Low Serum Alpha-fetoprotein Levels Research Articles

Development of machine learning-based personalized predictive models for risk evaluation of hepatocellular carcinoma in hepatitis B virus-related cirrhosis patients with low levels of serum alpha-fetoprotein

Introduction and ObjectivesThe increasing incidence of hepatocellular carcinoma (HCC) in China is an urgent issue, necessitating early diagnosis and treatment. This study aimed to develop personalized predictive models by combining machine learning (ML) technology with a demographic, medical history, and noninvasive biomarker data. These models can enhance the decision-making capabilities of physicians for HCC in hepatitis B virus (HBV)-related cirrhosis patients with low serum alpha-fetoprotein (AFP) levels. Patients and MethodsA total of 6,980 patients treated between January 2012 and December 2018 were included. Pre-treatment laboratory tests and clinical data were obtained. The significant risk factors for HCC were identified, and the relative risk of each variable affecting its diagnosis was calculated using ML and univariate regression analysis. The data set was then randomly partitioned into validation (20 %) and training sets (80 %) to develop the ML models. ResultsTwelve independent risk factors for HCC were identified using Gaussian naïve Bayes, extreme gradient boosting (XGBoost), random forest, and least absolute shrinkage and selection operation regression models. Multivariate analysis revealed that male sex, age >60 years, alkaline phosphate >150 U/L, AFP >25 ng/mL, carcinoembryonic antigen >5 ng/mL, and fibrinogen >4 g/L were the risk factors, whereas hypertension, calcium <2.25 mmol/L, potassium ≤3.5 mmol/L, direct bilirubin >6.8 μmol/L, hemoglobin <110 g/L, and glutamic-pyruvic transaminase >40 U/L were the protective factors in HCC patients. Based on these factors, a nomogram was constructed, showing an area under the curve (AUC) of 0.746 (sensitivity=0.710, specificity=0.646), which was significantly higher than AFP AUC of 0.658 (sensitivity=0.462, specificity=0.766). Compared with several ML algorithms, the XGBoost model had an AUC of 0.832 (sensitivity=0.745, specificity=0.766) and an independent validation AUC of 0.829 (sensitivity=0.766, specificity=0.737), making it the top-performing model in both sets. The external validation results have proven the accuracy of the XGBoost model. ConclusionsThe proposed XGBoost demonstrated a promising ability for individualized prediction of HCC in HBV-related cirrhosis patients with low-level AFP.

Long-term clinical outcomes of patients receiving proton beam therapy for caudate lobe hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) located in the caudate lobe (caudate HCC) is rare; however, patients with this type of tumour have poorer prognoses than those with HCC in other segments. Despite many published reports on the clinical usefulness of proton beam therapy (PBT) for HCC, data on the clinical outcomes of patients undergoing PBT for caudate HCC remain scarce. Therefore, the present study aimed to investigate the outcomes of this group of patients. Thirty patients with caudate HCC who underwent definitive PBT between February 2002 and February 2014 were retrospectively analysed. The total irradiation doses ranged from 55 to 77 (median 72.6) Gy relative biological dose. The median follow-up period was 37.5 (range, 3.0–152.0) months. The overall survival (OS) rates at one, three and five years were 86.6%, 62.8% and 46.1%, respectively. According to univariate and multivariate analyses, Child-Pugh A (P < 0.01), having a single tumour (P = 0.02) and a low serum alpha-fetoprotein level (AFP; P < 0.01) were significant factors predicting longer survival. The local control (LC) rates at one, three and five years were 100%, 85.9% and 85.9%, respectively, while the corresponding progression-free survival (PFS) rates were 65%, 27.5% and 22%, respectively. No grade 3 or worse adverse events were observed. PBT is effective and safe for the treatment of caudate HCC, and should therefore be considered a feasible option for intervention in patients with this disease.

