Lenvatinib Combined With Transarterial Chemoembolization as First-Line Treatment for Advanced Hepatocellular Carcinoma: A Phase III, Randomized Clinical Trial (LAUNCH)

The immune-reinforcements of Lenvatinib plus anti-PD-1 and their rationale to unite with TACE for unresectable hepatocellular carcinoma treatment

BACKGROUND

Despite encouraging clinical benefits have gained by anti-PD-1 and Lenvatinib combination, in-depth characterizations about the mechanisms of action remain poorly characterized. Furthermore, although the combination of systemic anti-PD-1 or Lenvatinib treatment and locoregional transcatheter arterial chemoembolization (TACE) is widely carried out to treat unresectable HCC in clinical, the efficacies of different combination regimens are uncertain due to limited researches.

METHODS

We firstly generated murine HCC models to validate the enhanced anti-tumor effects of anti-PD-1 and Lenvatinib combination therapy. Then single cell mass cytometry (CyTOF) was employed to phenotypically reveal their mechanisms of action. After that, we further compared the effectiveness of TACE plus Lenvatinib (i.e., TACE-Len) dual therapy with TACE, Lenvatinib plus anti-PD-1 (i.e., TACE-Len-PD-1) triple therapy as conversion therapy for unresectable HCC.

RESULTS

Lenvatinib and anti-PD-1 combination could generate activated immune profiles not only by increasing systemic CD4+, CD8+T cells and B cells proportions, but also by weakening the immune-tolerance functions derived from both immunosuppressive cells (i.e., MDSCs) and co-inhibitory mediators (i.e., PD-L1 and LAG-3). Meanwhile, our study also suggested that TACE-Len-PD-1 triple therapy could achieve better clinical responses with powerful immune profiles for unresectable HCC compared to TACE-Len dual therapy.

CONCLUSIONS

Our study provided a delicate immune landscape of anti-PD-1and Lenvatinib combination, and we also offered scientific evidences that TACE-Len-PD-1 triple therapy could fulfill better clinical benefits than TACE-Len dual therapy, which is anticipated to provide objective and effective evidences for clinical use.

Transarterial Chemoembolization: A Consistent and Continuously Evolving Therapy for Hepatocellular Carcinoma

Since its introduction in 1977, transarterial chemoembolization (TACE) has widely been accepted treatment for unresectable intermediate stage hepatocellular carcinoma (HCC). Conventional TACE (c-TACE) uses an emulsion of chemotherapeutic agent and ethiodized oil with subsequent embolization of the feeding artery using gelatin sponge. Drug eluting beads (DEB) were introduced in clinical practice in the 2000s and have since been used as an alternative to c-TACE with better outcomes, especially in larger tumors. Considering the widespread use of TACE in HCC, it is important to revisit the current knowledge and the advances that have developed for better safety and efficacy. This article aims to emphasize on the current knowledge and importance of TACE, touch upon the technical aspects including post-TACE care, response assessment, and discontinuation strategies and highlight the recent advances in the technology, catheters, and embolization particles. Thus, despite a rapid change in treatment algorithms and availability of newer drugs for HCC, TACE will remain an integral part of HCC treatment alone or in combination with other therapies.

Proposal of discontinuation criteria of atezolizumab plus bevacizumab after curative conversion therapy for unresectable early-to-intermediate-stage hepatocellular carcinoma: a multicenter proof-of-concept study

BACKGROUND

Achieving complete response (CR) is a desirable goal in early-to-intermediate-stage hepatocellular carcinoma (HCC). While systemic and locoregional therapies show promise, optimal drug discontinuation criteria remain unclear. This study aims to investigate drug-off criteria for atezolizumab plus bevacizumab as a proof-of-concept study.

METHODS

This retrospective multicenter study included child-pugh class A patients with unresectable HCC without extrahepatic spread or macrovascular invasion who received atezolizumab plus bevacizumab as first-line therapy. Modified clinical CR (mCCR) was defined as CR per mRECIST with sustained normal alpha-fetoprotein (AFP) levels (< 10.0 ng/dl). Recurrence-free survival (RFS) and overall survival (OS) were analyzed based on the "drug-off" criteria defined by following: (1) mRECIST CR with locoregional therapies, (2) sustained normalization of AFP/AFP-L3/ des-gamma-carboxy prothrombin (DCP) for 12-24 weeks, and (3) complete tumor vascularity disappearance by contrast-enhanced ultrasonography (CEUS) or pathological curative resection.

RESULTS

The median follow-up was 16.5 months (95% CI 15.2-17.8). Among 51 patients achieving mCCR, 11 underwent surgery, with pathological CR in three cases. In contrast, viable lesions were observed in 7 of 40 cases assessed using CEUS. All patients meeting the drug-off criteria (n = 9) showed no recurrence and none of them experienced mortality, while 45.2% (19/42) of those not meeting the criteria experienced recurrence (median RFS: 12.8 months, p = 0.007). The median OS was not reached in dug-off criteria met patients (n = 9), 37.7 months (95% CI: NA) in non-criteria met patients (n = 42), and 27.1 months (95% CI 16.7-37.6) in non-mCCR patients (n = 184) (p < 0.001).

CONCLUSION

In patients with unresectable and TACE-unsuitable early-to-intermediate-stage HCC who met the drug-off criteria, significantly improved RFS and OS were observed compared those who did not meet the criteria. However, further validation studies are required to confirm the utility of the criteria.

Advances in the treatment of hepatocellular carcinoma: An overview of the current and evolving therapeutic landscape for clinicians

Hepatocellular carcinoma (HCC) is the sixth most common malignancy and the third leading cause of cancer-related death worldwide. Contemporary advances in systemic and locoregional therapies have led to changes in peer-reviewed guidelines regarding systemic therapy as well as the possibility of downstaging disease that may enable some patients with advanced disease to ultimately undergo partial hepatectomy or transplantation with curative intent. This review focuses on all modalities of therapy for HCC, guided by modern-day practice-changing randomized data where available. The surgical management of HCC, including resection and transplantation, both of which have evolving criteria for what is considered biologically resectable and transplantable, as well as locoregional therapy (i.e., therapeutic embolization, ablation, radiation, and hepatic arterial infusion), are discussed. Historical and modern-day practice-changing trials evaluating immunotherapy with targeted therapies for advanced disease, as well as adjuvant systemic therapy, are also summarized. In addition, this article examines the critical dimension of toxicities and patient-oriented considerations to ensure a comprehensive and balanced discourse on treatment implications.

Biomarker, efficacy and safety analysis of transcatheter arterial chemoembolization combined with atezolizumab and bevacizumab for unresectable hepatocellular carcinoma

OBJECTIVE

Transcatheter arterial chemoembolization (TACE) combined with atezolizumab and bevacizumab (Atezo-Bev) [Atezo-Bev-TACE] has shown promising therapeutic efficacy in patients with unresectable hepatocellular carcinoma (uHCC). However, there is currently no published research on biomarkers that can predict the treatment outcomes of Atezo-Bev-TACE. This study aims to evaluate the predictive value of the baseline neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in uHCC patients undergoing Atezo-Bev-TACE treatment.

METHODS

This retrospective study included uHCC patients who received Atezo-Bev-TACE and tyrosine kinase inhibitors (TKIs) at the First Affiliated Hospital of the University of Science and Technology of China between November 1, 2020, and November 1, 2023. The primary endpoint of the study was the correlation between baseline NLR and PLR with overall survival (OS) and progression-free survival (PFS). The secondary endpoints were the efficacy and safety of the Atezo-Bev-TACE regimen.

RESULTS

Among the 71 enrolled patients with uHCC who received Atezo-Bev-TACE therapy, the objective response rate was 55.0%, with a median OS of 20.0 months (95% confidence interval [CI] 17.4-21.0 months) and a median PFS of 10.4 months (95% CI 7.7-13.1 months). Patients with tumor response had significantly lower baseline NLR and PLR values compared to those without response (2.5 vs. 4.0, P < 0.001; 106.9 vs. 131.3, P = 0.001). The optimal cut-off values for NLR and PLR were determined to be 2.9 and 148.0, respectively, based on receiver operating characteristic curves. Patients with baseline NLR < 2.9 had significantly longer median OS (not reached vs. 17.8 months, P = 0.014) and improved median PFS (15.6 months vs. 9.3 months, P = 0.034) compared to those with NLR ≥ 2.9. Similarly, patients with baseline PLR < 148.0 had a significantly better median OS (20.0 months vs. 12.0 months, P = 0.004) and longer median PFS (13.7 months vs. 6.4 months, P < 0.001) compared to those with PLR ≥ 148.0. Univariate and multivariate Cox regression analyses identified baseline PLR ≥ 148.0 as an independent risk factor for poorer survival outcomes. Additionally, most adverse events (AEs) observed during Atezo-Bev-TACE treatment were grade 1-2, with fewer grade 3-4 AEs, and no grade 5 AEs were reported. Comparative analysis between the Atezo-Bev-TACE group (71 patients) and the TKIs-TACE group (63 patients) demonstrated that the ORR of the TKIs-TACE group was 34.9%, lower than that of the Atezo-Bev-TACE group (55.0%). No statistically significant differences were observed in baseline characteristics between the two groups before treatment. The median OS in the Atezo-Bev-TACE group was 20.0 months, significantly superior to the 14.7 months in the TKIs-TACE group (P = 0.005). Similarly, the median PFS in the Atezo-Bev-TACE group was 10.4 months, significantly better than the 7.8 months in the TKIs-TACE group (P = 0.008).

