Changing hepatocellular carcinoma incidence and liver cancer mortality rates in the United States

Mediating Effects of Neighborhood-Level Socioeconomic Deprivation on the Association Between Race/Ethnicity and Advanced Hepatocellular Carcinoma

BACKGROUND

Racial/ethnic minorities are more likely than non-Hispanic whites (NHW) to be diagnosed with advanced stage hepatocellular carcinoma (HCC). We examined the role of neighborhood disadvantage as a mediator of the association between race/ethnicity and HCC stage at diagnosis.

METHODS

We used data from HCC cases diagnosed in Texas from 2007 to 2015. HCC cases were classified as local versus regional/advanced stage. A mediation model approach was used to estimate the average direct effect, average mediated (indirect) effect, total effect, and proportion mediated by the Area Deprivation Index (ADI), a composite measure of disadvantage.

RESULTS

7,622 had local while 6303 had regional/advanced HCC. 46.1% of cases were NHW, 15.0% non-Hispanic Black (NHB), and 38.9% Hispanic. NHBs were less likely than NHWs to be diagnosed with local stage HCC [total effect RR, 0.921; 95% confidence interval (95% CI), 0.898-0.947]; however, only 2.26% of this effect was mediated through ADI. Conversely, Hispanics were more likely than NHWs to be diagnosed with local stage HCC (total effect RR, 1.019; 95% CI, 1.001-1.037) and ADI mediated 12.56% of the effect of race/ethnicity on HCC stage. ADI was not associated with HCC stage and therefore was not a mediator of the association with HCC stage when we compared Hispanics with NHBs.

CONCLUSIONS

Neighborhood socioeconomic disadvantage may explain/mediate some of the association between race/ethnicity and HCC stage; however, the mediating effect was not uniform across populations.

IMPACT

For NHBs, other individual and neighborhood level factors, not reflected in the ADI, contribute to their lower likelihood of being diagnosed with local HCC. See related commentary by Lazo et al., p. 1254.

Hepatocellular Carcinoma Due to Nonalcoholic Fatty Liver Disease: Current Concepts and Future Challenges

Obesity has been labeled as the global pandemic of the 21st century, resulting from a sedentary lifestyle and caloric excess. Nonalcoholic fatty liver disease (NAFLD), characterized by excessive hepatic steatosis, is strongly associated with obesity and metabolic syndrome and is estimated to be present in one-quarter of the world population, making it the most common cause of the chronic liver disease (CLD). NAFLD spectrum varies from simple steatosis to nonalcoholic steatohepatitis (NASH) and cirrhosis. The burden of NAFLD has been predicted to increase in the coming decades resulting in increased rates of decompensated cirrhosis, hepatocellular carcinoma (HCC), and liver-related deaths. In the current review, we describe the pathophysiology of NAFLD and NASH, risk factors associated with disease progression, related complications, and mortality. Later, we have discussed the changing epidemiology of HCC, with NAFLD emerging as the most common cause of CLD and HCC. We have also addressed the risk factors of HCC development in the NAFLD population (including demographic, metabolic, genetic, dietary, and lifestyle factors), presentation of NAFLD-associated HCC, its prognosis, and the issue of HCC development in non-cirrhotic NAFLD. Lastly, the problems related to HCC screening in the NAFLD population, the remaining challenges, and future directions, especially the need to identify the high-risk individuals, will be discussed. We will conclude the review by summarizing the clinical evidence for treating fibrosis and preventing HCC in those at risk with NAFLD-associated HCC.

Immune cell infiltration and immunotherapy in hepatocellular carcinoma

Hepatocellular carcinoma is a highly malignant tumor and patients yield limited benefits from the existing treatments. The application of immune checkpoint inhibitors is promising but the results described in the literature are not favorable. It is therefore urgent to systematically analyze the immune microenvironment of HCC and screen the population best suited for the application of immune checkpoint inhibitors to provide a basis for clinical treatment. In this study, we collected The Cancer Genome Atlas Liver Hepatocellular Carcinoma (TCGA-LIHC)-related data sets to evaluate the immune microenvironment and immune cell infiltration (ICI) in HCC. Three independent ICI subtypes showing significant differences in survival were identified. Further, TCGA-LIHC immunophenoscore (IPS) was used to identify the differentially expressed genes between high- and low-IPS in HCC, so as to identify the immune gene subtypes in HCC tumors. The ICI score model for HCC was constructed, whereby we divided HCC samples into high- and low-score groups based on the median ICI score. The differences between these groups in genomic mutation load and immunotherapy benefit in HCC were examined in detail to provide theoretical support for accurate immunotherapy strategy in HCC. Finally, four genes were screened, which could accurately predict the subtype based on the tumor immune infiltration score. The findings may provide a basis and simplify the process for screening clinical drugs suitable for relevant subgroups.

Racial, Ethnic, and Socioeconomic Disparities in Curative Treatment Receipt and Survival in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) disproportionately affects racial, ethnic, and low socioeconomic status (SES) populations. However, the interaction between race, ethnicity, and neighborhood SES in HCC prognosis is not well explored. This study evaluates the interaction between race and ethnicity and neighborhood SES on curative treatment utilization and overall survival among patients with HCC in the United States. We conducted a retrospective cohort study of 13,874 patients aged ≥65 years diagnosed with HCC from 2001 through 2015 using the Surveillance, Epidemiology, and End Results Medicare-linked database. We performed multivariable logistic regression to examine the association between race, ethnicity, and curative treatment receipt across SES. We also evaluated the association between curative treatment receipt and overall survival using a Cox proportional hazards model. Among 13,874 patients, only 2,617 (18.9%) patients received curative treatment. Overall, Black patients had lower odds of receiving curative treatment than White patients (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.64-0.91). When stratified by neighborhood SES, Black patients living in high-poverty neighborhoods had lower odds of curative treatment receipt (OR, 0.64; 95% CI, 0.49-0.84) and worse survival (hazard ratio, 1.13; 95% CI, 1.02-1.25). Conversely, Hispanic and Asian patients had similar curative treatment receipt compared to White patients across all socioeconomic levels. Conclusion: Disparities in curative treatment receipt and overall survival are pronounced between Black and White patients. Black-White disparities appear to be moderated by neighborhood SES and are particularly evident among those living in high-poverty neighborhoods.

miR‑4730 suppresses the progression of liver cancer by targeting the high mobility group A1 pathway

As liver cancer (LC) is the sixth most commonly diagnosed malignancy, it is necessary to elucidate the molecular mechanisms responsible for LC progression. MicroRNAs (miRNAs/miRs) play crucial roles in tumor progression by regulating target gene expression. The present study assessed miRNA-4730 expression and function in LC. The effects of miR-4730 overexpression were examined in LC cell lines, and the target genes of miR-4730 were evaluated using microarray analysis and TargetScan data. In addition, the association between miR-4730 expression in tissue samples and the prognosis of 70 patients with LC was evaluated. miR-4730 expression was suppressed in LC tissues and cell lines. miR-4730 overexpression suppressed cell proliferation and cell cycle progression and promoted apoptosis. High mobility group A1 (HMGA1) was revealed as the direct target of miR-4730 using luciferase reporter assay, and the inhibition of downstream integrin-linked kinase (ILK) expression and Akt or glycogen synthase kinase 3β (GSK3β) phosphorylation was confirmed. The lower expression of miR-4730 in tissue samples was significantly associated with a worse recurrence-free survival of patients with LC. On the whole, miR-4730 suppressed tumor progression by directly targeting HMGA1 and inhibiting the ILK/Akt/GSK3β pathway. miR-4730 thus has potential for use as a prognostic marker and may prove to be a therapeutic target for miRNA-based therapies.

Biological Functions and Molecular Mechanisms of MiR-608 in Cancer

In recent years, microRNAs (miRNAs) have attracted much attention because of their prominent role in cancer. An increasing number of studies have shown that miRNAs play an important role in a variety of tumors. miR-608 has been reported to be decreased in cancers, especially in solid tumors. miR-608 is regarded as a tumor suppressor, which has been verified through a large number of experiments both in vivo and in vitro. miR-608 participates in many biological processes, including cell proliferation, invasion, migration, and apoptosis, by inhibiting transmembrane proteins and many signaling pathways. Here, we summarize the expression profile and biological functions and mechanism of miR-608, suggesting that miR-608 is an ideal diagnostic and prognostic biomarker and a treatment target for cancer.

Predicting Genomic Alterations of Phosphatidylinositol-3 Kinase Signaling in Hepatocellular Carcinoma: A Radiogenomics Study Based on Next-Generation Sequencing and Contrast-Enhanced CT

BACKGROUND

Exploring the genomic landscape of hepatocellular carcinoma (HCC) provides clues for therapeutic decision-making. Phosphatidylinositol-3 kinase (PI3K) signaling is one of the key pathways regulating HCC aggressiveness, and its genomic alterations have been correlated with sorafenib response. In this study, we aimed to predict somatic mutations of the PI3K signaling pathway in HCC samples through machine-learning-based radiomic analysis.

METHODS

HCC patients who underwent next-generation sequencing and preoperative contrast-enhanced CT were recruited from West China Hospital and The Cancer Genome Atlas for model training and validation, respectively. Radiomic features were extracted from volumes of interest (VOIs) covering the tumor (VOItumor) and peritumoral areas (5 mm [VOI5mm], 10 mm [VOI10mm], and 20 mm [VOI20mm] from tumor margin). Factor analysis, logistic regression analysis, least absolute shrinkage and selection operator, and random forest analysis were applied for feature selection and model construction. Model performance was characterized based on the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 132 HCC patients (mean age: 61.1 ± 14.7 years; 108 men) were enrolled. In the training set, the AUCs of radiomic signatures based on single CT phases were moderate (AUC 0.694-0.771). In the external validation set, the radiomic signature based on VOI10mm in arterial phase demonstrated the highest AUC (0.733) among all models. No improvement in model performance was achieved after adding the tumor radiomic features or manually assessed qualitative features.

