Cancer Translational Medicine

REVIEW
Year
: 2018  |  Volume : 4  |  Issue : 6  |  Page : 153--162

Research advancement in the tumor biomarker of hepatocellular carcinoma


Qing Du1, Xiaoying Ji2, Guangjing Yin3, Dengxian Wei3, Pengcheng Lin1, Yongchang Lu1, Yugui Li3, Qiaohong Yang4, Shizhu Liu5, Jinliang Ku5, Wenbin Guan6, Yuanzhi Lu7,  
1 College of Pharmacy, Qinghai Nationalities University, Xining, China
2 State Key Laboratory of Cancer Biology and Experimental Teaching Center of Basic Medicine, Fourth Military Medical University, Xi'an, China
3 Qinghai Forestry and Grassland Bureau, Qinghai Forest and Seedling Station, Xining, China
4 School of Basic Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
5 Qinghai Tianrong Agriculture and Animal Husbandry Technology Development Limited Company, Qinghai, China
6 College of Nature Conservation, Beijing Forestry University, Beijing, China
7 Department of Pathology and Precision Medicine, The First Affiliated Hospital of Jinan University, Jinan University, Jinan, China

Correspondence Address:
Mr. Guangjing Yin
No. 25, South of Xichuan Road, Xining, Qinhai
China
Dr. Qing Du
No. 3, Bayi Mid.Road, Chengdong District, Xining, Qinghai
China
Prof. Wenbin Guan
Mail Box 159, Beijing Forestry University, Beijing 100083
China
Prof. Yuanzhi Lu
No. 613, West Huangpu Avenue, Tianhe District, Guangzhou, Guangdong
China

Abstract

Hepatocellular carcinoma (HCC) is the third most common cause of mortality due to malignancy next to gastric cancer and esophageal cancer. Several causal factors have been proposed to be involved in the pathogenesis of HCC including regional and age difference, hepatitis virus, aflatoxin, chemicals, liver cirrhosis, and family heredity. Compared to the initial symptoms of HCC, the late symptoms are more obvious, which are liver pain, fatigue, emaciation, jaundice, and ascites. This paper summarized 30 biomarkers from organs, tissues, cells, and subcellular systems to be used for the diagnosis, detection, staging, and evaluation of the HCC so as to predict or prognoses diseases. The biomarker degrees of healthy people have a certain range of indicators. Pathological and clinical diagnostic methods are mainly used to detect various biomarkers related to HCC, such as the common detection of alpha-fetoprotein to detect HCC. Diverse indicators are determined by the modern technology so that we can explore and clarify the possible indicators associated with the pathogenesis of diseases in the organisms. In general, if one or more biomarkers are beyond the normal range, it would predict the presence of HCC in the body. Here, we try to provide a significant contribution toward clinical screening, prediction, diagnosis, treatment, and follow-up monitoring of HCC and related diseases through elucidating the conception, production and influencing factors, sources, and biochemical indicator-associated tumor markers.



How to cite this article:
Du Q, Ji X, Yin G, Wei D, Lin P, Lu Y, Li Y, Yang Q, Liu S, Ku J, Guan W, Lu Y. Research advancement in the tumor biomarker of hepatocellular carcinoma.Cancer Transl Med 2018;4:153-162


How to cite this URL:
Du Q, Ji X, Yin G, Wei D, Lin P, Lu Y, Li Y, Yang Q, Liu S, Ku J, Guan W, Lu Y. Research advancement in the tumor biomarker of hepatocellular carcinoma. Cancer Transl Med [serial online] 2018 [cited 2019 Jan 17 ];4:153-162
Available from: http://www.cancertm.com/text.asp?2018/4/6/153/248973


Full Text



 Introduction



Hepatocellular carcinoma (HCC) is a major killer among the malignant liver tumors and can be divided into two types: primary HCC and secondary HCC.[1] Primary hepatocellular carcinoma (PHC) originates from either the epithelium or mesenchymal tissue of the liver and has a high incidence in China[2] compared to second hepatocellular carcinoma (SHC). SHC refers to the invasion of the liver by malignant tumors originating different organs throughout the body. In general, it most commonly induced the liver metastases from malignant tumors of the stomach, biliary tract, pancreas, colon and rectum, ovary, uterus, lung, breast, and so on.[3] Biomarkers are the changes in the physiological, biochemical, immune, and genetic aspects of the organs, at cellular and subcellular level, caused by various organic and microenvironmental factors.

