- Email: [email protected]
Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection
Accepted Manuscript Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection Si-Jia Wu, M.D, Yi-Xin Lin, M.D, Hui Ye, M.D, Xian-Ze Xiong, M.D, Fu-Yu Li, M.D, Nan-Sheng Cheng, M.D, Professor PII:
S1743-9191(16)30990-6
DOI:
10.1016/j.ijsu.2016.10.033
Reference:
IJSU 3177
To appear in:
International Journal of Surgery
Received Date: 5 September 2016 Revised Date:
3 October 2016
Accepted Date: 21 October 2016
Please cite this article as: Wu S-J, Lin Y-X, Ye H, Xiong X-Z, Li F-Y, Cheng N-S, Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection, International Journal of Surgery (2016), doi: 10.1016/ j.ijsu.2016.10.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection
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Si-Jia Wu, Yi-Xin Lin, Hui Ye, Xian-Ze Xiong, Fu-Yu Li, Nan-Sheng Cheng
Si-Jia Wu (M.D.), Yi-Xin Lin (M.D.), Hui Ye (M.D.), Xian-Ze Xiong (M.D.), Fu-Yu Li (M.D.),
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Nan-Sheng Cheng (M.D.)- Department of Bile Duct Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, China
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Correspondence to: Nan-Sheng Cheng, M.D., Professor-Department of Bile Duct Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, China. Email address: [email protected]
First Author: Si-Jia Wu, M.D.- Department of Bile Duct Surgery, West China Hospital, Sichuan
[email protected]
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University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, China. Email address:
Telephone: +86-18782265863; +86-28-85422461
Fax: +86-28-85422462
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Author contributions: Si-Jia Wu and Nan-Sheng Cheng designed this subject; Si-Jia Wu drafted the manuscript; Si-Jia Wu, Yi-Xin Lin and Xian-Ze Xiong collected and analyzed data; Fu-Yu Li
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and Hui Ye critically revised the content; Nan-Sheng Cheng approved the final version of the manuscript.
Acknowledgements: none declared. Disclosure: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Conflicts of interest: Si-Jia Wu, Yi-Xin Lin, Fu-Yu Li, Hui Ye, Xian-Ze Xiong and Nan-Sheng Cheng have no potential conflicts of interest.
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Abstract Background: Alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH) are routinely tested before surgery and are easily obtained. They are also the
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most widely used tumor markers, which have a certain reference value in the diagnosis of hepatocellular carcinoma (HCC). The prognostic values of ALP, GGT and LDH have not been explored deeply and few studies have investigated the prognosis value of them in surgically treated HCC patients. Our study was performed to verify the prognostic significance of preoperative ALP,
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GGT and LDH in hepatitis B virus (HBV)-related HCC patients receiving curative hepatectomy.
Materials and methods: 469 pathologically confirmed HCC patients who received curative
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hepatectomy were retrospectively analyzed. Significant clinicopathological factors were collected and analyzed. Independent prognostic factors were indentified by the multivariate analysis. Overall survival (OS) and recurrence-free survival (RFS) curves were analyzed and compared between different groups.
Results: Patients with low level of ALP, GGT and LDH have favorable OS and RFS, even in
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cirrhosis subgroup. ALP, GGT and LDH were also closely related to some important clinicopathological parameters. GGT and LDH were significant independent prognostic factors of both OS and RFS, while ALP was just a significant independent prognostic factor of OS, rather than RFS.
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Conclusions: Preoperative ALP, GGT and LDH could predict prognosis in HBV-related HCC
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patients who received curative liver resection.
Keywords:
Alkaline phosphatase; Gamma-glutamyl transpeptidase; Lactate dehydrogenase;
Hepatocellular carcinoma; Liver resection; Prognostic factor.
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Introduction Hepatocellular carcinoma (HCC), the fifth most common malignancy with an increasing incidence, represents the commonest primary cancer of the liver [1]. The most important cause of
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HCC is hepatitis B virus (HBV) in China and patients with HBV-related HCC usually have hepatic parenchymatous lesion and cirrhosis. At present, the most commonly used radical therapeutic options are liver resection and liver transplantation [2]. Although liver transplantation has become much more sophisticated in recently years, its application is limited in China due to short of donor
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and stiff price. Thus, hepatectomy is the optimal curative therapeutic option and is still widely used in developing countries. However, the postsurgical cumulative recurrence rate in HBV-related HCC
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patients is high and the long-term outcome of HCC patients is still dismal. Although prognostic factors have been widely investigated, their clinical application cannot be realized in a short time [3]. Thus, to explore simple and dependable predictors is essential to identify patients with poor prognosis. Some
serum
liver
enzymes,
including
alanine
aminotransferase
(ALT),
aspartate
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aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), lactate dehydrogenase (LDH), hydroxybutyrate dehydrogenase (HBD) and α-fetoprotein (AFP), are routinely tested before surgery and are easily obtained. Of these, ALP, GGT and LDH are not widely used like AFP, which have a certain reference value in the diagnosis of HCC [4-10]. ALP, a
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hydrolase enzyme, can predict tumor patients’ prognosis and is mainly found in the liver, bile duct, bone and so on [10]; Besides catalyzing the transpeptidation and hydrolysis of the glutamyl group of
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glutathione, GGT also participates in the biotransformation, nucleic acid metabolism and tumorigenesis [11]; LDH, a metabolic enzyme that in relation to anaerobic glycolysis , can also affect tumor initiation and progression [14]. Thus, in addition to being simply and easily obtained from preoperative routine tests, ALP, GGT and LDH also may predict prognosis in HCC patients [1, 9-16]. Moreover, ALP is one of fundamental elements in the Chinese University Prognostic Index (CUPI) HCC staging system [17]. However, most of previous studies [1, 9-16] focused on HCC patients who received non-surgical treatments, such as radiofrequency ablation (RFA), sorafenib, transcatheter arterial chemoembolization (TACE), etc. To the best of our knowledge, few studies
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ACCEPTED MANUSCRIPT have investigated the prognosis value of the three liver enzymes in surgically treated HCC patients. To date, the prognostic value of ALP, GGT and LDH have not been explored deeply and widely in such patients just like AFP. Thus, our study was performed to verify the prognostic significance of ALP, GGT and LDH in
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surgically treated HBV-related HCC patients. We also investigated the relationship between clinicopathological parameters and the three liver enzymes in such patients.
Materials and methods
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2.1 Patients selection and data collection
During June 2007 and March 2013, 655 pathologically confirmed HCC patients who received
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curative hepatectomy at West China Hospital of Sichuan University were enrolled. Our inclusion criteria were as follows: (1) resectable primary HCC comfirmed by pathological diagnosis; (2) positive for HBV and negative for hepatitis C virus (HCV) infection; (3) underwent hepatectomy as the initial therapy; (4) Child-Pugh grade A or B; (5) generally in good condition. Conversely, exclusion criteria were as follows: (1) HCC combined with other tumors; (2) negative for both HBV
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and HCV; (3) recurrent HCC; (4) lost to follow-up; (7) incomplete data. Thus, 186 were excluded. Finally, altogether 469 HBV-related HCC patients who received curative liver resection were included in our retrospective study.
Preoperative patients’ demographics and clinical data, including age, gender, concomitant
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diseases, complete blood count, liver function test, ALP, GGT, LDH, AFP, imaging data, HBV and HCV markers were collected. Surgical details and postoperative pathological parameters were also
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recorded. All preoperative examinations, such as detailed medical history, physical examination, routine laboratory and imaging examinations were done two days before the surgery. All patients had signed the informed consent. We followed close to the Helsinki Declaration and our study was approved by the Ethics Committee of West China Hospital, Sichuan University. 2.2 Follow-up All the patients were regularly followed at the first, third and sixth month after the surgery, every three months for the first three years, every six months thereafter. Basic physical examination, complete blood count, liver function test, AFP level, HBV markers, and abdominal ultrasound
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ACCEPTED MANUSCRIPT examination were performed at each visit. Imaging examinations, including abdominal enhanced computed tomography scan, magnetic resonance imaging, and hepatic artery angiography examination were selectively carried out depending on the actual situations when recurrence was suspected. Patients with confirmed recurrence were further treated with individualized projects
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(Table 1). The overall survival (OS) was defined as the interval from the date of surgery to the date of death or the last follow-up. The recurrence-free survival (RFS) was defined as the interval from the date of surgery to the date of confirmed HCC recurrence or the last follow-up. The last follow-up
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date was 26 February, 2016. 2.3 Statistical analysis
Continuous data were presented as the median and the range, or mean±standard deviation (SD);
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Differences between the two groups were compared by the Mann-Whitney U test or the independent sample t test, respectively. Categorical data were compared by the Pearson’s chi-square analysis or the Fisher exact test. OS and RFS curves were analyzed using the Kaplan-Meier method and compared by the log-rank test. The best cut-off values of ALP, GGT and LDH were selected by the receiver operating characteristic (ROC) curve. Univariate and multivariate analysis of prognostic
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factors for OS and RFS were performed using the Cox proportional hazards model. A value of p<0.05 was considered statistically significant (derived from two-tailed test). Statistical analyses
Results
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were performed with SPSS software (version 17.0; SPSS Inc., Chicago, IL, United States).
3.1 Patient baseline characteristics
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A total of 469 HBV-related HCC patients who underwent curative liver resection were included
in our retrospective analysis. During the follow-up period, 261 (55.7%) patients developed recurrence and 159 (33.9%) patients died during follow-up. The median duration of follow-up was 42 months (range: 2
99 months). The 1-, 3- and 5-year OS rates for all patients included in our
study were 93.5%, 77% and 61.1%, respectively, and the 1-, 3- and 5-year RFS rates for all cases were 71.3%, 47.1% and 40.4%, respectively. Details of patient baseline characteristics are shown in Table 1. 3.2 Determination of the best cut-off value
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ACCEPTED MANUSCRIPT The ROC curve analysis revealed a best cut-off of 136.5 IU/L for ALP (Figure 1A), 81.5 IU/L for GGT (Figure 1B) and 203.5 IU/L for LDH (Figure 1C). Therefore, all 469 patients were divided into low ALP group (ALP 136.5 IU/L, n=293) and high ALP group (ALP>136.5 IU/L, n=176), or low GGT group (GGT 81.5 IU/L, n=251) and high GGT group (GGT>81.5 IU/L, n=218), or low 203.5 IU/L, n=280) and high LDH group (LDH>203.5 IU/L, n=189),
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LDH group (LDH respectively.
