Published online Nov 15, 2026. doi: 10.4251/wjgo.124074
Revised: June 30, 2026
Accepted: August 26, 2026
Published online: November 15, 2026
Processing time: 153 Days and 12.3 Hours
DNA replication stress is a central molecular event in tumorigenesis and cancer progression. As an essential component of the eukaryotic replisome, the GINS complex, composed of GINS1/PSF1, GINS2/PSF2, GINS3/PSF3,
Core Tip: This review highlights the GINS complex, a core component of the CMG helicase, as a candidate molecular link between DNA replication stress adaptation, cancer stemness, epithelial-mesenchymal transition, and therapeutic resistance in hepatocellular carcinoma (HCC). Current evidence is strongest for GINS1, GINS2, and GINS4, whereas HCC-specific functional validation of GINS3 remains limited. The GINS-CMG axis should therefore be viewed as a hypothesis-generating biomarker and translational concept rather than an established therapeutic target.
- Citation: Yang HW, Chen X, Wu WJ, Yang L, Fang XB. GINS complex couples DNA replication stress to therapeutic resistance in hepatocellular carcinoma. World J Gastrointest Oncol 2026; 18(11): 124074
- URL: https://www.wjgnet.com/1948-5204/full/v18/i11/124074.htm
- DOI: https://dx.doi.org/10.4251/wjgo.124074
Sustained proliferation is one of the defining biological features of cancer cells. To maintain rapid division, cancer cells must accurately replicate a large genome within a limited time frame. However, oncogene activation, tumor suppressor loss, metabolic reprogramming, hypoxia, an inflammatory microenvironment, and anticancer treatment can all perturb the replication process and induce DNA replication stress. Replication stress can promote tumor evolution by inducing DNA damage, chromosomal instability, and mutation accumulation, while also generating tumor-specific therapeutic vulnerabilities[1,2].
The GINS complex is a key structural unit of the DNA replication machinery. The acronym GINS is derived from the Japanese numerals go-ichi-ni-san and denotes a tetrameric complex composed of SLD5/GINS4, PSF1/GINS1, PSF2/GINS2, and PSF3/GINS3. Together with CDC45 and MCM2-7, GINS forms the Cdc45-MCM-GINS (CMG) helicase, the core motor that drives eukaryotic replication fork progression[3,4]. Structural and functional studies indicate that CMG is not only the central DNA unwinding apparatus but also a platform for recruiting DNA polymerases, fork protection factors, and checkpoint proteins[5].
In hepatocellular carcinoma (HCC), direct evidence currently focuses mainly on GINS1, GINS2, and GINS4, including their associations with tumor progression, poor prognosis, epithelial-mesenchymal transition (EMT), stemness, and phosphatidylinositol 3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/AKT/mTOR)- or POLE2/ferroptosis-related pathways[6-10]. In contrast, HCC-specific functional validation of GINS3 remains lacking, and its relevance is mainly inferred from database or expression-association analyses[11-13]. Therefore, this review does not assume that GINS1-4 are equally established mechanistic drivers in HCC. Instead, it summarizes the replication biology of the GINS-CMG complex while critically evaluating HCC-related evidence for GINS1, GINS2, and GINS4, with GINS3 mechanistic investigation highlighted as a future direction.
It should be emphasized that replication stress in HCC is shaped by liver-specific etiological and regenerative contexts rather than representing only a generic feature of proliferating solid tumors[14,15]. Hepatitis B virus (HBV)/hepatitis C virus (HCV) infection, alcohol-related liver injury, and metabolic-associated steatotic liver disease (MASLD)/metabolic dysfunction-associated steatohepatitis (MASH) may promote replication stress through distinct but overlapping mechanisms[16-19], including viral integration or viral protein-mediated transcriptional disturbance, chronic inflammation, oxidative stress, metabolic dysfunction, mitochondrial injury, and repeated hepatocyte regeneration. These etiological backgrounds may differentially influence the activation of GINS subunits, MCMs, CDC45, POLE, ATR-CHK1, and other replication or checkpoint networks. Therefore, in this review, the GINS complex is positioned as a candidate node within the HCC replication stress adaptation network, rather than as an already validated HCC-specific driver.