CONCLUSION

A baseline NLR ≥ 2.9 and PLR ≥ 148.0 may serve as predictive factors for poor OS and PFS in uHCC patients receiving Atezo-Bev-TACE treatment. Furthermore, the Atezo-Bev-TACE regimen demonstrates good efficacy and safety in the clinical management of uHCC patients.

RALOX-HAIC (raltitrexed + oxaliplatin) combined with lenvatinib improves survival and safety in elderly patients with unresectable hepatocellular carcinoma

OBJECTIVE

To explore the efficacy and safety of RALOX-HAIC (raltitrexed plus oxaliplatin) combined with lenvatinib in the treatment of elderly patients with unresectable hepatocellular carcinoma (uHCC), aiming to provide a safer and more effective therapeutic strategy for this patient population.

MATERIALS AND METHODS

A retrospective analysis was conducted on the clinical data of 82 elderly patients with uHCC who received treatment in the Department of Interventional Radiology at Wuhan Union Hospital from January 2019 to December 2022. Patients were divided into two groups based on their treatment strategy: HAIC + Lenvatinib group (N = 39) and TACE group (N = 43). The primary endpoints were the objective response rate (ORR), disease control rate (DCR), overall survival (OS), and progression-free survival (PFS) in the two groups. The secondary endpoint was the incidence of treatment-related adverse events in both groups.

RESULTS

The ORR and DCR after treatment were higher in the HAIC + Lenvatinib group compared to the TACE group (61.5% vs. 37.2%, 82.1% vs. 58.1%, P < 0.05). The HAIC + Lenvatinib group had a longer median progression-free survival (mPFS,9.2 months vs. 4.6 months, P < 0.001) and ​median overall survival(mOS, 18.1 months vs. 10.6 months, P < 0.001) compared to the TACE group. The incidence of abdominal pain and fever was significantly higher in the TACE group than in the HAIC + Lenvatinib group (including all grades and grades 3/4, P < 0.05). The incidence of hand-foot syndrome (all grades) was higher in the HAIC + Lenvatinib group compared to the TACE group (15.4% vs. 0.0%, P = 0.009), but there was no significant difference in the incidence of grade 3/4 hand-foot syndrome between the two groups (2.6% vs. 0.0%, P = 0.476).

CONCLUSION

This study demonstrates that RALOX-HAIC combined with lenvatinib provides superior survival outcomes and tolerability compared to TACE alone ​in elderly patients (≥ 70 years) with unresectable HCC. This combination therapy may be a feasible and safe option for improving the prognosis of elderly patients with uHCC.

Comparing PD-L1 and PD-1 inhibitors plus bevacizumab combined with hepatic arterial interventional therapies in unresetable hepatocellular carcinoma: A single-center, real-world study

With the rise of anti-vascular endothelial growth factor antibody and programmed cell death-ligand 1 (PD-L1) regimens, particularly bevacizumab and atezolizumab, as first-line treatments for advanced hepatocellular carcinoma (HCC), there is a need to explore PD-L1 and programmed cell death 1 inhibitors in combination therapies for unresectable HCC (uHCC). Integrating systemic therapies with locoregional approaches is also emerging as a potent strategy. This study compares the outcomes of atezolizumab (PD-L1 inhibitor) and sintilimab (programmed cell death 1 inhibitor) with bevacizumab or its biosimilar, combined with hepatic arterial interventional therapies (HAIT) in uHCC patients. From January 2020 to September 2023, a retrospective analysis was conducted on 138 uHCC patients at Sun Yat-sen University Cancer Center. The cohort included 69 patients treated with atezolizumab with bevacizumab (Bev/Ate) and 69 with bevacizumab biosimilar with sintilimab (Bio/Sin), combined with HAIT. The propensity score matching was also employed to further explore the efficacy and safety. The median progression-free survival (mPFS) was 13.8 months for the Bev/Ate group and 10.0 months for the Bio/Sin group (p = 0.188). The Bev/Ate group showed significantly longer intrahepatic mPFS (HR 0.381; 95% confidence interval 0.176-0.824; p = .018) and higher overall response rates compared with the Bio/Sin group (60.87% vs. 31.88%, p = .001; 69.57% vs. 49.28%, p = .024) based on Response Evaluation Criteria in Solid Tumors v1.1 and modified Response Evaluation Criteria in Solid Tumors criteria. Treatment-related adverse events were similar between groups (p > .050). Combining atezolizumab or sintilimab with bevacizumab or its biosimilar alongside HAIT provided similar overall PFS in uHCC patients. However, the atezolizumab-bevacizumab combination with HAIT showed superior intrahepatic PFS and control rates, warranting further validation.

Synergistic Effects of Transarterial Chemoembolization and Lenvatinib on HIF-1α Ubiquitination and Prognosis Improvement in Hepatocellular Carcinoma

PURPOSE

A recent trial has shown that adding transarterial chemoembolization (TACE) to lenvatinib therapy results in enhanced therapeutic efficacy in hepatocellular carcinoma (HCC). We aimed to assess the effectiveness of the lenvatinib and TACE combination in a real-world clinical context for managing HCC and to elucidate the molecular pathways involved.

EXPERIMENTAL DESIGN

This retrospective analysis included 199 patients diagnosed with HCC and having intrahepatic lesions between 2018 and 2021. The cohort was divided into those who received lenvatinib plus TACE (n = 62, combination group) and those who received lenvatinib monotherapy (n = 137, monotherapy group). To further explore the underlying mechanisms, Huh-7 cells were exposed to lenvatinib or a vehicle for 48 hours under normoxic or hypoxic conditions.

RESULTS

Propensity score-matched analysis revealed a significant improvement in both overall survival (adjusted HR, 0.38; 95% confidence interval, 0.24-0.59; P < 0.001) and progression-free survival (adjusted HR, 0.41; 95% confidence interval, 0.26-0.64; P < 0.001) in the combination group compared with the monotherapy group. In laboratory experiments, under hypoxic conditions, lenvatinib notably attenuated hypoxia-inducible factor-1α (HIF-1α) protein levels in Huh-7 cells without altering its mRNA levels. Intriguingly, lenvatinib facilitated the mouse double minute 2 homolog-mediated ubiquitination and subsequent degradation of HIF-1α. Additionally, cell viability assays confirmed a significant decrease in Huh-7 cell survival following lenvatinib treatment under hypoxic conditions.

CONCLUSIONS

The combination of lenvatinib and TACE significantly improved survival in patients with HCC. The mechanistic foundation seems to be the lenvatinib-triggered degradation of HIF-1α via the mouse double minute 2 homolog-dependent ubiquitination pathway, highlighting a potential therapeutic target in HCC treatment.

The efficacy of transarterial chemoembolization combined with helical iodine-125 seed implant, lenvatinib and PD-1 inhibitors in patients with hepatocellular carcinoma complicated by main portal vein tumor thrombus: a retrospective study

Purpose

To evaluate the efficacy and safety of a multimodal therapeutic approach involving transarterial chemoembolization (TACE) in conjunction with helical iodine-125 (I-125) seed implant, lenvatinib, and programmed cell death-1(PD-1) inhibitors for hepatocellular carcinoma (HCC) complicated by main portal vein tumor thrombus (MPVTT).

Material and methods

HCC patients with MPVTT treated with TACE coupled with helical I-125 implant, lenvatinib, PD-1 inhibitors between September 2019 and August 2022 were retrospectively analyzed, and constituted as study group. Those treated with TACE, helical I-125 seed implant, and sorafenib between December 2016 and August 2020 served as the historical control group. All patients received sorafenib or lenvatinib combined with PD-1 inhibitors within 3-7 days after TACE and helical I-125 seed implantation. The longest follow-up period for all patients in both groups was 36 months from the date of helical I-125 seed implantation. Primary outcome was overall survival time (OS), and secondary outcomes were progression free survival time (PFS), objective response rate (ORR), and disease control rate (DCR). The Cox proportional hazards regression model was employed to identify independent prognostic factors influencing OS and PFS. The value P < 0.05 was deemed statistically significant.

Results

A total of 53 patients were enrolled, with 22 assigned to the study group and 31 to the control group. The study group exhibited superior overall ORR(54.5% vs. 25.8%, P = 0.033) and overall DCR (77.3% vs. 64.5%, P = 0.319). Notably, the ORR and DCR of MPVTT were higher in the study group (86.4% vs. 51.6%, P = 0.008; and 95.5% vs. 83.9%, P = 0.382, respectively). Median OS (16.1 ± 6.1 months vs. 10.2 ± 0.8 months, P = 0.008) and PFS (13.6 ± 3.0 months vs. 6.1 ± 0.6 months, P = 0.014) were prolonged in the study group. The maximal tumor size, alpha fetoprotein level, and treatment modality were independent predictors for OS, while the maximal tumor size and treatment modality were independent determinants for PFS. Study group showed frequent hypothyroidism and reactive cutaneouscapillary (P < 0.01), with comparable grade 3/4 adverse events between groups.

Conclusions

The integration of the helical I-125 seed implant with TACE, lenvatinib, and PD-1 inhibitors is the safe and efficacious approach in the management of HCC complicated by MPVTT.

