Hepatocellular carcinoma prevention: A worldwide emergence between the opulence of developed countries and the economic constraints of developing nations

Present and future of new systemic therapies for early and intermediate stages of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a high mortality neoplasm which usually appears on a cirrhotic liver. The therapeutic arsenal and subsequent prognostic outlook are intrinsically linked to the HCC stage at diagnosis. Notwithstanding the current deployment of treatments with curative intent (liver resection/local ablation and liver transplantation) in early and intermediate stages, a high rate of HCC recurrence persists, underscoring a pivotal clinical challenge. Emergent systemic therapies (ST), particularly immunotherapy, have demonstrate promising outcomes in terms of increase overall survival, but they are currently bound to the advanced stage of HCC. This review provides a comprehensive analysis of the literature, encompassing studies up to March 10, 2024, evaluating the impact of novel ST in the early and intermediate HCC stages, specially focusing on the findings of neoadjuvant and adjuvant regimens, aimed at increasing significantly overall survival and recurrence-free survival after a treatment with curative intent. We also investigate the potential role of ST in enhancing the downstaging rate for the intermediate-stage HCC initially deemed ineligible for treatment with curative intent. Finally, we critically discuss about the current relevance of the results of these studies and the encouraging future implications of ST in the treatment schedules of early and intermediate HCC stages.

The Trends in Health Care Utilization and Costs Associated With Primary Liver Cancer: An Analysis of United States Hospitals Between 2016 and 2019

BACKGROUND

Primary liver cancer (PLC) has placed an increasing economic and resource burden on the health care system of the United States. We attempted to quantify its epidemiology and associated costs using a national inpatient database.

METHODS

Hospital discharge and insurance claims data from the National Inpatient Sample were used to conduct this analysis. Patients diagnosed with PLC (hepatocellular carcinoma or cholangiocarcinoma) were included in the study population, which was then stratified using patient demographics, comorbidities, degree of cancer spread, liver disease complications, and other descriptors. Trends were analyzed via regression curves for each of these strata from the years 2016 to 2019, with special attention to patterns in hospitalization incidence, inpatient mortality rate, total costs, and average per-capita costs. The resulting curves were evaluated using goodness-of-fit statistics and P-values.

RESULTS

Aggregate hospitalization incidence, inpatient mortality rates, and total costs were found to significantly increase throughout the study period (P=0.002, 0.002, and 0.02, respectively). Relative to their demographic counterparts, males, White Americans, and those older than 65 years of age contributed the largest proportions of total costs. These population segments also experienced significant increases in total expenditure (P=0.04, 0.03, and 0.02, respectively). Admissions deemed to have multiple comorbidities were associated with progressively higher total costs throughout the study period (P=0.01). Of the categorized underlying liver diseases, only admissions diagnosed with alcoholic liver disease or nonalcoholic fatty liver disease saw significantly increasing total costs (P=0.006 and 0.01), although hepatitis C was found to be the largest contributor to total expenses.

CONCLUSIONS

From 2016 to 2019, total costs, admission incidence, and inpatient mortality rates associated with PLC hospitalization increased. Strata-specific findings may be reflective of demographic shifts in the PLC patient populations, as well as changes in underlying chronic liver disease etiologies.

In silico, in vitro screening of antioxidant and anticancer potentials of bioactive secondary metabolites from an endophytic fungus (Curvularia sp.) from Phyllanthus niruri L

The main objective of this research work is to discover novel and efficient phytochemical substances from endophytic fungus found in medicinal plants. Curvularia geniculata L. (C. geniculata L.), an endophytic fungus isolated from Phyllanthus niruri L. (P. niruri L.), was tested against hepatoma cell lines (HepG2) in order to screen their antioxidant and anticancer potentials. The profiling of phytochemicals from the fungal extract was characterized using gas chromatography-mass spectrometry (GC-MS), and molecular docking was done for the identified compounds against one of the potential receptors predominantly present in the hepatocellular carcinoma cell lines. Among the phytochemicals found, 2-methyl-7-phenylindole had the highest binding affinity (- 8.8 kcal mol^-1) for the epidermal growth factor receptor (EGFR). The stability of 2-methyl-7-phenylindole in the EGFR-binding pockets was tested using in silico molecular dynamics simulation. The fungal extract showed the highest antioxidant activity as measured by DPPH, ABTS radical scavenging, and FRAP assays. In vitro cytotoxicity assay of fungal extract demonstrated the concentration-dependent cytotoxicity against HepG2 cells after 24 h, and the IC₅₀ (50% cell death) value was estimated to be 62.23 μg mL^-1. Typical morphological changes such as condensation of nuclei and deformed membrane structures are indicative of ongoing apoptosis. The mitochondria of HepG2 cells were also targeted by the endophytic fungal extract, which resulted in substantial generation of reactive oxygen species (ROS) leading to the destruction of mitochondrial transmembrane potential integrity. These outcomes suggest that the ethyl acetate extract of C. geniculata L. has the potential to be an antioxidant agent and further to be exploited in developing potential anticancer agents.

Knockout of Hepatocyte Growth Factor by CRISPR/Cas9 System Induces Apoptosis in Hepatocellular Carcinoma Cells

Background: CRISPR/Cas9 system is a prokaryotic adaptive immune response system that uses noncoding RNAs to guide the Cas9 nuclease to induce site-specific DNA cleavage. Hepatocyte growth factor (HGF) is a well-known growth factor that plays a crucial role in cell growth and organ development. According to recent studies, it has been reported that HGF promoted growth of hepatocellular carcinoma (HCC) cells. Here, we investigated the apoptotic effects in HCC cells. Methods: Crispr-HGF plasmid was constructed using GeneArt CRISPR Nuclease Vector. pMex-HGF plasmid that targets HGF overexpressing gene were designed with pMex-neo plasmid. We performed real time-polymerase chain reaction to measure the expression of HGF mRNA. We performed cell counting assay and colony formation assay to evaluate cell proliferation. We also carried out migration assay and invasion assay to reveal the inhibitory effects of Crispr-HGF in HCC cells. Furthermore, we performed cell cycle analysis to detect transfection of Crispr-HGF induced cell cycle arrest. Collectively, we performed annexin V/PI staining assay and Western blot assay. Results: In Crispr-HGF-transfected group, the mRNA expression levels of HGF were markedly downregulated compared to pMex-HGF-transfected group. Moreover, Crispr-HGF inhibited cell viability in HCC cells. We detected that wound area and invaded cells were suppressed in Crispr-HGF-transfected cells. The results showed that transfection of Crispr-HGF induced cell cycle arrest and apoptosis in HCC cells. Expression of the phosphorylation of mitogen activated protein kinases and c-Met protein was regulated in Crispr-HGF-transfected group. Interestingly, we found that the expression of HGF protein in conditioned media significantly decreased in Crispr-HGF-transfected group. Conclusions: Taken together, we found that inhibition of HGF through transfection of Crispr-HGF suppressed cell proliferation and induced apoptotic effects in HCC Huh7 and Hep3B cells.

Systematic review with meta-analysis: The effects of non-steroidal anti-inflammatory drugs and anti-platelet therapy on the incidence and recurrence of hepatocellular carcinoma

BACKGROUND

Chemoprevention with NSAIDs, including aspirin, and anti-platelet therapy (APT), has been suggested to reduce the incidence and recurrence of hepatocellular carcinoma (HCC).

AIM

To determine by meta-analysis whether NSAIDs and APT use affected HCC incidence, HCC recurrence and liver-related mortality in at-risk populations with chronic liver disease.

METHOD

Electronic databases including Pubmed, Scopus, Medline, Embase and Cochrane Library were searched (from inception to 31 May 2021) for eligible studies evaluating the impacts of NSAID or APT use on HCC incidence, recurrence and mortality. Data on HCC incidence, recurrence, liver-related mortality or bleeding complications had to be available. Studies were included if they evaluated adults with hepatitis B virus (HBV), hepatitis C virus (HCV), alcohol-related liver disease (ALD) or nonalcoholic steatohepatitis that were administered at least one NSAID or APT for a defined period of time and were followed for at least 6 months. The primary outcome was HCC incidence. Secondary outcomes included: HCC recurrence, liver-related mortality and bleeding complications. Data were pooled using a random effects model with hazard ratios (HRs) or odds ratio (OR), and 95% confidence intervals (CIs) presented.

