AFP、CA19-9、CEA聯合檢測對原發性肝癌的早期診斷價值

李嘉妍， 宋金云， 王建芳， 吳旭平

(東南大學附屬第二醫院 臨床科研中心， 南京 210003)

論著/肝臟腫瘤

AFP、CA19-9、CEA聯合檢測對原發性肝癌的早期診斷價值

李嘉妍， 宋金云， 王建芳， 吳旭平

(東南大學附屬第二醫院 臨床科研中心， 南京 210003)

目的 研究AFP、CA19-9、CEA聯合檢測對原發性肝癌進行早期診斷的臨床價值。 方法 收集2014年10月-2016年12月東南大學附屬第二醫院門診和住院的肝病患者248例，分為原發性肝癌組(n=88)和非腫瘤性肝病組(n=160),另選取130例健康體檢者為正常對照組。采用Roche cobas e 411 analyzer檢測3組患者的血清腫瘤標志物AFP、CA19-9、CEA水平，分析3種腫瘤標志物單個檢測和聯合檢測的靈敏度和特異度。采用Beckman Coulter AU5800檢測肝功能生化指標。采用Biotek ELX808檢測HBV血清學標志物和HCV抗體。應用受試者工作特征曲線(ROC曲線)對原發性肝癌患者的血清AFP、CA19-9、CEA及3者聯合檢測結果進行分析評價。計量資料多組間比較采用單因素方差分析，進一步兩兩比較采用SNK-q檢驗，2組間比較采用t檢驗；計數資料組間比較采用χ2檢驗。相關性分析采用Spearman分析。結果 在原發性肝癌組和非腫瘤性肝病組中，肝功能異?；颊叩腁FP、CA19-9均顯著高于肝功能正常組(原發性肝癌組：t值分別為35.64、3.38，P值均<0.05；非腫瘤性肝病組：t值分別為12.51、8.19，P值均<0.05)；原發性肝癌組中肝功能正?；颊叩腃EA均明顯高于非腫瘤性肝病組中肝功能正常患者和正常對照組(P值均<0.05)；原發性肝癌組中肝功能異?；颊叩腁FP、CA19-9、CEA水平均明顯高于非腫瘤性肝病組中的肝功能異?；颊吆驼φ战M(P值均<0.05)。血清AFP、CA19-9、CEA水平隨Child Pugh分級的升高而升高，在原發性肝癌組肝功能異?；颊咧?，AFP、CA19-9、CEA水平B級較A級，C級較B級均顯著升高(P值均<0.05)；在非腫瘤性肝病組肝功能異?；颊咧?， AFP、CA19-9水平B級較A級，C級較B級均顯著升高(P值均<0.05)，CEA水平C級顯著高于A、B級(P值均<0.05)。原發性肝癌組AFP、CA19-9、CEA的陽性率高于非腫瘤性肝病組和正常對照組(P值均<0.05)；各組的聯合檢測陽性率顯著高于單項檢測陽性率(P值均<0.05)。原發性肝癌組中，三項聯合檢測的靈敏度和特異度分別為86.36%和92.35%，單項檢測中AFP、CA19-9、CEA的靈敏度分別為71.59%、52.27%和39.77%，原發性肝癌患者的血清AFP、CA19-9、CEA及三者聯合檢測ROC曲線下面積分別為0.776、0.704、0.681及0.817。AFP在原發性肝癌組中與GGT相關(r=0.54,P=0.04)，在正常對照組中與IBil相關(r=0.50,P=0.01)；CA19-9在原發性肝癌組與ALT、 DBil、 IBil、TBil、TBA存在不同程度相關(r值分別為0.58、0.63、0.61、0.65、0.58，P值均<0.05)，在非腫瘤性肝病組與ALT、ALP、DBil、 IBil、TBil、TBA存在不同程度相關(r值分別為0.51、0.63、0.66、0.64、0.70、0.59，P值均<0.05)。結論 AFP能較好地反映肝損傷，但對原發性肝癌的診斷仍有部分假陰性；CEA輕度升高對原發性肝癌的指示性不強；CA19-9受ALP、膽紅素等因素影響明顯，假陽性較高；聯合檢測可提高原發性肝癌診斷的靈敏度，優于AFP、CA19-9、CEA的單項檢測，可為早期診斷和早期治療提供有力的依據。

