Hep B Blog

Category Archives: Liver Cancer

October is Liver Cancer Awareness Month!

October marks the start of Liver Cancer Awareness Month! This month let’s celebrate your liver for all it does for your body!


Action Alert: Urge ACIP to Recommend Universal Hepatitis B Vaccination for Adults in the US

universal hepatitis B recommendation for adults is critical in addressing the consistently low adult hepatitis B vaccination rates and eliminating viral hepatitis in the United States. Tell the CDC’s Advisory Committee on Immunization Practices (ACIP) that universal adult hepatitis is essential to preventing liver cancer.  Take action here.


What Does Your Liver Do?

The liver is such an important organ – it’s like the engine of your body. It does hundreds of vital things to make sure everything runs smoothly:

  • Stores vitamins, sugar, and iron to help give your body energy
  • Controls the production and removal of cholesterol
  • Clears your blood of waste products, drugs, and other poisonous substances
  • Makes clotting factors to stop excessive bleeding after cuts or injuries
  • Produces immune factors and removes bacteria from the bloodstream to combat infection
  • Releases a substance called “bile” to help digest food and absorb important nutrients

The Link Between Liver Cancer and Hepatitis B  

The most common type of liver cancer is “primary liver cancer” or hepatocellular carcinoma (HCC). Worldwide, the most common risk factor for primary liver cancer is chronic infection with the hepatitis B virus. Chronic viral hepatitis infections (hepatitis B and hepatitis C) cause about 80% of all liver cancers. Obesity, heavy alcohol use, fatty liver disease (NAFLD or NASH), and some metabolic disorders also increase the risk for primary liver cancer. People chronically infected with hepatitis B are more likely to develop liver cancer than uninfected people because the virus directly and repeatedly attacks the liver. These attacks over time can lead to increased liver damage, cirrhosis (scarring of the liver), and ultimately, liver cancer. People who have chronic hepatitis B can reduce their risk of liver cancer through regular medical monitoring, taking antiviral treatment if necessary, and making healthy lifestyle changes.

The best way to prevent liver cancer is to prevent hepatitis B infection! This is why hepatitis B vaccination is so important. When someone gets vaccinated to protect them from getting hepatitis B, they are also preventing liver cancer!

How Would I Know if I Have Liver Cancer?

If you have chronic hepatitis B, make sure you are getting routine surveillance for liver cancer every 6 months with your healthcare provider. This surveillance, which includes a combination of blood tests and liver imaging (ultrasound) is so important because early detection of liver cancer greatly improves the chances of survival with treatment. For patients in whom liver cancer is detected at an early stage and before symptoms occur – while the tumor is small and can be removed – the 5-year survival is greatly improved.  Learn more about who should be screened for liver cancer here.

Unfortunately, liver cancer is on the rise in the United States. The 2020 Annual Report to the Nation on the Status of Cancer found that the incidence of primary liver cancer in the United States increased by 2.5% overall and by 3.7% amongst women – the largest increase in incidence of any cancer between 2012-2016. Liver cancer was also stated as the second most common cause of death for Asian American and Pacific Islander males, who are disproportionately impacted by HBV, and the fifth most common cause of cancer deaths for men overall.

Making sure that people are protected from getting hepatitis B is so important in the U.S. – and establishing universal vaccination recommendations is essential to reducing liver cancer incidence and mortality. 

The Role of Universal Screening Guidelines for Hepatitis B

In the U.S., current childhood immunization recommendations by the Advisory Committee on Immunization Practices (ACIP) were established in the 1990s, and have significantly helped reduce rates of hepatitis B transmission over the past two decades, as more and more children have been vaccinated against hepatitis B. Individuals born prior to these recommendations, however, may be vulnerable to HBV, and span three generations: Baby Boomers, Generation X, and Millennials. Together, these groups account for approximately 63% of the U.S. population. Within this vulnerable population, the recent rise in incidence of hepatitis B cases has increased the most within 30- 49 year olds, attributed to the opioid epidemic. Of the 2.4 million Americans estimated to be living with hepatitis B, approximately 75% remain undiagnosed and may display no symptoms. This increases the risk of transmission to unvaccinated household members or sexual partners who are unaware that precautions should be taken to prevent transmission. Lack of awareness and low vaccination rates in this community leave millions of Baby Boomers, Generation X, and Millenials vulnerable to HBV.

Take Action: Sign the Petition to Support a Recommendation for  Hepatitis B Vaccination for All Adults!

The CDC’s Advisory Committee on Immunization Practices (ACIP) is currently reviewing evidence to determine if they should recommend universal adult hepatitis B vaccination. If the committee votes in favor of the proposal, this would mean that all adults in the United States would officially be recommended to receive the hepatitis B vaccine by the federal government. 

universal adult hepatitis B recommendation is critical in addressing the consistently low adult hepatitis B vaccination rates and eliminating viral hepatitis in the United States. Please add your name to support universal adult hepatitis B vaccination by Friday, October 15th here. For questions or more information, please reach out to Michaela.Jackson@hepb.org. 

 Other Resources

  1. Listen and LearnListen to B Heppy’s newest podcast episode “Liver Cancer and Hepatitis B”! We chat with Dr. Rothstein from the University of Pennsylvania about the relationship between hepatitis B and liver cancer. He offers provider insight and recommendations to individuals listening.
  2. Check Out Liver Cancer Connect – This program was created to provide individuals and families with the information and support they need when facing the challenge of primary liver cancer.
  3. Seek Community SupportHep B Community a global peer-led, volunteer-driven forum to support those living with and affected by hep B. They are dedicated to connecting people affected by hepatitis B with each other and verified experts in the field, who provide trustworthy and accurate advice.
  4. Learn More From Experts – Dr. Robert Gish talks about treatment options for liver cancer. How does the stage of cancer affect treatment? Why are screening and surveillance so important? What are the available treatments and what are the therapies in development? Find out by listening to the webinar.

Announcing New Liver Cancer Clinical Trials

Over the past few decades, there have been several advancements in liver cancer research and treatment. These have included improvements in chemotherapy treatments that can now successfully shrink tumors to a size at which they can be more easily surgically removed, and the development of therapies that block blood flow to tumors. Liver ablation (tissue removal) and transplantation techniques have also been greatly improved in recent years (Johns Hopkins Medicine, 2020). Many of these advancements would not have been possible without the help of clinical trial volunteers with liver cancer. Your contribution is important and valuable and may help research for the future. Learn more about these opportunities today.

