Nonalcoholic Cirrhosis Increased Risk of Digestive Tract Malignancies: A Population-Based Cohort Study

Association between nonalcholic fatty liver disease and pancreatic cancer: Epidemiology, mechanisms, and antidiabetic medication

Extrahepatic malignancies are the leading cause of death in patients with nonalcoholic fatty liver disease (NAFLD). Of these cancers, pancreatic cancer is one of the most lethal; however, the link between NAFLD and pancreatic cancer remains unclear. Recently, various research results have been reported on the association between NAFLD and pancreatic cancer, and the results of compiling this information revealed the following. First, the prevalence of pancreatic cancer in patients with NAFLD is at 0.26%. Second, the currently evident pathogenesis includes intrapancreatic risk factors, such as: (1) non-alcoholic fatty pancreas disease, and (2) intraductal papillary mucinous neoplasm; and extrapancreatic risk factors, such as: (1) insulin resistance and adipocytokines, (2) proinflammatory cytokines, and (3) dysbiosis. Finally, metformin and sodium-glucose cotransporter 2 inhibitors may reduce the risk of pancreatic cancer in diabetes patients with NAFLD. In this review, we summarize the recent evidence on the epidemiology and mechanisms for NAFLD-related pancreatic cancer. We further discuss the impact of anti-diabetic medication on pancreatic cancer.

Association between metabolic dysfunction-associated steatotic liver disease and risk of incident pancreatic cancer: a systematic review and meta-analysis of cohort studies

Background and objectives

Since the results of previous observational studies on the relationship between metabolic dysfunction-associated steatotic liver disease (MASLD) and pancreatic cancer were still controversial and inconsistent, we performed a systematic evaluation and meta-analysis of cohort studies to assess any potential association.

Methods

We conducted a systematic search of PubMed, Embase, and Web of Science databases from the database's inception up to November 30, 2023. For summary purposes, hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using random-effects models, and subgroup and sensitivity analyses were performed as well. The Egger's test and Begg's test were utilized to detect the publication bias.

Results

This meta-analysis included nine cohort studies with a total of 10,428,926 participants. The meta-analysis demonstrated an increased risk of pancreatic cancer in those with MASLD (HR = 1.32, 95% CI: 1.10-1.59, P = 0.003) with moderate heterogeneity (I2 = 54%, P = 0.03). Subsequent subgroup analyses revealed that the pooled HRs remained significantly unchanged, irrespective of the study area, nomenclature of fatty liver disease, and sample size. The results of the sensitivity analyses remained unchanged. No evidence of publication bias was found.

Conclusion

This meta-analysis indicated that MASLD was associated with a higher risk of pancreatic cancer. To further strengthen the association, future prospective cohort studies should take into account different ethnic groups, diagnostic methods of fatty liver, the severity of MASLD, and potential confounding factors, as well as explore the potential mechanisms of pancreatic cancer development in MASLD patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42023489137.

Extrahepatic Outcomes of Nonalcoholic Fatty Liver Disease: Nonhepatocellular Cancers

Nonalcoholic fatty liver disease (NAFLD) encompasses the entire spectrum of fatty liver disease in individuals without significant alcohol consumption, including isolated steatosis, steatohepatitis, and cirrhosis. The overall global prevalence of NAFLD is estimated to be 30%, and the associated clinical and economic burden will continue to increase. NAFLD is a multisystemic disease with established links to cardiovascular disease, type 2 diabetes, metabolic syndrome, chronic kidney disease, polycystic ovarian syndrome, and intra- and extrahepatic malignancies. In this article the authors review the potential mechanisms and current evidence for the association between NAFLD and extrahepatic cancers and the resultant impact on clinical outcomes.

Non-alcoholic fatty liver disease and increased risk of incident extrahepatic cancers: a meta-analysis of observational cohort studies

OBJECTIVE

We performed a meta-analysis of observational studies to quantify the magnitude of the association between non-alcoholic fatty liver disease (NAFLD) and risk of extrahepatic cancers.

DESIGN

We systematically searched PubMed, Scopus and Web of Science databases from the inception date to 30 December 2020 using predefined keywords to identify observational cohort studies conducted in individuals, in which NAFLD was diagnosed by imaging techniques or International Classification of Diseases codes. No studies with biopsy-proven NAFLD were available for the analysis. Meta-analysis was performed using random-effects modelling.