CONCLUSIONS

Machine-learning-based radiomic analysis had potential for characterizing alterations of PI3K signaling in HCC and could help identify potential candidates for sorafenib treatment.

Prognostic and biological role of the N-Myc downstream-regulated gene family in hepatocellular carcinoma

BACKGROUND

The N-Myc downstream-regulated gene (NDRG) family is comprised of four members (NDRG1-4) involved in various important biological processes. However, there is no systematic evaluation of the prognostic of the NDRG family in hepatocellular carcinoma (HCC).

AIM

To analyze comprehensively the biological role of the NDRG family in HCC.

METHODS

The NDRG family expression was explored using The Cancer Genome Atlas. DNA methylation interactive visualization database was used for methylation analysis of the NDRG family. The NDRG family genomic alteration was assessed using the cBioPortal. Single-sample Gene Set Enrichment Analysis was used to determine the degree of immune cell infiltration in tumors.

RESULTS

NDRG1 and NDRG3 were up-regulated in HCC, while NDRG2 was down-regulated. Consistent with expression patterns, high expression of NDRG1 and NDRG3 was associated with poor survival outcomes (P < 0.05). High expression of NDRG2 was associated with favorable survival (P < 0.005). An NDRG-based signature that statistically stratified the prognosis of the patients was constructed. The percentage of genetic alterations in the NDRG family varied from 0.3% to 11.0%, and the NDRG1 mutation rate was the highest. NDRG 1-3 expression was associated with various types of infiltrated immune cells. Gene ontology analysis revealed that organic acid catabolism was the most important biological process related to the NDRG family. Gene Set Enrichment Analysis showed that metabolic, proliferation, and immune-related gene sets were enriched during NDRG1 and NDRG3 high expression and NDRG2 low expression.

CONCLUSION

Overexpression of NDRG1 and NDRG3 and down-expression of NDRG2 are correlated with poor overall HCC prognosis. Our results may provide new insights into the indispensable role of NDRG1, 2, and 3 in the development of HCC and guide a promising new strategy for treating HCC.

Asian American/Pacific Islander and Hispanic Ethnic Enclaves, Neighborhood Socioeconomic Status, and Hepatocellular Carcinoma Incidence in California: An Update

BACKGROUND

Using more recent cancer registry data, we analyzed disparities in hepatocellular carcinoma (HCC) incidence by ethnic enclave and neighborhood socioeconomic status (nSES) among Asian American/Pacific Islander (AAPI) and Hispanic populations in California.

METHODS

Primary, invasive HCC cases were identified from the California Cancer Registry during 1988-1992, 1998-2002, and 2008-2012. Age-adjusted incidence rates (per 100,000 population), incidence rate ratios, and corresponding 95% confidence intervals were calculated for AAPI or Hispanic enclave, nSES, and the joint effects of ethnic enclave and nSES by time period (and the combination of the three periods), sex, and race/ethnicity.

RESULTS

In the combined time period, HCC risk increased 25% for highest versus lowest quintile of AAPI enclave among AAPI males. HCC risk increased 22% and 56% for lowest versus highest quintile of nSES among AAPI females and males, respectively. In joint analysis, AAPI males living in low nSES areas irrespective of enclave status were at 17% to 43% increased HCC risk compared with AAPI males living in areas of nonenclave/high nSES. HCC risk increased by 22% for Hispanic females living in areas of low nSES irrespective of enclave status and by 19% for Hispanic males living in areas of nonenclave/low nSES compared with their counterparts living in areas of nonenclave/high nSES.

CONCLUSIONS

We found significant variation in HCC incidence by ethnic enclave and nSES among AAPI and Hispanic populations in California by sex and time period.

IMPACT

Future studies should explore how specific attributes of enclaves and nSES impact HCC risk for AAPI and Hispanic populations.

Antitumor Effect of Regorafenib on MicroRNA Expression in Hepatocellular Carcinoma Cell Lines

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and is one of the leading causes of cancer-related deaths worldwide. Regorafenib, a multi-kinase inhibitor, is used as a second-line treatment for advanced HCC. Here, we aimed to investigate the mechanism of the antitumor effect of regorafenib on HCC and evaluate altered microRNA (miRNA) expression. Cell proliferation was examined in six HCC cell lines (HuH-7, HepG2, HLF, PLC/PRF/5, Hep3B, and Li-7) using the Cell Counting Kit-8 assay. Xenografted mouse models were used to assess the effects of regorafenib in vivo. Cell cycle analysis, western blotting analysis, and miRNA expression analysis were performed to identify the antitumor inhibitory potential of regorafenib on HCC cells. Regorafenib suppressed proliferation in HuH-7 cell and induced G0/G1 cell cycle arrest and cyclin D1 downregulation in regorafenib-sensitive cells. During miRNA analysis, miRNA molecules associated with the antitumor effect of regorafenib were found. Regorafenib suppresses cell proliferation and tumor growth in HCC by decreasing cyclin D1 via alterations in intracellular and exosomal miRNAs in HCC.

Patient Preferences for Hepatocellular Carcinoma Surveillance Parameters

BACKGROUND AND AIMS

Professional societies recommend abdominal ultrasound (US) with or without alpha fetoprotein (AFP) for hepatocellular cancer (HCC) surveillance; however, there are several emerging surveillance modalities, including abbreviated MRI and blood-based biomarker panels. Most studies have focused on provider perspectives for surveillance logistics, but few have assessed patient preferences. We aimed to measure preferences among patients with cirrhosis regarding HCC surveillance modalities.

METHODS

We conducted a choice-based conjoint survey to patients with cirrhosis at four institutions. Participants were provided 15 scenarios in which they were asked to choose surveillance modalities based on five test attributes: benefits, i.e. sensitivity for early HCC (range: 35-95%), physical harm, i.e. false positives requiring additional testing (range: 10-40%), financial harm, i.e. out-of-pocket costs (range: $10-100), test logistics and convenience, i.e. duration of testing (range: 10-60 min). Hierarchical Bayes discrete choice conjoint analysis was used to derive attribute importance, and preference shares were determined by simulation.

RESULTS

In total 91% (182/199) of approached patients consented to participate in the study and 98% (n=179) successfully completed the survey. Surveillance benefits (importance: 51.3%, 95%CI: 49.0-53.4%) were valued more than risk of physical harm (importance: 7.6%, 95%CI 7.0-8.2%), financial harm (importance: 15.2%, 95%CI 14.0-16.3%), convenience (importance: 9.3%, 95%CI 8.5-10.1%) and test logistics (importance: 16.7%, 95%CI 15.4-18.1%). Based on simulations including all possible tests, patients preferred abbreviated MRI (29.0%), MRI (23.3%), or novel blood-based biomarkers (20.9%) to ultrasound alone (3.4%) or with AFP (8.8%).

CONCLUSIONS

Patients with cirrhosis prioritize early HCC detection over potential surveillance-related harms or inconvenience.

Higher Enhancement Intrahepatic Nodules on the Hepatobiliary Phase of Gd-EOB-DTPA-Enhanced MRI as a Poor Responsive Marker of Anti-PD-1/PD-L1 Monotherapy for Unresectable Hepatocellular Carcinoma

Introduction

Immune checkpoint inhibitors (ICIs) are promising agents for the treatment of hepatocellular carcinoma (HCC). However, the establishment of noninvasive measure that could predict the response to ICIs is challenging. This study aimed to evaluate tumor responses to ICIs using the hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI), which was shown to reflect Wnt/β-catenin activating mutation.

Methods

A total of 68 intrahepatic HCC nodules from 18 patients with unresectable HCC and Child-Pugh class A liver function who received anti-programmed cell death 1 (PD-1)/programmed death-ligand 1 (PD-L1) monotherapy were enrolled in this study. All patients had viable intrahepatic lesions evaluable using the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI within the 6 months prior to the treatment. The relative enhancement ratio was calculated, and the time to nodular progression (TTnP) defined as 20% or more increase in each nodule was compared between higher or hypo-enhancement HCC nodules. Then, the progression-free survival (PFS) and objective response rate (ORR) per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1) were compared between patients with and without HCC nodules with higher enhancement on hepatobiliary phase images.

Results

The median PFS was 2.7 (95% confidence interval [CI]: 1.4-4.0) months in patients with HCC nodules with higher enhancement (n = 8) and 5.8 (95% CI: 0.0-18.9) months in patients with hypointense HCC nodules (n = 10) (p = 0.007). The median TTnP of HCC nodules with higher enhancement (n = 23) was 1.97 (95% CI: 1.86-2.07) months and that of hypointense HCC nodules (n = 45) was not reached (p = 0.003). The ORR was 12.5% (1/8) versus 30.0% (3/10); the disease control rate was 37.5% (3/8) versus 70.0% (7/10), respectively, in patients with or without higher enhancement intrahepatic HCC nodules.

Conclusion

The TTnP on HCC nodules with higher enhancement and the median PFS in patients who carried higher enhancement intrahepatic HCC nodules were significantly shorter than those in hypointense HCC nodules with anti-PD-1/PD-L1 monotherapy. The intensity of the nodule on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI is a promising imaging biomarker for predicting unfavorable response with anti-PD-1/PD-L1 monotherapy in patients with HCC.

MicroRNAs as Diagnostic Tools in Hepatocellular Carcinoma

Liver cancer is the fourth leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 80% of all liver cancers. The serum concentration of alpha-fetoprotein (AFP) is the only validated biomarker for HCC diagnosis. MicroRNAs (miRNAs) are small non-coding RNAs of 21–30 nucleotides playing a critical role in human carcinogenesis, with types of miRNAs with oncogenic (oncomiRs) or tumor suppressor features. The altered expression of miRNAs in HCC is associated with many pathological processes, such as cancer initiation, tumor growth, apoptosis escape, promotion of migration and invasion. Moreover, circulating miRNAs have been increasingly investigated as non-invasive biomarkers for HCC diagnosis. MiRNAs’ expression patterns are altered in HCC and several single miRNAs or miRNAs panels have been found significantly up or downregulated in HCC with respect to healthy controls or non-oncological patients (cirrhotic or with viral hepatitis). However, any of the investigated miRNAs or miRNAs panels has entered clinical practice so far. This has mostly to do with lack of protocols standardization, small sample size and discrepancies in the measurement techniques. This review summarizes the major findings regarding the diagnostic role of miRNAs in HCC and their possible use together with standard biomarkers in order to obtain an early diagnosis and easier differential diagnosis from non-cancerous liver disease.