肝腫瘤； 甲胎蛋白類； CA-19-9抗原； 癌胚抗原； 診斷

原發性肝癌是一種病死率高的惡性腫瘤，在世界范圍內的發病率呈逐漸上升趨勢[1]。由于影像學診斷和病理學檢測對早期診斷原發性肝癌價值有限，目前多采用腫瘤標志物檢測，輔助原發性肝癌早期診斷和治療。本文旨在探討血清腫瘤標志物AFP、CA19-9、CEA三者聯合檢測在原發性肝癌診斷中的價值。

1 資料與方法

1.1 研究對象 收集2014年10月-2016年12月于本院就診的肝病患者248例，其中經病理檢查確診的原發性肝癌患者88例(原發性肝癌組)，非腫瘤性肝病患者160例(非腫瘤性肝病組)，同時收集體檢健康的正常對照者130例(正常對照組)。本研究經醫院醫學倫理學委員會批準，且患者知情同意。

1.2 儀器 AFP、CA19-9和CEA采用Roche cobas e 411 全自動化學發光分析儀檢測，肝功能采用Beckman Coulter AU5800檢測，HBV血清學標志物和HCV抗體采用Biotek ELX808檢測。

1.3 檢測方法 所有研究對象均于清晨空腹采集外周血并及時分離血清，檢測患者肝功能指標及腫瘤標志物水平，嚴格按照說明書進行操作。陽性判斷標準分別為：AFP>20 μg/L，CA19-9>27 U/ml，CEA>4.7 ng/ml。AFP、CA19-9、CEA聯合檢測時其中1項陽性即視為三項聯合檢測為陽性。肝功能異常判斷標準為：轉氨酶(ALT>64 U/L或AST>50 U/L)、膽紅素(DBil>8.0 μmol/L或IBil>14.0 μmol/L或TBil>22.0 μmol/L)及其他生化指標[ALP>150 U/L或總膽汁酸(TBA)>12.0 μmol/L或GGT>37 U/L]3項中有2項升高者被認為肝功能異常。HBV血清學標志物和HCV抗體陽性標準參照文獻[2]。

2 結果

2.1 一般資料 原發性肝癌組88例患者中男67例，女21例，年齡33～75歲，平均(55.2±12.4)歲；HBsAg陽性83例，抗HCV陽性3例，HBsAg陽性合并抗HCV陽性2例；肝功能正常者25例，異常者63例。非腫瘤性肝病組160例患者中慢性肝炎55例，肝硬化57例，急性黃疸型病毒性肝炎48例；肝功能正常者92例，異常者68例。慢性肝炎55例患者中男43例,女12例,年齡20～67歲, 平均(37.50±10.06)歲，HBsAg陽性50例、抗HCV陽性3例、HBsAg陽性合并抗HCV陽性2例；肝硬化57例患者中男46例, 女11例, 年齡29～68歲, 平均(61 .34 ±30 .10)歲，HBsAg陽性49例、抗HCV陽性7例、HBsAg陽性合并抗HCV陽性1例；急性黃疸型病毒性肝炎48 例患者中男32例，女16例，年齡20～49歲, 平均(33.24±9.62)歲，抗HCV陽性5例、HBV感染43例。

2.2 3組AFP、CA19-9、CEA水平的比較 原發性肝癌組和非腫瘤性肝病組中，肝功能異常患者的AFP、CA19-9水平顯著高于肝功能正?；颊?P值均<0.05)(表1)。

原發性肝癌組和非腫瘤性肝病組的肝功能正?；颊吲c正常對照組3者間CA19-9和CEA水平比較差異有統計學意義(F值分別為19.08、94.95，P值均<0.05)。進一步兩兩比較，原發性肝癌組肝功能正常患者的CEA水平明顯高于非腫瘤性肝病組肝功能正?；颊吆驼φ战M(P值均<0.05)；原發性肝癌組與非腫瘤性肝病組的肝功能正常患者CA19-9水平均顯著高于正常對照組(P值均<0.05)。2組的肝功能異常患者與正常對照組3者間AFP、CA19-9、CEA水平比較差異均有統計學意義(F值分別為32.73、2.24、109.10，P值均<0.05)，進一步兩兩比較，原發性肝癌組肝功能異?；颊叩腁FP、CA19-9、CEA水平均明顯高于非腫瘤性肝病組肝功能異?；颊吆驼φ战M(P值均<0.05)(表1)。

