Abstract
Introduction
This article aims to evaluate the prognostic significance of pretreatment serum ɣ-glutamyl transpeptidase (GGT) levels in patients with intermediate (BCLC B) and advanced stage (BCLC C) hepatocellular carcinoma receiving transarterial chemoembolization (TACE) as first-line treatment.
Methods
In this single-center retrospective study, a total of 608 patients with BCLC B and BCLC C class were included who received TACE as first-line treatment modality. Patients were divided into low and high GGT groups based on a cutoff value of pretreatment serum GGT levels calculated by receiver operating curve. Overall survival was evaluated with Kaplan–Meier method, and intergroup significance was calculated by log-rank test for overall patients, each BCLC B and BCLC C group. Univariate and multivariate analysis were used for significance for prognostic factors.
Results
Median follow-up time was 20, 22, and 9 months for overall patients, BCLC B, and BCLC C group, respectively. Optimal cut value for GGT was calculated at 90.5 U/L. One-year and 3-year survival rates were 84.2% and 27.9% in low GGT, 49.4% and 8.6% in high-GGT group for overall patients. Multivariate analysis in overall patients showed Child–Pugh B (HR,1.801; 95%CI, 1.373–2.362, P < .001), ascites (1.393, 1.070–1.812; P = .014), multiple tumors (1.397, 1.137–1.716; P = .001), AST >40 (1.407, 1.095–1.808; P = .008), albumin <3.2 (.735, .612–.884; P = .001), AFP > 400 (1.648, 1.351–2.011; P < .001), high GGT (2.009, 1.631–2.475; P < .001), or receipt of chemo/ablation (.463, .377–.569; P < .001) as independent risk factors for overall survival. Serum GGT levels and AFP showed significant correlation in between with significance coefficient of .155 (P < .001).
Conclusion
Elevated pretreatment serum GGT level was feasible and promising independent prognostic marker for overall survival in intermediate and advanced stage hepatocellular carcinoma patients treated with TACE.
Keywords: hepatocellular carcinoma, BCLC B, BCLC C, serum GGT, ɣ-glutamyltranspeptidase, trans arterial chemoembolization, TACE
Graphical abstract
Hepatocellular carcinoma (HCC) is one of the most common cancers in world, and its incidence is on the rising trend in recent years. According the World Health Organization, about 905,677 new cases of liver cancer were detected and about 830,180 people died of the liver cancer all over the world in 2020.1 HCC is most common primary liver cancer and causes an important economic and living burden worldwide, especially in Asian continent.2 Liver cancer is the fifth most common cancer and second most common cause of cancer related deaths in Asia.1 Tumor resection and liver transplant is considered potentially curative treatment for HCC; however, a substantial number of patients are not eligible for curative surgeries and may not benefit from the systemic chemotherapy/external radiotherapy.3 The Barcelona Clinic Liver Classification is the most widely accepted staging system worldwide for treatment strategy of HCC.4 Transarterial chemoembolization (TACE) is currently considered first-line treatment method for intermediate stage HCC (BCLC B) patients.5 Multiple recent studies also established TACE as an effective and safe treatment option in BCLC C patients alone and in combination with chemotherapy.6,7 The HCC stage at which it is detected is very important factor in determining the overall survival of patients.8 Ultrasonography biannually with or without serum alfa-feto protein (AFP) levels is widely used as standard modality for HCC surveillance.9, 10, 11
ɣ-Glutamyltranspeptidase (GGT) is transferase enzyme that catalyzes the transfer of ɣ-glutamyl functional groups. GGT is integral component of cell membranes of vital organs like bile ducts, pancreas, kidneys, gall bladder, alimentary tract, spleen, and most importantly liver.12 It is associated with inflammation in extracellular hepatic microenvironment.13 GGT is also a marker of oxidative stress in carcinogenesis.14 In clinical practice, it is predominantly used as indicator for hepatobiliary diseases and liver disease from excessive alcohol consumption. GGT counteracts oxidative stress by breaking down extracellular glutathione and making its component amino acids available to the cells.12 GGT is involved in glutathione metabolism and have a possible role in tumor progression, invasion, and drug resistance.15 Previous researches suggest the relevance of GGT in patients of endometrial, cervical, breast cancer, and soft tissue sarcomas.16, 17, 18 Recent evidence suggests role of GGT in affecting both intracellular and extracellular microenvironment via modulation of redox equilibria.19
GGT is markedly elevated in alcoholic liver diseases and has been used for detection of hepatobiliary diseases due to its sensitive index of chronic liver disease.20 Due to its low specificity, it cannot be used as diagnostic biomarker for HCC; however, various studies have established its role as prognostic marker in HCC patients treated with liver transplantation, resection, and TACE.21, 22, 23, 24, 25 In this study, we collected data of total 608 patients with BCLC B and C stage and evaluated the prognostic significance of pretreatment serum GGT levels with overall survival of patients.
METHODS
Between January 2012 and December 2020, 889 consecutive patients of HCC based on characteristic imaging criteria or histological confirmation were included in the study, out of which 281 patients were excluded due to incomplete data, BCLC A group patients, or disseminated disease. The medical records of remaining 608 patients were reviewed (Figure 1). The collection of data was terminated on December 2021.
Figure 1.
Flowchart of study patients.