Comprehensive Analysis to Identify the Epithelial-Mesenchymal Transition-Related Immune Signatures as a Prognostic and Therapeutic Biomarkers in Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) is a highly heterogeneous disease with the high rates of the morbidity and mortality due to the lack of the effective prognostic model for prediction.

Aim: To construct a risk model composed of the epithelial–mesenchymal transition (EMT)-related immune genes for the assessment of the prognosis, immune infiltration status, and chemosensitivity.

Methods: We obtained the transcriptome and clinical data of the HCC samples from The Cancer Genome Atlas (TCGA) and The International Cancer Genome Consortium (ICGC) databases. The Pearson correlation analysis was applied to identify the differentially expressed EMT-related immune genes (DE-EMTri-genes). Subsequently, the univariate Cox regression was introduced to screen out the prognostic gene sets and a risk model was constructed based on the least absolute shrinkage and selection operator-penalized Cox regression. Additionally, the receiver operating characteristic (ROC) curves were plotted to compare the prognostic value of the newly established model compared with the previous model. Furthermore, the correlation between the risk model and survival probability, immune characteristic, and efficacy of the chemotherapeutics were analyzed by the bioinformatics methods.

Results: Six DE-EMTri-genes were ultimately selected to construct the prognostic model. The area under the curve (AUC) values for 1-, 2-, and 3- year were 0.773, 0.721, and 0.673, respectively. Stratified survival analysis suggested that the prognosis of the low-score group was superior to the high-score group. Moreover, the univariate and multivariate analysis indicated that risk score [hazard ratio (HR) 5.071, 95% CI 3.050, 8.432; HR 4.396, 95% CI 2.624, 7.366; p < 0.001] and stage (HR 2.500, 95% CI 1.721, 3.632; HR 2.111, 95% CI 1.443, 3.089; p < 0.001) served as an independent predictive factors in HCC. In addition, the macrophages, natural killer (NK) cells, and regulatory T (Treg) cells were significantly enriched in the high-risk group. Finally, the patients with the high-risk score might be more sensitive to cisplatin, doxorubicin, etoposide, gemcitabine, and mitomycin C.

Conclusion: We established a reliable EMTri-genes-based prognostic signature, which may hold promise for the clinical prediction.

LncRNA TLR8-AS1 suppresses miR-34a maturation in hepatocellular carcinoma to suppress cell proliferation and migration

TLR8-AS1 has been characterized as an oncogenic lncRNA in ovarian cancer, while its role in hepatocellular carcinoma (HCC) is unknown. This study aimed to explore the role of TLR8-AS1 in HCC. TLR8-AS1 expression in HCC and paired non-tumor tissues from 62 HCC patients was determined by RT-qPCR. The prognostic value of TLR8-AS1 for HCC was analyzed by performing a 5-year follow-up. Correlations between TLR8-AS1 and mature miR-34a and miR-34a precursor were analyzed by Pearson's correlation coefficient. The roles of TLR8-AS1 and miR-34a in regulating the proliferation and migration were explored by CCK-8 assay and Transwell migration assay. We found that TLR8-AS1 was upregulated in HCC and predicted poor survival. Across HCC tissues, TLR8-AS1 was inversely correlated with mature miR-34a, but not miR-34a precursor. In HCC cells, TLR8-AS1 overexpression downregulated mature miR-34a, but not miR-34a precursor. Cell proliferation and Transwell migration assay showed that TLR8-AS1 overexpression reduced the enhancing effects of miR-34a on cell proliferation and migration. TLR8-AS1 may suppress miR-34a maturation in HCC to suppress cell proliferation and migration.

Significance of cytoplasmic expression of telomerase reverse transcriptase in patients with hepatocellular carcinoma undergoing liver resection

Telomerase reverse transcriptase (TERT) is reportedly expressed in various types of cancer. However, to the best of our knowledge, the significance of subcellular expression of TERT in hepatocellular carcinoma (HCC) has not been evaluated in detail. The present study evaluated TERT expression in resected HCC tumor tissues using immunohistochemistry. TERT expression was assessed in both the cytoplasm and the nucleus of HCC cells. The associations between TERT expression and clinical characteristics, including expression levels of DNA-dependent protein kinase catalytic unit (DNA-PKcs) and 8-hydroxyganosine (8-OHdG), were investigated. Among the 135 HCCs, TERT expression was positive only in the cytoplasm in 86 tumors (63.7%), was positive only in the nucleus in 3 tumors (2.2%), was positive in both the cytoplasm and the nucleus in 5 tumors (3.7%) and was negative in 41 tumors (30.4%). Similar results were confirmed using another antibody for TERT. Cytoplasmic TERT expression was markedly associated with hepatitis B surface antigen, poor tumor differentiation, and expression levels of DNA-PKcs and 8-OHdG. However, TERT expression in the cytoplasm or in the nucleus was not significantly associated with the overall or recurrence-free survival periods. In conclusion, TERT was mainly expressed in the cytoplasm of HCC tissues. Cytoplasmic TERT expression was closely associated with hepatitis B virus-related HCC and DNA-PKcs expression, as well as oxidative stress.

Involvement of Kynurenine Pathway in Hepatocellular Carcinoma

Simple Summary

The kynurenine pathway (KP) is a biochemical pathway that synthesizes the vital coenzyme, nicotinamide adenine dinucleotide (NAD⁺). In cancer, the KP is significantly activated, leading to tryptophan depletion and the production of downstream metabolites, which skews the immune response towards tumour tolerance. More specifically, advanced stage cancers that readily metastasize evidence the most dysregulation in KP enzymes, providing a clear link between the KP and cancer morbidity. Consequently, this provides the rationale for an attractive new drug discovery opportunity for adjuvant therapeutics targeting KP-mediated immune tolerance, which would greatly complement current pharmacological interventions. In this review, we summarize recent developments in the roles of the KP and clinical trials examining KP inhibition in liver cancer.

Abstract

As the second and third leading cancer-related death in men and the world, respectively, primary liver cancer remains a major concern to human health. Despite advances in diagnostic technology, patients with primary liver cancer are often diagnosed at an advanced stage. Treatment options for patients with advanced hepatocarcinoma (HCC) are limited to systemic treatment with multikinase inhibitors and immunotherapy. Furthermore, the 5-year survival rate for these late-stage HCC patients is approximately 12% worldwide. There is an unmet need to identify novel treatment options and/or sensitive blood-based biomarker(s) to detect this cancer at an early stage. Given that the liver harbours the largest proportion of immune cells in the human body, understanding the tumour–immune microenvironment has gained increasing attention as a potential target to treat cancer. The kynurenine pathway (KP) has been proposed to be one of the key mechanisms used by the tumour cells to escape immune surveillance for proliferation and metastasis. In an inflammatory environment such as cancer, the KP is elevated, suppressing local immune cell populations and enhancing tumour growth. In this review, we collectively describe the roles of the KP in cancer and provide information on the latest research into the KP in primary liver cancer.

MicroRNA-135a expression is upregulated in hepatocellular carcinoma and targets long non-coding RNA TONSL-AS1 to suppress cell proliferation

Dysregulation of long non-coding RNAs (lncRNAs) results in development of human diseases, including hepatocellular carcinoma (HCC). lncRNA TONSL-AS1 has been reported to act as a tumor suppressor in gastric cancer. The present study aimed to investigate the role of TONSL-AS1 in hepatocellular carcinoma (HCC). Reverse transcription-quantitative PCR analysis was performed to detect the expression levels of TONSL-AS1 and microRNA (miRNA/miR)-135a in HCC tissues and paired adjacent normal tissues. A 5-year follow-up study was performed to determine the prognostic value of TONSL-AS1 in HCC. The association between miR-135a and TONSL-AS1 was assessed via overexpression experiments. The Cell Counting Kit-8 assay was performed to assess cell proliferation. The results demonstrated that TONSL-AS1 expression was downregulated in HCC tissues, which was associated with a lower survival rate in patients with HCC. TONSL-AS1 and miR-135a were predicted to interact with each other, whereby overexpression of miR-135a downregulated TONSL-AS1 expression. The results demonstrated that TONSL-AS1 and miR-135a were inversely correlated with each other. Notably, overexpression of TONSL-AS1 inhibited HCC cell proliferation, while overexpression of miR-135a promoted HCC cell proliferation and decreased the effect of overexpression of TONSL-AS1 on cell proliferation. Taken together, the results of the present study suggest that miR-135a expression is upregulated in HCC and targets lncRNA TONSL-AS1 to suppress cell proliferation.

Australia could miss the WHO hepatitis C virus elimination targets due to declining treatment uptake and ongoing burden of advanced liver disease complications

Australia was one of the first countries to introduce government-funded unrestricted access to direct-acting antiviral (DAA) therapy, with 88,790 treated since March 2016. However, treatment uptake is declining which could potentially undermine Australia's progress towards the WHO HCV elimination targets. Using mathematical modelling, we updated estimates for those living with chronic HCV in Australia, new cases of decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality among the HCV-cured and viraemic populations from 2015 to 2030. We considered various DAA treatment scenarios incorporating annual treatment numbers to 2020, and subsequent uptake per year of 6,790 (pessimistic), 8,100 (intermediate), and 11,310 (optimistic). We incorporated the effects of excess alcohol consumption and reduction in progression to DC and HCC among cirrhosis-cured versus viraemic individuals. At the end of 2020, we estimated 117,810 Australians were living with chronic HCV. New cases per year of DC, HCC, and liver-related mortality among the HCV viraemic population decreased rapidly from 2015 (almost eliminated by 2030). In contrast, the growing population size of those cured with advanced liver disease meant DC, HCC, and liver-related mortality declined slowly. The estimated reduction in liver-related mortality from 2015 to 2030 in the combined HCV viraemic and cured population is 25% in the intermediate scenario. With declining HCV treatment uptake and ongoing individual-level risk of advanced liver disease complications, including among cirrhosis-cured individuals, Australia is unlikely to achieve all WHO HCV elimination targets by 2030.

