A review.Sir, We read with great interest the study by Sideras et al (2015) that combines tissue microarrays (TMA) and immunohistochem. to investigate the expression pattern of 15 antigens belonging to different categories, including cancer testis antigens (CTAs) and oncofetal proteins in primary hepatocellular carcinoma (HCC).Because current therapies for HCC are far from ideal (Ilan, 2014) and immunotherapy has been proposed as a potential therapeutic option, the authors aimed at identifying a panel of relevant tumor antigens with broad expression in a Western European population of HCC patients and specific expression in the tumor tissue (Sideras et al, 2015).Cancer testis antigens represent a family of >200 proteins selectively expressed in malignant cells, but not in their natural counterpart except for human germ cells (Simpson et al, 2005; Gjerstorff et al, 2015; Grizzi et al, 2015).Among the different types of tumor antigens, CTAs identified highly promising therapeutic targets (Gjerstorff et al, 2015).In contrast to previous studies (Xu et al, 2012; Liang et al, 2013; Xia et al, 2013; Wang et al, 2015), Sideras et al (2015) found a low (<10% of patients) prevalence of expression of MAGE-A3/4, NY-ESO-1, MAGE-A1 and MAGE-A10.Moreover, a low (<10% of patients) prevalence of expression of the fetal specific glycoprotein alpha-fetoprotein (AFP) was found.Although its serum level falls rapidly after birth and its synthesis in adult life is repressed, >70% of HCC-affected patients have usually a high serum concentration of AFP.Today, AFP and ultrasonog. are the main tests for HCC surveillance in clin. practice, and in the interim, using ultrasonog. and AFP in combination may be the best strategy to optimize early HCC detection (Mehta and Singal, 2015).Sideras et al (2015) stated that the observed prevalence of expression of CTAs and oncofetal antigens was generally lower because previous studies have been conducted in East Asia where hepatitis B virus infection is the prevalent cause of HCC and the majority of HCC patients have liver cirrhosis.Furthermore, previous investigators used RT-PCR measuring mRNA expression, whereas they evaluated protein expression by immunohistochem.Here, we would like to discuss addnl. points underlying these discrepancies and that impact on the CTAs as immunotherapeutic targets.In an effort to accelerate translation of new developments in basic immunol. into cancer patients, representatives from eight immunotherapy organisations representing Europe, Japan, China and North America convened an 'Immunotherapy Summit' at the 24th Annual Meeting of the International Society for Biol. Therapy of Cancer (now called Society for Immunotherapy of Cancer, SITC).One of the concepts raised by SITC and defined as critical was the need to identify hurdles that impede effective translation of cancer immunotherapy (Fox et al, 2011).The critical hurdles highlighted have been grouped into nine general themes.Among these have been identified the 'complexity of cancer', its 'heterogeneity' and 'immune escape' (Fox et al, 2011).Hepatocellular carcinoma originates and progresses throughout a dynamic process involving different 'driven alterations' that ultimately lead to the malignant transformation of hepatocytes.Malignant transformation may occur regardless of the etiol. agent through a pathway of increased liver cell turnover, induced by chronic liver injury and regeneration in a context of inflammation, immune response and oxidative DNA damage (Li and Wang, 2015).Hepatocellular carcinoma is a heterogeneous disease in 'space' and in 'time'.The term 'heterogeneity' defines the presence of cell clones, within a tumoral mass, with different genetic aberrations that mediate divergent biol. defining the natural history of that particular tumor, i.e., one clone does not represent the entirety of the tumor cell population.This variability is what ultimately determines the evolutionary progression of neoplastic disease and its response to therapy (Luo et al, 2009).Singular cells respond differently to the same stimulus, with some not responding at all (Floor et al, 2012; Almendro et al, 2013).These considerations, in conjunction with the complexity of 'tumor-host' interactions caused by temporal changes in tumor phenotypes and an array of immune mediators expressed in the tumor microenvironment, might explain the limited reliability and applicability of current therapeutic strategies.Sideras et al (2015) did not report fundamental hallmarks of cancer, including 'cancer complexity', 'tumor heterogeneity' and 'field cancerization', i.e., the presence of abnormal tissue surrounding primary cancerous lesions.These observations lead us to reflect on the appropriateness of TMAs to state the CTAs and oncofetal proteins as potential therapeutic targets.It is known that diagnostic accuracy of a histol. assay may be affected if the 'target antigen' is uniquely present in a fraction of a tumor (Sottoriva et al, 2015).Tissue microarray consists of small fractions of tissue inserted into a recipient paraffin block such that a tissue section on a single glass slide can contain numerous patient samples in a spatially structured pattern.Although the study of whole-tissue sections for the evaluation of large tumor cohorts is tedious and costly, the genome-wide network of intra-tumor heterogeneity across multiple spatial and temporal scales, and patient-specific patterns of cancer evolution limits the appropriateness of investigating a small fraction of tissue, and is prone to controversial results and consequences for treatment design (Chiriva-Internati et al, 2004).In addition, Sideras et al (2015) applied a scoring system, called 'H-score' obtained by multiplying the intensity score (range: 0-3) with the level of % of pos. cells, where 1≤5%, 2=5-25%, 3=25-75% and 4 ≥75%.However, this approach generates equivalent 'math. products', (i.e., condition 1: intensity=1 multiplied with the level of % of pos. cells 2=5-25% is the same product obtained multiplying intensity=2 with the level of % of pos. cells 1≤5%; condition 2: intensity=1 multiplied with the level of % of pos. cells 3=25-75% is the same product obtained multiplying intensity=3 with the level of % of pos. cells 1 <5%; condition 3: intensity=1 multiplied with the level of % of pos. cells 4 ≥75% is the same product obtained multiplying intensity=2 with the level of % of pos. cells 2=5-25%; condition 4: intensity=2 multiplied with the level of % of pos. cells 3=25-75% is the same product obtained multiplying intensity=3 with the level of % of pos. cells 2=5-25%), although their biol. significance is completely different.In other words, these overlapping 'scores' subtend different impacts on the capacity of CTAs to elicit the immune response and the heterogeneous behavior of HCC.In conclusion, to advance our knowledge in a currently widely debated field of investigation such as that of immunotherapy and HCC, a clearer distinction must be made between the exploration of CTA expression pattern and their real application in human clin. trials.Because the anal. of CTA expression is useful in identifying patients who are most likely to benefit from immune intervention strategies, we need to adopt a more adequate exptl. approach and a change in our 'mind' from a 'qual.' or 'semi-quant.' to a more advanced 'quant.' thinking.