Bone metastases in hepatocellular carcinoma: an emerging issue

Mechanism exploration of Zoledronic acid combined with PD-1 in the treatment of hepatocellular carcinoma

How to increase the response of immune checkpoint inhibitors (ICIs) is a challenge. In clinical, we found that Zoledronic acid (ZA) may increase the anti-tumor effect of immunotherapy for hepatocellular carcinoma (HCC). To explore the underlying mechanism, we established a mouse model of HCC by subcutaneously injecting Hepa1-6 cell line. The result showed that the tumor volume in the ZA plus anti-PD-1 monocloning antibody (anti-PD-1 mAb) treatment groups was significantly smaller than that of control group, and the onset time of tumor inhibition was even shorter than that of the anti-PD-1 mAb group. Using flow cytometry (FC) to detect the proportion of major immune cell subsets in tumor tissues of each group of mice, we found that the synergistic anti-tumor effect of ZA and anti-PD-1 mAb may be related to ZA-induced polarization of macrophages toward the M1 phenotype. Next, we performed bulk RNA sequencing on tumor samples from different groups to obtain differentially expressed genes (DEGs), which were then input DEGs into pathway enrichment analysis. Data indicated that ZA participated in the M1-type polarization via ferroptosis-related pathways. Our results revealed how ZA involves in the anti-tumor effect of PD-1 monoclonal antibody and provided a potential therapeutic candidate for patients with HCC.

Chest wall mass as a sign of ignored hepatocellular carcinoma in an alcoholic cirrhotic patient: a case report

Bone metastasis of hepatocellular carcinoma (HCC) is usually seen in the course of advanced intrahepatic HCC. Isolated bone metastasis as an initial manifestation of HCC is uncommon.

CASE PRESENTATION

The authors report a case of a 68-year-old male with a history of chronic alcohol consumption who presented with epigastric pain, abdominal distension, and a hard, tender lump on the right posterolateral aspect of his back. Investigation revealed HCC with isolated metastasis to the posterior thoracic wall.

CLINICAL DISCUSSION

HCC usually develops secondary to chronic hepatitis B and C infection in the background of chronic liver disease. Common presenting symptoms of bone metastasis include local pain, neurological manifestations, palpable subcutaneous masses, and pathological fractures. An immunohistochemistry analysis is important to differentiate HCC from non-HCC metastasis in patients without known underlying HCC. Treatment is often directed towards palliative care as the prognosis is poor.

CONCLUSION

An isolated rib mass can be an initial presentation of metastatic HCC. Thus, HCC with bone metastasis should be considered in the differential diagnosis in patients presenting with painful swelling in the thoracic region.

Effects of Clinical and Tumor Characteristics on Survival in Patients with Hepatocellular Carcinoma with Bone Metastasis

Background

Advanced hepatocellular carcinoma (HCC) generally has a dismal prognosis. Bone metastases from HCC are infrequent, with a poorer prognosis. However, the survival influencing factors are not yet well understood.

Aim

The aim of the present study was to assess the clinical features and tumor characteristics of HCC patients with bone metastasis.

Methods

A cohort of 170,576 adult patients with HCC was studied using the National Cancer Database (NCDB) spanning from 2010 to 2019, and within this group, 5285 patients (3.1%) were diagnosed with bone metastasis. We performed the Kaplan-Meier method to calculate the median overall survival (OS). We included demographics (age at diagnosis, gender, race, insurance status), comorbidity score, and treatment characteristics.

Results

Of a total of 5285 HCC patients with bone metastasis, 86.2% were male and 61.2% were non-Hispanic white. Most patients (55.1%) were below 65, and 89% had a total Charlson-Deyo comorbidity score of under 3. Among patients with known tumor grade, 24.8% had well-differentiated tumors, and 36.1% had poorly differentiated tumors. Chemotherapy was administrated to 39.5% of patients. In univariate analysis, patients with well-differentiated tumors had better OS compared to poorly differentiated tumors (5.4 months vs 3.0 months, p = 0.001). Patients who received single or multiagent chemotherapy were significantly associated with improved OS compared to patients who did not receive chemotherapy (7.0 and 8.5 months vs 1.94 months, respectively). We also found mortality difference between age, comorbidity scores, facility types and race groups.

Conclusion

In this cohort analysis of NCDB data, we found better OS in treatment receipt, lower tumor grade, younger age, non-Hispanic Black and Hispanic race, treatment at academic facility and lower comorbidity score in HCC patients with bone metastasis. The study results may have a consequential impact on the treatment decisions for HCC patients with bone metastasis.

Bone Lesion-Derived Extracellular Vesicles Fuel Prometastatic Cascades in Hepatocellular Carcinoma by Transferring ALKBH5-Targeting miR-3190-5p

Bone is the second leading metastatic site for hepatocellular carcinoma (HCC). Patients with HCC and bone metastasis suffer poor quality of life and reduced survival time. Extracellular vesicles (EVs) are widely involved in HCC formation and metastasis. However, the communication between primary HCC and bone lesions mediated by EVs remains unclear and the possible effect of bone metastasis on the progression of HCC remains largely unknown. Here, bone-metastasized HCC-derived EVs (BM-EVs) are found to localize to orthotropic HCC cells and promote HCC progression. Mechanistically, miR-3190-5p (miR-3190) is upregulated in intracellular HCC cells isolated from bone lesions as well as in their derived EVs. miR-3190 in BM-EVs is transferred into orthotopic tumor cells and enhances their metastatic capacity by downregulating AlkB homolog 5 (ALKBH5) expression. Decreased level of ALKBH5 exacerbates the prometastatic characteristics of HCC by modulating gene expression in N6-methyladenosine-dependent and -independent ways. Finally, antagomir-miR-3190-loaded liposomes with HCC affinity successfully suppress HCC progression in mice treated with BM-EVs. These findings reveal that BM-EVs initiate prometastatic cascades in orthotopic HCC by transferring ALKBH5-targeting miR-3190 and miR-3190 is serving as a promising therapeutic target for inhibiting the progression of HCC in patients with bone metastasis.

