Hyperglycemia is a significant prognostic factor of hepatocellular carcinoma after curative therapy

Role of transcription factor FOXM1 in diabetes and its complications (Review)

Diabetes mellitus is a chronic metabolic disease commonly associated with complications such as cardiovascular disease, nephropathy and neuropathy, the incidence of which is increasing yearly. Transcription factor forkhead box M1 (FOXM1) serves an important role in development of diabetes and its complications. The present study aimed to review the association between FOXM1 with pathogenesis of diabetes and its complications. FOXM1 may be involved in development and progression of diabetes and its complications by regulating cell biological processes such as cell cycle, DNA damage repair, cell differentiation and epithelial‑mesenchymal transition. FOXM1 is involved in regulation of insulin secretion and insulin resistance, and FOXM1 affects insulin secretion by regulating expression of insulin‑related genes and signaling pathways; FOXM1 is involved in the inflammatory response in diabetes, and FOXM1 can regulate key genes associated with inflammatory response and immune cells, which in turn affects occurrence and development of the inflammatory response; finally, FOXM1 is involved in the regulation of diabetic complications such as cardiovascular disease, nephropathy and neuropathy. In summary, the transcription factor FOXM1 serves an important role in development of diabetes and its complications. Future studies should explore the mechanism of FOXM1 in diabetes and find new targets of FOXM1 as a potential treatment for diabetes and its complications.

Oncologists' responsibility, comfort, and knowledge managing hyperglycemia in patients with cancer undergoing chemotherapy: a cross sectional study

PURPOSE

To assess oncologists' responsibility, comfort, and knowledge managing hyperglycemia in patients undergoing chemotherapy.

METHODS

In this cross-sectional study, a questionnaire collected oncologists' perceptions about professionals responsible for managing hyperglycemia during chemotherapy; comfort (score range 12-120); and knowledge (score range 0-16). Descriptive statistics were calculated including Student t-tests and one-way ANOVA for mean score differences. Multivariable linear regression identified predictors of comfort and knowledge scores.

RESULTS

Respondents (N = 229) were 67.7% men, 91.3% White and mean age 52.1 years. Oncologists perceived endocrinologists/diabetologists and primary care physicians as those responsible for managing hyperglycemia during chemotherapy, and most frequently referred to these clinicians. Reasons for referral included lack of time to manage hyperglycemia (62.4%), belief that patients would benefit from referral to an alternative provider clinician (54.1%), and not perceiving hyperglycemia management in their scope of practice (52.4%). The top-3 barriers to patient referral were long wait times for primary care (69.9%) and endocrinology (68.1%) visits, and patient's provider outside of the oncologist's institution (52.8%). The top-3 barriers to treating hyperglycemia were lack of knowledge about when to start insulin, how to adjust insulin, and what insulin type works best. Women (ß = 1.67, 95% CI: 0.16, 3.18) and oncologists in suburban areas (ß = 6.98, 95% CI: 2.53, 11.44) had higher comfort scores than their respective counterparts; oncologists working in practices with > 10 oncologists had lower comfort scores (ß = -2.75, 95% CI: -4.96, -0.53) than those in practices with ≤ 10. No significant predictors were identified for knowledge.

CONCLUSION

Oncologists expected endocrinology or primary care clinicians to manage hyperglycemia during chemotherapy, but long wait times were among the top barriers cited when referring patients. New models that provide prompt and coordinated care are needed.

Hyperglycemia Alters O-GlcNAcylation Patterns of Hepatocytes in Mice Treated With Hepatoxic Carcinogen

BACKGROUND/AIM

Diabetes mellitus (DM) is an established risk for hepatocellular carcinoma (HCC), with unclarified mechanisms. This study investigated the effects of hyperglycemia on O-GlcNacylation in hepatocytes and its associations with hepatocarcinogenesis.

MATERIALS AND METHODS

Mouse and human HCC cell lines were used in an in vitro model of hyperglycemia. Western blotting was used to determine the effects of high glucose on O-GlcNacylation in HCC cells. Twenty 4-week-old C3H/HeNJcl mice were randomized into four groups: non-DM control, non-DM plus diethylnitrosamine (DEN), DM, and DM plus DEN. DM was induced using intraperitoneal injection of a single high dose of streptozotocin. DEN was used to induce HCC. All mice were euthanized at week 16 after DM induction, and the liver tissues were histologically examined using hematoxylin and eosin, and immunohistochemistry.

RESULTS

High glucose increased O-GlcNacylated proteins in mouse and human HCC cell lines compared with those cultured at normal glucose concentration. Mice with hyperglycemia or DEN treatment had increased O-GlcNacylated proteins in hepatocytes. No gross tumors were evident at the end of the experiment but hepatic morbidity was observed. Mice with hyperglycemia and DEN treatment showed greater histological morbidity in their livers, i.e. increased nuclear size, hepatocellular swelling and sinusoidal dilatation, compared with mice in the DM group or treated with DEN alone.

CONCLUSION

Hyperglycemia increased O-GlcNAcylation in both in vitro and animal models. Increased O-GlcNAcylated proteins may be associated with hepatic histological morbidities which then promote HCC development in carcinogen-induced tumorigenesis.

Glycemic burden and the risk of adverse hepatic outcomes in patients with chronic hepatitis B with type 2 diabetes

BACKGROUND AND AIMS

Type 2 diabetes (T2D) is common among patients with chronic hepatitis B infection (CHB) and has been associated with increased risk of carcinogenesis, including HCC. We investigated factors associated with HCC and fibrosis progression among patients with CHB with T2D (CHB+T2D).

