during July 2010 to September 2012. AASLD 2011 (Bruix
et.al.) evidence was followed to recruit HCC cases. Total 5 ml peripheral blood samples
were collected and Genomic DNA was isolated from blood followed by amplification and
RFLP using MboII and Hinf1 enzyme for 1298AC and 677CT respectively.
Results: Mean ages (±standard deviation) of HCC patients and controls were 56.55 (±
10.53) and 48.1 (±10.6) years, respectively. ALT and AST was significantly higher in HCC.
Out of 105 cases 12AA, 9AC and 80CC in comparison to 240 control (58AA, 26AC and
CC153). 1298CC are at higher risk in HCC than 1298AA. Out of 105 cases 12 CC, 58 CT
and 26TT in comparison to 240 control (17 CC, 156 CT and 63TT). 677TT genotype had
increased HCC risk.
Conclusions: Current study showed MTHFR1298CC genotype (O.R =1.87; p<0.5)
and 677TT genotype (OR=1.69, p<0.5) are at higher risk in HCC. A1298C and C677T
polymorphism may be an increased risk in HCC. The association needs further studies in
HCC patients.
Table I: Baseline characteristics
Characteristics
Cases
Control
Sex (male:female)
10:1
3:1
Age (years)
56.55 (± 10.53)
48.1 (±10.6)
Baseline value
Hb%
ALT (IU/ml)
AST (IU/ml)
Total Billirubin
5.2± 21.66%
84.44±35.04
107.66±35.99
2.4 ± 0.45
9.96 ± 2.7
22.6 ± 4.9
69.5± 17.2
1.4 ± 0.33
Cigarette smoking
Low dose
Average
Alcohol consumption
Low dose
Average
Personal & Family History of
chronic diseases
None
None
Table II: Distribution of the genotypes and allele frequencies of MTHFR A1298C
gene polymorphism in HCC cases and controls
Genotype
Cases (%)
(n=105)
Control (%)
(n=240)
P value
(95% CI)
Odd Ratio
(95% CI)
AA (normal)
12 (11.4%)
58 (24.1%)
0.00277
0.4058 [0.2- 0.777]
AC (risk)
9 (10.57%)
26 (8.8%)
0.269
0.772 [0.337- 1.68]
CC (risk)
80 (76.1%)
153 (63.75%)
0.0112
1.87[1.08-3.09]
MTHFR A1298C
Table III: Distribution of the genotypes and allele frequencies of MTHFR C677T
gene polymorphism in HCC cases and controls
Genotype
Cases (%)
(n=105)
Control (%)
(n=240)
P value
(95% CI)
Odd Ratio
(95% CI)
MTHFR C677T
CC (risk)
26 (28.76%)
63 (22.25%)
0.3896
0.924[0.539- 1.562]
CT (normal)
58 (55.23%)
156 (65.0%)
0.0445
0.665 [0.416-.064]
12(11.4%)
17(7.08%)
0.0971
1.69 [0.75- 3.68]
TT (risk)
ASSOCIATION OF
METHYLENETETRAHYDROFOLATE REDUCTASE
(MTHFR) A1298C & C667T GENE POLYMORPHISM
IN HEPATOCELLULAR CARCINOMA PATIENTS
FROM INDIA
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107
NUP155 IS REQUIRED FOR FULL INDUCTION OF
A SUBSET OF P53 TARGET GENES IN HCC
HYPOXIA INDUCES AN INCREASED NUMBER OF
PROGENITOR CELLS IN LATE BUT NOT IN EARLY
STAGES OF HEPATOCELLULAR CARCINOMA
Kerstin Holzer 1, Alessandro Ori 2, Juliane Winkler 1, Eva Eiteneuer 1, Martin Beck 2,
Peter Schirmacher 1, Stephan Singer 1 2
1
Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg,
2
Structural and Computational Biology, European Molecular Biology Laboratory,
69117 Heidelberg, Germany
Eliene Bogaerts 1, Femke Heindryckx 2, Anja Van den Bussche 1,
Anja Geerts 1, Hans Van Vlierberghe 1
1
Gastro-enterology and hepatology, Ghent university, Ghent, Belgium, 2Department of
Medical Biochemistry and Microbiology, Uppsala university, Uppsala, Sweden
Introduction: The nuclear pore complex (NPC) consists of approximately 30 different
nucleoporins (Nups) and is embedded in the nuclear envelope. Almost all signaling
cascades of oncogenic and tumorsuppressive pathways have to pass the NPC representing
the only gate between the cytoplasm and the nucleoplasm. Recent data suggest that NPC
components can modulate cancer-relevant pathways on different levels.
Introduction: Hepatocellular carcinoma(HCC) has a high incidence and is often detected
in advanced stages. Current treatment options are mostly based on nutrient deprivation by
decreasing angiogenesis, thus creating hypoxic conditions. This could lead to an altered
liver progenitor cell (LPC)-niche, creating a more aggressive, resistant tumor phenotype.
Understanding more about the influence of hypoxia on LPCs, is of vast importance to
improve hypoxia inducing therapies.
Aims: We aim to define the role of Nup155 in modulating the p53 pathway in HCC.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Methodology: In HepG2 cells (p53 wild-type) Nup155 was depleted by using two different
siRNAs followed by Nutlin- or Camptothecin(CPT) treatment to induce p53. Similar
experiments were performed in Hep3B-4Bv cells harboring a temperature-sensitive p53
mutant that acquires wild-type function by shifting the incubation temperature from 37° to
32°. The impact of Nup155 knockdown on p53 target gene expression was investigated
on protein and mRNA level by immunoblotting and qRT-PCR, respectively. Subsequent
mechanistic analyses involved p21 protein half-life experiments by using cycloheximide
treatment blocking mRNA translation. Potential alterations of p21 mRNA export were
tested by subcellular fractionation followed by qRT-PCR. To identify other p53 targets with
Nup155-dependency and to analyze global protein expression changes in the presence or
absence of Nup155 we conducted shotgun proteomics.
Results: Depletion of Nup155 in HepG2 cells by RNAi was followed by a significantly
reduced p21 protein accumulation upon Nutlin- and CPT-treatment. A selective impact on
p21 induction after Nup155 knockdown was also observed in Hep3B-4Bv cells and in a cell
line expressing p21 from a tet-sensitive cDNA construct (“tet-off”). Interestingly, p21 mRNA
induction was not significantly affected in these cells. Cycloheximide chase experiments did
not indicate obvious changes of p21 protein half-life upon Nup155 depletion. Furthermore,
p21 mRNA export was not significantly altered by Nup155 knockdown indicated by an
unchanged nuclear/cytoplasmic p21 mRNA-ratio. Hypothesizing that Nup155 may affect p21
mRNA translation we are currently performing polysomal fractionation. Shotgun proteomics
revealed distinct changes of protein expression after Nup155 depletion with the cytoplasmic
FMR1 interacting protein 2 (CYFIP2) being another p53 target dependent on Nup155.
Conclusions: We conclude that Nup155 regulates a subset of p53 target genes on a
post-transcriptional level by a different mechanism than previously described for Nup98.
Aims: Compare the effect of hypoxic conditions at different time points in
hepatocarcinogenesis to determine the time-dependent effect of hypoxia on LPC activation.
Methodology: HCC was induced in mice by weekly diethylnitrosamine (DEN) injections
(35mg/kg) for 22 weeks. To mimic a hypoxic reaction, pan-prolyl-hydroxylase-domain
inhibitor dimethyloxaloylglycine (DMOG) was administered twice a week (300µL,16mg/mL)
for 5weeks from week16-22, or therapeutically from week 22-27. Number of cytokeratin 19
(CK19) positive singular (LPCs) and ductular (cholangiocytes) cells per portal region were
counted and mRNA levels of the LPC markers prominin1(CD133), epithelial cadherin and
CK 7 and 19 were evaluated through qPCR analysis
Results: Both DMOG and PBS from week 16 to 22 in DEN induced mice resulted in
significantly increased numbers of ductular and singular cells compared to saline control.
Interestingly, on the RNA level, DMOG from week 16 to 22 only caused upregulation of
CD133, while in the PBS group, all LPC markers were significantly upregulated compared
to saline control. Even though no significant differences could be marked between PBS
and DMOG groups, increased stabilisation of the hypoxia inducible factor seems to play a
negative role in LPC activation and proliferation at this early stage.
Alternatively, therapeutically induced DMOG resulted in a significant increase in ductular
and singular CK19+ cells compared to both PBS and saline control. After 22 weeks of
DEN, 5w of PBS treatment showed no increase in the number of LPC or ducts in portal
areas, qPCR analysis did show CK19 and CD133 significantly upregulated compared to
saline control. In the therapeutic DMOG group , mRNA levels of all LPC markers were
significantly increased compared to saline control and CK7 compared to PBS.
Conclusions: We show timing to be essential in hypoxia mediated LPC activation and
differentiation in HCC. Possibly the lack of LPC response in earlier stages could unveil a
safe window for hypoxia inducing treatments.
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HUMAN AMNIOTIC MEMBRANE-DERIVED
PROTEINS DISPLAY ANTICANCER ACTIVITY IN
Introduction: Hepatocellular carcinoma (HCC) is a highly fatal primary liver malignancy.
HCC low survival rate depends, in part, on the resistance of this type of cancer to
conventional therapies. The potential of human amniotic membrane (hAM) in the treatment
of liver diseases has been explored in the past decade, particularly in the treatment of
hepatic cirrhosis and fibrosis. In fact, several studies indicate that in a near future hAM
may become one of the biomaterials for the treatment of liver diseases. However, until
now, there are no studies exploiting the application of hAM for the treatment of HCC.
Aims: The aim of this study is to evaluate the effect of hAM protein extracts (hAMPE)
in protein and DNA synthesis in three HCC cell lines. DNA induced-damage will be also
evaluated.
Methodology: hAM were obtained from healthy women with informed consent according
to the guidelines of Ethical Committee of Coimbra Hospital and University Centre
(Coimbra, Portugal). After the receipt, hAM were washed with phosphate buffered solution
and subjected to mechanical actions in order to extract proteins, which were quantified
using Nanodrop®. To study the effect of hAMPE in HCC, studies were performed in three
cell lines: HuH7 (mp53), HepG2 (wp53) and Hep3B2.1-7 (p53 under-expressed). Cells
were incubated with 1µg/µL of hAMPE during 72h. After this period, sulforhodamine B
and crystal violet assays were performed to assess protein and DNA synthesis. In order to
evaluate DNA damage, comet assay was carried out. Results: After treatment with hAMPE, protein synthesis decreased 85% in Hep3B2.1-7,
89% in HuH7 and 91% in HepG2 cell line. Regarding DNA synthesis, this value decreased
75% in Hep3B2.1-7, 66% in HepG2 and 41% in HuH7 cell line after treatment. Through
comet assay it was observed that HepG2 tail moment (product of tail length and total DNA
fraction in tail) increased 64 times. The tail moment of Hep3B2.1-7 increased 3 times.
There is no difference between hAMPE treated and untreated HuH7 cells tail moment. Conclusions: These results show that the treatment of HCC cell lines with hAMPE
decreases the protein and DNA synthesis, as well as increases the DNA damage,
suggesting that hAMPE may have a promising role in the HCC therapy.
Ana C. Mamede 1 2 3, Sara Guerra 1 4, Mafalda Laranjo 1 3, Ana F. Brito 1 3,
Kathleen Santos 1, Maria J. Carvalho 1 3 5, José G. Tralhão 1 6, Paulo Moura 5,
Ana M. Abrantes 1, Cláudio J. Maia 2, Maria F. Botelho 1 3
1
Biophysics Unit, CIMAGO, Faculty of Medicine, University of Coimbra, Coimbra,
2
CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã,
3
IBILI, Faculty of Medicine, University of Coimbra, Coimbra, 4Faculty of Sciences and
Technology, University of Coimbra, Coimbra, 5Obstetrics Service, Coimbra Hospital and
University Centre, Coimbra, 6Surgical Department - Surgery A, Coimbra Hospital and
University Centre, Coimbra, Portugal
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NEW INSIGHTS IN HOXA13 AND HOTTIP ROLE AS
PROGNOSTIC FACTORS IN HEPATOCELLULAR
CARCINOMA
NOTES
Luca Quagliata 1, Matthias Matter 1,Salvatore Piscuoglio 1, Tujana Boldanova 2,
Luigi Tornillo 1, Markus Heim 2, Clemente Cillo 3, Luigi Terracciano 1
1
Institute of Pathology - University Hospital Basel, Switzerland, 2Department of
Biomedicine, Hepatology Laboratory, University Hospital Basel, Basel, Switzerland,
3
Federico II University Medical School, Naples, Italy
Introduction: Previously, using gene expression data, we observed that among the
transcriptional factors family of HOX genes, HOXA13 is highly deregulated in hepatocellular
carcinoma samples (HCC). HOTTIP is a recently described lncRNA (long non-coding RNA)
located at the 5’ end of the HOXA locus (in physical contiguity with HOXA13) that binds the
WDR5/MLL complexes driving gene transcription along the entire HOXA locus. Lately, we
demonstrated for the first time that HOTTIP expression directly correlates with HOXA13
levels in HCC. Moreover, we reported that HOTTIP/HOXA13 deregulation as a key feature
in HCC development, controlling liver cancer cells apoptosis. Finally, we outlined HOTTIP/
HOXA13 expression levels as predictive markers of HCC patients’ outcome and disease
progression. Aims: Based on the analysis of Chromatin-Immunoprecipitation (ChiP) data, here we
further corroborate our findings by analysing a large cohort of HCC samples evaluating
HOXA13 levels and selected metastasis-associated genes directly regulated by HOXA13.
Methodology: A liver specific TMA (tissue microarray) has been immunohistochemically
stained using HOXA13, CK-7, CK-19, E-Cad (CDH1), Galectin-3, Prune and Nm23-H2
human-specific Abs. This TMA comprises a total of n=305 specimens, n=82 from normal
liver tissue, n=108 collected from cirrhotic patients and n=115 from HCCs. Staining have
been scored by expert pathologists and protein levels have been correlated with patients’
clinical-pathological data, including patients’ survival. Results: HOXA13 is altered in 41% of analysed samples, further confirming our previous
reports. In addition, again corroborating our gene expression-based data, HOXA13
immunohistochemistry (IHC) analysis revealed that higher HOXA13 levels are associated
with poorer patients’ outcome and higher grading (both Edmondson and BCLC).
Increased HOXA13 expression is linked with high liver stem progenitor markers levels,
CK-7 and CK19. Furthermore, our data revealed that high HOXA13 expression is coupled
with diminished levels of E-Cad and increased Gal-3, Prune and Nm23-H2, providing a
molecular basis for its clinical association with metastasis formation in HCC. Conclusions: Here we show that HOXA13 IHC-based protein levels can reliably predict
HCC disease outcome, thus further confirming our previous gene expression data
and making HOXA13 a suitable marker for liver carcinogenesis evaluation. Additional
experiments aiming to elucidate HOXA13 role in promoting metastasis are urgently
needed. BASIC SPEAKERS’ ABSTRACTS
EASL HCC SUMMIT
CIRCULATING MICRORNAS PROFILES IDENTIFY
CIRRHOTIC PATIENTS WITH HCC
CASPASE-3 TARGETING: A FURTHER TILE
SUSTAINING THE ANTI-APOPTOTIC ROLE OF
MIR-221 IN HEPATOCELLULAR CARCINOMA
Francesca Fornari 1, Manuela Ferracin 2, Maddalena Milazzo 1, Davide Trerè 3,
Sara Marinelli 1, Laura Venerandi 1, Alberto Borghi 1, Clarissa Patrizi 1, Francesco G. Foschi 4,
Massimo Negrini 2, Giuseppe F. Stefanini 4, Luigi Bolondi 1, Laura Gramantieri 1
1
Dipartimento di Medicina Clinica e Centro di Ricerca Biomedica Applicata, Policlinico
Universitario S.Orsola-Malpighi, Bologna, 2Dipartimento di Medicina Sperimentale e
Diagnostica e Centro Interdipartimentale per la Ricerca sul Cancro, Università di Ferrara,
Ferrara, 3Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Policlinico
Universitario S.Orsola-Malpighi, Bologna, 4Dipartimento di Medicina Interna,
Ospedale per gli Infermi, Faenza, Italy
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113
Francesca Fornari 1 , Maddalena Milazzo 1, Clarissa Patrizi 1, Elisa Callegari 2,
Silvia Sabbioni 2, Marzia Galassi 1, Massimo Negrini 2, Laura Gramantieri 1, Luigi Bolondi 1
1
Dipartimento di Medicina Clinica e Centro di Ricerca Biomedica Applicata, Policlinico
Universitario S.Orsola-Malpighi, Bologna, 2Dipartimento di Medicina Sperimentale e
Diagnostica e Centro Interdipartimentale per la Ricerca sul Cancro,
Università di Ferrara, Ferrara, Italy
Introduction: The performance of available circulating biomarkers in the screening and
diagnostic settings of HCC is sub-optimal, therefore both EASL and AASLD guidelines
identify the field of circulating non invasive biomarkers as a topic in which research efforts
should be perfused. Introduction: MicroRNA-221 (miR-221) is over-expressed in several cancer types
including hepatocellular carcinoma (HCC). It was previously demonstrated that miR-221
reduced apoptotic cell death through the direct targeting of pro-apoptotic genes, such as
BMF and PUMA. MiR-221 oncogenic role has been proved by our group in a liver-specific
miR-221 transgenic model, suggesting antagomiR-221 as a possible therapeutic tool for
the treatment of HCC.
Aims: The aim of this study was to test the performance of circulating microRNAs in
cirrhotic patients without liver lesions as well as in cirrhotic patients with small/unifocal and
advanced hepatocellular carcinoma (HCC).
Aims: This study aims to further characterize miR-221 involvement in the regulation of
apoptotic cell death and response to treatments throught the direct regulation of caspase-3
expression.
Methodology: The study was designed as a two phase epidemiological study, with a
hypothesis generating step conducted by means of microarray assay, specifically aimed
at discovering a genome-wide aberrantly regulated circulating miRNA panel able to
differentiate cirrhotic patients (N. 11) from HCC (N. 12) patients. The validation phase was
performed by qRT-PCR specific for the selected miRNAs in an independent series of 81
consecutive patients with cirrhosis (N. 20), unifocal/small HCC (N. 28) and intermediateadvanced HCC (N. 33). Logistic regression was used to assay circulating factors
independently associated with HCC. ROC curves were constructed and the AUC was
calculated, to explore the performance of specific miRNAs as diagnostic tests for HCC.
Methodology: An in vitro functional analysis was used to investigate miR-221 modulation
of caspase-3 expression in HCC cell lines. Luciferase-reporter assay was performed to
evaluate the interaction between miR-221 and its complementary binding site in caspase-3
mRNA. Chemiluminescent assays, FACS and Western blot analysis were performed to
evaluate apoptotic cell death in miR-221 or anti-miR-221 transfected HCC cells following
Doxorubicin treatment. Real Time PCR and Western blot analysis were employed to
analyse miR-221 and caspase-3 expression in liver tissues of miR-221 transgenic model.
Results: A signature of circulating miRNAs emerged as differentially expressed between
patients with LC and HCC in the training set. This miRNAs signature was confirmed in the
validation set where it differentiated patients with cirrhosis from patients with HCC. Higher
serum levels of specific miRNAs turned out to be an independent factor for the presence
of early HCC or of HCC with macro-vascular invasion. The AUC of a panel of selected
circulating miRNAs was higher than that of AFP.
Conclusions: Despite these results are very preliminary, this two stage study demonstrated
that circulating microRNAs deserve much attention as potential non invasive biomarkers
for HCC in the diagnostic setting.
Results: Western blot analysis and luciferase reporter assay showed a direct regulation
of caspase-3 target by miR-221 in different HCC cell lines. Annexin-V/FACS analysis
displayed an increase of apoptotic cell death in miR-221 silenced Hep3B and SNU449
cells following Doxorubicin challenge. In line with this data, an increase of caspase activity
and pro-apoptotic genes expression was observed in the same settings. An ex vivo
analysis showed a significant decrease of caspase-3 protein levels in liver tissues of miR221 transgenic mice with respect to wild type control animals.
Conclusions: MiR-221 regulates apoptotic cell death of HCC cells through the simultaneous
inhibition of caspase-3 protein and other pro-apoptotic molecules. Our data provide an
additional molecular rationale for miR-221 silencing as a novel therapeutic strategy, alone or
in combination with anti-cancer drugs, for the treatment of advanced HCCs.
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115
FUNCTIONAL CONSEQUENCES OF EPIGENETIC
REGULATED TUMOUR SUPPRESSOR MIRNA449-FAMILY IN HEPATOCELLULAR CARCINOMA
NOTES
Maria Sandbothe 1, Reena Buurman 1, Mareike Bütepage 1,
Brigitte Schlegelberger 1, Britta Skawran 1
1
Institute for Cell and Molecular Pathology, Hannover Medical School,
30623 Hannover, Germany
Aims: We hypothesized that the altered expression of miRNAs due to chromatin
remodeling may play a fundamental role in hepatocarcinogenesis.
Methodology: Therefore, we induced histone acetylation by HDAC inhibitors trichostatin
A (TSA) and by siRNA silencing of HDAC1-3, respectively, to identify deregulated miRNAs
and their target genes in four HCC cell lines (HepG2, HLE, HLF, and Huh7) and two
immortalized liver cell lines (THLE-2 and THLE-3). Differentially expressed mRNAs and
miRs were identified by expression profiling.
Results: Upon histone acetylation, the tumor suppressor miRNA-449a was reactivated
and its target gene c‑MET downregulated, which induced strong effects on proliferation
and survival in HCC. MiR-449a together with miR-449b and miR-449c belongs to the
relatively unknown miR-449 family which is coded in the second intron of the CDC20B
gene. So far, only a few direct targets of miR-449a have been validated. MiR-449b
and miR-449c have not yet been analyzed in depth. The miR-449 family shares seed
sequences and target genes with the p53-inducible miR-34 family. Using qPCR we also
found that miR-449b and miR-449c are significantly up-regulated after HDAC inhibition,
in contrast to the p53-inducible miR-34 family. Interestingly, our first results indicate that
miR-449b and miR-449c reduce proliferation and strongly promotes apoptosis in HCC cell
lines after HDAC inhibition.
Recently, we could show transfection of miR-449a, b and c into the cell lines HLE led to
a significantly reduced expression of BCL9-2 in RNA. BCL9-2 increases the expression
of a subset of canonical Wnt target genes but also regulates genes that are required for
initiation of colon cancer.
Conclusions: In particular we expect that histone deacetylation and many putative target
genes of epigenetically deregulated tumor suppressor miR-449 family can be targeted by
new therapeutic agents.
Introduction: Chromatin remodeling is a common hallmark in human tumor cells and this
process strongly alters the transcription of many genes and microRNAs (miRNAs). We
could show that histone deacetylases (HDAC1-3) are consistently up-regulated in primary
hepatocellular carcinoma (HCC). Selected miRNAs have been shown to play important
roles in carcinogenesis. Until now, it is largely unknown which miRNA genes are altered
due to histone deacetylation in HCC.
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117
UNSHIELDING IGF-II MRNA BY TARGETING
IGF2BP-2 AND 3 THROUGH DEMETHYLATING
THE MICRO-RNA LET-7A-3 GENE IN
Introduction: Insulin-like Growth Factor-II (IGF-II) is a strong mitogen with established
oncogenic effects in Hepatocellular Carcinoma (HCC). IGF-II expression is regulated by
a family of three RNA-binding proteins: the IGF-II mRNA-Binding Proteins (IGF2BPs).
IGF2BPs have varying effects on IGF-II. IGF2BP-1 induces IGF-II mRNA decay while
IGF2BP-2 and 3 shield IGF-II mRNA against decay. Still, the IGF-II-IGF2BPs interplay
has never been investigated in HCC. Our in silico analysis predicted miR-let-7a to target
IGF-II and both IGF2BP-2 and 3 with promising scores. Our previous findings showed that
the tumor suppressor let-7a is down-regulated in HCC. We found that hypermethylation of
the let-7a-3 gene is responsible for this down-regulation. In addition, we found an inverse
correlation in the expression of let-7a and IGF-II, which highlights the regulatory effect(s)
let-7a might exert on IGF-II in HCC.
Aims: We aimed at investigating the regulatory role of IGF2BP-2 and 3 on IGF-II. In
addition, we aimed to investigate if the expression of let-7a can be relieved by the
demethylating drug, decitabine. Also, the regulatory impact of let-7a on IGF-II needed to be
further validated. Last but not least, the regulation of IGF2BP-2 and 3 in HCC by miRNAs
is still obscure, and thus we aimed at investigating the impact of let-7a on IGF2BP-2 and
3 and hence on IGF-II expression stability.
Methodology: The HCC cell lines Huh-7 were cultured, followed by: (1) transfection
with either: (a) let-7a mimics, (b) let-7a inhibitors, (c) siRNAs against IGF2BP-2 and 3,
or (2) treatment with decitabine for 5 days. That was followed by total RNA extraction,
followed by reverse transcription to complementary DNA (cDNA) and amplification and
quantification with Real-time PCR.
Results: Knocking down IGF2BP-2 and 3 resulted in a significant down-regulation in IGFII mRNA expression. In addition, demethylation caused significant up-regulation in let-7a
and concomitant significant down-regulation in IGF-II. Also, forcing the expression of let7a resulted in a significant down-regulation in IGF-II mRNA. Forcing let-7a expression
resulted in significant down-regulation of both IGF2BP-2 and 3 while let-7a inhibitors
resulted in significant restoration of their expression.
Conclusions: IGF-II is shielded and stabilized by IGF2BP-2 and 3 in HCC. In addition,
we proved that let-7a is an epigenetically regulated miRNA. Also, let-7a has an indirect
impact on IGF-II through targeting the IGF-II regulators, IGF2BP-2 and 3.
Amr Waly 1 , Hend El Tayebi 1, Karim Hosny 2, Gamal Esmat 3, Ahmed Abdelaziz 1
1
The Molecular Pathology Research Group, German University in Cairo,
2
Department of General Surgery, Faculty of Medicine, Cairo University,
3
Department of Endemic Medicine and Hepatology, Cairo University, cairo, Egypt
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UPREGULATION OF SMAD7 EXPRESSION
IN HEPATOCELLULAR CARCINOMA AS A
POTENTIAL MECHANISM FOR LOSS OF
CYTOSTATIC TGF-BETA EFFECTS
Introduction: TGF-beta is critical in tumorigenesis of HCC with context-dependent
effects. It is accepted that the TGF-β signaling inhibitor Smad7may also act as tumorigenic
mediator in HCC, while its precise role remains unclear.
Aims: We investigated the expression profile of Smad7 in human HCC and its correlation
to clinicopathological parameters. We studied regulatory mechanisms of Smad7 induction,
its functional role in HCC and its impact on Sorafenib sensitivity.
Methodology: Smad7 expression in 140 paired human HCC patient samples was analyzed
by q-PCR and correlated to e.g. HCC etiology and survival. The role of Smad7 expression
levels in HCC was studied in HCC cell lines and FAH knockout mice. Methylation analysis
of the Smad7 promotor as well as overexpression and knockdown of transcription factor
YB1 were used to analyze Smad7 expression regulation.
Results: In 58.5% of 140 HCC samples we found Smad7 upregulation compared to
adjacent non-tumor tissue of the same patient correlating with HBV infection, tumor size
and grade. Smad7 was also upregulated in HCC tissue vs `normal´ liver tissue from nonHCC patients.
Although the above correlations were not verified when using normal tissue as reference,
Smad7 overexpression indicated a better prognosis for HCC patients with tumors > 5cm
and without cirrhosis. In TGF-beta responsive Huh7 cells, Smad7 overexpression inhibited
TGF-beta induced proliferation control. Hepatocyte specific Smad7 overexpression
increased proliferative activity in FAH knock out mice in the early phase of liver damage.
Knock down of intrinsically high Smad7 levels in TGF-beta insensitive FLC-4 cells using
RNAi partially restored the cytostatic response of FLC-4 to TGF‑beta.
We excluded differential methylation of a GC rich Smad7 promoter region as mechanism
for Smad7 upregulation in HCC. Instead we found involvement of the YB1 transcription
factor. Knock down of YB1 reduced Smad7 expression in Huh7 and FLC-4 cells and
overexpression of YB1 was found in 27 out of 28 patients with high Smad7 levels.
Immunofluorescence showed co-staining of Smad7 and YB1 in HCC samples of patients.
Finally, increased Smad7 expression sensitizes Huh7 cells for anti-proliferative effects of
Sorafenib.
Conclusions: Our results suggest that Smad7 upregulation may represent one
mechanism for loss of cytostatic TGF-β effects in early hepatocellular carcinoma. There
is evidence that Smad7 expression can be a biomarker in subgroups of HCC patients for
disease prognosis and Sorafenib treatment.
Teng Feng 1, Johanna Dzieran 1, Xing Gu 2, Hong L. Weng 1, Silke Marhenke 3,
Thomas S. Weiß 4, Otto Kollmar 5, Heike Allgayer 6, Ulrich Lehmann 7,
Christoph Meyer 1, Steven Dooley 1, Nadja M. Meindl-Beinker 1
1
Department of Medicine II, Section Molecular Hepatology, Medical Faculty Mannheim,
Heidelberg University, Mannheim, Germany, 2Department of Laboratory Medicine,
Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai,
China, 3Department of Gastroenterology, Hepatology and Endocrinology, Medical School
Hannover, Hannover, 4Department of Pediatrics and Juvenile Medicine, Center for Liver
Cell Research, University of Regensburg Hospital, Regensburg, 5Department of General,
Visceral, Vascular and Pediatric Surgery, University of Saarland, Homburg/Saar,
6
Department of Experimental Surgery, Medical Faculty Mannheim, Heidelberg University,
Mannheim, 7Institute of Pathology, Medical School Hannover, Hannover, Germany
CONTROL OF HEPATIC STELLATE CELLS OF
LIVER HEALTH AND DISEASE
Carolin Mogler 1 2, Matthias Wieland 2, Junhao Hu 2, Anja Runge 2,
Vijayshankar Sivanandam 2, Claudia Korn 2, Tabea Arnsperger 2, André Neumann 3,
Thomas Longerich 1, Peter Schirmacher 1, Hellmut Augustin 2
1
2
Institue of pathology, DKFZ, 3Division of Vascular Biology and Tumor Angiogenesis,
Medical Faculty Mannheim , Heidelberg, Germany
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121
EPIGENETIC REPROGRAMMING MODULATES
MALIGNANT PROPERTIES OF HUMAN LIVER
CANCER CELLS
Chiara Raggi 1, Valentina M. Factor 1, Daekwan Seo 1, Matthew C. Gillen 1,
Agnes Holczbauer 1, Jens U. Marquardt 1, Jesper B. Andersen 1, Snorri S. Thorgeirsson 1
1
Laboratory of Experimental Carcinogenesis, Center for Cancer Research, National
Cancer Institute, NIH, Bethesda, United States
Introduction: Endosialin is expressed by tumor-associated pericytes and stromal
myofibroblasts, identifying it as a marker of the activated mesenchymal lineage.
Introduction: Modulation of cellular fate in solid tumors is defined to a large extent by
DNMT1-regulated epigenetic machinery and cellular and non-cellular constituents in the
tumor-initiating cells (TICs) niche.
Aims: We consequently hypothesized that Endosialin may be functionally involved
in organ fibrosis, a process critically dependent on the recruitment and proliferation of
activated mesenchymal cells.
Results: In line with this hypothesis, expression profiling experiments of human liver tissue
samples revealed that Endosialin expression was significantly upregulated during liver
fibrosis and cirrhosis. Endosialin expression was most pronounced in portal fibroblasts and
hepatic stellate cells (HSC), which localized along the sinusoids in the space of Dissé and
also forming scar tissue of fibrotic septa and cirrhotic nodules. To mechanistically study
the role of Endosialin during liver fibrogenesis, we pursued CCl4-induced liver fibrosis
experiments in wildtype and Endosialin-deficient mice. CCl4-mediated liver damage was
similar in both genotypes. Surprisingly though, hepatocyte proliferation during early stages
of liver fibrosis was significantly elevated in the absence of Endosialin. To study proliferative
liver regeneration more directly, we pursued partial hepatectomy experiments and traced
hepatocyte proliferation during the rapid phase of liver regeneration. Proliferation of
hepatocytes during early liver regeneration was dramatically enhanced in Endosialindeficient mice suggesting a role of Endosialin in the regulation of proliferative processes.
Subsequently, Endosialin deficient mice were crossed into a virus inducible mouse
model of hepatocellular carcinoma (HCC) to investigate the onset and the progression
of hepatocarcinogenesis. According to our results Endosialin deficiency resulted in more
detectable tumor nodules and higher overall tumor burden.
Conclusions: We therefore postulate that Endosialin on HSC might function as negative
regulator of liver cell proliferation.
Aims: Current study examines the significance of the DNMT1-cellular interactions in
reprogramming of TICs properties.
Methodology: Seven HCC cell lines were plated in 2D culture at various cell densities
and exposed to a transient nontoxic dose of a DNMT1-inhibitor Zebularine (ZEB). After a
3-day treatment, cells were cultured in 3D non-adherent condition in ZEB- and serum-free
media to generate primary spheres (G1) which were then passaged through generation
G5. Differences in long-term self-renewal, gene expression, tumorigenicity and metastatic
potential of G1-G5 spheres were examined.
Results: Transient exposure to ZEB produced the differential cell density-depended
responses in 5/7 tested HCC cell lines. In cells grown at low density (LD), ZEB caused a
remarkable increase in G1 sphere formation. This effect persisted through G5. In striking
contrast, untreated LD cells failed to form primary spheres while the sphere forming
potential of high density (HD) and HD ZEB-treated (HDZ) cells rapidly decreased over
the first 3 generations. Likewise DNMT1 depletion by shRNA promoted acquisition of
self-renewal potential in LD cells. The increase in sphere forming potential of LDZ cells
strongly correlated with a stable overexpression of cancer stem cell-related markers and
key genes involved in self-renewal and epithelial-mesenchymal transition. Moreover, when
dissociated LDZ, HD and HDZ spheres were injected subcutaneously into NOD/SCID mice,
LDZ cells generated tumors more rapidly and were more metastatic. Both gene reactivation
and tumorigenicity progressively increased from G1 to G4. Tumors derived from G1-G4
LDZs were also increasingly more vascular. Global transcriptome analysis of LDZ spheres
at G1-G4 confirmed that a LDZ signature was enriched in genes associated with oncogenic
signaling pathways and could predict clinical outcome of liver cancer patients.
Conclusions: DNMT1 inhibition combined with cellular context-dependent cues results in
reprogramming of hepatic TICs which persists long after the drug removal and affects their
fate. These findings may provide a new venue for therapeutic strategy in HCC patients.
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INVESTIGATING HEPATITIS C
VIRUS-ASSOCIATED PATHOGENESIS AND
CARCINOGENESIS IN AN IMMUNOCOMPETENT
SMALL ANIMAL MODEL
NOTES
Daniel Rupp 1, Beate Straub 2, Mauricio Berriel Diaz 3, Thomas Longerich 2,
Florian Heinzmann 4, Rahel Klein 1, Lars Zender 5, Dirk Grimm 6, Stephan Herzig 3,
Volker Lohmann 1, Ralf Bartenschlager 1
1
2
Department for Infectious Diseases, Institute of Pathology, University of Heidelberg,
3
German Cancer Research Center, Heidelberg, 4Chronic Infections and Cancer,
Helmholtz Centre for Infection Research, Braunschweig, 5University of Tübingen,
Tübingen, 6Bioquant, University of Heidelberg, Heidelberg, Germany
Introduction: Chronic hepatitis C virus (HCV) infection still is a major health burden
affecting 130 to 170 million people world wide, which are at high risk to develop liver cirrhosis
and hepatocellular carcinoma (HCC). Thus far, there is no immunocompetent small animal
model allowing investigation of HCV-associated pathogenesis and carcinogenesis.
Aims: In this study we aim to establish an immunocompetent small animal model allowing
characterization of viral and host determinants that are involved in key processes of HCVassociated pathogenesis and carcinogenesis.
Methodology: Expression cassettes encoding for various HCV proteins that are derived
from different genotypes are constructed and analyzed for pathogenetic properties in
vivo. In a first proof of principle study constructs based on the pCAGGS-vector encoding
HCV core derived from genotype 2 and genotype 3 were delivered into the liver via
hydrodynamic tail vein injection. This vector allows integration into the host genome via
transposable elements and thus, long term expression of the viral gene.
Results: Although histopathological investigation revealed steatosis in one out of four mice
inoculated with the genotype 3-containing core construct 5 to 12 months after injection,
fibrosis, cirrhosis or tumor formation was not observed in these animals. Results obtained
by Western blot and PCR suggest that this is most likely due to very low frequency of cells
supporting long-term expression of the viral protein.
Conclusions: To overcome this limitation, we currently elucidate HCV expression in mice
by using vectors based on adeno-associated viruses (AAV). Their delivery is much less
stressful for the cardiovascular system, as compared to hydrodynamic tail vein injection.
Importantly, highly efficient liver-specific gene delivery and expression is mediated via
capsid proteins derived from AAV8 and a liver-specific promoter, respectively. Currently
we are elucidating possibilities offered by a flexible AAV-based transduction system to
investigate HCV-associated mechanisms contributing to pathogenesis and carcinogenesis
in a genotype-specific manner.
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QUANTITATIVE PHOSPHOPROTEOME ANALYSIS
OF HUMAN HEPATOCELLULAR CARCINOMAS
DEVELOPED ON NON-FIBROTIC LIVER
Conclusions: We have identified phosphopeptides signatures in human samples of
nfHCC that led to the identification of a deregulated PDK-dependent network in those
tumors. The elucidation of the functional causes and consequences of such deregulation
is ongoing.
Luc Negroni 1, Daniela Arma 2, Saïd Taouji 2, Violaine Moreau 2, Charles Balabaud 2,
Paulette Bioulac-Sage 2, Jean-Marie Schmitter 1, Jean Rosenbaum 2, Eric Chevet 2
1
UMR 5248, Centre de Génomique Fonctionnelle, Université de Bordeaux, 2INSERM
U1053, Université Bordeaux Segalen, Bordeaux, France
Introduction: Ten to 40% hepatocellular carcinoma (HCC) arise on non-cirrhotic liver,
including 5% on non-fibrotic liver (nfHCC). These tumors provide an interesting model
for the analysis of the hepatocarcinogenesis pathways without the confounding factors
associated with cirrhosis. Carcinogenesis has been often associated with the deregulation
of signaling pathways that involve a number of phosphorylation cascades. Quantitative
phosphoproteomics allows the global analysis of these events, but has never been used
in a large number of human HCC. Aims: Our aim was to use quantitative phosphoproteomics on a series of nfHCC samples,
thereby allowing the discovery of deregulated kinase cascades, and to validate some
of those on larger cohorts using medium throughput analytical tools (Alphascreen® and
AMMP®).
Fig. 1. Hierarchical clustering of the livers biopsies with phosphopeptides common to 18
nfHCC and significatively deregulated. A red color indicates over-representation, a green
color, under-representation.
Methodology: Tumors were defined as nfHCC when the non-tumor livers were classified
as F0 or F1 according to METAVIR. We used 18 surgical samples from nfHCC, and 6
samples of histologically normal liver as controls. Proteins were extracted and digested
with trypsin, phosphopeptides were purified on Ti02 matrices and labeled with iTRAQ
8-plex reagents for quantitative analysis on LTQ-Orbitrap XL. In addition 80 tumor and 20
non–tumor samples were analyzed for the activation status of select signaling pathways
such as ERK using Alphascreen® and AMMP®.
Results: A total of 315 different phosphopeptides were quantified in the whole series
of samples, and the analysis was focused on the 65 that were common in the 3 series
of 6 tumors. Non-supervised hierarchical clustering separated the HCC from the nonHCC groups (Fig. 1). Nineteen phosphopeptides were significantly more represented in
nfHCC than in controls, and 15 less abundant. Motif analysis showed that a consensus
site for proline-directed kinases (PDK) was significantly enriched (p < 0.05, Fig. 2) in overrepresented phosphopeptides. Because MAPK are prototypic PDKs and are deregulated
in many cancers, we analyzed their activation in a series of 80 nfHCC as compared to 20
non-tumor samples and found an overall increased activity in nfHCC samples.
Fig. 2. Analysis using pLOGO software of consensus phosphorylation sites showing
enrichment in SP sites in over-represented phosphopeptides.
EASL HCC SUMMIT
LONG-TERM IMPROVEMENT OF MORTALITY
WITH REDUCED HEPATOCELLULAR
CARCINOMA (HCC) INCIDENCE IN PATIENTS
WITH CHRONIC HEPATITIS B VIRUS (HBV)
INFECTION TREATED WITH NUCLEOTIDE
ANALOGUES
GLYCOMIC ANALYSIS OF SAFFRON-BASED
PROTECTION AGAINST HEPATOCELLULAR
CARCINOMA
Yuki Matsumura 1, Yuki Nakada 1, Mina Hamano 1, Miho Chiba 1,
Masafumi Naito 1, Toshifumi Ito 1
1
Osaka Koseinenkin Hospital, Osaka, Japan
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Introduction: Chronic HBV infection could lead to both liver cirrhosis (LC) and HCC.
NAs like lamivudine, adefovir, and entecavir were recently administered for chronic HBV
infected patients.
Aims: Aim of this study was to clarify contribution to mortality improvement and HCC
incidence reduction referring to characteristics of clinical backgrounds and laboratory
findings with applying NAs for chronic HBV infection.
Methodology: We excluded patients developing HCC within 6 months after the NAstreatment. One hundred chronic HBV infected patients taking NAs after January 2001
were enrolled for this retrospective study. We analyzed clinical backgrounds, mortality,
HCC occurrence, and changes in laboratory data.
Results: The enrolled patients consisted of 63 chronic hepatitis (CH) patients and 37
LC patients. In 50 months median observed period, 19 patients developed HCC by
September 2013, dividing those patients into two groups, non-HCC and HCC. Their
baseline characteristics were not different. The laboratory data were improved one year
after NAs administration comparing to baseline screening with statistical significance. The
cumulative HCC incidence rates at 5 years were 13% and 43% for the CH patients and
the LC patients, respectively (P < 0.001). No HCC have developed over 4 years after NAs
treatment. The cumulative survival probabilities at 5 yeas were 100% and 74.9% for the
CH patients and the LC patients, respectively (P < 0.02).
Conclusions: NAs-treatments for chronic HBV infected patients could suppress HCC
development with HBV-DNA reduction, leading to improvement of long-term mortality in
both CH and LC.
1
127
Amr Amin 1, Diane McCarthy 2, Nazar Zaki 3
Biology, UAE University, Al-Ain, United Arab Emirates, 2Ezose, NJ, United States,
3
College of IT, Al-Ain, United Arab Emirates
Introduction: Hepatocellular carcinoma (HCC) is one of the most common types of cancer
worldwide. Hepatocellular alterations that normally precede the appearance of HCC would
ultimately cause a discrepancy in the microenvironment of liver cells and may result in
changes in the proteomic profile of liver cells. Aims: The aim of the present study was to evaluate, in a rat model of liver cancer,
qualitative and quantitative changes in N-linked glycosylation of proteins that occur in
response to HCC and/or treatment with saffron-based biomolecules (SBB).
Methodology: Liver tissue samples of 4 groups of rats- 1) seven normal (non-tumorbearing) rats; 2) four untreated tumor-bearing rats; 3) seven tumor-bearing rats treated
with CH and 3) nine tumor-bearing rats treated with SH- were extracted and the liver
lysates were used for biochemical and GlycanMap® analyses. Briefly, GlycanMap®
analysis is high-throughput assay that provides a structural and quantitative readout of
protein-associated glycans using a unique, automated 96-well assay technology coupled
to matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDITOF MS) and custom bioinformatics. Results: SBB decreased the area of placental glutathione-S-transferase-positive foci
in livers of DEN-treated rats. Furthermore, saffron counteracted DEN-induced oxidative
stress in rats as assessed by restoration of superoxide dismutase and catalase levels and
diminishing of myeloperoxidase activity, malondialdehyde and protein carbonyl formation
in liver. 36 N-linked glycans were detected and quantified. 9 glycans showed statistically
significant differences between the groups. Of which, five high mannose glycans (G1Man9,
Man9, Man8, Man7,and Man6) were elevated in tumor-bearing animals as compared to
normals while four Glycans (G0 and bisG0 and their corresponding fucosylated glycans
G0F and bisG0F) were elevated in the SH treatment group compared to the CH treatment
and normal groups. BASIC POSTER ABSTRACTS
126
129
HUMAN BILE CONTAIN MICRORNA-LADEN
EXOSOMES THAT CAN BE USED FOR CANCER
DIAGNOSIS
MICRORNA-21 STIMULATES CANCER GROWTH
AND INVASION BY INHIBITING THE TUMOR
SUPPRESSOR EFFECTS OF SERPINI-1, PDCD4
AND PTEN
1
Ciprian Tomuleasa 1, Florin Selaru 2
Chemotherapy, Ion Chiricuta Cancer Center, Cluj Napoca, Romania, 2Medicine, 3The
Johns Hopkins University School of Medicine, Baltimore, United States
Introduction: Hepatocellular carcinoma (HCC) presents significant diagnostic challenges,
resulting in late patient diagnosis and poor survival rates. Consequently, significant efforts
are needed to develop improved diagnostics. MicroRNAs (miRs) have recently emerged
as a valuable class of diagnostic markers; however, thus far, neither exosomes nor miRs
within exosomes have been investigated in human bile.
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Aims: We aimed to comprehensively characterize human biliary exosomes, including
their miR content.
Methodology: Human bile specimens were obtained from patients under a Hopkins
Institutional Review Board (IRB) approval. Specimens were processed for exosome
isolation. The exosomes were analyzed with western blotting, transmission electron
microscopy (TEM) and nanoparticle tracking analysis (NTA). Multivariate Organization of
Combinatorial Alterations (MOCA) was utilized to analyze the data and develop a miRbased HCC diagnostic panel.
1
Tanase Timis 1, Ciprian Tomuleasa 1 and HCC Working group
Chemotherapy, Ion Chiricuta Cancer Center, Cluj Napoca, Romania
Introduction: Studies revealed that aberrant microRNAs play vital roles in oncogenesis
via regulation of various gene expression or protein translation. MicroRNA-21 (miR-21) is
abnormally expressed in many solid cancers such as liver adenocarcinoma and regulates
targets involved in cancer initiation and progression.
Aims: We investigated the function of miR-21 in liver cancer, and it’s potential targeting
of the tumor suppressor genes Serpini-1, phosphatase and tensin homolog (PTEN) and
programmed cell death protein 4 (PDCD4).
Methodology: After using quantitative RT-PCR in order to verify the overexpression of
miR-21 in two hepatocellular carcinoma cell lines. Western blotting confirmed the RTPCR data in a set of rescue experiments that microRNA-21 mimic, inhibitor, negative and
positive control. The protein levels of miR-21 targets Serpini-1, PTEN and PDCD4 was
measured. Afterwards, we evaluated it’s effect on tumor growth and invasion potential on
two different cell lines.
Results: We have established the presence of exosomes in human bile. In addition, we
have demonstrated that human biliary exosomes contain abundant miR species, which are
stable and therefore amenable to the development of disease marker panels. Furthermore,
we have characterized the protein content, size, numbers and size distribution of human
biliary exosomes. Finally, utilizing MOCA, we defined a novel biliary exosomal miR-based
panel for HCC diagnosis which demonstrated a sensitivity of 60% and specificity of 93%.
Results: RT-PCR results proved that miR-21 is overexpressed in hepatocellular carcinoma
cells when compared with hepatic cells. Western blot results further suggest that PTEN
and PDCD4 are regulated by miR-21, as miR-21 inhibitor increases the expression of
PTEN and PDCD4 proteins and significantly reduces cell proliferation, migration and
invasion. The control experiment proved that the miR-21 mimic significantly inhibits the
expression of PTEN and PDCD4 proteins, leading to an increase in cell invasion and
migration. Furthermore, and miR-21 inhibitor inhibits the apoptosis of cancer cell lines.
Conclusions: This study reports the results of a comprehensive characterization of
human biliary exosomes, including their miR content. In addition, these findings establish
the importance of using exosomes, rather than whole bile, for developing miR-based
disease markers in bile. The novel HCC panel developed herein represents a valuable
addition to current diagnostic methods.
Conclusions: MicroRNA-21 is overexpressed in hepatocellular carcinoma and it’s
aberrant expression may have important roles in cancer growth and dissemination by
modulating the expression of the tumor suppression genes PTEN and PDCD4, as well
as the pathways involved in mediating cell growth, migration, invasion and apoptosis.
Targeting of miR-21 may help us to develop novel therapeutics for liver cancer.
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131
B-CELL LYMPHOMA 3 PROTEIN MODULATES
LIVER INJURY AND REGENRATION IN VIVO
ASOCCIATION BETWEEN ANGIOPOEITIN-1
AND ANGIOPOEITIN-2 WITH STAGES OF LIVER
FIBROSIS AND GRADES OF INFLAMMATION IN
CHRONIC HEPATITIS C PATIENTS
Michael Nagel 1, Amrit Mann 1, Nadine Gehrke 1, Ari Weisman 2, Peter R. Galle 1,
Marcus A. Wörns 1, Jörn M. Schattenberg 1
1
I. Medizinische Klinik, 2Institute for Molecular Medicine Mainz ,
University Medical Center Mainz, 55131 Mainz, Germany
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Introduction: The present study aims at delineating the role of Bcl-3 (B-Cell Lymphoma)
in liver injury and regeneration. The proto-oncogene Bcl-3 has been reported to play a role
in hepatic cell-proliferation and -survival. Bcl-3 is an atypical member of IkB (Inhibitor of
Kappa B) family as it does not bind RelA or cRel-containing dimers. In nucleus, it seems
to regulate NF-kB (Nuclear Factor Kappa B) targets in association with p50 or p52. Bcl-3
has been shown to activate or suppress the NF-kB in vitro although the exact mechanisms
are not understood. HCC arises in the setting of chronic inflammation, a setting in which
NF-kB may play a significant role. Aberrant expression of Bcl-3 has been associated with
many cancers including HCC. Nuclear localization of p50 and p52, but not p65 in human
HCCs may be of significance and Bcl-3 could be a downstream target in modulation of the
NF-kB signaling.
Results: Hepatocyte-specific overexpression of Bcl-3 (Bcl-3Hepar) was achieved by cremediated deletion (Alfp-cre) of a lox-P-site flanked-Neo-Stop cassette switched before
Bcl-3 cDNA. Wildtype and Bcl-3Hepar mice were treated with GalactosamineN (GalN)
and lipopolysaccaride (LPS), a model of TNF-mediated acute liver injury. Liver injury assessed by serum ALT levels, histology, and caspase 8 activation - was less pronounced
in Bcl-3Hepar mice. Also, Bcl-3Hepar mice exhibited significantly elevated proliferation indices
(Ki67) as compared to the control animals hinting towards a role in the liver regeneration.
Significantly enhanced expression levels of NF-kB members RelA and cRel, NF-kB targets
IL-1beta and IL-6 as well as TLR4 (Toll-like receptor) were ascertained. Activation of the
p50 subunit of NFkB was significantly reduced. Interestingly, expression of RIP1 (receptor
interacting protein) an adaptor that mediates TNF- and TLR3/4-induced NF-kB activation
was significantly reduced, and that of RIP3, a key downstream regulator of TNF-mediated
necroptosis was significantly enhanced.
Conclusions: Bcl-3 mitigates TNF-mediated acute liver injury in mice. This is partially
mediated by enhanced proliferation and compromised activation the caspase8-dependent
apoptotic signaling pathway. Our preliminary results hint towards activation of an alternate
RIP3-dependent signalling pathway which may contribute to the equilibrium between
cell death and hepatocyte regeneration. These findings imply that Bcl-3 is an important
modulator of liver homeostasis.
Ángel Hernández-Bartolomé 1, Rosario Lopez-Muñoz 1, Yolanda Rodriguez-Muñoz 1,
Maria Jesus Borque 2, Paloma Sanz-Cameno 1, Ricardo Moreno-Otero 1, Luisa Garcia-Buey 1
1
Unit liver, Hospital Universitario de La Princesa, Madrid, Spain,
2
Biology Molecular Unit, Hospital Universitario de La Princesa, Madrid, Spain
Introduction: Hepatitis C virus (HCV) infection often progresses to chronic hepatitis
C (CHC), one of the leading causes of cirrhosis and hepatocellular carcinoma (HCC).
Angiogenesis is closely related to the pathogenesis of chronic liver disease and its
progression to HCC.
Aims: The purpose of this study was to analyze the expression of Angiopoietin-1 (Ang-1)
and Angiopoietin-2 (Ang-2) in liver tissue of CHC patients and uninfected subject
Methodology: The study included liver biopsies of 47 CHC patients and 8 healthy
individuals. Biopsies were classified according to the Metavir system and stored in
biological embedding medium (OCT) at -80°C until analysis. After thawing, biopsies were
homogenized in RIPA buffer with protease inhibitors and analyzed the expression of
Ang-1 and Ang-2 by western blotting and ELISA assays. Groups were compared using
Mann-Whitney non parametric test and data were analyzed by using Pearson correlation
coefficient.
Results: Ang-2 levels were significantly higher in CHC patients compared with uninfected
controls. Furthermore, we observed that Ang-2 levels were significantly higher (p <0.05) in
patients with elevated inflammation (A3) and advanced liver fibrosis (F3-F4). Interestingly,
the expression of Ang-2 was significantly and positively correlated with inflammation and
fibrosis in group of CHC patients (p <0.03 and 0.02, respectively), but Ang-1 expression
was not related to the progression of disease.
Conclusions: The relationship between expression Ang-2 and the progression disease
to HCC development may reflect the alteration of hepatic vascular homeostasis of these
patients and constitute an important target for therapeutic intervention.
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EASL HCC SUMMIT
133
ANGIOPOIETIN 2 EXPRESION IS ASSOCIATED
WITH PROGRESSION OF INFLAMMATION
AND FIBROSIS IN TISSUE LIVER OF CHRONIC
HEPATITIS C PATIENTS
NOTES
Ángel Hernández-Bartolomé 1, Rosario Lopez-Rodriguez 1, Maria Jesús Borque 1,
Yolanda Rodriguez-Muñoz 1, Luisa Garcia-Buey 1, Paloma Sanz-Cameno 1,
Ricardo Moreno-Otero 1
1
Liver Unit, Hospital Universitario de La Princesa, Madrid, Spain
Aims: The purpose of this study was to investigate the expression of Angiopoietin-2 (Ang2) in liver tissue of CHC patients and uninfected subject.
Methodology: The study included 55 liver biopsies of CHC patients (n = 47) and uninfected
controls (n = 8) of both sexes between 35-60 years old (archive Liver Unit). Biopsies were
classified according to the METAVIR system based on the liver inflammation degree and
fibrosis stage and stored in biological embedding medium (OCT) at -80°C until analysis.
After thawing, biopsies were homogenized at 4°C in RIPA buffer with protease inhibitors
and analyzed the expression of Ang-2 by western blotting and ELISA assays. Groups
were compared using Mann-Whitney non parametric test and data were analyzed by
using Pearson correlation coefficient.
Results: Ang-2 levels were significantly higher in liver biopsies of CHC patients compared
with uninfected controls. In turn, we observed that Ang-2 levels were significantly higher (p
<0.05) in patients with advanced grade inflammation (A3) and fibrosis (F3-F4). Interestingly,
the expression of Ang-2 was significantly and positively correlated with inflammation and
fibrosis in group of CHC patients (p <0.03 and 0.02, respectively).
Conclusions: The relationship between expression Ang-2 and the progression of CHC
may reflect the alteration of vacular homeostasis in liver of these patients and constitute
an important target for therapeutic intervention as potential marker to HCC development.