3.3 Correlation between clinicopathological variables and preoperarive ALP/GGT/LDH
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As shown in Table 2 (Table 2a, 2b, 2c), significant differences in tumor size, tumor number, vascular invasion, BCLC staging, albumin concentration, AST level and AFP level were found between low ALP group and high ALP group. Similarly, gender, tumor size, tumor number, vascular
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invasion, BCLC staging, albumin concentration, ALT level, AST level, AFP level and perioperative transfusion were significantly different between low GGT group and high GGT group. Similarly, significant differences in pathological differentiation, tumor size, tumor number, vascular invasion, BCLC staging, albumin concentration, ALT level, AST level and AFP level were detected between low LDH group and high LDH group. While no significant differences in other clinicopathological
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variables were found. Details of relationship between clinicopathological variables and preoperarive ALP/GGT/LDH are presented in Table 2 (Table 2a, 2b, 2c). 3.4 Determination of prognostic factors for OS and RFS
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Our univariate analysis revealed that tumor size, tumor number, vascular invasion, albumin concentration, AST level, ALP level, GGT level, LDH level and AFP level were significant
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preoperative prognostic factors associated with OS (Table 3). In multivariate analysis, tumor size, tumor number, vascular invasion, albumin concentration, ALP level, GGT level, LDH level and AFP level remained as significant independent prognostic factors of OS (Table 3). The results of univariate and multivariate analysis of prognostic factors for OS are shown in Table 3. Similarly, in univariate analysis, tumor size, tumor number, vascular invasion, albumin concentration, AST level, ALP level, GGT level, LDH level, AFP level and perioperative transfusion were significant prognostic factors associated with RFS (Table 4). Then, our multivariate analysis revealed that tumor size, tumor number, vascular invasion, albumin concentration, AST level, GGT
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ACCEPTED MANUSCRIPT level, LDH level, AFP level and perioperative transfusion remained as significant independent prognostic factors of RFS (Table 4). However, ALP level was found not to be an independent prognostic factor of RFS. The results of univariate and multivariate analysis of prognostic factors for RFS are shown in Table 4.
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3.5 Survival analysis
Both OS and RFS rates were significantly higher in low ALP group than high ALP group (Figure 2A, Figure 2B). The 5-year OS and RFS rates were 76.6% and 46.8% in low ALP group,
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and 35.1% and 29.7% in high ALP group, respectively (Figure 2A, Figure 2B). As to GGT, patients in low GGT group had better OS and RFS rates than those in high GGT group (Figure 2C, Figure 2D). The 5-year OS and RFS rates were 78.1% and 53.3% in low GGT group, and 41.6% and 25.4%
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in high GGT group, respectively (Figure 2C, Figure 2D). Similarly, the 5-year OS and RFS rates were 73.7% and 54% in low LDH group, and 43.1% and 20.4% in high LDH group, respectively (Figure 2E, Figure 2F). Patients in low LDH group still had more favourable OS and RFS rates when compared with those in high LDH group (Figure 2E, Figure 2F). 3.6 Subgroup analysis in patients with cirrhosis
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Our study included a large proportion of cirrhosis patients (69.7%), thus we performed subgroup analysis to evaluate the prognostic value of ALP, GGT and LDH in such patients. As shown in Figure 3, cirrhosis patients in low ALP group also had better OS and RFS rates than those
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in high ALP group (Figure 3A, Figure 3B). The similar situation was found in different GGT groups (Figure 3C, Figure 3D) or different LDH groups (Figure 3E, Figure 3F).
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The results of subgroup analysis were in line with the outcomes of survival analysis of the whole study population. Therefore, we concluded that our findings were reliable (Figure 2, Figure 3).
Discussion
ALP is a variation marker for either embryonic stem cell or other stem cells derived from the bone and adipose tissue [10]. Although ALP exists in all tissues throughout the entire body, it could indicate the proliferation of tumor cells [9-10, 18]. Some tumor cells, such as HepG2, also showed higher ALP activities in the nucleolus and change in the localization during cell cycles [9-10, 18].
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ACCEPTED MANUSCRIPT Thus ALP may play an important role in cell cycle regulation, cell proliferation and tumor formation. Interestingly, an elevated ALP was also observed in some benign diseases, such as cholangitis, choledocholithiasis, pancreatitis, hepatitis, etc. The common ground of these diseases is inflammation, which also exerts an enormous function on tumor formation. Therefore, ALP takes
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part in tumor formation and represents inflammation reactions either directly or indirectly, and it could predict the prognosis of HCC patients. With reference to GGT, its abnormal expression has been found in several human tumors [19]. As an oxidative stress marker, GGT can give rise to the
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pro-oxidant reactions, the latter can produce endogenous reactive oxygen species (ROS) in tumor cells and play an important role in tumor formation, cell proliferation and apoptosis [12, 20-21]. GGT is also correlated with inflammation, and some inflammatory cytokines can bring about the
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production of GGT [12, 22-23]. In addition, inflammation is closely correlated with tumor formation and progression, thus GGT has prognostic effects on HCC patients. Furthermore, LDH, a glycolytic enzyme, plays a crucial role in the conversion of pyruvate to lactate under anaerobic conditions [1, 13]. Up-regulation of LDH has been indicated to ensure an efficient glycolytic metabolism and a reduced demand for oxygen in tumor cells under hypoxic conditions [1, 13]. LDH was connected
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with hypoxia and the tumor angiogenesis pathway through the abnormal activation of the hypoxia inducible factor 1 (HIF-1) [1, 13-14]. Abnormal HIF-1 can upregulate corresponding genes and result in abnormal glycolytic energy metabolism, angiogenesis, cell survival and tumor formation. [1,
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13-14, 24]. Besides, LDH is also regulated by the PI3K/Akt/mTOR pathways which play an important role in tumor formation and progress. [14, 25]. Thus, LDH is closely related with the
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biological behavior of tumors, and can predict the prognosis of tumor patients. Generally speaking, the results of above basic studies showed that elevated ALP, GGT and LDH had a close relationship with tumor recurrence, formation and progress. In the present study, we determined the best cut-off values of ALP, GGT and LDH that were
suitable for our study population and medical center by the ROC curve analysis. After that, we explored the prognostic value of ALP, GGT and LDH in HBV-related HCC patients treated by curative liver resection and found that preoperative ALP, GGT and LDH could predict prognosis in surgically treated HCC patients. Patients with low levels of ALP, GGT and LDH might have
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ACCEPTED MANUSCRIPT favorable OS and RFS. We further performed survival analysis in cirrhosis subgroup. Then we found that the lower of them were, the better prognosis patients might have, and vice versa. The results of survival analysis in cirrhosis subgroup were consistent with the outcomes of survival analysis of the whole study population means that our findings were dependable. We also found that tumor size,
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tumor number, vascular invasion, BCLC staging, serum albumin concentration, AST level and AFP level were closely related to all of ALP, GGT and LDH. Moreover, in our multivariate analysis, GGT and LDH were also found to be significant independent prognostic factors of both OS and RFS.
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However, our multivariate analysis indicated that ALP was just a significant independent prognostic factor of OS, rather than RFS (Table 3, Table 4). While our present clinical study also found that patients with high levels of ALP, GGT and LDH might have poor OS and RFS. Our findings were
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not contradicted against the results of these previous basic studies, which demonstrated that ALP, GGT and LDH might predict prognosis in surgically treated HCC patients. Several studies [1, 9-16] have investigated similar issues, but most of them centered on non-surgically treated HCC patients and almost all of them studied only one marker among ALP, GGT and LDH. As far as we can determine, few studies have investigated the prognosis value of the
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three liver enzymes in surgically treated HCC patients [9-10, 12, 14]. Our study was the first one to explore the prognosis value of ALP, GGT and LDH simultaneously in HBV-related HCC patients treated by curative liver resection. Xu et al [9] found that both preoperative ALP and GGT were
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independent prognostic factors of OS and RFS and could predict survival outcomes in HCC patients. Some of our findings were in line with theirs, but their study population was a little different from
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ours. They included some HCV and non-hepatitis HCC patients. While in order to reduce clinical bias and increase the homogeneity of subject investigated, based on our inclusion and exclusion criteria, only HBV-related HCC patients were included in our study. In addition, due to the fact that HCC is mostly caused by HBV and HCV in China, the number of HCC patients without hepatitis is very small. Another difference is that we found ALP was just a significant independent prognostic factor of OS rather than RFS. Yu et al [10] studied the prognostic effects of ALP on HCC patients who underwent hepatectomy. However, they also included 297 HCV patients, 129 HBV and HCV patients and 125 non-hepatitis patients. ALP was also found to be a significant independent
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ACCEPTED MANUSCRIPT prognostic factor of both OS and RFS in their research. Fu et al [12] and Zhang et al [14] investigated the prognostic value of GGT and LDH in HCC patients, respectively. They also drew similar conclusions. Other studies [1, 11, 13, 15-16] explored the prognostic effects of GGT or LDH on patients who received non-surgical treatments and most of their outcomes were not contradictory
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with our findings. All in all, based on the above mentioned evidences, we concluded that our findings were credible.
Although our study was the first one to explore the prognosis value of ALP, GGT and LDH
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simultaneously in HBV-related HCC patients treated by curative liver resection, we must recognize that the current study still have several limitations. First, basic medical researches were not performed to explore the concrete effects of ALP, GGT and LDH on tumor formation and
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progression. Second, selection bias, withdraw bias and other clinical bias were inevitable due to the fact that our study was a retrospective study. Third, all data were collected from a single medical center and our sample size was still limited. In the future, prospective clinical studies with large sample size are urgently needed to confirm our conclusions and promote the clinical application of ALP, GGT and LDH. Basic medical researches with regard to this topic were also imminently
Conclusions
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needed to provide the basis for the clinical application of these three frequently used liver enzymes.
