BACKGROUND AND AIMS: Severe (Pi*ZZ) and heterozygous (Pi*MZ) alpha-1 antitrypsin deficiency (AATD) confer increased liver- and lung-related mortality, but the phenotype is highly variable. We aimed to evaluate the impact...BACKGROUND AND AIMS: Severe (Pi*ZZ) and heterozygous (Pi*MZ) alpha-1 antitrypsin deficiency (AATD) confer increased liver- and lung-related mortality, but the phenotype is highly variable. We aimed to evaluate the impact of obesity and diabetes mellitus on individuals with/without AATD. APPROACH AND RESULTS: Cohort 1 prospectively recruited 1678 Pi*ZZ adults from an international initiative with a systematic liver assessment. In all, 983 participants had a longitudinal follow-up. The data were compared with 16,768 Pi*MZ and 415,208 non-AATD individuals from the United Kingdom Biobank (cohort 2). Findings were ascertained by multivariable adjustment and propensity score matching. At baseline, diabetes was present in 52 (3%), overweight (BMI 25.0-29.9 kg/m 2 ) in 540 (52%), and obesity (BMI≥30 kg/m 2 ) in 266 (32%) Pi*ZZ adults. Pi*ZZ individuals with diabetes showed higher transaminases, and surrogates of advanced liver fibrosis (APRI≥1.0, LSM≥15 kPa) were 4-6 times more common [adjusted odds ratio (aOR) 5.7/4.3, p <0.01]. Elevated transaminases were rare among lean Pi*ZZ subjects, but more common in overweight (aOR 1.5/2.0) and obese Pi*ZZ participants (aOR 2.1/2.9). APRI≥1.0 was more than 4 times elevated in obese versus lean Pi*ZZ individuals (aOR 4.1, p <0.001). During a median follow-up of 4.2 years, 54 Pi*ZZ participants experienced a hepatic and 64 a pulmonary endpoint. While Pi*ZZ participants with diabetes/obesity had an increased risk of hepatic endpoints (aHR 6.03/3.38, p <0.001) compared with non-diabetic/lean Pi*ZZ subjects, overweight was associated with a decreased risk of pulmonary endpoints (aHR 0.45, p =0.004). CONCLUSIONS: Our data demonstrate the interaction between genetic and metabolic risk factors in AATD and provide evidence for patient management.
Yan N, Xia Y, Zhang Y
… +14 more, Sawaswong V, Xu X, Saito Y, Nanduri R, Dai M, Aibara D, Krausz KW, Takahashi S, Peiffer BJ, Parra MA, Sun Z, Hao H, Yan T, Gonzalez FJ
BACKGROUND AND AIMS: Alcohol-associated liver disease (ALD) represents a global health burden with limited therapeutic strategies. While the hepatocyte transcription factor CCAAT/enhancer-binding protein α (CEBPA) regula...BACKGROUND AND AIMS: Alcohol-associated liver disease (ALD) represents a global health burden with limited therapeutic strategies. While the hepatocyte transcription factor CCAAT/enhancer-binding protein α (CEBPA) regulates hepatic gene expression and liver fibrosis, its role in ALD pathogenesis remains undefined. Here, hepatocyte CEBPA was examined for its modulation of alcohol-associated hepatic steatosis and ALD. APPROACH AND RESULTS: Hepatocyte-specific CEBPA knockout mice, adeno-associated virus serotype transduction studies, and reporter gene assays were carried out using acute and chronic mouse ALD models. Western blotting was performed on liver tissues from human patients with ALD. Hepatic CEBPA expression decreased during ALD progression in human patient cohorts. Hepatocyte-specific Cebpa -knockout mice exhibited exacerbated alcohol-associated steatosis in both the acute and chronic ALD models. Inducible ablation of CEBPA in hepatocytes during late-stage ALD, accelerated disease progression, demonstrating the persistent protective function of CEBPA. Global transcriptomics identified Orm1 encoding orosomucoid 1 (ORM1) as the top CEBPA-upregulated gene in hepatocytes, while reporter assays and chromatin immunoprecipitation (ChIP) revealed that CEBPA directly activated Orm1 transcription by binding CEBPA response elements upstream of the Orm1 promoter. Loss of hepatocyte ORM1 potentiated the severity of ALD in mice. Conversely, restoring CEBPA or ORM1 via i.v. adeno-associated virus serotype 8 delivery or i.p. administeration of recombinant ORM1 protein rescued hepatic lipid accumulation and reduced disease progression. Consistently, serum ORM1, a hepatocyte-secreted hepatokine, inversely correlated with ALD severity in patients. CONCLUSIONS: These findings identify the hepatocyte CEBPA-ORM1 axis as a critical suppressor of ALD, offering therapeutic targets and nominating serum ORM1 as a potential biomarker for staging ALD severity.