RESULTS

We included 10 cohort studies with 182 202 middle-aged individuals (24.8% with NAFLD) and 8485 incident cases of extrahepatic cancers at different sites over a median follow-up of 5.8 years. NAFLD was significantly associated with a nearly 1.5-fold to twofold increased risk of developing GI cancers (oesophagus, stomach, pancreas or colorectal cancers). Furthermore, NAFLD was associated with an approximately 1.2-fold to 1.5-fold increased risk of developing lung, breast, gynaecological or urinary system cancers. All risks were independent of age, sex, smoking, obesity, diabetes or other potential confounders. The overall heterogeneity for most of the primary pooled analyses was relatively low. Sensitivity analyses did not alter these findings. Funnel plots did not reveal any significant publication bias.

CONCLUSION

This large meta-analysis suggests that NAFLD is associated with a moderately increased long-term risk of developing extrahepatic cancers over a median of nearly 6 years (especially GI cancers, breast cancer and gynaecological cancers). Further research is required to decipher the complex link between NAFLD and cancer development.

Incidence of Hepatocellular Carcinoma in Patients With Nonalcoholic Fatty Liver Disease: A Systematic Review, Meta-analysis, and Meta-regression

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD) may be a risk factor for hepatocellular carcinoma (HCC), but the extent of this association still needs to be addressed. Pooled incidence rates of HCC across the disease spectrum of NAFLD have never been estimated by meta-analysis.

METHODS

In this systematic review, we searched Web of Science, Embase, PubMed, and the Cochrane Library from January 1, 1950 through July 30, 2020. We included studies reporting on HCC incidence in patients with NAFLD. The main outcomes were pooled HCC incidences in patients with NAFLD at distinct severity stages. Summary estimates were calculated with random-effects models. Sensitivity analyses and meta-regression analyses were carried out to address heterogeneity.

RESULTS

We included 18 studies involving 470,404 patients. In patients with NAFLD at a stage earlier than cirrhosis, the incidence rate of HCC was 0.03 per 100 person-years (95% confidence interval [CI], 0.01-0.07; I² = 98%). In patients with cirrhosis, the incidence rate was 3.78 per 100 person-years (95% CI, 2.47-5.78; I² = 93%). Patients with cirrhosis undergoing regular screening for HCC had an incidence rate of 4.62 per 100 person-years (95% CI, 2.77-7.72; I² = 77%).

CONCLUSIONS

Patients with NAFLD-related cirrhosis have a risk of developing HCC similar to that reported for patients with cirrhosis from other etiologies. Evidence documenting the risk in patients with nonalcoholic steatohepatitis or simple steatosis is limited, but the incidence of HCC in these populations may lie below thresholds used to recommend a screening. Well-designed prospective studies in these subpopulations are needed. The protocol for this systematic review is registered in the Prospero database (registration number CRD42018092861).

Overweight with HBV infection limited the efficacy of TACE in hepatocellular carcinoma by inhibiting the upregulated HMGB1

Background

Transarterial chemoembolization (TACE) is an effective treatment for patients with hepatocellular carcinoma (HCC). However, the impact of hepatitis B viral (HBV) infection and body mass index (BMI) on TACE is controversial. The present study aimed to compare the influence of HBV and high BMI on TACE outcomes in advanced HCC.

Methods

Based on HBV infection history and BMI, patients were assigned to different subgroups. Blood samples were collected and analyzed by an enzyme-linked immunosorbent assay (ELISA) kit. The primary endpoint was progression-free survival (PFS) and the overall survival (OS) in the population.

Results

Compared to overweight combined HBV patients who received TACE, people with normal weight or no viral infection had significantly better OS and PFS. Sex, age, portal vein tumor thrombus, BCLC, ECOG, and tumor diameter are the main risk factors affecting PFS and OS. Except for the postoperative fever, no significant difference was detected in adverse reactions. Irrespective of TACE, the average expression of HMGB1 in hepatitis or obesity patients was higher than that in normal individuals and did not show upregulation after TACE. Patients without overweight or HBV infection had a low expression of serum HMGB1 that was substantially upregulated after TACE.

Conclusions

In this study, overweight combined HBV infection patients had shorter PFS and OS than other HCC patients. Thus, HBV and BMI maybe two factors affecting the efficacy of TACE via upregulated HMGB1.

1. High BMI combined with HBV infection has a negative impact on the PFS and OS of HCC patients treated with TACE.

2. Irrespective of TACE, the average HMGB1 in hepatitis and obesity patients was higher than that in normal individuals, which was not upregulated after TACE.

3. Patients without overweight and HBV infection had a low level of serum concentration of HMGB1 before TACE that was upregulated after TACE. Compared to others, these patients have severe changes in HMGB1 in the peripheral blood after treatment, indicating a higher risk of acute liver injury.

