Aetiology of chronic liver disease is a valuable factor for stratifying adverse outcomes of acute decompensation: prospective observational study

BACKGROUND/AIMS

Acute decompensation (AD) is defined as the development of complications related to portal hypertension and liver dysfunction that affect the progression of chronic liver disease (CLD) or liver cirrhosis (LC). Variations exist in patient demographics and prognostic outcomes of AD based on the aetiology of CLD, encompassing LC. However, limited research has been conducted to analyse these discrepancies across aetiologies.

METHODS

The prospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort consisted of 1,501 patients who were hospitalized with AD of CLD from July 2015 to August 2018. In this study, we assess the clinical attributes and prognostic implications of AD with CLD/LC stratified by the aetiology.

RESULTS

Among 1,501 patients, the mean age was 54.7 years old and 1,118 patients (74.5%) were men. The common events of AD were GI bleeding (35.3%) and jaundice (35.0%). There was a median follow-up of 8.0 months (1.0-16.0 months). The most common aetiology of CLD was alcohol (n = 1021), followed by viral hepatitis (n = 206), viral hepatitis with alcohol-related (n = 129), cryptogenic (n = 108) and autoimmune (n = 37). Viral hepatitis with alcohol-related CLD showed a poor liver function profile and a high frequency of acute-on-chronic liver failure (ACLF) [22.1% vs. 19.6% (alcohol CLD), 8.1% (viral CLD), 5.6% (autoimmune related CLD and 16.0% (cryptogenic CLD)] with worse adverse outcomes (mortality or liver transplantation) than other aetiologies. The difference in aetiology was a significant factor for 28-day adverse outcomes in multivariate analysis even in a high MELD score (≥15), which indicated poor baseline liver function and prognosis (p < 0.001).

CONCLUSION

The aetiology of CLD constitutes a pivotal determinant influencing both short- and long-term adverse outcomes of AD in CLD, even among individuals presenting with elevated MELD scores. Notably, patients afflicted with viral hepatitis should exercise caution even in the consumption of modest quantities of alcohol that induced the exacerbations in the adverse outcomes associated with AD.

Gut microbiota in hepatocellular carcinoma immunotherapy: immune microenvironment remodeling and gut microbiota modification

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality, with limited treatment options at advanced stages. The gut microbiota, a diverse community of microorganisms residing in the gastrointestinal tract, plays a pivotal role in regulating immune responses through the gut-liver axis. Emerging evidence underscores its impact on HCC progression and the efficacy of immunotherapy. This review explores the intricate interactions between gut microbiota and the immune system in HCC, with a focus on key immune cells and pathways involved in tumor immunity. Additionally, it highlights strategies for modulating the gut microbiota - such as fecal microbiota transplantation, dietary interventions, and probiotics - as potential approaches to enhancing immunotherapy outcomes. A deeper understanding of these mechanisms could pave the way for novel therapeutic strategies aimed at improving patient prognosis.

Nanostrategies synergize with locoregional interventional therapies for boosting antitumor immunity

Compared with traditional surgical resection, systemic chemotherapy, or radiotherapy, locoregional interventional therapies (LITs) possess their own advantages of minimally invasive procedure and immunomodulatory effects in cancer treatment. Local ablation and intravascular interventional therapy represent excellent LIT candidate to combine with immunotherapy. Diverse nanomaterials with excellent biocompatibility show promises in modulating antitumor immunity. In this review, we summarized several immune-LIT combinations, discussed the following immunomodulatory effects, and presented the novel nanostrategies for synergizing with the combination therapy. With continuous optimization, further promotion of clinical translation will ultimately benefit patients with personalized and tailored cancer strategy.

Predictive Factors and Nomogram (MAP-BNP) for Post Stereotactic Body Radiotherapy Survival in Advanced Hepatocellular Carcinoma Patients

BACKGROUND

Stereotactic body radiation therapy (SBRT) is a widely recognized approach for managing hepatocellular carcinoma (HCC), particularly in its advanced stages, with prognosis highly dependent on tumour burden and baseline liver function. This study aimed to develop a predictive model and nomogram that incorporates these factors to improve survival outcomes in advanced HCC patients treated with SBRT and systemic therapy.

METHODS

We retrospectively reviewed records of 110 patients with advanced HCC treated with SBRT between May 2020 and April 2023. Inclusion criteria included age ≥18 years, cirrhosis, and suitability for SBRT.

RESULTS

The median age was 63 years (range 28-84), with viral cirrhosis (40.9%) and NASH (38.2%) as the main aetiologies. At presentation, 83.6% of patients had portal vein thrombosis, 32.7% had nodal metastasis, and 50% had distant metastasis. The median tumour diameter was 9 cm, and 73.6% of patients had the multifocal disease.A median SBRT dose of 35 Gy (range 25-45 Gy) in 5 fractions was administered. Significant reductions in tumour markers were noted at three months: AFP levels dropped from a median of 309.75 ng/ml to 62 ng/ml (P = 0.015), and PIVKA II from 2230 mAU/ml to 345 mAU/ml (P = 0.001). Complete and partial responses were seen in 33% and 45% of patients, respectively. The median overall survival (OS) was 14 months (95% CI 11.7-16.2), with OS rates of 90%, 58%, and 34% at 6, 12, and 24 months. Progression-free survival (PFS) was 9 months (95% CI 6.4-11.5). Significant predictors of OS included multifocal tumour, portal vein thrombosis, lymph node involvement, serum bilirubin, serum albumin, and log PIVKA-II. The developed MAP-BNP nomogram achieved a C-index of 0.853, outperforming the Child-Turcotte-Pugh (0.62) and ALBI (0.64) scores. Patients were classified into low-risk (<200 points) and high-risk (>200 points) groups, with the low-risk group showing a significantly longer OS (P < 0.001).

CONCLUSION

The MAP-BNP nomogram, integrating tumour burden and liver function, provides a more individualized approach for predicting survival in advanced HCC patients treated with SBRT and systemic therapy, outperforming traditional staging systems.

Comprehensive Bioinformatics Analysis and Machine Learning of TTK as a Transhepatic Arterial Chemoembolization Resistance Target in Hepatocellular Carcinoma

Transhepatic arterial chemoembolization (TACE) is the standard treatment for intermediate-stage hepatocellular carcinoma (HCC). However, a significant proportion of patients are non-responders or poor responders to TACE. Therefore, our aim is to identify the targets of TACE responders or non-responders. GSE104580 was utilized to identify differentially expressed genes (DEGs) in TACE responders and non-responders. Following the protein-protein interaction (PPI) analysis, hub genes were identified using the MCC and MCODE plugins in Cytoscape software, as well as LASSO regression analysis. Gene set enrichment analysis (GSEA) was performed to investigate potential mechanisms. Subsequently, the hub genes were validated using data from The Cancer Genome Atlas (TCGA), the Cancer Cell Line Encyclopedia (CCLE), and The Human Protein Atlas (HPA) database. To evaluate the clinical significance of the hub genes, Kaplan-Meier (KM) survival and Cox regression analysis were employed. A total of 375 DEGs were identified, with 126 remaining following PPI analysis, and TTK, a dual-specificity protein kinase associated with cell proliferation, was ultimately identified as the hub gene through multiple screening methods. Data analysis from TCGA, CCLE, and HPA databases revealed elevated TTK expression in HCC tissues. GSEA indicated that the cell cycle, farnesoid X receptor pathway, PPAR pathway, FOXM1 pathway, E2F pathway, and ferroptosis could be potential mechanisms for TACE non-responders. Analysis of immune cell infiltration showed a significant correlation between TTK and Th2 cells. KM and Cox analysis suggested that HCC patients with high TTK expression had a worse prognosis. TTK may play a pivotal role in HCC patients' response to TACE therapy and could be linked to the prognosis of these patients.

PD-1/PD-L1 blockade therapy in hepatocellular carcinoma: Current status and potential biomarkers

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death and the sixth most prevalent cancer worldwide. However, most patients with HCC are at an advanced stage at the time of clinical diagnosis, making surgery impossible. In the past, targeted therapeutic drugs such as sorafenib and lenvatinib were the main treatments. With recent breakthroughs in medicine, immunotherapy, particularly immune checkpoint inhibitors (ICIs), has garnered interest and has been extensively studied for clinical treatment. In addition to single-agent therapies, combination regimens involving ICIs have also been developed. Despite this progress, not all patients with HCC benefit from immunotherapy. Therefore, to improve the treatment response rates, it is crucial to identify patients with HCC who are suitable for immunotherapy. The exploration and validation of markers to predict the outcomes of immunotherapeutic treatments in patients with HCC are of clinical importance. In this article, we provide a comprehensive review of research progress in immunotherapy, particularly ICIs and combination therapies, for HCC. Furthermore, we summarize the clinical indicators and tumor markers discovered in recent years to forecast immunotherapy outcomes in patients with HCC. We also outline predictive markers for the occurrence of immune-related adverse events in patients with HCC receiving immunotherapy and discuss future research directions in the immunotherapeutic treatment landscape.

Degradable starch microspheres transarterial chemoembolization (DSM-TACE) in patients with unresectable hepatocellular carcinoma: results from the Prospective Multicenter Observational HepaStar Trial

OBJECTIVES

Despite increasing interest, prospective data on the use of degradable starch microsphere-transarterial chemoembolization (DSM-TACE) in the management of patients with unresectable HCC are still scarce. The objective of the HepaStar study was to collect prospective safety and effectiveness data in a prospective multicenter observational study.

MATERIALS AND METHODS

Between January 2017 and December 2022, consecutive participants with unresectable or recurrent HCC treated with DSM-TACE as standard of care at 6 participating centers in Europe were enrolled. Tumor response was evaluated according to the mRECIST criteria. Overall survival (OS), progression-free survival (PFS), and adverse events (AEs) were assessed by using Kaplan-Meier analysis and Common Terminology Criteria for Adverse Events, version 5. Liver function deterioration was assessed by monitoring changes in liver blood tests during the follow-up.

RESULTS

Seventy-nine participants (median age, 69 years (IQR, 51-87 years); 67 men (85%)) were enrolled and treated. The median follow-up time was 18 months (IQR 9.5-38.0 months). The estimated median OS and PFS for the entire cohort was 32 months (CI, 95% 21-NaN) and 9 months (CI, 95% 7-NaN), respectively. Eleven (13.9%) participants experienced at least one grade 3 or 4 AE. The most frequent grade 3-4 AE was elevated bilirubin (2.2%, 5 of 79). Deterioration of bilirubin, AST, ALT, and albumin were observed in 24.1%, 23.7%, 19%, and 24% of participants, respectively.

CONCLUSION

DSM-TACE achieves promising survival in patients with unresectable or recurrent HCC. This technique shows a favorable safety profile both in terms of treatment-related AEs and liver function deterioration.

KEY POINTS

Question Although degradable starch microspheres transarterial chemoembolization is widely used in clinical practice across Europe, prospective data on its application in hepatocellular carcinoma patients remains limited. Findings Degradable starch microspheres transarterial chemoembolization results in promising survival rates, good tumor response rates, and low rates of treatment-related adverse events. Clinical relevance In patients with unresectable hepatocellular carcinoma, degradable starch microspheres transarterial chemoembolization represents a safe and effective alternative to more well-established chemoembolization techniques like conventional transarterial chemoembolization and drug-eluting beads transarterial chemoembolization.

