The Lancet



Supplementary Appendix

Plasma heat shock protein 90alpha as a biomarker for the diagnosis of liver cancer: An official, large-scale, and multicenter clinical trial

Yan Fu1,2,3*, Xiao Xu4*, Ddongsheng Huang5, Dawei Cui1, Lisheng Liu6, Junwei Liu5, Zenglei He4, Jingjing Liu1, Shusen Zheng4†, Yongzhang Luo1,2,3†

Affiliations:

1The National Engineering Laboratory for Anti-Tumor Protein Therapeutics, Tsinghua University, Beijing, People’s Republic of China.

2Beijing Key Laboratory for Protein Therapeutics, Tsinghua University, Beijing, People’s Republic of China.

3Cancer Biology Laboratory, School of Life Sciences, Tsinghua University, Beijing, People’s Republic of China.

4The First Affiliated Hospital, School of Medicine, Hangzhou, Zhejiang University, People’s Republic of China.

5Department of Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, People’s Republic of China.

6Clinical Laboratory, Shandong Cancer Hospital, Jinan, Shandong, People’s Republic of China.

*These authors contributed equally to this study

†Corresponding author. Shusen Zheng, School of Medicine, Zhejiang University, Hangzhou 310003, China. E-mail: shusenzheng@zju.; Yongzhang Luo, School of Life Sciences, Tsinghua University, Beijing 100084, China. E-mail: yluo@tsinghua.

Supplementary results:

Fig. S1. Plasma Hsp90α for differentiation grading of liver cancer.

[pic]

The concentrations of plasma Hsp90α in patients were measured by the ELISA kit. No significant differences were observed between liver cancer of different differentiation grades. Black horizontal lines indicate means, and error bars represent standard errors (SE). Low, middle, or high indicate differential grading of patients with liver cancer, respectively.

Fig. S2. The ratio of positive results for Hsp90α in patients with CC, HCC-CC, Other liver cancer.

[pic]

We extended plasma Hsp90α to other types of liver cancer. 62.44 ng/mL (AUC 0.966, 95% CI 0.957-0.975; sensitivity 92.7%, specificity 91.3%) were used as the cutoff value to calculate the positive ratio of plasma Hsp90α in CC, HCC-CC, and Other. Positive ratio of plasma Hsp90α in CC, HCC-CC, or Other were greater than 94.7%, which indicated that plasma Hsp90α can be used as a diagnosis biomarker in AFP-limited liver cancer, including cholangiocarcinoma, combined, and other types of liver cancer. CC represents Cholangiocarcinoma. HCC-CC means combined type of HCC and CC. Other including rare types of primary liver cancer such as angiosarcoma, hemangiosarcoma, or squamous cell carcinoma of the liver.

Fig. S3. Concentrations of plasma Hsp90α in different-size liver cancer.

[pic]

The levels of plasma Hsp90α were positively associated with tumor sizes. The levels of plasma Hsp90α were remarkably elevated in patients with small-size tumor (median 115.6 ng/mL, IQR 77.9-196.9; mean 144.1 ng/mL, SD 85.5; Table S5) than those in non-liver cancer control (P 19.85# |57.5 |96.3 | | |

| |> 3.01 |90.0 |50.9 |90 | |

| |> 3.88 |85.1 |64.8 |85 | |

| |> 6.64 |73.2 |90.1 | |90 |

| |> 5.89 |75.7 |84.7 | |85 |

*The best cutoff value for Hsp90α in the diagnosis of early-stage hepatocellular carcinoma (HCC); #The commonly used cut-off value for AFP in HCC diagnosis; AdSen means adjusted sensitivities at 90% or 85% when compared the specificities between Hsp90α and AFP; AdSpe indicates adjusted specificities at 90% or 85% when compared the sensitivities between Hsp90α and AFP.

Table S10. Concentrations of plasma Hsp90 in efficacy monitoring group.

| |Surgery (86) | |Interventional therapy (36) |

| | | |Tumor size increase (18) | |Tumor size decrease (18) |

|Hsp90α (ng/mL) |Before |205.9 | |Start |108.2 | |Start |191.5 |

| |After |150.3 | |End |166.5 | |End |126.6 |

|Difference |55.6 | |- 58.3 | |64.9 |

|(P value) |(0.002) | |(0.05) | |(0.005) |

| | | | | | |

Start means the measuring point before interventional therapy; End indicates the efficacy evaluation after interventional therapy.

