1、1066 Articles | JNCI Vol. 101, Issue 15 | August 5, 2009Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the third most common cause of cancer mortality. Most HCC cases (80%) occur in either Eastern Asia or sub-Saharan Africa ( 1 ). Most HCCs occur in men and among people
2、 aged 75 years and older ( 1 ). Major risk factors for the development of HCC are chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV), liver cirrhosis, exposure to aflatoxin B1, alcohol consumption, and diabetes. It has been estimated that 80% of HCC worldwide is etiologically
3、associated with HBV ( 2 ). The double-stranded DNA genome of HBV contains four over-lapping open reading frames that encode the surface protein (S), the core (nucleocapsid) protein core, a polymerase, and a multifunctional nonstructural protein called X. The PreS region (nucleotides 2854 155), which
4、 consists of the PreS1 and PreS2 domains, overlaps a region of the polymerase gene. The enhancer II (EnhII; nucleotides 1636 1744) and basal core promoter (BCP; nucleotides 1751 1769) regions overlap with the X gene (nucleotides 1374 1838). The pre-core region encodes the hepatitis B e antigen (HBeA
5、g), which is used clinically as an indicator of active viral replication ( 3 , 4 ). Expression of HBeAg and a high serum level of HBV (ie, a viral load 10 000 copies per milliliter) are associated with an increased risk of HCC ( 5 , 6 ). Eight HBV genotypes (genotypes A H) have been identifi ed base
6、d on a sequence divergence of greater than 8% over the entire HBV genome. Genotypes are further categorized into subgeno-types based on nucleotide sequence divergence between 4% and 8% ( 7 ). Patients who are infected with HBV genotypes that have Affiliation of authors: Department of Epidemiology, S
7、econd Military Medi-cal University, Shanghai, China . Correspondence to: Guangwen Cao, MD, PhD, Department of Epidemio-logy, Second Military Medical University, 800 Xiang-yin Rd, Shanghai 200433, China (e-mail: ). See “Funding” and “Notes” following “References.” DOI: 10.1093/jnci/djp180 2009 The A
8、uthor(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:/creativecommons.org/licenses/by-nc/2.0/uk/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work
9、is properly cited. ARTICLE Associations Between Hepatitis B Virus Mutations and the Risk of Hepatocellular Carcinoma: A Meta-Analysis Shijian Liu , Hongwei Zhang , Chunying Gu , Jianhua Yin , Yongchao He , Jiaxin Xie , Guangwen Cao Background The association between hepatitis B virus (HBV) mutations
10、 and hepatocarcinogenesis remains controver-sial because of conflicting data in the literature. We conducted a meta-analysis of case control and cohort studies to examine HBV PreS, enhancer II (EnhII), basal core promoter (BCP), and precore mutations in relation to the risk of hepatocellular carcino
11、ma (HCC). Methods We searched databases for studies of these associations that were published in English or Chinese up to August 31, 2008. HBV mutation specific odds ratios and relative risks were pooled by use of a random-effects model and stratified by potential confounders. All statistical tests
12、were two-sided. Results Of the 43 studies included in this meta-analysis, 40 used a case control design. The 43 studies evaluated a total of 11 582 HBV-infected participants, of whom 2801 had HCC. Statistically significant summary odds ratios of HCC were obtained for any PreS mutation (3.77, 95% con
13、fidence interval CI = 2.57 to 5.52), C1653T in EnhII (2.76, 95% CI = 2.09 to 3.64), T1753V (2.35, 95% CI = 1.63 to 3.40), and A1762T/G1764A in BCP (3.79, 95% CI = 2.71 to 5.29). PreS mutations were more strongly associated with an increased risk of HCC in subjects who were infected with HBV genotype