Scoping Review on Strategies for Safe Nucleot(s)ide Analogue Discontinuation and Optimising Functional Cure in Chronic Hepatitis B

Chronic hepatitis B (CHB) remains a global health challenge, contributing to significant morbidity and mortality. While long-term nucleos(t)ide analogue (NA) therapy effectively suppresses viral replication, achieving a functional cure remains rare. Current treatment guidelines primarily recommend indefinite therapy. However, long-term NA use poses many challenges, prompting interest in finite therapy. Recent studies suggest that carefully selected patients may safely discontinue NAs, leading to a functional cure in some cases. This review evaluates the latest evidence on NA discontinuation, highlighting key factors influencing outcomes. This review synthesises established and emerging evidence on NA discontinuation in CHB. It explores early studies that identified quantitative HBsAg (qHBsAg) as a predictor of sustained response and HBsAg seroclearance, followed by systematic reviews and meta-analyses reinforcing finite therapy as a feasible approach. Advances in predictive modelling, incorporating biomarkers, have refined patient selection for safe NA withdrawal. Additionally, this review assesses the risks associated with NA discontinuation, highlighting the importance of identifying high-risk patients for hepatic decompensation. Ethnicity-specific qHBsAg cut-offs are also discussed, recognising variations in treatment response between Asian and Caucasian populations. Finite NA therapy is emerging as a viable approach for achieving functional cure. Future strategies should integrate liver fibrosis assessment to enhance patient selection before NA discontinuation. Optimising re-treatment approaches requires balancing timing, immune response, and qHBsAg kinetics to maximise HBsAg seroclearance. Clinical perspectives on NA discontinuation remain a key research priority, necessitating standardised guidelines and improved post-NA monitoring strategies to ensure safe and effective finite therapy in CHB management.

Computed Tomography-Guided Online Adaptive Stereotactic Body Radiation Therapy for Liver Tumors: A Retrospective Study

PURPOSE

We present a computed tomography-guided online adaptive radiation therapy (CT-ART) experience in liver stereotactic body radiation therapy (SBRT).

METHODS AND MATERIALS

A retrospective registry study evaluated patients with hepatocellular carcinoma or liver metastasis treated with CT-ART. Physicians were offered 2 plans, the original plan transposed onto the cone beam CT with adapted contours and a new plan generated with updated contours. Treatment distance from planning target volume (PTV) to nearest organ at risk (OAR) was determined by calculating the distance from PTV to nearest OAR on cone beam CT for simulation and each fraction.

RESULTS

Thirteen patients received SBRT 45 to 60 Gy (median, 50 Gy) in 5 fractions. Median PTV was 98.6 cc. Of 65 fractions, 77% (50) were adapted. Distance from PTV to nearest OAR over the course of treatment varied for 10 of 13 patients (range, 0-1.1 cm). Three patients without change in PTV-OAR distance all had PTV-OAR overlap at simulation. Despite having no PTV-OAR overlap at time of simulation, during treatment, 3 patients developed an overlap between PTV and nearest OAR. PTV V100% ≥ 95% criteria were met in 92% of adapted and 64% of scheduled plans (P = .042) and among fractions with PTV and OAR overlap, 87% of adapted and 33% of scheduled plans met PTV V100% goal (P = .045). For fractions with PTV-OAR overlap, maximum dose (Dmax) to nearest OAR was lower with adapted plan (P = .026). Adapted plans had lower mean stomach Dmax (P = .012) and lower mean duodenum Dmax (P = .05).

CONCLUSIONS

We demonstrate the distance between PTV and nearest OAR varies throughout a course of CT-ART SBRT for liver tumors. Overlap between the PTV and OAR during treatment emerged in half of patients with separation between 0.1 and 1.5 cm at time of simulation. Among fractions with PTV-OAR overlap, adapted plans improved ability to meet PTV V100% goal while reducing Dmax to nearest OAR.

Transarterial chemoembolization combined with lenvatinib vs transarterial chemoembolization combined with sorafenib for unresectable hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND

Lenvatinib and sorafenib are tyrosine kinase inhibitors that are effective in the treatment of unresectable hepatocellular carcinoma (uHCC). The efficacy of which of them is better suited to combine transarterial chemoembolization (TACE) for the treatment of uHCC is ripe.

AIM

To compare the effectiveness of TACE combined with lenvatinib (TACE-lenvatinib) and TACE combined with sorafenib (TACE-sorafenib) in the treatment of uHCC, this study was carried out.

METHODS

Publicly available studies comparing the efficacy of TACE-lenvatinib and TACE-sorafenib in the treatment of uHCC were collected from PubMed, Embase and Cochrane Library, with a cut-off date of December 2024. Stata SE 15 software was used for statistical analysis.

RESULTS

A total of six studies involving 547 patients were included, 248 in the TACE-lenvatinib group and 299 in the TACE-sorafenib group. Meta-analysis results showed that TACE-lenvatinib was more effective than TACE-sorafenib in complete response [relative risk (RR) = 1.81, 95% confidence interval (CI): 1.11-2.96, P = 0.02], partial response (RR = 1.38, 95%CI: 1.12-1.70, P = 0.002), objective response rate (RR = 1.47, 95%CI: 1.24-1.74, P < 0.0001) and disease control rate (RR = 1.22, 95%CI: 1.00-1.49, P = 0.05). TACE-lenvatinib was significantly lower than TACE-sorafenib in progressive disease rate (RR = 0.54, 95%CI: 0.39-0.74, P = 0.002). No significant difference was found in stable disease rate (RR = 0.89, 95%CI: 0.60-1.33, P = 0.58) between the two groups. TACE-lenvatinib was significantly more effective than TACE-sorafenib in overall survival (hazard ratio = 2.00, 95%CI: 1.59-2.50, P < 0.05) and progression free survival (hazard ratio = 2.04, 95%CI: 1.49-2.86, P < 0.05). As regards adverse events, TACE-lenvatinib was better in reducing the incidence of hypertension than TACE-sorafenib, while no significant difference was found in overall adverse events, abdominal pain, fever, fatigue, nausea and vomiting, decreased appetite, liver dysfunction, hand-foot skin reaction, diarrhea, thrombocytopenia, and rash between the two groups.

CONCLUSION

In patients with uHCC, TACE-lenvatinib induced a better tumor response rate and survival outcome than TACE-sorafenib, while TACE-lenvatinib resulted in a higher incidence of hypertension than TACE-sorafenib. However, these conclusions are derived from currently available medical evidence, and further confirmation by more rigorously designed randomized controlled studies is still needed.

Prognostic value of preoperative fibrinogen, neutrophil-to-lymphocyte ratio, serum alpha-fetoprotein, and prealbumin for patients with primary liver cancer undergoing transarterial chemoembolization

BACKGROUND

Primary liver cancer, predominantly hepatocellular carcinoma (HCC), is a major cause of cancer-related mortality. Transarterial chemoembolization (TACE) is a key palliative option for unresectable HCC. However, prognostic outcomes after TACE vary significantly. This study evaluated the prognostic value of the fibrinogen and neutrophil-to-lymphocyte ratio (F-NLR) score, serum alpha-fetoprotein (AFP), and prealbumin (PA) in patients undergoing TACE.

AIM

To investigate the prognostic significance of F-NLR score, AFP, and PA in patients undergoing TACE.

METHODS

Variables such as F-NLR score, AFP, PA, and other clinical indicators were assessed. Follow-ups determined prognosis as good or poor. Statistical assessments, including receiver operating characteristic analyses, were performed to evaluate the prognostic significance and develop an integrated predictive model.

RESULTS

A retrospective analysis of 162 patients with primary liver cancer undergoing TACE was conducted. Low F-NLR scores and AFP levels and high PA were significantly associated with a good prognosis. The combined model, which integrated F-NLR, AFP, and PA, demonstrated a favorable prognostic predictive capability, with an area under the curve of 0.933.

CONCLUSION

Preoperative F-NLR, AFP, and PA are valuable prognostic predictors in patients with HCC undergoing TACE.

Improvement in renal function after switching from entecavir to tenofovir alafenamide in chronic hepatitis B patients with low estimated glomerular filtration rates

INTRODUCTION AND OBJECTIVES

Tenofovir alafenamide (TAF) and entecavir (ETV) are both considered renal-friendly nucleoside/nucleotide analogs (NAs). However, the difference between ETV and TAF in terms of renal function remains unclear. This study aims to compare the renal safety profiles of two antiviral medications directly and evaluate the impact of switching from ETV to TAF treatment on renal function in chronic hepatitis B (CHB) patients with low estimated glomerular filtration rates (eGFR).

PATIENTS AND METHODS

A total of 179 CHB patients who received TAF (n=84) or ETV (n = 95) between 2019 and 2023 were included in the study. Changes in eGFR levels between two treatment groups from baseline to 72 weeks were compared to measure the influence of these NAs on renal function.

RESULTS

At baseline, 84 patients were included in each treatment group after a 1:1 propensity score matching process. At week 48, a notable different changes in eGFR were observed between the two groups. Gender, baseline eGFR, and medication (TAF/ETV) were significantly correlated with eGFR abnormalities. Furthermore, eGFR abnormalities at week 48 led to the transition of 6 patients in the ETV group to TAF. eGFR significantly increased (83.60 ± 5.45 vs. 93.39 ± 9.88 mL/min/1.73 m2; p=0.031) and serum creatinine significantly decreased (81.47±11.36 vs. 74.9±10.67 μmol/L; p=0.046) from week 48 to 60. At week 48, the incidence of low-level viremia (LLV) was 19.0% in the ETV group and 16.7% in the TAF group, respectively (p>0.05). Pairwise comparisons revealed no significant difference in the percentage of LLV between the ETV continued group and the TAF continued group at week 48, 60, and 72. Additionally, there was also no significant difference in the proportion of LLV between the ETV+TAF combination group and the TAF+ETV combination group at week 48, 60, and 72.

CONCLUSIONS

There was a substantial difference in eGFR between ETV and TAF treatments at week 48. Gender, baseline eGFR, and medication (TAF/ETV) were all remarkably positive indicators of eGFR abnormalities. In patients receiving ETV, an early switch to TAF may result in the reversal of early-stage renal damage.

Opioid use and the risk of cancer incidence and mortality: a systematic review

There is abundant but discrepant scientific literature reporting an effect of opioids on the course of cancer. The International Agency for Research on Cancer monographs recently classified opium consumption as carcinogenic to humans in certain organs, raising concerns this may be due at least in part to the alkaloids opium contains (such as morphine and codeine). This systematic review investigated whether opioid exposure among cancer-free individuals is independently associated with the risk of future cancer incidence or cancer mortality. An electronic database search was conducted in PubMed, EMBASE, Web of Science, PsycINFO, International Pharmaceutical Abstracts, CINAHL and Scopus. Studies were included if they provided a statistical estimate of cancer mortality, cancer incidence, or cancer risk following opioid exposure. Study quality was assessed using the Newcastle-Ottawa Scale. Study characteristics and outcomes were extracted and analysed in a descriptive narrative synthesis. There were 27 studies that met the inclusion criteria, representing a total of 4,542,745 participants. Twelve of the 27 were rated as high quality according to the Newcastle-Ottawa Scale. The observed data is consistent with a small increase in the risk of cancer incidence or cancer mortality following opioid exposure, particularly in a subset of organs. There is, however, considerable uncertainty in the evidence given the substantial risk of bias in estimating the overall effect of opioid exposure on cancer outcomes in these studies. This review synthesises studies reporting cancer risk following opioid exposure and identifies the key methodological factors influencing ongoing uncertainty estimating the true effect. Rigorous epidemiological studies employing specific methods to minimize bias are warranted.

