Sorafenib in advanced hepatocellular carcinoma

The effectiveness and safety of therapies for hepatocellular carcinoma with tumor thrombus in the hepatic vein, inferior vena cave and/or right atrium: a systematic review and single-arm meta-analysis

BACKGROUND

This review evaluates the efficacy and safety of therapies for hepatocellular carcinoma (HCC) with hepatic vein tumor thrombus (HVTT), inferior vena cava tumor thrombus (IVCTT), and/or right atrium tumor thrombus (RATT).

RESEARCH DESIGN AND METHODS

A systematic review of PubMed, EMBASE, Cochrane Library, and Wanfang databases up to 22 August 2024, was conducted, focusing on overall survival (OS), progression -free survival (PFS), and adverse reactions.

RESULTS

Seven studies involving 453 patients were analyzed. Treatment strategies included surgery alone, local ± systemic therapy, and surgery with adjuvant therapy. The pooled 1-, 3-, and 5-year OS rates for all patients were 63.3%, 21.6% , and 8.3%, respectively. Surgery with adjuvant therapy achieved the highest 1-year OS, while local ± systemic therapy led to the best 5-year OS. The pooled 1-, 3-, and 5-year PFS rates for all patients were 56.8%, 9.4%, and 1.6%, respectively. Surgery alone commonly caused ascites and pleural effusion; the local ± systemic therapy commonly caused hepatic dysfunction and platelet abnormalities; and surgery with adjuvant therapy commonly caused peritoneal abscess.

CONCLUSION

Local ± systemic therapy provided the best long-term OS and manageable complications among the therapeutic strategies for HCC with HVTT, IVCTT, and/or RATT.

REGISTRATION

PROSPERO, (CRD42024573152).

USP22 promotes the proliferation and Sorafenib resistance of hepatocellular carcinoma cells via its deubiquitinase activity

BACKGROUND

Hepatocellular carcinoma remains one of the most lethal cancers, characterized by poor prognosis and low life expectancy. Unfortunately, there are very few molecular therapeutic options available for it. Sorafenib is a current standard first-line treatment for advanced hepatocellular carcinoma, however, drug resistance significantly limits its therapeutic efficacy.

METHODS

Ubiquitin-specific protease 22 (USP22) expression level and its prognostic significance in hepatocellular carcinoma were analyzed using The Cancer Genome Atlas (TCGA) database. A series of cellular experiments related to cell proliferation and ferroptosis, and mouse tumor-bearing experiments were performed to investigate the role of USP22 in hepatocellular carcinoma cell growth and Sorafenib resistance. Flag affinity purification coupled with mass spectrometry, co-immunoprecipitation, and ubiquitination assays were conducted to identify direct substrates of USP22. Spike-in chromatin-immunoprecipitation (ChIP)-seq, RNA-seq, and ChIP assays were employed to explore the transcriptional substrates of USP22 as an H2BK120ub deubiquitinase.

RESULTS

Analysis of TCGA database reveals that USP22 is highly expressed in hepatocellular carcinoma tissues, which is closely associated with poor patient prognosis. Our data further indicates that USP22 promotes the proliferation of hepatocellular carcinoma cells via deubiquitinating and stabilizing cyclin-dependent kinase 11B (CDK11B). Additionally, USP22 acts as a novel inducer of Sorafenib resistance and suppresses Sorafenib-triggered ferroptosis in hepatocellular carcinoma cells. It reduces the transcription of transferrin receptor (TFRC) by decreasing H2BK120ub occupancy at TFRC transcription start site (TSS) downstream region, thereby inhibiting ferroptosis upon Sorafenib treatment. Finally, animal experiments confirm the role of USP22 in promoting hepatocellular carcinoma cell growth and Sorafenib resistance in vivo. Taken together, this study demonstrates that USP22 promotes hepatocellular carcinoma growth and inhibits Sorafenib-induced ferroptosis by deubiquitinating non-histone substrate CDK11B and histone H2B, respectively.

CONCLUSIONS

Our findings suggest USP22 as a promising prognostic biomarker and therapeutic target for hepatocellular carcinoma patients, particularly those with Sorafenib resistance.

KEY POINTS

USP22 promotes the proliferation of hepatocellular carcinoma cells by deubiquitinating and stabilizing cyclin-dependent kinase CDK11B. USP22 enhances Sorafenib resistance of hepatocellular carcinoma cells by inhibiting ferroptosis through the USP22/H2BK120ub/TFRC axis.

PD-1 inhibitors improve the efficacy of tyrosine kinase inhibitors combined with transcatheter arterial chemoembolization in advanced hepatocellular carcinoma: a meta-analysis and trial sequential analysis

BACKGROUND

This meta-analysis and trial sequential analysis (TSA) aimed to evaluate the efficacy and safety of triple therapy with tyrosine kinase inhibitors (TKIs) combined with transcatheter arterial chemoembolization (TACE) plus programmed death 1 (PD-1) inhibitors (T-T-P) and dual therapy with TKIs combined with TACE (T-T) for the treatment of advanced unresectable hepatocellular carcinoma (uHCC).

METHODS

Literature related to the efficacy of TKIs combined with TACE plus PD-1 inhibitors in uHCC was searched using the Embase, PubMed, and Cocrane libraries. TSA was used to reduce false positive results due to random error.

RESULTS

Seventeen articles were included in this meta-analysis, including 2,561 patients. In the T-T-P group, OS [HR 0.45, 95% confidence interval (CI) 0.39-0.52; p = 0.000], PFS [HR 0.43, 95% CI 0.38 - 0.48; p = 0.000], were significantly prolonged compared to those in the T-T group; ORR (RR 1.59 [95% CI 1.39-1.81]; p = 0.000) and DCR (RR 1.26 [95% CI 1.15-1.37]; p = 0.000) were significantly higher. TSA analysis showed early results without further testing. Prognostic factor analysis demonstrated that portal vein tumor thrombus (PVTT) and extrahepatic metastasis were common independent risk factors for OS and PFS. Regarding grade 3/4 adverse events results showed no statistically significant differences in any of them.

CONCLUSIONS

Compared with T-T treatment group, the T-T-P treatment group exhibited a notable improvement in OS and PFS, particularly in cases of PVTT and extrahepatic metastasis. Furthermore, it can markedly enhance the ORR and DCR in patients with uHCC.

MEGF6 knockdown ameliorates lenvatinib-induced muscle differentiation suppression and enhances the antitumor effect of lenvatinib on hepatocellular carcinoma

Lenvatinib (LEN)-treated patients with hepatocellular carcinoma (HCC) are frequently accompanied by skeletal muscle loss, which is correlated with poor prognosis. Interactions between tumor and skeletal muscle may play a role in patient prognosis and tumor progression. We here demonstrated that LEN hindered proliferation and differentiation of the mouse myoblast cell line, C2C12 cells, by blocking the ERK1/2 and AKT signaling pathways. Transcriptome analysis revealed that multiple EGF-like domains 6 (Megf6) was upregulated in LEN-treated C2C12 cells. Furthermore, we observed that compared with normal adjacent tissues, MEGF6 was highly expressed in HCC tumor tissues according to the TCGA database, which suggested MEGF6-mediated interaction between tumor and skeletal muscle. The Megf6 knockdown restored the differentiation inhibition caused by LEN and ERK1/2 inhibitors; however, it had no significant impact on proliferation. Regarding mechanism, LEN increased Megf6 expression through the ERK1/2 signaling pathway, thereby resulting in myostatin expression elevation and myosin heavy chain protein expression repression. Furthermore, MEGF6 in LEN-treated C2C12 cell medium promoted tumor cell proliferation and impaired C2C12 cell differentiation when cultured with LEN-treated tumor cell medium. Clinically, patients who were accompanied by muscle mass loss and increased MEGF6 serum levels had shorter progression-free survival than those who were accompanied by muscle mass loss but no increased MEGF6 serum levels before and after LEN treatment. In conclusion, MEGF6 produced from muscle and tumor cells could impair muscle differentiation and enhance tumor proliferation. Therefore, MEGF6 is worth further investigating as a target for improving the prognosis of LEN-treated patients with HCC.

Response to systemic treatments and survival of fibrolamellar carcinomas: An AGEO-SFCE French multicenter retrospective cohort

INTRODUCTION

Fibrolamellar carcinomas (FLC) are rare and predominantly advanced hepatic malignancies, lacking a clear consensus on anti-tumor treatments (ATT). The primary objective of the study was to determine whether any ATT appeared to give favorable outcomes in terms of morphological objective response (ORR) and disease control (DCR) rate according to RECIST 1.1 criteria.

PATIENTS AND METHODS

This retrospective multicentric French cohort from 14 centers included 44 patients with histologically proven FLC who received at least one ATT (chemotherapy and/or tyrosine kinase inhibitors, TKI) and underwent at least one morphological evaluation. .

RESULTS

A total of 40 anti-tumor responses were analyzed after a first line treatment. No complete response was observed, with an ORR in 13 % of cases, a DCR in 55 % of cases and 45 % of disease progression. GEMOX regimen (n = 9) showed an ORR of 11 % and a DCR of 33 %; the combination of doxorubicin and platinum-based chemotherapy (n = 6) achieved an ORR of 33 % and a DCR of 83 %. For TKI, sorafenib (n = 10) and sunitinib (n = 3), there was no objective response, with a DCR of 40 % and 33 % respectively. The median and the 5-years overall survival were 3.3 years and 35 % (95 %CI=[0.23-0.54]) respectively.