The inclusion criteria for this study were (a) diagnosis of intermediate and advanced-stage HCC (BCLC class B and C) ineligible for curative treatments such as surgical resection and transplantation or local ablation; (b) peripheral blood tests obtained within 1 week before chemoembolization. Exclusion criteria were (a) patients having concomitant biliary obstruction; (b) previous radiation treatment or chemotherapy before undergoing chemoembolization; (c) previous malignant tumors or other primary tumors; (d) patients who had undergone prior surgery, local-regional therapies (radiofrequency ablation), or liver transplantation; (e) acute on chronic liver failure patients.
TACE Procedure
Appropriate prior imaging was acquired before the procedure in form of either triple-phase contrast-enhanced computed tomography (CT) or contrast-enhanced MRI. All CT scans were performed using 64 slice multidetector CT (GE healthcare) and MRI scans were performed on a 3 T MRI (GE,Signa, HDxt) in supine position using a dedicated 16 phased-array coil. TACE procedure was performed through right femoral arterial access using standard angiographic technique. Celiac and mesenteric angiogram were taken with help of 5F (Cobra/SIMS) catheter to identify the arterial feeders supplying the tumor. The segmental hepatic artery supplying the tumor was selectively cannulated with a microcatheter and Epirubicin plus lipiodol emulsion or drug eluding beads with doxorubicin were directly injected in tumor supplying artery. For tumors that did not have hepatic or superior mesenteric artery supply, other possible feeding arteries were cannulated, and drugs were injected. The end point of embolization was near stasis (sluggish) of blood flow. All hardwares were removed, and hemostasis was achieved with help of either manual compression or vascular closure device (Perclose Proglide, Abott).
Monitoring and assessment
All patients were followed up by laboratory tests including routine blood tests, liver function tests, serum AFP levels, and contrast-enhanced CT or MRI 1 month after the TACE procedure to evaluate the tumor response. For the patients without complete tumor response, repeat TACE procedure was performed between 1- and 2-month intervals. Following the treatment phase, survival follow-ups were conducted by telephone call or outpatient review until December 2021, or death, lost to follow-up. The primary clinical outcome evaluated was overall survival, defined as the interval between the first chemoembolization treatment and death or last follow-up.
Statistical Analysis
Survival receiver operating characteristic method along with area under curve was used to calculate the predictive accuracy of GGT level. The GGT cutoff level was determined by nearest neighbor estimator. The student's t-test and Chi-square tests were appropriately used for comparison of variables between groups. Overall survival was calculated from the date of patient's first TACE procedure to the date of patient's death or last follow-up. Kaplan–Meier method was used to draw the survival curves, and the differences were compared using Log rank test. P values less than 0.05 were considered statistically significant. Univariate and multivariate Cox regression model was used to identify factors independently associated with mortality. All analyses were performed with SPSS software (version 26.0; IBM, Armonk, New York).
Results
GGT Cutoff Value
Pretreatment serum GGT levels were measured in all 608 patients included in the analysis, median value was 76 (range, 10–1611). The cutoff value for predicting death at 1 year was 90.5 U/L (sensitivity, 68.5%; specificity, 71.4%; AUC, .728; 95%CI, .685–771) (Figure 2). On the basis of this cutoff value, 341 patients were classified in high-GGT group and remaining 267 patients were allotted to low-GGT group (Table 1). In BCLC B subgroup, 246 and 95 patients were classified into the high-GGT and low-GGT groups, similarly 157 and 110 patients in BCLC C subgroup were classified into the high-GGT and low-GGT groups.
Figure 2.
Receiver operating characteristic curve for baseline serum ɣ-glutamyl transpeptidase (GGT) level for predicting death at 1 year in all patients. The cutoff value for predicting death at one year was 90.5 U/L (sensitivity, 68.5%; specificity, 71.4%; AUC, .728; 95%CI, .685–771).
Table 1.
Comparison of the Clinicopathologic Data for Patients Assigned to the Low- and High-GGT Groups.
| Characteristics | Low GGT (<90.5) (341) | High GGT (>90.5) (267) | P Value | |
|---|---|---|---|---|
| Age (y) | 61.5 ± 9.7 | 60.0 ± 10.85 | .07 | |
| Sex | Male | 288(84.5) | 246(92.1) | .004 |
| Female | 53(15.5) | 21(7.9) | ||
| Liver disease etiology | HBV | 155(45.5) | 128(47.9) | .54 |
| HCV | 46(13.5) | 26(9.7) | .155 | |
| HBV and HCV | 17(5) | 11(4.1) | .613 | |
| NAFLD | 37(10.8) | 33(12.4) | .48 | |
| Alcoholic liver disease | 47(13.8) | 36(13.5) | .54 | |
| others | 39 (11.4) | 33(12.4) | .21 | |
| BCLC | BCLC B | 246(72.1) | 157(58.8) | <.001 |
| BCLC C | 95(27.9) | 110(41.2) | ||
| Child–Pugh class | A | 302(88.6) | 199(74.5) | <.001 |
| B | 39(11.4) | 68(25.5) | ||
| Ascites | Yes | 305(89.4) | 223(83.5) | .032 |
| Tumor size | >5 cm | 208(61) | 214(80.1) | <.001 |
| No of tumors | Multiple | 206((60.4) | 199(74.5) | <.001 |
| Infiltrative HCC | Yes | 8(2.3) | 11(4.1) | .212 |
| PVT | Yes | 64(18.8) | 89(33.3) | <.001 |
| Extrahepatic spread | Yes | 29(8.5) | 31(11.6) | .202 |
GGT, ɣ-glutamyltranspeptidase; BCLC, Barcelona Clinic Liver Classification; HCC, Hepatocellular carcinoma; AFP, alpha-fetoprotein; PVT, Portal vein thrombosis; DEB TACE, Drug-eluting bead transarterial chemoembolization; HBV, hepatitis B virus; HCV, hepatitis C virus; PIVKA, Protein induced by vitamin K absence-II; NAFLD, Non-alcoholic fatty liver disease; ALD, Alcohol related liver disease. Bold values signifies P values less than 0.05 were considered statistically significant.