APPROACH AND RESULTS

Chinese patients with CHB were prospectively recruited for the incidence of HCC and fibrosis progression defined by transient elastography. Among patients with CHB+T2D, glycemic control was assessed by mean glycated hemoglobin (HbA1c) and HbA1c variability determined using HbA1c measurements in the 5 years preceding recruitment. A total of 2330 patients with CHB were recruited (mean age 54.6 ±11.8 years old, 55.5% male, 57.9% antiviral-treated), with 671 (28.8%) having CHB+T2D (mean T2D duration 7.2 ± 4.6 years, mean HbA1c 7.2 ± 0.9%). T2D was independently associated with HCC (HR 2.080, 95% CI 1.343-3.222) and fibrosis progression (OR 4.305, 95% CI 3.416-5.424) in the overall cohort. In patients with CHB+T2D, factors reflecting glycemic burden (T2D duration [HR 1.107, 95% CI 1.023-1.198]), mean HbA1c (HR 1.851, 95% CI 1.026-3.339), time reaching target HbA1c (HbA1c-TRT; HR 0.978, 95% CI 0.957-0.999), liver stiffness (HR 1.041-1.043), and smoking (HR 2.726-3.344) were independently associated with HCC (all p < 0.05), but not HbA1c variability or controlled attenuation parameter. The same glycemic burden-related factors (T2D duration, mean HbA1c, and HbA1c-TRT), in addition to baseline fasting glucose, baseline HbA1c, AST and antiviral therapy, were independently associated with fibrosis progression at 3 years.

CONCLUSIONS

High glycemic burden was associated with HCC development and fibrosis progression among patients with CHB+T2D, highlighting the importance of glycemic control in reducing liver-related complications.

Diabetes Mellitus Management in the Context of Cranial Tumors

The study of the relationship between cancer and diabetes mellitus (DM) has been under investigation for many decades. Particularly in the field of neurology and neurosurgery, increasing emphasis has been put on the examination of comorbid DM in patients with cranial tumors. Namely, as the most common and invasive type of malignant adult brain tumor, glioblastoma (GBS) has been the focus of said research. Several mechanisms have been described in the attempt to elucidate the underlying association between DM and GBS, with the metabolic phenomenon known as the Warburg effect and its consequential downstream effects serving as the resounding culprits in recent literature. Since the effect seen in cancers like GBS exploits an upregulated form of aerobic glycolysis, the role of a sequela of DM, known as hyperglycemia, will be investigated. In particular, in the treatment of GBS, surgical resection and subsequent chemotherapy and/or radiotherapy are used in conjunction with corticosteroid therapy, the latter of which has been linked to hyperglycemia. Unsurprisingly, comorbid DM patients are significantly susceptible to this disposition. Further, this fact is reflected in recent literature that demonstrates the impact of hyperglycemia on cancer advancement and patient outcomes in several preclinical and clinical studies. Thus, this review will aim to underline the significance of diabetes and glycemic control via standard-of-care treatments such as metformin administration, as well as to describe emerging treatments such as the signaling modulation of insulin-like growth factor and the employment of the ketogenic diet.

Sex-specific effect of body mass index and fasting glucose on gastric cancer risk and all causes mortality; a cohort study of 5.17 million

BACKGROUND

Simultaneous evaluation of sex-specific effect of body mass index (BMI) and hyperglycemia on the risk of gastric cancer has been rarely reported. Here, we investigated the sex-specific effect of BMI and hyperglycemia on gastric cancer.

METHODS

Persons who underwent National gastric cancer screening from 2006 to 2007 and had no gastric cancer at baseline, were enrolled and followed up to 2015. The risk of gastric cancer by BMI and glucose was measured using risk ratios (RRs) and 95% confidence intervals (CI). Adjusted Cox analysis was performed to evaluate the risk of death.

RESULTS

Gastric cancers developed in 29,775 of 5.17 million. In the adjusted analysis, low BMI (<18.5 kg/m²; RR, 1.44; 95% CI, 1.36-1.53) and high fasting glucose (≥126 mg/dL; RR, 1.09; 95% CI, 1.05-1.13) increased the risk of gastric cancer. In sex-specific analysis, its risk by BMI was modified L-shape with cut-off value of 23 kg/m² in men and 18.5 kg/m² in women. Low BMI increased gastric cancer risk in men (RR, 1.39; 95% CI, 1.30-1.50) and women (RR, 1.48; 95% CI, 1.33-1.64). High fasting glucose increased the risk of gastric cancer in women (RR, 1.19; 95% CI, 1.11-1.28), but not in men. Low BMI increased all-cause mortality with cut-off value of 23 kg/m² in men and 18.5 kg/m² in women.

CONCLUSIONS

Gastric cancer risk and all-cause mortality by BMI was L-shape with sex-specific cut-off value. The effect of fasting glucose on gastric cancer risk was different by sex.

The prognostic role of diabetes mellitus type 2 in the setting of hepatocellular carcinoma: a systematic review and meta-analysis

AIM

To evaluate the effect of diabetes mellitus type 2 (T2DM) on the outcomes after treatment of hepatocellular carcinoma (HCC).

METHODS

PubMed and Cochrane Central Register of Controlled Trials Databases were systematically searched. Three HCC clinical outcomes were explored: death, progressive disease after locoregional therapies, and recurrence. Sub-analysis was performed according to the use of potentially curative (resection, transplantation, termo-ablation) or non-curative therapies. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare the pooled data between T2DM and non-T2DM groups.

RESULTS

A total of 27 studies were analyzed. Overall, 85.2% of articles were from Asia. T2MD was associated with an increased risk of death (OR 3.60; 95%CI 2.18-5.95; P<0.001), irrespective of the treatment approach: curative (OR 1.30 95%CI 1.09-1.54; P=0.003) or non-curative (OR 1.05; 95%CI 1.00-1.10; P=0.045), increased HCC recurrence (OR 1.30; 95%CI 1.03-1.63; P=0.03), and increased disease progressiveness (OR 1.24; 95%CI 1.09-1.41; P=0.001).

CONCLUSIONS

Current data provide strong evidence that T2DM unfavorably affects HCC progression and recurrence, and patients' survival after treatment, irrespective of the approach used.

