Changing etiology and epidemiology of hepatocellular carcinoma: Asia and worldwide

Hepatitis B virus genotype distribution and mutation patterns: Insights and clinical implications for hepatitis B virus positive patients

Hepatitis B virus (HBV) infection is still a major worldwide health concern, contributing to chronic liver disorders like hepatocellular carcinoma (HCC). This review comprehensively analyzes HBV genotype distribution, mutation patterns, and their clinical implications, focusing on diagnostic and therapeutic strategies for HBV-positive patients. The discussion begins with HBV virology, emphasizing its capacity for chronic hepatitis and its association with severe liver complications, notably HCC. Understanding HBV genotypes (A-J) and their distinct geographic distributions is crucial, as genotype variations influence disease progression and treatment responses. Genotypes like C are particularly linked to heightened HCC risk, highlighting the need for genotype-specific management strategies. The genomic structure of HBV, consisting of four open reading frames (ORFs) encoding essential viral proteins, is detailed, with emphasis on mutations within these ORFs influenced by host immune responses and antiviral therapies. These mutations contribute to viral resistance and virulence, impacting treatment outcomes through alterations in viral replication dynamics. Clinical implications are explored through genotype-specific impacts on disease outcomes and treatment approaches. Genotype and mutation analysis guide personalized treatment regimens, optimizing therapeutic efficacy while minimizing adverse effects and preventing drug resistance. Diagnostic molecular techniques such as polymerase chain reaction and sequencing are pivotal in genotype and mutation detection, facilitating tailored treatment decisions.

Investigating the functional role of BUB1B in aflatoxin B1-associated hepatocarcinogenesis

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide, stemming from a complex interplay of genetic, environmental, and lifestyle factors. Aflatoxin B1 (AFB1), a prevalent food contaminant, is a known HCC risk factor, but its molecular mechanisms remain incompletely understood. This study investigated the contribution of BUB1B, a crucial spindle assembly checkpoint regulator, in AFB1-induced hepatocyte malignant transformation, we assessed AFB1's impact on cell proliferation, viability, cell cycle regulation, and BUB1B expression. BUB1B knockdown via siRNA revealed its role in epithelial-mesenchymal transition (EMT), cell motility, and proliferation. AFB1 exposure significantly altered cell proliferation and cell cycle dynamics, correlating with increased BUB1B expression. Furthermore, we identified a significant interaction between BUB1B and the IL12A-JAK2/STAT4 signaling pathway, suggesting a mechanism for immune evasion and tumor progression. These findings highlight BUB1B's critical role in AFB1-induced hepatocarcinogenesis and establish its potential target for HCC. Further research is needed to fully elucidate the underlying molecular mechanisms and explore the therapeutic implications of BUB1B inhibition in HCC treatment.

Extracellular vesicles as a promising platform of precision medicine in liver cancer

Extracellular vesicles (EVs) are natural carriers of biological information and play pivotal roles in intercellular communication. EVs are biocompatible, have low immunogenicity, and are capable of traversing biological barriers, making them ideal tools for disease diagnosis and therapy. Despite their promising prospects, the full realization of EVs potential faces several challenges. This article aims to comprehensively review the biological and molecular features of EVs, their applications in liver cancer and possible underlying mechanisms, and the critical challenges affecting the clinical translation of EVs-based therapies in liver cancer.

Association between early job loss and prognosis among hepatocellular carcinoma survivors

BACKGROUND

Early job loss after curative treatment for hepatocellular carcinoma (HCC) is associated with significant socioeconomic and health challenges, potentially worsening patient outcomes.

AIMS

To examine the impact of early job loss on all-cause mortality among HCC survivors following curative treatment.

METHODS

We conducted a retrospective cohort study using Korean National Health Insurance Service data on 4578 HCC survivors (aged 35-54) with economic activity treated between 2009 and 2015. Primary and secondary outcomes were all-cause mortality and HCC recurrence, respectively. Early job loss was defined as a shift from insurer to dependent status. Adjusted hazard ratio (HR) and 95% confidence interval (CI) were estimated using multivariable Cox regression models, and subgroup analyses were performed. Causal mediation analysis assessed early HCC recurrence as a mediator between early job loss and all-cause mortality.

RESULTS

Among 4578 patients (median follow-up, 8.3 years), 1189 (26%) died including 989 (25%) in the job-maintained group and 200 (35%) in the early job loss group (P < .001). Early job loss was significantly associated with increased risk of all-cause mortality (adjusted HR 1.52 [95% CI 1.30-1.78]), but not with HCC recurrence (adjusted HR 1.07 [95% CI 0.91-1.25]). Subgroup analyses showed prominent association among middle-income level, non-liver cirrhosis, non-alcoholism, or surgical resection group. Early HCC recurrence plays a significant mediating role on the relationship between early job loss and all-cause mortality (mediated proportion 19%, 95% CI 5-31%).

CONCLUSIONS

Early job loss may increase risk of all-cause mortality among HCC survivors undergoing curative treatment.

Exploring the antitumor potential of cucurbitacin B in hepatocellular carcinoma through network pharmacology, molecular docking, and molecular dynamics simulations

Cucurbitacin B exhibits promising anticancer activity across various cancers; however, its precise mechanism remains unclear. This study integrates network pharmacology, molecular docking, and dynamics simulations to elucidate CuB's multitarget therapeutic mechanisms against HCC. Potential CuB targets were retrieved from CTD, HERB, SwissTargetPrediction, ETCM, and PharmMapper databases. HCC-related genes were sourced from GEO datasets (GSE216613, GSE101685, GSE62232, GSE46408), GeneCard, DisGeNET, OMIM, and TTD. Intersecting targets were analyzed via PPI networks (STRING/Cytoscape), followed by GO/KEGG enrichment (DAVID). Molecular docking (Autodock Vina), ADMET evaluation (ADMETlab 2.0), and molecular dynamics simulations (Amber20) validated interactions. Core targets were further verified using GEPIA, HPA, cBioPortal, and TIMER databases. A total of 139 shared targets were identified between CuB and HCC. Key targets included EGFR, MTOR, MMP9, HSP90AB1, STAT3, and TNF. KEGG pathway analysis revealed significant enrichment in the phosphatidylinositol 3-kinase/protein kinase B (PI3K-Akt) signaling pathway, alongside cancer-related pathways (e.g., lipid metabolism, EGFR tyrosine kinase inhibitor resistance). Molecular docking confirmed strong binding (energy < - 5.0 kcal/mol) between CuB and core targets (e.g., MTOR: - 8.2 kcal/mol; HSP90AB1: - 7.9 kcal/mol). ADMET profiling indicated favorable pharmacokinetic properties, and molecular dynamics simulations demonstrated stable ligand-receptor complexes (RMSD < 2.5 Å). External validation highlighted differential expression (HSP90AB1, TNF) and clinical correlations (CCND1, EGFR) in HCC. CuB exerts antitumor effects in HCC through multitarget modulation, primarily via PI3K-Akt signaling and interactions with EGFR, MTOR, and HSP90AB1. This study provides a mechanistic foundation for CuB's therapeutic potential in HCC, guiding future experimental and clinical investigations.

Myosteatosis and the survival of patients with hepatocellular carcinoma: a meta-analysis

Myosteatosis, characterized by fat infiltration into skeletal muscle, is increasingly recognized as a prognostic factor in hepatocellular carcinoma (HCC), although the results were not consistent. This meta-analysis aimed to summarize impact on overall survival (OS) and progression-free survival (PFS) in patients with HCC.A systematic search of PubMed, Embase, and Web of Science was conducted to identify observational studies reporting survival outcomes in HCC patients with and without myosteatosis. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. A total of 24 retrospective cohort studies involving 7436 HCC patients were included. Myosteatosis was significantly associated with poorer OS (HR: 1.60, 95% CI: 1.40-1.83, p < 0.001, I2 = 65%) and PFS (HR: 1.53, 95% CI: 1.33-1.76, p < 0.001, I2 = 36%). Subgroup analysis revealed a stronger association in Asian studies (HR: 1.74 for OS; 1.57 for PFS) compared to European studies (HR: 1.08 for OS; 1.05 for PFS). The prognostic impact remained significant regardless of anticancer treatment type, myosteatosis assessment method, sex-specific or universal cutoff values, and follow-up duration (p for subgroup differences all > 0.05). The results remained significant in studies adjusting for sarcopenia (HR: 1.89 for OS; 1.50 for PFS). Meta-regression analyses did not suggest any of the following variables may affect the results, including sample size, mean ages of the patients, proportions of men, follow-up durations, and study quality scores (p all > 0.05).Myosteatosis is independently associated with worse survival in HCC patients, particularly in Asian populations. These findings highlight the significance of assessing muscle quality as a prognostic factor in HCC.

