Progress and prospects of biomarkers in primary liver cancer (Review)

  • Authors:
    • Yu‑Xue Gao
    • Tong‑Wang Yang
    • Ji‑Ming Yin
    • Peng‑Xiang Yang
    • Bu‑Xin Kou
    • Meng‑Yin Chai
    • Xiao‑Ni Liu
    • De‑Xi Chen
  • View Affiliations

  • Published online on: April 1, 2020
  • Pages: 54-66
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Tumor biomarkers are important in the early screening, diagnosis, therapeutic evaluation, recurrence and prognosis prediction of tumors. Primary liver cancer is one of the most common malignant tumors; it has high incidence and mortality rates and seriously endangers human health. The main pathological types of primary liver cancer include hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) and combined HCC‑cholangiocarcinoma (cHCC‑CC). In the present review, a systematic outline of the current biomarkers of primary liver cancer is presented, from conventional blood biomarkers, histochemical biomarkers and potential biomarkers to resistance‑associated biomarkers. The important relationships are deeply elucidated between biomarkers and diagnosis, prognosis, clinicopathological features and resistance, as well as their clinical significance, in patients with the three main types of primary liver cancer. Moreover, a summary of several important biomarker signaling pathways is provided, which is helpful for studying the biological mechanism of liver cancer. The purpose of this review is to provide help for clinical or medical researchers in the early diagnosis, differential diagnosis, prognosis and treatment of HCC.

1. Introduction

Primary liver cancer is a common tumor worldwide, with a high incidence and mortality, and is a frequent cause of cancer death. Primary liver cancer mainly includes hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) and combined HCC-cholangiocarcinoma (cHCC-CC), with incidences of 75-85, 10-15 and 1-4.7%, respectively worldwide (1,2). HCC is a malignant tumor that originates from hepatocytes and is the fifth most common cancer and the third leading cause of cancer-associated deaths (3). ICC, the second most common primary liver tumor, is a malignant tumor that originates from the biliary epithelium (4). cHCC-CC is a rare type of primary hepatic carcinoma that has the characteristics of bi-directional differentiation of hepatocytes and bile duct epithelial cells (2,5). Although these cancers have different biological behaviours, it is sometimes diffcult to distinguish them by their biological characteristics. Therefore, the laboratory detection of liver cancer biomarkers, such as blood biomarkers and histochemical biomarkers, plays an important role i n the early monitoring, pathological classification, treatment options and prognosis of patients with primary liver cancer. The most widely used biomarker of primary liver cancer worldwide is α-fetoprotein (AFP); however, its sensitivity and specificity are not very satisfactory (3,4). It is of great significance for the diagnosis, treatment effect observation and prognosis judgement of primary liver cancer to combine different tumor biomarkers according to different clinical conditions, and to develop new biomarkers. In the present review, current clinical and experimental studies have been summarized to highlight the progress in biomarkers, as well as some new promising biomarkers, for clinical and medical research to diagnose and guide the therapy of primary liver cancer.

2. Blood biomarkers

Blood biomarkers are of great significance in the early diagnosis of liver cancer and mainly include categories related to proteins, cytokines, enzymes and isoenzymes as well as transcripts of associated genes (Table I). Regardless of the diverse acknowledged molecular indicators in liver cancer, each of them alone cannot be a specific biomarker in different types of liver cancer, and their combined application is important for the identification of liver cancer types.

Table I

Blood and histochemical biomarkers used for liver cancer.

Table I

Blood and histochemical biomarkers used for liver cancer.

BiomarkersB/TPositive rate (%)Sensitivity (%)Specificity (%)TypeSignificance(Refs.)
AFPB62.252 (>3 cm); 25 (<3 cm)-HCC, cHCC CCDiagnosis(3,7)
AFP/AFP L3B-8779HCCDiagnosis(11)
AFP-L3%B-35-45 (<2 cm); 80-90 (>5 cm)-HCCDiagnosis(13)
DCPB-8693HCCDiagnosis and indicator(16)
DCP and AFPB-80 (3-4 cm) 70 (2-3 cm)-HCCDiagnosis(20)
AFUB85HCCEarly diagnosis(24)
GP73B-9595Early HCCDiagnosis of Egyptian patients(29)
-6696.2Small HCC with negative AFPDiagnosis(30)
AFP and OPNB-65-HCCDiagnosis(32)
GPC-3T-97HCCDiagnosis, prognosis(48,51)
Hep Par 1T-8080HCCDiagnosis(56)
GST-10090HCC under a cirrhotic backgroundDiagnosis(65)
Arg-1T--100HCC with TMA and FNADiagnosis(67)
HSP70T---Early and small HCCDiagnosis(57,58)

[i] B, blood; T, tissue; AFP, α-fetoprotein; DCP, des-γ-carboxyprothrombin; AFU, α L fucosidase; GP73, Golgi protein 73; OPN, osteopontin; CA19 9, carbohydrate antigen 19 9; GPC-3, glypican 3; Hep Par 1, hepatocyte paraffin 1; GS, glutamine synthetase; Arg-1, arginase-1; HSP70, heat shock protein 70; CK, cytokeratin; HCC, hepatocellular carcinoma; ICC, intrahepatic cholangiocarcinoma; cHCC-ICC, combined HCC-cholangiocarcinoma.

AFP and AFP-L3

AFP is a ~70 kDa glycoprotein molecule consisting of 591 amino acids that is derived from fetal hepatocytes and the yolk sac. As a useful biomarker of liver cancer, AFP has been widely used in its diagnosis. However, AFP may also increase in hepatitis, liver cirrhosis and liver injury, especially in 10-20% of early-stage HCCs with elevated AFP-L3 levels (6). Moreover, serum AFP levels are not largely elevated in the 80% of HCC patients with small tumor sizes; the sensitivity of AFP in patients with HCC has been reported to be 52% for tumors >3 cm in diameter but only 25% for tumors <3 cm in diameter (3). The use of AFP in combination with a variety of serum biomarkers contributes to the early diagnosis of HCC, and can improve sensitivity and specificity compared with single use (3). AFP levels are not significantly changed in patients with ICC and, therefore, AFP may serve as a powerful biomarker to distinguish ICC from HCC (4). In one study, elevated serum AFP levels (>20 ng/ml) were detected in 58.3% of patients with cHCC-CC, which was slightly lower than that in patients with HCC (66.5%) and significantly higher than that in patients with ICC (13.7%) (5). Another study detected the elevation of AFP in 62.2% (28/45) of patients with cHCC-CC (7).

Due to the low specificity and sensitivity of AFP, other biomarkers are required to assist the diagnosis. AFP-L3 is a heteroplast of AFP, which is only derived from tumor tissue and is a specific biomarker for HCC. Clinical studies revealed a specificity of 90‑95% and a sensitivity of ~51% for AFP-L3 in early-stage HCC detection (8). The AFP-L3 fraction is more sensitive than AFP for small-sized tumors or for patients with early-stage HCC, is highly specific for HCC and reflects tumor features such as poor differentiation or malignant invasion (9,10). AFP-L3 may serve as a supplementary test variable to improve the diagnostic value of HCC detection in patients with relatively low AFP levels (9). The specificity and sensitivity of a combination of AFP and AFP-L3 were found to be 79 and 87%, respectively, in the diagnosis of HCC (11). Serum AFP-L3 levels and the percentage of AFP-L3 in total AFP (AFP-L3%) can be efficiently applied to distinguish HCC from benign liver diseases and to diagnose HCC early in the clinic (12). The sensitivity of AFP-L3% has been reported to be 35-45% for HCC tumors with a diameter <2 cm, and 80-90% for HCC tumors with a diameter >5 cm, respectively, with variation according to clinical features (13).

Des-γ-carboxyprothrombin (DCP)

DCP is a new serological biomarker of HCC, which is also known as prothrombin-induced by vitamin K absence-II, and is produced in HCC cells due to a defect in the carboxylation of the prothrombin precursor after translation and is elevated in patients with HCC (14,15). In one study, DCP exhibited higher sensitivity than AFP; the sensitivity and specificity of DCP were 85 and 75%, respectively (15). In another study, DCP exhibited significantly improved results compared with AFP and AFP-L3 in the diagnosis of HCC, with sensitivity and specificity up to 86 and 93%, respectively, for distinguishing HCC from cirrhosis (16). DCP has served as an effective biomarker for the diagnosis of HCC in Japan, South Korea and India, particularly for judging intrahepatic metastasis and prognosis (17). Studies have demonstrated that elevated DCP levels are indicative of larger tumor size, greater tumor numbers, a later clinical phase, bile duct invasion, vascular invasion and a shorter median survival time (14,18). A meta-analysis suggested that DCP should serve as an indicator of HCC in the established guidelines of other countries and regions, especially those with a high incidence of hepatitis B virus (HBV) infections, such as East Asia (with the exception of Japan) and Africa (19). A combination of DCP and AFP enhanced the sensitivity of HCC diagnosis to >80 and 70%, respectively, in tumors 3-4 and 2-3 cm in diameter (20).

