Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis

HES V2.0 surpasses GALAD for HCC detection: a review of multi-dimensional biomarker scores and studies

This was a narrative review of select studies published through September of 2024. We review the shift toward multi-dimensional scores such as HCC early detection screening (HES), GALAD, ASAP, and mt-HBT represents a significant advancement in biomarker research for hepatocellular carcinoma (HCC) detection. Unlike single biomarker approaches, these scores integrate various clinical and biochemical factors to enhance predictive accuracy by reflecting different complementary aspects of disease progression and HCC oncogenesis. Proper testing and validation of biomarker scores in phase 3 biomarker studies is essential before wide use can be recommended. We also review the comparative performance of biomarker scores in phase 3 studies. The new version of HES (HES V2.0) which includes AFP, AFP L3, DCP, and changes in their levels the past one year, if available, in addition to age, platelets, albumin, ALT and underlying liver disease etiology outperforms GALAD in detecting early-stage HCC with overall 6.7% higher sensitivity, and ASAP with 13.4%-18.0% higher sensitivity, both at fixed 90% specificity. HES V2.0 is a leading candidate biomarker score for prospective testing in clinical studies of early HCC detection.

Optimizing US for HCC surveillance

Ultrasound is the primary imaging modality used for surveillance of patients at risk for HCC. In 2017, the American College of Radiology Liver Imaging Reporting and Data Systems (ACR LI-RADS) introduced US LI-RADS to standardize the performance, interpretation, and reporting of US for HCC surveillance, with the algorithm recently updated as LI-RADS US Surveillance v2024. The American Association for the Study of Liver Diseases (AASLD) recommends reporting both the examination-level LI-RADS US Category as well as the US Visualization Score. The US Category conveys the overall findings of the exam and primarily determines follow up recommendations. The US Visualization Score conveys the expected sensitivity of the test and stratifies patients into appropriate surveillance pathways. One of the goals of routine surveillance is the detection of HCC at an early, potentially curable stage. Therefore, optimizing US technique is of critical importance. Increasing North American and worldwide utilization of LI-RADS US Surveillance, which includes technical recommendations, through education and outreach will undoubtedly benefit patients undergoing US HCC surveillance.

The epigenetic basis of hepatocellular carcinoma - mechanisms and potential directions for biomarkers and therapeutics

Hepatocellular carcinoma (HCC) is the sixth leading cancer worldwide and has complex pathogenesis due to its heterogeneity, along with poor prognoses. Diagnosis is often late as current screening methods have limited sensitivity for early HCC. Moreover, current treatment regimens for intermediate-to-advanced HCC have high resistance rates, no robust predictive biomarkers, and limited survival benefits. A deeper understanding of the molecular biology of HCC may enhance tumor characterization and targeting of key carcinogenic signatures. The epigenetic landscape of HCC includes complex hallmarks of 1) global DNA hypomethylation of oncogenes and hypermethylation of tumor suppressors; 2) histone modifications, altering chromatin accessibility to upregulate oncogene expression, and/or suppress tumor suppressor gene expression; 3) genome-wide rearrangement of chromatin loops facilitating distal enhancer-promoter oncogenic interactions; and 4) RNA regulation via translational repression by microRNAs (miRNAs) and RNA modifications. Additionally, it is useful to consider etiology-specific epigenetic aberrancies, especially in viral hepatitis and metabolic dysfunction-associated steatotic liver disease (MASLD), which are the main risk factors of HCC. This article comprehensively explores the epigenetic signatures in HCC, highlighting their potential as biomarkers and therapeutic targets. Additionally, we examine how etiology-specific epigenetic patterns and the integration of epigenetic therapies with immunotherapy could advance personalized HCC treatment strategies.

Genome-Wide Methylation Sequencing to Identify DNA Methylation Markers for Early-stage Hepatocellular Carcinoma in Liver and Blood

BACKGROUND

Hepatocellular carcinoma (HCC) is associated with a poor 5-year survival mainly due to detection at late stages. Better non-invasive surveillance methods are needed to improve early detection and maximize survival. We performed a strict assessment of DNA methylation markers (DMMs) for HCC detection.

METHODS

A total of 385 samples from liver tissues and blood were analyzed. Genome-wide Methylated DNA sequencing (MeD-seq) was initially performed on 46 liver tissues, followed by the validation using quantitative methylation-specific PCR (qMSP) on 175 liver tissues. The selected DMMs with and without ASAP/GAAD score were further evaluated in 180 blood samples. Additionally, MeD-seq was performed to validate the results on blood.

RESULTS

MeD-seq revealed a substantial number of differentially methylated regions (DMRs) in HCC tissues compared to non-HCC controls. By qMSP, the top 5 DMMs demonstrated strong performance in distinguishing cirrhotic HCC from cirrhosis controls in tissue (AUC 0.842 to 0.957). However, evaluation of these DMMs in blood showed lower performance in early HCC detection compared to cirrhosis in both the training (sensitivity 26.7-43.3%, 81.3% specificity) and validation cohorts (sensitivity 16.2-43.2%, 85.7% specificity). The addition of DMMs to the ASAP/GAAD score only provided an additional 5.4% sensitivity in the validation cohort compared to the ASAP/GAAD score alone. These findings were confirmed using MeD-seq analysis in blood samples, which revealed no detectable DMRs between cirrhotic HCC and cirrhosis controls. Interestingly, DNA methylation patterns in blood of healthy individuals differed strongly from both groups (cirrhosis and cirrhotic HCC).

CONCLUSION

DNA methylation patterns in liver tissue were distinctly different between HCC and controls. In blood, DMMs contributed minimally to early-stage HCC detection compared to cirrhosis, whether used alone or in combination with the ASAP/GAAD score. It is likely that high baseline DNA methylation related to cirrhosis and possibly the low input of tumor-related DNA impacts the use of DMMs in early HCC detection in blood.

Discovery and validation of a novel dual-target blood test for the detection of hepatocellular carcinoma across stages from cirrhosis

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common cancers. Early detection of HCC helps improve the patients' 5-year survival rate. Our goal was to identify superior methylation biomarkers to develop a methylation-specific quantitative PCR (MS‒qPCR) assay.

METHODS

A five-phase case-control study identified HCC methylation biomarkers via capture sequencing, TCGA/RNA-seq filtering, technical (MS-qPCR/Sanger) and biological (quadruplex MS-qPCR) validation. Methylated biomarkers were selected based on differential methylation expression using a tissue discovery cohort (43 HCC, 32 normal) and validated in plasma validation cohorts (Phase 1: 53 HCC, 52 cirrhosis, 20 benign, 50 healthy; Phase 2: 67 HCC, 81 cirrhosis). Then, the final assay's HCC detection performance was compared with existing blood-based surveillance methods.

RESULTS

Two methylated genes, OSR2 and TSPYL5, and a novel internal reference gene, SDF4, were identified and developed into an MS‒qPCR assay named Qliver. Qliver had an AUC of 0.955 (95% CI: 0.924-0.987) for distinguishing HCC patients from non-HCC patients in the Phase 1 plasma cohort, with a sensitivity of 88.68% (95% CI: 76.97%-95.73%) and a specificity of 89.34% (95% CI: 82.47%-94.20%), and 0.958 (95% CI: 0.927-0.989) for distinguishing HCC patients from cirrhosis patients in the Phase 2 plasma cohort, with a sensitivity of 88.06% (95% CI: 77.82%-94.70%) and a specificity of 92.59% (95% CI: 84.57%-97.23%). For the Phase 1 plus Plasma 2 cohort, Qliver had an AUC of at least 0.958 for detecting HCC in healthy individuals, cirrhosis patients and patients with benign liver diseases, which was superior to that of the GALAD score (AUC: 0.777 to 0.849). For BCLC stage 0 and A HCC patients, the sensitivity of Qliver ranged from 62.50% (95% CI: 24.49%-91.48%) to 72.73% (39.03%-93.98%), with a specificity of 90%. Overall, Qliver was superior to the AFP, AFP-L3, DCP and the GALAD score in terms of cirrhosis history, tumor stage, tumor size and tumor count.

CONCLUSIONS

Qliver demonstrated superior performance in detecting HCC compared with currently widely used blood biomarkers, suggesting its potential clinical benefit in HCC surveillance in high-risk populations.

Performance of the GALAD Model in an Asian Cohort Undergoing Hepatocellular Carcinoma Surveillance: A Prospective Cohort Study

BACKGROUND AND AIM

Current hepatocellular carcinoma (HCC) surveillance strategy has its limitations, consequently delaying early detection. The GALAD model has been validated in retrospective studies, with two published cut-off values yielding different sensitivities for HCCs of different etiologies. We evaluated the performance of GALAD model in HCC surveillance and determined the ideal cut-off value for our cohort.

