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

Integrated GMPS and RAMP3 as a signature to predict prognosis and immune heterogeneity in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a highly fatal malignant worldwide. As different expression levels of specific genes can lead to different HCC outcomes, we aimed to develop a gene signature capable of predicting HCC prognosis.

METHODS

In this study, transcriptomic sequencing and relevant clinical data were extracted from public platforms. The guanine monophosphate synthase (GMPS)|receptor activity-modifying protein 3 (RAMP3) gene pair was developed based on the relative values of gene expression levels. Nomograms were developed using R software. Immune status was assessed through single-sample gene set enrichment analysis. GMPS knockdown was achieved through siRNA transfection. Quantitative reverse transcription PCR, apoptosis assays, and cell proliferation were performed to verify the function of GMPS|RAMP3 in HCC cells.

RESULTS

Here, a gene pair containing GMPS and RAMP3 was successfully constructed. We demonstrated that the GMPS|RAMP3 gene pair was an independent predictor with strong prognostic prediction power, based on which a nomogram was established. Functional analysis revealed that the enrichment of cell cycle-related pathways and immune status differed considerably between the two groups, with cell cycle-related genes highly expressed in the high GMPS|RAMP3 value group. Finally, cell experiments indicated that GMPS knockdown significantly repressed proliferation, promoted apoptosis, and enhanced the sensitivity of HCC cells to gemcitabine.

CONCLUSIONS

The gene pair GMPS|RAMP3 is a novel prognostic predictor of HCC, providing a promising approach to the treatment and assessment of immune heterogeneity in HCC.

Assessing the Predictive Accuracy of the aMAP Risk Score for Hepatocellular Carcinoma (HCC): Diagnostic Test Accuracy and Meta-analysis

Purpose

We aimed to perform a meta-analysis with the intention of evaluating the reliability and test accuracy of the aMAP risk score in the identification of HCC.

Methods

A systematic search was performed in PubMed, Scopus, Cochrane, Embase, and Web of Science databases from inception to September 2023, to identify studies measuring the aMAP score in patients for the purpose of predicting the occurrence or recurrence of HCC. The meta-analysis was performed using the meta package in R version 4.1.0. The diagnostic accuracy meta-analysis was conducted using Meta-DiSc software.

Results

Thirty-five studies 102,959 participants were included in the review. The aMAP score was significantly higher in the HCC group than in the non-HCC group, with a mean difference of 6.15. When the aMAP score is at 50, the pooled sensitivity, specificity, negative likelihood ratio, and positive likelihood ratio with 95% CI was 0.961 (95% CI 0.936, 0.976), 0.344 (95% CI 0.227, 0.483), 0.114 (95% CI 0.087, 0.15), and 1.464 (95% CI 1.22, 1.756), respectively. At a cutoff value of 60, the pooled sensitivity, specificity, negative likelihood ratio, and positive likelihood ratio with 95% CI was 0.594 (95% CI 0.492, 0.689), 0.816 (95% CI 0.714, 0.888), 0.497 (95% CI 0.418, 0.591), and 3.235 (95% CI 2.284, 4.582), respectively.

Conclusion

The aMAP score is a reliable, accurate, and easy-to-use tool for predicting HCC patients of all stages, including early-stage HCC. Therefore, the aMAP score can be a valuable tool for surveillance of HCC patients and can help to improve early detection and reduce mortality.

Evolution of liver transplantation in the metabolic dysfunction-associated steatotic liver disease era: Tracking impact through time

Liver transplantation (LT) for metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing globally due to rising rates of obesity and metabolic syndrome, posing significant challenges. MASLD patients typically present with advanced age, higher body mass index (BMI), and metabolic comorbidities such as diabetes, hypertension, and dyslipidemia. Comprehensive pre-transplant evaluations are crucial for assessing surgical risks and preparing patients for transplantation. MASLD patients with higher BMI may experience longer operative times, potentially affecting intraoperative outcomes. In the months following LT, MASLD recipients face persistent challenges, including a higher incidence of metabolic syndrome and cardiovascular events compared to non-MASLD recipients. However, survival rates at 1-, 3-, and 5-years post-LT do not markedly differ from other etiologies, indicating comparable surgical outcomes. Optimizing outcomes in MASLD patients undergoing LT demands a multidisciplinary approach from pre-transplant assessment to post-transplant care. Strategies must address metabolic comorbidities, manage cardiovascular health, and monitor steatosis recurrence, which can be exacerbated by obesity and diabetes. This approach aims to mitigate long-term graft complications and mortality risks, ultimately enhancing transplant success and patient well-being. Continued research is essential to refine these approaches and meet the evolving challenges posed by MASLD as a leading indication for LT worldwide.

Clinical outcomes of modified transarterial chemoembolization vs. drug-eluting bead transarterial chemoembolization as initial treatment for single hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND & AIMS

Optimizing transarterial chemoembolization (TACE) can enhance treatment efficacy for hepatocellular carcinoma (HCC). This study compares modified TACE (M-TACE), which combines a lipiodol-based emulsion and drug-eluting beads, with drug-eluting bead TACE (DEB-TACE) as initial therapies for solitary HCC.

METHODS

In this retrospective study, 185 patients undergoing M-TACE or DEB-TACE were evaluated. Propensity score matching was used to create 69 balanced pairs. Initial tumor response, repeated treatments within six months, local tumor progression (LTP), overall survival (OS), and adverse events (AEs) were assessed.

RESULTS

M-TACE exhibited significantly higher initial complete response (CR) rates (39.1% vs. 23.2%, p = 0.043) and fewer repeated treatments within six months (1.7 ± 0.9 vs. 2.1 ± 0.7; p = 0.033) compared to DEB-TACE. LTP rates were notably lower with M-TACE at 12 months (39.1% vs. 65.2%, p = 0.002), and median time to LTP was prolonged with M-TACE (13.3 vs. 8.2 months, p = 0.038). Stratified analysis revealed a significantly longer OS in individuals achieving a CR after the initial M-TACE (50.5 vs. 33.4 months, p = 0.043). However, the overall study population did not exhibit a significant difference in OS between the two groups. Comparable AEs (all p > 0.05) were observed.

CONCLUSIONS

M-TACE showed higher initial CR rates, lower LTP rates, and extended time to LTP compared to DEB-TACE, indicating its potential to enhance TACE effectiveness for solitary HCC.

Predictive value of early-stage postoperative albumin-bilirubin grade on the overall survival of hepatocellular carcinoma patients undergoing resection

OBJECTIVES

The albumin-bilirubin (ALBI) and ΔALBI grades have attracted substantial attention for their ability to predict the overall survival (OS) of patients with hepatocellular carcinoma (HCC). This retrospective study aimed to evaluate the predictive value of the ALBI grade at different time points for the OS of patients with HCC who underwent surgical resection.

METHODS

The clinical data of patients with HCC who underwent radical resection in our hospital were collected and analyzed. The survival rate was analyzed using the Kaplan-Meier method and log-rank test. The risk factors influencing OS were identified via univariate and multivariate Cox regression analyses.

RESULTS

A total of 104 patients with HCC were included in this study. The 1-, 3-, and 5-year OS rates of these patients were 91.3%, 64.0%, and 60.2%, respectively. The OS rates were significantly higher in patients with early-stage postoperative ALBI grade 2 than in those with grade 3 (P < 0.001); however, the preoperative ALBI grade, later-stage postoperative ALBI grade, ΔALBI grade (early stage), or ΔALBI grade (later stage) did not affect the OS rate. Furthermore, resection of ≥3 Couinaud liver segments [hazard ratio (HR) = 4.74; 95% confidence interval (CI), 2.32-9.67; P < 0.001], occurrence of postoperative complications (HR = 2.95; 95% CI, 1.38-6.31; P = 0.005), and early-stage postoperative ALBI grade 3 (HR = 2.50; 95% CI, 1.18-5.31; P = 0.02) were identified as independent risk factors for the OS of patients with HCC.

CONCLUSION

Early-stage postoperative ALBI grade can be used to predict the OS of patients with HCC who have undergone radical hepatectomy. Early-stage postoperative ALBI grade 3, resection of ≥3 Couinaud liver segments, and occurrence of postoperative complications are independent risk factors affecting the OS of these patients.

Present and prospect of transarterial chemoembolization combined with tyrosine kinase inhibitor and PD-1 inhibitor for unresectable hepatocellular carcinoma

In this editorial, we comment on the article (World J Gastrointest Oncol 2024; 16: 1236-1247), which is a retrospective study of transarterial chemoembolization (TACE) combined with multi-targeted tyrosine kinase inhibitor (TKI) and programmed cell death protein-1 (PD-1) inhibitor for the treatment of unresectable hepatocellular carcinoma (HCC). Herein, we focus specifically on the mechanisms of this triple therapy, administration sequence and selection of each medication, and implications for future clinical trials. Based on the interaction mechanisms between medications, the triple therapy of TACE + TKI + PD-1 is proposed to complement the deficiency of each monotherapy, and achieve synergistic antitumor effects. Although this triple therapy has been evaluated by several retrospective trials, it is still controversial whether the triple therapy achieves better clinical benefits, due to the flawed study design and heterogeneity in medications. In addition, the administration sequence, which may greatly affect the clinical benefit, needs to be fully considered at clinical decision-making for obtaining better prognosis. We hope that this editorial could contribute to the design and optimization of future trials.

Diagnostic value of serum STIP1 in HCC and AFP-negative HCC

OBJECTIVE

This study aimed to investigate the diagnostic value of stress-induced phosphoprotein 1 (STIP1) in serum for hepatocellular carcinoma (HCC) and alpha-fetoprotein (AFP)-negative HCC (ANHC).

METHODS

In this study, serum samples were collected from 158 HCC patients and 63 non-HCC patients. Logistic regression analysis was performed to identify independent risk factors associated with HCC and ANHC. The diagnostic values of each index for HCC and ANHC were analyzed using receiver operating characteristic (ROC) curve analysis.

