雷旦生　喻晶

?

·論著·

血清異常凝血酶原水平在胰腺癌診治中的應用價值

雷旦生喻晶

目的檢測胰腺癌患者血清異常凝血酶原(PIVKA-Ⅱ)水平，探討其在胰腺癌診斷、療效評估中的臨床應用價值。 方法收集湖北省腫瘤醫(yī)院收治的112例胰腺癌、28例胰腺炎及79例健康者血清，應用化學發(fā)光法檢測血清PIVKA-Ⅱ水平，同時應用電化學發(fā)光法檢測血清CEA、CA19-9水平。繪制受試者工作特征(ROC)曲線，確定診斷臨界值，計算診斷敏感性、特異性，準確性。 結果112例胰腺癌患者的血清PIVKA-Ⅱ濃度為39.0(22.61，137.67)U/L，顯著高于30例胰腺炎患者的23.0(17.32，29.67)U/L及79例健康者的21.21(17.90，25.12)U/L，差異均有統(tǒng)計學意義(P值均<0.01)，而胰腺炎與健康者的差異無統(tǒng)計學意義。血清PIVKA-Ⅱ、CEA、CA19-9的ROC曲線下面積分別為0.793、0.707、0.849，診斷胰腺癌的臨界值分別為32.4、4.7、27.0 U/L；敏感性為61.6%、38.0%、66.1%；特異性為86.3%、96.3%、89.9%；準確性為71.7%、62.3%、75.0%。PIVKA-Ⅱ聯(lián)合CEA、CA19-9檢測的敏感性、特異性、準確性分別為90.2%、76.0%、84.3%。聯(lián)合檢測的敏感性顯著提高，特異性略有下降。胰腺癌患者血清PIVKA-Ⅱ水平與腫瘤分期有關。20例追蹤監(jiān)測的患者中15例經(jīng)手術或介入治療后血清PIVKA-Ⅱ水平較治療前顯著下降(50.6U/L比110.5 U/L,P<0.001)，5例姑息治療者中4例有不同程度升高。 結論檢測血清PIVKA-Ⅱ水平對胰腺癌的診斷及療效評估具有一定的臨床應用價值。

胰腺腫瘤；異常凝血酶原；診斷；監(jiān)測

PIVKA-Ⅱ是出現(xiàn)在維生素K缺乏、用華法林或苯丙香豆素治療的患者的一種異常脫羧基凝血酶原[1-3]。正常個體中無高濃度的PIVKA-Ⅱ，但惡性腫瘤患者中即便未出現(xiàn)維生素K缺乏，也可能存在高濃度的PIVKA-Ⅱ[3]。最早在1984年就發(fā)現(xiàn)部分肝癌患者的血中PIVKA-Ⅱ水平升高，且具有較高的診斷特異性。此外，PIVKA-Ⅱ對其他消化道腫瘤也有一定的臨床診斷價值[4-6]。胰腺癌因生理結構特征很容易發(fā)生肝轉移，且一般不易早期發(fā)現(xiàn)，死亡率高，素有“癌中之王”之稱。傳統(tǒng)的胰腺癌血清標志物有CEA、CA19-9[7-8]。CEA對胰腺癌的診斷敏感性不高，CA19-9診斷胰腺癌的敏感性雖高，但存在一定的假陽性，易受膽汁淤積的影響，因此臨床上一直在尋找胰腺癌新的診斷標志物。本研究檢測胰腺癌患者血PIVKA-Ⅱ水平，探討其在胰腺癌診治中的應用價值。

資料與方法

一、一般資料

選擇2015年2月20日至2015年10月20日湖北省腫瘤醫(yī)院肝膽胰科收治的經(jīng)病理證實的胰腺癌患者112例，其中男性83例，女性29例，年齡25～75歲，平均58歲。112例胰腺癌患者中局限期(Ⅰ～Ⅱ)14例，進展期(Ⅲ～Ⅳ)98例，其中12例晚期胰腺癌患者肝功能異常，被證實為肝轉移，其余患者觀察期內(nèi)肝功能正常。急、慢性胰腺炎患者28例，其中男性19例，女性9例，平均46歲，均無其他疾病。體檢健康者79例，其中男性45例，女性34例，平均41歲。排除標準：肝癌轉移性胰腺癌患者、伴有肝硬化的胰腺癌患者、存在凝血功能障礙的胰腺癌患者均不納入腫瘤組；伴有肝硬化、凝血功能障礙的胰腺炎患者也不納入良性病組。

