Tumor Radiomic Features on Pretreatment MRI to Predict Response to Lenvatinib plus an Anti-PD-1 Antibody in Advanced Hepatocellular Carcinoma: A Multicenter Study.

Introduction: Lenvatinib plus an anti-PD-1 antibody has shown promising antitumor effects in patients with advanced hepatocellular carcinoma (HCC), but with clinical benefit limited to a subset of patients. We developed and validated a radiomic-based model to predict objective response to this combination therapy in advanced HCC patients. Methods: Patients (N = 170) who received first-line combination therapy with lenvatinib plus an anti-PD-1 antibody were retrospectively enrolled from 9 Chinese centers; 124 and 46 into the training and validation cohorts, respectively. Radiomic features were extracted from pretreatment contrast-enhanced MRI. After feature selection, clinicopathologic, radiomic, and clinicopathologic-radiomic models were built using a neural network. The performance of models, incremental predictive value of radiomic features compared with clinicopathologic features and relationship between radiomic features and survivals were assessed. Results: The clinicopathologic model modestly predicted objective response with an AUC of 0.748 (95% CI: 0.656-0.840) and 0.702 (95% CI: 0.547-0.884) in the training and validation cohorts, respectively. The radiomic model predicted response with an AUC of 0.886 (95% CI: 0.815-0.957) and 0.820 (95% CI: 0.648-0.984), respectively, with good calibration and clinical utility. The incremental predictive value of radiomic features to clinicopathologic features was confirmed with a net reclassification index of 47.9% (p < 0.001) and 41.5% (p = 0.025) in the training and validation cohorts, respectively. Furthermore, radiomic features were associated with overall survival and progression-free survival both in the training and validation cohorts, but modified albumin-bilirubin grade and neutrophil-to-lymphocyte ratio were not. Conclusion: Radiomic features extracted from pretreatment MRI can predict individualized objective response to combination therapy with lenvatinib plus an anti-PD-1 antibody in patients with unresectable or advanced HCC, provide incremental predictive value over clinicopathologic features, and are associated with overall survival and progression-free survival after initiation of this combination regimen.

Radiographic and α-fetoprotein response predict pathologic complete response to immunotherapy plus a TKI in hepatocellular carcinoma: a multicenter study.

BACKGROUND: Pathologic complete response (pCR) following preoperative systemic therapy is associated with improved outcomes after subsequent liver transplant/resection in hepatocellular carcinoma (HCC). However, the relationship between radiographic and histopathological response remains unclear. METHODS: We retrospectively examined patients with initially unresectable HCC who received tyrosine kinase inhibitor (TKI) plus anti-programmed death 1 (PD-1) therapy before undergoing liver resection between March 2019 and September 2021 across 7 hospitals in China. Radiographic response was evaluated using mRECIST. A pCR was defined as no viable tumor cells in resected samples. RESULTS: We included 35 eligible patients, of whom 15 (42.9%) achieved pCR after systemic therapy. After a median follow-up of 13.2 months, tumors recurred in 8 non-pCR and 1 pCR patient. Before resection, there were 6 complete responses, 24 partial responses, 4 stable disease cases, and 1 progressive disease case, per mRECIST. Predicting pCR by radiographic response yielded an area under the receiver operating characteristic curve (AUC) of 0.727 (95% CI: 0.558-0.902), with an optimal cutoff value of 80% reduction in the enhanced area in MRI (called major radiographic response), which had a 66.7% sensitivity, 85.0% specificity, and a 77.1% diagnostic accuracy. When radiographic response was combined with α-fetoprotein response, the AUC was 0.926 (95% CI: 0.785-0.999); the optimal cutoff value was 0.446, which had a 91.7% sensitivity, 84.6%, specificity, and an 88.0% diagnostic accuracy. CONCLUSIONS: In patients with unresectable HCC receiving combined TKI/anti-PD 1 therapy, major radiographic response alone or combined with α-fetoprotein response may predict pCR.

Long non-coding RNA MALAT1 promotes angiogenesis and immunosuppressive properties of HCC cells by sponging miR-140.