4. Upregulated HMGB1 elevated the prognosis after TACE, but obesity and HBV infection resulted in the negative effect by inhibiting HMGB1 expression.

5. For advanced HCC, overweight combined HBV infection, PVTT, multiple lesions, and larger tumor diameter are negative factors for TACE.

The association between nonalcoholic fatty liver disease and esophageal, stomach, or colorectal cancer: National population-based cohort study

We investigated the association between nonalcoholic fatty liver disease (NAFLD) and gastrointestinal tract cancer in the general population. Retrospective data on individuals aged ≥20 years who received healthcare checkups from January 1, 2009 to December 31, 2009 were analyzed using the National Health Insurance Database in Korea. NAFLD was defined based on the fatty liver index (FLI ≥60). The primary outcome was newly diagnosed esophageal, stomach, or colorectal cancer using ICD-10 codes during follow-up until 31 December 2017. Cox regression analysis was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs). Among 8,120,674 subjects, 936,159 adults (11.5%) were identified as having NAFLD. Their mean age was 46.7 ± 14.1 years, and 52.1% were male. During the follow-up period (7.2 years), 3,792 esophageal, 57,292 stomach and 68,769 colorectal cancer cases were identified. FLI ≥60 was significantly associated with the development of esophageal (HR 2.10, 95% CI 1.88-2.35), stomach (HR 1.18, 95% CI 1.14-1.22), and colon cancer (HR, 1.23, 95% CI 1.19-1.26) after multivariable adjustment. Compared to subjects without NAFLD, all-cause mortality in patients with esophageal (HR 1.46, 95% CI 1.28-1.67), stomach (HR 1.26, 95% CI 1.18-1.34), and colorectal cancer (HR 1.16, 95% CI 1.10-1.22) was significantly increased in subjects with NAFLD (FLI ≥60). NAFLD defined using FLI was a good predictive indicator for GI tract malignancy and all-cause mortality in the general population. Subjects with NAFLD are needed for active surveillance of esophageal, stomach, and colorectal cancers.

Abnormal CD44 activation of hepatocytes with nonalcoholic fatty accumulation in rat hepatocarcinogenesis

BACKGROUND

Prevalence of nonalcoholic fatty liver disease (NAFLD) is rapidly increasing, and NAFLD has become one of the most common chronic liver diseases worldwide. With abnormal CD44 activation, the severe form of NAFLD can progress to liver cirrhosis and hepatocellular carcinoma (HCC). Thus, the molecular mechanism of CD44 in NAFLD needs to be identified.

AIM

To investigate the relationship between CD44 activation and malignant transformation of rat hepatocytes under nonalcoholic lipid accumulation.

METHODS

Sprague-Dawley rats were fed a high-fat (HF) for 12 wk to entice NAFLD and then with HF plus 2-fluorenylacetamide (0.05%) to induce HCC. Rats were sacrificed every 2 wk, and subsequently divided into the groups based on liver pathological examination (hematoxylin and eosin staining): NAFLD, denaturation, precancerosis, HCC, and control. Liver CD44 mRNA was detected by OneArray. Liver fat as assessed by Oil red O staining or CD44 by immunohistochemical assay was compared with their integral optic density. Serum CD44, alanine aminotransferase, aspartate aminotransferase, triglyceride, total cholesterol, and AFP levels were quantitatively tested.

RESULTS

Elevated CD44 was first reported in hepatocarcinogenesis, with increasing expression from NAFLD to HCC at the protein or mRNA level. The CD44 integral optic density values were significantly different between the control group and the NAFLD (t = 25.433, P < 0.001), denaturation (t = 48.822, P < 0.001), precancerosis (t = 27.751, P < 0.001), and HCC (t = 16.239, P < 0.001) groups, respectively. Hepatic CD44 can be secreted into the blood, and serum CD44 levels in HCC or precancerous rats were significantly higher (P < 0.001) than those in any of the other rats. Positive correlations were found between liver CD44 and CD44 mRNA (r_s = 0.373, P = 0.043) and serum CD44 (r_s = 0.541, P = 0.002) and between liver CD44 mRNA and serum CD44 (r_s = 0.507, P = 0.004). Moreover, significant correlations were found between liver CD44 and liver AFP (r_s = 0.572, P = 0.001), between serum CD44 and serum AFP (r_s = 0.608, P < 0.001), and between CD44 mRNA and AFP mRNA (r_s = 0.370, P = 0.044).

CONCLUSION

The data suggested that increasing CD44 expression is associated with the malignant transformation of hepatocytes in NAFLD.