Literature search statement: This narrative minireview was based on English-language literature identified from PubMed, Web of Science, and Google Scholar up to June 2026, using keywords related to GINS subunits, CMG helicase, DNA replication stress, HCC, stemness, therapeutic resistance, immunotherapy, liquid biopsy, and ferroptosis. HCC-focused studies were prioritized, whereas non-HCC evidence was used only as mechanistic background or hypothesis-generating support.
Eukaryotic DNA replication comprises origin licensing, origin firing, replication fork establishment, strand elongation, and replication termination. MCM2-7 is loaded onto replication origins during G1 phase. After entry into S phase, CDC45 and GINS are recruited under the regulation of kinases such as CDK and DDK, leading to the formation of the active CMG helicase[3,4]. The CMG helicase translocates along DNA through an ATP-dependent mechanism, promotes parental duplex unwinding, and coordinates the activities of DNA polymerase epsilon, Ctf4/AND-1, TIMELESS-TIPIN, CLASPIN, and other replisome-associated factors.
The four GINS subunits are structurally interdependent and form a stable tetramer. GINS1 and GINS2 are commonly linked to replication initiation and cell-cycle regulation, whereas GINS3 and GINS4 participate in maintaining complex stability and replication fork function. Because GINS is indispensable for CMG assembly and activity, dysregulated expression of any GINS subunit may influence origin activation, fork velocity, fork stability, and the DNA damage response. In tumor cells, GINS upregulation may help sustain replication throughput under high proliferative pressure. However, when replication stress exceeds the cellular tolerance threshold, the GINS-CMG axis may also become a candidate target for synthetic lethal therapeutic approaches.
DNA replication stress is commonly induced by several mechanisms. Activation of oncogenes such as MYC, RAS, cyclin E, and E2F may cause aberrant origin firing and premature S-phase entry. Insufficient nucleotide synthesis or metabolic disturbance can slow fork progression. Transcription-replication conflicts, R-loop accumulation, and abnormal chromatin architecture can impede fork movement. In addition, chemotherapy, radiotherapy, PARP inhibitors, and ATR/CHK1/WEE1 inhibitors further increase the replicative burden[1,2,20].
In HCC, these general sources of replication stress are superimposed on a liver-specific cycle of chronic injury and regeneration[14,15]. Chronic HBV or HCV infection, repeated proliferation within cirrhotic nodules, reactive oxygen species released by inflammatory cells, metabolic disturbance-associated abnormalities in nucleotide and energy supply[16,17], and driver events involving TERT, MYC, E2F, TP53, and CTNNB1/β-catenin may continuously expose hepa
Replication stress has both tumor-promoting and therapeutically exploitable consequences. Low to moderate replica
High expression of GINS subunits has been reported in multiple solid tumors and is often co-expressed with proliferation and replication markers such as Ki-67, MCMs, PCNA, CDC45, CDK1, and cyclin B1[11,12,23]. Mechanistically, GINS may promote the G1/S transition, enhance origin activation, stabilize the CMG helicase, support replication fork elongation, and help cancer cells accommodate oncogene-driven replication demand. Overexpression of GINS1 or CDC45 can increase origin firing and has been associated with whole-chromosome instability, suggesting that dysregulated replication initiation can extend from replication stress to mitotic errors and aneuploidy[22].
The link between replication-associated proteins and EMT is receiving increasing attention. In HCC, GINS1 has been reported to promote ZEB1-mediated EMT and metastasis. Mechanistically, GINS1 interacts with activated β-catenin and upregulates ZEB1, thereby enhancing migratory, invasive, and metastatic capacities[6]. This finding suggests that the oncogenic function of GINS1 extends beyond DNA replication itself and may connect cell-cycle status, replication activity, and metastatic phenotypes through the Wnt/β-catenin-ZEB1 axis.
PI3K/AKT/mTOR is a common pro-proliferative, metabolism-supporting, and anti-apoptotic signaling axis in HCC. GINS2 has been shown to be transcriptionally activated by E2F1 and to promote HCC cell proliferation, migration, invasion, and in vivo tumor growth through the PI3K/AKT/mTOR pathway[8]. GINS4 is also highly expressed in HCC, and functional analyses suggest that it may positively regulate the cell cycle and the PI3K/AKT/mTOR pathway[9]. More recent evidence further indicates that GINS4 may modulate PI3K/AKT signaling, cell-cycle progression, and ferroptosis sensitivity through POLE2[10].