Large Oncosome-Loaded VAPA Promotes Bone-Tropic Metastasis of Hepatocellular Carcinoma Via Formation of Osteoclastic Pre-Metastatic Niche

Tumor-derived extracellular vesicles (EVs) function as critical mediators in selective modulation of the microenvironment of distant organs to generate a pre-metastatic niche that facilitates organotropic metastasis. Identifying the organ-specific molecular determinants of EVs can develop potential anti-metastatic therapeutic targets. In the current study, large oncosomes (LOs), atypically large cancer-derived EVs, are found to play a crucial role in facilitating bone-tropic metastasis of hepatocellular carcinoma (HCC) cells by engineering an osteoclastic pre-metastatic niche and establishing a vicious cycle between the osteoclasts and HCC cells. Transmembrane protein, VAMP-associated protein A (VAPA), is significantly enriched on LOs surface via direct interaction with LOs marker αV-integrin. VAPA-enriched LOs-induced pre-metastatic education transforms the bone into a fertile milieu, which supports the growth of metastatic HCC cells. Mechanically, LOs-delivered VAPA integrates to plasma membrane of osteoclasts and directly interacts with and activates neural Wiskott-Aldrich syndrome protein (N-WASP) via dual mechanisms, consequently resulting in ARP2/3 complex-mediated reorganization of actin cytoskeleton in osteoclasts and osteoclastogenesis. Importantly, treatment with N-WASP inhibitor 187-1-packaged LOs (LOs/187-1) dramatically abolishes the inductive effect of VAPA-enriched LOs on pre-metastatic niche formation and precludes HCC bone metastasis. These findings reveal a plausible mechanism for bone-tropism of HCC and can represent a potential strategy to prevent HCC bone metastasis.

Emerging Perspectives of Bone Metastasis in Hepatocellular Carcinoma

Recent evidence suggests the global incidence and mortality of hepatocellular carcinoma (HCC) are increasing. Although the highest incidence of HCC remains entrenched in WHO regions with high levels of HBV-HCV infection, the etiology of this disease is rapidly changing to include other lifestyle risk factors. Extrahepatic metastasis is a frequent feature of advanced HCC and most commonly locates in the lungs and bone. Bone metastasis in HCC (HCC-BM) signals a more aggressive stage of disease and a poorer prognosis, simultaneously HCC-BM compromises the function and integrity of bone tissue. HCC induced osteolysis is a prominent feature of metastasis that complicates treatment needed for pathologic fractures, bone pain and other skeletal events like hypercalcemia and nerve compression. Early detection of bone metastases facilitates the treatment strategy for avoiding and relieving complications. Although recent therapeutic advances in HCC like targeting agents and immunotherapy have improved survival, the prognosis for patients with HCC-BM remains problematic. The identification of critical HCC-BM pathways in the bone microenvironment could provide important insights to guide future detection and therapy. This review presents an overview of the clinical development of bone metastases in HCC, identifying key clinical features and identifying potential molecular targets that can be deployed as diagnostic tools or therapeutic agents.

Skull Base Metastasis from Hepatocellular Carcinoma: Clinical Presentation and Efficacy of Radiotherapy

Purpose

Skull base metastasis (SBM) from hepatocellular carcinoma (HCC) presents detrimental survival outcomes with cranial nerve symptoms; however, they have received little attention. This study aimed to investigate the clinical presentation and efficacy of radiation therapy (RT) in patients with SBM from HCC.

Patients and Methods

We identified patients with SBM from HCC in Yonsei Cancer Center from 2005 to 2019. Image evaluations and SBM-related symptoms were reviewed. Overall survival was calculated using the Kaplan–Meier method and compared through the Log rank test. The oligometastasis group included patients with less than five foci of tumors, while the extensive metastasis group presented five or more sites.

Results

The incidence of SBM from HCC was 1.5% (58/3793 patients), commonly found in the middle cranial fossa. SBM associated symptoms presented in 51 patients, and the most common were head and neck area pain, and orbital symptoms, The palliation rate after RT was 65% (24/39 patients) for overall symptoms and 83.3% (20/24 patients) for cranial nerve symptoms. In whole cohort, overall survival was analyzed, and the median overall survival of patients with oligometastasis was better than extensive metastasis (23.7 months vs 1.8 months, p < 0.001). In subgroup who received RT (39 patients), the median overall survival was 23.7 and 2.7 months for patients with oligo and extensive metastasis, respectively (p < 0.001).

Conclusion

This study confirmed clinical features of SBM from HCC. Overall survival was generally poor, but patients presenting oligometastasis seemed to have possibility of relative long-term survival. Although radiation was effective in SBM-induced symptom relief, dose–response relationship in local control rate and overall survival needs further studies with larger number of patients.

Sphingosine-1-phosphate transporter spinster homolog 2 is essential for iron-regulated metastasis of hepatocellular carcinoma

Iron dyshomeostasis is associated with hepatocellular carcinoma (HCC) development. However, the role of iron in HCC metastasis is unknown. This study aimed to elucidate the underlying mechanisms of iron's enhancement activity on HCC metastasis. In addition to the HCC cell lines and clinical samples in vitro, iron-deficient (ID) mouse models were generated using iron-free diet and transferrin receptor protein knockout, followed by administration of HCC tumors through either orthotopic or ectopic route. Clinical metastatic HCC samples showed significant ID status, accompanied by overexpression of sphingosine-1-phosphate transporter spinster homolog 2 (SPNS2). Mechanistically, ID increased SPNS2 expression, leading to HCC metastasis in both cell cultures and mouse models. ID not only altered the anti-tumor immunity, which was indicated by phenotypes of lymphatic subsets in the liver and lung of tumor-bearing mice, but also promoted HCC metastasis in a cancer cell autonomous manner through the SPNS2. Since germline knockout of globe SPNS2 showed significantly reduced HCC metastasis, we further developed hepatic-targeting recombinant adeno-associated virus vectors to knockdown SPNS2 expression and to inhibit iron-regulated HCC metastasis. Our observation indicates the role of iron in HCC pulmonary metastasis and suggests SPNS2 as a potential therapeutic target for the prevention of HCC pulmonary metastasis.

