The interleukin 28B (IL28B) rs12979860 polymorphism is associated with treatment outcome in hepatitis C virus (HCV) genotype 1 and 4 patients. Its association with the histological features of chronic hepatitis C and disease severity needs further clarifications. To assess the correlation between IL28B genotype, HCV genotype and liver biopsy findings in untreated patients. Materials and Methods: Pre-treatment liver biopsies from 335 HCV Caucasian patients (59% males, age 50 years) enrolled in the MIST study were staged for fibrosis and inflammation according to the METAVIR and the Ishak scoring systems; steatosis was dichotomized as <5% or ≥5%. IL28B was typed by Taqman Single Nucleotide Polymorphism (SNP) genotyping assay. HCV genotype was 1 in 151 (45%), 2 in 99 (30%), 3 in 50 (15%) and 4 in 35 (10%) patients. IL28B genotype was CC in 117 (34%), CT in 166 (49%) and TT in 52 (15%). At univariate analysis, the IL28B CC genotype was associated with severe portal inflammation in HCV-1 patients (CC vs. CT/TT: 86% vs. 63%, p = 0.005), severe lobular inflammation in HCV-2 patients (CC vs. CT/TT: 44% vs. 23%, p = 0.03), and less fatty infiltration in HCV-1 patients (CC vs. CT/TT: 72% vs. 51%, p = 0.02). Despite the lack of any association between IL28B and fibrosis stage, in HCV-3 patients IL28B CC correlated with METAVIR F3-F4 (CC vs. CT/TT: 74% vs. 26%, p = 0.05). At multivariate analysis, the genotype CC remained associated with severe portal inflammation in HCV-1, only (Odds Ratio (OR): 95% Confidence Interval (CI): 3.24 (1.23–8.51)). IL28B genotype is associated with the histological features of chronic hepatitis C in a HCV genotype dependent manner, with CC genotype being independently associated with severe portal inflammation.

Background: Dysplastic nodules in cirrhosis herald a very high risk of transition to hepatocellular carcinoma. A better understanding of the relationships between dysplastic nodules and hepatocellular carcinoma development may help refining strategies of enhanced follow-up.Methods: All consecutive cirrhotics with a histologically proven de novo dysplastic nodule, were retrospectively identified and underwent alternating abdominal ultrasound and contrast-computed tomography every 3 months. An ultrasound-guided liver biopsy was the diagnostic gold standard, whereas surveillance and recall policies were according to current guidelines.Results: Among 36 patients with dysplastic nodule (21 low-grade, 15 high-grade, 17.4 +/- 2.6 mm), 17 (47%) showed arterial wash-in, 15 (42%) portal/venous hypodensity whereas 4 (11%) had neither pattern. During 6-128 (median 36) months, 21 patients developed a hepatocellular carcinoma at a rate of 13.8% per year, intranodular = 8.7% vs extranodular = 7.1% per year. Hepatocellular carcinoma occurred more frequently in high-grade than low-grade dysplastic nodules (32.2% vs 9.3% per year, p = 0.0039); the maximum time to hepatocellular carcinoma transformation was 27 months for intranodular vs 67 months for extranodular tumours (p = 0.025). No contrast-computed tomography pattern predicted neoplastic transformation of dysplastic nodules.Conclusion: The histological examination of liver nodules in cirrhosis lacking the imaging hallmark of hepatocellular carcinoma improves both prognostication and outcome of surveillance, since it dictates the intensity of the radiological follow-up. (C) 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Liver transient elastography (L-TE) is a reliable, noninvasive predictor of disease severity in chronic liver disease of viral aetiology (CLD). Owing to the relationships among severity of CLD, portal hypertension and spleen involvement, the assessment of splenic stiffness (S-TE) may have an added value in staging CLD. Of 132 CLD patients of viral aetiology, 48 with myeloproliferative disorders (MD) and 64 healthy volunteers (HV), were concurrently investigated by both L-TE and S-TE. Liver disease severity was staged by liver biopsy (LB; Metavir) taken concurrently with TE examination and upper gastrointestinal tract endoscopy for gastro-oesophageal varices. The S-TE inter-observer agreement was analysed by an intra-class correlation coefficient (ICC); L-TE and S-TE accuracy was evaluated by receiver operating characteristic (ROC) curve analysis. Logistic regression analysis assessed the independent effect of L-TE and S-TE as predictors of hepatic fibrosis stage. S-TE failed in 22 CLD (16.6%), 12 (25%) MD and 12 (18%) HV. In the three groups, the ICC was 0.89 (0.84-0.92), 0.90 (0.85-0.94) and 0.86(0.80-0.91), respectively. In the CLD group, L-TE and S-TE independently predicted significant fibrosis (OR 5.2 and 4.6) and cirrhosis (OR 7.8 and 9.1), but at variance from L-TE, S-TE was independent from liver necroinflammation and steatosis. The NPV of S-TE for gastro-oesophageal varices was 100% using a 48 kPa cut-off. In CLD, spleen stiffness alone or in combination with hepatic stiffness can be reliably and reproducibly assessed by TE with the added value of improving the noninvasive diagnosis of severe liver disease and excluding the presence of oesophageal varices.