Preoperative ALP, GGT and LDH might possibly predict prognosis in surgically treated HCC
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patients. Patients with low level of ALP, GGT and LDH might have favorable OS and RFS, even in cirrhosis patients. GGT and LDH could be significant independent prognostic factors of both OS and
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RFS, while ALP might possibly be just a significant independent prognostic factor of OS, rather than RFS.
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Figure legend:
Figure 1 Receiver operating characteristics (ROC) curves to determine the best cut-off value of
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alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH). A: ROC curve of ALP. B: ROC curve of GGT. C: ROC curve of LDH.
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Figure 2 Kaplan-Meier survival analysis of hepatocellular carcinoma patients receiving curative liver resection based on the level of alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH). A: Overall survival (OS) curve comparing low ALP group and high ALP group. B: Recurrence-free survival (RFS) curve comparing low ALP group and high ALP group. C: OS curve comparing low GGT group and high GGT group. D: RFS curve comparing
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low GGT group and high GGT group. E: OS curve comparing low LDH group and high LDH group. F: RFS curve comparing low LDH group and high LDH group. Patients with low level of ALP, GGT and LDH may have favorable OS and RFS.
Figure 3 Subgroup analysis in gurgically treated hepatocellular carcinoma patients with cirrhosis
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based on the level of alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH). A: Overall survival (OS) curve comparing low ALP group and high ALP
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group. B: Recurrence-free survival (RFS) curve comparing low ALP group and high ALP group. C: OS curve comparing low GGT group and high GGT group. D: RFS curve comparing low GGT group and high GGT group. E: OS curve comparing low LDH group and high LDH group. F: RFS curve comparing low LDH group and high LDH group. Cirrhosis patients with low level of ALP, GGT and LDH still have favorable OS and RFS.
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ACCEPTED MANUSCRIPT Table 2a Correlation between preoperative ALP and clinicopathological parameters ALP (IU/L) Variables
P value
136.5 (n=293)
Age (year, median (range))
>136.5 (n=176) 47 (17-81)
0.086
Gender (Male/Female)
245/48
149/27
0.766
Cirrhosis (Absent/Present)
87/206
55/121
0.722
25/226/42
12/136/28
0.744
234/59
104/72
<0.001
Tumor number (Single/Multiple)
261/32
133/43
Vascular invasion (Absent/Present)
261/32
124/52
235/26/32
99/25/52
Differentiation (Well/ Moderate/ Poor) Tumor size (cm,
5/>5)
BCLC staging (0+A/B/C) Total bilirubin (μmol/L,
28/>28)
143/33
207/86
93/83
ALT (IU/L,
45/>45)
179/114
95/81
AST (IU/L,
45/>45)
184/109
AFP (ng/ml, <400/ 400)
209/84
Transfusion (no/yes)
<0.001
<0.001 0.858
<0.001
218.67±79.32
0.130
87/89
0.005
81/95
<0.001
211.55±85.19
0.361
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Operation duration (min, mean±SD)
<0.001
SC
240/53
Albumin (g/L, >40/ 40)
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49 (18-78)
258/35
149/27
0.293
124 (65-281)
127 (65-251)
0.535
WBC (10 /L, median (range))
4.65 (2.91-9.75)
4.70 (2.48-10.99)
0.684
PT (sec, median (range))
11.8 (9.9-15.2)
11.8 (9.6-16.9)
0.935
Platelet count (109/L, median (range)) 9
ALP-alkaline
phosphatase;
BCLC-Barcelona
Clinic
Liver
Cancer;
ALT-alanine
aminotransferase;
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aminotransferase; AFP-alfa-fetoprotein; SD-standard deviation; WBC-white blood count; PT-prothrombin time
AST-aspartate
ACCEPTED MANUSCRIPT Table 2b Correlation between preoperative GGT and clinicopathological parameters GGT (IU/L) 81.5 (n=251)
Age (year, median (range)) Gender (Male/Female) Cirrhosis (Absent/Present) Differentiation (Well/ Moderate/ Poor) Tumor size (cm,
5/>5)
P value >81.5 (n=218)
49 (18-79)
47 (17-81)
0.099
199/52
195/23
0.003
85/166
57/161
0.070
25/192/34
12/170/36
0.161 <0.001
200/51
138/80
Tumor number (Single/Multiple)
222/29
172/46
Vascular invasion (Absent/Present)
219/32
166/52
197/22/32
137/29/52
BCLC staging (0+A/B/C) Total bilirubin (μmol/L,
28/>28)
177/41
180/71
120/98
ALT (IU/L,
45/>45)
177/74
97/121
AST (IU/L,
45/>45)
176/75
AFP (ng/ml, <400/ 400)
179/72
Transfusion (no/yes)
209.86±80.51 228/23
Platelet count (109/L, median (range)) WBC (109/L, median (range)) PT (sec, median (range))
0.005 0.002
0.001
0.806
<0.001 <0.001
95/123
<0.001
111/107
<0.001
218.95±83.65
0.232
179/39
0.005
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Operation duration (min, mean±SD)
SC
206/45
Albumin (g/L, >40/ 40)
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Variables
127 (65-263)
125 (65-281)
0.492
4.78 (2.91-10.99)
4.61 (2.48-9.75)
0.232
11.8 (9.6-15.2)
11.8 (9.6-16.9)
0.925
GGT-gamma-glutamyl transpeptidase; BCLC-Barcelona Clinic Liver Cancer; ALT-alanine aminotransferase; AST-aspartate
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aminotransferase; AFP-alfa-fetoprotein; SD-standard deviation; WBC-white blood count; PT-prothrombin time
ACCEPTED MANUSCRIPT Table 2c Correlation between preoperative LDH and clinicopathological parameters LDH (IU/L) 203.5 (n=280)
Age (year, median (range)) Gender (Male/Female) Cirrhosis (Absent/Present) Differentiation (Well/ Moderate/ Poor) Tumor size (cm,
5/>5)
P value >203.5 (n=189)
48 (19-81)
48 (17-79)
0.998
242/38
152/37
0.082
93/187
49/140
0.092
23/225/32
14/137/38
0.035 <0.001
221/59
117/72
Tumor number (Single/Multiple)
247/33
147/42
Vascular invasion (Absent/Present)
241/39
144/45
217/24/39
117/27/45
BCLC staging (0+A/B/C) Total bilirubin (μmol/L,
28/>28)
152/37
196/84
104/85
ALT (IU/L,
45/>45)
181/99
93/96
AST (IU/L,
45/>45)
196/84
AFP (ng/ml, <400/ 400)
186/94
Operation duration (min, mean±SD)
249/31
0.006
0.001
0.569
0.001 0.001
75/114
<0.001
104/85
0.013
208.77±78.26
0.113
158/31
0.095
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221.23±86.59
Transfusion (no/yes)
0.002
SC
231/49
Albumin (g/L, >40/ 40)
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Variables
Platelet count (109/L, median (range))
128.5 (65-273)
124 (65-281)
0.100
WBC (109/L, median (range))
4.67 (2.48-9.75)
4.65 (2.91-10.99)
0.312
PT (sec, median (range))
11.75 (9.6-15.2)
11.8 (9.6-16.9)
0.775
LDH-lactate dehydrogenase; BCLC-Barcelona
Clinic Liver
Cancer; ALT-alanine
aminotransferase; AST-aspartate
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aminotransferase; AFP-alfa-fetoprotein; SD-standard deviation; WBC-white blood count; PT-prothrombin time
ACCEPTED MANUSCRIPT Table 1 Baseline clinicopathological characteristics of the patients Clinicopathological parameters Included patients (N=469)
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48 (17-81) 394 (84%)/75 (16%) 142 (30.3%)/327 (69.7%) 37 (7.9%)/ 362 (77.2%)/ 70 (14.9%) 5.12±1.80 338 (72.1%)/131 (27.9%) 394 (84%)/75 (16%) 385 (82.1%)/84 (17.9%) 334 (71.2%)/51 (10.9%)/84 (17.9%) 13.8 (4.3-44.7) 41.8 (28.1-54.2) 39 (8-408) 40 (14-263) 113 (11-654) 71 (10-585) 188 (99-653) 290 (61.8%)/179 (38.2%) 214.56±82.44 407 (86.8%)/62 (13.2%) 126 (65-281) 4.66 (2.48-10.99) 11.8 (9.6-16.9) 261 19 (7.3%) 101 (38.6%) 38 (14.6%) 12 (4.6%) 91 (34.9%)
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Age (year), median (range) Gender, Male/Female, n (%) Cirrhosis, Absent/Present, n (%) Differentiation, Well/ Moderate/ Poor, n (%) Maximum tumor diameter (cm), mean±SD Tumor size (cm), 5cm/>5cm, n (%) Tumor number, Single/Multiple, n (%) Vascular invasion, Absent/Present, n (%) BCLC staging, 0+A/B/C, n (%) Total bilirubin (μ μmol/L), median (range) Albumin (g/L), median (range) ALT (IU/L), median (range) AST (IU/L), median (range) ALP (IU/L), median (range) GGT (IU/L), median (range) LDH (IU/L), median (range) AFP (ng/ml), <400/ 400, n(%) Operation duration (min), mean±SD Transfusion, no/yes, n (%) Platelet count (109/L), median (range) WBC (109/L), median (range) PT (sec), median (range) Treatment for recurrence (total 261) Repeat hepatectomy, n (%) TACE, n (%) RFA, n (%) PEIT, n (%) Other therapies, n (%)
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SD-standard deviation; BCLC-Barcelona Clinic Liver Cancer; ALT-alanine aminotransferase; AST-aspartate aminotransferase; ALP-alkaline phosphatase; GGT-gamma-glutamyl transpeptidase; LDH-lactate dehydrogenase; AFP-alfa-fetoprotein; WBC-white blood count; PT-prothrombin time; TACE-transcather hepatic arterial chemoembolization; RFA-radiofrequency ablation; PEIT-percutaneous ethanol injection therapy
ACCEPTED MANUSCRIPT Table 3 Prognostic factors for overall survival by univariate and multivariate analyses Univariate analysis
Multivariate analysis
Variables P-value
48 (17-81)
0.486
75 (16%)/394 (84%)
0.669
126 (65-281)
0.066
4.66 (2.48-10.99)
0.610
11.8 (9.6-16.9)
0.239
Age (year, median (range)) Gender (Female/ Male) 9
Platelet count (10 /L, median (range)) 9
WBC (10 /L, median (range)) PT (sec, median (range))
0.115 0.266
131 (27.9%)/338 (72.1%)
<0.001
75 (16%)/394 (84%)
<0.001
Vascular invasion (Present/Absent)
84 (17.9%)/385 (82.1%)
<0.001
Total bilirubin (μmol/L, >28/
86 (18.3%)/383 (81.7%)
Differentiation (Poor/ Moderate/ Well) Tumor size (cm, >5/
5)
Tumor number (Multiple/Single)
