Tumor Biology

, Volume 37, Issue 7, pp 9343–9355 | Cite as

Overexpression of annexin A4 indicates poor prognosis and promotes tumor metastasis of hepatocellular carcinoma

  • Wenwei Chen
  • Lihong Chen
  • Zhixiong Cai
  • Dong Liang
  • Bixing Zhao
  • Yongyi Zeng
  • Xiaolong Liu
  • Jingfeng Liu
Original Article


The prognosis of hepatocellular carcinoma (HCC) after surgical resection remains unsatisfactory for the majority of HCC patients who developed early recurrence or metastasis. There is still a lack of reliable biomarkers that can be used to predict the possibility of recurrence/metastasis in HCC patients after operation. In the current study, annexin A4, a calcium-dependent phospholipid-binding protein, has been found to be significantly elevated in HCC patients with early recurrence/metastasis, and had a strong correlation with portal vein tumor thrombosis (p = 0.03) and advanced BCLC stage (p = 0.002). Cox proportional hazards regression analysis revealed that annexin A4 was an independent prognostic predictor for both early recurrence/metastasis (HR = 1.519, p = 0.032) and overall survival (HR = 1.827, p = 0.009) after surgical resection. Meanwhile, Kaplan–Meier analysis showed that Patients with high-expression levels of annexin A4 had higher recurrence rate and shorter overall survival than those with low expression (log-rank test, p < 0.001). Furthermore, in vitro studies have demonstrated that overexpression of annexin A4 facilitated HCC cell migration and invasion via regulating epithelial–mesenchymal transition (EMT). In conclusion, annexin A4 has played important roles in the progression of HCC, and might act as a potential prognostic biomarker for HCC.


Annexin A4 Early recurrences/metastasis Epithelial–mesenchymal transition (EMT) Hepatocellular Carcinoma (HCC) Prognostic biomarker 



This work is supported by the key clinical specialty discipline construction program of Fujian, People’s Republic of China; the National Natural Science Foundation of China (Grant No. 31201008, Grant No. 31400634); the specialized Science and Technology Key Project of Fujian Province (Grant No. 2013YZ0002-3); the Science and Technology Infrastructure Construction Program of Fujian Province (Grant No. 2014Y2005); the scientific innovation project of Fujian provincial Health and Family Planning Commission (Grant No. 2014-CXB-24); the Scientific Foundation of Fuzhou City (Grant No. 2015-S-143-20).