Cancer stem-like cells are characterized by self-renewal, differentiation plasticity, quiescent or slow-cycling states, enhanced DNA repair capacity, antioxidant defenses, and therapeutic resistance. The relationship between cancer stemness and replication stress is not linear. On the one hand, stem-like cancer cells can avoid replication catastrophe by enhancing DNA damage repair, reducing replication speed, and maintaining fork stability. On the other hand, treatment-induced replication stress can select for or induce more plastic, drug-tolerant cellular states[24,25].
Recent studies in HCC further highlight the close relationship between cancer stemness and therapeutic resistance. Liver cancer stem-like cells maintain self-renewal and plasticity through pathways such as Wnt/β-catenin, Notch, Hedgehog, transforming growth factor (TGF)-β, PI3K/AKT/mTOR, Hippo/YAP, and epigenetic reprogramming, and may form residual tumor cell reservoirs under the pressure of tyrosine kinase inhibitors, immunotherapy, or locoregional treatment[24-26]. Consistent with the general concept of a resistance continuum, HCC cells may also undergo progressive transitions from stress tolerance and reversible drug-tolerant states to enhanced stemness and eventually stable resistant clones[27]. Recent studies of sorafenib-resistant HCC have suggested that replication licensing and replication fork-associated factors may correlate with cancer stemness indices and prognosis, indicating that remodeling of the replication machinery may contribute to the formation of drug-tolerant HCC cell states[28]. On this basis, the link between the GINS axis, stemness, replication stress adaptation, and therapeutic tolerance should be regarded as a testable mechanistic hypothesis rather than a fully established causal pathway.
In HCC, GINS1 has been linked to cell proliferation and stemness. E2F1 can enhance HCC cell proliferation and stemness by transcriptionally activating GINS1; GINS1 overexpression increases sphere-forming and proliferative capacities, whereas GINS1 knockdown produces the opposite effects[7]. This finding is important because the E2F1-GINS axis may represent a continuous program of cell-cycle activation, enhanced replication capacity, and stemness maintenance in HCC. Because E2F1 is also a central transcription factor for cell-cycle and replication genes, upstream E2F1 dysregulation may simultaneously activate GINS1/GINS2, MCMs, CDC45, PCNA, and DNA polymerase-related genes, thereby conferring higher replication potential and regenerative capacity after treatment.
Mechanistically, GINS may be linked to cancer stemness through three non-mutually exclusive routes. First, it may maintain replication fork stability when stem-like cells re-enter proliferative states, thereby preventing replication stress-induced cell death. Second, it may cross-talk with stemness-associated pathways such as β-catenin, PI3K/AKT/mTOR, E2F, and MYC to promote stemness programs involving OCT4, SOX2, NANOG, CD133, and EpCAM. Third, it may enhance DNA damage tolerance, allowing cancer stem-like cells to survive chemotherapy, targeted therapy, or radiotherapy. Although these mechanisms require further direct validation in HCC, existing studies of GINS1 and GINS2 provide a plausible biological foundation.
Therapeutic resistance can be classified into genetic and non-genetic forms. Increasing evidence indicates that cancer cells can undergo a continuum of cellular state transitions under drug pressure, including stress adaptation, epigenetic remodeling, metabolic change, and increased plasticity, ultimately leading to stable resistant states[27]. DNA replication stress is both part of the drug-induced cytotoxic mechanism and an important source of selective pressure that shapes drug-tolerant cell states.
To place the resistance continuum concept in an HCC-specific context, the GINS axis can be considered within the evolution of drug-tolerant cell states[27]. During the early phase of therapy, replication stress and DNA damage may eliminate highly sensitive cells while selecting for or inducing residual cells with stronger checkpoint activity, DNA repair capacity, antioxidant defenses, and stem-like plasticity[20,21,26,27]. With continued treatment, these residual cells may gradually acquire stable resistance through epigenetic remodeling, metabolic switching, activation of EMT/CSC programs, and reinforcement of replication stress-buffering networks[26-29]. Whether high GINS expression is merely a proliferation-associated marker in this process or functionally contributes to fork stability, post-treatment repopulation, and maintenance of resistant cell reservoirs remains to be validated using HCC-specific time-series models, single-cell analyses, and in vivo systems.
