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

Molecular and Functional Roles of MicroRNAs in the Progression of Hepatocellular Carcinoma-A Review

Liver cancer is the fourth leading cause of cancer deaths globally, of which hepatocellular carcinoma (HCC) is the major subtype. Viral hepatitis B and C infections, alcohol abuse, and metabolic disorders are multiple risk factors for liver cirrhosis and HCC development. Although great therapeutic advances have been made in recent decades, the prognosis for HCC patients remains poor due to late diagnosis, chemotherapy failure, and frequent recurrence. MicroRNAs (miRNAs) are endogenous, non-coding RNAs that regulate various molecular biological phenomena by suppressing the translation of target messenger RNAs (mRNAs). miRNAs, which often become dysregulated in malignancy, control cell proliferation, migration, invasion, and development in HCC by promoting or suppressing tumors. Exploring the detailed mechanisms underlying miRNA-mediated HCC development and progression can likely improve the outcomes of patients with HCC. This review summarizes the molecular and functional roles of miRNAs in the pathogenesis of HCC. Further, it elucidates the utility of miRNAs as novel biomarkers and therapeutic targets.

Electronic health record alerts enhance mass screening for chronic hepatitis B

To measure the effect of an electronic health record (EHR) alert on chronic hepatitis B (CHB) screening among at-risk Asian and Pacific Islanders (API). API patients who had not yet completed hepatitis B surface antigen (HBsAg) testing were identified by a novel EHR-based population health tool. At-risk API patients in Cohort 1 (primarily privately insured) and Cohort 2 (includes Medicare and/or Medicaid) were randomized to alert activation in their electronic medical charts or not. In total, 8299 API were found to be deficient in HBsAg completion at baseline within our health system. In Cohort 1, 1542 patients and 1568 patients were randomized to the alert and control respectively. In Cohort 2, 2599 patients and 2590 patients were randomized to the alert and control respectively. For both cohorts combined, 389 HBsAg tests were completed in the alert group compared to 177 HBsAg tests in the control group (p < 0.0001; OR = 2.3; 95% CI 1.94-2.80), but there was no increased detection of HBsAg positivity from the alert (15 versus 13 respectively, p = 0.09; OR = 0.5; 95% CI 0.24-1.09). Our results demonstrate that personalized, automated electronic alerts increase screening for CHB, but more comprehensive measures are needed to detect HBsAg positive patients.NIH Trial Registry Number: NCT04240678.

An Integrating Immune-Related Signature to Improve Prognosis of Hepatocellular Carcinoma

Growing evidence suggests that the superiority of long noncoding RNAs (lncRNAs) and messenger RNAs (mRNAs) could act as biomarkers for cancer prognosis. However, the prognostic marker for hepatocellular carcinoma with high accuracy and sensitivity is still lacking. In this research, a retrospective, cohort-based study of genome-wide RNA-seq data of patients with hepatocellular carcinoma was carried out, and two protein-coding genes (GTPBP4, TREM-1) and one lncRNA (LINC00426) were sorted out to construct an integrative signature to predict the prognosis of patients. The results show that both the AUC and the C-index of this model perform well in TCGA validation dataset, cross-platform GEO validation dataset, and different subsets divided by gender, stage, and grade. The expression pattern and functional analysis show that all three genes contained in the model are associated with immune infiltration, cell proliferation, invasion, and metastasis, providing further confirmation of this model. In summary, the proposed model can effectively distinguish the high- and low-risk groups of hepatocellular carcinoma patients and is expected to shed light on the treatment of hepatocellular carcinoma and greatly improve the patients' prognosis.

Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis

BACKGROUND & AIMS

Accurate estimates for the contemporary burden of chronic liver disease (CLD) are vital for setting clinical, research, and policy priorities. We aimed to review the incidence, prevalence, and mortality of CLD and its resulting complications, including cirrhosis and hepatocellular carcinoma (HCC).

METHODS

We reviewed the published literature on the incidence, prevalence, trends of various etiologies of CLD and its resulting complications. In addition, we provided updated data from the Centers for Disease Control and Global Burden of Disease Study on the morbidity and mortality of CLD, cirrhosis, and hepatocellular carcinoma (HCC). Lastly, we assessed the strengths and weaknesses of available sources of data in hopes of providing important context to these national estimates of cirrhosis burden.

RESULTS

An estimated 1.5 billion persons have CLD worldwide and the age-standardized incidence of CLD and cirrhosis is 20.7/100,000, a 13% increase since 2000. Similarly, cirrhosis prevalence and mortality has increased in recent years in the United States. The epidemiology of CLD is shifting, reflecting implementation of large-scale hepatitis B vaccination and hepatitis C treatment programs, the increasing prevalence of the metabolic syndrome, and increasing alcohol misuse.

CONCLUSIONS

The global burden of CLD and cirrhosis is substantial. Although vaccination, screening, and antiviral treatment campaigns for hepatitis B and C have reduced the CLD burden in some parts of the world, concomitant increases in injection drug use, alcohol misuse, and metabolic syndrome threaten these trends. Ongoing efforts to address CLD-related morbidity and mortality require accurate contemporary estimates of epidemiology and outcomes.

Long noncoding RNA MIR4435-2HG promotes hepatocellular carcinoma proliferation and metastasis through the miR-22-3p/YWHAZ axis

Long noncoding RNAs (lncRNAs) play the critical biological role in many malignant tumours. MIR4435-2HG has been proven to be a novel oncogenic lncRNA. However, the exact role and mechanism of MIR4435-2HG in hepatocellular carcinoma (HCC) remain unclear. Here, we found that MIR4435-2HG is overexpressed in HCC tissue compared to normal controls and that high level of MIR4435-2HG indicates a poorer prognosis in HCC patients. MIR4435-2HG enhances the growth and metastasis ability of HCC cells. MIR4435-2HG promotes the expression of YWHAZ by sponging miR-22-3p to liberate YWHAZ mRNA transcripts. MIR4435-2HG facilitates the proliferation and metastasis of HCC by modulating the miR-22-3p/YWHAZ axis. These results demonstrated the role and mechanism of MIR4435-2HG in malignant progression of HCC. MIR4435-2HG may be used as the prognostic marker and treatment target for the patient with HCC.

LncUBE2R2-AS1 acts as a microRNA sponge of miR-302b to promote HCC progression via activation EGFR-PI3K-AKT signaling pathway

Hepatocellular carcinoma (HCC) is a main cause of cancer-related deaths globally. Long non-coding RNAs (lncRNAs) play important roles in diverse cancers. LncRNA-UBE2R2-AS1 has been reported to promote apoptosis in glioma cell. However, the expressions, functions, and mechanisms of action of UBE2R2-AS1 in HCC are still unclear. UBE2R2-AS1 is increased in HCC tissues and cell lines. Increased expression of UBE2R2-AS1 is associated with large tumor size, multiple tumor number, advanced TNM stage, and poor survival of HCC patients. Functional experiments showed that knockdown UBE2R2-AS1 inhibited HCC growth and metastasis through in vitro and in vivo experiments. Regarding the mechanism, UBE2R2-AS1/miR-302b/EGFR established the ceRNA network involved in the modulation of cell progression of HCC cells via activation of PI3K-AKT signaling pathway. Overall, UBE2R2-AS1 may exhibit an oncogenic function in HCC via acting as a sponge for miR-302b to up-regulate EGFR, and may serve as a potential therapeutic target and a prognostic biomarker for HCC patients.

Construction of Ginsenoside Nanoparticles with pH/Reduction Dual Response for Enhancement of Their Cytotoxicity Toward HepG2 Cells

The aim of this study is to construct a pH- and reduction-responsive nanodrug delivery system to effectively deliver a ginsenoside (Rh₂) and enhance its cytotoxicity against human hepatocarcinoma cells (HepG2). Here, pullulan polysaccharide was grafted by urocanic acid and α-lipoic acid (α-LA) to obtain a copolymer, α-LA-conjugated N-urocanyl pullulan (LA-URPA), which was expected to have pH and redox dual response. Then, the copolymer LA-URPA was used to encapsulate ginsenoside Rh₂ to form Rh₂ nanoparticles (Rh₂ NPs). The results showed that Rh₂ NPs exhibited an average size of 119.87 nm with a uniform spherical morphology. Of note, Rh₂ NPs showed a high encapsulation efficiency of 86.00%. Moreover, Rh₂ NPs possessed excellent pH/reduction dual-responsive drug release under acidic conditions (pH 5.5) and glutathione (GSH) stimulation with a low drug leakage of 14.8% within 96 h. Furthermore, Rh₂ NPs with pH/reduction dual response had higher cytotoxicity than Rh₂ after incubation with HepG2 cells for 72 h, indicating that Rh₂ NPs had a longer circulation time. After the treatment with Rh₂ NPs, the excessive increase of reactive oxygen species and the decrease of superoxide dismutase, glutathione (GSH), and mitochondrial membrane potential suggested that the mitochondrial pathway mediated by oxidative stress played a role in this Rh₂ NP-induced apoptosis. In conclusion, this study provides a new strategy for improving the application of ginsenoside Rh₂ in the food and pharmaceutical fields.

