Predictive factors for transition to conversion therapy in hepatocellular carcinoma using atezolizumab plus bevacizumab.

BACKGROUND: To identify predictive factors associated with successful transition to conversion therapy following combination therapy with atezolizumab and bevacizumab in the treatment of unresectable hepatocellular carcinoma (HCC). METHODS: In total, 188 patients with HCC, who received atezolizumab plus bevacizumab combination therapy as the first-line chemotherapy, were studied. Patients who achieved complete response (CR) with systemic chemotherapy alone were excluded. Clinical factors possibly linked to successful transition to conversion therapy and the achievement of cancer-free status were identified. RESULTS: Fifteen (8.0%) patients underwent conversion therapy. In the conversion group, there was a significantly higher proportion of patients with Barcelona Clinic Liver Cancer (BCLC) stage A or B (73.3% versus [vs.] 45.1%; p = .03) and tended to have lower Child-Pugh scores and alpha-fetoprotein levels. Multivariate analysis revealed that BCLC stage was a predictive factor for the implementation of conversion therapy (A or B; odds ratio 3.7 [95% CI: 1.1-13]; p = .04). Furthermore, 10 (66.7%) patients achieved cancer-free status and exhibited a smaller number of intrahepatic lesions at the start of treatment (3.5 vs. 7; p < .01), and a shorter interval between systemic chemotherapy induction and conversion therapy (131 vs. 404 days; p < .01). In addition, the rate of achieving cancer-free status by undergoing surgical resection or ablation therapy was significantly higher (p = .03). CONCLUSION: BCLC stage was the sole predictive factor for successful transition to conversion therapy when using combination therapy with atezolizumab and bevacizumab to treat HCC. Furthermore, a small number of intrahepatic lesions and early transition to conversion therapy were associated with the achievement of cancer-free status.

Exploring compounds to be used as cosmetic agents that activate peroxisome proliferator-activated receptor alpha.

OBJECTIVE: The human epidermis is formed by the proliferation and differentiation of keratinocytes adjacent to the basement membrane. The outermost layer, the stratum corneum, is equipped with a barrier function that prevents water evaporation, and intercellular lipids play an important role in this barrier function. When the barrier is functioning normally, evaporation is prevented; however, when barrier function is impaired, moisture evaporates, resulting in dry and rough skin. Therefore, maintenance of normal barrier function is critical for maintaining normal skin function. Peroxisome proliferator-activated receptor α (PPARα) is mainly not only involved in lipid metabolism in the liver but is also expressed in the epidermis and is involved in inducing keratinocyte differentiation, promoting lipid production, maintaining barrier function and suppressing skin inflammation. Hence, compounds that activate PPARα are expected to control skin function. Therefore, we identified PPARα activators from among extracts of natural resources that have been approved for use in humans and analysed the effects of these extracts on skin function. METHODS: First, extracts of 474 natural resources were screened using a PPARα activator screening cell line independently constructed in our laboratory. Next, reporter assays were performed using the Gal4-chimera system to evaluate whether these extracts act as ligands for PPARα. We then analysed their effect on primary normal human epidermal keratinocyte cells by using real-time RT-PCR. Finally, we evaluated PPARα activation effect by the combination of these extracts. RESULTS: We identified 36 extracts having the effect of activating PPARα. In particular, #419, a Typha angustifolia spike extract, showed concentration-dependent transcriptional activation through PPARα-LBD and was considered to be likely to contain a compound that is a ligand of PPARα. #419 increased the expression of PPARα target genes and genes related to skin function in primary cultured human epidermal keratinocytes. Finally, the use of #419 in combination with nine extracts increased PPAR activity more than twice as much as #419 alone treatment. CONCLUSIONS: These results showed that the reporter cell line could be useful for discovering extracts of natural resources and that the identified Typha angustifolia spike extract could be used in cosmetics that activate PPARα, which expected to improve skin function.

