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World J Gastroenterol. Jun 28, 2006; 12(24): 3911-3914
Published online Jun 28, 2006. doi: 10.3748/wjg.v12.i24.3911
Circulating DNA level is negatively associated with the long-term survival of hepatocellular carcinoma patients
Ning Ren, Qing-Hai Ye, Lun-Xiu Qin, Bo-Heng Zhang, Yin-Kun Liu, Zhao-You Tang
Ning Ren, Qing-Hai Ye, Lun-Xiu Qin, Bo-Heng Zhang, Yin-Kun Liu, Zhao-You Tang, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Feng Lin Road, Shanghai 200032, China
Author contributions: All authors contributed equally to the work.
Supported by the National Science Fund for Distinguished Young Scholars, No. 30325041; General Program of National Natural Science Foundation of China, No. 30371378; Key Program Project of National Natural Science Foundation of China, No. 30430720; Key Program Project of Shanghai Science Technology Committee, No. 04JC14028
Correspondence to: Lun-Xiu Qin, Liver Cancer Institute and Zhongshan Hospital, Fudan University, 180 Feng Lin Road, Shanghai 200032, China. lxqin@zshospital.com
Telephone: +86-21-64041990-3056 Fax: +86-21-64037181
Received: August 31, 2005
Revised: October 15, 2005
Accepted: October 26, 2005
Published online: June 28, 2006


AIM: To quantify the circulating DNA in plasma from patients with hepatocellular carcinoma (HCC) and to evaluate its prognostic value.

METHODS: Blood samples were collected from 79 patients with HCC before operation, 20 patients with liver cirrhosis, and 20 healthy volunteers. Circulating DNA was extracted from plasma and quantified. The association between circulating DNA level and prognosis of HCC patients was evaluated.

RESULTS: Compared with the healthy volunteers (17.6 ± 9.5 ng/mL), a significant higher circulating DNA level was found in the patients with HCC (47.1 ± 43.7 ng/mL, P = 0.000) or with liver cirrhosis (30.0 ± 13.3 ng/mL, P = 0.002). The circulating DNA level was closely associated with tumor size (P = 0.008) and TNM stage (P = 0.040), negatively associated with the 3-year disease-free survival (DFS) (P = 0.017) and overall survival (OS) (P = 0.001).

CONCLUSION: Large or invasive tumor may release more circulating DNA, and higher level of circulating DNA may be associated with poor prognosis of HCC patients.

Key Words: Hepatocellular carcinoma, Prognosis, Circulating DNA


Hepatocellular carcinoma (HCC) is one of the most common and aggressive malignancies worldwide, and has been ranked the 2nd cancer killer in China since 1990s. The age-standardized mortality rate in China is as high as 34.7/100 000, accounting for 53% of all liver cancer deaths worldwide[1]. Although encouraging long-term survival of HCC patients has been obtained in some clinical centers, recurrence after surgical resection remains one of the major obstacles to further prolonging survival of HCC patients and the overall dismal outcome of patients with HCC has not been completely changed[2,3]. The extremely poor prognosis of HCC is largely due to a high rate of recurrence after surgery or intra-hepatic metastases that develop through invasion of the portal vein or spread to other parts of the liver[4,5].

Identifying biomarker with prognostic significance, especially for predicting recurrence has become an important aspect in HCC study[6]. Since patients with cancers, particularly with high metastatic potential, tend to have higher levels of DNA in plasma, and the molecular biologic findings of circulating DNA in cancer patients are mimicked to those of cancer cells, plasma DNA may be a candidate because of its less invasiveness, simple manipulation, and prognostic information available before operation[7,8]. Few reports have shown the existence of circulating DNA in HCC patients[9-11]. However, the association between circulating DNA level and prognosis of HCC patients is still unclear. In this study, we quantified the circulating DNA in plasma from patients with HCC and evaluated its prognostic value.

Patients and their clinicopathological characteristics

Seventy-nine patients who received surgical treatment for HCC at Liver Cancer Institute (Zhongshan Hospital) of Fudan University during August-December 2001 were enrolled in this study. The mean age of the patients was 51 years (range 21-83 years). All the patients had a normal liver function preoperatively. All tumors were histopathologically diagnosed as HCC (Table 1). TNM stages of the patients were classified according to the UICC TNM classification of primary liver cancer (6th edition)[12]. All the 79 patients were given informed consent and followed up till January 2005.

