Tumor Biology

, Volume 37, Issue 1, pp 211–216 | Cite as

Evaluation of annexin A2 and as potential biomarkers for hepatocellular carcinoma

  • Nevine El-Abd
  • Amal Fawzy
  • Tamer Elbaz
  • Sherif Hamdy
Research Article


Hepatocellular carcinoma (HCC) ranks as the fifth most common malignancy worldwide. Early detection of HCC is difficult due to the lack of reliable markers. We aimed to assess the diagnostic role of annexin A2 (ANXA2) and follistatin as serum markers for HCC patients. This study included 50 patients with confirmed diagnosis of HCC, 30 patients with chronic liver disease, and 20 normal persons. Subjects performed thorough assessment and laboratory investigations. Serum levels of alpha fetoprotein (AFP), annexin A2, and follistatin were measured using ELISA technique. Annexin A2 significantly increased in the sera of HCC patients (median, 69.6 ng/ml) compared to chronic liver disease patients (median, 16.8 ng/ml) and control group (median, 9.5 ng/ml) (p < 0.001). Follistatin was higher in sera of HCC patients (median, 24.4 ng/ml) compared to the control group (median, 4.2 ng/ml) (p = 0.002) while no such significant difference was achieved between HCC and chronic liver disease patients. At a cutoff level 29.3 ng/ml, area under the receiver-operating characteristic curve for ANXA2 was 0.910 (95 % confidence interval (CI) 0.84–0.97). For follistatin, it was 0.631 (95 % confidence interval 0.52˗0.74) at cutoff level 15.7 ng/ml. Combining both annexin A2 and AFP increased the diagnostic efficiency (98 % specificity, LR + 41 and 97.6 % PPV). Follistatin combined with AFP provided 92 % specificity while lower sensitivity (50 %) was observed. Serum ANXA2 is a promising biomarker for HCC, certainly when measured with AFP. Follistatin could not differentiate between HCC and chronic liver disease, but its combination with AFP improved the specificity for HCC diagnosis.


Annexin A2 Follistatin AFP Hepatocellular carcinoma 


Conflicts of interests

The authors declare that they have no conflict of interest. The study was not sponsored by any organization.