Long-Term Survival Impact of High-Grade Complications after Liver Resection for Hepatocellular Carcinoma: A Retrospective Single-Centre Cohort Study

Background and Objectives: Although complications after liver resection for hepatic cancer are common, the long-term impact of these complications on oncological outcomes remains unclear. This study aimed to investigate the potential effect of high-grade postoperative complications on long-term mortality and cancer recurrence after surgical resection of hepatocellular carcinoma. Materials and Methods: In a retrospective cohort study, patients undergoing curative liver resection for primary hepatocellular carcinoma between 2005 and 2016 were evaluated. The Clavien–Dindo (CD) grading system was used to classify patients into two groups of either high-grade complications (grade III or IV) or none or low-grade complications (grade 0 to II) within 30 days after surgery. The primary endpoint was all-cause mortality. Secondary endpoints were cancer-specific mortality and cancer recurrence. Weighted Cox proportional hazards regression models were used to calculate the adjusted hazard ratio (aHR) with a 95% confidence interval (CI) for the outcomes of interest. Results: A total of 1419 patients with a median follow-up time of 46.6 months were analysed. Among them, 93 (6.6%) developed high-grade complications after surgery. The most common complications were bile leakage (n = 30) in CD grade III and respiratory failure (n = 13) in CD grade IV. High-grade complications were significantly associated with all-cause mortality (aHR: 1.78, 95% CI: 1.55–2.06) and cancer-specific mortality (aHR: 1.34, 95% CI: 1.13–1.60), but not cancer recurrence (aHR: 0.92, 95% CI: 0.84–1.02). Independent influential factors for complications were sex, diabetes mellitus, clinically significant portal hypertension, oesophageal varices, multifocal cancer, intraoperative blood loss, and anaesthesia duration. Conclusions: Patients who had high-grade postoperative complications had a greater risk of long-term mortality after liver resection for hepatocellular carcinoma. Prevention of postoperative complications may serve as an effective strategy for improving long-term survival.

A guideline for the outpatient management of glycaemic control in people with cancer

Individuals with cancer are at increased risk of developing new-onset diabetes mellitus and hyperglycaemia, and an estimated 20% of people with cancer already have an underlying diagnosis of diabetes mellitus. People with both cancer and diabetes may have an increased risk of toxicities, hospital admissions and morbidity, with hyperglycaemia potentially attenuating the efficacy of chemotherapy often secondary to dose reductions and early cessation. Numerous studies have demonstrated that hyperglycaemia is prognostic of worse overall survival and risk of cancer recurrence. These guidelines aim to provide the oncology/haemato-oncology and diabetes multidisciplinary teams with the tools to manage people with diabetes commencing anti-cancer/glucocorticoid therapy, as well as identifying individuals without a known diagnosis of diabetes who are at risk of developing hyperglycaemia and new-onset diabetes.

High glucose induced c-Met activation promotes aggressive phenotype and regulates expression of glucose metabolism genes in HCC cells

Hepatocellular carcinoma (HCC) is strongly associated with metabolic dysregulations/deregulations and hyperglycemia is a common metabolic disturbance in metabolic diseases. Hyperglycemia is defined to promote epithelial to mesenchymal transition (EMT) of cancer cells in various cancers but its molecular contribution to HCC progression and aggressiveness is relatively unclear. In this study, we analyzed the molecular mechanisms behind the hyperglycemia-induced EMT in HCC cell lines. Here, we report that high glucose promotes EMT through activating c-Met receptor tyrosine kinase via promoting its ligand-independent homodimerization. c-Met activation is critical for high glucose induced acquisition of mesenchymal phenotype, survival under high glucose stress and reprogramming of cellular metabolism by modulating glucose metabolism gene expression to promote aggressiveness in HCC cells. The crucial role of c-Met in high glucose induced EMT and aggressiveness may be the potential link between metabolic syndrome-related hepatocarcinogenesis and/or HCC progression. Considering c-Met inhibition in hyperglycemic patients would be an important complementary strategy for therapy that favors sensitization of HCC cells to therapeutics.

High glucose: an emerging association between diabetes mellitus and cancer progression

The association of cancer and diabetes mellitus (DM) has been studied for decades. Hyperglycemia and the imbalance of hormones are factors that contribute to the molecular link between DM and carcinogenesis and cancer progression. Hyperglycemia alone or in combination with hyperinsulinemia are key factors that promote cancer aggressiveness. Many preclinical studies suggest that high glucose induces abnormal energy metabolism and aggressive cancer via several mechanisms. As evidenced by clinical studies, hyperglycemia is associated with poor clinical outcomes in patients who have comorbid DM. The prognoses of cancer patients with DM are improved when their plasma glucose levels are controlled. This suggests that high glucose level maybe be involved in the molecular mechanism that causes the link between DM and cancer and may also be useful for prognosis of cancer progression. This review comprehensively summarizes the evidence from recent pre-clinical and clinical studies of the impact of hyperglycemia on cancer advancement as well as the underlying molecular mechanism for this impact. Awareness among clinicians of the association between hyperglycemia or DM and cancer progression may improve cancer treatment outcome in patients who have DM.

Impact of metformin use on the recurrence of hepatocellular carcinoma after initial liver resection in diabetic patients

Background

Metformin is proposed to have chemopreventive effect of various cancer currently. However, the anti-cancer effect of metformin for diabetic patients with hepatocellular carcinoma (HCC) undergoing liver resection remains unclear. The aim of our cohort study was to assess whether metformin influence the recurrence of HCC.

Methods

We retrospectively enrolled 857 HCC patients who received primary resection from April 2001 to June 2016. 222 patients were diagnosed with diabetes mellitus (DM) from medical record. Factors influence the overall survival (OS) and recurrence-free survival (RFS) were analyzed by multivariate analysis.

Results

During the follow-up period (mean, 75 months), 471 (54.9%) patients experienced recurrence, and 158 (18.4%) patients died. Multivariate analysis revealed that DM (p = 0.015), elevated AST (p = 0.006), hypoalbuminemia (p = 0.003), tumor number (p = 0.001), tumor size (p < 0.001), vascular invasion (p <0.001), high Ishak fibrosis score (p <0.001), hepatitis B (p = 0.014), hepatitis C (p = 0.001) were independent predictors for RFS. In diabetic patients, only HbA1c>9% (p = 0.033), hypoalbuminemia (p = 0.030) and vascular invasion (p = 0.001) were independent risk factors for HCC recurrence; but the metformin use revealed no significance on recurrence. DM is a risk factor of HCC recurrence after resection. Adequate DM control can reduce the recurrence of HCC. However, the use of metformin does not reduce the risk of HCC recurrence in diabetic patient after initial resection. Hence, metformin may not have protective influences on HCC recurrence in diabetic patients who undergo initial liver resection.

Glucose Variability and Risk of Hepatocellular Carcinoma in Patients with Diabetes: A Nationwide Population-Based Study

BACKGROUND

Although diabetes is a well-known risk factor for hepatocellular carcinoma, exactly which metabolic parameters of diabetes are associated with hepatocellular carcinoma remain unexplored. In this study, we investigated the relationship between glucose variability (GV) and hepatocellular carcinoma in patients with diabetes through a nationwide population-based study.