GINS may be associated with therapeutic resistance through several mechanisms. First, it may enhance replication fork recovery and DNA damage tolerance. Many chemotherapeutic and targeted agents ultimately increase replication stress or DNA damage, and increased GINS-CMG activity may help tumor cells maintain fork progression and reduce therapy-induced replication catastrophe. Second, GINS may promote the expansion of highly proliferative resistant clones. Cells with high GINS expression generally exhibit stronger cell-cycle activity and may rapidly repopulate tumors after treatment, thereby driving recurrence. Third, GINS may link stemness and resistance. The association of GINS1 with HCC stemness, EMT, and metastasis suggests that it may contribute to maintenance of drug-resistant cell reservoirs[6,7]. Fourth, GINS may influence responses to targeted therapy and immunotherapy. Current systemic therapies for HCC include immune checkpoint inhibitor-based anti-angiogenic therapy, dual immunotherapy, and multitarget tyrosine kinase inhibitors, yet resistance remains a major clinical challenge[14,30]. High GINS expression may mark a replication stress-adapted state that intersects with these resistance mechanisms, particularly in highly proliferative, poorly differentiated, immunosuppressive, or stemness-enriched HCC subtypes.
Overall, the direct evidence for individual GINS subunits in HCC remains uneven[6,7,11]. GINS1, GINS2, and GINS4 have been supported by several HCC-focused functional or prognostic studies, whereas GINS3 currently lacks HCC-specific functional validation and is mainly supported by pan-database or complex-level expression associations[8-10,13]. Therefore, the following sections primarily discuss HCC-related evidence for GINS1, GINS2, and GINS4. GINS3 is considered mainly as a structural component of the GINS tetramer and CMG helicase, and its independent role in HCC should be regarded as an open question for future investigation rather than an established mechanistic node[3,4,11,13] (Figure 1).
HCC is the predominant histological type of primary liver cancer and remains a substantial global health burden. A global analysis based on 2022 data estimated approximately 685000 new HCC cases and 597000 HCC deaths, with HBV, HCV, alcohol consumption, metabolic dysfunction-associated steatotic liver disease, diabetes, obesity, aflatoxin exposure, and smoking jointly contributing to disease development[15]. The 2025 ESMO Clinical Practice Guideline covers diagnosis, staging, early-, intermediate-, and advanced-stage treatment, and follow-up for HCC, and emphasizes multidisciplinary management[30]. However, even as first-line immunotherapy-based combinations have become important standards of care for advanced HCC, recurrence, resistance, and the lack of precise predictive biomarkers remain major clinical bottlenecks.
Among GINS subunits, GINS1 has relatively stronger HCC-specific evidence. GINS1 promotes β-catenin/ZEB1-mediated EMT and metastasis and is associated with poor prognosis in HCC[6]. Another study showed that E2F1 enhances HCC cell proliferation and stemness through activation of GINS1[7]. Therefore, GINS1 may be one of the most promising GINS subunits for further mechanistic investigation in HCC, particularly in studies focused on the replication stress-EMT-stemness-resistance axis.
GINS2 is transcriptionally activated by E2F1 in HCC and promotes tumor progression through the PI3K/AKT/mTOR pathway[8]. From the perspective of replication stress, the E2F1-GINS2 axis may represent a canonical oncogene-driven replication program: E2F1 activates replication genes and promotes S-phase entry and origin firing; GINS2 provides CMG stability and fork progression capacity; and PI3K/AKT/mTOR supports protein synthesis, metabolic supply, and anti-apoptotic signaling.
GINS4 has been reported to be upregulated in HCC and associated with poor prognosis. Studies based on TCGA, UALCAN, DiseaseMeth, and other databases indicate that GINS4 may be regulated by hypomethylation and associated with the cell cycle and PI3K/AKT/mTOR signaling. A nomogram incorporating GINS4 expression and TNM stage showed prognostic predictive value[9]. Recent research further suggests that GINS4 silencing suppresses HCC cell proliferation and cell-cycle progression, promotes ferroptosis, and acts through POLE2-related PI3K/AKT signaling[10]. These findings provide a rationale for exploring a GINS4-DNA polymerase-replication fork stability axis.
