|Year : 2019 | Volume
| Issue : 3 | Page : 938-942
Study of serum level of vascular endothelial growth factor in patients with hepatocellular carcinoma
Ashraf G Dala1, Mohamed H Badr1, Fathia I Elbassal2, Mohamed A. A. Al Diyar3
1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Internal Medicine, Ministry of Health, El-Mahallah El-Kubra, Gharbia, Egypt
|Date of Submission||28-Dec-2017|
|Date of Acceptance||18-Feb-2018|
|Date of Web Publication||17-Oct-2019|
Mohamed A. A. Al Diyar
El-Mahallah El-Kubra, Gharbia
Source of Support: None, Conflict of Interest: None
The aim of this study was to investigate the role of serum vascular endothelial growth factor (VEGF) as a marker for diagnosis and early detection of hepatocellular carcinoma (HCC).
HCC is one of the most common malignancies. VEGF is a master regulator of angiogenesis in normal and malignant tissues.
Participants and methods
This was a cross-sectional study that was carried out in the Internal Medicine Department of El Menoufia University Hospital, Menoufia, throughout the period from July 2016 to April 2017. This research included three groups: group 1 included 40 cirrhotic patients with HCC, group 2 included 40 patients with liver cirrhosis without HCC, and group 3 included 10 healthy volunteers as a control group. All patients were clinically analyzed, underwent different biochemical assessments and assessment of VEGF.
Plotting of receiver operating curve implied that serum VEGF, at a cut-off of 872.5 pg/ml showed a diagnostic sensitivity of 83.3% and specificity of 81.7%. The area under the curve (AUC) was 0.8402. As regards serum α-fetoprotein, the diagnostic performance at the cut-off (320 ng/ml) showed a diagnostic sensitivity of 79.41%, specificity of 60%, and AUC of 0.766. As regards combination of serum α-fetoprotein and VEGF, it showed a diagnostic sensitivity of 82.5%, specificity of 80%, and AUC of 0.8842.
VEGF is suggested to be a promising diagnostic marker with high sensitivity for HCC, which can be used in screening patients with cirrhosis for early detection of HCC.
Keywords: cirrhosis, hepatocellular carcinoma, vascular endothelial growth factor
|How to cite this article:|
Dala AG, Badr MH, Elbassal FI, Al Diyar MA. Study of serum level of vascular endothelial growth factor in patients with hepatocellular carcinoma. Menoufia Med J 2019;32:938-42
|How to cite this URL:|
Dala AG, Badr MH, Elbassal FI, Al Diyar MA. Study of serum level of vascular endothelial growth factor in patients with hepatocellular carcinoma. Menoufia Med J [serial online] 2019 [cited 2019 Dec 7];32:938-42. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/938/268862
| Introduction|| |
Hepatocellular carcinoma (HCC) is known to be one among the foremost common malignancies and has an increasing incidence that causes countless cancer-related deaths globally . Because of the low positive rates of diagnosing of HCC, an oversized proportion of HCC patients would lose their chance to receive curative-intent therapies, corresponding to surgery, radiofrequency ablation, and liver transplantation. The prognosis of patients with advanced HCC, with or without prior treatment, is dismal because of the lack of effective therapy and the complex nature of liver disease . However, with the accumulating recognition of the underlying mechanisms of HCC, a variety of newly developed molecular targeted agents is rising . In recent years, much attention has been focused on revealing the molecular factors or pathways that account for tumor development, growth, and metastases. It is now recognized that angiogenesis is crucial for cancer development, survival, and invasion. The process of formation of the most recent vessel within the tumor microenvironment has been the target for therapeutic regimens. The growth of a tumor is a sublime process consisting of continuous, ordered periods that finally cause tumor revascularization . Angiogenesis occurs during development and vascular remodeling, as a controlled series of events leading to revascularization, which supports changing tissue requirements. Blood vessels and stoma components are responsive to proangiogenic and antiangiogenic factors that allow vascular remodeling during development, wound healing, and pregnancy. However, in pathological situations such as cancer, the same angiogenic signaling pathways are induced and exploited . Angiogenesis contributes to the numerous growths of many cancers, together with HCC; moreover, vascular epithelial cells are involved in these steps, once the dimension of the tumor exceeds 0.5 mm . Vascular endothelial growth factor (VEGF) is a master regulator of growth in traditional and malignant tissues. There are varied relations of VEGF, and every one of them exhibits biological functions by binding to completely different receptors. VEGF plays an important role in prompting proliferation of epithelial cells, thereby resulting in prorevascularization around and at intervals in tumor tissues. VEGF participates in many different processes corresponding to achievement of growth epithelium cells and activation of receptors concerning the proliferation of tumor cells . With regard to the essential roles of vascular epithelial protein in HCC, VEGF-targeted agents that are effective within the treatment of advanced disease are being developed . The aim of this study was to investigate the role of serum vascular epithelium protein as a marker for the diagnosis and early detection of HCC.
