Liver cancer: Pathogenesis and treatment


Continuation of metformin use after a diagnosis of cirrhosis significantly improved survival of patients with type II diabetes (DM)

Xiaodan Zhang1, Teresa Mettler1, William S. Harmsen2, W. Ray Kim1, Terry Therneau2, Lewis R. Roberts1, Roongruedee Chaiteerokij1

1 Division of Gastroenterology ond Hepatology, College of Medicine, Mayo Clinic, Rochester, MN; 2Department of Biomedical Statistics and Informatics, College of Medicine, Mayo Clinic and Mayo Clinic Cancer Center, Rochester, MN

Background: It has been suggested that metformin use reduces the risk of hepatocellular carcinoma in cirrhotic patients with DM. However, metformin is often discontinued after the diagnosis of cirrhosis due to concerns about adverse effects in patients with liver impairment. We investigated whether continuation of metformin after cirrhosis diagnosis improves survival of patients with DM. Aims: To compare survival of diabetic patients who continued metformin versus those who discontinued metformin after cirrhosis diagnosis. Methods: Diabetic patients in whom cirrhosis was diagnosed between 2000 and 2010 who were on metformin at the time of cirrhosis diagnosis were enrolled and their medical records were abstracted. Survival of those who continued metformin versus those who discontinued metformin after cirrhosis diagnosis was compared using the log-rank test. The hazard ratio (HR) and 95% confidence interval (CI) were calculated using Cox Proportional Hazards analysis. Results: 〇f the 250 patients on metformin at the time of cirrhosis diagnosis, 172 continued metformin while 78 discontinued metformin. Age, gender and baseline liver function were comparable between the 2 groups. Reasons for discontinuation of metformin were: diagnosis of cirrhosis (n=o1); uncontrolled plasma glucose (n=5); elevated serum creatinine (n=3); diarrhea, well controlled plasma glucose level, switch to insulin therapy, unstated reasons during hospitalization (n=2 for each), and heart disease (n=1). Patients who continued metformin had a significantly longer median survival than those who discontinued metformin (11. 8 vs. 5. 6 years, p<0.001) with 5 year-survival rates of 77. 5% vs. 55. 2%, respectively. By univariate analysis, continuation of metformin and high serum albumin level were significantly associated with better survival, whereas older age, increased Model for EndStage Liver Disease (MELD) score and increased serum AFP level were significantly associated with worse survival. Etiology of cirrhosis was also associated with survival. After adjusting for age, gender, albumin, MELD score and AFP level and etiology of cirrhosis, continuation of metformin was an independent predictor of better survival (HR 0.43, 95%CI 0.240.78, P<0.001). Conclusion: Continuation of metformin after cirrhosis diagnosis significantly reduced the risk of death by 57% and was significantly associated with better survival of patients with DM. Therefore, metformin should be considered in cirrhotic patients with DM if there is no specific contraindication. Validation of these results in a larger cohort is needed.


W. Ray Kim - Advisory Committees or Review Panels: Salix; Consulting: Bristol Myers Squibb, Gilead

Lewis R. Roberts - Advisory Committees or Review Panels: Inova; Grant/Research Support: Bristol Myers Squibb, Bayer, Nordion; Speaking and Teaching: Nordion

The following people have nothing to disclose: Xiaodan Zhang, Teresa Mettler, William S. Harmsen, Terry Therneau, Roongruedee Chaiteerakij


Metformin use improves survival of cholangiocarcinoma (CC) patients with type II diabetes (DM)

