Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases

Final Results of a Multicenter Prospective Study of Stereotactic Body Radiation Therapy for Previously Untreated Solitary Primary Hepatocellular Carcinoma (The STRSPH Study)

PURPOSE

To report final results of a prospective study of stereotactic body radiation therapy (SBRT) in patients with previously untreated solitary primary hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

This prospective, single-arm, multicenter phase 2 trial recruited patients with HCC who were unsuitable for, or refused, surgery and radiofrequency ablation, with 3-year overall survival rates as the primary endpoint and survival outcomes and adverse events as secondary endpoints. The prescribed SBRT dose was 40 Gy in 5 fractions. The final data were analyzed in November 2022.

RESULTS

Between 2014 and 2018, 36 patients (median age, 73.5 years) were registered; enrollment was closed before full recruitment due to slow accrual. Overall, 34 patients were analyzed for efficacy evaluation after excluding 2 patients. The median tumor size was 2.3 cm. The median follow-up times for all patients and for survivors were 49 and 56 months, respectively. The 3-year overall survival rate was 82% (95% confidence interval, 65%-92%). The 3-year local control rate was 93% (95% confidence interval, 76%-98%). Grade 3 or higher SBRT-related nonlaboratory toxicities were observed in 4 patients (11%). No grade 5 adverse events were observed.

CONCLUSIONS

Final results of this phase 2 trial suggest the efficacy and safety of SBRT for newly diagnosed early-stage HCC that is unfit for other local therapies. Although this study was underpowered by the small number of registrations, the excellent results indicate that SBRT may be an alternative option for the management of early-stage HCC.

Folate receptor 1 is a stemness trait-associated diagnostic and prognostic marker for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) can be classified into several subtypes based on molecular traits, aiding in prognostic stratification. The subtype with a poor prognosis is often associated with stem/progenitor features. This study focused on identifying circulating biomarkers for aggressive HCC.

METHODS

We searched for secretory proteins whose expression was positively associated with the stem/progenitor markers KRT19, EPCAM, and PROM1 in 2 independent HCC cohorts. Serum folate receptor 1 (FOLR1) levels were measured in 238 chronic liver disease and 247 HCC patients, evaluating their diagnostic and prognostic capabilities.

RESULTS

FOLR1 was identified as a secretory protein that was positively correlated with all 3 stem/progenitor markers and a poor prognosis in both the discovery and validation cohorts. Higher FOLR1 expression was detected in tumor than nontumor tissues and was associated with aggressive subtypes, and activation of p53, DNA repair, Myc, E2F, and PI3K/AKT/mTOR pathways. Serum FOLR1 levels correlated with tumoral FOLR1 expression in HCC patients and were significantly elevated compared with those in patients with chronic hepatitis or nonliver disease. Serum FOLR1 levels demonstrated diagnostic performance for HCC comparable to that of alpha-fetoprotein (AFP), and their combination increased the diagnostic accuracy. Elevated serum FOLR1 levels were associated with poor prognosis in HCC patients, regardless of treatment, especially in patients with early-stage disease. The multivariate analysis revealed that the serum FOLR1 level and the Gender, Age, AFP-L3, AFP, and Des-gamma-carboxy prothrombin (GALAD) score were independent predictors of a poor prognosis with their combination further stratifying prognosis.

CONCLUSIONS

FOLR1 is a stemness-associated biomarker for HCC, with serum levels serving as a diagnostic marker for HCC and a prognostic indicator for early-stage disease.

Prediction of treatment response and outcome of transarterial chemoembolization in patients with hepatocellular carcinoma using artificial intelligence: A systematic review of efficacy

PURPOSE

To perform a systematic literature review of the efficacy of different AI models to predict HCC treatment response to transarterial chemoembolization (TACE), including overall survival (OS) and time to progression (TTP).

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines until May 2, 2024.

RESULTS

The systematic review included 23 studies with 4,486 HCC patients. The AI algorithm receiver operator characteristic (ROC) area under the curve (AUC) for predicting HCC response to TACE based on mRECIST criteria ranged from 0.55 to 0.97. Radiomics-models outperformed non-radiomics models (AUCs: 0.79, 95 %CI: 0.75-0.82 vs. 0.73, 0.61-0.77, respectively). The best ML methods used for the prediction of TACE response for HCC patients were CNN, GB, SVM, and RF with AUCs of 0.88 (0.79-0.97), 0.82 (0.71-0.89), 0.8 (0.60-0.87) and 0.8 (0.55-0.96), respectively. Of all predictive feature models, those combining clinic-radiologic features (ALBI grade, BCLC stage, AFP level, tumor diameter, distribution, and peritumoral arterial enhancement) had higher AUCs compared with models based on clinical characteristics alone (0.79, 0.73-0.89; p = 0.04 for CT + clinical, 0.81, 0.75-0.88; p = 0.017 for MRI + clinical versus 0.6, 0.55-0.75 in clinical characteristics alone).

CONCLUSION

Integrating clinic-radiologic features enhances AI models' predictive performance for HCC patient response to TACE, with CNN, GB, SVM, and RF methods outperforming others. Key predictive clinic-radiologic features include ALBI grade, BCLC stage, AFP level, tumor diameter, distribution, and peritumoral arterial enhancement. Multi-institutional studies are needed to improve AI model accuracy, address heterogeneity, and resolve validation issues.

Role of Alcohol in Steatotic Liver Disease: Impact on Patients with Cardiometabolic Risk Factors

The new definition of steatotic liver disease (SLD), as a broader concept, was a step forward in the increasing recognition of the substantial overlap between alcohol and cardiometabolic risk factors (CMRFs), in a continuum way. The spectrum of pathophysiological aspects, ranging from liver steatosis to fibrosis, has similarities in MASLD and ALD. Also, there is now considerable evidence that the association of metabolic dysfunction with increased alcohol consumption impacts on the risk of severe liver disease and prognosis. The new MetALD class, as recently proposed, shows clear differences in prognosis when comparing with MASLD and ALD groups. However, there is room for improvement, such as considering the role of previous alcohol intake, fluctuations of consumption over time, including binge drinking, refinement of alcohol assessment, and better understanding of the role of biomarkers. In summary, SLD is no doubt a significant improvement, but the new classification needs to be dynamic and adapting to patients needing frequent reassessment. Furthermore, it brings opportunities for research on the interaction between alcohol consumption and CMRFs.

Role of noninvasive tests on the prediction of hepatocellular carcinoma in nonalcoholic fatty liver disease patients without cirrhosis: a systematic review and meta-analysis of aggregate and individual patient data

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) has been identified as an emerging risk factor for hepatocellular carcinoma (HCC). Identifying non-cirrhotic NAFLD patients at risk for HCC is crucial. We aimed to investigate the utility of noninvasive tests (NITs) as predictors for HCC and to determine optimal and cost-effective NIT cutoffs for HCC surveillance in non-cirrhotic NAFLD patients.

METHODS

Medline, EMBASE, and Scopus databases were searched for studies evaluating the relationship between NITs and HCC in this population. Random-effects models were used to estimate hazard ratios or risk ratios and 95% confidence interval (95% CI). Cutoffs of NITs for identifying high-risk patients for HCC were determined.

RESULTS

This systematic review comprised 20 studies. A meta-analysis of 379 194 patients was conducted using six studies with individual patient data and five studies with aggregate data. Among NITs studied, fibrosis-4 index (FIB-4), aspartate aminotransferase to platelet ratio index (APRI), and NAFLD fibrosis score (NFS) were significantly associated with HCC, with pooled risk ratio (95% CI) of 9.21 (5.79-14.64), pooled hazard ratio of 12.53 (6.57-23.90), and 13.32 (6.48-27.37), respectively. FIB-4, APRI, and NFS of more than 2.06, 0.65, and 0.51 resulted in the highest area under the receiver operating characteristics of 0.83, 0.80, and 0.85, respectively. Surveillance in patients with FIB-4 ≥ 5.91 and NFS ≥ 2.85 would be cost-effective with an annual HCC incidence of ≥15 per 1000 patient-years.

CONCLUSION

FIB-4, APRI, and NFS are associated with HCC development in non-cirrhotic NAFLD patients. Different NIT cutoffs may be used to enroll high-risk NAFLD patients for HCC surveillance, according to resource availability in different settings.

MR elastography vs a combination of common non-invasive tests for estimation of severe liver fibrosis in patients with hepatobiliary tumors

OBJECTIVES

To evaluate the accuracy of combined imaging and blood test indices related to liver fibrosis (LF) compared to magnetic resonance elastography (MRE) for estimating severe LF (F3-4) in preoperative patients.

METHODS

This retrospective study included patients who underwent MRE, gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI, and dynamic CT before liver resection. Liver stiffness measurement (LSM) using MRE, liver-to-spleen signal intensity ratio (LSR) using Gd-EOB-DTPA-enhanced MRI, and spleen volume normalized to body surface area (SV/BSA) using CT volumetry were measured. Laboratory parameters, including levels of type IV collagen 7S and hyaluronic acid, were also measured. Logistic regression and receiver operating characteristic analyses were performed to identify parameters that could estimate severe LF more accurately than LSM alone.

RESULTS

A total of 81 patients (mean age, 67 years ± 9.9 [SD]; 58 men) were enrolled. Multivariable logistic regression analysis indicated that LSR (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.05-0.37, p < 0.001), SV/BSA (OR: 1.25, 95% CI: 1.02-1.52, p = 0.03) and type IV collagen 7S (OR: 1.84, 95% CI: 1.12-3.00, p = 0.02) were associated with severe LF. Receiver operating characteristic analysis showed that for estimating severe LF, the area under the curve was significantly larger for the combination of LSR, SV/BSA, and type IV collagen 7S than for LSM alone (0.95 vs 0.85, p = 0.04).

CONCLUSION

The combined evaluation of LSR, SV/BSA, and type IV collagen 7S obtained by clinically common preoperative examinations was more accurate than MRE alone for estimating severe LF in preoperative patients.

KEY POINTS

Question What indicators among the imaging and blood tests commonly performed preoperatively can provide a more accurate estimate of severe LF compared to MRE? Findings The combination of LSR, SV/BSA, and type IV collagen 7S was more accurate than an LSM alone for estimating severe LF. Clinical relevance A combination of commonly performed non-invasive preoperative tests provides a more accurate estimation of severe LF than MR elastography, an examination with relatively limited.

