Hepatocellular carcinoma (HCC) can have viral or non-viral causes1–5. Non-alcoholic steatohepatitis (NASH) is an important driver of HCC. Immunotherapy has been approved for treating HCC, but biomarker-based stratification of patients for optimal response to therapy is an unmet need6,7. Here we report the progressive accumulation of exhausted, unconventionally activated CD8+PD1+ T cells in NASH-affected livers. In preclinical models of NASH-induced HCC, therapeutic immunotherapy targeted at programmed death-1 (PD1) expanded activated CD8+PD1+ T cells within tumours but did not lead to tumour regression, which indicates that tumour immune surveillance was impaired. When given prophylactically, anti-PD1 treatment led to an increase in the incidence of NASH–HCC and in the number and size of tumour nodules, which correlated with increased hepatic CD8+PD1+CXCR6+, TOX+, and TNF+ T cells. The increase in HCC triggered by anti-PD1 treatment was prevented by depletion of CD8+ T cells or TNF neutralization, suggesting that CD8+ T cells help to induce NASH–HCC, rather than invigorating or executing immune surveillance. We found similar phenotypic and functional profiles in hepatic CD8+PD1+ T cells from humans with NAFLD or NASH. A meta-analysis of three randomized phase III clinical trials that tested inhibitors of PDL1 (programmed death-ligand 1) or PD1 in more than 1,600 patients with advanced HCC revealed that immune therapy did not improve survival in patients with non-viral HCC. In two additional cohorts, patients with NASH-driven HCC who received anti-PD1 or anti-PDL1 treatment showed reduced overall survival compared to patients with other aetiologies. Collectively, these data show that non-viral HCC, and particularly NASH–HCC, might be less responsive to immunotherapy, probably owing to NASH-related aberrant T cell activation causing tissue damage that leads to impaired immune surveillance. Our data provide a rationale for stratification of patients with HCC according to underlying aetiology in studies of immunotherapy as a primary or adjuvant treatment.

Current imaging technologies do not sufficiently detect micrometastasis and therefore do not allow adequate stratification of patients with hepatocellular carcinoma (HCC) for curative or systemic therapy. In HCC, presence of stem cell-like, epithelial cell adhesion molecule (EpCAM)-positive cells correlates with tumor aggressiveness and formation of metastasis. Therefore, we investigated the prognostic relevance of EpCAM-positive circulating tumor cells (CTCs) in patients with HCC. Blood from 78 patients (19 patients in the control cohort and 59 patients with HCC) was tested for CTCs with the CellSearch TM system. Correlation analysis to overall survival (OS), the Barcelona Clinic Liver Cancer (BCLC) staging system, macroscopic and microscopic vascular invasion and alpha-fetoprotein (AFP) levels were performed. We detected 1 CTC in 18=59 HCC patients and in 1=19 patients with cirrhosis or benign hepatic tumor (p 5 0.026). OS was significantly shorter (460 vs. 746 days) in the CTC-positive cohort (p 5 0.017). Comparing BCLC stages, significant differences in CTC detection rates were also observed: BCLC stages A 1=9, B 6=31 and C 11=19 (p 5 0.006). Ten of 18 patients with macroscopic and 10=16 patients with microscopic vascular invasion exhibited positive findings in CTC testing (p 5 0.004 and p 5 0.006). Furthermore, CTC results correlated to AFP (cutoff > 400 ng=mL) levels (p 5 0.050). Our study demonstrates frequent presence of EpCAM-positive CTC in patients with intermediate or advanced HCC and its prognostic value for OS with possible implications for future treatment stratification.Hepatocellular carcinoma (HCC), the fifth most common cancer worldwide, has a rising incidence in Western countries, and is ranked third in global cancer-related mortality. 1-7 Most cases result from cirrhosis of the liver or chronic viral hepatitis. It is believed that alcoholic liver disease and nonalcoholic steatohepatitis (NASH) will play a dominant role as underlying etiology in Western countries in the near future. 4 Treatment of patients with confirmed HCC is based on the Barcelona Clinic Liver Cancer (BCLC) staging system. Patients with early-stage HCC (BCLC stage A) are selected for curative resection, local ablative therapy or orthotopic liver transplantation. Unfortunately, most patients in Western countries are diagnosed in an advanced stage (BCLC stage C), characterized by vascular invasion, metastases and an impaired performance status (PS 1-2). 8,9 The key problem in curative treatment in HCC (BCLC stage A) is recurrence after curative therapy. This might be owing to undetectable micrometastasis at initial staging. Therefore, it would be pivotal to rule out a possible metastatic dissemination at the time of diagnosis, including micrometastasis or potential "metastasis-initiating" circulating tumor cells (CTCs) in order to evaluate the true benefit of curative treatment. Furthermore, it is important to determine to what extent BCLC stage B patients (HCC limited to the liver) without CTC might benefit from curative th...

BACKGROUND & AIMS: The prevalence of nonalcoholic steatohepatitis (NASH) associated hepatocellular carcinoma (HCC) is increasing. However, strategies for detection of early-stage HCC in patients with NASH have limitations. We assessed the ability of the GALAD score, which determines risk of HCC based on patient sex; age; and serum levels of a-fetoprotein (AFP), AFP isoform L3 (AFP-L3), and des-gamma-carboxy prothrombin (DCP), to detect HCC in patients with NASH. METHODS: We performed a case-control study of 125 patients with HCC (20% within Milan Criteria) and 231 patients without HCC (NASH controls) from 8 centers in Germany. We compared the performance of serum AFP, AFP-L3, or DCP vs GALAD score to identify patients with HCC using receiver operating characteristic curves and corresponding area under the curve (AUC) analyses. We also analyzed data from 389 patients with NASH under surveillance for HCC in Japan, followed for a median of 167 months. During the 5-year screening period, 26 patients developed HCC. To compensate for irregular intervals of data points, we performed locally weighted scatterplot smoothing, linear regression, and a non-linear curve fit to assess development of GALAD before HCC development. RESULTS: The GALAD score identified patients with any stage HCC with an AUC of 0.96significantly greater than values for serum levels of AFP (AUC, 0.88), AFP-L3 (AUC, 0.86) or DCP (AUC, 0.87).