|Year : 2018 | Volume
| Issue : 3 | Page : 312-316
Diagnostic accuracy of lectin-reactive α-fetoprotein (AFP-L3) in the diagnosis of hepatitis C virus-related hepatocellular carcinoma
Atef Ahmed Ali Ibrahim, Roshdy Mohamed Khalaf Allah, Amr M El Hammady, Rizk Sayad Rizk Sarhan, Medhat A Khalil, Marwa Mohiy Eldin Abdel Rahman
Internal Medicine Department, Faculty of Medicine, Benha University, Egypt
|Date of Submission||27-Feb-2018|
|Date of Acceptance||21-Mar-2018|
|Date of Web Publication||07-Jan-2019|
Dr. Marwa Mohiy Eldin Abdel Rahman
Benha University, Benha, 55555
Source of Support: None, Conflict of Interest: None
Background Hepatocellular carcinoma (HCC) is one of the most malignant neoplasms. It has a very poor prognosis because the diagnosis is very late. Therefore, early detection is important in the management of this neoplasm. α-fetoprotein (AFP)-L3 has been recommended as a marker for early-stage HCC in many countries all over the world.
Aim The aim was to evaluate the potential clinical value of lens culinaris agglutinin-reactive AFP-L3 against total AFP in the diagnosis of hepatitis C virus-related HCC and to evaluate its role in disease diagnosis.
Materials and methods This study included 40 patients who were diagnosed as hepatocellular carcinoma (diagnosis was based on the BCLC staging classification), 20 patients with chronic liver disease, and 20 healthy subjects as a control group.
Results Results showed that there was a significant positive correlation between each of serum AFP and AFP-L3 and each of tumor size and tumor number among patients with HCC. The median value of both serum AFP-L3 and AFP-L3/AFP ratio was significantly higher in patients with HCC group when compared with patients with chronic liver disease and normal control individuals. Receiver operator characteristic curves were constructed for serum AFP, AFP-L3, and AFP-L3/AFP ratio as predictors of HCC. Serum AFP-L3 had the largest area under the curve. The best cut-off point for AFP as predictor of HCC was 128 ng/ml [sensitivity 75%, specificity 100%, positive predictive value (PPV) 100%, negative predictive value (NPV) 66.7%, and efficacy 83.3%]. The best cut-off point for AFP-L3 as predictor of HCC was 23 ng/ml (sensitivity 97.5%, specificity 100%, PPV 100%, NPV 95.2%, and efficacy 98.3%). The best cut-off point for AFP-L3/AFP ratio was 16% (sensitivity 97.5%, specificity 100%, PPV 100%, NPV 95.2%, and efficacy 98.3%).
Conclusion In conclusion, AFP-L3 is a promising marker for diagnosis of HCC especially when combined with AFP, as the diagnostic sensitivity was optimum, so both markers can be used in the screening of HCC.
Keywords: AFP-L3, AFP, diagnosis, hepatitis C, hepatocellular carcinoma, liver cirrhosis
|How to cite this article:|
Ibrahim AA, Allah RK, El Hammady AM, Sarhan RR, Khalil MA, Abdel Rahman MM. Diagnostic accuracy of lectin-reactive α-fetoprotein (AFP-L3) in the diagnosis of hepatitis C virus-related hepatocellular carcinoma. Benha Med J 2018;35:312-6
|How to cite this URL:|
Ibrahim AA, Allah RK, El Hammady AM, Sarhan RR, Khalil MA, Abdel Rahman MM. Diagnostic accuracy of lectin-reactive α-fetoprotein (AFP-L3) in the diagnosis of hepatitis C virus-related hepatocellular carcinoma. Benha Med J [serial online] 2018 [cited 2019 Dec 15];35:312-6. Available from: http://www.bmfj.eg.net/text.asp?2018/35/3/312/249426
| Introduction|| |
Hepatocellular carcinoma is the most frequent primary cancer of the liver . HCC is the sixth most common cancer in the world but the second most common cause of cancer death . Geographical distribution of HCC varies throughout the world. The burden of HCC has been increasing in Egypt, with a doubling in the incidence rate in the past 10 years . HCC represents the main complication of cirrhosis, and shows a growing incidence in Egypt, which may be the result of a shift in the relative importance of hepatitis B virus and hepatitis C virus (HCV) as primary risk factors .