P-value
3.090
2.149-4.444
<0.001
2.313
1.582-3.383
<0.001
5.835
3.992-8.530
<0.001
1.838
1.266-2.668
0.001
0.201
40/>40)
169 (36%)/300 (64%)
<0.001
ALT (IU/L, >45/
45)
195 (41.6%)/274 (58.4%)
0.166
AST (IU/L, >45/
45)
198 (42.2%)/271 (57.8%)
0.002
0.706
0.495-1.007
0.054
ALP (IU/L, >136.5/ 136.5)
176 (37.5%)/293 (62.5%)
<0.001
2.382
1.662-3.414
<0.001
GGT (IU/L, >81.5/
218 (46.5%)/251 (53.5%)
<0.001
2.376
1.604-3.519
<0.001
189 (40.3%)/280 (59.7%)
LDH (IU/L, >203.5/ AFP (ng/ml,
81.5) 203.5)
400/<400)
<0.001
1.807
1.262-2.587
0.001
179 (38.2%)/290 (61.8%)
<0.001
1.593
1.091-2.324
0.016
214.56±82.44
0.526
62 (13.2%)/407 (86.8%)
0.204
Operation duration (min, mean±SD) Transfusion (yes/no)
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Albumin (g/L,
28)
95% CI
SC
327 (69.7%)/142 (30.3%) 70 (14.9%)/362 (77.2%)/37 (7.9%)
Cirrhosis (Present/ Absent)
HR
RI PT
n (%) or value
AST-aspartate
aminotransferase;
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HR-hazard ratio; CI-confidence interval; WBC-white blood count; PT-prothrombin time; ALT-alanine aminotransferase; ALP-alkaline
phosphatase;
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dehydrogenase; AFP-alfa-fetoprotein; SD-standard deviation
GGT-gamma-glutamyl
transpeptidase;
LDH-lactate
ACCEPTED MANUSCRIPT Table 4 Prognostic factors for recurrence-free survival by univariate and multivariate analyses Univariate analysis
Multivariate analysis
Variables P-value
48 (17-81)
0.283
75 (16%)/394 (84%)
0.612
126 (65-281)
0.155
4.66 (2.48-10.99)
0.753
11.8 (9.6-16.9)
0.179
Age (year, median (range)) Gender (Female/ Male) 9
Platelet count (10 /L, median (range)) 9
WBC (10 /L, median (range)) PT (sec, median (range))
0.288 0.065
131 (27.9%)/338 (72.1%)
<0.001
75 (16%)/394 (84%)
<0.001
Vascular invasion (Present/Absent)
84 (17.9%)/385 (82.1%)
<0.001
Total bilirubin (μmol/L, >28/
86 (18.3%)/383 (81.7%)
Differentiation (Poor/ Moderate/ Well) Tumor size (cm, >5/
5)
Tumor number (Multiple/Single)
P-value
2.240
1.677-2.991
<0.001
2.550
1.865-3.487
<0.001
4.663
3.397-6.400
<0.001
1.916
1.462-2.510
<0.001
0.320
40/>40)
169 (36%)/300 (64%)
<0.001
ALT (IU/L, >45/
45)
195 (41.6%)/274 (58.4%)
0.139
AST (IU/L, >45/
45)
198 (42.2%)/271 (57.8%)
<0.001
1.484
1.128-1.953
0.005
ALP (IU/L, >136.5/ 136.5)
176 (37.5%)/293 (62.5%)
<0.001
1.233
0.942-1.614
0.128
GGT (IU/L, >81.5/
218 (46.5%)/251 (53.5%)
<0.001
1.683
1.286-2.203
<0.001
189 (40.3%)/280 (59.7%)
LDH (IU/L, >203.5/ AFP (ng/ml,
81.5) 203.5)
400/<400)
<0.001
1.806
1.379-2.366
<0.001
179 (38.2%)/290 (61.8%)
<0.001
2.642
2.006-3.479
<0.001
214.56±82.44
0.633
62 (13.2%)/407 (86.8%)
<0.001
1.462
1.051-2.035
0.024
Operation duration (min, mean±SD) Transfusion (yes/no)
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Albumin (g/L,
28)
95% CI
SC
327 (69.7%)/142 (30.3%) 70 (14.9%)/362 (77.2%)/37 (7.9%)
Cirrhosis (Present/ Absent)
HR
RI PT
n (%) or value
AST-aspartate
aminotransferase;
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HR-hazard ratio; CI-confidence interval; WBC-white blood count; PT-prothrombin time; ALT-alanine aminotransferase; ALP-alkaline
phosphatase;
AC C
EP
dehydrogenase; AFP-alfa-fetoprotein; SD-standard deviation
GGT-gamma-glutamyl
transpeptidase;
LDH-lactate
AC C
EP
TE D
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SC
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ACCEPTED MANUSCRIPT The prognostic value of alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH) have not been explored deeply and widely in surgically treated hepatocellular carcinoma (HCC) patients just like AFP. Our study was the first one to explore the prognosis value of ALP, GGT and LDH simultaneously in HBV-related HCC patients treated by
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curative liver resection. We found that preoperative ALP, GGT and LDH could predict prognosis
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in such patients.
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International Journal of Surgery Author Disclosure Form The following additional information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated.
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Please state any conflicts of interest
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We have no conflicts of interest
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Please state any sources of funding for your research We did not receive any sources of funding
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Please state whether Ethical Approval was given, by whom and the relevant Judgement’s reference number
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All patients had signed the informed consent. We followed close to the Helsinki Declaration and our study was approved by the Ethics Committee of West China Hospital, Sichuan University.
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Research Registration Unique Identifying Number (UIN) Please enter the name of the registry and the unique identifying number of the study. You can register your research at http://www.researchregistry.com to obtain your UIN if you have not already registered your study. This is mandatory for human studies only.
researchregistry1609 Nan sheng Cheng Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection September 05, 2016 11:50
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ACCEPTED MANUSCRIPT Author contribution Please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. Others, who have contributed in other ways should be listed as contributors. Si-Jia Wu and Nan-Sheng Cheng designed this subject; Si-Jia Wu drafted the manuscript; Si-Jia Wu, Yi-Xin Lin and Xian-Ze Xiong collected and analyzed data;
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Fu-Yu Li and Hui Ye critically revised the content; Nan-Sheng Cheng approved the
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final version of the manuscript.
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Guarantor The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
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Nan-sheng Cheng and Si-jia Wu are Guarantors.
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S1743-9191(16)30990-6
DOI:
10.1016/j.ijsu.2016.10.033
Reference:
IJSU 3177
To appear in:
International Journal of Surgery
Received Date: 5 September 2016 Revised Date:
3 October 2016
Accepted Date: 21 October 2016
Please cite this article as: Wu S-J, Lin Y-X, Ye H, Xiong X-Z, Li F-Y, Cheng N-S, Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection, International Journal of Surgery (2016), doi: 10.1016/ j.ijsu.2016.10.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection
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Si-Jia Wu, Yi-Xin Lin, Hui Ye, Xian-Ze Xiong, Fu-Yu Li, Nan-Sheng Cheng
Si-Jia Wu (M.D.), Yi-Xin Lin (M.D.), Hui Ye (M.D.), Xian-Ze Xiong (M.D.), Fu-Yu Li (M.D.),
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Nan-Sheng Cheng (M.D.)- Department of Bile Duct Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, China
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Correspondence to: Nan-Sheng Cheng, M.D., Professor-Department of Bile Duct Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, China. Email address: [email protected]
First Author: Si-Jia Wu, M.D.- Department of Bile Duct Surgery, West China Hospital, Sichuan
[email protected]
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University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, China. Email address:
Telephone: +86-18782265863; +86-28-85422461
Fax: +86-28-85422462
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Author contributions: Si-Jia Wu and Nan-Sheng Cheng designed this subject; Si-Jia Wu drafted the manuscript; Si-Jia Wu, Yi-Xin Lin and Xian-Ze Xiong collected and analyzed data; Fu-Yu Li
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and Hui Ye critically revised the content; Nan-Sheng Cheng approved the final version of the manuscript.
Acknowledgements: none declared. Disclosure: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Conflicts of interest: Si-Jia Wu, Yi-Xin Lin, Fu-Yu Li, Hui Ye, Xian-Ze Xiong and Nan-Sheng Cheng have no potential conflicts of interest.
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Abstract Background: Alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH) are routinely tested before surgery and are easily obtained. They are also the
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most widely used tumor markers, which have a certain reference value in the diagnosis of hepatocellular carcinoma (HCC). The prognostic values of ALP, GGT and LDH have not been explored deeply and few studies have investigated the prognosis value of them in surgically treated HCC patients. Our study was performed to verify the prognostic significance of preoperative ALP,
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GGT and LDH in hepatitis B virus (HBV)-related HCC patients receiving curative hepatectomy.
Materials and methods: 469 pathologically confirmed HCC patients who received curative
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hepatectomy were retrospectively analyzed. Significant clinicopathological factors were collected and analyzed. Independent prognostic factors were indentified by the multivariate analysis. Overall survival (OS) and recurrence-free survival (RFS) curves were analyzed and compared between different groups.