Advancing Treatment of Bone Metastases through Novel Translational Approaches Targeting the Bone Microenvironment

Bone metastases represent a lethal condition that frequently occurs in solid tumors such as prostate, breast, lung, and renal cell carcinomas, and increase the risk of skeletal-related events (SREs) including pain, pathologic fractures, and spinal cord compression. This unique metastatic niche consists of a multicellular complex that cancer cells co-opt to engender bone remodeling, immune suppression, and stromal-mediated therapeutic resistance. This review comprehensively discusses clinical challenges of bone metastases, novel preclinical models of the bone and bone marrow microenviroment, and crucial signaling pathways active in bone homeostasis and metastatic niche. These studies establish the context to summarize the current state of investigational agents targeting BM, and approaches to improve BM-targeting therapies. Finally, we discuss opportunities to advance research in bone and bone marrow microenvironments by increasing complexity of humanized preclinical models and fostering interdisciplinary collaborations to translational research in this challenging metastatic niche.

The homogeneity and heterogeneity of occurrence, characteristics, and prognosis in hepatocellular carcinoma patients with synchronous and metachronous bone metastasis

Purpose: Based on the one of the largest hepatocellular carcinoma (HCC) population with bone metastasis (BM) from the single center in Tianjin, China, the present study aimed to investigate the risk and survival of synchronous bone metastasis (sBM) and metachronous bone metastasis (mBM) in HCC, and to reveal characteristics and related factors of HCC patients with bone metastasis.

Methods: HCC patients with bone metastasis between 2009 and 2017 from Tianjin Medical University Cancer Institute & Hospital, Tianjin, China, were involved. Chi-square test/ Fisher's exact test and Logistic regression were used to estimate the risk factors of bone metastasis in HCC. Kaplan-Meier method was used to estimate the survival of HCC patients, and the Log-rank test was used to analyze the survival of HCC patients. The prognostic factors of HCC patients with BM were identified via Kaplan-Meier method and multivariable COX regression model.

Results: Among 4421 HCC patients, 128 patients with BM were identified. Of the 128 patients with BM, 77 patients (60.16%) were with sBM and 51 patients (39.84%) were with mBM. The incidence of sBM in HCC was 1.74% at initial diagnosis. The most common metastatic site of sBM was rib, followed by lumbar, thoracic, and sacral. The median latency time from HCC diagnosis to mBM was six months. The most common site of mBM was thoracic, followed by lumbar, sacral and rib. Alcohol-drinking history (P=0.027), numbers (P=0.023) and size (P=0.008) of intrahepatic tumor, lymph node metastasis (P<0.001), serum ALP (P=0.004) and HGB (P=0.004) level were found to be correlated with the occurrence of BM. The overall survival between non-BM and BM were statistically different (P=0.028).

Conclusion: The incidence of sBM in HCC was 1.74% at initial diagnosis. The median latency time from HCC diagnosis to mBM was 6 months. The characteristics between occurrence and prognosis showed significant difference between sBM and mBM. Early identification of high-risk BM population was essential for the improvement of both quality of life and prognosis. The revealed related factors can potentially guide sBM and mBM identification and early diagnosis in HCC.

Lung and lymph node metastases from hepatocellular carcinoma: Comparison of pathological aspects

BACKGROUND & AIMS

Extrahepatic metastasis from hepatocellular carcinoma (HCC) is a catastrophic event, yet organ-specific pathological characteristics of metastatic HCC remain unclear. We aimed to characterize the pathological aspects of HCC metastases to various organs.

METHODS

We collected intrahepatic HCC (cohort 1, n = 322) and extrahepatic metastatic HCC (cohort 2, n = 130) samples. Clinicopathological evaluation and immunostaining for K19, CD34, αSMA, fibroblast-associated protein (FAP), CAIX, VEGF, PD-L1, CD3, CD8, Foxp3, CD163 and epithelial-mesenchymal transition (EMT)-related markers were performed.

RESULTS

Independent factors for extrahepatic metastasis included BCLC stage B-C, microvascular invasion (MVI), vessels encapsulating tumour clusters (VETC)-HCC, K19 and FAP expression, and CD163+ macrophage infiltration (cohort 1, P < .05 for all). Lung metastases (n = 63) had the highest proportion of VETC-HCC and macrotrabecular-massive (MTM)-HCC. Lymph node metastases (n = 19) showed significantly high rates of EMT-high features, K19 expression, fibrous tumour stroma with αSMA and FAP expression, high immune cell infiltration, PD-L1 expression (combined positive score), CD3+, CD8+, Foxp3+ T cell and CD163+ macrophage infiltration (adjusted P < .05 for all). In both cohorts, EMT-high HCCs showed higher rates of K19 expression, fibrous tumour stroma, high immune cell infiltration, PD-L1 expression and CD3+ T cell infiltration, whereas EMT-low HCCs were more frequent among VETC-HCCs (P < .05 for all). Overall phenotypic features were not significantly different between paired primary-metastatic HCCs (n = 32).

CONCLUSIONS

Metastatic HCCs to various organs showed different pathological features. VETC and MTM subtypes were related to lung metastasis, whereas K19 expression, EMT-high features with fibrous tumour stroma and high immune cell infiltration were related to lymph node metastasis.