OBJECTIF: L'épiderme humain se forme grâce à la prolifération et à la différenciation des kératinocytes adjacents à la membrane basale. La couche externe, dite « couche cornée ¼, possède une fonction barrière qui empêche l'évaporation de l'eau, dans laquelle les lipides intercellulaires jouent un rôle important. Lorsque la barrière fonctionne normalement, l'évaporation est évitée ; mais lorsqu'elle est altérée, l'évaporation a lieu et la peau, privée d'hydratation, devient sèche et rêche. Par conséquent, il est capital de maintenir cette fonction barrière normale pour que la peau conserve son fonctionnement normal. Le récepteur alpha activé par proliférateurs de peroxysomes (PPARα) intervient surtout non seulement dans le métabolisme lipidique du foie, mais également dans l'épiderme ; il joue en effet un rôle dans l'induction de la différenciation des kératinocytes, la promotion de la production lipidique, le maintien de la fonction barrière et la suppression de l'inflammation de l'épiderme. Par conséquent, les activateurs du PPAR-α devraient être déterminants pour une bonne fonction cutanée. Nous avons donc identifié des activateurs du PPAR-α parmi des extraits de ressources naturelles dont l'utilisation chez l'homme est approuvée, et nous avons analysé les effets de ces extraits sur la fonction cutanée. MÉTHODES: Tout d'abord, des extraits de 474 ressources naturelles ont été sélectionnés à l'aide d'une lignée cellulaire de détection des activateurs du PPAR-α, construite indépendamment dans notre laboratoire. Ensuite, des tests de gènes rapporteurs ont été effectués à l'aide du système Gal4-chimera pour voir si ces extraits jouaient le rôle de ligands pour le PPAR-α. Nous avons ensuite analysé leur effet sur les cellules kératinocytaires épidermiques humaines normales primaires par RT-PCR en temps réel. Enfin, nous avons évalué l'effet d'activation du PPAR-α par l'association de ces extraits. RÉSULTATS: Nous avons identifié 36 extraits ayant pour effet d'activer le PPAR-α. En particulier, le n° 419, un extrait d'épi de Typha angustifolia, a montré une activation transcriptionnelle dépendante de la concentration par le PPAR-α-LBD et a été considéré comme susceptible de contenir un composé qui est un ligand du PPAR-α. Le n° 419 a augmenté l'expression des gènes cibles du PPAR-α et des gènes liés au fonctionnement de la peau dans les kératinocytes épidermiques humains primaires mis en culture. Enfin, l'utilisation du n° 419 en association avec neuf extraits a augmenté de plus du double l'activité du PPAR par rapport au traitement par le n° 419 seul. CONCLUSIONS: Ces résultats ont montré que la lignée cellulaire rapporteuse pourrait être utile pour découvrir des extraits de ressources naturelles et que l'extrait d'épi de Typha angustifolia identifié pourrait être utilisé dans des cosmétiques qui activent le PPAR-α, ce qui devrait améliorer la fonction cutanée.

Abnormal fucosylation of alpha-fetoprotein in patients with nonalcoholic steatohepatitis.

AIM: Nonalcoholic steatohepatitis (NASH) is a risk factor for nonvirus-related hepatocellular carcinoma, which is increasing in prevalence. The aim of this study was to clarify the clinical application of fucosylated alpha-fetoprotein (AFP-L3) in the process of nonalcoholic fatty liver (NAFL) disease development. METHODS: Serum samples from 115 diabetes mellitus (DM), 36 NAFL, and 119 NASH patients were analyzed for AFP-L3 expression using raw data of a micro total analysis system. These data were then compared with the clinical characteristics of the patients. A validation study was also undertaken with 55 samples (17 NAFL and 38 NASH). RESULTS: Trace amounts of AFP-L3 were detected in 3.5%, 16.7%, and 58.0% of patients with DM, NAFL, and NASH, respectively. The odds ratio of AFP-L3 positivity for the diagnosis of NASH in multivariate analysis was 9.81 (95% confidence interval, 3.77-25.5). The rates in patients without fibrosis or with stage 1, stage 2, stage 3, and stage 4 fibrosis were 14.7%, 31.3%, 63.0%, 86.2%, and 100%, respectively. The rates were significantly increased according to the advancement of liver fibrosis (p < 0.001); however, no difference in the positive rate of AFP-L3 was observed between patients with and without fatty livers and between patients with normal and abnormal transaminase. The same relationship was also observed in the validation cohort. CONCLUSION: Abnormal fucosylation of AFP occurred in patients with NASH, so it could be useful for the screening of NASH in patients with DM, as well as for the differential diagnosis of NASH and the evaluation of fibrosis.