BACKGROUND AND AIMS: Aminoacyl-tRNA synthetases (ARSs) exert canonical and emerging noncanonical roles in cancer. Given the frequent alterations in aspartate metabolism in HCC, we investigated the clinical and functional...BACKGROUND AND AIMS: Aminoacyl-tRNA synthetases (ARSs) exert canonical and emerging noncanonical roles in cancer. Given the frequent alterations in aspartate metabolism in HCC, we investigated the clinical and functional significance of aspartyl-tRNA synthetase (DARS1) in HCC. APPROACH AND RESULTS: DARS1 expression was evaluated in tumor and matched nontumoral tissues, in silico cohorts, and plasma samples. Functional assays were performed in liver cancer cell lines after genetic and pharmacological modulation of DARS1. In vivo validation was conducted using xenograft and orthotopic tumor models. Protein interactors of DARS1 were characterized by quantitative proteomics and confirmed by biochemical approaches. DARS1 abundance was increased in HCC, especially in highly aggressive tumors, and in plasma from patients with HCC. DARS1 overexpression increased aggressiveness in vitro and xenograft and orthotopic tumor formation in vivo, while genetic and pharmacological blockade of DARS1 impaired stemness in vitro without affecting normal-like cells. Proteomic profiling revealed a significant enrichment of high-aspartate proteins in DARS1-overexpressing cells, demonstrating a reshaping of the HCC proteome. Beyond its canonical role, DARS1 was found in the nucleus interacting with members of the SAGA transcriptional coactivator complex, including SUPT7L. This interaction affected MYC regulation, as DARS1 depletion reduced MYC protein levels, increased its phosphorylation, and enhanced drug-induced senescence, linking DARS1-SAGA activity to MYC-driven oncogenic pathways. CONCLUSIONS: DARS1 is frequently overexpressed in HCC and detectable in plasma, supporting its potential as a liquid biopsy biomarker. Functionally, DARS1 represents a novel vulnerability of HCC, acting through both proteome reshaping and noncanonical nuclear interactions with the SAGA complex that modulate MYC activity.
BACKGROUND AND AIMS: The hepatitis C virus (HCV) is a major cause of liver cirrhosis and cancer in humans, and an effective vaccine is urgently needed. Here, we evaluated the immunogenicity of a DNA prime and modified va...BACKGROUND AND AIMS: The hepatitis C virus (HCV) is a major cause of liver cirrhosis and cancer in humans, and an effective vaccine is urgently needed. Here, we evaluated the immunogenicity of a DNA prime and modified vaccinia Ankara (MVA) boost vaccine expressing H77 genotype 1a HCV immunogens to induce both T- and B-cell responses. APPROACH AND RESULTS: The non-structural (NS) immunogens expressed NS3, NS4, and NS5. The structural plus p7 immunogen (S-p7) expressed Core, E1, E2, and p7. We tested the immunogenicity of these vaccines in mice and rhesus macaques (RMs) with 2 or 3 doses of DNA followed by 1 or 2 doses of MVA. The NS immunogens induced CD4 and CD8 T-cell responses against multiple NS proteins, with a dominant CD4 T-cell response to NS3 and NS5, and a dominant CD8 T-cell response to NS3. The S-p7 immunogen induced E2-binding IgG titer with neutralizing activity against autologous and heterologous HCV pseudovirus particles. In addition, the S-p7 immunogen induced a CD4 and CD8 T-cell response directed against E1 (0.08% and 0.09%, respectively) and E2 (0.13% and 0.18%, respectively) in RMs. Co-delivery of S-p7 and NS vaccines elicited a T-cell response against the majority of HCV proteins, which was comparable to the T-cell response observed in humans with HCV resolution. CONCLUSIONS: These findings show that the DNA/MVA prime/boost vaccination induces a strong and broad CD4 and CD8 T-cell response to multiple HCV proteins and a neutralizing antibody response. These results aid in the development of vaccines for HCV.