14、 C than in those who were infected with HBV geno-type B, whereas the opposite was true for A1762T/G1764A. C1653T, T1753V, and A1762T/G1764A were more strongly associated with an increased risk of HCC in hepatitis B e antigen (HBeAg) positive subjects than in HBeAg-negative subjects. PreS mutations,
15、C1653T, T1753V, and A1762T/G1764A accumulated during the progression of chronic HBV infection from the asymptomatic carrier state to HCC ( P trend100 50 100 50 Source of population Community-based or from two or more countries 2 hospitals 1 hospital Mutation detection method DNA sequencing Line prob
16、e assay (eg, INNO-LiPA, OLA)RFLP, PAGE, self-made chips, microwell hybridization, or direct electrophoresis Matching of case and control subjects Confounder group 1 Age and sex Age or sex None Confounder group 2 HBeAg status and HBV genotypeHBeAg status or HBV genotypeNone * = designs other than coh
17、ort or nested, incidence, or prevalence case control not included in meta-analysis; INNO-LiPA = Innogenetics line probe assay; OLA = oligonucleotide ligation assay; RFLP = restriction fragment length polymorphism; PAGE = polyacrylamide gel electrophoresis; HBeAg = hepatitis B e antigen; HBV = hepati
18、tis B virus. jnci.oxfordjournals.org JNCI | Articles 1069was evaluated using the H9273 2test, P values, and I 2statistics ( 27 ). A random-effects model was used to obtain summary odds ratios or relative risks. We conducted a sensitivity analysis in which one study was removed and the rest were anal
19、yzed to evaluate whether the results were affected statistically significantly. Publication bias was evaluated by using funnel plots and the Egger test ( 28 ). A P value less than .1 was considered to indicate statistically signifi-cant publication bias. We stratified the HBV-infected participants i
20、nto age-, sex-, HBV genotype , and HBeAg status matched groups and then calculated the summary risk of HCC for HBV mutations. We also conducted analyses by grouping the control subjects according to stages (asymptomatic HBsAg carrier states, chronic hepatitis B, and liver cirrhosis) of chronic HBV i
21、nfection; the meta-analyses were performed using Review Manager version 5.0 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Summary estimates of HCC for PreS mutations, C1653T, T1753V, A1762T/G1764A, G1896A, and C1858T (a C-to-T substitution at nucleotide 1858) for pat
22、ients with HCC were calculated with the use of Stata software (version 9.1; Stata Corp, College Station, TX). The H9273 2test was used to examine differences in categorical variables, such as the frequen-cies of HBV mutations between subjects with and without HCC. A P value less than .05 was conside
23、red statistically significant. Epi Info software (version 3.3.2; http:/www.cdc.gov/epiinfo/epiinfo.htm ) from the Centers for Disease Control and Prevention (Atlanta, GA) was used for the analysis of linear trends in propor-tions of HBV mutations during the progression of HBV chronic infections. To
24、calculate the sensitivity and the specificity of single mutation and combined mutations for HCC, 2 2 tables were generated by using the pooled data for HCC and non-HCC sub-jects with and without a specific HBV mutation or combined mutations. The sensitivity was calculated as the ratio of HCC patient
25、s with the specific HBV mutation(s) to the HCC patients with and without the mutation(s); the specificity was calculated as the ratio of the non-HCC patients (or participants) without the specific HBV mutation(s) to the non-HCC patients (or partici-pants) with and without the mutation(s). All statis
26、tical tests were two-sided. Results We identified 1258 potentially relevant articles from our search of the published literature. We excluded 1215 articles, resulting in 43 articles for analysis ( Figure 1 ). Of the 43 included studies, 13 were from Mainland China ( 13 , 29 40 ), four were from Japa
