Combining single-cell and bulk RNA sequencing, NK cell marker genes reveal a prognostic and immune status in pancreatic ductal adenocarcinoma.

The NK cell is an important component of the tumor microenvironment of pancreatic ductal adenocarcinoma (PDAC), also plays a significant role in PDAC development. This study aimed to explore the relationship between NK cell marker genes and prognosis, immune response of PDAC patients. By scRNA-seq data, we found the proportion of NK cells were significantly downregulated in PDAC and 373 NK cell marker genes were screened out. By TCGA database, we enrolled 7 NK cell marker genes to construct the signature for predicting prognosis in PDAC patients. Cox analysis identified the signature as an independent factor for pancreatic cancer. Subsequently, the predictive power of signature was validated by 6 GEO datasets and had an excellent evaluation. Our analysis of relationship between the signature and patients' immune status revealed that the signature has a strong correlation with immunocyte infiltration, inflammatory reaction, immune checkpoint inhibitors (ICIs) response. The NK cell marker genes are closely related to the prognosis and immune capacity of PDAC patients, and they have potential value as a therapeutic target.

Expansion of KRAS hotspot mutations reactive T cells from human pancreatic tumors using autologous T cells as the antigen-presenting cells.

Adoptive cell therapy (ACT) with expanded tumor-infiltrating lymphocytes (TIL) or TCR gene-modified T cells (TCR-T) that recognize mutant KRAS neo-antigens can mediate tumor regression in patients with advanced pancreatic ductal adenocarcinoma (PDAC) (Tran et al in N Engl J Med, 375:2255-2262, 2016; Leidner et al in N Engl J Med, 386:2112-2119, 2022). The mutant KRAS-targeted ACT holds great potential to achieve durable clinical responses for PDAC, which has had no meaningful improvement over 40 years. However, the wide application of mutant KRAS-centric ACT is currently limited by the rarity of TIL that recognize the mutant KRAS. In addition, PDAC is generally recognized as a poorly immunogenic tumor, and TILs in PDAC are less abundant than in immunogenic tumors such as melanoma. To increase the success rate of TIL production, we adopted a well-utilized K562-based artificial APC (aAPC) that expresses 4-1BBL as the costimulatory molecules to enhance the TIL production from PDCA. However, stimulation with K562-based aAPC led to a rapid loss of specificity to mutant KRAS. To selectively expand neo-antigen-specific T cells, particularly mKRAS, from the TILs, we used tandem mini gene-modified autologous T cells (TMG-T) as the novel aAPC. Using this modified IVS protocol, we successfully generated TIL cultures specifically reactive to mKRAS (G12V). We believe that autologous TMG-T cells provide a reliable source of autologous APC to expand a rare population of neoantigen-specific T cells in TILs.

Single-cell RNA-seq reveals the genesis and heterogeneity of tumor microenvironment in pancreatic undifferentiated carcinoma with osteoclast-like giant-cells.

BACKGROUND: Undifferentiated carcinoma with osteoclast-like giant cells (OGCs) of pancreas (UCOGCP) is a rare subtype of pancreatic ductal adenocarcinoma (PDAC), which had poorly described histopathological and clinical features. METHODS: In this study, single-cell RNA sequencing (scRNA-seq) was used to profile the distinct tumor microenvironment of UCOGCP using samples obtained from one UCOGCP patient and three PDAC patients. Bioinformatic analysis was carried out and immunohistochemical (IHC) staining was used to support the findings of bioinformatic analysis. After quality control of the raw data, a total of 18,376 cells were obtained from these four samples for subsequent analysis. These cells were divided into ten main cell types following the Seurat analysis pipeline. Among them, the UCOGCP sample displayed distinct distribution patterns from the rest samples in the epithelial cell, myeloid cell, fibroblast, and endothelial cell clusters. Further analysis supported that the OGCs were generated from stem-cell-like mesenchymal epithelial cells (SMECs). RESULTS: Functional analysis showed that the OGCs cluster was enriched in antigen presentation, immune response, and stem cell differentiation. Gene markers such as LOX, SPERINE1, CD44, and TGFBI were highly expressed in this SMECs cluster which signified poor prognosis. Interestingly, in myeloid cell, fibroblasts, and endothelial cell clusters, UCOGCP contained higher percentage of these cells and unique subclusters, compared with the rest of PDAC samples. CONCLUSIONS: Analysis of cell communication depicted that CD74 plays important roles in the formation of the microenvironment of UCOGCP. Our findings illustrated the genesis and function of OGCs, and the tumor microenvironment (TME) of UCOGCP, providing insights for prognosis and treatment strategy for this rare type of pancreatic cancer.

