Diabetes mellitus and risk of hepatocellular carcinoma: a systematic review and meta-analysis

Incident Hepatocellular Carcinoma Risk in Patients Treated with a Sulfonylurea: A Nationwide, Nested, Case-Control Study

Several studies have shown that the use of sulfonylureas in patients with type 2 diabetes mellitus (T2DM) is associated with a higher risk of hepatocellular carcinoma (HCC). In this study, we investigated the effects of individual sulfonylureas on HCC development using the National Health Insurance Service-National Sample Cohort in South Korea. Among 47,738 subjects aged 40 years or older who had newly diagnosed with diabetes, 241 incident HCC cases and 1205 matched controls were identified. Adjusted odds ratios (ORs) as estimates of the relative risk of HCC were calculated using logistic regression analysis. Compared to patients never treated with a sulfonylurea, those treated with a sulfonylurea had a 1.7-fold increased risk of HCC development. Of the different types of sulfonylureas, the exclusive use of glimepiride was associated with a significantly elevated risk of HCC (OR = 1.89, 95% CI = 1.02-3.47) compared to those who were never treated with sulfonylureas. No significant associations were observed between exclusive gliclazide use and incident HCC (OR = 2.04, 95% CI = 0.75-5.52). In conclusion, the association between the use of sulfonylureas and risk of HCC was different according to the type of sulfonylurea, in patients with new-onset T2DM. Further prospective studies are warranted to confirm these results and translate them into clinical practice.

The changing epidemiology of primary liver cancer

PURPOSE OF REVIEW

In prior decades, liver cancer was viewed as a neoplasm that almost exclusively arose among high-risk populations in low- and middle-income countries. Incidence rates in some high-risk populations, however, have been declining, while rates in low-risk populations have been increasing, reflecting changes in underlying etiology. In this review, we highlight the evolving epidemiology of liver cancer, focusing on recent research and advances.

RECENT FINDINGS

Efforts to reduce or eliminate the risk associated with major risk factors such as hepatitis B virus (HBV), hepatitis C virus (HCV) and aflatoxin B1 (AFB1) have met with some success. As opposed to these favorable trends, the joint epidemics of obesity and diabetes have begun to affect liver cancer rates around the world.

SUMMARY

While there has been progress in combating the effects of some risk factors, the increasing prevalence of others poses a major threat to attempts to tackle the rising incidence of liver cancer globally.

Metformin modifies disparity in hepatocellular carcinoma incidence in men with type 2 diabetes but without chronic liver diseases

Background

We assessed racial/ethnic disparity in hepatocellular carcinoma (HCC) incidence among men with type 2 diabetes (T2D) but without chronic liver diseases (CLD), and whether metformin use modified the disparity.

Methods

Study cohort: the nationwide Veterans Administration Health Care System electronic medical records among 40‐89 years old men with T2D; without CLD, cancer, cardiovascular or renal diseases previously; insulin and thiazolidinedione naive. Logistic regression analyses compared HCC incidence between race/ethnicity groups under no metformin use adjusted for covariates and inverse propensity score weights (IPSW) for race/ethnicity. The generalizability technique integrated with IPSW was incorporated to compare covariates adjusted odds ratios (aOR) of HCC associated with metformin use among race/ethnicity groups.

Results

Study cohort: N = 84 433; 79.47% non‐Hispanic white (NHW), 15.5% non‐Hispanic African American (NHAA), 5.03% Hispanics; 36.76% metformin users; follow‐up 6.10 ± 2.87 years; age 67.8 ± 9.8 years, HbA1c 6.57 ± 0.98%; 0.14% HCC cases. Under no metformin use, HCC incidence was lower for NHAA vs NHW (aOR = 0.60 [0.40‐0.92]), similar between NHW and Hispanics. Metformin was associated with reduced HCC risk: aOR = 0.57 (0.40‐0.81) for NHW; aOR = 0.35 (0.25‐0.47) for NHAA; aOR = 0.31 (0.22‐0.43) for Hispanics. Metformin dose >1000 mg/d was neutral for NHW; less effective for NHAA (P = 0.02); more effective for Hispanics (P = 0.002).

Conclusions

In men with T2D but without CLD nor metformin use, HCC incidence was lower for NHAA compared to NHW or Hispanics; similar between NHW and Hispanics. Metformin use reduced HCC risk and modified the race/ethnicity disparity.

Impact

Metformin's heterogeneous HCC prevention effect elucidates potential interventions to modify HCC disparity in patients with T2D.

The Epidemiology of Hepatocellular Carcinoma in the USA

PURPOSE OF REVIEW

To discuss current knowledge and recent findings regarding the epidemiology of hepatocellular carcinoma (HCC) in the USA.

RECENT FINDING

The US incidence rate of HCC is increasing, although the pace may have somewhat slowed since 2010. In 2012, incidence rates of HCC in Hispanics surpassed those of Asians. The recent epidemiological changes in major risk factors for HCC include increasing hepatitis C virus post-sustained virologic response, suppressed hepatitis B virus on nucleoside analogues, and alcoholic and non-alcoholic fatty liver disease. Non-alcoholic fatty liver disease has the greatest proportion of the burden of the main risk factors for HCC in the USA, followed by alcoholic liver disease, and hepatitis C virus and hepatitis B virus infections. This review focuses on current knowledge regarding the recent epidemiological trends in HCC, with an emphasis on future directions.

Alcohol and hepatocellular carcinoma

BACKGROUND

Alcohol is classified as a Group 1 carcinogen by the International Agency for Research on Cancer because it induces hepatocellular carcinoma (among other cancers) in humans. An excessive alcohol intake may result in fatty liver, acute/chronic hepatitis, and cirrhosis and eventually lead to hepatocellular carcinoma. It has been reported that alcohol abuse increases the relative risk of hepatocellular carcinoma by 3- to 10-fold.

AIM AND METHODS

To clarify the known mechanisms of alcohol-related carcinogenesis, we searched Pubmed using the terms alcohol and immune mechanism, alcohol and cancer, and immune mechanism and cancer and summarized the articles as a qualitative review.

RESULTS

From a clinical perspective, it is well known that alcohol interacts with other factors, such as smoking, viral hepatitis, and diabetes, leading to an increased risk of hepatocellular carcinoma. There are several possible mechanisms through which alcohol may induce liver carcinogenicity, including the mutagenic effects of acetaldehyde and the production of ROS due to the excessive hepatic deposition of iron. Furthermore, it has been reported that alcohol accelerates hepatitis C virus-induced liver tumorigenesis through TLR4 signaling. Despite intense investigations to elucidate the mechanisms, they remain poorly understood.

CONCLUSION

This review summarizes the recent findings of clinical and pathological studies that have investigated the carcinogenic effects of alcohol in the liver.

Trends in hepatocellular carcinoma due to non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide and is associated with hepatocellular carcinoma (HCC), the most frequent malignant liver tumor. The increasing prevalence of obesity and diabetes is influencing the epidemiology of HCC with the most dramatic increases in NAFLD-related HCC seen in Western countries. Although cirrhosis is the major risk factor for HCC in NAFLD, there is increasing recognition that NAFLD-HCC occurs in the absence of cirrhosis. Areas covered: The epidemiology of NAFLD related HCC and its impact on changing the incidence of HCC globally. We overview risk factors for NAFLD-HCC in the presence and absence of cirrhosis and examine trends in liver transplantation (LT) related to NAFLD-HCC. Expert commentary: The incidence of NAFLD-related cirrhosis will continue to rise globally in parallel with risk factors of obesity and diabetes. Consequently, NAFLD-related HCC will become an increasingly important cause of liver-related morbidity and mortality and a common indication for LT worldwide. Further identification of risk factors for NAFLD-HCC and effective treatments for NAFLD are required to reduce this future burden of disease.

