Multimodal clinical parameters-based immune status associated with the prognosis in patients with hepatocellular carcinoma

Table 1 Survival predictors of routine blood tests in hepatocellular carcinoma

Ref.	Patients	Simple size	Variables	Threshold	Prediction performance
Liu et al[16]	HCC treated with hepatectomy	315	AST (U/L)		The median (Q1, Q3) data are 34 (27.5, 47.5) of group no recurrence, 40 (30, 50.75) of group recurrence, P = 0.041
Liu et al[16]	HCC treated with hepatectomy	315	ALT (U/L)		The median (Q1, Q3) data are 36 (24, 48) of group no recurrence, 40 (30, 56.75) of group recurrence, P = 0.042
Su et al[15]	HCC	2327	ALP (U/L)	172	The median OS in the high ALP group was significantly shorter than in the low ALP group (7.7 months vs 55.4 months)
Zhang et al[20]	HCC treated with hepatectomy	414	GGT (mg/L)	48.5	Kaplan-Meier analysis showed patients with GGT < 48.5 had significantly longer overall survival (P = 0.000)
Zhang et al[20]	HCC treated with LT	155	LDH (U/L)	80.5	Kaplan-Meier analysis showed high LDH levels significantly correlated with poor RFS (P = 0.001) and OS (P = 0.008)
Carr et al[21]	HCC	995	CRP (mg/L)	10, 50	With increase in CRP grouping, significant trend for increase in each of AFP, MTD and percent PVT parameters were found
Utsumi et al[22]	HCC	173	LCR	9500	Kaplan-Meier analysis showed high LCR group patients had longer RFS and OS compared to the low LCR group
Wen et al[24]	HCC	126	NLR	3.867	Median survival time was higher in patients with NLR (not achieved vs 18 months, P = 0.014)
Pang et al[18]	HCC treated by hepatic resection	172	PLT (/L)	148 × 109	Kaplan-Meier curves stratified by PLT (P = 0.021) showed significantly higher recurrence rates in non-cirrhotic patients with PLT ≥ 148 × 109/L
Ismael et al[25]	HCC treated with LT	212	PLR	150	PLR ≥ 150 to be a strong predictor of worse 5-year OS (40.2% vs 79.4%) and RFS (70.2% vs 95.9%) in HCC patients
Wang et al[26]	HCC treated with TACE	53	IL-2 (pg/mL)	0.025	P value of time to progression equals to 0.031
Wang et al[26]	HCC treated with TACE	53	IL-6 (pg/mL)	4.400	P value of time to progression equals to 0.013; P value of OS equals to 0.007
Peng et al[27]	HCC	423	TGF-β1	High/low	HCC patients with higher TGF-β1 expression had a shorter OS compared to those with lower expression (HR = 1.417, 95%CI: 1.014-1.979, P = 0.0411)
Müller et al[28]	HCC treated with TACE	280	PNI	37.59	Low PNI patients had shorter median OS than high PNI patients (7.5 months vs 21.4 months, P < 0.001)
Li et al[30]	HCC	1334	CONUT	8	Postoperative CONUTS ≥ 8 was an independent risk factor for complication III-V (OR = 2.054, 95%CI: 1.371-3.078, P < 0.001)

HCC: Hepatocellular carcinoma; LT: Liver transplant; TACE: Transarterial chemoembolization; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; GGT: Gamma-glutamyl transpeptidase; LDH: Lactate dehydrogenase; CRP: C-reactive protein; LCR: Lymphocyte-to-C-reactive protein ratio; NLR: Neutrophil-to-lymphocyte ratio; PLT: Platelet count; PLR: Platelet-to-lymphocyte ratio; IL-2: Interleukin-2; IL-6: Interleukin-6; TGF-β1: Transforming growth factor β1; PNI: Prognostic nutritive index; CONUT: Controlling nutritional status; OS: Overall survival; RFS: Recurrence-free survival; AFP: Alpha-fetoprotein; MTD: Maximum tumor dimension; PVT: Portal vein thrombosis; HR: Hazard ratio; CI: Confidence interval; OR: Odds ratio.

