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Cancer Biomarkers -1 (2018) 1–8 1

DOI 10.3233/CBM-181402
IOS Press

Diagnostic value of serum PIVKA-II levels

for BCLC early hepatocellular carcinoma and
correlation with HBV DNA
Jiali Wu, Zheyi Xiang, Le Bai, Lagu He, Li Tan, Min Hu and Yaping Ren∗
Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha 410011,
Hunan, China

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Abstract.

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BACKGROUND: It is reported that prothrombin induced by vitamin K absence-II (PIVKA-II) has a better performance of

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diagnosis for HCC, and has also been known to be an independent risk factor for vascular invasion. Few studies study the
relationship between PIVKA-II and HBV DNA.
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OBJECTIVE: To determine the clinical value of serum Prothrombin induced by vitamin K absence-II (PIVKA-II) in early
hepatocellular carcinoma (HCC), and to explore its relationship with vascular invasion and HBV DNA.
METHODS: In a Chinese cohort, we conducted a case-control study to compare the performances of a-fetoprotein (AFP) and
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PIVKA-II serum levels for diagnosis of HCC and early HCC. Fifty one healthy controls, 37 chronic hepatitis patients, 43 cirrhotic
patients and 143 HCC cases of which 48 (33.57%) had early stage HCC (n = 19 very early, n = 29 early) were enrolled. We
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explored the correlation between PIVKA-II serum level and several pathological features such as vascular invasion. The serum
levels of and AFP were measured by chemiluminescence assay (CLIA) and electrochemiluminescence assay (ECLA).
RESULTS: The serum levels of both PIVKA-II and AFP in HCC group were higher than that in chronic hepatitis, cirrhosis and
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healthy control groups. The sensitivity, specificity, positive predictive value, negative predictive value and kappa of PIVKA-II
were higher than AFP in the diagnosis of HCC. Serum PIVKA-II level was correlated with tumor size, tumor cell differentiation
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and BCLC staging (P < 0.05). For the diagnosis of early HCC, the combination of PIVKA-II (AUC 0.812; 95% CI, 0.702–
0.894) and AFP (0.797; 95% CI, 0.686–0.883) slightly improve the diagnostic performance for early HCC(AUC 0.849; 95%
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CI, 0.745–0.923). PIVKA-II > 166 mAU/ml is an independent risk factor for vascular invasion. The serum HBV DNA level in
cirrhosis and HCC patients was significantly higher than in chronic hepatitis patients. We detected a negative association between
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serum PIVKA-II and serum HBV DNA levels.

CONCLUSIONS: PIVKA-II was more efficient than AFP for the diagnosis of early HCC and has no correlation with serum
HBV DNA levels.
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Keywords: Hepatocellular carcinoma, prothrombin induced by vitamin K absence-II, alpha fetoprotein, HBV DNA load, vascular
invasion

1 1. Introduction wide [1,2]. Approximately 75% of liver cancers occur 5

in Asia, with China accounting for more than 50% of 6

2 Hepatocellular carcinoma (HCC) is currently the the world’s burden [3]. Although we have known more 7

3 fourth most common malignant cancer and the third and more comprehension of HCC and the treatment is 8

4 most common cause of cancer related death world- more advanced, its prognosis is still poor. It’s reported 9

that 1 year survival rate of HCC is 47% [4]. Five-year 10

survival rate is less than 10% [5]. The mortality rate 11

∗ Corresponding author: Yaping Ren, Department of Clinical Lab-
has been a high trend [6]. 12
oratory, The Second Xiangya Hospital, Central South University,
Changsha 410011, Hunan, China. Tel.: +86 0731 85292142; Fax: Screening of the high risk population of HCC could 13

+86 0731 85292142; E-mail: yapingren@csu.edu.cn. contribute to early detection, early diagnosis and early 14

