The most complete, liver cancer 10 markers combined test comparison assessment

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To improve the therapeutic effect of hepatocellular carcinoma, that is, the 5-year survival rate, it is necessary to improve the early diagnosis rate, that is, the detection ability, and the detection ability, that is, the sensitivity of detection.

The epidemiology of liver cancer in the world and China

The top 10 countries with the highest incidence of liver cancer in the world are Mongolia, Egypt, Gambia, Vietnam, Laos, Cambodia, Guinea, Thailand, China and South Korea.

Generally speaking, liver cancer has three stages: hepatitis B→cirrhosis→liver cancer.

The high-risk groups of liver cancer mainly include:

1.

2.

3.

In addition, stress at work and excessive mental stress can easily lead to weakened human immunity and promote the growth of cancer cells.

According to the clinically available liver cancer markers reported in the literature

At present, the clinically available inspection methods including the sensitivity of tumor markers are not up to the requirements.

Alpha-fetoprotein (AFP)

According to the regulations issued by the National Health Commission for the diagnosis and treatment of primary liver cancer (2019 edition), the current clinically most effective method for assessing the risk of hepatocellular carcinoma is serum AFP combined with ultrasound, once every 6-12 months.

In terms of specificity, AFP can also be elevated in acute and chronic viral hepatitis, cirrhosis, pregnancy and teratoma.

Alpha-fetoprotein heteroplasma-L3 (AFP-L3)

According to its different reactivity with the lectin Lens culinaris agglutinin (LCA), AFP has three glycosylation types: AFP-L1, AFP-L2 and AFP-L3.

Abnormal prothrombin (des-gammacarboxyprothrombin, DCP)

Protein induced by vitamin K absence or antagonist II (protein induced by vitamin K absence or antagonist II, PIVKA-II), produced by malignant liver cells (liver cancer cells), belongs to acquired vitamin K-dependent carboxylase system translation After the defect product.

When tested by ELISA, when the DCP level exceeds 0.

Glypican-3 (glypican-3, GPC3)

It is a membrane-localized heparin sulfate proteoglycan.

GPC3 can be detected in 40–53% of hepatocellular carcinoma patients, and GPC3 can be detected in 33% of hepatocellular carcinoma patients whose serum AFP and DCP (Des-gammacarboxyprothrombin, DCP) are negative.

Clinical observation revealed that soluble GPC3 (sGPC3), that is, the N-terminal part of GPC3 cut off by proteolytic enzymes.
In well-differentiated or moderately differentiated hepatocellular carcinoma, the detection of GPC3 is more sensitive than AFP.
If GPC3 and AFP are detected at the same time, the detection sensitivity can be increased from 50% to 72%.
GPC3-positive hepatocellular carcinoma patients have a poor prognosis [3].

Table 1: Diagnostic efficacy of serum markers reported in the literature for hepatocellular carcinoma

A cross sectional case control study involving 207 patients with hepatocellular carcinoma found that DCP is more sensitive and specific than AFP in distinguishing hepatocellular carcinoma from benign liver diseases.
The study included four groups of cases: a healthy control group, a non-cirrhotic chronic hepatitis group, a compensated cirrhosis group, and a histopathologically diagnosed hepatocellular carcinoma group.
In these 4 groups of cases, the levels of DCP and AFP increased with the severity of the disease (from normal to hepatocellular carcinoma), but the overlap (crossover) of DCP values ​​in each group was less than that of AFP, indicating that the DCP The specificity is better and the diagnostic value is clearer.

The conclusion of the study is that the sensitivity and specificity of the differential diagnosis of benign liver disease and hepatocellular carcinoma reach the best state when the DCP value reaches 125mAU/mL.
Table 1 compares the sensitivity and specificity of AFP, AFP-L3, DCP and their combined detection [3].

In an evaluation of a liver cancer early warning model based on online calculations with parameters, PIVKA-II and AFP showed better diagnostic sensitivity and specificity, while AFP-L3 and AFU were inferior to the former two.
The combination of PIVKA-II and AFP showed better performance in identifying primary liver cancer (HBV-HCC), chronic hepatitis B (CHB) or chronic hepatitis B cirrhosis (HBV-LC) caused by hepatitis B virus.
The diagnostic accuracy is better than that of AFP or PIVKA-II alone (the sensitivity of the training group is 88.
3%, the specificity is 85.
1%, and the sensitivity of the verification group is 87.
8%, and the specificity is 81.
0%).
The Nomogram including AFP, PIVKA-II, age, and gender has a good effect on the prediction of HBV-HCC [4].