Survival Rate
Total 608 patients with both BCLC B and C (534 male and 74 female) with median age of 61 years (range 15–96) were included in the study. All patients were followed up until December 2021 with median follow-up of 20 (2–84) months. At the last follow-up 106 (17.4%), patients were alive and 502 (82.6%) had died. Patients assigned to the low-GGT group had better survival rates as compared to the high-GGT group. At the time of analysis, the median number of TACE cycles performed on these patients was 1 (range 1–7). The 1-year, 3-year, and 5-year survival rates were higher for patients in low-GGT group versus high-GGT group, at 84.2%, 27.9%, and 11.4% versus 49.4%, 8.6%, and 1.9%, respectively in both BCLC B and C group patients (Figure 3). BCLC B group patients also showed higher 1-year (93.1% vs. 65.6%) and 3-year survival rate (34.6% vs. 12.7%) in low-GGT group than high-GGT group. Six-month (96.8% vs. 81.8%) and 1-year survival rate (61.1% vs. 26.4%) were greater in low-GGT group than high-GGT group in BCLC C patients (Figure 4).
Figure 3.
Kaplan–Meier curves for OS in all patients. The OS rates at 1, 3, and 5 years were 84.2%, 27.9%, and 11.4%, respectively, in low-GGT group (blue line) and 49.4%, 8.6%, and 1.9%, respectively, in the high-GGT group (red line). The log rank test was used to test intergroup difference (P < .001).
Figure 4.
Kaplan–Meier curves for overall survival (OS) in BCLC B and BCLC C group patients. The OS rates at 1, 3, and 5 years were 93.1%, 34.6%, and 13%, respectively, in low-GGT group (blue line) and 65.6%, 12.7%, and 2.5%, respectively, in the high-GGT group (red line) for BCLC B patients. Similarly, OS rates at 6 months, 9 months, 1 year, and 3 year were 96.8%, 82.1%,61.1%, and 10.5%, respectively, in low-GGT group (blue line) and 81.8%, 60%, 26.4%, and 2.7%, respectively, in the high-GGT group (red line) for BCLC C patients. The log rank test was used to test intergroup difference (P < .001) in each group. To be printed in color.
GGT level Relationship with Clinicopathologic Features
The comparison of the clinicopathological data between high and low GGT group revealed that high GGT levels were associated with the male sex (P = .004), BCLC C (P < .001), Child–Pugh class B (P < .001), ascites (P = .032), tumor > 5 cm, multiple tumors (P < .001), and portal vein thrombosis (P < .001). Higher prothrombin time (P < .001), high INR (P < .001), high AST (P < .001), high ALT (P < .001), and high ALP levels (P < .001) were also associated with high GGT levels in our study population (Table 1, Table 2). No association was observed between GGT levels and bilirubin, albumin, and AFP levels.
Table 2.
Relationship Between GGT Levels and Liver Function Tests.
| Characteristics | Low GGT (<90.5) (341) | High GGT (>90.5) (267) |
P Value | |
|---|---|---|---|---|
| Prothrombin time | Mean | 14.45 ± 2.13 | 13.7 ± 1.73 | <.001 |
| Total bilirubin (mg/dl) | Mean | 1.36 ± .78 | 1.34 ± .74 | .83 |
| INR | Mean | 1.29 ± .19 | 1.22 ± .17 | <.001 |
| AST(U/L) | Mean | 66.23 ± 43.27 | 91.12 ± 62.31 | <.001 |
| ALT(U/L) | Mean | 43.26 ± 28.65 | 63.35 ± 45.87 | <.001 |
| ALP (U/L) | Mean | 110.39 ± 51.93 | 194.47 ± 127.39 | <.001 |
| PIVKA (U/L) (n = 239) | Mean | 1166.82 ± 3302.74 | 4776.73 ± 16318.47 | .02 |
| Albumin (g/L) | Mean | 3.25 ± .59 | 3.29 ± .57 | .29 |
GGT, ɣ-glutamyltranspeptidase.
The univariate analysis for both BCLC B and C group patients included patients’ characteristics as covariates. The result showed that DEB TACE(P = .030), BCLC C group (P < .001), Child–Pugh class B (P < .001), ascites (P < .001), tumor >5 cm (P < .001), multiple tumors (P < .001), portal vein thrombosis (P < .001), metastasis (P < .001), bilirubin (P = .20), AST >40 (P < .001), ALP >120 (P < .001), AFP >400 (P < .001), albumin <3.2 (P < .001), GGT >90.5 (P < .001), and chemotherapy/ablation (P < .001) were associated with overall survival (Table 3).
Table 3.
