Feng YF, Zhou HK, Hu BB, Wang H, Liang HK, Wei L, Li QM, Su TM, Yin QB, Su MH, Jiang JN. Evaluating serum extra spindle pole bodies-like 1 protein vs p53 antibody for hepatitis B virus-related hepatocellular carcinoma diagnosis. World J Hepatol 2025; 17(7): 108850 [DOI: 10.4254/wjh.v17.i7.108850]
Corresponding Author of This Article
Jian-Ning Jiang, MD, PhD, Chief Physician, Professor, Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, China. gxjjianning@163.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Case Control Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Yan-Fei Feng, Hui-Kun Zhou, Bo-Bin Hu, Hang Wang, Heng-Kai Liang, Lu Wei, Qing-Mei Li, Tu-Mei Su, Qian-Bing Yin, Ming-Hua Su, Jian-Ning Jiang, Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
Jian-Ning Jiang, Guangxi Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor, Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
Jian-Ning Jiang, Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education, Nanning 530021, Guangxi Zhuang Autonomous Region, China
Co-corresponding authors: Ming-Hua Su and Jian-Ning Jiang.
Author contributions: Feng YF and Zhou HK contributed equally to this work; Su MH and Jiang JN have made crucial and indispensable contributions towards the completion of the project and thus qualified as co-corresponding authors; Feng YF, Zhou HK, Hu BB, Wang H, Liang HK, Wei L, Li QM, Su TM, and Yin QB performed the research and analyzed the data; Feng YF and Zhou HK analyzed the data and wrote the manuscript; Su MH and Jiang JN designed and supervised the study; All authors read and approved the final version.
Supported by National Natural Science Foundation of China, No. 81960115, No. 82160123 and No. 82260124; Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education, No. GKE-ZZ202107; Guangxi Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor, No. GKE-ZZ202218; and Guangxi Science and Technology Program, No. AD25069077.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of the First Affiliated Hospital of Guangxi Medical University (Approval No. 2025-E0320).
Informed consent statement: Consent was not obtained but the presented data are anonymized and risk of identification is low.
Conflict-of-interest statement: There are no conflicts of interest to disclose.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Data sharing statement:
No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jian-Ning Jiang, MD, PhD, Chief Physician, Professor, Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, China. gxjjianning@163.com
Received: April 25, 2025 Revised: May 31, 2025 Accepted: June 25, 2025 Published online: July 27, 2025 Processing time: 92 Days and 1.5 Hours
Abstract
BACKGROUND
Hepatitis B virus (HBV) infection is a leading cause of global hepatocellular carcinoma (HCC). Conventional biomarkers such as alpha-fetoprotein (AFP) demonstrate suboptimal sensitivity and specificity. Emerging evidence suggests that serum extra spindle pole bodies like 1 (ESPL1) protein and p53 antibody may improve diagnostic accuracy.
AIM
To assess and compare the diagnostic performance of serum ESPL1 protein and p53 antibody in HBV-related HCC (HBV-HCC).
METHODS
This case-control study from the First Affiliated Hospital of Guangxi Medical University enrolled 30 patients with chronic hepatitis B (CHB), 30 with HBV-related liver cirrhosis (HBV-LC), 55 with HBV-HCC, and 30 healthy controls. Serum ESPL1 protein and p53 antibody levels were quantified via ELISA. Diagnostic performance was evaluated using receiver operating characteristic (ROC) curve analysis, including sensitivity, specificity, and correlation with AFP.
RESULTS
Serum ESPL1 protein levels progressively increased across disease stages (CHB: 89.9 ng/L; HBV-LC: 188.83 ng/L; HBV-HCC: 317.63 ng/L), with a significantly higher area under the ROC curve (AUC = 0.917) than either p53 antibody (AUC = 0.725) or AFP (AUC = 0.678). p53 antibody levels were significantly elevated only in the HBV-HCC group. ESPL1 demonstrated superior sensitivity and concordance with histopathological findings. A significant correlation between ESPL1 and p53 antibody levels was observed exclusively in the HBV-HCC group (r = 0.320, P = 0.017), suggesting potential interplay in malignant transformation.
CONCLUSION
Serum ESPL1 protein, a promising biomarker for early HBV-HCC detection, outperforms p53 antibody in diagnostic reliability. Higher ESPL1 levels correlate with increased HCC risk in chronic HBV patients.
