Direct comparison of five serum biomarkers in early diagnosis of hepatocellular carcinoma

Figures & data

Table 1 Study population characteristics

Characteristics	HCC (n=202)	CHB (n=215)	LC (n=226)	HC (n=203)
Age (years), mean±SD	57.2±11.5	39.2±11.8	50.5±10.4	48.2±11.0
Gender, n (%)
Male	170 (84.2)	134 (62.3)	161 (71.2)	97 (47.8)
Female	32 (15.8)	80 (37.2)	65 (28.8)	106 (52.2)
Missing	–	1 (0.5)	–	–
HBV infection, n (%)
HBV+	132 (65.3)	215 (100.0)	184 (81.4)	0 (0)
HBV−	27 (13.3)	0 (0.0)	6 (2.7)	203 (100.0)
Missing	43 (21.3)	0 (0.0)	36 (15.9)	0 (0)
HCV infection, n (%)
HCV+	14 (6.9)	0 (0)	2 (8.9)	0 (0)
HCV−	133 (65.8)	31 (14.4)	100 (44.2)	203 (100.0)
Missing	55 (27.2)	184 (85.6)	124 (54.9)	0 (0)
TNM tumor stage, n (%)
I	94 (46.5)	–	–	–
>I	97 (48.0)	–	–	–
Missing	11 (5.4)	–	–	–
Child–Pugh, n (%)
A	–	–	91 (40.2)	–
B	–	–	66 (29.2)	–
C	–	–	38 (16.8)	–
Missing	–	–	31 (13.7)	–
Metastasis, n (%)
Yes	13 (6.4)	–	–	–
No	189 (93.6)	–	–	–

Note: “–” = not applicable.

Abbreviations: CHB, chronic hepatitis B virus infection; HBV, hepatitis B virus; HC, healthy control; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; LC, liver cirrhosis; TNM, tumor-node-metastasis.

Table 2 Direct comparison of the diagnostic performance of five markers in detecting HCC

AFP		AFP-L3		DCP		SCCA		CENPF
AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b
(a) HCC vs LC, CHB, and HC
0.72 (0.70–0.82)	43.7 (36.4–62.3)	0.67 (0.64–0.75)	42.6 (33.3–53.8)	0.82 (0.64–0.80)	65.2 (63.3–82.1)	0.48 (0.40–0.59)	7.5 (0–24.2)	0.65 (0.62–0.77)	20.4 (10.8–42.6)
(b) HCC vs LC and CHB
0.68 (0.67–0.79)	38.8 (29.4–50.0)	0.65 (0.62–0.73)	39.1 (28.3–52.8)	0.80 (0.62–0.80)	64.1 (59.7–80.3)	0.47 (0.35–0.60)	8.8 (0–31.0)	0.53 (0.44–0.68)	14.0 (0–29.0)
(c) HCC vs LC
0.67 (0.68–0.80)	40.1 (31.8–57.1)	0.65 (0.62–0.74)	40.5 (30.0–53.3)	0.78 (0.64–0.81)	57.2 (48.6–75.9)	0.47 (0.35–0.60)	8.8 (0–31.0)	0.52 (0.33–0.73)	11.8 (0–28.6)
(d) Early-stage HCC vs LC, CHB, and HC
0.64 (0.60–0.78)	36.5 (24.2–57.6)	0.56 (0.51–0.67)	23.4 (7.7–39.2)	0.74 (0.68–0.84)	51.0 (40.0–75.0)	0.48 (0.36–0.61)	8.0 (0–24.1)	0.45 (0.34–0.59)	6.8 (0–18.2)
(e) Early-stage HCC vs LC and CHB
0.61 (0.59–0.75)	30.2 (18.8–43.8)	0.54 (0.50–0.66)	22.1 (9.5–38.1)	0.72 (0.65–0.83)	45.5 (38.9–72.4)	0.47 (0.37–0.61)	7.0 (0–30.8)	0.52 (0.33–0.73)	11.8 (0–28.6)
(f) Early-stage HCC vs LC
0.62 (0.60–0.77)	30.6 (21.6–53.1)	0.55 (0.49–0.67)	22.8 (8.3–40.0)	0.73 (0.70–0.85)	48.3 (41.9–76.5)	0.48 (0.36–0.61)	8.0 (0–24.1)	0.45 (0.34–0.59)	6.8 (0–18.2)

Notes:

a AUC was adjusted for potential overfitting by the .632+ bootstrap method.

b .632+ bootstrap adjusted sensitivity at cutoffs yielding 90% specificity.

