Treatment of hepatocellular carcinoma with portal vein tumor thrombus: advances and challenges

A Machine Learning Model Based on Counterfactual Theory for Treatment Decision of Hepatocellular Carcinoma Patients

Purpose

To predict the efficacy of patients treated with hepatectomy and transarterial chemoembolization (TACE) based on machine learning models using clinical and radiomics features.

Patients and Methods

Patients with HCC whose first treatment was hepatectomy or TACE from June 2016 to July 2021 were collected in the retrospective cohort study. To ensure a causal effect of treatment effect and treatment modality, perfectly matched patients were obtained according to the principle of propensity score matching and used as an independent test cohort. Inverse probability of treatment weighting was used to control bias for unmatched patients, and the weighted results were used as the training cohort. Clinical characteristics were selected by univariate and multivariate analysis of cox proportional hazards regression, and radiomics features were selected using correlation analysis and random survival forest. The machine learning models (Deathhepatectomy and DeathTACE) were constructed to predict the probability of patient death after treatment (hepatectomy and TACE) by combining clinical and radiomics features, and an optimal treatment regimen was recommended. In addition, a prognostic model was constructed to predict the survival time of all patients.

Results

A total of 418 patients with HCC who received either hepatectomy (n=267, mean age, 58 years ± 11 [standard deviation]; 228 men) or TACE (n=151, mean age, 59 years ± 13 [standard deviation]; 127 men) were recruited. After constructing the machine learning models Deathhepatectomy and DeathTACE, patients were divided into the hepatectomy-preferred and TACE-preferred groups. In the hepatectomy-preferred group, hepatectomy had a significantly prolonged survival time than TACE (training cohort: P < 0.001; testing cohort: P < 0.001), and vise versa for the TACE-preferred group. In addition, the prognostic model yielded high predictive capability for overall survival.

Conclusion

The machine learning models could predict the outcomes difference between hepatectomy and TACE, and prognostic models could predict the overall survival for HCC patients.

Surgical outcome and risk scoring to predict survival after hepatic resection for hepatocellular carcinoma with portal vein tumor thrombosis

Backgrounds/Aims

The hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is classified as the advanced stage (BCLC stage C) with extremely poor prognosis, and in current guidelines is recommended for systemic therapy. This study aimed to evaluate the surgical outcomes and long-term prognosis after hepatic resection (HR) for patients who have HCC combined with PVTT.

Methods

We retrospectively analyzed 332 patients who underwent HR for HCC with PVTT at ten tertiary referral hospitals in South Korea.

Results

The median overall and recurrence-free survival after HR were 32.4 and 8.6 months, while the 1-, 3-, and 5-year overall survival rates were 75%, 48%, and 39%, respectively. In multivariate analysis, tumor number, tumor size, AFP, PIVKA-II, neutrophil-to-lymphocyte ratio, and albumin-bilirubin (ALBI) grade were significant prognostic factors. The risk scoring was developed using these seven factors-tumor, inflammation and hepatic function (TIF), to predict patient prognosis. The prognosis of the patients was well stratified according to the scores (log-rank test, p < 0.001).

Conclusions

HR for patients who have HCC combined with PVTT provided favorable survival outcomes. The risk scoring was useful in predicting prognosis, and determining the appropriate treatment strategy for those patients who have HCC with PVTT.

Yttrium-90 transarterial radioembolization and capecitabine in hepatocellular carcinoma with portal vein involvement

Hepatocellular carcinoma (HCC) with portal vein tumor thrombus is considered an advanced stage disease. Non-surgical local and systemic therapies are the only treatment options available. To analyze the survival and toxicity outcomes of systemic treatment concurrent with yttrium-90 transarterial radioembolization in HCC with liver-limited disease and portal vein involvement with Child-Pugh B liver reserve. The medical records of 22 patients who underwent yttrium-90 transarterial radioembolization concomitant with capecitabine chemotherapy as first-line treatment between 2014 and 2019 were retrospectively reviewed. Twenty-two patients were included in the study. Grade 3 to 4 side effects were evaluated, and hepatic encephalopathy developed in 1 patient after yttrium-90 transarterial radioembolization. In the fourth month of radiological evaluation, 11 patients had a partial response (50%), 5 patients had stable disease (22.7%), and 6 patients (27.3%) developed progressive disease. The median survival time was 21 months. Combined treatment with yttrium-90 transarterial radioembolization and capecitabine may be an effective and safe treatment option. Treatment was associated with a median overall survival of 21 months and a disease control rate of 72.7% at 4 months in patients with inoperable HCC.

TACE combined with portal particle implantation in a case of stage IIIa primary hepatocellular carcinoma treated with sequential anlotinib

Few cases of patients with Cheng's type III portal vein tumor thrombus (PVTT) have been reported to achieve radical cure without recurrence over time. In this study, we reported on a 55-year-old male patient with a diagnosis of stage IIIa China liver cancer staging (CNLC), PVTT Cheng's type III, mild cirrhosis, and chronic viral hepatitis B. TACE combined with radioactive iodine-125 (125I) particle implantation was applied to achieve radical treatment with sequential oral anlotinib hydrochloride capsules. This case might serve as a reference for the treatment of this disease.

Circular RNA circDLG1 contributes to HCC progression by regulating the miR-141-3p/WTAP axis

This study aims to explore novel and reliable biomarkers for predicting hepatocellular carcinoma (HCC) prognosis. Circular RNAs (circRNAs) were determined by analysis of human circRNA arrays and quantitative reverse transcription polymerase reactions. To test for an interaction between circDLG1, we used luciferase reporter assays, RNA immunoprecipitation, and fluorescence in situ hybridization assays that were employed to test the interaction between circDLG1, miR-141-3p, and WTAP. q-RT-PCR and western blot were used to evaluate the target regulation of miR-141-3p and WTAP. shRNA-mediated knockdown of circDLG1, proliferation, migration, and invasion experiment of metastasis were used to evaluate the function of circDLG. CircDLG1 rather than lining DLG1 was upregulated in HCC tissues, from HCC patients as well as HCC cell lines compared to normal controls. circDLG1 high expression in HCC patients was correlated with shorter overall survival. Knockdown of circDLG1 and miR-141-3p mimic could inhibit the tumorigenesis of HCC cells in vivo and in vitro. Importantly, we demonstrated that circDLG1 could act as a sponge of miR-141-3p to regulate the expression of WTAP, and further suppress the tumorigenesis of HCC cells. Our study reveals that circDLG1 can serve as a novel potential circulating biomarker for the detection of HCC. circDLG1 participates in the progression of HCC cells by sponging miR-141-3p with WTAP, providing new insight into the treatment of HCC.

Construction of HBV gene-related prognostic and diagnostic models for hepatocellular carcinoma

Background: Hepatocellular carcinoma (HCC) is a main cause of malignancy-related death all over the world with a poor prognosis. The current research is focused on developing novel prognostic and diagnostic models of Hepatocellular carcinoma from the perspective of hepatitis B virus (HBV)-related genes, and predicting its prognostic characteristics and potential reliable biomarkers for Hepatocellular carcinoma diagnosis. Methods: As per the information related to Hepatocellular carcinoma expression profile and the clinical data in multiple public databases, we utilized limma for assessing the differentially expressed genes (DEGs) in HBV vs non- hepatitis B virus groups, and the gene set was enriched, analyzed and annotated by WebGestaltR package. Then, STRING was employed to investigate the protein interactions. A risk model for evaluating Hepatocellular carcinoma prognosis was built with Lasso Cox regression analysis. The effect patients receiving immunotherapy was predicted using Tumor Immune Dysfunction and Exclusion (TIDE). Additionally, pRRophetic was used to investigate the drug sensitivity. Lastly, the Support Vector Machine (SVM) approach was utilized for building the diagnostic model. Results: The Hepatocellular Carcinoma Molecular Atlas 18 (HCCDB18) data set was utilized for the identification of 1344 HBV-related differentially expressed genes, mainly associated with cell division activities. Five functional modules were established and then we built a prognostic model in accordance with the protein-protein interaction (PPI) network. Five HBV-related genes affecting prognosis were identified for constructing a prognostic model. Then, the samples were assigned into RS-high and -low groups as per their relevant prognostic risk score (RS). High-risk group showed worse prognosis, higher mutation rate of TP53, lower sensitivity to immunotherapy but higher response to chemotherapeutic drugs than low-risk group. Finally, the hepatitis B virus diagnostic model of Hepatocellular carcinoma was established. Conclusion: In conclusion, the prognostic and diagnostic models of hepatitis B virus gene-related Hepatocellular carcinoma were constructed. ABCB6, IPO7, TIMM9, FZD7, and ACAT1, the five HBV-related genes that affect the prognosis, can work as reliable biomarkers for the diagnosis of Hepatocellular carcinoma, giving a new insight for improving the prognosis, diagnosis, and treatment outcomes of HBV-type Hepatocellular carcinoma.

The Feasibility of TACE Combined with TKIs Plus PD-1 Antibody for Advanced HCC

Objective

To evaluate the efficacy and safety of transarterial chemoembolization (TACE) combined with tyrosine kinase inhibitors (TKIs: sorafenib, lenvatinib, and apatinib) plus camrelizumab (TACE-TKIs-C) vs TACE combined with TKIs (TACE-TKIs) for advanced hepatocellular carcinoma (HCC).