27、n (41 44), seven were from Taiwan ( 15 17 , 45 48 ), three were from the United States ( 22 , 49 , 50 ), four were from Korea ( 51 54 ), two were from Hong Kong ( 14 , 55 ), two were from Gambia ( 56 , 57 ), one each were from Vietnam ( 58 ) and South Africa ( 59 ), and six were from two or more cou
28、ntries or regions ( 12 , 23 ,60 63 ). We found no related or relevant meta-analyses in the Cochrane library. A summary of the 43 included studies is given in Table 2 . These studies included 11 582 HBV-infected par-ticipants, of whom 2801 had HCC. The most commonly reported HBV mutations associated
29、with HCC risk were PreS mutations, A1762T/G1764A, G1896A, T1753V, C1653T, and C1858T. The risk estimates of HCC for PreS mutations, C1653T, T1753V, A1762T/G1764A, G1896A, and C1858T in individual case control and cohort studies and summary estimates are shown in Figure 2 . Overall, we observed stati
30、stically signifi cant associations between PreS mutations (summary OR = 3.77, 95% CI = 2.57 to 5.52), C1653T (summary OR = 2.76, 95% CI = 2.09 to 3.64), T1753V (summary OR = 2.35, 95% CI = 1.63 to 3.40), and A1762T/G1764A (summary OR = 3.79, 95% CI = 2.71 to 5.29), and the risk of HCC in both case c
31、ontrol and cohort studies. However, C1858T and G1896A were not statistically signifi cantly associated with HCC risk. Statistically signifi cant heterogeneity was found among studies of PreS mutations, T1753V, A1762T/G1764A, C1858T, and G1896A. When we excluded the publication(s) with statistically
32、signifi cant heterogeneity and repeated the analysis, the summary estimates for PreS mutations, T1753V, A1762T/G1764A, C1858T, and G1896A did not change statistically signifi cantly. Egger s test suggested no statistically signifi cant publication bias for the studies of C1653T, T1753V, A1762T/G1764
33、A, C1858T, and G1896A. However, statistically signifi cant publication bias was found in the studies of PreS mutations (Egger test t value = 3.47, 95% CI = 1.29 to 6.80, P = .01). The funnel plot for the studies of PreS mutations showed an asymmetrical distribution of the studies ( Figure 3 ), indic
34、ating publication bias . We extracted adjusted odds ratios and relative risks from the included studies. The summary adjusted odds ratio for PreS muta-tions from four studies ( 16 , 33 , 43 , 45 ) was 6.18 (95% CI = 2.63 to 14.47), for C1653T from fi ve studies ( 12 , 23 , 35 , 42 , 60 ) was 3.45 (9
35、5% CI = 1.12 to 10.65), for T1753V from six studies ( 12 , 23 , 35 , 42 , 46 , 60 ) was 2.56 (95% CI = 1.05 to 6.22), for A1762T/G1764A from 11 studies ( 12 , 15 , 17 , 23 , 35 , 42 , 45 , 46 , 50 , 55 , 60 ) was 4.87 (95% CI = 2.21 to 10.70), and for G1896A from nine studies ( 12 , 17 , 23 , 35 , 4
36、2 , 45 , 46 , 50 , 60 ) was 1.21 (95% CI = 0.72 to 2.03) ( Supplementary Figure 1 , available online). The summary adjusted relative risks for A1762T/G1764A and G1896A from two cohort studies ( 48 , 49 ) were 1.93 (95% CI = 1.27 to 2.92) and 1.12 (95% 1535 citations identified by search277 duplicate
37、 studies 1011 articles excluded after title review 302 not relevant to HBV mutation or HCC187 TP53 gene mutation and HBV 144 associated with antivirus treatment 378 associated with HCV 247 abstracts retrieved 175 articles excluded after abstract review 117 not relevant to HBV mutations 58 not releva
38、nt to HCC 72 full manuscripts retrieved29 articles excluded after review of full text 19 lacked control data2 participants coinfected with HCV or HDV3 authors published 2 related papers 5 small sample size 43 studies included in meta-analysis 1258 potentially relevant citations identifiedFigure 1 .
