Prognostic Value of Lactate Dehydrogenase in Patients with Hepatocellular Carcinoma: A Meta-Analysis. Biomed Res Int. 2018;2018:1723184. [PMID: 30687735 PMCID: PMC6327280 DOI: 10.1155/2018/1723184]

Lactic acid: The culprit behind the immunosuppressive microenvironment in hepatocellular carcinoma

As a solid tumor with high glycolytic activity, hepatocellular carcinoma (HCC) produces excess lactic acid and increases extracellular acidity, thus forming a unique immunosuppressive microenvironment. L-lactate dehydrogenase (LDH) and monocarboxylate transporters (MCTs) play a very important role in glycolysis. LDH is the key enzyme for lactic acid (LA) production, and MCT is responsible for the cellular import and export of LA. The synergistic effect of the two promotes the formation of an extracellular acidic microenvironment. In the acidic microenvironment of HCC, LA can not only promote the proliferation, survival, transport and angiogenesis of tumor cells but also have a strong impact on immune cells, ultimately leading to an inhibitory immune microenvironment. This article reviews the role of LA in HCC, especially its effect on immune cells, summarizes the progress of LDH and MCT-related drugs, and highlights the potential of immunotherapy targeting lactate combined with HCC.

Risk Factors for Post-Operative Pulmonary Infection in Patients With Brain Tumors: A Systematic Review and Meta-Analysis

Background: This study aims to analyze the risk factors for post-operative pulmonary infection in patients with brain tumors by meta-analysis to provide a reference for its prevention. Methods: PubMed, Embase, Web of Science, Cochrane Library, Ovid, and four Chinese databases (CNKI, SinoMed, VIP, and Wanfang databases) were searched for studies covering risk factors of pulmonary infection in patients with brain tumors, limited to the duration from the dates of inception of the respective databases to December 31, 2022. The Newcastle-Ottawa scale was used to assess the evidence. A meta-analysis of the factors affecting the incidence of pulmonary infection was performed using Revman 5.4 software. Results: Twelve studies were selected, covering 35,615 patients with brain tumors, among whom pulmonary infection occurred in 1,635 cases with an accumulated incidence of 4.6%, including 38 related risk factors. Meta-analysis results indicated: history of chronic pulmonary disease (odds ratio [OR], 5.74; 95% confidence interval [CI], 1.34-24.51; p = 0.02], diabetes mellitus (OR, 1.58; 95% CI, 1.29-1.95; p < 0.0001), history of cardiovascular disease (OR, 3.97; 95% CI, 2.18-7.24; p < 0.00001), age ≥60 years (OR, 1.55; 95% CI, 1.12-2.15; p = 0.009)], operation time ≥3 hours (OR, 1.03; 95% CI, 1.00-1.05; p = 0.03], Glasgow Coma Scale (GCS) score <13 (OR, 3.5; 95% CI, 1.90-6.46; p < 0.0001), and the American Society of Anesthesiologists classification (ASA) ≥3 (OR, 2.03; 95% CI, 1.68-2.46; p < 0.00001) as independent risk factors. Conclusions: History of chronic pulmonary disease, diabetes mellitus, history of cardiovascular disease, age ≥60 years, operation time ≥3 hours, GCS score <13, and the ASA grade ≥3 are independent risk factors for post-operative pulmonary infection in patients with brain tumors, which nursing staff should be aware of.

Association between lung immune prognostic index and survival of patients with metastatic urothelial carcinoma treated with pembrolizumab

INTRODUCTION AND OBJECTIVE

Lung immune prognostic index score (LIPI), calculated using the derived neutrophil-lymphocyte ratio and lactate dehydrogenase level, is reported for use in numerous malignancies, while its role on metastatic urothelial carcinoma (mUC) treated with pembrolizumab remains limited. We aimed to investigate association between LIPI and outcomes in this setting.

METHODS

We retrospectively evaluated 90 patients with mUC treated with pembrolizumab at four institutions. The associations between three LIPI groups and progression-free survival (PFS), overall survival (OS), objective response rates (ORRs) or disease control rates (DCRs) were assessed.