Based on currently limited HCC-specific evidence and established replication biology, a hypothesis-generating model can be proposed[1,2,6-8]. In this model, chronic liver injury, viral infection, metabolic dysfunction, and oncogene/E2F activation may increase the baseline burden of replication stress in HCC[14-17]. Therapy-induced DNA damage and checkpoint dependency may further increase the requirement for replication stress adaptation[20,21].
Upregulation of GINS1, GINS2, or GINS4 may help maintain CMG integrity, replication fork progression, and replisome stability, thereby supporting highly proliferative tumor cell states[3-5,12]. HCC-specific studies further suggest that GINS1, GINS2, and GINS4 are associated with EMT, stemness, PI3K/AKT/mTOR signaling, and POLE2/fer
These interactions could contribute to EMT, stemness, post-treatment repopulation, and therapeutic resistance[6,7,24,25]. HCC-related studies of cancer stem-like cells, treatment resistance, and sorafenib-resistant states further support this hypothesis-generating framework[26-29]. However, these mechanisms remain largely inferential and require direct validation in HCC organoids, patient-derived xenografts, genetically engineered mouse models, immunocompetent models, and single-cell time-series systems[31,32].
Within this framework, the GINS complex may be interpreted in three biological contexts. First, as a core component of the replication machinery, it supports DNA replication in highly proliferative tumor cells. Second, as a downstream effector of oncogene- and E2F-driven replication programs, it may intersect with PI3K/AKT/mTOR, β-catenin/ZEB1, and other signaling pathways involved in malignant progression. Third, as a candidate support node for replication stress adaptation, it may mark HCC subgroups with enhanced proliferation, stemness, therapeutic tolerance, and recur
Before discussing a GINS signature as a potential biomarker, its expression context should be clarified. Current HCC studies and public-database analyses suggest that GINS1, GINS2, and GINS4 are upregulated in HCC tissues compared with normal or adjacent non-tumor liver tissues and are associated with poor prognosis, whereas GINS3 is mainly supported by bioinformatic associations involving expression, methylation, and immune escape. However, unified quantitative comparisons across normal hepatocytes, chronic hepatitis, cirrhotic nodules, dysplastic nodules, and different stages of HCC using the same platform and cutoff are still lacking. Therefore, the GINS signature is positioned here as a candidate stratification indicator rather than as a mature clinical biomarker.
GINS1, GINS2, and GINS4 have all been associated with poor prognosis in HCC[6,8,9,11]. In addition, recent bioinformatic and clinical validation data suggest that GINS1 is upregulated in LIHC and may have diagnostic and prognostic value, although these findings remain largely observational and require prospective validation[33]. For GINS4, previous analyses reported overexpression in HCC and diagnostic discrimination between HCC and non-tumor or cirrhotic liver tissues, supporting its potential biomarker relevance while still requiring functional and clinical validation[9]. Future studies may develop a GINS signature to identify patients with highly proliferative tumors, high replication stress, and increased recurrence risk. A single GINS subunit may be affected by batch effects, detection platforms, and tumor purity. In contrast, integration of GINS1-4, MCMs, CDC45, PCNA, POLE2, ATR/CHK1, E2F target scores, and stemness scores may provide a more robust biomarker framework.
