Utility of combining PIVKA-II and AFP in the surveillance and monitoring of hepatocellular carcinoma in the Asia-Pacific region

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

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

Preoperative identification of hepatocellular carcinoma from focal liver lesions ≤ 20 mm in high-risk patients using clinical and contrast-enhanced ultrasound features

OBJECTIVE

We aimed to develop and validate a prediction model to identify HCC in focal liver lesions (FLLs) ≤20 mm among patients at risk for HCC based on clinical and contrast-enhanced ultrasound (CEUS) features.

METHODS

Between January 2022 and July 2023, 386 patients (mean age 58 ± 11 years; 277 male) at risk for HCC with FLLs ≤20 mm and clinical and preoperative CEUS data from three centers were retrospectively enrolled. Three prediction models based on clinical data (Cli-M), CEUS features (CEUS-M), and combined clinical and CEUS features (Com-M) were constructed using the training cohort (187 patients). Their predictive performance was evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA) in the internal and external validation cohorts. All patients were reclassified using the American College of Radiology CEUS Liver Imaging Reporting and Data System (CEUS LI-RADS) and combined with the best-performing model (modified LI-RADS).

RESULTS

The AUCs of Com-M were 0.873-0.951 in the training, internal, and external validation cohorts, which were higher than those of Cli-M (0.749-0.795, all P < 0.05) and CEUS-M (0.848-0.899, all P < 0.05). The sensitivity of LR-5 of modified LI-RADS was significantly improved from 83.1 % to 88.9 % (p＜0.001) in the training, internal and external validation cohort while there was no statistical different on its specificity (82.6 %-94.7 % vs 95.7 %-97.6 %., p = 0.162-0.650).

CONCLUSIONS

The model based on clinical and CEUS features can help identify HCC in FLLs ≤ 20 mm in high-risk patients.

CA19-9, CEA and PIVKA-Ⅱ as a novel panel of serum markers for diagnosis of pancreatic cancer

AIM

This retrospective study was aimed to evaluate the diagnostic value of a combination of carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA) and protein induced by vitamin K absence or antagonist-Ⅱ (PIVKA-II) in pancreatic cancer.

METHODS

Clinical data were collected from 111 pancreatic cancer patients and 158 patients with benign pancreatic diseases (BPD). Serum CA19-9, CEA and PIVKA-II were subjected to receiver operating characteristic curve (ROC) analysis alone and in combination for the diagnosis of pancreatic cancer.

RESULTS

Serum CA19-9, CEA, and PIVKA-II were higher in pancreatic cancer patients than in BPD patients (P < 0.001). ROC analysis indicated that the cutoff values were 99.390 for CA19-9, 3.065 for CEA, and 42.965 for PIVKA-II, at which the positive rate in pancreatic cancer was 78.38 % for CA19-9, 43.24 % for CEA and 48.65 % for PIVKA-Ⅱ. When serum CA19-9, CEA, and PIVKA-II were used alone, the areas under the curves (AUC), sensitivity and specificity were 0.821, 68.47 % and 89.24 % for CA19-9, 0.763, 61.26 % and 85.44 % for CEA, and 0.681, 45.95 % and 87.34 % for PIVKA-II. When serum CA19-9, CEA, and PIVKA-II were used in combination, the positivity rate was 94.59 % in pancreatic cancer with AUC of 0.903, sensitivity of 81.10 % and specificity of 88.00 %.

CONCLUSION

PIVKA-II is a potential serum marker of pancreatic cancer and the combination of CA19-9, CEA, and PIVKA-II is a novel panel of serum markers with promising diagnostic value for pancreatic cancer.

tRF-23-R9J89O9N9:A novel liquid biopsy marker for diagnosis of hepatocellular carcinoma

BACKGROUND

Non-coding small RNA, specifically tRNA-derived small RNAs (tsRNAs), are readily detectable in cancer patients, exhibit remarkable stability, and are present in high abundance. They play a significant role in tumor development. However, the clinical significance of serum tsRNAs in hepatocellular carcinoma (HCC) remains poorly understood. In this study, we explored the impact of a novel tsRNA, named tRF-23-R9J89O9N9, in the adjuvant diagnosis, disease monitoring, and prognosis assessment of HCC.

METHODS

The tRF-23-R9J89O9N9 was identified as the target molecule through screening the The Cancer Genome Atlas(TCGA) database. Its expression levels were measured using qRT-PCR. Various methods, including agarose gel electrophoresis, Sanger sequencing, gradient dilution experiments, room temperature stability tests, and repeated freeze-thaw assessments, were employed to evaluate the performance of tRF-23-R9J89O9N9. The correlation between tRF-23-R9J89O9N9 levels and clinicopathological parameters was analyzed using the χ2 test. The diagnostic value of tRF-23-R9J89O9N9 in HCC was assessed with ROC curve analysis, while the prognostic value was evaluated using Kaplan-Meier curves.

RESULTS

Serum tRF-23-R9J89O9N9 expression levels were significantly elevated in HCC patients, while levels in postoperative patients were restored to those of healthy subjects. Additionally, the expression of tRF-23-R9J89O9N9 related to TNM stage(P = 0.009), lymph node metastasis(P＜0.0001), and degree of differentiation(P＜0.0001). Furthermore, the combination of AFP, PIVKA-II, and CEA greatly improved the diagnostic value for HCC. Serum tRF-23-R9J89O9N9 was also identified as a potential biomarker for dynamic monitoring and prognosis of HCC.

CONCLUSIONS

tRF-23-R9J89O9N9 may regard as a potential novel biomarker for the adjuvant diagnosis of HCC.

Development of a chitosanase 3-like protein 1 assay kit and study of its application in patients with hepatocellular carcinoma

OBJECTIVE

The detection kit for plasma Chitinase-3-like Protein 1 was developed using the magnetic bead chemiluminescence method, in order to investigate the diagnostic value of DD, FDP, CHI3L1, AFP-L3 and PIVKA-II in hepatocellular carcinoma.

METHOD

The CHI3L1 detection kit was developed using the chemiluminescence method. The luminescence value obtained from the chemiluminescence analyzer was utilized for sensitive detection of CHI3L1, and the performance of the kit was evaluated accordingly. Moreover, this study enrolled 200 patients with hepatocellular carcinoma who were treated at the Oncology Department of the Affiliated Hospital of Jiangnan University between August 2022 and November 2023 as study subjects, while 100 healthy individuals undergoing physical examinations during the same period served as a control group. The plasma CHI3L1 levels in these subjects were measured using our institute's developed kit. Simultaneously, DD, FDP, AFP-L3, and PIVKA-II levels were assessed in all subjects to investigate their relationship with general pathology in patients with hepatocellular carcinoma. Additionally, ROC curves were generated to evaluate both single and combined detections' diagnostic efficacy for hepatocellular carcinoma.

RESULT

The serological index changes of DD, FDP, AFP-L3, PIVKA-II, and CHI3L1 were not associated with patient gender. The concentrations of AFP-L3 and PIVKA-II in the 45-59 age group were significantly higher than in other groups (P < 0.05). Additionally, DD, CHI3L1, and PIVKA-II levels were markedly elevated in patients with tumors > 5 cm, medium-to-high differentiation, nerve invasion, lymph node metastasis, or distant metastasis. In advanced liver cancer (stages III-IV), DD, FDP, and CHI3L1 concentrations were significantly higher than in early-stage patients (stages I-II). For single diagnostic analysis, the AUC for CHI3L1 was 0.923, while the combined AUC for all five indices was 0.961, indicating greater diagnostic value when used together. The CHI3L1 chemiluminescence detection kit had a minimum detection limit of 1.50 ng/mL, with precision and accuracy within 10%, and R > 0.99. Compared to a clinical reference kit, the correlation coefficient (R) was 0.994, meeting clinical performance evaluation criteria.

CONCLUSION

The CHI3L1 chemiluminescence kit developed meets clinical requirements. CHI3L1 can be used as an indicator for early screening of liver cancer, and the detection value of combined five indicators DD, FDP, AFP-L3, PIVKA-II and CHI3L1 is higher than that of single detection.

Prognostic Value of the ASAP Score for Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma: A Multicenter Analysis of 1,239 Patients

BACKGROUND AND AIMS

The ASAP score, which incorporates age, sex, alpha-fetoprotein (AFP), and protein induced by vitamin K absence-II, has demonstrated promise for early detection of hepatocellular carcinoma (HCC). However, its prognostic value after HCC treatment remains unknown. The current study sought to evaluate the prognostic value of the ASAP score to predict recurrence and survival following curative hepatic resection for HCC.

METHODS

This study using prospectively collected data included HCC patients who underwent curative-intent hepatic resection. The ASAP score was calculated preoperatively, and X-tile analysis was used to determine the optimal cutoff value. Univariate and multivariate analyses were performed to identify independent risk factors associated with recurrence and overall survival (OS).

RESULTS

Among 1239 patients in the analytic cohort, the optimal ASAP score cutoff was 4.8; patients were divided into low (n = 749) and high (n = 490) ASAP score subgroups. Patients with high ASAP scores had a higher incidence of 5-year recurrence (73.9% vs 51.0%, P < 0.001) and worse OS (31.7% vs 60.1%, P < 0.001) versus individuals with low scores. Multivariate analysis identified ASAP score ≥4.8 as an independent risk factor of both recurrence (hazard ratio [HR] 1.976, 95% confidence interval [CI]: 1.633-2.390, P < 0.001) and OS (HR 1.407, 95% CI 1.170-1.691, P < 0.001) after controlling for established clinicopathological factors.

