Updates on Systemic Therapy for Hepatocellular Carcinoma

A conceptual exploration on the synergistic anti-tumor effects of high-order combination of OHSV2-DSTEFAP5/CD3, CAR-T cells, and immunotoxins in hepatocellular carcinoma

Background

Although the treatment landscape for advanced hepatocellular carcinoma (HCC) has seen significant advancements in the past decade with the introduction of immune checkpoint inhibitors and antiangiogenic drugs, progress has fallen short of expectations. Recently, a novel engineered oncolytic virus (OHSV2) that secretes dual-specific T-cell engagers (DSTEs) targeting the fibroblast activation protein (FAP) was developed and combined with GPC3-targeting CAR-T cells and immunotoxins to exert a synergistic antitumor effect.

Methods

OHSV2-DSTEFAP5/CD3 was initially generated by transducing the DSTEs engaging FAP5 on fibroblasts into the backbone of our oncolytic virus OHSV2. An innovative high-order combination was devised in a xenograft mouse model to conceptually explore whether enhanced anti-tumor effects could be achieved. Additionally, the underlying mechanisms of synergistic effects and safety profiles were preliminarily investigated.

Results

OHSV2-DSTEFAP5/CD3 effectively targeted and eliminated fibroblasts in vitro while maintaining cytotoxicity and inducing immune activation compared to parental OHSV2. In vivo, dose-adjusted combination therapy resulted in a remarkable antitumor effect compared to control treatments, leading to tumor regression in 40% of mice without significant toxicity to major organs. Mechanistically, rather than directly depleting fibroblasts, OHSV2-DSTEFAP5/CD3 played an essential role in priming T-cell proliferation, infiltration, and activation, and inhibiting the supportive interaction between cancer cells and fibroblasts.

Conclusions

This high-order combination represents a novel multiple-wave immunotherapeutic approach for HCC. Despite being a conceptual exploration, this strategy has demonstrated promising therapeutic efficacy and acceptable safety profiles.

The use of machine learning in transarterial chemoembolisation/transarterial embolisation for patients with intermediate-stage hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths worldwide. Intermediate-stage HCC is often treated with either transcatheter arterial chemoembolisation (TACE) or transcatheter arterial embolisation (TAE). Integrating machine learning (ML) offers the possibility of improving treatment outcomes through enhanced patient selection. This systematic review evaluates the effectiveness of ML models in improving the precision and efficacy of both TACE and TAE for intermediate-stage HCC. A comprehensive search of PubMed, EMBASE, Web of Science, and Cochrane Library databases was conducted for studies applying ML models to TACE and TAE in patients with intermediate-stage HCC. Seven studies involving 4,017 patients were included. All included studies were from China. Various ML models, including deep learning and radiomics, were used to predict treatment response, yielding a high predictive accuracy (AUC 0.90). However, study heterogeneity limited comparisons. While ML shows potential in predicting treatment outcomes, further research with standardised protocols and larger, multi-centre trials is needed for clinical integration.

Menin-MLL1 complex cooperates with NF-Y to promote HCC survival

Identification of new therapeutic targets in hepatocellular carcinoma (HCC) remains critical. Chromatin regulating complexes are frequently mutated or aberrantly expressed in HCC, suggesting dysregulation of chromatin environments is a key feature driving liver cancer. To investigate whether the altered chromatin state in HCC cells could be targeted, we designed and utilized an epigenome-focused CRISPR library that targets genes involved in chromatin regulation. This focused approach allowed us to test multiple HCC cell lines in both 2D and 3D growth conditions, which revealed striking differences in the essentiality of genes involved in ubiquitination and multiple chromatin regulators vital for HCC cell survival in 2D but whose loss promoted growth in 3D. We found the core subunits of the menin-MLL1 complex among the strongest essential genes for HCC survival in all screens and thoroughly characterized the mechanism through which the menin-MLL1 complex promotes HCC cell growth. Inhibition of the menin-MLL1 interaction led to global changes in occupancy of the complex with concomitant decreases in H3K4me3 and expression of genes involved in PI3K/AKT/mTOR signaling pathway. Menin inhibition affected chromatin accessibility in HCC cells, revealing that increased chromatin accessibility at sites not bound by menin-MLL1 was associated with the recruitment of the pioneer transcription factor complex NF-Y. A CRISPR/Cas9 screen of chromatin regulators in the presence of menin inhibitor SNDX-5613 revealed a significantly increased cell death when combined with NFYB knockout. Together these data show that menin-MLL1 is necessary for HCC cell survival and cooperates with NF-Y to regulate oncogenic gene transcription.