Methods

In this two-center retrospective study, patients with advanced HCC treated with TACE-TKIs-C or TACE-TKIs were enrolled between January 1, 2018, to October 1, 2020. A total of 260 eligible patients received TACE-TKIs-C (N=70) or TACE-TKIs (N=190). The differences in overall survival (OS), progression-free survival (PFS) and tumor response were compared between two groups. Propensity score matching (PSM) analysis was applied to reduce patient selection bias. The risk factors affecting OS or PFS were analyzed.

Results

Fifty-three pairs of patients were matched after PSM analysis. Before PSM analysis, the median OS and PFS of TACE-TKIs-C were significantly longer than those of the TACE-TKIs (OS: not reached vs 12.0 months, P<0.0001; PFS: 10.0 months vs 6.0 months, P<0.0001). After PSM analysis, the median OS and PFS of TACE-TKIs-C were significantly longer than those of the TACE-TKIs (OS: Not reached vs 13.0 months, P<0.0001; PFS: 9.0 months vs 6.0 months, P<0.0001); the uni- and multivariate analysis revealed that TACE-TKIs-C treatment was a protective factor of OS and PFS. Grade 3 or 4 hypertension occurred in 14.3% of patients in the TACE-TKIs-C group and other high-grade toxic effects were infrequent.

Conclusion

In patients with advanced HCC, TACE-TKIs-C may improve overall and progression-free survival outcomes over TACE-TKIs with manageable safety profile.

A study of the clinical profile, predictors, prognostic features, and survival of patients with hepatocellular carcinoma having macroscopic portal vein tumor thrombosis

BACKGROUND

Macroscopic portal vein tumor thrombosis (PVTT) is considered a negative prognostic factor in hepatocellular carcinoma (HCC) patients. There is divergent opinion regarding management of these patients worldwide. We aimed to evaluate the clinical profile, predictors, prognostic features, and survival of patients of HCC with PVTT.

METHODS

Treatment-naïve HCC patients with and without PVTT were analyzed retrospectively using a prospectively accrued dataset. Patients with PVTT were further divided as per treatment groups for survival analysis.

RESULTS

Of 508 patients, 46.1% had radiological evidence of PVTT at presentation. On logistic regression, serum albumin (odds ratio [OR]=0.65, 95% confidence interval [CI]= 0.44-0.96; p= 0.031); international normalized ratio (OR = 3.78,95% CI = 1.42-10.00; p=0.008); alpha-feto protein >400 ng/mL (OR=3.58, 95%CI = 2.00-6.40; p <0.001); size of largest tumor nodule >5 cm (OR =6.37, 95%CI =2.03-19.99; p =0.002); and male gender (OR =1.84, 95%CI = 1.01-3.33; p = 0.045) were independent predictors for PVTT. Patients with PVTT amenable to aggressive therapies had significantly better median overall survival (in months) as compared to those receiving sorafenib or best supportive care only (13.1, 3.9, and 1.8 respectively, p<0.0001). Treatment modality received (p<0.001) and extrahepatic metastasis (p=0.006) were independent predictors of mortality in these patients.

CONCLUSION

Size of largest tumor nodule >5 cm and alpha-fetoprotein >400 ng/mL are strongly associated with the presence of PVTT in patients with HCC. A multidisciplinary approach may identify a subgroup of patients who can be offered aggressive therapies like surgery and/or locoregional therapy with significant survival benefit.

Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions

Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30-40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existing interventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.

Classification and Prognostic Characteristics of Hepatocellular Carcinoma Based on Glycolysis Cholesterol Synthesis Axis

Background

Liver hepatocellular carcinoma (LIHC) is among the most frequent causes of cancer-related death across the world with a considerably poor prognosis. The current study targeted providing a new type of LIHC from the perspective of the glycolysis/cholesterol synthesis axis, predicting its prognostic characteristics, and exploring the potential role and mechanism of the glycolysis/cholesterol synthesis axis in the occurrence and development of LIHC.

Methods

Based on the two expression profile data and clinical information of LIHC in The Cancer Genome Atlas (TCGA) database and hepatocellular carcinoma database (HCCDB), as well as glycolysis/cholesterol-related genes from the Molecular Signatures Database (MSigDB), unsupervised consistent clustering method was used to identify molecular subtypes. In addition, the differential genes were identified by limma package, and then the gene set was enriched, analyzed, and annotated by WebGestaltR package. At the same time, the immune infiltration analysis of tumor samples was carried out using the ESTIMATE to evaluate the tumor immune score of the samples. Finally, the differences in clinical characteristics among molecular subtypes were measured using univariate and multivariate Cox analyses.

Results

According to the median standardized expression levels of glycolysis/cholesterol production genes, samples were divided into four groups (molecular subtypes): Quiescent group, Glycolysis group, Cholesterol group, and Mixed group. Significant prognostic differences were observed among the four groups. In both TCGA and HCCDB18 datasets, the prognosis of subtype Mixed was the worst, while Quiescent had a good prognosis. Cell cycle and oncogenic pathways were significantly enriched in the Mixed group. In addition, glycolysis and cholesterol production gene expressions were related to the prognostic LIHC subtype classification genes' expression levels.

Conclusion

Metabolic classification regarding glycolysis and cholesterol production pathways provided new insights into the biological aspects of LIHC molecular subtypes and might help to develop personalized therapies for unique tumor metabolic profiles.

Characterizing PTP4A3/PRL-3 as the Potential Prognostic Marker Gene for Liver Hepatocellular Carcinoma

Background

A large number of cancer-related deaths in the world can be attributed to liver hepatocellular carcinoma (LIHC). The purpose of this study is to explore protein tyrosine phosphatase type IV A member 3 (PTP4A3/PRL-3) as a new and reliable biomarker to predict the prognosis of LIHC and determine the potential therapeutic targets or drugs that can be used for treating LIHC.

Methods

We included three LIHC datasets with clinical information and expression profiles from public databases. The expression level of PTP4A3 was analyzed, and based on the results, the samples were divided into high- and low-expression groups. The Kaplan–Meier survival analysis method was used to determine the relationship between PTP4A3 and prognosis. The enrichment differences among the functional pathways associated with the high- and low-expression groups were determined using the gene set enrichment analysis (GSEA) method. Five methods were used to determine the differences among the tumor microenvironment in the low- and high-expression groups. The sensitivity of the low- and high-expression groups toward different drug treatment methods was predicted by analyzing the Tumor Immune Dysfunction and Exclusion (TIDE) scores and determining the biochemical half-maximal inhibitory concentration (IC50).

Results

The expression levels of the LIHC and adjacent samples were analyzed, and it was observed that the expression level of PTP4A3 in tumor tissue was significantly higher than the expression level of the same gene in the adjacent samples. It was also inferred that it might be a cancer-promoting gene. It was concluded that high-expression results in a significantly poor prognosis. The high-expression group was significantly enriched in the tumor-related pathways, such as the PI3K-AKT signaling pathway. In addition, the results obtained by conducting immune infiltration analysis revealed a significant positive correlation between some immune scores and the gene PTP4A3. The drug KIN001−135 and gene PTP4A3 were also found to correlate positively with each other. CP466722, Pyrimethamine, AKT inhibitor VIII, Embelin, Cisplatin, QS11, Bexarotene, and Midostaurin negatively correlated with PTP4A3 associated with the three datasets. Moreover, the drugs Cisplatin, QS11, Midostaurin, and CP466722 were more sensitive toward the high-expression group than the low PTP4A3 expression group. Significant differences were observed in these cases.

Conclusion

PTP4A3/PRL-3 is potentially associated with the progression, metastasis, and invasion of LIHC. The prognosis of LIHC patients is negatively impacted by the high-expression levels of the gene. The results indicate that PTP4A3/PRL-3 is an important prognostic factor for LIHC and is a new potential prognostic detection target. The discovery of the 8 drugs that were negatively associated with PTP4A3 provided a new direction that can be developed in the future for the treatment of LIHC.

COVID-19 in Cirrhotic Patients: Is Portal Vein Thrombosis a Potential Complication?

INTRODUCTION

Several studies have demonstrated that thromboembolic events increased in patients with coronavirus infection, usually occurring in elderly patients with severe illness, associated with comorbid diseases such as diabetes and hypertension. Portal vein thrombosis (PVT) is a rare venous thromboembolic disease occurring typically in patients with an underlying disease such as decompensated cirrhosis with or without hepatocellular carcinoma (HCC).

AIM

To evaluate incidence of occurrence of acute PVT in cirrhotic patients infected with 2019 coronavirus disease (COVID-19).

METHODS

This cross-sectional, observational study involved 70 patients of the liver cirrhosis: (group A) 28 patients with liver cirrhosis infected with COVID-19, and 42 patients with liver cirrhosis as the control group matched for age and sex (group B). All patients were subjected to thorough medical history, routine investigations (complete blood count, liver, and renal function tests), imaging in the form of abdominal and Doppler ultrasonography to assess the presence of acute PVT, serum ferritin, D-dimer, C-reactive protein, and PCR of COVID-19 for group A only.

