Diagnostic Accuracy of the Circulating Cell-free DNA-based Epigenetic Biomarker mSEPT9 for Hepatocellular Carcinoma Detection Among Cirrhotic Patients: the SEPT9_CROSS Study
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 639
- 试验地点
- 2
- 主要终点
- Presence of hepatocellular carcinoma.
研究概览
简要总结
Brief Summary (Plain-Language Version - Compliant with ClinicalTrials.gov Guidelines)
The goal of this observational study is to learn whether a blood test called methylated SEPT9 (mSEPT9) can help diagnose hepatocellular carcinoma (HCC), the most common type of liver cancer, in people who already have cirrhosis. The study also compares how well this new test works compared with the current standard blood test called alpha-fetoprotein (AFP).
The main questions the study aims to answer are:
- Can the mSEPT9 blood test detect liver cancer earlier or more accurately than AFP in people with cirrhosis?
- Does combining both tests (AFP and mSEPT9) improve the accuracy of diagnosis?
The study, called SEPT9-CROSS, is a phase III, multicenter, cross-sectional diagnostic accuracy study. It includes 639 adults with cirrhosis who were enrolled across participating hospitals in France. After reviewing eligibility and exclusion criteria, 574 participants were included in the final analysis: 118 people with liver cancer and 456 people with cirrhosis but no liver cancer.
The main outcome (primary outcome) is the presence of liver cancer at the time of study enrollment, confirmed by imaging or biopsy based on international medical guidelines. An exploratory outcome looks at participants who developed liver cancer within 12 months after joining the study. This second measure helps researchers understand whether the test can identify early or hidden disease.
All participants gave written informed consent before joining the study. As part of their regular medical care, participants received clinical exams, blood tests, and imaging studies (such as ultrasound). During routine blood draws, an extra 20 milliliters of blood (about 4 teaspoons) was collected for the mSEPT9 test. These blood samples were processed and safely stored at the CRB Lorrain biobank at the University Hospital of Nancy, France, for later analysis.
The study compares the performance of AFP and mSEPT9 individually and in combination. Two diagnostic strategies were tested:
- Tier 1 (high sensitivity): A positive result if either AFP or mSEPT9 was high.
- Tier 2 (high specificity): A positive result only if both AFP and mSEPT9 were high.
Researchers used statistical models to measure how well the tests identified cancer. This included estimating the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and predictive values (how likely a result is to be correct). These calculations were repeated 10,000 times using computer simulations to ensure reliability.
Advanced Bayesian statistical models were also used to confirm the stability and strength of the results and to compare the performance of mSEPT9 and AFP. A risk model (called a nomogram) was created to estimate each participant's probability of having liver cancer based on their test results.
All analyses were planned before the study started and carried out using the software R (version 4.3.0) and Python (PyCharm environment) with validated scripts to ensure accuracy and reproducibility.
详细描述
Clinical Trial Rationale and Design
Epigenetic alterations represent a fundamental hallmark of human malignancy. Although individual epigenetic biomarkers have begun to enter clinical practice, their translational validation remains limited. This limitation is particularly evident in hepatocellular carcinoma (HCC), the most common primary malignant tumor of the liver. Alpha-fetoprotein (AFP) has long been used as a diagnostic biomarker for HCC; however, as stated in international guidelines from the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver, AFP lacks sufficient sensitivity and specificity for effective screening or early detection. Aberrant DNA methylation events are a frequent molecular feature of malignant transformation and can be detected in the circulation of patients with cancer using polymerase chain reaction-based assays.
Among epigenetic targets, the SEPT9 gene has emerged as a key regulator of cell division and a tumor suppressor whose promoter hypermethylation is closely associated with carcinogenesis. Experimental evidence implicates SEPT9 in the early stages of hepatocarcinogenesis, and promoter hypermethylation of SEPT9 has been consistently observed in human HCC. Loss or downregulation of SEPT9 expression due to aberrant promoter methylation has also been reported in several other malignancies.
Building on a proof-of-concept study conducted in France and an independent replication study in Germany, we previously demonstrated that plasma methylated SEPT9 (mSEPT9), a circulating cell-free DNA-based epigenetic biomarker, shows strong potential for the noninvasive diagnosis of HCC in patients with cirrhosis (EBioMedicine 2018:30:138-147). The SEPT9_CROSS study is a phase III, multicenter, cross-sectional diagnostic accuracy investigation designed to validate the clinical performance of plasma methylated SEPT9 (mSEPT9) for the diagnosis of HCC in a large-scale cohort of 639 patients with cirrhosis initially enrolled across participating centers. After application of the predefined eligibility and exclusion criteria, 65 patients were excluded, resulting in 574 analyzable patients retained in the final study population.