Women in the 2019 hepatitis C cascade of care: findings from the British Columbia Hepatitis Testers cohort study

BACKGROUND

Women living with hepatitis C virus (HCV) are rarely addressed in research and may be overrepresented within key populations requiring additional support to access HCV care and treatment. We constructed the HCV care cascade among people diagnosed with HCV in British Columbia, Canada, as of 2019 to compare progress in care and treatment and to assess sex/gender gaps in HCV treatment access.

METHODS

The BC Hepatitis Testers Cohort includes 1.7 million people who tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 2000 to 2019. Test results were linked to medical visits, hospitalizations, cancers, prescription drugs, and mortality data. Six HCV care cascade stages were identified: (1) antibody diagnosed; (2) RNA tested; (3) RNA positive; (4) genotyped; (5) initiated treatment; and (6) achieved sustained virologic response (SVR). HCV care cascade results were assessed for women, and an 'inverse' cascade was created to assess gaps, including not being RNA tested, genotyped, or treatment initiated, stratified by sex.

RESULTS

In 2019, 52,638 people with known sex were anti-HCV positive in BC; 37% (19,522) were women. Confirmatory RNA tests were received by 86% (16,797/19,522) of anti-HCV positive women and 83% (27,353/33,116) of men. Among people who had been genotyped, 68% (6756/10,008) of women and 67% (12,640/18,828) of men initiated treatment, with 94% (5023/5364) of women and 92% (9147/9897) of men achieving SVR. Among the 3252 women and 6188 men not yet treated, higher proportions of women compared to men were born after 1975 (30% vs. 21%), had a mental health diagnosis (42% vs. 34%) and had used injection drugs (50% vs. 45%). Among 1619 women and 2780 men who had used injection drugs and were not yet treated, higher proportions of women than men used stimulants (64% vs. 57%), and opiates (67% vs. 60%).

CONCLUSIONS

Women and men appear to be equally engaged into the HCV care cascade; however, women with concurrent social and health conditions are being left behind. Treatment access may be improved with approaches that meet the needs of younger women, those with mental health diagnoses, and women who use drugs.

Clinical Presentation of Hepatocellular Carcinoma in African Americans vs. Caucasians: A Retrospective Analysis

Hepatocellular carcinoma (HCC) remains an important form of cancer-related morbidity and mortality in the U.S. and worldwide. Previous U.S.-based studies on survival suggest ethnic disparities in HCC patients, but the complex interplay of multiple factors that contribute are still incompletely understood. Here we considered the influences of risk factors contributing towards HCC survival, including ethnic background, over ten years at a premier academic medical center with a majority (57.20%) African American (AA) population. Retrospective HCC data were collected from 2008–2018 at LSUHSC-Shreveport, an urban tertiary medical center. Data included demographics, comorbidities, liver disease characteristics, and tumor parameters. Statistical analysis was performed using Chi Square and one-way ANOVA. Results: 229 HCC patients were identified (male 78.6%). The mean HCC age at diagnosis was 61 years (SD = 7.3). Compared to non-Hispanic Caucasians (42.7%), AA patients (57.2% of total) were older at presentation, had more frequent diabetes/dyslipidemia/NAFLD (45 (34.3%) compared with 19 (19.3%) in non-Hispanic Caucasians, p = 0.02), and had a larger HCC burden at diagnosis. We conclude that compared to white patients, despite having similar BMI and MELD scores and rates of portal vein thrombosis, AA patients with HCC in our cohort were older at presentation, had a significantly increased incidence of modifiable metabolic risk factors including diabetes, higher AFP values, increased incidence of gallstones, and larger sized HCCs, and were more likely to be outside Milan criteria. These findings have important prognostic and diagnostic implications for developing a more targeted HCC surveillance program.

Machine Learning to Improve Prognosis Prediction of Early Hepatocellular Carcinoma After Surgical Resection

Background

Improved prognostic prediction is needed to stratify patients with early hepatocellular carcinoma (EHCC) to refine selection of adjuvant therapy. We aimed to develop a machine learning (ML)-based model to predict survival after liver resection for EHCC based on readily available clinical data.

Methods

We analyzed data of surgically resected EHCC (tumor≤5 cm without evidence of extrahepatic disease or major vascular invasion) patients from the Surveillance, Epidemiology, and End Results (SEER) Program to train and internally validate a gradient-boosting ML model to predict disease-specific survival (DSS). We externally tested the ML model using data from 2 Chinese institutions. Patients treated with resection were matched by propensity score to those treated with transplantation in the SEER-Medicare database.

Results

A total of 2778 EHCC patients treated with resection were enrolled, divided into 1899 for training/validation (SEER) and 879 for test (Chinese). The ML model consisted of 8 covariates (age, race, alpha-fetoprotein, tumor size, multifocality, vascular invasion, histological grade and fibrosis score) and predicted DSS with C-Statistics >0.72, better than proposed staging systems across study cohorts. The ML model could stratify 10-year DSS ranging from 70% in low-risk subset to 5% in high-risk subset. Compared with low-risk subset, no remarkable survival benefits were observed in EHCC patients receiving transplantation before and after propensity score matching.

Conclusion

An ML model trained on a large-scale dataset has good predictive performance at individual scale. Such a model is readily integrated into clinical practice and will be valuable in discussing treatment strategies.

Higher Enhancement Intrahepatic Nodules on the Hepatobiliary Phase of Gd-EOB-DTPA-Enhanced MRI as a Poor Responsive Marker of Anti-PD-1/PD-L1 Monotherapy for Unresectable Hepatocellular Carcinoma

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are promising agents for the treatment of hepatocellular carcinoma (HCC). However, the establishment of noninvasive measure that could predict the response to ICIs is challenging. This study aimed to evaluate tumor responses to ICIs using the hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI), which was shown to reflect Wnt/β-catenin activating mutation.

METHODS

A total of 68 intrahepatic HCC nodules from 18 patients with unresectable HCC and Child-Pugh class A liver function who received anti-programmed cell death 1 (PD-1)/programmed death-ligand 1 (PD-L1) monotherapy were enrolled in this study. All patients had viable intrahepatic lesions evaluable using the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI within the 6 months prior to the treatment. The relative enhancement ratio was calculated, and the time to nodular progression (TTnP) defined as 20% or more increase in each nodule was compared between higher or hypo-enhancement HCC nodules. Then, the progression-free survival (PFS) and objective response rate (ORR) per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1) were compared between patients with and without HCC nodules with higher enhancement on hepatobiliary phase images.

RESULTS

The median PFS was 2.7 (95% confidence interval [CI]: 1.4-4.0) months in patients with HCC nodules with higher enhancement (n = 8) and 5.8 (95% CI: 0.0-18.9) months in patients with hypointense HCC nodules (n = 10) (p = 0.007). The median TTnP of HCC nodules with higher enhancement (n = 23) was 1.97 (95% CI: 1.86-2.07) months and that of hypointense HCC nodules (n = 45) was not reached (p = 0.003). The ORR was 12.5% (1/8) versus 30.0% (3/10); the disease control rate was 37.5% (3/8) versus 70.0% (7/10), respectively, in patients with or without higher enhancement intrahepatic HCC nodules.

CONCLUSION

The TTnP on HCC nodules with higher enhancement and the median PFS in patients who carried higher enhancement intrahepatic HCC nodules were significantly shorter than those in hypointense HCC nodules with anti-PD-1/PD-L1 monotherapy. The intensity of the nodule on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI is a promising imaging biomarker for predicting unfavorable response with anti-PD-1/PD-L1 monotherapy in patients with HCC.

Upregulation of lncRNA NIFK-AS1 in hepatocellular carcinoma by m6A methylation promotes disease progression and sorafenib resistance

Long non-coding RNAs (LncRNAs) have recently emerged as vital regulators in the development and progression of hepatocellular carcinoma (HCC), providing new opportunities as novel therapeutic targets. Here we identified the lncRNA NIFK-AS1 as being highly expressed in HCC tissues and cells and showed this up-regulation resulted from METTL3-dependent m⁶A methylation. Functionally, knockdown of NIFK-AS1 inhibited the proliferation, colony formation, migration, and invasion of HCC cells. Moreover, these effects were elicited though AKT1 and we uncovered a ceRNA network involving an NIFK-AS1/miR-637/AKT1 axis with downstream effects on HCC progression involving regulation of MMP-7 and MMP-9 expression. From the clinical perspective, we showed that knockdown of NIFK-AS1 sensitized HCC cells to sorafenib through the up-regulation of the drug transporters OATP1B1 and OATP1B3. Clinical investigations showed HCC patients with low NIFK-AS1 expression benefited from sorafenib therapy and this phenomenon was reproduced in patient-derived tumor xenograft models (PDX) comparing HCC with low and high expression of NIFK-AS1. Taken together, these results suggest an essential role for NIFK-AS1 in HCC progression and promote NIFK-AS1 as a new therapeutic target and predictor of sorafenib benefit in HCC patients.