 The Causes Inducing Hepatocellular Carcinoma



There are six important causes which can possibly induce HCC as follows:

Area and age difference

HCC mainly occurs in southern Africa and the coastal areas of Asia and the Pacific, such as China. HCC often occurs in 40 years or older people, in both males and females.[4] In fact, the lifestyle can also influence the incidence of liver cancer.

Hepatitis virus

Researches reported that the HCC can be induced by the hepatitis viruses A, B, C, D, E, and G and TTV,[5] of which hepatitis B virus (HBV) and hepatitis C virus (HCV) are the most common cause.[6] HBV has a specific causal relationship with HCC. The mortality rate of HCC in men and women is significantly correlated with the history of HBV infection and acute hepatitis. HCV is closely related to HCC, especially in Japan.[7] The interval from HCV infection to diagnosis of cirrhosis or HCC is about 20–40 years. The infection rate of HCV in HCC is as high as 90%. Italian scholars believe that 0.4%–2.5% of people infected with HCV will develop into HCC.[8] HBV protein and HCV nucleoprotein are the possible culprits in the development of HCC.[9]

Aflatoxin

HCC has also been related to the long-term use of aflatoxin. In 1993, aflatoxin was classified as a carcinogen by the Cancer Research Institute of the World Health Organization. Due to its destructive effect on human and animal liver tissues, aflatoxin can lead to liver cancer and even death in severe cases. Aflatoxin B1 is found naturally in contaminated foods,[10] such as moldy rice, peanut, corn, some shells, and their processed products.

Chemical substances

Drugs and chemical poisons, such as smoking, alcohol, As,[11] and polluted water[12] can induce HCC. Alcoholic liver disease can also cause liver cancer, especially in patients who are already infected with HBV and HCV. Long-term heavy drinking is also more likely cause of liver cancer.

Liver cirrhosis

It is a common chronic progressive liver disease resulting in diffuse liver damage, caused by long-term or repeated action of one or more causes. Histopathologically, there is an extensive necrosis of hepatocytes, nodular regeneration of residual hepatocytes, proliferation of connective tissue, and formation of fibrous septum that leads to structural destruction of hepatic lobules and formation of pseudolobules. The liver gradually deforms, hardens, and develops into cirrhosis. Due to the effective compensatory function of the liver, there are no obvious symptoms in the early stage. In the later stage, liver function damage and portal hypertension are the prime manifestations along with systemic complications such as upper gastrointestinal bleeding, hepatic encephalopathy, secondary infection, hypersplenism, ascites, and cancer formation.[13]

Inherited hepatocellular carcinoma

HCC can be hereditarily inherited within the families. Therefore, the relative incidence of HCC when one's parents, brothers, or sisters have HCC is higher than that of other cancers,[14] mostly because of chromosomal mutations or the environmental influence.

 The Definition And Types Of Biomarker



Tumor biomarker is a set of substances produced and released by cancer cells, often existing in tumor cells or host body fluids in the form of antigens, enzymes, hormones, and other metabolites. These markers can help in tumor identification or diagnosis by assessing the change in their concentration within the body fluids, excretions, and tissues of cancer patients according to their biochemical or immunological characteristics. They can be roughly divided into two categories: secretion of cancer cells and expression in cancer cells.[15],[16] We elaborately classified the series of biomarker related to the HCC into five types according to their characteristics and existence [Table 1].{Table 1}

 The Origin And Function Of Biomarkers Related To Hepatocellular Carcinoma



Protein tumor markers

Chemically, few tumor biomarkers, such as enzymes and peptide hormones, are in the form of protein,[17] the degree of expression of which is shown in [Table 2].{Table 2}