Distal pancreatectomy with celiac artery resection acquires satisfactory survival for locally advanced pancreatic neck/body cancer.

BACKGROUND: s As a curative surgical procedure for pancreatic neck-body cancer with invasion to celiac artery (CA), the security and efficacy of distal pancreatectomy (DP) with en bloc resection of the celiac artery (DP-CAR) remain controversial. The purpose of this study was to identify the postoperative outcomes of DP-CAR. METHODS: A retrospectively analysis between January 2010 and January2019 was performed in a single center. 21 patients who underwent DP-CAR and 71 patients who underwent traditional DP for pancreatic neck-body cancer were included. Postoperative morbidity, mortality, overall survival (OS) and disease-free survival (DFS) were evaluated. RESULTS: There were no significant differences in major complications and mortality between two groups. The patients in DP-CAR group had more T4 tumor (61.9 vs 7.0%, P < 0.001). DP-CAR group had similar R0 resection compared with DP group (71.4% vs 87.3%, P = 0.090). The patients in DP-CAR group suffered more gastric ulcer, DGE and elevated levels of postoperative hepatic enzymes. OS (27.4 vs 32.6 months) and DFS (14.9 vs 19.5 months) between DP-CAR and DP groups were comparative (P = 0.305; P = 0.065). CONCLUSIONS: For the patients who had pancreatic neck-body cancer with invasion to CA, DP-CAR is safety and could achieve satisfactory R0 resection, OS, and DFS.

Prognostic Enigma of Pancreatic Solid Pseudopapillary Neoplasm: A Single-Center Experience of 63 Patients.

Background: Studies investigating prognostic factors of solid pseudopapillary neoplasm (SPN) have been published with conflicting findings. Methods: Retrospective analysis of 63 consecutive cases of SPN in our institution from January 2010 to December 2019 was carried out. The clinicopathological features, treatment practices along with survival associations were collected and analyzed. Results: Fifteen patients (23.8%) were male, and 48 (76.2%) were female, with a median age of 34.0 ± 14.5 years. The larger tumor size was correlated with the more mixed components (p = 0.000) and the higher Ki-67 index (p = 0.042). No recurrence was found in the nine patients whose tumors fulfilled the WHO criteria for malignancy due to the presence of at least perineural invasion (6.4%), angiovascular invasion (2.3%), and/or adjacent organ invasion (6.4%). Microscopic infiltrative growth was detected in 9 (14.3%) tumors, which was correlated significantly with the WHO criteria (p = 0.002), capsule invasion (p = 0.005), and pancreatic parenchyma invasion (p = 0.001), but not with disease-free survival (p = 0.13). CD99 was found to be positively expressed in 88.9% (40/45) of tumors and more likely to have depressed Ki-67 index (p = 0.016). After a median follow-up of 58 months, only two patients (3.2%) had a recurrence after their first operation outside of our hospital. No patient died due to tumor progression. Conclusions: Although survival is favorable with aggressive surgery, it is actually difficult to assess the prognostic factors of resected SPNs. Future investigations into the role of clinicopathological evaluation will unveil the prognostic enigma of pancreatic SPN after resection.

Case Report: Targeted Therapy for Metastatic Solid Pseudopapillary Neoplasm of the Pancreas With CTNNB1 and PTEN Mutations.

BACKGROUND: Solid pseudopapillary neoplasm (SPN) of the pancreas shows an indolent clinical behavior in cases undergoing surgical resection. The efficacy of combination therapy in the metastatic extrapancreatic SPN treatment remains largely unknown and a clinical challenge. CASE PRESENTATION: We report a case of a metastatic pancreatic SPN in a 45-year-old woman who presented with an aggressive peritoneal dissemination and hepatic metastases and still showed an indolent clinical course with combination therapy with repeated surgery and targeted therapy. Although the follow-up effect remains to be seen, this is the first report of practical experience of the targeted agents sunitinib and everolimus in metastatic SPN tumors based on the mutation status of PTEN (c.379G>A; p.G127R) and CTNNB1 (c.98C>G; p.S33C). To our knowledge, the PTEN variant identified in this case has not been previously reported in SPN. CONCLUSION: Evidence on variant genetics indicates that future molecular studies may not only help to explain the mechanism of SPN occurrence and development but are also more likely to direct to future precision treatments.