Core Tip: This study evaluates serum extra spindle pole bodies-like 1 (ESPL1) protein as a diagnostic biomarker for hepatitis B virus-related hepatocellular carcinoma (HBV-HCC), demonstrating superior sensitivity and accuracy compared to p53 antibody and alpha-fetoprotein (AFP). ESPL1 levels progressively increase from chronic hepatitis B to cirrhosis and HCC, correlating with disease progression. Mechanistically, ESPL1 overexpression due to HBV integration drives chromosomal instability, promoting oncogenesis. These findings support ESPL1 as a promising biomarker for early HBV-HCC detection. The study also suggests that ESPL1 may complement AFP in clinical settings, offering enhanced diagnostic reliability and supporting its potential as a novel candidate for HBV-HCC early detection.
Citation: Feng YF, Zhou HK, Hu BB, Wang H, Liang HK, Wei L, Li QM, Su TM, Yin QB, Su MH, Jiang JN. Evaluating serum extra spindle pole bodies-like 1 protein vs p53 antibody for hepatitis B virus-related hepatocellular carcinoma diagnosis. World J Hepatol 2025; 17(7): 108850
Hepatocellular carcinoma (HCC) is the sixth most commonly diagnosed malignancy worldwide and ranks as the third leading cause of cancer-related death[1]. In China, hepatitis B virus (HBV) infection is the primary etiological factor underlying HCC development[2]. Although antiviral therapies have reduced the incidence of HBV-related HCC (HBV-HCC), a significant proportion of patients with chronic HBV infection still progress to HCC[3].
Integration of HBV DNA into the host genome plays a pivotal role in HBV-HCC tumorigenesis[4]. These integration events often occur early in infection, triggering diverse molecular alterations that profoundly affect disease outcomes[5]. Notably, HBV genomic elements such as Direct Repeat 1, Direct Repeat 2, and the Basal Core Promoter have been shown to disrupt host chromosomal integrity and gene regulation, thereby promoting malignant transformation[6,7].
Several serum biomarkers, such as alpha-fetoprotein (AFP), AFP-L3, des-gamma-carboxy prothrombin (DCP), glypican 3 (GPC3), and golgi protein 73 (GP73), have been investigated for HBV-HCC diagnosis[8,9]. However, these markers' suboptimal sensitivity and specificity underscore the urgent need for more accurate diagnostic tools.
In a previous study[10], Alu-PCR analysis detected integration of the HBV S gene in 80% (8/10) of HBV-HCC patients. Further sequence analysis revealed that 75% (6/8) of these cases harbored a fusion of the HBV S gene with the human extra ESPL1 gene. ESPL1 encodes a cysteine endopeptidase essential for sister chromatid separation during mitosis. The resulting fusion gene product, evaluates serum extra spindle pole bodies-like 1 (ESPL1) protein, is secreted into the bloodstream and shows a progressive increase during disease progression, often preceding clinical diagnosis, and subsequently declines following tumor resection[11]. These findings suggest that serum ESPL1 protein may serve as a novel biomarker for early detection of HBV-HCC[12].
The tumor suppressor gene TP53 is frequently mutated in HCC[13,14]. Loss of wild-type p53 protein function disrupts cell cycle regulation, impairs DNA repair mechanisms, and compromises apoptotic pathways, thereby promoting tumor progression[15-18]. Therefore, the mutant p53 protein has attracted interest as a potential biomarker. Since wild-type p53 protein is weakly immunogenic, the presence of circulating p53 antibody reflects the expression of its mutated form[19-21]. As such, p53 antibody testing offers a relatively simple, non-invasive surrogate for TP53 mutation detection and may aid in HCC diagnosis and monitoring[22,23].
Guided by these findings, the present study investigates serum ESPL1 protein and mutated p53 antibody levels in patients at different stages of chronic HBV infection, examining their correlation and diagnostic performance. In addition, conventional biomarkers such as AFP and p53 immunohistochemistry (IHC) serve as references to evaluate the reliability and clinical utility of ESPL1 and p53 antibody detection in accurately diagnosing HBV-HCC.
MATERIALS AND METHODS
Study patients
All participants were selected from a longitudinal cohort with HBV infection at the First Affiliated Hospital of Guangxi Medical University, covering the period from 2002 to 2022. As this was a retrospective study based on existing clinical records, a priori power calculation was not applicable. Instead, all eligible cases (n = 145) that met the inclusion criteria were analyzed to enhance statistical robustness. The cohort size aligns with comparable studies in the literature[11]. To minimize bias, we used a well-defined cohort with clear criteria. Lab measurements were blinded, and standardized protocols ensured consistent data collection and analysis. Medical records were reviewed for accurate disease and exposure information. The institutional Ethics Committee approved the study (Approval No. 2025-E0320) conducted by the Declaration of Helsinki (1975), revised in 2024.