CONCLUSION

FLC have a poor prognosis; ATT show mild response rate. Further approaches and personalized medicine seem to be an unmet need for patients with FLC and new treatments should be urgently developed.

Impact of neutrophil-to-lymphocyte ratio on survival outcomes among cirrhotic and non-cirrhotic patients with advanced hepatocellular carcinoma under atezolizumab-bevacizumab combination therapy

Background

The efficacy of atezolizumab-bevacizumab in patients with hepatocellular carcinoma (HCC) has not been studied separately in cirrhotic and non-cirrhotic patients. Our aim was to evaluate the efficacy of atezolizumab-bevacizumab in these patients, in relation to baseline values of the neutrophil-to-lymphocyte ratio (NLR).

Methods

We divided 57 atezolizumab-bevacizumab-treated HCC patients according to baseline NLR (>3: NLR-H, ≤3: NLR-L) and studied overall survival (OS) and progression-free survival (PFS) in 4 groups: group A, non-cirrhotic/NLR-L; group B, non-cirrhotic/NLR-H; group C, cirrhotic/NLR-L; and group D, cirrhotic/NLR-H.

Results

The 4 groups were comparable except for etiology, ALBI grade, macrovascular invasion, Barcelona Clinic Liver Cancer stage and prior therapy. Median OS and PFS were 30, 10, 12 and 5 months, and 14, 4, 8 and 2 months, for groups A, B, C, D, respectively (P<0.001). By Cox regression, cirrhotic/NLR-H patients showed significantly worse OS and PFS. Cirrhotic/NLR-L patients had better OS (12 vs. 5 months, P=0.002) and PFS (8 vs. 2 months, P=0.028) compared to cirrhotic/NLR-H. NLR was significantly correlated with OS (P=0.015). Non-cirrhotic/NLR-L patients had better OS (30 vs. 10 months, P=0.006) and PFS (15 vs. 4 months, P=0.01) compared to non-cirrhotic/NLR-H patients. Prior therapy was significantly correlated with better OS (30 vs. 8 months, P<0.001) and PFS (24 vs. 4 months, P<0.001) in non-cirrhotic patients.

Conclusions

Cirrhotic/NLR-H HCC patients presented the worst survival. NLR is an independent risk factor for worse survival in cirrhotic patients. Prior therapy is the only factor significantly correlated with OS and PFS in non-cirrhotic patients.

Impact of time-of-day atezolizumab plus bevacizumab combination therapy infusion for unresectable hepatocellular carcinoma: A retrospective multicenter study

AIM

This study aimed to evaluate the impact of infusion timing of time-of-day on clinical outcomes in patients with unresectable hepatocellular carcinoma (HCC) treated with atezolizumab plus bevacizumab combination therapy.

METHODS

A retrospective analysis was conducted using data from 751 unresectable HCC patients treated with atezolizumab plus bevacizumab between September 2020 and April 2024. Patients were categorized into morning (AM; n = 351) and afternoon (PM; n = 400) groups based on infusion timing of time-of-day. Outcomes, including progression-free survival (PFS), overall survival, objective response rate, and disease control rate, were assessed using Kaplan-Meier survival analysis and Cox regression analysis.

RESULTS

The PFS was significantly longer in the AM group (8.6 months, 95% CI 7.6-10.5) compared with the PM group (6.0 months, 95% CI 5.4-7.0; p = 0.006). In contrast, overall survival was similar between the groups (AM: 24.7 months vs. PM: 21.4 months; p = 0.99). Cox regression analysis revealed that morning infusion was an independent favorable predictor of PFS (HR 1.23, 95% CI 1.04-1.45). Additionally, the AM group demonstrated superior objective response rate and disease control rate compared with the PM group, suggesting better tumor control.

CONCLUSION

Morning infusion of atezolizumab plus bevacizumab is associated with improved PFS and response rates in unresectable HCC patients, highlighting the potential for optimizing treatment outcomes through circadian timing.

Hepatic Recompensation Before Systemic Therapy for Hepatocellular Carcinoma Yields Comparable Survival to Compensated Cirrhosis

BACKGROUND AND AIMS

The survival outcomes associated with hepatic recompensation in patients with advanced hepatocellular carcinoma (HCC) treated with first-line systemic therapies remain unclear. We compared survival from the initiation of first-line systemic treatments for advanced HCC among patients with compensated, decompensated, and recompensated cirrhosis.

METHODS

A Latin American multicenter, prospective cohort study was conducted from 2018 to 2024, involving patients with HCC and Child-Pugh class A or B who received systemic therapy. At the time of first-line therapy, patients with cirrhosis were categorised as compensated (never decompensated), decompensated, or recompensated. Cox proportional hazards models were estimated.

RESULTS

Among 306 patients receiving first-line systemic therapy (sorafenib: 60.5%, atezolizumab + bevacizumab: 29.7%, lenvatinib: 9.1%), 240 had cirrhosis, with 30.4% having a history of hepatic decompensation. Of these, 57.5% (95% CI 45.4%-69.0%) achieved hepatic recompensation over a median period of 12 months. At the time of first-line therapy, 69.6% were compensated, 17.5% recompensated, and 12.9% decompensated. Metabolic-associated steatotic liver disease (MASLD) was the most common underlying aetiology in the recompensated group. Median survival was significantly shorter in the decompensated group (8.6 months) compared to the compensated group (17.2 months) [aHR 1.91 (95% CI 1.04-3.5); p = 0.03], without a significant difference between the recompensated and compensated groups [aHR 1.28 (95% CI 0.79-2.1); p = 0.31]. Tumour progression was the primary reason for treatment discontinuation, and similar access to second-line therapies was observed between the compensated and recompensated groups.

CONCLUSION

Patients with cirrhosis and advanced HCC who achieved hepatic recompensation might benefit from systemic therapies after a cautious observation period.

Targeting VEGF signaling for tumor microenvironment remodeling and metastasis inhibition: Therapeutic strategies and insights

The tumor microenvironment (TME) plays a pivotal role in cancer progression and metastasis, with vascular endothelial growth factor (VEGF) signaling serving as a key regulator of tumor angiogenesis and immune evasion. VEGF induces abnormal blood vessel formation, promoting tumor growth, immune suppression, and metastasis through epithelialmesenchymal transition (EMT). As a result, VEGF signaling has become a critical therapeutic target in cancer treatment. This review examines the molecular mechanisms driving VEGF-mediated tumor growth and angiogenesis, with a focus on the interaction between tumor and endothelial cells and the dual role of VEGF in fostering vascularization and immune suppression. Current anti-VEGF therapies, including monoclonal antibodies (e.g., bevacizumab) and tyrosine kinase inhibitors (TKIs), have demonstrated efficacy and have received FDA approval for various cancers; however, therapeutic resistance remains a significant challenge. Strategies to overcome resistance, such as novel VEGF inhibitors, vascular normalization approaches, and combination therapies with immune checkpoint inhibitors, have been explored. Additionally, future directions emphasize the need for personalized approaches to improve treatment efficacy and reduce metastasis. A comprehensive understanding of VEGF signaling in the TME may pave the way for more effective cancer therapies.

Harnessing immunotherapy for hepatocellular carcinoma: Principles and emerging promises

HCC is considered as one of the leadin causes of death worldwide, with the ability of resistance towards therapeutics. Immunotherapy, particularly ICIs, have provided siginficant insights towards harnessing the immune system. The present review introduces the concepts and possibilities of immunotherapy for HCC treatment, emphasizing its underlying mechanisms and capacity to enhance patient results, focusing on both pre-clinical and clinical insights. The functions of TME and immune evasion mechanisms typical of HCC would be evaluated along with how contemporary immunotherapeutic approaches are designed to address these challenges. Furthermore, the clinical application of immunotherapy in HCC is discussed, emphasizing recent trial findings demonstrating the effectiveness and safety of drugs. In addition, the problems caused by immune evasion and resistance would be discussed to increase potential of immunotherapy along with combination therapy.

Prompt initiation of durvalumab and tremelimumab for unresectable hepatocellular carcinoma in patients with chronic active hepatitis B: a phase 2 clinical trial

BACKGROUND

Chronic hepatitis B virus (HBV) infection is an etiology of HCC, but clinical trials using immune checkpoint inhibitors (ICIs) usually exclude patients with chronic active hepatitis B (serum HBV viral load > 2000 IU/mL). This study examined the safety and efficacy of concurrently administering the ICI and anti-HBV medications in this patient population.

METHODS

In this single-arm phase 2 clinical trial, we enrolled patients with advanced HCC and untreated chronic active hepatitis B. Patients received 1500 mg of durvalumab every 4 weeks alone or in combination with 300 mg of tremelimumab on day 1 (the STRIDE regimen). Anti-HBV treatment with entecavir was simultaneously initiated. The primary endpoint was the rate of HBV reactivation.

RESULTS

We enrolled 30 patients, whose mean baseline HBV viral load was 770,986 IU/mL. No patients experienced HBV reactivation or HBV-associated hepatitis. Hepatitis flare was noted in 8 (26.7%) patients, but none of them were associated with HBV reactivation. The objective tumor response rate was 10% and 25% for the durvalumab treatment alone and the STRIDE regimen, respectively.

