Progress in non-invasive detection of liver fibrosis

Construction and validation of somatic mutation-derived long non-coding RNAs signatures of genomic instability to predict prognosis of hepatocellular carcinoma

BACKGROUND

Long non-coding RNAs (LncRNAs) have been found to be a potential prognostic factor for cancers, including hepatocellular carcinoma (HCC). Some LncRNAs have been confirmed as potential indicators to quantify genomic instability (GI). Nevertheless, GI-LncRNAs remain largely unexplored. This study established a GI-derived LncRNA signature (GILncSig) that can predict the prognosis of HCC patients.

AIM

To establish a GILncSig that can predict the prognosis of HCC patients.

METHODS

Identification of GI-LncRNAs was conducted by combining LncRNA expression and somatic mutation profiles. The GI-LncRNAs were then analyzed for functional enrichment. The GILncSig was established in the training set by Cox regression analysis, and its predictive ability was verified in the testing set and TCGA set. In addition, we explored the effects of the GILncSig and TP53 on prognosis.

RESULTS

A total of 88 GI-LncRNAs were found, and functional enrichment analysis showed that their functions were mainly involved in small molecule metabolism and GI. The GILncSig was constructed by 5 LncRNAs (miR210HG, AC016735.1, AC116351.1, AC010643.1, LUCAT1). In the training set, the prognosis of high-risk patients was significantly worse than that of low-risk patients, and similar results were verified in the testing set and TCGA set. Multivariate Cox regression analysis and stratified analysis confirmed that the GILncSig could be used as an independent prognostic factor. Receiver operating characteristic curve analysis of the GILncSig showed that the area under the curve (0.773) was higher than the two LncRNA signatures published recently. Furthermore, the GILncSig may have a better predictive performance than TP53 mutation status alone.

CONCLUSION

We established a GILncSig that can predict the prognosis of HCC patients, which will help to guide prognostic evaluation and treatment decisions.

Staging liver fibrosis with various diffusion-weighted magnetic resonance imaging models

BACKGROUND

Diffusion-weighted imaging (DWI) has been developed to stage liver fibrosis. However, its diagnostic performance is inconsistent among studies. Therefore, it is worth studying the diagnostic value of various diffusion models for liver fibrosis in one cohort.

AIM

To evaluate the clinical potential of six diffusion-weighted models in liver fibrosis staging and compare their diagnostic performances.

METHODS

This prospective study enrolled 59 patients suspected of liver disease and scheduled for liver biopsy and 17 healthy participants. All participants underwent multi-b value DWI. The main DWI-derived parameters included Mono-apparent diffusion coefficient (ADC) from mono-exponential DWI, intravoxel incoherent motion model-derived true diffusion coefficient (IVIM-D), diffusion kurtosis imaging-derived apparent diffusivity (DKI-MD), stretched exponential model-derived distributed diffusion coefficient (SEM-DDC), fractional order calculus (FROC) model-derived diffusion coefficient (FROC-D) and FROC model-derived microstructural quantity (FROC-μ), and continuous-time random-walk (CTRW) model-derived anomalous diffusion coefficient (CTRW-D) and CTRW model-derived temporal diffusion heterogeneity index (CTRW-α). The correlations between DWI-derived parameters and fibrosis stages and the parameters' diagnostic efficacy in detecting significant fibrosis (SF) were assessed and compared.

RESULTS

CTRW-D (r = -0.356), CTRW-α (r = -0.297), DKI-MD (r = -0.297), FROC-D (r = -0.350), FROC-μ (r = -0.321), IVIM-D (r = -0.251), Mono-ADC (r = -0.362), and SEM-DDC (r = -0.263) were significantly correlated with fibrosis stages. The areas under the ROC curves (AUCs) of the combined index of the six models for distinguishing SF (0.697-0.747) were higher than each of the parameters alone (0.524-0.719). The DWI models' ability to detect SF was similar. The combined index of CTRW model parameters had the highest AUC (0.747).

CONCLUSION

The DWI models were similarly valuable in distinguishing SF in patients with liver disease. The combined index of CTRW parameters had the highest AUC.

Combination of serum alpha-fetoprotein, PIVKA-Ⅱ and glypican-3 in diagnosis of hepatocellular carcinoma: a meta-analysis

OBJECTIVES

To assess the value of serum alpha-fetoprotein (AFP), protein induced by vitamin K absence or antagonist-Ⅱ (PIVKA-Ⅱ) and glypican-3 (GPC-3) in the diagnosis of hepatocellular carcinoma (HCC).

METHODS

Studies of AFP, PIVKA-Ⅱ, GPC-3 or in combination for the diagnosis of HCC since 2002 were searched in PubMed, Web of Science and Embase databases. The literature was screened according to the inclusion and exclusion criteria, the quality of the included articles was evaluated by QUADAS checklist, and relevant data were extracted by Meta DiSc, Review Manager 5.4 and Stata 15.1. The diagnostic values of AFP, PIVKA-Ⅱ and GPC-3 alone or in combination for HCC were assessed with receiver operating characteristic (ROC) curve.

RESULTS

A total of 32 articles were included in the study. Meta-analysis showed that when a single marker was used to diagnose HCC, the area under the ROC curve (AUC) of PIVKA-Ⅱ was the highest (0.88, 95%CI: 0.85-0.91), followed by GPC-3 and AFP. The AUC of combination of serum markers was higher than that of a single marker, and the AUC of PIVKA-Ⅱ combined with GPC-3 was the highest (0.90, 95%CI: 0.87-0.92). When a single marker was used for diagnosis, the sensitivity of PIVKA-Ⅱ and GPC-3 were relatively high (0.75 and 0.76), while the specificity of PIVKA-Ⅱ (0.88) and AFP (0.87) were higher than that of GPC-3 (0.81). The sensitivity of the combination of serum markers was higher than that of a single marker, while the specificity was not significantly improved. When a single marker is used to diagnose HCC, the diagnostic odds ratio (DOR) of PIVKA-Ⅱ was the highest (22, 95%CI: 13-36), followed by GPC-3 and AFP. The DOR of the combination of two markers in the diagnosis of HCC was higher than that of a single marker, and the DOR of AFP combined with GPC-3 was the highest (25, 95%CI: 9-67). The DOR of the combination of the three markers was significantly reduced to 10 (95%CI: 7-45).

CONCLUSIONS

When a single marker is used, PIVKA-Ⅱ has a higher diagnostic value for HCC. The combination of two markers can significantly improve the diagnostic sensitivity, and AFP combined with PIVKA-Ⅱ is recommended for the diagnosis of HCC. The combination of all three markers failed to further improve the diagnostic value.

The lncRNA lnc-TSI antagonizes sorafenib resistance in hepatocellular carcinoma via downregulating miR-4726-5p expression and upregulating KCNMA1 expression

Acquired drug resistance is a main reason for limiting the application of sorafenib in HCC treatment. This study aimed to explore the role and mechanisms of a novel long non-coding RNA (lncRNA), lnc-TSI, in sorafenib resistance of HCC. The interaction between lnc-TSI and miR-4726-5p, and miR-4726-5p and KCNMA1 were predicted using bioinformatic tools. Expression of the molecules in the lnc-TSI/miR-4726-5p/KCNMA1 axis in clinical samples and cell lines, as well as the sorafenib resistant HCC cell lines, was determined using qRT-PCR or western blotting. Expressions of lnc-TSI, miR-4726-5p, and KCNMA1 were manipulated in HepG2 and Huh7 cells through plasmid transfection or lentivirus infection. The CCK-8, flow cytometry, and Tunel assays were employed to determine the role of this axis on sorafenib resistance of HCC. A xenograft model was established using sorafenib-resistant HepG2 and Huh7 cells followed by in vivo sorafenib treatments to confirm the in vitro findings. Lnc-TSI and KCNMA1 expressions were significantly downregulated in HCC clinical samples and cell lines, especially in sorafenib resistance ones, while mi-4726-5p presented a reversed expression pattern. Lnc-TSI interacted with miR-4726-5p, and Lnc-TSI acts as a ceRNA via sponging miR-4726-5p in HCC cells. Overexpression of lnc-TSI and KCNMA1 promoted apoptosis and decreased cell viability of sorafenib-treated HCC cells, thus alleviated sorafenib resistance. miR-4726-5p mimic reversed the KCNMA1-mediated sorafenib sensitivity-promoting effect, while additional overexpression of lnc-TSI reversed the effect of miR-4726-5p. In vivo analysis also showed that overexpression of ln-TSI diminished sorafenib resistance in mice inoculated with sorafenib-resistant HCC cells via increasing KCNMA1 expression and decreasing miR-4726-5p expression. The lnc-TSI/miR-4726-5p/KCNMA1 axis plays a critical role in regulating the resistance of HCC to sorafenib, and might serve as a therapeutic target to manage sorafenib resistance of HCC in clinic.

