Wangensteen, Kirk J

PURPOSE Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide. The higher incidence and earlier onset of HCC in sub-Saharan Africa suggest a potential role for a genetic predisposition. This study evaluated the association of TERT -rs2242652-(A), a variant linked to lower HCC risk, with HCC in populations from Ghana, Nigeria, and Cameroon, compared with a population from the United States. METHODS The study included 537 patients with HCC: United States (n = 348), Ghana (n = 79), Nigeria (n = 43), and Cameroon (n = 67). The control group had 2,872 cancer-free individuals: United States (n = 2,399), Ghana (n = 323), Nigeria (n = 85), and Cameroon (n = 65). Whole-exome sequencing was conducted using germline DNA, and data for TERT -rs2242652 were analyzed. Odds ratios (ORs) and 95% CIs were calculated using unconditional logistic regression. Chi-square tests assessed protective allele frequencies. RESULTS In the US cohort, TERT -rs2242652 was significantly associated with lower HCC risk (OR, 0.75 [95% CI, 0.58 to 0.96]; P = .02), with an allele frequency of 18.8% (15.4% in HCC cases v 19.3% in controls). In the combined sub-Saharan African population, no significant association was observed, but there was a trend toward decreased HCC risk (OR, 0.80 [95% CI, 0.53 to 1.22]; P = .29), with an allele frequency of 12.2% (10.6% in HCC cases v 12.9% in controls). Separate analyses of Ghanaian, Nigerian, and Cameroonian populations showed similar nonsignificant trends. The protective allele frequency in the combined African populations was significantly lower than in the US cohort ( P < .0001). CONCLUSION In sub-Saharan African populations, there was a lower frequency of the HCC protective allele TERT -rs2242652 compared with European Americans. These findings underscore the importance of multiethnic genetic studies in understanding population differences in HCC risk and developing prevention strategies.

Background: There is no consensus scoring system for staging and prognosis in hepatocellular carcinoma (HCC), which is the fourth leading cause of cancer-related mortality worldwide. Commonly used systems include the albumin–bilirubin (ALBI) score, the Barcelona staging classification (Barcelona Clinic Liver Cancer, BCLC), the Model for End-Stage Liver Disease (MELD), and the model to estimate survival in ambulatory HCC patients (MESIAH). Liver secretion of pseudocholinesterase (PCHE) has been linked to liver function but is poorly studied in the natural history of HCC. We evaluated whether serum PCHE level predicts HCC mortality and whether it enhances existing scoring systems. Methods: We conducted a retrospective cohort study of individuals diagnosed with HCC. We collected variables including PCHE level, clinical data used in scoring systems, and time to mortality or liver transplant. We then analyzed the association between these variables and survival using Kaplan–Meier curves, Cox proportional hazards regression models, receiver operating characteristic (ROC) curves, and area under the curve (AUC) calculations. Results: We identified 420 individuals with HCC who were tested for PCHE levels, with a follow-up time of more than 20 years. There was a strong inverse relationship between PCHE level and overall survival, with the lowest quartile having high mortality and poor outcomes. Low PCHE level was associated with hepatitis C virus (HCV) infection, vascular invasion, poor liver function, and a high likelihood of liver transplant. In contrast, the highest quartile was associated with metabolic dysfunction–associated steatotic liver disease (MASLD) as the underlying cause. Compared with validated scoring systems, ALBI, BCLC, MELD 3.0, and MESIAH, the PCHE level was an independent predictor of mortality. PCHE levels could predict 3-month survival as well as or better than the other scoring systems, with an AUC of 0.74. PCHE level could also predict mortality related to hepatectomy. The addition of PCHE level to MESIAH and ALBI scoring systems could further improve the ability to predict overall mortality in HCC. Conclusions: PCHE is a reliable stand-alone biomarker of HCC prognosis. It is an independent predictor of mortality and can improve the accuracy of existing scoring systems. Improved risk stratification could improve outcomes by informing treatment decisions regarding hepatectomy or other interventions.

ABSTRACT Introduction Hepatocellular carcinoma (HCC) development in patients with metabolic dysfunction‐associated steatotic liver disease (MASLD) is a growing health concern, but the underlying mechanisms are not fully understood. Epigenetic aging biomarkers, reflecting cellular and tissue aging, have been linked to various age‐related pathologies, but their association with MASLD‐HCC is unknown. We investigated associations between five epigenetic aging biomarkers and MASLD‐HCC risk. Methods We performed whole blood DNA methylation assay (Infinium 850k array) and calculated principal components‐based (PC) versions of HorvathAge, HannumAge, PhenoAge and GrimAge and the DunedinPACE aging rate. We further calculated relative age accelerations for PCHorvathAge, PCHannumAge, PCPhenoAge and PCGrimAge. The aging biomarkers were modelled as continuous variables and categorised into tertiles based on distributions among controls. Associations between each aging biomarker and MASLD‐HCC were examined using logistic regression, calculating odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for covariates. Results Data on 272 MASLD‐HCC cases and 316 cancer‐free MASLD controls recruited from six sites and matched on chronological age, sex and study site were analysed. Higher relative age accelerations of PCPhenoAge (OR T3 vs. T1 = 2.25, 95% CI: 1.45–3.50; OR continuous = 1.04, 95% CI: 1.02–1.07, p = 0.009), PCGrimAge (OR T3 vs. T1 = 3.97, 95% CI: 2.41–6.64; OR continuous = 1.16, 95% CI: 1.10–1.24, p = 8.76 × 10 −07 ) and DunedinPACE (OR T3 vs. T1 = 3.45, 95% CI: 2.17–5.55; OR continuous = 1.72, 95% CI: 1.43–2.10, p = 2.58 × 10 −08 ) were associated with MASLD‐HCC, but not PCHorvathAge or PCHannumAge. Conclusion Higher relative age accelerations of PCPhenoAge, PCGrimAge and DunedinPACE aging rate are associated with risk of MASLD‐HCC. These aging biomarkers could improve HCC risk assessment and facilitate risk stratification in patients with MASLD.

