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Xiang X, Bhowmick K, Shetty K, Ohshiro K, Yang X, Wong LL, Yu H, Latham PS, Satapathy SK, Brennan C, Dima RJ, Chambwe N, Sharifova G, Cacaj F, John S, Crawford JM, Huang H, Dasarathy S, Krainer AR, He AR, Amdur RL, Mishra L. Mechanistically based blood proteomic markers in the TGF-β pathway stratify risk of hepatocellular cancer in patients with cirrhosis. Genes Cancer 2024; 15:1-14. [PMID: 38323119 PMCID: PMC10843195 DOI: 10.18632/genesandcancer.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/05/2023] [Indexed: 02/08/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is the third leading cause of death from cancer worldwide but is often diagnosed at an advanced incurable stage. Yet, despite the urgent need for blood-based biomarkers for early detection, few studies capture ongoing biology to identify risk-stratifying biomarkers. We address this gap using the TGF-β pathway because of its biological role in liver disease and cancer, established through rigorous animal models and human studies. Using machine learning methods with blood levels of 108 proteomic markers in the TGF-β family, we found a pattern that differentiates HCC from non-HCC in a cohort of 216 patients with cirrhosis, which we refer to as TGF-β based Protein Markers for Early Detection of HCC (TPEARLE) comprising 31 markers. Notably, 20 of the patients with cirrhosis alone presented an HCC-like pattern, suggesting that they may be a group with as yet undetected HCC or at high risk for developing HCC. In addition, we found two other biologically relevant markers, Myostatin and Pyruvate Kinase M2 (PKM2), which were significantly associated with HCC. We tested these for risk stratification of HCC in multivariable models adjusted for demographic and clinical variables, as well as batch and site. These markers reflect ongoing biology in the liver. They potentially indicate the presence of HCC early in its evolution and before it is manifest as a detectable lesion, thereby providing a set of markers that may be able to stratify risk for HCC.
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Affiliation(s)
- Xiyan Xiang
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
- These authors contributed equally to this work
| | - Krishanu Bhowmick
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
- These authors contributed equally to this work
| | - Kirti Shetty
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD 21201, USA
| | - Kazufumi Ohshiro
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
| | - Xiaochun Yang
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
| | - Linda L. Wong
- Department of Surgery, University of Hawaii, Honolulu, HI 96813, USA
| | - Herbert Yu
- Department of Epidemiology, University of Hawaii Cancer Center, Honolulu, HI 96813, USA
| | - Patricia S. Latham
- Department of Pathology, The George Washington University, Washington, DC 20037, USA
| | - Sanjaya K. Satapathy
- Department of Medicine, Sandra Atlas Bass Center for Liver Diseases and Transplantation, North Shore University Hospital/Northwell Health, Manhasset, NY 11030, USA
| | - Christina Brennan
- Office of Clinical Research, Northwell Health, Lake Success, NY 11042, USA
- The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Richard J. Dima
- Office of Clinical Research, Northwell Health, Lake Success, NY 11042, USA
| | - Nyasha Chambwe
- Institute of Molecular Medicine, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Gulru Sharifova
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Fellanza Cacaj
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
| | - Sahara John
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
| | | | - Hai Huang
- The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44106, USA
| | | | - Aiwu R. He
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC 20007, USA
| | - Richard L. Amdur
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
- Quantitative Intelligence, The Institutes for Health Systems Science, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Lopa Mishra
- The Institute for Bioelectronic Medicine, The Feinstein Institutes for Medical Research and Cold Spring Harbor Laboratory, Division of Gastroenterology and Hepatology, Northwell Health, Manhasset, NY 11030, USA
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
- Department of Surgery, The George Washington University, Washington, DC 20037, USA
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Nishikawa H, Kim SK, Asai A. Body Composition in Chronic Liver Disease. Int J Mol Sci 2024; 25:964. [PMID: 38256036 PMCID: PMC10815828 DOI: 10.3390/ijms25020964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Body composition has recently been attracting people's attention, not only from a cosmetic standpoint but also from the perspective of health and longevity. The body is classified into three components: fat, bone, and lean soft tissue, and it is common to see an increase in body fat and a decrease in total body muscle mass with aging. Aging-related loss of muscle mass and muscle function is referred to as primary sarcopenia, while sarcopenia caused by disease-specific conditions is referred to as secondary sarcopenia. On the other hand, the liver-muscle axis has been attracting attention in recent years, and it has become clear that the liver and the skeletal muscles interact with each other. In particular, patients with cirrhosis are prone to secondary sarcopenia due to protein-energy malnutrition, which is a characteristic pathophysiology of the disease, suggesting the importance of the organ-organ network. In this review, we would like to outline the latest findings in this field, with a focus on body composition in liver diseases such as liver cirrhosis, fatty liver disease, alcoholic liver disease, and hepatocellular carcinoma.