GPER-Induced ERK Signaling Decreases Cell Viability of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is an aggressive malignancy with a poor prognosis. Effective biomarkers and specific therapeutic targets for HCC are therefore urgently needed. G protein-coupled estrogen receptor (GPER) plays a crucial role in numerous cancer types; however, its functions in HCC require further exploration. In the present study, we found a remarkable difference in GPER staining between tumor tissue (100/141, 70.9%) and matched non-tumor tissue (27/30, 90.0%). Compared with the GPER-negative patients, the GPER-positive patients with HCC were closely associated with female sex, negative hepatitis B surface antigen, small tumor size, low serum alpha fetoprotein level, and longer overall survival. Treatment with GPER-specific agonist G1 led to the sustained and transient activation of the EGFR/ERK and EGFR/AKT signaling pathways, respectively, in the HCC cell lines HCCLM3 and SMMC-7721, which express high levels of GPER. Interestingly, G1-induced EGFR/ERK signaling, rather than EGFR/AKT signaling mediated by GPER, was involved in decreasing cell viability by blocking cell cycle progression, thereby promoting apoptosis and inhibiting cell growth. Clinical analysis indicated that simultaneous high expression of GPER and phosphorylated-ERK (p-ERK) predicted improved prognosis for HCC. Finally, the activation of GPER/ERK signaling remarkably suppressed tumor growth in an HCC xenograft model, and this result was consistent with the in vitro data. Our findings suggest that specific activation of the GPER/ERK axis may serve as a novel tumor-suppressive mechanism and that this axis could be a therapeutic target for HCC.

Alpha-fetoprotein accelerates the progression of hepatocellular carcinoma by promoting Bcl-2 gene expression through an RA-RAR signalling pathway.

Previous studies have found that alpha‐fetoprotein (AFP) can promote the proliferation of hepatoma cells and accelerate the progression of hepatocellular carcinoma (HCC). However, the exact mechanism of action remains unclear. Recent bioinformatics studies have predicted the possible interaction between AFP and retinoic acid receptors (RARs). Thus, the purpose of this study was to investigate the molecular mechanism through which AFP promotes tumour cell proliferation by interfering with the RA‐RAR signal pathway. Our data indicated that AFP could significantly promote the proliferation and weaken ATRA‐induced apoptosis of hepatoma cells. Besides, cytoplasmic AFP interacts with RAR, disrupting its entrance into the nucleus, which in turn affects the expression of the Bcl‐2 gene. In addition, knockdown of AFP in HepG2 cells was synchronously associated with an incremental increase of RAR binding to DNA, as well as down‐regulation of Bcl‐2; the opposite effect was observed in AFP gene‐transfected HLE cells. Moreover, a similar effect of AFP was detected in tumour tissues with high serum AFP, but not in adjacent non‐cancerous liver tissues, or HCC tissues with low serum AFP levels. These results indicate that AFP acts as signalling molecule and prevents RAR from entering into the nucleus by interacting with RAR, thereby promoting the expression of Bcl‐2. Our data reveal a novel mechanism through which AFP regulates Bcl‐2 expression and further suggest that AFP may be used as a novel target for treating HCC.

Erythrocyte Sedimentation Rate and Gamma-glutamyl Transpeptidase Combined are Potent Predictors of Survival and Tumor Characteristics inHepatocellular Carcinoma Patients

Introduction: Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are acute phase reactants and Gamma-Glutamyl Transpeptidase (GGT) is a liver enzyme that is associated with prognosis in patients with Hepatocellular Carcinoma (HCC). Objective: To evaluate the value of ESR and GGT singly and together in HCC prognosis and as predictors of tumor aggressiveness parameters. Methods: The database from a large cohort of Turkish HCC patients was examined retrospectively for the prognostic usefulness of blood ESR and GGT levels and the associated patient subgroup characteristics. Results: Patients with low vs. high blood ESR or GGT values had greater than double survival, with Hazard Ratios (HR) by Cox regression of 1.543 and 1.833 respectively. The combination of ESR plus GGT was associated with a 3- fold survival difference and an HR of 2.410. Patients with high vs. low ESR plus GGT levels had significantly greater maximum tumor diameters, alpha-fetoprotein levels, multifocality and percent of patients with portal vein thrombosis. Significant survival differences were also found for patients with low serum alpha-fetoprotein levels. Addition of CRP levels to the ESR plus GGT combination added further discriminant survival information, but for greater computational complexity. Conclusions: ESR plus GGT is a useful and powerful prognosticator in HCC patients, including those with low alpha-fetoprotein levels and significantly associates with all the tumor parameters of HCC patients.