Long-term risk of HCC in a DAA-treated national hepatitis C cohort, and a proposed risk score

BACKGROUND

The risk of hepatocellular carcinoma (HCC) remains elevated in cirrhotic hepatitis C patients with sustained virological response (SVR) after DAA treatment. We assessed long-term HCC risk stratified by pretreatment liver stiffness measurement (LSM) and developed a risk score algorithm.

METHODS

This register-based nationwide cohort study of 7,227 DAA-treated patients with SVR evaluated annual HCC incidence rates (IRs) and cumulative incidences stratified by pretreatment LSM. The association between LSM and HCC risk was analyzed using multivariate Cox regression. A risk score algorithm was developed and internally validated in 2,664 individuals with LSM >9.5 kPa, assigning each patient a score based on risk factors, proportionally weighted by the association with HCC risk.

RESULTS

During a median follow-up of 1.8 years (3.2 years for LSM ≥12.5 kPa), 92 patients (1.3%) developed HCC. The IRs for LSM 9.5-12.4, 12.5-19.9 and ≥20 kPa were 0.21, 0.99 and 2.20 HCC/100 PY, respectively, with no significant risk reduction during follow-up. The HRs (and 95% CI) for LSM 9.5-12.5, 12.5-19.9 and ≥20 kPa are 1.19 (0.43-3.28), 4.66 (2.17-10.01) and 10.53 (5.26-21.08), respectively. Risk score models including FIB-4, alcohol, diabetes, age and LSM effectively stratified patients with LSM >9.5 kPa into low-, intermediate- and high-risk groups, with a Harrell's C of 0.799. Notably, 48% with LSM ≥9.5 kPa and 27% ≥12.5 kPa were classified as low-risk.

CONCLUSION

Pretreatment LSM is associated with HCC risk, which remains stable during the initial five years post-SVR. The HCC risk score algorithm effectively identifies low-risk patients, who may not require HCC surveillance.

Multiple features of cell-free mtDNA for predicting transarterial chemoembolization response in hepatocellular carcinoma

BACKGROUND

Transarterial chemoembolization (TACE) is the primary treatment modality for advanced HCC, yet its efficacy assessment and prognosis prediction largely depend on imaging and serological markers that possess inherent limitations in terms of real-time capability, sensitivity, and specificity. Here, we explored whether multiple features of cell-free mitochondrial DNA (cf-mtDNA), including copy number, mutations, and fragmentomics, could be used to predict the response and prognosis of patients with HCC undergoing TACE treatment.

METHODS

A total of 60 plasma cell-free DNA samples were collected from 30 patients with HCC before and after the first TACE treatment and then subjected to capture-based mtDNA sequencing and whole-genome sequencing.

RESULTS

Comprehensive analyses revealed a clear association between cf-mtDNA multiple features and tumor characteristics. Based on cf-mtDNA multiple features, we also developed HCC death and progression risk prediction models. Kaplan-Meier curve analyses revealed that the high-death risk or high-progression-risk group had significantly shorter median overall survival (OS) and progression-free survival than the low-death risk or low-progression-risk group (all p<0.05). Moreover, the change in cf-mtDNA multiple features before and after TACE treatment exhibited an exceptional ability to predict the risk of death and progression in patients with HCC (log-rank test, all p<0.01; HRs: 0.36 and 0.33, respectively). Furthermore, we observed the consistency of change between the cf-mtDNA multiple features and copy number variant burden before and after TACE treatment in 40.00% (12/30) patients with HCC.

CONCLUSIONS

Altogether, we developed a novel strategy based on profiling of cf-mtDNA multiple features for prognosis prediction and efficacy evaluation in patients with HCC undergoing TACE treatment.

Baseline Alpha-Fetoprotein Elevation and the Risk of Hepatocellular Carcinoma in Chronic Hepatitis B: A Multicentre Cohort Study

Alpha-fetoprotein (AFP) level and its changes in chronic hepatitis B (CHB) may influence the risk of future hepatocellular carcinoma (HCC). This study aims to evaluate the HCC risk in CHB patients with no overt HCC but with elevated AFP level and to explore the prognostic role of longitudinal changes in AFP and liver-related laboratory values. This multicentre cohort study included 10,639 CHB patients without a history of HCC from seven medical facilities in South Korea. Patients with a baseline serum AFP test and no HCC diagnosis on imaging within 3 months were included. Patients were categorised into high-AFP (≥ 10 ng/mL) and normal-AFP (< 10 ng/mL) groups. The primary outcome was the incidence of HCC within 2 years, with secondary outcomes focused on longitudinal changes in AFP and liver-related laboratory values. Propensity score matching (PSM) and Cox proportional hazard models were used to assess HCC risk. After 1:4 PSM, 1278 high-AFP and 3731 normal-AFP patients were analysed. The high-AFP group had a significantly higher 2-year incidence of HCC (HR: 4.29; 95% CI: 3.31-5.57). AFP levels increased in patients who developed HCC in both groups (p < 0.01). Among the high-AFP group, patients who did not develop HCC had elevated baseline alanine aminotransferase levels (p < 0.01), which decreased during follow-up (p < 0.01) unlike those who developed HCC. In conclusion, baseline AFP elevation in CHB patients is associated with an increased risk of developing HCC within 2 years. Longitudinal monitoring of AFP and liver-related laboratory values can help in risk stratification.

Ultrasound evaluation of chronic liver disease

Chronic liver disease is a world-wide epidemic. Any etiology that causes inflammation in the liver will lead to chronic liver disease. Presently, the most common inciting factor worldwide is steatotic liver disease. Recent advances in ultrasound imaging provide a multiparametric ultrasound methodology of diagnosing, staging, and monitoring treatment of chronic liver disease. Elastography has become a standard of care technique for the evaluation of liver fibrosis. Quantitative ultrasound allows for determination of the degree of fatty infiltration of the liver. Portal hypertension is the most important factor in determination of liver decompensation. B-mode findings combined with Doppler, and elastography techniques provide qualitative and quantitative methods of determining clinically significant portal hypertension. A newer method using contrast enhanced ultrasound may allow for a non-invasive quantitative estimation of the portal pressures. This paper reviews the use of multiparametric ultrasound in the evaluation of chronic liver disease including conventional B-mode ultrasound, Doppler, elastography and quantitative ultrasound for estimation of liver fat. The recent guidelines are presented and advised protocols reviewed.

The Search for Risk, Diagnostic, and Prognostic Biomarkers of Cholangiocarcinoma and Their Biological and Clinicopathologic Significance

Cholangiocarcinomas (CCAs) are a heterogeneous group of malignant tumors that originate from the biliary tract. They are usually diagnosed in advanced stages, leading to a poor prognosis for affected patients. As CCA often arises as a sporadic cancer in individuals lacking specific risk factors or with heterogeneous backgrounds, and there are no defined high-risk groups, the implementation of effective surveillance programs for CCA is problematic. The identification and validation of new biomarkers useful for risk stratification, diagnosis, prognosis, and prediction of treatment response remains an unmet need for patients with CCA, even though numerous studies have been conducted lately to try to discover and validate CCA biomarkers. In this review, we overview the available information about the different types of biomarkers that have been investigated in recent years using minimally invasive biospecimens (blood, serum/plasma, bile, and urine) and their potential usefulness in diagnosis, prognosis, and risk stratification. It is widely accepted that early detection of CCA will impact patients' outcomes, by improving survival rates, quality of life, and the possibility of less invasive and/or curative treatments; however, challenges to its translation and clinical application for patients with CCA need to be resolved.

Phase 3 Validation of PAaM for Hepatocellular Carcinoma Risk Stratification in Cirrhosis

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) risk stratification is an urgent unmet need for cost-effective HCC screening and early detection in patients with cirrhosis to improve poor HCC prognosis.

METHODS

Molecular (prognostic liver secretome signature with α-fetoprotein) and clinical (aMAP [age, male sex, albumin-bilirubin, and platelets] score) variable-based scores were integrated into PAaM (prognostic liver secretome signature with α-fetoprotein plus age, male sex, albumin-bilirubin, and platelets), which was subsequently validated in 2 phase 3 biomarker validation studies: the statewide Texas HCC Consortium and nationwide HCC Early Detection Strategy prospective cohorts, following the prospective specimen collection, retrospective blinded evaluation design. The associations between baseline PAaM and incident HCC were assessed using Fine-Gray regression, with overall death and liver transplantation as competing events.

RESULTS

Of 2156 patients with cirrhosis in the Texas HCC Consortium, PAaM identified 404 (19%) high-risk, 903 (42%) intermediate-risk, and 849 (39%) low-risk patients with annual HCC incidence rates of 5.3%, 2.7%, and 0.6%, respectively. Compared with low-risk patients, high- and intermediate-risk groups had sub-distribution hazard ratios for incident HCC of 7.51 (95% CI, 4.42-12.8) and 4.20 (95% CI, 2.52-7.01), respectively. Of 1328 patients with cirrhosis in the HCC early detection strategy, PAaM identified 201 high-risk (15%), 540 intermediate-risk (41%), and 587 low-risk (44%) patients, with annual HCC incidence rates of 6.2%, 1.8%, and 0.8%, respectively. High- and intermediate-risk groups were associated with sub-distribution hazard ratios for incident HCC of 6.54 (95% CI, 3.85-11.1) and 1.77 (95% CI, 1.02-3.08), respectively. Subgroup analysis showed robust risk stratification across HCC etiologies, including metabolic dysfunction-associated steatotic liver disease and cured hepatitis C infection.

CONCLUSIONS

PAaM enables accurate HCC risk stratification in patients with cirrhosis from contemporary etiologies.

Nomogram to Predict Tumor Remnant of Small Hepatocellular Carcinoma after Microwave Ablation

RATIONALE AND OBJECTIVES

This investigation sought to create a nomogram to predict the ablation effect after microwave ablation in patients with hepatocellular carcinoma, which can guide the selection of microwave ablation for small hepatocellular carcinomas.

