Advanced unresectable hepatocellular carcinoma: new biologics as fresh ammunition or clues to disease understanding?

Atezolizumab and Bevacizumab Targeted-Therapy in Advanced Hepatocellular Carcinoma: A Systematic Review of Cost-effectiveness Analyses

BACKGROUND

Atezolizumab (ATZ) plus bevacizumab (BVC) co-administration is one of the newest systemic interventions in advanced hepatocellular carcinoma (AHCC). This treatment approach is more costly and effective than other therapeutic interventions, significantly improving AHCC survival and health-related quality of life.

AIM

This economic study aimed to systematically review all cost-effectiveness analyses of ATZ/BVC combination in AHCC.

METHOD

A comprehensive search in scientific databases was performed using a highly sensitive syntax to find all related economic evaluations. The target population was AHCC patients. The intervention was ATZ/BVC, which was compared with sorafenib, nivolumab, and other anticancer strategies. We included studies that reported quality-adjusted life-years (QALYs) and/or life-years, costs, and incremental cost-effectiveness ratio (ICER), and finally, the characteristics of included studies were categorized.

RESULTS

Out of 315 identified records, 12 cost-effectiveness analyses were eligible for inclusion in the systematic review. Treatment costs were significantly higher with ATZ/BVC in all studies (from 61,397 to 253,687 USD/patient compared to sorafenib and nivolumab, respectively). Incremental QALYs/patient varied from 0.35 to 0.86 compared to sintilimab/BVC and sorafenib. Although ICERs for drugs varied widely, all were united in the lack of cost-effectiveness of the ATZ/BVC. The willingness-to-pay threshold in all studies was lower than the ICER, which indicated a reluctance to pay for this treatment strategy by the health systems.

CONCLUSION

The ATZ/BVC combination is an expensive targeted immunotherapy in AHCC. Significant discounts in ATZ and BVC prices are essential for this novel approach to be cost-effective and extensively used.

Lenvatinib in the treatment of unresectable hepatocellular carcinoma: a systematic review of economic evaluations

PURPOSE

This aim of this study was to conduct a systematic review of economic evaluations comparing lenvatinib to other vascular endothelial growth factor (VEGF) inhibitors and other treatment options in the management of unresectable hepatocellular carcinoma (uHCC).

METHODS

A comprehensive literature search was conducted using highly sensitive search syntax. The titles and abstracts of all records were studied and screened to identify eligible economic evaluations. To enable comparison across different countries, the results of economic evaluations make it possible to compare, the costs and ICER of all studies were converted into 2022 US dollars, and a 3% annual increase for inflation was applied. The quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. This study is conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Lenvatinib was found to be cost-effective (ICER = dominant) compared to most drugs in the included studies, except in studies where it was compared with donafenib or when the price of sorafenib was significantly discounted (e.g., with a 90% discount, the value of ICER was + 104,669 USD).

CONCLUSION

Lenvatinib was generally cost-effective in most studies, but not compared to donafenib or sorafenib (if the price sorafenib was significantly discounted).

FOXK2 affects cancer cell response to chemotherapy by promoting nucleotide de novo synthesis

AIMS

Nucleotide de novo synthesis is essential to cell growth and survival, and its dysregulation leads to cancers and drug resistance. However, how this pathway is dysregulated in cancer has not been well clarified. This study aimed to identify the regulatory mechanisms of nucleotide de novo synthesis and drug resistance.

METHODS

By combining the ChIP-Seq data from the Cistrome Data Browser, RNA sequencing (RNA-Seq) and a luciferase-based promoter assay, we identified transcription factor FOXK2 as a regulator of nucleotide de novo synthesis. To explore the biological functions and mechanisms of FOXK2 in cancers, we conducted biochemical and cell biology assays in vitro and in vivo. Finally, we assessed the clinical significance of FOXK2 in hepatocellular carcinoma.

RESULTS

FOXK2 directly regulates the expression of nucleotide synthetic genes, promoting tumor growth and cancer cell resistance to chemotherapy. FOXK2 is SUMOylated by PIAS4, which elicits FOXK2 nuclear translocation, binding to the promoter regions and transcription of nucleotide synthetic genes. FOXK2 SUMOylation is repressed by DNA damage, and elevated FOXK2 SUMOylation promotes nucleotide de novo synthesis which causes resistance to 5-FU in hepatocellular carcinoma. Clinically, elevated expression of FOXK2 in hepatocellular carcinoma patients was associated with increased nucleotide synthetic gene expression and correlated with poor prognoses for patients.