表1 3組血清AFP、CA19-9、CEA檢測結果

注：1)與正常對照組比較，P<0.05；2)與非腫瘤性肝病組的肝功能正?；颊弑容^；P<0.05；3)與非腫瘤性肝病組的肝功能異?；颊弑容^，P<0.05

2.3 不同Child-Pugh評分的肝功能異?；颊吣[瘤標志物水平的比較 依據Child-Pugh評分，將原發性肝癌組和非腫瘤性肝病組中肝功能異?；颊呔譃镃hild-Pugh A、B、C 3個亞組。在原發性肝癌組肝功能異常患者中，AFP、CA19-9、CEA水平B級較A級，C級較B級均顯著升高(P值均<0.05)；在非腫瘤性肝病組肝功能異常患者中， AFP、CA19-9水平B級較A級，C級較B級均顯著升高(P值均<0.05)，CEA水平C級顯著高于A、B級(P值均<0.05)(表2)。

2.4 3組AFP、CA19-9、CEA單項檢測及聯合檢測的陽性率 3組單項檢測和聯合檢測整體比較陽性率差異有統計學意義(χ2=20.23,P<0.05)，原發性肝癌組AFP、CA19-9、CEA的陽性率均高于非腫瘤性肝病組和正常對照組(P值均<0.05)。各組的聯合檢測陽性率顯著高于單項檢測陽性率(P值均<0.05)(表3)。

2.5 原發性肝癌組AFP、CA19-9、CEA單項及三項聯合檢測的靈敏度、特異度和AUC 原發性肝癌組三項聯合檢測的靈敏度和特異度分別為86.36%和92.35%；在單項檢測中，AFP靈敏度最高達71.59%， CA19-9和CEA的靈敏度分別為52.27%和39.77%。AFP、CA19-9、CEA的AUC分別為0.776、0.704、0.681，三項聯合檢測的AUC為0.817，高于單項檢測(圖1)。

表2 肝功能異常患者不同Child-Pugh評分的腫瘤標志物 水平比較

注：1)與Child-Pugh B級比較，P<0.05；2)與Child-Pugh C級比較，P<0.05

表3 3組AFP、CA199、CEA單項及三項聯合檢測的 陽性率[例(%)]

2.6 3組中AFP、CA19-9、CEA與肝功能指標的相關性分析 AFP在原發性肝癌組中與GGT相關(r=0.54,P=0.04)，在正常對照組中與IBil相關(r=0.50,P=0.01)。CA19-9在原發性肝癌組中與ALT、 DBil、 IBil、TBil、TBA存在不同程度相關(r值分別為0.58、0.63、0.61、0.65、0.58，P值均<0.05)，在非腫瘤性肝病組中與ALT、ALP、DBil、 IBil、TBil、TBA存在不同程度相關(r值分別為0.51、0.63、0.66、0.64、0.70、0.59，P值均< 0.05)。CEA在各組中與各指標未見明顯相關。

3 討論

隨著社會經濟的發展，生活方式的改變，原發性肝癌的相關危險因素普遍存在，早發現、早診斷、早治療是提高原發性肝癌患者生存率的關鍵。血清腫瘤標志物在血清中出現要早于臨床癥狀，當血清腫瘤標志物達到一定水平就能揭示某種腫瘤的存在[3]，對腫瘤的早期診斷有重要意義，所以腫瘤標志物的檢測越來越受到臨床醫生的重視。