| Participants and Methods|| |
The study was approved by the Ethical Committee of Menoufia Faculty of Medicine and an informed written consent obtained from each participant before the study was commenced. This study was carried out as a cross-sectional study and enclosed ninety people who were recruited from the Internal Medicine Department of El Menoufia University Hospital, Menoufia, throughout the period spanning from July 2016 to April 2017.
The enrolled participants were categorized into three categories: group 1 included 40 cirrhotic patients with carcinoma (26 male patients and 14 female patients, age ranging from 42 to 70, with mean age value of 59.1 years); group 2 included 40 patients with liver cirrhosis (24 male patients and 16 female patients with a mean age of 55.2 years); and group 3 included 10 healthy volunteers (control group) who were age and sex -matched (seven male individuals and three female individuals with a mean age of 57 years). Inclusion criteria included the following: patients with HCC and patients with liver cirrhosis secondary to hepatitis C virus infection. Exclusion criteria included the following: liver cirrhosis secondary to hepatitis B virus infection, use of toxic medication, schistosomiasis, and metabolic liver diseases. All patients underwent history taking, full clinical examination, and abdominal ultrasound and computed tomography. Complete laboratory assessment for liver function (alanine transaminase, aspartate transaminase, albumin, total bilirubin, and direct bilirubin) was performed using Hitachi 912 chemistry analyzer (Roche Diagnostics GmbH, Mannheim, Germany), α-fetoprotein (AFP) was analyzed using Cobas e411 automated analyzer (Roche Diagnostics GmbH) and evaluation of VEGF level was performed by enzyme-linked immune sorbent assay using the available commercial kit (Cloud-Clone, Houston, Texas, USA).
The gathered data were structured, tabulated, and statistically examined using SPSS software (Statistical Bundle for the Sociable Sciences, version 19; SPSS Inc., Chicago, Illinois, USA). For quantitative data, the number implies and SD was determined. For qualitative data, which explain a categorical group of data by rate of recurrence, percentage of every category, comparability between two groups and much more was analyzed using χ2-test. For comparability between more than two means of parametric data, F value of analysis of variance test was computed. Receiver operating characteristic (ROC) curve was used to check the level of sensitivity of VEGF to identify the role of serum vascular epithelium protein as a marker for diagnosis and detection of HCC. P value of less than 0.05 for interpretation of results of assessments of value was used .
| Results|| |
There was no statistically significant difference between three groups as regards their gender (P = 0.806). However, there was a statistical difference between the three groups with regarding their age, as the age of the HCC group was higher; the mean age of the HCC group was 59.10 ± 7.03 years, whereas the mean age of the cirrhosis group was 55.30 ± 6.71 years, and the mean age of the control group was 57.0 ± 4.06 years (P = 0.042) [Table 1].
