The n e w e ng l a n d j o u r na l of m e dic i n e
Sall4 in “Stemness”-Driven Hepatocarcinogenesis
Jens U. Marquardt, M.D., and Snorri S. Thorgeirsson, M.D., Ph.D.
Hepatocellular carcinoma is the most common
and deadly cause of primary liver cancer. Al-
though the incidence of hepatocellular carcinoma
is highest in Asia and sub-Saharan Africa, the
steadily increasing incidence in traditionally
low-incidence regions such as northern Europe
and the United States is a considerable public
health problem.1 Despite implementation of sur-
veillance programs, the majority of patients still
present with advanced stages of the disease, for
which curative options are limited.
Currently, the standard-of-care treatment for
advanced liver cancer is limited to the multiple
receptor tyrosine kinase inhibitor sorafenib.2
Furthermore, development of new therapies is
often hampered by the molecular complexity of
hepatocellular carcinoma as well as associated
inflammatory and fibrotic liver disease. Results
of ongoing clinical trials are discouraging over-
all, and they highlight the urgent and unmet
need for innovative treatment approaches in pa-
tients with advanced stages of hepatocellular
carcinoma.3
Cells with “stemness,” or stem-cell proper-
ties, are referred to as cancer stem cells or can-
cer-initiating cells. The concept that these cells
rest at the apex of the cancer hierarchy is an
evolving theme in cancer research.4 These cells
are by definition primarily responsible for initi-
ation and propagation of tumors as well as re-
lapse after therapy, and they are therefore of
major scientific interest. Several studies indicate
that hepatocellular carcinomas that harbor phe-
notypic features of stem cells and progenitor
cells constitute a subclass of therapeutically
challenging cancers that are associated with a
particularly poor prognosis.5 One of the stem-
ness genes associated with cancer is the human
homologue of the Drosophila spalt homeotic
gene, Sall4, which encodes a zinc-finger tran-
scription factor that is essential for the mainte-
nance of pluripotent and tissue stem cells.6 In
the liver, SALL4 is expressed at high levels in fe-
tal-liver progenitor cells but not in adult hepato-
cytes, and it plays a critical role in hepatic cell–
lineage commitment.7
In this issue of the Journal, Yong and col-
leagues8 hypothesize that, like other stem-cell
markers, such as the epithelial-cell adhesion
2316 n engl j med 368;24
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molecule (EpCAM), SALL4 could be an oncofetal
marker and an attractive therapeutic target in
hepatocellular carcinoma with progenitor-cell
origin (Fig. 1). The authors also report an onco­
fetal reactivation of SALL4 in 95 of 171 hepatitis
B–associated hepatocellular carcinoma specimens
(55.6%) at different stages. They validated this
finding in an independent group of specimens
obtained from 228 patients in Hong Kong who
had hepatocellular carcinoma as well as human
hepatoma cell lines. Most importantly, high
SALL4 expression was significantly associated
with overall survival among patients in both co-
horts in the study (the Hong Kong and Singa-
pore cohorts) and was an independent prognos-
tic factor in univariate analyses. Overexpressing
tumors had molecular profiles that were similar
to those of fetal progenitor cells and shared ac-
tivation of adverse gene sets with aggressive
stemness-associated hepatocellular carcinoma;
these findings provided support for the oncofe-
tal role of SALL4. Also, RNA interference–medi-
ated silencing of SALL4 reduced tumorigenicity,
increased apoptosis in human hepatoma cell
lines, and caused a reversal of the stemlike mo-
lecular profile of the cells. By using a specific
inhibitory 12-AA peptide against SALL4, the au-
thors convincingly showed that SALL4 affects
phosphatase and tensin homologue (PTEN) and
phosphatidylinositol 3-kinase (PI3K)–AKT signal-
ing through the interaction with the NuRD (nu-
cleosome remodeling and histone deacetylase
[HDAC]) complex. These mechanistic findings
extend those of a recent study that independently
provided evidence that SALL4 is a marker of stem-
cell–driven hepatocarcinogenesis and poor prog-
nosis.9 Finally, the authors elegantly showed a
biologic activity of the peptide and thereby
confirmed a potential therapeutic role for it in
SALL4-expressing tumors with stemlike fea-
tures and poor outcome.
Although these data are convincing, it is not
known whether targeting of SALL4 alone would
have sufficient antitumor activity or whether in-
hibition of the associated transcriptomic pro-
grams is required to prevent recurrent disease.
Another open question is whether responses to
SALL4 inhibition in stemness-associated tumors
vary according to the patient’s ethnic origin and
nejm.org june 13, 2013
 editorials