QSAR-Based Drug Repurposing and RNA-Seq Metabolic Networks Highlight Treatment Opportunities for Hepatocellular Carcinoma Through Pyrimidine Starvation

Background/Objectives: The molecular heterogeneity and metabolic flexibility of Hepatocellular Carcinoma (HCC) pose significant challenges to the efficacy of systemic therapy for advanced cases. Early screening difficulties often delay diagnosis, leading to more advanced stages at presentation. Combined with the inconsistent responses to current systemic therapies, HCC continues to have one of the highest mortality rates among cancers. Thus, this paper seeks to contribute to the development of systemic therapy options through the consideration of HCC's metabolic vulnerabilities and lay the groundwork for future in vitro studies. Methods: Transcriptomic data were used to calculate single and double knockout options for HCC using genetic Minimal Cut Sets. Furthermore, using QSAR modeling, drug repositioning opportunities were assessed to inhibit the selected genes. Results: Two single knockout options that were also annotated as essential pairs were found within the pyrimidine metabolism pathway of HCC, wherein the knockout of either DHODH or TYMS is potentially disruptive to proliferation. The result of the flux balance analysis and gene knockout simulation indicated a significant decrease in biomass production. Three machine learning algorithms were assessed for their performance in predicting the pIC50 of a given compound for the selected genes. SVM-rbf performed the best on unseen data achieving an R2 of 0.82 for DHODH and 0.81 for TYMS. For DHODH, the drugs Oteseconazole, Tipranavir, and Lusutrombopag were identified as potential inhibitors. For TYMS, the drugs Tadalafil, Dabigatran, Baloxavir Marboxil, and Candesartan Cilexetil showed promise as inhibitors. Conclusions: Overall, this study suggests in vitro testing of the identified drugs to assess their capabilities in inducing pyrimidine starvation on HCC.

Comparison of efficacy and safety of adjuvant therapies versus sorafenib in hepatocellular carcinoma: a systematic review and network meta-analysis

Purpose

Diverse novel therapeutic options for hepatocellular carcinoma (HCC) have surfaced in recent years. However, it is increasingly difficult to select the optimal medication. This research aims to assess overall survival (OS), progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), adverse events (AEs), and severe adverse events (SAEs) in HCC patients receiving adjuvant therapies compared to those receiving sorafenib.

Methods

Four databases were used to search articles. Only randomized controlled trials were included. Indicators such as OS, PFS, DCR, ORR, AEs and SAEs were used as outcomes. The protocol for this meta-analysis was registered with PROSPERO (Registration ID: CRD42024544394).

Results

Forty trials were included in this meta-analysis. The Oxaliplatin, Fluorouracil, and Leucovorin (OFL) + sorafenib group and the sintilimab + bevacizumab biosimilar group decreased the risk of death and increased PFS, ORR, and DCR. Yet, they also yielded remarkable adverse effects and severe adverse effects. To sum up, the atezolizumab + bevacizumab combination and tepotinib were recommended due to their favorable performance on all indexes.

Conclusion

This study further substantiates the efficacy of combination therapies in HCC, while they cause more toxicity in general. It is pressingly urgent to develop new drugs for liver cancer and find rational strategies to alleviate AEs.

Systematic Review Registration

PROSPERO, identifier CRD42024544394.

Impact of immunotherapy on the care patterns and outcomes of patients with advanced hepatocellular carcinoma

BACKGROUND

Modern immunotherapy with checkpoint inhibitors revolutionized cancer treatment and outcomes. This study aims to demonstrate how immunotherapy has impacted the national landscape of systemic treatment and palliative care in advanced hepatocellular carcinoma (HCC).

METHODS

Retrospective cohort selecting patients from the U.S.-based National Cancer Database (NCDB) with clinical stages T3b/T4 and stage IV HCC from 2010 to 2021. We performed a multivariable analysis using the Cox proportional hazard for overall survival (OS) comparisons and a logistic regression model to study immunotherapy use.

RESULTS

Immunotherapy use increased from 0.27 % in 2010 to 33.80 % in 2021. The median OS survival (in months) was 2 for untreated patients, 7.20 for chemotherapy, and 7.46 for immunotherapy. There was a better OS with immunotherapy (HR 0.59, 95 % CI 0.56-0.62). Systemic therapy for palliation increased from 14.41 % in 2010 to 25.32 % in 2021. Compared to surgical palliation, radiation (HR 0.61, 95 % CI 0.52-0.71) and systemic palliative (HR 0.59, 95 % CI 0.51-0.69) therapies improved OS.

CONCLUSION

From 2010 to 2021, there was a significant increase in the use of immunotherapy, parallel to a large shift toward systemic therapy use for palliative care in patients with advanced HCC. Immunotherapy was associated with a significant OS benefit in the palliative setting.