RESULTS

The STIP1, des-γ-carboxy prothrombin (DCP), and AFP levels were higher in the HCC groups than in the non-HCC groups (P < .05). Age, DCP, STIP1, and hepatitis B virus infection were independent predictors of HCC (P < .05). The diagnostic value of STIP1 for HCC was higher than that of DCP. Additionally, age, STIP1, and hepatitis B virus infection were independent predictors for ANHC patients. The ROC curve exhibited an area under the curve value of 0.919 for STIP1, with a diagnostic cutoff value of 68.5 U/mL. Moreover, 36 ANHC patients and 19 AFP-negative non-HCC patients were included to validate the diagnostic model. A total of 20 patients had STIP1 levels greater than 68.5 U/mL, resulting in diagnostic accuracy of 67.3%, sensitivity of 55.6%, and specificity of 89.5%.

CONCLUSION

STIP1 demonstrates excellent diagnostic value for HCC and ANHC.

Inter-reader agreement of LI-RADS treatment response algorithm among three readers with different seniorities for hepatocellular carcinoma after locoregional therapy

BACKGROUND

The accurate evaluation of tumor response after locoregional therapy is crucial for adjusting therapeutic strategy and guiding individualized follow-up.

PURPOSE

To determine the inter-reader agreement of the LR-TR algorithm for hepatocellular carcinoma treated with locoregional therapy among radiologists with different seniority.

MATERIAL AND METHODS

A total of 275 treated observations on 249 MRI scans from 99 patients were retrospectively collected. Three readers of different seniorities (senior, intermediate, and junior with 10, 6, and 2 years of experience in hepatic imaging, respectively) analyzed the presence or absence of features (arterial-phase hyperenhancement and washout) and evaluated LR-TR category.

RESULTS

There were substantial inter-reader agreements for overall LR-TR categorization (kappa = 0.704), LR-TR viable (kappa = 0.715), and LR-TR non-viable (kappa = 0.737), but fair inter-reader agreement for LR-TR equivocal (kappa = 0.231) among three readers. The inter-reader agreement was substantial for arterial-phase hyperenhancement (kappa = 0.725), but moderate for washout (kappa = 0.443) among three readers. The inter-reader agreements between two readers were substantial for overall LR-TR categorization (kappa = 0.734, 0.727, 0.652), LR-TR viable (kappa = 0.719, 0.752, 0.678), and LR-TR non-viable (kappa = 0.758, 0.760, 0.694), which were at the same level as the inter-reader agreements among three readers. In addition, the inter-reader agreements between two readers were substantial for arterial-phase hyperenhancement (kappa = 0.733, 0.766, 0.678), but moderate for washout (kappa = 0.473, 0.422, 0.446), which were at the same level as the inter-reader agreements among three readers.

CONCLUSION

LR-TR algorithm demonstrated overall substantial inter-reader agreement among radiologists with different seniority.

Predicting overall survival in hepatocellular carcinoma patients via a combined MRI radiomics and pathomics signature

OBJECTIVE

This study aims to develop and validate a radiopathomics model that integrates radiomic and pathomic features to predict overall survival (OS) in hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

This study involved 126 HCC patients who underwent hepatectomy and were followed for more than 5 years. Radiomic features were extracted from arterial-phase (AP) and portal venous-phase (PVP) MRI scans, whereas pathomic features were obtained from whole-slide images (WSIs) of the HCC patients. Using LASSO Cox regression, both radiomics and pathomics signatures were established. A combined radiopathomics nomogram for predicting OS was constructed and validated. The correlation between the radiopathomics nomogram and OS prediction was evaluated, demonstrating its potential clinical utility in prognosis assessment.

RESULTS

We selected four radiomic features from the AP and PVP MRI scans to construct a signature, achieving a concordance index (C-index) of 0.739 in the training cohort and 0.724 in the validation cohort; these results indicate favourable 5-year OS prediction. Similarly, from 1,141 pathomics features extracted from WSIs, 15 were chosen for a pathomics signature, which had C-indexes of 0.821 and 0.808 in the training and validation cohorts, respectively. The most robust performance was delivered by a radiopathomics nomogram, with C-index values of 0.840 in the training cohort and 0.875 in the validation cohort. Decision curve analysis (DCA) confirmed the highest net benefit achievable by the combined radiopathomics nomogram.

CONCLUSION

Our findings indicate that the radiopathomics nomogram can serve as a predictive marker for hepatectomy prognosis in HCC patients and has the potential to enhance personalized therapeutic approaches.

Systemic Therapies for Hepatocellular Carcinoma in India

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality in India. This review explores the epidemiological trends and the landscape of systemic therapy for HCC in the Indian context, acknowledging the recent shift in etiology from viral hepatitis to lifestyle-associated factors. A comprehensive review of the literature was conducted, including data from the Global Cancer Observatory and the Indian Council of Medical Research, along with a critical analysis of various clinical trials. The article investigates systemic therapies in-depth, discussing their mechanisms, efficacy, and adaptation to Indian healthcare framework. Progression-free survival with a hazard ratio of ≤0.6 compared to sorafenib, overall survival of ∼16-19 months, and objective response rate of 20-30% are the defining thresholds for systemic therapy clinical trials. Systemic therapy for advanced HCC in India primarily involves the use of tyrosine kinase inhibitors such as sorafenib, lenvatinib, regorafenib, and cabozantinib, with sorafenib being the most commonly used drug for a long time. Monoclonal antibodies such as ramucirumab and bevacizumab and immune-checkpoint inhibitors, such as atezolizumab, nivolumab, and pembrolizumab, are expanding treatment horizons. Lenvatinib has emerged as a cost-effective alternative, and the combination of atezolizumab and bevacizumab has demonstrated superior outcomes in terms of overall survival and progression-free survival. Despite these advances, late-stage diagnosis and limited healthcare accessibility pose significant challenges, often relegating patients to palliative care. Addressing HCC in India demands an integrative approach that not only encompasses advancements in systemic therapy but also targets early detection and comprehensive care models. Future strategies should focus on enhancing awareness, screening for high-risk populations, and overcoming infrastructural disparities. Ensuring the judicious use of systemic therapies within the constraints of the Indian healthcare economy is crucial. Ultimately, a nuanced understanding of systemic therapeutic options and their optimal utilization will be pivotal in elevating the standard of HCC care in India.

Evaluation of Hepatocellular Carcinoma Surveillance with Contrast-enhanced MRI in a High-Risk Western European Cohort

AIM

To investigate the utilization of MRI using a MRI liver protocol with extracellular contrast-enhanced series for hepatocellular carcinoma (HCC) surveillance in high-risk patients.

METHODS

Consecutive high-risk patients of a western European cohort who underwent repeated liver MRI for HCC screening were included. Lesions were registered according to the Liver Reporting & Data System (LIRADS) 2018. HCC was staged as very early stage HCC (BCLC stage 0) and more advanced stages of HCC (BCLC stage A-D). Differences in time interval between MRI's for BCLC stage 0 and stage A-D were calculated with the Mann-Whitney U test. The HCC cumulative incidence at one-, three- and five years was calculated with the Kaplan Meier estimator.

RESULTS

From 2010 to 2019 a total of 240 patients were included (71% male; median age: 57 years; IQR: 50-64 years) with 1350 MRI's. Most patients (83 %) had cirrhosis with hepatitis C as the most common underlying cause. Patients underwent on average four MRI's (IQR: 3-7). Forty-two patients (17.5%) developed HCC (52 HCC lesions: 43 LIRADS-5, eight LIRADS-4, and one LIRADS-TIV). Eighteen patients (43%) had BCLC stage 0 HCC with a significant shorter screening time interval (10 months; IQR: 6-21) compared to patients with BCLC stage A-D (21 months; IQR: 10-32) (p = 0.03). Thirty seven percent of patients with a LIRADS-3 lesion (n=43) showed HCC development within twelve months (median: 7.4 months). One, three- and five-year HCC cumulative incidence in cirrhotic patients was 1%, 10% and 17%, respectively.

CONCLUSION

High-risk patients who underwent surveillance with contrast-enhanced MRI developed HCC in 17.5 % during a follow up period of over 4 years median. Very early stage HCC was seen in compensated cirrhosis after a median time interval of 10 months. Later stages of HCC were related to prolonged screening time interval (median 21 months).

Multiphase MRI-Based Radiomics for Predicting Histological Grade of Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a highly heterogeneous cancer. Accurate preoperative prediction of histological grade holds potential for improving clinical management and disease prognostication.

PURPOSE

To evaluate the performance of a radiomics signature based on multiphase MRI in assessing histological grade in solitary HCC.

STUDY TYPE

Retrospective.

SUBJECTS

A total of 405 patients with histopathologically confirmed solitary HCC and with liver gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI within 1 month of surgery.

FIELD STRENGTH/SEQUENCE

Contrast-enhanced T1-weighted spoiled gradient echo sequence (LAVA) at 1.5 or 3.0 T.

ASSESSMENT

Tumors were graded (low/high) according to results of histopathology. Basic clinical characteristics (including age, gender, serum alpha-fetoprotein (AFP) level, history of hepatitis B, and cirrhosis) were collected and tumor size measured. Radiomics features were extracted from Gd-EOB-DTPA-enhanced MRI data. Three feature selection strategies were employed sequentially to identify the optimal features: SelectFromModel (SFM), SelectPercentile (SP), and recursive feature elimination with cross-validation (RFECV). Probabilities of five single-phase radiomics-based models were averaged to generate a radiomics signature. A combined model was built by combining the radiomics signature and clinical predictors.