BACKGROUND AND AIMS: While gemcitabine/cisplatin (GC) combined with anti-PD-L1 is a first-line regimen for advanced intrahepatic cholangiocarcinoma (ICC), efficacy remains limited and toxicity significant, highlighting t...BACKGROUND AND AIMS: While gemcitabine/cisplatin (GC) combined with anti-PD-L1 is a first-line regimen for advanced intrahepatic cholangiocarcinoma (ICC), efficacy remains limited and toxicity significant, highlighting the need to optimize the therapeutic strategy. We sought to investigate whether low-dose GC (LDGC) could unleash anti-PD-L1-mediated antitumor immunity along with reduced toxicity. APPROACH AND RESULTS: Multiple preclinical ICC mouse models were used to assess the antitumor efficacy and toxicity of LDGC combined with anti-PD-L1. Mechanisms were investigated via single-cell RNA sequencing, flow cytometry, and in vivo/vitro functional assays. Clinical correlation was evaluated in patient-derived tumor fragments and a pilot clinical trial in ICC patients. LDGC combined with anti-PD-L1 treatment efficiently improved tumor immune microenvironment (TIME) through reducing immunosuppressive SPP1 + tumor-associated macrophages (TAMs) while promoting CD8 + T-cell infiltration and cytotoxicity. LDGC reprograms the interplay between STAT1 and STAT3 transcriptional pathways in TAMs, thereby reducing SPP1 expression and weakening the inhibitory effect of the SPP1-VLA-4 signaling axis on CD8 + T cells, ultimately enhancing T-cell cytotoxicity and sensitizing antitumor response to anti-PD-L1. Furthermore, the ICC patients exhibited superior response and tolerance to LDGC combined with immunotherapy. CONCLUSIONS: This study highlights that LDGC remodels the immunosuppressive microenvironment and potentiates anti-PD-L1 therapy, providing a rational regimen for ICC.
Nurcis J, Foglia B, Rosso C
… +26 more, Provera A, Vecchio C, Maggiora M, Gambella A, Chianese U, Bocca C, Caviglia GP, Benedetti R, Novo E, Bossi F, Doto F, Kowalik MA, Caddeo A, Carucci P, Gaia S, Romagnoli R, Menconi A, Tusa I, Rovida E, Perra A, Bugianesi E, Altucci L, Albano E, Parola M, Sutti S, Cannito S
BACKGROUND AND AIMS: Oncostatin M (OSM) has been shown to contribute to metabolic dysfunction-associated steatohepatitis (MASH) progression to hepatocellular carcinoma (HCC). Here, we investigated its role in shaping an...BACKGROUND AND AIMS: Oncostatin M (OSM) has been shown to contribute to metabolic dysfunction-associated steatohepatitis (MASH) progression to hepatocellular carcinoma (HCC). Here, we investigated its role in shaping an immunosuppressive tumor microenvironment (TIME) in MASH-HCCs. APPROACH AND RESULTS: OSM role was investigated through combined analyses of MASLD/MASH patients with or without HCC, MASH-related HCCs originating in wild-type and hepatocyte-specific OSM receptor-β (hOSMRβ -/- ) deficient mice, and in vitro experiments performed on liver cancer and immune cell lines. Analysis of OSM-expressing HCC patients with mixed etiology (TCGA-database) revealed a positive correlation between OSM transcripts and those of several TIME markers. A similar pattern was also observed in murine MASH-HCC tumors. hOSMRβ -/- mice had significantly reduced tumor volume and weight without altering macrophage infiltration and OSM production. However, TIME markers transcripts were lower in HCCs from hOSMRβ -/- mice. These effects are associated with a lowering in tumor STAT3 phosphorylation and COX-2 activity. Single-cell RNA-seq analysis of human HCCs identified malignant hepatocytes as the source of CCL15, a cytokine associated with immunosuppression in HCCs. Circulating CCL15 was markedly elevated in both human and rodent MASH-HCCs and significantly reduced by hOSMRβ deletion. Blocking autocrine OSM signaling in HepG2 or Huh7 cells overexpressing OSM reduced STAT3 phosphorylation, CCL15 production, and prevented TIME markers expression by co-cultured macrophage-derived THP-1 cells. CONCLUSIONS: Our findings provide compelling evidence for an autocrine role of the OSM/OSMRβ axis in promoting CCL15 production by tumor cells, which, in turn, stimulates an immunosuppressive TIME in MASH-HCCs, suggesting OSM as a potential therapeutic target for HCC treatment.