Hepatic transcriptome profiling unveils candidate genes in cattle with liver abscesses under the influence of beef genetics in dairy cattle

Liver abscesses are a significant concern in cattle feeding, linked to visceral condemnation and carcass trimming; however, the molecular mechanism of development and progression of liver abscesses is unknown. This study aimed to evaluate the hepatic transcriptomic profile, immunohistochemistry, and IGF-I circulation in beef × dairy (Angus × Holstein) steers with and without liver abscesses. Samples were collected from twelve steers (final body weight of 719 ± 5.8 kg) originating from the same feedlot and were selected based on liver scores at harvest. The animals were divided into abscessed (n = 6) and healthy livers (n = 6). Blood samples were used to measure circulating insulin-like growth factor I (IGF-I) levels using an ELISA kit. Liver samples were divided into two portions; one portion was used for immunohistochemistry (IHC) to identify IGF-I receptor (IGF-IR) abundance, while the second portion was used for RNA extraction, library preparation, and sequencing (Illumina NovaSeq 6000 platform). Differentially expressed genes (DEGs) were identified with the DESeq2 R package, using an adjusted p-value ≤ 0.05 and fold change > 1.5. Sera IGF-I was not affected by liver condition; however, IGF-IR abundance was up-regulated in abscessed livers. A total of 568 DEGs were identified, with 372 up-regulated and 196 down-regulated in abscessed livers. Notably, the most highly up-regulated genes were FGF23, NXPH4, and CYP7A1, while EPHA6, CD70, and INHBA showed the most significant downregulation. Protein-protein interaction (PPI) network analysis identified THBS1 and COL1A2 as significant hub genes. The DEGs showed enrichment in biological processes related to angiogenesis, cell migration, adhesion, and extracellular matrix organization. Pathway analysis indicated activation in signaling pathways, including hepatic fibrosis, interleukin, and IGF-I signaling. These findings reveal candidate genes and pathways linked to inflammatory responses and tissue remodeling, offering valuable evidence that enhances our understanding of the progression of liver abscesses in cattle.

Inhibiting Pyk2/Src expression by miR-23b-3p suppressed liver cancer stem cell function and hepatic carcinoma progression

BACKGROUND

Liver cancer stem cells (LCSCs) are critical drivers of metastasis and chemoresistance in hepatocellular carcinoma (HCC). Proline-rich tyrosine kinase 2 (Pyk2) has been implicated in tumor progression, but its role in LCSC stemness and HCC malignancy remains unclear. This study explores the effects of Pyk2 and its regulation by miR-23b-3p on LCSC function and HCC progression.

METHODS

LCSCs were enriched from HepG2 and HCCLM3 cell lines, and Pyk2 knockdown was induced through siRNA transfection, with or without miR-23b-3p inhibitor co-transfection. We assessed cell proliferation, sphere formation, migration, invasion, and chemosensitivity. Stemness markers (Nanog, Oct4, Sox2, KLF4, and Bmi1) and Pyk2/Src signaling were analyzed via RT-qPCR, Western blotting, and immunohistochemistry. In vivo, tumor growth and Pyk2/Src expressions were evaluated in a BALB/c mouse xenograft model.

RESULTS

Pyk2 expression was significantly elevated in the identified LCSCs compared to the parental HCCs. Pyk2 knockdown significantly suppressed the LCSCs proliferation, sphere formation, migration, invasion, and enhanced chemosensitivity. The expression of stemness markers and miR-23b-3p was significantly inhibited in HCCLM3-LCSCsiPyk2 cells. miR-23b-3p inhibition restored Pyk2 level and Src phosphorylation, reversing the suppressive effects of Pyk2 knockdown. In BALB/c mice, tumor volume, weight, and Pyk2/Src expressions were significantly elevated in HCCLM3-LCSC and HCCLM3-LCSCsiPyk2+miR-23b-3p inhibitor groups comparing to HCCLM3/HCCLM3-LCSCsiPyk2 groups, whereas were even heightened in the HCCLM3-LCSC + miR-23b-3p inhibitor group.

CONCLUSIONS

Inhibiting Pyk2/Src expression by miR-23b-3p suppressed LCSCs function and aggravated HCC progression.

TRIAL REGISTRATION

Not applicable.

AI model using CT-based imaging biomarkers to predict hepatocellular carcinoma in patients with chronic hepatitis B

BACKGROUND & AIMS

Various hepatocellular carcinoma (HCC) prediction models have been proposed for patients with chronic hepatitis B (CHB) using clinical variables. We aimed to develop an artificial intelligence (AI)-based HCC prediction model by incorporating imaging biomarkers derived from abdominal computed tomography (CT) images along with clinical variables.

METHODS

An AI prediction model employing a gradient-boosting machine algorithm was developed utilizing imaging biomarkers extracted by DeepFore, a deep learning-based CT auto-segmentation software. The derivation cohort (n = 5,585) was randomly divided into the training and internal validation sets at a 3:1 ratio. The external validation cohort included 2,883 patients. Six imaging biomarkers (i.e. abdominal visceral fat-total fat volume ratio, total fat-trunk volume ratio, spleen volume, liver volume, liver-spleen Hounsfield unit ratio, and muscle Hounsfield unit) and eight clinical variables were selected as the main variables of our model, PLAN-B-DF.

RESULTS

In the internal validation set (median follow-up duration = 7.4 years), PLAN-B-DF demonstrated an excellent predictive performance with a c-index of 0.91 and good calibration function (p = 0.78 by the Hosmer-Lemeshow test). In the external validation cohort (median follow-up duration = 4.6 years), PLAN-B-DF showed a significantly better discrimination function compared to previous models, including PLAN-B, PAGE-B, modified PAGE-B, and CU-HCC (c-index, 0.89 vs. 0.65-0.78; all p <0.001), and maintained a good calibration function (p = 0.42 by the Hosmer-Lemeshow test). When patients were classified into four groups according to the risk probability calculated by PLAN-B-DF, the 10-year cumulative HCC incidence was 0.0%, 0.4%, 16.0%, and 46.2% in the minimal-, low-, intermediate-, and high-risk groups, respectively.

CONCLUSION

This AI prediction model, integrating deep learning-based auto-segmentation of CT images, offers improved performance in predicting HCC risk among patients with CHB compared to previous models.

IMPACT AND IMPLICATIONS

The novel predictive model PLAN-B-DF, employing an automated computed tomography segmentation algorithm, significantly improves predictive accuracy and risk stratification for hepatocellular carcinoma in patients with chronic hepatitis B (CHB). Using a gradient-boosting algorithm and computed tomography metrics, such as visceral fat volume and myosteatosis, PLAN-B-DF outperforms previous models based solely on clinical and demographic data. This model not only shows a higher c-index compared to previous models, but also effectively classifies patients with CHB into different risk groups. This model uses machine learning to analyze the complex relationships among various risk factors contributing to hepatocellular carcinoma occurrence, thereby enabling more personalized surveillance for patients with CHB.

Statistical Cure After Hepatectomy for Hepatitis B Virus-Associated Hepatocellular Carcinoma: A Risk-Stratification Model

BACKGROUND

Statistical cure, defined as achieving life expectancy comparable with that of disease-free individuals, has not been specifically investigated in hepatitis B virus-associated hepatocellular carcinoma (HBV-HCC), which accounts for more than 50% of the global HCC burden. This study aimed to develop a cure model for HBV-HCC after hepatectomy using matched HBV carriers and the general population as reference groups.

METHODS

From a Chinese multicenter database, HBV-HCC patients who underwent curative-intent hepatectomy were retrospectively reviewed. Independent prognostic factors were identified through Cox regression. A spline-based cure model was applied using two reference populations: matched Chinese HBV carriers (from Shanghai Center for Disease Control and Prevention) and the general population (from the National Bureau of Statistics).

RESULTS

The study analyzed 740 HBV-HCC patients. The following eight independent risk factors were identified: preoperative high viral load (hazard ratio [HR] 1.27), Child-Pugh grade (HR 1.21 and 1.43), multiple tumors (HR 1.70), tumor size greater than 5.0 cm (HR 1.47), macrovascular invasion (HR 3.33), microvascular invasion (HR 1.25), intraoperative blood transfusion (HR 1.21), and postoperative HBV reactivation (HR 1.89). The overall cure probability was 21.2% versus that for HBV carriers and 11.1% versus that for the general population. Risk stratification identified distinct groups relative to HBV carriers. Low risk (64.2%) showed an initial cure rate of 30.3% and achieved a 95% cure probability by 8.6 years, whereas high risk (10.5%) showed negligible cure probability.

CONCLUSIONS

This first HBV-HCC-specific cure model demonstrated that statistical cure is achievable for a subset of patients after hepatectomy. Risk stratification identifies patients with varying cure probabilities, providing valuable guidance for personalized treatment strategies and surveillance protocols.

Relationship between [18F]FDG PET/CT findings and claudin 18.2 expression in metastatic gastric cancer

AIM

Given that claudin 18.2 (CLDN18.2) is a cell surface protein specifically expressed by gastric cancer cells, anti-CLDN18.2 antibodies have demonstrated significant antitumor effects in patients with advanced gastric adenocarcinoma. The correlation of [18F]FDG PET/CT with CLDN18.2 expression remains unexplored. This study aimed to investigate whether CLDN18.2 expression was associated with [18F]FDG uptake and whether [18F]FDG PET/CT can be used to predict the CLDN18.2 status of gastric cancer.

METHODS

A retrospective analysis of [18F]FDG PET/CT images from 163 patients diagnosed with metastatic gastric cancer was conducted, and the expression of CLDN18.2 was assessed immunohistochemically. SUVmax, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were calculated in 3D mode using vendor-provided software. The relationship between PET metabolic parameters and CLDN18.2 status was analyzed.

RESULTS

CLDN18.2-negative tumors showed a higher median SUVmax of 13.2 (1.8-46.7) compared to CLDN18.2-positive tumors at 7.55 (2.3-34.8), with a significant difference (p < 0.001). The median TLG was significantly higher in CLDN18.2-negative tumors (231.6) than in CLDN18.2-positive ones (81.14), indicating greater metabolic activity (p = 0.001). Multivariate analysis suggested that SUVmax remained significantly correlated with the status of CLDN18.2 (p = 0.01). CLDN18.2 expression was predicted with an accuracy of 69.9% when the SUVmax value of 10.9 was used as a cutoff point for analysis.

CONCLUSION

Relatively reduced [18F]FDG uptake in metastatic gastric cancers correlates with positive CLDN18.2 expression compared to those with negative CLDN18.2 expression. [18F]FDG PET/CT may be useful for predicting the CLDN18.2 status of gastric cancer and thus aid in optimal treatment decisions.

KEY POINTS

Question The study resolves the clinical issue of determining the correlation between [18F]FDG PET/CT imaging and claudin 18.2 expression in metastatic gastric cancer. Findings Claudin 18.2-positive metastatic gastric cancers exhibit relatively lower [18F]FDG uptake than negative ones. The SUVmax of 10.9 moderately predicts claudin 18.2 expression. Clinical relevance [18F]FDG PET/CT imaging could be a noninvasive way to predict claudin 18.2 status in metastatic gastric cancer, helping to improve personalized treatment plans.

