Insufficient microwave ablation (iMWA) of hepatocellular carcinoma (HCC) often leads to rapid and aggressive recurrence, and effective intervention remains a formidable challenge. Here, we show that the DNA methylation machinery is aberrantly activated in residual HCC following iMWA. The heat-responsive stress protein HSP90α collaborates with the deubiquitinase USP7 to stabilize and upregulate DNA methyltransferase DNMT1, thereby transducing the sublethal heat-stress input from iMWA into an epigenetic output and elevating DNA methylation levels. Sublethal heat-stress-induced DNMT1 upregulation significantly promotes the growth and invasive potential of post-iMWA residual HCC cells, a process that involves disruption of propionate metabolism. Mechanistically, the propionate-metabolizing enzyme ACSS3 in residual HCC is found to be silenced by DNMT1-mediated promoter hypermethylation, impairing propionate-to-propionyl-coenzyme A (CoA) conversion. Reduction in propionyl-CoA production enhances the activity of the fatty acid β-oxidation (FAO) rate-limiting enzyme carnitine palmitoyltransferase 1 (CPT1), ultimately stimulating FAO-dependent ATP regeneration. Critically, we developed a liposomal CRISPR-dCas9-based locus-specific demethylation system for precise epigenetic reactivation of ACSS3 and demonstrated its ability to effectively prevent post-iMWA HCC recurrence and metastasis, with more pronounced efficacy when combined with propionate supplementation. Our findings identify a novel DNMT1-driven “epigenetic-metabolic cascade” as a central mechanism promoting HCC recurrence following iMWA, emphasizing the therapeutic potential of ACSS3-targeted methylation editing.

4149 Background: Selective internal radiation therapy (SIRT) with yttrium-90 microspheres is an established locoregional therapy for unresectable hepatocellular carcinoma (HCC) and may induce immunogenic modulation, providing a rationale for PD-(L)1 blockade combinations. However, outcomes with SIRT–PD-(L)1 doublets suggest room for improvement. Lenvatinib has biological plausibility to augment radiation- and immunotherapy-mediated effects via VEGFR/FGFR pathway inhibition. We evaluated the efficacy and safety of sequential SIRT followed by lenvatinib plus sintilimab and explored serum protein biomarkers for outcome stratification. Methods: SIRLENS-90 (NCT05992584) is a single-center, open-label, single-arm phase II trial in unresectable BCLC B/C HCC (ECOG 0–1, Child–Pugh 5–7) suitable for SIRT after mapping and 99m Tc-MAA simulation. Patients received yttrium-90 resin SIRT (partition-model dosimetry) followed 3–7 days later by lenvatinib (8/12 mg daily) plus sintilimab (200 mg IV Q3W). Primary endpoint: PFS by mRECIST. Secondary endpoints: PFS by RECIST v1.1, OS, ORR, DCR, and safety (CTCAE v5.0). Exploratory Olink proteomics and LASSO-penalized Cox modeling derived a baseline risk score. Results: Thirty patients were treated (mean age 57 years [(SD 9.9], 93% male, 87% HBV-related; 43% BCLC B, 57% BCLC C; 43% macrovascular invasion; 53% bilobar disease; 37% extrahepatic metastases; mean max tumor diameter 9.6 cm [SD 3.8; range 3.2–16.1]). Median follow-up was 23.4 months. Median PFS was 15.8 mo (95% CI 8.3–20.7) by mRECIST (6-, 12-, and 18-mo rates: 77%, 53%, 40%) and 17.0 mo (95% CI 8.3–20.7) by RECIST v1.1. Median OS was not reached (12-, 18-, and 24-mo OS rates: 83%, 73%, 68%). ORR was 83% (95% CI 65–94) by mRECIST and 60% (95% CI 41–77) by RECIST v1.1; DCR was 90% (95% CI 74–98) by both. Intrahepatic ORR was 93% (95% CI 78–99) by mRECIST. Grade 3–4 treatment-related AEs occurred in 47%, with treatment-related SAEs in 10% and no treatment-related deaths. A baseline risk score incorporating IL-5 (protective), CXCL11 (adverse), extrahepatic metastasis, and bilobar disease stratified PFS (log-rank P = 0.001) and OS ( P = 0.02), with optimism-corrected C-index 0.758 (for PFS). Conclusions: Yttrium-90 SIRT followed by lenvatinib plus sintilimab demonstrated encouraging activity with manageable toxicity in unresectable intermediate-to-advanced HCC. The cytokine-integrated baseline risk score is hypothesis-generating and warrants external validation. Clinical trial information: NCT05992584 .

