Purpose: We developed a novel systemic immune-inflammation index (SII) based on lymphocyte, neutrophil, and platelet counts and explored its prognostic value in hepatocellular carcinoma (HCC).Experimental Design: The SII was developed based on a retrospective study of 133 patients with HCC undergoing resection between 2005 and 2006, and validated in a prospective study of 123 patients enrolled from 2010 to 2011. The circulating tumor cell (CTC) level in the validation cohort was measured using the CellSearch system. Prediction accuracy was evaluated with area under the receiver operating characteristic curve (AUC).Results: An optimal cutoff point for the SII of 330 Â 10 9 stratified the patients with HCC into high (!330) and low SII (<330) groups in the training cohort. Univariate and multivariate analyses revealed the SII was an independent predictor for overall survival and relapse-free survival, and prognostic for patients with negative a-fetoprotein and Barcelona Clinic Liver Cancer stage 0þA. The AUCs of the SII for survival and recurrence were higher than other conventional clinical indices. An SII ! 330 was significantly associated with vascular invasion, large tumors, and early recurrence. CTC levels were significantly higher in the SII ! 330 group (1.71 AE 0.34 vs. 4.37 AE 1.04, P ¼ 0.029). In patients with detectable CTCs, those with SII ! 330 had higher recurrence rates and shorter survival time than patients with SII < 330. Conclusion:The SII was a powerful prognostic indicator of poor outcome in patients with HCC and is a promising tool for HCC treatment strategy decisions. The dismal outcome in patients with high SII scores might be related to higher CTC levels. Clin Cancer Res; 20(23); 6212-22. Ó2014 AACR.

Tregs are associated with HCC invasiveness, and intratumoral balance of regulatory and cytotoxic T cells is a promising independent predictor for recurrence and survival in HCC. A combination of depletion of Tregs and concomitant stimulation of effector T cells may be an effective immunotherapy to reduce recurrence and prolong survival after surgery.

Purpose: The aberrant expression of programmed cell death 1ligands 1and 2 (PD-Ls) on tumor cells dampens antitumor immunity, resulting in tumor immune evasion. In this study, we investigated the expression of PD-Ls in human hepatocellular carcinoma (HCC) to define their prognostic significance after curative surgery. Experimental Design: Immunohistochemistry was used to investigate PD-Ls expression as well as granzyme B + cytotoxic and FoxP3 + regulatory T cell infiltration on tissue microarrays containing 240 randomly selected HCC patients who underwent surgery. The results were further verified in an independent cohort of 125 HCC patients. PD-Ls expression on HCC cell lines was detected by Western blot assay. Results: Patients with higher expression of PD-L1 had a significantly poorer prognosis than patients with lower expression. Although patients with higher expression of PD-L2 also had a poorer survival, the difference in recurrence was not statistically significant. Multivariate analysis identified tumor expression of PD-L1 as an independent predictor for postoperative recurrence. No correlation was found between PD-Ls expression and granzyme B + lymphocyte infiltration, whereas a significant positive correlation was detected between PD-Ls expression and FoxP3 + lymphocyte infiltration. In addition, tumor-infiltrating cytotoxic and regulatory T cells were also independent prognosticators for both survival and recurrence. The prognostic value of PD-L1 expression was validated in the independent data set. Conclusion: Our data suggest for the first time that PD-L1 status may be a new predictor of recurrence for HCC patients and provide the rationale for developing a novel therapy of targeting the PD-L1/PD-1pathway against this fatal malignancy.

Epithelial cell adhesion molecule-positive (EpCAM 1 ) hepatocellular carcinoma (HCC) cells may constitute a tumor-initiating subpopulation in tumorigenic cell lines and HCC specimens. In the present study, EpCAM 1 circulating tumor cells (CTCs) were identified prospectively in HCC patients undergoing curative resection, and the prognostic significance and their stem cell-like characteristics were investigated further. Blood samples from 123 HCC patients were tested prior to resection and 1 month thereafter. CTCs were present in 66.67% of patients, and the cell count measured in 7.5 mL of blood (CTC 7.5 ) ranged between 1 and 34. Fifty-one patients had CTC 7.5 of !2 preoperatively, and these patients developed tumor recurrence earlier than those with CTC 7.5 of <2 CTCs (P < 0.001). A preoperative CTC 7.5 of !2 was an independent prognostic factor for tumor recurrence (P < 0.001). Its prognostic significance also applied to patients with alpha-fetoprotein (AFP) levels of 400 ng/mL or subgroups with low recurrence risk (all P < 0.05). A significant decrease of CTC-positive rates (66.67% to 28.15%, P < 0.05) and CTC 7.5 values (2.60 6 0.43 to 1.00 6 0.36, P < 0.05) was observed 1 month after resection. Patients with consistent CTC 7.5 <2 had lower recurrence rates than those with values consistently !2 (15.5% versus 87.50%, P < 0.001). EpCAM 1 CTCs displayed cancer stem cell biomarkers (CD133 and ABCG2), epithelial-mesenchymal transition, Wnt pathway activation, high tumorigenic potential, and low apoptotic propensity. Conclusion: Stem cell-like phenotypes are observed in EpCAM 1 CTCs, and a preoperative CTC 7.5 of !2 is a novel predictor for tumor recurrence in HCC patients after surgery, especially in patient subgroups with AFP levels of 400 ng/mL or low tumor recurrence risk. EpCAM 1 CTCs may serve as a real-time parameter for monitoring treatment response and a therapeutic target in HCC recurrence. (HEPATOLOGY 2013;57:1458-1468 H epatocellular carcinoma (HCC) is one of the most prevalent malignancies worldwide, and associated morbidity and mortality rates have escalated in recent years. 1 Despite improvements in surveillance and clinical treatment strategies, the prognosis of HCC remains very poor due to high incidence of recurrence and metastasis. 2 Traditional clinicopathological parameters such as tumor morphology,