RESULTS

Of 3773 articles screened, 19 studies were included, with a total of 147 283 participants. Aspirin use reduced the risk of HCC incidence (HR: 0.51, 95% CI: 0.36-0.72); and improved liver-related mortality (OR: 0.32, 95% CI: 0.15-0.70), with a small increased risk of gastrointestinal bleeding events (OR: 1.32, 95% CI: 1.08-1.94). With respect to HCC recurrence following treatment, analysis of all aspirin and NSAID treatment (including; aspirin only; non-aspirin NSAIDs only; and combination NSAIDs groups) was associated with a decreased risk of HCC recurrence (HR: 0.80, 95% CI: 0.75-0.86). By stratified analysis, only the non-aspirin NSAID group showed significant risk reduction (HR: 0.73, 95% CI: 0.63-0.84).

CONCLUSION

The study supports the use of aspirin in at-risk individuals to reduce the incidence of HCC and liver-related mortality. HCC recurrence following treatment was lower with NSAID treatment.

Comparison between Milan and UCSF criteria for liver transplantation in patients with hepatocellular carcinoma: a systematic review and meta-analysis

Background

Liver transplantation is the main treatment for hepatocellular carcinoma (HCC). However, because of the limited supply of transplant organs, it is necessary to adopt a criterion that selects patients who will achieve adequate survival after transplantation. The aim of this review is to compare the two main staging criteria of HCC for the indication of liver transplantation (Milan and UCSF) and to analyze the post-transplantation survival rate at 1, 3 and 5 years.

Methods

This is a systematic review and meta-analysis in which scientific articles from 5 databases (PubMed, Lilacs, Embase, Central, and Cinahl) were analyzed. The studies included in the review consisted of liver transplantation in patients with HCC in different subgroups according to donor type (deceased × living), population (eastern × western) and tumor evaluation (radiological × pathological) and adopted the Milan or UCSF criteria for the indication of the procedure.

Results

There was no significant difference between the Milan and UCSF criteria in the overall survival rate at 1, 3 or 5 years, and the overall estimated value found was 1.03 [0.90, 1.17] at 1 year, 1.06 [0.96, 1.16] at 3 years and 1.04 [0.96, 1.12] at 5 years. Regarding the analysis of the subgroups, no significant difference was observed in any of the subgroups with a follow-up of 1, 3 or 5 years.

Conclusions

Both the Milan and UCSF criteria have equivalent survival rate. Thus, less restrictive method would not result in a great loss in the final overall survival rate and would benefit a greater number of patients.

The prognostic value of postoperative circulating cell-free DNA in operable hepatocellular carcinoma

BACKGROUND

Tumor biomarkers are eagerly needed in monitoring the recurrence of operable hepatocellular carcinoma (HCC). Circulating cell-free DNA (cfDNA) is a promising noninvasive molecular biomarker for HCC. The current study aimed to evaluate the clinical significance of the postoperative cfDNA in operable HCC.

METHODS

This study enrolled 82 HCC patients from January 2018 to June 2019. All patients underwent liver surgery and were pathologically diagnosed with HCC. Postoperative blood samples were collected from each patient. A fluorometric dsDNA assay was used to measure the concentration of cfDNA. We explore the correlation between cfDNA and recurrence. Kaplan-Meier's curves were used to evaluate the recurrence-free survival (RFS). Univariate and multivariate Cox regression analyses were used for assessing the relative clinical variables in predicting recurrence.

RESULTS

Of the 82 HCC patients, 72 (87%) patients are male and the average age was 52.7 ± 12.8 years. The cfDNA-low and cfDNA-high groups had median recurrence times of 19.5 months and 14.0 months, respectively (p = .023). Multivariate analysis showed that postoperative cfDNA, tumour number and microvascular invasion (p < .050) were independent risk factors for recurrence in operable HCC.

CONCLUSIONS

Postoperative cfDNA is still a promising marker to predict prognosis in postoperative HCC patients although prospective and large multicenter clinical study is needed to further validate the relationship between cfDNA and HCC recurrence.

Metronomic Celecoxib Therapy in Clinically Available Dosage Ablates Hepatocellular Carcinoma via Suppressing Cell Invasion, Growth, and Stemness in Pre-Clinical Models

Objective

To investigate the anti-carcinogenic effect of metronomic Celecoxib (i.e., frequent administration in clinically available doses) against hepatocellular carcinoma (HCC) in the perspective of metastasis, spontaneous hepatocarcinogenesis, cancer invasion, proliferation, and stemness in vivo and in vitro.

Background

Celecoxib, a selective cyclooxygenase-2 (COX-2) inhibitor, is known to cause anti-carcinogenic effects for HCC in suprapharmacological doses. However, the effects of metronomic Celecoxib treatment on HCC cells remain unclear.

Methods

The in vivo chemopreventive effect of metronomic Celecoxib (10mg/kg/d) was investigated by the syngeneic HCC implantation model and spontaneous hepatocarcinogenesis in HBV-transgenic(HBVtg) mice individually. HCC cell lines were treated by either suprapharmacological (100 μM) or metronomic (4 μM) Celecoxib therapy. Anti-carcinogenic effects were evaluated using cell invasion, cancer proliferation, angiogenesis, and phenotype of cancer stem/progenitor cells (CSPC). The molecular mechanism of metronomic Celecoxib on HCC was dissected using Luciferase assay.

Results

In vivo metronomic Celecoxib exerted its chemopreventive effect by significantly reducing tumor growth of implanted syngeneic HCC and spontaneous hepatocarcinogenesis in HBVtg mice. Unlike suprapharmacological dose, metronomic Celecoxib can only inhibit HCC cell invasion after a 7-day course of treatment via NF-κB/MMP9 dependent, COX2/PGE2 independent pathway. Metronomic Celecoxib also significantly suppressed HCC cell proliferation after a 7-day or 30-day culture. Besides, metronomic Celecoxib reduced CSPC phenotype by diminishing sphere formation, percentage of CD90+ population in sphere cells, and expression of CSPC markers.

Conclusions

Metronomic Celecoxib should be investigated clinically as a chemopreventive agent for selected high-risk HCC patients (e.g., HCC patients after curative treatments).

Influence of miR-520e-mediated MAPK signalling pathway on HBV replication and regulation of hepatocellular carcinoma cells via targeting EphA2

We determined the role of miR-520e in the replication of hepatitis B virus (HBV) and the growth of hepatocellular carcinoma (HCC) cells. MiR-520e and EPH receptor A2 (EphA2) in HBV-positive HCC tissues and cells were detected, and we studied the impact of miR-520e and the EphA2 receptor in cellular and murine HBV replication models. We find that MiR-520e was upregulated and EphA2 was downregulated in HBV-positive HCC tissues and cells. MiR-520e was decreased in Huh7-X and HepG2-X cells in which HBx was stably expressed, but was dose-dependently elevated after interfering with HBx. Additionally, miR-520e mimic and si-EphA2 groups were reduced in association with increases in HBV DNA content, HBsAg and HBeAg levels, cell proliferation and were enhanced in the expressions of EphA2, p-p38MAPK/p38MAPK, phosphorylated extracellular signal-regulated kinase 1/2 (p-ERK1/2)/ERK1/2 and cell apoptosis. Furthermore, si-EphA2 reversed the promotion effect of miR-520e inhibitor on HBV replication and tumour cell growth. Upregulating miR-520e in rAAV8-1.3HBV-infected mouse resulted in reduced EphA2 in liver tissues and HBV DNA content in serum. We find that MiR-520e was decreased in HBV-positive HCC, while overexpression of miR-520e blocked p38MAPK and ERK1/2 signalling pathways by an inhibitory effect on EphA2 and ultimately reduced HBV replication and inhibited tumour cell growth. These data indicate a role for miR-520e in the regulation of HBV replication.

Transcatheter arterial chemoembolisation followed by three-dimensional conformal radiotherapy versus transcatheter arterial chemoembolisation alone for primary hepatocellular carcinoma in adults

BACKGROUND

Hepatocellular carcinoma, also called malignant hepatoma, is a primary malignancy of the liver. Despite regular surveillance conducted in high-risk populations, most people with hepatocellular carcinoma are diagnosed at an advanced stage. Consequently, only a minority of people with the disease are suitable for surgical resection when diagnosed.

OBJECTIVES

To compare the beneficial and harmful effects of transcatheter arterial chemoembolisation (TACE) followed by three-dimensional conformal radiotherapy (3-DCRT) versus TACE alone in adults with primary hepatocellular carcinoma, considered unsuitable for surgical resection.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science up to 31 May 2018. We checked reference lists for all included studies and related reviews for further relevant articles.