Changing treatment patterns for hepatocellular carcinoma: A Surveillance, Epidemiology, and End Results-Medicare study

BACKGROUND

From 2007 to 2017, sorafenib was the sole systemic therapy for hepatocellular carcinoma (HCC), but nine new therapies were approved from 2017 to 2022. No studies have yet examined population-level treatment patterns for HCC since these approvals.

METHODS

For this retrospective cohort, Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify patients who had HCC diagnosed between 2014 and 2019 with claims through 2020. The authors examined patient characteristics, comorbidities, and receipt of local (e.g., transplantation, resection, embolization) and systemic (e.g., sorafenib, lenvatinib, atezolizumab plus bevacizumab) therapies. Cohort characteristics, treatment patterns, and overall survival (OS) were analyzed, and χ2 tests and t-tests were used to compare treatments between the 2014-2017 and 2018-209 cohorts. Adjusted Cox models were used to compare median OS between treatment groups.

RESULTS

Among 11,766 patients (men, 69.2%; White, 76.9%; median age, 71 years), 60.5% received treatment within 1 year, which remained stable over time (2014-2017, 60.4%; 2018-2019, 61.0%; p = .84). The use of local therapy also remained stable (2014-2017, 52.1%; 2018-2019, 52.8%; p = .43), whereas the use of systemic therapy slightly decreased (2014-2017, 17.0%; 2018-2019, 15.2%; p = .01). First-line systemic treatments shifted significantly, with sorafenib use dropping from 84.5% (2014-2017) to 41.3% (2018-2019). The median OS among patients who received no treatment, systemic therapies first, or local therapies first was 2.2, 12.0, and 23.6 months, respectively. Patients who were diagnosed in 2019 had better OS (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.74-0.86) as did those who received systemic therapy first (HR, 0.33; 95% CI, 0.18-0.61), but survival was worse for those who received local therapy first (HR, 1.41; 95% CI, 1.08-1.84) compared with those who were diagnosed in 2014.

CONCLUSIONS

Local therapy patterns remained stable, but novel therapies replaced sorafenib as the preferred first-line treatment, improving survival.

Therapeutic Effects of Crocin Nanoparticles Alone or in Combination with Doxorubicin against Hepatocellular Carcinoma In vitro

OBJECTIVE

Crocin (CRO), the primary antioxidant in saffron, is known for its anticancer properties. However, its effectiveness in topical therapy is limited due to low bioavailability, poor absorption, and low physicochemical stability. This study aimed to prepare crocin nanoparticles (CRO-NPs) to enhance their pharmaceutical efficacy and evaluate the synergistic effects of Cro-NPs with doxorubicin (DOX) chemotherapy on two cell lines: human hepatocellular carcinoma cells (HepG2) and non-cancerous cells (WI38).

METHODS

CRO-NPs were prepared using the emulsion diffusion technique and characterized by transmission electron microscopy (TEM), scanning electron microscopy (SEM), Zeta potential, and Fourier transform infrared spectroscopy (FT-IR). Cell proliferation inhibition was assessed using the MTT assay for DOX, CRO, CRO-NPs, and DOX+CRO-NPs. Apoptosis and cell cycle were evaluated by flow cytometry, and changes in the expression of apoptotic gene (P53) and autophagic genes (ATG5 & LC3) were analyzed using real-time polymerase chain reaction.

RESULTS

TEM and SEM revealed that CRO-NPs exhibited a relatively spherical shape with an average size of 9.3 nm, and zeta potential analysis indicated better stability of CRO-NPs compared to native CRO. Significantly higher antitumor effects of CRO-NPs were observed against HepG2 cells (IC50 = 1.1 mg/ml and 0.57 mg/ml) compared to native CRO (IC50 = 6.1 mg/ml and 3.2 mg/ml) after 24 and 48 hours, respectively. Annexin-V assay on HepG2 cells indicated increased apoptotic rates across all treatments, with the highest percentage observed in CRO-NPs, accompanied by cell cycle arrest at the G2/M phase. Furthermore, gene expression analysis showed upregulation of P53, ATG5, and LC3 genes in DOX/CRO-NPs co-treatment compared to individual treatments. In contrast, WI38 cells exhibited greater sensitivity to DOX toxicity but showed no adverse response to CRONPs.

CONCLUSION

Although more in vivo studies in animal models are required to corroborate these results, our findings suggest that CRO-NPs can be a potential new anticancer agent for hepatocellular carcinoma. Moreover, they have a synergistic effect with DOX against HepG2 cells and mitigate the toxicity of DOX on normal WI38 cells.