Gender Disparity in Host Responses to Hepatitis B-Related Hepatocellular Carcinoma: A Case Series

Chronic hepatitis B virus (HBV) infection is one of the most common causes of hepatocellular carcinoma (HCC), a malignant tumor with high mortality worldwide. One remarkable clinical feature of HBV-related HCC is that the risk of development is higher in males and postmenopausal females compared to other females. Increasing evidence also indicates that the prognosis of HBV-associated HCC may involve gender disparity, with females having more favorable outcomes. The proposed mechanism of this gender disparity is thought to be complex and multifactorial. Attributions have been made to gender differences in behavioral risk factors, host stress, immune response, psychology, metabolic risk factors, tumor biology, and hormonal factors. Gender disparities in hormonal factors and stress with consequent incited inflammation and hepatocarcinogenesis in HBV-related HCC is a particularly burgeoning area of investigation. Clarifying these mechanisms could provide insight into HBV-related HCC pathogenesis, and potentially provide a target for prevention and treatment of this disease. Reported herein is a case series involving two families affected by vertically transmitted chronic hepatitis B, longitudinally observed over multiple decades, with family members demonstrating discordant outcomes related to HCC, with worse outcomes among affected males. As a supplement to this case, we review the currently available literature on gender differences in outcomes from HBV-related HCC. In reporting this case series, we aim to add our important observation to the current literature and highlight the need for further research in the mechanisms involved in gender disparity in the prognosis of HBV-related HCC.

Construction and antitumor activity of selenium nanoparticles decorated with the polysaccharide extracted from Citrus limon (L.) Burm. f. (Rutaceae)

Selenium nanoparticles (SeNPs), a potential cancer therapeutic agent, have attracted widespread attention owing to their high bioavailability and remarkable anticancer activity. Nevertheless, the poor water solubility and dispersibility of SeNPs seriously limit their applications. In the present study, we synthesized stable and individual spherical selenium nanoparticles (CL90-Tw-SeNP2) with an average diameter of approximately 79 nm using a polysaccharide extracted from Citrus limon (CL90) and Tween-80 as the decorator and stabilizers. The proportion of selenium in CL90-Tw-SeNP2 was 10.6%. CL90-Tw-SeNP2 possessed high stability and good dispersion in water for more than three months. The subsequent biological assay revealed that CL90-Tw-SeNP2 showed remarkable antitumor effects against HepG2 cells, with an IC₅₀ value of 49.13 μg/mL, by inducing cell apoptosis. Furthermore, an in vivo zebrafish assay to explore possible applications indicated that CL90-Tw-SeNP2 could inhibit the proliferation and migration of tumors and the zebrafish angiogenesis. These results indicated that CL90-Tw-SeNP2 could be a potential agent for cancer treatment, especially against human liver hepatoma cancer.

Long Non-coding RNA MAFG-AS1 Promotes Cell Proliferation, Migration, and EMT by miR-3196/STRN4 in Drug-Resistant Cells of Liver Cancer

Long non-coding RNAs (lncRNAs) have been shown to participate in the development and progression of several different types of cancer. Past studies indicated that lncRNA MAFG-antisense 1 (AS1) promotes colorectal cancer. However, the role of MAFG-AS1 in hepatocellular carcinoma (HCC) remains unclear. The aim of the present study is to examine the effect of lncRNA MAFG-AS1 on drug resistance HCC. The results indicated that MAFG-AS1 is upregulated in drug-resistant cells. Further, MAFG-AS1 promotes growth and migration of HCC by upregulating STRN4 through absorbing miR-3196. Thus, LncRNA MAFA-AS1 may become a novel target to treat HCC patients.

Identification of New Biomarker for Prediction of Hepatocellular Carcinoma Development in Early-Stage Cirrhosis Patients

Background

Liver cirrhosis is one of the major drivers of hepatocellular carcinoma (HCC). In the present study, we aimed to identify and validate new biomarker for early prediction of HCC development in early-stage cirrhosis patients.

Methods

mRNA expression and clinical parameters of GSE63898, GSE89377, GSE15654, GSE14520, and TCGA-HCC cohort and ICGC-HCC cohort were downloaded for analysis. Wilcoxon test was performed to identify DEGs. Univariate and multivariate Cox regression analysis were used to develop the risk signature, and ROC analysis was performed to analyze the predictive accuracy and sensitivity of the risk signature.

Results

There were 42 DEGs (including 28 upregulated genes and 14 downregulated genes) found in early-stage liver cirrhosis patients before developing HCC from GSE1565442. Then, a risk signature consisting of 8 DEGs could effectively classify early-stage cirrhosis patients into high-risk group with shorter HCC development time and low-risk group with longer HCC development time from GSE15654. Multivariate Cox analysis indicated that the risk signature was an independent prognostic factor for the prediction of HCC development and ROC analysis showed that the signature exhibited good predictive efficiency in predicting 2-, 5-, and 10-year HCC development. Mechanistically, significantly higher proportions of CD8 T cells were found to be enriched in cirrhosis patients with low risk score, and higher CD8 T cells were associated with longer HCC development time. Besides, the signature was an independent prognostic factor for poorer prognosis of early-stage liver cirrhosis patients of GSE15654. Moreover, the signature could also separate HCC patients from healthy controls and was also associated with the poorer prognosis of HCC patients from three HCC cohorts. Finally, we also identified HDAC inhibitors, such as trichostatin A, to be a potential chemopreventive treatment for the prevention of HCC development by targeting risk signature based on CMap analysis.

Conclusion

A risk signature was developed and validated for early prediction of HCC development, which may be a useful tool to set up individualized follow-up interval schedules.

The Maturation of Tumor Suppressor miR-497 in Hepatocellular Carcinoma is Inhibited by Oncogenic circRNA SCARB1

Introduction

Circular RNA (CircRNA) SCARB1 plays an oncogenic role in renal cell carcinoma, while its role in other cancers is unclear. The aim of this study was to explore the role of circRNA SCARB1 in hepatocellular carcinoma (HCC).

Methods

The expression of circRNA SCARB1, mature miR-497 and miR-497 precursor in HCC and paired non-tumor tissues from 64 HCC patients were analyzed by RT-qPCR. CircRNA SCARB1 was overexpressed in HCC cells, followed by the measurement of the expression levels of both mature miR-497 and miR-497 precursor to evaluate the effects of overexpression of circRNA SCARB1 on the maturation of miR-497. The effects of circRNA SCARB1 and miR-497 on the proliferation and migration of HCC cells were assessed by CCK-8 assay and Transwell assay, respectively.

Results

We found that circRNA SCARB1 was upregulated in HCC. In addition, mature miR-497 and miR-497 were downregulated in HCC. Correlation analysis showed that circRNA SCARB1 was inversely correlated with mature miR-497 but not miR-497 precursor. Consistently, in HCC cells, downregulated mature miR-497, but not miR-497 precursor, was observed in HCC cells transfected with circRNA SCARB1 expression vector. Analysis of cellular behaviors showed that overexpression of circRNA SCARB1 increased the proliferation and migration of HCC cells, while overexpression of miR-497 decreased cell proliferation and migration. Moreover, overexpression of miR-497 reduced the effects of overexpression of circRNA SCARB1.

Discussion

Therefore, circRNA SCARB1 is upregulated in HCC and promotes HCC cell proliferation and migration by suppressing the maturation of miR-497.

Immunological Microenvironment Predicts the Survival of the Patients with Hepatocellular Carcinoma Treated with Anti-PD-1 Antibody

INTRODUCTION

Although immune checkpoint inhibitors (ICIs) have been considered as promising agents for the treatment of advanced hepatocellular carcinoma (HCC), previous clinical trials revealed that the response to anti-programmed cell death protein 1 (anti-PD-1) monotherapy was as low as 20%. Identifying subgroups that respond well to ICIs is clinically important. Here, we studied the prognostic factors for anti-PD-1 antibody treatment based on the molecular and immunological features of HCC.

METHODS

Patients who were administered anti-PD1 antibody for advanced HCC at Kindai University Hospital were included. Clinicopathological backgrounds and antitumor responses were examined in 34 cases where tumor tissues before treatment were available. Transcriptome analysis was performed using 40 HCC samples obtained from surgical resection, and immune status was compared between 20 HCCs with activating mutations in β-catenin and those without the mutations using transcriptome-based immunogram.

RESULTS

Univariate analysis showed that the disease control rate was significantly better in patients with α-fetoprotein < 400 ng/mL, negative for β-catenin/glutamate synthetase (GS) staining, high combined positive score (CPS) of programmed death-ligand 1 (PD-L1), and increased infiltration of CD8⁺ cells in tumor tissues. Among them, negative staining of β-catenin/GS, CPS of PD-L1 ≥ 1, and high degree of CD8⁺ tumor-infiltrating lymphocytes (TILs) were significantly associated with longer survival in both progression-free survival (PFS) and overall survival (OS). The combination of these factors well stratified the survival of the patients on anti-PD-1 antibody in both PFS and OS (p < 0.0001 and p = 0.0048 for PFS and OS, respectively). In addition, the immunogram revealed that tumor-carrying mutations in β-catenin showed downregulation of immune-related genes, especially in those related to priming and activation by dendritic cells, interferon-γ response, inhibitory molecules, and regulatory T cells.

DISCUSSION/CONCLUSION

The combined score including Wnt/β-catenin activation, CPS of PD-L1, and degree of CD8⁺ TILs in HCC is informative for predicting the response to ICI in HCC cases. Constitutive activation of β-catenin can induce an immune cold phenotype with downregulation of immune-related genes, and immunohistochemistry-based evaluation is beneficial for identifying the subgroup that shows a good response to ICI.