Standard care

SALL4 Low

100 SALL4 low

SALL4 high
80

Survival (%)
60
40
20
0
0 20 40 60 80 100
Months

SALL4 High

PTEN AKT SALL4-based treatment

SALL4 peptide

PTEN AKT

Figure 1. SALL4-Based Classification of Human Hepatocellular Carcinoma.

SALL4 expression divides hepatocellular carcinomas into clinically distinct subgroups. High SALL4 levels, which in-
dicate stemness-driven tumors with activation of the PTEN–PI3K–AKT pathway, predict aggressive tumor growth.
The graph shows the hypothetical rate of survival among patients with the two subgroups of hepatocellular carcino-
ma. Stratification of human hepatocellular carcinomas according to SALL4 expression appears to be a promising
method to select targeted therapies such as the SALL4 peptide in highly individualized treatment regimens.

the cause of the hepatocellular carcinoma (e.g.,
hepatitis B virus, hepatitis C virus, and alcohol);
this variability has been repeatedly observed in
other targeted therapies.10 Also, the present data
do not resolve whether tumors that overexpress
SALL4 are derived from reprogrammed hepato-
cytes or rare stem cells; the latter might have a
major effect on the regenerative capacity of the
liver and should be considered in a therapeutic
context.
Clinically, the interaction of SALL4 with the
HDAC-containing NuRD complex underlines the
promising results of an ongoing phase 2 trial of
the HDAC inhibitor resminostat (ClinicalTrials
phase 2 trial of the c-MET inhibitor tivantinib;
this trial shows the necessity of mandatory biop-
sies for molecular subclassification in patients
with advanced hepatocellular carcinomas.11 Fur-
ther, Yong et al. elegantly show the benefit of
innovative treatment strategies in hepatocellular
carcinoma, including the targeting of genes
with stem-cell features such as SALL4. Clinical
translation of these important findings is ur-
gently needed to achieve individualized thera-
pies and ultimately improve the poor outcome
in patients with hepatocellular carcinoma.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.

.gov number, NCT00943449) and may warrant
further subgroup analyses in this trial. The sys-
tematically performed study by Yong and col-
leagues also provides support for findings in a
From the Laboratory of Experimental Carcinogenesis, Center
for Cancer Research, National Cancer Institute, National Insti-
tutes of Health, Bethesda, MD (J.U.M., S.S.T.); and the Depart-
ment of Medicine I, Johannes Gutenberg University, Mainz,
Germany (J.U.M.).

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 editorials

1. Forner A, Llovet JM, Bruix J. Hepatocellular carcinoma. Lan-
cet 2012;379:1245-55.
2. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced
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4. Jordan CT, Guzman ML, Noble M. Cancer stem cells. N Engl
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6. Yang J, Chai L, Gao C, et al. SALL4 is a key regulator of sur-
vival and apoptosis in human leukemic cells. Blood 2008;112:805-
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sive hepatocellular carcinoma. N Engl J Med 2013;368:2266-76.
9. Oikawa T, Kamiya A, Zeniya M, et al. Sal-like protein 4
(SALL4), a stem cell biomarker in liver cancers. Hepatology
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DOI: 10.1056/NEJMe1303026
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