METHODS

In this two-center retrospective study, 233 patients with hepatocellular carcinoma treated with microwave ablation (MWA) between January 2016 and December 2023 were enrolled and analyzed for their clinical baseline data, laboratory parameters, and MR imaging characteristics. Logistic regression analysis was used to screen the features, and clinical and imaging feature models were developed separately. Finally, a nomogram was established. All models were evaluated using the area under the curve (AUC), accuracy, sensitivity, specificity, and decision curve analysis (DCA).

RESULTS

Two models and a nomogram were developed to predict ablation outcomes after MWA based on a training set (n = 182, including complete ablation: 136, incomplete ablation: 46) and an external validation set (n = 51, complete ablation: 36, incomplete ablation: 15). The clinical models and nomogram performed well in the external validation cohort. The AUC of the nomogram was 0.966 (95% CI: 0.944- 0.989), with a sensitivity of 0.935, a specificity of 0.882, and an accuracy of 0.896.

CONCLUSIONS

Combining clinical data and imaging features, a nomogram was constructed that could effectively predict the postoperative ablation outcome in hepatocellular carcinoma patients undergoing MWA, which could help clinicians provide treatment options for hepatocellular carcinoma patients.

Seizing tumor factors for mortality and survival outcomes following liver resection in Indonesia's hepatocellular carcinoma patients

Backgrounds/Aims

The 3-year mortality rate for hepatocellular carcinoma (HCC) in Indonesia was 94.4%. This underscores a significant health issue in Southeast Asia, particularly in Indonesia due to its large population. This study aimed to characterize the outcomes of liver resection for HCC at a National Referral Center in Indonesia.

Methods

Between 2010 and 2020, all patients with HCC undergoing liver resection were included as subjects. Variables collected included sex, age, hepatitis status, and tumor's characteristics. Mortality and survival were the primary outcomes of the study.

Results

Among seventy patients, the mortality rate was 71.4%, with a median overall survival of 19.0 months (95% confidence interval [95%CI]: 6.831.2). Thirty-one patients (44.3%) had extra-large HCC tumors (> 10 cm). Those with extra-large tumors had a lower median survival of 8.0 months. Child-Pugh B and Edmonson-Steiner grade 4 were associated with an increased mortality risk, with unadjusted hazard ratios (HRs) of 2.2 (95%CI: 1.14.3, p = 0.026) and 3.2 (95%CI: 1.37.7, p = 0.011), respectively. Multivariate analysis indicated that Child-Pugh class B significantly increased the risk of mortality, with an adjusted HR of 2.3 (95%CI: 1.05.2, p = 0.046).

Conclusions

While surgical resection is feasible for tumors of any size, most clinical features are not statistically significantly associated with survival outcomes. The prevalence of extra-large tumors among Indonesian HCC patients highlights the importance of early diagnosis and intervention. Surgical intervention at an earlier stage and with better grade tumors could potentially enhance survival outcomes.

Equilibrium phase images of the liver using a contrast-enhancement boost instead of the portal vein phase

BACKGROUND

Three-phase dynamic computed tomography imaging is particularly useful in the liver region. However, dynamic imaging with contrast media has the disadvantage of increased radiation exposure due to multiple imaging sessions. We hypothesized that the contrast enhancement boost (CE-boost) technique could be used to enhance the contrast in equilibrium phase (EP) images and produce enhancement similar to that of portal vein phase (PVP) images, and if this is possible, EP imaging could play the same role as PVP imaging. We also speculated that this might allow the conversion of three-phase dynamic imaging to biphasic dynamic imaging, reducing patients’ radiation exposure.

AIM

To determine if the CE-boost of EP, CE-boost (EP) is useful compared to a conventional image.

METHODS

We retrospectively analyzed the cases of 52 patients who were diagnosed with liver cancer between January 2016 and October 2022 at our institution. From these computed tomography images, CE-boost images were generated from the EP and plane images. We compared the PVP, EP, and CE-boost (EP) for blood vessels and hepatic parenchyma based on the contrast-to-noise ratio (CNR), signal-to-noise ratio, and figure-of-merit (FOM). Visual assessments were also performed for vessel visualization, lesion conspicuity, and image noise.

RESULTS

The CE-boost (EP) images showed significant superiority compared to the PVP images in the CNR, signal-to-noise ratio, and FOM except regarding the hepatic parenchyma. No significant differences were detected in CNR or FOM comparisons within the hepatic parenchyma (P = 0.62, 0.67). The comparison of the EP and CE-boost (EP) images consistently favored CE-boost (EP). Regarding the visual assessment, the CE-boost (EP) images were significantly superior to the PVP images in lesion conspicuity, and the PVP in image noise. The CE-boost (EP) images were significantly better than the EP images in the vessel visualization of segmental branches of the portal vein and lesion conspicuity, and the EP in image noise.

CONCLUSION

The image quality of CE-boost (EP) images was comparable or superior to that of conventional PVP and EP. CE-boost (EP) images might provide information comparable to the conventional PVP.

Sensitive detection of circulating methylated SEPT9 in hepatocellular carcinoma patients using a novel quantitative PCR assay

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Early detection is crucial, yet reliable biomarkers are limited. Methylated SEPT9 (mSEPT9) has emerged as a promising biomarker for HCC. Building upon previous ExBP technology, we enhanced the semi-nested realtime PCR assay by integrating TaqMan probes, enabling quantitative detection of mSEPT9 in plasma samples of HCC patients. The assay was validated using synthetic DNA standards and plasma samples from 49 HCC patients, 20 chronic liver disease (CLD) patients, and 32 healthy donors (HDs). Our assay demonstrated sensitivity in detecting methylation ratios as low as 1 : 100 000. The assay showed a strong linear correlation between Ct values and methylation levels over four orders of magnitude (R2 = 0.96178), indicating robust quantification. Clinically, the assay revealed significant differences in ΔCt values between HCC patients (median ΔCt = 19.55) and controls (CLD: 29.32 and HDs: 26.19, p < 0.005). ROC analysis for HCC vs. controls yielded an AUC of 0.729, with 77.55% sensitivity and 59.62% specificity at the optimal cutoff (≤25.98). Notably, the assay identified 72.73% of HCC cases with AFP levels below 20 ng mL-1, underscoring its potential in detecting AFP-negative cases. These findings suggest that the novel mSEPT9 assay is a sensitive and specific tool for early HCC detection, offering prognostic value for clinical monitoring.

Monitoring Sorafenib Resistance and Efficacy in Hepatocellular Carcinoma Using [18F]Alfatide II and [18F]Fluorodeoxyglucose Positron Emission Tomography

Integrin αvβ3 expression is associated with sorafenib resistance in hepatocellular carcinoma (HCC). Therefore, monitoring its expression in HCC may serve as a valuable indicator of the efficacy of sorafenib treatment. In this study, longitudinal positron emission tomography (PET) was performed to assess [18F]Alfatide II and [18F]fluorodeoxyglucose ([18F]FDG) as suitable probes for evaluating the treatment efficacy of sorafenib in a Huh-7 human (HCC) xenograft model. Huh-7 tumor cells were used to establish both normal and sorafenib-resistant cell lines, and xenograft models were developed. The mice were categorized into four groups based on the cell type and treatment: normal nontreatment, normal treatment, sorafenib-resistant nontreatment, and sorafenib-resistant treatment. Huh-7 tumor mice received intragastric injections of sorafenib (30 mg/kg/day) or vehicle for 15 consecutive days. Tumor size and weight were assessed throughout the study. Longitudinal microPET/computed tomography (CT) scans with [18F]Alfatide II and [18F]FDG were acquired to quantitatively measure angiogenesis on days -2, 3, 7, and 14 and metabolism on days -1, 4, 8, and 15 following therapy initiation. The tumor uptake (ID%/gmean) of each probe was calculated. No significant difference in [18F]FDG uptake was observed between the normal and sorafenib-resistant groups (P = 0.452); however, [18F]Alfatide II uptake differed significantly between the two groups (P < 0.001). Sorafenib successfully inhibited normal Huh-7 tumor growth, inducing significant differences in tumor size 9 days after sorafenib treatment (P < 0.05). The uptake of [18F]Alfatide II in the tumor lesions changed significantly on day 14 (P = 0.001). However, no change was observed in the uptake of [18F]FDG (P > 0.05). The PET imaging data of [18F]Alfatide II and [18F]FDG were validated through ex vivo immunohistochemistry analysis targeting integrin αvβ3, VEGF, and GULT-1. [18F]Alfatide II PET was more effective in monitoring sorafenib resistance and therapeutic efficacy in the Huh-7 human HCC xenograft model than [18F]FDG.

Combination of CT/MRI LI-RADS With Second-Line Contrast-Enhanced Ultrasound Using Sulfur Hexafluoride or Perfluorobutane for Diagnosing Hepatocellular Carcinoma in High-Risk Patients

OBJECTIVE

The CT/MRI Liver Imaging Reporting and Data System (LI-RADS) demonstrates high specificity with relatively limited sensitivity for diagnosing hepatocellular carcinoma (HCC) in high-risk patients. This study aimed to explore the possibility of improving sensitivity by combining CT/MRI LI-RADS v2018 with second-line contrast-enhanced ultrasound (CEUS) LI-RADS v2017 using sulfur hexafluoride (SHF) or perfluorobutane (PFB).

MATERIALS AND METHODS

This retrospective analysis of prospectively collected multicenter data included high-risk patients with treatment-naive hepatic observations. The reference standard was pathological confirmation or a composite reference standard (only for benign lesions). Each participant underwent concurrent CT/MRI, SHF-enhanced US, and PFB-enhanced US examinations. The diagnostic performances for HCC of CT/MRI LI-RADS alone and three combination strategies (combining CT/MRI LI-RADS with either LI-RADS SHF, LI-RADS PFB, or a modified algorithm incorporating the Kupffer-phase findings for PFB [modified PFB]) were evaluated. For the three combination strategies, apart from the CT/MRI LR-5 criteria, HCC was diagnosed if CT/MRI LR-3 or LR-4 observations met the LR-5 criteria using LI-RADS SHF, LI-RADS PFB, or modified PFB.

