Diagnostic accuracy of PIVKA-II, ALPHA-Fetoprotein and a combination of both in diagnosis of Hepatocellular Carcinoma

Patients affected by liver cirrhosis are at high risk for developing hepatocellular carcinoma. The aim of this study was to evaluate the feasibility of PIVKA-II (protein induced by vitamin K absence or antagonist-II) alone or in combination with α-1 fetoprotein, as a screening marker for development of hepatocellular carcinoma. Subjects and methods: A case-control study was conducted on 103 Military Hospital. 53 patients affected by hepatocellular carcinoma were considered as cases, while 31 patients affected by liver cirrhosis were considered as control. Results: At the set cut-off value of 40 mAU/mL, PIVKA-II was more sensitive (92.45% vs. 81.13%), but less specific than α-1 fetoprotein at the set cut-off value of 10 ng/mL (61.29% vs. 83.87%). The negative predictive value of PIVKA in combination with α-1 fetoprotein was 88.23% and the sensitive was 96.2%. Conclusion: PIVKA- II was more sensitive but less specific than α-1 fetoprotein in diagnosis of hepatocellular carcinoma and PIVKA-II, when combined with α-1 fetoprotein, may be considered as a screening test for hepatocellular carcinoma due to its high sensitive and negative predictive value.

Journal of military pharmaco-medicine n02-2019 DIAGNOSTIC ACCURACY OF PIVKA-II, ALPHA-FETOPROTEIN AND A COMBINATION OF BOTH IN DIAGNOSIS OF HEPATOCELLULAR CARCINOMA Pham Van Tran1; Hoang Thi Minh1 SUMMARY Background/aim: Patients affected by liver cirrhosis are at high risk for developing hepatocellular carcinoma The aim of this study was to evaluate the feasibility of PIVKA-II (protein induced by vitamin K absence or antagonist-II) alone or in combination with α-1 fetoprotein, as a screening marker for development of hepatocellular carcinoma Subjects and methods: A case-control study was conducted on 103 Military Hospital 53 patients affected by hepatocellular carcinoma were considered as cases, while 31 patients affected by liver cirrhosis were considered as control Results: At the set cut-off value of 40 mAU/mL, PIVKA-II was more sensitive (92.45% vs 81.13%), but less specific than α-1 fetoprotein at the set cut-off value of 10 ng/mL (61.29% vs 83.87%) The negative predictive value of PIVKA in combination with α-1 fetoprotein was 88.23% and the sensitive was 96.2% Conclusion: PIVKA- II was more sensitive but less specific than α-1 fetoprotein in diagnosis of hepatocellular carcinoma and PIVKA-II, when combined with α-1 fetoprotein, may be considered as a screening test for hepatocellular carcinoma due to its high sensitive and negative predictive value * Keywords: Cirrhosis; Hepatocellular carcinoma; PIVKA-II; α-1 fetoprotein INTRODUCTION Chronic hepatitis, cirrhosis, hepatocellular carcinoma (HCC) are common and dangerous diseases of the liver Currently, there are many supportive methods for the diagnosis, treatment monitoring and prognosis of these diseases Non-invasive diagnostic methods have been developed One of these methods is the quantification of biomarkers circulating in the blood This method is easy to use and can be carried out regularly The most commonly utilized biomarker in clinical practice for HCC is α-1 fetoprotein (AFP) AFP may be used as a diagnostic and prognostic marker Serum AFP levels also correlate with tumor size, tumor doubling time and post-treatment relapse [1, 2] However, it is not recommended for routine screening because it lacks specificity AFP may be elevated in other malignancies (e.g gastric, embryonic cancer, intrahepatic cholangiocarcinoma), as well as in many benign conditions, both hepatic (e.g cirrhosis, necrosis, acute hepatitis), and extrahepatic (e.g pneumonia) Finally, AFP lacks sensitivity; serum AFP levels are high in only 40 - 60% of HCC cases and only 10 - 20% of early HCC [2] For these reasons, more sensitive and specific HCC markers are required 1.103 Military Hospital Corresponding author: Pham Van Tran (phamvantran@yahoo.fr) Date received: 