Although annular fibrosis is the hallmark of cirrhosis, other microscopic changes that affect liver function such as sinusoid capillarization or loss of metabolic zonation are common. A sustained virological response (SVR) may halt fibrosis deposition in hepatitis C virus (HCV)-infected patients, but its impact on the other cirrhosis-associated lesions is unknown. The aim of this study was to assess the impact of an SVR on cirrhosis-related histopathological features. Paired pre- and posttreatment liver biopsies from 38 HCV patients with cirrhosis with an SVR were analyzed. Fibrosis was staged using the METAVIR scoring system, and the area of fibrosis was measured using morphometry. Ductular proliferation, metabolic zonation, sinusoid capillarization, and hepatic stellate cell activation were assessed by anti-cytokeratin-7, anti-glutamine synthetase (GS), anti-cytochrome P4502E1 (CYP2E1), anti-CD34, and anti a-smooth muscle actin (aSMA). After 61 months from an SVR, cirrhosis regression was observed in 61%, and the collagen content decreased in 89%. Although periportal and lobular necroinflammation vanished, portal inflammation persisted in 66%. Ductular proliferation decreased in 92%. Before treatment, metabolic zonation was lost, as shown by GS and CYP2E1, in 71% and 88%, respectively, with normalization in 79% and 73%, after an SVR. Conversely, no changes in sinusoidal capillarization were observed after treatment, as assessed by CD34 (P = 0.41) and aSMA (P = 0.95). Finally, no differences in all the immunohistochemical scores emerged whether or not cirrhosis persisted. Conclusion: Cirrhosis regression and decreased fibrosis are frequently observed among HCV patients with cirrhosis with an SVR. Despite ductular proliferation vanishing and lobular zonation restoration, portal inflammation and sinusoidal capillarization may not regress after viral eradication. (HEPATOLOGY 2012)

716 PROGNOSTIC GENE-EXPRESSION SIGNATURE FOR HEPATITIS C-RELATED EARLY-STAGE LIVER CIRRHOSIS Y. Hoshida, A. Villanueva, A. Sangiovanni, M. Sole, C. Hur, K.L. Andersson, R.T. Chung, J. Gould, K. Kojima, S. Gupta, B. Taylor, A. Crenshaw, S. Gabriel, B. Minguez, M. Iavarone, S.L. Friedman, M. Colombo, J.M. Llovet, T. Golub. Broad Institute of Harvard and MIT, Dana-Farber Cancer Institute, Boston, MA, USA; Laboratori de Reserca Translacional d’Oncoloǵia Hepatica, IDIBAPS, Ciberehd, Hospital Clinic, Barcelona, Spain; Division of Gastroenterology, Fondazione Ca Granda IRCCS Ospedale Maggiore Policlinico, Universita degli Studi di Milano, Milan, Italy; Dept. of Pathology, Hospital Cĺinic, Barcelona, Spain; Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA; Liver Unit, Department of Medicine, Hospital Universitari Vall d’Hebron, Barcelona, Spain; Department of Liver Diseases, Mount Sinai School of Medicine, New York, NY, USA E-mail: hoshida@broadinstitute.org

