Lipid-Based Self-Microemulsion of Niclosamide Achieved Enhanced Oral Delivery and Anti-Tumor Efficacy in Orthotopic Patient-Derived Xenograft of Hepatocellular Carcinoma in Mice

Introduction

We previously identified niclosamide as a promising repurposed drug candidate for hepatocellular carcinoma (HCC) treatment. However, it is poorly water soluble, limiting its tissue bioavailability and clinical application. To overcome these challenges, we developed an orally bioavailable self-microemulsifying drug delivery system encapsulating niclosamide (Nic-SMEDDS).

Methods

Nic-SMEDDS was synthesized and characterized for its physicochemical properties, in vivo pharmacokinetics and absorption mechanisms, and in vivo therapeutic efficacy in an orthotopic patient-derived xenograft (PDX)-HCC mouse model. Niclosamide ethanolamine salt (NEN), with superior water solubility, was used as a positive control.

Results

Nic-SMEDDS (5.6% drug load) displayed favorable physicochemical properties and drug release profiles in vitro. In vivo, Nic-SMEDDS displayed prolonged retention time and plasma release profile compared to niclosamide or NEN. Oral administration of Nic-SMEDDS to non-tumor bearing mice improved niclosamide bioavailability and Cmax by 4.1- and 1.8-fold, respectively, compared to oral niclosamide. Cycloheximide pre-treatment blocked niclosamide absorption from orally administered Nic-SMEDDS, suggesting that its absorption was facilitated through the chylomicron pathway. Nic-SMEDDS (100 mg/kg, bid) showed greater anti-tumor efficacy compared to NEN (200 mg/kg, qd); this correlated with higher levels (p < 0.01) of niclosamide, increased caspase-3, and decreased Ki-67 in the harvested PDX tissues when Nic-SMEDDS was given. Biochemical analysis at the treatment end-point indicated that Nic-SMEDDS elevated lipid levels in treated mice.

Conclusion

We successfully developed an orally bioavailable formulation of niclosamide, which significantly enhanced oral bioavailability and anti-tumor efficacy in an HCC PDX mouse model. Our data support its clinical translation for the treatment of solid tumors.

Identification and validation of microtubule depolymerizing agent, CYT997, as a potential drug candidate for hepatocellular carcinoma

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) is a typically fatal malignancy with limited treatment options and poor survival rates, despite recent FDA approvals of newer treatment options. We aim to address this unmet need by using a proprietary computational drug discovery platform that identifies drug candidates with the potential to advance rapidly and successfully through preclinical studies.

METHODS

We generated an in silico model of HCC biology to identify the top 10 small molecules with predicted efficacy. The most promising candidate, CYT997, was tested for its in vitro effects on cell viability and cell death, colony formation, cell cycle changes, and cell migration/invasion in HCC cells. We used an HCC patient-derived xenograft (PDX) mouse model to assess its in vivo efficacy.

RESULTS

CYT997 was significantly more cytotoxic against HCC cells than against primary human hepatocytes, and sensitized HCC cells to sorafenib. It arrested cell cycle at the G2/M phase with associated up-regulations of p21, p-MEK1/2, p-ERK, and down-regulation of cyclin B1. Cell apoptosis and senescence-like morphology were also observed. CYT997 inhibited HCC cell migration and invasion, and down-regulated the expressions of acetylated tubulins, β-tubulin, glypican-3 (GPC3), β-catenin, and c-Myc. In vivo, CYT997 (20 mg/kg, three times weekly by oral gavage) significantly inhibited PDX growth, while being non-toxic to mice. Immunohistochemistry confirmed the down-regulation of GPC3, c-Myc, and Ki-67, supporting its anti-proliferative effect.

CONCLUSION

CYT997 is a potentially efficacious and non-toxic drug candidate for HCC therapy. Its ability to down-regulate GPC3, β-catenin, and c-Myc highlights a novel mechanism of action.

Gaps in Prenatal Hepatitis B Screening and Management of HBsAg Positive Pregnant Persons in the U.S., 2015-2020

BACKGROUND

The Advisory Committee for Immunization Practices (ACIP) recommends testing all pregnant women for hepatitis B surface antigen (HBsAg) and testing HBsAg-positive pregnant women for hepatitis B virus deoxyribonucleic acid (HBV DNA). HBsAg-positive pregnant persons are recommended by the American Association for the Study of Liver Diseases to receive regular monitoring, including alanine transaminase (ALT) and HBV DNA and antiviral therapy for active hepatitis and to prevent perinatal HBV transmission if HBV DNA level is >200,000 IU/mL.

METHODS

Using Optum Clinformatics Data Mart Database claims data, pregnant women who received HBsAg testing and HBsAg-positive pregnant persons who received HBV DNA and alt testing and antiviral therapy during pregnancy and after delivery during January 1, 2015-December 31, 2020 were analyzed.

RESULTS

Among 506,794 pregnancies, 14.6% did not receive HBsAg testing. Pregnant women more likely to receive testing for HBsAg (p<0.01) were persons aged ≥20 years, were Asian, had >1 child, or received education beyond high school. Among the 0.28% (1,437) pregnant women who tested positive for hepatitis B surface antigen, 46% were Asian. The proportion of HBsAg-positive pregnant women who received HBV DNA testing during pregnancy and in the 12 months after delivery was 44.3% and 28.6%, respectively; the proportion that received hepatitis B e antigen was 31.6% and 12.7%, respectively; the proportion that received ALT testing was 67.4% and 47%, respectively; and the proportion that received HBV antiviral therapy was 7% and 6.2%, respectively.

CONCLUSIONS

This study suggests that as many as half a million (∼14%) pregnant persons who gave birth each year were not tested for HBsAg to prevent perinatal transmission. More than 50% of HBsAg-positive persons did not receive the recommended HBV-directed monitoring tests during pregnancy and after delivery.

Universal Adult Hepatitis B Screening and Vaccination as the Path to Elimination

This Viewpoint describes new recommendations from the CDC regarding universal screening of adults for hepatitis B virus infection.

Gaps and Disparities in Chronic Hepatitis B Monitoring and Treatment in the United States, 2016-2019

BACKGROUND

Chronic hepatitis B (CHB) carries an increased risk of death from cirrhosis and hepatocellular carcinoma (HCC). The American Association for the Study of Liver Diseases recommends patients with CHB receive monitoring of disease activity, including ALT, hepatitis B virus (HBV) DNA, hepatitis B e-antigen (HBeAg), and liver imaging for patients who experience an increased risk for HCC. HBV antiviral therapy is recommended for patients with active hepatitis and cirrhosis.

METHODS

Monitoring and treatment of adults with new CHB diagnoses were analyzed using Optum Clinformatics Data Mart Database claims data from January 1, 2016, to December 31, 2019.

RESULTS

Among 5978 patients with new CHB diagnosis, only 56% with cirrhosis and 50% without cirrhosis had claims for≥1 ALT and either HBV DNA or HBeAg test, and among patients recommended for HCC surveillance, 82% with cirrhosis and 57% without cirrhosis had claims for≥1 liver imaging within 12 months of diagnosis. Although antiviral treatment is recommended for patients with cirrhosis, only 29% of patients with cirrhosis had≥1 claim for HBV antiviral therapy within 12 months of CHB diagnosis. Multivariable analysis showed patients who were male, Asian, privately insured, or had cirrhosis were more likely (P<0.05) to receive ALT and either HBV DNA or HBeAg tests and HBV antiviral therapy within 12 months of diagnosis.

CONCLUSION

Many patients diagnosed with CHB are not receiving the clinical assessment and treatment recommended. A comprehensive initiative is needed to address the patient, provider, and system-related barriers to improve the clinical management of CHB.