Alpha-fetoprotein and alpha-fetoprotein-L3

It is a glycoprotein which belongs to the albumin family and is mainly synthesized by fetal hepatocytes and yolk sacs. It has a high concentration in fetal blood, but it decreases after birth: albumin replaces alpha-fetoprotein (AFP) in 2–3 months after birth. It is difficult to detect AFP in adults, for its content in adult serum is very low. AFP has many important physiological functions including transportation, bi-directional regulation as growth regulator, immunosuppression, T-lymphocyte-induced apoptosis, and so on. At present, it is mainly used as a serum marker of the diagnosis and therapeutic monitoring of PHC.[18],[19] The normal reference value of serum AFP content is below 25ug/L.[20] AFP-L3 is derived from cancerous hepatocytes and has high specificity for HCC.[21] The content of AFP-L3 is related to portal vein invasion, tumor differentiation, and malignant features of PHC and prognosis of PHC.[22]

GP73

GP73 is an ideal serum marker for early diagnosis and evaluation of recurrence of HCC. Its sensitivity and specificity are much higher than AFP. It is a more sensitive marker of liver injury, an independent predictor of hepatic inflammation and significant fibrosis than ALT, and an early warning of HCC. Serum GP73 level is closely related to the severity of liver injury.[23],[24],[25] It can diagnose and monitor the degree of liver inflammation and prognosis in patients with chronic hepatitis B infection. It is also one of the strong risk factors for HCC.

Phosphatidylinositol proteoglycan-3

Phosphatidylinositol proteoglycan-3 (GPC-3) plays an important role in the progress of PHC. The expression of GPC-3 is progressively increased during malignant transformation of hepatocytes. The positive rate of GPC-3 in human HCC is significantly correlated with hepatitis B surface antigen, TNM stage, portal vein thrombus, and extrahepatic metastasis.[26]

Heat shock protein 27

Heat shock protein 27 (Hsp27), also known as heat shock protein beta-1, is a human protein that is encoded by the HSPB1 gene. Hsp27 is a chaperone of the small heat shock protein (sHsp) group: ubiquitin, α-crystallin, Hsp20, and others.[27] The common functions of sHsps are chaperone activity, signal transduction, thermotolerance, inhibition of apoptosis, regulation of cell development, and cell differentiation.

Osteopontin

Senger et al. reported for the first time in 1979 that a phosphorylated glycoprotein containing RGD integrin-binding region related to malignant transformation was associated with tumors, which was called transformation-related phosphoprotein. Later, Franzen et al. isolated a kind of phosphoprotein from bone matrix and teeth, which has similar properties to transformation-related phosphoprotein named osteopontin (OPN), which was also called as 44-kD osteo acid protein, PP69, OPN-1, urinary protein, secreted phosphoprotein, and bone saliva. OPN gene is a single coding gene located on chromosome 4q13, 8 kb in size, with 7 exons and 6 introns.

Serum ferritin

Serum ferritin (SF) is one of the main forms of iron stored in human body. Radioimmunoassay and enzyme-linked immunosorbent assay are currently used for its detection.

Cluster of differentiation 166

Cluster of differentiation 166 (CD166) antigen is a 100–105-kD type I transmembrane glycoprotein which is a member of the immunoglobulin superfamily of proteins. In humans, it is encoded by the ALCAM gene. It is also called as MEMD, SC-1/DM-GRASP/BEN in the chicken and KG-CAM in the rat. Some literature sources have also cited it as the CD6 ligand. CD166 protein expression is reported to be upregulated in a cell line derived from a metastasizing melanoma. CD166 plays an important role in mediating adhesion interactions between thymic epithelial cells and CD6+ cells during intrathymic T-cell development.[28] Recently, CD166 has also been used as a potential cancer stem cell marker.