20/12/2018 Date accepted: 21/01/2019 193 Journal of military pharmaco-medicine n02-2019 PIVKA-II (protein induced by vitamin K absence or antagonist II) also known as des-gamma-carboxyprothrombin - DCP), is an immature form of prothrombine without any coagulative function It is synthesized in the presence of acquired defects of precursor carboxylation found in patients with HCC [5] PIVKA-II may have a role in HCC progression by acting as an autologous growth factor [6] Moreover, high serum levels of PIVKA-II are associated with HCC size, microvascular invasion, metastatic dissemination and HCC relapse after liver transplantation and/or HCC nodule ablation PIVKA-II is a specific marker for HCC, it is poorly related to AFP and exhibits higher sensitivity and specificity than AFP in diagnosing HCC PIVKA-II is not elevated in benign hepatic diseases (e.g cirrhosis, necrosis), while it is elevated in HCC at early stage as well as in HCC nodules of all sizes For these reasons, some authors, and especially Japanese guidelines on HCC management proposed the use of PIVKA-II for routine follow-up in patients with high risk for developing HCC, as well as a prognostic biomarker before surgery to predict microvascular invasion, relapse and overall poor prognosis [4, 8] In detail, Japanese guidelines have suggested to consider as a diagnostic marker of HCC with high elevation of tumor markers, namely AFP ≥ 200 ng/mL and PIVKA-II ≥ 40 mAU/mL However, data on its performance as a diagnostic marker are still incomplete The aim of this study was: To evaluate the feasibility of PIVKA-II (protein induced by vitamin K absence or antagonist-II) alone or in combination with AFP, as a screening marker for development of HCC 194 SUBJECTS AND METHODS A case-control study was performed in Gastroenterology Department, 103 Military Hospital 53 patients affected by HCC were considered as cases, while 31 patients affected by liver cirrhosis were considered as control All patients are diagnosed definitively and grouped based on underwent historytaking, physical examination, routine laboratory examinations and abdominal imaging either by abdominal ultrasonography, CT-scanning Cases: Cytological evidence of HCC as assessed in AASLD Hepatocellular Carcinoma Guidelines [2] Controls: Chronic hepatitis, cirrhosis and absence of nodular hepatic lesions under abdominal ultrasonography In each patient: Take mL of anticoagulant blood with heparin after fasting for at least hours Centrifugal plasma separator AFP and PIVKA-II assay was performed using Architect ci16200 system of Abbott Company based on the principle of immunization with microcrystalline luminescence Statistical analysis was performed using software package SPSS statistic 2.2 RESULTS Table 1: Characteristics of patients (n = 84) Characteristics Cases (n = 53) Control (n = 31) p-value Males 50 (94.3%) 31 (100%) > 0.05 Age (years) 59 (32 - 87) 47 (18 - 74) > 0.05 No differences were observed in gender and age between the two groups Journal of military pharmaco-medicine n02-2019 RESULTS Table 1: Characteristics of patients (n = 84) Characteristics Cases (n = 53) Control (n = 31) p-value Males 50 (94.3%) 31 (100%) > 0.05 Age (years) 59 (32 - 87) 47 (18 - 74) > 0.05 No differences were observed in gender and age between the two groups Cases Control 80 70 60 50 40 30 20 10 gastrointestinal disorders right lower back pain Weight loss Fatigue Figure 1: The common clinical symptoms in two groups In HCC, the common clinical symptoms were fatigue and right lower back pain Other symptoms such as weight loss, gastrointestinal disorders were less frequent and are comparable to patients with chronic liver disease Table 2: Characteristics of tumor on abdominal ultrasonography and CT Characteristics Location Number of tumor Total of tumor Ultrasonography (%) CT (%) Right live 71.69 69.81 Left liver 3.77 3.77 Both lobes 24.54 26.42 tumor 60.38 50.94 tumors 22.64 30.19 ≥ tumors 16.98 18.87 89 97 Patients with primary tumors were on the right