α-L-fucosidase (AFU)

AFU is characterized as a lysosomal enzyme in all mammalian cells, enabling the degradation of a variety of fucose-containing fucoglycoconjugates (21,22). AFU has been demonstrated to serve as a useful biomarker for HCC, and the serum level of AFU in patients with HCC has been found to be higher than that in patients with benign hepatic diseases (23). AFU is considered as an earlier biomarker, able to diagnose 85% of patients with HCC 6 months prior to detection by ultrasonography (24). Serum AFU activity can return to normal after liver transplantation and successful intervention for HCC, while AFU is also elevated with the recurrence of HCC; therefore, AFU can serve as a follow-up biomarker for patients with HCC (21). The preoperative AFU level has been suggested to be powerful in the prediction of tumor recurrence and mortality in HCC patients with low levels of AFP (21). The AFU level is positively associated with tumor size in patients with HCC and can be combined with AFP for the early diagnosis of HCC (8).

Golgi protein 73 (GP73)

GP73 is a transmembrane glycoprotein of resident Golgi type II, with a molecular mass of ~70 kDa, and is expressed mainly in the epithelial cells of numerous human tissues (25). GP73 is hardly expressed in healthy subjects, but its expression is moderately increased in patients with cirrhosis and viral infection, and markedly increased in patients with HCC (25-27). A study reported that the sensitivity and specificity of GP73 for HCC were 74.6 and 97.4%, respectively, markedly higher in comparison with 58.2 and 85.3% for AFP (28). Another study revealed that the sensitivity and specificity of serum GP73 were each 95% for Egyptian patients with early HCC, and also suggested that GP73 was superior to AFP for the early diagnosis and examination of HCC (29). Furthermore, GP73 has been shown to be a powerful biomarker with a sensitivity, specificity and accuracy of 66, 96.2 and 84.6%, respectively, for the diagnosis of small HCC with negative AFP, which supports its potential contribution to the diagnosis of small HCC (30).

Osteopontin (OPN)

OPN is a highly modified, phosphorylated and glycosylated protein of extracellular matrix that binds to integrin and is expressed in a variety of cells, such as those of the immune system, epithelial tissues, smooth muscle cells, osteoblasts and tumors (31,32). In one study, the prevalence of autoantibodies against OPN was found to be 12.8, 15.6 and 3.1% in the serum of patients with HCC, liver cirrhosis and chronic hepatitis, respectively, compared with 0% in the serum of healthy individuals, and when OPN was combined with AFP to diagnose HCC, the sensitivity increased to 65% (32). In another study, OPN levels were shown to be much higher in patients with hepatitis C virus-associated HCC compared with healthy subjects and patients with chronic liver diseases (33). Furthermore, levels of serum OPN were found to be elevated a year prior to HCC diagnosis, with OPN indicated to be superior to AFP in differentiating cases of HCC from those of liver cirrhosis (33). A study using an OPN-knockout HCC mouse model revealed that OPN induced chemotactic migration, alternatively activated macrophages, increased tumor-associated macrophage infiltration and upregulated the expression of programmed death ligand 1 in HCC through activation of the colony stimulating factor-1 (CSF1)-CSF1 receptor pathway in macrophages (34). OPN may also be considered for use in the monitoring of microvascular invasion in chronic hepatitis B (CHB)-associated HCC, as it has been found to be upregulated in patients who did not receive antiviral therapy compared with antiviral-treated patients, and exhibited an association with tumor aggressiveness and poor prognosis (35).

Carbohydrate antigen 19-9 (CA19-9)

CA19-9 was originally identified in the culture medium of a human colorectal cancer cell line and is widely used to diagnose various adenocarcinomas, including cholangiocarcinoma (36); it is a significant serological biomarker in ICC. A study revealed that the sensitivity and specificity continuously increased with increasing CA19-9 serum concentration; when the serum level of CA19-9 was >632 U/ml, its sensitivity and specificity were 90.0 and 98.0%, respectively (37). In addition, the preoperative CA19-9 level can serve as an independent prognostic factor in patients with ICC (38). A study demonstrated that preoperative serum CA19-9 levels may be used to predict lymph node metastasis in patients with ICC (39).

At present, the triple detection of DCP, AFP and AFP-L3% is a common serum biomarker combination for the early diagnosis of HCC. The detection rate of HCC can be increased to 85.9% by the combined detection of these three biomarkers (40). In the prognostic evaluation of HCC, the higher the AFP, AFP-L3% and DCP levels, the lower the survival rate and the higher the recurrence rate (40). The increase in the three biomarkers is associated with the invasiveness of the tumors (40). DCP and AFP-L3% are positively associated with the size and stage of the tumors (40). A triple examination of cancer using DCP, AFP and AFP-L3% is helpful for the differential diagnosis of intrahepatic nodules. Authoritative guidelines and consensus, such as those of the Asia-Pacific Society of Hepatology (41), the Japan Society of Hepatology (42), Guidelines for the Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection (2015) (43) and Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China (2017) (44), recommend DCP, AFP and AFP-L3% for the screening of high-risk populations, the auxiliary diagnosis of liver cancer, the monitoring of therapeutic effect and as a predictor of prognosis and recurrence. In conclusion, AFP is of great value in the diagnosis and prognosis evaluation of HCC. DCP and AFP-L3, as classical serological indicators in the diagnosis of HCC, are complementary to AFP.

3. Histochemical biomarkers

Pathological diagnosis is the gold standard of primary liver cancer, whose main detection methods include hematoxylin and eosin (H&E) staining and immunohistochemistry (IHC). Tissue biomarkers are the true reflection of tumor tissue structure and cell morphology, and are more objective and accurate than various imaging examinations and chemical examinations (Table I). Therefore, tissue biomarkers serve an important role in the diagnosis, differential diagnosis, treatment and prognosis of patients with benign tumors, HCC, ICC and cHCC-CC (Table II).

Table II

Histochemical biomarkers with clinicopathological associations.

Table II

Histochemical biomarkers with clinicopathological associations.

BiomarkersTypeExpression levelAssociations(Refs.)
GPC-3HCCHighCell-cycle, migration, invasiveness, differentia tion grade, HBV infection, TNM stage, periportal cancerous embolus, extrahepatic metastasis, poor postoperative DFS and OS(47 49,51)
Hep Par 1HCCHighHepatocellular differentiation(53-55)
HSP70Small and early HCCHighVascular invasion, high stage, low grade, poor differentiation, cell proliferation, lymph node metastasis, high Ki 67 index and larger tumor size and portal vein invasion(58-60)
GSHCCHighβ-catenin gene mutations, higher recurrence and lower survival(63)
Arg-1HCCHighHepatocellular differentiation(69,70)
CK7ICCHighAggressive tumor phenotypes and adverse OS(73)
CK19ICCHighAggressive tumor phenotypes and adverse OS(73)

[i] GPC-3, glypican-3; Hep Par 1, hepatocyte paraffin 1; HSP70, heat shock protein 70; GS, glutamine synthetase; Arg-1, arginase-1; CK, cytokeratin; HCC, hepatocellular carcinoma; ICC, intrahepatic cholangiocarcinoma; HBV, hepatitis B virus; DFS, disease-free survival; OS, overall survival.

Glypican-3 (GPC-3)

GPC-3 is a membrane-bound heparan sulfate proteoglycan that belongs to the glypican family; it has an amino terminal protein and a membrane-bound carboxyl terminal protein (45,46). GPC-3 anchors at the glycosylphos-phatidylinositol of the membrane by the C-terminus; can be enzymatically lysed, releasing a soluble form of GPC-3; and is released into the serum by a lipase called notum (46) (Fig. 1). GPC-3 is overexpressed in up to 80% of patients with HCC and is able to distinguish HCC from ICC and other malignant tumors (47). GPC-3 is a promising biomarker for HCC with a specificity of up to 97%; it modulates cell-cycle progression, and promotes cellular migration and invasiveness in HCC cell lines (48,49). GPC-3 is specifically expressed in the HCC tumor tissue and is widely used to distinguish HCC from ICC. GPC-3 expression is associated with differentiation grade, and exhibits higher expression in moderately differentiated and poorly differentiated HCC than in well-differentiated HCC (47). A study revealed that GPC-3 is overexpressed in HCC tissue and can serve as a sensitive and specific biomarker to diagnose early HCC (50). Clinicopathological analysis demonstrated that the overexpression of GPC-3 was associated with poor postoperative disease-free survival and overall survival (OS) and that it was an independent risk factor (51). GPC-3 is associated with HBV infection, TNM stage, periportal cancerous embolus and extrahepatic metastasis, and can serve as a prognostic factor (51). GPC-3 is not only a powerful histochemical biomarker but also a serological biomarker. A study showed that the serum GPC-3 level was >300 ng/l in 50% of early HCC patients, although their serum AFP level was <100 µg/l, revealing that the serum GPC-3 level can be used to monitor early HCC and may serve a role in the diagnosis of HCC (24). Recently, a simple 2D imaging probe with minimal background fuorescence and high binding affinity for GPC-3 was developed, which has been shown to sensitively and selectively image HCC cells and a normal cell line overexpressing GPC-3, as well as to effectively differentiate between HCC-positive and para-carcinoma tissue regions (52).

