Cell-free DNA testing for early hepatocellular carcinoma surveillance

Abstract

Background: Liver cirrhosis (LC) is the highest risk factor for hepatocellular carcinoma (HCC) development worldwide. The efficacy of the guideline-recommended surveillance methods for patients with LC remains unpromising.

Methods: A total of 4367 LCs not previously known to have HCC and 510 HCCs from 16 hospitals across 11 provinces of China were recruited in this multi-center, large-scale, cross-sectional study. Participants were divided into Stage Ⅰ cohort (510 HCCs and 2074 LCs) and Stage Ⅱ cohort (2293 LCs) according to their enrollment time and underwent Tri-phasic CT/enhanced MRI, US, AFP, and cell-free DNA (cfDNA). A screening model called PreCar Score was established based on five features of cfDNA using Stage Ⅰ cohort. Surveillance performance of PreCar Score alone or in combination with US/AFP was evaluated in Stage Ⅱ cohort.

Findings: PreCar Score showed a significantly higher sensitivity for the detection of early/very early HCC (Barcelona stage A/0) in contrast to US (sensitivity of 51.32% [95% CI: 39.66%-62.84%] at 95.53% [95% CI: 94.62%-96.38%] specificity for PreCar Score; sensitivity of 23.68% [95% CI: 14.99%-35.07%] at 99.37% [95% CI: 98.91%-99.64%] specificity for US) (P < 0.01, Fisher's exact test). PreCar Score plus US further achieved a higher sensitivity of 60.53% at 95.08% specificity for early/very early HCC screening.

Interpretation: Our study developed and validated a cfDNA-based screening tool (PreCar Score) for HCC in cohorts at high risk. The combination of PreCar Score and US can serve as a promising and practical strategy for routine HCC care.

Funding: A full list of funding bodies that contributed to this study can be found in Acknowledgments section.

Keywords: Cell-free DNA; Early hepatocellular carcinoma; Liquid biopsy; Surveillance.

Fig. 1

Enrollment and Outcomes. BCLC: Barcelona clinic liver cancer; US: ultrasound; CT: Tri-phasic Computed Tomography; Magnetic MRI: Resonance Imaging.

Fig. 2

Comparation of three surveillance methods. Left: Geographic distribution of the participants in this prospective study. Red dots represented 16 clinic centers across 11 provinces of China. Right: Preparation, modality, diagnostic standard, and sensitivity of ultrasound, AFP, and PreCar Score method. cfDNA: cell-free DNA.

Fig. 3

Serial cfDNA analysis (PreCar Score) compared to PIVKA-II/AFP in PreCar Score positive patients with LC. (a) In patient EA-03-0011, PreCar Score was positive and PIVKA-II & AFP were both negative for each follow-up. The fourth follow-up MRI scan indicated a high signal intensity area (0.8 cm) on T2 weighted MRI in liver segment Ⅶ, suggesting hepatocellular carcinoma. HE and IHC staining showed the histopathological characteristics of the tissue biopsy. RFA: radiofrequency ablation. (b) In patient EA-02-0726, PreCar Score was positive and PIVKA-II & AFP were both negative for each follow-up. The third follow-up enhanced CT scan indicated a low-density area in liver segment Ⅵ, suggesting hepatocellular carcinoma. HE and IHC staining showed the histopathological characteristics of the tissue biopsy. TACE: transcatheter arterial chemoembolization.