1. Introduction. Journal of Hepatology 39 (2003)

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1 Journal of Hepatology 39 (2003) Lymph node enlargement within the hepatoduodenal ligament in patients with chronic hepatitis C reflects the immunological cellular response of the host Pierre Muller 1, Christophe Renou 2, *, Abdelouahid Harafa 2, Elisabeth Jouve 3, Gilles Kaplanski 4, Eric Ville 5, Jean-Jacques Bertrand 6, Caroline Masson 2, Thierry Benderitter 7, Philippe Halfon 8 1 Imagerie Médicale, Centre Hospitalier d Hyères, Hyères, France 2 Unité d Hépato-Gastroentérologie, Centre Hospitalier d Hyères, Hyères, France 3 CPCET, Hôpital de la Timone, Marseille, France 4 Laboratoire d Immunologie, Hôpital Sainte-Marguerite, Marseille, France 5 Service d Hépato-Gastroentérologie, Hôpital de la Timone, Marseille, France 6 Unité de Virologie, Centre Hospitalier d Hyères, Hyères, France 7 Laboratoire d Anatomo-pathologie, Toulon, France 8 Laboratoire Alphabio, Marseille, France Background/Aims: Lymph nodes in the hepatoduodenal ligament seem to be a common ultrasonographic finding in patients with chronic hepatitis C. Lymphadenopathic enlargement is associated with the histological hepatic features reflecting the immunological response of the host, but the correlation between lymphadenopathy, liver histology and the cellular immunoreactivity of the host has never been studied. Aim: (1) To specify the prevalence of within the hepatoduodenal ligament; and (2) to investigate whether lymphadenopathies might reflect the immunological response of the host. Methods: One hundred and eleven patients were enrolled in this study. Eleven chronic hepatitis B patients and 34 healthy volunteers served as controls. Results: Lymph nodes were detectable in 90 out of the 104 chronic hepatitis C patients studied. After logistic regression, a high CD8 level and the absence of post hepatitis C cirrhosis were associated with lymph node enlargement. The total lymph node volume was correlated with transaminase levels, inflammatory activity, and stage of fibrosis. Conclusions: (1) The prevalence of within the hepatoduodenal ligament is high; (2) lymph node enlargement is correlated with the immunological cellular response of the host; and (3) the total lymph node volume is correlated with hepatic necroinflammatory markers and the stage of fibrosis. q 2003 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Keywords: Chronic hepatitis C; Cirrhosis; Lymph node; Immunological response; Host 1. Introduction Inflammatory processes in organs frequently leads to hyperplasia of the regional. Enlargement of in the hepatoduodenal ligament is a common finding during ultrasonography in patients with chronic hepatitis C, but the exact prevalence is not known (from 22 Received 7 February 2003; received in revised form 19 June 2003; accepted 7 July 2003 * Corresponding author. Tel.: þ ; fax: þ address: crenou@ch-hyeres.fr (C. Renou). to 100%) because of the discrepancies existing between various studies [1,2]. The portal lymphodenopathic process in this group of patients is not yet clearly understood, but a positive correlation between (presence or volume) and hepatitis C viremia (presence or quantitative HCV-RNA) has been found to exist in previous studies, which suggests that lymphopathy might be the expression of a virological process [1,3]. The total lymph node volume has also been reported to be correlated with some histological features of the liver [1], which may reflect the immunologic response of the host. However, the question as to whether there exists a correlation between lymphadenopathy, liver histology and the cellular immunoreactivity of /$30.00 q 2003 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi: /s (03)00357-x

2 808 P. Muller et al. / Journal of Hepatology 39 (2003) the host has never been investigated so far to our knowledge. The aim of this study was to specify the prevalence of within the hepatoduodenal ligament and to investigate whether the existence of these lymphadenopathies might reflect the immunological response of the host in patients chronically infected with the hepatitis C virus. 2. Patients and methods 2.1. Patients Between January 2001 and April 2002, a total of 111 consecutive patients with histologically proven chronic hepatitis C were enrolled in the present study. In 104 (64 men and 40 women; age range, years; mean age, 44.9 ^ 11.4 years) of the 111 patients, adequate visualization of the hepatoduodenal ligament was achieved using a transabdominal ultrasound procedure. The reason for inadequate vizualization in the seven other patients was obesity. All 104 patients were negative for immunodeficiency antibody and had a daily alcoohol consumption of less than 20 g/day in the case of the women and 40 g/day in that of the men. Possible causes of perihepatic lymph node enlargement, including hepatopathies of other origin or malignant diseases, were ruled out on the basis of appropriate clinical, laboratory, and imaging investigations. The diagnosis of chronic hepatitis C was based on (1) an elevated ALT level for more than 3 months; (2) positive anti-hcv antibodies; and (3) presence of serum HCV-RNA detected by