Primary hepatocellular carcinoma (referred to as liver cancer) is a common digestive system malignancy worldwide, according to the data released by GLOBOCAN 2020, the number of new cases of liver cancer in the world is about 906,000, ranking 6th in malignant tumors, with 830,000 deaths, ranking 3rd in malignant tumors [1].
Liver cancer is particularly high in the mainland, accounting for more than 50% of new cases and deaths worldwide [2]. Although the incidence and case fatality rate of liver cancer in mainland China have shown a downward trend in recent years, due to factors such as large population base and aging, the burden of liver cancer is still relatively serious, and the screening and monitoring of high-risk groups of liver cancer is conducive to the early detection, early diagnosis and early treatment of liver cancer, which is the key to improving the efficacy of liver cancer, and its necessity and urgency [3].
At present, hepatectomy is an important means for liver cancer patients to achieve long-term survival, but the recurrence rate reported in the literature at 5 years after surgery > 60%, which has become a major influencing factor for further prolonging patient survival [4]. How to accurately predict and judge the risk of metastatic recurrence and give timely and accurate intervention mainly depends on clinical pathological features (including tumor size, staging and grading, vascular invasion, etc.), which is low in accuracy and difficult to meet clinical needs [5].
Because patients with the same clinical stage may have very different prognosis, small cancers can also recur early metastases. The development of products that accurately predict and evaluate metastatic recurrence in postoperative patients allows for further postoperative intervention in patients at higher risk of relapse and metastasis, thereby reducing the risk of postoperative recurrence and prolonging survival, while avoiding unnecessary postoperative intervention (overtreatment) in patients with low risk of recurrence [5]. Effective prevention and timely and reasonable treatment of recurrence are of great significance to reducing the case fatality rate and improving the overall survival rate [6].
Focusing on the precise diagnosis and treatment in the field of early screening and early diagnosis of liver cancer and postoperative metastatic recurrence monitoring, the IVD and LDT series products developed by Kuran Gene are being developed in an orderly manner.
Serum microRNAs are
Ideal marker for early liver cancer screening
Focusing on the exploration of new liver cancer screening and diagnosis and treatment strategies, HCC7S, a liver cancer early screening and auxiliary diagnosis project developed by Kuoran Gene and Professor Zhuang Shimei of the School of Life Sciences of Sun Yat-sen University, HCC7S identified a multimolecular prediction model composed of 7 serum microRNAs, which can warn of the occurrence of liver cancer earlier and more accurately than alpha-fetoprotein (AFP).
Through 3 stages (discovery, training, verification) and 4 independent population studies, a multimolecular predictive model composed of 7 serum microRNAs was established, which can better distinguish liver cancer and normal people, hepatitis B virus carriers, chronic hepatitis B and cirrhosis patients, and its accuracy and sensitivity of detecting liver cancer are much higher than that of serum AFP and B ultrasound, especially the advantages of detecting small liver cancer (tumor size ≤ 3 cm) and early liver cancer (BCLC stage 0 and stage A) are more obvious. At the same time, liver cancers that are AFP negative (AFP ≤ 20 ng/mL) can be better detected [7].
Serum miRNA is stable, easy and non-invasive, facilitating continuous dynamic monitoring and large-scale screening. The application of the HCC7S "7 MicroRNA Detection Kits (PCR Fluorescent Probe Method)" of the liver cancer early screening and auxiliary diagnosis project HCC7S helps to screen for early liver cancer, thereby improving the chance of surgical resection of liver cancer patients, reducing the recurrence rate and case fatality rate of patients, and benefiting the majority of liver disease patients.
In order to let more people understand the details of the project and the potential benefits brought by the future clinical benefits, Kuran Gene specially invited Professor Zhuang Shimei of the School of Life Sciences of Sun Yat-sen University to conduct an exclusive interview.
Broad Gene: We all know that primary hepatocellular carcinoma is one of the common malignant tumors in the world, and the mainland is also a big country of liver cancer, so in your opinion, the clinical significance of early screening and early diagnosis of liver cancer mainly includes what aspects?
