ClinicalChemistry 42:8

1263-1269 (1996)

Differential diagnosis between hepatocellular

carcinoma and cirrhosis through a discriminant
function based on results for serum analytes

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GIUSEPPE CASTALDO,’ GIovtI’INGELo ORIANI,1 MARIA MARINELLA LOFRANO,1 LUCIA CIMIN0,2
MARCO TOPA,2 GABRIELE BUDILLON,2 FRANCESCO SALVATORE,1 and LUCIA SACCHErrIl,*

We applied a multivariate analysis to a large series of serum in the evolution of chronic liver diseases from cirrhosis to
biochemical tests in an attempt to identi1y a function that HC.
could efficiently discriminate cirrhosis from hepatocellular
carcinoma (HG). We analyzed two successive temporal LNDENG TERMS: a-fetoprotein#{149}alkaline phosphatase . lactate

cohorts (1987-90; 1991-94) of HC and cirrhotic patients, dehydrogenase . ‘y-gbutamyltransferase . aspartate aminotrans-
all histologically classified (first cohort: 69 cirrhosis and 39 ferase #{149}
isoenzymes copper #{149}
#{149} statistics
HG; second cohort: 66 cirrhosis and 38 HC). Using data
from the first temporal cohort of patients, we obtained a
Hepatocebbubar carcinoma (I-IC), one of the most frequent
discriininant function based on seven serum analytes: a-fe-
human tumors [1], commonly (in 95% of cases) evolves from
toprotein, the hepatic isoenzyme of alkaline phosphatase,
cirrhosis, particularly in areas such as Southern Italy that have a
lactate dehydrogenase isoenzyme 5, total ‘y-glutamyltrans-
high incidence of hepatitis C and B viruses [2]? Hepatitis B virus
ferase (GGT), GGT isoforms complexed with low-density
is carcinogenic [3], and the C virus has been implicated in the
lipoprotein, aspartate aminotransferase, and copper. The
pathogenesis of liver cancer [3, 4]. Because of the evolution from
same panel of anabytes emerged when the second cohort
chronic hepatitis of various origins to, in most cases, cirrhosis
was tested and also when both cohorts were tested to- and then liver cancer, the need often arises to differentiate liver
gether. In the two successive cohorts (total, 212 patients) cirrhosisfrom HC. Furthermore, because HC is frequently
with a prevalence of cirrhosis vs HC of -2:1, the discrimi- superimposed on preexisting cirrhosis, monitoring cirrhotic
nant function correctly classified 93% of cases, the highest patients for early recognition of neoplasia is essential for opti-
percentage of correct classification of the two diseases mum treatment of HG. Several diagnostic procedures used thus
obtained so far by laboratory approaches. Validation with far have proved to be less than satisfactory. Computed tomog-
the jackknife reallocation statistical algorithm confirmed raphy has a low sensitivity in detecting neoplastic evolution in
these results. In addition, of six patients with liver cirrhosis cirrhotic patients [5]; similarly, magnetic resonance imaging has
for whom we had the opportunity of following up and bow diagnostic efficiency for correctly classifying malignant vs
observing the evolution to HG, five were classified as HC at nonmalignant liver diseases [6, 7]. In other cases, the instrumen-
diagnosis by the multivariate discnminant analysis; i.e., tal approaches may be more sensitive but are based on invasive
discriminant analysis provided a diagnostic bead time of procedures, such as ultrasound scanning-guided fine-needle
6-12 months over histology. This discriminant function, aspiration [8]. Finally, the clotting disorders typical of advanced
based on easy-to-perform serum biochemical tests, may cirrhosis often preclude liver biopsy via baparoscopy.
help solve a fundamental problem of differential diagnosis Within the realm of biochemical signals, high serum con-
centrations of cs-fetoprotein (AFP) are claimed to be strongly
predictive of HG [9], but AFP has a low diagnostic sensitivity
(-50%) and is thus not a great aid in differential and early
Dipartimento di Biochimica e Biotecnologie Mediche, Universit3 di Napoli
“Federico II,” via S.Pansini 5,1-80131 Naples, Italy, and CEINGE Biotecnologie
Avanzate, Naples, Italy.
2 Cattedra di Gasnoenterologia, Facoltl di Medicina e Chirurgia, Universith
di Napoli “Federico II.” Nonstandard abbreviations: HG, hepatocellular carcinoma; AFP, a-fetopro-
“Author for correspondence. Fax + 39 81 746 36 50. rein; MDA, multivariate discrimmant analysis; LD, lactate dehydrogenase; AP,
Received December 22, 1995; accepted April 1, 1996. alkaline phosphatase; and GGT, y-glutamyltransferase.