performing a standardized reverse transcription-polymerase chain rection (RT-PCR) using the Cobas Amplicor HCV version 2.0 test (Roche Molecular Systems, Branchburg, NJ, USA) with a lower detection limit of 50 IU/ml. The duration of the HCV infection was taken to be the time elapsing between the date of the first exposure to a risk factor (blood transfusion or first year of exposure to an intravenous drug) and the date of inclusion in this study Methods The subjects serum HCV-RNA levels were determined using the Cobas Amplicor HCV monitor version 2.0 test (Roche Diagnostics Branchburg, USA) with a detection threshold of 800,000 IU/ml. The HCV genotype was determined by performing a reverse hybridization assay (INNO-LiPA HCV II, Innogenetics, Ghent, Belgium). The total CD3, CD4, and CD8 lymphocyte levels were assessed in the blood using a flow cytometry system with monoclonal antibodies (Epicsw XL,Coulter Corporation, Miami, USA). The following laboratory tests for statistical analysis were run using commercially available kits: serum aspartate aminotransferase (AST, N, 37 U/l), serum alanine aminotransferase (ALT, N, 65 U/l), total serum gamma-globulin (6, N, 10 g/l), Ig G (5.6, N, 14.8 g/l), IgA (0.5, N, 4.1 g/l), IgM (0.2, N, 2.7 g/l). All the liver biopsy specimens were examined by the same experienced pathologist (T.B.), who was unaware of the virological and immunological data or the lymph node status of each patient. Biopsy specimens were assessed in terms of the histological activity index (HAI) described by Knodell et al. [4] and were also classified by grading and staging using the Metavir score [5]. Lymph nodes within the hepatoduodenal ligament were detected by performing transabdominal sonography (Odyssée, Ecoscan, Hitachi, France) at the time of the liver biopsy (ultrasound-guided liver biopsy) before any antiviral therapy was started. The sonographic examination was performed entirely in the morning on the patients after at least 12 h of fasting. Lymph nodes were all assessed by the same experienced radiologist (P.M.), who had no knowledge of the patients virological, histological, and immunological characteristics. Individual lymph node volume was expressed using the formula for an ellipsoid ½a=2 ðb=2þ2 4=3 PŠ, where a was measured on the longest axis of the node and b on the corresponding perpendicular axis. The two dimensions of each lymph node (a and b) were expressed in centimeters. The volumes of all individual within the hepatoduodenal ligament were added together and expressed in each patient as the total lymph node volume (ml or cm 3 ). Control subjects consisting of 34 healthy volunteers without any liver disease and 11 patients with chronic hepatitis B were examined during the same period. An appropriate ultrasound examination of the hepatoduodenal ligament was performed on 30 healthy volunteers and 10 patients with chronic hepatitis B. As with the patients with chronic hepatitis C, obesity was the only reason for unclear vizualization in five of the control subjects. The study was conducted in keeping with the 1975 Helsinki Declaration, and all the patients and control subjects gave their prior informed consent to the procedure Statistical analysis The significance level was taken to be P, 0:05 in all the statistical tests. The prevalence of was compared between chronic hepatitis C patients, chronic hepatitis B patients and healthy volunteers using the Chi square test. The significance level was assessed in univariate analyses using Student s test to compare quantitative values and Fisher s exact test to compare qualitative values. The Mann Whitney U-test was used to compare non-parametric variables in independent samples. Multivariate analysis was carried out by logistic regression. To assess the independent relationships between the CD3, CD4, CD8 levels and the presence of within the hepatoduodenal ligament, we started the multivariate analysis by including each of the lymphocyte counts, which was significantly different between patients with and without in the univariate analysis adjusted for objective criteria. Adjusted ORs and 95% confidence intervals were obtained from the coefficient of the final multivariate logistic model. The correlations between total lymph node volume and the patients demographic, virological, histological, and immunological characteristics were assessed using the Spearman correlation coefficient for the quantitative characteristics and the Kruskal Wallis or Mann Whitney test for the qualitative characteristics. Statistical analysis was performed using the Statistical Analysis System (SAS 8.1). 3. Results 3.1. Detection of in the hepatoduodenal ligament Lymph nodes were detectable in 90 of the 104 (87%) patients with chronic hepatitis C, in three of the 10 (30%) patients with chronic hepatitis B, and in six of the 30 (20%) healthy controls (Fig. 1). The prevalence of Fig. 1. Enlarged lymph node (LN) detected by abdominal ultrasonography in the hepatoduodenal ligament of a patient with chronic hepatitis C and no cirrhosis. HA, hepatic artery; PV, portal vein; IVC, inferior vena cava; AO, abdominal aorta; MSA, mesenteric superior artery; SA, splenic artery; PANC, pancreas.

