HYPERHOMOCYSTEINEMIA AND MTHFR C677T POLYMORPHISM IN PATIENTS WITH PORTAL VEIN THROMBOSIS COMPLICATING LIVER CIRRHOSIS

Background: Portal vein thrombosis (PVT) is serious complication of liver cirrhosis (LC), especially in the presence of hepatocellular carcinoma (HCC). The liver plays a key role in homocysteine (Hcy) metabolism: mild hyperhomocysteinemia (HHcy) has been described in LC. HHcy is a risk factor for deep vein thrombosis. Methylentetrahydrofolate- reductase (MTHFR) C677T polymorphism is the commonest determinant of mild HHcy and has been involved also in cancer development. Aim: To investigate a possible relation between HHcy, MTHFR status, HCC and PVT in patients affected by LC. Materials and methods: 100 patients affected by LC, 38 with (PVT group, 24 with HCC) and 62 without PVT (LC group, 14 with HCC) sex-, age-, liver disease stage and etiology-matched were assessed for thrombophilia, smoking status, plasma Hcy, MTHFRC677T polymorphism and homocysteine-related vitamin status. Results: A higher prevalence of HCC, HHcy and MTHFR TT status was observed in PVT group. No significant difference in vitamin statuswas observed between groups. PatientswithHCC showed significantly higher plasma Hcy and higher prevalence of HHcy than patients without HCC. They had also higher prevalence of MTHFR TT status. In patients with TT status (n = 11) and HCC, 10 had HHcy e 9 had PVT. Conclusions: Mild HHcy is associated to LC may have a role in PVT development and assessment of plasma Hcy may be suggested in patients with LC (especially if complicated by HCC). Association between HCC and MTHFR TT status is intriguing, due the postulated role for this polymorphism in cancer: it may represent a possible link between HCC and PVT

Treatment of chronic hepatitis C by pegylated interferon plus ribavirin combination therapy in aged patients : why not ?

Background & Aims: Pegylated interferon (PEG-IFN) plus ribavirin combination therapy has significantly improved the successful rate in virus eradication in patients affected by chronic hepatitis C. However, only few data are available with respect to antiviral effect and safety in aged patients. This study aimed at investigating the efficacy and tolerability of pegylated interferon (Peg-IFN) plus ribavirin therapy in aged patients with chronic hepatitis C (CH-C). Methods: A total of 473 patients [319 (67.4%) naive, 195 (41,2% female) with CH-C (genotype 1, n = 266; genotype 2, n = 112, genotype 3 = 72, genotype 4=23), of whom 68 (14.4%) over 65 years old (y.o.) (mean age 69±2 years) , were treated with Peg-IFN (alfa-2a or alfa-2b) plus ribavirin according to international guidelines. These patients were assessed for sustained viral response (SVR) rate and for all known main predictors of SVR in CH-C. Results: The overall SVR rate resulted similar in both age groups (270/405 (66.6%) in subjects <65 y.o vs. 41/68 (60.3%) in subjects ≥ 65 y.o, respectively, p=0.334). No significant difference in therapy discontinuance rate was observed between patients over and under 65 y.o. (4.4% vs. 4.9%, respectively), the most common reason being anemia in both groups. The table resumes the distribution of main known SVR predictors in the two considered groups < 65 years (n=405) ≥ 65 years (n=68) p Genotype (1-4/2-3) 252/153 37/31 0.229 High viral load (cut off 500.000 UI/ml) (yes/no) 154/251 16/52 0.028 PegIFN alfa 2a / PegIFN alfa 2b use 244/161 59/9 <.001 Rapid Viral Response (RVR) (yes/no)* 106/107 28/28 1.000 Early Viral Response (EVR) (yes/no) 308/97 50/18 0.76 Naive (yes/no) 275/130 44/24 0.675 Sex (male/female) 248/157 30/38 0.011 Grading (Ishak score) 4.89±2.13 5.77±1.88 0.022 Staging (Ishak score) 2.08±1.49 2.73±1.51 0.029 Liver cirrhosis (yes/no) 42/363 13/55 0.043 Therapy reduction (yes/no) 123/282 20/48 0.888 Ribavirin reduction (yes/no) 87/318 18/50 0.430 Use of erythropoietic fatctors (yes/no) 43/362 26/42 <.001 *data not available for all patients For patients over 65 y.o., at multivariate analysis, genotype 2/3 (OR, 2.56,95% CI 1.89-5.65 p = 0.026) and EVR (OR, 45.5,95% CI 26.2-125.3 p <0.001) were significant predictors of SVR. Factors related to EVR at multivariate analysis were naive status (OR 2.58, 95%CI 1.26-3.69, p=.001), therapy with PEGIFNalfa 2a (OR 3.56, 95% CI 1.68-5.65, p=.014) and ribavirin reduction (OR 0.789, 95% CI 0.568-0.895, p=.015). Conclusions: Aged patients can be candidates for Peg-IFN plus ribavirin therapy.The appropriate use of erythropietic factors in these patients may be useful to achieve a significant reduction in the rate of therapy discontinuation due to hematological side-effects. The response-guided therapy may be applied in predicting therapy efficay in these patients