BACKGROUND & AIMS:Transarterial chemoembolization (TACE) is widely used to treat unresectable hepatocellular carcinoma (HCC). Liver injury induced by TACE (TACE-LI) is the most common complication and limits long-term outcomes. Beyond the conventional understanding of direct TACE-induced damage to normal liver tissue, the underlying mechanisms of TACE-LI remain unclear. We aimed to elucidate the relationship between gut microbiota disturbances and TACE-LI. METHODS:Microbial multi-omics analysis, genetically engineered bacteria and transcriptomics were used to study microbiota disturbances and host responses in TACE-LI. RESULTS:Rats with antibiotic-depleted gut microbiota, as well as rats receiving fecal transplants from donor rats or patients who had undergone TACE, exhibited more severe TACE-LI. Limosilactobacillus reuteri (L. reuteri) abundance was significantly reduced in TACE-treated rats and patients with HCC. Reduced L. reuteri abundance after TACE led to decreased levels of tryptophan metabolite indole-3-lactic acid (ILA), while administration of live L. reuteri or ILA provided effective protection against TACE-LI. Mechanistically, L. reuteri relied on the key enzyme phenyllactate dehydrogenase to generate ILA. ILA inhibits the ATPase activity of heat shock protein 90, thereby deactivating the NOD-like receptor protein 3-inflammasome in macrophages and suppressing hepatic pro-inflammatory responses. Reduced levels of L. reuteri and ILA were correlated with aggravated LI and poorer overall survival in TACE-treated patients with HCC. CONCLUSIONS:This is the first study to identify gut microbiota disturbance, i.e. deficiency of L. reuteri metabolite ILA, as a significant cause of TACE-LI. Administration of L. reuteri or ILA may serve as a promising therapeutic strategy to mitigate TACE-related adverse effects and improve prognosis in HCC. IMPACT AND IMPLICATIONS:Transarterial chemoembolization (TACE) is widely used to treat unresectable hepatocellular carcinoma (HCC), but its long-term outcomes are limited by liver injury (LI). Beyond direct ischemic- or chemotherapy-induced liver damage, the mechanisms underlying TACE-induced LI (TACE-LI) remain unclear. We found that TACE disturbs the gut microbiota, notably reducing levels of Limosilactobacillus reuteri (L. reuteri) and its metabolite indole-3-lactic acid (ILA). These reductions were associated with aggravated TACE-LI and poorer overall survival in patients with HCC. Administration of L. reuteri or ILA significantly alleviated TACE-LI by suppressing macrophage-driven inflammation. This study is the first to identify gut microbiota disturbances as a key contributor to TACE-LI. Supplementing L. reuteri or ILA represents a safe and promising strategy to prevent TACE-LI, reduce TACE-related adverse effects, and improve prognosis in patients with HCC.

AIMTo explore the preliminary application of dual cone-beam CT (CBCT) for dose calculation and tumor-feeding arteries identification in 90Y-SIRT planning.Materials and MethodsA retrospective study analyzed 27 patients with unresectable primary/metastatic liver tumors eligible for 90Y-SIRT. Prior to angiography, dual CBCT and 99mTc-MAA injection, each patient underwent CTA scan. Tumor volume (TV) and liver lobe volume (LLV) were measured from CTA and dual CBCT images (TVcta vs TVcbct and LLVcta vs LLVcbct). Liver perfusion volume (LPV) was derived from 99mTc-MAA mapping and dual CBCT (LPVmma vs LPVcbct). Additionally, analyze the differences between an average calculated 90Y dosage derived from TVcbct and LPVcbct, and dosage calculated using TVcbct combined with LPVmma, against the mean clinically administered (Radioactivity). The Paired Wilcoxon test was applied to evaluate differences between these parameters throughout the study.ResultsThere were no significant differences in liver tumor and perfusion volume measurements (p-values of 0.792 and 0.084, respectively). There was a significant difference in LVcbct compare to LVcta (2083.88 ± 744.64 vs 2187.86 ± 807.28 cm³, p = 0.024), which may be due to differences in contrast agent delivery. No significant differences were found among the three methods of calculated 90Y dosage(TVcbct + LPVcbct, TVcbct +LPVmma, radioactivity)were (1.819 ± 1.241, 1.806 ± 1.240, 1.805 ± 1.236)(all P>0.05).ConclusionDual CBCT is a reliable alternative to the conventional method, while offering real-time procedural advantages for feeder artery identification and catheter positioning during 90Y-SIRT.

