Glypican-3 expression distinguishes small hepatocellular carcinomas from cirrhosis, dysplastic nodules, and focal nodular hyperplasia-like nodules

Peptide Binder to Glypican-3 as a Theranostic Agent for Hepatocellular Carcinoma

Glypican-3 (GPC3) is a membrane-associated glycoprotein that is significantly upregulated in hepatocellular carcinomas (HCC) with minimal to no expression in normal tissues. The differential expression of GPC3 between tumor and normal tissues provides an opportunity for targeted radiopharmaceutical therapy to treat HCC, a leading cause of cancer-related deaths worldwide. Methods: DOTA-RYZ-GPC3 (RAYZ-8009) comprises a novel macrocyclic peptide binder to GPC3, a linker, and a chelator that can be complexed with different radioisotopes. The binding affinity was determined by surface plasma resonance and radioligand binding assays. Target-mediated cellular internalization was radiometrically measured at multiple time points. In vivo biodistribution, monotherapy, and combination treatments with 177Lu or 225Ac were performed on HCC xenografts. Results: RAYZ-8009 showed high binding affinity to GPC3 protein of human, mouse, canine, and cynomolgus monkey origins and no binding to other glypican family members. Potent cellular binding was confirmed in GPC3-positive HepG2 cells and was not affected by isotope switching. RAYZ-8009 achieved efficient internalization on binding to HepG2 cells. Biodistribution study of 177Lu-RAYZ-8009 showed sustained tumor uptake and fast renal clearance, with minimal or no uptake in other normal tissues. Tumor-specific uptake was also demonstrated in orthotopic HCC tumors, with no uptake in surrounding liver tissue. Therapeutically, significant and durable tumor regression and survival benefit were achieved with 177Lu- and 225Ac-labeled RAYZ-8009, as single agents and in combination with lenvatinib, in GPC3-positive HCC xenografts. Conclusion: Preclinical in vitro and in vivo data demonstrate the potential of RAYZ-8009 as a theranostic agent for the treatment of patients with GPC3-positive HCC.

Hepatic Precancerous Lesions and Early Hepatocellular Carcinoma

This review discusses the diagnostic challenges of diagnosing and treating precursor lesions of hepatocellular carcinoma (HCC) in both cirrhotic and non-cirrhotic livers. The distinction of high-grade dysplastic nodule (the primary precursor lesion in cirrhotic liver) from early HCC is emphasized based on morphologic, immunohistochemical, and genomic features. The risk factors associated with HCC in hepatocellular adenomas (precursor lesion in non-cirrhotic liver) are delineated, and the risk in different subtypes is discussed with emphasis on terminology, diagnosis, and genomic features.

GPC3 gene expression and allelic discrimination of FZD7 gene in Egyptian patients with hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide, and especially in Egypt. Early diagnosis of HCC greatly improves the survival and prognosis of patients. Low sensitivity and specificity of alpha-fetoprotein (AFP) has led to the demand for novel biomarkers of HCC. The aim of the present study was to evaluate the validity of frizzled-7 (FZD7) and glypican-3 (GPC3) gene expression as potential biomarkers for HCC early diagnosis, and to investigate the association between FZD7 rs2280509 polymorphism and HCC risk.

Materials and methods

Quantification of FZD7 and GPC3 gene expression by real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) assay, and genotyping FZD 7 (rs2280509 SNP) gene polymorphism using RT-PCR.

Results

The current results revealed that FZD7 gene expression had a greater area under the curve (AUC) for identifying HCC than GPC3 gene expression and AFP levels. The combination of the three markers as a panel showed a better diagnostic performance with a greater AUC than any of the single markers alone (p < 0.05). The FZD7 rs2280509 polymorphism (CT) was found to be significantly associated with an increased risk of HCC. The CT genotype and T allele were significantly more prevalent in the HCC group compared to either the cirrhosis (p = 0.03) or control groups (p = 0.0009 and 0.002; respectively).

Conclusion

FZD7 and GPC3 gene expressions have a complementary role in early HCC detection, with a greater diagnostic sensitivity and accuracy than AFP. In addition, FZD7 rs2280509 polymorphism is significantly associated with an increased risk of HCC in the Egyptian population.

Delta-radiomics models based on multi-phase contrast-enhanced magnetic resonance imaging can preoperatively predict glypican-3-positive hepatocellular carcinoma

Objectives: The aim of this study is to investigate the value of multi-phase contrast-enhanced magnetic resonance imaging (CE-MRI) based on the delta radiomics model for identifying glypican-3 (GPC3)-positive hepatocellular carcinoma (HCC). Methods: One hundred and twenty-six patients with pathologically confirmed HCC (training cohort: n = 88 and validation cohort: n = 38) were retrospectively recruited. Basic information was obtained from medical records. Preoperative multi-phase CE-MRI images were reviewed, and the 3D volumes of interest (VOIs) of the whole tumor were delineated on non-contrast T1-weighted imaging (T1), arterial phase (AP), portal venous phase (PVP), delayed phase (DP), and hepatobiliary phase (HBP). One hundred and seven original radiomics features were extracted from each phase, and delta-radiomics features were calculated. After a two-step feature selection strategy, radiomics models were built using two classification algorithms. A nomogram was constructed by combining the best radiomics model and clinical risk factors. Results: Serum alpha-fetoprotein (AFP) (p = 0.013) was significantly related to GPC3-positive HCC. The optimal radiomics model is composed of eight delta-radiomics features with the AUC of 0.805 and 0.857 in the training and validation cohorts, respectively. The nomogram integrated the radiomics score, and AFP performed excellently (training cohort: AUC = 0.844 and validation cohort: AUC = 0.862). The calibration curve showed good agreement between the nomogram-predicted probabilities and GPC3 actual expression in both training and validation cohorts. Decision curve analysis further demonstrates the clinical practicality of the nomogram. Conclusion: Multi-phase CE-MRI based on the delta-radiomics model can non-invasively predict GPC3-positive HCC and can be a useful method for individualized diagnosis and treatment.

Current Concepts of Precancerous Lesions of Hepatocellular Carcinoma: Recent Progress in Diagnosis

The most common cause of hepatocellular carcinoma (HCC) is chronic hepatitis and cirrhosis. It is proposed that precancerous lesions of HCC include all stages of the disease, from dysplastic foci (DF), and dysplastic nodule (DN), to early HCC (eHCC) and progressed HCC (pHCC), which is a complex multi-step process. Accurately identifying precancerous hepatocellular lesions can significantly impact the early detection and treatment of HCC. The changes in high-grade dysplastic nodules (HGDN) were similar to those seen in HCC, and the risk of malignant transformation significantly increased. Nevertheless, it is challenging to diagnose precancerous lesions of HCC. We integrated the literature and combined imaging, pathology, laboratory, and other relevant examinations to improve the accuracy of the diagnosis of precancerous lesions.

Protective effects of butylated hydroxytoluene on the initiation of N-nitrosodiethylamine-induced hepatocellular carcinoma in albino rats

Diethylnitrosamine (DEN), a hepatocarcinogen, is found in a variety of smoked and fried foods and was reported to be hepatotoxic in mice. Butylated hydroxytoluene (BHT) is a potent antioxidant used in cosmetic formulations and as a food additive and preservative. As a result, BHT was studied as a potential inhibitor in the early stages of diethylnitrosamine (DEN)-induced HCC. Male Wistar albino rats (n = 24) were equally subdivided. Group 1 was the negative control; Group 2 and 3 administered BHT and DEN, respectively; Group 4 received BHT followed by DEN. Blood samples and rat livers were taken for biochemical and histological investigation. Hepatotoxicity was assessed by increased liver enzymes and HCC indicators, along with reduced antioxidant and pro-apoptotic factors. AFP, AFPL3, GPC3, GSH, SOD, MDA, CASP3 and BAX expression increased significantly after DEN treatment. DEN also reduced GPx, CAT, and CYP2E1 activity, and BCl-2 expression. Moreover, in the hepatic parenchyma, the DEN caused histological alterations. Pretreatment with BHT enhanced antioxidant status while preventing histopathological and most biochemical alterations. BHT pretreatment suppresses DEN-initiated HCC by decreasing oxidative stress, triggering intrinsic mitotic apoptosis, and preventing histopathological changes in liver tissue.