Phenotypic and metabolomic characteristics of mouse models of metabolic associated steatohepatitis

BACKGROUND

Metabolic associated steatohepatitis (MASH) is metabolic disease that may progress to cirrhosis and hepatocellular carcinoma. Mouse models of diet-induced MASH, which is characterized by the high levels of fats, sugars, and cholesterol in diets, are commonly used in research. However, mouse models accurately reflecting the progression of MASH in humans remain to be established. Studies have explored the potential use of serological metabolites as biomarkers of MASH severity in relation to human MASH.

METHODS

We performed a comparative analysis of three mouse models of diet-induced MASH in terms of phenotypic and metabolomic characteristics; MASH was induced using different diets: a high-fat diet; a Western diet; and a high-fat, high-cholesterol diet. Liver cirrhosis was diagnosed using standard clinical approaches (e.g., METAVIR score, hyaluronan level, and collagen deposition level). Mouse serum samples were subjected to nuclear magnetic resonance spectroscopy-based metabolomic profiling followed by bioinformatic analyses. Metabolomic analysis of a retrospective cohort of patients with hepatocellular carcinoma was performed; the corresponding cirrhosis scores were also evaluated.

RESULTS

Using clinically relevant quantitative diagnostic methods, the severity of MASH was evaluated. Regarding metabolomics, the number of lipoprotein metabolites increased with both diet and MASH progression. Notably, the levels of very low-density lipoprotein (VLDL) and low-density lipoprotein (LDL) significantly increased with fibrosis progression. During the development of diet-induced MASH in mice, the strongest upregulation of expression was noted for VLDL receptor. Metabolomic analysis of a retrospective cohort of patients with cirrhosis indicated lipoproteins (e.g., VLDL and LDL) as predominant biomarkers of cirrhosis.

CONCLUSIONS

Our findings provide insight into the pathophysiology and metabolomics of experimental MASH and its relevance to human MASH. The observed upregulation of lipoprotein expression reveals a feedforward mechanism for MASH development that may be targeted for the development of noninvasive diagnosis.

Evaluating M2BPGi as a Marker for Liver Fibrosis in Patients with Chronic Hepatitis B

BACKGROUND

The accurate evaluation of liver fibrosis is crucial for the treatment and follow up of chronic hepatitis B (CHB) patients.

AIM

We examined the efficiency of serum Mac-2 Binding Protein Glycosylation isomer (M2BPGi) in diagnosing liver fibrosis stages in CHB patients.

METHODS

A cross-sectional study was conducted on 177 adult CHB patients visiting the University Medical Center Ho Chi Minh City, Vietnam between October 2019 and December 2021. M2BPGi, ARFI, APRI, and FIB-4 were tested against FibroScan® for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The optimal M2BPGi cut-off values were identified based on the area under the receiver operating characteristic (AUROC) curve.

RESULTS

There was a strong agreement between M2BPGi and FibroScan® (r = 0.77, P < 0.001). The optimal M2BPGi cut-off index (C.O.I) for detecting significant fibrosis (F ≥ 2) was 0.79 with an AUROC of 0.77, 67.3% sensitivity, 70% specificity, 60.6% NPV, and 75.3% PPV. Compared with APRI (61%) and FIB-4 (47%), M2BPGi had the greatest sensitivity for diagnosing F ≥ 2. M2BPGi combined with APRI yielded highest diagnosis performance for F ≥ 2 with an AUROC of 0.87. The optimal cut-off index of M2BPGi for diagnosing cirrhosis (F4) was 1.3 with an AUROC of 0.91, 88% sensitivity, 87.4% specificity, 97% NPV, and 61% PPV. The AUROC of M2BPGi for diagnosing F4 was comparable to that of ARFI (0.93).

CONCLUSIONS

With cut-off values of 0.79 C.O.I and 1.3 C.O.I, M2BPGi could be an effective method for diagnosing significant fibrosis and cirrhosis in CHB patients, respectively.

Outcome of Very Early Onset Inflammatory Bowel Disease Associated With Primary Sclerosing Cholangitis: A Multicenter Study From the Pediatric IBD Porto Group of ESPGHAN

BACKGROUND

Whether primary sclerosing cholangitis related to inflammatory bowel disease (PSC-IBD) diagnosed before 6 years (ie, VEO-IBD) has a distinct phenotype and disease course is uninvestigated. We aimed to analyze the characteristics and natural history of VEO-PSC-IBD, compared with early and adolescent-onset PSC-IBD.

METHODS

This is a multicenter, retrospective, case-control study from 15 centers affiliated with the Porto and Interest IBD group of ESPGHAN. Demographic, clinical, laboratory, endoscopic, and imaging data were collected at baseline and every 6 months. Inflammatory bowel disease-related (clinical remission, need for systemic steroids and biologics, and surgery) and PSC-related (biliary and portal hypertensive complications, need for treatment escalation and liver transplantation, cholangiocarcinoma, or death) outcomes were compared between the 2 groups.

RESULTS

Sixty-nine children were included, with a median follow-up of 3.63 years (interquartile range, 1-11): 28 with VEO-PSC-IBD (23 UC [82%], 2 IBD-U [7%] and 3 [11%] CD), and 41 with PSC-IBD (37 UC [90%], 3 IBDU [7.5%] and 1 [2.5%] CD). Most patients with UC presented with pancolitis (92% in VEO-PSC-UC vs 85% in PSC-UC, P = .2). A higher number of patients with VEO-PSC-IBD were diagnosed with PSC/autoimmune hepatitis overlap syndrome than older children (24 [92%] vs 27 [67.5%] PSC-IBD, P = .03), whereas no other differences were found for PSC-related variables. Time to biliary strictures and infective cholangitis was lower in the VEO-PSC-IBD group (P = .01 and P = .04, respectively), while no difference was found for other outcomes. No cases of cholangiocarcinoma were reported.

CONCLUSIONS

Primary sclerosing cholangitis related to inflammatory bowel disease has similar baseline characteristics whether diagnosed as VEO-IBD or thereafter. A milder disease course in terms of biliary complications characterizes VEO-PSC-IBD.

Baseline metabolites could predict responders with hepatitis B virus-related liver fibrosis for entecavir or combined with FuzhengHuayu tablet

BACKGROUND

After receiving entecavir or combined with FuzhengHuayu tablet (FZHY) treatment, some sufferers with hepatitis B virus (HBV)-related liver fibrosis could achieve a histological improvement while the others may fail to improve even worsen. Serum metabolomics at baseline in these patients who were effective in treatment remain unclear.

AIM

To explore baseline serum metabolites characteristics in responders.

METHODS

A total of 132 patients with HBV-related liver fibrosis and 18 volunteers as healthy controls were recruited. First, all subjects were divided into training set and validation set. Second, the included patients were subdivided into entecavir responders (E-R), entecavir no-responders (E-N), FZHY + entecavir responders (F-R), and FZHY + entecavir no-responders (F-N) following the pathological histological changes after 48 wk' treatments. Then, Serum samples of all subjects before treatment were tested by high performance liquid chromatography-tandem mass spectrometry (LC-MS) high-performance LC-MS. Data processing was conducted using multivariate principal component analysis and orthogonal partial least squares discriminant analysis. Diagnostic tests of selected differential metabolites were used for Boruta analyses and logistic regression.

RESULTS

As for the intersection about differential metabolic pathways between the groups E-R vs E-N and F-R vs F-N, results showed that 4 pathways including linoleic acid metabolism, aminoacyl-tRNA biosynthesis, cyanoamino acid metabolism, alanine, aspartate and glutamate metabolism were screened out. As for the differential metabolites, these 7 intersected metabolites including hydroxypropionic acid, tyrosine, citric acid, taurochenodeoxycholic acid, benzoic acid, 2-Furoic acid, and propionic acid were selected.

CONCLUSION

Our findings showed that 4 metabolic pathways and 7 differential metabolites had potential usefulness in clinical prediction of the response of entecavir or combined with FZHY on HBV fibrotic liver.