The incidence and mortality of hepatocellular carcinoma (HCC) in China are among the highest in the world, imposing a heavy social burden. Liver resection and liver transplantation are the primary radical treatments for HCC, although most patients are no longer able to meet the surgical requirements at initial diagnosis. Yttrium-90 microsphere selective internal radiation therapy (90Y-SIRT) has the advantages of shrinking tumors, enlarging residual liver, regressing portal vein tumor thrombus and improving the quality of life, which can be used for conversion, downstaging and bridging therapy for HCC before surgical treatment, enabling patients regain the chance of radical treatment and reducing the postoperative recurrence rate. This review focuses on the clinical application and progress of 90Y-SIRT in this field.

Yttrium-90 microsphere selective internal radiation therapy (SIRT), also known as transarterial radioembolization, has become one of the pivotal treatments for liver cancer, particularly for selected advantageous patient groups. This review summarizes the characteristics of different patients with liver cancer that could obtain maximum benefit from SIRT and discusses key factors affecting efficacy and safety, including tumor characteristics, liver function, patient performance status, and treatment intent. In evaluating appropriate candidates, mapping serves as a crucial simulation procedure to assess tumor vascular anatomy, predict lung shunting, and guide catheter positioning and dose planning. This procedure substantially enhances therapeutic precision while minimizing the risk of nontarget radiation-related adverse events, such as radiation-induced pneumonitis and gastrointestinal toxicity. Several studies have suggested that SIRT is not only suitable for patients with early or limited hepatocellular carcinoma but can also be used as a bridging therapy for liver transplantation and conversion therapy for unresectable liver cancers. In combination with systemic treatments, SIRT has demonstrated survival benefits in patients with unresectable liver cancer. This review also highlights the importance of further optimizing patient screening through personalized dosimetry and mapping to ensure the precision and safety of treatment. A thorough review of relevant literature and clinical practice offers clinicians comprehensive suggestions on patient screening and clarifies the promise of SIRT in the liver cancer population.

Abstract Background Previous studies evaluating antiangiogenic agents plus immune checkpoint inhibitors for unresectable hepatocellular carcinoma (HCC) have shown encouraging results. This study was conducted to investigate the efficacy and safety of donafenib combined with sintilimab (Don-Sin) for advanced HCC. Methods This was a single-center, single-arm phase II trial recruiting patients with BCLC stage C HCC. A safety run-in cohort was planned with the first 6 patients receiving oral donafenib 200 mg twice daily and intravenous sintilimab 200 mg once every 3 weeks. Dose-limiting toxicities (DLTs) were evaluated to determine the recommended dose of donafenib for those enrolled thereafter. The primary endpoint of this study was progression-free survival (PFS) per mRECIST. Results 30 patients were enrolled. As 3 patients (50.0%) experienced DLTs during safety run-in, the initial dose of donafenib was adjusted to 200 mg once daily for subsequent patients. The primary endpoint was met with a median PFS of 6.2 (95% confidence interval [CI], 4.4-8.0) months per mRECIST (6.3 [95% CI, 5.4–7.2] months per RECIST 1.1). The objective response rate was 23.3% per mRECIST and 16.7% per RECIST 1.1, while the disease control rate reached 76.7% per mRECIST/RECIST 1.1. The median overall survival was 16.0 (95% CI, 13.5–18.5) months. Treatment-related adverse events (TRAEs) occurred in 28 patients (93.3%) and grade 3 TRAEs were observed in 9 patients (30.0%). Conclusions Don-Sin showed promising antitumor effects with an acceptable safety profile in patients with advanced stage HCC. The preliminary findings need to be further evaluated in phase III randomized controlled trials. Trial registration ClinicalTrials.gov (identifier: NCT05162352; date of registration: December 4, 2021).