Hepatic artery infusion chemotherapy combined with camrelizumab and apatinib as conversion therapy for patients with unresectable hepatocellular carcinoma: a single-arm exploratory trial

BACKGROUND

The development of systemic therapy, including targeted drugs and immune checkpoint inhibitors, has significantly improved the prognosis of patients with advanced unresectable hepatocellular carcinoma (uHCC). Hepatic arterial infusion chemotherapy (HAIC) has been gradually applied to the treatment of advanced uHCC, showing good potential as conversion therapy. We aimed to investigate the efficacy and safety of HAIC combined with camrelizumab and apatinib as conversion therapy for uHCC.

METHODS

This study was a single-arm exploratory trial (NCT05099848) in patients with uHCC. Eligible patients received apatinib 250 mg once daily, camrelizumab 200 mg on day 3, and HAIC with FOLFOX regimen (oxaliplatin 85 mg/m2 at hours 0-2, leucovorin 400 mg/m2 at hours 2-3, and fluorouracil 400 mg/m2 at hour 3, followed by fluorouracil 2400 mg/m2 for 46 h) on days 4-5 of each 21-day cycle for up to 8 cycles. Primary endpoints were conversion rate and margin-free (R0) resection rate.

RESULTS

Between March 2021 and July 2023, 19 patients were enrolled. Median follow-up was 14.9 months (interquartile range, 10.9-21.1). Disease became resectable in 14 (73.7%) of 19 patients; nine (47.4%) patients received R0 resection, while five (26.3%) refused surgery and opted for observation. Three (33.3%) of nine patients with surgery achieved major pathological response, including two (22.2%) with pathological complete response. Objective response and disease control rates were 47.4% (9/19) and 89.5% (17/19) per Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1 and both 89.5% (17/19) per modified RECIST. Survival data were immature. Fourteen (73.7%) of 19 patients had grade 3 or higher treatment-related adverse events, with the most common being increased alanine aminotransferase or aspartate aminotransferase (seven [36.8%]) and increased lymphocyte count (six [31.6%]). No treatment-related deaths occurred.

CONCLUSIONS

The combination of HAIC, camrelizumab, and apatinib as conversion therapy shows promising clinical benefits and a manageable safety profile in patients with uHCC. Future randomized controlled trials are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05099848. Registered on October 13, 2021.

The Combined Use of Lenvatinib and Locoregional Therapies for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a commonly diagnosed malignancy, with the treatment for transplant-ineligible localized disease traditionally relying on locoregional therapies, such as surgical resection, transarterial chemoembolization (TACE), and transarterial radioembolization (TARE). Systemic therapy has historically been reserved for advanced, unresectable HCC. However, lenvatinib, an oral multikinase inhibitor, has recently gained traction as part of a multimodal approach for localized HCC in combination with locoregional treatments. An upfront TACE or TARE can induce tumor hypoxia, leading to the upregulation of hypoxia-inducible factor-1 alpha (HIF-1α) and vascular endothelial growth factor (VEGF), which promotes tumor angiogenesis and progression. The rationale for combining lenvatinib with a locoregional therapy is to enhance tumor shrinkage while preserving liver function before a definitive intervention. Clinical trials, such as TACTICS and LAUNCH, have demonstrated improved outcomes with this approach. Additionally, retrospective studies, including those incorporating immune checkpoint inhibitors, have reported further benefits. This review explores the combination of lenvatinib with various locoregional modalities, including TARE, microwave ablation (MWA), and radiofrequency ablation (RFA), highlighting their indications and clinical outcomes. Furthermore, we discuss the ongoing and upcoming clinical trials investigating the integration of systemic agents with locoregional therapies for intermediate-stage HCC, including EMERALD-1, EMERALD-3, LEAP-012, and CheckMate 74W.

A questionnaire survey to explore the current treatment policies adopted for patients with advanced hepatocellular carcinoma at board-certified HPB training institutions in Japan: A JSHBPS project study 2023, Part 1

PURPOSE

To clarify the views of expert hepatobiliary surgeons on the management of advanced hepatocellular carcinoma (HCC) in real-world clinical practice.

METHODS

A questionnaire survey was conducted of Japanese board-certified HPB training centers.

RESULTS

A total of 100 centers responded to the survey. For solitary large (>10 cm) lesions, 77% of the respondents selected upfront surgery, while an increasing number of respondents selected combined therapy with atezolizumab + bevacizumab as the treatment of first choice as the number of lesions increased. In regard to the treatment of patients with vascular invasion, the proportion of respondents who selected systemic therapy with the intent to "potential conversion" surgery increased according to the extent of tumor thrombosis, while only a limited number of respondents excluded these groups of patients from potential surgical indications. As for the initial treatment for extrahepatic spread, consideration of systemic conversion therapy was the most commonly selected option, while upfront surgery was frequently selected for right adrenal metastasis (50%) and solitary hilar node involvement (35%).

CONCLUSIONS

The present survey clarified the current clinical approaches for the treatment of advanced HCC at HPB training centers. Future analysis, including survival outcomes, would offer important insights into the optimal management of advanced HCC.

Prognostic factors and clinical significance of preoperative systemic therapy in patients with borderline resectable hepatocellular carcinoma: A JSHBPS project study 2023, Part 2

PURPOSE

To explore factors influencing the prognosis in patients with borderline-resectable hepatocellular carcinoma (BR-HCC) undergoing surgery.

METHODS

The clinical data of patients with BR-HCC according to the definition in the Expert Consensus Statement 2023 were collected from board-certified HPB training centers and analyzed in detail.

RESULTS

Data of a total of 1509 patients with BR-HCC (BR1, n = 718 and BR2, n = 791) who underwent surgery were collected. The 5-year disease-specific survival rate (DSS) and 3-year recurrence-free survival rate (RFS) were determined as 40.8% and 19.7%, respectively. Multivariate analysis identified the oncological resectability category (i.e., BR2 vs. BR1) as a significant prognostic factor, and also the number of criteria fulfilled for classification into BR2 disease as being predictive of the DSS (hazard ratio (HR) [95% CI]: one factor: 1.32 [1.13-1.54]; two to three factors: 1.51 [1.15-1.96]). Preceding systemic therapy was significantly correlated with a longer DSS (HR, 0.41: 95% CI, 0.18-0.91) and RFS (HR, 0.80: 95% CI, 0.66-0.97) in the patients with BR1 disease, while its clinical significance was unclear in the patients with BR2 disease.

CONCLUSION

Multicenter data confirm the clinical relevance of the oncological resectability category and the potential advantage of preceding systemic therapy in a specific group of BR-HCC.

Anticancer effects of vitamin K combined with transarterial chemoembolization in hepatocellular carcinoma, a randomized controlled trial

BACKGROUND

We have previously reported that vitamin K dosing augments the anticancer effects of sorafenib by suppressing levels of des-γ-carboxy prothrombin, a known tumor growth and angiogenesis factor produced in HCC under sorafenib-induced ischemia. Herein, we aimed to establish whether vitamin K dosing could afford a similar anticancer effect when combined with transarterial chemoembolization (TACE).

METHODS

We performed a randomized controlled trial, assigning patients with unresectable HCC (1:1) to TACE + vitamin K or TACE alone groups. Co-primary endpoints were objective response rate and PFS; the secondary endpoint was safety.

RESULTS

The TACE + vitamin K group (n = 50) exhibited a significantly higher objective response rate than the TACE alone group (n = 51) (96.0% vs. 82.4%, p = 0.028). The PFS was significantly longer in the TACE + vitamin K group than that in the TACE alone group (median time: 262 days [95% confidence interval (CI), 35.8-488.2 days] vs. 146 days [95% CI, 111.6-180.4 days]; p = 0.013, hazard ratio: 0.55 [95% CI, 0.34-0.89]). There were no significant differences in the incidence of adverse events between groups.

CONCLUSIONS

Compared with TACE alone, vitamin K dosing combined with TACE improved anticancer outcomes.

CLINICAL TRIAL NUMBER

UMIN000026404.

Next‐Generation Flexible Embolic Systems: Targeted Transarterial Chemoembolization Strategies for Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) remains the gold standard for treating intermediate‐stage hepatocellular carcinoma (HCC), yet faces great challenges in overcoming tumor heterogeneity, hypoxia‐induced angiogenesis, and metastatic progression. The development of advanced flexible embolization materials marks a revolutionary leap in interventional therapy, offering opportunities to revolutionize embolization precision, drug delivery kinetics, and tumor microenvironment modulation. This comprehensive review systematically examines the paradigm shift toward next‐generation TACE technology, emphasizing the limitations of conventional approaches and innovations in flexible embolic agents. A detailed discussion of next‐generation nano‐flexible embolic systems is presented, emphasizing their unique coagulation dynamics, real‐time imaging capabilities, and therapeutic precision. The review delves into groundbreaking TACE strategies integrating hypoxia modulation, energy conversion therapeutics, and sophisticated tumor microenvironment engineering. Clinical translation aspects are thoroughly explored, including large‐scale trial outcomes, vascular recanalization dynamics, and patient‐specific treatment optimization. Looking forward, key frontiers in the field is identified: intelligent nanocomposite systems, synergistic combination therapies, and precision medicine approaches tailored to individual tumor biology. This work not only objectively evaluates current progress but also charts future research priorities, aiming to transform TACE from a palliative intervention to a precision medicine platform and ultimately reshaping the landscape of HCC treatment and patient care.