Serum endothelin-1 as predictor of ascitic decompensation in patients with liver cirrhosis

Background and aims: Intra- and extrahepatic endothelial dysfunction (ED) is considered to have a pivotal role in the development of portal hypertension (PH) in liver cirrhosis (LC). Serum levels of markers of ED (MED) are increased in LC patients; they correlate with the stage of liver disease. Aims of the present study were to assess 1) differences between MED in patients with compensated and decompensated LC; 2) possible prognostic role of MED in ascites development in compensated LC patients. Methods: 90 consecutive LC patients (mean age 65±9 years, 24 female) underwent a complete clinical, radiological and biochemical evaluation in order to assess stage and characteritics of disease; all subjects were assessed for MED [P-selectin, von Willebrand factor (vWF), endothelin-1 (ET-1), thrombomodulin (TM) and nitric oxide (NO)]. The 70 patients (mean age 65±9 years,19 female) with compensated LC (no ascites, cLC) underwent a 2 years-follow-up; their data were also compared with those of 20 (mean age 63±10 years, 5 female) LC patients with decompensated LC (presence of ascites, dLC) and those of 11 healthy controls (mean age 26±6.6 female). Results: ET-1, P-selectin and TM serum levels were significantly higher in LC and in dLC patients with respect to controls. NO and vWF serum levels were higher in dLC patients, whereas no difference was observed in cLC with respect to controls. 33/70 (47.1%) of cLC patients developed ascites at follow-up. At univariate analysis, predictors of ascites development in cLC patients were serum concentrations of ET-1 (OR=3.56, p=0.000), TM (OR=1.95, p=0.000) and P-selectin (OR=1.033, p=0.004) and Child-Pugh score (OR=1.05, p=0.041). At multivariate analysis (Cox regression), serum ET-1 and diabetes were independent predictors of early development of ascites during the follow-up (HR=2.631, p=0.004) in cLC patients. Efficiency (ROC method) of high levels (cut-off value=6 pg/ml) of ET-1 in predicting ascites development was good (AUC=0.803)

RICERCA DI DNA DI Pneumocystis jirovecii NEL LIQUIDO DI LAVAGGIO BRONCOALVEOLARE MEDIANTE IL TEST IN REAL-TIME PCR MYCASSAY™ PNEUMOCYSTIS