Application of multi-echo Dixon and MRS in quantifying hepatic fat content and staging liver fibrosis

This study associated the liver proton density fat fraction (PDFF), measured by multi-echo Dixon (ME-Dixon) and breath-hold single-voxel high-speed T2-corrected multi-echo 1H magnetic resonance spectroscopy (HISTO) at 1.5 T, with serum biomarkers and liver fibrosis stages. This prospective study enrolled 75 patients suspected of liver fibrosis and scheduled for liver biopsy and 23 healthy participants with normal liver function. The participant underwent ME-Dixon and HISTO scanning. The agreement of PDFF measured by ME-Dixon (PDFF-D) and HISTO (PDFF-H) were compared. Correlations between PDFF and serum fat biomarkers (total cholesterol, triglyceride, and high- and low-density lipoproteins) and the liver fibrosis stages were assessed. PDFF were compared among the liver fibrosis stages (F0-F4) based on clinical liver biopsies. The Bland-Altman plot showed agreement between PDFF-D and PDFF-H(LoA, - 4.44 to 6.75), which have high consistency (ICC 0.752, P < 0.001). The correlations with the blood serum markers were mild to moderate (PDFF-H: r = 0.261-0.410, P < 0.01; PDFF-D: r = 0.265-0.367, P < 0.01). PDFF-D, PDFF-H, and steatosis were distributed similarly among the liver fibrosis stages. PDFF-H showed a slight negative correlation with the liver fibrosis stages (r = - 0.220, P = 0.04). Both ME-Dixon and HISTO sequences measured liver fat content noninvasively. Liver fat content was not directly associated with liver fibrosis stages.

Advances in application of novel magnetic resonance imaging technologies in liver disease diagnosis

Liver disease is a major health concern globally, with high morbidity and mor-tality rates. Precise diagnosis and assessment are vital for guiding treatment approaches, predicting outcomes, and improving patient prognosis. Magnetic resonance imaging (MRI) is a non-invasive diagnostic technique that has been widely used for detecting liver disease. Recent advancements in MRI technology, such as diffusion weighted imaging, intravoxel incoherent motion, magnetic resonance elastography, chemical exchange saturation transfer, magnetic resonance spectroscopy, hyperpolarized MR, contrast-enhanced MRI, and ra-diomics, have significantly improved the accuracy and effectiveness of liver disease diagnosis. This review aims to discuss the progress in new MRI technologies for liver diagnosis. By summarizing current research findings, we aim to provide a comprehensive reference for researchers and clinicians to optimize the use of MRI in liver disease diagnosis and improve patient prognosis.

A Hierarchical Siamese Network for Noninvasive Staging of Liver Fibrosis Based on US Image Pairs of the Liver and Spleen

Due to the heterogeneity of ultrasound (US) images and the indeterminate US texture of liver fibrosis (LF), automatic evaluation of LF based on US images is still challenging. Thus, this study aimed to propose a hierarchical Siamese network that combines the information from liver and spleen US images to improve the accuracy of LF grading. There were two stages in the proposed method. In stage one, a dual-channel Siamese network was trained to extract features from paired liver and spleen patches that were cropped from US images to avoid vascular interferences. Subsequently, the L1 distance was used to quantify the liver-spleen differences (LSDs). In stage two, the pretrained weights from stage one were transferred into the Siamese feature extractor of the LF staging model, and a classifier was trained using the fusion of the liver and LSD features for LF staging. This study was retrospectively conducted on US images of 286 patients with histologically proven liver fibrosis stages. Our method achieved a precision and sensitivity of 93.92% and 91.65%, respectively, for cirrhosis (S4) diagnosis, which is about 8% higher than that of the baseline model. The accuracy of the advanced fibrosis (≥S3) diagnosis and the multi-staging of fibrosis (≤S2 vs. S3 vs. S4) both improved about 5% to reach 90.40% and 83.93%, respectively. This study proposed a novel method that combined hepatic and splenic US images and improved the accuracy of LF staging, which indicates the great potential of liver-spleen texture comparison in noninvasive assessment of LF based on US images.

Long noncoding RNA DSCR8 promotes the proliferation of liver cancer cells and inhibits apoptosis via the miR-22-3p/ARPC5 Axis

Emerging evidence shows that long noncoding RNAs (lncRNAs) play a vital role in the tumorigenesis and development of cancer, implying that some lncRNAs could be potential therapeutic targets. In this study, we employed Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) databases to construct a ceRNA network by bioinformatic analysis, and the Down syndrome critical region 8 (lncRNA_DSCR8)/miR-22-3p/actin-related protein 2/3 complex subunit 5 (ARPC5) axis was identified as a potential target in liver cancer (LC). Next, we found that DSCR8 is highly expressed in LC cell lines Hep3B and Huh7. In addition, sh-DSCR8 inhibits cell proliferation and promotes cell apoptosis. Furthermore, we certified that DSCR8 serves as function as a sponge for miR-22-3p, while ARPC5 is a target gene of miR-22-3p, and the functions of DSCR8 promoting LC cell proliferation could be rescued by miR-22-3p. This study suggests that lncRNA_DSCR8 promotes LC progression and inhibits its apoptosis by regulating the miR-22-3p/ARPC5 axis, signifying that DSCR8 could be a novel therapeutic target for LC.

ASAP Score versus GALAD Score for detection of hepatitis C-related hepatocellular carcinoma: A multicenter case-control analysis

Background

The GALAD and ASAP scores are two well-recognized algorithms to estimate the risk of hepatocellular carcinoma (HCC) based on gender, age, alpha-fetoprotein (AFP), protein induced by vitamin K absence or Antagonist-II (PIVKA-II) and AFP-L3 (included in the GALAD score but not in the ASAP score). The current study sought to compare the diagnostic performance of each score to detect HCC among patients infected with hepatitis C virus (HCV).

Methods

A multicenter case-control study was undertaken in which blood samples were collected from HCVinfected patients with and without HCC. Using the area under the receiver operating characteristic curve (AUROC), ASAP and GALAD scores were compared relative to diagnostic performance to detect any stage HCV-HCC and early-stage HCV-HCC.

Results

The analytic cohort included 168 HCV-HCC patients and a control group of 193 HCV-infected patients. The ASAP score had a higher AUROC to detect any stage HCV-HCC versus the GALAD score, both in the overall group (0.917 vs. 0.894, P=0.057) and in the cirrhosis subgroup (0.909 vs. 0.889, P=0.132). Similar results were noted relative to the detection of early-stage HCV-HCC, whether defined by BCLC staging (stage 0-A: 0.898 vs. 0.860, P=0.026) or 8^th TNM staging (stage I: 0.899 vs. 0.870, P=0.070). In subgroup analysis to detect AFP-negative HCV-HCC, the ASAP score also demonstrated a higher AUROC than the GALAD score to detect any stage HCV-HCC in the AFP-negative subgroup (0.815 vs. 0.764, P=0.063).

Conclusions

The ASAP score had better diagnostic performance for early detection of HCV-HCC compared with the GALAD score. The ASAP score may be preferrable to the GALAD score for HCC screening and surveillance among HCV-infected patients.

Biodistribution Profile of Magnetic Nanoparticles in Cirrhosis-Associated Hepatocarcinogenesis in Rats by AC Biosusceptometry

Since magnetic nanoparticles (MNPs) have been used as multifunctional probes to diagnose and treat liver diseases in recent years, this study aimed to assess how the condition of cirrhosis-associated hepatocarcinogenesis alters the biodistribution of hepatic MNPs. Using a real-time image acquisition approach, the distribution profile of MNPs after intravenous administration was monitored using an AC biosusceptometry (ACB) assay. We assessed the biodistribution profile based on the ACB images obtained through selected regions of interest (ROIs) in the heart and liver position according to the anatomical references previously selected. The signals obtained allowed for the quantification of pharmacokinetic parameters, indicating that the uptake of hepatic MNPs is compromised during liver cirrhosis, since scar tissue reduces blood flow through the liver and slows its processing function. Since liver monocytes/macrophages remained constant during the cirrhotic stage, the increased intrahepatic vascular resistance associated with impaired hepatic sinusoidal circulation was considered the potential reason for the change in the distribution of MNPs.

Diagnostic Performance of Acoustic Radiation Force Impulse Imaging in Evaluating Liver Fibrosis in Patients with Chronic Hepatitis B Infection: A Cross-Sectional Study

Background  Acoustic radiation force impulse point shear wave elastography (ARFI-pSWE), measuring shear-wave velocity (SWV), has been utilized to examine the liver stiffness caused by different etiologies. However, information on its reliability in staging liver fibrosis in chronic hepatitis B (CHB) patients is scarce.