Clinicopathological characteristics and surgical outcomes of sarcomatoid hepatocellular carcinoma.

BACKGROUNDHepatocellular carcinoma (HCC) is the sixth most common type of cancer and the fourth leading cause of cancer-related death worldwide. Sarcomatoid HCC, which contains poorly differentiated carcinomatous and sarcomatous components, is a rare histological subtype of HCC that differs from conventional HCC. It is highly aggressive and has a poor prognosis. Its clinicopathological characteristics, surgical outcomes and underlying mechanisms of its highly aggressive nature have not been fully elucidated.AIMTo examine the clinicopathological characteristics and surgical outcomes of sarcomatoid HCC and explore the histogenesis of sarcomatoid HCC.METHODSIn total, 196 patients [41 sarcomatoid HCC and 155 high-grade (Edmondson-Steiner grade III or IV) HCC] who underwent surgical resection between 2007 and 2017 were retrospectively reviewed. The characteristics and surgical outcomes of sarcomatoid HCC were compared with those of patients with high-grade HCC. The histological composition of invasive and metastatic sarcomatoid HCCs was evaluated.RESULTSSarcomatoid HCC was more frequently diagnosed at an advanced stage with a larger tumor and higher rates of nonspecific symptom, adjacent organ invasion and lymph node metastasis than high-grade HCC (all P < 0.05). Compared with high-grade HCC patients, sarcomatoid HCC patients are less likely to have typical dynamic imaging features of HCC (44.4% vs 72.7%, P = 0.001) and elevated serum alpha-fetoprotein levels (> 20 ng/mL; 36.6% vs 78.7%, P < 0.001). The sarcomatoid group had a significantly shorter median recurrence-free survival (5.6 mo vs 16.4 mo, log-rank P < 0.0001) and overall survival (10.5 mo vs 48.1 mo, log-rank P < 0.0001) than the high-grade group. After controlling for confounding factors, the sarcomatoid subtype was identified as an independent predictor of poor prognosis. Pathological analyses indicated that invasive and metastatic lesions were mainly composed of carcinomatous components.CONCLUSIONSarcomatoid HCC was associated with a more advanced stage, atypical dynamic imaging, lower serum alpha-fetoprotein levels and a worse prognosis. The highly aggressive nature of sarcomatoid HCC is perhaps mediated by carcinomatous components.

Small cells indifferentiated hepatoblasotma in childhood : a rare aggressive malignancy

A new born of two months years old was admitted for abdominal mass which the echography confirmed the hepatic origin. The biological analysis showed an elevated Lactic Acid Dehydrogenase (LDH) serum level, but no elevated alpha fetoprotein neither catecholamins nor other marquers. The abdominal scan confirmed hepatic mass at the expense of two segments. The fine needle scan guided biopsy was done and revealed a neoplastic proliferation of cells, histologically slightly larger than lymphocytes and measure (7-8 um) in size. They are round to oval with scant cytoplasm, relatively fine nuclear chromatin, inconspicuous nucleoli and only minimal mitotic activity. They grow in a diffuse pattern but usually form clusters either intimately inter-mixed with other epithelial cell types or forming nests in an almost ‘organoid’ pattern (A). Immunohistochemically, small cells showed positivity for pancytokeratin (B) as well as vimentin (D). They did not express alpha-fetoprotein (AFP) (C). Thus, the final diagnosis been retained : small cell undifferentiated hepatoblastomas (SCUD-HB) is associated with an aggressive biological course and poor survival. The negative prognostic impact is conferred even by small areas in an otherwise large tumor. Rarely, particularly in infants, the entire hepatoblastoma is composed of small undifferentiated cells ; such tumors account for approximately 5% of all hepatoblastomas. SCUD-HB is associated with low or normal serum AFP levels. SCUD-HB retain expression of INI1 but a small subset present morphological rhabdoid features, including loss of nuclear expression of INI1. Transition between the two types has been described.