Results: Patients with low level of ALP, GGT and LDH have favorable OS and RFS, even in
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cirrhosis subgroup. ALP, GGT and LDH were also closely related to some important clinicopathological parameters. GGT and LDH were significant independent prognostic factors of both OS and RFS, while ALP was just a significant independent prognostic factor of OS, rather than RFS.
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Conclusions: Preoperative ALP, GGT and LDH could predict prognosis in HBV-related HCC
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patients who received curative liver resection.
Keywords:
Alkaline phosphatase; Gamma-glutamyl transpeptidase; Lactate dehydrogenase;
Hepatocellular carcinoma; Liver resection; Prognostic factor.
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Introduction Hepatocellular carcinoma (HCC), the fifth most common malignancy with an increasing incidence, represents the commonest primary cancer of the liver [1]. The most important cause of
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HCC is hepatitis B virus (HBV) in China and patients with HBV-related HCC usually have hepatic parenchymatous lesion and cirrhosis. At present, the most commonly used radical therapeutic options are liver resection and liver transplantation [2]. Although liver transplantation has become much more sophisticated in recently years, its application is limited in China due to short of donor
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and stiff price. Thus, hepatectomy is the optimal curative therapeutic option and is still widely used in developing countries. However, the postsurgical cumulative recurrence rate in HBV-related HCC
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patients is high and the long-term outcome of HCC patients is still dismal. Although prognostic factors have been widely investigated, their clinical application cannot be realized in a short time [3]. Thus, to explore simple and dependable predictors is essential to identify patients with poor prognosis. Some
serum
liver
enzymes,
including
alanine
aminotransferase
(ALT),
aspartate
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aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), lactate dehydrogenase (LDH), hydroxybutyrate dehydrogenase (HBD) and α-fetoprotein (AFP), are routinely tested before surgery and are easily obtained. Of these, ALP, GGT and LDH are not widely used like AFP, which have a certain reference value in the diagnosis of HCC [4-10]. ALP, a
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hydrolase enzyme, can predict tumor patients’ prognosis and is mainly found in the liver, bile duct, bone and so on [10]; Besides catalyzing the transpeptidation and hydrolysis of the glutamyl group of
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glutathione, GGT also participates in the biotransformation, nucleic acid metabolism and tumorigenesis [11]; LDH, a metabolic enzyme that in relation to anaerobic glycolysis , can also affect tumor initiation and progression [14]. Thus, in addition to being simply and easily obtained from preoperative routine tests, ALP, GGT and LDH also may predict prognosis in HCC patients [1, 9-16]. Moreover, ALP is one of fundamental elements in the Chinese University Prognostic Index (CUPI) HCC staging system [17]. However, most of previous studies [1, 9-16] focused on HCC patients who received non-surgical treatments, such as radiofrequency ablation (RFA), sorafenib, transcatheter arterial chemoembolization (TACE), etc. To the best of our knowledge, few studies
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ACCEPTED MANUSCRIPT have investigated the prognosis value of the three liver enzymes in surgically treated HCC patients. To date, the prognostic value of ALP, GGT and LDH have not been explored deeply and widely in such patients just like AFP. Thus, our study was performed to verify the prognostic significance of ALP, GGT and LDH in
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surgically treated HBV-related HCC patients. We also investigated the relationship between clinicopathological parameters and the three liver enzymes in such patients.
Materials and methods
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2.1 Patients selection and data collection
During June 2007 and March 2013, 655 pathologically confirmed HCC patients who received
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curative hepatectomy at West China Hospital of Sichuan University were enrolled. Our inclusion criteria were as follows: (1) resectable primary HCC comfirmed by pathological diagnosis; (2) positive for HBV and negative for hepatitis C virus (HCV) infection; (3) underwent hepatectomy as the initial therapy; (4) Child-Pugh grade A or B; (5) generally in good condition. Conversely, exclusion criteria were as follows: (1) HCC combined with other tumors; (2) negative for both HBV
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and HCV; (3) recurrent HCC; (4) lost to follow-up; (7) incomplete data. Thus, 186 were excluded. Finally, altogether 469 HBV-related HCC patients who received curative liver resection were included in our retrospective study.
Preoperative patients’ demographics and clinical data, including age, gender, concomitant
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diseases, complete blood count, liver function test, ALP, GGT, LDH, AFP, imaging data, HBV and HCV markers were collected. Surgical details and postoperative pathological parameters were also
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recorded. All preoperative examinations, such as detailed medical history, physical examination, routine laboratory and imaging examinations were done two days before the surgery. All patients had signed the informed consent. We followed close to the Helsinki Declaration and our study was approved by the Ethics Committee of West China Hospital, Sichuan University. 2.2 Follow-up All the patients were regularly followed at the first, third and sixth month after the surgery, every three months for the first three years, every six months thereafter. Basic physical examination, complete blood count, liver function test, AFP level, HBV markers, and abdominal ultrasound
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ACCEPTED MANUSCRIPT examination were performed at each visit. Imaging examinations, including abdominal enhanced computed tomography scan, magnetic resonance imaging, and hepatic artery angiography examination were selectively carried out depending on the actual situations when recurrence was suspected. Patients with confirmed recurrence were further treated with individualized projects
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(Table 1). The overall survival (OS) was defined as the interval from the date of surgery to the date of death or the last follow-up. The recurrence-free survival (RFS) was defined as the interval from the date of surgery to the date of confirmed HCC recurrence or the last follow-up. The last follow-up
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date was 26 February, 2016. 2.3 Statistical analysis
Continuous data were presented as the median and the range, or mean±standard deviation (SD);
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Differences between the two groups were compared by the Mann-Whitney U test or the independent sample t test, respectively. Categorical data were compared by the Pearson’s chi-square analysis or the Fisher exact test. OS and RFS curves were analyzed using the Kaplan-Meier method and compared by the log-rank test. The best cut-off values of ALP, GGT and LDH were selected by the receiver operating characteristic (ROC) curve. Univariate and multivariate analysis of prognostic
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factors for OS and RFS were performed using the Cox proportional hazards model. A value of p<0.05 was considered statistically significant (derived from two-tailed test). Statistical analyses
Results
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were performed with SPSS software (version 17.0; SPSS Inc., Chicago, IL, United States).
3.1 Patient baseline characteristics
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A total of 469 HBV-related HCC patients who underwent curative liver resection were included
in our retrospective analysis. During the follow-up period, 261 (55.7%) patients developed recurrence and 159 (33.9%) patients died during follow-up. The median duration of follow-up was 42 months (range: 2
99 months). The 1-, 3- and 5-year OS rates for all patients included in our
study were 93.5%, 77% and 61.1%, respectively, and the 1-, 3- and 5-year RFS rates for all cases were 71.3%, 47.1% and 40.4%, respectively. Details of patient baseline characteristics are shown in Table 1. 3.2 Determination of the best cut-off value
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ACCEPTED MANUSCRIPT The ROC curve analysis revealed a best cut-off of 136.5 IU/L for ALP (Figure 1A), 81.5 IU/L for GGT (Figure 1B) and 203.5 IU/L for LDH (Figure 1C). Therefore, all 469 patients were divided into low ALP group (ALP 136.5 IU/L, n=293) and high ALP group (ALP>136.5 IU/L, n=176), or low GGT group (GGT 81.5 IU/L, n=251) and high GGT group (GGT>81.5 IU/L, n=218), or low 203.5 IU/L, n=280) and high LDH group (LDH>203.5 IU/L, n=189),
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LDH group (LDH respectively.
3.3 Correlation between clinicopathological variables and preoperarive ALP/GGT/LDH
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As shown in Table 2 (Table 2a, 2b, 2c), significant differences in tumor size, tumor number, vascular invasion, BCLC staging, albumin concentration, AST level and AFP level were found between low ALP group and high ALP group. Similarly, gender, tumor size, tumor number, vascular
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invasion, BCLC staging, albumin concentration, ALT level, AST level, AFP level and perioperative transfusion were significantly different between low GGT group and high GGT group. Similarly, significant differences in pathological differentiation, tumor size, tumor number, vascular invasion, BCLC staging, albumin concentration, ALT level, AST level and AFP level were detected between low LDH group and high LDH group. While no significant differences in other clinicopathological
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variables were found. Details of relationship between clinicopathological variables and preoperarive ALP/GGT/LDH are presented in Table 2 (Table 2a, 2b, 2c). 3.4 Determination of prognostic factors for OS and RFS
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Our univariate analysis revealed that tumor size, tumor number, vascular invasion, albumin concentration, AST level, ALP level, GGT level, LDH level and AFP level were significant
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preoperative prognostic factors associated with OS (Table 3). In multivariate analysis, tumor size, tumor number, vascular invasion, albumin concentration, ALP level, GGT level, LDH level and AFP level remained as significant independent prognostic factors of OS (Table 3). The results of univariate and multivariate analysis of prognostic factors for OS are shown in Table 3. Similarly, in univariate analysis, tumor size, tumor number, vascular invasion, albumin concentration, AST level, ALP level, GGT level, LDH level, AFP level and perioperative transfusion were significant prognostic factors associated with RFS (Table 4). Then, our multivariate analysis revealed that tumor size, tumor number, vascular invasion, albumin concentration, AST level, GGT
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ACCEPTED MANUSCRIPT level, LDH level, AFP level and perioperative transfusion remained as significant independent prognostic factors of RFS (Table 4). However, ALP level was found not to be an independent prognostic factor of RFS. The results of univariate and multivariate analysis of prognostic factors for RFS are shown in Table 4.