Local thermal ablation (TA) can not only reduce the tumor burden of hepatocellular carcinoma (HCC) but also stimulate the host anti-tumor immune response, offering a promising avenue for combination with immune checkpoint blockade (ICB). However, tumor recurrence and ICB resistance are associated with residual tumor masses caused by incomplete TA treatment. Thus, adjuvant therapy that can accurately eliminate residual HCC tumors post-TA is expected to improve prognosis. Bacteria-mediated tumor therapy has showed promising potential for tumor-targeting ability and in situ therapeutic proteins expression in the tumor. Here, we presented a kind of nonpathogenic engineered bacteria (named PD-1@EcM) for the potent tumor-targeting and acidic-controlled production of fusion protein comprising a mouse-derived anti-PD-1 single-chain variable fragment (scFv). A single injection of this engineered bacteria demonstrated a significantly tumor inhibition and extended survival in advanced murine primary and metastatic post-TA treatment HCC model. We observed that this engineered bacteria elicited an enhanced antitumour immune response resulting in an extensive priming of activated CD8+ T cells and polarization of tumor-associated macrophage from M2 phenotype to M1 phenotype. Taken together, this work provides a novel strategy to address major challenges in TA therapy and expand the current applications of bacteria-based platforms for precision therapy.

Purpose:To evaluate the efficacy and safety of sorafenib combined with tislelizumab (a programmed death-1 inhibitor) and transarterial chemoembolization (TACE) in patients with advanced-stage hepatocellular carcinoma (HCC). Patients and Methods:This was a single-center, single-arm phase II trial. Patients with HCC at Barcelona Clinic Liver Cancer stage C were recruited. Treatment with sorafenib (400 mg orally twice daily) and tislelizumab (200 mg intravenously every 3 weeks) was initiated 3-7 days after the first TACE procedure. Repeated TACE was performed on-demand. The primary endpoint of this study was overall survival (OS). Results:Thirty patients were enrolled. The median OS for the patients was 18.3 (95% CI = 14.6-22.0) months, with 12-, 18-, and 24-month OS rates of 90.0%, 54.0%, and 28.3%, respectively. The objective response rate was 53.3% per modified Response Evaluation Criteria in Solid Tumors (mRECIST) and 20.0% per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1). The disease control rate was 86.7% per mRECIST/RECIST 1.1. The median progression-free survival was 6.8 (95% CI = 4.5-9.0) months per mRECIST/RECIST 1.1. The median duration of response was 7.1 (95% CI = 6.1-8.1) months per mRECIST (n = 16) and 4.4 (95% CI = 0.9-7.9) months per RECIST 1.1 (n = 6). Treatment-related adverse events (TRAEs) occurred in 28 patients (93.3%), and grade 3 TRAEs were observed in 11 patients (36.7%). There were no grade 4/5 TRAEs. Conclusion:Sorafenib combined with tislelizumab and TACE showed promising antitumor activities with a manageable safety profile in patients with advanced-stage HCC. These preliminary findings warrant further evaluation in Phase III randomized trials.