3 P. Muller et al. / Journal of Hepatology 39 (2003) Table 1 Univariate analysis of epidemiological, biochemical, virological, and immunological characteristics and the presence of in chronic hepatitis C patients Enlargement of No enlargement of P value (N ¼ 90) (N ¼ 14) Age at the time of inclusion 44.0 ^ ^ a (years, mean ^ S.D.) Females (F/M ratio) 33/57 7/ b Estimated duration of infection c 19.9 ^ ^ d (years, mean ^ S.D.) Mode of contamination (%) Drug usage 59 (65.5) 7 (50) Transfusion 14 (15.5) 3 (21) 0.49 b Others 17 (19) 4 (29) Aspartate aminotransferase (U/l) 36.2 ^ ^ a Alanine aminotransferase (U/l) 87 ^ ^ a HCV genotype (%) 1 49 (55) 10 (71) 2 7 (8) 0 (0) 0.73 b 3 24 (27) 4 (29) 4 8 (9) 0 (0) 5 2 (2) 0 (0) Serum HCV-RNA (UI/ml, mean ^ S.D.) 2,025,414 ^ 2,067,562 1,433,000 ^ 886, a g-globulin (g/l, mean ^ S.D.) ^ ^ a Ig G (g/l, mean ^ S.D.) ^ ^ a IgA (g/l, mean ^ S.D ^ ^ a Ig M (g/l, mean ^ S.D.) 1.10 ^ ^ a CD3 (/mm 3, mean ^ S.D.) ^ ^ d CD4 (/mm 3, mean ^ S.D.) ^ ^ d CD8 (/mm 3, mean ^ S.D.) ^ ^ a CD4/CD8 ratio (mean ^ S.D.) 1.93 ^ ^ a a Mann Whitney test. b Fisher exact test. c Number of patients with a known blood risk factor for HCV contamination: 73/90 with and 10/14 without. d Student test. was significantly higher in the first group than in the two latter ones (P, 0:001) Correlation between demographic, virological, histological, immunological data and the presence of in the hepatoduodenal ligament of patients with chronic hepatitis C As shown in Table 1, the age at the time of the study was the only demographic parameter which differed significantly between the group with (n ¼ 90) and that without any (n ¼ 14). Patients of a younger age were found to be more likely to show enlarged (44.0 ^ 11.2 vs ^ 11.3 years, P ¼ 0:03). Neither the patients sex, the estimated duration of infection, nor the risk factors responsible for contamination were associated with any enlargement of the lymph nodes. Nor were the liver function tests (AST and ALT) correlated with the presence of. No significant correlation was found to exist between HCV genotypes and lymph node enlargement, even upon performing an analysis with separate subtypes (data not shown). No correlations were observed between enlarged and serum HCV-RNA levels, which suggests that the prevalence of was not correlated with any of the viral characteristics studied (Table 1). The correlations between histological scores (Knodell and METAVIR) and were assessed (Table 2). Lymph node enlargement was not found to be correlated with the total HAI of the Knodell score or with the four distinct histological subgroups in the HAI (portal inflammation, periportal necrosis, intralobular necrosis, and fibrosis). In contrast, a positive correlation was observed with both the Knodell and METAVIR scores between lymph node enlargement and the absence of post hepatitis C cirrhosis (P ¼ 0:006). No apparent correlations were observed between lymph node enlargement and the humoral response of the host, as assessed in this study by comparing the total serum gamma-globulin, Ig G, Ig A, and Ig M levels between HCV patients with and without, whereas the cellular response of the host was positively correlated with the presence of. Univariate analysis of individual baseline characteristics showed that elevated CD3 (P ¼ 0:01), CD4 (P ¼ 0:03) and CD8 (P ¼ 0:02)