Study design
Participants aged 18–70 years were classified into four groups: CHB, HBV-related liver cirrhosis (HBV-LC), HBV-HCC, and healthy controls. Each subject provided 5 mL of peripheral venous blood, and serum samples were stored at −80 °C until analysis. An overview of the experimental workflow is presented in Figure 1.
Figure 1 Research flowchart outlining participant enrollment, group allocation, and biomarker analysis.
CHB: Chronic hepatitis B; HBV-LC: Hepatitis B virus-related liver cirrhosis; HBV-HCC: Hepatitis B virus-related hepatocellular carcinoma; ESPL1: Extra spindle pole bodies-like 1; AFP: Alpha-fetoprotein; IHC: Immunohistochemistry; ROC: Receiver operating characteristic.
Inclusion criteria: (1) CHB group: Hepatitis B surface antigen (HBsAg) positivity with no imaging evidence of cirrhosis or regenerative nodules[24]; (2) HBV-LC group: HBsAg positivity with cirrhosis confirmed via histology or imaging [ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), or elastography][24]; (3) HBV-HCC group: HBsAg positivity with diagnosis of HCC confirmed by pathology or at least two imaging modalities (ultrasound, CT, MRI)[25]; and (4) Healthy controls: HBsAg-negative with no history of liver or systemic disease.
Exclusion criteria: Age < 18 or > 70 years, co-infection with other hepatitis viruses, LC or HCC of non-HBV etiology (alcohol, drugs, or other causes), concurrent malignancies and incomplete data. Participants who did not meet the inclusion criteria were not enrolled in the study. Reasons for non-participation at each stage were not systematically collected, but non-participation was primarily due to failure to meet the inclusion criteria.
Biomarker assays and histopathological evaluation
Serum ESPL1 concentrations were quantified using a commercial ELISA kit (Jianglai Biotechnology, Shanghai, China; linear range: 0–400 ng/L). The assay was performed according to the manufacturer's protocol. Briefly, samples and blanks were loaded into a 96-well plate, followed by incubation with enzyme-conjugated reagents, substrate development, and absorbance reading at 450 nm. Only plates yielding a standard curve with R² ≥ 0.99 were considered valid. Serum mutant p53 antibody levels were measured using a separate ELISA kit (Huamei Biotechnology, Henan, China; linear range: 0–100 ng/mL) following similar procedures. AFP levels were measured in the institutional clinical laboratory, while the Department of Pathology conducted p53 IHC using surgically resected HCC tissues.
Statistical analysis
Statistical analyses were performed using SPSS 22.0, GraphPad Prism 8, and MedCalc. Normally distributed data are presented as mean ± SD, while non-normally distributed variables are expressed as median (interquartile range). The Kruskal-Wallis test assessed intergroup differences in ESPL1 and p53 antibody levels. Spearman's rank correlation was employed to evaluate associations between ESPL1 and p53 antibody. Receiver operating characteristic (ROC) curves were generated to compare the diagnostic efficacy of ESPL1, p53 antibody, and AFP. The maximum Youden index (the sum of sensitivity and specificity minus 1) determined optimal cut-off values. Concordance between serum biomarkers and p53 IHC results was analyzed using paired χ2 tests. Statistical significance was set at P < 0.05.
RESULTS
General characteristics of the study population
A total of 145 eligible participants were included in the study: 30 with CHB (mean age 44.0 ± 7.8 years, 53.3% male), 30 with HBV-LC (mean age 45.9 ± 6.8 years, 66.7% male), 55 with HBV-HCC (mean age 55.3 ± 9.5 years, 92.7% male), and 30 healthy controls (mean age 40.5 ± 12.0 years, 43.3% male; Table 1).
Table 1 The characteristics of study subjects, n (%)/mean ± SD.