Abbreviations: AFP, alpha-fetoprotein; AFP-L3, lens culinaris agglutinin-reactive AFP; AUC, area under the curve; CENPF, centromere protein F autoantibody; CHB, chronic hepatitis B virus infection; DCP, des-gamma-carboxyprothrombin; HC, healthy control; HCC, hepatocellular carcinoma; LC, liver cirrhosis; SCCA, squamous cell carcinoma antigen; SEN, sensitivity; SPE, specificity.

Figure 1 Comparison of .632+ adjusted receiver operating characteristics curves of AFP, AFP-L3, DCP, SCCA, and CENPF for discriminating: (A) HCC vs CHB+LC+HC;

(B) HCC vs CHB+LC; (C) HCC vs CHB; (D) early-stage HCC vs CHB+LC+HC; (E) early-stage HCC vs CHB+LC; and (F) early-stage HCC vs LC.

Abbreviations: AFP, alpha-fetoprotein; AFP-L3, lens culinaris agglutinin-reactive AFP; AUC, area under the curve; CENPF, centromere protein F autoantibody; CHB, chronic hepatitis B virus infection; DCP, des-gamma-carboxyprothrombin; HC, healthy control; HCC, hepatocellular carcinoma; LC, liver cirrhosis; SCCA, squamous cell carcinoma antigen.

Table 3 (a) Diagnostic performance of four markers in detecting AFP-positive or AFP-negative patients with HCC

Marker	HCC vs LC+CHB+HC		HCC vs LC+CHB		HCC vs LC
	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b
AFP-positivec
AFP-L3	0.95 (0.89–0.99)	89.4 (82.6–100.0)	0.93 (0.90–0.98)	85.1 (70.0–100.0)	0.93 (0.91–0.99)	87.9 (71.4–100.0)
DCP	0.84 (0.63–0.85)	65.4 (61.4–88.9)	0.82 (0.62–0.84)	64.5 (59.5–87.9)	0.78 (0.63–0.84)	59.3 (50.0–83.3)
SCCA	0.46 (0.36–0.61)	7.8 (0–21.4)	0.45 (0.31–0.62)	8.4 (0–29.4)	0.45 (0.31–0.62)	8.4 (0–29.4)
CENPF	0.65 (0.62–0.81)	21.7 (5.9–47.6)	0.53 (0.40–0.71)	11.7 (0–29.2)	0.53 (0.40–0.71)	11.7 (0–29.2)
AFP-negativec
AFP-L3	0.48 (0.46–0.53)	6.7 (0–11.5)	0.46 (0.44–0.52)	7.2 (0–10.3)	0.46 (0.44–0.52)	7.0 (0–10.7)
DCP	0.78 (0.62–0.81)	56.3 (48.4–77.8)	0.76 (0.61–0.82)	56.6 (48.1–75.8)	0.73 (0.61–0.81)	52.1 (41.4–72.5)
SCCA	0.47 (0.36–0.59)	6.8 (0–27.3)	0.47 (0.34–0.63)	7.8 (0–38.1)	0.47 (0.34–0.63)	7.8 (0–38.1)
CENPF	0.60 (0.55–0.77)	20.0 (6.7–41.2)	0.50 (0.38–0.67)	12.5 (0–31.6)	0.50 (0.38–0.67)	12.5 (0–31.6)

(b) Diagnostic performance of four markers in detecting AFP-negative or AFP-positive patients with early-stage HCC

Marker	Early-HCC vs LC+ CHB+HC		Early-HCC vs LC+ CHB		Early-HCC vs LC
	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b
AFP-positivec
AFP-L3	0.85 (0.61–100.0)	75.4 (25.0–100.0)	0.83 (0.62–1)	74.0 (33.3–100.0)	0.83 (0.63–1)	73.7 (33.3–100.0)
DCP	0.72 (0.63–0.90)	41.4 (26.7–83.4)	0.70 (0.62–0.88)	42.6 (28.6–83.3)	0.68 (0.62–0.87)	37.1 (25.0–76.5)
SCCA	0.45 (0.33–0.60)	7.9 (0–22.2)	0.47 (0.33–0.64)	7.0 (0–33.3)	0.47 (0.33–0.64)	7.0 (0–33.3)
CENPF	0.54 (0.40–0.84)	12.2 (0–50.0)	0.44 (0.21–0.73)	4.9 (0–25.0)	0.44 (0.21–0.73)	4.9 (0–25.0)
AFP-negativec
AFP-L3	0.47 (0.44–0.54)	9.2 (0–14.3)	0.46 (0.43–0.53)	5.4 (0–13.3)	0.46 (0.43–0.53)	9.4 (0–13.3)
DCP	0.69 (0.61–0.82)	48.0 (28.6–70.0)	0.69 (0.59–0.82)	39.0 (29.4–68.8)	0.66 (0.60–0.81)	36.7 (23.8–64.7)
SCCA	0.49 (0.35–0.62)	10.8 (0–31.3)	0.46 (0.35–0.60)	7.2 (0–33.3)	0.46 (0.35–0.60)	7.2 (0–33.3)
CENPF	0.45 (0.30–0.67)	9.0 (0–22.2)	0.44 (0.32–0.60)	6.3 (0–30.0)	0.44 (0.32–0.60)	6.3 (0–30.0)

Note:

a AUC was adjusted for potential overfitting by the .632+ bootstrap method.

b .632+ bootstrap adjusted sensitivity at cutoffs yielding 90% specificity.

c The threshold is 20 ng/mL to define the positivity of AFP.