CONCLUSION

For patients with chronic active hepatitis B, ICI therapy could be promptly initiated as long as anti-HBV medications were administered simultaneously.

CLINICAL TRIAL REGISTRATION

NCT04294498.

Up-front resection for hepatocellular carcinoma: Assessing futility in the preoperative setting

OBJECTIVE

We sought to develop a predictive model to preoperatively identify patients with hepatocellular carcinoma (HCC) at risk of undergoing futile upfront liver resection (LR).

METHODS

Patients undergoing curative-intent LR for HCC were identified from a large multi-institutional database. Futile LR was defined by death or disease recurrence within six months postoperatively. Backward logistic regression was performed to identify factors associated with futility. Additionally, binary criteria were established for surgical candidacy, aiming to keep the likelihood of futility below 20 %.

RESULTS

Among 1633 patients with HCC, 264 (16.2 %) underwent futile upfront LR. Tumor burden score (TBS) (coefficient: 0.083, 95%CI: 0.067-0.099), alpha-fetoprotein (AFP) (coefficient: 0.254, 95%CI: 0.195-0.310), and albumin-bilirubin (ALBI) grade 2/3 (coefficient: 0.566, 95%CI: 0.420-0.718) were independently associated with an increased risk of futile LR. The model demonstrated strong discrimination and calibration in both derivation and validation cohorts. Low, intermediate, and high-risk groups were determined based on the risk model, each with an escalating likelihood of futility, worse histological features, and worse survival outcomes. Six distinct conditions based on AFP-adjusted-to-TBS criteria were established, all with a futility likelihood of less than 20 %. Patients fulfilling these criteria had significantly better long-term recurrence-free and overall survival. The futility risk model was made available online for wide clinical applicability: (https://altaf-pawlik-hcc-futilityofsurgery-calculator.streamlit.app/).

CONCLUSION

A preoperative risk model and AFP-adjusted-to-TBS criteria were developed and validated to predict the likelihood of futile LR among patients with HCC. This pragmatic clinical tool may assist clinicians in preoperative decision-making, helping them avoid futile surgery unlikely to offer long-term benefits.

Prognostic Significance of the BALAD Serological Model in Systemic Therapies for Hepatocellular Carcinoma: A Personalized Approach to the Prediction of Survival Benefit

PURPOSE

The BALAD model, a scoring system for staging hepatocellular carcinoma (HCC), is based on five serum markers: bilirubin, albumin, lens culinaris agglutinin-reactive alpha-fetoprotein [AFP], AFP, and des-gamma-carboxy prothrombin. It has shown good ability to predict survival in patients with HCC irrespective of stage and treatment, a high BALAD value being associated with a poor prognosis. However, its prognostic significance is unclear in patients with advanced unresectable HCC (uHCC) who undergo systemic therapies. We assessed the prognostic ability of BALAD in this subpopulation.

METHODS

In a multicenter cohort of 1,510 patients with advanced uHCC treated with first-line systemic therapies, the baseline BALAD score was calculated on the basis of pretreatment serum levels. Overall survival (OS), progression-free survival (PFS), overall response rate (ORR), and disease control rate (DCR) were calculated and related to the BALAD score.

RESULTS

In all, 502 patients were treated with sorafenib, 435 with lenvatinib, and 573 with atezolizumab plus bevacizumab. Irrespective of treatment regimen, OS, PFS, ORR, and DCR were all independently negatively correlated with the BALAD score. The beneficial effects of specific systemic therapy regimens differed according to the BALAD score.

CONCLUSION

The BALAD score had good prognostic ability for predicting OS and PFS in patients with advanced uHCC who underwent systemic therapies and was associated with treatment response. Application of the BALAD score offers increased precision in the prediction of outcome both for individual patients and for specific subgroups of patients with HCC.

Oncolytic virus VG161 in refractory hepatocellular carcinoma

Hepatocellular carcinoma remains a life-threatening malignancy with limited therapeutic options following the failure of second-line treatments1,2. Oncolytic viruses selectively replicate in and lyse cancer cells, releasing neoantigens and stimulating systemic antitumour immunity3, offering a potential therapeutic option. Here we present the results of a multicentre phase 1 clinical trial evaluating VG161, an engineered oncolytic herpes simplex virus that expresses IL-12, IL-15, IL-15Rα and a PD-1-PD-L1-blocking fusion protein4, for safety and efficacy in patients with advanced liver cancer. VG161 was well tolerated, with no dose-limiting toxicities observed, and it demonstrated promising efficacy by reshaping the tumour immune microenvironment and re-sensitizing tumours that were previously resistant to systemic treatments. Notably, we also found that patients who had previously been sensitive to checkpoint inhibitor therapy showed enhanced efficacy with VG161 treatment. Furthermore, we developed an efficacy-prediction model based on differentially expressed genes, which successfully identified patients who were likely to benefit from VG161 and predicted prolonged overall survival. These findings position VG161 as a promising third-line therapeutic option for refractory hepatocellular carcinoma. This provides a new avenue for treatment and advances the field of oncolytic virus-based immunotherapies. ClinicalTrials.gov registration: NCT04806464 .

Tremelimumab plus durvalumab versus sorafenib in first-line treatment of unresectable hepatocellular carcinoma: a cost-effectiveness analysis from the US payer perspective

OBJECTIVE

In a recently published 4-year overall survival (OS) update from the phase III clinical trial named HIMALAYA (NCT03298451), single tremelimumab plus regular interval durvalumab (a regimen termed STRIDE) demonstrated significantly improved OS compared with sorafenib in the first-line setting of unresectable hepatocellular carcinoma (uHCC). Although dual immunotherapy represents a novel treatment option for uHCC, the economic implications of these high-priced drugs require further exploration. This study aimed to evaluate the cost-effectiveness of STRIDE in uHCC to inform first-line treatment decisions and help allocate medical resources most effectively.

DESIGN

Using a partitioned survival model, we conducted a cost-effectiveness analysis comparing STRIDE to sorafenib in the first-line treatment of uHCC. Clinical information was gathered from the phase III HIMALAYA trial. Costs and health state utilities data were derived from previous literature. Uncertainty of the model was assessed through one-way sensitivity analysis and probabilistic sensitivity analysis.

OUTCOME MEASURES

Total costs, life years, quality-adjusted life years (QALYs), incremental QALYs and incremental cost-effectiveness ratio (ICER).

SETTING

US payer perspective.

PARTICIPANTS

393 participants in the STRIDE group and 389 participants in the sorafenib group who were diagnosed with uHCC and had no previous systemic treatment.

INTERVENTIONS

Single-dose tremelimumab plus monthly durvalumab (STRIDE) versus sorafenib.

RESULTS

Treatment with STRIDE provided an additional 0.51 QALYs at an incremental total cost of United States dollar ($)9812. The ICER of STRIDE was $19 239 per QALY compared with sorafenib, which falls below the willingness-to-pay threshold of $150 000 per QALY. Sensitivity analyses indicated that our results were robust to the variation ranges of key inputs.

CONCLUSION

In this economic evaluation comparing two first-line systemic therapies for uHCC patients, STRIDE was cost-effective compared with sorafenib from a US payer perspective. Our study is the first to demonstrate that immunotherapy can provide both survival benefits and economic viability in uHCC.

Systemic treatment in patients with hepatocellular carcinoma and advanced liver dysfunction

Systemic therapy represents the standard of care treatment for patients with advanced hepatocellular carcinoma (HCC). Given the increased risk of death from cirrhosis-related complications in patients with advanced liver dysfunction, pivotal phase III trials traditionally limited inclusion to patients with Child-Pugh class A, where death is more likely to be attributed to HCC progression. Therefore, Western guidelines recommend the use of systemic therapies primarily in patients with preserved liver function. However, patients with HCC and Child-Pugh class B are commonly encountered in clinical practice, but due to limited prospective evidence, there is no clear guidance on their optimal management.In this recent advances article, we discuss how the clinical course of cirrhosis can affect eligibility to treatment in the modern era of systemic therapy for HCC, elaborate on strategies to improve liver function in HCC patients by targeting cirrhosis-related and tumour-related factors and summarise the current literature on systemic therapy in HCC patients with Child-Pugh class B. Based on this information, we finally propose a clinical algorithm on how to systematically approach patients with HCC and advanced liver dysfunction in clinical practice.

Cadonilimab, a PD-1/CTLA-4 bispecific antibody in unresectable hepatocellular carcinoma: a real-world study

OBJECTIVE

This study retrospectively evaluated the safety and efficacy of cadonilimab combined with tyrosine kinase inhibitors (TKI) for the treatment of unresectable hepatocellular carcinoma (uHCC).

PATIENTS AND METHODS

Seventy-eight patients who received cadonilimab + TKI were included; 42 and 36 received it as first-line (1 L) and second-line and above (≥ 2 L) systemic treatment, respectively. Besides, ninety-five patients who received PD-1 inhibitor + TKI as first-line treatments were included. Safety was the primary endpoint; secondary endpoints were overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR).