A systematic review on leptin's role in defining cancer: special emphasis on immunomodulation, inflammation, and therapeutic interventions

Leptin, an adipokine related to obesity, is mainly known for its role in regulating energy homeostasis and appetite by working via the leptin receptor. Recently, different groups have demonstrated that apart from adipocytes, specific cell types associated with cancer and tumor microenvironments express leptin and leptin receptors. This tumor microenvironment-associated leptin-leptin receptor signaling contributes to the different hallmarks of cancer, ranging from inflammatory changes to metastasis. Eventually, it has also been reported that high serum level of leptin, a characteristic of obese people, is linked to enhanced tumor growth. On the other hand, leptin can influence both innate as well as adaptive immunity related to cancer. Overall, leptin's role in modulating cancer is controversial. So, in this review, we summarized the role of leptin in shaping different forms of cancer that are influenced by leptin-leptin receptor signaling with special emphasis on immunomodulation and inflammatory events and also discussed the possible therapeutic interventions to date. As this review work, with the collection of different updated knowledge, has summarized the role of leptin on cancer, it would be useful material to have on hand for both beginners as well as pioneers of these and related fields.

Prognostic Significance of Volumetric Parameters on Pretreatment FDG PET/CT in Patients With Hepatocellular Carcinoma Receiving Atezolizumab Plus Bevacizumab Therapy

BACKGROUND

This study aimed to assess prognostic significance of FDG PET/CT parameters in predicting progression-free survival (PFS) and overall survival (OS) in patients with hepatocellular carcinoma (HCC) treated with atezolizumab plus bevacizumab therapy.

PATIENTS AND METHODS

We retrospectively enrolled 78 patients with HCC who underwent FDG PET/CT before atezolizumab plus bevacizumab therapy and identified intrahepatic target tumor lesions on pretreatment imaging studies. From PET/CT images, we measured SUVmax, tumor-to-normal liver uptake ratio, metabolic tumor volume, and total lesion glycolysis (TLG) for intrahepatic tumor lesions, as well as SUVmax for extrahepatic metastatic lesions (extrahepatic SUVmax).

RESULTS

In comparisons of PET/CT parameters, patients with progressive disease demonstrated significantly higher TLG values than those achieving complete or partial response ( P < 0.05). In the multivariate survival analysis, TLG independently predicted both PFS ( P = 0.019) and OS ( P = 0.003). Metabolic tumor volume was significantly associated with OS alone ( P = 0.010), and extrahepatic SUVmax was significantly associated with only PFS ( P = 0.045). Patients with high TLG values experienced poorer PFS and OS than those with low TLG values ( P < 0.05).

CONCLUSIONS

TLG in intrahepatic HCC lesions was significantly associated with treatment response and served as an independent prognostic factor for PFS and OS. TLG could be a potential imaging biomarker for predicting clinical outcomes in patients with HCC receiving atezolizumab plus bevacizumab therapy.

DILI prediction in drug development: present and future

INTRODUCTION

Idiosyncratic drug-induced liver injury (iDILI) results in significant patient morbidity and significantly increases the risk of drug development. The current methods to screen for iDILI risk are inadequate.

AREAS COVERED

The general mechanism of iDILI and the current methods to screen for iDILI are reviewed. Then the potential for new biomarkers is explored.

EXPERT OPINION

Better biomarkers of iDILI risk should be based on the mechanism of iDILI. In general, it is an adaptive immune response, specifically CD8+ cytotoxic T cells, that is responsible for hepatocyte cell death, not direct toxicity of the drug. Therefore, in vitro cytotoxicity assays represent an artifact not the mechanism of iDILI. Activation of the adaptive immune response leading to iDILI requires an innate immune response, in particular activation of antigen presenting cells. The innate immune response is immediate and unlikely to be idiosyncratic. For example, studies have found that incubation of hepatocytes with drugs causes the release of molecules that activate THP-1-derived macrophages. The response of hepatocytes, the release of damage-associated molecular pattern molecules (DAMPs), especially in extracellular vesicles, and the response of antigen presenting cells (APCs) are likely to provide better biomarkers of iDILI risk.

The deficiency of virulence factor AerA in Aeromonas veronii alleviates intestinal injury and microbiota disorders in largemouth bass (Micropterus salmoides)

Aeromonas veronii is a zoonotic pathogen that causes considerable mortality in aquaculture, with typical manifestations of intestinal injury. Aerolysin (AerA) is a pivotal virulence factor that influences Aeromonas pathogenicity. This study aimed to investigate the functional mechanism of AerA in A. veronii-induced intestinal injury in largemouth bass (Micropterus salmoides). The results revealed that wild-type (WT) A. veronii infection provoked a noteworthy augmentation of abundance of A. veronii in the intestine, accompanied by inflammation, partial repression of immune response, intestinal injury and high mortality. Compared to WT A. veronii infection, significantly reduced levels of A. veronii in the intestine, inflammation, intestinal injury and mortality, as well as enhanced immune response were observed in AerA mutant (ΔAerA) A. veronii infection. In addition, an increase in abundance of A. veroniii in the intestine, inflammation, and higher mortality were once again perceived subsequent to the use of recombinant AerA protein to compensate for AerA depletion. These results demonstrated that AerA deficiency reduce the increased abundance of A. veronii in the intestine, inflammation and intestinal injury caused by A. veronii infection, thereby reducing the virulence of A. veronii. Our findings enhance the understanding of attributes and functional role of AerA in A. veronii infection, and provide guidance for the development of disease control strategies.

Adherence to dietary guidelines and liver cancer risk: Results from two prospective cohort studies

BACKGROUND AND AIMS

Although dietary factors have been extensively investigated as potential risk factors for liver cancer, the evidence is inconclusive. Our study systematically assessed the associations between ten dietary guidelines compliance scores and liver cancer risk among adult people, and found out the dietary patterns for liver cancer prevention.

METHODS

Participants of 59,844 men and 72,680 women, aged 40-74 years and living in urban Shanghai, were included in two prospective cohort studies conducted between 2002-2006 and 1996-2000, respectively. Dietary intakes were assessed during baseline in-person interviews using validated food-frequency questionnaires, and dietary guideline compliance scores were calculated by adjusting for total energy intake and adapting existing dietary recommendations. Hazards ratios (HRs) with 95 % confidence intervals (CIs) were evaluated by both tertile categories and per standard deviation (SD) increment using Cox proportional hazard regression models to assess the associations between ten dietary guideline compliance scores and liver cancer risk.

RESULTS

In the two cohorts, 431 male and 256 female incident liver cancer cases were identified during a mean follow-up of 11.90 and 17.44 years, respectively. There were no statistically significant associations between these ten dietary guidelines and male liver cancer risk (P > 0.05). In contrast, only the modified reversed Empirical Dietary Inflammation Pattern (rEDIP) tended to be associated with the low risk of female liver cancer (HR T3 vs. T1 = 0.67, 95 % CI: 0.48-0.92, Ptrend = 0.016, HR per SD = 0.94, 95 % CI: 0.85-1.03). The inverse associations appeared stronger between rEDIP and liver cancer risk at younger ages (<55 years) in women (HR per SD = 0.91, 95 % CI: 0.84-0.99) compared to the older women (≥55 years). There were suggestive but non-significant inverse associations between the modified Diabetes Risk Reduction Diet (mDRRD) (men: HR per SD = 0.92, 95 % CI: 0.84-1.02; women: HR per SD = 0.97, 95 % CI: 0.84-1.02) and the modified World Cancer Research Fund/American Institute for Cancer Research (mWCRF/AICR) (men: HR per SD = 0.93, 95 % CI: 0.84-1.02; women: HR per SD = 0.91, 95 % CI: 0.80-1.03) and liver cancer incidence. The associations of mDRRD (HR per SD = 0.82, 95 % CI: 0.75-0.98) and mWCRF/AICR (HR per SD = 0.83, 95 % CI: 0.74-0.99) on liver cancer risk were significant in men who ever smoked.

CONCLUSIONS

Our findings confirm that greater adherence to some healthy dietary patterns (i.e. rEDIP, mDRRD and mWCRF/AICR) is inversely associated with liver cancer risk, especially in certain populations. Future studies are required to confirm these findings and elucidate potential mechanisms.

A well-characterized mechanistic model for exploring known or hypothesized T cell mediated drug induced liver injury: current capabilities and challenges for future predictivity

BACKGROUND

Drug-induced liver injury (DILI) is an adverse event whose emergence can slow or halt drug development programs. Adaptive immune responses have been implicated for several DILI compounds, and drug-specific T cell responses have been characterized, but there are still many unknowns. We describe the extension of a quantitative systems toxicology (QST) model of DILI to include CD8+ T cell-mediated DILI.

RESEARCH DESIGN AND METHODS

To overcome deficits in quantitative data characterizing CD8+ T cell-mediated DILI, a translational strategy leveraged a well-defined mouse ovalbumin (OVA) antigen model and adapted it to represent mouse amodiaquine (AQ)-specific CD8+ T cell-mediated DILI, with further adaptations to represent human AQ-specific CD8+ T cell-mediated DILI.

RESULTS

DILIsym reproduced published data characterizing mouse OVA-specific CD8+ T cell-mediated hepatotoxicity, mouse AQ-specific CD8+ T cell-mediated DILI, and human AQ-specific CD8+ T cell-mediated DILI. Development identified main drivers of the CD8+ T cell response, as well as areas where in vitro assay data could inform the simulation of additional compounds.

CONCLUSIONS

The DILIsym CD8+ T cell sub-model is well-positioned for systematic testing to improve our understanding of CD8+ T cell-mediated DILI. It is not yet predictive but indicates a promising direction to reduce DILI events in drug development.

A self-gelling hemostatic powder boosting radiotherapy-elicited NK cell immunity to combat postoperative hepatocellular carcinoma relapse

Liver resection represents a main curative treatment for patients with early-stage hepatocellular carcinoma (HCC), but there is a rather high incidence of postoperative HCC relapse, which severely shortens long-term survival time. Currently, no standard adjuvant strategies are available for preventing HCC relapse in clinical practice. Impaired natural killer (NK) cell anti-tumor immunity has been disclosed as a crucial root of HCC relapse, indicating that reinstating NK cell anti-tumor immunity may show promise to curb HCC relapse. Coincidently, mounting evidence shows that radiotherapy (RT) can trigger NK cell anti-tumor immunity, though its mechanisms have never been completely elucidated. Herein, we uncover that RT can induce immunogenic cell death and activate cGAS-STING pathway in HCC cells to elicit NK cell anti-tumor immunity. However, RT is also revealed to enhance autophagy and CD73 expression in HCC cells, as well as neutrophil extracellular traps (NETs) formation, which largely limits RT-induced activation of NK cell anti-tumor immunity. Therefore, a cocktail of autophagy inhibitor 3-methyladenine, CD73 inhibitor ARL 67156 trisodium and NETs lyase DNase I may sensitize RT to reinvigorate NK cell anti-tumor immunity and thus prevent HCC relapse postresection. To minimize therapy-related side effects, a nanocomposite powder encapsulating such a triple-drug cocktail is developed. This powder can rapidly form adhesive hydrogel in situ after applied to surgical margin, consequently fulfilling liver-localized sustained drug delivery. Importantly, it can sensitize RT to reinstate NK cell anti-tumor immunity to combat postoperative HCC relapse in Heap1-6-HCC murine model. Besides, this powder can also generate rapid hemostasis in rat and porcine models. Altogether, this work provides an innovative strategy to thwart postoperative HCC relapse and bleeding.