METHODS

Patients undergoing 6-monthly HCC surveillance in Singapore General Hospital were recruited between December 2017-October 2018. Study serum specimens were prospectively collected and retrospectively tested using the μTASWako alpha-fetoprotein (AFP), AFP-L3, and protein induced by vitamin K antagonism-II (PIVKA-II) kits. GALAD score was calculated and compared with individual biomarkers using area under the curve (AUC) analysis. Published GALAD cut-offs of -0.63 and -1.95 were compared for their performance in HCC detection.

RESULTS

There were 207 patients (median age 59 years, 55.1% males). Hepatitis B was the commonest etiology (72.9%). By February 2023, with a median follow-up of 48.9 months, 20 patients had developed HCC. Eight patients developed HCC within 1 year from specimen collection. For HCC developing within 1 year, GALAD model detected HCC with an AUC of 0.84, greater than AFP (AUC 0.77), AFP-L3 (AUC 0.60), and PIVKA-II (AUC 0.67). GALAD at cut-off -1.95 achieved sensitivity and specificity of 75% and 92.5% for HCCs detected within 1 year, superior to cut-off -0.63 (sensitivity 12.5%, specificity 100%).

CONCLUSION

In this prospective study of HCC surveillance, the GALAD model performed better than individual biomarkers. The cut-off of -1.95 was more useful in our predominantly chronic hepatitis B cohort.

Risk factors and clinical outcomes in patients with HCV eradication by direct-acting antivirals: a systematic review and meta-analysis

BACKGROUND

In hepatitis C patients with sustained virologic response (SVR) achieved after direct-acting antivirals (DAAs), the incidence of adverse clinical outcomes can be reduced but not completely eliminated. This meta-analysis aims at estimating the incidence of clinical outcomes in hepatitis C patients after achieving SVR with DAAs.

METHODS

Literature search was carried out in PubMed, Cochrane Library database, Web of Science, and Embase. The primary endpoint was the incidence of hepatocellular carcinoma (HCC) occurrence, HCC recurrence, decompensated cirrhosis, and liver-related mortality, following DAA-induced elimination of hepatitis C virus (HCV). Subgroup analyses were performed according to age, gender, comorbidities, region, fibrosis stage, presence of decompensation, duration of follow-up, start point of follow-up, and HCC treatment modality. Furthermore, meta-regression was performed to explore sources of high heterogeneity.

RESULTS

Finally, 132 articles were included in our study. The pooled HCC occurrence rate was 1.50/100 person-years (95% CI, 1.35-1.65), HCC recurrence rate was 17.00/100 person-years (95% CI, 13.83-20.42), decompensation rate was 0.30/100 person-years (95% CI, 0.16-0.48), and liver-related mortality was 0.32/100 person-years (95% CI, 0.14-0.56). Meta-regression showed that duration of follow-up and fibrosis grade were important contributors to HCC occurrence. Age, start point of follow-up, and duration of follow-up were important contributors to HCC recurrence rate.

CONCLUSION

Patients with DAA-induced HCV elimination remain at risk for adverse outcomes, particularly those with cirrhosis and HCC history. The exposure to adverse outcomes tended to decrease over time, and the frequency and intensity of follow-up might be reduced in the future, which will require new scoring models to identify these individuals.

Multicenter evaluation of abbreviated MRI and ultrasound for detecting early-stage hepatocellular carcinoma

Background & aims

Abbreviated MRI (AMRI) has been proposed as an alternative to ultrasound for hepatocellular carcinoma (HCC) surveillance; however, comparative data for AMRI and ultrasound are needed. Thus, we evaluated the sensitivity and specificity of dynamic contrast-enhanced (DCE)-AMRI and ultrasound for early-stage HCC detection in patients with cirrhosis.

Methods

We conducted a multicenter retrospective case-control study among patients with cirrhosis (cases with early-stage HCC as per Milan Criteria; controls without HCC) who underwent an ultrasound and a DCE-MRI within a 6-month period between 2012 and 2019. HCC diagnosis was confirmed by imaging alone in 85% and by histopathology in 15% of patients. Dynamic AMRI examinations were simulated from the full MRI by selecting relevant sequences. Independent, blinded interpretations of ultrasounds and AMRI results were performed using Liver Imaging Reporting and Data System algorithms. Ultrasounds were considered positive if US-3 observations were detected. AMRI was considered positive if LR-4, LR-5, or LR-M were detected. Per-patient sensitivity and specificity for early-stage HCC detection were estimated, and cross-modality differences were tested.

Results

We included 216 cases and 432 controls. Patient-level sensitivity and specificity of AMRI were significantly higher compared with ultrasound: 80.1% (95% CI 76.1-83.6) vs. 71.1% (95% CI 66.6-75.2), p <0.001, and 91.9% (95% CI 89.9-93.5) vs. 72.3% (95% CI 69.3-75.2), p <0.001, respectively. AMRI sensitivity was significantly higher compared with ultrasound among patients with Child-Pugh B cirrhosis (80.8% vs. 57.4%, p <0.001) but not among those with Child-Pugh A (84.7% vs. 78.6%, p = 0.07) or Child-Pugh C cirrhosis (52.6% vs. 68.4%, p = 0.18).

Conclusions

Dynamic AMRI may be more sensitive and specific for early-stage HCC detection in patients with cirrhosis compared with ultrasound, although its relative benefit might be smaller in patients with Child-Pugh A cirrhosis. Larger direct comparative data sets are needed, particularly among patients with Child-Pugh C cirrhosis who may benefit from alternative surveillance strategies.

Impact and implications

Abbreviated MRI (AMRI) is increasingly recognized as an alternative to ultrasound for hepatocellular carcinoma (HCC) surveillance. However, existing data are limited by single-center samples, spectrum bias, and lack of comparative data for AMRI vs. ultrasound. We found that AMRI had significantly higher per-patient sensitivity and specificity compared with ultrasound for the detection of early-stage HCC, although its relative benefit might be smaller in patients with Child-Pugh A cirrhosis, and both modalities underperformed in patients with Child-Pugh C cirrhosis. If sufficiently validated, AMRI could be adopted into practice guidelines for HCC surveillance and serve as a preferred alternative in select subgroups of patients.

Enhancing Liver Nodule Visibility and Diagnostic Classification Using Ultrasound Local Attenuation Coefficient Slope Imaging

OBJECTIVE

B-mode ultrasound (US) presents challenges in accurately detecting and distinguishing between benign and malignant liver nodules. This study utilized quantitative US local attenuation coefficient slope (LACS) imaging to address these limitations.

MATERIALS AND METHODS

This is a prospective, cross-sectional study in adult patients with definable solid liver nodules at US conducted from March 2021 to December 2023. The composite reference standard included histopathology when available or magnetic resonance imaging. LACS images were obtained using a phantom-free method. Nodule visibility was assessed by computing the contrast-to-noise ratio (CNR). Classification accuracy for differentiating benign and malignant lesions was assessed with the area under the receiver operating characteristic curve (AUC), along with sensitivity and specificity.

RESULTS

The study enrolled 97 patients (age: 62 y ± 13 [standard deviation]), with 57.0% malignant and 43.0% benign observations (size: 26.3 ± 18.9 mm). LACS images demonstrated higher CNR (12.3 dB) compared to B-mode (p < 0.0001). The AUC for differentiating nodules and liver parenchyma was 0.85 (95% confidence interval [CI]: 0.79-0.90), with higher values for malignant (0.93, CI: 0.88-0.97) than benign nodules (0.76, CI: 0.66-0.87). A LACS threshold of 0.94 dB/cm/MHz provided a sensitivity of 0.83 (CI: 0.74-0.89) and a specificity of 0.82 (CI: 0.73-0.88). LACS mean values were higher (p < 0.0001) in malignant (1.28 ± 0.27 dB/cm/MHz) than benign nodules (0.98 ± 0.19 dB/cm/MHz).

CONCLUSION

LACS imaging improves nodule visibility and provides better differentiation between benign and malignant liver nodules, showing promise as a diagnostic tool.

Metabolomic liquid biopsy dynamics predict early-stage HCC and actionable candidates of human hepatocarcinogenesis

Background & Aims

Actionable candidates of hepatocarcinogenesis remain elusive, and tools for early detection are suboptimal. Our aim was to demonstrate that serum metabolome profiles reflect the initiation of hepatocellular carcinoma (HCC) and enable the identification of biomarkers for early HCC detection and actionable candidates for chemoprevention.

Methods

This global cohort study included 654 patients and 801 biospecimens. Following serum metabolome profiling across the spectrum of hepatocarcinogenesis, we conducted a phase II biomarker case-control study for early HCC detection. Findings were independently validated through in silico analysis, mRNA sequencing, and proteome profiling of primary HCC and non-tumoral tissue, and in vitro experiments.

