Furthermore, the high levels of CD95 and PD1 expression by CD4+ CTLs also implies that they have additional regulatory mechanisms (Supporting Fig. 4A). Future studies should determine which factors are responsible for the suppression of CD4+ CTLs in HCC patients. These data also suggest that the target of CD4+ CTLs in vivo could facilitate the boosting of the antitumor responses in HCC patients. It is currently not known why CD4+ CTLs are increased in HCC

patients with early stage disease. We found that the frequency of CD4+ CTLs in CHB and LC patients was much lower than in HCC patients, which was in accordance with the findings of a previous study15 that showed chronic HBV infection was not the principal reason for increased numbers of CD4+ CTLs in HBV-associated selleck products Hydroxychloroquine HCC patients. Three reasons may be involved in the increase in CD4+ CTL numbers in HCC patients: (1) the suppression of traditional cytotoxic immune cells might induce feedback compensation for the high incidence of CD4+ CTLs in HCC patients. For example, the cytolytic activity of CD8+ T lymphocytes and NK cells in

HCC patients is significantly abrogated during tumorigenesis.24, 33, 34 Indeed, Williams and Engelhard35 found that CD4+ T cells develop perforin-dependent cytotoxicity only in the absence of activated CD8+ T cells; (2) Abnormal immune activation due to the chronic inflammatory microenvironment is thought to be another major driving factor that induces CD4+ CTLs differentiation. Numerous reports have demonstrated that the presence of increased numbers of CD4+ CTLs is associated with chronic inflammatory processes, such as chronic viral infection or autoimmune diseases.5, 15, 17, 18, 36 Additionally, inflammation is also involved in all stages of tumor development and correlates with poor survival rates in HCC.37-40 Consistent with this hypothesis, we found that CD4+ CTLs in HCC

patients were highly medroxyprogesterone activated (high levels of CD38 and HLA-DR expression) (Supporting Fig. 4A); and (3) the increased numbers of CD4+ CTLs in tumor and nontumor regions may also be due to their recruitment into the liver from the peripheral blood, which is a similar finding to the previously reported role of CD8+ T cells.41 Future studies are warranted to confirm these hypotheses. In summary, this study demonstrated that a progressive decrease in the number of CD4+ CTLs was closely associated with HCC progression and poor survival rates in HCC patients. The intrinsic defects and extrinsic suppression by increased Treg cells may involve the impairment of CD4+ CTLs in HCC patients. These data highlight the novel role of CD4+ CTLs in the immunocompromised status of HCC patients, and also provide a potential therapeutic target for the treatment of HCC. Additional Supporting Information may be found in the online version of this article.