Deciphering the role of transforming growth factor-beta 1 as a diagnostic-prognostic-therapeutic candidate against hepatocellular carcinoma

Table 1 Research progress on the clinical utility of transforming growth factor-beta 1 as diagnostic marker against hepatocellular carcinoma

Ref.	Sample size HCC/control	Assay type	TGF-β1 level	Sample type	Outcome of the study
[60,61]	26/20	ELISA	Control: 1.4 ± 0.8 ng/mL	Plasma	TGF-β1 level showed a progressive elevation from cirrhotic to HCC patients to normal subjects. No significant association was found between plasma TGF-β1 and serum AFP levels
			HCC: 19.3 ± 1.95 ng/mL (P < 0.05)
[62,63]	70	ELISA	Control: 2.7 ± 0.7 ng/mL	Plasma	Elevated plasma TGF-β1 levels in HCC patients are associated with increased tumor size, overexpression of tissue inhibitor of metalloproteinase-1 and tumor severity
			HCC: 7.3 ± 4.3 ng/mL (P < 0.05)
[54,55]	94/50	125I-Radio Immuno Assay Kit	Control: 1.5-33.6 μg-1creatinine	Urine	Urinary TGF-β1 and serum AFP levels were higher in HCC than in cirrhotic patients. The study suggested that both TGF-β and AFP can be used as complementary biomarkers to distinguish between HCC and cirrhosis
			Cirrhotic: 4.3-52.5 μg-1creatinine
			HCC: 3.5-184 μg-1creatinine (P < 0.0001)
[64]	54/30	ELISA	TGF-β1 score	Serum	The study team calculated the serum concentration score based on the cut-off limit of 74 pg/mL and 637 pg/mL for TGF-β1 and sFas, respectively. TGF-β1 levels were higher than the cut off value in 23% HCC patients with negative AFP values, suggesting its diagnostic potential in AFP negative HCC
			Control: 0.6 ± 0.2
			HCC: 1.6 ± 0.5
[65]	38/23	ELISA	Control: 300 pg/mL	Plasma	Elevated plasma TGF-β1 level can be a useful diagnostic marker in detecting small HCC, with higher sensitivity than AFP
			HCC: 954.9 pg/mL (P < 0.0001)
[66]	70/32	ELISA	Control: 2 ng/mL	Plasma	Higher circulating TGF-β1 in HCC patients is associated with suppression of anti-tumor immunity and disease progression
			HCC: 7.5 ng/mL (P < 0.0001)
[52]	50/30	ELISA	Control: 0.67 ± 0.1 μg/mL	Serum	Aberrant TGF-β1 expression in HCC is associated with differentiation and worsening of HBV infection
			HCC: 2.21 ± 1.1 μg/mL (sensitivity = 89.5%, specificity = 94%)
		RT-PCR	Overexpression TGF-β1 mRNA in HCC patients, P < 0.0001		Circulating TGF-β1 level and TGF-β1 mRNA expression can be used as sensitive biomarkers for diagnosing HBV induced HCC
[56]	23/40	ELISA	Control: 14.35 ± 8.76 ng/mL	Serum	TGF-β1 is a sensitive diagnostic marker for HCC than AFP. Specificity can be increased with combined evaluation of TGF-β1 and AFP levels
			HCC: 64.35 ± 33.68 ng/mL (P < 0.05)
[67]	54/30	ELISA	Control: 39.5 ± 9.8 pg/mL	Serum	The study suggested elevated TGF-β1 and EGFR levels as reliable diagnostic markers for HCC induced, AFP negative HCC
			HCC: 1194 ± 331 pg/mL (P < 0.0001)
[68]	120/30	ELISA	Control: 250.16 ± 284.61 pg/mL	Serum	TGF-β1 showed progressive elevation during various stages of liver dysfunction. Higher TGF-β1 level in HCC is associated with tumor grade, pathological stage and invasiveness
			Cirrhotic: 487.98 ± 344.23 pg/mL
			HCC: 1687.47 ± 1642 pg/mL (P < 0.0001)
[69]	100/36	ELISA	Control: 57.29 ± 11.70 ng/mL	Serum	Serum levels of TGF-β were significantly higher in HCC patients than in normal controls
			HCC: 225.82 ± 48.93 ng/mL (P < 0.0001)

ELISA: Enzyme-linked immunosorbent assay; RT-PCR: Reverse transcription-polymerase chain reaction; HCC: Hepatocellular carcinoma; TGF-β: Transforming growth factor-beta; AFP: Alpha fetoprotein; HBV: Hepatitis B virus; EGFR: Epidermal growth factor receptor.