  1. 1.
    Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61(2):69–90.CrossRefPubMedGoogle Scholar
  2. 2.
    El-Zayadi AR, Badran HM, Barakat EM, et al. Hepatocellular carcinoma in Egypt: a single center study over a decade. World J Gastroenterol. 2005;11:5193–8.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Anwar WA, Khaled HM, Amra HA, El-Nezami H, Loffredo CA. Changing pattern of hepatocellular carcinoma (HCC) and its risk factors in Egypt: possibilities for prevention. Mutat Res. 2008;659(1–2):176–84.CrossRefPubMedGoogle Scholar
  4. 4.
    Gerke V, Moss SE. Annexins: from structure to function. Physiol Rev. 2002;82:331–71.CrossRefPubMedGoogle Scholar
  5. 5.
    Sharma MR, Koltowski L, Ownbey RT, et al. Angiogenesis associated protein annexin II in breast cancer: selective expression in invasive breast cancer and contribution to tumor invasion and progression. Exp Mol Pathol. 2006;81:146–56.CrossRefPubMedGoogle Scholar
  6. 6.
    Mohammad HS, Kurokohchi K, Yoneyama H, et al. Annexin A2 expression and phosphorylation are up-regulated in hepatocellular carcinoma. Int J Oncol. 2008;33:1157–63.PubMedGoogle Scholar
  7. 7.
    Inokuchi J, Narula N, Yee DS, et al. Annexin A2 positively contributes to the malignant phenotype and secretion of IL-6 in DU145 prostate cancer cells. Int J Cancer. 2009;124:68–74.CrossRefPubMedGoogle Scholar
  8. 8.
    Esposito I, Penzel R, Chaib-Harrireche M, et al. Tenascin C and annexin II expression in the process of pancreatic carcinogenesis. J Pathol. 2006;208:673–85.CrossRefPubMedGoogle Scholar
  9. 9.
    Shiozawa Y, Havens AM, Jung Y, et al. Annexin II/annexin II receptor axis regulates adhesion, migration, homing, and growth of prostate cancer. J Cell Biochem. 2008;105:370–80.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Ji NY, Park MY, Kang YH, et al. Evaluation of annexin II as a potential serum marker for hepatocellular carcinoma using a developed sandwich ELISA method. Int J Mol Med. 2009;24:765–71.PubMedGoogle Scholar
  11. 11.
    Wang Q, Keutmann HT, Schneyer AL, Sluss PM. Analysis of human follistatin structure: identification of two discontinuous N-terminal sequences coding for activin A binding and structural consequences of activin binding to native proteins. Endocrinology. 2000;141:3183–93.PubMedGoogle Scholar
  12. 12.
    Grusch M, Drucker C, Peter-Vorosmarty B, et al. Deregulation of the activin/follistatin system in hepatocarcinogenesis. J Hepatol. 2006;45(5):673–80.CrossRefPubMedGoogle Scholar
  13. 13.
    Rodgarkia-Dara C, Vejda S, Erlach N, et al. The activin axis in liver biology and disease. Mutat Res. 2006;613:123–37.CrossRefPubMedGoogle Scholar
  14. 14.
    Welt CK. The physiology and pathophysiology of inhibin, activin and follistatin in female reproduction. Curr Opin Obstet Gynecol. 2002;14:317–23.CrossRefPubMedGoogle Scholar
  15. 15.
    Sulyok S, Wankell M, Alzheimer C, Werner S. Activin: an important regulator of wound repair, fibrosis, and neuroprotection. Mol Cell Endocrinol. 2004;225(1–2):127–32.CrossRefPubMedGoogle Scholar
  16. 16.
    Beale G, Chattopadhyay D, Gray J, et al. AFP, PIVKAII, GP3, SCCA-1 and follisatin as surveillance biomarkers for hepatocellular cancer in non-alcoholic and alcoholic fatty liver disease. BMC Cancer. 2008;8:200.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Bruix J, Sherman M. Management of hepatocellular carcinoma. An update. Hepatology. 2011;53(3):1020–2.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Torane VP, Shastri JS. Comparison of ELISA and rapid screening tests for the diagnosis of HIV, hepatitis B and hepatitis C among healthy blood donors in a tertiary care hospital in Mumbai. Indian J Med Microbiol. 2008;26:284–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Thorpe GH, Bronstein I, Kricka LJ, Edwards B, Voyta JC. Chemiluminescent enzyme immunoassay of alpha-fetoprotein based on an adamantyl dioxetane phenyl phosphate substrate. Clin Chem. 1989;35(12):2319–21.PubMedGoogle Scholar
  20. 20.
    Zhang HJ, Yao DF, Yao M, et al. Expression characteristics and diagnostic value of annexin A2 in hepatocellular carcinoma. World J Gastroenterol. 2012;18(41):5897–904.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Forner A, Hessheimer AJ, Isabel Real M, Bruix J. Treatment of hepatocellular carcinoma. Crit Rev Oncol Hematol. 2006;60(2):89–98.CrossRefPubMedGoogle Scholar
  22. 22.
    Lokman NA, Ween MP, Oehler MK, Ricciardelli C. The role of annexin A2 in tumorigenesis and cancer progression. Cancer Microenviron. 2011;4:199–208.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Bandorowicz-Pikula J, Wos M, Pikula S. Do annexins participate in lipid messenger mediated intracellular signaling? A question revisited. Mol Membr Biol. 2012;29(7):229–42.CrossRefPubMedGoogle Scholar
  24. 24.
    Ueno N, Ling N, Ying SY, Esch F, Shimasaki S, Guillemin R. Isolation and partial characterization of follistatin: a single-chain Mr 35,000 monomeric protein that inhibits the release of follicle-stimulating hormone. Proc Natl Acad Sci. 1987;84(23):8282–6.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Krneta J, Kroll J, Alves F, et al. Dissociation of angiogenesis and tumorigenesis in follistatin- and activin-expressing tumors. Cancer Res. 2006;66(11):5686–95.CrossRefPubMedGoogle Scholar
  26. 26.
    Ogino H, Yano S, Kakiuchi S, et al. Follistatin suppresses the production of experimental multiple-organ metastasis by small cell lung cancer cells in natural killer cell-depleted SCID mice. Clin Cancer Res. 2008;14(3):660–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Fujiwara M, Marusawa H, Wang HQ, et al. Parkin as a tumor suppressor gene for hepatocellular carcinoma. Oncogene. 2008;27(46):6002–11.CrossRefPubMedGoogle Scholar
  28. 28.
    Liu Z, Ling Q, Wang J, Xie H, Xu X, Zheng S. Annexin A2 is not a good biomarker for hepatocellular carcinoma in cirrhosis. Oncol Let. 2013;6(1):125–9.Google Scholar
  29. 29.
    Sun Y, Gao G, Cai J, et al. Annexin A2 is a discriminative serological candidate in early hepatocellular carcinoma. Carcinogenesis. 2013;34:595–604.CrossRefPubMedGoogle Scholar
  30. 30.
    Zhao P, Zhang W, Tang J, et al. Annexin II promotes invasion and migration of human hepatocellular carcinoma cells in vitro via its interaction with HAb18G/CD147. Cancer Sci. 2010;101:387–95.CrossRefPubMedGoogle Scholar
  31. 31.
    Yuen MF, Norris S, Evans LW, Langley PG, Hughes RD. Transforming growth factor-beta 1, activin and follistatin in patients with hepatocellular carcinoma and patients with alcoholic cirrhosis. Scand J Gastroenterol. 2002;37(2):233–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Tomoda T, Nouso K, Miyahara K, et al. Prognotic impact of serum follistatin in patients with hepatocellular carcinoma. J Gastroenterol Hepatol. 2013;28(8):1391–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Mashima H, Kanzaki M, Nobusawa R. Derangements in the activin-follistatin system in hepatoma cells. Gastroenterology. 1995;108(3):834–40.CrossRefPubMedGoogle Scholar
  34. 34.
    Rossmanith W, Chabicovsky M, Grasl-Kraupp B, Peter B, Schausberger E, Schulte-Hermann R. Follistatin overexpression in rodent liver tumors: a possible mechanism to overcome activin growth control. Mol Carcinog. 2002;35(1):1–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Björklund M, Koivunen E. Gelatinase-mediated migration and invasion of cancer cells. Biochim Biophys Acta. 2005;1755(1):37–69.PubMedGoogle Scholar
  36. 36.
    Littlepage LE, Sternlicht MD, Rougier N, et al. Matrix metalloproteinases contribute distinct roles in neuroendocrine prostate carcinogenesis, metastasis, and angiogenesis progression. Cancer Res. 2010;70(6):2224–34.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© International Society of Oncology and BioMarkers (ISOBM) 2015

Authors and Affiliations

  • Nevine El-Abd
    • 1
  • Amal Fawzy
    • 2
  • Tamer Elbaz
    • 3
  • Sherif Hamdy
    • 3
  1. 1.Department of Clinical and Chemical PathologyCairo UniversityCairoEgypt
  2. 2.Department of Clinical and Chemical PathologyNational Cancer InstituteCairoEgypt
  3. 3.Department of Endemic HepatogastroenterologyCairo UniversityCairoEgypt

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