Two Nomograms to Select Hepatocellular Carcinoma Patients with Macroscopic Vascular Invasion for Hepatic Resection

Background: Hepatocellular carcinoma (HCC) patients with macroscopic vascular invasion (MaVI) have limited lifespans. According to recent studies, surgical treatment may be the most promising option. However, the current staging system does not select patients who will benefit most from hepatic resection. Study design: A total of 123 patients undergoing hepatic resection for HCC with macroscopic vascular invasion (MaVI) between 2010 and 2014 at The Third Affiliated Hospital of Sun Yat-sen University were selected. We developed nomograms for overall survival (OS) and recurrence-free survival (RFS) using a Cox proportional hazards model. We assessed nomogram model performance based on the concordance index (C-index) and a calibration plot. Results: The 1- and 3-year overall survival (OS) rates for all patients were 84% and 71%, respectively. Correspondingly, the 1- and 3-year recurrence-free survival (RFS) rates were 55% and 35%, respectively. In the multivariate Cox model, the extent of vascular invasion, tumour count, fibrinogen, HBV DNA load and serum potassium significantly affected prognosis. The C-index of the two nomograms were 0.80 and 0.69 for OS and RFS respectively. Based on our nomogram, patients predicted to have 1-year and 3-year RFS rates of more than 80% and 56% had actual 1-year and 3-year RFS rates of 81.8% and 57.1%, respectively, including 9.0% and 17.1% of the HCC patients with MaVI in our database. Conclusion: Surgical treatments are a therapeutic option that can provide more survival benefit for HCC patients with MaVI. With the help of our nomograms, selected HCC patients with MaVI can benefit from hepatic resection and have the same survival rate as that for early-stage HCC patients.

Identification and Experimental Validation of the Prognostic Significance and Immunological Correlation of Glycosylation-Related Signature and ST6GALNAC4 in Hepatocellular Carcinoma

PURPOSE

Glycosylation has been demonstrated to be involved in tumorigenesis, progression, and immunoregulation, and to present specific profiles in different tumors. In this study, we aimed to explore the specific glycosylation-related gene (GRG) signature and its potential immunological roles and prognostic implications in hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

The GRG expression profile was defined using the transcriptome data from The Cancer Genome Atlas and Gene Expression Omnibus. Univariate and the least absolute shrinkage and selection operator Cox analyses were performed to develop a GRG-based risk score model. A nomogram was subsequently established and validated. Its correlation with cancer immune microenvironment and drug susceptibility was further analyzed. The role and immunological correlation of ST6GALNAC4 were further experimentally validated at the tissue and cellular levels in HCC.

RESULTS

A total of 87 GRGs were identified to be significantly dysregulated in HCC, and a novel risk score model was constructed using eight critical GRGs, which demonstrated superior prognostic discrimination and predictive power in both training and validation groups. High risk scores in HCC patients were associated with lower OS. The model was also identified as an independent risk factor for HCC, and a novel nomogram was subsequently constructed and validated. Notably, significant correlations were found in risk scores with immune cells infiltration, tumor immunophenotyping, immune checkpoint genes' expression, and sensitivities to multiple drugs. Furthermore, we validated in local HCC samples that ST6GALNAC4 was significantly upregulated and its knockdown significantly inhibited the tumor proliferation, migration and invasion ability and affected the expression of immune checkpoints on hepatoma cells.

CONCLUSION

We identified a novel GRG-based model which showed significant prognostic and immunological correlations in HCC, and the oncogenic role of ST6GALNAC4 has been validated and may serve as a potential drug target.

The impact of chemotherapy-associated hemoglobin on prognosis of colorectal cancer patients receiving adjuvant chemotherapy

BACKGROUND AND OBJECTIVE

The association of chemotherapy-associated hemoglobin and survival of colorectal cancer (CRC) receiving adjuvant chemotherapy is uncertain. We sought to explore the prognostic value of chemotherapy-associated hemoglobin in CRC receiving adjuvant chemotherapy and the best cut point affecting prognosis.

METHODS

Three hundred and twenty stage II and III CRC patients receiving adjuvant FOLFOX chemotherapy from March 2003 to March 2012 were enrolled. The associations between chemotherapy-associated hemoglobin (the absolute levels of post-chemotherapy) or chemotherapy-associated hemoglobin change (change between the pre- and post-chemotherapy hemoglobins) and disease free survival (DFS) or overall survival (OS) of CRC, and the best cut point were investigated.