RESULTS

In total, 281 participants (237 males; mean age, 55 ± 11 years) with 306 observations (227 HCCs, 40 non-HCC malignancies, and 39 benign lesions) were included. Using LI-RADS SHF, LI-RADS PFB, and modified PFB, 20, 23, and 31 CT/MRI LR-3/4 observations, respectively, were reclassified as LR-5, and all were pathologically confirmed as HCCs. Compared to CT/MRI LI-RADS alone (74%, 95% confidence interval [CI]: 68%-79%), the three combination strategies combining CT/MRI LI-RADS with either LI-RADS SHF, LI-RADS PFB, or modified PFB increased sensitivity (83% [95% CI: 77%-87%], 84% [95% CI: 79%-89%], 88% [95% CI: 83%-92%], respectively; all P < 0.001), while maintaining the specificity at 92% (95% CI: 84%-97%).

CONCLUSION

The combination of CT/MRI LI-RADS with second-line CEUS using SHF or PFB improved the sensitivity of HCC diagnosis without compromising specificity.

Risk-stratified hepatocellular carcinoma surveillance in non-cirrhotic patients with MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD) is rapidly emerging as the leading global liver disorder and is poised to become the primary cause of hepatocellular carcinoma (HCC). Research indicates that nearly 50% of HCC cases in MASLD patients occur without cirrhosis, often presenting with more advanced and larger tumors. Despite this, current guidelines primarily focus on HCC screening in cirrhotic patients, with limited guidance for non-cirrhotic MASLD individuals. This narrative review seeks to identify key risk factors for HCC development, consolidate available screening methods, and propose a practical, risk-stratified algorithm for HCC surveillance in non-cirrhotic MASLD patients. We conducted a comprehensive review of studies published between 2017 and 2023 using PubMed, Embase, and CNKI, focusing on HCC risk factors and emerging screening strategies for non-cirrhotic MASLD cohorts. Key risk factors for HCC development in these patients include male sex, age over 65, hypertension, diabetes, mild alcohol consumption, smoking, dyslipidemia, elevated alanine aminotransferase levels, and a platelet count ≤ 150 × 109/L. Among the screening methods evaluated, circulating free DNA, alpha-fetoprotein (AFP) combined with protein induced by vitamin K absence or antagonist-II (PIVKA-II), and the GALAD score (incorporating Glypican-3, AFP, alpha-1-Antitrypsin, and des-gamma-carboxy prothrombin) demonstrated the highest performance. Based on these findings, we proposed a risk-stratified HCC surveillance algorithm that integrates GALAD and PIVKA-II into the existing sonography and AFP screening protocols. This review aims to provide clinicians with actionable recommendations for HCC screening in non-cirrhotic MASLD patients.

Ablative margin assessment for recurrence prediction in patients with hepatocellular carcinoma receiving radiofrequency ablation

BACKGROUND/PURPOSE

To predict outcomes for patients with hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) by assessing the ablative margin.

METHODS

We retrospectively analyzed 163 HCC patients with complete RFA treatment at National Taiwan University Hospital (NTUH) from 2015 to 2020. Local tumor progression (LTP) is defined as the reappearance of HCC around the ablative zone. Various ablative margins (AM) are measured on post-RFA computed tomography (CT), including the minimal and maximal AM covering or not covering the liver surfaces (AMCLSmin, AMCLSmax, AMULSmin, AMULSmax). Average ablative margins (AMCLSavg, AMULSavg) are calculated from the minimal and maximal AM. Tumors at high-risk locations, including subdiaphragmatic, subcapsular, and perivascular regions, were further analyzed. The Kaplan-Meier method was utilized to analyze the recurrence-free survival (RFS) of different groups of patients. Patients were grouped by their ablative margin width with a cutting-off value of 3 mm or 5 mm.

RESULTS

Of the 163 HCC patients enrolled, 29 had LTP within two years, and 20 had LTP after two years. AMULSmin and AMULSavg were shown to be significant factors contributing to local tumor recurrences. Patients with AMULSmin≧3 mm had significantly better RFS than those with AMULSmin<3 mm (p = 0.0236). In high-risk locations, AMULSavg ≧5 mm had better RFS in subdiaphragmatic and subcapsular regions, and AMULSavg ≧3 mm had better RFS in perivascular region.

CONCLUSION

Measuring the ablative margin without covering the liver surface (especially AMULSmin, AMULSavg) in the post-RFA CT may be helpful prognosis indicators of LTP and RFS in HCC patients.

Demographic and survival characteristics of untreated hepatocellular carcinoma patients: insights into the natural history and prognostic determinants

BACKGROUND

Hepatocellular carcinoma (HCC) patients with advanced symptoms or liver failure are often ineligible for transplantation, leading only to symptom control. Additionally, various factors lead to other HCC stage patients remaining in natural history.

OBJECTIVE

To describe the demographic of untreated HCC patients and to analyze survival-influencing factors.

METHODS

single-center retrospective observational study examining HCC patients diagnosed from 2015 to 2021 who received symptom control as their primary treatment. Baseline characteristics and survival data were collected and analyzed.

RESULTS

Of 685 HCC patients, 26% (n=181) remained in natural history, median age 71 years, 82% male patients, 93% with cirrhosis, 53% with previous decompensation. At a mean follow-up of 9.98 months, the mortality rate was 84%. While 49.8% of patients were BCLC-D stage, other reasons for remaining in natural history included frailty (25.4%) comorbidities (16%), and patient's treatment refusal (8%). Independent survival factors were BCLC stage, previous decompensation and diagnosis within the screening program, with 37% of untreated patients detected through surveillance.

CONCLUSIONS

Liver function, BCLC stage and functional status influence survival in natural HCC history. A significant 37% diagnosed through screening indicates inclusion criteria refinement necessity to avoid overdiagnosis and optimize resources.

Multiparametric magnetic resonance imaging-derived radiomics for the prediction of Ki67 expression in intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is an aggressive liver malignancy, and Ki67 is associated with prognosis in patients with ICC and is an attractive therapeutic target.

PURPOSE

To predict Ki67 expression based on multiparametric magnetic resonance imaging (MRI) radiomics multiscale tumor region in patients with ICC.

MATERIAL AND METHODS

A total of 191 patients (training cohort, n = 133; validation cohort, n = 58) with pathologically confirmed ICC were enrolled in this retrospective study. All patients underwent baseline abdominal MR scans in our institution. Univariate logistic analysis was conducted of the correlation between clinical and MRI characteristics and Ki67 expression. Radiomics features were extracted from the image of six MRI sequences (T1-weighted imaging, fat-suppression T2-weighted imaging, diffusion-weighted imaging, and 3-phases contrast-enhanced T1-weighted imaging sequences). Using the least absolute shrinkage and selection operator (LASSO) to select Ki67-related radiomics features in four different tumor volumes (VOItumor, VOI+8mm, VOI+10mm, VOI+12mm). The Rad-score was calculated with logistic regression, and models for prediction of Ki67 expression were constructed. The receiver operating curve was used to analyze the predictive performance of each model.

RESULTS

Clinical and regular MRI characteristics were independent of Ki67 expression. Four Rad-scores all showed favorable prediction efficiency in both the training and validation cohorts (AUC = 0.849-0.912 vs. 0.789-0.838). DeLong's test showed that there was no significant difference between the AUC of the radiomics scores, while the Rad-score (VOI+10mm) performed the most stable predictive efficiency with △AUC 0.033.

CONCLUSION

Multiparametric MRI radiomics based on multiscale tumor regions can help predict the expression status of Ki67 in ICC patients.

Ex-vivo 7T MRI of human explanted cirrhotic liver with HCC: quantitative and qualitative evaluation with radiological-pathological correlation

INTRODUCTION

Hepatocellular carcinoma's (HCC) pathological grading is a recognized factor influencing intrahepatic recurrence after treatment. Thus, understanding the HCC heterogeneity is crucial to select the best treatment option aiming at personalized medicine. 7T MRI can provide qualitative and quantitative data, potentially identifying imaging biomarkers for lesions characterization.

MATERIALS AND METHODS

From May 2019 to December 2019, all explanted livers of patients undergoing liver transplant were enrolled. All patients underwent whole body CT before liver transplant and all the explanted livers were evaluated (ex-vivo) by 7T MRI within 12 h from liver removal with qualitative and quantitative acquisitions, including 2D/3D magnetic resonance fingerprinting (MRF). First, two expert radiologists qualitatively and quantitatively evaluated the imaging data focusing on both lesions and surrounding tissue, comparing conventional and MRF sequences. Then, specimens were evaluated by an expert pathologist regarding both liver tissues and lesions, particularly focusing on HCC grading.

CONCLUSIONS

This work may represent the first step supporting the introduction of quantitative MR imaging (including MRF) in the clinical practice. Along with conventional protocol and dynamic contrast enhancement, the integration of quantitative MR imaging can provide imaging biomarkers useful to identify HCC lesions more prone to recurrence, leading to a better patient selection, according to a personalized medicine approach.

The potential efficacy of atezolizumab plus bevacizumab treatment for hepatocellular carcinoma patients with macroscopic portal vein tumor thrombus

PURPOSE

The prognosis of patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) in the first-order or main trunk/contralateral branches (Vp3/4) is poor. The present study aimed to clarify the real-world data of atezolizumab plus bevacizumab treatment (Ate/bev) for HCC patients with Vp3/4 PVTT.

METHODS

The subjects of this study were 22 consecutive HCC patients with Vp3/4 PVTT, who were treated with Ate/bev. Survival rates and radiological responses were evaluated based on the modified albumin-bilirubin (mALBI) grade [mALBI 1 + 2a (1/2a) versus 2b + 3 (2b/3)] using the modified Response Evaluation Criteria in Solid Tumors.

RESULTS

The median survival time of the 22 patients was 15.0 months, with 1- and 2-year survival rates of 62.7% and 49.3%, respectively. The objective response (OR) rates of patients with mALBI 1/2a and 2b/3 were 91.7% (11/12) and 10.0% (1/10), respectively, with a significant difference (p < 0.001). The 2-year survival rates of patients with mALBI 1/2a and 2b/3 were 78.6% and 20.0%, respectively, with a significant difference (p = 0.0041).