Hepatocyte paraffin 1 (Hep Par 1)

Hep Par 1 was first identified in a formalin-fixed failed allograft liver and is a monoclonal antibody that is highly sensitive and specific for hepatocellular differentiation (53-55). Hep Par 1 is a mitochondrial urea cycle antigen associated with mitochondrial antigens from malignant and non-malignant hepatic cells (54). A study reported that the rate of Hep Par 1 expression was 100% in well-differentiated and moderately differentiated HCC (55). Another report revealed that Hep Par 1, whose sensitivity and specificity were both 80% in well-differentiated HCC, was more likely to be negative in poorly differentiated and sclerosing HCC (56). Hep Par 1 was found to have low sensitivity in poorly differentiated HCC, and was not easily able to distinguish between HCC and adenocarcinoma (53). Therefore, Hep Par 1 can be combined with other biomarkers in morphologically difficult cases with poorly differentiated HCC and metastatic carcinoma of the liver to determine diagnoses.

Heat shock protein 70 (HSP70)

HSP70 is a member of a highly conserved protein family, and is expressed at low levels under normal conditions but serves a significant role in response to heat shock, hypoxia, genotoxic agents and nutrient starvation (57,58). HSP70 is a useful histochemical biomarker that is nucleocytoplasmic and mostly focally stained in HCC by IHC (57). Clinically, HSP70 is considered an indispensable biomarker that is significant clinically in distinguishing the diagnosis of well-differentiated small HCC (sHCC) from that of high-grade dysplastic nodules in liver biopsies and surgical specimens (57). A study identified that HSP70 served as the most highly upregulated gene in early HCC tissue sections (58). HSP70 is associated with vascular invasion, high stage, low grade, poor differentiation, cell proliferation, lymph node metastasis, high Ki-67 index and larger tumor size in HCC (59). However, another study reported that the overexpression of HSP 70 was associated wit h portal vein invasion, but could not predict the overall survival of patients with HCC (60).

Glutamine synthetase (GS)

GS is an enzyme of nitrogen metabolism that catalyzes the conversion of glutamate and ammonia to glutamine in the liver. GS is expressed in hepatocytes surrounding the terminal hepatic venues under normal conditions, but is diffusely located in hepatocellular tumors (61,62). Glutamine provides energy to tumor cells and so GS is diffusely expressed in HCC; the expression of HCC is closely associated with β-catenin gene mutations and the Wnt signaling pathway. GS positivity may imply specific epidemiological and genetic profiles for a subtype of HCC, which includes larger size, low grade, pseudoacini, hydropic changes, bile staining, lack of steatosis, and fibrosis, as well as tumor-specific and overall survival for HCC (62). GS can act as a detector of HCC recurrence, and its upregulation contributes to the increase in metastasis and markedly shorter disease-free survival time in HCC (63). GS and HSP70 positivity are more likely be observed in very well-differentiated HCC than in atypical neoplasms, and may be powerful biomarkers to distinguish between very well-differentiated HCC and atypical cases (64). Strikingly, in a study of cirrhotic and non-cirrhotic livers, the sensitivity of GS was 100% for HCC in cirrhotic livers, and the specificity was 90% (65). However, another study reported that HSP70 and GS immunoreactivity did not effectively identify tumor cell origin for ICC (66).

Arginase-1 (Arg-1)

Arg-1, an enzyme associated with the hydrolysis of arginine to ornithine and urea, has been observed to be a highly sensitive and specific biomarker for benign and malignant hepatocyte (67). Arg-1 is a powerful immunohistochemical and biomarker for HCC, is an enhancer of zeste homologue 2, and is considered a useful biomarker for hepatocellular differentiation (68-70). Arg-1 has been shown to be a more sensitive biomarker compared with Hep Par 1 in poorly differentiated HCC, as the latter is sometimes expressed in other non-hepatic tumors (69). Similar results in another study showed that Arg-1 had a higher sensitivity than Hep Par 1 for moderately differentiated and poorly differentiated HCC (70). A comparison of different markers using tissue microarray and fine-needle aspiration specimens revealed that Arg-1 is a superior specific biomarker for HCC, and its specificity was 100% in a large series of surgical cases (n=1,222) (67).

Cytokeratin (CK)7 and CK19

CK7 and CK19 are members of the cytokeratin family, which are intermediate filament proteins that are mainly expressed in epithelial cells and belong to type II (CK1-8) and type I (CK9-20), respectively. CK7 and CK19 are primarily located in pancreatic ducts, mammary gland ducts and liver bile ducts but are absent from hepatocytes (71). Therefore, CK7 and CK19 can be used as immunehistochemical biomarkers to distinguish ICC from HCC (72), as well as biliary epithelial differentiation. A study found that CK7 and CK19 were highly expressed in patients with ICC, which was closely associated with aggressive tumor phenotypes and adverse OS (73). In addition, compared with the expression of either CK7 or CK19 alone, the CK7/CK19 index was indicated as a superior independent prognostic factor for ICC. The patients with both high CK7 and CK19 expression, heterogeneous high CK7 or CK19 expression, and both low CK7 and CK19 expression had the lowest, intermediate and highest 5-year survival rates, respectively. Furthermore, when combined with the CK7/CK19 index and clinical-pathological risk factors, CK7 and CK19 were found to predict OS more accurately than traditional staging systems (73).

In summary, the commonly used hepatocyte markers are Hep Par-1, GPC-3, Arg-1 and GS, and the common bile duct cell biomarkers are CK7 and CK19. A reasonable combination of immunohistochemical biomarkers is needed to differentiate HCC from ICC and primary HCC from meta-static HCC.

4. Potential biomarkers

Although classical biomarkers of HCC have been routinely used, false positive results in their diagnosis of HCC occur, and their sensitivity and specificity are also insufficient. It is urgently necessary to develop more accurate and effective biomarkers for the early clinical staging, treatment monitoring and prognosis judgement of patients with HCC.

Gene biomarkers

The mutation of p53 is highly prevalent in human cancers, but its mutation is not always associated with evidently altered p53 protein expression in HCC (74). However, mutation of p53 is associated with tumor size, differentiation degree, TNM stage and vascular invasion, as well as to poor prognosis, angiogenesis, metastasis and resistance to standard therapies; therefore, the detection of the mutant p53 gene is significant for HCC (74,75). CTNNB1, encoding β-catenin, not only is one of the more commonly mutated genes for Wnt signaling activation in HCC but also is associated with mutations in telomerase reverse transcriptase (TERT) promoters (76). CTNNB1-mutated HCCs have been found to be well-differentiated, cholestatic, chromosomally stable and almost never steatotic, associated with an improved prognosis compared with other HCCs, and to usually display microtrabecular and/or acinar growth patterns (75). Mutation of TERT frequently occurs in HCC, suggesting that TERT overexpression is a significant risk factor in hepatocarcinogenesis (75,76). TERT upregulation with HCC has been found to be observably associated with intrahepatic metastasis but not markedly associated with other clinicopathological parameters, and therefore may only serve as a crucial prognostic indicator for late intrahepatic metastasis in HCC treated with curative resection (77). Isocitrate dehydrogenase (IDH) is the enzyme responsible for the conversion of isocitrate to α-ketoglutarate in the cytosol (IDH1) and mitochondria (IDH2). In one study, IDH1 and IDH2 mutations were observed in 10% of patients with ICC, were independently associated with a longer time to tumor recurrence after intrahepatic cholangiocarcinoma resection, and also exhibited an association with p53 overexpression in ICC (78). Fibroblast growth factor receptor (FGFR)2 is a member of the FGFR family that is stimulated by binding with fibroblast growth factors and functions as a serine/threo-nine kinase by activating the downstream Ras-MAPK-ERK pathway (79). FGFR2 gene fusion has been detected in 10-16% of ICCs, particularly in younger patients (≤40 years) with a non-obvious tendency for female sex; it affects the outcomes of patients with ICC, and contributes to the antitumor activity and manageable safety profile of derazantinib (80). Mutations of EPH receptor A2 (EPHA2), a member of the tyrosine kinase family, have been found to be frequent in ICC and exhibit a close association with lymph node metastasis, poorer differentiation, higher metastatic ability and angiogenesis in patients with ICC (81).