RESULTS

There was a significant difference between the two groups regarding Doppler ultrasound findings as 3 of the patients in group A had PVT (10.7%), 2 of them had HCC diagnosed by triphasic CT abdomen, and only 1 patient in group B had PVT (2.3%) (p < 0.05).

CONCLUSION

In cirrhotic patients infected with COVID-19, portal vein thrombosis may be a potential complication even in the absence of hepatocellular carcinoma; further prospective studies with longer follow-up may be needed.

Effect of transjugular intrahepatic portosystemic shunt combined with 125I particle implantation on portal vein tumor thrombus in hepatocellular carcinoma

OBJECTIVE

The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) combined with ¹²⁵I particle implantation in the treatment of portal vein tumor thrombus (PVTT) in hepatocellular carcinoma was discussed and analyzed in this study.

METHODS

A total of 127 patients with primary hepatocellular carcinoma (PHC) complicated with PVTT admitted to our hospital from March 2017 to June 2018 were enrolled. The patients were classified into an observation group (n=69) and a control group (n=58) in the light of the different treatment methods. The control group patients were treated with TIPS alone, and the observation group patients received ¹²⁵I particle implantation on the basis of TIPS in the control group. Subsequently, the clinical therapeutic efficacy, perioperative indicators, postoperative complications, quality of life and survival of patients before and after treatment were compared between the two groups.

RESULTS

The remission rate in the observation group was remarkably higher than that of the control group (P<0.05), and the difference in the overall response rate (ORR) of the two groups of patients was not statistically significant (P>0.05). The AFP, PLT, WBC and the diameter of the main portal vein in the two groups dropped substantially compared to those before treatment (P<0.05), and the AFP and the diameter of the main portal vein in the observation group were notably lower than those in the control group (P<0.05). After treatment, the ALT, AST and TBiL of the two groups were remarkably higher than those before treatment (P<0.05), and these indicators in the observation group were apparently higher than those in the control group (P<0.05). There was no significant difference in the incidence of postoperative gastrointestinal bleeding, fever, granulocytopenia and abnormal hepatic dysfunction between the observation group and the control group (P>0.05). The functional assessment of cancer therapy-hepatobiliary (FACT-Hep) scores of the two groups 6 months after operation was substantially lower than pre-op scores (P<0.05), and the observation group had apparently lower postoperative scores than the control group (P<0.05). The progression-free survival (PFS) and overall survival (OS) in the observation group were critically superior to those in the control group (P<0.05).

CONCLUSION

TIPS combined with ¹²⁵I particle implantation in the treatment of PHC patients with PVTT can help improve patients' clinical treatment efficacy after surgery while prolonging their postoperative survival. The treatment is safe and worthy of clinical promotion.

Treatments of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: Current Status and Controversy

The proportions of patients with hepatocellular carcinoma (HCC) involving portal vein tumor thrombus (PVTT) varies greatly in different countries or regions, ranging from 13% to 45%. The treatment regimens for PVTT recommended by HCC guidelines in different countries or regions also vary greatly. In recent years, with the progress and development of surgical concepts, radiotherapy techniques, systematic therapies (for example, VEGF inhibitors, tyrosine kinase inhibitors and immune checkpoint inhibitors), patients with HCC involving PVTT have more treatment options and their prognoses have been significantly improved. To achieve the maximum benefit, both clinicians and patients need to think rationally about the indications of treatment modalities, the occurrence of severe adverse events, and the optimal fit for the population. In this review, we provide an update on the treatment modalities available for patients with HCC involving PVTT. Trials with large sample size for patients with advanced or unresectable HCC are also reviewed.

Tumor in vein (LR-TIV) and liver imaging reporting and data system (LI-RADS) v2018: diagnostic features, pitfalls, prognostic and management implications

Vascular invasion by hepatocellular carcinoma (HCC), also known as tumor in vein (TIV), indicates highly invasive tumor behavior and is also associated with poor outcome. Because a diagnosis of TIV precludes liver transplantation, knowledge of the imaging findings to differentiate between TIV and bland thrombus is key for proper patient management. Prior versions of liver imaging reporting and data system (LI-RADS) included presence of TIV as part of LR-5 criteria. However, even if HCC is the most common liver malignancy associated with TIV, other tumors can have vascular invasion and may occur in cirrhotic patients. For these reasons, in LI-RADS v2017 LR-TIV has been introduced as a new different diagnostic category. The aim of this article is to discuss the diagnostic criteria of LR-TIV according to LI-RADS v2018 and analyze potential pitfalls encountered on daily clinical practice. Indeterminate cases and how to manage them will also be discussed.

Hydroxyethyl Starch Curcumin Enhances Antiproliferative Effect of Curcumin Against HepG2 Cells via Apoptosis and Autophagy Induction

It is well documented that curcumin (CUR), as a polyphenol molecule originated from turmeric, has many advantages such as antioxidative, anti-inflammatory, neuroprotective, and antitumor effects. However, because of its poor water solubility and low bioavailability, the biomedical applications of CUR are limited. So, in this study, we modified CUR with conjugation to a food-derived hydrophilic hydroxyethyl starch (HES) via an ester linkage to fabricate the amphiphilic conjugate HES-CUR prior to self-assembling into uniform nanoparticles (HES-CUR NPs). And, the results of the ¹H NMR spectra and FT-IR spectrum showed successful synthesis of HES-CUR NPs; moreover, the solubility and the drug loading efficiency of CUR were significantly increased. Next, we further explored the differences on the antitumor effects between HES-CUR NPs and CUR in HepG2 cells, and the results of the CCK8-assay and cell counting experiment showed that HES-CUR NPs exhibited a more significant antiproliferative effect than that of CUR in HepG2 cells. And HepG2 cells were more sensitive to apoptosis induced by HES-CUR NPs as evidenced by flow cytometry, increased cytochrome c level, and decreased full length caspase-3 and Bcl-2 protein expressions. Additionally, we found that the efficacy of HES-CUR NPs against HepG2 cells might be related to the enhanced degree of mitochondrial damage (decrease of the mitochondrial membrane potential and ATP) and autophagy (increased levels of Beclin-1 and LC3-II proteins). So, the findings in this study suggest that HES-CUR NPs have a great application potential in antitumor efficacy and play an important role in multiple signal pathways.

Outcomes of Living Donor Liver Transplantation in Patients With a History of Ruptured Hepatocellular Carcinoma

Background: Liver transplantation (LT) is considered a contraindication in patients with a history of hepatocellular carcinoma (HCC) rupture because ruptured HCCs are classified as T4 in the current American Joint Committee on Cancer TNM system. This study aimed to assess living donor liver transplantation (LDLT) in these patients and elucidate the factors that may have affected their outcomes.

Methods: Data of patients with a history of ruptured HCC who underwent LDLT between January 1999 and December 2019 were retrospectively reviewed.

Results: Among 789 patients who underwent LDLT for HCC, five (0.64%) had a history of HCC rupture. Three patients (60%) were treated with transarterial chemoembolization (TACE) or transarterial embolization (TAE) for hemostasis, and two patients (40%) achieved spontaneous hemostasis. One of two patients who achieved spontaneous hemostasis underwent surgical resection and LT at 1 week and 6 years after the rupture, respectively. The other patient underwent LT 2 days after the rupture. Four patients (80%) survived for >5 years, while two patients (40%) experienced recurrence and succumbed during the median follow-up duration of 85.3 months (range, 12.4–182.7). The recurrence first developed at 4.3 and 17.0 months after LT; these patients were managed well using surgical resection for peritoneal seeding and TACE for intrahepatic HCC.

Conclusion: LDLT can be considered a treatment method even in patients with a history of HCC rupture after full evaluation of tumor biology and risk of recurrence.

β-sitosterol induces reactive oxygen species-mediated apoptosis in human hepatocellular carcinoma cell line

Objective:

It is of interest to investigate the anti-proliferative effect of β-sitosterol (BS) on human hepatocellular carcinoma (HepG2) cell line.

Materials and Methods:

β-sitosterol treatments (0.6 and 1.2 mM/ml) were done in HepG2 and after 24 hr, cell viability was evaluated by MTT assay. Reactive oxygen species (ROS) accumulating potential of BS was assessed by dichloro-dihydro-fluorescein diacetate staining. Morphology related to apoptosis was investigated by acridine orange and ethidium bromide dual staining. Cytochrome c and caspase 3 expressions were evaluated by immunofluorescence and western blot analyses.

Results:

β-sitosterol induced cytotoxicity (p<0.001) and intracellular ROS in HepG2 cells in a dose-dependent manner. BS treatments accumulated induced intracellular ROS accumulation which led to membrane damage and mitochondrial toxicity. At the molecular level, BS treatments induced cytochrome c release from mitochondria and enhanced the protein expressions (p<0.05 vs 0.6 mM/ml and p<0.001 vs 1.2 mM/ml) of both caspase 3 and cleaved caspase 3.

Conclusion:

β-sitosterol induced ROS accumulation which plays a critical role in apoptosis via the intrinsic pathway in HepG2 cells. The present investigation paves the way for further in vivo studies.