CONCLUSION

Our findings establish FOXK2 as a novel regulator of nucleotide de novo synthesis, with potentially important implications for cancer etiology and drug resistance.

Decreased expression of 3-hydroxybutyrate dehydrogenase 1 is a prognostic marker and promotes tumor progression in hepatocellular carcinoma

Growing evidence indicates that altered metabolism represents the hallmark of hepatocellular carcinoma (HCC). The mitochondrial 3-hydroxybutyrate dehydrogenase 1 (BDH1) is a key catalytic enzyme in ketogenesis with unknown roles in HCC. Hundred and four tissue sample pairs (HCC tissues, n = 104; matched normal tissues, n = 104) were obtained and analyzed with immunohistochemical (IHC) staining to investigate the clinical and functional role and the diagnostic and prognostic value of BDH1 in HCC. In addition, RNA-Seq datasets from the Tumor Immune Estimation Resource (TIMER) (HCC group, n = 371; normal group, n = 50) and microarray datasets from the Gene Expression Omnibus (GEO) database (HCC tissues, n = 1671; normal tissues, n = 1479) were used to assess BDH1 expression in HCC. Several bioinformatic methods were performed to identify pathways regulated by BDH1. The IHC staining showed that BDH1 expression decreased in HCC tissues (n = 69) compared with that in adjacent normal tissues (n = 35, P < 0.001). Low BDH1 expression was associated with advanced clinical stage (P = 0.033) and vascular invasion (P = 0.007). Moreover, ectopic expression of BDH1 reduced tumor proliferation and suppressed the migration and invasion of HCC cells in vitro. Therefore, our data suggest that BDH1 is a potentially valuable diagnostic biomarker and therapeutic target for HCC.

Role of the Mitochondrial Citrate-malate Shuttle in Hras12V-Induced Hepatocarcinogenesis: A Metabolomics-Based Analysis

The activation of the Ras signaling pathway is a crucial process in hepatocarcinogenesis. Till now, no reports have scrutinized the role of dynamic metabolic changes in Ras oncogene-induced transition of the normal and precancerous liver cells to hepatocellular carcinoma in vivo. In the current study, we attempted a comprehensive investigation of Hras12V transgenic mice (Ras-Tg) by concatenating nontargeted metabolomics, transcriptomics analysis, and targeted-metabolomics incorporating [U-¹³C] glucose. A total of 631 peaks were detected, out of which 555 metabolites were screened. Besides, a total of 122 differently expressed metabolites (DEMs) were identified, and they were categorized and subtyped with the help of variation tendency analysis of the normal (W), precancerous (P), and hepatocellular carcinoma (T) liver tissues. Thus, the positive or negative association between metabolites and the hepatocellular carcinoma and Ras oncogene were identified. The bioinformatics analysis elucidated the hepatocarcinogenesis-associated significant metabolic pathways: glycolysis, mitochondrial citrate-malate shuttle, lipid biosynthesis, pentose phosphate pathway (PPP), cholesterol and bile acid biosynthesis, and glutathione metabolism. The key metabolites and enzymes identified in this analysis were further validated. Moreover, we confirmed the PPP, glycolysis, and conversion of pyruvate to cytosol acetyl-CoA by mitochondrial citrate-malate shuttle, in vivo, by incorporating [U-¹³C] glucose. In summary, the current study presented the comprehensive bioinformatics analysis, depicting the Ras oncogene-induced dynamic metabolite variations in hepatocarcinogenesis. A significant finding of our study was that the mitochondrial citrate-malate shuttle plays a crucial role in detoxification of lactic acid, maintenance of mitochondrial integrity, and enhancement of lipid biosynthesis, which, in turn, promotes hepatocarcinogenesis.