Gawrieh S, Lake JE, Debroy P
… +12 more, Sjoquist JA, Robison M, Tann M, Akisik F, Bhamidipalli SS, Saha CK, Zachary K, Robbins GK, Gupta SK, Chung RT, Chalasani N, Corey KE
Zhou SQ, Wang LN, Wu LF
… +20 more, Sun LY, Yang YC, Yang ZY, Wang ZY, He T, Li F, Chen LL, Li H, Zhu XD, Shen YH, Huang C, Ji Y, Gao Q, Zhou J, Fan J, Chen YJ, Song TQ, Xu B, Sun HC, China Liver Cancer Study Group Young Investigators (CLEAP)
BACKGROUND AND AIMS: Pathological complete response (pCR) following conversion therapy for initially unresectable hepatocellular carcinoma (uHCC) remains challenging to predict preoperatively. This study developed and va...BACKGROUND AND AIMS: Pathological complete response (pCR) following conversion therapy for initially unresectable hepatocellular carcinoma (uHCC) remains challenging to predict preoperatively. This study developed and validated a model integrating clinicopathological and radiomic features of the tumor to predict pCR. METHODS: In this multicenter retrospective study, temporal radiomics features were extracted from baseline, post-treatment, and delta (change) MRIs. Serum AFP response was calculated as log₁₀(preoperative AFP)/log₁₀(baseline AFP). Univariate analysis, collinearity assessment, LASSO, and random forest were employed to perform feature selection. Fourteen machine learning models were benchmarked, with performance evaluated by using comprehensive metrics AUC, NPV, PPV, sensitivity, specificity, calibration, and decision curve analysis. RESULTS: The model was developed and validated in a training (n=78), an internal test (n=32), and an independent validation cohort (n=44). The delta radiomic model significantly outperformed both baseline (test AUC: 0.835 vs. 0.483, p <0.05; validation AUC: 0.783 vs. 0.434, p <0.05) and preoperative models (test AUC: 0.685, p <0.05; validation AUC: 0.506, p <0.05), demonstrating superior predictive performance and generalization capability in predicting lesion-level pCR. Notably, when predicting patient-level pCR, the radiomic model also showed robust discrimination, with AUCs of 0.819 in the test set and 0.781 in the validation set. The combined radiomics-AFP model achieved even higher AUCs of 0.920 (test) and 0.857 (validation) in predicting lesion-level pCR. CONCLUSIONS: Dynamic radiomic changes effectively predict pCR in uHCC after conversion therapy. Combining delta radiomics with AFP response significantly improves predictive performance, offering a non-invasive method for assessing pCR and potentially guiding personalized treatment decisions.
Wassmer CH, Gelli M, Wong TCL
… +13 more, Li Z, Zorigtbaatar A, Marino R, Aceituno Sierra L, Adam R, Chan ACY, Heimbach J, Line PD, Mazzaferro V, Sapisochin G, Tabrizian P, Vogel A, Toso C
BACKGROUND AND AIMS: Liver transplantation has evolved from a treatment restricted to patients with end-stage liver disease to a therapeutic option for selected patients with primary and metastatic liver malignancies. Th...BACKGROUND AND AIMS: Liver transplantation has evolved from a treatment restricted to patients with end-stage liver disease to a therapeutic option for selected patients with primary and metastatic liver malignancies. This review explores the rapidly expanding field of transplant oncology, highlighting its role in hepatocellular carcinoma, colorectal liver metastasis, neuroendocrine liver metastasis, and intrahepatic and perihilar cholangiocarcinoma. Emphasis is placed on strategies to broaden eligibility, optimize donor organ use, and improve oncologic outcomes. APPROACH AND RESULTS: We synthesized current evidence from clinical series, registries, and experimental protocols to evaluate patient selection criteria, outcomes, and peri-transplant management. Key topics include downstaging approaches to meet transplant criteria, such as locoregional therapies and systemic regimens, and their prognostic implications. Advances in donor utilization have been analyzed for their capacity to expand the graft pool. In addition, the review addresses the integration of oncologic principles into immunosuppression regimens, balancing graft protection with cancer control. Collectively, the reported studies demonstrate improved survival and reduced recurrence when stringent selection and multimodal therapy were applied. CONCLUSIONS: Transplant oncology reshapes the therapeutic landscape of liver malignancies, with growing evidence supporting liver transplantation in carefully selected patients beyond traditional indications. Optimized downstaging, innovative donor strategies, and tailored immunosuppression are pivotal for safe expansion. Continued collaboration between the transplant and oncology disciplines, along with prospective trials, is essential to further define standardized protocols and solidify transplantation as a cornerstone of multidisciplinary cancer care.