581 Background: Yttrium-90 resin microspheres have been introduced into China in recent years, but the efficacy or safety on Chinese patients are rarely reported. This study aimed to evaluate the efficacy and safety of selective internal radiation therapy (SIRT) with yttrium-90 resin microspheres followed by lenvatinib and PD-1 inhibitor in Chinese patients with large (5.1–10.0 cm in diameter) or huge (>10.0 cm) advanced-stage hepatocellular carcinoma (HCC). Methods: Data of large or huge Barcelona Clinic Liver Cancer stage C HCC patients treated with SIRT followed by lenvatinib plus PD-1 inhibitor from November 2022 to October 2023 were prospectively collected and retrospectively analyzed. Key endpoints included overall survival (OS), progression-free survival (PFS), complete response rate (CRR), objective response rate (ORR), disease control rate (DCR) based on modified Response Evaluation Criteria in Solid Tumors, and adverse events (AEs) graded based on Common Terminology Criteria for Adverse Events v5.0. Risk factors affecting PFS were analyzed using univariate and multivariate Cox regression models. Results: A total of 30 patients (27 males, 3 females; mean age 54 ± 11 years) were included. The mean longest diameter of the tumor was 9.6 ± 4.2 cm (range: 5.2–17.6 cm). Nineteen (63.3%) patients had more than three intrahepatic lesions, 15 (50.0%) had vascular invasion, and 13 (43.3%) had extrahepatic metastasis. Sixteen (53.3%) patients had undergone prior anticancer therapies. Two patients received two SIRT procedures, and the rest had one. Lenvatinib and PD-1 inhibitor treatment was initiated 3–7 days after the initial SIRT procedure. CRR was 20.0%, ORR was 73.3%, and DCR was 90.0%. Median PFS was 8.0 months (95% CI, 5.6–10.4), and median OS was not reached. OS rates at 6, 12, and 18 months were 93%, 74%, and 74%, respectively. Univariate and multivariate analysis indicated that baseline alpha-fetoprotein levels, baseline eosinophil count, and neutrophil-to-lymphocyte ratio at 1 month after SIRT were independent risk factors for PFS. AEs of any grade occurred in 86.7% of patients, with grade 3 AEs in 23.3%, and no grade 4/5 AEs were recorded. Conclusions: SIRT followed by lenvatinib and PD-1 inhibitor demonstrates promising efficacy and a favorable safety profile in Chinese patients with large or huge advanced-stage HCC.

The development of manganese oxide-based chemodynamic immunotherapy is emerging as a key strategy against solid tumors. However, the limited efficacy of nanoplatform in inducing efficient tumor therapeutic effects and creating the prominent antitumor immune responses remains a crucial issue. In this study, we construct a novel multifunctional biomimetic nanovaccine comprising manganese oxide-loaded poly(2-diisopropylaminoethyl methacrylate) (MP) nanoparticles and a coating layer of hybrid cell membrane (RHM) derived from manganese oxide-remodeled 4T1 cells and dendritic cells (DCs) (collectively called MP@RHM) for combination chemodynamic immunotherapy. Compared with the nanovaccines coated with the single cell membrane, the MP@RHM nanovaccine highly efficiently activates both DCs and T cells to boost tumor-specific T cell, owing to the synergistic effects of abundant damage-associated molecular patterns, Mn2+, and T cell-stimulating moieties. Upon peritumoral injection, the MP@RHM nanovaccine targets both the tumor site for focused chemodynamic therapy and the lymph nodes for robust tumor-specific T cell priming, thereby achieving highly efficient chemodynamic immunotherapy. Moreover, as a preventive cancer nanovaccine, MP@RHM generates strong immunological memory to inhibit postoperative tumor metastasis and recurrence. Our study findings highlight a promising approach to construct a multifunctional biomimetic nanovaccine for personalized chemodynamic immunotherapy against solid tumors.

BACKGROUND Surgical resection and liver transplantation (LT) are the most effective curative options for hepatocellular carcinoma (HCC). However, few patients with huge HCC (> 10 cm in diameter), especially those with portal vein tumor thrombus (PVTT), can receive these treatments. Selective internal radiation therapy (SIRT) can be used as a conversion therapy for them because it has the dual benefit of shrinking tumors and increasing residual hepatic volume. However, in patients with huge HCC, high lung absorbed dose often prevents them from receiving SIRT. CASE SUMMARY A 35-year-old man was admitted because of emaciation and pain in the hepatic region for about 1 month. The computed tomography scan showed a 20.2 cm x 19.8 cm tumor located in the right lobe-left medial lobes with right portal vein and right hepatic vein invasion. After the pathological type of HCC was confirmed by biopsy, two conversions were presented. The first one was drug-eluting bead transarterial chemoembolization plus hepatic arterial infusion chemotherapy and lenvatinib and sintilimab, converted to SIRT, and the second one was sequential SIRT with continued systemic treatment. The tumor size significantly decreased from 20.2 cm x 19.8 cm to 16.2 cm x 13.8 cm, then sequentially to 7.8 cm x 6.8 cm. In the meantime, the ratio of spared volume to total liver volume increased gradually from 34.4% to 55.7%, then to 62.9%. Furthermore, there was visualization of the portal vein, indicating regression of the tumor thrombus. Finally, owing to the new tumor in the left lateral lobe, the patient underwent LT instead of resection without major complications. CONCLUSION Patients with inoperable huge HCC with PVTT could be converted to SIRT first and accept surgery sequentially.