SELECTION CRITERIA

We included all randomised clinical trials comparing TACE followed by 3-DCRT versus TACE alone in people with primary hepatocellular carcinoma.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as suggested by Cochrane. We presented the results of the fixed-effect model in the absence of statistical heterogeneity. Otherwise, we reported the results from the random-effects model meta-analysis. We assessed risk of bias of the included trials using bias risk domains and presented the review results incorporating the methodological quality of the trials using GRADE. Our main conclusions were based on the analysis up to three years' follow-up.

MAIN RESULTS

We identified eight randomised clinical trials (632 participants) that fulfilled our inclusion criteria. All eight trials were at high risk of bias, and we rated the evidence as low to very low certainty. The mean age ranged from 16 years to 78 years. The proportion of men ranged from 60% to 75% and the proportion of people with stage III primary hepatocellular carcinoma ranged from 22% to 85%. The median follow-up duration was 12 months (2 months to 38 months).TACE followed by 3-DCRT compared with TACE alone may have reduced all-cause mortality at three years' follow-up (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.73 to 0.88; 552 participants; 7 trials; low-certainty evidence). TACE followed by 3-DCRT compared with TACE alone may reduce the proportion of participants without tumour response (complete response plus partial response) (RR 0.49, 95% CI 0.39 to 0.61; 632 participants; 8 trials; low-certainty evidence). Data, from one trial on health-related quality of life, favoured the TACE followed by 3-DCRT group, but the provided data were ill-defined (very low-certainty evidence). None of the trials reported serious adverse events. The results on non-serious adverse events were as follows: TACE followed by 3-DCRT compared with TACE alone showed no difference in the results for proportion of participants with leukopenia (RR 1.12, 95% CI 0.92 to 1.34; 438 participants; 5 trials; very low-certainty evidence) and serum transaminases elevation (RR 1.67, 95% CI 0.66 to 4.27; 280 participants; 4 trials; very low-certainty evidence). However, the proportion of participants with total bilirubin elevation was larger in the TACE followed by 3-DCRT group than in the TACE alone group (RR 2.69, 95% CI 1.34 to 5.40; 172 participants; 2 trials; very low-certainty evidence). The rate of participants with serum alpha-fetoprotein (AFP) without decline or normalisation was significantly lower in the TACE followed by 3-DCRT group than in the TACE group, but these data were from one trial only (Chi² = 7.24, P = 0.007; very low-certainty evidence).

AUTHORS' CONCLUSIONS

TACE followed by 3-DCRT may be associated with lower all-cause mortality and increased tumour response, despite the increased toxicity expressed by a higher rise of total bilirubin. Our review findings should be considered with caution because of the methodological weaknesses in the included trials, resulting in low- to very low-certainty evidence. Data on serious adverse events and health-related quality of life are lacking. We are also very much uncertain in the results of the reported non-serious adverse events. High-quality trials are needed to assess further the role of TACE followed by 3-DCRT for unresectable hepatocellular carcinoma.

Indian Hedgehog links obesity to development of hepatocellular carcinoma

Obesity increases the risk of hepatocellular carcinoma (HCC), but precise identification and characterization of druggable oncogenic pathways that contribute to the progression of NAFLD to HCC, and hence to the increased incidence and aggressiveness of HCC in obese individuals is lacking. In this regard, we demonstrate that the Indian Hedgehog (Ihh) signaling pathway is upregulated in the fatty livers of mice consuming a high fat diet, and furthermore sustained in HCC tumors specifically within the context of a NAFLD microenvironment. Using a diet-induced mouse model of HCC wherein only obese mice develop HCC, targeted ablation of hepatocyte-secreted Ihh results in a decreased tumor burden and lower grade tumors. Ihh activation regulates the transdifferentiation of ciliated stellate cells and proliferation of Epcam⁺ ductal cells to promote fibrosis. Mechanistically, increased expression of hitherto uncharacterized effectors of Hh pathway, namely Myc and Tgf-β2 is critical to the observed physiology. This pro-tumorigenic response is driven by increased expression of Wnt5a to effect a poorly-differentiated and invasive tumor phenotype. Wnt5a secreted from activated stellate cells act on Ror2-expressing hepatocytes. We further demonstrate that Wnt5a expression is also elevated in poorly-differentiated HCC cells, suggesting that these ligands are also able to function in an autocrine positive feedback manner to sustain poorly-differentiated tumors. Taken together, our study provides a mechanistic understanding for how Ihh signaling promotes HCC tumorigenesis specifically in obese mice. We propose that therapeutic targeting of the Hh pathway offers benefit for patients with dietary / NAFLD-driven steatotic HCC.

The Diagnostic Performance of Liver MRI without Intravenous Contrast for Detecting Hepatocellular Carcinoma: A Case-Controlled Feasibility Study

Objective

To preliminarily evaluate the diagnostic performance of an unenhanced MRI for detecting hepatocellular carcinoma (HCC) with a case-control study design.

Materials and Methods

The case group consisted of 175 patients with initially-diagnosed HCC, who underwent a 3T liver MRI. A total of 237 HCCs were identified. The number of HCCs that were smaller than 1 cm, 1 cm ≤ and < 2 cm, and ≥ 2 cm were 19, 105, and 113, respectively. For the control group, 72 patients with chronic liver disease, who did not have HCC, were enrolled. Two radiologists independently reviewed the T2 half-Fourier acquisition single-shot turbo spin echo, T2 fast spin echos with fat saturation, T1 gradient in- and out-of-phase images, and diffusion-weighted images/apparent diffusion coefficient maps to detect HCC. Per-patient analyses were performed to evaluate the sensitivity and specificity of the non-contrast MRI for diagnosing HCC. Furthermore, the per-lesion sensitivity was also calculated according to tumor size.

Results

In the per-patient analyses, the sensitivity and specificity of reader 1 were 86.3% (151/175) and 87.5% (63/72), respectively; while those of reader 2 were 82.9% (145/175) and 76.4% (55/72), respectively. When excluding HCCs smaller than 1 cm, the sensitivity of reader 1 and 2 were 88.0% (147/167) and 86.2% (144/167), respectively. In the per-lesion analyses, the sensitivities of reader 1 and reader 2 were 75.9% (180/237) and 70.5% (167/237), respectively.

Conclusion

The per-patient sensitivity and specificity of non-contrast MRIs were within a reasonable range for the initial diagnosis of HCC. Non-contrast MRIs may have a potential for surveillance of HCC. Further confirmatory diagnostic test accuracy studies are needed.

Glypican-3 induces oncogenicity by preventing IGF-1R degradation, a process that can be blocked by Grb10

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and is a major cause of cancer-related death worldwide. Previously, we demonstrated that glypican-3 (GPC3) is highly expressed in HCC, and that GPC3 induces oncogenicity and promotes the growth of cancer cells through IGF-1 receptor (IGF-1R). In the present study, we investigated the mechanisms of GPC3-mediated enhancement of IGF-1R signaling. We demonstrated that GPC3 decreased IGF-1-induced IGF-1R ubiquitination and degradation and increased c-Myc protein levels. GPC3 bound to Grb10, a mediator of ligand-induced receptor ubiquitination, and the overexpression of Grb10 blocked GPC3-enhanced IGF-1-induced ERK phosphorylation. GPC3 promoted the growth of NIH3T3 and PLC-PRF-5 cells in serum-free medium but did not promote the growth of IGF-1R negative R- cells. Grb10 overexpression decreased GPC3-promoted cell growth. Therefore, the present study elucidates the mechanisms of GPC3-induced oncogenicity, which may highlight new strategies for the treatment of HCC.

Cytotoxic effect of a mannogalactoglucan extracted from Agaricus bisporus on HepG2 cells

A mannogalactoglucan (RK2-Ab; M_w 1.8×10⁴gmol^-1) composed by Man (27.3%), Gal (24.4%) and Glc (48.3%) was extracted and characterized from Agaricus bisporus, and its biological activity was evaluated on human hepatocarcinoma cells (HepG2). The partially-O-methylated alditol acetates together with the NMR data suggest the main chain to be composed of α-d-Galp (32.8%) and β-d-Glcp (37.0%) units (1→6)-linked, with β-d-Manp (14.6%), as non-reducing end units, substituting the side chains at O-2 (α-d-Galp units; 3.3%) and O-2 and O-4 (β-d-Glcp units; 3.6%). (1→2)-linked β-d-Glcp (2.7%) and β-d-Manp (6.0%) can also be observed. RK2-Ab reduced cellular viability of HepG2 cells, by both, the MTT and lactate dehydrogenase release assays, promoted the increase of cytochrome c release and decrease of ATP content. Suggesting that the mannogalactoglucan from A. bisporus may have antitumor activity by inducing apoptosis by the mitochondrial death pathway, and could be used in cancer therapy.