Risk of HBV reactivation in HBV/HCV-co-infected HCV-treated patients: A single-center study

Hepatitis B virus (HBV) reactivation in patients with HBV/hepatitis C virus (HCV) co-infection due to direct-acting antiviral agent (DAA) therapy is a growing concern. This study focused on 47 patients with chronic hepatitis C (CHC) and positivity for HBV surface antigen (HBsAg) who were treated with interferon (IFN)-based therapy, DAA, or DAA after IFN-based therapy failure and followed for a median of 53 months. Here, we aimed to determine HBV reactivation rates and associated factors, the incidence of HBV and liver-related events, and the rate of sustained virologic response (SVR) for HCV. Fifteen (15/47, 31.9%) patients experienced HBV reactivation during or after HCV treatment. This reactivation occurred significantly more frequently in patients who received DAA treatment after IFN-based treatment failure than in those who received IFN-based treatment (IFN-based vs. DAA vs. DAA treatment after IFN-based treatment failure 11.8% vs. 35.3% vs. 53.8%, respectively; p = 0.046). The interval from HCV treatment initiation to HBV reactivation was shortest in the DAA group (4.2 months), followed by the DAA after IFN-based treatment failure group (6.4 months) and the IFN-based treatment group (44.5 months) (p < 0.001). One case of HBV-related hepatitis spontaneously resolved after 4 weeks. The rate of SVR for the entire cohort was 87.2%, with no significant difference in this regard among the IFN-based treated, DAA-treated, and DAA-treated after IFN-based treatment failure arms at 82.4%, 88.2%, and 92.3%, respectively. HBV reactivation in HBsAg-positive CHC patients is more common and occurs earlier in those who receive DAA treatment after IFN-based treatment failure than in those with IFN-based treatment. Therefore, all patients with CHC should be tested for HBV exposure prior to DAA treatment. In addition, HBsAg positive patients, especially those among whom have previously experienced IFN-based treatment failure, should be closely monitored for HBV reactivation during DAA therapy.

Identification of transarterial chemoembolization candidates in advanced hepatocellular carcinoma patients classified solely by performance status 1: a multicenter retrospective study

The Barcelona Clinic Liver Cancer (BCLC) advanced stage of hepatocellular carcinoma (HCC) includes a heterogeneous population, and new patient-tailored therapeutic indications are needed. Emerging evidence suggest that patients in this stage with mild tumor-related symptoms may benefit from more aggressive treatments including transarterial chemoembolization (TACE) and obtain better outcomes. This study aimed to investigate the effects of TACE on HCC patients with mild tumor-related symptoms and risk-stratify them for selecting potential candidates for TACE. We retrospectively collected data from 745 patients with liver-confined HCC undergoing TACE at 15 different centers from January 2015 to November 2022. The prognostic abilities of performance status (PS score of 0 vs. 1) were separately evaluated in high- and low-risk groups using the Hepatoma Arterial-embolization Prognostic (HAP) scoring model and its variants. PS1 remained an independent prognostic factor for overall survival (OS) in the whole cohort (P = 0.035). Interestingly, it lost its prognostic value for patients in low-risk groups (grade A + B) in all the four HAP models. This population with PS1 alone achieved similar OS to their counterparts with PS0. Risk stratification based on HAP scoring models could discriminate potential candidates from HCC patients in BCLC-C stage with PS1 alone. These patients could be classified into BCLC-B stage and benefit from TACE treatment.

Selected laboratory-based biomarkers for assessing vitamin A deficiency in at-risk individuals

BACKGROUND

Vitamin A deficiency is a highly detrimental micronutrient deficiency associated with poor growth, impaired immune responses, increased incidence of disease, ocular impairments, and maternal and child mortality. Reliable diagnostic assessment of vitamin A status is crucial to inform its clinical management. Currently, direct index measures and dose response biomarkers have been developed to provide assessments of vitamin A status.

OBJECTIVES

To determine the accuracy of index tests routinely used as markers of subclinical vitamin A deficiency in individuals at risk for vitamin A deficiency. Secondary objectives are to assess covariates as sources of heterogeneity for the accuracy of index tests routinely used as markers of subclinical vitamin A deficiency.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and six other databases up to 18 August 2022, without restriction (any sex, age, pregnancy status, breastfeeding status, physiological condition, living in any country).

SELECTION CRITERIA

We included any studies implementing concurrent measurement of at least one reference standard and one index test to measure vitamin A status. Eligible studies included cross-sectional or cohort-accuracy studies; longitudinal studies; and direct, indirect, and random comparison studies, in which multiple index tests with a reference standard were evaluated. Interventional studies measuring vitamin A status following supplementation or intervention were also included, while case-control studies defining cases by vitamin A status were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies and extracted data. We evaluated the methodological quality, that is, risk of bias of included studies and their applicability by using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. When meta-analysis was appropriate, we used random-effects bivariate models to obtain pooled estimates of sensitivity and specificity. We stratified all analyses by the reference standard and cutoff used, and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 40 studies reporting 65 records. None of the studies was designed as a diagnostic test accuracy (DTA) study, limiting our analyses and assessments. Index test performance was described by 25 studies for serum or plasma retinol (SR) versus retinol isotope dilution (RID), 16 studies for SR versus liver vitamin A, eight studies for retinol-binding protein (RBP) versus retinol isotope dilution (RID), three studies for RBP versus liver vitamin A, one study for breast milk vitamin A versus RID, three studies for relative dose response (RDR) versus RID, and four studies for RDR versus liver vitamin A. No studies evaluating modified RDR were eligible for inclusion. Specificity data were available from all studies; sensitivity was often estimable from only a portion of studies due to some studies having no condition-positive cases according to the reference standard (zero true positive and false negative cases). One comparison, RDR versus RID, yielded no sensitivity data, therefore we could evaluate only pooled specificity data. We generally judged risk of bias as 'unclear' across studies. Serum or plasma retinol for diagnosing vitamin A deficiency SR pooled sensitivity against RID at the 0.1 μmol/g cutoff was 10% (95% confidence interval (CI) 2 to 38; 23 studies, 385 participants; very low-certainty evidence), and specificity was 92% (95% CI 85 to 96; 23 studies, 1110 participants; low-certainty evidence). SR pooled sensitivity against RID at the 0.07 μmol/g cutoff was 13% (95% CI 4 to 34; 24 studies, 246 participants; very low-certainty evidence), and specificity was 94% (95% CI 87 to 97, 24 studies, 1295 participants; low-certainty evidence). SR pooled sensitivity against liver vitamin A at the 0.1 μmol/g cutoff was 53% (95% CI 30 to 75; 16 studies, 192 participants; very low-certainty evidence) and specificity was 83% (95% CI 63 to 93; 16 studies, 370 participants; moderate-certainty evidence). SR pooled sensitivity against liver vitamin A at the 0.07 μmol/g cutoff was 54% (95% CI 33 to 74; 16 studies, 137 participants; very low-certainty evidence) and specificity was 79% (95% CI 57 to 91; 16 studies, 348 participants; moderate-certainty evidence). Retinol-binding protein for diagnosing vitamin A deficiency RBP pooled sensitivity against RID at the 0.1 μmol/g cutoff was 50% (95% CI 33 to 67; 8 studies, 30 participants; low-certainty evidence) and specificity was 76% (95% CI 72 to 81; 8 studies, 730 participants; moderate-certainty evidence). RBP pooled sensitivity against RID at the 0.07 μmol/g cutoff was 45% (95% CI 31 to 59; 8 studies, 47 participants; low-certainty evidence) and specificity was 77% (95% CI 71 to 82; 8 studies, 711 participants; moderate-certainty evidence). RBP pooled sensitivity against liver vitamin A at the 0.1 μmol/g cutoff was 0% (95% CI 0 to 100; 3 studies, 12 participants; very low-certainty evidence) and specificity was 98% (95% CI 84 to 100; 3 studies, 40 participants; very low-certainty evidence). RBP pooled sensitivity against liver vitamin A at the 0.07 μmol/g cutoff was 0% (95% CI 0 to 100; 3 studies, 9 participants; very low-certainty evidence) and specificity was 98% (95% CI 85 to 100; 3 studies, 43 participants; very low-certainty evidence) Relative dose response for diagnosing vitamin A deficiency RDR pooled sensitivity against RID at the 0.1 μmol/g and 0.07 μmol/g cutoffs were not estimable due to lack of true-positive and false-negative cases from three studies. RDR pooled specificity against RID at the 0.1 μmol/g cutoff was 89% (95% CI 26 to 99; 3 studies, 34 participants; low-certainty evidence), and RDR pooled specificity against RID at the 0.07 μmol/g cutoff was 91% (95% CI 54 to 99; 3 studies, 34 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Available data indicate that methods to determine vitamin A deficiency had generally low sensitivity, when estimable (0% to 54%), and generally high specificity (74% to 94%) in individuals at risk for vitamin A deficiency. Estimates should be interpreted with caution because no included studies were designed or conducted as DTA studies. Data assessing the accuracy of the breast milk vitamin A, RDR, and MRDR compared to reference standards, particularly in patients with vitamin A deficiency, are limited.

Relationship between high-sensitivity C-reactive protein to lymphocyte ratio (hs-CLR) and incision complications following medial opening-wedge high tibial osteotomy for knee osteoarthritis

PURPOSE

Inflammatory and markers have a vital role in the development and prediction of adverse events following surgical procedures. This study aims to examine the relationship between high-sensitivity C-reactive protein to lymphocyte ratio (hs-CLR) and incision complications (ie, poor healing of superficial incisions, wound infection) following medial opening-wedge high tibial osteotomy (MOWHTO) for unicompartmental knee osteoarthritis (KOA).

METHODS

This retrospective study analyzed patients who underwent MOWHTO for varus KOA between January 2021 and June 2024 in two tertiary referral hospitals. Baseline characteristics and laboratory test results were obtained through a review of inpatient medical records. The primary outcome measure was the incidence of incision complications occurring within 30 days postoperatively, determined by examining both inpatient records and outpatient follow-up documentation after discharge. To explore the relationship between hs-CLR and incision complications, we employed restricted cubic spline (RCS) analysis, receiver operating characteristic (ROC) curves, as well as univariate and multivariate logistic regression models.

RESULTS

There were 528 participants, including 190 males and 338 females, with a mean age of 56.2 ± 6.5 years. Within the 30 days following surgery, 48 patients (9.1%; 95% CI, 6.6% to 11.5%) experienced incision complications. Both the unadjusted and adjusted RCS analyses revealed the consistently significant nonlinear relationship (P < 0.05). ROC curve analysis identified an optimal hs-CLR cut-off value of 1.83, accordingly categorizing patients into low hs-CLR (n = 298) and high hs-CLR (n = 230) groups. Multivariate analyses employing two adjustment techniques demonstrated a significant relationship between a hs-CLR ≥ 1.83 and an increased risk of incision complications, with an odds ratio of 8.08 (95% CI, 3.16 to 20.63; P < 0.001) for "fully adjusted model" and of 8.99 (95%CI, 3.92 to 20.63; P < 0.001) for "backward elimination model".

CONCLUSION

This study demonstrated a robust association between preoperative hs-CLR and the risk of postoperative incision complications following MOWHTO for varus KOA. Although the observed odds ratios were substantial, the wide confidence intervals highlight the need for validation through larger, multicenter studies.

Magnetic resonance imaging features of intrahepatic bile duct adenoma: a 10-year retrospective study

BACKGROUND

Intrahepatic bile duct adenoma (BDA) is a rare tumor with limited understanding of its magnetic resonance imaging (MRI) features and clinical characteristics. This study aimed to analyze the MRI characteristics of BDA.

METHODS

This retrospective study analyzed MRI findings and clinical profiles of 33 patients diagnosed with bile duct adenomas (BDA) at Zhongshan Hospital Fudan University from January 2014 to January 2024. MRI features and clinical data were reviewed and analyzed.

