Prognostic Significance of Carcinoembryonic Antigen Staining in Cancer Tissues of Gastric Cancer Patients

Prognostic significance of post-preoperative tumor markers increments in patients with non-metastatic gastric cancer

PURPOSE

Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) are the most common tumor markers detected before and after gastric cancer (GC) surgery. However, the impact of post-preoperative CEA/CA19-9 increments on prognosis of GC remains unclear. In addition, there is no research incorporating post-preoperative CEA/CA19-9 increments into the prognostic model.

METHODS

Patients who underwent radical gastrectomy for GC at the First Affiliated Hospital of Anhui Medical University and Anhui Provincial Hospital from January 2013 to December 2017 were enrolled and divided into the discovery and validation cohort. Prognostic value of post-preoperative CEA/CA19-9 increments and preoperative CEA/CA199 levels were assessed by Kaplan-Meier log-rank analysis and compared by time-dependent receiver operating characteristic (t-ROC) curves. Multivariate Cox regression analysis was applied to establish the nomogram. The performance of the prognostic model was validated by the concordance index (C-index), calibration curve, and ROC curve analysis.

RESULTS

A total of 562 GC patients were included in this study. Overall survival (OS) rates decreased with an increasing number of incremental tumor markers after surgery. The t-ROC curves implied that the prognostic ability of the number of incremental post-preoperative tumor markers was superior to that of the number of positive preoperative tumor markers. Cox regression analysis suggested that the number of incremental post-preoperative tumor markers was an independent prognostic factor. The nomogram incorporated with the post-preoperative CEA/CA19-9 increments showed reliable accuracy.

CONCLUSIONS

Incremental post-preoperative CEA/CA19-9 were indicator of poor prognosis of GC. The prognostic value of post-preoperative CEA/CA19-9 increments exceed that of preoperative CEA/CA19-9 levels.

Proposal of the Second Cutoff of Serum Carcinoembryonic Antigen Levels to Stratify Patients into Low, Intermediate, and High Risks at Recurrences after Curative Resection of Gastric Cancer

INTRODUCTION

Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 are widely used for treating various cancers, with cutoff values of 5.0 ng/mL and 37.0 IU/mL, respectively. However, these cutoff values are not for specific diseases or purposes but are uniformly used for any disease and any purpose. It is also unclear as to whether patients are at equal risk of recurrence if they are below the cutoff values. This study aimed to investigate the optimal cutoff of serum tumor markers in the stratification of recurrence risk after curative resection of gastric cancer.

METHODS

We constructed a nine-center integrated database of patients who received gastrectomy between January 2010 and December 2014 with a 5-year follow-up period. We determined the cutoff value of preoperative serum tumor marker levels correlated with postoperative recurrences and evaluated its performance in risk stratification for recurrences in 948 patients with stage II/III gastric cancer who underwent radical resection.

RESULTS

The hazard ratio for postoperative recurrences increased at two points of preoperative CEA levels, 3.6 ng/mL and 5.0 ng/mL, which were set as cutoffs. These two cutoffs stratified relapse-free survival into three levels.

CONCLUSIONS

By adding a second cutoff value for preoperative serum CEA, which was proposed specifically for the prediction of recurrences, patients can be stratified into low-, intermediate-, and high-risk recurrences after curative resection of gastric cancer.

Prognostic Value of Tumor Markers in Gastric Cancer: A Tertiary Cancer Centre Experience

OBJECTIVES

Gastric cancer is a heterogeneous malignancy in terms of stage-wise prognosis. This study aimed at finding any prognostic significance of preoperative carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9 in resectable gastric cancer.

METHODS

A total of 57 patients at Kidwai Memorial Institute of Oncology, Bengaluru, India from January 2022 to March 2023 were included in this observational prospective study. Included patients had a resectable tumor at clinical staging. Patients were divided into two categories (raised and non-raised) based on serum tumor marker (CEA and CA 19-9) levels. Their relationship with clinicopathological features was studied. The association was studied using chi-square test, and p-value <0.05 was considered significant.

RESULTS

The mean age of the study group was 55.47 years with male predominance (63.2%, n=36). Raised CEA and CA 19-9 were seen in 15.8% (n=9) and 10.5% (n=6) patients, respectively, while both markers were raised in 5.3% (n=3). Raised CEA was found significantly associated with grade 3 adenocarcinoma stomach (OR 7.825, 95%CI: 1.374-44.562; p= 0.020) and intraoperative finding of inoperability due to occult intra-abdominal disease (p<0.05). CA 19-9 (pre- and post-operative levels) had no statistically significant association (p>0.05) with the grade of adenocarcinoma.