Healthy control group
CHB group
HBV-LC group
HBV-HCC group
Number (n)
30
30
30
55
Age (year)
40.5 ± 12.0
44.0 ± 7.8
45.9 ± 6.8
55.3 ± 9.5
Male
13 (43.3)
16 (53.3)
20 (66.7)
51 (92.7)
Follow-up time (year)
_
6.5
4.5
10.8
Comparison of serum ESPL1 protein and p53 antibody levels among groups
Serum ESPL1 protein levels were significantly elevated in the HBV-HCC group compared to the HBV-LC (317.63 vs 188.83 ng/L, P < 0.01), CHB (317.63 vs 89.90 ng/L, P < 0.001), and healthy control groups (317.63 vs 43.84 ng/L, P < 0.001). Additionally, ESPL1 levels in HBV-LC patients were significantly higher than those in the CHB (188.83 vs 89.90 ng/L, P < 0.05) and healthy control groups (188.83 vs 43.84 ng/L, P < 0.001). The CHB group also showed significantly higher ESPL1 levels than healthy controls (89.90 vs 43.84 ng/L, P < 0.01; Figure 2A).
Figure 2 Comparison of serum biomarker levels among study groups assessed by Kruskal-Wallis test.
A: The level of serum extra spindle pole bodies-like 1 (ESPL1) protein; B: The level of serum p53 antibody. ESPL1: Extra spindle pole bodies-like 1 CHB: Chronic hepatitis B; HBV-LC: Hepatitis B virus-related liver cirrhosis; HBV-HCC: Hepatitis B virus-related hepatocellular carcinoma; ns: Not significant.
In contrast, serum p53 antibody levels were significantly elevated only in the HBV-HCC group, with higher levels than both the HBV-LC (6.03 vs 1.81 ng/mL, P < 0.01), CHB (6.03 vs 2.00 ng/mL, P < 0.01), and healthy control groups (6.03 vs 1.42 ng/mL, P < 0.001). No significant differences were observed between the HBV-LC and CHB groups (1.81 vs 2.00 ng/mL, P = 1.00), HBV-LC and healthy controls (1.81 vs 1.42 ng/mL, P = 0.082), or between CHB and healthy controls (2.00 vs 1.42 ng/mL, P = 0.050; Figure 2B).
Correlation analysis of serum ESPL1 protein and p53 antibody expression levels in the experimental group
No significant correlation was found between serum ESPL1 protein and p53 antibody levels in the CHB or HBV-LC groups (P > 0.05; Figure 3A and B). However, a moderate positive correlation was observed in the HBV-HCC group (r = 0.320, P = 0.017), suggesting a potential link between these biomarkers in the malignant phase of disease progression (Figure 3C).
Figure 3 Scatter plots illustrating the correlation between serum extra spindle pole bodies-like 1 protein and p53 antibody levels.
A: In chronic hepatitis B group; B: In hepatitis B virus (HBV)-related liver cirrhosis group; C: In HBV-related hepatocellular carcinoma group. ESPL1: Extra spindle pole bodies-like 1.
Comparison and reliability analysis of diagnostic value of serum ESPL1 protein, p53 antibody and AFP in HBV-HCC
Among the 55 patients with HBV-HCC, serum ESPL1 protein showed the highest positivity rates across all stratified subgroups, regardless of AFP or p53 antibody status (Figure 4). ESPL1 antibody positivity was higher than p53 antibody positivity regardless of AFP status (Figure 4A and D). ESPL1 positivity exceeded that of AFP irrespective of p53 antibody expression (Figure 4B and E). Similarly, p53 antibody positivity was higher than AFP positivity regardless of ESPL1 status (Figure 4C and F).
Figure 4 Expression patterns of serum extra spindle pole bodies-like 1 protein, p53 antibody, and alpha-fetoprotein with hepatitis B virus-related hepatocellular carcinoma.
In the 55 patients diagnosed with hepatitis B virus hepatitis B virus-hepatocellular carcinoma, 49 (89.1%) were extra spindle pole bodies-like 1-positive, 35 (63.6%) were p53 antibody-positive, and 26 (47.3%) were alpha-fetoprotein-positive. A: In the 26 alpha-fetoprotein (AFP)-positive patients, 25 (96.2%) were extra spindle pole bodies-like 1 (ESPL1)-positive and 19 (73.1%) were p53 antibody-positive; B: In the 35 p53 antibody-positive patients, 32 (91.4%) were ESPL1-positive and 19 (54.5%) AFP-positive; C: In the 49 ESPL1-positive patients, 32 (65.3%) were p53 antibody-positive and 25 (51.0%) were AFP-positive. D: In the 29 AFP-negative patients, 24 (82.8%) were ESPL1-positive and 16 (55.2%) were p53 antibody-positive; E: In the 20 p53 antibody-negative patients, 17 (85.0%) tested positive for ESPL1, whereas 7 (35.0%) were AFP-positive; F: In the 6 ESPL1-negative patients, 3 (50.0%) were p53 antibody-positive, and 1 (16.7%) was AFP-positive. ESPL1: Extra spindle pole bodies-like 1; AFP: Alpha-fetoprotein.