ISSN 1574-0153/18/$35.00
c 2018 – IOS Press and the authors. All rights reserved
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2 J. Wu et al. / Diagnostic value of serum PIVKA-II levels for BCLC early HCC and correlation with HBV DNA

15 treatment, which are the key to improve the efficacy of health status (ECOG-0) and well-preserved liver func- 62

16 hepatocellular carcinoma. The serum alpha-fetoprotein tion (Child-Pugh A class). Early HCC (BCLC stage A) 63

17 (AFP) and ultrasound (US) are the primary means of is defined in patients presenting single tumors > 2 cm 64

18 early screening. Current guidelines recommend that or 3 nodules < 3 cm of diameter, ECOG-0 and Child- 65

19 US should be performed every 6 months for surveil- Pugh class A or B. Late stage HCC was a combina- 66

20 lance of high-risk groups [7]. However, it is reported tion of intermediate (BCLC stage B)/advanced (BCLC 67

21 that US is not reliable for detecting HCC at the early stage C) stages, defined by a single lesion > 5 cm, or 68

22 stage [8]. Although AFP is the most regularly used more than 3 lesions, or by the presence of macrovascu- 69

23 serum biomarker for HCC diagnosis and surveillance lar invasion or metastasis (lymph node/visceral). 70

24 worldwide, it was found to be normal or low concen- Controls were 37 patients with chronic hepatitis, 71

25 trations in about 30% of the HCC patients, while in- 43 patients with cirrhosis and enrolled during the 72

26 creasing levels could be seen in patients with chronic same period as HCC cases. Healthy controls included 73

27 hepatitis and cirrhosis [9,10]. Thus, it is important to 51 healthy volunteers. All patients (chronic hepatitis, 74

28 search for new serum markers for the early diagnosis cirrhosis and HCC patients) had chronic HBV infec- 75

29 of HCC. tion. The study protocol was reviewed and approved 76

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30 Prothrombin induced by vitamin K absence-II by The Second Xiangya Hospital Investigational Re- 77

31 (PIVKA-II) is a serum biomarker with highly sensitiv- view Board. Informed consent was obtained from all 78

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32 ity and specificity, used for the diagnosis and progno- participants. 79

sis monitoring of HCC. PIVKA-II is also superior to

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33

34 AFP in diagnosis of the early stages of HCC [11–13]. 2.2. Sample and assay
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35 Moreover, it has been suggested that elevated PIVKA-

36 II serum levels is associated with vascular invasion, Peripheral blood was obtained from each patient 81

a major risk factor for recurrence and mortality in prior to any HCC treatment. The serum was ob-
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37 82

38 HCC [14–16], therefore, predicting vascular invasion tained by centrifuging for 5 min at 3000 rpm and 83

39 is important in prognosis management. Hepatitis B stored at −80◦ C until testing. All serum samples were 84
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40 virus (HBV) is an important cause of the development kept in duplicate. AFP was measured by the elec- 85

41 of HCC. Although the development of vaccines and trochemiluminescence immunoassay. PIVKA-II was 86
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42 antimicrobial therapy can control the infection of HBV determined by the chemiluminescence enzyme im- 87

43 to a certain extent, the failure of the control of HBV in- munoassay. HBV DNA was extracted from 200 µL 88
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44 fection due to a variety of factors has set new obstacles aliquots of serum using a Hepatitis B Viral DNA 89

45 and difficulties for HCC prevention and treatment. Quantitative Fluorescence Diagnostic Kit (Sheng Xi- 90
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46 The aim of this study was to compare the accuracy ang BioInc., Changsha, Hunan, China), and quantified 91

47 of serum PIVKA-II and AFP levels in the diagnosis of by real-time polymerase chain reaction (PCR) is us- 92
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48 early HCC, and to detect relevance of PIVKA-II and ing an ABI 7000 real-time detection system (Applied 93

49 HBV DNA. Biosystems, Foster City, CA, USA). Levels of ala- 94

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nine aminotransferase (ALT), aspartate transaminase 95