Prediction of the prognosis of advanced hepatocellular carcinoma by TERT promoter mutations in circulating tumor DNA.

BACKGROUND ANDAIM: Human telomerase reverse transcriptase (TERT) promoter mutations were the most prevalent mutations in patients with hepatocellular carcinoma (HCC). We tried to detect the mutations with plasma circulating tumor DNA (ctDNA) in patients with advanced HCC and elucidated their clinical utility. METHODS: Circulating tumor DNA in plasma was extracted from 130 patients with advanced HCC who were treated with systemic chemotherapy (n = 86) or transcatheter arterial chemoembolization (n = 44), and TERT promoter mutations were examined with digital droplet polymerase chain reaction. The correlations between these mutations and the clinical outcome of patients were analyzed. RESULTS: Of the 130 patients examined, 71 patients (54.6%) were positive for TERT promoter mutations in ctDNA, of which 64 patients were -124bp G > A and 10 were -146bp G > A. The presence of TERT promoter mutations was correlated with large intrahepatic tumor size (P = 0.05) and high des-gamma carboxyprothrombin (P = 0.005). Overall survival of the patients with the mutations was significantly shorter than those without them (P < 0.001), and the patients with high (≥ 1%) fractional abundance of the mutant alleles showed shorter survival than those with low (< 1%) fractional abundance. Multivariate analysis revealed that TERT promoter mutation (hazard ratio [HR]: 1.94; 95% confidence interval [CI], 1.18-3.24; P < 0.01), systemic chemotherapy (HR: 2.38; 95% CI, 1.29-4.57; P < 0.01), and vascular invasion (HR: 2.16; 95% CI, 1.22-3.76; P < 0.01) were significant factors for poor overall survival. CONCLUSIONS: TERT promoter mutations in ctDNA were associated with short survival and could be a valuable biomarker for predicting the prognosis of patients with advanced HCC.

High expression of a vascular stricture-related marker is predictive of an early response to tolvaptan, and a low fractional excretion of sodium is predictive of a poor long-term survival after tolvaptan administration for liver cirrhosis.

AIM: Tolvaptan is a newly available diuretic that has a specific function in water reabsorption inhibition. Given that spironolactone or furosemide induces the aggravation of cirrhotic hyponatremia and dehydration, tolvaptan affects the management strategy of liver cirrhosis. Representative predictive markers of its response include renal function-related markers such as urea nitrogen or creatinine. However, vascular function-related markers have not been well investigated. We investigated the effect of the vascular function-related marker asymmetric dimethylarginine (ADMA) and the effective arterial blood volume (EABV) marker, fractional excretion of sodium (FENa), on the early tolvaptan response and survival in liver cirrhosis. METHODS: We prospectively recruited 49 patients who required add-on tolvaptan for refractory ascites or edema. Laboratory data were obtained immediately before and 1 day after tolvaptan administration. Patients exhibiting >1.5 kg weight loss after 1 week were categorized as early responders to tolvaptan. Patients were followed for a median of 200 days and were assessed for survival. RESULTS: Early responders showed lower creatinine levels (<1.0 mg/dL), and higher ADMA levels (≥0.61 nmol/mL) than others in a multivariate analysis. Patients with a shorter survival were positive for hepatocellular carcinoma and had a low FENa (<0.35%). CONCLUSION: Early responders showed higher ADMA levels reflecting vascular stricture, suggesting that higher vascular tonus is required for a tolvaptan early response. Patients with a shorter survival showed a lower FENa, reflecting a lower EABV and suggesting that adequate EABV is required for the prolonged survival after tolvaptan administration.

A Phase I/Ib trial of Ad-REIC in liver cancer: study protocol.