Chemokine CXCL1 may serve as a potential molecular target for hepatocellular carcinoma

The purpose of this study was to screen for changes in chemokine and chemokine‐related genes that are expressed in hepatocellular carcinoma (HCC) as potential markers of HCC progression. Total RNA was extracted from tumor and peritumor tissues from mice with HCC and analyzed using a PCR microarray comprising 98 genes. Changes in gene expression of threefold or more were screened and subsequently confirmed by immunohistochemical analyses and western blotting. Furthermore, whether chemokine knockdown by RNA interference (RNAi) could significantly suppress tumor growth in vivo was also evaluated. Finally, total serum samples were collected from HCC patients with HBV/cirrhosis (n = 16) or liver cirrhosis (n = 16) and from healthy controls (n = 16). The serum mRNA and protein expression levels of CXCL1 in primary liver cancer patients were detected by qRT‐PCR and western blot analysis, respectively. Several genes were up‐regulated in tumor tissues during the progression period, including CXCL1, CXCL2, CXCL3, and IL‐1β, while CXCR1 expression was down‐regulated. CBRH‐7919 cells carrying CXCL1 siRNA resulted in decreased tumor growth in nude mice. The differences in serum CXCL1 mRNA and protein levels among the HCC, hepatic sclerosis (HS), and control groups were significant (P < 0.001). The mRNA and protein levels of CXCL1 in the HCC group were up‐regulated compared with the HS group or the control group (P < 0.001). Several chemokine genes were identified that might play important roles in the tumor microenvironment of HCC. These results provide new insights into human HCC and may ultimately facilitate early HCC diagnosis and lead to the discovery of innovative therapeutic approaches for HCC.

The pan-deacetylase inhibitor panobinostat affects angiogenesis in hepatocellular carcinoma models via modulation of CTGF expression

Post-translational modifications of chromatin components are significantly involved in the regulation of tumor suppressor gene and oncogene expression. Connective tissue growth factor (CTGF) is an epigenetically regulated growth factor with functions in angiogenesis and cell-matrix interactions and plays a pivotal role in hepatocellular carcinoma (HCC). The pharmacologic inhibition of histone and protein deacetylases represents a new approach to interfere with pathways of apoptosis and angiogenesis. We investigated the effect of the pan-deacetylase inhibitor panobinostat (LBH589) on human HCC cell lines HepG2 (p53wt) and Hep3B (p53null) and in a subcutaneous xenograft model and explored the influence on angiogenesis. Specimens were characterized by quantitative real-time PCR. Protein was separated for western blotting against CTGF, VEGF, VEGF receptor-1 (VEGFR-1/FLT-1), VEGF receptor-2 (VEGFR-2/KDR), MAPK and phospho-MAPK. In vivo, HepG2 cells were xenografted to NMRI mice and treated with daily i.p. injections of 10 mg/kg panobinostat. After 1, 7 and 28 days, real-time PCR was performed. Immunohistochemistry and western blotting were examined after 28 days. An increased significant expression of CTGF was only seen after 24 h treatment with 0.1 µM panobinostat in HepG2 cells and Hep3B cells, whereas after 72 h treatment CTGF expression clearly decreased. In the xenografts, treatment with panobinostat showed a minimal CTGF expression after 1 day and 4 weeks, respectively. In vitro as well as in vivo, VEGF was not affected by panobinostat treatment at any time. In conclusion, panobinostat influences extracellular signaling cascades via CTGF-dependent pathways.

Epidemiology of hepatitis C: related hepatocellular carcinoma in Cameroon

Introduction

Hepatocellular carcinoma (HCC) is a global public health problem. Hepatitis C virus (HCV) infection accounts for close to 24% of HCC in developing countries especially when associated with cirrhosis. There exists no vaccine against HCV to prevent the occurrence of HCV-related HCC. A sound knowledge of the epidemiology and prevention of the initial infection is vital. The aim of our study was to determine the epidemiologic profile of HCV-related HCC in Cameroon to improve its’ management.

Methods

It was a prospective study of histologically proven HCV-related HCC seen in two University Centers in Yaounde, Cameroon from March 2012 to January 2013. Demographic data (age, gender), alcohol abuse (>80g/day), presence of cirrhosis, tobacco abuse and parenteral exposition were analyzed.

Results

Twenty-six patients with histologically proven HCV–related HCC were included (18 men (69.2%) and 8 women (30.8%); mean age +/- SD, 61.46+/-10.18 years). A total of 22 (84.6%) patients had a parenteral exposition, 02 (7.7%) patients were alcoholics and 06 (23.1%) patients were smokers. The proportion of patients with cirrhosis was 69.2% against 30.8% cirrhosis-free. Patients with cirrhosis were relatively younger than those cirrhosis-free (mean age +/- SD, 59.05+/-10.05 years vs 66.87+/- 8.72 years, p=0.06). HCV-related HCC was more prevalent in 60 years and above patients (53.8%, 95%CI: 33.4-73.4). The relative risk of HCC among alcoholics patients was high (RR: 1.5, 95%CI: 1.13-1.99, p<0.05).

Conclusion

In Cameroon, HCV-related HCC is more prevalent among age older than 60 years, a finding which is relatively less to that found in western countries, male gender is twice more at risk than female gender and cirrhosis frequency is less compared to that observed elsewhere. HCV and alcohol play a synergistic role in the occurrence of HCC in our environment.

Antioxidative dietary compounds modulate gene expression associated with apoptosis, DNA repair, inhibition of cell proliferation and migration

Many dietary compounds are known to have health benefits owing to their antioxidative and anti-inflammatory properties. To determine the molecular mechanism of these food-derived compounds, we analyzed their effect on various genes related to cell apoptosis, DNA damage and repair, oxidation and inflammation using in vitro cell culture assays. This review further tests the hypothesis proposed previously that downstream products of COX-2 (cyclooxygenase-2) called electrophilic oxo-derivatives induce antioxidant responsive elements (ARE), which leads to cell proliferation under antioxidative conditions. Our findings support this hypothesis and show that cell proliferation was inhibited when COX-2 was down-regulated by polyphenols and polysaccharides. Flattened macrophage morphology was also observed following the induction of cytokine production by polysaccharides extracted from viili, a traditional Nordic fermented dairy product. Coix lacryma-jobi (coix) polysaccharides were found to reduce mitochondrial membrane potential and induce caspase-3- and 9-mediated apoptosis. In contrast, polyphenols from blueberries were involved in the ultraviolet-activated p53/Gadd45/MDM2 DNA repair system by restoring the cell membrane potential. Inhibition of hypoxia-inducible factor-1 by saponin extracts of ginsenoside (Ginsen) and Gynostemma and inhibition of S100A4 by coix polysaccharides inhibited cancer cell migration and invasion. These observations suggest that antioxidants and changes in cell membrane potential are the major driving forces that transfer signals through the cell membrane into the cytosol and nucleus, triggering gene expression, changes in cell proliferation and the induction of apoptosis or DNA repair.

Chemoembolization of intermediate stage hepatocellular carcinomas: results from a Nordic tertiary liver cancer center

BACKGROUND

Transarterial chemoembolization (TACE) is used as palliative treatment of hepatocellular carcinoma (HCC). Most publications are from HCC patient populations where viral hepatitis is the primary cause of liver disease. In the Nordic countries, most patients have either alcohol-induced cirrhosis or are noncirrhotic. The aim of this single-center study was to evaluate patient characteristics, survival, and side effects of TACE in a Danish referral center for HCC treatment.

METHODS

Fifty-nine consecutive patients with HCC, treated with TACE, either chemoembolization with drug-eluting beads or conventional-TACE with Lipiodol, were included in the study. Their medical records were retrospectively reviewed, computed tomography images analyzed, and biochemical markers recorded. The primary endpoint was overall survival. Analyses were by intention to treat.