Cytokines

Cytokines refer to a broad and loose category of small proteins (~5–20 kDa) that are important in cell signaling. It can be said that cytokines are involved in autocrine, paracrine, and endocrine signaling as immunomodulating agents. Cytokines may include chemokines, interferons, interleukins, lymphokines, and tumor necrosis factors excluding hormones and growth factors. Cytokines are produced by a broad range of cells, including immune cells such as macrophages, B-lymphocytes, T-lymphocytes, and mast cells, as well as endothelial cells, fibroblasts, and various stromal cells.[29]

Transforming growth factor-beta 1

Transforming growth factor-beta 1 (TGFβ1) belongs to a newly discovered superfamily of TGFβ that regulates cell growth and differentiation. In addition to TGFβ, there are activins, inhibins, Mullerian-inhibiting substance, and bone morphogenetic proteins. In 1985, the gene of TGFβ was cloned successfully and expressed in Escherichia coli. At least four subtypes of TGFβ (1, 2, 3, and 4) are found of which TGFβ1, TGFβ2, and TGFβ3 are expressed in mammals. The genes of human TGFβ1, TGFβ2, and TGFβ3 are located on chromosomes 19q3, 1q41, and 14q24, respectively, and contain seven exons. Recently, it has been found that there are three types of TGFβ receptors (TGFβRs): type I, Type II, and Type III. Their molecular weights are 53, 70–85, and 250–350 kDa, respectively. Type I and Type II TGFβRs are glycoproteins, and their affinity with TGFβ1 is 10–80 times higher than that with TGFβ2. Type III receptor is a proteoglycan, which has a similar affinity to TGFβ1, TGFβ2, and TGFβ3. It is the main receptor of TGFβ and may play a major role in the biological function of TGFβ. TGFβR III is also known as endoglin or CD105, and TGFβ1 and TGFβ3 are its main ligands.

Insulin-like growth factor 2

Insulin-like growth factor 2 (IGF-II) is one of the three protein hormones that share structural similarity to insulin. The MeSH definition reads: “A well-characterized neutral peptide believed to be secreted by the liver and to circulate in the blood.” It has growth-regulating, insulin-like, and mitogenic activities. The growth factor has a major but not absolute, dependence, on somatotropin. It is believed to be a major fetal growth factor in contrast to IGF-I, which is a major growth factor in adults. There are two kinds of IGF family: IGF-I and IGF-II. The production of IGF-I is more dependent on GH, which has a strong growth-promoting effect and is an important growth factor in childhood. IGF-I synthesized in various tissues mostly plays an autocrine or paracrine role in promoting growth, while IGF-I synthesized in the liver enters the blood circulation and acts on target cells in an endocrine way.[30] The level of IGF-I in vivo is regulated by GH, and the secretion of GH is also negatively regulated by IGF-I. Insulin-like effect of IGF-II is stronger and plays an important role in fetal growth.

Hepatocyte growth factor

Hepatocyte growth factor ( HGF) was discovered as a substance that can stimulate the proliferation of hepatocytes. Its precursor is composed of 728 amino acid residues, which are hydrolyzed by protease to produce biologically active heterodimers. The mature HGF protein molecule is linked by disulfide bond through alpha-chain (molecular weight: 56–69 kD) and beta-chain (beta 1:34 kD, beta 2:32 kD). The alpha-chain contains four Kringle structures and 38% of plasminogen homology. The HGF gene is about 70 KB and consists of 18 exons and 17 introns. Later, it was found that HGF can also act on epithelial cells, hematopoietic cells, vascular endothelial cells, and other cells. It is a multifunctional factor that can regulate the growth, movement, and morphogenesis of many kinds of cells. By means of paracrine or autocrine mechanism and the interaction with epithelial stroma, it plays an important role in embryogenesis, wound healing, angiogenesis, tissue and organ regeneration, morphogenesis, and carcinogenesis.

Tumor-specific growth factor

Tumor-specific growth factor (TSGF) is an internationally recognized term for several carbohydrates and metabolites (lipoproteins, enzymes, and amino acids) associated with the growth of malignant tumors. TSGF is an index that can be used for census and early diagnosis. TSGF is a special substance produced by cancer cells. It can promote the growth and proliferation of malignant tumors. Because of the increased proliferation of capillaries, tumor tissue will be supplied with more blood, which leads to its crazy growth.

