du 2013 poynard biomarkers

7 févr. 2012

LiverCenter

TAGS (Truth in the Absence of Gold Standard):

Un foie sans référence ?

Thierry Poynard+

AP-HP Groupe Hospitalier Pitié Salpêtrière,UPMC Liver Center, Université Paris 6, INSERM U680, Biopredictive France

vendredi 18 janvier 13

7 févr. 2012

Biopsy=

Gold Standard

Biopsy=

0% False Positive0% False Negative

7 févr. 2012

Viral necrosisActivity

Fibrosis Steatosis

AlcoholAsh

Liver Injury

Serum biomarker Imaging biomarker

Geno-FibroTest

FibroScanGPHepatologist

EpidemiologistChoice

AixPlorer

7 févr. 2012

Too many subjects at risk of chronic liver disease (1.5 billions)

Serious adverse events of biopsy

Non-invasive alternatives to biopsy for staging

7 févr. 2012

Fibrosis biomarkers: 21 years history

SJG 2008

n=900,000

7 févr. 2012

Haptoglobin

Alpha2Macroglobulin

Apolipoprotein A1

Total Bilirubin

Gamma GT

In Situ In Serum: FibroTest

Imbert-Bismut, Lancet 2001

Liver Injury

Activated Stellate CellsFibrotic Matrix

7 févr. 2012

Rational of FibroTest:

• Alpha 2 macroglobulin: key protein for Collagenase metabolism

• Apolipoprotein A1 key protein for Collagen trapping

• Haptoglobin: key protein for binding Free Hemoglobin oxidant

• Total Bilirubin: specific marker of severe late Fibrosis

• Gamma Glutamyl Transpeptidase: sensitive marker of early Fibrosis

• No transaminases: to prevent inflammatory necrosis confusion (ActiTest)

• Proteomic has blindly proved the major diagnostic value of

• Apolipoprotein A1, A2M

• HaptoglobinParadis Cell Mol Biol 1996, Paradis Hepatology 1996, Mathurin Hepatology 1996, Imbert Bismut 2001, Langlois 2006, Watanabe 2009, Ho 2010

7 févr. 2012

FibroMAX: HCV-HBV-ALD-NAFLD

ActiTest

FibroTest SteatoTest

AshTest

NashTest

FibroMAX

7 févr. 2012

But: savoir répondre à ce QCM:

Parmi les propositions suivantes concernant les performances de la biopsie (25 mm) pour le diagnostic de fibrose, lesquelles sont vraies ?

1. La biopsie se trompe moins d’une fois sur 4, pour l’estimation du stade de fibrose METAVIR

2. La biopsie a une meilleure performance que le FibroTest pour le diagnostic de fibrose intermédiaire (Stade F2 vs F1)

3. L’estimation des performances d’un test non-invasifs nécessite de calculer les valeurs diagnostiques:

• pour le diagnostic de cirrhose: F4 vs F0/F1/F2/F3

• mais aussi pour le diagnostic de

• F3/F4 vs F2/F1/F0,

• F2/F3/F4 vs F0/F1,

• et F1/F2/F3/F4 vs F0.

7 févr. 2012

Period 1: 1991-2004 Optimistic

Looking for a fibrosis biomarker with accuracy > 90%

7 févr. 2012

Biopsy=

Gold Standard

Biopsy=

0% False Positive0% False Negative

7 févr. 2012

Liver Injury

Fibrotic Liver Disease

Hemorrhage Liver failure Cancer

FibroTest OK AUROC >80%

FibroTest OK FibroScan OKAUROC >80%

«Gray Zone»: Biopsy

Imbert Bismut 2001, Castera 2005vendredi 18 janvier 13

7 févr. 2012

Period 2: 2005-2009: Sceptic

Standard statistical methods were inappropriate

7 févr. 2012

• Sampling error Bedossa 2003

• Inter-observers variability Rousselet 2005

• Discordance studies Poynard 2004, Halfon 2006

• Prognostic studies Ngo 2006, Vergniol 2011

• Spectrum effect Poynard 2007, Lambert 2008

• Exceeding limits of biopsy Metha 2009

• Biopsy has a gray zone Poynard 2012

7 Key methodological issues:Biopsy is no more a perfect gold standard

Sampling error:AUROCs (F1 vs F2) of Biopsy vs Whole Liver according to length

Bedossa Hepatology 2003

AUROC 15 mm = 0.82AUROC 25 mm = 0.89

«We showed that with 25-mm long biopsy specimens, only 75% were scored correctly»