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3.5 Survival analysis
Both OS and RFS rates were significantly higher in low ALP group than high ALP group (Figure 2A, Figure 2B). The 5-year OS and RFS rates were 76.6% and 46.8% in low ALP group,
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and 35.1% and 29.7% in high ALP group, respectively (Figure 2A, Figure 2B). As to GGT, patients in low GGT group had better OS and RFS rates than those in high GGT group (Figure 2C, Figure 2D). The 5-year OS and RFS rates were 78.1% and 53.3% in low GGT group, and 41.6% and 25.4%
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in high GGT group, respectively (Figure 2C, Figure 2D). Similarly, the 5-year OS and RFS rates were 73.7% and 54% in low LDH group, and 43.1% and 20.4% in high LDH group, respectively (Figure 2E, Figure 2F). Patients in low LDH group still had more favourable OS and RFS rates when compared with those in high LDH group (Figure 2E, Figure 2F). 3.6 Subgroup analysis in patients with cirrhosis
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Our study included a large proportion of cirrhosis patients (69.7%), thus we performed subgroup analysis to evaluate the prognostic value of ALP, GGT and LDH in such patients. As shown in Figure 3, cirrhosis patients in low ALP group also had better OS and RFS rates than those
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in high ALP group (Figure 3A, Figure 3B). The similar situation was found in different GGT groups (Figure 3C, Figure 3D) or different LDH groups (Figure 3E, Figure 3F).
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The results of subgroup analysis were in line with the outcomes of survival analysis of the whole study population. Therefore, we concluded that our findings were reliable (Figure 2, Figure 3).
Discussion
ALP is a variation marker for either embryonic stem cell or other stem cells derived from the bone and adipose tissue [10]. Although ALP exists in all tissues throughout the entire body, it could indicate the proliferation of tumor cells [9-10, 18]. Some tumor cells, such as HepG2, also showed higher ALP activities in the nucleolus and change in the localization during cell cycles [9-10, 18].
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ACCEPTED MANUSCRIPT Thus ALP may play an important role in cell cycle regulation, cell proliferation and tumor formation. Interestingly, an elevated ALP was also observed in some benign diseases, such as cholangitis, choledocholithiasis, pancreatitis, hepatitis, etc. The common ground of these diseases is inflammation, which also exerts an enormous function on tumor formation. Therefore, ALP takes
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part in tumor formation and represents inflammation reactions either directly or indirectly, and it could predict the prognosis of HCC patients. With reference to GGT, its abnormal expression has been found in several human tumors [19]. As an oxidative stress marker, GGT can give rise to the
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pro-oxidant reactions, the latter can produce endogenous reactive oxygen species (ROS) in tumor cells and play an important role in tumor formation, cell proliferation and apoptosis [12, 20-21]. GGT is also correlated with inflammation, and some inflammatory cytokines can bring about the
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production of GGT [12, 22-23]. In addition, inflammation is closely correlated with tumor formation and progression, thus GGT has prognostic effects on HCC patients. Furthermore, LDH, a glycolytic enzyme, plays a crucial role in the conversion of pyruvate to lactate under anaerobic conditions [1, 13]. Up-regulation of LDH has been indicated to ensure an efficient glycolytic metabolism and a reduced demand for oxygen in tumor cells under hypoxic conditions [1, 13]. LDH was connected
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with hypoxia and the tumor angiogenesis pathway through the abnormal activation of the hypoxia inducible factor 1 (HIF-1) [1, 13-14]. Abnormal HIF-1 can upregulate corresponding genes and result in abnormal glycolytic energy metabolism, angiogenesis, cell survival and tumor formation. [1,
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13-14, 24]. Besides, LDH is also regulated by the PI3K/Akt/mTOR pathways which play an important role in tumor formation and progress. [14, 25]. Thus, LDH is closely related with the
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biological behavior of tumors, and can predict the prognosis of tumor patients. Generally speaking, the results of above basic studies showed that elevated ALP, GGT and LDH had a close relationship with tumor recurrence, formation and progress. In the present study, we determined the best cut-off values of ALP, GGT and LDH that were
suitable for our study population and medical center by the ROC curve analysis. After that, we explored the prognostic value of ALP, GGT and LDH in HBV-related HCC patients treated by curative liver resection and found that preoperative ALP, GGT and LDH could predict prognosis in surgically treated HCC patients. Patients with low levels of ALP, GGT and LDH might have
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ACCEPTED MANUSCRIPT favorable OS and RFS. We further performed survival analysis in cirrhosis subgroup. Then we found that the lower of them were, the better prognosis patients might have, and vice versa. The results of survival analysis in cirrhosis subgroup were consistent with the outcomes of survival analysis of the whole study population means that our findings were dependable. We also found that tumor size,
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tumor number, vascular invasion, BCLC staging, serum albumin concentration, AST level and AFP level were closely related to all of ALP, GGT and LDH. Moreover, in our multivariate analysis, GGT and LDH were also found to be significant independent prognostic factors of both OS and RFS.
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However, our multivariate analysis indicated that ALP was just a significant independent prognostic factor of OS, rather than RFS (Table 3, Table 4). While our present clinical study also found that patients with high levels of ALP, GGT and LDH might have poor OS and RFS. Our findings were
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not contradicted against the results of these previous basic studies, which demonstrated that ALP, GGT and LDH might predict prognosis in surgically treated HCC patients. Several studies [1, 9-16] have investigated similar issues, but most of them centered on non-surgically treated HCC patients and almost all of them studied only one marker among ALP, GGT and LDH. As far as we can determine, few studies have investigated the prognosis value of the
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three liver enzymes in surgically treated HCC patients [9-10, 12, 14]. Our study was the first one to explore the prognosis value of ALP, GGT and LDH simultaneously in HBV-related HCC patients treated by curative liver resection. Xu et al [9] found that both preoperative ALP and GGT were
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independent prognostic factors of OS and RFS and could predict survival outcomes in HCC patients. Some of our findings were in line with theirs, but their study population was a little different from
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ours. They included some HCV and non-hepatitis HCC patients. While in order to reduce clinical bias and increase the homogeneity of subject investigated, based on our inclusion and exclusion criteria, only HBV-related HCC patients were included in our study. In addition, due to the fact that HCC is mostly caused by HBV and HCV in China, the number of HCC patients without hepatitis is very small. Another difference is that we found ALP was just a significant independent prognostic factor of OS rather than RFS. Yu et al [10] studied the prognostic effects of ALP on HCC patients who underwent hepatectomy. However, they also included 297 HCV patients, 129 HBV and HCV patients and 125 non-hepatitis patients. ALP was also found to be a significant independent
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ACCEPTED MANUSCRIPT prognostic factor of both OS and RFS in their research. Fu et al [12] and Zhang et al [14] investigated the prognostic value of GGT and LDH in HCC patients, respectively. They also drew similar conclusions. Other studies [1, 11, 13, 15-16] explored the prognostic effects of GGT or LDH on patients who received non-surgical treatments and most of their outcomes were not contradictory
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with our findings. All in all, based on the above mentioned evidences, we concluded that our findings were credible.
Although our study was the first one to explore the prognosis value of ALP, GGT and LDH
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simultaneously in HBV-related HCC patients treated by curative liver resection, we must recognize that the current study still have several limitations. First, basic medical researches were not performed to explore the concrete effects of ALP, GGT and LDH on tumor formation and
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progression. Second, selection bias, withdraw bias and other clinical bias were inevitable due to the fact that our study was a retrospective study. Third, all data were collected from a single medical center and our sample size was still limited. In the future, prospective clinical studies with large sample size are urgently needed to confirm our conclusions and promote the clinical application of ALP, GGT and LDH. Basic medical researches with regard to this topic were also imminently
Conclusions
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needed to provide the basis for the clinical application of these three frequently used liver enzymes.
Preoperative ALP, GGT and LDH might possibly predict prognosis in surgically treated HCC
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patients. Patients with low level of ALP, GGT and LDH might have favorable OS and RFS, even in cirrhosis patients. GGT and LDH could be significant independent prognostic factors of both OS and
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RFS, while ALP might possibly be just a significant independent prognostic factor of OS, rather than RFS.
References
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ACCEPTED MANUSCRIPT Oncol. 10 (2009) 1111-1118. 3. Villanueva A, Hoshida Y, Toffanin S, Lachenmayer A, Alsinet C, Savic R, et al. New strategies in hepatocellular carcinoma: genomic prognostic markers. Clin Cancer Res. 16 (2010) 4688-4694. 4. Lopez JB, Balasegaram M, Thambyrajah V, Timor J. The value of liver function tests in
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5. Xu K, Meng XY, Wu JW, Shen B, Shi YC, Wei Q.. Diagnostic value of serum gamma-glutamyl transferase isoenzyme for hepatocellular carcinoma: a 10-year study. Am J Gastroenterol. 87 (1992)
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991-995.
6. Hann HW, Wan S, Myers RE, Hann RS, Xing J, Chen B, et al. Comprehensive analysis of
PLoS One. 7 (2012) e47687.
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common serum liver enzymes as prospective predictors of hepatocellular carcinoma in HBV patients.
7. Carr BI, Guerra V. Hepatocellular Carcinoma Extrahepatic Metastasis in Relation to Tumor Size and Alkaline Phosphatase Levels. Oncology. 90 (2016) 136-142.
8. Carr BI, Guerra V. Hepatocellular carcinoma size: platelets, γ-glutamyl transpeptidase, and alkaline phosphatase. Oncology. 85 (2013) 153-159.
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9. Xu XS, Wan Y, Song SD, Chen W, Miao RC, Zhou YY, et al. Model based on γ -glutamyltransferase and alkaline phosphatase for hepatocellular carcinoma prognosis. World J Gastroenterol. Aug 21; 20 (2014) 10944-10952.
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10. Yu MC, Chan KM, Lee CF, Lee YS, Eldeen FZ, Chou HS, et al. Alkaline phosphatase: does it have a role in predicting hepatocellular carcinoma recurrence? J Gastrointest Surg. Aug 15 (2011)
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1440-1449.