STATISTICAL TESTS

Pearson χ2 test/Fisher exact test, Wilcoxon rank sum test, interclass correlation coefficient (ICC), univariable/multivariable logistic regression analysis, area under the receiver operating characteristic (ROC) curve (AUC), DeLong test, calibration curve, Brier score, decision curve, Kaplan-Meier curve, and log-rank test. A P-value <0.05 was considered statistically significant.

RESULTS

High-grade HCCs were present in 33.8% of cases. AFP levels (odds ratio [OR] 1.89) and tumor size (>5 cm; OR 2.33) were significantly associated with HCC grade. The combined model had excellent performance in assessing HCC grade in the test dataset (AUC: 0.801), and demonstrated satisfactory calibration and clinical utility.

DATA CONCLUSION

A model that combined a radiomics signature derived from preoperative multiphase Gd-EOB-DTPA-enhanced MRI and clinical predictors showed good performance in assessing HCC grade.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 5.

Fibrosis-4 index stratifies risks of hepatocellular carcinoma in patients with chronic hepatitis C

BACKGROUND AND AIMS

Risk stratification for patients with a higher risk of hepatocellular carcinoma (HCC) is crucial. We aimed to investigate the role of the Fibrosis-4 (FIB-4) index in predicting chronic hepatitis C (CHC)-related HCC.

METHODS

A retrospective cohort study consecutively included treatment-naive CHC patients receiving longitudinal follow-up at the National Taiwan University Hospital from 1986 to 2014. The clinical data were collected and traced for HCC development. Multivariable Cox proportional hazard regression analysis was used to investigate the predictors for HCC.

RESULTS

A total of 1285 patients in the ERADICATE-C cohort were included. The median age was 54, 56% were females, and 933 had HCV viremia. There were 33%, 38%, and 29% of patients having FIB-4 index <1.45, 1.45-3.25, and ≥3.25, respectively. After a median of 9-year follow-up, 186 patients developed HCC. Multivariable analysis revealed that older age, AFP≥20 ng/mL, cirrhosis, and a higher FIB-4 index were independent predictors for HCC. Compared with patients with FIB-4 index <1.45, those with FIB-4 1.45-3.25 had a 5.51-fold risk (95% confidence interval [CI]: 2.65-11.46), and those with FIB-4 ≥ 3.25 had 7.45-fold risk (95% CI: 3.46-16.05) of HCC. In CHC patients without viremia, FIB-4 index 1.45-3.25 and FIB-4 ≥ 3.25 increased 6.78-fold and 16.77-fold risk of HCC, respectively, compared with those with FIB-4 < 1.45.

CONCLUSION

The baseline FIB-4 index can stratify the risks of HCC in untreated CHC patients, even those without viremia. The FIB-4 index should thus be included in the management of CHC.

Performance of LI-RADS category 5 vs combined categories 4 and 5: a systemic review and meta-analysis

OBJECTIVE

Computed tomography (CT)/magnetic resonance imaging (MRI) Liver Imaging Reporting and Data System (LI-RADS, LR) category 5 has high specificity and modest sensitivity for diagnosis of hepatocellular carcinoma (HCC). The purpose of this study was to compare the diagnostic performance of LR-5 vs combined LR-4 and LR-5 (LR-4/5) for HCC diagnosis.

METHODS

MEDLINE and EMBASE databases through January 03, 2023 were searched for studies reporting the performance of LR-5 and combined LR-4/5 for HCC diagnosis, using CT/MRI LI-RADS version 2014, 2017, or 2018. A bivariate random-effects model was used to calculate the pooled per-observation diagnostic performance. Subgroup analysis was performed based on imaging modalities and type of MRI contrast material.

RESULTS

Sixty-nine studies (15,108 observations, 9928 (65.7%) HCCs) were included. Compared to LR-5, combined LR-4/5 showed significantly higher pooled sensitivity (83.0% (95% CI [80.3-85.8%]) vs 65.7% (95% CI [62.4-69.1%]); p < 0.001), lower pooled specificity (75.0% (95% CI [70.5-79.6%]) vs 91.7% (95% CI [90.2-93.1%]); p < 0.001), lower pooled positive likelihood ratio (3.60 (95% CI [3.06-4.23]) vs 6.18 (95% CI [5.35-7.14]); p < 0.001), and lower pooled negative likelihood ratio (0.22 (95% CI [0.19-0.25]) vs 0.38 (95% CI [0.35-0.41]) vs; p < 0.001). Similar results were seen in all subgroups.

CONCLUSIONS

Our meta-analysis showed that combining LR-4 and LR-5 would increase sensitivity but decrease specificity, positive likelihood ratio, and negative likelihood ratio. These findings may inform management guidelines and individualized management.

CLINICAL RELEVANCE STATEMENT

This meta-analysis estimated the magnitude of changes in the sensitivity and specificity of imaging criteria when LI-RADS categories 4 and 5 were combined; these findings can inform management guidelines and individualized management.

KEY POINTS

There is no single worldwide reporting system for liver imaging, partly due to regional needs. Combining LI-RADS categories 4 and 5 increased sensitivity and decreased specificity and positive and negative likelihood ratios. Changes in the sensitivity and specificity of imaging criteria can inform management guidelines and individualized management.

Neighborhood Opportunity is Associated with Completion of Hepatocellular Carcinoma Surveillance Prior to the Diagnosis of Hepatocellular Carcinoma in Patients with Cirrhosis

BACKGROUND

The Ohio Opportunity Index (OOI) is a multidimensional index used to quantify neighborhood-level resources to access a wide array of factors that influence health. This study examined the relationship between neighborhood opportunity and completion of guideline-concordant hepatocellular carcinoma (HCC) screening in patients with cirrhosis.

METHODS

This retrospective study included patients with cirrhosis and HCC who received care at The Ohio State University Wexner Medical Center between 1/1/2015 and 12/31/2021. High opportunity was defined as a score greater than the third quartile of the study cohort. Modified Poisson regression models with robust variance examined the association, on the prevalence ratio (aPR) scale, between guideline-concordant HCC screening and high neighborhood opportunity status.

RESULTS

This study included 157 cirrhosis patients newly diagnosed with HCC. Only 25.5% of the patients completed HCC surveillance within 6 months prior to diagnosis. The OOI was a significant predictor of adherence in all models. For every ten-percentile increase in OOI score, there was a consistent increase in the prevalence ratio (PR) of pre-diagnosis HCC surveillance (PR=1.37, 95% CI 1.10-1.71). This effect remained significant after controlling for sociodemographic, clinical, and cirrhosis-related variables (adjusted PR=1.38, 95% CI 1.02-1.85. Compared to those with high OOI (i.e.,≥Q3), patients in the lowest opportunity quartile had a 64% lower prevalence of HCC screening (PR=0.36, 95% CI 0.26-0.50).

CONCLUSION

Neighborhood opportunity status has a dose-dependent effect on HCC surveillance adherence in patients with cirrhosis. Future studies should identify neighborhood-level interventions to reduce socioeconomic disparities in HCC diagnosis and outcomes.

Imaging of Cirrhosis and Hepatocellular Carcinoma: Current Evidence

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Early detection of HCC is a key factor in enabling curative therapies and improving overall survival. Worldwide, several guidelines are available for surveillance of at-risk populations and diagnosis of HCC. This article provides a current comprehensive update on screening and diagnosis of HCC.

Development of a liver disease-specific large language model chat interface using retrieval-augmented generation

BACKGROUND AND AIMS

Large language models (LLMs) have significant capabilities in clinical information processing tasks. Commercially available LLMs, however, are not optimized for clinical uses and are prone to generating hallucinatory information. Retrieval-augmented generation (RAG) is an enterprise architecture that allows the embedding of customized data into LLMs. This approach "specializes" the LLMs and is thought to reduce hallucinations.

APPROACH AND RESULTS

We developed "LiVersa," a liver disease-specific LLM, by using our institution's protected health information-complaint text embedding and LLM platform, "Versa." We conducted RAG on 30 publicly available American Association for the Study of Liver Diseases guidance documents to be incorporated into LiVersa. We evaluated LiVersa's performance by conducting 2 rounds of testing. First, we compared LiVersa's outputs versus those of trainees from a previously published knowledge assessment. LiVersa answered all 10 questions correctly. Second, we asked 15 hepatologists to evaluate the outputs of 10 hepatology topic questions generated by LiVersa, OpenAI's ChatGPT 4, and Meta's Large Language Model Meta AI 2. LiVersa's outputs were more accurate but were rated less comprehensive and safe compared to those of ChatGPT 4.

RESULTS

We evaluated LiVersa's performance by conducting 2 rounds of testing. First, we compared LiVersa's outputs versus those of trainees from a previously published knowledge assessment. LiVersa answered all 10 questions correctly. Second, we asked 15 hepatologists to evaluate the outputs of 10 hepatology topic questions generated by LiVersa, OpenAI's ChatGPT 4, and Meta's Large Language Model Meta AI 2. LiVersa's outputs were more accurate but were rated less comprehensive and safe compared to those of ChatGPT 4.

CONCLUSIONS

In this demonstration, we built disease-specific and protected health information-compliant LLMs using RAG. While LiVersa demonstrated higher accuracy in answering questions related to hepatology, there were some deficiencies due to limitations set by the number of documents used for RAG. LiVersa will likely require further refinement before potential live deployment. The LiVersa prototype, however, is a proof of concept for utilizing RAG to customize LLMs for clinical use cases.

Diabetes risk reduction diet and risk of liver cancer and chronic liver disease mortality: A prospective cohort study

BACKGROUND

We aimed to prospectively evaluate the association between a diabetes risk reduction diet (DRRD) score and the risk of liver cancer development and chronic liver disease-specific mortality.

METHODS

We included 98,786 postmenopausal women from the Women's Health Initiative-Observational Study and the usual diet arm of the Diet Modification trial. The DRRD score was derived from eight factors: high intakes of dietary fiber, coffee, nuts, polyunsaturated fatty acids, low intakes of red and processed meat, foods with high glycemic index, sugar-sweetened beverages (SSBs), and trans fat based on a validated Food-Frequency Questionnaire administered at baseline (1993-1998). Multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) for liver cancer incidence and chronic liver disease mortality were estimated using Cox proportional hazards regression models.