TMEM101 expression and its impact on immune cell infiltration and prognosis in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a cancer caused by inflammation, which affects the immune response and treatment outcomes. Finding new immune-related targets could improve HCC immunotherapy. New research suggests that TMEM family proteins can act as either tumor suppressors or oncogenes, but the role of TMEM101 in HCC development is unclear. This study conducted an analysis of TMEM101 mRNA expression and its correlation with clinical outcomes in HCC patients using RNA sequencing data from various open databases. Additionally, differences in TMEM101 expression in HCC cell lines and HCC tissue microarrays were examined using RT-qPCR, western blotting, and in situ hybridization staining. The findings presented herein offer initial evidence indicating a significant upregulation of TMEM101 mRNA expression in HCC, which is linked to a poorer prognosis. Furthermore, TMEM101 expression was found to be positively associated with the histological grade and clinical stage of HCC patients. Moreover, a notable reduction in promoter methylation of TMEM101 was observed in HCC patients. Cox regression analysis indicated that TMEM101 was an independent prognostic factor for overall survival (OS) in HCC patients. A nomogram incorporating TMEM101 and tumor stage was constructed and assessed. Comparative analysis with four established HCC diagnostic biomarkers (AFP, EFNA3, MDK, and SMYD5) using ROC curve and time-dependent ROC curves demonstrated the diagnostic potential of TMEM101 in HCC. Gene set enrichment analysis (GSEA) revealed a correlation between TMEM101 and the cell cycle, DNA replication, and repair signaling pathways, which were differentially enriched in the TMEM101 high expression phenotype. The findings from CIBERSORT analysis suggest that TMEM101's pro-tumor effect may be due to decreasing the number of anti-tumor immune cells (M1 macrophages and resting memory CD4+ T cells) and promoting M0 macrophage infiltration in the tumor microenvironment (TME). Overall, our study indicates that TMEM101 could serve as a promising diagnostic and prognostic biomarker for HCC.

Current Treatment Methods in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a prevalent malignant tumour worldwide. Depending on the stage of the tumour and liver function, a variety of treatment options are indicated. Traditional radiotherapy and chemotherapy are ineffective against HCC; however, the U.S. Food and Drug Administration (FDA) has approved radiofrequency ablation (RFA), surgical resection, and transarterial chemoembolization (TACE) for advanced HCC. On the other hand, liver transplantation is recommended in the early stages of the disease. Tyrosine kinase inhibitors (TKIs) like lenvatinib and sorafenib, immunotherapy and anti-angiogenesis therapy, including pembrolizumab, bevacizumab, tremelimumab, durvalumab, camrelizumab, and atezolizumab, are other treatment options for advanced HCC. Moreover, to maximize outcomes for patients with HCC, the combination of immune checkpoint inhibitors (ICIs) along with targeted therapies or local ablative therapy is being investigated. This review elaborates on the current status of HCC treatment, outlining the most recent clinical study results and novel approaches.

Systemic treatment of hepatocellular carcinoma secondary to non-alcoholic fatty liver disease

Hepatocellular carcinoma (HCC) is the third leading cause of cancer death globally, with 15% of cases arising on a background of non-alcoholic fatty liver disease (NAFLD). NAFLD is a heterogenous condition ranging from fatty liver to cirrhosis and is itself a growing global problem, with estimated worldwide prevalence of 50% in 2040. Pathophysiology of NAFLD-HCC is not well understood, there are no dedicated screening programs, and there have been no clinical studies of anti-cancer treatments in this population specifically. However, the NAFLD-HCC population appears different than other aetiologies - patients tend to be older, diagnosed at more advanced stages, have more comorbidities, and overall worse prognosis. Understanding of best treatment options for this group of patients is an urgent unmet clinical need. This narrative review discusses NAFLD-HCC pathophysiology and systemic treatment, and offers suggestions for future directions in this therapy area.

Impact of Sustained Virological Response on Long-Term Outcomes After Curative Resection in Patients with Hepatitis C Virus-Related Hepatocellular Carcinoma in the Era of Direct-Acting Antiviral Therapy

BACKGROUND

The present study aimed to clarify the long-term outcomes after curative resection of hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) in patients with and without sustained virologic response (SVR) to antiviral therapy.

PATIENTS AND METHODS

This single-center retrospective cohort study included 216 patients with HCV-related HCC who underwent primary curative resection. Patients were divided into preoperatively achieved SVR, postoperatively achieved SVR through direct-acting antiviral (DAA) therapy and no SVR groups. Associations of SVR and other clinicopathological and surgical variables with overall survival (OS) and recurrence-free survival (RFS) were analyzed. Propensity score (PS) matching was used to reduce selection bias.