miRNA biomarkers

microRNAs (miRNAs) are endog-enously expressed, highly conserved, small, noncoding RNA molecules, which are considered as promising candidates with non-invasive biomarkers for HCC and ICC (Table III). Exosomal miR-21 and miR-10b, hypoxia inducible factor (HIF)-1α and HIF-2α are activated via the acidic microenvironment of HCC, which further stimulates HCC cell proliferation, migration and invasion in vivo and in vitro. Furthermore, serum exosomal miR-21 and miR-10b levels exhibit an association with advanced tumor stage and HIF-1α and HIF-2α expression, which are also independent prognostic parameters for disease-free survival in early-stage HCC patients (82). A study found that plasma levels of miR-122 were significantly lower in patients with HCC compared with healthy controls and patients with chronic hepatitis C, while the expression of miR-224 was significantly higher (83). Furthermore, miR-122 and miR-224 were both directly associated with AFP, alanine transaminase, aspartate transaminase and alkaline phosphatase levels and the size of the tumor; therefore, they could be considered as noninvasive biomarkers for early diagnosis in the early stage of progressive HCC (83). In another study, miR-1204 levels were observed to be elevated in HCC tissues and cell lines, which promoted cell proliferation in vitro and tumor growth in vivo as well exhibiting an association with malignant clinical features, such as tumor size and advanced TNM stage, and inhibiting apoptosis in vitro (84). hsa-miR-210 has been identified as an independent prognostic factor, which was significantly overexpressed in venous metastasis positive HCC samples and associated with AFP level, pathological grade, TNM stage, tumor stage and vascular invasion (85). Recently, a study showed that miR-221 was upregulated in HCC tissues, cell lines and the blood of patients with HCC, and that miR-221 upregulation was associated with clinical TNM stage, tumor capsular infiltration and poor prognosis. The findings of the study suggested that combined serum miR-221 and AFP detection exhibits an improved performance than either alone for the early diagnosis of HCC (86). In patients with ICC, miR-191 is distinctly elevated in ICC tissue compared with adjacent normal bile duct tissues, and the overexpression of miR-191 has been shown to induce the proliferation, invasion and migration of cholangiocarcinoma cells in vitro and in vivo via the miR-191/TET1/p53 pathway (87). miR-424-5p has been shown to play different roles in the proliferation and metastasis of various tumors, acting as a suppressor or promotor (88). However, miR-424-5p has been found to be frequently downregulated in ICC tissues compared with adjacent normal tissues and in ICC cells compared with normal bile duct cells, with miR-424-5p knockdown inhibiting invasion and migration in ICC by targeting ARK5; therefore, the restoration of miR-424-5p expression has been suggested to be a promising strategy for ICC therapy (88).

Table III

miRNA biomarkers used for liver cancer.

Table III

miRNA biomarkers used for liver cancer.

BiomarkersTypeExpression levelAssociations(Refs.)
miR-21 and miR-10bHCCHighProliferation, migration, and invasion, advanced tumor stage, HIF-1α/ HIF-2α expression and disease free survival(82)
miR-122HCCLowAFP, ALT, AST and ALP levels, and tumor size(83)
miR-224HCCHighAFP, ALT, AST, ALP levels and tumor size(83)
miR-1204HCCHighProliferation, tumor growth, tumor size and advanced TNM stage, inhibited apoptosis(84)
hsa-miR-210HCCHighAFP level, pathological grade, TNM stage, tumor stage and vascular invasion(85)
miR-221HCCHighClinical TNM stage, tumor capsular infiltration and poor. prognosis(86)
miR-191ICCHighProliferation, invasion and migration(87)
miR-424-5pICCLowInvasion and migration(88)

[i] miR, microRNA; HCC, hepatocellular carcinoma; ICC, intrahepatic cholangiocarcinoma; HIF, hypoxia inducible factor; AFP, α-fetoprotein; ALT, alanine transaminase; AST, aspartate transaminase; ALP, alkaline phosphatase.

5. Resistance-associated biomarkers

Sorafenib has been considered the standard of care for patients with advanced unresectable HCC since 2007; however, in a proportion of patients it is ineffective in clinical application (89-91). Effective drug resistance biomarkers to guide clinical drug use are lacking. Glucose-regulated protein78 (GRP78) is an immunoglobulin heavy chain binding protein of the HSP70 family. A study found that autoantibodies against GRP78 may be promising diagnostic biomarkers for HCC, particularly when used in conjunction with AFP, with a sensitivity of 71.4% (90). In an in vitro study, GRP78 was found to increase the acquisition of sorafenib resistance in HCC, and GRP78 knockdown increased the efficacy of sorafenib-mediated cell death (91). Another study demonstrated that secreted GRP78 was associated with epidermal growth factor receptor (EGFR) via the EGFR-SRC-STAT3 signalling pathway, which conferred resistance to sorafenib (92). EGFR is a member of the HER/ErbB family of receptor tyrosine kinases, which is highly expressed in HCCs and associated with aggressive tumors, metastasis and poor patient survival significantly lower than that in patients with nonmetastatic HCC (93). EGFR may serve as a potential predictor of the resistance of HCC cells to sorafenib. A low expression level of EGFR or inhibition of the kinase activity of EGFR has been shown to increase the sensitization of HCC cells to sorafenib (94). EGFR is also overexpressed in ICC, with reported positivity rates ranging from 10 to 80% (95). Hepatocyte growth factor (HGF) is a member of the peptidase S1 family of serine proteases, and its receptor is c-Met, which is a single-pass tyrosine kinase receptor. c-Met has been observed to be overexpressed in >80% of patients with HCC, which is associated with poor prognosis and short survival (96). A study reported that, compared with sorafenib-sensitive HCC, patient specimens of sorafenib-resistant HCC exhibited increased levels of activated p-Met (97). Furthermore, c-Met expression was found to be expressed at markedly high levels in sorafenib-resistant HCC cells compared with their sorafenib-sensitive counterparts, and sorafenib treatment increased the production of HGF and the phosphorylation of c-Met (98). After 10 years of research, there are still no established drug resistance biomarkers to guide the clinical use of sorafenib in HCC. It is possible that the application of omics technology combined with bioinformatics to examine the association between patient outcome and resistance biomarker response to sorafenib could be an alternative approach in finding new biomarkers for HCC (89).

6. Biomarker-associated signaling pathways

Biomarker-associated signaling pathways contribute to revealing the mechanism of the occurrence and development of HCC. The present article summarizes the biomarker-associated signaling pathways involved in HCC progression, with a focus on the Wnt signaling pathway, c-Met signaling pathway, phosphatidylinositol 3-kinase (PI3K)/AKT signaling pathway and p53 signaling pathway (Fig. 2).

Wnt signaling pathway

Approximately 50% of HCCs are regulated by the Wnt/Frizzled/β-catenin pathway, and Wnt signaling is potentially activated in up to 95% of HCCs (99). GPC-3 can combine with Wnt and its receptor Frizzled to stimulate the Wnt signaling pathway, which is intimately associated with the nuclear/cytoplasmic localization of β-catenin (46). The activation of β-catenin and the aberrant expression of GS have intimate associations in HCC. A study found that a nuclear presence of β-catenin was associated with GS expression in all tumors, and 84% of HCCs showed the cytoplasmic presence of β-catenin associated with GS expression (100). In another study, Wnt activation was detected in HCC tissues and categorized into two subclasses, namely a CTNNB1 class and a Wnt-transforming growth factor (TGF)-β class (101). The CTNNB1 class was characterized by CTNNB1 mutations, nuclear β-catenin positivity, and tumor diameter >3 cm, while the Wnt-TGF-β class was characterized by TGF-β activation, cytoplasmic β-catenin positivity, vascular invasion, satellitosis and an increased risk of early recurrence after surgical resection (101).

c-Met signaling pathway

HGF/c-Met signaling is activated in HCC and promotes hepatocyte proliferation and regeneration. HGF and c-Met are upregulated in HCC, which is associated with early recurrence, metastasis and worse overall survival, as well as the inhibition of HCC apoptosis which facilitates HCC progression (102). Activation of the DCP-c-Met-Janus kinase 1-STAT3 kinase cascade stimulates HCC growth (13). Furthermore, GPC-3 has been shown to control the migration and motility of HCC cells via heparan sulfate chain-mediated growth combined with the HGF/Met pathway (103).

PI3K/AKT signaling pathway

The PI3K/AKT pathway is frequently activated in human cancer, including HCC, and regulates cell proliferation, metabolism, invasion, metastasis and resistance to various treatments (104,105). Phosphatase and tensin homologue deleted on chromosome 10 (PTEN), an inhibitor of the PI3K/AKT pathway in tumors, is often inactivated in HCC (105). TERT has been demonstrated to influence aberrant DNA methyltransferase 3B expression/aberrant DNA via PTEN downregulation and AKT overexpression to promote HCC development and progression (104). Furthermore, AFP suppresses autophagy and apoptosis and contributes to the promotion of proliferation, migration and invasion in HCC by interacting with PTEN and activating PI3K/AKT/mTOR signaling (105).

p53 signaling pathway

Mutations of the p53 signaling pathway are common in HCC, and the combination of p53 with hepatitis B virus X-protein in the cytoplasm has been shown to promote the development of HCC (106). p53 is principally controlled by the E3 ubiquitin ligase murine double minute 2 (MDM2). There is a dynamic balance between MDM2 and p53 in normal conditions, whereas in HCC cells, the balance is destroyed, and MDM2 is overexpressed and p53 is downregulated (106). Furthermore, a study demonstrated that GP73 knockdown promoted the accumulation of intracellular matrix metalloproteinase-2 (MMP2), suppressed MMP2 secretion and further inhibited invasion in HCC cells by inhibiting p53-p21 signaling pathways via a negative feedback loop (26).