(AST), total bile acid (TBA), direct bilirubin (DBIL), 96

50 2. Materials and methods Albumin (ALB) and total protein (TP) were deter- 97

mined using an ARCHITECTc8000 System (Abbott 98

51 2.1. Study subjects Laboratories, Irving, TX, USA). 99

52 The study was performed in the second Xiangya 2.3. Statistical analysis 100

53 Hospital of Central South University from Novem-

54 ber 2016 to March 2017. The diameter of the tu- All statistical analyses were carried out with IBM 101

55 mor was measured by ultrasound and/or CT. The tu- SPSS software (SPSS version 22.0, IBM, USA). P 102

56 mor differentiation was determined using Edmondson- value less than 0.05 was considered as statistically sig- 103

57 Steiner grade. HCC staging was determined using the nificant. Continuous variables were presented as means 104

58 Barcelona Clinic Liver Cancer (BCLC) staging sys- ± standard deviation, and were compared using the 105

59 tem [7]. Very early HCC (BCLC stage 0) is defined as Mann-Whitney test. To determine the optimal cut-off 106

60 the presence of a single tumor < 2 cm in diameter with- value for PIVKA-II and AFP in the diagnosis of HCC, 107

61 out vascular invasion/satellites in patients with good receiver operating characteristic (ROC) curves were 108
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J. Wu et al. / Diagnostic value of serum PIVKA-II levels for BCLC early HCC and correlation with HBV DNA 3

Table 1
Baseline characteristics of controls and HCC cases
HC (n = 51) Chronic hepatitis (n = 37) Cirrhosis (n = 43) HCC (n = 143) P value
Age 49.62 ± 10.51 43.22 ± 12.06 52.69 ± 9.12 53.58 ± 10.95 n.s.
Gender (male/female) 31/20 25/12 29/14 124/19 n.s.
ALT (u/l) 18.51 ± 7.73 447.64 ± 424.49 51.15 ± 65.61 64.37 ± 78.75 < 0.05
AST (u/l) 19.89 ± 5.01 342.36 ± 542.44 64.75 ± 68.09 93.56 ± 199.78 < 0.05
ALB (g/l) 43.55 ± 1.62 33.5 ± 4.27 30.14 ± 5.75 36.23 ± 4.92 < 0.05
DBIL (umol/l) 11.61 ± 2.84 120.64 ± 102.03 41.74 ± 66.65 21.27 ± 60.00 < 0.05
AST, aspartate aminotransferase; ALT, alanine aminotransferase; n.s., not significant; DBIL, Direct Bilirubin; Alb, Albumin; HC, health control;
HCC, hepatocellular carcinoma.

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Fig. 1. Serum levels of PIVKA-II and AFP among controls and hepatocellular carcinoma cases. #p < 0.05, between the two groups indicated by
the horizontal line. *p < 0.05, compared to the control subjects.
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109 constructed, and the area under the curve (AUC) was cirrhotic chronic hepatitis patients, cirrhosis without 130

110 calculated. Univariate analysis was obtained on pa- HCC patients (286 (44.5–4540.5) vs. 22 (17.5–25) vs. 131
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111 tients with HCC to identify potential predictors of vas- 25 (14–39) vs. 16 (12–28.5) mAU/ml, p < 0.05). 132

112 cular invasion. Variables with P value < 0.05 in uni- The median AFP level was significantly higher in the 133
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113 variate analysis were then subjected to multivariate HCC group than in the healthy control group and cir- 134

114 analysis and included in the logistic model to identify rhosis without HCC group (57.02 (8.38–504.2) vs. 135
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115 independent predictive factors of vascular invasion. 3.09 (2.05–3.95 vs. 3.17 (1.8–7.01) ng/ml, p < 0.05) 136

(Fig. 1). 137

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116 3. Results 3.3. Diagnostic performances of PIVKA-II and AFP 138