RESULTS

A total of 36 lesions were identified among 33 patients, with 31 cases presenting as solitary lesions. The average diameter was 9.2 ± 3.1 mm, predominantly subcapsular, located near the liver capsule, with the majority exhibiting well-defined margins. On T1-weighted imaging (T1WI), lesions displayed hypointensity, while T2-weighted imaging (T2WI) was slightly hypointense in most cases, enhancing the visibility of the lesions. Apparent diffusion coefficient (ADC) values averaged (1.93 ± 0.51)×10⁻³ mm²/s, significantly higher than surrounding liver tissue (P < 0.001), suggesting unique tissue properties. Notably, BDA, as a hypervascular tumor, displayed rim and non-rim enhancement patterns, along with a tendency for persistent enhancement.

CONCLUSION

The MRI features of BDA included small lesions near the liver capsule, characterized by distinct morphology and enhancement patterns, alongside elevated ADC values that distinguish them from malignant hepatic lesions. The findings emphasize the importance of MRI in the accurate diagnosis and management of BDA.

Neutrophil-derived ratios as predictors of short-term mortality in HBV-associated decompensated cirrhosis

BACKGROUND

Hepatitis B virus-associated decompensated cirrhosis (HBV-DC) is recognized as a critical illness with an increased risk of short-term mortality. Neutrophil-derived ratios, including neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-albumin ratio, neutrophil-to-high-density lipoprotein-cholesterol ratio, neutrophil-to-hemoglobin ratio, and neutrophil-to-platelet ratio, have emerged as potential prognostic markers in various liver diseases. The present study aimed to determine the effectiveness of these neutrophil-derived ratios for prediction of mortality in patients with HBV-DC.

METHODS

We conducted a retrospective analysis of HBV-DC patients at our hospital between April 2022 and April 2024. The study endpoint was the 30-day mortality rate. These neutrophil-derived ratios were calculated from data obtained during routine laboratory tests on admission. Disease severity was assessed using the Model for End-Stage Liver Disease (MELD) score. Multivariate regression analyses and receiver operating characteristic (ROC) curve analyses were conducted.

RESULTS

The study investigated 160 HBV-DC patients, of whom 23 (14.4%) experienced mortality within 30 days. Non-survivors exhibited markedly higher values for neutrophil-derived ratios than survivors. All neutrophil-derived ratios were associated with mortality in univariate analyses, but only NLR and MELD score remained as independent predictors of mortality in multivariate analyses. In the ROC analyses, NLR showed a similar prognostic value to MELD score. Moreover, both NLR and MELD score had high specificity for prediction of mortality in HBV-DC patients.

CONCLUSIONS

Among neutrophil-derived ratios, NLR stands out as a simple and reliable predictor of mortality in HBV-DC patients.

Association between hepatitis C virus infection and rheumatoid arthritis: a nationwide cross-sectional study

BACKGROUND

Patients infected with Hepatitis C Virus (HCV) often present with rheumatic symptoms, but its link to rheumatoid arthritis (RA) remains unclear. The purpose of this cross-sectional study was to investigate whether HCV infection is related to the risk for RA in adults.

METHODS

We analyzed data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES). HCV infection and RA status were determined through questionnaires. Covariates included gender, age, race, marital status, body mass index (BMI), high-sensitivity C-reactive protein (hs-CRP), and diabetes status. Multivariate logistic regression and subgroup analyses were used to assess the relationship between HCV infection and RA risk.

RESULTS

In this population-based study involving 5,825 participants aged 18-80 years (including 485 RA patients), we observed a significantly higher prevalence of HCV infection in the RA group compared with non-RA controls. After adjusting for covariates, multivariate logistic regression showed that HCV infection was associated with an increased risk of RA (OR = 1.93; 95%CI = 1.07-3.50, p < 0.05).

CONCLUSION

This study demonstrates that HCV infection is associated with the risk of RA in adults, underscoring the potential value of HCV screening in RA patients for improved disease management. However, causal interpretation is limited by the cross-sectional design and reliance on self-reported data.

Structural optimization of phthalazine derivatives for anti-HBV activities to improve oral bioavailability

The hepatitis B virus (HBV) capsid protein forms a protective nucleocapsid essential for viral replication, establishing capsid assembly modulation as a promising therapeutic strategy. Based on previous mechanistic studies, we identified phthalazine derivatives as potent HBV capsid assembly modulators (CAMs), with Yhhu6517 exhibiting submicromolar antiviral activity in vitro. However, its clinical translation was hindered by poor oral pharmacokinetics (PK), due to rapid first-pass metabolism of oxidation-prone primary alcohol groups. Through metabolic stability-guided structure-activity relationship (SAR) studies involving systematic replacement of primary alcohols with non-primary alcohol-derived hydrophilic groups, we optimized the fragments to yield compound 2p. This optimized candidate 2p maintained a potent anti-HBV activity (IC50 = 0.016 μM in HepG2.2.15 cells) while demonstrating improved an oral bioavailability (F = 80.6 % in mice) and enhanced plasma exposure (AUC0-24h = 10.3 μg·h/mL). These findings confirm phthalazine-based anti-HBV agents, with compound 2p emerging as a candidate for the further development.

SOX4 reprograms fatty acid metabolism through the CHREBP to inhibit ferroptosis in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality, characterized by aggressive progression and poor prognosis. Pathological angiogenesis in HCC is closely linked to metabolic reprogramming, particularly concerning fatty acid metabolism. The interplay between fatty acid metabolism and ferroptosis, a type of cell death driven by lipid peroxidation, is emerging as a crucial area of study. The transcription factor SOX4 is known to be overexpressed in various cancers, including HCC, and may play a key role in these processes. We assessed SOX4 expression in HCC using clinical samples and data from online databases. Next-generation RNA sequencing was employed to explore the effects of SOX4 on fatty acid metabolism, focusing on the CHREBP pathway. Functional assays, including lipid peroxidation and angiogenesis studies, were conducted to investigate the role of SOX4 in regulating ferroptosis and angiogenesis in HCC. SOX4 was found to be significantly upregulated in HCC and associated with enhanced angiogenesis. Mechanistically, SOX4 activated the CHREBP/SCD1 pathway, leading to increased production of monounsaturated fatty acids, which in turn inhibited ferroptosis. This suppression of ferroptosis contributed to the promotion of angiogenesis and tumor progression in HCC. In conclusion, SOX4 reprograms fatty acid metabolism via the CHREBP/SCD1 pathway, thereby inhibiting ferroptosis and promoting angiogenesis in HCC. These findings suggest that targeting the SOX4-CHREBP axis could represent a novel therapeutic strategy for HCC.

An immune-based predictive model for HBV clearance: validation in multicenter cohorts and mechanistic insights from in vivo studies

BACKGROUND

Chronic HBV infection is a major risk factor for hepatocellular carcinoma, posing a significant global health burden. However, predictive models for HBV clearance based on immune biomarkers remain limited.

METHODS

We systematically developed a predictive tool by quantifying mRNA expression levels of CD4⁺ T-cell subset transcription factors, cytokines, and immune checkpoints in PBMCs from chronic HBV patients and resolved HBV individuals using RT-qPCR. A binary logistic regression model was constructed in the training cohort, with performance evaluated by ROC and calibration curves, followed by internal and external validation in independent cohorts. For in vivo validation, an HBV-transfected mouse model was established via rapid tail vein injection of pGL3-CP-Fluc-HBV1.2C2 plasmid. Outcomes included body weight, HBsAg/HBV DNA levels, and luciferase activity. Kaplan-Meier analysis assessed cumulative clearance rates, while RT-qPCR tracked model-related mRNA dynamics in PBMCs.

RESULTS

The model identified GATA3, FOXP3, IFNG, TNF, and HAVCR2 as key genes, demonstrating robust predictive accuracy for HBV clearance. Dose-specific temporal patterns of immune gene regulation were observed, revealing distinct immunomodulatory mechanisms between groups.

CONCLUSION

This study establishes a reliable immune-based predictive model for HBV clearance and highlights divergent immune responses in chronic versus resolved infection.

Bulk and single-cell RNA sequencing identify prognostic signatures related to FGFBP2+ NK cell in hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) is a highly aggressive malignancy. As a specific immune cell subpopulation, FGFBP2+ NK cells play a crucial part in immune surveillance of HCC progression. This study set out to identify prognostic signature related to FGFBP2+ NK cell in HCC.

Methods

Bulk and scRNA-seq data were derived from the public databases. The single cell atlas of HCC and heterogeneity of natural killer (NK) cells were delineated by "Seurat" package. Pseudo-time trajectory of FGFBP2+ NK cell was constructed by "Monocle2" package. Cell-cell interactions were analyzed by "CellChat" package. Prognostic signature was screened to develop a RiskScore model, and the prediction robustness was verified. Immune cell infiltration and immunotherapy response were assessed between different risk groups. Drug sensitivity was predicted by "oncoPredict" package. The expressions of the prognosis gene signature were detected by in vitro test utilizing HCC cells. The effects of key genes on the proliferative, migratory and invasive capacity of HCC cells were assessed by EdU assay, wound healing and Transwell assay.

Results

The proportion of NK cell in HCC samples was markedly decreased than that in healthy samples. NK cell was further divided into three cell subpopulations, and FGFBP2+ NK cell was associated with the prognosis of HCC patients. Pseudo-time trajectory analysis of FGFBP2+ NK cell revealed two differential expression gene clusters. FGFBP2+ NK cell exhibited extensive intercellular communication in HCC. Further, eight prognostic signatures were identified, including six "risk" genes (UBE2F, AHSA1, PTP4A2, CDKN2D, FTL, RGS2) and two "protective" genes (KLF2, GZMH). RiskScore model was established with good prognostic prediction performance. In comparison to low-risk group, high-risk group had poorer prognosis, lower immune cell infiltration, and higher TIDE score. Moreover, 16 drugs showed significant correlation with RiskScore. Additionally, the expressions of GZMH was downregulated while FTL, PTP4A2, UBE2F, CDKN2D, RGS2, and AHSA1 were up-regulated in HCC cells. FTL and PTP4A2 silencing could suppress the proliferation, migration and invasion abilities of HCC cells.

Conclusion

This study identified eight prognostic gene signatures related to FGFBP2+ NK cell in HCC, which may serve as potential therapeutic targets for HCC.

Neutrophil–lymphocyte ratio is associated with worse outcomes in patients with cirrhosis: insights from the PRO-LIVER Registry

Background

Liver cirrhosis (LC) is a leading global cause of morbidity and mortality, with inflammation playing a key role in disease progression and clinical complications of LC. The Neutrophil/Lymphocyte Ratio (NLR), a readily available marker of systemic inflammation, has been linked to short-term adverse outcomes in LC, but data on long-term follow-up are limited. This study aimed to investigate the relationship between NLR and long-term all-cause mortality in an unselected cohort of LC patients.

Methods

Data were gathered from the Italian multicenter observational study “PRO-LIVER”. Patients with available data to calculate NLR at baseline were included. Baseline clinical determinants of NLR and the association of NRL with all-cause mortality at 2-year follow-up were evaluated.

Results

From the overall cohort (n = 753), 506 patients with LC (31% female, mean age 64.8 ± 11.9 years) were included in the analysis. Median value of NLR was 2.42 (Interquartile Range [IQR]: 1.61–3.52). At baseline, patients with NLR ≥ 2.42 were more likely to have Child–Pugh B or C, hepatocellular carcinoma (HCC), or portal vein thrombosis (PVT). After a median follow-up of 21 months, 129 patients died: 44 (17%) with NLR < 2.42 and 85 (34%) with NLR ≥ 2.42 (p < 0.001). At multiple-adjusted Cox regression analysis, NLR ≥ 2.42 was independently associated with all-cause mortality (HR: 1.65; 95% CI: 1.12–2.44; p = 0.012), along with age, Child–Pugh C class, HCC and PVT.

