|Year : 2019 | Volume
| Issue : 1 | Page : 359-362
Diagnostic value of serum Dickkopf-1 as a predictor of hepatocellular carcinoma in patients with liver cirrhosis
Ashraf G Dala1, Mohammed H Badr1, Mona S Habib2, Ahmed E El-Shandalaty3
1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Medical Biochemistry, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Gastroentology and Hepatology, Ahmed Maher Teaching Hospital, Cairo, Egypt
|Date of Submission||12-Oct-2017|
|Date of Acceptance||24-Dec-2017|
|Date of Web Publication||17-Apr-2019|
Ahmed E El-Shandalaty
El-Santa, El-Gharbia, 31631
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the significance of Dickkopf-1 (DKK-1) as a tumor marker for the diagnosis of hepatocellular carcinoma (HCC) in cirrhotic patients.
HCC is a major health problem and its prognosis still remains dismal.
Patients and methods
This cross-sectional study included 50 cirrhotic patients with HCC, 50 cirrhotic patients without HCC, and 20 healthy age-matched and sex-matched participants as controls. All patients and controls were subjected to the following: full history taking, full clinical examination, and investigations as complete blood count, kidney function tests, liver function tests, serum α-fetoprotein (AFP), serum DKK-1, abdominal ultrasound, and triphasic computed tomography scan were done.
DKK-1 level was significantly higher in the HCC group than in cirrhotic and control groups (P = 0.002). DKK-1 was significantly higher in multiple focal lesions (P = 0.010) and large focal lesions greater than 5 cm (P = 0.014). The best cut-off value of DKK-1 was 1.122 with a sensitivity of 80%, specificity of 77.1% with an area under curve of 0.810 and P value of less than 0.001. The validity of combined serum AFP and DKK-1 in the diagnosis of HCC showed an increased sensitivity of 92%, specificity of 77.1% with an area under curve of 0.882 and P value of less than 0.001.
DKK-1 was more sensitive and specific than AFP in the early diagnosis of HCC in cirrhotics. Combined use of DKK-1 and AFP increased the sensitivity and specificity for the diagnosis of HCC than serum AFP or DKK-1 alone.
Keywords: α-fetoprotein, Dickkopf-1, hepatocellular carcinoma, liver cirrhosis
|How to cite this article:|
Dala AG, Badr MH, Habib MS, El-Shandalaty AE. Diagnostic value of serum Dickkopf-1 as a predictor of hepatocellular carcinoma in patients with liver cirrhosis. Menoufia Med J 2019;32:359-62
|How to cite this URL:|
Dala AG, Badr MH, Habib MS, El-Shandalaty AE. Diagnostic value of serum Dickkopf-1 as a predictor of hepatocellular carcinoma in patients with liver cirrhosis. Menoufia Med J [serial online] 2019 [cited 2019 May 24];32:359-62. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/359/256141
| Introduction|| |
Hepatocellular carcinoma (HCC) is a common form of cancer in the world and is the third leading cause of cancer-related death . More than 80% of its incidence is found in developing countries; rates are more than twice as high in men compared with women. HCC is the most common form among primary liver cancers occurring worldwide, about 70–85% of liver tumors. Moreover, HCC is one of the most fatal cancers, with 5-year relative survival rates of less than 11%, even in developed countries . HCC is a bad complication of cirrhosis regardless of its etiology; the risk of malignancy varies according to the cause of cirrhosis .
HCC is multifactorial in origin and a number of associated major and minor risk factors have been identified. The major risk factors include aflatoxin, chronic hepatitis C virus, and hepatitis B virus infections. The minor risk factors include hereditary hemochromatosis, oral contraceptives and androgens, cigarette smoking, and membranous obstruction of the inferior vena cava .
Egypt has rising morbidity and mortality rates from HCC, where the relative frequency of HCC in Egypt increased from 4.0% in 1993 to 7.3% in 2003  This rising incidence of HCC in Egypt may be explained by the increasing prevalence of risk factors such as the emergence of hepatitis C virus over the same period of time, the contribution of hepatitis B virus infection, and improvements in screening programs and diagnostic tools, as well as the increased survival rate among patients with cirrhosis allowing time for some of them to develop HCC . Symptomatic advanced-stage HCC has dismal outcomes (5-year life expectancy <10%). In comparison, early detection of asymptomatic HCC is more amenable to treatment, with 5-year survival rates being greater than 50% for both resection and liver transplantation . Patients who develop HCC are usually asymptomatic. Suspicion for HCC should be heightened in patients with previously compensated cirrhosis who became decompensated and has jaundice, ascites, variceal bleeding, or encephalopathy . Some patients may have mild to moderate upper abdominal pain, low-grade fever, weight loss, early satiety, or a palpable mass in the upper abdomen. These symptoms often indicate an advanced lesion . Patients with HCC occasionally develop paraneoplastic syndrome .