|Table 1: Comparison among the different studied groups according to demographic data|
Click here to view
Comparison between the different studied groups with regard to liver function test revealed a high significant difference between the three studied groups, as liver function tests including alanine transaminase, aspartate transaminase, albumin, total bilirubin, and direct bilirubin were worse in the HCC group [Table 2].
|Table 2: Comparison among the different studied groups according to liver function|
Click here to view
Comparison between the different studied groups according to VEGF revealed a high significant difference between the three groups, as it was significantly elevated in the HCC group with the mean value of VEGF being 1572.13 ± 292.74 pg/ml, whereas the mean value of VEGF in the liver cirrhosis group was 469.0 ± 71.98 pg/ml, and the mean value of VEGF in the control group was 146.0 ± 33.48 pg/ml (P = 0.00001; [Table 3]).
|Table 3: Comparison among the different studied groups according to vascular endothelial growth factor|
Click here to view
Plotting of ROC curve implied that serum VEGF, at a cut-off of 872.5 pg/ml, showed a diagnostic sensitivity of 83.3% and specificity of 81.7%. The area under the curve (AUC) was 0.8402, as shown in [Figure 1]. As regards serum AFP, the diagnostic performance at the cut-off of 320 ng/ml showed a diagnostic sensitivity of 79.41%, specificity of 60%, and AUC of 0.766, as shown in [Figure 2]. As regards combination of serum AFP and vascular epithelium protein, it showed a diagnostic sensitivity of 82.5%, specificity of 80%, and AUC was 0.8842, as shown in [Figure 3].
|Figure 1: Serum vascular endothelial growth factor sensitivity and specificity for diagnosis of hepatocellular carcinoma|
Click here to view
|Figure 2: Serum α-fetoprotein sensitivity and specificity for diagnosis of hepatocellular carcinoma.|
Click here to view
|Figure 3: Combination of serum α-fetoprotein and serum vascular endothelial growth factor for diagnosis of hepatocellular carcinoma.|
Click here to view
| Discussion|| |
In the current study, Majority of HCC patients were male. This was in agreement with the study carried out by El-Serag , as he found that HCC is predominant among men, with increased male to female ratio in areas of high incidence.
AFP has long been considered the ideal serological marker for the detection of HCC, particularly if its concentration is greater than 500 ng/ml . Higher AFP levels were detected in patients with chronic liver disease, such as hepatitis, cirrhosis, or alcohol abuse .
We found that AFP level was higher in cirrhotic patients in comparison with controls, which is in agreement with Tai et al.  in their study, which observed elevated AFP levels in cirrhosis without HCC.
The study carried out by Chan et al. , who found that 965 of patients with benign liver conditions such as hepatitis and cirrhosis have AFP levels lower than 200 ng/ml, is in agreement with our study, as we found that nearly all cirrhotic patients have AFP levels lower than 200 ng/ml.
Di Bisceglie et al.  reported that AFP production is enhanced in the presence of inflammation, necrosis, and hepatocellular injury, possibly resulting from increased hepatocyte turnover.
As regards the diagnostic performance of AFP, the present study showed AFP at a value of 320 ng/ml, the sensitivity and specificity for HCC detection were 79.41 and 60%, respectively, whereas, in the study carried out by Yvamoto et al. , they found that AFP had a sensitivity of 28% and specificity of 99%, using a cut-off value of 200 ng/ml for differentiation between HCC and liver cirrhosis.
In contrast, a review published by Daniele et al.  showed that overall sensitivity values were between 39 and 65, and specificity values were between 76 and 94, once comparison was carried out between studies that preponderantly used a cut-off value of 20 ng/ml.
This indicated the necessity for standardization of a reference value for AFP that has not yet established. Usage of AFP for detection of early HCC lacks adequate sensitivity and specificity , as AFP levels were influenced by various factors such as etiology of chronic disease and progression of liver disease .