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Affiliation(s)
- Hiroki Nishikawa
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Soo Ki Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-8501, Hyogo, Japan
| | - Akira Asai
- Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
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Geladari E, Alexopoulos T, Kontogianni MD, Vasilieva L, Mani I, Alexopoulou A. Mechanisms of sarcopenia in liver cirrhosis and the role of myokines. Ann Gastroenterol 2023; 36:392-404. [PMID: 37396001 PMCID: PMC10304523 DOI: 10.20524/aog.2023.0804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/19/2023] [Indexed: 07/04/2023] Open
Abstract
Sarcopenia is a syndrome characterized by a decline in skeletal muscle quantity and/or quality, strength and performance, leading to unfortunate events, such as injurious falls or even death. It is not identical to frailty and malnutrition, even though there is a significant overlap among these syndromes. In patients with liver cirrhosis (LC), sarcopenia is classified as secondary and has been associated with increased morbidity and mortality during the pre- and post-transplantation period. It can be a result of malnutrition, hyperammonemia, low physical activity, endocrine abnormalities, accelerated starvation, metabolic disturbances, altered gut function leading to chronic inflammation, and alcohol abuse. Myokines are peptides mainly synthesized by contracting muscle and adipose tissue cells and may play a key role in the pathophysiology of sarcopenia. More than a hundred myokines have been recognized, but only a few have been investigated. They can be classified as negative regulators, such as myostatin, tumor growth factor-β, activins, growth differentiation factor-11, and positive regulators of muscle growth including follistatin, bone morphogenic proteins, and irisin. So far, only myostatin, follistatin, irisin and decorin have been studied in LC-associated sarcopenia. In this review, we focused on the mechanisms of cirrhosis-related sarcopenia and the role of myokines that have already been studied in the literature, either as markers helping in the diagnostic evaluation of sarcopenia, or as prognostic factors of survival. Standard therapeutic options to prevent or treat sarcopenia in LC are also being reported, as well as the possible therapeutic implication of myokines.
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Affiliation(s)
- Eleni Geladari
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Eleni Geladari, Theodoros Alexopoulos, Iliana Mani, Alexandra Alexopoulou)
| | - Theodoros Alexopoulos
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Eleni Geladari, Theodoros Alexopoulos, Iliana Mani, Alexandra Alexopoulou)
| | - Meropi D. Kontogianni
- Department of Nutrition and Dietetics, School of Health Science & Education, Harokopio University, Athens, Greece (Meropi D. Kontogianni)
| | - Larisa Vasilieva
- Gastroenterology Department, Alexandra Hospital (Larisa Vasilieva), Athens, Greece
| | - Iliana Mani
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Eleni Geladari, Theodoros Alexopoulos, Iliana Mani, Alexandra Alexopoulou)
| | - Alexandra Alexopoulou
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Eleni Geladari, Theodoros Alexopoulos, Iliana Mani, Alexandra Alexopoulou)
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Lee YT, Fujiwara N, Yang JD, Hoshida Y. Risk stratification and early detection biomarkers for precision HCC screening. Hepatology 2023; 78:319-362. [PMID: 36082510 PMCID: PMC9995677 DOI: 10.1002/hep.32779] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/25/2022] [Accepted: 08/28/2022] [Indexed: 12/08/2022]
Abstract
Hepatocellular carcinoma (HCC) mortality remains high primarily due to late diagnosis as a consequence of failed early detection. Professional societies recommend semi-annual HCC screening in at-risk patients with chronic liver disease to increase the likelihood of curative treatment receipt and improve survival. However, recent dynamic shift of HCC etiologies from viral to metabolic liver diseases has significantly increased the potential target population for the screening, whereas annual incidence rate has become substantially lower. Thus, with the contemporary HCC etiologies, the traditional screening approach might not be practical and cost-effective. HCC screening consists of (i) definition of rational at-risk population, and subsequent (ii) repeated application of early detection tests to the population at regular intervals. The suboptimal performance of the currently available HCC screening tests highlights an urgent need for new modalities and strategies to improve early HCC detection. In this review, we overview recent developments of clinical, molecular, and imaging-based tools to address the current challenge, and discuss conceptual framework and approaches of their clinical translation and implementation. These encouraging progresses are expected to transform the current "one-size-fits-all" HCC screening into individualized precision approaches to early HCC detection and ultimately improve the poor HCC prognosis in the foreseeable future.