二、標本采集及檢測

采用黃蓋含分離膠的進口真空采血管抽取待檢者空腹靜脈血2～4 ml，待血液自然凝固后以2 300 g(離心半徑5 cm)離心15 min分離血清，-80℃保存待測。采用ARCHITECT-IU2000化學發(fā)光分析儀及PIVKA-Ⅱ檢測試劑盒(美國Abbott公司)測定血清PIVKA-Ⅱ濃度，標準品及質控品均為原裝配套試劑。采用Cobas e601電化學發(fā)光免疫分析儀及CEA、CA19-9檢測試劑盒(瑞士Roche公司)測定血CEA、CA19-9濃度，應用BIORAD的腫瘤標志物質控品，室內(nèi)質控、室間質評均合格。

三、統(tǒng)計學處理

采用SPSS17.0軟件進行統(tǒng)計學分析。因樣本濃度均呈偏態(tài)分布，故以M(P25,P75)表示，組間比較采用非參數(shù)Kruskal-Wallis檢驗，兩兩比較采用MannWhitneyU檢驗。P<0.05為差異有統(tǒng)計學意義。敏感性=真陽性人數(shù)/(真陽性人數(shù)+假陰性人數(shù))×100%，特異性=真陰性人數(shù)/(真陰性人數(shù)+假陽性人數(shù))×100%，準確性=(真陽性人數(shù)+真陰性人數(shù))/總人數(shù)。繪制受試者工作特征(ROC)曲線，計算曲線下面積(AUC)，確定臨界值。

結　　果

一、胰腺癌、胰腺炎及健康者血清PIVKA-Ⅱ濃度

胰腺癌、胰腺炎及健康者血清PIVKA-Ⅱ水平分別為39.0(22.61，137.67)、23.0(17.32，29.67)、21.21(17.90，25.12)U/L，胰腺癌患者顯著高于胰腺炎患者及健康者，差異均有統(tǒng)計學意義(U=254.0，Z=-2.733；U=578.5，Z=-4.292；P值均<0.05)，而胰腺炎患者與健康者之間的差異無統(tǒng)計學意義(U=98.4，Z=-1.116，P>0.05)。

二、胰腺癌患者血清PIVKA-Ⅱ、CEA、CA19-9濃度對胰腺癌的診斷價值

胰腺癌患者血清PIVKA-Ⅱ、CEA、CA19-9的ROC曲線見圖1，各指標的AUC分別為0.793±0.058、0.707±0.069、0.849±0.053，診斷臨界值分別為32.4、4.7、27.0 U/L。

圖1　不同標志物診斷胰腺癌的ROC曲線

PIVKA-Ⅱ、CEA、CA19-9單指標及CEA+CA19-9、PIVKA-Ⅱ+CEA+CA19-9聯(lián)合檢測對胰腺癌診斷的敏感性、特異性、準確性見表1。2項或3項聯(lián)合檢測診斷胰腺癌的敏感性可從單項檢測的60%左右提高至80%或90%，特異性保持在88%或略降至76%。而2項、3項聯(lián)合檢測的差異無統(tǒng)計學意義(χ2=2.296，P=0.13)。

表1血清PIVKA-Ⅱ及CEA、CA19-9對胰腺癌的診斷價值

檢測指標陽性例數(shù)敏感性(%)特異性(%)準確性(%)PIVKA-Ⅱ6961.686.371.7CEA4338.096.362.3CA19-97466.189.975.0CEA+CA19-99080.488.683.8PIVKA-Ⅱ+CEA+CA19-910190.276.084.3

三、胰腺癌患者PIVKA-Ⅱ水平與腫瘤分期的關系

14例Ⅰ～Ⅱ期患者、98例Ⅲ～Ⅳ期患者血清PIVKA-Ⅱ水平分別為25.2(20.54，40.33)、39.7(23.45，152.23)U/L。Ⅲ～Ⅳ期患者顯著高于Ⅰ～Ⅱ期患者，Ⅰ～Ⅱ期患者又顯著高于健康者，差異均有統(tǒng)計學意義(U=251.6，Z=-2.971，P=0.014；U=226.5，Z=-2.052，P=0.021)。Ⅲ、Ⅳ期胰腺癌患者PIVKA-Ⅱ陽性率為63.3%，顯著高于Ⅰ～Ⅱ期患者的35.7%，差異有統(tǒng)計學意義(χ2=3.869，P=0.048)。