Combination locoregional and systemic therapies in hepatocellular carcinoma

Locoregional therapies play a fundamental role in the treatment of patients with early and intermediate and locally advanced hepatocellular carcinomas. With encouraging recent advances in immunotherapy-based systemic therapies, locoregional therapies are being both promoted and challenged by new systemic therapy options. Combined locoregional and systemic therapies might enhance treatment outcomes compared with either option alone. This Series paper summarises the existing data on locoregional and systemic therapies for hepatocellular carcinoma, and discusses evidence from studies investigating their combination with a focus on their synergistic efficacy and safety.

Fournier's Gangrene During Lenvatinib Treatment for Hepatocarcinoma

Antiangiogenic drugs such as lenvatinib have demonstrated significant benefits in patients with hepatocarcinoma (HCC), with an acceptable safety profile. However, serious side effects have been documented, though rare. In this report, we describe the case of a severe and unexpected toxicity encountered after about seven months of lenvatinib treatment. The patient developed a septic state, widespread cutaneous erythema with extensive necrotic involvement of the pelvic floor, with a diagnosis of Fournier's gangrene (FG). Emergency surgery, including sigmoidostomy and wide necrosectomy, was necessary, and further surgeries were performed in the following days due to persistent necrotic tissue. FG is a rare form of necrotizing fasciitis that has been described as rarely associated with several antiangiogenics, even in the absence of major risk factors. Cases of FG have been rarely documented in association with lenvatinib treatment, and this is the first report on a European HCC patient receiving an 8 mg daily dose. Considering the ever-growing use of antiangiogenics in HCC patients and their clinical complexity, it is crucial to be vigilant even about rare toxicities like FG, especially with known concomitant risk factors. Careful monitoring and a multidisciplinary approach are fundamental to promptly identify and address potentially life-threatening complications.

Advances in radiation therapy for HCC: Integration with liver-directed treatments

HCC is the fourth leading cause of cancer-related mortality with increasing incidence worldwide. Historically, treatment for early disease includes liver transplantation, surgical resection, and/or other local therapies, such as thermal ablation. As a result of technical advances and high-quality prospective data, the use of definitive external beam radiotherapy with ablative doses has emerged. Intermediate-stage disease has been generally addressed with arterially directed therapies (eg, chemoembolization or radioembolization) and external beam radiotherapy, while advanced stages have been addressed by systemic therapy or best supportive care. The role of each local/locoregional therapy has rapidly evolved in the context of novel pharmacotherapies, including immunotherapies and antiangiogenic agents. The combinations, indications, and timing of treatments vary widely among specialties and geographies. Here, we aim to synthesize the best quality evidence available regarding the efficacy and safety of different liver-directed modalities, with a focus on recent prospective clinical data of external beam radiotherapy within the context of other available liver-directed therapies across Barcelona Liver Classification (BCLC) stages.

Transarterial Chemoembolization for Hepatocellular Carcinoma: Current Role and Techniques

In the current systemic therapy era, such as immunotherapy and molecular targeted therapy, treatment strategy of hepatocellular carcinoma is changing. Transarterial chemoembolization is more expected as a curative treatment option than before. Therefore, it is important to learn key techniques of transarterial chemoembolization procedures to achieve complete response. This article delineates the current indications for transarterial chemoembolization and several techniques used for its implementation.

Systemic Therapy Combined with Locoregional Therapy in Intermediate-stage Hepatocellular Carcinoma

Recent advances in systemic therapy for hepatocellular carcinoma are remarkable. The treatment goal for advanced hepatocellular carcinoma is to prolong survival, while for intermediate-stage hepatocellular carcinoma, it is to achieve a cancer-free and drug-free status. Patients unsuitable for transarterial chemoembolization may benefit from prior systemic therapy with lenvatinib or atezolizumab plus bevacizumab. The TACTICS-L trial, a prospective phase II trial, demonstrated favorable progression-free and overall survival by lenvatinib-transarterial chemoembolization sequential therapy. The REPLACEMENT trial, a multicenter, prospective, single-arm phase II trial, confirmed combination immunotherapy efficacy with atezolizumab plus bevacizumabin a population exceeding up-to-seven criteria. In a proof-of-concept study, atezolizumab plus bevacizumab plus curative therapy showed a 35% complete response rate and 23% drug-free status in intermediate-stage hepatocellular carcinoma patients with a tumor burden exceeding up-to-seven criteria.

Latin American expert opinion letter on the feasibility of systemic therapies in combination with locoregional therapies for hepatocellular carcinoma

Recent advances in the systemic treatment of advanced hepatocellular carcinoma (HCC) with immunotherapy have once again reignited discussion over the role of combined therapy in earlier stages. This year, different international meetings have presented recent results from clinical trials on adjuvant therapy alone (IMBrave-050) and combined with transarterial chemoembolization (EMERALD-1 and LEAP-12). Increased enthusiasm for the use of adjuvant and neoadjuvant therapy for liver transplantation, surgery, and local-regional treatment of HCC has been shown. However, the initial results from these trials should be interpreted cautiously as we wait for final analyses and effects on overall survival. In this position paper from the special interest group from the Latin American Association for the Study of Liver Diseases (ALEH), we underline the caveats of the applicability of these potential treatments in our region, explore points of agreement, and highlight areas of uncertainty. Moreover, we underscore the role of hepatologists in the clinical decision-making process and management of these patients.

Identification of candidates with hepatocellular carcinoma to receive TACE combined with MWA by assessing tumor burden and radiologic features

Background

There is still no noninvasive, automated, and accurate model for guiding physicians in the decision-making of transarterial chemoembolization combined with microwave ablation (TACE-MWA) in intermediate-stage hepatocellular carcinoma (HCC).

Objectives

To develop a prognostic score based on the tumor burden and radiomic features for the prediction of the long-term survival of patients with intermediate-stage HCC after TACE-MWA.

Methods

From June 2008 to October 2022, a total of 2189 consecutive patients from seven tertiary-care hospitals with intermediate-stage HCC who received initial TACE combined with MWA were enrolled. Among them, 2189 were divided into training cohort (N = 1753), and internal test cohort (N = 436) in a single center, and 316 patients were assigned to external test cohort in another 6 centers. A prognostic scoring system was constructed using tumor burden and radiologic features (TBR) and compared with conventional predicting systems.

Results

In training cohort, multivariate Cox regression analysis suggested that tumor burden (hazard ratio (HR), 0.693; 95% confidence interval (CI): 0.505, 0.814; 1 point per 1.0 increase, p = 0.024), radiologic features (HR, 0.349; 95% CI: 0.236, 0.517; p < 0.001), and alpha-fetoprotein (HR, 1.629; 95% CI: 1.280, 2.073; p < 0.001) were independent prognostic factors for OS. A prognostic model that comprises TBR was built, which showed significantly higher AUC values than other clinical stagings in all three cohorts. Moreover, the TBR score provided greater net benefit across the range of reasonable threshold probabilities than other models. Based on cutoff values of 32 and 74 centiles of the TBR score, the cohort was divided into low-, middle-, and high-risk strata, which provide consistent performance in survival discrimination across different patient subgroups.

Conclusion

The TBR score serves as an efficient instrument for risk stratification, guiding the course of adjuvant targeted and immunotherapies for HCC patients undergoing TACE-MWA combined treatment.

Design

A retrospective, multi-institutional study.

Protocol of the IMPACT study: randomized, multicenter, phase 3 study evaluating the efficacy of immunotherapy (Atezolizumab) plus anti-VEGF therapy (Bevacizumab) in combination with transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma

BACKGROUND

Atezolizumab plus bevacizumab is recommended as a first-line treatment for unresectable hepatocellular carcinoma (uHCC). A subgroup analysis of the IMbrave150 trial showed shorter overall survival (OS) in uHCC patients with stable disease (SD) than patients with complete response (CR) or partial response (PR) after atezolizumab plus bevacizumab. Improving OS in patients with SD is an unmet medical need. Transcatheter arterial chemoembolization (TACE) may enhance treatment efficacy by controlling intrahepatic lesions and activating anti-tumor immunity. The IMPACT study aims to evaluate whether combining atezolizumab plus bevacizumab with TACE improves OS in patients with SD.

METHODS

IMPACT is a multicenter, phase 3 study being conducted in Japan, recruiting uHCC patients aged ≥ 18 years with Barcelona Clinic Liver Cancer stage A (single tumor ≥ 5 cm only, TACE unsuitable), stage B (TACE unsuitable) or stage C (excluding Vp3 or 4), Child-Pugh A liver function, and no prior systemic therapy. After 12 weeks of atezolizumab plus bevacizumab treatment as induction therapy, patients are being divided into two cohorts based on response: a randomized cohort for patients who achieve SD, or an atezolizumab plus bevacizumab followed by curative conversion (ABC-conversion) cohort for patients who achieve CR or PR. Patients in the randomized cohort are receiving atezolizumab plus bevacizumab and intrahepatic control TACE (Group A), or continuing atezolizumab plus bevacizumab (Group B). Patients in the ABC-conversion cohort are receiving atezolizumab plus bevacizumab. All cohorts can be considered for curative conversion therapies for residual tumors if these therapies are considered curative, in the patient's best interests, and deemed necessary by the investigator. The primary endpoint is OS for the randomized cohort and conversion rate for the ABC-conversion cohort. Secondary endpoints in both cohorts include progression-free survival, objective response rate, duration of response, time to CR, and safety. The study is expected to last 6.5 years from June 2023.