Introduction: Hepatitis C virus (HCV) infection often progresses to chronic hepatitis
C (CHC), one of the leading causes of cirrhosis and hepatocellular carcinoma (HCC).
Angiogenesis is closely related to the pathogenesis of chronic liver disease and its
progression to HCC.
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EASL HCC SUMMIT
135
TGF B1 AS SERUM BIOMARKER OF
Amila Mehmedovic 1, Rusmir Mesihovic 1, Zora Vukobrat-Bijedić 2, Nenad Vanis 1
1
Department of hepatology, 2Clinical Centre University of Sarajevo, Clinic for
gastroenterology and hepatology, Sarajevo, Bosnia and Herzegovina
Aims: The analysis of serum levels of TGF-β1 in HCC patients, according to BCLC scoring
system has been performed, to evaluate its role as biomarker. Methodology: Total of 150 subjects were divided into four groups, depending on the stage
of HCC (BCLC scoring system).Group 1:early stage;group 2: intermediate stage; group
3: advanced stage;group 4: terminal stage), and the control group.The analysis included
serum levels of cytokine TGF-β1. Used statistical methods: discriminant multivariate
analysis, ANOVA test, multiple correlation test and Student’s t-test for independent
samples. Charlson comorbidity index was determined for any possible influence of other
comorbid conditions. Results: The highest mean concentration of this cytokine was in group 3 (advanced
stage of HCC): 1023,55 pg/ml. ANOVA analysis proves that serum levels of TGF-β1 in the
control group differed with respect to the other as follows: in relation to group 1 at the level
of statistical significance p = 0.0028 (F =143.67); in relation to a group of 2 to p =0.0001
level (F = 230.23); in relation to group 3 at p <0.0001 (F = 2584).
By Student’s T test, TGF-b1 in group 1 was significantly different in comparison to group 3
at the level of significance p <0.0001; groups 1 vs.2 at level p <0.0001; 1 vs. 4 at level p =
0.003.Using Factor Analysis, significant stratification of predictive parameters in relation
to the cytokine TGF-β1 was made:1. Age (negative), 2. MELD score (negative), 3. ChildPugh (negative), 4.hystory of receiving transfusions, 5. IL-1 (negative), 6. fibrinogen..
The histogram 1 presents the average concentration of TGF-β1 in groups. Conclusions: Results suggests that differences in the levels of serum concentrations of
TGF ß1 can be used as biomarkers for staging and monitoring the progression of HCC, as
well as potential targets of therapy in stages B and C (according to BCLC scoring system).
BCLC (the Barcelona Clinic Liver Cancer) scoring system: group 1: Early stage –A; group
2 : Intermediate stage – B; group 3: advanced stage – C; group 4: terminal stage –D), and
control group (healthy subjects).
Introduction: The hepatocellular carcinoma (HCC) is one of the most common malignant
tumors and carries a poor survival rate. Increased understanding of cancer biology and
technological advances have enabled identification of a multitude of pathological, genetic,
and molecular events that drive hepatocarcinogenesis leading to discovery of numerous
potential biomarkers in this disease. The transforming growth factor-beta (TGF-β) cytokine
and its isoforms initiate a signaling cascade which is closely linked to liver fibrosis, cirrhosis
and subsequent progression to HCC.
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EASL HCC SUMMIT
137
EVALUATION OF ANNEXIN-II AND FOLLISTATIN
AS POTENTIAL SERUM MARKERS FOR
NOTES
Nevine E. Elabd 1, Amal Fawzy 2, Sherif Hamdy 3
Clinical and Chemical Pathology, Faculty of Medicine -Cairo University,
2
Clinical and Chemical Pathology, National Cancer institute, 3tropical medicine, faculty of
Medicine -Cairo University, Cairo, Egypt
1
Introduction: Hepatocellular carcinoma (HCC) is the most common primary cancer of
the liver. It has become the 5th most common malignancy worldwide and the third leading
cause of cancer-related death. Surgical resection is the most effective method for curing
this disease, but a large number of cases are not adapted to surgery because of their intrahepatic or distant metastases at the time of diagnosis. Therefore, it is important to develop
convenient serological markers for HCC to enable early diagnosis, as well as monitoring of
tumor aggressiveness, treatment responsiveness, recurrence and patient ‘s survival rate.
Annexin A2, (ANXA2) is a calcium-dependent phospholipid-binding protein .It has been
implicated in many functions, for example, exocytosis, endocytosis and immune response.
It may also play key roles in tumorigenesis. Follistatin (FST) is a glycoprotein that could
inhibit the release of follicle-stimulating hormone from pituitary cells. Several reports have
shown that follistatin regulates a variety of processes of angiogenesis and apoptosis. Aims: The aim of this study was to evaluate serum levels of annexin A2 and follistatin
as diagnostic serological markers for detection of HCC among high-risk patients and
compare them with other known tumor markers
Methodology: The study was conducted on 50 newly diagnosed patients with HCC
presented to the outpatients’ clinic at the National Cancer Institute (NCI), Cairo
University. It also included 30 post HCV/HBV patients and 20 volunteering apparently
healthy individuals as controls. A verbal consent was taken from all subjects. Liver
function tests in addition to serum Alpha fetoprotein (AFP), annexin A2 and follistatin were
measured for all subjects by ELISA.
Results: Annexin A2 was higher in the sera of HCC patients compared to hepatitis and
control groups. As for Follistatin, it was higher in the sera of HCC patients compared to
the control group, but when compared between HCC and hepatitis groups, it showed no
significant difference. Combining Annexin-A2 or Follistatin with AFP, markedly increased
the specificity for HCC diagnosis.
Conclusions: Annexin A2 is a promising diagnostic and prognostic marker for HCC
and its combination with AFP markedly increases the specificity (98%) and the positive
predictive value (97.6%). Follistatin could not differentiate between HCC and hepatitis, but
its combination with AFP improved the specificity for HCC diagnosis.
Keyword: Annexin A2, Follistatin, Hepatocellular carcinoma.
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139
IMMUNOLEVELS OF TRANSCRIPTION FACTOR
FOXM1 AND GLYCOLYTIC ENZYME HKII
CORRELATE WITH CD90+ AND CD133+ CANCER
STEM CELLS, OXIDATIVE AND NITROSATIVE
STRESS, AND DISEASE PROGRESSION IN
Lily Mei 1, Katherine Choi 1, Mamta Pant 1, Rohini Chennuri 1,
Ana Hinojosa 2, Hari Sreedhar 3, Michael Walsh 1, Ming Jin 1, Hui Xie 4,
Dragana Kopanja 5, Nissim Hay 5, Pradip Raychaudhuri 5, Grace Guzman 1
1
Department of Pathology, 2College of Liberal Arts and Sciences, 3Department of
Bioengineering, 4Division of Epidemiology and Biostatistics, 5Department of Biochemistry
and Molecular Genetics, University of Illinois at Chicago, Chicago, United States
Conclusions: Hepatocyte immunolevels of transcription factor FoxM1 and glycolytic
enzyme HKII correlate with markers for hepatic cancer stem cells CD90 and CD133.
Oxidative and nitrosative stress indicators 8-OHdG and iNOS correlate with fibrosis
and disease progression markers CK7 and CK19. CD90 correlates with increasing
tumor grade. These results further suggest FOXM1 and HKII play a role in promoting
hepatocarcinogenesis.
Introduction: Hepatocellular carcinoma (HCC) develops on a continuum of morphological
and molecular alterations in advancing chronic liver disease. FoxM1, HKII, 8-OHdG, and
iNOS have been implicated in a variety of cancers as markers for oncogenesis, increased
metabolic activity, oxidative and nitrosative stress respectively. We hypothesize that these
pro-oncogenic components act in concert to advance disease progression and influence
tumor differentiation in HCC.
Aims: To analyze immunomarkers of oncogenesis in non-dysplastic cirrhosis (NDC), liver
cell change/dysplasia in cirrhosis (LCC), HCC and normal liver controls.
Methodology: A progression liver tissue array constructed from 45 subjects with cirrhosis
and HCC, and 8 normal controls was analyzed. Standard immunohistochemistry (IHC)
was performed to determine levels of FOXM1, HKII, CD90, CD133, 8-OHdG, iNOS,
CK7 and CK19. Staining was analyzed by Aperio Image Analysis. Fisher exact test was
employed using SAS.
Results: Strong positive correlations were found between various IHC stains and disease
progression (Table 1). Tumor grade also correlated with CD90 hepatocyte cytoplasmic
staining (CD90HS).
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EASL HCC SUMMIT
141
IMMUNOHISTOCHEMICAL FEATURES OF
HEPATIC ADENOMAS IN MEN
NOTES
Renumathy Dhanasekaran 1, Yoo Na Kang 2, Rory Smoot 2, Catherine D. Moser 2,
Gregroy Gores 1, Tsung-Teh Wu 2, Taofic Mounajjed 2, Lewis R. Roberts 1
1
Gastroenterology and Hepatology, 2Mayo Clinic, Rochester, Rochester, United States
Introduction: Hepatic adenomas (HA) are benign tumors which were almost always
reported in women. But more recent literature has been describing an increase in the
incidence of this tumor among men. Since hepatic adenomas are rare in men, their
histopathologic and immunochemistry characteristics are not well understood.
Methodology: Patients who underwent surgical resection at a single center were included
in this study and were stratified based on gender. We compared clinical, histopathologic
and immunohistochemistry data in patients with a diagnosis of HA. Immunohistochemical
staining for liver-fatty acid binding protein (L-FABP), serum amyloid A (SAA), glutamine
synthetase (GS) and β-catenin (BC) were used to classify adenomas.
Results: A total of 188 nodules were resected from 105 patients. Men comprised 11.4%
(n=12) of the study group and had 16% (n=30) of the nodules. Overall 50% of the men
had multiple nodules and 25% had adenomatosis (>10 nodules). Two of them had an
underlying diagnosis of glycogen storage disorder and the rest of the adenomas were
sporadic. A high incidence (42%) of overweight/obese individuals was seen but the mean
BMI was not statistically different between men and women.
The largest subgroup by immunohistochemical staining was inflammatory adenomas
which were defined by abnormal SAA staining with BC negativity (41.4%). Steatotic
LFABP-ve nodules were the second most common subgroup (25%). One of the nodules
was beta catenin positive and one nodule showed isolated GS positivity. Men had a higher
percentage of inflammatory adenomas than women (p=0.039) and a trend towards a lower
percentage of steatotic tumors (p=0.060). BMI was not different between patients with the
different subtypes of hepatic adenomas.
Conclusions: This study reports immunohistochemistry features of hepatic adenomas
in one of the largest cohorts of men with this benign tumor. Based on our study results,
hepatic adenomas are not uncommon among men with no underlying risk factors and half
of them had multiple tumors. A higher rate of inflammatory adenomas and lower rate of
steatotic adenomas were noted in men than in women.
Aims: To compare immunohistochemical features of hepatic adenomas between men and
women to identify phenotypic gender differences. We will also compare demographics and
clinical features between men and women.
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143
IMPACT OF GLUTATHIONE PEROXIDASE 4
OVEREXPRESSION ON HEPATOCELLULAR
CARCINOMA: AN IN VITRO AND IN VIVO STUDY
Introduction: Glutathione peroxidase 4 (GPx4) is a selenium containing antioxidative
enzyme able to reduce lipid hydroperoxides. Whereas some evidence links GPx4
expression levels to colon cancer risk, the role of GPx4 in liver cancer remains to be
investigated.
Aims: To investigate the role of GPx4 overexpression in HCC in vitro and in vivo models.
Methodology: Expression plasmids with the porcine GPx4 gene under control of the
CMV promoter were transfected into human Huh7 and HCC-3 hepatocarcinoma cells. The
GPx4 transfection efficiency was evaluated by real-time PCR, western blotting, and activity
measurements. Free radical formation was measured by electron spin resonance spin
labelling. Cell migration was assessed both in a two-chamber assay as well as in a scratch
assay. Intrinsic and induced oxidative stress, cell cycle progression, and expression of
IL-8 and VEGF genes were investigated. The effect of GPx4 on tumour growth in vivo was
assessed by xenotransplantation into NSG recipient mice.
Results: In vitro, GPx4 overexpression increased the resistance of cells to oxidative
stress induced either by hydrogen peroxide or by linoleic acid peroxide (LOOH). Internal
radical formation both at base line and at prooxidative challenge by LOOH was reduced in
GPx4 overexpressing cells. GPx4 prevented LOOH-induced IL-8 but not VEGF formation.
GPx4 reduced migration of tumour cells in a two-chamber assay by 35±5% in HCC-3 and
by 64±11% in Huh7. Moreover, LOOH treatment increased the percentage of HCC cells in
G2/M phase of the cell cycle which was prevented by GPx4 overexpression.
In vivo, smaller tumours were formed by GPx4 overexpressing HCC cells in NSG mice
compared to cells expressing control plasmid. Median tumour weight after 6 weeks of
growth was reduced by GPx4 overexpression from 0.82±0.52 g to 0.32±0.24 g for HCC-3
cells (n=16, p=0.002) and from 0.85±0.66 g to 0.40±0.37 g for Huh7 cells (n=18, p=0.01).
Mouse VEGF and the IL-8 analogue CXCL1 were expressed at lower levels in tumours
derived from GPx4 overexpressing cells.
Conclusions: GPx4 overexpression interferes with the malignant potential of HCC cells
in vitro and in vivo. This work was supported by a grant from Herzfelder Familienstiftung to N.R.U., project
No. AP00585OFF.
Nataliya Rohr-Udilova 1, Dagmar Stoiber 2, Eva Bauer 2, Wen Li 3 1,
Martha Seif 1, Hubert Hayden 1, Regina Brigelius-Flohe 4, Klaus Stolze 5,
Robert Eferl 6, Markus Peck-Radosavljevic 1
1
Gastroenterology and Hepatology, Medical University of Vienna, 2Ludwig Boltzmann
Institute for Cancer Research, Vienna, Austria, 3Capital Medical University, Beijiing,
China, 4German Institute of Human Nutrition , Potsdam-Rehbrücke, Germany, 5Institute
of Pharmacology and Toxicology, Veterinary University of Vienna, 6Institute of Cancer
Research, Medical University of Vienna, Vienna, Austria
EASL HCC SUMMIT
SOLUBLE MIC PROTEINS IN HEPATITIS B VIRUS
INDUCED HEPATOCELLULAR CARCINOMA
GLUTAMINE PROTECTS AGAINST
BETA-CATENIN-DEPENDENT TUMOR
DEVELOPMENT IN LIVER
Van Tong Hoang 1, Nguyen L. Toan 2, Le H. Song 3, Nghiem X. Hoan 3,
Bui K. Cuong 2, Ho A. Son 2, Thomas Bock 4, Velavan TP 1
1
Institute of Tropical Medicine, University of Tuebingen, Tuebingen, Germany,
2
Department of Pathophysiology, Vietnam Military Medical University, 3Tran Hung Dao
Hospital, Hanoi, Vietnam, 4Department of Infectious Diseases,
Robert Koch Institute, Berlin, Germany
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Introduction: HBV infection is a main risk factor for HCC, which is the third leading
cause of cancer related deaths, and is associated with high incidence of HCC in high
prevalence areas of HBV infection. The human major histocompatibility complex class I
chain-related gene A and B (MICA, MICB) induced in response to viral infection including
HBV, modulates the NK and T cell mediated immune responses through NKG2D receptor
and is associated with several diseases including HCC.
Aims: The aim of this study is to investigate the role of soluble MICA and MICB (sMICA,
sMICB) protein in the progression of HBV-related liver disease and treatment response to
HBV-related HCC. Methodology: The sMICA and sMICB serum levels were measured in chronically HBVinfected Vietnamese patients including HCC and healthy controls by ELISA and correlated
with clinical and laboratory parameters as well as with therapeutic interventions of HBVrelated HCC. Results: The soluble MICA and MICB serum levels were elevated significantly in
HBV patients compared to healthy controls. Among patient subgroups, asymptomatic
individuals have highest sMICB serum levels while liver cirrhosis patients revealed lowest
sMICB serum levels. The sMICB serum levels were decreased in treated HCC patients
compared to non-treated HCC patients and were significantly correlated with platelet
counts. In addition, the liver enzymes such as alanine amino transferase (ALT), aspartate
transaminase (AST), total bilirubin and direct bilirubin were positively correlated with
sMICA levels.
Conclusions: The study demonstrated an important role of sMICA and sMICB serum
levels during immune response to the HBV infection, liver disease progression and
response to the HCC treatment.
145
Cécile Godard 1, Chiara Sartor 1, Moinard Christophe 2, Wouter H Lamers 3,
Christine Perret 1, Sabine Colnot 1
1
Inserm, 2Faculté de Pharmacie, Paris, France,
3
University of Amsterdam, Amsterdam, Netherlands
Introduction: Oncogenic events are known to alter cell metabolism, supporting the
aberrant growth of cancer cells. Tumors usually fuel their energetic needs through
aerobic glycolysis and/or through an enhanced glutamine metabolism. Twenty to 40%
of hepatocarcinomas present β-catenin-activating mutations: they strongly express
Glutamine Synthetase (GS), the major glutamine producer, which is also a transcriptional
β-catenin target in the liver.
Aims: We asked what is the role played by glutamine in β-catenin-driven tumor
development. For that purpose, we suppressed Glutamine Synthetase expression in mice
with an over-activated hepatic β-catenin.
Methodology: We previously studied the consequences of a conditional and hepatospecific Adenomatous Polyposis Coli (Apc) gene invalidation (Cre-loxP strategy), leading
to β-catenin over-activation (Colnot, PNAS 2004). When Apc is lost in all hepatocytes by
injecting a high dose of Cre-expressing adenovirus (AdCre), the quiescent hepatocytes
engage in cell division and accumulate a high amount of glutamine. Then the mice rapidly
become hepatomegalic and die from metabolic alterations. On the other hand, the loss of
Apc in single hepatocytes (by injecting a low dose of AdCre) is compatible with survival
and leads to the development of β-catenin-activated liver tumors 9 months thereafter.
We took advantage of these mouse models and interbred them with mice carrying floxed
on the 2nd to 6th exons of Glul gene encoding GS (He, Glia 2010). In this compound
invalidation model, we investigated hepatomegaly, proliferation, survival and followed
tumor development by echography.
Results: The combined loss of GS and Apc in the whole liver strongly decreased glutamine
liver accumulation. In this context, these lower glutamine levels seem to have no influence
on hepatocyte proliferation and hepatomegaly. Unexpectedly, the survival of compound
invalidated mice is shortened. In the tumoral model, the combined loss of GS and Apc
led to an earlier tumoral development, compared to Apc-null mice: GS-null/β-cateninactivated tumors appeared as soon as 4 months after AdCre injection.
Conclusions: Despite an enhanced glutamine anabolism in β-catenin over-activated
livers/tumors, glutamine seems to have no implication on hepatocyte proliferation, but
surprisingly protects against tumor development. This protection could occur through
the role played by glutamine in autophagy and in oxidative stress (as a precursor of
glutathione).
144
EASL HCC SUMMIT
MITOTIC KINESIN-LIKE PROTEIN 2
DEREGULATION IN HEPATOCELLULAR
CARCINOMA
MICRORNA EXPRESSION PATTERN IN
PBMCS FROM PATIENTS WITH HCV-RELATED
MALIGNANCIES
1
Florence Bourgain 1, Mathieu Boissan 1, Dominique Wendum 1, Joelle Sobczak-Thepot 1
Biology and Therapy of Hepato-Biliary Tumors, UPMC - Saint-Antoine Research Center
- Inserm UMRS_938, Paris, France
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Introduction: Mitotic kinesin-like protein 2 (MKlp2) is a plus-end microtubule-associated
motor required during mitosis exit for the final step of cytokinesis. It also contributes
to retrograde vesicular trafficking from the Golgi to the endoplasmic reticulum in
interphase. We recently investigated the expression pattern of MKlp2 in normal liver and
hepatocellular carcinomas (HCCs). We observed a dramatic accumulation of MKlp2 in
normal proliferating, preneoplastic and transformed hepatocytes suggesting that MKlp2
contributes to both normal and pathological hepatocyte proliferation. In addition MKlp2
overexpression was linked to tumor aggressiveness and genomic instability in human
HCCs.
Aims: The purpose of this study was to determine whether down regulation and
pharmacological inhibition of MKlp2 inhibited cell proliferation in vitro and in vivo.
Methodology: HuH6 human hepatoma cells were either treated with paprotrain, a
specific MKlp2 inhibitor, or transfected to constitutively express the KIF20A Sh-RNA. Cell
proliferation was quantified by MTT and clonogenic assays. Ploidy was determined by flow
cytometric analysis of DNA contents. Tumorigenicity was determined after sub-cutaneous
injection of 106 cells in Nude mice.
Results: We show here that both RNAi-mediated MKlp2 knockdown and pharmacological
inhibition of MKlp2 with paprotrain induced polyploidisation and inhibited cell proliferation.
In addition, RNAi-mediated MKlp2 knockdown inhibited tumorigenesis in the Nude mouse
model. Conclusions: These data support that MKlp2 is a candidate therapeutic target in
hepatocellular carcinoma. 147
Alessia Piluso 1, Elisa Fognani 1, Laura Gragnani 1, Elena Grandini 2,
Monica Monti 1, Barbara Boldrini 1, Teresa Urraro 1, Mauro Bernardi 2,
Giacomo Laffi 1, Pietro Andreone 2, Anna L. Zignego 1
1
Experimental and Clinical Medicine, University of Florence, Florence,
2
Department of Clinical Medicine, University of Bologna, Bologna, Italy
Introduction: Hepatocellular carcinoma (HCC) is a major malignancy worldwide and is
closely associated with HCV infection. Besides HCC, HCV is involved in the pathogenesis
of non-Hodgkin’s lymphoma (NHL). HCV is the only virus infecting humans, able to induce
two different malignancies.
We previously showed a down-regulation of miR-26b in peripheral blood mononuclear
cells (PBMCs) from patients with HCV-related mixed cryoglobulinemia (MC) or NHL, and
an up-regulation of miR-16, miR-21 and miR-155 in NHL patients.
Aims: The comparative analysis of miRNA expression between the two malignancies
could provide some hints on the issue of differential evolution of HCV infection to HCC or
NHL, suggesting the existence of common or distinct pathogenetic pathways and identify
new useful biomarkers.
Methodology: We analyzed the expression of a panel of microRNAs in PBMCs from HCV
patients with or without HCC.
Results: Results showed the up-regulation of miR-21 and down-regulation of miR-26b in
HCC patients compared to controls (p<0.001). MiR-146 levels were comparable in patients
and controls. The expression of miR-16 and miR-155 did not differ in HCC patients and
controls, indicating that their deregulated expression was limited to NHL patients. Conclusions: In conclusion, this study shows that some microRNA are differently
modulated in PBMCs from HCV patients who developed HCC or NHL, while others
follow a common behavior. Thus, microRNAs could represent non-invasive markers of
HCV-related cancerogenesis, useful to identify the existence of a malignancy and also to
discriminate between the two major HCV-related cancers.
146
EASL HCC SUMMIT
EXPRESSION OF TH1/TH2 CYTOKINES IN
HEPATITIS B MEDIATED HEPATOCELLULAR
CARCINOMA IN PATIENTS FROM NORTH EAST
INDIA
STUDY OF HNF4ALFA ROLE IN MOUSE LIVER
Manab Deka 1, Kangkana Kataki 1, Subhash Medhi 1, Sujoy Bose 2, Namrata Kumari 1,
B B Borthakur 3, Anupam Sarma 4,Amal C. Kataki 3
1
Department of Biological Science, 2Gauhati University, 3B Barooa Cancer Institute,
4
B Barua cancer institute, Guwahati, India
Introduction: Hepatitis B is one of the main causes of Hepatocellular Carcinoma (HCC)
worldwide. The infection by viruses lead to alter the Th1/Th2 cytokine profiles. The
investigation of Th1/Th2 markers in case of HCC may be useful in better prognosis and
management of the disease.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Aims: This study was targeted to estimate Th1/Th2 cytokines (IL-2, IL-4, IL-6, IL-10,
TNF-α and INF-γ) expression in HBV mediated HCC cases.
Methodology: A total of 15 cases were included in the study which include HBV mediated
Hepatocellular carcinoma (HCC) N= 10 and Healthy control N=5. Cytokine profiles of
the samples were analyzed using BD™ Cytometric Bead Array (CBA) Human Th1/Th2
Cytokine Kit II.
Results: In all the samples IL6 showed highest expression. Irrespective of the etiology
among HCC IL-6 showed highest concentration with an average of 1732.89 pg/µl±4310.63
followed by TNF-alpha with an average of 166.5pg/µl±484.844. The cytokine IL-2 didn’t
show any expression. Conclusions: From the above study conducted it can be concluded that there is a
significant increase in the expression of IL-6 in HBV mediated hepatocellular carcinoma
compared to normal control where there is no expression and may be a prognostic marker .
The small sample size is a limiting factor in this study which need further evaluation.
149
Chiara Sartor 1, Cécile Godard 1, Angélique Gougelet 1, Christine Perret 1, Sabine Colnot 1
1
Inserm-Institut Cochin, Paris, France
Introduction: Our laboratory is studying the role of beta-catenin signaling in the liver both
in a physiological and a pathological status, through the use of transgenic mice models.
In fact beta-catenin is able to establish and maintain the liver metabolic zonation, but also
is the cause of a percentage of liver cancers that are associated with a specific metabolic
phenotype.
Aims: We characterized the role of Hnf4α in vivo in beta-catenin-dependent zonation.
Knowing that beta-catenin is implicated in the emergence of liver tumors and that Hnf4α
is depicted as a tumor suppressor gene, we also developed an in vivo project to looking
further at its role in liver carcinogenesis.
Methodology: We used an hepatospecific and Tamoxifen-inducible knock-out of either
Hnf4α or Apc (Cre-loxP strategy). The Apc knock-out (Apc-ko) livers strongly over-activate
beta-catenin signaling, leading to tumor development. The Hnf4alfa-ko model has been
previously developed and described by Gonzalez’s group.
Results: In a first step, ChIP experiments performed in vivo (on hepatocytes activated or
inactivated for beta-catenin signaling) were analyzed combined to mRNA-Seq experiments.
We identified the presence of a Wnt Responsive Element (WRE) upstream beta-catenin
positive targets and showed a motif close to Hnf4 or PPAR Responsive Element (HRE)
upstream a pull of genes, 19% of that known as beta-catenin negative targets (Gougelet,
Hepatology, in press).
Next, we made a comparison between the Hnf4α-ko livers and the Apc-ko ones. One week
after inducible inactivation, the Hnf4α-ko livers have a modified zonation, as shown by
an extended staining of the Glutamine Synthetase (GS), a target of beta-catenin, and an
increase of proliferation that is similar to the Apc-ko ones. Thus, Hnf4α and beta-catenin
signaling look antagonistic. But 20% of Hnf4α-ko livers also show a disorganization of the
portal space, with a stenosis of the portal vein and an enlarged hepatic artery.
The cohort of mice depleted in Hnf4α and let live until 9 months do not develop tumors.
However a subset of which present some GS-positive nodules and a disorganization in
portal and pericentral areas.
Conclusions: Hnf4α and beta-catenin signalings seem antagonistic for liver zonation.
Moreover, Hnf4α is not a tumor suppressor per se, and it rather takes part to the
maintenance of a normal liver zonal architecture.
148
150
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
151
THE ROLE OF GROWTH HORMONE RECEPTOR
IN LIVER FIBROSIS AND CANCER
Introduction: Recently, growth hormone resistance and low serum levels of insulin
growth factor (IGF-1) have been associated with liver cirrhosis in humans, indicating a
role for growth hormone receptor, which itself controls various cellular functions including
the transcription of IGF-1 through signal transducer and activator of transcription 5 (Stat5)
signalling.
Aims: In order to elucidate whether the growth hormone receptor (GHR) plays an active
role in the establishment of fibrosis liver diseases or rather happens to be a major
consequence of this illness, we crossed mice lacking the Ghr/bp gene (Ghr -/-) with a
mouse model of inflammatory cholestasis and liver fibrosis, the Mdr2 knockout mouse
(Mdr2 -/-).
Methodology: Serum parameters and bile acid levels were analysed. Additionally
histological stainings, western blotting and RT-PCRs were conducted to gain mechanistic
insights.
Results: Our results indicate that Ghr-/-;Mdr2-/- mice show deregulation of bile acid
homeostasis and increased serum markers associated with inflammation and fibrosis. Bile
duct proliferation and extensive collagen deposition were also observed in Ghr-/-;Mdr2-/compared to Mdr2-/- mice, suggesting that Ghr-/-;Mdr2-/- developed a severe liver fibrosis
phenotype. Additionally, a greater down regulation of the hepato-protective genes Hnf6,
Egfr and Igf-1 accompanied by increased apoptosis was seen in Ghr-/-;Mdr2-/- compared to
control mice. Moreover, single knockout mice (Ghr-/-) developed bile infacts when fed with
1% cholic acid compared to Wt controls, indicating that hepatocytes upon loss of GHR
become more susceptible to toxic bile acid accumulation. Surprisingly, Ghr-/-;Mdr2-/- mice
showed a significant decrease in tumour incidence compared to Mdr2 -/- mice despite their
severe fibrotic phenotype indicating that loss of GHR signalling may slow the progression
from fibrosis/cirrhosis to cancer in the liver.
Conclusions: These findings suggest that loss of GHR signalling severely increased liver
fibrosis in a mouse model of inflammatory cholestasis, signifying the possible therapeutic
value of this pathway in the development of liver fibrosis treatments.
Patricia Stiedl 1, Leander Blaas 2, Viktoria Stanek 1, Jasmin Svinka 3,
Robert Mc Mahon 4, Gernot Zollner 5, Thierry Claudel 4, Mathias Mueller 6,
Wolfgang Mikulits 3, Harald Esterbauer 7, Robert Eferl 3, Johannes Haybeack 8,
Michael Trauner 4, Emilio Casanova 1
1
Ludwig Boltzmann Institute for Cancer Research, Vienna, Austria,
2
Department of Biosciences and Nutrition, Karolinska Institute, Huddinge, Sweden,
3
Department of Internal Medicine I, Institute for Cancer Research, Medical University of
Vienna, 4Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology
and Hepatology, Department of Internal Medicine III, Medical University of Vienna,
Vienna, 5Division of Gastroenterology and Hepatology, Department of Internal Medicine,
Medical University of Graz, Graz, 6Biomodels Austria, Institute of Animal Breeding and
Genetics, University of Veterinary Medicine Vienna,
7
Department of Laboratory Medicine, Medical University of Vienna, Vienna,
8
Institute of Pathology, Medical University of Graz, Graz, Austria
EASL HCC SUMMIT
CELL CYCLE DEREGULATION BY HCV
PROTEIN EXPRESSION, A POTENTIAL
HEPATOCARCINOGENIC TRIGGER
PI3K/AKT PATHWAY ACTIVATION BY HCV AND
ITS ROLE IN LIVER CARCINOGENESIS
Alexandre Florimond 1, Philippe Chouteau 1, Aurore Gaudin 1, Hervé Lerat 1,
Jean-Michel Pawlotsky 2 on behalf of INSERM U955 EQ18 and INSERM U955,
University of Paris-Est, Henri Mondor Hospital and National Reference Center for Viral
Hepatitis B, C, and Delta, Department of Virology Créteil, France
1
INSERM U955 EQ18, University of Paris-Est, 2INSERM U955 EQ18, University of ParisEst, National Reference Center for Viral Hepatitis B, C, and Delta, Créteil, France
Introduction: Chronic infection by hepatitis C virus (HCV) is a major risk factor for the onset
and progression of hepatocellular carcinoma (HCC), which appears to be principally related
to chronic local inflammation and fibrosis. Nevertheless, in vitro studies have shown that HCV
proteins can directly interact with cell cycle regulators, tumour suppressors or oncogenes.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Aims: Our goal was to study the hepatocyte cell cycle perturbation(s) induced in vivo by
the expression of HCV proteins after an acute liver injury (CCl4) using a transgenic mouse
model expressing the full HCV open reading frame (FL-N/35 mice).
Results: Early after the CCl4 challenge, no difference in the expression of immediate-early
genes, growth factors or cytokines was observed between the FL-N/35 mice and their
wild-type littermates (wt), suggesting that cell cycle initiation steps are not perturbed by
HCV protein expression.
In contrast, cyclin-A expression and BrdU incorporation at entry into the S-phase were
delayed in FL-N/35 mice compared to wt. At entry into the S-phase, Retinoblastoma
protein (Rb) phosphorylation (P-RBSer807/811) was reduced in FL-N/35 mice, suggesting a
G1/S transition impairment in the liver of these mice.
Chronic infection by HCV is associated with hepatic oxidative stress that could trigger
DNA damage, a well characterized cell cycle disruptor. As already published and as
observed by ourselves, FL-N/35 mouse livers display high levels of Reactive Oxygen
Species (ROS) in association with an increased mitochondrial DNA damage. It has been
established that the ATM pathway is activated by DNA double-strand breaks and leads
to cell cycle arrest. We observed that Chk2 and p53 phosphorylations (Chk2Thr68 and
p53Ser15) and p21waf1/cip1 expression, three actors of the ATM pathway, were significantly
higher in FL-N/35 mice than in wt mice at G1/S transition. Interestingly, these activations
were also present in untreated transgenic mice, indicating that such cell cycle brakes are
present independently of acute liver injury. Altogether, these results suggest that HCVinduced DNA-damage impairs hepatocyte cell cycle G1/S transition, at least in part viathe
activation of the ATM pathway.
Conclusions: The expression of HCV proteins in the liver of HCV transgenic mice, in
the absence of detectable local inflammation or immune response, inhibits the G1/S
transition which could result of a HCV-induced DNA damage/ATM pathway activation.
This phenomenon represents a potential trigger of liver carcinogenesis.
153
Mohamed R. Imache 1, Jacqueline Polyte 1, Jean-Michel Pawlotsky 2, Herve Lerat 1
1
Equipe 18, Université Paris Est - Inserm U955, 2Microbiology and Virology, Henri
Mondor Hospital, Creteil, France
Introduction: The Pi3K-AKT pathway is a critical intracellular node regulating cell survival
and proliferation. Activation of the AKT-pathway has been reported in many cancers,
including HCC. Activation of this pathway by HCV is debated. We have shown that c-MYC
is overexpressed through an AKT-dependent mechanism in HCV-infected patients and
transgenic mice expressing all HCV proteins. Aims: This study aimed at characterizing AKT activation during HCV infection and
deciphering the underlying molecular mechanisms.
Results: We observed a significant hyperphosphorylation of AKT-ser473 in non-tumoral
hepatic tissues from infected patients with HCC as compared to HBV-infected or alcoholic
patients. This activation was also found in 3 months-old HCV transgenic mouse livers
compared to wild-type, even after EGF treatment. AKT1, but not AKT2, was the activated
form. Our assessment of AKT phosphorylation modulators ruled out the involvement
of phosphatases PP2A and PHLPP, but showed an increase in the phosphorylation of
mTOR-ser2448 within the mTORC2 complex. This increase was associated with reduced
phosphorylation of Rictor-thr1135, p70S6K-thr389 and PDK1-ser241.
Conclusions: Our results suggest that HCV protein expression modulates the negative
feedback loop that controls AKT phosphorylation, thus leading to its hyperactivation.
The downstream effects of this HCV-induced Pi3K/AKT pathway activation and their
involvement in hepatic carcinogenesis are under study. Numerous molecules targeting the
PI3K/AKT pathway have been tested in other cancers than HCC. Our results suggest such
approaches could be valuable in the prevention or treatment of HCV-associated HCC.
152
EASL HCC SUMMIT
MICRORNA-125B MODULATES CELL GROWTH,
METABOLISM AND HBV REPLICATION VIA
LIN28B/LET7 AXIS
ANALYSIS OF DLC 1 GENE POLYMORPHISM
AMONG HEPATOCELLULAR CARCINOMA
PATIENTS IN INDIA
1
Wanyu Deng 1
Institute of Virology, Essen, Germany
Introduction: Previously, we showed that miR-1 upregulated HBV replication through
enhancement of HBV core promotor activity and it also inhibited cell growth. However,
miR-1 was expressed at a low level in hepatocytes.
Aims: Here, we asked whether miRNAs highly expressed in hepatocytes could also
modulate HBV replication.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Methodology: A number of miRNAs with decreased expression in hepatocellular
carcinoma were tested for their ability to influence HBV replication at different levels
including viral transcription, assembly, and virion production. Their involvement in the
control of cell proliferation was examined by transfection in established hepatoma cell
lines. RNA sequence assay was explored to determine the global gene expression pattern
in cells transfected with miRNAs.
155
Balachandar Vellingiri 1, Mohana Devi Subramaniam 2, Meyyazhagan Arun 2,
Balasubramanian Balamuralikrishnan 2, Keshavarao Sasikala 2
1
Human Molecular Genetics Laboratory, Department of Zoology, Bharathiar University,
Coimbatore , 2Zoology, Human Molecular Genetics Laboratory, Department of Zoology,
Bharathiar University, Coimbatore - 641 046, Tamil Nadu, India, Coimbatore, India
Introduction: Hepatocellular carcinoma (HCC) is the fifth most frequent malignant tumour
in man and the third for cancer related mortality worldwide, especially in parts of Asia
and Africa. The development of HCC is found to have both environmental and genetic
mechanism. The environmental aspects comprises chronic infection with hepatitis B
(HBV) and C virus (HCV), intake of alcohol, smoking, aflatoxin exposure, cirrhosis and
male gender. Loss of gene deleted in liver cancer 1 (DLC1) gene has been associated in
the progression of HCC.
Aims: The aim of the present study was to analyze the relationship between DLC1 gene
polymorphism and risk of HCC among South Indian population.
Results: Among the tested miRNAs, miR-125b was found enhance HBV replication
significantly. In constrast to miR-1, miR-125b did not regulate HBV transcription but
increased HBV replicative intermediate and nucleocapsid formation. It exerted a
synergistic effect on upregulation of HBV replication with miR-1. MiR-125b down regulated
RB phosphorylation and inhibited hepatoma cells proliferation by blocking cell cycle at
the G1/S phase transition. Moreover, miR-125b could modulate a number of liver-specific
metabolic pathways. MiR-125b reduced LIN28B and thereby upregulated the let-7 family
members to enhance HBV replication.
Methodology: Blood samples from 98 HCC patients and 98 controls were collected.
Genotyping of T>G, G>A, and C>T for HCC patients and controls was performed by
polymerase chain reaction- based restriction fragment length polymorphism (PCR-RFLP).
The association among HCC and polymorphism were analyzed.
Conclusions: This is the first time we identified a specific factor that positively influence
HBV replication in the post-transcriptional process. Our results demonstrated that some
miRNAs with the ability to arrest the cell cycle at the G1 phase may preferentially upregulate HBV replication. We also found miR-125b could regulate lin28b/let7 axis.
Conclusions: The genetic variants analyzed may lead to inter individual susceptibility
to HCC and very limited role of genetic polymorphism has been investigated and the
combined effect of these variants may interact by boosting up the risk of HCC in the study
population.
Results: The study on DLC1 polymorphism demonstrated differences in allele frequencies
compared to controls. Among three genotypes C/C genotype has a higher susceptibility to
HCC among the study population.
154
MUTATIONS IN TP53, CTNNB1 AND PIK3CA
GENES IN HEPATOCELLULAR CARCINOMA
ASSOCIATED WITH HEPATITIS B AND HEPATITIS
C VIRUS INFECTIONS
LONGITUDINAL MRI-BASED RESPONSE
MONITORING OF SORAFENIB TREATMENT
IN TRANSPLANTED VERSUS CHEMICALLY
INDUCED RAT HCC
1
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Franco M. Buonaguro 1, Luigi Buonaguro 1, Maria Lina Tornesello 1
Experimental Oncology, Istituto Nazionale Tumori Fond Pascale, Napoli, Italy
1
157
Claudia M. Gross 1
Radiology, Klinikum rechts der Isar, 81675 Munich, Germany
Introduction: Hepatocellular carcinoma (HCC) is the third leading cause of cancer death
worldwide. Hepatocarcinogenesis is a multistep process mainly associated with persistent
infection with hepatitis B (HBV) or C (HCV) viruses and always involving the accumulation
of genetic alterations over decades of chronic liver disease. Mutations in TP53 and
CTNNB1 genes are considered the cancer drivers for HCC development with variable
frequencies depending on the etiology.
Introduction: Reliable non-invasive imaging methods are required to improve tumor
detection, characterization and therapy response monitoring. In HCC development and
therapy, angiogenesis plays a major role, with the anti-angiogenic multikinase inhibitor
sorafenib being the only approved systemic drug in advanced disease stages. To validate
new non-invasive imaging methods, reliable model systems are required, faithfully
representing the human disease.
Aims: To evaluate the frequency and distribution of somatic mutations in TP53, CTNNB1
and PIK3CA genes in HBV- and HCV-related HCCs.
Aims: Goal of this work was the detection of sorafenib induced changes in tumor
vascularisation by magnet resonance imaging (MRI) in two commonly employed
preclinical rat HCC model systems, diethylnitrosamine induced (DEN) and orthotopically
transplanted (McA) HCC.
Methodology: The comprehensive review evaluating somatic mutations in TP53 and
CTNNB1 genes in HBV- and HCV-related HCC cases has been carried out retrieving
cases available from the Catalog of Somatic Mutations in Cancer (COSMIC). Moreover,
the mutational pattern of TP53 (exons 4-9) and CTNNB1 (exon 3) as well as PIK3CA (exon
9) genes in HCC from Southern Italy has been analyzed.
Results: The overall mutation frequency of TP53 and CTNNB1 was 33.3%, while hotspot
variations in PIK3CA were completely absent. CTNNB1 mutations were significantly
associated with young age (P=0.019) and moderately/poorly differentiated HCV-related
HCC (P=0.015).
Conclusions: The results obtained in our Southern Italian HCC series show that somatic
mutations in TP53 gene are similarly represented in HBV- (20%) and HCV-related (15.8%)
HCC cases and comparable to that previously reported among HCC cases from Northern
Italy (25%) and France (18%). Further studies are in progress and the extended analysis
of genetic alterations will help to identify molecular markers for liver cancer prevention,
diagnosis and treatment of HBV and HCV-associated liver cancer.
Methodology: Multifocal DEN and McA rat HCC was established in 8 week old male
Wistar rats and imaged by T2-weighted (T2w), dynamic contrast enhanced (DCE) and
diffusion weighted imaging (DWI) MRI. Imaging findings were correlated with histology.
Results: Volume analysis of DEN tumors displayed slower growth kinetics in treated (n=11)
compared to untreated animals (n=6) (fold change difference=2.5, p=0.0009). In contrast
McA tumors (n=3) grew faster compared to DEN tumors (fold change difference=3.2)
and no change in tumor volume was noted (n=4, fold change=3.3). In addition, perfusion
analyses showed higher values in untreated DEN (n=7; AUGC90rel_mean=5.51) compared to
McA tumors (n = 3; AUGC90rel_mean=1.94). Whereas DEN tumor perfusion (n=6; AUGC90rel_
=4.24) decreased in response to sorafenib, perfusion slightly increased in McA tumors
mean
(n=4, AUGC90rel_mean=2.27). These differences in tumor perfusion were confirmed by
histological findings.
Conclusions: In summary, we were able to quantify tumor volume and perfusion changes
longitudinally in orthotopic rat HCC by MRI. Analyses revealed DEN tumors only, which
more closely resemble human HCC, responsive to sorafenib treatment. This finding
underlines the need for a careful model system selection and further validates the DEN
model system for future imaging and therapy response studies.
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SURFACE MARKER PROFILING OF HUMAN
HEPATOCELLULAR CARCINOMA CELLS USING
HIGH THROUGHPUT FLOW CYTOMETRY
SCREENING
THE CROSS TALK BETWEEN HEPATIC STELLATE
CELLS AND HCC CELLS OFFSETTS SORAFENIB
EFFECTIVENESS VIA LAMININ-5 INTEGRINS
ENGAGEMENT
Kui Chen 1, Laurie Ailles 2 3, John E. Dick 2 4, Anand Ghanekar 1 5
Toronto General Research Institute, 2Ontario Cancer Institute, University Health
Network, 3Department of Medical Biophysics, 4Department of Molecular Genetics,
5
Department of Surgery, University of Toronto, Toronto, Canada
1
Introduction: Human hepatocellular carcinoma (HCC) demonstrates significant clinical,
phenotypic and genetic heterogeneity. Cell surface markers that can be used to consistently
identify bulk HCC cells or subpopulations thereof, such as tumor-initiating cells (TICs),
remain poorly defined.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Aims: We sought to characterize the distribution and frequency of CD antigens expressed
on the surface of primary human HCC cells in an unbiased fashion in order to identify
candidate molecules for investigation as markers of bulk HCC cells or HCC TICs.
Methodology: We obtained fresh human HCC resection specimens from 10 patients who
had not received any preoperative therapy. We stained the HCC cells with fluorescent
antibodies against 375 unique human CD antigens in 96-well plates. All cells were costained with anti-human CD45 in order to distinguish leukocytes from tumor cells. CD
antigen expression data was acquired on a BD LSR II flow cytometer equipped with a
96-well plate reader and analyzed using FloJo software. Heatmap analysis was performed
with Multiexperiment Viewer (MeV) software.
Results: We observed significant intertumoral heterogeneity with regards to the fractions
of CD45-negative HCC cells expressing different CD antigens, validating the heterogeneity
observed in clinical, histopathological, and genetic studies. However, we were able to
identify 20 antigens that were consistently expressed in more than 35% of HCC cells
in all samples analyzed. We also identified 50 CD antigens expressed consistently in
a small fraction of cells (0.5-5%) in all samples analyzed. The vast majority of these
consistently expressed antigens are not currently recognized to play a defined role in
HCC pathobiology.
Conclusions: High throughput flow cytometry screening is a viable platform for biological
discovery in the context of human HCC. Our further studies are aimed at i) exploring
whether the commonly expressed antigens can be utilized as novel cell surface markers of
bulk HCC cells with potential clinical applicability as novel HCC biomarkers; ii) determining
whether the infrequently expressed markers may represent novel populations of HCC
TICs; and iii) investigating whether defined cell surface marker profiles correlate with
clinical outcomes in the patients from whom the HCC specimens were obtained.
Gianluigi Giannelli 1, Amalia Azzariti1, Letizia Porcelli1, Anna Elisa Quatrale1, Erica Villa1
1
Emergency and Organ Transplantation, University of Bari, Bari, Italy
Introduction: The mechanisms responsible for resistance to Sorafenib are still unknown.
Laminin-5 (Ln-5) has recently been reported to be secreted by hepatic stellate cells
(HSCs), and to enhance the aggressiveness of HCC cells. Aims: Aim of this study is to investigate the effect of Ln-5 on Sorafeninb effectiveness in
HCC cells. Methodology: HCC cell lines were challenged in vitro with Sorafenib in the presence of
Ln-5 and of HSC conditioned medium. Results: Ln-5 and HSC-conditioned medium (CM) strongly reduced the effectiveness of
Sorafenib against the proliferation and apoptosis of different HCC cell lines expressinga3b1
but not a6b4, the two main Ln-5 receptors. Blocking antibodies against a3b1, but not
a6b4, completely reversed the effect of Ln-5. Transfected HCC cell line a3b1, but not
the wild type or the scramble control, evaded Sorafenib’s effect in the presence of Ln5. We found that NF-kB, p-Akt, Akt, ERK1/2, c-Myc, P-53, survivin and p-p38 were not
involved in this mechanism, whereas FAK was phosphorylated by Ln-5 and HSC-CM
and de-phosphorylated by Sorafenib. In the presence of Sorafenib, a3b1 positive but not
negative HCC cells showed FAK phosphorylation if exposed to Ln-5. a3b1 transfected
HCC cells, but not the wild or scramble type, showed FAK phosphorylation in the presence
of Sorafenib if Ln-5 was also present
Conclusions: To our knowledge this is the first study showing a mechanism of resistance
to Sorafenib, whereby Ln-5 phosphorylates FAK via a3b1, offsetting Sorafenib’s
effectiveness.
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CLINICAL ORAL
ABSTRACTS
CLINICAL SCHOOL
COURSE 23
BELGRADE . SERBIA
NOVEMBER 28 – 29 / 2014
LIVER CIRRHOSIS:
A SYSTEMIC DISEASE
Course Directors:
G. Jankovic, Belgrade, Serbia
H. Zoller, Innsbruck, Austria
Deadline for Application: August 30, 2014
EASL thanks its Premium Sponsors for their generous
contributions and support of the EASL Schools of Hepatology
The EASL Building
Phone: +41 22 807 03 60
Fax: +41 22 328 07 24
Email: [email protected]
Contact: [email protected]
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161
162
MOLECULAR PATHOGENESIS AND
TRANSLATIONAL RESEARCH
1
Josep M Llovet 1 2
ICREA , BCLC , Liver Unit, IDIBAPS, Hospital Clínic Barcelona, Barcelona, Spain,
2
Mount Sinai Liver Cancer Program, Icahn School of Medicine at Mount Sinai,
New York, United States
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163
INTEGRATION WITH A MOLECULAR
CLASSIFICATION OF CIRRHOSIS
1
Yujin Hoshida 1
Icahn Scool of Medicine at Mount Sinai, New York, United States
Liver cancer is the second cause of cancer mortality and a major health problem globally.
Only one molecular therapy, sorafenib, has been approved for advanced cases. There is
limited understanding of the pathogenesis of the disease. The field-effect predisposing
to HCC development is characterized by activation of signaling pathways related to ILsignaling, oxidative stress, EGF signaling and inflammation among other. Mutations in
promoter regions of TERT have been identified in 25% of cases in preneoplastic lesions.
Also inactivation of p53 in stellate cells appears to be a potential gatekeeper. During the
last decade and after applying next generation sequencing several drivers have been
identified. Each HCC contains around 35-40 mutations, among which 6-8 are considered
drivers. The main mutations described are in the promoter region of TERT, p53, CTNNB1,
ARIDA1A and Axin 1. Afterwards the landscape of mutations is characterized by a long
tail of mutated genes in <5% of cases, such as RAS, PI3K and others. In terms of high
level amplifications at 5-10% prevalence containing oncogenes are in 11q13 Cyclin D1
and FGF19 and 6p21 VEGFA, whereas other amplifications described contain Myc and
Met among others. All this molecular information should be directed to select populations
for proof-of concept trials, such as the one testing MEK inhibitors in RAS+ patients, or trial
enrichment, such as the one testing MET inhibitors in MET –positive populations.
Prognostic prediction is a key issue for better clinical management of liver cirrhosis and
hepatocellular carcinoma (HCC). Studies have revealed that genomic profile of diseased
liver is a source of molecular information predictive of variety of clinical outcomes such
as intrahepatic tumor metastasis, multi-centric HCC development, cirrhosis progression,
and death. It is also known that the prognostic information harbored in diseased liver is
independent of HCC tumor and complementary to each other. Integration of these different
types of prognostic information will improve precision of prognostic prediction and enable
more personalized patient management. For example, molecular biomarkers of HCC
risk will guide HCC surveillance as well as follow-up after curative surgery or ablation
of primary HCC tumors. In addition, such information may provide clues to treat and/
or prevent molecular drivers of poor prognosis and facilitate development of companion
biomarkers.
CLINICAL SPEAKERS’ ABSTRACTS
INTEGRATED OMICS STUDIES TO DELINEATE
TUMOR HETEROGENEITY IN LIVER CANCER
1
Liver cancer is extremely heterogeneous in its tumor biology and clinical presentation,
which impedes treatment options and poses a significant challenge to cancer management.
Inter- and intra-tumor heterogeneity has been recognized, possibly emanating from the
presence of cancer stem cells or selection by clonal evolution. To overcome this problem,
molecular-based technologies including genomic, transcriptomic and metabolomic
profiling, have been applied to liver specimens to distinguish tumor subgroups, which
allow for stratification of patients with greater homogeneity and can assist in molecular
re-staging. These various genome-based signatures also delineate critical gatekeepers of
cancer initiation and progression which can be further honed by integrative genomics to
identify key driver genes and functionally linked networks capable of determining patient
prognosis or therapeutic outcome. Examples of biologically relevant molecular signatures
and drivers include those linked to metastasis, tumor recurrence, cancer stem cells, tumor
metabolism and gender disparity. Furthermore, comparative genomics has revealed
that although signatures may share a common prognostic space, each carries unique
molecular changes linked to different sets of cancer hallmarks which collectively occupy
different tumor biological space. Integrative genomic approaches allow us to tease apart
these differences, rooted in tumor heterogeneity, to identify critical biomarkers for cancer
diagnosis and clinically relevant therapeutic targets that represent convergent cancer
driving molecular nodes.
165
TRANSLATIONAL TISSUE DIAGNOSTICS IN HCC
1
Anuradha Budhu 1, Stephanie Roessler 1, Xin W. Wang 1
Laboratory of Human Carcinogenesis, Center for Cancer Research, National Cancer
Institute, Bethesda, United States
EASL HCC SUMMIT
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FEBRUARY 13 - 16, 2014
Peter Schirmacher 1
Institute of Pathology, University Hospital, Heidelberg, Germany
Introduction: Although there is no targeted therapy available for HCC so far, challenges
of molecular tissue diagnostics for predictive and differential diagnostic purposes are
already visible.
Results: In differential diagnostics specific molecular markers support several important
questions.
1.
2.
3.
assessment of malignancy in highly differentiated hepatocellular neoplasms
differentiation of hepatocellular carcinoma from mimics and mixed or unusual hepatic
malignancies
identification of hepatocellular adenomas with higher malignant transformation
potential
These markers offer significant support for histological assessment and attempts are on
the way to further improve the respective marker panels. Correct categorisation is essential
for adequate therapeutic management. There are also recent indications that novel
molecular markers may support definition of some rarer HCC subtypes in coordination
with histopathological characteristics. In the future we are likely to see an improved and
combined histopathological and molecular subclassification of HCC, as witnessed in other
malignancies, such as breast cancer and NSCLC.
In predictive diagnostics several clinical trials are ongoing that require preemptive testing for
trial inclusion. These tests require either immunohistology (e.g. MET) or mutation analyses
(e.g. KRAS). In order to address trial and study center issues rational and comprehensive
testing and allocation measures (‘umbrella’ programs) are helpful. Furthermore, trial
associated analyses may help to identify patient subgroups responding (better) to therapy.
As trials may hopefully lead to novel approved therapies, concomitant, quality assured
testing has to be implemented in the diagnostic community and respective measures have
to be taken in parallel to clinical application (testing conditions, round robins etc.). These
measures, although only partly in place for liver cancer have been implemented in other
tumor entities and can be transferred to the HCC situation CLINICAL SPEAKERS’ ABSTRACTS
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BETA-CATENIN IN HEPATOCELLULAR CANCER:
BASIS OF PERSONALIZED MEDICINE
1
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NOTES
Satdarshan P. Monga 1
Department of Pathology, University of Pittsburgh, Pittsburgh, United States
Activation of Wnt signaling due to various reasons has been observed in a significant
subset of hepatocellular cancer (HCC) patients. In fact around 60% of HCC patients
display aberrant beta-catenin localization in the form of nuclear and/or cytoplasmic
staining. Around 1/3rd of these patients, exhibit point mutations in exon-3 of CTNNB1,
while others are more heterogeneous displaying mutations in AXIN1/2, silencing of Wnt
inhibitors or enhanced Wnt/Frizzled expression. Since b-catenin activation is associated
with enhanced expression of target genes that encode for proteins critical in tumor cell
proliferation, survival, metabolism, angiogenesis and cancer stem cell maintenance and
expansion, its therapeutic inhibition in a select group of patients is expected to be of high
translational value. Since b-catenin is also important in maintaining adherens junctions
(AJ) in the epithelial cells, we have shown its knockdown by various modalities to not
adversely impact AJ integrity due to compensation by gamma-catenin that maintains
contact with E-cadherin. However, b-catenin cannot be unequivocally targeted in every
HCC since enhanced liver injury and paradoxical increase in HCC was observed in
hepatocyte-specific b-catenin conditional knockout mice following chemical carcinogenexposure. Hence the treatment will need to be personalized with identification of a correct
subset of patients. Immunohistochemistry, when feasible, may identify such patients
with concomitant nuclear b-catenin and tumor-wide staining of its target Glutamine
Synthetase. Once identified, b-catenin inhibition is predicted to have significant therapeutic
consequences based on several proof-of-concept in vitro studies using HCC cell lines.
