Abstract:Laparoscopic anatomical hepatectomy is a difficult and risky procedure, containing a number of technical essentials. The choice of laparoscopic approach is considered to be one of the core techniques. After decades of development, approach selection of laparoscopic anatomical hepatectomy has gradually established a completely new field. Surgical design determines the selection of surgical approach which is variable and not independent. The authors’ team has developed a technique of laparoscopic anatomical hepatectomy with liver parenchymal transection-first approach through repeated practice in clinical settings since the laparoscopic liver surgery was carried out. In accordance with the clinical experience, the technique was found to be simple, fast, safe and effective, which overcomes the challenges of complicated operation and high technical risk of laparoscopic anatomical hepatectomy by the conventional approaches to some extent, and has certain clinical application value in laparoscopic anatomical hepatectomy.

Abstract:The tumor microenvironment in hepatocellular carcinoma (HCC) comprises a variety of cell types that include tumor-associated macrophages, tumor-associated neutrophils, myeloid-derived suppressor cells, cancer-associated fibroblasts and tumor infiltrating lymphocytes, etc., as well as extra-cellular components such as cytokines, growth factors, hormones, extracellular matrix. The immune microenvironment plays important roles in the progression, immune escape and therapeutic response of HCC. In recent years, dramatic advances have been achieved in immunotherapy based on inflammatory microenvironment modulation, and the emergence of immunotherapy provides a promising new strategy for the treatment of HCC. However, low objective response rate, and high adverse reaction and high resistance rates are still noted. Therefore, deep understanding of the role of the microenvironment in the progression of HCC and the exploration of the future development of immunotherapy will improve the response rates of the current treatment approaches, and be of great theoretical value and clinical significance for precise diagnosis and treatment of HCC.

Abstract:Background and Aims: Intraoperative bleeding is the main cause of conversion to laparotomy in anatomical laparoscopic hepatolobectomy (ALH), and effective control of blood inflow to the liver is the key step to achieve successful implementation of ALH. Traditionally, the hepatic inflow occlusion for ALH follows the conception of “Glissonean pedicle-first”, namely, isolation and division of the Glissonean pedicle (specifically, it can be divided into "intra-Glissonian approach" and "extra-Glissonian approach") are performed prior to liver parenchymal transection. However, this method is complicated and time-consuming. In the long-term clinical work, the authors have explored a new technique for hepatic inflow occlusion and named it as the "liver parenchymal dissection-first" (LPDF) method. This method just adjusts the order of operative procedures without expanding the scope of the operation, and it can simplify the hepatic inflow occlusion, and thereby facilitate the promotion and application of ALH. This paper was aimed to introduce a case of laparoscopic anatomical mesohepatectomy with LPDF method and preliminarily summarize the technical characteristics of LPDF. 
Methods: The clinical data of a patient with hepatocellular carcinoma (HCC) undergoing anatomical laparoscopic mesohepatectomy using LPDF technique in October 2019 were retrospectively analyzed. The HCC lesions in the patient involved the segments 8, 5 and 4b. During the operation, the perihepatic ligaments were dissociated, then the first porta hepatis was blocked, the liver parenchyma was fully dissected along the right side of the falciform ligament and toward the first and second porta hepatis (the left resection line) using ultrasonic scalpel until the exposure of a proper length of the intrahepatic right anterior Glissonean pedicle, which was then ligated and transected. As a result, the demarcation line of the right anterior lobe was appeared (the right resection line), and the right parenchymal resection was performed. Finally, the middle hepatic lobe and the lesions were completely resected after the intersection of the two cutting planes.
Results: The operative time was 260 min, the amount of intraoperative blood loss was 300 mL, and no blood transfusion was needed. The bowel function was recovered on postoperative day (POD) 3, and the patient was discharged from the hospital on POD 6. There were no complications such as massive intraperitoneal hemorrhage and bile leakage occurred. One month later, a 117 mm×87 mm fluid collection in the operation area was found by color doppler ultrasound, but no fever or abdominal pain was noted, and the number of white blood cells and level of total bilirubin were within the normal ranges. The fluid was gradually absorbed without treatment. 
Conclusion: LPDF is safe and feasible. It can facilitate the extra-Glissonian inflow occlusion for laparoscopic anatomical mesohepatectomy, and its application value in ALH is worthy of further exploration.