Malignant Rhabdoid Tumor, an Aggressive Tumor Often Misclassified as Small Cell Variant of Hepatoblastoma.

The clinical management of pediatric liver tumors involves stratification into risk groups. One previously defined, high-risk group of hepatoblastomas is the small cell undifferentiated variant. In light of molecular studies showing SMARCB1 deletion in these tumors, it is now recognized that most small cell, undifferentiated liver tumors represent an aggressive unrelated tumor—the malignant rhabdoid tumor (MRT). SMARCB1 is a member of the chromatin remodeling SWI/SNF complex and encodes the INI1 protein. The histologic diagnosis of MRT is currently based on INI1 negative immunoreactivity and the presence of rhabdoid morphology. INI1-negative small cell liver tumors lacking classic rhabdoid morphology are often misclassified as small cell undifferentiated hepatoblastomas (SCUD-HB), according to the current classification. Pediatric liver tumors diagnosed between 2003–2017 as SCUD-HB (four cases) or MRT (two cases) were identified from the Columbia University Pathology Department Archives. All tumors were associated with normal or low serum alpha fetoprotein levels, and showed an absence of immunohistochemical staining of hepatocellular markers (Hep-par1, Arginase) and loss of INI1 staining. Two cases were initially diagnosed as MRT, one with prominent rhabdoid morphology, the other with predominant small cell morphology. The remaining four cases with small cell morphology were classified as SCUD-HB. Ancillary molecular studies confirmed the loss of SMARCB1, supporting the diagnosis of MRT in all cases, proving morphology an unreliable criterion. It is critical to eliminate the term INI1-negative hepatoblastoma from the current classification scheme, and classify INI1-negative tumors as MRT, particularly since high-risk HB-chemotherapy regimens are not effective for treating MRT.

ALPHA-FETOPROTEIN AND PROLONGED NEONATAL JAUNDICE

Inroduction. The factors that may influence the development of prolonged neonatal jaundice in children that are breastfed, an increased levels of serum alphafetoprotein (AFP). AFP is a fetal glycoprotein binds and transport a variety of ligands such as bilirubin and fatty acids. However, the mechanism by which AFP levels are elevated in newborns with prolonged jaundice remains to be clarified. Aim of work. To determine content of serum alphafetoprotein in newborns with prolonged jaundice, who were breastfed. Material and methods. 53 children with prolonged neonatal jaundice were admitted to the hospital. The children were divided into groups depending on the duration of jaundice. The first group included 22 children with the duration of jaundice of more than 1 month, II group included 18 children with the duration of jaundice up to 1 month, III group (comparison) was 13 children with physiological jaundice of the newborn. All children were breastfed. Results. In the biochemical blood analysis there was an increase in the concentration of serum total bilirubin due to its indirect fraction of group I and II: mean levels of total bilirubin in blood serum in the children in group I were 264,9 ± 15,5 μmol/l; II group –285,2 ± 12,8 μmol/l (p >0.05), which was significantly outperforming in children of comparison group - 185,2 ± 6,3 μmol/l (p <0.05). The serum levels of AFP were increased in the groups of children involved in the study. Thus, in group I, the mean levels of AFP 811,12 ± of 28,56 ng/ml; in group II – 763,1 ± 28,4 ng/ml, which were significantly higher than the values of serum AFP levels in children of the comparison group – 452 ± 57,9 ng/ml (p<0.05). Every third child with prolonged jaundice was observed an increased content of hepatic transaminases. Thus, children with prolonged jaundice and an increased rate of hepatic transaminases: mean AlAT was in the range of 47,5 ± 6,3 U/l; AsAT 64,7 ± 13,7 Per U/l, had significantly higher levels of serum AFP - 793,5 ± 31,5 ng/ml; although in children with low transaminase levels of serum AFP was 700,9 ± 33,7 ng/ml (p<0.05). Conclusion. The findings suggest that children with the most prolonged course of jaundice, observed the maximum content of serum alpha-fetoprotein, indicating the role of damage of hepatocytes in the genesis of prolonged neonatal jaundice. In children with elevated hepatic transaminases levels of serum alpha-fetoprotein were significantly higher.

