Hepatocellular carcinoma in non-cirrhotic liver: A comprehensive review

Controversies of Direct-Acting Antivirals in Hepatocellular Carcinoma

Therapy for chronic hepatitis C virus infection with direct-acting antiviral agents (DAAs) has been highly successful in achieving sustained virological response (SVR) with associated improvements in liver dysfunction, liver-related mortality, and transplant-free survival. There is a high risk of hepatocellular carcinoma (HCC) with an annual incidence of 2% to 4% in patients with cirrhosis. Following DAAs treatment and achievement of SVR, the risk of incident and recurrent HCC drops significantly over time, with risk associated with demographic and liver disease-related factors. Several risk factors have been described including age, male, diabetes comorbidities, alcohol abuse, hepatitis B virus or human immunodeficiency virus-coinfection, and advanced liver disease or increased liver fibrosis. Recurrence risk after DAA therapy has been associated with baseline tumor burden, with increased risk with larger lesion(s), multifocal disease, elevated alpha-fetoprotein level, treatment type (curative vs palliative), and shorter interval between HCC complete response and DAA initiation. Overall, due to the heterogeneity among individual patient data and lack of adequately controlled data, there are no conclusive statements that can be drawn that DAAs exposure is directly associated with HCC occurrence or recurrence. However, the best available data suggest a decreased risk of incident HCC with DAA therapy and no increased risk of recurrence with DAAs after complete tumor response.

Clinical Characteristics and Survival of Hepatocellular Carcinoma: Insights from Single-Centre Experience in Saudi Arabia

Background Hepatocellular carcinoma (HCC) represents the most common primary liver malignancy, with a high fatality rate. Relatively, Saudi Arabia has a high incidence of HCC, which is detected in later stages with a poor prognosis. This study aims to investigate the patterns, outcomes, and mortality predictors of HCC in Saudi Arabia. Method A retrospective study from April 2018 to June 2022 included patients with HCC who were diagnosed and managed at the Najran Oncology Center, Saudi Arabia. Through our cancer registry, the patients' clinical, laboratory, radiological, and survival profiles were extracted and analyzed to assess factors associated with mortality using a univariate analysis. The overall survival was calculated by the Kaplan-Meier method. Results The study involved 52 patients with an average age of 74.6 years, predominantly male (the male-to-female ratio is 2.25:1). Viral infections were the primary cause of liver disease in 40.3% (n=21) of patients. At diagnosis, the Child-Pugh class distribution included 23.1% (n=12) patients in class A, 36.5% (n=19) patients in class B, and 40.4% (n=21) patients in class C. Uninodular tumors with ≤50% liver extension were observed in 65.4% (n=34) of cases, and 30.8% (n=16) had portal vein thrombosis. Elevated alpha-fetoprotein (AFP) levels were noted in 48.1% (n=25) of patients, with 23.1% (n=12) exceeding 400 ng/mL. Curative resection was performed in 32.7% (n=17) of patients. The mean survival time was 23±11.8 months (median of 22.5 months, minimum of six, and maximum of 49 months). Relapse occurred in seven (13.5%) cases, while new metastasis occurred in 20 (38.5%) cases. During the study period, 26 (50.0%) patients died. The main cause of death was disease progression in 15 (28.8%) patients. Univariate analysis showed that AFP>400 ng/mL (OR: 4.68; 95% CI: 1.87-11.66, p=0.001), presence of relapse (OR: 0.16; 95% CI: 0.03-0.78, p=0.023), abdominal ascites (OR: 3.38; 95% CI: 1.25-9.14, p=0.016), advanced the Cancer of the Liver Italian Program (CLIP) score (OR: 0.60; 95% CI: 0.41-0.88, p=0.009) were associated with higher mortality rate and were statistically significant. Conclusion Most cases of HCC in our patients were attributed to viral hepatitis, with the majority having liver cirrhosis. Higher AFP (>400 ng/mL), relapse, abdominal ascites, and a higher cancer CLIP score were associated with poorer outcomes. Targeted screening and health education should be advocated; in addition, social determinants should be proactively addressed.

Gene expression signatures of stepwise progression of Hepatocellular Carcinoma

The molecular pathogenesis of Hepatocellular Carcinoma (HCC) is a complex process progressing from premalignant stages to cancer in a stepwise manner. Mostly, HCC is detected at advanced stages, leading to high mortality rates. Hence, characterising the molecular underpinnings of HCC from normal to cancer state through precancerous state may help in early detection and improve its prognosis and treatment. In this work, we analysed the transcriptomic profile of tumour and premalignant samples from HCC or chronic liver disease patients, who had undergone either total or partial hepatectomy. The normal samples from patients with metastatic cancer/polycystic liver disease/ cholangiocarcinoma were also included. A gene co-expression network approach was applied to identify hierarchical changes: modules, pathways, and genes related to different trajectories of HCC and patient survival. Our analysis shows that the progression from premalignant conditions to tumour is accompanied by differences in the downregulation of genes associated with HNF4A activity and the immune system and upregulation of cell cycle genes, bringing about variability in patient outcomes. However, an increase in immune and cell cycle activity is observed in premalignant samples. Interestingly, co-expression modules and genes from premalignant stages are associated with survival. THBD, a classical marker for dendritic cells, is a predictor of survival at the premalignant stage. Further, genes linked to microtubules, kinetochores, and centromere are altered in both premalignant and tumour conditions and are associated with survival. Our analysis revealed a three-way molecular axis of liver function, immune pathways, and cell cycle driving HCC pathogenesis.

Ultrasound Attenuation Imaging vs MRI-PDFF, Echogenicity and Liver Function for Assessing Degree of Steatosis in NAFLD and Non-NAFLD Patients

ABSTRACT

Nonalcoholic fatty liver disease (NAFLD) is a primary cause of parenchymal liver disease globally. There are currently several methods available to test the degree of steatosis in NAFLD patients, but all have drawbacks that limit their use.The objective of this study is to determine if a new technique, ultrasound (US) attenuation imaging (ATI), correlates with magnetic resonance proton density fat fraction imaging and hepatic echogenicity as seen on gray scale US imaging.Fifty-four patients were recruited at the University of Washington Medical Center from individuals who had already been scheduled for hepatic US or magnetic resonance imaging (MRI). All participants then underwent both hepatic MRI proton density fat fraction and US. Ultrasound images were then evaluated using ATI with 2 observers who individually determined relative grayscale echogenicity.Analysis showed positive correlation between ATI- and MRI-determined fat percentage in the case group (Spearman correlation: 0.50; P = 0.015). Furthermore, participants with NAFLD tended to have a higher ATI than controls (median: 0.70 vs 0.54 dB/cm/MHz; P < 0.001).This study demonstrates that US ATI combined with grayscale imaging is an effective way of assessing the degree of steatosis in patients with moderate to severe NAFLD.

A Review of Resection and Surgical Ablation for Primary and Secondary Liver Cancers

The surgical management of primary and secondary liver tumors is constantly evolving. Patient selection, particularly with regard to determining resectability, is vital to the success of programs directed toward invasive treatments of liver tumors. Particular attention should be paid toward determining whether patients are best served with surgical resection or ablative therapies. A multidisciplinary approach is necessary to provide optimal care to patients with liver malignancy.

Radiofrequency ablation is an inferior option to liver resection for solitary hepatocellular carcinoma ≤ 5 cm without cirrhosis: A population-based study with stratification by tumor size

BACKGROUND

About 10%-20% of all individuals who develop hepatocellular carcinoma (HCC) do not have cirrhosis. Comparisons are rarely reported regarding the effectiveness of radiofrequency ablation (RFA) and liver resection (LR) in survival of HCC without cirrhosis and stratification by tumor size ≤ 5 cm.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database and identified 1505 patients with a solitary HCC tumor ≤ 5 cm who underwent RFA or LR during 2004-2015. Patients were classified into non-cirrhosis and cirrhosis groups and each group was categorized into three subgroups, according to tumor size (≤ 30 mm, 31-40 mm, 41-50 mm).

