Clinicomolecular Profile and Efficacy of Human Epidermal Growth Factor Receptor 2 (HER2)-Targeted Therapy for HER2-Amplified Advanced Biliary Tract Cancer

PURPOSE

This study aimed to investigate the clinicomolecular profiles and the efficacy of human epidermal growth factor receptor 2 (HER2)-targeted therapy in HER2-amplified biliary tract cancer (BTC).

METHODS

This study was an international collaboration that used combined data from the prospective SCRUM-Japan GOZILA and MONSTAR-SCREEN in Japan and retrospective reviews in the United States; patients with advanced BTC who had received systemic therapy were included. The clinicomolecular profiles were evaluated in an exploratory cohort, whereas the efficacy of HER2-targeted therapy was assessed in a biomarker-selected cohort.

RESULTS

Of the 439 patients in the exploratory cohort, 43 (10%) had HER2 amplification. The frequencies of coalterations were higher in patients with HER2 amplification versus patients without HER2 amplification including HER2 mutations (26% v 5%, P < .001), TP53 mutations (84% v 61%, P = .003), and BRAF amplification (9% v 2%, P = .030). There were no KRAS mutations identified in patients with HER2-amplified BTC. No significant difference in overall survival (OS) was observed between patients with and without HER2 amplification (median, 17.7 v 16.9 months; hazard ratio [HR], 0.95 [95% CI, 0.65 to 1.40]). Of the 60 patients with HER2-amplified BTC in the biomarker-selected cohort (43 from Japan and 17 from the United States), the OS was significantly longer in 29 patients who received HER2-targeted therapy than in those who did not receive HER2-targeted therapy (median, 24.3 v 12.1 months; HR, 0.39 [95% CI, 0.23 to 0.82]). Multivariate analysis identified HER2-targeted therapy as an independent prognostic factor for OS (HR, 0.29 [95% CI, 0.14 to 0.58]; P < .001).

CONCLUSION

HER2 amplification was found in 10% of advanced BTC and was not identified as an independent prognostic factor for OS. Patients with HER2-amplified BTC derive significant benefit from HER2-targeted therapy.

Efficacy and Safety of Immunochemotherapy in Advanced Triple-negative Breast Cancer: A Meta-analysis of Randomised Clinical Trials

AIMS

Based on the existing controversial clinical research results, this study conducted a comprehensive meta-analysis of relevant literature to clarify the benefits of immunochemotherapy (ICT)-which combines immune checkpoint inhibitors and chemotherapy (CT)-for patients with advanced triple-negative breast cancer (aTNBC).

MATERILAS AND METHODS

A thorough literature search was conducted up to February 15, 2024. Subsequently, meta-analyses were performed to aggregate hazard ratios (HRs) for progression-free survival (PFS) and overall survival (OS), odds ratios (ORs) for objective response rate (ORR) and relative risks (RRs) for adverse events (AEs).

RESULTS

Six randomised clinical trials (RCTs) involving 3,105 patients met the inclusion criteria. In comparison with CT, ICT yielded significant enhancements in PFS (HR, 0.80; 95%CI: 0.73-0.87), OS (HR, 0.87; 95%CI: 0.80-0.96), and ORR (OR, 1.34; 95%CI: 1.15-1.55) in the intention-to-treat population. However, ICT also exhibited an increase in grade ≥3 AEs (RR, 1.11; 95%CI: 1.04-1.19) and severe AEs (RR, 1.40; 95%CI: 1.18-1.66). Subgroup analyses revealed that ICT significantly improved PFS (HR, 0.67; 95%CI: 0.58-0.77), OS (HR, 0.75; 95%CI: 0.64-0.87), and ORR (OR, 1.47; 95%CI: 1.16-1.84) within the PD-L1-positive subgroup, whereas no statistically significant differences were detected for PD-L1-negative population.

CONCLUSION

ICT demonstrates superior efficacy over conventional CT in the treatment of aTNBC, albeit accompanied by heightened toxicity. Notably, the assessment of PD-L1 status may serve as a valuable biomarker in discerning aTNBC patients who are particularly predisposed to derive benefit from ICT.

PROSPERO NUMBER

CRD42024513270.

Precision surgery for hepatocellular carcinoma

Hepatocellular carcinoma arises in the setting of cirrhosis in most cases, requiring multidisciplinary input to define resectability. In this regard, more precise surgical management considers patient factors and anatomical states, including resection margins, tumour biology, and perioperative therapy. Together with advances in surgical techniques, this integrated approach has resulted in considerable improvements in patient morbidity and oncological outcomes. Despite this, recurrence rates in hepatocellular carcinoma remain high. As the systemic treatment landscape in hepatocellular carcinoma continues to evolve and locoregional options are increasingly used, we review current and future opportunities to individualise the surgical management of patients with hepatocellular carcinoma.

FABP5+ lipid-loaded macrophages process tumour-derived unsaturated fatty acid signal to suppress T-cell antitumour immunity

BACKGROUND & AIMS

Tumour-associated macrophages (TAMs) contribute to hepatocellular carcinoma (HCC) progression. However, while the pro-tumour and immunosuppressive roles of lipid-loaded macrophages are well established, the mechanisms by which lipid metabolism enhances the tumour-promoting effects of TAMs remain unclear.

METHODS

Single-cell RNA sequencing was performed on mouse and human HCC tumour samples to elucidate the landscape of HCC TAMs. Macrophages were stimulated with various long-chain unsaturated fatty acids (UFAs) to assess immunosuppressive molecule expression in vitro. Additionally, in vivo and in vitro studies were conducted using mice with macrophage-specific deficiencies in fatty acid-binding protein 5 (FABP5) or peroxisome proliferator-activated receptor γ (PPARγ).

RESULTS

Single-cell RNA sequencing identified a subpopulation of FABP5+ lipid-loaded TAMs characterized by enhanced immune checkpoint blocker ligands and immunosuppressive molecules in an oncogene-mutant HCC mouse model and human HCC tumours. Mechanistically, long-chain UFAs released by tumour cells activate PPARγ via FABP5, resulting in immunosuppressive properties in TAMs. FABP5 deficiency in macrophages decreases immunosuppressive molecule expression, enhances T cell-dependent antitumour immunity, diminishes HCC growth, and improves immunotherapy efficacy.

CONCLUSIONS

This study demonstrates that UFAs promote tumourigenesis by enhancing the immunosuppressive tumour microenvironment via FABP5-PPARγ signalling and provides a proof-of-concept for targeting this pathway to improve the efficacy of tumour immunotherapy.

IMPACT AND IMPLICATIONS

Despite the role of tumour-associated macrophages (TAMs) in promoting tumour progression being well established, the mechanisms by which lipid metabolism enhances the tumour-promoting effects of TAMs remain unclear. Our study reveals that FABP5-mediated unsaturated fatty acid metabolism in TAMs is crucial for modulating antitumour T-cell immunity and influencing the efficacy of immunotherapy. This finding provides novel insights into the immunomodulatory roles of FABP5+ lipid-loaded TAMs in hepatocellular carcinoma and suggests that targeting FABP5 could offer a new approach to liver cancer treatment.

A CT-Based Clinical-Radiomics Nomogram for Predicting the Overall Survival to TACE Combined with Camrelizumab and Apatinib in Patients with Advanced Hepatocellular Carcinoma

RATIONALE AND OBJECTIVES

To construct a computed tomography (CT)-based clinical-radiomics nomogram for estimating overall survival (OS) in advanced hepatocellular carcinoma (HCC) patients receiving transcatheter arterial chemoembolization (TACE) in combination with camrelizumab and apatinib.

METHODS

A retrospective recruitment of 150 patients with clinically or pathologically confirmed HCC was conducted, followed by their division into training cohort (n = 105) and test cohort (n = 45). To generate the radiomics score (Rad-score), a series of analyses were performed, including Pearson correlation analysis, univariate Cox analysis, and least absolute shrinkage and selection operator Cox regression analysis. Subsequently, a clinical-radiomics nomogram was constructed using the Rad-score combined with independent clinical prognostic factors, followed by assessments of its calibration, discrimination, reclassification, and clinical utility.

RESULTS

Five CT radiomics features were selected. The Rad-score showed a significant correlation with OS (P < 0.001). The clinical-radiomics nomogram demonstrated superior performance in estimating OS, with a concordance index (C-index) of 0.840, compared to the radiomics nomogram (C-index: 0.817) and the clinical nomogram (C-index: 0.661). It also exhibited high 1-year and 2-year area under the curves of 0.936 and 0.946, respectively. Additionally, the clinical-radiomics nomogram markedly enhanced classification accuracy for OS outcomes, as evidenced by net reclassification improvement and integrated discrimination improvement. Decision curve analysis confirmed its clinical utility.