Towards precision public health: Geospatial analytics and sensitivity/specificity assessments to inform liver cancer prevention

Objectives

Liver cancer (LC) continues to rise, partially due to limited resources for prevention. To test the precision public health (PPH) hypothesis that fewer areas in need of LC prevention could be identified by combining existing surveillance data, we compared the sensitivity/specificity of standard recommendations to target geographic areas using U.S. Census demographic data only (percent (%) Hispanic, Black, and those born 1950–1959) to an alternative approach that couples additional geospatial data, including neighborhood socioeconomic status (nSES), with LC disease statistics.

Methods

Pennsylvania Cancer Registry data from 2007-2014 were linked to 2010 U.S. Census data at the Census tract (CT) level. CTs in the top 80th percentile for 3 standard demographic variables, %Hispanic, %Black, %born 1950–1959, were identified. Spatial scan statistics (SatScan) identified CTs with significantly elevated incident LC rates (p-value<0.05), adjusting for age, gender, diagnosis year. Sensitivity, specificity, and positive predictive value (PPV) of a CT being located in an elevated risk cluster and/or testing positive/negative for at least one standard variable were calculated. nSES variables (deprivation, stability, segregation) significantly associated with LC in regression models (p < 0.05) were systematically evaluated for improvements in sensitivity/specificity.

Results

9,460 LC cases were diagnosed across 3,217 CTs. 1,596 CTs were positive for at least one of 3 standard variables. 5 significant elevated risk clusters (CTs = 402) were identified. 324 CTs were positive for a high risk cluster AND standard variable (sensitivity = 92%; specificity = 37%; PPV = 17.4%). Incorporation of 3 new nSES variables with one standard variable (%Black) further improved sensitivity (93%), specificity (62.9%), and PPV (26.3%).

Conclusions

We introduce a quantitative assessment of PPH by applying established sensitivity/specificity assessments to geospatial data. Coupling existing disease cluster and nSES data can more precisely identify intervention targets with a liver cancer burden than standard demographic variables. Thus, this approach may inform prioritization of limited resources for liver cancer prevention.

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Precision Public Health calls for linking surveillance data to identify fewer neighborhoods for intervention.

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Sensitivity/specificity methods can measure the utility of Precision Public Health by identifying optimal data combinations.

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Select combinations of linked Census and liver cancer registry data reduced neighborhood targets more than Census data alone.

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Precision Public Health improves the prioritization of liver cancer prevention efforts.

Digitoxin inhibits proliferation of multidrug-resistant HepG2 cells through G2/M cell cycle arrest and apoptosis

Hepatocellular carcinoma (HCC) remains a challenge in the medical field due to its high malignancy and mortality rates particularly for HCC, which has developed multidrug resistance. Therefore, the identification of efficient chemotherapeutic drugs for multidrug resistant HCC has become an urgent issue. Natural products have always been of significance in drug discovery. In the present study, a cell-based method was used to screen a natural compound library, which consisted of 78 compounds, and the doxorubicin-resistant cancer cell line, HepG2/ADM, as screening tools. The findings of the present study led to the shortlisting of one of the compounds, digitoxin, which displayed an inhibitory effect on HepG2/ADM cells, with 50% inhibitory concentration values of 132.65±3.83, 52.29±6.26, and 9.13±3.67 nM for 24, 48, and 72 h, respectively. Immunofluorescence, western blotting and cell cycle analyses revealed that digitoxin induced G₂/M cell cycle arrest via the serine/threonine-protein kinase ATR (ATR)-serine/threonine-protein kinase Chk2 (CHK2)-M-phase inducer phosphatase 3 (CDC25C) signaling pathway in HepG2/ADM cells, which may have resulted from a DNA double-stranded break. Digitoxin also induced mitochondrial apoptosis, which was characterized by changes in the interaction between Bcl-2 and Bax, the release of cytochrome c, as well as the activation of the caspase-3 and −9. To the best of our knowledge, the present study is the first report that digitoxin displays an anti-HCC effect on HepG2/ADM cells through G₂/M cell cycle arrest, which was mediated by the ATR-CHK2-CDC25C signaling pathway and mitochondrial apoptosis. Therefore, digitoxin could be a promising chemotherapeutic agent for the treatment of patients with HCC.

Emerging Evidence for Infectious Causes of Cancer in the United States

Worldwide, infectious agents currently contribute to an estimated 15% of new cancer cases. Most of these (92%, or 2 million new cancer cases) are attributable to 4 infectious agents: Helicobacter pylori, human papillomavirus, and hepatitis B and C viruses. A better understanding of how infectious agents relate to the US cancer burden may assist new diagnostic and treatment efforts. We review US-specific crude mortality rates from infection-associated cancers and describe temporal and spatial trends since 1999. We review the US-specific evidence for infection-cancer associations by reporting available estimates for attributable fractions for the infection-cancer associations. Death due to cancers with established infectious associations varies geographically, but estimates for the US attributable fraction are limited to a few observational studies. To describe the burden of infection-associated cancer in the United States, additional observational studies are necessary to estimate the prevalence of infection nationally and within subpopulations. As infectious associations emerge to explain cancer etiologies, new opportunities and challenges to reducing the burden arise. Improved estimates for the United States would help target interventions to higher-risk subpopulations.

Epigenetic changes associated with mechanisms of disparities in hepatocellular carcinoma

In addition to socioeconomic influences, biological factors are believed to play a role in health disparities. In this paper, we investigate miRNA, mRNA, and DNA methylation patterns that contribute to disparities in hepatocellular carcinoma (HCC). This is accomplished by integration of mRNA-Seq, miRNA-Seq, and DNA methylation data we acquired by analysis of liver tissues from 30 HCC patients consisting of European Americans (EAs), African Americans (AAs), and Asian Americans (Asians). Mixed-ANOVA models are applied to identify miRNAs, mRNAs, and DNA methylation sites that are significantly altered in tumor vs. adjacent normal tissues in a race-specific manner. Through integrated analysis, a refined list of differentially expressed mRNAs is obtained by selecting those that are targets of differentially expressed miRNAs and consist of promoter regions that are differentially methylated.

Geographic Variations of Potentially Curative Treatments for Hepatocellular Carcinoma in the United States: A SEER-Medicare Study

Background: Transplantation, surgical resection, radiofrequency ablation, and percutaneous ethanol injection are generally considered potentially curative treatments for patients with hepatocellular carcinoma (HCC). With the increasing incidence of HCC, it is critical to investigate geographic variations in curative treatments and their associations with survival among patients. Methods: A total of 6,782 patients with HCC during 2004 to 2011 were identified in the SEER-Medicare linked database and placed in quartiles based on the proportions undergoing potentially curative treatments per hospital referral region (HRR). Hierarchical Cox proportional hazards models were used to examine the association between regional potentially curative treatment patterns and survival across quartiles. Results: An average of 16.9% of patients with HCC underwent potentially curative treatments during 2004 to 2011, varying substantially from 0% to 34.5% across HRRs. Compared with patients residing in the lowest-quartile regions, those in the highest-quartile regions were more likely to be of other races (vs white or black), be infected with hepatitis B virus, and have more comorbidities. The 5-year survival was 4.7% in the lowest-quartile regions and 11.4% in the highest-quartile regions (P<.001). After controlling for confounders, patients in the highest-quartile regions had a lower risk of mortality (adjusted hazard ratio, 0.78; 95% CI, 0.72–0.85). Conclusions: Patients with HCC who resided in HRRs with higher proportions of potentially curative treatments had better survival. Given its proven survival benefits, prompt clinical and policy actions are needed to reduce variations in treatment utilization.

Surveillance for Hepatocellular Carcinoma in Patients with Non-Alcoholic Fatty Liver Disease: Universal or Selective?

Hepatocellular carcinoma (HCC), the most frequent primary liver cancer, is the sixth most common cancer, the fourth leading cause of cancer-related deaths worldwide, and accounts globally for about 800,000 deaths/year. Early detection of HCC is of pivotal importance as it is associated with improved survival and the ability to apply curative treatments. Chronic liver diseases, and in particular cirrhosis, are the main risk factors for HCC, but the etiology of liver disease is rapidly changing due to improvements in the prevention and treatment of HBV (Hepatitis B virus) and HCV (Hepatitis C virus) infections and to the rising incidence of the metabolic syndrome, of which non-alcoholic fatty liver (NAFLD) is a manifestation. NAFLD is now a recognized and rapidly increasing cause of cirrhosis and HCC. Indeed, the most recent guidelines for NAFLD management recommend screening for HCC in patients with established cirrhosis. Screening in NAFLD patients without cirrhosis is not recommended; however, the prevalence of HCC in this group of NAFLD patients has been reported to be as high as 38%, a proportion significantly higher than the one observed in the general population and in non-cirrhotic subjects with other causes of liver disease. Unfortunately, solid data regarding the risk stratification of patients with non-cirrhotic NAFLD who might best benefit from HCC surveillance are scarce, and specific recommendations in this field are urgently needed due to the increasing NAFLD epidemic, at least in Western countries. To further complicate matters, liver ultrasonography, which represents the current standard for HCC surveillance, has a decreased diagnostic accuracy in patients with NAFLD, and therefore disease-specific surveillance tools will be required for the early identification of HCC in this population. In this review, we summarize the most recent evidence on the epidemiology and risk factors for HCC in patients with NAFLD, with and without cirrhosis, and the evidence supporting surveillance for early HCC detection in these patients, reviewing the potential limitations of currently recommended surveillance strategies, and assessing data on the accuracy of potential new screening tools. At this stage it is difficult to propose general recommendations, and best clinical judgement should be exercised, based on the profile of risk factors specific to each patient.