Table 1 Circulating DNA level and clinicopathological features of HCC patients.
VariablenCirculating DNA level
Tumor number0.26
Tumor size0.008
≤ 5 cm441727
> 5 cm352411
Tumor capsule0.9
Vascular invasion0.179
Serum AFP0.79
≤ 20 μg/L241311
> 20 μg/L552827
TNM stage0.04
3-yr DFS0.008
3-yr OS0
Sample collection

Peripheral blood samples (5 mL) were collected from the HCC patients before surgical operation and put into an EDTA tube. Blood samples from 20 patients with compensated liver cirrhosis (histopathologically diagnosed by biopsy) and 20 healthy volunteers were collected as control. The blood samples were centrifuged at 3000 r/min for 10 min to separate buff coats and plasma. An additional centrifugation for 10 min was performed to produce cell-free plasma. Blood samples were then stored at -80°C prior to DNA extraction.

Plasma DNA quantification

Plasma and control lymphocyte DNAs were extracted with QIAamp® DNA Blood Midi Kit (Qiagen, Hilden, Germany) according to the blood and body fluid protocol of the manufacturer. Two milliliters of plasma was used, a DNA elution volume of 300 μL was obtained after extraction, and 10 μL of plasma DNA was mixed with equivalence 1:3000 SYBR green I (fluorescence dye). The mixture was analyzed by ultraviolet transilluminator system and photographed under stimulating wave of 345 nm and absorbing wave of 500 nm. The diagram was analyzed by software system to read its intensity[13]. The quantity of plasma DNA was calculated by regression equation which was established by intensity of standard DNA content.

Statistical analysis

Results were expressed as mean ± SD. Fisher’s exact test was used to compare qualitative data. P < 0.05 was considered statistically significant. Continuous variables were transformed into dichotomous variables before survival analysis. Student’s t-test was used for mean comparisons. Patients’ survival was calculated from the data of operation to the data of death or to the data of point. Survival curves were estimated according to the method of Kaplan-Meier and compared with a log-rank test. To identify the factors that might be of independent significance in influencing the disease-free survival (DFS) or overall survival (OS), a Cox stepwise proportional risk regression model was fitted. All statistical analyses were performed with Stata (version 7) statistical software.


Compared with the healthy volunteers (17.6 ± 9.5 ng/mL), a significant higher circulating plasma DNA level was found in the patients with HCC (47.1 ± 43.7 ng/mL, P = 0.000) or with liver cirrhosis (30.0 ± 13.3 ng/mL, P = 0.002). However, no significant difference was found in the circulating plasma DNA levels between the patients with HCC and liver cirrhosis (P = 0.191).

When we used 36.6ng/mL (mean healthy volunteers +2*SD)[14] as cutoff point of circulating DNA level, the 79 HCC patients were divided into high plasma DNA level group (HDNA) (≥ 36.6 ng/mL) and low plasma DNA level group (LDNA) (< 36.6 ng/mL). Significant differences were found in tumor size (P = 0.008) and TNM stage (P = 0.040) between the two groups of HCC patients (Table1).

The 3-year DFS rates for HDNA group and LDNA group were 22% and 47% respectively (P = 0.008), while the 3-year OS rates were 24% and 61% respectively (P = 0.000) (Table1). High circulating DNA level was independently associated with a poorer DFS and OS (P = 0.004, P = 0.000) (Figures 1A and 1B).

Figure 1
Figure 1 Disease-free (A) and overall survival (B) curves for HCC patients evaluated according to circulating DNA level. HDNA: High plasma DNA level ( ≥ 36.6 ng/mL); LDNA: Low plasma DNA level (< 36.6 ng/mL); DFS: Disease-free survival; OS: Overall survival.

The first discovery of extracellular nucleic acids in the circulation was reported in 1948 by Mandel and Métais[15], who demonstrated the presence of both DNA and RNA in the plasma of healthy and sick individuals. This work was particularly remarkable as it was reported only 4 years after the demonstration of DNA as the material of inheritance[16], and it even preceded the landmark paper by Watson and Crick[17] on the double helical structure of DNA. However, their work did not attract much attention, and further development of the field had to wait some 30 years until Leon[18] showed that cancer patients have much higher concentration of circulating DNA than those with non-malignant disease, which is decreased in some cases after anti-cancer therapy. Since then, several follow-up studies have been done to establish the possible value of free circulating DNA as a prognostic factor in patients with pancreatic carcinoma[19], esophageal adenocarcinoma[20], lung cancer[21], melanoma[22] and nasopharyngeal carcinoma[23].