A case of focal nodular hyperplasia with hepatic failure treated with liver transplantation

Focal nodular hyperplasia (FNH) is a benign nodular lesion, but because of its feature of portal tract vessel abnormality, it may induce portal hypertension. A 27-year-old woman was admitted with a fever. A large nodule with satellite lesions was found in the liver and cotton wool-like feature of arteries were detected on angiography. Technetium galactosyl serum albumin scintigraphy and diagnostic laparoscopy showed that the tumor site was functional, while the surrounding area was a non-functional fibrotic area. A biopsy specimen indicated that the nodular lesion was an FNH-like lesion. She experienced several instances of variceal rupture and suffered liver failure, receiving liver transplantation. The excised liver showed a centrally scarred area in the nodule, indicating that the diagnosis was FNH. We herein report this case as a rare case of FNH that progressed to liver failure.

Multi-Modal Imaging Probe for Glypican-3 Overexpressed in Orthotopic Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is rising steadily in incidence, and more effective methods are needed for early detection and image-guided surgery. Glypican-3 (GPC3) is a cell surface biomarker that is overexpressed in early-stage cancer but not in cirrhosis. An IRDye800-labeled 12-mer amino acid sequence was identified, and specific binding to GPC3 was validated in vitro and in orthotopically implanted HCC tumors in vivo. Over 4-fold greater binding affinity and 2-fold faster kinetics were measured by comparison with previous GPC3 peptides. Photoacoustic images showed peak tumor uptake at 1.5 h post-injection and clearance within ∼24 h. Laparoscopic and whole-body fluorescence images showed strong intensity from tumor versus adjacent liver with about a 2-fold increase. Immunofluorescence staining of human liver specimens demonstrated specific binding to HCC versus cirrhosis with 79% sensitivity and 79% specificity, and normal liver with 81% sensitivity and 84% specificity. The near-infrared peptide is promising for early HCC detection in clinical trials.

Efficient drug delivery by novel cell-penetrating peptide derived from Midkine, with two heparin binding sites braced by a length-specific helix

Cell-penetrating peptides (CPPs) have been regarded as potential drug carriers for cancer therapy. However, most well-studied CPPs fail to deliver exogenous drugs efficiently and selectively. In this study, a tumour-targeted CPP with high efficiency derived from heparin-binding domain (HBD) of Midkine (named HMD) was discovered. HMD exhibited higher delivery efficiency than classic CPPs (TAT and R9) and manifested selectivity in tumour cells. Normally, the positive charge is the key factor for the transmembrane activity of CPPs such as TAT and R9. Here, the length of α-helix inside CPP was found also important for in the recognition of heparan sulphate proteoglycans (HSPGs). Subsequently, the introduction of HMD enhanced the inhibitory effect of Momordica antiviral protein of 30 kDa (MAP30) on tumour cells, resulting in a 6.07-fold and 5.42-fold increase in HeLa cells and MGC80-3 cells respectively without enhanced cytotoxicity in normal cells. These results show that HMD possesses high efficiency and good tumour specificity and can be utilised as a promising agent for the tumour-targeted delivery of drug. This study is also a supplement to the existing theories about the biological activities of the α-helix in CPPs.

Evaluation of Glypican-3 Expression in Hepatocellular Carcinoma by Using IDEAL IQ Magnetic Resonance Imaging

RATIONALE AND OBJECTIVES

To investigate the value of iterative decomposition of water and fat with echo asymmetry and least squares estimation (IDEAL IQ) and gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) for evaluating Glypican-3 (GPC3) expression in hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Seventy-six patients with histopathologic diagnosis of HCC were retrospectively included in this study. In all patients IDEAL IQ and Gd-EOB-DTPA-enhanced MRI were performed preoperatively using a 3 T MRI system. For an identical slice through the liver of each patient a region of interest was drawn on the tumor in the hepatobiliary phase image and copied to the R2* map and fat fraction map produced by IDEAL IQ. A Mann-Whitney U test was used to compare the region of interest values of R2*, fat fraction and uptake of Gd-EOB-DTPA values between patients with positive and negative GPC3 expression HCC. Receiver operating characteristic analysis was used to determine the diagnostic performances of each of the MRI parameters in evaluating GPC3 expression and histological grade in HCC.

RESULTS

R2* value was significantly higher in cases of positive than negative GPC3 expression HCCs (p < 0.001), whereas there were no significant differences in fat fraction and uptake of Gd-EOB-DTPA between the 2 groups (both p > 0.05). R2* value had higher areas under receiver operating characteristic (0.881), sensitivity (85.96%), and specificity (84.21%) compared to the fat fraction and uptake of Gd-EOB-DTPA.

CONCLUSION

R2* value yielded from IDEAL IQ could reliably predict GPC3 expression in HCC prior to surgery.

The development of a Glypican-3-specific binding peptide using in vivo and in vitro two-step phage display screening for the PET imaging of hepatocellular carcinoma

Glypican-3 (GPC3) is a diagnostic biomarker for hepatocellular carcinoma (HCC). Although numerous designs targeting GPC3 have been reported, the HCC diagnostic agents with specific tumor accumulation and low background, particularly in normal liver tissue, are still in need. Peptides have attracted considerable attention as an imaging probe due to their low immunogenicity, short in vivo circulation time, and acceptable production cost. Herein, a two-step phage display screening approach was performed against GPC3-high expression tumor xenografts in vivo, followed by human recombinant GPC3 protein in vitro. A GPC3-specific binding peptide, named TJ12P2, with the sequence of Ser-Asn-Asp-Arg-Pro-Pro-Asn-Ile-Leu-Gln-Lys-Arg (SNDRPPNILQKR) was identified. The apparent Kd value between TJ12P2 and the GPC3 protein was measured as 158.2 ± 26.25 nM. After 18F labeling, 18F-AlF-NOTA-TJ12P2 was found accumulated in the tumors by positron emission tomography (PET) imaging in two HCC subcutaneous tumor models (HepG2 and SMMC-7721) with high GPC3 expression. Static PET imaging revealed that 18F-AlF-NOTA-TJ12P2 accumulation in the HepG2 and SMMC-7721 tumors reached 1.825 ± 0.296 %ID g-1 and 1.575 ± 0.520 %ID g-1, with tumor-to-muscle ratios of 4.14 ± 0.50 and 4.25 ± 0.25, respectively, at 30 min post-injection (p.i.). Much less accumulation (0.533 ± 0.078 %ID g-1) of the 18F-AlF-NOTA-TJ12P2 was found in the control PC3 tumors with low GPC3 expression. More importantly, no obvious normal liver uptake of TJ12P2 was observed in the abovementioned animal models. As a result, a novel peptide targeting GPC3, TJ12P2, with strong affinity and specificity was identified using a two-step phage display screening technique in the present study. The 18F-AlF-NOTA-TJ12P2 may be a promising PET imaging probe with translational potential for accurate HCC diagnosis.

RESULTS OF IMMUNOHISTOCHEMISTRY IN THE DIFFERENTIAL DIAGNOSIS OF EARLY HEPATOCELLULAR CARCINOMA AND NODULES WITH HIGH-GRADE DYSPLASIA IN PATIENTS WITH CIRRHOSIS

BACKGROUND

Hepatocellular carcinoma (HCC) is the most frequent primary cancer of the liver and cirrhosis is considered a pre-malignant disease. In this context, the evolutionary sequence from low grade dysplastic nodule and high grade dysplastic nodule (HGDN) to early HCC and advanced HCC has been studied. The differential diagnosis between HGDN and early HCC is still a challenge, especially in needle biopsies.

OBJECTIVE

To evaluate an immunohistochemistry panel to differentiate dysplastic nodules and HCC.

METHODS

Patients with cirrhosis who underwent surgical resection or liver transplantation were included. The sensitivity, specificity and accuracy for the diagnosis of neoplasia were analyzed by evaluating five markers: heat shock protein 70, glypican 3, glutamine synthetase, clathrin heavy chain and beta-catenin. P≤0.05 was considered statistically significant.