Disparities in utilization of services for racial and ethnic minorities with hepatocellular carcinoma associated with hepatitis C

BACKGROUND

Hepatitis C affects racial minorities disproportionately and is greatest among the black population. The incidence of hepatocellular carcinoma has increased with the largest increase observed in black and Hispanic populations, but limited data remain on whether hepatitis C hepatocellular carcinoma in racial-ethnic minorities have the same utilization of services compared with the white population.

METHODS

We used the database of the National Inpatient Sample to identify hepatitis C-hepatocellular carcinoma patients (N = 200,163) who underwent liver transplantation (n = 11,491), liver resection (n = 4,896), or ablation of liver lesions (n = 6,933) from 2005 to 2015. We estimated utilization over time and assessed differences in utilization and inpatient mortality across patient characteristics.

RESULTS

In multivariate analysis, factors associated with utilization of services included treatment year, sex, race, insurance status, hospital type, and comorbidity burden, with black and Hispanic patients having statistically significantly decreased utilization. Factors associated with inpatient mortality included treatment year, sex, race, insurance status, hospital type, hospital region, and comorbidity burden, with black patients having a statistically significantly greater risk of inpatient mortality.

CONCLUSION

We identified racial and socioeconomic factors which were associated with utilization of services and inpatient mortality for patients with hepatitis C hepatocellular carcinoma. Blacks were especially disadvantaged in the receipt of care. Further work to abrogate these findings is imperative to ensure equitable provision of surgical therapies.

Integrating Palliative Care in the Management of Patients With Advanced Liver Disease

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-patel a video presentation of this article.

A descriptive study of racial inequalities in mortality from hepatocellular cancer before and after licensure of lifesaving drugs for hepatitis C virus in the United States

BACKGROUND

Since 1979, mortality from hepatocellular cancer (HCC) has doubled in the United States (US). Lifesaving drugs, prohibitively expensive for some, were approved and marketed to treat hepatitis C virus (HCV), a major risk factor for HCC, beginning in 1997. After the prior introduction of other lifesaving innovations, including active retroviral drug therapy for human immunodeficiency virus and surfactant for respiratory distress syndrome of the newborn, racial inequalities in their mortalities increased in the US. In this descriptive study, we explored racial inequalities in mortality from HCC before and after licensure of HCV drugs in the US.

METHODS

The US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (WONDER) were used to describe HCC mortality rates from 1979 to 2016 in those 55 years of age and older, because they suffer the largest disease burden. Joinpoint regression was used to analyze trends. To estimate excess deaths, we applied White age-sex-specific rates to corresponding Black populations.

FINDINGS

From 1979 to 1998, racial inequalities in mortality from HCC in the US were declining but from 1998 to 2016 racial inequalities steadily increased. From 1998 to 2016, of the 16,770 deaths from HCC among Blacks, the excess relative to Whites increased from 27.8% to 45.4%, and the trends were more prominent in men. Concurrently, racial inequalities in mortality decreased for major risk factors for HCC, including alcohol, obesity and diabetes.

INTERPRETATION

These descriptive data, useful to formulate but not test hypotheses, demonstrate decreasing racial inequalities in mortality from HCC which were followed by increases after introduction of lifesaving drugs for HCV in the US. Among many plausible hypotheses generated are social side effects, including unequal accessibility, acceptability and/or utilization. Analytic epidemiological studies designed a priori to do so are necessary to test these and other hypotheses.

Among Medicare Patients With Hepatocellular Carcinoma, Non-alcoholic Fatty Liver Disease is the Most Common Etiology and Cause of Mortality

GOALS

The main purpose of this study was to assess the recent trends in mortality and health care utilization of hepatocellular carcinoma (HCC) among Medicare population in the United States.

BACKGROUND

The incidence of HCC is increasing in the United States.

MATERIALS AND METHODS

Data were obtained for a sample of Medicare beneficiary from 2005 to 2014. Diagnosis of HCC and etiology of liver disease were based on ICD-9 codes. Temporal trends in HCC rates, clinical, demographical and utilization parameters were analyzed by joinpoint regression model.

RESULTS

Study cohort included 13,648 Medicare recipients with HCC (mean age: 70.0 y, 62.8% male and 76.0% white). Non-alcoholic fatty liver disease (NAFLD) was the most common cause of HCC in the inpatient (32.07%) and outpatient (20.22%) followed by hepatitis C virus (HCV) (19.2% and 9.75%, respectively). Between 2005 and 2014, HCC rate per 100,000 Medicare recipients increased from 46.3 to 62.8 [average annual percentage change (AAPC) =3.4%, P<0.001]. Rate of HCV-HCC increased from 6.18 to 16.54 (AAPC=11.8%, P<0.001) while the NAFLD-HCC increased from 9.32 to 13.61, P<0.001). Overall 1-year mortality decreased from 46.2% to 42.1% (AAPC=-1.7%, P=0.004). Total charges increased from $67,679 to $99,420 (AAPC=5.1%, P<0.001) for inpatients and from $11,933 to $32,084 (P<0.001) for outpatients. On comparison of patients with hepatitis B virus-HCC, those with NAFLD-HCC (odds ratio: 1.87, P<0.001) had higher risk of mortality. On comparison of patients with hepatitis B virus-HCC, those with HCV-HCC had higher charges (percent change: 24.33%, 95% confidence interval: 1.02%-53.02%, P=0.040).

CONCLUSIONS

Although HCC rates are increasing, the overall mortality is decreasing. NAFLD is the most important cause of HCC and an independent predictor of HCC in the outpatient setting for Medicare patients with HCC.

The association between etiology of hepatocellular carcinoma and race-ethnicity in Florida

BACKGROUND AND AIM

The incidence of hepatocellular carcinoma (HCC) has risen considerably in the US since 1980. The main causes include metabolic disorders (NAFLD, diabetes, obesity, metabolic syndrome), alcohol-related disease (ALD) and hepatitis C and B virus infections (HCV, HBV). Etiology-specific HCC incidence rates by detailed race-ethnicity are needed to improve HCC control and prevention efforts.

METHODS

All HCC cases diagnosed in Florida during 2014-2015 were linked to statewide hospital discharge data to determine etiology. Age-specific and age-adjusted rates were used to assess the intersection between etiology and detailed racial-ethnicities, including White, African American, Afro-Caribbean, Asian, Cuban, Puerto Rican and Continental Hispanic (Mexican, South and Central American).

RESULTS

Of 3666 HCC cases, 2594 matched with discharge data. HCV was the leading cause of HCC among men and women (50% and 43% respectively), followed by metabolic disorders (25% and 37%) and ALD (16% and 9%). Puerto Rican and African American men had the highest HCV-HCC rates, 7.9 and 6.3 per 100 000 respectively. Age-specific rates for HCV-HCC peaked among baby boomers (those born in 1945-1965). Metabolic-HCC rates were highest among populations above age 70 and among Continental Hispanics. Afro-Caribbean men had high rates of HBV-HCC, whereas Puerto Rican men had high ALD-HCC.

CONCLUSIONS

HCC etiology is associated with specific race/ethnicity. While HCV-related HCC rates are projected to decrease soon, HCC will continue to affect Hispanics disproportionately, based on higher rates of metabolic-HCC (and ALD-HCC) among Continental Hispanics, who demographically represent 80% of all US Hispanics. Multifaceted approaches for HCC control and prevention are needed.

One-carbon metabolism-related micronutrients intake and risk for hepatocellular carcinoma: A prospective cohort study

Deficient intake of micronutrients involved in one-carbon metabolism (eg, choline, methionine, vitamin B₁₂ and folic acid) leads to hepatocellular carcinoma (HCC) development in rodents, but is under-investigated in humans. We investigated the association between one-carbon metabolism-related micronutrient intake and HCC risk in a prospective cohort of 494 860 participants with 16 years of follow-up in the NIH-AARP study. Dietary intakes and supplement use were ascertained at baseline using a food-frequency questionnaire. Total intake (diet plus supplements) of the following one-carbon metabolism-related micronutrients were calculated: folate, methionine and vitamins B₂ (riboflavin), B₃ (niacin), B₆ and B₁₂ . These micronutrients were examined both individually and simultaneously, with adjustment for covariates. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Over the 16-year follow-up period, 647 incident HCC cases were diagnosed. When examined individually, higher total vitamin B₃ intake was associated with a lower HCC risk (HR_{Q5 vs Q1} = 0.60; 95% CI = 0.42-0.85; P_trend = .008), and the association remained significant when all six micronutrients were examined simultaneously (HR_{Q5 vs Q1} = 0.32; 95% CI = 0.18-0.55; P_trend < .0001). Among participants with >3 years of follow-up, higher total vitamin B₃ intake was again associated with lower risk (HR_{Q5 vs Q1} = 0.37; 95% CI = 0.20-0.68; P_trend = .001), whereas higher total vitamin B₆ intake was associated with higher risk (HR_{Q5 vs Q1} = 2.04; 95% CI = 1.02-4.07; P_trend = .04). Restricted cubic spline analyses showed a dose-response inverse association between total vitamin B₃ intake and HCC risk, and dose-response positive association between total vitamin B₆ intake and HCC risk. The study suggests that higher vitamin B₃ intake is associated with lower HCC risk, whereas higher vitamin B₆ intake is associated with increased risk.