Abstract:Background and Aims: Resection of the caudate lobe is difficult and risky, because of its deep location and complex anatomical structure. Surgical resection of the caudate lobe for hepatocellular carcinoma (HCC) has long been a challenging problem in liver surgery. Therefore, this study was conducted to assess the feasibility and safety of surgical treatment of HCC in the caudate lobe. 
Methods: The clinical data of 51 patients with HCC in the caudate lobe who underwent surgical resection from 2008 to 2018 in Xiangya Hospital of Central South University were retrospectively analyzed.
Results: Operations were all uneventfully completed in the 51 patients. Surgical approaches included the left approach in 8 cases, the right approach in 5 cases, the anterior approach in 10 cases, and the left-right combined approach in 28 cases. The average operative time was (198.4±101.6) min, the time of liver parenchymal transection was 30 (10–118) min, the intraoperative blood loss was 700.8 (240–7 700) mL, and the amount of intraoperative blood transfusion was 602.9 (0–6 500) mL. The incidence rate of postoperative complications was 15.7%, including bile leakage occurred in 4 cases, abdominal fluid collection occurred in 2 cases, hepatic failure occurred in one case, and postoperative bleeding occurred in one case, which were all recovered by symptomatic treatment. No death occurred during perioperative period. The 51 patients were followed up for 2.5 to 68.6 months, the overall recurrence rate was 55.4%, and the 1-, 3-, and 5-year overall survival rates after surgery were 90.5%, 71.2%, and 52.8%, respectively.
Conclusion: By strictly following the indications for surgery, familiarizing with the anatomical characteristics of the caudate lobe, and selecting the best surgical approach, resection of the caudate lobe liver cancer is safe and feasible.

Abstract:Background and Aims: Studies have demonstrated that postoperative transarterial chemoembolization (TACE) may provide survival benefit in patients with hepatocellular carcinoma (HCC), especially those with high risk factors for recurrence. However, the definition of the patient populations benefited from this treatment remains controversial. Therefore, this study was conducted to investigate the clinical efficacy of microwave ablation-assisted liver resection combined with postoperative TACE in treatment of BCLC stage B HCC.  
Methods: The clinical data of HCC patients in BCLC stage B with 2 or 3 tumors, tumor maximum diameter >3 cm and positive microvascular invasion (MVI) undergoing microwave ablation-assisted liver resection from January 2010 to December 2014 in the Second Affiliated Hospital, Airforce Military Medical University were collected. The patients were divided into observation group and control group according to whether the postoperative TACE was performed. The survival analysis was performed by Kaplan-Meier method and the survival difference between the two groups was compared by Log-rank test. The factors affecting the prognosis of the patients were analyzed by Cox-proportional hazard regression model. 
Results: A total of 344 eligible patients were enrolled, of whom, 173 cases received postoperative TACE (observation group) and 171 cases did not undergo postoperative TACE (control group). The baseline data were comparable between the two groups of patients. The 1-, 3- and 5-year overall survival rates (OS) were 82.7%, 47.4% and 28.8% for observation group, and were 69.0%, 22.3% and 15.9% for control group; the 0.5-, 1- and 3-year disease-free survival rates (DFS) were 87.6%, 75.0% and 29.6% for observation group, and were 73.8%, 60.4% and 10.6% for control group, respectively. Both OS and DFS in observation group were significantly better than those in control group (both P<0.001). The results of univariate and multivariate analysis showed that treatment method, tumor size, albumin, total bilirubin, platelet and HBsAg were associated with OS (P<0.05). The multivariate analysis demonstrated that treatment method, tumor size, albumin, total bilirubin and HBsAg were associated with DFS (all P<0.05).
Conclusion: Microwave ablation-assisted liver resection combined with postoperative TACE can offer significant survival benefit in patients in BCLC stage B with 2-3 tumors, tumor maximal diameter larger than 3 cm and positive MVI. However, this conclusion still needs to be verified by multi-center and high-quality studies with large sample size. 