RESULTS

Based on the LIPI, good, intermediate, and poor groups were observed in 41 (45.6%), 33 (36.7%), and 16 (17.8%) patients, respectively. The PFS and OS were significantly correlated with the LIPI (median PFS: 21.2 vs. 7.0 vs. 4.0 months, p = 0.001; OS: 44.3 vs. 15.0 vs. 4.2 months, p < 0.001 in the LIPI good vs. intermediate vs. poor groups). Multivariable analysis further revealed that LIPI good (vs. intermediate or poor, hazard ratio: 0.44, p = 0.004) and performance status = 0 (p = 0.015) were independent predictors of a longer PFS. In addition, LIPI good (hazard ratio: 0.29, p < 0.001) were shown to be associated with a longer OS together with performance status = 0 (p < 0.001). The ORRs tended to be different among patients with Good LIPI compared with Poor, and DCRs were significantly different among the three groups.

CONCLUSIONS

LIPI, a simple and convenient score, could be a significant prognostic biomarker of OS, PFS, and DCRs for mUC treated with pembrolizumab.

The hepatocellular carcinoma modified Gustave Roussy Immune score (HCC-GRIm score) as a novel prognostic score for patients treated with atezolizumab and bevacizumab: A multicenter retrospective analysis

AIM

This study investigated whether or not the hepatocellular carcinoma modified Gustave Roussy Immune Score (HCC-GRIm-Score) serves as a prognostic indicator for HCC patients treated with atezolizumab and bevacizumab (Atez/Bev).

METHODS

A total of 405 HCC patients who received Atez/Bev from September 2020 to January 2022 at 22 different institutions were included in this retrospective study. The HCC-GRIm score was based on the combination of the albumin level (<3.5 g/L = 1 point), lactate dehydrogenase (≥245 U/L = 1 point), neutrophil-to-lymphocyte ratio (≥4.8 = 1 point), aspartate aminotransferase-to-alanine aminotransferase ratio (≥1.44 = 1 point), and total bilirubin level (≥1.3 mg/dl = 1 point). Patients were divided into the low-score group (0, 1, or 2 points) and the high-score group (3, 4, or 5 points).

RESULTS

There were 89 (22.0%), 141 (34.8%), 106 (26.2%), 49 (12.1%), 16 (4.0%), and 4 (1.0%) patients with scores of 0, 1, 2, 3, 4, 5, respectively. The progression-free survival (PFS) in the low-score group was significantly longer than that in the high-score group (median 7.8 vs. 3.5 months, p < 0.001). The median overall survival (OS) of the low-score group was not reached at the time cutoff, with a 1-year survival rate of 75.5%, whereas the median OS of the high-score group was 8.5 months, showing a significant difference (p < 0.001). A high HCC-GRIm score was a significant unfavorable factor associated with the PFS and OS in multivariate analyses (p = 0.002 and p < 0.001, respectively).

CONCLUSIONS

The HCC-GRIm score serves as a novel prognostic score for HCC patients treated with Atez/Bev.

Conversion surgery for advanced hepatocellular carcinoma after combination treatment of lenvatinib and camrelizumab: a case report

BACKGROUND

Hepatocellular carcinoma (HCC) is an aggressive malignancy with high morbidity and mortality. Conversion therapy can improve surgical resection rate and prolong survival time for patients with advanced HCC. We show that combination therapy with lenvatinib and camrelizumab is a novel approach to downstage unresectable HCC.

CASE PRESENTATION

A 49-year-old man was diagnosed with massive HCC with hilar lymph node and lung metastases. Since radical resection was not feasible, lenvatinib and camrelizumab were administered as first-line therapy. After 10 cycles of camrelizumab and continuous oral administration of lenvatinib, the tumor exhibited striking shrinkage in volume indicating a partial radiological response, accompanied by a reduction in the alpha-fetoprotein levels, followed by salvage resection. Intriguingly, an improvement in predictive biomarkers, like lactate dehydrogenase (LDH) and neutrophil-to-lymphocyte ratio (NLR), was observed. Notably, the pathological examination found high levels of necrosis in the resected tumor, and flow cytometry analysis indicated a significant increase in the ratio of CD5+ and CD5- B lymphocytes in the peripheral blood. After the treatment, the overall survival period was over 24 months, and no recurrence was observed 17-month post-surgery.