CONCLUSION

Preoperative ASAP score was independently associated with recurrence and survival after HCC resection. The clinical utility of the ASAP score may be applicable to both diagnosis and prognosis, potentially improving postoperative surveillance and management strategies for HCC patients.

Integrated spatial and single cell transcriptomics identifies PRKDC as a dual prognostic biomarker and therapeutic target in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality, with a pressing need for effective biomarkers and therapeutic targets. Despite the clinical use of alpha-fetoprotein (AFP) as a diagnostic biomarker, its limitations in sensitivity and specificity necessitate the identification of novel markers. In this study, we investigated the role of Protein Kinase, DNA-Activated, Catalytic Subunit (PRKDC) in HCC prognosis and its potential as a therapeutic target. Utilizing spatial transcriptomics and single-cell RNA sequencing (scRNA-seq), we dissected the cellular composition of PRKDC in HCC tissue samples, revealing its high expression in malignant cell subpopulations and its association with the tumor immune microenvironment. Through clinical signature analysis, we observed widespread PRKDC expression in HCC tissues, particularly in immune cells, highlighting its link to immune cell infiltration. Further analyses confirmed high PRKDC expression in malignant cells and its inhibitory effect on immune cell infiltration. Copy number variation (CNV) analysis revealed significant genomic instability, with PRKDC exhibiting both amplifications and deletions across chromosomal regions, underscoring its role in tumorigenesis. Functional overexpression of PRKDC in HCC cell lines enhanced cell proliferation, migration, and altered cell cycle dynamics, with a notable increase in the G2/S phase. Taken together, we first to integrate spatial transcriptomics and single-cell transcriptomics and bulk RNA-seq to reveal that PRKDC is a reliable prognostic biomarker and a potential therapeutic target. High PRKDC expression is associated with shorter survival times and an abnormal tumor microenvironment, highlighting its impact on immune cell infiltration and HCC prognosis. Targeting PRKDC could selectively inhibit its expression in tumor cells, providing new strategies for HCC treatment.

New insights into biomarkers and risk stratification to predict hepatocellular cancer

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

The immune-reinforcements of Lenvatinib plus anti-PD-1 and their rationale to unite with TACE for unresectable hepatocellular carcinoma treatment

BACKGROUND

Despite encouraging clinical benefits have gained by anti-PD-1 and Lenvatinib combination, in-depth characterizations about the mechanisms of action remain poorly characterized. Furthermore, although the combination of systemic anti-PD-1 or Lenvatinib treatment and locoregional transcatheter arterial chemoembolization (TACE) is widely carried out to treat unresectable HCC in clinical, the efficacies of different combination regimens are uncertain due to limited researches.

METHODS

We firstly generated murine HCC models to validate the enhanced anti-tumor effects of anti-PD-1 and Lenvatinib combination therapy. Then single cell mass cytometry (CyTOF) was employed to phenotypically reveal their mechanisms of action. After that, we further compared the effectiveness of TACE plus Lenvatinib (i.e., TACE-Len) dual therapy with TACE, Lenvatinib plus anti-PD-1 (i.e., TACE-Len-PD-1) triple therapy as conversion therapy for unresectable HCC.

RESULTS

Lenvatinib and anti-PD-1 combination could generate activated immune profiles not only by increasing systemic CD4+, CD8+T cells and B cells proportions, but also by weakening the immune-tolerance functions derived from both immunosuppressive cells (i.e., MDSCs) and co-inhibitory mediators (i.e., PD-L1 and LAG-3). Meanwhile, our study also suggested that TACE-Len-PD-1 triple therapy could achieve better clinical responses with powerful immune profiles for unresectable HCC compared to TACE-Len dual therapy.

CONCLUSIONS

Our study provided a delicate immune landscape of anti-PD-1and Lenvatinib combination, and we also offered scientific evidences that TACE-Len-PD-1 triple therapy could fulfill better clinical benefits than TACE-Len dual therapy, which is anticipated to provide objective and effective evidences for clinical use.

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

Background

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

Methods

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

Results

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

Conclusion

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

Cluster analysis of hepatocellular carcinoma prognosis using preoperative alpha-fetoprotein and des-gamma-carboxy prothrombin levels: a multi-institutional study

BACKGROUND

Hepatocellular carcinoma (HCC) remains the leading cause of cancer-related mortality worldwide and is characterized by high recurrence rates after curative resection. The tumor markers des-gamma-carboxy prothrombin (DCP) and alpha-fetoprotein (AFP) are crucial for HCC diagnosis and prognosis. However, their roles in the modern era of HCC epidemiology require reevaluation.

METHODS

This multi-institutional retrospective study analyzed 1515 patients who underwent hepatectomy for primary HCC. Patients were classified into 4 clusters using k-means analysis based on preoperative DCP and AFP levels. Clinicopathologic characteristics, overall survival (OS), and recurrence rate (RR) were evaluated using Cox proportional hazards models and area under the receiver operating characteristic curve (AUROC) comparisons.

RESULTS

Cluster 3 (concurrent elevations of DCP and AFP) had the poorest 5-year OS (52.8%) and the highest RR (79.3%), whereas cluster 4 (low levels of both markers) had the most favorable outcomes, with a 5-year OS rate of 71.5% and an RR of 55.7%. Cluster 1 (elevated DCP alone) was associated with larger tumors (median of 45 mm) and more frequent vascular invasion (43%) than cluster 2 (elevated AFP alone, median tumor size of 24 mm, and vascular invasion of 36%). DCP was a stronger predictor of 5-year OS in patients with preserved liver function (AUROC, 0.63), whereas AFP was more effective in stratifying RR in patients with impaired liver function (AUROC, 0.57). Non-B, non-C hepatitis (NBNC)-related HCC exhibited a distinct biomarker profile, with an elevated DCP level correlating with a higher 5-year RR (67%) than other etiologies.

CONCLUSION

Our study introduces tumor marker clustering as a novel analytical approach, providing a nuanced understanding of AFP and DCP's combined utility in predicting prognosis and recurrence. Our findings highlight the independent and complementary roles of these biomarkers, particularly in NBNC-related HCC and in cases with impaired liver function. AFP and DCP remain crucial tools for recurrence risk assessment, guiding personalized management strategies, such as surveillance, neoadjuvant therapies, and tailored postoperative interventions.

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

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

Paracancerous binuclear hepatocytes assessed by computer program is a novel biomarker for short term recurrence of hepatocellular carcinoma after surgery

Hepatocellular carcinoma (HCC) is notorious for its high likelihood of recurrence even after radical surgery, which calls for effective adjuvant therapy based on more precise patient selection. The decline of the abundance of binuclear hepatocytes (ABH) in paracancerous liver tissues has been reported to indicate pathological changes in liver cells, leading to short-term recurrence within 2 years. In this research, we analyzed 34 HCC patients and 22 patients underwent liver surgery for non-HCC diseases. An ImageJ script was used to assess binuclear hepatocytes in the HE-staining specimens of paracancerous liver tissues. ABH significantly decreased in HCC patients and indicated poorer outcomes. Immunohistochemistry (IHC) assays suggested ploidy-related regulation of arginase 1 (ARG1) expression. Our findings suggested computer-assisted assessment of ABH as a possible biomarker for short-term HCC recurrence.

Assessing the Validity of the AASLD Surgical Treatment Algorithm in Patients with Early-Stage Hepatocellular Carcinoma

Background/Aims

The aim of this study was to investigate the effect of a surgical treatment algorithm recently proposed by the American Association for the Study of Liver Diseases (AASLD) on survival outcomes in patients with early-stage hepatocellular carcinoma (HCC) and identify effective alternative treatment modalities when liver transplantation (LT) is not available.

Methods

We studied the clinical data of 1,442 patients who were diagnosed with early-stage HCC (a single lesion measuring 2-5 cm in size or 2 to 3 lesions measuring ≤3 cm in size) between 2013 and 2018 and classified as Child-Turcotte-Pugh (CTP) A or B. Analyses were separately performed for individuals recommended for resection (single lesion, CTP A and no clinically significant portal hypertension) and those recommended for LT (single lesion with impaired liver function such as CTP B or clinically significant portal hypertension or multiple lesions).

Results

Of 791 patients recommended for surgical resection, 85.8% underwent resection. The 5-year survival rate was higher for patients who underwent surgical resection than for those who received other treatments (89.4% vs 72.3%). Among 651 patients recommended for LT, only 3.4% underwent the procedure. The most common alternative treatment modalities were transarterial therapy (39.3%) followed by resection (28.9%) and ablation (27.8%). The overall survival rate associated with transarterial therapy was lower than that for resection and ablation, whereas that of the latter two treatments were comparable.

Conclusions

The survival outcomes of treatment strategies that most closely aligned with the algorithm proposed by the AASLD were superior to those of alternative treatment approaches. However, LT in patients with early-stage HCC can be challenging. When LT is not feasible, resection and ablation can be considered first-line alternative options.

Des-γ-carboxy Prothrombin in hepatocellular carcinoma post-operative recurrence risk evaluation

BACKGROUND

While the value of Des-γ-carboxy prothrombin in hepatocellular carcinoma diagnosis has been widely acknowledged, whether or how Des-γ-carboxy prothrombin could be used in recurrence evaluation remains largely unexplored.