Tumor-derived alpha-fetoprotein impairs the differentiation and T cell stimulatory activity of human dendritic cells

Several tumor-derived factors have been implicated in DC dysfunction in cancer patients. Alpha-fetoprotein (AFP) is an oncofetal antigen that is highly expressed in abnormalities of prenatal development and several epithelial cancers, including hepatocellular carcinoma (HCC). In HCC patients exhibiting high levels of serum AFP, we have observed a lower ratio of myeloid-to-plasmacytoid circulating DC compared to patients with low serum AFP levels and healthy donors, suggesting that AFP alters DC differentiation in vivo. To test the effect of AFP on DC differentiation in vitro, peripheral blood monocytes from healthy donors were cultured in the presence of cord blood-derived normal AFP (nAFP) or HCC tumor-derived AFP (tAFP), and DC phenotype and function was assessed. Although the nAFP and tAFP isoforms only differ at one carbohydrate group, low (physiological) levels of tAFP, but not nAFP, significantly inhibited DC differentiation. tAFP-conditioned DC expressed diminished levels of DC maturation markers, retained a monocyte-like morphology, exhibited limited production of inflammatory mediators, and failed to induce robust T cell proliferative responses. Mechanistic studies revealed that the suppressive activity of tAFP is dependent on the presence of low molecular weight (LMW) species that i) co-purify with tAFP, and ii) are abundant in the LMW fractions of both tumor and non-tumor cell lysates. These data reveal the unique ability of tAFP to serve as a chaperone protein for ubiquitous LMW molecules, which function cooperatively to impair DC differentiation and function. Therefore, novel therapeutic approaches that antagonize the regulatory properties of tAFP will be critical to enhance immunity and improve clinical outcomes.

Gd-EOB-DTPA-enhanced magnetic resonance imaging and alpha-fetoprotein predict prognosis of early-stage hepatocellular carcinoma

The survival of patients with hepatocellular carcinoma (HCC) is often individually different even after surgery for early-stage tumors. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) has been introduced recently to evaluate hepatic lesions with regard to vascularity and the activity of the organic anion transporter OATP1B3. Here we report that Gd-EOB-DTPA-enhanced MRI (EOB-MRI) in combination with serum alpha-fetoprotein (AFP) status reflects the stem/maturational status of HCC with distinct biology and prognostic information. Gd-EOB-DTPA uptake in the hepatobiliary phase was observed in ∼15% of HCCs. This uptake correlated with low serum AFP levels, maintenance of hepatocyte function with the up-regulation of OATP1B3 and HNF4A expression, and good prognosis. By contrast, HCC showing reduced Gd-EOB-DTPA uptake with high serum AFP levels was associated with poor prognosis and the activation of the oncogene FOXM1. Knockdown of HNF4A in HCC cells showing Gd-EOB-DTPA uptake resulted in the increased expression of AFP and FOXM1 and the loss of OATP1B3 expression accompanied by morphological changes, enhanced tumorigenesis, and loss of Gd-EOB-DTPA uptake in vivo. HCC classification based on EOB-MRI and serum AFP levels predicted overall survival in a single-institution cohort (n=70), and its prognostic utility was validated independently in a multi-institution cohort of early-stage HCCs (n=109). This noninvasive classification system is molecularly based on the stem/maturation status of HCCs and can be incorporated into current staging practices to improve management algorithms, especially in the early stage of disease.