γ-glutamyl transferase (gamma-glutamyl transferase, GGT)

Serum GGT in normal adults is mainly secreted by liver Kupffer cells and bile duct endothelial cells, and the activity of GGT in hepatocellular carcinoma tissues is increased.
The total GGT can be divided into 13 isozymes, some of which are only detected in the serum of patients with hepatocellular carcinoma.
The detection sensitivity of GGTII isoenzyme in giant hepatocellular carcinoma can reach 74.
0%, while the detection sensitivity in small hepatocellular carcinoma is only 43.
8%.
The combined detection of GGTII, DCP and AFP can significantly improve the sensitivity [3].

Serum alpha-1-fucosidase (AFU)

AFU is a lysosomal enzyme, which is widely present in all mammalian cells, blood and body fluids.
Its function is to hydrolyze the glycosidic bond between fucose and glycoprotein and glycolipid.
The AFU activity in the serum of patients with hepatocellular carcinoma increased (1418.
62 ± 575.
76 nmol/mL/h), while that of healthy adults was 504.
18 ± 121.
88 nmol/mL/h, and patients with liver cirrhosis were 831.
25 ± 261.
13 nmol/mL/h, chronic hepatitis It is 717.
71 ± 205.
86 nmol/mL/h.
When the cut-off value is 870 nmol/mL/h, the sensitivity of AFU is 81.
7% and the specificity is 70.
7%.
The combined detection of AFU and AFP is considered to be valuable for early diagnosis of hepatocellular carcinoma and can be used as a valuable supplement to the diagnostic efficiency of AFP.

In patients with liver cirrhosis, when the AFU activity exceeds 700 nmol/mL/h, 82% of patients indicate that hepatocellular carcinoma will develop within a few years.
85% of patients with hepatocellular carcinoma have an increase in AFU activity 6 months earlier than that of hepatocellular carcinoma detected by ultrasound [3].
Another study of 512 cases of liver cancer found that when the cut-off value was set to 24 U/L, the sensitivity of AFU for liver cancer detection was 56.
1% and the specificity was 69.
2%.
When the cut-off value is set to 20 ng/mL, the sensitivity of AFP for liver cancer detection is 58.
2%, and the specificity is 85.
2%.
The conclusion is that the diagnostic efficiency of AFU is worse than that of AFP, which can be used as a supplement [5].

Human carbonyl reductase 2

The enzyme is expressed in human liver and kidney.
In the liver, it is very important for the detoxication of active α-dicarbon-based compounds and reactive oxygen species produced by hepatocellular carcinoma.
Studies have found that the level of human carbonyl reductase 2 is inversely related to the pathological grade of hepatocellular carcinoma, that is, the higher the pathological grade of liver cancer cells, the lower the level of human carbonyl reductase 2 [3].

Golgi phosphoprotein 2 (GOLPH2)

It is a Golgi-related protein.
It is reported to be more sensitive than AFP in detecting hepatocellular carcinoma.
The expression of GOLPH2A is increased in 71% of hepatocellular carcinoma patients and 85% of patients with cholangiocarcinoma.
Serum GOLPH2 protein can be detected by ELISA.
In patients with hepatitis C, the detection of serum GOLPH2 protein by dynamic ELISA method can be used as an effective marker for monitoring the occurrence of hepatocellular carcinoma [3].

Tumor-specific growth factor (TSGF)

Malignant tumors release TSGF into the blood during the growth process, so serum TSGF can indicate the presence of tumors.
TSGF can be used as a diagnostic marker for hepatocellular carcinoma.
When the cut-off value is 62U/mL, its sensitivity can reach 82%.
If it is detected simultaneously with other tumor markers, its accuracy can be higher.
When TSGF (cut-off value is 65U/mL), AFP (cut-off value of 25 ng/mL), and ferritin (cut-off value of 240 ng/mL) are simultaneously detected, the sensitivity is reported to reach 98.
4% , The specificity can reach 99% [3].

Basic Fibroblast Growth Factor (bFGF)

It is a soluble heparin-binding polypeptide and a strong mitogen for endothelial cells.
Serum bFGF higher than the median level (>10.
8 pg/mL) predicts a decline in disease-free survival.
Targeted therapy for bFGF has an encouraging effect on hepatocellular carcinoma [3].

Clinical challenges of early diagnosis of liver cancer

The key indicator of early diagnosis of hepatocellular carcinoma is the discovery of liver cancer with a tumor diameter of less than 2 cm.
However, the diagnostic power of currently used ultrasound, CT, magnetic resonance (MRI) and serum soluble hepatocellular carcinoma markers cannot detect 2CM liver cancer.
Not only that, there are still about 30% of the currently used serum liver cancer markers and even large liver cancer that cannot be detected, resulting in missed detection.
AFP, which is listed as a diagnostic index for liver cancer, has poor diagnostic efficiency, low sensitivity and specificity, and has limited detection capabilities for large liver cancers, let alone small liver cancers.
The sensitivity of the various serum markers listed in Table 1 is less than 90% whether they are tested individually or in combination.