Production, physiological response, and calcium and magnesium balance of lactating Holstein cows fed different sources of supplemental magnesium with or without ruminal buffer

The objective of this study was to evaluate the effects of dietary replacement of magnesium oxide (MgO) with calcium-magnesium hydroxide [CaMg(OH)₂] and its interaction with ruminal buffer (sodium sesquicarbonate) supplementation on production, Ca and Mg balance, and overall physiological response of mid-lactation Holstein dairy cows. Sixty cows averaging 40.5 ± 7.0 kg of milk/d were used. Treatments were assigned following a 2 × 2 factorial arrangement: (1) MgO, (2) MgO + buffer, (3) CaMg(OH)₂, or (4) CaMg(OH)₂ + buffer. Diets were formulated to have 16.5% of crude protein, 1.82 Mcal/kg of net energy for lactation, 0.67% Ca, 0.39% P, and 0.25% Mg, all on a dry matter (DM) basis. Treatments were individually top dressed. Milk production, composition, and DM intake were evaluated. A subsample of 20 cows were randomly selected for the evaluation of Ca and Mg balance, blood gases, and electrolytes. Ruminal fluid was also collected for evaluation of pH and Ca and Mg solubility. Effects of Mg source, buffer, and the interaction Mg source × buffer were analyzed through orthogonal contrasts. An interaction of Mg source × buffer was found for DM intake and feed efficiency, in which cows fed CaMg(OH)₂ had a similar feed efficiency regardless of ruminal buffer inclusion; however, when cows were fed MgO, the inclusion of buffer reduced feed efficiency. No effects on body weight and milk yield were observed. Buffer addition tended to increase the concentrations of fat, protein, and solids-not-fat, without affecting the yields of these milk components. Magnesium source and buffer did not affect ruminal fluid, blood, urine, or fecal pH; however, buffer supplementation increased urinary pH. Treatment with CaMg(OH)₂ increased blood concentration of HCO₃^-, total CO₂, and base excess compared with cows fed MgO. No differences were observed in the ruminal solubility of Ca and Mg or on milk or urinary Ca and Mg excretion. Greater plasma Mg concentration was observed for animals fed MgO compared with cows fed CaMg(OH)₂; however, both sources were above the threshold recommended in the literature for dairy cows. Also, a reduction in fecal Mg excretion was observed in animals fed CaMg(OH)₂. In summary, we provide evidence that CaMg(OH)₂ could replace MgO without affecting performance, overall physiological response, or Ca and Mg balance of mid-lactating dairy Holstein cows.

Knowledge and Attitude Related to Hepatitis C among Medical Students in the Oral Direct Acting Antiviral Agents Era in Vietnam

BACKGROUND

Medical students play important frontline roles in the prevention, early detection, and treatment of hepatitis C. This study investigated knowledge and attitudes toward hepatitis C among 5th- and 6th-year medical students and possible associated factors.

METHODS

A cross-sectional survey was conducted among 2000 students from eight medical universities using a self-administered structured questionnaire.

RESULTS

The mean knowledge and attitude scores for hepatitis C were 20.1 ± 4.0 (out of 26) and 10.6 ± 2.9 (out of 20), respectively. Approximately, three-quarters (74.4%) of the participants had a good knowledge score, but only a small proportion (3.1%) obtained a good attitude score. Although the participants had fairly high knowledge about the causes, consequences, and transmission routes of hepatitis C, there were important gaps in their knowledge about hepatitis C screening and treatment. In multivariate analysis, female students, 5th-year students, and students from the central provinces had significantly higher knowledge and attitude scores. There was a low positive correlation between knowledge and attitude scores.

CONCLUSION

This study points out the need to update the medical training curriculum to improve the knowledge and attitude of students about hepatitis C infection.

Costs and health impact of delayed implementation of a national hepatitis B treatment program in China

Background

Hepatitis B virus (HBV) infection is a leading public health problem in China. COVID-19 pandemic has interrupted the delivery of health care interventions worldwide, including HBV infection control.

Methods

In this study, we used a Markov model to quantify the costs and population health impact of HBV treatment in China for the following scenarios: 1) current practice with only 17% of treatment eligible HBV infected adults receiving antiviral treatment; 2) reaching the World Health Organization (WHO) treatment target of 80% by 2030 with a steady increase in treatment rate beginning in 2022; and 3) the effect of a 1-5-year delay in meeting the 2030 WHO treatment target. A one-way as well as a probabilistic sensitivity analysis were conducted.

Results

Without increasing antiviral treatment for treatment eligible HBV infected adults, the life-time health care costs for the estimated 89.2 million adults living with HBV in China is US$1305 billion and 10.8 million (12%) will die from HBV-related liver disease. Increasing treatment to achieve the WHO 80% target by 2030 would save US$472 billion and prevent 3.3 million HBV-related deaths. We estimated that a 1-year delay beyond 2030 in reaching the WHO 80% treatment target would likely lead to US$55 billion increase in future health care costs, and an additional 334 000 future deaths from HBV-related liver disease or cancer.

Conclusions

Reaching the WHO 2030 with minimal delays would have an immense health and economic benefit. Implementing a national treatment program for HBV in China should be a key priority for policymakers.

Cost-Effectiveness of Hepatitis B Testing and Vaccination of Adults Seeking Care for Sexually Transmitted Infections

BACKGROUND

The estimated number of people living with hepatitis B virus (HBV) infection acquired through sexual transmission was 103,000 in 2018, with an estimated incidence of 8300 new cases per year. Although hepatitis B (HepB) vaccination is recommended by the Advisory Committee for Immunization Practices for persons seeking evaluation and treatment for sexually transmitted infections (STIs), prevaccination testing is not yet recommended. Screening may link persons with chronic hepatitis B to care and reduce unnecessary vaccination.

METHODS

We used a Markov model to calculate the health impact and cost-effectiveness of 1-time HBV testing combined with the first dose of the HepB vaccine for adults seeking care for STI. We ran a lifetime, societal perspective analysis for a hypothetical population of 100,000 aged 18 to 69 years. The disease progression estimates were taken from recent cohort studies and meta-analyses. In the United States, an intervention that costs less than $100,000 per quality-adjusted life-year (QALY) is generally considered cost-effective. The strategies that were compared were as follows: (1) vaccination without HBV screening, (2) vaccination and hepatitis B surface antigen (HBsAg) screening, (3) vaccination and screening with HBsAg and anti-HBs, and (4) vaccination and screening with HBsAg, anti-HBs, and anti-HBc. Data were obtained from Centers for Medicare & Medicaid services reimbursement, the Centers for Disease Control and Prevention vaccine price list, and additional cost-effectiveness literature.

RESULTS

Compared with current recommendations, the addition of 1-time HBV testing is cost-saving and would prevent an additional 138 cases of cirrhosis, 47 cases of decompensated cirrhosis, 90 cases of hepatocellular carcinoma, 33 liver transplants, and 163 HBV-related deaths, and gain 2185 QALYs, per 100,000 adults screened. Screening with the 3-test panel would save $41.6 to $42.7 million per 100,000 adults tested compared with $41.5 to $42.5 million for the 2-test panel and $40.2 to $40.3 million for HBsAg alone.

CONCLUSIONS

One-time HBV prevaccination testing in addition to HepB vaccination for unvaccinated adults seeking care for STI would save lives and prevent new infections and unnecessary vaccination, and is cost-saving.

Designing Flexible Longitudinal Regimens: Supporting Clinician Planning for Discontinuation of Psychiatric Drugs

Clinical decision support tools have typically focused on one-time support for diagnosis or prognosis, but have the ability to support providers in longitudinal planning of patient care regimens amidst infrastructural challenges. We explore an opportunity for technology support for discontinuing antidepressants, where clinical guidelines increasingly recommend gradual discontinuation over abruptly stopping to avoid withdrawal symptoms, but providers have varying levels of experience and diverse strategies for supporting patients through discontinuation. We conducted two studies with 12 providers, identifying providers’ needs in developing discontinuation plans and deriving design guidelines. We then iteratively designed and implemented AT Planner, instantiating the guidelines by projecting taper schedules and providing flexibility for adjustment. Provider feedback on AT Planner highlighted that discontinuation plans required balancing interpersonal and infrastructural constraints and surfaced the need for different technological support based on clinical experience. We discuss the benefits and challenges of incorporating flexibility and advice into clinical planning tools.

NIR-II imaging of hepatocellular carcinoma based on a humanized anti-GPC3 antibody

Liver cancer, of which hepatocellular carcinoma (HCC) is the most common form, is one of the most lethal cancers worldwide. The five-year survival rate for HCC is below 9%, which can be attributed to late diagnosis and limited treatment options at the late stage. Therefore, safe and efficient imaging strategies are urgently needed to facilitate HCC diagnosis and stage evaluation. The development of the second near infrared window (NIR-II, 1000-1700 nm) fluorescence imaging offers the advantages of enhanced resolutions, deeper penetration depth, and less autofluorescence compared to traditional NIR-I window (700-900 nm) imaging. Herein, an HCC targeted NIR-II fluorescent probe, GPC-ICG, was developed by labelling a humanized anti-GPC3 monoclonal antibody with indocyanine green (ICG). Compared to the negative control IgG-ICG probe, the GPC3-ICG probe demonstrated specific GPC3 targeting capability in vitro. And for GPC3 positive Huh-7 tumor bearing mice, the GPC3-ICG probe specifically accumulated in subcutaneous xenografts, with a tumor-background ratio (TBR) of up to 3. The NIR-II imaging of mice organs ex vivo also indicated that GPC3-ICG specifically targeted Huh-7 tumor tissue. Overall, GPC3-ICG is a promising NIR-II probe for GPC3 targeted imaging of HCC.