圖1 單項和聯合檢測診斷原發性肝癌的ROC曲線分析

AFP、CA19-9、CEA是臨床上常見的腫瘤標志物，主要用于消化道、乳腺以及呼吸道等系統腫瘤的檢測。AFP主要在胎兒肝臟中合成，隨著胎兒的發育肝臟逐漸發育成熟，AFP逐漸接近成人水平。當肝細胞癌變時，部分肝細胞恢復產生AFP的功能，使血清AFP水平升高，因此，AFP被廣泛用于肝癌的輔助診斷[4]。CA19-9是由消化道腫瘤細胞分泌的一種類糖脂抗原，是一種與腺癌高度相關的抗原物質，又稱胃腸癌相關抗原[5-6]。臨床檢測發現CA19-9在原發性肝癌中也有較高表達，有研究[7-9]報道，CA19-9在原發性肝癌患者中陽性率為40%～70%左右。CEA是從結腸腺癌和胎兒腸組織中提取的一種腫瘤相關抗原，是一種光譜腫瘤標志物，在轉移性肝癌、胃癌、肺癌、結腸癌等中存在不同程度的陽性率[10]。

肝臟腫瘤標志物與肝功能密切相關[11-12]。本研究原發性肝癌中的AFP陽性率為71.59%，與以往的報道相近[13-14]，肝功能異常組血清AFP水平顯著高于正常組，血清AFP能較好地反映肝功能，但對部分AFP陰性的肝癌患者不存在診斷價值。在原發性肝癌組中，AFP與GGT呈正相關，與以往的報道一致[15]。在原發性肝癌組和非腫瘤性肝病組中，CA19-9與膽紅素、ALP呈正相關，提示CA19-9與膽汁排出順暢程度有關。當存在明顯的膽道梗阻時，CA19-9失去了作為腫瘤標志物的意義，這與文獻報道一致[12]，因此，CA19-9需要聯合多項肝功能生化指標及AFP、CEA才能提高對原發性肝癌診斷的準確度。CEA受肝功能生化指標影響小，在原發性肝癌組中陽性率較低，本研究中僅為39.77%，因此需要聯合AFP、CA19-9進行分析以提高對原發性肝癌診斷的準確度。

AFP能較好地反映肝損傷，但對原發性肝癌的診斷仍有部分假陰性；CEA在3組中受肝功能生化指標影響較?。籆A19-9受ALP、膽紅素等因素影響明顯，假陽性較高；聯合檢測AFP、CA19-9、CEA可提高原發性肝癌診斷的靈敏度，優于AFP、CA19-9、CEA的單項檢測，可為早期診斷和早期治療提供有力的依據。

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引證本文：LI JY, SONG JY, WANG JF, et al. Value of combined detection of AFP, CA19-9, and CEA in early diagnosis of primary liver cancer[J]. J Clin Hepatol, 2017, 33(7): 1291-1295. (in Chinese) 李嘉妍， 宋金云， 王建芳， 等. AFP、CA19-9、CEA聯合檢測對原發性肝癌的早期診斷價值[J]. 臨床肝膽病雜志, 2017, 33(7): 1291-1295.

(本文編輯：王 瑩)

Value of combined detection of AFP, CA19-9, and CEA in early diagnosis of primary liver cancer

LIJiayan,SONGJinyun,WANGJianfang,etal.

(ClinicalResearchCenter,TheSecondAffiliatedHospitalofSoutheastUniversity,Nanjing210003,China)