METHODS

A population-based cohort study including 674,178 diabetic subjects participating in more than three health examinations within 5 years from the index year (2009 and 2010) were followed until the end of 2017. The coefficient of variation, SD, variability independent of the mean, and average real variability were calculated as GV indices.

RESULTS

During a median follow-up of 6.7 years, there were 5,494 cases of hepatocellular carcinoma. When groups were classified according to glucose level, the highest risk for hepatocellular carcinoma was observed when the basal blood glucose level was 180 mg/dL or greater [adjusted HR (aHR), 1.19; 95% confidence interval (CI), 1.08-1.31]. We observed increasing trends for the relationship between GV and hepatocellular carcinoma in multivariable Cox proportional analyses. The risk of hepatocellular carcinoma increased by 27% (aHR, 1.27; 95% CI, 1.17-1.38) for the highest quartile of GV relative to the lowest quartile. These findings were consistent regardless of the presence of chronic viral hepatitis or cirrhosis, alcohol consumption, or body mass index.

CONCLUSIONS

GV was an independent predictor of hepatocellular carcinoma, even after adjusting for confounding factors. There was a linear relationship between increase in GV and prevalence of hepatocellular carcinoma.

IMPACT

Visit-to-visit GV might be helpful for identifying patients with diabetes at high risk of hepatocellular carcinoma.

Natural Progression of Non-Alcoholic Steatohepatitis to Hepatocellular Carcinoma

Non-alcoholic steatohepatitis (NASH) is a chronic and progressive form of non-alcoholic fatty liver disease (NAFLD). Its global incidence is increasing which makes NASH an epidemic and a public health threat. Due to repeated insults to the liver, patients are at risk for developing hepatocellular carcinoma (HCC). The progression of NASH to HCC was initially defined according to a two-hit model which involved the development of steatosis, followed by lipid peroxidation and inflammation. However, current research defines a “multi-hit” or “multi-parallel hit” model which synthesizes several contributing pathways involved in progressive fibrosis and oncogenesis. This perspective considers the effects of cellular, genetic, immunologic, metabolic, and endocrine pathways leading up to HCC which underscores the complexity of this condition. This article will provide an updated review of the pathogenic mechanisms leading from NASH to HCC as well as an exploration of the role of biomarkers and screening.

High glucose upregulates FOXM1 expression via EGFR/STAT3 dependent activation to promote progression of cholangiocarcinoma

AIMS

Epidemiological studies indicate diabetes mellitus and hyperglycemia as risk factors of cancers including cholangiocarcinoma (CCA). How high glucose promotes cancer development and progression, however, is still unrevealed. In this study, insight into the molecular pathway of high glucose promoting progression of CCA cells was investigated.

MAIN METHODS

Human CCA cell lines, KKU-213A and KKU-213B were cultured in normal glucose (NG; 5.56 mM) or high glucose (HG; 25 mM) and used as NG and HG cells. Forkhead box M1 (FOXM1) expression was transiently suppressed using siFOXM1. Western blotting and image analysis were employed to semi-quantitatively determine the expression levels of the specified proteins. The migration and invasion of CCA cells were revealed using Boyden chamber assays.

KEY FINDINGS

All HG cells exhibited higher expression of FOXM1 than the corresponding NG cells in a dose dependent manner. Suppression of FOXM1 expression by siFOXM1 significantly reduced migration and invasion abilities of CCA cells by suppression of Slug and MMP2 expression. Inhibition of STAT3 activation using Stattic, significantly suppressed expression of FOXM1 and Slug and decreased migration and invasion abilities of HG cells. In addition, EGFR expression was significantly higher in HG cells than NG cells and increased dependently with glucose concentration. Inhibition of EGFR activation by cetuximab significantly suppressed STAT3 activation and FOXM1 expression.

SIGNIFICANCE

The mechanism of high glucose promoting progression of CCA cells was revealed to be via in part by upregulation of FOXM1 expression under EGF/EGFR and STAT3 dependent activation.

Incidence and Survival of Hepatocellular Carcinoma in Type 2 Diabetes Patients with Cirrhosis Who Were Treated with and without Metformin

PURPOSE

To evaluate metformin's benefit on the incidence and survival of hepatocellular carcinoma (HCC) in cirrhosis with type 2 diabetes mellitus (T2DM) patients.

PATIENTS AND METHODS

We conducted a retrospective study from 2006 to 2019. The patients were assigned to metformin exposure if they administered metformin at least 3 months after diagnosis of cirrhosis. The outcomes were incidence and survival of HCC in T2DM with cirrhosis treated with metformin compared with those who were not treated with metformin. For the incidence of HCC, the follow-up time was 5 years after cirrhosis was diagnosed. For the survival of HCC, we censored for vital status in June 2019.

RESULTS

Of 1061 patients, the patients were divided into 719 patients with metformin exposure and 342 in metformin non-exposure. In metformin exposure, 125 patients (17.4%) developed HCC. In metformin non-exposure, 128 patients (37.4%) developed HCC. Metformin exposure had a significantly lower risk of developing HCC in multivariate analysis HR 0.48 (0.36-0.61); P<0.001. For the survival of HCC, 327 patients were recruited. One-hundred and sixty-two patients were in metformin exposure and 165 patients were in metformin non-exposure. Sixty patients (37%) in metformin exposure died, while 84 patients (50.9%) in metformin non-exposure died. The median survival of metformin exposure and metformin non-exposure were 6.9 years and 3.88 years, respectively; P=0.003. In univariate analysis, the metformin exposure was significantly associated with better survival than in the non-exposure group, HR 0.63 (0.45-0.88); P=0.006. No significant difference was observed in multivariate analysis between two groups, HR 1.07 (0.74-1.54); P=0.72.

CONCLUSION

Metformin exposure was associated with a lower incidence of HCC in cirrhosis with T2DM patients and seemed to extend survival. Continuing metformin in patients with cirrhosis with T2DM should be considered if there was no contraindication.

Related Factors of Hepatocellular Carcinoma Recurrence Associated With Hyperglycemia After Liver Transplantation

BACKGROUND

Recurrence of hepatocellular carcinoma (HCC) is the main factor affecting the prognosis of patients with HCC undergoing liver transplantation (LT). In this study, we investigated the influencing factors of tumor recurrence and survival after LT for HCC, especially the long-term correlation with elevated fasting blood glucose (FBG).