RESULTS

Treatment-related adverse events (TRAEs) of any grade occurred in 84.6% of the patients, with grade ≥ 3 in 20.5%. In patients with a Child-Pugh score of ≥ 8 (CP ≥ 8), any grade TRAEs occurred in 88.2%, and grade ≥ 3 in 20.6%. The overall cohort's median progression-free survival (mPFS) was 3.6 months, whereas the median overall survival (mOS) was 8.8 months. In the 1 L group, mPFS was 6.7 months versus 2.3 months in ≥ 2 L. In the 1 L group, mOS was 13.7 months versus 3.2 months in ≥ 2 L. For CP < 8, 1 L mPFS was 7.6 months, mOS not reached; CP ≥ 8 had mPFS of 5.2 months, mOS of 5.6 months. For CP < 8 in ≥ 2 L, mPFS was 3.1 months, mOS 8.8 months; CP ≥ 8 had mPFS of 1.4 months, mOS of 2.2 months. After propensity score matching (PSM), the incidence of TRAEs of any grade was 77.1%, with grade ≥ 3 accounting for 17.1% in the PD-1 group. In the PD-1/CTLA-4 group, the incidence of TRAEs of any grade was 80.0%, and that of grade ≥ 3 TRAEs was 17.1%. The mPFS was 6.7 months in the PD-1/CTLA-4 group versus 3.3 months in the PD-1 group. The mOS was 13.7 months in the PD-1/CTLA-4 group versus 6.7 months in the PD-1 group.

CONCLUSION

Cadonilimab + TKI showed a favorable trend in safety and efficacy, especially when applied as first-line systemic therapy for uHCC. This study offers a clinical reference for its use in systemic uHCC therapy, particularly in patients with advanced liver dysfunction.

Hepatocellular Carcinoma and the Role of Liver Transplantation: An Update and Review

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. Multiple treatment modalities are available for the management of HCC, depending on its stage as determined by the Barcelona Clinic Liver Cancer staging system. Because liver transplantation (LT) theoretically removes the cancer and replaces the organ at risk for future malignancy, LT is often considered the most definitive and one of the most efficacious treatment options for HCC. Nevertheless, the success and efficacy of liver transplantation depend on various tumor characteristics. As a result, multiple criteria have been developed to assess the appropriateness of a case of HCC for LT, with the pioneering Milan Criteria established in 1996. Over the past 20 to 30 years, these criteria have been critically evaluated, expanded, and often liberalized to make LT for patients with HCC a more universally applicable option. Furthermore, the development of other treatment modalities has enabled downstaging and bridging strategies for HCC prior to LT. In this narrative and comprehensive review, we provided an update on recent trends in the epidemiology of HCC, selection criteria for LT, implementation of LT across different regions, treatment modalities available as bridges, downstaging strategies, alternatives to LT, and, finally, post-LT surveillance.

FBL promotes hepatocellular carcinoma tumorigenesis and progression by recruiting YY1 to enhance CAD gene expression

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Accumulating evidence suggests that epigenetic dysregulation contributes to the initiation and progression of HCC. We aimed to investigate key epigenetic regulators that contribute to tumorigenesis and progression, providing a theoretical basis for targeted therapy for HCC. We performed a comprehensive epigenetic analysis of differentially expressed genes in LIHC from the TCGA database. We identified fibrillarin (FBL), an rRNA 2'-O-methyltransferase, as an essential contributor to HCC. A series of in vitro and in vivo biological experiments were performed to investigate the potential mechanisms of FBL. FBL knockdown suppressed the proliferation of HCC cells. In vivo studies using cell-derived xenograft (CDX), patient-derived xenograft (PDX), and diethylnitrosamine (DEN)-induced HCC models in Fbl liver-specific knockout mice demonstrated the critical role of FBL in HCC carcinogenesis and progression. Mechanistically, FBL regulates the expression of CAD in HCC cells by recruiting YY1 to the CAD promoter region. We also revealed that fludarabine phosphate is a novel inhibitor of FBL and can inhibit HCC growth in vitro and in vivo. The antitumor activity of lenvatinib has been shown to be synergistically enhanced by fludarabine phosphate. Our study highlights the cancer-promoting role of the FBL-YY1-CAD axis in HCC and identifies fludarabine phosphate as a novel inhibitor of FBL. A schematic diagram depicting the FBL-YY1-CAD signaling pathway and its regulatory role in HCC progression.

Predictive factors and prognostic models for Hepatic arterial infusion chemotherapy in Hepatocellular carcinoma: a comprehensive review

Hepatocellular carcinoma (HCC) is a prevalent and lethal cancer, often diagnosed at advanced stages where traditional treatments such as surgical resection, liver transplantation, and locoregional therapies provide limited benefits. Hepatic arterial infusion chemotherapy (HAIC) has emerged as a promising treatment modality for advanced HCC, enhancing anti-tumor efficacy through targeted drug delivery while minimizing systemic side effects. However, the heterogeneous nature of HCC leads to variable responses to HAIC, highlighting the necessity for reliable predictive indicators to tailor personalized treatment strategies. This review explores the factors influencing HAIC success, including patient demographics, tumor characteristics, biomarkers, genomic profiles, and advanced imaging techniques such as radiomics and deep learning models. Additionally, the synergistic potential of HAIC combined with immunotherapy and molecular targeted therapies is examined, demonstrating improved survival outcomes. Prognostic scoring systems and nomograms that integrate clinical, molecular, and imaging data are discussed as superior tools for individualized prognostication compared to traditional staging systems. Understanding these predictors is essential for optimizing HAIC efficacy and enhancing survival and quality of life for patients with advanced HCC. Future research directions include large-scale prospective studies, integration of multi-omics data, and advancements in artificial intelligence to refine predictive models and further personalize treatment approaches.

USP24 promotes hepatocellular carcinoma progression by deubiquitinating and stabilizing YAP1

Yes-associated protein 1 (YAP1) plays a pivotal role in promoting the progression of hepatocellular carcinoma (HCC). Emerging evidence shows that inducing YAP1 degradation represents a promising strategy. Here, we identified USP24 as a bona fide deubiquitinating enzyme for YAP1. USP24 directly interacts with and deubiquitinates YAP1, thereby stabilizing YAP1 protein levels. Clinically, USP24 was significantly upregulated in HCC tissues and correlated with poor patient prognosis. Depletion of USP24 significantly suppressed the proliferation of HCC cells in vitro, which could be rescued by restoration of YAP1. Consistent with these findings, USP24 knockdown inhibited tumor growth in a xenograft mouse model. Overall, our study reveals that the USP24/YAP1 axis plays a critical role in the malignant progression of HCC, thus providing rationale for potential therapeutic interventions for YAP1-driven HCC.

Systemic therapy for hepatocellular carcinoma, from the early to the advanced stage: a Japanese perspective

Systemic therapy has now become mainstream for the treatment of hepatocellular carcinoma (HCC) and is also changing from molecular-targeted therapy, such as with sorafenib and lenvatinib, to immunotherapy, such as with the atezolizumab plus bevacizumab and durvalumab plus tremelimumab combination regimens. Molecular-targeted therapy is selected as the first-line treatment when immunotherapy is not indicated or as second- or later-line treatment when immunotherapy is ineffective. It is necessary to select the appropriate treatment taking into consideration the expected treatment efficacy and adverse events, as well as the hepatic reserve. Currently, newer agents and combination regimens as first-line/second-line treatment for advanced-stage HCC, combined therapy with transarterial chemoembolization for intermediate-stage HCC, and perioperative adjuvant therapy for curative treatment for early-stage HCC are being developed. Therefore, systemic therapy is now indicated for any stage of the disease. While local therapies were previously used as the main treatment strategy for HCC, systemic therapy in combination with local therapies is being actively attempted at present. Systemic therapy is currently the main focus of development of novel treatments for HCC.

In vivo RNAi screen and validation reveals Ngp, Hba-a1, and S100a8 as novel inhibitory targets on T lymphocytes in liver cancer

Background

Hepatocellular carcinoma (HCC) represents the third deadliest cancer worldwide with limited treatment options. Immune checkpoint inhibitors (ICIs) have revolutionized HCC therapy, but immune suppression within the tumor microenvironment remains a major challenge. Therefore, in this study, we aimed to define novel ICI molecules arising on T cells during aggressive HCC development.

Methods

Using autochthonous HCC models, we performed microarray analyses followed by in vivo RNA interference screen and identified several new ICI molecules on CD4 and CD8 T lymphocytes in HCC-bearing mice. Short hairpin RNA (shRNA)-mediated knockdown of the ICI molecules was performed to validate their functional role in T cell activity and survival of HCC-bearing mice. Finally, we searched for the presence of the defined ICI molecules in HCC patients.

Results

We identified neutrophilic granule protein (Ngp), hemoglobin subunit alpha-1 (Hba-a1), and S100 calcium-binding protein a8 (S100a8) as novel inhibitory molecules of T cells in HCC. The specific shRNA-based knockdown of these inhibitory targets was safe, led to a downregulation of classical ICI molecules (PD-1, PD-L1, 4-1BBL, CD160), and kept liver parameters under control in murine HCC. Besides, we detected upregulation of S100A8 and S100A9 in blood and liver tissues in HCC patients, supporting their clinical relevance.

Conclusion

The obtained results pave the way for the use of the newly defined ICI molecules Ngp, Hba-a1, and S100a8 as novel immunotherapeutic targets in further preclinical and clinical studies in HCC patients.

