What are all the biomarkers used for the diagnosis and monitoring of Hepatocellular Carcinoma (HCC)?

Biomarkers for Hepatocellular Carcinoma (HCC)

Alpha-fetoprotein (AFP) remains the primary serum biomarker used in clinical practice for HCC surveillance and diagnosis, though its sensitivity for early-stage disease is limited, prompting the development of combination biomarker panels and novel markers to improve detection accuracy. 1

Established Serum Biomarkers

Alpha-Fetoprotein (AFP)

• AFP is the most widely used and only routinely adopted serum biomarker for HCC management, despite limitations in sensitivity (particularly <20% for early-stage HCC) and specificity 1, 2
• When combined with ultrasound, AFP increases sensitivity for early-stage HCC detection from 45% to 63% compared to ultrasound alone 1
• AFP is recommended by multiple guidelines including EASL (2025), though some Western guidelines (AASLD 2005/2011, NCCN) have excluded it from diagnostic criteria due to inconsistent performance 1

AFP-L3 (Lectin-bound AFP)

• AFP-L3% improves AFP performance when used in combination for early HCC diagnosis 1
• Commonly used in Japan and included in Japanese guidelines (J-HCC, JSH) 1, 3
• Part of the GALAD biomarker panel 1

Des-gamma-carboxy Prothrombin (DCP/PIVKA-II)

• DCP enhances diagnostic accuracy when combined with AFP and AFP-L3 1, 3
• Recommended by Japanese guidelines and mentioned in Chinese NHFPC standards 1
• Component of the GALAD scoring system 1

Combination Biomarker Panels

GALAD Score

• The GALAD model (Gender, Age, AFP-L3, AFP, DCP) demonstrates >70% sensitivity for overall HCC detection and >60% for early-stage HCC in multinational validation studies with 2,430 HCC patients 1
• In NAFLD patients specifically, GALAD showed 68% sensitivity and 95% specificity at a cut-off of -0.63 1
• GALAD represents the most validated multi-biomarker panel but still requires phase III/IV cohort studies before routine adoption 1

HCC Early Detection Strategy (HES)

• Combines AFP with ALT, platelet count, and optional previous AFP value to increase sensitivity 5-10% over AFP alone 1
• Uses longitudinal biomarker trends rather than single-threshold assessment 1

Tissue-Based Biomarkers (Immunohistochemistry)

Diagnostic Panel for Pathological Confirmation

• The International Consensus Group recommends diagnosing HCC if at least 2 of 3 markers are positive: Glypican-3 (GPC3), Heat Shock Protein 70 (HSP70), and Glutamine Synthetase (GS) 1
• This combination achieves 72% sensitivity and 100% specificity 1

Individual Tissue Markers

• GPC3: 68-72% sensitivity with >92% specificity 1
• HSP70: Part of the validated diagnostic triad 1
• Glutamine Synthetase (GS): Completes the three-marker panel 1
• CD34: Assesses capillarization of sinusoids 1
• Keratin 19 (K19): At >5% positivity, correlates with poorest outcomes and identifies progenitor cell origin; useful for detecting mixed HCC/cholangiocarcinoma 1
• EpCAM: Marker for potential progenitor cell origin 1

Emerging Biomarkers Under Investigation

Protein Biomarkers (Phase 1-2 Studies)

• Glypican-3 (GP73): Currently being evaluated beyond tissue use 1
• Osteopontin: Under investigation 1
• Squamous cell carcinoma antigen: In evaluation phase 1
• Human hepatocyte growth factor: Being studied 1
• Insulin growth factor-1 (IGF-1): Under assessment 1

Liquid Biopsy Markers

• Plasma-based methylation markers (cell-free DNA): A 6-marker panel demonstrated 95% overall sensitivity, 75% for stage 0, and 93% for stage A HCC at 86% specificity in phase 2 studies 1
• Circulating tumor cells: Source for potential biomarkers 2
• Circulating nucleic acids: Including DNA, messenger RNAs, and non-coding RNAs 1, 2
• Exosomes: Emerging biomarker source 2

Genetic Markers

• AFP-mRNA, TGF-beta1-mRNA, IGF-II-mRNA: Used for monitoring distant metastasis or postoperative recurrence 4
• Three-gene signature (GPC3, LYVE1, survivin): >80% accuracy for discriminating dysplastic nodules from small HCCs (<2 cm) 1

Clinical Application Framework

For Surveillance

• Use ultrasound combined with AFP every 6 months for high-risk patients with cirrhosis 1
• Consider AFP-L3 and DCP in addition to AFP where available (particularly in Japan) 1, 3
• For patients with obesity or poor ultrasound visualization, consider MRI-based surveillance 1

For Diagnosis

• Imaging remains the primary diagnostic modality (contrast-enhanced MRI or CT) 1
• Biopsy with immunohistochemistry is required for nodules 1-2 cm with inconclusive imaging 1
• Apply the GPC3/HSP70/GS panel for pathological confirmation when morphology is unclear 1

For Monitoring Treatment Response

• AFP, AFP-L3, DCP, and GP73 serve as surrogate markers for treatment response and recurrence monitoring 1
• Longitudinal trends are more informative than single measurements 1

Important Caveats

• Most novel biomarkers remain in phase 1-2 (case-control) studies and lack validation in prospective cohort studies before clinical adoption 1
• Increased sensitivity from combination panels comes with decreased specificity, increasing false positives and surveillance costs 1
• Needle biopsy carries a 2.7% risk of tumor seeding (median 17 months post-biopsy), though this is manageable and does not affect overall survival 1
• AFP has limited sensitivity for early-stage HCC, detecting <20% of small tumors 1, 5
• Large ongoing cohort studies (Early Detection Research Network, Texas HCC Consortium) will facilitate phase III validation of promising biomarkers 1