RESULTS

Log rank test showed the best cut points for chemotherapy-associated hemoglobin and chemotherapy-associated hemoglobin change were respectively 90 g/L, 30 g/L. Cox regression model showed chemotherapy-associated hemoglobin < 90 g/L was the independent prognostic factor for DFS (HR, 2.221; 95% CI = 1.157-4.262), OS (HR, 2.058; 95% CI = 1.009-4.197), respectively, but no association of chemotherapy-associated hemoglobin change ⩾ 30g/L and DFS (HR, 2.063; 95% CI = 0.929-4.583), OS (HR, 1.386; 95% CI = 0.553-3.471) was found.

CONCLUSIONS

Chemotherapy-associated hemoglobin < 90 g/L has a significant prognostic value in CRC receiving adjuvant chemotherapy, which is a significant biomarker in the individualized management and may suggest the simple indication for the treatment of anemia in adjuvant chemotherapy in CRC.

Prognostic Role and Potential Mechanisms of N6-methyladenosine-related Long Noncoding RNAs in Hepatocellular Carcinoma

BACKGROUND AND AIMS

Numerous studies have explored the important role of N6-methyladenosine (m6A) in cancer. Nonetheless, the interaction between m6A and long noncoding RNAs (lncRNAs) is poorly investigated. Herein, we systematically analyzed the role and prognostic value of m6A-related lncRNAs in hepatocellular carcinoma (HCC).

METHODS

The m6A-related lncRNAs were identified based on the correlation coefficients with m6A-related genes in HCC from The Cancer Genome Atlas. Subsequently, a novel risk score model was determined using the least absolute shrinkage and selection operator Cox regression analyses. Univariate and multivariate Cox analyses were used to identify independent prognostic factors for overall survival (OS) of HCC; thereafter, a prognostic nomogram was constructed.

RESULTS

A total of 259 lncRNAs showed significant correlations with m6A in HCC, while 29 lncRNAs had prognostic significance. Further, six critical m6A-related lncRNAs (NRAV, SNHG3, KDM4A-AS1, AC074117.1, AC025176.1, and AL031985.3) were screened out to construct a novel risk score model which classified HCC patients into high- and low-risk groups. Survival analyses revealed that patients in the high-risk group exhibited worse OS, both in the training and validation groups. The risk score was also identified as an independent prognostic factor of OS, and a nomogram was established and verified with superior prediction capacity. Besides, the risk score significantly correlated with the expression of immune checkpoint genes and immune subtypes.

CONCLUSIONS

These findings indicated the significant role of m6A-related lncRNAs in HCC and the potential application of the novel risk score model for prognostic prediction.

Rapamycin inhibits activator protein-1 but not nuclear factor-kappaB activity of mature bone marrow-derived dendritic cells

Rapamycin (Rapa), a recently introduced immunosuppressive drug, appears to be effective in preventing acute allograft rejection episodes. Its effects on differentiation and maturation of dendritic cells (DCs) have been studied. In this report, we evaluated the effects of Rapa on the intracellular signal transduction pathways in mature DCs. The results showed that Rapa did not depress p65, p50, or IkappaBalpha expression. However, it dramatically reduced activator protein-1 activation. The fact that Rapa exerts a specific effect on activator protein-1 activity in mature DCs may contribute to its unique actions to prevent allograft rejection and induce immune tolerance.

Effects of gene transfer CTLA4Ig and anti-CD40L monoclonal antibody on islet xenograft rejection in mice

Blockade of a costimulatory pathway by adenovirus-mediated cytotoxic T lymphocyte associated antigen 4 immunoglobulin (CTLA4-Ig) gene transfer and anti-CD40L mAb(MR1) have been reported to enhance graft survival in several experimental transplantation models. In this study, we investigated the effects of gene transfer of CTLA4Ig and MR1 on islet xenograft rejection in mice. Recombinant adenovirus AdCTLA4Ig was constructed to express CTLA4Ig. Islet grafts from adult male DA rats transferred with AdCTLA4Ig were transplanted to streptozocin-induced diabetic Balb/c mice. The diabetic mice were treated with MR1 after transplantation. We evaluated the islet xenograft mean survival time as well as changes in interleukin-2 (IL-2) and tumor necrosis factor-alpha (TNF-alpha) levels in transplanted mice. The mean survival of islet xenografts in the MR1 treatment group was 34.9 +/- 5.62 days, in the AdCTLA4Ig treatment group it was 56.5 +/- 10.64 days, and in the AdCTLA4Ig plus MR1 treatment group it was 112.9 +/- 19.26 days, all significantly prolonged compared with an untreated group (8.1 +/- 0.83 days). Within 1 week after transplantation the levels of IL-2 and TNF-alpha showed sharp increases in the untreated group, being significantly higher than those observed prior to transplantation. In conclusion, using both AdCTLA4Ig and MR1 can improve the islet xenograft survival. The beneficial effects of the combined use of the 2 reagents were superior to either 1 alone, possibly related to down-regulated expression of Th1 cell-related cytokines.