Dickkopf-1 (DKK-1), a secreted protein involved in head formation in embryonic development, binds to the low-density lipoprotein receptor-related protein-5/6 (LRP5/6) Wnt co-receptor and prevents the formation of active Wnt–Frizzled–LRP5/6 receptor complexes, thus blocking the canonical Wnt/β-catenin signaling pathway . The Wnt pathway plays an important role in cancer  and thus DKKs are one of those Wnt modulators . DKK-1 is downregulated in human colon tumors, while overexpression was found in multiple myelomas, Wilms' tumors, and human hepatoblastomas . DKK-1 was found specifically overexpressed in cancer cells as a secreted protein, and it had potential to be used as a tumor-specific serum biomarker for various human cancers, especially for HCC, it was proposed that the performance of DKK-1 was better than α-fetoprotein (AFP) in distinguishing HCC patients . The study aimed to evaluate the significance of DKK-1 as a tumor marker for the diagnosis of HCC in cirrhotic patients.
| Patients and Methods|| |
This cross-sectional study was conducted on 100 patients recruited from Ahmed Maher Teaching Hospital, Cairo, Egypt in the period from September 2016 to September 2017. This study was approved by the Ethics Committee of Menoufia Faculty of Medicine, and informed consent was taken from each patient.
Patients were divided as follows: HCC group consisted of 50 patients with liver cirrhosis and HCC (diagnosis of HCC based on the presence of typical vascular pattern of early enhancement of the arterial phase with rapid washout of portal venous phases of triphasic computed tomography scan). Cirrhotic group consisted of 50 patients with liver cirrhosis without HCC. Control group had 20 healthy age-matched and sex-matched participants.
Exclusion criteria included patients with any other malignancies such as liver metastasis, cancer pancreas, cholangiocarcinoma, or patients with chronic illness.
All patients and controls were subjected to the following: full history taking, clinical examination, and laboratory investigations which included analysis of hemoglobin concentration and prothrombin time were done according to the manufacturer's instructions using specific kits supplied by Randox Laboratories (Crumlin, UK). Measurement of serum creatinine, urea, alanine aminotransferase, aspartate aminotransferase, bilirubin, and albumin were done as described by the manufacturer using the specific kits supplied by Sigma Aldrich (St. Louis, Missouri, USA).
Measurement of serum AFP was done by specific human AFP enzyme-linked immunosorbent assay kit (RayBiotech, Norcross, Georgia, USA). Measurement of serum DKK-1 levels was done by Human DKK-1 enzyme-linked immunosorbent assay kit (RayBiotech) according to the manufacturer's instructions.
Abdominal ultrasonography was done to assess the presence of liver cirrhosis, ascites, and hepatic focal lesions. Triphasic spiral computed tomography abdomen was done in different phases of contrast enhancement (hypervascular in the arterial phase with rapid washout in the portal venous or delayed phases).
The data collected were tabulated and analyzed by the statistical package for the social sciences (SPSS) version 22 (2013; IBM, Armonk, New York, USA).
Kruskal–Wallis test was used for comparison of quantitative variables between more than two groups of not normally distributed data with least significant differences test as the post-hoc test. Spearman's correlation was not used for normally distributed ones. The power of the study was 80% with a confidence level of 95%.
Descriptive statistics was presented as mean and SD, and number and percentage and analyzed by applying χ2-test. Student's t-test was used for comparing two groups of normally distributed variables; Mann–Whitney U-test, correlation coefficient test (r-test), and regression analysis were also performed whenever appropriate. Results were considered of significance at P value less than 0.05 and highly significant at P value less than 0.001.
| Results|| |
DKK-1 could be used as marker of HCC as the level of DKK-1 in HCC group was significantly higher than in cirrhotic and control groups (2.27 ± 2.04, 0.93 ± 0.31, 0.99 ± 0.53 ng/ml, respectively) (P = 0.002) [Table 1].
|Table 1: Comparison between α-fetoprotein and Dickkopf-1 levels among the studied groups (n=120)|
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DKK-1 could be used as a predictor of the number and size of HCC lesions as it was significantly higher in multiple focal lesions than in single lesions (P = 0.010) while no significant difference being found between both groups as regarding AFP (P = 0.419) [Table 2].