Patient Recruitment and Sample Handling
研究设计
- 研究类型
- Interventional
- 分配方式
- Non Randomized
- 干预模型
- Parallel
- 主要目的
- Diagnostic
- 盲法
- Triple (Participant, Care Provider, Investigator)
盲法说明
The index test (mSEPT9) will be reported at the final step of the research, at time of data analysis.
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patient aged 18 and over.
- •Patient with a diagnosis of cirrhosis (alcohol, HBV, HBC, NASH, hemochromatosis, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis) with or without hepatocellular carcinoma (for each arm).
- •Affiliation to the French Social Security System (Health Insurance)
- •NON-INCLUSION CRITERIA FOR CASES :
- •Malignant liver tumor other than HCC: cholangiocarcinoma, hepatic metastasis of a carcinoma (e.g., colorectal adenocarcinoma);
- •History of HCC treated by surgical resection, focal destruction [radiofrequency, stereotactic radiotherapy (CYBERKNIFE®)], arterial chemoembolization, or radioembolization within the last five years.
- •NON-INCLUSION CRITERIA FOR CASES AND CONTROLS:
- •Legal protection measures;
- •Pregnant woman;
- •Hemodialysis, ongoing (possibility of interference with the test);
- •Presence of associated cancer (e.g., colorectal adenocarcinoma, urothelial carcinoma, breast carcinoma, etc.) since less than five years;
- •Presence of a hematological malignancy (no time limit).
排除标准
- 未提供
研究组 & 干预措施
HCC-positive cirrhotic patients (Cases)
Patients with cirrhosis and a diagnosis of hepatocellular carcinoma established according to the American Association for the Study of Liver Diseases (AASLD) guidelines were enrolled at the participating centers. Each participant underwent testing with the plasma methylated SEPT9 (mSEPT9) assay (Epi proColon 2.0 CE; Epigenomics, Berlin, Germany).
干预措施: "Epi proColon 2.0 CE" test from Epigenomics, Inc (Berlin, Germany) (Diagnostic Test)
HCC-free cirrhotic patients (Controls)
Patients with cirrhosis without evidence of hepatocellular carcinoma (HCC) were enrolled as part of an established HCC surveillance program involving abdominal ultrasonography and alpha-fetoprotein measurement every six months in the participating centers. Each participant underwent testing with the plasma methylated SEPT9 (mSEPT9) assay (Epi proColon 2.0 CE; Epigenomics, Berlin, Germany).
干预措施: "Epi proColon 2.0 CE" test from Epigenomics, Inc (Berlin, Germany) (Diagnostic Test)
结局指标
主要结局
Presence of hepatocellular carcinoma.
时间窗: The diagnosis of HCC will be based on overall patient's evaluation including clinical, biological and imaging workup which will be carried out during the consultation and/or the three months preceding or following the inclusion consultation.
Hepatocellular carcinoma (HCC) diagnosis was established according to international AASLD/EASL criteria, based on characteristic imaging findings or histopathologic confirmation. All HCC determinations were adjudicated by experienced hepatologists blinded to mSEPT9 test results to prevent assessment bias. The primary outcome was the presence of HCC at inclusion, confirmed by imaging or histopathology. An exploratory outcome (Primary outcome M12) was prespecified, including both baseline HCC and new HCC diagnosed within 12 months after inclusion, to minimize potential misclassification related to early or subclinical disease and to assess the temporal stability of diagnostic performance. For both outcomes, a "strict" analytical variant excluded controls who developed HCC within 12 months, ensuring temporal consistency and avoiding contamination bias.
次要结局
- Presence of early hepatocellular carcinoma. Early hepatocellular carcinoma will be defined as a tumor smaller than 30 mm according to Kudo M (Liver Cancer. 2013;2:69-72).(The diagnosis will be based on an overall patient's evaluation including clinical, biological and imaging workup which will be carried out during the consultation and/or the three months preceding or following the inclusion consultation.)
研究者
OUSSALAH Abderrahim, MD, PhD
OUSSALAH Abderrahim, MD, PhD
Central Hospital, Nancy, France