VEGF levels were found to be higher among HCC patients with statistically significant difference compared with cirrhotic patients and controls, and, additionally, vascular epithelium protein levels were high in cirrhotic patients with hepatitis C virus with statistically significant difference compared with controls, which is in accordance with the study carried out by Yvamoto et al. , as they found that serum VEGF level in patients with HCC was increased compared with patients with liver cirrhosis. However, serum VEGF in liver cirrhosis patients was higher when compared with the control group.
In addition, it agrees with Elsadek et al.  who reported that the mean plasma VEGF level within the HCC group was considerably above that of the cirrhotic non-HCC group, and each group had considerably higher median plasma VEGF level, when compared with the control group. This important elevation was expected, as maturation is essential for each event and progression of HCC; it can also be explained by the tissue transcript level of vascular epithelium protein within the cancer . These data matched the function of VEGF to push neovascularisation and epithelial tissue cell proliferation concerning carcinogenesis .
The finding that vascular epithelium protein is overexpressed within the non-HCC patients may be explained by the fact that activation of vascular epithelium protein precedes the presence of liver neoplasm . Similar results were found by El-Mezayen and Darwish , who reported that there was an elevated value of VEGF in HCC patients, compared to each of the control and cirrhotic groups.
In the current study, the validity and discontinuity points of VEGF in identification of HCC from cirrhotic patients and controls were calculated using the ROC curve, with a value of 872.5 pg/ml, AUC of 0.843 with a high sensitivity of 83.3%, and high specificity of 81.7% in prediction of HCC, which partly agree with the study carried out by Yvamoto et al. , who found that serum VEGF levels were used to calculate sensitivity and specificity, with values of 65 and 85, respectively (using a cut-off value of 220 pg/ml).
Elsadek et al.  found that the best cut-off value of plasma VEGF for identification of HCC was 271.85 pg/ml, with sensitivity of 90 and specificity of 90. However, Mukozu et al.  found that the cut-off value of plasma VEGF for the identification of HCC was 108.85 pg/ml, with a sensitivity of 86.4%, specificity of 96.2% and AUC of 0.988.
While adding AFP to VEGF, discontinuous values of sensitivity and specificity for detection of HCC were 82.5 and 80%, respectively. In accordance with our findings, Atta et al.  found that exploitation of each plasma VEGF and serum AFP levels accrued the sensitivity and specificity for detection of HCC to 100 and 98.7%, respectively, and the AUC was 0.99.
| Conclusion|| |
These findings showed that serum VEGF may be a promising diagnostic marker, with high sensitivity for HCC, which may be utilized in screening patients with liver disease for early detection of HCC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hollebecque A, Malka D, Ferté C, Ducreux M, Boige V. Systemic treatment of advanced hepatocellular carcinoma: from disillusions to new horizons. Eur J Cancer 2015; 51
Niu ZS, Niu XJ, Wang M. Management of hepatocellular carcinoma: predictive value of immunohistochemical markers for postoperative survival. World J Hepatol 2015; 7
Ginsburg M, Zivin SP, Wroblewski K, Doshi T, Vasnani RJ, van Ha TG. Comparison of combination therapies in the management of hepatocellular carcinoma: transarterial chemoembolization with radiofrequency ablation versus microwave ablation. J Vasc Interv Radiol 2015; 26
Zhu AX, Duda DG, Sahani DV, Jain RK. HCC and angiogenesis: possible targets and future directions. Nat Rev Clin Oncol 2011; 8