The price tag of a potential cure for chronic hepatitis B infection: A cost threshold analysis for USA, China and Australia

BACKGROUND & AIMS

We aim to capture the economic impact of a potential cure for chronic hepatitis B infection (CHB) in three countries (USA, China and Australia) with different health systems and epidemics to estimate the threshold drug prices below which a CHB cure would be cost-saving and/or highly cost-effective.

METHODS

We simulated patients' hepatitis B progression, under three scenarios: current long-term suppressive antiviral therapy, functional cure defined as sustained undetectable HBsAg and HBV DNA, and partial cure defined as sustained undetectable HBV DNA only after a finite, 48-week treatment.

RESULTS

Compared with current long-term antiviral therapy, a 30% effective functional cure among patients with and without cirrhosis in the USA, China and Australia would yield 17.50, 17.32 and 20.42 QALYs per patient, and 20.61, 20.42 and 20.62 QALYs per patient respectively. In financial terms, for CHB patients with and without cirrhosis, this would be cost-saving at a one-time treatment cost under US$11 944 and US$6694, respectively, in the USA, US$1744 and US$1001 in China, and US$12 063 and US$10 983 in Australia.

CONCLUSION

We show that in purely economic terms, a CHB cure will be highly cost-effective even if effective in only 30% of treated patients. The threshold price for cure is largely determined by the current antiviral drug costs, since it will replace a daily antiviral pill that is inexpensive and effective, although not curative. The likely need for combination therapies to achieve cure will also present cost challenges. While cost-effectiveness is important, it cannot be the only consideration, as cure will provide many benefits in addition to reduced liver disease and HCC, including eliminating the need for a long-term daily pill and reducing stigma often associated with chronic viral infection.

P–015 Characterization of ultrastructural morphology of human sperms by field-emission scanning electron microscopy using the NanoSuit method

Study question

Can the NanoSuit method to observe sperm cells in wet conditions help treat male infertility using a field emission scanning electron microscope (FE-SEM)?

Summary answer

Compared with the conventional fixation method, the NanoSuit method can easily prepare FE-SEM samples without causing contraction and denaturation of human sperm cells.

What is known already

Evaluation of sperm morphology by optical microscopy is important for identifying male infertility. FE-SEM observation is useful for a more detailed evaluation of sperm morphology; however, a lot of the morphological information of the cells is lost by chemical fixation, dehydration, and freeze-drying. The NanoSuit method enables FE-SEM observation of unfixed cells under a high vacuum environment by electron beam polymerization of extracellular substances called NanoSuit. It has been reported that a sample prepared by the NanoSuit method retains the morphological information of live cells better than a sample prepared by the conventional fixation method.

Study design, size, duration

This laboratory study was conducted with informed consent and IRB approval. Semen parameters were within the WHO normal reference range.

Participants/materials, setting, methods

The conventional fixation method sample was prepared by fixing (glutaraldehyde and osmium), dehydration (ethanol and t-butyl alcohol), and freeze-drying. The NanoSuit method sample was introduced into the FE-SEM directly without conducting the above treatments. For observation, a JSM–7100F (JEOL, Japan) was used at an acceleration voltage of 1.0 kV. The vacuum level of the observation chamber was 10–3 to 10–6 Pa.

Main results and the role of chance

Sperm head segmentation (acrosome, equatorial segment, and post acrosome), midpiece, and tail including endpiece could be clearly identified in the FE-SEM sample prepared by the NanoSuit method. Transmission electron microscopy revealed the existence of a thin polymerized extra layer, the NanoSuit, on the surface of the sperm. It is suggested that the presence of the NanoSuit layer enables FE-SEM observation of the unfixed sperm. The conventional fixation method causes a statistically significant contraction in the sperm head size compared to that calculated from optical micrographs (13.5 μm2 vs. 11.6 μm2, p &lt; 0.001). Furthermore, wheat germ agglutinin (WGA), a lectin, which is known to have the ability to bind to the sperm surface, did not bind to the fixed FE-SEM samples. This means that the original cell surface properties are lost in the fixed sperm sample. On the other hand, the FE-SEM sample prepared by the NanoSuit method did not show a statistically significant contraction of the sperm head compared to that calculated from optical micrographs (13.2 μm2 vs 12.9 μm2, p = 0.416); it also revealed a detailed binding pattern of gold-labelled WGA to the sperm surface. These results indicate that the NanoSuit method can prepare FE-SEM samples without sperm contraction and denaturation.

Limitations, reasons for caution

Characteristic sperm morphology in patients with male infertility should be investigated in future studies.

Wider implications of the findings: The NanoSuit method does not use chemical carcinogens and can prepare an FE-SEM sample in a shorter time than the conventional fixation method. The evaluation of ultrastructural morphology of unfixed sperms by this method may be useful for the identification of new morphological features and the evaluation of male infertility.

Trial registration number

Not applicable

Cost-Effectiveness of One-Time Universal Screening for Chronic Hepatitis B Infection in Adults in the United States

BACKGROUND

An estimated 862,000 to 2.4 million people have chronic hepatitis B infection (CHB). Left undiagnosed and untreated CHB increases risk of death from liver cirrhosis or liver cancer. Hepatitis B screening is recommended for pregnant women and populations with increased CHB risk, but diagnosis rates remain low with only 33% of people with CHB aware of their infection.. This study aimed to assess the cost-effectiveness of universal adult screening for CHB.

METHODS

We used a Markov model to calculate the costs, population health impact and cost-effectiveness of one-time universal screening and CHB monitoring and treatment compared to current practice. Sensitivity analysis was performed on model parameters to identify thresholds for cost-savings or cost-effectiveness based on willinness-to-pay of $50,000/QALY . The analysis assumed testing would be performed during routine healthcare visits, and generic tenofovir or entecavir would be dispensed for treatment. Testing costs were based on Medicare reimbursement rates.

RESULTS

At an estimated 0.24% prevalence of undiagnosed CHB, universal HBsAg screening in adults 18-69 years old is cost-saving compared with current practice if antiviral treatment drug costs remain below $894 per year. Compared with current practice, universal screening would avert an additional 7.4 cases of compensated cirrhosis, 3.3 cases of decompensated cirrhosis, 5.5 cases of hepatocellular carcinoma, 1.9 liver transplants, and 10.3 HBV related deaths at a savings of $263,000 per 100,000 adults screened.

CONCLUSION

Universal HBsAg screening of adults in the US general population for CHB is cost-effective and likely cost-saving compared to current CHB screening recommendations.

Prevalence of Hepatitis B Vaccination Coverage and Serologic Evidence of Immunity Among US-Born Children and Adolescents From 1999 to 2016

IMPORTANCE

The World Health Assembly has called for the elimination of hepatitis B and C by 2030. As hepatitis B has no cure, the US strategy to eliminate hepatitis B has focused on prevention through vaccination. However, there are limited data on the trend in vaccine-associated immunity since the US implementation of universal infant hepatitis B vaccination.

OBJECTIVE

To compare self-reported hepatitis B vaccination coverage among children and adolescents with serologic evidence of immunity and infection in the US from 1999 to 2016.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2016. US-born persons aged 2 to 18 years without missing hepatitis B serologic test results and with reported vaccination history were included. Data were analyzed from September 2017 to June 2018.

MAIN OUTCOMES AND MEASURES

The proportion of participants who reported complete vaccination for hepatitis B and who had positive serologic test results indicating immunity.

RESULTS

Of 21 873 children and adolescents, 51.2%% were male, and the mean (SD) age was 10.6 (4.6) years. The survey reported that hepatitis B vaccination coverage increased significantly from 1999 to 2016 (from 62.6% [95% CI, 58.6%-66.4%] to 86.3% [95% CI, 82.9%-89.2%]; P < .001). Vaccine-associated immunity also increased from 1999 to 2016 among children aged 2 to 5 years (from 60.7% [95% CI, 48.8%-71.4%] to 65.2% [95% CI, 57.4%-72.3%]; P = .001) but decreased among children aged 6 to 10 years (from 64.6% [95% CI, 57.7%-70.9%] to 46.5% [95% CI, 39.1%-54.0%]; P < .001), adolescents aged 11 to 13 years (from 68.8% [95% CI, 58.1%-77.8%] to 26.2% [95% CI, 18.6%-35.5%]; P < .001), and adolescents aged 14 to 18 years (from 68.5% [95% CI, 62.9%-73.6%] to 15.6% [95% CI, 12.2%-19.8%]; P < .001). By birth year, serologic evidence of vaccine-associated immunity significantly decreased in the 1994-2003 NHANES birth cohort but not among those born between 1988 and 1993. Non-US-born children and adolescents did not show the same decreasing trend in immunity.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, decreasing hepatitis B immunity was observed among US-born children and adolescents in the 1994-2003 NHANES birth cohort despite increasing rates of hepatitis B vaccination coverage. These findings suggest a possible need for surveillance and a booster vaccine dose for hepatitis B as those without serologic evidence of immunity become young adults and may engage in behaviors associated with an increased risk for infection.

