Scientific context:
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the fourth leading cause of cancer death (1). More than 800,000 new HCC cases are diagnosed annually, and more than 800,000 patients die each year (2). It develops in a cirrhotic liver in about 90% of cases, appearing rarely on healthy livers or with non-cirrhotic chronic liver diseases (3).
Curative treatments such as hepatic resection, liver transplantation and percutaneous ablation are offered in only 30-40% of patients (4). Therefore, the majority of patients receive palliative care to increase survival. Treatments include transarterial chemoembolization (TACE), transarterial radioembolization (TARE), systemic therapies with chemo or molecular targeted therapies (sorafenib and regorafenib).
Currently, serum alpha-fetoprotein (AFP) is the most widely used marker for diagnosing HCC. However, with a cut-off value of 20 ng/mL, the sensitivity of AFP is only 60%, and therefore AFP alone should not be used for screening (5). Indeed, AFP levels are not elevated in 80% of patients with small tumors (6, 7). On the other hand, AFP levels can be increased in patients with chronic liver disease (e.g. hepatitis) (8). Furthermore, the use of AFP in HCC surveillance remains controversial (9).
Progastrin is an intracellular protein that is, or not, maturated into gastrin. When progastrin is maturated into gastrin, it is released from the cells. When gastrin is produced by the G cells of the stomach antrum, it plays its role to control acidic secretions during digestion. If progastrin is not maturated into gastrin, it is released from the cells as such and named hPG80. This only happens in tumor cells: progastrin becomes a circulating protein, hPG80, which can be detected in the blood of cancer patients.
The expression of the progastrin gene, GAST, is frequently increased, at early stages of tumor development, especially in colorectal cancer (but also in other cancers such as stomach, pancreatic, lung or ovarian cancer) (10). Several signaling pathways have been involved in this process. In particular, activation of the Wnt/β-catenin pathway leads to overexpression of GASTand is involved in hepatic regeneration and in the transcriptional control of the metabolic compartmentalization of hepatic functions. Three types of liver tumors are associated with an aberrant activation of the Wnt/β-catenin pathway: hepatoblastoma, HCC and hepatocellular adenoma. In this context, hPG80 dosage might be used for early diagnosis of HCC.
hPG80, a new blood based biomarker
Non Pathologic Condition
Progastrin is not found in the blood
of healthy people.
When progastrin is maturated into gastrin, it is released from the cells.
When gastrin is produced by the G cells of the stomach antrum, it plays its role to control acidic secretions during digestion.
Objective
Pathologic Condition
hPG80 is detected in the blood
of cancer patients.
When progastrin is not maturated into gastrin, it is released from the cells as such and named hPG80.
This only happens in tumor cells, whatever the tumor cell: progastrin becomes a circulating protein, hPG80, which can be detected in the blood of cancer patients.
Objectives:
-
Evaluate the value of hPG80 blood levels in monitoring of treatment response and recurrence in hepatocellular carcinoma patients.
-
Examine whether hPG80 outperforms AFP to diagnose and monitor the disease.
-
Analyze whether hPG80 levels were influenced by inflammation, assessed by CRP concentration.
Patients:
The hepatocellular carcinoma (HCC) cohort (PRO-HCC) came from the CHU (Centre Hospitalier Universitaire) Montpellier biobank (BB-0033-00031; the “Liverpool” collection; DC 2014-2328; AC 2014-2335; Montpellier, France).
PRO-HCC is a cohort of 84 patients with HCC, managed with local or systemic treatments (nevaxar, tepotinib, regorafenib, nivolumab, anti-FGR or carbozantinib), including molecular targeted agents (“Liverpool” collection).
Results:
5.1
hPG80 is detected at all stages
Figure 2.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort at progression vs remission.
(A) All patients (n=84): Changes in median hPG80 levels from baseline (11.54 pM (IQR: 3.25 pM-28.28 pM)), to progression (15.71 pM (IQR:6.33-37.26 pM)), or remission (1.99 pM (IQR: 0.00-8.30 pM)).
(B) Patients with normal alfa-fetoprotein (AFP) value (n=32): Changes in median hPG80 levels from baseline (14.16 pM (IQR: 7.56 pM-42.34 pM)), to progression (18.33 pM (IQR: 11.71 pM-53.70 pM)), or remission (1.47 pM (IQR: 0.21 pM-4.44 pM)).
Figure 1.
hPG80 levels at different disease stages (focal, n=23; locally advanced, n=42; metastatic, n=19) and at disease remission after treatment (n=32).
In order to simplify the reading of the graph, only statistically significant differences were shown on the graph.
All the other comparisons were tested and none of them were significant.
The study cohort comprises 84 patients with HCC at different disease stages: focal (n=23); locally advanced (n=42), metastatic (n=19) and at disease remission after treatment (n=32).