The pharmaceutical company Bristol Myers Squibb (BMS) is now enrolling for two clinical studies in liver cancer (also called hepatocellular carcinoma or HCC). These trials have the reference numbers CA209-9DW and CA209-74W. If eligible and you are willing and able to take part, you will be helping to advance research.

One of these trials is researching a study drug called nivolumab. Researchers want to find out how well the study drug works, both with and without ipilimumab in combination with trans-arterial ChemoEmbolization (TACE), when compared to TACE alone in participants with intermediate-stage HCC. Eligible trial participants must be at least age 18 years old and must not have had a liver transplant, or be on the waiting list for a liver transplant. This is not a full list of trial requirements.

Another trial is researching nivolumab in combination with another study drug called ipilimumab (also called Yervoy) in participants with advanced HCC. Researchers in this trial want to find out how well this study drug combination works when compared to other drugs called sorafenib or lenvatinib. Eligible trial participants must be at least 18 years old and must not have had any type of prior chemotherapy. This is not a full list of trial requirements.

For more details about each trial, including full trial requirements, lists of tests and procedures used to determine trial eligibility, and more details about Bristol Myers Squibb, please visit the BMSStudyConnect website.

Before you decide to enroll in a clinical trial, you can download the Study Participant’s Guide. This guide is available in many languages on this site, and includes information about trial participation, why clinical studies are important, questions to ask your doctor before participating, guidance on transportation and lodging during a clinical trial, helpful tips on how to prepare to take part in a trial, and links to helpful resources.

References

Johns Hopkins Medicine. (2020). 4 Liver Cancer Treatment Advances. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/4-liver-cancer-treatment-advances.

Liver Cancer Among Men

June is Men’s Health Month. This month we bring awareness to preventable health problems and encourage early detection and treatment of disease among men and boys. In 2020, The World Health Organization found that liver cancer is the third leading cause of cancer deaths with 830,000 deaths.1 Liver cancer occurs more often in men than in women with it being the 5th most commonly occurring cancer in men and the 9th most commonly occurring cancer in women.2

There are two main types of liver cancers, hepatocellular carcinoma (HCC) which accounts for about 75% of liver cancer cases, and intrahepatic cholangiocarcinoma which accounts for 12-15% of cases. Liver cancer especially impacts Asian countries like Mongolia, Vietnam, Laos, Cambodia, Thailand, and China. Hepatitis B is the leading cause of HCC globally. Of the 300 million individuals living with a chronic hepatitis B diagnosis, about 25% will develop HCC.3

Risk Factors

HCC affects men with an incidence 2x-4x higher than women due to differences in behavioral risk factors and biological factors.3 Research has found men were less likely to undergo HCC screening and more likely to smoke.  Additionally, studies have shown alcohol is a major risk factor for HCC. In the United States, HCC associated with alcohol is higher among men than in women at 27.8% and 15.4% respectively.3

Biologically, there is evidence estrogen (a female hormone) decreases IL-6 mediated hepatic inflammation and viral production.3 Studies have demonstrated IL-6 may promote virus survival and/or exacerbation of the disease.4 In the context of hepatitis B, men are at an increased risk for HCC as they do not produce estrogen which would help decrease the risk of IL-6, in turn, promoting viral survival.

Prevention

The great news is that HCC can be prevented by preventing hepatitis B. There is a safe and effective vaccine that can be completed in either 2 or 3 doses over a span of 3 months. Ask your healthcare provider for the hepatitis B vaccine series.

If you are unsure of your hepatitis B status, you can get tested! Ask your healthcare provider for the “Hepatitis B Panel” – it should include 3 parts. The panel is super simple and only requires one sample of blood.  If you are of Asian descent and male, it is especially important for you to get tested as liver cancer disproportionately impacts individuals from Asian countries and men.

If you have chronic hepatitis B, make sure your doctor screens you regularly for liver cancer. Typically done with a combination of blood tests and imaging, liver cancer screening can help detect HCC early when it is still curable.

As we wrap up June and Men’s Health Month, you are encouraged to get vaccinated and tested for hepatitis B. Take control of your health, and don’t wait!

References

  1. https://www.who.int/news-room/fact-sheets/detail/cancer
  2. https://www.wcrf.org/dietandcancer/liver-cancer-statistics/
  3. Wu EM, Wong LL, Hernandez BY, et al. Gender differences in hepatocellular cancer: disparities in nonalcoholic fatty liver disease/steatohepatitis and liver transplantation. Hepatoma Res. 2018;4:66. doi:10.20517/2394-5079.2018.87
  4. Velazquez-Salinas L, Verdugo-Rodriguez A, Rodriguez LL, Borca MV. The Role of Interleukin 6 During Viral Infections. Front Microbiol. 2019;10:1057. Published 2019 May 10. doi:10.3389/fmicb.2019.01057

 

Author: Evangeline Wang

Contact Information: info@hepb.org

 

Hepatitis B and Liver Cancer

Tomorrow, February 4th, marks World Cancer Day! This day harnesses the international community to “raise awareness, improving education and catalysing personal, collective and government action, we’re working together to reimagine a world where millions of preventable cancer deaths are saved and access to life-saving cancer treatment and care is equal for all – no matter who you are or where you live.”

Hepatitis B and Liver Cancer

Cancer is a disease in which normal cells change and grow uncontrollably, that can form a lump called a tumor or mass. A tumor can be benign (not cancerous) or malignant (cancerous). The name of the cancer depends on the part of the body where the cancer first started. The term “primary liver cancer” refers to hepatocellular carcinoma (HCC), the most common type of liver cancer, which starts in liver cells called “hepatocytes.”

In the United States, primary liver cancer has become the fastest growing cancer in terms of incidence (new cases), in both men and women. From 2012-2016, the incidence of liver cancer increased by 2.5%, the largest increase of any cancer during the time period. In 2018, an estimated 42,220 new cases of liver cancer were diagnosed and an estimated 30,200 people died.