METHODS

We performed a multicenter retrospective analysis including an Exploration Cohort (1074 patients, 5133 Des-γ-carboxy prothrombin measurements) and a Validation Cohort (263 patients, 612 Des-γ-carboxy prothrombin measurements) to investigate whether Des-γ-carboxy prothrombin could evaluate patients' prognosis. We introduced the Des-γ-carboxy prothrombin dynamic rate as a normalized quantitative measurement of Des-γ-carboxy prothrombin dynamic change. Des-γ-carboxy prothrombin dynamic rates were further applied in a high-risk liver cirrhosis patient cohort (PreCar Cohort, 542 liver cirrhosis patients, 2023 Des-γ-carboxy prothrombin measurements).

RESULTS

Here, we show a post-operative decrease of Des-γ-carboxy prothrombin in the Exploration Cohort, making the Des-γ-carboxy prothrombin threshold in diagnosis unsuitable for prognosis, while Des-γ-carboxy prothrombin dynamic rates significantly associate with recurrence risk. Categorizing patients based on Des-γ-carboxy prothrombin dynamic rates and final concentrations shows that patients negative for both exhibit the best median recurrence-free survival and patients positive for both show the worst median recurrence-free survival. Patients with consistently positive status have a significantly lower median recurrence-free survival compared to those whose status reverted to negative. These findings are validated in the Validation Cohort. Furthermore, the Des-γ-carboxy prothrombin dynamic rates in the PreCar Cohort can identify an additional 28% of cirrhosis patients progressing to hepatocellular carcinoma.

CONCLUSIONS

These results expand on the clinical utilization of the hepatocellular carcinoma diagnosis biomarker, Des-γ-carboxy prothrombin, by proposing a quantification measurement of Des-γ-carboxy prothrombin dynamics to monitor hepatocellular carcinoma recurrence. This measurement is not limited in prognosis but can also improve the sensitivity of early hepatocellular carcinoma screening.

Tumor burden score combined with AFP and PIVKA-II (TAP score) to predict the prognosis of hepatocellular carcinoma patients after radical liver resection

BACKGROUND

Our study aimed to combine the morphological behavior (tumor burden score, TBS) and the biological behavior (AFP and PIVKA-II) to predict the prognosis of HCC patients after radical liver resection.

METHODS

A total of 1766 HCC patients were divided into the training cohort (n = 1079) and the validation cohort (n = 687) with a ratio of 6:4. The Kaplan-Meier method was used to analyze the recurrence-free (RFS) and overall survival (OS). The multivariable Cox regression model was established based on the variables screened by the least absolute shrinkage and selection operator (LASSO) regression to identify variables independently associated with recurrence-free survival (RFS) and overall survival (OS). Constructing our prognostic score (TBS-LN(AFP + PIVKA-II) score, TAP score) based on regression coefficients and the predictive ability of the TAP score was compared with Barcelona Clinic Liver Cancer (BCLC) stage.

RESULTS

The TAP score had good performance in stratifying RFS (p < 0.001) and OS (p < 0.001) in the training cohort and the validation cohort. There still existed significant differences in the intergroup comparisons among three TAP score groups for RFS and OS in the training cohort and the validation cohort. In our LASSO-Cox regression model, the TAP score was independently associated with RFS and OS. The TAP score also outperformed the BCLC stage in predicting RFS (1, 2 and 3 years) and OS (1, 3 and 5 years).

CONCLUSIONS

The TAP score had good performance in predicting the prognosis of HCC patients after radical liver resection and was superior to the BCLC stage.

The GALAD score performs better than AFP in hepatocellular carcinoma screening: a single-centre, case-control study in Malaysia

Aim of the study

Hepatocellular carcinoma (HCC) in Malaysia is a growing health concern, despite regular liver ultrasound and α-fetoprotein (AFP) surveillance. The GALAD model incorporates AFP, lens culinaris agglutinin- reactive α-fetoprotein (AFP-L3), protein induced by vitamin K antagonist-II (PIVKA-II), gender and age to predict the probability of HCC. Our objective was to evaluate the diagnostic ability of GALAD compared to AFP in HCC screening.

Material and methods

A single-centre, case control study recruited newly diagnosed HCC and cirrhotic patients. Serum biomarkers were quantified using a microfluidic-based automated immunoanalyzer. The diagnostic ability of AFP, AFP-L3, PIVKA-II and GALAD was assessed using receiver operating characteristic curve (ROC) and corresponding area under the curve (AUC) analysis.

Results

Among the 44 HCC cases, GALAD score achieved the highest AUC value of 0.94 (95% confidence interval [CI]: 0.90-0.98, p < 0.0001) significantly surpassing AFP (0.89), AFP-L3 (0.84) and PIVKA-II (0.88). The GALAD score demonstrated 84.1% sensitivity and 93.8% specificity at the standard cut-off (-0.63) and 88.6%/92.2% at its best cut-off (-1.035) for detecting any stage of HCC, outperforming AFP (79.5%/92.2%), AFP-L3 (59.1%/94.9%) and PIVKA-II (79.5%/84.9%). The sensitivity of the GALAD score was 100% in earlystage HCC (BCLC0/A).

Conclusions

GALAD outperformed conventional biomarkers, facilitating early detection, improved treatment options and ultimately a higher survival rate for HCC patients.

Comparative Validation of Prediction Models for HCC Outcomes in Living Donor Liver Transplantation: Superiority of Tumor Markers to Imaging Study

BACKGROUND

Living donor liver transplantation (LDLT) offers timely curative treatment for unresectable hepatocellular carcinoma (HCC). This study aims to validate and compare previous prediction models for HCC outcomes in 488 LDLT recipients.

METHODS

For 488 patients who underwent LDLT for HCC, pretransplant imaging studies assessed by modified RECSIT criteria, tumor markers such as alpha feto-protein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA II), and explant pathology were recruited. C-index of models for the HCC outcomes was compared, followed by further investigation for the predictive performances of the best model.

RESULTS

We found MoRAL (11√PIVKA-II + 2√AFP) demonstrated a higher C-index for HCC recurrence than other models that included radiologically viable tumor number and/or size (MoRAL: 0.709, Milan: 0.537, UCSF: 0.575, Up-to-7: 0.572, French AFP: 0.634, Pre-MORAL: 0.637, HALT-HCC: 0.626, Metroticket2.0: 0.629) and also had the highest C-index for HCC-specific deaths (0.706). Five-year HCC recurrence was well stratified upon dividing the patients into three groups by MoRAL cutoffs (11.9% for MoRAL < 100, 29.6% for MoRAL 100-200, and 48.6% for MoRAL > 200, p < 0.001). However, patients with major vessel invasion or portal vein tumor thrombus showed similarly high HCC recurrence regardless of this grouping (p = 0.612).

CONCLUSION

The MoRAL, based on tumor markers, showed the best predictive performance for HCC recurrence and HCC-specific death among the validated models, except in cases with major vessel invasion or portal vein tumor thrombus.

Key prognostic factors in transarterial chemoembolization combined with sorafenib treatment for hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND

Hepatocellular carcinoma (HCC) is a prevalent malignancy worldwide, with portal vein tumor thrombosis (PVTT) worsening its prognosis and complicating management. The combination of transarterial chemoembolization (TACE) and the targeted agent sorafenib has been proposed to improve treatment outcomes. This study investigates the prognostic factors influencing the effectiveness of this combined treatment in HCC patients with PVTT.

METHODS

A retrospective cohort study was conducted on 299 patients diagnosed with HCC and PVTT who underwent TACE and sorafenib treatment between January 2018 and December 2022. Patients were categorized into good-prognosis (n = 197) and poor-prognosis (n = 102) groups based on Response Evaluation Criteria in Solid Tumors (RECIST) assessed four weeks post-treatment. Prognostic factors were analyzed using univariate and multivariate analyses to identify significant determinants affecting therapeutic outcomes.

RESULTS

Key prognostic factors included tumor number, differentiation, size, PVTT extent, Child-Pugh class, ECOG performance status, hospitalization duration, and AFP levels. Patients with a single tumor had better outcomes (OR 0.358, P = 0.002), whereas poor differentiation (OR 4.561, P = 0.005) and larger tumor size (OR 0.347, P < 0.001) were associated with worse prognosis. A higher Child-Pugh class (OR 0.563, P = 0.035) and better ECOG performance (OR 2.710, P = 0.025) improved prognosis, while prolonged hospitalization and elevated AFP levels were linked to poorer outcomes. ASA classification and HCC morphology did not significantly impact prognosis.

CONCLUSION

The prognosis of HCC with PVTT treated with TACE and sorafenib is significantly influenced by tumor characteristics, liver function, and overall patient health. Identifying these factors can aid in refining personalized treatment strategies to improve survival outcomes.

Development and validation of a new prognostic tool for hepatocellular carcinoma undergoing resection: The Weighted Alpha-Fetoprotein Tumor Burden Score (WATS)

PURPOSE

This study aimed to develop and validate a novel prognostic index, the Weighted Alpha-Fetoprotein Tumor Burden Score (WATS), for predicting outcomes in hepatocellular carcinoma (HCC) patients undergoing resection.

MATERIALS AND METHODS

A total of 772 resected HCC patients were included. WATS was developed and validated using an 8:2 cohort split. The score was derived from multivariate Cox regression, resulting in the formula: WATS = 0.73 × tumor number +0.17 × tumor size +0.1 × ln AFP. The time-dependent ROC curve assessed the score's predictive ability, while restricted cubic splines evaluated the dose-response relationship between WATS and prognostic outcomes. Kaplan-Meier curves and multivariate Cox regression further validated the prognostic accuracy.