Hepatic stress associated with pathologies characterized by disturbed glucose production

The liver is an organ with many facets, including a role in energy production and metabolic balance, detoxification and extraordinary capacity of regeneration. Hepatic glucose production plays a crucial role in the maintenance of normal glucose levels in the organism i.e. between 0.7 to 1.1 g/l. The loss of this function leads to a rare genetic metabolic disease named glycogen storage disease type I (GSDI), characterized by severe hypoglycemia during short fasts. On the contrary, type 2 diabetes is characterized by chronic hyperglycemia, partly due to an overproduction of glucose by the liver. Indeed, diabetes is characterized by increased uptake/production of glucose by hepatocytes, leading to the activation of de novo lipogenesis and the development of a non-alcoholic fatty liver disease. In GSDI, the accumulation of glucose-6 phosphate, which cannot be hydrolyzed into glucose, leads to an increase of glycogen stores and the development of hepatic steatosis. Thus, in these pathologies, hepatocytes are subjected to cellular stress mainly induced by glucotoxicity and lipotoxicity. In this review, we have compared hepatic cellular stress induced in type 2 diabetes and GSDI, especially oxidative stress, autophagy deregulation, and ER-stress. In addition, both GSDI and diabetic patients are prone to the development of hepatocellular adenomas (HCA) that occur on a fatty liver in the absence of cirrhosis. These HCA can further acquire malignant traits and transform into hepatocellular carcinoma. This process of tumorigenesis highlights the importance of an optimal metabolic control in both GSDI and diabetic patients in order to prevent, or at least to restrain, tumorigenic activity during disturbed glucose metabolism pathologies.

Type 2 diabetes mellitus increases the risk of hepatocellular carcinoma in subjects with chronic hepatitis B virus infection: a meta-analysis and systematic review

Background

Type 2 diabetes mellitus has been proved to be a risk factor of hepatocellular carcinoma, but how diabetes affects incidence of hepatocellular carcinoma among patients with chronic hepatitis B virus infection remains controversial.

Methods

A comprehensive search of Medline and Embase was performed. Incidence of hepatocellular carcinoma in chronic hepatitis B patients was the primary outcome. Pooled HRs and 95% CIs were calculated to assess the correlation between diabetes and incidence of hepatocellular carcinoma.

Results

Five cohort studies and two case–control studies were identified, with a total of 21,842 chronic hepatitis B patients. The diabetes mellitus cohort was found to have increased incidence of hepatocellular carcinoma (pooled HR 1.77, 95% CI 1.28–2.47; fixed effect) and worse overall mortality (pooled RR 1.93, 95% CI 1.64–2.27; fixed effect) in comparison with those without diabetes. In case–control studies, hepatocellular carcinoma cases were found to have an insignificantly elevated diabetes mellitus rate in comparison with the control group.

Conclusion

Type 2 diabetes mellitus is significantly associated with increased risk of hepatocellular carcinoma among patients with chronic hepatitis B virus infection, and aggressive management of diabetes mellitus is strongly suggested.

Update in global trends and aetiology of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver responsible for an increasing number of cancer-related deaths, especially in developing economies of Asia and Africa. A plethora of risk factors have been described in the literature. Some of the important ones include chronic viral hepatitis, liver cirrhosis, environmental toxins such as aflatoxin, non-alcoholic fatty liver disease, lifestyle factors like alcohol consumption, smoking, and dietary factors, metabolic diseases like diabetes mellitus and obesity, and genetic and hereditary disorders. The development of HCC is complex involving sustained inflammatory damage leading to hepatocyte necrosis, regeneration, and fibrotic deposition. It also poses multiple challenges in diagnosis and treatment despite advances in diagnostic, surgical, and other therapeutic advancements. This is a narrative review of findings of multiple studies that were retrieved from electronic databases like PubMed, MEDLINE, Embase, Google Scholar, Scopus, and Cochrane. We summarise the current knowledge regarding the epidemiology and various risk factors for the development of HCC with a brief note on various prevention strategies.

Association of fasting serum glucose level and type 2 diabetes with hepatocellular carcinoma in men with chronic hepatitis B infection: A large cohort study

BACKGROUND

It is unclear whether elevated fasting serum glucose level and type 2 diabetes (T2DM) are associated with an increased risk of hepatocellular carcinoma (HCC), irrespective of obesity in patients with chronic hepatitis B.

PATIENTS AND METHODS

Our study population comprised 214,167 Korean men with chronic hepatitis B in the National Health Insurance Service (NHIS) database between January 2002 and December 2006. Data on new events of HCC were obtained by records of the NHIS during the follow-up. We used Cox proportional hazards models adjusted for sociodemographic, lifestyle, health status and clinical conditions to estimate the hazard ratio (HR) and 95% confidence intervals (95% CIs) of HCC associated with different categories of fasting serum glucose level and T2DM, using fasting serum glucose <90 mg/dL as reference.

RESULTS

During the 8 years of follow-up, there were 11,241 HCCs in men with chronic hepatitis B. Compared with the reference group, fasting serum glucose level of more than 140 mg/dL (HR = 1.46; 95% CI: 1.36-1.57; p < 0.001) and presence of T2DM (HR = 1.23; 95% CI: 1.15-1.34; p < 0.001) were associated with an increased risk of HCC after controlling for potential confounders. Significant association with fasting serum glucose and HCC was found for both non-obese (<25 kg/m²) and obese (≥25.0 kg/m²) patients (P_trend < 0.001).

CONCLUSION

In this cohort of men with chronic hepatitis B infection, elevated fasting serum glucose level and T2DM were significantly associated with an increased risk of HCC, regardless of obesity. Glycaemic control in men with chronic hepatitis B patients should be considered in clinical practice to prevent HCC.

Cancer incidence among Finnish people with type 2 diabetes during 1989-2014

Diabetes and cancer are common diseases both with enormous impact on health burden globally. The increased risk of several types of cancer among people with type 2 diabetes mellitus has been indicated repeatedly. This study aimed at exploring and describing the association between type 2 diabetes and cancer incidence. A cohort of 428,326 people with type 2 diabetes was identified from the Finnish National Diabetes Register and followed up through a register linkage with the Finnish Cancer Registry for cancer incidence during 1988-2014. A total of 74,063 cases of cancer occurred in this cohort in 4.48 million person-years. This accounted for 16% more than the expected cancer incidence in the Finnish general population; the standardized incidence ratio (SIR) was 1.16 (95% confidence interval [CI] 1.15-1.16). There was a statistically significant excess of cancers of lip (SIR = 1.40, CI = 1.28-1.53), liver (SIR = 2.44, CI = 2.35-2.53), pancreas (SIR = 1.75, CI = 1.70-1.79), stomach (SIR = 1.22, CI = 1.18-1.26), colon (SIR = 1.22, CI = 1.19-1.25), gallbladder and bile ducts (SIR = 1.29, CI = 1.21-1.36), non-melanoma skin (SIR = 1.18, CI = 1.15-1.22), kidney (SIR = 1.42, CI = 1.37-1.47), bladder (SIR = 1.17, CI = 1.13-1.21), and thyroid (SIR = 1.22, CI = 1.12-1.31). There was a small statistically significant decrease in prostate cancer incidence (SIR = 0.95, CI = 0.93-0.96). This study showed an association between type 2 diabetes mellitus and the incidence of cancer at numerous sites in the Finnish population.

