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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 700-705

Evaluation of serum prolactin as a potential tumor marker in hepatocellular carcinoma


1 Internal Medicine Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Clinical Oncology and Nuclear Medicine Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Medical Biochemistry Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
4 Internal Medicine Department, Ministry of Health, Tanta, Gharbia, Egypt

Date of Submission19-Sep-2016
Date of Acceptance06-Nov-2016
Date of Web Publication15-Nov-2017

Correspondence Address:
Mohamad A Abouhabal
Tanta, Gharbia, 31741
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.218290

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  Abstract 

Objectives
The aim of this study was to evaluate serum prolactin (PRL) as a potential tumor marker in the detection of hepatocellular carcinoma (HCC).
Background
HCC ranks fifth among the most prevalent cancers worldwide. In Egypt, the incidence of HCC had been doubling because of hepatitis C viral infection. New serum tumor markers are required for the diagnosis of HCC instead of α-fetoprotein (AFP) (the most widely used marker) due to its poor diagnostic accuracy. Prolactin receptor has been identified in a variety of human tissues, such as the liver. When PRL binds to its receptor, it leads to the activation of Janus kinase 2, a tyrosine kinase that can phosphorylate the STAT (signal transducer and activator of transcription) proteins and subsequently functions in cell proliferation and differentiation.
Patients and methods
Eighty adult patients were selected for this study. They were categorized as follows: group I, which included 10 healthy controls, age and sex matched; group II, which included 40 patients with cirrhosis; and group III, which included four patients with newly diagnosed HCC in addition to cirrhosis. Routine tests for liver cirrhosis and HCC were carried out. Serum PRL was measured using enzyme-linked immunosorbent assay.
Results
Serum PRL was significantly elevated in the HCC group when compared with the other two groups. There was a significant difference between single and multiple lesions as regards PRL level in the HCC group; it was higher in cases of multiple lesions. Significant positive correlations were found between PRL on one hand and AFP, aspartate aminotransferase platelet ratio index, and tumor size on the other hand. At a cutoff level of at least 44.5 ng/ml, serum PRL had 92.5% sensitivity, 77.5% specificity, 80.43% positive protective value, and 91.18% negative protective value for the diagnosis of HCC.
Conclusion
Significantly elevated serum PRL in HCC patients may act as promising and potentially complementary biomarker with AFP. It may offer more effective early detection of HCC.

Keywords: α-fetoprotein (AFP), hepatocellular carcinoma, serum prolactin


How to cite this article:
AbdElatty EA, Elshayeb EI, AbdelGhani AE, El Ghobashy YA, Abouhabal MA. Evaluation of serum prolactin as a potential tumor marker in hepatocellular carcinoma. Menoufia Med J 2017;30:700-5

How to cite this URL:
AbdElatty EA, Elshayeb EI, AbdelGhani AE, El Ghobashy YA, Abouhabal MA. Evaluation of serum prolactin as a potential tumor marker in hepatocellular carcinoma. Menoufia Med J [serial online] 2017 [cited 2019 Nov 17];30:700-5. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/700/218290


  Introduction Top


Hepatocellular carcinoma (HCC) ranks fifth among the most prevalent cancers worldwide, and is considered the third most common cause of cancer-related deaths. HCC is frequently the long-term sequel of chronic hepatitis B (HBV) and hepatitis C (HCV) infection [1]. In Egypt, the incidence of HCC had been increasing with a doubling in the incidence rate in the past 10 years; 90% of HCC cases were attributed to HCV infection as Egypt has the highest prevalence rate of HCV worldwide [2],[3].

HCC diagnosis can be achieved by measuring the serum α-fetoprotein (AFP) level combined with imaging techniques [4],[5]. AFP is not yet recommended for HCC surveillance by the American Association for the Study of Liver Diseases as its sensitivity and specificity cannot be satisfactory in HCC detection [6]. Improvement in early diagnosis is still needed because only 30% of patients with HCC are candidates for potentially curative treatments [7]. Thus, the discovery of an effective, reliable tool for the early diagnosis of HCC will play a main role in improving HCC patients' prognosis [8]. Biomarkers from body fluids such as serum and plasma are suitable for the early diagnosis of HCC because they are easily accessible [9].

