Hepatic CD4 T Cells Predict Hepatocellular Carcinoma Risk on Metabolic Dysfunction-Associated Steatohepatitis Patients

<h4>Background & aims</h4>Metabolic dysfunction-associated steatohepatitis (MASH) increasingly drives hepatocellular carcinoma (HCC) development. We characterized inflammatory infiltrates in liver biopsies from MASH patients who developed HCC versus controls to identify predictive immune signatures.<h4>Method</h4>Formalin-fixed paraffin-embedded (FFPE) liver biopsies from MASH patients were categorized as pre-HCC MASH (n = 10) or control MASH (n = 13) by the ESCALON consortium. Standardized histological analysis and multiplexed immunohistochemistry were performed targeting CD4, CD8, PD1, PDL1, FoxP3, CXCR6, CD3, CD68, and CD20 using a PhenoImager Fusion scanner. Single-cell RNA-seq datasets characterized hepatic CD4 T cell heterogeneity. Clinical parameters measured included ALT, AST, GGT, alkaline phosphatase, platelets, and INR.<h4>Results</h4>Pre-HCC MASH showed inflammation extending from portal to periportal areas versus portal-only distribution in controls. Analysis of 291,908 cells revealed significantly higher CD4+ density (p = 0.0243) and CD4+PD1+ cells (p = 0.017) in pre-HCC patients, while CD8+ and regulatory T cell densities remained unchanged. Single-cell RNA-seq identified potential phenotypic shifts from Th1 cytotoxicity toward tissue-repair and Th17 CD4+ T cells in MASH livers. Combined immunological and clinical variables (sex, age, CD4+ T cell numbers, ALT, alkaline phosphatase and platelets) achieved excellent predictive performance (ROC-AUC = 0.944) for HCC development.<h4>Conclusions</h4>Increase in liver CD4+ T cell infiltration characterizes MASH-to-HCC progression. These immune signatures combined with clinical parameters demonstrate remarkable predictive value for identifying high-risk MASH patients.