RESULTS

In patients without cirrhosis, LR showed better 5-year HCC cancer-specific survival than RFA in all tumor size subgroups (≤ 30 mm: 82.51% vs. 56.42%; 31-40 mm: 71.31% vs. 46.83%; 41-50 mm: 74.7% vs. 37.5%; all P < 0.05). Compared with RFA, LR was an independent protective factor for HCC cancer-specific survival in multivariate Cox analysis [≤ 30 mm: hazard ratio (HR) = 0.533, 95% confidence interval (CI): 0.313-0.908; 31-40 mm: HR = 0.439, 95% CI: 0.201-0.957; 41-50 mm: HR = 0.382; 95% CI: 0.159-0.916; all P < 0.05]. In patients with cirrhosis, for both tumor size ≤ 30 mm and 31-40 mm groups, there were no significant survival differences between RFA and LR in multivariate analysis (all P > 0.05). However, in those with tumor size 41-50 mm, LR showed significantly better 5-year HCC cancer-specific survival than RFA in both univariate (54.72% vs. 23.06%; P < 0.001) and multivariate analyses (HR = 0.297; 95% CI: 0.136-0.648; P = 0.002).

CONCLUSIONS

RFA is an inferior treatment option to LR for patients without cirrhosis who have a solitary HCC tumor ≤ 5 cm.

From Non-Alcoholic Steatohepatitis (NASH) to Hepatocellular Carcinoma (HCC): Epidemiology, Incidence, Predictions, Risk Factors, and Prevention

Non-alcoholic fatty liver disease (NAFLD) affects up to a quarter of the adult population in many developed and developing countries. This spectrum of liver disease ranges from simple steatosis to non-alcoholic steatohepatitis (NASH) and cirrhosis. The incidence of NASH is projected to increase by up to 56% over the next 10 years. There is growing epidemiological evidence that NAFLD has become the fastest-growing cause of hepatocellular carcinoma (HCC) in industrialized countries. The annual incidence of HCC varies between patients with NASH cirrhosis and patients with noncirrhotic NAFLD. In this review, NAFLD/NASH-associated HCC will be described, including its epidemiology, risk factors promoting hepatocarcinogenesis, and management of HCC in patients with obesity and associated metabolic comorbidities, including preventive strategies and therapeutic approaches to address this growing problem.

Hepatocellular Carcinoma in Non-Fibrotic Liver: A Narrative Review

Hepatocellular carcinoma (HCC) in a non-fibrotic liver (F0) is considered to be rare, and there is a marked paucity of studies in the literature on this HCC type. A review of the literature shows some important clinical and tumor characteristics: (a) it occurs mainly in young female and elder male patients; (b) clinically, under normal hepatic function, alpha-fetoprotein level is often normal, and there are no risk factors; (c) associated with metabolic disease; (d) macroscopically, single large lesions are noted; and (e) microscopically, the lesions are well-differentiated and encapsulated. Radiological imaging results are straightforward, showing arterial hyperenhancement and later wash-out. The combined use of B-mode and contrast-enhanced (CE) ultrasound (US) is the most reliable and cost-effective diagnostic method. Few peri-and post-operative complications are noted and 5-year survival is not inferior to patients with HCC on fibrosis liver despite the lesion's large size. Most clinicians believe that HCC is unlikely to occur if patients have no symptoms and normal hepatic function. Although detailed clinical data are very limited, we expect that this review will help to improve the clinical management of HCC in non-fibrotic livers.

Upregulation of lncRNA PTOV1-AS1 in hepatocellular carcinoma contributes to disease progression and sorafenib resistance through regulating miR-505

Increasing evidence has displayed the vital influence of lncRNA in tumorigenesis and chemoresistance of cancer treatment. This study investigated the function of lncRNA PTOV1-AS1 in hepatocellular carcinoma (HCC) and its role in sorafenib resistance. The relative expression of lncRNA and miRNA was measured by RT-qPCR. The cellular activities including cell proliferation and invasion were explored by CCK-8 and Transwell assays. Bioinformatics analysis and dual-luciferase reporter assay were used to predict the targeting miRNA of PTOV1-AS1. The expression levels of PTOV1-AS1 were higher in HCC tissues than that in the normal tissues and associated with patients' overall survival. Knockdown of PTOV1-AS1 decreased cell proliferation rate and invasion number. After treatment with different concentrations of sorafenib, the sorafenib-resistant hepatoma cells were conducted. PTOV1-AS1 expression levels were increased in HepG2-SR and Huh7-SR cells. PTOV1-AS1 knockdown repressed the proliferation, invasion, and drug resistance of sorafenib-resistant HCC cells by targeting the expression of miR-505. In conclusion, the expression of PTOV1-AS1 is increased in HCC and sorafenib-resistance HCC cells, as well as is associated with patients' prognosis. Inhibition of PTOV1-AS1 expression can reduce the resistance of sorafenib-resistant HCC cells, which may play a role by targeting the negative regulation of miR-505 expression.

Artificial intelligence-based prediction of molecular and genetic markers for hepatitis C-related hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) is the main cause of mortality from cancer globally. This paper intends to classify public gene expression data of patients with Hepatitis C virus-related HCC (HCV+HCC) and chronic HCV without HCC (HCV alone) through the XGboost approach and to identify key genes that may be responsible for HCC.

Methods

The current research is a retrospective case-control study. Public data from 17 patients with HCV+HCC and 35 patients with HCV-alone samples were used in this study. An XGboost model was established for the classification by 10-fold cross-validation. Accuracy (AC), balanced accuracy (BAC), sensitivity, specificity, positive predictive value, negative predictive value, and F1 score were utilized for performance assessment.

Results

AC, BAC, sensitivity, specificity, positive predictive value, negative predictive value, and F1 scores from the XGboost model were 98.1, 97.1, 100, 94.1, 97.2, 100, and 98.6%, respectively. According to the variable importance values from the XGboost, the HAO2, TOMM20, GPC3, and PSMB4 genes can be considered potential biomarkers for HCV-related HCC.

Conclusion

A machine learning-based prediction method discovered genes that potentially serve as biomarkers for HCV-related HCC. After clinical confirmation of the acquired genes in the following medical study, their therapeutic use can be established. Additionally, more detailed clinical works are needed to substantiate the significant conclusions in the current study.

Protein kinases: The key contributors in pathogenesis and treatment of nonalcoholic fatty liver disease-derived hepatocellular carcinoma

Protein kinases (PKs), one of the largest protein families, can be further divided into different groups based on their substrate or structure and function. PKs are important signaling messengers in numerous life activities, including cell metabolism, proliferation, division, differentiation, senescence, death, and disease. Among PK-related diseases, nonalcoholic fatty liver disease (NAFLD) has been recognized as a major contributor to hepatocellular carcinoma (HCC) and liver transplantation. Unfortunately, NAFLD-derived HCC (NAFLD-HCC) has poor prognosis because it is typically accompanied by older age, multiple metabolic syndromes, obstacles in early-stage diagnosis, and limited licensed drugs for treatment. Accumulating evidence suggests that PKs are implicated in the pathogenic process of NAFLD-HCC, via aberrant metabolism, hypoxia, autophagy, hypoxia, gut microbiota dysbiosis, and/or immune cell rearrangement. The present review aims to summarize the latest research advances and emphasize the feasibility and effectiveness of therapeutic strategies that regulate the expression and activities of PKs. This might yield clinically significant effects and lead to the design of novel PK-targeting therapies. Furthermore, we discuss emerging PK-based strategies for the treatment of other malignant diseases similar to NAFLD-HCC.