Long Noncoding RNA CERS6-AS1 Accelerates the Proliferation and Migration of Pancreatic Cancer Cells by Sequestering MicroRNA-15a-5p and MicroRNA-6838-5p and Modulating HMGA1.

OBJECTIVES: As one of the most aggressive human tumors, pancreatic cancer (PC) is accompanied by poor treatment and prognosis. Although emerging evidence has highlighted the importance of long noncoding RNAs in multiple cancers, the specific regulatory roles mostly remain obscure. Our aim was to disclose the role of CERS6 antisense RNA 1 (CERS6-AS1) in PC. METHODS: Quantitative real-time polymerase chain reaction analysis was used to examine the expression of CERS6-AS1 in PC cell lines. Western blot analysis was used to assess the protein levels of high-mobility group AT-hook 1 (HMGA1). Colony formation, 5-ethynyl-20-deoxyuridine, transwell, and wound healing assays were performed to detect the functions of CERS6-AS1 on PC development. In addition, RNA pull-down, RNA immunoprecipitation, and luciferase reporter assays were implemented to delve into the regulatory mechanism of CERS6-AS1 in PC. RESULTS: CERS6-AS1 was significantly upregulated in PC. CERS6-AS1 silence obviously inhibited cell proliferation and migration in PC. Furthermore, CERS6-AS1 sponged microRNA-15a-5p (miR-15a-5p) and microRNA-6838-5p (miR-6838-5p) to regulate HMGA1. Moreover, rescue assays verified that CERS6-AS1 was involved in cell proliferation and migration in PC via targeting miR-15a-5p/miR-6838-5p/HMGA1 axis. CONCLUSIONS: CERS6-AS1 enhanced HMGA1 expression to contribute to the progression of PC by sequestering miR-15a-5p and miR-6838-5p.

Advancing the Time to the Initiation of Adjuvant Chemotherapy and Improving Postoperative Outcome: Enhanced Recovery after Surgery in Pancreaticoduodenectomy.

Early initiation of chemotherapy could improve overall survival after pancreaticoduodenectomy (PD). The concept of enhanced recovery after surgery (ERAS), which aims to reduce the stress response to surgery and accelerate recovery, is relatively limited in PD. The aim of the study was to retrospectively analyze the relationships of ERAS with the time of initiation of postoperative chemotherapy and recovery in PD patients. Between January 1, 2008 and December 31, 2017, all patients who underwent open PD for malignant tumor at our unit were studied retrospectively. Patients were divided into ERAS and conventional groups. The time to initiation of adjuvant chemotherapy and postoperative outcomes were analyzed. There were 344 consecutive patients in this study, with 203 patients in the ERAS group. There were no significant differences between the ERAS and conventional groups in morbidity, mortality, and readmission. The median time of initiation of adjuvant chemotherapy in the ERAS group (54.1 days) was significantly shorter than that of initiation of adjuvant chemotherapy in the conventional group (67.8 days). The ERAS group had a shorter postoperative length of stay than the conventional group (14.9 vs 19.3 days). The ERAS program is safe and feasible in PD. These protocols improve postoperative recovery and advance the time of initiation of adjuvant chemotherapy.

Safety and long-term outcomes of anatomic left hepatic trisectionectomy for intermediate and advanced hepatocellular carcinoma.

BACKGROUND AND AIM: Anatomic left hepatic trisectionectomy (ALHT) is a complex hepatic resection, and its outcomes in hepatocellular carcinoma (HCC) still remain unclear. This paper focuses on the assessment of the safety and long-term effects of ALHT on intermediate and advanced HCC patients with tumors that occupy the left liver lobe. METHODS: This study performed a retrospective analysis of consecutive HCC patients who underwent ALHT in a single-center cohort between December 2004 and December 2011. RESULTS: ALHT was performed on 34 intermediate and advanced HCC patients (0.05%) of 17064 HCC patients who had undergone hepatic resection. Among them, 12 (33.3%) developed postoperative complications. Based on the multivariate analysis, we found that a serum prealbumin level of 170 mg/L is associated with an increased risk of morbidity (P=0.008). The one-year, two-year, three-year, and five-year overall survival rates were 61%, 27%, 11%, and 11%, respectively. The median overall survival was 13 months (range, 2-89 months). Based on the multivariate analysis, we also found that patients with an A/G ratio <1.5 are more likely to have poor prognosis than those with an A/G ratio ≥ 1.5 (P=0.014). Multiple tumors are associated with worse outcomes (P=0.020). CONCLUSIONS: ALHT is safe for intermediate and advanced HCC patients with tumors that occupy the left lobe and with preoperative Child-Pugh class A liver function. Low preoperative serum prealbumin level may increase the risk of postoperative complications. Although early intrahepatic recurrence rate is high, some patients, especially those with a single tumor and normal A/G ratio, exhibit long-term survival.