7 févr. 2012

0,2250

0,4500

0,6750

0,9000

0,39 0,38 0,35

F0 F1 F2 F3 F4

Inter-Observers variability:Biopsy has lower inter-observers concordance for intermediate stages

Rousselet, Hepatology 2005

7 févr. 2012

Discordances studies: independent endpoints

• 537 prospective cases

• 154 (29%) discordances FibroTest/Biopsy

• Error attributable

• To FibroTest: 2%

• To Biopsy: 18%

Poynard Clin Chem 2004, Halfon AJG 2006

7 févr. 2012

Meta-analysis of prognostic studies: 6 publications and 21 assessmentsFibroTest (4 studies, 2396 patients), APRI (5 studies, 2422 patients), FIB4 (3 studies,1184 patients)

First author, year Disease Biomarker assessed with area under the ROC curve

Ngo, 2006 HCV FibroTest, APRI, Biopsy

Ngo, 2008 HBV FibroTest, APRI, Biopsy

Naveau, 2009 ALD FibroTest, APRI, FIB4, HepaScore, FibroMeter, Biopsy

Nunes, 2010 HCV APRI, FIB4

Parkes, 2010 Mixed ELF, Biopsy

Vergniol, 2011 HCV FibroTest, APRI, FibroScan, FIB4, Biopsy

Poynard Gastroenterol Hepatol 2011

Meta-analysis of the prognostic value of biomarkers vs biopsy

Survival without liver deaths

Poynard Gastroenterol Hepatol 2011

Only FibroTest has same prognostic value than biopsy

Liver stiffness FibroTest

5 years prognostic value in chronic hepatitis C

Vergniol Gastroenterology 2011vendredi 18 janvier 13

7 févr. 2012

3/7 key methodological issues not well understoodBiopsy is no more a perfect gold standard

DANA=4

DANA=Difference between Advanced and non-advanced fibrosis stages

Obuchowski measure=AUROCs Pair-wise comparison between all stages

Black and White Spectrum

FibroTest AUROC=0.98

DANA=1

Gray Spectrum

DANA=2.5

Standard Spectrum

7 févr. 2012

Hazardous Tables due to Spectrum Effect (1)

Interpretation of AUROC Interpretation of AUROC Interpretation of AUROC

AUROC Score* Biopsy length FibroTest and Spectrum

0.90-1 Excellent F0 vs F4

0.80-0.90 Good 25 mm F1 vs F2 F01 vs F234

0.70-0.80 Fair 5 mm F1 vs F2 F0 vs F2

0.60-0.70 Poor 5 mm F0 vs F1 F1 vs F2

0.50-0.60 Fail

*Sebastiani CCLM 2011, Bedossa Hepatology 2003, Poynard Clin Chem 2007vendredi 18 janvier 13

7 févr. 2012

Hazardous Tables due to Spectrum Effect (October 2012)

Ochi Hepatology 2012

Real-time tissue elastography cut-off values by stage in the training set were 2.47 for F1, 2.67 for F2, 3.02 for F3, and 3.36 for F4. Usingthese cut-off values, the diagnostic accuracy of hepatic fibrosis in the validation set was 82.6%-96.0% in all stages.

The area under the receiver operating characteristic curve of elastic ratio better correlated than serum fibrosis markers in both early and advanced fibrosis stages.

Conclusion: Real-time tissue elastography is useful in evaluating hepatic fibrosis and PH in patients with NAFLD. (HEPATOLOGY 2012;1271-1278)

7 févr. 2012

Using 25 mm liver biopsy a perfect market cannot be validated

Black shading represents the set of conditions under which the AUROC values exceed what has already been observed

Metha J Hepatol 2009

7 févr. 2012

Exceeding limits of biopsy: >90% accuracy is impossible for advanced fibrosis

«Comparison of 8 diagnostic algorithms for liver fibrosis in hepatitis C: New algorithms are more precise and entirely non-invasive».