Roongruedee Chaiteerakij, Esha Baichoo, Lewis R. Roberts

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN

Background: CC is a lethal cancer with suboptimal treatment outcomes. New therapeutic agents that can prolong patient survival are needed. Our recently published data showed that metformin reduced the risk for development of intrahepatic CC (ICC). Whether metformin use improves survival of CC patients is unknown. Aims: To determine whether metformin use while receiving CC treatment improves survival outcomes of CC patients. Methods: Diabetic patients in whom CC was diagnosed between 2000 and 2011 were enrolled. Clinical information was abstracted. Survival of CC patients with DM who took metformin versus that of patients who did not take metformin after CC diagnosis was compared using the Log Rank test. The hazard ratio (HR) and 95% confidence interval (CI) were calculated using Cox Proportional Hazards analysis. Results: There were 198 CC patients with DM (106 ICC, 92 extrahepatic CC). The median survival of the entire cohort was 9.4 months. Females had a longer median survival than males (9. 9 vs. 9. 0 months, p=0.03). Age, ethnicity, primary sclerosing cholangitis, viral hepatitis B and C infection, cirrhosis, obesity and smoking were not associated with survival outcome. Of the 1 98 patients, 63 (32%) had a history of metformin use prior to CC diagnosis and 53 (27%) were on metformin at the time of CC diagnosis. Of the 53 patients on metformin at the time of CC diagnosis, 21 remained on metformin while receiving CC treatment. Metformin was discontinued in 16 patients after CC diagnosis due to elevated liver enzymes (n=7), for unstated reasons during hospitalization (n=3) or while an outpatient (n=3), renal failure (n=2), and post tumor resection (n=1). No information on metformin use after CC diagnosis was available on the remaining 16 patients. Two patients were started on metformin after CC diagnosis for the treatment of newly diagnosed DM. The 23 CC patients with DM who took metformin while receiving CC treatment had a significantly better median survival than the 159 patients who did not take metformin while receiving CC treatment (21. 5 vs. 9. 0 months, p=0.03) with a HR (95%CI) of 0.58 (0.34-0.92) (p=0.02). Compared to the 16 patients for whom metformin was held after CC diagnosis, the 23 patients who took metformin had a better median survival (21. 5 vs. 12. 3 months, p=0.04) with a HR (95%CI) of 0.47 (0.22-1. 01) (p=0.05). A history of metformin use prior to CC diagnosis was not associated with improved survival. Conclusion: Metformin use while receiving CC treatment reduced the risk of death by 42% and significantly improved survival of CC patients with DM. Further validation of these findings in a larger study is needed.



The Changing Characteristics of Hepatocellular Cancer Over Time

Linda L. Wong1,2, Makoto Ogihara3, Naoky Tsai4, Brenda Y. Hernandez2, Herbert Yu2

1 Surgery, Univ of Hawaii School of Medicine, Honolulu, HI; 2Cancer Center, University of Hawaii, Honolulu, HI; 3Transplant Center, Queens Medical Center, Honolulu, HI; 4Liver Center, Queens Medical Center, Honolulu, HI

Background: The incidence of hepatocellular cancer (HCC) is increasing in the US and varying incidence of viral hepatitis and fatty liver disease over time is felt to be responsible for this overall increase. We sought to better characterize the differences over a 20 year period in Hawaii, the state with the highest incidence of HCC in the US. Methods: This is a retrospective study of 821 patients who were referred for HCC. Cases were separated into four 5-year eras from 1993 to 2012. Data collected included: demographics, viral risk factors, diabetes (DM), body mass index, alpha fetoprotein (AFP). Patients were presumed to have nonalcoholic steatohepatitis (NASH) if no other etiology of liver disease was identified and alcohol was not a factor. This included patients from the earlier eras who were deemed “cryptogenic”. Differences between factors were analyzed with chi-square analysis. Results: Increasing numbers of HCC cases were referred to the center over succeeding eras. There were no differences in mean age or gender distribution over time. With succeeding eras, there were fewer Asians and more Whites. There were also fewer immigrants and less hepatitis B related HCC. Hepatitis し related HCC appears to have peaked in the third era. Metabolic factors of DM, hyperlipidemia and mean BMI have increased over time. Although more patients had NASH in the recent eras, the percentage was similar over time. Increasing proportion of patients had normal AFP with succeeding eras. In the entire cohort, 49. 6% of NASH patients and 33. 2% of non-NASH patients had a normal AFP. (p=0.007) Conclusions: The characteristics of HCC are changing over time and it may be more difficult to diagnose these patients as viral hepatitis is playing a progressively smaller role. Metabolic factors seem to be an increasing risk factor and AFP seems to be a less important biomarker especially in NASH related HCC. Clearly better biomarkers and diagnostic tools will be necessary to identify HCC in the future.

Era 1 (1993-1997)Era 2 (1998-2004)Era 3 (2003-2007)Era 4 (2008-2012)
Mean Age (years)62. 460.061. 352. 6NS
%males67. 172. 379. 975. 5NS
%USBom57. 355. 259. 762. 4p=0.001
%HBV positive44. 438. 428. 628p<0.0001
%HCV positive27. 032. 142. 739. 4p<0.0001
% Diabetes33. 730.824. 834. 7p<0.0001
%Hyperlipidemia6. 79. 918. 925. 7p<0.0001
Mean BMI24. 825. 926. 627. 0p=0.045
NASH (%)15/85 (17. 6%)27/159 (17. 0%)26/234 (11. 1%)57/343 (16. 6%)NS
%Normal AFP (20 ng/dL)24. 734. 632. 541. 1p=0.005