A Summary of the 2020 Gastric Cancer Summit at Stanford University

There exists no coherent national strategy for the early detection or prevention of gastric cancer in the United States (US), even among identified high-risk groups such as Asian Americans, African Americans, Hispanic Americans, and Alaska Native/American Indian peoples. As a result, patients with gastric cancer in the US are diagnosed at later stages and demonstrate worse overall survival compared to nations of East Asia with established screening programs (Table 1). The under-recognition of gastric cancer risk within minority communities is a significant unaddressed healthcare disparity.

Abstract LB-110: Computational discovery and preclinical validation of therapeutic leads with novel MOAs for hepatocellular carcinoma and pancreatic ductal adenocarcinoma

Hepatocellular carcinoma (HCC) and pancreatic ductal adenocarcinoma (PDAC) have among the lowest 5-year survival rates of all cancer types at 18% and 9%, respectively. Treatment options for patients with liver or pancreatic cancer are relatively unchanged over the past 10 years. HCC has seen the recent FDA-approval of multi-kinase inhibitor therapies with similar mechanisms of action, including cabozantinib, regorafenib, and lenvatinib, and the immune checkpoint inhibitor nivolumab (conditionally). Despite these advances, the survival rate and median survival time for HCC patients remain poor. The picture for PDAC patients is similar, although with even greater need for new therapies. We present results from a powerful and efficient computational drug discovery platform that produces drug discovery hits with first-in-class mechanisms of action that can advance rapidly and successfully through preclinical validation studies. The twoXAR discovery platform uses an artificial-intelligence framework to integrate diverse patient-derived data sets and build holistic and unbiased models of human disease biology. The utilization of diverse, proprietary algorithms and deep learning principles provides a highly sensitive platform to elucidate detailed disease-specific associations between biology and biomedical data that are integrated with a library of existing drug molecules to deliver novel, high-value drug discovery hits. The twoXAR platform delivers drug discovery hits with known pharmacological properties and preserves the data-driven links to disease biology; this facilitates validation and optimization studies. We employed the twoXAR platform to build in-silico disease models of HCC and PDAC using disease-specific data and generated a set of 10 molecules with predicted efficacy in HCC and a second, independent set of 11 molecules with predicted efficacy in PDAC. These independent sets of disease-specific drug discovery hits represented novel mechanisms of action that had not been tested previously as potential clinical therapies for HCC or PDAC, respectively. TXR-311 and TXR-312, and TXR-405 and TXR-411 were discovered as validated hits for HCC and PDAC, respectively, using in vitro cell proliferation and viability assays with HCC and PDAC tumor cell lines. In these studies, TXR-311 inhibited proliferation and viability of five different HCC tumor cell lines with IC50 values that were 70-fold lower than IC50 values for sorafenib and displayed greater than 500-fold selectivity against primary human hepatocytes. In subsequent in vivo efficacy studies using two HCC patient-derived xenograft (PDX) tumor models, TXR-311 showed excellent tolerability and displayed significant tumor growth inhibition efficacy compared to vehicle-treated controls. TXR-311 presents a first-in-class lead for further development as a potential HCC therapy.

Citation Format: Isaac Hakim, Mei-Sze Chua, Wei Wei, Li Ma, Elizabeth Noblin, Samuel So, Aaron C. Daugherty, Timothy S. Heuer. Computational discovery and preclinical validation of therapeutic leads with novel MOAs for hepatocellular carcinoma and pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-110.

Barriers to Disease Monitoring and Liver Cancer Surveillance Among Patients with Chronic Hepatitis B in the United States

Chronic hepatitis B infection (CHB) is a condition that needs ongoing care such as monitoring for liver enzymes (ALT) and HBV DNA tests in treated and untreated patients, and annual imaging evaluation for liver cancer. Although follow-up care and treatment might seem straight forward, an estimated two-thirds of those who are aware of their infection are not seeing a health care provider, and more than half of those who are eligible for treatment do not receive it. This study aimed to compile and examine studies related to the barriers of disease monitoring, treatment, and liver cancer surveillance for CHB patients in the United States (US). A total of 4439 studies on monitoring and surveillance of CHB published between 2007 and 2018 were identified through a search of electronic databases. After critical assessment, the authors included 42 studies, divided into categories: 'patient-related barriers'; 'provider-related barriers'; and 'system-related barriers'. Among the patient-related barriers, one of the most frequent factors invoked in failing to have adequate surveillance was lack of patient's knowledge. In the provider-related barrier category, a lack of disease knowledge and adherence to guidelines was frequently reported. For the system-related barrier category, the only recurrent mention was a lack of clarity in guidelines or lack of guidelines from certain national institutions. This review summarizes and highlights the need for long-term disease management improvement of chronic hepatitis B infection for patients and healthcare providers that care for them.

Postpartum atypical hemolytic uremic syndrome: Evaluating thrombotic microangiopathy in the pregnant woman

Acute kidney injury in women during pregnancy and the puerperium is often ascribed to hypertensive complications of pregnancy, especially pre-eclampsia. However, rarer causes, including atypical hemolytic uremic syndrome (aHUS) can be triggered by pregnancy. We present a case of a woman with post-partum acute kidney injury due to aHUS, which was successfully treated with the C5a inhibitor eculizumab. We also present a summary of the evaluation and management of thrombotic microangiopathy in pregnancy.

Changing Landscape of Liver Cancer in California: A Glimpse Into the Future of Liver Cancer in the United States

BACKGROUND

Asians and Hispanics currently have the highest incidence rates of hepatocellular carcinoma (HCC) in the United States. The numbers of these minority populations are rapidly increasing, reshaping the demographic in the United States and particularly California, where approximately one-third of US Asians and Hispanics reside. With the changing demographic and rising incidence of HCC that has tripled during the past three decades, it is important to forecast the future burden of HCC by age, sex, and race/ethnicity to plan prevention and control strategies for HCC.

METHODS

We used four Surveillance, Epidemiology, and End Results Program registries to obtain incidence data for California during 2000 to 2013, and 14 registries to represent non-California states. We applied age-period-cohort models to estimate future HCC incidence rates, and estimated HCC burden by multiplying incidence forecasts by corresponding US Census population projections.

RESULTS

Our forecasts for California suggest that in 2030 Hispanics and blacks will have the highest HCC incidence rates and Asians the lowest. While incidence among whites, blacks, and Hispanics in California increased successively for each birth year cohort from 1915 through 1955, incidence among Asians in California decreased for each successive birth year cohort from 1915 through 1975. In contrast, consistent declines were not seen among Asians in the rest of the United States. In California, the estimated burden of HCC is 6482 new cases in 2030, where 80.0% of these patients are older than 65 years (vs 44.5% in 2014). The relative increase of burden in 2030 vs 2014 for this 65 years and older age group is especially high among Hispanics (318.3%), whereas it is the lowest among Asians (53.2%) in California.

CONCLUSIONS

Prevention efforts in California should target persons currently ages 50 to 64 years who will make up the older age group (>65 years) in 2030, especially among Hispanics with the most rapid increase of HCC burden through 2030.

Knowledge, attitudes and medical practice regarding hepatitis B prevention and management among healthcare workers in Northern Vietnam

BACKGROUND AND AIM

Vietnam's burden of liver cancer is largely due to its high prevalence of chronic hepatitis B virus (HBV) infection. This study aimed to examine healthcare workers' (HCWs) knowledge, attitude and practices regarding HBV prevention and management.

METHODS

A cross-sectional survey among health care workers working at primary and tertiary facilities in two Northern provinces in Vietnam in 2017. A standardized questionnaire was administered to randomly selected HCWs. Multivariate regression was used to identify predictors of the HBV knowledge score.

RESULTS

Among the 314 participants, 75.5% did not know HBV infection at birth carries the highest risk of developing chronic infection. The median knowledge score was 25 out of 42 (59.5%). About one third (30.2%) wrongly believed that HBV can be transmitted through eating or sharing food with chronic hepatitis B patients. About 38.8% did not feel confident that the hepatitis B vaccine is safe. Only 30.1% provided correct answers to all the questions on injection safety. Up to 48.2% reported they consistently recap needles with two hands after injection, a practice that would put them at greater risk of needle stick injury. About 24.2% reported having been pricked by a needle at work within the past 12 months. More than 40% were concerned about having casual contact or sharing food with a person with chronic hepatitis B infection (CHB). In multivariate analysis, physicians scored significantly higher compared to other healthcare professionals. Having received training regarding hepatitis B within the last two years was also significantly associated with a better HBV knowledge score.