CONCLUSION

Ate/bev was effective for treating HCC patients with Vp3/4 PVTT. OR rate and MST were favorable, particularly for patients with preserved liver function (mALBI 1/2a), suggesting its great potential for the treatment of HCC in patients with Vp3/4 PVTT.

Comparison of tenofovir versus entecavir for preventing hepatocellular carcinoma in chronic hepatitis B patients: an umbrella review and meta-analysis

There are several meta-analyses about the comparison of tenofovir disoproxil fumarate (TDF) versus entecavir (ETV) for preventing hepatocellular carcinoma in patients with chronic HBV infection published in recent years. However, the conclusions vary considerably. This umbrella review aims to consolidate evidence from various systematic reviews to evaluate differences in hepatocellular carcinoma prevention between two drugs. Systematic searches were conducted using PubMed, Embase, and Web of Science to identify original meta-analyses. Finally, twelve studies were included for quantitative analyses. We found that TDF treatment was associated with a significantly lower risk of HCC than ETV (hazard ratio, 0.80; 95% CI 0.75-0.86, p < 0.05). The lower risk of HCC in patients given TDF compared with ETV persisted in subgroup analyses performed with propensity score-matched cohorts, cirrhosis cohorts, nucleos(t)ide naïve cohorts and Asian cohorts. In the cohorts of non-Asia and patients without cirrhosis, there was no difference exhibited between these two drugs. Subsequent analyses showed TDF treatment was also associated with a lower incidence of death or transplantation than patients receiving ETV. Overall, the preventive effect of these two drugs on HCC has been studied in several published meta-analyses, but few were graded as high-quality evidence, meanwhile, most of which had high overlap. Thus, future researchers should include updated cohorts or conduct prospective RCTs to further explore this issue.

Clinical Characteristics of Hepatitis B Virus-Associated Hepatocellular Carcinoma Patients in Southwest Nigeria

Hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality in West Africa, but its presentation is poorly understood. In this study, we describe the clinical characteristics of HBV-associated HCC patients in Lagos, Nigeria. Data for all cases were collected at the emergency and gastroenterology units (2017-2019), considering chronic carriers as controls. Clinical data and routine biochemical and radiologic test results were extracted from the files. The serum biomarkers (Osteopontin, AFP-L3, DCP) were investigated. For some cases, the hepatitis B viral load was determined. The mean age of the cases (n = 92) was 41.4 years, compared to 39.9 years for the controls (n = 100). Clinically, 69.5% of cases presented with ascites, 66.3% had nodules occupying >50% of the liver, and 67.4% had moderate hepatic encephalopathy. The mean viral load and the median values of Osteopontin, AFP-L3, and DCP for the cases were significantly higher than for the controls (p < 0.001). The area under the curve, sensitivity, and specificity were significantly higher for Osteopontin, compared with DCP and AFP-L3 (p < 0.001). Most HCC patients presented at a late disease stage, when the prognosis is usually poor. Especially Osteopontin seems to have potential for early HCC detection and could possibly complement AFP and abdominal ultrasound scan for risk-group screening.

Cytokine-Induced Killer Cell Immunotherapy Reduces Recurrence in Patients with Early-Stage Hepatocellular Carcinoma

BACKGROUND/OBJECTIVES

Cytokine-induced killer (CIK) cell immunotherapy has shown promise in reducing recurrence and improving survival outcomes in hepatocellular carcinoma (HCC). We evaluated the efficacy and safety of CIK cell therapy in a real-world clinical setting.

METHODS

A retrospective analysis was conducted on 49 patients who received CIK cell therapy after curative resection or radiofrequency ablation, compared with 49 matched control patients via 1:1 propensity score matching. The primary endpoint was recurrence-free survival (RFS), and the secondary endpoint was overall survival (OS).

RESULTS

The median follow-up durations were 19.1 months for the immune cell group and 67.7 months for the control group. In univariable analysis, the immune cell group demonstrated a prolonged RFS than the control group (hazard ratio [HR], 0.32; 95% CI, 0.15-0.71; log-rank p = 0.001). The median RFS was not reached in the immune cell group but was 48.62 months in the control group. A multivariable Cox regression model identified CIK cell therapy as a significant factor associated with a reduced risk of HCC recurrence (adjusted HR, 0.32; 95% CI, 0.15-0.71; p = 0.005). The median OS was not reached in either group; no significant differences in OS were observed between the immune cell and control groups (log-rank p = 0.082). The overall incidence of adverse events was low, and no Grade 3 or 4 events were reported.

CONCLUSIONS

Adjuvant CIK cell immunotherapy after curative treatment significantly prolongs RFS in early-stage HCC patients. Further research regarding the broader applications of CIK cell immunotherapy in HCC is warranted.

Diagnostic Values of Magnetic Resonance Imaging and Computed Tomography for Predicting Macrotrabecular-Massive Hepatocellular Carcinoma Subtype: A Meta-analysis

BACKGROUND

The diagnostic accuracy of magnetic resonance imaging (MRI) vs. computed tomography (CT) for predicting macrotrabecular-massive hepatocellular carcinoma (MTM-HCC) is yet to be ascertained. Therefore, this meta-analysis aimed to summarise the diagnostic accuracies of MRI and CT for MTM-HCC.

METHODS

A comprehensive literature search of PubMed and Embase was conducted up to 20 August 2024, to evaluate the diagnostic performance of MRI and CT for the diagnosis of MTM-HCC. Pooled sensitivity and specificity were calculated for MRI and CT using a bivariate random-effects model. Subgroup analyses based on different covariates were conducted to compare the diagnostic performances of MRI and CT.

RESULTS

15 studies involving 2299 patients, including 706 with MTM-HCC and 1593 with non-MTM-HCC were analysed. Comparative analysis revealed no significant differences between MRI and CT in pooled sensitivity (66% vs. 82%, respectively) and specificity (88% vs. 79%, respectively) for the diagnosis of MTM-HCC (P=0.53), with comparable areas under the summary receiver operating characteristic curves of 0.87 and 0.86, respectively. In the subgroup analysis of imaging methods within radiomics, CT had significantly higher sensitivity and specificity than MRI (98% vs. 85% [sensitivity], 83% vs. 79% [specificity], P=0.01). In the other subgroups, including age, the most common aetiology of liver disease, the proportion of patients with cirrhosis, and tumour size, there were no significant differences (all P>0.05).

CONCLUSION

CT and MRI had comparable predictive performances for the non-invasive diagnosis of MTM-HCC. In the subgroup of radiomics-based imaging methods, CT outperformed MRI. Nevertheless, multicenter prospective studies with uniform design are needed to confirm these findings.

Impact of microvascular invasion risk on tumor progression of hepatocellular carcinoma after conventional transarterial chemoembolization

OBJECTIVE

To assess tumor progression in patients with hepatocellular carcinoma (HCC) without macrovascular invasion who underwent treatment with conventional transarterial chemoembolization (cTACE) based on microvascular invasion (MVI) risk within 2 years.

METHODS

This retrospective investigation comprised adult patients with HCC who had either liver resection or cTACE as their first treatment from January 2016 to December 2021. A predictive model for MVI was developed and validated using preoperative clinical and MRI data from patients with HCC treated with liver resection. The MVI predictive model was applied to patients with HCC receiving cTACE, and differences in tumor progression between the MVI high- and low-risk groups were examined throughout 2 years.

RESULTS

The MVI prediction model incorporated nonsmooth margin, intratumoral artery, incomplete or absent tumor capsule, and tumor DWI/T2WI mismatch. The area under the receiver operating characteristic curve (AUC) for the prediction model, in the training cohort, was determined to be 0.904 (95% CI, 0.862-0.946), while in the validation cohort, it was 0.888 (0.782-0.994). Among patients with HCC undergoing cTACE, those classified as high risk for MVI possessed a lower rate of achieving a complete response after the first tumor therapy and a higher risk of tumor progression within 2 years.

CONCLUSIONS

The MVI prediction model developed in this study demonstrates a considerable degree of accuracy. Patients at high risk for MVI who underwent cTACE treatment exhibited a higher risk of tumor progression within 2 years.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

Identifying potential signatures of immune cells in hepatocellular carcinoma using integrative bioinformatics approaches and machine-learning strategies

Hepatocellular carcinoma (HCC) is a malignant tumor regulated by the immune system. Immunotherapy using checkpoint inhibitors has shown encouraging outcomes in a subset of HCC patients. The main challenges in checkpoint immunotherapy for HCC are to expand treatment options and to broaden the beneficiary population. Therefore, the search for potential signatures of immune cells is meaningful in the development of immunotherapy for HCC. The HCC related datasets were downloaded from the Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA). Differential expression analysis and functional analysis were performed first. Then support vector machine-recursive feature elimination (SVM-RFE), random forests (RF), least absolute shrinkage and selection operation (LASSO), and weighed gene co-expression network analysis (WGCNA) were employed to screen for critical genes, and receiver operating characteristic (ROC) analysis was performed to compare diagnostic performance. Subsequently, single-sample gene set enrichment analysis (ssGSEA) was used to explore the relationship between signatures and immune cells. Finally, we validated the expression of these biomarkers in human HCC samples. 531 overlapping differentially expressed genes (DEGs) were identified. Furthermore, enrichment analysis revealed pathways associated with immune activation processes, immune cell involvement and inflammatory signaling. After using multiple machine-learning strategies, extracellular matrix protein 1 (ECM1), leukemia inhibitory factor receptor (LIFR), sushi repeat containing protein X-linked (SRPX), and thromboxane A2 receptor (TBXA2R) were identified as critical signatures, and exhibited high expression in tumor-adjacent normal tissues. According to the ssGSEA results, ECM1, LIFR, SRPX and TBXA2R were all significantly associated with diverse immune cells, such as monocytes and neutrophils. Moreover, immunostaining of human HCC samples showed that these critical signatures all colocalized with CD14-positive monocytes. Our findings report the potential signatures of immune cells in HCC and confirm that they localize in monocytes of tumor-adjacent normal tissues. ECM1, LIFR, SRPX and TBXA2R could become new potential targets for predictive diagnosis, early intervention and immunotherapy of HCC in the future.