Lower alpha fetoprotein and higher risk of hepatocellular carcinoma, study from the type 2 diabetes mellitus patients

AIMS

To explore the association of type 2 diabetes mellitus (T2DM) with hepatocellular carcinoma (HCC) and alpha fetoprotein (AFP).

METHODS

750 patients with T2DM (T2DM group), 800 healthy people (control group) and 501 patients newly diagnosed with HCC were recruited from 2010 to 2016. The HCC patients were further divided into a HCC with T2DM (HCC+DM) group and a HCC without diabetes mellitus (HCC+NDM) group.

RESULTS

The T2DM group had a 12.61% lower geometric mean AFP level than the healthy control group (2.08 vs. 2.38 μg/L, P < 0.001). Of 501 HCC patients, 230 (45.91%) had T2DM. When compared to the HCC+NDM group, the HCC+DM group had a higher negative rate of AFP (55.22% vs. 37.26%, P < 0.001), worse liver function (P = 0.011) and a 64.87% lower geometric mean AFP level (25.71 vs. 73.18 μg/L, P < 0.001). T2DM was significantly associated with the risk of high-grade (grade 3 and 4) HCC (OR = 2.02, 95% CI 1.18-3.44, P = 0.010).

CONCLUSIONS

T2DM was associated with lower AFP level, worse liver function and higher risk of high-grade HCC. We speculated that low AFP levels in diabetics might delay and interfere with HCC diagnosis, leading to higher degree of malignant HCC.

Clinicopathologic characteristics andoutcomes of hepatocellular carcinoma associated with chronic hepatitis B versus hepatitis C infection

BACKGROUND

Hepatocellular carcinoma (HCC) is a primary liver malignancy and one of the most common cancers worldwide. Few studies in Saudi Arabia have compared the clinicopathologic characteristics of HCC caused by hepatitis B virus (HBV) versus hepatitis C virus (HCV) and their effect on patient survival and prognosis.

OBJECTIVES

Identify differences in clinicopathological characteristics and outcomes of hepatocellular carcinoma (HCC) caused by HBV versus HCV.

DESIGN

A retrospective medical records review.

SETTING

Tertiary medical center in Riyadh.

PATIENTS AND METHODS

We included all new cases of HCC with underlying HBV and HCV infection diagnosed between January 2013 and September 2017 that met inclusion criteria.

MAIN OUTCOME MEASURES

Clinical, biochemical, pathological and radiological characteristics, and survival differences were compared between HCC that developed in HBV- and HCV-infected patients.

SAMPLE SIZE

Of 253 patients evaluated, 172 patients were included in the study.

RESULTS

Of the 172 patients, 110 (64%) had HCV-associated HCC and 62 (36%) had HBV-associated HCC. More patients with HBV infection were males (P=.003) and were younger (P=.015) than HCV patients. HCV-infected patients who developed HCC had more advanced cirrhosis (P=.048). The prevalence of comorbidities and pre-existing cir.rhosis was similar in both groups. Seven patients (6.8%) with underlying HCV developed HCC in the absence of cirrhosis. Patients with HBV-associated HCC were less likely to meet Milan criteria at initial diagnosis than those with HCV-associated HCC (33.9% vs. 52.7%, respectively, P=.017). HBV-associated HCC occurred at a more advanced Barcelona Clinic Liver Cancer stage. The overall median survival and treatment outcome for each modality was comparable.

CONCLUSIONS

HBV- and HCV-associated HCC have distinct clinical and pathological characteristics, necessitating different screening policies to optimize HCC surveillance and management. However, viral etiology did not affect the treatment outcome and long-term survival.

LIMITATIONS

Conducted in a single-center, retrospective and lacks information about the use of antiviral treatment.

CONFLICT OF INTEREST

None.

Epidemiological dimensions of the association between type 2 diabetes and cancer: A review of observational studies

Type 2 diabetes (T2D) is a major cause of complications and death in many countries. The possible causal relation between T2D and cancer has been the aim of many research investigations. In view of the importance of the topic we carried out a narrative review of observational studies to summarize the available evidence of the association between T2D and cancer. To deal with the problem of abundance of published studies, we reviewed up to December 2017, the literature of meta-analyses of observational studies first, then we reviewed cohort studies not reported in meta-analyses because of more recent publication. We found that the association of T2D with risk of colorectal cancer was robust, whereas the evidence of the associations with other cancer sites was lower. Some of the observed associations could be overestimated, due to publication bias, unmeasured confounders (such as obesity) and surveillance bias. In conclusion a probable causal association of T2D with risk of colorectal cancer was confirmed. A possible causal association with pancreatic, endometrial, hepatocellular and gallbladder carcinoma was also found. Substantial uncertainty exists for other cancer sites.

Hepatocellular carcinoma after prior sorafenib treatment: incidence, healthcare utilisation and costs from German statutory health insurance claims data

OBJECTIVE

To estimate both the number of patients with hepatocellular carcinoma (HCC) eligible annually for second-line therapy following sorafenib in Germany and the healthcare costs accrued by patients meeting eligibility criteria.

METHODS

Patients with an HCC diagnosis and one or more sorafenib prescription were identified from samples of > 3 million insured persons in each of 2012, 2013 and 2014 using the anonymised Betriebskrankenkasse health insurance scheme database. Incidence rates from 2013 were extrapolated to the German population using data from the statutory health insurance system database and Robert Koch Institute. Resource use and cost data were collected for a subset of patients with follow-up data post-sorafenib.

RESULTS

Between 1032 and 1484 patients with HCC in Germany (893-1390 publicly insured patients) were estimated as likely to be eligible for second-line therapy after sorafenib annually. For post-sorafenib analyses, 117 patients were identified with HCC, one or more sorafenib prescription and considered potentially eligible for second-line treatment, 15 of whom were alive after 12 months' follow-up. Total mean costs per patient accrued in the 12 months after sorafenib treatment ended were €11,152 (hospital care, €6483 [58.1%]; outpatient prescriptions, €3137 [28.1%]).

CONCLUSION

The estimated number of publicly insured HCC patients annually eligible for second-line therapy in Germany was < 1400 and mean total costs accrued in the year after completion of sorafenib therapy were approximately €11,000 per patient for the German statutory healthcare system. These estimates can be used when evaluating the budgetary impact of new second-line therapies for advanced HCC in Germany.