Targeting Metabolism: Innovative Therapies for MASLD Unveiled

The recent introduction of the term metabolic-dysfunction-associated steatotic liver disease (MASLD) has highlighted the critical role of metabolism in the disease's pathophysiology. This innovative nomenclature signifies a shift from the previous designation of non-alcoholic fatty liver disease (NAFLD), emphasizing the condition's progressive nature. Simultaneously, MASLD has become one of the most prevalent liver diseases worldwide, highlighting the urgent need for research to elucidate its etiology and develop effective treatment strategies. This review examines and delineates the revised definition of MASLD, exploring its epidemiology and the pathological changes occurring at various stages of the disease. Additionally, it identifies metabolically relevant targets within MASLD and provides a summary of the latest metabolically targeted drugs under development, including those in clinical and some preclinical stages. The review finishes with a look ahead to the future of targeted therapy for MASLD, with the goal of summarizing and providing fresh ideas and insights.

Exploring RNA binding proteins in hepatocellular carcinoma: insights into mechanisms and therapeutic potential

Hepatocellular carcinoma (HCC), the most prevalent type of primary liver cancer, is linked to elevated global incidence and mortality rates. Elucidating the intricate molecular pathways that drive the progression of HCC is imperative for devising targeted and effective therapeutic interventions. RNA-binding proteins (RBPs) serve as pivotal regulators of post-transcriptional processes, influencing various cellular functions. This review endeavors to provide a comprehensive analysis of the expression, function, and potential implications of RBPs in HCC. We discuss the classification and diverse roles of RBPs, with a particular focus on key RBPs implicated in HCC and their association with disease progression. Additionally, we explore the mechanisms by which RBPs contribute to HCC, including their impact on gene expression, cell proliferation, cell metastasis, angiogenesis, signaling pathways, and post-transcriptional modifications. Importantly, we examine the potential of RBPs as therapeutic targets and prognostic biomarkers, offering insights into their relevance in HCC treatment. Finally, we outline future research directions, emphasizing the need for further investigation into the functional mechanisms of RBPs and their clinical translation for personalized HCC therapy. This comprehensive review highlights the pivotal role of RBPs in HCC and their potential as novel therapeutic avenues to improve patient outcomes.

NEIL3 Deficiency Enhances HCC Cell Sensitivity to Oxaliplatin by Inhibiting the Fanconi Anaemia Pathway

Despite some achievements in oxaliplatin-based chemotherapy for the treatment of advanced hepatocellular carcinoma (HCC), the abnormal activation of DNA damage repair pathways in HCC cells remains a major problem, limiting the efficacy of oxaliplatin-based chemotherapy. In a previous study, we found that endonuclease VIII-like protein 3 (NEIL3) is expressed in a high proportion of patients with HCC and associated with an unfavourable prognosis. However, the role of NEIL3 in chemoresistance is still unclear. The aim of this study was to evaluate whether and how NEIL3 regulates oxaliplatin anti-tumour efficacy. Gene expression after oxaliplatin treatment in HCC cell lines was assessed by real-time quantitative PCR, western blot analysis and bioinformatics analysis. The effect of NEIL3 on regulating oxaliplatin efficacy was assessed using cell counting kit-8 assays, colony formation assays, flow cytometry and an in vivo nude mice study. Mechanistic insights into the sensitivity to oxaliplatin mediated by the inhibition of NEIL3 were obtained through immunofluorescence and RNA sequencing analyses. Our findings demonstrated that NEIL3 expression was markedly downregulated after oxaliplatin administration. NEIL3 knockdown impaired cell viability and colony formation and increased apoptosis in HCC cells exposed to oxaliplatin. In addition, NEIL3 inhibition reduced tumour progression and enhanced oxaliplatin efficacy in xenograft nude mice models. Furthermore, knocking down NEIL3 significantly increased the oxaliplatin-mediated inhibition of the Fanconi anaemia pathway. Our results revealed that NEIL3 may be a promising therapeutic target for improving oxaliplatin efficacy in the treatment of HCC.

Detrimental impact of gastric acid suppressants on vascular endothelial growth factor receptor tyrosine kinase inhibitors efficacy: evidence from a systematic review and meta-analysis

BACKGROUND

This meta-analysis evaluated the prevalence of gastric acid suppressants (GASs) in patients receiving vascular endothelial growth factor receptor tyrosine kinase inhibitors (VEGFR-TKIs) and explored drug-drug interactions (DDIs).

METHODS

PubMed, Embase, and Cochrane Library were searched upto 20 October 2024. Studies comparing VEGFR-TKIs monotherapy versus VEGFR-TKIs with GASs, reporting pharmacodynamic (PD), pharmacokinetic (PK), or adverse events (AEs), were analyzed using random-effects models. Subgroups included cancer types and VEGFR-TKI types.

RESULTS

24 studies comprising 6,406 patients were included. The prevalence of GASs use in VEGFR-TKIs users was 40% (95% CI 31-50%). GASs significantly impaired survival, increasing mortality risk by 29% (OS HR 1.29,95% CI 1.14-1.45) and progression risk by 31% (PFS HR 1.31, 95% CI 1.06-1.61). PK analyses revealed clinically meaningful exposure reductions (AUC0-24GMR 0.78, 90% CI 0.65-0.94; Cmax GMR 0.80, 90% CI 0.70-0.91). AE incidence (except vomiting) did not differ between groups.

CONCLUSION

GASs may reduce the efficacy of most types of VEGFR-TKIs by decreasing their bioavailability, thereby having a detrimental effect on patient survival outcomes. It is recommended to give priority to H2 receptor antagonists (H2RAs) and monitor blood drug concentrations to optimize efficacy.

PROTOCOL REGISTRATION

www.crd.york.ac.uk/prospero identifier CRD42024597729.

Post-treatment adverse events ranking in targeted immunotherapy for hepatocellular carcinoma: A network meta-analysis based on risk probability assessment

BACKGROUND

Despite the rapid evolution of targeted and immunotherapies for hepatocellular carcinoma (HCC), a systematic comparison of their adverse event profiles remains limited. This review addresses this critical gap by synthesizing data from 13 randomized controlled trials (RCTs) to prioritize treatment regimens on the basis of safety, thereby guiding clinical decision-making in an era of expanding therapeutic options.

METHODS

Clinical studies focusing on targeted and immunotherapies in HCC patients were chosen from databases such as PubMed, Embase, Web of Science and the Cochrane Library, which spans from 2008 to 2023. Data processing and evaluation followed PRISMA guidelines, with a random-effects model employed to merge the data. Network models were then developed, with adverse events serving as the primary endpoint for analysis.

RESULTS

A comprehensive review of the relevant literature was conducted, identifying 13 randomized controlled trials (RCTs) encompassing 13 treatment protocols for HCC. This study included a total of 10,760 patients. Adverse events within the same category were initially consolidated, followed by the sequential construction of a network model to assess the risk probabilities associated with different targeted immunotherapy regimens for various adverse events and establish priority rankings.

CONCLUSIONS

Cabozantinib, camrelizumab, and their combination therapy for HCC are associated with a higher incidence of common adverse reactions, whereas durvalumab, lenvatinib, and their combination therapy are less likely to cause common adverse effects.

L-741626 inhibits hepatocellular carcinoma progression by targeting Ref-1 to suppress MAPK/ERK signalling pathway activity

Hepatocellular carcinoma (HCC) is a common and challenging malignancy of the digestive tract. Unfortunately, patients with advanced HCC frequently experience limited long-term benefits from current treatments, highlighting the critical need for innovative therapeutic agents. The discovery and development of new small-molecule compounds that target tumours have become crucial aspects of cancer research. In this study, we report on L-741626, a compound that has significant inhibitory effects on HCC. Both in vivo and in vitro experiments confirmed that L-741626 inhibited the growth of HCC by suppressing the MAPK/ERK signalling pathway. Molecular docking simulations and drug affinity responsive target stability assays further identified redox Factor 1 (Ref-1) as a target of L-741626. Ref-1 is overexpressed in HCC and is correlated with poor prognosis and high stage. Further studies demonstrated that Ref-1 interacts with CRAF, a crucial component of the MAPK/ERK signalling pathway. Knockdown of Ref-1 in HCC cells led to inhibition of the MAPK/ERK pathway. Sorafenib is a well-established targeted therapy for the treatment of HCC, with its primary antitumor mechanism being the inhibition of the MAPK/ERK signalling pathway. However, the presence of tumor stem cells is a key factor contributing to resistance to sorafenib. Our study demonstrates that L-741626 can suppress tumor stemness in HCC. The combination of L-741626 and sorafenib significantly enhances the sensitivity of HCC, resulting in increased tumoricidal effects. Our findings reveal a novel pharmacological effect of L-741626, which inhibits MAPK/ERK signalling activity in HCC by targeting Ref-1. Furthermore, L-741626 exhibits a synergistic effect when combined with sorafenib, suggesting a new potential approach for HCC treatment.