liver, followed by both lobes Most patients had a tumor The results of abdominal ultrasonography and CT were not uniform across all parameters 195 Journal of military pharmaco-medicine n02-2019 Table 3: Concentration of AFP and PIVKA-II Cases (n = 53) Median (min - max) Controls (n = 31) Median (min - max) p-value AFP (ng/mL) 1286.28 (2.27 - 866610) 4.59 (1.26 - 55.73) < 0.001 PIVKA-II (mAU/mL) 5742 (23.02 - 2302372) 27.10 (6.38 - 30312) < 0.001 Both serum AFP (1286.28 vs 4.59 ng/mL, p < 0.001) and serum PIVKA-II concentrations (5.742 vs 27.10, p < 0.001) were higher in the case group Figure 2: Linear correlation between AFP and PIVKA-II in HCC Serum levels of AFP and PIVKA-II were correlated (ρ < 0.05) Figure 3: Received operating characteristics curve (ROC) comparing specificity and sensitivity of PIVKA-II and AFP in detecting HCC 196 Journal of military pharmaco-medicine n02-2019 The performance of both PIVKA-II and AFP in the diagnosis of HCC were plotted on a ROC curve (figure 2) showing similar areas under curve for both markers; specifically, areas under curve (AUC) for PIVKA-II (cut-off: 40 mAU/mL) and AFP (cut-off: 10 ng/mL) were 0.864 (95%CI = 0.777 - 0.950) and 0.925 (95%CI = 0.870 - 0.981), respectively Table 4: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of AFP, PIVKA-II and the combination of both in detecting HCC AFP > 10 ng/mL PIVKA-II > 40 mAU/mL AFP > 10 ng/mL + PIVKA-II > 40 mAU/mL Sensitivity (%) 81.13 92.45 96.2 Specificity (%) 83.87 61.29 48.38 PPV (%) 89.58 80.32 76.11 NPV (%) 72.22 82.6 88.23 At the set cut-off value of 40 mAU/mL, PIVKA-II was more sensitive (92.45% vs 81.13%) but less specific than AFP at the set cut-off value of 10 ng/mL (61.29% vs 83.87%) The negative predictive value of PIVKA in combination with AFP was 88.23% and it was higher when compared both to AFP (72.22%) and PIVKA alone (82.6%) (table 2) DISCUSSION HCC is the sixth most common cancer in the world and the third most common cause of cancer-related death In our study, patients with HCC were older than patients without HCC and men dominate the two groups Male predominance may be explained by greater exposure to toxins, HCV prevalence and hepatocyte androgenic stimulation [9] Imaging methods play an important role in the diagnosis and evaluation of treatment outcome as well as relapse after treatment In clinical practice today, ultrasound and CT are the most widely used method We conducted simultaneous study of ultrasonographic and CT results of patients who studied, the results were quite similar between the two methods with liver tumors mainly concentrated in the right liver, a few patients have tumor in the left liver and most patients had a tumor (table 2) Patients with cirrhosis, especially if due to HBV or HCV, are at high risk for developing HCC and, therefore, undergo active surveillance with six-monthly upper abdominal ultrasound However, researches for the identification of an effective serum marker for screening of HCC are currently ongoing AFP is widely used for this purpose, even though it is not recommended by neither EASL nor AASLD Guidelines because of its low sensitivity and specificity [9] AFP is elevated in only 40 - 60% of cases of HCC Sensitivity is even lower in early HCC cases, with serum elevation of AFP in only 10 - 20% of cases Moreover, 197 Journal of military pharmaco-medicine n02-2019 as a non-specific inflammation and regeneration marker, it may also be elevated in liver diseases (e.g liver cirrhosis and hepatic necrosis), as well as in some extra-hepatic conditions such as pneumonia and embryonal tumors [3] PIVKA-II is an abnormal prothrombine due to carboxyl group deficiency at gamma position in 10 glutamic acid molecules located at the N-terminal side of the prothrombine Carboxylation (COOH binding) is dependent on the presence of vitamin K The loss of carboxyl group in 10 glutamic acid molecules should reduce the ability of Ca2+ to bind to prothrombine and may cause reversibility normal blood clotting The role of