Professor Zhuang: As you said, the incidence of liver cancer is high in the world, and the new incidence and death of liver cancer in China account for about half of the global cases. Hepatitis B virus (HBV) infection and aflatoxin exposure are the main causative factors of liver cancer in mainland China, as are long-term alcohol abuse and a high-fat diet. Patients with chronic hepatitis cirrhosis are at high risk of liver cancer.
Due to the insidious and rapid progression of liver cancer, there is still a lack of effective early screening methods, resulting in 60-70% of patients in the middle and advanced stages when they seek medical treatment, missing the opportunity for effective treatment, and the five-year overall survival rate of liver cancer patients is only about 10%.
However, if liver cancer can be detected and removed at an early stage, the five-year survival rate of patients can be improved to more than 50%. Therefore, early screening and early diagnosis and treatment are the most effective ways to improve the quality of life and survival time of patients and reduce mortality, and can also greatly reduce the economic burden on families and society.
Broad Gene: Can you talk about what your team considered when developing the "Serum MicroRNA Liver Cancer Diagnostic Markers and Kits"?
Professor Zhuang: In addition to obtaining 3 authorized invention patents, our R&D work has also been published by the top international journal Lancet Oncology (16:804-15, 2015) as a fast track, and the editors of the International Liver Cancer Guidelines have also written a special concurrent review, affirming that the molecular combination Cmi we found provides promising diagnostic accuracy, pointing out that our work has opened the door to microRNA screening for early liver cancer (Lancet Oncology). 16：743-45）。
The reason why our work has attracted the attention of international peers is due to the fact that we have a very special research cohort, and we have unique considerations in terms of operability, stability and universality of clinical applications.
1. Select serum microRNA with good stability as the detection index: microRNA is acid and alkali resistant to high temperature, which is a good disease screening marker. In addition, we use serum (without cells), not plasma, to avoid interference that can occur with cells present in large quantities of plasma.
2. Select markers with strong clinical operability: We selected microRNAs that are significantly elevated in the serum of liver cancer patients as candidate molecules, rather than those that are reduced. In addition, we eliminated extremely highly abundant molecules within hepatocytes (such as miR-122) to avoid them being released into the bloodstream when chronic hepatitis triggers cellular damage, resulting in false-positive results.
3. Rigorous multi-model multi-center verification: Our research and development has gone through three stages: discovery, training modeling and verification. The selected combination CMI obtained more than 80% diagnostic accuracy after four model analyses during the training stage, and was subsequently verified in 3 population cohorts from different medical centers.
4. Pay special attention to the detection of early liver cancer/subclinical stage microhepatic carcinoma: In the regular follow-up of patients with chronic hepatitis, we found 27 patients with small liver cancer (tumor less than 3cm at the time of diagnosis), and verified the diagnostic effect of Cmi by testing their series of serums in the first 12, 9, 6 and 3 months before clinical diagnosis.
5. Easy to promote and universal: the serum demand is small, the detection steps are simple, and the instrument can also be configured in the grass-roots hospital.
Broad Gene: After listening to your introduction, the study does have good operability, stability and universality in clinical applications, so compared with the main screening methods in the current clinic, such as serum markers, imaging, etc., based on the "serum microRNA liver cancer diagnostic markers and kits" technology system developed by your team, what are the advantages over traditional methods in early screening and early diagnosis of liver cancer?
Professor Zhuang: At present, serum alpha-fetoprotein (AFP) and B ultrasound are mainly used to screen for liver cancer, but their accuracy and sensitivity to detect early liver cancer are not ideal. The literature reports that in patients with clinically diagnosed liver cancer, the AFP level in about 40-60% of cases is still below the alert value (20 ng/ml); the sensitivity of AFP to detect early liver cancer is only 7-23%. The detection rate of ultrasound on liver cancer depends on the size of the tumor and the experience of the operator.