CONCLUSION

A CT-based clinical-radiomics nomogram exhibits strong potential for predicting OS in advanced HCC patients undergoing TACE combined with camrelizumab and apatinib.

Combination locoregional and systemic therapies in hepatocellular carcinoma

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

IDHIRA: a prospective, observational study on ivosidenib in patients with IDH1 R132-mutated advanced cholangiocarcinoma

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov identifier is NCT06607302.

Depth of Radiographic Response as an Independent Prognostic Factor for Patients with Initially Unresectable Hepatocellular Carcinoma Receiving Hepatectomy following Targeted Therapy plus Immunotherapy

Introduction

Surgical resection following systemic therapy is feasible in patients with initially unresectable hepatocellular carcinoma (HCC). However, postoperative tumor recurrence is common after surgery, and the factors affecting this recurrence remain unclear. This study aimed to assess factors influencing postoperative outcomes in patients with initially unresectable HCC undergoing hepatectomy after systemic therapy.

Methods

This study retrospectively enrolled patients with initially unresectable HCC who underwent hepatectomy after targeted therapy plus immunotherapy (with or without locoregional therapy). Multivariate Cox regression analyses were used to identify the independent prognostic factors for recurrence-free survival (RFS) and overall survival (OS). Machine learning was used to determine the RFS rates at different intervals for different radiographic responses.

Results

Eighty-one patients who underwent R0 hepatectomy after systemic therapy were included. With a median follow-up of 17.4 (interquartile range: 7.2-22.3) months, median RFS and OS were not reached. Preoperative tumor downstaging and achieving pathological complete response were associated with improved RFS and OS. Multivariate Cox analyses identified radiographic response as an independent prognostic factor for RFS and OS. Furthermore, a radiographic response >40% (assessed using the Response Evaluation Criteria in Solid Tumors, version 1.1) or >50% (assessed using the modified Response Evaluation Criteria in Solid Tumors) was associated with a longer RFS (p = 0.006 and 0.003, respectively).

Conclusion

Radiographic response depth was an independent prognostic factor in patients with initially unresectable HCC who underwent hepatectomy following targeted therapy plus immunotherapy, and the response to systemic therapy may be the determining factor for patient prognosis after surgery.

HER2-targeted therapies: Unraveling their role in biliary tract cancers

Biliary tract cancers (BTCs) constitute a heterogeneous group of malignancies with rising incidence and limited therapeutic options in advanced stages, leading to increased overall mortality. Extensive genomic profiling has identified key oncogenic drivers in BTCs that represent promising therapeutic targets and could change the treatment paradigm. Evidence suggests improved survival outcomes for patients with actionable molecular alterations who received matched targeted therapies. Human epidermal growth factor receptor 2 (HER2) is a receptor tyrosine kinase and proto-oncogene that has been extensively studied as a prognostic biomarker and a therapeutic target in multiple solid organ malignancies. Recent clinical trials on the combination of trastuzumab with tucatinib, FOLFOX, or pertuzumab for previously treated, HER2-positive, advanced BTCs have shown improved outcomes compared to current second-line therapies. Early evidence from observational studies on trastuzumab-containing regimens as first-line suggests promising efficacy. Furthermore, the recent tumor-agnostic approval of trastuzumab deruxtecan for HER2-positive solid tumors has formally introduced HER2-directed agents in the BTC therapeutic arsenal. This review aims to summarize the rapidly evolving landscape of HER2-directed agents for BTCs, highlighting current evidence of survival benefit. Beginning with a concise presentation of the structural and functional aspects of HER2, we detail the frequency and prognostic significance of HER2 alterations in BTCs and discuss all available preclinical and clinical data on anti-HER2 agents tested for BTCs.

Safety and efficacy of living donor liver transplantation for unresectable perihilar cholangiocarcinoma: A single center prospective study

BACKGROUND

The prognosis for unresectable perihilar cholangiocarcinoma (phCCA) is extremely poor. Liver transplantation in combination with neoadjuvant chemoradiation therapy has become the treatment of choice for unresectable phCCA in the USA. In 2018, we launched a prospective study to evaluate the safety and efficacy of living donor liver transplantation (LDLT) for unresectable phCCA.

METHODS

A total of 10 patients were enrolled in this study between 2018 and 2024. Finally, five patients with unresectable phCCA underwent LDLT after neoadjuvant chemotherapy, radiation, and staging laparotomy, while the other five patients dropped out of the protocol.

RESULTS

The median follow-up period was 23.7 months. The overall survival rate for the five patients who underwent LDLT was 100% after one year. Hepatic artery thrombosis and delayed gastric emptying occurred in two and three cases, respectively. The histological efficacy of preoperative treatment was grade IIb and III, according to the Evans classification, in all five patients. All surgical margins and dissected lymph nodes were negative. Four patients were alive with no evidence of disease recurrence while one patient had recurrence 10 months after LDLT.

CONCLUSIONS

LDLT is feasible and may be a last-resort treatment option for unresectable phCCA, although the long-term outcomes need to be carefully monitored.

CLINICAL TRIAL REGISTER AND CLINICAL REGISTRATION NUMBER

The UMIN registration number for this study is 000033348.

Low-Level Viremia Impairs Efficacy of Immune Checkpoint Inhibitors in Unresectable Hepatocellular Carcinoma

BACKGROUND AND AIMS

The impact of low-level viremia(LLV) on the efficacy of immune checkpoint inhibitors (ICIs) in unresectable hepatocellular carcinoma(uHCC) patients remains unclear. This study aims to investigate the effect of LLV on the outcomes of ICIs-based therapy in patients with uHCC.

METHODS

In this multicenter retrospective study, we included patients with uHCC who received ICIs-based therapy at four centres between January 2019 and December 2022. All patients were positive for HBsAg and were on nucleos(t)ide analogues (NAs) antiviral therapy. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to balance baseline characteristics between the LLV and maintained virological response (MVR) groups. Proteomic analysis was performed on a subset of patients to identify differential protein expression.

RESULTS

A total of 329 patients (mean age 56 years; 92.4% male; 70.8% BCLC stage C) were included, with 170 patients in the LLV group and 159 in the MVR group. The objective response rate (ORR) was significantly lower in the LLV group compared to the MVR group (21.2% vs. 36.5%, p = 0.002), as was the disease control rate (DCR) (78.8% vs. 92.5%, p < 0.001). Median progression-free survival (mPFS) was shorter in the LLV group (7.6 vs. 12.6 months, p < 0.001), as was median overall survival (mOS) (22.8 vs. 40.0 months, p < 0.001). These differences remained consistent after PSM and IPTW adjustments. Multivariate analysis identified LLV as the only independent risk factor for overall survival (hazard ratio [HR] 0.522, 95% CI 0.348-0.781; p = 0.002). Proteomic analysis revealed significant differences in the expression of Flt3L, SLAMF1 and FGF-5 proteins between the LLV and MVR groups.

CONCLUSION

LLV is associated with poorer responses to ICIs-based therapy and reduced survival in patients with HBV-related uHCC.

Analysis of treatment benefits and prognostic factors for posttransplant HCC recurrence in a large Euro-American-Asian cohort

Posttransplant HCC recurrence significantly impacts survival, yet its management is challenging due to limited evidence. With recent advancements in HCC treatment, updated data on managing recurrent diseases are needed. In this retrospective study across 6 centers (2000-2022), we employed Cox proportional-hazards regression and log-rank tests to assess survival differences. A prognostic score model was developed to categorize patient survival. The efficacy of tyrosine kinase inhibitors was evaluated through propensity score matching. In our study, 431 of 3349 (14%) patients with HCC who underwent transplantation developed recurrence within a median interval of 18 (IQR: 9-32) months. One hundred forty-seven (34%) underwent curative-intent treatments, 207 (48%) received palliative treatments, and 77 (18%) were given best-supportive care. Patients undergoing curative-intent treatments had better survival from the time of recurrence with a median survival of 45 (95% CI: 36-63) months and 1/3/5-year survival of 90%/56%/43% compared to those receiving noncurative treatments (median: 11 [95% CI: 10-13] mo, 1/3/5-y survival of 46%/10%/7%, log-rank p < 0.001). Patients with recurrence diagnosed in the era 2018-2022 showed improved survival over the previous era (HR 0.64 [95% CI: 0.47-0.86]). Multivariable analysis identified 5 prognostic factors: ineligibility for curative-intent treatment (HR: 3.5 [95% CI: 2.7-4.6]), recurrence within 1 year (HR: 1.7 [95% CI: 1.3-2.1]), poor tumor differentiation (HR: 1.5 [95% CI: 1.1-1.9]), RETREAT score ≥3 (HR: 1.4 [95% CI: 1.1-1.8]), and alpha-fetoprotein at recurrence ≥400 ng/mL (HR: 1.4 [95% CI: 1.1-1.9]). These factors contributed to a prognostic scoring system (0-9) that stratified patients into 3 prognosis groups. Both propensity score-matched analysis and multivariable regression indicated that lenvatinib was not statistically superior to sorafenib in terms of efficacy. Curative-intent treatments should be advocated for patients with posttransplant recurrence whenever possible. Prognostic factors linked to aggressive tumor biology significantly influence survival. Advancements in HCC management have improved survival outcomes over the past 5 years.