Univariate Analysis of Factors Associated With Overall Survival in Both BCLC B and C Group Patients.
| Characteristics | Hazard Ratio | 95% CI | P Value | |
|---|---|---|---|---|
| Age (y) | >55 yr | .821 | .666–1.013 | .065 |
| Sex | Male | .799 | .609–1.048 | .105 |
| Type of TACE | DEB TACE | 1.227 | 1.020–1.476 | .030 |
| Liver disease etiology | HBV | .927 | .778–1.106 | .401 |
| HCV | .809 | .615–1064 | .129 | |
| HBV and HCV | 1.106 | .713–1.715 | .652 | |
| NAFLD | 1.292 | .992–1.356 | .098 | |
| ALD | 1.034 | 1.025–1.427 | .138 | |
| Others | 1.121 | .998–1.439 | .249 | |
| BCLC | BCLC C | 2.400 | 1.998–2.883 | <.001 |
| Child–Pugh class | B | 3.009 | 2.415–3.750 | <.001 |
| Ascites | Yes | 2.076 | 1.621–2.657 | <.001 |
| Tumor size | >5 cm | 1.794 | 1.475–2.182 | <.001 |
| No of tumors | Multiple | 1.554 | 1.284–1.880 | <.001 |
| PVT | Yes | 2.358 | 1.934–2.875 | <.001 |
| Metastasis | Yes | 2.274 | 1.730–2.989 | <.001 |
| Prothrombin time | ≤14 | 1.181 | .991–1.408 | .064 |
| >14 | ||||
| Total bilirubin (mg/dl) | ≤1.2 | 1.231 | 1.033–1.468 | .020 |
| >1.2 | ||||
| INR | ≤1.1 | 1.202 | .961–1.502 | .107 |
| >1.1 | ||||
| AST(U/L) | ≤40 | 1.853 | 1.468–2.338 | <.001 |
| >40 | ||||
| ALT(U/L) | ≤30 | 1.159 | .955–1.407 | <.135 |
| >30 | ||||
| ALP (U/L) | ≤120 | 1.673 | 1.400–1.998 | <.001 |
| >120 | ||||
| AFP (ng/mL) | ≤400 | 1.928 | 1.599–2.325 | <.001 |
| >400 | ||||
| Albumin (g/L) | ≤3.2 | .647 | .542–.772 | <.001 |
| >3.2 | ||||
| GGT (U/L) | ≤90.5 | 2.120 | 1.771–2.539 | <.001 |
| >90.5 | ||||
| Chemo/ablation | Yes | .411 | .338–.501 | <.001 |
AFP, alpha feto-protein; ALT, alanine aminotransferase; AST: Aspartate aminotransferase; BCLC, Barcelona Clinic Liver Classification; GGT, ɣ-glutamyltranspeptidase; INR, International normalized Ratio; PVT, portal vein thrombosis; TACE, Trans arterial chemoembolization. Bold values signifies P values less than 0.05 were considered statistically significant.
Multivariate analysis in overall patients showed Child–Pugh B (HR, 1.801; 95%CI, 1.373–2.362, P < .001), ascites (1.393, 1.070–1.812; P = .014), multiple tumors (1.397, 1.137–1.716; P = .001), AST >40 (1.407, 1.095–1.808; P = .008), albumin <3.2 (.735, .612–.884; P = .001), AFP > 400 (1.648, 1.351–2.011; P < .001), high GGT (2.009, 1.631–2.475; P < .001), and receipt of oral chemotherapy/ablation (.463, .377–.569; P < .001) as independent risk factors for overall survival (Table 4).
Table 4.
Multivariate Analysis of Factors Associated With Overall Survival in Both BCLC B and C Group Patients.
| Charazcteristics | Univariate P value | Multivariate analysis |
||
|---|---|---|---|---|
| Hazard Ratio | 95% CI | P value | ||
| Type of TACE(DEB) | .030 | 1.087 | .894–1.321 | .401 |
| BCLC | <.001 | 1.110 | .750–1.643 | .603 |
| Child–Pugh score | <.001 | 1.801 | 1.373–2.362 | <.001 |
| Ascites | <.001 | 1.393 | 1.070–1.812 | .014 |
| Tumor size >5 cm | <.001 | 1.123 | .899–1.403 | .306 |
| Multiple tumors | <.001 | 1.397 | 1.137–1.716 | .001 |
| PVT | <.001 | 1.237 | .834–1.835 | .291 |
| Mets | <.001 | 1.401 | .975–2.014 | .068 |
| Chemotherapy/ablation | <.001 | .463 | .377–.569 | <.001 |
| Bilirubin (1.2) | .02 | .951 | .788–1.147 | .596 |
| AST (40) | <.001 | 1.407 | 1.095–1.808 | .008 |
| ALP (120) | <.001 | 1.060 | .869–1.292 | .567 |
| Albumin (3.2) | <.001 | .735 | .612–.884 | .001 |
| AFP (400) | <.001 | 1.648 | 1.351–2.011 | <.001 |
| GGT (90.5) | <.001 | 2.009 | 1.631–2.475 | <.001 |
AFP, alpha feto-protein; AST: Aspartate aminotransferase; BCLC, Barcelona Clinic Liver Classification; GGT, ɣ-glutamyltranspeptidase; PVT, portal vein thrombosis; TACE, Trans arterial chemoembolization. Bold values signifies P values less than 0.05 were considered statistically significant.