Regorafenib combined with transarterial chemoembolization for unresectable hepatocellular carcinoma: a real-world study

BACKGROUND

The benefits and tolerability of transarterial chemoembolization (TACE) combined with regorafenib as a second-line therapy has not been reported for unresectable hepatocellular carcinoma (HCC). This study aimed to explore the benefits and tolerability of TACE combined with second-line regorafenib in patients with unresectable advanced HCC and failure to first-line treatment.

METHODS

This was a multicenter retrospective study of patients with progression after first-line sorafenib and/or lenvatinib between 01/2019 and 04/2020 at four tertiary hospitals in China. The patients were treated with TACE. Then, 5-7 days after the first TACE, the patients started taking regorafenib for 3 weeks every 4-week cycle. The overall survival (OS), time to progression (TTP), progression-free survival (PFS), and adverse events (AEs) were observed.

RESULTS

The median follow-up was 5.6 (range 0.7, 17.0) months. The median age was 60 (range 35, 79) years. There were 32 (84.2%) males. The patients underwent a median of three TACE sessions (range 1-13). The initial doses of regorafenib were 20 mg/d (n = 1, 2.6%), 80 mg/d (n = 10, 26.3%), 120 mg/d (n = 15, 39.5%), and 160 mg/d (n = 11, 28.9%). The incidence of grade 3/4 AEs was 15.8%. Two patients stopped regorafenib due to AEs. The median OS was 14.3 months. The median PFS and TTP were 9.1 (95% CI 4.0, 14.2) and 9.1 (95% CI 5.5, 12.8) months, respectively.

CONCLUSIONS

The present study provides real-world evidence indicating that regorafenib combined with TACE was beneficial and tolerable in patients with unresectable HCC. Additional prospective large-scale studies are required for confirmation.

The Progress in the Treatment of Hepatocellular Carcinoma With Portal Vein Tumor Thrombus

Hepatocellular carcinoma (HCC) is one of most prevalent cancer and is a serious healthcare issue worldwide. Portal vein tumor thrombus (PVTT) is a frequent complication and remains as the blockage in the treatment of HCC with high recurrence rate and poor prognosis. There is still no global consensus or standard guideline on the management of HCC with PVTT. In western countries, Sorafenib and Lenvatinib are recommended as the first-line treatment options for HCC patients with PVTT where this condition is now regarded as BCLC Stage C regardless of PVTT types. However, there is growing evidence that supports the close relationship of the extent of PVTT to the prognosis of HCC. Besides the targeted therapy, more aggressive treatment modalities have been proposed and practiced in the clinic which may improve the prognosis of HCC patients with PVTT and prolong the patients’ survival time, such as transarterial chemoembolization, radiotherapy, hepatic resection, liver transplantation, and various combination therapies. Herein, we aim to review and summarize the advances in the treatment of HCC with PVTT.

Lenvatinib plus TACE with or without pembrolizumab for the treatment of initially unresectable hepatocellular carcinoma harbouring PD-L1 expression: a retrospective study

Purpose

The aim of this retrospective study was to compare the clinical outcomes of pembrolizumab-lenvatinib-transarterial chemoembolization (TACE) versus lenvatinib-TACE sequential therapy in selected populations of Chinese patients with initially unresectable hepatocellular carcinoma (uHCC) harbouring programmed cell death ligand-1 (PD-L1) expression.

Methods

Consecutive patients with initial PD-L1-positive uHCC who received pembrolizumab-lenvatinib-TACE or lenvatinib-TACE sequential therapy were retrospectively identified from three medical institutions during 2016–2020. The primary endpoints included the rate of conversion therapy, defined as converting initially uHCC to hepatectomy, overall survival (OS), and progression-free survival (PFS); secondary endpoint was the frequency of key adverse events (AEs).

Results

In total, 220 consecutively recruited patients were retrospectively reviewed, 78 of whom were ineligible according to the current criteria, leaving 142 patients [pembrolizumab-lenvatinib-TACE: n = 70, median age 58 years (range 36–69) and lenvatinib-TACE: n = 72, 57 years (35–68)] who were eligible for the study. The median duration of follow-up was 27 months [95% confidence interval (CI), 26.3–28.7 months]. At the last follow-up, the rate of conversion therapy was 25.7% in the pembrolizumab-lenvatinib-TACE group and 11.1% in the lenvatinib-TACE group (p = 0.025). The median OS was 18.1 months (95% CI 16.5–20.7) in the pembrolizumab-lenvatinib-TACE group versus 14.1 months (95% CI 12.2–16.9) in the lenvatinib-TACE group [hazard ratio (HR) 0.56, 95% CI 0.38–0.83; p = 0.004]. A distinct difference in the median PFS interval between the groups was detected [9.2 months (95% CI 7.1–10.4) in the pembrolizumab-lenvatinib-TACE group vs. 5.5 months (95% CI 3.9–6.6) in the lenvatinib-TACE group (HR 0.60; 95% CI 0.39–0.91; p = 0.006)]. The rates of the key AEs assessed, which were hypertension, nausea, and rash, were higher in the pembrolizumab-lenvatinib-TACE group than in the lenvatinib-TACE group (all p < 0.05).

Conclusion

Among the selected populations of patients with initial PD-L1-positive uHCC, pembrolizumab-lenvatinib-TACE sequential therapy may have promising antitumour activity, with an acceptable conversion rate and a well-characterized safety profile.

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation-part one: curative intention

Hepatocellular carcinoma (HCC) offers unique management challenges as it commonly occurs in the setting of underlying chronic liver disease. The management of HCC is directed primarily by the clinical stage. The most commonly used staging system is the Barcelona-Clinic Liver Cancer system, which considers tumor burden based on imaging, liver function and the patient's performance status. Early-stage HCC can be managed with therapies of curative intent including surgical resection, liver transplantation, and ablative therapies. This manuscript reviews the various treatment options for HCC with a curative intent, such as locablative therapy types, surgical resection, and transplant. Indications, contraindications and outcomes of the various treatment options are reviewed. Multiple concepts relating to liver transplant are discussed including Milan criteria, OPTN policy, MELD exception points, downstaging to transplant and bridging to transplant.

Hepatocellular carcinoma patients with portal vein thrombosis treated with robotic radiosurgery: Interim results of a prospective study

BACKGROUND

This is a prospective study evaluating the role of stereotactic body radiotherapy (SBRT) with CyberKnife (CK) in Indian patients suffering from hepatocellular carcinoma with portal vein thrombosis (HCC-PVT).

METHODS

Patients with inoperable HCC-PVT, good performance score (PS), and liver function are accrued for treatment on CK (version M6) and planned with Multiplan (iDMS V2.0). Triple-phase contrast computed tomography (CT) scan was done for contouring, and the gross tumor volume (GTV) included contrast-enhancing mass within main portal vein and adjacent parenchymal disease. Dose prescription was as per-risk stratification protocol (22-50 Gy in 5 fractions) while achieving the constraints of mean liver dose <15 Gy, 800 cc liver <8 Gy, and the duodenum max of ≤24 Gy).

RESULTS

Seventy-two HCC-PVT accrued till date (mean age 63 years [38-76 years], 96% male; Child-Pugh [CP] A 84%, B 9%; Barcelona-Clinic Liver Cancer [BCLC] C 96%; PS0-1: 80%, Karnofsky performance score [KPS]>70: 88%; co-morbidities 42%; infective 12%, alcohol intake 31%, adjuvant sorafenib 39%). CP scores 5, 6, 7, and 8 were in 35%, 32%, 8%, and 18%, respectively. Focal disease with portal vein thrombus (PVT) in 21%, liver involvement >50% and <50% in 46% and 32%. Liver cancer study group of Japan staging-based portal vein invasion VP2, VP3, and VP4 in 22%, 29%, and 40%. Cancer of the Liver Italian Programm (CLIP) scores 1, 2, 3, 4, and 5 were in 8%, 26%, 31%, 26%, and 7%, respectively. Mean follow-up was 7.3 months (median 6 months, standard deviation [SD] 6; range 3-30 months). Mean actuarial overall survival (OS) was 11.4 months (SE 1.587; 95% CI: 8-14.2 months). Six months and 12 months actuarial OS 55% and 38%, respectively. At last follow-up, 25/69 (36%) were alive and 44/69 (64%) were dead. Among 54 patients evaluated for response assessment, 23 (30%) had radiological confirmed PVT response, 1 (3%) had response of IVC thrombus, and 30 (42%) had no or minimal response to SBRT. Actuarial OS in responders and non-responders were 14.4 months (95% CI 9.4-19.2) and 7.4 months (95% CI 4.9-9.7), p-value: 0.022. Six and 12 months survival in responders and non-responders were 65.7% and 37% and 49% and 24.6%, respectively. Post-SBRT, 4 (12%) patients underwent transarterial chemoembolization (TACE) 3 patients (8%) and 1 patient (4%) transarterial radioembolization (TARE). Post-CK, (<4 weeks) 2 patients (4%) had decompensation.

CONCLUSIONS

PVT response or recanalization after SBRT is a statistically significant prognostic factor for survival function in HCC-PVT.