DISCUSSION

IMPACT is evaluating the efficacy of combination therapy with atezolizumab plus bevacizumab and TACE, as well as exploring the efficacy of curative conversion therapy. The results should contribute to establishing a response-guided treatment strategy for uHCC by determining optimal treatment according to the therapeutic effect of atezolizumab plus bevacizumab.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCT), identifier: jRCTs051230037. Registered 13 June 2023.

PROTOCOL VERSION

8 May 2024; version 1.4.

Immune checkpoint inhibitor plus tyrosine kinase inhibitor with or without transarterial chemoembolization for unresectable hepatocellular carcinoma

Background and aims

Transcatheter arterial chemoembolization (TACE) has been combined with immune checkpoint inhibitor (ICI)-based systemic therapies for unresectable hepatocellular carcinoma (uHCC) with promising efficacy. However, whether the addition of TACE to the combination of ICI and tyrosine kinase inhibitor (TKI) (ICI+TKI+TACE) is superior to ICI+TKI combination therapy is still not clear. Thus, this study compares the efficacy of ICI+TKI+TACE triple therapy and ICI+TKI doublet therapy in patients with uHCC.

Methods

uHCC patients treated with either ICI+TKI+TACE triple therapy or ICI+TKI doublet therapy were retrospectively recruited between January 2016 and December 2021 at Eastern Hepatobiliary Surgery Hospital. The patients from ICI+TKI+TACE group and ICI+TKI group were further subjected to propensity score matching (PSM). The primary outcome was progression-free survival (PFS). The secondary outcomes were overall survival (OS) and objective response rate (ORR). Post-progression survival (PPS) as well as treatment-related adverse events (TRAEs) were also assessed.

Results

A total of 120 patients were matched. The median PFS was 8.4 months in ICI+TKI+TACE triple therapy group versus 6.6 months in ICI+TKI doublet therapy group (HR 0.72, 95%CI 0.48-1.08; p=0.115). Similar results were obtained in term of OS (26.9 versus 24.2 months, HR 0.88, 95% CI 0.51-1.52; p=0.670). The ORR in the triple therapy group was comparable with that in the doublet therapy group (16.6% versus 21.6%, p=0.487). Further subgroup analysis for PFS illustrated that patients without previous locoregional treatment (preLRT) (10.5 versus 3.7 months, HR 0.35 [0.16-0.76]; p=0.009), without previous treatment (10.5 versus 3.5 months, HR 0.34 [0.14-0.81]; p=0.015) or treated with lenvatinib (14.8 versus 6.9 months, HR 0.52 [0.31-0.87]; p=0.013) can significantly benefit from triple therapy compared with doublet therapy. A remarkable interaction between treatment and preLRT (p=0.049) or TKIs-combined (p=0.005) was also detected in term of PFS. Post progression treatment significantly improved PPS in both groups. The incidence of TRAEs was comparable between two groups.

Conclusions

The addition of TACE to ICI+TKI combination therapy did not result in a substantial improvement in efficacy and prognosis of patients. However, in selected uHCC patients (without preLRT or treated with lenvatinib as combination), ICI+TKI+TACE triple therapy may remarkably improve PFS.

Neoadjuvant therapy for hepatocellular carcinoma-priming precision innovations to transform HCC treatment

Hepatocellular carcinoma (HCC) is increasing in prevalence globally, and cure remains limited with non-operative treatment. Surgical intervention, through resection or transplantation, offers a potential for cure for select patients. However, many patients present with advanced or unresectable disease, and recurrence rates remain high. Recent advances in systemic therapies, particularly immune checkpoint inhibitors, have demonstrated promise in treating unresectable HCC and as adjuvant therapy. Evidence from adjuvant trials highlights the synergistic potential of combined liver-directed and systemic therapies. These findings have ignited growing interest in neoadjuvant therapy across various scenarios: (1) as a bridging strategy while awaiting transplantation, (2) for downstaging disease to enable transplantation, (3) for converting unresectable disease to a resectable state, or (4) as neoadjuvant treatment in operable cases. Early-stage trials of neoadjuvant therapy in resectable HCC have reported promising outcomes. To realize the potential of neoadjuvant treatment for HCC, thoughtfully designed, adequately powered, multi-center clinical trials are essential.

Comparative Efficacy of Lenvatinib Plus Immunotherapy and Regorafenib Plus Immunotherapy After Lenvatinib Failure for Advanced Hepatocellular Carcinoma: A Retrospective Study

BACKGROUND

The combination of regorafenib and immune checkpoint inhibitor (ICI) has been the most popular second-line systemic therapy for advanced hepatocellular carcinoma (HCC). However, considering the good anti-tumor performance of lenvatinib, combined immunotherapy on the basis of lenvatinib after first-line lenvatinib failure is also popular in clinical practice. This study aimed to compare the efficacy and safety of regorafenib plus ICI (TACE-R-I) versus lenvatinib plus ICI (TACE-L-I) in patients with advanced HCC after lenvatinib failure.

METHODS

In this single-center retrospective study, 164 patients with advanced HCC were enrolled from January 2019 to March 2024 in China. All patients were aged ≥ 18 years, clinically or pathologically diagnosed with HCC. All patients received trans-arterial chemoembolization (TACE) as local treatment. Overall survival (OS), progression-free survival (PFS), and treatment-related adverse events (TRAEs) were compared between groups. The Cox regression model was used to analyze the factors associated with OS and PFS.

RESULTS

We compared 77 patients from each group after propensity score matching (PSM). There was no significant difference in the OS (p = 0.255) or PFS (p = 0.387) between groups. However, in the subgroup (distant metastases, Barcelona Clinic Liver Cancer (BCLC) stage C or tumor thrombus), the TACE-R-I group showed better survival benefit than the TACE-L-I group. The multivariable Cox regression model suggested that BCLC stage and alpha-fetoprotein (AFP) were independently associated with OS. Distant metastases, tumor thrombus and Child-Pugh were independent associated factors for PFS (p < 0.05). The frequency of grade ≥ 3 TRAEs was not significantly different between groups (p ≥ 0.05).

CONCLUSION

Our study demonstrated that in patients with greater tumor burden, the TACE-R-I group showed better OS and PFS benefits than the TACE-L-I group. However, in the overall population of HCC patients, there was no significant difference in efficacy and safety between the groups.

A concise review of updated global guidelines for the management of hepatocellular carcinoma: 2017-2024

Many guidelines for hepatocellular carcinoma (HCC) have been published and are regularly updated worldwide. HCC management involves a broad range of treatment options and requires multidisciplinary care, resulting in significant heterogeneity in management practices across international communities. To support standardized care for HCC, we systematically appraised 13 globally recognized guidelines and expert consensus statements, including five from Asia, four from Europe, and four from the United States. These guidelines share similarities but reveal notable discrepancies in surveillance strategies, treatment allocation, and other recommendations. Geographic differences in tumor biology (e.g., prevalence of viral hepatitis, alcohol-related liver disease, or metabolic dysfunction-associated steatotic liver disease) and disparities in available medical resources (e.g., organ availability, healthcare infrastructure, and treatment accessibility) complicate the creation of universally applicable guidelines. Previously, significant gaps existed between Asian and Western guidelines, particularly regarding treatment strategies. However, these differences have diminished over the years. Presently, variations are often more attributable to publication dates than to regional differences. Nonetheless, Asia-Pacific experts continue to diverge from the Barcelona Clinic Liver Cancer system, particularly with respect to surgical resection and locoregional therapies, which are viewed as overly conservative in Western guidelines. Advancements in systemic therapies have prompted ongoing updates to these guidelines. Given that each set of guidelines reflects distinct regional characteristics, strengths, and limitations, fostering collaboration and mutual complementarity is essential for addressing discrepancies and advancing global HCC care.

Protein regulator of cytokinesis 1 regulates autophagy in hepatitis B virus‑associated liver cancer development

Hepatitis B protein x (HBx) is considered a critical contributor to hepatitis B virus (HBV)‑associated liver cancer development. Protein regulator of cytokinesis 1 (PRC1) has been implicated in hepatocarcinogenesis. However, the clinical relevance, biological functions and related regulatory mechanisms of PRC1 in HBV‑associated liver cancer have not yet been clarified. PRC1 expression profiles in liver cancer were obtained from The Cancer Genome Atlas and Gene Expression Profiling Interactive Analysis database and through reverse transcription‑quantitative polymerase chain reaction and immunohistochemistry assays. A series of in vitro and in vivo assays were used to explore the function of the PRC1 gene and the possible mechanisms through which it affects HBV‑associated liver cancer. PRC1 was overexpressed in HBV‑positive liver cancer tissues. Functional studies in vitro demonstrated that HBx induced the expression of the PRC1 gene, which promoted cell autophagy and enhanced viability, invasion and migration. Furthermore, the knockdown of the PRC1 gene or treatment with the autophagosome inhibitor 3‑methyladenine blocked the HBx‑induced autophagic flux, disrupted the formation of autophagosomes, and promoted cell apoptosis. Liver cancer xenograft animal model experiments revealed that inhibition of autophagy by 3‑methyladenine or silencing of the PRC1 gene attenuated HBx‑induced malignant behavior in vivo. The absence of autophagy inhibited the expression of Bcl‑2, induced the expression of Bax, and regulated the levels of Th1 and Th2 cytokines. These results elucidate a mechanism wherein the PRC1 gene participates in the occurrence and development of HBV‑associated liver cancer by modulating autophagy. PRC1 could be a potential therapeutic target for liver cancer.