The prolactin (PRL) is a protein hormone, as well as a cytokine, which is synthesized and secreted from specialized cells of the anterior pituitary gland, named lactotrophs. More than 300 functions exerted by PRL in vertebrates have been recognized, and they reflect the ubiquitous distribution of its receptors, as well as the fact that PRL is synthesized in many extrapituitary tissues [10].

The prolactin receptor (PRLR) belongs to the class 1 cytokine receptor superfamily and has been identified in a variety of human tissues, such as the liver and gastrointestinal tract [11]. When PRL binds to its receptor, the ligand-bound PRLR will dimerize with another one. This dimerization leads to the activation of Janus kinase 2 (JAK2), a tyrosine kinase that can phosphorylate the STAT (signal transducer and activator of transcription) proteins, and subsequently functions in cell proliferation and differentiation [12].

Our aim was to evaluate serum PRL as a potential tumor marker in the detection of HCC.


  Patients and Methods Top


Study population

The current prospective study enrolled 80 adult patients with chronic liver diseases (with or without HCC) who were selected from the Internal Medicine Department, Faculty of Medicine and National Liver Institute, Menoufia University in Shebien El Kom Menoufia and Shebien El Kom Teaching Hospital from January 2015 to September 2015. Ten healthy age and sex matched individuals served as the control group (group I). The study protocol was approved by the ethical scientific committee of Menoufia University. Informed medical consent was obtained from all participants before the study. The patients were subdivided. Group II included 40 patients with cirrhosis and group III included 40 patients with newly diagnosed HCC in addition to cirrhosis. Patients with cholangiocarcinoma, liver metastasis, and patients with other malignancies were excluded.

Study design and biochemical assays

All participants were subjected to detailed history and clinical assessment. Liver cirrhosis was diagnosed on the basis of history, clinical examination, laboratory findings, and abdominal ultrasonography (US). The severity of liver disease was assessed using Child–Pugh score [13] and model for end-stage liver disease score [14]. Patient's viral infection status was determined using HCV antibody and HBV surface antigen, and positive cases were confirmed using PCR. HCC was diagnosed using abdominal US, abdominal triphasic computed tomography, and serum AFP. Tumor characteristics were detected (tumor size, focal lesion number, site, and portal vein invasion). Aspartate aminotransferase (AST)/platelet ratio index (APRI) was also evaluated [15].

Fasting venous blood samples (7 ml) were collected by trained laboratory technicians. The blood was left to clot at 37°C, and then centrifuged at 4000 rpm for 10 min. EDTA-added whole blood was used for complete blood picture, and serum was used for other biochemical assays. Two milliliter serum was separated for assaying PRL. Viral marker for chronic viral hepatitis (HCV antibody and HBVs antigen) was determined using the enzyme-linked immunosorbent assay (ELISA) technique and positive cases were confirmed using PCR. Serum AFP was evaluated using the ELISA technique. Serum PRL was evaluated using Abcam's Prolactin ELISA kit (ab108655). This assay uses a quantitative sandwich enzyme immunoassay technique (Biocompare, South San Francisco, CA, USA). Level of PRL was calculated through interpolation from a reference curve generated in the same assay with reference standards of known concentrations. All assays were performed in duplicate according to the manufacturer's instructions.