CONCLUSIONS

A combination of lenvatinib and camrelizumab may be a new conversion therapy for initially unresectable HCC to resectable HCC, thus contributing to improve the disease prognosis. In addition, the combination regimen could cause an activated immune response, and LDH, NLR, and CD5+ B-cell levels might be predictors for immunotherapy efficacy.

Evaluation of Lactate Dehydrogenase and Alkaline Phosphatase as Predictive Biomarkers in the Prognosis of Hepatocellular Carcinoma and Development of a New Nomogram

Background

Tumor proliferation is frequently accompanied by aberrant enzyme production. We aim to investigate the potential predictive value of both plasma alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) in patients with HCC and to develop a nomogram to assess the prognosis of HCC.

Methods

The trial involved 2327 patients between May 2015 and March 2022. Within 7 days of enrollment, the levels of ALP and LDH were measured, and their association with survival was assessed. And we had developed and validated a new nomogram based on ALD and ALP.

Results

Using X-tile software, the optimal cut-off values were determined to be ALP = 172 U/L and LDH = 241 U/L. The high ALP (≥ 172), LDH (≥ 241), and ALP/LDH (≥ 0.91) groups had lower median overall survival (mOS) than low ALP (< 172), LDH (< 241), and ALP/LDH (< 0.91) groups (all p < 0.001). In addition, elevated ALP and LDH levels are independent negative prognostic indicators. Moreover, we established that the area under the curve (AUC) values of the predicted 1-, 2-, and 3-year survival rates of receiver operating characteristic curve (ROC) based on the nomogram were 0.79, 0.77, and 0.74, respectively. In addition, the calibration curves and decision curve analyses (DCA) demonstrated that this model possessed strong predictive capability.

Conclusion

ALP, LDH and ALP/LDH can be employed as biomarkers for predicting the prognosis of HCC. Furthermore, the nomograph based on ALH and ALP demonstrates good HCC prediction performance. For HCC patients with high ALH or ALP or ALP/LDH, close surveillance program and adjuvant therapy should be considered.

Warburg effect in colorectal cancer: the emerging roles in tumor microenvironment and therapeutic implications

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related death worldwide. Countless CRC patients undergo disease progression. As a hallmark of cancer, Warburg effect promotes cancer metastasis and remodels the tumor microenvironment, including promoting angiogenesis, immune suppression, cancer-associated fibroblasts formation and drug resistance. Targeting Warburg metabolism would be a promising method for the treatment of CRC. In this review, we summarize information about the roles of Warburg effect in tumor microenvironment to elucidate the mechanisms governing Warburg effect in CRC and to identify novel targets for therapy.

The relationship between objective measures of physical function and serum lactate dehydrogenase in older adults with cancer prior to treatment

BACKGROUND

Lactate dehydrogenase (LDH) reflects tumor burden and is a prognosticator of all-cause mortality in patients with cancer. Objective measures of physical function are associated with clinically relevant outcomes in older adults with cancer. However, whether physical function is associated with LDH in geriatric oncology is unknown. The objective of this study was to assess the relationship between objective measures of physical function and serum LDH in older adults with cancer prior to treatment.

METHODS

Data from older adults with cancer prior to treatment were retrieved from an institutional database and medical records within a tertiary cancer centre. Physical function measures involved muscle strength and physical performance. Muscle strength and physical performance were assessed through grip strength and the Short Physical Performance Battery (SPPB), respectively. LDH was log transformed using the natural logarithm. Multivariable logistic regression was used to examine the relationship between objective measures of physical function and LDH prior to treatment in all participants. Stratified analyses were performed for participants with solid and hematological cancers.