Results

Aspartic acid, glutamic acid, taurine, and hypoxanthine were differentially abundant in the serum across chronic liver disease, cirrhosis, initial HCC, and progressed HCC, independent of sex, age, and etiology. In a phase II biomarker case-control study, a blood-based metabolite signature yielded an AUC of 94% to discriminate between patients with early-stage HCC and controls with cirrhosis, including independent validation. Unsupervised biclustering (MoSBi), lipid network analysis (LINEX2), and pathway enrichment analysis confirmed alterations in amino acid-, lipid-, and nucleotide-related pathways. In tumor tissue, these pathways were significantly deregulated regarding gene and protein expression in two independent datasets, including actionable targets RRM2, GMPS, BCAT1, PYCR2, and NEU1. In vitro knockdown confirmed a functional role in proliferation and migration, as exemplified for PYCR2.

Conclusions

These findings demonstrate that serum metabolome profiling indicates deregulated metabolites and pathways during hepatocarcinogenesis. Our liquid biopsy approach accurately detects early-stage HCC outperforming currently recommended surveillance tools and facilitates identification of actionable candidates for chemoprevention.

Impact and implications

Deregulated cellular metabolism is a hallmark of cancer. In smaller studies, circulating metabolite profiles have been associated with HCC, although mainly in the context of fatty liver disease. Translation strategies for primary prevention or early detection are lacking. In this global study, we present an unsupervised landscape of the altered serum metabolome profile during hepatocarcinogenesis, independent of age, sex, and etiology. We provide a blood-based metabolite signature that accurately identifies early-stage HCC in a phase II biomarker study including independent validation. Further RRM2, GMPS, BCAT1, PYCR2, and NEU1 are identified in tumor tissue as actionable candidates for prevention. Our data provide the rationale for clinical trials testing liquid biopsy metabolome-based signatures for early HCC detection and the development of chemoprevention strategies.

Exam quality of ultrasound and dynamic contrast-enhanced abbreviated MRI and impact on early-stage HCC detection

PURPOSE

MRI is a potential alternative to ultrasound for hepatocellular carcinoma (HCC) detection. We evaluated the impact of ultrasound and dynamic abbreviated MRI (AMRI) exam quality on early-stage HCC detection.

METHODS

We conducted a multicenter case-control study among patients with cirrhosis (cases with early-stage HCC per Milan Criteria; controls without HCC) who underwent both a liver ultrasound and dynamic contrast-enhanced (DCE) AMRI within 6 months in 2012-2019. Two radiologists performed independent, blinded interpretations of both exams for HCC detection and scored exam quality as no/mild, moderate, or severe limitations. Associations between exam quality, patient characteristics, and HCC detection were assessed by odds ratios (OR).

RESULTS

Of 216 cases and 432 controls, severe limitations were reported in 7% and 8% of ultrasounds and DCE-AMRIs, respectively. Severe limitations at ultrasound were associated with obesity (OR 2.08, 95%CI [1.32-3.32]) and metabolic dysfunction-associated steatotic liver disease (MASLD) (OR 1.98 [1.12-3.44]) but not for DCE-AMRI. Decompensated cirrhosis (Child-Pugh C) was associated with severe limitations for both ultrasound (OR 2.54 [1.37-4.58]) and DCE-AMRI (OR 3.96 [2.36-6.58]). Compared to exams with no/mild limitations, exams with severe limitations had lower sensitivity for ultrasound (79.6% vs. 21.7%, P < 0.001) and AMRI (86.1% vs. 50.0%, P = 0.001). In patients in whom ultrasound was severely limited, DCE-AMRI had significantly higher odds of early-stage HCC detection than ultrasound (OR 8.23 [1.25-54.02]).

CONCLUSIONS

HCC detection by DCE-AMRI may be preferred in patients with severe limitations at ultrasound due to obesity and MASLD. Both modalities remain limited for patients with decompensated cirrhosis, for whom alternative strategies may be needed.

Combining AFP, PIVKA-II, and GP73 has diagnostic utility for hepatitis B-associated hepatocellular carcinoma and is consistent with liver pathology results

Although liquid biopsy has garnered increasing attention in recent years for diagnosing hepatocellular carcinoma (HCC), serum biomarkers continue to hold significant value for HCC diagnosis due to their simple operation, cost-effectiveness, and high efficiency. This study aimed to screen for the optimal diagnostic combinations of alpha fetoprotein (AFP), a protein induced by vitamin K deficiency or antagonist II (PIVKA-II), golgi glycoprotein 73 (GP73), and routine clinical indicators for diagnosing hepatitis B-associated HCC (HBV-HCC). A retrospective analysis was conducted on 358 HBV-HCC patients treated at Taizhou People's Hospital from August 2015 to October 2021; 124 patients with chronic hepatitis B (CHB) and 241 patients with hepatitis B cirrhosis composed the control group. With liver pathology as the gold standard, the concordance between the screened indicators and liver pathology for HCC diagnosis was analyzed by Cohen's kappa coefficient. In the CHB group, AFP, PIVKA-II, and GP73 were statistical significance, and the triple biomarker combination achieved the highest AUC (0.908) for HCC diagnosis, surpassing the efficacy of both individual indicators and two biomarker combinations. In both the Child‒Pugh A and Child‒Pugh B&C cirrhosis groups, AFP and PIVKA-II were significantly different between patients with and without HCC, and the AUC values of AFP combined with PIVKA-II for HCC diagnosis were 0.969 and 0.956, respectively. Using liver pathology as the gold standard, the Kappa values of the above combinations in the three groups were 0.866, 0.780, and 0.800, respectively. The triple combination of AFP, PIVKA-II, and GP73 in the CHB group and the combination of AFP and PIVKA-II in both the Child‒Pugh A and Child‒Pugh B&C cirrhosis groups had excellent diagnostic accuracy for HCC, consistent with liver pathology, and were superior to the diagnostic ability of individual biomarkers.

Predictors of hepatocellular carcinoma in LR-M category lesions, a multi-institutional analysis

PURPOSE

The Liver Imaging Reporting and Data System (LI-RADS, LR) provides a framework for diagnosing hepatocellular carcinoma (HCC, LR-5). However, not all HCCs meet LR-5 criteria and are instead categorized as LR-M, probably or definitely malignant but not specific for HCC, necessitating biopsy for diagnosis. The purpose is to identify factors associated with HCC in LR-M observations.

METHODS

This is an IRB-approved, retrospective analysis of participants from 8 institutions that had a LR-M observation on CT or MRI with corresponding histopathologic diagnosis. Demographics and biochemical data were examined. Central review using the LI-RADS v2018 algorithm was performed. Kappa statistics defined inter-reader agreement. Random forest and logistic regression analyses generated a model for HCC diagnosis.

RESULTS

162 participants with 162 LR-M observations were included. 46% of observations (74/162) were HCC and 37% were cholangiocarcinoma (60/162). Two of 34 imaging features- observation size and intra-lesion iron- showed moderate to strong inter-reader agreement (Kappa ≥ 0.60) while the remainder showed weak or no agreement (Kappa < 0.60). Random forest analysis showed biochemical features to be more predictive of HCC than imaging features. Logistic regression analysis of a model based on INR and AFP provided a 72% sensitivity and 61% specificity for HCC by Youden's index and a 90% specificity threshold yielded 38% sensitivity, 75% positive predictive value, and 66% negative predictive value.

CONCLUSIONS

Our results show INR and AFP are associated with HCC in LR-M observations. A high-specificity threshold may assist in the non-invasive diagnosis of HCC in the appropriate setting. In certain at-risk patients with a LR-M observation on diagnostic imaging, serum AFP and INR maybe useful tools for the non-invasive diagnosis of HCC.

Hepatocellular Carcinoma and the Role of Liver Transplantation: An Update and Review

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. Multiple treatment modalities are available for the management of HCC, depending on its stage as determined by the Barcelona Clinic Liver Cancer staging system. Because liver transplantation (LT) theoretically removes the cancer and replaces the organ at risk for future malignancy, LT is often considered the most definitive and one of the most efficacious treatment options for HCC. Nevertheless, the success and efficacy of liver transplantation depend on various tumor characteristics. As a result, multiple criteria have been developed to assess the appropriateness of a case of HCC for LT, with the pioneering Milan Criteria established in 1996. Over the past 20 to 30 years, these criteria have been critically evaluated, expanded, and often liberalized to make LT for patients with HCC a more universally applicable option. Furthermore, the development of other treatment modalities has enabled downstaging and bridging strategies for HCC prior to LT. In this narrative and comprehensive review, we provided an update on recent trends in the epidemiology of HCC, selection criteria for LT, implementation of LT across different regions, treatment modalities available as bridges, downstaging strategies, alternatives to LT, and, finally, post-LT surveillance.