Multimodal treatment involving molecular targeted agents and on-demand transcatheter arterial chemoembolization for advanced hepatocellular carcinoma: A case report and review of the literature

Formulating sequential therapeutic strategies based on the pathological conditions of patients and by using molecular targeted agents (MTAs) and transcatheter arterial chemoembolization (TACE) is crucial for the treatment of unresectable advanced hepatocellular carcinoma (HCC). The current report presents the case of a patient with HCC involving a large intrahepatic primary tumor and lung metastases, and discusses treatment strategies for advanced HCC based on the current literature. Sequential therapy with MTAs was effective after TACE. Lenvatinib was effective for treating the metastases in the lungs and spleen. Only the progressing intrahepatic tumor was additionally treated with TACE. The patient has been alive for 3 years and continued lenvatinib treatment without HCC progression or decline in liver function. In conclusion, although multiple MTAs introduced into the clinic have been gradually replacing TACE, on-demand TACE in the multidisciplinary treatment of advanced HCC may be effective for intrahepatic hypervascular tumors resistant to MTAs, including lenvatinib. It may be possible to re-initiate lenvatinib treatment with good efficacy against distant metastatic lesions, thereby contributing to long-term survival.

A Review of Hepatitis B Virus and Hepatitis C Virus Immunopathogenesis

Despite the advances in therapy, hepatitis B virus (HBV) and hepatitis C virus (HCV) still represent a significant global health burden, both as major causes of cirrhosis, hepatocellular carcinoma, and death worldwide. HBV is capable of incorporating its covalently closed circular DNA into the host cell's hepatocyte genome, making it rather difficult to eradicate its chronic stage. Successful viral clearance depends on the complex interactions between the virus and host's innate and adaptive immune response. One encouraging fact on hepatitis B is the development and effective distribution of the HBV vaccine. This has significantly reduced the spread of this virus. HCV is a RNA virus with high mutagenic capacity, thus enabling it to evade the immune system and have a high rate of chronic progression. High levels of HCV heterogeneity and its mutagenic capacity have made it difficult to create an effective vaccine. The recent advent of direct acting antivirals has ushered in a new era in hepatitis C therapy. Sustained virologic response is achieved with DAAs in 85-99% of cases. However, this still leads to a large population of treatment failures, so further advances in therapy are still needed. This article reviews the immunopathogenesis of HBV and HCV, their properties contributing to host immune system avoidance, chronic disease progression, vaccine efficacy and limitations, as well as treatment options and common pitfalls of said therapy.

Identification of an m6A-Related Signature as Biomarker for Hepatocellular Carcinoma Prognosis and Correlates with Sorafenib and Anti-PD-1 Immunotherapy Treatment Response

Background

N6-methyladenosine (m6A) modification plays an essential role in diverse key biological processes and may take part in the development and progression of hepatocellular carcinoma (HCC). Here, we systematically analyzed the expression profiles and prognostic values of 13 widely reported m6A modification-related genes in HCC.

Methods

The mRNA expression of 13 m6A modification-related genes and clinical parameters of HCC patients were downloaded from TCGA, ICGC, GSE109211, and GSE78220. Univariate and LASSO analyses were used to develop risk signature. Time-dependent ROC was performed to assess the predictive accuracy and sensitivity of risk signature.

Results

FTO, YTHDC1, YTHDC2, ALKBH5, KIAA1429, HNRNPC, METTL3, RBM15, YTHDF2, YTHDF1, and WTAP were significantly overexpressed in HCC patients. YTHDF1, HNRNPC, RBM15, METTL3, and YTHDF2 were independent prognostic factors for OS and DFS in HCC patients. Next, a risk signature was also developed and validated with five m6A modification-related genes in TCGA and ICGC HCC cohort. It could effectively stratify HCC patients into high-risk patients with shorter OS and DFS and low-risk patients with longer OS and DFS and showed good predictive efficiency in predicting OS and DFS. Moreover, significantly higher proportions of macrophages M0 cells, neutrophils, and Tregs were found to be enriched in HCC patients with high risk scores, while significantly higher proportions of memory CD4 T cells, gamma delta T cells, and naive B cells were found to be enriched in HCC patients with low scores. Finally, significantly lower risk scores were found at sorafenib treatment responders and anti-PD-1 immunotherapy responders compared to that in nonresponders, and anti-PD-1 immunotherapy-treated patients with lower risk scores had better OS than patients with higher risk scores.

Conclusion

A risk signature developed with the expression of 5 m6A-related genes could improve the prediction of prognosis of HCC and correlated with sorafenib treatment and anti-PD-1 immunotherapy response.

Complications After Complex Gastrointestinal Cancer Surgery: Benefits and Costs Associated with Inter-hospital Transfer Among Medicare Beneficiaries

BACKGROUND

Inter-hospital transfer (IHT) may help reduce failure-to-rescue (FTR) by transferring patients to centers with a higher level of expertise than the index hospital. We sought to identify factors associated with an IHT and examine if IHT was associated with improved outcomes after complex gastrointestinal cancer surgery.

METHODS

Medicare Inpatient Standard Analytic Files were utilized to identify patients with >1 postoperative complication following resection for esophageal, pancreatic, liver, or colorectal cancer between 2013 and 2017. Multivariable logistic regression was used to examine the association of different factors with the chance of IHT, as well as the impact of IHT on failure-to-rescue (FTR) and expenditures.

RESULTS

Among 39,973 patients with >1 postoperative complications, 3090 (7.7%) patients were transferred to a secondary hospital. The median LOS at the index hospital prior to IHT was 10 days (IQR, 6-17 days). Patients who underwent IHT more often had experienced multiple complications at the index hospital compared with non-IHT patients (57.7% vs. 38.9%) (p<0.001). Transferred patients more commonly had undergone surgery at a low-volume index hospital (n=218, 60.2%) compared with non-IHT (n=10,351, 25.9%) patients (p<0.001). On multivariate analysis, hospital volume remained strongly associated with transfer to an acute care hospital (ACH) (OR 5.53; 95% CI 3.91-7.84; p<0.001), as did multiple complications (OR 2.01, 95% CI 1.56-2.57). The incidence of FTR was much higher among IHT-ACH patients (20.2%) versus non-IHT patients (11.5%) (OR 1.51, 95% CI 1.11-2.05) (p<0.001). Medicare expenditures were higher among patients who had IHT-ACH ($72.1k USD; IQR, $48.1k-$116.7k) versus non-IHT ($38.5k USD; IQR, $28.1k-$59.2k USD) (p<0.001).

CONCLUSION

Approximately 1 in 13 patients had an IHT after complex gastrointestinal cancer surgery. IHT was associated with high rates of FTR, which was more pronounced among patients who underwent surgery at an index low-volume hospital. IHT was associated with higher overall CMS expenditures.

Tumor Immune Microenvironment and Immunosuppressive Therapy in Hepatocellular Carcinoma: A Review

Liver cancer has the fourth highest mortality rate of all cancers worldwide, with hepatocellular carcinoma (HCC) being the most prevalent subtype. Despite great advances in systemic therapy, such as molecular-targeted agents, HCC has one of the worst prognoses due to drug resistance and frequent recurrence and metastasis. Recently, new therapeutic strategies such as cancer immunosuppressive therapy have prolonged patients' lives, and the combination of an immune checkpoint inhibitor (ICI) and VEGF inhibitor is now positioned as the first-line therapy for advanced HCC. Since the efficacy of ICIs depends on the tumor immune microenvironment, it is necessary to elucidate the immune environment of HCC to select appropriate ICIs. In this review, we summarize the findings on the immune microenvironment and immunosuppressive approaches focused on monoclonal antibodies against cytotoxic T lymphocyte-associated protein 4 and programmed cell death protein 1 for HCC. We also describe ongoing treatment modalities, including adoptive cell transfer-based therapies and future areas of exploration based on recent literature. The results of pre-clinical studies using immunological classification and animal models will contribute to the development of biomarkers that predict the efficacy of immunosuppressive therapy and aid in the selection of appropriate strategies for HCC treatment.

The Mortality and Overall Survival Trends of Primary Liver Cancer in the United States

BACKGROUND

Recent trends of hepatocellular carcinoma (HCC) mortality and outcome remain unknown in the United States (US). We investigated the recent trends of primary liver cancer (excluding intrahepatic cholangiocarcinoma) mortality and HCC stage, treatment, and overall survival (OS) in the US.

METHODS

US Cancer Mortality database was analyzed to investigate the trend of primary liver cancer mortality. We analyzed the SEER 18 database to assess the temporal trend of tumor size, stage, treatment, and OS of HCC. Cox regression analysis investigated the association between HCC diagnosis year and OS. All statistical tests were 2-sided.

RESULTS

During 2000-2018, liver cancer mortality rates increased until 2013, plateaued during 2013-2016 (annual percent change [APC] = 0.1%/yr, 95% confidence interval [CI] = -2.1% to 2.4%; P=0.92), and started to decline during 2016-2018 (APC = -1.5%/yr, 95% CI= -3.2% to 0.2%; P=0.08). However, mortality continues to increase in American Indians/Alaska Natives, individuals aged 65 or older, and in 33 states. There was a 0.61% (95% CI = 0.53% to 0.69%; P<0.001) increase in localized stage HCC and 0.86 mm (95% CI= -1.10 to -0.62; P<0.001) decrease in median tumor size per year. One-year OS rate increased from 36.3% (95% CI = 34.3% to 38.3%) to 58.1% (95% CI = 56.9% to 59.4%) during 2000-2015, and five-year OS rate almost doubled from 11.7% (95% CI = 10.4% to 13.1%) to 21.3% (95% CI = 20.2% to 22.4%) during 2000-2011. Diagnosis year (per year) (adjusted hazard ratio = 0.96; 95% CI = 0.96 to 0.97) was independently associated with OS in multivariable analysis.

CONCLUSIONS

Primary liver cancer mortality rates have started to decline in the US with demographic and state-level variation. With an increasing detection of localized HCC, the OS of HCC has improved over the past decades.

Comparison of Hepatocellular Carcinoma in Hispanic and Non-Hispanic Patients

BACKGROUND

Hepatocellular carcinoma (HCC) is the fastest growing cancer in the United States. Studies have shown that compared to Blacks and non-Hispanic Whites, Hispanics have a higher HCC incidence and mortality rate. Most studies investigating HCC in Hispanics have been conducted utilizing data largely from the Western and Southern United States. These findings may, however, not be highly representative of Hispanics in the Northeast, given the nonhomogenous distribution and diversity of Hispanics across the United States.