RESULTS AND CONCLUSION

After a median follow-up of 22.0 years, 216 incident liver cancer cases and 153 chronic liver disease deaths were confirmed. A higher DRRD score was significantly associated with a reduced risk of developing liver cancer (HRTertile 3 vs. Tertile 1 = 0.69; 95% CI: 0.49-0.97; Ptrend = 0.03) and chronic liver disease mortality (HRT3 vs. T1 = 0.54; 95% CI: 0.35-0.82; Ptrend = 0.003). We further found inverse associations with dietary fiber and coffee, and positive associations with dietary glycemic index, SSBs, and trans fat. A higher DRRD score was associated with reduced risk of developing liver cancer and chronic liver disease mortality among postmenopausal women.

Deep Learning Model for Predicting Proliferative Hepatocellular Carcinoma Using Dynamic Contrast-Enhanced MRI: Implications for Early Recurrence Prediction Following Radical Resection

RATIONALE AND OBJECTIVES

The proliferative nature of hepatocellular carcinoma (HCC) is closely related to early recurrence following radical resection. This study develops and validates a deep learning (DL) prediction model to distinguish between proliferative and non-proliferative HCCs using dynamic contrast-enhanced MRI (DCE-MRI), aiming to refine preoperative assessments and optimize treatment strategies by assessing early recurrence risk.

MATERIALS AND METHODS

In this retrospective study, 355 HCC patients from two Chinese medical centers (April 2018-February 2023) who underwent radical resection were included. Patient data were collected from medical records, imaging databases, and pathology reports. The cohort was divided into a training set (n = 251), an internal test set (n = 62), and external test sets (n = 42). A DL model was developed using DCE-MRI images of primary tumors. Clinical and radiological models were generated from their respective features, and fusion strategies were employed for combined model development. The discriminative abilities of the clinical, radiological, DL, and combined models were extensively analyzed. The performances of these models were evaluated against pathological diagnoses, with independent and fusion DL-based models validated for clinical utility in predicting early recurrence.

RESULTS

The DL model, using DCE-MRI, outperformed clinical and radiological feature-based models in predicting proliferative HCC. The area under the curve (AUC) for the DL model was 0.98, 0.89, and 0.83 in the training, internal validation, and external validation sets, respectively. The AUCs for the combined DL and clinical feature models were 0.99, 0.86, and 0.83 in these sets, while the AUCs for the combined DL, clinical, and radiological model were 0.99, 0.87, and 0.8, respectively. Among models predicting early recurrence, the DL plus clinical features model showed superior performance.

CONCLUSION

The DL-based DCE-MRI model demonstrated robust performance in predicting proliferative HCC and stratifying patient risk for early postoperative recurrence. As a non-invasive tool, it shows promise in enhancing decision-making for individualized HCC management strategies.

Utility of pelvic CT in patients undergoing surveillance for hepatocellular carcinoma: A retrospective multi-institutional study

OBJECTIVE

To determine the frequency, characteristics and clinical significance of incidental pelvic findings reported on abdominopelvic CT performed for hepatocellular carcinoma (HCC) surveillance in at-risk patients.

MATERIAL AND METHODS

This two-center retrospective study received institutional review board approval with a waiver of informed consent. The radiologic reports of the CT exams performed 1/1/2010-2/28/2023 for HCC surveillance were reviewed. Exams were obtained with intravenous contrast material and included hepatic arterial and portal venous phases of the abdomen; images of the pelvis were acquired during the portal venous phase. Reported imaging findings and imaging-related recommendations either by the radiologists or the corresponding caregiver, if present, were retrospectively tabulated. The patient's medical records were reviewed to determine if there were any recommendations that were considered clinically important and culminated in any further interventions or treatments.

RESULTS

259 adults (1st center: mean age, 60 ± 11 years, 49% male and 2nd center: 56.26 ± 6.2 years, 48% male) at risk for HCC underwent 327 abdominopelvic CT exams for HCC surveillance at two centers. A total of 622 pelvic findings (mean, 2.2/ exam) were reported, including 131 bladder, 120 alimentary tract, 133 vascular, 51 gynecologic, 37 prostate, 33 lymph node, 27 inguinal, 44 peritoneal, and 46 skeletal. 52 of 622 reported findings (8.3%) were associated with actionable recommendations. 24 of the 52 actionable recommendations/clinical suggestions were implemented as follows: five complimentary imaging, ten additional laboratory tests, and nine non-imaging recommendations. Of note, only eight applied recommendations culminated in a clinical outcome, which included four urinary tract infection treatments.

CONCLUSION

Pelvic CT findings were associated with a clinical benefit to the patient in 1.3% of exams. These results suggest that pelvic imaging should be omitted from CT-based HCC surveillance.

CLINICAL RELEVANCE

Without compromising valuable information, patients undergoing HCC surveillance-CT may not require additional pelvic coverage.

Diagnostic performance of Sonazoid-enhanced CEUS in identifying definitive hepatocellular carcinoma in cirrhotic patients according to KLCA-NCC 2022 and APASL 2017 guidelines

OBJECTIVE

This study aims to assess the diagnostic performance of Sonazoid-contrast-enhanced ultrasound (CEUS) in identifying definitive HCC within hepatic nodules in cirrhotic patients, comparing the KLCA-NCC 2022 and APASL 2017 diagnostic guidelines.

MATERIALS AND METHODS

This retrospective study analyzed cirrhotic patients who underwent Sonazoid-CEUS for liver lesion evaluation between October 2019 and October 2023. HCC diagnosis was based on the KLCA-NCC 2022 and APASL 2017 guidelines. Inter-reader agreement on CEUS imaging features and the diagnostic accuracy of the guidelines were evaluated. Sensitivity and specificity comparisons were made using McNemar's test.

RESULTS

Among 400 patients with 432 lesions, CEUS showed excellent inter-reader consistency in detecting arterial phase hyperenhancement and Kupffer defects. The KLCA-NCC 2022 criteria notably enhanced sensitivity to 96.2%, with specificity and accuracy of 93.8% and 95.8%, respectively. APASL 2017 achieved the highest sensitivity at 97.8%, although specificity dropped to 46.9%, resulting in an accuracy of 90.3%. The KLCA-NCC 2022 guidelines demonstrated significantly higher specificity than APASL 2017 (p < 0.001), while APASL 2017 exhibited the highest sensitivity at 97.8%. Notably, the KLCA-NCC 2022 guidelines also demonstrated an impressive positive predictive value of 98.9%.

CONCLUSION

Sonazoid-enhanced CEUS, particularly when applied using the KLCA-NCC 2022 guidelines, is an effective diagnostic tool for HCC.

CRITICAL RELEVANCE STATEMENT

Perfluorobutane CEUS, particularly in accordance with the KLCA-NCC 2022 guidelines, emerges as a valuable adjunct for diagnosing HCC in cirrhotic patients. It demonstrates superior positive predictive value and specificity compared to APASL 2017, underscoring its potential as an effective diagnostic tool.

KEY POINTS

Contrast-enhanced (CE)US using Sonazoid with KLCA-NCC 2022 guidelines is highly effective for HCC diagnosis. KLCA-NCC 2022 criteria showed high accuracy, 96.2% sensitivity, and 98.9% PPV. CEUS demonstrated excellent inter-reader consistency in detecting arterial phase hyperenhancement and Kupffer defects.

Significance of anatomical resection and wide surgical margin for HCC patients with MVI undergoing laparoscopic hepatectomy: A multicenter study

OBJECTIVE

To investigate the impact of surgical resection margin and hepatic resection type on prognosis and compare their prognostic significance on patients with hepatocellular carcinoma (HCC) with or without microvascular invasion (MVI) who underwent laparoscopic liver resection (LLR).

METHODS

A retrospective analysis was conducted on 320 patients with HCC who underwent LLR. According to the grading of MVI, patients were classified as M0, M1 and M2. Patients were divided into the anatomical resection (AR) and nonanatomical resection (NAR) groups according to the hepatic resection type. Survival and Cox regression analyses were performed to explore the effects of AR and NAR, wide and narrow resection margin on overall survival (OS) and time to recurrence (TTR).

RESULTS

In the whole cohort, narrow resection margin was an independent risk factor for OS and TTR, whereas NAR was not. Subgroup analysis showed that narrow resection margin and NAR were both independent risk factors for OS and TTR in HCC patients with MVI. The 5-year OS and TTR rates of the two groups (NAR-wide resection margin and AR-narrow resection margin) with M1 were 85.3 % versus 62 % and 34.4 % versus 60.2 %. Similarly, the 5-year OS and TTR rates of the two groups (NAR-wide resection margin and AR-narrow resection margin) with M2 were 80.2 % versus 47.9 % and 30.8 % versus 64.8 %.

CONCLUSIONS

Anatomical hepatectomy and wide resection margin were independent protective factors for HCC patients with MVI receiving LLR. Nonetheless, wide resection margin had a greater impact on prognosis than anatomical hepatectomy.

Prognostic significance of early and multiple recurrences after curative resection for hepatocellular carcinoma

BACKGROUND

In hepatocellular carcinoma (HCC), postoperative recurrence remains high. This study aimed to evaluate the recurrence patterns and prognosis of HCC after curative hepatectomy.

METHODS

Among 352 patients with primary HCC who underwent initial hepatectomy between January 2002 and December 2022, 151 with recurrence were assessed for the relationship between recurrence pattern and prognosis.