Table 2 Research progress on the clinical utility of transforming growth factor-beta 1 as a prognostic marker against hepatocellular carcinoma

Ref.	Sample size HCC/control	Sample and assay type	TGF-β1 level		Survival rate (%), (patients with higher TGF-β1 vs patients with lower TGF-β1)		Outcome of the study
[75]	571/551	Plasma	Control: 3.58 ± 0.17 log10 pg/mL		1 yr survival (47 vs 60)	3 yr survival (28 vs 36) P < 0.05	Plasma TGF-β1 levels showed a positive correlation with tumor size, invasion and extrahepatic metastasis and inversely correlated with survival rates in HCC patients
		ELISA	Cirrhotic: 3.20 ± 0.37 log10 pg/mL
			HCC: 3.83 ± 0.31 log10 pg/mL
[83]	126	Tumor tissue	84% samples (106/126) showed high intra-tumoral TGF-β1 expression		5 yr survival (8.5 vs 45.6)		TGF-β1 and FGFR4 were positively correlated in HCC tumor tissues and showed a significant association with shorter survival rates in patients
		Immunohistochemistry	64.3% samples (81/126) showed high peri-tumoral TGF-β1 expression
[80]	84/20	Tumor tissue	TGF-β1 overexpression found in 59.5% samples (50/84) than that of normal liver tissue		1 yr survival (28 vs 79.4)	5 yr survival (12 vs 62.6)	TGF-β1 expression was dominant, whereas ELF expression was suppressed in HCC tissues
		Immunohistochemistry					Patients with high TGF-β1 and lower ELF expression are associated with poor overall survival and post-operative disease free survival compared with low TGF-β1 and high ELF group
[76]	184/30	Plasma and tumor tissue	Elevated plasma TGF-β1 level		2 yr survival ( 51 vs 77)	3 yr survival (4 vs 68), P < 0.05	Higher TGF-β1 expression in tumor tissues triggers Treg cells mediated immunosuppression in tumor microenvironment and contribute to poor prognosis in HCC
		ELISA and immunohistochemistry	TGF-β1 was strongly stained in tumor tissue
[84]	40	Serum	Before RFA: 63.22 ± 23.61 ng/mL	After RFA: 56.33 ± 24.24 ng/mL	NA		Radiofrequency ablation lowered TGF-β1 and AFP L3% expression in HCC patients
		ELISA					Low TGF-β1 and AFP L3% levels were observed in the no recurrence group, suggesting its potential as prognostic markers for HCC

ELISA: Enzyme-linked immunosorbent assay; HCC: Hepatocellular carcinoma; TGF-β: Transforming growth factor-beta; AFP: Alpha feto protein; ELF: Embryonic liver fodrin; FGFR: Fibroblast growth factor receptor 4.

Table 3 Clinical trials of transforming growth factor-beta 1 blockade with Galunisertib in hepatocellular carcinoma and other cancers

Drug	Title of the study	Treatment	Phase	Status	Trial ID
Galunisertib	A study of Galunisertib on the immune system in participants with cancer	Monotherapy	Phase I	Completed	NCT02304419
Galunisertib	Galunisertib (LY2157299) and stereotactic body radiotherapy in advanced hepatocellular carcinoma	Combination with radiotherapy	Phase I	Completed	NCT02906397
Galunisertib	A study of LY2157299 in participants with unresectable hepatocellular cancer	Combination with Nivolumab	Phase II	Completed	NCT02423343
Galunisertib	A study of LY2157299 in participants with unresectable hepatocellular cancer	Combination with Sorafenib	Phase I	Completed	NCT02240433
Galunisertib	A study of LY2157299 in participants with advanced hepatocellular carcinoma	Combination with Sorafenib	Phase II	Completed	NCT02178358
Galunisertib	A study of LY2157299 in participants with hepatocellular carcinoma	Combination with Sorafenib/Ramucirumumab	Phase II	Completed	NCT01246986
Galunisertib	Galunisertib and Capecitabine in advanced resistant TGF-beta activated colorectal cancer (EORTC1615)	Combination with Capecitabine	Phase II	Withdrawn	NCT03470350
Galunisertib	A study of LY2157299 in participants with pancreatic cancer (advanced or has spread to another part of the body)	Combination with Gemcitabine	Phase I	Completed	NCT02154646
Galunisertib	A study of Galunisertib (LY2157299) and Durvalumab (MEDI4736) in participants with metastatic pancreatic cancer	Combination with Durvalumab	Phase I	Completed	NCT02734160

TGF: Transforming growth factor.