CONCLUSIONS

Findings from the survey indicated an immediate need to implement an effective hepatitis B education and training program to build capacity among Vietnam's healthcare workers in hepatitis B prevention and control and to dispel hepatitis B stigma.

Population Health And Economic Impacts Of Reaching Chronic Hepatitis B Diagnosis And Treatment Targets In The US

The National Academies of Sciences, Engineering, and Medicine have concluded that eliminating the public health problem of chronic hepatitis B is feasible. We examined the economic and public health impact of reaching the World Health Organization targets of having 90 percent of chronic hepatitis B cases diagnosed and 80 percent being treated by 2030 in the United States with an annual incremental increase in screening and treatment rates. To reach the targets by 2030 would require screening approximately 14.5 million adults in at-risk populations to diagnose an estimated 870,000 undiagnosed cases and would result in substantial health gains: an increase of 16.5 million quality-adjusted life-years (QALYs), and reductions in liver-related deaths of 37 percent and in cases of compensated cirrhosis of 24 percent, decompensated liver cirrhosis of 51 percent, and liver cancer of 35 percent. Achieving the targets by 2030 would be highly cost-effective at $103 per QALY and would be cost-saving if the antiviral drug price were no more than $114 per month. Achieving them by 2025 would be cost-saving and would reduce liver-related deaths by 47 percent.

Knowledge, attitudes and practices of hepatitis B prevention and immunization of pregnant women and mothers in northern Vietnam

Background and aim

Infection at birth due to mother-to-child (MTC) transmission is the most common cause of chronic hepatitis B virus (HBV) infection in Vietnam. This study was undertaken to examine the knowledge, attitudes, and practices of pregnant women and mothers in Vietnam concerning HBV prevention and immunization.

Methods

A cross-sectional survey was conducted in Quang Ninh and Hoa Binh provinces in 2017. A standardized questionnaire was administered to women when they received care at primary and tertiary maternal health clinics. Multivariate regression was used to identify predictors of HBV knowledge and practices.

Results

Among the 380 women surveyed, 50.3% were pregnant and 49.7% were postpartum. Despite 70.3% of participants reported having received information about HBV during their pregnancy, only 10.8% provided correct answers to all questions regarding HBV transmission routes and preventive measures. Around half of the participants incorrectly believed that HBV is transmitted through sneezing, contaminated water or sharing foods with chronic HBV patients. Although 86.1% of participants believed that HBV vaccination is necessary for infants, only 66.1% responded they were definitely willing to have their own child vaccinated within 24 hours. More than a third of participants expressed concern about having casual contacts or sharing foods with chronic HBV patients. In multivariate analysis, having received information about HBV during their pregnancy was significantly associated with better HBV knowledge score. Delivery at provincial level clinics was a strong predictor for perinatal HBV screening and hepatitis B birth dose administration.

Conclusions

The results highlight the need to prioritize educating pregnant women and mothers in future public health campaigns in order to increase knowledge, reduce misperception, and improve hepatitis B vaccine birth dose coverage in Vietnam.

Abstract LB-390: A transfer RNA derived small RNA affects translation in rapidly dividing cells and a target for hepatocellular carcinoma

There are tens of thousands of different transfer RNA-derived small RNAs (tsRNAs) of 18-40 nucleotides in length in mammalian cells. In recent years there is accumulating evidence suggesting that these RNAs can play different yet important roles in gene regulations. Nevertheless, in most cases, the biological roles of these RNAs have yet to be defined. Using a variety of locked nucleic acid/antisense oligonucleotide (LNA/ASO)-mediated strategies, we found that inhibition of one specific 3'tsRNA, induces apoptosis in rapidly dividing cells. Inhibition of the tsRNA but not the mature tRNA reduced the translation of ribosomal protein S28 (RPS28) and S15 (RPS15) mRNAs and led to a block in pre-18S ribosomal RNA processing, and ultimately a decrease in the number of 40S ribosomal subunits. Using a modified ChIRP method, we found that the tsRNA binds to ribosomal protein S28 mRNA and by genetic complementation analyses established the binding sites contained within the mRNAs. Furthermore, we established that tsRNA binds to duplexed target sites in RPS28 and RPS15 mRNAs and enhances their translation by perhaps helping to unfold their secondary structures. The systemic delivery of a specific anti-tsRNA oligonucleotides into mice (the tsRNA sequence is the same in mouse and humans) did not cause liver injury in normal mice but induced apoptosis and a significant growth retardation of patient-derived orthotopic hepatocellular carcinomas surgically implanted into mouse livers. Our result establishes a newly defined post-transcriptional mechanism of gene regulation and provides a novel target for cancer therapeutics.

Citation Format: Hak Kyun Kim, Gabriele Fuchs, Shengchun Wang, Wei Wei, Yue Zhang, Hyesuk Park, Biswajoy Roy-Chaudhuri, Pan Li, Jianpeng Xu, Kirk Chu, Feijie Zhang, Mei-sze Chua, Samuel So, Cliff Zhang, Peter Sarnow, Mark A. Kay. A transfer RNA derived small RNA affects translation in rapidly dividing cells and a target for hepatocellular carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-390.

A transfer-RNA-derived small RNA regulates ribosome biogenesis

tRNA-derived small RNAs (tsRNAs; also called tRNA-derived fragments (tRFs)) are an abundant class of small non-coding RNAs whose biological roles are not well defined. We show that inhibition of a specific tsRNA, LeuCAG3′tsRNA, induces apoptosis in rapidly dividing cells in vitro and in a patient-derived orthotopic hepatocellular carcinoma model in mice. This tsRNA binds at least two ribosomal protein mRNAs (for RPS28 and RPS15) to enhance their translation. Reduction of RPS28 mRNA translation blocks pre-18S ribosomal RNA processing, resulting in a decrease in the number of 40S ribosomal subunits. These data establish another post-transcriptional mechanism that can fine-tune gene expression during different physiological states and provide a potential new target for treating cancer.

5-Hydroxymethylcytosine signatures in cell-free DNA provide information about tumor types and stages

5-Hydroxymethylcytosine (5hmC) is an important mammalian DNA epigenetic modification that has been linked to gene regulation and cancer pathogenesis. Here we explored the diagnostic potential of 5hmC in circulating cell-free DNA (cfDNA) using a sensitive chemical labeling-based low-input shotgun sequencing approach. We sequenced cell-free 5hmC from 49 patients of seven different cancer types and found distinct features that could be used to predict cancer types and stages with high accuracy. Specifically, we discovered that lung cancer leads to a progressive global loss of 5hmC in cfDNA, whereas hepatocellular carcinoma and pancreatic cancer lead to disease-specific changes in the cell-free hydroxymethylome. Our proof-of-principle results suggest that cell-free 5hmC signatures may potentially be used not only to identify cancer types but also to track tumor stage in some cancers.

Perinatal transmission in infants of mothers with chronic hepatitis B in California

AIM

To evaluate maternal hepatitis B virus (HBV) DNA as risk for perinatal HBV infection among infants of HBV-infected women in California.

METHODS

Retrospective analysis among infants born to hepatitis B surface antigen (HBsAg)-positive mothers who received post vaccination serologic testing (PVST) between 2005 and 2011 in California. Demographic information was collected from the California Department of Public Health Perinatal Hepatitis B Program databaseand matched to birth certificate records. HBV DNA level and hepatitis B e antigen (HBeAg) status were obtained from three large commercial laboratories in California and provider records if available and matched to mother infant pairs. Univariate analysis compared infected and uninfected infants. Multivariate analysis was restricted to infected infants and controls with complete maternal HBV DNA results using a predefined high HBV DNA level of > 2 × 10⁷ IU/mL, a 5:1 ratio of cases to controls and a two-sided confidence level of 95%.

RESULTS

A total of 17687 infants were born to HBsAg positive mothers in California between Jan 1 2005 and Dec 31, 2011. Among 11473 infants with PVST, only 125 (1.1%) were found to be HBV infected. Among these infected infants, lapses in Advisory Committee on Immunization Practices recommended post exposure prophylaxis (PEP) occurred in only 9 infants. However, PEP errors were not significantly different between infected and uninfected infants. Among the 347 uninfected and infected infants who had maternal HBeAg and HBV DNA level, case-control analysis found HBeAg positivity (70.4% vs 28.9%, OR = 46.76, 95%CI: 6.05-361.32, P < 0.001) and a maternal HBV DNA level ≥ 2 × 10⁷ IU/mL (92.6% vs 18.5%, OR = 54.5, 95%CI: 12.22-247.55, P < 0.001) were associated with perinatal HBV infection. In multivariate logistic regression, maternal HBV DNA level ≥ 2 × 10⁷ IU/mL was the only significant independent predictor of perinatal HBV infection.