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in order to distinguish patients with HCC from 139

117 3.1. Patient characteristics controls 140

118 Two hundred seventy four participants were divided

When the usual clinical cut-offs (40 mAU/ml for 141
119 into four groups: (1) Healthy controls (n = 51); (2)
PIVKA-II, 10 ng/ml for AFP) were used , the PIVKA- 142
120 non-cirrhotic chronic hepatitis (n = 37); (3) cirrhosis
121 without HCC (n = 43); (4) HCC (n = 143). Healthy II of sensitivity, specificity, positive predictive value 143

122 controls comprised 51 healthy volunteers. ALT, AST, (PPV), negative predictive value (NPV) and Kappa 144

123 ALB and DBIL were higher (P < 0.05) in the HCC were 76.92%, 86.26%, 85.94%, 77.39% and 0.629 and 145

124 group than in the non-HCC groups. Patients character- 64.34%, 73.28%, 72.44%, 65.31% and 0.374 for AFP. 146

125 istics are outlined in Table 1. PIVKA-II had a better performance than AFP for diag- 147

nosis of early HCC, with sensitivity of 58.54%, speci- 148

126 3.2. PIVKA-II and AFP serum levels in controls and ficity of 82.61%, PPV of 50% and NPV of 87.2%. 149

127 HCC patients For AFP, sensitivity, specificity, PPV and NPV were 150

47.37%, 88.35%, 75%, and 69.47%, respectively (Ta- 151

128 The median PIVKA-II level was significantly higher ble 2). According to the cut-off levels (40 mAU/ml for 152

129 in HCC patients than in healthy control patients, non- PIVKA-II), 8 cases of 19 patients with very early stage 153
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4 J. Wu et al. / Diagnostic value of serum PIVKA-II levels for BCLC early HCC and correlation with HBV DNA

Table 2
Diagnostic accuracy of the markers to differentiate between malignant cases and controls
Sensitivity % Specificity % Kappa PPV % NPV %
HCC
AFP (ng/ml) 64.34 73.28 0.374 72.44 65.31
PIVKA-II (mAU/ml) 76.92 86.26 0.629 85.94 77.39
AFP + PIVKA-II (in series) 53.02 93.13 0.454 89.14 64.55
AFP + PIVKA-II (in parallel) 88.1 66.41 0.55 74.12 83.65
Very early and early HCC
AFP 47.37 88.35 0.068 75 69.47
PIVKA-II 58.54 82.61 0.078 50 87.02
AFP + PIVKA-II (in series) 70.97 82.43 0.078 45.83 93.13
AFP + PIVKA-II (in parallel) 44.19 89.25 0.064 79.17 63.36
PPV, positive predictive value; NPV, negative predictive value.

Table 3
Correlation between AFP and PIVKA-II serum levels and pathological characteristics of hepatocellular carcinomas

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PIVKA-II (mAU/ml) P AFP (ng/ml) P
Number of nodules > 0.05 > 0.05
Single (n = 25) 32179 ± 99969.99 1224.92 ± 3841.43

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Multiple (n = 118) 18851.28 ± 87237.86 8260.34 ± 32308.23
Tumor size < 0.05 > 0.05

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< 3 cm (n = 25) 232.52 ± 74.84 1063.76 ± 2697.89
3 ∼ 5 cm (n = 40) 4104.93 ± 7010.31 7452.28 ± 33211.14
> 5 cm (n = 78)
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27191.45 ± 103461.86 2083.05 ± 8401.31
Tumor differentiation < 0.05 > 0.05
Well-differentiated (n = 41) 3706.83 ± 14704.65 2794.89 ± 11123.92
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Moderately/poorly differentiated (n = 33) 5641.64 ± 10590.45 7945.35 ± 36477.41