METHODS

Some 148 HCC patients diagnosed between 1996 and 2012 were identified from a tertiary center in the northeastern United States. Hispanic patients were randomly matched to non-Hispanic White patients by year of diagnosis. Patient characteristics, HCC risk factors, treatment, and outcome were recorded. A Kaplan-Meier (KM) plot with log-rank tests was used for survival analysis.

RESULTS

Compared to non-Hispanic White patients (n=89), Hispanic HCC patients (n=59) were more likely to have chronic hepatitis C infection (69.5% vs. 38.2%, p < 0.01), alcoholic liver disease (37.3% vs. 21.4%, p = 0.04) and were less likely to have chronic hepatitis B infection (6.8% vs. 24.7%, p = 0.01), and private insurance (37.3% vs. 57.3%, p = 0.02). Hispanics were more likely to be diagnosed with an earlier stage disease (Barcelona Clinic Liver Cancer, BCLC stages A and B) compared to non-Hispanic patients (71.7% vs. 36.8%, p < 0.01) and were more likely to receive locoregional treatment. Although Hispanics trended towards improved overall survival, this finding did not hold when stratified by the BCLC stage.

CONCLUSION

Risk factors for HCC in the northeastern Hispanic population are like those found among Hispanics in other US regions. Other research suggests Hispanics are at increased risk for hepatic injury and HCC. However, HCC in this northeastern Hispanic population appears to be less aggressive (earlier stage and trend towards better overall survival) than non-Hispanics. Further research may be needed to identify potential differences by ethnic group for HCC risk factors, presentation, and outcomes.

Hepatitis C-positive Black patients develop hepatocellular carcinoma at earlier stages of liver disease and present with a more aggressive phenotype

BACKGROUND

In the United States, mortality after a diagnosis of hepatocellular carcinoma (HCC) is higher in patients who are Black than in patients of other racial groups. The objective of this study was to clarify factors contributing to this disparity by analyzing liver and tumor characteristics in patients with HCC who have a history of hepatitis C virus (HCV) infection.

METHODS

Records of patients with HCV and HCC at the authors' institution from 2003 to 2018 were retrospectively reviewed. Race and ethnicity were self-identified. Imaging, laboratory, and pathologic features were compared between Black and non-Black cohorts.

RESULTS

Among 1195 individuals with HCC, 390 identified as Black. At the time of HCC diagnosis, Black patients had better liver function, as measured by Child-Pugh score, Model of End-Stage Liver Disease score, histology of nontumor tissue, and fibrosis-4 (FIB-4) score (all P < .05). FIB-4 scores were <3.25 in 31% of Black patients. In addition, Black patients had less early stage HCC (20.2% vs 32.3%; P < .05), larger tumors (median [interquartile range]: 3.5 cm [2.2-6.2 cm] vs 3.1 cm [2.1-5.1 cm]; P < .01), more multiple tumors (median, [interquartile range]: 1 tumor [1-3 tumors] vs 1 tumor [1-2 tumors]; P = .03), more poorly differentiated tumors (30.3% vs 20.5%; P < .05), and more microvascular invasion (67.2% vs 56.5%; P < .05).

CONCLUSIONS

Black patients with HCV exposure develop HCC at earlier stages of liver disease than members of other racial groups. Nearly one-third would not qualify for HCC screening using the common FIB-4 cirrhosis threshold. Practice guidelines that stress HCC surveillance for cirrhotic patients with HCV may need to be revised to be more inclusive for Black patients. In addition, tumors in Black patients carry worse prognostic features, and molecular studies are needed to characterize their biologic properties.

Epidemiological projections of viral-induced hepatocellular carcinoma in the perspective of WHO global hepatitis elimination

Hepatitis B is an eminent risk factor for hepatocellular carcinoma (HCC) in Southeast Asia and sub-Saharan Africa, whereas hepatitis C is a key risk factor for HCC in Western Europe and North America. Increased awareness of the global burden of viral hepatitis resulted, in May 2016, in the adoption of the first global health sector strategy on viral hepatitis by the World Health Assembly, which calls for the elimination of viral hepatitis as a public health threat by 2030. Although the incidence of liver cancer resulting from viral infections has increased since the 1990s, the implementation of public health interventions, such as hepatitis B vaccination and antiviral therapies might have reduced the global burdens of HCC. Hepatitis B immunization in infancy has been associated with a reduction in the risk of infant fulminant hepatitis, chronic liver disease, and HCC in Taiwan. Achieving viral hepatitis elimination by 2030 can be accelerated by improving the access to HCC screening programs. HCC surveillance programs in developed countries must be refined to increase an access to personalized surveillance program, whereas the limited access to surveillance and treatment of HCC in developing countries remains a significant public health issue.

Changes in liver-related mortality by etiology and sequelae: underlying versus multiple causes of death

Background

The expanded definition of liver-related deaths includes a wide range of etiologies and sequelae. We compared the changes in liver-related mortality by etiology and sequelae for different age groups between 2008 and 2018 in the USA using both underlying and multiple cause of death (UCOD and MCOD) data.

Methods

We extracted mortality data from the CDC WONDER. Both the absolute (rate difference) and relative (rate ratio and 95% confidence intervals) changes were calculated to quantify the magnitude of change using the expanded definition of liver-related mortality.

Result

Using the expanded definition including secondary liver cancer and according to UCOD data, we identified 68,037 liver-related deaths among people aged 20 years and above in 2008 (29 per 100,000) and this increased to 90,635 in 2018 (33 per 100,000), a 13% increase from 2008 to 2018. However, according to MCOD data, the number of deaths was 113,219 (48 per 100,000) in 2008 and increased to 161,312 (58 per 100,000) in 2018, indicating a 20% increase. The increase according to MCOD was mainly due to increase in alcoholic liver disease and secondary liver cancer (liver metastasis) for each age group and hepatitis C virus (HCV) and primary liver cancer among decedents aged 65–74 years.

Conclusion

The direction of mortality change (increasing or decreasing) was similar in UCOD and MCOD data in most etiologies and sequelae, except secondary liver cancer. However, the extent of change differed between UCOD and MCOD data.

lncRNA GABPB1 intronic transcript 1 upregulates pigment epithelium-derived factor via miR-93 to suppress cell proliferation in hepatocellular carcinoma

Liver cancer ranks in the top 10 most common malignancies for both mortality rate and incidence worldwide. Hepatocellular carcinoma (HCC) is the most common subtype of liver cancer. It has been reported that long non-coding RNA GABPB1 intronic transcript 1 (IT1) is downregulated in lung cancer and predicts poor survival. However, its role in live cancer remains unclear. Therefore, the present study aimed to investigate the role of GABPB1-IT1 in HCC. A total of 64 patients with HCC (40 males and 24 females; range, 43-67 years old; mean age=55.1±5.1 years) were enrolled at the 96604 Military Hospital of the Chinese People's Liberation Army between May 2012 and May 2014. The expression levels of GABPB1-IT1 and microRNA (miR)-93 in tumor and adjacent normal tissues were measured using quantitative PCR. A dual luciferase activity assay was performed to analyze the interaction between miR-93 and GABPB1-IT1. A Cell Counting Kit-8 assay was used to analyze the effect of miR transfection on the proliferation of SNU-398 cells. It was demonstrated that GABPB1-IT1 can interact with miR-93 in HCC cells, while overexpression of GABPB1-IT1 and miR-93 in HCC cells did not affect the expression of each other. GABPB1-IT1 was downregulated in HCC tissues compared with paired non-tumor tissues and predicted poor survival. Notably, overexpression of GABPB1-IT1 in HCC cells led to upregulation of pigment epithelium-derived factor (PEDF), a target of miR-93. In addition, overexpression of GABPB1-IT1 reduced the enhancing effects of miR-93 on HCC cell proliferation. Therefore, GABPB1-IT1 may upregulate PEDF through miR-93 to suppress cell proliferation in HCC.

Disparities in Hepatocellular Carcinoma Incidence, Stage, and Survival: A Large Population-Based Study

BACKGROUND

Liver cancer is one of the most rapidly increasing cancers in the United States, and hepatocellular carcinoma (HCC) is its most common form. Disease burden and risk factors differ by sex and race/ethnicity, but a comprehensive analysis of disparities by socioeconomic status (SES) is lacking. We examined the relative impact of race/ethnicity, sex, and SES on HCC incidence, stage, and survival.

METHODS

We used Surveillance, Epidemiology, and End Results (SEER) 18 data to identify histologically confirmed cases of HCC diagnosed between January 1, 2000 and December 31, 2015. We calculated age-adjusted HCC incidence, stage at diagnosis (local, regional, distant, unstaged), and 5-year survival, by race/ethnicity, SES and sex, using SEER*Stat version 8.3.5.

RESULTS

We identified 45,789 cases of HCC. Incidence was highest among low-SES Asian/Pacific Islanders (API; 12.1) and lowest in high-SES Whites (3.2). Incidence was significantly higher among those with low-SES compared with high-SES for each racial/ethnic group (P < 0.001), except American Indian/Alaska Natives (AI/AN). High-SES API had the highest percentage of HCC diagnosed at the local stage. Of all race/ethnicities, Blacks had the highest proportion of distant stage disease in the low- and high-SES groups. Survival was greater in all high-SES racial/ethnic groups compared with low-SES (P < 0.001), except among AI/ANs. Black, low-SES males had the lowest 5-year survival.

CONCLUSIONS

With few exceptions, HCC incidence, distant stage at diagnosis, and poor survival were highest among the low-SES groups for all race/ethnicities in this national sample.

IMPACT

HCC prevention and control efforts should target low SES populations, in addition to specific racial/ethnic groups.

The Impact of Liver Transplantation on Hepatocellular Carcinoma Mortality in the United States

BACKGROUND

Hepatocellular carcinoma (HCC) carries a poor prognosis. Liver transplantation (LT) is potentially curative for localized HCC. We evaluated the impact of LT on U.S. general population HCC-specific mortality rates.

