DNMT2‐m5C‐ACLY Axis Promotes Lenvatinib Resistance in Hepatocellular Carcinoma Through Histone Acetylation‐Mediated Notch Pathway

ABSTRACT Lenvatinib serves as a first‐line therapy for advanced hepatocellular carcinoma (HCC), but its clinical efficacy is severely limited by acquired drug resistance. Consequently, the identification of therapeutic targets to reverse lenvatinib resistance may offer novel strategies to achieve enhanced and durable treatment responses. In this study, a global elevation in the levels of m5C modification is observed in lenvatinib‐resistant cells compared with their parental counterparts. DNA methyltransferase 2(DNMT2), functioning as an RNA methyltransferase, is markedly upregulated in lenvatinib‐resistant specimens and correlated with poor patient survival outcomes. Both in vitro and in vivo experiments indicated that DNMT2 downregulation effectively overcame lenvatinib resistance by reducing HCC cell proliferation and promoting apoptosis, thereby restoring drug sensitivity. Mechanistically, DNMT2 functioned together with Y‐box binding protein 1 (YBX1) to stabilize downstream adenosine triphosphate citrate lyase (ACLY) mRNA through m5C modification. This process activated the Notch signaling pathway by increasing intracellular acetyl‐CoA levels and promoting histone acetylation, driving the progression of lenvatinib resistance. Critically, pharmacological inhibition of ACLY combined with lenvatinib treatment enhanced the therapeutic efficacy against HCC and could reduce the tumor burden in multiple preclinical models. Collectively, the findings indicate the importance of the DNMT2‐ACLY‐NOTCH signaling axis in lenvatinib resistance and propose novel combinatorial therapies to improve HCC treatment outcomes.