Statistical analysis

The collected data were tabulated and analyzed using SPSS version 17 software (SPSS Inc., Chicago, Illinois, USA). Categorical data were presented as number and percentages, whereas quantitative data were expressed as mean and SD. Comparison of continuous data between more than two groups was made using one-way analysis of variance for parametric data and the Kruskal–Wallis test was used for nonparametric data. The c2-test and Fischer exact test were used for comparison between categorical data. The Spearman test was used for correlations between different parameters (nonparametric). Receiver operating characteristic (ROC) curve was used for the estimation of sensitivity, specificity, cutoff level, positive predictive value (PPV), and negative predictive value (NPV). The accepted level of significance in this work was stated at 0.05 (P < 0.05 was considered significant).


  Results Top


The demographic data of the studied groups are shown in [Table 1]. Ninety percent of the HCC patients were symptomatic. Abdominal US and computed tomography showed that all HCC occurred in addition to cirrhosis (100%); ascites were present in 60% of the HCC patients and portal vein thrombosis was present in 30% of cases. As regards the focal lesion, there was a higher incidence of multiple lesions (77.5%), and the size of the focal lesion ranged from 2.5 to 12.5 cm, with a mean of 5.84 ± 2.57. Comparison between all studied groups as regards liver functions tests are shown in [Table 2]. The mean value of serum AFP and PRL was significantly elevated in the HCC group when compared with the other two groups [Table 2]. In relation to the number of focal lesions, there was a significant difference between single and multiple lesions as regards PRL level in the HCC group; it was higher in multiple lesions [Table 3]. Significant positive correlations were found between serum PRL on one hand and AFP, APRI, and tumor size on the other hand [Table 4]. Nonsignificant correlations were found between serum PRL and other parameters [Table 4]. ROC analysis curves and the corresponding area under the curve (AUC) were calculated for providing the accuracy of the AFP and PRL in the diagnosis of HCC. Sensitivity (i.e., true-positive rate), specificity (i.e., true-negative rate), PPV, NPV, and cutoff values showing the best equilibrium between sensitivity and specificity were evaluated. At cutoff level of at least 105.5 ng/ml, serum AFP had 93.33% sensitivity, 46.67% specificity, 63.64% PPV, and 87.5% NPV for the diagnosis of HCC. At cutoff level of at least 51.5 ng/ml, serum AFP had 95% sensitivity, 65% specificity, 73.08% PPV, and 92.86% NPV for the diagnosis of HCC. At cutoff level of at least 44.5 ng/ml, serum PRL had 92.5% sensitivity, 77.5% specificity, 80.43% PPV, and 91.18% NPV for the diagnosis of HCC [Table 5] and [Figure 1], [Figure 2].
Table 1: Demographic data of the studied groups

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Table 2: Laboratory characteristics among the studied groups

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Table 3: Serum prolactin level in single and multiple hepatocellular carcinoma lesions

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Table 4: Correlation between serum prolactin and different variables of the hepatocellular carcinoma group

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Table 5: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of serum (α-fetoprotein and prolactin) among the studied cirrhotic patients

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Figure 1: Receiver operating characteristic (ROC) curve of α-fetoprotein (AFP).

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Figure 2: Receiver operating characteristic (ROC) curve of serum prolactin.

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  Discussion Top


A marker for the early diagnosis of HCC should meet the following requirements: first, it should achieve high accuracy, which would increase the probability of a diagnosis being made before spread and thus increase the cure rate; second, specimen collection for detecting the marker should be easily operable and noninvasive; and, third, the cost-effectiveness should be considered [8].

In HCC, serum AFP-L3 and Des-gammacarboxy prothrombin are two of the most studied alternative HCC tumor markers and may be more effective compared with AFP alone in differentiating HCC from nonmalignant hepatopathy and predicting prognosis. However, their superiority in detecting early-stage HCCs remains doubtful [16].

This study was conducted on 80 patients. Their ages ranged from 40 to 71 years. The patients were divided as follows: 40 patients with liver cirrhosis, 40 patients with liver cirrhosis and HCC, and 10 healthy individuals as a control group. Their ages ranged from 48 to 61 years.