CONCLUSION

This study indicates a benefit in estimating CEA for the prediction of prognosis in gastric cancer. CEA levels have been found to predict chances of finding occult intra-abdominal metastasis in gastric cancer.

A novel nomogram integrated with PDL1 and CEA to predict the prognosis of patients with gastric cancer

INTRODUCTION

This study aimed to develop a prognostic nomogram for patients with gastric cancer (GC) based on the levels of programmed death 1 ligand 1 (PDL1) and carcinoembryonic antigen (CEA).

METHODS

The nomogram was developed using data from a primary cohort of 247 patients who had been clinicopathologically diagnosed with GC, as well as a validation cohort of 63 patients. Furthermore, the nomogram divided the patients into three different risk groups for overall survival (OS)-the low-risk, middle-risk, and high-risk groups. Univariate and multivariate Cox hazard analyses were used to determine all of the factors included in the model. Decision curve analysis and receiver operating characteristic (ROC) curves were used to assess the accuracy of the nomogram.

RESULTS

The Kaplan-Meier survival analysis revealed that metastasis stage, clinical stage, and CEA and PDL1 levels were predictors for progress-free survival (PFS) and OS of patients with GC. Metastasis stage, clinical stage, and CEA and PDL1 levels were found to be independent risk factors for the PFS and OS of patients with GC in a multivariate analysis, and the nomogram was based on these factors. The concordance index of the nomogram was 0.763 [95% confidence interval (CI) 0.740-0.787]. The area under the concentration-time curve of the nomogram model was 0.81 (95% CI 0.780-0.900). According to the decision curve analysis and ROC curves, the nomogram model had a higher overall net efficiency in forecasting OS than clinical stage, CEA and PDL1 levels.

CONCLUSION

In conclusion, we proposed a novel nomogram that integrated PDL1 and CEA, and the proposed nomogram provided more accurate and useful prognostic predictions for patients with GC.

A novel high-risk subpopulation identified by CTSL and ZBTB7B in gastric cancer

BACKGROUND

Gastric cancer (GC) is characterised by a heterogeneous tumour microenvironment (TME) that is closely associated with the response to treatment, especially immunotherapies. However, most previous GC molecular subtyping systems need complex gene signatures and examination methods, restricting their clinical applications. Thus, we developed a new TME-based molecular subtype using only two genes.

METHODS

Nine independent GC cohorts at the tissue- or single-cell level with more than 2000 patients were used in this study, including data we examined by single-cell sequencing, quantitative RT-PCR and immunochemistry/immunofluorescence staining. Nine different methods, five existing molecular subtypes and a series of signatures were used to evaluate the TME and molecular characteristics of GC.

RESULTS

We established a CTSL/ZBTB7B subtyping system and uncovered the novel CTSLHighZBTB7BLow high-risk subgroup, but characterised by relative higher immune cell infiltration and lower tumour purity. This subgroup demonstrate higher levels of immune checkpoints and more enrichment of cancer-related pathways compared with other cases.

CONCLUSIONS

We identified a high-risk subpopulation with unique TME features based on expressions of CTSL and ZBTB7B, suggesting a counterbalancing phenotype between immunostimulatory and immunosuppressive mechanisms. This subtyping system could be used to select treatment and management strategies for GC.

Glycan expression profile of signet ring cell gastric cancer cells and potential applicability of rBC2LCN-targeted lectin drug conjugate therapy

BACKGROUND

Signet ring cell carcinoma (SRC) is a distinct subtype of gastric cancer (GC); however, the specific characteristics of cancer cell surface glycans and glycosylation remain unclear. In this study, we investigated SRC-specific glycans using lectin microarray and evaluated the potential applicability of a glycan-targeting therapy.

METHODS

SRC cell lines (NUGC-4 and KATO-III) and non-SRC (NSRC) cell lines (NCI-N87, SNU-1, and MKN-45) were subjected to lectin microarray analysis to identify the SRC-specific glycans. Additionally, we performed immunohistochemical lectin staining and evaluated the anti-tumor effects of lectin drug conjugates (LDCs) using high-affinity lectins for SRC.