Metabolic Cause of Cirrhosis Is the Emerging Etiology for Primary Liver Cancer in the Asia-Oceania Region: Analysis of Global Burden of Disease (GBD) Study 2021

INTRODUCTION

Studies have shown a change in the etiological profile of liver cancer globally. We aimed to analyze the burden and changes in etiology of liver cancer in the Asia-Oceania region.

METHODS

The burden of liver cancer in Asia-Oceania was estimated using data from the 2021 Global Burden of Disease (GBD) Study. The analysis included age-standardized incidence (ASIR), prevalence (ASPR), mortality (ASMR), and disability-adjusted life years (DALY) per 100 000 population.

RESULTS

The Asia-Oceania region contributed 68.6%, 68.8%, and 67.3% of the global incidence, prevalence, and mortality of liver cancer in 2021. In 2021, Mongolia, Tonga, and South Korea had the highest ASIR, ASPR, and ASMR, whereas Australia, New Zealand, and Guam had the greatest increase in incidence and mortality rates. Viral hepatitis remained the most common etiology of liver cancer, with 47.7% and 26.1% of cases being related to hepatitis B virus (HBV) and hepatitis C virus (HCV), respectively. Around 14.5% and 7.1% of cases were related to alcohol and nonalcoholic steatohepatitis (NASH), respectively; however, the annual change in the ASIR was the highest for NASH. Alcohol, drug abuse, tobacco use, and metabolic syndrome, contributed to 15.2%, 11.7%, 11.5%, and 9.0% of liver cancer mortality in 2021; however, the change in death from 1990 to 2021 was the highest for metabolic syndrome.

CONCLUSION

Viral hepatitis remains the most common cause of liver cancer, with NASH having the highest annual rate of change in ASIR and liver cancer deaths in Asia-Oceania.

Association between allopurinol and hepatocellular carcinoma: analysis of genetic risk and patient survival

BACKGROUND

Despite the widespread clinical use of allopurinol for managing hepatocellular carcinoma (HCC) and gout, its potential hepatotoxicity and its effect on the risk of HCC remain unclear. This study aimed to comprehensively assess the potential correlations between allopurinol exposure and HCC risk.

METHODS

We utilized genome-wide association study data from the IEU OpenGWAS project as instrumental variables (IVs) for Mendelian randomization (MR) analysis to investigate the causal relationship between allopurinol and HCC. Subsequently, we investigated the potential mediating factors (gout, liver fat, and percentage of liver fat, etc.) between allopurinol use and HCC. Furthermore, we analyzed assessed survival outcomes using the Kaplan-Meier method to compare patient subgroups by differential Xanthine dehydrogenase (XDH) expression.

RESULTS

MR analysis established a causal link between allopurinol use and increased HCC risk (OR: 1.013, 95% CI 1.004-1.023, p = 0.006). Causal relationships were also observed between gout (OR: 1.011, p = 0.008) and HCC. Mediation analysis indicated that gout mediated 61.6% of the effect of allopurinol on HCC. Survival analysis showed that higher expression of XDH was associated with improved survival of HCC patients (HR = 0.62, 95% CI 0.441-0.884, p = 0.008), indicating a 38% decrease in mortality risk compared to the lower expression group.

CONCLUSIONS

This study demonstrated a causal relationship between allopurinol use and an increased risk of HCC based on genetic evidence. Allopurinol should be used with caution in patients with or at risk for HCC.

Statin use and liver-related prognosis among patients with MASLD

Background & Aims

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a highly prevalent liver condition. We investigated whether statin use reduces liver-related events (LREs) risk among patients with MASLD or MASLD with increased alcohol intake (MetALD).

Methods

This nationwide cohort study included individuals aged ≥40 years with MASLD/MetALD undergoing health examinations between 2012 and 2013. The primary outcome was LREs; hepatocellular carcinoma (HCC), decompensated liver cirrhosis (DLC), and liver-related mortality. Secondary outcomes included HCC, DLC, and steatotic liver disease (SLD) regression, all-cause mortality, cardiovascular diseases (CVD)-related mortality, and liver-related mortality, respectively. Multivariable Cox regression was performed to estimate the risk of LREs associated with statin use.

Results

Among 516,575 individuals (median follow-up: 10.1 years), statin users experienced significantly lower LRE rates (1.6%) compared with non-users (2.0%, p <0.001). Multivariable Cox regression analysis revealed that statin use was associated with reduced risks of LREs (adjusted hazard ratio [aHR] 0.64, 95% CI 0.61-0.68), HCC (aHR 0.52, 95% CI 0.47-0.58), DLC (aHR 0.58, 95% CI 0.52-0.65), all-cause mortality (aHR 0.81, 95% CI 0.78-0.84), CVD-related mortality (aHR 0.87, 95% CI 0.80-0.95), and liver-related mortality (aHR 0.51, 95% CI 0.46-0.57). Furthermore, statin use was associated with SLD regression (aHR 1.18, 95% CI 1.15-1.21). Stratified analyses consistently demonstrated risk reductions across all subgroups, particularly in patients with elevated alanine aminotransferase levels. Sensitivity analyses confirmed the robustness of these associations.

Conclusions

Statins are significantly associated with reduced LRE risk in patients with MASLD, especially among those with elevated alanine aminotransferase levels, suggesting a viable preventive strategy for such population.

Impact and implications

Our study provides critical evidence supporting the role of statins in reducing liver-related events in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), a condition with significant global health impact. These findings are particularly relevant for clinicians managing high-risk patients with MASLD, especially those with elevated alanine aminotransferase levels, as they highlight the potential for statins to mitigate both liver and cardiovascular risks. By demonstrating the robustness of these results through comprehensive sensitivity and stratified analyses, our research underscores the importance of integrating statin therapy into the management of MASLD. This has practical implications for physicians, researchers, and policymakers in developing guidelines and preventive strategies to improve long-term liver and cardiovascular outcomes.

Advancements in autoimmune hepatitis epidemiology, treatment and complication - a 15-year retrospective study

INTRODUCTION AND OBJECTIVES

Autoimmune hepatitis (AIH) is a rare, heterogeneous liver disease marked by autoantibodies, hypergammaglobulinemia, and distinct histological features. Predominantly affecting women, its incidence and prevalence show significant regional variability globally. Therefore, our aim is to examine the trends of AIH and to assess its demographics, management, and disease progression using an extensive population-based database.

MATERIALS AND METHODS

This retrospective, population-based study analyzed data from 2.7 million adults in Clalit Health Services, focusing on autoimmune hepatitis (AIH) diagnoses between 2009 and 2023. Data reordered included demographics, clinical details, and treatment regimens. Key outcomes tracked were the development of cirrhosis and its complications.

RESULTS

This study included 992 AIH patients with a median age of 51.5 years, 80.4 % female, and a median follow-up of 6.1 years. Obesity was present in 23.2 %, and 10.9 % had thyroid disease. At diagnosis, 22.9 % had cirrhosis, and an additional 137 patients developed cirrhosis during follow-up, leading to a total prevalence of 36.5 %. Among cirrhotic patients, 29.9 % experienced decompensation, 25.3 % developed ascites, 9.3 % had variceal bleeding, and 10.4 % developed hepatic encephalopathy. Hepatocellular carcinoma (HCC) occurred in 5.24 % of cirrhotic patients, with an incidence rate of 6.32 cases per 1000 patient-years. Overall, 11.2 % of cirrhotic patients underwent liver transplantation. The proportion of AIH patients diagnosed with cirrhosis at the time of diagnosis significantly decreased over the study period (p = 0.0028).

CONCLUSIONS

This study demonstrates a decreasing trend in AIH patients diagnosed with cirrhosis, suggesting earlier detection and improved management, alongside a lower documented incidence of HCC.

Targeting metabolic diseases with celastrol: A comprehensive review of anti-inflammatory mechanisms and therapeutic potential

ETHNOPHARMACOLOGICAL RELEVANCE

Tripterygium wilfordii is a traditional Chinese medicine used to treat rheumatic diseases, with properties such as clearing heat, detoxifying, dispelling wind, and relieving pain. In recent years, its active compound, celastrol, garnered significant attention for its potential therapeutic effects on metabolic diseases. Celastrol exhibits bioactivities such as regulating metabolic functions and anti-inflammatory effects, positioning it as a promising candidate for the treatment of obesity, diabetes, atherosclerosis (AS), and non-alcoholic fatty liver disease (NAFLD).

AIM OF THE REVIEW

This review aims to explore the pharmacological mechanisms of celastrol in metabolic diseases, focusing on its anti-inflammatory mechanisms and metabolic regulation effects, providing theoretical support for further investigation of its therapeutic potential in metabolic diseases.

METHODS

Literature was retrieved from PubMed, Web of Science, Scopus, Cochrane, and Google Scholar. This review primarily focuses on anti-inflammatory mechanisms of celastrol, its metabolic regulation, and toxicity studies, by systematically analyzing its effects in obesity, diabetes, AS, and NAFLD, providing scientific evidence for its potential clinical applications.

RESULTS

Celastrol regulates multiple signaling pathways, particularly inhibiting NF-κB and activating AMPK, reducing the production of pro-inflammatory cytokines and improving insulin sensitivity, enhancing its therapeutic potential in metabolic diseases. Additionally, celastrol regulates adipogenesis and energy metabolism by influencing key transcription factors such as PPARγ and SREBP-1c. Numerous studies highlight its role in alleviating oxidative stress and improving mitochondrial function, further enhancing its metabolic benefits.

CONCLUSION

In summary, celastrol holds great promise as a multi-target therapeutic agent for metabolic diseases, offering anti-inflammatory, metabolic regulatory, and antioxidative benefits. Despite these, challenges remain for the clinical application of celastrol due to its poor bioavailability and potential toxicity. Advanced formulation strategies and targeted delivery systems are urgently needed to overcome challenges related to bioavailability and clinical translation.

Role of hepatotropic viruses in promoting hepatocellular carcinoma-current knowledge and recent advances

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide, with chronic infections by hepatotropic viruses such as hepatitis B virus (HBV), and hepatitis C virus (HCV), being major risk factors. Chronic infections with these viruses are the leading cause of HCC worldwide, with HBV alone responsible for over 50% of cases. Despite advances in direct-acting antivirals (DAAs) for HCV and nucleos(t)ide analogues (NAs) for HBV, challenges remain in HCC prevention, early detection, and treatment. Recent research highlights the role of viral-induced metabolic alterations, such as the Warburg effect, mitochondrial dysfunction, and lipid dysregulation, in promoting HCC. Moreover, immune checkpoint inhibitors have emerged as effective treatments for advanced HCC, though responses vary between HBV- and HCV-related cancers. Additionally, novel therapeutic approaches and metabolic-targeted therapies offer promising avenues for virus-associated HCC treatment. Advancements in liquid biopsy biomarkers and artificial intelligence-driven diagnostics are improving HCC surveillance and risk stratification, potentially enabling earlier interventions. While HBV vaccination has significantly reduced HCC incidence, disparities in global vaccination coverage persist. Furthermore, antiviral therapies combined with structured surveillance programs have proven effective in reducing HCC incidence and mortality. This review highlights the complex connection between viral, genetic, and environmental factors in HCC development and underscores the importance of integrated prevention strategies to reduce its burden globally.

Synergistic effects of L-arginine and argininosuccinate synthetase 1 in inducing apoptosis in hepatocellular carcinoma

BACKGROUNDS/AIMS

Hepatocellular carcinoma (HCC) is a malignant cancer with an increasing incidence worldwide. Although numerous efforts have been made to identify effective therapies for HCC, current strategies have limitations. We present a new approach for targeting L-arginine and argininosuccinate synthetase 1 (ASS1).

METHODS

ASS1 expression in HCC cell lines and primary hepatocytes was detected using polymerase chain reaction and western blotting. Proliferation, migration, signaling pathways, and nitric oxide production in HCC cell lines were measured using MTS, colony formation, wound healing, Western blot, and Griess assays.

RESULTS

ASS1 expression varied among the HCC cell lines, and cisplatin cytotoxicity was ASS1-dependent. L-arginine alone induced apoptosis in HCC cell lines, regardless of ASS1 expression; however, its effect was enhanced in ASS1-expressing HCC cell lines. Cisplatin cytotoxicity also increased, suggesting that L-arginine acts as a sensitizer to cisplatin in HCC cell lines. ASS1 and L-arginine produced nitric oxide and inhibited key proliferation- and survival-related signaling pathways such as PI3K/Akt and MAPK. Additionally, ASS1 and L-arginine reduced the expression of PKM1 and PKM2 in the glycolysis pathway.

CONCLUSIONS

Our study revealed that ASS1 and L-arginine exhibited anticancer effects in HCC and sensitized cisplatin-resistant HCC cells to chemotherapy. The combination of ASS1 and L-arginine significantly enhanced the anticancer effects, even in HCC cell lines with low or absent ASS1 expression. These findings highlight the critical roles of arginine and ASS1 in HCC and suggest that increasing arginine availability could be a promising therapeutic strategy.

Comparison of hepatocellular carcinoma incidence after long-term treatment with besifovir vs. tenofovir AF

Besifovir dipivoxil maleate (BSV) is a novel antiviral agent widely used in South Korea for treating chronic hepatitis B (CHB). This study aimed to compare the incidence of hepatocellular carcinoma (HCC) following long-term use of BSV versus tenofovir alafenamide fumarate (TAF), utilizing large-scale national data. A total of 41,949 patients were analyzed, with propensity score matching (PSM) yielding 2,239 BSV and 6,717 TAF patients. The HCC incidence rate per 1,000 person-years was 1.8 for BSV versus 2.4 for TAF before matching (P = 0.057) and 1.6 versus 2.2 after matching (P = 0.284). Multivariate Cox regression identified age, male sex, antiviral duration, Charlson Comorbidity Index (CCI) score, and decompensated cirrhosis as significant risk factors for HCC, while antiviral type was not (HR 1.12, P = 0.413). Subgroup analyses showed no significant differences in HCC incidence between BSV and TAF in cirrhotic or non-cirrhotic patients. These findings suggest that BSV offers comparable efficacy to TAF in preventing HCC and is a promising option for CHB management. Longer-term studies with larger cohorts are necessary to confirm these results and assess the full impact of BSV on HCC prevention.

Cytokine-Induced Killer Cell Immunotherapy Reduces Recurrence in Patients with Early-Stage Hepatocellular Carcinoma

BACKGROUND/OBJECTIVES

Cytokine-induced killer (CIK) cell immunotherapy has shown promise in reducing recurrence and improving survival outcomes in hepatocellular carcinoma (HCC). We evaluated the efficacy and safety of CIK cell therapy in a real-world clinical setting.

METHODS

A retrospective analysis was conducted on 49 patients who received CIK cell therapy after curative resection or radiofrequency ablation, compared with 49 matched control patients via 1:1 propensity score matching. The primary endpoint was recurrence-free survival (RFS), and the secondary endpoint was overall survival (OS).

RESULTS

The median follow-up durations were 19.1 months for the immune cell group and 67.7 months for the control group. In univariable analysis, the immune cell group demonstrated a prolonged RFS than the control group (hazard ratio [HR], 0.32; 95% CI, 0.15-0.71; log-rank p = 0.001). The median RFS was not reached in the immune cell group but was 48.62 months in the control group. A multivariable Cox regression model identified CIK cell therapy as a significant factor associated with a reduced risk of HCC recurrence (adjusted HR, 0.32; 95% CI, 0.15-0.71; p = 0.005). The median OS was not reached in either group; no significant differences in OS were observed between the immune cell and control groups (log-rank p = 0.082). The overall incidence of adverse events was low, and no Grade 3 or 4 events were reported.

CONCLUSIONS

Adjuvant CIK cell immunotherapy after curative treatment significantly prolongs RFS in early-stage HCC patients. Further research regarding the broader applications of CIK cell immunotherapy in HCC is warranted.

Lower incidence of hepatocellular carcinoma with tenofovir alafenamide in chronic hepatitis B: Evidence from a large-scale cohort

Background & Aims

Tenofovir alafenamide (TAF) lacks extensive research regarding its impact on hepatocellular carcinoma (HCC). This study evaluated and compared the effects of TAF, tenofovir disoproxil fumarate (TDF), and entecavir (ETV) on HCC incidence using nationwide claim data.

Methods

In total, 75,816 patients with treatment-naïve HBV were included in the study and divided into TAF (n = 25,680), TDF (n = 26,954), and ETV (n = 23,182) groups after exclusions. Propensity score matching (1:1:1) resulted in 17,537 patients per group. HCC incidence rates were compared among the groups.

Results

Before matching, the incidence of HCC was significantly lower in the TAF group compared with the TDF and ETV groups (11.47 vs. 15.04 and 14.24 per 1,000 person-years). The incidence rate ratio (IRR) for TDF was 1.31 (1.19-1.44) and for ETV was 1.24 (1.12-1.37). Before matching, the TAF group had a significantly lower HCC compared with TDF and ETV in both patients with and without cirrhosis. After matching, the TAF group had a lower HCC incidence compared with the TDF group (12.38 vs. 15.39, IRR 1.24, p <0.001) but not with ETV group (IRR 1.08, p = 0.219). In patients with cirrhosis, TAF had lower HCC incidence compared with TDF and ETV (30.25 vs. 39.56 and 38.51, respectively). In patients without cirrhosis, the TAF group had a lower HCC incidence compared with the TDF group (IRR 1.19, p = 0.030) but not the ETV group (IRR 0.85, p = 0.066). Cox regression analysis showed that the TAF group had a significantly lower HCC incidence compared with the TDF (hazard ratio 1.335, p <0.001) and ETV groups (hazard ratio 1.162, p = 0.011), after adjusting for age, gender, and cirrhosis status.

Conclusions

The TAF group consistently demonstrated a lower incidence of HCC compared with the TDF and ETV groups, especially in patients with cirrhosis.

Impact and implications

This work aimed to fill the knowledge gap regarding the comparative efficacy of tenofovir alafenamide (TAF), tenofovir disoproxil fumarate (TDF), and entecavir (ETV) in reducing the incidence of hepatocellular carcinoma (HCC) in patients with chronic HBV. The results are particularly crucial for healthcare providers and policymakers, because they highlight the significantly lower incidence of HCC associated with TAF, especially in patients with cirrhosis. These results suggest TAF as a preferable antiviral therapy option to mitigate HCC risk, thus influencing clinical decision-making and healthcare guidelines. From a practical perspective, these findings can guide physicians in prescribing more effective treatments, assist researchers in designing further studies to explore the mechanisms behind the effectiveness of TAF, and inform policymakers to craft healthcare policies that optimize patient outcomes while considering potential limitations, such as the observational nature of the study and residual confounding factors.

Liver cancer in Saudi Arabia: A registry-based nationwide descriptive epidemiological and survival analysis

Liver cancer is a major worldwide health concern characterized by increasing rates of occurrence. It ranks as the sixth most prevalent form of cancer and is the third highest contributor to cancer-related fatalities globally. This study aimed to describe the epidemiology of liver cancer in Saudi Arabia and to analyze the factors associated with it. This retrospective medical record review included all the patients diagnosed with a liver cancer from January 2014 to December 2020. The incidence data were obtained and collected from the Saudi Cancer registry. The net survival percentage was obtained in global cancer observatory website of the International Agency for Research on Cancer. There were 3066 occurrences of liver cancer among Saudi Nationals during the years 2014 and 2020. The majority of patients consisted of males, accounting for 2105 individuals, which represents 68.7 % of the total. The predominant morphologies are Hepatocellular carcinoma (2520, 82.2 %), choliangocarcinoma (267, 8.7 %), Adenocarcinoma (5.1 %), and malignant neoplasm (3.4 %). The age-standardized incidence rate for males between 2014 and 2020 varied from 4.0 per 100,000 to 4.8 per 100,000, whilst for females it ranged from 1.5 per 100,000 to 2.4 per 100,000. The age-standardized incidence rate among Saudi nationals is 4.7 cases per 100,000, while the age-standardized mortality rate is 4.6 deaths per 100,000. Liver cancer is a significant global health problem, marked by its high occurrence and typically poor survival rates. By emphasizing risk factors, it enhances the implementation practices that may help to provide appropriate care to maximize favourable outcomes.

Tenofovir Disoproxil Fumarate Versus Entecavir: Effects on Lipid Profiles and Cardiovascular Outcomes in People Living With Chronic Hepatitis B

While entecavir (ETV) and tenofovir disoproxil fumarate (TDF) effectively manage chronic hepatitis B, their long-term effects on lipid metabolism and cardiovascular outcomes remain unclear. This study compares the impact of ETV, TDF, and treatment-naïve (control group) on hyperlipidemia and major adverse cardiac events (MACE) in people living with chronic hepatitis B (PLWHB). We used claim data from the South Korean National Health Insurance Service. Propensity score matching was used to account for confounding factors. The 5-year cumulative incidence of dyslipidemia was 7.10% for TDF, 12.17% for ETV, and 18.55% for the control group, with incidence rates per 1000 person-years of 14.5, 25.5, and 38.9, respectively. TDF showed a significantly lower risk of dyslipidemia compared to ETV (IRR: 0.56, p < 0.001) and the control group, which was confirmed in Cox regression analysis (HR: 0.392 vs. control, p < 0.001). For MACE, the 5-year cumulative incidence was 9.11% for TDF, 10.98% for ETV, and 12.32% for the control group, with incidence rates per 1000 person-years of 18.4, 22.5, and 24.8, respectively. TDF demonstrated a reduced risk compared to ETV (IRR: 0.817, p < 0.001), which was similarly supported by Cox regression analysis (HR: 0.728 vs. control, p < 0.001). In conclusion, TDF not only reduces the risk of hyperlipidemia but is also associated with a reduced risk of MACE compared to ETV or treatment-naive group in PLWHB.

Structural insights into antibody-based immunotherapy for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common types of primary liver cancer and remains a leading cause of cancer-related deaths worldwide. While traditional approaches like surgical resection and tyrosine kinase inhibitors struggle against the tumor's immune evasion, monoclonal antibody (mAb)-based immunotherapies have emerged as promising alternatives. Several therapeutic antibodies that counter the immunosuppressive tumor microenvironment have demonstrated efficacy in clinical trials, leading to FDA approvals for advanced HCC treatment. A crucial aspect of advancing these therapies lies in understanding the structural interactions between antibodies and their targets. Recent findings indicate that mAbs and bispecific antibodies (bsAbs) can target different, non-overlapping epitopes on immune checkpoints such as PD-1 and CTLA-4. This review delves into the epitope-paratope interactions of structurally unresolved mAbs and bsAbs, and discusses the potential for combination therapies based on their non-overlapping epitopes. By leveraging this unique feature, combination therapies could enhance immune activation, reduce resistance, and improve overall efficacy, marking a new direction for antibody-based immunotherapy in HCC.

Structure-activity relationship studies of Imidazo[1',2':1,6]pyrido[2,3-d]pyrimidine derivatives to develop selective FGFR inhibitors as anticancer agents for FGF19-overexpressed hepatocellular carcinoma

The aberrant activation of fibroblast growth factor (FGF) and FGF receptor (FGFR)-mediated signaling pathways are associated with cancer development, including hepatocellular carcinoma (HCC). A novel series of imidazo[1',2':1,6]pyrido[2,3-d]pyrimidine, containing an acrylamide covalent warhead, were synthesized as selective FGFR 1-4 inhibitors. Compound 7n was identified as the most potent inhibitor against FGFR1, 2, and 4, with IC50 values of 8/4 nM (FGFR1/2) and 3.8 nM (FGFR4), and the covalent docking analyses suggested that 7n form a covalent adduct with cysteine residue on the hinge or p-loop of FGFR. Compound 7n exhibited a favorable pharmacokinetic profile and significant in vivo antitumor efficacy in human liver cancer xenograft mouse models (xenograft, FGF/FGFR-dependent HCC cells).

Worse survival of hepatocellular cancer patients with membranous insulin receptor overexpression

Hepatocellular cancer (HCC) therapy is in need for an ideal companion diagnostic. Preclinical experimental studies have identified the insulin receptor (IR) and its synergistic counterpart, the IGF1 receptor (IGF1R), as relevant in HCC development, and the ligands IGF1 and IGF2 have been found to be elevated in HCC. This study aimed to bridge the gap to the clinical setting and explore whether the IR or the IGF1R would be of prognostic significance and would be associated with clinicopathologic parameters in HCC patients. In our retrospective cohort study located at the University Hospital Schleswig-Holstein, Campus Kiel, Germany, HCC samples of 139 patients were examined for IR and IGF1R expression by immunohistochemistry. A HistoScore was correlated with clinicopathological characteristics and survival. IR overexpression was frequently observed and was associated with clinicopathological parameters and survival. Membranous IR expression was associated with worse tumor specific survival (p = 0.043). Intriguingly, membranous IR expression was associated with worse tumor specific survival (p = 0.017) in the subgroup of patients undergoing sorafenib therapy. IGF1R expression was not associated with survival. In conclusion, our results suggest that membranous IR expression plays a role in HCC prognosis and treatment resistance, inspiring future validation as a potential companion diagnostic in HCC.

Construction of a tumor immune microenvironment-related risk scoring model for prognosis of hepatocellular carcinoma

OBJECTIVE

This study aims to develop a prognostic model for HCC based on TME-related factors.

INTRODUCTION

Hepatocellular carcinoma (HCC) is characterized by a poor prognosis, largely due to the complex and heterogeneous interactions between stromal and immune cells within the tumor microenvironment (TME).

METHODS

Genome and transcriptome data, as well as clinical information of HCC patients, were obtained from the Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO). The TME score was evaluated using the "ESTIMATE" R package. Differentially expressed genes (DEGs) associated with TME phenotype were analyzed using the LIMMA R-package. Survival outcomes were compared using Kaplan-Meier curves with log-rank test and Cox proportional hazards model. Protein-Protein Interaction (PPI) networks integrated with multivariate survival and LASSO analyses were utilized to identify TME-related hub genes for a risk score model. A nomogram predicting prognosis of HCC patients was developed through four independent cohorts.

RESULTS

The TME scores showed a negative correlation with tumor progression and survival in HCC patients. We identified 50 core genes with high connectivity in the PPI network, as along with 33 key DEGs associated with survival in HCC. Intersection analysis revealed six hub genes -CXCL8, CXCL1, CCR7, IL7R, MMP9, and CD69. The risk score based on these six TME-related hub genes was significantly associated with overall survival and clinicopathological characteristics of HCC patients. Furthermore, the nomogram demonstrated its ability to discriminate HCC patients from healthy individuals using peripheral blood mononuclear cells.

CONCLUSION

We have developed a TME-related risk scoring model for HCC patients and identified six hub gene panel that serve as a potential biomarker for personalized prognosis of immunotherapy and non-invasive diagnostics of HCC.

Self-testing strategy to eliminate hepatitis C as per World Health Organization's goal: Analysis of disease burden and cost-effectiveness

BACKGROUND/AIMS

The World Health Organization (WHO) aims to eliminate hepatitis C virus (HCV) by 2030; therefore, widespread HCV screening is required. The WHO recommends HCV self-testing (HCVST) as a new approach. We aimed to evaluate disease burden reduction using the HCVST screening strategy and identify the most cost-effective approach.

METHODS

We developed a dynamic open-cohort Markov model to assess the long-term effects and costeffectiveness of HCVST in the Republic of Korea from 2024 to 2030. Strategies for comparison included universal, birth cohort, high-risk group screening, and no screening, focusing on the following: (1) incremental costeffectiveness ratio (ICER) per disability-adjusted life-year (DALY) saved; (2) severe liver disease cases; and (3) liverrelated death reduction.

RESULTS

Universal HCVST screening is the most effective strategy for achieving the WHO goal by 2030, substantially lowering the incidence of severe liver disease by 71% and preventing liver-related deaths by 69%, thereby averting 267,942 DALYs. Moreover, with an ICER of US$8,078 per DALY and high cost-effectiveness, the sensitivity results prove that cost-effectiveness is robust. Although high-risk group screening offers the lowest cost compared with other strategies, its effectiveness in preventing severe liver disease is minimal, falling short of the current WHO goal.

CONCLUSION

Our study confirms that universal HCVST screening is a cost-effective strategy aligned with the WHO goal to eliminate HCV by 2030. Despite its higher costs compared to risk-based screening, the disease burden can be significantly reduced by providing effective HCVST access to individuals who might otherwise not be tested.

Microwave ablation vs. single-needle radiofrequency ablation for the treatment of HCC up to 4 cm: A randomized-controlled trial

Background & Aims

Radiofrequency ablation (RFA) is the standard treatment for small hepatocellular carcinoma (HCC), specifically for tumors <3 cm in size and numbering fewer than three, excluding surgical candidates. Microwave ablation (MWA) is an innovative approach believed to have theoretical benefits over RFA; however, these advantages are yet to be empirically verified. Therefore, we evaluated and compared the effectiveness of MWA and RFA in managing HCC tumors up to 4 cm in size.

Methods

In this multicenter randomized controlled trial conducted across five centers in Japan, eligible participants had up to 4 tumors, each up to 4 cm in size, and were not considered for surgery. Patients were randomly assigned to undergo MWA or RFA. The primary outcome was the rate of local tumor progression (LTP), whereas secondary outcomes included overall survival (OS) and intra- and extrahepatic recurrence-free survival (RFS) at the end of the 2-year follow up.

Results

In total, 240 participants were screened from July 12, 2018, to December 7, 2021. Four participants were excluded: three did not meet inclusion criteria, and one died from an unknown cause during treatment. Consequently, 119 (130 lesions) and 117 (136 lesions) participants were treated with MWA and RFA, respectively. The proportion of lesions with LTP at the 2-year follow up was significantly lower in the MWA group (20 [16.4%] lesions) than in the RFA group (38 [30.4%] lesions) (risk ratio, 0.54; p = 0.007). OS and both intra- and extrahepatic RFS did not significantly differ between groups.

Conclusions

MWA is more effective than RFA in reducing local tumor progression for HCC tumors up to 4 cm. However, no differences were observed in OS and RFS.

Impact and implications

While some randomized control trials (RCTs) have compared the efficacy of microwave ablation (MWA) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC), the superiority of MWA over RFA remains unverified despite its theoretical benefit. This study is the first to demonstrate the utility of MWA over single-needle RFA for patients with HCC, with a significant difference between the two groups in the proportion of lesions with local tumor progression after a 2-year follow up. Moreover, the two techniques were safe, with only two severe complications reported in the entire study cohort. Given that an RCT differs slightly from daily clinical situations, practical and anatomical criteria for selecting the optimal technique on a lesion-by-lesion basis are required.

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.

Enhancing global hepatocellular carcinoma management: Bridging Eastern and Western perspectives on dexamethasone and N-acetylcysteine before transarterial chemoembolization

This article explores the integration of Eastern and Western perspectives on the use of dexamethasone and N-acetylcysteine as premedications in transarterial chemoembolization for hepatocellular carcinoma (HCC). By examining key concerns raised by Western researchers, particularly regarding the different etiologies of liver cirrhosis, and contrasting them with robust clinical data from Asia, this article highlights the necessity for region-specific research and proposes future directions for global HCC management.

Gene targets with therapeutic potential in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide. Major treatments include liver transplantation, resection, and chemotherapy, but the 5-year recurrence rate remains high. Late diagnosis often prevents surgical intervention, contributing to poor patient survival rates. Carcinogenesis in HCC involves genetic alterations that drive the transformation of normal cells into malignant ones. Enhancer of zeste homolog 2 (EZH2), a key regulator of cell cycle progression, is frequently upregulated in HCC and is associated with advanced stages and poor prognosis, making it a potential biomarker. Additionally, signal transducer and activator of transcription 3, which binds to EZH2, affects disease staging and outcomes. Targeting EZH2 presents a promising therapeutic strategy. On the other hand, abnormal lipid metabolism is a hallmark of HCC and impacts prognosis. Fatty acid binding protein 5 is highly expressed in HCC tissues and correlates with key oncogenes, suggesting its potential as a biomarker. Other genes such as guanine monophosphate synthase, cell division cycle associated 5, and epidermal growth factor receptor provide insights into the molecular mechanisms of HCC, offering potential as biomarkers and therapeutic targets.

Chronic Hepatitis C Infection Treated with Direct-Acting Antiviral Agents and Occurrence/Recurrence of Hepatocellular Carcinoma: Does It Still Matter?

Hepatitis C virus (HCV) infection is a significant risk factor for liver cirrhosis and hepatocellular carcinoma (HCC). Traditionally, the primary prevention strategy for HCV-associated HCC has focused on removing infection through antiviral regimes. Currently, highly effective direct-acting antivirals (DAAs) offer extraordinary success across all patient categories, including cirrhotics. Despite these advancements, recent studies have reported that even after sustained virologic response (SVR), individuals with advanced liver disease/cirrhosis at the time of DAA treatment may still face risks of HCC occurrence or recurrence. Based on this premise, this review tries to shed light on the multiple mechanisms that establish a tumorigenic environment, first, during chronic HCV infection and then, after eventual viral eradication by DAAs. Furthermore, it reviews evidence reported by recent observational studies stating that the use of DAAs is not associated with an increased risk of HCC development but rather, with a significantly lower chance of liver cancer compared with DAA-untreated patients. In addition, it seeks to provide some practical guidance for clinicians, helping them to manage HCC surveillance of patients who have achieved SVR with DAAs.

Predicting Microvascular Invasion in Liver Transplant Recipients for Hepatocellular Carcinoma

BACKGROUND

Among primary liver tumors, hepatocellular carcinoma (HCC) is considered the most common hepatic tumor. Liver transplantation is one of the curative treatment options for HCC. However, the risk of HCC recurrence after liver transplantation varies and is influenced by various factors. Microvascular invasion (MVI) is a major factor associated with HCC recurrence after a liver transplant (LT). The study assessed the pre-transplant factors to predict MVI on explant liver specimens.

METHODS

The retrospective study included adult LT recipients with HCC on explant specimens to identify pre-transplant predictors of MVI. Univariate analyses, including Mann-Whitney U tests and chi-square tests, were conducted to assess associations between variables and MVI. Logistic regression was employed for multivariate analysis, including variables significant in univariate analysis. Pearson or Spearman correlation coefficients were calculated to examine correlations between continuous variables. Cohen's kappa coefficient was used to measure inter-rater reliability.

RESULTS

Out of 523 LT recipients, 136 (26%) were diagnosed with HCC based on pre-transplant imaging and histopathological analysis of the explanted liver. Descriptive data showed an average age of 54.06 ± 8.16 years (range: 15-70), with a majority being male (76.47%). Hepatitis C (HCV) was the leading etiology (72.8%). Most patients had moderately differentiated grade-II tumors (75.7%) and met the Milan criteria (74.3%). Mean pre-operative alpha-fetoprotein (pre-op AFP) levels were 104.42 ± 308.38 ng/ml. 74.3% were within the Milan criteria. MVI was present in 28.7%. The frequency of MVI among HCCs within vs. outside Milan criteria was not statistically significant (26.73% vs. 34.28% (p = 0.395)). Univariate analysis revealed that pre-op AFP levels (p = 0.001), Child-Turcotte Pugh class (p=0.05), and body mass index (p=0.02) were significantly associated with MVI. Multivariate logistic regression analysis showed that pre-op AFP was the only independent predictor of MVI (OR: 1.006, 95% CI: 1.003-1.008, p < 0.001).

CONCLUSION

This study not only reinforces the clinical significance of pre-op AFP levels as a simple pre-transplant predictor of MVI in patients with HCC but also advocates for the safety of liver transplantation beyond conventional Milan criteria, promoting extended LT protocols.

The Influence of Sex and Age on Survival in Patients with Hepatocellular Carcinoma

Background and Aim: Age and biological sex are risk factors for hepatocellular carcinoma (HCC) occurrence, but their impact on overall survival (OS) is a matter of debate. This study aims to investigate how sex and age at diagnosis, along with other associated factors (i.e., comorbidities, etiologies, therapy) impact OS in the HCC population. Method: Data from two HCC cohorts-a prospective registry from the University Hospital of Bern, Switzerland, and a retrospective registry from General Hospital Vienna, Austria-were combined and analyzed. Clinical and laboratory data were reviewed, and OS was compared using Kaplan-Meier curves and the log-rank test. Cox regression models with penalized splines were applied to examine how age at diagnosis influenced OS. Results: Of 1547 HCC patients, 1284 (84.1%) were male. Females were older (67 vs. 63 years, p < 0.001) and had lower rates of liver cirrhosis (p < 0.001), cardiac comorbidities (p < 0.001), and diabetes (p < 0.001). No significant difference in median OS between men and women was observed (18 months vs. 16 months, p = 0.304). Mortality risk increased with age, particularly between 60 and 70 years. However, after adjusting for treatment, the age effect became non-significant (p = 0.171). Conclusions: After controlling the model for therapy, neither age nor sex independently influenced OS in HCC patients, underscoring the impact of therapy on survival.

Management of non-alcoholic fatty liver disease-associated hepatocellular carcinoma

In recent years, with the decline in HBV and HCV infections, there has been a corresponding reduction in both the morbidity and mortality of virus-associated HCC. Nevertheless, rising living standards, coupled with the increasing prevalence of metabolic disorders like diabetes and obesity, have led to a rapid surge in non-alcoholic fatty liver disease-associated hepatocellular carcinoma (NAFLD-HCC) incidence. The mechanisms underlying the progression from NAFLD to NAFLD-HCC are multifaceted and remain incompletely understood. Current research suggests that genetic predisposition, metabolic dysregulation, lipotoxicity, oxidative stress, and inflammation are key contributing factors. Given the complexity of these mechanisms and the frequent occurrence of metabolic comorbidities like type 2 diabetes mellitus (T2DM) and cardiovascular disease in NAFLD-HCC patients, there is a pressing need for tailored therapeutic strategies, along with novel prevention, monitoring, and treatment approaches that are personalized to the patient's pathophysiology. Due to the limited depth of research, incomplete understanding of pathogenesis, and insufficient clinical data on NAFLD-HCC treatment, current therapeutic approaches largely rely on tumor staging. In this review, we synthesize current research on the pathogenesis, surveillance, diagnosis, treatment, and prevention of NAFLD-HCC, and offer perspectives for future studies, particularly regarding its underlying mechanisms.

Evolving epidemiology of non-alcoholic fatty liver disease in South Korea: incidence, prevalence, progression, and healthcare implications from 2010 to 2022

BACKGROUND/AIMS

Non-alcoholic fatty liver disease (NAFLD), now the most common chronic liver worldwide, has become a significant public health concern. This study aims to analyze the evolving epidemiology of NAFLD in South Korea.

METHODS

We utilized claim data from the Korean National Health Insurance Service from 2010 to 2022 to analyze NAFLD's incidence, prevalence, and progression.

RESULTS

From 2010 to 2022, the incidence and prevalence rates of NAFLD each increased from 1.87% to 4.47% and from 10.49% to 17.13%, respectively. The differences in prevalence rates between urban and rural areas were minimal in 2012 and 2022, yet both areas showed significant increases in the prevalence of NAFLD over the decade. The NAFLD group had a higher prevalence of comorbidities compared to the control group, and the most common comorbid condition was hypertension. Moreover, the ten-year incidence rates of malignancy, heart disease, and stroke in the NAFLD group were 13.42%, 15.72%, and 8.36%, respectively, which were significantly higher than those in the control group. The incidence rates of cirrhosis and hepatocellular carcinoma in NAFLD over 10 years were 2.22% and 0.77%, respectively. The total medical costs of NAFLD patients more than doubled over ten years and were all significantly higher than those of the control group.

CONCLUSION

A significant increase in NAFLD prevalence and its impact on healthcare utilization was observed in South Korea. With NAFLD leading to serious liver diseases and increased healthcare costs, integrated care strategies that include both medical treatment and lifestyle modifications are essential.

Pathology and diagnostic approaches to well-differentiated hepatocellular lesions: a narrative review

Well-differentiated hepatocellular lesions (WDHLs) are liver tumors or nonneoplastic lesions in which the cells closely resemble normal hepatocytes. These lesions often include focal nodular hyperplasia, hepatocellular adenoma, macroregenerative nodule, dysplastic nodule, and well-differentiated hepatocellular carcinoma. The diagnosis of these lesions remains challenging because of their morphological similarities, particularly when examined using needle biopsy. The accurate diagnosis of WDHLs is crucial for patient management and prognosis. This review addresses the histopathological characteristics and diagnostic approaches of WDHLs.

Alterations of Nutrient Elements in Hepatocellular Carcinoma Patients Treated with Atezolizumab-Bevacizumab

Currently, the combination of atezolizumab and bevacizumab (Atez/Bev) is recommended as the first-line therapy for patients with advanced hepatocellular carcinoma (HCC). However, there is a lack of research on the levels of nutrient elements in advanced HCC patients receiving Atez/Bev treatment. In this study, data from 35 patients with advanced HCC and 37 healthy individuals of similar age and sex were included. The levels of alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase were significantly increased in patients with HCC. These levels returned to the reference range after three rounds of Atez/Bev treatment. Additionally, the levels of blood urea nitrogen and creatinine (Cr) increased after Atez/Bev treatment. In HCC patients, the levels of calcium (Ca), iron (Fe), and copper (Cu) were significantly higher, while the levels of sodium (Na), magnesium (Mg), and zinc (Zn) were significantly lower compared to healthy individuals. These changes were reversed after Atez/Bev treatment. In conclusion, our findings indicate that treatment with Atez/Bev influences the levels of Ca, Fe, Cu, Na, Mg, and Zn in patients with HCC. The alterations in these elements caused by Atez/Bev treatment require mechanistic research in the future.

A Potential Pneumothorax Induced by Immune Checkpoint Inhibitors: A Case Report and Literature Review

Background and Objectives: Immune checkpoint inhibitors (ICIs), which target immune checkpoints in cancer cells, are increasingly used as a mainstay in anticancer treatment. The combination of atezolizumab and bevacizumab is also a first-line treatment for hepatocellular carcinoma (HCC). However, ICIs can cause immune-related adverse events (IrAEs) which range from mild to severe, potentially leading to the need for discontinuing immunotherapy. We report a case of a pneumothorax, a rare side effect caused by IrAEs. Materials and Methods: This paper reports a case of a 78-year-old male HCC patient who developed a recurrent pneumothorax, suspected to be an adverse effect of ICIs. Results: The patient was a current smoker with a 30 pack-year smoking history. Prior to initiating ICIs, a chest CT scan showed mild emphysema and fibrosis attributable to smoking. Following ICI treatment, the patient developed a recurrent pneumothorax. Further tests revealed no underlying cause for the pneumothorax other than the ICIs and smoking, and there were no signs of intrapulmonary metastasis or pneumonitis. Conclusions: When a pneumothorax occurs in a patient undergoing immunotherapy, it is important to consider it as a potential adverse effect of the treatment. Special attention should be given to the possibility that immunotherapy may exacerbate underlying lung conditions. Patients should be advised on the importance of smoking cessation. As there are currently no guidelines for resuming immunotherapy after a pneumothorax, it is crucial to weigh the risks and benefits and consider dose reduction or discontinuation of the medication.

Absence of Survival Impact from Hepatitis During Immunotherapy in 193 Patients with Advanced Hepatocellular Carcinoma - An Observational Study from Taiwan

Background

Hepatitis often occurs after initiating immune checkpoint inhibitor (ICI) treatment. The time and grade of hepatitis after ICI starts and the prognostic role of immune-related hepatitis in patients with advanced hepatocellular carcinoma (aHCC) remain unclear.

Methods

In this real-world analysis, we enrolled aHCC patients receiving ICIs, documented the highest level of liver enzymes during/after ICIs, and analyzed the survival impact of different hepatitis patterns.

Results

One hundred and ninety-three aHCC patients receiving ICIs were recruited. During ICIs, 88.6% of patients experienced aspartate transaminase (AST) elevations (Grade III/IV: 7.8%). For alanine transaminase (ALT), 81.3% had elevated levels (Grade III/IV: 3.6%), and 41.5% of patients had elevated bilirubin levels (Grade 3/4: 6.7%). The median AST, ALT, and total bilirubin values significantly increased after ICI treatment initiated (all p < 0.001) and, similarly, after excluding progressive disease (p = 0.014, p = 0.002, p < 0.001). The median time of hepatitis occurrence is from the 4.0th to 15.9th weeks. Multivariable analysis showed that patterns of liver enzyme change of AST and total bilirubin in patients receiving ICIs significantly correlate to overall survival (OS, p = 0.009 and 0.001, respectively). After ICI termination, patients with elevated bilirubin (p = 0.003) and AST (p = 0.005) would indicate poor survival, with adjustment of viral hepatitis and ICI responses.

Conclusion

Hepatitis emerges between the 4th and 20th weeks post-ICI initiation. Changes in liver enzymes during ICI therapy do not directly affect OS, implying the safety of ICI use when corticosteroids are promptly administered if clinically indicated.

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.

Mapping the Hidden Terrain of Hepatocellular Carcinoma: Exploring Regional Differences in Incidence and Mortality across Two Decades by Using the Largest US Datasets

Background: There is an observed variation in the burden of hepatocellular carcinoma (HCC) across different US populations. Our study aims to comprehensively assess variations in HCC incidence and mortality rates across different regions of the US. Understanding these geographical differences is crucial, given prior evidence indicating variations in the incidence of viral hepatitis and metabolic dysfunction-associated steatotic liver disease and varying access to curative HCC treatment among states. Methods: HCC age-adjusted incidence rates between 2001 and 2021 were obtained from the United States Cancer Statistics (USCS) database (which covers approximately 98% of the US population). HCC age-adjusted mortality rates between 2000 and 2022 were obtained from the National Center of Health Statistics (NCHS) database (covering approximately 100% of the US population). The rates were categorized by US geographical region into West, Midwest, Northeast, and South. Incidence rates were also categorized by race/ethnicity. Time trends [annual percentage change (APC) and average APC (AAPC)] were estimated by using Joinpoint Regression via the weighted Bayesian Information Criteria (p < 0.05). Results: Between 2001 and 2021, there were 491,039 patients diagnosed with HCC in the US (74.2% males). The highest incidence rate per 100,000 population was noted in the West (7.38), followed by the South (6.85). Overall incidence rates increased between 2001 and 2015 and then significantly decreased until 2021 (APC = -2.29). Most cases were in the South (38.8%), which also had the greatest increase in incidence (AAPC = 2.74). All four geographical regions exhibited an overall similar trend with an increase in incidence over the first 10-15 years followed by stable or decreasing rates. While stratification of the trends by race/ethnicity showed slight variations among the regions and groups, the findings are largely similar to all race/ethnic groups combined. Between 2000 and 2022, there were 370,450 patients whose death was attributed to HCC in the US (71.6% males). The highest mortality rate per 100,000 population was noted in the South (5.02), followed by the West (4.99). Overall mortality rates significantly increased between 2000 and 2013 (APC = 1.90), then stabilized between 2013 and 2016, and then significantly decreased till 2022 (APC = -1.59). Most deaths occurred in the South (35.8%), which also had the greatest increase in mortality (AAPC = 1.33). All four geographical regions followed an overall similar trend, with an increase in mortality over the first 10-15 years, followed by stable or decreasing rates. Conclusions: Our analysis, capturing about 98% of the US population, demonstrates an increase in HCC incidence and mortality rates in all geographical regions from 2000 to around 2014-2016, followed by stabilizing and decreasing incidence and mortality rates. We observed regional variations, with the highest incidence and mortality rates noted in the West and South regions and the fastest increase in both incidence and mortality noted in the South. Our findings are likely attributable to the introduction of antiviral therapy. Furthermore, demographic, socioeconomic, and comorbid variability across geographical regions in the US might also play a role in the observed trends. We provide important epidemiologic data for HCC in the US, prompting further studies to investigate the underlying factors responsible for the observed regional variations in HCC incidence and mortality.

Development and validation of a prognostic nomogram to predict the recurrence of AFP-negative and DCP-positive hepatocellular carcinoma after curative resection

Purpose

Approximately one-third of hepatocellular carcinoma (HCC) cases are characterized by alpha-fetoprotein (AFP) negativity (AFP-NHCC. Among these patients, around 60% exhibit des-gamma-carboxyprothrombin (DCP) positivity, and DCP-positive patients have a poorer prognosis. As a curative treatment, recurrence after liver resection poses significant challenges to the prognosis of HCC patients. Therefore, it is necessary to determine the relevant risk factors of these patients and provide timely treatment options.

Methods

This study included 540 patients who underwent resection at Beijing You'an Hospital. 292 patients from 2014 to 2018 constituted the training cohort, while 248 patients from 2018 to 2020 constituted the validation cohort. All patients underwent routine follow-ups until December 2023. Variables were identified through Cox regression, and a nomogram was developed. The nomogram was evaluated using time-dependent receiver operating characteristic curves (ROC), calibration curves, Decision curve analysis (DCA), and Kaplan-Meier (KM) curve analysis.

Results

We found that age, tumor number, tumor size, γ-glutamyl transpeptidase (γ-GT), and prothrombin time (PT) are independent risk factors for HCC recurrence, and a nomogram was developed and validated based on this result to predict recurrence-free survival (RFS) at 1, 2, and 3 years. The performance of the nomogram was further confirmed by the ROC curve, calibration curve, and DCA, all of which showed favorable results. The KM curve analysis clearly distinguishes between two groups of people with different risks in terms of prognosis in both the training and validation sets.

Conclusion

In summary, we established and validated a novel nomogram by multivariate Cox regression analysis to predict recurrence in DCP-positive patients with AFP-NHCC after resection. The nomogram, including age, tumor number, tumor size, γ-GT, and PT, demonstrates better predictive ability for AFP-NHCC patients with DCP positive.

Impacts of smoking on alcoholic liver disease: a nationwide cohort study

Objectives

Smoking is a preventable risk factor for morbidity and mortality in patients with liver disease. This study aims to explore the additional risks of smoking in the development of alcoholic liver disease (ALD), cirrhosis, and hepatocellular carcinoma (HCC) in high-risk drinkers.

Methods

Data from the National Health Insurance Service, including claims and health check-up information spanning 2011 to 2017, were used. The overall alcohol consumption was calculated, and ALD was defined based on ICD-10 codes. High-risk drinking was defined as 7 or more drinks for men and 5 or more for women, twice weekly. Half of the high-risk drinkers were smokers, decreasing in men but stable at 20% for women.

Results

ALD prevalence was 0.97% in high-risk drinkers and 1.09% in high-risk drinkers who smoked, higher than 0.16% in social drinkers (p < 0.001). ALD incidence over 3-years was highest in high-risk drinkers who smoked (2.35%), followed by high-risk drinkers (2.03%) and social drinkers (0.35%) (p < 0.001). Cirrhosis and HCC followed similar patterns, with prevalence and incidence was highest in drinkers who smoked. 3-year mortality was 0.65% in high-risk drinkers who smoked, compared to 0.50% in high-risk drinkers and 0.24% in social drinkers (p < 0.001). Smoking increased the incidence of ALD, cirrhosis, and HCC by 1.32, 1.53, and 1.53 times, respectively (all p < 0.001). Gender-specific analysis revealed higher risk ratios (RR) for women in ALD, alcoholic cirrhosis, and HCC, particularly among high-risk drinkers who smoked. Women showed significantly increased RR in ALD (6.08 to 12.38) compared to men (4.18 to 4.40), and similar trends were observed for cirrhosis and HCC.

Conclusion

Smoking significantly heightens the risk of ALD, cirrhosis, and HCC, especially in women, among high-risk drinkers. This emphasizes the importance of smoking cessation, particularly for female patients with ALD.

Overall Survival and the Impact of Albumin-bilirubin Grade in Patients with Advanced Hepatocellular Carcinoma: Data from a Tertiary Care Hospital in a Lower-middle-income Country

Background and aim

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Most patients are diagnosed at an advanced stage, limiting their treatment options. The traditional assessment of liver function using the Child-Pugh score has limitations due to its subjectivity. The albumin-bilirubin (ALBI) grade delivers a more precise evaluation of liver function. This study examines overall survival (OS) in advanced HCC patients treated with first-line systemic therapy and the impact of ALBI grading on these outcomes.

Materials and methods

A total of 104 patients with advanced HCC treated between January 2017 and December 2023 with one of the three first-line therapy options: Sorafenib, lenvatinib or atezolizumab/bevacizumab were retrospectively analyzed. The Kaplan-Meier method was utilized to examine the survival results, and the log-rank test was employed to evaluate the variations in survival among ALBI grades and therapy types. Cox proportional hazards regression examined the impact of ALBI grading and other covariates on OS, with a significance threshold of p < 0.05 for the multivariable model.

Results

The median age of HCC patients was 58.5 years, with 70% males, and a primary etiology of hepatitis C (43%). The median OS and time to progression (TTP) in this cohort were 9 months and 3.25 months. In ALBI grade I patients, the OS was 21 months, while in grade II or III patients, it was just 5 months. Treatment-related side effects necessitated dose reductions in over 84% of patients. Albumin-bilirubin grade, Child-Pugh class, and treatment modifications due to adverse effects were significant predictors of survival.

Conclusion

Lenvatinib appears to have better survival outcomes compared to other options. The albumin-bilirubin grading is a useful method for evaluating liver function and forecasting survival rates for individuals with HCC.

Clinical significance

Our findings support the use of ALBI grading in clinical decision-making for advanced HCC.

How to cite this article

Naviwala MSS, Tariq M, Ahmed F, et al. Overall Survival and the Impact of Albumin-bilirubin Grade in Patients with Advanced Hepatocellular Carcinoma: Data from a Tertiary Care Hospital in a Lower-middle-income Country. Euroasian J Hepato-Gastroenterol 2024;14(2):251-257.

Inflammatory Response in the Pathogenesis and Treatment of Hepatocellular Carcinoma: A Double-Edged Weapon

Hepatocellular carcinoma (HCC) is the most frequent among primary liver tumors (90%) and one of the main causes of cancer-related death. It develops usually in a chronically inflamed environment, ranging from compensatory parenchymal regeneration to fibrosis and cirrhosis: carcinogenesis can potentially happen in each of these stages. Inflammation determined by chronic viral infection (hepatitis B, hepatitis C, and hepatitis delta viruses) represents an important risk factor for HCC etiology through both viral direct damage and immune-related mechanisms. The deregulation of the physiological liver immunological network determined by viral infection can lead to carcinogenesis. The recent introduction of immunotherapy as the gold-standard first-line treatment for HCC highlights the role of the immune system and inflammation as a double-edged weapon in both HCC carcinogenesis and treatment. In this review we highlight how the inflammation is the key for the hepatocarcinogenesis in viral, alcohol and metabolic liver diseases.

Immunotherapy as a Complement to Surgical Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver tumor in adults, and the fourth leading cause of cancer-related deaths worldwide. While surgical and ablative therapies remain the standard of care in early localized disease, late presentation with advanced stages of disease, impaired hepatic function, or local recurrence following surgical resection preclude operative management as the sole treatment modality in a subgroup of patients. As such, systemic therapies, namely immunotherapy, have become an integral part of the HCC treatment algorithm over the past decade. While agents, such as atezolizumab/bevacizumab, have well-established roles as first-line systemic therapy in intermediate- and advanced-stage HCC, the role of immunotherapy in disease amenable to surgical management continues to evolve. In this review, we will discuss the current evidence and aggregate impact of immunotherapy in the context of HCC amenable to surgical management, including its application in the neoadjuvant and adjuvant settings.