4 810 P. Muller et al. / Journal of Hepatology 39 (2003) Table 2 Univariate analysis of histological characteristics and the presence of (Knodell and METAVIR scores) in chronic hepatitis C patients Enlargement of No enlargement of P value (N ¼ 90) (N ¼ 14) HAI (Knodell) (mean ^ S.D.) 8.5 ^ ^ a Portal inflammation (Knodell) (mean ^ S.D.) 2.6 ^ ^ a Periportal necrosis (Knodell) (mean ^ S.D.) 2.2 ^ ^ a Intralobular necrosis (Knodell) (mean ^ S.D.) 1.9 ^ ^ a Fibrosis (Knodell) (mean ^ S.D.) 1.8 ^ ^ a Cirrhosis (%) F4 (METAVIR) 18 (20) 8 (57) b or fibrosis ¼ 4 (Knodell) Grade of activity (METAVIR) (mean ^ S.D.) 1.9 ^ ^ a Stage of fibrosis (METAVIR) (mean ^ S.D.) 1.9 ^ ^ a a Mann Whitney test. b Fisher exact test. lymphocyte subsets were each predictive of the presence of lymphodenopathy. After stepwise logistic regression, a low CD8 lymphocyte subset was the only significant immunological factor to be negatively correlated with lymph node enlargement. This statistical analysis provided an estimate of the effect of the CD8 level on lymph node enlargement; the results of the unadjusted analysis were significant [OR ¼ 0.24, 95% CI ( ), P ¼ 0:02, Table 1] and were still significant after adjustment with the baseline characteristics [OR ¼ 0.21, 95% CI ( ), P ¼ 0:003, Table 3]. The presence of a post hepatitis C cirrhosis was also negatively correlated with lymph node enlargement in this model (P ¼ 0:01), but this factor appeared to be less important in comparison with the low CD8 lymphocyte subset (Table 3) Lymph node volume in the hepatoduodenal ligament The total lymph node volume within the hepaticoduodenal ligament of chronic hepatitis C was found to have increased, although not significantly, in comparison with patients with chronic hepatitis B and healthy volunteers (chronic hepatitis C ¼ 0.9 ^ 0.8 ml, chronic hepatitis Table 3 Multivariate analysis of factors associated with the enlargement of within the hepatoduodenal ligament Odds ratio (95% CI) P value Age at the time of inclusion: 0.59 under 50 years (vs. ^ 50 years ) Low CD3 value (vs. normal or elevated value) 0.32 Low CD4 value (vs. normal or elevated value) 0.47 Low CD8 value (vs. normal or elevated value) 0.21 [ ] Cirrhosis (vs. no cirrhosis) F4 (METAVIR) 0.17 [ ] 0.01 or fibrosis ¼ 4 (Knodell) B ¼ 0.5 ^ 0.3 ml, healthy volunteers ¼ 0.7 ^ 0.3, P ¼ 0:49) Correlation between demographic, virological, histological, immunological data and the total lymph node volume in the hepatoduodenal ligament of patients with chronic hepatitis C Chronic hepatitis C patients without any within the hepaticoduodenal ligament were not included in this statistical analysis (n ¼ 14). A significant positive association was observed between the lymph node volume of the 90 remaining patients and the levels of the serum transaminases (AST, P ¼ 0:003; ALT, P ¼ 0:02, Table 4). Morever, the correlations observed between the total lymph node volume and the total HAI showed the existence of a positive trend between these two parameters, although these Table 4 Correlations between total volume and different quantitative variables in chronic hepatitis C patients with enlargement of (n 5 90) Spearman correlation coefficients (R and P values) Age at the time of inclusion (years) 0.02 (P ¼ 0:87) Estimated duration of infection (years) (P ¼ 0:19) a Aspartate aminotransferase (U/l) 0.31 (P ¼ 0:003) Alanine aminotransferase (U/l) 0.24 (P ¼ 0:02) Serum HCV-RNA (UI/ml) 0.03 (P ¼ 0:71) g-globulin (g/l) 0.11 (P ¼ 0:27) Ig G (g/l) 0.12 (P ¼ 0:26) IgA (g/l) 0.12 (P ¼ 0:25) Ig M (g/l) (P ¼ 0:82) CD3 (/mm 3 ) (P ¼ 0:11) CD4 (/mm 3 ) (P ¼ 0:09) CD8 (/mm 3 ) (P ¼ 0:27) CD4/CD8 ratio (P ¼ 0:92) HAI (Knodell) 0.18 (P ¼ 0:09) a 73 patients with had a known blood risk factor for HCV contamination.