As shown in Figure 1 and 2A, hPG80 was detected in the blood of HCC patients whatever the stages.
Patients in remission after disease management had lower hPG80 levels compared to those with active cancers.
5.2
Comparison between hPG80 and AFP
Figure 3.
hPG80 and AFP levels in all HCC patients.
5.3
Diagnostic performance of hPG80 in HCC patients
Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic discriminative accuracy of hPG80 levels in HCC patients compared to healthy blood donors control group.
As shown on Figure 3, hPG80 levels displayed high predictive significance, with an area under the curve (AUC) value of 0.85 (95% CI: 0.79-0.91; p< 0.0001) when compared to healthy blood donors.
Figure 4.
Diagnostic discriminative accuracy of hPG80 in patients with HCC compared to 137 healthy blood donors (age 18-25 years old) using Receiver Operating Characteristics (ROC) curve analysis.
5.4
hPG80 and AFP kinetics in HCC patients receiving cancer treatment
Individual concentration versus time curves of hPG80 evolved consistently with disease activity and AFP kinetics in most patients. This is illustrated by seven typical patients profiles (Figure 5, 6 and 7).
Figure 5.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort.
Longitudinal kinetics of alfa-fetoprotein (AFP) and hPG80 in 4 typical HCC patients during treatments.
Figure 6.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort.
Illustrative hPG80 longitudinal changes around and during disease management (baseline; remission; progression), with associated imaging obtained at the same times (multifocal liver involvement at baseline; remission after treatment with nivolumab; new liver lesions on ultrasound at progression) in a typical patient.
Figure 7.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort with imaging.
Longitudinal kinetics of alfa-fetoprotein (AFP) and hPG80 during treatments in 2 typical HCC patients, with consistent imaging findings.
The AFP of the patient in panel A was not informative due to low concentration below the upper limit-of-normal 20 ng/ml cut-off.
5.5
hPG80 and AFP kinetics in HCC patients receiving cancer treatment
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the fourth leading cause of cancer death (1). More than 800,000 new HCC cases are diagnosed annually, and more than 800,000 patients die each year (2). It develops in a cirrhotic liver in about 90% of cases, appearing rarely on healthy livers or with non-cirrhotic chronic liver diseases (3).
Curative treatments such as hepatic resection, liver transplantation and percutaneous ablation are offered in only 30-40% of patients (4). Therefore, the majority of patients receive palliative care to increase survival. Treatments include transarterial chemoembolization (TACE), transarterial radioembolization (TARE), systemic therapies with chemo or molecular targeted therapies (sorafenib and regorafenib).
Currently, serum alpha-fetoprotein (AFP) is the most widely used marker for diagnosing HCC. However, with a cut-off value of 20 ng/mL, the sensitivity of AFP is only 60%, and therefore AFP alone should not be used for screening (5). Indeed, AFP levels are not elevated in 80% of patients with small tumors (6, 7). On the other hand, AFP levels can be increased in patients with chronic liver disease (e.g. hepatitis) (8). Furthermore, the use of AFP in HCC surveillance remains controversial (9).
Progastrin is an intracellular protein that is, or not, maturated into gastrin. When progastrin is maturated into gastrin, it is released from the cells. When gastrin is produced by the G cells of the stomach antrum, it plays its role to control acidic secretions during digestion. If progastrin is not maturated into gastrin, it is released from the cells as such and named hPG80. This only happens in tumor cells: progastrin becomes a circulating protein, hPG80, which can be detected in the blood of cancer patients.
The expression of the progastrin gene, GAST, is frequently increased, at early stages of tumor development, especially in colorectal cancer (but also in other cancers such as stomach, pancreatic, lung or ovarian cancer) (10). Several signaling pathways have been involved in this process. In particular, activation of the Wnt/β-catenin pathway leads to overexpression of GAST and is involved in hepatic regeneration and in the transcriptional control of the metabolic compartmentalization of hepatic functions. Three types of liver tumors are associated with an aberrant activation of the Wnt/β-catenin pathway: hepatoblastoma, HCC and hepatocellular adenoma. In this context, hPG80 dosage might be used for early diagnosis of HCC.
Non Pathologic Condition
hPG80 is not found in the blood
of healthy people.
When progastrin is maturated into gastrin, it is released from the cells.
When gastrin is produced by the G cells of the stomach antrum, it plays its role to control acidic secretions during digestion.
Objective
Pathologic Condition
When progastrin is not maturated into gastrin, it is released from the cells as such and named hPG80.
This only happens in tumor cells, whatever the tumor cell: progastrin becomes a circulating protein, hPG80, which can be detected in the blood of cancer patients.
hPG80 is detected in the blood
of cancer patients.