METHODS

The Transplant Cancer Match Study links the U.S. transplant registry with 17 cancer registries. We calculated age-standardized incidence (1987-2017) and incidence-based mortality (IBM) rates (1991-2017) for adult HCCs. We partitioned population-level IBM rates by cancer stage and calculated counterfactual IBM rates assuming transplanted cases had not received a transplant.

RESULTS

Among 129,487 HCC cases, 45.9% had localized cancer. HCC incidence increased on average 4.0% annually [95% confidence interval (CI) = 3.6-4.5]. IBM also increased for HCC overall (2.9% annually; 95% CI = 1.7-4.2) and specifically for localized stage HCC (4.8% annually; 95% CI = 4.0-5.5). The proportion of HCC-related transplants jumped sharply from 6.7% (2001) to 18.0% (2002), and further increased to 40.0% (2017). HCC-specific mortality declined among both nontransplanted and transplanted cases over time. In the absence of transplants, IBM for localized HCC would have increased at 5.3% instead of 4.8% annually.

CONCLUSIONS

LT has provided survival benefit to patients with localized HCC. However, diagnosis of many cases at advanced stages, limited availability of donor livers, and improved mortality for patients without transplants have limited the impact of transplantation on general population HCC-specific mortality rates.

IMPACT

Although LT rates continue to rise, better screening and treatment modalities are needed to halt the rising HCC mortality rates in the United States.See related commentary by Zhang and Thrift, p. 435.

County Differences in Liver Mortality in the United States: Impact of Sociodemographics, Disease Risk Factors, and Access to Care

BACKGROUND AND AIMS

Data have demonstrated state-wide variability in mortality rates from liver disease (cirrhosis + hepatocellular carcinoma), but data are lacking at the local level (eg, county) to identify factors associated with variability in liver disease-related mortality and hotspots of liver disease mortality.

METHODS

We used Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research data from 2009 to 2018 to calculate county-level, age-adjusted liver disease-related death rates. We fit multivariable linear regression models to adjust for county-level covariates related to demographics (ie, race and ethnicity), medical comorbidities (eg, obesity), access to care (eg, uninsured rate), and geographic (eg, distance to closest liver transplant center) variables. We used optimized hotspot analysis to identify clusters of liver disease mortality hotspots based on the final multivariable models.

RESULTS

In multivariable models, 61% of the variability in among-county mortality was explained by county-level race/ethnicity, poverty, uninsured rates, distance to the closest transplant center, and local rates of obesity, diabetes, and alcohol use. Despite adjustment, significant within-state variability in county-level mortality rates was found. Of counties in the top fifth percentile (ie, highest mortality) of fully adjusted mortality, 60% were located in 3 states: Oklahoma, Texas, and New Mexico. Adjusted mortality rates were highly spatially correlated, representing 5 clusters: South Florida; Appalachia and the eastern part of the Midwest; Texas and Oklahoma; New Mexico, Arizona, California, and southern Oregon; and parts of Washington and Montana.

CONCLUSIONS

Our data demonstrate significant intrastate differences in liver disease-related mortality, with more than 60% of the variability explained by patient demographics, clinical risk factors for liver disease, and access to specialty liver care.

Trends in the Incidence of Hepatocellular Carcinoma in Washington DC: A Single Institutional Cohort Study (1959-2013)

The African American (AA) community in Washington DC is at an elevated risk for hepatocellular carcinoma (HCC) that has a dismal prognosis. The recent rapid increase in the incidence and diagnosis of HCC and liver metastases (LM) in DC prompted us to evaluate the past six decades of this incidence and some of its underlying causes using a single institutional cohort in a hospital located in the center of the city. Electronic medical and pathology records of 454 liver cancer patients from 1959 to 2013 at Howard University Hospital (HUH) were reviewed. Demographic, clinical and pathology characteristics were examined, and statistical analysis was performed using Wilcoxon rank-sum test. Incidence of HCC rose substantially between 1959 and 2013, increasing eight-fold from 1.05 to 8.0 per 100,000 AAs. The rate of increase in the last decade was highest at 550%. Cases were disproportionately male (67.2%), and median age at diagnosis was 57 years. Towards the last decade, the most common etiology for HCC was nonalcoholic fatty liver disease (NAFLD) followed by NAFLD/HCV combination. Liver cancer was clustered in the eastern region of DC in wards 4, 5, 7, and 8. Cases of liver metastases clinically diagnosed and confirmed by biopsies increased 96.4% from 1959 to 1968 to 2009-2013. This study confirms that HCC incidence has been increasing (initially driven by HCV, and NAFLD in the latter decades) more rapidly in DC than previously believed, highlighting the impact of case definitions especially regarding NAFLD in the context of changing diagnostic approaches including the revised ICD10. The rising burden, disproportionate population distribution, and low survival rate among AAs emphasize the importance of prevention and early detection as a public health imperative.

lncRNA HAND2-AS1 overexpression inhibits cancer cell proliferation in hepatocellular carcinoma by downregulating RUNX2 expression

Background

The long non‐coding RNA HAND2 antisense RNA 1 (HAND2‐AS1) acts as a tumor suppressor in several malignancies, but its role in hepatocellular carcinoma (HCC) remains unknown. In this study, we aimed to investigate the function of HAND2‐AS1 in HCC.

Methods

The expression levels of HAND2‐AS1 and runt‐related transcription factor 2 (RUNX2) were determined in patients with HCC and HCC cell lines using quantitative real‐time polymerase chain reaction and western blot analyses. Cell proliferation was determined using Cell Counting Kit‐8 assay, and the correlation between HAND2‐AS1 and RUNX2 expression was also investigated.

Results

The plasma level of HAND2‐AS1 was downregulated and that of RUNX2 was upregulated in patients with early‐stage HCC compared with those in healthy controls. No significant differences in the plasma levels of HAND2‐AS1 and RUNX2 were found among hepatitis B virus (HBV)‐positive, hepatitis C virus (HCV)‐positive, and HBV‐ and HCV‐negative patients with HCC. The plasma levels of HAND2‐AS1 and RUNX2 were inversely correlated in the patient groups but not in the control group. HAND2‐AS1 overexpression led to the downregulation of RUNX2 expression in human HCC cells, whereas RUNX2 failed to significantly affect HAND2‐AS1 expression. HAND2‐AS1 overexpression inhibited and RUNX2 overexpression promoted the proliferation of HCC cells. RUNX2 overexpression attenuated the inhibitory effects of HAND2‐AS1 overexpression on cancer cell proliferation.

Conclusion

HAND2‐AS1 overexpression inhibits cancer cell proliferation in HCC by downregulating RUNX2 expression.

A comparison of factors associated with the temporal improvement in the overall survival of BCLC stage 0 hepatocellular carcinoma patients

BACKGROUND

It is uncertain whether the prognosis of Barcelona Clinical Liver Cancer (BCLC) stage 0 hepatocellular carcinoma (HCC) has improved.

AIMS

To evaluate whether the outcomes of BCLC stage 0 patients has improved, and if so, what are the reasons behind the noted improved outcome.

METHODS

A total of 591 patients with BCLC stage 0 HCC diagnosed at Samsung Medical Center, Seoul, Korea were grouped based on year of diagnosis (earlier cohort; 2007-2009 and later cohort; 2013-2015) and compared.

RESULTS

The overall survival (OS) was improved for BCLC stage 0 patients at later cohort (5-year survival rate: 82.1% vs. 92.0% for earlier cohort and later cohort, p = 0.015). However, after adjustment, the treatment period was not an independent factor for OS, especially when the albumin-bilirubin (ALBI) grade was adjusted. The incidence of liver cirrhosis (LC)-related death was increased from 10.4% to 33.3%, while the incidence of HCC-related death decreased from 57.5% to 28.6% in the latter cohort.

CONCLUSIONS

The survival improvement of BCLC stage 0 patients was largely explained by better liver function at diagnosis. Mortality from LC-related death was increasing, which calls for careful attention for finding strategies for preserving the liver function for BCLC stage 0 patients.

MicroRNAs in the Pathogenesis of Hepatocellular Carcinoma: A Review

Simple Summary

Hepatocellular carcinoma (HCC) is one of the most frequently occurring cancers, and the prognosis for late-stage HCC remains poor. A better understanding of the pathogenesis of HCC is expected to improve outcomes. MicroRNAs (miRNAs) are small, noncoding, single-stranded RNAs that regulate the expression of various target genes, including those in cancer-associated genomic regions or fragile sites in various human cancers. We summarize the central roles of miRNAs in the pathogenesis of HCC and discuss their potential utility as valuable biomarkers and new therapeutic agents for HCC.

Abstract

Hepatocellular carcinoma (HCC) is the seventh most frequent cancer and the fourth leading cause of cancer mortality worldwide. Despite substantial advances in therapeutic strategies, the prognosis of late-stage HCC remains dismal because of the high recurrence rate. A better understanding of the etiology of HCC is therefore necessary to improve outcomes. MicroRNAs (miRNAs) are small, endogenous, noncoding, single-stranded RNAs that modulate the expression of their target genes at the posttranscriptional and translational levels. Aberrant expression of miRNAs has frequently been detected in cancer-associated genomic regions or fragile sites in various human cancers and has been observed in both HCC cells and tissues. The precise patterns of aberrant miRNA expression differ depending on disease etiology, including various causes of hepatocarcinogenesis, such as viral hepatitis, alcoholic liver disease, or nonalcoholic steatohepatitis. However, little is known about the underlying mechanisms and the association of miRNAs with the pathogenesis of HCC of various etiologies. In the present review, we summarize the key mechanisms of miRNAs in the pathogenesis of HCC and emphasize their potential utility as valuable diagnostic and prognostic biomarkers, as well as innovative therapeutic targets, in HCC diagnosis and treatment.