Using previously characterized mouse model that induces HCC via CTNNB1 mutations,
we now show that b-catenin knockdown after tumor development has a dramatic impact
on tumor growth such that majority of mice showed no evidence of HCC. Additional small
molecule has also been identified that affects beta-catenin signaling in several HCC cell
lines as well as in vivo in a Wnt reporter zebrafish. Thus, we demonstrate in vivo efficacy
of b-catenin therapeutic inhibition as a treatment option in HCC.
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GENE SIGNATURES AND PCR-ARRAYS: ARE
THEY OF PRACTICAL USE TODAY?
1
Andreas Teufel 1
Universitätsklinikum Regensburg, Regensburg, Germany
Over the past decade multiple clinical relevant gene expression signatures have been
reported in HCC. These studies reported potential value in diagnosis as well as prediction
of survival, metastatic spread, or recurrence after resection. However, considerable
heterogeneity across these signatures resulted in a diversity in numbers of genes and
differences in prognostic relevance. Thus, validation of these signatures in independent
patient cohorts remained difficult. As a result, these signatures are still not integrated into
clinical routine diagnostics and clinical decision making. This may in particular be due
to cirrhotic tissue generally used as controls, being itself significantly altered compared
to normal liver tissue. Furthermore, cirrhosis may be induced by significantly differing
underlying chronic liver diseases. However, increased robustness in diverse patient
cohorts will be necessary for a successful translation of these signatures into clinical routine
testing. More robust signatures may in particular be achieved by (further) reduction of the
number of genes / parameters in gene signatures allowing to analyze these parameters
in more robust technological approaches. Furthermore, recent reports have also
demonstrated that a successful integration of data from diverse biological layers such as
gene expression, methylation or protein expression may also contribute to reproducibility
and stability of gene expression signatures in HCC. However, the development of
more integrative signatures will also rely on advances in the field of bioinformatics and
the development of more sophisticated integrative algorithms. Nevertheless, hallmark
signaling of tumors, well established for the majority of solid tumors, such as proliferative
signaling, resistance against cell death, immortality, pro-angiogenic signaling, activation
of invasive and metastatic programs as well as pro-inflammatory signaling could be
recapitulated for HCC. Recent work has further demonstrated that many gene expression
changes and mutations found in tumor genome sequencing experiments were overlapping
in common signaling pathways. These data suggest that focusing on superimposed
biological functions or signaling pathways rather than single genes may also be helpful
in identifying robust genetic signatures. In summary, although several genetic signatures
had significant predictive ability, the successful translation into and rigorous evaluation
for a clinical application is yet to be generated. Milestone steps to achieve this goal will
be successful data integration, data reduction but also precise clinical and histological
definition of patient cohorts to be studied for future signature development.
References
Nault JC, Zucman-Rossi J. Genetics of hepatocellular carcinoma: The next generation. J
Hepatol. 60: 224-6, 2014.
Teufel A, Marquardt JU, Staib F, Galle PR. Snapshot liver transcriptome in hepatocellular
carcinoma. J Hepatol. 56: 990-2, 2012.
Marquardt JU, Galle PR, Teufel A. Molecular diagnosis and therapy of hepatocellular
carcinoma (HCC): an emerging field for advanced technologies. J Hepatol. 56: 267-75,
2012.
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HEPATOCELLULAR CARCINOMA:
EPIDEMIOLOGY AND GLOBAL BURDEN
1
Shiv Kumar Sarin 1, A Jindal 1, AS Bhadoria 1
Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
Hepatocellular carcinoma (HCC) is one of the major causes of liver related mortality
in cirrhosis. It is the sixth most common cancer worldwide and the third leading cause
of cancer mortality. There is significant geographic and racial disparity in the incidence
and risk for development of HCC. Majority of all liver cancers occur in high-rate areas
(>20 HCC /100,000 persons) mainly in Asia (China, Japan and Korea) and Sub-Sahara
Africa (Zimbabwe and Egypt), where chronic Hepatitis B Virus (HBV) infection and/or
Aflatoxin B1 exposure are common. However, among low-rate areas (<10 HCC /100,000
persons) which includes northern Europe as well as North and South America, Hepatitis
C Virus (HCV) infection, alcohol and metabolic syndrome play more important roles. The
length of time these factors have been present determine the risk of HCC development.
Environmental, host genetic, and viral factors can also affect the risk of HCC. Often
patients with HCC presents late and only in less than a third of patients it is curable at
presentation, rest have 1-year survival of less than 50% and the 5-year survival < 10%.
More than 80% of HCC patients are cirrhotic. The 5-year cumulative risk of developing
HCC in cirrhosis ranges between 5% and 30%, more in Asians and in the presence of
Hepatitis B/C and decompensated cirrhosis. At least 80% of HCC have positive serology
for hepatitis B and/or hepatitis C viruses, with male predominance. Contrary to west, it
is not unusual to have HCC before fourth decade in areas where HBV is hyperendemic
(e.g, East Asia), as the infection acquired is largely perinatal. There are several known
risk factors for HCC, such as advanced age, male gender, high viral load, raised ALT,
HBeAg positive status cirrhosis, and some of these form the basis of HCC risk scores
such as GAG-HCC, CU-HCC and REACH-B. Suppression of HBV viral replication through
effective use of antiviral therapy or Interferon therapy has been shown to reduce but not
eliminate the risk of HCC. A 5-fold higher risk to develop HCC among non-cirrhotic chronic
HBV infected subjects is documented in comparison to healthy cohorts. A study conducted
by us also revealed that HBsAg-negative and antibody positive (anti-HBe and/or total antiHBc) have 12.34 times higher risk for HCC, irrespective of presence of cirrhosis. Finally,
other factors such as HBV genotype D (vs. A, in India) and genotype C (vs. A/B, except
Taiwan where B <50 yrs is more often associated with HCC), presence of basal core
promoter mutations, such as T1762 and A1764, mutations in Pre-S, positive family history
of HBV also play an important role.
HCV infection is associated with a 15- 20 fold increase in risk for HCC compared with
HCV-negative subjects; nearly two times more with genotype 1b. Successful HCV cure
substantially reduces (57-75%) the risk. Predicting role of HCV viral load and genotype is
still controversial.
For the past century, the global risk of HCC has been largely driven by HBV and HCV
infection. This is rapidly changing. Common risk factors relevant to HCC risk include
chronic alcohol intake (> 50 g/day), presence of diabetes (OR-2.5), obesity (OR1.5), chronic smoking and co-infections (HBV/HCV, HIV/HCV and HBV/HDV). Alcohol
might induce HCC risk by the production of acetaldehyde and free radicals during its
metabolism, cytochrome P4502E1 induction, modulation of cell regeneration, promotion
or exacerbation of nutritional deficiencies, and alterations of the immune system. It is still
uncertain whether alcohol is related to HCC independently of cirrhosis. Non-alcoholic fatty
liver disease/Non-alcoholic Steatohepatitis (NASH) with or without metabolic syndrome
is already emerging as the one of the commonest risk factor of HCC and intrahepatic
choalngiocarcinoma. The later is gradually becoming an important differential diagnosis of
HCC. A fair proportion of HCC developing in NASH patients occurs in non-cirrhotic livers,
elderly subjects and with metabolic syndrome. Small amount of alcohol consumption,
NASH and obesity individually add to the risk of developing HCC. Insulin resistance
increases the risk of HCC substantially. From nearly 60% of all HCC due to HBV, there is a
change in the trend with rise in the HCC due to alcohol and NASH in the past two decades
in our country. Of the 468 HCC recently analyzed by us, about 18% have association
with alcohol or obesity and no underlying viral infections. Coffee consumption has been
shown in several studies and meta-analysis to reduce the risk of cirrhosis and HCC. The
relative risk for coffee drinkers vs non-coffee drinkers was 0.54 from case-control studies
and 0.64 from cohort studies in development of HCC. Early assessment of hepatic fibrosis
using non-invasive tests such as fibroscan, reduction in alcohol consumption, large scale
surveillance programs and universal vaccination against hepatitis B would help reduce the
growing burden and late detection of HCC.
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Massimo Colombo 1
1st Division of Gastroenterology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, University of Milan, Milan, Italy
1
Surveillance of at risk patients is an effective strategy to improve both treatment of
hepatocellular carcinoma (HCC). The international societies EASL, AASLD and APASL
concurrently identify patients with cirrhosis as the main target of surveillance whereas the
algorithms slightly differ with respect to targets, modalities of screening and recall policies.
AASLD and EASL identify non cirrhotic patients with chronic hepatitis B as ideal candidates
for screening, AASLD focusing on Asian males older than 40 years of age and Asian
females older than 50 years together with all HBV carriers with a family history of HCC and
African/north American blacks older than 20 years, since these patient categories are at
increased risk of liver cancer as a consequence of early exposure to the hepatitis B virus.
EASL suggests screening for all patients with clinically active hepatitis B as well for those
with a family history of HCC (understudied in the West compared to EASL).
AASLD identifies patients with NAFLD as being at risk of developing liver cancer. However,
NAFLD embraces a broad set of patients ranging from those with hepatic steatosis to
patients with full-blown cirrhosis, not to speak about the many patients with competing risks
with liver mortality, and issues in the recall policy algorithms based on contrast imaging
techniques thought to be accurate in patients with cirrhosis and chronic active hepatitis
B, only. EASL recommends screening of chronic hepatitis C patients with bridging fibrosis
(Metavir F3), too, given the increased prevalence of HCC in these patients, however,
bridging fibrosis being frequently misdiagnosed with either a percutaneous liver biopsy or
such non invasive approaches, as Fibrotest and Transient elastography.
Abdominal US is the standard of care for surveillance, whereas the serum alpha-fetoprotein
(AFP) assay is no longer considered for screening (and diagnosis) by the western societies
due to its poor accuracy and the lack of a standardized recall policy. A meta-analysis of
studies of surveillance indicated that the semiannual combination of US+AFP has no added
value compared to US alone for the early diagnosis of HCC. This notwithstanding, the
AFP assay still holds a place in the recommendations by APASL, where high risk patients
with chronic viral hepatitis or cirrhosis, will receive the test in combination with serum desgamma-carboxy-prothrombin (DCP), an abnormal prothrombin protein elaborated by the
neoplastic liver cells and AFP-L3, a fucosylated variant of AFP that most hepatologists in
the West are reluctant to adopt for both screening and diagnosis of HCC.
All societies share the same recommendation for semiannual surveillance with abdominal
US, as the intervals of screening are not dictated by the level of cancer risk, but rather
by the growth rate of the tumor, which in fact takes 6 months to double its volume, on
average. While the goal of intensified screening every 3 months is to identify liver cancer
at the smallest size in order to optimize treatment, the effectiveness of this policy is in fact
not evidence based. In a randomized controlled study in patients with alcohol and HCV
related cirrhosis in France, the cumulative five-year incidence of HCC nodules detected
with a 3 month US screening was as high as in the arm undergoing 6 month screening
(10.0% vs 12.3%), with no differences in the cumulative incidence of small tumors, rates
of access to curative treatments (62% vs 58%) and liver-related mortality (85% vs 86%).
Noticeably, the higher five-year cumulative incidence of liver nodules in the 3 month arm
(41% vs 28%) clearly heralds a greater economic burden to reach a final diagnosis in this
arm, which might negatively impact on morbidity and cost utility ratio of the strategy of
intensified screening.
The diagnostic algorithm of a nodule detected during surveillance is framed by a
standardized recall policy, which in the West varies according to the size of the nodule
whereas in the APASL world depends on arterial uptake of the contrast. Owing to the
fact that a less than 10 mm HCC is difficult to diagnose by contrast CT scan or MRI as
a consequence of immature arterialization of the nodule, an enhanced follow-up with US
every 3 months to detect any increase in size or change in echo pattern may guide further
investigations with radiology or echo-guided liver biopsy. Conversely, nodules greater than
10 mm in diameter, which represent 80% of tumors detected during surveillance, can be
diagnosed by CT or MRI imaging whenever the specific pattern of an intense contrast
uptake during the arterial phase (wash-in) is seen together with a contrast wash-out during
the venous/delayed phase. Contrast-enhanced US is not recommended by AASLD and
EASL to diagnose HCC, because it may fail to distinguish intrahepatic cholangiocarcinoma
from HCC in cirrhosis. This is not the policy of APASL which suggests US enhanced by
hepatospecific contrast to diagnose hypovascular tumors.
While a typical “wash-in + wash-out” pattern suffices to diagnose an HCC >10 mm using
a single imaging technique in a sequential study, a liver biopsy is deemed necessary to
confirm the diagnosis of nodules which do not display these characteristic features at
contrast imaging. It should be borne in mind, however, that non-invasive diagnosis of a de
novo HCC is recommended in cirrhotic patients and patients with chronic hepatitis B, only.
All in all, all societies acknowledge that surveillance is a standard of care for HCC whereas
future efforts should be geared toward removing the barriers to universal surveillance of at
risk patients by concentrating on improving access to testing and consequent treatment.
SCREENING FOR HCC: WHOM, HOW,
AND HOW OFTEN
COST EFFICACY ANALYSIS OF HCC SCREENING
1
Morris Sherman 1, Wendong Chen 1
University of Toronto, Toronto, Canada
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DIAGNOSIS OF HCC
1
Ahmed Ba-Ssalamah 1
Radiology, Medical University of Vienna, Vienna, Austria
There have been about 10 cost efficacy analyses looking at screening for HCC. Each
describes a different model of the disease, with different transition frequencies, different
starting populations, and different interventions. However, most come to the conclusion
that screening for HCC is effective and cost effective, meaning that the intervention
prolongs life over the whole cohort by more than 3 months, and does so at an incremental
cost-effectiveness ratio of less than $50,000/QALY. However, different analyses come to
different conclusions as which method of HCC screening is most cost effective. Some
describe testing with AFP as the most cost effective, whereas others find that either
ultrasound alone or ultrasound plus AFP is most cost effective. CT scan and MRI, with
one exception, are found to be cost-ineffective. We constructed a systematic review of
meta-analyses of HCC screening. We found 12 studies meeting our criteria. Results were
expressed a ratio normalized for gross domestic product of the country where the analysis
was done. This allowed comparison of costs between studies in different countries. The
analysis found that screening with ultrasound alone at 6 monthly intervals was the most
cost-effective method of HCC screening. This is validation of the AASLD and EASL
recommendations.
The introduction of multidetector CT (MDCT) for abdominal imaging has changed the face
of the diagnostic work-up of HCC. MDCT scans can acquire thin slices less than 1 mm
thick over a large volume in less than 20 seconds during one breath-hold. In combination
with optimized contrast material administration, using a care bolus technique, and the
performance of 3 D reconstructions, we not only can detect and characterize HCC lesions,
but also obtain a complete staging of the disease in the chest, the whole abdomen (including
lymph nodes), as well as the musculoskeletal system. Therefore, CT scan has become
the workhorse in the diagnostic work-up of HCC. The use of a combined PET-CT scan is
revolutionary for oncologic diseases; however, its value is limited in the initial diagnosis of
HCC, but may be helpful during follow-up to detect recurrent disease or distant metastases.
The continuous development of MRI hardware and software technology, including the use
of high-field-strength (3 Tesla) scanners in daily clinical practice, has made this technique
the most sensitive and specific imaging modality for the detection of HCC. Using new
sequences, such as DWI and SWI, it is possible to differentiate the numerous nodules that
occur with liver cirrhosis, such as regenerative nodules and dysplastic nodules, especially
after administration of hepatobiliary contrast agents. Furthermore, contrast-enhanced MRI
in combination with DWI is considered the most sensitive technique for the follow-up of
HCC after TACE or RFA. In this presentation, the diagnostic radiologic algorithm for the
differential diagnosis of HCC, and the treatment options based on radiologic findings, as
well as follow-up and surveillance, will be discussed.
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OTHER DIAGNOSTIC TOOLS: CEUS,
PET-CT AND OTHERS
1
Fabio Piscaglia 1
Div of Internal Medicine, Dpt Medical and Surgical Sciences,
University of Bologna, Bologna, Italy
Contrast Enhanced Ultrasound (CEUS) is performed in Europe with the single contrast
agent registered for liver investigation, namely sulfur exafluoride (SonoVue®) , which is a
pure blood pool agent, whereas Sonazoid® is also registered for liver investigations in Far
East Asian Countries. The latter agent undergoes uptake by the reticulo endothelial cells
after having circulated in the arterial and venous phases. The vascular phases (arterial,
portal and venous) are the same for the various contrast agents.
CEUS is able to depict the typical vascular pattern of enhancement of hepatocellular
carcinoma (HCC), corresponding to homogeneous hyperenhancement in ther arterial
phase followed up by wash-out in the venous phase. However this pattern is observed
also in approximately 50% of the cases of mass forming peripheral CholangioCellular
Carcinoma (CCC) arising in cirrhosis. At variance, the latter entity (CCC) usually (but not
always) doesn’t show wash-out at contrast enhanced CT or MRI, due to the different
pharmacokinetics of CT/MRI and ultrasound contrast agents. For these reasons and
specifically the risk of false positive diagnosis of HCC in case of CCC, CEUS, initially
introduced in the American (AASLD) guidelines in 2005, was dropped from both the 2011
AASLD and the 2012 EASL guidelines for the diagnosis of HCC. However, the same
choice was not made by other continental and national important hepatology societies
(Asian, Japanese, Italian). The pattern of hyperenhancement+wash out at CEUS may
not be 100% specific for HCC, but it is anyhow totally specific for malignancy. Conversely
CCC may show hyperenhancement in the arterial phase at CT/MRI, but tend to lack
venous wash-out, as it happens in some non malignant (expecially in some high grade
dysplastic) hepatocellular nodules. This means that no definitive diagnosis is possible
by CT/MRI imaging alone by the latter techniques (not even of benign versus malignant
nature) in case of CCC. The lack of a diagnostic pattern for CCC at CR/MRI would imply
a biopsy, whose false negative rate at first attempt is reported as high as 35% in small
nodules (Forner, Hepatology 2008). Moreover, the rate of CCC among newly developed
liver nodules has been repeatedly reported to range between 0.5 and 2%. Thus, since
only half CCC show the typical HCC pattern, the risk of misdiagnosis would be less than
1% of newly developed nodules and in most instance, a misdiagnosis would not affect the
treatment strategy (e.g. surgical resection).
Moreover, some subtle CEUS features, such as rapid and marked wash-out tend to
suggest the possibility of CCC based on expert opinion, but endorsed by the European
Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). Briefly,
it has to be acknowledged that the “typical” CEUS pattern of HCC may include a ≤1%
risk of CCC and that the role of such risk of misdiagnosis has been differently weighted
by various hepatology societies. On practical grounds, CEUS is usually less sensitive
than CT or MRI in detecting wash-out, whereas it is highly sensitive in identifying arterial
hyperenhancement thanks to its real time modality. Hence, in the instance in which CEUS
shows a typical malignant pattern, but discrepant from CT or MRI (which are always
recommended to stage the disease), with wash-out detected only by CEUS but not by CT/
MRI, a high suspicion of CCC should arise.
When instead wash-out is not detected by CEUS, but it is present at CT/MRI a diagnosis
of HCC is reached, with the lack of wash out at CEUS suggesting a more differentiated
tumor than in cases where wash-out is present at all imaging modality.
Positron Emission Tomography (PET) may be performed with different tracers. The most
interesting for HCC are 11C-acetate and 18F-fluoro-deoxyglucose (18F-FDG, classical
tracer). High signal with 11C-acetate are usually found in well differentiated HCC, whereas
the contrary happens with 18-FDG, the latter also in sites of metastatic disease. However,
both tracers are not highly sensitive and they are no better than CT or MRI in terms of
accuracy, despite 18-FDG is more sensitive than nuclear scan for bone metastasis. 18FDG is also poorly sensitive for lung metastasis from HCC smaller than 1 cm. Thus,
PET has no current role in the diagnostic algorythm of HCC. It has rather a prognostic
role, since high tumor signal with 18-FGD is associated with higher recurrence rate and
shorter time to progression after radical treatments of HCC. PET with 18FDG may also be
utilized to detect extrahepatic spread when this diagnosis is relevant and the risk for it is
consistent (primary HCC >5 cm) (Lee JE, WJG 2012).
HISTOLOGICAL CLASSIFICATION OF HCC:
OLD-FASHIONED OR STILL HOT?
1
Michael Torbenson 1
Johns Hopkins Hospital, Baltimore, United States
Liver tumors are classified into subtypes because subtypes are relevant to clinical care
and to tumor biology. Historically and today, the only important liver tumor classification
systems are those based on tumor morphology revealed by light microscopy. Now and in
the future, advances in science will lead to new discoveries in liver tumor biology. How do
we best incorporate these new discoveries into tumor classification? Some have advocated
that there should be no incorporation, but instead, old ways of tumor classification should
be discarded and new molecular classifications embraced. In this regard, “out with the
old, in with the new” has become an increasingly common theme in the scientific study
of liver tumors. I hope to convince you otherwise. Morphology is a direct expression of
genetics in the tumor microenvironment. Should a botanist study only DNA and ignore
the forest? Likewise, the molecular study of tumors without morphology is inherently
limiting. By examining specific examples, we will see how direct observation of tumor
morphology through light microscopy strengthens molecular studies and how molecular
studies can in turn refine light microscopy classifications. Histological classifications are
old, but not old fashioned. Molecular classifications are hot now, but all things cool, and
their longevity in the end will depend on their relevance to clinical care and tumor biology.
Future classification of liver tumors will be derived by incorporating together histology and
molecular findings and the future lies to neither alone but to both together.
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RESECTION FOR HCC, CURRENT DATA
Christian Toso 1
Services de chirurgie viscérale et transplantation,
Hôpitaux Universitaires de Genève, Geneva, Switzerland
1
Outcomes after liver resection for hepatocellular carcinoma have improved over the
recent years, with expected five-year patient survival rates of 50-80% (Lim et al. BJS
2012). These improvements are linked to better patient selection, improved pre-operative
liver parenchyma preparation and refined peri-operative patient management.Factors
generally accepted as contra-indications for surgery include advanced liver disease (Child
B and especially C), signs of portal hypertension (hepatic venous pressure gradient >10
mmHg) and the presence of extra-hepatic disease. In addition, recent data also brought
attention on the risks linked to HCC liver resection in patients with NASH, with up to 18%
mortality at 90 days. Such patients with metabolic disease and abnormal liver parenchyma
should be selected carefully and pre-surgery portal vein embolization should be used
liberally (Cauchy et al. BJS 2013). A variety of patients with HCC can benefit from surgery.
They include patients with single small (≤3 cm) HCCs, although some of them would
be better treated by radio-frequency ablation. The choice between both techniques
should be based on tumor location (HCC bulging at the liver surface is better resected
and HCC deep in the parenchyma is better treated by RFA). Large HCCs can be well
treated by resection. They are expected to have a good biology (slow growing without
metastasis) and require only minimal functional liver parenchyma resection. Patients with
oligo-nodular HCCs may also benefit from resection, although transplantation may be
preferred in young patients without major co-morbidities.Pre-surgery liver parenchyma
preparation has improved over the recent years. Portal vein embolization helps increasing
the volume and the quality of the expected liver remnant within four weeks, allowing more
extreme resections. This strategy is currently the best studied pro-regenerative tool, but
radiofrequency embolization has recently also gained attention. It helps both treating the
HCC and promoting the growth of the contra-lateral liver lobe, yet requiring more time
to achieve a significant effect (control CT is usually performed at three months)(Gaba et
al Ann Surg Oncol 2009).Thanks to the help of multidisciplinary teams, patients can be
better prepared for surgery. This includes promoting smoking cessation, which decreases
post-operative lung complications even after a few days without smoking. Pre-surgery
exercising (daily walking) is recommended in order to have the patients “as fit as possible”
at the time of resection. With the implementation of “enhanced recovery after surgery”
programs patients are mobilized early, with the use of epidural analgesia for the first
few days, the gastric tube is removed in the OR and the bladder catheter on day one
(Schulz et al. BJS 2013). Finally, selected patients can benefit from minimally invasive
surgery, with the potential of a faster recovery.Overall, the multi-disciplinary choice of
the HCC treatment, the liberal use of pro-regenerative liver strategies, the appropriate
patient preparation to surgery and the establishment of enhanced recovery after surgery
programs can help further improving HCC resection outcomes and cost-effectiveness.
178
RESECTION OR RFA AS FIRST LINE TREATMENT
FOR EARLY STAGE HCC?
Alejandro Forner 1 , Alexandre Liccioni 1, Alessia Gazzola 1,
Roberto Di Donato 1, Maria Reig 1
1
BCLC group. Liver Unit. Barcelona, Barcelona, Spain
Hepatocellular carcinoma is the sixth most frequent neoplasia worldwide and currently
constitutes the main cause of death in cirrhotics. The only chance to cure this disease
is diagnosing it at an asymptomatic, early stage, when potential curative treatments are
available. For that reason, surveillance for HCC is accepted and is based on biannual
ultrasound. The widely application of surveillance in this population and the continuous
imaging technical improvements has allowed the more frequent detection of solitary,
small lesions (<2cm) in patients with preserved liver function. At that point, HCC may
have not still developed peritumoral spread, and thus, any treatment able to completely
remove the tumor has a high chance to cure the disease. Classically, liver resection has
been considered the treatment of choice since it removes completely the tumor and the
surrounding liver parenchyma. If the explant analysis shows a vaguely nodular HCC with
neither microvascular invasion nor satellites, the probability of early tumor recurrence
is almost zero and the long- term outcome is outstanding. Percutaneous ablation has
been considered the treatment of choice for early HCC when surgical resection was
not recommended. Ablation is based on the destruction of the tumor by the injection of
several substance, mainly alcohol or acetic acid, or by temperature modification, being the
radiofrequency ablation (RFA) the most widely used technique. Technical improvements
associated with an increasing experience have allowed high rates of complete response
after RFA, particularly in those HCC smaller than 2 cm. Since in these very early tumors
(≤2cm) the probability of dissemination is very low, and the probability of complete
response with a safe margin with RFA is high (90–100%), it is likely that resection and
RFA are similar in terms of outcome. Up to know, only three randomized-controlled trials
coming form Asia have compared both options in early HCC with contradictory results.
Cost-effectiveness analyses using a Markov model concluded that for very early HCC
(single nodule <2cm) in Child-Pugh class A patients, RFA provided similar life-expectancy
and quality-adjusted life-expectancy at a lower cost. Several cohort studies endorse these
figures and in fact, the only advantage of surgical resection in this setting would be the
opportunity to assess the risk of early recurrence by pathology (microvascular invasion or
satellites). If a high risk of recurrence is detected in the specimen, liver transplant should
be indicated (the so called “ab initio” indication).
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If a patient is not candidate for liver transplant, the availability of the pathology
characteristics will not change the treatment strategy. For this reason, resection will not
offer better survival than ablation in BCLC 0 patients and RFA would become the first-line
option, leaving surgery for those patients with treatment failure. This is the major change
introduced in the BCLC in 2012 and represents a major refinement in the treatment
approach of patients with very early HCC.
References:
1. Chen MS, Li JQ, Zheng Y, Guo RP, Liang HH, Zhang YQ, et al. A prospective randomized
trial comparing percutaneous local ablative therapy and partial hepatectomy for small
hepatocellular carcinoma. Ann Surg 2006;243:321–328.
2. Cho YK, Kim JK, Kim WT, Chung JW. Hepatic resection versus radiofrequency ablation
for very early stage hepatocellular carcinoma: a Markov model analysis. Hepatology
2010;51:1284–1290.
3. Cucchetti A, Piscaglia F, Cescon M, Colecchia A, Ercolani G, Bolondi L, Pinna AD.
Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation
for early hepatocellular carcinoma. J Hepatol. 2013;59:300–7.
4. EASL-EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma.
J Hepatol 2012;56:908-943.
5. Feng K, Yan J, Li X, Xia F, Ma K, Wang S, Bie P, et al. A randomized controlled trial of
radiofrequency ablation and surgical resection in the treatment of small hepatocellular
carcinoma. J Hepatol 2012;57:794-802.
6. Forner A, Llovet JM, Bruix J. Hepatocellular carcinoma. Lancet 2012;379:1245-1255.
7. Fuks D, Dokmak S, Paradis V, Diouf M, Durand F, Belghiti J. Benefit of initial resection
of hepatocellular carcinoma followed by transplantation in case of recurrence: An
intention-to-treat analysis. Hepatology 2012;55:132–140.
8. Germani G, Pleguezuelo M, Gurusamy K, Meyer T, Isgro G, Burroughs AK. Clinical
outcomes of radiofrequency ablation, percutaneous alcohol and acetic acid injection
for hepatocelullar carcinoma: a meta-analysis. J Hepatol 2010;52:380–388.
9. Huang GT, Lee PH, Tsang YM, Lai MY, Yang PM, Hu RH, et al. Percutaneous ethanol
injection versus surgical resection for the treatment of small hepatocellular carcinoma:
a prospective study. Ann Surg 2005;242:36–42.
10.Livraghi T, Meloni F, Di Stasi M, Rolle E, Solbiati L, Tinelli C, Rossi S. Sustained
complete response and complications rate after radiofrequency ablation of very
early hepatocellular carcinoma in cirrhosis. Is resection still the treatment of choice?
Hepatology 2008;47:82-89.
11. N’Kontchou G, Mahamoudi A, Aout M, Ganne-Carrie N, Grando V, Coderc E, Vicaut E, et
al. Radiofrequency ablation of hepatocellular carcinoma: Long-term results and prognostic
factors in 235 Western patients with cirrhosis. Hepatology 2009;50:1475-1483.
12.Rodríguez de Lope C, Tremosini S, Forner A, Reig M, Bruix J. Management of HCC.
J Hepatol 2012;56 Suppl:S75-87.
13.Sala M, Fuster J, Llovet JM, Navasa M, Sole M, Varela M, et al. High pathological risk
of recurrence after surgical resection for hepatocellular carcinoma: an indication for
salvage liver transplantation. Liver Transpl 2004;10:1294–1300.
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RESECTION FOR LARGE AND MULTIFOCAL HCC
1
Jigjidsuren Chinburen 1, Michelle Gillet 1, Enkhbold Chinbold 1
Hepato pancreato biliary surgery, National Cancer Center, Ulaanbaatar, Mongolia
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PROGRESS IN PERCUTANEOUS TREATMENT
1
Jens Ricke 1
University Hospital Magdeburg A.ö.R, Magdeburg, Germany
Introduction: Hepatocellular carcinoma (HCC) is the first leading cause of cancer-related
mortality in both men and women in Mongolia, and its incidence is among the highest
worldwide. HCC is strongly associated with liver cirrhosis and hepatitis B and C infections.
Surgical resection remains the first-line therapeutic strategy for HCC despite recent
advancements in treatment modalities. However, underlying liver diseases significantly
limit the number of HCC patients eligible for surgical resection. In general, only 20% to
30% of patients with HCC are eligible for resection because of compromised liver function
reserve.
Aims: Indications for surgical treatment of patients with large or vascular invasive
hepatocellular carcinoma (HCC) remain controversial. According to the Barcelona Clinic
Liver Cancer (BCLC) classification, hepatic resection should be performed only in patients
with early stage HCC (BCLC stages 0 and A), but no for patients with intermediate and
advanced stages (BCLC stages B and C). This study aimed to determine whether hepatic
resection improves survival for patients with BCLC stages B and C HCC.
Methodology: A retrospective review of 347 HCC patients who underwent hepatic
resection at the National Cancer Center (NCC) of Mongolia between 2008 and 2012 was
conducted. Of 347 patients, 125 had BCLC stage 0/A disease, 211 had stage B disease
and 11 had stage C disease. Mortality and survival outcomes were analyzed.
Results: For patients with BCLC stages 0/A, B and C disease 30-day hospital mortality
was 1.6, 2.8 and 0%, respectively. The 1-year overall survival rates were 91.2% in BCLC
stage 0/A patients, 80.1% in stage B patients and 31.2% in stage C patients (p<0.001);
and the 2-year overall survival rates were 68% in stage 0/A patients and 51.8% in stage
B patients (p=0.05). All patients with stage C disease died within 432 days after surgery. Serum alpha-fetoprotein (AFP) level above 600 ng/ml was found to be an independent
predictor of overall survival.
Conclusions: Patients with BCLC stages B and C HCC can tolerate hepatic resection
with low mortality and survival benefits, especially those with serum AFP below 600 ng/
ml. These results show that hepatic resection can provide survival benefit for patients
with advanced HCC especially in resource-poor settings with limited access to adjuvant
therapy.
New image guided, percutaneous techniques are available for both early as well as
advanced stages of HCC. For image guided ablation of HCC up to 3 cm RFA has evolved
as the standard application in the past years. Despite a lack of comparative data on efficacy,
microwave ablation has replaced RF treatment in many centers due to facilitated use
and shorter intervention time. Irreversible electroporation is another new local treatment
which has not yet progressed beyond the experimental stage. A single arm multicenter
trial assessing 28 HCC patients only has been presented recently, and further data on
treatment of other hepatic malignancies with IRE is equally limited. Consequently, IRE
use can only be supported in clinical trials today. Radiation techniques overcome intrinsic
problems of thermal ablation such as cooling effects, unfavorable location such as in the
liver hilum or liver dome, or excessive tumor size. Stereotactic body irradiation (SBRT) is
limited by the number and size of lesions; however, the non-invasiveness of the technique
(except for the large body volume simultaneously exposed to low-dose radiation including
liver parenchyma) represents a significant advantage. CT-guided brachytherapy has
proven to be effective also in very large and multiple tumors. A recent randomized study
indicated advantages over TACE in advanced patients predominately due to much more
durable local control even in multiple tumors. Finally, as percutaneous treatments only
represent a fraction of the tool box available for HCC, their sequential use as well as their
combination with other interventional techniques or systemic treatments (i.e. Sorafenib)
bares very strong potential for improved outcomes. Data on sequential or multimodal use
of ablation techniques is hard to gather; as of today, no in-depth recommendations exist on
how to sequence the surgical, interventional and systemic toolbox for an individual patient.
The SPACE trial comparing a very strict sequence of sorafenib and TACE with placebo and
TACE failed to proof a benefit; the TACE 2 trial with more flexibility in sequencing TACE
and sorafenib still is recruiting. SORAMIC, a trial randomizing patients to Y90 followed by
sorafenib or sorafenib only has recently published an interim safety analyses with positive
results. Data on the effectiveness of that treatment sequence can be expected by the end
of 2015.
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ADJUVANT AND NEOADJUVANT TREATMENT
WITH RESECTION
1
Francis Yao 1
University of California, San Francisco, United States
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OLT FOR HCC - EXTENDING THE INDICATION
1
Yaman Tokat 1
Organ Transplantation and Research Center, Izmir, Turkey
- One of the major challenges of hepatic resection for hepatocellular carcinoma (HCC) is
the high incidence of HCC recurrence (within 1-2 years) or de novo HCC (> 2 years) after
curative resection.
- Pre-operative local regional therapy (chemoembolization) has not been shown in
randomized controlled trials (RCT) to improve outcome after resection.
- There has been no proven benefit of systemic chemotherapy in HCC, and the safety and
toxicity are of major concern after resection in patients with cirrhosis. Most RCT involving
Uracil-tegafur, Carmofur, Epirubicin + Carmofur, and Cepecitabine have shown no benefit.
- Acyclic retinoid Polyprenoic Acid has been shown in one study by Muto et al. in 1996 to
have a significant benefit in preventing second HCC after resection (2). Additional studies
using Peretinoin are currently in progress.
- A recent RCT involving 31 Japanese centers using vitamin K2 (Menatetrenone) did
not show a significant benefit of vitamin K2 in DFS or time to recurrence after curative
resection (2).
- Results of Sorafenib as adjuvant treatment in the prevention of HCC recurrence after
resection (STORM trial: http://clinicaltrials.gov.com, NCT00692770) are not yet available.
- Many RCTs have investigated anti-viral therapy (primarily Interferon based regimen) after
resection for patients with chronic hepatitis C or B, with mixed results. Meta-analysis of
these RCT before 2012 appears to favor treatment (3). However, a recent large RCT
of adjuvant alpha-interferon from the Taiwan Cooperative Oncology group involving 268
patients (80% HBV and 20% HCV) showed that alpha-interferon did not reduce postoperative recurrence of HCC (4).
- The advance of new Direct Acting Agents (DAA) for hepatitis C with very high rates of
sustained virologic response opens the opportunity for future studies of these new anti-viral
agents in preventing HCC after resection for patients with chronic hepatitis C infection (5).
References
1. Muto Y, et al. N Engl J Med 1996;334:1561-1567.
2. Yoshida H, et al. Hepatology 2011;54:532-540.
3. Breitenstein S, et al. Br J Surg 2009;975-981.
4. Chen LT, et al. Ann Surg 2012;255:8-17.
5. Schmidt WN et al. Clin Gastroenterol Hepatol 2013 [Epub]
Introduction: In liver transplantation (LT) for hepatocellular carcinoma (HCC), patient
selection depends on morphological features. We performed a clinicopathological analysis
of risk factors that affected survival after liver transplantation for HCC.
Aims:
Methodology: Between June 2004 and September 2013, 710 liver transplants (533
living donor LT and 177 deceased donor LT) were performed in Florence Nightingale
Hospital, Liver Transplantation Unit. In a total of 130 patients were diagnosed HCC after
the examination of the pathology specimens. Ten patients were excluded (4 patients with
perioperative death and 6 patients with mixed HCC and cholangiocellular carcinoma) and
the remaining 120 patients were analyzed retrospectively.
Results: There were 106 male and 14 female patients. The mean age was 55.3 (range,
23-72). In a mean follow-up of 36.1 (range, 1-105) months, recurrence was seen in 19
patients (15.8%). Of 24 patients with post-transplant mortality, 14 were related to HCC
recurrence. The recurrence rate was significantly higher in patients with a pre-LT alphafetoprotein (AFP)>400 (5/9, 55.5%) vs. those with pre-LT AFP
Conclusions: In patients with HCC, pre-LT AFP>400 and grade 3 histologic differentiation
are indicators of poor prognosis after LT. For better patient selection for LT, prognostic
criteria related to tumor biology should also be considered.
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MANAGEMENT OF HCC ON THE OLT
WAITING LIST
1
Chris Verslype 1, Fredeik Nevens 1
Division of Hepatology, University Hospitals Leuven, Leuven, Belgium
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PATIENT SELECTION FOR TACE IN
INTERMEDIATE STAGE HCC
1
Wolfgang Sieghart 1
Department of Internal Medicine III, Division of Gastroenterology/Hepatology, Liver
Cancer (HCC)-Study Group, Medical University Vienna, Vienna, Austria
In addition to the bridging strategy, many centers also consider patients as candidates
for liver transplantation once they have been successfully “down-staged” to the country
specifc listing criteria for HCC. Due to the low number of prospective studies with welldefined entry criteria, and the lack of information on several of the above mentioned
outcome parameters, it is difficult to define specific decision criteria on the most effective
treatment plan.
Nevertheless, many studies have identified risk factors for tumor progression and poor
outcomes, such as the lack of a (sustained) response to neo-adjuvant treatments, poor
tumor differentiation, vascular invasion and high values of alfa-foetoprotein. In the near
future, more insights in tumor biology may provide us with better prognostic and predictive
markers.
The implementation of some of these factors in transplant allocation systems is likely to
optimize the results of liver transplant programs.
Transarterial chemoembolization (TACE) is the standard of care for patients with
intermediate stage HCC (BCLC-B). However, intermediate stage HCC patients comprise
a very heterogeneous patient population concerning tumor load and liver function.
Furthermore, TACE rarely achieves complete radiologic response with a single session,
so most patients need to be retreated with TACE. Thus, both, patient selection criteria
at baseline and for re-treatment with TACE are needed in order to avoid TACE induced
harm and to maximize the survival benefit for HCC patients. This presentation focuses on
recent advancements of patient selection at baseline as well as for retreatment with TACE
in patients with intermediate HCC.
In most transplant centers, patients with HCC within the Milan criteria are treated
with loco-regional therapies (e.g. radiofrequency ablation, resection, trans-arterial
chemoembolization) while on the waiting list for LT (“bridging strategy”). In addition to
country specific priority rules for listing, the main driver for these neo-adjuvant bridging
strategies is to prevent dropout from the waiting list. To evaluate however the full impact
of a neo-adjuvant strategy, other factors should also be considered, such as the response
to neo-adjuvant treatments, the recurrence of HCC after LT, the survival after LT and the
intention-to-treat survival after listing. Interpretation of the current literature data is difficult,
mainly because of the lack of information on all of these outcome parameters. However,
there is a consensus that there is a limited benefit of a bridging therapy in patients with
small tumors (T1) and a short anticipated waiting list to LT (< 6 months).
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RADIOEMBOLIZATION
1
Bruno Sangro 1
Liver Unit, Clinica Universidad de Navarra, and Centro de Investigacion Biomedica en
Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Pamplona, Spain
EASL HCC SUMMIT
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SORAFENIB AND NEW DRUGS IN FIRST
LINE IN HCC
1
Andrew X. Zhu 1
Massachusetts General Hospital Cancer Center,
Harvard Medical School, Boston, United States
Radioembolization (RE) (also called Selective Internal Radiation Therapy or SIRT) is a form
of intravascular brachytherapy that consists in the injection of radioactive microspheres into
the hepatic arteries with the aim of delivering tumoricidal doses of radiation to liver tumors
irrespective of their number, size, and location. The lack of a significant ischemic effect allows
the consideration of RE for patients with macrovascular invasion and thrombosis. Although
well-tolerated by far, some 5-10% of patients may develop radioembolization-induced liver
disease (REILD) consisting in liver decompensation with jaundice and ascites.RE has a
clear palliative role in the management of hepatocellular carcinoma (HCC) by inducing
tumor necrosis and delaying progression. Tumor shrinkage occurs almost invariably after
RE although it may take 3-6 months for the optimal response to manifest and median
time to response can consequently be as long as 6 months. Available data suggest the
ability of RE to achieve complete pathological necrosis in similar if not better rates than
conventional TACE.For patients in the intermediate stage, cohort series and comparative
effectiveness studies (including a small pilot randomized controlled trial) suggest that there
is no survival difference between RE and TACE. Hence, many centers have recognized RE
as a treatment option in intermediate-stage patients, particularly in those with a high tumor
burden or in those that progress or do not respond well to TACE. Among patients in the
advanced stage, outcomes are particularly encouraging in those with branch portal vein
thrombosis with overall survival exceeding that reported with the use of sorafenib and a
few patients responding to the point of being downstaged to resection. Importantly, besides
resulting in similar (if not better) survival in this population, RE is devoid of the significant
side effects of Sorafenib.While the European Society of Medical Oncology and the
National Comprehensive Cancer Networks have listed RE as a treatment option for HCC,
the American and European Associations for the Study of the Liver have not. Randomized
studies would probably be required to get RE universally accepted as first-line option in a
defined subgroup of patients with HCC. Several international, randomized controlled trials
are now in progress that investigate the role of RE when added to Sorafenib or examine in
a head-to-head comparison, Sorafenib vs. Y90 in prolonging the survival of intermediate
to advanced HCC patients. And a randomized phase 2 is comparing TACE and Y90 in
intermediate disease with time to progression as primary endpoint.Novel applications of
RE that deserve further research include i) the ability of apply high radiation doses to small
sectors of liver tissue in “radiation segmentectomy”; ii) the ability of right lobe RE to induce
significant contralateral hypertrophy that may enable anatomic liver resections otherwise
contraindicated because of a small future liver remnant; and iii) the ability of RE to allow
downsizing to liver transplantation or percutaneous ablation.
Advanced HCC carries a poor prognosis and systemic therapy with cytotoxic agents provides
marginal benefit. Improved understanding of the mechanism of hepatocarcinogenesis
coupled with the arrival of many newly developed molecularly targeted agents has
provided the unique opportunity to study some of these novel agents in advanced HCC.
Despite the successful approval and extensive application of sorafenib, the prognosis for
patients with advanced HCC remains poor and the benefits with sorafenib are modest.
In the past few years, there have been renewed and continued interests and active
research in developing other molecularly targeted agents in HCC. While the initial efforts
are focusing on anti-angiogenic therapy, other agents targeting the epidermal growth
factor-receptor, mammalian target of rapamycin (mTOR), hepatocyte growth factor/c-Met
among others have entered HCC clinical trials. Combining different molecularly targeted
agents or combining targeted agents with chemotherapy represent other strategies under
investigation. The author will attempt to summarize the current status of other molecularly
targeted agents or regimens beyond sorafenib under development in first line therapy for
advanced HCC and discuss the future perspectives.
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1
Markus Peck-Radosavljevic 1
Department of Gastroenterology and Hepatology,
Medizinische Universität Wien, Vienna, Austria
According to Globocan 2012, over 62000 deaths per year have to be attributed to primary
liver cancer, which makes it the 7th most common cause of cancer related death in
Europe (http://globocan.iarc.fr). Almost 70% of patients are diagnosed in a non-curatively
treatable disease stage and many of those will end up getting first line drug treatment
with Sorafenib, which will prolong the time to radiologic progression to 5,5 months from
the initiation of treatment. So far, no clear answer can be given to the question of what to
do upon progression under Sorafenib treatment or intolerance to it. So, development of
drugs for second line treatment of HCC are currently the major focus in drug development
for liver cancer. The first drug with definitive data from a prospective controlled phase III
trial was Brivanib. In a trial with 2:1 randomization into Brivanib (800 mg per day) versus
Placebo until disease progression or unescapable toxicity in patients that had failed
prior Sorafenib treatment, no survival benefit for Brivanib (median OS 9,4 month) versus
placebo (median OS 8,2 month) could be demonstrated [1]. While subgroup analysis for
OS didn’t show any signal for survival benefit in a specific subgroup, time to progression as
well as disease control rate was significantly better in the Brivanib group. The second trial
to report definitive phase III results just recently was the randomized Placebo controlled
Everolimus study, where 546 patients were 2:1 randomized into the Everolimus versus
Placebo group. Again, Everolimus (7,6 month) was not able to confer a survival benefit
over Placebo (7,3 month median) and neither the subgroup analysis for OS nor the time
to progression was significantly improved by Everolimus. Only the disease control rate
was significantly better for Everolimus (56%) compared to Placebo (45%; p=0,01) [4].
The monoclonal VEGFR2 antibody Ramucirumab is undergoing phase III testing in the
second line setting in HCC (www.clinicaltrials.gov NCT01140347) after successful first
line phase II data were obtained [3]. This Placebo-controlled second line trial has stopped
recruiting patients and they follow up for survival is ongoing. One very interesting secondline phase III trial currently ongoing is the Placebo- controlled evaluation of Tivantinib,
a c-met inhibitor. Tivantinib was shown in a Placebo controlled phase II trial to improve
survival in advanced stage HCC patients with high c-met expression in the tumor tissue,
well patients with low expression did not benefit from Tivantinib treatment [2].
If successful, this would be the first drug for treatment of HCC to use a molecular marker
as predictive biomarker for drug selection. In addition to Tivantinib, other c-met inhibitors
are undergoing clinical development in earlier phase trials at the moment. Likewise,
Refametinib, a MEK-inhibitor, is undergoing phase-II testing in ras-mutated HCC
(NCT01655693), highlighting the potential importance of molecular testing for a more
personalized approach to drug treatment of HCC.Furthermore Regorafenib, a multikinase
inhibitor similar but more potent than Sorafenib (NCT01774344) and a nanoparticle
linked Doxorubicin (NCT01655693) are also undergoing phase III testing in patients that
failed Sorafenib with advanced stage HCC. Several other targeted agents are currently
undergoing second line phase II testing in advanced HCC to explore the possibility of
development in this indication. Until one of these drugs yields a positive result we will
not have an evidenced based suggestion of what to do with patients that fail Sorafenib
treatment. While patients that are intolerant to Sorafenib can sometimes be treated with
a reduced dose of sorafenib, many investigators at the moment consider treatment
with Sorafenib beyond progression as a reasonable alternative to no treatment at all. In
the end, in the second line setting, a more personalized approach might be needed to
confer a survival advantage to these patients. This would require an improved molecular
understanding of liver cancer as well as rapid and reliable testing for key driver mutations
in an individual cancer and effective treatments to counter them. c-met inhibition and rasinhibition might be an initial step to more sophisticated use of molecularly targeted agents.
References
1. Llovet JM, Decaens T, Raoul JL, Boucher E, Kudo M, Chang C, et al. Brivanib versus
Placebo in Patients with Advanced Hepatocellular Carcinoma (HCC) Who Failed or
Were Intolerant to Sorafenib: Results from the Phase 3 BRISK-PS Study. J Hepatol
2012;56: A1398.
2. Santoro A, Rimassa L, Borbath I, Daniele B, Salvagni S, Van Laethem JL, et al.
Tivantinib for second-line treatment of advanced hepatocellular carcinoma: a
randomised, placebo-controlled phase 2 study. Lancet Oncol 2013;14(1): 55-63.
3. Zhu AX, Finn RS, Mulcahy M, Gurtler J, Sun W, Schwartz JD, et al. A Phase II and
Biomarker Study of Ramucirumab, a Human Monoclonal Antibody Targeting the VEGF
Receptor-2, as First-Line Monotherapy in Patients with Advanced Hepatocellular
Cancer. Clin Cancer Res 2013;19(23): 6614-6623.
4. Zhu AX, Kudo M, Assenat E, Cattan S, Kang Y-KL, Ho Yeong , Poon RT, et al.
EVOLVE-1: Phase 3 Study of Everolimus for Advanced HCC that Progressed During
or After Sorafenib. J Clin Oncol 2014: ASCO-GI.
SECOND LINE DRUG TREATMENT FOR
RADIOLOGY IN ASSESSING RESPONSE OR AS
PREDICTIVE TOOL
1
Rita Golfieri 1
Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi,
Bologna, Italy
Survival has the key role in the assessment of treatment efficacy in solid tumors, but
objective radiologic response has been widely accepted as an auxiliary surrogate end
point. For radiologic response evaluation, in 1979 the World Health Organization (WHO)
response criteria were introduced, based on the sum of bidimensional perpendicular
products and in 2000 the Response Evaluation Criteria in Solid Tumors (RECIST) were
introduced, based on the sum of the unidimensional longest diameters, further revised
to version 1.1 in 2009. Both WHO and RECIST criteria were designed for the evaluation
of cytotoxic agents, aimed at reducing tumor size, and have been proven as valuable
response assessment methods to well reflect patient survival. By converse, molecular
targeted therapy or locoregional treatments frequently induce necrosis without tumor
shrinkage in size and, therefore, clinical benefit could be only correlated with necrosis
of a viable tumor. To overcome these limitations, recently, the European Association
for the Study of the Liver (EASL) and the American Association for the Study of Liver
Disease (AASLD) have proposed new methods, including the concept of viable enhancing
lesion modifying WHO (into EASL) and RECIST (into mRECIST) criteria, respectively.
Viability defined as contrast enhancement is one of the key patterns of HCC and is more
important for assessing clinically response after locoregional treatments in HCC patients,
since WHO and RECIST criteria underestimate complete or partial responses based on
necrosis development without lesion shrinkage. In fact, some studies confirmed that, after
TACE, 38–50% of Partial Response and 58–86% of Stable Disease according to RECIST
were reclassified to complete response and objective response in EASL. The presence
of response according to EASL and mRECIST was demonstrated as independent
predictors of survival in HCC patients undergoing TACE. However, EASL and mRECIST
methods should be further extensively validated upon their correlation with the survival
in HCC patients undergoing locoregional and molecular targeted therapies, also taking
into account some limitations in their practical applicability, due to imaging complexities
still unaddressed, as recently advised.Furthermore, the optimal method for response
evaluation, chosen among CEUS, CT, PET-CT and MRI, to be employed in the follow up
after locoregional treatments has still to be clearly addressed.
EASL HCC SUMMIT
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193
BEST SUPPORTIVE CARE FOR
1
Jean-Luc Raoul 1
Paoli-Calmettes Institute, Marseille, France
Best supportive care are the only recognized treatment for end-stage hepatocellular
carcinoma (HCC) and must be used in other stages if required. Best supportive care aim
to treat symptoms in order to improve patients’ quality of life, eventually performance
status and survival. In the field of HCC the main symptoms physician will have to treat
are pain, fatigue, anorexia, depression, encephalopathy and ascitis. Pain can be related
to the tumor itself or to extrahepatic metastases (particularly bones). End stage patients
will have impaired drug metabolism and frequently also impaired renal function restricting
our analgesic choice. Paracetamol at reduced doses (2 – 3 g/d) can be used for mild pain
in patients not actively drinking alcohol. The liver is the main site of metabolism for most
opioids. Half-life of morphine is double and opioids can increase the risk for encephalopathy.
Hydromorphone and fentanyl derivatives may be the best choices; the initial doses may be
reduce and the interval initially increased but that needs to be reassessed daily. NSAIDs
must be avoided due to the high risk of hepatorenal syndrome. If pain is related to a well
recognized abnormality, specific treatment can be given (radiotherapy / cementoplasty if
bone metastases).Primary and secondary prophylaxis but also treatment of overt hepatic
encephalopathy are still based on lactulose. Anorexia is very common and participates
in malnutrition. Parenteral nutrition is poorly tolerated and its efficacy questionable; the
best option is to propose oral nutritional supplements and dietetary counseling are useful.
More than half of patients complained of unsatisfactory sleep and fatigue at extreme with
inversion of sleep pattern (particularly in case of encephalopathy); behavioral modifications
are a better solution than sedatives. Depression is present in > 50% of cirrhotic and more
in HCC patients and amplifies pain and other symptoms. Non pharmacological treatment
are the first line and antidepressants (Selective Serotonin Reuptake Inhibitors) initially
at low dose can be useful.To conclude, best supportive cares are very important in HCC
patients particularly in end-stage; due to impaired liver function the use of most drugs is
difficult.
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EASL HCC SUMMIT
CLINICAL POSTER
ABSTRACTS
195
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Poster Board Number C1
FINAL ANALYSIS OF EFFICACY AND SAFETY
IN EUROPEAN PATIENTS TREATED WITH
SORAFENIB FOR LESS THAN OR GREATER
THAN 28 WEEKS IN THE GIDEON STUDY
CLINICAL POSTER ABSTRACTS
Introduction: The global, international, non-interventional GIDEON (Global Investigation
of therapeutic decisions in hepatocellular carcinoma [HCC] and of its treatment with
sorafeNib) study investigated the safety and efficacy of sorafenib in >3200 patients with
unresectable (u) HCC in real-life clinical practice. We report the final analysis of safety and
efficacy in European GIDEON patients according to duration of sorafenib treatment: ≤28
weeks or >28 weeks.
Aims: The primary study endpoint was to evaluate the safety of sorafenib. Secondary
endpoints included overall survival (OS) and time to progression (TTP). Patient
demographics, disease characteristics and treatment history were recorded at enrolment.
Sorafenib dose, concomitant medications, performance status, liver function, adverse
events (AEs) and efficacy were recorded at follow-up visits.