Our Cmi can well distinguish between liver cancer patients and various non-cancer populations, including healthy people, hepatitis B carriers, chronic hepatitis B patients, hepatitis B virus infection patients with cirrhosis, its sensitivity and accuracy are significantly better than AFP (AFP > 20ng/ml or 400ng/ml as indicators), and nearly 80% of AFP-negative liver cancer patients can be detected. Cmi has particular advantages in detecting small liver cancer (less than), early liver cancer (BCLC stage 0+A), and subclinical minimal liver cancer.
For example, the data of 12 months before the clinical diagnosis of small liver cancer (Cmi and AFP20 detected liver cancer sensitivity of 30% and 7% respectively) and 9 months before diagnosis (Cmi and AFP20 detected liver cancer sensitivity is 48% and 11%), it can be seen that the sensitivity and accuracy of Cmi detecting subclinical minimal liver cancer are much higher than that of AFP. More specific data is described in detail in our published paper (Lancet Oncol 16:804-15, 2015).
The sensitivity and accuracy of the Cmi model are significantly better than those of AFP[7]
Broad Gene: Based on this cooperation with Broad Gene in the transformation of serum microRNA liver cancer diagnostic markers and kit products, I would like to ask you to look forward to the application prospects in the field of early liver cancer screening and early diagnosis, and who are the beneficiaries? What can it bring to its target demographic?
Professor Zhuang: Based on the results of the kit developed, the main beneficiaries are all liver cancer patients, especially small liver cancer, early liver cancer, AFP-negative liver cancer and subclinical stage microhepatic cancer patients, as well as high-risk groups of liver cancer, including patients with chronic hepatitis and cirrhosis.
There are a considerable number of people with chronic hepatitis cirrhosis in the mainland, using non-invasive and easy-to-operate markers for long-term follow-up monitoring, screening out small liver cancer / early liver cancer / subclinical stage micro liver cancer, early treatment, can greatly improve the survival rate and quality of life of liver cancer patients, reduce mortality, has great clinical significance and social value.
Molecular prediction of metastatic recurrence with up to 90% accuracy
Postoperative metastatic recurrence monitoring of liver cancer is currently mainly based on clinical pathological features (including tumor size, stage and grading, vascular invasion, etc.), the accuracy is low, the main reasons include small cancer will also be high metastasis, and some patients have similar clinical pathological characteristics but different prognosis, often resulting in postoperative adjuvant therapy, poor efficacy, large side effects, poor quality of life, high medical costs.
Focusing on the problem of postoperative metastasis recurrence monitoring of liver cancer, the HCC5R "Liver Cancer Postoperative Metastasis Recurrence Risk Assessment Kit" developed by Kuoran Gene and the team of Professor Qin Lunxiu of the Department of General Surgery of Huashan Hospital affiliated to Fudan University has confirmed the feasibility of molecular prediction of metastasis based on innovative research on metastasis and key molecules, and created a new method for predicting metastatic recurrence.
For low-risk groups, regular follow-up can be used to avoid unnecessary postoperative intervention (excessive treatment); for high-risk groups, more active preventive interventions can be used to reduce the risk of postoperative recurrence. Thus achieving the effect of reducing postoperative recurrence, prolonging survival, improving the quality of life, and reducing costs, it has important economic and social value.
Change the mode of prevention and treatment of postoperative metastatic recurrence
HCC5R "Liver Cancer Postoperative Metastasis Recurrence Risk Assessment Kit" based on 153 metastatic-related genes with and without metastasis, which can correctly predict liver cancer metastasis, and a small sample study found that the accuracy of distinguishing liver cancer from metastasis was 90% [8].
Two independent large samples confirmed that they could accurately predict the prognosis of liver cancer, making them the second large-scale confirmed metastatic prediction model (the first being breast cancer) in the world [9]. Further optimized into the "five-gene prediction model", large-sample prospective studies confirmed that its accuracy rate > 70%.
In 2021, at the 2nd Black Technology Conference on Cancer Diagnosis and Treatment co-sponsored by Beijing Heathic Clinical Oncology Research Foundation (Heathco Foundation), Liangyihui, and arterial network, HCC5R "Liver Cancer Postoperative Metastasis Recurrence Risk Assessment Kit" won the most academic value award, which was highly concerned by top oncology experts, medical investment fields and industry leaders in China.