BCLC staging < 0.05 < 0.05
Very early (BCLC 0, n = 19)* 239 ± 838.32 1382.34 ± 3108.191
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Early (BCLC A, n = 29)* 21431 ± 101623.31 1953.95 ± 7760.61

Late (BCLC B–C, n = 95) 23360.95 ± 94670.02 20718.19 ± 70647.46
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PIVKA-II, prothrombin induced by vitamin-K-absence-II; AFP, a-fetoprotein; HCC, hepatocellular carcinoma; *p < 0.05, compared to the late
stage (BCLC B–C).
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154 and 16 cases of 29 patients with early stage had ele-

155 vated PIVKA-II levels.
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156 3.4. Performance of PIVKA-II, AFP and a

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157 combination of markers in differentiating HCC

158 cases from controls
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159 The optimal cutoff values for PIVKA-II and AFP in

160 differentiating HCC cases from non-cirrhotic chronic
161 hepatitis and cirrhosis without HCC controls were
162 104 mAU/ml and 209.2 ng/ml, respectively. The sen-
163 sitivity and specificity at these cutoff values were
164 65.73% and 92.5% for PIVKA-II (AUC 0.862; 95%
165 CI, 0.810–0.904) and 39.86% and 87.5% for AFP
166 (AUC 0.671; 95% CI, 0.606–0.733), respectively. The
167 optimal cutoff values for PIVKA-II and AFP in differ-
168 entiating HCC cases from cirrhosis without HCC con-
169 trols were 26 mAU/ml and 7.66 ng/ml, respectively.
170 The sensitivity and specificity at these cutoff values Fig. 2. Receiver operating characteristics (ROC) curve comparing
171 were 74.42% and 86.01% for PIVKA-II (AUC 0.803 ; serum levels of PIVKA-II, AFP and a combination of PIVKA-II and
172 95% CI, 0.738–0.857) and 79.1% and 76.2% for AFP AFP in patients with early hepatocellular carcinomas vs. controls.
173 (AUC 0.873 ; 95% CI, 0.817–0.917), respectively.
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J. Wu et al. / Diagnostic value of serum PIVKA-II levels for BCLC early HCC and correlation with HBV DNA 5

Table 4
Predictive factors of vascular invasion in hepatocellular carcinomas
Parameters Univariate analysis Multivariate analysis
OR (95% CI) P value OR (95% CI) P value
Gender 1.236 (0.371–4.12) 0.73
Age 1.394 (0.413–4.706) 0.593
PIVKA-II (mAU/ml) 2.636 (1.119–6.212) 0.027 2.997 (1.217–7.381) 0.017
AFP (ng/ml) 1.108 (0.483–2.546) 0.808
PT (sec) 0.814 (0.355–1.87) 0.628
INR 0.975 (0.425–2.237) 0.952
ALT (u/g) 1.167 (0.509–2.68) 0.716
AST (u/g) 1.053 (0.459–2.415) 0.904
TP (g/l) 1.26 (0.548–2.895) 0.586
ALB (g/l) 0.697 (0.302–1.605) 0.396
DBIL (umol/l) 2.56 (1.09–6.01) 0.031 2.919 (1.1188–7.17) 0.019
PT, prothrombin time; INR, international normalized ratio.

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Fig. 3. Correlation between serum PIVKA-II and HBV DNA. There was a negative correlation between the serum HBV DNA and the serum
PIVKA-II levels in (a) chronic hepatitis patients (r = −0.082; P = 0.667), (b) cirrhosis patients (r = 0.019; P = 0.921); (c) HBeAg-negative
HCC patients (r = −0.166; P = 0.466), (d) HBeAg-positive HCC patients (r = −0.056; P = 0.755).