ROC curve analysis revealed that serum ESPL1 protein achieved a significantly greater AUC compared to p53 antibody (0.917 vs 0.725, P < 0.05) and AFP (0.917 vs 0.678, P < 0.05). No significant difference was observed between the p53 antibody and AFP (0.725 vs 0.678, P > 0.05). The Youden index of ESPL1 is closer to 1. The sensitivity, overall diagnostic accuracy, and negative predictive value were all significantly higher for ESPL1 than for the other two markers (P < 0.05). ESPL1 also demonstrated the lowest false negative rate (FNR). However, no significant differences were observed in specificity, false positive rate, or positive predictive value among the three biomarkers (Figure 5, Tables 2 and 3).
Figure 5 Receiver operating characteristic curves of serum extra spindle pole bodies-like 1, p53 antibody and alpha-fetoprotein for diagnosing hepatitis B virus-related hepatocellular carcinoma.aP < 0.05 vs p53 antibody; bP < 0.05 vs alpha-fetoprotein. ESPL1: Extra spindle pole bodies-like 1; AFP: Alpha-fetoprotein; AUC: Area under the receiver operating characteristic curve.
Table 2 Receiver operating characteristic curve analysis of serum biomarkers in the diagnosis of HBV-related hepatocellular carcinoma.
Analysis of the relationship between serum ESPL1 protein, p53 antibody, AFP, and the concordance rate of p53 protein IHC in HBV-HCC tissue
Among the 35 HBV-HCC patients who underwent surgical resection, p53 protein IHC staining of HBV-HCC tissues was positive in 85.7% of cases. When p53 IHC was used as a diagnostic reference, serum ESPL1 protein demonstrated significantly higher concordance than either p53 antibody or AFP (P < 0.05). No significant difference was found between the concordance rates of p53 antibody and AFP (P > 0.05; Table 4). These findings reinforce the superior reliability of ESPL1 as a non-invasive diagnostic marker for HBV-HCC.
Table 4 Correlation analysis between serum biomarkers and p53 immunohistochemistry concordance in hepatocellular carcinoma tissue.
The ESPL1 gene encodes a cysteine endopeptidase crucial for the stable cohesion and subsequent separation of sister chromatids during mitotic metaphase and anaphase[26]. Integrating HBV DNA into the ESPL1 genomic locus can aberrantly activate ESPL1 transcription, resulting in overexpression and extracellular secretion of ESPL1 protein into the bloodstream, where it becomes detectable in serum[11]. Pathological overexpression of ESPL1 disrupts mitotic checkpoint control, leading to chromatid segregation errors, multipolar spindle formation, and chromosomal instability—hallmarks of oncogenic transformation[27,28]. This process fosters aneuploidy and uncontrolled clonal proliferation, functionally linking ESPL1 dysregulation to hepatocarcinogenesis[12,29]. Our results corroborate this mechanism, supporting the use of serum ESPL1 protein as a minimally invasive molecular biomarker for the early detection of HBV-HCC.
Simultaneously, the tumor suppressor TP53 plays a central role in maintaining genomic integrity by regulating DNA repair, cell cycle arrest, and apoptosis[30,31]. TP53 mutations compromise these regulatory functions and are commonly implicated in tumorigenesis. Although mutated p53 protein can be detected in liver tumor tissues via IHC[23,32,33], its clinical applicability is limited by the invasive nature of tissue acquisition and inconsistent expression. Alternatively, anti-p53 antibody in peripheral blood represent a non-invasive surrogate reflecting the host immune response to mutant p53 antigens[22,23]. However, their diagnostic sensitivity, particularly in early-stage HCC, remains suboptimal and underexplored in HBV-HCC.
Our data demonstrate a gradual increase in serum ESPL1 protein levels across disease stages, from CHB to HBV-LC and finally to HBV-HCC, indicating a dynamic correlation with disease progression. In contrast, p53 antibody levels remained relatively low in CHB and HBV-LC, rising significantly only in the HBV-HCC group (Figure 2). This pattern aligns with findings from Feng et al[32] and Wang et al[11], who reported increasing ESPL1 levels with HBV-related liver disease progression. Likewise, studies by Atta et al[33] and El Azm et al[34] confirmed elevated p53 antibody levels in HCC patients relative to LC and healthy controls. It must be acknowledged that the diagnostic utility of p53 antibody in HBV-HCC is constrained by its indirect detection of TP53 mutations and variable host immune responses[19,22]. Its limited sensitivity in early-stage HCC[23] explains its inferior performance vs ESPL1, which shows progressive elevation from CHB to HBV-HCC.