Introduzione: Pneumocystis jirovecii (Pj) è un fungo opportunista patogeno responsabile di gravi malattie respiratorie nell'ospite immunocompromesso. La diagnosi di polmonite da Pj (PCP) si basa su prove radiologiche e sulla rilevazione microscopica di antigeni mediante immunofluorescenza (IF); se non diagnosticata e/o non trattata tempestivamente, la malattia può portare a insufficienza respiratoria e morte. Il presente studio retrospettivo intende valutare l’efficacia del test in real-time PCR (MycAssay Pneumocystis, MycPcpAssay, Myconostica) su piattaforma ABI PRISM 7300 per la rilevazione di DNA fungino in campioni di BAL provenienti da pazienti con diagnosi di PCP. Metodi: il DNA, estratto mediante MycXtra (Myconostica), da 20 campioni di BAL da 8 pazienti con diagnosi clinica di PCP, da 7 pazienti con diagnosi clinica di aspergillosi invasiva (AI) e da 5 controlli negativi, è stato amplificato con il kit MycPcpAssay. I risultati della real-time PCR sono stati confrontati con i risultati ottenuti con i test diagnostici di IF (Merifluor Pneumocystis, Meridian) e di biologia molecolare Pj Alert kit (Nanogen) in uso presso il laboratorio. Risultati: dei 20 campioni analizzati, 12 sono risultati MycPcpAssay-positivi per Pj: 8 campioni appartengono al gruppo di pazienti con diagnosi di PCP e 4 campioni appartengono al gruppo con diagnosi di AI. In particolare, la positività di 3 di 4 soggetti con diagnosi di AI è stata confermata da Pj Alert kit; nessuno dei 5 soggetti appartenenti al gruppo di controllo è risultato positivo mediante PCR. Questi dati sono stati confrontati con i risultati ottenuti in IF: 6 pazienti IF positivi erano anche PCR positivi; 5 pazienti IF negativi erano PCR positivi e un paziente IF positivo era PCR negativo sia col test MycPcpAssay che col Pj Alert kit. Conclusioni: questi dati, che devono essere considerati preliminari al fine di una validazione del kit MycAssay Pneumocystis su piattaforma ABI PRISM 7300, forniscono una prima indicazione dell’efficacia del kit per la rilevazione del DNA di Pj in BAL di pazienti con sospetta PCP

Efficacy and safety of combination therapy with pegylated interferon and ribavirin in aged patients with chronic hepatitis C

Background & Aims: Combination therapy with pegylated interferon (PEGIFN) and ribavirin has significantly improved virus eradication rate in patients affected by HCV-related chronic hepatitis (C-HC). However, only few data are available with respect to efficacy and safety of this therapy in aged patients. This study aimed at investigating efficacy and tolerability of combination therapy in aged patients with CH-C. Methods: 473 patients [319 (67.4%) naive, 195 (41,2% female) with CH-C (genotype 1, n=266; genotype 2, n=112, genotype 3, n=72, genotype 4, n=23), of whom 68 (14.4%) over 65 years old (mean age 69\ub12 years), were treated with Peg-IFN (alpha-2a or alpha-2b) plus ribavirin according to international guidelines from January 2007 to July 2011. These patients were assessed for sustained viral response (SVR) rate and for all known main predictors of SVR in CH-C. Results: The overall SVR rate resulted similar in both age groups [270/405 (66.6%) in subjects <65 years vs. 41/68 (60.3%) in subjects 6565 years, respectively, p=0.334)]. Overall, therapy discontinuance rate was low, with no significant difference between patients over or under age 65 (4.4% vs. 4.9%, respectively), the most common reason for discontinuance being anemia in both groups.For patients over 65, at multivariate analysis, non-na\uefve status, EVR and use of hematological growth factors were independent predictors of SVR. Factors independently related to EVR at multivariate analysis were non-naive, staging, genotype 2-3 vs. genotype1-4 and use of hematological growth factors Conclusions: Aged patients can be candidates for Peg-IFN plus ribavirin therapy. The appropriate use of hematological factors in these patients may be useful to achieve a significant reduction in the rate of therapy discontinuation due to hematological side-effects. The response-guided therapy may be applied in predicting therapy efficacy in this patient grou