RESULTS

The early recurrence group (within 6 months postoperatively; n = 38) had significantly higher serum alpha-fetoprotein (p = 0.002), des-γ-carboxyprothrombin (DCP; p = 0.004) levels and Barcelona Clinic Liver Cancer (BCLC) stage (p < 0.001), larger tumor size (p < 0.001), higher incidence of multiple tumors (p = 0.002) and lower overall survival (OS) (p < 0.001) than the late recurrence group (> 6 months postoperatively; n = 113). The tumor size (p = 0.013) and BCLC stage (p = 0.001) were independent risk factors for early recurrence within 6 months in multivariate analysis. The multiple recurrence group (intrahepatic multinodular recurrence or distant metastasis; n = 89) had significantly lower prognostic nutritional index (p = 0.026), larger tumor size (p = 0.017), lower incidence of liver cirrhosis (p = 0.03) than the single recurrence group (single nodule recurrence; n = 62). The multiple recurrence group, especially patients with ≥ three intrahepatic nodules and distant metastases, had lower postoperative OS (p < 0.001) and shorter time to recurrence (p < 0.001) than the single recurrence group. When the patients were classified into three groups: late recurrence with one or two tumors (Group A; n = 74), early recurrence or three or more tumors or distant metastasis (Group B; n = 54), and early recurrence with three or more tumors or distant metastasis (Group C; n = 23), OS was significantly lower in Groups B and C than Group A (p < 0.001).

CONCLUSIONS

Patients with early recurrence within 6 months after surgery and three or more recurrence nodule or distant metastasis exhibited poor prognosis after initial recurrence, and they should be carefully followed up.

Yttrium-90 radioembolization treatment strategies for management of hepatocellular carcinoma

As the third leading cause of cancer-related deaths worldwide, hepatocellular carcinoma (HCC) represents a significant global health challenge. This paper provides an introduction and comprehensive review of transarterial radioembolization (TARE) with Yttrium-90 (Y90), a widely performed transcatheter procedure for HCC patients who are not suitable candidates for surgery. TARE involves the targeted delivery of radioactive microspheres to liver tumors, offering a promising treatment option for managing HCC across various stages of the disease. By evaluating Y90 TARE outcomes across early, intermediate, and advanced stages of HCC, the review aims to present a thorough understanding of its efficacy and safety. Additionally, this paper highlights future research directions focusing on the potential of combination therapies with systemic and immunotherapies, as well as personalized treatments. The exploration of these innovative approaches aims to improve treatment outcomes, reduce adverse events, and provide new therapeutic opportunities for HCC patients. The review underscores the importance of ongoing research and clinical trials to optimize TARE further and integrate it into comprehensive HCC treatment paradigms.

An overview of risk assessment and monitoring of malignant transformation in cirrhotic nodules

Cirrhotic liver nodules can progress to hepatocellular carcinoma (HCC) through a multi-step carcinogenesis model, with dysplastic nodules being particularly high risk. Currently, monitoring the progression of non-HCC cirrhotic nodules is primarily through dynamic observation, but there is a lack of sensitive, efficient, and convenient methods. Dynamic monitoring and risk evaluation of malignant transformation are essential for timely treatment and improved patient survival rates. Routine liver biopsies are impractical for monitoring, and imaging techniques like ultrasound, computed tomography, and magnetic resonance imaging are not suitable for all patients or for accurately assessing subcentimeter nodules. Identifying serum biomarkers with high sensitivity, specificity, and stability, and developing a multi-index evaluation model, may provide a more convenient and efficient approach to monitoring pathological changes in cirrhotic nodules.

Cirrhosis in primary practice: many patients remain potentially undiagnosed and are not receiving liver cancer surveillance

BACKGROUND AND AIM

Most patients with cirrhosis have compensated disease and are cared for in primary care; however, the exact epidemiology within Australia remains largely unknown. The aim of this study was to assess cirrhosis care in an Australian primary care setting by evaluating rates of cirrhosis diagnosis, appropriate hepatocellular carcinoma (HCC) surveillance and specialist communication.

METHODS

Electronic medical records in consenting general practices were reviewed using the "Liver Toolkit" to identify patients with an existing cirrhosis diagnosis. Individual cases were reviewed to identify outcomes of interest.

RESULTS

One hundred seventy-one patients with confirmed cirrhosis across nine general practices were identified (74% male, mean age: 61.2 years). There was significant variation in the rate of cirrhosis diagnosis between practices (range 31.7-637.9 per 100 000 patients, P < 0.0001). Patients with cirrhosis had predominately compensated disease (75% Child-Pugh A) and common etiologies of cirrhosis were alcohol (49%), hepatitis C (47%), and metabolic dysfunction-associated steatotic liver disease (29%). Forty-two patients (25%) had received appropriate HCC surveillance. Predictors of inadequate HCC surveillance were time from last specialist correspondence (odds ratio [OR] = 1.06 per month increase, 95% confidence interval [CI]: 1.02-1.10, P = 0.002) and hepatitis B (OR = 0.24, 95% CI: 0.06-0.98, P = 0.047). Specialist correspondence with primary care was older than 2 years or absent in 37% of cases.

CONCLUSIONS

There was a 20-fold difference in the rate of cirrhosis diagnosis between general practices within Sydney, suggesting a large proportion of patients remain undiagnosed. Three quarters of patients with diagnosed cirrhosis are not receiving appropriate HCC surveillance.

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.

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.

Combining CEUS and CT/MRI LI-RADS major imaging features: diagnostic accuracy for classification of indeterminate liver observations in patients at risk for HCC

PURPOSE

To determine the diagnostic accuracy of combining CEUS and CT/MRI LI-RADS major imaging features for the improved categorization of liver observations indeterminate on both CT/MRI and CEUS.

MATERIALS AND METHODS

A retrospective analysis using a database from a prospective study conducted at 11 centers in North America and Europe from 2018 to 2022 included a total of 109 participants at risk for HCC who had liver observations with indeterminate characterization (LR3, LR-4, and LR-M) on both CEUS and CT/MRI. The individual CEUS and CT/MRI LI-RADS major features were extracted from the original study and analyzed in various combinations. Reference standards included biopsy, explant histology, and follow-up CT/MRI. The diagnostic performance of the combinations of LI-RADS major features for definitive diagnosis of HCC was calculated. A reverse, stepwise logistical regression sub-analysis was also performed.

RESULTS

This study included 114 observations indeterminate on both CT/MRI and CEUS. These observations were categorized as LR-3 (n = 37), LR-4 (n = 41), and LR-M (n = 36) on CT/MRI and LR-3 (n = 48), LR-4 (n = 36), LR-M (n = 29), and LR-TIV (n = 1) on CEUS. Of them, 43.0% (49/114) were confirmed as HCC, 37.3% (43/114) non-malignant, and 19.3% (22/114) non-hepatocellular malignancies. The highest diagnostic accuracy among the combinations of imaging features was achieved in CT/MRI LR-3 observations, where the combination of CEUS arterial phase hyper-enhancement (APHE) + CT/MRI APHE had 96.7% specificity, 75.0% positive predictive value (PPV), and 86.5% accuracy for HCC.

CONCLUSION

The combination of LI-RADS major features on CT/MRI and CEUS showed higher specificity, PPV, and accuracy compared to individual modalities' assessments, particularly for CT/MRI LR-3 observations.

Epidemiological, diagnostic, therapeutic and prognostic impact of hepatitis B and D virus infection on hepatocellular carcinoma: A review of the literature

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for >90% of primary liver cancer cases, and chronic infections with hepatitis B virus (HBV) and hepatitis D virus (HDV) are major contributors.

METHODS

A comprehensive literature review was conducted using the MEDLINE (PubMed) database, focusing on studies related to HBV, HDV, and HCC.

RESULTS

HBV contributes to HCC through mechanisms like viral integration into the host genome, chronic inflammation, and immune modulation, leading to genomic instability and altered cell signaling. HDV exacerbates HBV-induced liver damage, accelerating fibrosis and cirrhosis, and significantly increasing HCC risk. Antiviral therapies and vaccinations have majorly reduced the burden of HBV-related HCC, but HDV remains challenging to treat due to limited therapeutic options. Emerging treatments like Bulevirtide showed promising results.

CONCLUSION

This review highlights the critical impact of HBV and HDV co-infections on HCC development, emphasizing the need for more effective therapeutic strategies. While advances in antiviral therapies have reduced the incidence of HBV-related HCC, the high burden of HDV-related complications persists. Future research should focus on improving treatments for HDV and understanding its unique contribution to HCC pathogenesis.

Association between antithrombotic agents use and hepatocellular carcinoma risk: a two-sample mendelian randomization analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common primary liver cancer worldwide. Multiple observational studies demonstrated a negative association between the use of antithrombotic agents and the risk of HCC. However, the precise causal relationship between these factors remains uncertain. Therefore, our study used a two-sample Mendelian randomization (MR) analysis to assess the causal link between these two factors.

METHOD

The summary statistics of single nucleotide polymorphisms (SNPs) associated with the use of antithrombotic agents were acquired from a genome-wide association study (GWAS) performed on individuals of European descent. A two-sample MR analysis was performed using the inverse variance weighting (IVW), the weighted median estimate, the MR-Egger regression, and the weighted-mode estimate. Sensitivity analysis of the primary findings was performed using MR-PRESSO, MR-Egger regression, Cochran's Q test, and Leave-one-out analysis.

RESULTS

Ten SNPs associated with the use of antithrombotic agents were selected as instrumental variables. The MR analysis performed using the four methods mentioned above revealed a negative causal association between the use of antithrombotic agents and HCC. Univariate MR estimates based on the inverse variance weighting (IVW) method suggested a negative causal association between the use of antithrombotic agents and HCC [odds ratio (OR) 0.444, 95% confidence interval (CI) 0.279 to 0.707, P = 0.001]. The other methods also produced similar results. No heterogeneity and horizontal pleiotropy were found.

CONCLUSION

Our findings suggested an inverse causal association of antithrombotic agents with the risk of HCC.