Nanomaterials for liver cancer targeting: research progress and future prospects

The incidence and mortality rates of liver cancer in China remain elevated. Although early-stage liver cancer is amenable to surgical resection, a significant proportion of patients are diagnosed at advanced stages. Currently, in addition to surgical resection for hepatocellular carcinoma, the primary treatment modalities predominantly include chemotherapy. The widespread use of chemotherapy, which non-selectively targets both malignant and healthy cells, often results in substantial immunosuppression. Simultaneously, the accumulation of chemotherapeutic agents can readily induce drug resistance upon reaching the physiological threshold, thereby diminishing the efficacy of these treatments. Besides chemotherapy, there exist targeted therapy, immunotherapy and other therapeutic approaches. Nevertheless, the development of drug resistance remains an inevitable challenge. To address these challenges, we turn to nanomedicine, an emerging and widely utilized discipline that significantly influences medical imaging, antimicrobial strategies, drug delivery systems, and other related areas. Stable and safe nanomaterials serve as effective carriers for delivering anticancer drugs. They enhance the precision of drug targeting, improve bioavailability, and minimize damage to healthy cells. This review focuses on common nanomaterial carriers used in hepatocellular carcinoma (HCC) treatment over the past five years. The following is a summary of the three drugs: Sorafenib, Gefitinib, and lenvatinib. Each drug employs distinct nanomaterial delivery systems, which result in varying levels of bioavailability, drug release rates, and therapeutic efficacy.

Systemic Treatment for Unresectable Hepatocellular Carcinoma: A Surgeon's Perspective

In recent years, the standard treatment for hepatocellular carcinoma (HCC) has changed dramatically due to the emergence of potent systemic treatment options. These advanced therapies have led to increased survival benefits for patients with advanced or intermediate-stage HCC. Advancements in HCC treatments also offer the possibility of conversion therapy for initially unresectable HCC. However, the treatment of HCC is becoming increasingly complex, due to the expanding availability of systemic therapies, their use in combination with locoregional therapies, and their perioperative applications. Patient characteristics such as liver function, esophageal and gastric variceal status, and treatment goal (downstaging resection or long-term maintenance treatment), are the most critical factors when selecting a systemic treatment strategy. Consequently, the necessity to tailor a personalized and comprehensive treatment strategy for individual patients is growing. This review briefly summarizes the current systemic treatment regimens for HCC from a surgeon's perspective. It is based on results from clinical studies as well as personal experience and introduces the concept of a patient-centered, treatment goals-driven, individualized systemic treatment strategy for managing HCC.

Molecular subtyping combined with multiomics analysis to study correlation between TACE refractoriness and tumor stemness in hepatocellular carcinoma

BACKGROUND

Transarterial chemoembolization (TACE) refractoriness is a significant challenge in treating intermediate to advanced-stage hepatocellular carcinoma (HCC). A few studies suggest that liver cancer stem cells (LCSCs) may be associated with TACE refractoriness. This study aims to explore the potential correlation between TACE refractoriness and HCC stemness, highlighting its clinical significance.

METHODS

This research encompassed the analysis of diverse HCC datasets, including RNA-sequencing, microarray, single-cell RNA-sequencing, and clinical cohorts. We identified common genes between TACE refractoriness and tumor stemness (TSGs). Unsupervised clustering was employed to classify HCC patients into different clusters based on TSGs (TRS clusters). The study explored the differences in clinical prognosis, biological characteristics, genomic variations, immune landscapes, and treatment responses among the TRS clusters.

RESULTS

Patients with TACE-refractoriness demonstrated significantly higher tumor stemness. Our study identified 33 TSGs and established two TRS clusters, including C1 and C2. C1 was associated with TACE refractoriness, elevated tumor stemness, and poorer prognosis. Genomic alterations were found to be significantly different between the TRS clusters. The C1 exhibited signs of immunosuppression and lower activity of immune effector cells, while the C2 had a more robust immune response and higher level of immune cell presence. Single-cell RNA-seq revealed distinct cell type characteristics in each subtypes, with the C1 showing a higher proportion of stem cells and malignant cells.

CONCLUSION

Our findings establish a connection between TACE refractoriness and tumor stemness in HCC, proposing a novel subtype classification to guide personalized treatment. Insights gained may facilitate overcoming TACE refractoriness and the development of innovative therapies.

Creation of an innovative diagnostic framework for hepatocellular carcinoma employing bioinformatics techniques focused on senescence-related and pyroptosis-related genes

BACKGROUND

Liver hepatocellular carcinoma (LIHC) continues to pose a major global health concern and is characterized by elevated mortality rates and a lack of effective therapies. This study aimed to explore differential gene expression linked to cellular senescence and pyroptosis in LIHC and to develop a prognostic risk model for use in clinical settings.

METHODS

We acquired datasets from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO). DESeq2 was used to identify differentially expressed genes associated with cell senescence and pyrodeath. The least absolute shrinkage and selection operator (LASSO) regression model was developed using cellular senescence- and pyroptosis-related differentially expressed genes (CSR&PRDEGs), and its predictive performance was evaluated with Kaplan-Meier survival analysis and time-dependent receiver operating characteristic (ROC) curves. We also performed various functional analyses of the genes. These findings were validated by real-time fluorescence quantitative polymerase chain reaction (PCR).

RESULTS

Using bioinformatics analysis, we developed a prognostic risk framework incorporating six critical genes: ANXA2, APOA1, EZH2, IGF2BP3, SQSTM1, and TNFRSF11B.The model demonstrated a statistically significant difference in overall survival between the high-risk and low-risk groups (p < 0.05). Additionally, real-time fluorescence quantitative PCR confirmed that genes ANXA2, APOA1, EZH2, IGF2BP3, SQSTM1, and TNFRSF11B were significantly overexpressed in the peripheral blood of patients with LIHC in comparison to normal volunteers, thereby validating the prognostic risk model's accuracy.

CONCLUSIONS

This study systematically elucidated the functions of genes associated with senescence and pyroptosis in LIHC cells. The constructed prognostic risk model serves to guide the development of personalized treatment plans, enhance patient management via risk stratification, facilitate the identification of high-risk patients, intensify monitoring or implement proactive interventions, thereby providing a novel perspective for the diagnosis and treatment of LIHC.

Gastrointestinal side effects in hepatocellular carcinoma patients receiving transarterial chemoembolization: a meta-analysis of 81 studies and 9495 patients

Background

Transarterial chemoembolization (TACE) is a widely used treatment for hepatocellular carcinoma (HCC), combining targeted chemotherapy and embolization. While effective, TACE can be associated with significant gastrointestinal (GI) side effects, impacting a patient's quality of life.

Objectives

Quantify the prevalence of key GI complications (diarrhea, nausea, GI toxicity, abdominal pain) following TACE.

Design

Systematic review was performed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, focusing on studies that reported side effects of TACE. Studies not involving cTACE or drug-eluting bead TACE (DEB-TACE), non-HCC studies, meta-analyses or systematic reviews, and inaccessible publications were excluded.

Data sources and methods

A PubMed search for clinical and randomized trials was conducted. Extracted data included study identifiers, demographics, TACE details, and GI side effect prevalences. The Mixed Methods Appraisal Tool assessed study quality and bias.

Results

The analysis included data from 81 studies with 121 individual study arms and 9495 patients. Diarrhea was reported in 38 studies, with a mean prevalence of 23.46% (2.5; 95% confidence interval (CI): 18.39-28.544) and a weighted prevalence of 23.5%. Nausea was most frequently reported, mentioned in 67 studies, with a mean prevalence of 34.66% (2.4; 95% CI: 29.89-39.44) and a weighted prevalence of 32.5%. Abdominal pain was reported in 59 studies, with the highest mean prevalence of 48.07% (2.9; 95% CI: 42.20-53.93) and a weighted prevalence of 46.1%. GI toxicity was reported in 32 studies, with a mean prevalence of 8.85% (1.4; 95% CI: 5.99-11.70) and a weighted prevalence of 9.9%. DEB-TACE generally led to slightly higher rates of nausea, diarrhea, abdominal pain, and GI toxicity compared to conventional TACE. The type of chemotherapy agent influenced prevalence of GI-side effects, with high prevalences observed for agents such as zinostatin and cisplatin.

Conclusion

This meta-analysis synthesizes current evidence on managing GI side effects in TACE. Standardizing reporting and developing effective management strategies are crucial to improving patient outcomes.

Immunotherapy improved the efficacy of TACE or TACE plus MTTs in HCC patients: A meta-analysis

BACKGROUND

Although several studies have compared the efficacy and safety of transarterial chemoembolization (TACE) without immune checkpoint inhibitors (ICIs) and TACE with ICIs, there is still a lack of meta-analysis.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched until July 2023 for studies comparing the efficacy and safety of TACE without ICIs (TACE ± molecular targeted therapies [MTTs]) and TACE without ICIs (TACE ± MTTs + ICIs). Outcomes included overall survival (OS), progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and adverse events (AEs).