Patients who develop HCC usually have no symptoms other than those related to their chronic liver disease. Metastases from HCC, spread through lymphatic or hematic system, are more frequently placed in abdominal and thoracic lymph nodes, lung, bones, and adrenal glands. Less frequent sites of metastases are brain, spleen, and breast . Imaging of the lesion usually begins with ultrasound, which provides information on the shape, echogenicity, growth pattern, and vascular involvement of the tumor . The most reliable diagnostic tests are triple-phase helical computed tomography and triple-phase dynamic contrast-enhanced MRI .
α-Fetoprotein (AFP) is an oncofetal glycoprotein that has been used as a tumor marker for HCC. However, it is not specific for HCC; elevated serum AFP can also be seen in patients with chronic liver disease without HCC such as acute or chronic viral hepatitis, particularly in hepatitis C . Development and applications of biological chemistry have determined that total AFP can be divided into three different glycoforms (AFP-L1, AFP-L2, and AFP-L3) according to their binding ability to the lectin lens agglutinin . AFP-L3 is the lectin lens agglutinin-affinitive AFP glycoform, with an additional α1–6 fucose residue attached at the reducing terminus of N-acetylglucosamine. AFP-L3 appears to be produced only by cancer cells . In patients with AFP less than 20 ng/ml, measurements of AFP-L3% by the highly sensitive method before treatment was more useful for diagnosis and prognosis of HCC than by the conventional method . The aim of this study was to evaluate the potential clinical value of lens culinaris agglutinin-reactive AFP-L3 against total AFP in the diagnosis of HCV-related HCC.
| Materials and methods|| |
This study included 80 subjects who were classified into two groups:
(1) Patient’s groups, which included the following:
- Group 1 (patients with HCC) (n=40) − this included 40 patients with primary HCC who were positive for HCV antibody. They were 35 (87.5%) male and five (12.5%) female patients, whose mean age was 43.97±6.54 years. According to Barcelona Clinic Liver Cancer) staging system, they were divided into five stages:
- Stage 0 (n=3): single tumor less than 2 cm, Child–Pugh A (7.5%).
- Stage A (n=11): single tumor less than 3 cm (27.5%).
- Stage B (n=2): large multinodular tumor, Child–Pugh A-B (5.0%).
- Stage C (n=9): in which there is vascular invasion and extrahepatic manifestations, Child–Pugh A-B (22.5%).
- Stage D (n=15): terminal stage, Child–Pugh C (37.5%).
- Group 2 (pathological control patients) (n=20): this included another 20 patients with liver cirrhosis. There were 18 (90%) male and two (10%) female patients, whose age ranged from 33 to 58 years (mean: 46.1±6.3 years).
(2) Control group
(c) Group 3: healthy control (n=20) − there were 17 (85%) male and three (15%) female individuals, whose age ranged from 41 to 58 years (mean: 47.35±22.12 years).
The following were the inclusion criteria:
- Both male and nonpregnant female participants.
- Adults older than 18 years.
- Patients with HCC.
- Patients with cirrhosis.
- Patients with hepatitis C infection (positive serological test for antibodies or HCV RNA).
The following were the exclusion criteria:
- Children and patients younger than 18 years.
- Infection with hepatitis B virus by hepatitis B virus surface antigen.
- Patients with impaired kidney function test results.
The patients were examined through clinical assessment and laboratory and radiological investigations.
Detection of serum α-fetoprotein-L3 levels by an enzyme-linked immunosorbent assay.
Measured observations were spread on worksheet of Microsoft® Excel® version 2007. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS®) for Windows® version 15.0.
Descriptive data were calculated for the data in the form of mean and SD for quantitative data.
- Student’s t-test: the probability of values was calculated. P greater than 0.05 is considered nonsignificant, P less than 0.05 is considered significant, and P less than 0.01 is considered highly significant.
- Correlation study: Spearman’s rank correlation (r) was performed. Receiver operating characteristic curve analysis was used to compare clinical utility between AFP-L3 and AFP. The area under the receiver operating characteristic was calculated and performed comparing those with HCC and chronic liver disease and control group.
| Results|| |
[Table 1] shows that mean age (in years) of group I was 43.97±6.54 years, group II was 46.1±6.3 years, and that of group III was 47.35±22.12 years. There was male predominance (male : female=7 : 1) in group I. There was no significant statistical difference between the groups regarding the occupation or residence (P>0.05). There is significant statistical difference between the HCC group and both liver cirrhosis and normal groups (P<0.05) regarding smoking.