Lu K, Shen X, Guo Z
… +20 more, Chen J, He L, Xian A, Mei S, Han Y, Zhao Y, Chen J, Shi S, Miao G, Xu Y, Zhou Z, Zhang L, Zhai C, Wang Z, Zhang L, Zheng M, Yao L, Huang W, Wang Y, Xian X
BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a critical pathological stage that can progress to liver fibrosis and hepatocellular carcinoma, and its development is closely asso...BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a critical pathological stage that can progress to liver fibrosis and hepatocellular carcinoma, and its development is closely associated with dysregulation of the hepatic immune microenvironment, in which macrophages make a crucial contribution. However, the precise mechanisms mediated by macrophages underlying the pathogenesis of this disease remain incompletely understood. APPROACH AND RESULTS: In the present study, we demonstrate that under MASLD conditions, KIF13B expression is markedly downregulated in monocyte-derived macrophages, and deletion of myeloid-derived Kif13b predisposes mice to diet-induced MASLD. Mechanistically, Kif13b deficiency impairs proteasome-dependent degradation of the glycosyltransferase STT3A in macrophages, thereby enhancing cathepsin D (CTSD) glycosylation and secretion to promote lipid accumulation and inflammatory responses in livers. Further analyses reveal that the detrimental effects of CTSD depend on its interaction with the hepatocyte membrane protein Thrombospondin 1 (THBS1). In addition, we identify the transcription factor ZNF384 as a potential upstream regulator of KIF13B gene through directly binding to its promoter for the transcriptional activation, which expression is also significantly downregulated in the context of MASLD. CONCLUSIONS: Collectively, our study establishes a novel regulatory axis, ZNF384/KIF13B/STT3A/CTSD/THBS1, essential for macrophage-hepatocyte crosstalk during MASLD progression and provides potential therapeutic targets for the treatment of MASLD.
BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly prevalent in aging populations. Dietary anthocyanins have been shown to exert metabolic benefits in aging and age-asso...BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly prevalent in aging populations. Dietary anthocyanins have been shown to exert metabolic benefits in aging and age-associated metabolic disorders. However, its role in protecting against age-dependent hepatic steatosis and the underlying mechanisms remain poorly defined. APPROACH AND RESULTS: In 18-month-old mice, dietary cyanidin-3-O-β-glucoside (Cy-3-G) markedly reduced hepatic triglyceride accumulation and improved serum liver enzyme levels without altering systemic glucose metabolism, body composition, or muscle function. Transcriptomic and pathway analyses identified hepatic farnesoid X receptor (FXR) signaling as the primary mediator of Cy-3-G-induced improvements in lipid metabolism. Studies in hepatocyte-specific FXR knockout mice confirmed that this pathway is essential, while in vitro assays showed that Cy-3-G does not directly activate FXR in hepatocytes, underscoring the importance of microbiota-derived signals. Notably, Limosilactobacillus reuteri was identified as a key bacterium expanded by Cy-3-G, which increased bile salt hydrolase activity and promoted the breakdown of FXR-inhibitory tauro-β-MCA. Fecal microbiota transfer, synthetic community cultures, and direct L. reuteri supplementation further validated its causal role in lowering tauro-β-MCA and improving hepatic steatosis. CONCLUSIONS: Cy-3-G alleviates age-dependent hepatic steatosis by selectively promoting L. reuteri expansion and reshaping bile acid composition to activate hepatic FXR signaling. These findings identify a gut microbiota-mediated mechanism by which a dietary anthocyanin mitigates age-related MASLD.
