Application of Tumor Biomarkers as Screening Tools in Early Detection of Hepatocellular Carcinoma


avatar Zahra Heidari 1 , 2 , avatar Bita Moudi ORCID 1 , 2 , *

Infectious Diseases and Tropical Medicine Research Center, Zahedan University of Medical Sciences, Zahedan, IR Iran
Department of Histology, School of Medicine, Zahedan University of Medical Sciences, Zahedan, IR Iran

how to cite: Heidari Z, Moudi B. Application of Tumor Biomarkers as Screening Tools in Early Detection of Hepatocellular Carcinoma. Gene Cell Tissue. 2015;2(4):e33012.

1. Embryonic Antigen

1.1. Alpha-Fetoprotein (AFP)

AFP, the most available tumor biomarker, is currently used for early detection of HCC. Serum AFP had a sensitivity of 41% - 65% and specificity of 80% - 94% (13). Alpha-Fetoprotein has a positive rate ranging from 60% to 80%. Furthermore, AFP is positive during pregnancy, embryonic tumors and some gastrointestinal tumors. It is a major biomarker in benign liver diseases and exists in the serum and liver of patients with HCC. When total AFP is 10 - 200 ng/mL, the diagnostic specificity for HCC reaches 100%. Moreover, AFP does not correlate with other biomarkers, thus it can be used as an independent factor for the early diagnosis of HCC (14-16).

2. Proteantigen

2.1. Glypican-3 (GPC3)

GPC3 is a potential marker for HCC. It links to the cell membrane by a glycosylphosphatidylinositol anchor. It is a heparan sulfate proteoglycans that is involved in regulating cell growth. Furthermore, GPC3 can remove tumorigenic growth factors (such as hepatocyte growth factor and vascular endothelial growth factor) from the cell surface and inhibit the growth of HCC (17, 18). There is no correlation between GPC3 expression and AFP level, tumor size and stage (19).

2.2. Heat Shock Protein 70 (HSP70)

HSP70 is a potential marker for HCC. It is expressed when someone is exposed to carcinogens. It is a conserved stress response protein and can promote cells to repair damages. Immunohistochemical staining, showed that the positive rate of HSP70 was 56.3 in HCC (20). Its stain intensity was associated with tumor size and stage. The sensitivity and specificity of HSP70 in detecting HCC was 57.5 and 85%, respectively (21, 22).

3. Cytokines

3.1. Transforming Growth Factor-β1 (TGF-β1)

TGF-β1 is a growth factor involved in the regulation of cell proliferation and immune function. It is expressed in tumor cells. It can inhibit the proliferation of Cytotoxic T Lymphocytes (CTL) and promote the growth of tumor cells. Furthermore, TGF-β1 may be used as an indicator to diagnose HCC related to HBV with sensitivity and specificity of 89.5 and 94.0%, respectively (23-25).

3.2. Vascular endothelial growth factor (VEGF)

VEGF has a vital role in tumor angiogenesis. It can induce new vessel formation and promote tumor metastasis. The level of VEGF is higher in HCC patients than healthy individuals. It has been revealed that the expression of VEGF is correlated with tumor prognosis and recurrence. It seems that overexpression of VEGF is a useful biological marker of tumors (26, 27).

4. Genetic Biomarkers

4.1. Alpha-Fetoprotein mRNA

This is a marker for spreading of HCC in the blood in active HCC cells. It is a predictor for HCC recurrence and has a positive rate of 82.4% in recrudescent patients (14).

4.2. MicroRNAs

These are non-coding RNAs that block translation by inducing the degradation of target mRNAs. MiR-500 is a new biomarker for HCC. It could downregulate liver development and then upregulate cirrhosis (28). Thus, MiR-500 is a promising biomarker of HCC.

5. Enzymes and Isozymes

5.1. Des-γ-Carboxyprothrombin (DCP)

DCP is induced by the absence of vitamin K. Vitamin K-dependent carboxylation system fails and causes the production of DCP in malignant liver cells. Its level is associated with a larger tumor. It is an accurate tumor marker compared with AFP (29, 30).