METHODS

Clinical data from 165 patients with HCC after LT in the General Hospital of Southern Theater Command of PLA between January 2013 and December 2016 were retrospectively analyzed. Disease-free survival (DFS) and overall survival (OS) rates, demographic characteristics, tumor characteristics, and surgical and postoperative data were evaluated.

RESULTS

Among 165 patients, 144 completed over 60 months of follow-up; the median follow-up period was more than 36 months. DFS rates were 76.97%, 51.52%, and 34.73% for 1, 3, and 5 years, respectively. The OS rate for 5 years was 40.28%. Independent risk factors for 1-year DFS were maximum tumor diameter >5 cm, age <49 years, and platelet transfusion. Independent risk factors for 3- and 5-year DFS were maximum tumor diameter >5 cm, capsular invasion, and FBG ≥6.1 mmol/L. Independent risk factors for OS were maximum tumor diameter >5 cm, capsular invasion, and FBG ≥6.1 mmol/L.

CONCLUSION

Elevated FBG after LT for HCC may promote medium- to long-term tumor recurrence and affect OS. Age <49 years, platelet transfusion, maximum tumor diameter, capsular invasion, and microvascular invasion in patients with HCC also impact survival and tumor recurrence after LT.

Type 2 diabetes mellitus worsens the prognosis of intermediate-stage hepatocellular carcinoma after transarterial chemoembolization

AIMS

The aim of this study was to investigate the impact of type 2 diabetes mellitus (T2DM) on the prognosis of hepatocellular carcinoma (HCC) patients following transarterial chemoembolization (TACE).

METHODS

Time to progression (TTP) and cancer-specific mortality (CSM) in competing risk model were compared in patients with (n = 289) or without (n = 763) T2DM. Propensity score matching (PSM) was used to reduce bias between the two groups. Multivariate competing risk regression was used to evaluate independent risk factors for TTP and CSM.

RESULTS

The T2DM group showed significantly worse 5-year TTP and CSM rates than the non-T2DM group both in the whole cohort (n = 1052) and the PSM cohort (n = 514) (81.3% vs. 70.9%, P < 0.001, and 61.5% vs. 49.3%, P = 0.006; 81.4% vs. 68.6%, P = 0.003, and 61.7% vs. 43.2%, P = 0.014, respectively). Multivariate competing risk regression identified T2DM as an independent risk factor for TTP and CSM before and after PSM (hazard ratio: 1.37 [95% confidence interval: 1.07-1.77] and 1.36 [1.05-1.75]; 1.29 [1.04-1.60] and 1.24 [1.02-1.52], respectively). T2DM worsened the long-term outcomes of patients in the cirrhosis subgroup but not those in the noncirrhosis subgroup.

CONCLUSIONS

T2DM worsened the long-term survival of intermediate-stage HCC patients who underwent TACE, especially in patients with cirrhosis.

NF-κB and STAT3 co-operation enhances high glucose induced aggressiveness of cholangiocarcinoma cells

AIMS

The present report aimed to investigate the underlying genes and pathways of high glucose driving cholangiocarcinoma (CCA) aggressiveness.

MAIN METHODS

We screened and compared the gene expression profiles obtained by RNA sequencing, of CCA cells cultured in high and normal glucose. Results from the transcriptomic analysis were confirmed in additional cell lines using in vitro migration-invasion assay, Western blotting and immunocytofluorescence.

KEY FINDINGS

Data indicated that high glucose increased the expression of interleukin-1β (IL-1β), an upstream regulator of nuclear factor-κB (NF-κB) pathway, through the nuclear localization of NF-κB. High glucose-induced NF-κB increased the migration and invasion of CCA cells and the expression of downstream NF-κB targeted genes associated with aggressiveness, including interleukin-6, a potent triggering signal of the signal transducer and activator of transcription 3 (STAT3) pathway. Such effects were reversed by inhibiting NF-κB nuclear translocation which additionally reduced the phosphorylation of STAT3 at Y705.

SIGNIFICANCE

These results indicate that NF-κB is activated by high glucose and they suggest that NF-κB interaction with STAT3 enhances CCA aggressiveness. Therefore, targeting multiple pathways such as STAT3 and NF-κB might improve CCA treatment outcome especially in condition such as hyperglycemia.

Postoperative hyperglycemia affects survival after gastrectomy for cancer: A single-center analysis using propensity score matching

BACKGROUND

No data are present currently on the potential correlation between postoperative hyperglycemia and long-term outcomes after gastric surgery for cancer. The aim of this study was to investigate the effects of postoperative hyperglycemia on survival after curative gastrectomy for cancer.

METHODS

All patients who underwent gastric surgery for cancer with curative intent were reviewed retrospectively. Diabetic patients and patients who needed pancreatic resection were excluded. In all patients, a prepared intravenous infusion of NaCl and carbohydrates (Isolyte Baxter 2,000 mL/day; glucose 50.0 g/L;Ringers lactate 1,000 mL/day) was used, and the patients were kept nil by mouth until the fourth postoperative day. The glucose levels were monitored during the first 72 hours. The study population was divided into normoglycemic and hyperglycemic patients according to the blood glucose level (<140 mg/dL and ≥140 mg/dL, respectively). The 2 groups were matched for age, sex, type of operative procedure, TNM status, and lymph node status.

RESULTS

After matching, 104 patients were included for the analysis. Perioperative morbidity accounted for 18.3% with a greater rate for hyperglycemic patients (12% vs 31%; P = .018). When compared with normoglycemic patients, hyperglycemic patients had worse overall survival (45% vs 57%; P = .05) and worse disease-free survival (46% vs 68%; P = .02). On the multivariate analysis, hyperglycemia was an independent risk factor for a worse overall and disease-free survival.

CONCLUSION

Postoperative hyperglycemia owing to surgical stress conditions can affect postoperative outcomes. Additionally, hyperglycemia may be a factor that promotes gastric cancer progression.