Hepatocellular carcinoma (HCC) is the most prevalent primary liver cancer in adults. Previous studies in our laboratory found that long non-coding RNA metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) was upregulated in HCC cells, which could affect the metastasis and invasion of HCC. However, the underlying mechanism remains unknown. Herein, we studied the interaction between MALAT1 and miR-140 on the regulation of angiogenesis and immunosuppressive properties. We revealed that the expression of MALAT1 and VEGF-A was significantly increased in HCC cells. Knockdown of MALAT1 in HCC cells suppressed the production of VEGF-A, impaired the angiogenesis of HUVECs, and facilitated the polarization of macrophage toward the M1 subset. Mechanistically, the interaction between MALAT1 and miR-140 or between miR-140 and VEGF-A was confirmed by multiple assays. Besides, a negative correlation between MALAT1 and miR-140 was found in HCC tissues. Furthermore, miR-140 inhibition significantly increased VEGF-A expression, promoted angiogenesis of HUVECs, and redirected the polarization of macrophages toward the M2 subset. In addition, in vivo studies also verified the regulatory network of the MALAT1/miR-140 axis on VEGF-A in HCC progression. In summary, this study revealed the mechanism that MALAT1 worked as a putative HCC promotor via inhibiting miR-140. Therefore, targeting MALAT1 or miR-140 might alleviate the progression of HCC in the future.

The clinical value of total plasma cell-free DNA in hepatitis B virus-related hepatocellular carcinoma.

BACKGROUND: Circulating cell-free DNA (cfDNA), which is present in the blood, is related to the apoptosis and necrosis of cancer cells; inflammation also influences the total plasma level of cfDNA. However, the total plasma cfDNA level has not been investigated in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) who experience cancer and HBV infection at the same time. The aim of the study was to investigate total plasma cfDNA in patients with HBV-related HCC. METHODS: HBV-related HCC patients were included from January 2018 to May 2019. All patients underwent hepatectomy and were diagnosed with HCC by histopathology. Peripheral blood samples were obtained preoperatively, and the levels of total plasma cfDNA were quantitated by a fluorometric double-stranded DNA (dsDNA) assay. We examined the correlation between cfDNA and clinical parameters, and recurrence-free survival was evaluated using Kaplan-Meier curves. RESULTS: Forty-eight HBV-related HCC patients were included. The average age in years was 50.90±13.15, and the mean albumin level was 41.63±5.38 g/L. HBV-DNA, Child-Turcotte-Pugh (CTP) class, TNM stage, tumor number and vascular invasion showed a relationship with total plasma cfDNA (P<0.05), and albumin, prothrombin time (PT) and tumor diameter had linear correlation with plasma cfDNA. Based on multivariate analysis, tumor diameter, vascular invasion, and CTP class (P<0.05) were independent risk factors of total plasma cfDNA. Median recurrence times for low-cfDNA and high-cfDNA groups were 14.729±0.712 and 9.264±1.22 months (P=0.026). CONCLUSIONS: In addition to tumor diameter and vascular invasion, CTP class can influence total plasma cfDNA in HBV-related HCC patients, and the total plasma cfDNA level can be used as a biomarker to predict early recurrence in HBV-related HCC patients.

Overexpression of MMSET is correlation with poor prognosis in hepatocellular carcinoma.

The multiple myeloma SET domain (MMSET) involved in the t(4;14)(p16;q32) chromosomal translocation encodes a histone lysine methyltransferase. High expression of MMSET is common translocation in multiple myeloma (MM) and is associated with the worst prognosis. Recent studies have shown that overexpression of MMSET is significant in other tumor types compared to their normal tissues. However, little is known about its role in hepatocellular carcinoma (HCC). In these study we investigate the expression of MMSET in HCC and to make correlations with clinicopathologic features. Twenty-eight pairs of HCC and adjacent non-tumor tissues, and eight normal liver tissues were collected for MMSET detection by western blotting and real time-PCR analysis. Immunohistochemistry was used to determine the expression of MMSET in HCC and adjacent non-tumor tissues from 103 patients. Overexpression of MMSET was significantly associated with Edmondson stage, vascular invasion. Moreover, Kaplan-Meier curves showed that MMSET upregulated was associated with shorter overall survival and disease-free survival in HCC patient. In conclusion, our study demonstrates for the first time that overexpression of MMSET is an independent prognostic factor and is correlated with poor survival in HCC patients.