7. Conclusions

The key to solving the difficulties in the treatment of primary liver cancer mainly lies in early diagnosis and treatment. Biomarkers serve an important role in diagnosis, differential diagnosis and prognosis; they enable targeted therapy and also provide benefits for the progress of disease research. Early diagnosis is very important for the prognosis and treatment of patients with liver cancer, and the sensitivity and specificity of tumor biomarkers are of great significance for the early diagnosis of liver cancer. The combined application of several biomarkers is conducive to the early diagnosis of liver cancer. At present, AFP, AFP-L3 and DCP are common serum biomarkers used to diagnose liver cancer earlier in internal and external clinical settings. Recently, numerous studies have investigated novel serum biomarkers, such as AFU, GP73 and OPN, to provide accurate diagnosis and early treatment for patients. The final diagnosis and pathological classification of primary liver cancer have been achieved using H&E staining and IHC, and confirmed via histochemical biomarkers, including classical biomarkers (GPC-3, Hep Par 1, HSP70, GS, Arg-1, CK7 and CK19). These biomarkers indicate the differentiation degree, histological type, clinico-pathological features and prognosis. Furthermore, a number of studies have shown that gene-targeted therapies have a good curative effect. Notably, integrated genomic studies have revealed potential therapeutic targets in HCC and ICC, including CTNNB1 and IDH, respectively. Therefore, genetic biomarkers in patients with liver cancer favor individualized gene-targeted therapy and improve prognosis. In the current review, various tumor biomarkers are summarized in different liver cancers, such as HCC, ICC and cHCC-CC (Fig. 3). Novel tumor biomarkers may be used in clinical practice in the near future, which brings new hope for the early diagnosis and accurate treatment of patients with liver cancer. Targeted drugs are being studied for some biomarkers, and individualized treatment is conducted for patients to improve their quality of life and survival. Further study of biomarker-related signaling pathways will contribute to the deep exploration of the mechanism underlying the occurrence and development of HCC. The development of biotechnology is also prompting researchers to use modern technology to improve the sensitivity of diagnostic biomarkers of HCC to achieve the early diagnosis of HCC, increase the cure rate and reduce mortality.


This review was supported by the National Science and Technology Major Special Program of the 13th Five-Year Plan for the Prevention and Control of Major Infectious Diseases such as AIDS and Viral Hepatitis (grant no. 2018ZX10302205-005), Capital's Funds for Health Improvement and Research (grant no. 2018-1-1151), the National Natural Science Foundation of China (grant no. 81672026) and Beijing Natural Science Foundation (grant no. 7192084).

Availability of data and materials

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Authors' contributions

YXG wrote the manuscript, searched literatures and made figures and lists . X N L and DXC provided article ideas, modified the lists and revised the manuscript.. TWY, JMY, PXY, BXK and MYC performed literature research and collected relevant articles. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.


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Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA and Jemal A: Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 68:394–424. 2018. View Article : Google Scholar : PubMed/NCBI


Gera S, Ettel M, Acosta-Gonzalez G and Xu R: Clinical features, histology, and histogenesis of combined hepatocellular-cholan-giocarcinoma. World J Hepatol. 6:300–309. 2017. View Article : Google Scholar


Saffroy R, Pham P, Reffas M, Takka M, Lemoine A and Debuire B: New perspectives and strategy research biomarkers for hepatocel-lular carcinoma. Clin Chem Lab Med. 45:1169–1179. 2007. View Article : Google Scholar


Zhou YM, Yang JM, Li B, Yin ZF, Xu F, Wang B, Liu P and Li ZM: Clinicopathologic characteristics of intrahepatic chol-angiocarcinoma in patients with positive serum a-fetoprotein. World J Gastroenterol. 14:2251–2254. 2008. View Article : Google Scholar : PubMed/NCBI


Yin X, Zhang BH, Qiu SJ, Ren ZG, Zhou J, Chen XH, Zhou Y and Fan J: Combined hepatocellular carcinoma and cholangiocarci-noma: Clinical features, treatment modalities, and prognosis. Ann Surg Oncol. 19:2869–2876. 2012. View Article : Google Scholar : PubMed/NCBI


Yamashita T, Forgues M, Wang W, Kim JW, Ye Q, Jia H, Budhu A, Zanetti KA, Chen Y, Qin LX, et al: EpCAM and alpha‑fetoprotein expression defnes novel prognostic subtypes of hepatocellular carcinoma. Cancer Res. 68:1451–1461. 2008. View Article : Google Scholar : PubMed/NCBI


Li R, Yang D, Tang CL, Cai P, Ma KS, Ding SY, Zhang XH, Guo DY and Yan XC: Combined hepatocellular carcinoma and cholangiocarcinoma (biphenotypic) tumors: Clinical characteristics, imaging features of contrast-enhanced ultrasound and computed tomography. BMC Cancer. 16:1582016. View Article : Google Scholar : PubMed/NCBI


Bertino G, Ardiri A, Malaguarnera M, Malaguarnera G, Bertino N and Calvagno GS: Hepatocellualar carcinoma serum markers. Semin Oncol. 39:410–433. 2012. View Article : Google Scholar : PubMed/NCBI


Hagiwara S, Kudo M, Kawasaki T, Nagashima M, Minami Y, Chung H, Fukunaga T, Kitano M and Nakatani T: Prognostic factors for portal venous invasion in patients with hepatocellular carcinoma. J Gastroenterol. 41:1214–1219. 2006. View Article : Google Scholar


Tamura Y, Igarashi M, Kawai H, Suda T, Satomura S and Aoyagi Y: Clinical advantage of highly sensitive on-chip immunoassay for fucosylated fraction of alpha-fetoprotein in patients with hepatocellular carcinoma. Dig Dis Sci. 55:pp. 3576–3583. 2010, View Article : Google Scholar : PubMed/NCBI


Choi J, Kim GA, Han S, Lee W, Chun S and Lim YS: Longitudinal assessment of three serum biomarkers to detect very early stage hepatocellular carcinoma. Hepatology. 69:1983–1994. 2019. View Article : Google Scholar


Choi JY, Jung SW, Kim HY, Kim M, Kim Y, Kim DG and Oh EJ: Diagnostic value of AFP‑L3 and PIVKA‑II in hepatocellular carcinoma according to total-AFP. World J Gastroenterol. 19:339–346. 2013. View Article : Google Scholar : PubMed/NCBI


Taketa K: Alpha-fetoprotein: Reevaluation in hepatology. Hepatology. 12:1420–1432. 1990. View Article : Google Scholar : PubMed/NCBI


Zhang YS, Chu JH, Cui SX, Song ZY and Qu XJ: Des‑γ-carboxy prothrombin (DCP) as a potential autologous growth factor for the development of hepatocellular carcinoma. Cell Physiol Biochem. 34:903–915. 2014. View Article : Google Scholar


Hu B, Tian X, Sun J and Meng X: Evaluation of individual and combined applications of serum biomarkers for diagnosis of hepatocellular carcinoma: A meta‑analysis. Int J Mol Sci. 14:23559–23580. 2013. View Article : Google Scholar : PubMed/NCBI


Volk ML, Hernandez JC, Su GL, Lok AS and Marrero JA: Risk factors for hepatocellular carcinoma may impair the performance of biomarkers: A comparison of AFP, DCP, and AFP-L3. Cancer Biomark. 3:79–87. 2007. View Article : Google Scholar : PubMed/NCBI


Song P, Tobe RG, Inagaki Y, Kokudo N, Hasegawa K, Sugawara Y and Tang W: The management of hepatocellular carcinoma around the world: A comparison of guidelines from 2001 to 2011. Liver Int. 32:1053–1063. 2012. View Article : Google Scholar : PubMed/NCBI


Yamamoto K, Imamura H, Matsuyama Y, Kume Y, Ikeda H, Norman GL, Shums Z, Aoki T, Hasegawa K, Beck Y, 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. 45:1272–1282. 2010. View Article : Google Scholar : PubMed/NCBI


Chen J, Wu G and Li Y: Evaluation of serum des-gamma-carboxy prothrombin for the diagnosis of hepatitis B virus-related hepatocellular carcinoma: A meta-analysis. Dis Markers. 2018:pp. 89060232018, View Article : Google Scholar : PubMed/NCBI


Masuzaki R, Karp SJ and Omata M: New serum markers of hepatocellular carcinoma. Semin Oncol. 39:pp. 434–439. 2012, View Article : Google Scholar : PubMed/NCBI


Wang K, Guo W, Li N, Shi J, Zhang C, Lau WY, Wu M and Cheng S: Alpha‑1‑fucosidase as a prognostic indicator for hepatocellular carcinoma following hepatectomy: A large-scale, long-term study. Br J Cancer. 110:1811–1819. 2014. View Article : Google Scholar : PubMed/NCBI


Mintz K, Waidely E, Zhou Y, Peng Z, Al‑Youbi AO, Bashammakh AS, El‑Shahawi MS and Leblanc RM: Carbon dots and gold nanoparticles based immunoassay for detection of alpha-L-fucosidase. Anal Chim Acta. 1041:114–121. 2018. View Article : Google Scholar : PubMed/NCBI


El‑Tayeh SF, Hussein TD, El‑Houseini ME, Amer MA, El‑Sherbini M and Elshemey WM: Serological biomarkers of hepatocellular carcinoma in Egyptian patients. Dis Markers. 32:255–263. 2012. View Article : Google Scholar


Waidely E, Al‑Youbi AO, Bashammakh AS, El‑Shahawi MS and Leblanc RM: Alpha-l-fucosidase immunoassay for early detection of hepatocellular carcinoma. Anal Chem. 89:9459–9466. 2017. View Article : Google Scholar : PubMed/NCBI