Asarone and metformin delays experimentally induced hepatocellular carcinoma in diabetic milieu

AIMS

The evidence suggests that the hyperglycemia and hyperinsulinemia of diabetes mellitus (DM) are risk factors for the development of hepatocellular carcinoma (HCC). The aim of the present study was to examine the effect of streptozotocin (STZ)-induced DM on promoting diethylnitrosamine (DEN) induced HCC in male wistar rats. Further, we investigated the administration of (α)-and (β)-asarone and metformin HCl on experimentally induced diabetic-hepatocellular carcinoma.

MATERIALS AND METHODS

Diabetes was induced by single dose of STZ (55 mg/2 ml/kg b.w. i.p.) and HCC by single dose of DEN (200 mg/ml/kg b.w. i.p.). Another group received the STZ followed by DEN two weeks later to mimic diabetic-HCC. The combined dose of (α)-and (β)-asarone (50 μg/1.5 ml/kg b.w. p.o. in the ratio of 1:1) and metformin HCl (250 mg/1.5 ml/kg b.w. p.o.) treatment was compared with the STZ + DEN group. The blood and liver samples were collected at the end of 12 and 18-weeks to study biochemical and histopathological changes in liver.

KEY FINDINGS

The STZ induced diabetes promoted the tumor progression due to administration of DEN. The treatment of asarones and metformin significantly reduced the levels of glucose, glycosylated hemoglobin, liver dysfunction markers and tumor biomarkers along with an increase in level of insulin when compared to diabetic-HCC group. Histopathological examination indicated that asarones and metformin attenuate the inflammation, fibrosis, cirrhosis and development of spontaneous HCC.

SIGNIFICANCE

The STZ can be used to promote the DEN induced HCC. Treatment with (α)-and (β)-asarone attenuates the effect of STZ + DEN induced HCC akin to metformin.

Do smoking and alcohol behaviours influence GI cancer survival?

Little is known about the role of alcohol and smoking in GI cancer survival compared to GI cancer development. We systematically reviewed the evidence for a role of smoking and alcohol in prognosis among GI cancer patients and inform whether smoking or alcohol cessation interventions or guidelines for GI cancer patients are likely to improve prognosis. A total of 84 relevant studies were identified. Continued smokers, particularly heavy smokers, had worse prognosis than never smokers in most GI cancers. However, more evidence is needed to establish the likely impact of smoking cessation interventions amongst GI cancer patients. Heavy alcohol drinkers had worse prognosis in oesophageal squamous cell carcinoma and hepatocellular carcinoma patients. Light alcohol consumption was not associated with worse prognosis from any GI cancer, though further studies are needed. UK guidelines for the general population recommending under 14 units (∼7 drinks) per week may be sufficient for GI cancer patients, until further evidence is available.

Facilitatory effect of insulin treatment on hepatocellular carcinoma development in diabetes

BACKGROUND

To evaluate the effect of insulin treatment on the incidence and/or severity of hepatocellular carcinoma (HCC) in a mouse model of HCC based on diabetes.

METHODS

We recently reported that neonatal streptozotocin (STZ) treatment causes type 1 diabetes and subsequent HCC in ddY, Institute for Animal Reproduction (DIAR) mice. Newborn male DIAR mice were divided into three groups based on STZ and insulin (INS) treatment. STZ was subcutaneously injected (60 mg/g) into the STZ-treated group (DIAR-nSTZ mice, N = 13) and the STZ/insulin-treated group (DIAR-nSTZ/INS mice, N = 20). A physiologic solution was injected into the control group (DIAR-control mice, N = 8) 1.5 days after birth. Insulin was subcutaneously injected into the DIAR-nSTZ/INS mice according to the following protocol: 2 IU/day at 4-5 weeks of age, 3 IU/day at 5-7 weeks of age, and 4 IU/day at 7-12 weeks of age. All mice were fed a normal diet and were subjected to physiological and histopathological assessments at 12 weeks of age.

RESULTS

DIAR-nSTZ mice had significantly lower body weight and higher blood glucose levels than DIAR-control mice, whereas no significant differences were observed between DIAR-nSTZ/INS mice and control mice. At 12 weeks of age, lower weight of paratesticular fat and higher levels of total cholesterol, triglyceride, and free fatty acids were observed in DIAR-nSTZ mice compared to DIAR-control mice, whereas there were no significant differences between DIAR-nSTZ/INS mice and DIAR-control mice. In the livers of DIAR-nSTZ mice, HCC was observed in 15% of cases, and dysplastic nodules were observed in 77% of cases. In the livers of DIAR-nSTZ/INS mice, HCC was observed in 39% of cases and dysplastic nodules were observed in 61% of cases (p = 0.011). Moreover, the average tumor size was significantly larger in STZ/INS-treated mice than in STZ-treated mice. Immunohistochemical analysis demonstrated that the expression of ERK1/2, downstream substrates of insulin signaling that activate cell proliferation, was significantly higher in STZ/INS-treated mice compared to STZ-treated mice.

CONCLUSIONS

Insulin treatment promoted, rather than inhibited, the progression of liver carcinogenesis in DIAR-nSTZ mice. Hyperinsulinemia rather than hyperglycemia can accelerate the progression of HCC via insulin signaling.

The anti-diabetic drug exenatide, a glucagon-like peptide-1 receptor agonist, counteracts hepatocarcinogenesis through cAMP-PKA-EGFR-STAT3 axis

Epidemiological studies have demonstrated a close association of type 2 diabetes and hepatocellular carcinoma (HCC). Exenatide (Ex-4), a potent diabetes drug targeting glucagon-like peptide-1 receptor (GLP-1R), is protective against non-alcoholic fatty liver disease (NAFLD). However, the Ex-4 function and GLP-1R status have yet been explored in HCC. Herein we investigated the effect of Ex-4 in diethylnitrosamine (DEN)-treated mice consuming control or high-fat high-carbohydrate diet. Administration of Ex-4 significantly improved obesity-induced hyperglycemia and hyperlipidemia and reduced HCC multiplicity in obese DEN-treated mice, in which suppressed proliferation and induced apoptosis were confined to tumor cells. The tumor suppression effects of Ex-4 were associated with high expression of GLP-1R and activation of cyclic AMP (cAMP) and protein kinase A (PKA). Importantly, Ex-4 also downregulated epidermal growth factor receptor (EGFR) and signal transducer and activator of transcription 3 (STAT3), which lie downstream of cAMP-PKA signaling, resulting in suppression of multiple STAT3-targeted genes including c-Myc, cyclin D1, survivin, Bcl-2 and Bcl-xl. The growth inhibitory effects of Ex-4 were consistent in GLP-1R-abundant hepatoma cell lines and xenograft mouse model, wherein both PKA and EGFR had obligatory roles in mediating Ex-4 functions. In addition, Ex-4 also effectively suppressed inflammatory and fibrotic phenotypes in mice fed with methionine-choline-deficient (MCD) diet and choline-deficient ethionine-supplemented (CDE) diet, respectively. In summary, Ex-4 elicits protective functions against NAFLD and obesity-associated HCC through cAMP-PKA-EGFR-STAT3 signaling, suggesting its administration as a novel approach to reduce HCC risk in diabetic patients.