RESULTS

Thirty-five patients (59 %) had HCC on a background of liver cirrhosis most often caused by alcohol (60 % of cirrhotics or 35 % overall). Before the first chemoembolization, the patients had a median Child-Pugh score of 6 (5-7) and a median MELD score of 10 (6-21). Median survival after chemoembolization was 18.9 months (13.1-24.7). TACE patients were hospitalized for an average of 3 days (2-30). Prolonged stay was most often due to side effects-eg. pain (31 %), fever (14 %), nausea (10 %), and infection (10 %). Thirty-three patients (56 %) did not have any side effects.

CONCLUSIONS

In this cohort, we observed an acceptable survival following TACE without significant side effects.

An international comparison of stakeholder motivation to implement liver cancer control

BACKGROUND

The World Health Organization offers clear guidance on the development of national cancer control programmes based on a country's level of resources, yet the motivation to implement such programmes may be driven by factors other than resources.

OBJECTIVES

To compare stakeholder motivation to implement a national liver cancer control programme and assess if variation in motivation was associated with stakeholder characteristics or with national indicators of need and resources.

METHODS

Relevant stakeholders were purposively selected from 13 countries (Australia, China, France, Germany, Italy, Japan, Nigeria, South Korea, Spain, Taiwan, Thailand, Turkey and USA) to participate in a structured survey on liver cancer control. Respondents included 12 individuals working in clinical, 5 in policy and 3 in advocacy roles from each country. Stakeholders' motivation was measured using a scale grounded in expectancy theory and knowledge gained during previous qualitative interviews. Comparisons across countries and respondent characteristics were conducted using hierarchical regression. Country level motivation scores, holding constant individual level covariates, were correlated with indicators of need and resources and tested using Pearson's correlation coefficients.

RESULTS

In total, 260 stakeholders, equally drawn from the study countries, completed the survey (45% response rate). At the national level, motivation was highest in Nigeria, Thailand and China (P < 0.001), and lowest in Italy (P < 0.001) and Germany (P = 0.003). Higher motivation was observed among stakeholders working at the international level relative to the local level (P = 0.017). Motivation was positively associated with a country's relative burden of liver cancer (P = 0.015) and negatively associated with their level of resources (P = 0.018).

CONCLUSIONS

This study provides the first empirical evidence on the motivation of stakeholders to implement national cancer control programmes. Furthermore, we demonstrate that motivation is more clearly associated with a country's cancer control needs rather than resources.

Inhibition of HepG2 cell proliferation by ursolic acid and polysaccharides via the downregulation of cyclooxygenase-2

Cyclooxygenase (COX)-2, a multi-functional molecule, is overexpressed in hepatocellular carcinomas. In order to understand cell proliferation and its association with COX-2 in HepG2 cells in the presence of ursolic acid (UA), viili exopolysaccharides (VEPS) and Astragalus polysaccharides (APS), the cell proliferation, superoxide dismutase (SOD) and metabolic malondialdehyde (MDA) of fatty acids, COX-2, prostaglandin E2 (PGE2), as well as apoptotic morphology and rate were investigated. The results revealed that the activities of SOD, COX-2 and PGE2 were reduced, MDA was markedly decreased, apoptotic blebs were induced, and HepG2 cells were accumulated in the G1 and sub G1/apoptotic phases in test groups. The results indicated that UA, VEPS, APS and any combination of these possess anticancer properties, particularly by downregulating COX-2 expression, which may have increased internal oxidation and triggered apoptosis together with a change in internal antioxidant response elements, leading to a reduction in cell proliferation.

The inflammation-based scores to predict prognosis of patients with hepatocellular carcinoma after hepatectomy

The aims of this study were to compare the prognostic ability of inflammation-based prognostic scores including the Glasgow Prognostic Score (GPS), the modified Glasgow Prognostic Score (mGPS), neutrophil to lymphocyte ratio, prognostic index, and prognostic nutritional index (PNI) for patients with hepatocellular carcinoma (HCC) undergoing hepatectomy, and to propose the combination of staging systems and inflammation scores to improve the prognostic power. Data for 349 patients who underwent hepatectomy as initial treatment for HCC between 2008 and 2009 were retrieved from a prospective database. The association of inflammation scores with clinicopathological variables and overall survival (OS) was analyzed, and the concordance index (C-index) was calculated to compare the predictive ability of each inflammation scores and staging systems including Barcelona Clinic Liver Cancer (BCLC) and Cancer of the Liver Italian Program (CLIP) scores. The median follow-up period was 39 months, the 1, 2, and 3 year OS was 75.4, 67.0, and 59.0 %, respectively, and the median OS was 39 months. All inflammation scores, except PNI, were associated with tumor size, major/microvascular invasion and clinical stages, and the GPS and mGPS had a higher C-index (0.608). Multivariate analysis showed that the GPS, BCLC, and CLIP were independently associated with OS. The combined GPS and CLIP (C-index = 0.705) were superior to CLIP alone (C-index = 0.686) or the GPS alone in prognostic ability. The prognostic ability of the GPS is superior to other inflammation scores for patients undergoing hepatectomy as initial treatment for HCC. Combining GPS and CLIP improved the prognostic power.

Low-dose chemotherapy of hepatocellular carcinoma through triggered-release from bilayer-decorated magnetoliposomes

Low-dose (LD) chemotherapy is a promising treatment strategy that may be improved by controlled delivery. Polyethylene glycol-stabilized bilayer-decorated magnetoliposomes (dMLs) have been designed as a stimuli-responsive LD chemotherapy drug delivery system and tested in vitro using Huh-7 hepatocellular carcinoma cell line. The dMLs contained hydrophobic superparamagnetic iron oxide nanoparticles within the lipid bilayer and doxorubicin hydrochloride (DOX, 2 μM) within the aqueous core. Structural analysis by cryogenic transmission electron microscopy and dynamic light scattering showed that the assemblies were approximately 120 nm in diameter. Furthermore, the samples consisted of a mixture of dMLs and bare liposomes (no nanoparticles), which provided dual burst and spontaneous DOX release profiles, respectively. Cell viability results show that the cytotoxicity of DOX-loaded dMLs was similar to that of bare dMLs (∼10%), which indicates that spontaneous DOX leakage had little cytotoxic effect. However, when subjected to a physiologically acceptable radiofrequency (RF) electromagnetic field, cell viability was reduced up to 40% after 8h and significant cell death (>90%) was observed after 24h. The therapeutic mechanism was intracellular RF-triggered DOX release from the dMLs and not intracellular hyperthermia due to nanoparticle heating via magnetic losses.

Family history of hepatocellulcar carcinoma is not associated with its patients' prognosis after hepatectomy

BACKGROUND

Family history of liver cancer is a major risk factor for hepatocellular carcinoma (HCC). In this study, we investigated the prognosis of patients with HCC with or without family history.

METHODS

Data for 1,313 patients who underwent hepatectomy as initial treatment for HCC between 2000 and 2008 at a tertiary cancer center hospital were retrieved from a prospective database. A positive family history was defined as a self-reported history of HCC in first-degree relatives. Clinicopathologic characteristics were compared by family history. Kaplan-Meier method and Cox proportional hazards regressions were applied for overall survival (OS) and disease-free survival (DFS).

RESULTS

Of 1,313 patients, 169 patients (12.9%) had first-degree relatives with a history of HCC. There were no significant differences between patients with or without family history in basic clinicopathologic characteristics. In either whole group or each stage according to the TNM staging system, first-degree family history was not associated with survival in all patients, hepatitis B virus-positive patients, as well as male patients. Multivariate analysis revealed that first-degree family history was not a prognostic factor, either for OS or DFS.

CONCLUSION

A first-degree family history of HCC is not associated with its patients' prognosis after hepatectomy.

A modified TNM-7 staging system to better predict the survival in patients with hepatocellular carcinoma after hepatectomy

OBJECTIVE

To evaluate the accuracy of the 7th edition of the American Joint Committee on Cancer staging system (TNM-7) for patients undergoing hepatectomy for hepatocellular carcinoma (HCC) and to propose a modified TNM system for better prediction of survival.

METHODS

Clinico-pathological data for 1,313 patients who underwent hepatectomy as initial treatment for HCC between 2000 and 2008 were retrieved from a prospective database. Overall survival (OS) and disease-free survival (DFS) were analyzed to evaluate the predictive value.