RESULTS

One hundred and fifty-six nodules were included; of these, 57 were HCC, 14 HGDN, 18 low grade dysplastic nodules and 67 regenerative macronodules. Sensitivity of HCC diagnosis was 64.9% for glypican 3 and 77.2% for glutamine syntetase, while specificity was 96.0% and 96.0% respectively. When the panel of four markers was considered (excluding beta catenin), the specificity ranged from 87.9% for one positive marker to 100% for at least three markers. The best accuracy for HCC diagnosis was obtained with at least two positive markers, which was associated with a sensitivity of 82.5% and specificity of 99%.

CONCLUSION

Differential diagnosis of dysplastic nodules and HCC by morphological criteria can be challenging. Immunomarkers are useful and should be used for the differential diagnosis between HCC and HGDN.

Pathologic and molecular features of hepatocellular carcinoma: An update

Morphological diversity and several new distinct pathologic subtypes of hepatocellular carcinoma (HCC) are now well-recognized. Recent advances in tumor genomics and transcriptomics have identified several recurrent somatic/genetic alterations that are closely related with histomorphological subtypes and have therefore, greatly improved our understanding of HCC pathogenesis. Pathologic subtyping allows for a diagnosis which is clinically helpful and can have important implication in patient prognostication as some of these subtypes are extremely aggressive with vascular invasion, early recurrence, and worst outcomes. Several targeted treatments are now being considered in HCC, and the reporting of subtypes may be quite useful for personalized therapeutic purpose. This manuscript reviews the recently identified histomorphological subtypes and molecular alterations in HCC.

Biopsies of hepatocellular carcinoma with no reticulin loss: an important diagnostic pitfall

The reticulin stain is a critical diagnostic aide used to differentiate benign hepatocellular proliferations from well differentiated hepatocellular carcinoma (HCC). Rarely, however, hepatocellular carcinomas do not show definitive loss of reticulin in liver biopsy specimens. To study this group of tumors, 11 HCC with no reticulin loss in 10 patients were collected and studied. Analysis of demographics showed a typical enrichment for men with a typical age for HCC presentation of 69 ± 7 years for adults. The background livers showed advanced fibrosis or cirrhosis in 6 of 6 cases with available information. The tumors were all well differentiated. Cytological atypia was mild and consisted of very mild nuclear atypia (8 cases), mild increase in N:C ratio (3 cases), and pseudorosette formation (4 cases). The cytological/architectural atypia was insufficient in isolation to diagnose HCC. Additional studies, however, showed an increased Ki-67 proliferative rate (N = 10/10 stained cases). The Ki-67 proliferative rate was estimated to be between 5 and 10% in all tested cases and was clearly increased from adjacent liver at low power. Glypican 3 positivity (4 tumors) and alpha fetoprotein (AFP) (1/8 stained cases) positivity also helped make the diagnosis of HCC. Morphologically, the HCC had conventional morphology with five showing steatosis/steatohepatitic features and one showing intratumoral fibrosis. A control group of macroregenerative/dysplastic nodules showed no increase in Ki-67 proliferation and no staining for glypican 3. These findings highlight an important diagnostic pitfall: rare HCC show no reticulin loss on biopsy. In these challenging cases, additional findings are useful to make a diagnosis of HCC: increased Ki-67 and positive staining for aberrant expression of proteins such as glypican 3 or AFP.

Targeting Glycans and Heavily Glycosylated Proteins for Tumor Imaging

Simple Summary

Distinguishing malignancy from healthy tissue is essential for oncologic surgery. Targeted imaging during an operation aids the surgeon to operate better. The present tracers for detecting cancer are directed against proteins that are overexpressed on the membrane of tumor cells. This review evaluates the use of tumor-associated sugar molecules as an alternative for proteins to image cancer tissue. These sugar molecules are present as glycans on glycosylated membrane proteins and glycolipids. Due to their location and large numbers per cell, these sugar molecules might be better targets for tumor imaging than proteins.

Abstract

Real-time tumor imaging techniques are increasingly used in oncological surgery, but still need to be supplemented with novel targeted tracers, providing specific tumor tissue detection based on intra-tumoral processes or protein expression. To maximize tumor/non-tumor contrast, targets should be highly and homogenously expressed on tumor tissue only, preferably from the earliest developmental stage onward. Unfortunately, most evaluated tumor-associated proteins appear not to meet all of these criteria. Thus, the quest for ideal targets continues. Aberrant glycosylation of proteins and lipids is a fundamental hallmark of almost all cancer types and contributes to tumor progression. Additionally, overexpression of glycoproteins that carry aberrant glycans, such as mucins and proteoglycans, is observed. Selected tumor-associated glyco-antigens are abundantly expressed and could, thus, be ideal candidates for targeted tumor imaging. Nevertheless, glycan-based tumor imaging is still in its infancy. In this review, we highlight the potential of glycans, and heavily glycosylated proteoglycans and mucins as targets for multimodal tumor imaging by discussing the preclinical and clinical accomplishments within this field. Additionally, we describe the major advantages and limitations of targeting glycans compared to cancer-associated proteins. Lastly, by providing a brief overview of the most attractive tumor-associated glycans and glycosylated proteins in association with their respective tumor types, we set out the way for implementing glycan-based imaging in a clinical practice.

[Hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) belongs to the most prevalent and deadliest cancers worldwide. It can be attributed to well-defined risk factors (mainly chronic viral hepatitis and alcoholic/nonalcoholic steatohepatitis) leading to liver cirrhosis, a premalignant condition for the development of preneoplastic hepatocellular lesions and finally liver cancer. By applying strict morphological criteria and a panel of immunohistological markers, early HCC can be differentiated from its precursor lesions and other highly differentiated hepatocellular lesions even in most biopsy specimens. Integrative characterization led to the association of histological features and molecular subgroups of human HCC. This potentially relevant clinical development was recognized by the recently updated WHO classification of liver cancer resulting in the introduction of several HCC subtypes. These are characterized by a distinct combination of histological and molecular features, biological behavior, and clinical characteristics, allowing for a distinction from other HCC without specified features. Whether this development sets the corner stone for precision oncology of human HCC patients must be monitored.

Diagnostic performance of ultrasonography-guided core-needle biopsy according to MRI LI-RADS diagnostic categories

Purpose

According to the American Association for the Study of Liver Diseases (AASLD) guidelines, biopsy is a diagnostic option for focal hepatic lesions depending on the Liver Imaging Reporting and Data System (LI-RADS) category. We evaluated the diagnostic performance of ultrasonography-guided core-needle biopsy (CNB) according to LI-RADS categories.

Methods

A total of 145 High-risk patients for hepatocellular carcinoma (HCC) who underwent magnetic resonance imaging (MRI) followed by CNB for a focal hepatic lesion preoperatively were retrospectively enrolled. Focal hepatic lesions on MRI were evaluated according to LI-RADS version 2018. Pathologic results were categorized into HCC, non-HCC malignancies, and benignity. The categorization was defined as correct when the CNB pathology and surgical pathology reports were identical. Nondiagnostic results were defined as inadequate CNB pathology findings for a specific diagnosis. The proportion of correct categorizations was calculated for each LI-RADS category, excluding nondiagnostic results.

Results

After excluding 16 nondiagnostic results, 131 lesions were analyzed (45 LR-5, 24 LR-4, 4 LR-3, and 58 LR-M). All LR-5 lesions were HCC, and CNB correctly categorized 97.8% (44/45) of LR-5 lesions. CNB correctly categorized all 24 LR-4 lesions, 16.7% (4/24) of which were non-HCC malignancies. All LR-M lesions were malignant, and 62.1% (36/58) were non-HCC malignancies. CNB correctly categorized 93.1% (54/58) of LR-M lesions, and 12.5% (3/24) of lesions with CNB results of HCC were confirmed as non-HCC malignancies.