RESULTS

Patients with pre-SVR (108) and post-SVR (28) had better liver function and less liver fibrosis than those without SVR (80). In multivariate analysis, pre- or post-SVR [hazard ratio (HR), 0.13; 95% confidence interval (CI), 0.03-0.38; P < 0.001] was the only independent predictor of OS. For RFS, pre- or post-SVR (HR, 0.36; 95% CI, 0.18-0.64; P = 0.001) was one of several independent predictors. The study population was divided into the SVR (136 patients) and non-SVR groups. After PS matching, OS and RFS were significantly better in the SVR group (n = 53) than in the non-SVR group (n = 53) (P <0.001 and P = 0.012, respectively). Additionally, OS rates of SVR achieved with DAA were significantly higher than those achieved with interferon (P = 0.019).

CONCLUSIONS

Achieving SVR by DAA before or after curative resection suppressed recurrence and prevented death in patients with HCV-related HCC.

Liver cell cancer surveillance practice in Nigeria: Pitfalls and future prospects

Hepatocellular carcinoma (HCC) is a disease of public health concern in Nigeria, with chronic hepatitis B and C infections contributing most to the disease burden. Despite the increasing incidence of HCC, surveillance practices for early diagnosis and possible cure are not deeply rooted in the country. This article aims to review the current status of HCC surveillance in Nigeria, stressing the encounters, breaches, and potential prospects. Several factors, such as limited tools for screening and diagnostics, insufficient infrastructure, and low cognizance among the doctors, and the general public affect the surveillance practices for HCC in Nigeria. Moreover, the lack of standardized guidelines and protocols for HCC surveillance further intensifies the suboptimal diagnosis and treatment. Nevertheless, there are opportunities for refining surveillance practices in the country. This would be achieved through boosted public health sensitization campaigns, integrating HCC screening into routine clinical services, and leveraging technological developments for early detection and monitoring. Furthermore, collaboration between government agencies, healthcare providers, and international organizations can facilitate the development of comprehensive HCC surveillance programs personalized to the Nigerian setting. Thus, HCC surveillance practice faces substantial challenges. By addressing the drawbacks and leveraging prospects, Nigeria can improve HCC surveillance, with subsequent improved outcomes for individuals at risk of developing the disease.

Liver cell cancer surveillance practice in Nigeria: Pitfalls and future prospects

Hepatocellular carcinoma (HCC) is a disease of public health concern in Nigeria, with chronic hepatitis B and C infections contributing most to the disease burden. Despite the increasing incidence of HCC, surveillance practices for early diagnosis and possible cure are not deeply rooted in the country. This article aims to review the current status of HCC surveillance in Nigeria, stressing the encounters, breaches, and potential prospects. Several factors, such as limited tools for screening and diagnostics, insufficient infrastructure, and low cognizance among the doctors, and the general public affect the surveillance practices for HCC in Nigeria. Moreover, the lack of standardized guidelines and protocols for HCC surveillance further intensifies the suboptimal diagnosis and treatment. Nevertheless, there are opportunities for refining surveillance practices in the country. This would be achieved through boosted public health sensitization campaigns, integrating HCC screening into routine clinical services, and leveraging technological developments for early detection and monitoring. Furthermore, collaboration between government agencies, healthcare providers, and international organizations can facilitate the development of comprehensive HCC surveillance programs personalized to the Nigerian setting. Thus, HCC surveillance practice faces substantial challenges. By addressing the drawbacks and leveraging prospects, Nigeria can improve HCC surveillance, with subsequent improved outcomes for individuals at risk of developing the disease.

Association of IL-6 G-174C (rs1800795) variant with the susceptibility to hepatocellular carcinoma in patients with chronic hepatitis

AIM

An ineffective immune response resulting from dysregulation of cytokine production might encourage viral persistence and cause chronic viral hepatitis to worsen. This study examined the relationship between alterations in interleukin-6 (IL-6) levels and the IL-6 - 174 G > C (rs1800795) polymorphism, as well as how this polymorphism affects the development and progression of chronic hepatitis brought on by hepatitis B (HBV) and hepatitis C (HCV) into hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Whole blood samples from 126 Egyptian patients with HCC (111 with HCV and 15 with HBV), as well as 126 age- and sex-matched healthy individuals, were used to extract DNA. Using PCR-based allele-specific amplification (ASA), the existence of the IL-6 G-174C polymorphism was investigated. Additionally, each participant's serum IL-6 levels were determined using an enzyme-linked immunosorbent assay (ELISA).

RESULTS

The primary observations revealed that HCC patients had greater serum levels of IL-6 compared to the control groups (p < 0.001). Patients with the variant (CG and GG) genotype in the HCC group were found to have more disease severity indicated by higher levels of alpha-fetoprotein (AFP) and a higher ascites grade, as well as increased inflammatory activity as defined by higher levels of IL-6 and C-reactive protein (CRP) (p < 0.001 for both) in comparison to patients with the wild-type (CC) genotype (p < 0.001 and p = 0.002, respectively).