The number of hepatocellular carcinoma foci as predictor of poor response to tumor-directed therapies in patients awaiting liver transplantation: a prospective cohort study

BACKGROUND AND AIMS

Tumor-directed therapies (TDTs) are a constitutive part of hepatocellular carcinoma (HCC) treatment in patients awaiting liver transplantation (LT). While most patients benefit from TDTs as a bridge to LT, some patients drop out from the waiting list due to tumor progression. The study aimed to determine the risk factors for poor treatment outcome following TDTs among patients with HCC awaiting LT.

METHODS

A total of 123 patients with HCC were evaluated with 92 patients meeting Milan Criteria enrolled in the prospective cohort study. Tumor response was evaluated using the modified Response Evaluation Criteria for Solid Tumors for HCC 1 month after the procedure. The risk factors for progressive disease (PD) and dropout were evaluated.

RESULTS

After TDT, 55 patients (59.8%) achieved complete or partial response (44.6% and 15.2% respectively), 17 patients (18.5%) had stable disease, and 20 patients (21.7%) were assessed as PD. Multivariate analysis revealed a significant and independent association between the number of HCC foci and PD ( P  = 0.03, OR = 2.68). There was no statistically significant association between treatment response and demographics, MELDNa score, pre-and post-treatment alpha-fetoprotein (AFP), cumulative tumor burden the largest tumor size, or TDT modality. PD was the major cause of dropout in our cohort. Pre-treatment AFP levels ≥200 ng/ml had a strong association with dropout after TDTs ( P  = 0.0005).

CONCLUSION

This study demonstrated the presence of multifocal HCC is the sole prognostic factor for PD following TDTs in HCC patients awaiting LT. We recommend prioritizing patients with multifocal HCC within Milan criteria by exception points for LT to improve the dropout rate.

SEER-based risk stratification system for patients with primary non-cirrhotic liver cancer

BACKGROUND

Little research has been done on the factors affecting the survival of patients with non-cirrhotic hepatocellular carcinoma (HCC-NCL). Our aim was to develop and validate a nomogram and a new risk stratification system that can evaluate overall survival (OS) in HCC-NCL patients.

METHODS

We retrospectively analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2019 to study HCC-NCL patients. The patients were randomly split into training and validation groups at a 7:3 ratio and subjected to single-factor and multi-factor COX regression analysis. We then developed a nomogram and evaluated its accuracy and clinical validity using time-dependent ROC, DCA, and calibration curves. We compared the nomogram with the AJCC staging system by calculating C-index, NRI, and IDI. Finally, we used Kaplan-Meier curves to compare the nomogram and AJCC staging. These analyses were performed without altering the original intended meaning.

RESULTS

AFP levels, surgical intervention, T-stage, tumor size, and M-stage were independent prognostic indicators for overall survival among the HCC-NCL population studied. We developed a nomogram based on these factors, and time-dependent ROC, calibration curves, DCA analyses, and C-index proved its accuracy. Compared to the AJCC staging system, the nomogram showed better prognostic accuracy through time-dependent ROC, DCA analyses, C-index, NRI, IDI, and Kaplan-Meier curves.

CONCLUSION

We have developed and validated a survival nomogram applicable to HCC-NCL patients, with risk stratification. Our nomogram offers personalized treatment and management options superior to those provided by the AJCC staging system.

Hypermethylation of DNA Methylation Markers in Non-Cirrhotic Hepatocellular Carcinoma

Aberrant DNA methylation changes have been reported to be associated with carcinogenesis in cirrhotic HCC, but DNA methylation patterns for these non-cirrhotic HCC cases were not examined. Therefore, we sought to investigate DNA methylation changes on non-cirrhotic HCC using reported promising DNA methylation markers (DMMs), including HOXA1, CLEC11A, AK055957, and TSPYL5, on 146 liver tissues using quantitative methylation-specific PCR and methylated DNA sequencing. We observed a high frequency of aberrant methylation changes in the four DMMs through both techniques in non-cirrhotic HCC compared to cirrhosis, hepatitis, and benign lesions (p < 0.05), suggesting that hypermethylation of these DMMs is specific to non-cirrhotic HCC development. Also, the combination of the four DMMs exhibited 78% sensitivity at 80% specificity with an AUC of 0.85 in discriminating non-cirrhotic HCC from hepatitis and benign lesions. In addition, HOXA1 showed a higher aberrant methylation percentage in non-cirrhotic HCC compared to cirrhotic HCC (43.3% versus 13.3%, p = 0.039), which was confirmed using multivariate linear regression (p < 0.05). In summary, we identified aberrant hypermethylation changes in HOXA1, CLEC11A, AK055957, and TSPYL5 in non-cirrhotic HCC tissues compared to cirrhosis, hepatitis, and benign lesions, providing information that could be used as potentially detectable biomarkers for these unusual HCC cases in clinical practice.

Laparoscopic right posterior sectionectomy for a large hepatocellular carcinoma close to inferior vena cava

Approximately 20% of hepatocellular carcinomas (HCC) occur in noncirrhotic livers. Resection may be considered for patients with HCC, provided sufficient future liver remnant is available, regardless of the tumor size. Tumors located posteriorly near the right hepatic vein (RHV), or inferior vena cava can be managed through anterior or caudal approaches. RHV is typically conserved during right posterior sectionectomy. When a large posteriorly placed tumor causes chronic compression on RHV, the right anterior section drainage is redirected preferentially to the middle hepatic vein. The division of RHV in such instances does not cause congestion of segments 8 and 5. The technical complexity of laparoscopic right posterior sectionectomy arises from the large transection surface, positioned horizontally. We describe in this multimedia article, a case of large HCC in segments 6 and 7, which was successfully treated using laparoscopic anatomic right posterior sectionectomy.

Contribution of viral and bacterial infections to senescence and immunosenescence

Cellular senescence is a key biological process characterized by irreversible cell cycle arrest. The accumulation of senescent cells creates a pro-inflammatory environment that can negatively affect tissue functions and may promote the development of aging-related diseases. Typical biomarkers related to senescence include senescence-associated β-galactosidase activity, histone H2A.X phosphorylation at serine139 (γH2A.X), and senescence-associated heterochromatin foci (SAHF) with heterochromatin protein 1γ (HP-1γ protein) Moreover, immune cells undergoing senescence, which is known as immunosenescence, can affect innate and adaptative immune functions and may elicit detrimental effects over the host's susceptibility to infectious diseases. Although associations between senescence and pathogens have been reported, clear links between both, and the related molecular mechanisms involved remain to be determined. Furthermore, it remains to be determined whether infections effectively induce senescence, the impact of senescence and immunosenescence over infections, or if both events coincidently share common molecular markers, such as γH2A.X and p53. Here, we review and discuss the most recent reports that describe cellular hallmarks and biomarkers related to senescence in immune and non-immune cells in the context of infections, seeking to better understand their relationships. Related literature was searched in Pubmed and Google Scholar databases with search terms related to the sections and subsections of this review.

DNA methylation markers in the detection of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and has a poor prognosis. Epigenetic modification has been shown to be deregulated during HCC development by dramatically impacting the differentiation, proliferation, and function of cells. One important epigenetic modification is DNA methylation during which methyl groups are added to cytosines without changing the DNA sequence itself. Studies found that methylated DNA markers can be specific for detection of HCC. On the basis of these findings, the utility of methylated DNA markers as novel biomarkers for early-stage HCC has been measured in blood, and indeed superior sensitivity and specificity have been found in several studies when compared to current surveillance methods. However, a variety of factors currently limit the immediate application of these exciting biomarkers. In this review, we provide a detailed rationalisation of the approach and basis for the use of methylation biomarkers for HCC detection and summarise recent studies on methylated DNA markers in HCC focusing on the importance of the aetiological cause of liver disease in the mechanisms leading to cancer.

Hepatocellular Carcinoma Genetic Classification

ABSTRACT

Hepatocellular carcinoma (HCC) represents a significant global burden, with management complicated by its heterogeneity, varying presentation, and relative resistance to therapy. Recent advances in the understanding of the genetic, molecular, and immunological underpinnings of HCC have allowed a detailed classification of these tumors, with resultant implications for diagnosis, prognostication, and selection of appropriate treatments. Through the correlation of genomic features with histopathology and clinical outcomes, we are moving toward a comprehensive and unifying framework to guide our diagnostic and therapeutic approach to HCC.