Significant Efficacy of Apatinib in a Patient With Hepatocellular Carcinoma Lung Metastases After Liver Transplantation: A Case Report

Antiangiogenesis therapy plays an important role in the treatment of advanced hepatocellular carcinoma (HCC). However, treatment options for HCC recurrence after liver transplantation are currently limited. Apatinib is a small tyrosine kinase inhibitor molecule targeting vascular endothelial growth factor receptor-2. Here, we report for the first time one case of a patient with advanced HCC who received apatinib after occurring lung metastasis 7 months after liver transplantation. He took 500 mg of apatinib daily for one month, which was decreased to 250 mg daily because of side effects. The patient was confirmed to have a partial response, according to the Response Evaluation Criteria in Solid Tumors, for 10 months, and the progression-free survival time was greater than 21 months. Our data and experience have indicated that apatinib may be a good choice for HCC recurrence after liver transplantation.

Efficient derivation of functional hepatocytes from mouse induced pluripotent stem cells by a combination of cytokines and sodium butyrate

BACKGROUND

Hepatocyte transplantation has been proposed as an alternative to whole-organ transplantation to support many forms of hepatic insufficiency. Unfortunately, the lack of donor livers makes it difficult to obtain enough viable human hepatocytes for hepatocyte-based therapies. Therefore, it is urgent to find new ways to provide ample hepatocytes. Induced pluripotent stem (iPS) cells, a breakthrough in stem cell research, may terminate these hinders for cell transplantation. For the promise of iPS cells to be realized in liver diseases, it is necessary to determine if and how efficient they can be differentiated into functional hepatocytes.

METHODS

In this study, we directly compared the hepatic-differentiation capacity of mouse iPS cells and embryonic stem (ES) cells with three different induction approaches: conditions via embryonic body (EB) formation plus cytokines, conditions by combination of dimethyl sulfoxide and sodium butyrate and chemically defined, serum free monolayer conditions. Among these three induction conditions, more homogenous populations can be promoted under chemically defined, serum free conditions. The cells generated under these conditions exhibited hepatic functions in vitro, including glycogen storage, indocynine green (ICG) uptake and release as well as urea secretion. Although efficient hepatocytes differentiation from mouse iPS cells were observed, mouse iPS cells showed relatively lower hepatic induction efficiency compared with mouse ES cells.

RESULTS

Mouse iPS cells would be efficiently differentiated into functional hepatocytes in vitro, which may be helpful in facilitating the development of hepatocytes for transplantation and for research on drug discovery.

CONCLUSION

We demonstrate that mouse iPS cells retain full potential for fetal liver development and describe procedures that facilitates the efficient generation of highly differentiated human hepatocyte-like cells from iPS cells in vitro.

Prognostic Role and Potential Mechanisms of the Ferroptosis-Related Metabolic Gene Signature in Hepatocellular Carcinoma

PURPOSE

Ferroptosis, as a novel regulated cell death form, has a close interaction with metabolism, which is largely unknown in cancer. In the present study, we conducted a comprehensive analysis of ferroptosis-related metabolic genes to delineate the metabolic signatures induced by ferroptosis and evaluate its prognostic significance in hepatocellular carcinoma (HCC).

METHODS

The ferroptosis-related metabolic genes (Fer-MRGs) were identified by correlation analyses with transcriptome data from The Cancer Genome Atlas and Gene Expression Omnibus. Then, univariate and the least absolute shrinkage and selection operator Cox regression analysis was used to establish a novel risk score model. Univariate and multivariate COX analyses were used to identify independent prognostic factors for overall survival (OS) of HCC, and a nomogram was developed. The Fer-MRGs' expression was further evaluated by quantitative real-time polymerase chain reaction in HCC.

RESULTS

A total of 77 metabolic genes were identified as Fer-MRGs, and 26 were found with prognostic values for OS of HCC. Then, a novel nine-gene (AKR1C3, ATIC, G6PD, GMPS, GNPDA1, IMPDH1, PRIM1, RRM2, and TXNRD1) risk score model was constructed. Survival analyses showed worse OS in high-risk patients both in the training and validation groups. The model was also identified as an independent prognostic factor for HCC, and a prognostic nomogram for OS was further established with superior discriminative capacity and prediction accuracy. Notably, close correlations were also identified between the risk score and the expression of immune checkpoint genes, immune subtypes of tumor, and susceptibility of HCC to chemotherapeutic agents. Finally, elevated expression of eight Fer-MRGs (except for IMPDH1) was further verified in 16 pairs of HCC tumor and adjacent tissues.