Low Serum Alpha-fetoprotein Level an Important Predictor for Therapeutic Outcome in Egyptian Patients with Chronic Hepatitis C: A Data-Mining Analysis

Background Data mining can build predictive models for the response to antiviral therapy in chronic HCV patients. Objective To develop a prediction model for therapeutic outcome in chronic HCV genotype-4 patients using different decision-trees learning algorithms. Study Design Data of 3719 chronic HCV patients who had received PEG-IFN/RBV therapy at Cairo-Fatemia Hospital, Egypt was retrieved. Factors predictive of SVR were explored using data mining analysis. Weka implementations C4.5, classification and Reduced Error Pruning tree were constructed using 22 attributes from initial patients’ data. Results End of treatment response and estimated SVR were 61.6%, 52.5% respectively. Low median AFP; 2.9 ng/ml was significantly associated with SVR; compared to relapse group 5.06 ng/ml; p value<0.01. AFP was identified as the most decisive variable of initial split by both decision-tree models. Various cutoff levels were related to different probability of SVR. Baseline AFP ≤2.48 ng/ml was associated with 72%SVR while levels ≥ 7.8 ng/ml demonstrated 32%. Other attributes such as age, BMI, ALT, hepatic fibrosis and activity were less decisive in prediction of response. This was further confirmed by univariate logistic regression analysis; p value<0.01. Conclusion Low AFP Levels were significantly related to SVR in an HCV population presumably genotype-4 as demonstrated by data mining.

Congenital Deficiency versus Hereditary Persistence of Human Alpha-fetoprotein: A Meta-analysis and Overview of Potential Biomedical Consequences

Human alpha-fetoprotein (AFP) is a 70 kD tumor-associated fetal protein (oncofetal protein) which has been utilized clinically as a biomarker for both multiple cancers and for fetal defects including neural tube defects and chromosomal abnormalities. Extreme low and high levels of serum AFP in conjunction with gene mutations have now been established in disorders such as congenital deficiency (CD) and hereditary persistence (HP) of AFP. The objectives of the present review are to compare the clinical manifestations and analyze the mutational basis of these two AFP genetic disorders in accordance with presently accepted models of AFP gene regulation. The regulatory elements of AFP gene expression i.e., enhancers, promoters, and silencers are described in light of the genetic alterations expressed by the CD- and HP-AFP patients. By use of structure/function peptide mapping of the full-length AFP amino acid sequence, the potential biomedical consequences exhibited by CD-AFP and HP-AFP patients are presented and discussed. A new prospective on placental dysfunction in these AFP genetic disorders has also been introduced. Using AFP reference levels in maternal serum, cord blood, newborn blood, pediatric and adult serum, AFP serum concentrations are presented that could alert the obstetrician of potential CD-AFP during pregnancy. Knowledge of such serum values could provide tools to allow clinicians to distinguish between adult HP-AFP and malignant/non-malignant diseases such as liver and germ cell tumors, cirrhosis, hepatitis, and various liver disorders. Knowledge of AFP reference levels might serve to guide the clinician in avoiding: a) misguided diagnoses; b) unnecessary treatments and therapies; and c) undue anxieties and stress during pregnant and non-pregnant states.

Adult hepatoblastoma: Learning from children

Hepatoblastoma is the most common malignant liver tumour in infants and young children. Its occurrence in the adult population is debated and has been questioned. The aim of this paper is to review the histological and clinical features of adult hepatoblastoma as described in the adult literature, and to compare the findings with those of paediatric hepatoblastoma. The developmental and molecular aspects of hepatoblastoma are reviewed and their potential contribution to diagnosis of adult hepatoblastoma discussed. Case reports of adult hepatoblastoma identified by a PubMed search of the English, French, German, Italian, and Spanish literature through March 2011 were reviewed. Forty-five cases of hepatoblastoma were collected. Age at presentation was variable. Survival was uniformly poor, except for the rare patients who presented with the relatively differentiated, foetal type. The common denominator between adult and paediatric cases is the occurrence of embryonal or immature aspect of the tumours. Whether the adult cases of hepatoblastoma represent blastemal tumours, stem cell tumours, or unusual differentiation patterns in otherwise more frequent adult liver tumours remains to be established. Adult tumours labelled as hepatoblastoma are characterised by malignant appearing mesenchymal components. Surgical management is the cornerstone of therapy in children and also appears to confer an improved prognosis in adults. Whether adult hepatoblastoma exists, remains controversial. Indeed, several features described in adult cases are markedly different from hepatoblastoma as it is understood in children, and other differential diagnoses should also be entertained. Nonetheless, hepatoblastoma should be considered in adults presenting with primary liver tumours in the absence of pre-existing liver disease. Adult and paediatric patients with immature hepatoblastoma appear to have worse outcomes, and adults presenting with presumed hepatoblastoma have an overall poorer prognosis than children with hepatoblastoma. In all patients, surgery should be the treatment of choice, neoadjuvant chemotherapy is advisable.