Identification of a Subtype of Hepatocellular Carcinoma with Poor Prognosis Based on Expression of Genes within the Glucose Metabolic Pathway

Hepatocellular carcinoma (HCC) is the most prevalent primary cancer and a highly aggressive liver malignancy. Liver cancer cells reprogram their metabolism to meet their needs for rapid proliferation and tumor growth. In the present study, we investigated the alterations in the expression of the genes involved in glucose metabolic pathways as well as their association with the clinical stage and survival of HCC patients. We found that the expressions of around 30% of genes involved in the glucose metabolic pathway are consistently dysregulated with a predominant down-regulation in HCC tumors. Moreover, the differentially expressed genes are associated with an advanced clinical stage and a poor prognosis. More importantly, unsupervised clustering analysis with the differentially expressed genes that were also associated with overall survival (OS) revealed a subgroup of patients with a worse prognosis including reduced OS, disease specific survival, and recurrence-free survival. This aggressive subtype had significantly increased expression of stemness-related genes and down-regulated metabolic genes, as well as increased immune infiltrates that contribute to a poor prognosis. Collectively, this integrative study indicates that expressions of the glucose metabolic genes could be used as potential prognostic markers and/or therapeutic targets, which might be helpful in developing precise treatment for patients with HCC.

Identification of the Consistently Altered Metabolic Targets in Human Hepatocellular Carcinoma

BACKGROUND & AIMS

Cancer cells rely on metabolic alterations to enhance proliferation and survival. Metabolic gene alterations that repeatedly occur in liver cancer are largely unknown. We aimed to identify metabolic genes that are consistently deregulated, and are of potential clinical significance in human hepatocellular carcinoma (HCC).

METHODS

We studied the expression of 2,761 metabolic genes in 8 microarray datasets comprising 521 human HCC tissues. Genes exclusively up-regulated or down-regulated in 6 or more datasets were defined as consistently deregulated. The consistent genes that correlated with tumor progression markers (ECM2 and MMP9) (Pearson correlation P < .05) were used for Kaplan-Meier overall survival analysis in a patient cohort. We further compared proteomic expression of metabolic genes in 19 tumors vs adjacent normal liver tissues.

RESULTS

We identified 634 consistent metabolic genes, ∼60% of which are not yet described in HCC. The down-regulated genes (n = 350) are mostly involved in physiologic hepatocyte metabolic functions (eg, xenobiotic, fatty acid, and amino acid metabolism). In contrast, among consistently up-regulated metabolic genes (n = 284) are those involved in glycolysis, pentose phosphate pathway, nucleotide biosynthesis, tricarboxylic acid cycle, oxidative phosphorylation, proton transport, membrane lipid, and glycan metabolism. Several metabolic genes (n = 434) correlated with progression markers, and of these, 201 predicted overall survival outcome in the patient cohort analyzed. Over 90% of the metabolic targets significantly altered at the protein level were similarly up- or down-regulated as in genomic profile.

CONCLUSIONS

We provide the first exposition of the consistently altered metabolic genes in HCC and show that these genes are potentially relevant targets for onward studies in preclinical and clinical contexts.

TP53 and RET may serve as biomarkers of prognostic evaluation and targeted therapy in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver. Genomic analysis is conducted to identify genetic alterations in driver genes which are all druggable targets for cancer therapy. In the present study, we performed an exome sequencing of 45 driver genes in 100 paired samples from HCC patients including tumors and matched adjacent normal tissues using Illumina HiSeq 2000 platform. Non-synonymous mutations were ascertained using the iPLEX MassARRAY system and Sanger sequencing. Clinicopathological relevance with genetic variations was assessed using SPSS software. The prognostic analyses of patients with gene mutation status were summarized using Kaplan-Meier curves. Sixty-one non-synonymous somatic mutations were identified in 43% of the HCC patients. The most frequent mutations were: TP53 (20%), RET (6%), PLCE1 (5%), PTEN (4%) and VEGFR2 (3%). Patients with mutations in TP53 had a lower overall survival (OS) (P=0.002) than those without mutations. Recurrent mutations in the Ret proto‑oncogene (RET) were associated with poor outcomes for both disease‑free survival (DFS) (P=0.028) and OS (P=0.001) in HCC patients. The mutational status of sorafenib-targeted genes were associated with decreased DFS (P=0.039), and decreased OS (P=0.15) without statistical significance. Mutual exclusion of TP53 and RET mutations were observed in the present study. In conclusion, patients with TP53 mutations, RET mutations and sorafenib-targeted gene mutations were demonstrated to be associated with poor HCC prognosis, which suggests that both TP53 and RET may serve as biomarkers of prognostic evaluation and targeted therapy in HCC.

Time for paradigm change in management of hepatocellular carcinoma: is a personalized approach on the horizon?