四、PIVKA-Ⅱ水平監(jiān)測對胰腺癌患者療效及預后評估的價值

對112例胰腺癌患者中20例進行追蹤監(jiān)測，其中15例在手術或介入治療后1個月的血PIVKA-Ⅱ、CEA、CA19-9水平分別為50.6、11.3、88.2 U/L，較治療前的110.5、36.4、234.5 U/L顯著下降，差異均有統(tǒng)計學意義(U值分別為327.4、209.3、368.1，Z值分別為-2.734、-1.875、-2.865，P值分別為<0.001、0.004、<0.001)。5例行姑息治療的晚期患者每2周檢測1次，至2015年10月20日截止，其中4例患者3項標志物均有不同程度升高(升高40%～4倍)，1例患者在觀察期內(nèi)病情穩(wěn)定，各項指標均未見顯著升高。

討　　論

胰腺癌是死亡率最高的腫瘤之一，不易早期發(fā)現(xiàn)，患者生存期短[9-10]。目前臨床常用的胰腺癌標志物有CEA、CA19-9[7-8]。PIVKA-Ⅱ即維生素K缺乏或拮抗劑Ⅱ誘導的蛋白，Liebman等最早于1984年發(fā)現(xiàn)其在部分肝癌患者中升高，且具有較高的診斷特異性[1-3]。檢測PIVKA-Ⅱ水平可用于輔助診斷肝細胞癌(HCC)、監(jiān)測HCC高?；颊?丙型肝炎病毒感染、肝炎/肝硬化、乙型肝炎病毒感染)和評估HCC療效[2]。此后有報道PIVKA-Ⅱ在縱膈卵巢囊腫[3]、消化道的結腸癌[4]、胃癌[5-6]、胰腺的肝樣癌[11]中也有高表達。

本研究結果顯示，胰腺癌患者血清PIVKA-Ⅱ濃度顯著高于急、慢性胰腺炎和健康人群。PIVKA-Ⅱ與CEA、CA19-9[12-13]單項檢測診斷胰腺癌時，以CA19-9敏感性最高，CEA特異性最好。PIVKA-Ⅱ診斷胰腺腺癌的敏感性為61.6%，特異性為86.3%，PIVKA-Ⅱ聯(lián)合CEA、CA19-9檢測診斷胰腺癌的敏感性可提高到90.2%，特異性保持在76%，大大提高胰腺癌診斷的靈敏度。

本結果還顯示，胰腺癌患者血清PIVKA-Ⅱ水平與腫瘤分期顯著相關，分期晚的患者血清PIVKA-Ⅱ水平高，甚至可高達1 000 U/L以上。血清PIVKA-Ⅱ水平還可監(jiān)測病情的變化及預后。治療前PIVKA-Ⅱ水平越高的胰腺癌患者預后差，手術或介入治療有效患者血PIVKA-Ⅱ水平下降，部分晚期胰腺癌肝轉移患者經(jīng)介入治療后PIVKA-Ⅱ水平也有一定程度下降，因此，檢測血清PIVKA-Ⅱ水平對胰腺癌的診斷及療效評估具有重要的臨床應用價值。

[1]Seo SI, Kim HS, Kim WJ, et al. Diagnostic value of PIVKA-Ⅱ and alpha-fetoprotein in hepatitis B virus-associated hepatocellular carcinoma[J]. World J Gastroenterol, 2015, 21(13):3928-3935. DOI: 10.3748/wjg.v21.i13.3928.

[2]Poté N, Cauchy F, Albuquerque M, et al. Performance of PIVKA-Ⅱ for early hepatocellular carcinoma diagnosis and prediction of microvascular invasion[J]. J Hepatol, 2015,62(4):848-854. DOI: 10.1016/j.jhep.2014.11.005.

[3]Akutsu N, Adachi Y, Isosaka M, et al. Mediastinal yolk sac tumor producing protein induced by vitamin K absence or antagonist-Ⅱ[J]. Intern Med, 2015,54(12):1531-1536. DOI: 10.2169/internalmedicine.54.4025.

[4]Kato K, Iwasaki Y, Taniguchi M, et al. Primary colon cancer with a high serum PIVKA-Ⅱ level[J]. Int J Surg Case Rep, 2015,6(3):95-99. DOI: 10.1016/j.ijscr.2014.11.072.

[5]Ogasawara N, Takahashi E, Matsumoto T, et al. Prolonged survival in a case of chemotherapy-sensitive gastric cancer that produced alpha-fetoprotein and protein induced by vitamin K antagonist-II[J]. Case Rep Gastroenterol, 2015, 9(1):113-119. DOI: 10.1159/000382072.

[6]Takahashi Y, Inoue T, Fukusato T. Protein induced by vitamin K absence or antagonist Ⅱ-producing gastric cancer[J]. World J Gastrointest Pathophysiol, 2010, 1(4):129-136. DOI: 10.4291/wjgp.v1.i4.129.