Histopathology and immunohistochemistry of large hepatocellular carcinoma with undetectable or low serum levels of alpha-fetoprotein.

To explore the pathomorphological characteristics of large hepatocellular carcinoma (LHCC) with low serum alpha-fetoprotein (AFP) level. Specimens obtained from surgically resected LHCC with undetectable or low levels of serum AFP were fixed in formalin, embedded in paraffin, and prepared as serial sections. Routine hematoxylin and eosin as well as immunohistochemical stains (LSAB method) were used to test for expression of AFP, alpha-1-antitrypsin, epithelial membrane antigen, and vimentin. Some characteristics of the histopathological changes and immunohistochemical reactions of the cancerous tissues were observed under the light microscope. The majority of the cases (19/30) of LHCC with undetectable or low levels of serum AFP were of the clear-cell-type HCC, with 2 being positive for AFP expression at the periphery of the cytoplasm. The clear cell is the morphological manifestation of disturbance in glycogen and/or lipid metabolism of hepatoma cells. Such changes might be one of the factors hindering the synthesis of AFP and resulting in negative or low level serum AFP of the patient.

Prenatal Genetic Testing

CME Educational Objectives 1. Describe the currently available prenatal screening and diagnostic tests for Down syndrome. 2. Recognize the autosomal recessive conditions for which carrier testing is available and determine how these should be offered to women during the preconception and prenatal period. 3. Identify the appropriate use of genetic services during the preconception and prenatal period.

Quantitative Proteomic Signature of Liver Cancer Cells: Tissue Transglutaminase 2 Could Be a Novel Protein Candidate of Human Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most common diseases worldwide, with extremely poor prognosis due to failure in diagnosing it early. Alpha-fetoprotein (AFP) is the only available biomarker for HCC diagnosis; however, its use in the early detection of HCC is limited, especially because about one-third of patients afflicted with HCC have normal levels of serum AFP. Thus, identifying additional biomarkers that may be used in combination with AFP to improve early detection of HCC is greatly needed. A quantitative proteomic analysis approach using stable isotope labeling with amino acids in cell culture (SILAC) combined with LTQ-FT-MS/MS identification was used to explore differentially expressed protein profiles between normal (HL-7702) and cancer (HepG2 and SK-HEP-1) cells. A total of 116 proteins were recognized as potential markers that could distinguish between HCC and normal liver cells. Certain proteins, such as AFP, intercellular adhesion molecule-1 (ICAM-1), IQ motif containing GTPase activating protein 2 (IQGAP2), claudin-1 (CLDN1) and tissue transglutaminase 2 (TGM2), were validated both in multiple cell lines and in 61 specimens of clinical HCC cases. TGM2 was overexpressed in some of the AFP-deficient HCC cells (SK-HEP-1 and Bel-7402) and in about half of the tumor tissues with low levels of serum AFP (17/32, AFP-negative HCC). Trace amounts of TGM2 were found to be expressed in the samples with high serum AFP (26/29, AFP-positive HCC). Moreover, TGM2 expression in liver tissues showed an inverse correlation with the level of serum AFP in HCC patients. Notably, TGM2 existed in the supernatant of the AFP-deficient SK-HEP-1, SMMC-7721 and HLE cells, and it was found to be induced in AFP-producing cells (HepG2) by specific siRNA silence assay. Serum TGM2 levels of 109 HCC patients and 42 healthy controls were further measured by an established ELISA assay; the levels were significantly higher in HCC patients, and they correlated with the histological grade and tumor size. These data suggest that TGM2 may serve as a novel histological/serologic candidate involved in HCC, especially for the individuals with normal serum AFP. These novel findings may provide important clues to identify new biomarkers of HCC and indirectly improve early detection of the disease.