Liver cancer mortality also continues to increase, especially among Caucasian, Alaskan Native, American Indian and Hispanic males. Liver cancer disproportionately impacts certain communities more than others: in the U.S., it is now the 5th most common cause of cancer death for men overall, but the 2nd most common cause of cancer death among Asian American and Pacific Islander men, and the 4th most common cause of cancer death among Alaskan Native, American Indian and Hispanic males. The five-year survival rate is about 18%.

Worldwide, the most common risk factor for liver cancer is chronic infection with the hepatitis B virus. Chronic viral hepatitis infections (hepatitis B and hepatitis C) cause at least 80% of all liver cancers. In the United States, the leading cause is chronic hepatitis C virus infections because of the greater number of Americans infected with this virus. Chronic infections with hepatitis B or C are responsible for making liver cancer the most common cancer in many parts of the world. Take a look at other factors which might put you at a higher risk for developing liver cancer.

Prevention

The hepatitis B vaccine was named the first “anti-cancer” vaccine by the U.S. Food and Drug Administration because it prevents chronic hepatitis B infections, thereby preventing liver cancer caused by the hepatitis B virus. In the United States, the hepatitis B vaccine is recommended for all infants and children, and adults at high risk for infection. In many countries, including the United States, vaccinating newborns with the hepatitis B vaccine at birth has resulted in a dramatic reduction in the number of new cases of liver cancer caused by hepatitis B. For more information about the vaccine, visit here.

For more information about liver cancer please visit our Liver Cancer Connect page.

 References

https://www.worldcancerday.org/about-us

https://www.hepb.org/research-and-programs/liver/

 

 

 

Your Liver and Hepatitis B

 

Your Liver and Hepatitis B

 Happy Liver Cancer Awareness Month! Your liver is an important organ for digesting food and breaking down toxins. Its main functions include: filtering blood from the digestive tract and transporting it back to the rest of the body, removing toxins from the blood, and storing important nutrients that keep the body healthy.

Hepatitis B is a viral infection of your liver that can cause serious damage over time. Chronic infection with the hepatitis B virus (HBV) can ultimately lead to scarring, cirrhosis, liver cancer, and liver failure. Liver cancer is the 3rd deadliest cancer worldwide, with 5-year survival rates of only 19%. There are few effective treatments for liver cancer, and we, therefore, must rely on prevention and early detection in order to save lives. Chronic hepatitis B infection causes approximately 78% of hepatocellular carcinoma (HCC), or primary liver cancer. The key to saving lives is ensuring that individuals infected with HBV are diagnosed and linked with appropriate care, including regular screening for liver cancer.

In the U.S., liver cancer incidence and death rates are increasing at a faster rate than any other cancer and are projected to continue to rise through at least 2030. Up to 2.2 million people are chronically infected by HBV in the U.S. and the majority is unaware of their infection. Identifying, managing and treating those with HBV infection can help prevent liver cancer in many people. Additionally, regularly screening people with chronic hepatitis B  for liver cancer can aid with early detection and treatment of liver cancer. If diagnosed early, liver cancer can be treated and even cured.

Below are some practices you can easily incorporate into your daily life and routine to keep your liver healthy while living with hepatitis B.

Healthy Liver Tips

  1. Reduce alcohol intake: Alcoholic beverages can damage or destroy liver cells and create additional health problems.
  2. Eat a healthy diet: Increase the amount of whole foods in your diet like fruits and vegetables while decreasing the amount of refined carbohydrates (pastas, white rice, white bread), processed sugar, and saturated fats which can create a healthy environment for your liver.
  3. Daily exercise: It is recommended for adults to exercise at least 60 minutes per day. Not only does this have many other health benefits, but it can reduce the fat surrounding your liver which can decrease your risk of liver cancer.
  4. Avoid the use of illicit drugs: Drugs like marijuana, cocaine, heroin, inhalants, or hallucinogens put stress on your liver and reduce its functioning capability.
  5. Wash produce and read labels on household chemicals: Pesticides and other chemicals can contain toxins which are harmful to your liver.

Incorporating these healthy practices does not have to be difficult. Choose one of the five tips that is most convenient with your current lifestyle and use it as a starting point for a healthier routine. By gradually incorporating each healthy liver tip into your lifestyle, you can reduce your risk of a negative liver outcome creating a healthier you!

Resources for Liver Cancer and Hepatitis B

Please join Hepatitis B Foundation, Hep B United and Hep B United Philadelphia’s webinar on October 20th at 3PM ET to learn more about hepatitis B and liver cancer. Dr. Kenneth Rothestein, Director of Regional Outreach and Regional Hepatology from Penn Medicine will be highlighting the importance of liver cancer screening for prevention. Register here!

To promote and ultimately prevent liver cancer this October we are pleased to share the Centers for Disease Control and Prevention’s Know Hepatitis B (KHB) Campaign Product of the Month – the Infographic: “Get Tested for Hepatitis B.”

The CDC’s Know Hepatitis B Campaign’s infographic, “Get Tested for Hepatitis B” encourages Asian Americans and Pacific Islanders to get tested for hepatitis B. This 2-page downloadable document is available in English, Traditional Chinese, Vietnamese and Korean languages and answers commonly asked questions about hepatitis B.

For more information about the Know Hepatitis B Campaign, visit the campaign website.

 

Author: Evangeline Wang, Program Coordinator, Hepatitis B Foundation

Contact Information: info@hepb.org

Does Hepatitis Delta Increase My Risk for Liver Cancer?

 

 

 

 

 

The short answer is, possibly.  Although there is extensive research to support the role of hepatitis delta in accelerating the risk for progression to cirrhosis (liver scarring) compared to hepatitis B infection (1,2) only, strong data directly linking an increase in risk for hepatocellular carcinoma (HCC) is lacking. It is known that coinfection promotes continually progressing inflammation within the liver by inducing a strong immune response within the body; where it essentially attacks itself (3), but the specific role of hepatitis delta in HCC isn’t fully understood. It gets complicated because although cirrhosis is usually present in hepatitis B patients who also have HCC, but scientists have not pinpointed a specific way that the virus may impact cancer development (4). There have been some small studies that have documented a correlation between hepatitis delta and an increase in HCC, but some analysis’s have even called the extent of its involvement in HCC as ‘controversial’ (5). However, other scientific studies may suggest the contrary.