Phenformin synergistically sensitizes liver cancer cells to sorafenib by downregulating CRAF/ERK and PI3K/AKT/mTOR pathways

Sorafenib is a first-line drug to treat advanced hepatocellular carcinoma (HCC), which can prolong the median overall survival of patients by approximately 3 months. Phenformin is a biguanide derivative that has been shown to exhibit antitumor activity superior to that of metformin. We herein explored the ability of phenformin to enhance the anti-cancer activity of sorafenib against HCC and the mechanisms underlying such synergy. The Hep-G2 and SMMC-7721 HCC cell lines were treated with sorafenib and/or phenformin, after which the proliferation of these cells was evaluated via MTT and colony formation assays, while invasion and apoptotic cell death were evaluated via Transwell and flow cytometry assays, respectively. In addition, protein levels were assessed by Western blotting, drug synergy was assessed with the CompuSyn software, and xenograft models were established by implanting Hep-G2 cells into nude mice and then assessing drug antitumor efficacy. Sorafenib and phenformin exhibited a synergistic ability to suppress HCC cell proliferation, migration, and survival. Phenformin further bolstered the ability of sorafenib to inhibit the CRAF/ERK and PI3K/AKT/mTOR pathways. Strikingly, the combination of these two drugs achieved better in vivo efficacy in a murine model system, without causing significant weight loss or hepatorenal toxicity. Sorafenib and phenformin can synergistically suppress CRAF/ERK and PI3K/AKT/mTOR pathway activation in HCC cells, and may thus represent a promising approach to treating this deadly cancer.

Trends and In-Hospital Outcomes of Splanchnic Vein Thrombosis Associated with Gastrointestinal Malignancies: A Nationwide Analysis

Introduction

Gastrointestinal cancers have a strong association with splanchnic vein thrombosis (SVT), yet the hospitalization data is unknown.

Objective and Methods

We analyzed around 78 million discharges from the 2007-2017 Nationwide Inpatient Sample with an inclusion criterion of adult patients admitted for portal or hepatic vein thrombosis as a primary diagnosis with a gastrointestinal or hepatobiliary malignancy as a secondary diagnosis. The outcomes were in-hospital mortality, complication rates, and resource utilization. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.

Results

Out of the total 32,324 hospitalizations for SVT, 3,220 (10%) were associated with a GI malignancy, of which hepatocellular carcinoma (HCC) and pancreatic cancer were the most common. Portal vein thrombosis accounted for 95% of these hospitalizations. Admissions for pancreatic cancer-associated SVT have increased by 7.2 times from 2007 to 2017. Patients with SVT and concomitant GI malignancies were significantly older and had a higher comorbidity score than those with SVT without GI malignancy. Risk of inpatient mortality for SVT patients were significantly higher for patients with gastric cancer (rate: 12.1%, OR 8.6, 95% CI: 1.8-39.7) and HCC (rate: 7.6%, OR 2.77, 95% CI 1.5-4.8) as compared to non-GI malignancy-related SVT. Odds of variceal bleeding were significantly higher for patients with HCC (OR 1.67, 95% CI: 1.2-2.34) than patients without GI malignancy.

Conclusions

Digestive cancer-associated SVTs constitute 10% of all SVT related hospitalizations and are significantly increasing in the past decade. We report the baseline characteristics and predictors of inpatient mortality in this study.

Occlusion of the internal jugular vein in differentiated thyroid carcinoma: Causes and diagnosis

Occlusion of the internal jugular vein (IJV) can be observed in thyroid cancer either on preoperative imaging with ultrasound or cross-sectional imaging, particularly contrast-enhanced CT-scan, and can be detected during follow-up when using these same imaging modalities. For thyroid cancer, four different causes of occlusion of the IJV can be identified: venous thrombosis associated with a hypercoagulable state, tumor thrombus in the vein, compression or invasion of the IJV by thyroid disease or lymph node metastases, and fibrotic collapse of the IJV following lateral neck dissection. Clinicians managing patients with thyroid cancer need to be aware of and able to diagnose each of these conditions. The overall patient impact and appropriate management of each will be discussed.

Surgical management of hepatocellular carcinoma patients with portal vein thrombosis: The United States Safety Net and Academic Center Collaborative Analysis

BACKGROUND

Although consensus guidelines generally discourage any surgical management (ASM; i.e., resection and/or transplantation) in patients with hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT), recent series from Asia have challenged this paradigm.

METHODS

Patients from the US Safety Net Collaborative database (2012-2014) with localized HCC and radiographically confirmed PVT were propensity-score matched based on demographic and clinicopathologic factors associated with receipt of ASM and overall survival (OS). OS was compared between patients undergoing ASM and those not selected for surgery.

RESULTS

Of 1910 HCC patients, 207 (14.5%) had localized disease and PVT. The majority received either liver-directed therapies (LDTs; 34%) and/or targeted systemic therapies (36%). Twenty-one patients (10.1%) underwent ASM (resection [n = 11], transplantation [n = 10]); a third experienced any complication with no 30-day mortalities. Independent predictors of undergoing ASM were younger age, recent hepatology consultation, and lower model of end-stage liver disease (MELD) score. After matching for age, comorbidities, MELD, tumor size, receipt of LDT, or systemic therapy, OS was significantly longer for patients selected for ASM versus non-ASM patients (median not reached vs. 5.8 months, p < .001).

CONCLUSION

In a large North American multi-institutional cohort, a minority of HCC patients with PVT were selected for ASM. Resection or transplantation was associated with improved survival and may have a role in the multimodality management in selected patients.

Phase Ib Study of Lenvatinib Plus Pembrolizumab in Patients With Unresectable Hepatocellular Carcinoma

PURPOSE

The immunomodulatory effect of lenvatinib (a multikinase inhibitor) on tumor microenvironments may contribute to antitumor activity when combined with programmed death receptor-1 (PD-1) signaling inhibitors in hepatocellular carcinoma (HCC). We report results from a phase Ib study of lenvatinib plus pembrolizumab (an anti-PD-1 antibody) in unresectable HCC (uHCC).

PATIENTS AND METHODS

In this open-label multicenter study, patients with uHCC received lenvatinib (bodyweight ≥ 60 kg, 12 mg; < 60 kg, 8 mg) orally daily and pembrolizumab 200 mg intravenously on day 1 of a 21-day cycle. The study included a dose-limiting toxicity (DLT) phase and an expansion phase (first-line patients). Primary objectives were safety/tolerability (DLT phase), and objective response rate (ORR) and duration of response (DOR) by modified RECIST (mRECIST) and RECIST version 1.1 (v1.1) per independent imaging review (IIR; expansion phase).

RESULTS

A total of 104 patients were enrolled. No DLTs were reported (n = 6) in the DLT phase; 100 patients (expansion phase; included n = 2 from DLT phase) had received no prior systemic therapy and had Barcelona Clinic Liver Cancer stage B (n = 29) or C disease (n = 71). At data cutoff, 37% of patients remained on treatment. Median duration of follow-up was 10.6 months (95% CI, 9.2 to 11.5 months). Confirmed ORRs by IIR were 46.0% (95% CI, 36.0% to 56.3%) per mRECIST and 36.0% (95% CI, 26.6% to 46.2%) per RECIST v1.1. Median DORs by IIR were 8.6 months (95% CI, 6.9 months to not estimable [NE]) per mRECIST and 12.6 months (95% CI, 6.9 months to NE) per RECIST v1.1. Median progression-free survival by IIR was 9.3 months per mRECIST and 8.6 months per RECIST v1.1. Median overall survival was 22 months. Grade ≥ 3 treatment-related adverse events occurred in 67% (grade 5, 3%) of patients. No new safety signals were identified.

CONCLUSION

Lenvatinib plus pembrolizumab has promising antitumor activity in uHCC. Toxicities were manageable, with no unexpected safety signals.

Combined effect of recombinant human adenovirus p53 and curcumin in the treatment of liver cancer

The development of an effective therapeutic intervention for liver cancer is a worldwide challenge that remains to be adequately addressed. Of note, TP53, which encodes the p53 protein, is an important tumor suppressor gene, 61% of TP53 is functionally inactivated in liver cancer. Recombinant human adenovirus p53 (rAd-p53) is the first commercial product that has been used for gene therapy. In the present study, the combined mechanistic effects of rAd-p53 and curcumin, a naturally occurring compound with previously reported anti-inflammatory, antioxidant and anti-cancer properties, were assessed in liver cancer cells, using HepG2 cells as the model cell line. The administration of either curcumin or rAd-p53 promoted apoptosis, suppressed epithelial-mesenchymal transition (EMT) and blocked G2/M phase progression in HepG2 cells, which were potentiated further when both agents were applied together. Combined rAd-p53 and curcumin treatment resulted in higher p53 (P<0.01) and p21 (P<0.01) expression compared with rAd-p53 or curcumin were added alone, suggesting an additive effect on TP53 expression. Additionally, curcumin and rAd-p53 were demonstrated to regulate the activation of mitogen-activated protein kinases (MAPKs) ERK1/2, p38 MAPK and JNK. These results indicated that the combination of rAd-p53 with curcumin synergistically potentiates apoptosis and inhibit EMT compared with either rAd-p53 or curcumin treatment alone via the regulation of TP53 regulation. Mechanistically, this effect on TP53 expression may involve the ERK1/2, p38 MAPK and JNK signaling pathways. The current study provides new insights that can potentially advance the development of therapeutic strategies for liver cancer treatment.