CONCLUSION

The rs1800795 SNP in the IL-6 gene was associated with increased inflammatory activity and high levels of IL-6, indicating that this SNP may play a role in the development of HCC in Egyptian patients with chronic viral hepatitis.

Lenvatinib versus Sorafenib Second-Line Therapy in Patients with Hepatocellular Carcinoma Progressed to Atezolizumab plus Bevacizumab: A Retrospective Real-World Study

INTRODUCTION

The most frequently used first-line treatment in patients with advanced hepatocellular carcinoma (HCC) is atezolizumab plus bevacizumab. Upon progression after this treatment, the standard of care in many countries is sorafenib, due to the lack of reimbursement for other drugs. Several randomized trials are currently underway to clarify the best second-line therapy in patients with HCC. This real-world study aimed to compare outcomes reached by lenvatinib and sorafenib second-line therapy in this setting.

METHODS

The overall cohort included 891 patients with HCC from 5 countries treated with atezolizumab plus bevacizumab in first-line setting between October 2018 and April 2022. At the data cut-off (May 2022), 41.5% of patients were continuing a first-line treatment, 5.5% were lost at follow-up, and 53.0% of patients had progressive disease after first-line therapy. 51.5% of patients with progressive disease received a second-line treatment, while 48.5% did not receive any subsequent therapy. Between patients receiving second-line treatment, 11.1% of patients underwent transarterial chemoembolization, 21.0% received sorafenib, 35.4% underwent lenvatinib, and 32.5% were treated with other drugs.

RESULTS

Lenvatinib second-line subgroup achieved a median overall survival (mOS) of 18.9 months, significative longer (p = 0.01; hazard ratio [HR]: 2.24) compared to sorafenib subgroup that reached a mOS of 14.3 months. The multivariate analysis highlighted albumin-bilirubin 1 grade (p < 0.01; HR: 5.23) and lenvatinib second-line therapy (p = 0.01; HR: 2.18) as positive prognostic factors for OS. The forest plot highlighted a positive trend in terms of OS in favor of patients treated with lenvatinib second-line regardless of baseline characteristics before first-line therapy.

CONCLUSION

These results suggest that, in patients with HCC progressed to first-line atezolizumab plus bevacizumab, lenvatinib second-line therapy is associated to an improved survival compared to sorafenib.

Biomarker discovery in hepatocellular carcinoma (HCC) for personalized treatment and enhanced prognosis

Hepatocellular carcinoma (HCC) is a leading contributor to cancer-related deaths worldwide and presents significant challenges in diagnosis and treatment due to its heterogeneous nature. The discovery of biomarkers has become crucial in addressing these challenges, promising early detection, precise diagnosis, and personalized treatment plans. Key biomarkers, such as alpha fetoprotein (AFP) glypican 3 (GPC3) and des gamma carboxy prothrombin (DCP) have shown potential in improving clinical results. Progress in proteomic technologies, including next-generation sequencing (NGS), mass spectrometry, and liquid biopsies detecting circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA), has deepened our understanding of HCC's molecular landscape. Immunological markers, like PD-L1 expression and tumor-infiltrating lymphocytes (TILs), also play a crucial role in guiding immunotherapy decisions. Despite these advancements, challenges remain in biomarker validation, standardization, integration into clinical practice, and cost-related barriers. Emerging technologies like single-cell sequencing and machine learning offer promising avenues for further exploration. Continued investment in research and collaboration among researchers, healthcare providers, and policymakers is vital to harness the potential of biomarkers fully, ultimately revolutionizing HCC management and improving patient outcomes through personalized treatment approaches.

Sorafenib plus memory-like natural killer cell immunochemotherapy boosts treatment response in liver cancer

BACKGROUND

Heterogeneity of hepatocellular carcinoma (HCC) presents significant challenges for therapeutic strategies and necessitates combinatorial treatment approaches to counteract suppressive behavior of tumor microenvironment and achieve improved outcomes. Here, we employed cytokines to induce memory-like behavior in natural killer (NK) cells, thereby enhancing their cytotoxicity against HCC. Additionally, we evaluated the potential benefits of combining sorafenib with this newly developed memory-like NK cell (pNK) immunochemotherapy in a preclinical model.

METHODS

HCC tumors were grown in SD rats using subcapsular implantation. Interleukin 12/18 cytokines were supplemented to NK cells to enhance cytotoxicity through memory activation. Tumors were diagnosed using MRI, and animals were randomly assigned to control, pNK immunotherapy, sorafenib chemotherapy, or combination therapy groups. NK cells were delivered locally via the gastrointestinal tract, while sorafenib was administered systemically. Therapeutic responses were monitored with weekly multi-parametric MRI scans over three weeks. Afterward, tumor tissues were harvested for histopathological analysis. Structural and functional changes in tumors were evaluated by analyzing MRI and histopathology data using ANOVA and pairwise T-test analyses.