Risk factors associated with late hepatocellular carcinoma detection in patients undergoing regular surveillance

Hepatocellular carcinoma (HCC) has a very poor prognosis with a 5-year survival rate of < 20%; hence, early diagnosis is crucial. Despite regular checkups for high-risk groups of HCC, there are a few cases in which it is discovered as a late-stage HCC. Therefore, this study aimed to investigate the characteristics of patients with delayed HCC detection during regular surveillance. Between January 2010 and December 2020, we analyzed patients with newly diagnosed HCCs who underwent HCC surveillance by ultrasound or computed tomography scan at least twice and were followed up for more than 1 year for hepatitis B, hepatitis C, and chronic liver disease. The mean age of 223 HCC patients was 70 years, of which 152 were male, accounting for 68.1%. Among them, 196 patients (87%) were diagnosed with Barcelona clinic liver cancer stage 0 or A, while 27 (13%) were diagnosed with Barcelona clinic liver cancer stages B and C. When classified according to the TNM criteria, 154 patients (69%) were in stage I, and 69 (31%) were in stage II or higher. Multivariate analysis was performed to identify the risk factors for patients diagnosed with late-stage HCC. The Child-Turcotte-Pugh (CTP) score was identified as a highly significant factor (P = .002, HR 1.547, 95% CI 1.177-2.032), whereas the presence of cirrhosis, body mass index, and sex had no significant effect. We found that in patients with chronic liver disease who were screened regularly, those with higher CTP scores were more likely to be diagnosed with HCC in the late-stages. Therefore, although the presence of cirrhosis is also important for HCC surveillance, careful attention is needed in patients with high CTP scores.

Applications of Dynamic Contrast-Enhanced Ultrasound in Differential Diagnosis of Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma in Non-cirrhotic Liver

OBJECTIVE

The aim of the work described here was to investigate the value of dynamic contrast enhanced ultrasound (DCE-US) and quantitative analysis in pre-operative differential diagnosis of intrahepatic cholangiocarcinoma (ICC) and hepatocellular carcinoma (HCC) in non-cirrhotic liver.

METHODS

In this retrospective study, patients with histopathologically proven ICC and HCC lesions in non-cirrhotic liver were included. All patients underwent contrast-enhanced ultrasound (CEUS) examinations with an Acuson Sequoia unit (Siemens Healthineers, Mountain View, CA, USA) unit or LOGIQ E20 (GE Healthcare, Milwaukee, WI, USA) within 1 wk before surgery. SonoVue (Bracco, Milan, Italy) was used as the contrast agent. B-mode ultrasound (BMUS) features and CEUS enhancement patterns were analyzed. DCE-US analysis was performed by VueBox software (Bracco). Two regions of interest (ROIs) were set in the center of the focal liver lesions and their surrounding liver parenchyma. Time-intensity curves (TICs) were generated, and quantitative perfusion parameters were obtained and compared between the ICC and HCC groups using the Student t-test or Mann-Whitney U-test.

RESULTS

From November 2020 to February 2022, patients with histopathologically confirmed ICC (n = 30) and HCC (n = 24) lesions in non-cirrhotic liver were included. During the arterial phase (AP) of CEUS, ICC lesions exhibited heterogeneous hyperenhancement (13/30, 43.3%), heterogeneous hypo-enhancement (2/30, 6.7 %) and rim-like hyperenhancement (15/30, 50.0%), whereas all HCC lesions exhibited heterogeneous hyperenhancement (24/24, 100.0%) (p < 0.05). Subsequently, most of the ICC lesions exhibited AP wash-out (83.3%, 25/30), whereas a few cases exhibited wash-out in the portal venous phase (PVP) (15.7%, 5/30). In contrast, HCC lesions exhibited AP wash-out (41.7%, 10/24), PVP wash-out (41.7%, 10/24) and a small part of late phase wash-out (16.7%, 4/24) (p < 0.05). Compared with those of HCC lesions, TICs of ICCs revealed earlier and lower enhancement during the AP, faster decline during the PVP and reduced area under the curve. The combined area under the receiver operating characteristic curve (AUROC) of all significant parameters was 0.946, with 86.7% sensitivity, 95.8% specificity and 90.7% accuracy in differential diagnosis between ICC and HCC lesions in non-cirrhotic liver, which improved the diagnostic efficacy of CEUS (58.3% sensitivity, 90.0% specificity and 75.9% accuracy).

CONCLUSION

ICC and HCC lesions in non-cirrhotic liver might exhibit some overlap of CEUS features in diagnosis. DCE-US with quantitative analysis would be helpful in pre-operative differential diagnosis.

The future of hepatology

The field of hepatology has made impressive progress over its ~75 years of existence. Advances in understanding liver function and its dysregulation in disease, genetic determinants of disease, antiviral therapy, and transplantation have transformed the lives of patients. However, there are still significant challenges that require ongoing creativity and discipline, particularly with the emergence of fatty liver diseases, as well as managing autoimmune disease, cancer, and liver disease in children. Diagnostic advances are urgently needed to accelerate risk stratification and efficient testing of new agents with greater precision in enriched populations. Integrated, holistic care models should be extended beyond liver cancer to diseases like NAFLD with systemic manifestations or extrahepatic comorbidities such as cardiovascular disease, diabetes, addiction, and depressive disorders. To meet the growing burden of asymptomatic liver disease, the workforce will need to be expanded by incorporating more advanced practice providers and educating other specialists. The training of future hepatologists will benefit from incorporating emerging skills in data management, artificial intelligence, and precision medicine. Continued investment in basic and translational science is crucial for further progress. The challenges ahead are significant, but with collective effort, the field of hepatology will continue to make progress and overcome obstacles.

The possible role of Helicobacter pylori in liver diseases

According to previous studies, Helicobacter pylori infection is associated with liver disease. In order to better understand the risk of acquiring various liver diseases, we reviewed current knowledge on the impact of H. pylori on the onset, intensification, and progression of various liver diseases caused by the infection of H. pylori. It has been estimated that between 50 and 90% of people worldwide have been infected with H. pylori. The bacterium is mostly responsible for inflamed gastric mucosa, ulcers, and cancers associated with the gastric mucosa. Through the active antioxidant system in H. pylori, the bacteria can neutralize free radicals by synthesizing VacA, a toxin that causes cell damage and apoptosis. Furthermore, there is a possibility that CagA genes may play a role in cancer development. People who have been infected with H. pylori are likely to develop lesions in the skin, the circulation system, and the pancreas. Moreover, transferring blood from the stomach may allow H. pylori to colonize the liver. The bacterium worsened liver function during autoimmune inflammation, toxic injury, chronic HCV infection, chronic HBV infection, and liver cirrhosis. Increasing portal pressure, hyperammonemia, and esophageal varices may be associated with H pylori infection. As a result, it is crucial to diagnose and treat this infection in patients with H. pylori.

Hepatocellular Carcinoma and Non-Alcoholic Fatty Liver Disease: A Modern Context for an Ancient Disease

Hepatocellular Carcinoma (HCC) is a leading cause of cancer-related deaths worldwide [...].

Metastatic hepatocellular carcinoma of the oral cavity - A report of two cases

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide that is etiologically linked to a previous hepatitis B infection. We describe two cases of HCC metastasis to the oral cavity in 60- and 67-year-old male patients. The first case was a diffuse, hard swelling in the left body of the mandible. Histopathologic and immunohistochemical analysis was done, and a positive for CK7, CK19, HEPPAR and TTF and a negative for NAPSIN were found to be diagnostic of metastatic HCC. Subsequent examination of the serum alfa- fetoprotein (AFP) level showed a high value of 450 ng/ml, confirmatory of HCC. The second case was a pedunculated, reddish, mobile soft tissue growth on the retromolar region. Its macroscopic and histopathologic features themselves were confirmatory of HCC, and the elicited history was corroborant of metastasis.