Clinical problems to be solved

It is currently impossible to detect hepatocellular carcinoma smaller than 2CM, which means that the long-term survival rate of patients with liver cancer cannot be improved.
The ability to diagnose small liver cancer below 2CM and then surgically remove it is an effective measure for the treatment of hepatocellular carcinoma, which can make liver cancer patients survive for a long time.
The screening of liver cancer through liver ultrasound, CT, and MRI imaging is impractical, expensive and ineffective, and the procedures are cumbersome.
Because imaging diagnosis is often missed, small liver cancer cannot be detected, and ultrasound examination is affected by obesity, liver cirrhosis, and operation.
The impact of user experience, even experienced operators still need to compare the imaging results before and after the patient, so the feasibility of large-scale census is very low.

Measures taken

Domestic and foreign countries have developed a mathematical model based on the patient’s age and gender, combined with the results of AFP, DCP and AFP-L3, to diagnose liver cancer.
However, although various models have certain diagnostic value, there are still problems of one kind or another from clinical needs.
Moreover, some models are not suitable for the characteristics of the Chinese population.

Current work and exploration to be considered

The ideal way to improve the diagnosis rate of early liver cancer (small liver cancer) is of course to find a new type of high sensitivity, which can be detected alone or combined with another marker to achieve a sensitivity of more than 90%, with good specificity (up to 85%).
The above or after the joint inspection, the specificity remains more than 85%), that is, only 10 of 100 liver cancers are missed, and only 15 of the cases suggesting liver cancer are not liver cancer in the end.
However, the difficulty of exploring such an efficient liver cancer marker is quite high.
From the current point of view, there is still no biomarker that can improve the sensitivity of liver cancer detection to more than 90% without reducing the specificity without reducing the diagnostic performance after combined detection with AFP or DCP or AFP-L3 or AFU.

EGF and TSGF are broad-spectrum biomarkers.
Although their sensitivity is high, their shortcomings are poor specificity.
Many inflammations and benign tumors are also increased, which will increase the burden of clinical identification/exclusion diagnosis and increase the cost of diagnosis and treatment.
Therefore, the clinical application value is very limited.
For some time, people have tried to improve the predictive ability of liver cancer by combining the clinical indicators of patients with the detection results of liver cancer markers to perform mathematical model calculations, that is, to carry out effective joint detection based on the existing reported or used liver cancer markers.
And establish a tumor prediction mathematical model (nomogram) to improve detection sensitivity.
The goal is to detect or warn of 2CM liver cancer, and then use ultrasound, CT or MRI or further pathological examinations to diagnose or exclude liver cancer.
Its diagnostic efficiency is better than that of a single Ultrasound, CT, and MRI are all superior.

Note: The Japanese Association of Liver Diseases issued the "Clinical Practice Guidelines for Liver Cancer: 2017 Update of the 4th Edition of the Guidelines for Liver Cancer Diagnosis and Treatment of the Japan Liver Disease Association".

The update pointed out that when the patient has any of the following three items, it is considered to be a high-risk group of liver cancer: liver cirrhosis, chronic hepatitis B or chronic hepatitis C.
Among high-risk patients, those with liver cirrhosis caused by hepatitis B or C are considered to be extremely high-risk groups.
After radical treatment of liver cancer (surgical resection), there is a recurrence rate of ≥10% every year, and the recurrence rate is 70-80% in 5 years.

Therefore, post-treatment monitoring for the extremely high-risk patient group should also be sufficiently rigorous.
Ultrasound examination is the first choice of screening methods, and it is performed at the same time as AFP, DCP, and AFP-L3.
For high-risk groups, the above-mentioned screening methods are carried out every 6 months, while for extremely high-risk groups, it is carried out every 3 months.
For very high-risk groups or patients who are not easy to undergo liver ultrasound, such as liver atrophy, severe obesity, and postoperative morphological changes, this regular screening can be performed simultaneously with dynamic CT or dynamic MRI.
When new nodules are found on ultrasound, dynamic CT/MRI is used as the differential diagnosis.

Even if the tumor is not detected by ultrasound, dynamic CT/MRI scanning should be considered in the following cases: persistent AFP elevation, or AFP ≥200 ng/mL, or DCP ≥40 mAU/mL, or AFP-L3 ≥15%.
In the 4th edition, the measures related to CT enhanced scanning of the previous edition are re-adopted (omitted).
In the case of small liver cancer (≥1.
5CM or even 1CM), a variety of CT, MRI, ultrasound enhanced scanning measures, as well as angiography scans, liver biopsy can be considered (omitted).
Other smaller liver tumors also follow the principle of ultrasound examination every 3 months.
Dynamic CT/MRI scanning is only used when the ultrasound finds that the tumor is enlarged or the tumor markers are elevated [7].

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