5 P. Muller et al. / Journal of Hepatology 39 (2003) Table 5 Relationship between total volume and qualitative variables in chronic hepatitis C patients with enlargement of lymph nodes (n 5 90) Mean ^ S.D. P value Fig. 2. Grade of activity according to METAVIR scoring system and the total lymph node volume in chronic hepatitis C patients. results were not statistically significant (P ¼ 0:09, Table 4). This trend was observed more clearly with the grade of activity when using the Metavir scoring system (Fig. 2). Finally, the total lymph node volume in HCV-infected patients was positively correlated with the stage of fibrosis in terms of the Knodell score (P ¼ 0:01) and the METAVIR score (P ¼ 0:03; Table 5, Fig. 3). Using the METAVIR score, the mean lymph node volume in chronic hepatitis C patients with F0 (n ¼ 14), F1 (n ¼ 27), F2 (n ¼ 18), F3 (n ¼ 13), and F4 (n ¼ 18) was 0.5 ^ 0.3 ml, 0.7 ^ 0.4 ml, 0.8 ^ 0.5 ml, 1.0 ^ 0.5 ml, and 1.4 ^ 1.4 ml, respectively (Fig. 3). Similar statistical results were obtained using the Knodell score (Fig. 3). 4. Discussion The results of the present study confirm that lymph node enlargement occurring within the hepatoduodenal ligament in patients with chronic hepatitis C is a common ultrasound finding [1,6]. The discrepancies between various previous studies on lymph node prevalence may have been partly due to the virological characteristics of the HCV patients included. In fact, those studies where a lower prevalence of was observed were carried out on patients with positive HCV-RNA viremia along with patients with a spontaneous resolution of HCV infection [2,3]. In contrast, Dietrich et al. detected in all 104 HCV chronically infected patients with appropriate vizualization of the liver hilus [1]. It can be hypothesized that the absence of lymph node enlargement may reflect a lack of immunological response by the host in the absence of HCV in the blood and liver. In the present study, were detected in six of the 30 healthy volunteers (20%) and in three of the 10 patients (30%) with chronic hepatitis B. The low prevalence of enlarged observed in these two populations as compared with the data published in the study by Metreweli et al. and Choi et al. was probably due to the small size of our two control populations [7,8]. Sex Male 0.74 ^ a Female 1.04 ^ 0.97 Mode of contamination Drug usage 0.98 ^ b Transfusion 0.63 ^ 0.21 Others 0.95 ^ 0.92 HCV genotype ^ b ^ ^ ^ ^ 0.26 Portal inflammation (Knodell) ^ a ^ ^ ^ ^ 1.31 Periportal necrosis (Knodell) ^ a ^ ^ ^ ^ 0.63 Intralobular necrosis (Knodell) ^ a ^ ^ ^ ^ 1.29 Fibrosis (Knodell) 0.01 a ^ ^ ^ ^ 1.52 Cirrhosis: F4 (METAVIR) or fibrosis ¼ 4 (Knodell) 1.46 ^ a No cirrhosis 0.79 ^ 0.50 Grade of activity (METAVIR) ^ a ^ ^ ^ 1.00 Stage of fibrosis (METAVIR) ^ a ^ ^ ^ ^ 1.48 a Kruskal Wallis test. b Mann Whitney test. The present findings show that enlarged hepatoduodenal occur significantly more frequently in HCV patients in the absence of post hepatitis C cirrhosis. A correlation between post hepatitis C cirrhosis and

6 812 P. Muller et al. / Journal of Hepatology 39 (2003) Fig. 3. Stage of fibrosis according to METAVIR index and Knodell score and the total lymph node volume in chronic hepatitis C patients. the presence of enlarged in the hepatoduodenal ligament has been assessed previously only by Cassani et al. [3]. There are at least two possible reasons why no correlations were observed in the latter study between this liver complication and. First, Cassani s patients were not always HCV-RNA positive, as were all the patients in our own study. Secondly, in Cassani s report, the diagnosis of cirrhosis was mainly based on clinical evidence (ascites, esophageal varices), whereas the evidence was only histological in the present study. From the clinical point of view, it would be possible to reassure worried HCV patients when enlarged are detected