CONCLUSION

In California, transmission is low and most infected infants receive appropriate PEP and vaccination. Maternal HBV DNA ≥ 2 × 10⁷ IU/mL is associated with high risk of perinatal infection.

Reversal of cancer gene expression correlates with drug efficacy and reveals therapeutic targets

The decreasing cost of genomic technologies has enabled the molecular characterization of large-scale clinical disease samples and of molecular changes upon drug treatment in various disease models. Exploring methods to relate diseases to potentially efficacious drugs through various molecular features is critically important in the discovery of new therapeutics. Here we show that the potency of a drug to reverse cancer-associated gene expression changes positively correlates with that drug's efficacy in preclinical models of breast, liver and colon cancers. Using a systems-based approach, we predict four compounds showing high potency to reverse gene expression in liver cancer and validate that all four compounds are effective in five liver cancer cell lines. The in vivo efficacy of pyrvinium pamoate is further confirmed in a subcutaneous xenograft model. In conclusion, this systems-based approach may be complementary to the traditional target-based approach in connecting diseases to potentially efficacious drugs.

Computational Discovery of Niclosamide Ethanolamine, a Repurposed Drug Candidate That Reduces Growth of Hepatocellular Carcinoma Cells In Vitro and in Mice by Inhibiting Cell Division Cycle 37 Signaling

BACKGROUND & AIMS

Drug repositioning offers a shorter approval process than new drug development. We therefore searched large public datasets of drug-induced gene expression signatures to identify agents that might be effective against hepatocellular carcinoma (HCC).

METHODS

We searched public databases of messenger RNA expression patterns reported from HCC specimens from patients, HCC cell lines, and cells exposed to various drugs. We identified drugs that might specifically increase expression of genes that are down-regulated in HCCs and reduce expression of genes up-regulated in HCCs using a nonparametric, rank-based pattern-matching strategy based on the Kolmogorov-Smirnov statistic. We evaluated the anti-tumor activity of niclosamide and its ethanolamine salt (NEN) in HCC cell lines (HepG2, Huh7, Hep3B, Hep40, and PLC/PRF/5), primary human hepatocytes, and 2 mouse models of HCC. In one model of HCC, liver tumor development was induced by hydrodynamic delivery of a sleeping beauty transposon expressing an activated form of Ras (v12) and truncated β-catenin (N90). In another mouse model, patient-derived xenografts were established by implanting HCC cells from patients into livers of immunocompromised mice. Tumor growth was monitored by bioluminescence imaging. Tumor-bearing mice were fed a regular chow diet or a chow diet containing niclosamide or NEN. In a separate experiment using patient-derived xenografts, tumor-bearing mice were given sorafenib (the standard of care for patients with advanced HCC), NEN, or niclosamide alone; a combination of sorafenib and NEN; or a combination sorafenib and niclosamide in their drinking water, or regular water (control), and tumor growth was monitored.

RESULTS

Based on gene expression signatures, we identified 3 anthelmintics that significantly altered the expression of genes that are up- or down-regulated in HCCs. Niclosamide and NEN specifically reduced the viability of HCC cells: the agents were at least 7-fold more cytotoxic to HCCs than primary hepatocytes. Oral administration of NEN to mice significantly slowed growth of genetically induced liver tumors and patient-derived xenografts, whereas niclosamide did not, coinciding with the observed greater bioavailability of NEN compared with niclosamide. The combination of NEN and sorafenib was more effective at slowing growth of patient-derived xenografts than either agent alone. In HepG2 cells and in patient-derived xenografts, administration of niclosamide or NEN increased expression of 20 genes down-regulated in HCC and reduced expression of 29 genes up-regulated in the 274-gene HCC signature. Administration of NEN to mice with patient-derived xenografts reduced expression of proteins in the Wnt-β-catenin, signal transducer and activator of transcription 3, AKT-mechanistic target of rapamycin, epidermal growth factor receptor-Ras-Raf signaling pathways. Using immunoprecipitation assays, we found NEN to bind cell division cycle 37 protein and disrupt its interaction with heat shock protein 90.

CONCLUSIONS

In a bioinformatics search for agents that alter the HCC-specific gene expression pattern, we identified the anthelmintic niclosamide as a potential anti-tumor agent. Its ethanolamine salt, with greater bioavailability, was more effective than niclosamide at slowing the growth of genetically induced liver tumors and patient-derived xenografts in mice. Both agents disrupted interaction between cell division cycle 37 and heat shock protein 90 in HCC cells, with concomitant inhibition of their downstream signaling pathways. NEN might be effective for treatment of patients with HCC.

Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-years for 32 Cancer Groups, 1990 to 2015: A Systematic Analysis for the Global Burden of Disease Study

IMPORTANCE

Cancer is the second leading cause of death worldwide. Current estimates on the burden of cancer are needed for cancer control planning.

OBJECTIVE

To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 32 cancers in 195 countries and territories from 1990 to 2015.

EVIDENCE REVIEW

Cancer mortality was estimated using vital registration system data, cancer registry incidence data (transformed to mortality estimates using separately estimated mortality to incidence [MI] ratios), and verbal autopsy data. Cancer incidence was calculated by dividing mortality estimates through the modeled MI ratios. To calculate cancer prevalence, MI ratios were used to model survival. To calculate YLDs, prevalence estimates were multiplied by disability weights. The YLLs were estimated by multiplying age-specific cancer deaths by the reference life expectancy. DALYs were estimated as the sum of YLDs and YLLs. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility. Countries were categorized by SDI quintiles to summarize results.

FINDINGS

In 2015, there were 17.5 million cancer cases worldwide and 8.7 million deaths. Between 2005 and 2015, cancer cases increased by 33%, with population aging contributing 16%, population growth 13%, and changes in age-specific rates contributing 4%. For men, the most common cancer globally was prostate cancer (1.6 million cases). Tracheal, bronchus, and lung cancer was the leading cause of cancer deaths and DALYs in men (1.2 million deaths and 25.9 million DALYs). For women, the most common cancer was breast cancer (2.4 million cases). Breast cancer was also the leading cause of cancer deaths and DALYs for women (523 000 deaths and 15.1 million DALYs). Overall, cancer caused 208.3 million DALYs worldwide in 2015 for both sexes combined. Between 2005 and 2015, age-standardized incidence rates for all cancers combined increased in 174 of 195 countries or territories. Age-standardized death rates (ASDRs) for all cancers combined decreased within that timeframe in 140 of 195 countries or territories. Countries with an increase in the ASDR due to all cancers were largely located on the African continent. Of all cancers, deaths between 2005 and 2015 decreased significantly for Hodgkin lymphoma (-6.1% [95% uncertainty interval (UI), -10.6% to -1.3%]). The number of deaths also decreased for esophageal cancer, stomach cancer, and chronic myeloid leukemia, although these results were not statistically significant.

CONCLUSION AND RELEVANCE

As part of the epidemiological transition, cancer incidence is expected to increase in the future, further straining limited health care resources. Appropriate allocation of resources for cancer prevention, early diagnosis, and curative and palliative care requires detailed knowledge of the local burden of cancer. The GBD 2015 study results demonstrate that progress is possible in the war against cancer. However, the major findings also highlight an unmet need for cancer prevention efforts, including tobacco control, vaccination, and the promotion of physical activity and a healthy diet.

The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013

BACKGROUND

With recent improvements in vaccines and treatments against viral hepatitis, an improved understanding of the burden of viral hepatitis is needed to inform global intervention strategies. We used data from the Global Burden of Disease (GBD) Study to estimate morbidity and mortality for acute viral hepatitis, and for cirrhosis and liver cancer caused by viral hepatitis, by age, sex, and country from 1990 to 2013.

METHODS

We estimated mortality using natural history models for acute hepatitis infections and GBD's cause-of-death ensemble model for cirrhosis and liver cancer. We used meta-regression to estimate total cirrhosis and total liver cancer prevalence, as well as the proportion of cirrhosis and liver cancer attributable to each cause. We then estimated cause-specific prevalence as the product of the total prevalence and the proportion attributable to a specific cause. Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs).

FINDINGS

Between 1990 and 2013, global viral hepatitis deaths increased from 0·89 million (95% uncertainty interval [UI] 0·86-0·94) to 1·45 million (1·38-1·54); YLLs from 31·0 million (29·6-32·6) to 41·6 million (39·1-44·7); YLDs from 0·65 million (0·45-0·89) to 0·87 million (0·61-1·18); and DALYs from 31·7 million (30·2-33·3) to 42·5 million (39·9-45·6). In 2013, viral hepatitis was the seventh (95% UI seventh to eighth) leading cause of death worldwide, compared with tenth (tenth to 12th) in 1990.