Overall Survival of Young Patients with Hepatocellular Carcinoma in Barcelona Clinic Liver Cancer Stage B in a Retrospective Study Based on a Multicenter Cohort

BACKGROUND

Hepatocellular carcinoma (HCC) is usually diagnosed in patients at the age of > 45 years. We aimed to determine the prognosis of patients with HCC at the age of 30-44 years compared with that of patients at a more senior age.

METHODS

Based on the Sun Yat-sen University Cancer Center database, a total of 1745 patients with HCC were retrospectively enrolled and were assigned to three age groups (30-44, 45-59, and 60-70 years). The primary endpoint was overall survival. Among baseline characteristics, five variables including sex, serum albumin level, total bilirubin level, the maximum tumor diameter, and the number of tumor nodules were adjusted using propensity score matching.

RESULTS

Patients aged 30-44 years presented a worse overall survival, a greater number of HCC nodules, a greater maximum tumor diameter, and higher serum alpha-fetoprotein (AFP) concentration than those aged 45-59 years in a crude analysis (p < 0.05). Using propensity score matching, the difference in overall survival between the two cohorts was canceled (p > 0.05).

CONCLUSION

The prognosis of patients with HCC at age 30-44 years was equal to that of patients aged 45-59 years.

Characteristics of Hepatocellular Carcinoma by Sex in Mexico: A Multi-Institutional Collaboration

Liver cancer is the fourth leading cause of cancer-related death worldwide. In Mexico, there is a high burden of liver cancer mortality in rural states, affecting both women and men equally. Thus, we aimed to describe the demographic and clinical characteristics of hepatocellular cancer (HCC) by sex in Mexico. Demographic and clinical information was extracted retrospectively from the medical records of patients with HCC initially treated (2015-2022) at institutions participating in a national survey across the country. The male-to-female ratio was calculated at the national and regional levels, and the results were stratified by sex. Among 697 HCC patients, the age at diagnosis was 65.4 ± 11.9 years and 20% were diagnosed at ≥75 years. The male-to-female ratio was 1.4:1, ranging from 1:1 in the northwestern and southwestern regions, to 2.1:1 in the western region. The proportion of cirrhosis was similar between the sexes; however, the etiology of cirrhosis differed: cryptogenic cirrhosis was higher in women and alcohol consumption was higher in men. Men had a higher proportion of advanced HCC, poor/undifferentiated tumors, and ≥4 nodules than women. HCC in the Mexican population affects both men and women at a 1.4:1 male-to-female ratio. This unique proportion by sex could be explained by the differences in the prevalence of risk factors across our heterogeneous country.

Stereotactic body radiotherapy alone versus stereotactic body radiotherapy after incomplete transarterial therapy for hepatocellular carcinoma

INTRODUCTION

We investigated the clinical outcomes of stereotactic body radiation therapy (SBRT) alone versus SBRT after incomplete transarterial chemoembolization (TACE) for a single recurrent hepatocellular carcinoma (HCC) smaller than 5 cm.

METHODS

We retrospectively reviewed the medical records of patients who underwent SBRT for a single recurrent HCC ≤5 cm, without vascular invasion or extrahepatic metastasis. Patients were divided into the SBRT-alone group and the TACE-SBRT group. The primary outcome was the local control (LC) rate, and secondary outcomes were survivals and treatment-related toxicities. We additionally conducted a propensity score matching (PSM) analysis.

RESULTS

A total of 477 patients were available for analysis. Among them, 54 patients received SBRT without prior treatment to the target lesion (SBRT-alone group), whereas 423 patients received SBRT for viable HCC after TACE (TACE-SBRT group). The 3-year LC rates did not differ between the two groups (SBRT-alone group, 88.6% vs. TACE-SBRT group, 89.6%, P = 0.918). The 3-year rates of overall survival, out-of-field intrahepatic recurrence-free survival and recurrence-free survival were also not significantly different (P = 0.479, 0.290 and 0.273, respectively). Even after PSM, LC and survival rates at 3 years were not significantly different.

CONCLUSION

SBRT alone demonstrated comparable local control and survival outcomes to SBRT following incomplete TACE. SBRT alone may be considered an alternative treatment option for a single recurrent HCC smaller than 5 cm when curative treatments or TACE are not feasible.

The clinical prognostic risk stratification system for HIV infected hepatocellular carcinoma

BACKGROUND

Patients with human immunodeficiency virus (HIV) are more susceptible to liver cancer because of their compromised immune system. There is no specific prognostic model for HIV-infected hepatocellular carcinoma (HCC) patients.

METHODS

Clinical data of 85 patients with HIV-infected HCC was divided into a 7:3 ratio for training and internal validation sets, while the data of 23 patients with HIV-infected HCC was served as the external validation set. Data of 275 HIV-negative HCC patients was considered as external HIV-negative validation set. Variables associated with overall survival (OS) in the training set were used to develop the HIV-infected HCC prognosis (HIHP) model. The model was tested in the internal and external validation sets. The predictive accuracy of the model was assessed with conventional HIV-negative HCC prognostic scoring systems.

RESULTS

In the training set, variables independently associated with OS in multivariable analysis were organ involvement and tumor number. The HIHP model demonstrated a significant association with OS in the training set, with a median OS of 13 months for low risk, 7 months for medium risk, and 3 months for high risk (p < 0.001). The HIHP model showed a significant association with OS, and exhibited greater discriminative abilities compared to conventional HIV-negative HCC prognostic models both in the internal and external validation sets. In the external HIV-negative validation set, the HIHP model did not show better discrimination than conventional HIV-negative HCC scores.

CONCLUSION

The new model presented in the work provided a more accurate prognostic prediction of OS in HIV-infected HCC patients. However, the model is not applicable to patients with HIV-negative HCC.

Management of non-alcoholic fatty liver disease-associated hepatocellular carcinoma

In recent years, with the decline in HBV and HCV infections, there has been a corresponding reduction in both the morbidity and mortality of virus-associated HCC. Nevertheless, rising living standards, coupled with the increasing prevalence of metabolic disorders like diabetes and obesity, have led to a rapid surge in non-alcoholic fatty liver disease-associated hepatocellular carcinoma (NAFLD-HCC) incidence. The mechanisms underlying the progression from NAFLD to NAFLD-HCC are multifaceted and remain incompletely understood. Current research suggests that genetic predisposition, metabolic dysregulation, lipotoxicity, oxidative stress, and inflammation are key contributing factors. Given the complexity of these mechanisms and the frequent occurrence of metabolic comorbidities like type 2 diabetes mellitus (T2DM) and cardiovascular disease in NAFLD-HCC patients, there is a pressing need for tailored therapeutic strategies, along with novel prevention, monitoring, and treatment approaches that are personalized to the patient's pathophysiology. Due to the limited depth of research, incomplete understanding of pathogenesis, and insufficient clinical data on NAFLD-HCC treatment, current therapeutic approaches largely rely on tumor staging. In this review, we synthesize current research on the pathogenesis, surveillance, diagnosis, treatment, and prevention of NAFLD-HCC, and offer perspectives for future studies, particularly regarding its underlying mechanisms.

Clinical study on conversion therapy of hepatocellular carcinoma - summary and comparison of clinical data from a single center of consecutive four years

AIM

The purpose of this study was to interpret real-world clinical data to analyze the surgical safety and survival outcomes of patients with initial unresectable hepatocellular carcinoma (uHCC) after conversion therapy.

METHODS

A retrospective analysis was performed on 2984 hepatocellular carcinoma (HCC) patients hospitalized in Shandong Cancer Hospital Affiliated to Shandong First Medical University from June 1st, 2019 to June 1st, 2023. Clinicopathological features, response to systemic and/or loco-regional treatments, surgical resection rate after conversion therapy, surgical safety, and postoperative recurrence were analyzed.

RESULTS

A total of 38 patients were successfully converted to obtain surgical resection. 35 patients underwent radical resection. A high objective response rate (ORR) (52.6% under RECIST v1.1 and 78.9% under mRECIST criteria) was observed in patients under conversion therapy, and the disease control rate (DCR) was 100%. Pathologic complete response (pCR) was 42.9%. Treatment-related adverse events (TRAEs) of any grade were observed in 37 patients (97.4%). Safety of conversion or direct surgery continues to improve. The median follow-up time was 19.3 months. The 1-year Disease-free survival (DFS) rate of patients with direct surgery and patients with conversion surgery were 91.4% and 86.8%, respectively.

CONCLUSIONS

With conversion therapy, a small percentage (1.81%) of uHCC patients are likely to be converted to radical resection. Local combined systemic therapy is a relatively safe and effective conversion therapy, and the safety of surgery is gradually improved after successful conversion. Preliminary follow-up data showed satisfactory survival benefits for patients undergoing conversion surgery.

TRIAL REGISTRATION

This was a retrospective study and it did not interfere with treatment decisions.

Prognostic Value of Myosteatosis and Albumin-Bilirubin Grade for Survival in Hepatocellular Carcinoma Post Chemoembolization

OBJECTIVE

This study aimed to investigate the prognostic value of preoperative myosteatosis and the albumin-bilirubin (ALBI) grade in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE) and develop a robust prognostic score based on these factors.

METHODS

Patients with HCC who underwent TACE between January 2009 and December 2020 were included. Multivariate Cox regression analysis identified prognostic factors. CT-based body composition parameters were acquired from baseline abdominal CT images at the level of the third lumbar vertebra. A prognostic score (Myo-ALBI) was developed based on the presence of preoperative myosteatosis and the ALBI grade, and its prognostic value was evaluated.