Purpose  The aim of the study is to examine the diagnostic performance of ARFI-pSWE and determine the optimal SWV cut-off values to predict significant fibrosis ( F ≥2) and cirrhosis (F4) in CHB patients.

Material and Methods  All 114 adult CHB patients visiting the University Medical Center, Ho Chi Minh City, Vietnam between February 2019 and March 2021 underwent liver stiffness measurement using ARFI-pSWE and FibroScan. SWV results were tested against FibroScan for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The area under the receiver operating characteristic (AUROC) curve was used to identify the optimal SWV cut-off values.

Results  There was a strong agreement between ARFI-pSWE and FibroScan ( r  = 0.92, p <0.001). The optimal SWV cut-off value for detecting significant fibrosis was 1.37 m/s with an AUROC of 0.975, sensitivity of 83.3%, specificity of 100%, PPV of 100%, and NPV of 81%. The optimal cut-off value for predicting cirrhosis was 1.70 m/s with an AUROC of 0.986, sensitivity of 97%, specificity of 93%, PPV of 95%, and NPV of 96%.

Conclusion  ARFI-pSWE could be an effective technique for evaluating liver fibrosis in CHB patients. SWV cut-off values of 1.37 and 1.70 m/s could be used to diagnose significant fibrosis and cirrhosis, respectively.

Four-copy number alteration (CNA)-related lncRNA prognostic signature for liver cancer

The objective of this study was to identify CNA-related lncRNAs that can better evaluate the prognosis of patients with liver cancer. Prognostic molecular subtypes were identified, followed by tumor mutation and differential expression analyses. Genomic copy number anomalies and their association with lncRNAs were also evaluated. A risk model was built based on lncRNAs, as well as a nomogram, and the differences in the tumor immune microenvironment and drug sensitivity between the High_ and Low_risk groups were compared. Weighted gene co-expression network analysis was used to identify modules with significant enrichment in prognostic-related lncRNAs. In total, two subtypes were identified, TP53 and CTNNB1 were common high-frequency mutated genes in the two subtypes. A total of 8,372 differentially expressed (DE) mRNAs and 798 DElncRNAs were identified between cluster1 and cluster2. In addition, a four-lncRNA signature was constructed, and statistically significant differences between the Low_ and High_risk groups were found in terms of CD8 T cells, resting memory CD4 T cells, etc. Enrichment analysis showed that prognostic-related lncRNAs were involved in the cell cycle, p53 signaling pathway, non-alcoholic fatty liver disease, etc. A prognostic prediction signature, based on four-CNA-related lncRNAs, could contribute to a more accurate prognosis of patients with liver cancer.

Part 2: Disease of the Heart and Liver: A Relationship That Cuts Both Ways

Diseases known to affect both the heart and liver include a variety of infectious, autoimmune, and metabolic disorders, as well as toxins: most commonly alcohol. As damage to both the heart and liver progresses, transplantation is a reasonable therapeutic option. Heart failure patients with underlying congestive hepatopathy receiving cardiac transplant have demonstrated improved liver enzyme levels posttransplant. Patients with severe end-stage liver disease requiring a liver transplant must undergo careful preoperative evaluation as surgical stress exposes the myocardium to high levels of catecholamines. Clinicians must consider both cardiac and hepatic complications when evaluating heart failure, cirrhosis, and nonalcoholic fatty liver disease. In Part 2 of this review, we discuss new noninvasive techniques for assessing liver fibrosis in the preoperative stage. Both serum and radiologic studies, such as transient elastography, have begun to take the place of liver biopsy due to their decreased morbidity. Last, we explore the current research examining the benefit of combined heart-liver transplant, although more longitudinal outcome studies are needed.

Noninvasive proteomic biomarkers for alcohol-related liver disease

Alcohol-related liver disease (ALD) is a major cause of liver-related death worldwide, yet understanding of the three key pathological features of the disease-fibrosis, inflammation and steatosis-remains incomplete. Here, we present a paired liver-plasma proteomics approach to infer molecular pathophysiology and to explore the diagnostic and prognostic capability of plasma proteomics in 596 individuals (137 controls and 459 individuals with ALD), 360 of whom had biopsy-based histological assessment. We analyzed all plasma samples and 79 liver biopsies using a mass spectrometry (MS)-based proteomics workflow with short gradient times and an enhanced, data-independent acquisition scheme in only 3 weeks of measurement time. In plasma and liver biopsy tissues, metabolic functions were downregulated whereas fibrosis-associated signaling and immune responses were upregulated. Machine learning models identified proteomics biomarker panels that detected significant fibrosis (receiver operating characteristic-area under the curve (ROC-AUC), 0.92, accuracy, 0.82) and mild inflammation (ROC-AUC, 0.87, accuracy, 0.79) more accurately than existing clinical assays (DeLong's test, P < 0.05). These biomarker panels were found to be accurate in prediction of future liver-related events and all-cause mortality, with a Harrell's C-index of 0.90 and 0.79, respectively. An independent validation cohort reproduced the diagnostic model performance, laying the foundation for routine MS-based liver disease testing.

Heterogeneous Iron Oxide/Dysprosium Oxide Nanoparticles Target Liver for Precise Magnetic Resonance Imaging of Liver Fibrosis

Challenges remain in precisely diagnosing the progress of liver fibrosis in a noninvasive way. We here synthesized small (4 nm) heterogeneous iron oxide/dysprosium oxide nanoparticles (IO-DyO NPs) as a contrast agent (CA) for magnetic resonance imaging (MRI) to precisely diagnose liver fibrosis in vivo at both 7.0 and 9.4 T field strength. Our IO-DyO NPs can target the liver and show an increased T₂ relaxivity along with an increase of magnetic field strength. At a ultrahigh magnetic field, IO-DyO NPs can significantly improve spatial/temporal image resolution and signal-to-noise ratio of the liver and precisely distinguish the early and moderate liver fibrosis stages. Our IO-DyO NP-based MRI diagnosis can exactly match biopsy (a gold standard for liver fibrosis diagnosis in the clinic) but avoid the invasiveness of biopsy. Moreover, our IO-DyO NPs show satisfactory biosafety in vitro and in vivo. This work illustrates an advanced T₂ CA used in ultrahigh-field MRI (UHFMRI) for the precise diagnosis of liver fibrosis via a noninvasive means.

Beyond the Liver Function Tests: A Radiologist's Guide to the Liver Blood Tests

Liver blood tests (often also known as liver chemistries, liver tests, or the common misnomer liver function tests) are routinely used in diagnosis and management of hepatobiliary disease. Abnormal liver blood test results are often the first indicator of hepatobiliary disease and a common indication for abdominal imaging with US, CT, or MRI. Most of the disease entities can be categorized into hepatocellular or cholestatic patterns, with characteristic traits on liver blood tests. Each pattern has a specific differential, which can help narrow the differential diagnosis when combined with the clinical history and imaging findings. This article reviews the major liver blood tests as well as a general approach to recognizing common patterns of hepatobiliary disease within these tests (hepatocellular, cholestatic, acute liver failure, isolated hyperbilirubinemia). Examples of hepatobiliary disease with hepatocellular or cholestatic patterns are presented with characteristic test abnormalities and imaging findings. The commonly encountered scenario of chronic hepatitis with possible fibrosis is also reviewed, with discussion of potential further imaging such as elastography. The role of liver blood tests and imaging in evaluating complications of hepatic transplant is also discussed. Overall, integrating liver blood test patterns with imaging findings can help the radiologist accurately diagnose hepatobiliary disease, especially in cases where imaging findings may not allow differentiation between different entities. ^©RSNA, 2021.

Matrix metalloproteinase-1 as a non-invasive biomarker to assess liver fibrosis in children with chronic liver disease

Background

Abnormal extracellular matrix (ECM) turnover is linked to liver fibrosis as it reflects an imbalance between repair and progressive substitution of the liver parenchyma by scar tissue. Matrix metalloproteinases (MMPs) are the primary enzymes involved in ECM breakdown. So, this study aims to measure the value of serum matrix metalloproteinase-1 (MMP-1) in children with chronic liver diseases (CLD) in comparison with liver biopsy and serum biomarkers. A hundred twenty children with chronic liver diseases and sixty healthy children as a control group were included in this study. Both groups were evaluated via medical history, clinical, radiological, laboratory investigations, and serum MMP-1 level was measured by ELISA. Liver biopsy was performed for studied patients only.

