新型肿瘤标志物(PIVKA-II) 临床应用进展及评价

新型肿瘤标志物（PIVKA-II)临床应用进展及评价第二军医大学东方肝胆外科医院高春芳2013.10.12武汉healthyliverChronichepatitisCirrhosisCancer(HCC)慢性炎症以及逐渐加深的肝脏损伤典型的乙型肝炎病程ViralmarkerFibrosismarkerTumormarker现有肝癌相关肿瘤标志物AFP及其异质体AFP-L3GP73DCP*α-L-Fucosidase(AFU)CA19-9CA125CEA……CandidateHCCSerumMarkers•Glypican-3(GPC3)•TransformingGrowthFactor-1(TGF-1)•Insulin-LikeGrowthFactor(IGF)•Interleukin(IL)-6andIL-10•γ-GlutamylTransferase(GGT)•Tumorspecificgrowthfactor(TSGF)•Vascularendothelialgrowthfactor(VEGF)•HumanCervicalCancerOncogene(HCCR)•Tumor-DerivedAutoantibody(TAA)Etc.MarkersReferencesCutoffvalueSensitivitySpecificitySpecimenGPC3Hippoetal.(2004)2.0ng/ml51%90%serumGP73Marreroetal.(2005)10relativeunits69%75%serumTGF-β1Songetal.(2002)800pg/ml68%95%plasmaTsaietal.(1997)32mg/gcreatinine67.4%91.0%urinaryIGF-IITsaietal.(2003)4.9mg/gprealbumin31%100%serumIL-6Hsiaetal.(2007)NA46%95%plasmaIL-10Hsiaetal.(2007)NA50%96%plasmaGGTCuietal.(2003)40mAUml-174.2%(43.8%forsmallHCC)82.2%serumHCCRYoonetal.(2004)15μg/ml78.2%95.7%serumClinicaChimicaActa395(2008)19–26•维生素K缺乏诱导蛋白ProteinInducedbyVitaminKAbsenceorantagonist-IIabnormalprothrombinproteinPIVKA-II简介•Des-gamma-carboxyprothrombin,DCP（又名脱γ羧基凝血酶原）•T1/260H(2.5days)•在以下患者的血清中出现-维生素K缺乏的患者-使用华法林治疗的患者-HCC患者1984年首次被描述为肿瘤标志物原发性肝癌的一种血清标志物—脱-γ-羧基(异常)凝血酶原LiebmanHA，etal.NEnglJMed1984;310:1427–31•在经活检确实为肝细胞癌的76个患者中，我们发现有69个患者(91%)的血清含有脱-γ-羧基凝血酶原，平均水平为900ng/ml)。相反，在慢性活动性肝炎患者(平均水平10ng/ml)或转移性肝癌患者(平均水平42ng/ml)中，异常凝血酶原的水平很低，且在正常人中检测不到。•在5个使用维生素K治疗的患者中，异常凝血酶原含量没有降低，说明它的出现并不是因为维生素K缺乏导致。•行肿瘤手术切除术的2名患者和1名使用化疗的患者，其血清异常凝血酶原浓度显著降低，而在疾病复发后又随之增加。血清甲胎蛋白的含量与异常凝血酶原水平基本不具相关性。Researchdesign:1.largephase2biomarkercase-controlstudyin7academicmedicalcentersintheUnitedStates2.ControlswerepatientswithcompensatedcirrhosisandcaseswerepatientswithHCC3.AFP,DCP,AFP-L3levelsweremeasuredblindedtoclinicaldatainacentralreferencelab.HCCdiagnosis:DCP0.85(95%CI0.80-0.86)AFP0.77(95%CI0.73-0.81)combineAFP+DCP0.88(95%CI0.85-0.90)EarlyHCCdiagnosis:DCP0.84(95%CI0.81-0.87)AFP0.68(95%CI0.64-0.72)combineAFP+DCP0.83(95%CI0.79-0.86)SMMC7721HepG2外源性DCP促进肝癌细胞的生长，且存在量效关系HepG2SMMC7721A:VEGFB:TGFαC:FGFEGFRVEGF本实验室数据大样本临床case-control验证HCC313胆管癌83转移性肝癌29肝血管瘤31肝硬化75健康对照194合计725非HCC阳性阴性阳性率(%)合计肝硬化21542875肝血管瘤031031继发性肝癌32610.3429胆系肿瘤305336.1483健康人群61881.54194合计6035217.04412DCP阳性阴性阳性率(%)合计HCC2555881.46313非HCC6035217.04412合计315410725DCP总体阳性分布情况TheSensitivityandSpecificityofAFP,DCP,andDCP&AFPMarkerCutoffSensitivitySpecificityYIDCP4081.0%85.9%0.669(mAU/mL)46.580.2%87.9%0.681AFP2088.4%78.1%0.665(ng/mL)780.5%87.1%0.676DCP+AFP40+20OR97.8%67.1%0.649AND71.6%96.9%0.685AFP&DCPROCAreaUndertheCurveTestResultVariable(s)AreaStd.ErroraAsymptoticSig.bAsymptotic95%ConfidenceIntervalLowerBoundUpperBoundAFP.886.013.000.861.912DCP.868.015.000.840.897Thetestresultvariable(s):AFP,DCPhasatleastonetiebetweenthepositiveactualstategroupandthenegativeactualstategroup.Statisticsmaybebiased.a.Underthenonparametricassumptionb.Nullhypothesis:truearea=0.5AUCCutoffSensitivitySpecificity95%CIAFPDCP0.8860.8686.946.580.8%80.2%87.4%87.9%0.861-0.9120.840-0.897AFPDCPHCCNon-HCC小计HCC182133315Non-HCC50360410小计232493725DCP与AFP诊断效率一致性比较Kappa值：0.47Intra-assayandinter-assayCVIntra-assayMean±SDCV(%)inter-assayMean±SDCV(%)LMH47.33±1.15553.33±5.516406±35.032.441.000.5547.33±1.2255.389±9.566493.78±85.712.591.731.32结论•DCP是可与AFP媲美的临床原发性肝癌标志物，具有良好的诊断敏感性和特异性，可用于辅助临床原发性肝癌患者的早期诊断；•肝癌细胞产生DCP，自分泌和旁分泌的DCP促进肝癌细胞及血管内皮细胞的生长、迁移；•DCP的致病机理与KDR-PLC-γ-MAPK及Erk1/2MAPK信号传导通路密切相关。