Background: The management of hepatocellular carcinoma (HCC) with high tumor burden and major portal vein tumor thrombosis (PVTT) remains a great challenge. The authors aimed to investigate the efficacy and safety of lenvatinib plus drug-eluting bead transarterial chemoembolization (DEB-TACE) and hepatic arterial infusion chemotherapy (HAIC) with oxaliplatin, fluorouracil and leucovorin (Len+DEB-TACE+HAIC) versus lenvatinib plus DEB-TACE (Len+DEB-TACE) for HCC greater than 7.0 cm accompanied with major PVTT. Materials and methods: This multicenter retrospective cohort study evaluated consecutive patients with HCC (> 7.0 cm) and major PVTT who received Len+DEB-TACE+HAIC (Len+DEB-TACE+HAIC group) or Len+DEB-TACE (Len+DEB-TACE group) between July 2019 and June 2021 from eight institutions in China. Objective response rate (ORR), time to progression (TTP), overall survival (OS), and treatment-related adverse events (TRAEs) were compared between the two groups by propensity score matching (PSM). Results: A total of 205 patients were included. After PSM, 85-paired patients remained in the study cohorts. Patients in the Len+DEB-TACE+HAIC group had higher ORR (61.2% vs. 34.1%, P < 0.001), longer TTP (median, 9.8 vs. 5.9 months, P < 0.001), and prolonged OS (median, 16.7 vs. 12.5 months, P < 0.001) than those in the Len+DEB-TACE group. The ORR and TTP of both intrahepatic tumor (ORR: 64.7% vs. 36.5%, P < 0.001; median TTP: 10.7 vs. 7.0 months, P < 0.001) and PVTT (ORR: 74.1% vs. 47.1%, P < 0.001; median TTP: 17.4 vs. 7.6 months, P < 0.001) were better in the Len+DEB-TACE+HAIC group than the Len+DEB-TACE group. The frequency of grade 3-4 TRAEs in the Len+DEB-TACE+HAIC group were comparable to those in the Len+DEB-TACE group (38.8% vs. 34.1%, P = 0.524). Conclusion: The addition of HAIC to Len+DEB-TACE significantly improved ORR, TTP, and OS over Len+DEB-TACE with an acceptable safety profile for large HCC with major PVTT.

BACKGROUND & AIMS: Cirrhotic portal hypertension (CPH) is the leading cause of mortality in patients with cirrhosis. Over 50% of patients with CPH treated with current clinical pharmacotherapy still present variceal bleeding or sometimes death owing to insufficient reduction in portal pressure. Elevated intrahepatic vascular resistance (IHVR) plays a fundamental role in increasing portal pressure. Because of its potent effect in reducing portal pressure and maintaining normal portal inflow to preserve liver function, lowering the IHVR is acknowledged as an optimal anti-CPH strategy but without clinical drugs. We aimed to investigate the protective effect of microbial-derived Urolithin A (UroA) in IHVR and CPH. METHODS: Carbon tetrachloride or bile duct ligation surgery was administered to mice to induce liver fi brosis and CPH. 16S rRNA gene sequencing was used for microbial analysis. Transcriptomics and metabolomics analyses were employed to study the host and cell responses. RESULTS: UroA was remarkably deficient in patients with CPH and was negatively correlated with disease severity. UroA deficiency fi ciency was also confirmed fi rmed in CPH mice and was associated with a reduced abundance of UroA-producing bacterial strain ( Lactobacillus murinus, , L. murinus). ). Glutaminolysis of hepatic stellate cells (HSCs) was identified fi ed as a previously unrecognized target of UroA. UroA inhibited the activity of glutaminase1 to suppress glutaminolysis, which counteracted fi brogenesis and contraction of HSCs and ameliorated CPH by relieving IHVR. Supplementation with UroA or L. murinus effectively ameliorated CPH in mice. CONCLUSIONS: We for the first time identify the deficiency of gut microbial metabolite UroA as an important cause of CPH. We demonstrate that UroA exerts an excellent anti-CPH effect by suppressing HSC glutaminolysis to lower the IHVR, which highlighted its great potential as a novel therapeutic agent for CPH.