11. Ma H, Zhang L, Tang B, Wang Y, Chen R, Zhang B, et al. γ-Glutamyltranspeptidase is a prognostic marker of survival and recurrence in radiofrequency-ablation treatment of hepatocellular carcinoma. Ann Surg Oncol. Sep 21(2014) 3084-3089. 12. Fu S, Guo Z, Li S, Kuang M, Hu W, Hua Y, et al. Prognostic value of preoperative serum gamma-glutamyltranspeptidase in patients with hepatocellular carcinoma after hepatectomy. Tumour Biol. Oct 8 (2015). 13. Scartozzi M, Faloppi L, Bianconi M, Giampieri R, Maccaroni E, Bittoni A, et al. The role of
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ACCEPTED MANUSCRIPT LDH serum levels in predicting global outcome in HCC patients undergoing TACE: implications for clinical management. PLoS One. 7(2012) e32653. 14. Zhang JP, Wang HB, Lin YH, Xu J, Wang J, Wang K, et al. Lactate Dehydrogenase Is an Important Prognostic Indicator for Hepatocellular Carcinoma after Partial Hepatectomy. Transl
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Oncol. Dec 8(2015) 497-503.
15. Zhang JB, Chen Y, Zhang B, Xie X, Zhang L, Ge N, et al. Prognostic significance of serum gamma-glutamyl transferase in patients with intermediate hepatocellular carcinoma treated with
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transcatheter arterial chemoembolization. Eur J Gastroenterol Hepatol. 23 (2011) 787-793.
16. Guiu B, Deschamps F, Boulin M, Boige V, Malka D, Ducreux M, et al. Serum gamma-glutamyl-transferase independently predicts outcome after transarterial chemoembolization
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of hepatocellular carcinoma: external validation. Cardiovasc Intervent Radiol. 35(2012) 1102-1108. 17. Leung TW, Tang AM, Zee B, Lau WY, Lai PB, Leung KL, et al. Construction of the Chinese University Prognostic Index for hepatocellular carcinoma and comparison with the TNM staging system, the Okuda staging system, and the Cancer of the Liver Italian Program staging system: a study based on 926 patients. Cancer. 94(2002) 1760-1769.
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18. Yamamoto K, Awogi T, Okuyama K, Takahashi N. Nuclear localization of alkaline phosphatase in cultured human cancer cells. Med Electron Microsc. Mar 36(2003) 47-51. 19. Hanigan MH, Frierson Jr HF, Swanson PE, De Young BR. Altered expression of
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gamma-glutamyl transpeptidase in human tumors. Hum Pathol. 30(1999) 300-305. 20. Corti A, Franzini M, Paolicchi A, Pompella A. Gammaglutamyltransferase of cancer cells at the
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crossroads of tumor progression, drug resistance and drug targeting. Anticancer Res. 30(2010) 1169-1182.
21. Toyokuni S, Okamoto K, Yodoi J, Hiai H. Persistent oxidative stress in cancer. FEBS Lett. 358 (1995) 1-3.
22. Daubeuf S, Accaoui MJ, Pettersen I, Huseby NE, Visvikis A, Galteau MM. Differential regulation of gammaglutamyltransferase mRNAs in four human tumour cell lines. Biochim Biophys Acta. 1568(2001) 67-73. 23. Bouman L, Sanceau J, Rouillard D, Bauvois B. Gammaglutamyl transpeptidase expression in
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ACCEPTED MANUSCRIPT Ewing’s sarcoma cells: up-regulation by interferons. Biochem J. 364(2002) 719-724. 24. Semenza GL. HIF-1: mediator of physiological and pathophysiological responses to hypoxia. J Appl Physiol. 88(2000) 1474-1480. 25. Zha X, Wang F, Wang Y, He S, Jing Y, Wu X, et al. Lactate dehydrogenase B is critical for
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hyperactive mTOR-mediated tumorigenesis. Cancer Res. 71(2011) 13-18.
Figure legend:
Figure 1 Receiver operating characteristics (ROC) curves to determine the best cut-off value of
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alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH). A: ROC curve of ALP. B: ROC curve of GGT. C: ROC curve of LDH.
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Figure 2 Kaplan-Meier survival analysis of hepatocellular carcinoma patients receiving curative liver resection based on the level of alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH). A: Overall survival (OS) curve comparing low ALP group and high ALP group. B: Recurrence-free survival (RFS) curve comparing low ALP group and high ALP group. C: OS curve comparing low GGT group and high GGT group. D: RFS curve comparing
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low GGT group and high GGT group. E: OS curve comparing low LDH group and high LDH group. F: RFS curve comparing low LDH group and high LDH group. Patients with low level of ALP, GGT and LDH may have favorable OS and RFS.
Figure 3 Subgroup analysis in gurgically treated hepatocellular carcinoma patients with cirrhosis
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based on the level of alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH). A: Overall survival (OS) curve comparing low ALP group and high ALP
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group. B: Recurrence-free survival (RFS) curve comparing low ALP group and high ALP group. C: OS curve comparing low GGT group and high GGT group. D: RFS curve comparing low GGT group and high GGT group. E: OS curve comparing low LDH group and high LDH group. F: RFS curve comparing low LDH group and high LDH group. Cirrhosis patients with low level of ALP, GGT and LDH still have favorable OS and RFS.
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ACCEPTED MANUSCRIPT Table 2a Correlation between preoperative ALP and clinicopathological parameters ALP (IU/L) Variables
P value
136.5 (n=293)
Age (year, median (range))
>136.5 (n=176) 47 (17-81)
0.086
Gender (Male/Female)
245/48
149/27
0.766
Cirrhosis (Absent/Present)
87/206
55/121
0.722
25/226/42
12/136/28
0.744
234/59
104/72
<0.001
Tumor number (Single/Multiple)
261/32
133/43
Vascular invasion (Absent/Present)
261/32
124/52
235/26/32
99/25/52
Differentiation (Well/ Moderate/ Poor) Tumor size (cm,
5/>5)
BCLC staging (0+A/B/C) Total bilirubin (μmol/L,
28/>28)
143/33
207/86
93/83
ALT (IU/L,
45/>45)
179/114
95/81
AST (IU/L,
45/>45)
184/109
AFP (ng/ml, <400/ 400)
209/84
Transfusion (no/yes)
<0.001
<0.001 0.858
<0.001
218.67±79.32
0.130
87/89
0.005
81/95
<0.001
211.55±85.19
0.361
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Operation duration (min, mean±SD)
<0.001
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240/53
Albumin (g/L, >40/ 40)
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49 (18-78)
258/35
149/27
0.293
124 (65-281)
127 (65-251)
0.535
WBC (10 /L, median (range))
4.65 (2.91-9.75)
4.70 (2.48-10.99)
0.684
PT (sec, median (range))
11.8 (9.9-15.2)
11.8 (9.6-16.9)
0.935
Platelet count (109/L, median (range)) 9
ALP-alkaline
phosphatase;
BCLC-Barcelona
Clinic
Liver
Cancer;
ALT-alanine
aminotransferase;
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aminotransferase; AFP-alfa-fetoprotein; SD-standard deviation; WBC-white blood count; PT-prothrombin time
AST-aspartate
ACCEPTED MANUSCRIPT Table 2b Correlation between preoperative GGT and clinicopathological parameters GGT (IU/L) 81.5 (n=251)
Age (year, median (range)) Gender (Male/Female) Cirrhosis (Absent/Present) Differentiation (Well/ Moderate/ Poor) Tumor size (cm,
5/>5)
P value >81.5 (n=218)
49 (18-79)
47 (17-81)
0.099
199/52
195/23
0.003
85/166
57/161
0.070
25/192/34
12/170/36
0.161 <0.001
200/51
138/80
Tumor number (Single/Multiple)
222/29
172/46
Vascular invasion (Absent/Present)
219/32
166/52
197/22/32
137/29/52
BCLC staging (0+A/B/C) Total bilirubin (μmol/L,
28/>28)
177/41
180/71
120/98
ALT (IU/L,
45/>45)
177/74
97/121
AST (IU/L,
45/>45)
176/75
AFP (ng/ml, <400/ 400)
179/72
Transfusion (no/yes)
209.86±80.51 228/23
Platelet count (109/L, median (range)) WBC (109/L, median (range)) PT (sec, median (range))
0.005 0.002
0.001
0.806
<0.001 <0.001
95/123
<0.001
111/107
<0.001
218.95±83.65
0.232
179/39
0.005
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Operation duration (min, mean±SD)
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206/45
Albumin (g/L, >40/ 40)
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Variables
127 (65-263)
125 (65-281)
0.492
4.78 (2.91-10.99)
4.61 (2.48-9.75)
0.232
11.8 (9.6-15.2)
11.8 (9.6-16.9)
0.925
GGT-gamma-glutamyl transpeptidase; BCLC-Barcelona Clinic Liver Cancer; ALT-alanine aminotransferase; AST-aspartate
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aminotransferase; AFP-alfa-fetoprotein; SD-standard deviation; WBC-white blood count; PT-prothrombin time
ACCEPTED MANUSCRIPT Table 2c Correlation between preoperative LDH and clinicopathological parameters LDH (IU/L) 203.5 (n=280)
Age (year, median (range)) Gender (Male/Female) Cirrhosis (Absent/Present) Differentiation (Well/ Moderate/ Poor) Tumor size (cm,
5/>5)
P value >203.5 (n=189)
48 (19-81)
48 (17-79)
0.998
242/38
152/37
0.082
93/187
49/140
0.092
23/225/32
14/137/38
0.035 <0.001
221/59
117/72
Tumor number (Single/Multiple)
247/33
147/42
Vascular invasion (Absent/Present)
241/39
144/45
217/24/39
117/27/45
BCLC staging (0+A/B/C) Total bilirubin (μmol/L,
28/>28)
152/37
196/84
104/85
ALT (IU/L,
45/>45)
181/99
93/96
AST (IU/L,
45/>45)
196/84
AFP (ng/ml, <400/ 400)
186/94
Operation duration (min, mean±SD)
249/31
0.006
0.001
0.569
0.001 0.001
75/114
<0.001
104/85
0.013
208.77±78.26
0.113
158/31
0.095
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221.23±86.59