CONCLUSION

These results indicated the intense interaction between ferroptosis and metabolism, the significant role of ferroptosis-related MRGs, and the great potential of the novel risk score model for prognosis prediction in HCC.

Prediction of chronic kidney disease progression used by calcineurin inhibitor concentration and estimated glomerular filtration rate early after liver transplantation

BACKGROUND

Chronic kidney disease (CKD) is a common late complication in liver-transplanted patients who have received long-term therapy with calcineurin inhibitors (CNIs). Aims: To analyze kidney disease progression after liver transplantation.

METHODS

We analysed the clinical data of adult single-organ liver transplant recipients performed at our centre between October 2003 and September 2009. The patients with the estimated glomerular filtration rate (eGFR) greater than 60 ml/min/1.73 m2 before surgery were included in the study.

RESULTS

69 patients with complete follow-up data were analysed. We found that eGFR at 1 or 2 years after liver transplantation correlated well with eGFR at 5 years. In addition, our results showed that patients whose eGFR declined below 60 at 2 years after liver transplantation would develop an irreversible renal injury in the following years. At 2 years, 12 patients had an eGFR less than 60, which were maintained in 11 patients at 5 years (Sensitivity = 11/12, 91.67%; Specificity = 57/58, 98.28%, Youden's index = 89.95%). The annual rate of eGFR reduction of the tacrolimus group was greater than that of the tacrolimus sparing group based on the value-time variation curve in our study. Moreover, the tacrolimus concentration influenced the CKD progression at 1 and 2 years with an under the ROC curve of 0.73 and 0.78 when Youden's index was at its maximum and the tacrolimus concentrations were 8.55 and 5.96 ng/ml, respectively.

CONCLUSION

We confirmed that eGFR at 2 years after liver transplantation is useful for observing a meaningful change in eGFR and renal damage. Obtaining the appropriate serum concentration of an early decrease of the dose of CNIs and transforming non-nephrotoxic immunosuppressants would help improve renal function to prevent CKD progression and end-stage renal disease (ESRD).

Camrelizumab (SHR-1210) treatment for recurrent hepatocellular carcinoma after liver transplant: A report of two cases

Immune checkpoint inhibitors are generally contraindicated for post-transplant patients. However, we report two patients with metastatic hepatocellular carcinoma (HCC) treated with camrelizumab (SHR-1210), an anti-programmed cell death 1 (PD-1) agent, after liver transplant. Before undergoing immunotherapy, both patients underwent liver allograft biopsy and obtained negative PD-L1 expression in tumor and liver graft specimens by immunohistochemistry. Then, camrelizumab (200 mg) was administered once every 3 weeks. During immunotherapy, the targeted therapy was continued, and the immunosuppression regimen was adjusted to a low-dose level. No graft rejection or other severe adverse reactions were observed. The disease remained stable (SD, mRECIST) for 3 months in one patient and 10 months in the other. Therefore, camrelizumab may have safety and potential benefits in advanced HCC after liver transplant.

Successful treatment of stage IIIB intrahepatic cholangiocarcinoma using neoadjuvant therapy with the PD-1 inhibitor camrelizumab: A case report

BACKGROUND

The prognosis of intrahepatic cholangiocarcinoma (ICC) with lymph node metastasis is poor. The feasibility of surgery is not certain, which is a contraindication according to the National Comprehensive Cancer Network guidelines. The role of immunotherapy as a neoadjuvant therapy for ICC is not clear. We herein describe a case of ICC with lymph node metastasis that was successfully treated with neoadjuvant therapy.

CASE SUMMARY

A 60-year-old man with a liver tumor was admitted to our hospital. Enhanced computed tomography and magnetic resonance imaging revealed a space-occupying lesion in the right lobe of the liver. Multiple subfoci were found around the tumor, and the right posterior branch of the portal vein was invaded. Liver biopsy indicated poorly differentiated cholangiocytes. According to the American Joint Committee on Cancer disease stage classification, ICC with hilar lymph node metastasis (stage IIIB) and para-aortic lymph node metastasis was suspected. A report showed that two patients with stage IIIB ICC achieved a complete response (CR) 13 mo and 16 mo after chemotherapy with a PD-1 monoclonal antibody. After multidisciplinary consultation, the patient was given neoadjuvant therapy, surgical resection and lymph node dissection, and postoperative adjuvant therapy. After three rounds of PD-1 immunotherapy (camrelizumab) and two rounds of gemcitabine combined with cisplatin regimen chemotherapy, the tumor size was reduced. Therefore, a partial response was achieved. Exploratory laparotomy found that the lymph nodes of Group 16 were negative, and the tumor could be surgically removed. Therefore, the patient underwent right hemihepatectomy plus lymph node dissection. The patient received six rounds of chemotherapy and five rounds of PD-1 treatment postoperatively. After 8 mo of follow-up, no recurrence was found, and a CR was achieved.