BACKGROUND & AIMS:Our retrospective study has suggested encouraging outcomes of lenvatinib combined with PD-1 inhibitor and transarterial chemoembolization (TACE) on advanced hepatocellular carcinoma (HCC). This phase II trial was conducted to prospectively investigate the efficacy and safety of lenvatinib, sintilimab (a PD-1 inhibitor) plus TACE (Len-Sin-TACE) in patients with advanced stage HCC. METHODS:This was a single-arm phase II trial. Patients with BCLC stage C HCC were recruited. They received lenvatinib (bodyweight ≥60 kg, 12 mg; bodyweight <60 kg, 8 mg) orally once daily, sintilimab (200 mg) intravenously once every 3 weeks, and on demand TACE. The primary endpoint was progression-free survival (PFS) per mRECIST. RESULTS:Thirty patients were enrolled. The primary endpoint was met with a median PFS of 8.0 (95% confidence interval [CI]: 6.1-9.8) months per mRECIST, which was the same as that per RECIST 1.1. The objective response rate was 60.0% per mRECIST and 30.0% per RECIST 1.1. The disease control rate was 86.7% per mRECIST/RECIST 1.1. The median duration of response was 7.4 (95% CI: 6.6-8.2) months per mRECIST (n = 18) and 4.3 (95% CI: 4.0-4.6) months per RECIST 1.1 (n = 9). The median overall survival was 18.4 (95% CI: 14.5-22.3) months. Treatment-related adverse events (TRAEs) occurred in 28 patients (93.3%) and grade 3 TRAEs were observed in 12 patients (40.0%). There were no grade 4/5 TRAEs. CONCLUSIONS:Len-Sin-TACE showed promising antitumour activities with a manageable safety profile in patients with advanced stage HCC. The preliminary results need to be further evaluated with phase III randomized trials.

Microwave ablation (MWA) is a frequently adopted regional therapy for treating hepatocellular carcinoma (HCC) in clinic. However, incomplete microwave ablation (IMWA) is often inevitable due to the restraint of ablating large tumors or tumors in special locations, resulting in a high recurrence rate of HCC. Moreover, the most promising immune checkpoint blockade (ICB)-based immunotherapy is raising hindered by the toxicity and insufficient immune response. To overcome these barriers, we conjugate small nanovesicle (smDV)-derived from matured dendritic cells (mDCs) with anti-CTLA-4 antibody (smDV-aCTLA-4) using a metabolic tagging technology, which could trigger the infiltration of cytotoxic T cells (CTLs) and adopted tumor-infiltrating lymphocytes (TILs) in residual HCC after IMWA. In HCC microenvironment, the administration of smDV-aCTLA-4 could promote antigen presentation and immune checkpoint suppression to activate CTLs and improve the safety of anti-CTLA-4 antibody. Moreover, the anti-tumor efficacy of CTLs elicited by smDV-aCTLA-4 could also be further enhanced by anti-programmed death 1 (aPD-1) antibody. In addition, compared to the adoptive TILs therapy, the treatment using smDV-aCTLA-4-bonded TILs (smDV-aCTLA-4@TILs) could promote the proliferation and infiltration of cytotoxic TILs in residual HCC after IMWA. Our results clearly evidenced the potency of a new type of engineered DC nanovesicles in reducing HCC recurrence after IMWA.