Predicting the early therapeutic response to hepatic artery infusion chemotherapy in patients with unresectable HCC using a contrast-enhanced computed tomography-based habitat radiomics model: a multi-center retrospective study

OBJECTIVE

Predicting the therapeutic response before initiation of hepatic artery infusion chemotherapy (HAIC) with fluorouracil, leucovorin, and oxaliplatin (FOLFOX) remains challenging for patients with unresectable hepatocellular carcinoma (HCC). Herein, we investigated the potential of a contrast-enhanced CT-based habitat radiomics model as a novel approach for predicting the early therapeutic response to HAIC-FOLFOX in patients with unresectable HCC.

METHODS

A total of 148 patients with unresectable HCC who received HAIC-FOLFOX combined with targeted therapy or immunotherapy at three tertiary care medical centers were enrolled retrospectively. Tumor habitat features were extracted from subregion radiomics based on CECT at different phases using k-means clustering. Logistic regression was used to construct the model. This CECT-based habitat radiomics model was verified by bootstrapping and compared with a model based on clinical variables. Model performance was evaluated using the area under the curve (AUC) and a calibration curve.

RESULTS

Three intratumoral habitats with high, moderate, and low enhancement were identified to construct a habitat radiomics model for therapeutic response prediction. Patients with a greater proportion of high-enhancement intratumoral habitat showed better therapeutic responses. The AUC of the habitat radiomics model was 0.857 (95% CI: 0.798-0.916), and the bootstrap-corrected concordance index was 0.842 (95% CI: 0.785-0.907), resulting in a better predictive value than the clinical variable-based model, which had an AUC of 0.757 (95% CI: 0.679-0.834).

CONCLUSION

The CECT-based habitat radiomics model is an effective, visualized, and noninvasive tool for predicting the early therapeutic response of patients with unresectable HCC to HAIC-FOLFOX treatment and could guide clinical management and decision-making.

Pharmacological mechanisms of carvacrol against hepatocellular carcinoma by network pharmacology and molecular docking

BACKGROUND

Preclinical studies have demonstrated that carvacrol possesses various biological and pharmacological properties, including anti-hepatocellular carcinoma (HCC) effects. However, the molecular basis of its therapeutic action on HCC remains unclear.

OBJECTIVE

The aim of this study was to investigate and further validate the multi-target therapeutic mechanism of carvacrol against HCC.

METHODS

The chemical structure of carvacrol was obtained from the PubChem database, and its potential targets were identified using SwissTargetPrediction, HERB, and BATMAN-TCM. HCC-specific genes were screened from the TCGA-LIHC cohort. The therapeutic targets of carvacrol against HCC were determined through the intersection of these datasets. Subsequently, a multivariate Cox regression prognostic model was established. Molecular docking was performed to analyze the interactions between carvacrol and its therapeutic targets. Additionally, molecular dynamics simulations were conducted to validate the molecular docking results using Discovery Studio 2019 software.

RESULTS

A total of 223 carvacrol targets and 882 HCC-specific genes were identified. Fifteen therapeutic targets of carvacrol against HCC were obtained, including CA2, AR, ALB, AURKA, ALPL, EPHX2, BCHE, IL1RN, AGRN, CRP, DMGDH, APOA1, SOX9, HPX, and CHKA. The prognostic model accurately and independently predicted survival outcomes. AGRN and AURKA were significantly associated with HCC overall survival. Molecular docking and molecular dynamics simulations demonstrated that carvacrol exhibited strong potential for stable binding to the therapeutic targets AGRN and AURKA.

CONCLUSION

Our findings elucidate the multi-target mechanism of action of carvacrol against HCC, providing a foundation for future research on its application in HCC management.

HES V2.0 outperforms GALAD for detection of HCC: A phase 3 biomarker study in the United States

BACKGROUND AND AIMS

The original hepatocellular carcinoma early detection screening (HES) score, which combines alpha-fetoprotein (AFP) with age, alanine aminotransferase, and platelets, has better performance than AFP alone for early HCC detection. We have developed HES V2.0 by adding AFP-L3 and des-gamma-carboxy prothrombin to the score and compared its performance to GALAD and ASAP scores among patients with cirrhosis.

APPROACH AND RESULTS

We conducted a prospective-specimen collection, retrospective-blinded-evaluation phase 3 biomarker cohort study in patients with cirrhosis enrolled in imaging and AFP surveillance. True-positive rate (TPR)/sensitivity and false-positive rate for any or early HCC were calculated for GALAD, ASAP, and HES V2.0 scores within 6, 12, and 24 months of HCC diagnosis. We calculated the AUROC curve and estimated TPR based on an optimal threshold at a fixed false-positive rate of 10%. We analyzed 2331 patients, of whom 125 developed HCC (71% in the early stages). For any HCC, HES V2.0 had higher TPR than GALAD overall (+7.2%), at 6 months (+3.6%), at 12 months (+7.2%), and 24 months (+13.0%) before HCC diagnosis. HES V2.0 had higher TPR than ASAP for all time points (+5.9% to +12.0%). For early HCC, HES V2.0 had higher sensitivity/TPR than GALAD overall (+6.7%), at 12 months (+6.3%), and 24 months (+14.6%) but not at 6 months (+0.0%) and higher than ASAP for all time points (+13.4% to +18.0%).

CONCLUSIONS

In a prospective cohort study, HES V2.0 had a significantly higher performance for identifying new HCC, including early stage, than GALAD or ASAP.

Expression of miR-15b-5p and toll-like receptor4 as potential novel diagnostic biomarkers for hepatitis C virus-induced hepatocellular carcinoma

Objectives

Globally, hepatocellular Carcinoma (HCC) ranks seventh in women's cancer and fifth in men's cancer. Early identification can minimize mortality and morbidity. MicroRNAs and Toll-like receptors have been suggested as potential new biomarkers for HCC; Therefore, we explored Toll-like receptor 4 (TLR-4) and miRNA 15b-5p as new non-invasive HCC biomarkers and early detection approaches.

Methodology

In this case-control study, four primary groups were formed from 400 patients who participated in this study: 100 hepatitis C (HCV) patients without cirrhosis or HCC, 100 HCV with cirrhosis patients, 100 HCC and HCV patients, and 100 healthy controls. The HCC diagnosis was confirmed according to the American Association for the Study of Liver Disease (AASLD) Practice Guidelines. Triphasic computed tomography was used to assess the HCC tumor size. Real-time PCR was used to analyze miRNA 15b-5p and Toll-like receptor 4 (TLR-4) expression profiles.

Results

Significant diagnostic performance was achieved by miRNA 15b-5p in differentiating the HCC group from the control group, with 90 % sensitivity and 88 % specificity (AUC] 0.935, p < 0.001), while TLR-4 had moderate diagnostic performance with 85 % sensitivity and 86 % specificity (AUC:0.885, p < 0.001).

Conclusions

The ability of miR-15b-5p to recognize HCC was positive and it outperformed Toll-like receptor4. MiR-15b-5p has the potential to be a more precise and predictive biological marker for HCC than Toll-like receptor4. Future studies exploring different miRNAs and HCC cases from various etiologies are required to better understand the role of miRNAs in this disease and allow for more effective strategies.

Cholesterol Targeted Catalytic Hydrogel Fueled by Tumor Debris can Enhance Microwave Ablation Therapy and Anti-Tumor Immune Response

The immunosuppressive residual tumor microenvironment (IRTM) is a key factor in the high recurrence and metastasis rates of hepatocellular carcinoma (HCC) after microwave ablation (MWA). Cholesterol-rich tumor fragments significantly contribute to IRTM deterioration. This study developed a cholesterol-targeted catalytic hydrogel, DA-COD-OD-HCS, to enhance the synergy between MWA and immune checkpoint inhibitors (ICIs) for HCC treatment. Cholesterol oxidase (COD), modified with dimethyl maleic anhydride (DA) for release in acidic IRTM, is used to degrade cholesterol. Oxydextran (OD) and hemin-chitosan (HCS) formed a dual network gel, ensuring long-term fixation of COD and hemin in the IRTM post-MWA. In both in vitro and in vivo HCC models, DA-COD-OD-HCS effectively released COD, degraded cholesterol, and induced tumor cell ferroptosis, enhancing the antitumor immune response. Combined with anti-PD-L1 immunotherapy, this strategy inhibited primary tumor growth and distant metastases, without side effects on adjacent tissues. This work highlights that cholesterol-targeting catalytic hydrogels fueled by tumor debris can significantly improve the efficacy of MWA and ICIs, offering a novel therapeutic approach for HCC.

Advancements in locoregional therapy for advanced hepatocellular carcinoma: Emerging perspectives on combined treatment strategies

Hepatocellular carcinoma (HCC) persists as a leading cause of cancer-related mortality, often diagnosed at advanced stages with limited treatment options. Locoregional therapies (LRTs) are crucial in HCC management, playing significant roles in neoadjuvant and palliative treatments, among others. However, the unique disease background of HCC necessitates multidisciplinary and integrated treatment strategies. The therapeutic landscape for advanced HCC has been significantly broadened by the advent of combined therapies, presenting multiple approaches aimed at improving long-term survival, which remains a critical challenge. This review offers a comprehensive overview of major LRTs for HCC, highlighting recent technological advancements and exploring the challenges and limitations in their application, and presents the latest developments in combination therapies, including combinations between different LRTs and their integration with systemic treatments. Additionally, we outline future directions for the development of integrated treatment modalities for advanced HCC.

Trajectories of postoperative hepatitis B virus (HBV) DNA and HBV-related hepatocellular carcinoma outcomes

BACKGROUND

Preoperative hepatitis B virus (HBV) DNA level has been shown to correlate with the prognosis of patients with HBV-associated hepatocellular carcinoma (HCC) following liver resection, but its dynamic changes have not been reported. The aim of this longitudinal multicenter retrospective observational study was to describe the trajectory of HBV DNA after R0 liver resection in patients receiving antiviral therapy and to investigate its impact on clinical outcomes.

METHODS

This study included patients with HBV-related HCC from nine hospitals in China who received antiviral therapy and R0 hepatectomy between 2015 and 2016. A latent class growth mixed model (LCGMM) was applied to group the trajectories of HBV DNA changes. The relative importance of each variable to predict survival was evaluated using the χ2.