CONCLUSION

Neoadjuvant therapy combined with surgical resection is useful for advanced-stage ICC. This is the first report of successful treatment of stage IIIB ICC using neoadjuvant therapy with a PD-1 inhibitor.

A Novel Nine-Gene Signature Associated With Immune Infiltration for Predicting Prognosis in Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide, and its prognosis remains unsatisfactory. The identification of new and effective markers is helpful for better predicting the prognosis of patients with HCC and for conducting individualized management. The oncogene Aurora kinase A (AURKA) is involved in a variety of tumors; however, its role in liver cancer is poorly understood. The aim of this study was to establish AURKA-related gene signatures for predicting the prognosis of patients with HCC. Methods: We first analyzed the expression of AURKA in liver cancer and its prognostic significance in different data sets. Subsequently, we selected genes with prognostic value related to AURKA and constructed a gene signature based on them. The predictive ability of the gene signature was tested using the HCC cohort development and verification data sets. A nomogram was constructed by integrating the risk score and clinicopathological characteristics. Finally, the influence of the gene signature on the immune microenvironment in HCC was comprehensively analyzed. Results: We found that AURKA was highly expressed in HCC, and it exhibited prognostic value. We selected eight AURKA-related genes with prognostic value through the protein-protein interaction network and successfully constructed a gene signature. The nine-gene signature could effectively stratify the risk of patients with HCC and demonstrated a good ability in predicting survival. The nomogram showed good discrimination and consistency of risk scores. In addition, the high-risk group showed a higher percentage of immune cell infiltration (i.e., macrophages, myeloid dendritic cells, neutrophils, and CD4+T cells). Moreover, the immune checkpoints SIGLEC15, TIGIT, CD274, HAVCR2, and PDCD1LG2 were also higher in the high-risk group versus the low-risk group. Conclusions: This gene signature may be useful prognostic markers and therapeutic targets in patients with HCC.

Inhibition of rejection in murine islet xenografts by CTLA4Ig and CD40LIg gene transfer

BACKGROUND

Costimulatory signals play a vital role in T cell activation. Blockade of costimulatory pathway by CTLA4Ig or CD40LIg have enhanced graft survival in experimental transplantation models yet mechanisms remain undetermined. We investigated the effects of CTLA4Ig and CD40LIg gene transfer on islet xenografts rejection in rats.

METHODS

Human islets were infected with recombinant adenoviruses containing CTLA4Ig and CD40LIg genes and implanted beneath the kidney capsule of diabetic rats. Levels of blood sugar, morphological changes, and survival of grafts were recorded. Expressions of CTLA4Ig, CD40LIg and insulin were detected by immunohistochemical staining and cytokines levels were quantified by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Blood glucose levels in transplant rats decreased to normal level on the 2nd day post transplantation. The mean blood glucose in the control group, CTLA4Ig transfected group, CD40LIg transfected group and CTLA4Ig + CD40LIg cotransfected group increased on days 8, 24, 21, 68, post transplantation respectively. The grafts in control group, CTLA4Ig transfected group, CD40LIg transfected group and CTLA4Ig + CD40LIg cotransfected group survived for (8 ± 1), (29 ± 4), (27 ± 3), and (74 ± 10) days, respectively. Survival in CTLA4Ig + CD40LIg cotransfected group was significantly longer. Survivals of CTLA4Ig transfected group and CD40LIg transfected group were significantly longer than control group. In control animals, serum interleukin-2 and tumor necrosis factor α concentration significantly increased within seven days post transplantation. Haematoxylin eosin staining of grafts showed live islets in situ of transplant rats without inflammatory cell infiltration. Immunohistochemical staining confirmed the expression of insulin at islets in all experimental groups.

CONCLUSIONS

Transfer of CTLA4Ig and CD40LIg genes, especially the cotransfer of both, inhibits rejection of murine islet xenografts. Downregulated expressions of Th1 cells related cytokines might be related to the beneficial effects.

Severe bile duct complication after yttrium-90 radioembolization therapy in a patient with recurrent hepatocellular carcinoma after liver transplantation: A case report

Patients with recurrent hepatocellular carcinoma (HCC) following liver transplantation (LT) have a poor prognosis owing to rapid tumor progression. Yttrium-90 radioembolization (90Y-RE) has been shown to be a safe and efficacious transarterial radioembolization treatment for patients with advanced HCC. However, to our knowledge, no data are available for patients with recurrent HCC following LT. Here we report a case of severe bile duct complication after transarterial radioembolization with yttrium-90 in a patient who experienced HCC recurrence following LT. The present case suggests that 90Y-RE should be cautiously performed in patients with recurrent HCC following LT.