RESULTS

A total of 20 studies involving 2587 HCC patients were included in the meta-analysis. Eighteen studies including 2116 patients looked at the difference in OS between TACE ± MTTs or TACE ± MTTs + ICIs. Compared with TACE ± MTTs, TACE ± MTTs + ICIs were associated with significantly improved OS (HR, 0.37; 95 % CI, 0.30-0.46). Thirteen studies including 1650 patients investigated the difference in PFS between TACE ± MTTs or TACE ± MTTs + ICIs. The outcome showed that TACE ± MTTs + ICIs were associated with longer PFS (HR, 0.50; 95 % CI, 0.41-0.61, P < 0.001). Eighteen studies including 1971 patients investigated the difference in tumor response (ORR and DCR) between TACE ± MTTs or TACE ± MTTs + ICIs. The outcomes indicated that TACE ± MTTs + ICIs bring higher ORR and DCR compared to TACE ± MTTs (ORR: OR, 2.39; 95 % CI, 1.97-2.89, P < 0.001; DCR: OR, 2.30; 95 % CI, 1.84-2.88). Moreover, to look at the direct impact of ICIs, we investigated the difference in OS, PFS, ORR, DCR, AEs, and severe AEs between TACE + tyrosine kinase inhibitors (TKIs) and TACE + TKIs + ICIs. The results indicated that the addition of ICIs provided longer OS, longer PFS, higher ORR, and higher DCR, but did not bring additional AEs and severe AEs.

CONCLUSION

Immune checkpoint inhibitors improved the efficacy of TACE or TACE plus MTTs and prolonged the survival of patients with hepatocellular carcinoma. Meanwhile, the addition of immune checkpoint inhibitors to the TACE + TKIs did not bring additional adverse events.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

Arginine-Loaded Nano-Calcium-Phosphate-Stabilized Lipiodol Pickering Emulsions Potentiates Transarterial Embolization-Immunotherapy

Transarterial chemoembolization (TACE) continues to stand as a primary option for treating unresectable hepatocellular carcinoma (HCC). However, the increased tumor hypoxia and acidification will lead to the immunosuppressive tumor microenvironment (TME) featuring exhausted T cells, limiting the effectiveness of subsequent therapies following TACE. Herein, a stable water-in-oil lipiodol Pickering emulsion by employing calcium phosphate nanoparticles (CaP NPs) as stabilizers is developed and used to encapsulate L-arginine (L-Arg), which is known for its ability to modulate T-cell metabolism. The obtained L-Arg-loaded CaP-stabilized lipiodol Pickering emulsion (L-Arg@CaPL) with great emulsion stability can not only neutralize the tumor acidity via reaction of CaP NPs with protons but also enable the release of L-Arg, thereby synergistically promoting the reinvigoration of exhausted CD8+ T cells and effectively reversing tumor immunosuppression. As a result, TACE therapy with L-Arg@CaPL shows greatly improved therapeutic responses as demonstrated in an orthotopic liver tumor model in rats. This study highlights an effective yet simple nanoparticle-stabilized Pickering emulsion strategy to promote TACE therapy via modulation of the immunosuppressive TME, presenting great potential for clinical translation.

Dual-drug loaded chondroitin sulfate embolization beads enhance TACE therapy for HCC by integrating embolization, chemotherapy, and anti-angiogenesis

Hepatocellular carcinoma (HCC) is a major public health threat due to its high incidence and mortality rates. Transcatheter arterial chemoembolization (TACE), the primary treatment for intermediate-to-advanced hepatocellular carcinoma (HCC), commonly utilizes embolic agents loaded with anthracycline-based cytotoxic drugs. Post-TACE, the hypoxic microenvironment in the tumor induced by embolization stimulates the formation of new blood vessels, potentially leading to revascularization and diminishing TACE's efficacy. In clinical practice, combined therapy for liver cancer using TACE and oral targeted drugs often encounters the limitation that targeted drugs cannot efficiently reach the tumor site following TACE. We have developed chondroitin sulfate microspheres (CMs) capable of encapsulating both the cytotoxic drug idarubicin (Ida) and the vascular inhibitor Lenvatinib (Len), thereby achieving a triple therapeutic effect on liver cancer: embolic starvation, drug toxicity, and efficient inhibition of neovascularization.

Systemic Therapy for Hepatocellular Carcinoma

Systemic therapy for hepatocellular carcinoma has evolved from sorafenib to now include immune checkpoint blockade, either atezolizumab/bevacizumab or durvalumab/tremelimumab, and soon to include camrelizumab/rivoceranib and nivolumab/ipilimumab. Second-line therapy remains predominantly either a multikinase inhibitor or ramucirumab. Areas of development include testing immune checkpoint-based regimens in the adjuvant setting after surgery, ablation, or transarterial embolization. Also of interest are studies for patients with Child-Pugh B liver function and adding new checkpoint molecules to the current standard platforms.

Transarterial Chemoembolization With or Without Systemic Therapy for Unresectable Hepatocellular Carcinoma: A Retrospective Comparative Study

INTRODUCTION

Standard treatments provide limited benefits for patients with intermediate- or advanced-stage hepatocellular carcinoma (HCC). This retrospective observational study aimed to assess the potential improvements in outcomes associated with systemic therapies in patients receiving transarterial chemoembolization (TACE) for initially unresectable HCC.

METHODS

Between February 2019 and March 2023, we reviewed patients diagnosed with intermediate-to-advanced HCC who were treated with either TACE or TACE combined with antiangiogenic agents and immune checkpoint inhibitors (combination therapy) as their initial treatment. To address potential confounding biases, patients were further stratified into surgical and non-surgical cohorts, and separate analyses were conducted. The primary endpoints were progression-free survival (PFS) and overall survival (OS), with safety profiles also evaluated.

RESULTS

Among 279 patients with initially unresectable intermediate or advanced HCC, 156 successfully underwent curative-intent liver resection after preoperative treatments (TACE group, n = 69; combination group, n = 87), while 123 patients continued with non-surgical treatments (TACE group, n = 31; combination group, n = 92). After propensity score matching, 26 matched patient pairs were generated within the non-surgical cohort. The combination group exhibited significantly improved PFS in non-surgical patients compared with the TACE group (9.4 vs. 7.2 months, p = 0.043). Cox proportional hazards analysis further confirmed that combination therapy was associated with improved PFS (hazard ratio = 0.476, 95% confidence interval: 0.257-0.883, p = 0.019). For surgical patients exceeding the up-to-seven criteria, the combination group demonstrated superior median PFS (18.0 vs. 14.6 months, p = 0.03) and OS (not reached vs. 50.1 months, p = 0.049) compared with the TACE group. Adverse events were manageable, with no treatment-related fatalities reported.

CONCLUSION

Combination therapy with TACE demonstrated enhanced survival benefits for patients with intermediate to advanced HCC, particularly in surgical patients with higher tumor burdens.

FBXO22 promotes HCC angiogenesis and metastasis via RPS5/AKT/HIF-1α/VEGF-A signaling axis

The gene F-box only protein 22 (FBXO22) has been discovered to promote the development of liver cancer tumors. Nevertheless, there remains considerable ambiguity regarding the involvement of FBXO22 in the processes of angiogenesis and metastasis in hepatocellular carcinoma (HCC). Our study has confirmed a significant upregulation of FBXO22 expression in both HCC samples and cellular models. The increased level of FBXO22 correlates strongly with the number of tumors, presence of vascular invasion, and poor prognosis. Experimental investigations have shown that FBXO22 significantly enhances angiogenesis and metastasis of HCC both in vitro and in vivo. Mechanistically, FBXO22 interacts with and ubiquitinates 40S ribosomal protein S5 (RPS5) on Lys85, thereby promoting its K48-linked ubiquitin-mediated degradation in the cytoplasm. Following a decrease in the expression of RPS5, activation of downstream PI3K/AKT signaling pathway occurs, leading to elevated levels of HIF-1α and vascular endothelial growth factor A (VEGF-A). Our study has shown that FBXO22 facilitates HCC angiogenesis and metastasis via the RPS5/AKT/HIF-1α/VEGF-A signaling axis. Notably, inhibition of FBXO22 enhances the efficacy of Lenvatinib both in vitro and in vivo. Therefore, FBXO22 may present itself as a potential target for therapeutic intervention in the treatment of HCC.

Complete remission in an advanced hepatocellular carcinoma patient with AXIN1 mutation after systemic therapy: A case report

Primary hepatocellular carcinoma (HCC) is a common malignancy with high morbidity and mortality. Despite progress in systemic therapies, survival in advanced HCC remains poor due to patient heterogeneity and individual differences, necessitating a personalized approach rather than relying solely on guidelines. Here, we present an exceptional case study in which a systematic regimen without immune checkpoint inhibitors was chosen based on the patient's specific genetic test results. Remarkably effective with long-term survival benefits were observed as a result. This case underscores the importance of incorporating tumor profiling and personalized treatment plans, in addition to adhering to guidelines and standards, for delivering more efficacious and well-tolerated therapeutic options to patients with liver cancer.

Unraveling the therapeutic potential of Calculus Bovis in liver cancer: A novel step for targeted cancer treatment

Hepatocellular carcinoma is one of the leading causes of cancer-related deaths globally, and effective treatments are urgently needed. The present study aimed to investigate the inhibitory effect of Calculus Bovis (CB) on liver cancer and the underlying mechanisms. CB inhibited M2 tumor-associated macrophage polarization and modulated the Wnt/β-catenin signaling pathway, thereby suppressing the proliferation of liver cancer cells. The inhibitory effect on liver cancer growth was confirmed by both in vivo and in vitro experiments (detailed by Huang et al). The present study provides a theoretical basis for the application of CB for the treatment of liver cancer, providing new avenues for liver cancer treatment.