Safety and Efficacy of Anti-Human Epidermal Growth Factor 2 Agents in the Treatment of Biliary Tract Cancers: A Systematic Review

PURPOSE

Limited treatment options exist for patients with locally advanced or metastatic biliary tract cancers (BTCs). Recently, several clinical trials provided preliminary evidence for human epidermal growth factor receptor 2 (HER2) as a new target for patients with HER2-expressing BTC. We conducted a systematic review and pooled analysis of the safety and efficacy of anti-HER2 agents in patients with advanced BTCs.

METHODS

A comprehensive search of PubMed/MEDLINE and EMBASE was performed to identify phase I, II, or III clinical trials published between January 2019 and March 2024 that evaluated anti-HER2 therapy in locally advanced or metastatic BTC. Participant data included in the analysis were from trials evaluating the efficacy and safety of various anti-HER2 agents. The primary end points included objective response rate (ORR), disease control rate (DCR), and progression-free survival (PFS). The secondary end points included incidence of treatment-related adverse events (TRAEs), rate of treatment discontinuation, and death.

RESULTS

The analysis included 368 patients from eight publications diagnosed with advanced BTC. Patients were treated with several anti-HER2 agents including zanidatamab, pertuzumab plus trastuzumab, tucatinib plus trastuzumab, trastuzumab deruxtecan, trastuzumab plus chemotherapy, trastuzumab-pkrb plus chemotherapy, and neratinib. The pooled ORR and DCR were 34% (95% CI, 24 to 44) and 64% (95% CI, 51 to 77), respectively. The pooled weighted PFS and median overall survival were 4.8 and 9.4 months, respectively. The pooled duration of response for the reporting trials was 5.0 months. In the study cohort, 82.6% of patients experienced any adverse event and 32.1% experienced a grade 3-4 adverse event. Only 5.7% of the patients discontinued treatment secondary to TRAEs.

CONCLUSION

In patients with HER2-expressing BTCs, anti-HER2 therapies are viable options, particularly in the second-line setting.

Emerging evidence-based role for external-beam radiation therapy in hepatocellular carcinoma

The primary curative therapies for hepatocellular carcinoma are resection or liver transplantation. For patients requiring downstaging or who are unresectable at presentation, the landscape of local treatment options has vastly changed over the past decades. This change is partly due to the paucity of high-level evidence to guide the selection of liver-directed therapies, where physician preference and treatment patterns have historically resulted in relegating external-beam radiation therapy (EBRT) to a secondary option in the treatment of hepatocellular carcinoma in cases where arterially directed therapies or thermal ablations were not possible. However, technology advancements have substantially improved the ability to treat liver malignancies with high doses of radiation therapy and to minimise doses to uninvolved hepatic parenchyma and other nearby organs. These advancements have enabled safe treatment of hepatocellular carcinoma with EBRT, with low risk of toxicity. Recent randomised trials support the role of EBRT in the treatment of hepatocellular carcinoma from early to advanced stages. These trials identified that EBRT improved several key patient-centred outcomes, including overall survival when using stereotactic body radiotherapy and sorafenib compared with sorafenib alone in unresectable hepatocellular carcinoma, recurrence-free survival with the use of adjuvant EBRT in select patients after hepatocellular carcinoma resection, and quality of life for patients with painful hepatocellular carcinoma masses treated with palliative EBRT. With emerging high-quality evidence, hepatocellular carcinoma therapeutic guidelines should include the growing role of EBRT in improving the quality and quantity of life for patients with liver cancer.

Concordance of ctDNA and tissue genomic profiling in advanced biliary tract cancer

BACKGROUND & AIMS

Recent advances in molecular profiling have enabled the identification of potential therapeutic targets for biliary tract cancer (BTC). However, in patients with BTC, molecular profiling is hindered by challenges in obtaining adequate tissue samples. Circulating tumor DNA (ctDNA) may offer an alternative to tissue-based analysis. Herein, we aimed to assess the concordance between ctDNA and tissue genomic profiling in a large cohort of Asian patients with advanced BTC, and to evaluate the feasibility of liquid biopsy in BTC treatment.

METHODS

This study included patients with systemic treatment-naive advanced BTC, treated at CHA Bundang Medical Center between January 2019 and December 2022. We enrolled patients with available baseline tissue-based next-generation sequencing, and sufficient plasma samples for ctDNA analysis (AlphaLiquid®100 from IMBdx).

RESULTS

Among 102 enrolled patients, 49.0% had intrahepatic cholangiocarcinoma, 26.5% extrahepatic cholangiocarcinoma, and 24.5% gallbladder cancer. The concordance between intra-patient ctDNA and tumor tissue mutations revealed a sensitivity of 84.8%, and positive predictive value of 79.4%. ctDNA revealed targetable alterations in 34.3% of patients - including FGFR2 fusions, IDH1 mutations, microsatellite instability-high, ERBB2 amplifications, PIK3CA mutations, BRCA1/2 mutations, and MET amplifications. Notably, a novel FGFR2-TNS1 fusion was identified in ctDNA, which was not targeted in the tissue NGS panel. A high maximum somatic variant allele frequency in ctDNA was associated with poor prognosis after gemcitabine/cisplatin-based chemotherapy, in terms of both overall survival (p = 6.9 × 10-6) and progression-free survival (p = 3.8 × 10-7).

CONCLUSIONS

Among patients with advanced BTC, ctDNA-based genotyping showed acceptable concordance with tissue genomic profiling. Liquid biopsy using ctDNA could be a valuable complement to tissue-based genomic analysis in BTC.

IMPACT AND IMPLICATIONS

Our study is the first large-scale investigation of the clinical utility of liquid biopsy, focusing on circulating tumor DNA (ctDNA), as an alternative to conventional tumor tissue analysis, among Asian patients with advanced biliary tract cancer. The results demonstrated acceptable concordance between analysis of ctDNA vs. tissue for identifying therapeutic targets and potentially actionable genetic alterations. This indicates that ctDNA analysis can provide critical insights regarding advanced biliary tract cancer treatment, particularly in cases where it is challenging to obtain or analyze tumor tissue.

Clinical benefit of immune checkpoint inhibitors in elderly cancer patients: Current evidence from immunosenescence pathophysiology to clinical trial results

The age-related decline in immunity appears to be associated not only with cancer development but also with differential responses to immune checkpoint inhibitors (ICIs). Despite their increasing utility across various malignancies and therapeutic settings, limited data -derived primarily from subgroup analyses of randomized controlled trials (RCTs), pooled meta-analyses, and retrospective studies- are available on the effects of aging on their efficacy and toxicity. Immunosenescence, characterized by the progressive decline of the function of the immune system, and inflammaging, a state of persistent low-grade sterile inflammation, may influence ICI outcomes. Additionally, the incidence, severity, and subtypes of immune-related adverse events (irAEs) may differ between older and younger individuals due to loss of immunotolerance. In the current review, starting from a a comprehensive discussion of the pathophysiology of immunosenescence, we proceed to critically review age-related retrospective and randomized evidence supporting FDA-approved ICIs. We highlight similarities or differences across age groups and the clinical benefit of ICIs in elderly versus younger cancer patients. The optimal integration of ICIs in geriatric oncology necessitates greater inclusion of this patient demographic in RCTs along with real-world data in order to acquire robust data which will guide evidence-based treatment decisions for this population.