Type 2 Diabetes and Risk of Incident Cancer in China: A Prospective Study Among 0.5 Million Chinese Adults

Using data from the China Kadoorie Biobank Study, we conducted a prospective investigation on the association between type 2 diabetes mellitus (T2DM) and cancer risk in Chinese adults. A total of 508,892 participants (mean age = 51.5 (standard deviation, 10.7) years) without prior cancer diagnosis at baseline (2004-2008) were included. We documented 17,463 incident cancer cases during follow-up through December 31, 2013. Participants with T2DM had increased risks of total and certain site-specific cancers; hazard ratios were 1.13 (95% confidence interval (CI): 1.07, 1.19) for total cancer, 1.51 (95% CI: 1.29, 1.76) for liver cancer, 1.86 (95% CI: 1.43, 2.41) for pancreatic cancer, and 1.21 (95% CI: 1.01, 1.47) for female breast cancer. The associations were largely consistent when physician-diagnosed and screen-detected T2DM were analyzed separately, except for colorectal cancer (for physician-diagnosed T2DM, HR = 0.91 (95% CI: 0.73, 1.13), and for screen-detected T2DM, HR = 1.44 (95% CI: 1.18, 1.77)). In participants without a prior diagnosis of T2DM, higher random blood glucose levels were positively associated with risks of total cancer, liver cancer, and female breast cancer (all P's for trend ≤ 0.02). In conclusion, T2DM is associated with an increased risk of new-onset cancer in China, particularly cancers of the liver, pancreas, and female breast.

Deficiency of fibroblast growth factor 21 (FGF21) promotes hepatocellular carcinoma (HCC) in mice on a long term obesogenic diet

OBJECTIVE

Non-alcoholic fatty liver (NAFL) associated with obesity is a major cause of liver diseases which can progress to non-alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Fibroblast growth factor 21 (FGF21) plays an important role in liver metabolism and is also a potential marker for NAFL. Here we aimed to test the effect of FGF21 deficiency on liver pathology in mice consuming a conventional high fat, high sucrose (HFHS) obesogenic diet for up to 52 weeks.

METHODS

C57BL6 WT and FGF21 KO mice were fed a conventional obesogenic diet and were evaluated at 16 and 52 weeks. Evaluation included metabolic assessment, liver pathology, and transcriptomic analysis.

RESULTS

With consumption of HFHS diet, FGF21 deficient mice (FGF21 KO) develop excess fatty liver within 16 weeks. Hepatic pathology progresses and at 52 weeks FGF21 KO mice show significantly worse fibrosis and 78% of mice develop HCC; in contrast only 6% of WT mice develop HCC. Well differentiated hepatocellular carcinomas in FGF21 KO mice were characterized by expanded hepatic plates, loss of reticulin network, cytologic atypia, and positive immunostaining for glutamine synthetase. Microarray analysis reveals enrichment of several fibroblast growth factor signaling pathways in the tumors.

CONCLUSIONS

In addition to attenuating inflammation and fibrosis in mice under a number of dietary challenges, we show here that FGF21 is required to limit the progression from NAFL to HCC in response to prolonged exposure to an obesogenic diet. The induction of hepatic FGF21 in response to the high fat, high sucrose obesogenic diet may play an important role in limiting progression of liver pathology from NAFL to HCC.

Retrospective database analysis of cancer risk in patients with type 2 diabetes mellitus in China

OBJECTIVE

To investigate the association between type 2 diabetes (T2D) and the risk of overall cancer and site-specific cancers in a Chinese population.

RESEARCH DESIGN AND METHODS

Tianjin Urban Employee Basic Medical Insurance database (2003-2014) was used to identify patients with newly onset T2D in 2009, patients with prevalent T2D prior to 2009, and general individuals without T2D. Overall and site-specific cancer incidence rates and incidence rate ratios relative to general population were calculated for both incident and prevalent T2D cohorts. Multivariate Cox proportional hazards models adjusting for baseline characteristics and potential bias were conducted. Subgroup analyses based on gender and age were further conducted.

RESULTS

For the year 2009, 21,208 patients with onset T2D (mean age 58.8 years; 48.1% female), 28,248 patients with prevalent T2D (mean age 63.7 years; 50.2% female) and 744,339 general individuals (mean age 43.2 years; 47.7% female) were identified. Controlling for confounders, diabetic patients had an overall 56%-59% higher risk of developing cancer, among which the highest risks by site were liver (adjusted hazard ratio [aHR] = 1.80-2.48), colorectal (aHR = 2.41-2.69) and stomach (aHR = 2.02-2.51) cancers (all p < .05). Patients with prevalent T2D had increased cancer risk in the pancreas (aHR = 4.52, p < .001). Female diabetic patients had increased risk in the kidneys (aHR = 3.22-3.31, p < .01). Patients aged between 50 and 59 years had the highest relative risk (90% higher), while the relative risk was the lowest among patients ≥70 (45% higher).

CONCLUSION

Type 2 diabetes was associated with increased overall cancer risk led by liver, colorectal and stomach cancers. Patients with longer diabetes duration were associated with higher pancreatic cancer risk and female diabetic patients had a higher risk of kidney cancer.

Progress and challenges in the prevention and control of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is rapidly becoming the most common liver disease worldwide. Individuals with NAFLD have a high frequency of developing progressive liver disease and metabolism-related comorbidities, which result from of a lack of awareness and poor surveillance of the disease and a paucity of approved and effective therapies. Managing the complications of NAFLD has already begun to place a tremendous burden on health-care systems. Although efforts to identify effective therapies are underway, the lack of validated preclinical NAFLD models that represent the biology and outcomes of human disease remains a major barrier. This review summarizes the characteristics and prevalence of the disease and the status of our understanding of its mechanisms and potential therapeutic targets.

Global Epidemiology, Prevention, and Management of Hepatocellular Carcinoma

The incidence rate of hepatocellular carcinoma (HCC) is rising. It is one of the most common cancers worldwide and accounts for substantial morbidity and mortality. Chronic hepatitis B virus (HBV) infection, chronic hepatitis C virus (HCV) infection, and nonalcoholic fatty liver disease (NAFLD) are the most important etiologies of HCC, and effective screening and management strategies are crucial to reduce the HCC risk. For HBV, which accounts for the majority of HCC cases, most infections were acquired via perinatal and early horizontal transmission. Universal vaccination of newborns has led to a decline in HCC incidence compared with the pre-vaccination era. Effective antiviral therapies with nucleos(t)ide analogues or pegylated interferon reduced the incidence of HCC. For HCV, the emergence of effective direct-acting antiviral (DAA) agents has substantially improved cure rates; therefore all patients with HCV should be considered for DAA treatment. The most important obstacle in eliminating HCV is access to therapy. For NAFLD, the global incidence is increasing rapidly, thus its impact on HCC incidence may be explosive. Progression to HCC in NAFLD happens particularly in those with nonalcoholic steatohepatitis (NASH) and exacerbated by metabolic syndrome, or PNPLA3 gene polymorphism. Lifestyle changes are imperative while drug therapy has yet to demonstrate substantive protective effects on HCC prevention. For management of HCC, early diagnosis via imaging surveillance among persons with HCC risk factors remains the most important strategy to identify early-stage disease appropriate for resection or transplantation.

Risk factors for hepatocellular carcinoma by age, sex, and liver disorder status: A prospective cohort study in Korea

BACKGROUND

To the authors' knowledge, relatively little is known regarding the interaction of risk factors for hepatocellular carcinoma (HCC) with age, sex, and liver disorder status.

METHODS

The authors followed 504,646 Korean patients aged 40 to 80 years who underwent routine health checkups between 2002 and 2003 until 2013 via linkage to national hospital discharge records.