A standard approach to expose the recurrent laryngeal nerve during endoscopic thyroidectomy.

PURPOSE: Exposing the recurrent laryngeal nerve (RLN) during all types of thyroid surgery is essential to protect this nerve. Endoscopic thyroidectomy (ET) has gained acceptance from both patients and physicians, in part due to the cosmetic benefits. Therefore, the avoidance of intraoperative RLN impairment during ET is of critical significance. We have developed a standard approach to expose the RLN during ET that prevents RNL impairment. PATIENTS AND METHODS: ET was performed in 120 consecutive patients with thyroid disease. In order to develop a standard procedure that protects the RLN, several steps that differed from the traditional open procedure were introduced. First, the thyroid gland was freed from the isthmus instead of the superior pole. Then, the inferior pole of the thyroid gland was meticulously freed, and the lateral side of the thyroid gland was freed followed by the superior pole. At this point, the RLN was easily visualized in the tracheoesophageal groove. The thyroidectomy was then performed simultaneously with exposure of the RLN from the inferior to superior aspects. All RLNs were exposed when hemithyroidectomies, subtotal thyroidectomies, or total thyroidectomies were performed. The operative time and parathyroid hormone (PTH) and calcium levels were recorded prospectively and analyzed. RESULTS: Using this method, all RLNs were easily exposed within 15 minutes. Only one case of transient RLN palsy occurred due to accidental contact of the harmonic scalpel to the nerve. Postoperative hypocalcemia occurred in 23 cases (19.2%), and the PTH level decreased significantly in 33 cases (27.5%). The PTH levels returned to normal within 3 months. CONCLUSION: Use of the described approach to expose and protect the RLN when performing ET is safe and feasible.

Increased expression of cyclooxygenase-2 and increased infiltration of regulatory T cells in tumors of patients with hepatocellular carcinoma.

BACKGROUND: Studies on Cox-2 and Foxp3+ regulatory T cells (Treg) in hepatocellular carcinoma (HCC) showed that Treg suppress local immune response in a Cox-2-dependent fashion. AIMS: To investigate Cox-2 expression, Foxp3+ Treg infiltration and CD4+ T cell frequency in HCC tumors. METHODS: Tumors and the corresponding nontumor hepatitis B virus-related liver tissues from 40 HCC patients with hepatitis B virus infection, plus 10 liver samples from patients with hemangioma as controls, were assessed for Cox-2 expression, Foxp3+ Treg and total CD4+ T cell numbers using immunohistochemistry. Serum TGF-beta1 was assessed by ELISA. RESULTS: Reduced Cox-2 expression, increased Treg and increased CD4+ T cells were shown in tumor as compared with nontumor tissues. Moreover, of 40 tumor tissues, 23 that expressed Cox-2 showed increased Foxp3+ Treg and reduced CD4+ T cells compared with the remaining 17 that did not express Cox-2. Correlation analyses showed that within tumors Treg infiltration correlated positively with Cox-2 expression, and that Treg infiltration or Cox-2 expression correlated negatively with CD4+ T cells. Additionally, serum TGF-beta1 was higher in HCC patients than in controls. CONCLUSION: Within tumors, Cox-2 expression, Treg infiltration and CD4+ T cell frequency were increased, and the Cox-2 expression correlated positively with Treg infiltration and negatively with CD4+ T cell frequency.

Correlation between expression of cyclooxygenase-2 and the presence of CD4+ infiltrating T-lymphocyte in human primary hepatocellular carcinoma.