The rapidly evolving landscape of HCC: Selecting the optimal systemic therapy

Over the past years, there has been a remarkable advance in the systemic treatment options for advanced HCC. The overall survival has gradually increased over time, with larger benefits for patients with sensitive tumors and preserved liver function, the latter being an essential condition for the delivery of sequential lines of treatment and optimization of clinical outcomes. With the approval of new first-line agents and the introduction of immune checkpoint inhibitor-based therapies, the treatment landscape of advanced HCC is becoming wider than ever. Atezolizumab plus bevacizumab and, more recently, durvalumab plus tremelimumab have entered the clinical practice and are the current standard of care for treatment-naïve patients, surpassing sorafenib and lenvatinib monopoly. As no head-to-head comparisons are available among all the first-line treatment options, the recommendation for the most appropriate choice and sequence is patient-driven and integrates efficacy data with clinical comorbidities, background liver disease, and the safety profile of available drugs. In addition, predictive biomarkers for successful patients' stratification are yet to be available and constitute the focus of ongoing research. The treatment algorithm is likely to become even more complex since systemic therapeutic approaches are now being translated into earlier stages of the disease, with an impact on the evolution of the sequential treatment of patients with HCC.

Arthralgia in patients with cancer receiving immune checkpoint inhibitors: a systematic review and meta-analysis

BACKGROUND

Although immune checkpoint inhibitors (ICIs) are widely used for patients with cancer, evidence of the impact of ICIs on the incidence of arthralgia remains limited.

OBJECTIVE

To evaluate the impact of ICIs on arthralgia incidences in patients with cancer.

METHODS

We performed a systematic review to identify phase 3 randomized control trials (RCTs) evaluating ICIs in patients with cancer and reporting the incidence of arthralgia. We performed a meta-analysis to pool odds ratios (ORs) of any grade and grade 3-5 arthralgia.

RESULTS

Forty RCTs (n = 26,610) were included. The incidence of any-grade and grade 3-5 treatment-related arthralgia was 12.0% (n = 1,125/9,395) and 0.54% (n = 47/8,723). The addition of an ICI to systemic therapy, such as chemotherapy, significantly increased any-grade (OR 1.32, 95% CI: 1.13-1.54, p = 0.001) and grade 3-5 arthralgia (OR 1.78, 95% CI: 1.08-2.94, p = 0.02) with low heterogeneity among ICI subtype subgroups (I2 = 0%). ICI monotherapy was associated with higher incidences of arthralgia than non-taxane (OR 6.83, 95% CI: 3.05-15.30, p < 0.001) but not than taxane chemotherapy (OR 0.74, 95% CI: 0.44-1.24, p = 0.25).

CONCLUSIONS

These results could guide oncologists to assess arthralgia in patients receiving ICIs.

166Ho-RadioEmbolizaTiOn Using personalized prediCtive dosimetry in patients with Hepatocellular carcinoma: A prospective, single-centre study (RETOUCH)

BACKGROUND AND AIMS

Holmium-166 (166Ho) radioembolization could offer a more individualized approach in terms of imaging and dosimetry. We aim to evaluate the feasibility and safety of 166Ho selective internal radiation therapy (SIRT) using a higher tumour dose than previously administered determined by 166Ho-scout as a surrogate marker in HCC patients.

METHODS

This is an open-label, prospective, non-randomized, single-centre pilot study that included patients with HCC that received 166Ho-SIRT if the work-up using 166Ho-scout showed a tumour-absorbed dose ≥150 Gy, a non-tumoural liver absorbed dose less than 60 Gy and a lung absorbed dose less than 30 Gy. Primary endpoints were feasibility and safety-toxicity profiles at 24-48 h and 1 month. Overall response rates (ORR) at 3 months (mRECIST, RECIST 1.1 and metabolic response by FDG and choline PET CT) and time to progression (TTP) represented the secondary endpoints.

RESULTS

Fifteen patients with large tumours (mean diameter 55.67 ± 28.42 mm) received 17 166Ho-SIRT treatments between July 2020 and June 2022. All the attempted treatments were accomplished. Mean administered tumour dose was 183.18 ± 71.71 Gy, while non-tumour liver dose was 30.29 ± 14.56 Gy. Median time of follow-up was 12 months (IQR 9-16). Only grade 1-2 clinical and biological AEs were observed. There were no liver decompensations. At 3 months, objective response was achieved for all target lesions (CR 78.57%, PR 21.43% according to mRECIST). Median TTP was 18.8 (range 2.9; n.e.) months.

CONCLUSION

Personalized 166Ho-SIRT with a tumour delivered dose ≥150 Gy was feasible and safe for HCC patients with promising response rates.

Current status and prospects of targeted therapy for cholangiocarcinoma based on molecular characteristics

Cholangiocarcinoma (CCA) is a serious public health issue due to its insidious onset and dismal prognosis. The past few years have witnessed and highlighted the development of understanding and management of CCA. The combination of gemcitabine and cisplatin (GP) chemotherapy regimen with immunotherapy using immune checkpoint inhibitors has been considered the new standard first-line treatment alternative for advanced CCA. Notably, the proportion of patients with advanced CCA with targetable genetic mutations is approximately 40 %, and these patients may be considered for molecularly targeted therapy in the second-line treatment. In this review, we highlight the advances and progress in targeted therapies for advanced CCA, with special attention to data from Asian populations, including Chinese. In addition, we present in detail the phosphatase tension homolog (PTEN), a novel biomarker for both of first-line chemotherapy and second-line targeted therapy in advanced CCA, and its ability to forecast prognosis in patients with CCA. The mechanisms of rapid resistance to targeted agents warrant further investigation and address in light of the development of new targeted therapies. Precision medicine is gradually playing an increasing role in achieving optimal therapeutic outcomes.

Immune checkpoint inhibitor-associated myocarditis: a historical and comprehensive review

The most fatal side effect associated with revolutionary immune checkpoint inhibitor (ICI) cancer therapies is myocarditis, a rare and devastating complication with a mortality rate approaching 40%. This review comprehensively examines the limited knowledge surrounding this recently recognized condition, emphasizing the absence of evidence-based therapeutic strategies, diagnostic modalities, and reliable biomarkers that hinder effective management. It explores advancements in preclinical models that are uncovering disease mechanisms and enabling the identification of therapeutic targets. These efforts have informed the design of early clinical trials aimed at reducing mortality. With the growing prevalence of ICI therapies in oncology, addressing critical gaps, such as long-term outcomes and risk stratification, has become increasingly urgent. By synthesizing current evidence, this work seeks to enhance understanding and guide the development of strategies to improve patient outcomes and ensure the continued safe use of ICIs in cancer care.

What can real-world data teach us about treating patients with unresectable hepatocellular carcinoma?

INTRODUCTION

Hepatocellular carcinoma (HCC) remains a major global health concern, as it is the most common primary liver cancer and the fourth leading cause of cancer-related mortality.

AREAS COVERED

Immune checkpoint inhibitors (ICIs) have significantly shifted the treatment paradigm, offering promising survival outcomes. However, the controlled conditions of randomized clinical trials (RCTs) often fail to reflect real-world complexities, emphasizing the necessity for strong real-world evidence (RWE). RWE, in most cases derived from observational studies, provides critical insights into the effectiveness, safety, and tolerability of systemic therapies across diverse populations and settings. The authors searched MEDLINE, Ovid Embase, and Scopus for full-text published articles in any language from the inception to 30 June 2024.This review evaluates RWE on systemic therapies for advanced HCC, including tyrosine kinase inhibitors (TKIs) like sorafenib and lenvatinib, ICIs such as nivolumab and pembrolizumab, and combination therapies like atezolizumab/bevacizumab and durvalumab/tremelimumab.

EXPERT OPINION

Studies reveal discrepancies in treatment efficacy and adverse event profiles between RCTs and routine clinical practice, underscoring the need for individualized treatment strategies. RWE highlights the influence of liver disease etiology, liver function, and tumor burden on treatment outcomes, guiding therapy selection.

Comparative Outcome Analysis of Lenvatinib Versus Sorafenib for Recurrence of Hepatocellular Carcinoma After Liver Transplantation

BACKGROUND

Hepatocellular carcinoma (HCC) recurs after liver transplantation (LT) in ~17% of patients. We aimed to retrospectively compare the outcomes of patients treated with different tyrosine kinase inhibitors (TKIs) for recurrent HCC post-LT.

METHODS

Patients with recurrent HCC post-LT between 2006 and 2019 were included. The impact of sorafenib and lenvatinib treatment for recurrent disease was assessed using survival analysis with an a priori multivariable Cox regression (alpha-fetoprotein [AFP] at recurrence, recurrence lesion diameter, single-site versus multisite metastases).