Table 2 Immune status and biomarkers of immune cells

Immune components	Immune status
DCs	Decreased antigen presentation, decreased quantity, impaired function
Macrophages	Antigen presentation disorder, activates Th2 immune response, promotes Tregs
MDSC	Inhibits by free radicals, arginase, and TGF-β
Neutrophils	Positively correlated with the stage of cancer
NK cells	The number and the cytolytic activity decrease. Higher total CD56+ NK cells have a good prognosis
T lymphocytes	Decreased, inhibitory receptor expression increased (decreased CD3+ T cells, CD4+ T cells and CD4+/CD8+ T cell ratio. Increased CD8+ CD28- T and CD4+ CD25+ T cells)
Tfh	Decreased CXCR5CD4+, associated with tumor progression
Treg	Increases T cells, inhibits T cells proliferation, IFN-γ secretion, and NK cells response. Poor prognostic markers
Th17 cells	Increased, unspecified effect, and associated with disease progression. Elevated Th17 and Th1 numbers may promote progression as prognostic markers
CIK	Decreased, weakened anti-cancer effect
NK T cells	Dual action, promoting Th2 cytokines. Correlated with invasion and metastasis

DCs: Dendritic cells; MDSC: Myeloid-derived suppressor cells; NK: Natural killer cell; Tfh: T follicular helper cell; Treg: Regulatory T cell; Th: T helper cell; CIK: Cytokine-induced killer cell; TGF-β: Transforming growth factor β; CXCR: C-X-C chemokine receptor; IFN-γ: Interferon-γ.

Table 3 Changes and impacts of cytokines and chemokines

Immunomodulatory factor	Quantitative changes and functional status
Th1 cytokines	The tumor microenvironment decreases and induces CD8+ T cells (IL-2 is significantly reduced, which is directly related to prognosis while the levels of TGF-β and IL-6 are increased. Others such as IFN-γ, IL-8, IL-15 and IL-18 have been implicated in invasion and metastasis)
Th2 cytokines	Elevated, associated with tumor progression (showing a shift from Th1 to Th2)
Pro-inflammatory cytokines	Involved in pathogenesis and tumor escape
Anti-inflammatory cytokines	Ascending, associated with progression (IL-6 is associated with poor prognosis. IL-37 expression levels were correlated with tumor burden and survival improvement)
Chemokine ligand-receptor axis	Relevant to tumor progression and metastasis (CCR6-CCL20 axis and CXCL12-CXCR4 axis expression were higher, which was positively correlated with clinical stage. Increased CXCR3 expression was correlated with tumor burden and cancer stage)

IL: Interleukin; TGF-β: Transforming growth factor β; IFN-γ: Interferon-γ; Th: T helper cell; CXCR: C-X-C chemokine receptor; CXCL: C-X-C motif chemokine ligand; CCL: C-C motif chemokine ligand; CCR: C-C chemokine receptor.

Table 4 Relationships between imaging features and prognosis of different imaging examinations in hepatocellular carcinoma

Imaging examination	Imaging features		Prognosis
CT	Tumor number	≤ 3	Good
		> 3	Poor
	Maximum diameter of the tumor	≤ 5 cm	Good
		> 5 cm	Poor
	Tumor envelope	Exist	Good
		Absence	Poor
	Irregular edge reinforcement	Absence	Good
		Exist	Poor
	Distribution of tumors across lobes	Absence	Good
		Exist	Poor
	Envelop invasion (arch-string ratio)	≤ 1	Good
		> 1	Poor
	Diaphragm invasion	Absence	Good
		Exist	Poor
	Cirrhosis	Absence	Good
		Exist	Poor
	The proportion of tumor convex	< 25%	Good
		≥ 25%	Poor
	Portal vein occlusion	Absence	Good
		Exist	Poor
MRI	Peritumoral enhancement	Absence	Good
		Exist	Poor
	Intratumoral necrosis	Absence	Good
		Exist	Poor
	Internal aneurysm	Absence	Good
		Exist	Poor
	Tumor edge	Smooth	Good
		Rag	Poor
	Multifocality	Absence	Good
		Exist	Poor
	Low density ring	Exist	Good
		Absence	Poor
Ultrasound	Tumor enhancement starts for a long time	Absence	Good
		Exist	Poor
	The arterial phase was highly enhanced	Absence	Good
		Exist	Poor
	The portal phase was low and enhanced	Absence	Good
		Exist	Poor
	The delay period is low and enhanced	Absence	Good
		Exist	Poor
DSA	The arrival time is reduced	No	Good
		Yes	Poor
	The peak time rises	No	Good
		Yes	Poor
	Increased filling rate	No	Good
		Yes	Poor
	The curve width is elevated	No	Good
		Yes	Poor
	The mean passage time was increased	No	Good
		Yes	Poor
Radiomics	First-order statistics	Different phases based on CT or MRI
	Texture features
	Wavelet decompositions

CT: Computed tomography; MRI: Magnetic resonance imaging; DSA: Digital subtraction angiography.