Multimodal Imaging-Based Potential Visualization of the Tumor Microenvironment in Bone Metastasis

Bone metastasis (BM) is the most common malignant bone tumor and a significant cause of morbidity and mortality for patients with cancer. Compared to other metastatic organs, bone has unique characteristics in terms of the tumor microenvironment (TME). Precise assessments of the TME in BM could be an important step for developing an optimized management plan for patient care. Imaging approaches for BM have several advantages, such as biopsy not being required, multiple site evaluation, and serial assessment in the same sites. Owing to the developments of new imaging tracers or imaging modalities, bone TME could be visualized using multimodal imaging techniques. In this review, we describe the BM pathophysiology, diagnostic principles of major imaging modalities, and clinically available imaging modalities to visualize the TME in BM. We also discuss how the interactions between various factors affecting the TME could be visualized using multimodal imaging techniques.

Exosomal tumor necrosis factor-α from hepatocellular cancer cells (Huh-7) promote osteoclast differentiation

Bone is the common extra-hepatic site for cancer metastasis. Hepatic cancer is associated with a higher incidence of pathological fracture. However, this important regulatory mechanism remains unexplored. Thus, exosome-mediated cell-cell communication between hepatocellular cancer and bone might be key to osteolytic bone destruction. Huh-7 exosomes were characterized for size and exosome marker expressions (CD63, Alix). Exosome mediated osteoclast differentiation in the RAW 264.7 cells was monitored from day 1 to 6 and multinucleated osteoclast formation and bone resorption activity were analyzed. The osteoclastogenic factor expressions in the exosomes and osteoclast differentiation markers such as tumor necrosis factor receptor 6 (TRAF6), nuclear factor κB (NF-κB), nuclear factor of activated T-cells, cytoplasmic 1 (NFATc1), and cathepsin K (CTSK) were analyzed using western blot. Exosomes released by liver cancer cells (Huh-7) promoted osteoclast differentiation in RAW 264.7 cells. Analysis of osteoclastogenic factors in the exosomes showed that exosomes were specifically enriched with tumor necrosis factor α (TNF-α). Huh-7 exosomes promoted osteoclast differentiation by significantly increasing the number of TRAP-positive multi nucleated osteoclasts and resorption pits. Importantly, exosomes upregulated osteoclast markers TRAF6, NF-κB, and CTSK expressions. Further, neutralizing exosomal TNF-α reverted exosome-mediated osteoclast differentiation in RAW 264.7 cells. Collectively, our findings show that cellular communication of exosomal TNF-α from hepatocellular cancer cells (Huh-7) regulates osteoclast differentiation through NF-κB/CTSK/TRAP expressions. Thus, exosomal TNF-α might act as an important therapeutic target to prevent hepatocellular cancer mediated pathological bone disease.

Spinal Cord Compression as Initial Presentation in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy and aggressive neoplasms with high metastatic potential to the lung, regional lymph nodes, and bone. Metastatic spinal cord compression due to HCC is a rare, unusual initial presentation and is a neurosurgical emergency. We present two cases of HCC where spinal cord compression was the initial presentation before the diagnosis of HCC. Our first patient presented with bilateral flank pain. The biopsy of the chest wall showed HCC. However, a CT scan of the abdomen showed metastatic involvement of the T11 vertebra. He was found to have severe spinal canal stenosis on MRI of the back without neurological deficit. He underwent an emergent tumor decompression of the T11 vertebra with kyphoplasty. Our second patient was a young man who presented with cord compression symptoms, which included bilateral leg weakness and an inability to void. An urgent laminectomy with decompression of the lumbar spine was performed. He received radiotherapy for spinal metastasis and started systemic therapy for HCC. Unfortunately, he failed multiple lines of systemic therapy, and the progression of the disease complicated his clinical course with spinal cord compression for the second time.

H19 Promotes HCC Bone Metastasis Through Reducing Osteoprotegerin Expression in a Protein Phosphatase 1 Catalytic Subunit Alpha/p38 Mitogen-Activated Protein Kinase-Dependent Manner and Sponging microRNA 200b-3p

BACKGROUND AND AIMS

Bone is the second most frequent site of metastasis for HCC, which leads to an extremely poor prognosis. HCC bone metastasis is typically osteolytic, involving the activation of osteoclasts. Long noncoding RNA H19 plays an important role in the pathogenesis of human cancers. Nonetheless, the mechanism underlying the participation of H19 in HCC bone metastasis remains unclear.

APPROACH AND RESULTS

The current study established a mouse HCC bone metastasis model by using serial intracardiac injection and cell isolation to obtain cells with distinct bone metastasis ability. H19 was highly expressed in these cells and in clinical HCC bone metastasis specimens. Both osteoclastogenesis in vitro and HCC bone metastasis in vivo were promoted by H19 overexpression, whereas these processes were suppressed by H19 knockdown. H19 overexpression attenuated p38 phosphorylation and further down-regulated the expression of osteoprotegerin (OPG), also known as osteoclastogenesis inhibitory factor. However, up-regulated OPG expression as well as suppressed osteoclastogenesis caused by H19 knockdown were recovered by p38 interference, indicating that p38 mitogen-activated protein kinase (MAPK)-OPG contributed to H19-promoted HCC bone metastasis. Furthermore, we demonstrated that H19 inhibited the expression of OPG by binding with protein phosphatase 1 catalytic subunit alpha (PPP1CA), which dephosphorylates p38. SB-203580-mediated inactivation of p38MAPK reversed the down-regulation of HCC bone metastasis caused by H19 knockdown in vivo. Additionally, H19 enhanced cell migration and invasion by up-regulating zinc finger E-box binding homeobox 1 through the sequestration of microRNA (miR) 200b-3p.

CONCLUSIONS

H19 plays a critical role in HCC bone metastasis by reducing OPG expression, which is mediated by the PPP1CA-induced inactivation of the p38MAPK pathway; and H19 also functions as a sponge for miR-200b-3p.