RESULTS

Of 446 patients, 63% were male, and the mean age was 62.4 years. Preoperative myosteatosis was present in 41.5% of patients. The BCLC stages were mostly B (67.9%). Multivariate analysis shows that preoperative myosteatosis, ALBI grade 2, and ALBI grade 3 were independent prognostic factors. The Myo-ALBI grade was incorporated into a prognostic model, including alpha-fetoprotein and up-to-seven criteria, to generate a nomogram. The C-index of the nomogram based on the Myo-ALBI grade (0.743) was significantly higher than the non-Myo-ALBI nomogram (0.677), the up-to-seven criteria (0.653), the ALBI grade (0.616), and the Child-Pugh class (0.573) (all p < 0.05). The t-ROC curve for the nomogram was consistently superior to the other models throughout the observation period in all patients and the BCLC-B subgroup.

CONCLUSIONS

The combination of preoperative CT-derived myosteatosis and ALBI grade enhances prognostication for patients with unresectable HCC undergoing TACE. The Myo-ALBI nomogram constructed in this study could support individualized prognosis prediction, assisting in treatment decision-making for HCC patients.

Risk of Malignancy in Indeterminate Liver Nodules Among Patients with Cirrhosis: A Retrospective Cohort Study

BACKGROUND

Several studies have shown a higher risk of liver cancer from indeterminate liver nodules, but the exact occurrence and predictors of liver cancer in this group are still unclear. Our aim is to study the development of liver cancer in this population and identify any potential risk factors.

METHODS

This retrospective study evaluated cirrhotic patients with indeterminate liver nodules from 2013 to 2023.Data from electronic patient records was analyzed to assess the association between HCC and baseline factors. Subgroup exploratory analysis compared characteristics of patients with de novo HCC and those with nodule transformation HCC.

RESULTS

Out of 116 patients with liver nodules, 19 (16%) developed HCC in up to 7.5-year follow-up. Univariate Cox regression analysis showed a significant association between HCC incidence and smoking [hazard ratio (HR) 2.60, 95% Confidence Interval [CI] 1.01-6.74), nodule diameter exceeding 2 cm (HR 5.41, 95% CI 1.45-20.18), and baseline LI-RADS score 3 (HR 3.78, 95% CI 1.36-19.52). Multivariate Cox regression analysis revealed significant independent associations with nodule diameters 1 cm to < 2 cm (adjusted HR 3.35, 95% CI 1.06-10.60) and greater than 2 cm (adjusted HR 5.85, 95% CI 1.10-31.16), as well as with LI-RADS 3 lesions (adjusted HR 3.75, 95% CI 1.16-12.11) with adjusting other potential predictors and covariates.

CONCLUSION

Our findings show a higher incidence of HCC in patients with indeterminate liver nodules, increasing over time and reaching 30% at seven years. Nodules larger than 1-2 cm or LI-RADS 3 lesions pose increased risk for HCC. Enhanced surveillance is necessary given the lack of clear management guidelines.

Mass spectrometry-based multi-omics analysis reveals distinct molecular features in early and advanced stages of hepatocellular carcinoma

Hepatocellular Carcinoma (HCC) is a serious primary solid tumor that is prevalent worldwide. Due to its high mortality rate, it is crucial to explore both early diagnosis and advanced treatment for HCC. In recent years, multi-omics approaches have emerged as promising tools to identify biomarkers and investigate molecular mechanisms of biological processes and diseases. In this study, we performed proteomics, phosphoproteomics, metabolomics, and lipidomics to reveal the molecular features of early- and advanced-stage HCC. The data obtained from these omics were analyzed separately and then integrated to provide a comprehensive understanding of the disease. The multi-omics results unveiled intricate biological pathways and interaction networks underlying the initiation and progression of HCC. Moreover, we proposed specific potential biomarker panels for both early- and advanced-stage HCC by overlapping our data with CPTAC database for HCC diagnosis, and deduced novel insights and mechanisms related to HCC origination and development, such as glucose depletion during tumor progression, ROCK1 deactivation and GSK3A activation.

Predictive models and treatment efficacy for liver cancer patients with bone metastases: A comprehensive analysis of prognostic factors and nomogram development

Background

Bone metastasis considerably undermines the prognosis of advanced primary liver cancer patients. Though its impact is well-recognized, the clinical field still lacks robust predictive models that can accurately forecast patient outcomes and aid in treatment effectiveness evaluation. Addressing this gap is paramount for improving patient management and survival.

Materials and methods

We conducted an extensive analysis using data from the SEER database (2010-2020). COX regression analysis was applied to identify prognostic factors for primary liver cancer with bone metastasis (PLCBM). Nomograms were developed and validated to predict survival outcomes in PLCBM patients. Additionally, propensity score matching and Kaplan-Meier survival analyses lent additional insight by dissecting the survival advantage conferred by various treatment strategies.

Results

A total of 470 patients with PLCBM were included in our study. The median overall survival (OS) and cancer-specific survival (CSS) for these patients were both 5 months. We unveiled several independent prognosticators for OS and CSS, spanning demographic to therapeutic parameters like marital status, cancer grade, histological type, and treatments received. This discovery enabled the formulation of two novel nomograms-now verified to eclipse the predictive prowess of the traditional TNM staging system regarding discrimination and clinical utility. Additionally, propensity score matching analysis showed the effectiveness of surgeries, radiotherapy, and chemotherapy in improving OS and CSS outcomes for PLCBM patients.

Conclusions

Our investigation stands out by introducing pioneering nomograms for prognostic evaluation in PLCBM, a leap forward compared to existing tools. Far exceeding mere academic exercise, these nomograms hold immense clinical value, serving as a foundation for nuanced risk stratification systems and delivering dynamic, interactive guides, allowing healthcare professionals and patients to assess individual bone metastasis survival probabilities and personalize treatment selection.

Identified a novel prognostic model of HCC basing on virus signature for guiding immunotherapy

Oncolytic viral immunotherapy is a cancer treatment that uses native or genetically modified viruses that selectively replicate and destroy tumor cells. In this study, we aimed to construct a virus-based prognostic model for risk assessment and prognosis prediction in patients with hepatocellular carcinoma (HCC) and determine the most appropriate virus as a candidate vector for oncolytic virus immunotherapy. Microbiome and RNA sequencing data and clinical information were obtained from The Cancer Genome Atlas, and viruses with prognostic value were identified (Deltabaculovirus, Sicinivirus, and Cytomegalovirus) to construct the prognostic model. Correlation analyses were performed to evaluate the predictive function of the viral signature. Bioinformatics analyses were conducted to explore the functional enrichment of viral expression in HCC. The risk score generated by this model could distinguish patients with different survival outcomes, have excellent reliability and accuracy, and could be used as an independent prognostic indicator. The high-risk score group showed significantly lower overall survival, and this trend was also observed in subgroups with different clinicopathological features. Furthermore, Deltabaculovirus positively correlated with amino acid metabolism, energy metabolism signaling pathways, peroxisomes, and complement coagulation cascades. In addition, Deltabaculovirus was significantly related to immune cell infiltration; therefore, patients with high Delta-baculovirus expression might respond better to HCC immunotherapy. Our study identified a promising predictive viral signature for assessing clinical prognosis and guiding immunotherapy in HCC. Deltabaculovirus might be a suitable viral vector for oncolytic virus immunotherapy.

Novel Biomarkers for Early Detection of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality globally. Most patients present with late diagnosis, leading to poor prognosis. This narrative review explores novel biomarkers for early HCC detection. We conducted a comprehensive literature review analyzing protein, circulating nucleic acid, metabolite, and quantitative proteomics-based biomarkers, evaluating the advantages and limitations of each approach. While established markers like alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin, and AFP-L3 remain relevant, promising candidates include circulating tumor DNA, microRNAs, long noncoding RNAs, extracellular vesicle, and metabolomic biomarkers. Multi-biomarker panels like the GALAD score, Oncoguard, and Helio liver test show promise for improved diagnostic accuracy. Non-invasive approaches like urine and gut microbiome analysis are also emerging possibilities. Integrating these novel biomarkers with current screening protocols holds significant potential for earlier HCC detection and improved patient outcomes. Future research should explore multi-biomarker panels, omics technologies, and artificial intelligence to further enhance early HCC diagnosis and management.

Multi-stage mechanisms of tumor metastasis and therapeutic strategies

The cascade of metastasis in tumor cells, exhibiting organ-specific tendencies, may occur at numerous phases of the disease and progress under intense evolutionary pressures. Organ-specific metastasis relies on the formation of pre-metastatic niche (PMN), with diverse cell types and complex cell interactions contributing to this concept, adding a new dimension to the traditional metastasis cascade. Prior to metastatic dissemination, as orchestrators of PMN formation, primary tumor-derived extracellular vesicles prepare a fertile microenvironment for the settlement and colonization of circulating tumor cells at distant secondary sites, significantly impacting cancer progression and outcomes. Obviously, solely intervening in cancer metastatic sites passively after macrometastasis is often insufficient. Early prediction of metastasis and holistic, macro-level control represent the future directions in cancer therapy. This review emphasizes the dynamic and intricate systematic alterations that occur as cancer progresses, illustrates the immunological landscape of organ-specific PMN creation, and deepens understanding of treatment modalities pertinent to metastasis, thereby identifying some prognostic and predictive biomarkers favorable to early predict the occurrence of metastasis and design appropriate treatment combinations.