Disclosures:Linda L. Wong - Speaking and Teaching: Bayer, Bayer

The following people have nothing to disclose: Makoto Ogihara, Naoky Tsai, Brenda Y. Hernandez, Herbert Yu


A novel immunotherapeutic treatment for experimental hepatocellular carcinoma (HCC) using the host-defense derived peptide LTX-315

Fal Dog Line1, 3, Jihua Shi1, 3, Janne M. Nestvold2, Meng Yu Wong2, Gunnar Kvalheim2, øystein Rekdol4, 5

1 Dept. Transplantation, Oslo University Hospital, Oslo, Norway; 2Department of Cancer Medicine, Oslo University Hospital, Oslo, Norway; 3lnstitute for Surgical Research, Oslo University Hospital, Oslo, Norwoy; 4Dept of Medical Biology, University of Tromsø, Tromsø, Norway; 5Lytix Biophama, Oslo, Norway

Host defense peptides can kill pathogens directly and have immune-modulating properties. Shorter chemically modified peptides derived from host defense peptides, have shown potent anti-neoplastic properties on different types of cancers (1). The aim of the present study was to test whether the 9-mer peptide, LTX-315, could be utilized as a novel immunotherapeutic agent for hepatocellular carcinoma in a rodent model Two main treatment regimens were utilized: In group A, liver tumors were induced in Male Fisher rats by direct intrahepatic (i. h.) injection of 1 x 106 JM1 cells. After 5 days the animals were treated intratumorally with LTX-315 for three consecutive days. In group B, a vaccination protocol consisting of s. c. injection of LTX-315 and cell lysate of JM1 cells once weekly for 4 consecutive weeks was used. After another 4 weeks animals were inoculated with 1 x 106 JM1 cells s. c.. Control animals in both groups received saline instead of LTX-315. Tumors in group A were successfully ablated in 6 out of 7 treated animals, whereas all control animals developed a lethal hepatic tumor in the course of 3-4 weeks. Re-challenge with 1 x 106 JM1 cells s. c. one month after treatment did not lead to tumor development, whereas control animals developed large s. c. tumors in the course of 2-3 weeks. In group B, the 5 animals developed a slow growing tumor with maximal size after 29 days, that subsequently regressed completely in the course of the next 3040 days. The animals were protected against i. h. and s. c. rechallenge with JM1 cells after another 50 and 100 days respectively, whereas controls had to be sacrificed 3 weeks after inoculation due to large tumor burden To investigate whether the treatments (A and B) invoked a transferrable antitumor response, 6 new animals were subjected to total body irradiation and thereafter immunologically reconstituted by infusion of 3 x 106 splenocyfes from the cured animals in either group A or B. This led to complete protection against both intrahepatic and subcutaneous tumor growth, whereas irradiated control animals reconstituted with splenocytes from wild type animals developed large s. c. or intrahepatic tumors. Conclusion: LTX-315 can induce specific, transferrable long lasting immune response against experimental HCC tumors, both when used intra-lesionally and in a preemptive vaccine together with HCC cell lysate. LTX-315 is being developed for the treatment of solid tumors and is currently in phase 1. References. 1. Therapeutic vaccination against a murine lymphoma by intratumoral injection of a cationic anticancer peptide. Berge et al. Cancer Immunol Immunother (2010) 59: 1285-1294.Disclosures:

0ystein Rekdal - Management Position: Lytix Biopharma; Patent Held/Filed: Lytix Biopharma; Stock Shareholder: Lytix Biopharma

The following people have nothing to disclose: Pal Dag Line, Jihua Shi, Janne M. Nestvold, Meng Yu Wang, Gunnar Kvalheim


Phase I Trial of Alpha-Fetoprotein-Derived Peptides in the Treatment of Hepatocellular Carcinoma

Eishiro Mizukoshi, Tatsuyo Yamashita, Kuniaki Arai, Hajime Sunagozaka, Kazumi Fushmi' Hidetoshi Nakagawa, Kazutoshi Yomada, Kiichiro Kaji, Masaaki Kitahara, Shuichi Kaneko