Enzyme markers

Enzyme markers include enzyme-labeled antigens, antibodies, and SPA.[31] Enzyme-labeled antibodies are the most commonly used enzyme markers, which are prepared by connecting enzymes with specific antibodies by appropriate methods. The quality of enzyme-labeled antibodies mainly depends on the high purity, activity, and affinity of the used enzyme and antibodies followed by a good preparation method.[32]

Des-γ-carboxy prothrombin

Des-γ-carboxy prothrombin (DCP) referred to as abnormal prothrombin is a protein induced by deficiency of Vitamin K or antagonist-II, also known as PIVKA-II, which can appear in the serum of patients with Vitamin K deficiency or HCC.[33] There is no correlation between DCP and AFP. By DCP and AFP, the sensitivity of diagnosing HCC could be increased to 71%. Serum level of AFP and DCP in patients with HCC can be used to monitor the therapeutic effect of HCC and predict the risk of recurrence.[34],[35] However, the incidence of intrahepatic metastasis, portal vein invasion, thrombosis of hepatic venous aneurysms, and capsular infiltration was higher in DCP-positive patients. DCP is recommended for screening of high-risk population, diagnosis of liver cancer, monitoring of therapeutic effect, and as a predictive tool for prognosis and recurrence.

Alpha-L-fucosidase

Alpha-L-fucosidase (AFU) is a lysosomal acid hydrolase. In 1980, French scholar Deugnier et al. found that AFU has good sensitivity and high positive rate in the diagnosis of HCC, which is more than three times the positive rate of AFP. It is of great value in the diagnosis of AFP-negative cases and small-cell HCC and is useful in the diagnosis of early primary HCC. AFU is mainly involved in the catabolism of various glycolipids, glycoproteins, and mucopolysaccharides containing fucoidan. It widely exists in lysosomes and body fluids of human tissues and cells, such as samples of serum, urine, saliva, and tear. For analysis, the specimens should be cleared, stored at 4°C for 3 days, and stored at − 20°C for 3 months to avoid repeated freezing and thawing. Hemolysis, jaundice, hyperlipidemia, and contaminated specimens can seriously affect the results.

Serum gamma-glutamyltransferase

Gamma-glutamyltransferase (GGT) is primarily present in kidney, liver, and pancreatic cells. Even though renal tissue has the highest level of GGT, the enzyme present in the serum appears to originate primarily from the hepatobiliary system. GGT activity is elevated in all forms of liver disease. GGT is more sensitive than alkaline phosphatase, leucine aminopeptidase, aspartate transaminase, and alanine aminotransferase in detecting obstructive jaundice, cholangitis, and cholecystitis; its rise occurs earlier than other enzymes and persists longer.[36] Increased elevations of GGT is also observed in patients with either primary or secondary neoplasms. Elevated levels of GGT are noted not only in the sera of patients with alcoholic cirrhosis but also in the majority of sera of persons consuming heavy alcohol. Studies have emphasized the value of serum GGT levels in detecting alcohol-induced liver disease.

Matrix metalloproteinases

Matrix metalloproteinases (MMPs) are a large family of enzymes that need Ca2+, Zn2+, and other metal ions as cofactors. The MMPs share a common domain structure. The three common domains are the pro-peptide, the catalytic domain, and the hemopexin-like C-terminal domain, which are linked to the catalytic domain by a flexible hinge region. Its family members have a similar structure, generally consisting of five different functional domains:[37]

Hydrophobic signal peptide sequencePropeptide region, the main role is to maintain the stability of the proenzyme. When this region is cutoff by exogenous enzymes, MMPs get activatedThe catalytic active region, with zinc ion-binding sites, plays an important role in enzyme catalysisThe proline-rich hinge regionThe carboxyl-terminal region, related to the substrate specificity of the enzyme.

MMPs can degrade almost all kinds of protein components in extracellular matrix, destroy the histological barrier of tumor cell invasion, and play a key role in the invasion and metastasis of tumors.[38] Therefore, the role of MMPs in the invasion and metastasis of tumors has been paid more and more attention.