Hepatocellular carcinoma (HCC) is the fifth most frequent cancer form but the second leading cause of all cancer-related deaths. There are several reasons for high mortality in the HCC cohort: lack of effective screening programs and consequently late diagnosis, multifactorial origin with cumulative risk factors, complex carcinogenesis, tumor heterogeneity, unpredictable impacts of individual microenvironment on tumor development and progression, and, as the consequence, frequently untargeted therapy and cancer resistance toward currently applied treatment approaches. The currently applied 'treat and wait' approach is inappropriate in the overall HCC management. Urgent need in paradigm change toward predictive, preventive and personalized medicine is discussed in this review article. Innovative strategies for an advanced predictive, preventive and personalized medicine approach in the overall HCC management benefiting the patient are presented.

Inhibition of hypoxia-inducible factor via upregulation of von Hippel-Lindau protein induces "angiogenic switch off" in a hepatoma mouse model

“Angiogenic switch off” is one of the ideal therapeutic concepts in the treatment of cancer. However, the specific molecules which can induce “angiogenic switch off” in tumor have not been identified yet. In this study, we focused on von Hippel-Lindau protein (pVHL) in hepatocellular carcinoma (HCC) and investigated the effects of sulfoquinovosyl-acylpropanediol (SQAP), a novel synthetic sulfoglycolipid, for HCC. We examined mutation ratio of VHL gene in HCC using 30 HCC samples and we treated the HCC-implanted mice with SQAP. Thirty clinical samples showed no VHL genetic mutation in HCC. SQAP significantly inhibited tumor growth by inhibiting angiogenesis in a hepatoma mouse model. SQAP induced tumor “angiogenic switch off” by decreasing hypoxia-inducible factor (HIF)-1, 2α protein via pVHL upregulation. pVHL upregulation decreased HIFα protein levels through different multiple mechanisms: (i) increasing pVHL-dependent HIFα protein degradation; (ii) decreasing HIFα synthesis with decrease of NF-κB expression; and (iii) decrease of tumor hypoxia by vascular normalization. We confirmed these antitumor effects of SQAP by the loss-of-function experiments. We found that SQAP directly bound to and inhibited transglutaminase 2. This study provides evidence that upregulation of tumor pVHL is a promising target, which can induce “angiogenic switch off” in HCC.

Multimodal treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) represents the most common liver cancer with an increasing incidence and it accounts for the third most common cause of cancer-related death worldwide. Even though the clinical diagnosis and management of HCC improved significantly in the last decades, this malignant disease is still associated with a poor prognosis. It has to be distinguished between patients with HCCs, which developed from liver cirrhosis, and patients without underlying liver cirrhosis as classification systems, prognosis estimation and therapy recommendations differ in-between. In case of HCC in patients with liver cirrhosis in Europe, treatment allocation and prognosis estimation are mainly based on the Barcelona-Clinic Liver Cancer (BCLC) staging system. Based on this staging system different surgical, interventional radiological/sonographical and non-interventional procedures have been established for the multimodal treatment of HCC. The BCLC classification system represents a decision guidance; however because of its limitations in selected patients treatment allocation should be determined on an individualized rather than a guideline-based medicine by a multidisciplinary board in order to offer the best treatment option for each patient. This review summarizes the current management of HCC and illustrates controversial areas of therapeutic strategies.

The EGFR signalling system in the liver: from hepatoprotection to hepatocarcinogenesis

The liver displays an outstanding wound healing and regenerative capacity unmatched by any other organ. This reparative response is governed by a complex network of inflammatory mediators, growth factors and metabolites that are set in motion in response to hepatocellular injury. However, when liver injury is chronic, these regenerative mechanisms become dysregulated, facilitating the accumulation of genetic alterations leading to unrestrained cell proliferation and the development of hepatocellular carcinoma (HCC). The epidermal growth factor receptor (EGFR or ErbB1) signaling system has been identified as a key player in all stages of the liver response to injury, from early inflammation and hepatocellular proliferation to fibrogenesis and neoplastic transformation. The EGFR system engages in extensive crosstalk with other signaling pathways, acting as a true signaling hub for other growth factors, cytokines and inflammatory mediators. Here, we briefly review essential aspects of the biology of the EGFR, the other ErbB receptors, and their ligands in liver injury, regeneration and HCC development. Some aspects of the preclinical and clinical experience with EGFR therapeutic targeting in HCC are also discussed.