Wei C, Yang X, Liu N, Geng J, Tai Y, Sun Z, Mei G, Zhou P, Peng Y, Wang C, et al: Tumor microenvironment regulation by the endoplasmic reticulum stress transmission mediator Golgi protein 73 in mice. Hepatology. 70:851–870. 2019. View Article : Google Scholar : PubMed/NCBI


Liu Y, Zhang X, Zhou S, Shi J, Xu Y, He J, Lin F, Wei A, Zhou L and Chen Z: Knockdown of Golgi phosphoprotein 73 blocks the trafficking of matrix metalloproteinase‑2 in hepatocellular carcinoma cells and inhibits cell invasion. J Cell Mol Med. 23:2399–2409. 2019. View Article : Google Scholar : PubMed/NCBI


Block TM, Comunale MA, Lowman M, Steel LF, Romano PR, Fimmel C, Tennant BC, London WT, Evans AA, Blumberg B S, et al: use of targeted glycoproteomics to identify serum glycoproteins that correlate with liver cancer in woodchucks and humans. Proc Natl Acad Sci USA. 102:pp. 779–784. 2005, View Article : Google Scholar : PubMed/NCBI


Mao Y, Yang H, Xu H, Lu X, Sang X, Du S, Zhao H, Chen W, Xu Y, Chi T, et al: Golgi protein 73 (GOLPH2) is a valuable serum marker for hepatocellular carcinoma. Gut. 59:1687–1693. 2010. View Article : Google Scholar : PubMed/NCBI


Ibrahim GH, Mahmoud MA and Aly NM: Evaluation of circulating transforming growth factor-beta1, glypican-3 and Golgi protein-73 mRNAs expression as predictive markers for hepatocellular carcinoma in Egyptian patients. Mol Biol Rep. 40:7069–7075. 2013. View Article : Google Scholar : PubMed/NCBI


Zhang Z, Zhang Y, Wang Y, Xu L and Xu W: Alpha‑fetoprotein‑L3 and Golgi protein 73 may serve as candidate biomarkers for diagnosing alpha-fetoprotein-negative hepatocellular carcinoma. Onco Targets Ther. 9:123–129. 2015.


Lamort AS, Giopanou I, Psallidas I and Stathopoulos GT: Osteopontin as a link between infammation and cancer: The thorax in the spotlight. Cells. 8:pii: E815. 2019, View Article : Google Scholar


Ying X, Zhao Y, Wang JL, Zhou X, Zhao J, He CC, Guo XJ, Jin GH, Wang LJ, Zhu Q and Han SX: Serum anti‑osteopontin autoantibody as a novel diagnostic and prognostic biomarker in patients with hepatocellular carcinoma. Oncol Rep. 32:1550–1556. 2014. View Article : Google Scholar : PubMed/NCBI


Shang S, Plymoth A, Ge S, Feng Z, Rosen HR, Sangrajrang S, Hainaut P, Marrero JA and Beretta L: Identification of osteo-pontin as a novel marker for early hepatocellular carcinoma. Hepatology. 55:483–490. 2012. View Article : Google Scholar


Zhu Y, Yang J, Xu D, Gao XM, Zhang Z, Hsu JL, Li CW, Lim SO, Sheng YY, Zhang Y, et al: Disruption of tumour-associated macrophage trafficking by the osteopontin‑induced colony‑stimulating factor-1 signalling sensitises hepatocellular carcinoma to anti-PD-L1 blockade. Gut. 9:1653–1666. 2019. View Article : Google Scholar


Liu K, Duan J, Liu H, Yang X, Yang J, Wu M and Chang Y: Precancer antiviral treatment reduces microvascular invasion of early‑stage Hepatitis B‑related hepatocellular carcinoma. Sci Rep. 9:22202019. View Article : Google Scholar


Qin XL, Wang ZR, Shi JS, Lu M, Wang L and He QR: Utility of serum CA19-9 in diagnosis of cholangiocarcinoma: In comparison with CEA. World J Gastroenterol. 10:427–432. 2004. View Article : Google Scholar : PubMed/NCBI


Minato H, Nakanuma Y and Terada T: Expression of blood group-related antigens in cholangiocarcinoma in relation to non-neoplastic bile ducts. Histopathology. 28:411–419. 1996. View Article : Google Scholar : PubMed/NCBI


Wang Y, Li J, Xia Y, Gong R, Wang K, Yan Z, Wan X, Liu G, Wu D, Shi L, et al: Prognostic nomogram for intrahepatic cholangiocarcinoma after partial hepatectomy. J Clin Oncol. 31:1188–1195. 2013. View Article : Google Scholar : PubMed/NCBI


Yamada T, Nakanishi Y, Okamura K, Tsuchikawa T, Nakamura T, Noji T, Asano T, Tanaka K, Kurashima Y, Ebihara Y, et al: Impact of serum carbohydrate antigen 19-9 level on prognosis and prediction of lymph node metastasis in patients with intrahepatic cholangiocarcinoma. J Gastroenterol Hepatol. Feb 10–2018, Epub ahead of print. View Article : Google Scholar


Carr BI, Kanke F, Wise M and Satomura S: Clinical evaluation of lens culinaris agglutinin-reactive alpha-fetoprotein and des-gamma-carboxy prothrombin in histologically proven hepatocellular carcinoma in the United States. Dig Dis Sci. 52:776–782. 2007. View Article : Google Scholar : PubMed/NCBI


Omata M, Cheng AL, Kokudo N, Kudo M, Lee JM, Jia J, Tateishi R, Han KH, Chawla YK, Shiina S, et al: Asia‑Pacific clinical practice guidelines on the management of hepatocellular carcinoma: A 2017 update. Hepatol Int. 11:317–370. 2017. View Article : Google Scholar : PubMed/NCBI


Kokudo N, Hasegawa K, Akahane M, Igaki H, Izumi N, Ichida T, Uemoto S, Kaneko S, Kawasaki S, Ku Y, et al: Evidence-based clinical practice guidelines for hepatocellular carcinoma: The Japan society of hepatology 2013 update (3rd JSH‑HCC Guidelines). Hepatol Res. 45:2015. View Article : Google Scholar


World Health Organization (WHO): Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection. WHO; Geneva: 2015


Zhou J, Sun HC, Wang Z, Cong WM, Wang JH, Zeng MS, Yang JM, Bie P, Liu LX, Wen TF, et al: Guidelines for diagnosis and treatment of primary liver cancer in China (2017 Edition). Liver Cancer. 7:235–260. 2018. View Article : Google Scholar : PubMed/NCBI


Nishida T and Kataoka H: Glypican 3-targeted therapy in hepatocellular carcinoma. Cancers (Basel). 11. pii: E1339. 2019, View Article : Google Scholar


Chen C, Huang X, Ying Z, Wu D, Yu Y, Wang X and Chen C: Can glypican‑3 be a disease‑specific biomarker? Clin Transl Med. 6:182017. View Article : Google Scholar


Shirakawa H, Kuronuma T, Nishimura Y, Hasebe T, Nakano M, Gotohda N, Takahashi S, Nakagohri T, Konishi M, Kobayashi N, et al: Glypican-3 is a useful diagnostic marker for a component of hepatocellular carcinoma in human liver cancer. Int J Oncol. 34:649–656. 2009.PubMed/NCBI


Capurro M, Wanless IR, Sherman M, Deboer G, Shi W, Miyoshi E and Filmus J: Glypican-3: A novel serum and histochemical marker for hepatocellular carcinoma. Gastroenterology. 125:89–97. 2003. View Article : Google Scholar : PubMed/NCBI


Kolluri A and Ho M: The role of glypican-3 in regulating Wnt, YAP, and hedgehog in liver cancer. Front Oncol. 9:7082019. View Article : Google Scholar : PubMed/NCBI


Liu H, Li P, Zhai Y, Qu CF, Zhang LJ, Tan YF, Li N and Ding HG: Diagnostic value of glypican-3 in serum and liver for primary hepa-tocellular carcinoma. World J Gastroenterol. 16:4410–4415. 2010. View Article : Google Scholar : PubMed/NCBI


Wang L, Yao M, Pan LH, Qian Q and Yao DF: Glypican‑3 is a biomarker and a therapeutic target of hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int. 14:361–366. 2015. View Article : Google Scholar : PubMed/NCBI


Han HH, Qiu YJ, Shi YY, Wen W, He XP, Dong LW, Tan YX, Long YT, Tian H and Wang HY: Glypican-3-targeted precision diagnosis of hepatocellular carcinoma on clinical sections with a supramolecular 2D imaging probe. Theranostics. 8:3268–3274. 2018. View Article : Google Scholar : PubMed/NCBI


Kakar S, Muir T, Murphy LM, Lloyd RV and Burgart LJ: Immunoreactivity of Hep Par 1 in hepatic and extrahepatic tumors and its correlation with albumin in situ hybridization in hepatocellular carcinoma. Am J Clin Patho. 119:361–366. 2003. View Article : Google Scholar