1263
1264 Gastaldo et al.: Discriminant function differentiating between hepatocellubar carcinoma and cirrhosis

diagnosis. Similar conclusions can be drawn for isoforms of AFP ANALYTICAL METHODS
[10, ii] and for various other biochemical signals [12-15]. Serum from each patient was collected and processed within 2 h
After a bong-term study, we recently obtained good results in for the analysisof lactatedehydrogenase (LD) and LD isoen-
differentiating between malignant and nonmalignant ascitesin zyrnes, AFP, total alkaline phosphatase (AP), AP isoenzymes
patients with ascites of unknown origin [16] and between (bone, hepatic, biliary, and intestinal), total y-glutamyltrans-
primary and secondary liver cancer [17]. In both cases we used ferase (GGT), GGT isoenzymes, 5 ‘-nucleotidase, leucine ami-
associations of biochemical analytes selected via multivariate nopepudase, cholinesterase, iron, ferritin, and copper. In addi-
discriminantanalysis(MDA). tion, a panel of other hematochemical indices was also
Well before undertaking these studies, we started to analyze examined: aspartate aminotransferase, abanine aminotransferase,
a large variety of biochemical analytes and subjected the results total bilirubin, cholesterol, triglycerides, glucose, and urea. Iron,
to MDA to select the variables that could best differentiate total serum enzyme activities (U/L), and the other hemato-
between cirrhosis and HG. We wanted to avoid recourse to liver chemical indiceswere evaluated at 37 #{176}G with a Hitachi 737

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biopsy, which is considered the “gold standard” for differenti- automated analyzer (Boehringer Mannheim, Mannheim, Ger-
ating between these two conditions. Because in a high percent- many) and Boehringer reagents. Serum AFP and ferritin were
age of cases HG has been described as a multicbonal neoplasia evaluated with an ELISA method on the Hitachi ES 300
[18], we used MDA also to select a panel of biochemical tests automated analyzer with reagents from the same company.
that, by assessing various different biochemical abnormalities, Serum LD and AP isoenzymes were analyzed after zone elec-
could discriminate HG from cirrhosis. trophoresiswith materialsfrom Helena Labs. (Beaumont, TX).
Serum GGT isoenzymes were analyzed with a previously de-
Patients and Methods scribed cellulose acetate electrophoretic procedure [21, 22], and
the GGT isoforms complexed with low-density lipoproteins
PATIENTS
were analyzed with the precipitation method previously de-
All the new patients admitted to the Hepatology Division of our
scribed [23, 24]. Serum copper was analyzed by atomic absorp-
Medical School between 1987 and 1994 (first cohort, 1987-90;
tion spectrometry (flame method; samples predibuted with 10
second cohort, 1991-94) were enrolled in the study. The
mL/L nitric acid) at 324.8 nm (Perkin-Elmer, Norwalk, CT).
procedures used in our study were approved by the Ethics
The same methods were used to analyze the various bio-
Committee of our Medical School. Histological diagnoses were
chemical indices during the whole period of the study. Inaccu-
obtained for all patients, as were the results of other conven-
racy, checked by using both intra- and interlaboratomy quality-
tional clinical and instrumental approaches. Two homogeneous
control systems, was practically constant: GVs were <5.0% for
groups of patients were successively enrolled. The first cohort of
all analytes except the GGT, AP, and LD isoenzymes, for which
patients included 39 with HG and 69 with cirrhosis. The HG
the GVs were always <10%.
cases were staged according to Okuda et al. [19], a three-stage
classification based on the presence of ascites, serum albumin (>
STATISTICAL ANALYSES
or <30 gIL), serum bilirubin (> or <30 mg/L), and tumor size
We applied the statistical procedure previously used to select a
(<or >50% of the whole liver area). Seventeen of these patients
panel of ascitic biochemical indices to discriminate malignant
were at Okuda stage 1, 16 at stage 2, and 6 at stage 3. The 69
ascites from ascites that was due to liver cirrhosis or to HG [16].
cirrhotic patients were staged according to Child and Turcotte We have also used this procedure to select a panel of serum
[20], i.e., a three-stage classification based on the presence of biochemical indices that discriminates HG from secondary liver
encephabopathy and ascites and various values for serum biliru- cancer [17]. The distribution of all the analyte values in HG and
bin, albumin, and prothrombin activity (the Quick test). Of cirrhosis patients were compared by the nonparametric Mann-
these patients, 37 were at Ghibd stage A, 27 at stage B, and 5 at Whitney test.After evaluating the diagnostic sensitivity-i.e.,
stage C. The second cohort recruited consisted of 38 HG true positive/(true positive + false negative), diagnostic speci-
patients (Okuda 1, 17; Okuda 2, 18; and Okuda 3, 3) and 66 ficity-i.e., true negative/(true negative + falsepositive)and
cirrhotic patients (Child A, 44; Child B, 19; Child C, 3). Of the diagnostic efflciency-(true positives + true negatives)/grand
total of77 HG, 55 (73%) were hepatitis C-positive and 14(18%) total of tested subjects-as described by Galen and Gambino
were hepatitis B surface antigen-positive. [25], we used receiver-operating characteristic (ROG) plots[26]
All 77 cases of HG (total of both cohorts) were superimposed to determine the best cutoff values for the analytes and for the
on liver cirrhosis. Most of the HG were also classified on the discriminant function (see below) [26]. To compare the ROG
basis of the number of liver lesions (1 lesion, 35 HG; 2 lesions, plots, we compared the areas under the curves [26].
10 HG; 3 or 4 lesions, 6 HG; diffuse HG, 13 cases)and the The fitting of all the analytes to a gaussian distribution was
diameter (or the sum of diameters for multiple-lesion HG) of checked with the Shapiro-Wilks method. Most of the variables
the neoplastic lesion (<5 cm, 12 HG; 5-10 cm, 16 HG; >10 cm, deviated significantly from gaussian distribution in original
16 HG). The number of cases included in this study does not scale; in subsequent procedures, therefore, we used the natural
reflect the prevalence of the two diseases in our geographical logarithm (In) of the results for all the anabytes. The ln
area, but does reflect the prior prevalence of cirrhosis and HG transformation of the results yielded a gaussian distribution for
(-2:1) seen in a highly specialized Hepatology Division in the all the analytes except AFP. In any case, however, MDA is
Naples area. reasonably robust against deviations from gaussian distribution.
 Chemisi-,y
Clinical 42, No. 8, 1996 1265