Have incidence rates of liver cancer peaked in the United States?

BACKGROUND

Liver cancer incidence has increased for several decades in the United States. Recently, reports have suggested that rates of hepatocellular carcinoma (HCC), the dominant form of liver cancer, had declined in certain groups. However, to the authors' knowledge, the most recent histology-specific liver cancer rates have not been reported to date.

METHODS

The authors examined the incidence of HCC and intrahepatic cholangiocarcinoma (ICC) from 1992 through 2016 using data from the Surveillance, Epidemiology, and End Results registries. Age-standardized incidence rates were calculated by histology, sex, race and/or ethnicity, and age. Trends were analyzed using the National Cancer Institute's Joinpoint Regression Program to estimate the annual percent change.

RESULTS

Between 2011 and 2016, HCC rates significantly declined (annual percent change, -1.9%), with more prominent declines noted among males, Asian/Pacific Islanders, and individuals aged <50 years. Conversely, ICC rates increased from 2002 through 2016.

CONCLUSIONS

Declining HCC rates may persist due to improved treatment of the hepatitis C virus and/or competing causes of mortality among individuals with fatty liver disease.

4,4'‑Bond secalonic acid D targets SP cells and inhibits metastasis in hepatocellular carcinoma

The existence of cancer stem cells (CSCs) is considered to be the main reason for chemoresistance, metastasis and the ultimate failure of treatment in hepatocellular carcinoma (HCC). However, there are a few chemical agents that may inhibit CSCs. The present study identified that 4,4'‑bond secalonic acid D (4,4'‑SAD), a compound isolated from the marine‑derived fungus Penicillium oxalicum, inhibited the growth of side population (SP) cells isolated from human liver cancer cell lines PLC/PRF/5 and HuH‑7 by attenuating the expression of ATP‑binding cassette superfamily G member 2. Furthermore, the results of wound healing, Transwell, western blotting and reverse transcription‑quantitative PCR assays demonstrated that 4,4'‑SAD suppressed the invasion and migration of SP cells by downregulating matrix metallopeptidase 9 (MMP‑9) and upregulating the antagonist tissue inhibitor of metalloproteinases 1 in vitro. Moreover, in vivo study results found that 4,4'‑SAD had anti‑lung metastasis efficacy via the decrease of MMP‑9 expression in the H22 HCC model of Kunming mice. Therefore, the present study identified the potential of 4,4'‑SAD as a promising candidate for the treatment of advanced liver cancer.

The polymorphism rs975484 in the protein arginine methyltransferase 1 gene modulates expression of immune checkpoint genes in hepatocellular carcinoma

Protein arginine methyltransferase 1 (PRMT1) is a key regulator of hepatic immune responses. Recently, we reported that PRMT1 regulates the tumor immune response in hepatocellular carcinoma (HCC). Here we found that PRMT1 expression in human HCC correlates with that of programmed cell death 1 ligand 1 (PD-L1), PD-L2, and other checkpoint genes. PRMT1 deletion in mice reduced PD-L1 and PD-L2 expression in tumors and reduced the efficiency of PD-1 antibody treatment in a diethylnitrosamine-induced HCC mouse model, suggesting that PRMT1 regulates the hepatic immune checkpoint. Mice had reduced PD-L1 and PD-L2 expression when PRMT1 was specifically deleted in tumor cells or macrophages, but PRMT1 deletion in dendritic cells did not alter PD-L1 and PD-L2 expression. rs975484 is a common polymorphism in the human PRMT1 gene promoter, and we found that it alters PRMT1 expression in blood monocytes and tumor-associated macrophages in human HCC. PRMT1 expression was higher in individuals with a GG genotype than in individuals with a CC genotype, and heterozygous carriers had intermediate expression. Luciferase reporter assays indicated that this differential expression is due to an extra C/EBPβ-binding site in the PRMT1 promoter of individuals carrying the minor G allele. The rs975484 genotype also correlated with PRMT1 target expression in HCC. Individuals with the GG genotype had significantly higher levels of the PRMT1 targets PD-L1, PD-L2, and VISTA than those with the CC genotype. We conclude that PRMT1 critically controls immune checkpoints in mice and humans and that the PRMT1 polymorphism rs975484 affects checkpoint gene expression in HCC.

Global incidence trends in primary liver cancer by age at diagnosis, sex, region, and etiology, 1990-2017

BACKGROUND

The incidence of primary liver cancer (PLC) continues to increase worldwide. The incidence trends and patterns of PLC associated with different age at diagnosis remain unknown.

METHODS

We collected detailed information on PLC between 1990 and 2017 from Global Burden of Disease Study 2017. Estimated annual percentage changes in the PLC age-standardized incidence rate (ASR) diagnosed by age, sex, region, and etiology were calculated to quantify the temporal trends in PLC ASR.

RESULTS

Globally, the number of PLC cases for which the age at diagnosis was <30 years decreased from 17,381 in 1990 to 14,661 in 2017, whereas the number of PLC cases diagnosed at age 30 to 59 and ≥60 years old increased from 216,561 and 241,189 in 1990 to 359,770 and 578,344 in 2017, respectively. The ASR of PLC cases with age at diagnosis <30 years and between 30 and 59 years decreased in both sexes, whereas the ASR of PLC with age at diagnosis ≥60 years increased in males and remained stable in females at the global level. Males had a more dramatic increase in PLC diagnosed at age ≥60 years but a milder decrease in PLC diagnosed between 30 and 59 years of age. This decrease was attributed largely to the reduction in PLC caused by hepatitis B and hepatitis C and was consistent in most regions except for developed countries, in which the ASR of PLC increased irrespective of sex and age. The ASR of PLC due to nonalcoholic steatohepatitis (NASH) increased by the greatest magnitude in most regions.

CONCLUSION

PLC in highly endemic regions has been partly alleviated due to the potent control of hepatitis, especially among young and middle-aged people. However, an unfavorable trend was observed in most developed countries and in elderly populations. As such, PLC prevention schedules should give more attention to NASH and elderly patients.

DSM-TACE of HCC: Evaluation of Tumor Response in Patients Ineligible for Other Systemic or Loco-Regional Therapies

PURPOSE

 To analyze tumor response, survival and safety in patients with non-resectable hepatocellular carcinoma (HCC) treated with transarterial hepatic chemoembolization using degradable starch microspheres (DSM-TACE) combined with doxorubicin who had no local interventional or systemic therapy alternative according to an interdisciplinary conference.

MATERIALS AND METHODS

 In this retrospective study, 28 patients (23 male, 5 female, median age 67 years) with unresectable HCC, serum bilirubin levels < 3 mg/dl and contraindications to Sorafenib, RFA, SIRT or cTACE were included. DSM-TACE was performed using Embocept^® S (15 ml) and doxorubicin (50 mg/25 ml) three times every 4-6 weeks. Patients were initially staged using the Barcelona Clinic Liver Cancer System (BCLC). Basic liver function was evaluated with the MELD-score. Tumor response was assessed using the modified Response Evaluation Criteria in Solid Tumors (mRECIST).

RESULTS

 DSM-TACE could be technically successfully performed in all 28 patients. At control imaging after three treatments, the overall rates of complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) were 14.3 %, 25 %, 39.3 % and 21.4 %, respectively, according to mRECIST. With regard to BCLC stages, the results were as follows (CR, PR, PD): BCLC A (n = 8): 7.1 %, 7.1 %, 10.7 %, 1.2 %; BCLC B (n = 12): 0 %, 10.7 %, 17.9 %, 14.3 %; BCLC C (n = 5): 0 %, 3.6 %, 10.7 %, 3.6 %; BCLC D (n = 3): 3.6 %, 3.6 %, 0 %, 3.6 %. According to this, DSM-TACE showed an overall good median survival of 682 days, although the patients' survival was strictly dependent on BCLC stage.

CONCLUSION

 DSM-TACE is a safe and promising treatment alternative for patients with unresectable HCC who are ineligible for other loco-regional therapies.

KEY POINTS

  · DSM-TACE is a safe treatment alternative for patients ineligible for other local or systemic treatments.. · DSM-TACE did not influence the MELD-score in our study population.. · Patients treated with DSM-TACE showed an overall good median survival of 682 days, strictly dependent on BCLC stage..