Current Challenges in Imaging-Based Cancer Screening, From the AJR Special Series on Screening

The early detection of cancer confers many significant benefits for patients, primarily by enabling less invasive and more effective treatments and thus lowering disease mortality. Radiology is integral to early cancer detection, playing either a primary or complementary role in screening programs. Imaging-based screening is often performed in conjunction with other screening tests and may involve multiple modalities depending on patient demographics and cancer type. When developing a screening program for cancer early detection, both its potential benefits and harms need to be assessed. These harms, although specific to the modality and cancer, often include overdiagnosis, overtreatment, and false-positive examinations. As radiology technology improves and new tools become available, the ratios of risk to harm of imaging-based screening will shift, and screening recommendations will need to adapt accordingly. Radiologists must be major partners in the development and execution of screening guidelines to ensure the highest quality of care for their patients. This review discusses the major challenges of cancer screening programs and guidelines, exploring sources of evidence as well as harms of overdiagnosis and overtreatment. The article focuses on the most common cancer types that incorporate imaging-based screening including lung cancer, breast cancer, colon cancer, prostate cancer, and hepatocellcular carcinoma.

New insights into biomarkers and risk stratification to predict hepatocellular cancer

Hepatocellular carcinoma (HCC) is the third major cause of cancer death worldwide, with more than a doubling of incidence over the past two decades in the United States. Yet, the survival rate remains less than 20%, often due to late diagnosis at advanced stages. Current HCC screening approaches are serum alpha-fetoprotein (AFP) testing and ultrasound (US) of cirrhotic patients. However, these remain suboptimal, particularly in the setting of underlying obesity and metabolic dysfunction-associated steatotic liver disease/steatohepatitis (MASLD/MASH), which are also rising in incidence. Therefore, there is an urgent need for novel biomarkers that can stratify risk and predict early diagnosis of HCC, which is curable. Advances in liver cancer biology, multi-omics technologies, artificial intelligence, and precision algorithms have facilitated the development of promising candidates, with several emerging from completed phase 2 and 3 clinical trials. This review highlights the performance of these novel biomarkers and algorithms from a mechanistic perspective and provides new insight into how pathological processes can be detected through blood-based biomarkers. Through human studies compiled with animal models and mechanistic insight in pathways such as the TGF-β pathway, the biological progression from chronic liver disease to cirrhosis and HCC can be delineated. This integrated approach with new biomarkers merit further validation to refine HCC screening and improve early detection and risk stratification.

Plasma protein levels and hepatocellular carcinoma: a Mendelian randomization study with drug screening implications

BACKGROUND

Hepatocellular carcinoma (HCC) remains a significant cause of cancer-related mortality, highlighting the need for novel therapeutic strategies. Identifying key proteins and potential therapeutic agents is critical for improving treatment outcomes.

METHODS

We employed Mendelian randomization to identify proteins associated with HCC risk and utilized drug enrichment and molecular docking analyses to discover potential therapeutic agents. The efficacy of identified drugs was evaluated in vitro using immune-tumor co-culture systems and in vivo in a murine HCC model. Single-cell expression profiling and clinical sample analyses were conducted to explore expression patterns.

RESULTS

Our analyses identified 16 proteins linked to HCC pathogenesis. Among the therapeutic agents tested, Belinostat significantly enhanced T cell-mediated cytotoxicity against HCC cells and effectively reduced tumor growth in vivo. Single-cell analysis revealed significant modulation of immune cells within the tumor microenvironment, suggesting potential mechanisms for the observed therapeutic effects.

CONCLUSION

This study highlights the potential of Belinostat as a promising therapeutic agent for HCC. By modulating immune responses and tumor growth, Belinostat offers a novel approach to HCC treatment, warranting further clinical investigation to validate its efficacy and therapeutic potential.

Application of immunofluorescence-based detection of AFP-L3 in the diagnosis of hepatocellular carcinoma

Alpha-fetoprotein (AFP) together with Lens culinaris-agglutinin-reactive fraction of AFP (AFP-L3) serve as the preferred tumor markers for hepatocellular carcinoma (HCC) diagnosis. The authors performed diagnostic value analysis on AFP along with AFP-L3 as individual biomarkers and together to determine the optimal biomarker option. Researchers evaluated 149 HCC patient sera and 70 healthy control sera using automatic microchip capillary electrophoresis and liquid phase combination-based analysis. They found the area under the curve value for the conventional marker AFP reached 0.844 and the diagnostic value of AFP-L3 was 0.923. The diagnostic effectiveness did not enhance as both biomarkers were combined for testing. The performance metrics of AFP-L3 increase during disease progression which leads to complete diagnostic sensitivity and perfect specificity and an area under the curve value of 1 during Barcelona clinical liver cancer and D stage.

Serum Golgi protein 73 (GP73) is a diagnostic and prognostic marker of hepatocellular carcinoma

Introduction

Hepatocellular carcinoma (HCC) constitutes a significant global health burden, and is characterized by limited early detection methods and poor survival rates. Golgi protein 73 (GP73), previously associated with liver-related diseases, has a controversial diagnostic value for HCC. The present study aimed to determine the diagnostic efficacy of serum GP73 (sGP73) levels in HCC and to explore their potential correlations with the development of HCC.

Methods

The levels of sGP73 and serum alpha-fetoprotein (sAFP) were measured in 134 HCC patients, 200 healthy controls (HCs), and 45 non-HCC patients with various liver diseases. Additionally, immunohistochemical staining was conducted on paraffin-embedded tissue samples obtained from 30 HCC patients to examine the expression of CD4+ T cells, CD8+ T cells, Foxp3+ Treg cells, Ki-67, and interferon-gamma (IFN-γ) in the tissue specimens.

Results

sGP73 and sAFP were markedly higher in HCC patients than in HCs and non-HCC patients. However, sGP73 showed significantly higher sensitivity as a diagnostic marker for HCC than sAFP. The combination of sGP73 and sAFP further improved the accuracy (AUROC: 0.830). Besides, in the immunohistochemical staining analyses, sGP73-positive patients had lower expression of CD4+ and CD8+ T cells, higher expression of Foxp3+ Treg cells, higher expression of nuclear Ki67, and lower expression of IFN-γ than GP73-negative patients. In addition, sGP73-positive patients tended to have higher mortality rate, higher rate of metastasis, higher AFP levels, and more pronounced liver inflammation and damage than GP73-negative patients.

Conclusions

sGP73 could be utilized as a marker for the diagnosis of HCC, and may be implicated in the development of HCC through its interactions with the tumor microenvironment.

Plasma methylated HIST1H3G as a non-invasive biomarker for diagnostic modeling of hepatocellular carcinoma

Background

DNA methylation carrying epigenetic aberrations could potentially serve as a non-invasive tool for revolutionizing cancer diagnosis and monitoring. Here, we comprehensively evaluated the diagnostic value of plasma methylated HIST1H3G, and constructed diagnostic and prognostic models aimed at facilitating early detection and improving the prognosis of hepatocellular carcinoma (HCC).

Methods

The level of HIST1H3G promoter methylation in HCC tissues was evaluated based on the UALCAN database, followed by validation through serum samples collected from HCC patients. We recruited 205 participants, encompassing 70 HCC patients, 79 liver cirrhosis (LC) patients, 46 hepatitis patients and 10 HCC patients before and after treatment with either transarterial chemoembolization (TACE) or radiofrequency ablation (RFA). Analysis of plasma HIST1H3G was performed using methylation-specific quantitative polymerase chain reaction (qPCR). Diagnostic and prognostic prediction models were formulated using the random forest algorithm, and the performance of these models was rigorously evaluated through receiver operating characteristics curve (ROC) analysis.

Results

The methylation level of HIST1H3G was markedly elevated in both HCC tissues and plasma samples derived from HCC patients. HIST1H3G, PIVKA-II, total bilirubin (TBIL) and age were selected as the optimal markers and were included in the development of a diagnostic model. This model demonstrated superior accuracy in distinguishing HCC from high-risk populations, outperforming alpha-fetoprotein (AFP) in both the training cohort consisting of LC patients and the validation cohort comprising hepatitis patients. Additionally, HIST1H3G and albumin (Alb) were chosen to establish a prediction model for early HCC diagnosis, and this model exhibited a remarkable ability to identify early HCC. Furthermore, our prognostic prediction model proved effective in predicting the prognosis and survival outcomes of HCC patients.

Conclusion

Together, we identified and validated a diagnostic model that incorporated methylated HIST1H3G and clinically applicable serological indicators in HCC. The findings of our study established a pivotal foundation for the development of a non-invasive approach to identification and management in HCC.