Boursier et al, Hepatology 2012

7 févr. 2012

Misleading presentation using biopsy as Gold-Standard

Boursier Hepatology 2012

Mathematically impossible with biopsy as «Gold Standard

7 févr. 2012

Review of tests by Gebo, Hepatology 2002

« These panels of tests may have the greatest value in predicting fibrosis or cirrhosis »

« Biochemical tests were best at predicting no or minimal fibrosis, or at predicting advanced fibrosis/cirrhosis, and were poor at predicting intermediate levels of fibrosis »

FibroTest/FibroSure has a Gray Zone

Biopsy has a Gray Zone

7 févr. 2012

Review of fibrosis tests by Nguyen, Hepatology 2011

7 févr. 2012

Liver Biopsy Analysis Has a Low Level of Performance for Diagnosis of IntermediateStages of Fibrosis

The gray anatomy of 27,869 virtual biopsies and 6,500 patients

Poynard Clin Gastro Hepatol 2012Poynard, BMC 2005, J Hepatol 2011

7 févr. 2012

The gray zone of liver biopsy: 27,864 virtual biopsies

Poynard Clin Gastro Hepatol 2012

Lower gray zone of FibroTest relative to biopsy

Decrease FibroTest F2vsF1 58% lower compared with F1vsF0 41% lower compared with 4vsF3.

Biopsyn=27,864

Fibrotestn=6500

Poynard Clin Gastro Hepatol 2012

7 févr. 2012

Biopsy is no more a perfect gold standard

FibroTest and Elastography have similar performance

2006: Approval Markers French Health Authorities HCV2011: Guidelines EASL 2011

Benefit/Risk must be evaluated for each change in the formula:

It takes time for one stable formula: the example of 360,000 FibroTest

High Risk False Positive Negative

5/954 (0.52%)

38/7494 (0.51%)

FibroTest Global Quality Estimates

High Risk False Positive Negative3349/345,695 (0.97%)

491/24,872 (1.97%)

FibroScan (Roulot et al 2008)>7.1 kPa= 12.6%: False Positives ?

Poynard BMC Gastro 2011, Roulot J Hepatol 2008

One Test, One formula

360,000 FibroTest for Quality Control

Risk of False positive/negative of FibroTest

• Tertiary center: 1.97%

• HIV co-infection: 1.77%

• Sub-Saharan origin: 2.61%

7 févr. 2012

Which Fibrometer for patients with Hepatitis C ? Too many variants = Risk of false positive

FibroMeter Variant Year Components

FM-1G 2005 PLT, PI, AST, A2M, HA, Urea, Age

FM-2G V* 2008 + Gender

FM-3G 2008 Switch GGT/HA

FM-3G+ (CirrhoMeter) 2009 New formula for cirrhosis

FM-HICV 2010 AST, A2M, PI

CSF-Index 2011 Combined with LSM

SF-Index 2011 Combined with LSM

C-Index 2011 Combined with LSM

*ONLY one ( FM-2G V) is approved by Haute Autorité de Santé

PLT: platelet counts, PI prothrombin index, AST aspartate amino transferase, A2M alpha2 macroglobulin, HA hyaluronic acid

7 févr. 2012

Biopsy vs Serum markerMain advantages/disadvantages

Serum Marker FibroTest

Less accurate for intermediate stages

No grey zone relatively to biopsy

Fibrosis only ActiTest/SteatoTest

Delays result proprietary tests 1-48h

False positive/hemolysis/inflammation/Gilbert

Yes but 0.97% (3349/345695; 0.94-1.00)

Nguyen Hepatology, 2011 Poynard BMC Gastro 2011vendredi 18 janvier 13

7 févr. 2012

Period 3: 2010-----

Welcome in a world without perfect Gold Standard

7 févr. 2012

Gold Standard

25 mm Biopsy 0%False PositiveFalse Negative

7 févr. 2012

Truth in the Absence of

Gold Standard

25 mm Biopsy 25%False PositiveFalse Negative

7 févr. 2012

Area of fibrosis estimated by biopsy according to its length (mm) in subjects scoring METAVIR F0 (no fibrosis) on large surgical section.

Area of fibrosis >5.3%: 16.3% false positives 20mm biopsy for diagnosis of advanced fibrosis >16.5%: 0.3% false positives 20mm biopsy for diagnosis of cirrhosis.