39、Flow chart of article selection. HBV = hepatitis B virus; HCC = hepatocellular carcinoma; HCV = hepatitis C virus; HDV = hepatitis D virus. 1070 Articles | JNCI Vol. 101, Issue 15 | August 5, 2009Table 2.Characteristics of studies included in the meta-analysis * Study: first author, year (reference)
40、DesignCountry or areaMean age, yMale (%)No. of case subjectsNo. ofcontrolsubjects orsubjectsin cohortMutation siteDetection methodHBV genotypeQuality score Matching factorsAgeSexHBeAg statusGenotype Huy, 2003 ( 63 )PCC12 countries H11002H1100249338PreS1, PreS2SA, B, C, D, E, FH11002H11002H11002H1100
41、25 7 Kim, 2008 ( 53 )PCCKoreaH11002H1100260124C1653T, T1753V, A1762T/G1764ASCH11002H11002H11002+5 7 Mun, 2008 ( 54 )PCCKoreaH11002H110024080PreS1, PreS2SC2H11002H11002H11002+5 7 Sakamoto, 2006 ( 61 ) PCCJapan, Philippines53.7873169C1653T, A1762T/ G1764A, C1858T, G1862T, G1888H, G1809T, C1812T, G1896
42、ASA, B, CH11002+ H11002H110025 7 Yuan, 2007 ( 13 ) PCCChina49.591.234207C1653T, T1753V, A1762T/G1764A, T1856C, C1858T, G1896A, G1898A, G1899ASB, C+H11002+5 7 Zhang, 2006 ( 37 )PCCChinaH11002H110023057A1762T/G1764AHNDH11002H11002H11002H110024 Zhou, 2007 ( 39 )PCCChinaH11002H110023678A1762T/G1764A, G1
43、896AHNDH11002H11002H11002H110024 Baptista, 1999 ( 59 ) PCCSouth AfricaH11002H110025952T1753V, A1762T/G1764A, G1809T, C1812TSND+H11002H11002H110025 7 Blackberg, 2003 ( 62 )PCCSweden, others 6181.31619T1753V, A1762T/ G1764A, G1896A, PreS1, PreS2SA, B, C, DH11002+8 Chen, 2006 ( 45 ) PCCTaiwan45.288.050
44、102A1762T/G1764A, G1896A, PreSINNO-LiPAB, C+H11002H11002H110025 7 Choi, 2007 ( 51 )PCCKorea51.980.672228PreS1, PreS2SCH11002H11002+5 7 Deng, 2004 ( 30 )ICCChinaH11002H11002114100A1762T/G1764APCR and ELISANDH11002H11002H11002H110024 Ding, 2006 ( 31 )ICCChina47.587.54040A1762T/G1764AGCB, CH11002H11002
45、H11002H110024 Fang, 2002 ( 32 ) PCCChinaH11002H1100236115A1762T/G1764A, G1896ASB, CH11002H11002H11002H110024 Gao, 2007 ( 33 )PCCChina55.688.52653PreS1, PreS2SCH11002H11002H11002+5 7 Ito, 2006 ( 60 )ICCJapan, United States, Hong Kong50.790.04080C1653T, T1753V, A1762T/G1764A, G1896ASND+8 Laskus, 1998
46、( 56 )ICCGambia45.4852733A1762T/G1764A, G1896A, G1899ASND+H11002H110025 7 Lin, 2007 ( 16 )ICCTaiwan558964202PreSEB, CH11002H11002H11002+ 4 (Table continues)jnci.oxfordjournals.org JNCI | Articles 1071Study: first author, year (reference)DesignCountry or areaMean age, yMale (%)No. of case subjectsNo.
47、 ofcontrolsubjects orsubjectsin cohortMutation siteDetection methodHBV genotypeQuality score Matching factorsAgeSexHBeAg statusGenotype Liu, 2006 ( 17 )PCCTaiwan5461.9200160A1762T/G1764A, G1896AINNO-LiPAB, CH11002H11002H11002H110024 Livingston, 2007 ( 22 )ICCUnited States39.174471129A1762T/G1764A, G
48、1896AINNO-LiPAA, C, D, F+H11002+5 7 Muroyama, 2006 ( 41 ) PCCJapan56.5953936C1485T, A1762T/G1764A, G1896ASC+H11002+5 7 Mendy, 2008 ( 57 )PCCGambiaH11002H1100213889A1762T/G1764A, G1896AOLANDH11002H11002H11002H110024 Ni, 2003 ( 47 )ICCTaiwan9.6751231G1896ASND+H11002H11002H110024 Shinkai, 2007 ( 42 ) P
49、CCJapan5585.08080C1653T, T1479C, C1485T, G1499H, G1613A, T1753V, A1762T/G1764A, G1896ASC2+8 Song, 2005 ( 58 )PCCVietnam5683.34874A1762T/G1764A, G1766A, T1773C, C1858TSNDH11002+ H11002H110024 Sugauchi, 2003 ( 43 )PCCJapanH11002H1100224136PreS1, PreS2SB, C+H110025 7 Sung, 2008 ( 14 )ICCHong Kong5180100100T31C, T53C, C1165T, A1499G, G1613A, A1762T/G1764A, G1899A, T2170C/G, T2441C, A/T2525C, T2712VSB, C1, C2+H11002H110025 7 Tan