Role of genomics in liver transplantation for cholangiocarcinoma

PURPOSE OF REVIEW

The purpose of this review is to summarize the current knowledge of cholangiocarcinoma molecular biology and to suggest a framework for implementation of next-generation sequencing in all stages of liver transplantation. This is timely as recent guidelines recommend increased use of these technologies with promising results.

RECENT FINDINGS

The main themes covered here address germline and somatic genetic alterations recently discovered in cholangiocarcinoma, particularly those associated with prognosis and treatment responses, and nascent efforts to translate these into contemporary practice in the peri-liver transplantation period.

SUMMARY

Early efforts to translate molecular profiling to cholangiocarcinoma care demonstrate a growing number of potentially actionable alterations. Still lacking is a consensus on what biomarkers and technologies to adopt, at what scale and cost, and how to integrate them most effectively into care with the ambition of increasing the number of patients eligible for liver transplantation and improving their long-term outcomes.

Current Advancements in Serum Protein Biomarkers for Hepatitis B Virus-Associated Hepatocyte Remodeling and Hepatocellular Carcinoma

BACKGROUND

Hepatitis B virus (HBV)-related liver cancer is the third most common cause of cancer-related death globally. Hepatocyte remodeling, also known as hepatocyte transformation and immortalization, and hepatocellular carcinoma (HCC), are brought on by persistent inflammation caused by HBV in the host hepatocytes. One of the main concerns in the perspective of HBV-induced hepatocyte remodeling and liver cancer is accurately identifying cancer stages to maximize early screening and detection. Biological signatures have a significant impact on solving this problem.

OBJECTIVE

This review article aimed to discuss the novel serum protein biomarkers for HBV-induced hepatocyte remodeling and HCC.

METHODS

The information was collected from various peer-reviewed journals through electronic searches utilizing various search engines, including PubMed, Google Scholar, HINARI, and Cochrane Library from 2017 to 2024. Keywords for searches included "serum protein biomarkers in HBV-HCC," "blood-based biomarkers in HBV-HCC," and "viral biomarkers for HBV-HCC."

RESULTS

Recently, novel protein signatures have been discovered for the early diagnosis, treatment, and prognosis of HBV-induced hepatic cell remodeling and HCC from proteomic data sets. We have discussed the recent literature on the clinical utility of the protein signatures for the diagnosis and forecasting of HBV-associated hepatocyte remodeling and HCC, including golgi protein 73 (GP73), glypican-3 (GPC3), midkine (MDK), des-γ-carboxy-prothrombin (DCP), von Willebrand factor (vWF), pentraxin 3 (PTX3), pseudouridine synthases 7 (PUSs 7), squamous cell carcinoma antigen (SCCA), and osteopontin (OPN).

CONCLUSION

All these protein markers also exhibit the survival of HBV-related HCC patients, the proliferation, migration, antiapoptosis, mitogenesis, transformation, and angiogenesis of HBV-infected hepatocytes.

LI-RADS Ultrasound Surveillance Version 2024: Comparison With Version 2017 for Hepatocellular Carcinoma Detection and Risk Factors for Visualization Score C

BACKGROUND. The LI-RADS Ultrasound Surveillance algorithm was updated in 2024, incorporating α-fetoprotein (AFP) and a visualization score of VIS-C into management recommendations after nonpositive results. OBJECTIVE. The purpose of this study was to compare the diagnostic performance of LI-RADS Ultrasound Surveillance version 2017 (v2017) and version 2024 (v2024) for the detection of hepatocellular carcinoma (HCC) in at-risk patients and to identify predictors of VIS-C on follow-up surveillance examinations. METHODS. This retrospective analysis included 407 patients (230 men and 177 women; median age, 56 years) with cirrhosis who underwent rounds of semiannual surveillance ultrasound as part of a prospective trial from November 2011 to August 2014. Two radiologists independently assigned ultrasound categories to round 1 examinations and visualization scores to round 1 and round 2 examinations; a third radiologist adjudicated disagreements. The AFP level was considered positive if elevated or increasing from preenrollment values, per v2024 criteria. The reference standard for HCC was positive biopsy or an LR-5 observation on MRI. Diagnostic performance was compared between v2017 and v2024. Logistic regression analyses were performed to identify predictors of a round 2 VIS-C result, with attention given to risk factors for VIS-C described in v2024. RESULTS. HCC was diagnosed in 28 patients (6.9%). LI-RADS Ultrasound Surveillance v2024, in comparison with v2017, showed greater sensitivity for reader 1 (64.3% vs 42.9%, p = .03) and reader 2 (64.3% vs 39.3%, p = .02) and lower specificity for reader 1 (82.1% vs 92.6%, p < .001) and reader 2 (82.3% vs 92.9%, p < .001). All seven patients with HCC detected by v2024 but not v2017 by means of consensus assessments had increasing AFP; two also had elevated AFP. Among 299 patients who underwent round 2 ultrasound after negative round 1 v2024 surveillance results, the only independent predictor of a round 2 VIS-C result was a round 1 VIS-C result (adjusted OR = 21.04 [95% CI, 10.84-40.83], p < .001). For 88 of these patients with round 1 VIS-C, no v2024 risk factor showed a significant univariable association with repeat VIS-C. CONCLUSION. Compared with v2017, LI-RADS Ultrasound Surveillance v2024 had higher sensitivity but lower specificity for HCC detection, which was primarily related to increasing, rather than elevated, AFP. The only independent predictor of VIS-C on subsequent ultrasound was the initial VIS-C result. CLINICAL IMPACT. The findings support the use of LI-RADS Ultrasound Surveillance v2024 to improve HCC detection in at-risk patients.

Cost-Effective Identification of Hepatocellular Carcinoma from Cirrhosis or Chronic Hepatitis Virus Infection Using Eight Methylated Plasma DNA Markers

Early detection of hepatocellular carcinoma (HCC) in patients with liver cirrhosis (LC) and/or hepatitis virus B/C infection (HVI) improves survival, highlighting the need for accurate, affordable diagnostic tools. Here, 11 methylated DNA markers (MDMs) are identified during marker discovery. In phase I, each selected MDM is validated in 175 plasma samples (HCC, n = 85; LC/HVI, n = 72) by the CO-methylation aMplification rEal-Time PCR (COMET) assay. Of these, 8 MDMs are qualified for phase II study, where a logistic regression model (COMET-LR) is trained and validated with 336 plasma samples (HCC, n = 211; LC/HVI, n = 113; training vs validation, 2:1). In the validation, the COMET-LR achieved 90.0% sensitivity at 97.4% specificity. Notably, sensitivity in patients with TNM stage I, diameter<3 cm, AFP-negative (<20 ng mL-1), PIVKA-II-negative (<40 mAU mL-1) is 82.4%, 77.8%, 88.6%, and 85.7%, respectively. The COMET-LR outperformed multiple protein markers (AFP, AFP-L3, and PIVKA-II) and published scores for HCC screening (GALAD, Doylestown, and ASAP), in terms of both sensitivity and specificity. The assay represents a significant advancement in addressing the unmet need for accurate, non-invasive, accessible, and cost-effective early detection tools for LC/HVI individuals. Further validation in a prospective cohort is warranted.

Effectiveness of noncontrast-abbreviated magnetic resonance imaging in a real-world hepatocellular carcinoma surveillance

OBJECTIVES

Noncontrast-abbreviated magnetic resonance imaging (NC-AMRI) is emerging as a promising alternative to ultrasound (US) for surveillance of hepatocellular carcinoma (HCC) in at-risk patients. We aimed to assess the effectiveness of NC-AMRI in a real-world surveillance population, and to evaluate the appropriateness of NC-AMRI in selected patients with inadequate prior US.

MATERIALS AND METHODS

This retrospective study included Child-Pugh class A or B adults with chronic hepatitis B or cirrhosis from any cause who underwent NC-AMRI between December 2018 and August 2022. Early- and very early-stage detection, receipt of curative treatment, and false referral were evaluated. Subgroup analysis was performed for patients with inadequate prior US examinations. Descriptive statistics were used.

RESULTS

Among the 1853 patients (mean age, 58.8 years; 1045 males), 68 HCCs developed in 61 (61/1853, 3.3%, 95% confidence interval: 2.5-4.2) patients. The proportions of early- and very early-stage detection were 95.1% (58/61, 72.2-100.0) and 70.5% (43/61, 51.0-95.0); receipt of curative treatment, 67.2% (41/61, 48.2-91.2); and proportion of false referral, 12.9% (9/70, 5.9-24.4). Among the 375 patients with inadequate prior US, the proportions of early- and very early-stage detection were 94.7% (18/19, 56.2-100.0) and 57.9% (11/19, 28.9-100.0); receipt of curative treatment, 52.6% (10/19, 25.2-96.8); and proportion of false referrals, 17.4% (4/23, 4.7-44.5).