CITATION FORMAT

· Haubold J, Reinboldt MP, Wetter A et al. DSM-TACE of HCC: Evaluation of Tumor Response in Patients Ineligible for Other Systemic or Loco-Regional Therapies. Fortschr Röntgenstr 2020; 192: 862 - 869.

Hepatocellular Protein Arginine Methyltransferase 1 Suppresses Alcohol-Induced Hepatocellular Carcinoma Formation by Inhibition of Inducible Nitric Oxide Synthase

Alcohol is a well-established risk factor for hepatocellular carcinoma (HCC), but the mechanisms by which alcohol promotes liver cancer are not well understood. Studies suggest that ethanol may enhance tumor progression by increasing hepatocyte proliferation and through alcohol-induced liver inflammation. Protein arginine methyltransferase 1 (PRMT1) is the main enzyme responsible for cellular arginine methylation. Asymmetric dimethyl arginine, produced by PRMT1, is a potent inhibitor of nitric oxide synthases. PRMT1 is implicated in the development of several types of tumors and cardiovascular disease. Our previous work has shown that PRMT1 in the liver regulates hepatocyte proliferation and oxidative stress and protects from alcohol-induced liver injury. However, its role in HCC development remains controversial. In this study, we found that hepatocyte-specific PRMT1-knockout mice develop an increased number of tumors in an N-nitrosodiethylamine (DEN) alcohol model of liver tumorigenesis in mice. This effect was specific to the alcohol-related component because wild-type and knockout mice developed similar tumor numbers in the DEN model without the addition of alcohol. We found that in the presence of alcohol, the increase in tumor number was associated with increased proliferation in liver and tumor, increased WNT/β-catenin signaling, and increased inflammation. We hypothesized that increased inflammation was due to increased oxidative and nitrosative stress in knockout mice. By blocking excess nitric oxide production using an inducible nitric oxide synthase inhibitor, we reduced hepatocyte death and inflammation in the liver and prevented the increase in WNT/β-catenin signaling, proliferation, and tumor number in livers of knockout mice. Conclusion: PRMT1 is an important protection factor from alcohol-induced liver injury, inflammation, and HCC development.

Evolution of etiology, presentation, management and prognostic tool in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide, but its current status is unclear. We aimed to investigate the evolution of etiology, presentation, management and prognostic tool in HCC over the past 12 years. A total of 3349 newly diagnosed HCC patients were enrolled and retrospectively analyzed. The comparison of survival was performed by the Kaplan-Meier method with the log-rank test. Hepatitis B and C virus infection in HCC were continuously declining over the three time periods (2004–2007, 2008–2011, 2012–2015; p < 0.001). At diagnosis, single tumor detection rate increased to 73% (p < 0.001), whereas vascular invasion gradually decreased to 20% in 2012–2015 (p < 0.001). Early stage HCC gradually increased from 2004–2007 to 2012–2015 (p < 0.001). The probability of patients receiving curative treatment and long-term survival increased from 2004–2007 to 2012–2015 (p < 0.001). The Cancer of Liver Italian Program (CLIP) and Taipei Integrated Scoring (TIS) system were two more accurate staging systems among all. In conclusion, the clinical presentations of HCC have significantly changed over the past 12 years. Hepatitis B and C virus-associated HCC became less common, and more patients were diagnosed at early cancer stage. Patient survival increased due to early cancer detection that results in increased probability to undergo curative therapies.

Differential Impact of Age Among Liver Transplant Candidates With and Without Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fastest-rising cause of cancer-related mortality in the United States and is a leading indication for liver transplantation (LT). Changes have been noted in the age of the population with chronic liver disease, but how this change affects patients with HCC is unknown. This study aims to characterize trends and transplant-associated outcomes among patients ≥65 years old listed for LT with HCC. Using the United Network for Organ Sharing database, we analyzed all patients ≥18 years old listed for LT during 2003-2017 in the United States in 2 groups (<65 or ≥65 years). Time trends between HCC and non-HCC patients were compared and stratified by disease etiology. Competing-risks and Cox proportional hazards regressions associated HCC and age with wait-list and post-LT survival. There were 161,724 LT candidates included: 14% were ≥65 years old at listing and 25% had HCC. The proportion of patients ≥65 years old rose significantly faster among those with HCC, as compared with those without HCC (Δ = 0.80; P < 0.001). Age ≥65 years was significantly associated with both wait-list mortality (adjusted subhazard ratio, 1.51; 95% confidence interval [CI], 1.40-1.64) and post-LT mortality (adjusted hazard ratio, 1.50; 95% CI, 1.41-1.60) in the multivariate analysis. There were significant interactions between age and HCC on both wait-list (P < 0.001) and post-LT mortality (P = 0.04), suggesting that older age does not impact patients with HCC as much as patients without HCC. The proportion of older adults with HCC listed for LT has nearly tripled from 2003 to 2017, and the rapidly growing population of older adults with HCC may provide an opportunity to expand LT access without compromising outcomes.

Disparities in Hepatocellular Carcinoma Surveillance: Dissecting the Roles of Patient, Provider, and Health System Factors

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.

High NDRG3 expression facilitates HCC metastasis by promoting nuclear translocation of β-catenin

NDRG1 has been reported to exert pivotal roles in tumor progression and metastasis via Wnt/β-catenin signaling pathway. However, little is known about the role of NDRG3 in hepatocarcinogenesis despite its classification in the same subfamily of NDRG1. The present study was aimed to characterize the expression pattern and understand the biological roles of NDRG3 in hepatocarcinogenesis, as a means to exploit its therapeutic potential. It was observed that NDRG3 was up-regulated in HCC tissues and higher NDRG3 expression was associated with significantly shorter overall survival. Furthermore, a lower level of NDRG3 exhibited marked positive correlation with metastasis-free survival. In vitro and in vivo experiments revealed that knock-down of NDRG3 inhibits HCC metastasis and angiogenesis. We further demonstrated that activation of WNT/β-catenin signaling and enhanced CSC-like properties were responsible for NDRG3- mediated promoting effect on HCC. In conclusion, the principal findings demonstrated that high NDRG3 expression facilitates HCC metastasis via regulating the turnover of β-catenin, as well as provides a potential therapeutic target for future therapeutic interventions.

Ubiquitin-specific protease 7 is a drug-able target that promotes hepatocellular carcinoma and chemoresistance

Background

Ubiquitin-specific protease 7 (USP7) is a de-ubiquitin enzyme that plays an essential role in multiple cancers and becomes a target for treatment. However, the role of USP7 and its therapeutic value for HCC remains unclear.

Methods

USP7 expression was examined in HCC tissues by western blot and immunohistochemistry. The correlation of USP7 and HCC prognosis was analyzed by Kaplan–Meier survival method. Mass spectrometry was determined and cell proliferation and tumorigenicity assays were conducted in vitro and in vivo treated by P22077 and sgRNA-USP7.

Results

USP7 expression was significantly increased in HCC and associated with its progression. Interestingly, many HCC cells are sensitive to USP7 inhibition by using P22077. P22077 treatment not only induced cell death but also inhibited cell proliferation and migration in Huh7 and SK-Hep1 cells. In a xenograft model, P22077 efficiently inhibited tumor growth. In chemo-resistant HCC cells, P22077 decreased cell sensitivity to chemotherapy. In addition, mass spectrometry reveals 224 of significantly changed proteins upon P22077 treatment.

Conclusions

We demonstrate a critical role of USP7 in HCC devolvement and chemoresistance. Disruption of USP7 function results in dis-regulated several key biological processes and subsequently activates BAX. USP7 might be a novel and drug-able target in HCC.

The disparities in gastrointestinal cancer incidence among Chinese populations in Shanghai compared to Chinese immigrants and indigenous non-Hispanic white populations in Los Angeles, USA

Gastrointestinal cancer patterns are distinct among populations. Our study aims to compare the incidence and risk of gastrointestinal cancers between Chinese American and non-Hispanic whites in Los Angeles, CA, USA, to those of people indigenous to Shanghai to elucidate the changing patterns of gastrointestinal cancers. Cancer incidence data from 1988 to 2012 were extracted from the Cancer Incidence in Five Continents plus database. The age standardized incidence and estimated annual percentage change were calculated to estimate the temporal trends of gastrointestinal cancers. Traditional Poisson regression models and three-factor constrained Poisson regression models were applied to compare the gastrointestinal cancer risk across populations. The incidences of oesophageal, stomach, liver and gall bladder cancers were higher among indigenous Chinese residents of Shanghai than among the other two populations in Los Angeles. While the incidences of colorectal and pancreatic cancer were higher among non-Hispanic whites, Chinese American immigrants were considered to be at an intermediate level for most gastrointestinal cancers. The gender-specific gastrointestinal cancer disparities across populations, especially between Shanghai Chinese and non-Hispanic US whites, were significant regardless of age, period or cohort scale. However, the regional differences in gastrointestinal cancer rates decreased over time. Most gastrointestinal cancer patterns in Chinese American immigrants were more aligned to those of their new country of residence than to those of their original country. The disparities in gastrointestinal cancers across populations indicate that environmental factors might play a key role in cancer genesis. Shift in environmental exposures may result in significant changes in gastrointestinal cancer incidence.