[Table 2] shows that alanine transaminase (ALT), aspartate transaminase (AST), prothrombin time, and total bilirubin median results showed a highly significant difference between groups I and III (P<0.01). Furthermore, ALT and AST showed a highly significant difference between group II when compared with group III (P<0.01), but there was no significant difference between groups I and II (P>0.05). The median serum levels of AFP yielded a highly significant difference between groups I and II (P<0.01) and between groups II and III (P<0.01) as well as between groups II and III (P<0.01).
|Table 2 Statistical comparison of laboratory parameters in the different studied groups using Mann–Whitney U-test|
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[Table 3] shows that the median values of AFP and AFP-L3 were highly significant with respect to staging of HCC, increasing from stage 0 to C (P<0.01). No significant correlation was found among different stages regarding AFP-L3/AFP ratio (P>0.05).
|Table 3 Statistical comparison of α-fetoprotein (ng/ml), α-fetoprotein-L3 (ng/ml), and α-fetoprotein-L3/α-fetoprotein ratio among the three different stages of hepatocellular carcinoma|
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[Table 4] shows that the best cut-off point for AFP as predictor of HCC was 128 ng/ml [sensitivity 75%, specificity 100%, positive predictive value (PPV) 66.7%, negative predictive value (NPV) 100%, and efficacy 83.3%]. The best cut-off point for AFP-L3 as predictor of HCC was 23 ng/ml (sensitivity 97.5%, specificity 100%, PPV 100%, NPV 95.2%, and efficacy 98.3%). The best cut-off point for AFP-L3/AFP ratio was 16% (sensitivity 97.5%, specificity 100%, PPV 100%, NPV 95.2%, and efficacy 98.3%).
|Table 4 Receiver operator characteristics and multireceiver operator characteristics analysis of α-fetoprotein, α-fetoprotein-L3 and α-fetoprotein-L3/α-fetoprotein ratio in the present study regarding group I versus II|
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| Discussion|| |
HCC is the sixth most common cancer in the world, but the second most common cause of cancer death . HCC represents the main complication of cirrhosis and shows a growing incidence in Egypt .
In this study, mean age (in years) of group I was 43.97±6.54 and group II was 46.1±6.3 years, as shown in [Table 1]. This age difference is in agreement with another study , which reported that the age of patients with HCC ranged between 42 and 70 years (mean: 58.70±5.76 years), which may be explained by that liver cancer are generally attributed to HCV and chronic HCV. In this study, the male to female ratio of patients with HCC was 7 : 1, which is an effect of predominance in males, which is very close to the data proved by another study, which showed male preponderance (male : female=4.2 : 1) regarding HCC sex predominance . There is no significant statistical difference among the groups regarding occupation. In this study, 45.0% of HCC cases were farmers, and this result was similar to that of another study, which reported only 23.3% of HCC cases were farmers. There is significant statistical difference between the HCC group and both liver cirrhosis and normal groups regarding smoking (62.9% of HCC cases had history of smoking).
In the current work, there was a statistically significant difference between HCC and cirrhosis groups regarding clinical data, including weight loss and liver consistency. There is no significant statistical difference between the groups regarding other symptoms such as jaundice, abdominal pain, bleeding, hepatic encephalopathy, ascites, and fever. These results are in agreement with another author who reported that clinical features of HCC are often similar to those caused by the underlying hepatic disease . According to this study, ALT, AST, total bilirubin, and prothrombin time median results showed a highly significant difference between groups I and II as shown in [Table 2]. Furthermore, ALT and AST showed a highly significant difference between group I when compared with group III (control) and was significantly higher in group II when compared with group III, but there was no significant difference between groups II and III. This is close to the data supported by another author who stated that liver enzymes are indicators of the severity of hepatocellular damage which is evident in HCC .