LncRNA TMPO-AS1 promotes hepatocellular carcinoma cell proliferation, migration and invasion through sponging miR-329-3p to stimulate FOXK1-mediated AKT/mTOR signaling pathway

Purpose

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer‐related death worldwide. Numerous analyses have revealed the abnormal expression of long non‐coding RNAs (lncRNAs) in HCC cells. This study aims to explore biological functions of lncRNA TMPO‐AS1 (TMPO antisense RNA 1) in HCC cell proliferation, apoptosis, invasion and migration.

Methods

The gene expression in HCC tissues and cell lines were measured by qRT‐PCR. The role of TMPO‐AS1 in HCC was confirmed by CCK‐8, colony formation, TUNEL, transwell and western blot as well as by in vivo experiments. RNA pull down and luciferase reporter assays were utilized to prove the binding relationship between TMPO‐AS1/FOXK1 (forkhead box K1) andmiR‐329‐3p. Rescue assays elucidated the regulatory effects of TMPO‐AS1/miR‐329‐3p/FOXK1/AKT/mTOR pathway on cellular activities in HCC.

Results

TMPO‐AS1was upregulated in HCC tissues and cells and its depletion inhibits HCC cell proliferation, invasion, migration, and EMT process as well as tumor growth. Furthermore, TMPO‐AS1 could bind with miR‐329‐3p, which suppressed HCC cell proliferation. FOXK1 served as the target gene of miR‐329‐3p and TMPO‐AS1 upregulated FOXK1 by sponging miR‐329‐3p in HCC cells. Additionally, FOXK1 overexpression or miR‐329‐3p inhibitor neutralized the repressing effects of TMPO‐AS1 knockdown on HCC development. Finally, it verified that TMPO‐AS1 could regulate AKT/mTOR pathway via FOXK1 to promote HCC.

Conclusion

TMPO‐AS1 contributes to HCC progression by sponging miR‐329‐3p to activate FOXK1‐mediated AKT/mTOR signaling pathway.

Bioinformatics analysis of key biomarkers and potential molecular mechanisms in hepatocellular carcinoma induced by hepatitis B virus

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for up to 90% of all primary hepatic malignancies; it is the sixth most common cancer and the second most common cause of cancer mortality worldwide. Numerous studies have shown that hepatitis B virus and its products, HBV integration, and mutation can induce HCC. However, the molecular mechanisms underpinning the regulation of HCC induced by HBV remain unclear.

METHODS

We downloaded 2 gene expression profiling datasets, of HBV and of HCC induced by HBV, from the gene expression omnibus (GEO) database. Differentially expressed genes (DEGs) between HCC and HBV were identified to explore any predisposing changes in gene expression associated with HCC. DEGs between HCC and adjacent healthy tissues were investigated to identify genes that may play a key role in HCC. Any overlapping genes among these DEGs were included in our bioinformatics analysis. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses of overlapping genes were performed using the Metascape online database; the protein-protein interaction (PPI) network was analyzed using the STRING online database; and we obtained the hub genes of the PPI network using Cytoscape software. An overall survival (OS) analysis of hub genes was performed using km-plotter and the gene expression profiling interactive analysis (GEPIA) online database. The expression levels of hub genes were determined using the TCGA and GEPIA databases. Finally, the relationships between hub genes and tumors were analyzed using the comparative toxicogenomics database (CTD).

RESULTS

We identified 113 overlapping genes from the 2 datasets. Using functional and pathway analyses, we found that the overlapping genes were mainly related to the AMPK signaling pathway and cellular responses to cadmium ions. C8A, SPP2, KLKB1, PROZ, C6, FETUB, MBL2, HGFAC, C8B, and ANGPTL3 were identified as hub genes and C8A, SPP2, PROZ, C6, HGFAC, and C8B were found to be significant for survival.

CONCLUSION

The DEGs re-analyzed between HCC and hepatitis B enable a systematic understanding of the molecular mechanisms of HCC reliant on hepatitis B virus.

Functional analysis of miR-767-5p during the progression of hepatocellular carcinoma and the clinical relevance of its dysregulation

Aberrant microRNA (miRNA) expression is a central hallmark of hepatocellular carcinoma (HCC) and identification of the mechanisms underlying the miRNA actions should provide invaluable resource for revealing the molecular basis of different malignant behaviors in HCC. Previous high-throughput analysis has identified miR-767-5p as a unique miRNA signature of HCC, but the biological relevance and corresponding molecular basis of miR-767-5p in HCC is still in its infancy. The current study was, therefore, designed to elucidate whether changes in miR-767-5p expression levels affect HCC pathogenesis, and to further identify the putative targets. miR-767-5p expression was observed to be upregulated by ~ 3.7-fold in surgical HCC specimens as compared to that in adjacent normal hepatic tissues, and this up-regulation trend correlated well to disease progression and predicted a poor prognosis in HCC patients. Functionally, miR-767-5p-overexpressing cells had a significantly higher proliferative, migratory, and invasive potential, and exhibited an enhanced anchorage-dependent clonogenesis and a tumor formation potential in vivo. Mechanistically, PMP22, a core component of integral membrane glycoprotein of peripheral nervous system myelin, was further identified as a direct down-stream target of miR-767-5p in HCC cells. Conversely, stable ectopic expression of PMP22 abrogated the promoting effects of miR-767-5p on HCC aggressive phenotype. Collectively, the available data suggest that as a potent oncomiR, miR-767-5p actions along HCC progression are in part mediated by its function as a posttranscriptional repressor of PMP22 signaling.

Sorafenib treatment has the potential to downstage advanced hepatocellular carcinoma before liver resection

Sorafenib is acknowledged as the standard therapy for advanced hepatocellular carcinoma (HCC) but in the clinical practice the treatment of these patients is extremely complex and needs to be personalized. New evidence suggests that surgical resection-based multimodal treatments may improve outcome in these patients. There is no strong evidence supporting the ability of sorafenib in downstage HCC before surgery. We presented a case of a 53-year-old man with well-compensated HCV-cirrhosis complicated with HCC and neoplastic portal vein thrombosis. The patient was treated initially with sorafenib with optimal radiological and serological response and subsequently with liver resection. Pathological examination showed necrotic portal thrombosis and massive necrosis of a metastatic regional node confirming radiological evidence. This finding suggests that sorafenib exhibits a potential to downstage advanced HCC which is not irrelevant. A possible combination of different modalities has to be considered in the view of a personalized medicine.

Comparison of stereotactic body radiation therapy with and without sorafenib as treatment for hepatocellular carcinoma with portal vein tumor thrombosis

Stereotactic body radiation therapy (SBRT) has emerged as a treatment option for unresectable hepatocellular carcinoma (HCC) patients. However, the treatment outcomes for patients with portal vein tumor thrombosis (PVTT) remain poor. In this study, we evaluate the efficacy of SBRT with and or without sorafenib for advanced HCC with PVTT.Fifty four HCC patients with PVTT treated with SBRT using the Cyberknife system was retrospectively analyzed between January 2009 and June 2016. Of these, sorafenib combined with SBRT was administered to 18 patients and SBRT alone was administered to 36 patients. SBRT was designed to target the liver tumor and tumor thrombosis, with a radiation dose of 36 to 45 Gy (median 40 Gy) given in 3 to 5 fractions.The mean follow-up period for SBRT with sorafenib and SBRT alone was 13.22 ± 10.07 months and 15.33 ± 22.01 months, respectively. The response rate was comparable in both groups. Complete response and partial response rates were 77.77% for SBRT with sorafenib and 75.00% without sorafenib (P = .43). The median progression-free survival rate was 6 months (2-11 months) versus 3 months (2-5.6 months) (P = .24) and the 1- and 2-year progression-free survival rates were 25.7% and 15.2% versus 11.1% and 8.3% (P = .1225). The median, 1- and 2-year overall survival rates (OSR) were 12.5 months, 55.6% and 17.7% versus 7 months (5-13.5 months), 33.3% and 11.1% (P = .28), for SBRT with sorafenib versus SBRT alone groups, respectively.The result of our study shows that SBRT with sorafenib administered group resulted in a higher median, progression-free, and OSR for HCC patients with PVTT. However, the trends did not attain statistical significance. A large-scale randomized study is needed to assess the benefits of SBRT with sorafenib administration for patient with PVTT.

The Treatment of Hepatocellular Carcinoma With Portal Vein Tumor Thrombosis

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death worldwide. HCC is also is a tumor with a distinct ability to invade and grow within the hepatic vasculature. Approximately 20% of patients with HCC have macrovascular invasion (MVI) at the time of diagnosis. MVI is associated with dismal prognosis, with median survival ranging from 2 to 5 months. Current staging systems designate MVI as advanced disease. Recent advances in multimodal approaches, including systemic therapies, radiation therapy, liver-directed therapies, and surgical approaches, in the treatment of HCC with MVI have rendered this disease process more treatable with improved outcomes and are discussed here.