Predicting tumor dynamics in treated patients from patient-derived-xenograft mouse models: a translational model-based approach

This study presents a translational modeling framework designed to predict tumor size dynamics in cancer patients undergoing anticancer treatment, using data from patient-derived xenograft (PDX) mice. In the first step, a population tumor growth inhibition (TGI) model to estimate the distribution of exponential tumor growth rates and anticancer drug potency in PDX mice was built. Then, model parameters were allometrically scaled from mice to humans to inform a TGI model predicting tumor size dynamics in cancer patients. Longitudinal tumor dynamics predicted by the PDX-informed TGI model were expressed in terms of tumor progression events to allow validation against literature time-to-progression (TTP) data. The proposed approach was tested on two case studies: gemcitabine treatment for pancreatic cancer and sorafenib treatment for hepatocellular cancer. The framework successfully predicted median tumor size dynamics, closely aligned with clinical TTP curves for gemcitabine-pancreatic cancer case study. While predictions for extreme tumor size percentiles highlighted potential avenues for refinement, such as incorporating resistance mechanisms, the overall accuracy underscored the goodness of the approach. For the sorafenib-hepatocellular cancer case study, the framework provided plausible tumor size predictions, with TTP curves closely aligned with clinical observations, despite the limited availability of clinical data prevented a full validation. Overall, the translational modeling framework showed potential for predicting tumor dynamics in cancer patients, with results suggesting its applicability as a valid tool to support early decision-making in oncology.

Targeting TIME in advanced hepatocellular carcinoma: Mechanisms of drug resistance and treatment strategies

Hepatocellular carcinoma (HCC) is the predominant form of primary liver cancer. While early-stage HCC can be effectively managed with surgical resection and other interventions, treatment options for advanced HCC are limited. Current systemic treatments for advanced HCC include VEGF-targeted tyrosine kinase inhibitors (Sorafenib, Lenvatinib), and the combination therapy of anti PD-1/PD-L1 and anti VEGF (Atezolizumab plus Bevacizumab, Camrelizumab plus Rivoceranib). However, the lack of response to these drugs and the emergence of acquired drug resistance significantly impairs their efficacy. Numerous studies have demonstrated that the tumor immune microenvironment (TIME) plays a crucial role in modulating the response to these therapies. Various immune cells and their secreted factors within the TIME play a pivotal role in the emergence of secondary drug resistance in HCC. This article reviews the mechanism of TIME promoting drug resistance, discusses the influence of current systemic HCC treatment drugs on TIME, and evaluates how these TIME changes affect the efficacy of treatment. A deeper understanding of the interaction between TIME and systemic treatment drugs may be beneficial to enhance the treatment effect, mitigate drug resistance of advanced HCC, and ultimately improve the prognosis of patients.

Patient with Atezolizumab-induced Encephalitis in Hepatocellular Carcinoma

A 65-year-old man treated with atezolizumab plus bevacizumab for hepatocellular carcinoma was admitted to our hospital with a fever, difficulty in moving, and aphasia. The patient became comatose immediately after admission. Imaging and cerebral fluid tests revealed no evidence of malignancy or infection. A diagnosis of atezolizumab-induced encephalitis was made, and steroid pulse therapy was initiated on admission, immediately after which the patient regained consciousness and was able to talk and walk. He was discharged with slight paralysis of his legs and was able to resume chemotherapy. An early diagnosis and treatment are required to improve the prognosis of encephalitis.

BIRC2 blockade facilitates immunotherapy of hepatocellular carcinoma

BACKGROUND

The effectiveness of immunotherapy in hepatocellular carcinoma (HCC) is limited, however, the molecular mechanism remains unclear. In this study, we identified baculoviral IAP repeat-containing protein 2 (BIRC2) as a key regulator involved in immune evasion of HCC.

METHODS

Genome-wide CRISPR/Cas9 screening was conducted to identify tumor-intrinsic genes pivotal for immune escape. In vitro and in vivo models demonstrated the role of BIRC2 in protecting HCC cells from immune killing. Then the function and relevant signaling pathways of BIRC2 were explored. The therapeutic efficacy of BIRC2 inhibitor was examined in different in situ and xenograft HCC models.

RESULTS

Elevated expression of BIRC2 correlated with adverse prognosis and resistance to immunotherapy in HCC patients. Mechanistically, BIRC2 interacted with and promoted the ubiquitination-dependent degradation of NFκB-inducing kinase (NIK), leading to the inactivation of the non-canonical NFκB signaling pathway. This resulted in the decrease of major histocompatibility complex class I (MHC-I) expression, thereby protecting HCC cells from T cell-mediated cytotoxicity. Silencing BIRC2 using shRNA or inhibiting it with small molecules increased the sensitivity of HCC cells to immune killing. Meanwhile, BIRC2 blockade improved the function of T cells both in vitro and in vivo. Targeting BIRC2 significantly inhibited tumor growth, and enhanced the efficacy of anti-programmed death protein 1 (PD-1) therapy.

CONCLUSIONS

Our findings suggested that BIRC2 blockade facilitated immunotherapy of HCC by simultaneously sensitizing tumor cells to immune attack and boosting the anti-tumor immune response of T cells.

Five-year overall survival update from the HIMALAYA study of tremelimumab plus durvalumab in unresectable HCC

BACKGROUND & AIMS

In the phase III HIMALAYA study (NCT03298451), STRIDE (Single Tremelimumab Regular Interval Durvalumab) significantly improved overall survival (OS) versus sorafenib in unresectable HCC (uHCC) and demonstrated long-term survival benefits. We report an updated exploratory analysis of OS with 5 years of follow-up, including survival by multiple tumour response measures.

METHODS

Participants were randomised to STRIDE (tremelimumab plus durvalumab), durvalumab or sorafenib. OS, depth of response and serious adverse events (AEs) were assessed. Extended long-term survivors (eLTS; ≥48 months beyond randomisation) were described. Updated data cut-off: 01 March 2024.

RESULTS

Median (95% CI) follow-up durations were 62.49 (59.47-64.79) months (STRIDE) and 59.86 (58.32-61.54) months (sorafenib). The OS HR (95% CI) for STRIDE versus sorafenib was 0.76 (0.65-0.89). OS rates at 60 months for STRIDE versus sorafenib were 19.6% versus 9.4% overall, 28.7% versus 12.7% in participants achieving disease control per RECIST v1.1 and 50.7% versus 26.3% in participants achieving >25% tumour shrinkage. No late-onset treatment-related serious AEs were reported for STRIDE. There were more eLTS with STRIDE (83/393, 21.1%) than sorafenib (45/389, 11.6%), and extended long-term survival occurred across all clinically relevant subgroups.

CONCLUSIONS

At 5 years, STRIDE sustained an OS benefit versus sorafenib and maintained a manageable safety profile. OS benefit with STRIDE was improved in participants with disease control. Data suggest that any degree of tumour shrinkage with STRIDE can be associated with improved OS, indicating that conventional response measures may not fully capture STRIDE benefits. Nevertheless, participants experiencing deep responses appear to have the greatest benefit. STRIDE continues to set new benchmarks in uHCC with 1 in 5 patients alive at 5 years.

IMPACT AND IMPLICATIONS

The phase III HIMALAYA study showed that STRIDE (Single Tremelimumab Regular Interval Durvalumab) improved overall survival (OS) versus sorafenib in participants with unresectable HCC (uHCC), including after 4 years of follow-up. Understanding the efficacy and safety of STRIDE over the longer term is important for healthcare providers; here, we demonstrate that STRIDE sustained an OS benefit versus sorafenib and maintained a manageable safety profile after 5 years of follow-up. OS benefit with STRIDE was improved in participants with disease control and any degree of tumour shrinkage, indicating that conventional response measures may not fully capture the benefits of STRIDE. These findings are important as they set new benchmarks in uHCC and may help guide clinical decisions in the future.

Endogenous protein S100A14 stabilizes glutaminase to render hepatocellular carcinoma resistant to sorafenib

BACKGROUND

Many cases of advanced hepatocellular carcinoma (HCC) are resistant to the widely used drug sorafenib, which worsens prognosis. While many studies have explored how acquired resistance emerges during drug exposure, the mechanism underlying primary resistance before treatment still remain elusive.

METHODS

Single-cell lineage tracing and RNA sequencing were performed to identify primary sorafenib-resistant lineages in HCC. Differential gene expression analysis was employed to identify the biomarkers of drug-resistant lineage cells. Cell viability and colony formation assays were adopted to assess the involvement of S100A14 on sorafenib resistance. Co-immunoprecipitation (CO-IP) and mass spectrometry analysis were conducted to uncover the downstream targets and regulatory mechanisms of S100A14 in primary resistance to sorafenib. In vivo mouse xenograft experiments were carried out to assess the effect of S100A14 or its interacting protein glutaminase (GLS) on primary resistance to sorafenib in HCC.

RESULTS

Single-cell lineage tracing identified a cluster of sorafenib primary resistant cells, and S100A14, a Ca2+-binding protein, was determined to be a critical biomarker for primary resistance to sorafenib. Knockdown of S100A14 significantly increases sorafenib treatment sensitivity in HCC cells. Mechanistically, S100A14 binds to GLS and blocks its phosphorylation at residues Y308 and S314, which in turn inhibits its ubiquitination and subsequent degradation. By stabilizing GLS, S100A14 reduces oxidative stress in HCC cells, thereby antagonizing sorafenib-induced apoptosis. Inhibiting S100A14 or GLS significantly improved sorafenib efficacy against xenograft tumors in vivo.