RESULTS

In the training cohort, AUCs for progression-free survival (PFS) at 1, 2, 3, 4, and 5 years were 0.683, 0.664, 0.661, 0.633, and 0.620, respectively; for overall survival (OS), they were 0.757, 0.732, 0.703, 0.672, and 0.670, respectively. In the validation cohort, AUCs for PFS were 0.711, 0.654, 0.671, 0.662, and 0.684, respectively; for OS, they were 0.724, 0.688, 0.642, 0.698, and 0.721, respectively. WATS outperformed other complex indicators and staging systems. RCS analysis showed a linear relationship between WATS and outcomes. The nomogram based on WATS demonstrated excellent discrimination, calibration, and clinical benefit.

CONCLUSION

WATS is a novel, reliable prognostic tool for HCC post-resection, offering enhanced patient stratification and risk assessment, thereby improving clinical management.

Criteria and prognostic models for patients with hepatocellular carcinoma undergoing liver transplantation

Hepatocellular carcinoma (HCC) is a leading cause of cancer-associated death globally. Liver transplantation (LT) has emerged as a key treatment for patients with HCC, and the Milan criteria have been adopted as the cornerstone of the selection policy. To allow more patients to benefit from LT, a number of expanded criteria have been proposed, many of which use radiologic morphological characteristics with larger and more tumors as surrogates to predict outcomes. Other groups developed indices incorporating biological variables and dynamic markers of response to locoregional treatment. These expanded selection criteria achieved satisfactory results with limited liver supplies. In addition, a number of prognostic models have been developed using clinicopathological characteristics, imaging radiomics features, genetic data, and advanced techniques such as artificial intelligence. These models could improve prognostic estimation, establish surveillance strategies, and bolster long-term outcomes in patients with HCC. In this study, we reviewed the latest findings and achievements regarding the selection criteria and post-transplant prognostic models for LT in patients with HCC.

Efficacy and safety of the combination of envafolimab and lenvatinib in unresectable hepatocellular carcinoma: a single-arm, multicentre, exploratory phase II clinical study

Currently, therapeutic combinations of immune checkpoint inhibitors (ICIs) with anti-angiogenic agents have shown promising outcomes and have the potential to establish a new standard of care. The efficacy and safety of the first-line combination of envafolimab (an ICI) and lenvatinib (an anti-tumor angiogenesis drug) for the treatment of patients with inoperable hepatocellular carcinoma (HCC) have not been demonstrated. Unresectable HCC patients with an Eastern Cooperative Oncology Group (ECOG) physical status score ≤ 1 and a Child-Pugh score ≤ 7 who had not received systemic therapy were included in this single-arm, exploratory, multicentre phase II clinical study. All patients were required to meet the criteria of being at least 18 years of age, having no history of other malignancies, and existing at least one measurable lesion. The patients were treated with envafolimab (150 mg, QW, subcutaneous) in combination with lenvatinib (12 mg for patients weighing over 60 kg, 8 mg for patients weighing under 60 kg). The co-primary endpoint of the study was overall survival (OS), while surrogate endpoints included progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and safety. Between March 2022 and April 2023, 36 patients were enrolled, 30 of whom were treated with envafolimab plus lenvatinib. At data cutoff, the median follow-up duration was 20 months (95% CI 18.9-21.1). Among the 30 assessable patients (patients treated according to the trial protocol), the median overall survival (mOS) and median progression-free survival (mPFS) for the therapy comprising envafolimab alongside lenvatinib were 18.5 months (95% CI 13.2-23.8) and 9.4 months (95% CI 1.6-15.6), respectively. The ORR and the DCR (evaluated according to mRECIST criteria) reached 40% and 80%, respectively. In terms of safety, 23 patients (76.7%) experienced at least one treatment-related adverse event (TRAE), of which the most common was elevated aspartate aminotransferase (AST, 23.3%). Furthermore, grade 3 and higher TRAEs occurred in 30%. This study demonstrates that envafolimab in combination with lenvatinib exhibits favourable anti-cancer activity and a manageable safety profile for the first-line treatment of patients with unresectable HCC.

Comparative evaluation of multimarker algorithms for early-stage HCC detection in multicenter prospective studies

Background & Aims

We compared the clinical performance of the novel GAAD (gender [biological sex], age, alpha-fetoprotein [AFP], des-gamma carboxyprothrombin [DCP]) and GALAD (gender [biological sex], age, AFP, Lens culinaris agglutinin-reactive AFP [AFP-L3], DCP) algorithms to deduce the clinical utility of AFP-L3 for detecting early-stage hepatocellular carcinoma (HCC) from chronic liver disease (CLD).

Methods

An algorithm development study (STOP-HCC-ARP) and clinical validation study (STOP-HCC-MCE) were conducted, recruiting adult participants with HCC (confirmed by radiology or pathology) or CLD in an international, multicenter, case-control design. Serum biomarkers were measured using Elecsys assays (GAAD and GALAD [Cobas]) or μTASWAKO assays (GALAD [μTASWAKO]) while blinded to case/control status.

Results

In STOP-HCC-ARP (algorithm development cohort), 1,006 patients {297 HCC (41.4% early-stage [Barcelona Clinic Liver Cancer {BCLC} 0/A) and 709 CLD} were included. Area under the curve (AUCs) for discriminating between early-stage HCC vs. CLD were 91.4%, 91.4%, and 90.8% for GAAD (Cobas), GALAD (Cobas), and GALAD (μTASWAKO), respectively. The clinical validation cohort of STOP-HCC-MCE comprised 1,142 patients, (366 HCC cases [48% early-stage], 468 specificity samples and 302 CLD); AUCs for GAAD (Cobas), GALAD (Cobas), and GALAD (μTASWAKO) for discriminating between early-stage HCC vs. CLD were 91.4%, 91.5%, and 91.0%, respectively; AUCs were 94.7-95.0% for all-stage HCC. The GAAD and GALAD algorithms demonstrated similar good performance regardless of disease etiology, presence of cirrhosis, geographical region, and within pan-tumor specificity panels (p <0.001).

Conclusions

GAAD (Cobas) demonstrated good clinical performance, similar to GALAD (Cobas and μTASWAKO) algorithms, in differentiating HCC and CLD controls, across all disease stages, etiologies, and regions; therefore, AFP-L3 may have a negligible role in GALAD for HCC surveillance.

Impact and implications

To improve the detection of early-stage hepatocellular carcinoma (HCC) from benign chronic liver disease (CLD), algorithms combining demographic characteristics and serum biomarkers, such as GAAD and GALAD, have been developed. GAAD combines gender (biological sex), age, alpha-fetoprotein (AFP), des-gamma carboxy-prothrombin (DCP); GALAD combines the same characteristics and biomarkers as GAAD with the addition of Lens culinaris agglutinin-reactive AFP (AFP-L3). Changing disease etiologies and treatment paradigms have raised questions regarding the utility of AFP-L3 in HCC surveillance. Our work demonstrates that the GAAD (Cobas) algorithm demonstrated good clinical performance and was as sensitive and specific as the GALAD (Cobas) and GALAD (μTASWAKO) algorithms in differentiating HCC and CLD controls, across all disease stages, etiologies, and geographical regions; therefore, AFP-L3 may have a negligible role in HCC detection. Our study provides supporting evidence that in participants with CLD undergoing guideline-directed HCC surveillance, the GAAD (Cobas) algorithm may be used as an effective method for the detection of HCC, potentially resulting in improved patient outcomes.

3D synergistic tumor-liver analysis further improves the efficacy prediction in hepatocellular carcinoma: a multi-center study

BACKGROUND

Besides tumorous information, synergistic liver parenchyma assessments may provide additional insights into the prognosis of hepatocellular carcinoma (HCC). This study aimed to investigate whether 3D synergistic tumor-liver analysis could improve the prediction accuracy for HCC prognosis.

METHODS

A total of 422 HCC patients from six centers were included. Datasets were divided into training and external validation datasets. Besides tumor, we also performed automatic 3D assessment of liver parenchyma by extracting morphological and high-dimensional data, respectively. Subsequently, we constructed a tumor model, a tumor-liver model, a clinical model and an integrated model combining information from clinical factors, tumor and liver parenchyma. Their discrimination and calibration were compared to determine the optimal model. Subgroup analysis was conducted to test the robustness, and survival analysis was conducted to identify high- and low-risk populations.

RESULTS

The tumor-liver model was superior to the tumor model in terms of both discrimination (training dataset: 0.747 vs. 0.722; validation dataset: 0.719 vs. 0.683) and calibration. Moreover, the integrated model was superior to the clinical model and tumor-liver model, particularly in discrimination (training dataset: 0.765 vs. 0.695 vs. 0.747; validation dataset: 0.739 vs. 0.628 vs. 0.719). The AUC of the integrated model was not influenced by AFP level, BCLC stage, Child-Pugh grade, and treatment style in training (6 months p value: 0.245-0.452; 12 months p value: 0.357-0.845) and validation (6 months p value: 0.294-0.638; 12 months p value: 0.365-0.937) datasets. With a risk score of 1.06, high- and low-risk populations demonstrated significant difference for progression-free survival (p < 0.001 in both datasets).

CONCLUSIONS

Combined with clinical factors, 3D synergistic tumor-liver assessment improved the efficacy prediction of HCC.