Aliment Pharmacol Ther 2011; 34: 353–362SummaryBackground Transient elastography has gained popularity to stage liver fibrosis in chronic viral hepatitis, however, diagnostic cut‐offs for severe fibrosis in chronic hepatitis B are poorly defined.Aim To evaluate an algorithm with two distinct cut‐offs for positive and negative prediction of significant fibrosis and cirrhosis in chronic hepatitis B patients.Methods Two cohorts of treatment‐naïve patients with chronic hepatitis B (125 training and 92 validations) were consecutively and concurrently examined by percutaneous liver biopsy and transient elastography. Fibrosis was staged by Metavir (significant fibrosis = F ≥ 2; cirrhosis = F4) in ≥2 cm long liver tissue cores.Results A >13.1 kPa positive and a ≤9.4 kPa negative cut‐off for cirrhosis had a >90% sensitivity and specificity, with an accuracy of 94%. The corresponding cut‐offs for F ≥ 2 were >9.4 and ≤6.2 kPa, thus classifying 56% of patients with an overall accuracy of 90%. In the validation cohort, F4 and F ≥ 2 were predicted by the above transient elastography cut‐offs with an overall accuracy >90%. In 165 patients with higher than upper limit of normal transaminase activity the dual cut‐off algorithm of transient elastography was as accurate as in the 52 patients with normal alanine aminotransferase values in the prediction and exclusion of cirrhosis, only.Conclusions A dual cut‐off algorithm allowed for correctly classifying both significant fibrosis and cirrhosis in the majority of the patients with chronic hepatitis B, independent of alanine aminotransferase values, thus reducing the need for liver biopsy investigations.

Dynamic contrast imaging techniques are considered the standard of care for the radiological diagnosis of hepatocellular carcinoma (HCC) in cirrhosis. However, the accuracy of radiological diagnosis depends largely on the degree of arterial hypervascularization, which increases with tumor size. Owing to the interplay and prognostic relevance of tumor vascularization and cell differentation, we asked ourselves whether tumor grade also affects the outcome of radiological diagnosis. Sixty-two HCCs (47 of which measured 1-2 cm) were consecutively detected in 59 patients with compensated cirrhosis under surveillance with ultrasound and confirmed by way of echo-guided biopsy and concurrent investigations with contrast-enhanced ultrasound (CE-US), computed tomography (CT), and gadolinium magnetic resonance imaging (MRI). Tumor cell differentiation was evaluated using Edmondson-Steiner criteria in liver cores of 0.9-5.0 cm (median 1.6 cm). Eighteen (29%) HCCs were grade I (1.5 cm), 28 (45%) were grade II (1.5 cm), 16 (26%) were grade III (1.8 cm), and none were grade IV. Contrast wash-in and wash-out were concurrently demonstrated in 21 (34%) tumors by way of CE-US, including three (16%) grade I and 18 (41%) grade II-III ( P = 0.08); in 32 (52%) tumors by way of CT, including three (16%) grade I and 29 (66%) grade II-III ( P = 0.0006); and 28 (47%) tumors by way of MRI, including three grade I (16%) and 25 (57%) grade II-III ( P = 0.01). Among 1- to 2-cm tumors, the radiological diagnosis was achieved in two of 16 grade I and 17of 31 grade II-III tumors ( P = 0.006). Conclusion: Tumor grade, a relevant predictor of disease severity, influences the accuracy of dynamic contrast techniques in the diagnosis of HCC. Hepatology 2010