[Effects of CD40LIg gene-modified bone marrow mesenchymal stem cells on liver graft rejection in rats]

OBJECTIVE

To study the effects of cluster of differentiation 40 ligand immunoglobulin (CD40LIg) gene-modified bone marrow mesenchymal stem cells (MSCs) on liver graft rejection in rats.

METHODS

The orthotopic liver transplantation models were established with DA rats as the donors and Lewis rats as the recipient. MSCs infected with the recombinant adenoviruses containing CD40LIg gene were infused into the liver graft after transplantation. The liver function, survival of the recipient rats and the morphological changes of the liver grafts were observed after the transplantation. The serum levels of the cytokines interferon-γ (INF-γ) and interleukin-2 (IL-2) in the recipient rats were quantified by ELISA.

RESULTS

The survival of the recipient rats receiving transplantation of genetically modified MSCs (group D) was significantly prolonged compared with that of the control group (group A), MSCs group (group B) and gene transfection group (group C); the survival of groups B and C were significantly longer than that of group A (F=7.615, P<0.05). The level of serum alanine aminotransferase, total bilirubin, IL-2 and INF-γ were significantly higher in group A than in the other 3 groups (F=8.738, P<0.05). HE staining of the liver grafts showed severe acute rejection in group A, mild acute graft rejection in groups B and group C, but no rejection in group D.

CONCLUSION

CD40LIg gene-modified MSCs can prolong the survival of the recipient rats and suppress graft rejection following liver transplantation.

Liver transplantation following two conversions in a patient with huge hepatocellular carcinoma and portal vein invasion: A case report

BACKGROUND

Surgical resection and liver transplantation (LT) are the most effective curative options for hepatocellular carcinoma (HCC). However, few patients with huge HCC (> 10 cm in diameter), especially those with portal vein tumor thrombus (PVTT), can receive these treatments. Selective internal radiation therapy (SIRT) can be used as a conversion therapy for them because it has the dual benefit of shrinking tumors and increasing residual hepatic volume. However, in patients with huge HCC, high lung absorbed dose often prevents them from receiving SIRT.

CASE SUMMARY

A 35-year-old man was admitted because of emaciation and pain in the hepatic region for about 1 month. The computed tomography scan showed a 20.2 cm × 19.8 cm tumor located in the right lobe-left medial lobes with right portal vein and right hepatic vein invasion. After the pathological type of HCC was confirmed by biopsy, two conversions were presented. The first one was drug-eluting bead transarterial chemoembolization plus hepatic arterial infusion chemotherapy and lenvatinib and sintilimab, converted to SIRT, and the second one was sequential SIRT with continued systemic treatment. The tumor size significantly decreased from 20.2 cm × 19.8 cm to 16.2 cm × 13.8 cm, then sequentially to 7.8 cm × 6.8 cm. In the meantime, the ratio of spared volume to total liver volume increased gradually from 34.4% to 55.7%, then to 62.9%. Furthermore, there was visualization of the portal vein, indicating regression of the tumor thrombus. Finally, owing to the new tumor in the left lateral lobe, the patient underwent LT instead of resection without major complications.

CONCLUSION

Patients with inoperable huge HCC with PVTT could be converted to SIRT first and accept surgery sequentially.

Activation of gut FXR improves the metabolism of bile acids, intestinal barrier, and microbiota under cholestatic condition caused by GCDCA in mice