Conclusion

In agreement with AASLD guidelines, CNB could be helpful for LR-4 lesions, but is unnecessary for LR-5 lesions. In LR-M lesions, CNB results of HCC did not exclude non-HCC malignancy.

Diagnosis of Focal Nodular Hyperplasia (FNH) after Liver Transplantation

Following liver transplantation (LT), recipients can develop benign and malignant hepatic masses just like any other patient. Patients transplanted for hepatocellular carcinoma (HCC) undergo surveillance imaging, and any new mass seen on imaging must be carefully evaluated to rule out recurrent cancer. Focal nodular hyperplasia (FNH) is a benign tumor of the liver that most often occurs in women and is rarely symptomatic. It is important to distinguish FNH from more serious etiologies, such as recurrent HCC and other malignancies, since the treatments differ greatly. To date, there have been very few reports of FNH occurring in a liver allograft. We present a case of a patient with a history of a carcinoid tumor who underwent LT for HCC. Several years posttransplant, the patient was found to have a liver mass with classic features of HCC on imaging. The liver biopsy revealed the unexpected diagnosis of FNH. This finding avoided unnecessary treatment for HCC, which is associated with morbidity, especially in the posttransplant setting. We present our diagnostic approach, discuss the clinicopathologic and imaging findings of FNH, and review the literature on FNH in the posttransplant setting.

The Role of Glypicans in Cancer Progression and Therapy

Glypicans are a family of heparan sulfate proteoglycans that are attached to the cell membrane via a glycosylphosphatidylinositol anchor. Glypicans interact with multiple ligands, including morphogens, growth factors, chemokines, ligands, receptors, and components of the extracellular matrix through their heparan sulfate chains and core protein. Therefore, glypicans can function as coreceptors to regulate cell proliferation, cell motility, and morphogenesis. In addition, some glypicans are abnormally expressed in cancers, possibly involved in tumorigenesis, and have the potential to be cancer-specific biomarkers. Here, we provide a brief review focusing on the expression of glypicans in various cancers and their potential to be targets for cancer therapy.

The Significance of Circulating Tumor Cells in Patients with Hepatocellular Carcinoma: Real-Time Monitoring and Moving Targets for Cancer Therapy

Hepatocellular carcinoma (HCC) is ranked as the sixth most common cancer around the world. With the emergence of the state-of-the-art modalities lately, such as liver transplantation, image-guided ablation, and chemoembolization, the death rate is still high due to high metastasis rate after therapy. Observation by biannual ultrasonography allows effective diagnosis at an early stage for candidates with no extrahepatic metastasis, but its effectiveness still remains unsatisfactory. Developing a new test with improved effectiveness and specificity is urgently needed for HCC diagnosis, especially for patients after first line therapy. Circulating tumor cells (CTCs) are a small sub-population of tumor cells in human peripheral blood, they release from the primary tumor and invade into the blood circulatory system, thereby residing into the distal tissues and survive. As CTCs have specific and aggressive properties, they can evade from immune defenses, induce gene alterations, and modulate signal transductions. Ultimately, CTCs can manipulate tumor behaviors and patient reactions to anti-tumor treatment. Given the fact that in HCC blood is present around the immediate vicinity of the tumor, which allows thousands of CTCs to release into the blood circulation daily, so CTCs are considered to be the main cause for HCC occurrence, and are also a pivotal factor for HCC prognosis. In this review, we highlight the characteristics and enrichment strategies of CTCs, and focus on the use of CTCs for tumor evaluation and management in patients with HCC.

Peptide vaccine as an adjuvant therapy for glypican-3-positive hepatocellular carcinoma induces peptide-specific CTLs and improves long prognosis

There is no established postoperative adjuvant therapy for hepatocellular carcinoma (HCC), and improvement of patient prognosis has been limited. We conducted long‐term monitoring of patients within a phase II trial that targeted a cancer antigen, glypican‐3 (GPC3), specifically expressed in HCC. We sought to determine if the GPC3 peptide vaccine was an effective adjuvant therapy by monitoring disease‐free survival and overall survival. We also tracked GPC3 immunohistochemical (IHC) staining, CTL induction, and postoperative plasma GPC3 for a patient group that was administered the vaccine (n = 35) and an unvaccinated patient group that underwent surgery only (n = 33). The 1‐y recurrence rate after surgery was reduced by approximately 15%, and the 5‐y and 8‐y survival rates were improved by approximately 10% and 30%, respectively, in the vaccinated group compared with the unvaccinated group. Patients who were positive for GPC3 IHC staining were more likely to have induced CTLs, and 60% survived beyond 5 y. Vaccine efficacy had a positive relationship with plasma concentration of GPC3; high concentrations increased the 5‐y survival rate to 75%. We thus expect GPC3 vaccination in patients with HCC, who are positive for GPC3 IHC staining and/or plasma GPC3 to induce CTL and have significantly improved long‐term prognosis.

A novel model of liver cancer stem cells developed from induced pluripotent stem cells

Background

Liver cancer is the second most common cause of cancer-related death. Every type of tumours including liver cancer contains cancer stem cells (CSCs). To date, the molecular mechanism regulating the development of liver CSCs remains unknown.

Methods

In this study, we tried to generate a new model of liver CSCs by converting mouse induced pluripotent stem cells (miPSCs) with hepatocellular carcinoma (HCC) cell line Huh7 cells conditioned medium (CM). miPSCs treated with CM were injected into the liver of BALB/c nude mice. The developed tumours were then excised and analysed.

Results

The primary cultured cells from the malignant tumour possessed self-renewal capacity, differentiation potential and tumorigenicity in vivo, which were found rich in liver cancer-associated markers as well as CSC markers.

Conclusions

We established a model of liver CSCs converting from miPS and showed different stages of stemness during conversion process. Our CSC model will be important to assess the molecular mechanisms necessary to develop liver CSCs and could help in defeating liver cancer.

Diagnostic value of serum glypican-3 alone and in combination with AFP as an aid in the diagnosis of liver cancer

BACKGROUND

Recently, a series of studies have been published to examine the possible diagnostic and prognostic values of glypican-3 (GPC3) in liver cancer with conflicting results observed. Thus, the present study aimed to assess the values of preoperative serum GPC3 alone and in combination with AFP for the diagnosis of liver cancer.

METHODS

An enzyme-linked immunoassay was used to quantify serum GPC3 in hepatocellular carcinoma group (HCC, n = 210), intrahepatic cholangiocarcinoma group (ICC, n = 36), combined hepatocellular cholangiocarcinoma group (cHCC-CC, n = 8), metastatic liver cancer group (MLC, n = 10) and normal controls (NC, n = 134).

RESULTS

The area under the curve (AUC) of GPC3 for HCC versus NC was 0.879, with a sensitivity of 79.52% at an optimal cutoff value of 0.0414 ng/mL; when GPC3 was combined with AFP, the AUC and sensitivity were increased to 0.925 and 88.10%, respectively. In addition, 43 of 68 AFP-negative patients had elevated GPC3 levels. Furthermore, the positive rate of GPC3 was significantly higher than the that of AFP for HCC in early stage.

CONCLUSIONS

Serum GPC3 was superior to AFP for the diagnosis of early-stage HCC, and may be complementary to AFP for distinguishing HCC from NC.

Classification and Prognosis Prediction from Histopathological Images of Hepatocellular Carcinoma by a Fully Automated Pipeline Based on Machine Learning

OBJECTIVE

The aim of this study was to develop quantitative feature-based models from histopathological images to distinguish hepatocellular carcinoma (HCC) from adjacent normal tissue and predict the prognosis of HCC patients after surgical resection.

METHODS

A fully automated pipeline was constructed using computational approaches to analyze the quantitative features of histopathological slides of HCC patients, in which the features were extracted from the hematoxylin and eosin (H&E)-stained whole-slide images of HCC patients from The Cancer Genome Atlas and tissue microarray images from West China Hospital. The extracted features were used to train the statistical models that classify tissue slides and predict patients' survival outcomes by machine-learning methods.