RESULTS

The 1-, 3-, 5-year OS and DFS of 1,313 patients were 79.2, 55.4, 45.5 %, and 52.6, 36.1, 31.8 %, respectively. Multivariate analysis revealed that major vascular invasion was the most important prognostic factor for both OS and DFS, along with tumour number and size. Patients with pT1 and pT2 disease had significantly better OS and DFS than those with pT3 disease (P < 0.001). There was no significant difference between pT3a and pT4 (P = 0.552) but patients with pT3b disease had a worse OS and DFS than those with pT4 disease (P = 0.006 and P < 0.001, respectively). A modified TNM system within the existing framework was proposed to combine the current pT3a and pT4 together as the new pT3 and to change pT3b to the new pT4. Analysis showed that this modified system had a better prognostic power than either TNM-6 or TNM-7.

CONCLUSION

TNM-7 would seem to be inaccurate for staging advanced HCC. The modified system can improve both the prognostic accuracy and the hazard discrimination of disease to be consistent among subgroups of HCC.

Perillyl alcohol as a protective modulator against rat hepatocarcinogenesis via amelioration of oxidative damage and cell proliferation

In the present study, we have evaluated the chemopreventive effects of perillyl alcohol (POH) against diethylnitrosamine-initiated and 2-AAF (2-acetylaminofluorine)-promoted hepatocarcinogenesis in Wistar rats. Efficacy of POH against 2-AAF-induced hepatotoxicity was evaluated in terms of biochemical estimation of antioxidant enzyme activities, histopathological changes and expression levels of proliferative markers. 2-AAF is a potent hepatotoxicant and a hepatic carcinogen that induces its effect by causing oxidative stress. Pre-treatment of POH prevented oxidative stress and tumour incidences. POH suppressed 2-AAF-induced early tumour markers, namely ornithine decarboxylase activity, thymidine phosphorylase and proliferating cell nuclear antigen (PCNA) protein and also suppressed the expression of pro-apoptotic protein P53. Histopathological findings revealed that POH-pretreated groups showed marked recovery. From our results, it could be concluded that POH markedly protects against chemically induced liver cancer and acts possibly by virtue of its antioxidant and antiproliferative activities.

Sorafenib in liver cancer

INTRODUCTION

With growing knowledge of the molecular pathway of carcinogenesis, targeted therapies have become the 'blue ocean' of cancer treatment. sorafenib is an oral multikinase inhibitor that targets Raf/mitogen-activated protein (MAP) kinase/extracellular signal-regulated kinase (ERK) (Raf/MEK/ERK) and several tyrosine kinases (VEGFR-2, VEGFR-3, PDGFR-β) that has shown efficacy in hepatocellular carcinoma (HCC).

AREAS COVERED

An updated summary of the preclinical and clinical experience with sorafenib in HCC is presented in this paper. Data are based on abstracts from international conferences and journal articles found in a PubMed search of literature published up to December 2011.

EXPERT OPINION

Based on favorable data from preclinical and clinical trials, sorafenib has been approved as a standard therapy in advanced HCC. However, further efforts to understand the additional roles of sorafenib in the treatment of HCC are still necessary. Data for sorafenib will guide the development of new drugs for the treatment of HCC.

RASSF1A Ala133Ser polymorphism is associated with increased susceptibility to hepatocellular carcinoma in a Turkish population

AIM

The tumor suppressor gene Ras association domain family 1 isoform A (RASSF1A) regulates cell cycle regulation, apoptosis and microtubule stability and is inactivated by promoter hypermethylation at a high frequency in hepatocellular carcinoma (HCC). A guanine (G)/thymine (T) common single nucleotide polymorphism (SNP) at first position of codon 133 in RASSF1A gene determines an alanine (Ala) to serine (Ser) (Ala133Ser) amino acidic substitution which may alter cancer risk by influencing the function of RASSF1A protein.

METHODS

To determine the association of the RASSF1A Ala133Ser polymorphism with the risk of HCC development in a Turkish population, a hospital-based case-control study was designed consisting of 236 subjects with HCC and 236 cancer-free control subjects matched for age, gender, smoking and alcohol status. The genotype frequency of the RASSF1A Ala133Ser polymorphism was determined by using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay.

RESULTS

Allele and genotype associations of RASSF1A Ala133Ser polymorphism with HCC susceptibility were observed in comparisons between the patient and control samples (P<0.001). Risk of HCC development in this Turkish population was significantly increased in carriers of the Ser133 variant allele of Ala133Ser polymorphism (Ala/Ser and Ser/Ser genotypes) when compared with homozygote Ala/Ala genotype (OR=5.47, 95% CI=3.63-8.25, P=0.001).

CONCLUSION

Because our results suggest for the first time that the Ser133 allele of RASSF1A Ala133Ser polymorphism may be a genetic susceptibility factor for HCC in the Turkish population, further independent studies are required to validate our findings in a larger series, as well as in patients of different ethnic origins.

The significance of Exonuclease 1 K589E polymorphism on hepatocellular carcinoma susceptibility in the Turkish population: a case-control study

Exonuclease 1 (Exo 1) is an important nuclease involved in mismatch repair system that contributes to maintain genomic stability, to modulate DNA recombination, and to mediate cell cycle arrest. A guanine (G)/adenine (A) common single nucleotide polymorphism at first position of codon 589 in Exo 1 gene determines a glutamic acid (Glu, E) to lysine (Lys, K) (K589E) aminoacidic substitution which may alter cancer risk by influencing the activity of Exo 1 protein. Exo 1 K589E polymorphism has been studied in various cancers, but its association with hepatocellular carcinoma (HCC) has yet to be investigated. To determine the association of the Exo 1 K589E polymorphism with the risk of HCC development in a Turkish population, a hospital-based case-control study was designed consisting of 224 subjects with HCC and 224 cancer-free control subjects matched for age, gender, smoking and alcohol status. The genotype frequency of the Exo 1 K589E polymorphism was determined by using a polymerase chain reaction-restriction fragment length polymorphism assay. Our data shows that the Lys/Lys genotype of the Exo 1 K589E polymorphism is associated with increased risk of HCC development in this Turkish population [odds ratio (OR) = 2.15, 95% confidence interval (CI): 1.13-4.09, P = 0.02]. Furthermore, according to stratified analysis, a significant association was observed between the homozygote Lys/Lys genotype and HCC risk in the subgroups of male gender (OR = 2.67, 95% CI: 1.27-5.61, P = 0.009) and patients with non-viral-related HCC (OR = 3.14, 95% CI: 1.09-8.99, P = 0.03). Because our results suggest for the first time that the Lys/Lys homozygote genotype of Exo 1 K589E polymorphism may be a genetic susceptibility factor for HCC in the Turkish population, further independent studies are required to validate our findings in a larger series, as well as in patients of different ethnic origins.

RPL36 as a prognostic marker in hepatocellular carcinoma

Ribosomal proteins (RP) play key roles in the regulation of apoptosis, multidrug resistance and carcinogenesis. The aim of this study was to investigate the expression of ribosomal protein L36 (RPL36) in hepatocellular carcinoma (HCC) and to correlate it with clinicopathological parameters and clinical outcome. Liver specimens were obtained from 60 HCC patients who had undergone a partial hepatectomy. Expression of RPL36 in tumor tissue and surrounding non-tumorous tissues was evaluated on a tissue microarray by immunohistochemistry. RPL36 was expressed in 45 of 60 (75%) HCC by immunohistochemistry, but was not detected in corresponding non-tumors. RPL36 expression correlated significantly with serum levels of albumin (P= 0.044) and prothrombin time (P= 0.026), which reflect liver synthetic function. Moreover, expression of RPL36 was found to be higher in patients with early tumor stages (I/II) (P= 0.038) or without portal vein thrombosis (P= 0.005). In univariate analysis, patients with RPL36 expression revealed better overall survival (P= 0.037). By multivariate survival analysis, RPL36 expression was found to be an independent prognostic factor for overall survival (P= 0.026). Our data suggest that RPL36 may be involved in the early stage of hepatocarcinogenesis, and it can be used as an independent and potential prognostic marker for resected HCC.