Abstract:Background and Aims: Resent studies have demonstrated that dual-specificity phosphatase 2 (DUSP2) exerts a tumor suppressor function in variety of malignant tumors. However, the expression and function of DUSP2 in hepatocellular carcinoma (HCC) are still unclear. This study was conducted to investigate the expression of DUSP2 in HCC tissue and its clinical significance.  
Methods: The surgical specimens and clinical data of 104 HCC patients treated from January 2010 to December 2014 were collected. The DUSP2 expression in HCC tissues was determined by immunohistochemical staining. The relations of DUSP2 expression with the clinical characteristics and prognosis of the patients were analyzed. The risks factors for tumor-free survival rate and overall survival rate of the HCC patients were determined by Cox proportional hazard model.
Results: In the tissue samples of the 104 patients, high DUSP2 expression accounted for 59.6% (62/104), and low DUSP2 expression accounted for 40.4% (42/104). DUSP2 expression was irrelevant to the age, sex and tumor size (all P>0.05), while it was significantly associated with the degree of tumor differentiation (P=0.018), number of tumors (P=0.048), distant metastases (P=0.001) and serum HBV level (P=0.018). Kaplan Meier survival analysis showed that both 3-year disease-free survival rate and 3-year overall survival rate of patients with low DUSP2 expression were significantly lower than those of patients with high DUSP2 expression (25.2% vs. 63.3%, P=0.004; 42.5% vs. 85.5%, P=0.002). Cox proportional hazard model analysis showed that low differentiation degree, distant metastasis and low DUSP2 expression were the independent risk factors for both tumor-free survival rate and overall survival rate of HCC patients (all P<0.05). 
Conclusion: The DUSP2 expression in the tumor tissue is closely associate with the tumor differentiation, number of tumor and metastasis as well as the prognosis of HCC patients. DUSP2 can be used as a molecular marker to predict the prognosis of HCC patients and those with low DUSP2 expression may have a poor prognosis.

Abstract:Background and Aims: Studies have demonstrated that long non-coding RNA RUSC1-AS1 (lncRNA RUSC1-AS1) has a close relationship with the malignant biological behaviors of tumors. However, its role in hepatocellular carcinoma (HCC) is still unclear. Our previous study demonstrated that there are binding interactions between lncRNA RUSC1-AS1 and microRNA-326 (miR-326). Therefore, this study was conducted to investigate the expression of lncRNA RUSC1-AS1 in HCC, and whether it regulates the biological behaviors of HCC cells by targeting miR-326. 
Methods: The expressions of lncRNA RUSC1-AS1 and miR-326 in 41 paired specimens of HCC tissue and tumor adjacent were detected by qRT-PCR. Using lncRNA RUSC1-AS1 expression inhibition plasmid/negative control plasmid, miR-326 mimics/negative control sequences and miR-326 inhibitors/negative control sequences as tools, the changes in proliferative ability, migration and invasion abilities, and apoptosis as well as the expressions of the related proteins in HCC MHCC97-H cells after different transfection treatments were determined by MTT assay, Transwell assay, flow cytometry and western blot analysis, respectively. The targeting relationship between lncRNA RUSC1-AS1 and miR-326 was analyzed by luciferase report assay, and then validated by qRT-PCR.
Results: In HCC tissue compared with adjacent tissue, the expression level of lncRNA RUSC1-AS1 was significantly increased, and the expression level of miR-326 was significantly decreased (both P<0.05). In MHCC97-H cells after transfection with lncRNA RUSC1-AS1 expression inhibition plasmid or miR-326 mimics, the proliferative ability as well as the migration and invasion abilities were significantly reduced, while the apoptosis rate was significantly increased, and the protein expression levels of cyclin D1, MMP-2, MMP-9, Bcl-2 were significantly reduced, while the protein expression levels of P21, Bax were significantly increased (all P<0.05). In MHCC97-H cells transfected with lncRNA RUSC1-AS1 expression inhibition plasmid with simultaneous transfection of miR-326 inhibitors, the influences of the former on MHCC97-H cells were abolished (all P<0.05). The results of luciferase report assay and qRT-PCR validation showed that miR-326 was a target molecule for lncRNA RUSC1-AS1. 
Conclusion: The expression of lncRNA RUSC1-AS1 is up-regulated in HCC, and it can promote the malignant biological behaviors of HCC cells by targeting miR-326.