RESULTS

HCC occurred in 2744 individuals. In the sex-adjusted and age-adjusted analysis, cirrhosis increased the incidence of HCC by 42-fold, followed by hepatitis B virus (21-fold), hepatitis C virus (HCV; 19-fold), male sex (4.3-fold), and each 5-year age increment (1.24-fold). In the multivariable adjusted analysis, diabetes increased the risk of HCC by 80%, alcohol consumption ≥80 g/day increased the risk by 75%, alcohol consumption of 40 to 79 g/day increased the risk by 37%, and being a current smoker increased the risk by 25%. The multivariable adjusted hazard ratios of male sex and HCV were 6.27 and 5.72, respectively, at age <50 years, but were 2.09 and 22.51, respectively, at age ≥70 years. Each 20 g/day of alcohol consumption increased the risk of HCC by 6% (P = .11), 8% (P = .02), 16% (P<.001), and 30% (P<.001), respectively, in individuals aged <50 years, 50 to 59 years, 60 to 69 years, and 70 to 80 years. In individuals without a liver disorder, body mass index was found to be positively associated with HCC, whereas patients with a liver disorder demonstrated an inverse association. Women had higher adjusted hazard ratios associated with age and cirrhosis compared with men.

CONCLUSIONS

With advancing age, the effects of alcohol use and HCV on the development of HCC become stronger, whereas the effect of male sex weakens. Lifetime moderate alcohol consumption may cause HCC in the elderly. Smoking increases the risk of HCC irrespective of viral hepatitis, and diabetes increases the risk of HCC independent of cirrhosis. Cancer 2018;124:2748-2757. © 2018 American Cancer Society.

Projections of primary liver cancer to 2030 in 30 countries worldwide

Primary liver cancer (PLC) is the sixth most common cancer worldwide and the second most common cause of cancer death. Future predictions can inform health planners and raise awareness of the need for cancer control action. We predicted the future burden of PLC in 30 countries around 2030. Incident cases of PLC (International Classification of Diseases, Tenth Revision, C22) were obtained from 30 countries for 1993-2007. We projected new PLC cases to 2030 using age-period-cohort models (NORDPRED software). Age-standardized incidence rates per 100,000 person-years were calculated by country and sex. Increases in new cases and rates of PLC are projected in both sexes. The largest increases in rates are, among men, in Norway (2.9% per annum), US whites (2.6%), and Canada (2.4%) and, among women, in the United States (blacks 4.0%), Switzerland (3.4%), and Germany (3.0%). The projected declines are in China, Japan, Singapore, and parts of Europe (e.g., Estonia, Czech Republic, Slovakia). A 35% increase in the number of new cases annually is expected compared to 2005. This increasing burden reflects both increasing rates (and the underlying prevalence of risk factors) and demographic changes. Japan is the only country with a predicted decline in the net number of cases and annual rates by 2030. Conclusion: Our reporting of a projected increase in PLC incidence to 2030 in 30 countries serves as a baseline for anticipated declines in the longer term through the control of hepatitis B virus and hepatitis C virus infections by vaccination and treatment; however, the prospect that rising levels of obesity and its metabolic complications may lead to an increased risk of PLC that potentially offsets these gains is a concern. (Hepatology 2018;67:600-611).

Association of processed food, synergistic effect of alcohol and HBV with Hepatocellular Carcinoma in a high incidence region of India

BACKGROUND

Dietary factors, tobacco, and alcohol use have been identified as important factors of rising various cancer incidence in several northeastern states of India. However, little is known about the factors associated with hepatocellular carcinoma (HCC) in this region. The aim of the paper was to identify the factors associated with HCC in the northeast region.

METHODS

A case-control study was conducted in Arunachal Pradesh and Sikkim, two northeastern states of India, including 104 histologically-confirmed cases of HCC and same number (104) of age and sex matched control enrolled. Logistic regression analysis was performed to identify the factors associated with HCC.

RESULTS

A statistically significant association was demonstrated between HCC and alcohol consumption, consumption of 'Sai-mod' (OR 2.77, CI 1.57-4.87) a homemade alcohol beverage, and with HBV (OR 7.97, CI 3.36-18.94). Positive synergism index (S = 3.04) was observed between HBV and alcohol consumption to risk of HCC. Higher intake of processed meat (OR 2.56, CI 1.09-6.03) and processed fish (OR 2.24, CI 1.02-4.95) were found associated with increased risk of HCC; and decreased risk of HCC with fresh fish, fruits, and milk.

CONCLUSIONS

Strong relationship between different dietary factors, alcohol beverage with HCC suggests that control on dietary and drinking habit will be an important strategy to combat HCC in this region. Risk factors identified in this study will help to plan more effectively targeted risk reduction strategies and programs in this region.

Clear cell hepatocellular carcinoma: origin, metabolic traits and fate of glycogenotic clear and ground glass cells

Clear cell hepatocellular carcinoma (CCHCC) has hitherto been considered an uncommon, highly differentiated variant of hepatocellular carcinoma (HCC) with a relatively favorable prognosis. CCHCC is composed of mixtures of clear and/or acidophilic ground glass hepatocytes with excessive glycogen and/or fat and shares histology, clinical features and etiology with common HCCs. Studies in animal models of chemical, hormonal and viral hepatocarcinogenesis and observations in patients with chronic liver diseases prone to develop HCC have shown that the majority of HCCs are preceded by, or associated with, focal or diffuse excessive storage of glycogen (glycogenosis) which later may be replaced by fat (lipidosis/steatosis). In ground glass cells, the glycogenosis is accompanied by proliferation of the smooth endoplasmic reticulum, which is closely related to glycogen particles and frequently harbors the hepatitis B surface antigen (HBsAg). From the findings in animal models a sequence of changes has been established, commencing with preneoplastic glycogenotic liver lesions, often containing ground glass cells, and progressing to glycogen-poor neoplasms via various intermediate stages, including glycogenotic/lipidotic clear cell foci, clear cell hepatocellular adenomas (CCHCA) rich in glycogen and/or fat, and CCHCC. A similar process seems to take place in humans, with clear cells frequently persisting in CCHCC and steatohepatitic HCC, which presumably represent intermediate stages in the development rather than particular variants of HCC. During the progression of the preneoplastic lesions, the clear and ground glass cells transform into cells characteristic of common HCC. The sequential cellular changes are associated with metabolic aberrations, which start with an activation of the insulin signaling cascade resulting in pre-neoplastic hepatic glycogenosis. The molecular and metabolic changes underlying the glycogenosis/lipidosis are apparently responsible for the dramatic metabolic shift from gluconeogenesis to the pentose phosphate pathway and Warburg-type glycolysis, which provide precursors and energy for an ever increasing cell proliferation during progression.

Diabetes Mellitus and Risk of Hepatocellular Carcinoma

The occurrence of hepatocellular carcinoma (HCC) is two to three times higher in patients with diabetes mellitus (DM), the prevalence of which is increasing sharply worldwide. The purpose of this review was to describe clinical links between DM and HCC and potential biological mechanisms that may account for this association. We evaluated the role of potential pathways that could account for the development of HCC with different etiologies in the presence of DM. In addition, we also briefly discuss the potential effect of other factors such as type and dosage of antidiabetic medicines and duration of DM on HCC risk.

Differences in risk factors of malignancy between men and women with type 2 diabetes: A retrospective case-control study

BACKGROUND

The aim of this multicenter, retrospective, case-control study was to identify differences in risk factors of malignancy between men and women with type 2 diabetes.