This study will assess the safety and efficacy of the administration of adenoviral vector expressing the human-reduced expression in immortalized cells (Ad-REIC) to a liver tumor in patients with hepatocellular carcinoma (HCC) or liver metastasis of pancreatic cancer. A Phase I clinical study of Ad-REIC administration to a liver tumor in a patient with HCC or liver metastasis of pancreatic cancer will be conducted. The study is a single-arm, prospective, nonrandomized, noncomparative, open-label, single-center trial performed in Okayama University Hospital, Okayama, Japan. Ad-REIC will be injected into the liver tumor under ultrasound guidance. Ad-REIC administration will be repeated a total of three-times every 2 weeks. The primary end point is the dose-limiting toxicity and incidence of adverse events. The secondary end points are the objective response rate and disease control rate. This study aims to expand the indication of Ad-REIC by assessing its safety and efficacy in patients with HCC or liver metastasis of pancreatic cancer.

A case of serous cystic neoplasm with form changes on an image obtained during long-term follow-up.

A 45-year-old man presented with a 24-mm macrocystic lesion at the pancreatic head, which was detected by computed tomography (CT). During six years of follow-up, CT, MRI, and endosonographic images of the cystic lesion showed that the cystic lesion had enlarged to 42mm, with the appearance of a thick cyst wall. Since a cystic tumor could not be ruled out, surgery was performed. Pathological examination of the resected specimen revealed microcystic-type serous cystadenoma of the pancreas, with the presence of internal bleeding in the cyst and hemorrhage and thick fibrous tissue in the cyst wall. We could observe a serous cystic neoplasm with prismatic form changes on an image obtained during long-term follow-up. Thus, we considered this case to be useful for investigating the natural history of serous cystic neoplasm of the pancreas.

Two cases of unresectable advanced HER2-positive gastric cancer perforation during chemotherapy with trastuzumab.

Case 1 was a 70-year-old man, and case 2 was a 65-year-old woman. Both were diagnosed with type 2 advanced HER2-positive gastric cancer. Capecitabine, cisplatin, and trastuzumab (HXP therapy) were administered to both patients. However, both patients developed peritonitis caused by gastric cancer perforation during HXP therapy on day 38 for case 1 and day 8 for case 2. Emergency omentum filling and gastric segmental resection were performed for both patients. The same chemotherapy regimen was continued after the surgery, and partial response was observed in both patients. Because most advanced HER2-positive gastric cancers are ulcers, we should always consider the risk of gastric cancer perforation while administering HXP therapy, which has a high cytoreductive effect. Good convalescence can be expected by continuing chemotherapy after emergency surgery due to gastric cancer perforation.

Long-term outcome of elderly patients (75 years or older) with hepatocellular carcinoma.

AIM: The aim of this study was to evaluate the long-term outcome of elderly patients with hepatocellular carcinoma (HCC) aged 75 years or older. METHODS: The study included 422 patients with HCC, who were divided into two age groups: 75 years or older (n = 140) and younger than 75 (n = 282). Outcomes were compared between the two groups. RESULTS: The number of elderly patients treated with supportive care alone (33 patients; 24%) was significantly higher than younger patients (30 patients; 11%, P < 0.01). The 1-, 3-, 5- and 7-year overall survival rates of the elderly patients (81%, 55%, 39% and 23%, respectively) were worse than those of younger patients (85%, 64%, 49% and 36%, respectively, P = 0.042). However, the overall survival rate of the elderly group after excluding 63 patients treated with supportive care alone, was similar to that of the younger group (P = 0.615). Multivariate analysis identified age, total bilirubin levels, albumin levels, serum des-γ-carboxy prothrombin levels, tumor size, number of HCC nodules, vascular invasion, extrahepatic metastasis and treatment modality as independent and significant factors of overall survival. CONCLUSION: Advanced age is a negative prognostic factor in patients with HCC due to the tendency for frequent use of conservative treatment rather than locoregional or surgical treatment.

CD34(+) cell therapy is safe and effective in slowing the decline of hepatic reserve function in patients with decompensated liver cirrhosis.

