Background & aimsUnexplained interpatient variation and treatment failure in HCC prompt for renewed approaches. Hepatic neurons, belonging to the autonomic nervous system (ANS), mediate liver/whole body cross-talks. Pathological innervation of the ANS have been identified in cancer, nurturing tumor stroma and conferring stronger carcinogenic properties. MethodsWe characterized the innervation of liver tumors from the French Liver Biobank, then applied bioinformatics to the TCGA, several other datasets and a European validation cohort, to re-evaluate patient stratification. Cell biology and pharmacology studies were also done. ResultsDensely packed nucleated DCX+, synaptophysin+, NeuN+, VAChT+, TH-, CD31-, CD45- clusters, to date undetected, were identified in human HCCs, and independently confirmed by scRNA-seq data. Using the new concept of neuronal score, human and rat HCCs displayed tightly netrin-1-associated neural reconfiguration towards cholinergic polarity along with CLD progression, cancer onset and many features of aggressive (proliferative class) HCC, including shortened survival. This score was conditioned by tumoral hepatocytes, and predicted sorafenib efficacy in the STORM HCC phase 3 trial. Conversely, intratumoral adrenergic lymphocytes were enriched in TEMRA and cytotoxic phenotypes. Amongst all cholinergic transcripts, the medically-targeted CHRM3 receptor was enriched in HCC and associated with cells’ and tumors’ pathogenic traits, displayed adverse prognostic value by the log-rank test in HCC stages 1-2, while collapsing upon experimental re-differentiation. Its pharmacological inhibition by low concentrations of anticholinergic drugs, but not cholinomimetics, decreased anchorage-independent and anoikis growth, synergized with sorafenib and lenvatinib in HCC class 1 to 3 lines, yet not in primary human hepatocytes, and preserved mature hepatocytic functions. ConclusionThese data identify cholinergic processes as instrumental in liver carcinogenesis, and support the use of EMA/FDA-approved cholinergic drugs in HCC research. Impact and implicationsHCC care has long been hampered by the enigmatic nature of disease evolution, as well as of response or resistance to treatment. Hepatic neurons are likely the least studied liver cell type and mediate patients singularities to the organ in real-time. Cholinergic inputs identified in this study as pathogenic may be targeted with the well charted pharmacopoeia of neurotropic drugs already available, for basic or clinical research purposes, with an expected high level of safety.
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