|Table 2: Comparison between single and multiple focal lesions regarding α-fetoprotein and Dickkopf-1|
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AFP and DKK-1 levels were significantly higher in patients with focal lesions greater than or equal to 5 cm than in those with lesions less than 5 cm (P = 0.033 and 0.014, respectively) [Table 3].
|Table 3: Comparison among different sizes of hepatocellular carcinoma regarding α-fetoprotein and Dickkopf-1|
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The best cut-off value of DKK-1 was 1.122 ng/ml with a sensitivity of 80% and specificity of 77.1%. So DKK-1 value was significant in the diagnosis of HCC cases with an area under curve (AUC) of 0.810 and P value of less than 0.001 [Table 4].
|Table 4: Validity of serum α-fetoprotein, Dickkopf-1, and combined α-fetoprotein+Dickkopf-1 in the diagnosis of hepatocellular carcinoma cases|
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The validity of combined serum AFP and DKK-1 in the diagnosis of HCC showed an increased sensitivity of 92%, specificity of 77.1% with the AUC being 0.882 where it increased than with AFP alone or DKK-1 alone, and P value of less than 0.001 [Table 4].
| Discussion|| |
HCC is the most common form of primary liver cancer. Globally, liver cancer is the fifth and the seventh most common cancer in men and women, respectively . A new serologic marker with sufficient sensitivity and specificity are required to detect HCC at early stages. So far, several candidates for serum proteins, such as lectin-reactive AFP or des-gamma-carboxyprothrombin, have been studied to find a better, more convenient surveillance tool. However, most of those markers have been shown to be unsatisfactory in diagnosing small HCCs because of low sensitivity, which ranged from 20 to 48% .
In this study, DKK-1 level was significantly higher in the HCC group than in the cirrhotic group and controls. This agreed with Seung et al.  who found that the serum DKK-1 level was significantly higher in HCC patients with a median of 1.48 than in the three control groups (healthy participants, patients with chronic hepatitis, and those with liver cirrhosis with a median of 0.85). Among the three control groups, DKK-1 levels were statistically similar (median 0.90 in healthy participants vs. 0.72 ng/ml in chronic hepatitis patients vs. 0.81 ng/ml in liver cirrhosis patients).
We also measured serum AFP of the HCC group which was significantly higher than the cirrhotic group and controls. Also, there was a significant difference between cirrhotic group and controls that agreed with the results of Hussein et al. .
There was significant difference in the DKK-1 level according to the tumor size [mean of DKK-1 in tumor size <5 cm (1.08 ± 0.27) and ≥5 cm (3.06 ± 2.3)] and number of focal lesions [mean of DKK-1 in single focal lesion (1.51 ± 0.71) and multiple focal lesions (3.61 ± 2.90)], with a significant positive correlation between serum DKK-1 and HCC number and HCC size.
Seung et al.  have found a progressive elevation in the level of DKK-1 with increasing HCC stage. The patients with early-stage HCC had the lowest median level of DKK-1 (1.37 ng/ml), while the patients with advanced HCC had the highest median level of DKK-1 (1.66 ng/ml).
Also, Yu et al. , Tung et al. , and Shen et al.  found that there is correlation between serum DKK-1 level and a larger tumor size (≥5 cm).
In the present study, at a cut-off point of 1.122 ng/ml for DKK-1, the sensitivity of DKK-1 (80%) is higher than that of AFP (68%). But the use of combined AFP and DKK-1 as markers of HCC increased sensitivity to 92%, the specificity of DKK-1 (77.1%) is higher than that of AFP (74.3%). The AUC of DKK-1 (0.810) is higher than that of AFP (0.802). But the use of combined AFP and DKK-1 as markers of HCC increases the AUC to 0.882.
Our results are close to that obtained by Ge et al. , who found a cut-off value of DKK-1 of 1.31 ng/ml, a sensitivity of 79.78%, and a specificity of 89.37% for detecting HCCs, also AFP had a sensitivity of 71.91% and a specificity of 88.04%. Combined serum DKK-1 and AFP had a sensitivity of 88.76% and a specificity of 87.71% for detecting HCCs.
| Conclusion|| |
The significant elevation of DKK-1 and AFP from normal persons to liver cirrhosis to HCC makes the periodic measurement of plasma DKK-1 and AFP important. DKK-1 is more sensitive and specific than AFP in the diagnosis of patients with HCC from those with nonmalignant chronic liver disease.
