Disertasi

Peran HIF-1α dan VEGF di Lingkungan Mikro Tumor pada Rekurensi Dini Karsinoma Sel Hati Pascareseksi: Kajian pada TILs, CD4+, CD8⁺, Sel T Regulatorik, serta Ekspresi PD-L1, dan PD-1 = Association of HIF-1α and VEGF in the Tumor Microenvironment of Early Recurrent Hepatocellular Carcinoma after Resection: Focus on TILs, CD4⁺ T Cells, CD8⁺ T Cells, Regulatory T Cells, PD-L1, and PD-1 Expression

Kanker hati merupakan masalah kesehatan global dan 90% kasus adalah karsinoma sel hati (KSH). Reseksi hati adalah terapi kuratif utama pada KSH stadium awal dengan kesintasan lima tahun 70–80%. Namun, rekurensi pasca-reseksi masih merupakan masalah dengan angka rekurensi dalam 6 bulan mencapai 31 ,9%. Faktor klinis dan hipoksia mikro lingkungan tumor ditunjukkan oleh ekspresi hypoxia inducible factor-1 alpha (HIF-1α) yang berperan pada rekurensi dini. Penelitian ini bertujuan untuk mengetahui hubungan HIF-1 α, vascular endothelial growth factor (VEGF), TILs, CD4+, CD8⁺, Treg (CD4+FoxP3 +), PD-1, dan PD-L1, serta karakteristik klinis terhadap rekurensi dini pasien KSH enam bulan pascareseksi. Penelitian nested case-control multisenter ini melibatkan 49 pasien KSH yang menjalani reseksi hati di RS Kanker Dharmais, RSUP Fatmawati, dan RSUPN Cipto Mangunkusumo (201 4–2024). Data klinis diperoleh dari rekam medis, TILs melalui pulasan HE, serta pulasan IHK untuk HIF-1α, VEGF, TILs, CD4+, CD8⁺, Treg (CD4+FoxP3 +), PD-1 dan PD-L1. Analisis disease free survival diawali dengan identifikasi distribusi data analisis Mann Whitney-U, mencari titik potong menggunakan kurva receiver operating characteristic (ROC) yang bermakna, dilanjutkan kurva Kaplan-Meier. Eksplorasi HIF-1α melalui analisis jalur dan analisis multivariat menggunakan regresi Cox pada variabel yang memenuhi uji asumsi proporsional hazard. Sebanyak 22,45% pasien mengalami rekurensi dini. Penurunan CD4⁺ intratumoral (HR 7,98; IK 95%: 1 ,63–39,07) dan penurunan CD8⁺ peritumoral (HR 4,98; IK 95%: 1,14–21,70) berhubungan dengan peningkatan risiko rekurensi. HIF-1 α, VEGF, TILs, Treg (CD4+FoxP3 +), PD-1, dan PD-L1 tidak menunjukkan hubungan (p > 0,05). Simpulan: Penurunan CD4⁺ intratumoral dan CD8⁺ peritumoral berperan penting pada mekanisme imun antitumor terhadap rekurensi dini pasca-reseksi, sedangkan faktor pro-tumor tidak menunjukkan hubungan. Pemantauan ketat perlu dilakukan terhadap pasien KSH yang mengalami penurunan ekspresi CD4⁺ intratumoral dan CD8⁺ peritumoral. Cut-offyang dihasilkan terbukti bermakna serta memiliki nilai sensitivitas dan spesifisitas yang tinggi sehingga berpotensi diterapkan dalam stratifikasi risiko klinis.
Kata Kunci: CD4, CD8, HIF-1 α, KSH, PD-1, PD-L1, rekurensi dini, TILs, Treg, VEGF


Liver cancer remains a major global health concern, with approximately 90% of cases classified as hepatocellular carcinoma (HCC). Hepatic resection serves as the primary curative therapy for early-stage HCC, yielding a five-year survival rate of 70–80%. However, postoperative recurrence remains a major challenge, with recurrence rates reaching 31.9% within six months. Several studies have identified clinical factors and tumor microenvironmental hypoxia, indicated by HIF-1α expression, as contributors to early recurrence. This study aims to determine the association of HIF-1α, VEGF, tumor-infiltrating lymphocytes (TILs), CD4⁺, CD8⁺, Treg (CD4⁺FoxP3⁺), PD-1, PD-L1, and clinical characteristics with early recurrence following hepatic resection in HCC patients. A multicenter nested case–control study was conducted on liver tissues from 49 HCC patients who underwent resection at Dharmais, Fatmawati, and Cipto Mangunkusumo Hospitals (2013–2024). Clinical data were obtained from medical records, tumor-infiltrating lymphocytes (TILs) were assessed using HE staining, and immunohistochemical staining was performed for HIF-1α, VEGF, TILs, CD4⁺, CD8⁺, Treg (CD4⁺FoxP3⁺), PD-1, and PD-L1. Analyses included the Mann– Whitney U test, ROC curve determination of optimal cut-offs, Kaplan–Meier survival analysis, pathway exploration, and multivariate Cox regression. Early recurrence occurred in 22.45% of patients. Low intratumoral CD4⁺ expression (HR 7.98; 95% CI: 1.63–39.07) and low peritumoral CD8⁺ expression (HR 4.98; 95% CI: 1.14–21.70) were associated with recurrence, while HIF-1α, VEGF, Treg, PD-1, and PD-L1 were not (p > 0.05). Conclusions: Low intratumoral CD4⁺ and peritumoral CD8⁺ infiltration play crucial roles in the antitumor immune mechanism against early recurrence, whereas pro-tumor factors showed no association. These findings highlight the importance of monitoring patients with reduced antitumor CD4+, and CD8+ as the identified cutoff values may aid clinical risk stratification after resection.
Keywords: CD4+, CD8⁺, early reccurence, HIF-1α, PD-1, PD-L1, TILs, Treg, VEGF.