Abbreviations: AFP, alpha-fetoprotein; AFP-L3, lens culinaris agglutinin-reactive AFP; AUC, area under the curve; CENPF, centromere protein F autoantibody; CHB, chronic hepatitis B virus infection; DCP, des-gamma-carboxyprothrombin; HC, healthy control; HCC, hepatocellular carcinoma; LC, liver cirrhosis; SCCA, squamous cell carcinoma antigen; SEN, sensitivity; SPE, specificity.

Table 4(a) Diagnostic performance of marker combinations in detecting HCC

Marker	HCC vs LC+CHB +HC		HCC vs LC+CHB		HCC vs LC
	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b
AFP+AFP-L3	0.69 (0.65–0.78)	46.5 (35.2–57.7)	0.66 (0.63–0.76)	40.9 (30.8–53.7)	0.66 (0.63–0.77)	43.4 (30.8–55.3)
AFP+DCP	0.87 (0.68–0.84)	73.8 (63.6–84.2)	0.84 (0.67–0.83)	68.2 (59.4–78.5)	0.83 (0.68–0.84)	64.2 (53.9–76.6)
AFP-L3+DCP	0.84 (0.64–0.83)	71.0 (60.4–83.3)	0.82 (0.62–0.82)	66.3 (54.5–77.8)	0.81 (0.63–0.83)	63.7 (52.8–77.8)
AFP+AFP-L3+DCP	0.85 (0.64–0.84)	73.7 (60.8–85.1)	0.83 (0.63–0.83)	65.7 (54.7–78.6)	0.81 (0.64–0.84)	64.5 (52.8–78.7)

(b) Diagnostic performance of marker combinations in detecting early-stage HCC

Marker	Early-stage HCC vs LC+CHB+HC		Early-stage HCC vs LC +CHB		Early-stage HCC vs LC
	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b	AUC (95% CI)a	SEN at 90% SPE (95% CI)b
AFP+AFP-L3	0.58 (0.49–0.69)	26.8 (10.0–42.9)	0.56 (0.46–0.68)	25.0 (9.5–41.7)	0.56 (0.45–0.68)	25.7 (7.7–42.1)
AFP+DCP	0.79 (0.73–0.88)	59.8 (46.4–77.4)	0.77 (0.71–0.86)	56.0 (43.2–70.6)	0.75 (0.71–0.87)	52.6 (37.0–68.6)
AFP-L3+DCP	0.72 (0.64–0.84)	47.9 (33.3–72.2)	0.69 (0.61–0.83)	42.9 (25.0–64.3)	0.67 (0.61–0.83)	42.5 (22.2–63.7)
AFP+AFP-L3+DCP	0.72 (0.61–0.85)	49.7 (34.8–73.3)	0.70 (0.58–0.83)	45.3 (25.0–64.3)	0.68 (0.59–0.83)	42.7 (23.1–64.7)

Note:

a AUC was adjusted for potential overfitting by the .632+ bootstrap method.

b .632+ bootstrap adjusted sensitivity at cutoffs yielding 90% specificity.

Abbreviations: AFP, alpha-fetoprotein; AFP-L3, lens culinaris agglutinin-reactive AFP; AUC, area under the curve; CHB, chronic hepatitis B virus infection; DCP, des-gamma-carboxyprothrombin; HC, healthy control; HCC, hepatocellular carcinoma; LC, liver cirrhosis; SEN, sensitivity; SPE, specificity.

Figure 2 Comparison of .632+ adjusted receiver operating characteristics curves of four different multi-marker combinations for discriminating: (A) HCC vs CHB+LC+HC; (B) HCC vs CHB+LC; (C) HCC vs CHB; (D) early-stage HCC vs CHB+LC+HC; (E) early-stage HCC vs CHB+LC; and (F) early-stage HCC vs LC.

Abbreviations: AFP, alpha-fetoprotein; AFP-L3, lens culinaris agglutinin-reactive AFP; AUC, area under the curve; CENPF, centromere protein F autoantibody; CHB, chronic hepatitis B virus infection; DCP, des-gamma-carboxyprothrombin; HC, healthy control; HCC, hepatocellular carcinoma; LC, liver cirrhosis; SCCA, squamous cell carcinoma antigen.