Diffusion-weighted and dynamic contrast-enhanced magnetic resonance imaging after radiation therapy for bone metastases in patients with hepatocellular carcinoma

The objectives of this study were to assess changes in apparent diffusion coefficient (ADC) and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) parameters after radiation therapy (RT) for bone metastases from hepatocellular carcinoma (HCC) and to evaluate their prognostic value. This prospective study was approved by the Institutional Review Board. Fourteen patients with HCC underwent RT (30 Gy in 10 fractions once daily) for bone metastases. The ADC and DCE-MRI parameters and the volume of the target lesions were measured before (baseline) and one month after RT (post-RT). The Wilcoxon signed-rank test was used to compare the parameters between the baseline and post-RT MRI. The parameters were compared between patients with or without disease progression in RT fields using the Mann–Whitney test. Intraclass correlation coefficients were used to evaluate the interobserver agreement. The medians of the ADC, rate constant [k_ep], and volume fraction of the extravascular extracellular matrix [v_e] in the baseline and post-RT MRI were 0.67 (range 0.61–0.72) and 0.75 (range 0.63–1.43) (× 10^–3 mm²/s) (P = 0.027), 836.33 (range 301.41–1082.32) and 335.80 (range 21.86–741.87) (× 10^–3/min) (P = 0.002), and 161.54 (range 128.38–410.13) and 273.99 (range 181.39–1216.95) (× 10^–3) (P = 0.027), respectively. The medians of the percent change in the ADC of post-RT MRI in patients with progressive disease and patients without progressive disease were − 1.35 (range − 6.16 to 6.79) and + 46.71 (range 7.71–112.81) (%) (P = 0.011), respectively. The interobserver agreements for all MRI parameters were excellent (intraclass correlation coefficients > 0.8). In conclusion, the ADC, k_ep, and v_e of bone metastases changed significantly after RT. The percentage change in the ADC was closely related to local tumor progression.

Serum lnc34a is a potential prediction biomarker for bone metastasis in hepatocellular carcinoma patients

Background

Early screening and intervention therapies are crucial to improve the prognosis of hepatocellular carcinoma (HCC) patients with bone metastasis. We aimed to identify serum lncRNA as a prediction biomarker in HCC bone metastasis.

Methods

The expression levels of lnc34a in serum samples from 157 HCC patients were detected by quantitative real-time polymerase chain reaction (PCR). Univariate analysis and multivariate analysis were performed to determine statistically significant variables.

Results

Expression levels of lnc34a in serum from HCC patients with bone metastasis were significantly higher than those without bone metastasis. The high expressions of lnc34a, vascular invasion and Barcelona Clinic Liver Cancer (BCLC) stage were associated with bone metastasis by analysis. Moreover, lnc34a expression was specifically associated with bone metastasis rather than lung or lymph node metastasis in HCC.

Conclusions

High serum lnc34a expression was a independent risk factor for developing bone metastasis in HCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07808-6.

LncZEB1-AS1 regulates hepatocellular carcinoma bone metastasis via regulation of the miR-302b-EGFR-PI3K-AKT axis

In patients with hepatocellular carcinoma (HCC), disease progression and associated bone metastasis (BM) can markedly reduce quality of life. While the long non-coding RNA (lncRNA) zinc finger E-box binding homeobox 1 antisense 1 (ZEB1-AS1) has been shown to function as a key regulator of oncogenic processes in HCC and other tumor types, whether it plays a role in controlling HCC BM remains to be established. In the current study, we detected the significant upregulation of lncZEB1-AS1 in HCC tissues, and we found this expression to be associated with BM progression. When we knocked down this lncRNA in HCC cells, we found that this significantly reduced their migratory, invasive, and metastatic activity both in vitro and in vivo. At a mechanistic level, we found that lncZEB1-AS1 was able to target miR-302b and to thereby increase PI3K-AKT pathway activation and EGFR expression, resulting in the enhanced expression of downstream matrix metalloproteinase genes in HCC cells. In summary, our results provide novel evidence that lncZEB1-AS1 can promote HCC BM through a mechanism dependent upon the activation of PI3K-AKT signaling, thus highlighting a potentially novel therapeutic avenue for the treatment of such metastatic progression in HCC patients.

ADAM17-regulated CX3CL1 expression produced by bone marrow endothelial cells promotes spinal metastasis from hepatocellular carcinoma

Spinal metastasis occurs in 50-75% of bone metastases caused by hepatocellular carcinoma (HCC), and HCC-derived spinal metastasis can lead to a less favorable prognosis. Recently, several studies have demonstrated that C-X3-C motif chemokine ligand 1 (CX3CL1) is closely associated with cancer metastasis, and its secretion is modulated by a disintegrin and metalloproteinase 17 (ADAM17). Bone marrow endothelial cells (BMECs) are an essential component of bone marrow. However, little is known about the roles in and effects of BMECs on HCC spinal metastasis. The present study demonstrated that CX3CL1 and C-X-C motif chemokine receptor 3 (CXCR3) expression was upregulated in HCC spinal metastases, and that CX3CL1 promoted the migration and invasion of HCC cells to the spine. Western blot analysis revealed that the Src/protein tyrosine kinase 2 (PTK2) axis participated in CX3CL1-induced HCC cell invasion and migration. CX3CL1 also increased the expression of M2 macrophage markers in THP-1 monocytes. BMECs promoted the migration and invasion of Hep3B and MHCC97H cells by secreting soluble CX3CL1, whereas the neutralization of CX3CL1 inhibited this enhancement. CX3CL1 enhanced the activation of the phosphatidylinositol-4,5-bisphos-phate 3-kinase catalytic subunit alpha (PIK3CA)/AKT serine/threonine kinase 1 (AKT1) and Ras homolog family member A (RHOA)/Rho associated coiled-coil containing protein kinase 2 (ROCK2) signaling pathways through the Src/PTK2 signaling pathway. Furthermore, ADAM17 was activated by mitogen-activated protein kinase (MAPK) z14 in BMECs and significantly promoted the secretion of CX3CL1. HCC cells enhanced the recruitment and proliferation of BMECs. The overexpression of CX3CR1 facilitated the spinal metastasis of HCC in a mouse model in vivo. In addition, in vivo experiments revealed that BMECs promoted the growth of HCC in the spine. The present study demonstrated that CX3CL1 participates in HCC spinal metastasis, and that BMECs play an important role in the regulation of CX3CL1 in the spinal metastatic environment.