RESULTS

Seven hundred fifty-four patients underwent LT for HCC, of whom 120 (15.9%) developed recurrence. Of these patients, 56 received TKIs: sorafenib (n = 42) or lenvatinib (n = 14). The median age at LT was 60.8 y (interquartile range, 54.0-66.2); 52 (93%) were men and 26 (46%) were within Milan criteria at listing. Baseline characteristics at recurrence were comparable between the 2 groups, including largest tumor diameter ( P  = 0.15), receipt of local therapies before TKI ( P  = 0.33), and single-site recurrence ( P  = 0.75), and time from interventional treatment to start of TKI ( P  = 0.44). The AFP at recurrence was higher in the sorafenib group (95.0 versus 3.0 µg/L, P  < 0.001). The median overall survival (OS) after initiation of TKI treatment was longer in the lenvatinib group (15.0 mo [95% confidence interval [CI], 11.5-31.5] versus 7.8 mo [95% CI, 4.0-15.4]; P  = 0.02) with a 2.3-fold a priori adjusted effect on OS (adjusted hazard ratio 2.32 [95% CI, 1.03-5.20], P  = 0.04).

CONCLUSIONS

Our findings suggest lenvatinib is a valuable treatment option for patients with HCC recurrence after LT.

Is concurrent LR-5 associated with a higher rate of hepatocellular carcinoma in LR-3 or LR-4 observations? An individual participant data meta-analysis

BACKGROUND

The Liver Imaging Reporting and Data System (LI-RADS) does not consider factors extrinsic to the observation of interest, such as concurrent LR-5 observations.

PURPOSE

To evaluate whether the presence of a concurrent LR-5 observation is associated with a difference in the probability that LR-3 or LR-4 observations represent hepatocellular carcinoma (HCC) through an individual participant data (IPD) meta-analysis.

METHODS

Multiple databases were searched from 1/2014 to 2/2023 for studies evaluating the diagnostic accuracy of CT/MRI for HCC using LI-RADS v2014/2017/2018. The search strategy, study selection, and data collection process can be found at https://osf.io/rpg8x . Using a generalized linear mixed model (GLMM), IPD were pooled across studies and modeled simultaneously with a one-stage meta-analysis approach to estimate positive predictive value (PPV) of LR-3 and LR-4 observations without and with concurrent LR-5 for the diagnosis of HCC. Risk of bias was assessed using a composite reference standard and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2).

RESULTS

Twenty-nine studies comprising 2591 observations in 1456 patients (mean age 59 years, 1083 [74%] male) were included. 587/1960 (29.9%) LR-3 observations in 1009 patients had concurrent LR-5. The PPV for LR-3 observations with concurrent LR-5 was not significantly different from the PPV without LR-5 (45.4% vs 37.1%, p = 0.63). 264/631 (41.8%) LR-4 observations in 447 patients had concurrent LR-5. The PPV for LR-4 observations with concurrent LR-5 was not significantly different from LR-4 observations without concurrent LR-5 (88.6% vs 69.5%, p = 0.08). A sensitivity analysis for low-risk of bias studies (n = 9) did not differ from the primary analysis.

CONCLUSION

The presence of concurrent LR-5 was not significantly associated with differences in PPV for HCC in LR-3 or LR-4 observations, supporting the current LI-RADS paradigm, wherein the presence of synchronous LR-5 may not alter the categorization of LR-3 and LR-4 observations.

Hepatocellular Carcinoma with Vascular Invasion Treated with Resin Yttrium-90 Transarterial Radioembolization Using Single Compartment Dosimetry

PURPOSE

To report outcomes in hepatocellular carcinoma (HCC) patients with lobar and segmental vascular invasion treated with resin Yttrium-90 transarterial radioembolization (Y90-TARE) with single-compartment MIRD (Medical Internal Radiation Dose) model.

MATERIALS AND METHODS

This was a retrospective IRB approved study of patients with a diagnosis of HCC with vascular invasion undergoing resin Y90-TARE from 2014 to 2022 (n = 61). Patients with Body Surface Area dosimetry (n = 20), main portal vein invasion (n = 6) and patients with an ECOG of > 2 were excluded (n = 1) with a final cohort of 34 patients.

RESULTS

Study population consisted of 34 patients, median age 62 years [60-71], tumor size 4.2 (2.8-7.4) cm, and 82% male. The median prescribed dose was 170 (126-200) Gy. The objective response rate at 6 months was 67% and disease control rate was 72%. The median survival was 18 months, median progression-free survival was 9.8 months. The 1- and 3-year survival rates were 76% and 57% in patients prescribed > 180 Gy, compared to 29% and 15% in patients with < 180 Gy (p = 0.01). Five of 15 Childs-Pugh A, ECOG < 1 patients (33%) were downstaged to resection, with complete pathologic necrosis in 40%, and 1 and 3-year survival rates of 100%. Grade-3 adverse events were seen in only 5/34 (15%), with no grade-4 or 5 adverse events.

CONCLUSION

Resin Y90-TARE using single compartment MIRD model for HCC with segmental and lobar vascular invasion can result in downstaging to resection in 33% of patients and higher prescribed doses (> 180 Gy) result in improved survival.

HGF/c-Met Promotes Breast Cancer Tamoxifen Resistance Through the EZH2/HOTAIR-miR-141/200a Feedback Signaling Pathway

Tamoxifen is one of the most frequently used endocrine medications for the treatment of estrogen receptor-positive (ER + ) breast cancer (BC). Unfortunately, tamoxifen resistance (TR) brings more challenges to the clinical treatment, and the mechanisms of TR have not yet been fully clarified. HGF/c-Met is closely associated with cancer metastasis, but whether it is involved in TR remains unclear. In our study, we found that the activation of HGF/c-Met was crucial for TR maintenance. Synergistic interaction with HOTAIR and EZH2 accelerated HGF expression by repressing miR-141/200a. Additionally, HGF/c-Met activated NF-κB, forming a positive feedback loop of EZH2/HOTAIR-miR-141/200a-HGF/c-Met-NF-κB. Our findings indicated that HGF/c-Met functioned as an important biomarker for TR, and HGF/c-Met inhibition provided a novel approach to TR treatment.

Expression of PCED1A in Hepatocellular Carcinoma and Colorectal Cancer and Its Relationship with Immune Infiltration: Potential as a Diagnostic Marker

BACKGROUND

Hepatocellular carcinoma (HCC) and colorectal cancer (CRC) pose a significant threat to human health worldwide, characterized by intricate pathogenesis. A PC-esterase domain containing 1A (PCED1A) is a critical number of the GDSL/SGNH superfamily.

AIM

The aim of this study is to explore the diagnostic value of PCED1A in HCC and CRC and its relationship with immune infiltration.

METHODS

The Cancer Genome Atlas (TCGA) database, Gene Expression Omnibus (GEO) database, the Cancer Cell Line Encyclopedia database (CCLE), and the Human Protein Atlas (HPA) were used to detect the expression of PCED1A in tissues and cells. Cibersoft, Timer, and Xcell were used to analyze the effect of PCED1A on immune cell infiltration. The relationship between PCED1A and the immune checkpoint was analyzed. The coexpression analysis of PCED1A was conducted using the LinkedOmics database.

RESULTS

PCED1A was increased in HCC and CRC with poor prognosis. Immunohistochemistry demonstrated that PCED1A was highly expressed in HCC and CRC compared to corresponding normal tissues. PCED1A expression was related to poor overall survival (OS) and progression-free survival (PFS). High PCED1A expression was strongly associated with M2 macrophages, impacting HCC progression. Conversely, low PCED1A expression was closely related to Th2 cells in CRC. In addition, the checkpoint named PDCD1 showed a good correlation with PCED1A high expression group in HCC and CRC. Lastly, the PCED1A and ZNF family showed a complex and intertwined relationship through coexpression analysis on the LinkedOmics database.

CONCLUSION

PCED1A, related to tumor immune infiltration, is a promising diagnostic biomarker and a valuable therapeutic target for HCC and CRC.