Hepatoblastoma with a low serum alpha-fetoprotein level at diagnosis: The SIOPEL group experience

Aim of the study To investigate the characteristics of patients with hepatoblastoma and low serum alpha-fetoprotein (AFP) at diagnosis. Patients and methods Inclusion of all 21 patients accrued onto SIOPEL trials, whose serum AFP was <100 ng/ml at diagnosis. Slides of all 15 patients with available histological material were centrally reviewed. Results Median age: 10 months. Disease extension at diagnosis: PRETEXT group: II (3 patients), III (10 patients) and IV (8 patients). Extra-hepatic extension: 8 patients. Multifocal tumour: 8 patients. Histology at review: wholly epithelial subtype: 11/15 patients including nine with a small-cell undifferentiated histology. Outcome: only 9 patients achieved a partial response and 16 died. Median survival: 4.4 months. Two-year overall survival: 24% (confidence interval 10–45%). Conclusion This study clearly identifies patients with hepatoblastoma and low serum AFP at diagnosis as a high-risk subgroup with extensive disease at diagnosis, poor response to chemotherapy and a poor outcome.

Reproductive factors and extreme levels of maternal serum alpha‐fetoprotein: a population‐based study

Levels of maternal alpha-fetoprotein (AFP) are increased during multiple gestations and preeclampsia but little is known regarding AFP levels in relation to other reproductive factors. Consequently, the objective of this work was to describe the possible relationship between AFP levels during pregnancy and maternal age at birth, maternal age at first birth, parity, time since previous birth and gender of the offspring. Based on national registries we obtained the reproductive history on a population-based cohort of 44 227 women who had serum AFP levels determined in gestational weeks 14-21 and whose present and previous pregnancies resulted in live-born singletons. Many previous births and an interval of less than 2 years since last birth were significantly associated with extremely low levels of AFP in the mother. However, age at first birth and age at present pregnancy did not influence the AFP level. Women who gave birth to a girl had AFP levels that were 5%[95% confidence interval (CI) 4-6%] lower than those of women who had a boy. Adjustment for birthweight did not significantly affect the estimate. Low serum AFP levels in pregnancy are significantly correlated with high parity and with a short interval between births. The significantly lower levels of AFP in women who gave birth to girls could indicate a possible gender-specific regulatory mechanism.

Reproductive factors and extreme levels of maternal serum alpha-fetoprotein: a population-based study

Background. Levels of maternal alpha-fetoprotein (AFP) are increased during multiple gestations and preeclampsia but little is known regarding AFP levels in relation to other reproductive factors. Consequently, the objective of this work was to describe the possible relationship between AFP levels during pregnancy and maternal age at birth, maternal age at first birth, parity, time since previous birth and gender of the offspring. Methods. Based on national registries we obtained the reproductive history on a population-based cohort of 44 227 women who had serum AFP levels determined in gestational weeks 14–21 and whose present and previous pregnancies resulted in live-born singletons. Results. Many previous births and an interval of less than 2 years since last birth were significantly associated with extremely low levels of AFP in the mother. However, age at first birth and age at present pregnancy did not influence the AFP level. Women who gave birth to a girl had AFP levels that were 5%[95% confidence interval (CI) 4–6%] lower than those of women who had a boy. Adjustment for birthweight did not significantly affect the estimate. Conclusions. Low serum AFP levels in pregnancy are significantly correlated with high parity and with a short interval between births. The significantly lower levels of AFP in women who gave birth to girls could indicate a possible gender-specific regulatory mechanism.