liver cancer diagnostics and future trends

Liver Cancer Diagnosis

Presented by Group 3Thet Su Wynn

Chawalit ChatupheeraphatLe Van Chuong

Contents

Liver Cancer1

Serum Tumor Markers2

Imaging Markers3

Biopsy4

Future Trend5

Liver CancerLiver cancer is a cancer which originates

in the liver

There are 4 main types Hepatocellular carcinoma (HCC) Cholangiocarcinoma Angiosarcoma Hepatoblastoma

The major types is Hepatocellular carcinoma (HCC)

Sign & Symptom Sign and symptom of liver cancer is no

specific abdominal mass  abdominal pain emesis anemia back pain  jaundice  itching weight loss Fever

Diagnosis of Liver cancer Following medical guideline, The test should done

before liver cancer investigation Hepatitis B and C Cirrhosis

Viral Hepatitis HBV or HCV antibody detection Viral load

Cirrhosis Patient history (Alcohol, Drug) Liver function test Prothrombin time Imaging

Liver Cancer Diagnosis

HCC Diagnosis

Non-Invasive Methods

Serological markers

Imaging markers

Genetic markers

Invasive Methods

Biopsy

Serum tumor markersUse for early screening and low

invasiveness

Alpha-fetoprotein (AFP)

Gramma-glutamyl tranferase

Len culinaris agglutin reactive AFP (AFP-L3)

Prothrombin induced by vitamin K absense II (PIVKA-II)

α-Fetoprotein (AFP)Serum AFP, a fetal-specific glycoprotein

antigen, is the most widely used tumor marker for detecting patients with HCC

AFP level > 200 ng/ml in liver cancerAFP is not specific for HCC. Can high in

other diseases Other cancer eg. Testicular cancer, Germ line tumor,

Gastric cancer Viral hepatitis infection Pregnancy

ɣ-glutamyl transferase(GGT) Gamma-glutamyl transferase (GGT) is a membrane-

bound enzyme catabolizing reduced glutathione to cysteine and glycine

Primarily present in kidney, liver, and pancreatic cells

Normal value 9-48 U/L (Increase in aging)

GGT is not specific for HCC. Can high in other condition

Alcohol Phenytoin Phenobarbital Aging

Len culinaris agglutin reactive AFP (AFP-L3)

AFP can be fractionated by affinity electrophoresis into 3 glycoforms: L1, L2, and L3

 The L3 isoform is specific to malignant tumors

Can bind to Lens culinaris agglutinin (LCA), which is isolated from Lens culinaris (lentil) seeds

Len culinaris agglutin reactive AFP (AFP-L3)

Results for AFP-L3 are represented as a ratio of LCA-reactive AFP to total AFP (AFP-L3%). 

Cut-off > 15%

AFP-L3% was found to have sensitivity of 96.9%, specificity of 92.0%,

Khien VV, et al.,Int J Biol Markers. 2001 Apr-Jun;16(2):105-11.

Prothrombin induced by vitamin K absense II (PIVKA-II)

Prothrombin induced by vitamin K absence or antagonist-II (PIVKA-II) is an abnormal prothrombin devoid of coagulation activity

Serum PIVKA-II was elevated with a high prevalence and with a high specificity in patients with HCC

The overall sensitivity and specificity of serum PIVKA-II in the detection of HCC have been shown to be 4862% and 8198%, respectively

YOUNG JOON YOONScandinavian Journal of Gastroenterology, 2009; 44: 861-866

Prothrombin induced by vitamin K absence II (PIVKA-II)

Sample Value (ng/ml)

Hepatocellular carcinoma 101.07 ± 78.30 ng/ml,

Cirrhosis 2.45 ± 4.25 ng/ml

Chronic hepatitis 1.50 ± 0.98 ng/ml

Healthy person 0.79 ± 0.75 ng/mlBalkrishan Sharma, Hepatol Lnt. 2010 4(3):569-576

Imaging techniques used for HCC diagnosis

Ultrasound

CT Scan

MRI Scan

Imaging techniques used for HCC diagnosis

Ultrasonography Contrast enhanced US (CEUS)