CONCLUSIONS

Our results demonstrate that S100A14 plays a pivotal role in promoting primary resistance to sorafenib by stabilizing GLS to reduce oxidative stress, and acts as a potential therapeutic target to enhance the efficacy of sorafenib in HCC patients.

Self-assembled nanoplatform-mediated co-delivery of brusatol to sensitize sorafenib for hepatocellular carcinoma treatment

Sorafenib (Sor), recognized as a frontline multi-kinase inhibitor, constitutes the primary targeted therapy for hepatocellular carcinoma (HCC). Despite its potential, many HCC patients exhibit reduced responsiveness to Sor, thereby undermining its therapeutic efficacy. Recent studies highlight the importance of nuclear factor erythroid-2-related factor 2 (Nrf2) activation in HCC, which contributes to Sor resistance. Brusatol (Bru), a plant-derived Nrf2 inhibitor, counteracts this resistance but faces challenges due to its poor solubility in aqueous media. In this study, we developed a glutathione (GSH)-responsive nanoplatform that effectively dispersed in water for the co-delivery of Bru and Sor (B/S NP). This approach enhanced Bru's therapeutic efficacy and increased Sor sensitivity in HCC. Our nanoplatform significantly reduced Nrf2 expression, thereby increasing Sor sensitivity both in vitro and in vivo, while presenting a favorable biosafety profile. These findings suggest that the nanoplatform-mediated co-delivery of Bru and Sor offers an innovative approach to enhance Sor's effectiveness in HCC treatment.

Silibinin-Conjugated Galactose Dendrimers for Targeted Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) remains one of the most prevalent and lethal forms of liver cancer, contributing significantly to global cancer-related mortality. Conventional treatments, including surgical resection, liver transplantation, and systemic therapies such as multikinase inhibitors and immune checkpoint inhibitors, often face limitations such as systemic toxicity and drug resistance, emphasizing the urgent need for more effective therapeutic strategies. In this study, we developed a galactose-functionalized dendrimer (Gal24) conjugated with a natural flavonoid, silibinin, (Gal24-Sil), for HCC therapy. In our previous study, we developed a Gal24 dendrimer to target hepatocytes in vivo. Here, we further demonstrated that the conjugation of silibinin to Gal24 dendrimer platform significantly enhanced its solubility and efficacy. In vitro studies demonstrated that Gal24-Sil conjugates significantly improved the anticancer efficacy of silibinin in HepG2 and Hep3B liver cancer cells. The conjugate induced an inflammatory response and reactive oxygen species (ROS) generation, triggering cellular apoptosis and necrosis. Furthermore, Gal24-Sil effectively reduced cell proliferation by promoting mitochondrial membrane potential (MMP) depolarization and inducing DNA damage. Our findings demonstrate the potential of Gal24-Sil as a promising nanoplatform for HCC therapy, offering enhanced therapeutic efficacy over free Silibinin. This study highlights the broader applicability of the Gal24 dendrimer platform for addressing various liver diseases.

The efficacy and safety of adding hepatic arterial infusion chemotherapy using cisplatin to lenvatinib for advanced hepatocellular carcinoma

AIM

Combination therapy with lenvatinib and hepatic arterial infusion chemotherapy (HAIC) using cisplatin had a high antitumor effect for advanced hepatocellular carcinoma (HCC); however, the efficacy of adding HAIC using cisplatin to lenvatinib remains unclear.

METHODS

We retrospectively reviewed the charts of advanced HCC patients who were treated with lenvatinib or lenvatinib plus HAIC using cisplatin and compared the efficacy between them. The patients received 12 mg or 8 mg of lenvatinib once daily by weight in both groups, and 65 mg/m2 of cisplatin through the hepatic artery every 4 weeks in the lenvatinib plus HAIC group.

RESULTS

A total of 140 patients were included in this analysis, with 40 patients in each of the lenvatinib group and lenvatinib plus HAIC groups selected through propensity score matching analysis. Objective response rate (20.0 vs. 67.5%, p < 0.001), progression-free survival (median 4.6 vs. 9.2 months, p = 0.032), and overall survival (median 12.1 vs. 20.6 months, p = 0.024) for the lenvatinib plus HAIC group were significantly better compared with those for the lenvatinib group. Subgroup analysis suggested a greater prognostic benefit in patients with larger tumor size, vascular invasion, and those with prior treatment with immune checkpoint inhibitors. Although the main grade 3-4 adverse events more frequently observed in the lenvatinib plus HAIC group were hematological toxicities, all were manageable.

CONCLUSIONS

Adding HAIC using cisplatin to lenvatinib improved the response to treatment and outcome for advanced HCC patients. Further studies are needed to confirm these results and explore the clinical positioning of lenvatinib plus HAIC.

Usefulness of the Early Increase of Peripheral Blood Lymphocyte Count in Predicting Clinical Outcomes for Patients with Advanced Hepatocellular Carcinoma Treated with Durvalumab Plus Tremelimumab

BACKGROUND/OBJECTIVES

Durvalumab plus Tremelimumab (Dur/Tre) therapy is expected to have good therapeutic efficacy for patients with advanced hepatocellular carcinoma (HCC). However, the predictors of clinical response and prognosis have not been established. Here, we retrospectively investigated the predictors for therapeutic response and clinical prognosis of Dur/Tre therapy.

METHODS

This retrospective single-center study, which included 30 patients, aimed to evaluate predictors of treatment efficacy of Dur/Tre therapy for advanced HCC. Factors associated with an objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and immune-mediated adverse events (imAEs) were examined. We especially focused on the initial change in peripheral lymphocyte count at 2 weeks after Dur/Tre introduction from baseline (Δlymphocyte).

RESULTS

Seventeen patients (56.7%) diagnosed with HCC BCLC stage C were enrolled. The median observational period was 11 months. The ORR and disease control rate (DCR) were 30.0% and 53.3%, respectively. The median PFS was 3.7 months and OS was not reached. The high Δlymphocyte was an independent predictor of objective response (hazard ratio [HR], 1.004; p = 0.016). The high Δlymphocyte (above +245/µL) was an independent predictive factor for better PFS (HR, 0.308; 95% CI, 0.095-0.998; p = 0.049), and the median PFS was significantly prolonged in the high Δlymphocyte (above +245/µL) compared to low Δlymphocyte (less than +245/µL) (not reached vs. 1.96 months, log-rank p = 0.003).

CONCLUSIONS

In Dur/Tre therapy, the early increase in peripheral blood lymphocyte count was useful for predicting clinical response and prognosis.

COPS5 Triggers Ferroptosis Defense by Stabilizing MK2 in Hepatocellular Carcinoma

Sorafenib, which is proven to serve as a potent ferroptosis inducer, is used as a first-line treatment for patients with advanced hepatocellular carcinoma (HCC), but it has limited clinical benefits, mainly due to drug resistance. Herein, using genome-wide CRISPR/Cas9 knockout screening and multiple functional studies, this work identifies COP9 signalosome subunit 5 (COPS5) as a driver of sorafenib resistance and a suppressor of ferroptosis in HCC. Consistently, the amplification and overexpression of COPS5 are frequently observed in clinical HCC samples, which are associated with poor patient prognosis and might predict patient response to sorafenib therapy. Mechanistically, COPS5 stabilized mitogen-activated protein kinase 2 (MK2) through deubiquitination and, in turn, induced the activation of heat shock protein beta-1 (HSPB1), a ferroptosis repressor, thereby protecting HCC cells from ferroptosis and consequently leading to sorafenib resistance and tumor progression, while its own expression could be induced by sorafenib treatment via activating transcription factor 4 (ATF4)-activated transcription. Furthermore, pharmacological inhibition of COPS5/MK2 synergize with sorafenib to induce ferroptosis and suppress HCC progression. This data reveals the crucial role of COPS5 in triggering ferroptosis defense and sorafenib resistance through the activation of the MK2-HSPB1 axis in HCC and highlights the potential of targeting COPS5/MK2 combined with sorafenib as a promising strategy for treating HCC.

Antisense-mediated exon skipping targeting EZH2 suppresses tumor growth in a xenograft mouse model of hepatocellular carcinoma

Enhancer of zeste homolog 2 (EZH2) catalyzes trimethylation of histone H3 at lysine 27 (H3K27me3), which promotes heterochromatin formation and gene silencing. Expression of EZH2 is frequently elevated in various malignancies, including hepatocellular carcinoma (HCC). Silencing of EZH2 has been pursued as a promising strategy to halt cancer progression. Here, we identified antisense oligonucleotides (ASOs) that efficiently silence EZH2 through promoting skipping of its exon 14, an exon encoding part of the essential CXC domain, increasing production of an internally shortened isoform that exerts dominant negative effect on the full-length EZH2. A lead ASO, hybridizing to an exonic splicing enhancer element bound by SRSF3, robustly promoted exon 14 skipping not only in cultured human HCC cell lines but also in mouse peripheral tissues after systemic administration, leading to dramatic reduction of EZH2 and H3K27me3 levels. The lead ASO potently inhibited HCC cell proliferation through multiple mechanisms including enhanced apoptosis, cell-cycle arrest, and reversed epithelial-mesenchymal transition, which is likely attributable to the suppression of diverse cancer-related pathways. In an orthotopic xenograft HCC mouse model, ASO treatment repressed tumor growth, improved tissue phenotype, and extended the median survival. Our data highlight therapeutic potential of the lead exon-skipping ASO in treating HCC.