Transarterial radioembolization versus chemoembolization for hepatocellular carcinoma: a meta-analysis

Background

Currently, inoperable hepatocellular carcinoma (HCC) is treated by both transarterial radioembolization (TARE) and transarterial chemoembolization (TACE). However, their relative efficacy and outcomes remain unclear. This meta-analysis aimed to compare TARE and TACE to evaluate their safety and efficacy in treating inoperable HCC patients.

Methods

Relevant studies were identified by searching the Web of Science, PubMed, and Wanfang databases. Pooled analyses were used to compare treatment response rates, complications, and overall survival (OS) outcomes between the TARE and TACE groups.

Results

This analysis selected 8 studies comprising 1026 and 358 patients that respectively underwent TACE and TARE treatment. The results revealed that the TARE group had significantly higher pooled total response, disease control, and 1-year OS rates compared to the TACE group (P = 0.04, 0.003, and 0.02, respectively), with a corresponding increase in OS (P = 0.0002). Furthermore, rates of complications including fever and abdominal pain were also reduced in the TARE group (P = 0.006 and 0.02, respectively). Moreover, there were no significant differences in the pooled analyses of complete response rates, fatigue, nausea/vomiting, 3-year OS, or 5-year OS between these groups (P = 0.24, 0.69, 0.15, 0.73, and 0.38, respectively). Significant heterogeneity was detected for endpoints including fatigue, nausea/vomiting, fever, abdominal pain, OS duration, and 3-year OS (I2 = 89%, 82%, 72%, 90%, 96%, and 66%, respectively). All endpoints exhibited no significant risk of publication bias.

Conclusions

This study revealed that relative to TACE, TARE performed using 90Y can yield significantly higher treatment response rates and prolong HCC patient survival with fewer treatment-related side effects.The PRISMA guidelines were used to guide the execution and publication of this meta-analysis. The study is registered at INPLASY.COM (No. INPLASY202380017).

Systematic review registration

INPLASY.COM, identifier INPLASY202380017.

Prediction of Pathologic Response in Unresectable Hepatocellular Carcinoma After Downstaging with Locoregional and Systemic Combination Therapy

Background

The combination of locoregional and systemic therapy may achieve remarkable tumor response for unresectable hepatocellular carcinoma (HCC).

Objective

We aimed to investigate the correlation between radiologic and pathologic responses following combination therapy, evaluate their prognostic values, and to establish a non-invasive prediction system for pathologic response.

Methods

This single-center retrospective study included 112 consecutive patients with HCC who underwent locoregional and systemic combination therapy followed by liver resection or transplantation. Radiologic response was assessed with Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 and modified RECIST (mRECIST). Pathologic necrosis percentage was assessed to determine major pathologic response (MPR, ≥90% tumor necrosis) and pathologic complete response (100% tumor necrosis). Performance of the response criteria in predicting pathologic response was assessed with the area under the receiver operator characteristic curve (AUC).

Results

Among all radiologic and pathologic response criteria, MPR was the only independent predictor of post-resection recurrence-free survival (RFS) (adjusted hazard ratio 0.34, 95% CI 0.16-0.72, p=0.004). In addition, mRECIST showed stronger correlation with pathologic response than RECIST 1.1 (spearman r values: 0.76 vs 0.42, p<0.001). A prediction system for MPR was developed that included a combination of mRECIST response (ie, >70% decrease of viable target lesions) with either >90% decrease in AFP (for AFP-positive group, n=75) or >80% decrease in PIVKA-II (for AFP-negative group, n=37), which yielded a respective AUC of 0.905 and 0.887. Furthermore, the system-defined dual-positive responders showed improved median RFS (not reached) than non-responders (7.1 months for AFP-positive group [p=0.043] and 13.3 months for AFP-negative group [p=0.099]).

Conclusion

mRECIST was more indicative of pathologic response after combination therapy than RECIST 1.1. Integration of mRECIST with AFP or PIVKA-II responses allowed for accurate prediction of MPR and could support decision-making on subsequent curative-intent treatment.

Chinese expert consensus on sequential surgery following conversion therapy based on combination of immune checkpoint inhibitors and antiangiogenic targeted drugs for advanced hepatocellular carcinoma (2024 edition)

Up to half of hepatocellular carcinoma (HCC) cases are diagnosed at an advanced stage, for which effective treatment options are lacking, resulting in a poor prognosis. Over the past few years, the combination of immune checkpoint inhibitors and anti-angiogenic targeted therapy has proven highly efficacious in treating advanced HCC, significantly extending patients' survival and providing a potential for sequential curative surgery. After sequential curative hepatectomy or liver transplantation following conversion therapy, patients can receive long-term survival benefits. In order to improve the long-term survival rate of the overall population with liver cancer and achieve the goal of a 15% increase in the overall 5-year survival rate outlined in the Healthy China 2030 blueprint, the Professional Committee for Prevention and Control of Hepatobiliary and Pancreatic Diseases of Chinese Preventive Medicine Association, Chinese Society of Liver Cancer, and the Liver Study Group of Surgery Committee of Beijing Medical Association organized in-depth discussions among relevant domestic experts in the field. These discussions focused on the latest progress since the release of the Chinese expert consensus on conversion therapy of immune checkpoint inhibitors combined antiangiogenic targeted drugs for advanced hepatocellular carcinoma (2021 Edition) and resulted in a new consensus on the modifications and supplements to related key points. This consensus aims to further guide clinical practice, standardize medical care, and promote the development of the discipline.

Advances in systemic therapy leading to conversion surgery for advanced hepatocellular carcinoma

Recently, a systemic therapy for advanced hepatocellular carcinoma (HCC) has been developed. The regimen for unresectable HCC varies and includes single or multi-tyrosine kinase inhibitors, monoclonal antibodies, immune checkpoint inhibitors, or their combinations. Treatment with these agents begins with sorafenib as the first-line drug for unresectable HCC. Subsequently, several systemic therapies, including lenvatinib, ramucirumab, cabozantinib, and regorafenib have been investigated and established. With advances in systemic therapy for unresectable HCC, the prognosis of patients with unresectable HCC has improved significantly than previously. Conversion surgery, consisting of systemic therapy and surgery, showed the possibility of improving the prognosis than systemic therapy alone. Although a combination of atezolizumab and bevacizumab is mostly used for initially unresectable HCC to conduct conversion surgery because of the high response rate and fewer adverse events compared to others, many trials are being conducted to assess their efficacy for initially unresectable HCC. However, the appropriate timing of surgery and interval between systemic therapy and surgery remain controversial. To address these issues, a multidisciplinary team can play a vital role in determining the strategies for treating unresectable HCC. This review describes previous and current trends in the treatment of HCC, with a particular focus on conversion surgery for initially unresectable HCC.

All You Need to Know About TACE: A Comprehensive Review of Indications, Techniques, Efficacy, Limits, and Technical Advancement

Transcatheter arterial chemoembolization (TACE) is a proven and widely accepted treatment option for hepatocellular carcinoma and it is recommended as first-line non-curative therapy for BCLC B/intermediate HCC (preserved liver function, multifocal, no cancer-related symptoms) in patients without vascular involvement. Different types of TACE are available nowadays, including TAE, c-TACE, DEB-TACE, and DSM-TACE, but at present there is insufficient evidence to recommend one TACE technique over another and the choice is left to the operator. This review then aims to provide a comprehensive overview of the current literature on indications, types of procedures, safety, and efficacy of different TACE treatments.

Study on the Mechanism of Notch Pathway Mediates the Role of Lenvatinib-resistant Hepatocellular Carcinoma Based on Organoids

BACKGROUND

The emergence of treatment resistance has hindered the efficacy of targeted therapies used to treat patients with hepatocellular carcinoma (HCC).

OBJECTIVE

This study aimed to explore the mechanism of organoids constructed from lenvatinib-resistant HCC cells.

METHODS

Hep3B cell and human HCC organoids were cultured and identified using hematoxylin and eosin staining and Immunohistochemistry. Lenvatinib-sensitive/ resistant Hep3B cells were constructed using lenvatinib (0, 0.1, 1, and 10 μM) and lenvatinib (0, 1, 10, and 100 μM). qRT-PCR and flow cytometry were utilized to determine HCC stem cell markers CD44, CD90, and CD133 expressions. Transcriptome sequencing was performed on organoids. Western blot evaluated Notch pathwayrelated proteins (NOTCH1 and Jagged) expressions. Furthermore, DAPT, an inhibitor of the Notch pathway, was used to investigate the effects of lenvatinib on resistance or stemness in organoids and human HCC tissues.

RESULTS

The organoids were successfully cultivated. With the increase of lenvatinib concentration, sensitive cell organoids were markedly degraded and ATP activity was gradually decreased, while there was no significant change in ATP activity of resistant cell organoids. CD44 expressions were elevated after lenvatinib treatment compared with the control group. KEGG showed that lenvatinib treatment of organoids constructed from Hep3B cells mainly activated the Notch pathway. Compared with the control group, NOTCH1 and Jagged expressions elevated, and ATP activity decreased after lenvatinib treatment. However, ATP activity was notably decreased after DAPT treatment. Moreover, DAPT inhibited lenvatinib resistance and the increase in the expressions of CD44 caused by lenvatinib. Besides, 100 μM lenvatinib significantly inhibited the growth and ATP activity of human HCC organoids, and DAPT increased the inhibitory effect of lenvatinib.

CONCLUSION

Lenvatinib regulated resistance and stemness in organoids via the Notch pathway.