CONCLUSION

NC-AMRI may be an effective HCC surveillance modality given the results related to early- and very early-stage detection, receipt of curative treatment, and false referral. NC-AMRI can be an alternative HCC surveillance strategy, especially for patients with inadequate prior US examinations.

KEY POINTS

Question There is insufficient evidence to support the use of noncontrast-abbreviated MRI as an effective surveillance tool in large real-life populations under surveillance. Findings Using noncontrast-abbreviated MRI, most patients who developed HCCs during surveillance were diagnosed at an early stage, with an acceptable false referral rate of 12.9%. Clinical relevance Noncontrast-abbreviated MRI is an effective HCC surveillance modality, especially for patients with inadequate prior ultrasound examinations.

Hepatocellular Carcinoma After HCV Eradication with Direct-Acting Antivirals: A Reappraisal Based on New Parameters to Assess the Persistence of Risk

Approximately 95% of patients with chronic hepatitis C achieve viral eradication through direct-acting antiviral (DAA) treatment. Ensuing clinical benefits include halting liver fibrosis, thereby reducing the need for liver transplantation, and decreasing both liver-related and overall mortality. It is well established that, although ameliorated, the risk of developing hepatocellular carcinoma (HCC) persists, particularly among patients with pre-treatment advanced fibrosis/cirrhosis. Current guidelines recommend indefinite HCC surveillance in these patients. However, a recent Markov model evaluation shows that HCC surveillance is cost-effective only for patients with cirrhosis but not so for those with F3 fibrosis, a finding which points out the need to better define the risk of HCC in hepatitis C patients after cure and further characterize pre- and post-treatment factors that might affect the incidence of HCC in this setting. We reviewed the literature analyzing this aspect. Here we summarize the main findings: male gender and older age are independent predictors of increased risk of post-cure HCC development. Moreover, non-invasive tests for hepatic fibrosis, namely FIB4, APRI, and liver stiffness, measured before and after treatment and their post-therapy change, contribute to better stratifying the risk of HCC occurrence. Furthermore, low serum albumin, as well as an AFP above 7 ng/mL prior to and after DAA therapy, also constitute independent predictors of HCC development. Considering these findings, we propose to classify patients with HCV viral eradication and advanced fibrosis/cirrhosis into groups of low, medium, or high risk of HCC and to adopt adequate surveillance strategies for each group, including protocols for abbreviated magnetic resonance imaging (MRI) for those at the highest risk.

Recent advances and issues in imaging modalities for hepatocellular carcinoma surveillance

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Early detection via surveillance plays a crucial role in enabling curative treatment and improving survival rates. Since the initial randomized controlled trial, biannual ultrasound (US) has been established as the standard surveillance method because of its accessibility, safety, and low cost. However, US has some limitations, including operator dependency, suboptimal sensitivity for early-stage HCC, and challenges such as a limited sonic window that may result in inadequate examination. Alternative imaging modalities, including contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), have demonstrated higher sensitivity for detecting very early-stage HCC. Recent advancements, such as low-dose CT with deep learning-based reconstruction, have enhanced the safety and feasibility of CT-based surveillance by reducing radiation exposure and amount of contrast media. MRI, particularly with gadoxetic acid or abbreviated protocols, offers superior tissue contrast and sensitivity, although its accessibility and cost remain challenges. Tailored surveillance strategies based on individual risk profiles and integration of advanced imaging technologies have the potential to enhance the detection performance and cost-effectiveness. This review highlights the recent developments in imaging technologies for HCC surveillance, focusing on their respective strengths and limitations.

Identification of serum phosphatidylinositol glycan anchor biosynthesis class U protein as diagnostic biomarker for breast cancer

BACKGROUND

Finding markers of breast cancer that are strong specificity and high. Sensitivity is important. The expression of phosphatidylinositol U（PIGU） protein is increased in a variety of tumor cells, but the role of its secreted fragment in breast cancer is lacking.

METHODS

Differential expression analysis was performed in breast cancer patients by bioinformatics method. Univariate survival analysis and ROC curve plotting were used to explore the correlation between serum PIGU and the prognosis of breast cancer patients. ELISA was used to detect serum PIGU level. Electrochemiluminescence immunoassay was used to determine serum carcinoembryonic antigen (CEA), carbohydrate antigen-153(CA153) and carbohydrate antigen-125 (CA125) levels.

RESULTS

The expression level of PIGU protein in breast cancer tumor tissues was higher than that in normal tissues, and PIGU expression level was a prognostic risk factor for breast cancer patients (HR > 1, p < 0.05) and had good predictive power (AUC = 0.8941). Compared with healthy individuals, the serum PIGU level of breast cancer patients was significantly highly expressed (p < 0.01), and the serum PIGU expression level was weakly positively correlated with CEA (r = 0.3270), but not significantly correlated with CA153 and CA125 (p > 0.05).

CONCLUSION

PIGU has the potential to be a predictive prognostic marker for breast cancer.

Long-Term Outcome of Chronic Hepatitis B-Histological Score and Viral Genotype Are Important Predictors of Hepatocellular Carcinoma

Current guidelines to prevent hepatocellular carcinoma (HCC) by chronic hepatitis B virus (HBV) infection are based on risk assessments that include age, sex, and virological and biochemical parameters. The study aim was to investigate the impact of predictive markers on long-term outcomes. The clinical outcomes of 100 patients with chronic hepatitis B were investigated 30 years after a baseline assessment that included liver biopsy. A favourable outcome-HBsAg loss or HBeAg-negative infection (ENI; previously termed 'inactive carrier')-was observed in 74% of all patients, whereas 7% developed HCC. HBsAg loss was observed in 75% of patients with genotype A, compared with 42%, 33% and 0% with genotypes D, B and C, respectively (p < 0.0001). HCC developed in 3 patients (33%) with genotype C as compared with 3 (17%), 1 (2%) and 0 patients with genotypes B, D and A, respectively (p < 0.0001). In multiple logistic regression analysis, both HBsAg loss and HCC were associated with HBV genotype and baseline HBV DNA level, and HCC also with histological score. The results suggest that genotyping and histological assessment may improve outcome prediction and help decisions about HCC screening, particularly in populations with HBV-infected individuals of mixed geographic origin.

Role of biomarkers in the diagnosis and management of HCC

For many cancers, biomarkers have served as an important tool across the cancer care continuum from risk stratification and early detection to diagnosis and treatment. Alpha-fetoprotein (AFP) remains one of the few validated biomarkers for patients with HCC. Although AFP has shown potential for each of these steps, its performance, when used alone, has often been suboptimal. There continue to be discordant recommendations about AFP's value when combined with ultrasound for surveillance, as well as its role in diagnostic algorithms. Conversely, high AFP levels are associated with aggressive tumor biology and survival, so it remains a key factor for the selection of candidates for liver transplant. There have been immense efforts to identify and validate additional biomarkers for each of these steps in the HCC care continuum. Indeed, biomarker panels have shown promising data for HCC risk stratification and surveillance among patients with cirrhosis, as well as prognostication and detection of minimal residual disease in patients undergoing HCC treatment. Several large prospective studies are currently ongoing to evaluate the role of these emerging biomarkers in clinical practice.

A concise review of updated global guidelines for the management of hepatocellular carcinoma: 2017-2024

Many guidelines for hepatocellular carcinoma (HCC) have been published and are regularly updated worldwide. HCC management involves a broad range of treatment options and requires multidisciplinary care, resulting in significant heterogeneity in management practices across international communities. To support standardized care for HCC, we systematically appraised 13 globally recognized guidelines and expert consensus statements, including five from Asia, four from Europe, and four from the United States. These guidelines share similarities but reveal notable discrepancies in surveillance strategies, treatment allocation, and other recommendations. Geographic differences in tumor biology (e.g., prevalence of viral hepatitis, alcohol-related liver disease, or metabolic dysfunction-associated steatotic liver disease) and disparities in available medical resources (e.g., organ availability, healthcare infrastructure, and treatment accessibility) complicate the creation of universally applicable guidelines. Previously, significant gaps existed between Asian and Western guidelines, particularly regarding treatment strategies. However, these differences have diminished over the years. Presently, variations are often more attributable to publication dates than to regional differences. Nonetheless, Asia-Pacific experts continue to diverge from the Barcelona Clinic Liver Cancer system, particularly with respect to surgical resection and locoregional therapies, which are viewed as overly conservative in Western guidelines. Advancements in systemic therapies have prompted ongoing updates to these guidelines. Given that each set of guidelines reflects distinct regional characteristics, strengths, and limitations, fostering collaboration and mutual complementarity is essential for addressing discrepancies and advancing global HCC care.