Both plasma and serum samples have frequently been used in the analysis of cell-free DNA. Of particular interest is that the concentrations in serum samples are significantly higher than those in matched plasma samples, which is mainly generated in vitro by lysis of white blood cells, suggesting that serum is not suitable for monitoring the concentration of cell-free DNA[24]. A recent work performed a quantitative comparison of matched serum and plasma DNA in patients with colorectal liver metastases and found that serum and plasma DNA level is not correlated with colorectal liver metastases. Furthermore, while serum DNA is significantly associated with the presence of metastases, only plasma DNA is predictive of recurrence, indicating that serum DNA might represent an indirect but tumor-related process, and that plasma DNA better reflects the in vivo levels of circulating DNA[14]. Different blood processing protocol may also influence the level of circulating DNA[25]. The plasma obtained by centrifugation alone at various speeds, without subsequent microcentrifugation, has been shown to have substantial amounts of cellular components which may led to the detection of aberrantly high total concentrations of plasma DNA[26]. Therefore, in our study, an additional centrifuge for 10 min was performed to produce cell-free plasma. In order to exclude interference of cell death caused by hepatitis or liver resection, normal liver function test is required for patients’ blood sample collection before operation.

In our study, according to the cutoff point of circulating DNA level, the 79 HCC patients were divided into high plasma DNA level group (HDNA) and low plasma DNA level group (LDNA). In HDNA group, 59% (24 of 41) patients had tumor size larger than 5cm while there were only 29% (11 of 38) patients had tumor size larger than 5cm in LDNA group (P = 0.008). We also observed that there were 49% (20 of 41) patients with TNM stage III/IV in HDNA group, while there were only 26% (10 of 38) patients with TNM stage III/IV in LDNA group (P = 0.040). The mean circulating plasma DNA level was significantly associated with tumor size and TNM stage, indicating that large or invasive tumor may release more circulating DNA and higher level of plasma circulating DNA may be associated with poor prognosis.

Multivariate analysis further confirmed that high circulating DNA level was an independent predictor for poorer 3-year DFS and OS. Furthermore, among patients with TNM stage III or IV, there was no remarkable difference in the 3-year DFS and 3-year OS between HDNA group and LDNA group (P = 1.000, P = 0.448), while among patients with TNM stage I or II, the 3-year DFS and 3-year OS of patients with HDNA were 24% (5/21) and 38% (8/21), which were much lower than those of patients with LDNA, the 3-year DFS was 57% (16/28) (P = 0.020), the 3-year OS was 75% (21/28) (P = 0.009). These data suggest that circulating DNA level is negatively associated with the long-term survival of hepatocellular carcinoma patients and might be supplementary to traditional TNM staging.

In conclusion, circulating DNA in liver cancers opens a new research area and eventually be comes a suitable source for development of noninvasive diagnostic methods for HCC.