Transfusion (no/yes)
0.002
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231/49
Albumin (g/L, >40/ 40)
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Variables
Platelet count (109/L, median (range))
128.5 (65-273)
124 (65-281)
0.100
WBC (109/L, median (range))
4.67 (2.48-9.75)
4.65 (2.91-10.99)
0.312
PT (sec, median (range))
11.75 (9.6-15.2)
11.8 (9.6-16.9)
0.775
LDH-lactate dehydrogenase; BCLC-Barcelona
Clinic Liver
Cancer; ALT-alanine
aminotransferase; AST-aspartate
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aminotransferase; AFP-alfa-fetoprotein; SD-standard deviation; WBC-white blood count; PT-prothrombin time
ACCEPTED MANUSCRIPT Table 1 Baseline clinicopathological characteristics of the patients Clinicopathological parameters Included patients (N=469)
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48 (17-81) 394 (84%)/75 (16%) 142 (30.3%)/327 (69.7%) 37 (7.9%)/ 362 (77.2%)/ 70 (14.9%) 5.12±1.80 338 (72.1%)/131 (27.9%) 394 (84%)/75 (16%) 385 (82.1%)/84 (17.9%) 334 (71.2%)/51 (10.9%)/84 (17.9%) 13.8 (4.3-44.7) 41.8 (28.1-54.2) 39 (8-408) 40 (14-263) 113 (11-654) 71 (10-585) 188 (99-653) 290 (61.8%)/179 (38.2%) 214.56±82.44 407 (86.8%)/62 (13.2%) 126 (65-281) 4.66 (2.48-10.99) 11.8 (9.6-16.9) 261 19 (7.3%) 101 (38.6%) 38 (14.6%) 12 (4.6%) 91 (34.9%)
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Age (year), median (range) Gender, Male/Female, n (%) Cirrhosis, Absent/Present, n (%) Differentiation, Well/ Moderate/ Poor, n (%) Maximum tumor diameter (cm), mean±SD Tumor size (cm), 5cm/>5cm, n (%) Tumor number, Single/Multiple, n (%) Vascular invasion, Absent/Present, n (%) BCLC staging, 0+A/B/C, n (%) Total bilirubin (μ μmol/L), median (range) Albumin (g/L), median (range) ALT (IU/L), median (range) AST (IU/L), median (range) ALP (IU/L), median (range) GGT (IU/L), median (range) LDH (IU/L), median (range) AFP (ng/ml), <400/ 400, n(%) Operation duration (min), mean±SD Transfusion, no/yes, n (%) Platelet count (109/L), median (range) WBC (109/L), median (range) PT (sec), median (range) Treatment for recurrence (total 261) Repeat hepatectomy, n (%) TACE, n (%) RFA, n (%) PEIT, n (%) Other therapies, n (%)
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SD-standard deviation; BCLC-Barcelona Clinic Liver Cancer; ALT-alanine aminotransferase; AST-aspartate aminotransferase; ALP-alkaline phosphatase; GGT-gamma-glutamyl transpeptidase; LDH-lactate dehydrogenase; AFP-alfa-fetoprotein; WBC-white blood count; PT-prothrombin time; TACE-transcather hepatic arterial chemoembolization; RFA-radiofrequency ablation; PEIT-percutaneous ethanol injection therapy
ACCEPTED MANUSCRIPT Table 3 Prognostic factors for overall survival by univariate and multivariate analyses Univariate analysis
Multivariate analysis
Variables P-value
48 (17-81)
0.486
75 (16%)/394 (84%)
0.669
126 (65-281)
0.066
4.66 (2.48-10.99)
0.610
11.8 (9.6-16.9)
0.239
Age (year, median (range)) Gender (Female/ Male) 9
Platelet count (10 /L, median (range)) 9
WBC (10 /L, median (range)) PT (sec, median (range))
0.115 0.266
131 (27.9%)/338 (72.1%)
<0.001
75 (16%)/394 (84%)
<0.001
Vascular invasion (Present/Absent)
84 (17.9%)/385 (82.1%)
<0.001
Total bilirubin (μmol/L, >28/
86 (18.3%)/383 (81.7%)
Differentiation (Poor/ Moderate/ Well) Tumor size (cm, >5/
5)
Tumor number (Multiple/Single)
P-value
3.090
2.149-4.444
<0.001
2.313
1.582-3.383
<0.001
5.835
3.992-8.530
<0.001
1.838
1.266-2.668
0.001
0.201
40/>40)
169 (36%)/300 (64%)
<0.001
ALT (IU/L, >45/
45)
195 (41.6%)/274 (58.4%)
0.166
AST (IU/L, >45/
45)
198 (42.2%)/271 (57.8%)
0.002
0.706
0.495-1.007
0.054
ALP (IU/L, >136.5/ 136.5)
176 (37.5%)/293 (62.5%)
<0.001
2.382
1.662-3.414
<0.001
GGT (IU/L, >81.5/
218 (46.5%)/251 (53.5%)
<0.001
2.376
1.604-3.519
<0.001
189 (40.3%)/280 (59.7%)
LDH (IU/L, >203.5/ AFP (ng/ml,
81.5) 203.5)
400/<400)
<0.001
1.807
1.262-2.587
0.001
179 (38.2%)/290 (61.8%)
<0.001
1.593
1.091-2.324
0.016
214.56±82.44
0.526
62 (13.2%)/407 (86.8%)
0.204
Operation duration (min, mean±SD) Transfusion (yes/no)
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Albumin (g/L,
28)
95% CI
SC
327 (69.7%)/142 (30.3%) 70 (14.9%)/362 (77.2%)/37 (7.9%)
Cirrhosis (Present/ Absent)
HR
RI PT
n (%) or value
AST-aspartate
aminotransferase;
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HR-hazard ratio; CI-confidence interval; WBC-white blood count; PT-prothrombin time; ALT-alanine aminotransferase; ALP-alkaline
phosphatase;
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dehydrogenase; AFP-alfa-fetoprotein; SD-standard deviation
GGT-gamma-glutamyl
transpeptidase;
LDH-lactate
ACCEPTED MANUSCRIPT Table 4 Prognostic factors for recurrence-free survival by univariate and multivariate analyses Univariate analysis
Multivariate analysis
Variables P-value
48 (17-81)
0.283
75 (16%)/394 (84%)
0.612
126 (65-281)
0.155
4.66 (2.48-10.99)
0.753
11.8 (9.6-16.9)
0.179
Age (year, median (range)) Gender (Female/ Male) 9
Platelet count (10 /L, median (range)) 9
WBC (10 /L, median (range)) PT (sec, median (range))
0.288 0.065
131 (27.9%)/338 (72.1%)
<0.001
75 (16%)/394 (84%)
<0.001
Vascular invasion (Present/Absent)
84 (17.9%)/385 (82.1%)
<0.001
Total bilirubin (μmol/L, >28/
86 (18.3%)/383 (81.7%)
Differentiation (Poor/ Moderate/ Well) Tumor size (cm, >5/
5)
Tumor number (Multiple/Single)
P-value
2.240
1.677-2.991
<0.001
2.550
1.865-3.487
<0.001
4.663
3.397-6.400
<0.001
1.916
1.462-2.510
<0.001
0.320
40/>40)
169 (36%)/300 (64%)
<0.001
ALT (IU/L, >45/
45)
195 (41.6%)/274 (58.4%)
0.139
AST (IU/L, >45/
45)
198 (42.2%)/271 (57.8%)
<0.001
1.484
1.128-1.953
0.005
ALP (IU/L, >136.5/ 136.5)
176 (37.5%)/293 (62.5%)
<0.001
1.233
0.942-1.614
0.128
GGT (IU/L, >81.5/
218 (46.5%)/251 (53.5%)
<0.001
1.683
1.286-2.203
<0.001
189 (40.3%)/280 (59.7%)
LDH (IU/L, >203.5/ AFP (ng/ml,
81.5) 203.5)
400/<400)
<0.001
1.806
1.379-2.366
<0.001
179 (38.2%)/290 (61.8%)
<0.001
2.642
2.006-3.479
<0.001
214.56±82.44
0.633
62 (13.2%)/407 (86.8%)
<0.001
1.462
1.051-2.035
0.024
Operation duration (min, mean±SD) Transfusion (yes/no)
M AN U
Albumin (g/L,
28)
95% CI
SC
327 (69.7%)/142 (30.3%) 70 (14.9%)/362 (77.2%)/37 (7.9%)
Cirrhosis (Present/ Absent)
HR
RI PT
n (%) or value
AST-aspartate
aminotransferase;
TE D
HR-hazard ratio; CI-confidence interval; WBC-white blood count; PT-prothrombin time; ALT-alanine aminotransferase; ALP-alkaline
phosphatase;
AC C
EP
dehydrogenase; AFP-alfa-fetoprotein; SD-standard deviation
GGT-gamma-glutamyl
transpeptidase;
LDH-lactate
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT The prognostic value of alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH) have not been explored deeply and widely in surgically treated hepatocellular carcinoma (HCC) patients just like AFP. Our study was the first one to explore the prognosis value of ALP, GGT and LDH simultaneously in HBV-related HCC patients treated by
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curative liver resection. We found that preoperative ALP, GGT and LDH could predict prognosis
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in such patients.
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International Journal of Surgery Author Disclosure Form The following additional information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated.
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Please state any conflicts of interest
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We have no conflicts of interest
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Please state any sources of funding for your research We did not receive any sources of funding
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Please state whether Ethical Approval was given, by whom and the relevant Judgement’s reference number
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All patients had signed the informed consent. We followed close to the Helsinki Declaration and our study was approved by the Ethics Committee of West China Hospital, Sichuan University.
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Research Registration Unique Identifying Number (UIN) Please enter the name of the registry and the unique identifying number of the study. You can register your research at http://www.researchregistry.com to obtain your UIN if you have not already registered your study. This is mandatory for human studies only.
researchregistry1609 Nan sheng Cheng Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection September 05, 2016 11:50
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ACCEPTED MANUSCRIPT Author contribution Please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. Others, who have contributed in other ways should be listed as contributors. Si-Jia Wu and Nan-Sheng Cheng designed this subject; Si-Jia Wu drafted the manuscript; Si-Jia Wu, Yi-Xin Lin and Xian-Ze Xiong collected and analyzed data;
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Fu-Yu Li and Hui Ye critically revised the content; Nan-Sheng Cheng approved the
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final version of the manuscript.
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Guarantor The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
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Nan-sheng Cheng and Si-jia Wu are Guarantors.
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