Conclusions

NLR is associated with long-term all-cause mortality in LC. NLR may serve as a potentially easily available tool to aid risk refinement in LC.

Trial registration number

ClinicalTrials.gov Identifier: NCT01470547.

Long-term effects of peginterferon-based therapy versus nucleos(t)ide analogue monotherapy in non-cirrhotic HBeAg-positive chronic hepatitis B patients

BACKGROUND & AIMS

The long-term clinical benefits of interferon (IFN)-based therapy compared to nucleos(t)ide analogue (NA) monotherapy in HBeAg-positive chronic hepatitis B (CHB) have not been well defined. This study aimed to evaluate the cumulative incidence of new-onset cirrhosis, serological responses, and hepatocellular carcinoma (HCC) development between these treatment strategies.

METHODS

Two independent cohorts of non-cirrhotic, HBeAg-positive CHB patients were analyzed: a treatment-naïve cohort (n = 686) and an NA-experienced cohort (n = 531). Patients received either IFN-based therapy or NA monotherapy. Propensity score matching (PSM) was employed to minimize intergroup heterogeneity. The primary endpoint was the cumulative incidence of new-onset cirrhosis.

RESULTS

After PSM, the 10-year cumulative incidence of new-onset cirrhosis was significantly lower in the IFN-based therapy group compared to the NA monotherapy group in both the treatment-naïve (3.3 % vs 20.0 %, p = 0.005) and NA-experienced (4.9 % vs 20.9 %, p = 0.034) cohorts. IFN-based therapy also resulted in significantly higher serological response rates across both cohorts, including HBeAg loss (treatment-naïve: 84.7 % vs 55.6 %; NA-experienced: 60.4 % vs 43.6 %, both p < 0.001) and HBsAg loss (treatment-naïve: 14.3 % vs 5.7 %, p = 0.006; NA-experienced: 10.2 % vs 1.3 %, p < 0.001). Subgroup analysis showed that patients receiving IFN-based therapy who achieved HBeAg loss within 96 weeks had the greatest long-term benefits, with lower cirrhosis incidence and higher HBsAg loss rates. Although the incidence of HCC was lower in the IFN-based group, the difference did not reach statistical significance (both p > 0.05).

CONCLUSIONS

IFN-based therapy provides superior long-term benefits over NA monotherapy in reducing cirrhosis risk and enhancing serological responses in HBeAg-positive CHB patients.

A CECT-Based Radiomics Nomogram Predicts the Overall Survival of Patients with Hepatocellular Carcinoma After Surgical Resection

Objective: The primary objective of this study was to develop and validate a predictive nomogram that integrates radiomic features derived from contrast-enhanced computed tomography (CECT) images with clinical variables to predict overall survival (OS) in patients with hepatocellular carcinoma (HCC) after surgical resection. Methods: This retrospective study analyzed the preoperative enhanced CT images and clinical data of 202 patients with HCC who underwent surgical resection at the Affiliated Hospital of North Sichuan Medical College (Institution 1) from June 2017 to June 2021 and at Nanchong Central Hospital (Institution 2) from June 2020 to June 2022. Among these patients, 162 patients from Institution 1 were randomly divided into a training cohort (112 patients) and an internal validation cohort (50 patients) at a 7:3 ratio, whereas 40 patients from Institution 2 were assigned as an independent external validation cohort. Univariate and multivariate Cox proportional hazards regression analyses were performed to identify clinical risk factors associated with OS after HCC resection. Using 3D-Slicer software, tumor lesions were manually delineated slice by slice on preoperative non-contrast-enhanced (NCE) CT, arterial phase (AP), and portal venous phase (PVP) images to generate volumetric regions of interest (VOIs). Radiomic features were subsequently extracted from these VOIs. LASSO Cox regression analysis was employed for dimensionality reduction and feature selection, culminating in the construction of a radiomic signature (Radscore). Cox proportional hazards regression models, including a clinical model, a radiomic model, and a radiomic-clinical model, were subsequently developed for OS prediction. The predictive performance of these models was assessed via the concordance index (C-index) and time-ROC curves. The optimal performance model was further visualized as a nomogram, and its predictive accuracy was evaluated via calibration curves and decision curve analysis (DCA). Finally, the risk factors in the optimal performance model were interpreted via Shapley additive explanations (SHAP). Results: Univariate and multivariate Cox regression analyses revealed that BCLC stage, the albumin-bilirubin index (ALBI), and the NLR-PLR score were independent predictors of OS after HCC resection. Among these three models, the radiomic-clinical model exhibited the highest predictive performance, with C-indices of 0.789, 0.726, and 0.764 in the training, internal and external validation cohorts, respectively. Furthermore, the time-ROC curves for the radiomic-clinical model showed 1-year and 3-year AUCs of 0.837 and 0.845 in the training cohort, 0.801 and 0.880 in the internal validation cohort, and 0.773 and 0.840 in the external validation cohort. Calibration curves and DCA demonstrated the model's excellent calibration and clinical applicability. Conclusions: The nomogram combining CECT radiomic features and clinical variables provides an accurate prediction of OS after HCC resection. This model is beneficial for clinicians in developing individualized treatment strategies for patients with HCC.

Navigating the complexities: challenges and opportunities in conversion therapy for advanced hepatocellular carcinoma

Primary liver cancer ranks as the sixth most prevalent malignant tumor and stands as the second leading cause of cancer-related mortality globally, posing a significant threat to public health. Hepatocellular carcinoma (HCC) is the most common type of liver cancer worldwide. Surgical resection remains the cornerstone treatment for achieving radical cure and prolonged survival in HCC patients. Contrary to Western countries, the majority of HCC patients in China present with hepatitis B virus infection and consequent liver cirrhosis, with most cases diagnosed at an intermediate or advanced stage. This complexity results in a poor prognosis. Recent advancements in local therapeutic techniques and the introduction of systemic therapies, including targeted and immunotherapy agents, have provided new avenues for both clinical and basic conversion therapy for advanced HCC. Integrating multi-dimensional local and systemic therapies, multi-modal sequential, and comprehensive multidisciplinary approaches into the management of HCC patients has demonstrated promising conversion success rates. This holistic management strategy involves combining multiple treatment modalities vertically and coordinating various disciplines horizontally. However, significant challenges remain, including the precise selection of patients eligible for conversion therapy, the optimal choice of conversion therapy regimens, and the accurate determination of surgical timing post-conversion therapy. Addressing these challenges is crucial for hepatobiliary surgeons. High-quality, randomized controlled trials are urgently needed to generate robust evidence for clinical practice. This review aims to synthesize the latest research developments both in China and internationally and examines key issues in the realm of HCC conversion therapy.

RALOX-HAIC (raltitrexed + oxaliplatin) combined with lenvatinib improves survival and safety in elderly patients with unresectable hepatocellular carcinoma

OBJECTIVE

To explore the efficacy and safety of RALOX-HAIC (raltitrexed plus oxaliplatin) combined with lenvatinib in the treatment of elderly patients with unresectable hepatocellular carcinoma (uHCC), aiming to provide a safer and more effective therapeutic strategy for this patient population.

MATERIALS AND METHODS

A retrospective analysis was conducted on the clinical data of 82 elderly patients with uHCC who received treatment in the Department of Interventional Radiology at Wuhan Union Hospital from January 2019 to December 2022. Patients were divided into two groups based on their treatment strategy: HAIC + Lenvatinib group (N = 39) and TACE group (N = 43). The primary endpoints were the objective response rate (ORR), disease control rate (DCR), overall survival (OS), and progression-free survival (PFS) in the two groups. The secondary endpoint was the incidence of treatment-related adverse events in both groups.

RESULTS

The ORR and DCR after treatment were higher in the HAIC + Lenvatinib group compared to the TACE group (61.5% vs. 37.2%, 82.1% vs. 58.1%, P < 0.05). The HAIC + Lenvatinib group had a longer median progression-free survival (mPFS,9.2 months vs. 4.6 months, P < 0.001) and ​median overall survival(mOS, 18.1 months vs. 10.6 months, P < 0.001) compared to the TACE group. The incidence of abdominal pain and fever was significantly higher in the TACE group than in the HAIC + Lenvatinib group (including all grades and grades 3/4, P < 0.05). The incidence of hand-foot syndrome (all grades) was higher in the HAIC + Lenvatinib group compared to the TACE group (15.4% vs. 0.0%, P = 0.009), but there was no significant difference in the incidence of grade 3/4 hand-foot syndrome between the two groups (2.6% vs. 0.0%, P = 0.476).

CONCLUSION

This study demonstrates that RALOX-HAIC combined with lenvatinib provides superior survival outcomes and tolerability compared to TACE alone ​in elderly patients (≥ 70 years) with unresectable HCC. This combination therapy may be a feasible and safe option for improving the prognosis of elderly patients with uHCC.

A spreadable self-gelling hemostatic powder sensitizes CAR-NK cell therapy to prevent hepatocellular carcinoma recurrence postresection

Adoptive natural killer cell therapy (ANKCT) harbors great potential for combating postsurgical hepatocellular carcinoma (HCC) recurrence, but its efficacy is limited by tumor microenvironment (TME)-meditated repression on NK cell function and insufficient NK cell homing to tumor sites. Therefore, herein we develop a nanocomposite sprayable self-gelling powder enabling liver-localized codelivery of three FDA-approved drugs including calcitriol (Cal), gemcitabine (Gem), and tazemetostat (Taz) to address these challenges. This powder can be laparoscopically spread to liver wound sites, where it rapidly absorbs interfacial liquid to form a bulk adhesive pressure-resistant hydrogel in situ, implying its application potential in minimally surgery. Moreover, its application to liver resection bed significantly sensitizes allogenic NK and EpCAM chimeric antigen receptor modified-NK-92 (EpCAM-CAR-NK) cell infusion to prevent HCC recurrence in orthotopic Heap1-6 tumor-bearing and patient-derived tumor xenograft (PDX) HCC murine models. Additionally, this powder can allow for an effective hemostatic effect in rat and porcine models due to its powerful tissue adhesion-seal and erythrocyte-aggregating effects. Altogether, our newly developed hemostatic self-gelling powder can significantly sensitize ANKCT to combat HCC recurrence in a manner compatible with surgical treatment of HCC.

A review of the progress and challenges of developing dendritic-based vaccines against hepatitis B virus (HBV)

Hepatitis B virus (HBV) infections that last a long time are a significant public health problem worldwide. About 254 million people around the world are chronically sick with HBV. Each year, 1.2 million new cases occur, and in 2022, 1.1 million people will die from the disease. So, it has been essential to work on finding ways to treat and avoid HBV. The process of therapeutic vaccination involves giving people a non-infectious form of a virus to start or improve immune reactions specific to HBV. This helps keep HBV infections under control. Dendritic cells (DCs) play a significant part in beginning the adaptive immune response, which could decide how well an HBV infection is treated. DC-based treatment has been looked into for people with chronic HBV (CHB) infection and has shown some sound effects. Vaccines for CHB that use DCs boost antiviral immunity by improving T cells and breaking the immune system's resistance against HBV. In these vaccines, DCs are loaded with HBV antigens (like HBsAg, HBcAg, or peptides) outside of the body and then put back into the patient to make the immune system work better. In conclusion, this DC treatment is a biological therapy method with a good chance of being used. This study examined the different DC-based medicines that can treat and prevent HBV. Finally, we've talked about clinical studies, the current problems, how to fix them, and the future of this vaccine for treating and preventing HBV.