Hepatic resection for multiple hepatocellular carcinoma less than 5 cm: a prospective comparative study.

BACKGROUND/AIMS: Treatment of multiple hepatocellular carcinoma (HCC) remains a critical issue. In addition, the prognosis and prognostic factors of multiple HCC after hepatic resection are rarely prospectively documented. METHODOLOGY: The clinicopathologic and follow-up data of 81 patients who underwent curative resection of HCC between January 2008 and January 2009 were prospectively collected. Patients were categorized according to the size of the largest tumor: group A (n = 40, two or three HCCs with maximum tumor diameter > 3 cm and < or = 5 cm) and group B (n = 41, two or three HCCs with maximum tumor diameter < or = 3 cm). The two groups were compared for clinicopathologic data and survival results. RESULTS: The 1-, 2-, 3-, and 4-year survival rates of group A were 75.0%, 58.0%, 50.0%, and 44.0%, respectively, while the survival rates of group B were 93.0%, 80.0%, 66.0%, and 47.0%, respectively. The 1-, 2-, 3-, and 4-year disease-free survival rates of group A were 43.0%, 30.0%, 23.0%, and 15.0%, respectively, comparing to 71.0%, 54.0%, 44.0%, and 36.0% in group B, respectively. The median overall cumulative survival time of group A and group B were 36.0 and 44.5 months, respectively (P = 0.322). The median disease-free survival time of group A was 10.0 months and was significantly shorter than that of group B (30.0 months, P = 0.011). CONCLUSIONS: Resection may provide comparative survival benefits even for patients with multiple HCCs with maximum tumor diameter > 3 cm and < or = 5 cm.

Effects of nucleoside analogue on patients with chronic hepatitis B-associated liver failure: meta-analysis.

PURPOSE: The effectiveness of nucleoside analogue on patients with chronic hepatitis B-associated liver failure is still controversial. To address this issue, we did a review of the literatures and analyzed the data with emphasis on the survival and reduction in serum HBV DNA level. METHODS: We searched 11 randomized controlled trials that included 654 patients with chronic hepatitis B-associated liver failure. 340 patients adopted nucleoside analogue, such as lamivudine (LAM), entecavir (ETV), telbivudine (LdT), or tenofovir disoproxil fumarate (TDF), and the remaining 314 patients adopted no nucleoside analogue or placebo. A meta-analysis was carried out to examine the survival, HBV e antigen serologic conversion, and reduction in serum HBV DNA level. The pooled odds ratio (OR) was used to reflect the treatment effects. RESULTS: The overall analysis revealed nucleoside analogue significantly improved 1-month (OR = 2.10; 95% CI, [1.29, 3.41]; p = 0.003), 3-month (OR = 2.15; 95% CI, [1.26, 3.65]; p = 0.005), 12-month survival (OR = 4.62; 95% CI, [1.96, 10.89]; p = 0.0005). Comparison of 3-month HBV DNA showed significant reduction for adoptive nucleoside analogue patients (OR = 54.47; 95% CI, [16.37, 201.74]; p<0.00001). Comparison of 3-month HBV e antigen serologic conversion showed a highly significant improvement of HBV e antigen lost for patients received adoptive antiviral therapy (OR = 6.57; 95% CI, [1.64, 26.31]; p = 0.008). CONCLUSIONS: The benefits of nucleoside analogue on patients with chronic hepatitis B-associated liver failure is significant for improving patient survival, HBV e antigen serologic conversion, and rapid reduction of HBV DNA levels.

Negative correlation of LIV-1 and E-cadherin expression in hepatocellular carcinoma cells.