Combination of aloin and metformin enhances the antitumor effect by inhibiting the growth and invasion and inducing apoptosis and autophagy in hepatocellular carcinoma through PI3K/AKT/mTOR pathway

Hepatocellular carcinoma (HCC) is a devastating and highly metastatic cancer worldwide. Metformin (MET) is the priority drug for treatment of type 2 diabetes; however, it possesses multiple biological effects like anticancer and hepatoprotective activity. Herein, we examined the effects of aloin (barbaloin) and MET as well as combination treatment in HCC cell line in vitro and in vivo. As a result, aloin and MET alone exhibited inhibitory effects on proliferation and invasion of HepG2 and Bel-7402 cells. Specially, combination treatment of aloin and MET showed enhanced inhibitory effects in vitro. Aloin and MET alone induced apoptosis and autophagy in vitro. Similarly, aloin and MET cooperated to promote apoptosis and autophagy in HepG2 and Bel-7402 cells. In the HepG2 xenograft models, aloin in combination with MET confine tumor growth and facilitate apoptosis and autophagy. Both the in vitro and in vivo results showed that aloin and MET alone as well as combination treatment activated the PI3K/AKT/mTOR pathway. Overall, our research demonstrated that the concomitant treatment with aloin and MET enhances the antitumor effect by inhibiting the growth and invasion as well as inducing apoptosis and autophagy in HCC through PI3K/AKT/mTOR pathway.

miR-31 Modulates Liver Cancer HepG2 Cell Apoptosis and Invasion via ROCK1/F-Actin Pathways

PURPOSE

Liver cancer is one of the most common malignant tumor in the world. miR-31 is downregulated in liver cancer and associated with tumor growth and metastasis. However, the underlying mechanism remains unclear.

METHODS

Cellular apoptosis was detected via MTT, TUNEL assay, LDH release and Annexin V/PI flow-cytometry analysis. Cellular migration and invasion were measured by the Transwell chamber assay. Mitochondrial functions were evaluated via mitochondrial membrane potential JC-1 staining and mPTP opening assessment. The mitophagy activity was examined via Western blots.

RESULTS

In the present study, our results confirm that miR-31 promotes apoptosis and inhibits proliferation and metastasis in liver cancer HepG2 cells. In vitro, miR-31 promotes HepG2 cell apoptosis through the mitochondrial pathway as indicated by mitochondrial potential reduction, increased mPTP opening time, cty-c release and imbalance of pro- and anti-apoptotic proteins. Furthermore, miR-31 reduces the energy generation by inhibiting mitochondrial respiratory function. At last, it is demonstrated that miR-31 triggers the mitochondrial damage via ROCK1/F-actin pathway. Inhibiting the ROCK1/F-actin pathway abolishes the effects of miR-31 mimic on mitochondrial injury, apoptosis, proliferation arrest and migration inhibition.

CONCLUSION

Our results reveal that miR-31 can inhibit HepG2 cell survival and metastasis by activating the ROCK1/F-actin pathway.

Hepatocellular Carcinoma-How to Determine Therapeutic Options

Deciding on specific treatment strategies involves not only tumor stage, performance status, and severity of underlying liver disease, but additional factors such as biomarkers, organ availability, and radiographic tumor response to treatment. In this review, we present hepatocellular carcinoma (HCC) cases to highlight how to determine therapeutic options for HCC in specific scenarios, including resection versus liver transplant, choice of initial local regional treatment, tumor downstaging, and systemic therapies for advanced HCC.

Is hepatic resection better than transarterial chemoembolization in hepatocellular carcinoma with portal vein tumor thrombosis?

Background

The management of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remains controversial. We compared the outcomes of hepatic resection (HR) and transarterial chemoembolization (TACE).

Methods

Comprehensive online databases search was performed. Comparative studies measuring survival in HCC patients with PVTT undergoing HR versus TACE were included. Pooled risk ratios with corresponding 95% confidence intervals (CI) were calculated for overall survival (OS) at 1, 3, and 5 years. Study quality and heterogeneity was assessed.

Results

Six studies comprising 1,320 patients were included. HR was done in 526 (39.8%) patients and TACE in 794 (60.2%) patients. Meta-analysis of all included studies showed improved OS in HR compared to TACE patients at 1-year (OR: 1.49, 95% CI: 1.16-1.92, P=0.002), 3-year (OR: 3.33, 95% CI: 1.55-7.12, P=0.002) and 5-year (OR: 3.91, 95% CI: 1.42-10.77, P=0.008). Survival benefit conferred by HR was 7-33 months. This benefit was mostly noted in tumors with PVTT types I and II and those with single lesions. Age, ECOG status, and STROBE score did not contribute to differences in survival.

Conclusions

Long-term survival outcomes of HCC with PVTT are superior in patients undergoing hepatectomy compared to TACE. Further experience with randomized clinical trials may be warranted to confirm these findings.

Serum Vascular Endothelial Growth Factor in Patients with Hepatocellular Carcinoma and its Validity as a Tumor Biomarker

Background:

Hepatocellular Carcinoma (HCC) is one of the most common cancers associated with deaths worldwide and the presence of valid biomarkers for early diagnosis in high-risk patients can ameliorate the outcome of HCC. Vascular Endothelial Growth Factor (VEGF) has been found to play an essential role in the process of HCC growth and progression.

Objectives:

Therefore, we evaluated the serum VEGF levels in patients with HCC and liver cirrhosis and estimated its significant value for differentiating HCC patients from liver cirrhosis patients.

Material and methods:

Eighty-one subjects were enrolled in the study, 30 patients had HCC, 31 patients had liver cirrhosis and 20 were healthy control subjects. VEGF and AFP were measured using ELIZA. Abdominal ultrasound and triphasic abdominal computed tomography were performed in all subjects. Receiver Operating Characteristics curve analysis was performed for serum VEGF to determine its validity as a tumor biomarker.

Results:

The median levels of the serum VEGF were highly expressed in the HCC group (418 pg/ml) and the liver cirrhosis group (308 pg/ml) with no significant difference (P = 0.767); however both groups showed a significant increase compared to the control group (0.8 pg/ml, P <0.000). Serum VEGF showed high sensitivity (100%) and high specificity (100%) in differentiating HCC patients from controls with a cut-off value of ≥ 64.2 pg/ml, although it showed low sensitivity (29.2%) and specificity (85.7%) for differentiating HCC patients from liver cirrhosis patients.

Conclusion:

VEGF can be used as a reliable biomarker for differentiating HCC patients from healthy subjects but it can't be used as a reliable biomarker for differentiating HCC patients from high-risk patients as liver cirrhosis. The elevated serum VEGF levels in HCC and liver cirrhosis patients can elucidate the crucial role of angiogenesis in HCC and liver cirrhosis.

A Novel Prognostic Scoring Model Based on Albumin and γ-Glutamyltransferase for Hepatocellular Carcinoma Prognosis

AIM

To investigate the predictive value of albumin (ALB) and γ-glutamyltransferase (GGT) in hepatocellular carcinoma (HCC) patients undergoing curative resection. We sought to establish a new scoring model for predicting the prognosis of HCC patients undergoing curative resection.

PATIENTS AND METHODS

A retrospective analysis was performed in 303 HCC patients who underwent curative resection. Preoperative risk factors for survival were investigated using univariate and multivariate analyses. On the basis of significant factors, a prognostic scoring model was established. The overall survival (OS) and recurrence-free survival (RFS) were compared between different groups.

RESULTS

Multivariate Cox regression showed that preoperative decreased ALB levels and elevated GGT levels were significantly associated with poor OS and RFS. Multivariate analysis showed that ALB level, GGT level, portal vein tumor thrombus, and tumor number were independent prognostic factors for both OS and RFS. Thereafter, we established a preoperative prognostic scoring model combining the four risk factors. The results revealed that higher risk scores might mean worse OS and RFS.

CONCLUSION

Preoperative ALB and GGT levels are potentially useful biomarkers for predicting the prognostic outcomes in HCC patients undergoing curative resection. Our new prognostic scoring model qualifies as a novel prognostic predictor for HCC patients after curative resection.

Thrombophilia in hepatocellular carcinoma

Background

Chronic liver disease and hepatocellular carcinoma (HCC) can cause a disturbance in the coagulation system. In this study, we aimed to assess the risk factors for venous thromboembolism either acquired or hereditary in patients with HCC.

Results

Serum levels of proteins C and S, AT activity, and lipoprotein (a) were significantly lower in both HCC and cirrhotic patients while homocysteine levels were significantly higher in HCC patients. The prevalence of activated protein C resistance (APCR) and factor V Leiden (FVL) mutation was higher in HCC patients but with no significant differences between the studied groups. With multivariate analysis, prothrombin time, Fbg, protein C and S deficiency, increased lipoprotein (a), hyperhomocysteinemia, APCR, and FVL mutation were independent risk factors for thromboembolic complications in HCC patients.

Conclusions

Thrombophilic abnormalities are prevalent in HCC patients, and they have a substantial increased risk of venous thromboembolism.