Results

The mean MMP-1 was 15.2 ± 5.1 ng/ml in children with CLD, and 64.7 ± 27.4 ng/ml in the control group. MMP-1 was statistically lower in the children with CLD than controls (p < 0.001). The mean ± SD of aspartate aminotransferase to platelet ratio index (APRI) and fibrosis-4 (FIB-4) scores in all studied cases showed a significant trend of increase with progressive fibrosis stage evident with histological METAVIR scoring system, while serum MMP-1 concentration was decreased significantly with increasing the degree of fibrosis in CLD group (P 0.001). Serum MMP-1 was indirectly correlated with serum biomarkers and the degree of fibrosis in patients.

Conclusions

MMP-1 is a useful non-invasive marker for detection of the stage of liver fibrosis in children with chronic liver diseases.

Rare Case of Budd-Chiari Syndrome in a Young Child: A Diagnostic Conundrum

Budd-Chiari syndrome (BCS) is an uncommon vascular disorder in which venous thrombosis prevents the venous outflow of the liver. The obstruction is primarily at the level of hepatic veins and inferior vena cava. Here, we present a case of a two-and-a-half-year-old male child who presented with complaints of abdominal distension for two months and fever and watery diarrhea for one month. Physical examination showed the patient was anemic with palmar erythema. He was started on an empirical treatment of cefotaxime, metronidazole, and amikacin. Sensitivity and culture reports for blood and urine samples were negative, but abdominal computed tomography (CT) scan showed characteristic findings for BCS with caudate lobe hypertrophy. After the symptomatic treatment of the patient, a liver transplant was suggested as a last resort.

SERS diagnosis of liver fibrosis in the early stage based on gold nanostar liver targeting tags

In order to realize the accurate and early diagnosis of liver fibrosis, a long slow pathological process which may lead to cirrhosis or even liver cancer, liver targeting tags made up of gold nanostars and glycyrrhetinic acid are reported in this paper. Gold nanostars (GNSs) and GNS liver targeting tags (GLTTs) were injected into model mice with stage S1 liver fibrosis and normal mice via the tail vein respectively, then the SERS spectra were collected. GLTTs had a better detection effect on liver tissue than unmodified GNSs (12.85 times), and better detection reproducibility as well. Moreover, according to the MTT and survival analysis experiments, GLTTs also had better biocompatibility. Hence, the changes of 10 SERS signals and other substances in the early stage of liver fibrosis were analyzed at the molecular level, and the SERS characteristic peaks that could be used for the diagnosis of early liver fibrosis were screened out. Revealed by the experimental results, the GLTTs designed and prepared were applicable to the efficient SERS detection of early liver fibrosis in mice, and the strategy we have proposed might be a potential approach for the early diagnosis of this disease in clinics.

Preliminary experience with 3T magnetic resonance elastography imaging of the liver

Background

Magnetic resonance elastography (MRE) is a promising non-invasive technique for the identification and quantification of hepatic fibrosis. This manuscript describes our early experience with MRE for the assessment of the presence and staging of liver fibrosis on a 3T magnetic resonance imaging (MRI) system.

Objectives

The purpose of this study was to describe the MRE physics, procedure, interpretation and drawbacks, along with a few recommendations as per our experience.

Method

Magnetic resonance elastography was performed on 85 patients with a 3T MRI and the images were analysed both qualitatively and quantitatively. Liver stiffness was assessed by drawing freehand geographic regions of interest on the elastograms to cover the maximum portion of the hepatic parenchyma within the 95% confidence maps on each slice. Correlation with histopathology was performed whenever available.

Results

Of the 80 patients who met the inclusion criteria, 41 patients displayed a normal liver stiffness measurement (LSM) and 39 patients had a raised LSM. In the patients who had a raised LSM, 14 patients had Stage I–II fibrosis, 8 patients had Stage II–III fibrosis, 6 patients had Stage III–IV fibrosis, 4 patients had Stage IV fibrosis or cirrhosis and 7 patients had non-alcoholic steatohepatitis. The mean thickness of the waves increased with increasing stages of fibrosis. The waves became gradually darker medially in patients with normal LSM as compared to the patients with raised LSM. Histopathology with METAVIR scoring was available in 46 patients, which agreed with the MRE findings in all except two patients.

Conclusion

Magnetic resonance elastography is a suitable non-invasive modality for the identification and quantification of hepatic fibrosis.

Effects of losartan and l-serine in a mouse liver fibrosis model

Hepatic fibrosis is a common liver disease caused by excessive collagen deposition in the liver. Since liver transplantation is the only current treatment for cirrhosis with worsened fibrosis, a new strategy to develop anti-fibrosis drugs with no adverse effects is necessary. In recent studies, amino acids have been applied as a type of therapy in various fields. l-serine plays a major role in antioxidant production via the maintenance of nicotinamide adenine dinucleotide phosphate hydride production in the mitochondria. l-serine may reduce fibrotic lesions in a mouse model of chronic liver injury. This study used 27 six-week-old C57BL/6 mice and injected them three times a week for eight weeks with carbon tetrachloride (CCl₄) (1.5 mg/kg, 10% v/v CCl₄ in olive oil) to create a hepatic fibrosis mouse model. The mice, which weighed approximately 20-30 g, were randomly classified into four groups: 1) the olive oil group, which received intraperitoneal injection of olive oil (1.5 mg/kg, 3 times per week for 8 weeks); 2) the CCl4-only group; 3) the CCl4 + losartan (10 mg/kg, PO, 5 days on, weekend off for 8 weeks) group; and 4) the CCl4 + l-serine (100 g/L, free access for 8 weeks) group. Hematoxylin and eosin staining and Masson's trichrome staining showed reduced inflammatory cell deposition and collagen deposition in the liver tissue in the l-serine supplemented group. l-serine was found to reduce the spread of hepatic fibrosis and has potential use in clinical settings. Based on these histopathological observations, l-serine is a potential anti-fibrosis drug.

PIVKA-II serves as a potential biomarker that complements AFP for the diagnosis of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors of the digestive system and has high morbidity and mortality rates. It is essential to search new biomarkers to improve the accuracy of early HCC diagnosis. Therefore, we evaluated the diagnostic value of prothrombin induced by vitamin K deficiency or antagonist- II (PIVKA-II) as a potential biomarker that complements α-fetoprotein (AFP) in HCC by detecting the serum PIVKA-II levels.

METHODS

Serum PIVKA-II levels were compared in 168 HCC patients, 150 benign liver disease patients and 153 healthy controls to investigate the PIVKA-II potential to be a HCC biomarker. Receiver operating characteristic curve (ROC) analysis was used to evaluate the value of PIVKA-II in the diagnosis of HCC and its complementary role of AFP. The correlation between serum PIVKA-II levels and clinicopathological characteristics was analyzed to study the value of PIVKA-II in assessing HCC progression and prognosis. Finally, the ability of PIVKA-II in assessing the surgical treatment effects of HCC was studied by comparing the pre- and post-operative serum PIVKA-II levels in 89 HCC patients.

RESULTS

Serum PIVKA-II levels in HCC patients were significantly higher than that in patients with benign liver disease and healthy controls. The PIVKA-II performance in the diagnosing HCC as an individual biomarker was remarkable. The combined detection of PIVKA-II and AFP improved the diagnostic efficiency of HCC. PIVKA-II retained significant diagnosis capabilities for AFP-negative HCC patients. Significant correlations were found between PIVKA-II expression levels and some clinicopathological characteristics, including tumor size, tumor stage, tumor metastasis, differentiation degree and complications. PIVKA-II expression obviously decreased after surgical resection.

CONCLUSIONS

PIVKA-II is a promising serum biomarker for the HCC diagnosis that can be used as a supplement for AFP. The combined diagnosis of the two markers greatly improved the diagnostic efficiency of HCC. The PIVKA-II levels in HCC patients were widely associated with clinicopathological characteristics representing tumor cell dissemination and/or poor prognosis. PIVKA-II can be used to evaluate the curative effects of HCC resection.

US Elastography in Hepatic Fibrosis-Radiology In Training

A 72-year-old woman with an elevated body mass index and moderate alcohol intake was seen in the gastroenterology clinic. The patient had a past history of abnormal liver function tests and previous biopsy-proven steatosis with early fibrosis. She was reevaluated, following an initial loss to follow-up, by using US elastography to assess for fibrosis progression. The utility of US elastography in the noninvasive diagnosis and longitudinal monitoring of hepatic fibrosis is discussed. An overview of available technologies, including transient elastography and shear-wave elastography, is provided. ^©RSNA, 2021 Online supplemental material is available for this article.