Antibodies and antigens

Antibody is a protective protein produced by the stimulation of antigen. It is secreted by plasma cells (effector B-cells) and used by the immune system to identify and neutralize large Y-shaped proteins of foreign substances such as bacteria and viruses. It is only found in body fluids such as vertebrate blood and on the surface of cell membranes of B-cells. A unique feature of an antibody is its recognition of a specific foreign object, which is called an antigen. Antibodies can be divided into agglutinin, sedimentation hormone, antitoxin, lysin, opsonin, neutralizing antibody, and complement-binding antibody. X-ray crystallographic analysis showed that the antibody was composed of four polypeptide chains, and the number of disulfide bonds was different between the four polypeptide chains. Ig can form a “Y” structure, called Ig monomer which is the basic unit of antibody.[39] Antigens are usually proteins, peptides, and polysaccharides while lipids and nucleic acids can become antigens only when combined with proteins and polysaccharides.

Squamous cell carcinoma antigen

Squamous cell carcinoma antigen (SCCA) is a tumor cell-associated antigen, which can be used as a serological and histological marker for many kinds of squamous cell carcinoma. SCCA is a member of ovalbumin family and has the function of serine protease inhibitor. It has been found that the level of SCCA protein in blood is closely related to some advanced squamous cell carcinomas, so it can be used as a biomarker.[40] In addition, it was reported that SCCA protein (SCCA1, SCCA2, and SCCA-PD) was overexpressed in the liver of 85% of patients with HCC.[41] The normal reference value of SCCA in serum was determined by chemiluminescence method: < 2.5 ng/mL.

Carcinoembaryonic antigen

Carcinoembaryonic antigen is a tumor-associated antigen first extracted from colon cancer and embryonic tissues by Gold and Freedman in 1965. It is an acid glycoprotein with the characteristics of human embryonic antigen. It exists on the surface of cancer cells differentiated from endodermal cells and is a structural protein of cell membrane. It is a proteoglycan complex that exists in empty organs such as colon, normal embryonic intestine, pancreas, and liver. Formed in the cytoplasm, it is secreted to the outside of the cell through the cell membrane and then into the surrounding body fluid. It can be widely found in the digestive duct tissues of endoderm and normal embryo and in trace in the serum of normal people. Its cutoff value is generally 5 ug/L, and the marker is abnormally increased when malignant tumors occur.[42],[43]

CA19-9, CA12-5, CA50, and CA15-3

In the 1980s, experts used hybridoma technology to obtain tumor-specific macromolecule glycoprotein antigen and developed a monoclonal antibody recognition system. Commonly used CA series are CA19-9, CA12-5, CA50, and CA15-3. Saccharide antigen 19-9 is an antigen recognized by Koprowski et al. in 1979 by the monoclonal antibody (NS19-9) prepared by human colon cancer culture strain (SW1116) for immunogen. CA19-9 is a kind of glycoprotein on cell membrane which is a component of many mucosal cells. Abnormally elevated levels are mainly secreted by gastrointestinal empty organ tumor cells. As per the reports, CA19-9 is posed as highly sensitive in diagnosis and treatment monitoring of pancreatic cancer. Serum CA19-9 levels can slightly increase in benign diseases such as biliary inflammation, cirrhosis, biliary calculi, and acute or chronic pancreatitis. The critical value of serum CA19-9 is 0-40 kU/L.[44] CA12-5 is a glycoprotein that can be bound by monoclonal antibody OC125 detected by Bast et al. from epithelial ovarian cancer antigen in 1983. The positive critical value of CA12-5 in serum of normal people is 35 kU/L. CA50 is a nonspecific broad-spectrum tumor marker. When cells become malignant, glycosylase is activated, resulting in the change of glycosyl structure on the surface of cells that turn into CA50. The concentration of CA50 in normal blood is below 20 ug/L, while the same is elevated in many patients with malignant tumors. CA 15-3 is a glycoprotein antigen with a molecular weight of 400000 D. In 1984, Hilkens et al. made mouse monoclonal antibodies (115-D8) from glycoprotein MAM-6 on human milk fat globule membrane, and in 1984, Kufu et al. made monoclonal antibodies (DF-3) from the membrane of hepatic metastatic breast cancer cells. These antibodies recognized CA15-3. Its antigenic determinant is partly sugar and partly polypeptide, and its serum concentration is < 25,000 u/L.