5.2. Gamma-Glutamyl Transferase (GGT)

This enzyme is secreted by endothelial cells of the bile duct and hepatic Kupffer cells. Its activity increases in HCC tumors. In addition, cholestasis and inflammation can improve the level of GGT. Gamma-Glutamyl Transferase mRNA is widely distributed in liver tissues of HCC patients. Therefore, GGT can be a biomarker for diagnosis of HCC.

5.3. Glutamine Synthetase (GS)

GS induces the synthesis of glutamine. Glutamine is an important energy source for tumor cells. The level of GS increases in patients with precancerous lesions, which can change to advanced-HCC. It has been reported that GS is a new target in development of HCC (specificity 89%; sensitivity 100%) (31, 32).

6. New Discoveries

6.1. Hepatocyte Paraffin 1 (HepPar 1)

This antigen can differentiate between normal and malignant hepatocytes. It is expressed in normal human liver cells. Decreasing expression of HepPar 1 is seen in HCC. It seems that reduction of HepPar 1-positive cells is associated with HCC (33). Therefore, HepPar 1 can be considered as a new valuable marker for the diagnosis of HCC.



  • 1.

    Bosch FX, Ribes J, Borras J. Epidemiology of primary liver cancer. Semin Liver Dis. 1999;19(3):271-85. [PubMed ID: 10518307].

  • 2.

    Njei B, Rotman Y, Ditah I, Lim JK. Emerging trends in hepatocellular carcinoma incidence and mortality. Hepatology. 2015;61(1):191-9. [PubMed ID: 25142309].

  • 3.

    El-Serag HB, Kanwal F. Epidemiology of hepatocellular carcinoma in the United States: where are we? Where do we go? Hepatology. 2014;60(5):1767-75. [PubMed ID: 24839253].

  • 4.

    Franca AV, Elias Junior J, Lima BL, Martinelli AL, Carrilho FJ. Diagnosis, staging and treatment of hepatocellular carcinoma. Braz J Med Biol Res. 2004;37(11):1689-705. [PubMed ID: 15517086].

  • 5.

    Merat S, Malekzadeh R, Rezvan H, Khatibian M. Hepatitis B in Iran. Arch Iran Med. 2000;3(4):192-201.

  • 6.

    Shamszad M, Farzadegan H. Hepatitis B related cirrhosis and hepatocellular carcinoma in Iran. J Irn Med Council. 1982;8:238.

  • 7.

    Takayama T, Makuuchi M, Hirohashi S, Sakamoto M, Yamamoto J, Shimada K, et al. Early hepatocellular carcinoma as an entity with a high rate of surgical cure. Hepatology. 1998;28(5):1241-6. [PubMed ID: 9794907].

  • 8.

    Takayama T, Kosuge T, Yamazaki S, Hasegawa H, Okazaki N, Takayasu K, et al. Malignant transformation of adenomatous hyperplasia to hepatocellular carcinoma. Lancet. 1990;336(8724):1150-3.

  • 9.

    Tsuda H, Hirohashi S, Shimosato Y, Terada M, Hasegawa H. Clonal origin of atypical adenomatous hyperplasia of the liver and clonal identity with hepatocellular carcinoma. Gastroenterology. 1988;95(6):1664-6. [PubMed ID: 2846405].

  • 10.

    Arakawa M, Kage M, Sugihara S, Nakashima T, Suenaga M, Okuda K. Emergence of malignant lesions within an adenomatous hyperplastic nodule in a cirrhotic liver. Observations in five cases. Gastroenterology. 1986;91(1):198-208. [PubMed ID: 3710069].

  • 11.

    Sakamoto M, Hirohashi S. Natural history and prognosis of adenomatous hyperplasia and early hepatocellular carcinoma: multi-institutional analysis of 53 nodules followed up for more than 6 months and 141 patients with single early hepatocellular carcinoma treated by surgical resection or percutaneous ethanol injection. Jpn J Clin Oncol. 1998;28(10):604-8. [PubMed ID: 9839500].