Hepatocellular Carcinoma Screening: From Current Standard of Care to Future Directions

Hepatocellular carcinoma (HCC) represents a significant portion of global cancer incidence and mortality. Screening with ultrasound with or without alpha-fetoprotein is recommended for those at high-risk. Although screening can lead to earlier treatment and better outcomes, existing screening paradigms have several flaws. Ultrasound does not capture all early lesions and has lower efficacy in specific populations such as patients with obesity or those with metabolic dysfunction-associated steatotic liver disease (MASLD). Additionally, individuals with noncirrhotic MASLD and chronic hepatitis C also develop HCC, although not at high enough rates to justify screening based on current standards. These individuals, however, represent a substantial proportion of new HCC cases given rising MASLD rates and the endemic nature of hepatitis C in certain regions. Risk-stratifying these populations may reveal subsets that are higher risk and warrant screening. Several imaging advances, including contrast-enhanced ultrasound and abbreviated MRI protocols, may improve detection compared with the current approach. Evaluation of risk stratification and validation of these new imaging methods via clinical trials would likely lead to adjusting screening guidelines. This narrative review provides a diagnostic and interventional radiology-focused summary of the HCC screening guidelines and their recent evolution and highlights emerging imaging methods as potential screening tools of the future.

Persisting challenges in the early detection of hepatocellular carcinoma

INTRODUCTION

Prognosis in patients with HCC is largely determined by stage at diagnosis, highlighting the importance of effective early detection strategies. HCC surveillance is associated with increased early detection and reduced HCC-related mortality and is currently recommended in patients with cirrhosis or chronic HBV infection.

AREAS COVERED

We performed a targeted literature review to identify limitations of current HCC surveillance practices and strategies for improvement.

EXPERT OPINION

Semi-annual ultrasound continues as the cornerstone modality for HCC surveillance but has limited sensitivity for detecting early-stage HCC, particularly in patients with obesity and non-viral etiologies. Although sensitivity for early-stage HCC can be improved by using ultrasound with alpha fetoprotein, this strategy misses over one-third of HCC at an early stage. Emerging imaging and biomarker-based surveillance strategies currently remain in varying stages of validation and are not yet ready for routine use in practice. The cost-effectiveness of surveillance in patients with non-cirrhotic liver disease related to hepatitis C or metabolic dysfunction-associated steatotic liver disease continues to be debated, although subgroups with advanced fibrosis may warrant surveillance. Finally, the effectiveness of surveillance is diminished by underuse in clinical practice, particularly in racial minority and low-income groups, highlighting a need for interventions to increase utilization.

Machine learning and multi-omics characterization of SLC2A1 as a prognostic factor in hepatocellular carcinoma: SLC2A1 is a prognostic factor in HCC

Hepatocellular carcinoma (HCC) is characterized by high incidence, significant mortality, and marked heterogeneity, making accurate molecular subtyping essential for effective treatment. Using multi-omics data from HCC patients, we applied diverse clustering algorithms to identify three HCC subtypes (HSs) with distinct prognostic characteristics. Among these, HS1 emerged as an immune-compromised subtype associated with the poorest prognosis. Additionally, we developed a novel, robust, and highly accurate machine learning-guided prognostic signature (MLPS) by integrating multiple machine learning algorithms and their combinations. Our study also identified SLC2A1, the core gene of MLPS, as being highly expressed during advanced stages of tumor progression. Knockdown experiments demonstrated that reducing SLC2A1 expression significantly suppressed the malignant behavior of HCC cells. Furthermore, SLC2A1 expression was linked to responsiveness to dasatinib and vincristine, suggesting potential therapeutic relevance. MLPS and SLC2A1 offer promising tools for individualized prognosis prediction and targeted therapy in HCC, providing new opportunities to improve patient outcomes.

Clinical Characteristics of Hepatitis B Virus-Associated Hepatocellular Carcinoma Patients in Southwest Nigeria

Hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality in West Africa, but its presentation is poorly understood. In this study, we describe the clinical characteristics of HBV-associated HCC patients in Lagos, Nigeria. Data for all cases were collected at the emergency and gastroenterology units (2017-2019), considering chronic carriers as controls. Clinical data and routine biochemical and radiologic test results were extracted from the files. The serum biomarkers (Osteopontin, AFP-L3, DCP) were investigated. For some cases, the hepatitis B viral load was determined. The mean age of the cases (n = 92) was 41.4 years, compared to 39.9 years for the controls (n = 100). Clinically, 69.5% of cases presented with ascites, 66.3% had nodules occupying >50% of the liver, and 67.4% had moderate hepatic encephalopathy. The mean viral load and the median values of Osteopontin, AFP-L3, and DCP for the cases were significantly higher than for the controls (p < 0.001). The area under the curve, sensitivity, and specificity were significantly higher for Osteopontin, compared with DCP and AFP-L3 (p < 0.001). Most HCC patients presented at a late disease stage, when the prognosis is usually poor. Especially Osteopontin seems to have potential for early HCC detection and could possibly complement AFP and abdominal ultrasound scan for risk-group screening.

Update on the Complications and Management of Liver Cirrhosis

Liver cirrhosis represents the advanced pathological stage of chronic liver disease, characterized by the progressive destruction and regeneration of the hepatic parenchyma over years, culminating in fibrosis and disruption of the vascular architecture. As a leading global cause of morbidity and mortality, it continues to affect millions worldwide, imposing a substantial burden on healthcare systems. Alcoholic/nonalcoholic fatty liver disease and chronic viral hepatitis infection, hepatitis C (HCV) in particular, remain leading causes of cirrhosis. Despite significant advances in understanding the pathogenesis of cirrhosis, its management is still complex due to the multifaceted complications, including ascites, hepatic encephalopathy, variceal bleeding, and hepatocellular carcinoma, all of which severely compromise the patient outcomes and quality of life. This review aims at filling a critical gap by providing a comprehensive summary of the latest evidence on the complications and management of liver cirrhosis. Evidence-based therapies targeting both the etiologies and complications of cirrhosis are essential for improving outcomes. While liver transplantation is considered a definitive cure, advancements in pharmacological therapies offer promising avenues for halting and potentially reversing disease progression. This review summarizes the latest management strategies for cirrhosis and its associated complications, emphasizing the importance of early intervention and novel therapeutic options for improving outcomes and quality of life in affected individuals.

The Diagnosis and Staging of Hepatocellular Carcinoma: A Review of Current Practices

Promoting the early detection and diagnosis of hepatocellular carcinoma (HCC) is a critical strategy to improve patient outcomes as this can lead to greater access to curative treatments. This review highlights the diagnostic tests for HCC, including the use of the Liver Imaging Reporting and Data System systems and histopathology. Staging is essential for informing prognosis and guiding treatment decisions; this review also covers a widely used and well-validated staging system called the Barcelona-Clinic Liver Cancer (BCLC) algorithm. The BCLC incorporates tumor status, liver function, and patient performance to stage patients with newly diagnosed HCC.

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Surveillance for Hepatocellular Carcinoma

This article reviews surveillance for the detection of early stage hepatocellular carcinoma, covering the rationale for surveillance, optimal selection of persons needing surveillance, methods and frequency of screening, strategies for addressing barriers to surveillance, and trends for future improvement in surveillance leading to more effective cancer control and improved patient outcomes. The importance of integrating liver cancer surveillance as a core component of national public health programs is emphasized. The impact of emerging technologies for identifying persons at risk, stratifying individual risk to improve the cost-effectiveness of surveillance programs, and improving the performance, accessibility, and convenience of surveillance are discussed.

Hepatocellular carcinoma: updates on epidemiology, surveillance, diagnosis and treatment

Hepatocellular carcinoma (HCC) is a major global burden, ranking as the third leading cause of cancer-related mortality. HCC due to chronic hepatitis B virus (HBV) or C virus (HCV) infection has decreased due to universal vaccination for HBV and effective antiviral therapy for both HBV and HCV, but HCC related to metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease is increasing. Biannual liver ultrasonography and serum α-fetoprotein are the primary surveillance tools for early HCC detection among high-risk patients (e.g., cirrhosis, chronic HBV). Alternative surveillance tools such as blood-based biomarker panels and abbreviated magnetic resonance imaging (MRI) are being investigated. Multiphasic computed tomography or MRI is the standard for HCC diagnosis, but histological confirmation should be considered, especially when inconclusive findings are seen on cross-sectional imaging. Staging and treatment decisions are complex and should be made in multidisciplinary settings, incorporating multiple factors including tumor burden, degree of liver dysfunction, patient performance status, available expertise, and patient preferences. Early-stage HCC is best treated with curative options such as resection, ablation, or transplantation. For intermediate-stage disease, locoregional therapies are primarily recommended although systemic therapies may be preferred for patients with large intrahepatic tumor burden. In advanced-stage disease, immune checkpoint inhibitor-based therapy is the preferred treatment regimen. In this review article, we discuss the recent global epidemiology, risk factors, and HCC care continuum encompassing surveillance, diagnosis, staging, and treatments.