INTERPRETATION

Viral hepatitis is a leading cause of death and disability worldwide. Unlike most communicable diseases, the absolute burden and relative rank of viral hepatitis increased between 1990 and 2013. The enormous health loss attributable to viral hepatitis, and the availability of effective vaccines and treatments, suggests an important opportunity to improve public health.

FUNDING

Bill & Melinda Gates Foundation.

Evaluation of the first open-access hepatitis B and safe injection online training course for health professionals in China

BACKGROUND

Despite the high prevalence of chronic hepatitis B virus (HBV) infection in China, HBV infection prevention and long-term care knowledge of health professionals is inadequate. To address this knowledge gap, we developed an open-access evidence-based online training course, "KnowHBV", to train health professionals on prevention of HBV transmission and safe injections. We conducted an evaluation of the course with health professionals in China to examine its effectiveness in improving knowledge and learner's satisfaction of the course.

METHODS

Between July and December 2011, 1015 health professionals from selected hospitals and disease control institutions of Shandong province registered for the course and 932 (92 %) completed the three-module course. Participants' demographic information, pre- and post-course knowledge test results and learner's feedback were collected through the course website.

RESULTS

Pre-course knowledge assessment confirmed gaps in HBV transmission routes, prevention and long-term care knowledge. Only 50.4 % of participants correctly identified all of the transmission routes of HBV, and only 40.7 % recognized all of the recommended tests to monitor chronically infected persons. The number of participants that answered all six multi-part multiple-choice knowledge questions correctly increased from 183 (19.7 %) before taking the course to 395 (42.4 %) on their first attempt upon completion of the course. Over 90 % of the 898 participants who completed the learner-feedback questionnaire rated the course as 'good' or 'very good'; over 94 % found the course instructional design helpful; 57.5 %, 65.7 % and 68.5 % reported that half or more than half of the course content in modules 1, 2 and 3 respectively provided new information; and 93.2 % of the participants indicated they preferred the online learning over traditional face-to-face classroom learning.

CONCLUSIONS

The "KnowHBV" online training course appears to be an effective online training tool to improve HBV prevention and care knowledge of the health professionals in China.

Copy number gain of granulin-epithelin precursor (GEP) at chromosome 17q21 associates with overexpression in human liver cancer

BACKGROUND

Granulin-epithelin precursor (GEP), a secretory growth factor, demonstrated overexpression in various human cancers, however, mechanism remain elusive. Primary liver cancer, hepatocellular carcinoma (HCC), ranks the second in cancer-related death globally. GEP controlled growth, invasion, metastasis and chemo-resistance in liver cancer. Noted that GEP gene locates at 17q21 and the region has been frequently reported to be amplified in subset of HCC. The study aims to investigate if copy number gain would associate with GEP overexpression.

METHODS

Quantitative Microsatellite Analysis (QuMA) was used to quantify the GEP DNA copy number, and fluorescent in situ hybridization (FISH) was performed to consolidate the amplification status. GEP gene copy number, mRNA expression level and clinico-pathological features were analyzed.

RESULTS

GEP DNA copy number determined by QuMA corroborated well with the FISH data, and the gene copy number correlated with the expression levels (n = 60, r = 0.331, P = 0.010). Gain of GEP copy number was observed in 20% (12/60) HCC and associated with hepatitis B virus infection status (P = 0.015). In HCC with increased GEP copy number, tight association between GEP DNA and mRNA levels were observed (n = 12, r = 0.664, P = 0.019).

CONCLUSIONS

Gain of the GEP gene copy number was observed in 20% HCC and the frequency comparable to literatures reported on the chromosome region 17q. Increased gene copy number contributed to GEP overexpression in subset of HCC.

Suppressing the CDC37 cochaperone in hepatocellular carcinoma cells inhibits cell cycle progression and cell growth

BACKGROUND & AIMS

The molecular cochaperone CDC37 regulates the activities of multiple protein kinases, and is an attractive broad-spectrum target in many types of cancers in which it is over-expressed. This study investigates the antitumour effects of inhibiting CDC37 in human hepatocellular carcinoma (HCC).

METHODS

A total of 91 patients were enrolled for CDC37 mRNA detection by using quantitative real-time PCR. Cell proliferation, gene expression changes and tumourigenicity were determined by targeting CDC37 using RNA interference in human hepatoma cell lines.

RESULTS

We confirmed the significant over-expression of CDC37 transcript and protein in HBV-associated HCC patients. Using a CDC37-specific small oligo-siRNA, we silenced CDC37 expression in HepG2 and Huh7 hepatoma cell lines, and observed inhibition of in vitro cell proliferation, cell cycle arrest at the G1 phase, and enhanced apoptosis. Specifically, we found concomitant down-regulation of Cyclin D1, CDK4, and pRB (S807/811 and S795) upon CDC37 suppression, which could mediate the arrest of cell cycle progression at the G1 phase. Gene expression profiling further identified several genes involved in cell proliferation, cell cycle progression, and apoptosis that are regulated by CDC37 suppression. Huh7 cells with stable knockdown of CDC37 showed decreased in vitro colony formation ability, and significantly slowed xenograft growth in vivo.

CONCLUSIONS

On the basis of the observed antitumour effects of inhibiting CDC37 expression, we propose that CDC37 is a promising therapeutic target in HCC. Its ability to regulate multiple pathways makes it potentially valuable in treating the heterogeneous subtypes of this malignancy.

Enhanced performance of dye-sensitized solar cells based on TiO2 nanotube membranes using an optimized annealing profile

Free standing TiO₂ nanotube membranes are transferred onto FTO slides in front-side illuminated dye-sensitized solar cells (DSSCs). The electronic properties of the tubes and, as a result, the efficiency of the DSSCs can be considerably improved by ramped annealing.

Epigenetics in hepatocellular carcinoma: An update and future therapy perspectives

Hepatocellular carcinoma (HCC), the predominant form of adult liver malignancies, is a global health concern. Its dismal prognosis has prompted recent significant advances in the understanding of its etiology and pathogenesis. The deregulation of epigenetic mechanisms, which maintain heritable gene expression changes and chromatin organization, is implicated in the development of multiple cancers, including HCC. This review summarizes the current knowledge of epigenetic mechanisms in the pathogenesis of HCC, with an emphasis on HCC mediated by chronic hepatitis B virus infection. This review also discusses the encouraging outcomes and lessons learnt from epigenetic therapies for hematological and other solid cancers, and highlights the future potential of similar therapies in the treatment of HCC.

Abstract 715: Molecular imaging of hepatocellular carcinoma using radiolabeled monoclonal antibody PET probes targeting glypican-3

Background: Glypican-3 (GPC3) is a cell-surface protein which is over-expressed in more than 50% of hepatocellular carcinoma (HCC) patients, but is negligibly expressed in normal livers, benign liver lesions, and tissues adjacent to HCC. GPC3 is therefore a potential molecular target for HCC diagnosis.

Methods: Two radiotracers, 64Cu-DOTA-GPC3 and 89Zr-DFO-GPC3, were synthesized based on the human anti-GPC3 monoclonal antibody (MAb clone 1G12). These radiotracers were used for positron emission tomography (PET) imaging of subcutaneous or orthotopic HCC xenografts in nude mice, generated from HCC cell lines expressing high (HepG2), moderate (Hep3B), or low (PLC/PRF/5) levels of GPC3. Biodistribution analysis and tumor-to-liver ratios were calculated to assess the performance and specificity of these radiotracers.