  • 12.

    Hamilton SR, Aaltonen LA. Pathology and genetics of tumours of the digestive system. Lyon: IARC press; 2000.

  • 13.

    Debruyne EN, Delanghe JR. Diagnosing and monitoring hepatocellular carcinoma with alpha-fetoprotein: new aspects and applications. Clin Chim Acta. 2008;395(1-2):19-26. [PubMed ID: 18538135].

  • 14.

    Singhal A, Jayaraman M, Dhanasekaran DN, Kohli V. Molecular and serum markers in hepatocellular carcinoma: predictive tools for prognosis and recurrence. Crit Rev Oncol Hematol. 2012;82(2):116-40. [PubMed ID: 21680198].

  • 15.

    Leerapun A, Suravarapu SV, Bida JP, Clark RJ, Sanders EL, Mettler TA, et al. The utility of Lens culinaris agglutinin-reactive alpha-fetoprotein in the diagnosis of hepatocellular carcinoma: evaluation in a United States referral population. Clin Gastroenterol Hepatol. 2007;5(3):394-402. [PubMed ID: 17368240].

  • 16.

    Kobayashi M, Hosaka T, Ikeda K, Seko Y, Kawamura Y, Sezaki H, et al. Highly sensitive AFP-L3% assay is useful for predicting recurrence of hepatocellular carcinoma after curative treatment pre- and postoperatively. Hepatol Res. 2011;41(11):1036-45. [PubMed ID: 21883741].

  • 17.

    Zittermann SI, Capurro MI, Shi W, Filmus J. Soluble glypican 3 inhibits the growth of hepatocellular carcinoma in vitro and in vivo. Int J Cancer. 2010;126(6):1291-301. [PubMed ID: 19816934].

  • 18.

    Capurro MI, Xiang YY, Lobe C, Filmus J. Glypican-3 promotes the growth of hepatocellular carcinoma by stimulating canonical Wnt signaling. Cancer Res. 2005;65(14):6245-54. [PubMed ID: 16024626].

  • 19.

    Shirakawa H, Kuronuma T, Nishimura Y, Hasebe T, Nakano M, Gotohda N, et al. Glypican-3 is a useful diagnostic marker for a component of hepatocellular carcinoma in human liver cancer. Int J Oncol. 2009;34(3):649-56. [PubMed ID: 19212669].

  • 20.

    Joo M, Chi JG, Lee H. Expressions of HSP70 and HSP27 in hepatocellular carcinoma. J Korean Med Sci. 2005;20(5):829-34. [PubMed ID: 16224158].

  • 21.

    Tremosini S, Forner A, Boix L, Vilana R, Bianchi L, Reig M, et al. Prospective validation of an immunohistochemical panel (glypican 3, heat shock protein 70 and glutamine synthetase) in liver biopsies for diagnosis of very early hepatocellular carcinoma. Gut. 2012;61(10):1481-7. [PubMed ID: 22287594].

  • 22.

    Luk JM, Lam CT, Siu AF, Lam BY, Ng IO, Hu MY, et al. Proteomic profiling of hepatocellular carcinoma in Chinese cohort reveals heat-shock proteins (Hsp27, Hsp70, GRP78) up-regulation and their associated prognostic values. Proteomics. 2006;6(3):1049-57. [PubMed ID: 16400691].

  • 23.

    Zhou L, Liu J, Luo F. Serum tumor markers for detection of hepatocellular carcinoma. World J Gastroenterol. 2006;12(8):1175-81. [PubMed ID: 16534867].

  • 24.

    Balzarini P, Benetti A, Invernici G, Cristini S, Zicari S, Caruso A, et al. Transforming growth factor-beta1 induces microvascular abnormalities through a down-modulation of neural cell adhesion molecule in human hepatocellular carcinoma. Lab Invest. 2012;92(9):1297-309. [PubMed ID: 22732936].