The survival rate of hepatocellular carcinoma in Asian countries: a systematic review and meta-analysis

Hepatocellular carcinoma or Liver cancer (LC) is the sixth most common cancer and the fourth cause of death worldwide in 2018. There has not been a comprehensive study on the survival rate of patients with LC in Asia yet. Therefore, the present study was conducted to evaluate the survival rate of patients with LC in Asian countries. The methodology of the present study is based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. The researchers searched five international databases including Medline/PubMed, Scopus, Embase, Web of Knowledge and ProQuest until July 1, 2018. We also searched Google Scholar for detecting grey literature. The Newcastle-Ottawa Quality Assessment Form was used to evaluate the quality of selected papers. A total of 1425 titles were retrieved. 63 studies met the inclusion criteria. Based on the random-effect model one-year, three-year and five-year survival rate of LC were 34.8 % (95 % CI; 30.3-39.3), 19 % (95 % CI ; 18.2-21.8) and 18.1 % (95 % CI ;16.1-20.1) respectively. According to the results of our study, the LC survival rate in Asian countries is relatively lower than in Europe and North America.

14-CpG-Based Signature Improves the Prognosis Prediction of Hepatocellular Carcinoma Patients

Background

Epigenetic dysregulation via alteration of DNA methylation often occurs during the development and progression of cancer, including hepatocellular carcinoma (HCC). In the past, many patterns of single-gene DNA methylation have been extensively explored in the context of HCC prognosis prediction. However, the combined model of a mixture of CpGs has rarely been evaluated. In the present study, we aimed to develop and validate a CpG-based signature model for HCC patient prognosis.

Methods

Data from methylation profiling of GSE73003, GSE37988, and GSE57958 from the Gene Expression Omnibus (GEO) database and 371 HCC patients from the Cancer Genome Atlas (TCGA) were downloaded. The 371 HCC patients were randomly divided into a development cohort (N = 263) and a validation cohort (N = 108). Two algorithms, least absolute shrinkage and selection operator (LASSO) and robust likelihood-based survival analysis, were used to select the most significant CpGs associated with overall survival (OS) time and were used to develop and validate a methylation-based signature (MSH) for HCC patient prognosis. In addition, the prognostic efficacy of the MSH was compared with that of AJCC TNM classification and other CpG-based MSHs from TCGA. Finally, a nomogram incorporating the MSH and clinicopathologic factors was also developed.

Results

Fourteen differential CpGs associated with OS were identified in HCC patients. The MSH, based on these 14 differential CpGs, could effectively divide HCC patients into two distinct subgroups with high risk or low risk of death (P < 0.0001) in the development cohort (26.35 vs 83.18 months, HR = 3.83, 95% CI: 2.56–5.90, P < 0.0001) and in the validation cohort (40.37 vs 107.03 months, HR = 2.23, 95% CI: 1.22–4.17, P=0.01). Univariate analysis showed that the MSH was significantly associated with OS, and the multivariate analysis also showed that the MSH was an independent prognostic factor for the OS of HCC patients in the two cohorts. In addition, stratified survival analysis indicated that the MSH still exhibited good prognostic value in different subgroups classified by AFP, cirrhosis, Child-Pugh A, tumor histologic grade, and AJCC stage. Moreover, time-dependent ROC analysis showed better performance of the MSH in predicting 3-year and 5-year survival of HCC patients than of AJCC stage and other CpG-based signatures from TCGA. The MSH-based nomogram also performed well in predicting 1-year, 3-year, and 5-year OS (C-index: 0.709).

Conclusion

The 14-CpG-based signature is significantly associated with OS and may be used as a novel prognostic biomarker for HCC patients.

Overexpression of long non-coding RNA cancer susceptibility 11 is involved in the development of chemoresistance to carboplatin in hepatocellular carcinoma

The long non-coding (lnc)RNA cancer susceptibility 11 (CASC11) promotes gastric cancer, however its role in other diseases is unknown. The present study demonstrated upregulation of lncRNA CASC11 and microRNA (miR)-21 in hepatocellular carcinoma (HCC). Furthermore, the expression of CASC11 was positively correlated with that of miR-21 in HCC tumors. Moreover, overexpression of lncRNA CASC11 led to upregulation of miR-21 in HCC cells, whereas overexpression of miR-21 had no effect on CASC11 levels. The levels of lncRNA CASC11 and miR-21 were found to be upregulated in the plasma of patients with HCC during chemotherapy. In vitro cell experiments demonstrated upregulation of lncRNA CASC11 in HCC cells treated with carboplatin. Additionally, overexpression of lncRNA CASC11 promoted, whereas its knockdown inhibited the viability of HCC cells following carboplatin treatment. Finally, overexpression of miR-21 ameliorated the effects of lncRNA CASC11 knockdown on cell viability. Thus, these findings suggest that upregulation of lncRNA CASC11 is involved in the development of chemoresistance to carboplatin in patients with HCC, via the upregulation of miR-21.

Rising Mortality From Alcohol-Associated Liver Disease in the United States in the 21st Century

OBJECTIVES

In contrast with other developed nations, life expectancy is decreasing in the United States, in part due to increasing mortality from alcohol-associated liver disease (ALD). Up-to-date estimates of ALD mortality are necessary for setting public health priorities to reverse this concerning trend. We therefore aimed to assess current (2017) estimates of ALD mortality and temporal trends from 1999 to 2017.

METHODS

Using national data from the Centers for Disease Control and Prevention, we analyzed stratified ALD mortality rates between 1999 and 2017. We determined the age-adjusted death rates, stratified by sex and categorized by age, race/ethnicity, urbanization, and census region. We also identified statistically significant changes in the annual rate difference (ARD), annual percentage change (APC), and average APC in ALD mortality.

RESULTS

In 2017, mortality from ALD was higher than any other year since 1999 with age-adjusted rates of 13.1 per 100,000 (95% confidence interval [CI] 12.9-13.3) in men and 5.6 per 100,000 (95% CI 5.4-5.7) in women. Mortality was highest among men and women who were middle aged, Native American, and from rural areas. Since 2006, ALD mortality has increased in almost every age group and race with the exception of non-Hispanic black men. Absolute increases in mortality rates have been particularly pronounced in Native American women (2005-2017 ARD 0.8, 95% CI 0.6-0.9), non-Hispanic/white men (2006-2017 ARD 0.4, 95% CI 0.3-0.4), and non-Hispanic/white women (2013-2017 ARD 0.4, 95% CI 0.3-0.5).

DISCUSSION

Mortality from ALD is increasing over time in most demographic groups. Increased effort is needed to develop targeted public health strategies to address high and increasing ALD mortality.

Hepatocellular Carcinoma Incidence Is Decreasing Among Younger Adults in the United States

BACKGROUND & AIMS

Incidence rates for hepatocellular carcinoma (HCC) increased rapidly in the United States since the 1990s, but have plateaued or started to decrease in other industrialized countries. It unclear if and when a similar trend will be observed in the United States. We examined trends in HCC incidence rates in the United States by age, sex, and race/ethnicity of patients.

METHODS

We calculated age-adjusted HCC incidence rates using data from the Surveillance, Epidemiology, and End Results program of cancer registries from 1992 through 2015. We estimated incidence rates by 10-year age group and used joinpoint regression to quantify the magnitude and direction of trends, overall and by sex and race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and Asian/Pacific Islander).

RESULTS

HCC incidence increased by 4.8% per year from 1992 through 2010 (from 4.1 per 100,000 to 9.4 per 100,000) but then started to plateau (annual percentage change, -0.7; 95% CI, -2.0 to 0.7). Incidence rates steadily increased among persons 60 years or older in all racial/ethnic groups except Asian/Pacific Islanders 70 to 79 years old. In contrast, incidence rates decreased in younger and middle-aged adults, in men and women of all races/ethnicities, beginning in the mid-2000s. Rates decreased by 6.2% per year in persons 40 to 49 years old and by 10.3% per year in persons 50 to 59 years old. Annual decreases in incidence were larger among middle-aged blacks (17.2% decrease per year since 2012) compared with adults of the same age in other racial/ethnic groups.

CONCLUSIONS

In an analysis of data from the Surveillance, Epidemiology, and End Results program of cancer registries from 1992 through 2015, we found the incidence of HCC to be decreasing among younger and middle-aged adults in the United States, regardless of sex, race, or ethnicity. It is unclear whether current decreases in incidence will reduce the burden of HCC in the future.

Superb microvascular imaging technique in depicting vascularity in focal liver lesions: more hypervascular supply patterns were depicted in hepatocellular carcinoma

Purpose

To investigate the capacity of Superb Microvascular Imaging (SMI) to detect microvascular details and to explore the different SMI features in various focal liver lesions (FLLs) and the correlation between SMI and microvessel density (MVD).