Polymorphisms of hemochromatosis, and alpha-1 antitrypsin genes in Egyptian HCV patients with and without hepatocellular carcinoma

Hereditary hemochromatosis and alpha-1antitrypsin deficiency are genetic diseases characterized by endoplasmic reticulum (ER) stress with subsequent development of liver disease. Our aim was to estimate the frequency of hemochromatosis gene (HFE) mutant alleles (C282Y and H63D) and alpha-1 antitrypsin S/Z variants among Egyptian HCV cirrhotic patients and in hepatocellular carcinoma patients and to evaluate their effects on disease progression. HFE and alpha-1 antitrypsin polymorphisms were characterized in 200 Egyptian patients with HCV infection (100 patients complicated with cirrhosis, 100 patients with HCC) and 100 healthy subjects who had no history of any malignancy. The frequencies of HD genotype of H63D mutation were significantly increased in HCC patients compared to control group and to cirrhosis group. Also, the frequencies of DD genotype were significantly increased In HCC group compared to control group and to cirrhosis group. Our results suggested that Carriers of the D allele of H63D mutation were significantly more likely to develop HCC.

Controlling liver cancer internationally: A qualitative study of clinicians' perceptions of current public policy needs

BACKGROUND

Liver cancer is the fifth most common cancer in men and the seventh for women. Usually because of late diagnosis, the prognosis for liver cancer remains poor, resulting in liver cancer being the third most common cause of death from cancer. While some countries have treatment guidelines, little is known or understood about the strategies needed for liver cancer control internationally.

OBJECTIVE

To explore leading liver cancer clinician's perceptions of the current public policy needs to control liver cancer internationally.

METHODS

Key informant interviews were conducted with a range of liver cancer clinicians involved in policy in eleven countries. Interviews were digitally recorded, transcribed verbatim, translated (where necessary), de-identified and analyzed by two researchers using a constant comparative method.

RESULTS

Twenty in-depth semi-structured interviews were conducted in: Australia, China, France, Germany, Italy, Japan, Spain, South Korea, Taiwan, Turkey and the United States. Nine themes were identified and cluster into three groups: 1) Promoting prevention via early risk assessment, focusing on viral hepatitis and other lifestyle factors; 2) Increasing political, public and medical community awareness; and 3) Improving funding for screening, liver cancer surveillance and treatment.

CONCLUSION

This study is an important step towards developing an evidence-based approach to assessing preparedness for implementing comprehensive liver cancer control strategies. Evaluation mechanisms to assess countries' performance on the needs described are needed. Future research will concentrate of understanding how these needs vary across countries and the optimal strategies to improve the diagnosis and prognosis of patients with liver cancer internationally.

DEC1 nuclear expression: A marker of differentiation grade in hepatocellular carcinoma

AIM: To investigate the expression patterns of human differentiated embryo chondrocyte 1 (DEC1) in hepatocellular carcinoma (HCC) and corresponding adjacent non-tumor and the normal liver tissues, the association between DEC1 expression and histopathological variables and the role of DEC1 in hepatocarcinogenesis.

METHODS: The expression of DEC1 was detected immunohistochemically in 176 paraffin-embedded sections from 63 patients with HCC and 50 subjects with normal liver tissues.

RESULTS: DEC1 protein was persistently expressed in the cytoplasm of hepatocytes in normal liver and HCC tissues. Compared with adjacent non-tumor liver tissues, HCC tissues showed high nuclear expression of DEC1 protein. However, high DEC1 nuclear expression was more frequently detected in well-differentiated (83.3%) than in moderately (27.3%) and poorly differentiated HCC (16.7%). Low DEC1 expression was associated with poor histological differentiation and malignancy progression. A correlation was found between the nuclear expression of DEC1 protein and histological differentiation (r = 0.376, P = 0.024).

CONCLUSION: DEC1 is expressed in the cytoplasm of hepatocytes and because nuclear DEC1 expression is decreased with decreasing differentiation status of HCC, nuclear DEC1 might be a marker of HCC differentiation.

[Combined interferon, ribavirin treatment and the occurrence of hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) is the sixth most common cause of cancer-related death worldwide. Primary hepatocellular carcinoma can be found most frequently (80-90%) in patients with liver cirrhosis. The most frequent causes of liver cirrhosis are chronic hepatitis B and C virus infections and chronic alcohol consumption. The treatment and elimination of the etiological factors decreases the risk of HCC. The authors summarize the literary data, where effect of modern antiviral treatment has been examined according to the occurrence of HCC. It can be stated, that the antiviral therapy (interferon and nucleoside analogues) is able to decrease the risk of HCC or the recurrence of the tumor after curative treatment of HCC, in case of non responder state, as well. Drugs used for the insurance of equilibrium in redox state can also help in the decrease of HCC risk.

Efficacy and cost of a hepatocellular carcinoma screening program at an Australian teaching hospital

BACKGROUND AND AIM

Western countries are seeing an increasing prevalence of chronic viral hepatitis and a subsequent rise in the incidence of hepatocellular carcinoma (HCC). Screening patients at high risk of HCC has become standard practice. The aim of this study was to assess the efficacy and cost of screening high-risk individuals for HCC in an Australian tertiary hospital.

METHODS

A retrospective review was performed of all patients who underwent HCC screening at the Austin Hospital in Melbourne between 1 October 1998 and 31 August 2004. HCC screening was carried out in all cirrhotic patients and male non-cirrhotic patients with chronic hepatitis B virus. Screening consisted of 6-monthly alpha fetoprotein (AFP) measurements and ultrasounds (US). Outcomes of those who had HCC detected were followed up until 15 February 2007. Patients who had HCC satisfying the Milan criteria for liver transplantation were considered to have potentially curable tumor. Costs for the diagnostic tests were obtained from the 2004 Australian Medicare Benefits Schedule.

RESULTS

A total of 268 patient records were reviewed as part of the study. Chronic viral hepatitis accounted for 63% of the patients (n = 167). US screening was carried out at a median of 6.5 months and AFP measurements at a median of 4.0 months. HCC was detected in 22 patients (8.2%) at an incidence of 2.7% per year. These patients had a mean follow up of approximately 5.0 years after tumor detection. At the time of diagnosis, 17 patients had potentially curable tumor and 10 were alive at the conclusion of follow up. Of these 10 patients, six were successfully transplanted, three were successfully treated with radiological therapies and one was awaiting transplantation. The total cost of the screening program over the study period, including secondary investigations, was $A300,568. The cost per HCC detected was $13,662 and cost per potentially curable HCC was $17,680.

CONCLUSION

An effective HCC screening program can be provided through a multi-disciplinary outpatient facility in an Australian teaching hospital. Further stratification of the high risk patient cohort may improve the cost effectiveness of this screening program.

SOX4 overexpression regulates the p53-mediated apoptosis in hepatocellular carcinoma: clinical implication and functional analysis in vitro

BACKGROUND AND AIMS

The underlying molecular mechanisms of hepatocellular carcinoma (HCC) remain poorly understood due to its complex development process. The human T cell-specific transcription factor sex-determining region Y-related high-mobility group (HMG) box 4 (SOX4) has been linked to development and tumorigenesis. In this study, we characterized the roles of SOX4 in regulation of the p53 transcription activity and evaluated the expression patterns and prognostic value of the transcription factor SOX4 in HCC.

METHODS

The expression levels of human SOX4 were examined in HCC samples obtained from 58 patients having curative partial hepatectomy. The interaction and effects of SOX4 on the p53 pathway were assessed in HCC cell lines. Luciferase reporter assay to examine p53-mediated transcription of target genes was performed. The association of SOX4 expression level with tumor recurrence and overall survival was evaluated.

RESULTS

We showed that the HMG box domain of SOX4 interacted with p53, resulting in the inhibition of p53-mediated transcription by the Bax promoter. More importantly, SOX4 overexpression led to a significant repression of p53-induced Bax expression and subsequent repression of p53-mediated apoptosis induced by gamma-irradiation. In clinicopathological analysis, nuclear overexpression of SOX4 was observed in 37 out of 58 (63.8%) HCC samples, and this correlated with diminished risk of recurrence (P = 0.014) and improved overall survival time (P = 0.045) in HCC patients.

CONCLUSION

These results suggest that SOX4 contributes to hepatocarcinogenesis by inhibiting p53-mediated apoptosis and that its overexpression might be a useful prognostic marker for survival after surgical resection.