Extrahepatic Malignancies in Nonalcoholic Fatty Liver Disease

PURPOSE OF REVIEW

Malignancy is the second most common cause of death in individuals with nonalcoholic fatty liver disease (NAFLD). Understanding unique characteristics of malignancy risk beyond hepatocellular carcinoma in NAFLD has significant implications in counseling and personalized preventative measures in this high-risk population. Herein, we systematically review the literature reporting extra-hepatic malignancies in NAFLD and discuss the key biological mechanisms underpinning the association between excess adiposity and cancer risk.

RECENT FINDINGS

Several studies have shown significant associations between NAFLD and extrahepatic malignancies. The strongest association was found with cancers of the gastrointestinal tract and hormone-sensitive cancers. Recent data support sex-specific differences in cancer risk increase in NAFLD: colorectal cancer in men and uterine cancer in women. The risk of cancer development is higher in NAFLD than obesity alone.

SUMMARY

A growing body of observational evidence over the last decade supports the association between NAFLD and extrahepatic malignancies. This association requires further studies, ideally designed to include more detailed measures of body fat deposition beyond BMI in well-characterized, large cohorts of NAFLD patients, to determine if screening policies should be individualized in this group.

Favorable clinical outcome of nonalcoholic liver cirrhosis patients with coronary artery disease: A population-based study

AIM

To elucidate the prevalence and risk of mortality of nonalcoholic liver cirrhosis (LC) patients with coronary artery disease (CAD).

METHODS

The study cohort included newly diagnosed nonalcoholic LC patients age ≥ 40 years old without a diagnosis of CAD from 2006 until 2011 from a longitudinal health insurance database. The mean follow-up period for the study cohort was 1152 ± 633 d. The control cohort was matched by sex, age, residence, and index date. Hazard ratios (HRs) were calculated using the Cox proportional hazard model and the Kaplan-Meier method.

RESULTS

After exclusion, a total of 3409 newly diagnosed nonalcoholic cirrhotic patients were identified from one million samples from the health insurance database. We found that CAD (5.1% vs 17.4%) and hyperlipidemia (20.6% vs 24.1%) were less prevalent in nonalcoholic LC patients than in normal subjects (all P < 0.001), whereas other comorbidities exhibited an increased prevalence. Among the comorbidities, chronic kidney disease exhibited the highest risk for mortality (adjusted HR (AHR) = 1.76; 95%CI: 1.55-2.00, P < 0.001). Ascites or peritonitis exhibited the highest risk of mortality among nonalcoholic cirrhotic patients (AHR = 2.34; 95%CI: 2.06-2.65, P < 0.001). Finally, a total of 170 patients developed CAD after a diagnosis of nonalcoholic LC. The AHR of CAD in nonalcoholic LC patients was 0.56 (95%CI: 0.43-0.74, P < 0.001). The six-year survival rates for nonalcoholic LC patients with and without CAD were 52% and 50%, respectively (P = 0.012).

CONCLUSION

We conclude that CAD was less prevalent and associated with a reduced risk of mortality in nonalcoholic cirrhotic patients.

Cancer risk in patients with osteoporosis: a population-based cohort study

BACKGROUND

Osteoporosis has been associated with cancer development. We conducted a nationwide population-based cohort study in Taiwan to evaluate this possible association of osteoporosis with subsequent cancer development.

METHODS

A total of 35,979 patients diagnosed with osteoporosis between 2000 and 2010 identified from the National Health Insurance Research Database comprised the osteoporosis cohort, and each patient was randomly frequency matched with one individual from the general population (without osteoporosis) based on age, sex, and year of osteoporosis diagnosis to form the non-osteoporosis (control) cohort. Cox proportional hazard regression analysis was used to calculate adjusted hazard ratios and 95% confidence intervals and determine the effect of osteoporosis on cancer risk.

RESULTS

Patients with osteoporosis showed a significantly higher risk of developing liver and thyroid cancers and lower risk of colorectal cancer than did individuals without osteoporosis. Male patients with osteoporosis had a significantly increased risk for liver cancer, whereas female patients with osteoporosis had a significantly increased risk for thyroid cancer, but a significantly decreased risk for overall and colorectal cancers. In addition, more significant findings were observed when age ≤64 years or the follow-up duration was ≤5 years; however, a significantly lower risk for colorectal cancer was observed when follow-up duration was >5 years. Study limits including lack of data for some health-related behaviors, inclusion criteria of osteoporosis and potential selection bias have been discussed.

CONCLUSION

Patients with osteoporosis showed a higher risk for liver and thyroid cancers and a lower risk for colorectal cancer than did control individuals. Stratified analyses by sex, age, and follow-up duration showed various patterns in different cancers.