Incidence and management of hepatic immune‑related adverse events in advanced urologic cancers treated with immune checkpoint inhibitors: A multicenter retrospective study

The present study aimed to evaluate the incidence, characteristics and management of hepatic immune-related adverse events (irAEs) in patients with advanced or metastatic urothelial carcinoma (UC) and renal cell carcinoma (RCC) receiving immune checkpoint inhibitors (ICIs). Data regarding the demographics, ICI regimens and hepatic irAEs from 213 patients with metastatic UC or metastatic RCC receiving ICIs between February 2018 and September 2023 at three tertiary medical centers (Inje University Busan Paik Hospital, Busan, South Korea; Dongnam Institute of Radiological and Medical Sciences Cancer Center, Busan, South Korea; Pusan National University Hospital, Busan, South Korea) in South Korea were collected and retrospectively analyzed. Hepatic irAEs were graded using the Common Terminology Criteria for Adverse Events version 5.0 and classified based on R value patterns. Among the 213 patients evaluated, 76 (35.6%) experienced at least one irAE, whereas 48 (22.5%) developed hepatic irAEs. The median onset time for hepatic irAEs was 6.5 weeks, with incidence rates being higher with combination therapies than with monotherapies (31.8 vs. 18.3%; P=0.014). Furthermore, 72.9 and 27.1% of the patients had grade 1-2 and 3-4 hepatic irAEs, respectively. The patterns of liver toxicity included cholestatic (35.4%), mixed (35.4%) and hepatocellular (29.2%). All patients with grade 1-2 hepatic irAE recovered with supportive treatment without ICI discontinuation or corticosteroids use. Among the 13 patients with grade ≥3 hepatic irAEs, 12 recovered with high-dose corticosteroids, while 1 died due to fulminant hepatitis. Hepatic irAEs are common in patients with advanced and metastatic urologic cancers who are treated with ICIs, particularly with combination therapies. Most cases have low-grade irAE that are manageable without ICI discontinuation; however, severe cases require prompt recognition and treatment with corticosteroids. These findings emphasize the importance of regular liver function monitoring and appropriate management strategies for hepatic irAEs in patients with urologic cancer receiving ICI therapy.

Cancer-associated fibroblasts in hepatocellular carcinoma: heterogeneity, mechanisms and therapeutic targets

Hepatocellular carcinoma (HCC) is one of the common malignant cancers worldwide. Although immunotherapy has improved the treatment outcome in HCC, a significant percentage of patients with advanced HCC still cannot benefit from immunotherapy. Therefore, developing new targets or combination therapeutic strategies to improve the efficacy of immunotherapy is urgently needed. A deeper understanding of the mechanisms underlying immune regulation may help in this regard. The tumor microenvironment (TME) consists of a diverse set of components modulating the efficacy of immunotherapy. Cancer-associated fibroblasts (CAFs) are critical components of the TME and can regulate both tumor and immune cells through secreted cytokines and exosomes that impact various signaling pathways in target cells. CAF-derived cytokines can also participate in extracellular matrix (ECM) remodeling, thereby impacting cancer progression and tumor responsiveness to immunotherapy among other effects. A thorough understanding of the phenotypic and functional profile dynamism of CAFs may lead the way for new treatment strategies and/or better treatment outcomes in HCC patients. In this review, we outline the biomarkers and functional heterogeneity of CAFs in HCC and elaborate on molecular mechanisms of CAFs, including anti-programmed cell death protein 1 (PD-1)/PD-ligand 1 (PD-L1) immunotherapy. We also examine current clinical implications of CAFs-related targets as potential therapeutic candidates in HCC.

The Impact of Radiation Dose and Tumour Burden on Outcomes in Hepatocellular Carcinoma: 11-Year Experience in a 413-Patient Cohort Treated with Yttrium-90 Resin Microsphere Radioembolisation

Introduction

Transarterial radioembolisation (RE) using yttrium-90 (Y-90) microspheres is a widely used locoregional therapy for a broad spectrum of hepatocellular carcinoma (HCC) given its favourable safety profile. We evaluated the real-world outcomes of unresectable HCC treated with resin Y-90 RE and the relationship between tumour absorbed dose and subsequent curative therapy with survival.

Methods

Included were consecutive patients treated with Y-90 resin microspheres RE for unresectable HCC between January 2008 and May 2019 at the National Cancer Centre Singapore/Singapore General Hospital. The outcomes were stratified by tumour burden, distribution, presence of portal vein invasion (PVI) and liver function to improve prognostication.

Results

The median overall survival (OS) evaluated on 413 included patients was 20.9 months (95% CI: 18.2-24.0). More than half of the patients (214/413, 51.8%) had HCC beyond up-to-seven criteria, and 37.3% had portal vein invasion (154/413, 37.3%). Majority (71.7%) had dosimetry calculated based on the partition model. Patients who received ≥150 Gy to tumour had significantly better outcomes (OS 32.2 months, 95% CI: 18.3-46.4) than those who did not (OS 17.5 months, 95% CI: 13.7-22.7, p < 0.001). Seventy patients (17%) received curative therapies after tumour was downstaged by Y-90 RE and had better OS of 79.7 months (95% CI: 40.4 - NE) compared to those who did not receive curative therapies (OS 17.1 months; 95% CI: 13.5-20.4, p < 0.001). RE-induced liver injury was observed in 5.08% of the patients while 3.2% of the patients had possible radiation pneumonitis but none developed Grade 3-4 toxicity. For HCC without PVI, OS differed significantly with performance status, albumin-bilirubin grade, tumour distribution, and radiation dose; for HCC with PVI, Child-Pugh class and AFP were significant predictors of survival.

Conclusions

Treatment outcomes for unresectable HCC using Y-90 RE were favourable. Incorporating tumour burden and distribution improved prognostication. Patients who received tumour absorbed dose above 150 Gy had better OS. Patients who subsequently received curative therapies after being downstaged by Y-90 RE had remarkable clinical outcomes.

Advances in radiation therapy for HCC: Integration with liver-directed treatments

HCC is the fourth leading cause of cancer-related mortality with increasing incidence worldwide. Historically, treatment for early disease includes liver transplantation, surgical resection, and/or other local therapies, such as thermal ablation. As a result of technical advances and high-quality prospective data, the use of definitive external beam radiotherapy with ablative doses has emerged. Intermediate-stage disease has been generally addressed with arterially directed therapies (eg, chemoembolization or radioembolization) and external beam radiotherapy, while advanced stages have been addressed by systemic therapy or best supportive care. The role of each local/locoregional therapy has rapidly evolved in the context of novel pharmacotherapies, including immunotherapies and antiangiogenic agents. The combinations, indications, and timing of treatments vary widely among specialties and geographies. Here, we aim to synthesize the best quality evidence available regarding the efficacy and safety of different liver-directed modalities, with a focus on recent prospective clinical data of external beam radiotherapy within the context of other available liver-directed therapies across Barcelona Liver Classification (BCLC) stages.

British Society of Gastroenterology guidelines for diagnosis and management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease which, if untreated, often leads to cirrhosis, liver failure and death. The last British Society of Gastroenterology (BSG) guideline for the management of AIH was published in 2011. Since then, our understanding of AIH has advanced in many areas. This update to the previous guideline was commissioned by the BSG and developed by a multidisciplinary group. The aim of this guideline is to review and summarise the current evidence, in order to inform and guide diagnosis and management of patients with AIH and its variant syndromes. The main focus is on AIH in adults, but the guidelines should also be relevant to older children and adolescents.

TRANSMIT: Utilizing discarded livers from donors with a history of cancer for patients lacking access to standard allocation - A compassionate use exploratory study

Background

A substantial number of viable donor livers are discarded due to the donor's underlying malignancy. Concurrently, patients with certain liver malignancies - such as unresectable colorectal cancer liver metastases (CRC-LM), unresectable intrahepatic or perihilar cholangiocarcinoma (iCCC/phCCC), or unresectable hepatocellular carcinoma (HCC) responding to immunotherapy - often face poor survival outcomes and are deemed ineligible for potentially curative liver transplantation. In this context, a rational risk-benefit analysis suggests that transplanting an organ with a theoretical risk of tumor transmission may be justifiable for these patients facing otherwise short-term fatal outcomes.

Methods

The TRANSMIT study is a compassionate use exploratory study aimed at assessing the utility and safety of using donor organs from individuals with a current or past history of cancer for liver transplantation in patients with liver malignancies (CRC-LM, i/phCCC, HCC) who are not eligible for regular organ allocation. The study will evaluate the utilization rate of donor organs that would otherwise be discarded, overall survival, progression-free survival, and tumor transmission rates at one and three years, stratified by indication.

Discussion

Donor organs from individuals with a current or past history of cancer may represent a valuable and safe resource for expanding the limited donor pool, particularly for patients who lack access to standard organ allocation.

Drug resistance in TKI therapy for hepatocellular carcinoma: Mechanisms and strategies

Tyrosine kinase inhibitors (TKIs) are such as sorafenib the first-line therapeutic drugs for patients with advanced hepatocellular carcinoma. However, patients with TKI-resistant advanced liver cancer are insensitive to TKI treatment, resulting in limited survival benefits. This paper comprehensively reviewed the mechanisms underlying TKI resistance in hepatocytes, investigating activation of tumor signaling pathways, epigenetic regulation, tumor microenvironment, and metabolic reprogramming. Based on resistance mechanisms, it also reviews preclinical and clinical studies of drug resistance strategies and summarizes targeted therapy combined with immunotherapy currently in investigational clinical trials. Understanding the interactions and clinical studies of these resistance mechanisms offers new hope for improving and prolonging patient survival.