e14574 Background: Surveillance with abdominal US of cirrhotic patients increases the identification of small hepatocellular carcinoma (HCC) to be treated with radical therapies. Aim: To define the treatment applicability and efficacy in de novo diagnosed HCC nodules according to BCLC criteria. Methods: Consecutive liver nodules (LN) detected in patients withChild-Pugh A cirrhosis under surveillance were investigated with contrast-enhanced ultrasound (CE-US), dynamic computed tomography (CT) and dynamic magnetic resonance (MR) and fine-needle biopsy (FNB). HCC were staged with chest CT scan, and bone scintigraphy, treated according to BCLC criteria, and followed with CT/MR at least every 3 months. EASL modified criteria were used to assess treatment response. Results: 84 consecutive de-novo liver nodules, including 12 US undetected revealed by CT/MR, (7 < 1 cm, 66 1-2 cm, 11 > 2 cm in size), were identified in 69 patients, mean age 65 years (43-84), 51 (74%) males. Forty-five patients had 51 HCC nodules, including 6 missed by US (5 < 1 cm, 38 between 1-2 cm, 8 > 2 cm). HCC was single nodule in 44 (98%) patients at US, decreasing to 40 (87%) after staging, all BCLC A. First line treatment was radio interstitial thermal ablation (RITA) in 26 (58%) patients, percutaneous ethanol injection ( PEI) in 9 (20%), resection in 8 (17%), transarterial chemoembolization (TACE) in 2 (4%). Complete response (CR) was achieved in 31 (69%) patients, partial response (PR) in 9 (20%), stable disease (SD) in 1 (2%) and progression (P) in 1 (2%), Three (7%) patients were lost to follow-up. OLT was performed in 4 (9%) patients after bridge therapy. During a mean follow-up of 21 (7-37) months, recurrence occurred in 3 (7%) patients and additional LN developed in 17 (36%) patients in liver segments other than the treated ones, including 3 HCC (mean annual incidence of 4.1%), 2 MRN, 1 non- Hodgkin lymphoma, 11 still undefined. HCC metastases developed in 3 (7%). Conclusions: Radical treatment of early HCC in cirrhotics under surveillance is applicable to 96% of the patients, to give overall CR rates of 69%), while OLT was performed in a minority (9%) of patients only. No significant financial relationships to disclose.

Background Contrast-enhanced ultrasound (CE-US), contrast CT scan and gadolinium dynamic MRI are recommended for the characterisation of liver nodules detected during surveillance of patients with cirrhosis with US. Aim To assess the sensitivity, specificity, diagnostic accuracy and economic impact of all possible sequential combinations of contrast imaging techniques in patients with cirrhosis with 1–2 cm liver nodules undergoing US surveillance. Patients/methods 64 patients with 67 de novo liver nodules (55 with a size of 1–2 cm) were consecutively examined by CE-US, CT, MRI, and a fine-needle biopsy (FNB) as diagnostic standard. Undiagnosed nodules were re-biopsied; non-malignant nodules underwent enhanced imaging follow-up. The typical radiological feature of hepatocellular carcinoma (HCC) was arterial phase hypervascularisation followed by portal/venous phase washout. Results HCC was diagnosed in 44 (66%) nodules (2, <1 cm; 34, 1–2 cm; 8, >2 cm). The sensitivity of CE-US, CT and MRI for 1–2 cm HCC was 26, 44 and 44%, with 100% specificity, the typical vascular pattern of HCC being identified in 22 (65%) by a single technique versus 12 (35%) by at least two techniques carried out at the same time point (p=0.028). Compared with the cheapest dual examination (CE-US+CT), the cheapest single technique of stepwise imaging diagnosis of HCC was equally expensive (€26 440 vs €28 667), but led to a 23% reduction of FNB procedures (p=0.031). Conclusions In patients with cirrhosis with a 1–2 cm nodule detected during surveillance, a single imaging technique showing a typical contrast pattern confidently permits the diagnosis of HCC, thereby reducing the need for FNB examinations.

final results of the CHANGH cohort study.