LIV-1, a zinc transporter, is a mediator downstream of STAT3 both in zebrafish and mammalian cells, and is involved in epithelial-mesenchymal transition (EMT). Despite LIV-1 participates in cancer growth and metastasis, little is known about the association of LIV-1 with human liver cancer development. Therefore, the expression of LIV-1 mRNA was analyzed by reverse transcriptase polymerase chain reaction (RT-PCR) in 4 cultured cell lines (3 carcinoma and 1 normal liver cell lines), and the localization of LIV-1 protein was investigated by immunohistochemistry. Expression of LIV-1 protein was analyzed by Western blot both in 4 cultured cell lines and 120 liver tissues (100 carcinoma and 20 histologically normal tissues), and the relationship between its expression and clinicopathological finding was investigated in 100 hepatocellular carcinoma(HCC) tissues. Then stable siRNA expressing Hep-G2 cells were generated to assess the function of LIV-1 in liver cancer cells. We found that LIV-1 mRNA was more highly expressed in liver cancer cell lines compared to normal liver cell line. Western blot showed the expression of LIV-1 was higher in 61% liver carcinoma tissues than that in normal liver tissues. Down-regulated LIV-1 cells showed significant inhibition of proliferation in vitro and reduction of tumor growth in vivo. Furthermore, E-cadherin expression increased in LIV-1 siRNA expressing Hep-G2. These findings indicated that LIV-1 may induce the EMT in HCC cells.

Adoptive immunotherapy in postoperative hepatocellular carcinoma: a systemic review.

PURPOSE: The effectiveness of immunotherapy for postoperative hepatocellular carcinoma patients is still controversial. To address this issue, we did a systemic review of the literatures and analyzed the data with emphasis on the recurrence and survival. METHODS: We searched six randomized controlled trials that included adoptive immunotherapy in the postoperative management of hepatocellular carcinoma and compared with non-immunotherapy postoperation. A meta-analysis was carried out to examine one- and 3-year recurrence and survival. RESULTS: The overall analysis revealed significantly reduced risk of 1-year recurrence in patients receiving adoptive immunotherapy (OR=0.35; 95% CI, 0.17 to 0.71; p=0.003), in that the risk of 3-year recurrence with a pooled OR estimated at 0.31 (95% CI 0.16 to 0.61; p=0.001). However, no statistically significant difference was observed for 3-year survival between groups with adoptive immunotherapy and without adjuvant treatment (OR=0.91; 95% CI, 0.45 to 1.84; P=0.792). CONCLUSIONS: Adjuvant immunotherapy with cytokine induced killer cells or lymphokine activated killer cells may reduce recurrence in postoperative hepatocellular carcinoma patients, but may not improve survival.

Comparison of transcatheter arterial chemoembolization and microsphere embolization for treatment of unresectable hepatocellular carcinoma: a meta-analysis.

PURPOSE: Survival of patients with surgically unresectable hepatocellular carcinoma (HCC) is very poor due to the limited effective treatments available. Transhepatic arterial chemoembolization (TACE) and microsphere embolization may offer hope for such patients; however, to date, their efficacy has not been evaluated. This study was designed to compare the effectiveness of these two treatments for patients with unresectable HCC. METHODS: This meta-analysis searched literature using various databases and revealed 13 studies on surgically unresectable HCC patients treated with TACE or microsphere embolization. Response rate, 1-year survival, overall survival, and time to progression were then analyzed and compared. RESULTS: These thirteen studies included 597 and 1,233 patients with unresectable HCC for microsphere embolization and chemoembolization treatments, respectively. The data showed that microsphere embolization therapy was significantly better for longer overall survival, 1-year survival, longer time to progression, and complete or partial response rate than that of chemoembolization treatment. CONCLUSIONS: These data demonstrated that microsphere embolization treatment of patients with surgically unresectable HCC provided much better survival and treatment response than that of TACE.

P16 gene hypermethylation and hepatocellular carcinoma: a systematic review and meta-analysis.