High-concentration glucose enhances invasion in invasive ductal breast carcinoma by promoting Glut1/MMP2/MMP9 axis expression

Type 2 diabetes mellitus (T2DM) has been considered to be a risk factor for numerous human cancers. Hyperglycemia is one of the most direct internal environmental changes for patients with T2DM. Increasing evidence reveals that a high concentration of glucose can promote tumor progression, while its role for migration and invasion of invasive ductal breast carcinoma (IDBC) cells remains unclear. In the present study, it was demonstrated that IDBC patients with T2DM suffered an increased tumor size and more frequent lymphatic and distant metastasis compared with those without T2DM (P<0.05). MCF-7 breast carcinoma cells, which were cultured in a high glucose concentration medium (25.00 mM), exhibited increased invasion (P<0.05). In addition, the expression of glucose transporters (Gluts), matrix metalloproteinase 2 (MMP2) and matrix metalloproteinase 9 (MMP9) in IDBC tissues with T2DM was significantly higher compared to those without T2DM. Downregulation of glucose transporter 1 (Glut1) by small interfering RNA may markedly suppress MCF-7 cell invasion as well as the expression of MMP2 and MMP9. These results suggest that T2DM can affect the malignant features of tumors in IDBC. The high glucose concentration in the tumor microenvironment may enhance IDBC invasion via upregulating Glut1/MMP2/MMP9 axis expression.

Potential of alpha-fetoprotein as a prognostic marker after curative radiofrequency ablation of hepatocellular carcinoma

AIM

Recurrence of hepatocellular carcinoma (HCC) is observed frequently, even after curative treatments. The aim of this study is to elucidate the risk factors for recurrence of HCC after radiofrequency ablation (RFA), focusing on the carcinogenic potential of the liver assessed by α-fetoprotein (AFP).

METHODS

We enrolled 357 consecutive patients who underwent complete ablation by RFA for primary HCC (≤3 cm, ≤3 tumors) and analyzed the correlation between 17 critical parameters, including AFP and HCC recurrence.

RESULTS

Recurrence was observed in 236 patients during a mean observation period of 54.3 months. Multivariate analysis revealed that multiple tumors (risk ratio [RR] = 1.70, 95% confidence interval [CI] = 1.27-2.26, P < 0.001), high AFP (>10 ng/mL, RR = 1.45, 95% CI = 1.09-1.94, P < 0.001) and high des-γ-carboxyprothrombin (>40 mAU/mL, RR = 1.52, 95% CI = 1.13-2.02, P < 0.005) were significantly correlated with recurrence. AFP was selected as a significant factor even when the cut-off level was set lower (≤5 ng/mL). The risk of recurrence increased linearly according to the increase of the lowest AFP level after RFA and the adjusted ratios relative to AFP less than 5 ng/mL were 1.56, 2.14, 2.57 and 3.13 in AFP 5-10 ng/mL, 10-20 ng/mL, 20-50 ng/mL and over 50 ng/mL, respectively. In addition, the recurrence rate was predicted by the AFP level after RFA, regardless of the level before the treatment.

CONCLUSION

AFP less than 5 ng/mL after curative RFA was an important predictor of a better prognosis and was considered to indicate the low carcinogenic potential of the non-cancerous liver.

Neutrophil-to-lymphocyte ratio predicts recurrence after radiofrequency ablation in hepatitis B virus infection

BACKGROUND AND AIM

Radiofrequency ablation (RFA) is an established treatment for small hepatocellular carcinoma (HCC) wherein non-recurrence is essential for long-term survival. Recently, neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation that is associated with tumor-associated macrophages (TAMs), was suggested to be a prognostic marker of HCC treated with RFA. Therefore, we evaluated predictive factors, including NLR, associated with recurrence after curative RFA.

METHODS

A total of 163 patients initially diagnosed with HCC and treated with RFA were enrolled. We retrospectively analyzed factors associated with recurrence and survival after RFA. Furthermore, TAMs were evaluated using surgically resected specimens.

RESULTS

Hepatitis C virus (HCV) infection was the most frequent cause of HCC in this population (111 cases, 68.1%), whereas hepatitis B virus (HBV) infection accounted for 26 cases (16.0%). Recurrence, mostly intrahepatic distant recurrence, was found in 101 cases (61.9%). Recurrence and posttreatment NLR were independent prognostic factors related to survival, and male sex, HCV infection, serum des-γ-carboxy prothrombin >  40 AU/L, and posttreatment NLR were associated with recurrence. Pretreatment NLR showed no association with recurrence, whereas posttreatment NLR showed prognostic value. Interestingly, pretreatment NLR >  2.5 was significantly associated with recurrence in HBV-HCC patients (odds ratio 3.439, P = 0.037) not but HCV-HCC (odds ratio 1.430, P = 0.17). Furthermore, TAMs were increased in the peripheral area of HCCs with HBV infection compared with those with HCV.

CONCLUSIONS

Recurrence of HCC after RFA was strongly associated with survival. NLR is useful as a predictive marker of recurrence, especially in HBV-HCC patients.