Evaluating the impact of treatment sequencing on outcomes in hepatocellular carcinoma: a comparative analysis of TACE and systemic therapies

This study aimed to evaluate how the timing of transarterial chemoembolization (TACE) relative to systemic therapy (tyrosine-kinase inhibitors [TKIs] and immune checkpoint inhibitors [ICIs]) influences oncological outcomes in patients with hepatocellular carcinoma (HCC). A retrospective analysis was conducted on HCC patients treated with TACE plus TKIs and ICIs from January 2018 to February 2023. We compared objective response rate (ORR), disease control rate (DCR), overall survival (OS), and progression-free survival (PFS) between patients receiving TACE before versus after systemic therapies. Multivariate Cox regression analyses identified potential prognostic factors. Of the 194 patients enrolled, 111 received TACE before systemic therapies, and 83 after. The median age at diagnosis was 52.8 years. There were no significant differences in ORR (40.72% vs. 30.41%, p = 0.989) or DCR (48.45% vs. 35.57%, p = 0.770) between the groups. Likewise, OS (18.73 vs. 18.20 months, p = 0.091) and PFS (11.53 vs. 10.05 months, p = 0.336) were similar regardless of treatment sequence. In the result of Cox analysis, a 20% decrease in AFP from baseline at one month was associated with improved OS (HR = 0.35, 95% CI 0.17-0.70, p = 0.003) and PFS (HR = 0.69, 95% CI 0.49-0.96, p = 0.028). Large tumor size (≥ 10 cm) was a poor prognostic factor for OS (HR = 2.12, 95% CI 1.07-4.21, p = 0.032), and the presence of portal vein tumor thrombus adversely affected PFS (HR = 2.31, 95% CI 1.47-3.62, p < 0.001). The sequencing of TACE and systemic therapies does not significantly impact the prognosis of advanced HCC. A 20% reduction in AFP within one month of treatment commencement emerges as a protective prognostic factor for HCC.

Envafolimab plus lenvatinib and transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma: a prospective, single-arm, phase II study

Evidences regarding the feasibility of transcatheter arterial chemoembolization (TACE)-based therapy for unresectable hepatocellular carcinoma (uHCC) remains limited. This study aimed to investigate the efficacy and safety of TACE combined with envafolimab and lenvatinib for uHCC. Eligible patients with uHCC received envafolimab and lenvatinib after TACE until disease progression, conversion to surgery, intolerable toxicities, or death. The primary endpoint was the objective response rate (ORR) assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. Between March 2022 and July 2022, 38 patients were included for safety analysis, and 36 patients were included for efficacy analysis. As of the data cutoff (13 December 2023), the median follow-up was 16.9 months. The ORR was 50%, and disease control rate (DCR) was 83.3% per RECIST 1.1 (ORR and DCR of both 83.3% per modified RECIST (mRECIST)). The median progression-free survival (PFS) was 7.58 months. Of 36 patients, 17 patients were converted to resectable HCC with a surgical conversion rate of 47.2%, and 16 patients underwent surgery with R0 resection rate of 100%, pathologic complete response (pCR) rate of 31.3%. Overall incidences of treatment-related adverse events (TRAEs) of any grade was 97.4%. Grade ≥ 3 TRAEs were observed in 52.6% patients. No treatment-related deaths occurred. Image mass cytometry (IMC) analysis revealed that combined treatment improved the immune status of the tumor microenvironment, and resident macrophages had the potential to predict efficacy of this treatment. Envafolimab plus lenvatinib and TACE yielded promising survival outcomes and conversion efficiency with a tolerable safety profile. Trial registration Clinical trials: NCT05213221.

Tumor Growth Pattern and Intra- and Peritumoral Radiomics Combined for Prediction of Initial TACE Outcome in Patients with Primary Hepatocellular Carcinoma

Purpose

Non-invasive methods are urgently needed to assess the efficacy of transarterial chemoembolization (TACE) and to identify patients with hepatocellular carcinoma (HCC) who may benefit from this procedure. This study, therefore, aimed to investigate the predictive ability of tumor growth patterns and radiomics features from contrast-enhanced magnetic resonance imaging (CE-MRI) in predicting tumor response to TACE among patients with HCC.

Patients and Methods

A retrospective study was conducted on 133 patients with HCC who underwent TACE at three centers between January 2015 and April 2023. Enrolled patients were divided into training, testing, and validation cohorts. Rim arterial phase hyperenhancement (Rim APHE), tumor growth patterns, nonperipheral washout, markedly low apparent diffusion coefficient (ADC) value, intratumoral arteries, and clinical baseline features were documented for all patients. Radiomics features were extracted from the intratumoral and peritumoral regions across the three phases of CE-MRI. Seven prediction models were developed, and their performances were evaluated using receiver operating characteristic (ROC) and decision curve analysis (DCA).

Results

Tumor growth patterns and albumin-bilirubin (ALBI) score were significantly correlated with tumor response. Tumor growth patterns also showed a positive correlation with tumor burden (r = 0.634, P = 0.000). The Peritumor (AUC = 0.85, 0.71, and 0.77), Clinics_Peritumor (AUC = 0.86, 0.77, and 0.81), and Tumor_Peritumor (AUC = 0.87, 0.77, and 0.80) models significantly outperformed the Clinics and Tumor models (P < 0.05), while the Clinics_Tumor_Peritumor model (AUC = 0.88, 0.81, and 0.81) outperformed the Clinics (AUC = 0.67, 0.77, and 0.75), Tumor (AUC = 0.78, 0.72, and 0.68), and Clinics_Tumor (AUC = 0.82, 0.83, and 0.78) models (P < 0.05 or 0.053, respectively). The DCA curve demonstrated better predictive performance within a specific threshold probability range for Clinics_Tumor_Peritumor.

Conclusion

Combining tumor growth patterns, intra- and peri-tumoral radiomics features, and ALBI score could be a robust tool for non-invasive and personalized prediction of treatment response to TACE in patients with HCC.

Multiparametric MRI based deep learning model for prediction of early recurrence of hepatocellular carcinoma after SR following TACE

BACKGROUND

Surgical resection (SR) following transarterial chemoembolization (TACE) is a promising treatment for unresectable hepatocellular carcinoma (uHCC). However, biomarkers for the prediction of postoperative recurrence are needed.

PURPOSE

To develop and validate a model combining deep learning (DL) and clinical data for early recurrence (ER) in uHCC patients after TACE.

METHODS

A total of 511 patients who received SR following TACE were assigned to derivation (n = 413) and validation (n = 98) cohorts. Deep learning features were taken from the largest tumor area in liver MRI. A nomogram using DL signatures and clinical data was made to forecast early recurrence risk in uHCC patients. Model performance was evaluated using area under the curve (AUC).

RESULTS

A total of 2278 subsequences and 31,346 slices multiparametric MRI including contrast-enhanced T1WI, T2WI and DWI were input in the DL model simultaneously. Multivariable analysis identified three independent predictors for the development of the nomogram: tumor number (hazard ratio [HR]:3.42, 95% confidence interval [CI]: 2.75-4.31, P = 0.003), microvascular invasion (HR: 9.21, 6.24-32.14; P < 0.001), and DL scores (HR: 17.46, 95% CI: 12.94-23.57, P < 0.001). The AUC of the nomogram was 0.872 and 0.862 in two cohorts, significantly outperforming single-subsequence-based DL mode and clinical model (all, P < 0.001). The nomogram provided two risk strata for cumulative overall survival in two cohorts, showing significant statistical results (P < 0.001).

CONCLUSIONS

The DL-based nomogram is essential to identify patients with uHCC suitable for treatment with SR following TACE and may potentially benefit personalized decision-making.

Optimizing liver health before and after gene therapy for hemophilia A

ABSTRACT

Gene therapy for severe hemophilia A uses an adeno-associated virus (AAV) vector and liver-specific promoters that depend on healthy hepatocyte function to achieve safe and long-lasting increases in factor VIII (FVIII) activity. Thus, hepatocyte health is an essential aspect of safe and successful gene therapy. Many people living with hemophilia A have current or past chronic hepatitis C virus infection, metabolic dysfunction-associated steatosis or steatohepatitis, or other conditions that may compromise the efficacy and safety of AAV-mediated gene therapy. In addition, gene therapy may induce an immune response to transduced hepatocytes, leading to liver inflammation and reduced FVIII activity. The immune response can be treated with immunosuppression, but close monitoring of liver function tests and factor levels is necessary. The long-term risk of hepatocellular carcinoma associated with gene therapy is unknown. Routine screening by imaging for hepatocellular carcinoma, preferable every 6 months, is essential in patients at high risk and recommended in all recipients of hemophilia A gene therapy. This paper describes our current understanding of the biologic underpinnings of how liver health affects hemophilia A gene therapy, and provides practical clinical guidance for assessing, monitoring, and managing liver health both before and after gene therapy.

ASH1L in Hepatoma Cells and Hepatic Stellate Cells Promotes Fibrosis-Associated Hepatocellular Carcinoma by Modulating Tumor-Associated Macrophages

Hepatocellular carcinoma (HCC) often occurs in the context of fibrosis or cirrhosis. Methylation of histone is an important epigenetic mechanism, but it is unclear whether histone methyltransferases are potent targets for fibrosis-associated HCC therapy. ASH1L, an H3K4 methyltransferase, is found at higher levels in activated hepatic stellate cells (HSCs) and hepatoma cells. To determine the role of ASH1L in vivo, transgenic mice with conditional Ash1l depletion in the hepatocyte cell lineage (Ash1lflox/floxAlbcre) or HSCs (Ash1lflox/floxGFAPcreERT2) are generated, and these mice are challenged in a diethylnitrosamine (DEN)/carbon tetrachloride (CCl4)-induced model of liver fibrosis and HCC. Depleting Ash1l in both hepatocytes and HSCs mitigates hepatic fibrosis and HCC development. Multicolor flow cytometry, bulk, and single-cell transcriptomic sequencing reveal that ASH1L creates an immunosuppressive microenvironment. Mechanically, ASH1L-mediated H3K4me3 modification increases the expression of CCL2 and CSF1, which recruites and polarizes M2-like pro-tumorigenic macrophages. The M2-like macrophages further enhance tumor cell proliferation and suppress CD8+ T cell activation. AS-99, a small molecule inhibitor of ASH1L, demonstrates similar anti-fibrosis and tumor-suppressive effects. Of pathophysiological significance, the increased expression levels of mesenchymal ASH1L and M2 marker CD68 are associated with poor prognosis of HCC. The findings reveal ASH1L as a potential small-molecule therapeutic target against fibrosis-related HCC.