Similarly, univariate and multivariate analyses were performed separately in each BCLC B and BCLC C groups. The multivariate analyses of BCLC B group revealed that multiple number of tumors (HR 1.533; 95%CI, 1.197–1.962; P < .001), receipt of oral chemotherapy/ablation (.450, .351–.578, <.001), albumin <3.2 (.735, .612–.884; P = .001), AFP > 400 (1.686, 1.285–2.213; P < .001), and high GGT >90.5 (1.891,1463–2.445; P < .001) were identified as independent risk factors for overall survival (Table 5).
Table 5.
Multivariate Analysis of Factors Associated With Overall Survival in BCLC B Group Patients.
| Characteristics | Univariate P value | Multivariate |
||
|---|---|---|---|---|
| Hazard Ratio | 95% CI | P value | ||
| Ascites | .011 | 1.272 | .844–1.918 | .251 |
| Tumor size >5 cm | <.001 | 1.167 | .918–1.484 | .207 |
| Multiple tumors | <.001 | 1.533 | 1.197–1.962 | <.001 |
| Chemotherapy/ablation | <.001 | .450 | .351–578 | <.001 |
| INR(1.1) | .045 | 1.226 | .894–1.681 | .206 |
| Bilirubin(1.2) | .029 | .990 | .776–1.262 | .934 |
| AST(40) | <.001 | 1.261 | .927–1.715 | .139 |
| ALP(120) | <.001 | 1.203 | .940–1.541 | .142 |
| Albumin(3.2) | <.001 | .673 | .531–.854 | .001 |
| AFP(400) | <.001 | 1.686 | 1.285–2.213 | <.001 |
| GGT(90.5) | <.001 | 1.891 | 1.463–2.445 | <.001 |
AFP, alpha feto-protein; AST: Aspartate aminotransferase; GGT, ɣ-glutamyltranspeptidase; INR, International normalized Ratio. Bold values signifies P values less than 0.05 were considered statistically significant.
Multivariate Cox regression analysis in BCLC C group revealed that Child–Pugh B (HR 1.700; 95%CI, 1.237–2.337; P = .001), receipt of oral chemotherapy/ablation (.437, .300–.635, <.001), PT > 14 (1.357, 1.006–1.831; P = .046), AFP > 400 (1.503, 1.106–2.043; P = .009), and high GGT >90.5 (2.021, 1.421–2.875; P < .001) as independent risk factors for overall survival (Table 6).
Table 6.
Multivariate Analysis of Factors Associated With Overall Survival in BCLC C Group Patients.
| Characteristics | Univariate P value | Multivariate |
||
|---|---|---|---|---|
| Hazard Ratio | 95% CI | P value | ||
| Age (55) | .035 | .737 | .536–1.013 | .060 |
| Child–Pugh score | <.001 | 1.700 | 1.237–2.337 | .001 |
| Ascites | .003 | 1.368 | .961–1.948 | .082 |
| HCV | .047 | .587 | .338–1.020 | .059 |
| Chemotherapy/ablation | <.001 | .437 | .300–.635 | <.001 |
| PT (14) | .042 | 1.357 | 1.006–1.831 | .046 |
| AST (40) | .004 | 1.165 | .717–1.892 | .538 |
| ALT (30) | .015 | 1.053 | .700–1.586 | .803 |
| ALP (120) | .026 | .792 | .542–1.157 | .227 |
| AFP (400) | .011 | 1.503 | 1.106–2.043 | .009 |
| GGT (90.5) | <.001 | 2.021 | 1.421–2.875 | <.001 |
AFP, alpha feto-protein; ALT, alanine aminotransferase; AST: Aspartate aminotransferase; GGT, ɣ-glutamyltranspeptidase; HCV, Hepatitis C Virus etiology; INR, International normalized Ratio.
Correlation Between AFP Levels and GGT Levels
Correlation between GGT levels and serum AFP levels were done using spearman correlation which revealed significant correlation between both entities, and it was calculated .155 with P value of <.001 (Table 7 and Figure 5). Kaplan–Meier curves were also plotted for overall survival at 1 year between high- and low-GGT groups. Similarly, Kaplan–Meier curve was also plotted for high- and low-AFP groups (Figure 6). Both these curves showed significant intergroup differences (P values < .001) and following the similar fashion results, indicating higher mortality in high-GGT and high-AFP groups compared to low-GGT and low-AFP groups.
Table 7.
Comparison of Multivariate Analysis of BCLC B and C Groups in Our Study.
| Characteristics | BCLC B Group |
BCLC C Group |
||
|---|---|---|---|---|
| Hazard Ratio (95% CI) | P value | Hazard Ratio (95% CI) | P value | |
| Child–Pugh score | – | – | 1.700(1.237–2.337) | .001 |
| Multiple tumors | 1.533(1.197–1.962) | <.001 | – | – |
| Chemotherapy/ablation | .450 (.351–578) | <.001 | .437(.300–.635) | .001 |
| PT (14) | – | – | 1.357(1.006–1.831) | .046 |
| Albumin (3.2) | .673(.531–.854) | .001 | – | – |
| AFP (400) | 1.686(1.285–2.213) | <.001 | 1.503(1.106–2.043) | .009 |
| GGT (90.5) | 1.891(1.463–2.445) | <.001 | 2.021(1.421–2.875) | <.001 |
AFP, alpha feto-protein; GGT, ɣ-glutamyltranspeptidase; PT, Prothrombin time.
Figure 5.
Correlation graph between serum AFP and serum GGT levels.
Figure 6.