BACKGROUND AND AIM: Preclinical studies in rodent models of chronic liver fibrosis have shown that transplantation of peripheral blood (PB) CD34(+) cells leads to hepatic regeneration and a reduction of liver fibrosis by suppressing hepatic stellate cell activity and increasing matrix metalloproteinase activity. The aim of this study was to examine the safety and clinical efficacy of intrahepatic transplantation of autologous granulocyte colony-stimulating factor (G-CSF)-mobilized PB-CD34(+) cells in patients with decompensated liver cirrhosis. METHODS: PB-CD34(+) cells were isolated from G-CSF-mobilized apheresis products. Ten patients were treated with G-CSF-mobilized PB-CD34(+) cells (treatment group) and seven patients were treated with standard medical therapy. For mobilization, patients in the treatment group received subcutaneous injections of 10 µg G-CSF/kg/day for 5 days. The cells were then injected at three different doses (5 × 10(5) , 1 × 10(6) and 2 × 10(6) cells/kg) through the hepatic artery. Thereafter, all patients were followed up for 24 months. RESULTS: G-CSF treatment and leukapheresis were well tolerated, and no serious adverse events were observed. Patients in the treatment group had a significant but transient splenomegaly. After 24 weeks, serum albumin was significantly increased in patients who had received middle or high doses of CD34(+) cells compared with baseline. Doppler ultrasound showed a significant increase in hepatic blood flow velocity and blood flow volume after CD34(+) cell therapy. The hepatic vein pressure gradient decreased in two patients who received high-dose CD34(+) cells at week 16. CONCLUSIONS: CD34(+) cell therapy is feasible, safe and effective in slowing the decline of hepatic reserve function.

Modelling climate change impacts on the seasonality of water resources in the Upper Ca River Watershed in Southeast Asia.

The impact of climate change on the seasonality of water resources in the Upper Ca River Watershed in mainland Southeast Asia was assessed using downscaled global climate models coupled with the SWAT model. The results indicated that temperature and evapotranspiration will increase in all months of future years. The area could warm as much as 3.4(°)C in the 2090 s, with an increase of annual evapotranspiration of up to 23% in the same period. We found an increase in the seasonality of precipitation (both an increase in the wet season and a decrease in the dry season). The greatest monthly increase of up to 29% and the greatest monthly decrease of up to 30% are expected in the 2090 s. As a result, decreases in dry season discharge and increases in wet season discharge are expected, with a span of ± 25% for the highest monthly changes in the 2090 s. This is expected to exacerbate the problem of seasonally uneven distribution of water resources: a large volume of water in the wet season and a scarcity of water in the dry season, a pattern that indicates the possibility of more frequent floods in the wet season and droughts in the dry season.

Initial clinical experience with durvalumab plus tremelimumab in patients with unresectable hepatocellular carcinoma in real­world practice.

Although durvalumab plus tremelimumab (Dur/Tre) has been approved as first-line therapy for patients with unresectable hepatocellular carcinoma (u-HCC), its outcomes in real-world clinical practice are unclear. The present study aimed to evaluate the efficacy and safety of Dur/Tre treatment. This multicenter study was conducted between March 2023 and January 2024, and included 120 patients with u-HCC treated with Dur/Tre. Among the patients, 44 had no history of systemic treatment. Progression-free survival (PFS), therapeutic response and adverse events (AEs) were assessed. The objective response rate (ORR) and disease control rates (DCR) were 15.8 and 53.3%, respectively. The median PFS was 3.9 months. The incidence rates of AEs of any grade and those grade 3 or higher were 83.3 and 36.7%, respectively. Liver injury was the most frequent AE of any grade and grade 3 or higher. Although there was no significant difference in ORR and PFS between the first and later line groups (ORR 15.8 vs. 15.7%, P=0.986; PFS 4.5 vs. 3.6 months, P=0.213), there was a significant difference in DCR between the two groups (65.8 vs. 45.9%, P=0.034). No significant differences were noted between the first- and later-line treatment groups regarding the incidence rate of AEs. Decision tree analysis revealed that poor liver function and advanced age were significant variables for discontinuation owing to AEs. In conclusion, Dur/Tre as first-line therapy had better disease control responses compared with later-line therapy; however, this regimen should be carefully administered to patients with deteriorating hepatic function or advanced age.