RESULTS

Among women the most prevalent malignancies were: breast and uterine cancers (35.6% and 14.4% respectively), while among men there were: colorectal and prostate cancers (24.5% and 13.3% respectively). In both gender metformin use was associated with lower cancer risk. Obesity and insulin treatment in dose-dependent and time-varying manner were associated with significantly increased risk of malignancy in females. In men, unexpectedly, cardiovascular disease was more prevalent in control group. Other variables did not show significant association with malignancy risk.

MATERIALS AND METHODS

118 women and 98 men with type 2 diabetes mellitus who developed cancer after diagnosis of diabetes and the same number of strictly age matched controls with type 2 diabetes and without malignancy were included into the study. Diabetes duration, antidiabetic medications use, glycated hemoglobin level, body mass index, smoking habits, occupation, presence of comorbidities and aspirin use were included into analyses.

CONCLUSIONS

Metformin demonstrated protective effect against cancer in both sexes. Obesity and insulin treatment seem to have greater impact on cancer risk among women.

Diabetes as a risk factor of hospitalization in the surgical ward due to cancer in the elderly and middle-aged population

INTRODUCTION

Diabetes can be considered as a risk factor of several types of malignancy. Surgery is one of the primary methods of cancer treatment. The objective of this study was to evaluate the association between diabetes and hospital admissions to the surgery unit due to malignancy among elderly and middle-aged people.

MATERIAL AND METHODS

Data for analysis were taken from the medical records of 7,694 patients aged > 45, hospitalized in the General Surgery Ward in the Specialist District Hospital in Stalowa Wola in the Subcarpathian (Podkarpacie) Province, Poland, in the years 2010-2013. Among them malignancy was diagnosed in 652 patients and diabetes in 370 subjects. Ninety-three patients suffered from both diabetes and cancer.

RESULTS

Diabetes was associated with significantly elevated risk of hospitalization due to malignancy compared with the non-diabetic population, odds ratio (OR) 4.051 (95% confidence interval: 3.154-5.203), p < 0.001. Among people with diabetes, elderly patients (> 65 years) had higher risk of hospital admission due to cancer compared with the middle-aged population, OR = 5.238 (2.873-9.550), p < 0.001. Also, urban residents had higher risk compared with rural inhabitants, OR = 2.272 (1.375-3.752), p = 0.002.

CONCLUSIONS

Patients with diabetes, especially elderly and urban inhabitants, are at high risk of hospital admission due to malignancy. This indicates the need for oncological vigilance in such patients for early detection and treatment of cancers common in this population.

Type 2 diabetes mellitus and risk of hepatocellular carcinoma: spotlight on nonalcoholic fatty liver disease

The incidence of both type 2 diabetes mellitus (T2DM) and multiple cancer types are rapidly increasing worldwide. Several studies documented that T2DM is closely associated with an increased incidence of cancer. However, while some methodological considerations preclude a definitive association between T2DM and the risk of certain cancers, the relationship between T2DM and increased risk of incident hepatocellular carcinoma (HCC) remains significant even after adjustment for detection bias and reverse causation, indicating that such association is clinically reliable and robust. In addition, a number of observational studies also showed that T2DM is associated with higher mortality among persons with HCC. Some recent meta-analyses suggested that treatment with metformin may be associated with a lower risk of HCC, and may also beneficially influence HCC prognosis, whereas treatment with sulphonylureas or insulin seems to be related to a higher HCC risk. The underlying biological mechanisms linking T2DM and HCC are complex and difficult to elucidate, but the existence of close inter-connections among T2DM, obesity and nonalcoholic fatty liver disease (NAFLD) induces hepatic/systemic insulin resistance and causes the release of multiple pro-inflammatory cytokines, vasoactive factors and pro-oxidant molecules, which are all potentially implicated in the development and progression of HCC. In this clinical review, we discuss the epidemiological evidence linking T2DM to the risk of HCC. Moreover, we also briefly discuss the putative underlying mechanisms linking T2DM, NAFLD and HCC, and the potential effect of certain hypoglycemic agents on the risk of developing HCC.

Epidemiology of Hepatocellular Carcinoma in the Asia-Pacific Region

Hepatocellular carcinoma (HCC) is the predominant primary liver cancer in many countries and is the third most common cause of cancer-related death in the Asia-Pacific region. The incidence of HCC is higher in men and in those over 40 years old. In the Asia-Pacific region, chronic hepatitis B virus and hepatitis C virus infections are the main etiological agents; in particular, chronic hepatitis B infection (CHB) is still the major cause in all Asia-Pacific countries except for Japan. Over the past two decades, the incidence of HCC has remained stable in countries in the region except for Singapore and Hong Kong, where the incidence for both sexes is currently decreasing. Chronic hepatitis C infection (CHC) is an important cause of HCC in Japan, representing 70% of HCCs. Over the past several decades, the prevalence of CHC has been increasing in many Asia-Pacific countries, including Australia, New Zealand, and India. Despite advancements in treatment, HCC is still an important health problem because of the associated substantial mortality. An effective surveillance program could offer early diagnosis and hence better treatment options. Antiviral treatment for both CHB and CHC is effective in reducing the incidence of HCC.

Prognostic nomogram for patients with non-B non-C hepatocellular carcinoma after curative liver resection

BACKGROUND

The proportion of the both serum hepatitis B surface antigen and hepatitis C antibody negative hepatocellular carcinoma (NBNC HCC) patients are tended to increase recently. We investigated the characteristics and surgical outcome for those patients after liver resection.

METHODS

Four hundred and thirty-five NBNC patients were involved in our study. According to the results of the HBcAb in the serum, those patients were divided into HBcAb-positive subgroup (n = 328) and HBcAb-negative subgroup (n = 107). Based on the multivariate risk factors, the nomogram was constructed for predicting the possibility for over survival (OS) rate.

RESULTS

For all of the NBNC HCC patients, the median OS was 57 months with 5-year OS rate 54.0%. The positive HBcAb NBNC patients were associating with a better liver function (p = 0.026), higher AFP (p < 0.001) and more proportion of micro-vascular invasion (p = 0.001). Multivariate analysis revealed that worse liver function (Child-Pugh B, HR = 1.93; 95% CI: 1.23-3.04), vascular invasion (MIVI vs negative, HR = 1.86; 95% CI: 1.21-2.86, MAVI vs negative, HR = 2.05; 95% CI: 1.37-3.06), poorer ES differentiation (HR = 2.34; 95% CI: 1.67-3.30) and larger tumor size (HR = 1.10; 95% CI: 1.06-1.15) were associated with the worse OS.

CONCLUSION

We established a novel prognostic nomogram to predict the OS of NBNC HCC patients after liver resection. The prognosis of NBNC HCC was mainly determined by tumor stage and liver function not by the previous etiologies.

Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update

There is great geographical variation in the distribution of hepatocellular carcinoma (HCC), with the majority of all cases worldwide found in the Asia–Pacific region, where HCC is one of the leading public health problems. Since the “Toward Revision of the Asian Pacific Association for the Study of the Liver (APASL) HCC Guidelines” meeting held at the 25th annual conference of the APASL in Tokyo, the newest guidelines for the treatment of HCC published by the APASL has been discussed. This latest guidelines recommend evidence-based management of HCC and are considered suitable for universal use in the Asia–Pacific region, which has a diversity of medical environments.