Cirrhosis

Advanced fibrosis

Poynard J Hepatol 2012vendredi 18 janvier 13

7 févr. 2012

Poynard J Hepatol 2011

FibroTest FibroScan

5-30 mm Biopsy

7 févr. 2012

Distribution of 1893 subjects according to the 16 possible combinations of the 4 tests' results: presumed advanced fibrosis (present=1) or not (=0)

16 combinations of 4 tests results16 combinations of 4 tests results16 combinations of 4 tests results16 combinations of 4 tests results Number of subjectsNumber of subjects

FibroTest LSM ALT Biopsy Observed Expected by model

0 0 0 0 621 615.5

0 0 0 1 186 191.1

1 1 1 1 276 277.0

Poynard, J Hepatol 2011 vendredi 18 janvier 13

7 févr. 2012

Reference Biopsy Reference Latent Class

FibroTest Se LSM Se Biopsie Se

Performance for Advanced Fibrosis: Sensitivity

The standard cutoffs: 0.48 FibroTest, 8.8 kPa Stiffness

7 févr. 2012

8993 96

FibroTest Sp LSM Sp Biopsy Sp

Performance for Advanced Fibrosis: Specificity

7 févr. 2012

FibroTest Se LSM Se Biopsie Se

Performance for Cirrhosis: Sensitivity

7 févr. 2012

100 89 8795 93

FibroTest Sp LSM Sp Biopsy Sp

Performance for Cirrhosis: Specificity

The standard cutoffs: for cirrhosis 0.74 for FibroTest, and 14.5 kilo-Pascal for stiffness (LSM)

7 févr. 2012

Specificity Sensitivity

SWE Fibrotest 1 TE-M Fibrotest 2 TE-XL FibroTest 3

7 févr. 2012

Period 3: 2010-----

Improving serum biomarker

7 févr. 2012

HCV-GenoFibroTest: Liver injury, Virus Resistance, Host Genes for treatment Response and Tolerance

ActiTest

FibroTest SteatoTest

HCV-GenoFibroTest

Viral Load

Viral Resistance

UGT1A1

Genotype

7 févr. 2012

Period 3: 2010-----

Combining serum and imaging biomarkers

7 févr. 2012

• 11 Published studies

• n=2,260

• Standardized AUROC

• Advanced Fibrosis

• 0.89 (0.84-0.95)

Friedrich Rust et al Gastroenterology 2008, Poynard et al SJG 2008

Elastography

7 févr. 2012

Oliveri WJG 2008

7 févr. 2012

Pitfalls of Fibroscan

3.1% Failures and Unreliable results 15.8%

7 févr. 2012

Choice of FibroScan Cutoffs

Castera 2005, Ketanneh 2007Roulot 2008

For F2: 7.1 or 8.8 kPa ? Patients: false negatives ?Low negative predictive value

Healthy volunteers: 7.1 kPa 12.6% false positives ?

For screening 7.1 kPa ?

For patients 8.8 kPa ?

No rationale for changing cutoff according to liver disease

F2 8.8 kPa F4 14.5 kPa

F4 0.73

F2 0.48

Poynard PlosOne 2008vendredi 18 janvier 13

A la ParisienneFibrotestFirst Line

If not interpretableBiopsy

FibroTest ActiTest

If not interpretableFibroscan

Prevalence

Serum biomarker

FibroTest

Imaging biomarker

FibroScan

Elasto-FibroTest

Poynard, CRHG 2012vendredi 18 janvier 13

7 févr. 2012

Elasto-FibroTest®

• 1289 patients with CHC and 604 healthy volunteers

• Appropriate methods

• Obuchowski measures

• Methods without Gold Standard

Poynard, CRHG 2012

7 févr. 2012

Elasto-FibroTest® 1289 patients with CHC and 604 healthy volunteers

• For the diagnosis of cirrhosis Elasto-FibroTest has significantly higher performances than FibroTest or Fibroscan alone.

• For the diagnosis of advanced fibrosis (F234) no improvement in performance has been observed vs FibroTest alone, when a method without gold standard was used.