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Affiliation(s)
- Yi-Te Lee
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, California
| | - Naoto Fujiwara
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California; Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, Los Angeles, California; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yujin Hoshida
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Warner II ER, Satapathy SK. Sarcopenia in the Cirrhotic Patient: Current Knowledge and Future Directions. J Clin Exp Hepatol 2023; 13:162-177. [PMID: 36647414 PMCID: PMC9840086 DOI: 10.1016/j.jceh.2022.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 06/13/2022] [Indexed: 02/07/2023] Open
Abstract
Cirrhosis predisposes to abnormalities in energy, hormonal, and immunological homeostasis. Disturbances in these metabolic processes create susceptibility to sarcopenia or pathological muscle wasting. Sarcopenia is prevalent in cirrhosis and its presence portends significant adverse outcomes including the length of hospital stay, infectious complications, and mortality. This highlights the importance of identification of at-risk individuals with early nutritional, therapeutic and physical therapy intervention. This manuscript summarizes literature relevant to sarcopenia in cirrhosis, describes current knowledge, and elucidates possible future directions.
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Key Words
- ACE, angiotensin-converting enzyme
- ACE-I, angiotensin-converting enzyme inhibitor
- AKI, acute kidney injury
- ALM, appendicular lean mass
- ARB, angiotensin receptor blocker
- ASM, appendicular skeletal mass
- AT1R, angiotensin type 1 receptor
- AT2R, angiotensin type 2 receptor
- ATP, adenosine-5′-triphosphate
- AWGS, Asian Working Group for Sarcopenia
- BCAA, branched chained amino acids
- BIA, bioelectrical impedance analysis
- BMI, body mass index
- CART, classification and regression tree
- CKD, chronic kidney disease
- CRP, C-reactive protein
- DEXA, dual energy X-ray absorptiometry
- EAA, essential amino acids
- ESPEN-SIG, European Society for Clinical Nutrition and Metabolism Special Interests Groups
- ESRD, end-stage renal disease
- EWGSOP, European Working Group on Sarcopenia in Older People
- FAD, flavin adenine dinucleotide
- FADH2, flavin adenine dinucleotide +2 hydrogen
- FNIH, Foundation for the National Institutes of Health
- GTP, guanosine-5′-triphosphate
- GnRH, gonadotrophin-releasing hormone
- HCC, hepatocellular carcinoma
- HPT, hypothalamic-pituitary-testicular
- IFN-γ, interferon γ
- IGF-1, insulin-like growth factor 1
- IL-1, interleukin-1
- IL-6, interleukin-6
- IWGS, International Working Group on Sarcopenia
- LH, luteinizing hormone
- MELD, Model for End-Stage Liver Disease
- MuRF1, muscle RING-finger-1
- NAD, nicotinamide adenine dinucleotide
- NADH, nicotinamide adenine dinucleotide + hydrogen
- NADPH, nicotinamide adenine dinucleotide phosphate
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NF-κβ, nuclear factor κβ
- NHANES, National Health and Nutritional Examination Survey
- PMI, psoas muscle index
- PMTH, psoas muscle thickness
- RAAS, renin-angiotensin-aldosterone system
- ROS, reactive oxygen species
- SARC-F, Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls
- SHBG, sex hormone binding globulin
- SMI, skeletal muscle index
- SNS, sympathetic nervous system
- SPPB, Short Performance Physical Battery
- TNF-α, tumor necrosis factor α
- UCSF, University of California, San Francisco
- UNOS, United Network of Organ Sharing
- cirrhosis
- energy
- mTOR, mammalian target of rapamycin
- metabolism
- muscle
- sarcopenia
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Affiliation(s)
- Edgewood R. Warner II
- Department of Medicine, Donald and Barbara Zucker School of Medicine/Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Sanjaya K. Satapathy
- Division of Hepatology and Northwell Health Center for Liver Diseases and Transplantation, Department of Medicine, Donald and Barbara Zucker School of Medicine/Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
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Viral eradication by direct-acting antivirals does not decrease the serum myostatin level in hepatitis C virus-infected patients. Nutrition 2022; 101:111699. [DOI: 10.1016/j.nut.2022.111699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/07/2022] [Accepted: 04/10/2022] [Indexed: 11/18/2022]