Bone metastasis as primary presentation of pancreatic ductal adenocarcinoma: A case report and literature review

PDAC bone metastases represent a clinical challenge characterized by multifaceted biological entity.

The molecular mechanism of LncRNA34a-mediated regulation of bone metastasis in hepatocellular carcinoma

Background

Bone metastasis (BM) has long been recognized as a major threat to the quality of life of hepatocellular cancer (HCC) patients. While LncRNA34a (Lnc34a) has been shown to regulate colon cancer stem cell asymmetric division, its effect on HCC BM remains unknown.

Methods

In situ hybridization and quantitative real-time polymerase chain reaction (qRT-PCR) were used to detect the expression of Lnc34a in HCC tissues and cell lines. Ventricle injection model was constructed to explore the effect of Lnc34a on BM in vivo. The methylation of miR-34a promoter and histones deacetylation were examined by using bisulfate-sequencing PCR and chromatin immunoprecipitation assays. RNA pull down and RNA immunoprecipitation were performed to investigated the interaction between Lnc34a and epigenetic regulators. Dual-luciferase reporter assay was conducted to find miR-34a target. The involvement of TGF-β pathway in the BM from HCC was determined by qRT-PCR, western, and elisa assays.

Results

We found that Lnc34a was significantly overexpressed in HCC tissues and associated with BM. Both in vitro and in vivo experiments indicate that the restoration or knockdown of Lnc34a expression in HCC cells had a marked effect on cellular migration, invasion, and metastasis. Mechanistic analyses suggested that Lnc34a epigenetically suppresses miR-34a expression through recruiting DNMT3a via PHB2 to methylate miR-34a promoter and HDAC1 to promote histones deacetylation. On the other hand, miR-34a targets Smad4 via the TGF-β pathway, followed by altering the transcription of the downstream genes (i.e., CTGF and IL-11) that are associated with BM.

Conclusions

Our study is the first to document the pro-bone metastatic role of Lnc34a in BM of HCC and reveal a novel mechanism for the activation of the TGF-β signaling pathway in HCC BM, providing evidence of a potential therapeutic strategy in HCC BM.

Electronic supplementary material

The online version of this article (10.1186/s12943-019-1044-9) contains supplementary material, which is available to authorized users.

A randomized trial of conventional fraction versus hypofraction radiotherapy for bone metastases from hepatocellular carcinoma

External beam radiotherapy (EBRT) has been reported to be effective in palliating painful bone metastases, but the optimal fractions and doses for treating bone metastases from hepatocelluar carcinoma (HCC) are not established. This study aimed to compare toxicity and efficacy for conventional fraction versus hypofraction schedules. From January 2009 through December 2014, 183 patients with HCC bone metastases were randomly assigned to conventional fraction EBRT (Group A) or hypofraction radiotherapy (Group B). Study outcomes were pain relief, response rate and duration, overall survival, and toxicity incidence. Median follow-up time was 9.3 months. Response times were 6.7 ± 3.3 fractions in Group A and 4.1 ± 1.2 fractions in Group B (p <0.001). Pain relief rates were 96.7% and 91.2% in Group A and B, respectively (p=0.116). Time to treatment failure for Group A was significantly longer than Group B (p=0.025). Median overall survival was similar between two groups (p=0.628). Toxicity incidence in both groups was minimal, with no significant differences observed.

In conclusion, hypofractionated radiotherapy is safe for patients with HCC bone metastases and may achieve earlier pain relief compared to conventional radiotherapy. This protocol should be considered for patients with shorter predicted survival times.

Value of Bone Scans in Work-up of Patients With Hepatocellular Carcinoma for Liver Transplant

Background

The purpose of this study was to review the value of bone scans (BS) in the assessment of bone metastases from early-stage hepatocellular carcinoma (HCC) in patients assessed or waiting for liver transplant (LTx).

Methods

We reviewed BS studies performed at our center for patients with early-stage HCC either being assessed for LTx, or on the waiting list for LTx, from January 2010 to May 2017. The BS findings were classified as positive, equivocal, or negative. Correlation with final outcome based on clinical and radiological follow-up was performed.

Results

There were 360 BS performed in 186 patients during the study period with a mean age of 58.7 years (range, 34.9-70.4 years) and most were male patients (161/186 [86.6%]). None of the BSs resulted in delisting of patients from the LTx waiting list. Three BSs were reported as positive for metastases. All 3 were proven to be false positives on follow-up. Fourteen studies reported equivocal findings, none of which were confirmed to be metastases on follow-up. There was 1 false-negative BS: a bone metastasis was detected incidentally on magnetic resonance imaging and proven on biopsy.

Conclusions

We have demonstrated that the diagnostic yield of BS in early HCC patients who are candidates for LTx is minimal, challenging the current inclusion of BS in guidelines for staging these HCC patients.

Profile of Surgically-treated Metastatic Extremity Bone Tumours at a University Hospital in Hong Kong

Background/Purpose

Metastatic deposits in bones increase overall morbidity in cancer patients. The orthopaedic oncologist aims at controlling the skeletal morbidity as a way of reducing the overall morbidity in the survival period of the cancer patient. This study investigated the characteristics of metastatic extremity bone tumours requiring surgical treatment, with a view to setting a template for a local database of extremity metastatic bone tumours in Hong Kong.