Kanazawa Univ, Kanazawa, Japan

Background: Alpha-fetoprotein (AFP) is a normal fetal serum protein synthesized in the liver. This protein is produced during fetal development, and the production stops soon after birth, but it is produced again in hepatocellular carcinoma (HCC). The presence of specific cytotoxic T cell (CTL) against this selfantigen in the T-cell repertoire, not deleted centrally or peripherally, has been demonstrated, suggesting that this is a promising target antigen for HCC immunotherapy. Recently, we identified AFP-derived, HLA-A*2402-restricted CTL epitopes and AFP was an attractive target for T-cell-based immunotherapy for HCC (Int J Cancer 118: 1194-1204, 2006). In comparative analysis of various tumor associated antigen-derived peptides, AFP357 and AFP403 peptides are frequently recognized by PBMCs of HCC patients and could induce AFP-specific CTLs (Hepatology 53: 1206-1216, 2011). In this study, we present the results of a phase I trial of 2 kinds of AFP-derived peptides (AFP357 and AFP403) in advanced HCC patients. Methods: Fifteen HLA-A24-positive patients with advanced HCC presenting at Kanazawa University Hospital between March 2010 and March 2012 were analyzed (trial registration: しMIN000003514). Each 3mg of peptide were administered emulsified with incomplete Freund's adjuvant by subcutaneously immunization 3 times biweekly. Adverse events/toxicities were categorized and graded by the Common Terminology Criteria of Adverse Events. Criteria for discontinuation included unacceptable toxicities and disease progression defined as progressive disease by Response Evaluation Criteria in Solid Tumors criteria. Immunologic response was monitored by interferon-gamma enzyme-linked immunospot assay. Results: No serious adverse drug reactions were observed and the treatment was well tolerated. The overall induction of immune responses in the patients that completed at least 3 times injection was 5/15 (33%). Regarding antitumor effect, 1 and 8 patients showed complete response and stable disease, respectively. In the relationship between immunological and anti-tumor responses, 4 of 5 (80%) patients with immune responses after vaccination showed CR or SD. Specially, the patient with the most increased AFP-specific CTLs after vaccination showed CR. In addition, disappearance of metastatic tumor in abdominal wall and stabilization of multiple lung metastatic lesions for more than 24 months were noted in 1 of the 8 patients with SD. Conclusion: The safety and antitumor effect of AFP-derived peptides have the possibility to provide clinical benefits in HCC patients. The vaccination study could be recommended in further stages of clinical trials.


Shuichi Kaneko - Grant/Research Support: MDS, Co., Inc, Chugai Pharma., Co., Inc, Toray Co., Inc, Daiichi Sankyo., Co., Inc, Dainippon Sumitomo, Co., Inc, Ajinomoto Co., Inc, MDS, Co., Inc, Chugai Pharma., Co., Inc, Toray Co., Inc, Daiichi Sankyo., Co., Inc, Dainippon Sumitomo, Co., Inc, Ajinomoto Co., Inc, Bayer Japan

The following people have nothing to disclose: Eishiro Mizukoshi, Tatsuya Yamashita, Kuniaki Arai, Hajime Sunagozaka, Kazumi Fushimi, Hidetoshi Nakagawa, Kazutoshi Yamada, Kiichiro Kaji, Masaaki Kitahara


Impact of PNPLA3 (rs738409 C>G) variant in hepatocellular carcinoma: evidence from a meta-analysis

Eric Trêpo1,2, Pietre Nahon3, 4, Gianluca Bontempi5, Luca Valenti6, Edmondo Falleti7, Hans Dieter Nischalke8, Samia Hamza9, Stefono Ginonni Corradini10, Maria Antonella Burzo11, Erwan Guyof12, 13, Benedetto Donati6, Ulrich Spengler8, Patrick Hillon9, 14, Pierluigi Toniuffo7, Jeon Henrion15, Philippe Mathurin16, 17, Christophe Moreno1,2, Stefano Romeo11, 18, Pierre Deltenre1, 16

1Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; 2Laboratory of Experimental Gastroenterology, Universite Libre de Bruxelles, Brussels, Belgium; 3INSERM U773, Centre de Recherche Bichat Beaujon CRB3, University Paris 7, Paris, France; 4Liver Unit, Jean Verdier Hospital, APHP, University of paris 13, Bondy, France; 5Machine Learning Group, Department of Computer Science, Université Libre de Bruxelles, Brussels, Belgium; 6Department of Pathophysiology and Transplantation, Universita degli Studi di Milano, and Internal Medicine, Fondazione IRCCS Ca' Granda Ospedole Policlinico, Milan, Italy; 7Department of Medicol Sciences Experimental and Clinical, Medical Liver Transplantation Unit, University of Udine, Udine, Italy; 8Department of Internal Medicine I, University of Bonn, Bonn, Germany; 9Service d'Hépato-gastroentérologie, CHU du Bocoge, Dijon, France; 10Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy; 11Department of Molecular ond Clinical Medicine and Center for Cardiovascular and Metabolic Research, Sahlgrenska Academy' university of Gothenburg, Gothenburg, Sweden; 12UFR SMBH/INSERM U698, University paris 13, Bobigny France; 13Biochemistry Unit, Jean Verdier Hospital, APHP, University paris 13, Bondy, France; 14INSERM U866, University of Burgundy, Dijon, France; 15Service d'Hépato-Gastroentérologie, Hôpital de Jolimont, Haine-Saint-Paul, Belgium; 16Service d'Hépato-Gastroentérologie' Hopital Huriez, CHRU Lille, Lille, France; 17INSERM U995, Universite Lille Nord de France, F-59000, Lille, France; 18Clinical Nutrition Unit, Department of Medical and Surgical Sciences, University Magna Graecia, Catanzaro, Italy

Background: The incidence of hepatocellular carcinoma (HCC) is increasing in Western countries. Although several clinical factors have been identified, many individuals never develop HCC, suggesting a genetic susceptibility. However, only a few single nucleotide polymorphisms (SNPs) have been reproducibly shown to be linked to HCC onset to date. A variant (rs738409 C>G) in the PNPLA3 gene, associated with liver damage in chronic liver diseases has been recently linked to HCC in chronic hepatitis し(CHC) and alcoholic liver disease (ALD). Nonetheless, a significant association with HCC related to CHC has not been consistently observed and the strength of rs738409 impact on HCC remains unclear. Patients and Methods: We performed a meta-analysis to evaluate the association between rs738409 and HCC. For inclusion, a study had to: a) include patients with cirrhosis; b) assess the presence of rs738409 in individuals with and without HCC. This metaanalysis involved all researchers that have been studying the link between this SNP and HCC in cirrhotic patients from European descent prior to and through the first quarter of 2013. Each study investigator provided a database including patient genotype counts and clinical data in ALD and CHC patients. Results: This meta-analysis included 7 studies involving 2, 503 cirrhotic patients, 877 patients with HCC (cases) and 1, 626 without (controls). The additive model was the genetic model of inheritance that most adequately addressed the association between rs738409 and HCC. In the overall analysis, rs738409 was strongly associated with HCC (OR per G allele, = 1. 77 [1. 42-2. 19], P= 2. 78 x 10-7). Among the 1, 374 ALD patients (442 cases, 932 controls), rs738409 had a significant impact on HCC onset (OR=2. 20 [1. 80-2. 67], P= 4. 71 x 1015) without any evidence of heterogeneity (p=0.50, I2=0%). Among the 957 CHC patients (372 cases, 585 controls), rs738409 was also significantly associated with HCC (〇R=1. 55 [1. 02-2. 35], P= 4. 04 x 10-2) but with a significant heterogeneity (p=2. 44 x 10-2, I2=64. 0%). After the exclusion of one study that showed a significant deviation from HardyWeinberg equilibrium rs738409 remained linked to HCC related to CHC (しR=1. 77, 95% CI=1. 20-2. 61, p=3. 82 x 103) with less heterogeneity (p=0.16, 12=43. 0%). Conclusion: The rs738409 SNP exerts a marked influence on hepatocarcinogenesis in cirrhotic patients of European descent. The impact of rs738409 was particularly evident in patients with ALD-related cirrhosis but was milder in patients with CHCrelated cirrhosis. These findings provide a strong argument for performing mechanistic studies to better understand the role of PNPLA3 in HCC development.


Patrick Hillon - Grant/Research Support: Roche; Speaking and Teaching: Janssen Cilag, MSD, Gilead, Bayer

Philippe Mathurin - Board Membership: Schering-Plough, Janssen-Cilag, BMS, Gilead; Consulting: Roche, Bayer, Boehringer

Pierre Deltenre - Consulting: Schering-Plough, BMS, Janssen-Cilag; Grant/Research Support: Schering-Plough; Speaking and Teaching: Schering-

The following people have nothing to disclose: Eric Trepo, Pierre Nahon, Gianluca Bontempi, Luca Valenti, Edmondo Falleti, Hans Dieter Nischalke, Samia Hamza, Stefano Ginanni Corradini, Maria Antonella Burza, Erwan Guyot, Benedetta Donati, Ulrich Spengler, Pierluigi Toniutto, Jean Henrion, Christophe Moreno, Stefano Romeo