Table 1. Serum analytes with a significantly different distribution (P <0.01, Mann-WhItney U test) between patients
affected by cirrhosis and those affected by hepatocarcinoma (HC) In the first cohort (1987-90).
Cirrhosis (n = 69) HC

Variable Unit Mean” SD P n Mean” SD

Albumin g/L 38.5” 4.6 0.0008 38 34.8 4.6
Copper .tmol/L 103.5 29.6 0.0011 37 122.9 34.7
5-NT U/L 16.8 17.5 <0.0001 37 27.9 22.1
LAP U/L 47.4 40.6 0.0006 38 57.4 24.3
AST U/L 87.7 63.0 0.0036 39 218.0 468.4
LD U/L 170 58.4 <0.0001 39 422.6 734.6
L05 IJ/L 16.6 12.1 <0.0001 39 54.2 50.3

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AP ti/L 287.0 154.5 <0.0001 38 505.0 336.1
Hepatic AP ti/L 42.0 44.8 <0.0001 37 133.0 101.8
AFP g/L 34.0’’ 63.4 <0.0001 39 22537.0 77789.9
CEA g/L 3312 2.9 0.0045 38 8.0 14.8
GGT ti/L 120.0 289.9 <0.0001 39 171.0 134.2
GGT-LDL ti/L 15.7 35.2 <0.0001 35 51.9 70.8
LD4/LD5 0.83 0.32 0.0034 39 0.67 0.34
5’NT, 5-nucleotidase; LAP, leucine aminopeptidase; AST, aspartate aminotransferase; CEA, carcinoembryonic antigen.
a Geometric mean.
n = 68.