Explainable and Robust Deep Learning for Liver Segmentation Through U-Net Network

Background/Objectives: Clinical imaging techniques, such as magnetic resonance imaging and computed tomography, play a vital role in supporting clinicians by aiding disease diagnosis and facilitating the planning of appropriate interventions. This is particularly important in malignant conditions like hepatocellular carcinoma, where accurate image segmentation, delineating the liver and tumor, is a critical initial step in optimizing diagnosis, staging, and treatment planning, including interventions like transplantation, surgical resection, radiotherapy, portal vein embolization, and other procedures. Therefore, effective segmentation methods can significantly influence both diagnostic accuracy and treatment outcomes. Method: In this paper, we propose a deep learning-based approach aimed at accurately segmenting the liver in medical images, thus addressing a critical need in hepatic disease diagnosis and treatment planning. We consider a U-Net architecture with residual connections to capture fine-grained anatomical details. We also take into account the prediction explainability, aiming to highlight, in the image under analysis, the areas that are symptomatic for a certain segmentation. In detail, by exploiting the U-Net architecture, two different models are trained with two annotated datasets of computed tomography medical images, resulting in four different experiments. Results: We consider two different datasets to improve robustness and generalization across diverse patient populations and imaging conditions. Experimental results demonstrate that the proposed method obtains interesting performances, with an accuracy ranging from 0.81 to 0.93. Conclusions: We thus show that the proposed method can provide a reliable and efficient solution for automated liver segmentation, promising significant advancements in clinical workflows and precision medicine.

Efficacy and safety of immune checkpoint inhibitors in advanced biliary tract cancer: a real-world study

Background

Immune checkpoint inhibitors (ICIs) combined with gemcitabine and cisplatin chemotherapy have become the standard first-line treatment for advanced biliary tract cancer (BTC). However, real-world evidence on domestic ICIs widely used in China and the therapeutic outcomes across treatment lines remains limited. This study aimed to assess the real-world effectiveness and safety profiles of ICIs in advanced BTC patients, while concurrently elucidating potential efficacy variations among distinct ICI subtypes.

Methods

We analyzed patients with unresectable, locally advanced, or metastatic BTC treated with ICIs at West China Hospital (January 2019-October 2023). Primary endpoint was overall survival (OS), while secondary endpoints included progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and safety. Kaplan-Meier survival curves, propensity score matching (PSM), and Cox proportional hazards regression analyzed treatment efficacy.

Results

A total of 221 advanced BTC patients were enrolled. Among them, 137 patients received ICIs treatment in the first line, while 84 patients in the second or later lines. For patients treated with ICIs as first-line therapy, the median OS was 15.7 months (95% CI: 13.1-19.8) and PFS was 8.4 months (95% CI: 7.6-10.3). In contrast, patients treated in second or later lines had shorter median OS of 9.8 months (95% CI: 8.1-12.3) and median PFS of 5.6 months (95% CI: 4.2-6.8). The reduced efficacy in later-line treatments may reflect prior therapeutic resistance and generally poorer patient conditions compared to first-line recipients. 211 (95.5%) patients experienced at least one adverse event (AE), and 93 (42.1%) of them experienced grade 3 or higher AEs. The incidence of immune-related adverse events (irAEs) was 35.8%, with 8.6% of patients experiencing grade 3-4 irAEs. The most common ICI treatments are with Durvalumab or Sintilimab, which we are interested in comparing. Durvalumab showed numerically superior OS vs Sintilimab (19.3 vs 10.2 months, p<0.001) in unmatched analysis, though significance attenuated after PSM (16.1 vs 13.1 months, p=0.299).

Conclusion

ICIs demonstrate robust efficacy and manageable toxicity in real-world settings, supporting their use in both first- and later-line treatments for advanced BTC. However, whether domestic ICI alternatives remain viable options warranting further validation.

Peripheral blood CD4+/CD8+ T cell ratio may have potential for predicting the treatment response of durvalumab plus tremelimumab therapy (STRIDE) for unresectable hepatocellular carcinoma: Preliminary report

BACKGROUND

This preliminary study evaluated the clinical impact of peripheral blood T lymphocyte differentiation patterns to predict the treatment response to durvalumab plus tremelimumab therapy (a regimen termed STRIDE).

METHODS

We investigated 21 patients with unresectable hepatocellular carcinoma (HCC) treated with STRIDE. The treatment response was evaluated 4-8 weeks after the initiation of STRIDE using the modified response evaluation criteria in solid tumors. The correlation between pretreatment peripheral blood T lymphocytes differentiation patterns, with a focus on the peripheral blood CD4+/CD8+ T cell ratio and response to STRIDE, was then investigated.

RESULTS

Of the 21 patients, 5 (24%) had an objective response (OR). The median peripheral blood CD4+/CD8+ T cell ratio (CD4/8-R) of the cohort was 1.4. A receiver operating characteristic curve showed the optimal cutoff value for predicting an OR to STRIDE determined by the Youden index to be 2.5. Of the seven patients with a CD4/8-R ≥2.5, four (57%) had an OR. In contrast, of the 14 patients with a CD4/8-R <2.5, only one patient (7%) had an OR. Finally, the OR rate (ORR) was significantly higher in the group with a CD4/8-R ≥2.5 at the time of STRIDE initiation (p = 0.025).

CONCLUSIONS

The peripheral blood CD4+/CD8+ T cell ratio is a potential predictive biomarker for the response to STRIDE therapy in HCC patients.

Transarterial Chemoembolization for Hepatocellular Carcinoma: Current Role and Techniques

In the current systemic therapy era, such as immunotherapy and molecular targeted therapy, treatment strategy of hepatocellular carcinoma is changing. Transarterial chemoembolization is more expected as a curative treatment option than before. Therefore, it is important to learn key techniques of transarterial chemoembolization procedures to achieve complete response. This article delineates the current indications for transarterial chemoembolization and several techniques used for its implementation.

Global trends in artificial intelligence applications in liver disease over seventeen years

BACKGROUND

In recent years, the utilization of artificial intelligence (AI) technology has gained prominence in the field of liver disease.

AIM

To analyzes AI research in the field of liver disease, summarizes the current research status and identifies hot spots.

METHODS

We searched the Web of Science Core Collection database for all articles and reviews on hepatopathy and AI. The time spans from January 2007 to August 2023. We included 4051 studies for further collection of information, including authors, countries, institutions, publication years, keywords and references. VOS viewer, CiteSpace, R 4.3.1 and Scimago Graphica were used to visualize the results.

RESULTS

A total of 4051 articles were analyzed. China was the leading contributor, with 1568 publications, while the United States had the most international collaborations. The most productive institutions and journals were the Chinese Academy of Sciences and Frontiers in Oncology. Keywords co-occurrence analysis can be roughly summarized into four clusters: Risk prediction, diagnosis, treatment and prognosis of liver diseases. "Machine learning", "deep learning", "convolutional neural network", "CT", and "microvascular infiltration" have been popular research topics in recent years.

CONCLUSION

AI is widely applied in the risk assessment, diagnosis, treatment, and prognosis of liver diseases, with a shift from invasive to noninvasive treatment approaches.

Comparison of the diagnostic and prognostic value of criteria for immune checkpoint inhibitor related myocarditis

BACKGROUND

Myocarditis is a dreaded complication of immune-checkpoint inhibitor (ICI) therapy but challenging to diagnose. There are no published data comparing the two leading diagnostic criteria for ICI-related myocarditis (ICIrM) and their association with cardiovascular events.

METHODS

In this retrospective cohort study, we reviewed all patients who underwent ICI therapy and had cardiac troponin assessment for possible myocarditis across three tertiary institutions from 2011 to 2022. ICIrM was adjudicated by the Bonaca et al. criteria and the ESC-ICOS guidelines. A propensity matched control group was identified of patients treated with ICI without developing myocarditis. Baseline characteristics and long-term outcomes, including cardiac death, MACE (myocardial infarction, TIA/stroke, heart failure), and arrhythmias data were curated, and patients diagnosed with ICIrM by each criteria were compared to controls for cardiovascular events.