The essential role of YAP O-GlcNAcylation in high-glucose-stimulated liver tumorigenesis

O-GlcNAcylation has been implicated in the tumorigenesis of various tissue origins, but its function in liver tumorigenesis is not clear. Here, we demonstrate that O-GlcNAcylation can enhance the expression, stability and function of Yes-associated protein (YAP), the downstream transcriptional regulator of the Hippo pathway and a potent oncogenic factor in liver cancer. O-GlcNAcylation induces transformative phenotypes of liver cancer cells in a YAP-dependent manner. An O-GlcNAc site of YAP was identified at Thr241, and mutating this site decreased the O-GlcNAcylation, stability, and pro-tumorigenic capacities of YAP, while increasing YAP phosphorylation. Importantly, we found via in vitro cell-based and in vivo mouse model experiments that O-GlcNAcylation of YAP was required for high-glucose-induced liver tumorigenesis. Interestingly, a positive feedback between YAP and global cellular O-GlcNAcylation is also uncovered. We conclude that YAP O-GlcNAcylation is a potential therapeutic intervention point for treating liver cancer associated with high blood glucose levels and possibly diabetes.

Yap is a transcriptional factor involved in tumorigenesis. Here the authors show that a previously unknown post-translational modification of Yap, O-GlcNAcylation, increases its transcriptional activity and is required for high glucose-induced liver cancer development.

Insulin resistance and the risk of hepatocellular carcinoma in chronic hepatitis B patients

BACKGROUND AND AIM

We analyzed whether insulin resistance (IR) assessed by homeostasis model assessment (HOMA2-IR) index can stratify hepatocellular carcinoma (HCC) risk in patients with chronic hepatitis B virus (HBV) infection.

METHODS

A retrospective cohort of 1696 chronic HBV-infected patients (age: 50.0 ± 7.8 years, men = 964 [56.8%]) who underwent detailed health checkup program including C-peptide and fasting blood glucose measurement and followed up for more than a year were analyzed.

RESULTS

During a median follow-up of 5.0 years (range, 1.0-10.5 years), 24 patients (1.4%) developed HCC. The HCC incidence rate was higher for patients with higher HOMA2-IR value than those with lower HOMA2-IR value (1.7% vs 0.5% for HOMA2-IR >1.200 vs ≤1.200, P = 0.009). HOMA2-IR was a significant factor associated with HCC development in multivariable-adjusted model (HR [95% CI]: 3.25 [1.13-9.31], adjusted for age, sex, cirrhosis, and HBV DNA levels). The association between HOMA2-IR and HCC was markedly attenuated and became no longer statistically significant (HR [95% CI]: 1.93 [0.57-6.51]) when further adjusted for obesity, hypertension, and diabetes. In subgroup analysis, HOMA2-IR value was an independent factor associated with HCC in patients without overt metabolic abnormalities (hypertension, diabetes, and metabolic syndrome) but not for those with overt metabolic abnormalities.

CONCLUSION

Insulin resistance assessed by HOMA2 was associated with the risk of HCC, indicating that HOMA2-IR can be a useful tool for stratifying the risk of HCC in chronic HBV-infected patients, particularly in patients without overt metabolic abnormalities.

Hepatocellular carcinoma in non-alcoholic steatohepatitis: Current knowledge and implications for management

With the prevalence of hepatitis C virus expected to decline, the proportion of hepatocellular carcinoma (HCC) related to non-alcoholic steatohepatitis (NASH) is anticipated to increase exponentially due to the growing epidemic of obesity and diabetes. The annual incidence rate of developing HCC in patients with NASH-related cirrhosis is not clearly understood with rates ranging from 2.6%-12.8%. While multiple new mechanisms have been implicated in the development of HCC in NASH; further prospective long-term studies are needed to validate these findings. Recent evidence has shown a significant proportion of patients with non-alcoholic fatty liver disease and NASH progress to HCC in the absence of cirrhosis. Liver resection and transplantation represent curative therapeutic options in select NASH-related HCC patients but have placed a significant burden to our healthcare resources and utilization. Currently NASH-related HCC is the fastest growing indication for liver transplant in HCC candidates. Increased efforts to implement effective screening and preventative strategies, particularly in non-cirrhotic NASH patients, are needed to reduce the future impact imposed by NASH-related HCC.

Type 2 Diabetes and Hepatocellular Carcinoma: Risk Factors and Pathogenesis

PURPOSE OF REVIEW

This review aims to assess the epidemiological evidence for a link between type 2 diabetes and hepatocellular carcinoma and to investigate possible pathophysiological mechanisms.

RECENT FINDINGS

The presence of type 2 diabetes significantly increases the risk of developing hepatocellular carcinoma, and treatment with metformin may be associated with a lower risk. Treatment with insulin and sulphonylureas may be associated with increased risk. The pathophysiology underlying development of hepatocellular carcinoma in this context is complex and is likely to involve increased proinflammatory mediators, oxidative stress, JNK-1 activation, increased IGF-1 activity, altered gut microbiota and immunomodulation. Hepatocellular carcinoma incidence is increasing and this is likely to be linked to the increasing incidence of type 2 diabetes, obesity and the metabolic syndrome. These conditions increase the risk of developing hepatocellular carcinoma, and a greater understanding of the underlying pathophysiology may help with the development of novel treatments.

The anti-diabetic drug exenatide, a glucagon-like peptide-1 receptor agonist, counteracts hepatocarcinogenesis through cAMP-PKA-EGFR-STAT3 axis

Epidemiological studies have demonstrated a close association of type 2 diabetes and hepatocellular carcinoma (HCC). Exenatide (Ex-4), a potent diabetes drug targeting glucagon-like peptide-1 receptor (GLP-1R), is protective against non-alcoholic fatty liver disease (NAFLD). However, the Ex-4 function and GLP-1R status have yet been explored in HCC. Herein we investigated the effect of Ex-4 in diethylnitrosamine (DEN)-treated mice consuming control or high-fat high-carbohydrate diet. Administration of Ex-4 significantly improved obesity-induced hyperglycemia and hyperlipidemia and reduced HCC multiplicity in obese DEN-treated mice, in which suppressed proliferation and induced apoptosis were confined to tumor cells. The tumor suppression effects of Ex-4 were associated with high expression of GLP-1R and activation of cyclic AMP (cAMP) and protein kinase A (PKA). Importantly, Ex-4 also downregulated epidermal growth factor receptor (EGFR) and signal transducer and activator of transcription 3 (STAT3), which lie downstream of cAMP-PKA signaling, resulting in suppression of multiple STAT3-targeted genes including c-Myc, cyclin D1, survivin, Bcl-2 and Bcl-xl. The growth inhibitory effects of Ex-4 were consistent in GLP-1R-abundant hepatoma cell lines and xenograft mouse model, wherein both PKA and EGFR had obligatory roles in mediating Ex-4 functions. In addition, Ex-4 also effectively suppressed inflammatory and fibrotic phenotypes in mice fed with methionine-choline-deficient (MCD) diet and choline-deficient ethionine-supplemented (CDE) diet, respectively. In summary, Ex-4 elicits protective functions against NAFLD and obesity-associated HCC through cAMP-PKA-EGFR-STAT3 signaling, suggesting its administration as a novel approach to reduce HCC risk in diabetic patients.

