Advances in the OLD-HEPAMARKER Research Programme

At present, and despite the efforts made by numerous research groups, there are no non-invasive biomarkers, which allow an early and reliable diagnosis of the development of liver tumours in patients at risk, although several markers have shown promising results. Nor are the mechanisms that tumour cells develop to defend themselves against chemotherapy known in detail, although in recent years some advances have been made that may enable a personalised medicine to offer better results in the future.

One of the objectives of the individual project "Serum metabolomic analysis for the detection of preneoplastic liver damage in people with age-increased fragility" is to validate the diagnostic capacity of a group of metabolites selected in a recent study carried out in a small number of patients with liver tumours. 

In the previous study, performed in patients with hepatocarcinoma (HCC, mean age 60 years), intrahepatic ACH (iCCA, mean age 71 years) and older healthy subjects (Control), several metabolites were identified in serum with better diagnostic values for iCCA and for HCC than those presented by nonspecific tumor markers CA 19-9 and AFP, which are usually measured in blood to aid in the diagnosis of ACH and HCC, respectively. In addition, the joint analysis of four metabolites; two amino acids: glycine and aspartic acid, and two sphingomyelins: SM(42:3) and SM(43:2), was found to accurately discriminate between the two types of tumors.

In order to carry out a validation study, it is necessary to obtain a large number of samples from patients, which is why we have contacted researchers from different Spanish and European hospitals.

In the case of the iCCA it is more complicated, as it is a rare tumor, but thanks to the recent launch of a European Network for the Study of Cholangiocarcinoma (ENS-CCA, http://www.enscca.org, @CcaEns) and one of its projects, the creation of an anonymized database of ACH cases with information on available biological samples along with the clinical and epidemiological characteristics of each case, we have access to a significant number of patient samples.

The inclusion criteria to be met by the patients who can be selected for the study and the exclusion criteria have been defined (Figure 1).

Figure 1. Inclusion and exclusion criteria for patients selected for validation metabolomic analysis.

Within the information collected from patients to compare results are included: age, gender, underlying diseases (cirrhosis, viral hepatitis, non-alcoholic fatty liver, alcoholism, diabetes), tumor characteristics (location, size, number, existence or not of metastasis), blood test values, with special attention to parameters that are used to check the health of the liver and that may help detect some liver diseases. These parameters include: bilirubin, transaminases (ALT, AST), alkaline phosphatase, gamma-glutamyltransferase, total proteins, or albumin. 

Figure 2. Parameters that are analyzed in blood that give us information on liver health.

One characteristic observed in the initial study is that most patients with HCC had underlying cirrhosis, whereas this only occurred in 20% of patients with iCCA. 

In order for a marker to have diagnostic value, it must serve to distinguish the presence of a tumour from other pathologies of the liver and, in our case, it must also make it possible to discriminate between the two types of liver tumour. In addition, it should not be affected by the presence of other pathologies, or by the taking of medications, frequent in elderly people, some of which may affect the metabolism, as may be the case of statins to lower cholesterol levels.

Therefore, in the validation study we propose to include patients with iCCA with different underlying diseases, mainly cirrhosis and fatty liver, and among the patients with HCC will be selected a group that do not have cirrhosis and another with overweight / obesity. 

Currently, the number of patients of each type (n=40) is about to be reached in order to begin the processing of the samples and the determination of metabolites and, subsequently, to analyse the results.

Another objective of the study is to identify markers to discriminate the distal AAC (dCCA) located in the head of the pancreas from ductal adenocarcinoma of the pancreas (PDAC). This is important, since each type of tumor requires a different pharmacological treatment and in some patients, especially in the elderly, a biopsy cannot be performed to have a confirmation by pathological anatomy of the tumor. In addition, it is important to distinguish it from other benign pathologies such as cysts or pancreatitis.

Currently, the metabolomic study has already been carried out in subjects with dCCA, PDAC, benign pathologies of the pancreas and healthy subjects (n=40 cases/group) divided into two independent patient cohorts (research and confirmation), the data have already begun to be analysed and in the coming weeks we will have preliminary results. 

We hope that several metabolites can be identified that, perhaps analyzed together, and with other available data from the clinical history and other tests performed on these older patients, can help in the diagnosis of these tumors.

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