The first cohort of patients was used to select, among all the results of the MDA on the first cohort of patients. First, we used
variables, the linear combination that best discriminated HG the jackknife procedure, in which one patient at a time is
from cirrhosis. To avoid introducing into the model any vari- excluded, the rule is rederived from the remaining data, and the
ables that were correlated among themselves [27], we checked rederived rube is used to classify the excluded patient [29]. This
the correlation between all pairs of anabytes by calculating the algorithm removes much of the bias of the simple reallocation
Pearson r coefficient. Of the highly correlated variables method [27]. Second, we tested the validity of the discriminant
(r >0.50), only the most significant one was used for further function prospectively with 104 patients (38 HG and 66 cirrho-
analysis[28]. The MDA was carried out stepwise with use of the sis) recruited later (199 1-1994).
minimum Wilks’ lambda (ratio between within-groups sum of After the positive check of the validity of the first discrimi-
squares and the total sum of squares) to evaluate the group nant function, we calculated a second function to cover the
discrimination. At the first step, the variable with the greatest overall population, i.e., a pool of the two cohorts studied. The
discriminant power was selected; at each of the following steps, validity of this second MDA was also verified by the jackknife
the selection criteria were reevaluated for all variables not in the reallocation method, which confirmed the correct classification
model, and the one with the largest acceptable criterion value rate of the MDA.
was included. The variables previously selected were reevaluated
to check if they met the removal criterion. Any variable that met Results
this criterion was removed, and the variable selection was In this long-term study of cirrhotic and HG cases we measured
concluded when no more variables met entry or removal a large variety of biochemical tests, including all the major
criteria. markers used so far, to differentiate between the two phases of
The discriminant score, calculated for each patient on the chronic liver disease. Table I shows the analytes that were
basis of a linear combination of variables selected by MDA, was significantly different between the two disorders (P <0.01,
used to classify the patients into one of two groups, according to nonparametric Mann-Whitney U-test) for the first cohort of
Bayes’ rule [29], which takes into account not only the proba- patients. Notwithstanding the high significance of the differ-
bility that a case belongs to one of two groups on the basis of the ences in the mean values for all these analytes, there was always
discriminant score (conditional probability) but also the inher- some degree of overlap between the cases of the two clinical
ent probability that the case belongs to one of the two groups in situations, so that no cutoff value efficiently discriminated HG
the absence of any information (prior probability). In our case, from cirrhotic patients. To enhance the discrimination power,
the observed proportions of cases in each group were used as we entered all of the anabytes into the SPSS computer program
estimates of the prior probabilities because we considered our for MDA, after having bog-transformed their measured values;
sample to be representative of the patient population. The we alsospecifieda prevalenceof 2:1 for cirrhosisvs HG. Total
diagnosticsensitivity and specificity of the discriminationfunc- protein, bilirubin, alanine aminotransferase, cholinesterase,
tion were evaluated by taking into account the rate of misclas- iron,LD isoenzymes 2-4, cholesterol,and triglycerides were
sification of this reallocation method. excluded from the Wibks analysis of the MDA because they were
We used two statistical techniques to cross-validate the correlated to other, more significant, variables [28].
1266 Gastaldo et ab. : Discriminant function differentiating between hepatocellular carcinoma and cirrhosis

Table 2. Differential dIagnosis between cIrrhosis and HC by serum bIochemical Indices selected by MDA In two consecutive
cohorts of patients.
1987-90 cohort 1991-94 cohort

Cases correctly classified, no. (%) Cases correctly classified, no. (%)
Cirrhosis HC n” Cirrhosis HC

Cirrhosis 68 67 (98.5) 1 (1.5) 60 58 (96.7) 2 (3.3)

HC 31 3 (9.7) 28 (90.3) 31 5 (16.2)
26 (83.8)
Overall diagnostic efficiency, %“ 96.0 92.3
Discrimiriant score: 0.31 x In copper - 0.23 x In AST + 0.30 X riAFP - 0.50 x In GGT + 0.15 x In GGT isoforms complexed to low- and
very-low-density lipoproteins + 0.81 X In LD5 + 0.69 x InHep AP - 4.53.
AST,aspartate aminotransferase; Hep, hepatic.

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“Only cases with no missing values were entered into the MDA.
b Cutoff = 0.86 (<0.86 = cirrhosis; >0.86 = tIC).