Cell markers

All types of cells form different tissues and organs function in a coordinated fashion. Large-scale single-cell sequencing and biology experiment studies are now rapidly opening up new ways to track the underlying mechanism behind this coordinated function by revealing substantial cell markers for distinguishing different cell types in tissues.

MicroRNAs

Small noncoding RNAs that regulate the translation of many genes have emerged as key factors involved in several biological processes, including development, differentiation, and cell proliferation. Recent studies have uncovered the contribution of microRNAs (miRNAs) in cancer pathogenesis, as they can behave as oncogenes or tumor suppressor genes. In addition, other studies have demonstrated their potential values in the clinical management of HCC patients as some miRNAs may be used as prognostic or diagnostic markers.[45],[46],[47],[48],[49],[50] Hung et al.[45] summarized the role of miRNAs in carcinogenesis and progression of HCC. Several identified a plethora of miRNAs some of which are upregulated: MiR-15a, 16-1,17,18,19, 20a, 25, 92-1, 93, 106b, 148a, 155, 216a, 221, 222, 224, and 519d,[51],[52],[53],[54],[55],[56],[57],[58],[59],[60] while some are downregulated: MiR17, 26a, 29, 34a, 122, 124, 125b, 126, 141, 146a, 195, 198, 199a, 200, and 449.[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77]

Cyclic tumor cell

Cyclic tumor cells (CTCs) are those cancer cells that enter human peripheral blood and are commonly referred to as circulating tumor cells. In 1869, Ashworth, who was an Australian doctor, first introduced the concept of circulating cancer cells. Later in 1976, Nowell revised the definition of CTC, saying that they originate from primary or metastatic tumors, acquire the ability to detach from basement membrane, and enter blood vessels through tissue matrix. Epithelial-mesenchymal transition occurs when tumor cells enter the peripheral blood circulation. Therefore, CTC poses different phenotypes, including epithelial cell phenotype, mesenchymal cell phenotype, and mixed epithelial-mesenchymal cell phenotype. Malignant tumors are transferred to other organs of the body through blood transmission, and metastasis is the main cause of death in cancer patients. Tumor cells invade the surrounding tissues, enter the blood and lymphatic system, form circulating tumor cells (CTC), reach distal tissues, then exudate and adapt to the new microenvironment, and eventually “sow,” “proliferate,” and “colonize” all of which are referred to as metastases. Therefore, early detection of CTC in blood plays an important role in judging prognosis and strategizing individualized treatment of patients.

Human cervical cancer oncogene

Human cervical cancer oncogene (HCCR) is a new gene initially identified in human cervical cancer and later found to be expressed in most human tumors. Studies have shown that HCCR can be used as a marker for early diagnosis of HCC and breast cancer. HCCR expression is regulated by mitogen-activated protein kinase and phosphatidylinositol-3-kinase pathway. Gene interference technique is used to detect HCCR, which is associated with proliferation, apoptosis, invasion, and migration of cancer cells.

Alpha-fetoprotein-microRNA

Through establishing a sensitive nested reverse transcription polymerase chain reaction method, we can detect AFP mRNA in peripheral blood to reflect the hematogenous spread of HCC cells.

P53

It is a human cancer suppressor gene. The gene encodes a protein with a molecular weight of 43.7 KDa but is named P53 because the protein band appears at 53 KDa shown by Marker. More than 50% of all malignant tumors have mutations in this gene. The protein encoded by this gene is a transcriptional factor which controls the initiation of cell cycle. Many signals about cell health are sent to the p53 gene. After the mutation of p53 gene, the regulation of cell growth, apoptosis, and DNA repair is lost due to the change of its spatial conformation. The p53 gene is thus transformed from an antioncogene to an oncogene. P53 has abnormally similar gene structure, about 20 Kb long, consisting of 11 exons and 10 introns. The first exon does not encode, while the exons 2, 4, 5, 7, and 8 encode five highly conserved domains. 13–19, 117–142, 171–19-2, 236–258, and 270–286, respectively. The P53 gene is transcribed onto 2.5-Kb gene, encoding 393 amino acid proteins with a molecular weight of 53 KD. The expression of P53 gene is regulated at least at two levels, transcriptional and posttranscriptional. The level of P53 gene is very low in nontransformed or nongrowing cells.[78],[79],[80]