174 The performance of PIVKA-II in differentiating for early HCC (AUC 0.849; 95% CI, 0.745–0.923) , 183

175 early HCC cases from cirrhosis without HCC controls and slightly improved performance of the overall HCC 184

176 was also better than that of AFP (AUC 0.812; 95% diagnosis (AUC 0.924; 95% CI, 0.876–0.958) (Fig. 2). 185

177 CI, 0.702–0.894 vs. 0.797; 95% CI, 0.686–0.883), with

178 a sensitivity of 69.77% and a specificity of 79.31% 3.5. Correlation between PIVKA-II, AFP serum 186

179 at a cut-off of 21 mAU/ml. For AFP, sensitivity and levels and HCC pathological characteristics 187

180 specificity for a cut-off of 7.66 ng/ml were 75.86% and

181 79.07%, respectively. The combination of PIVKA-II In the HCC group, the PIVKA-II serum level was 188

182 and AFP slightly improve the diagnostic performance significantly higher in moderately/poorly differenti- 189
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6 J. Wu et al. / Diagnostic value of serum PIVKA-II levels for BCLC early HCC and correlation with HBV DNA

190 ated HCC. In the tumor size group, the PIVKA-II in distinguishing patients with HCC from the pa- 234

191 serum level showed significant differences between tients with nonmalignant disease. For the diagnosis 235

192 any two subgroups. In the BCLC staging group, the of early HCC and the overall HCC, the combination 236

193 PIVKA-II serum level was significantly higher in the of PIVKA-II and AFP slightly improve the diagnos- 237

194 early stage and late stage compared to the very early tic performance. In addition, the PIVKA-II serum level 238

195 stage group. In the number of nodules group, the > 166 mAU/ml was an independent risk factor for vas- 239

196 PIVKA-II and AFP serum level had no significant dif- cular invasion. We found a negative association be- 240

197 ferences. The AFP serum level showed no significant tween serum PIVKA-II and serum HBV DNA levels. 241

198 differences in the tumor size group, tumor differentia- PIVKA-II was found originally in patients with 242

199 tion group and BCLC staging group (Table 3). HCC by Liebman in 1984 [17]. Prothrombin is usu- 243

ally synthesized by the liver in the body. The Gla 244

200 3.6. Predictive factors for vascular invasion region, one of the functional domains has 10 γ- 245

carboxyglutamic acid residues. When one or more 246

201 In this study, we collected the vascular invasion re- residues are not fully carboxylated as gamma-carboxy- 247

202 sult of 91 HCC patients in, which 31 patients have vas- glutamic acid in the absence of vitamin K or the pres- 248

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203 cular invasion. As summarized in Table 4, the PIVKA- ence of its antagonist inhibiting vitamin K-dependent 249

204 II serum level and Direct Bilirubin were statistically carboxylase activity, PIVKA-II is generated with a loss 250

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205 significant predictors of vascular invasion in univariate of coagulation activity. Although the basic mechanism 251

analysis. On multivariate analysis, a PIVKA-II level > of PIVKA-II production has not been fully clarified,

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206 252

207 166 mAU/ml (OR 2.997; 95% CI, 1.217–7.381; P = there are various factors such as vitamin K and γ-
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208 0.017) and a Direct Bilirubin level > 6.05 umol/l (OR glutamyl carboxylase may contribute to the production 254

209 2.919; 95% CI, 1.1188–7.17; P = 0.019) were the in- of PIVKA-II [18–20]. 255

dependent predictors of vascular invasion. In recent years, many studies were conducted in
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210 256

Asian countries, and proved the PIVKA-II had an ex- 257

3.7. The serum level of HBV DNA and he association cellent performance on the diagnosis of HCC. Our re- 258
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211

212 of serum PIVKA-II and HBV DNA sults are consistent with them [7,21–25]. In this study, 259

the serum levels of PIVKA-II and AFP in serum sam- 260

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213 In the chronic hepatitis group, there is no correlation ples were measured in 143 HCC patients, 37 patients 261

214 between serum PIVKA-II and serum HBV DNA (n = with chronic hepatitis, 43 patients with liver cirrho- 262
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215 30, r = −0.082; P = 0.667). In the cirrhosis group, sis and 51 healthy subjects. The results showed that 263