Predicting hepatocellular carcinoma outcomes and immune therapy response with ATP-dependent chromatin remodeling-related genes, highlighting MORF4L1 as a promising target

BACKGROUND

Hepatocellular carcinoma (HCC) continues to be a major cause of cancer-related death worldwide, primarily due to delays in diagnosis and resistance to existing treatments. Recent research has identified ATP-dependent chromatin remodeling-related genes (ACRRGs) as promising targets for therapeutic intervention across various types of cancer. This development offers potential new avenues for addressing the challenges in HCC management.

METHODS

This study integrated bioinformatics analyses and experimental approaches to explore the role of ACRRGs in HCC. We utilized data from The Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO), applying machine learning algorithms to develop a prognostic model based on ACRRGs' expression. Experimental validation was conducted using quantitative real-time Polymerase Chain Reaction (qRT-PCR), Western blotting, and functional assays in HCC cell lines and xenograft models.

RESULTS

Our bioinformatics analysis identified four key ACRRGs-MORF4L1, HDAC1, VPS72, and RUVBL2-that serve as prognostic markers for HCC. The developed risk prediction model effectively distinguished between high-risk and low-risk patients, showing significant differences in survival outcomes and predicting responses to immunotherapy in HCC patients. Experimentally, MORF4L1 was demonstrated to enhance cancer stemness by activating the Hedgehog signaling pathway, as supported by both in vitro and in vivo assays.

CONCLUSION

ACRRGs, particularly MORF4L1, play crucial roles in modulating HCC progression, offering new insights into the molecular mechanisms driving HCC and potential therapeutic targets. Our findings advocate for the inclusion of chromatin remodeling dynamics in the strategic development of precision therapies for HCC.

Hepatocellular Carcinoma: The Search for an Optimal Screening Test

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and the third leading cause of cancer-related death, with a 5-year survival rate of 10%-12%. It usually develops in the setting of chronic liver disease (CLD), with chronic viral hepatitis, alcohol, and non-alcoholic fatty liver disease (NAFLD) being the most common risk factors. Some patients are at higher risk of developing hepatocellular cancer, so it is important to screen them regularly to diagnose the disease at an early stage and improve their chances for curative treatment. Six-monthly ultrasound with or without alpha-fetoprotein (AFP) is the currently recommended surveillance method. AFP has been used as a biomarker for liver cancer; however, it has low sensitivity and specificity, which necessitates the search for other, more accurate biomarkers. Promising biomarkers include lens culinaris agglutinin-reactive AFP, des-gamma-carboxy prothrombin, methylated DNA markers, plasma microRNA expression, circulating tumor DNA, and circulating tumor cells. In addition, combinations of biomarkers, like the GALAD score and the Doylestown algorithm, may help in the early detection of HCC. In this review, we summarize the screening tests for early detection of HCC that have been studied over the last decade.

Rapid evaluation of hepatocellular carcinoma by detecting plasma exosomes with time-resolved fluorescence immunochromatographic test strips

Time-resolved fluorescence immunochromatographic test strips (TRFIS) was developed for the rapid detection of hepatocellular carcinoma (HCC)-specific plasma exosomes (hExos) by targeting the hExo-surface membrane protein glypican-3 (GPC3). The GPC3-TRFIS could directly detect plasma exosomes without the isolation and purification process, and the whole immunoassay could be completed within 15 min. The visual detection limit of GPC3-TRFIS was 3.44 × 10^9 particles/mL, with a minimum detection limit of 1.8 × 10^9 particles/mL. For analysis of the clinical HCC samples, GPC3-TRFIS shows high specificity for detection of hExo, and was nearly unreactive for healthy donors' samples. GPC3-TRFIS was able to efficiently distinguish HCC patients (19 cases) from healthy donors (19 cases). Overall, the developed TRFIS offers the benefits of high sensitivity, simple operation, and no need of large precision instruments and professional technical personnel for rapid detection of plasma hExos, and supplies a novel approach for early screening of HCC.

Evolution of Liver Resection for Hepatocellular Carcinoma: Change Point Analysis of Textbook Outcome over Twenty Years

Background and Objectives: The aim of this study was to comprehensively analyze the evolution in textbook outcome (TO) achievement after liver resection for hepatocellular carcinoma (HCC) over two decades at a single tertiary referral center. Materials and Methods: All consecutive liver resections for HCC at Seoul National University Bundang Hospital from 2003 to 2022 were analyzed. The included 1334 patients were divided into four groups by time intervals identified through change point analysis. TO was defined as no intraoperative transfusions, positive margins, major complications, 30-day readmission or mortality, and prolonged length of hospital stay (LOS). Results: Multiple change point analysis identified three change points (2006, 2012, 2017), and patients were divided into four groups. More recent time interval groups were associated with older age (59 vs. 59 vs. 61 vs. 63 years, p < 0.0001) and more comorbidities. Minimally invasive procedures were increasingly performed (open/laparoscopic/robotic 37.0%/63.0%/0%) vs. 43.8%/56.2%/0% vs. 17.1%/82.4%/0.5% vs. 22.9%/75.9%/1.2%, p < 0.0001). TO achievement improved over time (1.9% vs. 18.5% vs. 47.7% vs. 62.5%, p < 0.0001), and LOS was the greatest limiting factor. Conclusions: TO after liver resection improved with advances in minimally invasive techniques and parenchymal sparing procedures, even in older patients with more comorbidities and advanced tumors.

Prognostic significance of early alpha fetoprotein and des-gamma carboxy prothrombin responses in unresectable hepatocellular carcinoma patients undergoing triple combination therapy

Background

Recent advancements in combination therapy for unresectable hepatocellular carcinoma (uHCC) have shown promise, but reliable serological prognostic indicators are currently lacking for patients undergoing triple combination therapy of stereotactic body radiation therapy (SBRT), immunotherapy, and targeted therapy. We aimed to investigate the prognostic significance of early alpha fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) responses in these patients.

Methods

This retrospective research included 115 uHCC patients treated with SBRT in combination with immunotherapy and targeted therapy (triple therapy) at our institution from April 2021 to December 2022. Participants were categorized into high AFP and high DCP cohorts based on baseline levels. AFP and DCP responses were defined as decreases from baseline of over 50% and 70%, respectively, according to ROC curve analysis. Differences in overall survival (OS), progression-free survival (PFS), and objective response rate (ORR) were assessed between the tumor biomarker response and non-response groups.

Results

Multivariate analysis indicated that AFP or DCP response at 6-8 weeks post-therapy significantly influenced ORR (high AFP cohort: odds ratio [OR] 5.50, 95% CI 2.04-14.83, p=0.001; high DCP cohort: OR 7.99, 95%CI 2.82-22.60, p<0.001). The median PFS was notably longer in tumor biomarker response groups (high AFP cohort: 13.7 vs 6.2 months, hazard ratio [HR] 0.36, 95% CI 0.20-0.62, p<0.001; high DCP cohort: 15.6 vs 9.3 months, HR 0.44, 95% CI 0.26-0.74, p=0.002). AFP or DCP response was associated with prolonged OS (high AFP cohort: not reached vs. 21.9 months, HR 0.47, 95% CI 0.22-0.99, p=0.047; high DCP cohort: not reached vs. 20.6 months, HR 0.35, 95% CI 0.14-0.86, p=0.022).

Conclusion

AFP or DCP response at 6-8 weeks post-therapy predicts better oncological outcomes in patients with uHCC treated with triple therapy.

Prognostic significance of postoperative serological incomplete conversion of AFP and PIVKA-II after hepatic resection for hepatocellular carcinoma: a multicenter analysis of 1755 patients

BACKGROUND

The value of serum biomarkers, particularly alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II), gains increasing attention in prognostic evaluation and recurrence monitoring for patients with hepatocellular carcinoma (HCC). This study investigated the implications of serological incomplete conversion (SIC) of these 2 biomarkers as prognostic indicators for long-term outcomes after HCC resection.

METHODS

A multicenter observational study was conducted on a cohort of HCC patients presenting with AFP (>20 ng/mL) or PIVKA-II (>40 mAU/mL) positivity who underwent curative-intent resection. Based on their postoperative AFP and PIVKA-II levels at first postoperative follow-up (4~8 weeks after surgery), these patients were stratified into the serological incomplete conversion (SIC) and serological complete conversion (SCC) groups. The study endpoints were recurrence and overall survival (OS).

RESULTS

Among 1755 patients, 379 and 1376 were categorized as having SIC and SCC, respectively. The SIC group exhibited 1- and 5-year OS rates of 67.5% and 26.3%, with the corresponding recurrence rates of 53.2% and 79.0%, respectively; while the SCC group displayed 1- and 5-year OS rates of 95.8% and 62.5%, with the corresponding recurrence rates of 16.8% and 48.8%, respectively (both P < .001). Multivariate Cox regression analysis demonstrated that postoperative SIC was an independent risk factor for both increased recurrence (HR: 2.40, 95% CI, 2.04-2.81, P < .001) and decreased OS (HR: 2.69, 95% CI, 2.24-3.24, P < .001).

CONCLUSION

The results emphasize that postoperative incomplete conversion of either AFP or PIVKA-II is a significant prognostic marker, indicating a higher risk for adverse oncologic outcomes following HCC resection. This revelation has crucial implications for refining postoperative adjuvant therapy and surveillance strategies for HCC patients.