In this study, most of the patients with HCC were Child B (45.0%), followed by Child C (37.5%) and then Child A (17.5%). A total of 30 patients, representing 75% of HCC cases, had single focal hepatic lesions, and multiple hepatic focal lesions were present in the rest of cases. Twenty (50.0%) patients had their tumor size less than 3 cm, whereas 25% had their tumor size between 3 and 5 cm, and 25% had tumor size of more than 5 cm. In the present study, the right lobe was predominantly more affected (75%) than left lobe (5%) and both lobes (5%). This was in agreement with El-Zayadi et al. , who mentioned that HCC lesion was prevalent more in right lobe more than left lobe; this can be explained by the issue that the right lobe is six times larger than the left lobe.
In this study, we found that there is a statistically highly significant elevation (P<0.001) in the median serum AFP in HCC group when compared with cirrhotic group and healthy group. This is in agreement with another study . We found that the median values of both serum AFP-L3 and AFP-L3/AFP ratio are significantly higher in patients with HCC group when compared with patients with chronic liver disease and normal control individuals, and this matches with the study by Davis et al.  who revealed that AFP-L3 is produced only by malignant liver cells. The median values for serum AFP-L3 and AFP-L3/AFP ratio were increasing from stage 0 to stage C, as shown in [Table 3], and were higher in stage C. AFP-L3 expression shows a tendency toward early vascular invasion and a potential for rapid growth, so it may be used as prognostic tool .
Assessment of the diagnostic performance of AFP as a marker for distinguishing HCC from benign liver diseases and healthy candidates revealed that at a cut-off of 128 ng/ml the diagnostic sensitivity was 75%, the specificity was 100%, PPV was 100%, NPV was 66.7%, and efficacy was 83.3%, as shown in [Table 4]. Another study by Motawa et al.  examined the diagnostic performance of AFP in the diagnosis of HCC. It gave 68.2% sensitivity and 75% specificity, but they used 19.8 ng/ml as a cut-off for AFP and used a different staging system from ours. In our study, AFP-L3 at a cut-off of 23 ng/ml showed sensitivity of 97.5%, specificity 100%, PPV 100%, NPV 95.2% and efficacy of 93.3%; therefore, it was more specific than AFP. This result is close to a study by Debruyne and Delanghe  in which AFP-L3 showed sensitivity of 90% and specificity of 95%. A possible cause for their higher performance is that they studied larger number of cases (n=334), which included larger tumor sizes. In another study by Davis et al.  that assessed the diagnostic performance of AFP-L3 in the diagnosis of HCC, the sensitivity of AFP-L3 was found to be stage related in HCC. The overall sensitivity of AFP-L3 for HCC was ∼60%. In small HCC (HCC <2 cm in diameter), AFP-L3 had a sensitivity of only 45%. The sensitivity increased with increase in size of the HCC, and reached 90% when HCC was 5 cm in diameter or greater.In our study, AFP-L3/AFP ratio with 16% as a cut-off value had a sensitivity of 97.5%, specificity of 100%, PPV of 100%, NPV of 95.2%, and efficacy of 98.3%. This was close to another study by Tanwandee et al.  which had a cut-off of 15%, yielding a sensitivity of 82% specificity of 71%, PPV of 83%, and NPV of 69%, but they used different staging system and had larger number of patients with HCC (n=61).
In conclusion, AFP-L3 is a promising marker for diagnosis of HCC especially when combined with AFP, as the diagnostic sensitivity was optimum, so both markers can be used in the screening of HCC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
El-Serag HB, Rudolph KL. Hepatocellular carcinoma, epidemiology and molecular carcinogenesis. Gastroenterology 2007; 132:2557.
Theise ND, Chen C, Kew MK. Liver Cancer. In: Stewart BW, Wild CP, editors. World Cancer Report 2014. Lyon: International Agency for Research on Cancer; 2014. 578.
Gomaa AI, Khan SA, Toledano MB, Waked I, Taylor-Robinson SD. Hepatocellular carcinoma: epidemiology, risk factors and pathogenesis. World J Gastroenterol 2008; 14:4300–4308.
Gomaa AI, Hashim MS, Waked I. Comparing staging systems for predicting prognosis and survival in patients with hepatocellular carcinoma in Egypt. PLoS One 2014; 9:e90929.
Uchino K, Tateishi R, Shiina S, Kanda M, Masuzaki R, Kondo Y et al.