Opportunities to address gaps in early detection and improve outcomes of liver cancer

Death rates from primary liver cancer (hepatocellular carcinoma [HCC]) have continued to rise in the United States over the recent decades despite the availability of an increasing range of treatment modalities, including new systemic therapies. Prognosis is strongly associated with tumor stage at diagnosis; however, most cases of HCC are diagnosed beyond an early stage. This lack of early detection has contributed to low survival rates. Professional society guidelines recommend semiannual ultrasound-based HCC screening for at-risk populations, yet HCC surveillance continues to be underused in clinical practice. On April 28, 2022, the Hepatitis B Foundation convened a workshop to discuss the most pressing challenges and barriers to early HCC detection and the need to better leverage existing and emerging tools and technologies that could improve HCC screening and early detection. In this commentary, we summarize technical, patient-level, provider-level, and system-level challenges and opportunities to improve processes and outcomes across the HCC screening continuum. We highlight promising approaches to HCC risk stratification and screening, including new biomarkers, advanced imaging incorporating artificial intelligence, and algorithms for risk stratification. Workshop participants emphasized that action to improve early detection and reduce HCC mortality is urgently needed, noting concern that many of the challenges we face today are the same or similar to those faced a decade ago and that HCC mortality rates have not meaningfully improved. Increasing the uptake of HCC screening was identified as a short-term priority while developing and validating better screening tests and risk-appropriate surveillance strategies.

Hepatic Outcomes of Nonalcoholic Fatty Liver Disease Including Cirrhosis and Hepatocellular Carcinoma

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide and represents a significant cause of cirrhosis and hepatocellular carcinoma (HCC). Almost 20% of patients with NAFLD and advanced fibrosis develop cirrhosis, of which 20% can progress to decompensated liver stage. Although patients with cirrhosis or fibrosis continue to have a high risk for HCC progression, growing evidence shows that NAFLD-HCC can develop even in the absence of cirrhosis. Current evidence characterizes NAFLD-HCC primarily as a condition with late presentation, lower response to curative therapy, and poor prognosis.

Risk of adverse outcomes following treatment with direct acting antiviral drugs in HCV infected patients with liver cirrhosis

Introduction

Hepatitis C virus (HCV) is the second major cause of death in Pakistan. Previously, interferon-based regimens were considered highly recommended therapy for HCV patients. Since 2015, interferon-based therapy has been replaced with interferon-free therapy also known as Direct Acting Antiviral (DAA) drugs. The treatment response of interferon-free regimens has been reported as highly effective treatment option with more than 90% sustained virological response (SVR) in chronic HCV infected patients in western countries of the world.

Objective

This study aims to analyze the treatment response of DAA drugs in HCV-infected Pakistani population with liver cirrhosis.

Methodology

We collected the total 94 sample of the HCV infected patients, from June 2020 to September 2020. Forty-six (46) patients were cirrhotic, and forty-eight (48) patients were non-cirrhotic. Data was analyzed using IBM SPSS version 21 software.

Conclusion

The findings of our study suggest that the response rate was 82.60% in HCV cirrhotic patients and 68.75% in HCV non-cirrhotic patients. Our study showed that overall treatment response was independent of age and gender. We also observed some adverse effects such as hepatocellular carcinoma, portosystemic encephalopathy (PSE), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), upper gastrointestinal bleeding (UGIB), ascites, among patients following treatment with interferon-free regimens.

Prognostication algorithm for non-cirrhotic non-B non-C hepatocellular carcinoma-a multicenter study under the aegis of the French Association of Hepato-Biliary Surgery and liver Transplantation

Background

Liver resection and local ablation are the only curative treatment for non-cirrhotic hepatocellular carcinoma (HCC). Few data exist concerning the prognosis of patients resected for non-cirrhotic HCC. The objectives of this study were to determine the prognostic factors of recurrence-free survival (RFS) and overall survival (OS) and to develop a prognostication algorithm for non-cirrhotic HCC.

Methods

French multicenter retrospective study including HCC patients with non-cirrhotic liver without underlying viral hepatitis: F0, F1 or F2 fibrosis.

Results

A total of 467 patients were included in 11 centers from 2010 to 2018. Non-cirrhotic liver had a fibrosis score of F0 (n=237, 50.7%), F1 (n=127, 27.2%) or F2 (n=103, 22.1%). OS and RFS at 5 years were 59.2% and 34.5%, respectively. In multivariate analysis, microvascular invasion and HCC differentiation were prognostic factors of OS and RFS and the number and size were prognostic factors of RFS (P<0.005). Stratification based on RFS provided an algorithm based on size (P=0.013) and number (P<0.001): 2 HCC with the largest nodule ≤10 cm (n=271, Group 1); 2 HCC with a nodule >10 cm (n=176, Group 2); >2 HCC regardless of size (n=20, Group 3). The 5-year RFS rates were 52.7% (Group 1), 30.1% (Group 2) and 5% (Group 3).

Conclusions

We developed a prognostication algorithm based on the number (≤ or >2) and size (≤ or >10 cm), which could be used as a treatment decision support concerning the need for perioperative therapy. In case of bifocal HCC, surgery should not be a contraindication.

A Chronic Cough and Something More: An Unusual Presentation of Hepatocellular Carcinoma

Liver cancer is one of the main contributors to cancer-related death and is the fifth most frequent cancer worldwide. Hepatocellular carcinoma (HCC), the most common of liver cancers, is most frequently diagnosed incidentally during routine imaging in high-risk patients with cirrhosis. However, patients with advanced disease may present with upper abdominal pain, early satiety, weight loss, and a palpable upper abdominal mass. We describe a case of HCC in a 69-year-old male presenting exclusively with an intractable cough, which improved after transarterial chemoembolization-raising awareness of the importance of having a systematic and physiopathology-based approach to chronic cough to have an adequate diagnosis and treatment.

Comparison of Four Albumin-Based Liver Reserve Models (ALBI/EZ-ALBI/PALBI/PAL) against MELD for Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization

(1) Background: The severity of liver functional reserve plays an important role in the management of hepatocellular carcinoma (HCC). Noninvasive models such as the model for end-stage liver disease (MELD), albumin-bilirubin (ALBI) grade and easy (EZ)-ALBI grade, platelet-albumin-bilirubin (PALBI) and platelet-albumin (PAL) are used to evaluate liver dysfunction. We aimed to compare the prognostic performance of these four albumin-based models against MELD in HCC patients undergoing transarterial chemoembolization (TACE). (2) Methods: A total of 1038 treatment naïve HCC patients who received TACE as the primary treatment were enrolled. A multivariate Cox model was used to determine independent survival predictors. (3) Results: Multivariate analysis revealed that higher serum creatinine and α-fetoprotein level, vascular invasion, large tumor size, ALBI grades 2-3, EZ-ALBI grades 2-3, PALBI grades 2-3, PAL grades 2-3, but not the MELD score, were independent predictors associated with decreased survival in different Cox models. Among these models, the PALBI grade had the highest homogeneity and lowest corrected Akaike information criteria value, followed by EZ-ALBI, PAL, ALBI and, lastly, MELD. (4) Conclusions: All four albumin-based liver reserve models are better prognostic tools than MELD score in HCC patients undergoing TACE. Of these, the PALBI score is the best model to evaluate the liver reserve and should be considered a surrogate marker in these patients.