-----------------------

|Characteristic |Auxiliary diagnosis study |Efficacy monitoring group (122) |

| |(782) | |

| | |Surgery (86) |Chemotherapy (36) |

|Sex | | | |

|Male |670 |76 |27 |

|Female |112 |10 |9 |

|Age | | | |

|0-50 |248 |33 |6 |

|>50 |532 |53 |30 |

|NA |2 |0 |0 |

|TNM stage | | | |

|I-II |538 | | |

|III-VI |211 | | |

|NA |33 | | |

|Histological type | | | |

|HCC |531 | | |

|CC |57 | | |

|HCC-CC |65 | | |

|Other |56 | | |

|NA |73 | | |

|Differentiation | | | |

|Low |76 | | |

|Middle |461 | | |

|High |25 | | |

|NA |220 | | |

|Characteristic |Healthy control (572) |At-risk liver diseases (171) |

| | |Hepatitis (146) |Cirrhosis (18) |FNH (7) |

|Sex | | | | |

|Male |288 |88 |15 |6 |

|Female |284 |58 |3 |1 |

|Age | | | | |

|0-50 |495 |106 |3 |4 |

|>50 |77 |40 |15 |3 |

|Group |No. |Median (IQR) |Mean (SD) |

| | |(ng/mL) |(ng/mL) |

|HC |572 |30.0 (21.1-42.2) |34.0 (20.8) |

|At-risk |171 |26.8 (18.6-43.6) |43.6 (54.8) |

|Non-LC |743 |29.6 (20.5-42.6) |36.2 (32.2) |

|LC |782 |159.9 (96.7-246.8) |181.5 (105.4) |

|Early-LC |534 |152.5 (89.6-230.1) |172.7 (101.6) |

|Late-LC |209 |183.3 (111.7-262.6) |200.5 (110.4) |

|Small-LC |117 |115.6 (77.9-196.9) |144.1 (85.5) |

|Group |No. |Median (IQR) |Mean (SD) |

| | |(ng/mL) |(ng/mL) |

|Hsp90α |

|HCC |531 |160.8 (96.7-248.4) |179.8 (106.8) |

|AFP-negative HCC |198 |152.9 (92.0-246.0) |177.0 (99.0) |

|AFP-positive HCC |311 |99.6 (99.6-250.2) |187.9 (112.5) |

|Early-stage HCC |409 |152.3 (91.9-233.6) |175.9 (105.8) |

|Late-stage HCC |104 |191.4 (119.1-286.1) |213.5 (113.1) |

|AFP-limited LC |178 |181.5 (117.6-254.4) |195.3 (102.1) |

|AFP |

|HC |330 |2.7 (0.9-4.6) |6.5 (38.7) |

|At-risk |156 |3.3 (2.5-5.7) |37.1 (195.5) |

|Non-LC |486 |2.890.0 (1.7-4.7) |16.3 (115.9) |

|Early-stage HCC |395 |43.1 (6.0-924.2) |4429.0 (13969.0) |

|Late-stage HCC |97 |361.9 (10.9-5042.0) |11525.0 (29006.0) |

|HCC |509 |72.1 (7.0-1583.0) |5616.0 (17549.0) |

|Hospital sites |Principal investigator |No. of participants |

|The First Affiliated Hospital of Zhejiang University |Shusen Zheng |611 |

|Zhejiang Province People's Hospital |Dongsheng Huang |839 |

|The Tumor Hospital of Shandong Province |Xianrang Song |197 |

|Variable |Auxiliary diagnosis group (782) |

| |Negative (57) |Positive (725) |P value |

|Age (year) | | | |0.58 |

| |≤55 |29 |335 | |

| |>55 |28 |388 | |

| |Missing |2 | | |

|Gender | | | |0.84 |

| |Female |7 |105 | |

| |Male |50 |620 | |

|Cirrhosis | | | |0.88 |

| |No |17 |194 | |

| |Yes |35 |429 | |

| |Missing |107 | | |

|Tumor size (cm) | | | |3 |4 |480 | |

| |Missing |104 | | |

|TNM stage | | | |0.03 |

| |I+II |46 |488 | |

| |III+IV |8 |201 | |

| |Missing |39 | | |

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