BACKGROUND/AIMS: Recent studies have found that Cyclooxygenase-2(Cox-2) is frequently inappropriately expressed in primary hepatocellular carcinoma (HCC), suggesting that abnormal Cox-2 expression plays an important role in hepatocarcinogenesis. But it remains controversial in these reports. Moreover, there are only a few studies on the correlation between Cox-2 and infiltrating immunocytes in the tumor-microenvironment. CD4+ tumor-infiltrating lymphocytes (TIL) and infiltrating immunocytes around the tumor are closely correlated to the development of the tumor, but so far no reports are available showing the relationship among Cox-2, CD4+ TIL of tumor and CD4+ infiltrating T-lymphocytes of adjoining non-tumorous (ANT) tissues in tumor-microenvironment. This study is designed to appropriately select and collect patients' specimens to better reflect Cox-2 expression in human HCC, and also to stress the correlation among Cox-2, CD4+ TIL and CD4+ infiltrating T-lymphocytes in the tumor-microenvironment. METHODOLOGY: Tumor tissue, and its matched ANT tissue removed less than 1 cm from the solid tumor border, were obtained from 25 HCC patients all of whom came from Hunan province, China, and were infected with hepatitis B virus (HBV). Normal liver tissues of 10 hemangiomas were collected as controls. Both Cox-2 expression and the number of CD4+ TIL and CD4+ infiltrating T-lymphocyte were detected by immunohistochemistry, and data were analyzed closely with patients' clinical figures so as to investigate the correlation between the 3 elements. RESULTS: In 25 HCC patients, remarkably higher Cox-2 expression in both tumor and ANT tissues was observed compared with normal liver tissues (p < 0.001). The percentage of Cox-2 positive cells was, remarkably, higher in ANT tissues than in tumors (p < 0.001). Similarly the distribution of CD4+ T cells was significantly higher in ANT tissue than in tumor tissue (p < 0.0001), and also significantly higher in tumor tissue than in normal tissue (p < 0.0001). Importantly, in the group of patients with Cox-2-expressing tumors, the number of CD4+ infiltrating T-lymphocyte in ANT tissues was 79.4(+)9.92/hpf, which is obviously lower (p = 0.019) than that of the group with non-Cox-2-expressing tumors with the number of CD4+ infiltrating T-lymphocyte in ANT tissues at 118.13(+)12.47/hpf. Cox-2 expression of tumors showed a significant negative correlation with number of CD4+ infiltrating T cells of ANT tissues (r = 0.499, p = 0.024). The number of CD4+ TILs are lower in Cox-2-expressing tumors than in non-Cox-2-expressing tumors, but there was not statistical significance (p = 0.057). CONCLUSIONS: Taken together we suggest in the tumor-microenvironment of HCC the expression of Cox-2 may inhibit the number CD4+ infiltrating T-lymphocyte in ANT tissues. As a result, Cox-2 overexpression may contribute to both suppression of local immune responses and enhancement of metastatic potential in human HCC.

[Surgical treatment of recurrent laryngeal nerve injury caused by thyroid operation].

OBJECTIVE: To study the surgical treatment of recurrent laryngeal nerve (RLN) injury caused by thyroid operation. METHODS: From 1970 to 2001, 50 patients with RLN injury were caused by thyroid operation. The causes, location, type, operative procedures and follow-up were retrospectively analyzed. RESULTS: Unilateral RLN injury occurred in 46 cases and bilateral nerve injury in 4 cases. The RLN injuries were located within 2cm below the point of RLN entering to throat in 45 nerves (83.3%), other places in 6 nerves (11.3%), and unknown location in 3 nerves (5.4%). Transection of the nerve was found in 19 nerves (36.5%), suture or scare pressing the nerve in 35 nerves (64.8%). All the injured nerves were repaired surgically. Meanwhile all 4 patients with bilateral RLN injuries underwent tracheotomy. Of the 50 cases, 44 cases (88.0%) were followed up for more than 1.5 years. Among the 44 followed-up patients, phonation was restored to normal or obvious improvement in 42 cases (95.5%), and improvement in 2 (4.5%). Of the 35 patients with 39 nerves underwent indirect or direct laryngoscopy, the affected vocal cord movement entirely recovered in 21 cords (53.8%), partially recovered in 7 cords (17.9%), uncovered in 11 cords (28.3%). There was no relation between the recovery of phonation or vocal cord movement with the timing or the procedure of repairing operation. CONCLUSIONS: The location of most RLN injuries caused by thyroid surgery are just below the point of RLN entering to throat, and most are mechanical injury, and need operation to resolve the cause. Once the RLN injury is made, an operation should be performed as early as possible.