Glucose induced activation of canonical Wnt signaling pathway in hepatocellular carcinoma is regulated by DKK4

Elevated glycemic index, an important feature of diabetes is implicated in an increased risk of hepatocellular carcinoma (HCC). However, the underlying molecular mechanisms of this association are relatively less explored. Present study investigates the effect of hyperglycemia over HCC proliferation. We observed that high glucose culture condition (HG) specifically activates canonical Wnt signaling in HCC cells, which is mediated by suppression of DKK4 (a Wnt antagonist) expression and enhanced β-catenin level. Functional assays demonstrated that a normoglycemic culture condition (NG) maintains constitutive expression of DKK4, which controls HCC proliferation rate by suppressing canonical Wnt signaling pathway. HG diminishes DKK4 expression leading to loss of check at G0/G1/S phases of the cell cycle thereby enhancing HCC proliferation, in a β-catenin dependent manner. Interestingly, in NOD/SCID mice supplemented with high glucose, HepG2 xenografted tumors grew rapidly in which elevated levels of β-catenin, c-Myc and decreased levels of DKK4 were detected. Knockdown of DKK4 by shRNA promotes proliferation of HCC cells in NG, which is suppressed by treating cells exogenously with recombinant DKK4 protein. Our in vitro and in vivo results indicate an important functional role of DKK4 in glucose facilitated HCC proliferation.

High Glucose Stimulates Tumorigenesis in Hepatocellular Carcinoma Cells Through AGER-Dependent O-GlcNAcylation of c-Jun

Epidemiologic studies suggest that hepatocellular carcinoma (HCC) has a strong relationship with diabetes. However, the underlying molecular mechanisms still remain unclear. Here, we demonstrated that high glucose (HG), one of the main characteristics of diabetes, was capable of accelerating tumorigenesis in HCC cells. Advanced glycosylation end product-specific receptor (AGER) was identified as a stimulator during this process. Mechanistically, AGER activated a hexosamine biosynthetic pathway, leading to enhanced O-GlcNAcylation of target proteins. Notably, AGER was capable of increasing activity and stability of proto-oncoprotein c-Jun via O-GlcNAcylation of this protein at Ser73. Interestingly, c-Jun can conversely enhance AGER transcription. Thereby, a positive autoregulatory feedback loop that stimulates diabetic HCC was established. Finally, we found that AG490, an inhibitor of Janus kinase, has the ability to impair AGER expression and its functions in HCC cells. In conclusion, AGER and its functions to stimulate O-GlcNAcylation are important during liver tumorigenesis, when high blood glucose levels are inadequately controlled.

Dietary sugar intake increases liver tumor incidence in female mice

Overnutrition can promote liver cancer in mice and humans that have liver damage caused by alcohol, viruses, or carcinogens. However, the mechanism linking diet to increased liver tumorigenesis remains unclear in the context of whether tumorigenesis is secondary to obesity, or whether nutrients like sugar or fat drive tumorigenesis independent of obesity. In male mice, liver tumor burden was recently found to correlate with sugar intake, independent of dietary fat intake and obesity. However, females are less susceptible to developing liver cancer than males, and it remains unclear how nutrition affects tumorigenesis in females. Herein, female mice were exposed to the liver carcinogen diethylnitrosamine (DEN) and fed diets with well-defined sugar and fat content. Mice fed diets with high sugar content had the greatest liver tumor incidence while dietary fat intake was not associated with tumorigenesis. Diet-induced postprandial hyperglycemia and fasting hyperinsulinemia significantly correlated with tumor incidence, while tumor incidence was not associated with obesity and obesity-related disorders including liver steatosis, glucose intolerance, or elevated serum levels of estrogen, ALT, and lipids. These results simplify the pathophysiology of diet-induced liver tumorigenesis by focusing attention on the role of sugar metabolism and reducing emphasis on the complex milieu associated with obesity.

High glucose enhances progression of cholangiocarcinoma cells via STAT3 activation

Epidemiological studies have indicated diabetes mellitus (DM) as a risk of cholangiocarcinoma (CCA), however, the effects and mechanisms of high glucose on progression of CCA remain unclear. This study reports for the first time of the enhancing effects of high glucose on aggressive phenotypes of CCA cells via STAT3 activation. CCA cells cultured in high glucose media exerted significantly higher rates of cell proliferation, adhesion, migration and invasion than those cultured in normal glucose. The phosphokinase array revealed STAT3 as the dominant signal activated in response to high glucose. Increased nuclear STAT3, p-STAT3 and its downstream target proteins, cyclin D1, vimentin and MMP2, were shown to be underling mechanisms of high glucose stimulation. The link of high glucose and STAT3 activation was confirmed in tumor tissues from CCA patients with DM that exhibited higher STAT3 activation than those without DM. Moreover, the levels of STAT3 activation were correlated with the levels of blood glucose. Finally, decreasing the level of glucose or using a STAT3 inhibitor could reduce the effects of high glucose. These findings suggest that controlling blood glucose or using a STAT3 inhibitor as an alternative approach may improve the therapeutic outcome of CCA patients with DM.

Simple sugar intake and hepatocellular carcinoma: epidemiological and mechanistic insight

Sugar intake has dramatically increased during the last few decades. Specifically, there has been a clear trend towards higher consumption of fructose and high fructose corn syrup, which are the most common added sugars in processed food, soft drinks and other sweetened beverages. Although still controversial, this rising trend in simple sugar consumption has been positively associated with weight gain and obesity, insulin resistance and type 2 diabetes mellitus and non-alcoholic fatty liver disease. Interestingly, all of these metabolic alterations have also been related to the development of hepatocellular carcinoma. The purpose of this review is to discuss the evidence coming from epidemiological studies and data from animal models relating the consumption of simple sugars, and specifically fructose, with an increased risk of hepatocellular carcinoma and to gain insight into the putative molecular mechanisms involved.

Hyperglycemia as a risk factor for cancer progression

As the prevalence of diabetes mellitus is substantially increasing worldwide, associated diseases such as renal failure, cardiovascular diseases, fatty liver, and cancers have also increased. A number of cancers such as pancreatic, liver, breast, and female reproductive cancers have shown an increased prevalence and a higher mortality rate in diabetic patients compared to healthy subjects. Thus, this suggests an association between diabetes, especially type 2 diabetes and cancer incidence and progression. Recent studies have suggested that hyperinsulinemia, chronic inflammation and hyperglycemia, all frequently seen in diabetics, may lead to increased tumor growth; the underlying molecular mechanisms of this association are not fully understood. In particular, chronic hyperglycemic episodes could serve as a direct or indirect mediator of the increase in tumor cell growth. Here, we will discuss our current understanding how hyperglycemia and cancer risk may be linked, and what the implications are for the treatment of diabetic cancer patients.