e14606 Background: Contrast-enhanced ultrasound (CE-US), contrast computerized tomography (CT)-scan and gadolinium dynamic magnetic resonance (MRI), are recommended for the characterization of liver nodules detected during surveillance of cirrhotics with US. In a recent study of 64 patients with 67 liver nodules, a sensitivity of 26%, 44% and 44% for CE-US, CT, and MRI for 1-2 cm hepatocellular carcinoma (HCC), with 100% specificity were demonstrated. Aim: To correlate the vascular pattern on contrast-enhanced imaging techniques with cell differentiation (grade) of HCC. Methods: Seventy-five cirrhotic patients were consecutively examined by CE-US, CT, MRI and a fine-needle biopsy as diagnostic standard. The typical radiological feature of HCC was arterial phase hypervascularization followed by portal/venous phase wash-out. Histopathological diagnoses were made according to the Edmonson grading system. Results: HCC was diagnosed in 52 (66%) nodules (3 < 1 cm, 41 1-2 cm, 8 > 2 cm). Tumor grading was grade I in 14 (27%, median diameter 1.5 cm), grade II in 24 (46%, median diameter 1.5 cm), grade III in 14 (27%, median diameter 1.8 cm), grade IV in none. There was no relationship between tumor differentiation and etiology of liver disease (virus vs alcohol), nodule size and alfafetoprotein levels. At CT scan, the typical vascular pattern was present in 27/52 (52%) HCC: 3 (21%) grade I, 14 (58%) grade II, 10 (71%) grade III (p = 0.02). On CE-US, the typical vascular pattern was present in 17/52 (33%) HCC: 3 grade I (21% of all grade I), 8 grade II (33% of all grade II), 6 grade III (43% of all grade III) (p = 0.48). At MRI, the typical vascular pattern was present in 23/52 (52%) HCC: 3 (21%) grade I, 11 (50%) grade II, 9 (64%) grade III (p = 0.06). The AASLD criteria for radiological diagnosis of HCC were present in 2 grade I HCC (14%), 11 grade II HCC (46%) and 9 grade III HCC (64%) (p = 0.02). Conclusions: The diagnostic accuracy of the AASLD radiological criteria for HCC is low in grade I tumors but appreciably increases in grade II and III HCC. No significant financial relationships to disclose.

e14576 Background: The diagnostic sensitivity of fine needle biopsy (FNB) for liver nodules in cirrhotic patients is both operator and disease characteristic dependant. The performance FNB needs to be not standardized. Aim: To compare the diagnostic accuracy of one vs. two FNB intra-nodule plus one extra-nodule passage. Methods: A FNB was performed with a 21-gauge trenchant needle for microhistology (Biomol, HS Hospital Service, Italy) with two passages within and one outside the nodule, and processed separately. The diagnosis was made by histology and confirmed by enhanced follow-up for non malignant lesions. FNB was repeated in all patients with unsolved histological diagnosis, i.e., similar histologic features within and outside the liver nodule. Patients with non malignant nodules underwent a repeat US every 3 months, an abdominal CT/MRI every 6 months and repeated FNB if nodules changed in size/vascular pattern. The histological diagnosis was according the International Working Party criteria. Results: 48 prospectively enrolled cirrhotics, 44 (92%) Child-Pugh A, had 67 liver nodules (mean diameter 1.9 cm); 2 (3%) < 1 cm, 39 (58%) 1-2 cm, 15 (22%) 2-3 cm, 11 (17%) > 3 cm. The final diagnosis was 41 (61%) hepatocellular carcinoma (HCC), 1 (2%) cholangiocarcinoma (CCC), 15 (22%) MRN, 4 (6%) low grade dysplastic nodule (LGDN), 4 (6%) high grade dysplastic nodule (HGDN), 2 (3%) lymphoma. 36 HCC (82%) were diagnosed with first passage whereas 5 additional HCC (8%) were diagnosed with the second passage. FNB needed to be repeated in 2 (3%) cases with similar histological features within and outside the liver nodule. In the 39 nodules of 1-2 cm, the corresponding final diagnosis was: 17 (43%) HCC, 1 (3%) CCC, 3 (8%) MRN, 11 (28%) LGDN, 5 (13%) HGDN, 2 (5%) lymphoma. Fifteen HCC (37%) were identified by one passage and 2 (5%) by two passages. FNB needed to be repeated in 2 patients. A parenchymal sub-glissonian hematoma (1%) was the only complication. Conclusions: Two passages FNB allows to increase by 12% the final diagnosis of HCC in small liver nodules detected during surveillance of patients with cirrhosis. No significant financial relationships to disclose.