Methods

A retrospective review of metastatic extremity bone tumours treated surgically at a university hospital in Hong Kong, from January 2006 to December 2015, is presented.

Results

In total, 126 patients were studied. The lung (28.6%) was the most common source of metastasis to the extremity bones. The femur (70.1%) was most commonly involved. Pathological fractures (47.4%) were the most common indications for surgery. Intramedullary nailing (57.3%) was the most common surgical treatment. The overall postoperative complication rate was 8.7%. The mean duration of follow-up was 10.8 ± 4.1 months. Furthermore, 79.4% of the patients died within the study period, with mean duration of postoperative survival of 6.1 ± 1.1 months. Spinal compression ( p = 0.001), indication for surgery ( p = 0.001), age of the patient ( p = 0.001), and option of surgical treatment ( p = 0.000319) were found to have significantly affected the duration of postoperative survival.

Conclusion

The surgical management of extremity bone metastasis is a key consideration in averting potentially crippling morbidity. Options of treatment need be carefully chosen in appropriate patients for a good outcome.

Outcomes of metastatic spinal cord compression secondary to primary hepatocellular carcinoma with multidisciplinary treatments

Few studies have reported progression-free survival (PFS) and overall survival (OS) of Metastatic spinal cord compression (MSCC) patients with primary hepatocellular carcinoma (HCC) following surgery and adjuvant therapies. Enrolled in this study were 155 MSCC patients with primary HCC who received surgery and adjuvant therapies between 2000 and 2015. Kaplan-Meier methods and Cox’s proportional hazards regression mode were performed to investigate the clinical features and prognostic factors affecting PFS and OS. The median PFS and OS was 7.0 months and 9.7 months, respectively. 92.9% patients responded well to surgery according to the Visual Analogue Scale, Frankel Score and postoperative complication occurrences. 68 (43.9%) patients who received circumferential decompression achieved better PFS than the remaining 87 (56.1%) patients who received laminectomy. Favorable outcomes were achieved after surgery during the perioperative period. Circumferential decompression was associated with better PFS than laminectomy. The postoperative Frankel Score E, Eastern Cooperative Oncology Group performance score of 1 or 2, no visceral metastasis, administration of postoperative radiation and the use of Sorafenib were found to be significant predictors of better PFS and OS. Patients who previously underwent resection of primary HCC with/without liver transplantation tended to have a better OS.

Scapular metastasis of hepatocellular carcinoma presenting as acute bleeding and hematoma: A case report of safe and effective treatment

RATIONALE

The occurrence of bleeding and hematoma from bone metastasis of hepatocellular carcinoma (HCC) is extremely rare.

PATIENT CONCERNS

We present a case of scapular metastasis of HCC in a 69-year-old man who presented with acute bleeding and hematoma.

DIAGNOSES

Chest computed tomography showed a large hematoma within the right pectoral muscle of the right upper chest and an exophytic metastatic mass in the right scapula with bony destruction, which caused the intramuscular hematoma. The final diagnosis was scapular metastasis of HCC presenting as acute bleeding and hematoma.

INTERVENTIONS

Selective right subclavian angiography showed a hypervascular metastatic lesion in the right scapula. Subsequently, embolization of the tumoral feeding artery using a microcoil was performed and tumoral bleeding was stopped.

OUTCOMES

The patient was discharged on hospital day 14 without any complications.

LESSONS

Despite being extremely rare, the possibility of bleeding from bone metastasis of HCC needs to be considered. Transcatheter arterial embolization may be an effective means to treat bleeding from bone metastasis of HCC.

High-dose radiotherapy is associated with better local control of bone metastasis from hepatocellular carcinoma

We evaluated the pain and radiologic response, time to progression, and dose-response relationship after palliative radiotherapy for bone metastasis from hepatocellular carcinoma. We retrospectively reviewed the medical records of 91 patients between January 2004 and August 2012. The reviewed medical records included data on changes in pain, local tumor progression, and radiologic response evaluated via follow-up images. The radiologic response was assessed based on the Response Evaluation Criteria In Solid Tumors. The pain response was defined according to the International Bone Metastases Consensus Working Party palliative radiotherapy endpoints. Median radiation dose was 40 Gy (range, 20-66 Gy), with various fraction sizes (range, 2.0-6.0 Gy). Pain response rate was 81.4%. During the follow-up periods, radiologic local tumor progression was found in 42 patients (46.2%). The median time to progression was 14.1 months. When the patients were divided into two groups according to their radiation dose (< 55 Gy10 vs. ≥ 55 Gy10), the pain response rates of the high- and low-dose groups did not differ significantly (p = 0.728). However, the radiologic response rate and the time to progression showed significant differences between the two groups (p = 0.009 and p = 0.018, respectively). With dose escalation, higher radiologic response rates and a longer time to progression were achieved in patients with mass-forming bone metastases from hepatocellular carcinoma.

Bone Metastases of Hepatocellular Carcinoma: Appearance on MRI Using a Standard Abdominal Protocol

OBJECTIVE

The purpose of this study is to describe the MRI features of hepatocellular carcinoma (HCC) bone metastases.

MATERIALS AND METHODS

Thirty-three consecutive patients were included. Two radiologists performed qualitative and quantitative analysis. The coordinator searched for clinical and epidemiologic features related to patients and their primary liver tumors. Earlier MRI studies were also reviewed to determine whether bone metastases were already present and prospectively identified. Descriptive statistics and the Lin concordance correlation coefficient were used.