The Multifaceted Roles of Macrophages in NAFLD Pathogenesis

Nonalcoholic fatty liver disease (NAFLD) is the liver manifestation of the metabolic syndrome. NAFLD constitutes a spectrum of pathologies ranging from simple hepatic steatosis (nonalcoholic fatty liver) to the more progressive form of steatohepatitis and fibrosis, which can culminate in liver cirrhosis and hepatocellular carcinoma. Macrophages play multiple roles in the context of NAFLD pathogenesis by regulating inflammatory responses and metabolic homeostasis in the liver and thereby may represent an attractive therapeutic target. Advances in high-resolution methods have highlighted the extraordinary heterogeneity and plasticity of hepatic macrophage populations and activation states thereof. Harmful/disease-promoting as well as beneficial/restorative macrophage phenotypes co-exist and are dynamically regulated, thus this complexity must be taken into consideration in strategies concerning therapeutic targeting. Macrophage heterogeneity in NAFLD includes their distinct ontogeny (embryonic Kupffer cells vs bone marrow-/monocyte-derived macrophages) as well as their functional phenotype, for example, inflammatory phagocytes, lipid- and scar-associated macrophages, or restorative macrophages. Here, we discuss the multifaceted role of macrophages in the pathogenesis of NAFLD in steatosis, steatohepatitis, and transition to fibrosis and hepatocellular carcinoma, focusing on both their beneficial and maladaptive functions at different disease stages. We also highlight the systemic aspect of metabolic dysregulation and illustrate the contribution of macrophages in the reciprocal crosstalk between organs and compartments (eg, the gut-liver axis, adipose tissue, and cardiohepatic metabolic interactions). Furthermore, we discuss the current state of development of pharmacologic treatment options targeting macrophage biology.

Spontaneously Ruptured Hepatocellular Carcinoma: Computed Tomography-Based Assessment

Spontaneously ruptured hepatocellular carcinoma (SRHCC) is an uncommon and life-threatening complication in patients with hepatocellular carcinoma (HCC). It is usually associated with chronic liver disease and has a poor prognosis with a high mortality rate during the acute phase. SRHCC can cause a severe and urgent condition of acute abdomen disease and requires a correct diagnosis to achieve adequate treatment. Clinical presentation is related to the presence of hemoperitoneum, and abdominal pain is the most common symptom (66–100% of cases). Although the treatment approach is not unique, trans-arterial (chemo)embolization (TAE/TACE) followed by staged hepatectomy has shown better results in long-term survival. A multi-phase contrast-enhanced CT (CECT) scan is a pivotal technique in the diagnosis of SRHCC due to its diagnostic accuracy and optimal temporal resolution. The correct interpretation of the main CT findings in SRHCC, such as active contrast extravasation and the sentinel clot sign, is fundamental for a prompt and correct diagnosis. Furthermore, CT also plays a role as a post-operative control procedure, especially in patients treated with TAE/TACE. Therefore, a multi-phase CECT scan should be the diagnostic tool of choice in SRHCC since it suggests an immediate need for treatment with a consequent improvement in prognosis.

Fe-MnO2 nanosheets loading dihydroartemisinin for ferroptosis and immunotherapy

Ferroptosis has emerged as a therapeutic tactic to trigger cancer cell death driven by abnormal accumulation of reactive oxygen species (ROS). However, a single ferroptosis treatment modality is often limited. In this work, a combination therapy of ferroptosis and immunotherapy for cancer was proposed. Specifically, a versatile nanodrug was designed for the multiple treatment of hepatocellular carcinoma (HCC) by loading dihydroartemisinin (DHA) on Fe³⁺-doped MnO₂ nanosheets (Fe-MnO₂/DHA). Firstly, Fe-MnO₂/DHA was degraded by glutathione (GSH) in the tumor microenvironment (TME) to release Fe²⁺, Mn²⁺ and DHA, leading to aberrant ROS accumulation due to Fenton/Fenton-like reaction. Secondly, breakage of endoperoxide bridge from DHA was caused by Fe²⁺ to further induce oxidative stress. Thirdly, the depleted GSH promoted the inactivation of glutathione peroxidase 4 (GPX4), resulting in lipid peroxide (LPO) accumulation. The resulting LPO and ROS could induce ferroptosis and apoptosis of liver cancer cells. Furthermore, Fe-MnO₂/DHA mediated three-pronged stimulation of oxidative stress, resulting in high levels of targeted immunogenic cell death (ICD). It could enhance the infiltration of CD4⁺ T and CD8⁺ T cells, and promote macrophage polarization. DHA also acted as an immunomodulator to inhibit regulatory T cells (Tregs) for systemic antitumor. Overall, Fe-MnO₂/DHA presents a multi-modal therapy for HCC driven by ferroptosis, apoptosis and immune activation, significantly advancing synergistic cancer treatment.

Imaging Diagnosis of Hepatocellular Carcinoma: A State-of-the-Art Review

Hepatocellular carcinoma (HCC) remains not only a cause of a considerable part of oncologic mortality, but also a diagnostic and therapeutic challenge for healthcare systems worldwide. Early detection of the disease and consequential adequate therapy are imperative to increase patients' quality of life and survival. Imaging plays, therefore, a crucial role in the surveillance of patients at risk, the detection and diagnosis of HCC nodules, as well as in the follow-up post-treatment. The unique imaging characteristics of HCC lesions, deriving mainly from the assessment of their vascularity on contrast-enhanced computed tomography (CT), magnetic resonance (MR) or contrast-enhanced ultrasound (CEUS), allow for a more accurate, noninvasive diagnosis and staging. The role of imaging in the management of HCC has further expanded beyond the plain confirmation of a suspected diagnosis due to the introduction of ultrasound and hepatobiliary MRI contrast agents, which allow for the detection of hepatocarcinogenesis even at an early stage. Moreover, the recent technological advancements in artificial intelligence (AI) in radiology contribute an important tool for the diagnostic prediction, prognosis and evaluation of treatment response in the clinical course of the disease. This review presents current imaging modalities and their central role in the management of patients at risk and with HCC.

Prospective Comparison of Hepatocellular Carcinoma Behavior and Survival of Patients who Did or Did not Receive HCV Direct-Acting Antivirals

BACKGROUND & AIMS

The safety and efficacy of hepatitis C (HCV) direct-acting antivirals (DAAs) have been established in several real-world trials; however, some reports have claimed an association between DAAs and hepatocellular carcinoma (HCC) occurrence or aggressive behavior. We aimed to prospectively examine differences in de-novo HCC tumor behavior and overall survival (OS) in DAAs-treated versus HCV-untreated patients as measured by BCLC progression during a two-year follow-up period.

METHODS

This multicenter cohort study recruited 523 patients with de-novo HCV-related HCC. After exclusion criteria were applied, 353 patients were placed into; Group 1, including 236 patients without a history of DAAs therapy, and Group 2 including 117 patients with de-novo HCC developed after receiving DAAs. Patients were then stratified in each group according to BCLC staging (Liver, 2018). All patients received standard of care management and were followed until death or a maximum of 2 years.

RESULTS

No statistically significant differences were observed between the two groups regarding tumor characteristics (number and size of lesions) and criteria for aggressiveness upon presentation. Among all BCLC stages, DAAs treated patients showed significantly lower baseline Fib4 values than DAA untreated patients in BCLC-0 stage (4.1 vs 7.7, p 0.019). No statistically significant differences were evident in HCC progression in the different BCLC stages at 12 and 24 months follow up periods (p 0.0718 and 0.279 respectively). Significantly better survival was recorded in Group 1 compared to Group 2 patients for BCLC stages C and D (p = 0.003 and 0.01, respectively).

CONCLUSION

HCC may develop at an earlier stage of liver disease after DAAs therapy. No defensive role was found for DAAs treatment in delaying HCC progression that occurs after viral eradication.
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Hepatocellular carcinoma in non-alcoholic steatohepatitis without cirrhosis

Cirrhosis is an emerging major cause of the development of hepatocellular carcinoma (HCC), but in non-alcoholic fatty liver disease (NAFLD), up to 50% of patients with HCC had no clinical or histological evidence of cirrhosis. It is currently challenging to propose general recommendations for screening patients with NAFLD without cirrhosis, and each patient should be evaluated on a case-by-case basis based on the profile of specific risk factors identified. For HCC screening in NAFLD, a valid precision-based screening is needed. Currently, when evaluating this population of patients, the use of non-invasive methods can guide the selection of those who should undergo a screening and surveillance program. Hence, the objective of the present study is to review the epidemiology, the pathophysiology, the histopathological aspects, the current recommendations, and novel perspectives in the surveillance of non-cirrhotic NAFLD-related HCC.