ABSTRACT Background & Aims Steatotic liver disease (SLD) is characterised by liver fat accumulation exceeding 5%. Lean body weight (BMI ≤ 25 kg/m 2 ) with non‐alcoholic SLD is a rare phenotype, and the balance of risks related to metabolic conditions or genetic predisposition, or the risk of progressive liver disease, is not known. This study evaluates clinical and genetic predictors of non‐alcoholic SLD and advanced liver disease in lean individuals. Methods We used International Classification of Disease codes, radiology and pathology review to identify 177 lean non‐alcoholic SLD cases (47 cryptogenic, 130 MASLD), 677 matched lean controls, and 3090 overweight/obese SLD cases in the Mayo Clinic Biobank and Tapestry databases. We performed case–control and cross‐sectional comparisons of clinical and genetic factors between these groups, using univariable and multivariable analyses. Results Lean individuals with non‐alcoholic SLD exhibited metabolic and genetic profiles that were intermediate between those of lean controls without SLD and overweight/obese SLD individuals, including intermediate rates of diabetes, hypertension, hyperlipidaemia and of homozygosity for the risk allele of PNPLA3 . Multivariable analysis indicated that diabetes was an independent predictor of SLD among lean individuals. Among lean individuals with non‐alcoholic SLD, those with metabolic‐associated SLD (MASLD), as compared to those with cryptogenic SLD (without metabolic risk factor), were more likely to be homozygous for risk alleles in GCKR . The Fib‐4 score, a tool for screening advanced liver disease in SLD, accurately predicted advanced fibrosis among lean individuals with non‐alcoholic SLD. Conclusion Diabetes serves as a primary predictor of non‐alcoholic SLD in lean individuals. These results support the recommendation to screen for SLD in patients with diabetes, regardless of BMI. The GCKR risk allele is associated with MASLD in lean individuals, and the risk factors for cryptogenic SLD remain unclear.

Background Eosinophilic oesophagitis (EoE) is a food allergen-induced inflammatory disorder characterised by interleukin (IL)-13-mediated oesophageal inflammation and epithelial basal cell hyperplasia (BCH). The role of mitochondria in EoE pathogenesis remains elusive. Design Prompted by single cell transcriptomics data, we interrogated the role of mitochondria in EoE pathobiology using patient biopsies, EoE-mouse models and oesophageal epithelial cells grown in monolayer and three-dimensional (3D) organoid cultures treated with EoE-relevant cytokines. 3D organoids and EoE-bearing mice were treated with omeprazole—a proton-pump inhibitor used as first-line EoE therapy. We performed CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) interference in mouse organoids to identify the key mitochondrial regulatory genes whose depletion may lead to BCH. We analysed mitochondrial membrane potential, mass and superoxide production by flow cytometry, cellular oxygen consumption by respirometry, mitochondrial structures and perturbation of cellular energy homeostasis by immunoblotting. Results Mitochondrial dysfunction appeared to be a hallmark of EoE-related BCH where mitochondrial structural damage was associated with impaired oxidative respiratory capacity, elevation of mitochondrial superoxide and decreased adenosine triphosphate (ATP) production, as corroborated by activation of the adenosine monophosphate (AMP) -activated protein kinase and suppression of mammalian target-of-rapamycin signalling. Depletion of PGC1A, the master regulator of mitochondria biogenesis, recapitulated EoE-related BCH, suggesting that mitochondrial dysfunction drives BCH. Further, omeprazole alleviated mitochondrial damage and dysfunction in EoE-related BCH modelled in mice and patient-derived organoids. Conclusion Mitochondrial dysfunction is tightly linked to perturbation of redox homeostasis in EoE-related BCH, which is promoted by IL-13 and reversible with omeprazole treatment.