Because hepatitis delta cannot survive without hepatitis B, and doesn’t integrate into the body the same way, it may not be directly responsible for cancer development, but it has been suggested that the interactions between the two viruses may play a role (6). It has also been suggested that hepatitis delta may play a role in genetic changes, DNA damage, immune response and the activation of certain proteins within the body – similarly to hepatitis B and may amplify the overall cancer risk (7,8). One of these theories even suggests that hepatitis delta inactivates a gene responsible for tumor suppression, meaning it may actually promotes tumor development, a process that has been well-documented in HCC cases (9,10).

Regardless of the specific impact or increase in risk for HCC due to the hepatitis delta virus, hepatitis B is known to increase someone’s risk, with 50-60% of all HCC globally attributable to hepatitis B (11). People with hepatitis delta coinfection still need to be closely monitored by a liver specialist, as 70% of people with both viruses will develop cirrhosis within 5-10 years (12). Monitoring may be blood testing and a liver ultrasound to screen for HCC every 6 months. Closer monitoring may be required if cirrhosis is already present, or to monitor response to treatment (interferon).

For more information about hepatitis delta, visit www.hepdconnect.org.

References:

  1. Manesis EK, Vourli G, Dalekos G. Prevalence and clinical course of hepatitis delta infection in Greece: A 13-year prospective study. J Hepatol. 2013;59:949–956.
  2. Coghill S, McNamara J, Woods M, Hajkowicz K. Epidemiology and clinical outcomes of hepatitis delta (D) virus infection in Queensland, Australia. Int J Infect Dis. 2018;74:123–127.
  3. Zhang Z, Filzmayer C, Ni Y. Hepatitis D virus replication is sensed by MDA5 and induces IFN-β/λ responses in hepatocytes. J Hepatol. 2018;69:25–35.
  4. Nault JC. Pathogenesis of hepatocellular carcinoma according to aetiology. Best Pract Res Clin Gastroenterol. 2014;28:937–947.
  5. Puigvehí, M., Moctezuma-Velázquez, C., Villanueva, A., & Llovet, J. M. (2019). The oncogenic role of hepatitis delta virus in hepatocellular carcinoma. JHEP reports: innovation in hepatology, 1(2), 120–130.
  6. Romeo R, Petruzziello A, Pecheur EI, et al. Hepatitis delta virus and hepatocellular carcinoma: an update. Epidemiol Infect. 2018;146(13):1612‐1618.
  7. Majumdar A, Curley SA, Wu X. Hepatic stem cells and transforming growth factor β in hepatocellular carcinoma. Nat Rev Gastroenterol Hepatol. 2012;9:530–538.
  8. Mendes M, Pérez-Hernandez D, Vázquez J, Coelho AV, Cunha C. Proteomic changes in HEK-293 cells induced by hepatitis delta virus replication. J Proteomics. 2013;89:24–38.
  9. Chen M, Du D, Zheng W. Small Hepatitis Delta Antigen Selectively Binds to Target mRNA in Hepatic Cells: A Potential Mechanism by Which Hepatitis D Virus Down-Regulates Glutathione S-Transferase P1 and Induces Liver Injury and Hepatocarcinogenesis. Biochem Cell Biol. August 2018.
  10. Villanueva A, Portela A, Sayols S. DNA methylation-based prognosis and epidrivers in hepatocellular carcinoma. 2015;61:1945–1956.
  11. Hayashi PH, Di Bisceglie AM. The progression of hepatitis B- and C-infections to chronic liver disease and hepatocellular carcinoma: epidemiology and pathogenesis. Med Clin North Am. 2005;89(2):371‐389.
  12. Abbas, Z., Abbas, M., Abbas, S., & Shazi, L. (2015). Hepatitis D and hepatocellular carcinoma. World journal of hepatology, 7(5), 777–786.

 