Establishment of sex-specific reference intervals for PIVKA-II in Southwest China: A real-world data analysis

OBJECTIVE

We aim to establish the sex-related reference intervals (RIs) of PIVKA-II in southwest China by indirect method with the real-world data.

METHODS

Between 29 July 2016 and 5 February 2024, PIVKA-II test data were collected from 120,780 healthy adult participants (aged 18 to 97 years) in the Laboratory Information System (LIS) of West China Hospital to establish reference intervals. Additionally, a validation group comprised of 2068 healthy adults was evaluated using the same detection algorithm and platform. Following the CLSI EP28-A3 guideline, Box-Cox transformation was applied for normal transformation, and outliers were identified using the Tukey method. Furthermore, we employed the standard normal deviate test (z-test) recommended by Harris and Boyd to determine whether to stratify reference intervals by age and sex subclasses.

RESULTS

We successfully established population-specific RI for PIVKA-II in southwest China using an indirect method. By utilizing a robust dataset and conducting rigorous statistical analyses, we delineated sex-specific RIs, with values of 0-35 mAU/mL for males and 0-29 mAU/mL for females according to the normal distribution method, and 0-32 mAU/mL for males and 0-28 mAU/mL for females using the non-parametric method. These intervals are more suitable for the local population than those derived from manual methods.

CONCLUSION

These RIs provide valuable guidance for the accurate interpretation of PIVKA-II levels in the local population.

Comparison of laparoscopic hepatectomy and radiofrequency ablation for small hepatocellular carcinoma patients: a SEER population-based propensity score matching study

This study was designed to compare the efficacy of laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) in terms of their therapeutic effect on small hepatocellular carcinoma (SHCC). The SEER database was employed to integrate SHCC patients who had received treatment with either LH (n = 1132) or RFA (n = 797). The LH group (n = 623) and the RFA group (n = 623) were matched with 1:1 propensity score matching (PSM) in order to reduce the possibility of selection bias. The Kaplan-Meier method and Cox proportional hazards regression method were employed to ascertain the prognostic factors associated with overall survival (OS) and disease-specific survival (DSS). Both before and after PSM, the 1, 3 and 5-years OS and DSS were significantly higher in the LH groups compared to the RFA group. Besides, for SHCC with tumor size ≤ 2cm (n = 418), even P values not reaching statistical significance, the survival curves were compatible with a superiority of LH over RFA for OS and DSS in overall (P = 0.054 and P = 0.077), primary SHCC (P = 0.110 and P = 0.058) and recurrent SHCC (P = 0.068 and P = 1.000) cohorts. In contrast, for SHCC with tumor size between 2 and 3 cm (n = 828), LH group always had a better OS and DSS in the all cohorts (all P < 0.05). In addition, higher AFP level, poor differentiation grade, recurrent tumor and treatment type were independent prognostic factors for OS, while poor differentiation grade, larger tumor size and treatment type were the independent prognostic factors for DSS (all P < 0.05). LH was associated with better OS and DSS than RFA in SHCC patients. Even in tumor size ≤ 2 cm, LH still should be the first choice as its long-term survival benefits.

Cross-sectional study on the diagnostic significance of plasma exosomal miRNAs in HBV-related hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC) associated with Hepatitis B Virus (HBV) is one of the most severe malignancies in East Asia, where early diagnosis is crucial for improving patient prognosis. So we aim to identify effective early diagnostic model for HCC.

DESIGN AND METHODS

We enrolled 108 early-stage HCC patients and 102 non-HCC individuals underlying HBV infection, collecting plasma exosomal miRNAs (exo-miRNAs) from all participants. These patients were randomly assigned to sequencing, screening, training, and validation group. After preliminary screening of candidate exo-miRNAs by next-generation high-throughput sequencing, qPCR data from the screening group were utilized in conjunction with the random forest machine learning algorithm to identify candidate exo-miRNAs with diagnostic potential. Subsequently, logistic regression diagnostic model was constructed using the relative expression levels of candidate exo-miRNAs, alpha-fetoprotein (AFP) levels and clinical parameters of gender and the presence of cirrhosis from the training group. The diagnostic accuracy of diagnostic model was subsequently validated in the validation group.

RESULTS

Firstly, we identified miR-212-5p, miR-1248, and miR-1250-5p as candidate exo-miRNAs with potential diagnostic value. The exo-miRNAs panel, which consisted of miR-212-5p, miR-1248, miR-1250-5p, along with clinical parameters of gender and cirrhosis, achieved an AUC of 0.8634 (95% CI: 0.8027-0.9241), demonstrating diagnostic performance non-inferior to AFP in the independent dataset. Subsequently, by combining exo-miRNAs, AFP level and clinical parameter of gender, we enhanced the diagnostic panel, miRAGe, which exhibited an AUC of 0.9499 (95% CI: 0.9192-0.9806), sensitivity of 0.8900, and specificity of 0.9468.

CONCLUSION

Our study indicates that the miRAGe panel has low rate of both missed diagnosis and misdiagnosis rates, potentially serving as a useful diagnostic tool for HBV-related HCC in early stage, which may subsequently contribute to improve the prognosis.

Prediction of microvascular invasion in hepatocellular carcinoma with conventional ultrasound, Sonazoid-enhanced ultrasound, and biochemical indicator: a multicenter study

PURPOSE

To develop and validate a preoperative prediction model based on multimodal ultrasound and biochemical indicator for identifying microvascular invasion (MVI) in patients with a single hepatocellular carcinoma (HCC) ≤ 5 cm.

METHODS

From May 2022 to November 2023, a total of 318 patients with pathologically confirmed single HCC ≤ 5 cm from three institutions were enrolled. All of them underwent preoperative biochemical, conventional ultrasound (US), and contrast-enhanced ultrasound (CEUS) (Sonazoid, 0.6 mL, bolus injection) examinations. Univariate and multivariate logistic regression analyses on clinical information, biochemical indicator, and US imaging features were performed in the training set to seek independent predictors for MVI-positive. The models were constructed and evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis in both validation and test sets. Subgroup analyses in patients with different liver background and tumor sizes were conducted to further investigate the model's performance.

RESULTS

Logistic regression analyses showed that obscure tumor boundary in B-mode US, intra-tumoral artery in pulsed-wave Doppler US, complete Kupffer-phase agent clearance in Sonazoid-CEUS, and biomedical indicator PIVKA-II were independently correlated with MVI-positive. The combined model comprising all predictors showed the highest AUC, which were 0.937 and 0.893 in the validation and test sets. Good calibration and prominent net benefit were achieved in both sets. No significant difference was found in subgroup analyses.

CONCLUSIONS

The combination of biochemical indicator, conventional US, and Sonazoid-CEUS features could help preoperative MVI prediction in patients with a single HCC ≤ 5 cm.

CRITICAL RELEVANCE STATEMENT

Investigation of imaging features in conventional US, Sonazoid-CEUS, and biochemical indicators showed a significant relation with MVI-positivity in patients with a single HCC ≤ 5 cm, allowing the construction of a model for preoperative prediction of MVI status to help treatment decision making.

KEY POINTS

MVI status is important for patients with a single HCC ≤ 5 cm. The model based on conventional US, Sonazoid-CEUS and PIVKA-II performs best for MVI prediction. The combined model has potential for preoperative prediction of MVI status.

Prognosis of Patients with Hepatocellular Carcinoma Treated with TACE: A New Score Combining Alpha-Fetoprotein and Des-γ-Carboxy Prothrombin

Purpose

Hepatocellular carcinoma (HCC) represents a significant global health problem, requiring precise prognostic tools for optimal treatment stratification. This study aimed to develop a new risk prediction score, called AD score, based on the serum markers alpha-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP), to offer an objective and accurate preoperative assessment of HCC in patients undergoing transarterial chemoembolization (TACE).

Patients and Methods

This was a retrospective study that included 295 HCC patients who were subjected to TACE (training set, n=147; testing set, n=148). Serum AFP and DCP levels were log-transformed to construct the AD score. Multivariate Cox regression analysis on cirrhosis subgroups validated the objectivity of the model. Performance comparison of established models (Child Pugh, BCLC, ALBI, Up-to-seven, Six-and-twelve, Four and seven, HAP score, mHAP-II, FAIL-T score), was assessed through time-dependent receiver operating characteristic (ROC) curves and risk stratification.

Results

The AD score, incorporating lgAFP and lgDCP, demonstrated superior predictive accuracy than the existing models. Time-dependent ROC curve revealed the consistent superiority of the AD score over a 5-year period. The risk stratification into low, intermediate, and high group based on the AD score showed a significant survival difference in both training and testing set.

Conclusion

For HCC patients undergoing TACE, the AD score serves as an objective and straightforward prognostic tool, enhancing predictive accuracy and showcasing its clinical utility. It demonstrates potential significance as a crucial addition to preoperative risk assessment for TACE.