RESULTS

The tumors were allowed to grow for six days post-cell implantation before treatment commenced. At baseline, tumor diameter averaged 5.27 mm without significant difference between groups (p = 0.16). Both sorafenib and combination therapy imposed greater burden on tumor dimensions compared to immunotherapy alone in the first week. By the second week of treatment, combination therapy had markedly expanded its therapeutic efficacy, resulting in the most significant tumor regression observed (6.05 ± 1.99 vs. 13.99 ± 8.01 mm). Histological analysis demonstrated significantly improved cell destruction in the tumor microenvironment associated with combination treatment (63.79%). Interestingly, we observed fewer viable tumor regions in the sorafenib group (38.9%) compared to the immunotherapy group (45.6%). Notably, there was a significantly higher presence of NK cells in the tumor microenvironment with combination therapy (34.79%) compared to other groups (ranging from 2.21 to 26.50%). Although the tumor sizes in the monotherapy groups were similar, histological analysis revealed a stronger response in pNK cell immunotherapy group compared to the sorafenib group.

CONCLUSIONS

Experimental results indicated that combination therapy significantly enhanced treatment response, resulting in substantial tumor growth reduction in alignment with histological analysis.

The Impact of Infections in Patients Treated with Atezolizumab Plus Bevacizumab for Unresectable Hepatocellular Carcinoma

Background: The therapeutic landscape of unresectable hepatocellular carcinoma (uHCC) continues to evolve. Atezolizumab, an anti-programmed cell death ligand 1 (PD-1) immune checkpoint inhibitor (ICI), in combination with bevacizumab, has substantially improved outcomes. This study aims to evaluate the incidence, risk factors, and outcomes in patients who develop infections while receiving atezolizumab and bevacizumab for uHCC. Methods: Patients who received atezolizumab and bevacizumab for uHCC at a single hospital network were included. Types and rates of infections were reported. Covariates compared among infected and non-infected cohorts included age, sex, race, comorbidities, Eastern Cooperative Oncology Group (ECOG) performance status, immunosuppressive use, chronic infections, number of cycles of ICIs given, antibiotic or antiviral therapies at ICI initiation, and line of therapy (first-line, second-line, greater than second-line). Results: Out of 810 evaluable patients, 34 uHCC patients were treated with atezolizumab plus bevacizumab. The mean ± SD age was 66.29 ± 9.39; 28 (82.35%) were males. There were 17 (50%) patients with reported infection, with bacterial infection occurring in 12 (70.59%) patients and COVID-19 in 4 (23.5%). Of the infected patients, eight (47.06%) had one infection, five (29.41%) had two infections, and two (11.76%) had three or more infections. Infected and non-infected patients received a median of 12 (IQR: 5-17) and 4 (IQR: 3-12) ICI cycles (p = 0.18), respectively. Infections did not negatively impact OS or PFS but resulted in treatment delays and discontinuation in 11 (64.71%) and 7 (41.18%) patients, respectively. At the last follow-up, 19 (55.88%) patients died, 9 (52.94%) in the non-infected group vs. 10 (58.82%) in the infected group (p = 1.0). Conclusions: While a broad array of infections occurred in 50% of the patients in this cohort, it did not negatively impact survival outcomes. However, it did impact morbidity, with more all-cause admissions and treatment delays.

Survival benefit of living donor liver transplant for patients with hepatocellular carcinoma

With the increasing incidence of hepatocellular carcinoma (HCC) in both the United States and globally, the role of liver transplantation in management continues to be an area of active conversation as it is often considered the gold standard in the treatment of HCC. The use of living donor liver transplantation (LDLT) and the indications in the setting of malignancy, both generally and in HCC specifically, are frequently debated. In terms of both overall survival and recurrence-free survival, LDLT is at least equivalent to DDLT, especially when performed for disease within Milan criteria. Emerging and compelling evidence suggests that LDLT is superior to DDLT in treating HCC as there is a significant decrease in waitlist mortality. As the oncologic indications for liver transplantation continue to expand and the gap between organ demand and organ availability continues to worsen, high volumes centers should consider using LDLT to shrink the ever-expanding waitlist.