Hepatitis B Research Review: May

This month, research from Melbourne, Australia indicates that the kinases TBK1 and IKKε act redundantly to initiate STING-induced, NF-kB-mediated transcription of proinflammatory cytokines. Nearby researchers also working in Melbourne have demonstrated that an HBV vaccine composed of glycosylated HBV surface protein outperforms those currently in use.  Also, researchers at St. Jude Children’s Research Hospital in Memphis, Tennessee have elucidated the role of caspase-6 in influenza A virus host defense.
  • TBK1 and IKKε Act Redundantly to Mediate STING Induced NF-kB Responses in Myeloid Cells – Cell Reports
    • This paper from The Walter and Eliza Hall Institute of Medical Research in Melbourne, Australia deciphers the role of the kinases TBK1 and IKKε in STING-induced, NF-kB-mediated cytokine production. Stimulator of Interferon Genes (STING) protein is a vital component of the innate immune system. Cyclic guanosine monophosphate-adenosine monophosphate (cGAMP) synthase (cGAS), is a pattern recognition receptor (PRR) that senses cytoplasmic double-stranded DNA (dsDNA). In response to dsDNA binding, cGAS catalyzes the production of 2’3′-cGAMP, a cyclic dinucleotide (CDN) which activates STING by direct binding. Once bound to 2’3′-cGAMP, STING dimers undergo a conformational change and translocate from the endoplasmic reticulum (ER) to the Golgi apparatus. At the Golgi, the serine-threonine protein kinase TANK-binding kinase 1 (TBK1) phosphorylates STING at residues in its C-terminal tail (CTT). This phosphorylation causes the recruitment of interferon regulatory factor 3 (IRF3) to STING which is also phosphorylated by TBK1. Phosphorylated IRF3 forms dimers and translocates to the nucleus where it induces the expression of type I interferons (IFN-I) such as IFN-β. IFN-I production and secretion lead to the activation of numerous IFN-stimulated genes (ISGs) which induce a robust antiviral state in the cell. Concomitant to IFN-I induction, STING activation is also known to induce a set of proinflammatory cytokines through the transcription factor called nuclear factor-kB (NF-kB). These cytokines include tumor necrosis factor alpha (TNFα) and interleukins (IL) IL-1β and IL-6. While TBK1 and to a much lesser extent IkB kinase ε (IKKε) are needed for IRF3-mediated IFN-I transcription, several lines of evidence indicate that they may be unnecessary for STING-induced NF-kB activity. For instance, the CTT region of STING, critical to IFN induction, is observed only in vertebrates. While STING activation in the invertebrate species Drosophila melanogaster and Nematostella vectensis results in NF-kB-mediated transcription of cytokines, it does not induce IFN-I transcription. Additionally, ubiquitination of STING at lysine residues K244 and K288 which is required for its trafficking from the ER to the Golgi is essential for IFN-I induction, but not for NF-kB activation. Finally, phosphorylation of STING at serine residues S358 and S366 in the CTT is required for IRF3 activation but is unnecessary for NF-kB activity. This publication reports that while TBK1 kinase activity is critical for IRF3 activation, TBK1 and IKKε act redundantly and in a kinase-independent manner to activate NF-kB signaling. To determine this, conditional TBK1-knockout mice were generated. These mice were the offspring of mice “floxed” for TBK1 and “RosaCre” mice (ROSA26-CreERT2). The floxed mice were mutated to have their TBK1 gene sandwiched between two lox P sites (Tbk1fl/fl). The RosaCre mice were mutated to constituatively produce a fusion protein of the Cre recombinase and the estrogen receptor (CreER).  The TBK1 conditional knockout mice (Tbk1fl/fl x RosaCre) transcribe TBK1 until they are treated with the synthetic steroid tamoxifen. Tamoxifen binds the the CreER fusion protein (CreERT) and causes its translocation to the nucleus where it binds to lox P sites and its recombinase activity causes the deletion of the TBK1 gene. Conditional knockout mice had to be used to study TBK1 because complete constituative TBK1 knockout is lethal to mice. Primary bone marrow-derived macrophages (BMDM) were obtained from both tamoxifen-treated wild-type Tbk1fl/fl (WT) and Tbk1fl/fl x RosaCre (TBK1 knockout) mice. When subjected to the STING agonist 2’3′-cGAMP, BMDMs from WT mice showed phosphorylation of IRF3 by Western blot and secretion of IFN-β by ELISA. Under the same treatment, BMDMs derived from TBK1 knockout mice showed drastically reduced IRF3 phosphorylation and IFN-β secretion. Interestingly, BMDMs derived from both WT and TBK1 knockout mice secreted similar levels of TNFα when treated with 2’3′-cGAMP. Next, BMDCs from normal mice were immortalized and CRISPR/Cas9 was used to knockout expression of TBK1, IKKε, or both. Significantly, while TNFα secretion upon 2’3′-cGAMP treatment was modestly reduced by the knockout of either TBK1 or IKKε, it was almost completely ablated by the knockout of both genes. Interestingly, knockout of both genes had no effect on the secretion of TNFα in response to treatment with lipopolysaccharide (LPS). Finally, in order to determine the upstream signaling responsible for STING-mediated NF-kB activity, two proteins were investigated: transforming growth factor b-activated kinase 1 (TAK1) and inhibitor of nuclear factor kappa-B kinase subunit beta (IKKβ). Small molecule inhibitors were used to inhibit TAK1 and IKKβ prior to treatment with the mouse STING agonist DMXAA. Inhibition of both TAK1 and IKKβ resulted in diminished NF-kB activity, implicating their role as kinase activators of NF-kB downstream of STING. Taken together, these results indicate that TBK1 and IKKε act redundantly to carry out STING-mediated NF-kB activity. Additionally, it is likely that TAK1 acts downstream of TBK1 and IKKε to activate the IKK complex, resulting in NF-kB activity. This finding has direct therapeutic significance for STING-driven autoimmune disorders such as chronic polyarthritis. Many strategies for overcoming such diseases only target the IFN-I-producing pathway, while pro-inflammatory cytokine production may go unchecked. This finding elucidates a less-studied arm of STING signaling which is important for basic science and future therapies.
  •  Glycoengineered Hepatitis B Virus-Like Particles with Enhanced Immunogenicity – Vaccine
    • This paper from the Royal Melbourne Institute of Technology University in Melbourne, Australia shows that an HBV vaccine using glycosylated HBV surface protein may have better efficacy than the current vaccine. HBV encodes three surface proteins (large, medium, and small) which are truncated forms of the same protein. The small HBV surface protein (HBsAgS) contains the major antigenic determinants of the protein. In the absence of other viral proteins, HBsAgS will self-assemble into non-infectious particles termed subviral particles (SVP), also known as virus-like particles (VLP). VLPs are the major species of HBV viral particle secreted from infected hepatocytes. When grown in mammalian cells in vivo, approximately half of HBsAgS molecules receive N-glycosylation at asparagine residue N146. N-glycosylation is the addition of an oligosacharide molecule to the nitrogen atom of an asparagine residue within a protein. These modifications occur in the endoplasmic reticulum (ER) and are important for the function of proteins and for signaling within the cell. The current HBV vaccines are composed of HBsAgS VLPs grown in yeast. In contrast to VLPs grown in mammalian cells, yeast-derived VLPs have no N-glycosylation. Additionally, HBV vaccines contain adjuvants which aid in immune system stimulation. The widely-used HBV vaccines Engerix-B (GlaxoSmithKine) and Recombivax HB (Merck) contain the adjuvants aluminum hydroxide and aluminum hydroxyphosphate respectively. Aluminum salts stimulate the immune system by causing activation of the NLR family pyrin domain-containing protein 3 (NLRP3) inflammasome pathway. Upon vaccination, aluminum salt crystals are taken into local dendritic cells via phagocytosis where they rupture the lysosome, causing activation of the NLRP3 inflammasome which includes active caspase 1. The catalytic activity of caspase 1 cleaves pro-interleukin 1β (IL-1β) as well as gasdermin D into their active forms. Cleaved gasdermin D forms pores in the cell membrane resulting in the rapid release of pro-inflammatory IL-1β and ultimately causing pyroptosis, an immunogenic form of cell death. This publication shows that using glycosylated HBsAgS VLPs in the presence of aluminum hydroxide may result in a more immunogenic vaccine than that which is currently used. To study the effect of HBsAgS glycosylation, first N-terminal FLAG-tagged wild-type (WT) HBsAgS and point-mutated variants were expressed in HEK 293 cells. Variants used were threonine-to-asparagine mutant T116N and asparagine-to-glutamine mutant N146Q. The T116N mutant contained an additional asparagine available for glycosylation on the domain of HBsAgS which faces the lumen of the ER. On the other hand, the N146Q mutant lacked the asparagine which is typically N-glycosylated. SDS-PAGE followed by Coomassie staining revealed that about 50% of WT HBsAgS was glycosylated, running as two distinct bands at 27 kDa (glycosylated) 24 kDa (non-glycosylated).  