Comparison of Kaplan–Meier curves between high- and low-GGT groups with high- and low-AFP groups. Log rank test showing significant intergroup differences in both groups (P < .001).
Discussion
HCC patients who are not suitable for locoregional therapy, tumor resection or liver transplantation can benefit greatly from TACE. TACE has been already established as first-line modality for intermediate stage (BCLC B) HCC patients, and few recent guidelines have suggested that it can also be used to treat advanced stage HCC (BCLC C) to reduce the tumor burden and for down staging of the disease.4,9 No single therapy can be applicable to all the patients, and treatment modality is to be selected on individual patient's characteristics and clinical status. Treatment outcome also vary greatly even in same stage disease in between patients due to tumor and patient heterogeneity. Hence, the BCLC Classification system serves as the patient eligibility criteria for TACE considering both the tumor burden and underlying hepatic function. In current clinical practice, AFP has been generally used as both diagnostic and prognostic biomarkers for HCC patients. Apart from AFP levels, tumor size, tumor number, portal vein thrombosis, and extra hepatic metastasis were also shown to be associated with the prognosis of these patients. Few studies have evaluated other serum biological markers for prognostic significance in HCC patients treated with transplant, resection, and ablation therapy. Very limited research is being done assessing the value of GGT as prognostic biomarker in HCC patients treated with TACE.24,25 In our study, we tried to establish the prognostic significance of the pretreatment serum GGT levels with the overall survival of the patients who were treated with TACE. We found out that pretreatment high-GGT levels (>90.5 U/L) were associated with poor overall survival in both BCLC B and BCLC C group patients. Apart from high-GGT levels, high-AFP levels (>400 ng/ml) and receipt of additional chemotherapy/ablation were also associated with overall survival of patients in both groups. These results were aligned with the previous findings considering the GGT as significant prognostic biomarker for HCC patients treated with TACE (Table 8 and 9).
Table 9.
Comparison of Our Study With Existing Literature.
| Study | Design | Outcome |
|---|---|---|
| Zhang et al. (2011)25 | Retrospective study, total 277 BCLC B group patients were included who received TACE as first line treatment. Overall survival comparison Univariate and multivariate analysis for prognostic factor significance | Median follow-up time 18.7 months. I year and 3year survival rates were 71.6% and 38.5% in normal GGT and 48.8% and 16.9% in high GGT group(P = .002) GGT levels >50 U/L (HR 1.75, 95%CI:1.146–2.643, P = .009), tumor >7 cm (1.632; 1.231–2.162, P = .001), Ascites (1.74; 1.257–3.919, P = .006) were independent risk factors for OS |
| Guo et al.(2020)24 | Retrospective study, 140 BCLC C group patients treated with TACE. Overall survival comparison by Log rank test | Optimal cut value of GGT 119.5U/L in men and 175 U/L in women. 6, 9 and 12 months OS rates were 81.7%, 72.4% and 62.9% in low GGT group and 58.8%, 35.7% and 28.8%, respectively for High GGT group (P < .001). Multivariate Cox Regression analysis identified high GGT level (HR, 2.71; 95%CI, 1.67–4.40; P < .001), multiple tumors (3.05,1.23–7.53; P = .02), Target treatment(.41,.24-.72; P = .002) or ablation(.35,.18-.66; P = .001) as independent prognostic factors for OS |
| Our Study | Retrospective collection of data in BCLC B and BCLC C patients treated with TACE Overall survival comparison by Log rank test, Univariate and multivariate analysis performed | Median follow up time was 20, 22 and 9 months for overall patients, BCLC B and BCLC C group respectively. Optimal Cut value for GGT 90.5 U/L. 1 year and 3-year survival rates were 84.2% and 27.9% in low GGT, 49.4% and 8.6% in high GGT group for overall patients. BCLC B group: High vs Low GGT Group 1 year OS rates (65.6% vs 93.1%), 3-year OS rate (12.7% vs 34.6%) BCLC C group: High vs Low GGT Group 6m OS rates (81.8% vs 96.8%), 1 year OS rate (26.4% vs 61.1%) Multivariate analysis in overall patients showed Child Pugh B (HR, 1.801; 95%CI, 1.373–2.362, P < .001), Ascites (1.393,1.070–1.812; P = .014), multiple tumors (1.397,1.137–1.716; P .001), AST >40 (1.407,1.095–1.808; P = .008), albumin <3.2 (.735,.612-.884; P = .001), AFP>400 (1.648,1.351–2.011; P < .001), High GGT (2.009,1.631–2.475; P < .001) Or Chemo/ablation(.463,.377–.569 P < .001) as independent risk factors for overall survival. |
BCLC, Barcelona Clinic Liver Classification; GGT, ɣ-glutamyltranspeptidase; HR, hazard ratio; OS, overall survival; TACE, Trans arterial chemoembolization.
Table 8.
Correlation Coefficient Between Serum AFP and GGT Levels.
| Correlations | ||||
|---|---|---|---|---|
| AFP | GGT | |||
| Spearman's rho | AFP | Correlation Coefficient | 1.000 | 0.155a |
| Sig. (2-tailed) | <.001 | |||
| N | 608 | 608 | ||
| GGT | Correlation Coefficient | 0.155a | 1.000 | |
| Sig. (2-tailed) | <.001 | . | ||
| N | 608 | 608 | ||
AFP, alpha feto-protein; GGT, ɣ-glutamyltranspeptidase.
Correlation is significant at the .01 level (2-tailed).