Importantly, a potential GINS signature should be positioned as complementary to, rather than competitive with, established HCC biomarkers and classification systems. Serum alpha-fetoprotein (AFP), AFP-L3, and DCP/PIVKA-II remain clinically relevant tools for HCC detection, risk assessment, and monitoring, whereas composite models such as GALAD integrate demographic and serological variables to improve diagnostic performance[30,34]. These markers mainly reflect tumor burden, malignant transformation, or secretion-related phenotypes. By contrast, a GINS-based signature would more directly represent a tumor-intrinsic biological state characterized by cell-cycle activation, DNA replication demand, and potential replication stress adaptation. Similarly, transcriptomic and integrative molecular classifications, including Hoshida S1-S3 and TCGA/iClust subtypes, capture broader biological programs such as proliferation, MYC/AKT activation, Wnt/TGF-β signaling, differentiation status, immune contexture, and metabolic reprogramming[35-37]. Therefore, GINS should not be proposed as a replacement for AFP, AFP-L3, DCP, GALAD, or molecular sub
| Subunit | Evidence level | Current HCC evidence | Reported or proposed mechanisms | Translational implication | Main limitation |
| GINS1 | Moderate | Functional and prognostic evidence in HCC | E2F1 activation; beta-catenin/ZEB1-mediated EMT; proliferation and stemness | Candidate marker for aggressive, stemness-enriched HCC | Direct evidence for therapy resistance remains limited |
| GINS2 | Moderate | Functional evidence in HCC | E2F1-mediated transcriptional activation; PI3K/AKT/mTOR signaling | Candidate marker of proliferative and replication-active HCC | Role in drug resistance and immune response remains unclear |
| GINS3 | Low/inferential | Mainly bioinformatic or association-based evidence | Methylation, expression association, possible immune escape; structural role in GINS tetramer | Hypothesis-generating biomarker | Lacks HCC-specific functional validation |
| GINS4 | Moderate | Prognostic and functional evidence in HCC | Cell-cycle regulation; PI3K/AKT signaling; POLE2/ferroptosis-related axis | Candidate marker and potential replication-fork/ferroptosis-related node | Needs in vivo validation and therapeutic testing |
Direct targeting of GINS or the CMG helicase remains at a very early stage. ATP-competitive small molecules have been reported to inhibit human CMG ATPase and helicase activities at low micromolar concentrations[38]. However, this evidence is derived mainly from biochemical assays or non-HCC models and cannot be directly translated into therapeutic applicability in HCC. Therefore, GINS/CMG-targeted therapy discussed in this review should be interpreted as a replication stress-based hypothesis rather than as a clinically established therapeutic strategy.
Theoretically, GINS/CMG inhibition may complement ATR/CHK1/WEE1 inhibition, PARP inhibition, tyrosine kinase inhibitors, or immunotherapy[20-22,39]. GINS/CMG inhibition may weaken replication fork progression and replisome stability, whereas ATR/CHK1/WEE1 inhibition or PARP inhibition may further perturb checkpoint signaling, fork protection, and DNA damage repair[20-22]. In parallel, tyrosine kinase inhibitors and immunotherapy may impose additional proliferative, metabolic, vascular, or immune-mediated selective pressure on HCC cells[30]. Therefore, a replication stress-adapted state marked by high GINS expression may theoretically represent a vulnerable state for rational combination therapy, especially in highly proliferative or stemness-enriched HCC.
However, no study has yet validated the synergistic effect of GINS/CMG inhibitors with sorafenib, lenvatinib, regorafenib, atezolizumab-bevacizumab, or durvalumab-tremelimumab in HCC cell lines, organoids, patient-derived xenografts, or animal models. Before this concept can be advanced toward preclinical translation, several key questions must be addressed. First, does GINS/CMG inhibition selectively affect HCC cells with high GINS expression or high replication stress? Second, because CMG is essential for DNA replication in normal proliferating cells, would CMG inhibition cause unacceptable toxicity in bone marrow, intestinal epithelium, or regenerating liver tissue[3-5,12]? Third, can a GINS-based signature predict sensitivity to replication stress-targeted therapy or rational combination therapy? Fourth, can GINS/CMG inhibition reverse established resistance or only prevent the emergence of drug-tolerant states?
Only after these issues are systematically resolved in HCC-specific experimental models can the GINS-CMG axis be considered an actionable target for combination treatment. At present, its most appropriate translational positioning is as a candidate stratification marker and a hypothesis-generating therapeutic concept for replication stress-focused precision oncology in HCC.
GINS-based liquid biopsy remains an exploratory direction rather than a validated application. Liquid biopsy studies in HCC mainly focus on ctDNA/cfDNA, circulating tumor cells, exosomal RNA, circulating microRNAs, and methylation markers[40,41]. Although these approaches provide non-invasive opportunities for recurrence monitoring and treatment-response assessment, no study has yet demonstrated that a GINS signature can be reliably detected in circulating tumor cells, exosomal RNA, or cfRNA for HCC stratification. Therefore, GINS-based liquid biopsy should be regarded as a future research direction.