AIM: To quantitatively investigate the effect of p16 hypermethylation on hepatocellular carcinoma (HCC) and hepatocirrhosis using a meta-analysis of available case-control studies. METHODS: Previous studies have primarily evaluated the incidence of p16 hypermethylation in HCC and corresponding control groups, and compared the incidence of p16 hypermethylation in tumor tissues, pericancer liver tissues, normal liver tissues and non-tumor liver tissues with that in other diseases. Data regarding publication information, study characteristics, and incidence of p16 hypermethylation in both groups were collected from these studies and summarized. RESULTS: Fifteen studies, including 744 cases of HCC and 645 non-tumor cases, were identified for meta-analysis. Statistically significant odds ratios (ORs) of p16 hypermethylation were obtained from tumor tissues and non-tumorous liver tissues of HCC patients (OR 7.04, 95% CI: 3.87%-12.78%, P < 0.0001), tumor tissues of HCC patients and healthy liver tissues of patients with other diseases (OR 12.17, 95% CI: 6.64%-22.31%, P < 0.0001), tumor tissues of HCC patients and liver tissues of patients with non-tumorous liver diseases (OR 6.82, 95% CI: 4.31%-10.79%, P < 0.0001), and cirrhotic liver tissues and non-cirrhotic liver tissues (OR 4.96, 95% CI: 1.45%-16.96%, P = 0.01). The pooled analysis showed significantly increased ORs of p16 hypermethylation (OR 6.98, 95% CI: 4.64%-10.49%, P < 0.001) from HCC tissues and cirrhotic tissues. CONCLUSION: P16 hypermethylation induces the inactivation of p16 gene, plays an important role in hepatocarcinogenesis, and is associated with an increased risk of HCC and liver cirrhosis.

Intraductal papillary mucinous neoplasms of the pancreas--predictors of malignancy.

BACKGROUND/AIMS: Preoperative determination of malignancy in Intraductal Papillary Mucinous Neoplasms (IPMN) remains problematic. The aim of this study was to review our experience with surgical resection for IPMN and to identify the clinicopathological features that predicted malignancy in IPMN. METHODOLOGY: Forty patients who underwent pancreatic resection for IPMN at a single tertiary center between January 1996 and March 2008 were retrospectively analyzed. RESULTS: Thirteen patients (32.5%) had adenomas, 4 (10%) borderline IPMN, 18 (45%) carcinoma in situ, and 5 (12.5%) invasive carcinoma. Patients with benign IPMN had 1-, 3-, and 5-year overall survival rates of 100%, 94.1%, and 88.2%, respectively and 1-, 3-, and 5-year disease-free survival rates of 100%, 94.1%, and 88.2%, respectively. Patients with malignant IPMN had 1-, 3-, and 5-year overall survival rates of 100%, 65.2%, and 56.5%, respectively and 1-, 3-, and 5-year disease-free survival rates of 91.3%, 47.8%, and 43.5% respectively. After a median follow-up of 39 months (range, 9 - 89) months, there were 5 patients with disease recurrences (12.5%) in patients with IPMN with invasive carcinoma after operation. Abdominal pain, jaundice, main-duct or mixed type, tumor size, mural nodule and size of mural nodule, were predictive of malignant IPMN by univariate analysis, and size of mural nodule was identified as the only independent predictive factor for malignancy. CONCLUSIONS: The optimal management of IPMN remains controversial and should be individualized based on the balance between risk and benefit.

Hydrogen-rich saline protects against liver injury in rats with obstructive jaundice.

BACKGROUND: Hydrogen selectively reduces levels of hydroxyl radicals and alleviates acute oxidative stress in many models. Hydrogen-rich saline provides a high concentration of hydrogen that can be easily and safely applied. AIMS: In this study, we investigated the effects of hydrogen-rich saline on the prevention of liver injury induced by obstructive jaundice in rats. METHODS: Male Sprague-Dawley rats (n=56) were divided randomly into four experimental groups: sham operated, bile duct ligation (BDL) plus saline treatment [5 ml/kg, intraperitoneal (i.p.)], BDL plus low-dose hydrogen-rich saline treatment (5 ml/kg, i.p.) and BDL plus high-dose hydrogen-rich saline treatment (10 ml/kg, i.p.). RESULTS: The liver damage was evaluated microscopically 10 days after BDL. Serum alanine aminotransferase and aspartate aminotransferase levels, tissue malondialdehyde content, myeloperoxidase activity, tumour necrosis factor-alpha, interleukin (IL)-1beta, IL-6 and high-mobility group box 1 levels were all increased significantly by BDL. Hydrogen-rich saline reduced levels of these markers and relieved morphological liver injury. Additionally, hydrogen-rich saline markedly increased the activities of anti-oxidant enzymes superoxide dismutase and catalase and downregulated extracellular signal-regulated protein kinase (ERK)1/2 activation. CONCLUSIONS: Hydrogen-rich saline attenuates BDL-induced liver damage, possibly by the reduction of inflammation and oxidative stress and the inhibition of the ERK1/2 pathway.