Method: Eighty-three liver lesions were enrolled in our study, including 35 hepatocellular carcinomas (HCCs) and 48 non-HCCs. All patients underwent color Doppler flow imaging (CDFI) and SMI examination and were categorized into subgroups according to Adler semiquantitative grading (grade 0–3) or the microvascular morphologic patterns (pattern a-f). The correlation between SMI blood flow signal percentage and MVD was assessed.

Results

Compared with CDFI, SMI detected more high-level blood flow signals (grade 2–3) and more hypervascular supply patterns (pattern e-f) in HCCs (p < 0.05). Furthermore, more hypervascular supply patterns and fewer hypovascular supply patterns were detected in HCC compared with non-HCC (p < 0.05). Based on Adler’s grading or microvascular morphologic patterns, the areas under the receiver operating characteristic curve were 0.696 and 0.760 for SMI, 0.583 and 0.563 for CDFI. The modality of “SMI-microvascular morphologic pattern” showed the best diagnostic performance. There was significant correlation between MVD and the SMI blood flow signal percentage (vascular index, VI) in malignant lesions (r = 0.675, p < 0.05).

Conclusion

SMI was superior to CDFI in detecting microvascular blood flow signals. More hypervascular supply patterns were depicted in HCC than in non-HCC, suggesting a promising diagnostic value for SMI in the differentiation between HCC and non-HCC. Meanwhile, we were the first to demonstrate that SMI blood flow signal percentage (VI) was correlated with MVD in malignant lesions.

Irreversible Electroporation: Background, Theory, and Review of Recent Developments in Clinical Oncology

Irreversible electroporation (IRE) has established a clinical niche as an alternative to thermal ablation for the eradication of unresectable tumors, particularly those near critical vascular structures. IRE has been used in over 50 independent clinical trials and has shown clinical success when used as a standalone treatment and as a single component within combinatorial treatment paradigms. Recently, many studies evaluating IRE in larger patient cohorts and alongside other novel therapies have been reported. Here, we present the basic principles of reversible electroporation and IRE followed by a review of preclinical and clinical data with a focus on tumors in three organ systems in which IRE has shown great promise: the prostate, pancreas, and liver. Finally, we discuss alternative and future developments, which will likely further advance the use of IRE in the clinic.

Sex-dependent effects of estrogen pellets in human liver cancer xenograft models

Liver cancer shows noticeable differences in the incidence rate and mortality between genders. To investigate the estrogen effect on tumor progression in liver cancer, we developed a xenograft model using estrogen pellets. SK-Hep1 cells (human male liver carcinoma) were inoculated into male or female nude mice. Subsequently, estrogen pellets were subcutaneously implanted into these xenograft models. Interestingly, the marked adverse effect of estrogen pellets (0.5 mg/21 days) were observed in the male-derived xenograft model, with increased ulcerative dermatitis in male mice than in female mice. Additionally, necrosis was observed in male mice with SK-Hep1-derived tumors. However, the estrogen pellet (0.5 mg/60 days) did not exhibit these adverse effects. Tumor growth in female mice was significantly suppressed by estrogen (0.5 mg/60 days). Tumor growth was also suppressed in male mice implanted with estrogen (0.5 mg/60 days), but the suppression was not significant. We found that estrogen-induced skin damage was more severe in male mice than female mice. The tumor suppression of estrogen was effective in female mice compared to male mice bearing liver cancer. The results suggest that the sex difference affects estrogen activity and thus should be considered in the preclinical assessment.

The Hispanic Paradox in Patients With Liver Cirrhosis: Current Evidence From a Large Regional Retrospective Cohort Study

BACKGROUND

Despite lower socioeconomic status, Hispanics in the United States paradoxically maintain equal or higher average survival rates compared to non-Hispanic Whites (NHW).

METHODS

We used multivariable Cox regression to assess whether this "Hispanic paradox" applies to patients with liver cirrhosis using a retrospective cohort of twenty 121 patients in a Chicago-wide electronic health record database.

RESULTS

Our study population included 3279 (16%) Hispanics, 9150 (45%) NHW, 4432 (22%) African Americans, 529 (3%) Asians, and 2731 (14%) of other races/ethnic groups. Compared to Hispanics, NHW (hazard ratio [HR] 1.26; 95% confidence interval [CI], 1.16-1.37), African American (HR 1.26; 95% CI, 1.15-1.39), and other races/ethnic groups (HR 1.55; 95% CI, 1.40-1.71) had an increased risk of death despite adjustment for age, sex, insurance status, etiology of cirrhosis, and comorbidities. On stratified analyses, a mortality advantage for Hispanics compared to NHW was seen for alcohol cirrhosis (HR for NHW 1.35; 95% CI, 1.19-1.52), hepatitis B (HR for NHW 1.35; 95% CI, 0.98-1.87), hepatitis C (HR for NHW 1.21; 95% CI, 1.06-1.38), and nonalcoholic steatohepatitis (HR for NHW 1.14; 95% CI, 0.94-1.39). There was no advantage associated with Hispanic race over NHW in cases of hepatocellular carcinoma or cholestatic liver disease.

CONCLUSIONS

Hispanic patients with cirrhosis experience a survival advantage over many other racial groups despite adjustment for multiple covariates.

LncRNA ASB16-AS1 Promotes Growth And Invasion Of Hepatocellular Carcinoma Through Regulating miR-1827/FZD4 Axis And Activating Wnt/β-Catenin Pathway

Background

To date, although several long noncoding RNAs (lncRNAs) are reported to regulate hepatocellular carcinoma (HCC) development, their relationship still remains elusive. ASB16-AS1 is a poorly researched novel lncRNA. We aimed to investigate its function in HCC progression.

Methods

qRT-PCR and in situ hybridization (ISH) were used to analyze ASB16-AS1 expression in HCC tissues. CCK8, Edu incorporation and colony formation were used to determine cell proliferation. Transwell assay was used to examine migration and invasion. Luciferase reporter assay was used to analyze the interactions among ASB16-AS1, miR-1827 and FZD4.

Results

Bioinformatics analysis identified ASB16-AS1 was overexpressed in HCC tissues, which was further validated by qRT-PCR and in situ hybridization (ISH). Besides, ASB16-AS1 was demonstrated to be a potential indicator for HCC prognosis. Functional studies showed ASB16-AS1 knockdown attenuated proliferation, migration and invasion of HCC cells. Mechanistically, ASB16-AS1 directly interacted with miR-1827 and promoted FZD4 expression by sponging miR-1827. Overexpressed FZD4 eventually activated Wnt/β-catenin pathway and contributed to HCC progression.

Conclusion

Our work is the first to identify ASB16-AS1 as an oncogene that enhances HCC progression by modulating miR-1827/FZD4/Wnt/β-catenin pathways.

SO2 derivatives and As co-exposure promote liver cancer metastasis through integrin αvβ3 activation

Arsenic (As) and sulfur dioxide (SO₂) are two environmental pollutants that have been shown to promote the development of human cancer. In recent years, due to increased pollution, humans are often exposed to SO₂, in addition to As. Despite the development and implementation of standards for environment and air quality, cases of disease caused by As or SO₂ continue to rise alarmingly. It is currently unknown whether simultaneous exposure to As and SO₂ results in increased cancer promoting activity. In this study, concentrations of As and SO₂ below the limits established by the world health organization (WHO) in force environmental standards (concentrations of As should be lower than 1×10^-2 mg/L and SO₂ should be lower than 50 μg/m³), were employed to investigate possible, long-term, synergistic effects of As and SO₂, by using cell-based assays. We found that co-exposure to these pollutants significantly promotes HepG2 cancer cell migration, while As or SO₂ alone have no remarkable effects. Integrins αvβ3 play a key role in this process, as cilengitide, an integrin αvβ3 inhibitor, substantially prevented As and SO₂-induced cell migration. MMPs, IL-8, and TGF-β were also involved in the induced cell migration. In summary, combined exposure to As and SO₂ promotes integrin-dependent cell migration and may be of relevance for the activation of mechanisms underlying liver cancer progression.

Changing trends in liver cancer incidence by race/ethnicity and sex in the US: 1992-2016

PURPOSE

Liver cancer incidence continues to increase while incidence of most other cancers is decreasing. We analyze recent and long-term trends of US liver cancer incidence by race/ethnicity and sex to best understand where to focus preventive efforts.

METHODS

Liver cancer incidence rates from 1992 to 2016 were obtained from the Surveillance, Epidemiology, and End Results registry. Delay-adjusted age-standardized incidence trends by race/ethnicity and sex were analyzed using joinpoint regression. Age-specific incidence was analyzed using age-period-cohort models. Hepatitis C seroprevalence by cohort was calculated using National Health and Nutrition Examination Survey data.

RESULTS

Liver cancer incidence has peaked in males and Asian or Pacific Islanders. Hispanic males, a high-incidence population, are experiencing a decrease in incidence, although not yet statistically significant. In contrast, incidence continues to increase in females, although at lower rates than in the 1990s, and American Indian/Alaska Natives (AI/ANs). Liver cancer incidence continues to be higher in males. Non-Hispanic Whites have the lowest incidence among racial/ethnic groups. Trends largely reflect differences in incidence by birth-cohort, which increased considerably, particularly in males, for those born around the 1950s, and continues to increase in females and AI/ANs. The patterns in males are likely driven by cohort variations in Hepatitis C infection.