Compliance with ethical standards

Conflict of interest


Supplementary material

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  1. 1.
    El–Serag HB, Rudolph KL. Hepatocellular carcinoma: epidemiology and molecular carcinogenesis. Gastroenterology. 2007;132(7):2557–76.CrossRefPubMedGoogle Scholar
  2. 2.
    El-Serag HB. Hepatocellular carcinoma. N Engl J Med. 2011;365(12):1118–27.CrossRefPubMedGoogle Scholar
  3. 3.
    W-q C, Zheng R-s, S-w Z, Li N, Zhao P, G-l L, et al. Report of incidence and mortality in China cancer registries, 2008. Chin J Cancer Res. 2012;24(3):171–80.CrossRefGoogle Scholar
  4. 4.
    Poon RT. Prevention of recurrence after resection of hepatocellular carcinoma: a daunting challenge. Hepatology. 2011;54(3):757–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Portolani N, Coniglio A, Ghidoni S, Giovanelli M, Benetti A, Tiberio GAM, et al. Early and late recurrence after liver resection for hepatocellular carcinoma: prognostic and therapeutic implications. Ann Surg. 2006;243(2):229–35.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Imamura H, Matsuyama Y, Tanaka E, Ohkubo T, Hasegawa K, Miyagawa S, et al. Risk factors contributing to early and late phase intrahepatic recurrence of hepatocellular carcinoma after hepatectomy. J Hepatol. 2003;38(2):200–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Gerke V, Moss SE. Annexins: from structure to function. Physiol Rev. 2002;82(2):331–71.CrossRefPubMedGoogle Scholar
  8. 8.
    Gerke V, Creutz CE, Moss SE. Annexins: linking Ca2+ signalling to membrane dynamics. Nat Rev Mol Cell Biol. 2005;6(6):449–61.CrossRefPubMedGoogle Scholar
  9. 9.
    Ortiz-Zapater E, Peiró S, Roda O, Corominas JM, Aguilar S, Ampurdanés C, et al. Tissue plasminogen activator induces pancreatic cancer cell proliferation by a non-catalytic mechanism that requires extracellular signal-regulated kinase 1/2 activation through epidermal growth factor receptor and annexin A2. Am J Pathol. 2007;170(5):1573–84.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Babbin BA, Lee WY, Parkos CA, Winfree LM, Akyildiz A, Perretti M, et al. Annexin I regulates SKCO-15 cell invasion by signaling through formyl peptide receptors. J Biol Chem. 2006;281(28):19588–99.CrossRefPubMedGoogle Scholar
  11. 11.
    Zhao P, Zhang W, Tang J, Ma XK, Dai JY, Li Y, 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(2):387–95.CrossRefPubMedGoogle Scholar
  12. 12.
    de Graauw M, van Miltenburg MH, Schmidt MK, Pont C, Lalai R, Kartopawiro J, et al. Annexin A1 regulates TGF-β signaling and promotes metastasis formation of basal-like breast cancer cells. Proc Natl Acad Sci U S A. 2010;107(14):6340–5.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Masaki T, Tokuda M, Ohnishi M, Watanabe S, Fujimura T, Miyamoto K, et al. Enhanced expression of the protein kinase substrate annexin I in human hepatocellular carcinoma. Hepatology. 1996;24(1):72–81.PubMedGoogle Scholar
  14. 14.
    Mohammad HS, Kurokohchi K, Yoneyama H, Tokuda M, Morishita A, Jian G, et al. Annexin A2 expression and phosphorylation are up-regulated in hepatocellular carcinoma. Int J Oncol. 2008;33(6):1157–63.PubMedGoogle Scholar
  15. 15.
    Pan QZ, Pan K, Weng DS, Zhao JJ, Zhang XF, Wang DD, et al. Annexin A3 promotes tumorigenesis and resistance to chemotherapy in hepatocellular carcinoma. Mol Carcinog. 2013;54(8):598–607.CrossRefPubMedGoogle Scholar
  16. 16.
    Guo W, Man X, Yuan H, Shi J, Xue J, Wu M, et al. Proteomic analysis on portal vein tumor thrombus-associated proteins for hepatocellular carcinoma. Zhonghua yi xue za zhi. 2007;87(30):2094–7.PubMedGoogle Scholar
  17. 17.