[7]Dranka-Bojarowska D, Lekstan A, Olakowski M, et al. The assessment of serum concentration of adiponectin, leptin and serum carbohydrate antigen-19.9 in patients with pancreatic cancer and chronic pancreatitis. J Physiol Pharmacol, 2015, 66(5):653-663.

[8]Reitz D, Gerger A, Seidel J, et al. Combination of tumour markers CEA and CA19-9 improves the prognostic prediction in patients withpancreatic cancer[J]. J Clin Pathol, 2015, 68(6):427-433. DOI: 10.1136/jclinpath-2014-202451.

[9]楊尹默.胰腺癌外科治療的熱點與難點[J].中華消化外科雜志,2015,14(8):612-614.DOI:10.3760/cma.j.issn.1673-9752.2015.08.004.

[10]張?zhí)?曹喆,趙玉沛.胰腺癌的化療與放療[J].中華消化外科雜志,2015,14(8):619-622.DOI:10.3760/cma.j.issn.1673-9752.2015.08.006.

[11]Matsueda K, Yamamoto H, Yoshida Y, et al. Hepatoid carcinoma of the pancreas producing protein induced by vitamin K absence or antagonist Ⅱ(PIVKA-Ⅱ) and alpha-fetoprotein (AFP)[J]. J Gastroenterol, 2006, 41(10):1011-1019. DOI:10.1007/s00535-006-1889-8.

[12]曾彥博，王凱旋，李兆申.胰腺癌標志物的新進展[J].中華胰腺病雜志，2011,11(6)：448-450. DOI: 10.3969/j.issn.1673-8640.2014.03.017.

[13]張泉東，金政錫，郝迪斯.腫瘤標志物與胰腺癌相關性的研究進展[J].國際免疫學雜志，2014,37(1)：57-60. DOI: 10.3760/cma.j.issn.1674-1935.2011.06.025.

(本文編輯：屠振興)

Clinical application of serum PIVKA-Ⅱ level in the diagnosis and treatment of pancreatic cancer

LeiDansheng,YuJing.

DepartmentofClinicalLaboratory,CancerHospitalofHubeiProvince,Wuhan430079,China

Correspondingauthor:YuJing,Email:14043237@qq.com

ObjectiveSerum abnormal prothrombin (PIVKA-Ⅱ) level was detected in pancreatic cancer patients and its clinical value in diagnosing and treating pancreatic cancer was explored. MethodsA total of 112 pancreatic cancer patients, 28 benign pancreatic diseases patients and 79 healthy controls were collected from Cancer Hospital of Hubei Province. Serum PIVKA-Ⅱ level was determined by chemiluminescent immunoassay (CLIA). CEA and CA19-9 level was detected by electrochemiluminescence immunoassay (ECLIA). Receiver operation characteristic (ROC) curve was drawn and the cut-off value was set. The sensitivity, specificity and accuracy were calculated. ResultsPIVKA-Ⅱ level in 112 pancreatic cancer patients was 39.0(22.61, 137.67)U/L[median(quartile range)],which was significantly higher than that in 30 patients with benign pancreatic disease [23.0(17.32, 29.67)U/L] and 79 healthy controls[21.21(17.9, 25.12)U/L].The differences were statistically significant (P<0.01). However, there was no significant difference between benign pancreatic disease patients and healthy controls. ROC analysis showed that area under curve(AUC) for PIVKA-Ⅱ, CEA and CA19-9 was 0.793, 0.707 and 0.849.The cut-off value for discriminating pancreatic cancer was established at 32.4, 4.7 and 27.0 U/L for PIVKA-Ⅱ, CEA and CA19-9. The sensitivity was 61.6%, 38.0% and 66.1%, and the specificity was 86.3%, 96.3% and 89.9%,and the accuracy was 71.7%, 62.3% and 75.0%, respectively. The sensitivity, specificity and accuracy of PIVKA-Ⅱ combined with CEA and CA19-9 was 90.2%, 76.0% and 84.3%. The sensitivity was obviously higher, while the specificity was lower. Serum PIVKA-Ⅱ level was associated with advanced tumor stage. There were 20 patients who were followed up. PIVKA-Ⅱ level in 15 cases were decreased after surgery or interventional therapy (50.6 U/Lvs110.5 U/L,P<0.001), which was increased in 4 of the five cases who received palliative care to a various degree. ConclusionsPIVKA-Ⅱ detection could benefit the diagnosis and prognosis monitoring of pancreatic cancer.

Pancreatic neoplasms;Abnormal prothrombin;Diagnosis;Monitoring

10.3760/cma.j.issn.1674-1935.2016.04.001

430079武漢，湖北省腫瘤醫(yī)院檢驗科

喻晶，Email:14043237@qq.com

2015-12-18)