However, HBsAgS mutant T116N ran as two predominant bands at 27 kDa (monoglycosylated) and 29 kDa (diglycosylated). HBsAgS mutant N146Q ran as a single band at 24 kDa, indicating no glycosylation. This result confirmed that about half of HBsAgS produced in mammalian cells are N-glycosylated at N146 and no other amino acid. Both HBsAgS mutants formed VLPs similar to WT as viewed by transmission electron microscopy. VLPs were mostly spherical with some elongated in shape. Next, following removal of N-glycans using the enzyme peptide:N-glycosidase F (PNGase), quantitative N-glycome profiling was conducted using an advanced spectrometry technique called porous graphitized carbon liquid chromatography-electrospray ionization-tandem mass spectrometry (PGC-LC-ESIMS/MS). The T116N mutant was found to have a greater N-glycan density than WT HBsAgS, but a similar distribution of N-glycan types. Finally, the immunogenicity of glycoengineered HBsAg was tested using a mouse model of vaccination. BALB/c mice were immunized at weeks 1, 3, 5, and 7 with purified WT or T116N HBsAgS in the presence or absence of aluminum hydroxide. Some mice were immunized with Engerix-B as a control group. Serum samples were taken at weeks 2, 4, 6, 8, and 18 post-vaccination and analyzed by an ELISA assay against yeast-derived VLPs. Mice immunized with T116N HBsAgS combined with aluminum hydroxide had the highest titer of anti-HBsAgS antibodies at every time point tested. This indicates that hyper-glycosylated HBsAg is more effective than non-glycosylated HBsAg in mounting an immune response. The authors propose that hyper-glycosylated HBsAgS is more readily taken into antigen-presenting cells (APCs) due to an increased affinity for manose-binding lectin receptors expressed on those cells. Additionally, hyper-glycosylation of HBsAgS may lower its strength of adsorption with aluminum hydroxide, making it more prone to release and antigen processing. Taken together, these results demonstrate that glycoengineered HBsAgS formed VLPs and when combined with aluminum hydroxide, exhibited increased immunogenicity in BALB/c mice in comparison to a currently used vaccine. This publication shows one way in which molecular cloning techniques may be used to improve the efficiency and reliability of HBV vaccines.
  • Caspase-6 Is a Key Regulator of Innate Immunity, Inflammasome Activation, and Host Defense – Cell
    • This paper from St. Jude Children’s Research Hospital in Memphis, Tennessee shows that caspase-6 mediates inflammasome activation and plays a role in the activation of the programmed cell death (PCD) pathways pyroptosis, apoptosis, and necroptosis (PANoptosis). The caspase family of proteins are cysteine-aspartic proteases which cleave proteins between cysteine and aspartic acid residues. Caspases play essential rolls in inflammation and PCD pathways. Caspases exist as inactive zymogens (pro-forms) within the cell until they are cleaved, resulting their active form. Caspases are grouped as being either inflammatory (caspase-1, -4, -5, and -11) or apoptotic (caspase-3, -6, -7, -8, -9 and -10). However, emerging evidence has demonstrated crosstalk between these groups under certain conditions. Inflammatory caspases can play a role in PCD pathways and apoptotic caspases can play a role in inflammatory pathways. While caspase-6 has long been considered an executioner caspase in the apoptotic pathway, its major functions have remained unknown. This publication demonstrates that caspase-6 is an essential upstream component of Z-DNA binding protein 1 (ZBP1)-mediated inflammasome activation and subsequent PANoptosis. The NLR family pyrin domain-containing protein 3 (NLRP3) inflammasome is a multimeric structure consisting of NLRP3, apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC), and caspase 1 subunits. NLRP3 inflammasome activation results in caspase-1 mediated cleavage of pro-interleukin 1β (IL-1β) as well as gasdermin D into their active forms. Cleaved gasdermin D forms pores in the cell membrane resulting in the rapid release of pro-inflammatory IL-1β and ultimately causing pyroptosis. The NLRP3 inflammasome can be activated by a variety of stimuli including canonical stimuli (pore-forming toxins, ATP) and non-canonical stimuli (intracellular LPS sensed by caspase-4/5). Additionally, this group has previously demonstrated that the NLRP3 inflammasome can also be activated by ZBP1 sensing of influenza A virus (IAV). In order to discern if caspase-6 is involved in NLRP3 inflammasome activation, bone marrow-derived macrophages (BMDMs) were derived from caspase-6 knockout (Casp6–/–) mice. Caspase-6 was shown to be dispensable for both canonical and non-canonical activation of the NLRP3 inflammasome, as caspase-1 cleavage was shown via Western blot and secretion of both IL-1β and IL-18 was shown via ELISA. However, when infected with IAV, Casp6–/– BMDMs failed to display caspase-1 cleavage and cytokine release compared to the wild-type (WT) control. This indicates that caspase-6 plays an essential role in IAV-induced NLRP3 inflammasome activation and pyroptosis. As this group and others have shown that ZBP1 regulates various forms PCD in response to IAV infection, next the roll of caspase-6 in PCD pathways was investigated. Overall cell death 12 hours following IAV infection was reduced by about 50% in Casp6–/– BMDMs as measured by SYTOX Green nucleic acid stain and high-content imaging. To investigate this phenomenon further, CRISPR-Cas9 was used to generate caspase-6 knockout (Casp6KO) mouse embryonic fibroblasts (MEFs). IAV-induced cell death was largely ablated in Casp6KO MEFs compared to WT MEFs as measured by SYTOX Green nucleic acid stain and high-content imaging. Furthermore, Casp6KO MEFs showed highly reduced IAV-induced cleavage of apoptotic caspases-3, -7, and -8 as measured by Western blot. Additionally, Casp6–/– BMDMs showed highly reduced cleavage of the pyroptosis effector gasdermin D and phosphorylation of the necroptosis effector pseudokinase mixed lineage kinase domain-like (MLKL) upon IAV infection. Taken together, these results indicate that caspase-6 plays a critical role in the IAV-induced PCD pathways pyroptosis, apoptosis, and necroptosis. Interestingly, Casp6–/– BMDMs were still susceptible to necroptosis by the classical trigger of TNFα plus zVAD, indicating an IAV-specific necroptotic function of caspase-6. In a mouse model, the authors found that caspase-6 deficiency increased susceptibility to IAV infection. Upon IAV infection, ZBP1 recruits RIPK1 and RIPK3 via the receptor-interacting protein homotypic interaction motif (RHIM) to form a cell death complex. It has been demonstrated that from this complex, RIPK3 activates parallel pathways of apoptosis and necroptosis. In order to explore if this complex directly regulates caspase-6 cleavage, Ripk3–/– and Zbp1–/– BMDMs were utilized. Both Ripk3–/– and Zbp1–/– BMDMs showed reduced cleavage of caspase-6, -8, -7, -3 and gasdermin D as well as reduced MLKL phosphorylation. This result confirms the previous finding that in response to IAV infection, ZBP1 and RIPK3 mediate both apoptotic and necroptotic pathways and suggests a third role for RIPK3 in IAV-induced, ZBP1-mediated pyroptosis. This result also indicates that caspase-6 is regulated at the level of the ZBP1-RIPK3 complex when taken together with the finding that caspase-6 deletion affected all three forms of PCD. Additionally, similar experiments using BMDMs lacking either gasdermin D or NLRP3 both showed no change in caspase-6 cleavage. To determine which protein in the ZBP1-RIPK3 complex interacts with caspase-6, components of the complex (RIPK1, RIPK3, ZBP1, caspase-8) were individually over-expressed in HEK293T cells via transfection alongside a catalytically dead, FLAG-tagged caspase-6, followed by co-immunoprecipitation (Co-IP) using an anti-FLAG antibody. Only RIPK3 was pulled down alongside FLAG-caspase-6, indicating that caspase-6 interacts with RIPK3. Further Co-IP experiments in immortalized BMDMs utilizing a doxycycline-inducible FLAG-caspase-6 showed that increased levels of caspase-6 improved the ability of RIPK3 to interact with ZBP1. This indicates that caspase-6 may promote IAV-induced PANoptosis by facilitating the interaction of ZBP1 with RIPK3. This paper identifies a previously unknown role for caspase-6 in regulating ZBP1-mediated inflammasome activation and PANoptosis. Additionally, caspase-6 was shown to be essential for host defense against AIV in a mouse model. The results presented here further elucidate the complex interactions of cell death effectors in the context of IAV infection. These findings may help in the development of novel IAV therapies as well as treatments for diseases with abnormally regulated cell death pathways.