An Early Increase in IL-10 and TNF-α Levels Following Atezolizumab Plus Bevacizumab Treatment Predicts Survival in Advanced Hepatocellular Carcinoma Patients: A Prospective Cohort Study

Background/Objectives: Reliable biomarkers for predicting outcomes in hepatocellular carcinoma (HCC) treated with atezolizumab plus bevacizumab (Ate/Bev) are still lacking. Cytokines, which play a crucial role in immune regulation and HCC progression, have potential as predictive markers, but data supporting their use are limited. This study aimed to evaluate the impact of early changes in cytokine levels on the clinical outcomes of advanced HCC patients. Methods: We prospectively enrolled 32 advanced HCC patients, collecting blood samples before the first and second Ate/Bev treatments. These samples were analyzed for IL-2, IL-6, IL-10, IL-12, IL-17, IFN-γ, and TNF-α levels to assess changes post-treatment. The primary outcome was overall survival, with a secondary focus on progression-free survival (PFS) at 6 months. Results: The mean age of the participants was 64.2 years, with the majority being male (93.8%). Patients showing increased IL-10, IL-17, and TNF-α levels had significantly better survival (p < 0.05) and marginally improved PFS compared to those with decreased cytokine levels. Interestingly, a positive correlation was noted between changes in IL-10 and TNF-α levels (p = 0.009). Furthermore, a multivariable analysis revealed that increased levels of IL-10 and TNF-α were significant predictors of enhanced survival (hazard ratio, 0.07; 95% confidence interval, 0.01-0.46; p = 0.005). Conclusions: An early increases in IL-10 and TNF-α after Ate/Bev treatment may serve as effective biomarkers for clinical outcomes in advanced HCC patients.

Multi-stage mechanisms of tumor metastasis and therapeutic strategies

The cascade of metastasis in tumor cells, exhibiting organ-specific tendencies, may occur at numerous phases of the disease and progress under intense evolutionary pressures. Organ-specific metastasis relies on the formation of pre-metastatic niche (PMN), with diverse cell types and complex cell interactions contributing to this concept, adding a new dimension to the traditional metastasis cascade. Prior to metastatic dissemination, as orchestrators of PMN formation, primary tumor-derived extracellular vesicles prepare a fertile microenvironment for the settlement and colonization of circulating tumor cells at distant secondary sites, significantly impacting cancer progression and outcomes. Obviously, solely intervening in cancer metastatic sites passively after macrometastasis is often insufficient. Early prediction of metastasis and holistic, macro-level control represent the future directions in cancer therapy. This review emphasizes the dynamic and intricate systematic alterations that occur as cancer progresses, illustrates the immunological landscape of organ-specific PMN creation, and deepens understanding of treatment modalities pertinent to metastasis, thereby identifying some prognostic and predictive biomarkers favorable to early predict the occurrence of metastasis and design appropriate treatment combinations.

Management Consensus Guidelines for Hepatocellular Carcinoma: 2023 Update on Surveillance, Diagnosis, Systemic Treatment, and Posttreatment Monitoring by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan

Hepatocellular carcinoma (HCC) is the leading cause of cancer-related mortality in Taiwan. The Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan established HCC management consensus guidelines in 2016 and updated them in 2023. Current recommendations focus on addressing critical issues in HCC management, including surveillance, diagnosis, systemic treatment, and posttreatment monitoring. For surveillance and diagnosis, we updated the guidelines to include the role of protein induced by vitamin K absence or antagonist II (PIVKA-II) and gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in detecting HCCs. For systemic treatment, the updated guidelines summarize the multiple choices available for targeted therapy, immune checkpoint inhibitors, and a combination of both, especially for those carcinomas refractory to or unsuitable for transarterial chemoembolization. We have added a new section, posttreatment monitoring, that describes the important roles of PIVKA-II and EOB-MRI after HCC therapy, including surgery, locoregional therapy, and systemic treatment. Through this update of the management consensus guidelines, patients with HCC may benefit from optimal diagnosis, therapeutic modalities, and posttreatment monitoring.

Liquid Chromatography/Tandem Mass Spectrometry-Based Simultaneous Analysis of 32 Bile Acids in Plasma and Conventional Biomarker-Integrated Diagnostic Screening Model Development for Hepatocellular Carcinoma

Imaging tests, tumor marker (TM) screening, and biochemical tests provide a definitive diagnosis of hepatocellular carcinoma (HCC). However, some patients with HCC may present TM-negative results, warranting a need for developing more sensitive and accurate screening biomarkers. Various diseases exhibit increased blood levels of bile acids, biosynthesized from cholesterol in the liver, and they have been associated with HCC. Herein, we analyzed plasma bile acids using liquid chromatography/tandem mass spectrometry and integrated them with conventional biomarkers to develop a diagnostic screening model for HCC. Plasma samples were obtained from patients diagnosed with chronic hepatitis, hepatic cirrhosis (HC), and HCC. A QTRAP 6500 mass spectrometer and a Nexera liquid chromatograph with a YMC-Triart C18 analytical column were used. The mobile phase A was a 20 mmol/L ammonium formate solution, and mobile phase B was a methanol/acetonitrile mixture (1:1, v/v) with 20 mmol/L ammonium formate. After determining the concentrations of 32 bile acids, statistical analysis and diagnostic screening model development were performed. Plasma concentrations of bile acids differed between sample groups, with significant differences observed between patients with HC and HCC. By integrating bile acid results with conventional biochemical tests, a potential diagnostic screening model for HCC was successfully developed. Future studies should increase the sample size and analyze the data in detail to verify the diagnostic efficacy of the model.

Combined DeRitis ratio and alkaline phosphatase on the prediction of portal vein tumor thrombosis in patients with hepatocellular carcinoma

Portal vein tumor thrombosis (PVTT) is one of the common complications of HCC and represents a sign of poor prognosis. PVTT signifies advanced liver cancer, deteriorating liver function, and heightened susceptibility to intrahepatic dissemination, systemic metastasis, and complications related to portal hypertension. It is important to seek novel strategies for PVTT arising from HCC. Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) represents a worse liver function, less treatment tolerance, and poor prognosis. This study aimed to investigate the diagnostic value of the combination of the DeRitis ratio (AST/ALT) and alkaline phosphatase (ALP) index (briefly named DALP) in predicting the occurrence risk of PVTT in patients with HCC. We performed a retrospective study enrolling consecutive patients with HCC from January 2017 to December 2020 in Hebei Medical University Third Hospital. ROC analysis was performed to estimate the predictive effectiveness and optimal cut-off value of DALP for PVTT occurrence in patients with HCC. Kaplan-Meier analysis revealed the survival probabilities in each subgroup according to the risk classification of DALP value. Univariate and multivariate Logistics regression analyses were applied to determine the independent risk for poor prognosis. ROC analysis revealed that the optimal cut-off value for DALP was 1.045, with an area under the curve (AUC) of 0.793 (95% CI 0.697-0.888). Based on the DALP classification (three scores: 0-2) with distinguishable prognoses, patients in the score 0 group had the best prognosis with a 1-year overall survival (OS) of 100%, whereas score 2 patients had the worst prognosis with 1-year OS of 72.4%. Similarly, there was a statistically different recurrence-free survival among the three groups. Besides, this risk classification was also associated with PVTT progression in HCC patients (odds ratio [OR] 5.822, P < 0.0001). Pathologically, patients in the score 2 group had more advanced tumors considering PVTT, extrahepatic metastasis, and ascites than those in score 0, 1 groups. Moreover, patients with a score of 2 had more severe hepatic inflammation than other groups. Combination of DeRitis ratio and ALP index presented a better predictive value for PVTT occurrence in patients with HCC, contributing to the tertiary prevention.

Construction and evaluation of a liver cancer risk prediction model based on machine learning

BACKGROUND

Liver cancer is one of the most prevalent malignant tumors worldwide, and its early detection and treatment are crucial for enhancing patient survival rates and quality of life. However, the early symptoms of liver cancer are often not obvious, resulting in a late-stage diagnosis in many patients, which significantly reduces the effectiveness of treatment. Developing a highly targeted, widely applicable, and practical risk prediction model for liver cancer is crucial for enhancing the early diagnosis and long-term survival rates among affected individuals.

AIM

To develop a liver cancer risk prediction model by employing machine learning techniques, and subsequently assess its performance.

METHODS

In this study, a total of 550 patients were enrolled, with 190 hepatocellular carcinoma (HCC) and 195 cirrhosis patients serving as the training cohort, and 83 HCC and 82 cirrhosis patients forming the validation cohort. Logistic regression (LR), support vector machine (SVM), random forest (RF), and least absolute shrinkage and selection operator (LASSO) regression models were developed in the training cohort. Model performance was assessed in the validation cohort. Additionally, this study conducted a comparative evaluation of the diagnostic efficacy between the ASAP model and the model developed in this study using receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA) to determine the optimal predictive model for assessing liver cancer risk.

RESULTS

Six variables including age, white blood cell, red blood cell, platelet counts, alpha-fetoprotein and protein induced by vitamin K absence or antagonist II levels were used to develop LR, SVM, RF, and LASSO regression models. The RF model exhibited superior discrimination, and the area under curve of the training and validation sets was 0.969 and 0.858, respectively. These values significantly surpassed those of the LR (0.850 and 0.827), SVM (0.860 and 0.803), LASSO regression (0.845 and 0.831), and ASAP (0.866 and 0.813) models. Furthermore, calibration and DCA indicated that the RF model exhibited robust calibration and clinical validity.

CONCLUSION

The RF model demonstrated excellent prediction capabilities for HCC and can facilitate early diagnosis of HCC in clinical practice.

The ARH score, a practical guide to decision-making for retreatment with hepatic arterial infusion chemotherapy in hepatocellular carcinoma patients

BACKGROUND

Hepatic arterial infusionchemotherapy (HAIC) is a promising option for large unresectable hepatocellular carcinoma (HCC). Identifying patients who could benefit from continuous HAIC remains a challenge. We aimed to establish an objective model to guide the decision for retreatment with HAIC.