RESULTS

Chronic hepatitis C virus infection was the most common cause of liver disease (20/32; 62.5%), and diffuse and multifocal HCC were the most frequent types of liver HCCs (28/33; 84.8%). Most lesions were located at the spine (109/155; 70.3%), with high signal intensity on fat-suppressed T1-weighted (54/62; 87.1%) and T2-weighted (53/62; 85.5%) images. Bone metastases were predominantly nodular (48/62; 77.4%), confined to the vertebral body (40/60; 66.7%), and best visualized at the arterial phase (40/62; 64.5%). The ring pattern of enhancement was present in 23 of 62 lesions, and the remaining lesions showed diffuse enhancement. Thirty-five of 62 (56.4%) bone metastases showed arterial peak of enhancement. In 13 of 33 (39.9%) patients, bone metastases were not prospectively reported.

CONCLUSION

Most patients with bone metastases had chronic hepatitis C virus infection and diffuse or multifocal HCC. Metastases are most commonly appreciated as hypervascular focal moderately intensely enhancing nodular masses on the hepatic arterial dominant phase images, with concomitant moderately high signal intensity on fat-suppressed T1- and T2-weighted images.

ESC reverses epithelial mesenchymal transition induced by transforming growth factor-β via inhibition of Smad signal pathway in HepG2 liver cancer cells

Background

Epithelial mesenchymal transition (EMT) mediated by TGF-β pays an important role in malignant tumor acquired abilities of migration and invasion. Our previous study showed that the extract of Stellera chamaejasme L. (ESC) was against proliferation of a variety of tumor cells, but there were no studies in the effects of ESC on EMT in tumor cells. In this study, TGF-β was adopted to induce EMT in HepG2 cells and the influence of ESC on EMT was observed.

Methods

MTT assay was used to observe the cell viability. Wound healing assay and transwell assay were used to observe the migration and invasion activities. Western blot and immunofluorescence methods were used to observe the expression of proteins.

Results

We found that HepG2 cells induced by TGF-β showed mesenchymal morphology, down-regulation of epithelial marker E-cadherin and up-regulation of mesenchymal marker Vimentin, indicating that TGF-β could mediate epithelial mesenchymal induction in HepG2 cells. ESC could reverse the mesenchymal morphology and regulate expressions of marker proteins in HepG2 induced by TGF-β and significantly inhibit TGF-β induced HepG2 cell migration and invasion. We further found that ESC could also significantly depress Smad2 phosphorylation and nuclear translocation, and ESC had coordination with SB432542, a specific inhibitor of TβRI kinases.

Conclusions

These results suggested that the ESC could reverse epithelial mesenchymal transition induced by TGF-β via inhibition Smad2 signaling pathway.

Imaging of bone metastasis: An update

Early detection of skeletal metastasis is critical for accurate staging and optimal treatment. This paper briefly reviews our current understanding of the biological mechanisms through which tumours metastasise to bone and describes the available imaging methods to diagnose bone metastasis and monitor response to treatment. Among the various imaging modalities currently available for imaging skeletal metastasis, hybrid techniques which fuse morphological and functional data are the most sensitive and specific, and positron emission tomography (PET)/computed tomography and PET/magnetic resonance imaging will almost certainly continue to evolve and become increasingly important in this regard.

Palliative external-beam radiotherapy for bone metastases from hepatocellular carcinoma

The incidence of bone metastases (BMs) from hepatocellular carcinoma (HCC) is relatively low compared to those of other cancers, but it has increased recently, especially in Asian countries. Typically, BMs from HCC appear radiologically as osteolytic, destructive, and expansive components with large, bulky soft-tissue masses. These soft-tissue masses are unique to bone metastases from HCC and often replace the normal bone matrix and exhibit expansive growth. They often compress the peripheral nerves, spinal cord, or cranial nerves, causing not only bone pain but also neuropathic pain and neurological symptoms. In patients with spinal BMs, the consequent metastatic spinal cord compression (MSCC) causes paralysis. Skull base metastases (SBMs) with cranial nerve involvement can cause neurological symptoms. Therefore, patients with bony lesions often suffer from pain or neurological symptoms that have a severe, adverse effect on the quality of life. External-beam radiotherapy (EBRT) can effectively relieve bone pain and neurological symptoms caused by BMs. However, EBRT is not yet widely used for the palliative management of BMs from HCC because of the limited number of relevant studies. Furthermore, the optimal dosing schedule remains unclear, despite clinical evidence to support single-fraction radiation schedules for primary cancers. In this review, we outline data describing palliative EBRT for BMs from HCC in the context of (1) bone pain; (2) MSCC; and (3) SBMs.

Natural history of malignant bone disease in hepatocellular carcinoma: final results of a multicenter bone metastasis survey

Background

Bone is an uncommon site of metastasis in patients with advanced hepatocellular carcinoma (HCC). Therefore, there are few studies concerning the natural history of bone metastasis in patients with HCC.

Patients and Methods

Data on clinicopathology, survival, skeletal-related events (SREs), and bone-directed therapies for 211 deceased HCC patients with evidence of bone metastasis were statistically analyzed.

Results

The median age was 70 years; 172 patients were male (81.5%). The median overall survival was 19 months. The median time to the onset of bone metastasis was 13 months (22.2% at HCC diagnosis); 64.9% patients had multiple bone metastases. Spine was the most common site of bone metastasis (59.7%). Most of these lesions were osteolytic (82.4%); 88.5% of them were treated with zoledronic acid. At multivariate analysis, only the Child Score was significantly correlated with a shorter time to diagnosis of bone metastases (p = 0.001, HR = 1.819). The median survival from bone metastasis was 7 months. At multivariate analysis, HCC etiology (p = 0.005), ECOG performance status (p = 0.002) and treatment with bisphosphonate (p = 0.024) were associated with shorter survival after bone disease occurrence. The site of bone metastasis but not the number of bone lesions was associated with the survival from first skeletal related event (SRE) (p = 0.021) and OS (p = 0.001).

Conclusions

This study provides a significant improvement in the understanding the natural history of skeletal disease in HCC patients. An early and appropriate management of these patients is dramatically needed in order to avoid subsequent worsening of their quality of life.