Poynard, CRHG 2012

7 févr. 2012

Poynard, CRHG 2012vendredi 18 janvier 13

7 févr. 2012

Epilogue Universitaire

Résultat du QCM

7 févr. 2012

1. La biopsie de 25 mm se trompe moins d’une fois sur 4, pour l’estimation du stade de fibrose : Faux c’est bien 25%

«We showed that with 25-mm long biopsy specimens, only 75% were scored correctly»

Bedossa, Hepatology 2003

7 févr. 2012

2. La biopsie a une meilleure performance que le FibroTest pour le diagnostic de fibrose intermédiaire (Stade F2 vs F1) : Faux

« Liver Biopsy Analysis Has a Low Level of Performance for Diagnosis of Intermediate Stages of Fibrosis»

Poynard, CGH 2012

7 févr. 2012

3. L’estimation des performances d’un test non-invasif nécessite de calculer les valeurs diagnostiques des combinaisons de stades: Faux

« AUROC analysis led to discordant results depending onhow the fibrosis stages were grouped together.

We recommend the Obuchowski measure...»

Poynard, Clin Chem 2007, Lambert, Clin Chem 2008

7 févr. 2012

Epilogue de Recherche Clinique

18 janv. 2013

Estimer la survie de la fibrose après guérison virologique de l’hépatite chronique C

18 janv. 2013

Rationnel: L’ hépatite C est une maladie virale et fibrosante

• La mortalité est essentiellement due aux complications de la fibrose

• La guérison virologique (SVR) est considérée comme la première étape pour diminuer la mortalité

• Cette diminution de la mortalité doit passer par une diminution de la progression de la fibrose, déjà documentée à court terme

• La survenue de carcinome hépato-cellulaire (CHC) chez des guéris virologiques a été observée dès 1996, suggérant la persistance d’un risque de complications

Poynard Lancet 1997, Backus CGH 2012, MMWR Recomm Rep 2012, Hirashima JGH 1996

18 janv. 2013

Rationnel: Les marqueurs non-invasifs de fibrose sont plus appropriés que la biopsie

• Aucune large étude prospective n’a estimé l’impact de la guérison virologique sur la dynamique de la fibrose a moyen terme

• 1094 patients SVR avec 2 biopsies à 2 ans

• 60 patients SVR avec 2 biopsies à 4 ans

• Biomarqueurs non-invasifs comme le FibroTest permettent ces études, car largement validé versus biopsie pour:

• Le diagnostic de tous les stades de fibrose

• La dynamique de progression de la fibrose

• Le pronostic: prédiction de la morbidité et de la mortalité

Poynard Gastroenterology 2002, Poynard AVT 2010, Ellis J Hepatol 2012

Fibrosis progression: FibroTest similar to BiopsyProgression to cirrhosis in 2472 patients

Biopsy FibroTest

Poynard et al, J Hepatol 2012

18 janv. 2013

0 10 20 30 40 50 60 70 80 90Years

10MenWomen

Poynard et al, J Hepatol 2012

Transition to cirrhosis (n=57,275) using 342,346 tests

1997: FIBRO-FRANCE-HCV Cohort2012: Analysis of Fibrosis Survival

1269 patients

932 patients with reliable FibroTest and FibroscanIncluded in the survival analysis

337 Not included: 298 tests non reliable or missing

14 no test performed before transplantation13 spontaneous clearance

5 less than 6 months interval5 HBV PCR positive

2 Miscellaneous

4245 Fibrotest136 x2161 x3173 x4156 x5119 x6187 >6

2710 Fibroscan369 x2398 x347 x4118 x5

613 Biopsy479 x0323 x1100 x230 x3

18 janv. 2013

Survie sans complications du VHC

n = 933NS

SVR n=43 HCC1 CholangiocarcinomeTous F4 avant2 F2 après

18 janv. 2013

Nouvelle maladie:

Post hepatitis Disease

Poynard AFEF/ AASLD 2012

18 janv. 2013

Implications

• Continuer à surveiller les fibroses avancées chez les «Guéris virologiques»

• Traiter plus tôt, avant F2 ?

• Changer les modèles pharmaco-économiques

• Trouver des anti-fibrosants

Geno-FibroTestGP

HepatologistEpidemiologist

Genetician

Supersonic

7 févr. 2012

«Despite ductular proliferation vanishing and lobular zonation restoration, portal inflammation and sinusoidal capillarization may not regress after viral eradication. (HEPATOLOGY 2012;56:532-543)»

7 févr. 2012

France: 12,000,000 at Risk100%

Death 15,000/year0.1%

Biomarker10% F2

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