PITPNA-AS1 abrogates the inhibition of miR-876-5p on WNT5A to facilitate hepatocellular carcinoma progression

LncRNA PITPNA-AS1 was a newly identified lncRNA which has never been studied in cancers. Whether PITPNA-AS1 participated in the development of hepatocellular carcinoma (HCC) is obscure. Given the coaction of lncRNAs and miRNAs to carcinogenesis, the purpose of the present research is to inquire how PITPNA-AS1 affects HCC progression. Firstly, PITPNA-AS1 was observed to be heightened in HCC tissues. Then function assays proved that overexpressing or silencing PITPNA-AS1 could manipulate the proliferation and motility of HCC cells. Besides, PITPNA-AS1 was located in the cytoplasm. Among the candidate miRNAs of PITPNA-AS1, miR-876-5p was an obvious target. Moreover, mechanism experiments validated that PITPNA-AS1 modulated WNT5A expression by targeting miR-876-5p. Rescue experiments affirmed that WNT5A silencing rescued the miR-876-5p suppression-induced cellular processes in PITPNA-AS1-silenced Hep3B cells. And in vivo experiments determined that PITPNA-AS1 regulated HCC progression in vivo via miR-876-5p/WNT5A pathway. In conclusion, this work shed lights on the modulatory mechanism of PITPNA-AS1/miR-876-5p/WNT5A axis in HCC, which might be pivotal for exploring effective diagnostic biomarkers and treatment strategies for HCC patients.

Development and Validation of CAGIB Score for Evaluating the Prognosis of Cirrhosis with Acute Gastrointestinal Bleeding: A Retrospective Multicenter Study

INTRODUCTION

Acute gastrointestinal bleeding (GIB) is a major cause of death in liver cirrhosis. This multicenter study aims to develop and validate a novel and easy-to-access model for predicting the prognosis of patients with cirrhosis and acute GIB.

METHODS

Patients with cirrhosis and acute GIB were enrolled and randomly divided into the training (n = 865) and validation (n = 817) cohorts. In the training cohort, the independent predictors for in-hospital death were identified by logistic regression analyses, and then a new prognostic model (i.e., CAGIB score) was established. Area under curve (AUC) of CAGIB score was calculated by receiver operating characteristic curve analysis and compared with Child-Pugh, model for end-stage liver disease (MELD), MELD-Na, and neutrophil-lymphocyte ratio (NLR) scores.

RESULTS

In the training cohort, hepatocellular carcinoma (HCC), diabetes, total bilirubin (TBIL), albumin (ALB), alanine aminotransferase (ALT), and serum creatinine (Scr) were independent predictors of in-hospital death. CAGIB score = diabetes (yes = 1, no = 0) × 1.040 + HCC (yes = 1, no = 0) × 0.974 + TBIL (μmol/L) × 0.005 - ALB (g/L) × 0.091 + ALT (U/L) × 0.001 + Scr (μmol/L) × 0.012 - 3.964. In the training cohort, the AUC of CAGIB score for predicting in-hospital death was 0.829 (95% CI 0.801-0.854, P < 0.0001), which was higher than that of Child-Pugh (0.762, 95% CI 0.732-0.791), MELD (0.778, 95% CI 0.748-0.806), MELD-Na (0.765, 95% CI 0.735-0.793), and NLR (0.587, 95% CI 0.553-0.620) scores. In the validation cohort, the AUC of CAGIB score (0.714, 95% CI 0.682-0.746, P = 0.0006) remained higher than that of Child-Pugh (0.693, 95% CI 0.659-0.725), MELD (0.662, 95% CI 0.627-0.695), MELD-Na (0.660, 95% CI 0.626-0.694), and NLR (0.538, 95% CI 0.503-0.574) scores.

CONCLUSION

CAGIB score has a good predictive performance for prognosis of patients with cirrhosis and acute GIB.

Chemotherapeutic perfusion of portal vein after tumor thrombectomy and hepatectomy benefits patients with advanced hepatocellular carcinoma: A propensity score-matched survival analysis

BACKGROUND

Portal vein tumor thrombus (PVTT) is a common complication in hepatocellular carcinoma (HCC), signaling dismal outcomes. This study was conducted to evaluate the survival benefit of postoperative portal vein perfusion chemotherapy (PVC) in patients with HCC and PVTT.

METHODS

A retrospective review was conducted in 401 consecutive patients with HCC and PVTT who underwent hepatic resection between January 2009 and December 2015 and 67 patients received adjuvant postoperative PVC. A propensity score matching (PSM) was used to match patients with and without PVC at a ratio of 1:1.

RESULTS

After PSM, the median time to recurrence (TTR) and overall survival (OS) were significantly longer in PVC group compared with control group (12.3 vs 5.8 months, P = .001; 19.0 vs 13.4 months, P = .037; respectively). At 1, 2, 3, and 5 years, the cumulative recurrence rates in PVC group were 48.1%, 86.5%, 92.3% ,96.2%, respectively, with OS rates of 63.8%, 37.9%, 24.4%, 18.3%, respectively; whereas cumulative recurrence rates of 76.6%, 91.5%, 94.3%, and 97.2%, respectively and OS rates of 55.4%, 23.0%, 12.4%, and 12.4%, respectively were recorded for the control group. In multivariate analysis, postoperative PVC emerged as a significant predictor for TTR (hazard ratio [HR], 0.523; P = .001) and OS (HR, 0.591; P = .010). PVC could reduce early recurrence (≤1 year) rate after surgical resection (40.3% vs 64.2%, P = .006) and clinical outcomes were further enhanced by adding sorafenib to postoperative PVC.

CONCLUSIONS

Compared with surgical resection alone, postoperative adjuvant PVC treatment boosts survival and reduces early tumor recurrences in patients surgically treated for HCC and PVTT.

Inhibitory effects of genistein in combination with gefitinib on the hepatocellular carcinoma Hep3B cell line

Combination therapy is an important method for treating advanced hepatocellular carcinoma (HCC). Gefitinib is an epidermal growth factor receptor (EGFR) inhibitor, which has profound effects on HCC. The purpose of the present study was to investigate the effects of genistein in combination with gefitinib on the proliferation and apoptosis of HCC cells and the associated mechanism. Cell counting kit-8 assay was performed to calculate the IC₅₀ values and cytotoxicity, whilst flow cytometry was used to assess cell apoptosis. Protein expression was detected using western blot analysis. The IC₅₀ of genistein and gefitinib on Hep3B cells were calculated to be 128.078 and 13.657 µM, respectively. Genistein in combination with gefitinib significantly inhibited cell viability, promoted apoptosis and reduced EGFR, vascular endothelial growth factor receptor and platelet-derived growth factor receptor phosphorylation. Genistein in combination with gefitinib promoted the expression of cleaved caspase-3 and cleaved poly ADP-ribose polymerase. In addition, combined treatment of genistein and gefitinib strongly inhibited the activation of the Akt/Erk/mTOR signaling pathway. In conclusion, findings from the present study suggest that genistein in combination with gefitinib inhibit HCC cell proliferation and promote apoptosis by inhibiting the Akt/Erk/mTOR pathway.

Hepatocellular carcinoma and macrovascular tumor thrombosis: treatment outcomes and prognostic factors for survival

PURPOSE

To determine the treatment outcome and prognostic factors for survival in patients with hepatocellular carcinoma (HCC) and macrovascular tumor thrombosis (MTT).

METHODS

Between January 2010 and December 2018, 66 patients diagnosed with HCC and MTT, who received specific treatment were included. Various clinical and imaging data, treatment methods, outcomes, prognostic factors, and overall survival were evaluated. Outcomes were compared with those of 24 patients treated with supportive care.

RESULTS

Most patients with HCC and MTT showed disease progression (80.3%) and a low 5-year survival rate. The median survival time after treatment was 13 months (vs. supportive care group 3 months, p < 0.001). Main branch MTT (p = 0.036), extent of tumor thrombus > 1 segment (p = 0.039), presence of ascites (p = 0.009) and among treatment methods, systemic therapy alone (p = 0.007), and supportive care (p < 0.001) compared with combined local with systemic therapies were prognostic factors for poor survival.

CONCLUSIONS

Although most patients with HCC and MTT showed disease progression, median survival time was significantly longer than that with supportive care. Main branch and > 1 segment involvement of MTT and presence of ascites were significant prognostic factors for poor survival. Combined local and systemic therapy over systemic therapy alone are recommended for patients with these advanced stage HCCs.

Effect of Codonopsis pilosula Polysaccharides on the Growth and Motility of Hepatocellular Carcinoma HepG2 Cells by Regulating β-Catenin/TCF4 Pathway

Objective. To study the effect of Codonopsis pilosula polysaccharide (CPP) on the growth and motility of HepG2 cells and its possible mechanism. Methods. Cells were randomly divided into Control group, CPP (5 μM) group, CPP (10 μM) group, and CPP (20 μM) group. The proliferation, invasion, migration ability, and expression of proteins involved in the epithelial-mesenchymal transition (EMT) and signaling pathway of HepG2 cells were detected by CCK8 assay, BrdU staining, Transwell, Scratch test, and Western blot, respectively. Results. Codonopsis pilosula polysaccharide inhibited the proliferation of HepG2 cells cultured in vitro along with the expression level of Ki67 and PCNA protein (P<0.05), decreased the number of invasive cells (P<0.05), and reduced the scratch closure rate (P<0.05). It also adjusted the expression of vascular endothelial growth factor (VEGF), E-cadherin, and N-cadherin (P<0.05). Other than that, downregulation of β-catenin, TCF4, and c-Myc protein expression (P<0.05) was observed as well. Conclusion. Codonopsis pilosula polysaccharide can inhibit the proliferation and motility of HepG2 cells cultured in vitro, and the underlying mechanism is proposed to be related to the inhibition of the β-catenin/TCF4 pathway.