Results: Overall, 1113 patients from 22 European countries were evaluable. The
median age was 66 years (range 15–94 years) and 83.3% were male. The duration of
treatment (DoT) was ≤28 weeks in 66.7% of patients and >28 weeks in 33.3%. Baseline
characteristics were similar with the exception that patients treated for >28 weeks tended
to have a better ECOG performance status (0–1) (91.4% vs 81.2%) and a lower proportion
of Child-Pugh B status (11.3% vs 24.1%) than patients treated for ≤28 weeks. The median
time from diagnosis to the start of sorafenib treatment was greater in patients with DoT
>28 weeks (4.8 months) compared with ≤28 weeks (2.9 months). The majority of patients
received the recommended daily dose of sorafenib (800 mg). The incidence of drugrelated AEs was greater in patients with a DoT >28 weeks compared with ≤28 weeks
(78.2% vs 64.2%); however, the incidences of serious AEs (SAEs), drug-related SAEs
and AEs resulting in permanent discontinuation of sorafenib were lower in patients with
a DoT >28 weeks. Median OS was longer in patients with DoT >28 weeks (23.8 months)
compared with patients with DoT ≤28 weeks (5.8 months).
Conclusions: The safety of sorafenib in European GIDEON uHCC patients appears to
be consistent with the published safety data. OS was longer in patients with a DoT >28
weeks, which was probably related to the better baseline condition of these patients prior
to the start of treatment.
Disclosure of Interest: A. Criotoru; J.-P. Bronowicki: received consulting, lecture fees
and research support from Bayer/Onyx Pharmaceuticals, V. Ratziu; P. Stal; G. Bodoky:
received consulting fees from Bayer/Onyx Pharmaceuticals, B. Daniele; J. Turnes; P.
Mathurin: received consulting and lecture fees from Bayer/Onyx Pharmaceuticals, M. Cox:
received compensated employment from Bayer
Adina E. Criotoru 1, Vlad Ratziu 2, Per I. Stal 3, Jean-Pierre Bronowicki 4,
György M. Bodoky 5, Bruno Daniele 6, Christos Papandreou 7, Juan Turnes 8,
Phillipe Mathurin 9, Michael Cox 10, Fatima Serejo 11
1
Department of Medical Oncology, Fundeni Clinical Institute, Bucharest, Romania,
2
Service d’Hépato-Gastroentérologie, Université Pierre et Marie Curie and Hospital Pitié
Salpêtrière, Paris, France, 3Department of Gastroenterology and Hepatology, Karolinska
University Hospital, Stockholm, Sweden, 4Department of Hepatogastroenterology, Centre
Hospitalier Universitaire de Nancy, Université Henri Poincaré–Nancy, Vandoeuvrelès-Nancy, France, 5Department of Oncology, St László Teaching Hospital, Budapest,
Hungary, 6Department of Oncology, G. Rummo Hospital, Benevento, Italy, 7Department
of Medical Oncology, University Hospital of Larissa, Larissa, Greece, 8Gastroenterology
Department, Hospital de Montecelo, Complejo Hospitalario de Pontevedra, Pontevedra,
Spain, 9Services des Maladies de l’Appareil Digestif, Hôpital Claude Huriez, Lille,
France, 10Bayer Healthcare, Basel, Switzerland, 11Center of Gastroenterology, Liver Unit,
Hospital de Santa Maria, Faculty of Medicine, Lisbon, Portugal
EASL HCC SUMMIT
STUDY OF FACTORS ASSOCIATED WITH POOR
SURVIVAL IN PATIENTS WITH NONRESECTABLE
ROLE OF DIETARY SUPPLEMENT AND
SORAFINEB IN THE MANAGEMENT OF ENDSTAGE HCC PATIENTS
Alaa A. Taha 1, Abdel-Aziz Saleem 1, Mohammad Al-Talkawy 1, Nevin Yilmaz 2
1
Hepatogastroenterology, Theodor Bilharz Research Institute, Cairo, Egypt,
2
Hepatogastroenterology, Mugla University, Mugla, Turkey
1
199
Mamun A. Mahtab 1, Sheikh F. Akbar 2, Salimur Rahman 1
Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka-1213, Bangladesh,
2
Medical Sciences, Toshiba General Hospital, Tokyo, Japan
Introduction: Hepatocelluar carcinoma (HCC) ia a major malignancy in Egypt with a
rising incidence over the last two decades and it is one of the leading causes of malignant
mortalities in male patients. Majority of patients present at late nonresectable stages of
the disease and this may be attributed to lack of effective surveillance program for patients
with chronic hepatitis and hepatic cirrhosis.
Introduction: A total of 96 patients with end stage HCC were enrolled in this study. Thirtyeight patients with end-stage HCC (Barcelona Clinic Liver Cancer [BCLC] staging C and
D) were enrolled in the study as control and did not receive any specific medication as per
their desire. Thirty-four patients with end-stage HCC (BCLC staging C and D) received only
oncoxin, a dietary supplement containing high concentrations of vitamins, amino acids,
and herbal extracts. Twenty-four patients with end-stage HCC received both oncoxin and
sorafenib.
Aims: The aim of this work is to study the factors associated with poor survival in patients
with nonresectable HCC.
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Results: The study included 889 patients (744 males and 145 females) who presented
with nonresectable HCC. Patients were fully evaluated and closely followed up for disease
progression and complications. Their demographic, clinical, laboratory and radiological
data were analyzed for detection of risk factors associated with poor survival.
Median survival in our patients was 23 months. Two independent factors were recognized
to be associated with poor survival when detected at first presentation of patients; ascites
(median survival 11 months, p=0.019) and portal vein tumor thrombosis (median survival
9 months, p=0.012). Other factors associated with adverse prognosis and poor survival
included markedly elevated serum alpha feto protein (AFP) levels > 1000 ng/ml (p=0.023),
hyperbilirubinemia (p=0.027), elevated serum gamma glutamyl transpeptidase (GGT)
levels (p=0.029), elevated serum alkaline phosphatase levels (p=0.34) and elevated
serum aspartate aminotransferase (AST) levels (p=0.046). Survival was not influenced by
age, gender nor the etiologic hepatitis virus.
Main causes of death in our series included advanced hepatic encephalopathy (32%),
severe sepsis including spontaneous bacterial peritonitis (27.7%), hepatorenal syndrome
(21.3%) and osophagogastric variceal bleeding (19%).
Conclusions: In conclusion, the presence of ascites and/or portal vein tumor thrombosis
at first presentation of the disease is independentally associated with poor survival in
patients with nonresectable HCC. Other factors associated with poor survival include
elevated serum AFP, bilirubin, GGT, alkaline phosphatase and AST levels.
Aims: To evaluate the role of only dietary supplement or a combination of dietary
supplement and sorafenib for management of patients with end-stage hepatocellular
carcinoma (HCC).
Results: Only 4 of 38 patients (11%) of control group survived for more than 2 months
and all of them died within 3 months of enrollment. In contrast 16 of 34 patients (47%)
receiving only oncoxin survived for more than 2 months. Four patients receiving only
oncoxin survived for more than 6 months. Although there were no notable adverse effects
of patients receiving only oncoxin, 8 patients receiving both oncoxin and sorafenib showed
adverse effects for which sorafenib were discontinued. Ten of 16 patients (62%) that
continued both oncoxin and sorafenib survived for more than 6 months. Regarding QOL
on the basis of Karnofsky Performance Scale Index decreased in all patients of control
group (decreased to 50%; at one month after study commencement compared to their
levels of 100% at enrollment). However, the levels of QOL mostly increased in majority of
patients receiving oncoxin and oncoxin plus sorafenib.
Conclusions: This study indicates that different regimen of dietary supplement alone or
with sorafenib may be used for management of end-stage HCC.
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EVALUATION OF COMBINED
RADIOFREQUENCY ABLATION FOLLOWED
BY CHEMOEMBOLIZATION VERSUS
CHEMOEMBOLIZATION IN MANAGEMENT OF
SORAFENIB FOR ADVANCED HEPATOCELLULAR
CARCINOMA IN PATIENTS WITH ALCOHOLIC
CIRRHOSIS AND COMORBIDITIES. EFFICACY
AND TOLERABILITY IN REAL-LIFE SETTING
Ahmed K. El Dorry 1, Nevien F. Elfouly 3, Eman M. F. Barakat 2, Amal T. AbdElMoez 2,
Mervet A. F. Mawad 3, Mohammed K. Shaker2
1
Department of Radiology Medicine, Faculty of Medicine, Ain Shams University, Egypt,
2
Department of Tropical Medicine, Faculty of Medicine, Ain Shams University, Egypt,
3
Atomic Energy Authority, Egypt
Introduction: Hepatocellular carcinoma (HCC), is the third most common cause of
cancer-related death. If left untreated, liver cancer has a poor prognosis.
Aims: to asses the value of combined radiofrequency ablation followed by
chemoembolization (RFA-TACE) versus trans-arterial chemoembolization (TACE) alone
in the management of hepatocellular carcinoma.
GENEVA, SWITZERLAND
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Results: Patients and Methods: 50 HCC patients categorized into 2 groups according
to the modality of locoregional treatment, 25 HCC patients treated with radiofrequency
ablation (RFA) followed by chemoembolization within 5 days and 25 HCC patients
treated with trans-arterial chemoembolization (TACE) alone. All patients were categorized
according to BCLC Staging System of HCC pre and post-treatment.
Results: Complete response (CR) were achieved in (100%) and (84%) of HCC patients
after one month from combined therapy (RFA-TACE) and TACE alone respectively. But
for lesions more than 5 cm (13.3%) of patients were more liable to partial response (PR)
and progressive disease (PD) after chemoembolization alone, however non of the patients
underwent combined therapy was liable for PR and/ or PD. The rate of objective response
after 7 month was (84%) and (44%) in RFA-TACE and TACE group respectively. The local
tumor progression rate at one year was (16.0%) and (56.0%) in RFA-TACE and TACE
group respectively. One year disease free survival rate was (56%) and (24%) in RFATACE and TACE group respectively, and overall survival rate was (88%) in RFA-TACE
group, while (80%) in TACE alone group.
Conclusions: Combined RFA and TACE appear to be effective modality for the treatment
of HCC in a good selected patient.
Petros Giovanis 1, Valter Vincenzi 2, Carla Manuppelli 2, Marilisa Marcante 1, Dagmar
Dannhauser 2, Laura Ciasullo 2, Viviana Lovat 3, Mauro Giusto 1, Massimo Boaretto 2
1
Medical Oncology, 2Internal Medicine and Hepatoloy, 3Pharmacy, Azienda Ulss 1,
Belluno, Italy, Belluno, Italy
Introduction: Sorafenib has shown survival benefit in patients with hepatocellular
carcinoma (HCC). HCC from alcoholic cirrhosis is a severe liver disease.
Aims: Scanty data concerning the efficacy of sorafenib in these patients are available.
Methodology: Since February 2009 we screened 67 Child-Pugh liver function class A
consecutive pts bearing the above characteristics. Fifty-one pts (76,1%), 49 males and
2 females, median age of 71.5 years (range 53-80), received 400 mg sorafenib b.i.d.
Predominant cause of HCC was alcohol consumption in 39 pts (76.4%), chronic HCV/HBV
infection in 11 pts (21.5%), and hemosiderosis in 1 pt (1.9%). All but 4 pts suffered from
multiple comorbidities, 28 of them (55%) presented cardiovascular disease and diabetes.
Median number of concomitant medications was 5 (range 1-11). Eleven pts never received
locoregional treatment, and none had received previous systemic therapy.
Results: Time to progression was 4.5 months (range 1-39), overall survival 8 months
(2-48+). Regarding tolerability, mild and severe fatigue was presented in 16 pts (36%),
diarrhoea in 7 (13.7%), hand-foot skin reaction in 2 pts (3.9%). Five pts (9.8%) presented
major cardiovascular toxicity, three of them (5.8%) life-threatening cardiovascular events:
cardiac infraction, ventricular tachycardia, transient ischemic attack and atrial fibrillation,
respectively after 18, 39 and 3 months of sorafenib. Two out of these 5 pts (3.9%)
presented atrial fibrillation after 6 months of treatment. One pt discontinued sorafenib
because of severe hypocalcemia after 29 months of treatment.
Conclusions: Treatment with sorafenib in pts affected by HCC and alcoholic cirrhosis is
effective and well tolerated with good-level compliance. CLINICAL POSTER ABSTRACTS
200
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203
INFLUENCE OF SARCOPENIA IN SORAFENIB
DISCONTINUATION DURING ADVANCED
HEPATOCARCINOMA TREATMENT
Introduction: Sarcopenia is a condition characterized by muscle wasting, it has been
associated with poor outcomes in patients affected by cirrhosis and solid tumors, and with
a higher rate of toxicity during chemotherapy. Sorafenib is the most widespread treatment
for advanced hepatocarcinoma (HCC). Little is known about the influence of sarcopenia
on Sorafenib treatment.
Aims: To analyze the tolerance of sorafenib treatment in sarcopenic cirrhotic patients
compared to non-sarcopenic ones.
Methodology: We conducted a preliminary retrospective study on 13 consecutive patients
from a single centre affected by advanced hepatocarcinoma and treated with sorafenib that
stopped the medication. Before treatment a computed tomography scan was performed
and skeletal muscle cross-sectional area was calculated. A transverse CT image with a
multiplanar reconstruction (MPR) from L3 was collected from each scan. Images were
analyzed manually marking the muscles areas identified by Hounsfield unit thresholds of
29 to 150.23 and then summed. The Cross-sectional areas were subsequently normalized
for height obtaining the skeletal muscle index, expressed as cross-sectional muscle area/
height. Limits for sarcopenia were considered 38.5 cm2/m2 for women and 52.4 cm2/m2
for men.
Results: Patients were mainly males (84%), etiology of liver disease was HCV in 31%,
alcohol in 23%, NASH in 23%, mixed in 15% and other causes in the remaining 8%. In our
study 23% of the patients (3/13) was non-sarcopenic and 77% (10/13) was sarcopenic.
The two groups had similar baseline characteristics: age was 63 vs 65 years (P= 0,78),
albumin level was 3,29 vs 3,18 gr/dl (P= 0,70), total proteins were 6,73 vs 6,75 gr/dl
(P= 0,70), international normalized ratio (INR) was 1,33 vs 1,22 (P= 0,369), BMI was 25
vs 23,3 (P= 0,419). There was no statistically significant difference in number of days
on treatment before discontinuation in the two groups (P= 0,5), with an overall time in
treatment of 92 days. Interestingly the most common reason of interruption was the
occurrence of an adverse event 69% (9/13) compared to progression of HCC 31% (4/13)
without difference between the two groups (P= 1). The most common adverse events were
bleeding and diarrhea (grade 2-4) respectively in 15% and in 31% of the patients.
Conclusions: Sarcopenia is present with high prevalence in patients affected by advanced
HCC. In our cohort sarcopenic patients were not associated with a higher rate of toxicity
nor with shorter period of treatment compared to non sarcopenic.
Elia Gigante 1, Sara Gallina 1, Ilaria Deli 1, Francesco Carbonetti 2, Elsa Iannicelli 2,
Gianfranco Delle Fave 1, Massimo Marignani 1
1
2
Digestive and Liver Diseases, Radiology, School of Medicine and Psychology
University “Sapienza”, S. Andrea Hospital, Rome, Italy
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205
EXPERIENCES WITH LARGE HEPATOCELLULAR
CARCINOMA: JAKARTA PERSPECTIVE
1
NOTES
Adianto Nugroho 1, Toar Lalisang 1
Department of Surgery, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
Introduction: Since tumor size is closely related to survival and recurrence of hepatocellular
carcinoma (HCC), management guidelines often rely on this factor in selection of the most
appropriate treatment. Consequently, in many established guidelines, large HCC might be
considered not suitable for surgical resection. However, in areas where diagnosis of early
HCC is something rare, partly due to lack of surveillance and low patient awareness of
the disease, most patients present with a large tumor size and decreased liver function.
Fortunately, some of them are resectable in term of no vascular extension and adequacy
of future liver remnant.
Results: We reported our experience with 9 cases of large HCC in our center. The median
age was 65 (range 38 – 78) years old, with male predominancy. The tumor was mainly
located in the left hemiliver (66.67%) with mean diameter of 13.89 ± 5.73 cm. Preoperative
Trans-arterial Chemo Embolization was performed in 3 patients (33.3%). One case had
a histopathologic HCC grade IV, 4 grade III and 4 grade II. Cirrhosis of the remaining
liver was found in 4 cases and fibrosis in 5 others. P53 expression was presence in all
cases. No perioperative mortality with only one patient known to have recurrence, possibly
because of multicentricity.
Conclusions: A large size tumor is associated with risk of spontaneous rupture, major
vascular invasion, extra-hepatic metastasis, and inadequate remnant liver. Although
the risk of postoperative liver failure and recurrence might increase, surgical resection
should never be discouraged for large HCC, because it offers considerable advantage
for the patient. Relief of severe pain, diminished risk of rupture, and possibility of cure
are entitled with resection. In summary, surgery for resectable large HCC is feasible with
regards to good patient selection and comprehensive perioperative management in a
multidisciplinary team. CLINICAL POSTER ABSTRACTS
Aims: We did a retrospective study of HCC patient underwent surgical resection in Cipto
Mangunkusumo Hospital, Faculty of Medicine University of Indonesia from January 2012
- June 2013
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SEVERE 25-HYDROXYVITAMIN D DEFICIENCY
IDENTIFIES HEPATOCELLULAR CARCINOMA
PATIENTS WITH A POOR PROGNOSIS
Table: Univariate and multivariate analyses of parameters associated with overall survival.
Univariate analysis
Multivariate analysis
Parameter
HR
95% CI1
P value
Introduction: Vitamin D is involved in many biological functions. It is has been identified
as prognostic factor in several diseases and even as potential treatment option in multiple
cancers. The role of vitamin D in patients with Hepatocellular carcinoma (HCC) remains
inconclusive although there is evolving evidence that vitamin D may modulate cancer
development and progression.
Age ≤ 65 years
0.954
0.573-1.589
0.856
BCLC3 stage AB
0.439
0.259-0.744
0.002
25(OH)D3 ≤ 10 ng/ml
2.225
1.331-3.719
CLIP 0-2
0.331
Aims: To evaluate vitamin D as prognostic parameter, HCC patients were prospectively
recruited and 25-hydroxyvitamin D3 (25(OH)D3) levels were determined. Vitamin D levels
were compared to stages of liver cirrhosis and HCC stages with non-parametric KruskalWallis-tests and Spearman correlations. The association of the 25(OH)D3 levels and
overall survival (OS) was assessed in uni- and multivariate Cox regression models.
CRP ≤ 0.5 mg/dl
0.222
Results: 200 HCC patients were included. The mean follow-up time was 322 ± 342 days
with a range of 1-1508 days. 19 patients underwent liver transplantation and 60 patients
died within the observation time. The mean serum 25(OH)D3 concentration was 17 ± 13
ng/ml with a range of 1 to 72 ng/ml. 25(OH)D3 serum levels negatively correlated with
the stage of liver cirrhosis as well with stages of HCC. Patients with severe 25(OH)D3
deficiency had the highest mortality risk (hazard ratio 2.225, 95 % confidence interval
1.331 - 3.710, P = 0.002). Furthermore, very low 25(OH)D3 levels were associated with
mortality independently from the CLIP score and C-reactive protein levels in a multivariate
Cox regression model (Table).
Conclusions: We conclude, that 25(OH)D3 deficiency is a prognostic indicator for a poor
outcome in HCC patients.
4
5
HR2
95 % CI
P value
0.002
1.755
1.040-2.962
0.035
0.194-0.565
< 0.001
0.488
0.282-0.845
0.010
0.119-0.414
< 0.001
0.273
0.145-0.513
< 0.001
Abbreviations: 1CI, confidence interval; 2HR, hazard ration; 3BCLC, Barcelona liver clinic;
4
CLIP, Cancer of the Liver Italian Program; 5CRP, C-reactive protein.
Fabian Finkelmeier 1, Bernd Kronenberger 1, Verena Köberle 1,
Stefan Zeuzem 1, Albrecht Piiper 1, Oliver Waidmann 1
1
Medizinische Klinik 1, Klinikum der Goethe-Universität, Frankfurt, Germany
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PERSONALIZED SORAFENIB THERAPY FOR
Giuseppe Cabibbo 1, Massimo Lavarone 2, Marcello Maida 1, Arezia Di Martino 1,
Emanuele Orlando 1, Claudio Zavaglia 3, Antonio Grieco 4, Erica Villa 5, Fabio Piscaglia 6,
Vito Di Marco 1, Massimo Colombo 2, Antonio Craxì 1, Calogero Cammà 1
1
Section of Gastroenterology, DIBIMIS, Policlinico P. Giaccone, University of Palermo,
Palermo, 21st Division of Gastroenterology, Fondazione IRCCS Ca‘ Granda Maggiore
Hospital, University of Milan, 3Struttura Complessa di Epatologia e Gastroenterologia,
Azienda Ospedaliera Niguarda Ca’ Granda, Milan, 4Institute of Internal Medicine, School
of Medicine, Catholic University of the Sacred Heart, Rome, 5Dipartimento di Medicina
Interna, UO Gastroenterologia, Universita` di Modena & Reggio Emilia, Modena,
6
Division of Internal Medicine, Department of Digestive Disease and Internal Medicine,
General and University S. Orsola-Malpighi Hospital, Bologna, Italy
The median survival was 21.6 months (mo) in treated group A versus 15.7 mo in untreated
group A, 12.9 mo in treated group C versus 7.3 mo in untreated group C, and 4.9 mo in
treated group B versus 7 mo in untreated group B. Conclusions: Individual variables of HCC patients treated with sorafenib have a more
accurate prediction of survival than the stages Barcelona Clinic Liver Cancer classification.
Introduction: Due to the wide heterogeneity of intermediate/advanced hepatocellular
carcinoma (HCC), a confident prediction of survival in individual patients treated with
sorafenib is lacking. Results: The survival curves of patients included in the SOFIA study (Iavarone M et al.
Hepatology. 2011) and in a previous published cohort of untreated patients (Cabibbo
G et al. World J Hepatol. 2012) were derived from predictors of death identified from
multivariate analysis of the SOFIA study.Six groups of patients were evaluated. Survival
curves of patients with Performance Status (PS) 0, without macrovascular invasion or
distant metastases, namely extra-hepatic spread (ES) and mainly treated with half-dose
of sorafenib (better patient profile – treated group A), patients with PS 1 or 2, with ES
and mainly treated with full-dose of sorafenib (worst patient profile – treated group B),
patients not included in group A or B (intermediate patient profile – treated group C),
were compared with survival curves of untreated patients with PS 0, without ES (better
patient profile – untreated group A), untreated patients with PS 1 or 2, with ES (worst
patient profile – untreated group B), and untreated patients not included in group A or B
(intermediate patient profile – untreated group C).
Aims: By identification of individual predictor of survival, we sought to establish an
individualized survival prediction for HCC patients treated with sorafenib. 210
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PROSPECTIVE EVALUATION OF THE
CORRELATION BETWEEN HEMOSTATIC STATUS
AND INCIDENCE OF PORTAL VEIN THROMBOSIS
IN PATIENTS WITH LIVER CIRRHOSIS AND
Introduction: Studies which explore the hypercoagulable state associated with neoplastic
disease and its correlation with the risk of developing portal vein thrombosis (PVT) in
patients with hepatocellular carcinoma (HCC) are lacking. Aims: The aim of the present study was to evaluate the thrombophilic role of HCC in
cirrhotics and to correlate coagulation profile of these patients with the incidence of
PVT. Methods: cirrhotic patients with and without HCC were prospectively enrolled
in the study. Age- and sex-matched healthy individuals constituted the control group
for thromboelastometry (ROTEM). All patients underwent: ROTEM, platelet count,
determination of prothrombin time and of levels of pro and anticoagulation factors. During
follow-up, PVT onset in both patients with and without HCC was recorded
Results: 76 cirrhotics, 41 with HCC and 35 without HCC, were included. Forty-eight
healthy volunteers were included as the control group. Volume of active HCC was >5 cm3
in 18 patients. Levels of pro and anticoagulation factors were similar between patients with
and without HCC, but fibrinogen was increased in HCC patients with active volume >5cm3
HCC compared to those with ≤5cm3HCC bulk (348,72mg/dL±124,06mg/dL vs 237,64mg/
dL±99,18mg/dL) and to cirrhotics without HCC (260,57mg/dL±126,07mg/dL) (p=0,006).
Platelet count was significantly increased in HCC patients compared to non-HCC patients,
especially in Child Class A subjects. Patients with HCC showed significantly lower
clotting time and maximum clot formation at ROTEM compared to healthy controls. The
hypercoagulable state was present even when HCC patients were compared to cirrhotics
without HCC, and was more evident when performing a subgroup analysis of Child Class
A patients, with statistically significant differences in MCF EXTEM/NATEM e CFT NATEM.
One-year-incidence of PVT was 19,5% (8/41) and 5.7% (2/35) in HCC and non-HCC
patients, respectively (p=0,04). In the HCC group, 4/8 PVT occurred in patients in Child
Class A. Fibrinogen test of ROTEM, MCF and AUC were statistically elavated in HCC
patients who later developed PVT
Conclusions: Cirrhotics with HCC demonstrate a prothrombotic hemostatic balance
resulting in an increased risk of PVT development. ROTEM seems to be a sensitive
method to identify hypercoagulability, that would otherwise be undetected by routine
laboratory testing. Further investigations are needed to determine whether patients with
HCC should receive prophylactic anticoagulation for PVT prevention. CLINICAL POSTER ABSTRACTS
Alberto Zanetto 1, Alberto Ferrarese 1, Alessandro Vitale 2, Umberto Cillo 2,
Kryssia-Isabel Rodriguez 1, Mariangela Fadin 3, Sabrina Gavasso 3, Claudia Radu 3,
Paola Zerbinati 3, Paolo Simioni 3, Fabio Farinati 4, Giacomo Germani 1,
Francesco Paolo Russo 1, Patrizia Burra 1, Marco Senzolo 1
1
Multivisceral Transplant Unit, Department of Surgical, Oncological and
Gastroenterological Sciences, 2Hepatobiliary Surgery and Liver Transplantation Unit,
Padua University Hospital, 3Department of Cardiologic, Thoracic, and Vascular Sciences
, 4Gastroenterology, Department of Surgical, Oncological and Gastroenterological
Sciences, Padua University Hospital, Padova, Italy
212
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LAPAROSCOPIC RADIOFREQUENCY ABLATION
VERSUS HEPATIC RESECTION IN THE
TREATMENT OF VERY EARLY HEPATOCELLULAR
CARCINOMA IN CIRRHOTIC CARCINOMA: A
COHORT STUDY
Introduction: Available studies have shown conflicting results concerning survival rates
for patients with cirrhosis and concurrent very early (VE) hepatocellular carcinoma (HCC)
(stage 0 according BCLC classification: single <2 cm or carcinoma in situ, Child A) treated
by laparoscopic radiofrequency ablation (LRFA) or hepatic resection (HR). Even if very
few comparative studies between HR and RFA have been reported for VE-HCC, some
experts have recommended modification of BCLC therapeutic algorithm in this subgroup
of patients: RFA should be the first-line therapy and HR should be considered only in
patients with failure of or contraindications to RFA
Aims: To compare HR versus LRFA as initial treatment for VE-HCC on survival, disease
free survival (DFS) and HCC recurrences in a large cohort of patients followed in clinical
practice.
Methodology: Two independent cohort series (Milan, Creteil), which include 855
patients with HCC who underwent HR (n=529) or LRFA (n=326), were retrospectively
analysed. 176 patients had a VE HCC. Patients not suitable to HR (requiring a very large
parenchymal loss at HR, due to the position of the lesion) were treated by LRFA (n=92),
the others underwent HR (n=84). At the time of surgical procedure no relevant differences
were seen between the 2 groups in term of liver disease status. In any case, Kaplan-Meier
method was used to assess overall survival (OS), tumour recurrence rate and diseasefree survival (DFS) before and after propensity score matching
Results: The 1-, 3- and 5-year OS rates for the LRFA group and the HR group were 92%,
66%, 46% and 94%, 89%, 75% respectively. The corresponding DFS rates for the 2 groups
were 64%, 30%, 14%, and 82%, 58%, 39%, respectively. OS and DFS were significantly
lower in the RFA group than in the HR group (p=0.0029 and p=0.0002, respectively).
The 5-year HCC recurrence rate was higher in the LRFA group than in the HR group
(82% vs. 56%; p=0.0008). After propensity score matching, only survival rates become not
significantly different. Multivariate analysis confirmed that treatment and BCLC stage are
the only predictive factors for survival and intra-hepatic recurrences
Conclusions: HR yielded better disease-free survival rates than LRFA with not significant
difference in survival. HR should be preferred in patients with peripheral tumours or
with tumours located near gallbladder, main biliary ducts, bowel loops or big vessels, in
which RFA may be less effective, if not dangerous. HR is the first-line option treatment for
patients with VE-HCC
Roberto Santambrogio 1, Mara Costa 1 2, Savino Bruno 3, Michael D. Kluger 2 4,
Juan Salceda 2, Andrea Belli 5 2, Alexis Laurent 2, Matteo Barabino 1,
Enrico Opocher 1, Daniel Azoulay 2, Daniel Cherqui 6 4
1
Chirurgia 2 – Epato-bilio-pancreatica e Digestiva , A.O. San Paolo – Università degli
Studi, Milano, Italy, 2Service de Chirurgie Digestive, Hepato-bilio-pancreatique et
Transplantation Hepatique, Hôpital Henri Mondor, Créteil, France, 3Medicina Interna ed
Epatologia, A.O. Fatebenefratelli ed Oftalmico, Milano, Italy, 4Section of Hepatobiliary
Surgery and Liver Transplantation, Department of Surgery, New York Presbyterian
Hospital – Weill-Cornell Medical Center, New York, United States, 5Dipartimento di
Chirurgia Oncologica Addominale, Istituto Nazionale Tumori “G. Pascale” , Napoli, Italy,
6
Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
214
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SORAFENIB FOR THE TREATMENT OF
RECURRENT HEPATOCELLULAR CARCINOMA
AFTER LIVER TRANSPLANTATION. TWO CASES
WITH FATAL OUTCOME
NOTES
Giovanni Perricone 1, Andrea Mancuso 1, Claudio A. Zavaglia 1, Chiara Mazzarelli 1,
Antonella Foschi 1, Aldo Airoldi 1, Luca S. Belli 1
1
Epatologia e Gastroenterologia, A.O. Ospedale Niguarda, Milano, Italy
Results: The median time to recurrence was 15 months (mo) (range 2–66). The sites
of metastasis were: only liver in 3 pts, liver and extrahepatic in 8, only extra-hepatic in
4. Neoplastic portal thrombosis was observed in 2 pts. Median serum alpha-fetoprotein
levels before sorafenib administration was 62 ng/ml (range 2– 11143). Mean age at
sorafenib start was 56±7 years. Maximum daily tolerated dose was 800 mg in 4 pts, 400 in
10 and 200 in 1. Eleven pts received everolimus. Median treatment duration was 78 days
(range 15–444). No grade 4 reaction was observed. Grade 3 adverse events occurred in
7/15 pts: fatigue (33%), hypophosphatemia (27%), cholestasis (13%), skin rash (13%)
and hand-foot skin reaction (13%). Two pts died probably due to drug toxicity. Both the
pts were taken everolimus plus sorafenib and had a partial response at CT. One patient
died of massive gastrointestinal bleeding from a severe hemorrhagic gastropathy, without
signs of portal hypertension. Another patient was hospitalized for weight loss and severe
diarrhea 4 mo after sorafenib start and died 17 days later. Overall, 2 mo after the start
of treatment, using mRECIST criteria, 2 pts (13%) showed a partial response, 2 (13%)
showed a stable disease and 9 (60%) showed a progressive disease. None of the pts
achieved a complete response. Treatment response could not be assessed in 2 pts. From
the start of the treatment the median survival was 5 mo (range 1–18). From the date of LT,
median survival was 27 mo (range 6–106).
Conclusions: Our data suggests that in pts with recurrent HCC after LT the combination
of sorafenib and everolimus is badly tolerated and can be associated with relevant
treatment-related mortality. Moreover, the treatment benefit is limited.
Introduction: Hepatocellular carcinoma (HCC) recurrence occurs in 8–20% after liver
transplantation (LT). Sorafenib has demonstrated a survival benefit in non –transplanted
cirrhotics with advanced HCC not amenable to surgical/locoregional treatments. However,
efficacy and safety of sorafenib in the post-LT setting has been scarcely studied.
Methodology: We reviewed the outcome of a consecutive cohort of 15 patients (pts)
(12 M and 3 F) treated with sorafenib for recurrent HCC after LT deemed not eligible to
surgical, ablative or loco-regional treatment from October 2008 to July 2013.
216
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PRETREATMENT NEUTROPHIL - TO LYMPHOCYTE RATIO IN CIRRHOTIC PATIENTS
WITH HCC
Introduction: Neutrophil-to-lymphocyte ratio (NLR) is associated with prognosis in many
cancers. Accumulating evidence suggest that there is a prognostic value of the NLR in
HCC cases. Also, NLR has a role in predicting HCC response to both surgical and non
surgical treatment.
Aims: Our aim was to examine the correlation of the pretreatment NLR with the two most
important factors affecting the prognosis of HCC cases, the tumour burden and the degree
of liver function impairment .We also aimed at defining the possible cut-off values of NLR
in relation to these factors.
Methodology: 97 consecutive cirrhotic patients, 86 males (88.7%) and 11 females
(11.3%) was diagnosed as having HCC based on the EASL criteria .Serology for HCV
was positive in 94 cases (96.9%). Neutrophil- lymphocyte ratio (NLR) was calculated by
dividing the neutrophil count by the lymphocyte count, provided that there was no ongoing
infection. Tumour staging was done using Seventh edition TNM staging system for HCC.
Child-Pugh score of each patient was calculated. Transaminases levels were measured
and AST/ALT ratio was calculated.
Results: We found that the higher the NLR, the more advanced the TNM tumour stage
(r = 0.304, p = 0.003).
The cut-off value of NLR above it patients had a higher possibility of advanced tumour
stage (beyond TNM stage II) was 2.25. The sensitivity of this cut- off value was 58.6 %
and the specificity was 66.7%.
Also, we found that, the higher the NLR, the higher the Child-Pugh score.
(r = 0.212, p = 0.037).
The cut -off value of NLR above it patients had a higher possibility of high Child-Pugh
score (more than 6) was 2.016. The sensitivity of this cut off value was 62.5% and the
specificity was 54.5%.
There was a significant positive correlation between the NLR and the AST/ALT ratio
(r = 0.240, p =.022).
Conclusions: Pretreatment high NLR is associated with more advanced tumour stage
and more degree of liver function impairment in cirrhotic patients with HCC.
Figure 1: NLR with TNM Stage
Hany R. Shabana 1, Salah El-Gamal 1, Ehab Abdel-Khalek 2 1,
Abd-Elmohsen E. El-Desoky 2, Talal A. Amer 3, Ibrahim A. Abdel-Aal 4, Marwa S. Askar 5
1
Internal medicine, specialized medical hospital,mansoura university, 2Internal medicine,
specialized medical hospital, 3Radiodiagnosis, Mansoura university hospital, 4Clinical
pathology, Mansoura faculty of medicine, Mansoura, 5Blood Bank,
Aga hospital,Ministry of health, Aga, Egypt
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THE INDIAN NATIONAL ASSOCIATION FOR
STUDY OF THE LIVER (INASL) CONSENSUS ON
PREVENTION, DIAGNOSIS AND MANAGEMENT
OF HEPATOCELLULAR CARCINOMA IN INDIA
PERCUTANEOUS LOCAL INJECTION OF
ETHANOL AND MITOXANTRONE IN TREATMENT
OF HEPATOCELLULAR CARCINOMA
Ashish Kumar 1 on behalf of The INASL Task-Force on Hepatocellular Carcinoma
1
Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
Ahmed Bihery 1, Mostafa El-Shamy 1, Talaat El-Mokadem 2, Tarik Zaher 1,
Walid Abd El Dayem 1, Talaat Fathy 1, Mohamed Emara 1
1
2
Tropical Medicine, Clinical Oncology, Faculty of Medicine, Zagazig University,
Zagazig, Egypt
Introduction: Hepatocellular carcinoma (HCC) is one of the major causes of morbidity,
mortality and healthcare expenditure in patients with chronic liver disease. There are no
consensus guidelines on diagnosis and management of HCC in India.
Introduction: New therapeutic choices have been developed for hepatocellular carcinoma
(HCC), including percutaneous ablation therapy, transarterial chemoembolization,
radiation therapy and molecular target therapy. Ablation of liver tumors is currently the
main alternative to formal liver resection.
Results: The Indian National Association for Study of the Liver (INASL) set up a TaskForce on HCC in 2011, with a mandate to develop consensus guidelines for diagnosis
and management of HCC, relevant to disease patterns and clinical practices in India.
The Task-Force first identified various contentious issues on various aspects of HCC and
these issues were allotted to individual members of the Task-Force who reviewed them
in detail. The Task-Force used the Oxford Center for Evidence Based Medicine – Levels
of Evidence of 2009 for developing an evidence-based approach. A 2-day round table
discussion was held on 9th and 10th February, 2013 at Puri, Odisha, to discuss, debate,
and finalize the consensus statements. The members of the Task-Force reviewed and
discussed the existing literature at this meeting and formulated the INASL consensus
statements for each of the issues. These guidelines will be published in the official journal
of INASL.
Conclusions: These are the first clinical practice guidelines generated by INASL on the
diagnosis and management of HCC in India. These guidelines are evidence based and
are aimed at providing the best possible care to the patients of HCC in India according
to the current evidence. They will also ensure a uniformity of diagnostic and treatment
approaches of HCC in the entire country and will also serve as framework for future
research on HCC in India.
Aims: This work aimed at comparing percutaneous ethanol injection (PEI) with combined
percutaneous ethanol and mitoxantrone injection (PIM) in treatment of HCC. This study
included 125 patients with 131 HCC lesions which were randomly divided into two groups;
group I composed of 68 lesions in 65 patients treated with PEI. Group II composed of 63
lesions in 60 patients treated with PEI and PIM. Clinical assessment, laboratory evaluation
and CT studies were performed to all patients pre treatment and at 3, 6, and 12 months
post treatment. Each focal lesion was considered as one subject.
Results: The percentage of ablation in both groups at 3, 6, 12 months were 60.3%, 48.5%
and 39.7% in group I respectively versus 85.5%, 74.6% and 68% in group II respectively
with a statistical significant difference between the two groups. There is an increased
number of local recurrence in group I compared to group II. Side effects and complications
are comparable in both groups.
Conclusions: Combination of PEI and PIM is better than PEI alone without additional
complication and recurrence rate seemed to be better in combination therapy than PEI
alone.
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SORAFENIB AFTER RFA IN HCC PATIENTS:
A PILOT STUDY
Giorgio De Stefano 1, Nunzia Farella 1, Valentina Iodice 1, Giulia Iorre 1,
Giosuè Calabria 1, Umberto Scognamiglio 1, Tiziana Ascione 1, Antonio Giorgio 1
1
Ultrasound Unit for Infectious Diseases, AORN dei Colli, Naples, Italy
Introduction: This prospective study investigates the efficacy and safety of sorafenib after
radiofrequency ablation (RFA) in patients with hepatocellular carcinoma (HCC).
Aims: Ninety-five HCC patients (67 males, 72.0±6.6 years) received sorafenib after
RFA (n=44, 5 with intermediate and 39 with advanced HCC) or sorafenib only (n=51, 10
intermediate and 41 advanced). Patients received RFA either because they were noteligible to transcatheter arterial chemoembolization (intermediate HCC) or for debulking
(advanced HCC). Time to progression (TTP), response rate (RR), duration of sorafenib
treatment and adverse effects were evaluated.
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Results: Patients with large HCC were 20 (45.1%) in the RFA/sorafenib group and 23
(45.1%) in the sorafenib group; patients with multifocal HCC were 24 (54.5%) and 28
(54.9%), respectively. Nodules were 86 in the RFA/sorafenib group (median diameter
50mm) and 116 in the sorafenib group (51mm). Patients on RFA/sorafenib underwent a
median of 2 RFA sessions.
At a 12-month follow-up, TTP was longer with sorafenib/RFA (10.3±8.0 vs 7.2±6.7 months,
p=0.04). RR was 61% with RFA/sorafenib and 40% with sorafenib (p<0.001; 2 vs 1
complete responses). Duration of sorafenib therapy was also longer with RFA/sorafenib
(10.9±8.0 vs 7.3±6.7 months, p=0.039).
Hand-foot skin reaction was observed in 4 patients on RFA/sorafenib and in 8 patients on
sorafenib, erythema in 4 versus 10 patients, and diarrhoea in 7 versus 19. Conclusions: Sorafenib after RFA resulted in a higher TTP and RR than sorafenib alone,
and no new safety concerns were reported. These findings support a sequential treatment
with RFA and sorafenib in HCC patients.
SUBSEGMENTECTOMY TREATMENT FOR
HEPATOCELLULAR CARCINOMA PATIENTS WITH
PORTAL HYPERTENSION
1
Keming Zhang 1, Zhengyu Zhu 2
Hepatobiliary Surgery Center, 302 Military Hospital of China, Beijing , 2Hepatobiliary
Surgery Center, 302 Military Hospital of China, Beijing, China
Introduction: The role of clinically significant portal hypertension on the prognosis of
cirrhotic patients undergoing hepatic resection for hepatocellular carcinoma (HCC) is
debated.
Aims: In this study, our aim was to assess the therapeutic efficiency of subsegmentectomy
treatment HCC patients with portal hypertension
Methodology: Between 2009 and 2013, we reviewed a total of 126 cirrhotic patients
with PHT (defined by the presence of esophageal varices or a platelet count of <100,000/
microL in association with splenomegaly).underwent hepatectomy for single HCC. The
patients were classified into the limited hepatic resection (n =84) and segmentectomy or
subsegmentectomy (n=42) groups.
Results: Among Child-Pugh class A patients, both the 3-year overall survival and diseasefree survival rates in the segmentectomy or subsegmentectomy group were significantly
better than those in the limited hepatic resection group (78% versus 56%, P=0.046, and
44% versus 26%, P=0.038, respectively). In Child-Pugh class B patients, the 3-year
overall survival analysis did not show significant differences in two groups (32% versus
18%, P=0.52). The morbidity rate reached no statistical significance in two groups among
Child-Pugh class A /B(34% vs 31%,P = 0.56).
Conclusions: PHT should not be considered an absolute contraindication to a hepatectomy
in cirrhotic patients. Segmentectomy and subsegmentectomy, for early-stage tumours is
an option for Child-Pugh class A patients with PHT
220
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ITALY GIDEON FINAL ANALYSIS SORAFENIBTREATED PATIENTS: PROGNOSTIC VALUE OF
BASELINE CHARACTERISTICS AND STAGING
SYSTEMS
Salvatore D’Angelo 1, Vito Lorusso 2, Maria R. Piras 3, Domenico Sansonno 4,
Lydia Giannitrapani 5, Antonio Benedetti 6, Vincenzo Montesarchio 7, Adolfo F. Attili 8,
Sergio Frustaci 9, Sandro Barni 10, Mario Pirisi 11, Daniela Carpani 12,
Giulia Magini 13, Bruno Daniele 14
1
2
Unità Fegato, AORN San G. Moscati, Avellino, UOC Oncologia Medica, IRCCS
Ospedale di Bari, Bari, 3SC Gastroenterologia, Azienda Osp. G. Brotzu, Cagliari,
4
Scienze Biomediche e Oncologia Umana. Sez Medicina Interna e Oncologia Clinica,
Università degli Studi di Bari A.Moro, Bari, 5DiBiMIS, UOC Medicina Interna ed
Epatologia, AOUP Paolo Giaccone, Palermo, 6Clinica di Gastroenterologia, AUO
Ospedali Riuniti, Torrette di Ancona, 7UOC di Oncologia, AORN dei Colli - Ospedali
Monaldi-Cotugno-CTO, Napoli, 8UOC di Gastroenterologia, Policlinico Umberto I,
Roma, 9SOC Oncologia Medica B, Centro di Riferimento Oncologico CRO, Aviano,
10
Oncologia, AO Ospedale Treviglio - Caravaggio, Treviglio, 11SCDU Medicina Interna
1, AOU Maggiore della Carità, Novara, 12Medical Department, Bayer Spa, Milano,
13
USC Gastroenterologia, AO Papa Giovanni XXIII, Bergamo, 14U.O. Oncologia Medica,
Azienda Osp. Gaetano Rummo, Benevento, Italy
Results: Prognostic values of baseline characteristics and various staging systems for
median overall survival (OS) and time to progression (TTP) in the intent-to-treat population
(n=274) are shown in the table.
Conclusions: Final data of the Italian cohort of patients in the GIDEON study are
consistent with the overall study results. As previously reported in other studies, baseline
characteristics and scoring/staging systems, including ECOG PS, Child-Pugh status,
BCLC stage, CLIP and MELD scores, appear to be useful prognostic factors for OS.
Further analyses will be presented.
Disclosure of Interest: D. Carpani: Bayer Employee; B. Daniele: Consultancy Bayer
Healthcare
Introduction: The GIDEON study (Global Investigation of therapeutic DEcisions in
hepatocellular carcinoma and of its treatment with sorafeNib - NCT00812175) a large,
global, prospective, non-interventional study was conducted across 5 regions in 39
countries. In Italy 278 patients were enrolled and results are reported here. Aims: The primary aim was evaluate the safety of sorafenib in HCC patients in whom the
decision to treat with sorafenib was made in clinical practice
Methodology: Baseline characteristics were recorded at study entry; safety and efficacy
outcomes were collected during follow-up. Baseline characteristics and staging/scoring
systems were evaluated and analyzed in relation to patient outcomes. CLINICAL POSTER ABSTRACTS
224
n
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Median OS (days)
Baseline characteristics
Median TTPa (days)
b
ECOG PSc
0
168
617
231
1
84
285
184
2
20
79
125
AFP, ng/mLc
<400
179
475
211
≥400
80
358
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Table Legend :
AFP, alpha-fetoprotein; BCLC, Barcelona Clinic Liver Cancer; CLIP, Cancer of the Liver
Italian Program; ECOG PS, Eastern Cooperative Oncology Group performance status;
MELD, model for end-stage liver disease; NA, Not Assessable; TNM, tumor node metastasis.
aTTP defined as time (days) from start of sorafenib to date of first documented disease
progression (PD). Only radiologically documented PD of tumor considered as PD.
bAt start of therapy ; cPatients with unknown status not shown; dNon-evaluable patients
not shown; eMELD missing (n=60);
Child-Pughd
A
214
616
219
B
31
189
84
C
2
NA
248
BCLCd
A
33
NA
818
B
87
475
211
C
142
318
147
611
D
5
NA
MELDe
<10
136
525
231
10–<20
74
351
127
20–<30
3
NA
194
30–<40
1
NA
354
CLIPd
0
23
662
156
1
87
655
367
2
73
332
166
3
32
316
115
4–6
19
295
189
TNMd
I
24
NA
150
II
43
617
161
IIIA
98
365
189
IIIB
3
NA
NA
IIIC
34
358
261
IV
52
287
126
Staging systemb
EASL HCC SUMMIT
227
LOW MIR-125B EXPRESSION IN
HEPATOCELLULAR CARCINOMA PREDICTS
RECURRENCE AFTER LIVER TRANSPLANTATION
HEPATOCELLULAR CARCINOMA IN CIRRHOSIS:
PROGNOSTIC FACTORS AND SURVIVAL
Claudio De Vito 1, Christophe Bourdeaux 2, Céline Delucinge-Vivier 3,
Christian Toso , Jan Lerut 2, Christine Sempoux 5, Gilles Mentha 4, Laura Rubbia-Brandt 1
1
Clinical pathology, Geneva University Hospitals, , Geneva, Switzerland, 2Department of
Abdominal and Transplantation Surgery, Cliniques Universitaires Saint-Luc, Brussels,
Belgium, 3University of Geneva, 4Division of Visceral and Transplantation Surgery,
Geneva University Hospitals , Geneva, Switzerland, 5Department of Pathology, Cliniques
Universitaires Saint-Luc, Brussels, Belgium
4
Introduction: Liver transplantation (LT) using Milan criteria (MC) provides the best option
of cure for cirrhotic patients with hepatocellular carcinoma (HCC). Despite accurate
selection 10-15% of patients develop HCC recurrence after LT supporting the identification
of new markers to better select transplant candidates. MicroRNAs (miRNAs) are small
non-coding RNA that regulate gene expression at the post-transcriptional level and are
involved in many liver diseases including HCC.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Aims: The aim of this study is to identify a miRNA signature related to HCC recurrence
after LT.
Methodology: From 1987 to 2010, 54 patients from two liver transplant centers (Geneva
and Brussels) were retrospectively included in this study. 27 patients who developed HCC
recurrence after LT and 27 matched patients for age, gender, number and size of tumors,
MC, microvascular invasion, tumor differentiation and year of LT were selected. MiRNA
from tumor were extracted from formalin fixed paraffine embedded tissue and miRNA
expression profile was performed using Nanostring technology and validated by qRT-PCR.
Results: Patients with recurrent and non recurrent HCC showed no statistically difference
among the criteria selection except for alpha-foeto-protein (AFP) (p<0.001). 53 miRNAs
were statistically differentially expressed between the two groups among which 38 and 15
were respectively up-regulated and down-regulated in recurrent HCC compared to non
recurrent HCC. Mir-125b, a known tumor suppressor miRNA in HCC, was identified to be
down-regulated in recurrent HCC and validated by qRT-PCR. Overall survival (OS) and
recurrence free survival (RFS) using Kaplan-Meier analysis shown that low level of mir125b is significally associated with a shorter OS (p<0.001) and RFS (p<0.001). Moreover
no correlation was observed between mir-125b expression and AFP using regression
analysis (p=0.02, r2=0.11).
Conclusions: In this study we identified that low expression of mir-125b is associated with
HCC recurrence and shorter OS after LT. An assessment of mir-125b in HCC prior to LT
might provide an additional marker for a better selection of liver transplant candidates and
to reduce HCC recurrence.
Yosra Said 1, Zeineb Ben Ali 1, Kaouther El Jeri 1, Hanene Ben Temime 1,
Radhouane Dabbeche 1, Slim bouzaidi 1, Haifa Mekki 1, Leila Mouelhi 1, Fatma houissa 1,
Sana Khedher 1, Mohammed Salem 1, Mohammed Kouni Chahed 2, Taoufik Najjar 1
1
Gastroenterology, 2Epidemiology, Charles Nicolle Hospital, Tunis, Tunisia
Aims: To evaluate prognostic factors and survival of hepatocellular cancer (HCC) in a
Tunisian population.
Methodology: We conducted a retrospective study including consecutive patients who
were hospitalized with HCC occurring in cirrhotic liver during a 10-years period.
Results: A total of 101 cirrhotic patients with HCC were included; 64 male and 37 female.
Mean age was 65,4 years (31-88 years). Causative factors of liver cirrhosis included
hepatitis C and B in 62,2% and 25,7% of cases respectively . The Child Pugh class
was A, B and C in 30,7%, 50,5% and 18,8% of patients respectively. The diagnosis of
HCC was non invasive, relying on imaging and alphafetoprotein in most cases (95%).
Eighty four patients (83,2%)had an advanced HCC, with vascular or extra hepatic spread
in 58(57,5%)of them. Treatment was curative in 14 cases, based on surgical resection
in one case and percutaneous ablation in 13 cases. Six patients received transarterial
chemoembolization as a palliative treatment. In 71 patients, only symptomatic treatment
was given. The median survival period was 11 months. The 3-year survival rate was
59.1% Univariate analysis showed the factors associated with better survival for HCC
patients were surveillance, Child-Pugh classification A, low serum AFP level(<200 ng/ml),
small tumour (<3 cm), no vascular invasion , curative treatment options, Okuda stage I,
CLIP score <2, BCLC stage A and B. In multivariate analysis, the factors associated with
better survival were surveillance (p=0.003), Child-Pugh classification (p=0.01), and BCLC
stage (p = 0.035).
Conclusions: In our study surveillance, Child-Pugh classification and BCLC stage were
determined to be important prognostic factors .HCC surveillance for cirrhotic patients
could detect HCC at early and curative stages.
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229
URINARY PROTON NUCLEAR MAGNETIC
RESONANCE SPECTROSCOPY IDENTIFIES
ALTERED METABOLIC PATHWAYS IN
Nimzing G. Ladep 1 on behalf of PROLIFICA; Anthony Dona 2,
Shahid Khan 1, Edith Okeke 3, Maud Lemoine 4, Ramou Njie 4, John Chetwood 1,
Duguru Mary 3, Deborah Garside 1, Haddy Fye 4, Mary Crossey 1, Mark Thursz 1,
Elaine Holmes 2, Simon D. Taylor-Robinson 1
1
2
Medicine, Imperial College London, London, United Kingdom, 3Jos University Teaching
Hospital, Jos, Nigeria, 4Medical Research Council, Fajara, The Gambia
Aims: To identify altered HCC pathways using urinary proton nuclear magnetic resonance
spectroscopy (NMR) of patients from Africa.
Methodology: Urine samples were collected at two sites in West Africa on the casecontrol platform of the “Prevention of Liver Fibrosis and Carcinoma in Africa” (PROLIFICA)
study. 600MHz NMR spectrometer was used to acquire one-dimensional spectral data
from the urine samples. The initial test sample from 202 subjects were validated by a
second cohort, comprising 463 subjects [141 with HCC, 56 with cirrhosis (Cir), 178 with
non-cirrhotic liver disease (DC) and 88 healthy volunteers (NC )]. Identified metabolites
were confirmed using statistical total correlation spectroscopy (STOCSY) tool, as well as
by comparing urinary spectra with corresponding reference standards.
Results: Multivariate modelling of the spectral data showed distinct urinary metabolic
profiles of patients with HCC, compared to Cir, DC and NC with high sensitivity and
specificity. Several metabolites were significantly altered (p<0.0001) in urine of HCC
patients, compared to non-HCC liver disease controls. Using the Kyoto Encyclopaedia of
Genes and Genomes (KEGG) pathway mapping tool, we identified several pathways that
could be altered in HCC.
Conclusions: Urinary NMR of the studied population has identified metabolites that were
perturbed in HCC, suggesting alteration of several pathways requiring further trawling.
Introduction: Metabonomics offer opportunities to appraise global outcomes of metabolic
changes and which can provide insights to altered pathways in hepatocellular carcinoma
(HCC). PROGRAMME AND ABSTRACTS
INDEPENDENCE OF SERUM AUTOTAXIN LEVELS
FROM THE STATUS OF HEPATOCELLULAR
CARCINOMA
BILE DUCT INJURY AFTER TACE
Mayuko Kondo 1, Hitoshi Ikeda 1 2, Takeaki Ishizawa 3, Kenichiro Enooku 1,
Yasunori Tokuhara 2, Ryunosuke Ohkawa 2, Baasanjav Uranbileg 2, Ryosuke Tateishi 1,
Haruhiko Yoshida 1, Yutaka Yatomi 2, Norihiro Kokudo 3, Kazuhiko Koike 1
1
Department of Gastroenterology, 2Department of Clinical Laboratory Medicine,
3
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery,
Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Introduction: Although autotaxin (ATX) has been speculated to play a role in cancer
invasion or metastasis as an autocrine motility factor, its clinical significance in
hepatocellular carcinoma (HCC) has not been fully understood yet.
Aims: To clarify the clinical significance of ATX in HCC pathophysiology.
Methodology: Serum levels and mRNA expression in HCC of ATX were evaluated in
consecutive 148 HCC patients treated with radiofrequency ablation (RFA) and 30 patients
with hepatic resection.
EASL HCC SUMMIT
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Results: Although increased serum ATX levels were observed in almost all the patients
treated with RFA, they were not reduced after RFA. Furthermore, serum ATX levels were
associated not with tumor burden but with the parameters predicting for liver fibrosis, i.e.,
liver stiffness values, serum hyaluronic acid levels, serum type IV collagen 7S levels,
and aspartate aminotransferase-to-platelet ratio index. Then, in surgically-treated
patients, there was no significant correlation between serum ATX levels and ATX mRNA
expression levels in HCC tissues. Notably, ATX mRNA expression levels in HCC tissues
were not higher than those in peri-tumorous tissues; increased ATX mRNA expression
was observed in tumorous tissues compared to peri-tumorous tissues in 8 of 30 patients.