Hepatocellular carcinoma with extra hepatic metastasis: clinical features and prognostic factors. Cancer 2011; 117:4475–4483.
Chu Yu S, Metreweli C, Lau W. Safety of percutaneous biopsy of HCC with an 18 gauge automated needle. Clin Radiol 1996; 52:907–911.
Arguedas MR, Chen VK, Eloubeidi MA, Fallon MB. Screening for hepatocellular carcinoma in patients with hepatitis C cirrhosis: a cost-utility analysis. Am J Gastroenterol 2003; 98:679–690.
Collier J, Sherman M. Screening for hepatocellular carcinoma. Hepatology 1998; 27:273–278.
Khien V, Mao HV, Chinh TT, Ha PT, Bang MH, Lac BV et al.
Clinical evaluation of lentil lectin-reactive alpha-fetoprotein-L3 in histology-proven hepatocellular carcinoma. Int J Biol Markers 2001; 16:105–111.
Du MQ, Hutchinson WL, Johnson PJ, Williams R. Differential alpha-fetoprotein lectin binding in hepatocellular carcinoma. Diagnostic utility at low serum levels. Cancer 1991; 67:476–480.
Toyoda H, Kumada T, Tada T, Kaneoka Y, Maeda A, Kanke F, Satomura S. Clinical utility of highly sensitive lens culinaris agglutinin reactive alpha-fetoprotein in hepatocellular carcinoma patients with alpha-fetoprotein <20 ng/mL. Cancer Sci 2011; 102:1025–1031.
Theise ND, Chen C, Kew MK. Liver cancer. In: Stewart BW, Wild CP, editors. World Cancer Report 2014. Lyon: International Agency for Research on Cancer; 2014. 578.
Baghdady I, Fouad F, Sayed M, Shoaib A, Salah Y, Elshayeb E et al.
Serum markers for the early detection of hepatocellular carcinoma in patients with chronic viral hepatitis C infection. Menoufia Med J 2014; 27:744–750. [Full text]
Tariq M, Ahad W, Tahir M, Ahmed A, Shafique HM. Frequency of hepatocellular carcinoma in cirrhotic patients with hepatitis-C virus positive patients in Karachi-Pakistan. Int J Res Med Sci 2015; 3:159.
Trevisani F, D’Intino PE, Caraceni P, Pizzo M, Stefanini GF, Mazziotti A et al.
Etiologic factors and clinical presentation of hepatocellular carcinoma. Differences between cirrhotic and non-cirrhotic Italian patients. Cancer 1995; 75:2220–2232.
Suruki R, Hayashi K, Kusumoto K, Uto H, Ido A, Tsubouchi H, Stuver S. Alanine aminotransferase level as a predictor of hepatitis C virus-associated hepatocellular carcinoma incidence in a community-based population in Japan. Int J Cancer 2006; 119:192.
El-Zayadi A, Badran H, Barakat E. Hepatocellular carcinoma in Egypt: a single center study over a decade. World J Gastroenterol 2005; 11:5193–5198.
Motawa E, Mamdouh M, Mahmoud A, El Din AS, Hussein TD. Serum alpha-L-fucosidase enzyme activity as a marker for hepatocellular carcinoma. J Egypt Nat Cancer Inst 2001; 13:277–283.
Davis GL, Dempster J, Meler JD, Orr DW, Walberg MW, Brown B et al.
Hepatocellular carcinoma: management of an increasingly common problem. Proc (Bayl Univ Med Cent) 2008; 21:266–280.
Motawa E, Mohammed S, Wael M, Tarek D, Omar S, Anwar A. Enhanced detection of hepatocellular carcinoma. Cancer Control 2006; 12:248–253.
Debruyne EN, Delanghe JR. Diagnosing and monitoring hepatocellular carcinoma with alpha-fetoprotein, new aspects and applications. Clin Chim Acta 2008; 359:19–26.
Tanwandee T, Setthasin S, Charatcharoenwitthaya P, Chainuvati S, Leelakusolvong S, Pausawasdi N et al.
Clinical utility of lens culinaris agglutinin-reactive alpha-fetoprotein in the diagnosis of hepatocellular carcinoma: evaluation in a Thai referral population. J Med Assoc Thai 2009; 92:49–56.
[Table 1], [Table 2], [Table 3], [Table 4]