CONCLUSIONS

Liver cancer incidence appears to have peaked among males. However, important differences in liver cancer trends by race/ethnicity and sex remain, highlighting the need for monitoring trends across different groups. Preventive interventions should focus on existing liver cancer disparities, targeting AI/ANs, females, and high-incidence groups.

Higher expression of SATB2 in hepatocellular carcinoma of African Americans determines more aggressive phenotypes than those of Caucasian Americans

In the United States, Hepatocellular Carcinoma (HCC) incidence has tripled over the past two decades. The disease has disproportionately affected minority and disadvantaged populations. The purpose of this study was to examine the expression of SATB2 gene in HCC cells derived from African Americans (AA) and Caucasian Americans (CA) and assess its oncogenic potential by measuring cell viability, spheroid formation, epithelial‐mesenchymal transition (EMT), stem cell markers and pluripotency maintaining factors in cancer stem cells (CSCs). We compared the expression of SATB2 in human primary hepatocytes, HCC cells derived from AA and CA, and HCC CSCs. Hepatocellular carcinoma cells derived from AA expressed the higher level of SATB2 than those from CA. By comparison, normal human hepatocytes did not express SATB2. Higher expression of SATB2 in HCC cells from AA was associated with greater growth rate, cell viability, colony formation and EMT characteristics than those from CA. Knockout of SATB2 in CSCs by Crispr/Cas9 technique significantly inhibited the expression of SATB2 gene, stem cell markers (CD24, CD44 and CD133), pluripotency maintaining factors (c‐Myc, KLF4, SOX2 and OCT4), and EMT compared with non‐targeting control group. The expression of SATB2 was negatively correlated with miR34a. SATB2 rescued the miR‐34a‐mediated inhibition of CSC's viability. These data suggest that SATB2 is an oncogenic factor, and its higher expression may explain the disparity in HCC outcomes among AA.

Characterization of liver nodules in patients with chronic liver disease by MRI: performance of the Liver Imaging Reporting and Data System (LI-RADS v.2018) scale and its comparison with the Likert scale

OBJECTIVES

To evaluate the performance of the LI-RADS v.2018 scale by comparing it with the Likert scale, in the characterization of liver lesions.

METHODS

A total of 39 patients with chronic liver disease underwent MR examination for characterization of 44 liver lesions. Images were independently analyzed by two radiologists using the LI-RADS scale and by another two radiologists using the Likert scale. The reference standard used was either histopathological evaluation or a 4-year MRI follow-up. Receiver operating characteristic analysis was performed.

RESULTS

The LI-RADS scale obtained an accuracy of 80%, a sensitivity of 72%, a specificity of 93%, a positive predictive value (PPV) of 93% and a negative predictive value (NPV) of 70%, while the Likert scale achieved an accuracy of 79%, a sensitivity of 73%, a specificity of 87%, a PPV of 89% and a NPV of 70%. The area under the curve (AUC) was 85% for the LI-RADS scale and 83% for the Likert scale. The inter-observer agreement was strong (k = 0.89) between the LI-RADS evaluators and moderate (k = 0.69) between the Likert evaluators.

CONCLUSIONS

There was no statistically significant difference between the performances of the two scales; nevertheless, we suggest that the LI-RADS scale be used, as it appeared more objective and consistent.

Are There Upper Limits in Tumor Burden for Down-Staging of Hepatocellular Carcinoma to Liver Transplant? Analysis of the All-Comers Protocol

Patients with hepatocellular carcinoma (HCC) within the University of California, San Francisco down-staging (UCSF-DS) criteria (one lesion > 5 cm and ≤ 8 cm; two to three lesions each ≤ 5 cm; or four to five lesions each ≤ 3 cm with total tumor diameter ≤ 8 cm) who achieved successful down-staging (DS) to Milan criteria had similar outcomes after liver transplantation (LT) compared with HCC initially meeting the Milan criteria. Nevertheless, little is known about the outcome of DS in patients with initial tumor burden exceeding the UCSF-DS criteria, defined as "all-comers" (AC). We compared the intention-to-treat (ITT) outcomes of DS in 74 patients in the AC group and 133 patients in the UCSF-DS group. Successful DS to Milan was observed in 64.8% of the AC group versus 84.2% of the UCSF-DS group (P < 0.001). The sum of tumor number and largest tumor diameter was significantly associated with successful DS (hazard ratio [HR] 0.87, P < 0.05). The cumulative probability of dropout within 1 year and 3 years was 53.5% and 80.0%, respectively, for AC versus 25.0% and 36.1%, respectively, for UCSF-DS (P < 0.0001). Factors predicting dropout included sum of tumor number and largest tumor diameter greater than 8 (HR 1.79, P = 0.049) and Child class B and C (HR 2.54, P = 0.001). The AC group also had a significantly lower liver transplant (LT) rate (13.5% versus 59.0%, P < 0.001). ITT survival at 1 year and 5 years was 77.4% and 21.1%, respectively, in AC versus 85.5% and 56.0%, respectively, in UCSF-DS (P < 0.001). Three of 10 patients in the AC group who underwent LT developed HCC recurrence. Conclusion: We observed a significantly lower LT probability and inferior ITT survival with DS in the AC group versus the UCSF-DS group. Our results suggest that an upper limit in tumor burden exists beyond which successful LT after DS becomes an unrealistic goal.

microRNA-17 functions as an oncogene by downregulating Smad3 expression in hepatocellular carcinoma

The sekelsky mothers against dpp3 (Smad3) functions as a transcriptional modulator activated by transforming growth factor-β (TGF-β). Accumulated evidences indicated that Smad3 played the important roles in carcinogenesis and progression of hepatocellular carcinoma (HCC). Up to now, the regulatory mechanism of Smad3 in HCC still remains unclear. It has been known that some particular microRNAs (miRNAs) involve in carcinogenesis through the regulation of gene expressions with targeting mRNAs. In our study, the unknown candidates of miRNAs that target Smad3 mRNA were searched by using a newly established in vivo approach, the miRNA in vivo precipitation (miRIP). Using a loss-of-function assay, we demonstrated that miR-17 directly targeted Smad3 in HCC cells and inhibition on miR-17 increased Smad3 expression. Furthermore, we found that downregulation on Smad3 expression was consistent with high level of miR-17 in HCC tissues of patients when compared with around normal liver tissues. The manipulated miR-17 silence in HCC cells suppressed their growth of both in vitro and in vivo. Such suppression on cell growth could be recovered through downregulating Smad3. In addition, miR-17 affected cell proliferation through arresting cell cycle in G1 phase. The negative correlation between levels of miR-17 and protein levels of Smad3 was supported by the results of analysis with HCC tissue chip. In summary, for the first time, we confirmed that miR-17 directly targeted Smad3 mRNA and downregulated Smad3 protein expression in HCC. Our results indicated that the increased expression of miR-17 promoted carcinogenesis of HCC through down-regulations of Smad3, suggesting miR-17 might serve as the potential diagnostic and therapeutic targets for clinical HCC.

Smoking as an Independent Risk Factor for Hepatocellular Carcinoma Due to the α7-Nachr Modulating the JAK2/STAT3 Signaling Axis

BACKGROUND

Hepatocellular carcinoma (HCC) is a worldwide health problem. Currently, there is no effective clinical therapeutic strategy for HCC. Smoking is associated with several malignant diseases including cancers.

EXPERIMENTAL APPROACH

However, the impact of smoking on HCC is still unresolved. Retrospectively reviewed HCC patients diagnosed between 1 January 2010 and 31 December 2015 at Taipei Medical University-Shuang Ho Hospital (Ministry of Health and Welfare). We found that smoking was associated with a poor prognosis, especially recurrence and patient survival after curative surgery using a clinicopathological analysis.

RESULTS

Our univariate and multivariate analyses showed that the α7-nicotinic acetylcholine receptor (α7-nAChR) was an oncogene and risk factor for post-resection recurrence. The α7-nAChR was overexpressed in HCC tissues compared to their non-tumor counterparts. Silencing the α7-nAChR reduced the viability of HCC cells, suppressed cellular proliferation, attenuated migration and invasion, and diminished the tumor's sphere-formation ability, with concurrent downregulation of expression levels of the TGR5, p-JAK2, p-STAT3 (Tyr705/Ser727), RhoA, ROCK1, MMP2, and MMP9 proteins. Furthermore, a positive correlation was found between α7-nAChR and JAK2 expressions (p = 0.01) in HCC specimens, as well as their membranous co-localization.

CONCLUSION

Together, we demonstrated that the α7-nAChR may be an independent prognosticator of the progression and prognosis of HCC patients. These findings suggest that the α7-nAChR drives the progression and recurrence of HCC through JAK2/STAT3 signaling and is a novel target for anti-HCC therapy.