Abstract:Background and Aims: Hepatocellular carcinoma (HCC) is the most common primary liver cancers, and has a poor prognosis. Dysregulation of autophagy can promote the occurrence and development of HCC. This study was designated to investigate the potential prognostic roles of autophagy-related long non-coding RNAs (lncRNAs) in HCC patients and construct a risk prediction model based on autophagy-related lncRNAs.  
Methods: The transcriptomic and clinical data of 374 HCC samples and 50 normal control samples in TCGA database were analyzed using bioinformatics approaches, and the list of autophagy-related genes were obtained from HADb. The lncRNAs associated with autophagy genes were screened by Person’s correlation analysis. Three hundred and forty-two HCC samples obtained by selection were randomly assigned to train dataset and validation dataset with a ratio of 70%:30% using caret package in R. The autophagy-related lncRNAs with prognostic significance were identified by Kaplan-Meier method and univariate Cox regression analysis. Then, the autophagy-related lncRNAs with independent prognostic significance were determined by multivariate stepwise regression Cox analysis to construct a prognostic prediction model. After the risk scores were calculated using Cox regression coefficient, the patients were divided into low risk group and high risk group, the relationship between the risk score and clinicopathologic features as well as the overall survival (OS) was analyzed, and then was verified in the validation dataset. 
Results: A total of 347 lncRNAs were identified as autophagy-related lncRNAs (|R2|>0.3, P<0.001), including 26 lncRNAs with prognostic value for HCC patients. The risk model for predicting the prognosis of the patients was derived from the multivariate stepwise regression Cox analysis based on 12 autophagy-related lncRNAs (CYTOR, DANCR, LINC01138, LUCAT1, Mapkapk5-AS1, NRAV, NRSN2-AS1, LINC01871, LINC00864, LINC02362, TMEM220-AS1 and PSMB8-AS1). The risk scores of the 12- autophagy-related lncRNAs prognostic model was sufficiently associated with tumor grade, tumor stage and T stage (all P<0.05), but irrelevant to the age and sex of the patients (both P>0.05). In this model, the area under curve (AUC) of the time-dependent ROC for the 1, 3 and 5-year overall survival were 0.801, 0.819 and 0.787 in the train dataset, and the AUC of the time-dependent ROC for the 1, 3 and 5-year overall survival were 0.694, 0.733 and 0.746 in the validation dataset. 
Conclusion: The identified autophagy-related lncRNAs may play critical roles in the oncobioloy of HCC, and the 12- autophagy-related lncRNAs has certain predictive value for the prognosis of HCC.

Abstract:Background and Aims: Previous studies have shown that Bcl-2 inhibitor of transcription 1 (Bit1) is abnormally expressed in a variety of tumors and plays an important role in tumor progression. However, The expression level and clinical significance of Bit1 in hepatocellular carcinoma (HCC) are worthy to be investigated. Therefore, this study was aimed to investigate the clinical significance of Bit1 in HCC by determining the Bit1 expression in HCC tissue and its relationship with the  clinicopathologic parameters and prognosis of HCC patients. 
Methods: The mRNA and protein expressions of Bit1 in surgical specimens of HCC tissue and corresponding adjacent tissues from HCC patients were determined by qRT-PCR and Western blot, respectively. The protein expressions of Bit1 in 90 pairs of HCC tumor tissue and corresponding adjacent tissue in HCC tissue chip were determined by immunohistochemical staining, and the relations of Bit1 expression with the clinicopathologic variables and the prognosis of HCC patients were analyzed.
Results: The results of qRT-PCR and Western blot showed that both Bit1 mRNA and protein expressions in HCC tissue were significantly upregulated compared with tumor adjacent tissue (both P<0.05). The results of immunohistochemical staining showed that Bit1 protein was localized in the cytoplasm and its high expression rate in HCC tissue was significantly higher than that in tumor adjacent tissue (P<0.05), and the expression of Bit1 in HCC tissue was significantly related to tumor recurrence and pathological grade of HCC patients (both P<0.05). Kaplan-Meier survival analysis showed that the overall survival rate and disease-free survival rate in patients with high Bit1 protein expression were lower than those in patients with low Bit1 protein expression, but both did not reach a statistical significance (P=0.547, 0.414). 
Conclusion: Bit1 presents a high expression in HCC tissues, and is closely related to tumor recurrence and pathological grade, suggesting that Bit1 may be an important molecule that affects tumor progression, and it is expected to become a target for individualized treatment of HCC patients.