Finally, serum ATX levels in surgically-treated HCC patients were rather correlated with
ATX mRNA expression levels in peri-tumorous tissues as well as with liver fibrosis stage.
Conclusions: The increase in serum ATX levels in HCC patients may not be caused by
abundant ATX production in HCC tissues but by fibrosis in the background livers.
1
231
Xiaoyu Wen 1, Qinglong Jin 1, Yue Qi 1, Junqi Niu 1
Hepatology, The first hospital of Jilin University, Changchun, China
Introduction: TACE (transcatheter arterial chemoembolization) has been widely accepted
as a safe and effective treatment of primary and secondary malignant hepatic tumors.
Despite the excellent therapeutic effects of TACE, a spectrum of complications occurs
after TACE of hepatocellular carcinoma (HCC). Among these, complications related to
bile duct injury have been reported including a biliary stricture; biloma; biliary peritoneum;
hemobilia and biliopleural fstulas. Here we report two cases of bile duct injury that develop
after TACE of HCC.
Aims: To report two rare cases about bile duct injury after tace.
Methodology: A 46-year old man developed intrahepatic biloma within 2 months of
chemoembolization. A 53-year old man developed bile duct necrosis in 3 months after
chemoembolization. They were admitted because of the epigastric discomfort and jaundice
respectively. On CT, Intrahepatic biloma appeared as a round, solitary, or multiple cystic
area and the bile duct necrosis appeared as bile duct vanishing. Because of the clinical
symptoms, the patient with intrahepatic biloma was treated by percutaneous drainage and
the patient with bile duct necrosis was treated with gallbladder drainage. The latter patients
died of hepatic failure 2 months after discharge and another patient is in the follow up.
Results: According to the reference, in patients with hepatocellular carcinoma, potential
risk factors of bile duct injury due to TACE such as a tumor smaller than 5 cm and
dilatation of intrahepatic bile duct However, other potential risk factors such as Child-Pugh
classification and presence of portal vein tumor thrombus did not influence the incidence
after discharge and another patient is in the follow up.
Conclusions: For the two cases, we think the technical-related risk factors such as
proximal injection of drugs and repeated injection with a frequency of less than 3 months
significantly influenced the incidence of bile duct injury. CLINICAL POSTER ABSTRACTS
230
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233
EPIDEMIOLOGY OF HEPATOCARCINOMA
IN TRANSILVANIA
1
NOTES
Elena C. Rezi 1
Internal Medicine D epartment, Polisano Medical Centre, Sibiu, Romania
Introduction: Few studies have been done to establish the epidemiology of HCC in
Transylvania.
Aims: To study the prevalence of HCC in Transylvania.
Methodology: We have performed a retrospective study on a 7 years period of observation.
From the total of 7224 patients who were hospitalized on the Gastroenterology Department
of the Clinical Hospital from Sibiu, 80 were diagnosed with HCC.
Conclusions: The prevalence of the HCC among the hospitalized patients from
Transylvania is about 1.1%. The majority of the patients diagnosed with hepatocellular
cancer live in urban areas. In urban areas, HCC affects older patients with hepatitis C virus
or alcohol-related cirrhosis.
Results: The HCC prevalence was 1.107% from the hospitalized patients. 75% from them
are from urban areas. The medium age of the patients from rural areas was 63.1 years,
comparing with 64.66 years at those from urban areas (p=0.3677). HHC affected patients
with hepatitis C virus more in urban areas than in rural (18.18% comparing with 10%).
15.15% from the HHC etiologies in the urban areas were alcohol-related, versus only 10%
in the rural areas. The medium size of the liver lesions at the patients from urban areas
was 6.782 cm, comparing with only 4.785 cm at the patients from rural areas (p=0.0457).
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ALPHA-FETOPROTEIN CHANGES AS
SURVEILLANCE TEST FOR HEPATOCELLULAR
CARCINOMA: RESULTS OF A CASE-CONTROL
STUDY
Introduction: In patients with cirrhosis surveillance for hepatocellular carcinoma (HCC)
is highly recommended.
Aims: In this case-control study we evaluated the efficiency of overtime elevation of alphafetoprotein (AFP) as surveillance test for HCC.
Methodology: we recruited 80 patients newly diagnosed with HCC (cases) from
January 2000 to February 2009 during a semiannual surveillance program based on
ultrasonography and AFP measurement at 4 referral centers. They were matched 1:2
for age, gender, etiology and Child-Pugh class (at time of case diagnosis) with cancerfree controls undergoing the same surveillance program at the same centers (training
group, TG). Validation group (VG) consisted of 36 patients newly diagnosed with HCC
at only 1 center matched 1:3 with cancer-free controls from March 2009 to May 2013.
AFP values at 12 (T-12) and 6 (T-6) months before and at the time of HCC diagnosis
(T0) and a positive difference between AFP at T0 and T-6 (Δ6+) or T-12 (Δ12+) were
collected. To align AFP measurements we considered as T0 for controls the date of
AFP measurement closest to the date of HCC diagnosis of the corresponding case.
Regression analysis was used to assess the association between AFP and HCC.
Results: In TG AFP increased from T-12 to T0 in HCC (p=0.001) whereas remained
stable in controls (p=0.126). AFP was also significantly higher in HCC than controls
at each time point (p<0.001). At multivariate analysis AFP T0 and AFP Δ6+ were
independently associated with the diagnosis of HCC (Odds ratio: 1.031 and 2.402,
respectively). The area under the curve of AFP T0 was 0.76 and its best cut-off was 10
ng/ml (AFP10) with a sensitivity of 66.3% and specificity of 80.6%. In order to improve
the performance of the surveillance test we combined AFP10 with AFP Δ6+ obtaining a
sensitivity of 80% (95%CI 74.3-84.8%), with NPV of 86.2% (95%CI 81-90.2%). Appling
this test at the 3% HCC prevalence reported in literature NPV raised to 99% (95%CI
96.5-99.8%). VG confirmed 10 ng/ml as AFP T0 best cut-off value with similar sensibility
(66.7%) and an increased specificity (88.9%) versus TG. The combination of AFP 10 and
AFP Δ6+ allowed to obtain a sensitivity up to 80.6% (95%CI 73-86.5%) with an high NPV
value (90.5%, 95%CI 84.2-94.6).
Conclusions: Combination of AFP as a single dosage with a cut-off of 10 ng/mL and the
presence of a positive difference between the values of AFP in the last 6 months increased
accuracy of HCC identification in cirrhotic patients.
Fabio Conti 1, Maurizio Biselli 1, Marta Frigerio 1, Annagiulia Gramenzi 1,
Marco Dall’Agata 1, Maura D’Angelo 1, Edoardo G. Giannini 2, Fabio Farinati 3,
Paolo Del Poggio 4, Mauro Bernardi 1, Franco Trevisani 1, Pietro Andreone 1
1
Department of Medical and Surgical Sciences, University of Bologna, Bologna,
2
Department of Internal Medicine, University of Genoa, Genoa, 3Department of Surgical
and Gastroenterological Sciences, University of Padua, Padua, 4Division of Medicine,
Treviglio-Caravaggio Hospital, Treviglio, Italy
PIVKA-II : A TISSUE BIOMARKER
OF MICROVASCULAR INVASION IN
HEPATOCELLULAR CARCINOMAS
IS FIB-4 INDEX USEFULL FOR PREDICTING
OCCURENCE OF HEPATOCELLULAR
CARCINOMA IN PATIENTS WITH HEPATITIS
C VIRUS HAS GOT NORMAL ALANINE
AMINOTRANSFERASE LEVELS
Nicolas Poté 1, Miguel Albuquerque 1, Mohamed Achahboun 1, Laurent Castera 2,
Jacques Belghiti 3, Pierre Bedossa 1, Valérie Paradis 1
1
2
Pathology, Hepatology, 3Liver Surgery, Beaujon Hospital, Clichy, France
EASL HCC SUMMIT
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237
Goktug Sirin 1, Omer Sentürk 1, Altay Celebi 1, Sadettin Hülagu 1
1
Gastroenterology, Kocaeli University, Kocaeli, Turkey
Introduction: Microvascular invasion (mVI) is a main prognostic factor of hepatocellular
carcinoma (HCC). mVI tissue biomarkers have been identified without any further
validation. We previously reported that PIVKA-II (Protein Induced by Vitamin K absence or
Antagonist-II) serum level was correlated with mVI in patients with HCC associated with
chronic liver diseases (Paradis V et al EASL 2013).
Introduction: The FIB-4 index is a simple formula to predict liver fibrosis based on
standard biochemical values, using age, aspartate aminotransferase(AST), alanine
aminotransferase (ALT), and platelet count.
Aims: The aim of the study was to assess the prognostic value of PIVKA expression in a
western series of HCC tumor samples.
Aims: We investigated the use of the FIB-4 index in predicting the incidence of hepatocellular
carcinoma (HCC) in patients with hepatitis C virus has got normal ALT levels.
Methodology: A set of 84 HCC dpecimens obtained from liver resection or transplantation
were studied. Immunohistochemistry was performed using anti-PIVKA-II antibody (EIDIA,
dilution 1/200). Immunostaining scoring system was based on a 3-grade scale (0: < 10%
positive tumoral cells, 1: 10% ≤ positive tumoral cells < 50% and 2: ≥ 50% positive tumoral
cells).
Methodology: A total of 114 patients with ALT levels persistently less than or equal to
35 IU/L during the observation period over 2 years were included. None of the patients
received antiviral therapy. Factors associated with the cumulative incidence of HCC were
determined.
Results: HCC mean size was 3.1±2.2 cm. Tumor was well and moderately to poorlydifferentiated in 40% and 60%, respectively. mVI was present in 52% of cases. PIVKA-II
serum level median value was 101 AU (ranges 4-75,000). PIVKA immunostaining was
scored 0, 1 and 2 in 39, 17 and 28 HCC, respectively. PIVKA tumor expression was
correlated with mVI (p=0.05). No correlation was observed with tumor size or differentiation.
PIVKA-II serum level increased with % of positive tumoral cells (p=0,08).
Conclusions: This study shows the prognostic value of PIVKA-II in tumor samples of
HCC. Its performance in biopsy samples needs to be investigated.
Results: HCC developed in 11 of 114 patients (9.65%). The rates of HCC at 3 and 5 years
were 0.6% and 2.4%, respectively. When patients were categorized based on the FIB-4
index: ≤2.0 (n=66), >2.0 and ≤4.0 (n=32), and >4.0 (n=16), the cumulative incidences of
HCC at 5 years were 0.1%, 0.6%, and 4.6%, and those at 8 years were 4%, 20.1%, and
33.3%, respectively. The patients with FIB-4 index > 4.0 was at a highest risk for HCC
development (p<0.001). Factors that were significantly associated with the incidence of
HCC by multivariate analysis were FIB-4 index >2.0 (hazard ratio: 4.70 [95% confidence
interval, 2.124–11.234]; p<0.001) and FIB-4 index >4.0 (5.90 [2.624–16.112] ; p<0.001),
α-fetoprotein(AFP) >10 ng/ml (2.352[1.25–4.823] ; p<0.001) and AFP >20 ng/ml (4.211
[2.112–8.242] ; p<0.001). There was no significant statistically correlation between FIB-4
index and AFP.
Conclusions: The FIB-4 index is closely associated with the risk of HCC in patients with
hepatitis C virus has got normal ALT levels.
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239
Tab.1
Total population (n=58)
Male (n%)
48 (83%)
Age (mean±ds)
Introduction: ARFI is a noninvasive method to measure LS during the routine ultrasound
examination. It has already been demonstrated that LS measured by Fibroscan can be a
prognostic factor for major complications of CLD.
Aims: The aim of our study is correlate LS assessed with ARFI and occurrence of HCC.
Methodology: Two hundred-nine patients affected by chronic liver disease with different
etiology were included in our study:62.5% had a clinical diagnosis of cirrhosis(Child Pugh’s
score 6.4±1.5/MELD 8.1±4.7).In all patients LS was evaluated at the enrollment: the
assessment was made on the right lobe and the medium value of ten measurements was
considered as result. We transform the obtained result expressed in m/s in kPa applying
Young’s module. We exclude from analysis patients with diagnosis of hepatocellular
carcinoma (n22) and those with incident HCC occurred in the first six months after the
enrollment (n2). We stratify the remaining in two groups choosing as cut off the median value
of LS obtained in our population:≤15.6 kPa(GROUP1-G1; n95) and >15.6(GROUP2-G2;
n87). The median follow up(FU) is 561 days (range:12-1120).
Results: HCC develop in 10 pts; 5 in G1 and 5 in G2. As Kaplan Meyer’s curves show
(Fig 1), the cumulative incidence (CI) of HCC increase accordingly to LS values (Log Rank
p=0.001). The incidence of HCC after 24 months of FU is 6.8% in G2 vs 3 % in G1.The
mean time of occurrence of HCC in G2 was 397±331 days vs 556±304 in G1(p=ns).
68.3±9.8
65.7-70.8
SFA (mm2) (mean±ds)
16,188 ± 10,673
13,382.1-18,995.2
VFA (mm2) (mean±ds)
12,618.8 + 6,829.5
Cirrhosis (n) %
54 (93%)
CP score (mean±ds)
10,823.1-14,415.5
5.9±1
Meld score (mean±ds)
Adriano De Santis 1, Chiara Bassanelli 1, Marinella Lupo 1, Claudia Iegri 1,
Carmela A. Di Ciesco 1, Giulia Gallusi 1, Mariana Forlino 1, Adolfo F. Attili 1
1
Clinical Medicine, La Sapienza University, Rome, Italy
95% LCL-UCL
5.6-6.2
7.6±3.3
6.7-8.6
BCLC(n)(%)
B /C
25 (42%)33 (58%)
ECOG (n)(%)
0/1
43 (74%)15 (26%)
SFA
Tab.2
VFA
> median
(29 pts)
≤ median (29pts)
p
>
median(29pts)
≤
median(29pts)
p
CP score (mean±ds)
5.8±1.04
6.2±1.01
ns
6±1.07
6±1.04
ns
Meld score
(mean±ds)
7.7±3.5
7.6±3.4
ns
7.9±3.4
7.4±3.4
ns
BCLC C (n%)
15 (52%)
18 (62%)
ns
15 (52%)
18 (62%)
ns
ECOG 0 (n%)
24(82%)
19 (66%)
ns
22 (76%)
21 (72%)
ns
Conclusions: Our preliminary data suggest that LS measured with ARFI could define the
risk of occurrence of HCC in patients affected by CLD as already shown for Fibroscan.
Further data are required.
LIVER STIFFNESS (LS) ASSESSED WITH
(ARFI) CAN IDENTIFY PATIENTS AFFECTED BY
CHRONIC LIVER DISEASE (CLD) AT HIGHER RISK
OF HEPATOCELLULAR CARCINOMA (HCC)
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RS4374383 SINGLE NUCLEOTIDE
POLYMORPHISM OF MERTK GENE IS
ASSOCIATED WITH HEPATOCELLULAR
CARCINOMA (HCC) IN PATIENTS WITH HCV
CIRRHOSIS
NOTES
Vincenza Calvaruso 1, Stefania Grimaudo 1, Maria Rosaria Pipitone 1,
Maria Grazia Bavetta 1, Giuseppe Cabibbo 1, Elisabetta Conte 1, Antonio Craxì 1, Vito Di Marco 1
1
Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
Introduction: MERTK gene encode factors involved in phagocytosis of apoptotic cells by
macrophages. Genome-wide association (GWA) studies reported that rs4374383-SNP of
MERTK gene is associated with fibrosis in patients with HCV chronic infection.
Aims: We evaluated if rs4374383-SNP influenced the risk of liver events in patients with
HCV-cirrhosis.
Results: Among 404 patients enrolled (mean age:58.2±8.6 years, 63% men, 84%
genotype 1), 17.5%, 45.8% and 36.6% had AA, GA and GG MERTK gene respectively.
104 patients (25.7%) achieved a Sustained Virological Response (SVR). During the followup (median:81 months; range:12-144) LD was observed in 95 patients (23.5%) while 90
patients (22.3%) developed HCC. By multivariate analysis EV (HR:2.21; 95%CI:1.32-3.72;
p=0.003), platelets (HR:0.98; 95%CI:0.97-0.99; p<0.001), albumin (HR:0.37; 95%CI:0.190.71; p=0.003), and SVR (HR:0.20; 95%CI:0.08-0.49; p<0.001) were independently
associated to LD. The variables independently associated to HCC were age (HR:1.03;
95%CI:1.00-1.06; p=0.049), gender (HR:0.58; 95%CI:0.36-0.95; p=0.032), GGT (HR:1.21;
95%CI:1.08-1.36; p=0.001), SVR (HR:0.27; 95%CI:0.13-0.60; p=0.001) and rs4374383SNP (AA:HR:2.68; 95%CI:1.45-4.91; p=0.001–AG:HR:1.69; 95%CI:1.01-2.94; p=0.047).
The risk to developed HCC was of 0.98 per 100 persons/years in patients with SVR and of
2.42, 4.19 and 7.64 per 100 persons/years in no responder to therapy with genotype GG,
GA and AA of rs4374383 SNP, respectively
Conclusions: The AA MERTK allele is associated with high risk of HCC in HCV cirrhosis.
MERTK gene is involved in the regulation of inflammatory responses and may be involved
in the angiogenesis and growth of liver cancer.
Methodology: A prospective cohort of patients with compensated HCV cirrhosis treated
with Peg-IFN alfa-2b/Ribavirin were evaluated for rs4374383-SNP using the TaqMan
SNP-genotyping allelic discrimination method. All patients were screened for esophageal
varices (EV) and underwent to surveillance for HCC by ultrasound every six months.
Multivariate Cox regression analysis were used to determine factors associated with
development of liver decompensation (LD) and hepatocellular carcinoma (HCC).
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(ARFI) AS PREDICTOR OF ASCITES IN
CIRRHOTICS UNDERGOING RESECTION FOR
HEPATOCELLULAR CARCINOMA (HCC): A NEW
FRIEND FOR THE PHYSICIAN?
Conclusions: Our study shows that LS evaluated with ARFI could be useful for a better
selection of patients candidate to resection allowing to individuate patients with higher risk
of post-surgery decompensation.
Clinical characteristics of enrolled population
at baseline (n=27)
Introduction: ARFI has been used to predict hepatic decompensation after resection
in patients with liver stiffness values compatible with mild-moderate fibrosis. Data about
ARFI as predictor of post-surgical ascites in cirrhotics lack.
Aims: To assess the role of liver stiffness (LS) evaluated with ARFI in predicting the
occurrence of ascites after liver resection for HCC in cirrhotics.
Methodology: Between December 2010 and September 2013, 28 patients underwent
surgical resection for HCC. For each patient, LS was performed about 89 days before
surgery (median value; 95 %CI: 62-128 d). One patient without cirrhosis was excluded
from the analysis.
Results: Clinical characteristics of the population are represented in Tab.1. One patients
died two days after surgical resection for perioperatory massive bleeding. In this patient
basal LS was 31.2 kPa. During follow-up the only complication observed was the
occurrence of ascites. Median value of LS was 14.5 kPa (95%CI: 6.9-18.3); the population
was stratified according to stiffness median value in group A (≥14.5 kPa;14 pts) and
group B (<14.5 kPa;13 pts). These two groups did not differ according to Child-Pugh,
MELD, BCLC and age. In group A, 7 patients out of 14 developed ascites with a mean
time of 21.7 days (range: 4-67), while in group B no complication occurred (p=0.02). At
multiple regression including age, CP score,MELD score and BCLC,LS resulted to be the
only independent predictor of ascites (p=0.0018; 95%C.I: 0.01-0.04). At ROC curve for
ascites and LS, the value of 14.5 kPa resulted as the best cut-off in identifying patients
that develop post-surgical ascites (sensitivity: 84%; specificity:67%) with an AUC of 0.86
(95%CI: 0.54-0.96).
Age (years, mean + ds)
68.5 ± 8.7
Sex:
• M (n- %)
• F (n- %)
17 (63%)
10 (37%)
BCLC
• A (n- %)
• B (n- %)
21 (78%)
6 (22%)
Child-Pugh score (mean ± ds)
5.2 ± 0.45
Meld score (mean + ds)
7.2 ± 1.2
Prior procedures
• TACE (n- %)
• Radio frequency (n- %)
• Resection (n- %)
• Sorafenib (n- %)
3
1
1
1
(11%)
(4%)
(4%)
(4%)
Adriano De Santis 1, Gianluca Grazi 2, Massimo Rossi 3, Claudia Iegri 1,
Marinella Lupo 1, Chiara Bassanelli 1, Giulia Gallusi 1, Mariana Forlino 1,
Carmen Di Ciesco 1, Andrea Scarinci 2, Adolfo F. Attili 1
1
Clinical Medicine Department, La Sapienza University, Gastroenterology Division,
2
Department of Hepato-biliary-pancreatic Surgery, Cancer National Institute Regina
Elena, 3Department of Trasplant Surgery, La Sapienza University, Rome, Italy
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MAXIMUM ONCOLOGICAL EFFECT INDUCED
BY NEOADJUVANT TRANSARTERIAL CATHETER
EMBOLIZATION HAS NO IMPACT ON DISEASEFREE SURVIVAL OF LIVER TRANSPLANT
RECIPIENTS WITH A SINGLE HEPATOCELLULAR
CARCINOMA WITHIN THE MILAN CRITERIA
Introduction: Transarterial catheter embolization (TACE) is the most used method
for neoadjuvant treatment of liver transplantation (LT) candidates with hepatocellular
carcinoma (HCC) within the Milan criteria. Nevertheless, its impact on post-operative
recurrence is controversial.
Aims: To evaluate whether maximum oncological effect, defined complete response
according to modified Response Evaluation Criteria In Solid Tumors (mRECIST) and
extensive necrosis (>=70%) of the HCC nodule on pathological examination, resulted in
distinct disease-free survival (DFS).
Methodology: Retrospective review of adult LT recipients with a single HCC nodule within
the Milan criteria according to preoperative imaging who underwent neoadjuvant TACE
from July, 2006 through October, 2013. Patients with maximum oncological effect (group
A) were compared to those without these characteristics (group B).
Results: Group A had 14 patients, group B had 34 patients. Similar demographic,
laboratorial, radiological, and pathological data were observed. Group A presented with
more severe liver dysfunction at LT, defined by higher Child-Pugh (7.5±1.7 vs. 6.5±1.2,
p 0.02), and MELD (15.8±7.5 vs. 11.1±3.0, p 0.04) scores. On pathological examination,
the frequency of encapsulated lesions was significantly higher in group A (92.9% vs.
52.9%, p 0.009).
Independent predictors of complete response according to mRECIST associated with
extensive necrosis (>=70%) were encapsulated lesions (OR 10.0 CI95% 1.08-92.2,
p 0.042), and MELD score (OR 1.28 CI95% 1.01-1.63). Post-LT recurrence rates (A 0%
vs. B 11.8%, p 0.238), and DFS were similar (A 1, 3 and 5 years 100% vs. B 1 year
91%, 3 and 5 years 87%, p 0.259). Multivariate analysis using a Cox proportional hazards
model confirmed that complete response associated with extensive necrosis was a poor
independent predictor of DFS (HR 1.0 CI95% 0.0-3.3, p 0.837).
Conclusions: TACE as neoadjuvant treatment of HCC for patients with a single HCC
nodule within the Milan criteria waiting LT is incapable of modifying clinically significant
oncological outcomes despite radiological response and extensive pathological necrosis.
The objective of maximum oncological effect of TACE before LT is not relevant to postLT outcomes, and may guide LT teams towards a more balanced use of this therapeutic
resource.
Guilherme Felga 1, Paolo Salvalaggio 1, Lidiane V. Marins 2,
Bianca Della-Guardia 1, Marcelo Bruno Rezende 1, Marcio Dias Almeida 1
1
Liver Transplantation Unit, 2Department of pathology, Hospital Israelita Albert Einstein,
São Paulo, Brazil
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247
COMPARISON OF SURVIVAL OF
HEPATOCELLULAR CARCINOMA PATIENTS IN
STAGE BCLC C BEFORE AND AFTER APPROVAL
OF SORAFENIB
Arndt Weinmann 1 2, Sandra Koch 1 2, Martin Sprinzl 1 2, Henning Schulze-Bergkamen 3,
Christoph Düber 4, Hauke Lang 5, Gerd Otto 6, Peter R. Galle1, Marcus Wörns 1 2
1
Ist Medical Department, 2Clinical Registry Unit, University Medical Center of the
Johannes Gutenberg University Mainz, Mainz, 3Department of Medical Oncology,
National Center for Tumor Diseases (NCT), Heidelberg, 4Department of Diagnostic and
Interventional Radiology, 5Department of Department of General, Visceral and Transplant
Surgery, 6Department of Transplantation and Hepatobiliopancreatic Surgery, University
Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
Etiology of liver disease was alcoholic cirrhosis/ chronic hepatitis C/ chronic hepatitis
B/ NASH/ other liver diseases in 163 (35.6%)/ 87 (19%)/ 48 (10.5%)/ 21 (4.6%)/ 110
(24%). Comparing the periods the number of pts with chronic hepatitis C decreased
significantly (P1: n= 54 (25.5%), P2: n= 33 (13.4%), p< 0.05). Child-Pugh score A/B/C
was 47.6%/27.4%/2.4% in P1 vs. 29.7%/39.8%/1.2% in P2 (p=0.153). There was no
significant difference in the presence of portal vein thrombosis (P1: 41% vs. P2: 37.8%) or
in the presence of ascites between the periods (P1: 19.8% vs. P2: 17.5%, p= 0.637). The
median tumor size was significantly higher in P1 7 cm vs. 6.3 cm (p<0.05).
Transarterial Chemoembolisation (TACE) was used in 91 (42.9%)/75 (30.5%) of patients
in P1/2 (p=0.07). The resection rate was 17.9% in P1 vs. 24% in P2 (p=0.218).
Sorafenib was used in 10 pts in P1 (4.7%) and 61 pts (24.8%) in P2 and in 0 (0%) in P1
and 30 pts (12.2%) as the firstline therapy.
Median OS was significantly longer in P2 (10.2 months) compared to P1 (7.8 months, p<
0.05). Conclusions: While OS improved significantly between periods P1 and P2, but the
number of patients treated with sorafenib was low. Further analysis is needed to evaluate
the contribution of Sorafenib to the OS improvement between periods.
Introduction: Sorafenib demonstrated a significant improvement of overall survival (OS)
for patients with hepatocellar carcinoma (HCC) in in two phase III trials. Since its approval
in 2007 it became the standard of care for patients in stage BCLC C. So far, efficacy of
sorafenib in rouine clinical prectice needs to be defined.
Methodology: Retrospective analysis of HCC patients treated at the University Medical
Center of the Johannes Gutenberg-University Mainz between 2001 and 2012. Data was
extracted from our clinical registry. The cohort was separated into two groups on the basis
of the year of initial diagnosis: P1: 2001 to 2006 and P2: 2007 to 2012. Patients who
received a liver transplantation were excluded from the analysis. The OS was appraised
by the Kaplan-Meier method.
Results: 458 of 1251 pts were classified as stage BCLC C between 2001 and 2012
(median age 66 years, 85.2% male), 212 in P1 (median age 66 years, 82.5% male) and
246 in P2 ( (median age 67 years, 87.4% male).
Aims: To compare the OS of a western cohort of HCC patients in stage BCLC C before
and after the approval of Sorafenib.
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249
CORRELATION BETWEEN LDH LEVELS AND
RESPONSE TO SORAFENIB IN HCC PATIENTS
IDENTIFICATION OF RESPONDERS TO
SORAFENIB IN HEPATOCELLULAR CARCINOMA:
IS TUMOUR VOLUME MEASUREMENT THE WAY
FORWARD?
Rodolfo Sacco 1, Lorenzo Fornaro 2, Caterina Vivaldi 2, Chiara Caparello 2,
Gianna Musettini 2, Gianluca Masi 2, Valeria Mismas 1, Barbara Ginanni 3,
Antonio Romano 1, Giampaolo Bresci 1 and ITA.LI.CA. Group
1
Gastroenterology, 2Oncology, 3Radiology, Pisa University Hospital, Pisa, Italy
Introduction: Lactate dehydrogenase (LDH) is a predictor of clinical outcome in
hepatocellular carcinoma (HCC) patients. However, the predictive role of LDH on the
clinical outcomes of sorafenib treatment has been poorly documented. Aims: The correlation between LDH levels and clinical outcomes in HCC patients treated
with sorafenib included in the Nation-wide Italian database ITA.LI.CA. is investigated here.
Methodology: The ITA.LI.CA. database contains data of 5136 HCC patients treated at
18 Italian Centers. All patients treated with sorafenib treatment and with available LDH
values were considered. A ROC analysis was performed to find a suitable threshold for
baseline LDH levels. Overall Survival (OS) and time to progression (TTP) were compared
in patients with LDH above and below the identified threshold. Study endpoints were also
evaluated according to different patterns of LDH levels during treatment.
GENEVA, SWITZERLAND
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Results: Baseline LDH levels were available for 97 patients (85 males, 61 in BCLC-C
stage); data on LDH levels during sorafenib were reported for 10 patients. Mean
baseline LDH concentration was 324±141 U/L.The most accurate cut-off value for LDH
concentration was 297 U/L. Both study endpoints were equal in patients with LDH values
≥297 U/L (n=47) and in those with lower LDH concentrations (n=52) (OS: 12.0 months in
each population; TTP: 4.0 months in each group).During treatment, LDH values decreased
in three patients (mean difference=-219 U/L). Patients with decreased LDH concentrations
have a prolonged OS versus those with unmodified/increased values (p=0.0083; all
patients with decreasing LDH arealive, median OS for patients with increasing LDH was
8.0 months). Median TTP was 19.0 months in patients with decreasing LDH and 3.0
monthsin those with increasing values (p=0.008).
Conclusions: The clinical benefits of sorafenib do not seem influenced by baseline LDH.
However, a decreased LDH concentration during sorafenib might be associated with
improved clinical outcomes.
Rodolfo Sacco 1, Irene Bargellini 2, Alessandra Scionti 2, Valeria Mismas 1,
Chiara Caparello 3, Caterina Vivaldi 3, Gianluca Masi 3, Giampaolo Bresci 1,
Carlo Bartolozzi 2 and ITA.LI.CA Group
1
Gastroenterology, 2Radiology, 3Oncology, Pisa University Hospital, Pisa, Italy
Introduction: Early assessment of hepatocellular carcinoma (HCC) response during
sorafenib (SO) treatment is challenging, since tumour necrosis can be inhomogeneous as
far as extension and radiological appearance.
Aims: We retrospectively evaluated prognostic value of different imaging criteria, such
as RECIST (Response Evaluation Criteria in Solid Tumours) 1.1, EASL (European
Association for the Study or The LIver), modifìed RECIST (mRECIST), tumour density
and volume variations, in the early follow-up of SO treatment.
Methodology: The stucly inclucled 22 patients (18 male. mean age 68 years). Two
independent radiologists reviewed baseline and 2months follow-up computed tomography
(CT) images to assess response according to RECIST 1.1, mRECIST, EASL. Choi’s
criteria (decreased tumour density ≥15%) ancl arterial-enhancing tumour volume ratio.
Alfa-fetoprotein (AFP) variations were expressed as AFP ratio.
Results: Response criteria and volume measurements were reproducible (k> 0.80). The
overall disease control rate was 40.9% by EASL and mRECIST and 27.3% by RECIST
1.1; a ≥15% decrease in tumour density was observed in 9 patients (40.9%). Mean volume
ratio was 1.73 ± 2.12; mean AFP ratio was 14 ± 37. One-year overall survival rate was
65.9%. Volume ratio resulted to be the only prognostic factor for survival, with 1-year
cumulative survival rates of 90% for volume ratio 1.1 and 45.4% for volume ratio > 1.1
(P=0.04)
Conclusions: Tumour volume measurements are reproducible and should be considered
as an alternative to RECIST, mRECIST and/or EASL since they may provide an early
prognostic marker of response in HCC patients treated with SO.
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251
ACOUSTIC RADIATION FORCE IMPULSE (ARFI)
IN PREDICTING POST-RADIOEMBOLIZATION
(TARE) LIVER FAILURE IN PATIENTS
WITH INTERMEDIATE AND ADVANCED
Age (years, mean + ds)
66.7 + 10
Sex:
• M (n- %)
• F (n- %)
16 (76%)
5 (23%)
Introduction: Currently, only few blood parameters are reported as predictive of liver
failure post-TARE, such as bilirubin values greater than 2 mg/dl.
Liver Disease:
• Cirhosis
• Chronic hepatitis
20 (95%)
1 (5%)
Aims: We aimed to assess a possible role of liver stiffness (LS) evaluated with ARFI, in
predicting post-TARE hepatic decompensation (HD)
Etiology
• Virus
• Alcohol
• Virus and alcohol
• Others
13 (62%)
5 (24%)
1 (5%)
2 (9%)
BCLC
• B (n- %)
• C (n- %)
15 (71%)
6 (29%)
Child-Pugh score (mean ± ds)
Meld score (mean + ds)
5.6 ± 0.7
8.3 ± 1.9
HCC type
• Uninodular
• Multinodular
2 (10%)
19 (90%)
HCC diameter (mean ± ds)
82 + 42 mm
Clinical characteristics of enrolled population
at baseline (n=21)
Methodology: 39 consecutive patients were evaluated for TARE between April 2012 and
November 2013.Of these: 21 pts underwent SIRT, 11 pts (28.2 %) were excluded for
technical contraindications and/or disease severity and 7 pts (17.9 %) are still waiting for
the angiographic evaluation. Pre–treatment LS was available in 19 pts out of 21(90.4 %)
Results: Baseline clinical characteristics of the population are summarized in Table 1.
Median LS value was 16.6 kPa. Choosing it as a cut-off,we divided the population into
two groups: A (≥16.6 kPa;10 pts) and B (<16.6 kPa;9 pts). Age, CP score, MELD score
and BCLC stage were overlapping in the two subgroups. HCC size was lower in group
A (72.1 ± 29 mm) than in group B (92 ± 58 mm), although not significantly. HD rate was
similar in the two groups (A: 40 % vs B: 44 %; p = ns), but the mean time to onset was
significantly longer in the latter (A: 19.5 ± 15.7 d vs B: 57.5 ± 25.7 d; P = 0.04). Per protocol
overall survival was 256.4 + 210 d; no differences were observed between the two groups
(A:256.4±210 d vs B: 244.4±165 d; p = ns).
Conclusions: The shorter time to onset of HD after TARE in pts with lower LS suggest
a possible correlation between these variables that need to be confirmed expanding
population.
Adriano De Santis 1, Claudia Iegri 1, Marinella Lupo 1, Giulia Gallusi 1, Mariana Forlino 1,
Chiara Bassanelli 1, Carmela A. Di Ciesco 1, Giuseppe Pizzi 2, Adolfo F. Attili 1
1
La Sapienza University Clinical Medicine Department, Gastroenterology Division,
2
Department of Interventional Radiology, Cancer National Institute Regina Elena,
Rome, Italy
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COMPLETE CAUDATE LOBECTOMY VIA
ANTERIOR APPROACH FOR TUMORS IN OR
INVOLVING THE PARACAVAL PORTION: A
SINGLE CENTER EXPERIENCE WITH 63 CASES
SELF-EFFICACY IN COPING WITH CANCER
AFFECTING THE MENTAL RELATED QUALITY
OF LIFE IN LIVER CANCER PATIENTS AFTER
RECEIVING TREATMENTS
Weiping Zhou 1, Zhenguang Wang 1, Joseph W.-Y. Lau 2
The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital,
Second Military Medical University, Shanghai 200438, China, Shanghai, China, 2Faculty
of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong
Kong, Hong Kong
1
1
253
Shiow-Ching Shun 1, Yeur-Hur Lai 1, Chien-Hung Chen 2
Department of Nursing, 2Department of Medicine, National Taiwan University,
Taipei, Taiwan
Aims: Caudate lobectomy via anterior approach is a proper but technically demanding
operation for tumors in the paracaval portion. Our objective was to share our experiences
and surgical tips on caudate lobectomy via anterior hepatic transection.
Methodology: From August 2004 to September 2013, there were 63 cases of caudate
lobectomy via anterior approach performed in our department. Clinicopathologic correlates,
surgical correlates, complications and survival were analyzed.
Results: All 63 cases of caudate lobectomy via anterior hepatic transaction were
succeeded performed without perioperative death. The median age was 47 years (range,
18-68 years) and the median tumor size was 9.2 cm (range, 3-30 cm). The operating time
was 205 minutes in median (range, 120-445 minutes) and blood loss was 800 ml in median
(range, 200-5000 ml). There were 36 patients (57.1%) who received blood transfusion
in operation. 8 patients (12.7%) received isolated complete caudate lobectomy while 55
patients (87.3%) took mesohepatectomy plus complete caudate lobectomy. The morbidity
of the postoperative complications was 42.9%. We performed the hepatic parenchymal
transection using clamp-crush method (N=47) and ultrasonic scalpel (N=16). Patients in
the ultrasonic scalpel group had less morbidity of surgical complications (morbidity: 18.8%
versus 51.1%, P=0.024) and less severe complications (P=0.041).
Conclusions: The technique for caudate lobectomy via anterior hepatic transection can
improve the success and safety for resection of tumors from the paracaval portion. Using
ultrasonic scalpel during hepatic parenchymal transection can help to save the vascular
exclusion time and operation time, reduce the morbidity of surgical complications.
Aims: The aim of this study was to identify if the self-efficacy in coping with cancer before
discharge was associated with health-related quality of life in liver cancer patients after
receiving non-surgical treatments including transcathether hepatic chemoembolization,
percutaneous ethanol injection, and radiofrequency ablation.
Methodology: Data were collected three times including the day before discharge (T1),
and eighth (T2) weeks after discharge by using a set of structured questionnaires to assess
patients’ care quality of life, symptom distress, fatigue, anxiety, depression, and level of
self-efficacy in a teaching hospital in Northern Taiwan. Health-related quality of life and
its associated factors were examined by descriptive analysis and the significant factors
associated with the level of quality of life at T3 were identified by multiple regression.
Results: Patients with liver cancer (N = 114) reported that fatigue was the most distressed
symptom after treatment. Self–efficacy at T1 was associated with the level of anxiety (r
= -0.247, p = 0.020) and physical and mental related quality of life at two months after
treatment (T2). However, after controlling other associated factors, the level of selfefficacy (β =0 .115, p < 0.005) before discharge was significant factor associated with
mental related quality of life (QOL) at 8 weeks after treatment.
Conclusions: The level of self-efficacy in coping with cancer before discharge is an
important factor to affect the level of mental –related QOL after 8 weeks of treatment.
Therefore, health providers should closely assess the self-efficacy in coping with cancer
after discharge in order to improve their mental-related QOL after discharge.
Introduction: Caudate lobectomy via anterior approach is a proper but technically
demanding operation for tumors in the paracaval portion. Our objective was to share our
experiences and surgical tips on caudate lobectomy via anterior hepatic transection.
Introduction: Many patients with hepatocellular carcinoma (HCC) frequently received
medical treatments because of its high recurrent rate. However, the short stay of
hospitalization and unpredictability of treatment outcome, the self-efficacy in cancer care
might be the important role affecting the level of quality of life after discharge.
255
A RCT TO COMPARE PRINGLE MANOEUVRE
WITH HEMI-HEPATIC VASCULAR INFLOW
OCCLUSION IN LIVER RESECTION FOR
CIRRHOSIS
ALCOHOL, OBESITY AND TOBACCO AS RISK
FACTORS FOR HEPATOCELLULAR CARCINOMA
Junsheng Ni 1, Weiping Zhou 2, Joseph W. Lau 3
The Third Department of Hepatic Surgery, 2The Third Department of Hepatic Surgery,
Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai
200438, China, Shanghai, China, 3Faculty of Medicine, Prince of Wales Hospital, The
Chinese University of Hong Kong, Shatin, Hong Kong, SAR, Hong Kong
1
Introduction: The duration of hepatic vascular inflow occlusion and the amount of
intraoperative blood loss have significant negative impacts on postoperative morbidity,
mortality, and long-term survival outcomes of patients who receive partial hepatectomy for
hepatocellular carcinoma (HCC) with cirrhosis.
Aims: To compare the perioperative outcomes of partial hepatectomy for HCC
superimposed on hepatitis B-related cirrhosis using two different occlusion techniques.
EASL HCC SUMMIT
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Methodology: A randomized controlled trial was carried out to evaluate the impact of two
different vascular inflow occlusion techniques. The postoperative short-term results were
compared.
Results: During the study period, 252 patients received partial hepatectomy for HCC with
cirrhosis. Of these patients, 120 patients were randomized equally into two groups: the
Pringle manoeuvre group (n=60) and the hemi-hepatic vascular inflow occlusion group
(n=60). The number of patients who had poor liver function on postoperative day 5 (POD 5)
with ISLGS Grade B or worse were 24, and 13, respectively (p=0.030). The postoperative
complication rate was significantly higher in the Pringle manoeuvre group (40% versus
22%, p=0.30). However, the Pringle manoeuvre group had significantly shorter operating
time(116 mins versus 136 mins, p=0.012) although there was no significant difference in
intraoperative blood loss between the 2 groups [200ml (range 10-5000ml)] versus [300ml
(range 100-1000ml)], (p=0.511). There was no perioperative mortality.
Conclusions: The results indicated that for patients with HCC with cirrhosis, hemi-hepatic
vascular inflow occlusion was a better inflow occlusion method than Pringle manoeuvre.
1
Adriana Babameto 1, Klerida Shehu 2, Edlira Ibro 3, Pranvera Kristani 4
Gastroenterology & Hepatology, 2University of Technical Sciences, University Hospital
Center “ Mother Theresa”, 3Gastroenterology & Hepatology, Specialistic Polyclinic,
Tirana, 4Gastroenterology & Hepatology, Hospital of Durres, Durres, Albania
Introduction: The role of alcohol as an important risk factor for hepatocellular carcinoma
(HCC) has been described in different studies, while it is not the same for tobacco which
role as a risk factor for HCC is still discussed. Recently, some studies have reported also
obesity to be like a risk factor for HCC.
Aims: To evaluate the role of alcohol, tobacco and obesity as risk factors for HCC in
Albanian patients.
Methodology: Patients with HCC, cirrhosis with HCC and cirrhosis without HCC were
enrolled in the study. We studied the role of alcohol and tobacco as well as obesity related
to the presence of HCC.
Results: In the study were enrolled 65 patients with HCC and 100 patients with cirrhosis
without HCC. It was found significant correlation between alcohol, tobacco and obesity.
Comparing HCC cases to the cirrhotic group without HCC, it was found that the risk of
HCC increased 4-fold for alcohol, 2-fold for tobacco and 2.5-fold with obesity. Also a dosedependent relationship between alcohol and tobacco exposure with risk of HCC was
noted.
Conclusions: Alcohol, tobacco and obesity seem to be independent risk factors for HCC
in our patients. They seem to be synergic factors increasing the risk of HCC. It shows to
be a useful data for the surveillance of cirrhotic patients for HCC occurrence.
254
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257
HCC MANAGEMENT WITH SORAFENIB AND
TACE: ITALIAN EXPERIENCE FROM GIDEON
(GLOBAL INVESTIGATIONAL OF THERAPEUTIC
DECISIONS IN HCC AND OF ITS TREATMENT
WITH SORAFENIB)
1
UOC Oncologia Medica, IRCCS Ospedale di Bari, Bari, , 2UO Oncologia Medica,
AO G. Rummo, Benevento, 3SC Gastroenterologia, AO G. Brotzu, Cagliari, 4Scienze
Biomediche e Oncologia Umana. Sez Medicina Interna e Oncologia Clinica, Università
degli Studi di Bari A.Moro, Bari, 5DiBiMIS, UOC Medicina Interna ed Epatologia, AOUP
Paolo Giaccone, Palermo, 6Clinica di Gastroenterologia, AUO Ospedali Riuniti, Torrette
di Ancona, 7UOC di Oncologia, AORN dei Colli - Ospedali Monaldi-Cotugno-CTO, Napoli,
8
UOC di Gastroenterologia, Policlinico Umberto I, Roma, 9SOC Oncologia Medica
B, Centro di Riferimento Oncologico CRO, Aviano, 10Gastroenterologia, Ospedale
Univeristario Gemelli-Università Cattolica, Roma, 11Unità di Chirurgia Epatobiliare e
Trapianto Epatico, AOU di Padova, Padova, 12Medical Department, Bayer Spa, Milano,
13
U.O. Diagnosi e terapia delle epatiti e ambulatorio trapianto di fegato, IRCCS A.U.O.
San Martino-IST , Genova, 14Unità Fegato, AORN San G. Moscati, Avellino, Italy
Introduction: The global, prospective, non-interventional GIDEON study (NCT00812175)
enrolled 3371 patients (pts) with HCC treated with sorafenib (SOR) in real-life practice
conditions. We report the outcomes of HCC pts treated with SOR in Italy according to prior
or concomitant (ct) use of transarterial chemoembolization (TACE).
Aims: The primary aim of the study was evaluate the safety of sorafenib in HCC patients
in clinical practice.
Methodology: Patients with unresectable HCC for whom a decision to treat with SOR
was taken were eligible for inclusion. Disease and pts characteristics were assessed at
baseline. SOR dose, adverse events ( AEs) and outcomes were recorded at follow-up.
Results: Of the 278 pts enrolled in Italy, 274 received at least one dose of SOR. In total
36.5 % (n=100) pts received prior TACE and 4 % (n=11) ctTACE. A higher proportion of
ECOG PS 0 pts received prior TACE or ctTACE. Median daily SOR dose was 776 mg
(n=241) across all subgroups. Duration of treatment was longer in pts with prior TACE
or ctTACE (19.3 weeks [wks], 15.7 wks, 38.9 wks and 15.9 wks in pts with prior TACE,
no prior TACE, ctTACE and no ctTACE, respectively). The overall incidence of AEs and
serious AEs was similar across these subgroups. Drug-related AEs was greater in pts
with prior TACE (79%) than those who received no prior TACE (60%) and in pts with prior
ctTACE (91%) than those who received no prior ctTACE (66%).The most frequent drugrelated AEs were diarrhea (24%), fatigue (23%) and hand foot skin reaction (24%). There
were no new unexpected AEs. Median OS was 97.5 wks, 47.7 wks and 51.7 wks in pts
with prior TACE, no prior TACE and no ctTACE respectively (not assessable in ctTACE
group).
Conclusions: The safety profile of SOR in pts treated with prior or concurrent TACE
is consistent with those observed in previous clinical trials without new safety signals
in a real-life setting in Italian centers. Diifferences in baseline characteristics may have
played a role in OS. Given the observational nature of the study a selection bias cannot
be excluded. CLINICAL POSTER ABSTRACTS
Vito Lorusso 1, Domenico Germano 2, Maria T. Zolfino 3, Domenico Sansonno 4,
Giuseppe Montalto 5, Antonio Benedetti 6, Vincenzo Montesarchio 7, Adolfo F. Attili 8,
Sergio Frustaci 9, Antonio Gasbarrini 10, Umberto Cillo 11, Daniela Carpani 12,
Antonino Picciotto 13, Salvatore D’Angelo 14
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ONE YEAR DISEASE-FREE FOLLOW UP AFTER
ORTHOTOPIC LIVER TRANSPLANTATION IN A
MULTICENTRIC HEPATOCELLULAR CARCINOMA
PATIENT SUBMITTED TO SYSTEMIC
CHEMOTHERAPY WITH SORAFENIBE
INTRAOPERATIVE BLOOD SALVAGE DURING
LIVER TRANSPLANTATION IN PATIENTS WITH
Mariana D. C. Toro 1, Ilka Boin1, Angela Cristina L. Malheiros 1,
Jazon R. S. Almeida 1, Tiago Seva-Pereira 1, Elaine C. Ataide 1, Adilson R. Cardoso 1,
Cristina Aparecida A. Caruy 1, Raquel S. B. Stucchi 1, Carmen S. P. Lima 1
1
Digestive Surgery, State University of Campinas, Campinas, Brazil
259
Mariana D. C. Toro 1, Angela Cristina L. Malheiros1, Jazon R. S. Almeida 1,
Tiago Seva-Pereira 1, Elaine C. Ataide 1, Adilson R. Cardoso 1,
Cristina Aparecida A. Caruy 1, Raquel S. B. Stucchi 1, Ilka Boin
1
Digestive Surgery, State University of Campinas, Campinas, Brazil
Aims: The aim of this report was to show a successful case where the patient had HCC
outside the Milan criteria and was submitted to liver transplantation after entering the Milan
criteria.
Methodology: A 51-year-old male with hepatic cirrhosis secondary to hepatitis C virus
infection, was reported to our service with hepatic mass in a screening examination. It
was confirmed as a 4.4cm HCC, grade II of Edmonson-Steiner, in segment VIII after MRI
scan and guided biopsy. The patient was included on the liver transplantation waiting list,
but after tumor drop-out occurred was removed. At this time a CT scan showed a 6.4cm
HCC-compatible tumor and several small-HCC suspect images.
After a one-year period of Doxorubicin and Sorafenib based chemotherapy the patient
had a repeat CT scan which found a reduction to 4.6cm in the main lesion, with no more
contrast enhancement, and the disappearance of the several small-HCC suspect lesions.
This was considered as a successful downstaging and the patient was transplanted with a
deceased donor and piggyback technique with no major complications. At one year followup the patient showed no signs of recurrence on thoracic and abdominal scans while there
were normal alpha-fetoprotein and liver function
Results: Histopathological analysis of liver explants shows a 3.2cm completely necrotic
tumor, grades I/II Edmonson-Steiner, ranging from 0.8 to 1.6cm. Eighteen months diseasefree follow-up could be based on biological characteristics of the tumor or by effects of the
chemotherapic treatment.
Conclusion: Sorafenibe showed to be efficient in reducing and maintaining the control of
HCC in a cirrhotic patient and also after the postoperative period.
Aims: To analyze the prognosis of patients with HCC, who were transplanted and
submitted or not to IBS. Also, to correlate the use of IBS with tumor recurrence (TR) and
survival rates (SVR).
Methodology: Eighty-three liver transplant patients with histological examination of HCC,
incidental or otherwise, were selected between 1998 and 2010, and distributed into groups
according to the use or not of IBS. In each subgroup the SVR, TR, number and size of liver
nodules, use of blood products, duration of the surgery, length of hospital stay, donor`s
and recipients` data were analysed. The tests used were non-parametric and survival rate
using Kapaln-Meyer and Cox hazard proportional regression.
Results: In the graph 1 we can see the survival curves analyses. We observe that higher
MELD score and longer survival time in patients with TR - and IBS. The patients with tumor
recurrence had lower survival but non related to IBS use.
Conclusion: IBS can be used safely and has no influence on survival or TR after liver
transplantation.
Introduction: Orthotopic liver transplantation (OLT) is widely accepted as gold-standard
treatment for cirrhotic patients with HCC, but this indication is limited by the Milan criteria.
Introduction: Hepatocellular carcinoma (HCC) patients, with MELD higher than 10, are
indicated for liver transplantation rather than liver resection. However, in transplantation
surgery there is often the need for blood transfusion. To avoid homologous blood
transfusions, intraoperative blood salvage (IBS) is used. Nevertheless, the literature
contraindicates the use of IBS in cases of carcinoma for the reason that it would reimplant
tumor cells in the bloodstream. Incidental findings of HCC in transplanted patients using
IBS allows the study of association of survival rates and tumor recurrence.
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IMPACT OF THE IMMUNOSUPPRESSION IN THE
LATE RECURRENCE OF HEPATOCELLULAR
CARCINOMA AFTER SEQUENTIAL
TRANSPLANTATION LIVER-KIDNEY
Renato F. Da Silva1, Dalisio D. S. Neto 1, Fabio L. C. Fernandes 1,
Helen C. C. de Felício 1, Paulo C. Arroyo Júnior 1, Willian J. Duca 1,
Ida M. M. Fernandes 1, Rita C. M. A. da Silva 1
1
General Surgery, Faculty of Medicine of São José do Rio Preto,
São José do Rio Preto, Brazil
Introduction: The liver transplantation is one of the most effective therapeutic option for
hepatocellular carcinoma (HCC) in early stage, however the recurrence can occur and is
more frequent within the first two or three years after the transplant. We describe a case
of late recurrence of HCC after sequential liver-kidney.
Eighteen months after renal transplantation in routine examinations the alpha-fetoprotein
increased from 6.7 ng/ml to 232.6 ng/ml, TC Chest which identified nodules smaller
than 1 cm in the right lung and bone scintigraphy showed no metastasis. The patient
underwent thoracotomy. The planned lobectomy was not performed due to disseminated
disease including pleura. Sorafenib was used, without response. The patient died 13
months after de recurrence and the histo-pathological exam demonstrated metastatic
HCC in lung with the same strain of the primary liver tumor.
Conclusion: These findings suggest a possible influence of increased
immunosuppressant schemes in later recurrence of HCC. This can be one more alert for
tailoring immunosuppresion even after double transplantation
Methodology: We present a patient with late recurrence of HCC after sequential liverkidney transplantation. The recurrence occurred 101 months after transplantation of the
liver and 22 months after kidney transplantation, namely, very late recurrence compared
to liver transplantation and earlier in relation to kidney transplantation.
Results: Since May 2003 he underwent liver transplantation because of HCC, the
patient was stable and in use of low-dose of immunosuppresion: 1mg of Sirolimo
on alternative days and Mycophenolate Sodium 360 twice a day. In December 2009
after renal transplantation received high doses of immunosuppression: induction with
Thymoglobulin (ATG), in three doses, with a total dose of 4.5 mg\kg and corticosteroids
increased to 45 mg prednisone\day, Mycophenolate Sodium 720 mg twice a day and
Sirolimus was kept 1 mg every other day. Progressed to acute rejection eleven days
after the transplantation, which was treated with pulse Solumedrol 1gr for three days,
and then the prescription was maintained with prednisone at a dose of 25 mg twice a/
day, and Sirolimos was increased to 2 mg twice a day.
Aims: Discuss the possible influence of over immunosuppression related to late
recurrence of the tumor after sequential transplantation liver and kidney.
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263
GAMMA GLUTAMYL TRANSPEPTIDASE (GGT):
IS THERE ANY CORRELATION BETWEEN GGT
AND ALPHA-FETOPROTEIN (AFP) LEVELS IN
CIRRHOTIC PATIENTS WITH HEPATOCELULAR
CARCINOMA?
Renato F. Da Silva1, Cibele M. de Oliveira 1, Patrícia D. S. F. Pereira 1,
Paulo C. Arroyo Júnior 1, Willian J. Duca 1, Helen C. C. de Felício 1,
João Paulo C. do Amaral 1, José Eduardo P. Monteiro ,1, Rita D. C. M. A. da Silva 1
1
Faculty of Medicine of São José do Rio Preto, São José do Rio Preto, Brazil
Introduction: The alpha-fetoprotein (AFP) is currently used as prognosis in HCC. Some
studies suggest that serum gamma glutamyl transpeptidase levels (gGT) can also have
this role. We want to know whether there is interaction among the values of GGT and
AFP in cirrhotic patients with HCC in order to investigate the possible role of GGT in this
context.
The patients were dichotomized according to GGT cutting level = 166 UI/L (Classification
Tree). Among the patients with GGT<= 166 UI/L, median AFP value (variation) was
41,5 ng/ml (1,1 – 100.672,00) and among those with GGT > 166 UI/L was 180 ng/ml (
2,4- 219.200,00), p= 0,014. There was no difference among the diameter of the largest
nodule between the two groups: median 4,6 cm (0,6-26) and median 5 cm (2- 15,4) to
GGT<= 166 UI/L and > 166 UI/L, respectively, p = 0,11.