Mechanistically, the progressive rise in serum ESPL1 may reflect the cumulative effect of persistent overexpression following HBV integration. Aberrant ESPL1 activity promotes chromosomal instability, leading to genomic damage and subsequent TP53 inactivation, facilitating mutated p53 accumulation and immune recognition[27,35]. These events may represent a sequential oncogenic cascade, wherein ESPL1 overexpression precedes TP53 mutation and p53 antibody generation (Figure 6). This model explains why p53 antibodies do not rise until later stages and why ESPL1 and p53 antibody levels correlate positively only in HBV-HCC (Figure 3C).
Figure 6 Proposed mechanism of accumulative effects involving extra spindle pole bodies-like 1 gene integration and mutated p53 protein overexpression in the progression to hepatitis B virus-related hepatocellular carcinoma.
Comparison with AFP, a conventional biomarker for HBV-HCC, further supports the diagnostic value of ESPL1. In our cohort, ESPL1 demonstrated superior AUC values and Youden index scores compared to p53 antibody and AFP (Figures 4 and 5, Table 2) and exhibited the lowest FNR, thereby reducing the risk of missed diagnoses. These findings are consistent with prior literature noting the diagnostic limitations of AFP and p53 antibody due to low sensitivity and specificity[22,36], particularly in early-stage disease. In contrast, ESPL1’s robust performance highlights its potential as a reliable and sensitive biomarker for early HBV-HCC detection.
In addition, our evaluation considered the reliability of p53 IHC as a diagnostic reference, a method validated in prior studies showing high concordance with histopathologically confirmed HCC[37,38]. Consistent with these findings, p53 IHC exhibited an 85.7% positivity rate in surgically resected HBV-HCC tissues in this study. When using p53 IHC as a reference standard, ESPL1 protein achieved a significantly higher diagnostic concordance than p53 antibody or AFP (Table 4), reinforcing that serum ESPL1 may offer enhanced accuracy in HBV-HCC detection. Previous studies have also reported the unique diagnostic advantage of ESPL1 over DCP and AFP in detecting HBV-HCC[32].
Although emerging biomarkers such as GPC3 and GP73 offer improved specificity, each exhibits significant limitations, such as poor sensitivity for GPC3 or false-positive elevations of GP73 in non-malignant liver disease[39,40]. Therefore, a multi-marker strategy is likely to be more effective. Our data suggest that a combined model integrating ESPL1 with p53 antibody and AFP coule yield complementary diagnostic strengths: ESPL1's progressive elevation with the disease, the p53 antibody's specificity for mutated TP53, and AFP's established clinical utility. Although prospective validation is required, this integrated model may enhance diagnostic accuracy in challenging scenarios such as AFP-negative or early-stage HBV-HCC.
Despite the strengths of this study, including biomarker comparisons across serum and tissue platforms, several limitations should be acknowledged. The study was conducted at a single tertiary referral center in China, potentially introducing selection bias and limiting generalizability. While the sample size sufficed for primary analysis, subgroup comparisons lacked adequate power. Moreover, the absence of an external validation cohort restricts the assessment of diagnostic thresholds across diverse populations. Future multicenter studies involving longitudinal follow-up and external cohorts are warranted to validate our findings, evaluate biomarker dynamics, and establish clinically applicable cut-off values.
CONCLUSION
In conclusion, while p53 antibody and AFP are established markers for HBV-HCC, our findings indicate that serum ESPL1 protein affords superior diagnostic efficacy. Rising ESPL1 levels correlate with progression from chronic HBV infection to HBV-LC and, ultimately, HBV-HCC, suggesting a potential role in early detection. Consequently, ESPL1 protein may offer significant clinical utility for HBV-HCC screening and warrants further investigation in larger, longitudinal cohorts.
ACKNOWLEDGEMENTS
We would like to extend our heartfelt appreciation to the patients and their families for their invaluable contributions to this study.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade A, Grade B, Grade D
Novelty: Grade A, Grade B, Grade C
Creativity or Innovation: Grade B, Grade B, Grade C
Scientific Significance: Grade B, Grade B, Grade C
P-Reviewer: Li JJ; Luan SJ S-Editor: Liu H L-Editor: A P-Editor: Zhang YL
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