Table 5 Impact on immune microenvironment and prognosis of immunohistochemical markers in hepatocellular carcinoma

Category	Marker	Impact on immune microenvironment	Impact on prognosis	Clinical decision-guiding value
Immunosuppressive	PD-L1/PD-1	Induces T-cell exhaustion via PD-1/PD-L1	High expression: Improved objective response rate and disease control rate to PD-1/PD-L1 inhibitors in advanced HCC	Predictive: Supports the selection of PD-1/PD-L1 inhibitor therapy
	CTLA-4	Blocks CD28- B7 costimulation; expands Tregs	High expression: Increased Treg infiltration and poorer OS	Emerging target: Informs the potential for combination immunotherapy strategies
	TIM-3	Triggers T-cell apoptosis; polarizes M2 macrophages	Co-expression with PD-1: Reduced OS	Mechanistic insight: Supports the development of dual-targeting approaches
Proliferation/invasion	Ki-67	Drives cell-cycle dysregulation	High expression (> 30%): Increased tumor recurrence after liver transplantation	Prognostic: May necessitate more intensive post-transplant surveillance
	MMP-2/9	Degrades ECM; recruits MDSCs	High expression: Promotes HCC invasion and metastasis	Prognostic: Indicates high risk of metastasis, warranting comprehensive staging and follow-up
Angiogenic	DCP (PIVKA-II)	Activates VEGF pathway	Post-treatment decline: Predicts improved clinical outcomes	Monitoring: Serves as a surrogate biomarker for monitoring treatment efficacy in AFP-negative HCC
	GP73	Promotes angiogenesis via mTOR-VEGFA	High expression: Poor prognosis in HCC	Prognostic: Identifies patients with aggressive disease for more aggressive management
Metabolic dysregulation	AFP	Suppresses DC maturation and contributes to immunosuppression	Baseline AFP < 400 ng/mL or an early AFP response (≥ 75% decline): Predicts improved OS	Predictive and monitoring: Key for patient selection and early efficacy assessment in atezolizumab + bevacizumab therapy
	AFP-L3	Evades variant associated with immune evasion	AFP-L3% > 10%: Poorer OS and higher early recurrence rates	Risk stratification: Identifies high-risk patients for adjuvant therapy or closer monitoring
Tumor suppressor dysfunction	P53	Mutant recruits MDSCs; secretes immunosuppressive cytokines	Drives HCC progression and immunosuppression: Predicts poor prognosis	Prognostic: Suggests high-risk biology, informing the need for adjuvant therapy or enrollment in clinical trials
Immune infiltration	CD3+ T-cells	Mediates antitumor immunity (TCR-MHC)	High intratumoral density: Favorable prognostic factor for improved RFS	Prognostic: May support de-escalation of aggressive therapy in early-stage disease
Emerging targets	LAG-3	Binds MHC-II; synergizes with PD-1 to exhaust T-cells	High expression: Links to inferior RFS and OS	Emerging target: Informs the rationale for combining anti-PD-1 with anti-LAG-3 therapy

PD-L1: Programmed death-ligand 1; PD-1: Programmed cell death protein 1; CTLA-4: Cytotoxic T-lymphocyte-associated protein 4; TIM-3: T-cell immunoglobulin and mucin-domain containing-3; MMP-2/9: Matrix metalloproteinase-2/9; DCP: Des-gamma-carboxy prothrombin; PIVKA-II: Protein induced by vitamin K absence/antagonist-II; Ki-67: Kiel-67; GP73: Golgi protein 73; AFP: Alpha-fetoprotein; AFP-L3: Alpha-fetoprotein L3 fraction; P53: Tumor protein p53; LAG-3: Lymphocyte-activation gene 3; Tregs: Regulatory T cells; ECM: Extracellular matrix; MDSCs: Myeloid-derived suppressor cells; VEGF: Vascular endothelial growth factor; mTOR: Mammalian target of rapamycin; VEGFA: Vascular endothelial growth factor A; DC: Dendritic cell; TCR: T-cell receptor; MHC: Major histocompatibility complex; MHC-II: Major histocompatibility complex class II; OS: Overall survival; HCC: Hepatocellular carcinoma; RFS: Recurrence-free survival.