Conclusion: Our data identified a cutoff value that showed interaction among GGT and
AFP. When GGT were greater than 166 UI/L the AFP values were significantly higher
compared to patients with lower GGT. The clinical significance of this finding can’t be
explained from this analysis. Therefore the analysis of other variables can clarify the
role of GGT in patients with HCC.
Methodology: Retrospective study of patients with diagnosis of hepatocellular
carcinoma, from 1998 to 2012, in a School Hospital. The studied variables were:
gender, age, tumor diameter, number of nodules and Edmondson-Steiner histology
classification. Classification Tree was applied to verify possible interaction among the
variables. The Mann-Whitney test was used to compare the continuous variables with
non normal distribution. Results: The records of 277 patients with hepatocellular carcinoma were reviewed.
Male gender was 84,5% and the mean age was 57 years old. The Edmondson-Steiner
histology classification (degree 1 to 4) showed this distribuction: G1=33,3 %, G3= 56,9%
and G4 = 9,8%. The number of nodules was: 1- 64,6%, 2- 10,2%, 3 - 3,4% and multiple
nodules -21,8%. The median AFP value was 60,7 ng/ml (ranging from 1,1 ng/ml to
219.200,00 ng/ml). The median GGT value was 124,5 UI/L ( ranging from 10 UI/L to
967 UI/L).
Aims: To analyze the correlation between gGT and AFP levels in cirrhotic patients with
hepatocellular carcinoma.
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265
MOLECULAR ANALYSIS OF THE GENE GSTP1
ALA114VAL POLYMORPHISM IN PATIENTS
WITH CIRRHOSIS AND HEPATOCELLULAR
CARCINOMA (HCC)
NOTES
Gislaine D. Ferreira 1, Pamela R. Francelin 1, Renato F. Da Silva 2,
Rita D. C. M. A. da Silva 1, Ana Lívia S. Galbiatti 1, Anelise Russo 1, Vivian R. Corea 1,
Paulo C. Arroyo Júnior 2, William J. Duca 2, André R. de Oliveira 1, Leonardo P. Stuchi 1,
Helen C. de Felício 3, Érika C. Pavarino 1, Eny M. G. Bertolo 1
1
2
Clinical Department, General Surgery, 3Nurse Department, Faculty of Medicine of São
José do Rio Preto, São José do Rio Preto, Brazil
Introduction: Hepatocellular carcinoma (HCC), epithelial tumor derived from hepatocytes,
is rated as the most frequent primary tumor of the liver. Observed genetic variation within
and between populations have been postulated as an influence on the risk factors for
HCC. Currently, the most studied are genetic variants of glutathione S-transferase (GST).
Methodology: We included 284 individuals (84 patients and 200 controls). The etiology
of cirrhosis were: HCV= 35; HBV= 10; HCV and alcohol=26; alcohol=50. Molecular
analysis was performed by Polymerase Chain Reaction – Restriction Fragment Length
Polymorphism PCR-RFLP. The studied variables were: age, gender, alcohol consumption,
virus C infection and cirrhosis. For statistical analysis, the chi-square and multiple logistic
regression tests were adopted, with p ≤ 0.05 and 95% CI considered significant.
Results: The results showed that age ≥ 42 years (OR 18.33, 95% CI 6.01 to 55.91, p =
0.000), female gender (OR 0.20, 95% CI 0.07 to 0.54 p = 0.001), alcohol consumption (OR
3.89, 95% CI 1.64 to 9.23, p = 0.002) and the presence of GSTP1 Ala114Val polymorphism
(OR 5.26, 95% CI 1.64 to 16, 87, p = 0.005) are risk factors for developing cirrhosis
and hepatocellular carcinoma. Virus C infection in conjunction with alcohol consumption
(OR 66.76, 95% CI 1.16 to 3829.18, p = 0.042) increases the chance of development of
cirrhosis for hepatocellular carcinoma.
Conclusion: Individuals aged ≥ 42 years old, female gender, alcohol consumption
and presence of the GSTP1 Ala114Val polymorphism may be predictive factors for the
development of cirrhosis and hepatocellular carcinoma. Virus C infection in conjunction
with alcohol consumption can further increase the chance of development of cirrhosis for
hepatocellular carcinoma.
Aims: To analyze GSTP1 Ala114Val polymorphism in patients with cirrhosis and
hepatocellular carcinoma and in individuals with no history of cancer (control group), in
order to identify biomarkers of susceptibility for HCC.
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VASCULAR ENDOTHELIAL GROWTH FACTOR
GENETIC VARIANTS RELATED TO GENDER
IN HEPATOCELLULAR CARCINOMA AND
CIRRHOSIS: PRELIMINARY RESULTS
Introduction: Hepatocellular carcinoma (HCC) is the most common liver cancer with risk
factors as cirrhosis secondary to B and C hepatitis, nonalcoholic steatohepatitis, alcohol,
besides genetic alterations. In this context, the vascular endothelial growth factor (VEGF)
is associated to the carcinogenic process.
Aims: Evaluate the association of C936T-VEGF polymorphism with HCC and Cirrhosis,
and its association with gender, and also clinical and epidemiologic variables.
Methodology: We studied 232 individuals with age between 8 and 92 years old, distributed
in 3 groups: G1- 34 patients with HCC (19 males and 15 females); G2- 95 patients with
cirrhosis without HCC (71 males and 24 females); e G3- 104 healthy individuals in the
control group (36 males and 68 females). The causes of cirrhosis in the studied groups
were: G1 – HVC: 5, HVB: 2, HVC + alcohol: 3, alcohol: 5, miscellaneous: 8; G2 - HVC:
26, HVB: 5, HVC + alcohol: 18, alcohol: 28, miscellaneous: 18. The VEGF variants were
analyzed by PCR/RFLP. The variables analyzed were gender, alcoholism, diabetes,
systemic arterial hypertension and genotype. We used Fisher’s exact test or Chi-Square,
with significance level P<0.05.
Results: The homozygous wild genotype (CC) was highlighted in all groups (G1=67.3%,
G2=75.8% and G3=72.0%, P>0.05), as well as the allele C (G1=0.84, G2=0.87
and G3=0.82, P>0.05). The CC genotype was more frequent in female on G3 (78%),
compared to female with HCC on G1 (67% P=0.026). The presence of -/T genotype were
more frequent in male patients on G2 (75%), in comparison with G3 (40%, P=0.044). The
comparison among patients with HCC and Cirrhosis and also HCC and healthy patients
showed no difference for the -/T genotype (P= 0.231 and P=1.0, respectively). Alcoholism
was more frequent among G2 (46.3%), compared to G3 (21%, P=0.0005). Diabetes was
more frequent among G1 (35%) and G2 (35%), related to G3 (1%, P=0.0001).
Conclusion: VEGF genetic variants, by itself, are not associated with HCC or Cirrhosis.
However, the CC genotype showed significant association with healthy females, while the
presence of the -/T genotype showed association with cirrhotic male patients. Our data
suggest association of cirrhosis with diabetes and alcoholism as well as for -/T genotype
in male gender. The number of patients in this study limits major clinical conclusions. The
continuation of this study with more patients will contribute to the better understanding
about the role of the VEGF polymorphism on hepatic carcinogenesis.
Victor Nogueira 1, Rita C. M. A. da Silva 1, Renato F. Da Silva1, Rafael F. Ferreira 1,
Marcela A. D. S. Pinhel 1, Graciele D. Tenani 1, Michele L. Gregório 1, Willian J. Duca 2,
Joao G. da Silva Castro Andrade 1, Erika Yuki Yvamoto 1, Paulo C. Arroyo Júnior 2,
Helen C. de Felicio 3, Marcelo A. Nakazone 1, Dorotéia R. S. Souza 2
1
Clinical Department , 2Surgery Department, 3Nurse Department, Faculty of Medicine of
São José do Rio Preto, São José do Rio Preto, Brazil
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269
CURATIVE TREATMENT IN THE MANAGEMENT
OF SMALL HEPATOCELLULAR CARCINOMA
NOTES
Rania Hefaiedh, Hayfa Romdhane 1, Nour Elleuch 1,
Rym Ennaifer 1, Houda Ben Nejma 1, Najet Bel Hadj 1
1
Hepatology and Gastroenterology, Mongi Slim University Hospital, La Marsa, Tunisia
Introduction: Hepatocellular carcinoma is the first liver tumor worldwide. Therefore, it is a
matter of debate whether surgical treatment (hepatic resection) or percutaneous treatment
(radiofrequency ablation or alcoholic injection) should be preferred for the treatment of
patients with small hepatocellular carcinoma.
Aims: The aim of our study was to compare the long-term outcome and the survival
between surgically and percutaneously treated small hepatocellular carcinomas.
Results: Among the sixty three patients who were diagnosed for hepatocellular carcinoma,
twenty eight carried a small hepatocellular carcinoma with a mean age of 63 years and sex
ratio of 0.64. Etiology of cirrhosis was post viral in 96%. Hepatic resection was performed
in 15 cases (53.5%) while percutaneous treatment was proposed for 13 cases (46.5%)
based on radiofrequency ablation in 9 cases (69%) and alcoholic injection in 4 cases
(31%). Overall survival was significantly lower in the surgical resection group than in the
percutaneous treatment group. The corresponding 6 months and 1 year overall survival
rates for the surgical resection group and the percutaneous treatment group were 100%,
100%, 20%, and 52%, respectively (p=0,04). The disease free survival for percutaneous
treatment and surgical resection were not significantly different.
Conclusion: Our results showed the efficacy and safety of percutaneous ablation
treatments (radiofrequency ablation or alcohol injection) which were better than those
of surgical treatment (hepatic resection) in patients with small hepatocellular carcinoma.
Percutaneous treatments had the advantages over surgical resection in being less
invasive and having lower morbidity.
Methodology: A non-randomized comparative retrospective study was performed in the
department of hepatology of Mongi Slim hospital during a period of three years. The study
included all patients carrying a small hepatocellular carcinoma (according to Milan criteria)
which were divided into two groups: group 1 including patients who underwent surgical
treatment, and group 2 including patients who underwent percutaneous treatment. Patients
with a follow up lower than 6 months were excluded from the study. The cumulative
disease-free and overall survival between the two groups was compared.
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RADIOEMBOLIZATION WITH YTTRIUM-90
MICROSPHERES IN TREATMENT OF ADVANCED
VASCULAR INVASION; FIRST EGYPTIAN PILOT
STUDY
Introduction: The Barcelona Clinic of Liver Cancer (BCLC) considered portal vein
thrombosis in cirrhotic patients as the main obstacle against locoregional therapy among
patients with advanced Hepatocellular Carcinoma (HCC). Sorafenib is considered the firstline therapy for advanced HCCs, but in case of disease progression or intolerable adverse
events there is no available second-line therapy. The selective intrahepatic application of
Yttrium-90 microspheres is a new adjuvant technology in recent intervention radiology,
because they are concentrated in tumor bed and sequentially has a high concentrated
dose of local directed radiation with least local and systemic adverse effects.
Aims: Our Aim is to clarify the safety and efficacy of radioembolization in HCC especially
with vascular invasion.
Methodology: Between 04/2009 and 01/2013, Sixty Four patients with advanced HCC
especially with portal vein invasion not candidates for surgical or curative options, had
been treated by selective internal radiotherapy (SIRT) with Yttrium-90 microspheres. All
patients had chronic liver disease with Child-Pugh points range between 5-7 points. The
treatment was performed in a lobar fashion through the right or left hepatic artery. Post
therapeutic assessment had been evaluated clinically in respect to WHO performance
status, tumor marker (AFP) and radiological response according to modified RECIST
criteria in sequential CT-scans. Safety of this technique has been evaluated according to
CTCv3 (Common Terminology Criteria version 3).
Results: In this prospective pilot study; 52 advanced HCC patients, Child A liver cirrhosis
are representing 61%, vascular invasion in 82%, advanced HCC BCLC stage “C” in 90%
with median observation period of 10 months, the time to radiological progression is 10.8
months (95% CI: 4.9 – 16.8), the overall median survival is 12.1 months (95% CI 5.6
– 18.7 mons). Partial radiological response rate was achieved in is 75% in respect to
RECIST criteria respectively. The main post-therapeutic AE’s were 45% transient fatigue
syndrome, 29% transient lymphopenia, and hyperbilirubinemia 12% with has grade 3-4
toxicity; during the first 4 weeks after therapy but neither visceral nor pulmonary toxicity
had been reported.
Conclusion: Yttrium-90 is safe and effective treatment in patients with advanced HCC,
especially it has trends to improve overall survival and time to progression of HCC,
furthermore randomized control trials with and against systemic therapy is warranted.
Ahmed El Dorry 1, Amr El Fouly 2, Mahmoud El Metenei 3, Mohamed S. Ghazy 1,
Mohamed El Garieb 1, Khalid Taleeb 4, Emad El Kaddi 5, Mohamed K. Shaker 6 and
Hepatoma Group - Ain Shams University Hospitals - Egypt
1
Intervention Radiology, Ain Shams University, 2Hepatology, Egyptian Atomic Energy
Authority, 3Liver Transplant Surgery, Ain Shams University, 4Nuclear Medicine,
5
Intervention Radiology, International Medical Center,
6
Tropical Medicine, Ain Shams University, Cairo, Egypt
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273
Adriano De Santis 1, Claudia Iegri1, Giulia Gallusi 1, Michele Di Martino 1 2,
Chiara Bassanelli 1 2, Mariana Forlino 1 2, Carmen D. Ciesco
1
Gastronterology Division, Clinical Medicine Department, 2Radiology Department,
Policlinico Umberto 1, Rome, Italy
Total population (n=58)
95% LCL-UCL
Male (n%)
48 (83%)
Age (mean±ds)
68.3±9.8
65.7-70.8
SFA (mm2) (mean±ds)
16,188 ± 10,673
13,382.1-18,995.2
VFA (mm2) (mean±ds)
12,618.8 + 6,829.5
10,823.1-14,415.5
Cirrhosis (n) %
54 (93%)
CP score (mean±ds)
5.9±1
5.6-6.2
Meld score (mean±ds)
7.6±3.3
6.7-8.6
BCLC(n)(%)
B /C
25 (42%)33 (58%)
ECOG (n)(%)
0/1
43 (74%)15 (26%)
Introduction: A potential relationship between body fat content and response to Sorafenib
treatment has been suggested for renal cell carcinoma but not in HCC.
Tab.2
Aims: Sorafenib is a highly lipophilic molecule. So, we supposed that in well nourished
pts, Sorafenib could be stored and then steadily released thus maintaining long-term
higher plasma levels than in underweight pts. Our aim was to evaluate a potential
relationship between subcutaneous (SFA) and visceral fat area (VFA), and survival in pts
with advanced HCC treated with Sorafenib.
CP score (mean±ds)
Methodology: SFA and VFA were retrospectively measured at the level of the umbilicus, as
previously described [1],on baseline CT scan of 58 pts with HCC candidates to Sorafenib.
Tab.1
Results: The baseline clinical-anthropometric characteristics of pts are summarized in
table 1.Given the absence of reference interval of SFA and VFA in literature, the values
were dichotomized using the median of observed distribution as the cut-off (≤ or > 14061
mm2 – SFA- and ≤ or > 11534 mm2- VFA).Clinical characteristics of pts stratified according
SFA and VFA value are showed in table 2. Time to progression (TTP) was longer in pts
with higher SFA and VFA although not significantly. In pts with higher SFA mean survival
was significantly longer (319.3 ± 244.4 days vs 194.3 ± 224.4 d; p=0.04). Also in pts with
higher VFA the mean survival was longer but not significantly. At multivariate analysis SFA
was confirmed as the only independent predictive factors of better survival (Regression
coefficient: - 0.000059; CI: - 0.000118-0; RR: 0.99; p = 0.04). The Kaplan Meyer analysis
for survival stratified according SFA is reported in Figure 1.
SFA
VFA
> median
(29 pts)
≤ median
(29pts)
p
> median
(29pts)
≤ median
(29pts)
p
5.8±1.04
6.2±1.01
ns
6±1.07
6±1.04
ns
Meld score (mean±ds) 7.7±3.5
7.6±3.4
ns
7.9±3.4
7.4±3.4
ns
BCLC C (n%)
15 (52%)
18 (62%)
ns
15 (52%)
18 (62%)
ns
ECOG 0 (n%)
24(82%)
19 (66%)
ns
22 (76%)
21 (72%)
ns
Conclusion: Our study suggest a role of SFA as a predictor of better survival in pts treated
with Sorafenib.So,the maintenance of nutritional status during Sorafenib treatment seems
to be an important goal.
CHUBBY IS BEATIFUL: SUBCUTANEOUS FAT
AREA AS PREDICTOR OF BETTER SURVIVAL
IN PATIENTS WITH HCC TREATED WITH
SORAFENIB
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MICRO –RNA SIGNATURE IN EGYPTIAN
PATIENTS WITH CHRONIC HEPATITIS C
RELATED HEPATOCELLULAR CARCINOMA
HEPATOCELLULAR CARCINOMA IN POST VIRAL
HEPATITIS CIRRHOTIC PATIENTS: A STUDY
FROM PAKISTAN
Heba Omar and El-Garem H., Shehab H., Al-Akel W., Amer A., Shaker O.
1
Muhammad Asad 1, Umair Arif 1, Muhammad R. Hafeez 1
Department of Medicine, Quaid-e-Azam Medical College/Bahawal Victoria Hospital,
Bahawalpur. Pakistan, Bahawalpur, Pakistan
Introduction: MicroRNA (miRNA) is a small noncoding RNA gene product known to
post-transcriptionally modulate gene expression by negatively regulating the stability of
its target mRNAs. Several miRNAs were found to be potential diagnostic, prognostic, or
metastatic markers for hepatocellular carcinoma (HCC).
Introduction: Cirrhosis secondary to viral hepatitis is a common disease in the developing
countries. With the advancement in the treatment of complications of cirrhosis and decrease
in the mortality, more patients are noe presenting with hepatocellular carcinoma (HCC).
Aims: Evaluation of serum miRNA-122 and miRNA-221expression that can represent a
possible non-invasive signature for early diagnosis of HCC among patients HCV-chronic
liver disease.
Aims: There is increased incidence of HCC in cirrhotic patients. Studies are lacking in
this part of world. We carried out this study to have an insight into the magnitude of this
problem, to identify the common presentations of HCC and to devise a roadmap to the
early diagnosis of such patients with our limited resources.
Methodology: This prospective study was conducted on 90 adult patients of both sex with
HCV-related chronic liver disease and chronic hepatitis C related HCC. In addition to 10
healthy control individuals, patients were stratified into; interferon-naïve chronic hepatitis C
(CH) (n=30), post-hepatitis C compensated cirrhosis (n=30) and treatment-naïve HCC (n=30).
All patients and controls have undergone full clinical assessment and lab investigations in
addition to the evaluation of the level of serum miRNA expression by RT-PCR.
An informed written consent was taken from all participants in addition to an institutional
ethical committee approval.
The ROC curves were performed to determine the best cutoff, sensitivity and specificity
values for the candidate markers that could differentiate HCC patients from non HCC
patients (chronic HCV and liver cirrhosis groups).
Results: The median level of miRNA-221 expression (0.92) was significantly downregulated in HCC patients compared to non-HCC patients (1.81) (p value 0.03).In
contrast, median level of miRNA-122 expression showed non-significant up-regulation in
HCC patients (p value 0.21). At a cutoff 1.82, miRNA-221 yielded 87% sensitivity and
40% specificity in differentiating HCC patients from non-HCC patients (chronic HCV and
liver cirrhosis groups) as shown in figure (1). Both miRNA-221 and miRNA-122 were not
significantly related to the characteristic of hepatic focal lesion (size, number, site)
Conclusion: MiRNA-221 expression could represents a potential non- invasive diagnostic
marker for early detection of HCC
Methodology: It is a prospective analytical study carried out at Bahawal Victoria Hospital,
Bahawalpur. Pakistan from January 2011 to January 2013. Only the patients with
documented cirrhosis were included in this study. The patients were diagnosed on the
basis of hepatitis B, C and D polymerase chain reaction. The serum alpha fetoprotein
(AFP) was measured and the ascitic fluid analysis was done. The liver imaging was done
by ultrasonography and computed tomography scan. The data was analyzed with the help
of SPSS version 10. A p-value of <0.05 was considered significant.
Results: A total of 87 patients who developed hepatocellular carcinoma (HCC) were included
in this study. Out of them, Hepatitis B group included 12.64% (n=11), Hepatitis C 33.33% (n=29),
Hepatitis B/C co infection 36.78% (n=32), Hepatitis B/D 8.05% (n=7) and the Hepatitis B/D/C
co infection 9.19% (n=8). Thus, Hepatitis C was found in 79.31% whereas Hepatitis B in 58%.
58.62% (n=51) had ascites, 60.78% (n=31) of whom demonstrated hemorrhagic ascites,
with 87.09% (n=27) patients showing malignant cells on microscopic examination
of ascitic fluid. Spontaneous bacterial peritonitis was confirmed in 33.33% (n=17).
AFP was raised in 94.25% (n=82). 26.82% (n=22) had AFP levels more
than four times the upper limit of normal (xULN), 69.51% (n=57) had
AFP lmore than 3xULN and 9.75% (n=8) had values more than 2Xuln.
On imaging, unifocal lesion was seen in 90.80% (n=79), whereas 9.20% (n=8) showed
multifocal lesions. 50.77% (n=52) had lesions >3 cm compared with 40.22% (n=35) who
had lesions <3 cm.
Conclusion: HCC is a late complication of cirrhosis. Investigations as simple as ascitic
fluid examination and ultrasonography of abdomen may aid tremendously in diagnosing
this disease.
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TREATMENT OF HEPATOCELLULAR
CARCINOMA: A MONOCENTRIC TUNISIAN
STUDY
PREDICTORS OF HCC RECURRENCE
FOLLOWING LIVER TRANSPLANTATION: THE
SIGNIFICANCE OF ALPHA-FETOPROTEIN
Hayfa Romdhane, Rania Hefaiedh, Nour Elleuch, Rym Ennaifer,
Houda Ben Nejma, Najet Bel Hadj Brik
277
Evangelia Fatourou 1, James Maggs 1, John O’Grady 1, Michael Heneghan 1,
Alberto Quaglia 1, Varuna Aluvihare 1, Kosh Agarwal 1, Nigel Heaton 1, Abid Suddle 1
1
Institute of Liver Studies, King’s College Hospital, London, United Kingdom
Aims: The purpose of this study was to describe, on a Tunisian serie, the epidemiology of
HCC in cirrhosis and to analyze the different treatments used and their results.
Methodology: We conducted a retrospective study including all patients hospitalized
between 2009 and 2012 in the Mongi Slim University Hospital for HCC on liver cirrhosis.
Data were collected from the medical records of gastroenterology, surgery and radiology
department.
Results: Sixty eight patients were included in the study (42 men and 26 women). The
average age was 62 years . HCC was considered “small” in 28 cases (41.2%). Surgical
resection was indicated in 20.6% of patients (n=14), percutaneous destruction (with
alcohol or radiofrequency) in 20.6 % patients (n=14), intrahepatic chemoembolization in
35.3% of patients (n=24) and the association of several radiological techniques in 5.9% of
patients (n=4). Surgical treatment consisted in tumorectomy in 5 cases, segmentectomy in
7 cases and a right or left hepatectomy in 2 cases. The post-operative course was mostly
simple: one patient developped a liver abcess and one had a decompensated cirrhosis.
Three patients among those who underwent surgery had a reccurence of HCC treated by
radiofrequency in 1 case and by chemoembolization in 2 cases. Percutaneous treatment
was performed in 1 to 4 sessions. No complications were observed after the procedure.
Treatment outcomes were total tumor necrosis in 66.6% of cases, partial necrosis in
16.7% and tumor progression in A6.7% of cases. The most frequent complications were
decompensation of cirrhosis (16.6%), followed by splenic infraction (4.1%). The results
of chemoembolization were a total tumor necrosis in 20.9% of cases, partial necrosis or
stable tumor in 50% and tumor progression in 29.1% of cases. Treatment with Sorafenib
was indicated in 4 cases with a median survival of 3 months. Finally, symptomatic treatment
was decided in 12 patients because of tumor extension or advance cirrhosis.
Conclusion: Our study illustrates the high incidence of HCC in our center. A curative
treatment has been proposed in only 41.2% of patients. This underlines that patients are
usually referred to us at a palliative stage, because of delay in diagnosis. Much remains to
be done in the field of early detection.
Introduction: Liver transplantation (LT) is a curative option for a subset of patients with
hepatocellular carcinoma (HCC). High pre-LT alpha-fetoprotein (AFP) and transplantation
beyond Milan criteria have been associated with HCC recurrence.
Aims: To determine predictors of recurrence following LT in patients meeting radiological
Milan criteria (1997-2010) or United Kingdom Transplant (UKT) criteria (2010-2011) in a
single liver transplant centre.
Methodology: We analysed a prospectively collected database of 382 consecutive
patients transplanted for HCC from 1997-2011. Explanted livers were evaluated for
the number and diameter of lesions, histological differentiation and microvascular or
macrovascular invasion. Based on the above, we identified a subset of patients who were
beyond Milan criteria histologically. Various epidemiological and laboratory characteristics
were examined.
Results: Of 382 patients that received liver transplantation, 303 (79.3%) were male, mean
age 55.6±9.6 years and mean follow up 59.5±45.3 months. The most common underlying
aetiology of liver disease was hepatitis C (n=140, 37%), followed by alcohol (n=82, 21.5%)
and hepatitis B (n=64, 16.8%). Based on liver explant findings, 92/382 (24.3%) patients
were outside Milan criteria at the time of LT. Fourty-six patients (12.0%) had evidence
of HCC recurrence following LT. In univariate analysis, post-transplant recurrence was
significantly associated with poor histological differentiation (p=0.04), AFP>100 ng/ml
(p<0.0001), microvascular invasion (p=0.004) and transplantation beyond histological
Milan criteria. Multivariate analysis showed that AFP>100 ng/ml (OR 4.470, 95%CI 1.70211.741; P=0.002) and transplantation beyond histological Milan criteria (OR 2.843, 95%CI
1.077-7.504; P=0.035) were independent predictors of tumour recurrence following LT.
Conclusion: As LT beyond the histological Milan criteria was associated with significantly
increased HCC recurrence, expansion of current radiological criteria is not warranted. PreLT AFP levels are a valuable marker of tumour recurrence and should be further explored
as part of current listing criteria.
Introduction: Hepatocellular carcinoma (HCC) is a real public health problem because of
its frequency and severity. It develops in more than 90% of cases in a cirrhotic liver, which
determines the choice of therapy.
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279
PROGENITOR CELL MARKERS IN
CLINICO-PATHOLOGICAL CORRELATIONS
AND PROGNOSTIC VALUE
Introduction: Hepatocellular carcinoma (HCC) is a heterogeneous disease of distinct
clinical subgroups. Keratin 19 (K19) immunopositivity has been proposed to represent
hepatic progenitor cell (HPC) origin of HCC and has been correlated with poorly
differentiated histology and aggressive tumor behaviour. Similarly, Epithelial Cell Adhesion
Molecule (EpCAM) immunophenotype has been used to classify HCC into different
subtypes with prognostic implication and may represent a possible biomarker for HPC
origin.
Aims: Aim of this study was to assess the expression of HPC markers in HCC in correlation
with clinicopathological parameters and prognosis.
Methodology: We assessed the expression of K19 and EpCAM by immunohistochemistry
in a series of seventy-four Greek patients with HCC (mean age 65.52±10.8 years, male
72.9%) followed up for 39.6±25.3 months. HCCs were considered K19-positive or EpCAMpositive if >5% tumor cells were immunostained.
Results: K19-specific and EpCAM-specific immunoexpression were detected in tumor
cells of 8/74(10.81%) and 21/74 (28.37%) HCCs, respectively. K19 immunopositivity
tended to correlate with micro-vascular invasion (p=0.065) but there was no correlation
with other clinico-pathological parameters. EpCAM immunopositivity was significantly
correlated with advanced TNM stage (p=0.007). In univariate analysis, decreased
recurrence-free survival (RFS) was associated with K19 immunopositivity (p<0.001),
advanced TNM stage ≥ III (p=0.024) and microvascular invasion (p=0.005). Similarly,
decreased overall survival (OS) was significantly associated with K19 immunopositivity
(p=0.03) and microvascular invasion (p=0.014). In multivariate analysis, K19 positivity
was the only independent predictor of RFS (OR=7.534, 95%CI=2.473-22.935; p<0.001)
and OS (OR=3.317, 95%CI=1.195-9.208; p=0.021). EpCAM positivity did not show any
correlation with recurrence-free or overall survival.
Conclusion: K19 but not EpCAM immunoexpression is an independent predictor of patient
survival in a cohort of Greek patients with HCC and could be used to subgroup HCCs
according to tumor aggressiveness. Inclusion of K19 immunopositivity, as a parameter of
tumor aggressiveness in HCC, may increase the predictive value of currently used scoring
systems.
Evangelia Fatourou 1, Despina Karandrea 2, John Koskinas 3, Marina Palaiologou 4,
Thalia Syminelaki 4, Menelaos Karanikolas 5, Evangelos Felekouras 6,
Efstathios Antoniou 7, Emmanouil Manesis 8, Johanna Deladetsima 9, Dina Tiniakos 4
1
Institute of Liver Studies, King’s College Hospital, London, United Kingdom,
2
Department of Pathology, Aretaieion Hospital, 32nd Department of Internal Medicine,
MedicalSchool, National & Kapodistrian University of Athens, 4Laboratory of HistologyEmbryology, Medical School, National & Kapodistrian University of Athens, Athens,
Greece, 5Department of Anesthesiology, Washington University School of Medicine,
Saint Louis, MO, United States, 61st Department of Surgery, 72nd Department of Surgery,
8
2nd Department of Internal Medicine, 91st Department of Pathology, Medical School,
National & Kapodistrian University of Athens, Athens, Greece
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ROLE OF 1H MR SPECTROSCOPY IN
EVALUATING RESPONSE OF HEPATOCELLULAR
CARCINOMA TO RADIOFREQUENCY ABLATION”
NOTES
Dina H. Ziada, Sherif Alsaadany, Manal Hamisa
Introduction: The evaluation of the effectiveness of radiofrequency ablation is critical in
determining the success of hepatocellular carcinoma treatment .Studies have reported
an increase in choline-containing compounds relative to lipids in HCC compared with the
amounts found in background cirrhosis and a reduction in this ratio has been recorded
after effective local ablation treatment for HCC.
Aims: The aim of our work is to study the role of MR spectroscopy in evaluating the
response of hepatocellular carcinoma (HCC) to radiofrequency ablation.
Results: RFA was performed on 31 nodules of 25 patients. (AFP) was more than 200 in
18 patients. Post-RFA, AFP levels showed significant decrease in fourteen of them. The
choline resonance peak of HCC was elevated compared with normal liver parenchyma
in the control group. After RFA both the amplitude and the area of choline resonance
peak significantly descended. The choline-to-lipid ratio was 0.334±0.023 in normal liver
which was significantly increased in HCC (0.421±0.021)(P=0.01 ). This ratio significantly
decreased after RFA to 0.2360±.034 (P<0.001). The five patients who had incomplete
necrosis of HCC showed an elevated choline peak in the peripheral part of the tumor but
no elevation in choline peak in the central necrotic part of the tumor. A second intervention
effectively decreased the choline concentration in the peripheral part of the tumor
Conclusion: 1H MR spectroscopy is a useful tool for detection of early response of HCC
to RFA and can be valuable in differentiation between complete and incomplete necrosis
of the HCC lesions after RFA.
Methodology: This study was carried out on 25 HCC patients eligible for RF ablation.
All patients underwent percutaneous RFA. Patient’s evaluations were done before RFA,
one, two and four weeks later, in the form of liver function tests, CBC, alfa fetoprotein
(AFP),abdominal triphasic C.T and 1H MR spectroscopy
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283
RISK OF HCC AND ITS PREDICTORS IN VIRAL
HEPATITIS COINFECTED PATIENTS
Kakharman I. Yesmembetov 1, Dzhamal T. Abdurakhmanov 1, Alexey N. Mukhin 1
Hepatology, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
Introduction: Worldwide, more than 350 million people are considered to have chronic
HBV infection and 5%, 1%/7-15% of them are thought be coinfected with HDV and/or
HCV, due to shared routes of transmission.
Aims: Studies, evaluating risk of HCC in HBV, HDV and/or HCV coinfected patients,
produced conflicting results. As coinfection with hepatitis viruses results in more severe
liver disease, it may therefore carry a higher risk for HCC. We aimed to assess the risk for
HCC and to identify its’ predictors in HBV, HDV and/or HCV coinfected patients.
Methodology: HBsAg (+) patients with serum markers of HDV and/or HCV, followed-up
from Jan 2002 to Jan 2011 were included in the study.
According to logistic regression analysis, AFP was the only statistically significant predictor
of HCC (table 2).
Table 2. Predictor of HCC in group D
Predictor
β
Sig.
Exp (B) (CI 95%)
AFP
0.030
0.042
1.031 (1.001-1.061)
1 (1.8%) patient (age 43, male) in group BC developed HCC during follow-up with mean
duration of the disease when diagnosing HCC of 26.5 years. None of the predictors were
able to statistically significantly predict risk for HCC.
None of the patients in group BCD developed HCC during follow-up.
Group D, BC and BCD patients had 3.8%, 3.5% and 0% 5-year risk of HCC, respectively
(figure 1).
Results: Out of 495 HBsAg (+) patients, 82 (16.6%), 56 (11.3%) and 20 (4%) patients
had markers of HDV (group D), HCV (group BC) and HCV/HDV (group BCD) coinfection,
respectively. Group BCD patients were significantly younger compared to other groups
and were predominantly male (table 1).
Table 1. General characteristics of patients
Group D
Group BC
Group BCD
p
Mean age
40.7±13.8
42.4±15.4
33±9.4
0.039
Male
50%
57.1%
90%
0.005
67.1%, 19.6% and 40% of patients in groups D, BC and BCD had liver cirrhosis,
respectively, demonstrating association of HDV with more pronounced liver injury and
higher proportion of liver cirrhosis, compared to non-HDV patients.
8 (9.8%) patients (mean age 50.8 years, male 50%) in group D developed HCC during
follow-up with mean duration of the disease when diagnosing HCC of 28±9.7 years.
Conclusion: HDV infection was associated with the highest risk for HCC. Group BCD had
no cases of HCC during follow-up, but demonstrated high rate of liver cirrhosis, despite
being significantly younger, thus given the same duration of the disease, they may present
higher risk of HCC. Studies including more patients and with longer duration are needed
to further clarify this issue.
1
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DEVELOPMENT OF HEPATOCELLULAR
CARCINOMA IN A HBEAG-NEGATIVE CHRONIC
HEPATITIS B PATIENT WITHOUT CIRRHOSIS
UNDER THE LONG-TERM VIROLOGICAL
SUPPRESSION WITH LAMIVUDINE PLUS
ADEFOVIR THERAPY
Emine Günal 1, Can P. Eyigün 2
Infectious Disaease and Clinical Microbiology, Diyarbakır Military Hospital, Diyarbakır,
2
Infectious Disaease and Clinical Microbiology, Gülhane Military Medical Faculty,
Ankara, Turkey
Introduction: The risk of hepatocellular carcinoma (HCC) is particularly high in chronic
hepatitis B (CHB) patients with cirrhosis. Studies have shown the benefits of treatment for
preventing HCC with reducing disease progression in HBV-related cirrhosis. However, the
long-term efficacy of adefovir dipivoxil (ADV) in combination with lamivudine treatment on
HCC incidence in non-cirrhotic patients is still unclear.
Aims: We report a case of HCC in a HBeAg-negative CHB patient which developed 70
months following biochemical remission and virological suppression with lamivudine plus
ADV therapy.
Methodology: Case: A 56-year-old man with CHB was treated 12 years ago with
recombinant interferon (IFN) alpha-2b, 5.000.000 U by three times a week for 24 weeks.
Initially, his liver histology was consistent with a moderate activity and 3\6 fibrosis stage.
Lamivudine monotheraphy was started 6 years after because of sustained virological
and biochemical response couldn’t be achieved after IFN theraphy but the levels of
aminotransferase and hepatitis B virus (HBV)-DNA in serum had low-watched. Control
biopsy prior to lamivudine monotherapy showed mild activity and the same stage of
fibrosis. After 8 weeks of lamivudine treatment, virological and biochemical response
were obtained, and continued until the end of second year when virological breakthrough
occured due to lamivudine-resistance. Virological remission was achieved again 4 months
after ADV addition to ongoing lamivudine treatment. Patient was followed every 6 months
with alpha-fetoprotein (AFP) and ultrasound scan for HCC.
Results: HCC was suspected by ultrasonography 70 months after the start of lamivudine.
Aminotransferases and AFP were in the normal range, HBV DNA was undetectable in
serum when HCC was diagnosed. Dynamic computed tomography identified HCC by
the finding of a focal hypervascular liver lesion (43x35x36 mm in size) in segment 4B–8.
Pathological examination revealed moderately differentiated HCC with no metastasis.
Partial hepatectomy was performed, and no recurrence was occured within 4-year
follow-up.
Conclusion: Although excellent biochemical and virological remission were achieved
with ADV addition to ongoing lamivudine treatment in our case atleast for 4 years, it
wasn’t enough to suppress hepatocarcinogenesis. Long-term treatment with more potent
antivirals that have a higher resistance barrier may be more effective to reduce HCC risk
in lamivudine-resistant patients. Further and multi-centered studies are needed to clarify
this topic.
1
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287
HEPATOCELLULAR CARCINOMA IN A
LONG-TERM SUSTAINED VIROLOGICAL
RESPONDER FOLLOWING PEGYLATED
INTERFERON PLUS RIBAVIRIN COMBINATION
THERAPY FOR CHRONIC HEPATITIS C
1
NOTES
Emine Günal 1Can P. Eyigün 2
Infectious Disaease and Clinical Microbiology, Diyarbakır Military Hospital, Diyarbakır,
2
Infectious Disaease and Clinical Microbiology, Gülhane Military Medical Faculty,
Ankara, Turkey
Introduction: It is well known that long-term complications of hepatitis C virus (HCV)
infection including hepatocellular carcinoma (HCC) and cirrhosis are eliminated or
decrease in sustained virological responders after treatment.
Methodology: Case: A 60-year-old man with HCV genotype 1b was treated with pegylated
interferon alpha-2b in combination with ribavirin for a total of 52 weeks. Initially, his liver
histology was consistent with a mild activity and 1\6 fibrosis stage due to chronic hepatitis
C. After 28 weeks of treatment, aminotransferase levels were in the normal range and HCV
RNA (polymerase chain reaction) was undetectable in serum. Sustained and complete
response were obtained with normalization of aminotransferases and disappearance of
HCV RNA in serum continuously. HCV-RNA was also not detected in the liver tissue after
treatment, but histopathological examination was the same as before. He followed up for
HCC based on biochemical and ultrasound evaluation every 6 months.
Results: HCC was detected 48 months after cessation of therapy with the elevation of
serum aminotransferases and alpha-fetoprotein for the first time, then splenomegaly and
acid were revealed by ultrasonography. HCC was diagnosed by computed tomography
and angiography, and then treated through transarterial embolization but patient died of
liver failure within 2 months.
Conclusion: Successful treatment in our case didn’t prevent development of HCC even in
non-cirrhotic liver. Our case indicates the importance of not underestimating risk of HCC
development even many years after sustained and complete response to HCV treatment.
Long-term follow up are always mandatory and should include more carefully and closely
surveillance for HCC.
Aims: We report a case from Turkey who developed HCC 4 years after sustained and
complete response to pegylated interferon plus ribavirin combination theraphy.
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HIGH LEVELS OF CIRCULATING ENDOTHELIAL
CELLS AND RISK OF PROGRESSION IN
PATIENTS WITH LOCALLY ADVANCED OR
METASTATIC HEPATOCELLULAR CARCINOMA
RECEIVING SORAFENIB
Introduction: Circulating endothelial cells (CEC) seems to reflect the activity of
antiangiogenic agents on tumor neo-angiogenesis.
Aims: In this hypothesis-generated study we investigated the behaviour of CEC and
hematopoietic progenitor cells (HPC) in patients (pts) with hepatocellular carcinoma
(HCC) receiving sorafenib, and whether CECs levels were associated with time to
progression (TTP).
Methodology: CECs (CD45neg/CD34bright/CD31pos/CD146pos/VEGFR2pos) and HPCs
(CD45dim/CD34bright) of advanced HCC pts receiving sorafenib 400 mg twice daily were
counted in fresh blood samples using four-color flow cytometry at baseline and every 4
weeks until disease progression or unacceptable toxicity. Assessment of tumor response
was performed with CT (or MRI) according to RECIST criteria.
Results: Twenty-four HCC pts, 23 men and 1 female, median age 70 years (range 5283), Child-Pugh class A were enrolled in the study. The etiology was alcoholic cirrhosis
in 20 pts, chronic hepatitis C virus infection in 4 pts. Stage of disease was BCLC C in
13 pts, stage B not amendable any more to loco-regional treatment in 11 pts. All pts
previously received loco-regional therapies. Three pts are still on treatment at 4, 17, 19
months, presenting stable disease. Twenty one pts interrupted treatment, of which 17
for progressive disease (PD) with a TTP of 3.2 months (range 1-6), and 4 for adverse
events: severe asthenia, anorexia and weight loss, after 22 days (range 15-35).
Median baseline CECs and HPCs levels were 67 cells/ml (range 10-141) and 1300 cells/
ml (range 342-2546), respectively. After 4 weeks of treatment we observed a 169.8%
increase in CECs levels, and a 71.3% decrease in HPCs levels. A continuous increase
on CECs levels was observed in all pts who interrupted the treatment for PD or major
toxicity. An opposite kinetic effect was observed in all 3 pts still on treatment, where
CECs returned to baseline levels within 12 weeks of treatment.
Conclusion: Treatment with sorafenib significantly changed CECs levels in HCC pts.
Continuous increase of CEC counts during sorafenib treatment was observed with
rapid progression, while a decrease in the CECs numbers was observed with stable
disease and delayed tumor progression. The modulation of this cell population might
be critical for achieving treatment response or induce resistance to sorafenib or other
antiangiogenic agents. Further investigation into the possible role of CECs as potential
biomarker or as a target of anti-angiogenic therapy are warranted.
Petros Giovanis 1, Valter Vincenzi 2, Graziano Pianezze 3, Carla Manuppelli 2,
Manuele Toniolo 3, Dagmar Dannhauser 2, Laura Ciasullo 2, Massimo Boaretto 2,
Mauro Giusto 1, Patrizia Pontisso 4
1
2
3
Medical Oncology, Internal Medicine, Research Laboratory, Azienda Ulss 1, Belluno,
Italy, Belluno, 4Department of Medicine, University of Padua, Padua, Italy
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THE APPLICATION OF DATA MINING
TECHNIQUES TO EXPLORE PREDICTORS OF
HCC BASED ON THE NON-INVASIVE ROUTINE
WORKUP IN EGYPTIAN PATIENTS WITH
CHRONIC HEPATITIS
1
Abubakr Awad 1, Dalia Omran 2, Mahasen Mabrouk 2, Ashraf Omar 2
Computer Science, Faculty of Computers and Information, Cairo University, 2Endemic
Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
Conclusion: Data mining analysis explores data to discover hidden patterns, trends and
enables the development of models to diagnose HCC utilizing simple laboratory data
as an alternative to liver biopsy avoiding invasive procedures. AFP, cirrhosis, AST, and
ascites are simple variables that have the prospective to support clinical decisions, without
imposing extra costs for additional examinations.
What is new: To our knowledge this study has highlighted that a new cutoff value of
AFP≥50.3 ng/ml to diagnose HCC in cirrhotic patients; and that the field of data mining
can be used to solve real health problems that Egypt is currently facing with great success.
Introduction: Hepatocellular carcinoma (HCC) is the second most common malignancy in
Egypt due to the heavy burden of hepatitis C virus. The stage of hepatocellular carcinoma
(HCC) dictates the therapeutic choice, making early detection a primary objective. These
findings emphasize the need for an innovative, economic, reliable, non-invasive technique
for predicting early HCC diagnosis utilizing simple clinical, and laboratory data. Data
mining is a method of predictive analysis which can explore tremendous volumes of rich
information found in electronic health records to discover hidden patterns and relationships.
Methodology: This cross sectional study focused on 315 chronic HCV patients (31 chronic
hepatitis, 149 cirrhosis, and 135 HCC), between years 2010-2011. Using data mining
analysis, we constructed a C4.5 implementation of decision tree learning algorithms with
internal validation of 10 folds cross validation for predicting HCC.
Results: Decision tree algorithm was able to diagnose HCC with sensitivity 83.5% and
specificity 83.3% using only routine data. The correctly classified Instances were 263
(83.5%), and the incorrectly classified Instances were 52 (16.5%). Out of 34 attributes, the
decision-tree models showed that Serum level of AFP with an optimal cutoff value of ≥50.3
ng/ml was selected as the best predictor of HCC. To a less extent cirrhosis, AST>64U/L,
and ascites were variables associated with HCC as shown in figure. This was further
confirmed using multivariate logistic regression analysis.
Aims: To develop a non-invasive model for early diagnosis of HCC. This model should be
economical, reliable, easy to apply and acceptable by domain experts.
293
ASSESSMENT OF PIVKA II AS A MARKER IN
RECURRENT HEPATOCELLULAR CARCINOMA
AFTER RADIOFREQUENCY ABLATION THERAPY
LOCOREGIONAL TREATMENTS FOR
HEPATOCELLULAR CARCINOMA IN CIRRHOTIC
PATIENTS: ASSESSMENT OF LIVER FUNCTION
BY 13C-AMINOPYRINE BREATH TEST
Mohsen M. Maher 1, Wesam A. Ibrahim 1, Osama M. Hetta 2, Ahmed M. El-Ghandour
1
Internal Medicine Department, 2Radiology Department,
Ain Shams University, Cairo, Egypt
Introduction: Hepatocellular carcinoma is the most frequent primary hepatic malignancy.
Radiofrequency ablation therapy (RFA) is one of the most recent curative treatment of
early diagnosed hepatocellular carcinoma. Recurrence rate is high following treatment.
So tumor marker protein induced by vitamin K absence (PIVKA II) level can be used as a
predictor of prognosis of patients following RFA therapy and to diagnose recurrence more
earlier for better outcome.
Aims: To detect the importance of PIVKA II as a tumor marker in patients with recurrent
HCC after curative radiofrequency ablation therapy. Methodology: This study was done on 40 patients with hepatocellular carcinoma which is
diagnosed by abdominal ultrasonography, triphasic CT and alphafetoprotein and treated
by radiofrequency ablation therapy 2 years ago before the study, all patients from Internal
Medicine Department and Radiology Department in Ain Shams University hospitals. The
patients divided into 2 groups according to recurrence then PIVKA II serum level measured
by enzyme immunoassay method and the statistics were done using chi square test,
independent sample t test, Mann-whitney test and spearmann’s correlation coefficient. CLINICAL POSTER ABSTRACTS
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Results: The patients divided into 2 groups: Group I: 20 patients with hepatocellular
carcinoma who developed recurrence after curative radiofrequency ablation therapy, all
patients in group I are males with mean age (54.45 ± 7.7), 16 patients were diabetics,
and all of them were HCV+ve and HBV-ve. Group II: 20 patients who did not develop
recurrence after curative radiofrequency ablation therapy, all patients in group II are males
with mean age (55.9 ± 6.63), 8 patient were diabetics, 18 patients from them were HCV+ve
and 2 patients were HCV –ve and all of them were HBV-ve. Comparison between group
I and group II as regard PIVKA II level showing highly statistically significant relationship
between PIVKA II level and the recurrence of HCC after RFA therapy as P = 0.000. Conclusion: There were high PIVKAII level in patients with recurrent HCC after curative
RFA therapy. So PIVKAII (DCP) can be used to predict poor prognosis after RFA therapy
of HCC. So patients who have high PIVKAII before treatment of HCC should be carefully
followed, because of high incidence of HCC recurrence after curative RFA therapy.
Marco Guarracino, Pietro Coccoli, Marco Sanduzzi Zamparelli, Costantino Sgamato,
Maria Grazia Iannuzzi, Gerardo Nardone
Introduction: Hepatocellular carcinoma (HCC) is the sixth common cancer in the world
and the third cause of death for cancer. Orthotopic liver transplantation is the choice
treatment but it is hampered by organ availability. An alternative treatment according to
Barcellona criteria are the mini invasive percutaneous locoregional treatments, including
percutaneous ethanol injection (PEI) and radiofrequency termoablation (RFA).
Aims: While the efficacy of locoregional treatments is well-known, its impact on liver
function remains unclear. This is a critical issue since, HCC develops in more than 90%
of cases in cirrhotic patients. Aim of this study was to evaluate in patients with HCC the
effects of locoregional treatments (PEI and RFA) on liver function by 13-C Aminopyrine
breath test (13-C ABT).
Methodology: We prospectively included 20 consecutive patients (M/F: 11/9, mean age
68) with HCC candidate to loco-regional therapy (PEI or RFA). The effectiveness of the
therapy was evaluated by contrast-enhanced ultrasound (CEUS) after procedures, US
(the following day and at 90th day) and TC (after 30 days). Liver function was evaluated
by 13-C ABT laboratory parameters (Albumin, Protrombin time, AST, ALT, Bilirubin, GGT,
ALP, LDH, AFP). 13-C ABT was performed by administering 13-C Aminopyrine 2mg/kg of
body weight, dissolved in 200ml of water; then breath samples were collected baseline and
each 30 minutes for 2 h. All these tests were performed before treatment, and repeated 24
h, 7, 30 and 90 days after the procedure.
Results: Ten patients underwent PEI and 10 RFA. No significant differences were found
in terms of demographic carachteristics, etiology and Child-Pugh score between the
groups. Both PEI and RFA were effective in 100% of the cases. After a transient increase
of AST (p<0,001), ALT (p<0,001) and Bilirubin (p<0,01) for both procedures, all these
values returned to baseline levels at the end of follow up, while GGT, ALP and LDH values
did not change during the 90 days. Six out of 20 patients showed an elevated value of
AFP at baseline that declined up to normal during the follow-up. Finally, liver function,
as explored by 13C-ABT, after an initial reduction in the first days treatment, showed a
complete recovery, up to reach value higher than baseline (baseline mean value: %dose/h
3,17 - cum/dose 4,5; 90th day mean value: %dose/h 3,81 - cum/dose 5,31)
Conclusion: RFA and PEI do not affect liver function in cirrhotic patients as detected by
13CABT in the short and long period CLINICAL POSTER ABSTRACTS
292
294
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
295
SINGLE CENTER EXPERIENCE OVER A DECADE
IN LIVING DONOR LIVER TRANSPLANTATION
FOR EGYPTIAN PATIENTS WITH
HEPATOCELLULAR CARCINOMA: STRETCHING
THE LIMITS
Iman Montasser1, Mahmoud El Meteini 1, Hany Dabbous 1, Mohammed Sakr1
and Ain Shams Center For Organ Transplantation (ASCOT)
1
Ain Shams University, Cairo, Egypt
Introduction: Liver transplantation emerged as rewarding therapy to cure hepatocellular
carcinoma (HCC). Extensions of Milan criteria have been proposed with encouraging
results. The development of HCC is mainly due to the high rate of C infection among
Egyptian patients .Living donor liver transplantation (LDLT) for HCC in cirrhotic patients
has emerged as a rewarding therapy for a cure and a successful alternative especially in
countries where a DDLT program is lacking.
Results: The median follow up period was 31.6 months. The underlying liver disease
was related to HCV in 139 cases (95.2%).Ninety-five patients (65%) were fulfilling Milan
criteria, 40 patients (27.5 %) were within University of California San Francisco criteria
(UCSF) and 11patients (7.5%) were beyond; maximum tumor burden 14.5 cm in one.
One hundred and thirty four (91.8%) are alive till April 2012, 127 (87%) being recurrence
free .HCC recurrence occurred in 19 patients (13%), 12 patients were within Milan criteria
and 7 were beyond Milan. Within patients beyond UCSF; one case had HCC recurrence.
Microvascular invasion and AFP > 400 were significant prognostic factors for recurrence.
Conclusion: Within community with high incidence of HCC, stretching the limits could be
justified based on tumor characters and its biological behavior
Methodology: Methods: 590 Egyptian patients underwent LDLT; of them, 172 (32%)
patients were transplanted for HCC. Twenty six cases (15.1%) were excluded due to early
postoperative mortality (n=22) or due to non HCC related mortality (n=4). One hundred forty
six patients were retrospectively reviewed to determine prognostic factors for recurrence.
Data were collected, coded, tabulated, and analyzed using SPSS®v12.0. Numerical
variables were presented as mean (standard deviation) or median (range) as appropriate,
while categorical variables were presented as frequency (%).Analysis of categorical data
was performed by chi-square test or Fisher’s exact test while that of numerical variables
was performed by student-t test. Kaplan-Meier survival analysis was performed for the
significant risk factors of recurrent HCC with application of log rank test to compare levels
of each factor. P value < 0.05 was considered statistically significant.
Aims: The aim of this work was to determine the different prognostic factors for HCC after
LDLT. Survival of the patients was recorded.
296
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FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
297
ANATOMO-CLINICAL ASPECTS OF
HEPATOCELLULAR CARCINOMA IN ALGERIA :
MONOCENTRIC STUDY OF 280 CASES
DELTA HEPATITIS-RELATED HEPATOCELLULAR
CARCINOMA: NEW MESSAGES FROM EASTERN
FRONT
Yazid Chikhi1, Saadi Berkane 1,2, Salima Cheraitia2, Nassima Ali Arous2,
Rachid Ould Gougam2, Omar Louahadj2, Fadela lounes2, Meroua Bendaoud3,
Razika Zemba3, Sonia Ait Younes4, Zine Charef Amir4, Chareazed Sufan4,
Fatima Asselah4, Hocine Asselah2
Ahmet C. Dulger, Rafet Mete 1, M. Kürşat Türkdogan 1 2,
Senar Ebinç 1 2 3, Hüseyin Akdeniz 1 2 3 4
1
Namik Kemal University School of Medicine, Tekirdag, 2Gastroenterology, Bezmi
Alem University Faculty of Medicine, İstanbul, 3Gastroenterology, Yuzuncuyil University
Medical School Turkey, 4Radiology, İstanbul Hospital, Van, Turkey
Aims: The aim of our study was to determine the epidemiological, etiological CHC to
provide an optimal care.
Methodology: From January 1988 to december 2012, 280 HCC were collected, this study
distinguishes two periods: before 2009 a retrospective study (n = 120) and prospectively
from 2009 to December 2012 (n = 160). The diagnosis of HCC was selected according to
the criteria of Barcelona.
Results: Collected on 280 cases, 182 men and 98 women (sex ratio 2.4), the average
age is 61 years. The diagnosis is revealed by pain in the right hypochondrium (39%),
impaired general condition (37%), liver tumor (31%), jaundice (7.3%). It is revealed by
a screening ultrasound in 9.6% of cases during the period before 2009 and 21% after
2009. Underlying cirrhosis was found in 71% of cases, chronic liver disease in 15% and
a healthy liver 7% of cases. B and C viruses are implicated in 21% and 39% respectively.
Our CHC were in most cases stages C and D (BCLC classification). The treatment
consisted of liver transplantation (n = 1), hepatic resection (n = 27), alcohol / radio
frequency (n = 8), chemoembolization (n = 26) sorafenib (n = 12). The median survival of
12 months was 13%.
Conclusion: This study reveals the late diagnosis of HCC, the time has changed little
despite the application of screening recommendations and the necessity of a national
program to fight against viral hepatitis.