RESULTS

A total of 59 patients (mean age was 73.1 ± 10.2 years, 60.1% male) were identified as having a diagnosis of ICIrM by Bonaca criteria (16 definite, 13 probable and 30 possible myocarditis). Forty-seven of these patients met the ESC-ICOS guidelines criteria, and all patients meeting either set of ICIrM criteria were treated with steroid therapy. At 3-year follow up, patients diagnosed with ICIrM by the Bonaca criteria had a high risk of cardiac mortality (HR 17.84, 95%CI 2.36-134.62, p = 0.005), MACE (HR 4.90, 95%CI 2.40-10.02, p < 0.001) and arrhythmias (HR 3.33, 95%CI 1.78-6.21, p < 0.001) when compared to matched controls. ICIrM by ESC-ICOS criteria was similarly predictive of cardiac mortality, MACE, and arrhythmias (HR 15.01, 95%CI 1.96-114.76, p = 0.009, HR 5.18, 95%CI 2.33-11.53, p < 0.001, and HR 3.41, 95%CI 1.73-6.70, p < 0.001 respectively).

CONCLUSION

The ESC-ICOS guidelines were more restrictive than the Bonaca et al. criteria for the diagnosis of ICIrM but similar in terms of prognostic value.

Health-related quality of life in participants with advanced biliary tract cancer from the randomized phase III KEYNOTE-966 study

BACKGROUND & AIMS

In the randomized, double-blind, phase 3 KEYNOTE-966 trial, pembrolizumab plus gemcitabine and cisplatin demonstrated a significant improvement in overall survival as first-line therapy for advanced biliary tract cancer (BTC). We present the prespecified health-related quality of life (HRQoL) outcomes from KEYNOTE-966.

METHODS

HRQoL was assessed using the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), EORTC QLQ-BIL21, and EuroQoL 5 Dimensions 5 Levels (EQ-5D-5L) questionnaires. Data from the latest time point with ≥60% completion and ≥80% compliance (week 18) were compared to baseline. Least squares means (LSM) for change from baseline to week 18 were compared using a constrained longitudinal analysis model in six prespecified domains: QLQ-C30 global health status/quality of life (GHS/QoL), physical functioning, and role functioning; QLQ-BIL21 pain and jaundice scores, and EQ-5D-5L visual analog score. The analysis population was all treated participants with ≥1 completed HRQoL assessment. Between-arm difference in time to confirmed deterioration (TTD) was assessed using a stratified Cox proportional hazards model with randomization stratification factors.

RESULTS

KEYNOTE-966 randomized 1,069 participants into the study (n=533 pembrolizumab arm; n=536 placebo arm). Questionnaire compliance was >87% from baseline to week 18 in both arms. LSM changes from baseline to week 18 were similar between arms for all prespecified domains. TTD estimates were also similar between arms, including GHS/QoL (median not reached [NR] in the pembrolizumab arm versus 21.2 months in the placebo arm; HR=0.86, 95% CI=0.70-1.07); jaundice (NR versus NR; HR=1.20, 95% CI=0.94-1.54), and pain (NR versus NR; HR=0.79, 95% CI=0.59-1.05).

CONCLUSION

HRQoL was maintained after adding pembrolizumab to gemcitabine and cisplatin, further supporting this regimen as first-line treatment for advanced BTC.

IMPACT AND IMPLICATIONS

Biliary tract cancer (BTC) is often diagnosed at late stages because most patients do not present with disease-specific symptoms. Compared with the general population, patients with advanced BTC report worse physical, emotional, and functional well-being. In KEYNOTE-966, adding the programmed cell death protein 1 (PD-1) inhibitor pembrolizumab to gemcitabine and cisplatin as first-line therapy for participants with advanced BTC produced a statistically significant and clinically meaningful improvement in overall survival. The prespecified patient-reported outcomes results from KEYNOTE-966 presented herein demonstrated that health-related quality of life was maintained after adding pembrolizumab to gemcitabine and cisplatin, further supporting this regimen as first-line treatment for advanced BTC.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT04924062.

Future perspectives on immunotherapy for hepatocellular carcinoma

In recent years, several global phase III trials have shown that combinations of immune checkpoint inhibitors (ICIs) offer superior efficacy and survival compared to multi-kinase inhibitors, establishing them as the gold standard for treating patients with advanced hepatocellular carcinoma (HCC). This success has led to investigations into expanding the use of immunotherapy into various other settings and populations, including neoadjuvant and adjuvant therapies, patients with decompensated liver function and those awaiting liver transplantation. Despite its proven efficacy, a significant number of patients still develop resistance to immunotherapy, highlighting the need for innovative strategies to address this challenge. Approaches aimed at enhancing tumour immunogenicity, such as combining immunotherapy with transarterial chemoembolization or radiation therapies, show significant promise. Additionally, novel immunotherapeutics - such as triplet therapy, bispecific antibodies, adoptive T-cell therapy and cancer vaccines - are in early development for HCC. These agents have demonstrated potential for synergistic effects with existing ICIs, with initial studies yielding positive outcomes. In this review, we offer our future perspective on immunotherapy, emphasizing emerging indications, novel combination strategies and the development of new immunotherapeutic agents. Overall, the future of immunotherapy in HCC is brimming with extraordinary potential, set to transform the treatment landscape and redefine the possibilities for managing this challenging disease.

Liposomal irinotecan for previously treated patients with biliary tract cancer: A pooled analysis of NIFTY and NALIRICC trials

BACKGROUND & AIMS

Liposomal irinotecan (nal-IRI) combined with fluorouracil (5-FU)/leucovorin (LV) as a second-line treatment for biliary tract cancer (BTC) following progression on gemcitabine-based therapy yielded conflicting outcomes in the Korean NIFTY and German NALIRICC trials. This necessitated a comprehensive pooled analysis to evaluate its efficacy and safety.

METHODS

Individual patient data were pooled from the intention-to-treat populations of the NIFTY and NALIRICC trials. The primary endpoint was progression-free survival (PFS).

RESULTS

A total of 278 patients were included: 137 in the nal-IRI plus 5-FU/LV group and 141 in the 5-FU/LV group. The nal-IRI plus 5-FU/LV group showed significantly longer median PFS (3.6 months [95% CI 2.7-4.4] vs. 1.8 months [95% CI 1.5-2.6]; hazard ratio 0.65, p <0.001). Median overall survival was 8.1 months (95% CI 6.0-8.9) and 6.1 months (95% CI 5.3-7.5), respectively (hazard ratio 0.77, p = 0.051). Objective response rates were also higher in the nal-IRI plus 5-FU/LV group than in the 5-FU/LV group (17.5% vs. 2.8%; p <0.001). Post-study irinotecan-containing therapy was administered in 4 (2.9%) and 21 (15.3%) patients in the nal-IRI plus 5-FU/LV group and 5-FU/LV group, respectively. Adverse events varied by ethnicity, with gastrointestinal toxicities more common in Germans and neutropenia more prevalent in Koreans; treatment discontinuation without disease progression occurred in 31.3% vs. 8.0%, respectively.

CONCLUSION

The addition of nal-IRI to 5-FU/LV significantly improved PFS and objective response rates, supporting its potential as subsequent-line therapy. Differences in safety profiles underscore the relevance of ethnicity for nal-IRI in patients with BTC.

IMPACT AND IMPLICATIONS

Current standard of care for second-line therapy in patients with advanced biliary tract cancer (BTC) is FOLFOX. This study provides robust evidence supporting the potential role of adding liposomal irinotecan (nal-IRI) to fluorouracil and leucovorin (5-FU/LV) as a subsequent therapy for patients with BTC who have progressed on gemcitabine-based regimens. The findings demonstrate significant improvements in progression-free survival and objective response rates in a patient population for whom treatment options are limited. Furthermore, the study underscores the necessity of considering ethnic differences in adverse event profiles to optimize treatment administration and patient outcomes.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03524508 and NCT03043547.

Lenvatinib-induced pemphigus erythematosus in hepatocellular carcinoma: a unique case report

Adjuvant lenvatinib in combination with transarterial chemoembolization (TACE) has demonstrated prolonged disease-free survival in hepatocellular carcinoma patients at high risk of recurrence post-resection. Here, we present the case of a 68-year-old woman who developed serious side effects including pemphigus erythematosus (PE) linked to lenvatinib usage. Initially treated for breast cancer with radical surgery in April 2018 followed by adjuvant therapy, she was later diagnosed with liver cancer, initially mistaken for metastatic breast cancer to the liver. Although systemic treatment for advanced breast cancer was received, the tumor continued to progress and required partial removal of the liver after final evaluation. Subsequent pathology revealed hepatocellular carcinoma combined with risk factors for recurrence, prompting adjuvant therapy with TACE and oral lenvatinib. After three weeks of lenvatinib administration, the patient developed a skin rash diagnosed as PE through skin pathology. Treatment involved oral methylprednisolone, intravenous human immune globulin, and supportive care, resulting in a cure within a month. This unique case highlights the importance of further research not only on lenvatinib but also on monitoring and managing adverse reactions associated with targeted drugs to optimize patient safety and treatment outcomes.