A Phase 3 Biomarker Validation of GALAD for the Detection of Hepatocellular Carcinoma in Cirrhosis

BACKGROUND & AIMS

Better surveillance tests for hepatocellular carcinoma (HCC) are needed. The GALAD score (gender, age, α-fetoprotein [AFP] L3, AFP, and des-γ carboxyprothrombin) has been shown to have excellent sensitivity and specificity for HCC in phase 2 studies. We performed a phase 3 biomarker validation study to compare GALAD with AFP in detecting HCC.

METHODS

This is a prospective study of patients with cirrhosis enrolled at 7 centers. Surveillance for HCC was performed every 6 months at each site, and HCC diagnosis was confirmed per American Association for the Study of Liver Diseases guidelines. Blood for biomarker research was obtained at each follow-up visit and stored in a biorepository. Measurements of AFP, AFP-L3, and des-γ carboxyprothrombin) were performed in a FujiFilm laboratory by staff blinded to clinical data. The performance of GALAD in detecting HCC was retrospectively evaluated within 12 months before the clinical diagnosis. All analyses were conducted by an unblinded statistician in the Early Detection Research Network data management and coordinating center.

RESULTS

A total of 1,558 patients with cirrhosis were enrolled and followed for a median of 2.2 years. A total of 109 patients developed HCC (76 very early or early stage), with an annual incident rate of 2.4%. The areas under the curve for AFP and GALAD within 12 months before HCC were 0.66 and 0.78 (P < .001), respectively. Using a cutoff for GALAD of -1.36, the specificity was 82%, and the sensitivity at 12 months before HCC diagnosis was 62%. For comparison, performance of AFP at 82% specificity showed 41% sensitivity at 12 months before HCC diagnosis (P = .001).

CONCLUSIONS

GALAD score, compared to AFP, improves the detection of HCC within 12 months before the actual diagnosis.

The value of contrast-enhanced ultrasound fusion imaging in percutaneous liver biopsy for liver lesions invisible on conventional B-mode ultrasound

Background

Ultrasound (US) is the most commonly used imaging method for guiding percutaneous liver biopsies. For lesions that are invisible on B-mode ultrasound (BMUS), contrast-enhanced ultrasound (CEUS) improves the contrast between neoplasms and liver parenchyma, while emerging fusion imaging techniques can enhance the localization of lesions. Therefore, our study aimed to assess the value of CEUS fusion imaging in detecting and guiding percutaneous liver biopsy for lesions invisible on BMUS.

Methods

Patients with focal liver lesions (FLLs) identified on computed tomography (CT) or magnetic resonance imaging (MRI) but not visible on BMUS were retrospectively included at Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University from September 2019 to December 2023. All patients underwent BMUS fusion imaging and CEUS fusion imaging. We evaluated the lesion visibility, detection rate of BMUS fusion, and CEUS fusion before liver biopsy and the rate of technical success and diagnostic success after CEUS fusion-guided biopsy.

Results

This study included 70 FLLs from 61 patients. The mean visibility score of the 70 lesions on BMUS was 1.51±0.52. BMUS fusion detected 31 (31/70, 44.3%) lesions, yielding a mean visibility score of 1.81±1.03. CEUS fusion detected 63 (63/70, 90%) lesions, and achieved a mean visibility score of 2.90±0.30, which was significantly higher than that of BMUS fusion. Subgroup analysis corroborated the superiority of CEUS fusion in detecting infiltrative lesions and lesions <2 cm. Finally, CEUS fusion-guided liver biopsy achieved a technical success rate of 98.4% and a diagnostic success rate of 82.0% (50/61).

Conclusions

Compared with conventional BMUS or BMUS fusion imaging, the combination of CEUS and fusion imaging enabled an increase in the detection rate and lesion visibility of BMUS-invisible lesions, particularly for infiltrative masses and small-sized lesions, thereby increasing operators' confidence and success rate during the percutaneous liver biopsy.

Machine learning models for predicting hepatocellular carcinoma development in patients with chronic viral hepatitis B infection

Background

Chronic hepatitis B (CHB) infection is the major risk factor for hepatocellular carcinoma (HCC).

Objective

To develop machine-learning models for predicting an individual risk of HCC development in CHB-infected patients.

Methods

Machine learning models were constructed using features from follow-up visits of CHB patients to predict the diagnosis of HCC development within 6 months after each index follow-up. We developed 4 model variants using all features, with alpha fetoprotein (AFP) (AF A ) and without AFP (AFN ); and selected features, with AFP (SF A ) and without AFP (SFN ). Performance was evaluated using 10-fold cross-validation on a derivation cohort and further validated on an independent cohort.

Results

In the derivation cohort of 2,382 patients, of whom 117 developed HCC, AFA achieved higher sensitivity (0.634, 95% confidence interval [CI]: 0.559-0.708) and specificity (0.836; 0.830-0.842) than AF N (sensitivity 0.553; 0.476-0.630 and specificity 0.786; 0.779-0.792). SFA also achieved higher sensitivity (0.683; 0.611-0.755 vs. 0.658; 0.585-0.732) and specificity (0.756; 0.749-0.763 vs. 0.744; 0.737-0.751) than SFN . Performance of SFA and SFN were tested in another cohort of 162 patients in which 57 patients developed HCC. SFA achieved sensitivity and specificity of 0.634 (0.522-0.746) and 0.657 (0.615-0.699), while sensitivity and specificity of SFN were 0.690 (0.583-0.798) and 0.651 (0.609-0.693), respectively.

Conclusion

The machine learning models demonstrate good performance for predicting short-term risk for HCC development and may potentially be used for tailoring surveillance interval for CHB patients.

Evaluation of screening program for hepatocellular carcinoma at a single center

Background

Hepatocellular carcinoma (HCC) is the seventh most common cancer in the world and is a form of liver cancer that starts in the cells of the liver. The best way to increase the chances of survival for people at high risk for HCC is to detect it early through regular monitoring. For monitoring purposes, it is recommended to conduct ultrasound exams every 4 to 6 months, sometimes in combination with alpha-fetoprotein tests.

Aim of the work

Assess the HCC surveillance and its ability to detect HCC patients early on and improve their management.

Patients and methods

The study involved 300 patients of hepatocellular carcinoma (HCC) investigated at Menoufia University’s Institute of National Liver in Egypt. Patients were evaluated using the Liver Cancer of Barcelona Clinic (BCLC) staging system. Furthermore, the patients were classified into three surveillance categories: no surveillance, routine surveillance, and sporadic surveillance.

Results

A substantial difference statistically among the groups that received and did not receive surveillance with consideration for the stage of hepatocellular carcinoma (HCC) in particular was found. Patients who were observed usually got their diagnoses earlier. Those who were not under surveillance frequently had advanced cases of hepatocellular carcinoma upon diagnosis (HCC).

Conclusion

High-risk patients were regularly investigated for having HCC is necessary for early disease detection, appropriate therapy, and improved survival. Consistent monitoring with AFP and ultrasound allows for early detection of HCC.

Cost-effectiveness of monitoring and liver cancer surveillance among patients with inactive chronic hepatitis B

Patients with chronic hepatitis B infection (CHB) have an increased risk for death from liver cirrhosis and hepatocellular carcinoma (HCC). In the United States, only an estimated 37% of adults with chronic hepatitis B diagnosis without cirrhosis receive monitoring with at least an annual alanine transaminase (ALT) and hepatitis B deoxyribonucleic acid (DNA), and an estimated 59% receive antiviral treatment when they develop active hepatitis or cirrhosis. A Markov model was used to calculate the costs, health impact and cost-effectiveness of increased monitoring of adults with HBeAg negative inactive or HBeAg positive immune tolerant CHB who have no cirrhosis or significant fibrosis and are not recommended by the current American Association for the Study of Liver Diseases (AASLD) clinical practice guidelines to receive antiviral treatment, and to assess whether the addition of HCC surveillance would be cost-effective. For every 100,000 adults with CHB who were initially not recommended for treatment, if the monitoring rate increased from the current 37% to 90% and treatment rate increased from 59% to 80%, 4,600 cases of cirrhosis, 2,450 cases of HCC and 4,700 HBV-related deaths would be averted with a gain of 45,000 QALYs and a savings of $180 million in lifetime health care costs. At a willingness to pay threshold of $100,000/QALY, the addition of HCC surveillance with the standard recommended biannual liver ultrasound and alfa fetoprotein levels is likely cost-effective if the HCC risk ≥ 0.55%/year. Regular monitoring of persons with inactive or immune tolerant CHB who are initially not recommended to receive antiviral treatment in the United States is cost-saving. The addition of HCC surveillance with biannual US and AFP would be cost-effective for individuals with HCC incidence ≥ 0.55%/year.