RESULTS

A total of 1733 quantitative image features were extracted from each histopathological slide. The diagnostic classifier based on 31 features was able to successfully distinguish HCC from adjacent normal tissues in both the test [area under the receiver operating characteristic curve (AUC) 0.988] and external validation sets (AUC 0.886). The random-forest prognostic model using 46 features was able to significantly stratify patients in each set into longer- or shorter-term survival groups according to their assigned risk scores. Moreover, the prognostic model we constructed showed comparable predicting accuracy as TNM staging systems in predicting patients' survival at different time points after surgery.

CONCLUSIONS

Our findings suggest that machine-learning models derived from image features can assist clinicians in HCC diagnosis and its prognosis prediction after hepatectomy.

Precision pathology analysis of the development and progression of hepatocellular carcinoma: Implication for precision diagnosis of hepatocellular carcinoma

Outcomes for patients with hepatocellular carcinoma (HCC) remain poor because the condition is often unresponsive to the available treatments. Consequently, the early and precise diagnosis of HCC is crucial to achieve improvements in prognosis. For patients with chronic liver disease, the assessment of liver fibrosis is also important to ascertain both the staging of fibrosis and the risk of HCC occurrence. Early HCC was first described in 1991 in Japan and was defined internationally in 2009. As the concept of early HCC spread, the multistage hepatocarcinogenesis process became accepted. Consequently, improvements in imaging technology made the early diagnosis of HCC possible. At present, the most appropriate therapeutic strategy for HCC is determined using an integrated staging system that assesses the tumor burden, the degree of liver dysfunction and the patient performance status; however, pathological and molecular features are not taken into account. The recent introduction of several new therapeutic agents will change the treatment strategy for HCC. Against this background, HCC subclassification based on tumor cellular and microenvironmental characteristics will become increasingly important. In this review, we give an overview of how pathological analysis contributes to understanding the development and progression of HCC and establishing a precision diagnosis of HCC.

A meta-analysis of the prognostic significance of Golgi protein 73 in hepatocellular carcinoma in Chinese patients

INTRODUCTION

In recent years, an increasing number of studies have revealed the possible prognostic significance of Golgi protein 73 (GP73) in hepatocellular carcinoma (HCC), but the results are still controversial. Therefore, we performed a meta-analysis to explore the possible correlation between GP73 and prognostic value in HCC.

MATERIAL AND METHODS

Relevant publications were searched for in PubMed, EMBASE, Cochrane Library and the Chinese Biomedical Literature Database up to March 2018. Odds ratios (ORs) or hazard ratios (HRs) and 95% confidence intervals (CI) of eligible studies were assessed by either fixed-effect or random effects models. Publication bias analysis was also performed to assess the reliability of the meta-analysis results.

RESULTS

In total, 9 studies including 1292 patients with HCC were included and analysed systematically in the study. The results indicated that GP73 overexpression was significantly associated with later tumour stage, higher tumour grade and poor overall survival (OS). Combined analysis of three studies showed no statistical correlation between high GP73 expression and disease-free survival (DFS). Subgroup analyses were also performed to illustrate the relationship between high GP73 expression and OS.

CONCLUSIONS

The meta-analysis suggested that overexpression of GP73 may be associated with poor prognosis in HCC and may also have a predictive role for HCC invasion and metastasis.

Study on Diagnostic Values of Astrocyte Elevated Gene 1 (AEG-1) and Glypican 3 (GPC-3) in Hepatocellular Carcinoma

OBJECTIVES

To investigate the diagnostic potential of AEG-1 and GPC-3 in hepatocellular carcinoma (HCC).

METHODS

AEG-1 and GPC-3 immunohistochemistry were performed on HCC, adjacent nontumor tissue (ANT), and dysplastic nodules (DN).

RESULTS

H score of AEG-1 or GPC-3 in HCC was significantly higher than in ANT or DN. In HCC, 92% and 54% showed AEG-1 and GPC-3 positivity, respectively. In ANT, 16.2% were AEG-1 and 7.6% GPC-3 positive. AEG-1 staining was mostly diffuse, whereas GPC-3 frequently showed focal staining. AEG-1 alone showed high sensitivity but low specificity and accuracy. GPC-3, on the other hand, showed high specificity but low sensitivity and accuracy. Combination of both stains boosted the sensitivity, specificity, and accuracy to 94.6%, 89.5%, and 90.5%, respectively, when only diffuse staining was considered as positive.

CONCLUSIONS

AEG-1 or GPC-3 alone seemed not an ideal marker for HCC. The combination of AEG-1 and GPC-3 might improve early diagnosis of HCC.

Meta-analysis and systematic review of prognostic significance of Glypican-3 in patients with hepatitis B-related hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common malignant cancer and the second cause of cancer-related death worldwide. Glypican-3 (GPC3) is established as an important prognostic factor for HCC but the results are still controversial. Moreover, its utility as an immunohistochemical marker for HCC is not conclusive. Herein we aimed to find the prognostic significance of GPC3 in HCC patients. The PubMed, Web of Science, EMBASE, SCOPUS and Cochrane library databases were searched and eligible studies based on the GPC3 expression and survival outcome of HCC (odds ratios or hazard ratios) included in the current meta-analysis. The STATA 12.0 and RevMan 5.3 software were used for statistical evaluations. 17 articles contained 2618 patients, were included in the recent meta-analysis. Our findings revealed a significant association between tumor stage, higher tumor grade, presence of vascular invasion, shorter overall survival, shorter disease-free survival and high expression of GPC3. The subgroup analyses based on sample size, cutoffs and follow-up period were also conducted to examine the association between GPC3 and OS and also to increase the homogeneity of study. Current study found a significant association between GPC3 expression and poor prognosis of HCC and specially related to the HCC invasion and progression. It was recommended to design more prospective studies based on the relationship between GPC3 and HCC to confirm our results.

Clinical significance of glypican-3-positive circulating tumor cells of hepatocellular carcinoma patients: A prospective study

The utility of glypican-3 (GPC3) expression for the detection of circulating tumor cells (CTCs) in hepatocellular carcinoma (HCC) patients has not been elucidated. The aim of this study was to identify associations between the presence of GPC3-positive CTCs and clinicopathological factors of these patients, furthermore, to evaluate whether CTC can predict microscopic portal vein invasion (mPVI). This study was done on 85 patients who underwent hepatectomy as the first-line treatment and whose preoperative imaging showed no evidence of macroscopic PVI and distant metastases. Peripheral blood was collected from all patients immediately before surgery. Cells were purified initially by density gradient centrifugation followed by immunomagnetic positive enrichment based upon the expression of GPC3. The numbers of CTCs contained in the enriched samples were enumerated via flow cytometry. Protocol validation using HepG2 cells spiked into 8.0 mL of blood from a healthy volunteer indicated that we were able to recover 12.1% of the tumor cells. A median number of 3 CTCs (range: 0-27) was detected in the 8.0 mL of peripheral blood of the 85 analyzed HCC patients. Thirty-three patients had CTCs ≥5, and these patients had a higher incidence of mPVI (p < 0.001), a lower disease-free survival (p = 0.015), and a lower overall survival (p = 0.047) than those with CTCs <5. Multivariate analysis identified CTCs ≥5 as an independent predictor of mPVI (p < 0.001). In conclusion, preoperative GPC3-positive CTCs ≥5 was a risk factor of mPVI and poor prognosis, and therefore may be a useful biomarker for HCC patient outcomes.

Human Liver Regeneration: An Etiology Dependent Process

Regeneration of the liver has been an interesting and well-investigated topic for many decades. This etiology and time-dependent mechanism has proven to be extremely challenging to investigate, certainly in human diseases. A reason for this challenge is found in the numerous interactions of different cell components, of which some are even only temporarily present (e.g., inflammatory cells). To orchestrate regeneration of the epithelial cells, their interaction with the non-epithelial components is of utmost importance. Hepatocytes, cholangiocytes, liver progenitor cells, and peribiliary glands have proven to be compartments of regeneration. The ductular reaction is a common denominator in virtually all liver diseases; however, it is predominantly found in late-stage hepatic and biliary diseases. Ductular reaction is an intriguing example of interplay between epithelial and non-epithelial cells and encompasses bipotential liver progenitor cells which are able to compensate for the loss of the exhausted hepatocytes and cholangiocytes in biliary and hepatocytic liver diseases. In this manuscript, we focus on the etiology-specific damage that is observed in different human diseases and how the liver regulates the regenerative response in an acute and chronic setting. Furthermore, we describe the importance of morphological keynotes in different etiologies and how spatial information is of relevance for every basic and translational research of liver regeneration.