JTS-653 blocks afferent nerve firing and attenuates bladder overactivity without affecting normal voiding function.

PURPOSE: We evaluated the role of TRPV1 in bladder overactivity based on afferent nerve firing and urodynamic parameters using the selective TRPV1 antagonist JTS-653. MATERIALS AND METHODS: We evaluated the effects of JTS-653 on the increased pelvic nerve discharge and intravesical pressure induced by intravesical infusion of 100 µM capsaicin in anesthetized rats. The effects of JTS-653 on the urodynamic parameters of bladder overactivity induced by intravesical infusion of 30 nM resiniferatoxin or 0.2% acetic acid, or on normal bladder activity were evaluated by cystometry in conscious rats. The effects of JTS-653 on carbachol induced contraction were investigated using bladder muscle strips. RESULTS: JTS-653 significantly suppressed the capsaicin induced increase in nerve discharge and intravesical pressure. Intravesical infusion of resiniferatoxin or acetic acid decreased the intercontraction interval and voided volume. JTS-653 significantly increased the intercontraction interval and voided volume in rats with resiniferatoxin or acetic acid induced bladder overactivity without affecting maximal voiding pressure. The antimuscarinic agent propiverine significantly decreased maximal voiding pressure but did not affect the intercontraction interval or voided volume in rats with acetic acid induced bladder overactivity. In normal rats JTS-653 showed no significant effects on the intercontraction interval, voided volume or maximal voiding pressure. JTS-653 did not affect carbachol induced contraction of the bladder muscle. CONCLUSIONS: Our findings suggest that TRPV1 is involved in bladder overactivity via afferent nerve activation but it is not associated with normal voiding function. A TRPV1 antagonist would be a useful drug for bladder overactivity with a different pharmacological profile than antimuscarinic agents.

Behavior of antimony(V) during the transformation of ferrihydrite and its environmental implications.

In this study, we investigated the behavior of Sb(V) during the transformation of poorly crystalline Fe(III) oxyhydroxides (two-line ferrihydrite) with various Sb/Fe molar ratios at pH 6.0. Both XRD and Fe EXAFS analyses confirmed that goethite and hematite are the primary transformation products of the ferrihydrite in the presence of Sb(V). The crystallization kinetics showed that the transformation rate with Sb(V) was approximately the same as that of the control (without Sb(V)), which indicates that the presence of Sb(V) does not influence the transformation rate to a noticeable extent. Throughout the transformation, Sb(V) dominantly partitioned in the solid phase and no desorption of Sb(V) was observed. Furthermore, Sb EXAFS analyses suggested that Sb(V) in the solid phase is structurally incorporated into crystalline goethite and/or hematite generated by the ferrihydrite transformation. Hence, Sb(V) transfers into the thermodynamically stable solids from the metastable ferrihydrite with aging, indicating a rigid immobilization of Sb(V). These findings are valuable for making predictions on the long-term fate of Sb associated with ferrihydrite in natural environments.

Orally administered selective TRPV1 antagonist, JTS-653, attenuates chronic pain refractory to non-steroidal anti-inflammatory drugs in rats and mice including post-herpetic pain.

Chronic pain refractory to non-steroidal anti-inflammatory drugs (NSAIDs) is a major problem and drugs for such pain are needed. Many studies suggest that transient receptor potential vanilloid type 1 (TRPV1) is associated with NSAID-refractory chronic pain. Therefore, we investigated the involvement of TRPV1 in NSAID-refractory chronic pain using experimental models for NSAID-refractory chronic pain reflecting severe arthritic and postherpetic pain. The selective TRPV1 antagonist JTS-653 {(3S)-3-(hydroxymethyl)-4-(5-methylpyridin-2-yl)-N-[6-(2,2,2-trifluoroethoxy)pyridin-3-yl]-3,4-dihydro-2H-benzo[b][1,4]oxazine-8-carboxamide} reversed mechanical hyperalgesia on day 7 after injection of complete-Freund-adjuvant into the hindpaw in rats at 0.3 mg/kg, whereas indomethacin showed no effect. JTS-653 reduced chronic pain at 0.3 mg/kg in herpes simplex virus-1-inoculated mice that has been reported as NSAID-refractory pain. JTS-653 partially attenuated mechanical hyperalgesia in the L5 spinal nerve ligation model in rats at 0.3 mg/kg, whereas indomethacin showed no effect. Both JTS-653 and indomethacin reduced formalin-induced pain in the second phase, whereas they showed no effect in the first phase. JTS-653 did not affect the nociception of noxious thermal and mechanical stimuli and motor coordination in normal rats. These findings demonstrate the TRPV1 involvement in NSAID-refractory chronic pain reflecting severe arthritic and postherpetic pain. TRPV1 antagonists would be useful for the treatment of NSAID-refractory chronic pain.