Abstract:Background and Aims: There are many anatomical variations of the arteries supplying the liver. Currently, the anatomical classification methods of the liver arteries are mainly Michels’ classification and Hiatt’s classification. However, new types of anatomical variations have continually been discovered. So, previous classification systems cannot meet the clinical needs. This study was conducted to analyze the anatomical variations of the liver supplying arteries by imaging observation, so as to create an accurate classification method and provide precise scientific information for clinical work. 
Methods: The imaging data of patients undergoing biphasic contrast-enhanced scanning of abdominal multi-slice spiral CT from January 2019 to March 2019 were reviewed. The patterns of the arteries supplying the liver were observed, the relevant data were recorded and categorical analysis was performed. 
Results: The CT imaging data of 1 520 patients were selected, including 967 males and 553 females. Of the patients, 1 504 cases (98.95%) met Michels’ classification, and 16 cases (10.53‰) did not meet Michels’ classification; 1 507 cases (99.14%) met Hiatt’s classification, and 13 cases (8.55‰) did not meet Hiatt’s classification. By analyzing the anatomical variations of the arteries supplying the liver from the aspects of the origin of the common hepatic artery (CHA), the origin of the accessory left hepatic artery (ALHA) and the types of the arteries supplying the liver, the authors proposed the seven-type classification (according to the origin of the CHA) and five-type classification (according to the anatomical variation of the left and right liver supplying arteries and the combination of different variations) for classifying the anatomical types of the arteries supplying the liver. In the seven-type classification, 1 471 cases (96.78%) were classified as type I, 25 cases (1.64%) were type II, 7 cases (0.46%) were type III, 5 cases (0.33%) were type IV, 4 cases (0.26%) were type V, 4 cases (0.26%) were type VI, and 4 cases (0.26%) were type VII. In the five-type classification, 1 381 cases (90.86%) were classified as type I, 87 cases (5.72%) were type II, 38 cases (2.50%) were type III, 10 cases (0.66%) were type IV, and 4 cases (0.26%) were type V.
Conclusion: The new classification methods proposed in this study cover all possible anatomical variations, which simplify the complex situation of taking simultaneously into account the CHA and the hepatic supplying arteries for classification in previous studies. The frameworks of the classifications are clear, consistent with the anatomical reality and clinical cognition, and they can provide theoretical basis and guidance for clinical work.

Abstract:Background and Aims: The clinical significance of systemic inflammation assessed with laboratory analysis of blood samples has been validated in variety of cancers. hepatocellular carcinoma (HCC) is an inflammation-driven cancer, and inflammation has been shown to be correlated with poor differentiation, microvascular invasion and micrometastasis. This study was conducted to investigate the prognostic value of the lymphocyte-to-monocyte ratio (LMR) in patients with HCC after hepatectomy. 
Methods: The clinical data 88 HCC patients undergoing radical hepatectomy in the Affiliated Nanjing Hospital of Nanjing University of Chinese Medicine between January 2012 and December 2016 were retrospectively analyzed. The prognostic predictive power of LMR for HCC was analyzed by ROC curve, which was compared with those of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). The relations of LMR with the clinicopathologic factors as well as the disease-free survival (DFS) and overall survival (OS) of the HCC patients were determined. The risk factors for DFS and OS were determined by Cox regression model.
Results: The cut-off diagnostic value of LMR determined by ROC was 2.87, and the area under the curve (AUC) was 0.757, and its efficiency in estimating the prognosis of HCC was greater than those of NLR (AUC=0.687) and PLR (AUC=0.583). The patients were divided into low LMR group (LMR ≤2.87) and high LMR group (LMR >2.87) according to the cut-off value of LMR. The number of cases with lesion number >3 in high LMR group was significantly less than that in low LMR group (P=0.048); both DFS and OS in high LMR group were significantly superior than those in low LMR group (both P<0.05); results of stage-stratified comparison (BCLC A/B, BCLC C/D; CNLC I/II, CNLC III/IV) showed that except the DFS had no significant difference between high LMR group and low LMR group among patients classified as CNLC I/II stage group (P=0.132), either DFS or OS in high LMR group were significantly superior than that in low LMR in all other stage groups (all P<0.05). LMR was an independent prognostic factor for DFS (P=0.001), while BCLC stage (P=0.000) and LMR (P=0.000) were independent prognostic factors for OS. In addition, after adjustment for LMR, PLR, and NLR as a continuous variable, only LMR had a prognostic value (P=0.001).
Conclusion: LMR is an independent prognostic factor for OS and DFS in HCC patients after hepatectomy, and its predictive value is possibly superior to that of NLR or PLR. Using LMR combined HCC stage to grade the risk of patients may probably make a more precise assessment.