RESULTS

Six hundred and eighty-four patients with HCC who met the inclusion exclusion criteria were included. Patients were divided into 5 trajectories of HBV DNA changes using LCGMM. By combining subgroups with similar survival characteristics, patients were reclassified into three groups: slow decline, slow zeroing, and fast zeroing group, the 5-year OS rates are 34.5 %, 53.0 %, 70.9 %, respectively. Multifactorial COX regression results showed that ALBI grade, HBV reactivation, cirrhosis, maximum tumor diameter, microvascular invasion, and HBV DNA trajectory groups were independent risk factors for OS.

CONCLUSIONS

HBV DNA trajectories were associated with OS for patients with HBV-related HCC after R0 liver resection, and it is necessary to receive antiviral therapy and to monitor HBV status regularly.

External Beam Radiation therapy After Transarterial Chemoembolization Versus Transarterial Chemoembolization Alone for Treatment of Inoperable Hepatocellular Carcinoma: A Randomized Phase 3 Trial

PURPOSE

To compare the outcomes of transarterial chemoembolization (TACE) alone with those of TACE combined with external beam radiation therapy (EBRT) in patients with hepatocellular carcinoma (HCC) in a multicenter randomized study.

METHODS AND MATERIALS

From 2017 to 2022, 74 HCC patients with tumors confined to the liver without vascular invasion were treated with either TACE only (TACE group, 39 patients) or TACE combined with EBRT (TACE + EBRT group, 35 patients). The primary outcome measured was overall survival (OS). Secondary outcomes included progression-free survival (PFS), local tumor control, and the assessment of treatment-related toxicity.

RESULTS

Due to slow accrual, the trial was closed prematurely after enrolling 74 patients. All patients received 2 cycles of TACE before randomization. The TACE and TACE + EBRT groups showed comparable patient and tumor characteristics. The TACE group underwent a median of 3 TACE cycles, and the TACE + EBRT group received 2 cycles of TACE, and a median of 5500 cGy in 15 fractions. For the TACE group, the median local control (LC) duration was 13.1 months, whereas for the TACE + EBRT group, the median LC was not achieved (P < .001). The PFS was recorded at 11.6 months in the TACE group compared with 15.4 months in the TACE + EBRT group (P = .072). The median OS reached 36.8 months for the TACE group and extended to 47.1 months for the TACE + EBRT group (P = .654). The incidence of toxicity was comparable between both groups.

CONCLUSIONS

Although the number of patients enrolled in this clinical trial did not meet expectations. TACE combined with EBRT was shown to be more effective than TACE alone in improving LC without increasing toxicity, whereas PFS and OS were slightly improved. TACE + EBRT can be used as a standard treatment option for patients with inoperable but confined intrahepatic HCC.

Stereotactic Body Radiotherapy vs Sorafenib Alone in Hepatocellular Carcinoma: The NRG Oncology/RTOG 1112 Phase 3 Randomized Clinical Trial

Importance

Most patients with locally advanced hepatocellular carcinoma (HCC) recur within the liver following systemic therapy.

Objective

To determine whether stereotactic body radiation therapy (SBRT) improves outcomes in patients with locally advanced HCC compared with sorafenib alone.

Design, Setting, and Participants

This multicenter phase 3 randomized clinical trial randomized patients with HCC 1:1 to sorafenib or SBRT followed by sorafenib, stratified by performance status, liver function, degree of metastases, and macrovascular invasion. Eligible patients had HCC unsuitable for or refractory to standard local-regional therapies and were candidates for first-line systemic therapy. Data were collected from April 2013 to March 2021, and data were analyzed from July 2022 to August 2023.

Intervention

Personalized SBRT, 27.5 to 50 Gy in 5 fractions.

Main Outcomes and Measures

The primary end point was overall survival (OS). Secondary end points were progression-free survival (PFS), adverse events, and quality of life.

Results

Of 193 patients randomized, 177 were eligible. Accrual was stopped early due to a change in standard-of-care systemic therapy. Of 177 included patients, 150 (84.7%) were male, and the median (IQR) age was 66 (60-72) years. Macrovascular invasion was seen in 131 (74.0%). As of July 1, 2022, the median OS was 12.3 months (90% CI, 10.6-14.3) with sorafenib vs 15.8 months (90% CI, 11.4-19.2) following SBRT and sorafenib (hazard ratio [HR], 0.77; 90% CI, 0.59-1.01; 1-sided P = .06). Adjusting for stratification factors, OS was improved with SBRT (HR, 0.72; 95% CI, 0.52-0.99; 2-sided P = .04). Median PFS was improved from 5.5 months (95% CI, 3.4-6.3) with sorafenib to 9.2 months (95% CI, 7.5-11.9) with SBRT and sorafenib (HR, 0.55; 95% CI, 0.40-0.75; 2-sided P < .001). Treatment-related grade 3 or higher adverse events were seen in 37 of 88 (42%) and 39 of 83 (47%) of patients treated with sorafenib vs SBRT and sorafenib, respectively (P = .52). There were 2 treatment-related deaths in the sorafenib group (death not otherwise specified and liver failure) and 1 in the SBRT and sorafenib group (lung infection). At 6 months, improved quality of life was seen in 2 of 20 (10%) and 6 of 17 (35%) of patients treated with sorafenib and SBRT and sorafenib, respectively.

Conclusions and Relevance

In this phase 3 randomized clinical trial, among patients with locally advanced HCC, SBRT was associated with a clinically important but not statistically significant improved overall survival compared with sorafenib alone.

Trial Registration

ClinicalTrials.gov Identifier: NCT01730937.

Involvement of β-catenin expression in hepatocellular carcinoma prognosis in a cohort of patients undergoing curative treatment

BACKGROUND

Hepatocellular carcinoma is a tumor of epithelial origin that arises from the action of different carcinogens on the hepatocytes and has a high worldwide incidence. The prognostic markers of this disease have not been completely established. Mutations in the gene encoding β-catenin are overexpressed in hepatocellular carcinoma. The objective of our study was to correlate the molecular expression of β-catenin in hepatocellular carcinoma with the already known prognostic markers.

METHODS

We conducted an observational and prospective cohort study on adult patients diagnosed with hepatocellular carcinoma from whom samples of nontumor and tumor liver parenchyma were taken intraoperatively to correlate the molecular expression of β-catenin in hepatocellular carcinoma with the known prognostic markers.

RESULTS

A total of 81 samples were collected, of which 48 met the inclusion criteria. The final sample was divided into patients with a diagnosis of hepatocellular carcinoma on a cirrhotic liver, corresponding to 31 patients (64.6%), and patients with a diagnosis of hepatocellular carcinoma on a noncirrhotic liver, corresponding to 17 patients (35.4%). We found that overexpression of β-catenin and the neutrophil/lymphocyte ratio are independently related to disease-free survival, and both overexpression and molecular repression of β-catenin are independently related.

CONCLUSION

Molecular overexpression of β-catenin in hepatocellular carcinoma compared with nontumor tissue is associated with worse disease-free survival, and its combination with a high neutrophil-lymphocyte ratio worsens this prognosis.

Risk of hepatocellular carcinoma in Asian patients with primary biliary cholangitis: A nationwide and hospital cohort study

Background & Aims

Large-scale studies on the association between primary biliary cholangitis (PBC) and hepatocellular carcinoma (HCC) in Asians are scarce. This study aimed to evaluate the incidence of HCC and its risk factors in a nationwide cohort.

Methods

The data of 4,882 patients with PBC and 38,603 matched controls were extracted from the Korean National Health Insurance Service (2007-2020) and analyzed. The incidence of HCC and its risk factors in patients with PBC were assessed and compared with those in the matched controls. The results were validated in a multicenter hospital cohort of 862 patients with PBC, recruited from Asan Medical Center (n = 815) and Yeouido St. Mary's Hospital (n = 47) in Korea.

Results

In total, 105 patients with PBC developed HCC over the median follow-up period of 5.42 years, yielding an incidence rate of 3.7/1,000 person-years (PYs), which was significantly higher than that in the controls (0.5/1,000 PYs; adjusted hazard ratio: 9.07; 95% CI: 6.71-12.27). PBC, older age, male sex, diabetes, and smoking were identified as significant risk factors for HCC. Twenty-three of the 862 patients with PBC developed HCC in the multicenter hospital cohort, yielding an incidence of 4.0/1,000 PYs (95% CI: 2.4-5.7). Older age (subdistribution hazard ratio [SHR]: 1.05, 95% CI: 1.00-1.10), male sex (SHR: 3.00, 95% CI: 1.11-8.13), current alcohol consumption (SHR: 3.70, 95% CI: 1.08-12.59), and cirrhosis (SHR: 5.17, 95% CI: 2.07-12.93) were identified as risk factors in the hospital cohort.

Conclusions

Patients with PBC were at a significantly higher risk of developing HCC. Older age and male sex were consistent risk factors in both cohorts.

Impact and implications

Notable heterogeneity has been observed among different studies in terms of the incidence of hepatocellular carcinoma (HCC) in patients with primary biliary cholangitis (PBC). Large-scale studies on the association between PBC and HCC in Asians are scarce. In our nationwide cohort study, patients with PBC exhibited a significantly heightened risk of developing HCC and mortality than the age- and sex-matched controls. Individuals with PBC had a 9.1-fold higher risk of developing HCC than their matched counterparts, with an incidence rate of 3.7/1,000 person-years. Older age, male sex, smoking, and diabetes were identified as prominent risk factors for HCC in patients with PBC in the nationwide cohort. Older age, male sex, and alcohol consumption were identified as the factors significantly contributing to the elevated risk of HCC in patients with PBC in validation multicenter hospital cohort.

Clinical Significance of Acyl-CoA Dehydrogenase Short Chain and Its Anti-tumor Role in Hepatocellular Carcinoma by Inhibiting Canonical Wnt/β-Catenin Pathway

BACKGROUND

The pathogenesis of hepatocellular carcinoma (HCC) emphasizes metabolic disorders. HCC patients showed abnormally low expression of Acyl-CoA dehydrogenase short chain (ACADS).

OBJECTIVES

This study aimed to elucidate the clinical significance and mechanistic role of ACADS in HCC.