Leong AS, Sormunen RT, Tsui WM and Liew CT: Hep Par 1 and selected antibodies in the immunohistological distinction of hepatocellular carcinoma from cholangiocarcinoma, combined tumours and metastatic carcinoma. Histopathology. 33:318–324. 1998. View Article : Google Scholar : PubMed/NCBI


Ibrahim TR and Abdel‑Raouf SM: Immunohistochemical study of glypican-3 and HepPar-1 in differentiating hepatocellular carcinoma from metastatic carcinomas in FNA of the liver. Pathol Oncol Res. 21:379–387. 2015. View Article : Google Scholar


Kakar S, Gown AM, Goodman ZD and Ferrell LD: Best practices in diagnostic immunohistochemistry: Hepatocellular carcinoma versus metastatic neoplasms. Arch Pathol Lab Med. 131:1648–1654. 2007.PubMed/NCBI


Wang C, Zhang Y, Guo K, Wang N, Jin H, Liu Y and Qin W: Heat shock proteins in hepatocellular carcinoma: Molecular mechanism and therapeutic potential. Int J Cancer. 138:1824–1834. 2016. View Article : Google Scholar : PubMed/NCBI


Chuma M, Sakamoto M, Yamazaki K, Ohta T, Ohki M, Asaka M and Hirohashi S: Expression profiling in multistage hepatocarcinogenesis: Identification of HSP70 as a molecular marker of early hepatocellular carcinoma. Hepatology. 37:198–207. 2003. View Article : Google Scholar


Shin E, Ryu HS, Kim SH, Jung H, Jang JJ and Lee K: The clinicopathological signifcance of heat shock protein 70 and glutamine synthetase expression in hepatocellular carcinoma. J Hepatobiliary Pancreat Sci. 18:pp. 544–550. 2011, View Article : Google Scholar : PubMed/NCBI


Kang GH, Lee BS, Lee ES, Kim SH, Lee HY and Kang DY: Prognostic significance of p53, mTOR, c-Met, IGF-1R, and HSP70 overexpression after the resection of hepatocellular carcinoma. Gut Liver. 8:79–87. 2014. View Article : Google Scholar : PubMed/NCBI


Evason KJ, Grenert J P, Ferrell LD and Kakar S: Atypical hepato-cellular adenoma-like neoplasms with β-catenin activation show cytogenetic alterations similar to well-differentiated hepatocellular carcinomas. Hum Pathol. 44:750–758. 2013. View Article : Google Scholar


Dal Bello B, Rosa L, Campanini N, Tinelli C, Torello Viera F, D'Ambrosio G, Rossi S and Silini EM: Glutamine synthetase immunostaining correlates with pathologic features of hepa-tocellular carcinoma and better survival after radiofrequency thermal ablation. Clin Cancer Res. 16:2157–2166. 2010. View Article : Google Scholar : PubMed/NCBI


Osada T, Nagashima I, Tsuno NH, Kitayama J and Nagawa H: Prognostic significance of glutamine synthetase expression in unifocal advanced hepatocellular carcinoma. J Hepatol. 33:247–253. 2000. View Article : Google Scholar : PubMed/NCBI


Nguyen TB, Roncalli M, Di Tommaso L and Kakar S: Combined use of heat-shock protein 70 and glutamine synthetase is useful in the distinction of typical hepatocellular adenoma from atypical hepatocellular neoplasms and well-differentiated hepatocellular carcinoma. Mod Pathol. 29:283–292. 2016. View Article : Google Scholar : PubMed/NCBI


Uthamalingam P, Das A, Behra A, Kalra N and Chawla Y: Diagnostic value of glypican3, heat shock protein 70 and glutamine synthetase in hepatocellular carcinoma arising in cirrhotic and non-cirrhotic livers. J Clin Exp Hepatol. 8:173–180. 2018. View Article : Google Scholar : PubMed/NCBI


Lagana SM, Moreira RK, Remotti HE and Bao F: Glutamine synthetase, heat shock protein-70, and glypican-3 in intrahepatic cholangiocarcinoma and tumors metastatic to liver. Appl Immunohistochem Mol Morphol. 21:254–257. 2013.


Timek DT, Shi J, Liu H and Lin F: Arginase‑1, HepPar‑1, and Glypican-3 are the most effective panel of markers in distinguishing hepatocellular carcinoma from metastatic tumor on fine‑needle aspiration specimens. Am J Clin Pathol. 138:pp. 203–210. 2012, View Article : Google Scholar : PubMed/NCBI


Pesce JT, Ramalingam TR, Mentink‑Kane MM, Wilson MS, El Kasmi KC, Smith AM, Thompson RW, Cheever AW, Murray PJ and Wynn TA: Arginase-1-expressing macrophages suppress Th2 cytokine‑driven infammation and fibrosis. PLoS Pathog. 5:e10003712009. View Article : Google Scholar


Fujiwara M, Kwok S, Yano H and Pai RK: Arginase‑1 is a more sensitive marker of hepatic differentiation than HepPar-1 and glypican-3 in fine-needle aspiration biopsies. Cancer Cytopathol. 120:230–237. 2012. View Article : Google Scholar : PubMed/NCBI


Yan BC, Gong C, Song J, Krausz T, Tretiakova M, Hyjek E, Al‑Ahmadie H, Alves V, Xiao SY, Anders RA and Hart JA: Arginase-1: A new immunohistochemical marker of hepatocytes and hepatocellular neoplasms. Am J Surg Pathol. 34:pp. 1147–1154. 2010, View Article : Google Scholar : PubMed/NCBI


Moll R, Divo M and Langbein L: The human keratins: Biology and pathology. Histochem Cell Biol. 129:705–733. 2008. View Article : Google Scholar : PubMed/NCBI


Ryu HS, Lee K, Shin E, Kim SH, Jing J, Jung HY, Lee H and Jang JJ: Comparative analysis of immunohistochemical markers for differential diagnosis of hepatocelluar carcinoma and cholan-giocarcinoma. Tumori. 98:478–484. 2012. View Article : Google Scholar : PubMed/NCBI


Liu LZ, Yang LX, Zheng BH, Dong PP, Liu XY, Wang ZC, Zhou J, Fan J, Wang XY and Gao Q: CK7/CK19 index: A potential prognostic factor for postoperative intrahepatic cholangiocarcinoma patients. J Surg Oncol. 117:pp. 1531–1539. 2018, View Article : Google Scholar : PubMed/NCBI


Pinato DJ, Pirisi M, Maslen L and Sharma R: Tissue biomarkers of prognostic significance in hepatocellular carcinoma. Adv Anat Pathol. 21:270–284. 2014. View Article : Google Scholar : PubMed/NCBI


Calderaro J, Couchy G, Imbeaud S, Amaddeo G, Letouzé E, Blanc JF, Laurent C, Hajji Y, Azoulay D, Bioulac-Sage P, et al: Histological subtypes of hepatocellular carcinoma are related to gene mutations and molecular tumour classification. J Hepatol. 67:727–738. 2017. View Article : Google Scholar : PubMed/NCBI


Totoki Y, Tatsuno K, Covington KR, Ueda H, Creighton CJ, Kato M, Tsuji S, Donehower LA, Slagle BL, Nakamura H, et al: Trans-ancestry mutational landscape of hepatocellular carcinoma genomes. Nat Genet. 46:1267–1273. 2014. View Article : Google Scholar : PubMed/NCBI


Yu JI, Choi C, Ha SY, Park CK, Kang SY, Joh JW, Paik SW, Kim S, Kim M, Jung SH and Park HC: Clinical importance of TERT overexpression in hepatocellular carcinoma treated with curative surgical resection in HBV endemic area. Sci Rep. 7:122582017. View Article : Google Scholar : PubMed/NCBI


Wang P, Dong Q, Zhang C, Kuan PF, Liu Y, Jeck WR, Andersen JB, Jiang W, Savich GL, Tan TX, et al: Mutations in isocitrate dehydrogenase 1 and 2 occur frequently in intrahepatic cholangiocarcinomas and share hypermethylation targets with glioblastomas. Oncogene. 32:3091–3100. 2013. View Article : Google Scholar


Xu YF, Liu HD, Liu ZL, Pan C, Yang XQ, Ning SL, Zhang ZL, Guo S and Yu JM: Sprouty2 suppresses progression and correlates to favourable prognosis of intrahepatic cholangiocar-cinoma via antagonizing FGFR2 signalling. J Cell Mol Med. 22:5596–5606. 2018. View Article : Google Scholar : PubMed/NCBI


Mazzaferro V, El‑Rayes BF, Droz Dit Busset M, Cotsoglou C, Harris W P, Damjanov N, Masi G, Rimassa L, Personeni N, Braiteh F, et al: Derazantinib (ARQ 087) in advanced or inoperable FGFR2 gene fusion-positive intrahepatic cholangio-carcinoma. Br J Cancer. 120:165–171. 2019. View Article : Google Scholar


Sheng Y, Wei J, Zhang Y, Gao X, Wang Z, Yang J, Yan S, Zhu Y, Zhang Z, Xu D, et al: Mutated EPHA2 is a target for combating lymphatic metastasis in intrahepatic cholangiocarcinoma. Int J Cancer. 144:2440–2452. 2019. View Article : Google Scholar