Hepatic Steatosis Predicts Higher Incidence of Recurrence in Colorectal Cancer Liver Metastasis Patients

Purpose: Colorectal liver metastasis (CRLM) is the major cause of death due to colorectal cancer. Although great efforts have been made in treatment of CRLM, about 60–70% of patients will develop hepatic recurrence. Hepatic steatosis was reported to provide fertile soil for metastasis. However, whether hepatic steatosis predicts higher incidence of CRLM recurrence is not clear. Therefore, we aimed to determine the role of hepatic steatosis in CRLM recurrence in the present study.

Methods: Consecutive CRLM patients undergoing curative treatment were retrospectively enrolled and CT liver-spleen attenuation ratio was used to detect the presence of hepatic steatosis. In patients with hepatic steatosis, we also detected the presence of fibrosis. Besides, a systematic literature search was performed to do meta-analysis to further analyze the association between hepatic steatosis and CRLM recurrence.

Results: A total of 195 eligible patients were included in our center. Patients with hepatic steatosis had a significantly worse overall (P = 0.0049) and hepatic recurrence-free survival (RFS) (P = 0.0012). Univariate and multivariate analysis confirmed its essential role in prediction of RFS. Besides, hepatic fibrosis is associated with worse overall RFS (P = 0.039) and hepatic RFS (P = 0.048). In meta-analysis, we included other four studies, with a total of 1,370 patients in the case group, and 3,735 patients in the control group. The odds ratio was 1.98 (95% CI: 1.25–3.14, P = 0.004), indicating that patients with steatosis had a significantly higher incidence of CRLM recurrence.

Conclusion: In summary, patients with hepatic steatosis had a significantly worse overall and hepatic RFS and it's associated with higher incidence of CRLM recurrence.

Value of KPNA4 as a diagnostic and prognostic biomarker for hepatocellular carcinoma

It is important to identify novel biomarkers to improve hepatocellular carcinoma (HCC) diagnosis and treatment. Herein, we reported the role of karyopherin α4 (KPNA4) in HCC patients through public data mining and examined the results using clinical samples in our center. Our results revealed that KPNA4 expression level was positively correlated with the infiltration of CD8⁺ T cells, B cells, dendritic cells, CD4⁺ T cells, neutrophils and macrophages. In addition, KPNA4 expression was significantly associated with T cell exhaustion. KPNA4 mRNA and protein expression levels were significantly higher in cancerous tissue than in normal tissue. Besides, the increased expression of KPNA4 indicated poor overall survival. Univariate and multivariate Cox regression analyses showed KPNA4 could be viewed as an independent risk factor for HCC patients. Moreover, our experimental results were consistent with those obtained from bioinformatic results. These findings revealed KPNA4 may serve as a novel prognostic biomarker and a potential therapeutic target for HCC.

Exosomal microRNA-155 as a biomarker for hepatic fibrosis diagnosis and progression

Background

Pathological examination of liver biopsies remains the gold standard for evaluating the stage of hepatic fibrosis, which are a number of disadvantages associated with biopsy. The aim of the present study was to investigate the potential of exosomal microRNA (miR)-155 as a non-invasive biomarker for the diagnosis and progression of hepatic fibrosis.

Methods

Exosomal miR-155 quantity was analyzed by sampling serum exosomes of patients with hepatic fibrosis and a hepatic fibrosis rat model. A total of 94 patients were divided into three groups based on Child-Pugh rating. Additionally, 30 patients with primary liver fibrosis who underwent liver transplantation were divided into the low miR-155 expression group and the high expression group; 56 rats were divided into 7 groups (n=8, 0, 2, 4, 6, 8, 10, and 12 weeks). Rats in every group were intravenously injected with CCl4 (3% vol/vol in olive oil; 0.3 mL/100 g body weight) twice weekly to produce different degrees of liver necrosis and liver fibrosis.

Results

Exosomal miR-155 was found to be closely associated with the progression of cirrhosis and clinical prognostic indicators of cirrhosis. Exosomal miR-155 gradually increased with the severity of hepatic necrosis and fibrosis.

Conclusions

The findings of the present study indicate that exosomal miR-155 can act as a non-invasive biomarker for the diagnosis and progression of hepatic fibrosis.

Liver Fibrosis in Non-alcoholic Fatty Liver Disease: From Liver Biopsy to Non-invasive Biomarkers in Diagnosis and Treatment

An increasing percentage of people have or are at risk to develop non-alcoholic fatty liver disease (NAFLD) worldwide. NAFLD comprises different stadia going from isolated steatosis to non-alcoholic steatohepatitis (NASH). NASH is a chronic state of liver inflammation that leads to the transformation of hepatic stellate cells to myofibroblasts. These cells produce extra-cellular matrix that results in liver fibrosis. In a normal situation, fibrogenesis is a wound healing process that preserves tissue integrity. However, sustained and progressive fibrosis can become pathogenic. This process takes many years and is often asymptomatic. Therefore, patients usually present themselves with end-stage liver disease e.g., liver cirrhosis, decompensated liver disease or even hepatocellular carcinoma. Fibrosis has also been identified as the most important predictor of prognosis in patients with NAFLD. Currently, only a minority of patients with liver fibrosis are identified to be at risk and hence referred for treatment. This is not only because the disease is largely asymptomatic, but also due to the fact that currently liver biopsy is still the golden standard for accurate detection of liver fibrosis. However, performing a liver biopsy harbors some risks and requires resources and expertise, hence is not applicable in every clinical setting and is unsuitable for screening. Consequently, different non-invasive diagnostic tools, mainly based on analysis of blood or other specimens or based on imaging have been developed or are in development. In this review, we will first give an overview of the pathogenic mechanisms of the evolution from isolated steatosis to fibrosis. This serves as the basis for the subsequent discussion of the current and future diagnostic biomarkers and anti-fibrotic drugs.

Nonalcoholic Fatty Liver Disease-Associated Liver Fibrosis Is Linked with the Severity of Coronary Artery Disease Mediated by Systemic Inflammation

METHODS AND RESULTS

We conducted a retrospective study of 531 patients with ultrasonogram-confirmed NAFLD who underwent percutaneous coronary intervention (PCI). Then, all patients were separated into four categories by Gensini score (0, 0-9, 9-48, and ≥48) for use in ordinal logistic regression analysis to determine whether NAFLD fibrosis was associated with increased Gensini scores. Mediation analysis was used to investigate whether systemic inflammation is a mediating factor in the association between NAFLD fibrosis and CAD severity. FIB - 4 > 2.67 (OR = 5.67, 95% CI 2.59-12.38) and APRI > 1.5 (OR = 14.8, 95% CI 3.24-67.60) remained to be independent risk factors for the severity of CAD after adjusting for conventional risk factors, whereas among the inflammation markers, only neutrophils and neutrophil-to-lymphocyte ratio (NLR) were independently associated with CAD. Multivariable ordinal regression analysis suggested that increasing Gensini score (0, 0-9, 9-48, and ≥48) was associated with advanced NAFLD fibrosis. ROC curve showed that either fibrosis markers or inflammation markers, integrating with traditional risk factors, could increase the predictive capacity for determining CAD. Inflammation markers, especially neutrophils and NLR, were mediators of the relationship between NAFLD fibrosis and CAD severity.

CONCLUSIONS

NAFLD patients with advanced fibrosis are at a high risk of severe coronary artery stenosis, and inflammation might mediate the association between NAFLD fibrosis and CAD severity.

Radiomics Improves Cancer Screening and Early Detection

Imaging is a key technology in the early detection of cancers, including X-ray mammography, low-dose CT for lung cancer, or optical imaging for skin, esophageal, or colorectal cancers. Historically, imaging information in early detection schema was assessed qualitatively. However, the last decade has seen increased development of computerized tools that convert images into quantitative mineable data (radiomics), and their subsequent analyses with artificial intelligence (AI). These tools are improving diagnostic accuracy of early lesions to define risk and classify malignant/aggressive from benign/indolent disease. The first section of this review will briefly describe the various imaging modalities and their use as primary or secondary screens in an early detection pipeline. The second section will describe specific use cases to illustrate the breadth of imaging modalities as well as the benefits of quantitative image analytics. These will include optical (skin cancer), X-ray CT (pancreatic and lung cancer), X-ray mammography (breast cancer), multiparametric MRI (breast and prostate cancer), PET (pancreatic cancer), and ultrasound elastography (liver cancer). Finally, we will discuss the inexorable improvements in radiomics to build more robust classifier models and the significant limitations to this development, including access to well-annotated databases, and biological descriptors of the imaged feature data.See all articles in this CEBP Focus section, "NCI Early Detection Research Network: Making Cancer Detection Possible."