RESULTS

A total of 257 participants (mean age: 80.2y) were included in the analysis. Most participants were females (50.6%) and were diagnosed with locally advanced (26.8%), gastrointestinal disease (35.0%). The multivariable analysis indicated that SPPB was inversely associated with LDH in all participants (B = -0.019, 95%CI = -0.036 to -0.002, p = 0.028). Notably, the inverse relationship between SPPB and LDH persisted only in patients with hematological malignancies in the multivariable model of the stratified analysis (B = -0.049, 95%CI = -0.087 to -0.011, p = 0.013). Neither grip strength alone nor the combination of low grip strength and/or SPPB were associated with LDH. Compared to participants with metastatic disease, those with localized or locally advanced disease had lower serum LDH.

CONCLUSION

Physical performance is inversely associated with serum LDH in older adults with hematological cancers prior to treatment.

New Insights Into a Classification-Based Microvascular Invasion Prediction Model in Hepatocellular Carcinoma: A Multicenter Study

Background and Aims

Most microvascular invasion (MVI)-predicting models have not considered MVI classification, and thus do not reflect true MVI effects on prognosis of patients with hepatocellular carcinoma (HCC). We aimed to develop a novel MVI-predicting model focused on MVI classification, hoping to provide useful information for clinical treatment strategy decision-making.

Methods

A retrospective study was conducted with data from two Chinese medical centers for 800 consecutive patients with HCC (derivation cohort) and 250 matched patients (external validation cohort). MVI-associated variables were identified by ordinal logistic regression. Predictive models were constructed based on multivariate analysis results and validated internally and externally. The models' discriminative ability and calibration ability were examined.

Results

Four factors associated independently with MVI: tumor diameter, tumor number, serum lactate dehydrogenase (LDH) ≥ 176.58 U/L, and γ-glutamyl transpeptidase (γ-GGT). Area under the curve (AUC)s for our M2, M1, and M0 nomograms were 0.864, 0.648, and 0.782. Internal validation of all three models was confirmed with AUC analyses in D-sets (development datasets) and V-sets (validation datasets) and C-indices for each cohort. GiViTI calibration belt plots and Hosmer-Lemeshow (HL) chi-squared calibration values demonstrated good consistency between observed frequencies and predicted probabilities for the M2 and M0 nomograms. Although the M1 nomogram was well calibrated, its discrimination was poor.

Conclusion

We developed and validated MVI prediction models in patients with HCC that differentiate MVI classification and may provide useful guidance for treatment planning.

Metabolism-Associated Epigenetic and Immunoepigenetic Reprogramming in Liver Cancer

Metabolic reprogramming and epigenetic changes have been characterized as hallmarks of liver cancer. Independently of etiology, oncogenic pathways as well as the availability of different energetic substrates critically influence cellular metabolism, and the resulting perturbations often cause aberrant epigenetic alterations, not only in cancer cells but also in the hepatic tumor microenvironment. Metabolic intermediates serve as crucial substrates for various epigenetic modulations, from post-translational modification of histones to DNA methylation. In turn, epigenetic changes can alter the expression of metabolic genes supporting on the one hand, the increased energetic demand of cancer cells and, on the other hand, influence the activity of tumor-associated immune cell populations. In this review, we will illustrate the most recent findings about metabolic reprogramming in liver cancer. We will focus on the metabolic changes characterizing the tumor microenvironment and on how these alterations impact on epigenetic mechanisms involved in the malignant progression. Furthermore, we will report our current knowledge about the influence of cancer-specific metabolites on epigenetic reprogramming of immune cells and we will highlight how this favors a tumor-permissive immune environment. Finally, we will review the current strategies to target metabolic and epigenetic pathways and their therapeutic potential in liver cancer, alone or in combinatorial approaches.