Abnormal bile acid (BA) metabolism is involved in liver fibrosis. In a previous study, we discovered that the hydrophobic BA glycochenodeoxycholate (GCDCA) induced liver fibrosis and that GW4064, an agonist of farnesoid X receptor (FXR), alleviated liver fibrosis caused by GCDCA. However, the impacts of GCDCA on liver BAs, gut BAs, the intestinal barrier, and the gut microbiota are unclear, and obtaining this information would provide additional information into the role of GCDCA in the development of liver fibrosis. In the present study, ultra-performance liquid chromatography‒tandem mass spectrometry revealed that mice administered GCDCA by gavage had higher levels of total and primary liver BAs than those in the control group, and a significant reduction in primary liver BAs was observed in the GCDCA + GW4064 group compared with those in the GCDCA group. Compared with those in the control group, the mice administered GCDCA by gavage had greater levels of total and primary BAs in the gut, especially T-alpha-MCA and T-beta-MCA, and no significant differences in the terminal ileum were observed between the GCDCA and GCDCA + GW4064 groups. Immunohistochemistry indicated that GCDCA administration inhibited gut FXR and FGF15 expression, whereas GW4064 activated gut FXR and promoted FGF15 expression. Moreover, immunohistochemistry revealed that GCDCA administration decreased mucin2, claudin-1, occludin, and ZO-1 expression, whereas GW4064 restored their expression. 16S rDNA sequencing revealed that the alpha diversity of the microbiota did not significantly differ among the three groups, but differences in the beta diversity of the microbiota were observed among the three groups. At the phylum level, GCDCA significantly disturbed the gut microbiota, as indicated by reductions in Desulfobacterota, Bacteroidota, and Actinobacteria in the GCDCA group compared with those in the control group. However, significantly increased abundances of Proteobacteria, Cyanobacteria, and Patescibacteria were noted in the GCDCA group compared with the control group. GW4064 administration significantly improved the microbiota structure at the phylum level. The efficacy of GW4064 was also observed at the genus level. Correlation analyses revealed fewer relationships between the gut microbiota and gut BAs, whereas the gut microbiota was more closely related to liver BAs in the GCDCA and GW4064 intervention groups. Together, GCDCA induced cholestasis and disturbed BA metabolism in the gut and liver, as well as the intestinal barrier and structure of the gut microbiota. Activation of gut FXR improved intestinal barrier injury and alleviated BA metabolism dysfunction and dysbacteriosis caused by GCDCA under cholestatic conditions.

IMPORTANCE

Glycochenodeoxycholate (GCDCA) is a hydrophobic bile acid (BA) in humans and is highly increased in the serum and stool of liver fibrosis patients. However, the effects of GCDCA were not comprehensively investigated in the process of liver bile acid metabolism, gut microbiota, and intestinal barrier. It was reported that GCDCA can promote liver fibrosis via the NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome pathway in mice, and gut farnesoid X receptor activation alleviated the fibrosis caused by GCDCA in our previous study. Gut microbiota is also responsible for BA metabolism; meanwhile, BA metabolism may also exert an effect on the intestinal barrier. Nowadays, the comprehensive understanding of gut microbiota and intestinal barrier in relation to BA disorder was still insufficient. Current study further investigated the role of GCDCA in BA metabolism, gut microbiota, and intestinal barrier to help understand the effects of GCDCA in liver fibrosis, which may provide intervention methods for liver fibrosis caused by dysregulation of BA metabolism.

Prognostic value of combined pretreatment fibrinogen and neutrophil-lymphocyte ratio in digestive system cancers: a meta-analysis of 17 retrospective studies

BACKGROUND

Several epidemiological studies have reported the relationship between the combined pretreatment fibrinogen and neutrophil-lymphocyte ratio (F-NLR) and prognosis of digestive system cancers (DSCs). However, the results are controversial. We aimed to assess the prognostic value of F-NLR in patients with DSCs.

METHODS

A comprehensive search for relevant studies was conducted until June, 2020. Studies that evaluated the association of the F-NLR score with survival outcome in patients with any DSCs were included. The hazard ratio (HR) and 95% confidence interval (CI) were calculated using a fixed-effects model. All data analyses were performed using the STATA 12.0 software.

RESULTS

A total of 17 studies involving 5,767 participants were included in the meta-analysis. We found that high F-NLR score was significantly associated with poor overall survival (OS) in patients with DSCs (HR =2.0; 95% CI, 1.78-2.24). In addition, patients with high F-NLR score had poor disease-free survival/progression-free survival/recurrence-free survival (DFS/PFS/RFS) (HR =2.01; 95% CI, 1.47-2.74) and DFS (HR =1.97; 95% CI, 1.35-2.87). Sensitivity analyses for OS confirmed that the results were stable.

CONCLUSIONS

High F-NLR score is significantly associated with poor prognostic outcomes in patients with DSCs and can serve as an effective prognostic indicator for the Asian population.

Management of anastomotic biliary stricture through utilizing percutaneous transhepatic cholangioscopy

AIM

Occurrence of anastomotic biliary stricture (AS) remains an essential issue following hepatobiliary surgeries, and percutaneous transhepatic cholangioscopy (PTCS) has great therapeutic significance in handling refractory AS for patients with altered gastrointestinal anatomy after cholangio-jejunostomy. This present study aimed to investigate feasibility of PTCS procedures in AS patients for therapeutic indications.

MATERIALS AND METHODS

This study was a single-center, retrospective cohort study with a total number of 124 consecutive patients who received therapeutic PTCS due to AS. Clinical success rate, required number, and adverse events of therapeutic PTCS procedures as well as patients survival state were reviewed.