CTDNA testing accurately assesses the risk of postoperative recurrence of liver cancer
Molecular residual disease (MRD), also known in some cases as minimal residual disease or measurable residual disease [10], is increasingly clinically suggestive that MRD status is clearly associated with recurrence and prognosis in patients with tumors [11-15].
The postoperative MRD detection program for liver cancer is mainly aimed at liver cancer patients undergoing non-palliative surgery, and the tumor circulating DNA (ctDNA) is detected through the NGS platform after surgery, and the mutation information of tumor-related hotspot genes is obtained, so as to assess the risk of postoperative recurrence of liver cancer and assist clinicians in formulating personalized adjuvant treatment plans.
ctDNA detection process[16]
About Professor Chin Lun So
Qin Lunxiu is the Director of Surgery of Huashan Hospital Affiliated to Fudan University/ Executive Vice President of Huashan Hospital North Hospital, and the Director of The Institute of Tumor Metastasis of Fudan University. He is the recipient of the National Outstanding Youth Fund, the Yangtze River Scholar Distinguished Professor, the leader of the innovation team of the Ministry of Education, and the chief scientist of 973, and enjoys the special allowance of the State Council. He has been mainly engaged in hepatobiliary surgery for 30 years, and has been surgically treating more than 400 patients with hepatobiliary tumors every year. At the same time, he is engaged in the research of tumor metastasis recurrence, and undertakes many topics such as the National Science and Technology Major Special Liver Cancer Project, the 973 and the National Natural Science Foundation of China International Cooperation Major Project. He has published more than 180 SCI papers, 90 newsletters/first authors (14 IF>10), including Cancer Cell, Cell Metabolism, Gut, Hepatology, etc., and has been selected into the list of highly cited scholars in China (hi-index 54) for three consecutive years and obtained 12 patents.
About Professor Chuang Shimei
Zhuang Shimei is a professor at Sun Yat-sen University and a returned doctor. He graduated from Shanghai Medical College of Fudan University with a bachelor's degree in clinical medicine, and has a doctorate in pediatrics and a doctorate in cell biology, with both clinician experience and basic research background. He has been selected/awarded the Jiang Scholar Distinguished Professor of the Ministry of Education, the National Science Foundation for Outstanding Young People, the National 100 Million Talents Project, the Young and Middle-Aged Experts with Outstanding Contributions, the Special Government Allowance of the State Council, and the Nanyue Baijie. He has been engaged in the research of the pathogenesis of liver cancer, early detection and precision treatment strategies for a long time. As a corresponding/co-corresponding author, he has published a series of high-level research papers in international leading journals of oncology and hepatology, including several ESI highly cited papers, journal cover papers, and concurrent expert review papers. He has been continuously selected into the list of "China's Highly Cited Scholars". As the first inventor, he has been authorized to have 15 Invention Patents in China, of which 3 have been transferred. Some of his achievements won the second prize of the "National Natural Science Award" (2014), the first prize of the "Outstanding Scientific Research Achievement Award of the Ministry of Education (Natural Science)" (2013, 2019), and the first prize of the Natural Science Award of the Guangdong Science and Technology Award (2013, 2019).
About the Broad Gene
Founded in 2015 and headquartered in Shanghai, Kuoran Gene has three high-tech enterprises and a specialized new small giant enterprise, which is committed to providing one-stop molecular diagnostic solutions for multiple application scenarios, including cancer early screening, diagnosis and monitoring, and drug research and development services, with 6 IVD product registration and declaration reserves, serving more than 500 hospitals and scientific research institutions in China, and establishing a huge genomic database. The company has shanghai and Xuzhou double R & D center, two medical laboratories ("zero defect" through CAP authoritative certification) and precision medicine science and technology research institute, with the "product + service" model to carry out tumor molecular diagnosis, tumor immune microenvironment detection and pathogenic microbial detection and other businesses, to provide clinicians with integrated solutions for the diagnosis and treatment of patients, to achieve the concept of "precision medicine practitioners", and to promote the development of medical undertakings in mainland China.
bibliography:
[1] Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021; 71(3):209-249.