Predictive factors and clinical outcomes in decompensated non-cirrhotic chronic hepatitis B patients treated with entecavir or tenofovir disoproxil fumarate

BACKGROUND & AIMS

Little is known about the short-term and long-term outcomes of non-cirrhotic chronic hepatitis B (CHB) patients who experience hepatic decompensation. Therefore, this study aimed to investigate the clinical outcomes of decompensated non-cirrhotic CHB patients.

METHODS

We conducted a retrospective study and enrolled a total of 304 decompensated non-cirrhotic CHB patients. Cox regression model was used to analyze factors associated with all-cause mortality. Additionally, the incidence of HBsAg seroclearance and its associated factors were estimated by the competing risk analysis.

RESULTS

The median follow-up time was 4.36 years (IQR 1.04-7.16). Out of the total enrolled patients, 63 (20.72 %) patients either died or underwent liver transplantation, and 14 patients achieved HBsAg seroclearance. Risk factors associated with 1-month, 3-month, and long-term all-cause mortality were the presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores. The cumulative incidence of HBsAg seroclearance was 1.78 %, 3.72 %, 4.25 %, 5.68 %, 5.68 %, 8.28 %, and 8.28 % at the 1-year, 2-year, 3-year, 4-year, 5-year, 6-year, and 7-year follow-up, respectively. Independent predictors for HBsAg seroclearance were baseline alanine aminotransferase (ALT)≧ 25 times upper limit of normal (subdistribution hazard ratio [sHR] = 5.97; 95 %CI, 1.82-19.63; p = 0.0032) and HBV DNA <5 log10 IU/ml (sHR = 4.43; 95 %CI, 1.55-12.63; p = 0.0054).

CONCLUSIONS

The presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores were associated with short-term and long-term all-cause mortality. Additionally, lower HBV DNA levels and higher ALT levels at baseline were independently predictive of sequential HBsAg seroclearance.

EASL Clinical Practice Guidelines on the management of hepatitis B virus infection

The updated EASL Clinical Practice Guidelines on the management of hepatitis B virus (HBV) infection provide comprehensive, evidence-based recommendations for its management. Spanning ten thematic sections, the guidelines address diagnostics, treatment goals, treatment indications, therapeutic options, hepatocellular carcinoma surveillance, management of special populations, HBV reactivation prophylaxis, post-transplant care, HBV prevention strategies, and finally address open questions and future research directions. Chronic HBV remains a global health challenge, with over 250 million individuals affected and significant mortality due to cirrhosis and hepatocellular carcinoma. These guidelines emphasise the importance of early diagnosis, risk stratification based on viral and host factors, and tailored antiviral therapy. Attention is given to simplified algorithms, vaccination, and screening to support global HBV elimination targets. The guidelines also discuss emerging biomarkers and evolving definitions of functional and partial cure. Developed through literature review, expert consensus, and a Delphi process, the guidelines aim to equip healthcare providers across disciplines with practical tools to optimise HBV care and outcomes worldwide.

Retrospective Analysis of the Effect of Sarcopenia on Mortality and Morbidity in Liver Transplant Patients

BACKGROUND

Sarcopenia significantly influences morbidity and mortality in liver transplant recipients. The psoas muscle area index and prognostic nutritional index (PNI) are potential indicators of sarcopenia's impact on postoperative outcomes. However, their association with postoperative morbidity and mortality in cadaveric liver transplant recipients remains underexplored.

METHODS

Data from 52 patients who underwent cadaveric liver transplantation at Çukurova University over 10 years were analyzed. Sarcopenia was assessed using psoas muscle area index (cutoffs, 4.62 mm²/cm² for males and 2.66 mm²/cm² for females, based on Bahat et al) and PNI (cutoffs, ≤45 for low and >45 for high, based on Li et al). Postoperative morbidity was evaluated using the Clavien-Dindo classification. The main outcomes were overall survival and morbidity rates.

RESULTS

Sarcopenic patients had shorter survival (62.2 ± 16.4 months) compared with nonsarcopenic patients (83.6 ± 11.4 months), although this difference was not statistically significant (P = .370). Sarcopenia was more common in males, Child-Pugh C patients, those with ascites, American Society of Anesthesiologists score of ≥3, and a Clavien-Dindo grade of ≥3 patients. It was significantly associated with low body mass index and albumin levels (P < .05) and was more prevalent in the low PNI group. A significant correlation was observed between PNI and Child-Pugh score (P = .012), alpha fetoprotein, and albumin levels (P = .007 and P = .001).

CONCLUSION

Sarcopenia negatively impacts survival, whereas a higher PNI correlates with a lower mortality risk. Further multicenter prospective studies with a larger population are needed to validate these findings.

TIM-3 teams up with PD-1 in cancer immunotherapy: mechanisms and perspectives

Immunotherapy using immune checkpoint inhibitors (ICIs) has become a prominent strategy for cancer treatment over the past ten years. However, the efficacy of ICIs remains limited, with certain cancers exhibiting resistance to these therapeutic approaches. Consequently, several immune checkpoint proteins are presently being thoroughly screened and assessed in both preclinical and clinical studies. Among these candidates, T cell immunoglobulin and mucin-domain containing-3 (TIM-3) is considered a promising target. TIM-3 exhibits multiple immunosuppressive effects on various types of immune cells. Given its differential expression levels at distinct stages of T cell dysfunction in the tumor microenvironment (TME), TIM-3, along with programmed cell death protein 1 (PD-1), serves as indicators of T cell exhaustion. Moreover, it is crucial to carefully evaluate the impact of TIM-3 and PD-1 expression in cancer cells on the efficacy of immunotherapy. To increase the effectiveness of anti-TIM-3 and anti-PD-1 therapies, it is proposed to combine the inhibition of TIM-3, PD-1, and programmed death-ligand 1 (PD-L1). The efficacy of TIM-3 inhibition in conjunction with PD-1/PD-L1 inhibitors is being evaluated in a number of ongoing clinical trials for patients with various cancers. This study systematically investigates the fundamental biology of TIM-3 and PD-1, as well as the detailed mechanisms through which TIM-3 and PD-1/PD-L1 axis contribute to cancer immune evasion. Additionally, this article provides a thorough analysis of ongoing clinical trials evaluating the synergistic effects of combining PD-1/PD-L1 and TIM-3 inhibitors in anti-cancer treatment, along with an overview of the current status of TIM-3 and PD-1 antibodies.

Risk factors and clinical outcomes in patients with HCV eradication by direct-acting antivirals: a systematic review and meta-analysis

BACKGROUND

In hepatitis C patients with sustained virologic response (SVR) achieved after direct-acting antivirals (DAAs), the incidence of adverse clinical outcomes can be reduced but not completely eliminated. This meta-analysis aims at estimating the incidence of clinical outcomes in hepatitis C patients after achieving SVR with DAAs.

METHODS

Literature search was carried out in PubMed, Cochrane Library database, Web of Science, and Embase. The primary endpoint was the incidence of hepatocellular carcinoma (HCC) occurrence, HCC recurrence, decompensated cirrhosis, and liver-related mortality, following DAA-induced elimination of hepatitis C virus (HCV). Subgroup analyses were performed according to age, gender, comorbidities, region, fibrosis stage, presence of decompensation, duration of follow-up, start point of follow-up, and HCC treatment modality. Furthermore, meta-regression was performed to explore sources of high heterogeneity.

RESULTS

Finally, 132 articles were included in our study. The pooled HCC occurrence rate was 1.50/100 person-years (95% CI, 1.35-1.65), HCC recurrence rate was 17.00/100 person-years (95% CI, 13.83-20.42), decompensation rate was 0.30/100 person-years (95% CI, 0.16-0.48), and liver-related mortality was 0.32/100 person-years (95% CI, 0.14-0.56). Meta-regression showed that duration of follow-up and fibrosis grade were important contributors to HCC occurrence. Age, start point of follow-up, and duration of follow-up were important contributors to HCC recurrence rate.

CONCLUSION

Patients with DAA-induced HCV elimination remain at risk for adverse outcomes, particularly those with cirrhosis and HCC history. The exposure to adverse outcomes tended to decrease over time, and the frequency and intensity of follow-up might be reduced in the future, which will require new scoring models to identify these individuals.

Relationship between the systemic immune-inflammatory index and overactive bladder risk: A cross-sectional assessment involving United States Adults

AIMS

This study aimed to evaluate the association between the systemic immune-inflammatory index (SII) and the risk of overactive bladder (OAB) in the adult United States population.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010 were analyzed. A non-pregnant cohort aged ≥20 years with available SII and OAB data was included. Weighted univariate and multivariate logistic regression analyses were performed to assess the association between SII and OAB risk. Additionally, subgroup, interaction, and restricted cubic spline analyses were conducted.

RESULTS

A total of 4,545 participants were included, of whom 16.13% had OAB, with a mean SII of 5.75 ± 0.07. OAB risk increased with higher SII tertiles. In the fully adjusted model (Model 2), individuals in the highest SII tertile exhibited a 41% higher risk of OAB compared to those in the lowest tertile (OR: 1.41, 95% CI: 1.13-1.76, P = 0.004). Two-piece-wise regression analysis identified an SII breakpoint at 3.40, where a significant positive association was found for SII ≥ 3.40 (OR = 1.06, P < 0.0001), whereas no significant association was detected for SII < 3.40 (P = 0.06). Subgroup and interaction analyses revealed a consistent relationship between SII and OAB across different population strata, except for diabetes mellitus.

CONCLUSION

SII, an easily accessible biomarker, was independently associated with an increased risk of OAB, highlighting its potential utility in diagnostic prediction.

Differential Infiltration of T-Cell Populations in Tumor and Liver Tissues Predicts Recurrence-Free Survival in Surgically Resected Hepatocellular Carcinoma

Background/Objectives: Liver and tumor-infiltrating T cells in hepatocellular carcinoma (HCC) are heterogeneous, comprising the CD69+ tissue-resident T-cell and the CD69- circulating T-cell populations. However, the impact of these distinct T-cell populations on patient prognosis is unclear; hence, further studies are needed. Methods: Tumor and distant liver tissues from 57 HCC patients with various chronic liver disease etiologies were analyzed. Single-cell dissociation and flow cytometry were used to assess CD69+ and CD69- T-cell populations and their correlation with recurrence-free survival (RFS). Results: CD69+/CD69- subpopulations within CD4+ and CD8+ T cells varied by patient and alcohol etiology. CD69- populations among CD4+ T cells were less frequent in both tumor and non-tumor tissues of alcohol-related HCC patients (p < 0.05). Higher frequencies of CD69-CD4+ and CD8+ T cells in tumors and CD69+CD103+CD8+ T cells in liver tissues were associated with better RFS. CD69- T cells expressed lower PD-1 levels, indicating less exhaustion, with PD-1 expression inversely correlated with CD69- frequency. PD-1 expression was higher in CD69-CD4+ T cells in alcohol-related HCC. Conclusions: We provided a detailed analysis of the heterogeneous characteristics of tumor- and liver-infiltrating T cells in HCC, emphasizing the distinct roles of CD69+ and CD69- cell populations and their impact on RFS. CD69+ T cells were associated with immune exhaustion and tumor aggressiveness, whereas CD69- T cells appeared to significantly contribute to the influence of alcohol intake on the immune landscape of HCC in the tumor microenvironment. However, further research should validate these findings in larger cohorts to enhance our understanding.