Meet our guest blogger, David Schad, B.Sc., Junior Research Fellow at the Baruch S. Blumberg Institute studying programmed cell death such as  apoptosis and necroptosis in the context of hepatitis B infection under the direction of PI Dr. Roshan Thapa. David also mentors high school students from local area schools as part of an after-school program in the new teaching lab at the PA Biotech Center. His passion is learning, teaching and collaborating with others to conduct research to better understand nature.

 

Protecting Yourself From Liver Cancer While Living with Hepatitis B

This Liver Cancer Awareness Month, we are connecting the dots between hepatitis B and liver cancer. Hepatitis B is responsible for up to 60% of all liver cancer cases worldwide. In fact, some of the highest rates of liver cancer are found in places with extremely high rates of hepatitis B, such as sub-Saharan Africa and Southeast Asia. Although liver cancer is the sixth most common cancer in the world, it is the second most common cause of cancer deaths. Liver cancer prevention should be a priority for all living with hepatitis B. Luckily, there are steps that you can take to prevent liver cancer – whether you are living with hepatitis B or not! 

The Importance of Regular Check-Ups

Did you know that a chronic hepatitis B infection can lead to liver cancer without signs of previous damage such as cirrhosis?  Many people do not realize that chronic hepatitis B is the primary global risk factor for developing liver cancer. Cirrhosis – or scarring or the liver – is often a risk factor for liver cancer, but it is not always the case for those living with hepatitis B. This is one of the reasons why it is so important for family members and sexual partners of infected individuals to get tested as well! Lack of symptoms does not mean that damage is not occurring. 

Visiting a doctor regularly is the best way to prevent liver cancer if you are living with hepatitis B. The standard recommendation for visiting your doctor is every six months however this can vary based upon the severity of your infection. The doctor will take a few blood tests, along with an ultrasound examination of the abdominal area to determine the health of the liver. Based upon these tests and other risk factors, the doctor will be able to determine if liver damage is occurring and can guide you on which steps you should take next. 

If damage is detected early enough, progression to liver cancer can be prevented through highly effective treatments that stop or slow the virus from reproducing in your liver. However, it is important to note that not everyone living with hepatitis B needs treatment. Current treatments have been proven to be most effective when there are signs of active liver damage. Hepatitis B can be managed through regular monitoring by a knowledgeable doctor and lifestyle changes that can go a long way in protecting your body. 

Early detection of liver cancer is extremely important. The average 5-year survival rate once diagnosed with liver cancer ranges from 10% -14%. However, with early detection and proper treatment, those numbers rise to over 50%! This significant difference is because if liver cancer is caught early, a doctor can link you to life-saving treatments including chemotherapy, surgical options, ablation techniques, intra-arterial therapies or a liver transplant. Regular monitoring by a knowledgeable doctor will hopefully identify the markers of liver cancer before it occurs, but if you are living with liver cancer, there are treatment options and resources available to you. 

