Decoding neoantigen-encoding tumor-specific transcripts unveils a shared target reservoir for immunotherapy in hepatocellular carcinoma

ABSTRACT Background and Aims Primary liver cancer, predominantly hepatocellular carcinoma (HCC), has limited therapeutic options. While mutation-derived neoantigen vaccine holds promise, its success is hindered by low antigen availability. This study explores transcriptome-derived neoantigens (neoantigen-encoding tumor-specific transcripts, neoTSTs) in HCC, characterizing their features, generation mechanisms, and therapeutic potential. Approach and Results We analyzed RNA-seq data from 1,013 liver cancer patients and constructed a multi-layered reference dataset. Using a customized pipeline, we identified an average of 60 neoTSTs per patient, significantly surpassing mutation-derived neoantigens (neoMuts). NeoTSTs exhibited higher population frequencies, with 73.1% providing multiple epitopes, and were validated through mass spectrometry and HLA transgenic mouse models. Mechanistically, neoTSTs were generated via retained introns, transposable element activation, HNF4A-regulated alternative promoters, and de novo transmembrane domain (TMD) generation. Single-cell analysis revealed neoTSTs cover >75% of tumor cells and identified antigen-presenting cancer-associated fibroblasts (apCAFs) that enriched in immunotherapy responders and amplified CD4⁺ T-cell responses via MHC-II presentation. In murine HCC models, neoTST vaccination outperformed neoMuts, inducing dual MHC-I/II activation and significant tumor growth inhibition. Conclusions NeoTSTs represent a superior neoantigen source in HCC, compensating for the limitations of mutation-derived targets. Their abundance, sharedness, and dual MHC pathway activation highlight their potential for personalized immunotherapy, particularly in low-TMB tumors. Graphic Abstract