Tian XP, Wang CY, Jin XH, Li M, Wang FW, Huang WJ, Yun JP, Xu RH, Cai QQ and Xie D: Acidic microenvironment up‑regu-lates exosomal miR-21 and miR-10b in early-stage hepatocellular carcinoma to promote cancer cell proliferation and metastasis. Theranostics. 9:1965–1979. 2019. View Article : Google Scholar :


Amr KS, Elmawgoud Atia HA, Elazeem Elbnhawy RA and Ezzat WM: Early diagnostic evaluation of miR-122 and miR-224 as biomarkers for hepatocellular carcinoma. Genes Dis. 4:215–221. 2017. View Article : Google Scholar


Wang L, Sun L, Wang Y, Yao B, Liu R, Chen T, Tu K, Liu Q and Liu Z: MiR-1204 promotes hepatocellular carcinoma progression through activating MAPK and c-Jun/AP1 signaling by targeting ZNF418. Int J Biol Sci. 15:pp. 1514–1522. 2019, View Article : Google Scholar : PubMed/NCBI


Ji J, Rong Y, Luo CL, Li S, Jiang X, Weng H, Chen H, Zhang WW, Xie W and Wang FB: Up-regulation of hsa-miR-210 promotes venous metastasis and predicts poor prognosis in hepatocellular carcinoma. Front Oncol. 8:5692018. View Article : Google Scholar : PubMed/NCBI


Li F, Wang F, Zhu C, Wei Q, Zhang T and Zhou YL: MiR-221 suppression through nanoparticle-based miRNA delivery system for hepatocellular carcinoma therapy and its diagnosis as a potential biomarker. Int J Nanomedicine. 13:2295–2307. 2018. View Article : Google Scholar : PubMed/NCBI


Li H, Zhou ZQ, Yang ZR, Tong DN, Guan J, Shi BJ, Nie J, Ding XT, Li B, Zhou GW and Zhang ZY: MicroRNA‑191 acts as a tumor promoter by modulating the TET1-p53 pathway in intrahepatic cholangiocarcinoma. Hepatology. 66:136–151. 2017. View Article : Google Scholar : PubMed/NCBI


Wu J, Yang B, Zhang Y, Feng X, He B, Xie H, Zhou L, Wu J and Zheng S: MiR-424-5prepresses the metastasis and invasion of intrahepatic cholangiocarcinoma by targeting ARK5. Int J Biol Sci. 15:pp. 1591–1599. 2019, View Article : Google Scholar :


Marisi G, Cucchetti A, Ulivi P, Canale M, Cabibbo G, Solaini L, Foschi FG, De Matteis S, Ercolani G, Valgiusti M, et al: Ten years of sorafenib in hepatocellular carcinoma: Are there any predictive and/or prognostic markers. World J Gastroenterol. 24:4152–4163. 2018. View Article : Google Scholar : PubMed/NCBI


Shao Q, Ren P, Li Y, Peng B, Dai L, Lei N, Yao W, Zhao G, Li L and Zhang J: Autoantibodies against glucose‑regulated protein 78 as serological diagnostic biomarkers in hepatocellular carcinoma. Int J Oncol. 41:1061–1067. 2012. View Article : Google Scholar : PubMed/NCBI


Chiou JF, Tai CJ, Huang MT, Wei PL, Wang YH, An J, Wu CH, Liu TZ and Chang YJ: Glucose‑regulated protein 78 is a novel contributor to acquisition of resistance to sorafenib in hepatocel-lular carcinoma. Ann Surg Oncol. 17:pp. 603–612. 2010, View Article : Google Scholar


Li R, Yanjiao G and Wubin H: Secreted GRP78 activates EGFR‑SRC‑STAT3 signaling and confers the resistance to sora-feinib in HCC cells. Oncotarget. 8:19354–19364. 2017. View Article : Google Scholar : PubMed/NCBI


Hu H, Gao L, Wang C, Li Y, Ma H, Chen L, Qin J, Liu B, Liu Y and Liang C: Lower serum soluble-EGFR is a potential biomarker for metastasis of HCC demonstrated by N-glycoproteomic analysis. Discov Med. 19:333–341. 2015.PubMed/NCBI


Ezzoukhry Z, Louandre C, Trécherel E, Godin C, Chauffert B, Dupont S, Diouf M, Barbare JC, Mazière JC and Galmiche A: EGFR activation is a potential determinant of primary resistance of hepatocellular carcinoma cells to sorafenib. Int J Cancer. 131:2961–2969. 2012. View Article : Google Scholar : PubMed/NCBI


Komposch K and Sibilia M: EGFR signaling in liver diseases. Int J Mol Sci. 17:pii: E30. 2015, View Article : Google Scholar


Firtina Karagonlar Z, Koc D, Iscan E, Erdal E and Atabey N: Elevated hepatocyte growth factor expression as an autocrine c-Met activation mechanism in acquired resistance to sorafenib in hepatocellular carcinoma cells. Cancer Sci. 107:pp. 407–416. 2016, View Article : Google Scholar : PubMed/NCBI


Xiang Q, Chen W, Ren M, Wang J, Zhang H, Deng DY, Zhang L, Shang C and Chen Y: Cabozantinib suppresses tumor growth and metastasis in hepatocellular carcinoma by a dual blockade of VEGFR2 and MET. Clin Cancer Res. 20:pp. 2959–2970. 2014, View Article : Google Scholar : PubMed/NCBI


Han P, Li H, Jiang X, Zhai B, Tan G, Zhao D, Qiao H, Liu B, Jiang H and Sun X: Dual inhibition of Akt and c‑Met as a second-line therapy following acquired resistance to sorafenib in hepatocellular carcinoma cells. Mol Oncol. 11:320–334. 2017. View Article : Google Scholar : PubMed/NCBI


Capurro M, Martin T, Shi W and Filmus J: Glypican‑3 binds to Frizzled and plays a direct role in the stimulation of canonical Wnt signaling. J Cell Sci. 127:pp. 1565–1575. 2014, View Article : Google Scholar : PubMed/NCBI


Austinat M, Dunsch R, Wittekind C, Tannapfel A, Gebhardt R and Gaunitz F: Correlation between beta-catenin mutations and expression of Wnt-signaling target genes in hepatocellular carcinoma. Mol Cancer. 7:212008. View Article : Google Scholar : PubMed/NCBI


Lachenmayer A, Alsinet C, Savic R, Cabellos L, Toffanin S, Hoshida Y, Villanueva A, Minguez B, Newell P, Tsai H W, et al: Wnt-pathway activation in two molecular classes of hepatocellular carcinoma and experimental modulation by sorafenib. Clin Cancer Res. 18:4997–5007. 2012. View Article : Google Scholar : PubMed/NCBI


Hu CT, Wu JR, Cheng CC and Wu WS: The therapeutic targeting of HGF/c-Met signaling in hepatocellular carcinoma: Alternative approaches. Cancers (Basel). 9. pii: E58. 2017, View Article : Google Scholar


Gao W, Kim H and Ho M: Human monoclonal antibody targeting the heparan sulfate chains of glypican-3 inhibits HGF-mediated migration and motility of hepatocellular carcinoma cells. PLoS One. 10:e01376642015. View Article : Google Scholar : PubMed/NCBI


Yu J, Yuan X, Sjöholm L, Liu T, Kong F, Ekström TJ, Björkholm M and Xu D: Telomerase reverse transcriptase regulates DNMT3B expression/aberrant DNA methylation phenotype and AKT activation in hepatocellular carcinoma. Cancer Lett. 434:33–41. 2018. View Article : Google Scholar : PubMed/NCBI


Wang S, Zhu M, Wang Q, Hou Y, Li L, Weng H, Zhao Y, Chen D, Ding H, Guo J and Li M: Alpha-fetoprotein inhibits autophagy to promote malignant behaviour in hepatocellular carcinoma cells by activating PI3K/AKT/mTOR signaling. Cell Death Dis. 10:pp. 832019, View Article : Google Scholar


Meng X, Franklin DA, Dong J and Zhang Y: MDM2‑p53 pathway in hepatocellular carcinoma. Cancer Res. 74:7161–7167. 2014. View Article : Google Scholar : PubMed/NCBI

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Gao YX, Yang TW, Yin JM, Yang PX, Kou BX, Chai MY, Liu XN and Chen DX: Progress and prospects of biomarkers in primary liver cancer (Review). Int J Oncol 57: 54-66, 2020
Gao, Y., Yang, T., Yin, J., Yang, P., Kou, B., Chai, M. ... Chen, D. (2020). Progress and prospects of biomarkers in primary liver cancer (Review). International Journal of Oncology, 57, 54-66.
Gao, Y., Yang, T., Yin, J., Yang, P., Kou, B., Chai, M., Liu, X., Chen, D."Progress and prospects of biomarkers in primary liver cancer (Review)". International Journal of Oncology 57.1 (2020): 54-66.
Gao, Y., Yang, T., Yin, J., Yang, P., Kou, B., Chai, M., Liu, X., Chen, D."Progress and prospects of biomarkers in primary liver cancer (Review)". International Journal of Oncology 57, no. 1 (2020): 54-66.