With combined use of AFP and DKK-1, the sensitivity is 92%, specificity is 77% with the AUC being 0.882, where it increases than that with serum AFP alone or DKK-1 alone.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jiang H, Dong Q, Luo X, Shi B, Wang H, Gao H, et al
. The monoclonal antibody CH12 augments 5-fluorouracil-induced growth suppression of hepatocellular carcinoma xenografts expressing epidermal growth factor receptor variant III. Cancer Lett 2014; 342
Castello G, Scala S, Palmieri G, Curley SA, Izzo F. HCV-related hepatocellular carcinoma: from chronic inflammation to cancer. Clin Immunol 2010; 134
Nash KL, Woodall T, Brown ASM, Davies SE, Alexander GJM. Hepatocellular carcinoma in patients with chronic hepatitis C virus infection without cirrhosis. World J Gastroenterol 2010; 16
Zakhary NI, El-Merzabani MM, El-Sawi NM, Saleh SM, Moneer MM, Mohamad RH. Impact of different biochemical markers in serum of patients with benign and malignant liver diseases. J Adv Res 2011; 43
Lehman EM, Wilson ML. Epidemiology of hepatitis viruses among hepatocellular carcinoma cases and healthy people in Egypt: a systematic review and metaanalysis. Int J Cance 2009; 124
Anwar WA, Khaled HM, Amra HA, El-Nezami H, Loffredo CA. Changing pattern of hepatocellular carcinoma (HCC) and its risk factors in Egypt: possibilities for prevention. Mutat Res 2008; 659
Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. American Association for the Study of Liver Diseases (AASLD) practice guideline. Hepatology 2011; 53
Sugano S, Miyoshi K, Suzuki T, Kawafune T, Kubota M. Intrahepatic arteriovenous shunting due to hepatocellular carcinoma and cirrhosis, and its change by transcatheter arterial embolization. Am J Gastroenterol 1994; 89
Kew MC. Tumors of the liver. In: Zakim D, Boyer T, editors Hepatology: a textbook of liver disease. Philadelphia: WB Saunders Company; 1996. 1513.
Hwang SJ, Li CP, Chu CW, Wu JC, Lai CR, Chiang JH, et al
. Thrombocytosis: a paraneoplastic syndrome in patients with hepatocellular carcinoma. World J Gastroenterol 2004; 10
Zorn AM. Wnt signaling: antagonistic Dickkopfs. Curr Biol 2001; 11
Polakis P. Wnt signaling and cancer. Genes Dev 2000; 14
Tian E, Zhan F, Walker R, Rasmussen E, Ma Y, Barlogie B, et al
. The role of the Wnt-signaling antagonist DKK1 in the development of osteolytic lesions in multiple myeloma. N Engl J Med 2003; 349
Seung UK, Jeon HP, Hyon SK, Lee JM, Lee HG, Kim H, et al
. Serum Dickkopf-1 as a biomarker for the diagnosis of hepatocellular carcinoma. Yonsei Med J 2015; 56
Ge T, Shen Q, Wang N, Zhang Y, Ge Z, Chu W, et al
. Diagnostic values of alpha-fetoprotein, dickkopf-1, and osteopontin for hepatocellular carcinoma. Med Oncol 2015; 32
Poustchi H, Sepanlou S, Esmaili S, Mehrabi N, Ansarymoghadam A. Hepatocellular carcinoma in the world and the Middle East. Middle East J Digest Dis 2010; 2
Song BC, Chung YH, Kim JA, Choi WB, Suh DD, Pyo SI, et al
. Transforming growth factor-beta1 as a useful serologic marker of small hepatocellular carcinoma. Cancer 2002; 94
Hussein MM, Ibrahim AA, Khattab NA, El-Fouly RF, El-Fouly NF. Serum transforming growth factor beta1 in hepatitis C virus related chronic liver disease and hepatocellular carcinoma patients. Med J Cairo Univ 2010; 78
Yu B, Yang X, Xu Y, Yao G, Shu H, Lin B. Elevated expression of DKK1 is associated with cytoplasmic/nuclear beta-catenin accumulation and poor prognosis in hepatocellular carcinomas. J Hepatol 2009; 50
Tung EK, Mak CK, Fatima S, Lo RC, Zhao H, Zhang C, et al
. Clinicopathological and prognostic significance of serum and tissue Dickkopf-1 levels in human hepatocellular carcinoma. Liver Int 2011; 31
Shen Q, Fan J, Yang XR, Tan Y, Zhao W, Xu Y, et al
. Serum DKK1 as a protein biomarker for the diagnosis of hepatocellular carcinoma. a large-scale, multicentre study. Lancet Oncol 2012; 13
[Table 1], [Table 2], [Table 3], [Table 4]