Reversal of sorafenib resistance in hepatocellular carcinoma by curcumol: insights from network pharmacology, molecular docking, and experimental validation

Background

Curcumol, a bioactive sesquiterpenoid extracted from traditional Chinese medicine (TCM), has demonstrated potential in overcoming tumor drug resistance. However, its mechanisms in reversing drug resistance, particularly in hepatocellular carcinoma (HCC) resistant to sorafenib, are not yet fully elucidated. This study aims to explore the molecular mechanisms by which curcumol reverses sorafenib resistance in HCC using a combination of network pharmacology, molecular docking, and in vivo and in vitro experiments.

Methods

We identified curcumol targets and genes associated with sorafenib-resistant HCC, resulting in a set of overlapping targets. These intersection targets underwent enrichment analysis using DAVID, and a protein-protein interaction (PPI) network was constructed via the STRING database and Cytoscape. Molecular docking confirmed the binding of curcumol to core targets. In vitro assays, including CCK-8, colony formation assay, apoptosis detection, wound healing, and Transwell assays, evaluated curcumol's effects on sorafenib-resistant HCC cells. Western blotting assessed the impact on PI3K/AKT and JAK/STAT3 signaling pathways. Additionally, a sorafenib-resistant HCC xenograft mouse model was established to observe the in vivo efficacy of curcumol combined with sorafenib.

Results

We identified 117 potential targets for curcumol in reversing sorafenib resistance in HCC. Among them, five core targets-ALB, STAT3, HSP90AA1, HSP90AB1, and SRC-showed strong binding affinity with curcumol. KEGG pathway analysis of the intersecting genes highlighted significant involvement of the PI3K/AKT, JAK/STAT3, Ras, Rap1, HIF-1, FoxO, and mTOR signaling pathways. In vitro experiments revealed that curcumol significantly enhanced the sensitivity of sorafenib-resistant HCC cells to sorafenib, inhibiting cell proliferation, invasion, and migration while promoting apoptosis. In vivo studies further confirmed that curcumol combined with sorafenib effectively inhibited tumor growth in sorafenib-resistant HCC models.

Conclusion

This study provides compelling evidence that curcumol can reverse sorafenib resistance in HCC by modulating multiple signaling pathways, including PI3K/AKT and JAK/STAT3 pathways. Our findings suggest that curcumol holds promise as a novel therapeutic agent for overcoming drug resistance in HCC, offering a new avenue for clinical intervention.

Discovery and evaluation of novel Benzohydroxamic acid-indole derivatives as dual inhibitors of ADAM17 and HDAC2 with antitumor activity

Hepatocellular carcinoma (HCC) has garnered significant attention from researchers due to its high recurrence rate and invasive characteristics. The design of drugs with dual-target combined effects represents a promising strategy in cancer treatment. Our observations suggest that ADAM17 and HDAC may inhibit the unfavorable prognostic signaling pathway Notch1 in HCC through distinct mechanisms, thereby suppressing tumor cell proliferation and metastasis. Consequently, this study utilized the ADAM17 inhibitor ZLDI-8 as a lead compound and developed a series of dual ADAM17/HDAC2 inhibitors by integrating strategies such as backbone leaping and pharmacophore fusion. We assessed the anti-hepatocellular carcinoma activity of these compounds, focusing on their anti-proliferative, pro-apoptotic, and anti-metastatic properties. Notably, ZSNI-21 effectively inhibited the proliferation of Bel-7402 cells and demonstrated significant anti-metastatic capabilities against HCC-LM3 cells, with its targeting confirmed. Additionally, its in vivo safety was validated. To date, there have been no reports on dual ADAM17/HDAC2 inhibitors, marking this as a novel endeavor.

Combination locoregional and systemic therapies in hepatocellular carcinoma

Locoregional therapies play a fundamental role in the treatment of patients with early and intermediate and locally advanced hepatocellular carcinomas. With encouraging recent advances in immunotherapy-based systemic therapies, locoregional therapies are being both promoted and challenged by new systemic therapy options. Combined locoregional and systemic therapies might enhance treatment outcomes compared with either option alone. This Series paper summarises the existing data on locoregional and systemic therapies for hepatocellular carcinoma, and discusses evidence from studies investigating their combination with a focus on their synergistic efficacy and safety.

Survival Outcomes Associated With Radiological Progressive Disease Subtypes in Patients With Atezolizumab and Bevacizumab-Treated HCC

BACKGROUND AND AIM

To assess the relationship between survival outcomes and subtypes of radiological progressive disease (PD) in patients with hepatocellular carcinoma (HCC) treated with atezolizumab and bevacizumab (Atezo/Bev).

METHODS

A total of 462 patients with Atezo/Bev-treated HCC diagnosed with radiological PD during follow-up were enrolled. PD was classified into three categories: progression or emergence of intrahepatic lesions (PD-IH), macroscopic vascular invasion (PD-MVI), and extrahepatic spread lesions (PD-EHS). We defined PD-multiple as the presence of two or more PD categories. Subsequent analysis was categorized into the "PD-IH or PD-EHS" and "PD-MVI or PD-multiple" groups.

RESULTS

The median progression-free survival (PFS) durations for patients with PD-IH, PD-MVI, PD-EHS, and PD-multiple were 5.3, 3.2, 3.9, and 3.5 months (p = 0.003). Patients with "PD-IH or PD-EHS" and "PD-MVI or PD-multiple" had median PFS of 5.2 and 3.5 months (p < 0.001). Median overall survival (OS) for PD-IH, PD-MVI, PD-EHS, and PD-multiple was 22.3, 15.1, 19.4, and 14.2 months (p = 0.002). The OS for patients with "PD-IH or PD-EHS" and "PD-MVI or PD-multiple" was 21.4 and 14.5 months (p < 0.001). Multivariate analysis demonstrated that ECOG-PS ≥ 1 (hazard ratio (HR), 1.508), α-fetoprotein levels ≥ 100 ng/mL (HR, 1.293), albumin-bilirubin grade ≥ 2 (HR, 1.573), liver cirrhosis (HR, 1.361), and PD subtypes PD-MVI or PD-multiple (HR, 1.735) were independently associated with OS.

CONCLUSIONS

Patients with HCC undergoing Atezo/Bev treatment, diagnosed with PD-multiple (not solely based on IH or EHS) or PD-MVI, experienced poor prognosis, specifically in terms of OS.

Comprehensive profiling of lipid metabolic reprogramming expands precision medicine for HCC

BACKGROUND AND AIMS

Liver HCC is the second leading cause of cancer-related deaths worldwide. The heterogeneity of this malignancy is driven by a wide range of genetic alterations, leading to a lack of effective therapeutic options. In this study, we conducted a systematic multi-omics characterization of HCC to uncover its metabolic reprogramming signature.

APPROACH AND RESULTS

Through a comprehensive analysis incorporating transcriptomic, metabolomic, and lipidomic investigations, we identified significant changes in metabolic pathways related to glucose flux, lipid oxidation and degradation, and de novo lipogenesis in HCC. The lipidomic analysis revealed abnormal alterations in glycerol-lipids, phosphatidylcholine, and sphingolipid derivatives. Machine-learning techniques identified a panel of genes associated with lipid metabolism as common biomarkers for HCC across different etiologies. Our findings suggest that targeting phosphatidylcholine with saturated fatty acids and long-chain sphingolipid biosynthesis pathways, particularly by inhibiting lysophosphatidylcholine acyltransferase 1 ( LPCAT1 ) and ceramide synthase 5 ( CERS5 ) as potential therapeutic strategies for HCC in vivo and in vitro. Notably, our data revealed an oncogenic role of CERS5 in promoting tumor progression through lipophagy.

CONCLUSIONS

In conclusion, our study elucidates the metabolic reprogramming nature of lipid metabolism in HCC, identifies prognostic markers and therapeutic targets, and highlights potential metabolism-related targets for therapeutic intervention in HCC.

New Scenarios in Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND AND AIMS

Despite liver transplantation (LT) is considered the optimal treatment for hepatocellular carcinoma (HCC), particularly in patients with impaired liver function, the shortage of donors has forced the application of very restrictive criteria for selecting ideal candidates for whom LT can offer the best outcome. With the evolving LT landscape due to the advent of direct-acting antivirals (DAAs) and the steady increase in donors, major efforts have been made to expand the transplant eligibility criteria for HCC. In addition, the emergence of immune checkpoint inhibitors (ICIs) for the treatment of HCC, with demonstrated efficacy in earlier stages, has revolutionized the therapeutic approach for these patients, and their integration in the setting of LT is challenging. Management of immunological compromise from ICIs, including the wash-out period before LT and post-LT immunosuppression adjustments, is crucial to balance the risk of graft rejection against HCC recurrence. Additionally, the effects of increased immunosuppression on non-hepatic complications must be understood to prevent them from becoming obstacles to long-term OS.

METHODS AND RESULTS

In this review, we will evaluate the emerging evidence and its implications for the future of LT in HCC. Addressing these novel challenges and opportunities, while integrating the current clinical evidence with predictive algorithms, would ensure a fair balance between individual patient needs and the overall population benefit in the LT system.