BACKGROUND AND AIMS: Alcohol use disorder (AUD) imposes a substantial burden on healthcare systems in the United States. Although pharmacological treatments are effective, they remain underutilized. Real-world evidence o...BACKGROUND AND AIMS: Alcohol use disorder (AUD) imposes a substantial burden on healthcare systems in the United States. Although pharmacological treatments are effective, they remain underutilized. Real-world evidence on the economic impact and clinical effectiveness of AUD pharmacotherapy is limited. APPROACH AND RESULTS: We conducted a retrospective cohort study using Optum's de-identified Clinformatics Data Mart Database, including individuals aged ≥21 years with a new diagnosis of AUD between 2017 and 2023. Patients who initiated AUD pharmacotherapy within 1 year of diagnosis (treated group) were matched 1:1 to untreated counterparts using propensity score matching. Outcomes included alcohol-associated emergency department (ED) visits, inpatient (IP) admissions, and associated medical charges during a 1-year follow-up. Cost-effectiveness was assessed using incremental cost-effectiveness ratios (ICERs). Among 218,260 patients with AUD (109,130 matched pairs), MAUD use was associated with a significantly lower likelihood of alcohol-associated hospitalization (37.6% vs. 41.4%, p <0.001) and lower total alcohol-associated medical charges ($47,697 vs. $50,403, p <0.001), with savings driven predominantly by reduced IP utilization. Cost savings were observed across all liver disease strata and were greatest in patients with moderate-to-severe liver disease, where MAUD was associated with nearly $27,000 lower mean IP charges and a 9% absolute reduction in hospitalization risk. The greatest efficiency was also observed in patients with moderate-to-severe liver disease: each $0.03 spent on AUD medication corresponded to $1 in medical cost savings. CONCLUSIONS: AUD pharmacotherapy is significantly associated with lower alcohol-associated healthcare utilization, particularly IP care, and medical charges in real-world settings, with the largest economic benefits observed in patients without advanced liver disease. These findings support broader implementation of pharmacologic treatment for AUD, including in patients with ALD, and underscore the importance of early intervention to maximize cost-effectiveness.
BACKGROUND AND AIMS: Unlike other immune-based combinations for hepatocellular carcinoma (HCC), long-term data for atezolizumab-bevacizumab (AB) are lacking, as the IMbrave150 trial closed after a median follow-up of 15....BACKGROUND AND AIMS: Unlike other immune-based combinations for hepatocellular carcinoma (HCC), long-term data for atezolizumab-bevacizumab (AB) are lacking, as the IMbrave150 trial closed after a median follow-up of 15.6 months. Consequently, reports of long-term outcomes for AB rely mainly on real-world evidence. We evaluated long-term effectiveness, safety, and clinically relevant on-treatment events in a large prospective real-world cohort of patients treated with AB. APPROACH AND RESULTS: We analyzed 538 patients prospectively enrolled in the Italian ARTE database. Outcomes included overall survival (OS), safety, liver decompensation, rate of patients achieving drug-free disease-free status. On-treatment events were modelled as time-dependent covariates in Cox regression models. After a median follow-up of 24.2 months, median OS was 19.7 months (95% CI 17.2-22.2), with a 36-month survival rate of 30.0%. Independent factors influencing OS included ECOG-PS >0, ALBI grade >1, AFP >400 ng/mL, multinodularity, macrovascular invasion, and on-treatment events (objective response, progression, or liver decompensation). Grade ≥3 AEs occurred in 36.8% of patients; 5 late-onset severe toxicities arose beyond 24 months. Liver decompensation unrelated to tumor progression occurred in 14.1% patients. Eighty patients (14.9%) underwent surgical or locoregional procedures after the initiation of AB; 24 (4.4%) achieved a drug-free disease-free status. CONCLUSIONS: Our data confirmed the sustained effectiveness of AB without new safety concerns. Surgical/locoregional treatments after the start of AB and liver decompensation were common, highlighting the need for a multidisciplinary and integrated approach in advanced HCC.