Among the variables inserted, the statistical procedure se- Table 3), 9 cases of HG and 4 cases of cirrhosis were incorrectly
lected serum AFP (gfL), liver AP isoenzyme, LD5, GGT, classified. To evaluate the comparative power of the discrimi-
GGT isoforms complexed with low- and very-low-density ii- nant function in differentiating between HG and cirrhosis, we
poprotein, aspartate aminotransferase, and copper (ji.molIL) for plotted a ROG curve for the discriminant function and for other
a discrilninant function that correctly classified 90.3% of the analytes that had previously been found to be significantly
HG and 98.5% of cirrhotic patients (96.0% diagnostic efficien- different between HC and cirrhosis (see Fig. 2). The best curve
cy). Table 2 shows the numerical values for the discriminant in terms of diagnostic efficiency is clearly the one calculated with
equation, the cutoff selected, and the cases correctly classified the discriminant function reported above. The difference be-
for the two diseases in the first temporal cohort of patients (left tween the area under the curve of this ROC plot and the values
panel). Applying this discriminant function to the second cohort obtained with all the other analytes listed in Table 1 was always
(right panel) of patients admitted to the study yielded a diag- highly significant (P <0.001), demonstrating that the MDA is
nostic efficiency of 92.3%, confirming the results obtained in more efficient than any univariate anabyte.
the first cohort. Finally, we pooled the data of both cohorts, and The diagnostic sensitivity of the MDA score for HG detec-
again confirmed that the overall MDA selected with very high tion is 100% in the HG subgroup with >2 lesions and in the HG
diagnostic efficiency the same analytes previously chosen in the subgroup with total lesion diameter >10 cm. However, the
two separate cohorts of patients. The final equation is reported diagnostic sensitivity for single-lesion HG was 69.2%, and that
in Table 3. for HG with a totallesiondiameter <5 cm was 75%.
To further validate the final discriminant equation, we Figure 3 shows the probability for each patient of being
checked by the jackknife reallocation
it algorithm and again
confirmed its high discriminatory power: diagnostic sensitivity
85.5%; diagnostic specificity 96.9%; and overall diagnostic :
efficiency 93.2%.
The scattergram in Fig. I shows the numerical MDA score ‘
for each patient, classified as cirrhosis or HG on the basis of ...
histology. At the cutoff chosen by the MDA (0.70 as reported in ...

2 #{149}....
dIagnosIs between cirrhosis
Table 3. DIfferential and HC by #{149}:#{149}:::

MDA In the overall population (both cohorts) of patients. #{149}#{149}: #{149}.

1987-94 population #{149}
#{149} ..:#{149}.

cases correctly classified, o . .1.111.8.

no. (%) #{149}
.‘:.
n” Cirrhosis HC -1 #{149}

Cirrhosis 128 124 (97) 4 (3) ::.;.::

HC 62 9(14.5) 53(85.5) -2 #{149}#{149}..#{149}.

Overall diagnostic efficiency, %‘‘ 93.2 .#{149}.

Discriminant score: 0.45 X In copper - 0.50 x In AST + 0.24 x In -3
AFP - 0.48 x InGGT + 0.27 x InGGT isoformscomplexedto
low- and very-low-density lipoproteins + 1.13 X InLD5 + 0.50 X - 4
In Hep AP - 4.54. HC Cirrhosis
AST, aspartateaminotransferase; Hep, hepatic.
Fig. 1. Scattergram of the MDA score attributed to each patient of the
Only cases with no missing values were entered into the MDA. . .
b Cutoff = 0.70(<0.70= cirrhosis; >0.70 = HC). two temporal cohorts combined, classified as cirrhosis or HC by
histology.
 Clinical Chemisiiy 42, No. 8, 1996 1267

% of Cirrhosis Correctly Classified

Table 4. MDA score and probability of being affected by
(Diagnostic Specificity)
100 90 80 70 60 50 40 30 20 10 0
hepatocarclnoma in six cirrhotic patients who evolved to
HC 6-12 months afterMDA.
Case
90
1 2 3 4 5 6
80 MDA score 1.88 0.52 0.81 1.38 2.37 1.22
Probabilityof being affected 95 37 56 84 98 77
li 70 by HC at time of MDA, %

60
Table 4 shows the values of the MDA in these six patients at
ZU) diagnosis, together with the probability each patient at that time