Associated measurement of fucosylated levels of AFP, DCP, and GPC3 for early diagnosis in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is a serious health problem worldwide, especially in Asian countries, such as China. However, there are difficulties in diagnosing and treating hepatocellular carcinoma. The alteration of fucosylated proteins was closely associated with carcinogenesis. This study is designed to evaluate the early diagnostic value of associated detection of fucosylated alpha-fetoprotein (fuc-AFP), fucosylated des-γ-carboxy prothrombin (fuc-DCP), and fucosylated glypican 3 (fuc-GPC3) in hepatocellular carcinoma.

METHODS

All serum specimens collected from patients were diagnosed by complete clinicopathological examination and then subjected to the associated detection of fuc-AFP, fuc-DCP, and fuc-GPC3 by protein microarray. Canonical discriminant analysis was adopted to discriminate between the hepatocellular carcinoma group and the benign liver disease group.

RESULTS

A total of 51 patients with hepatocellular carcinoma and 47 patients in the benign liver disease group were included in this study. Fuc-AFP, fuc-DCP, and fuc-GPC3 were significantly higher in the hepatocellular carcinoma group than in the benign liver disease group. The sensitivity, specificity, and accuracy of canonical discriminant analysis classification were 80.4%, 97.9%, and 88.8%, respectively.

CONCLUSIONS

Fuc-AFP, fuc-DCP, and fuc-GPC3 are effective and useful tumor biomarkers. Associated measurement of these biomarkers with canonical discriminant analysis classification is a promising method for the early diagnosis of hepatocellular carcinoma.

Novel biomarkers in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths and the fifth most common cancer worldwide. Most of these patients are seen with advanced disease at the time of presentation. In spite of its high prevalence, there are not many therapeutic options available for patients with advanced-stage HCC. There is an urgent need for improving early detection and prognostication of patients with HCC. In addition, the development of new therapies targeting specific pathways involved in the pathogenesis of HCC should be a major goal for future research, with the objective of improving outcomes of patients with HCC. Biomarkers represent a relatively easy and noninvasive way to detect and estimate disease prognosis. In spite of the numerous efforts to find molecules as possible biomarkers, there is not a single ideal marker in HCC. Many new findings have shown promising results both in diagnosing and treating HCC. In this review, we summarized the most recent and relevant biomarkers in HCC.

Proteoglycans Are Attractive Biomarkers and Therapeutic Targets in Hepatocellular Carcinoma

Proteoglycans, which consist of a protein core and glycosaminoglycan chains, are major components of the extracellular matrix and play physiological roles in maintaining tissue homeostasis. In the carcinogenic tissue microenvironment, proteoglycan expression changes dramatically. Altered proteoglycan expression on tumor and stromal cells affects cancer cell signaling pathways, which alters growth, migration, and angiogenesis and could facilitate tumorigenesis. This dysregulation of proteoglycans has been implicated in the pathogenesis of diseases such as hepatocellular carcinoma (HCC) and the underlying mechanism has been studied extensively. This review summarizes the current knowledge of the roles of proteoglycans in the genesis and progression of HCC. It focuses on well-investigated proteoglycans such as serglycin, syndecan-1, glypican 3, agrin, collagen XVIII/endostatin, versican, and decorin, with particular emphasis on the potential of these factors as biomarkers and therapeutic targets in HCC regarding the future perspective of precision medicine toward the "cure of HCC".

A GPC3-specific aptamer-mediated magnetic resonance probe for hepatocellular carcinoma

Purpose

To construct and test a hepatocellular carcinoma (HCC)-targeted magnetic resonance probe based on a glypican-3 (GPC3)-specific aptamer (AP613-1) with ultrasmall superpara-magnetic iron oxide (USPIO).

Methods

Oleic acid-coated USPIO nanoparticles were modified with amino polyethylene glycol on the surface. Amino groups of the USPIO nanoparticles were reacted with the carboxyl group of 5' carboxyl-modified AP613-1, forming an aptamer-mediated USPIO (Apt-USPIO) probe. The material characterization of this probe including transmission electron microscopy (TEM), zeta potential, dynamic laser scattering, and magnetic behavior was carried out. The targeting efficiency and magnetic resonance imaging (MRI) performance of Apt-USPIO were evaluated both in vitro and in vivo with USPIO alone as a control. The cytotoxicity and bio-compatibility of Apt-USPIO and USPIO were analyzed by cell counting kit-8 tests in vitro and animal experiments in vivo.

Results

TEM imaging revealed that the Apt-USPIO nanoparticles were spherical in shape and well dispersed. Specific uptake of Apt-USPIO in Huh-7 cells could be observed using the Prussian blue staining test; however, no uptake of USPIO could be found. In vitro phantom T₂-weighted MRI showed a significant decrease of the signal intensity in Apt-USPIO-incubated Huh-7 cells compared to USPIO-incubated Huh-7 cells. In vivo T₂-weighted MRI showed significantly negative enhancement in the Huh-7 tumors enhanced with Apt-USPIO, whereas no enhancement was found with USPIO alone. Excellent biocompatibility of Apt-USPIO and USPIO was also demonstrated.

Conclusion

In this study, a molecular MRI probe which was highly specific to GPC3 on HCC was successfully prepared. Our results validated the targeted imaging effect of this Apt-USPIO probe in vivo for GPC3-expressing HCCs in xenograft mice.

Signal Transducer and Activator of Transcription 3 for the Differentiation of Hepatocellular Carcinoma from Cirrhosis

Background:

Overexpression and constitutive activation of signal transducer and activator of transcription (STAT) 3 have been suggested in the tumorigenesis of many human cancers, including multiple carcinomas, melanoma, and lymphoma. The diagnosis of hepatocellular carcinoma (HCC) in lobectomy specimens is usually straightforward, but distinguishing cirrhosis from well-differentiated HCC can be challenging in core biopsies. Our aims were to investigate the expression level of STAT3 and phosphorylated STAT3 (pSTAT3) in HCC and cirrhosis, and the application of STAT3 in the differential diagnosis of HCC and cirrhosis.

Methods:

Sixty cases were divided into three groups: patients with HCC only (Group 1), HCC and cirrhosis (Group 2), and cirrhosis only (Group 3). Formalin-fixed and paraffin-embedded tissue sections were stained immunohistochemically for STAT3, pSTAT3, and CD163. The values obtained from the tissue sections of each group were compared in statistical analysis.

Results:

STAT3 showed a high level in HCC and was a significant marker for differentiating HCC from cirrhosis (P < 0.0001). The odds ratio between HCC and cirrhosis increased 34.4 times when the intensity of STAT3 increased by 1 level. Spearman's correlation and Chi-square tests also demonstrated that expression level of STAT3 did not correlate with age, gender, or the presence of a cirrhotic background.

Conclusions:

STAT3 staining differs significantly in HCC and cirrhosis. The findings reinforce the role of STAT3 in the tumorigenesis of HCC and provide a useful marker to differentiate HCC from cirrhosis in challenging liver biopsies.