Unraveling the Synergy between Atezolizumab and Bevacizumab for the Treatment of Hepatocellular Carcinoma

Tyrosine kinase inhibitors (TKIs) with antiangiogenic properties, such as sorafenib, have been the standard choice to systemically treat hepatocellular carcinoma for over a decade. More recently, encouraging results were obtained using immune checkpoint inhibitors, although head-to-head comparisons with sorafenib in phase 3 trials could not demonstrate superiority in terms of overall survival. The IMbrave150 was a breakthrough study that resulted in atezolizumab/bevacizumab, a combination of an antiangiogenic and an immune checkpoint inhibitor, as a new standard of care for advanced HCC. This review discusses the mode of action, clinical efficacy, and biomarker research for both drug classes and for the combination therapy. Moreover, the synergy between atezolizumab and bevacizumab is highlighted, unraveling pathophysiological mechanisms underlying an enhanced anticancer immunity by changing the immunosuppressed to a more immunoreactive tumor microenvironment (TME). This is achieved by upregulation of antigen presentation, upregulation of T-cell proliferation, trafficking and infiltration, impairing recruitment, and proliferation of immunosuppressive cells in the TME. However, more insights are needed to identify biomarkers of response that may improve patient selection and outcome.

Clinical features and management issues of NAFLD-related HCC: what we know so far

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is replacing viral hepatitis as the leading cause of chronic liver disease and hepatocellular carcinoma (HCC) in many Western countries. NAFLD-associated HCC usually affects older patients with multiple comorbidities, frequently develops in the absence of cirrhosis, and is often diagnosed later with worse chance of survival. The worse prognosis is also due to limited surveillance strategies and a lower efficacy of standard treatments.

AREAS COVERED

We evaluate the available literature to understand the current surveillance strategies and treatment limitations in the workup of NAFLD-associated HCC, focusing on the differences with HCC associated with other liver diseases.

EXPERT OPINION

In this review we discuss epidemiology and risk factors for HCC in NAFLD patients and address key HCC surveillance and management issues. Although most data are still preliminary, the detection of non-cirrhotic NAFLD patients at increased risk for HCC and the potential adoption of novel screening tools could lead to accurate and suitable HCC surveillance and management strategies for NAFLD patients.

Advanced Hepatocellular Carcinoma in Adults Without Cirrhosis: A Single-Institution Retrospective Review

Background

Although up to one in five cases of hepatocellular carcinoma (HCC) occurs in patients without cirrhosis, there is scarce literature characterizing non-cirrhotic HCC (NCHCC). Existing NCHCC research is primarily limited to surgical case series and there is a lack of data on unresectable NCHCC.

Aim

The purpose of this retrospective review was to compare the characteristics of unresectable NCHCC and cirrhotic hepatocellular carcinoma (CHCC).

Methods

A retrospective chart review of adult patients with unresectable HCC treated from 2007 to 2017 was performed at the University of Florida Shands Hospital. The data set was stratified into two cohorts: NCHCC and CHCC. Continuous variables were compared using Wilcoxon-Mann-Whitney tests and Kruskal-Wallis rank-sum tests. Categorical variables were compared using Pearson's Chi-squared tests and Fisher's exact tests. Overall survival was explored utilizing the Kaplan-Meier and log-rank method.

Results

There were 1494 adult patients included in the final analysis, including 264 patients (17.7%) with NCHCC and 1230 patients (82.3%) with CHCC. Median age was 61.0 years old and median follow-up time was 30.2 months. NCHCC patients were older than CHCC patients (66.3 years vs 61.9 years; p < 0.0001). NHCC tumors were larger than CHCC tumors (7.92 ± 4.85 vs 4.38 ± 3.12 cm; p < 0.0001) and more likely to be associated with distant metastases (23.35% vs 15.91%; p = 0.0055). There was no difference in overall survival, with a median of 23.5 months in NCHCC and 22.4 months in CHCC (p = 0.9196).

Conclusion

Our findings suggest that unresectable NCHCC and CHCC have unique characteristics but similar overall survival. To the best of our knowledge, this is the largest comparison of CHCC and NCHCC.

Pathogenesis to management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver cancer whose incidence continues to rise in many parts of the world due to a concomitant rise in many associated risk factors, such as alcohol use and obesity. Although early-stage HCC can be potentially curable through liver resection, liver-directed therapies, or transplantation, patients usually present with intermediate to advanced disease, which continues to be associated with a poor prognosis. This is because HCC is a cancer with significant complexities, including substantial clinical, histopathologic, and genomic heterogeneity. However, the scientific community has made a major effort to better characterize HCC in those aspects via utilizing tissue sampling and histological classification, whole genome sequencing, and developing viable animal models. These efforts ultimately aim to develop clinically relevant biomarkers and discover molecular targets for new therapies. For example, until recently, there was only one approved systemic therapy for advanced or metastatic HCC in the form of sorafenib. Through these efforts, several additional targeted therapies have gained approval in the United States, although much progress remains to be desired. This review will focus on the link between characterizing the pathogenesis of HCC with current and future HCC management.

Role of the Hippo pathway in liver regeneration and repair: recent advances

Although the signaling pathways involved in normal liver regeneration have been well characterized, less has been done for livers affected by chronic tissue damage. These "abnormal livers" have an impaired regenerative response that leads to liver repair and fibrosis. The tumor suppressor Hippo pathway plays a key role in liver regeneration and repair. On this basis, this review discusses recent studies focusing on the involvement of the Hippo signaling pathway during "normal healthy liver regeneration" (i.e., in a normal liver after 2/3 partial hepatectomy) and "abnormal liver regeneration" (i.e., in a liver damaged by chronic disease). This could be an important question to address with respect to new therapies aimed at improving impaired liver regenerative responses. The studies reported here have shown that activation of the Hippo coactivators YAP/TAZ during normal liver regeneration promotes the formation of a new bile duct network through direct BEC proliferation or/and hepatocyte dedifferentiation to HPCs which can trans-differentiate to BECs. Moreover, YAP/TAZ signaling interaction with other signaling pathways mediates the recruitment and activation of Kupffer cells, which release mitogenic cytokines for parenchymal and/or non-parenchymal cells and engage in phagocytosis of cellular debris. In addition, YAP-mediated activation of stellate cells (HSCs) promotes liver regeneration through the synthesis of extracellular matrix. However, in chronically diseased livers, where the predetermined threshold for proper liver regeneration is exceeded, YAP/TAZ activation results in a reparative process characterized by liver fibrosis. In this condition, YAP/TAZ activation in parenchymal and non-parenchymal cells results in (i) differentiation of quiescent HSCs into myofibroblastic HSCs; (ii) recruitment of macrophages releasing inflammatory cytokines; (iii) polarization of macrophages toward the M2 phenotype. Since accumulation of damaged hepatocytes in chronic liver injury represent a significant risk factor for the development of hepatocarcinoma, this review also discussed the involvement of the Hippo pathway in the clearance of damaged cells.

Interventional Management of Portal Hypertension in Cancer Patients

PURPOSE OF REVIEW

To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches.

RECENT FINDINGS

In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.

Hereditary hemochromatosis: Temporal trends, sociodemographic characteristics, and independent risk factor of hepatocellular cancer – nationwide population-based study

BACKGROUND

Hereditary hemochromatosis (HH) has an increased risk of hepatocellular cancer (HCC) both due to genetic risks and iron overload as iron overload can be carcinogenic; HH impacts the increasing risk of HCC, not only through the development of cirrhosis but concerning hepatic iron deposition, which has been studied further recently.