Remodeling of Mitochondrial Plasticity: The Key Switch from NAFLD/NASH to HCC

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and the third-leading cause of cancer-related mortality. Currently, the global burden of nonalcoholic fatty liver disease (NAFLD) has dramatically overcome both viral and alcohol hepatitis, thus becoming the main cause of HCC incidence. NAFLD pathogenesis is severely influenced by lifestyle and genetic predisposition. Mitochondria are highly dynamic organelles that may adapt in response to environment, genetics and epigenetics in the liver ("mitochondrial plasticity"). Mounting evidence highlights that mitochondrial dysfunction due to loss of mitochondrial flexibility may arise before overt NAFLD, and from the early stages of liver injury. Mitochondrial failure promotes not only hepatocellular damage, but also release signals (mito-DAMPs), which trigger inflammation and fibrosis, generating an adverse microenvironment in which several hepatocytes select anti-apoptotic programs and mutations that may allow survival and proliferation. Furthermore, one of the key events in malignant hepatocytes is represented by the remodeling of glucidic-lipidic metabolism combined with the reprogramming of mitochondrial functions, optimized to deal with energy demand. In sum, this review will discuss how mitochondrial defects may be translated into causative explanations of NAFLD-driven HCC, emphasizing future directions for research and for the development of potential preventive or curative strategies.

Prognostic value of lactate dehydrogenase for melanoma patients receiving anti-PD-1/PD-L1 therapy: A meta-analysis

BACKGROUND

Several studies indicate the level of pretreatment lactate dehydrogenase (LDH) may be associated with the prognosis of patients receiving immune checkpoint inhibitors targeting programmed death receptor-1 (PD-1)/programmed death ligand 1 (PD-L1) which had been reported to dramatically improve the survival of patients with advanced or metastatic melanoma; however, no consensus has been reached because the presence of controversial conclusions. This study was to perform a meta-analysis to comprehensively explore the prognostic values of LDH for melanoma patients receiving anti-PD1/PD-L1 monotherapy.

METHODS

A systematic electronic search in the databases of PubMed, EMBASE and the Cochrane library was performed to identify all related articles up to April, 2020. The pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained to assess the prognostic values of pretreatment LDH in blood for overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 22 eligible studies involving 2745 patients were included. Of them, 19 studies with 20 results assessed the OS and the pooled analysis showed that an elevated pretreatment LDH level was significantly associated with a worse OS (HR = 2.44; 95% CI: 1.95-3.04, P < .001). Thirteen studies reported PFS and meta-analysis also revealed that a higher pretreatment LDH level predicted a significantly shorter PFS (HR, 1.61; 95% CI, 1.34-1.92; P < .001). Although heterogeneity existed among these studies, the same results were acquired in subgroup analyses based on sample size, country, study design, cut-off of LDH, type of PD-1/PD-L1 inhibitors and statistics for HRs (all HRs > 1 and P < .05).

CONCLUSION

This meta-analysis suggests LDH may serve as a potential biomarker to identify patients who can benefit from anti-PD-1/PD-L1 and then schedule treatments.

Association Between Statin Use, Intensity and Acute Liver Injury in Human Immunodeficiency Virus, Hepatitis C Virus, and Uninfected US Veterans

OBJECTIVE

We sought to evaluate the relationship between acute liver injury (ALI) and statins utilizing the Veterans Affairs Informatics and Computing Infrastructure (VINCI) database.

METHODS

This retrospective cohort study, spanning January 2000-December 2018, compared ALI (aminotransferase > 200 U/L, severe ALI, and hospitalization with ALI) in statin users and non-users among uninfected, hepatitis C virus (HCV) mono-infected, human immunodeficiency virus (HIV)/HCV co-infected, and HIV mono-infected veterans within 18 months. We estimated adjusted Cox proportional hazards models comparing statin users and non-users and comparing statin intensity level with non-use; and estimate Cox proportional hazards models utilizing time-dependent coding of statin intensity. Adjusted models included restricted cubic splines of the propensity score as an adjustment variable.

RESULTS

From a total of 166,439 patients who met the study criteria, statin initiators were older, had higher values of body mass index, higher values of low-density lipoprotein cholesterol and triglycerides, and lower values of high-density lipoprotein cholesterol. HCV mono-infected and HIV/HCV co-infected cohorts had the highest rates of ALI, and statin users had lower rates across all outcomes of ALI compared with non-users in unadjusted analysis. Statin use is associated with a lower risk of all ALI outcomes compared with non-users. Patients on a high intensity are not associated with a statistically significant increase in risk for any ALI outcome. For each additional 30 days of treatment, there was a reduced risk of any ALI outcome across all cohorts.