A novel multimarker assay for the phenotypic profiling of circulating tumor cells in hepatocellular carcinoma

Current clinicopathologic staging systems and serum biomarkers poorly discriminate tumor biology in hepatocellular carcinoma (HCC), with high recurrence rates following curative-intent surgical resection and liver transplantation (LT). Identification of accurate biomarkers for improved prognostication and treatment selection is a critical unmet need. We sought to develop a novel "liquid-biopsy" assay capable of detecting HCC circulating tumor cells (CTCs) and characterizing phenotypic subpopulations with prognostic significance. Using HCC cell lines, a tissue microarray, and human blood samples, an antibody cocktail targeting the cell-surface markers asialoglycoprotein receptor (ASGPR), glypican-3, and epithelial cell adhesion molecule was optimized for HCC CTC capture using the NanoVelcro CTC Assay. The ability of HCC CTCs and vimentin (VIM)-positive CTCs (a subpopulation expressing an epithelial-to-mesenchymal phenotype) to accurately discriminate tumor stage, recurrence, progression, and overall survival (OS) was evaluated in a prospective study of 80 patients. Multimarker capture detected greater numbers of CTCs than any individual antibody alone for both cell line and patient samples (P < 0.001). HCC CTCs were identified in 59/61 (97%) patients, and HCC (median, 6 CTCs) and non-HCC patients (median, 1 CTC; area under the receiver operating characteristic curve [AUROC] = 0.92; P < 0.001; sensitivity = 84.2%; specificity = 88.5%) were accurately discriminated. VIM-positive CTCs accurately discriminated early-stage, LT eligible patients (median, 0 CTCs) from locally advanced/metastatic, LT ineligible patients (median, 6 CTCs; AUROC = 0.89; P = 0.001; sensitivity = 87.1%; specificity = 90.0%), and predicted OS for all patients (hazard ratio [HR], 2.21; P = 0.001), and faster recurrence after curative-intent surgical or locoregional therapy in potentially curable early-stage HCC (HR, 3.14; P = 0.002). In conclusion, we developed a novel multimarker CTC enrichment assay that detects HCC CTCs with high efficiency and accuracy. A phenotypic subpopulation of VIM-positive CTCs appears to signify the presence of aggressive underlying disease and occult metastases and may have important implications for treatment selection. Liver Transplantation 24 946-960 2018 AASLD.

Overexpression of glypican-3 is a predictor of poor prognosis in hepatocellular carcinoma: An updated meta-analysis

BACKGROUND

Glypican-3 (GPC3) has been widely recognized in the progression of liver tumors for several years. The relationship between overexpression of GPC3 and the poorer prognosis of patients with hepatocellular carcinoma (HCC) was performed by 2 meta-analyses. However, there were also some latest literatures that indicated different conclusions distinctly. It is necessary for us to carry out a meta-analysis by adding the latest data from current studies to explore the correlation between GPC3 and prognostic value in HCC.

METHODS

We conducted a meta-analysis including a total of 14 studies to assess the potential prognostic significance of GPC3 expression for overall survival (OS) and disease-free survival (DFS). The expression of GPC3 was assessed by immunohistochemistry.

RESULTS

Fourteen studies with 2364 patients were incorporated in the meta-analysis. The combined hazard ratios (HRs) revealed that the overexpression of GPC3 could forecast a poor OS [n = 2233 in 12 studies, HR = 1.40, 95% confidence interval (95% CI): 1.07-1.85, Z = 2.42, P = .02] and DFS (n = 1308 in 10 studies, HR = 1.61, 95% CI: 1.13-2.30, Z = 2.63, P = .008) in HCC patients. Subgroup treated by hepatectomy indicated that the pooled HR of OS was 1.43 (95% CI: 1.01-2.01, P = .04) and the combined HR of DFS was 1.59 (95% CI: 1.09-2.31, P = .02). The pooled odds ratios (ORs) showed that high GPC3 expression was also extensively associated with worse tumor differentiation, later tumor stage, presence of vascular invasion, and hepatitis B virus (HBV) infection. Subgroup analyses for GPC3 on HCC OS based on the studies categorized by regions, follow-up period, and sample size were also conducted.

CONCLUSION

The meta-analysis indicated that overexpression of GPC3 was significantly associated with poor prognosis in patients with HCC.

Update on Ancillary Testing in the Evaluation of High-Grade Liver Tumors

Tissue diagnosis is the gold standard for mass lesions of the liver, but needle core biopsies may sometimes prove challenging. Presented here is a review of a panel of immunohistochemical stains, including hepatocyte in paraffin 1, arginase-1, polyclonal carcinoembryonic antigen, CD10, bile salt export pump, glypican-3, as well as in situ hybridization for albumin RNA, to establish hepatocellular origin in cases in which hepatocellular carcinoma is suspected but the sample is limited or the morphology is challenging, as it may be with cases of scirrhous, fibrolamellar carcinoma, intrahepatic cholangiocarcinoma, and combined hepatocellular-cholangiocarcinoma.

Hepatitis C Virus Mimics Effects of Glypican-3 on CD81 and Promotes Development of Hepatocellular Carcinomas via Activation of Hippo Pathway in Hepatocytes

Glypican (GPC)-3 is overexpressed in hepatocellular carcinomas (HCCs). GPC3 binds to CD81. Forced expression of CD81 in a GPC3-expressing HCC cell line caused activation of Hippo, a decrease in ezrin phosphorylation, and a decrease in yes-associated protein (YAP). CD81 is also associated with hepatitis C virus (HCV) entry into hepatocytes. Activation of CD81 by agonistic antibody causes activation of tyrosine-protein kinase SYK (SYK) and phosphorylation of ezrin, a regulator of the Hippo pathway. In cultures of normal hepatocytes, CD81 agonistic antibody led to enhanced phosphorylation of ezrin and an increase in nuclear YAP. HCV E2 protein mimicked GPC3 and led to enhanced Hippo activity and decreased YAP in cultured normal human hepatocytes. HCC tissue microarray revealed a lack of expression of CD81 in most HCCs, rendering them insusceptible to HCV infection. Activation of CD81 by agonistic antibody suppressed the Hippo pathway and increased nuclear YAP. HCV mimicked GPC3, causing Hippo activation and a decrease in YAP. HCV is thus likely to enhance hepatic neoplasia by acting as a promoter of growth of early CD81-negative neoplastic hepatocytes, which are resistant to HCV infection, and thus have a proliferative advantage to clonally expand as they participate in compensatory regeneration for the required maintenance of 100% of liver weight (hepatostat).

In vivo fluorescence imaging of hepatocellular carcinoma using a novel GPC3-specific aptamer probe

Background

Glypican-3 (GPC3) is highly expressed in most of the hepatocellular carcinomas (HCCs), even in small HCCs. It may be used as a potential biomarker for early detection of HCC. The aptamer is a promising targeting agent with unique advantages over antibody. This study was to introduce a novel GPC3 specific aptamer (AP613-1), to verify its specific binding property in vitro, and to evaluate its targeting efficiency in vivo by performing near-infrared (NIR) fluorescence imaging on an HCC xenograft model.

Methods

AP613-1 was generated from the systematic evolution of ligands by exponential enrichment. Flow cytometry and aptamer-based immunofluorescence imaging were performed to verify the binding affinity of AP613-1 to GPC3 in vitro. NIR Fluorescence images of nude mice with unilateral (n=12) and bilateral (n=4) subcutaneous xenograft tumors were obtained. Correlation between the tumor fluorescence intensities in vivo and ex vivo was analyzed.

Results

AP613-1 could specifically bind to GPC3 in vitro. In vivo and ex vivo tumors, fluorescence intensities were in excellent correlation (P<0.001, r=0.968). The fluorescence intensity is significantly higher in tumors given Alexa Fluor 750 (AF750) labeled AP613-1 than in those given AF750 labeled initial ssDNA library both in vivo (P<0.001) and ex vivo (P=0.022). In the mice with bilateral subcutaneous tumors injected with AF750 labeled AP613-1, Huh-7 tumors showed significantly higher fluorescence intensities than A549 tumors both in vivo (P=0.016) and ex vivo (P=0.004).

Conclusions

AP613-1 displays a specific binding affinity to GPC3 positive HCC. Fluorescently labeled AP613-1 could be used as an imaging probe to subcutaneous HCC in xenograft models.