-
Evaluate the value of hPG80 blood levels in monitoring of treatment response and recurrence in hepatocellular carcinoma patients.
-
Examine whether hPG80 outperforms AFP to diagnose and monitor the disease.
-
Analyze whether hPG80 levels were influenced by inflammation, assessed by CRP concentration.
The hepatocellular carcinoma (HCC) cohort (PRO-HCC) came from the CHU (Centre Hospitalier Universitaire) Montpellier biobank (BB-0033-00031; the “Liverpool” collection; DC 2014-2328; AC 2014-2335; Montpellier, France).
PRO-HCC is a cohort of 84 patients with HCC, managed with local or systemic treatments (nevaxar, tepotinib, regorafenib, nivolumab, anti-FGR or carbozantinib), including molecular targeted agents (“Liverpool” collection).
5.1
hPG80 is detected at all stages
Figure 2.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort at progression vs remission.
(A) All patients (n=84): Changes in median hPG80 levels from baseline (11.54 pM (IQR: 3.25 pM-28.28 pM)), to progression (15.71 pM (IQR:6.33-37.26 pM)), or remission (1.99 pM (IQR: 0.00-8.30 pM)).
(B) Patients with normal alfa-fetoprotein (AFP) value (n=32): Changes in median hPG80 levels from baseline (14.16 pM (IQR: 7.56 pM-42.34 pM)), to progression (18.33 pM (IQR: 11.71 pM-53.70 pM)), or remission (1.47 pM (IQR: 0.21 pM-4.44 pM)).
Figure 1.
hPG80 levels at different disease stages (focal, n=23; locally advanced, n=42; metastatic, n=19) and at disease remission after treatment (n=32).
In order to simplify the reading of the graph, only statistically significant differences were shown on the graph.
All the other comparisons were tested and none of them were significant.
The study cohort comprises 84 patients with HCC at different disease stages: focal (n=23); locally advanced (n=42), metastatic (n=19) and at disease remission after treatment (n=32).
As shown in Figure 1 and 2A, hPG80 was detected in the blood of HCC patients whatever the stages.
Patients in remission after disease management had lower hPG80 levels compared to those with active cancers.
5.2
Comparison between hPG80 and AFP
Figure 3.
hPG80 and AFP levels in all HCC patients.
5.3
Diagnostic performance of hPG80 in HCC patients
Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic discriminative accuracy of hPG80 levels in HCC patients compared to healthy blood donors control group.
As shown on Figure 3, hPG80 levels displayed high predictive significance, with an area under the curve (AUC) value of 0.85 (95% CI: 0.79-0.91; p< 0.0001) when compared to healthy blood donors.
Figure 4.
Diagnostic discriminative accuracy of hPG80 in patients with HCC compared to 137 healthy blood donors (age 18-25 years old) using Receiver Operating Characteristics (ROC) curve analysis.
5.4
hPG80 and AFP kinetics in HCC patients receiving cancer treatment
Individual concentration versus time curves of hPG80 evolved consistently with disease activity and AFP kinetics in most patients. This is illustrated by seven typical patients profiles (Figure 5, 6 and 7).
Figure 5.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort.
Longitudinal kinetics of alfa-fetoprotein (AFP) and hPG80 in 4 typical HCC patients during treatments.
Figure 6.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort.
Illustrative hPG80 longitudinal changes around and during disease management (baseline; remission; progression), with associated imaging obtained at the same times (multifocal liver involvement at baseline; remission after treatment with nivolumab; new liver lesions on ultrasound at progression) in a typical patient.
Figure 7.
hPG80 kinetics in patients receiving cancer treatments in PRO-HCC cohort with imaging.
Longitudinal kinetics of alfa-fetoprotein (AFP) and hPG80 during treatments in 2 typical HCC patients, with consistent imaging findings.
The AFP of the patient in panel A was not informative due to low concentration below the upper limit-of-normal 20 ng/ml cut-off.
5.5
hPG80 and AFP kinetics in HCC patients receiving cancer treatment
Figure 8.
Impact of CRP on hPG80 levels in patients with cancer. Baseline hPG80 concentrations versus C reactive protein levels (CRP) in the PRO-HCC cohort.
As shown on Figure 8, we found no link between hPG80 and inflammation status, assessed by CRP concentration, suggesting that, if any, impact of inflammation is probably limited.
hPG80 is detected in the blood of HCC patients whatever the stage and remission is associated to lower levels of hPG80.
Upon treatment, hG80 follows disease evolution and witnesses treatment efficacy and recurrence.
Therefore, these data support the potential use of hPG80 as a biomarker for HCC patient follow-up.
In addition, we showed that hPG80 is a better biomarker than AFP to detect HCC.
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