Aims: So, this study was conducted to determine the clinical and radiologic aspects of
delta hepatitis-related HCC in the Van region of Eastern Turkey. The aim was also to
define the association between laboratory parameters and radiologic features. Methodology: Current study was conducted from 2006 to 2013 in Hepatology clinic of the
Yuzuncuyil University School of Medicine. 35 patients (15 female, age 58.3± 10.8) with
HDV-related HCC were included for the study. Diagnosis of HCC was made by biopsy
(avaible in 30) or by clinical data plus radiologic examination. Demographics, Child-Pugh
scores, laboratory values including tumor markers were noted. Serological markers of
hepatitis D virus infection (antiHDV IgG) were also determined by ELISA test in patients
with chronic hepatitis B patients. Thereafter, radiologic findings including diameters of
portal and splenic vein as well as largest diameter of tumor mass were studied. Pearson
correlation analysis was used to determine the relationship between parameters.
Results: Twenty-five patients (71.4%) were resident in rural areas of the Van prefecture.
At baseline, elevated levels of AST (107±74,68), ALT (65,26±45,88), AFP (180,47
±177,12) GGT (170,10±121,86) and CRP (37,04±39,77) are the main laboratory features
among the patients. Detoriation of liver dysfunction as reflected by the higher CTP scores
(7,87±2,26 points) was also a common finding in the study group. Additionally, patients
were likely to have larger tumor masses (7,41 ± 4,76 cm). Diameters of portal and splenic
veins were also larger than normal values (16,33± 4,93 and 12,69 ±5,43, respectively).
There was no statistical differences between genders (p>0.05). Most importantly, levels of
AFP were positively correlated with portal vein diameters (p<0.01). Furthermore, elevated
leves of CRP were also positively correlated with CA-19.9 levels (p<0.01).
Conclusion: Our hospital’s experience documents that the percentage of patients who
may be considered as liver transplantation candidates is still very low. Rural clustering
of the new cases was a striking finding in the current study. Higher AFP levels may also
predict the presence of enlargement of portal vein in patients with HDV-related HCC.
Introduction: Hepatocellular carcinoma develops mainly in liver cirrhosis. In Algeria,
cirrhosis is associated with a chronic viral infection B or C in 90% of cases. The prevalence
of HBsAg is about 2.15% and that of HCV infection at least 1%. Introduction: Hepatitis delta virus (HDV) is a small, defective and single -strand RNA
genome contained virus. It has been responsible nearly 25% of hepatocellular carcinoma
(HCC) cases in eastern part of Turkey.
EASL HCC SUMMIT
A RETROSPECTIVE STUDY FROM EASTERN
PART OF TURKEY
ANTIVIRAL THERAPY FOR PREVENTION
OF HEPATOCELLULAR CARCINOMA AND
MORTALITY IN CHRONIC HEPATITIS B:
SYSTEMATIC REVIEW AND META-ANALYSIS
Ahmet C. Dulger, Müge Tanrıtanır 1, Kürşat Türkdogan 1 2,
Rafet Mete 1 2 3, Bilge Gultepe 1 2 3 4
1
Gastroenterology, Yuzuncuyil University Medical School Turkey, Van, 2Gastroenterology,
Vakıf Gureba Hospital, İstanbul, 3Namik Kemal University, Gastroenterology, Tekirdag,
4
Microbiology, Yuzuncuyil University Medical School Turkey, Van, Turkey
Introduction: Hepatocellular carcinoma (HCC) is one of the commonest liver cancers in
the world as well as in Turkey. Low socioeconomic status is a major risk factor for cirrhosis
as well as HCC. Liver transplantation and liver resection are the main options for long-term
survival in HCC patients fullfilling good prognostic criteria according to recent guidelines.
Treatment allocation is based on the BCLC allocation system.
Aims: Therefore, the aim of this retrospective study was to assess the socioepidemic and
clinic features of the HCC patients.
Methodology: We completed a retrospective chart review of patients with HCC admitted
to the Yuzuncuyil University Gastroenterology clinic between January 1, 2006 and
December 31, 2012. Diagnosis of HCC was based on non-invasive criteria or pathology.
Socioepidemiologic, clinic, and radiologic parameters were recorded on SPSS. One-way
ANOVA tests and chi-square tests were used as statistical analysis.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Results: Seventy-three patients’ data were assessed: 53 male and 20 female; median
age 59±14.1 (43-75) years; and the commonest etiology was hepatitis B (71.4%) followed
by delta hepatitis (26.5%). Of these, 76% of patients were resident in rural areas of the
prefecture. Child-Turcot-Pugh (CTP) scores of the villagers were significantly higher than
patients who were resident in the city center (8.06±2.45 versus 6.71±1.93; p<0.05). HBVDNA levels were not statistically different between delta hepatitis group and hepatitis B
group (62164±338284 versus 61191±272546, p=0.991). Additionally, male patients were
more likely to have elevated ALT levels than female counterparts (79.19±59.02 versus
43.90±34.23; p=0.24). Most importantly, distant metastasis among HCC patients with
portal vein thrombosis was 54.2% compared to 24.4% in HCC patients with patent portal
vein (p=0.02). Metastatic patients had also a higher mean tumor diameters (8.88 ±4.64)
and a higher gamma glutamyl transferase (GGT) levels (266.7±228.9) than non-metastatic
patients (5.83±3.71, p=0.004 and 162.7±137.7, p=0.021).
Conclusion: Living in rural areas was a risk factor for HCC and was associated with an
increased risk of having higher CTP scores. Delta hepatitis was the second cause of HCC
in eastern part of Turkey. Portal vein thrombosis, higher tumor diameters and higher GGT
levels migth be a useful tool in predicting metastatic disease in HCC patients. This study
underscores the importance of further examination of this unique patient group in an effort
to endorse the early diagnosis.
1
299
Maja Thiele 1 2, Lise-Lotte Gluud 2, Emilie K. Dahl 3, Aleksander Krag 1
Department of Gastroenterology and Hepatology, Odense University Hospital, Odense
C, 2Department of Medicine, Copenhagen University Hospital Gentofte, Hellerup,
3
Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
Introduction: The effect of antiviral therapy on clinical outcomes in HBV is not established.
Aims: To assess the effect of antiviral treatment (interferons and/or nucleo(t)side
analogues) versus placebo or no intervention on prevention of hepatocellular carcinoma
(HCC) and mortality in chronic hepatitis B (HBV).
Methodology: Systematic review with meta-analyses of randomised controlled trials and
observational studies (prospective cohorts and case control series).
Results: We included eight RCTs, eight prospective cohort studies and 19 case-control
studies with a total of 3433 patients allocated to antiviral therapy and 4625 controls. The
maximum duration of follow up was 23 years. Random effects meta-analysis of RCTs
found no effect of antiviral therapy on HCC. Cohort studies found that antiviral therapy
increased the risk of HCC (risk ratio, 1.43 [95% CI, 1.06 to 1.95]) whereas case control
studies found a decreased risk of HCC in the intervention group (risk ratio, 0.69 [CI, 0.54
to 0.88]). There was a clear difference between the results of RCTs and observational
studies (test for subgroup differences, P < 0.001). Antiviral therapy did not affect mortality
in RCTs, but reduced mortality in case control studies (overall relative risk, 0.76 [CI 0.63 to
0.92]; test for subgroup differences, P = 0.406).
Conclusion: The effect of antiviral therapy on HCC in HBV remains to be established.
There is clear evidence of bias suggesting that the estimated treatment effects is closely
related to the study design. Although there was a positive effect in the sensitivity analyses,
the strength of the evidence does not allow for extrapolation to clinical practice as research
design plays an essential role in the overall assessment.
298
300
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
301
Francesca Romana Ponziani 1, Maria Assunta Zocco 2, Matteo Garcovich 2,
Emanuele Rinninella 2, Antonio Gasbarrini and the HEPATOCAT
multidisciplinary group for the treatment of HCC
1
Internal Medicine and Gastroenterology, 2A Gemelli Hospital, Rome, Italy
All
HBV
HCV
P value
Gender (Male/
Female)
203/63
58/16
145/47
0.623
Age (mean ± SD)
66 ± 10
62 ± 11
68 ± 10
<0.001
<=40 years
4/257 (1.5%)
3/71 (4.2%)
1/186 (0.5%)
0.013
40-60 years
59/257 (21.8%)
22/71 (31%)
37/186 (20%)
Introduction: Hepatocellular Carcinoma (HCC) is one of the most common complications
of HCV and HBV-related liver disease. Young age, large and multinodular HCCs are typical
of HBV patients, which accounts for 50% of the cases, while the presence of cirrhosis is
the most common characteristic in HCV ones.
>60
194/257 (75.5%)
46/71 (65%)
148/186 (79.5%)
cirrhosis
261/266 (98%)
71/74 (96%)
190/192 (99%)
CHILD A/B/C
181/57/16/7
45/20/4/2
136/37/12/5
0.506
AFP (mean ± SD)
1479 ± 450
2676 ± 10200
996 ± 4697
0.091
Aims: To report the epidemiology and features of HCC in an Italian single center comparing
HBV and HCV patients.
<=20
113/226 (50%)
34/65 (52%)
79/161 (49%)
0.462
21-200
66/226 (30.5%)
15/65 (23%)
51/161 (32%)
201-1000
21/226 (9%)
6/65 (9%)
15/161 (9%)
>1000
26/226 (11%)
10/65 (15%)
16/161 (10%)
BCLC 0/A/B/C/D
35/118/58/34/21
6/32/21/10/5
29/86/37/24/16
0.372
Single lesion
143/266 (54%)
39/74 (53%)
104/192 (54%)
0.830
Multinodular
123/266 (46%)
35/74 (47%)
88/192 (46%)
Tumor <5 cm
209/263 (79.5%)
50/74 (67.5%)
159/189 (84%)
0.003
Tumor >5 cm
54/263 (20.5%)
24/74 (32.5%)
30/189 (16%)
Macrovascular
invasion
35/266 (13%)
13/74 (17.5%)
22/192 (11.5%)
0.079
Metastases
11/266 (4%)
7/74 (9.5%)
4/192 (21%)
0.007
Methodology: 266 Caucasian cirrhotic patients with HCV or HBV cirrhosis or chronic
hepatitis were selected from the prospective database of the HEPATOCAT multidisciplinary
group for the treatment of HCC. Patients with non HCC tumors were excluded from the
analysis. Age, sex, BCLC, number and size of lesions, Child-Pugh score when applicable,
vascular invasion and metastasis were evaluated. Chi-square and Student’s t-tests were
used to compare data; a two-sided P value of 0.05 was considered statistically significant.
Results: Patients’ characteristics are shown in Table 1. 192 (72.2%) patients were HBV
infected AND 74 PATIENTS (27.8%) hcv infected. HBV-related liver disease seems
associated to a younger age (p<0.001) and larger HCCs (p=0.005) than HCV, while
no difference was found in degree of liver dysfunction, number of lesions and vascular
invasion. Furthermore, metastases were more common among patients with HBV infection
(p=0.007).
Conclusion: In our series of Italian patients, HBV-related HCC is more common in young
people and more aggressive than HCV-related one, since it presents with lesions of larger
size and more prone to develop metastases.
HCC EPIDEMIOLOGY
302
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
303
Francesca Romana Ponziani 1, Maria Assunta Zocco 2, Matteo Garcovich 2,
Valentina Cesario 2, Francesca D’Aversa 2, Teresa Antonella Di Rienzo 2,
Anna Maria De Gaetano 2, Emanuele Rinninella 2, Davide Roccarina 2,
Maria Chiara Campanale 2, Federico Barbaro 2, Annalisa Tortora 2, Gianluigi Caracciolo 2,
Giovanni Gigante 2, Gianluca Ianiro, Massimo Siciliano, Brigida Eleonora Annicchiarico,
Alessandro Milani, Giovanni Gasbarrini, Salvatore Agnes, Alfonso Wolfango Avolio,
Antonio Grieco, Gennaro Nuzzo, Felice Giuliante, Gian Ludovico Rapaccini,
Maurizio Pompili, Antonio Gasbarrini and HEPATOCAT
multidisciplinary group for the treatment of HCC
1
Internal Medicine and Gastroenterology, 2A Gemelli Hospital, Rome, Italy
Introduction: Portal vein thrombosis (PVT) is a relatively common complication in
cirrhotics (prevalence 0.6%>16%, 6.5% in patients with hepatocellular carcinoma-HCC).
To date, there are no data concerning the impact of PVT, both malignant or non-malignant,
on HCC treatment outcome.
Mean±SD/Frequency
AGE (years)
64±9 (35-87)
SEX
167M/42F
Liver disease
Chronic hepatopathy 23/209 (11%)/cirrhosis 176/209 (84.2%)/none 9/209
(4.3%)
Etiology of liver disease
Viral 143/209 (68.4%)/alcoholic 30/209 (14.4%)/viral+alcoholic 10/209 (4.8%)/
other 17/209 (17.1%)/none 5/209 (2.4%)
BCLC
A: 94/186 (50.5%) B: 39/186 (20.9%) C: 54/186 (29%)
D: 19/186 (10.2%) 23 no cirrhosis
Milano criteria “in”
108/205 (98.1%)
Child-Pugh
A: 113/186 (60.7%) B: 32/186 (17.2%) C: 5/186 (2.6%) 23 no cirrhosis
MELD
11±0,6 (6-26)
PVT
No 151/209 (72.2%)/ non-malignant 12/209 (5.7%)/ malignant 46/209 (22%)
Caval invasion
6/209 (2.8%)
Metastasis
9/209 (4.3%)
Methodology: 209 cirrhotic patients with HCC were selected from the database of the
HEPATOCAT multidisciplinary group for the treatment of HCC. Patients’ characteristics
were shown in table 1.
Results: 96/209 patients enrolled (45.9%) experienced TF, and 77 (36.8%) TR. mPVT
was associated to TF (p=0.004; chi-squared 11.262) and to TR (p=0.042; chi-squared
6.362). Viral or alcoholic liver disease etiology (p=0.044; chi-squared 18.742) were the
most common among patients with mPVT or nmPVT, mPVT occurred in HCC outside
Milan criteria while nmPVT in HCC within Milan criteria (p=0.001; chi-squared 14.365),
finally caval invasion was frequent in mPVT patients but non in nmPVT ones (p=0.008;
chi-squared 9.672); however only HCC outside Milan criteria (OR 0.743 p=0.017;
95%CI -0.538,-0.54) and caval invasion (OR 2.172 p=0.039; 95%CI 0.040,1.512) were
independently associated with PVT occurrence.
Treatment outcome was evaluated according to m-RECIST criteria as absence of
complete response to single or repeated treatment (treatment failure, TF; tumor
recurrence after complete response, TR). mPVT or nmPVT was diagnosed by contrast
enhanced CT or MRI.
Conclusion: mPVT has a negative impact on HCC treatment, since it is associated with
a higher risk of TF or TR. PVT seems more common in patients with HCC outside Milan
criteria and caval invasion; in particular, mPVT is more frequent in patients with advanced
BCLC stage.
Aims: To retrospectively investigate the impact of malignant (mPVT) or non-malignant
PVT (nmPVT) on HCC treatment outcome and to evaluate factors associated with PVT
development.
Patient’s characteristic
HCC TREATMENT AND PVT
ASSOCIATION OF TNF-ALPHA
CHARACTER OF NBNC-HCC
305
Dalia Shaalan 1, Amal K. Selim 1, Raghda E.-S. Farag 1 2, Basem El-deek 1 2 3
1
Medical Biochemistry Department., 2Tropical Medicine Department., 3Community
Medicine , Mansoura Faculty of Medicine, Mansoura University, Egypt, Mansoura, Egypt
Naota Taura, Tatsuki Ichicawa 1, Kazuhiko Nakao 1
and Nagasaki Association Study of Liver Disease (NASLD) group
1
Department of Gastroenterology and Hepatology,, Graduate School of Biomedical
Sciences Nagasaki University, Nagasaki, Japan
Introduction: TNF-α plays a pivotal role in the host immune response to hepatitis C virus
infection as a well characterized inflammatory mediator and may be implicated in the
development of hepatocellular carcinoma (HCC).
Introduction: HCC often develops in patients with liver cirrhosis caused by hepatitis B
virus (HBV), hepatitis C virus (HCV), excessive alcohol consumption, or nonalcoholic
fatty liver disease. Of the hepatitis viruses which cause HCC, HCV is predominant in
Japan.However, It has been reported that the number and ratio of both HBsAg and HCVab
negative HCC (HCC-nonBC) steadily increases in Japan.
Aims: The aim of the present study was to investigate the frequency of TNF-α 308
promoter genotype and its association with the risk of developing hepatocellular carcinoma
in Egyptians.
Methodology: One hundred twelve of gender-matched and age-matched patients with
HCC and unrelated ninety six healthy controls were genotyped for TNF308 with polymerase
chain reaction and direct sequencing. DNA was extracted from peripheral blood of all
cases and controls. DNA analysis was carried out by polymerase chain reaction (PCR),
then restriction digestion of the PCR products (RFLP) for TNF-α 308 gene.
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Results: Among HCC patients carriers of A alleles were significantly more frequent with
7.02 –fold higher risk of developing HCC among HCC /HBV group than control (OR=4.02,
95% CI=3.41-14.63, Corrected p value by using benferroni correction is <0 .001). That
risk increases to 14.05 fold in HCC/HCV when compared to control (OR= 14.04, 95%
CI 7.02-28.51, p<0 .001). On the other hand, the carriers of G alleles were significantly
more frequent among control when compared to either HCC/HBV or HCC/HCV groups
(OR=0.14, 95% CI = 0.07-0.29, and OR= 0.07, 95% CI =0.04-0.14 respectively, p<0 .001).
Patients with HCC with HBV or HCV had a lower frequency of TNF308.GG genotype
(38.5 % and 21.6%% vs 82% in control; OR=0.11, 0.05; with 95%CI (0.04-0.25) and (0.020.12), p value is <0 .001). The frequency of TNF-α-308 GA genotypes was higher in HCC
patients with HBV or HCV than control (52% and 51.7% % vs 14.6%; OR= 6.33, 6.23
with 95% CI (2.7-15.03) and (2.75-14.43) ; P<0 .001). When comparing the frequency
of TNF308.AA genotype among the studied groups, it was significantly more frequent in
HCC patients versus control ( OR=3.04 , 3018 ; with 95% CI (2.14-3.85) and (2.49-4.06)
, p=0.007, p<0 .001).
Conclusion: This study concluded that, individuals carrying the A allele of TNFα -308
polymorphism may be more susceptible to hepatocellular carcinoma either in homozygous
or heterozygous state.
Aims: The aim of this study was to determine the frequencies and utilities of elevated
α-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) levels as biomarkers in
cryptogenic HCC.
Methodology: A total of 2,368 patients with HCC diagnosed between 1999 and 2010 in
Nagasaki Association Study of Liver (NASLD), were recruited for this study. The etiology
of HCC was categorized to four groups; HCC-B: HBsAg positive and HCVAb negative,
HCC-C: HCVAb positive and HBsAg negative, HCC-BC: both of HBsAg and HCVAb
positive, HCC-nonBC: both of HBsAg and HCVAb negative. The significance of factor
were examined for HCC-nonBC using logistic regression analysis.
Results: Multivariate analysis identified age (≥70 years, hazard ratio [HR] 1.63), sex
(female, HR 1.73), BMI (≥25, HR 2.12), alcohol consumption (excessive, HR 14.73),
platelet count (<116,000 /μL, HR 1.88), AST (<56 IU/L, HR 1.47), ALT (<46 IU/L, HR
2.48), AFP (20-199 ng/mL, HR 0.60; ≥200 ng/mL, HR 0.63), DCP (20-199 mAU/mL, HR
1.64; ≥200 mAU/mL, HR 2.08), and TNM stage (II, HR1.67; III, HR1.88; IV, HR 2.40), as
independent and significant risk factors for HCC-nonBC. According to TNM stage, the
median AFP levels in HCC-nonBC with TNM stages I, II, and III were significantly lower
than in either HCC-B or HCC-C. In TNM stage IV, the median AFP level in HCC-nonBC
was significantly lower than in either HCC-B or HCC-BC. The median DCP levels in HCCnonBC with TNM stages I and II were significantly higher than those in either HCC-B or
HCC-C. In TNM stage III, the median DCP level in HCC-nonBC was significantly higher
than that in HCC-C. However, there were no significant differences in median DCP level
among HCC patients at TNM stage IV. The survival rate of patients in the high DCP group
(≥200 mAU/mL) was significantly lower than that of patients classified as having low DCP
(40-199 mAU/mL) or being DCP negative (<40 mAU/mL) in the HCC-B, HCC-C, and HCCnonBC groups (p ≤ 0.001; log-rank test).
Conclusion: DCP was more sensitive than AFP for the diagnosis of early stage cryptogenic
HCC. DCP should be used as the main serum test for cryptogenic HCC detection.
304
EASL HCC SUMMIT
DIAGNOSIS OF PRIMARY LIVER TUMORS THE
ROLE OF 18F-FDG AND 18F-FLUOROCHOLINE
GOSSYPOL: AN OPTION IN HEPATOCELLULAR
CARCINOMA THERAPY?
Ana F. Brito 1 2, Marina Ribeiro 1, Ana M. Abrantes 2 1, Francisco Castro-Sousa 3,
José G. Tralhão 3, Maria F. Botelho 1 2 and Biophysics Unit, IBILI - Faculty of Medicine,
University of Coimbra; Center of Investigation on Environmental, Genetics and
Oncobiology (CIMAGO), Faculty of Medicine, Coimbra; Portugal
1
Biophysics Unit, Faculty of Medicine, University of Coimbra, 2Center of Investigation on
Environmental, Genetics and Oncobiology (CIMAGO), 3Surgical Department,
Surgery A, HUC, Coimbra, Portugal
Introduction: The incidence of primary liver tumors (PLT) has increased in recent years,
especially in developing countries. Hepatocellular carcinoma (HCC) is the most common
PLT (80%) followed by cholangiocarcinoma (CaC) (10%).
Aims: A major difficulty is to obtain an accurate diagnosis that allows also distinguishing
between PLTs. The aim of this work is to study the uptake profile of 18F-FDG and
18
F-Fluorocholine in two PLT cell lines a HCC cell line and a CaC cell line.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Methodology: The cell lines used were HuH7 (HCC) and TFK1 (CaC). 18F-FDG and
18
F-Fluorocholine were incubated in a cell suspension with 2×106 cells/ml (25µCi/ml).
Samples of 200μl were collected to eppendorf tubes for tracer uptake determination.
Eppendorfs were then centrifuged and radioactivity of cell pellets and supernatants was
measured with a well-type gamma counter.
307
Ana F. Brito1, Ana M. Abrantes 1 2, Marina Ribeiro 1, Ana C. Gonçalves 2, Ana B.
Sarmento-Ribeiro, Francisco Castro-Sousa 1 3, José G. Tralhão 1 2 3, Maria F. Botelho 1 2
1
Environmental, Genetics and Oncobiology (CIMAGO), 3Surgical Department, Surgery A,
HUC, Coimbra, Portugal
Introduction: Gossypol, a natural compound extracted from the cotton plant has been
shown to inhibit the growth of several tumour cell lines, including hepatocellular carcinoma
(HCC) cells. This compound is a potent inhibitor of Bcl-2 family of antiapoptotic proteins.
On the other hand it is known that gossypol is a competitive inhibitor of GLUT1 whose
expression is increased in HCC and promotes tumorigenesis.
Aims: This study aims to test the anticancer effect of gossypol in three HCC cell lines,
study its effect on Bax and Bcl2 expression as well as check its effect on 18F-FDG uptake
(a glucose analogue). We also intend evaluated the effect of gossypol on cell cycle.
Methodology: The cell lines used are HepG2 (wp53), HuH7(mp53) and Hep3b2.1-7(p53
null). Cell lines were incubated with gossypol in several concentrations. Cell proliferation
was evaluated by MTT test. The type of cell death and the percentage of live cells
were assessed by flow cytometry. Bax, Bcl2 and GLUT1 expression and cell cycle was
also assessed by flow cytometry. For uptake studies, 18F-FDG was incubated in a cell
suspension in cells pre-incubated with gossypol and control cells. Samples were collected
to eppendorf tubes for tracer uptake calculation. Eppendorfs were then centrifuged and
radioactivity of cell pellets and supernatants was measured with a well-type gamma
counter.
Results: We observed, in both cell lines, a higher 18F-Fluorocholine uptake than 18F-FDG
uptake. However, it was found that CaC cell line has a higher uptake of both tracers than
HCC cell line. After 120 minutes with radiopharmaceuticals incubation, the 18F-FDG uptake
by HCC cell line is about 1.6% and by CaC cell line is about 3%. For 18F-Fluorocholine the
uptake by HCC cell line is about 6% and by CaC cell line 30%.
Results: The concentration necessary to achieve the IC50 is higher for HuH7 cells. More
sensitive cell line is Hep3B2.1-7.Flow cytometry results show that gossypol induces high
apoptosis in HepG2 and HuH7 cells. In Hep3B2.1-7 cell line there is a balance between
apoptosis and necrosis. This compound also induced Bax activation in all cell lines.
Gossypol causes a delay in pre-G1 phase on cell cycle. For the three cell lines studied,
gossypol was able to decrease the percentage of 18F-FDG uptake.
Conclusion: These results show that both cell lines under study have higher
18
F-Fluorocholine than 18F-FDG uptake, and CaC cell line has a higher uptake of both
radiopharmaceuticals than HCC cell line. Although the results are not very satisfactory for
HCC, in the case of CaC there is an increased uptake, mainly, of 18F-Fluorocholine. So,
18
F-Fluorocholine may provide an option for the diagnosis of this pathology.
Conclusion: Gossypol has anti-proliferative effect on HCC. The decrease of cell
proliferation could be associated with lower glucose uptake, as was shown with 18F-FDG.
Cell death occurs primarily by apoptosis through Bax activation. This compound could
help to overcome resistance to chemotherapy and radiotherapy in this type of tumor,
contributing to the existence of a personalized therapy.
306
308
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
309
STUDY OF MULTIDRUG RESISTANCE IN
HEPATOCELLULAR CARCINOMA: THE ROLE OF
NUCLEAR MEDICINE
Introduction: Surgical resection and liver transplantation offer the best chance of a
cure for Hepatocellular Carcinoma (HCC). However, only less than 15% of patients are
candidates to these therapies and are treated with other therapies such as chemotherapy.
However HCC is known to be highly resistant to chemotherapy, which is due in part to
overexpression of multidrug resistance proteins (MDR).
Aims: A method to measure the function of these proteins involves the study of
radiolabeled substrate 99mTc-MIBI uptake. Studies have demonstrated that 18F-FDG uptake
is associated with tumor differentiation and the expression of MDR proteins in HCC. Tthis
study aims evaluate and compare the uptake and retention of 18F-FDG and 99mTc-MIBI in
three human HCC cell lines with different expression levels of p53 and to correlate with the
expression of three MDR proteins (Pgp, MRP1 and LRP).
Methodology: Human HCC cell lines used were HepG2 (wp53), HuH7(mp53) and
Hep3B2.1-7(p53null). Cell suspensions with 2x106cells/ml were incubated with 25µCi/ml
of 18F-FDG or 99mTc-MIBI. Samples of 200μl were collected at different periods of time
which were centrifuged separating the supernatant from the pellet. Activity was measured
in a well counter. 18F-FDG and 99mTc-MIBI retention was obtained by incubating the cell
suspension with radioisotope during 60 minutes. Thereafter, the cells were centrifuged
and medium renewed. The following procedure was similar to the uptake studies. The
proteins levels of Pgp, MRP1 and LRP were determined by flow cytometry. To evaluate
MDR modulation, retention studies were performed in the presence of verapamil (Pgp
inhibitor) prior to incubation with 18F-FDG.
Results: Hep3B2.1-7 cell line is one that has higher levels of uptake and retention of
18
F-FDG and also 99mTc-MIBI. The HepG2 cell line has a lower uptake and retention and a
higher expression of MRP1. The levels of Pgp and LRP expression are similar for all cell
lines. Through studies of modulation was verified, by incubating the cells with verapamil, a
considerable increase in 18F-FDG and 99mTc-MIBI retention in all cell lines.
Conclusion: There is an inverse relationship between MRP1 expressions and uptake and
retention of 99mTc-MIBI and 18F-FDG. Through modulation studies it was found that Pgp
has an active role on MDR phenomenon in HCC. The uptake and retention profiles for the
two radiopharmaceuticals are similar, showing that the 18F-FDG can be used to study the
action of MDR proteins in HCC cells, presented as an alternative to 99mTc-MIBI.
Ana F. Brito 1 2, Mónica Mendes 1, Marina Ribeiro 1, Ana M. Abrantes 1 2,
Ana C. Gonçalves 2 3, Ana B. Sarmento-Ribeiro 2 3, Francisco Castro Sousa 1.2 4,
José G. Tralhão 1 2 4, Maria F. Botelho 1 2
1
Environmental, Genetics and Oncobiology (CIMAGO), 3Applied Molecular Biology and
Hematology Group, Faculty of Medicine, University of Coimbra, 4Surgical Department,
Surgery A, HUC, Coimbra, Portugal
EASL HCC SUMMIT
HEPATOCELLULAR CARCINOMA AND
QUERCETIN: A CURIOUS RELATIONSHIP
MULTIMODALITY TREATMENT OF
HEPATOCELLULAR CARCINOMA IN A SINGLE
TERTIARY REFERRAL CENTRE
Ana F. Brito 1 2, Marina Ribeiro 1, Ana M. Abrantes 1 2, Ana C. Gonçalves 2,
Ana B. Sarmento-Ribeiro, Francisco Castro Sousa 1 3,
José G. Tralhão 1 2 3, Maria F. Botelho 1 2
1
Biophysics Unit, Faculty of Medicine, University of Coimbra,
2
Center of Investigation on Environmental, Genetics and Oncobiology (CIMAGO),
3
Surgical Department, Surgery A, HUC, Coimbra, Portugal
Introduction: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy.
Glucose transporter-1 (GLUT1) expression is increased in HCC and promotes tumorigenesis.
Flavonoids, including quercetin, have shown potential as GLUT1 function inhibition and they
can be useful as therapeutic weapons against this highly aggressive kind of tumor.
Aims: The aim of this study is to evaluate the potential anticancer effect of quercetin on
two HCC cell lines which differ on p53 expression, evaluate its effect on 18F-FDG uptake
and in GLUT-1 expression.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Methodology: Two different HCC cell lines (HepG2 (wp53) and HuH7 (mp53)) were used.
In order to assess the effect of quercetin in these cell lines, the cells were incubated in the
presence of different concentrations of this compound for different periods of time, and after
cell proliferation was evaluated by the MTT test in order to calculate half maximal inhibitory
concentration (IC50). The type of cell death was assessed by flow cytometry using the
double staining with annexin-V and propidium iodide. Bax, Bcl2 and GLUT1 expression
was also assessed by flow cytometry. For uptake studies, 18F-FDG was incubated in a
cell suspension in cells pre-incubated with quercetin and control cells. At different times,
samples were collected to eppendorf tubes for uptake calculation. Eppendorfs were then
centrifuged and radioactivity of pellets and supernatants was measured with a well-type
gamma counter.
Results: Quercetin inhibits cell proliferation in HepG2 and HuH7 cell lines in a timedependent manner. Quercetin does not inhibit GLUT1 expression, however this compound
is able to decrease the 18F-FDG uptake in both cell lines. Flow cytometry results have
shown that quercetin has a cytotoxic effect only at high concentrations of this compound.
When cell death occurs, is mainly by apoptosis and this is accompanied by a Bax activation.
Conclusion: This study showed that quercetin has a considerable anti-proliferative effect
in HepG2 and Huh7 cell lines. This compound probably modifies the function but not the
expression of GLUT1, since it inhibits 18F-FDG (a glucose analogue that is transported
into the cell by GLUT1 and GLUT3) uptake. In this context quercetin may represent a new
therapeutic option in HCC.
311
Angelo Sangiovanni 1, Michela Triolo 1, Matteo Angelo Manini 1, Massimo Lavarone
, Sara Vavassori 1, Cristina Della Corte 1, Laura Virginia Forzenigo 2, Antonio Nicolini 2,
Giorgio Rossi 3, Massimo Colombo 1
1
1st Division of Gastroenterology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico , 2Division of Radiology, 3Division of Surgery and Liver Transplant, Fondazione
IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
1
Aims: Multimodality treatment of hepatocellular carcinoma (HCC) is a common clinical
practice. Comorbidities, liver and no-liver related conditions, led to an incomplete
adherence to the AASLD guidelines for the treatment of HCC. The impact of this behavior
is not fully investigated. The aim is to define the clinical impact of multimodality treatment
of HCC in cirrhotic patients attending a single tertiary referral centre.
Methodology: 292 consecutive cirrhotic patients with a de-novo diagnosis of HCC, 218
(75%) males, mean age 66 (31-87), 230 (79%) Child-Pugh A, 145 (50%) BCLC A0-3, 54
(18%) A4, 49 (17%) B and 45 (15%) C, were observed between 2007 and 2011. HCC
treatments were decided by a multidisciplinary team of experts on intention-to-treat
according to the AASLD guidelines. Restaging was performed every 1-3 months by CT/
MRI after treatment. Patient and tumor characteristics and blood tests were considered as
predictors of survival and tested by univariate and multivariate Cox proportional hazards
model (STATA 10.0 Statistical Package).
Results: During a mean trial time of 36 months 78 (27%) patients died and 25 (9%) were
lost. Overall 1, 3 and 5 yr survival was 91%, 68% and 53 % respectively (99%, 81% and
68% for BCLC A, 94%, 62%, 35% for BCLC B, 52%, 12% and 0% for BCLC C). First line
treatment was: 31 (11%) liver transplantation (OLT), 43 (15%) resection, 116 (40%) local
ablation, 53 (18%) chemoembolization, 27 (9%) sorafenib, 22 (8%) best supportive care
(BSC). Adherence to AASLD guidelines was in 220 (75%) patients. 43 (15%) received
a treatment recommended by AASLD for a more advanced stage, 29 (10%) for a less
advanced stage. Complete response was achieved in 137 (47%) after first line treatment
(including 31 OLT), in 19 (6%) after second line, in 5 (2%) after third line. HCC recurred
after OLT in 6 (19%). Independent predictors of survival were: treatment choice (HR 1.76
95% CI 1.39-2.24, p <0.000), BCLC (HR 1.83, 95% CI 1.29-2.61, p=0.001), AFP > 100ng/
mL, (HR 2.53, 95% CI 1.48.4-32, p=0.001), encephalopathy (HR 2.29, 95% CI 1.21-4.37,
p =0.01), ascites (HR 1.78, 95% CI 1.08-2.95, p=0.024).
Conclusion: In the clinical practice of a tertiary referral centre, adherence to AASLD
guidelines for HCC treatment was in two third of the patients and a complete response in
more than half of the cases. The multidisciplinary decision of treatment choice is one of the
strongest predictors of HCC survival.
310
EASL HCC SUMMIT
CONTRAST ENHANCED ULTRASOUND (CEUS)
IN THE DIAGNOSIS AND IN THE FOLLOW UP OF
PREDICTIVE BIOMARKER FOR SORAFENIB
THERAPY IN HEPATOCELLULAR CARCINOMA
Daniela Santovito, Vincenzo O. Palmieri, Lara Ricci, Caterina Capobianco, Alfonso
Mele, Francesco Minerva, Giuseppe Palasciano
Introduction: The contribution of CEUS in the diagnosis of HCC is controversial with
some guidelines (AASLD, 2011; EASL, 2012) that exclude and other (AISF, 2012) that
state a specific role.
Aims: To evaluate the accuracy of CEUS in the diagnosis of HCC in cirrhosis and of
relapse or residual of HCC after treatment.
Methodology: Retrospective evaluation of 113 cirrhotic patients with histologically
diagnosis of HCC (median age 71 yrs, 83M/30F, 86 HCV and 15 HBV); 92 subjects
underwent to treatment (6 surgery, 62 TACE; 98 RFA; 25 combination of TACE and RFA,
14 sorafenib); the diagnosis of HCC on CEUS was confirmed on the typical partner:
sustained hyperenhancement in the arterial, loss of hyperenhancement in portal and
delayed phases.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Results: 72 patients had both CEUS (n=73) and TC (n=71) or MR (n=2) for the initial
diagnosis of HCC, of which 23 with a nodule <20 mm, 50 with a nodule > 20 mm; among
treated patients, 28 presented a residual or a relapse of HCC and 34 a complete necrosis.
Sensitivity, specificity, PPV, NPV of CEUS and TC/MR in the initial of HCC were: small
HCC: 66,6vs94, 100vs100, 100vs100, 33vs75; larger HCC: 75vs94, 100vs100, 100vs100,
28vs60. In the diagnosis of residual or relapse of HCC and in that of complete necrosis,
the concordance CEUS/TC or MR was 94% and 89%, false negative CEUS were 3% and
11%, false negative TC/MR were 3% and 0.
Conclusion: CEUS may have a role in the initial diagnosis of large HCC and in the follow
up of treated HCC nodules.
313
Takuya Honda 1 2, Tatsuki Ichikawa 1, Naota Taura 1, Hisamitsu Miyaaki 1,
Satoshi Miuma 1, Hidetaka Shibata 1, Shinjiro Uchida 1, Yasuhiro Kamo 1, Takemasa Seno 1,
Emi Yoshimura 1, Ikuko Takahara 1, Kazuto Ashizawa 2, Kazuhiko Nakao 1
1
Gastroenterology and Hepatology, Nagasaki University Honpital, 2Clinical Oncology
Center, Nagasaki University, Nagasaki, Japan
Introduction: Sorafenib, the first agent demonstrated to have efficacy to improve the
survival of patients with advanced hepatocellular carcinoma (HCC), is an active multikinase
inhibitor affecting angiogenesis and tumor proliferation.
Aims: We analyzed cytokines related to angiogenesis or cell proliferation, and tried to
determine their utility as biomarkers of sorafenib treatment effect for HCC.
Methodology: A total of 33 patients with HCC diagnosed between 2009 and 2012 in
the Department of Gastroenterology and Hepatology, Nagasaki University Hospital, were
recruited for this study. We evaluated the biomarker of all patients in plasma vascular
endothelial growth factor (VEGF), hepatocyte growth factor (HGF), des-gamma-carboxy
prothrombin (DCP) and interleukin-8 (IL-8) levels at the start of sorafenib therapy, and
examined the association between objective tumor response, progression-free survival
and overall survival.
Results: We evaluated patients for Response Evaluation Criteria in Solid Tumors (RECIST),
17out of 33 patients (51%) achieved disease control. The median progression-free survival
day of all patients was 120 days. They were categorized into two groups as follows: 1)
17 were classified as the responder group: partial response (PR) or stable disease (SD),
and 2)16 were put into the non-responder group: progressive disease (PD). There were
no significant differences in the VEGF, HGF and DCP levels. However, the plasma IL-8
was significant lower the responder group than the non-responder group (p = 0.00459).
The progression-free survival of 17 patients with low IL-8 level (<12.0 pg/ml) group was
significantly longer than the high IL-8 (=>12.0 pg/ml) gorup patients (P = 0.00092).
Conclusion: The plasma level of IL-8 can be a predictive marker to assess the tumor
response and progression-free survival to sorafenib therapy.
312
EASL HCC SUMMIT
ROLE OF THE ERK5 SIGNALLING IN THE HUMAN
GENETIC AND EPIGENETIC ALTERATIONS OF
P16 & RASSF1A GENE IN HEPATOCELLULAR
CARCINOMA FROM NORTH INDIA
315
Giovanni Di Maira1, Elisabetta Rovida 1, Nadia Navari 1 2, Stefania Cannito 1 2 3,
Persio Dello Sbarba 1 2 3, Maurizio Parola 1 2 3, Fabio Marra 1 2 3
1
Dipartimento di Oncologia Sperimentale, 2Medicina Sperimentale e Clinica, University of
Florence, Florence, 3Dipartimento di Medicina e Oncologia Sperimentali ,
University of Turin, Turin, Italy
Sunil K. Polipalli 1, Vijay K. Karra 1, Rajesh Ruttala 1,
Phani K. Gumma 1, Premashis Kar 1, Seema Kapoor 2
1
Medicine, 2Pediatrics, Maulana Azad Medical College & Associated Lok
Nayak Hospital, New Delhi, India
Introduction: The large majority of hepatocellular carcinomas (HCC) arises on a chronically
injured liver, in the presence of fibrosis or cirrhosis, underscoring the relationship between
stromal changes and the onset of cancer. As current treatment options for hepatocellular
carcinoma (HCC) are limited, it is critical to identify novel therapeutic targets.
Aims: ERK5 is a member of the MAPK family implicated in several biologic actions relevant
for tumor development. Deregulation of the ERK5 pathway has been associated with cancer.
Aim of this study was to understand the role of ERK5 in HCC in vitro and in vivo. Methodology: Huh-7 and HepG2 were cultured by standard methods. Liver tissue was
obtained from HCC and peritumoral areas. ERK5 was silenced by siRNA transfection or
with shRNA and lentiviral vectors. The specific ERK5 inhibitor XMD8-92 was also used.
In vivo development of HCC was evaluated using the Huh-7 xenograft model in athymic
nude mice.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Results: ERK5 showed more abundant nuclear localization in patients with HCC or
cirrhosis than in normal liver, indicating ERK activation. ERK5 silencing in HCC cells or
exposure to XMD8-92 blocked the increase in migration and invasion induced by EGF or
serum. Similar results were observed in response to hypoxia. ERK5 silencing or inhibition
caused cytoskeletal remodeling and rearrangement of focal adhesions, consistent with
a reduction in cell motility. ERK5 activation was necessary for the growth of HCC cells,
affecting the G1/S transition. In a mouse model of HCC xenograft, administration of XMD892 significantly decreased tumor volume by 40% compared to vehicle. In mice injected with
Huh-7 silenced for ERK5 using a lentiviral shRNA vector, the rate of tumor appearance
was significantly lower (4/16 mice, 25%) than in animals inoculated with cells transduced
with non targeting shRNA (9/15, 60%). In addition, at the end of the experiment, tumor
volume was smaller in the presence of ERK5 silencing.
Conclusion: The ERK5 pathway is critical for HCC tumor development and growth in
vivo. Blocking the ERK5 pathway should be further investigated as a novel approach for
the treatment of HCC.
Introduction: The tumor suppressor genes are mainly inactivated by an epigenetic
change involving promoter hypermethylation in hepatocarcinogenesis. Our knowledge
about molecular alterations during hepatocarcinogenesis is still fragmentary, due to lack
of comprehensive genetic and epigenetic analyses in the same set of hepatocellular
carcinomas (HCCs).
Aims: The study aims at the possible clinical impact of p16INK4A & RASSF1A methylation
and the potential risk factors for this epigenetic alteration
Methodology: In this study, we conducted mutational screening in p16 gene and methylation
assays of p16 and RASSF1A genes in 50 patients of HCCs and their neighboring noncancerous tissues. All samples were collected from the residents in North India.
Results: We found HBV infection and chronic hepatitis/cirrhosis in 80.3% and 94.1%
of the cases, respectively. Mutations were identified in 18 out of 50 (36.0%) samples,
with p16 alterations in 14 cases and β-catenin mutations in two tumors. No mutations
were identified in the neighboring tissues. Interestingly, 9 out of 14 (64.3%) tumors
carrying p16 mutations displayed substitution of GTG to ATG (Val Met) at codon 74, a
characteristic change believed to be induced by aflatoxin-B1. Furthermore, p16 mutation
was significantly associated with shorter recurrence-free survival (P = 0.004). The results
also revealed aberrant methylation in two genes in as high as 80% of tumors and 30%
of adjacent tissues. The frequency of RASSF1A hypermethylation was much higher than
that of p16INK4a in both HCC and neighboring tissues, indicating that deregulation of
RASSF1A may precede the p16 genes.
Conclusion: Our data suggest that aberrant methylation occurs before mutation and is
an early event in the development of this set of HCC. Our findings highlight p16 as a
prognostic factor of HCC and RASSF1A as a potential target in preventing malignant
transformation of hepatocytes.
314
316
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
317
HBV DNA INTEGRATION IN PATIENTS
WITH OCCULT HBV INFECTION AND
Carlo Saitta 1, Teresa Pollicino 1, Giuseppina Raffa 1, Antonio Bertuccio 1,
Marika Lanza 1, Gianluca Tripodi 1, Adalberto Barbera 2, Angelo Sangiovanni 3,
Antonina Smedile 4, Giuseppe Navarra 2, Giovanni Raimondo 1
1
Internal Medicine, Unit of Clinical and Molecular Hepatology - University Hospital of
Messina, 2Uman Pathology, Unit of Oncological Surgery - University Hospital of Messina,
Messina, 3Medicine, Division of Gastroenterology - Fondazione IRCCS Cà Granda
Ospedale Maggiore Policlinico , Milan, 4Internal Medicine, Gastro-Hepatology Unit University Hospital of Turin, Turin, Italy
Introduction: HBV DNA integration into the cellular genome is an important pro-oncogenic
event in chronic HBV infected patients. Viral integration may occur also in HBsAg-negative
patients with occult HBV infection (OBI), although extensive studies have not been
performed in this field.
In all cases viral integration appeared randomly distributed throughout the host genome.
X gene sequences were found in 17 cases, preS-S regions in 14 cases, preCore-Core
region in 6 cases.
Neither β-catenin nor TP53 mutations were revealed in any case. In addition, Arg72Pro
TP 53 polymorphism was equally distributed in the different sub-groups evaluated
independently of occult or overt HBV infection and HBV DNA integration. No case had the
Arg249Ser TP53 polymorphism.
Conclusion: HBV DNA integration is a frequent finding in tumour tissues from patients
with OBI as well as overt infection. X and preS/S are the viral genomic regions more often
involved in the integration process. Integrations occur at level of regulatory and functional
genes in most cases. Our findings indicate that viral integration may exert a pathogenic
role in hepatocarcinogenesis in all HBV-infected cases independently of the HBsAg status
as well as of the β-catenin and TP53 genetics. OBI testing may allow the identification of
HBsAg negative patients with higher risk of developing HCC.
Methodology: Frozen tumour specimens from 69 HCC Italian patients were examined
(49 OBI-positive diagnosed by HBV DNA detection in liver tissue, 10 HBsAg-positive, 10
HBsAg-negative/OBI-negative). Tumour DNA extracts were studied by Alu-PCR technique
to reveal HBV DNA integration into the host genome. The molecular characterization of the
virus-genome junctions was performed by cloning and sequencing analyses. Furthermore,
PCR amplification and direct sequencing of exon 3 of β-catenin and of the entire TP53
gene were performed.
Results: Integrated HBV DNA was detected in 37/49 (75.5%) OBI-positive HCC samples,
in 8/10 (80%) tumours from HBsAg-positive patients and in 0/10 OBI-negative HCC
samples. In 64% of OBI cases, HBV integrants were found in intergenic regions of human
genome, while in 36% they were located in intragenic regions, including genes involved in
cell growth and adhesion, angiogenesis and cell signalling.
Aims: Our aim was to investigate and characterize HBV DNA integration and to perform
a genetic analysis of β-catenin and TP53 in tumours from OBI patients with hepatocellular
carcinoma (HCC).
318
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
319
SURVEILLANCE OF HEPATOCELLULAR
CARCINOMA: HOW IT WORKS IN CENTRAL
SLOVAKIA
NOTES
Lubomir Skladany1 2 3 4 , Janka Badinkova 1 2 3 4 ,
Svetlana A. Selcanova 1 2 3 4, Stanislav Okapec 1 2 3 4
1
Hepatology/ Liver Transplantation, 2Oncology, 3Radiology, 4Surgery,
University Hospital, Banska Bystrica, Slovakia
Introduction: One randomized and several observational trials supported hypothesis that
surveillance (S) of hepatocellular carcinoma (HCC) lowers mortality probably via earlier
diagnosis (Dg) and therapy (Th).
Methodology: Setting: Outpatient clinic of Liver Unit, regional university hospital in central
Slovakia. Inclusion process: Step 1 - december 2010: Electronic survey of the database
with key words …liver cirrhosis, chronic hepatitis B“; it gave rise to Group A: pts at HCC
risk, in whom S should have been recommended. Step 2 - Group B (pts with written
reccommended S) has been formed by manual analysis of Group A charts for signs of
S recommendation: yes/no; and S mode: 2a) at least 2 US exams in 6-monthly(mo)
intervals, 2b) at least 2 alpha-fetoprotein (AFP) exams, same intervals. Less than 2a) or
2b) was categorized as non-S. Step 3) Manual scrutiny of Group B charts for new lesions.
Exclusion criteria: Insufficient data/loss to follow-up.
Results: Lenght of follow-up: 39mo (12-120). 1) Group A:445pts; exclusion
criteria=52pts(12%); 2) Group B=393pts. Men:243 (62%), age:65,1years(y)(53-79).
Etiology of liver disease. ALD:153pts (39%), NASH:58 (15%), HBV:81 (21%), HCV:39
(10%), AIH:25 (6%), PSC:13(3%), cryptogenic=10(2,5%), PBC:7 (2%), others 7 (2%).
Surveillance has not been performed despite recommendation in 60pts (15%); in remaining
333pts with S, the mode has been US alone in 3pts (1%), AFP alone in 171 (51%) and
US+AFP in 139 (42%). 3) HCC was diagnosed in 10 of 393pts (2,5%), 7 men, age 56,5y.
HCC diameter - 45 mm (9-120).
Conclusion: This analysis of HCC-surveillance in central Slovakia has shown its very
serious reserves: 1) it is not recommended in 12% of indicated cases; 2) it is not performed
in 15% of recommendations; 3) it does not follow guidelines in vast majority of cases –
especially striking is overuse of allready disquallified (by guidelines) AFP; 4) therefore and
not surprisingly, diameter of lesions on HCC Dg is far from the goal. Action plan has been
conceived and is being realized.
Aims: According to guidelines relevant to study interval, S should have been performed
by semiannual ultrasonography (US). In an analysis of over 100 consecutive patients
(pts) with HCC from this centre only 23% were diagnosed by S. This has led authors to
evaluate the process of S in more detail: 1) in how many of indicated patients has the S
been actually performed; 2) what were the methods of S; 3) what was the outcome.
320
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FEBRUARY 13 - 16, 2014
EASL HCC SUMMIT
321
CARCINOVIC STUDY: CLINICAL COURSE
AND RADIOLOGICAL FEATURES OF
HEPATOCELLULAR CARCINOMA IN HIV/HCV
CO-INFECTED PATIENTS
Moana Gelu-Simeon 1, Maïté Lewin 2, Rodolphe Sobesky 1, Marita Ostos 1,
Elina Teicher 3, Faroudy Boufassa 4, Laurence Meyer 4, Hélène Fontaine 5,
Dominique Salmon-Céron 6, Jean-Claude Trinchet 7, Jean-Charles Duclos-Vallée 1
1
Centre Hépato-Biliaire, 2Radiology, Paul Brousse hospital, Villejuif, 3Infectious disease,
4
Epidemiology INSERM U1018, Bicêtre hospital, Le Kremlin-Bicêtre,
5
Hepatology, 6Infectious disease, Cochin hospital, Paris,
7
Hepatology, Jean Verdier hospital, Bondy, France
Results: To date, 30 HIV/HCV pts (n=27 men (90%), median age = 49 years [43-65])
had radiological confirmation of HCC (Prethevic (n=20), HepaVih (n=10)). At diagnosis,
median CD4 count was 345/mm3 [24-1121] and aFP was 31.7 ng/ml [3.5-18740]. The
clinical course of the liver disease was measured by two variables: the median duration
from cirrhosis to HCC diagnosis, 4.5 years [0-18], and the median duration from first
positive HCV serology to HCC diagnosis, 15 years [6-15]. The radiological diagnosis
showed nodular forms in 24/30 pts (80%) with 1 nodule in 17/24 pts (70.8%), and tumoral
portal thrombosis in 6/30 pts (20%). The median diameter of the main nodule was 25
mm [12-125]. Overall free survival was 65% and 35% at 12 and 60 months respectively.
A combination of curative treatments and a palliative combination in 16/30 pts (53.3%)
and in 9/30 cases (30%), respectively. A palliative treatment was performed in 5/30 pts
(16.7%). 16/30 patients (53.3%) died during a median follow-up of 16.5 months [1-74]). In
11/30 pts (36.7%) the death was due to tumor progression.
Conclusion: In our series we observed (1) a classical radiological presentation in most
cases, (2) a short clinical course in HIV/HCV co-infected pts with HCC.
Introduction: A significant increase in decompensated cirrhosis and occurrence of
hepatocellular carcinoma (HCC) in HIV/HCV co-infected patients (pts) is well established,
partly due to a longer survival life under effective antiviral therapy and faster evolution
of liver disease. To date, the prognosis of HCC in HIV/HCV co-infected pts is globally
poor and there is a lack of radiological data.
Methodology: A new cohort untitled Carcinovic, including HIV/HCV co-infected pts with
HCC have been created from three multicenter cohorts, (i) Prethevic cohort (n=98 pts)
including HIV/HCV pts with end stage liver disease, (ii) HepaVih cohort (n=1225 pts)
studying the evolution of HIV/HCV co-infected pts, (iii) CirVir cohort (n=1823 pts) including
pts with viral cirrhosis. Cases of HCC were prospectively and retrospectively included
since February 2012. The diagnosis of HCC was primarily based on imaging interpretation
of two experimented radiologists to determine typical imaging features (according to
Barcelona criteria). The clinical and radiological data have been collected at radiological
diagnosis and survival has been analyzed. CLINICAL POSTER ABSTRACTS
Aims: To study clinical course and radiological features of HCC in HIV/HCV co-infected
pts from three national prospective cohorts.
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HEPATOCELLULAR CARCINOMA SCREENING
IS INDICATED EVEN AFTER SUSTAINED
VIROLOGICAL RESPONSE: -MOROCCAN
UNIVERSITY HOSPITAL EXPERIENCE-
NOTES
Younès Cherradi, Rajaa Afifi 1, Hanaa Benbrahim 1, Wafaa Essamri 1,
Imane Benelbarhdadi 1, Fatima Zahra Ajana, Omar Hadj El Malki 2,
Mustapha Benazzouz, Abdellah Essaid
1
Department of Hepatogastroenterology Médecine “C”, Ibn Sina Hospital.,
2
Biostatistic, clinical and epidemiological research laboratory,
Mohammed V university- Souissi, Rabat, Morocco
Introduction: In Morocco, Hepatitis C virus (HCV) infection is the first major cause
for hepatocellular carcinoma (HCC). Antiviral treatment limits fibrosis progression and
reduces the risk of developing liver cancer but few cases of HCC in treated HVC-carriers
had been reported.
Aims: The aim of this study is to define predictive factors and highly risk groups for
developing HCC.
Results: Three hundred sixty nine HVC-treated patients were considered from January
2002 to April 2010. Twenty HCC were reported with 12 female (60%) and 8 male (40%).
The mean age was 61 years old [40- 72]. The mean time of HCC occurrence is 5 +/-2
years. Fifty Three percent of patients had genotype 1 HCV, 47% had genotype 2 HCV.
Severe fibrosis was reported in 94.6% at the beginning of treatment. The risk of HCC
was not significant according to gender and genotypes (respectively p= 0.63 and p=0.87).
Advanced age and severe fibrosis were significant risk factors (respectively p=0.003 and
p= 0. 0001). The comparison of sustained virological responders to patients who didn’t
achieve sustained virological response (SVR) shows significant
Results: HCC was reported in 2.6% of the first group vs. 12.5% of non-responders
(p=0.004) which demonstrates that SVR reduces significantly the risk of developing HCC.
Conclusion: In our series, 5% of previously treated patients developed an HCC. Advanced
age and severe fibrosis (F>2) at HCV diagnosis are predictive factors of HCC occurrence. SVR
reduces considerably the risk of HCC occurrence but screening is indicated even after SVR.
Methodology: it’s a retroprospective and analytic study. It concerns all HCV carriers who
developed HCC after antiviral treatment. We compare HCV-treated patients who didn’t
develop HCC to patients with HCC. We used khi-2 and Ficher Exact analysis.