Evaluating clinical and prognostic implications of Glypican-3 in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most deadly cancers worldwide. In patients with HCC, histopathogical differentiation is an important indicator of prognosis; however, because determination of HCC differentiation is difficult, the recently described immunohistochemical (IHC) marker glypican3 (GPC3) might assist in HCC prognostication.The goal of our study was to investigate GPC3's IHC staining pattern and define the relationship between its expression and patients' clinicopathologic features and overall survival. We retrieved clinical parameters from 101 pathologically diagnosed HCC patients' medical records and classified these patients into 4 clinical score categories (0–3) based on increasing GPC3 staining intensity and the percentage of stained tumor cells in their resection and biopsy specimens. Histopathological samples were well, moderately, and poorly differentiated in 33, 22, and 12 patients, respectively, and the GPC3 expression rate was 63%, 86%, and 92%,respectively. The median overall survival was 49.9 months (confidence interval (CI): 35.3–64.6 months) for clinical scores 0–1 and 30.7 months (CI: 19.4–41.9 months) for clinical scores 2–3. This difference was not statistically significant (P = .06) but showed a strong trend. In conclusion, a greater GPC3 expression is associated with a worse HCC prognosis and may be a promising prognostic marker.

Combining expression of GPC3 in tumors and CD16 on NK cells from peripheral blood to identify patients responding to codrituzumab

Background

Codrituzumab, a monoclonal antibody targeting an oncofetal protein glypican-3 (GPC3) expressed on cell surface of hepatocellular carcinoma (HCC) induces antibody-dependent cellular cytotoxicity (ADCC) and inhibits tumor growth in preclinical studies. Based on this mechanism, tumor GPC3 expression and CD16 expression on NK cells, which are the effector cells of ADCC, were investigated to correlate with codrituzumab's clinical efficacy in patients with advanced HCC.

Results

Joint analyses of the two biomarkers revealed that both high levels of GPC3 and CD16 were required for patients to benefit from codrituzumab; lack of either one of them would lead to a loss of the therapeutic effect.

Conclusions

These results suggest the combination of tumor GPC3 expression and CD16 expression on NK cells from peripheral blood at baseline as a composite biomarker to select HCC patients for codrituzumab.

Impact

The conclusion warrants a future study in an HCC population with both high GPC3 expression and high levels of CD16 at baseline to establish codrituzumab's therapeutic benefit in HCC.

Methods

Data from a phase II clinical trial of codrituzumab were used for the analyses. GPC3 expression in baseline tumor biopsies was determined by immunohistochemistry (IHC) analysis, and baseline CD16 expression on NK cells were quantified by peripheral blood lymphocyte immunophenotyping. According to high or low expression of GPC3 and CD16, different patient subgroups were formed; for each subgroup, overall survival of patients having high codrituzumab exposure was compared to that of patients receiving placebo.

Role of Glypican-3 in the growth, migration and invasion of primary hepatocytes isolated from patients with hepatocellular carcinoma

BACKGROUND

Recently, Glypican-3 (GPC3) has been identified as a potential hepatocellular carcinoma (HCC) diagnostic and/or therapeutic target. GPC3 has been found to be up-regulated in HCC and to be absent in normal and cirrhotic liver. As yet, however, the molecular characteristics of GPC3 and its role in HCC cell physiology and development are still undefined.

METHODS

Human hepatocyte cultures were established from 10 HCC patients. Additional liver samples were obtained from 5 patients without cirrhosis and/or HCC. Soft agar colony formation, (co-)immunofluorescence and Western blot assays were used to characterize the hapatocyte cultures. The expression of GPC3 in the hepatocytes was silenced using siRNA, after which, apoptosis, scratch wound migration and transwell invasion assays were performed.

RESULTS

We found that in HCC precursor hepatocytes GPC3 is increasingly expressed in different forms and at different locations, i.e., a non-cleaved form (70 kDa) was found to be localized in the cytoplasm while a N-terminal cleaved form (N-GPC3: 40 kDa) was fond to be localized in the cytoplasm and at the extracellular side of hepatocyte membranes. In addition, we found that the non-cleaved form of GPC3 co-localizes with Furin-Convertase in the Golgi apparatus. We also found that, similar to GPC3, Furin-Convertase is expressed in HCC precursor cells, suggesting a role in GPC3 processing. Subsequent siRNA-mediated GPC3 silencing resulted in a temporary inhibition of cell proliferation, migration and ivasion, while inducing apoptosis in transformed hepatocytes.

CONCLUSION

Our data reveal new aspects of the role of GPC3 in early hepatocyte transformation. In addition we conclude that GPC3 may serve as a new HCC immune-therapeutic target.

Imaging the expression of glypican-3 in hepatocellular carcinoma by PET

The glypican-3 (GPC3) receptor is overexpressed in hepatocellular carcinoma (HCC) and is a potential diagnostic and therapeutic target. GPC3-targeted molecular imaging will be helpful to differentiate diagnosis and guide therapy. In the present study, we will develop a novel PET probe for imaging the expression of GPC-3. L5 (sequence: RLNVGGTYFLTTRQ), a GPC3 targeting peptide, was labeled with 5-carboxyfluorescein (FAM) and ¹⁸F-fluoride. Cell binding tests were performed to identify the binding specificity of FAM-L5 and ¹⁸F radiolabeled peptide. MicroPET/CT imaging was used to determine the potential of a novel PET tracer for visualizing HCC tumors with a high expression of GPC3. In vitro binding tests showed that the uptake of FAM-L5 in HepG2 cells (high expression of GPC3) was significantly higher than that of HL-7702 cells (negative expression of GPC3) (mean fluorescent intensity: 14,094 ± 797 vs. 2765 ± 314 events, t = 32.363, P = 0.000). Confocal fluorescent imaging identified that FAM-L5 accumulated where the GPC3 receptor was located. A novel PET tracer (¹⁸F-AlF-NODA-MP-6-Aoc-L5) was successfully labeled by chelation chemistry. In vitro cell uptake studies showed that ¹⁸F-AlF-NODA-MP-6-Aoc-L5 can bind to HepG2 tumor cells and was stable in PBS and mouse serum stability tests. MicroPET/CT showed that HepG2 tumors could be clearly visualized with a tumor/muscle ratio of 2.46 ± 0.53. However, the tumor/liver ratio was low (0.93 ± 0.16) due to the high physiological uptake in the liver. This study demonstrates that FAM and the ¹⁸F-labeled L5 peptide can selectively target HCC with a high expression of GPC3 in vitro and in vivo. ¹⁸F-AlF-NODA-MP-C6-L5 has the potential to be a GPC3 target tracer but requires some chemical modifications to achieve a high enough tumor/liver ratio for detection of the tumor in the liver.

Cellular characteristics of keratin 19-positive canine hepatocellular tumours explain its aggressive behaviour

The expression of the hepatic progenitor cell marker keratin 19 (K19) in canine hepatocellular carcinomas is linked with a poor prognosis. To better understand this aggressive behaviour, K19-positive hepatocellular carcinomas (n=5) and K19-negative hepatocellular adenomas (n=6) were immunohistochemically stained for proteins involved in malignant tumour development. The K19-positive carcinomas showed marked positivity for platelet-derived growth factor receptor alpha polypeptide (PDGFRα), laminin, integrin beta-1/CD29, B-cell-specific Moloney murine leukaemia virus Integration site 1, glypican-3 (GPC-3) and prominin-1/CD133, in contrast with K19-negative hepatocellular adenomas. Conversely, neurofibromatosis type 2 was highly expressed in the hepatocellular adenomas in contrast with the hepatocellular carcinomas. This expression pattern is clearly in line with the observed aggressive behaviour. The presence of the malignancy markers PDGFRα and GPC-3 might make it possible to develop specific strategies to intervene in tumour growth and to devise novel serological tests and personalised treatment methods for canine hepatocellular carcinomas.

Immunohistochemistry in the Diagnosis of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) can be difficult to distinguish from its mimics, including metastatic tumor, benign hepatocellular lesion, and high-grade dysplastic nodule, especially when limited biopsy material is available. Hence, the judicious use of immunohistochemical stains is necessary to establish a correct diagnosis. This article describes advantages and disadvantages of immunohistochemical markers that are most commonly used to distinguish between these lesions. Diagnostic workup of malignant liver mass (HCC and its histologic variants vs metastatic tumor) as well as well-differentiated hepatocellular lesion (well-differentiated HCC vs focal nodular hyperplasia vs hepatocellular adenoma) is also discussed.