Prolonged Complete Remission Using Tislelizumab for Hepatocellular Carcinoma After Adjuvant Chemotherapy Failure: A Case Report

In recent years, there have been limited reports on the efficacy of later-line anti-programmed cell death -1 (PD-1) therapy in achieving prolonged and complete remission in patients with hepatocellular carcinoma (HCC). Tislelizumab, a humanized anti-PD-1 monoclonal IgG4 antibody, has shown promising results in the treatment of HCC. This report highlights the case of a patient with HCC who experienced the development of lung metastatic lesions following HCC resection and chemotherapy, but achieved a prolonged complete response (CR) after receiving tislelizumab treatment. In April 2017, a 56-year-old male diagnosed with primary HCC underwent hepatectomy and hepatic arterial infusion pump placement. Following the surgery, the patient received adjuvant hepatic arterial infusion chemotherapy (HAIC) with 4 cycles of cisplatin+5-fluorouracil (PF) regimen starting in June 2017. In May 2018, lung metastatic lesions were detected, and the patient underwent 4 cycles of oxaliplatin+leucovorin+5-fluorouracil (FOLFOX) chemotherapy. However, the disease progressed in August 2018, leading to the administration of arsenic trioxide treatment. Despite this, further progression was observed in October 2018, prompting the patient's enrollment in a clinical trial for tislelizumab therapy. Initially, the patient achieved a partial response (PR) to tislelizumab, which was followed by a CR that lasted for almost 4 years. Unfortunately, tislelizumab treatment had to be discontinued due to immune-related adverse events (AE). Subsequently, the patient received lenvatinib and maintained a CR until July 2023. Tislelizumab monotherapy, when used as a third-line treatment, has demonstrated remarkable efficacy in facilitating patients with advanced HCC to attain a durable CR.

Treatment options for advanced hepatocellular carcinoma: the potential of biologics

INTRODUCTION

Advanced hepatocellular carcinoma (HCC) represents a significant global health burden, whose treatment has been recently revolutionized by the advent of biologic treatments. Despite that, innovative therapeutic regimens and approaches, especially immune-based, remain to be explored aiming at extending the therapeutic benefits to a wider population of patients.

AREAS COVERED

This review comprehensively discusses the evolving landscape of biological treatment modalities for advanced HCC, including immune checkpoint inhibitors, antiangiogenic monoclonal antibodies, tumor-targeting monoclonal antibodies either naked or drug-conjugated, therapeutic vaccines, oncolytic viruses, adoptive cell therapies, and cytokine-based therapies. Key clinical trials and preclinical studies are examined, highlighting the actual or potential impact of these interventions in reshaping treatment paradigms for HCC.

EXPERT OPINION

Tailored and rational combination strategies, leveraging the synergistic effects of different modalities, represent a promising approach to maximize treatment efficacy in advanced HCC, which should aim at conversion endpoints to increase the fraction of patients eligible for curative approaches. The identification of predictive biomarkers holds the key to optimizing patient selection and improving therapeutic outcomes.

Emerging targets in lipid metabolism for cancer therapy

Cancer cells perturb lipid metabolic pathways for a variety of pro-tumorigenic functions, and deregulated cellular metabolism is a hallmark of cancer cells. Although alterations in lipid metabolism in cancer cells have been appreciated for over 20 years, there are no FDA-approved cancer treatments that target lipid-related pathways. Recent advances pertaining to cancer cell fatty acid synthesis (FAS), desaturation, and uptake, microenvironmental and dietary lipids, and lipid metabolism of tumor-infiltrating immune cells have illuminated promising clinical applications for targeting lipid metabolism. This review highlights emerging pathways and targets for tumor lipid metabolism that may soon impact clinical treatment.

Epidemiology of Hepatocellular Carcinoma in Taiwan

BACKGROUND

Hepatocellular carcinoma (HCC) is a major contributor to the world's cancer burden. Understanding the HCC incidence rate in Taiwan is thus an interesting avenue of research.

METHODS

From an NHI database, those patients who had been newly diagnosed with HCC and who had been listed on a registry in a catastrophic illness dataset during the years 2013-2021 were enrolled in this study. Antineoplastic agent usage and comorbidities were also studied.

RESULTS

The incidence rate of HCC decreased from 57.77 to 44.95 in 100,000 from 2013 to 2021. The average age of patients with HCC increased from 65.54 years old with a CCI score of 4.98 in 2013 to 67.92 years old with a CCI score of 5.49 in 2021. Among these HCC patients, the patients under antineoplastic agent treatment decreased from 53.47% to 31.41% from 2013 to 2021. The presence of comorbidities in HCC patients was about 55.77-83.01% with mild liver disease and 29.93-37.30% with diabetes (without complications) in the period 2013-2021.

CONCLUSIONS

The incidence rate of HCC slightly decreased in Taiwan. Due to antineoplastic agent usage decreasing over time, these results may indicate that more early-stage HCC patients detected in recent years were mainly treated with surgeries.