Benefits of prolonged-release pirfenidone plus standard of care treatment in patients with advanced liver fibrosis: PROMETEO study

Background and aims

Pirfenidone (PFD), an oral antifibrotic drug, has been authorized by the EMA and FDA for treatment of idiopathic pulmonary fibrosis. Few studies have addressed its use in advanced liver fibrosis (ALF). We evaluated a prolonged-release formulation (PR-PFD) plus standard of care on disease progression in ALF.

Methods

281 ALF patients from 12 centers receiving PR-PFD (600 mg bid) were screened; 122 completed 1 year of treatment. Additionally, 74 patients received only standard of care regimen. Average age was 64 ± 12 years, 58% female. 43.5% had fatty liver disease (NAFLD), 22.5% viral hepatitis C (VHC), 17% autoimmune hepatitis (AIH), and 17% alcoholic liver disease (ALD). Baseline fibrosis was F4 in 74% and F3 in 26%. Antifibrotic effects were assessed by transient elastography (Fibroscan^®) and Fibro Test^® (FT); Cytokines and PFD plasma levels were tracked and quality of life evaluated.

Results

We found a significant reduction in fibrosis in 35% of PR-PFD patients and only in 4.1% in non PR-PFD patients. Child–Pugh score improved in 29.7%. Biochemical values remained stable; 40.6% and 43.3% decreased ALT or AST, respectively. TGFβ1 (pg/mL) levels were lower in PFD-treated patients. PFD serum concentration (µg/mL) was higher (8.2 ± 1.7) in fibrosis regression profile (FRP) patients compared to fibrosis progression profile (FPP) patients (4.7 ± 0.3 µg/mL, p < 0.01). 12% reported transient burning or nausea and 7% photosensitivity. Quality of life (Euro-Qol scale) improved from 62 ± 5 to 84 ± 3 (p < 0.001) and from 32 ± 3 to 42 ± 2 (p < 0.008) (FACIT scale).

Conclusions

PR-PFD is efficacious and safe in ALF and associated with promising antifibrotic effects.

Trial registration

Clinical trial number: NCT04099407.

Deep residual nets model for staging liver fibrosis on plain CT images

PURPOSE

The early diagnosis of liver fibrosis is crucial for the prevention of liver cirrhosis and liver cancer. As gold standard for staging liver fibrosis, liver biopsy is an invasive procedure that carries the risk of serious complications. The aim of this study was to evaluate the performance of the residual neural network (ResNet), a non-invasive methods, for staging liver fibrosis using plain CT images.

METHODS

This retrospective study involved 347 patients subjected to liver CT scanning and liver biopsy. For each patient, we selected three axial images adjacent to the puncture location in the eighth or ninth inter-space on the right side. After processing and enhancement (rotation, translation, and amplification), these images were used as input data for the ResNet model. The model used a fivefold cross-validation method. In each fold, the images of approximately 80% of the total sample size (278 patients) were used for training the ResNet model, the other 20% (69 patients) were used for testing the trained network, with the liver biopsy pathology results as gold standard. The proportion of patients in each fibrosis stage was equal for training and test groups. The final result was the mean of the fivefold cross-validation in the test group. The performance of the ResNet model was evaluated for the test group by receiver operating characteristic (ROC) analysis.

RESULTS

For the ResNet model, the area under the ROC curve (AUC) for assessing cirrhosis (F4), advanced fibrosis (F3 or higher), significant fibrosis (F2 or higher), and mild fibrosis (F1 or higher) was 0.97, 0.94, 0.90, and 0.91, respectively.

CONCLUSIONS

The ResNet model analysis of plain CT images exhibited high diagnostic efficiency for liver fibrosis staging. As a convenient, fast, and economical non-invasive diagnostic method, the ResNet model can be used to assist radiologists and clinicians in liver fibrosis evaluations.

The diagnostic and prognostic role of RhoA in hepatocellular carcinoma

The aim of this study was to investigate the expression level of Ras homolog gene family, member A (RhoA) in patients with hepatocellular carcinoma (HCC) and to investigate the prognostic and diagnostic value of RhoA. Data mining from various data bases and wet experiments on samples from Peking Union Medical College Hospital showed that RhoA mRNA and protein expression were significantly higher in the HCC tissues than in the normal tissues. Higher expression at both the mRNA and protein levels was associated with a poorer prognosis. High sensitivity (92.5%) and specificity (90.0%) were observed in the diagnostic model based on protein level rather than mRNA level. RhoA expression was modulated by genetic amplification. The lysosome, pathogenic Escherichia coli infection, purine metabolism and pyrimidine metabolism pathways were mainly enriched in the high RhoA level group, while the hedgehog signaling, linoleic acid metabolism, olfactory transduction and taste transduction pathways were enriched in the low RhoA level group. RhoA is commonly upregulated in HCC tissues, and its expression at both the mRNA and protein levels is associated with poor prognosis. Notably, RhoA protein levels serve as a diagnostic biomarker for HCC.

Identification of CELSR2 as a novel prognostic biomarker for hepatocellular carcinoma

Background

CELSR2 is postulated to be a receptor involved in contact-mediated communication; however, the specific function of this particular member has not been determined in hepatocellular carcinoma (HCC).

Methods

Here, we explored the expression and function of CELSR2 in HCC patients through data mining and examined the results using clinical samples and in vitro experiments.

Results

It was found that CELSR2 mRNA and protein expression levels were significantly higher in cancerous tissue than in normal tissue. The increased mRNA expression of CELSR2 was significantly associated with overall survival (OS) in HCC patients. Moreover, the genetic alteration rate of CELSR2 gene in HCC can reach 8%, and these alterations would deeply influence its neighboring genes, then jointly affecting the occurrence and development of tumor through cell adhesion and numerous common carcinogenic pathways. Our in vitro results indicated that the depletion of CELSR2 inhibited liver cancer cell proliferation and invasion. Univariate and multivariate Cox regression analyses showed that CELSR2 could be viewed as an independent risk factor for HCC patients.

Conclusions

This study demonstrated that data mining could efficiently reveal the roles of CELSR2 in HCC and its potential regulatory networks. The CELSR2 protein level may serve as a novel prognostic biomarker for HCC.

Application of Image Fusion in Diagnosis and Treatment of Liver Cancer

With the accelerated development of medical imaging equipment and techniques, image fusion technology has been effectively applied for diagnosis, biopsy and radiofrequency ablation, especially for liver tumor. Tumor treatment relying on a single medical imaging modality might face challenges, due to the deep positioning of the lesions, operation history and the specific background conditions of the liver disease. Image fusion technology has been employed to address these challenges. Using the image fusion technology, one could obtain real-time anatomical imaging superimposed by functional images showing the same plane to facilitate the diagnosis and treatments of liver tumors. This paper presents a review of the key principles of image fusion technology, its application in tumor treatments, particularly in liver tumors, and concludes with a discussion of the limitations and prospects of the image fusion technology.

[Three-dimensional visualization combined with indocyanine green fluorescence imaging in diagnosis and treatment of primary hepatocellular carcinoma]

OBJECTIVE

To explore the value of three-dimensional visualization technology (3DVT) combined with indocyanine green (ICG) fluorescence imaging in the diagnosis and treatment of primary hepatocellular carcinoma (HCC).

METHODS

We retrospectively analyzed the clinical data of 154 patients with HCC admitted to the Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University between January, 2016 and November, 2018. In 57 of the patients (3DVT group), preoperative CT and Gd-EOB-DTPA-enhanced MRI were performed and 3D visualization and surgical planning was carried out before the operation; intraoperative ICG florescence imaging was performed for real-time detection of the tumor location and demarcation, intrahepatic satellite lesions and metastases. According to the intraoperative fluorescent signals and 3D visualization-based surgical planning, the final surgical plan was determined. In the other 97 patients (control group), conventional surgical assessment and surgical resection of the tumor was carried out. The preoperative imaging findings, intraoperative tumor detection, postoperative laboratory results, pathological reports, and follow-up data of the patients were analyzed.