• Contrast agents– Sonazoid– SonoVue– Levovist

• Used to– Evaluate hypervascularity– Hypoechoic in the Kupffer phase of Sonazoid CEUS

Imaging techniques used for HCC diagnosis

Computed tomography (CT) scan Dynamic CT Dynamic contrast-

enhanced CT (Iodine) Multiphasic spiral CT Multi-detector CT

(MDCT) scan CT Angiography

Imaging techniques used for HCC diagnosis

Magnetic resonance imaging (MRI) scan Gadolinium ethoxybenzyl diethylenetriamine

pentaacetic acid-enhanced MRI (EOB-MRI)• Organic anion transporting polypeptide 1B3 (OATP1B3)

(major transporters of gadoxetic acid in human HCC) Super paramagnetic iron oxide agents for MRI (SPIO-

MRI)

Imaging techniques used for HCC diagnosis

Wash-in in the arterial phase

Wash-out in the late phase

Differential diagnosisBenign tumor of the liver

Hemangioma• 3 cm, multiple in up to 50% of patients• Lesions with well-defined margins

Focal nodular hyperplasia (FNH) Hepatocellular adenoma

Cholangiocarcinomas

LCSGJ

Confirmation Test

Biopsy is the definitive diagnosis

Percutaneous FNA

Needle core biopsy

Under US or CT

guidance

Laboratory ProceduresFixation, Tissue processing and embeddingConventional staining – H&E stainSpecial staining – Trichrome staining for collagen

- Reticulin stain - Iron stain - PAS stain - Fat stain (oil red O) - Orcein stain

Immunofluorescence stain of AFP IHC (anti-AFP, pCEA, CK7, CK18, CK20, CA 19-9, CD34, etc)

Confirmation TestBiopsy is the definitive

diagnosis

• Trabeculae• Large nucleus• Deeply

eosinophilic cells

• Thick fibrous bands

• AFP expression significantly increased in HCC

Hepatocellular carcinoma showing strong cytoplasmic staining to CK 18

B

Cholangiocarcinomashowing positive cytoplasmic stain for CK-7

Sawan A.S. JKAU: Med. Sci., Vol. 16 No. 4, pp: 37-48 (2009)

IHC profile of HCC, CC and metastatic GIT carcinoma

Biopsy

A small biopsy can be representative of changes in the whole liver.

It is a safe and effective means to confirm suspicious lesions of cancers.

The sensitivity, specificity and accuracy are superior to any other diagnostic test. (>95%)

Genetic markers - 1

AFP mRNA will be the most valuable markers for HCC (in active HCC)

It could be used as significant HCC marker in blood

also serves as a predictor for HCC recurrence

Feng Y. et al (2005). Clinica ChimicaActa, vol 361(1-2), 119–127

Genetic markers - 2

miRNA is remarkably stable in both circulation and tissues.

The stability of circulating miRNA allows reliable enumeration, which is vital as a novel diagnostic biomarker.

They can be detected with RT-PCR, microarray and next-generation sequencing.

miRNAs – miR-500, miR-29, miR-122, miR-21, etc

Recurrence Related microRNAs in Hepatocellular Carcinoma

http://www.mdpi.com/1422-0067/14/1/1105

Genetic markers – 3 (related genes)

Δ-like 1 homolog (DLK1) is progenitor cell marker in fetal liver.

DLK1 expression is significantly elevated in HCC.Hepatoma-associated gene (HTA) is the tumor-

specific gene.Villin1 (Vil1) is the newly identified marker for HCC.They all are the potential candidate molecular

markers for HCC

To improve the early diagnostic tools To predict the transfer and recurrence of

tumors To improve sensitivity and specificity of

diagnosis

Novel markers

miRNA

Genetic

markers

Novel biomarkers

Effective combined methods

TGF-β1

GPC3

AFP

To be resulted in improved treatment and prognosis

FUTU

RE

TREN

DS

www.themegallery.com

OrganizationsAmerican Association for the Study of

Liver Diseases (AASLD)European Association for the Study of

the Liver and the European Organization for Research and Treatment of Cancer (EASL-EORTC)

Asian Pacific Association for the Study of the Liver (APASL)

Japan Society of Hepatology (JSH)

Imaging techniques used for HCC diagnosis