PIVKA-II in liver cancer was first reported in 1984 by Liebman H.A et al In the first time, the role of PIVKA-II in the diagnosis, prognosis, evaluation of the effectiveness of HCC treatment was studied as well as the most clinical application in Japan In recent times, role of PIVKA-II has been paid more attention to research by the United States, some European countries, as well as in Asia In chronic liver disease and HCC, the biological processes of AFP and PIVKA are independent of each other Most studies in Japan and Asia have shown that PIVKA-II plays a better role than AFP, especially with respect to tumor size, correlation with thrombosis or invasion of blood vessels, assess the possibility of relapse after treatment [5] When conducting AFP and PIVKA-II levels in patients with chronic liver disease and HCC, performing a quantitative test on the 198 same principle and the same analytical system we found that both plasma PIVKA-II and AFP levels were statistically significantly different in patients with chronic hepatitis and cirrhosis This is also consistent with many other studies in the world as authored by Inagaki Y et al [5] Similarly to other authors, we observed correlation between PIVKA-II and AFP serum levels This allowed us to evaluate the combined performance of both markers in the diagnosis of HCC, as suggested by already available evidence [10] When cut-off values of 40 mAU/mL for PIVKA-II and 10 ng/mL for AFP were selected, we showed that PIVKA-II had a higher sensitivity but a lower specificity than AFP Combining both markers further increased overall sensitivity and negative predictive value at the expense of specificity (88.23%) These results slightly differed from a recent French study in which the authors showed that PIVKA-II had a better performance than AFP for early HCC diagnosis with a sensitivity of 77% (vs 61%), a specificity of 82% (vs 50%), a positive predictive value of 76% (vs 51%) and a negative predictive value of 83% (vs 62%), at a cut-off values of 42 mAU/mL for PIVKA-II and 5.5 ng/mL for AFP [7] CONCLUSION PIVKA-II was more sensitive but less specific than AFP in diagnosis of HCC and PIVKA-II, when combined with AFP, may be considered as a screening test for HCC due to its high sensitive and negative predictive value Journal of military pharmaco-medicine n02-2019 REFERENCES 1.Bruix J, Sherman M American Association for the study of liver diseases: Management of HCC: An update Hepatology 2011, 53 (3), pp.1020-1022, Ertle J.M, Heider D, Wichert M, Keller B, Kueper R, Hilgard P, Gerken G, Schlaak J.F: A combination of α-fetoprotein and des-γcarboxy prothrombine is superior in detection of hepatocellular carcinoma Digestion 2013, 87 (2), pp.121-131 Liebman H.A, Furie B.C, Tong M.J, Blanchard R.A, Lo K.J, Lee S.D, Coleman M.S, Furie B Des-γ-carboxy (abnormal) prothrombine as a serum marker of primary hepatocellular carcinoma N Engl J Med 1984, 310 (22), pp.1427-1431 Zhang Y.S, Chu J.H, Cui S.X, Song Z.Y, Qu X.J Des-γ-carboxy prothrombin (DCP) as a potential autologous growth factor for the development of HCC Cell Physiol Biochem 2014, 34 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evolving story Gut 2011, 60 (8), pp.1139-1151 10 Kuromatsu R, Tanaka M, Shimauchi Y, Shimada M, Tanikawa K, Watanabe K, Yokoo T: Usefulness of ED036 kit for measuring serum PIVKA-II levels in small HCC J Gastroenterol 1997, 32 (4), pp.507-512 199 ... diagnosed definitively and grouped based on underwent historytaking, physical examination, routine laboratory examinations and abdominal imaging either by abdominal ultrasonography, CT-scanning... abdominal ultrasonography In each patient: Take mL of anticoagulant blood with heparin after fasting for at least hours Centrifugal plasma separator AFP and PIVKA-II assay was performed using Architect... (ROC) comparing specificity and sensitivity of PIVKA-II and AFP in detecting HCC 196 Journal of military pharmaco-medicine n02-2019 The performance of both PIVKA-II and AFP in the diagnosis of HCC