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50
had of being affected by HG, as the Bayesian curve clearly shows
40 MDA0 p (Fig. 3).
GGTL.
a 30 AFPi- S
Discussion
The incidence of HG is increasing in most countries [1], but also
20
treatment of neoplasia is becoming increasingly efficient. The
10 effects are obviously rebated to a timely diagnosis. Because most
HG cases develop after cirrhosis, there is often the need to
0 discriminate between these clinically confounding disorders.
Fig. 2. ROC plot of AFP and GGT isoforms complexed to low- and Imaging and other instrumental techniques are usually invasive
very-low-density lipoproteins (GGTL) as compared with the discriminant or insufficiently sensitive, particularly for small lesions [30, 31];
function obtained after the MDA described for the discrimination for example, one must sample the nodules, particularly HG
between HC and cirrhosis. nodules, by needle biopsy, which can be difficult because very
Histologicalexamination of liver biopsy specimens (gold standard) was used for
small nodules can elude the imaging technology used. More-
diagnosis in all cases.
over, the diagnostic efficiency of the individual biochemical
indices described above ranges over a wide spectrum but never
affectedby either of the two diseases on the basis of the completely discriminates between HG and cirrhosis. The GGT
individual discriminant scores. Thus, by consulting the MDA isoforms complexed with low- and very-low-density lipoprotein
score, one may predict the probability for each individual patient discriminate HG from cirrhosis with a diagnostic efficiency of
of being affected by HG. -85% [22]; 50% of HG are associated with significantly
During the study, we had the opportunity of observing six increased values of serum AFP [9]; and AFP isoforms have a
cases of liver cirrhosis that evolved to HG. The MDA of these diagnostic efficiency of -80% [11]. G-reactive protein is no
patients calculated at diagnosis showed that five of them were more efficient than AFP [15]. Also in the present study, none of
classified as HG and not as cirrhosis; at that time, however, all the biochemical variables evaluated discriminated between HG
the other clinical, histological, and instrumental indicators and cirrhosis satisfactorily because of the barge overlap of values
favored a diagnosis of liver cirrhosis. Only after 6-12 months between the two populations. Therefore, the panel of analytes
did histology show a clear picture of HG in these five patients. included in the discriminantfunction appears so farto be the
best indicatorto discriminatebetween livercirrhosisand HG.
Some cases of HG have a multiclonal origin [18]; thus, the
combination of unrelated variables [27], each reflecting different
0.9
biochemical abnormalities associated with neoplasia, increases
I
0.8

0.7
/ the diagnostic efficiency of the variables in our panel. Fluctua-
tions of LD concentration reflect the impaired glycobytic me-
a
0.6 tabolism in cancer cells [32]; LD isoenzyme 5 is produced
0.5 predominantly by muscle and liverand isincreasedin the serum
a
of HG patients [32]. The fraction of GGT complexed to low-
0.4
and very-low-density lipoprotein (an adjunctive tool with which
0.3 to discriminate HG from cirrhosis) is a signal of the cholestasis
.0
a
.0
0
0.2 associated with HG [22]. The hepatic isoenzyme of AP is
Classified as CirTb,,,/
0. overproduced by neoplastic liver cells [33], and serum copper is
-. #{149},
#{149} increased in HG because of the reduced biliary excretion of the
-4 -3 .2 -1 0 1 2 3 4 ion and the increased production by neoplastic cells of fetal
Dlscriminant Patient Score copper-binding proteins [14]. Finally, the increase in serum AFP
Fig. 3. Relation between the probability of being affected by HC and the in HG patients is due to the reexpression of the related gene,
score obtained from the MDA for each patient. which is usually repressed in adult subjects.
1268 Gastabdo et ab.: Discriminant function differentiating between hepatoceblubar carcinoma and cirrhosis

The panel selected via MDA showed a diagnostic sensitivity patients with cirrhosis: CT sensitivity and specificity in 200
for HG of 85%, higher than or comparable with that of other, consecutive transplant patients. Radiology 1994:193:645-50.
sometimes invasive tools, including instrumental approaches. 6. Kamba M, Suto Y, Kato 1. Chondroitin sulfate iron colloid-en-
hanced MR imaging in patients with hepatocellular carcinoma.
For example, for approximately the same number or fewer cases,
Comparison with CT during arterial portography. Acta Radiol
the diagnostic sensitivity of computed tomography for HG was 1994:35:570-5.
70% [5], that of magnetic resonance imaging ranged between 7. Ferrucci iT. Liver tumor imaging. Cancer 1991:67:1189-95.
80% and 90% [6], and that of cytology by fine-needle aspiration 8. Borzio M, Borzio F, Macchi R, Croce AM, Bruno S, Ferrari A, Servida
biopsy for HG was <85% [34]. E. The evaluation of fine-needle procedures for the diagnosis of
An additional result of our study is the probability plot, focal liver lesions in cirrhosis. i Hepatol 1994:20:117-21.
which allows calculation on the basis of the MDA score of each 9. Fu-Sun V. Kong-Nien S. Epidemiology and early diagnosis of
primary liver cancer in China. Adv Cancer Res 1986:46:85-8.
patient’s probability for being affected by HG. This can help
10. Hirai H, Taketa K. Lectin affinity electrophoresis of alpha-fetopro-
physicians to plan the best therapeutic strategy for each patient,