AIM

To evaluate HH yearly trends, patient demographics, symptoms, comorbidities, and hospital outcomes. The secondary aim sheds light on the risk of iron overload for developing HCC in HH patients, independent of liver cirrhosis complications. The study investigated HH (without cirrhosis) as an independent risk factor for HCC.

METHODS

We analyzed data from National Inpatient Sample (NIS) Database, the largest national inpatient data collection in the United States, and selected HH and HCC cohorts. HH was first defined in 2011 International Classification of Disease - 9^th edition (ICD-9) as a separate diagnosis; the HH cohort is extracted from January 2011 to December 2019 using 275.01 (ICD-9) and E83.110 (ICD-10) diagnosis codes of HH. Patients were excluded from the HH cohort if they had a primary or secondary diagnostic code of cirrhosis (alcoholic, non-alcoholic, and biliary), viral hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), and non-alcoholic steatohepatitis (NASH). We removed these patients from the HH cohort to rule out bias or ICD-10 diagnostic errors. The HCC cohort is selected from January 2011 to December 2019 using the ICD-9 and ICD-10 codes of HCC. We selected a non-HCC cohort with the 1:1 fixed ratio nearest neighbor (greedy) propensity score method using the patients' age, gender, and race. We performed multivariate analysis for the risk factors of HCC in the HCC and non-HCC matched cohort. We further analyzed HH without cirrhosis (removing HH patients with a diagnosis of cirrhosis) as an independent risk factor of HCC after adjusting all known risk factors of HCC in the multivariate model.

RESULTS

During the 2011-2019 period, a total of 18031 hospitalizations with a primary or secondary diagnosis of HH (excluding liver diseases) were recorded in the NIS database. We analyzed different patients’ characteristics, and we found increments in inpatient population trend with a Ptrend < 0.001 and total hospital cost of care trend from $42957 in 2011 to $66152 in 2019 with a Ptrend < 0.001 despite no change in Length of Stay over the last decade. The multivariate analyses showed that HH without cirrhosis (aOR, 28.8; 95%CI, 10.4–80.1; P < 0.0001), biliary cirrhosis (aOR, 19.3; 95%CI, 13.4–27.6; P < 0.0001), non-alcoholic cirrhosis (aOR, 17.4; 95%CI, 16.5–18.4; P < 0.0001), alcoholic cirrhosis (aOR, 16.9; 95%CI, 15.9–17.9; P < 0.0001), hepatitis B (aOR, 12.1; 95%CI, 10.85–13.60; P < 0.0001), hepatitis C (aOR, 8.58; 95%CI, 8.20–8.98; P < 0.0001), Wilson disease (aOR, 4.27; 95%CI, 1.18–15.41; P < 0.0001), NAFLD or NASH (aOR, 2.96; 95%CI, 2.73–3.20; P < 0.0001), alpha1-antitrypsin deficiency (aOR, 2.10; 95%CI, 1.21–3.64; P < 0.0001), diabetes mellitus without chronic complications (aOR, 1.17; 95%CI, 1.13–1.21; P < 0.0001), and blood transfusion (aOR, 1.80; 95%CI, 1.69–1.92; P < 0.0001) are independent risk factor for liver cancer.

CONCLUSION

Our study showed an increasing trend of in-hospital admissions of HH patients in the last decade. These trends were likely related to advances in diagnostic approach, which can lead to increased hospital utilization and cost increments. Still, the length of stay remained the same, likely due to a big part of management being done in outpatient settings. Another vital part of our study is the significant result that HH without cirrhosis is an independent risk factor for HCC with adjusting all known risk factors. More prospective and retrospective large studies are needed to re-evaluate the HH independent risk in developing HCC.

Design, Synthesis, and Biological Evaluation of Novel Dihydropyridine and Pyridine Analogs as Potent Human Tissue Nonspecific Alkaline Phosphatase Inhibitors with Anticancer Activity: ROS and DNA Damage-Induced Apoptosis

Small molecules with nitrogen-containing scaffolds have gained much attention due to their biological importance in the development of new anticancer agents. The present paper reports the synthesis of a library of new dihydropyridine and pyridine analogs with diverse pharmacophores. All compounds were tested against the human tissue nonspecific alkaline phosphatase (h-TNAP) enzyme. Most of the compounds showed excellent enzyme inhibition against h-TNAP, having IC₅₀ values ranging from 0.49 ± 0.025 to 8.8 ± 0.53 µM, which is multi-fold higher than that of the standard inhibitor (levamisole = 22.65 ± 1.60 µM) of the h-TNAP enzyme. Furthermore, an MTT assay was carried out to evaluate cytotoxicity against the HeLa and MCF-7 cancer cell lines. Among the analogs, the most potent dihydropyridine-based compound 4d was selected to investigate pro-apoptotic behavior. The further analysis demonstrated that compound 4d played a significant role in inducing apoptosis through multiple mechanisms, including overproduction of reactive oxygen species, mitochondrial dysfunction, DNA damaging, and arrest of the cell cycle at the G1 phase by inhibiting CDK4/6. The apoptosis-inducing effect of compound 4d was studied through staining agents, microscopic, and flow cytometry techniques. Detailed structure–activity relationship (SAR) and molecular docking studies were carried out to identify the core structural features responsible for inhibiting the enzymatic activity of the h-TNAP enzyme. Moreover, fluorescence emission studies corroborated the binding interaction of compound 4d with DNA through a fluorescence titration experiment.

Imaging Features of Hepatocellular Carcinoma in the Non-Cirrhotic Liver with Sonazoid-Enhanced Contrast-Enhanced Ultrasound

PURPOSE

To investigate the Sonazoid-enhanced contrast-enhanced ultrasound (CEUS) features of hepatocellular carcinoma (HCC) in a non-cirrhosis liver background, in comparison to those in liver cirrhosis.

METHODS

In this retrospective study, 19 patients with surgery and histopathologically proven HCC lesions in non-cirrhosis liver background were included regarding Sonazoid-enhanced CEUS characteristics. Two radiologists evaluated the CEUS features of HCC lesions according to the WFUMB (World Federation of Societies for Ultrasound in Medicine and Biology) guidelines criteria. Thirty-six patients with HCC lesions in liver cirrhosis were included as a control group. Final diagnoses were confirmed by surgery and histopathological results.

RESULTS

Liver background of the non-cirrhosis group including normal liver (n = 7), liver fibrosis (n = 11), and alcoholic liver disease (n = 1). The mean size of non-cirrhosis HCC lesions was 60.8 ± 46.8 mm (ranging from 25 to 219 mm). During the arterial phase of Sonazoid-enhanced CEUS, most HCCs in non-cirrhotic liver (94.7%, 18/19) and in cirrhotic liver (83.3%, 30/36) presented non-rim hyperenhancement. During the portal venous phase, HCC lesions in the non-cirrhosis liver group showed relatively early washout (68.4%, 13/19) (p = 0.090). Meanwhile, HCC lesions in liver cirrhosis background showed isoenhancement (55.6%, 20/36). All lesions in the non-cirrhotic liver group showed hypoenhancement in the late phase and the Kupffer phase (100%, 19/19). Five cases of HCC lesions in liver cirrhosis showed isoenhancement during the late phase and hypoenhancement during the Kupffer phase (13.9%, 5/36). The rest of the cirrhotic HCC lesions showed hypoenhancement during the late phase and the Kupffer phase (86.1%, 31/36). Additional hypoenhanced lesions were detected in three patients in the non-cirrhosis liver group and eight patients in the liver cirrhosis group (mean size: 13.0 ± 5.6 mm), which were also suspected to be HCC lesions.

CONCLUSIONS

Heterogeneous hyperenhancement during the arterial phase as well as relatively early washout are characteristic features of HCC in the non-cirrhotic liver on Sonazoid-enhanced CEUS.