Replication stress and DNA damage may influence cGAS-STING signaling through chromosomal instability, mi
First, most current studies on GINS in HCC rely on public datasets, retrospective bioinformatic analyses, and in vitro functional assays[6-8,11]. Robust in vivo evidence remains lacking. In particular, no study has yet used HCC organoids, patient-derived xenografts, genetically engineered mouse models, or immunocompetent models to demonstrate that GINS directly drives therapeutic resistance or that GINS inhibition reverses resistance to sorafenib, lenvatinib, immune checkpoint inhibitor-based combinations, or other systemic therapies[9,10,31,32]. Therefore, current associations between GINS expression, stemness, and resistance should be interpreted cautiously as hypothesis-generating evidence rather than causal proof. Second, whether high GINS expression is merely a marker accompanying proliferation or a causal driver of replication stress adaptation and drug resistance remains to be determined using time-series analyses, single-cell approaches, organoids, and animal models. Third, GINS1-4 function as a highly coordinated complex, yet many studies focus on a single subunit and neglect CMG activity at the complex level. Fourth, the relationships between GINS and the immune microenvironment, immunotherapy response, and metabolic reprogramming remain unclear. Fifth, the development of direct GINS/CMG-targeting drugs is still at an early stage, and selectivity, toxicity, and therapeutic windows require careful evaluation (Table 1).
Future research should prioritize the following directions. First, multi-omics datasets, including TCGA, ICGC, CPTAC, single-cell RNA sequencing, spatial transcriptomics, and proteomics, should be integrated to construct a comprehensive landscape of the GINS-CMG-replication stress axis in HCC. Second, the causal effects of the GINS axis on stemness, metastasis, and therapeutic resistance should be validated in HCC organoids, patient-derived xenografts, and immunocompetent mouse models. Third, drug screening should be performed to determine whether high GINS expression predicts sensitivity to ATR/CHK1/WEE1/PARP/CMG inhibitors. Fourth, GINS signatures should be analyzed together with molecular subtypes of HCC, immune infiltration, tumor mutational burden, Wnt/β-catenin activation, TP53 status, and E2F target scores. Fifth, it should be determined whether GINS inhibition can reverse resistance to sorafenib, lenvatinib, regorafenib, atezolizumab-bevacizumab, or durvalumab-tremelimumab. Sixth, given that GINS3 represents the weakest part of the current evidence chain, future studies should systematically evaluate its expression regulation, contribution to CMG stability, role in replication fork protection, and coordination with GINS1/2/4 in HCC cell lines, organoids, patient-derived xenografts, and genetically engineered mouse models. These studies are needed to determine whether GINS3 has HCC-relevant biological functions beyond its structural role within the GINS complex.
From a precision oncology perspective, future studies should analyze the distribution of a GINS signature across molecular subtypes of HCC. For example, E2F/MYC-proliferative, TP53-mutant, or PI3K/AKT/mTOR-activated HCC may be more likely to show high replication-gene expression; Wnt/β-catenin-activated HCC may also display immune-exclusion features and altered immunotherapy responses; and TERT promoter mutation, chromosomal instability, and high tumor proliferation scores may be associated with the GINS-CMG axis. We do not assume that these subtypes are already proven to be sensitive to GINS targeting; rather, we propose that GINS signatures should be analyzed together with TCGA/iClust, Hoshida S1-S3, immune classifications, Wnt/β-catenin status, TP53 status, and E2F target scores.
The GINS complex is a core component of the DNA replication machinery and supports DNA replication programs in proliferating cells by participating in CMG helicase formation and replication fork progression. In HCC, current studies show that GINS1, GINS2, and GINS4 are associated with tumor progression, poor prognosis, EMT, stemness, and PI3K/AKT/mTOR signaling, whereas HCC-specific evidence for GINS3 remains very limited. Based on the available evidence, high GINS expression should be cautiously interpreted as a candidate marker of high proliferation and replication stress adaptation. Whether GINS functions as a causal driver that actively promotes HCC malignant progression, therapeutic resistance, and recurrence remains to be rigorously validated in prospective clinical cohorts, time-series models, single-cell analyses, organoids, patient-derived xenografts, and animal models. Future studies centered on the GINS-CMG-replication stress response axis, with explicit evidence grading and rational combination-therapy testing, may provide a new conceptual and translational framework for precision stratification, recurrence prediction, and resistance reversal in HCC.
We would like to express our sincere gratitude to Teacher Xie from the Department of Science and Education and the two Teachers Yang for their assistance.
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