Combination of radiofrequency ablation and transcatheter arterial chemoembolization improves survival in advanced hepatocellular carcinoma complicating liver cirrhosis

Background: Treatment of hepatocellular carcinoma (HCC) still remains a controversial issue. In particular, for patients with HCC status exceeding the criteria for “curative” options (advanced HCC) there is no defined standard of therapy. Aim: To evaluate efficacy of combined treatment with radiofrequency ablation (RFA) and transcatether arterial chemio-embolization (TACE) in advanced HCC. Materials and Methods: We performed a retrospective study to compare the cumulative survival rate of patients with advanced HCC treated with combined therapy (simultaneous application of TACE and RFA) [RFA-TACE group, n=35] vs. those treated only by TACE [TACE group, n=36] or those treated only by conservative option [Control group, n=36]. HCC was confirmed by imaging and/or histology. All patients were monitored at one-three months after treatment and every six months by imaging to check for treatment success and/or HCC recurrence. In order to minimize possible bias due to the retrospective design, a propensity score approach was used in analysing the results. Results: The median survival time were 31 months for TACE-RFA group, 21 months for patients in TACE group and 10 months in control group, respectively. The 6-month survival rate was 96%, 90% and 78% in TACE-RFA group, TACE group and control group, respectively; the 1-year survival rate was 89%, 75% and 20.3%. At 3 years from HCC diagnosis, 6% of control group patients were alive, versus 34% and 45% of TACE and TACE-RFA group, respectively. Survival rates difference between groups were significant (p=0.011 and p<0.001 TACE and Controls with respect to TACE-RFA group). Treatment allocation (HR 2.14, p=0.022), and complete treatment response were important independent predictors (HR 3.25, p=0.018) of survival. Conclusion: Based on the results of this study we conclude that the combination of RFA and TACE may represent a promising approach for the treatment of advanced HCC complicating liver cirrhosis. nevertheless, a better definition of patient’s characteristics and technical approaches together with larger scale-randomized trials are needed

Pharmacological and toxicological evaluation of a new series of thymidylate synthase inhibitors as anticancer agents

Thymidylate synthase (TS) is responsible for catalysing the de novo biosynthesis of doexythymidine monophosphate and is a target for many anticancer drugs. A series of thymidylate synthase inhibitors (TSIs), synthesised in our laboratory, were submitted to primary anticancer screening by the National Cancer Institute (NCI). Four compounds, 3,3bis(4-methoxyphenyl)-1H, 3H-naphtho[1,8-cd]pyran-1-one (MR7), 6-chloro-3,3-bis(4-hydroxyphenyl)-]H,3H-naphtho[1,8cdjpyran-1-one (MR21), 3,3-bis(3-fluoro-4-hydroxyphenyl)IH,3H-naphtho[1,8-cd]pyran-l-one (MR35) and 6-bromo-3,3bis(3-chloro-4-hydro.xyphenyl)-1H,3H-naphtho[1,8-cd]pyran-l- one (MR36), passed the criteria and were automatically scheduled for evaluation against the full panel of 60 human tumour cell lines. In this study, the antiproliferative activity of the substances against SK-MEL-2 cells (from metastatic tissue) and SK-MEL-28 cells (from primary malignant melanoma cells) was investigated. Neutral Red uptake and the MTT test were performed to confirm the results of the NCI, and [H-3]thymidine incorporation was performed as a test of the proliferation rate. Our results indicated that compounds MR21 and MR36 were the most active agents and the [H-3]-thymidine test was the best in predicting toxicity against melanoma cells

Improvement of survival in patients with intermediate stage (BCLC-B) hepatocellular acrcinoma complicating liver cirrhosis by combination therapy with radiofrequency ablation and transcatheter chemioembolization

Efficacia del trattamento combinato di radiofrequenza e chemioembolizzazione vs. chemioembolizzaione semplice in pazienti selezionati con HCC in stadio intermedio (BCLC score). Approccio con Propensity score matchin