Abstract Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a fast-rising global public health problem. About 10% of patients with MASLD will develop hepatocellular carcinoma (HCC), but molecular markers for predicting future risk of HCC development in patients with MASLD are lacking. We investigated whether protein biomarkers in pre-malignant plasma samples can predict susceptibility to HCC in the setting of MASLD. Methods: A nested case-control study was performed among patients with MASLD who later developed HCC (cases) and MASLD patients who never progressed to HCC (controls), matched on age at MASLD diagnosis (± 1-year), sex, the year of blood sample collection, and length of follow-up (± 1-year). MASLD at baseline was determined by the presence of hepatic steatosis (assessed by imaging or biopsy) plus at least one cardiometabolic condition (obesity, diabetes mellitus, hypertension, or dyslipidemia). Archival baseline plasma samples stored at -80oC were used to perform the SomaScan 7k v4.0 assay. We also performed genotyping of the well-established HCC susceptibility variant, PNPLA3-rs738409 (I148M), among the cases and controls. The study sample was split into discovery (70%) and validation (30%) sets, and we selected promising protein biomarkers in the discovery set using differential expression analysis with volcano plots and Bonferroni-corrected p-values. A final set of significant proteins was used for prediction modeling in the validation sample, calculating area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and accuracy. Results: The study sample included 54 MASLD to HCC cases and 54 MASLD controls, split into discovery and validation sets. We identified five significantly differentially expressed proteins in the discovery set, four overexpressed (TSP2, GPR56, MIC-1, TIMP-1) and one under-expressed (IGFALS) in the cases versus controls. Fitting the five proteins in the validation sample yielded an AUC=0.88, sensitivity=0.87, specificity=0.75, and accuracy=0.81. Adding PNPLA3-rs738409 to the model improved the model’s specificity and accuracy (AUC=0.88, sensitivity=0.87; specificity=0.81, accuracy=0.84). Conclusions: Our findings show that a five-protein biomarker panel can robustly predict future HCC development in patients with MASLD. Adding a well-established HCC genetic risk variant, PNPLA3-rs738409, slightly improved the model’s performance. These initial findings provide evidence of HCC prediction with baseline plasma biomarkers and genetic risk variants, toward improving risk stratification and enhancing early detection of HCC in the setting of metabolic perturbations. Citation Format: Ampem Darko Jnr Siaw, Sebastian M. Armasu, Jacob A. Frank, Irene K. Yan, Kirk J. Wangensteen, Tushar Patel, Samuel O. Antwi. Protein biomarkers of HCC development in patients with metabolic liver disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 2350.

Abstract Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) affects about 32% of adults worldwide and is projected to increase in many parts of the world. Liver cancer is a recognized complication of end-stage MASLD. An estimated 20% of patients with MASLD will progress to cirrhosis, a premalignant state in liver cancer evolution. Because MASLD is usually asymptomatic, its progression to cirrhosis can be difficult to detect early for timely intervention. There are currently no known biological markers for predicting cirrhosis risk in patients with MASLD, making it challenging to identify patients at risk of disease progression. The aim of this study was to identify plasma protein biomarkers that can predict future cirrhosis development in patients with MASLD. Methods: We performed a nested case-control study among patients with MASLD at baseline who later progressed to cirrhosis and control patients with MASLD at baseline who never progressed to cirrhosis, matched on age at MASLD diagnosis (± 1-year), sex, race, year of blood sample collection, and length of follow-up (± 1-year). An aptamer-based array (SOMAscan™) platform was used to measure over 7000 proteins in baseline plasma samples obtained from the participants. The study sample was split 70/30 for training and validation analyses. We identified plasma protein biomarkers significantly differentially expressed in the training sample, adjusting for multiple testing with Bonferroni-corrected p-values. The significant set of proteins from the training set was used for prediction modeling in the validation sample, computing prediction metrics (area under the curve [AUC], sensitivity, specificity, and accuracy). Results: A total of 64 MASLD to cirrhosis cases matched to 64 MASLD controls were included in the analysis. Six protein biomarkers (PTPRU, ATL2, MFAP4, C7, CSTN2, and COLEC11) were overexpressed in cases, compared to controls, in the training data. Prediction modeling of the six-protein biomarker panel in the validation sample yielded an AUC = 0.85, sensitivity = 0.72, specificity = 0.78, and accuracy = 0.75. Conclusions: We have identified a panel of six plasma protein biomarkers that predict risk of cirrhosis development in patients with MASLD. These proteins could serve as candidates for future mechanistic studies on MASLD progression to advanced liver disease. If validated in larger studies and with assays suitable for clinical laboratory testing (e.g., ELISA), these protein biomarkers could be useful clinically for cirrhosis risk prediction in MASLD patients, and hence those at risk of liver cancer, enabling timely surveillance or interventions to prevent disease progression. Citation Format: Pasang Sherpa, Sebastian M. Armasu, Jacob A. Frank, Irene K. Yan, Kirk J. Wangensteen, Tushar Patel, Samuel O. Antwi. Predicting cirrhosis risk in patients with metabolic dysfunction-associated steatotic liver disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 2335.

Pediatric genetic and metabolic liver diseases comprise a broad spectrum of conditions and represent the second most common indication for liver transplantation following biliary atresia. The decision to transplant can be challenging and requires consideration of several factors, including hepatic involvement, extrahepatic manifestations, and anticipated posttransplant outcomes. This review examines pediatric genetic and metabolic liver diseases, their pathophysiology, clinical presentation, and the role of liver transplantation.