The effects of Stichopus japonicus acid mucopolysaccharide on the apoptosis of the human hepatocellular carcinoma cell line HepG2

In this study, the effects of Stichopus japonicus acid mucopolysaccharide (SJAMP) on the apoptosis of the human hepatocellular carcinoma cell line HepG2 were examined. The underlying mechanism was investigated by determining the effect of SJAMP on the expression of Bcl-2 and nm23-H1 genes in HepG2 cells. In vitro cultured HepG2 cells were treated with different concentrations of SJAMP. The dimethylthiazol (MTT) assay was used to determine the inhibition of cell proliferation. Expression of Bcl-2 and nm23-H1 genes was determined by Western blot analysis. The results showed that SJAMP inhibited the proliferation of HepG2 cells in a time- and dose-dependent manner, SJAMP induced apoptosis in HepG2 cells, and SJAMP decreased the expression of Bcl-2 and increased the expression of nm23-H1. We conclude that SJAMP inhibits the proliferation of HepG2 cells by inducing apoptosis. These results provide a theoretical basis for the utilization of SJAMP as a potential antitumor component for the treatment of hepatocellular carcinoma.

MRI versus 64-row MDCT for diagnosis of hepatocellular carcinoma

AIM: To compare the diagnostic capability of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) for the detection of hepatocellular carcinoma (HCC) tumour nodules and their effect on patient management.

METHODS: A total of 28 patients (25 male, 3 female, mean age 67 ± 10.8 years) with biopsy-proven HCC were investigated with 64-row MDCT (slice 3 mm native, arterial and portal-venous phase, 120 mL Iomeprol, 4 mL/s, delay by bolus trigger) and MRI (T1fs fl2d TE/TR 2.72/129 ms, T2tse TE/TR 102/4000 ms, 5-phase dynamic contrast-enhanced T1fs fl3d TE/TR 1.56/4.6, Gadolinium-DTPA, slice 4 mm). Consensus reading of both modalities was used as reference. Tumour nodules were analyzed with respect to number, size, and location.

RESULTS: In total, 162 tumour nodules were detected by consensus reading. MRI detected significantly more tumour nodules (159 vs 123, P < 0.001) compared to MDCT, with the best sensitivity for early arterial phase MRI. False-negative CT findings included nodules ≤ 5 mm ( n = 5), ≤ 10 mm ( n = 17), ≤ 15 mm ( n = 12 ), ≤ 20 mm ( n = 4 ), and 1 nodule > 20 mm. MRI missed 2 nodules ≤ 10 mm and 1 nodule ≤ 15 mm. On MRI, nodule diameters were greater than on CT (29.2 ± 25.1 mm, range 5-140 mm vs 24.1 ± 22.7 mm, range 4-129 mm, P < 0.005). In 2 patients, MDCT showed only unilobar tumour spread, whereas MRI revealed additional nodules in the contralateral lobe. Detection of these nodules could have changed the therapeutic strategy.

CONCLUSION: Contrast-enhanced MRI is superior to 64-row MDCT for the detection of HCC nodules. Patients should be allocated to interventional or operative treatment according to a dedicated MRI-protocol.

MDCT versus MRI assessment of tumor response after transarterial chemoembolization for the treatment of hepatocellular carcinoma

The purpose of this study was to compare the ability of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) to evaluate treatment results after transarterial chemoembolization (TACE), with a special focus on the influence of Lipiodol on calculation of tumor necrosis according to EASL criteria. A total of 115 nodules in 20 patients (17 males, 3 females; 69.5 +/- 9.35 years) with biopsy-proven hepatocellular carcinoma were treated with TACE. Embolization was performed using a doxorubicin-Lipiodol emulsion (group I) or DC Beads loaded with doxorubicin (group II). Follow-up included triphasic contrast-enhanced 64-row MDCT (collimation, 0.625 mm; slice, 3 mm; contrast bolus, 120 ml iomeprol; delay by bolus trigger) and contrast-enhanced MRI (T1 native, T2 native; five dynamic contrast-enhanced phases; 0.1 mmol/kg body weight gadolinium-DTPA; slice thickness, 4 mm). Residual tumor and the extent of tumor necrosis were evaluated according to EASL. Contrast enhancement within tumor lesions was suspected to represent vital tumor. In the Lipiodol-based TACE protocol, MDCT underestimated residual viable tumor compared to MRI, due to Lipiodol artifacts (23.2% vs 47.7% after first, 11.9% vs 31.2% after second, and 11.4% vs 23.7% after third TACE; p = 0.0014, p < 0.001, and p < 0.001, respectively). In contrast to MDCT, MRI was completely free of any artifacts caused by Lipiodol. In the DC Bead-based Lipiodol-free TACE protocol, MRI and CT showed similar residual tumor and rating of treatment results (46.4% vs 41.2%, 31.9 vs 26.8%, and 26.0% vs 25.6%; n.s.). In conclusion, MRI is superior to MDCT for detection of viable tumor residuals after Lipiodol-based TACE. Since viable tumor tissue is superimposed by Lipiodol artifacts in MDCT, MRI is mandatory for reliable decision-making during follow-up after Lipiodol-based TACE protocols.

Green tea consumption and the risk of liver cancer in Japan: the Ohsaki Cohort study

OBJECTIVES

To investigate the association between green tea consumption and liver cancer incidence.

METHODS

We prospectively followed 41,761 Japanese adults aged 40-79 years, without a history of cancer at the baseline or any missing data for green tea consumption frequency. Cox proportional hazards models were used to calculate hazard ratios (HR) with 95% confidence intervals (CI), adjusted for age, alcohol drinking, smoking, the consumption of coffee, vegetables, dairy products, fruit, fish, and soybean.

RESULTS

Over 9 years of follow-up, among 325,947 accrued person-years, the total incidence of liver cancer was 247 cases. We found that green tea consumption was inversely associated with the incidence of liver cancer. In men, the multivariate-adjusted HRs (95% CIs) for liver cancer incidence with different green tea consumption categories were 1.00 (reference) for <1 cup/day, 0.83 (0.53-1.30) for 1-2 cups/day, 1.11 (0.73-1.68) for 3-4 cups/day, and 0.63 (0.41-0.98) for >/=5 cups/day (p for trend = 0.11). The corresponding data among women were 1.00 (reference), 0.68 (0.35-1.31), 0.79 (0.44-1.44), 0.50 (0.27-0.90) (p for trend = 0.04).

CONCLUSIONS

Green tea consumption is associated with a reduced risk of liver cancer incidence.

Proteomic identification of molecular targets of gambogic acid: role of stathmin in hepatocellular carcinoma

Gamboge has been developed as an injectable drug for cancer treatment in China. In this study, the inhibition ratio and their IC(50) values of two derivatives from Gamboge in hepatocellular carcinoma (HCC) were determined. Proteomic approach was employed to reveal the target proteins of these two derivatives, gambogic acid (GA), and gambogenic acid (GEA). HCC cells were cultured under varied conditions with the addition of either GA or GEA. Twenty differentially expressed proteins were identified and the four most distinctly expressed proteins were further validated by Western blotting. GA and GEA revealed inhibitory effects on HCC cell proliferation. The expression of cyclin-dependent kinase 4 inhibitor A and guanine nucleotide-binding protein beta subunit 1 were upregulated by both xanthones, whilst the expression of 14-3-3 protein sigma and stathmin 1 (STMN1) were downregulated. Furthermore, overexpression of STMN1 in HCC cells decreased their sensitivity, whilst small interfering RNAs targeting STMN1 enhanced their sensitivity to GA and GEA. In conclusion, our study suggested for the first time that STMN1 might be a major target for GA and GEA in combating HCC. Further investigation may lead to a new generation of anticancer drugs exerting synergistic effect with conventional therapy, thus to promote treatment efficacy.

Prevention of hepatocellular carcinoma in nonviral-related liver diseases

Although chronic infection with hepatitis B virus and/or hepatitis C virus are the most important risk factors for hepatocellular carcinoma (HCC) worldwide, other causes of cirrhosis can also lead to HCC. Given the high prevalence of alcoholism and the worldwide obesity epidemic, the relevant importance of nonviral liver disease-related HCC is expected to increase in the future. Some evidence supports mechanistic interactions between host or environmental factors and chronic viral hepatitis in the development of HCC. For example, food- and water-borne carcinogens have contributed to unusually high rates of HCC in parts of China and sub-Saharan Africa. With some of these conditions, appropriate public health measures to reduce the population's exposure to known etiologic agents, or early therapeutic intervention for 'at-risk' individuals before development of cirrhosis (e.g. hereditary hemochromatosis) can prevent HCC. Community-based programs to discourage and deal with excessive alcohol intake, to promote tobacco smoking awareness, to avoid exposure to aflatoxin and other food toxins, and measures to reduce the pandemic of obesity and diabetes are vital for effective interruption of the rising tide of HCC from nonviral liver disease.