What research topics should be focused on regarding molecular markers in hepatocellular carcinoma (HCC)?

Priority Research Topics for Molecular Markers in Hepatocellular Carcinoma

The most critical research priorities for molecular markers in HCC should focus on linking molecular subclasses to therapeutic response in clinical trials, developing validated liquid biopsy tools for early detection, and creating tissue biomarkers that predict treatment response to enable precision medicine. 1

Highest Priority: Translating Molecular Knowledge into Clinical Decision-Making

Linking Molecular Signatures to Treatment Response

• All clinical trials must mandate tumor tissue collection and link molecular subclasses with therapeutic response and survival outcomes to enable precision medicine approaches similar to breast and lung cancer 1
• The current failure to connect molecular characterization with treatment selection explains why some drugs fail in phase III trials despite promising preclinical data 1
• Research should focus on identifying predictive biomarkers (not just prognostic) that determine which patients respond to specific systemic therapies, including immunotherapy combinations 1
• The EASL guidelines (2025) specifically emphasize that AFP can serve as a surrogate biomarker for atezolizumab plus bevacizumab treatment response, demonstrating the feasibility of this approach 1

Developing Validated Tissue Biomarkers for Treatment Selection

• Transition to mandatory biopsy for all HCC cases once tissue biomarkers predicting treatment response become available 1
• Current reliance on imaging-based diagnosis without tissue characterization prevents molecular profiling and limits therapeutic advances 1
• Research must validate the GPC3/HSP70/GS immunohistochemistry panel (72% sensitivity, 100% specificity) for broader clinical implementation beyond diagnostic confirmation 2
• Investigation of macrotrabecular-massive HCC subtype and its marker ESM1 is critical, as this histological variant has distinct clinical behavior and may require different treatment approaches 1

Second Priority: Early Detection and Surveillance Biomarkers

Liquid Biopsy Development

• Validate plasma-based methylation marker panels that achieved 95% overall sensitivity and 75% sensitivity for stage 0 HCC at 86% specificity in phase 2 studies 2
• These methylation panels represent the most promising advancement beyond AFP and require multicenter validation studies 2
• Research should focus on circulating tumor DNA (ctDNA) detection and genetic alterations in plasma/serum for early detection 3
• The GALAD model (Gender, Age, AFP-L3, AFP, DCP) demonstrates >70% sensitivity for overall HCC and >60% for early-stage disease, requiring validation in diverse populations including NAFLD-related HCC 2

Improving Surveillance in High-Risk Populations

• Develop tools to stratify patients into high, intermediate, and low-risk categories to adjust surveillance intensity and make programs cost-effective 1
• The three-gene signature (GPC3, LYVE1, survivin) showing >80% accuracy for discriminating dysplastic nodules from small HCCs (<2 cm) needs prospective validation 2
• Research must address the rising burden of NAFLD-related HCC, where traditional surveillance markers perform poorly 2

Third Priority: Understanding Tumor Heterogeneity and Resistance Mechanisms

Intratumoral Heterogeneity Characterization

• Spatial transcriptomics and single-cell sequencing studies are essential to map intratumoral heterogeneity and identify dominant clones driving progression 1
• Research should investigate how intratumoral heterogeneity affects treatment response and resistance development 1
• Studies must examine the tumor microenvironment composition, including immune cell infiltration patterns that correlate with immunotherapy response 4

Mechanisms of Treatment Resistance

• Define molecular mechanisms of escape and resistance to systemic therapies, particularly immunotherapy combinations 1
• Investigate the role of methylation changes in biomarker regulation, as abnormal methylation patterns differ between tumors and precancerous tissues 4
• Research should examine how immune infiltration (particularly B cells and dendritic cells) affects biomarker expression and treatment outcomes 4

Fourth Priority: Prognostic and Predictive Biomarkers for Surgical/Interventional Therapies

Post-Treatment Recurrence Prediction

• Validate AFP-L3 and DCP as predictors of early HCC recurrence after liver transplantation, as these strongly predict recurrence in recent studies 1
• Research must identify biomarkers predicting recurrence after resection, radiofrequency ablation, and other locoregional therapies 1
• Investigate circulating tumor-associated antigens (AFP, MAGEs, CK19) as markers of disseminated HCC cells predicting metastatic recurrence 3

Biomarkers for Treatment Selection in Curative Settings

• Develop molecular signatures that identify which patients benefit from adjuvant therapy after resection or ablation 1
• Research should examine whether poor tumor differentiation markers can refine transplant candidate selection beyond Milan criteria 1

Fifth Priority: Novel Biomarker Discovery Using Advanced Technologies

Genomic and Proteomic Profiling

• Utilize next-generation sequencing, transcriptomics, and proteomics to identify novel biomarkers with higher sensitivity and specificity than current markers 1, 5
• The custom gene expression panel approach examining HCC hub genes (TOP2A, CDK1, BIRC5), drug target genes (GPC3, IGF2, c-MET), and somatic mutant genes (CTNNB1, GLUL, LGR5, TERT) should be expanded and validated 5
• Research must identify biomarkers distinguishing proliferative versus normal-like HCC subtypes, as these may require different therapeutic approaches 5

Metabolomics and Novel Marker Classes

• Investigate metabolomics to identify sensitive biomarkers in serum or urine for early HCC detection 1
• Research should examine angiogenesis regulators (VEGF, intratumor MVD) and invasion/metastasis factors (E-cadherin, catenins, MMPs, uPA system) as prognostic markers 3, 6

Critical Implementation Considerations

Study Design Requirements

• All biomarker studies must include prospective validation in independent cohorts with adequate sample sizes 2
• Research should compare biomarker performance across different etiologies (HBV, HCV, NAFLD, alcohol) as marker performance varies by underlying liver disease 2
• Studies must report positive and negative predictive values, not just sensitivity and specificity, to assess clinical utility 1

Avoiding Common Pitfalls

• Do not pursue biomarkers in isolation—combination panels consistently outperform single markers 2
• Avoid retrospective studies using surgical specimens only, as these represent selected populations and don't reflect the full HCC spectrum 1
• Research must address the lack of standardization in biomarker measurement techniques and cut-off values across laboratories 2

Regulatory and Clinical Translation Pathway

• Biomarker development should follow the framework outlined in the ILCA white paper on biomarker development 1
• Studies must demonstrate clinical utility (impact on patient outcomes), not just analytical validity 2
• Research should examine cost-effectiveness to ensure biomarkers can be implemented in resource-limited settings where HCC burden is highest 1