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Kubota N, Fujiwara N, Hoshida Y. Liver cancer risk-predictive molecular biomarkers specific to clinico-epidemiological contexts. Adv Cancer Res 2022; 156:1-37. [PMID: 35961696 PMCID: PMC7616039 DOI: 10.1016/bs.acr.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hepatocellular carcinoma (HCC) risk prediction is increasingly important because of the low annual HCC incidence in patients with the rapidly emerging non-alcoholic fatty liver disease or cured HCV infection. To date, numerous clinical HCC risk biomarkers and scores have been reported in literature. However, heterogeneity in clinico-epidemiological context, e.g., liver disease etiology, patient race/ethnicity, regional environmental exposure, and lifestyle-related factors, obscure their real clinical utility and applicability. Proper characterization of these factors will help refine HCC risk prediction according to certain clinical context/scenarios and contribute to improved early HCC detection. Molecular factors underlying the clinical heterogeneity encompass various features in host genetics, hepatic and systemic molecular dysregulations, and cross-organ interactions, which may serve as clinical-context-specific biomarkers and/or therapeutic targets. Toward the goal to enable individual-risk-based HCC screening by incorporating the HCC risk biomarkers/scores, their assessment in patient with well-defined clinical context/scenario is critical to gauge their real value and to maximize benefit of the tailored patient management for substantial improvement of the poor HCC prognosis.
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Affiliation(s)
- Naoto Kubota
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Naoto Fujiwara
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yujin Hoshida
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States.
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Perisetti A, Goyal H, Yendala R, Chandan S, Tharian B, Thandassery RB. Sarcopenia in hepatocellular carcinoma: Current knowledge and future directions. World J Gastroenterol 2022; 28:432-448. [PMID: 35125828 PMCID: PMC8790553 DOI: 10.3748/wjg.v28.i4.432] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/29/2021] [Accepted: 01/11/2022] [Indexed: 02/06/2023] Open
Abstract
Liver cancer is the second most occurring cancer worldwide and is one of the leading causes of cancer-related deaths. Hepatocellular carcinoma (HCC) is the most common (80%-90%) type among malignant liver cancers. Sarcopenia occurs very early in HCC and can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Multiple prognostic stating systems have been developed in HCC, such as Barcelona Clinic Liver Cancer, Child-Pugh score and Albumin-Bilirubin grade. However, the evaluation of patients' performance status is a major limitation of these scoring systems. In this review, we aim to summarize the current knowledge and recent advances about the role of sarcopenia in cirrhosis in general, while focusing specifically on HCC. Additionally, the role of sarcopenia in predicting clinical outcomes and prognostication in HCC patients undergoing loco-regional therapies, liver resection, liver transplantation and systematic therapy has been discussed. A literature review was performed using databases PubMed/MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL on April 1, 2021, to identify published reports on sarcopenia in HCC. Sarcopenia can independently predict HCC-related mortality especially in patients undergoing treatments such as loco-regional, surgical liver transplantation and systemic therapies. Basic research is focused on evaluating a balance of anabolic and catabolic pathways responsible for muscle health. Early clinical studies have shown promising results in methods to improve sarcopenia in HCC which can potentially increase prognosis in these patients. As sarcopenia occurs very early in HCC, it can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Further, sarcopenia measurement can obviate the confounding caused by the abdominal ascites in these patients. The use of sarcopenia can add to the existing scoring systems to better prognosticate the HCC.
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Affiliation(s)
- Abhilash Perisetti
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
- Department of Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, IN 46825, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, The Wright Center for Graduate Medical Education, Scranton, PA 18501, United States
| | - Rachana Yendala
- Department of Hematology and Oncology, Conway Regional Medical Center, Conway, AR 72034, United States
| | - Saurabh Chandan
- Department of Internal Medicine, Gastroenterology and Hepatology Division, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Ragesh Babu Thandassery
- Department of Medicine, Central Arkansas Veterans Healthcare System, Little Rock, AR 72205, United States
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