RESULTS

In 3DVT group, 63 and 70 lesions were detected by preoperative CT and MRI, respectively; compared with CT examination, intraoperative ICG florescence imaging revealed additional 17 lesions, among which 10 were pathologically confirmed as HCC and 7 as cirrhosis nodules. The median volume of bleeding was 300 mL in 3DVT group, significantly less than that in the control group (400 mL; Z=2.291, P=0.022). In both groups, serious complications or perioperative death occurred in none of the patients. The incidence of postoperative complications was significantly lowed in 3DVT group than in the control group [21% (12/57) vs 48.4% (47/97); χ2=11.406, P=0.001]. The overall disease-free survival rate at 2 years after the operation was significantly higher in 3DVT group than in the control group (74.9% vs 28.9%, P=0.022).

CONCLUSIONS

3DVT combined with ICG fluorescence imaging allows precise preoperative diagnosis, surgical planning and implementation, intraoperative detection of small liver cancers and precise navigation for HCC treatment, thereby helping to reduce postoperative complications and improve the disease-free survival rate of the patients.

Application Value of Magnetic Resonance Perfusion Imaging in the Early Diagnosis of Rat Hepatic Fibrosis

Objective

To assess the application value of perfusion-weighted imaging (PWI) in early diagnosis, quantitation, and hepatic fibrosis staging by analyzing the related parameters in hepatic fibrosis.

Methods

A total of 60 rats were randomly divided into the hepatic fibrosis and control groups, and carbon tetrachloride (CCL4) was used to establish the liver fibrosis model. All rats underwent PWI examination, and the trend of the time-signal intensity curve (TIC, automatically generated by the software) was observed. Also, the perfusion parameters, maximum signal reduction ratio (SRRmax), time to peak (TTP), and mean transit time (MTT), were analyzed and compared with pathological staging.

Results

The TIC curve was characterized by slow wash-in and wash-out with a low and wide peak. The PWI perfusion parameters were statistically significant in specific groups (P < 0.05): SRRmax values (control group and F3, F4), TTP, and MTT values (control group and F2–F4, F1 and F3, F1 and F4, and F2 and F4 in addition to TTP values for F1 and F2). Pearson's correlation analysis showed a negative correlation of SRRmax with hepatic fibrosis stage (r = −0.439, P < 0.05), while TTP and MTT values were positively correlated with hepatic fibrosis stage (TTP, r = 0.798; MTT, r = 0.647; all P < 0.001).

Conclusions

PWI perfusion parameters reflect the degree of hepatic fibrosis, especially TTP and MTT, and PWI is recommended for the early diagnosis of liver fibrosis for timely intervention and treatment of the disease and delaying its progression.

Integrated multiomic analysis reveals comprehensive tumour heterogeneity and novel immunophenotypic classification in hepatocellular carcinomas

OBJECTIVE

Hepatocellular carcinoma (HCC) is heterogeneous, especially in multifocal tumours, which decreases the efficacy of clinical treatments. Understanding tumour heterogeneity is critical when developing novel treatment strategies. However, a comprehensive investigation of tumour heterogeneity in HCC is lacking, and the available evidence regarding tumour heterogeneity has not led to improvements in clinical practice.

DESIGN

We harvested 42 samples from eight HCC patients and evaluated tumour heterogeneity using whole-exome sequencing, RNA sequencing, mass spectrometry-based proteomics and metabolomics, cytometry by time-of-flight, and single-cell analysis. Immunohistochemistry and quantitative polymerase chain reactions were performed to confirm the expression levels of genes. Three independent cohorts were further used to validate the findings.

RESULTS

Tumour heterogeneity is considerable with regard to the genomes, transcriptomes, proteomes, and metabolomes of lesions and tumours. The immune status of the HCC microenvironment was relatively less heterogenous. Targeting local immunity could be a suitable intervention with balanced precision and practicability. By clustering immune cells in the HCC microenvironment, we identified three distinctive HCC subtypes with immunocompetent, immunodeficient, and immunosuppressive features. We further revealed the specific metabolic features and cytokine/chemokine expression levels of the different subtypes. Determining the expression levels of CD45 and Foxp3 using immunohistochemistry facilitated the correct classification of HCC patients and the prediction of their prognosis.

CONCLUSION

There is comprehensive intratumoral and intertumoral heterogeneity in all dimensions of HCC. Based on the results, we propose a novel immunophenotypic classification of HCCs that facilitates prognostic prediction and may support decision making with regard to the choice of therapy.

USP22 Deubiquitinates CD274 to Suppress Anticancer Immunity

PD-1 (CD279)-PD-L1 (CD274) inhibitory signaling is critical for cancer immune evasion, and thus has become one of the major targets in anticancer immunotherapy. There are several studies that demonstrate the potent effects of posttranslational modifications of CD274 on immune inactivation and suppression, such as ubiquitination, phosphorylation, glycosylation, and palmitoylation. However, the regulatory mechanisms for CD274 deubiquitination are still largely unclear. Here, we identified ubiquitin-specific protease 22 (USP22) as a novel deubiquitinase of CD274. USP22 directly interacted with the C terminus of CD274, inducing its deubiquitination and stabilization. Across multiple cancer types, USP22 was highly expressed and frequently altered in liver cancer, closely correlating with poor prognosis of these patients. Genetic depletion of USP22 inhibited liver cancer growth in an immune system-dependent manner, increased tumor immunogenicity and tumor-infiltrating lymphocytes, and improved therapeutic efficacy of CD274-targeted immunotherapy and CDDP-based chemotherapy in mice. We demonstrate that targeting USP22 is a promising strategy to potentiate anticancer immunity for CD274-amplified cancer.

The Effect of Splenectomy on the Reversal of Cirrhosis: a Prospective Study

Background

Studies have demonstrated that liver fibrosis can be reversed by medication treatments. After splenectomy, cirrhosis patients have short-term changes in several serum markers for cirrhosis and liver stiffness.

Aims

To investigate the effect of splenectomy on the severity of cirrhosis.

Methods

A total of 62 patients with cirrhosis and portal hypertension receiving splenectomy from December 2014 to July 2017 were enrolled. The degree of cirrhosis was preoperatively and postoperatively evaluated by serum markers, including hyaluronan (HA), laminin, amino-terminal propeptide of type III procollagen (PIIINP), type IV collagen (C-IV), liver stiffness (FibroScan), and liver volume.

Results

HA levels significantly increased at 1 week and 1 month postoperation (both P < 0.05), whereas the levels of PIIINP and C-IV significantly decreased from 1 month to 12 months postoperation (all P < 0.05). In addition, elastography examination demonstrated that the FibroScan score significantly reduced from 1 month to 24 months postoperation as compared with the baseline level (all P < 0.05). CT scan showed that the liver volume significantly increased at 6 months postoperation (P < 0.05). Furthermore, the alteration trends of these serum markers and the FibroScan score were further confirmed by the multivariate linear regression.

Conclusions

These observations suggested that splenectomy may result in long-term reversal of cirrhosis.

Comprehensive analysis of a ceRNA network reveals potential prognostic cytoplasmic lncRNAs involved in HCC progression

The aberrant expression of long noncoding RNAs (lncRNAs) has drawn increasing attention in the field of hepatocellular carcinoma (HCC) biology. In the present study, we obtained the expression profiles of lncRNAs, microRNAs (miRNAs), and messenger RNAs (mRNAs) in 371 HCC tissues and 50 normal tissues from The Cancer Genome Atlas (TCGA) and identified hepatocarcinogenesis‐specific differentially expressed genes (DEGs, log fold change ≥ 2, FDR < 0.01), including 753 lncRNAs, 97 miRNAs, and 1,535 mRNAs. Because the specific functions of lncRNAs are closely related to their intracellular localizations and because the cytoplasm is the main location for competitive endogenous RNA (ceRNA) action, we analyzed not only the interactions among these DEGs but also the distributions of lncRNAs (cytoplasmic, nuclear or both). Then, an HCC‐associated deregulated ceRNA network consisting of 37 lncRNAs, 10 miRNAs, and 26 mRNAs was constructed after excluding those lncRNAs located only in the nucleus. Survival analysis of this network demonstrated that 15 lncRNAs, 3 miRNAs, and 16 mRNAs were significantly correlated with the overall survival of HCC patients (p < 0.01). Through multivariate Cox regression and lasso analysis, a risk score system based on 13 lncRNAs was constructed, which showed good discrimination and predictive ability for HCC patient survival time. This ceRNA network‐construction approach, based on lncRNA distribution, not only narrowed the scope of target lncRNAs but also provided specific candidate molecular biomarkers for evaluating the prognosis of HCC, which will help expand our understanding of the ceRNA mechanisms involved in the early development of HCC.