Results: The anti-GPC3 MAb showed high binding affinity to recombinant human GPC3 protein in vitro (KD = 0.40 ± 0.04 nM), and specifically identified HCC cell lines and human specimens with high GPC3 expression. In vivo, 64Cu-DOTA-GPC3 showed significantly higher uptake in HepG2 xenografts (17.05 ± 1.31% ID/g) compared with non-specific 18F-fluoro-deoxy-glucose (18F-FDG) (3.17 ± 0.59% ID/g), and the non-targeting 64Cu-DOTA-IgG (5.10 ± 1.27% ID/g) at 72 h post-injection (p.i.) (p &lt; 0.005). However, the tumor-to-liver ratio was only 0.46 ± 0.32 at 72 h p.i., due to high uptake of 64Cu-DOTA-GPC3 in the liver. To increase tumor-to-liver ratio, we synthesized the 89Zr-DFO-GPC3 radiotracer, which displayed specific cellular uptake in GPC3-positive cells in vitro, and also internalized over time in these cells. In vivo, 89Zr-DFO-GPC3 showed high and specific uptake in the subcutaneous HepG2 xenografts, but not in the non-HCC, GPC3-negative ones (PC3 and A375M). Consistently, in vivo biodistribution analysis demonstrated significantly higher uptake of 89Zr-DFO-GPC3 in HepG2 xenografts at 48 h p.i. (10.80 ± 1.69% ID/g, n=4) and 192 h p.i. (8.76 ± 1.12% ID/g, n=4), compared to 1.19 ± 0.27% ID/g in PC3 xenografts and 2.02 ± 0.58% ID/g in A375M xenografts at 192 h time point (p &lt; 0.005) The tumor-to-liver ratios for HepG2 xenografts at 48 h and 192 h were 2.64 ± 0.20, and 4.10 ± 0.17, respectively. More importantly, 89Zr-DFO-GPC3 was able to delineate orthotopic HCC xenografts from the surrounding normal liver. Biodistribution analysis in these orthotopic xenografts showed uptake of 14.0 ± 2.50% ID/g for HepG2; 7.71 ± 1.64% ID/g for Hep3B; and 5.54 ± 1.00% ID/g for PLC/PRF/5 at 168 h p.i. The corresponding tumor-to-liver ratios were 6.65 ± 1.33 for HepG2, 6.15 ± 1.75 for PLC/PRF/5, and 4.29 ± 0.52 for Hep3B.

Conclusion: We demonstrate that anti-GPC3 MAb-based PET probes can detect GPC3-positive HCCs in subcutaneous and orthotopic animal models. Especially, 89Zr-DFO-GPC3 is a promising probe and clinically useful probe for the specific imaging of GPC3-positive HCCs.

Citation Format: Xiaoyang Yang, Susan Hoppmann, Hongguang Liu, Mark Allegretta, Mei-Sze Chua, Zhen Cheng, Samuel So. Molecular imaging of hepatocellular carcinoma using radiolabeled monoclonal antibody PET probes targeting glypican-3. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 715. doi:10.1158/1538-7445.AM2013-715

Assessment and comparison of magnetic nanoparticles as MRI contrast agents in a rodent model of human hepatocellular carcinoma

The purpose of this study was to synthesize, characterize and tailor the surface properties of magnetic nanoparticles with biocompatible copolymer coatings and to evaluate the efficiency of the resulting nanoconjugates as magnetic resonance imaging (MRI) contrast agents for liver imaging. Magnetic nanoparticles with core diameters of 10 and 30 nm were synthesized by pyrolysis and were subsequently coated with a copolymer containing either carboxyl (SHP) or methoxy groups as termini. All four formulas, and ferumoxides (Feridex I.V.(®)), were individually injected intravenously into separate, normal Balb/C mice (at 2.5, 1.0 and 0.56 mg Fe kg(-1)), and the animals underwent T(2)-weighted MRI at multiple time points post injection (p.i.) to evaluate the hepatic uptake and clearance. Furthermore, we compared the abilities of the new formulas and Feridex to detect tumors in an orthotropic Huh7 tumor model. Transmission electron microscopy (TEM) revealed a narrow size distribution of both the 10 and 30 nm nanoparticles, in contrast to a wide size distribution of Feridex. MTT, apoptosis and cyclin/DNA flow cytometry assays showed that the polymer coated nanoparticles had no adverse effect on cell growth. Among all the tested formulas, including Feridex, SHP-30 showed the highest macrophage uptake at the in vitro level. In vivo MRI studies on normal mice confirmed the superiority of SHP-30 in inducing hypointensities in the liver tissue, especially at clinical dose (0.56 mg Fe kg(-1)) and 3 T field. SHP-30 showed better contrast-to-noise ratio than Feridex on the orthotropic Huh7 tumor model. SHP-30 was found to be an efficient contrast agent for liver MR imaging. The success of this study suggests that, by improving the synthetic approach and by tuning the surface properties of IONPs, one can arrive at better formulas than Feridex for clinical practice.

Abstract 5620: Therapeutic targeting of glypican-3 using TGF-β2 as a novel treatment approach for HCC

Objective Glypican-3 (GPC3) is a valuable diagnostic marker and a potential therapeutic target in hepatocellular carcinoma (HCC). It is over-expressed in more than 60% of the HCC tumors. As a histological marker, GPC3 can be used to distinguish HCC cells from cirrhotic, non-tumorous liver. As a diagnostic marker, GPC3 be used to complement the diagnostic potential of AFP for screening of HCC patients. Previously we found that GPC3 knockdown can suppress HCC tumor growth both in vitro and in vivo. Gene expression analysis revealed that GPC3 suppression significantly up-regulated the expression of TGF-β2 at both RNA and protein levels. TGF-β2 itself possesses anti-proliferative effect in GPC3 positive HCC cell lines (HepG2 and Huh7). This study aims at evaluating the use of TGF-β2 as a novel treatment approach for HCC by targeting the GPC3/TGFβ signaling axis. Materials and methods To study the effects of TGF-β2 on HCC cells, cell lines with different level of GPC3 expression (HepG2, Huh7, Hep3B, Hep40, PLC/PRF/5, SNU-398, SNU-182, SNU-449, SNU-475) were treated with 1 or 5 ng/ml of rhTGF-β2 for 48 hours in their normal culture media supplemented with 10% FBS. Cell proliferation was determined by using MTT assay and colony formation assay. Cell cycle progression was measured by using flow cytometry. The presence of self-renewing cancer cells was determined by spheroid formation assay. Gene expression analysis was performed to identify the genes associated with TGF-β2 treatment in HCC cells. For in vivo study, orthotopic xenografts of HCC patient tumors in mice were established, and mice were injected with 100 ng of rhTGF-β2 every week via i.p. injection. Tumor growth was monitored by using non-invasive bioluminescence imaging. Results TGF-β2 effectively inhibited the growth of GPC3 positive cells as shown by the decreased cell proliferation and colony formation (HepG2, Huh7, Hep40, PLC.PRF/5, Hep3B and SNU-398). Additionally, GPC3 positive cells responded to TGF-β2 treatment with down-regulation of anti-apoptotic genes (Bcl-2, Bcl-xL and Mcl-1) and cell cycle arrest at G0/G1 phase. Cells with no endogenous GPC3 expression did not respond to TGF-β2 treatment. Moreover, TGF-β2 treatment inhibited self-renewal of GPC3 positive HCC cell lines as shown by inhibition of spheroid formation (P&lt;0.01 compared to untreated cells). Gene expression analysis revealed that TGF-β2 treatment down-regulated the expression of GPC3 (72%, P&lt;0.05), NDRG1 (56%, P&lt;0.05) and CDC37 (56%, P&lt;0.05), three genes that were reported to promote HCC tumor progression. In vivo, TGF-β2 inhibited HCC xenograft growth, after 3 weeks of treatment (P&lt;0.05 compared to PBS control), as shown by the bioluminescence imaging. Conclusions In conclusion, molecular targeting of GPC3 by using rhTGF-β2 offers a novel treatment option for the clinical management of GPC3-positive HCC patients by targeting the GPC3/TGFβ signaling axis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5620. doi:1538-7445.AM2012-5620

In vivo MRSI of hyperpolarized [1-(13)C]pyruvate metabolism in rat hepatocellular carcinoma

Hepatocellular carcinoma (HCC), the primary form of human adult liver malignancy, is a highly aggressive tumor with average survival rates that are currently less than 1 year following diagnosis. Most patients with HCC are diagnosed at an advanced stage, and no efficient marker exists for the prediction of prognosis and/or response(s) to therapy. We have reported previously a high level of [1-(13)C]alanine in an orthotopic HCC using single-voxel hyperpolarized [1-(13)C]pyruvate MRS. In the present study, we implemented a three-dimensional MRSI sequence to investigate this potential hallmark of cellular metabolism in rat livers bearing HCC (n = 7 buffalo rats). In addition, quantitative real-time polymerase chain reaction was used to determine the mRNA levels of lactate dehydrogenase A, nicotinamide adenine (phosphate) dinucleotide dehydrogenase quinone 1 and alanine transaminase. The enzyme levels were significantly higher in tumor than in normal liver tissues within each rat, and were associated with the in vivo MRSI signal of [1-(13)C]alanine and [1-(13)C]lactate after a bolus intravenous injection of [1-(13)C]pyruvate. Histopathological analysis of these tumors confirmed the successful growth of HCC as a nodule in buffalo rat livers, revealing malignancy and hypervascular architecture. More importantly, the results demonstrated that the metabolic fate of [1-(13)C]pyruvate conversion to [1-(13)C]alanine significantly superseded that of [1-(13)C]pyruvate conversion to [1-(13)C]lactate, potentially serving as a marker of HCC tumors.