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tein increased specificity and sensitivity as a marker of hepato-
e.g., invasive diagnostic approaches, further monitoring, ther- cellular carcinoma. i Chromatogr 1992:604:91-4.
apy, and so on. 11. Burditt U, iohnson MM, iohnson Pi, Williams R. Detection of
The MDA panel we present also indicated the presence of hepatocellular
carcinomaspecific
aipha-fetoprotein
by isoelectric
HG in five of the six patients affected by cirrhosis that during the focusing. Cancer 1994:74:25-9.
study evolved to neoplasia. The bead time for this was -6-12 12. Deugnier Y, David V, Leray G, Blayau M, Le Gall iY. Les marqueurs
biologiques du carcinome hepato-cellulaire. Ann Biol Clin 1988;
months ahead of the other diagnostic approaches, including
46:85-8.
histology. Combined with an acceptable diagnostic sensitivity
13. Hachem H, Favre G, Raynal G, Blavy G, Canal P, Soula G. Serum
(75%) of the MDA for HG with a diameter <5 cm, this result is apolipoproteins A-I, A-Il and B in hepatic metastases; comparison
relevant for screening for early diagnosis of HG. Although with other liver diseases: hepatomas and cirrhosis. i Clin Chem
ultrasound and AFP have been proposed for the screening of Clin Biochem 1986;24:161-6.
general populations [9], their cost in a population screening for 14. Guigui B, Mavier P, Lescs MC, Pinaudeau V. Dhumeaux D, Zafrani
HG would be very high [35]. Given that the risk categories for ES. Copper and copper-binding protein in liver tumors. Cancer
HG have been clearly identified, a screening program should be 1988:61:1155- 8.
15. Fabris C, Pirizi M, Soardo G, Falleti E, Pezzetta F, Vitulli D, et al.
limited to these high-risk groups, i.e., subjects with cirrhosis and
Valueofserum C-reactive proteinmeasurement inthe detection
chronic hepatitis from hepatitis B and C viruses. The relatively of hepatocellular carcinoma superimposed on liver cirrhosis. i
low cost of using this noninvasive procedure involving a panel of Cancer Res Clin Oncol 1994;12O:229-32.
biochemical tests could make it a valid contributory tool for HG 16. Castaldo G, Oriani G, Cimino L, Topa M, Mostarda I, Castellano L,
screening. et al. Total discrimination of peritoneal malignant ascites from
cirrhosis- and hepatocarcinoma-associated ascites by assays of
ascitic cholesterol and lactate dehydrogenase. Clin Chem 1994;
In conclusion, with all the caution accorded to generalizations,
40:478-83.
the combination of unrelated biochemical tests selected by the
17. Castaldo G, Oriani G, Cimino L, Topa M, Budillon G, Salvatore F,
MDA as reported here is an efficient tool for the differential Sacchetti L. Discriminant function based on biochemical serum
diagnosis of cirrhosis and HG, and perhaps also for the moni- analytes differentiates hepatocarcinoma from secondary liver
toring of high-risk groups who may be evolving to HG, i.e., for neoplasia. Clin Chem 1995;41:439-43.
the early identification of the neoplasia. 18. Tsuda H, Oda T, Sakamoto M, Hirohashi S. Different pattern of
chromosomal allele loss in multiple hepatocellular carcinomas as
evidence of their muttifocal origin. Cancer Res 1992:52:1504-9.
19. Okuda K, Obata H, Nakajima Y, Ohtsuki T, Okasaki N, Ohnishi K.
Grants from the CNR, Targeted Projects “ACRO” (SP4), and
Prognosis of primary hepatocellular carcinoma. Hepatology 1984;
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