Lipid profile is associated with the incidence of cognitive dysfunction in viral cirrhotic patients: A data-mining analysis.

AIM: Cognitive dysfunction (CD) is frequently observed in cirrhotic patients. However, the biochemical profiles associated with CD remain unclear. We investigated the biochemical profiles associated with the incidence of CD in cirrhotic patients by using multivariate analyses, including a decision-tree algorithm. METHODS: In this study, 27 viral cirrhotic patients were enrolled. All subjects underwent neuropsychiatric tests; two or more abnormal results were defined as CD. A logistic regression model was used for multivariate stepwise analysis. A decision-tree algorithm was constructed, and the categorical differences based on the decision-tree model were analyzed by χ(2) -tests. RESULTS: Multivariate stepwise analysis showed the levels of total bilirubin, triglycerides and free fatty acids (FFA) as independent bioparameters associated with the incidence of CD in cirrhotic patients. The decision-tree algorithm showed that among patients with FFA of 514 mEq/L or more, 77.8% had CD. Meanwhile, among patients with FFA of less than 514 mEq/L and triglycerides of 106 mg/dL or more, 20.0% had CD. The sensitivity, specificity and accuracy for the incidence of CD using the lipid profile (FFA >514 mEq/L or triglycerides <106 mg/dL) were 85.7% (12/14), 61.5% (8/13) and 74.1% (20/27), respectively. CONCLUSION: The levels of total bilirubin, FFA and triglycerides are independently associated with the incidence of CD in cirrhotic patients. In addition, a decision-tree algorithm revealed that FFA of more than 514 mEq/L or triglycerides of less than 106 mg/dL is a profile associated with the incidence of CD. Thus, this lipid profile could be a possible screening bioparameter for CD in cirrhotic patients.

Synchronous Double Primary Combined Hepatocellular-cholangiocarcinoma and Cholangiolocarcinoma in a Cirrhotic Liver.

Both combined hepatocellular-cholangiocarcinoma (cHCC-CCA) and cholangiolocarcinoma are rare primary liver cancers. cHCC-CCA is believed to originate from transformed hepatocellular carcinoma or liver stem/progenitor cells. Cholangiolocarcinoma is characterized by ductular reaction-like anastomosing cords and glands resembling cholangioles or canals containing hepatocellular carcinoma components and adenocarcinoma cells. According to the 2019 revision of the World Health Organization criteria, a subtype with stem cell features as a subclassification of cHCC-CCA was abolished for lack of conclusive evidence of the stem cell origin theory. That led to the classification of cholangiolocarcinoma with hepatocytic differentiation as cHCC-CCA. Consequently, cholangiolocarcinoma without hepatocytic differentiation is classified as a subtype of small-duct cholangiocarcinoma and is assumed to originate from the bile duct. Herein, we report the first case of double primary cHCC-CCA and cholangiolocarcinoma without hepatocytic differentiation in different hepatic segments of a cirrhotic liver. We believe this case supports the validity of the new World Health Organization criteria because the pathological finding of cHCC-CCA in this case shows the transformation of hepatocellular carcinoma to cholangiocarcinoma. Furthermore, this case may demonstrate that immature ductular cell stemness and mature hepatocyte cell stemness in hepatocarcinogenesis can coexist in the same environment. The results provide valuable insights into the mechanisms of growth, differentiation, and regulation of liver cancers.