    Liu S, Sun MZ, Tang JW, Wang Z, Sun C, Greenaway FT. High-performance liquid chromatography/nano-electrospray ionization tandem mass spectrometry, two-dimensional difference in-gel electrophoresis and gene microarray identification of lymphatic metastasis-associated biomarkers. Rapid Commun Mass Spectrom. 2008;22(20):3172–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Liu S-H, Lin C-Y, Peng S-Y, Jeng Y-M, Pan H-W, Lai P-L, et al. Down-regulation of annexin A10 in hepatocellular carcinoma is associated with vascular invasion, early recurrence, and poor prognosis in synergy with p53 mutation. Am J Pathol. 2002;160(5):1831–7.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Mussunoor S, Murray G. The role of annexins in tumour development and progression. J Pathol. 2008;216(2):131–40.CrossRefPubMedGoogle Scholar
  20. 20.
    Dreier R, Schmid KW, Gerke V, Riehemann K. Differential expression of annexins I, II and IV in human tissues: an immunohistochemical study. Histochem Cell Biol. 1998;110(2):137–48.CrossRefPubMedGoogle Scholar
  21. 21.
    Lin LL, Chen CN, Lin WC, Lee PH, Chang KJ, Lai YP, et al. Annexin A4: A novel molecular marker for gastric cancer with Helicobacter pylori infection using proteomics approach. Proteomics Clin Appl. 2008;2(4):619–34.CrossRefPubMedGoogle Scholar
  22. 22.
    Duncan R, Carpenter B, Main L, Telfer C, Murray G. Characterisation and protein expression profiling of annexins in colorectal cancer. Br J Cancer. 2008;98(2):426–33.CrossRefPubMedGoogle Scholar
  23. 23.
    Shen J, Person MD, Zhu J, Abbruzzese JL, Li D. Protein expression profiles in pancreatic adenocarcinoma compared with normal pancreatic tissue and tissue affected by pancreatitis as detected by two-dimensional gel electrophoresis and mass spectrometry. Cancer Res. 2004;64(24):9018–26.CrossRefPubMedGoogle Scholar
  24. 24.
    Deng S, Wang J, Hou L, Li J, Chen G, Jing B, et al. Annexin A1, A2, A4 and A5 play important roles in breast cancer, pancreatic cancer and laryngeal carcinoma, alone and/or synergistically. Oncol Lett. 2013;5(1):107–12.PubMedGoogle Scholar
  25. 25.
    Kim A, Enomoto T, Serada S, Ueda Y, Takahashi T, Ripley B, et al. Enhanced expression of annexin A4 in clear cell carcinoma of the ovary and its association with chemoresistance to carboplatin. Int J Cancer. 2009;125(10):2316–22.CrossRefPubMedGoogle Scholar
  26. 26.
    Han EK-H, Tahir S, Cherian S, Collins N, Ng S. Modulation of paclitaxel resistance by annexin IV in human cancer cell lines. Br J Cancer. 2000;83(1):83–8.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Yamashita T, Nagano K, Kanasaki S-I, Maeda Y, Furuya T, Inoue M. Annexin A4 is a possible biomarker for cisplatin susceptibility of malignant mesothelioma cells. Biochem Biophys Res Commun. 2012;421(1):140–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Matsuzaki S, Enomoto T, Serada S, Yoshino K, Nagamori S, Morimoto A, et al. Annexin A4-conferred platinum resistance is mediated by the copper transporter ATP7A. Int J Cancer. 2014;134(8):1796–809.CrossRefPubMedGoogle Scholar
  29. 29.
    Choi CH, Sung CO, Kim H-J, Lee Y-Y, Song SY, Song T, et al. Overexpression of annexin A4 is associated with chemoresistance in papillary serous adenocarcinoma of the ovary. Hum Pathol. 2013;44(6):1017–23.CrossRefPubMedGoogle Scholar
  30. 30.
    Zimmermann U, Balabanov S, Giebel J, Teller S, Junker H, Schmoll D, et al. Increased expression and altered location of annexin IV in renal clear cell carcinoma: a possible role in tumour dissemination. Cancer Lett. 2004;209(1):111–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Mogami T, Yokota N, Asai-Sato M, Yamada R, Koizume S, Sakuma Y, et al. Annexin A4 is involved in proliferation, chemo-resistance and migration and invasion in ovarian clear cell adenocarcinoma cells. PLoS ONE. 2013;8(11):e80359.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Lu ZJ, Liu SY, Yao YQ, Zhou YJ, Zhang S, Dai L, et al. The effect of miR-7 on behavior and global protein expression in glioma cell lines. Electrophoresis. 2011;32(24):3612–20.CrossRefPubMedGoogle Scholar
  33. 33.