in the hepatoduodenal ligament during an abdominal sonography performed in the course of the viral infection. In fact, the enlargement of was found in this study to be correlated with the absence of post hepatitis C cirrhosis. Whatever the stage of liver disease involved, the presence of enlarged suggests either the occurrence of a change in viral parameters such as a rise in the viral replication rate or an increase in the immunemediated inflammatory response to the host. The former hypothesis can be ruled out in this study, since the serum HCV-RNA level was not selected as predictor of enlarged when performing the univariate analysis on the data. Nevertheless, Cassani et al. observed a correlation between the presence or absence of HCV-RNA in the serum and the enlargement of the abdominal in a group of patients with positive anti-hcv [3]. These results suggest that the existence of HCV-RNA in the serum but not the degree of HCV-RNA replication may be correlated with the enlargement of. Few studies have focused so far on the possible correlations between the immunoreactivity and more specifically the cellular immune response of the host, and the occurrence of enlarged within the hepatoduodenal ligament. Only two studies have dealt with the correlations between the humoral response associated with HCV infection and lymph node enlargement; and none of them have brought to light the existence of any relationship between these two parameters as done here [2,3]. To our knowledge, this is the first time that a correlation between and the cellular response of the host has been observed. One of the main results obtained in this study was the positive relationship observed between lymph node volume and two hepatic necroinflammatory markers: the levels of the serum transaminases and the inflammatory activity of the liver. A strong correlation was also observed between lymph node volume and the stage of fibrosis using Knodell and METAVIR scores. A significant positive correlation between lymph node volume and inflammatory liver activity was previously described in two studies where HCV patients had larger and severe inflammatory activity [1,9]. Morever, the decrease in the total lymph node volume seems to be associated with an improvement in the histological activity index after virological treatment in HCV patients with a sustained virological response [10]. All in all, these data suggest that the size of the developing in the hepatoduodenal ligament might serve as a marker of histological liver status in HCV patients who have undergone no prior therapy and a marker of therapeutic response after successful virological treatment. Local lymph node enlargement during chronic hepatitis C is more likely to be due to HCV lymphocyte proliferation and clonal expansion, a common finding during the immune response to infection. Since no lymph node biopsies were performed in this study, we looked at the liver histology along with blood T cell subpopulations, in order to assess the immune response. Lymph node enlargement was found to be positively associated with the absence of cirrhosis, the CD4 counts, and more importantly, the CD8 counts. In addition, lymph node volume was correlated with liver inflammation. Although these data are certainly indirect evidence, they are in agreement with recent animal and human studies showing that the T cells, and especially the CD8 responses, are involved in the control of HCV infection and explain chronic liver damage [11,12]. On the other hand, the absence of lymph node enlargement in patients with cirrhosis may be attributable to immune exhaustion and predominant fibrosis, possibly secondary to excess transforming growth factor beta secretion, a cytokine abundantly produced by liver cells [13]. Another explanation may be lymph node architecture destruction, as occurs in the case of HIV infection [14]. Interestingly, a