Sal-like protein 4

Sal-like protein 4 (SALL4) is a transcription factor encoded by a member of the Spalt-like (SALL) gene family. The SALL genes were identified based on their sequence homology to Spalt, which is a homeotic gene originally cloned in Drosophila melanogaster that is important for terminal trunk structure formation during embryogenesis and imaginal disc development at the larval stages. There are four human SALL proteins (SALL1, SALL2, SALL3, and SALL4) with structural homology and plays diverse roles in embryonic development, kidney function and cancer. The SALL4 gene encodes at least three isoforms termed A, B, and C through alternative splicing with the A and B forms being the most studied. SALL4 can alter gene expression and change through its interaction with many co-factors and epigenetic complexes. It is also known as a key embryonic stem cell factor. SALL4 contains one zinc finger in its amino (N-) terminus and three clusters of zinc fingers that each coordinates with two cysteines and two histidines that potentially confer nucleic acid binding activity. SALL4B lacks two of the zinc finger clusters found in the A isoform. It remains unclear which zinc finger cluster is responsible for SALL4's DNA-binding property.[81],[82],[83]

Cadherin-17

Cadherin-17 (CDH17) is a protein that in humans is encoded by the CDH17 gene.

This gene is a member of the cadherin superfamily, encoding calcium-dependent, membrane-associated glycoproteins. The encoded protein is cadherin-like, consisting of an extracellular region, containing 7 cadherin domains, and a transmembrane region lacking the conserved cytoplasmic domain. The protein is a component of the gastrointestinal tract and pancreatic ducts, acting as an intestinal proton-dependent peptide transporter in oral absorption of many medically important peptide-based drugs.[84] The protein may also play a role in the morphological organization of liver and intestine.

 The Biomarker-Based Diagnosis Of Hepatocellular Carcinoma



In general, using biomarkers, there are two different ways to diagnose and detect HCC.[85] One is pathology section examining the liver tissue and extrahepatic tissue,[86] and the other is clinical diagnostic methods including flow cytometry, radioimmunoassay, B-type supernatant imaging, computed tomography, radionuclide scanning, X-ray angiography, nuclear magnetic resonance, imaging examination, computed tomography and magnetic resonance imaging, and so on.[87]

 Biomarker Application in the Detection, Screening, Diagnosis, and Treatment of Hepatocellular Carcinoma



Although surgery is the first choice for the treatment of HCC, in addition, we should choose the additional suitable strategy to maintain an optimal health of the patient.[88],[89],[90] Biomarkers not only can be used for disease diagnosis but also for disease staging. During the clinical treatment, biomarkers can be used to evaluate the safety and efficacy of new drugs or therapies in the target populations.[91],[92] Moreover, in addition to monitoring recurrence indicators, they also can be used in the aspects of prognosis judgment surgery, chemotherapy, and/or radiotherapy. We can use biomarkers to search for metastatic tumors of unknown origin.[93] The discovery and prognosis of HCC require proper management of patients' physical condition and emotions in all aspects, dynamic observation of patients' symptoms, signs and auxiliary examinations,[94],[95] regular follow-up, monitoring of disease development, recurrence, or treatment-related adverse reactions.[96],[97]

Acknowledgments

We would like to thank Dr. Xing Jinliang for providing us the professional direction regarding the manuscript contents and excellent advice on collaborative approaches.

Financial support and sponsorship

This work was financially supported by special development of Key Laboratory of Qinghai Science and Technology Department (2015-Z-Y09) and by Qinghai Science and Technology Research Project (2016-ZJ-903).

Conflicts of interest

There are no conflicts of interest.

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