    Lin L-L, Huang H-C, Juan H-F. Revealing the molecular mechanism of gastric cancer marker annexin A4 in cancer cell proliferation using exon arrays. PLoS ONE. 2012;7(9):e44615.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Xin W, Rhodes DR, Ingold C, Chinnaiyan AM, Rubin MA. Dysregulation of the annexin family protein family is associated with prostate cancer progression. Am J Pathol. 2003;162(1):255–61.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Mozos A, Sole M, Miquel R, Petit A, Nadal A, Fernández PL. Usefulness and limitations of alpha-methylacyl-CoA racemase expression in the hepatobiliary system and pancreas: a wide tissue microarray analysis of normal and neoplastic epithelia. Anal Quant Cytol Histol. 2010;32(5):261–8.PubMedGoogle Scholar
  36. 36.
    Toyama A, Suzuki A, Shimada T, Aoki C, Aoki Y, Umino Y, et al. Proteomic characterization of ovarian cancers identifying annexin-A4, phosphoserine aminotransferase, cellular retinoic acid-binding protein 2, and serpin B5 as histology-specific biomarkers. Cancer Sci. 2012;103(4):747–55.CrossRefPubMedGoogle Scholar
  37. 37.
    Fromowitz FB, Viola MV, Chao S, Oravez S, Mishriki Y, Finkel G, et al. Ras p21 expression in the progression of breast cancer. Hum Pathol. 1987;18(12):1268–75.CrossRefPubMedGoogle Scholar
  38. 38.
    Kalluri R, Weinberg RA. The basics of epithelial-mesenchymal transition. J Clin Invest. 2009;119(6):1420–8.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Huang X, Zeng Y, Xing X, Zeng J, Gao Y, Cai Z, et al. Quantitative proteomics analysis of early recurrence/metastasis of huge hepatocellular carcinoma following radical resection. Proc Natl Acad Sci U S A. 2014;12:22.Google Scholar
  40. 40.
    Thiery JP, Acloque H, Huang RY, Nieto MA. Epithelial-mesenchymal transitions in development and disease. Cell. 2009;139(5):871–90.CrossRefPubMedGoogle Scholar
  41. 41.
    Yang J, Weinberg RA. Epithelial-mesenchymal transition: at the crossroads of development and tumor metastasis. Dev Cell. 2008;14(6):818–29.CrossRefPubMedGoogle Scholar
  42. 42.
    Kan H, Guo W, Huang Y, Liu D. MicroRNA-520g induces epithelial–mesenchymal transition and promotes metastasis of hepatocellular carcinoma by targeting SMAD7. FEBS Lett. 2015;589(1):102–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Wong T-S, Gao W, Chan JY-W. Transcription regulation of E-cadherin by zinc finger E-box binding homeobox proteins in solid tumors. Biomed Res Int. 2014;2014:921564.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Zhang W, Shi X, Peng Y, Wu M, Zhang P, Xie R, et al. HIF-1α promotes epithelial-mesenchymal transition and metastasis through direct regulation of ZEB1 in colorectal cancer. PLoS ONE. 2015;10(6):e0129603.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Yuan D, Xia H, Zhang Y, Chen L, Leng W, Chen T, et al. P-Akt/miR-200 signaling regulates epithelial-mesenchymal transition, migration and invasion in circulating gastric tumor cells. Int J Oncol. 2014;45(6):2430–8.PubMedGoogle Scholar
  46. 46.
    Yun E, Baek S, Xie D, Tseng S, Dobin T, Hernandez E, et al. DAB2IP regulates cancer stem cell phenotypes through modulating stem cell factor receptor and ZEB1. Oncogene. 2014;34(21):2741–52.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Oncology and BioMarkers (ISOBM) 2016

Authors and Affiliations

  • Wenwei Chen
    • 1
  • Lihong Chen
    • 2
    • 3
    • 4
  • Zhixiong Cai
    • 2
    • 3
  • Dong Liang
    • 2
    • 3
  • Bixing Zhao
    • 2
    • 3
  • Yongyi Zeng
    • 1
    • 2
    • 3
  • Xiaolong Liu
    • 2
    • 3
  • Jingfeng Liu
    • 1
    • 2
    • 3
  1. 1.Liver Disease Center, The First Affiliated Hospital of Fujian Medical UniversityFuzhouPeople’s Republic of China
  2. 2.The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian ProvinceMengchao Hepatobiliary Hospital of Fujian Medical UniversityFuzhouPeople’s Republic of China
  3. 3.The Liver Center of Fujian Province, Fujian Medical UniversityFuzhouPeople’s Republic of China
  4. 4.Department of PathologySchool of Basic Medical Science, Fujian Medical UniversityFuzhouPeople’s Republic of China

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