Abstract:Background and Aims: Gut microbiota is closely related to the occurrence and development of hepatocellular carcinoma (HCC). This association suggests that gut microbiota balance should also be an important target for the treatment of HCC in addition to the treatment of primary liver diseases. Therefore, this study was aimed to explore the influencing factors for gut microbiota in patients with HCC. 
Methods: A total of 121 HCC patients were enrolled. Fecal DNA samples of the HCC patients were extracted, and the relative abundance of gut microbiota was analyzed by quantitative real-time PCR. Intestinal dysbacteriosis (ID) was diagnosed by Bifidobacterium/Enterobacteriaceae (B/E) <1. The major factors affecting the gut microbiota in HCC patients were determined by univariate and multiple linear regression analysis .
Results: The abundance of Bifidobacterium was significantly lower than that of Enterobacteriaceae in patients with HCC [Log5 (6.24±1.30)/g vs. Log5(7.59±1.11)/g, P<0.000]. The incidence of ID was 77.69% (94/121). Multiple linear regression analysis showed that monocyte was the only main influencing factor for Bifidobacterium (P<0.000) and ID (P=0.008); total bilirubin (P=0.011), sex (P=0.027) and fasting blood glucose (P=0.038) were the main influencing factors for Enterobacteriaceae. 
Conclusion: Monocyte, total bilirubin, sex and fasting blood glucose are possibly important factors affecting the gut microbiota and thereby cause ID in HCC patients. The correlation between these factors and gut microbiota may not only provide the potential targets for modulating gut microbiota in HCC patients, but also give a solid theoretical basis for gut microbiota intervention as a therapeutic strategy for HCC.

Abstract:14-3-3ζ protein as the central regulatory factor of intracellular signal transduction process plays an important role in the occurrence and development of hepatocellular carcinoma (HCC). Several studies indicated that the expression of 14-3-3ζ protein is elevated significantly in HCC, and participate in various cellular processes such as cell proliferation, invasion, and apoptosis. Additionally, by interacting with a multitude of target proteins, 14-3-3ζ protein can regulate a variety of signaling pathways that contribute to the occurrence and development of HCC, this suggests that it may be used as a potential biomarker for the early diagnosis, prognostic prediction, chemoresistance and treatment of HCC. The overexpression of 14-3-3ζ protein is associated with the increased risk of recurrence and metastasis and the reduced survival rate of HCC patients. The authors review the impact of 14-3-3ζ protein on regulation of expression, biological function and the occurrence and development of HCC and the relevant research progress.

Abstract:Bromodomain 4 (BRD4), a member of the bromodomain and extraterminal protein family, plays an important role in the physiological activities of normal cells and tumor cells by regulating gene transcription and cell cycle. As a transcriptional and epigenetic regulator, BRD4 gene overexpression, rearrangement and mutation are often associated with a variety of diseases, especially malignant tumors. Here, the authors review and analyze the function of BRD4 and its inhibitors in transcriptional regulation and their interaction with tumor cells, hoping to provide new ideas for relevant clinical treatment.

Abstract:Germinal center kinases (GCK) are a type of serine/threonine protein kinase characterized by having a conserved serine/threonine protein-kinase domain, and together with p21-activated protein-kinases (PAK), they belong to the sterile twenty (Ste20)-like kinase family, which are involved in a wide variety of physiological processes, and some of them can cause stress responses to external stimuli, such as cell proliferation, apoptosis, skeleton rearrangement. Stk25 as an important· member of the subgroup III of the GCK family (GCKIII), in addition to participating in the above-mentioned physiological processes, simultaneously exerts important functions in energy metabolism and the occurrence and development of tumors. Here, the authors address the structural characteristics, biological effects, energy metabolism regulation and anti-tumor effects of STK25, so as to provide a reference for its translation into clinical treatment of tumors.