Baseline GGT levels can act as identifying factors for patients carrying poor prognosis who may require treatment adjustment or in need of adjunctive treatment to slow down the disease process. In BCLC C patients, the disease is rapidly progressing with portal vein invasion and extra hepatic spread, so in these groups of patients, prognostic biomarkers can make significant difference in the clinical outcome if identified in the early course of the treatment. Currently, AFP is most accepted tumor marker for prognosis of HCC. In our study, high-AFP levels were significantly associated with the decreased overall survival and showed significant correlation with the GGT levels for 1-year overall survival. Our results add to the previous studies done to evaluate the prognostic significance of GGT in HCC patients treated with TACE.21,23, 24, 25
The exact pathogenesis of association of high-GGT levels with decreased patient survival is still not clearly known. GGT is a membrane-bound enzyme that is involved in glutathione metabolism. It is one is main water soluble antioxidant in the cell and considered as vital component of protection system against oxidative stress.15 The prooxidant activity of GGT can act as contributory factor to persistent oxidative stress in tumor cells and modulate the tumor progression. GGT is commonly used as marker for hepatobiliary disease, but it also regulates cell proliferation, apoptosis, and resistance to anticancer drugs.26
In our study, we have included both intermediate and advanced stage HCC patients covering wide spectrum of the disease and in both groups high-GGT levels (>90 U/L) were associated with poor overall survival, which aligns with the previous studies.24,25 High serum AFP levels and receipt of additional chemotherapy/ablation post TACE were also found as significant prognostic factors for overall survival in these patients. Since in our study more than one third of patients were not related to hepatitis virus and comprises of nonalcoholic fatty liver disease or alcoholic liver disease, the cutoff GGT value came out to be on higher side for the patient population. This study however has few limitations as it is a single-center retrospective study, lack of randomization, and incomplete data acquisition may lead to the introduction of bias. Because the study has spanned almost over a decade long period, differences in procedural protocol and medical care may have contributed to different clinical outcomes.
In conclusion, elevated pretreatment serum GGT levels and serum AFP levels were feasible and promising independent prognostic marker for intermediate and advanced stage HCC patients treated with TACE. GGT can act as useful biomarker to identify patients who have poor prognosis or high morbidities and need prompt treatment adjustment or enhancement. The underlying molecular pathogenesis however requires further study, which may help in discovery of novel effective treatment strategies for HCC.
Credit authorship contribution statement
Yashwant Patidar: Conceptualization, Methodology, Reviewing the manuscript, Editing and finalizing the manuscript.
Gaurav Meena: Data curation, Data analysis, first draft of manuscript.
Amar Mukund: Clinical management, imaging evaluation.
Manoj Kumar Sharma and Shiv Kumar Sarin: Patient enrolling and supervising the research.
Conflicts of interest
The authors have none to declare.
Funding
This study was not supported by any funding.
Financial disclosure
None
Informed consent
The study has obtained IRB approval from the requirement to obtain informed consent was waived considering the retrospective nature of the study.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jceh.2023.04.009.
Appendix A. Supplementary data
The following are the supplementary data to this article.
References
- 1.Liu Y., Liu L. Changes in the epidemiology of hepatocellular carcinoma in Asia. Cancers. 2022 Sep 15;14:4473. doi: 10.3390/cancers14184473. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kulik L., El-Serag H.B. Epidemiology and management of hepatocellular carcinoma. Gastroenterology. 2019 Jan;156:477–491.e1. doi: 10.1053/j.gastro.2018.08.065. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Inchingolo R., Posa A., Mariappan M., Spiliopoulos S. Locoregional treatments for hepatocellular carcinoma: current evidence and future directions. World J Gastroenterol. 2019 Aug 28;25:4614–4628. doi: 10.3748/wjg.v25.i32.4614. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Reig M., Forner A., Rimola J., et al. BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update. J Hepatol. 2022 Mar;76:681–693. doi: 10.1016/j.jhep.2021.11.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kotsifa E., Vergadis C., Vailas M., et al. Transarterial chemoembolization for hepatocellular carcinoma: why, when, how? J Personalized Med. 2022 Mar 10;12:436. doi: 10.3390/jpm12030436. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Wholey M., Palacios R., Iii, Wholey D., Mendez A. Safety and long-term survival outcome in patients with unresectable Barcelona clinic liver cancer (BCLC) stages C and D advanced hepatocellular carcinoma treated with 40 μm drug-eluting bead transcatheter arterial chemoembolization. Cureus. 2022 Apr;14 doi: 10.7759/cureus.24047. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Patidar Y., Chandel K., Condati N.K., Srinivasan S.V., Mukund A., Sarin S.K. Transarterial chemoembolization (TACE) combined with Sorafenib versus TACE in patients with BCLC stage C hepatocellular carcinoma - a retrospective study. J Clin Exp Hepatol. 2022 Jun;12:745–754. doi: 10.1016/j.jceh.2021.12.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ahn J.C., Lee Y.T., Agopian V.G., et al. carcinoma surveillance: current practice and future directions. Hepatoma Res. 2022 Mar 11;8:10. doi: 10.20517/2394-5079.2021.131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Omata M., Cheng A.L., Kokudo N., et al. Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. Hepatol Int. 2017 Jul;11:317–370. doi: 10.1007/s12072-017-9799-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Marrero J.A., Kulik L.M., Sirlin C.B., et al. Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American association for the study of liver diseases. Hepatol Baltim Md. 2018 Aug;68:723–750. doi: 10.1002/hep.29913. [DOI] [PubMed] [Google Scholar]
- 11.European Association for the Study of the Liver; European Organisation for Research and Treatment of Cancer EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012 Apr;56:908–943. doi: 10.1016/j.jhep.2011.12.001. Erratum in: J Hepatol. 2012 Jun;56(6):1430. PMID: 22424438. [DOI] [PubMed] [Google Scholar]
- 12.Whitfield J.B. Gamma glutamyl transferase. Crit Rev Clin Lab Sci. 2001 Aug;38:263–355. doi: 10.1080/20014091084227. [DOI] [PubMed] [Google Scholar]
- 13.Li Q., Lu C., Li W., Huang Y., Chen L. The gamma-glutamyl transpeptidase-to-albumin ratio predicts significant fibrosis and cirrhosis in chronic hepatitis B patients. J Viral Hepat. 2017 Dec;24:1143–1150. doi: 10.1111/jvh.12751. [DOI] [PubMed] [Google Scholar]
- 14.Fentiman I.S. Gamma-glutamyl transferase: risk and prognosis of cancer. Br J Cancer. 2012 Apr 24;106:1467–1468. doi: 10.1038/bjc.2012.128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Corti A., Franzini M., Paolicchi A., Pompella A. Gamma-glutamyltransferase of cancer cells at the crossroads of tumor progression, drug resistance and drug targeting. Anticancer Res. 2010 Apr;30:1169–1181. [PubMed] [Google Scholar]
- 16.Hochwald S.N., Michael Rose D., Brennan M.F., Burt M.E. Elevation of glutathione and related enzyme activities in high-grade and metastatic extremity soft tissue sarcoma. Ann Surg Oncol. 1997 Jun 1;4:303–309. doi: 10.1007/BF02303579. [DOI] [PubMed] [Google Scholar]
- 17.Seebacher V., Polterauer S., Grimm C., et al. Prognostic significance of gamma-glutamyltransferase in patients with endometrial cancer: a multi-centre trial. Br J Cancer. 2012 Apr;106:1551–1555. doi: 10.1038/bjc.2012.16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Polterauer S., Hofstetter G., Grimm C., et al. Relevance of gamma-glutamyltransferase – a marker for apoptotic balance – in predicting tumor stage and prognosis in cervical cancer. Gynecol Oncol. 2011 Sep 1;122:590–594. doi: 10.1016/j.ygyno.2011.05.027. [DOI] [PubMed] [Google Scholar]
- 19.Pompella A., De Tata V., Paolicchi A., Zunino F. Expression of gamma-glutamyltransferase in cancer cells and its significance in drug resistance. Biochem Pharmacol. 2006 Jan 12;71:231–238. doi: 10.1016/j.bcp.2005.10.005. [DOI] [PubMed] [Google Scholar]
- 20.Krishnamurthy H.A. The serum gamma glutamyl transpeptidase - a non invasive diagnostic bio marker of chronic anicteric non alcoholic liver diseases. J Clin Diagn Res JCDR. 2013 Apr;7:691–694. doi: 10.7860/JCDR/2013/5569.2883. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ince V., Carr B.I., Bag H.G., et al. Gamma glutamyl transpeptidase as a prognostic biomarker in hepatocellular cancer patients especially with >5 cm tumors, treated by liver transplantation. Int J Biol Markers. 2020 Jun;35:91–95. doi: 10.1177/1724600820921869. [DOI] [PubMed] [Google Scholar]
- 22.Fu S.J., Zhao Q., Ji F., et al. Elevated preoperative serum gamma-glutamyltranspeptidase predicts poor prognosis for hepatocellular carcinoma after liver transplantation. Sci Rep. 2016 Jul 6;6 doi: 10.1038/srep28835. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Liao M, Qin W, Liao Y, Yao R, Yu J, Liao W. Prognostic Value of Gamma-Glutamyl Transpeptidase to Lymphocyte Count Ratio in Patients With Single Tumor Size ≤ 5 cm Hepatocellular Carcinoma After Radical Resection. Front Oncol. 2019;9:347. doi: 10.3389/fonc.2019.00347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Guo J., Liu S., Gao S., et al. γ-Glutamyltranspeptidase as a prognostic biomarker in advanced hepatocellular carcinoma treated with transarterial chemoembolization. J Vasc Intervent Radiol. 2021 Mar;32:419–428.e2. doi: 10.1016/j.jvir.2020.07.020. Epub 2020 Oct 14. PMID: 33067120. [DOI] [PubMed] [Google Scholar]
- 25.Zhang J.B., Chen Y., Zhang B., et al. Prognostic significance of serum gamma-glutamyl transferase in patients with intermediate hepatocellular carcinoma treated with transcatheter arterial chemoembolization. Eur J Gastroenterol Hepatol. 2011 Sep;23:787–793. doi: 10.1097/MEG.0b013e32834902dd. [DOI] [PubMed] [Google Scholar]
- 26.Zhu Y., Zhang A.J., Wu D.B., et al. Prognostic significance of the pretreatment serum gamma-glutamyltransferase levels in Chinese patients with non-metastatic cervical cancer. Oncotarget. 2017 Nov 1;8:115701–115708. doi: 10.18632/oncotarget.22273. [DOI] [PMC free article] [PubMed] [Google Scholar]
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