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INTRATUMORAL INJECTION OF S-NITROSO-NACETYLCYSTEINE (SNAC) IN A RODENT MODEL
OF NON-ALCOHOLIC STEATOHEPATITIS (NASH)RELATED HEPATOCELLULAR CARCINOMA (HCC)
Jose Tadeu Stefano 1, Mariana M. Torres, Isabel V. A. Pereira, Bruno Cogliati 2,
Marcelo G. Oliveira 3, Flair J. Carrilho 1, Claudia P. Oliveira 1
1
São Paulo Clínicas Liver Cancer Group, Hospital das Clínicas, Instituto do Câncer
do Estado de São Paulo, University of São Paulo School of Medicine, 2Department of
Pathology, School of Veterinary Medicine and Animal Science, University of São Paulo,
São Paulo, 3Institute of Chemistry, University of Campinas (UNICAMP),
Campinas, SP, Brazil
Results: Residual HCC and hepatocholangiocarcinoma were observed in all samples of
animal treated with saline solution and none necrosis focus were observed in this group.
Residual HCC and hepatocholangiocarcinoma with necrosis were evident in 66.6% (2 of
3 animals) of ethanol group and similarly in the SNAC group 66.6% (4 of 6 animals) with
residual HCC and hepatocholangiocarcinoma. The difference between SNAC and alcohol
was that alcohol caused more complete necrosis. Conclusion: This model replicates the major stages of NASH including cirrhosis and HCC
and could be used in novel therapeutic approaches. Besides, these results suggest that
the SNAC offers a new form of anti-HCC therapy.
Background: We developed a rat model that reproduces NASH with cirrhosis and HCC
and evaluated the effectiveness of SNAC intratumoral injection in this animal model in
comparison with alcohol and saline solution.
Methodology: Adult Sprague-Dawley rats, weighing 250-300g, were fed a cholinedeficient high fat diet (35% total fat, 54% trans fatty acid enriched) and simultaneously
exposed to diethylnitrosamine (13-15 mg/day) in drinking water during 16 weeks to induce
NASH, cirrhosis and HCC. B-mode and Doppler ultrasonography was performed weekly
in these experimental rats. Based in our previous studies, the animals with NASH that
developed focal liver lesions with suggestive malignancy were underwent elastography
and contrast-enhanced ultrasonography. Tissue stiffness of the nodules on elastography
were classified in negative (elastic strain) or positive (hard and no strain) comparing with
surrounding liver parenchyma. Contrasted study classified focal lesions according to type
of enhancement and wash out. After imaging diagnostic of HCC the animals were treated
with one of 0.1 ml of intratumoral injection of ethanol (n=3), saline solution (n=3) and
SNAC (n=6; 2500µM). After 72 hours of the experiment, autopsies were done to collect
liver samples for morphological and histological examination. CLINICAL POSTER ABSTRACTS
Introduction: Hepatocellular carcinoma (HCC) is a well-recognized complication
of advanced Nonalcoholic steatohepatitis (NASH). Previous studies by our group
demonstrated in vitro that S-nitroso-N-acetylcysteine (SNAC), an NO donor, has an
antiproliferative effect. However, the in vivo effect of SNAC over NASH-related HCC has
not been addressed.
SPLENOSIS MIMICKING HEPATIC TUMOR:
A CASE REPORT
SURGERY IN LIVER HAEMANGIOMA
Giovanni Battista Levi Sandri, Quirino Lai , Fabio Melandro , Nicola Guglielmo ,
Marco Di Laudo 1, Manuela Garofalo, Pasquale B. Berloco 1
1
Surgery, La Sapienza, Roma, Italy
1
1
1
Introduction: Hepatocellular carcinoma (HCC) is the most common type of liver cancer.
Most cases of HCC are secondary to either a viral hepatitis infection (hepatitis B or C)
or cirrhosis. Splenosis is a heterotopic implantation of splenic fragments into exposed
vascularised peritoneal and intrathoracic surfaces, following splenic injury or elective
splenectomy.
Aims: We present a case of a 54-years-old Caucasian man coming to our unit for HCC in
patient with HBV cirrhosis.
Methodology: Patient history began four month earlier when a accidental Hepatitis B
diagnosis was made. After a first echography a computer tomography was performed
in other institute. Report of CT-scan confirm a HCC presence at segment III (picture 1).
A hepatic wedge resection was performed and patient was discharged at day seven.
Histopathology showed a 4,5x3,5x1,5cm mass brownish with whitish dots. Microscopy
study revealed a capsulated spleen with no evidence of neoplasia (picture 2 and 3).
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Results: Autotransplant of splenic tissue may occur anywhere in the body, but is most
commonly observed in the peritoneal cavity. Splenosis is easily misinterpreted as a tumor
condition, many case in pancreas are described. There are few previous reports of hepatic
splenosis mimicking hepatocellular carcinoma. Treatment usually requires surgery and
confirmation by pathology.
Conclusion: A missed diagnosis of hepatic splenosis can have a significant negative
impact on cirrhotic patient’s. In case of patient in waiting list for liver transplantation an
accurate attention should be done in patient with history of accidental splenectomy.
327
Giovanni Battista Levi Sandri, Quirino Lai 1, Fabio Melandro 1,
Nicola Guglielmo 1, Marco Di Laudo 1, Pasquale B. Berloco 1
1
Surgery, La Sapienza, Roma, Italy
Introduction: Liver haemangioma (LH) are the most common benign liver tumors. LH do
not require surgery except if they cause important symptoms: commonly, pain caused by
the size of the tumor is the first symptom described.
Aims: The purpose of this study is to analyze analyze a cohort of 32 patients with the intent
to underline the role of surgery for giant haemangioma. We evaluated the LH presentation,
surgical indications, laboratory biomarkers and surgical outcome.
Methodology: We retrospectively analyze all patients who underwent to a surgical
removal of LH from January 2001 to December 2010 in Rome “La Sapienza” center.
Results: Median age was 45 years-old [21-80], 7 men and 25 women. All patient had
normal laboratory values (bilirubin, Alanine aminotranferease, aspartate aminotransferase
and alpha fetoprotein). Median hospital stay was 6.6 day. Morbidity was represented by
one incisional hernia, no death was observed after surgery.
Conclusion: Surgery for benign pathologies, such as haemangioma, is not contraindicated,
mainly if it is symptomatic. Liver resection could be complicated, morbidity and mortality
are still present in this surgery. Only if a significant increase of volume in a symptomatic
case, surgery could be recommended to the patient.
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MANAGEMENT OF INTERMEDIATE
STAGE OF HCC: A COMPARISON BETWEEN
CONVENTIONAL AND DRUG-ELUTING
BEADS TACE
Igino Rigato 1 2 3, Riccardo Patti 4, Manuela Pastoricchio 2, Flora Masutti 1 2 3,
Devis Pascut 1, Valentina Lanzilotti 2, Fabio Pozzi 2 5, Cristiana Abazia 1 2,
Claudio Tiribelli 1 2 3, Lory S. Croce’ 1 2 3
1
FIF (italian liver foundation), 2medical science department, University of Trieste,
3
Centro clinico Studi Fegato AOUTS, 4medical science department, FIF
(italian liver foundation), 5Radiologia AOUTS, Trieste, Italy
Introduction: According to the EASL-EORTC Clinical Practice Guidelines (J Hepatol 2012
56:908-43), patients affected by Hepatocellular Carcinoma (HCC) at intermediate stage
(multinodular asymptomatic tumors without an invasive pattern), are eligible for treatment
with Trans Arterial Chemio Embolization (TACE)
In the DEB TACE group no severe side effects were observed: 1) pain never exceeded
7 according to the Numeric Rating Scale (NRS), and successfully treated with minor
analgesic drugs; 2) nausea and vomiting was observed in only 6 patients. Conversely in
the Conventional TACE group, pain was observed in all the patients, always with a value
over 5 NRS and responsive only to major analgesic drugs (oppioids); nausea and vomiting
was also recorded in all patients. Of notice average hospitalization was 2 days in the DEB
TACE group and 12 days in the Conventionl TACE
Conclusion: We did not observe significant difference between the two techniques of
treatment regarding the response to treatment or the survival rate. The great difference
was found in the days of hospitalization and frequency and severity of side effects. We
conclude that in patients where the main indication for treatment is the palliation of the
disease, the choice of a treatment that reduces the stress of the patients (less side effects
and few days in the hospital) must be preferred.
Methodology: 73 patients affected by HCC were treated with DEB-TACE and compared
with an historic cohort of 59 patients treated with conventional TACE. In both groups,
doxorubicin was used in association with the embolization particles. Patients were
stratified according to Child-Pugh, CLIP and BCLC. The response to treatment was
evaluated by CT scan at 3 months after treatment. Overall survival, side effects and days
of hospitalization were considered.
Results: Overall survival rate in both groups was comparable when the patients were
stratified by either BCLC stage (median±ES: BCLC stage A 33±7 months (m) vs 33±5m
and 27±5 vs 21±2m in stage B), Child Pugh (CP) class (CP A: 31±3m vs 31±4 m; CP B:
28±8m vs 23±4 m) or CLIP classification (CLIP 0 38±7m vs 39±8m) for DEB TACE; CLIP
1 26±4m vs 28±3m; CLIP 2, 21± 4 vs 23±6m). Response rate of treated lesions was
comparable in both groups as previously reported (Varela J hep 2007; Poon Clin gast hep
2007).
Aims: The aim of this study is to compare the outcome of conventional TACE (using
gelfoam-lipiodol particles) with drug-eluting beads (DEB) TACE in particular to evaluate
side effects and clinical outcome
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STRATEGY TREATMENT OF SURGICAL
RESECTION INCREASES THE SURVIVAL RATE
OF SELECTED HEPATOCELLULAR CARCINOMA
PATIENTS IN BARCELONA CLINIC LIVER
CANCER STAGE C
NAFLD-ASSOCIATED HEPATOCELLULAR
CARCINOMA IN CIRRHOTIC AND NONCIRRHOTIC PATIENTS IN BRAZIL
Chih-Wen Lin
Introduction: Sorafenib is the only approved agent recommended by the American
Association Study of Liver Disease guidelines for hepatocellular carcinoma (HCC) patients
in Barcelona Clinic Liver Cancer (BCLC) stage C.
Aims: This study aims to evaluate and compare overall survival in HCC patients in BCLC
stage C treated with different therapies or supportive care alone.
Methodology: We retrospectively reviewed the medical records of 358 newly diagnosed
hepatocellular carcinoma patients between 2005 and 2012 in BCLC stage C and ChildPugh class A were analyzed and compared at E-DA hospital, Taiwan.
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Results: Six-six patients were treated with supportive care alone and 292 were treated
with surgical resection (52/292, 17.9%), local ablation treatment (5/292, 1.8%), transarterial
embolization (137/292, 46.9%), systemic chemotherapy or radiotherapy (86/292,
29.5%), and sorafenib (12/292, 4.1%). Median survival was 12 months (95% confidence
interval, 8.6-14.3) in treated patients compared with 4.2 months in the supportive care
group (hazard ratio, 0.52; 95% confidence interval, 0.36-0.62; p<0.001). Patients who
underwent surgical resection had the better survival rate compared to patients undergoing
other treatments (39.6 months versus 7.9 months, p<0.0001). The 5-year survival rate
after surgical resection was 37.4%. Furthermore, a combination of aggressive surgical
treatment and effective preoperative transarterial embolization treatment in HCC patients
in BCLC stage C and Child-Pugh class A.
Conclusion: Strategy treatment of surgical resection causes excellent results in HCC
patients in BCLC stage C and Child-Pugh class A. Although sorafenib is currently
recommended, oncologists and hepatologists should select optimal candidates for surgical
resection to get better survival.
331
Luciana Kikuchi 1, Claudia P. Oliveira 1, Claudia M. Tani 1,
Mario R. Alvares-Da-Silva 2, Jose Tadeu Stefano 1, Gabriela Belitzki 2,
Marcio Augusto Diniz 1, Aline L. Chagas 1, Regiane S. D. S. M. Alencar 1,
Denise C. P. Vezozzo 1, Gilmar R. Santos 1, Venancio A. F. Alves 1, Flair J. Carrilho 1
1
São Paulo Clínicas Liver Cancer Group, Hospital das Clínicas, Instituto do Câncer do
Estado de São Paulo, University of São Paulo School of Medicine, 2Gastroenterology,
School of Medicine, Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de
Porto Alegre, São Paulo, Brazil
Aims: This study was designed to assess the clinocopathological features and the survival
of non-alcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC)
in a Brazilian population.
Methodology: From January 2010, 44 patients with HCC related to NAFLD from the FLIP
consortium were retrieved retrospectively from 2 centres in Brazil. Unless features of the
metabolic syndrome were present, or NAFLD was evident from histology or ultrasound,
cases were regarded as cryptogenic. Diagnosis of HCC was confirmed by histology in 19
patients and 25 patients presented typical imaging patterns according to AASLD/EASL
guidelines. BCLC guideline was followed to conduct HCC therapy. Overall survival rate
was calculated from the date of HCC diagnosis to date of death.
Results: Thirty-two (73%) NAFLD-related cases and 12 (27%) cryptogenic cases were
collected over 24 months. Population consisted of 17 women and 27 men with a mean age
of 65 years. Most (81%) patients had been diagnosed with obesity, diabetes, hypertension,
or dyslipidemia. Five patients (11%) had a non-cirrhotic liver. HCC was detected by
surveillance in 56%. In 19 patients whose HCC diagnosis was made by histology, most
were classified as well-deferentiated HCC. Most patients (70%) had a single nodule with
a median size of 50 mm. At diagnosis, most patients were classified as BCLC A (43%).
Regarding HCC therapy, TACE was employed as initial therapy in 11 patients, resection
and percutaneous ethanol injection in 4 patients (each), and radiofrequency ablation in
1. Seven patients were submitted to orthotopic liver transplant and four patients received
sorafenib. Among non-cirrhotic patients, tumor size varied from 15 to 109 mm, but all were
eligible for curative therapy (4 resection and 1 percutaneous ethanol injection). The 1 and
2-year overall survival rates 81 and 66%, respectively.
Conclusion: NAFLD is an important predisposing condition for HCC in the absence
of other liver diseases. NAFLD-associated HCC occurs frequently with cirrhosis in our
cohort. In this setting, most HCC cases were detected in a regular screening program
and had early tumor. In non-cirrhotic NAFLD patients, treatment schedule can be more
aggressive as liver function is not deteriorated.
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CHALLENGES FACING BCLC THERAPEUTIC
ALGORITHM IN TREATMENT OF 1437 EGYPTIAN
Ahmed El Dorry 1, Amr El Fouly 2, Ashraf El Breedy, Neveen Elfoly 3,
Mohamed Salah 4, Mohamed S. Hassan 1, Mahmoud El Metenei 5, Mohamed K. Shaker 4
and Hepatoma Group - Ain Shams University Hospitals - Egypt
1
Intervention Radiology, Ain Shams University, 2Hepatology, 3Tropical Medicine, Egyptian
Atomic Energy Authority, 4Tropical Medicine, 5Liver Transplant Surgery, Ain Shams
University, Cairo, Egypt
Introduction: Hepatitis C virus (HCV) is the main cause of liver cirrhosis in 15-18% of
Egyptian population. The expected annual incidence of Hepatocellular Carcinoma (HCC)
is approximately 12000 new cases. A statistical model predicts to reach the peak of HCC
related mortality by year 2040. HCC is ranked the 2nd common malignancy in males.
Challenges facing treatment of HCC in Egypt are ignorance, poverty, lake of uniform
standard health insurance, shortage of equipments, cadaveric transplantation and
surgical theaters that could cover demands all over the country; all these factors led to;
Liver resection in 15%, Living Donor liver transplantation in 14%, and Sorafenib in 9%
among each indicated HCC population. Meanwhile locoregional therapies cover 92.5%
of indicated heat ablation, and 81% of the indicated TACE. Locoregional therapy could
replace 76% of the indicated patients for either resection or transplantation, but treatment
of BCLC-C is still challenging.
Conclusion: For socio-economic reasons, treatment of HCC is still challenging and
defective in respect to BCLC therapeutic algorithm among Egyptians, but fortunately
single or combined locoregional therapy could compensate the shortage especially in
surgical options.
Methodology: 1437 Egyptian HCC patients diagnosed during between 2009 & 2012
classified with different staging systems especially Performance status, Child-Pugh
classification, BCLC staging looking for the proper decision making fitting each single
case.
Results: HCV infection is considered the main etiology of liver cirrhosis in Egypt 93%
(1232/1325). HBsAg is positive in 13.7% (103/751). Males have 6 folds higher risk of HCC
than females. The prevalence of HCC is more common during the 6th & 8th decades 77.4%.
Half of patients (51%) have good Child A liver cirrhosis at time of diagnosis, while Child
B & C are 37% and 12% respectively. Decision making in respect to BCLC therapeutic
algorithm are; BCLC Stage (A=24%), (B=21%), (C=41%), and (D=14%). Thus, BCLC-A1
“Resection” is indicated in 4.7%(67), BCLC-A2 = “Local ablation” in 4.1%(59), BCLC-A3
& A4= “Orthotropic liver transplantation” in 15%(209), BCLC-B = “TACE” in 20.3%(290),
BCLC-C = “Sorafenib” in 40%(568) and finally BCLC-D = “Best supportive care” in
13%(187).
Aims: Our aim is to clarify at time of diagnosis, the indicated number of patients in each
Barcelona Clinic of Liver Cancer (BCLC) stage, meanwhile to focus on actual decisions
to highlight and realize the requirements and shortage in management of HCC in Egypt.
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NEUTROPHIL-TO-LYMPHOCYTE RATIO:
A GOOD PREDICTOR OF DROP OUT IN
HEPATOCELLULAR CANCER PATIENTS WAITING
FOR LIVER TRANSPLANTATION
Quirino Lai, Edward Castro Santa, Juan M. Rico Juri, Rafael S. Pinheiro, Jan Lerut
Conclusion: NLR is a good predictor of drop-out risk but not of post-LT recurrence. AFP
slope is superior to NLR in relation to selecting both waiting list and transplanted patients.
Larger studies looking at the role of NLR as a selection tool of LT recipients are warranted.
Introduction: During the last years there has been increasing evidence that systemic
inflammation in patients with hepatocellular cancer (HCC) is related to poorer survival.
Elevated neutrophil-to-lymphocyte ratio (NLR) has been shown to have a high efficacy in
predicting outcome of these patients.
Aims: The aim of this study is to evaluate the role of NLR as a selection tool in HCC
patients waiting for liver transplantation (LT) and to look at its potential to predict drop-out
on the waiting list and post-LT recurrence.
Results: At c-statistics, the last NLR determination was the best prognostic test of dropout with an AUROC curve of 67.2 (p-value: 0.05). Alpha-foeto-protein (AFP) slope was
the best prognostic test of post-LT recurrence (AUROC: 67.1; p-value: 0.05). The last
NLR had a poor ability to predict post-LT recurrence. At multivariable Cox regression
analysis, AFP slope > 15 ng/mL/month (HR 2.4; p-value: 0.003) and last NLR > 5.4 (HR:
1.8; p-value: 0.03) were the unique risk factors for drop-out. NLR was not a predictor of
post-LT recurrence.
The last NLR > 5.4 allowed to stratify well the patients in relation to intention-to-treat (ITT)
survival analysis. Patients exceeding the mentioned cut-off value had a 5-year survival
of 48.2% vs. 64.5% in patients not meeting this threshold limit (p 0.02). NLR had a poor
ability in stratifying the patients in relation to tumor-free survival (TFS) (p 0.4). AFP slope
allowed to stratify the population both in ITT and TFS analyses (Fig. 1).
Methodology: During the period January 1995–March 2012, 181 patients with a preoperatively proven diagnosis of HCC entered the waiting list for LT. Thirty-five (19.3%)
patients dropped out from the list during and 146 (80.7%) patients were transplanted. As
of October 31, 2012, the median follow-up from moment of WL registration for the entire
population was 4.2 years (interquartile ranges [IQR]: 1.8-8.3).
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EFFECT OF LEPTIN ADMINISTRATION
ON ETHANOL INDUCED APOPTOSIS
AND FIBROGENESIS IN THE MOUSE
Balasubramaniyan Vairappan 1, Murugaiyan Gopal 2,
Ramachandra R. Bhonde 2, Nalini Namasivayam 1
1
Biochemistry and Biotechnology, Annamalai University, Chidambaram,
2
Biotechnology, National Center for Cell Science, Pune, India
Introduction: Obesity is associated with hepatocellular carcinoma (HCC). Leptin, an
anti-obesity hormone exerts potent modulatory properties both in vivo and in vitro.
Aims: We have previously shown that reduction of hepatotoxicity with leptin in vivo. The
aim of this study was to evaluate the effect of leptin on ethanol induced fibrogenesis and
apoptosis in mouse hepatocellular carcinoma (HCC) cell lines.
In addition, ethanol significantly increased the reactive oxygen species (ROS) and the
expressions of mRNA of caspase-3 (2 fold), procollagen type I (about 24 fold), MMP
2 (3.8 fold), MMP 9 (2.5 fold) and TIMP-1 (1.3 fold) as compared to untreated control
mouse HCC cell lines. Leptin coadministration significantly down regulated the mRNA
expressions of caspase-3 (3 fold), procollagen type I (3 fold), MMP 2 (2 fold), MMP 9
(4.5 fold) and TIMP-1 (10 fold) as compared to that of ethanol alone treated mouse HCC
cell lines.
Conclusion: Thus, our experimental data provide evidence above the potential
protective effect of leptin on ethanol elicited damage in the mouse HCC cell lines,
warranting population based and mechanistic studies.
Results: Ethanol exposure significantly reduced the cell viability as evidenced by 3-(4,5
dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide (MTT) (P<0.05) and trypan blue
dye exclusion method (TBE) (P<0.05). Moreover, ethanol treated cells significantly
lowered thymidine incorporation (P<0.05) and increased DNA fragmentation. Ethanol
incubations also significantly increased the % of apoptotic cells (P<0.05). These results
were compared with that of untreated control cell lines. Leptin cotreatment with ethanol
showed significantly raised (P<0.05) cell viability, DNA synthesis and significantly
(P<0.05) decreased apoptotic cells and DNA ladder formation.
Methodology: In vitro, 48 h after treatment with or without leptin (31.2nM), ethanol (500
mM) and leptin+ethanol to mouse HCC cell lines. Results were statistically evaluated
using one way analysis of variance (ANOVA) followed by Duncan_s Multiple Range Test
(DMRT).
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339
Jean-Pierre Bronowicki 1, Philippe Mathurin 2, Fatima Serejo 3,
Per I. Stal 4, Juan T. Vazquez 5, Vlad Ratziu 6, György M. Bodoky 7, Adina E. Croitoru 8,
Bruno Daniele 9, Marc Fellous 10, Christos Papandreou 11
1
INSERM Unité 954, Centre Hospitalier Universitaire de Nancy, Université Henri
Poincaré–Nancy, Vandoeuvre-lès-Nancy, 2Services des Maladies de l’Appareil
Digestif, Hôpital Claude Huriez, Lille, France, 3Center of Gastroenterology, Liver
Unit, Hospital de Santa Maria, Faculty of Medicine, Lisbon, Portugal, 4Department of
Gastroenterology and Hepatology, Karolinska University Hospital, and Department of
Medicine – Huddinge, Karolinska Institutet, Stockholm, Sweden, 5Gastroenterology
Department, Hospital de Montecelo, Complejo Hospitalario de Pontevedra, Pontevedra,
Spain, 6Université Pierre et Marie Curie and Hospital Pitié Salpêtrière, Paris, France,
7
Department of Oncology, St László Teaching Hospital, Budapest, Hungary, 8FUNDENI
Clinical Institute, Bucharest, Romania, 9Department of Medical Oncology, G. Rummo
Hospital, Benevento, Italy, 10Bayer HealthCare Pharmaceuticals, Basel, Switzerland,
11
Department of Medical Oncology, University Hospital of Larissa, Larissa, Greece
Aims: GIDEON is a prospective, non-interventional study, completion of which provides
a global database of >3200 Sor-treated unresectable HCC (uHCC) pts, allowing for
evaluation of a pt population with broad baseline characteristics, including Child-Pugh
(CP) B pts with more advanced liver dysfunction. The results for the European pt subset
are presented.
Methodology: Data were collected in pts for whom a decision to treat with Sor had been
made in clinical practice. Adverse events (AEs), dosing, and outcomes data were collected
during follow-up.
Results: 1113 pts in European countries were evaluable for safety. Overall, the incidence
of AEs and drug-related (DR) AEs was similar across CP subgroups, although serious AEs
(SAEs) were more common in CP-B than CP-A pts. The rate of DRAEs (event per patientyear) was comparable for CP-A and CP-B pts. The average daily Sor dose was similar;
duration of treatment was longer in CP-A (Table). In the intent-to-treat population (n=1115),
median overall survival (OS) (months [95% CI]) was longer in CP-A (15.0[13.3-17.1]) than
CP-B pts (4.9[4.0-6.2]).Median OS was shorter in pts with a higher CP-B score: 7 (6.1[4.010.0]); 8 (8.4 [3.1-9.0]); 9 (3.1 [2.2-4.3]).
Conclusion: Sor safety and dosing during treatment seem to be consistent across pts
irrespective of liver function. Pts with CP-B disease may have a higher rate of serious
AEs. As anticipated, CP status is a strong prognostic factor for OS in uHCC pts.
FINAL ANALYSIS OF EUROPEAN SUBSET
OF GIDEON (GLOBAL INVESTIGATION OF
THERAPEUTIC DECISIONS IN HEPATOCELLULAR
CARCINOMA AND OF ITS TREATMENT WITH
SORAFENIB [SOR]) IN SOR-TREATED PATIENTS
(PTS): CLINICAL FINDINGS IN PTS WITH LIVER
DYSFUNCTION
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
THE LEADING LIVER ASSOCIATION IN EUROPE
APPLY FOR AN EASL
FELLOWSHIP PROGRAMME!
INDEX
Post-Doc Research Fellowships
• Entry-Level Research Fellowships
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investigators within different European institutions, actively promote scientific exchange
among research units in Hepatology, and enable physician scientists to take leave from
clinical duties to spend 6-12 months in a research laboratory.
EASL EDUCATIONAL ACTIVITY
• No restrictions on applicant’s nationality
• Leading European hosting institutions
arded
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For application conditions, deadlines and details visit www.easl.eu
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[email protected]
www.easl.eu
EASL HCC SUMMIT
341
A
Abazia, C.
328
Abdel-Aal, I.A.
216
Abdelaziz, A.
116
Abd El Dayem, W.
219
Abdel-Khalek, E.
216
AbdElMoez, A.T.
200
Abdurakhmanov, D.T.
282
Abramovitch, R.
70
Abrantes, A.M. 108, 306, 307, 308, 310
Achahboun, M.
236
Adams, D.
62
Aerts, R.
54
Afifi, R.
322
Agarwal, K.
277
Agnes, S.
302
Ahmed, G.
98
Ailles, L.
158
Airoldi, A.
214
Ait Younes, S.
296
Akbar, S.F.
199
Akdeniz, H.
297
Al-Akel, W.
274
Albuquerque, M.
236
Alencar, S.D.S.M.
331
Ali Arous, N.
296
Allgayer, H.
118
Almeida, S.
244, 258, 259
Alsaadany, S.
280
Al-Talkawy, M.
198
Aluvihare, V.
277
Alvares-Da-Silva, M.R.
331
Alves, V.A.F.
331
Amer, A.
274
Amer, W.
216, 274
Amin, A.
127
Andersen, J.B.
52, 121
Andreone, P.
147, 234
Angel, P.
56
Annicchiarico, B.E.
302
Antoniou, E.
278
Antrobus, R.
48
Arif, U.
275
Arma, D.
124
Arnsperger, T.
120
Arreguin Camacho, L.O.
52
Arroyo Jr., P.C.
260, 262, 264, 266
Arroyo Júnior, P.C.
260
Arun, M.
155
Asad, M.
275
Ascione, T.
220
Ashizawa, K.
313
Asim, M.
102
Askar, M.S.
216
Assela, h.
296
Asselah, F.
296
Ataide, E.C.
258, 259
Attili, A.F.
222, 238, 242, 250, 256
Augustin, H.
120
Avolio, A.W.
302
Awad, A.
290
Azoulay, D.
212
Azzariti, A.
159
B
Babameto, A.
Bachelot, L.
Badinkova, J.
Bakiri, L.
Balabaud, C.
Balakrishnan, A.
Balamuralikrishnan, B.
Banks, P.
Barabino, M.
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
255
76
318
82
124
96
155
60
212
Barakat, E.M.F.
Barbaro, F.
Barbera, A.
Bargellini, I.
Barni, S.
Bartenschlager, R.
Bartolozzi, C.
Ba-Ssalamah, A.
Bassanelli, C.
Bauer, A.
Bavetta, M.G.
Beck, M.
Bedossa, P.
Belghiti, J.
Belitzki, G.
Belli, A.
Belli, L.S.
Ben Ali, Z.
Benazzouz, M.
Benbrahim, H.
Bendaoud, M.
Benedetti, A.
Benelbarhdadi, I.
Ben Nejma, H.
Ben Temime, H.
Berkane, S.
Berloco, P.
Bernardi, M.
Berriel Diaz, M.
Bertoletti, A.
Bertolo, E.M.G.
Bertuccio, A.
Bhadoria, A.S.
Bharali, D.
Bhonde, R.R.
Bihery, A.
Bioulac-Sage, P.
200
302
316
249
222
122
249
175
238, 242, 250, 272
142
240
106
236
236
331
212
214
227
322
322
296
222, 256
322
268, 276
227
296
326, 327
147, 234
90, 122
64
264
316
170
104
336
219
124
343
Biselli, M.
234
Blaas, L.
150
Boaretto, M.
201, 288
Bock, C.
144
Bodoky, G.M.
196, 338
Bogaerts, E.
91, 92, 107
Boin, I.
258, 259
Boissan, M.
146
Boldanova, T.
110
Boldrini, B.
147
Bolondi, L.
112, 113
Bonino, F.
64
Borghi, A.
112
Borque, M.J.
131, 132
Borthakur, B.B.
148
Bose, S.
148
Botelho, M.F.
108, 306, 307, 308, 310
Boufassa, F.
320
Bourdeaux, C.
226
Bourgain, F.
146
Bouzaidi, S.
227
Bresci, G.
248, 249
Breuhahn, K.
52, 81
Brigelius-Flohe, R.
142
Brito, A.F.
108, 306, 307, 308, 310
Bronowicki, J-P.
196, 338
Brooks, J
57
Bruix, J.
86
Brunetto, M.
64
Bruno, B.
212
Bruns, T.
62
Buccoliero, F.
46
Budhu, A.
72, 164
Buonaguro, F.M.
156
Buonaguro, L.
156
Burra, P.
210
Bütepage, M.
114
INDEX
INDEX
342
INDEX
Buurman, R.
C
Cabibbo, G.
Calabria, G.
Callegari, E.
Calvaruso, V.
Cammà, C.
Campanale, M.C.
Cannito, S.
Caparello, C.
Capobianco, C.
Caracciolo, G.
Carbonetti, F.
Cardoso, A.R.
Carmeliet, P.
Carpani, D.
Carrilho, F.J.
Caruy, C.A.A.
Carvalho, M.J.
Casanova, E.
Castera, L
Castro Santa, E.
Castro-Sousa, F.
Cavallone, D.
Celebi, A.
Celton-Morizur, S.
Cesario, V.
Ceulemans, A.
Chagas, A.L.
Chahed, M.K.
Chan, L.
Charef Amir, Z.
Chen, C-H.
Chen, K.
Chennuri, R.
Chen, W.
114
208, 240
220
113
240
208
302
314
248, 249
312
302
202
258, 259
92
222, 256
324, 331
258, 259
108
150
236
334
306, 307, 308, 310
64
237
44
302
54
331
227
64
296
253
158
138
174
Cheraitia, S.
Cherqui, D.
Cherradi, Y.
Chetwood, J.
Chevet, E.
Chiba, M.
Chikhi, Y.
Chinbold, E.
Chinburen, J
Choi, K.
Chouteau, P.
Christophe, M.
Ciasullo, L.
Ciccorossi, p.
Ciesco, C.D.
Cillo, C.
Cillo, U.
Claudel, T.
Coccoli, P.
Cogliati, B.
Colnot, S.
Colombo, M.
Comhaire, A.
Conte, E.
Conti, F.
Corea, V.R.
Costa, M.
Couton, D.
Cox, M.
Craxì, A.
Criotoru, A.E.
Croce, L.S.
Croitoru, A.E.
Crossey, M.
Cuong, B.K.
Curbishley, S.M.
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
296
212
322
228
124
126
296
182
182
138
152
145
201, 288
64
272
110
210, 256
150
293
324
76, 80, 145, 149
172, 208, 311
92
240
234
264
212
44
196
208, 240
196
328
338
228
144
62
D
Dabbeche, R.
227
Dabbous, H.
294
Dahl, E.K.
299
Dall’Agata, M.
234
D’Angelo, M.
234
D’Angelo, S.
222, 256
Daniele, B.
196, 222, 338
Dannhauser, D.
201, 288
da Silva Castro Andrade, J.G.
266
da Silva, R.C.M.A
262, 264
da Silva, R.C.M.A.
260, 266
Da Silva, R.F.
260, 262, 264, 266
D’Aversa, F.
302
de Felício, H.C.C.
260, 262, 264, 266
De Gaetano, A.M.
302
Deka, M.
148
Deladetsima, J.
278
Deli, I.
202
Della Corte, C.
311
Della-Guardia, B.
244
Delle Fave, G.
202
Dello Sbarba, P.
314
Del Poggio, P.
234
Delucinge-Vivier, C.
226
Denechaud, P-D.
49
Deng, W.
154
de Oliveira, A.R.
264
de Oliveira, C.M.
262
De Ponti, A.M.
56
De Santis, A.
238, 242, 250, 272
Desdouets, C.
44
De Stefano, G.
220
De Vito, C.
226
Dhanasekaran, R.
140
Dhar, D.
59
Di Ciesco, C.A.
238, 242, 250
EASL HCC SUMMIT
Dick, J.E.
Di Donato, R.
Di Laudo, M.
Di Maira, G.
Di Marco, V.
Di Martino, A.
Di Martino, M.
Diniz, M.A.
Di Rienzo, T.A.
do Amaral, J.P.C.
Dona, A.
Dooley, S.
Düber, C.
Duca, W.J.
Duclos-Vallée, J-C.
Dzieran, J.
E
Ebinç, S.
Eferl, R.
Eheim, A.
Eiteneuer, E.
Elabd, N.E.
El Breedy, A.
El-deek, B.
El-Desoky, A-E.E-
El Dorry, A.
El Dorry, A.K.
Elfoly, N.
El Fouly, A.
Elfouly, N.F.
El-Gamal, S.
El-Garem, H.
El Garieb, M.
El-Ghandour, A.M.
Elisabetta, C.
El Jeri, K.
345
158
180
326, 327
314
208, 240
208
272
331
302
262
228
118
246
260, 262, 264, 266
320
118
297
142, 150
90
106
136
332
304
216
270, 332
200
332
270, 332
200
216
274
270
292
46
227
INDEX
344
El Kaddi, E.
Ella, E.
Elleuch, N.
El Malki, O.H.
El Meteini, M.
El Metenei, M.
El-Mokadem, T.
El-Shamy, M.
El Tayebi, H.
Emara, M.
Empsen, C.
Ennaifer, R.
Enooku, K.
Esmat, E.
Essaid, A.
Essamri, W.
Esterbauer, H.
Eyigün, C.P.
270
70
268, 276
322
294
270, 332
219
219
116
219
54
268, 276
230
116
322
322
150
284, 286
F
Factor, V.M.
Fadin, M.
Fajas, L.
Farag, R.E-S.
Farella, N.
Farinati, F.
Farzhenah, F.
Fathy, T.
Fatourou, E.
Fawzy, A.
Felekouras, E.
Felga, G.
Fellous, M.
Feng, T.
Fernandes, F.L.C.
Fernandes, I.M.M
Ferracin, M.
52, 121
210
49
304
220
210, 234
64
219
277, 278
136
278
244
338
118
260
260
112
Ferrarese, A.
210
Ferreira, G.D.
264
Ferreira, R.F.
266
Finkelmeier, F.
206
Fisher, C.P
138, 266, 294
Fleischmann-Mundt, B.
57
Florimond, A.
152
Fognani, E.
147
Fontaine, H.
320
Font Burjada, J.
59
Forgues, M.
72
Forlino, M.
238, 242, 250, 272
Fornari, F.
112, 113
Fornaro, L.
248
Forner, A.
180
Forzenigo, L.V.
311
Foschi, A.
214
Foschi, F.G.
112
Francelin, P.R.
264
Frigerio, M.
234
Fromenty, B.
44
Frustaci, S.
222, 256
Fullard, N.
60
Fye, H.
228
G
Galassi, M.
Galbiatti, A.L.S.
Galle, P.R.
Galli, A.
Gallina, S.
Gallusi, G.
Galun, E.
Garcia-Buey, L.
Garcovich, M.
Garofalo, M.
Garside, D.
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
113
264
52, 130, 246
46
202
238, 242, 250, 272
70
131, 132
300, 302
326
228
Gasbarrini, A.
Gasbarrini, G.
Gaudin, A.
Gavasso, S.
Gazzola, A.
Geerts, A.
Gehring, A.
Gehrke, N.
Gelu-Simeon, M.
Gentric, G.
Germani, G.
Germano, D.
Gerwins, P.
Ghanekar, A.
Ghazy, M.S.
Giannelli, G.
Giannin, E.G.
Giannitrapani, L.
Gigante, E.
Gigante, G.
Gillen, M.C.
Gillet, M.
Gilmour, K.
Ginanni, B.
Giorgio, A.
Giovanis, P.
Giuliante, F.
Giusto, M.
Gluud, L-L.
Godard, C.
Goga, A.
Goldenberg, D.
Golfieri, R.
Gomez-Quirez, L.
Gonçalves, A.C.
Gonzalez, E.
Gopal, M.
256, 300, 302
302
152
210
180
92, 107
64
130
320
44
210
256
91
158
270
159
234
222
202
302
121
182
64
248
220
201, 288
302
201, 288
299
76, 80, 145, 149
96
70
192
52
307, 308, 310
149
336
Gores, G.
Gougelet, A.
Govaere, O.
Gragnani, L.
Gramantieri, L.
Gramenzi, A.
Graña, O.
Grandini, E.
Grazi, G.
Gregório, M.L.
Gremeaux, L.
Grieco, A.
Grimaudo, S.
Grimm, D.
Gross, C.M.
Guarracino, M.
Guerra, S.
Guglielmo, N.
Gultepe, B.
Gumma, P.K.
Günal, E.
Gürlevik, E.
Gu, X.
Guzman, G.
H
Hadj Brik, B.
Hafeez, M.R.
Hamacher, R.
Hamano, M.
Hamdy, S.
Hamisa, M.
Hashani, M.
Hassan, M.S.
Haybeack, J.
Hayden, H.
Hay, N.
347
140
76, 80, 149
54
147
78, 112, 113
234
82
147
242
266
54
208, 302
240
122
157
293
108
326, 327
298
315
284, 286
57
118
138
276
275
82
126
136
280
94
332
150
142
138
INDEX
INDEX
346
INDEX
Heaton, N.
Hefaiedh, R.
Heim, D.
Heim, M.
Heindryckx, F.
Heinzmann, F.
Heneghan, M.
He, P.
Hernández-Bartolomé, A.
Herzig, S.
Hess, J.
Hetta, O.M.
Hinojosa, A.
Hoang, V.T.
Hoan, N.X.
Hoare, M.
Holczbauer, A.
Holmes, H.
Holzer, K.
Honda, T.
Hoover, S.
Hoshida, Y.
Hosny, K.
Houissa, F.
Hu, J.
Hülagu, S.
I
Ianiro, G.
Iannicelli, E.
Iannuzzi, M.G.
Ibrahim, W.A.
Ibro, E.
Ichikawa, T.
Iegri, C.
Ikeda, H.
Imache, M.R.
277
268, 276
70
110
91, 92, 107
122
277
72
131, 132
45, 90, 122
56
292
138
144
144
48
121
228
106
313
72
163
116
227
120
237
302
202
293
292
255
305, 313
238, 242, 250, 272
230
153
Iodice, V.
Iorre, G.
Ishizawa, T.
Ito, T.
Ito, Y.
220
220
230
126
48
J
Jindal, A.
Jin, M.
Jin, Q.
Jurk, D.
K
Kamo, Y.
Kang, Y.N.
Kapoor, S.
Karandrea, D.
Karanikolas, M.
Karin, M.
Kar, P.
Karra, V.K.
Kataki, A.C
Kataki, K.
Khakpoor, A.
Khan, S.
Khedher, S.
Kikuchi, L.
Klein, R.
Kluger, M.D.
Knigin, D.
Köberle, V.
Koch, S.
Koike, K.
Kokudo, N.
Kollmar, O.
Komuta, M.
Kondo, M.
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
170
138
231
60
Kopanja, D.
Korn, C
Koskinas, J.
Kossatz, U.
Krag, A.
Kristani, P.
Kronenberger, B.
Kubicka, S.
Kühnel, F.
Kumar, A.
Kumari, N.
138
120
278
74
299
255
206
57
57
218
148
313
140
315
278
278
59
98, 102, 104, 315
315
148
148
64
228
227
331
122
212
56
206
246
230
230
118
54
230
L
Ladep, N.
Laffi, G.
Lai, Q.
Lai, Y-H.
Lalisang, T.
Lamers, W.H.
Lang, H.
Lanza, M.
Lanzilotti, V.
Laranjo, M.
Lau, J.W-Y
Lau, J.W-Y.
Laurent, A.
Lavarone, M.
Lee, Y-H.
Lehmann, U.
Lehner, P.
Lemoine, M.
Lerat, H.
Lerut, J.
Levi Sandri, G.B.
Lewin, M.
Liccioniv, A.
Li, K-K.
228
147
326, 327, 334
253
204
145
246
316
328
108
254
252
212
208, 311
52
118
48
228
152, 153
226, 334
326, 327
320
180
62
Lima, C.S.P.
Lin, G.
Li, W.
Llovet, J.M.
Lohmann, V.
Longerich, T.
Lopez-Muñoz, R.
Lopez-Rodriguez, R.
Lorusso, V.
Louahadj, O.
Lounes, F.
Lovat, V.
Luli, S.
Lupo, M.
M
Mabrouk, M.
Maggs, J.
Magini, G.
Maher, M.M.
Mahtab, M.A.
Maia, C.J.
Maida, M.
Maini, M.
Malek, N.P.
Malheiros, A.C.L.
Mamede, A.C.
Mancuso, A.
Manesis, E.
Manini, M.A.
Mann, A.
Mann, D.A.
Mann, J.
Manns, M.P.
Manuppelli, C.
Marcante, M.
Marhenke, S.
349
258
72
142, 330
162
122
75, 120, 122
131
132
222, 256
296
296
201
60
238, 242, 250
290
277
222
292
199
108
208
64
74
258, 259
108
214
278
311
130
60
60
57, 63, 96
201, 288
201
118
INDEX
348
Marignani, M.
202
Marinelli, S.
112
Marins, L.V.
244
Marquardt, J.U.
52, 121
Marra, F.
314
Marroncini, G.
46
Mary, D.
228
Masi, G.
248, 249
Masutti, F.
328
Matheson, N.
48
Mathurin, P.
196, 338
Matsumura, Y.
126
Matter, M.S.
110
Mawad, M.A.F.
200
Mazzarelli, C.
214
Mazzoni, A.
64
McCarthy, D.
127
Mc Mahon, R.
150
Medhi, S.
98, 148
Mehmedovic, A.
134
Mei, L.
138
Meindl-Beinker, N.M.
118
Meissburger, B.
90
Mekki, H.
227
Melandro, F.
326, 327
Mele, A.
312
Mello, T.
46
Mendes, M.
308
Menon, S.
48
Mentha, G.
226
Mesihovic R.
134
Mete, R.
297, 298
Meyer, K.
118, 238, 259, 272, 320
Mikulits, W.
54, 150
Milani, A.
302
Milani, S.
46
Milazzo, M.
112, 113
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Minerva, F.
Mismas, V.
Miuma, S.
Miyaaki, H.
Mogler, C.
Monga, S.P.
Montalto, G.
Montasser, I.
Monteiro, J.E.P.
Montesarchio, V.
Monti, M.
Moreau, V.
Moreno-Otero, R.
Moriconi, F.
Morris, E.
Moser, C.D.
Mouelhi, L.
Mounajjed, T.
Moura, P.
Mueller, M.
Mukhin, A.N.
Musettini, G.
312
248, 249
313
313
120
166
256
294
262
222, 256
147
124
131, 132
64
64
140
227
140
108
150
282
248
N
Nachmansson, N.
Nagel, M.
Nahon, P.
Naito, M.
Najjar, T.
Nakada, Y.
Nakagama, H.
Nakao, K.
Nakazone, M.A.
Namasivayam, N.
Nardone, G.
Narita, M.
Navari, N.
70
130
43
126
227
126
59
305, 313
266
336
293
48
314
Navarra, G.
Negrini, M.
Negroni, L.
Neto, D.D.S.
Neumann, A.
Nevens, F.
Nicolini, A.
Ni, J.
Niu, J.
Njie, R.
Nogueira, V.
Nugroho, A.
Nuzzo, G.
316
112, 113
124
260
120
54, 186
311
254
231
228
266
204
302
O
Oakley, F.
O’Grady, J.
Ohkawa, R.
Okapec, S.
Okeke, E.
Olam, D.
Oliveira, C.P.
Oliveira, M.G.
Omar, A.
Omar, H.
Omran, D.
Opocher, E.
Ori, A.
Orlando, E.
Ostos, M.
Ostroumov, D.
Ott, M.
Otto, G.
Ould Gougam, R.
60
277
230
318
228
70
324, 331
324
290
274
290
212
106
208
320
63
96
246
296
P
Palaiologou, M.
278
351
Palasciano, G.
312
Palmieri, V.O.
312
Pant, M.
138
Papandreou, C.
196, 338
Pappo, O
70
Paradis, V.
44, 236
Paridaens, A.
92
Park, E. J.
59
Park, Y.N.
66
Parola, M.
314
Pascut, D.
328
Pastoricchio, M.
328
Patrizi, C.
112, 113
Patti, R.
328
Pavarino, E.C.
264
Pawella, L.
94
Pawlotsky, J-M.
152, 153
Peck-Radosavljevic, M.
142, 190
Pereira, I.V.A.
324
Pereira, P.D.S.F.
262
Perini, F.
46
Perret, C.
76, 80, 145, 149
Perricone, G.
214
Petz, M.
54
Pianezze, G.
288
Picciotto, A.
256
Pietschman, T.
58
Piiper, A.
206
Pikarsky, E.
56
Piluso, A.
147
Pinheiro, R.S.
334
Pinhel, M.A.D.S.
266
Pinna, F.
52
Pipitone, M.R.
240
Piras, M.R.
222
Pirenne, J.
54
Pirisi, M.
222
INDEX
INDEX
350
Piscaglia, F.
Piscuoglio, S.
Pizzi, G.
Polipalli, S.K.
Pollicino, T.
Polvani, S.
Polyte, J.
Pompili, L.
Pontisso, P.
Ponziani, F.R.
Porcelli, L.
Poté, N.
Pozzi, F.
Pusterla, T.
176, 208
110
250
315
316
46
153
302
288
300, 302
159
236
328
56
Q
Qasim, W.
Qin, L-X.
Qi, Y.
Quaglia, A.
Quatrale, A.E.
64
72
231
277
159
R
Radu, C.
Raffa, G.
Raggi, C.
Rahman, S.
Raimondo, G.
Raoul, J-L.
Rapaccini, G.L.
Ratziu, V.
Raychaudhuri, P.
Reig, M.
Resheq, Y.J.
Rezende, M.B.
Rezi, E.C.
Ribeiro, M.
210
316
121
199
316
193
302
196, 197, 338
138
180
62
244
232
306, 307, 308, 310
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Ricci, L.
Ricke, J.
Rico Juri, J.M.
Rigato, I.
Rinninella, E.
Rivkin, L.
Roberts, L.R.
Roccarina, D.
Rodriguez, K-I.
Rodriguez-Muñoz, Y.
Roessler, S.
Rohr-Udilova, N.
Romano, A.
Romdhane, H.
Rosenbaum, J.
Roskams, T.
Rossi, G.
Rossi, M.
Rovida, E.
Rubbia-Brandt, L.
Runge, A.
Rupp, D.
Russo, A.
Russo, F.P.
Ruttala, R.
312
183
334
328
300, 302
70
140
302
210
131, 132
72, 164
142
248
268, 276
124
50, 54
311
242
314
226
120
122
264
210
315
S
Sabbioni, S.
Sacco, R
Said, Y.
Saitta, C.
Sakr, M.
Salah, M.
Salama, R.
Salceda, J.
Saleem, A-A.
Salem, M.
113
248, 249
227
316
294
332
48
212
198
227
Salmon-Céron, D.
320
Salvalaggio, P.
244
Sandbothe, M.
114
Sanduzzi Zamparelli, M.
293
Sangiovanni, A.
311, 316
Sangro, B.
188
Sansonno, D.
222, 256
Santambrogio, R.
212
Santos, G.R.
331
Santos, K.
108
Santovito, D.
312
Sanz-Cameno, P.
131, 132
Sarin, S.K.
170
Sarma, A.
148
Sarma, M.P.
98, 104
Sarmento-Ribeiro, A.B.
307, 308, 310
Sartor, C.
76, 80, 145, 149
Sasikala, K.
155
Scarinci, A.
242
Schirmacher, P.
94, 106, 120, 165
Schlegelberger, B.
114
Schmitter, J-M.
124
Schnitzer Perlman, T.
70
Schulze-Bergkamen, H.
246
Scionti, A.
249
Scognamiglio, U.
220
Seif, M.
142
Selaru, F.
128
Selcanova, S.A.
318
Selim, A.K.
304
Sempoux, C.
226
Seno, T.
313
Sentürk, O.
237
Senzolo, M.
210
Seo, D.
121
Serejo, F.
196, 338
Seva-Pereira, T.
258, 259
EASL HCC SUMMIT
Sgamato, C.
Shaalan, D.
Shabana, H.R.
Shaker, M.K.
Shaker, O.
Shehab, H.
Shehu, K.
Sherman, M.
Shibata, H.
Shun, S-C.
Siciliano, M.
Sieghart, W.
Simioni, P.
Simpson, R.M.
Singer, S.
Sirin, G.
Sivanandam, V.
Skawran, B.
Skladany, L.
Smedile, A.
Smoot, R.
Sobczak-Thepot, J.
Sobesky, R.
Song, L.H.
Son, H.A.
Souza, D.R.S.
Sprinzl, M.
Sreedhar, H.
Stal, P.I.
Stanek, V.
Stauss, H.
Stefanini, G.F.
Steinfeld, I.
Steinfeld, R.
Stein, I.
Stiedl, P.
Stock, P.
353
293
304
216
200, 270, 332
274
274
255
174
313
253
302
187
210
72
106
237
120
114
318
316
140
146
320
144
144
266
246
138
196, 338
150
64
112
70
70
56
150
196, 338
INDEX
INDEX
352
INDEX
Stoiber, D.
Stolze, K.
Stoyanov, E.
Straub, B.
Straub, B.K.
Stucchi, R.S.B.
Stuchi, L.P.
Subramaniam, M.D.
Suddle, A.
Sufan, C.
Svinka, J.
Syminelaki, T.
T
Tadeu Stefano, J.
Taha, A.A.
Takahara, I.
Taleeb, K.
Tang, Z-Y.
Tani, C.M.
Tanrıtanır, M.
Taouji, S.
Tarocchi, M.
Tateishi, R.
Taura, N.
Taylor-Robinson, S.D.
Teicher, E.
Tempesti, S.
Tenani, G.D.
Terracciano, L.
Terris, B.
Teufel, A.
Thiele, M.
Thorgeirsson, S.S.
Thrasher, A.
Thursz, M.
Timis, T.
142
142
70
122
94
258, 259
264
155
277
296
150
278
324, 331
198
313
270
72
331
298
124
46
230
305, 313
228
320
46
266
110
76
168
299
51, 52, 121
64
228
129
EASL HCC SUMMIT
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
Tiniakos, D.
278
Tiribelli, C.
328
Toan, N.L.
144
Tokat, Y.
185
Tokuhara, Y.
230
Tomuleasa, C
128, 129
Toniolo, M.
288
Topal, B.
54
Torbenson, T.
178
Tornesello, M.L.
156
Tornillo, L
110
Toro, M.D.C.
258, 259
Torre, C.
80
Torres, M.M.
324
Tortora, A.
302
Toso, C.
179, 226
Tralhão, J.G.
108, 306, 307, 308, 310
Trauner, M.
150
Trerè, D.
112
Trevisani, F.
234
Trinchet, J-C.
320
Triolo, M.
311
Tripodi, G.
316
Trivedi, P.J.
62
Türkdogan, M.K.
297, 298
Turnes, J.
196
U
Uchida, S.
Uranbileg, B.
Urraro, T.
313
230
147
V
Vairappan, B.
Van den broeck, A.
Van den Bussche, A.
van den Eynde, K.
336
54
107
54
Vandewynckel, Y.P.
van Grunsven, L.
Vanis, N.
Vankelecom, H.
Van Vlierberghe, H.
Vavassori, S.
Vazquez, J.T.
Veber, P.
Velavan, T.P.
Vellingiri, B.
Venerandi, L.
Verslype, C.
Vezozzo, D.C.P.
Villa, E.
Villanueva, A.
Vincenzi, V.
Vitale, A.
Vivaldi, C.
Vogel, A.
Vukobrat-Bijedić, Z.
W
Wagner, E.F.
Waidmann, O.
Walsh, M.
Waly, A.
Wang, X.
Weekes, M.
Wege, H.
Weinmann, A.
Weisman, A.
Weiß, T.S.
Wendum, D.
Weng, H.L.
Wen, X.
Weston, C.J.
Wieland, M.
92
54
134
54
91, 92, 107
311
338
80
144
155
112
186
331
159, 208
68
201, 288
210
248, 249
84
134
82
206
138
116
72, 164, 252
48
70
246
130
118
146
118
231
62
120
355
Wilson, C.L.
Winkler, J.
Wirth, T.C.
Wolf, B.
Woller, N.
Wörns, M.
Wouters, J.
Wu, X.
Wu, Y.
60
106
63
74
57
246
54
72
140
X
Xie, H.
Xue, S-A.
138
64
Y
Yao, F.
Yatomi, Y.
Ye, Q-H.
Yesmembetov, K.I.
Yilmaz, N.
Yoshida, H.
Yoshimura, E.
Yumemura, A.
Yvamoto, E.Y.
184
230
72
282
198
230
313
59
266
Z
Zaher, T.
Zahra Ajana, F.
Zaki, N.
Zanetto, A.
Zavaglia, C.A.
Zemba, R.
Zender, L.
Zerbinati, P.
Zeuzem, S.
Zhang, K.
Zhan, H.
219
322
127
210
208, 214
296
122
210
206
221
64
INDEX
354
356
GENEVA, SWITZERLAND
FEBRUARY 13 - 16, 2014
NOTES
INDEX
Zhou, W.
Zhu, A.X.
Zhu, Z.
Ziada, D.H.
Zignego, A.L.
Zimmermann, H.W.
Zocco, M.A.
Zolfino, M.T.
Zollner, G.
252, 254
189
221
280
147
62
300, 302
256
150
EASL HCC SUMMIT
357
358
NOTES
LONDON.
UNITED KINGDOM
APRIL 9 - 13 / 2014
www.easl.eu
www.easl.eu/gplus
www.easl.eu/youtube

Basic Programme: FEBRUARY Clinical Programme: MOLECULAR PATHOGENESIS

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