BACKGROUND:It is now understood that HBV can induce innate and adaptive immune response disorders by affecting immunosuppressive macrophages, resulting in chronic HBV infection. However, the underlying mechanism is not fully understood. Dysregulated protein acetylation can reportedly influence the differentiation and functions of innate immune cells by coordinating metabolic signaling. This study aims to assess whether HBV suppresses macrophage-mediated innate immune responses by affecting protein acetylation and to elucidate the underlying mechanisms of HBV immune escape.METHODS:We investigated the effect of HBV on the acetylation levels of human THP-1 macrophages and identified potential targets of acetylation that play a role in glucose metabolism. Metabolic and immune phenotypes of macrophages were analyzed using metabolomic and flow cytometry techniques. Western blot, immunoprecipitation, and immunofluorescence were performed to measure the interactions between deacetylase and acetylated targets. Chronic HBV persistent infected mice were established to evaluate the role of activating the tricarboxylic acid (TCA) cycle in macrophages for HBV clearance.RESULTS:Citrate synthase/pyruvate dehydrogenase complex hyperacetylation in macrophages after HBV stimulation inhibited their enzymatic activities and was associated with impaired TCA cycle and M2-like polarization. HBV downregulated Sirtuin 3 (SIRT3) expression in macrophages by means of the toll-like receptor 2 (TLR2)-NF-κB- peroxisome proliferatoractivated receptor γ coactivator 1α (PGC-1α) axis, resulting in citrate synthase/pyruvate dehydrogenase complex hyperacetylation. In vivo administration of the TCA cycle agonist dichloroacetate inhibited macrophage M2-like polarization and effectively reduced the number of serum HBV DNA copies.CONCLUSIONS:HBV-induced citrate synthase/pyruvate dehydrogenase complex hyperacetylation negatively modulates the innate immune response by impairing the TCA cycle of macrophages. This mechanism represents a potential therapeutic target for controlling HBV infection.

Hepatocellular carcinoma (HCC) with lung metastasis is associated with poor prognosis and poor therapeutic outcomes. Studies have demonstrated that stiffened stroma can promote metastasis in various tumors. However, how the lung mechanical microenvironment favors circulating tumor cells remains unclear in metastatic HCC. Here, we found that the expression of cell migration-inducing hyaluronan-binding protein (CEMIP) was closely associated with lung metastasis and can promote pre-metastatic niche formation by increasing lung matrix stiffness. Furthermore, upregulated serum CEMIP was indicative of lung fibrotic changes severity in patients with HCC lung metastasis. By directly targeting CEMIP, pirfenidone can inhibit CEMIP/TGF-β1/Smad signaling pathway and reduce lung metastases stiffening, demonstrating promising antitumor activity. Pirfenidone in combination with sorafenib can more effectively suppress the incidence of lung metastasis compared with sorafenib alone. This study is the first attempt to modulate the mechanical microenvironment for HCC therapy and highlights CEMIP as a potential target for the prevention and treatment of HCC lung metastasis. CEMIP mediating an HCC-permissive microenvironment through controlling matrix stiffness. Meanwhile, Pirfenidone could reduce metastasis stiffness and increases the anti-angiogenic effect of Sorafenib by directly targeting CEMIP.

Purpose To investigate the efficacy and safety of tyrosine-kinase inhibitor (TKI) combined with iodine-125 seed brachytherapy (TKI-I) versus TKI alone for patients with hepatocellular carcinoma (HCC) refractory to transarterial chemoembolization (TACE). Methods Data of patients with TACE-refractory HCC who received TKI (sorafenib or lenvatinib) or TKI-I from September 2018 to December 2020 were retrospectively analyzed. A propensity score matching (PSM) was performed to diminish potential bias. The primary endpoints were overall survival (OS) and time to progression (TTP). Tumor responses and treatment-related adverse events (TRAEs) were also compared between the two groups. Results A total of 132 patients were included in this study. Under PSM, 48 paired patients were selected for comparison. The median OS was 23.2 (95% CI 20.9–25.1) months in the TKI-I group versus 13.9 (95% CI 11.1–16.7) months in the TKI group ( P < 0.001). The median TTP was 12.8 (95% CI 10.1–15.5) months in the TKI-I group versus 5.8 (95% CI 5.0-6.6) months in the TKI group ( P < 0.001). Patients in the TKI-I group had higher objective response rate (68.8% vs. 33.3%, P = 0.001) and disease control rate (89.6% vs. 66.7%, P = 0.007) than those in the TKI group. The incidence and severity of TRAEs in the TKI-I group were comparable to those in the TKI group (any grade, 89.7% vs. 92.2%, P = 0.620; ≥grade 3, 33.8% vs. 32.8%, P = 0.902). Conclusions TKI-I was safe and significantly improved survival over TKI alone in HCC patients with TACE refractoriness.