CONCLUSIONS

Statin initiators had a lower risk of any ALI outcome compared with non-users within 18 months regardless of HIV and/or HCV status.

Phosphatidylinositol-3,4,5-trisphosphate dependent Rac exchange factor 1 is a diagnostic and prognostic biomarker for hepatocellular carcinoma

BACKGROUND

Phosphatidylinositol-3,4,5-trisphosphate dependent Rac exchange factor 1 (P-Rex1) was reported to be a risk factor in several cancers, including breast cancer, lung cancer, and melanoma, but its expression and role in hepatocellular carcinoma (HCC) have not yet been fully studied.

AIM

To explore the expression of P-Rex1 in HCC, and further evaluate its potential application in the diagnosis and prognosis of HCC, especially in hepatitis B virus (HBV)-related patients.

METHODS

P-Rex1 expression in HCC was evaluated by real-time-quantitative polymerase chain reaction. The expression of P-Rex1 was subjected to correlation analysis with clinical features, such as lymph node invasion, distant metastasis, HBV infection, patient's age and gender. Receiver operating characteristic analysis was used to examine the potential role of P-Rex1 as a diagnostic biomarker in HCC. Kaplan-Meier analysis was used to determine the association between P-Rex1 expression and overall survival, progression-free survival and relapse-free survival. Bioinformatic analysis was used to validate the clinical findings.

RESULTS

P-Rex1 expression was significantly increased in HCC tumors than adjacent tissues. The expression of P-Rex1 was higher in HCC patients with lymph node invasion, distant metastasis, HBV infection and positive alpha-fetoprotein, respectively. The receiver operating characteristic analysis showed that P-Rex1 was a diagnostic biomarker with a higher area under the curve value, especially in patients with HBV infection. Survival analysis showed that patients with higher P-Rex1 expression had a favorable survival rate, even in early-stage patients.

CONCLUSION

P-Rex1 expression was highly increased in HCC, and the expression level of P-Rex1 was positively correlated with tumor progression. P-Rex1 has a higher efficiency in the diagnosis of HBV-related HCC, and could also be used as a favorable prognostic factor for HCC patients.

Impact of Baseline Characteristics on the Overall Survival of HCC Patients Treated with Sorafenib: Ten Years of Experience

Background

Sorafenib has been established as the standard of care for patients with advanced hepatocellular carcinoma (HCC) since 2007 on the basis of two landmark trials (SHARP and Asia-Pacific). Ten years have passed since then and, despite much research in the field, still no validated real-life prognostic markers are available for HCC patients treated with this drug. Therefore, going through 10 years of research into sorafenib of several Italian Cancer Centers, we conducted a field-practice study aimed at identifying baseline clinical factors that could be significantly associated with overall survival (OS).

Method

Univariate/multivariate analyses were conducted to retrospectively identify the impact of baseline characteristics on the OS of 398 advanced HCC patients treated with sorafenib.

Results

Based on univariate analysis, α-fetoprotein (AFP), albumin, AST, bilirubin, Child-Pugh, ECOG, systemic immune-inflammation index (SII), albumin-bilirubin (ALBI) grade, and portal vein thrombosis were significantly associated with shorter OS. Following adjustment for clinical covariates positive in univariate analysis, the multivariate analysis including AFP, age, etiology, albumin, aspartate transaminase (AST), bilirubin, Child-Pugh, LDH, platelet-to-lymphocyte ratio, ECOG, ALBI grade, portal vein thrombosis, SII, and BCLC stage identified increase in LDH, age >70 years, no viral etiologies, ECOG >0, albumin <35, ALBI grade 2, and AST >40 as prognostic factors for poorer OS based on the 5% significance level.

Conclusion

Our study highlights that baseline hepatic function, patient-centered variables, and etiology have prognostic value. These findings might have implications in terms of therapeutic decision-making and patient counseling.