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Ferroportin‐associated iron overload (also known as the ferroportin disease) was clinically recognised in 1999,1 and linked in 2001 to the A77D mutation of ferroportin (FPN).2 Owing to the mild clinical expressivity reported in the literature, doubts have been raised on the penetrance of the genetic defect and the rationale for iron‐removal therapy.3 However, so far, no prospective data have been collected pertaining to this disorder.
The proband (subject V13, table 11)) was diagnosed at the age 59 years. After being on weekly phlebotomy for 2 years, he was on a maintenance programme for 18 years (one phlebotomy every 3 months). At the age of 79 years, he refused to continue on phlebotomy. In 2006, at the age of 83 years, hepatic ultrasound (US) examination of the proband identified two hyperechoic nodules in the liver; contrast‐enhanced MRI scan confirmed the US examination findings and a US‐guided liver biopsy documented a well‐differentiated hepatocellular carcinoma (fig 1A1A),), as shown by antihepatocyte antibody stain (not shown here), in the absence of cirrhosis. Strong p53‐positive stain was also detected in the tumour specimen by using a specific antibody (fig 1B1B).). The level of serum α fetoprotein was 5.0 ng/ml (normal value <10 ng/ml). The patient reported no alcohol intake for the past two decades. No antibodies against hepatitis C virus and hepatitis B virus (HBV) were found. However, HBV sequences corresponding to all the four different viral genomic regions tested were detected by nested PCR in the tumour biopsy specimen. In addition, HBV DNA was also found in the liver specimens collected at the age 59 and 79 years. The patient's liver nodules were treated by chemoembolisation.
All the proband's relatives, underwent regular phlebotomy, except for two who showed low adherence and, after reaching iron depletion, underwent phlebotomy occasionally, usually once a year (subject VI33 and VI36; table 11).). Both patients presented signs of the progression of fibrosis as compared with the first assessment reported in 19991 (fig 1C,D1C,D),), with appreciable increase in portal blood flow in subject VI33 at colour Doppler US examination (velocity 17 cm/s), and liver iron content more than twofold the normal value.
In conclusion, the ferroportin disease may progress if not properly treated, and complicate with liver cancer even without cirrhosis, in the presence of cocarcinogenic factors, such as occult HBV infection. The hallmark of the classic FPN disease is marked iron accumulation in Kupffer cells.4 Kupffer cells are vital in producing fibrogenic mediators,5 in immunological tumour surveillance and disposal of transformed hepatocytes.6,7 Selective and massive iron overload might impair these activities and favour fibrogenesis and carcinogenesis. Macrophage iron overload is very resistant to iron withdrawal in this disorder, even in patients who are apparently well treated (fig 1E,F1E,F).). As for the development of liver cancer in the proband, we speculate that adequate phlebotomy “controlled” the oncogenic potential of HBV (which was present in the patient's liver since his first hospital admission at the age of 59 years). However, once the 20‐year‐long treatment was discontinued, the underlying hepatitis B infection could express its cofactorial oncogenic activity and contribute, with the rising iron burden, to the development of neoplastic nodules. In this vein, iron‐dependent loss in p53 growth‐suppressor activity, also implicated in liver carcinogenesis in classic haemochromatosis,8 may have had a role and facilitated the HBV oncogenic potential.9 Our results prompt for a thorough lifelong maintenance therapy and regular screening for liver cancer in the patients with ferroportin disease.
Competing interests: None.