216 there is no correlation between serum PIVKA-II and PIVKA-II was more sensitive and specific than AFP in 264
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217 serum HBV DNA (n = 30, r = 0.019; P = 0.921). the diagnosis of HCC, and its consistency with the gold 265

218 In HCC patients, we collected the serum level of standard was better than that of AFP, included early 266
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219 HBV DNA in 68 patients among 143 HCC patients. HCC. The combination of the AFP and PIVKA-II 267

220 We detected a negative association between serum could compensate for the deficiency of single marker. 268
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221 PIVKA-II and serum HBV DNA levels in the HBeAg- In different clinic-pathologic features, the performance 269

222 negative HCC group (n = 34, r = −0.166; P = of PIVKA-II was still better than AFP. It is worth not- 270

223 0.466), but not in the HBeAg-positive HCC patients ing that according to the cut-off levels (40 mAU/ml 271

224 group (n = 34, r = −0.056; P = 0.755) (Fig. 3). for PIVKA-II), 8 cases of 19 patients with very early 272

225 In the HCC group, there is no correlation between stage and 16 cases of 29 patients with early stage had 273

226 serum PIVKA-II and serum HBV DNA (n = 68, r = elevated PIVKA-II levels. In the very early and early 274

227 −0.031; P = 0.803). HCC group, PIVKA-II has the sensitivity of 58.54% 275

and the specificity of 82.61%, respectively. In this ex- 276

periment, the sensitivity of PIVKA-II to early and very 277

228 4. Discussion early HCC is still not ideal, may be related to too few 278

cases, or we may observe only a single result. Contin- 279

229 In this study, we evaluated the performance of uous monitoring of serum PIVKA-II levels may be im- 280

230 PIVKA-II for the diagnosis of HCC and explored portant to the diagnosis of early HCC. We found the 281

231 the relationship between PIVKA and different clinic- correlation between serum PIVKA-II level and several 282

232 pathologic features. Our study showed that the serum HCC prognostic factors, such as tumor size, tumor dif- 283

233 PIVKA-II level had a better performance than AFP ferentiation and BCLC staging. We detected a negative 284
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J. Wu et al. / Diagnostic value of serum PIVKA-II levels for BCLC early HCC and correlation with HBV DNA 7

285 association between serum PIVKA-II and serum HBV used as a screening biomarker for HCC in high risk 336

286 DNA levels. population. Moreover, we found that high PIVKA-II 337

287 Some studies have shown that persistent HBV infec- serum levels are significantly associated with the pres- 338

288 tion may be the main cause of liver cancer. HBV in- ence of vascular invasion and other pathological char- 339

289 fection may be related to liver cell damage and can- acteristics. 340

290 cer, vascular proliferation and cancer tissue infiltra-

291 tion have been HBV-related [26].Recent studies have
292 shown that HBV-DNA load is closely related to the Acknowledgments 341
293 recurrence of HCC, so it is important to detect HBV-
294 DNA in the blood of patients [27,28]. However, in
This work was supported by the Hunan Science and 342
295 this study, we detected a negative association between
296 serum PIVKA-II and serum HBV DNA levels. The Technology Project (Grant No. 2014FJ3096). 343

297 reason may be that persistent infection of HBV causes

298 normal function of liver cells, causing abnormal eleva-
299 tion of PIVKA-II. Conflict of interest 344

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300 More and more studies quested the accuracy of
301 PIVKA-II in European patients [29–31], with differ- The authors declare no competing financial inter- 345

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302 ent demography and the etiology of liver diseases from ests. 346

Asian patients. These studies also proved PIVKA-II

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303

304 was more sensitive than AFP for differentiating HCC fv

305 from patients with cirrhosis or chronic hepatitis. The References 347
306 present study showed that the PIVKA-II level was an
independent predictor of vascular invasion and high
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