GFD-Net: A novel semantic similarity methodology for the analysis of gene networks

Since the popularization of biological network inference methods, it has become crucial to create methods to validate the resulting models. Here we present GFD-Net, the first methodology that applies the concept of semantic similarity to gene network analysis. GFD-Net combines the concept of semantic similarity with the use of gene network topology to analyze the functional dissimilarity of gene networks based on Gene Ontology (GO). The main innovation of GFD-Net lies in the way that semantic similarity is used to analyze gene networks taking into account the network topology. GFD-Net selects a functionality for each gene (specified by a GO term), weights each edge according to the dissimilarity between the nodes at its ends and calculates a quantitative measure of the network functional dissimilarity, i.e. a quantitative value of the degree of dissimilarity between the connected genes. The robustness of GFD-Net as a gene network validation tool was demonstrated by performing a ROC analysis on several network repositories. Furthermore, a well-known network was analyzed showing that GFD-Net can also be used to infer knowledge. The relevance of GFD-Net becomes more evident in Section "GFD-Net applied to the study of human diseases" where an example of how GFD-Net can be applied to the study of human diseases is presented. GFD-Net is available as an open-source Cytoscape app which offers a user-friendly interface to configure and execute the algorithm as well as the ability to visualize and interact with the results(http://apps.cytoscape.org/apps/gfdnet).

Diabetes mellitus increases the risk of hepatocellular carcinoma in treatment-naïve chronic hepatitis C patients in China

We investigated the link between diabetes mellitus (DM) and hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) risk in treatment-naïve chronic hepatitis C (CHC) patients in China.To examine the association between DM and HCC, we conducted a case-control study of 300 Chinese CHC patients with HCC, compared to an age- and sex-matched control group of 517 CHC patients not diagnosed with HCC.We found that DM was more prevalent in the HCC patient group (18.7%) than in the CHC-only patient group (10.8%). We conducted logistic regression analyses adjusting for demographics features and other HCC risk factors and found that DM increased the risk of HCC development nearly 2-fold [adjusted odds ratio (AOR), 95% confidence interval (95% CI), 1.80 (1.17-2.75)]. Meanwhile, the proportion of HCC patients and CHC-only patients with liver cirrhosis were 79.3% and 46.2%, respectively, yielding an AOR of 4.62 (95% CI, 3.31-6.46). Multivariate analyses comparing the risk of HCV-related HCC development in DM patients with and without liver cirrhosis revealed that the estimated AOR (95% CI) for those with liver cirrhosis was 5.60 (2.25-13.96). However, the HCC risk decreased significantly with a later age of diabetes onset (AOR [95% CI], 0.94 [0.89-0.99]).DM was associated with an increased risk for HCC development in treatment-naïve CHC patients in China. Furthermore, liver cirrhosis and an early DM diagnoses further increased the risks of HCC development in patients diagnosed with both CHC and DM.

Breath-print analysis by e-nose may refine risk stratification for adverse outcomes in cirrhotic patients

BACKGROUND & AIMS

The spectrum of volatile organic compounds in the exhaled breath (breath-print, BP) has been shown to characterize patients with cirrhosis and with worse hepatic function. However, the association of different BPs with clinically relevant outcomes has not been described yet. Hence, we aimed to evaluate the association between BPs, mortality and hospitalization in cirrhotic patients and to compare it with that of the "classical" prognostic indices (Child-Pugh Classification [CPC] and MELD).

METHODS

Eighty-nine cirrhotic patients (M/F 59/30, mean age 64.8 ± 11.3, CPC A/B/C 37/33/19) were recruited and followed up for a median time of 23 months. Clinical and biochemical data were collected. Breath collection and analysis were obtained through Pneumopipe^® and BIONOTE e-nose respectively.

RESULTS

Four different BP clusters (A, B, C, D) were identified. BP clusters A and D were associated with a significantly increased risk of mortality (HR 2.9, 95% confidence intervals [CI] 1.5-5.6) and hospitalization (HR 2.6, 95% CI 1.4-4.6), even in multiple adjusted models including CPC and MELD score (adjusted [a]HR 2.8, 95% CI 1.1-7.0 for mortality and aHR 2.2, 95% CI 1.1-4.2 for hospitalization). CPC C maintained the strongest association with both mortality (aHR 17.6, 95% CI 1.8-174.0) and hospitalization (aHR 12.4, 95% CI 2.0-75.8).

CONCLUSIONS

This pilot study demonstrates that BP clusters are associated with significant clinical endpoints (mortality and hospitalization) even independently from "classical" prognostic indices. Even though further studies are warranted on this topic, our findings suggest that the e-nose may become an adjunctive aid to stratify the risk of adverse outcomes in cirrhotic patients.

Chronic hepatitis B and fatty liver: Issues in clinical management

With an increasing incidence of non-alcoholic fatty livers, the existence of concomitant hepatitis B and fatty liver is becoming more common in clinical practice. In clinical practice, the concomitant existence of hepatitis B and fatty livers raises practical issues in clinical management. It becomes more difficult for the clinician to decide on the mode of treatment in the case of elevated Alanine aminotransferase (ALT) and in deciding potential causes, whether they are related to chronic hepatitis B or to non-alcoholic steatohepatitis (NASH). With evolving changes in the practice and knowledge of non-alcoholic fatty liver disease and chronic hepatitis B, clinical judgment on the predominant disease becomes essential for their coexistence. This short review is aimed at reviewing the evidence available on the frequency of the two diseases existing concomitantly, possible ways of differentiating the two, the prognosis, outcomes of treatment and a possible common pathway.

Diabetes Mellitus Heightens the Risk of Hepatocellular Carcinoma Except in Patients With Hepatitis C Cirrhosis

OBJECTIVES

As most hepatocellular carcinoma (HCC) patients have cirrhosis, the association between diabetes and HCC may be confounded by the fact that diabetes is common in patients with cirrhosis. The aim of this study is to investigate whether diabetes increases the risk of HCC in patients with cirrhosis and whether the etiology of liver disease modifies the association between diabetes and HCC.

METHODS

All liver cirrhosis patients who had repeated radiographic evaluation of the liver (that is, ultrasound, computed tomography, or magnetic resonance image) at Mayo Clinic Rochester between January 2006 and December 2011 were included. The Cox proportional hazard regression analysis was used to investigate the effect of diabetes on the risk of HCC.

RESULTS

A total of 739 patients met the eligibility criteria, of whom 253 (34%) had diabetes. After a median follow-up of 38 months, 69 (9%) patients developed HCC. In patients without hepatitis C virus (HCV) infection, diabetes was significantly associated with the risk of developing HCC (hazard ratio (HR)=2.1, 95% confidence interval (CI)=1.1-4.1), whereas in patients with HCV, there was no association (HR=0.8, 95% CI=0.4-1.8). When adjusted for covariates, the interaction between HCV and diabetes remained significant (HR for non-HCV=1.9, 95% CI=0.9-3.7; HR for HCV=0.6, 95% CI=0.2-1.3). Lack of association between diabetes and HCC was externally validated in 410 patients with HCV cirrhosis enrolled in the HALT-C trial.

CONCLUSIONS

Diabetes increases the risk of HCC in patients with non-HCV cirrhosis. In HCV cirrhosis patients who already have very high risk, diabetes may not increase the risk any further.