METHODS

Between 2015 and 2020, the data of patients with large unresectable HCC without macrovascular invasion or extrahepatic spread undergoing multiple HAIC cycles from 3 different centers were retrieved. We investigated the basic tumor parameters and the effect of HAIC on liver function and tumor response, and their impact on overall survival (OS). A point score (ARH, Assessment for Retreatment with HAIC) was built by using a stepwise Cox regression model in the training cohort (n = 112) and was validated in an independent validation cohort (n = 71).

RESULTS

The high α-fetoprotein before the second cycle of HAIC, an increase in Child-Pugh score, and undesirable radiologic tumor responses remained independent negative prognostic factors and were used to create the ARH score. The prognosis of HCC patients deteriorated significantly with the increase in ARH score. The median OS of patients with ARH score 0-2 points and ≥ 2.5 points were 19.37 months and 11.60 months (P < 0.001). All of these results had been confirmed in the external validation cohort and demonstrated significance across multiple subgroups.

CONCLUSIONS

The ARH score makes an excellent prediction of the prognosis of HCC patients who received retreatment of HAIC. Patients with an ARH score ≥ 2.5 prior to the second cycle of HAIC may not profit from further sessions.

Early identification of hepatocellular carcinoma patients at high-risk of recurrence using the ADV score: a multicenter retrospective study

BACKGROUND

Postoperative recurrence is a vital reason for poor 5-year overall survival in hepatocellular carcinoma (HCC) patients. The ADV score is considered a parameter that can quantify HCC aggressiveness. This study aimed to identify HCC patients at high-risk of recurrence early using the ADV score.

METHODS

The medical data of consecutive HCC patients undergoing hepatectomy from The First Affiliated Hospital of Nanjing Medical University (TFAHNJMU) and Nanjing Drum Tower Hospital (NJDTH) were retrospectively reviewed. Based on the status of microvascular invasion and the Edmondson-Steiner grade, HCC patients were divided into three groups: low-risk group (group 1: no risk factor exists), medium-risk group (group 2: one risk factor exists), and high-risk group (group 3: coexistence of two risk factors). In the training cohort (TFAHNJMU), the R package nnet was used to establish a multi-categorical unordered logistic regression model based on the ADV score to predict three risk groups. The Welch's T-test was used to compare differences in clinical variables in three predicted risk groups. NJDTH served as an external validation center. At last, the confusion matrix was developed using the R package caret to evaluate the diagnostic performance of the model.

RESULTS

350 and 405 patients from TFAHNJMU and NJDTH were included. HCC patients in different risk groups had significantly different liver function and inflammation levels. Density maps demonstrated that the ADV score could best differentiate between the three risk groups. The probability curve was plotted according to the predicted results of the multi-categorical unordered logistic regression model, and the best cut-off values of the ADV score were as follows: low-risk ≤ 3.4 log, 3.4 log < medium-risk ≤ 5.7 log, and high-risk > 5.7 log. The sensitivities of the ADV score predicting the high-risk group (group 3) were 70.2% (99/141) and 78.8% (63/80) in the training and external validation cohort, respectively.

CONCLUSION

The ADV score might become a valuable marker for screening patients at high-risk of HCC recurrence with a cut-off value of 5.7 log, which might help surgeons, pathologists, and HCC patients make appropriate clinical decisions.

Biomarkers for diagnosis and therapeutic options in hepatocellular carcinoma

Liver cancer is a global health challenge, causing a significant social-economic burden. Hepatocellular carcinoma (HCC) is the predominant type of primary liver cancer, which is highly heterogeneous in terms of molecular and cellular signatures. Early-stage or small tumors are typically treated with surgery or ablation. Currently, chemotherapies and immunotherapies are the best treatments for unresectable tumors or advanced HCC. However, drug response and acquired resistance are not predictable with the existing systematic guidelines regarding mutation patterns and molecular biomarkers, resulting in sub-optimal treatment outcomes for many patients with atypical molecular profiles. With advanced technological platforms, valuable information such as tumor genetic alterations, epigenetic data, and tumor microenvironments can be obtained from liquid biopsy. The inter- and intra-tumoral heterogeneity of HCC are illustrated, and these collective data provide solid evidence in the decision-making process of treatment regimens. This article reviews the current understanding of HCC detection methods and aims to update the development of HCC surveillance using liquid biopsy. Recent critical findings on the molecular basis, epigenetic profiles, circulating tumor cells, circulating DNAs, and omics studies are elaborated for HCC diagnosis. Besides, biomarkers related to the choice of therapeutic options are discussed. Some notable recent clinical trials working on targeted therapies are also highlighted. Insights are provided to translate the knowledge into potential biomarkers for detection and diagnosis, prognosis, treatment response, and drug resistance indicators in clinical practice.

Disease modifiers and novel markers in hepatitis B virus-related hepatocellular carcinoma

Chronic hepatitis B (CHB) infection is responsible for 40% of the global burden of hepatocellular carcinoma (HCC) with a high case fatality rate. The risk of HCC differs among CHB subjects owing to differences in host and viral factors. Modifiable risk factors include viral load, use of antiviral therapy, co-infection with other hepatotropic viruses, concomitant metabolic dysfunctionassociated steatotic liver disease or diabetes mellitus, environmental exposure, and medication use. Detecting HCC at early stage improves survival, and current practice recommends HCC surveillance among individuals with cirrhosis, family history of HCC, or above an age cut-off. Ultrasonography with or without serum alpha feto-protein (AFP) every 6 months is widely accepted strategy for HCC surveillance. Novel tumor-specific markers, when combined with AFP, improve diagnostic accuracy than AFP alone to detect HCC at an early stage. To predict the risk of HCC, a number of clinical risk scores have been developed but none of them are clinically implemented nor endorsed by clinical practice guidelines. Biomarkers that reflect viral transcriptional activity and degree of liver fibrosis can potentially stratify the risk of HCC, especially among subjects who are already on antiviral therapy. Ongoing exploration of these novel biomarkers is required to confirm their performance characteristics, replicability and practicability.

Hepatocellular Carcinoma in Asia: Physician and Patient Perspectives on Surveillance, Diagnosis, and Treatment

PURPOSE

In several Asian countries, hepatocellular carcinoma (HCC) is a leading cause of cancer deaths. HCC risk factors in Asia differ from those elsewhere and are changing with the treatment landscape as systemic treatment options increase. This study was conducted to gain insight from physicians and patients into HCC screening, diagnosis, and treatment strategies in Indonesia, Korea, Malaysia, Singapore, Taiwan, Thailand, and Vietnam.

METHODS

Two cross-sectional, anonymized, online surveys were completed between July and December 2022 by physicians diagnosing and treating HCC (55 questions on risk factors, surveillance, diagnosis, and treatment) and patients ≥ 18 years old diagnosed with HCC (36 questions on disease knowledge, quality of life, and experiences of diagnosis and treatment).

RESULTS

Responses were received from 276 physicians in all 7 countries and 130 patients in Thailand, Taiwan, and Vietnam. From the physician's perspective, surveillance programs are widespread but identify insufficient HCC cases; only 18% are early-stage HCC at diagnosis. From the patient's perspective, knowledge of risk factors increases after diagnosis, but few seek support from patient associations; patients would benefit from better communication from their doctors. Treatment affordability and side effects are key issues for patients.

CONCLUSIONS

Awareness of the risk factors for HCC should be raised in primary care and the general population, and surveillance should identify early-stage HCC. Because patients rely on their doctors for support, doctors should better understand their patients' needs, and patients could be supported by trained nurses or case managers. Programs are needed to increase patients' access to proven HCC treatments.

CEUS LI-RADS in Combination With the Serum Biomarker-Based ASAP Model Improves the Diagnostic Performance of HCC in High-Risk Patients

OBJECTIVE

To assess the diagnostic efficacy of the CEUS LI-RADS combined with a model constructed on the basis of age, sex, AFP, and PIVKA-II (ASAP) for the diagnosis of HCC in high-risk patients.

METHODS

This retrospective study included 366 liver lesions from 366 patients who underwent liver CEUS. All liver lesions were characterized and categorized according to CEUS LI-RADS v2017. Two modified methods were applied: LR-3/4/M nodules accompanied by AFP > 200 ng/mL (Criterion 2) or ASAP model score > 0.5256 and CA 19-9 in the normal range (Criterion 3) were recategorized as LR-5. The reference criteria included histopathological or comprehensive imaging and the clinical follow-up results. The diagnostic performance was evaluated and compared by the sensitivity, specificity, PPV, and NPV.

RESULTS

The incidence of HCC in LR-3, LR-4, LR-5, and LR-M was 33.3% (4/12), 86.4% (38/44), 98.5% (191/194) and 82.7% (81/98), respectively. After using Criterion 2 compared to CEUS LI-RADS v2017, the sensitivity of the modified LR-5 for diagnosing HCC increased from 60.8% to 70.7% (p < 0.01) with little effect on its specificity (94.2% vs. 92.3%, p = 1.00) or PPV (98.5% vs. 98.2%, p = 0.86). After using Criterion 3, the sensitivity of the modified LR-5 for the diagnosis of HCC was further improved to 86.9% (p < 0.01), and its specificity and PPV were not significantly changed (92.3% and 98.6%, both p > 0.05).

CONCLUSION

CEUS LI-RADS combined with the serum biomarker-based ASAP model improved the sensitivity of LR-5 in diagnosing HCC with little effect on its specificity and PPV.