In the present study, the male-to-female ratio was 4: 1. This is in line with a study on the prevalence and epidemiological features of HCC conducted in Egypt, which included 321 HCC patients and reported that the male-to-female ratio was 5: 1; of them, 82.55% were male and 17.45% were female [17]. This is in line with the findings of Hussein et al. [18], who found that the percentage of male patients (75%) was higher than that of female patients (25%).

This variability was explained by Yu et al. [19], as it may be attributed to the differences in exposure to risk factors, as HBV and HCV are more prevalent in male patients. Abdel-Wahab et al. [20] reported that male population have greater exposure to carcinogens and environmental factors as they participate more in outdoor activities compared with female population.

Yang and Roberts [21] also reported that the risk for HCC is 2–7 times higher in men than in women. The explanation for this is that estrogen effects might suppress interleukin-6-mediated inflammation in women, reducing both liver injury and compensatory proliferation; moreover, testosterone effects could increase androgen receptor signaling in men, promoting liver cell proliferation.

Our study showed that there were significant differences as regards alanine aminotransferase, AST, total bilirubin, and direct bilirubin (P < 0.001). This is in agreement with the findings of El-Folly et al. [22], who reported that serum level of alanine aminotransferase, AST, and bilirubin were higher among patients with HCC than among those with chronic liver disease.

In the present study, AFP level of the HCC group was significantly higher compared with the cirrhotic group and the control group (P < 0.001). This is in line with the findings of Baghdady et al. [23], who stated that there was a highly significant elevation of AFP level in HCC patients, and this is in agreement with the findings of Hussein et al. [18], who showed a significant elevation of serum AFP in HCC patients.

In our study, there was a highly significant statistical difference among studied groups as regards PRL (P < 0.0001), with a higher level of PRL in the HCC group compared with the cirrhotic group and the control group.

Moreover, our study showed that there was a significant difference between single and multiple lesions as regards PRL level in the HCC group; it was higher in cases of multiple lesions.

It has been reported by García-Caballero et al. [24] that PRL promoted HCC progression, whereas PRL inhibition led to reduced tumor growth and longer latency. Furthermore, HCC is known to highly express PRLRs.

In the present study, there was a significant positive correlation between PRL and APRI (P = 0.0243) and tumor size (P = 0.0001) in the HCC group.

These findings are in line with another study performed by Wang et at. [25], who found that there was a significant positive correlation between PRL and AFP levels (P = 0.043).

In our study, at cutoff level of at least 51.5 ng/ml, serum AFP had 95% sensitivity, 65% specificity, and AUC of 0.95 for the diagnosis of HCC. At cutoff level of at least 44.5 ng/ml, serum PRL had 92.5% sensitivity, 77.5% specificity, and AUC of 0.92 for the diagnosis of HCC.

Wang et al. [25] also reported that the AUC for PRL and AFP were calculated to be 0.820 and 0.942, respectively. The AUC of AFP was significantly higher than that for PRL. On the basis of the ROC analysis, the optimal cutoff values and the corresponding sensitivity and specificity for AFP and PRL were calculated. The optimal cutoff value for PRL was reached at 39.9 ng/ml, with 77.3% sensitivity and 70.9% specificity. At the commonly adopted cutoff value of 20 ng/ml for AFP, its sensitivity and specificity were 52 and 100%, respectively. Surprisingly, the optimal cutoff value for AFP in the Singapore General Hospital cohort was determined to be 4.0 ng/ml, with 89.9% sensitivity and 92.7% specificity.

Moreover, Wang et al. [25] reported a significantly elevated PRL level in patients with resectable HCC compared with non-HCC chronic HBV carriers.


  Conclusion Top


Significantly elevated serum PRL in HCC patients may act as promising and potentially complementary biomarker with AFP. It may offer more effective early detection of HCC.

We recommend large-scale multicenter studies covering the different Egyptian populations to better clarify the diagnostic performance of this new biomarker among our Egyptian patients, either alone or in combination with AFP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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