S- Editor Wang J L- Editor Wang XL E- Editor Ma WH

1.  Pisani P, Parkin DM, Bray F, Ferlay J. Erratum: Estimates of the worldwide mortality from 25 cancers in 1990. Int. J. Cancer, 83, 18-29 (1999). Int J Cancer. 1999;83:870-873.  [PubMed]  [DOI]
2.  Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics, 2001. CA Cancer J Clin. 2001;51:15-36.  [PubMed]  [DOI]
3.  Tang ZY. Hepatocellular carcinoma--cause, treatment and metastasis. World J Gastroenterol. 2001;7:445-454.  [PubMed]  [DOI]
4.  Yuki K, Hirohashi S, Sakamoto M, Kanai T, Shimosato Y. Growth and spread of hepatocellular carcinoma. A review of 240 consecutive autopsy cases. Cancer. 1990;66:2174-2179.  [PubMed]  [DOI]
5.  Genda T, Sakamoto M, Ichida T, Asakura H, Kojiro M, Narumiya S, Hirohashi S. Cell motility mediated by rho and Rho-associated protein kinase plays a critical role in intrahepatic metastasis of human hepatocellular carcinoma. Hepatology. 1999;30:1027-1036.  [PubMed]  [DOI]
6.  Qin LX, Tang ZY. The prognostic significance of clinical and pathological features in hepatocellular carcinoma. World J Gastroenterol. 2002;8:193-199.  [PubMed]  [DOI]
7.  Anker P, Mulcahy H, Stroun M. Circulating nucleic acids in plasma and serum as a noninvasive investigation for cancer: time for large-scale clinical studies. Int J Cancer. 2003;103:149-152.  [PubMed]  [DOI]
8.  Stroun M, Anker P, Maurice P, Lyautey J, Lederrey C, Beljanski M. Neoplastic characteristics of the DNA found in the plasma of cancer patients. Oncology. 1989;46:318-322.  [PubMed]  [DOI]
9.  Wong IH, Zhang J, Lai PB, Lau WY, Lo YM. Quantitative analysis of tumor-derived methylated p16INK4a sequences in plasma, serum, and blood cells of hepatocellular carcinoma patients. Clin Cancer Res. 2003;9:1047-1052.  [PubMed]  [DOI]
10.  Chang YC, Ho CL, Chen HH, Chang TT, Lai WW, Dai YC, Lee WY, Chow NH. Molecular diagnosis of primary liver cancer by microsatellite DNA analysis in the serum. Br J Cancer. 2002;87:1449-1453.  [PubMed]  [DOI]
11.  Niu Q, Tang ZY, Qin LX, Ma ZC, Zhang LH. Loss of heterozygosity at D14S62 and D14S51 detected by a simple and non-radioactive method in plasma DNA is a potential marker of metastasis and recurrence after curative hepatic resection in hepatocellular carcinoma. Hepatogastroenterology. 2003;50:1579-1582.  [PubMed]  [DOI]
12.  Sobin LH, Wittekind CH.  TNM Classification of Malignant Tumours, 6th Ed. New York: Wiley-Liss 2002; 81-83.  [PubMed]  [DOI]
13.  Vitzthum F, Geiger G, Bisswanger H, Brunner H, Bernhagen J. A quantitative fluorescence-based microplate assay for the determination of double-stranded DNA using SYBR Green I and a standard ultraviolet transilluminator gel imaging system. Anal Biochem. 1999;276:59-64.  [PubMed]  [DOI]
14.  Thijssen MA, Swinkels DW, Ruers TJ, de Kok JB. Difference between free circulating plasma and serum DNA in patients with colorectal liver metastases. Anticancer Res. 2002;22:421-425.  [PubMed]  [DOI]
15.  Mandel P, Métais P. Les acides nucléiques du plasma sanguin chez l’homme. CR. Acad Sci Paris. 1948;142:241-243.  [PubMed]  [DOI]
16.  Avery OT, MacLeod CM, McCarty M. Studies on the chemical nature of the substance inducing transformation of pneumococcal types. Induction of transformation by a desoxyribonucleic acid fraction isolated from Pneumococcus type III. 1944. Mol Med. 1995;1:344-365.  [PubMed]  [DOI]
17.  WATSON JD, CRICK FH. Molecular structure of nucleic acids; a structure for deoxyribose nucleic acid. Nature. 1953;171:737-738.  [PubMed]  [DOI]
18.  Leon SA, Shapiro B, Sklaroff DM, Yaros MJ. Free DNA in the serum of cancer patients and the effect of therapy. Cancer Res. 1977;37:646-650.  [PubMed]  [DOI]
19.  Castells A, Puig P, Móra J, Boadas J, Boix L, Urgell E, Solé M, Capellà G, Lluís F, Fernández-Cruz L. K-ras mutations in DNA extracted from the plasma of patients with pancreatic carcinoma: diagnostic utility and prognostic significance. J Clin Oncol. 1999;17:578-584.  [PubMed]  [DOI]
20.  Kawakami K, Brabender J, Lord RV, Groshen S, Greenwald BD, Krasna MJ, Yin J, Fleisher AS, Abraham JM, Beer DG. Hypermethylated APC DNA in plasma and prognosis of patients with esophageal adenocarcinoma. J Natl Cancer Inst. 2000;92:1805-1811.  [PubMed]  [DOI]
21.  Sozzi G, Conte D, Mariani L, Lo Vullo S, Roz L, Lombardo C, Pierotti MA, Tavecchio L. Analysis of circulating tumor DNA in plasma at diagnosis and during follow-up of lung cancer patients. Cancer Res. 2001;61:4675-4678.  [PubMed]  [DOI]
22.  Taback B, Fujiwara Y, Wang HJ, Foshag LJ, Morton DL, Hoon DS. Prognostic significance of circulating microsatellite markers in the plasma of melanoma patients. Cancer Res. 2001;61:5723-5726.  [PubMed]  [DOI]
23.  Lin JC, Wang WY, Chen KY, Wei YH, Liang WM, Jan JS, Jiang RS. Quantification of plasma Epstein-Barr virus DNA in patients with advanced nasopharyngeal carcinoma. N Engl J Med. 2004;350:2461-2470.  [PubMed]  [DOI]
24.  Lee TH, Montalvo L, Chrebtow V, Busch MP. Quantitation of genomic DNA in plasma and serum samples: higher concentrations of genomic DNA found in serum than in plasma. Transfusion. 2001;41:276-282.  [PubMed]  [DOI]
25.  Taback B, O'Day SJ, Hoon DS. Quantification of circulating DNA in the plasma and serum of cancer patients. Ann N Y Acad Sci. 2004;1022:17-24.  [PubMed]  [DOI]
26.  Chiu RW, Poon LL, Lau TK, Leung TN, Wong EM, Lo YM. Effects of blood-processing protocols on fetal and total DNA quantification in maternal plasma. Clin Chem. 2001;47:1607-1613.  [PubMed]  [DOI]