  • 25.

    Dong ZZ, Yao DF, Yao M, Qiu LW, Zong L, Wu W, et al. Clinical impact of plasma TGF-beta1 and circulating TGF-beta1 mRNA in diagnosis of hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int. 2008;7(3):288-95. [PubMed ID: 18522884].

  • 26.

    Xiang ZL, Zeng ZC, Fan J, Tang ZY, Zeng HY, Gao DM. Gene expression profiling of fixed tissues identified hypoxia-inducible factor-1alpha, VEGF, and matrix metalloproteinase-2 as biomarkers of lymph node metastasis in hepatocellular carcinoma. Clin Cancer Res. 2011;17(16):5463-72. [PubMed ID: 21712445].

  • 27.

    Zhang L, Wang JN, Tang JM, Kong X, Yang JY, Zheng F, et al. VEGF is essential for the growth and migration of human hepatocellular carcinoma cells. Mol Biol Rep. 2012;39(5):5085-93. [PubMed ID: 22161247].

  • 28.

    Yamamoto Y, Kosaka N, Tanaka M, Koizumi F, Kanai Y, Mizutani T, et al. MicroRNA-500 as a potential diagnostic marker for hepatocellular carcinoma. Biomarkers. 2009;14(7):529-38. [PubMed ID: 19863192].

  • 29.

    Yamamoto K, Imamura H, Matsuyama Y, Kume Y, Ikeda H, Norman GL, et al. AFP, AFP-L3, DCP, and GP73 as markers for monitoring treatment response and recurrence and as surrogate markers of clinicopathological variables of HCC. J Gastroenterol. 2010;45(12):1272-82. [PubMed ID: 20625772].

  • 30.

    Naraki T, Kohno N, Saito H, Fujimoto Y, Ohhira M, Morita T, et al. γ-Carboxyglutamic acid content of hepatocellular carcinoma-associated des-γ-carboxy prothrombin. Biochimica et Biophysica Acta. 2002;1586(3):287-98.

  • 31.

    Osada T, Sakamoto M, Nagawa H, Yamamoto J, Matsuno Y, Iwamatsu A, et al. Acquisition of glutamine synthetase expression in human hepatocarcinogenesis. Cancer. 1999;85(4):819-31.<819::aid-cncr9>;2-e.

  • 32.

    Cadoret A, Ovejero C, Terris B, Souil E, Levy L, Lamers WH, et al. New targets of beta-catenin signaling in the liver are involved in the glutamine metabolism. Oncogene. 2002;21(54):8293-301. [PubMed ID: 12447692].

  • 33.

    Minervini MI, Demetris AJ, Lee RG, Carr BI, Madariaga J, Nalesnik MA. Utilization of hepatocyte-specific antibody in the immunocytochemical evaluation of liver tumors. Mod Pathol. 1997;10(7):686-92. [PubMed ID: 9237179].

  • 34.

    Di Tommaso L, Franchi G, Park YN, Fiamengo B, Destro A, Morenghi E, et al. Diagnostic value of HSP70, glypican 3, and glutamine synthetase in hepatocellular nodules in cirrhosis. Hepatology. 2007;45(3):725-34. [PubMed ID: 17326147].

  • 35.

    Di Tommaso L, Destro A, Seok JY, Balladore E, Terracciano L, Sangiovanni A, et al. The application of markers (HSP70 GPC3 and GS) in liver biopsies is useful for detection of hepatocellular carcinoma. J Hepatol. 2009;50(4):746-54. [PubMed ID: 19231003].

  • 36.

    Di Tommaso L, Destro A, Fabbris V, Spagnuolo G, Laura Fracanzani A, Fargion S, et al. Diagnostic accuracy of clathrin heavy chain staining in a marker panel for the diagnosis of small hepatocellular carcinoma. Hepatology. 2011;53(5):1549-57. [PubMed ID: 21520170].