Carmeliet P, Jain RK. Molecular mechanisms and clinical applications of angiogenesis. Nature 2011; 473
Fidler IJ. The organ microenvironment and cancer metastasis. Differentiation 2002; 70
Tseng PL, Tai MH, Huang CC, Wang CC, Lin JW, Hung CH, et al
. Over expression of VEGF is associated with positive p53 immunostaining in hepatocellular carcinoma (HCC) and adverse outcome of HCC patients. J Surg Oncol 2008; 98
Abou-Alfa GK, Amadori D, Santoro A, Figer A, de Greve J, Lathia C. Safety and efficacy of sorafenib in patients with hepatocellular carcinoma (HCC) and Child-Pugh A versus B cirrhosis. Gastrointest Cancer Res 2011; 4
Goodman SN. Toward evidence-based medical statistics: the P
- value fallacy. Ann Intern Med 1999; 130
El-Serag HB. Epidemiology of viral hepatitis and hepatocellular carcinoma. Gastroenterology 2012; 142
Gomes MA, Priolli DG, Tralhão JG, Botelho MF. Hepatocellular carcinoma: epidemiology, biology, diagnosis, and therapies. Rev Assoc Med Bras 2013; 59
Van der Veek PPJ, de Vos Nederveen WH, Cappel WH, Langers AMJ, van Hoek B. Two patients with extremely elevated tumor markers: where is the malignancy? Gastroenterol Res Pract 2011; 2011
Tai WC, Hu TH, Wang JH, Hung CH, Lu SN, Changchien CS, et al
. Clinical implications of alpha-fetoprotein in chronic hepatitis C. J Formos Med Assoc 2009; 108
Chan SL, Mo FK, Johnson PJ, Hui EP, Ma BB, Ho WM, et al
. New utility of an old marker: serial alpha-fetoprotein measurement in predicting radiologic response and survival of patients with hepatocellular carcinoma undergoing systemic chemotherapy. J Clin Oncol 2009; 27
Di Bisceglie AM, Sterling RK, Chung RT, Everhart JE, Dienstag JL, Bonkovsky HL, et al
. Serum alpha-fetoprotein levels in patients with advanced hepatitis C: results from the HALT-C Trial. J Hepatol 2005; 43
Yvamoto EY, Ferreira RF, Nogueira V, Pinhe MA, Tenani GD, Andrade JG, et al
. Influence of vascular endothelial growth factor and alpha-fetoprotein on hepatocellular carcinoma. Genet Mol Res 2015; 14
Daniele B, Bencivenga A, Megna AS, Tinessa V. Alpha-fetoprotein and ultrasonography screening for hepatocellular carcinoma. Gastroenterology 2004; 127
Lok AS, Sterling RK, Everhart JE, Wright EC, Hoefs JC, Di Bisceglie AM, et al
. Des-gamma-carboxy prothrombin and alpha-fetoprotein as biomarkers for the early detection of hepatocellular carcinoma. Gastroenterology 2010; 138
Hu L, Lau SH, Tzang CH, Wen JM, Wang W, Xie D, et al
. Association of Vimentin over expression and hepatocellular carcinoma metastasis. Oncogene 2004; 23
Elsadek B, Mansour A, Saleem T, Warnecke A, Kratz F. The antitumor activity of a lactosaminated albumin conjugate of doxorubicin in a chemically induced hepatocellular carcinoma rat model compared to sorafenib. Dig Liver Dis 2017; 49
Sharma T, Dhingra R, Singh S, Sharma S, Tomar P, Malhotra M, et al
. Aflibercept: a novel VEGF targeted agent to explore the future perspectives of anti-angiogenic therapy for the treatment of multiple tumors. Mini Rev Med Chem 2013; 13
Grizzi F, Weber C, Di Ieva A. Antiangiogenic strategies in medulloblastoma: reality or mystery. Pediatr Res 2008; 63
El-Mezayen HA, Darwish H. Development of a novel scores for early detection of hepatocellular carcinoma among high-risk hepatitis C virus patients. Tumour Biol 2014; 35
Mukozu T, Nagai H, Matsui D, Kanekawa T, Sumino Y. Serum VEGF as a tumor marker in patients with HCV-related liver cirrhosis and hepatocellular carcinoma. Anticancer Res 2013; 33
Atta MM, Atta HM, Gad MA, Rashed LA, Said EM, Hassanien SS, et al
. Clinical significance of vascular endothelial growth factor in hepatitis C related hepatocellular carcinoma in Egyptian patients. J Hepatocell Carcinoma 2016; 3
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]