METHODS

We investigated the expression patterns and significance of ACADS in HCC by analyzing multiple public databases and clinical samples (Chip data). Immunohistochemistry was employed to observe the expression levels of ACADS in HCC tissues. In vitro experiments involved silencing or overexpressing ACADS in HCC cell lines, with protein expression levels determined by Western blotting. Functional validation included CCK-8, Transwell, and scratch wound healing assays. TOPFlash and FOPFlash reporter gene assays, co-immunoprecipitation, and immunofluorescence were used to explore the interaction between ACADS and β-catenin.

RESULTS

ACADS was low expressed in HCC and was clinically associated with vascular invasion, TNM stage, and AFP levels. The low ACADS expression in HCC patients was negatively correlated with their survival. Overexpression of ACADS significantly suppressed the viability, migration, and invasive capacity of HCC cells, whereas silencing ACADS had the opposite effect. Mechanistically, co-immunoprecipitation experiments indicated that there was an interaction between ACADS and β-catenin. Overexpression of ACADS inhibited β-catenin activity and resulted in decreased nuclear β-catenin translocation and increased its cytoplasmic level. Immunofluorescence results also showed a decrease in β-catenin nuclear import following ACADS overexpression, whereas silencing ACADS led to an enhancement of its nuclear translocation.

CONCLUSION

ACADS emerges as a potentially valuable biomarker for HCC prognosis, exhibiting tumor-suppressive functions in HCC by participating in the regulation of β-catenin activity.

Development and Validation of a PIVKA-II-Based Model for HCC Risk Stratification in Patients With HCV-Related Cirrhosis Successfully Treated With DAA

BACKGROUND AND AIMS

Patients with hepatitis C virus (HCV)-related cirrhosis with sustained virological response (SVR) to direct-acting antivirals (DAA) remain at risk of developing hepatocellular carcinoma (HCC). Recently, serum protein induced by vitamin K absence or antagonist-II (PIVKA-II) has shown promising results as an HCC-predictive biomarker. We aimed to develop and validate a PIVKA-II-based model for HCC risk stratification in cirrhotic patients with SVR to DAA.

METHODS

A total of 1220 consecutive patients (Turin, n = 531; Pisa, n = 335; Milan, n = 354) with HCV-related cirrhosis treated with DAA were included in the study. Patients were retrospectively allocated to the training cohort (Turin+Pisa; median follow-up [FU] 39, 22-55 months; incident HCC: 93 [10.7%]) and validation cohort (Milan; median FU 49.0, 35.0-52.0 months; incident HCC: 19 [5.4%]). Serum PIVKA-II levels were measured using the LumipulseG system (Fujirebio, Japan) at SVR12 (Turin and Pisa cohorts) or the end of treatment (Milan cohort).

RESULTS

Using Cox regression analysis, a model including PIVKA-II combined with age, sex, ALT, AST, γGT, platelet count, albumin and total bilirubin was derived from the training cohort (C-index = 0.72). In the validation cohort, the model showed a C-index of 0.71 with an area under the curve of 0.84 for identifying patients who developed HCC during the first 12 months of FU. When patients were grouped into three risk categories, the cumulative incidence of HCC was 2.7%, 4.0% and 14.3% in the low-, medium- and high-risk groups, respectively (p < 0.001). Notably, no HCC occurred within 3 years of FU in the low-risk group.

CONCLUSIONS

Our PIVKA-II-based model showed satisfactory accuracy for HCC risk stratification and may represent a valuable tool for implementing risk-based surveillance protocols in patients with HCV-related cirrhosis with SVR to DAA.

Hierarchically Positioning Laparoscopic Microwave Ablation in the Therapeutic Span of Early Hepatocellular Carcinoma: A Real-Life Comparative Analysis

BACKGROUND

Laparoscopic microwave ablation (LMWA) has yet to gain a specific place in treatment guidelines for early hepatocellular carcinoma (HCC). This study compared the outcomes of LMWA and trans-arterial chemoembolization (TACE) for early non-resectable patients with HCC, taking percutaneous radiofrequency ablation (PRFA) as the reference treatment.

METHODS

A retrospective multicenter observational study was conducted, enrolling non-transplantable, non-resectable patients who had early HCC treated with LMWA (n = 658) from Padua and Milan centers, and with PRFA (n = 844), and TACE (n = 425) from the ITA.LI.CA multicenter database. The matching-adjusted indirect comparison (MAIC) method was used to obtain weighted LMWA and TACE populations similar to the reference PRFA population.

RESULTS

Laparoscopic ablation showed an excellent safety profile, and MAIC-weighted early postoperative deaths were comparable among the groups. The MAIC-weighted overall survival was similar between the LMWA (1-, 3-, and 5 year survival of 91.0 %, 67.9 %, 47.0 %, respectively) and PRFA (1-, 3- and 5 year survivals of 90.0 %, 64.7 %, 46.6 %, respectively) groups (p = 0.678) and significantly better for the LMWA group than for the TACE group (1-, 3- and 5 year survivals of 84.7 %, 48.8 %, 33.6 %, respectively) (p < 0.001). Weighted multivariate overall survival analysis and competing risk/subgroup analyses confirmed the non-inferiority of LMWA to PRFA and its superiority to TACE. The LMWA- and PRFA-treated patients had a significantly lower risk of HCC-related death (p = 0.004) than the TACE-treated patients (p = 0.001). Conversely, the groups did not differ significantly in terms of non-HCC-related deaths.

CONCLUSIONS

The non-inferiority of LMWA to PRFA, its superiority to TACE, and its applicability to a wide range of presentations with few contraindications support its inclusion among radical therapies for treating early-HCC patients.

Dual-drug loaded chondroitin sulfate embolization beads enhance TACE therapy for HCC by integrating embolization, chemotherapy, and anti-angiogenesis

Hepatocellular carcinoma (HCC) is a major public health threat due to its high incidence and mortality rates. Transcatheter arterial chemoembolization (TACE), the primary treatment for intermediate-to-advanced hepatocellular carcinoma (HCC), commonly utilizes embolic agents loaded with anthracycline-based cytotoxic drugs. Post-TACE, the hypoxic microenvironment in the tumor induced by embolization stimulates the formation of new blood vessels, potentially leading to revascularization and diminishing TACE's efficacy. In clinical practice, combined therapy for liver cancer using TACE and oral targeted drugs often encounters the limitation that targeted drugs cannot efficiently reach the tumor site following TACE. We have developed chondroitin sulfate microspheres (CMs) capable of encapsulating both the cytotoxic drug idarubicin (Ida) and the vascular inhibitor Lenvatinib (Len), thereby achieving a triple therapeutic effect on liver cancer: embolic starvation, drug toxicity, and efficient inhibition of neovascularization.

A Phase 3 Biomarker Validation of GALAD for the Detection of Hepatocellular Carcinoma in Cirrhosis

BACKGROUND & AIMS

Better surveillance tests for hepatocellular carcinoma (HCC) are needed. The GALAD score (gender, age, α-fetoprotein [AFP] L3, AFP, and des-γ carboxyprothrombin) has been shown to have excellent sensitivity and specificity for HCC in phase 2 studies. We performed a phase 3 biomarker validation study to compare GALAD with AFP in detecting HCC.

METHODS

This is a prospective study of patients with cirrhosis enrolled at 7 centers. Surveillance for HCC was performed every 6 months at each site, and HCC diagnosis was confirmed per American Association for the Study of Liver Diseases guidelines. Blood for biomarker research was obtained at each follow-up visit and stored in a biorepository. Measurements of AFP, AFP-L3, and des-γ carboxyprothrombin) were performed in a FujiFilm laboratory by staff blinded to clinical data. The performance of GALAD in detecting HCC was retrospectively evaluated within 12 months before the clinical diagnosis. All analyses were conducted by an unblinded statistician in the Early Detection Research Network data management and coordinating center.

RESULTS

A total of 1,558 patients with cirrhosis were enrolled and followed for a median of 2.2 years. A total of 109 patients developed HCC (76 very early or early stage), with an annual incident rate of 2.4%. The areas under the curve for AFP and GALAD within 12 months before HCC were 0.66 and 0.78 (P < .001), respectively. Using a cutoff for GALAD of -1.36, the specificity was 82%, and the sensitivity at 12 months before HCC diagnosis was 62%. For comparison, performance of AFP at 82% specificity showed 41% sensitivity at 12 months before HCC diagnosis (P = .001).

CONCLUSIONS

GALAD score, compared to AFP, improves the detection of HCC within 12 months before the actual diagnosis.

Toxin protein LukS-PV targeting complement receptor C5aR1 inhibits cell proliferation in hepatocellular carcinoma via the HDAC7-Wnt/β-catenin axis

Hepatocellular carcinoma (HCC) is one of the common malignant tumors. Complement system has become a new focus of cancer research by changing the biological behavior of cancer cells to influence the growth of cancer. Recent studies reported that the complement C5a-C5aR1 axis can promote the malignant phenotype of multiple tumors through various signaling pathways. LukS-PV (Panton-Valentine), the S component of Staphylococcus aureus-secreted PV leucocidin, can also bind C5aR1 specifically. This project aims to investigate the role of LukS-PV on HCC cell proliferation and explore underlying molecular mechanisms. Our findings revealed that LukS-PV targeting C5aR1 inhibited HCC cell proliferation in vitro and in vivo. Interestingly, we discovered that LukS-PV inhibited the proliferation of HCC cells by upregulating the acetylation level of β-catenin to promote its protein degradation. In addition, histone deacetylase (HDAC)7 identified as a regulator mediates the deacetylation of β-catenin. Furthermore, our results showed that LukS-PV inhibited proliferation in HCC cells by downregulating HDAC7 to promote the degradation of β-catenin through ubiquitin-proteasome system. Collectively, our findings revealed that LukS-PV targeting C5aR1 inhibits HCC cell proliferation through the HDAC7-Wnt/β-catenin axis. These results revealing a novel mechanism that LukS-PV as a bacterial toxin inhibits HCC cell proliferation through epigenetic remodeling by targeting complement receptor C5aR1, suggest the strong potential of LukS-PV as a promising candidate for HCC treatment.