Preventing Liver Cancer 

Educating oneself is the first step in prevention! If you have hepatitis B, be aware of the risk factors and behaviors that can increase your likelihood of liver damage and liver cancer, such as consuming alcohol and high amounts of junk food, and lack of exercise. Non-Alcoholic Fatty Liver Disease (NAFLD) can also increase your risk of cancer, so it is important to discuss NAFLD risk factors and prevention tips with your doctor. Groups such as the CDC Division of Viral Hepatitis and the American Association for the Study of Liver Diseases all provide free fact sheets, call lines, and literature by experts that can help you understand what may be occurring in your body and to make educated choices. You can also check out our Liver Cancer Connect resource for more information or for liver cancer support. 

The hepatitis B vaccine is also the first anti-cancer vaccine ever created! Remember that the vaccine is typically given in a set of 3 doses. It is extremely important to take all three in order to receive lifelong protection from hepatitis B-related liver cancer. In the U.S., there is also a 2-dose vaccine available, so you can be fully protected with fewer doses! If you are worried about the cost of the birth dose for your infant or the vaccine for yourself, many countries have free health clinics that can administer it or link you to an organization that can help. 

Another key to preventing liver cancer is to get tested for hepatitis B. If you have not received your vaccine and you think you fall into a high-risk group, talk to your doctor about getting tested. Because hepatitis B often has no symptoms, it is important to get screened even if you do not feel ill. An early diagnosis means that you can begin any needed treatment sooner and prevent irreversible damage from occurring. Like the vaccines, your local doctor or health clinic may be able to test you for free or reduced cost – just ask! Some local community groups also provide free hepatitis B testing, so be sure to look out for flyers and announcements about them in your community as well

Join Us For a Twitter Chat for Liver Cancer Awareness Month!

 

 

 

 

October is Liver Cancer Awareness Month. Each year in the United States, about 33,000 people get liver cancer and a large portion of liver cancer cases are caused by viral hepatitis. Viral hepatitis is preventable and when diagnosed and linked to care early, can be treated to prevent liver cancer from developing. The majority of people living with hepatitis B and hepatitis C are unaware of their status and often find out after serious damage has occurred. Liver cancer is one of the only cancers that continues to rise steadily each year. On Wednesday, October 23 at 3PM ET representatives from Hepatitis B Foundation, CDC’s Division of Viral Hepatitis, and NASTAD will co-host a twitter chat to discuss the link between liver cancer and viral hepatitis as well as the importance of engaging communities most affected, particularly patients, in our response.

A large part of our chat this year is centered upon the patient voice. The patient perspective is essential to our efforts to prevent liver cancer and improving the lives of those affected by it. Jacki Chen, one of the Hepatitis B Foundation’s #justB storytellers and Karen Hoyt, a hepatitis C patient advocate with the National Viral Hepatitis Roundtable,  will be joining this year’s twitter chat as featured guest to share their unique experiences.

Below are the questions to be discussed during the chat. How can you participate? Join the conversation that day and throughout the month with the hashtag #LiverChat19. Share any resources or strategies you have that raise awareness about the link between liver cancer and hepatitis as well as how to better engage communities most affected, particularly patients, in our work. We also encourage you to share any videos or photos you have of your work in your communities or activities during Liver Cancer Awareness Month!

· Q1: What are things everyone should know about liver cancer, and also the link between hepatitis and liver cancer?

· Q2: What can people do to prevent hepatitis, or for those living with hepatitis, what can be done to protect the liver and prevent liver cancer?

· Q3: What are the barriers that keep people from getting screened for hepatitis and liver cancer and how can they be addressed?

· Q4: Why are some communities more vulnerable to hepatitis and liver cancer, and how do we address the disparities?

· Q5: How do we engage communities most affected by hepatitis or liver cancer in our work? Why is this important?

· Q6: What resources are available to educate others about hepatitis B & C and liver cancer? What resources are needed?

· Q7: Who are your key partners in addressing liver cancer? Who would you like to engage more in your work? (Tag them here!)

· Q8: What is one lesson learned or piece of advice for others who want to expand their work on the link between viral hepatitis and liver cancer?

· Q9: Centering the voices of patients and liver cancer survivors is incredibly important in improving our response and ensuring their needs are being met. How do you do this in your work? How can we as a community do this better?

Co-hosts and featured partners of the chat include:

· Hepatitis B Foundation – @hepbfoundation

· NASTAD – @NASTAD

· CDC Division of Viral Hepatitis – @cdchep

· CDCNPIN will be moderating the chat – @cdcnpin

· Jacki Chen – @jacki0362

· Karen Hoyt – @hepatitisIhelpC

· Global Liver Institute- @GlobalLiver

· American Liver Foundation- @liverUSA

Confirmed participants and their handles include:

· National Viral Hepatitis Roundtable- @NVHR1

· Hep B United – @hepbunited

· Hep B United Philadelphia – @hepbunitedphila

· Liver Cancer Connect – @LiverCancerConn

· Hepatitis Delta Connect – @HepDConnect

· Hepatitis Education Project – @HepEduProject

· Minnesota Department of Health – @MNHealth

· Hep Free Hawaii – @HepFreeHawaii

· Hawaii Health – @HIgov_Health

· Hep Free NYC – @HepFreeNYC

· MD Anderson Cancer Center – @MDAndersonNews

· AAPCHO – @HepBPolicy

. HHS Viral Hepatitis – HHS_ViralHep

· Kiiza Alexander – @KiizaAlexander

· Minnesota Health Department – @MNHealth

·HHS Division of Viral Hepatitis – @HHS_ViralHep

·HHS Division of Viral Hepatitis – @HHS_ViralHep

·Rowaye Ridwan – @otunbaridwan

·Hassan Muhammad Bature – @Hasanb1980

·Lilian Mary Nabuya – @Inabunya

·Wenyue Lu – @lu_wenyue

·Dave Nkengeh – @Davy_Tazinkeng

·Hepatitis B Initiative of Washington D.C. – @HBIDC

· Shakur Xassan – @sheykoshee

· Temple University Center for Asian Health- @KnowCancer

· Asian Health Coalition -@CAHE_AHC

·Maryland Cancer Collaborative

Just getting started with Twitter? Do you wish to join the conversation but you don’t know how? Type #LiverChat19 in the search box of the Twitter application to follow the chat, and click on “Latest”. Email michaela.jackson@hepb.org to be added to the list of confirmed participants!