RESULTS

These 124 patients previously underwent choledochojejunostomy or hepatico-jejunostomy, and there was post-surgical altered gastrointestinal anatomy. Overall, 366 therapeutic PTCS procedures were performed for these patients through applying rigid choledochoscope, and the median time of PTCS procedures was 3 (1-11). Among these patients, there were 34 cases (27.32%) accompanied by biliary strictures and 100 cases (80.65%) were also combined with biliary calculi. After therapeutic PTCS, most patients presented with relieved clinical manifestations and improved liver functions. The median time of follow-up was 26 months (2-86 months), and AS was successfully managed through PTCS procedures in 104 patients (83.87%). During the follow-up period, adverse events occurred in 81 cases (65.32%), most of which were tackled through supportive treatment.

CONCLUSION

PTCS was a feasible, safe and effective therapeutic modality for refractory AS, which may be a promising alternative approach in clinical cases where the gastrointestinal anatomy was changed after cholangio-jejunostomy.

Efficiency of percutaneous transhepatic cholangioscopy in the treatment of biliary complications after liver transplantation

BACKGROUND

Percutaneous transhepatic cholangioscopy (PTCS) has provided an alternative therapeutic option for handling refractory biliary complications in liver transplanted recipients. This study aimed to evaluate short-term PTCS efficiency in the management of biliary complications following liver transplantation.

METHODS

Clinical data of 25 patients who received therapeutic PTCS due to biliary complications after liver transplantation were retrospectively analyzed.

RESULTS

Therapeutic PTCS was successfully performed in 25 patients. Biliary complications were anastomotic strictures in seven cases, intrahepatic cholangiolithiasis in four cases, extra-and intrahepatic cholangiolithiasis in three cases, choledocholithiasis complicated with anastomotic strictures in four cases, intrahepatic cholangiolithiasis complicated with non-anastomotic strictures in one case, intrahepatic cholangiolithiasis complicated with anastomotic strictures in five cases, intrahepatic cholangiolithiasis complicated with anastomotic strictures and ischemic cholangitis in one case. The median time between liver transplantation and first PTCS was 24 months, and median times of PTCS was 2.6. Clinical manifestations were significantly improved in most patients after PTCS, and biliary complications were successfully managed through PTCS in 15 cases, which were partially effective in eight cases and ineffective in two cases. PTCS was more effective in tackling anastomotic strictures and cholangiolithiasis.

CONCLUSION

PTCS was an effective therapeutic modality for treating refractory biliary complications following liver transplantation.

Immunotherapy as adjuvant therapy for a patient with adenosquamous carcinoma of the intrahepatic bile duct: A case report and literature review

Adenosquamous carcinoma (ASC) is a rare histological type of intrahepatic cholangiocarcinoma, which includes both adenocarcinoma and squamous cell carcinoma. The clinical features, physical examination, routine laboratory tests, and imaging examinations of patients with ASC are nonspecific. ASC is easily misdiagnosed as hepatocellular carcinoma, and patients with ASC always have a poor prognosis. This study reports a patient with ASC who was diagnosed based on pathological results, underwent surgical resection, and received postoperative chemotherapy (gemcitabine plus cisplatin) combined with immunotherapy (sintilimab). During the 1-year follow-up, the patient was in good condition, and no signs of cancer recurrence were noted. This case highlights that surgical resection and chemotherapy combined with immunotherapy may be feasible for patients with ASC.

Nrf2 deficiency causes hepatocyte dedifferentiation and reduced albumin production in an experimental extrahepatic cholestasis model

The transcription factor Nrf2 modulates the initiation and progression of a number of diseases including liver disorders. We evaluated whether Nrf2 mediates hepatic adaptive responses to cholestasis. Wild-type and Nrf2-null mice were subjected to bile duct ligation (BDL) or a sham operation. As cholestasis progressed to day 15 post-BDL, hepatocytes in the wild-type mice exhibited a tendency to dedifferentiate, indicated by the very weak expression of hepatic progenitor markers: CD133 and tumor necrosis factor-like weak induced apoptosis receptor (Fn14). During the same period, Nrf2 deficiency augmented this tendency, manifested by higher CD133 expression, earlier, stronger, and continuous induction of Fn14 expression, and markedly reduced albumin production. Remarkably, as cholestasis advanced to the late stage (40 days after BDL), hepatocytes in the wild-type mice exhibited a Fn14+ phenotype and strikingly upregulated the expression of deleted in malignant brain tumor 1 (DMBT1), a protein essential for epithelial differentiation during development. In contrast, at this stage, hepatocytes in the Nrf2-null mice entirely inhibited the upregulation of DMBT1 expression, displayed a strong CD133+/Fn14+ phenotype indicative of severe dedifferentiation, and persistently reduced albumin production. We revealed that Nrf2 maintains hepatocytes in the differentiated state potentially via the increased activity of the Nrf2/DMBT1 pathway during cholestasis.