Objective To investigate the value of combined measurement of alpha-fetoprotein (AFP), carbohydrate antigen 19-9 (CA19-9), and carcinoembryonic antigen (CEA) in the early diagnosis of primary liver cancer. Methods A total of 248 patients who visited the outpatient service or were hospitalized in The Second Hospital of Nanjing from October 2014 to December 2016 were enrolled and divided into primary liver cancer group with 88 patients and non-tumor liver disease group with 160 patients. A total of 130 healthy subjects who underwent physical examination were enrolled as normal control group. The Roche cobas e 411 analyzer was used to measure the serum levels of the tumor markers AFP, CA19-9, and CEA, and the sensitivities and specificities of these markers or a combination of them were analyzed. Beckman Coulter AU5800 was used to measure biochemical parameters for liver function, and Biotek ELX808 was used to measure hepatitis B virus markers and HCV antibody. The receiver operating characteristic (ROC) curve was used to analyze the results of measurements of serum AFP, CA19-9, and CEA alone or in combination in patients with primary liver cancer. A one-way analysis of variance was used for comparison of continuous data between multiple groups and the SNK-qtest was used for further comparison between two groups; thet-test was used for comparison of continuous data between two groups. The chi-square test was used for comparison of categorical data between groups. The Spearman correlation analysis was also performed. Results In the primary liver cancer group and the non-tumor liver disease group, the patients with abnormal liver function had significantly higher levels of AFP and CA19-9 than those with normal liver function (primary liver cancer group:t=35.64 and 3.38, bothP<0.05; non-tumor liver disease group:t=12.51 and 8.19, bothP<0.05). Among the patients with normal liver function, the primary liver cancer group had a significantly higher level of CEA than the non-tumor liver disease group and the normal control group (allP<0.05). Among the patients with abnormal liver function, the primary liver cancer group had significantly higher levels of AFP, CA19-9, and CEA than the non-tumor liver disease group and the normal control group (allP<0.05). The serum levels of AFP, CA19-9, and CEA increased with the increase in Child-Pugh class. Among the patients with abnormal liver function in the primary liver cancer group, Child-Pugh class B patients had significant increases in the levels of AFP, CA19-9, and CEA compared with Child-Pugh class A patients, and Child-Pugh class C patients had significant increases compared with Child-Pugh class B patients (allP<0.05). Among the patients with abnormal liver function in the non-tumor liver disease group, Child-Pugh class B patients had significant increases in the levels of AFP and CA19-9 compared with Child-Pugh class A patients, and Child-Pugh class C patients had significant increases compared with Child-Pugh class B patients (allP<0.05); Child-Pugh class C patients had a significant increase in the level of CEA than Child-Pugh class A/B patients (P<0.05). The primary liver cancer group had significantly higher positive rates of AFP, CA19-9, and CEA than the non-tumor liver disease group and the normal control group (allP<0.05), and the positive rates of these tumor markers were significantly higher when measured in combination than when measured alone (allP<0.05). In the primary liver cancer group, a combination of the three tumor markers had a sensitivity of 86.36% and a specificity of 92.35%, while AFP, CA19-9, and CEA measured alone had sensitivities of 71.59%, 52.27%, and 39.77%, respectively. In the patients with primary liver cancer, the areas under the ROC curve for serum AFP, CA19-9, CEA, and a combination of them were 0.776, 0.704, 0.681, and 0.817, respectively. AFP was positively correlated with gamma-glutamyl transpeptidase in the primary liver cancer group (r=0.54,P=0.04) and was positively correlated with indirect bilirubin (IBil) in the normal control group (r=0.50,P=0.01). In the primary liver cancer group, CA19-9 was positively correlated with alanine aminotransferase (ALT), direct bilirubin (DBil), IBil, total bilirubin (TBil), and total bile acid (TBA) (r=0.58, 0.63, 0.61, 0.65, and 0.58, allP<0.05), and in the non-tumor liver disease group, CA19-9 was positively correlated with ALT, alkaline phosphatase (ALP), DBil, IBil, TBil, and TBA (r=0.51, 0.63, 0.66, 0.64, 0.70, and 0.59, allP<0.05). Conclusion AFP can well reflect liver injury, but it may yield false-negative results in the diagnosis of primary liver cancer. A mild increase in CEA does not strongly indicate primary cancer. CA19-9 is easily influenced by the factors including ALP and bilirubin and has a high false-positive rate. Combined measurement of AFP, CA19-9, and CEA can improve the sensitivity of the diagnosis of primary liver cancer and is better than single measurement of AFP, CA19-9, or CEA. Therefore, it provides a strong basis for early diagnosis and treatment.

liver neoplasms；alpha-fetoproteins；CA-19-9 antigen；carcinoembryonic antigen；diagnosis

10.3969/j.issn.1001-5256.2017.07.017

2016-12-01；

2017-01-22。

李嘉妍(1988-)，女，主要從事肝炎分子生物學相關研究。

吳旭平，電子信箱：xuping_wu@yahoo.com。

R735.7

A

1001-5256(2017)07-1291-05