correlation between lymph node enlargement and liver inflammation has been observed in primary biliary cirrhosis, another model of chronic liver inflammation [15]. In the latter case, however, cirrhosis did not appear to be associated with the absence of, which suggests that this finding may be somewhat specific to viral diseases. In conclusion, the present study confirms the high lymph node prevalence occurring within the hepatoduodenal ligament in patients with chronic hepatitis C in comparison with chronic hepatitis B patients and healthy subjects. In patients with chronic hepatitis C, the occurrence of enlargement and the total lymph node volume are strongly correlated with the histological liver features. The absence

7 P. Muller et al. / Journal of Hepatology 39 (2003) of in this setting is predictive of the existence of an end-stage in the liver disease and might be partly due to a decrease in the cell-mediated response. Acknowledgements The authors would like to thank Jacques Renou (MSc, Eng) for the very helpful discussion of the manuscript. References [1] Dietrich CF, Lee J-H, Herrmann G, Teuber G, Roth WK, Caspary WF, et al. Enlargement of perihepatic in relation to liver histology and viremia in patients with chronic hepatitis C. Hepatology 1997;26: [2] Soresi M, Carroccio A, Bonfissuto G, Agate V, Magliarisi C, Aragona F, et al. Ultrasound detection of abdominal lymphadenomegaly in subjects with hepatitis C virus infection and persistently normal transaminases: a predictive index of liver histology severity. J Hepatol 1998;28: [3] Cassani F, Valentini P, Cataleta M, Manotti P, Francesconi R, Giostra F, et al. Ultrasound-detected abdominal lymphadenopathy in chronic hepatitis C: high frequency and relationship with viremia. J Hepatol 1997;26: [4] Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz N, et al. Formulation and application of a numerical scoring system for assessing histological activity in asymptomatic chronic active hepatitis. Hepatology 1981;1: [5] The METAVIR cooperative group, Inter and intra-observer variation in the assessment of liver biopsy of chronic hepatitis C. Hepatology 1994;20: [6] Lyttkens K, Prytz H, Forsberg L, Hederström E, Hägesrtrand I. Ultrasound, hepatic and chronic active hepatitis. J Hepatol 1994;21: [7] Metreweli C, Ward SC. Ultrasound demonstration of in the hepatoduodenal ligament ( Daisy Chain nodes ) in normal subjects. Clin Radiol 1995;50: [8] Choi MS, Lee JH, Koh KC, Paik SW, Rhee P-L, Kim JJ, et al. Clinical significance of enlarged perihepatic in chronic hepatitis B. J Clin Gastroenterol 2001;32: [9] Wedemeyer H, Ockenga J, Frank H, Tillmann HL, Schuler A, Caselitz M, et al. Perihepatic lymphadenopathy: a marker of response to interferon alpha in chronic hepatitis C. Hepatogastroenterology 1998; 45: [10] Dietrich CF, Stryjek-Kaminska D, Teuber G, Lee JH, Caspary WF, Zeuzem S. Perihepatic as a marker of antiviral response in patients with chronic hepatitis C infection. AJR 2000;174: [11] Cooper S, Erickson AL, Adams EJ, Kansopon J, Weiner AJ, Chien DY, et al. Analysis of a successful immune response against hepatitis C virus. Immunity 1999;10: [12] Lechner F, Wong DK, Dunbar PR, Chapman R, Chung RT, Dohrenwend P, et al. Analysis of successful immune response in persons infected with hepatitis C virus. J Exp Med 2000;191: [13] O Farrelly C, Crispe IN. Prometheus through the looking glass: reflections on the hepatic immune system. Immunol Today 1999;20: [14] Pantaleo G, Graziosi C, Demarest JF, Butini L, Montroni M, Fox CH, et al. HIV infection is active and progressive in lymphoid tissue during the clinically latent stage of disease. Nature 1993;362: [15] Dietrich CF, Leuschner MS, Zeuzem S, Herrmann G, Sarrazin C, Caspary WF, et al. Peri-hepatic lymphadenopathy in primary biliary cirrhosis reflects progression of the disease. Eur J Gastroenterol Hepatol 1999;11: