Epidemiology of liver cancer in South Korea

Mortality Risk According to Changes in Alcohol Consumption Post-Diagnosis Among Liver Cancer Patients

BACKGROUND AND AIMS

Excess alcohol consumption causes liver cancer; however, its change effects on patient survival remain unclear. This study evaluated associations between alcohol consumption changes post-diagnosis and mortality risk in liver cancer survivors.

METHODS

The study included 16 637 patients, who were diagnosed with liver cancer between 2002 and 2017 and followed up until 2019, using the Korean National Health Insurance Service Database. Alcohol consumption levels were measured at pre- and post-diagnosis, and their associations with mortality risks were assessed with Cox proportional hazard models.

RESULTS

Drinkers accounted for 54.46% and 9.39% of men and women, respectively, before diagnosis, and 14.70% and 2.34% after diagnosis. Compared with persistent non-current drinkers in men, post-diagnosis drinking at any pre-diagnosis intake level was associated with 25%-67% increased risks of all-cause mortality. Adjusted hazard ratios (95% confidence intervals) were 1.59 (1.24, 2.03) for non-current/heavy drinkers (i.e., transitioned from non-current to heavy drinking post-diagnosis), 1.54 (1.26, 1.88) for light-to-moderate/heavy drinkers, and 1.67 (1.45, 1.92) for heavy/heavy drinkers. No significant association was observed among women. Compared with persistent drinkers, quitting among men presented lower risks in light-to-moderate (0.80 [0.70, 0.91]) and heavy drinkers (0.61 [0.53, 0.71]). Quitting was beneficial even among heavy drinkers at advanced stages (0.47 [0.24, 0.92] and 0.50 [0.25, 0.99] for all-cancer and liver cancer mortalities, respectively).

CONCLUSIONS

Post-diagnosis alcohol consumption is associated with increased mortality risks in liver cancer survivors, particularly men, with more pronounced effects than pre-diagnosis behaviour. Alcohol cessation benefits patient prognosis, even for heavy drinkers with advanced-stage liver cancer.

Risk of ischemic stroke in korean patients with Cancer: Insights from national health insurance data

OBJECTIVES

This study aimed to compare the cumulative incidence of ischemic stroke between patients with and without cancer, estimate the hazard ratio of stroke in patients with cancer compared to those without cancer, and compare our results with those of other nationwide studies.

MATERIALS AND METHODS

We recruited 91,424 patients diagnosed with cancer from the Korean National Health Insurance Service database between 2011 and 2015 and enrolled 182,848 controls. These participants were followed up for 5 years. We estimated the hazard ratios for ischemic stroke occurrence in the patient groups for all cancer types and nine specific cancer types during follow-up at 6 months and 1, 3, and 5 years.

RESULTS

For all cancer types, except colorectal, gallbladder, bile duct, and head and neck cancers, the slope of the cumulative increase in ischemic stroke in the early period was higher than that in longer follow-up durations. Ischemic stroke risk was elevated after the 6-month follow-up in patients with cancer compared to patients without cancer (95% confidence interval [CI]: 1.56-1.94). Over 3-5 years, Ischemic stroke risk increased in patients with lung (CI: 1.56-2.04), pancreatic (CI: 1.33-1.95), and liver cancers (CI: 1.07-1.39), compared to cancer-free individuals, whereas no significant increase was observed in patients with thyroid (CI: 0.79-1.13), stomach (CI: 0.92-1.17), colorectal (CI: 0.69-1.48), gallbladder (CI: 0.91-9.89), bile duct (CI: 0.39-3.50), and head and neck (CI: 0.26-74.30) cancers.

CONCLUSION

Our findings regarding stomach, colorectal, and liver cancers differ from the results of Western studies. Conducting a nationwide study within each country, rather than applying findings from other countries, is preferable for predicting and preventing ischemic stroke development in patients with cancer when using insurance-based data.

Male preference for TERT alterations and HBV integration in young-age HBV-related HCC: implications for sex disparity

BACKGROUND/AIMS

Hepatocellular carcinoma (HCC) exhibits significant sex disparities in incidence, yet its molecular mechanisms remain unclear. We explored the role of telomerase reverse transcriptase (TERT) genetic alterations and hepatitis B virus (HBV) integration, both known major contributors to HCC, in sex-specific risk for HBV-related HCC.

METHODS

We examined 310 HBV-related HCC tissues to investigate sex-specific TERT promoter (TERT-pro) mutations and HBV integration profiles, stratified by sex and age, and validated with single-cell RNA sequencing (scRNA-seq) data.

RESULTS

Tumors predominantly exhibited TERT-pro mutations (26.0% vs. 0%) and HBV-TERT integration (37.0% vs. 3.0%) compared to non-tumorous tissues. While TERT-pro mutations increased with age in both sexes, younger males (≤60 years) showed marked predominance compared to younger females. Males had significantly more HBV integrations at younger ages, while females initially had fewer integrations that gradually increased with age. Younger males' integrations showed significantly greater enrichment in the TERT locus compared to younger females, alongside a preference for promoters, PreS/S regions, and CpG islands. Overall, TERT genetic alterations were significantly sex-differential in younger individuals (75.3% in males vs. 23.1% in females) but not in older individuals (76.9% vs. 83.3%, respectively). These alterations were associated with increased TERT expression. The skewed TERT abnormalities in younger males were further corroborated by independent scRNA-seq data.

CONCLUSION

Our findings highlight the critical role of TERT alterations and HBV integration patterns in the male predominance of HCC incidence among younger HBV carriers, offering insights for future exploration to optimize sex-specific patient care and HCC surveillance strategies.

A Risk Prediction Model for Hepatocellular Carcinoma in the General Population Without Traditional Risk Factors for Liver Disease

BACKGROUND AND AIM

Existing hepatocellular carcinoma (HCC) prediction models for the general population without traditional risk factors for chronic liver disease are limited. This study aimed to develop an HCC prediction model for individuals lacking these traditional risk factors.

METHODS

The total of 138 452 adult participants without chronic viral hepatitis or significant alcohol intake who underwent regular health checkup at a tertiary hospital in South Korea were followed up for the development of HCC. Risk factors for HCC development were analyzed using Cox regression analysis, and prediction model was developed using the risk factors.

RESULTS

Significant predictors of HCC development included older age, male sex, higher body mass index, presence of diabetes mellitus, and levels of aspartate aminotransferase, total cholesterol, and platelet count. A new HCC prediction model using these variables was developed. Harrell's concordance index and Heagerty's integrated area under the receiver operating characteristics (AUROC) curve of the model were 0.88 (95% confidence interval [CI] 0.85-0.91) and 0.89 (95% CI 0.86-0.91), respectively. The 5- and 10-year AUROC were 0.89 (95% CI 0.88-0.89) and 0.87 (95% CI 0.87-0.88), respectively. This model significantly outperformed the FIB-4 scoring model in predicting HCC and effectively stratified individuals into low-, intermediate-, and high-risk groups with significantly different cumulative incidences of HCC.

CONCLUSIONS

The new model, based on clinical parameters, provides a valuable tool for clinicians to stratify HCC risk in the general population without risk factors for chronic liver disease.

Arachidonic acid metabolism as a novel pathogenic factor in gastrointestinal cancers

Gastrointestinal (GI) cancers are a major global health burden, representing 20% of all cancer diagnoses and 22.5% of global cancer-related deaths. Their aggressive nature and resistance to treatment pose a significant challenge, with late-stage survival rates below 15% at five years. Therefore, there is an urgent need to delve deeper into the mechanisms of gastrointestinal cancer progression and optimize treatment strategies. Increasing evidence highlights the active involvement of abnormal arachidonic acid (AA) metabolism in various cancers. AA is a fatty acid mainly metabolized into diverse bioactive compounds by three enzymes: cyclooxygenase, lipoxygenase, and cytochrome P450 enzymes. Abnormal AA metabolism and altered levels of its metabolites may play a pivotal role in the development of GI cancers. However, the underlying mechanisms remain unclear. This review highlights a unique perspective by focusing on the abnormal metabolism of AA and its involvement in GI cancers. We summarize the latest advancements in understanding AA metabolism in GI cancers, outlining changes in AA levels and their potential role in liver, colorectal, pancreatic, esophageal, gastric, and gallbladder cancers. Moreover, we also explore the potential of targeting abnormal AA metabolism for future therapies, considering the current need to explore AA metabolism in GI cancers and outlining promising avenues for further research. Ultimately, such investigations aim to improve treatment options for patients with GI cancers and pave the way for better cancer management in this area.

Stereotactic body radiotherapy alone versus stereotactic body radiotherapy after incomplete transarterial therapy for hepatocellular carcinoma

INTRODUCTION

We investigated the clinical outcomes of stereotactic body radiation therapy (SBRT) alone versus SBRT after incomplete transarterial chemoembolization (TACE) for a single recurrent hepatocellular carcinoma (HCC) smaller than 5 cm.

METHODS

We retrospectively reviewed the medical records of patients who underwent SBRT for a single recurrent HCC ≤5 cm, without vascular invasion or extrahepatic metastasis. Patients were divided into the SBRT-alone group and the TACE-SBRT group. The primary outcome was the local control (LC) rate, and secondary outcomes were survivals and treatment-related toxicities. We additionally conducted a propensity score matching (PSM) analysis.

RESULTS

A total of 477 patients were available for analysis. Among them, 54 patients received SBRT without prior treatment to the target lesion (SBRT-alone group), whereas 423 patients received SBRT for viable HCC after TACE (TACE-SBRT group). The 3-year LC rates did not differ between the two groups (SBRT-alone group, 88.6% vs. TACE-SBRT group, 89.6%, P = 0.918). The 3-year rates of overall survival, out-of-field intrahepatic recurrence-free survival and recurrence-free survival were also not significantly different (P = 0.479, 0.290 and 0.273, respectively). Even after PSM, LC and survival rates at 3 years were not significantly different.

CONCLUSION

SBRT alone demonstrated comparable local control and survival outcomes to SBRT following incomplete TACE. SBRT alone may be considered an alternative treatment option for a single recurrent HCC smaller than 5 cm when curative treatments or TACE are not feasible.

Targeting ferroptosis: the role of non-coding RNAs in hepatocellular carcinoma progression and therapy

One of the most common tumors is hepatocellular carcinoma (HCC), and the prognosis for late-stage HCC is still not good. It is anticipated that improved outcomes would result from a deeper comprehension of the pathophysiology of HCC. Ferroptosis as a new discovered cell death type is linked to the progression of HCC and may be crucial for its detection, prevention, therapy, and prognosis. Numerous studies suggest that epigenetic alterations mediated by non-coding RNAs (ncRNA) might influence cancer cell susceptibility to ferroptosis. This study elucidates the processes of ferroptosis and delineates the paths by which ncRNAs influence HCC by modulating ferroptosis. Furthermore, it offers significant insights into ferroptosis-associated ncRNAs, intending to discover novel therapeutic approaches for HCC. It also explores innovative concepts for the future use of ncRNA-based ferroptosis-targeted therapeutics.

Molecular Targets of Plant-based Alkaloids and Polyphenolics in Liver and Breast Cancer- An Insight into Anticancer Drug Development

Liver and Breast cancer are ranked as the most prevailing cancers that cause high cancer-related mortality. As cancer is a life-threatening disease that affects the human population globally, there is a need to develop novel therapies. Among the available treatment options include radiotherapy, chemotherapy, surgery, and immunotherapy. The most superlative modern method is the use of plant-derived anticancer drugs that target the cancerous cells and inhibit their proliferation. Plant-derived compounds are generally considered safer than synthetic drugs/traditional therapies and could serve as potential novel targets to treat liver and breast cancer to revolutionize cancer treatment. Alkaloids and Polyphenols have been shown to act as anticancer agents through molecular approaches. They disrupt various cellular mechanisms, inhibit the production of cyclins and CDKs to arrest the cell cycle, and activate the DNA repairing mechanism by upregulating p53, p21, and p38 expression. In severe cases, when no repair is possible, they induce apoptosis in liver and breast cancer cells by activating caspase-3, 8, and 9 and increasing the Bax/Bcl-2 ratio. They also deactivate several signaling pathways, such as PI3K/AKT/mTOR, STAT3, NF-κB, Shh, MAPK/ERK, and Wnt/β-catenin pathways, to control cancer cell progression and metastasis. The highlights of this review are the regulation of specific protein expressions that are crucial in cancer, such as in HER2 over-expressing breast cancer cells; alkaloids and polyphenols have been reported to reduce HER2 as well as MMP expression. This study reviewed more than 40 of the plant-based alkaloids and polyphenols with specific molecular targets against liver and breast cancer. Among them, Oxymatrine, Hirsutine, Piperine, Solamargine, and Brucine are currently under clinical trials by qualifying as potent anticancer agents due to lesser side effects. As a lot of research is there on anticancer compounds, there is a desideratum to compile data to move towards clinical trials phase 4 and control the prevalence of liver and breast cancer.

Genome-Wide Association Study to Identify Genetic Factors Linked to HBV Reactivation Following Liver Transplantation in HBV-Infected Patients

This study utilized a genome-wide association study (GWAS) to investigate the genetic variations linked to the risk of hepatitis B virus (HBV) reactivation in patients who have undergone liver transplantation (LT), aiming to enhance understanding and improve clinical outcomes. Genotyping performed on a selected patients from the Korean Organ Transplantation Registry (KOTRY) data using high-throughput platforms with the Axiom Korea Biobank array 1.1. The discovery cohort included 21 patients who experienced HBV reactivation (cases) and 888 patients without HBV reactivation (controls) following LT. The replication cohort consisted of 5 patients with HBV reactivation (cases) and 312 patients without HBV reactivation (controls) after LT. Additive logistic regression analysis was conducted using PLINK software ver 1.9, with adjustments for age and gender. The GWAS findings from the discovery cohort were validated using the replication cohort. The GWAS identified several single-nucleotide polymorphisms (SNPs) in the RGL1, CDCA7L, and AQP9 genes that were significantly linked to HBV reactivation after LT, with genome-wide significance thresholds set at p < 10-7. Down-regulation of RGL1 cDNAs was observed in primary duck hepatocytes infected with duck HBV. Overexpression of CDCA7L was found to promote hepatocellular carcinoma cell proliferation and colony formation, whereas knocking down CDCA7L inhibited these processes. Additionally, the absence of AQP9 triggered immune and inflammatory responses, leading to mild and scattered liver cell pyroptosis, accompanied by compensatory liver cell proliferation. This study provides critical insights into the genetic factors influencing HBV reactivation after LT, identifying significant associations with SNPs in RGL1, CDCA7L, and AQP9. These findings hold promise for developing predictive biomarkers and personalized management strategies to improve outcomes for HBV-infected LT recipients.

Prognostic Efficacy of the Albumin-Bilirubin Score and Treatment Outcomes in Hepatocellular Carcinoma: A Large-Scale, Multi-Center Real-World Database Study

Introduction

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality globally, with treatment outcomes closely tied to liver function. This study evaluates the prognostic utility of the albumin-bilirubin (ALBI) score compared to the traditional Child-Pugh (CP) grading, leveraging real-world evidence from a large-scale, multi-center database.

Methods

The Liver Cancer IN Korea (LINK) research network, a multi-center initiative, retrospectively collected electronic health records from three academic hospitals in South Korea, encompassing HCC patients diagnosed between 2015 and 2020. Inclusion criteria mandated at least one HCC treatment and excluded patients with other primary cancer diagnoses. The study followed patients until death, the last visit, or June 2021, employing standardized data processing and rule-based algorithms for data consistency. The prognostic efficacy of ALBI scores and CP scores was compared through time-dependent receiver operating characteristic (ROC) curves and the inverse probability censoring weighting method.

Results

From 25,248 newly diagnosed patients, 10,297 were included, with 65.82% having hepatitis B etiology and a mean follow-up of 27.49 months. Patients' classification by modified ALBI (mALBI) grade at diagnosis revealed: grade 1 (48.87%), 2a (20.50%), 2b (24.54%), and 3 (5.17%), with a minimal percentage missing (0.92%). Transarterial therapy (54.07%) and tyrosine kinase inhibitors (84.14% as the first-line systemic therapy) were predominant treatments. The ALBI score demonstrated greater prognostic efficacy than the CP score in long-term outcomes, with time-dependent area under the ROC curve analysis showing a score of 0.71 for ALBI versus 0.67 for CP at 60 months. Furthermore, higher mALBI grades were significantly associated with poorer survival outcomes, as indicated by both univariate and multivariate Cox proportional regression model analyses (p < 0.001).

Conclusions

The study confirmed the ALBI score's superior prognostic ability over the CP score, especially evident in long-term outcomes, suggesting a shift toward more nuanced liver function assessment tools in real-world clinical practice.

Targeting the p53-p21 axis in liver cancer: Linking cellular senescence to tumor suppression and progression

Liver cancer is a major health epidemic worldwide, mainly due to its high mortality rates and limited treatment options. The association of cellular senescence to tumorigenesis and the cancer hallmarks remains a subject of interest in cancer biology. The p53-p21 signalling axis is an important regulator in restoring the cell's balance by supporting tumor suppression and tumorigenesis in liver cancer. We review the novel molecular mechanisms that p53 and its downstream effector, p21, employ to induce cellular senescence, making it last longer, and halt the proliferation of damaged hepatocytes to become tumorous cells. We also examine how dysregulation of this pathway contributes to HCC pathogenesis, proliferation, survival, acquired resistance to apoptosis, and increased invasiveness. Furthermore, we comprehensively describe the molecular cross-talk between the p53-p21 signalling axis and major cell cycle signalling pathways, including Wnt/β-catenin, PI3K/Akt, and TGF-β in liver cancer and provide an overview of promising candidates for chemoprevention and future therapeutic strategies. This review article explores the roles of the p53-p21 pathway in liver cancer, examining its function in promoting cellular senescence under normal conditions and its potential role in cancer progression. It also highlights novel therapeutic drugs and drug targets within the pathway and discusses the implications for treatment strategies and prognosis in liver cancer.

Clinical outcomes of transarterial chemoembolization in Child-Turcotte Pugh class A patients with a single small (≤3 cm) hepatocellular carcinoma

BACKGROUND AND AIM

Transarterial chemoembolization (TACE) is one of the standard modalities used to treat unresectable hepatocellular carcinoma (HCC), but the effectiveness of TACE for treating patients with a solitary small (≤3 cm) HCC and well-preserved liver function has not been definitively established. This study aimed to determine the therapeutic impact of TACE in patients with these characteristics.

METHODS

This multicenter (four university hospitals) retrospective cohort study analyzed the medical records of 250 patients with a solitary small (≤3 cm) HCC and Child-Turcotte-Pugh (CTP) class A liver function diagnosed over 10 years. Posttreatment outcomes, including overall survival (OS), recurrence-free survival (RFS), and adverse events, were assessed following TACE therapy.

RESULTS

One hundred and thirty-eight of the 250 patients (55.2%) treated with TACE achieved complete remission (CR). Overall median OS was 77.7 months, and median OS was significantly longer in the CR group than in the non-CR group (89.1 vs. 58.8 months, P = 0.001). Median RFS was 19.1 months in the CR group. Subgroup analysis identified hypertension, an elevated serum albumin level, and achieving CR as significant positive predictors of OS, whereas diabetes, hepatitis c virus infection, and tumor size (>2 cm) were poor prognostic factors of OS.

CONCLUSIONS

The study demonstrates the effectiveness of TACE as a viable alternative for treating solitary small (≤3 cm) HCC in CTP class A patients.

Intricate effects of post-translational modifications in liver cancer: mechanisms to clinical applications

Liver cancer is a significant global health challenge, with hepatocellular carcinoma (HCC) being the most prevalent form, characterized by high incidence and mortality rates. Despite advances in targeted therapies and immunotherapies, the prognosis for advanced liver cancer remains poor. This underscores the urgent need for a deeper understanding of the molecular mechanisms underlying HCC to enable early detection and the development of novel therapeutic strategies. Post-translational modifications (PTMs) are crucial regulatory mechanisms in cellular biology, affecting protein functionality, interactions, and localization. These modifications, including phosphorylation, acetylation, methylation, ubiquitination, and glycosylation, occur after protein synthesis and play vital roles in various cellular processes. Recent advances in proteomics and molecular biology have highlighted the complex networks of PTMs, emphasizing their critical role in maintaining cellular homeostasis and disease pathogenesis. Dysregulation of PTMs has been associated with several malignant cellular processes in HCC, such as altered cell proliferation, migration, immune evasion, and metabolic reprogramming, contributing to tumor growth and metastasis. This review aims to provide a comprehensive understanding of the pathological mechanisms and clinical implications of various PTMs in liver cancer. By exploring the multifaceted interactions of PTMs and their impact on liver cancer progression, we highlight the potential of PTMs as biomarkers and therapeutic targets. The significance of this review lies in its potential to inform the development of novel therapeutic approaches and improve prognostic tools for early intervention in the fight against liver cancer.

TCBIR/CD320: a potential therapeutic target upregulated in endothelial cells and associated with immune cell infiltration in liver hepatocellular carcinoma

CD320, which is a transmembrane protein responsible for facilitating the absorption of vitamin B12, plays a key role in this process. However, the relationships between CD320 and immune cell infiltration levels remain unclear, with limited studies investigating the diagnostic and prognostic significance of CD320 in hepatocellular carcinoma. We used various databases, including the TIMER, GEPIA, UALCAN and TCGA databases to investigate the expression levels of CD320 in hepatocellular carcinoma. Subsequently, we analyzed the prognosis of hepatocellular carcinoma patients with different expression levels of CD320. Furthermore, we also performed Western blot, immunohistochemistry, and immunofluorescence analyses to validate the results of the database analysis. Finally, the functions of CD320 in hepatocellular carcinoma were also confirmed via relevant cell experiments and angiogenesis assays. We found that CD320 expression was significantly upregulated in tumor vascular endothelial cells. Moreover, the knockdown of CD320 led to a reduction in angiogenesis in endothelial cells. Increased expression of CD320 was also correlated with a poor prognosis in patients with hepatocellular carcinoma, which suggested that CD320 may be a potential prognostic marker. Finally, TIMER analysis demonstrated that the infiltration of six immune cell types was significantly associated with high expression levels of CD320 in hepatocellular carcinoma. Herein, we demonstrated that CD320 may play an important role in angiogenesis in hepatocellular carcinoma. These findings suggested that CD320 may be a potential clinical prognostic marker and immunotherapy target for hepatocellular carcinoma.

Sorafenib vs. Lenvatinib in advanced hepatocellular carcinoma after atezolizumab/bevacizumab failure: A real-world study

BACKGROUND/AIMS

Atezolizumab plus bevacizumab (ATE+BEV) therapy has become the recommended first-line therapy for patients with unresectable hepatocellular carcinoma (HCC) because of favorable treatment responses. However, there is a lack of data on sequential regimens after ATE+BEV treatment failure. We aimed to investigate the clinical outcomes of patients with advanced HCC who received subsequent systemic therapy for disease progression after ATE+BEV.

METHODS

This multicenter, retrospective study included patients who started second-line systemic treatment with sorafenib or lenvatinib after HCC progressed on ATE+BEV between August 2019 and December 2022. Treatment response was assessed using the Response Evaluation Criteria in Solid Tumors (version 1.1.). Clinical features of the two groups were balanced through propensity score (PS) matching.

RESULTS

This study enrolled 126 patients, 40 (31.7%) in the lenvatinib group, and 86 (68.3%) in the sorafenib group. The median age was 63 years, and males were predominant (88.1%). In PS-matched cohorts (36 patients in each group), the objective response rate was similar between the lenvatinib- and sorafenib-treated groups (5.6% vs. 8.3%; P=0.643), but the disease control rate was superior in the lenvatinib group (66.7% vs. 22.2%; P<0.001). Despite the superior progression- free survival (PFS) in the lenvatinib group (3.5 vs. 1.8 months, P=0.001), the overall survival (OS, 10.3 vs. 7.5 months, P=0.353) did not differ between the two PS-matched treatment groups.

CONCLUSION

In second-line therapy for unresectable HCC after ATE+BEV failure, lenvatinib showed better PFS and comparable OS to sorafenib in a real-world setting. Future studies with larger sample sizes and longer follow-ups are needed to optimize second-line treatment.

Comprehensively analysis of IL33 in hepatocellular carcinoma prognosis, immune microenvironment and biological role

IL33 plays an important role in cancer. However, the role of liver cancer remains unclear. Open-accessed data was obtained from the Cancer Genome Atlas, Xena, and TISCH databases. Different algorithms and R packages are used to perform various analyses. Here, in our comprehensive study on IL33 in HCC, we observed its differential expression across cancers, implicating its role in cancer development. The single-cell analysis highlighted its primary expression in endothelial cells, unveiling correlations within the HCC microenvironment. Also, the expression level of IL33 was correlated with patients survival, emphasizing its potential prognostic value. Biological enrichment analyses revealed associations with stem cell division, angiogenesis, and inflammatory response. IL33's impact on the immune microenvironment showcased correlations with diverse immune cells. Genomic features and drug sensitivity analyses provided insights into IL33's broader implications. In a pan-cancer context, IL33 emerged as a potential tumour-inhibitor, influencing immune-related molecules. This study significantly advances our understanding of IL33 in cancer biology. IL33 exhibited differential expression across cancers, particularly in endothelial cells within the HCC microenvironment. IL33 is correlated with the survival of HCC patients, indicating potential prognostic value and highlighting its broader implications in cancer biology.

Non-metastatic hip fractures surgery in patients with active cancer: benefit and risk

PURPOSE

Although rare, non-metastatic proximal femoral fracture (PFF) can develop in patients with active cancer. However, little data are available regarding the risks and benefits of surgical treatment in such patients. The purpose of his study was to investigate the risks and benefits of surgical treatment of PFF in patients with and without cancer.

METHODS

We retrospectively examined the medical records of all patients treated for PFF, excluding those with pathological fracture, at our hospital from July 2013 to December 2020. The patients were divided into two groups; The active cancer group and the standard group. We investigated in both groups about surgical and medical complications during the perioperative period, walking ability two weeks postoperatively, and one-year postoperative mortality rate.

RESULT

After the inclusion and exclusion criteria, 39 patients in the active cancer group and 331 patients in the standard group were finally investigated. There were no statistically significant differences between the two groups. The complication rate did not appear statistical significance between two groups (16.7% in active cancer group vs 10.7% in standard group: p = 0.272). Walking ability was also similar in two groups. Mortality rate at one year was significantly higher in the active cancer group. (41.2% in active cancer group vs 6.0% in standard group: p < 0.05).

CONCLUSION

Although the active cancer group had a higher mortality rate at one year, which was influenced by the prognosis of the cancer, the benefits of surgical intervention, such as regaining walking ability, were the same in patients with and without active cancer.

The perioperative experience and needs of hepatocellular carcinoma patients in interventional therapy: a phenomenological qualitative study

OBJECTIVE

This study aims to investigate the perioperative experience and needs of patients with liver cancer for interventional therapy, in order to provide the basis for further improving a patient's medical experience and satisfaction.

METHODS

A semi-structured in-depth interview was conducted for 16 patients with liver cancer in interventional therapy using the phenomenological research method of qualitative research. The themes were analyzed, summarized, refined and extracted using the Colaizzi analytical procedure.

RESULTS

The study results revealed that the perioperative experience and needs of patients with liver cancer for interventional therapy could mainly be summarized into seven themes: anxiety, fear and helplessness; not understanding the specific procedures of interventional therapy; worrying that the disease would not be treated as expected; lack of understanding of perioperative adverse reactions and the inability to cope with these; concern on the financial burden of health care costs on families; concerned on the physical and mental health of the dependent; the further improvement of diagnosis and treatment procedures.

CONCLUSION

Patients with liver cancer undergo a complex psychological experience during interventional therapy. In clinical practice, a patient's psychological needs and changes should be valued, in order to provide a targeted psychological intervention, health guidance and social support, thereby improving the medical experience and satisfaction of patients.

Blocking the E2F transcription factor 1/high-mobility group box 2 pathway enhances the intervention effects of α-santalol on the malignant behaviors of liver cancer cells

In view of the tumor-inhibiting effect of α-santalol in various cancers and the role of E2F transcription factor 1 (E2F1) as an important target for anticancer research, this study investigates the relation between α-santalol and E2F1, as well as the effect of α-santalol on liver cancer progression and the corresponding mechanism. Concretely, liver cancer cells were treated with different concentrations of α-santalol. The IC50 value of α-santalol was determined using Probit regression analysis. Then, transcription factors that are targeted by α-santalol and differentially expressed in liver cancer were screened out. The clinicopathological impact of E2F1 and its targets were evaluated and predicted. The expressions of E2F1 and high-mobility group box 2 (HMGB2) and their correlation in the liver cancer tissues were analyzed by bioinformatics. The effects of E2F1 and HMGB2 on the biological characteristics of liver cancer cells were examined through loss/gain-of-function and molecular assays. With the extension of treatment time, the inhibitory effects of 10 μmol/L and 20 μmol/L α-santalol on cancer cell survival rate were enhanced (P < 0.001). E2F1 and HMGB2 were highly expressed and positively correlated in liver cancer tissues (P < 0.05). High E2F1 expression was correlated with large tumors and high TNM stages (P < 0.05). E2F1 knockdown promoted the effects of α-santalol on dose-dependently inhibiting viability, colony formation, invasion and migration (P < 0.05). Moreover, E2F1 knockdown reduced the IC50 value and HMGB2 level, while HMGB2 overexpression produced opposite effects. HMGB2 overexpression and E2F1 knockdown mutually counteracted their effects on the IC50 value and on the viability and apoptosis of α-santalol-treated liver cancer cells (P < 0.01). Collectively, blocking the E2F1/HMGB2 pathway enhances the intervention effects of α-santalol on the proliferation, migration and invasion of liver cancer cells.

Hsa_circ_0005397 promotes hepatocellular carcinoma progression through EIF4A3

PURPOSE

The purpose of this study was to explore the expression and potential mechanism of hsa_circ_0005397 in hepatocellular carcinoma progression.

METHODS

Quantitative reverse transcription-polymerase chain reaction(qRT-PCR) was used to measure the expression level of hsa_circ_0005397 and EIF4A3 from paired HCC tissues and cell lines. Western Blot (WB) and immunohistochemistry (IHC) were used to verify the protein level of EIF4A3. The specificity of primers was confirmed by agarose gel electrophoresis. Receiver Operating Characteristic (ROC) Curve was drawn to analyze diagnostic value. Actinomycin D and nuclear and cytoplasmic extraction assays were utilized to evaluate the characteristics of hsa_circ_0005397. Cell Counting kit-8 (CCK-8) and colony formation assays were performed to detect cell proliferation. Flow cytometry analysis was used to detect the cell cycle. Transwell assay was performed to determine migration and invasion ability. RNA-binding proteins (RBPs) of hsa_circ_0005397 in HCC were explored using bioinformatics websites. The relationship between hsa_circ_0005397 and Eukaryotic Translation Initiation Factor 4A3 (EIF4A3) was verified by RNA Binding Protein Immunoprecipitation (RIP) assays, correlation and rescue experiments.

RESULTS

In this study, hsa_circ_0005397 was found to be significantly upregulated in HCC, and the good diagnostic sensitivity and specificity shown a potential diagnostic capability. Upregulated expression of hsa_circ_0005397 was significantly related to tumor size and stage. Hsa_circ_0005397 was circular structure which more stable than liner mRNA, and mostly distributed in the cytoplasm. Upregulation of hsa_circ_0005397 generally resulted in stronger proliferative ability, clonality, and metastatic potency of HCC cells; its downregulation yielded the opposite results. EIF4A3 is an RNA-binding protein of hsa_circ_0005397, which overexpressed in paired HCC tissues and cell lines. In addition, expression of hsa_circ_0005397 decreased equally when EIF4A3 was depleted. RIP assays and correlation assay estimated that EIF4A3 could interacted with hsa_circ_0005397. Knockdown of EIF4A3 could reverse hsa_circ_0005397 function in HCC progression.

CONCLUSIONS

Hsa_circ_0005397 promotes progression of hepatocellular carcinoma through EIF4A3. These research findings may provide novel clinical value for hepatocellular carcinoma.

hsa_circ_0002980 prevents proliferation, migration, invasion, and epithelial-mesenchymal transition of liver cancer cells through microRNA-1303/cell adhesion molecule 2 axis

BACKGROUND

Liver cancer (LC) is a rare malignancy. Circular RNA (circRNA) dysregulation is associated with LC metastasis. hsa_circ_0002980 was found to be unexpectedly downregulated in LC tissues; however, its specific function remains unclear.

METHODS

hsa_circ_0002980 expression was confirmed using RT-qPCR. The effects of circ_0002980 on the proliferation, metastasis, and EMT-related proteins of LC cells were assessed using clone formation, flow cytometry, Transwell assays, and Western blotting. The relationship between circ_0002980 and miR-1303 or miR-1303 and CADM2 was analyzed using a dual-luciferase reporter assay. Thereafter, the influence of these three genes on LC cell progression was determined through rescue experiments.

RESULTS

hsa_circ_0002980 expression was lower in LC. circ_0002980 overexpression inhibited the proliferation, migration, invasion, and EMT of LC cells. In addition, circ_0002980 specifically binds to miR-1303, and the accelerated effect of miR-1303 overexpression on LC progression was partially reversed by circ_0002980. Moreover, miR-1303 can also target CADM2, and CADM2-mediated prevention can also be attenuated by miR-1303 overexpression.

CONCLUSIONS

In LC cells, circ_0002980 upregulation prevents cell proliferation, metastasis, and EMT by affecting the miR-1303/CADM2 axis. Therefore, this axis may be a novel therapeutic target in LC.

The Association of Perfluoroalkyl Substance Exposure and a Serum Liver Function Marker in Korean Adults

Perfluoroalkyl substances (PFAS), widely used throughout industry and daily life, are currently one of the environmental pollutants garnering the most attention worldwide. Recently, environmental pollutants have had a high profile as one of the main causes of chronic liver disease, such as non-alcoholic fatty liver disease. Research on PFAS is actively underway. Although Korea has a remarkably high prevalence of chronic liver disease, and it continues to increase, only a few studies have revealed the relationship between PFAS and liver disease. In addition, regulations on PFAS in Korea are delayed compared to developed countries, such as Europe and the United States, and public interest is insufficient compared to others. Therefore, we would like to investigate the exposure of Koreans to PFAS in the blood and examine the relationship between these substances and markers of liver function (AST, ALT, and GGT). This study was based on the results of the Korean National Environmental Health Survey (KoNEHS) 2018–2020 (Cycle 4), and a total of 2961 subjects were selected. The concentration of PFAS in the blood of Korean adults was measured to be significantly higher based on the geometric mean compared to the results of recently investigated American adults based on the National Health and Nutrition Examination Survey (NHANES, 2017-2018). A multivariable linear regression analysis adjusted for age, sex, body mass index (BMI), smoking status, alcohol intake, and regular exercise was performed to examine changes in three liver function markers as the serum PFAS concentration increased. We found that some of the five PFAS (PFOA, PFOS, PFHxS, PFNA, and PFDeA) were significantly associated with increased liver enzymes. It is necessary to recognize the threat of PFAS to the human body and to discuss regulations and alternatives in earnest. Continuous follow-up studies are required through a well-designed cohort.

Impact of hepatitis B virus infection on the risk of gallbladder polyps: a cohort study

BACKGROUND/AIMS

We aimed to determine whether hepatitis B virus (HBV) or hepatitis C virus (HCV) infection remains an important risk factor for gallbladder polyps (GBPs) in the current context of reduced prevalence of these infections.

METHODS

The cohort included 392,913 asymptomatic adults who underwent abdominal ultrasonography (US).

RESULTS

The prevalence of GBP sized ≥ 5 mm, ≥ 10 mm, and overall (< 5, 5-9 and ≥ 10 mm) was 2.9%, 0.1%, and 12.8%, respectively. The prevalence of hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), and hepatitis C antibody (anti-HCV) positivity was 3.2%, 26.7%, and 0.1%, respectively. The GBP risk was significantly increased in HBsAg-positive individuals, with an adjusted odds ratio of 1.66 (95% confidence interval, 1.49-1.85) for GBP ≥ 5 mm, 2.39 (1.53-3.75) for GBP ≥ 10 mm, and 1.49 (1.41-1.59) for overall, whereas there was no significant association between anti-HCV positivity and GBP risk. The GBP risk did not increase significantly in individuals who tested negative for HBsAg but positive for HBcAb.

CONCLUSION

The presence of HBsAg may be an independent risk factor for GBP development in the current context of a indecreasing prevalence of HBsAg positivity. A more comprehensive evaluation of GBP during abdominal US surveillance of HBsAg-positive individuals may be necessary.

New-onset dyslipidemia in adult cancer survivors from medically underserved areas: a 10-year retrospective cohort study

BACKGROUND

Cancer survival rates are increasing; however, studies on dyslipidemia as a comorbidity of cancer are limited. For efficient management of the disease burden, this study aimed to understand new-onset dyslipidemia in medically underserved areas (MUA) among cancer survivors > 19 years.

METHODS

This study used 11-year (2009-2019) data from the Korean National Health Insurance Service sample cohort. Cancer survivors for five years or more (diagnosed with ICD-10 codes 'C00-C97') > 19 years were matched for sex, age, cancer type, and survival years using a 1:1 ratio with propensity scores. New-onset dyslipidemia outpatients based on MUA were analyzed using the Cox proportional hazards model.

RESULTS

Of the 5,736 cancer survivors included in the study, the number of new-onset dyslipidemia patients was 855 in MUA and 781 in non-MUA. Cancer survivors for five years or more from MUA had a 1.22-fold higher risk of onset of dyslipidemia (95% CI = 1.10-1.34) than patients from non-MUA. The prominent factors for the risk of dyslipidemia in MUA include women, age ≥ 80 years, high income, disability, complications, and fifth-year cancer survivors.

CONCLUSIONS

Cancer survivors for five years or more from MUA had a higher risk of new-onset dyslipidemia than those from non-MUA. Thus, cancer survivors for five years or more living in MUA require healthcare to prevent and alleviate dyslipidemia.

A nationwide study on the current treatment status and natural prognosis of hepatocellular carcinoma in elderly

The aim of this study was to identify the treatment status and natural prognosis of hepatocellular carcinoma (HCC) patients aged 65 years or older in Korea. We analyzed 3,492 patients' data from the liver cancer stage of the Central Cancer Registry of National Cancer Center. The most common etiology of HCC was hepatitis B (32.7%), followed by hepatitis C. 2624 patients (69.2%) received first-line active treatment for HCC. The most frequently selected treatment was transarterial chemoembolization (TACE), followed by surgical resection and radiofrequency ablation (RFA). The proportion of patients receiving supportive care increased with age. Second-line treatment was performed in only 36.7% of cases, with all others choosing supportive care. Among the various treatments, liver transplantation was found to have the greatest effect in reducing the risk of death (HR [hazard ratio] 0.164, 95% CI [confidence interval] 0.061-0.444), followed by resection, RFA, radioembolization, and TACE. A similar pattern was observed when sub-analyzing the age group over 75 years old. The median survival for untreated HCC in Barcelona Clinic Liver Cancer stage 0/A/B/C/D was 3.7 years, 2.3 years, 7.9 months, 3.9 months, and 2.9 months, respectively. This study highlights the current status of elderly patients with HCC in Korea. While the proportion of patients receiving supportive care is high among the elderly, effective treatment can improve their survival rate.

Experience of Lifetime Health Maintenance Program: An Observational Study of a 30-Year Period of Outpatient Primary Care in a Tertiary Hospital

BACKGROUND

This study aimed to identify the clinical content of patients registered with the Lifetime Health Maintenance Program (LHMP) under the care of a single family physician who introduced and operated the program in Korea at a tertiary hospital for over 30 years.

METHODS

We analyzed the electronic medical records of 745 patients who had registered for more than 3 times with the LHMP under the care of a single family physician between January 1, 2010 and December 31, 2019. We reviewed medical records from June 1989, when the hospital was established, to February 2022. The participants' age at the time of LHMP enrollment, sex, initial consultation date, final consultation date, and consultation content were evaluated.

RESULTS

Patients visited the LHMP for various reasons, including acute symptom management, chronic disease management, psychiatric consultation, counseling on health behaviors, health checkups, and vaccination. The top five diagnoses for acute symptom management were upper respiratory infection, abdominal pain, dizziness/vertigo, headache, and lower back pain, whereas those for chronic disease management were dyslipidemia, hypertension, osteoarthritis, osteoporosis/osteopenia, and diabetes. More than one in five patients received psychiatric consultation and counseling on health behaviors. As the duration of the program enrollment increased, the proportion of patients visiting the LHMP for acute symptoms, vaccinations, and health checkups also increased. Furthermore, the number of categories of consultation content increased for each patient.

CONCLUSION

The LHMP emphasized the need to systematize regular primary care physicians in Korea. Policy changes are necessary to strengthen primary care, and the LHMP serves as an intermediate step in organizing regular primary care physicians in Korea.

Local Therapies for Hepatocellular Carcinoma and Role of MRI-Guided Adaptive Radiation Therapy

Hepatocellular carcinoma (HCC) is the most common liver tumor, with a continually rising incidence. The curative treatment for HCC is surgical resection or liver transplantation; however, only a small portion of patients are eligible due to local tumor burden or underlying liver dysfunction. Most HCC patients receive nonsurgical liver-directed therapies (LDTs), including thermal ablation, transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and external beam radiation therapy (EBRT). Stereotactic ablative body radiation (SABR) is a specific type of EBRT that can precisely deliver a high dose of radiation to ablate tumor cells using a small number of treatments (or fractions, typically 5 or less). With onboard MRI imaging, MRI-guided SABR can improve therapeutic dose while minimizing normal tissue exposure. In the current review, we discuss different LDTs and compare them with EBRT, specifically SABR. The emerging MRI-guided adaptive radiation therapy has been reviewed, highlighting its advantages and potential role in HCC management.

Overview of Asian clinical practice guidelines for the management of hepatocellular carcinoma: An Asian perspective comparison

Hepatocellular carcinoma (HCC) is highly prevalent and the third most common cause of cancer-related death in Asia. In contrast to the West, the main etiology of HCC in many Asian countries except Japan is chronic hepatitis B virus infection. Differences in the major causes of HCC lead to significant clinical and treatment differences. This review summarizes and compares guidelines on managing HCC from China, Hong Kong, Taiwan, Japan, and South Korea. From oncology and socio-economic perspectives, factors such as underlying diseases, staging methods, government policies, insurance coverage, and medical resources contribute to varying treatment strategies among countries. Furthermore, the differences in each guideline are fundamentally caused by the lack of incontrovertible medical evidence, and even existing results of clinical trials can be interpreted differently. This review will provide a complete overview of the current Asian guidelines for HCC in recommendations and in practice.

Disparities in stage at diagnosis for liver cancer in China

Background

The stage at diagnosis is a major factor in making treatment strategies and cancer control policies. However, the stage distribution for liver cancer in China was not well studied. In this multi-center hospital-based study, we aimed to identify the distribution and factors associated with stage at diagnosis for liver cancer in China.

Methods

We included patients diagnosed with primary liver cancer in 13 hospitals of 10 provinces covering various geographic and socioeconomic populations during 2016-2017 in China. The stage distribution overall, and by sex and age at diagnosis were analyzed. We used logistic regression to identify the factors associated with stage III-IV disease. We further compared these estimates with data from the USA.

Results

We included 2,991 patients with known stage at diagnosis in China. The proportion of patients diagnosed with stage I, II, III, and IV was 17.5%, 25.6%, 29.3%, and 27.6%, respectively. The proportion of stage III-IV cases was higher in women [65.1% vs 54.9%, adjusted odds ratio (OR) = 1.5, 95% CI: 1.2, 1.8] and those ≥ 60 years (61.6% vs 52.8%, OR = 1.4, 95% CI: 1.2, 1.6). We found an increased risk of stage III-IV among drinkers and those without a family history of cancer. Compared to the USA, our study population had a substantially higher proportion of stage III-IV cases (56.9% vs 45.6%).

Conclusion

The disparities in liver cancer stage at diagnosis among different populations within China, and between China and the USA, imply the necessity for improving cancer awareness and early detection for liver cancer in China.

Accuracy Validation of the Elecsys HBsAg II Quant Assay and Its Utility in Resolving Equivocal Qualitative HBsAg Results

Background and Objectives: There are reports of false qualitative HBsAg results, because of various causes, such as samples with low HBsAg concentrations that may produce false positives. The main aims of this study were to validate the analytical accuracy and to assess the utility of the Elecsys assay compared to that of the qualitative HbsAg assay as a screening test in resolving equivocal qualitative HbsAg results. Materials and Methods: The limit of blank (LoB), the limit of detection (LoD), the limit of quantification (LoQ), and linearity were estimated to validate the analytical accuracy of the Elecsys HBsAg II Quant assay. A total of 449 serum samples showing initial equivocal results (1-50 index) were evaluated by Elecsys HBsAg II Quant and ADVIA Centaur HBsAg II assays. Results: The LoQ of the assay was determined to be 0.050 IU/mL, as provided by the manufacturer. The Kappa agreement between the two assays was almost perfect, at 0.9669, despite seven discordant results. With a specificity of 100% at new cut-off index value ≥5.42, about 78 samples (17%, 78/449) with index value ≥5.42 were interpreted as positives without further duplicate tests, however the remaining 371 samples with index value <5.42 need to be confirmed with additional HBV marker assays. Conclusions: We confirm that the Elecsys HBsAg II Quant assay is accurate and sensitive for HBV infection and recommend it as an alternative confirmatory HBsAg assay for resolving equivocal qualitative HBsAg results.

Hepatocellular carcinoma and hepatitis C virus treatments: The bold and the beautiful

The occurrence of hepatocellular carcinoma (HCC) is one of the most serious complications of hepatitis C virus (HCV) infection. Recently, effective antiviral medications have made sustained viral response (SVR) or cure a realistic therapeutic goal for most chronic HCV patients. Given HCV's tumorigenic propensity, it is not surprising that achieving SVR is helpful in preventing HCC. This review briefly summarizes and discusses the existing evidence on the relationship between hepatic carcinogenesis and viral eradication by antivirals, which is mainly divided into interferon-based and direct-acting antivirals (DAAs) based therapy. DAAs have changed the treatment landscape of chronic HCV, reaching high rates of SVR even in patients with advanced cirrhosis, with few contraindications and little side effects. Although some early reports suggested that DAA treatment increased the chance of HCC occurrence, more subsequent observational studies have refuted this theory. The probability of HCC recurrence after HCV eradication appears to be decreasing over time following SVR. Despite virological suppression/cure, individuals with liver cirrhosis are still at risk of HCC and should be monitored. There is a considerable need for markers/scores to predict the long-term risk of HCC in patients with HCV-related liver disease who attain SVR with direct-acting antivirals.

Hepatocellular carcinoma incidence is decreasing in Korea but increasing in the very elderly

BACKGROUND/AIMS

A comprehensive analysis of trends in the incidence of hepatocellular carcinoma (HCC) is important for planning public health initiatives. We aimed to analyze the trends in HCC incidence in South Korea over 10 years and to predict the incidence for the year 2028.

METHODS

Data from patients with newly diagnosed HCC between 2008 and 2018 were obtained from Korean National Health Insurance Service database. Age-standardized incidence rates (ASRs) were calculated to compare HCC incidence. A poisson regression model was used to predict the future incidence of HCC.

RESULTS

The average crude incidence rate (CR) was 22.4 per 100,000 person-years, and the average ASR was 17.6 per 100,000 person-years between 2008 and 2018. The CR (from 23.9 to 21.2 per 100,000 person-years) and ASR (from 21.9 to 14.3 per 100,000 person-years) of HCC incidence decreased during the past ten years in all age groups, except in the elderly. The ASR of patients aged ≥80 years increased significantly (from 70.0 to 160.2/100,000 person-years; average annual percent change, +9.00%; P<0.001). The estimated CR (17.9 per 100,000 person-years) and ASR (9.7 per 100,000 person-years) of HCC incidence in 2028 was declined, but the number of HCC patients aged ≥80 years in 2028 will be quadruple greater than the number of HCC patients in 2008 (from 521 to 2,055), comprising 21.3% of all HCC patients in 2028.

CONCLUSION

The ASRs of HCC in Korea have gradually declined over the past 10 years, but the number, CR, and ASR are increasing in patients aged ≥80 years.

Nurses' comfort care of transarterial chemoembolization patients based on their perceptions around postembolization syndrome and symptom interference

AIM

Post-embolization syndrome is a common adverse event following trans-arterial chemoembolization, which negatively impacts the daily life of the patients involved. This study examined whether perceptions around post-embolization syndrome and symptom interference among nurses affect their comfort care performance toward patients who have undergone this procedure.

DESIGN

A descriptive cross-sectional study.

METHODS

One hundred and fifty registered nurses were surveyed from September to November 2020. Perceived post-embolization syndrome, symptom interference, and comfort care (including physical, psychospiritual, sociocultural, and environmental dimensions) were measured. Data were analyzed using t-tests, analysis of variance, Pearson's correlation, and a multivariate analysis of variance.

RESULTS

There were no individual effects found of perceived post-embolization syndrome or symptom interference on nurses' comfort care performance. However, statistically significant interaction effects were found in terms of their sociocultural and environmental care.

CONCLUSION

Nurses who recognized both high post-embolization syndrome and symptom interference among their patients were found to provide greater sociocultural and environmental care. As such, nurses should improve their early symptom and symptom interference detection protocols based on current care guidelines and provide physical, psychospiritual, sociocultural, and environmental comfort care.

Imaging features of hepatobiliary MRI and the risk of hepatocellular carcinoma development

OBJECTIVE

This study aimed to determine whether hepatocellular carcinoma (HCC) risk and time to HCC development differ according to hepatobiliary magnetic resonance imaging (MRI) findings among people at risk for developing HCC.

MATERIALS AND METHODS

A total of 199 patients aged 40 years or older with liver cirrhosis or chronic liver disease who underwent gadoxetic acid-enhanced hepatobiliary MRI between 2011 and 2015 were analyzed. An independent radiologist retrospectively reviewed MRI findings, blinded to clinical information, and categorized them into low-risk features, high-risk features and high-risk nodules. High-risk features were defined as liver cirrhosis diagnosed by imaging. High-risk nodules were defined as LR-3 or LR-4 nodules based on LI-RADS version 2018. The primary outcome was development of HCC within 5-year of MRI evaluation.

RESULTS

HCC was diagnosed in 28 patients (14.1%). HCC development was null for those with low-risk features (n = 84). The cumulative incidence rates of HCC were 0%, 2.3%, 13.4% and 22.1% at 1-, 2-, 3- and 5-year for those with high-risk features (n= 64), and were 19.1%, 31.8%, 37.3% and 46.7% at 1-, 2-, 3- and 5-year for those with high-risk nodules (n= 51). Among 28 patients developed HCC, the median time from baseline MRI to HCC diagnosis was 33.1 months (interquartile range: 25.9-46.7 months) for high-risk feature group, and 17.3 months (interquartile range: 6.2-26.5 months) for high-risk nodule group.

CONCLUSIONS

HCC risk and time to HCC development differ according to baseline hepatobiliary MRI findings, indicating that hepatobiliary MRI findings can be used as biomarkers to differentiate HCC risk.

Liver Diseases in South Korea: A Pulse Check of the Public's Knowledge, Awareness, and Behaviors

PURPOSE

National surveys in Korea have spotlighted suboptimal levels of awareness among the public towards liver-related health and diseases, leading to progressive reform of national policies and education efforts. This study aimed to assess the status of the Korean public's knowledge towards liver-related diseases.

MATERIALS AND METHODS

A self-reported, cross-sectional, web-based questionnaire study was conducted between February-March 2020 among 1000 Korean adults. Questionnaire items assessed the knowledge, awareness, and behaviors towards liver-related health and diseases.

RESULTS

About half (50.9%-52.1%) knew untreated/chronic viral hepatitis could lead to liver failure and/or cancer. Misconceptions pertaining to viral hepatitis transmission risks exist with only 26.3% knowing viral hepatitis B cannot be transmitted by dining with an infected individual. About one-fifth (22.2%) were aware of an available cure for viral hepatitis C. Less than half were aware of the risk factors associated with nonalcoholic steatohepatitis (NASH), despite 72.4% and 49.5% having heard of fatty liver disease and NASH, respectively. More than one-third were unlikely to seek medical consultation even if exposed to viral hepatitis risk factors or upon diagnosis with a liver condition. Reasons for this low urgency included costs-related concerns, perceptions of being healthy, and the viewpoint that the condition is not life-threatening.

CONCLUSION

The public's knowledge towards liver-related diseases in Korea was found to be lacking, which could account for a lower sense of urgency towards screening and treatment. More efforts are needed to address misperceptions and dispel stigma in an effort to encourage pro-health seeking behaviors.

Risk Association of Liver Cancer and Hepatitis B with Tree Ensemble and Lifestyle Features

The second-largest cause of death by cancer in Korea is liver cancer, which leads to acute morbidity and mortality. Hepatitis B is the most common cause of liver cancer. About 70% of liver cancer patients suffer from hepatitis B. Early risk association of liver cancer and hepatitis B can help prevent fatal conditions. We propose a risk association method for liver cancer and hepatitis B with only lifestyle features. The diagnostic features were excluded to reduce the cost of gathering medical data. The data source is the Korea National Health and Nutrition Examination Survey (KNHANES) from 2007 to 2019. We use 3872 and 4640 subjects for liver cancer and hepatitis B model, respectively. Random forest is employed to determine functional relationships between liver diseases and lifestyle features. The performance of our proposed method was compared with six machine learning methods. The results showed the proposed method outperformed the other methods in the area under the receiver operator characteristic curve of 0.8367. The promising results confirm the superior performance of the proposed method and show that the proposed method with only lifestyle features provides significant advantages, potentially reducing the cost of detecting patients who require liver health care in advance.

Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications

ABSTRACT

The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.

Clinical Outcomes of Hepatitis B Virus-Related Hepatocellular Carcinoma Patients with Undetectable Serum HBV DNA Levels

BACKGROUND AND AIMS

Some hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients show undetectable serum HBV DNA levels at HCC diagnosis. The risk of HBV reactivation and its impact on clinical outcomes are not well-unknown.

METHODS

This retrospective cohort study included a total of 985 HBV-related HCC patients with undetectable serum HBV DNA levels (< 12 IU/mL) at HCC diagnosis (112 were antiviral treatment (AVT)-naïve; 873 were receiving AVT). Incidence and risk factors for HBV reactivation (re-detection of HBV DNA in serum) during follow-up, as well as its association to overall survival, were assessed.

RESULTS

During a median of 33.4 months of follow-up (range: 0.2-124.2 months), HBV reactivation was observed in 279 patients. HBV reactivation rate was significantly lower for patients receiving AVT than AVT-naïve patients (three-year cumulative incidence rate: 27.3% versus 56.0%; P < 0.001). In multivariable-adjusted analysis, the risk of HBV reactivation was lower for those receiving AVT compared to AVT-naïve patients (adjusted hazard ratio: 0.39, 95% confidence interval: 0.29-0.54). Overall survival was significantly lower for those experiencing HBV reactivation than those who did not (71.5% and 85.7% at five-year) and was associated with higher risk of overall mortality (adjusted hazard ratio: 5.15, 95% confidence interval: 3.60-7.38).

CONCLUSION

More than half of AVT-naïve patients experienced HBV reactivation within three years, which was associated with increased risk of overall mortality. The risk of HBV reactivation was lower for those receiving AVT, suggesting that prompt AVT needs to be considered for AVT naïve HBV-related HCC patients with undetectable HBV DNA levels.

Impact of discriminant factors on the comfort-care of nurses caring for trans-arterial chemoembolisation patients

PURPOSE

This study was conducted to identify the levels of comfort-care provided by trans-arterial chemoembolisation (TACE) nurses and examine the discriminant factors thereof.

METHODS

Nurses (n = 146) with experience in caring for TACE patients, participated in this study. The data were collected using an online self-rated questionnaire and analysed with descriptive statistics and discriminant analysis. The discriminating factors included perception of post-embolisation syndrome and symptom interference, caring attitude, barriers to pain and nausea/vomiting management, and supportive care competence.

RESULTS

The participants were classified into three groups, depending on the level of their comfort-care: "low" (n = 27), "moderate" (n = 88), and "high" (n = 31) comfort-care groups. One function significantly discriminated between the low and high comfort-care groups and correctly classified 79.3% of the participants in the cross-validation run. Supportive care competence (0.864), caring attitude (0.685), perception of symptom interference (0.395), perception of post-embolisation syndrome (0.321), and barriers to nausea/vomiting management (- 0.343) were significant discriminant factors of comfort-care.

CONCLUSION

A low proportion of the participants provided high levels of comfort-care, which was determined by five discriminant factors. The study's findings imply that the development of supportive care competence, authentic human caring attitude, early detection of patients' symptoms and symptom interference, and the development of manuals and guidelines for removing barriers for nausea and vomiting are needed to improve the comfort-care of nurses caring for TACE patients.

Incidence, mortality, and survival of liver cancer using Korea central cancer registry database: 1999-2019

Backgrounds/Aims

Historically, incidence and survival analysis and annual traits for primary liver cancer (LC) has not been investigated in a population-based study in Korea. The purpose of the current study is to determine incidence, survival rate of patients with primary LC in Korea.

Methods

We conducted a retrospective cohort study using Korea Central Cancer Registry based on the Korea National Cancer Incidence Database. Statistical analysis including crude rate and age-standadized rate (ASR) of incidence and mortality was performed for LC patients registered with C22 code in International Classification of Diseases, tenth revision from 1999 to 2019. Subgroup analysis was performed for hepatocellular carcinoma (HCC, C22.0) and intrahepatic cholangiocarcinoma (IHCC, C22.1).

Results

The crude incidence rate of HCC (21.0 to 22.8 per 100,000) and IHCC (2.3 to 5.6 per 100,000) increased in the observed period from 1999 to 2019. The ASR decreased in HCC (20.7 to 11.9 per 100,000) but remained unchanged in IHCC (2.4 to 2.7 per 100,000). The proportion of HCC patients diagnosed in early stages (localized or regional Surveillance, Epidemiology, and End Results or SEER stage) increased significantly over time. As expected, 5-yeat survival rate of HCC was greatly improved, reaching 42.4% in the period between 2013 and 2019. This trait was more prominent in localized SEER stage. On the other hand, the proportion of IHCC patients diagnosed in localized stage remained unchanged (22.9% between 2013 and 2019), although ASR and 5-year survival rate showed minor improvements.

Conclusions

A great improvement in survival rate was observed in patients with newly diagnosed HCCs. It was estimated to be due to an increase in early detection rate. On the contrary, detection rate of an early IHCC was stagnant with a minor improvement in prognosis.

Four-copy number alteration (CNA)-related lncRNA prognostic signature for liver cancer

The objective of this study was to identify CNA-related lncRNAs that can better evaluate the prognosis of patients with liver cancer. Prognostic molecular subtypes were identified, followed by tumor mutation and differential expression analyses. Genomic copy number anomalies and their association with lncRNAs were also evaluated. A risk model was built based on lncRNAs, as well as a nomogram, and the differences in the tumor immune microenvironment and drug sensitivity between the High_ and Low_risk groups were compared. Weighted gene co-expression network analysis was used to identify modules with significant enrichment in prognostic-related lncRNAs. In total, two subtypes were identified, TP53 and CTNNB1 were common high-frequency mutated genes in the two subtypes. A total of 8,372 differentially expressed (DE) mRNAs and 798 DElncRNAs were identified between cluster1 and cluster2. In addition, a four-lncRNA signature was constructed, and statistically significant differences between the Low_ and High_risk groups were found in terms of CD8 T cells, resting memory CD4 T cells, etc. Enrichment analysis showed that prognostic-related lncRNAs were involved in the cell cycle, p53 signaling pathway, non-alcoholic fatty liver disease, etc. A prognostic prediction signature, based on four-CNA-related lncRNAs, could contribute to a more accurate prognosis of patients with liver cancer.

Changing epidemiology of hepatocellular carcinoma in Asia

Liver cancer is the fifth most common cancer and the second leading cause of malignant death in Asia, and Asia reports 72.5% of the world's cases in 2020. As the most common histological type, hepatocellular carcinoma (HCC) accounts for the majority of incidence and mortality of liver cancer cases. This review presents the changing epidemiology of HCC in Asian countries in recent years. Globally, aged, male and Asian populations remain the group with the highest risk of HCC. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are still the leading risk factors of HCC with a slight decline in most Asian countries, which is mainly attributed to HBV vaccination of newborns, prevention of HCV horizontal transmission and treatment of chronic hepatitis. However, the prevalence of HCC caused by metabolic factors, including metabolic syndrome, obesity and non-alcoholic fatty liver diseases, is increasing rapidly in Asian countries, which may eventually become the major cause of HCC. Excessive alcohol consumption continues to be an important risk factor as the average consumption of alcohol is still growing. Hopefully, great effort has been made to better prevention and treatment of HCC in most Asian regions, which significantly prolongs the survival of HCC patients. Asian countries tend to use more aggressive intervention than European and American countries, but it remains unclear whether this preference is related to a better prognosis. In conclusion, HCC remains a major disease burden in Asia, and the management of HCC should be adjusted dynamically based on the changing epidemiology.

Trend Analysis and Prediction of Hepatobiliary Pancreatic Cancer Incidence and Mortality in Korea

BACKGROUND

This study aimed to analyze the current trends and predict the epidemiologic features of hepatobiliary and pancreatic (HBP) cancers according to the Korea Central Cancer Registry to provide insights into health policy.

METHODS

Incidence data from 1999 to 2017 and mortality data from 2002 to 2018 were obtained from the Korea National Cancer Incidence Database and Statistics Korea, respectively. The future incidence rate from 2018 to 2040 and mortality rate from 2019 to 2040 of each HBP cancer were predicted using an age-period-cohort model. All analyses, including incidence and mortality, were stratified by sex.

RESULTS

From 1999 to 2017, the age-standardized incidence rate (ASIR) of HBP cancers per 100,000 population had changed (liver, 25.8 to 13.5; gallbladder [GB], 2.9 to 2.6; bile ducts, 5.1 to 5.9; ampulla of Vater [AoV], 0.9 to 0.9; and pancreatic, 5.6 to 7.3). The age-standardized mortality rate (ASMR) per 100,000 population from 2002 to 2018 of each cancer had declined, excluding pancreatic cancer (5.5 to 5.6). The predicted ASIR of pancreatic cancer per 100,000 population from 2018 to 2040 increased (7.5 to 8.2), but that of other cancers decreased. Furthermore, the predicted ASMR per 100,000 population from 2019 to 2040 decreased in all types of cancers: liver (6.5 to 3.2), GB (1.4 to 0.9), bile ducts (4.3 to 2.9), AoV (0.3 to 0.2), and pancreas (5.4 to 4.7). However, in terms of sex, the predicted ASMR of pancreatic cancer per 100,000 population in females increased (3.8 to 4.9).

CONCLUSION

The annual incidence and mortality cases of HBP cancers are generally predicted to increase. Especially, pancreatic cancer has an increasing incidence and will be the leading cause of cancer-related death among HBP cancers.

Alcohol-related hepatocellular carcinoma is a heterogenous condition: Lessons from a latent class analysis

BACKGROUND

Alcohol-associated hepatocellular carcinoma (AL-HCC) poor prognosis has been attributed to diagnosis at a later stage. However, host factors and specific health trajectories have been associated with severe outcomes in alcohol-related liver disease. We hypothesize AL-HCC is not a homogeneous condition but encompasses subgroups yielding different outcomes.

AIMS

Our aim was to provide a first attempt at a clinical phenotyping of AL-HCC.

METHODS

We analysed data for the calendar years 2007-2013 from the French nationwide administrative hospital database. We selected patients with AL-HCC only. Clustering of AL-HCC phenotypes was performed by latent class analysis (LCA).

RESULTS

The study included 11 363 patients with AL-HCC, mainly male (89.6%), median age 67 years [IQR: 61; 74] of which 71.2% had at least one metabolic comorbidity. Five phenotypes were identified. Phenotype 1 (41.4%) displayed high rates of unrecognized cirrhosis prior to HCC diagnosis (81%), low rates of metabolic comorbidities (diabetes 13%), and mostly compensated liver disease at HCC diagnosis while the four other phenotypes displayed high rates of metabolic comorbidities (diabetes up to 100%), various patterns of liver disease trajectories and overall 42% unrecognized cirrhosis. In adjusted survival analysis, compared to phenotype 1, risk of death after HCC diagnosis was significantly different for all phenotypes.

CONCLUSION

LCA uncovers AL-HCC is a heterogeneous condition with distinct phenotypes yielding specific survival outcomes. Frequent unrecognized cirrhosis prior to HCC underlines the urgent need for implementing strategies to identify the underlying liver disease prior to HCC onset in patients with documented alcohol use disorders and metabolic comorbidities.

Association of the presence of allergic disease with subsequent risk of liver cancer in a nationwide retrospective cohort among Koreans

A number of studies have proposed an inverse association between allergic diseases and risk of cancer, but only a few studies have specifically investigated the risk of primary liver cancer, including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). The aim of this study was to evaluate the association of allergic diseases with risk of primary liver cancer. We conducted a retrospective cohort study of the Korean National Health Insurance Service database consisted of 405,512 Korean adults ages 40 and above who underwent health screening before January 1st, 2005. All participants were followed up until the date of liver cancer, death, or December 31st, 2013, whichever happened earliest. Those who died before the index date or had pre-diagnosed cancer were excluded from the analyses. Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for risk of primary liver cancer according to the presence of allergic diseases, including atopic dermatitis, asthma, and allergic rhinitis. The aHR (95% CI) for overall liver cancer among allergic patients was 0.77 (0.68–0.87) compared to those without allergic disease. Allergic patients had significantly reduced risk of HCC (aHR, 0.72; 95% CI 0.62–0.85) but not ICC (aHR, 0.95; 95% CI 0.73–1.22). The presence of allergies was associated with significantly lower risk of liver cancer among patients whose systolic blood pressure is lower than 140 mmHg (aHR, 0.64; 95% CI 0.62–0.78 for overall liver cancer; aHR, 0.64; 95% CI 0.52–0.78 for HCC) but this effect was not observed among patients whose systolic blood pressure is higher than 140 mmHg (aHR, 0.91; 95% CI 0.71–1.18 for overall liver cancer; aHR, 0.91; 95% CI 0.71–1.18 for HCC) The aHR (95% CI) for overall liver cancer of allergic patients with and without chronic hepatitis virus infection were 0.60 (95% CI 0.44–0.81) and 0.77 (95% CI 0.64–0.93), respectively. In addition, allergic patients without cirrhosis showed significantly lower risk of overall liver cancer (aHR, 0.73; 95% CI 0.63–0.83). Patients with allergic diseases have significantly lower risk of primary liver cancer compared to those without allergic diseases, which supports the rationale for immunotherapy as an effective treatment for liver cancer.

Real-World Treatment Patterns and Health-Resource Utilization in Patients with Hepatocellular Carcinoma (HCC) Following Failure of Sorafenib: A Retrospective Chart Review of 127 Patients in South Korea

BACKGROUND

European, US, Asian and Korean treatment guidelines all recommend sorafenib as first-line systemic therapy in patients with hepatocellular carcinoma (HCC). However, due to the emergence of several new treatments, post-sorafenib treatment patterns in real-world clinical practice are less well understood.

OBJECTIVE

This study aimed to characterize current treatment patterns and healthcare resource utilization (HRU) in patients with HCC following the failure of first-line sorafenib in a real-world setting in Korea.

PATIENTS AND METHODS

A chart review was conducted in 127 HCC patients who received systemic therapy or best supportive care following failure of first-line systemic treatment with sorafenib (2016-2018). Anonymized data on patient characteristics, treatment patterns, and survival were abstracted by 37 physicians in Korea.

RESULTS

The mean (range) age of patients was 60 (37-79) years; 63 patients had low alpha-fetoprotein (AFP < 400 ng/mL), 64 patients had high alpha-fetoprotein (AFP ≥ 400 ng/mL). Post-sorafenib, 64 (50%) patients had systemic therapy. Regorafenib, used by 54 (84%) patients in second-line, and nivolumab monotherapy, by ten (56%) patients in third-line, were the most common therapies. Hepatologist visits and hospitalizations, at an average rate of 6.89 (95% CI 6.37-7.45) and 2.24 (95% CI 1.95-2.57) per patient-year, respectively, were the key contributors of HRU. The median overall survival (95% CI) from discontinuation of sorafenib was 13.0 (9.8-20.7), 6.5 (5.0-9.5) and 9.5 (6.7-12.3) months in the low AFP, high AFP and overall group, respectively.

CONCLUSION

This real-world evidence research on treatment patterns reflected current clinical guidelines and highlighted fast progressing nature and continuing high mortality in HCC, especially among the high AFP group, underlying a need for new treatments that can lengthen survival. Results from this real-world chart review, together with existing clinical trial data, can inform future evaluations of new HCC treatments that estimate their health economic impact in Korea.

Better survival of patients with hepatitis B virus-related hepatocellular carcinoma in South Korea: Changes in 16-years cohorts

Aims

The incidence and mortality of hepatocellular carcinoma (HCC) have decreased over time in South Korea, where hepatitis B virus (HBV) in endemic. This study investigated the changes in the characteristics and clinical outcomes of HCC patients in Korea.

Methods

Patients initially diagnosed with HCC and treated at the National Cancer Center, Korea between 2000 and 2015 (n = 4,291) were followed up until February 2017. Differences in patient characteristics and outcomes were compared between chronological cohorts: cohort A (2000–2004, n = 1,157) vs. B (2005–2009, n = 1,678) vs. C (2010–2015, n = 1,456).

Results

The median age of the patient cohort was 57 years (range, 13–98 years), and male predominance was noted (81.6%). HBV infection was the most common etiology (74.8%). The proportion of patients diagnosed with good liver function and small tumors (<2 cm) increased significantly over time: 74.6%, 79.9%, and 87.4% for Child–Pugh class A (p<0.001) and 8.0%, 8.5%, and 12.0% for modified UICC stage I (p<0.001) in cohorts A, B, and C, respectively. Median overall survival improved significantly over time: 14.4 months (95% confidence interval [CI], 12.0–16.8 months), 22.9 months (95% CI, 20.3–25.5 months), and 53.6 months (95% CI, 45.7–61.5 months) in cohorts A, B, and C, respectively. HBV-related patients showed significantly improved survival (12.7 vs. 20.4 vs. 64.5 months, p<0.001) associated with the use of antiviral treatments (adjusted hazard ratio, 0.72; 95% CI, 0.64–0.80).

Conclusions

The survival of patients with HCC, especially HBV-related HCC, has improved significantly over time in Korea.