[2] Zhou M, Wang H, Zeng X, et al. Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017[J]. Lancet, 2019, 394(10204): 1145-58.
National multi-center prospective liver cancer very early warning screening project (PreCar) expert group. Expert consensus on early screening strategy for liver cancer in China[J]. Liver, 2021, 26(8):7.
[4] Shim JH, Jun MJ, Han S, et al. Prognostic nomograms for prediction of recurrence and survival after curative liver resection for hepatocellular carcinoma[J]. Ann Surg, 2015, 261(5): 939-946.
Yang Xin, Jia Huliang, Qin Lunxiu. Research Progress on molecular mechanisms and prediction of postoperative recurrence of liver cancer[J]. Chinese Journal of Practical Surgery,2019,39(10):1030-1035.
[6] Research on individualization and new strategies for the comprehensive surgical treatment of viral hepatitis-related liver cancer, Chen Xiaoping, Shen Feng, et al. Expert Consensus on Recurrence Prevention and Treatment of Hepatocellular Carcinoma After Hepatic Resection (2020 Edition)[J]. Chinese Journal of Practical Surgery, Vol. 41, No. 1, 2021, pp. 20-30, ISTIC PKU CSCD, 2021: Major Special Project on the Prevention and Treatment of Infectious Diseases of the Ministry of Science and Technology.
[7] Lin XJ, Chong Y, Guo ZW, et al. A serum microRNA classifier for early detection of hepatocellular carcinoma: a multicentre, retrospective, longitudinal biomarker identification study with a nested case-control study. Lancet Oncol. 2015;16(7):804-815.
[8] Ye QH, Qin LX, Forgues M, et al. Predicting hepatitis B virus positive metastatic hepatocellular carcinomas using gene expression profiling and supervised machine learning[J]. Nat Med, 2003, 9(4): 416-423.
[9] Roessler S, Jia HL, Budhu A, et al. A unique metastasis gene signature enables prediction of tumor relapse in early-stage hepatocellular carcinoma patients[J]. Cancer Res, 2010, 70(24): 10202-10212.
Wu Yilong, Lu Shun, Cheng Ying, et al. Expert consensus on molecular residual lesions of non-small cell lung cancer[J]. Evidence-Based Medicine, 2021, 21(3):7.
[11] GARCIA-MURILLAS I, CHOPRA N, COMINO-M NDEZ I, et al. Assessment of Molecular Relapse Detection in Early-Stage Breast Cancer[J]. JAMA Oncol, 2019, 5(10): 1473-1478.
[12] RADOVICH M, JIANG G, HANCOCK B A, et al. Association of circulating tumor DNA and circulating tumor cells after neoadjuvant chemotherapy with disease recurrence in patients with triple - negative breast cancer: Preplanned secondary analysis of the BRE12-158 randomized clinical trial [J]. JAMA Oncol, 2020, 6(9): 1410-1415.
[13] TIE J, COHEN J D, WANG Y, et al. Circulating tumor DNA analyses as markers of recurrence risk and benefit of adjuvant therapy for stage Ⅲ colon cancer[J]. JAMA Oncol, 2019, 5 (12): 1710-1717.
[14] SAUSEN M, PHALLEN J, ADLEFF V, et al. Clinical implications of genomic alterations in the tumour and circulation of pancreatic cancer patients[J]. Nat Commun, 2015, 6: 7686.
[15] PARIKH A R, VAN SEVENTER E E, SIRAVEGNA G, et al. Minimal residual disease detection using a plasma – only circulating tumor DNA assay in colorectal cancer patients[J]. Clin Cancer Res, 2021.
[16] Pantel K, Alix-Panabières C. Liquid biopsy and minimal residual disease-latest advances and implications for cure. Nat Rev Clin Oncol. 2019;16(7):409-424.