RESULTS

Among the 96 lectins tested, 11 high-affinity and 8 low-affinity lectins were identified for SRC. Glycan-binding motifs varied in the high-affinity lectins, but 5 (62.5%) low-affinity lectins bound the same glycan structure, α2-6-linked sialic acids. The ratio of signal intensity in SRC to NSRC (SRC/NSRC) was highest in the rBC2LCN lectin (1.930-fold), followed by the BPL lectin (1.786-fold). rBC2LCN lectin showed high affinity for both SRC cell lines and one of the three NSRC cell lines (NCI-N87). The therapeutic effects of the LDC, rBC2LCN-PE38 (rBC2LCN, and Pseudomonas exotoxin A), showed cytocidal effects in vitro and tumor regression in in vivo mouse xenograft models.

CONCLUSION

We reported specific glycan profiles in SRC cells, showing reduced α2-6-linked sialic acids. Additionally, we found a targeted therapy using rBC2LCN lectin might be applicable as an alternative treatment option for patients with SRC.

Prognostic significance of the preoperative hemoglobin to albumin ratio for the short-term survival of gastric cancer patients

BACKGROUND

Hemoglobin and albumin are associated with the prognosis of gastric cancer (GC) patients. However, the prognostic value of the hemoglobin to albumin ratio (HAR) for the short-term survival of GC patients with D2 radical resection has not been studied.

AIM

To investigate the significance of the HAR in evaluating the short-term survival of GC patients after D2 radical resection and to construct a nomogram to predict the prognosis in GC patients after surgery, thus providing a reference for the development of postoperative individualized treatment and follow-up plans.

METHODS

Cox regression and Kaplan-Meier analysis was used for prognostic analysis. Logistic regression was used to analyze the relationships between HAR and the clinicopathological characteristics of the GC patients. A prognostic nomogram model for the short-term survival of GC patients was constructed by R software.

RESULTS

HAR was an independent risk factor for the short-term survival of GC patients. GC patients with a low HAR had a poor prognosis (P < 0.001). Low HAR was markedly related to high stage [odds ratio (OR) = 0.45 for II vs I; OR = 0.48 for III vs I], T classification (OR = 0.52 for T4 vs T1) and large tumor size (OR = 0.51 for ≥ 4 cm vs < 4 cm) (all P < 0.05). The nomogram model was based on HAR, age, CA19-9, CA125 and stage, and the C-index was 0.820.

CONCLUSION

Preoperative low HAR was associated with short-term survival in GC patients. The prognostic nomogram model can accurately predict the short-term survival of GC patients with D2 radical resection.

Expression of Matrix Metalloproteinase-7 Predicts Poor Prognosis in Gastric Cancer

To date, no potential markers have been established for predicting prognosis in gastric cancer. Matrix metalloproteinase-7 (MMP-7) has been suggested as a prognostic marker in several cancers. In this study, we aimed to determine the expression of the MMP-7 protein and its polymorphisms in gastric cancer tissues. The association between MMP-7 expression level and clinicopathological characteristics was also evaluated. MMP-7 protein expression and its polymorphisms were investigated in a total of 400 patients using immunohistochemistry and TaqMan SNP genotyping assays. The correlation of MMP-7 expression with clinicopathological characteristics, including tumor location, tumor size, histologic type, lymphatic invasion, vascular invasion, pathological T stage, pathological TNM stage, residual tumor, and CEA level, was investigated. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a multivariate Cox proportional hazards regression model. MMP-7 expression was found in 283 of 400 (70.75%) gastric cancer tissues. Expression of MMP-7 was significantly associated with poor clinicopathological characteristics, including vascular invasion ( $\text{OR}=6.61$ , $95\%\text{CI}=4.26–9.89$ , $p=0.024$ ), lymphatic invasion ( $\text{OR}=8.17$ , $95\%\text{CI}=4.47–12.39$ , $p=0.017$ ), undifferentiated histologic type ( $\text{OR}=2.46$ ; 95% CI, 1.31–4.52; $p=0.014$ ), higher TNM stage (stage IV) ( $\text{OR}=1.48$ , $95\%\text{CI}=1.08–3.08$ , $p=0.047$ ), and high CEA level ( $\text{OR}=5.96$ , $95\%\text{CI}=2.12–8.12$ , $p=0.026$ ). We further observed a significant association of the variant genotype; gastric cancer patients carrying GG of MMP-7 (-181A/G; rs11568818) had a greater increased risk of MMP-7 expression than did wild-type (WT) carriers (AG: odds ratio $\left(\text{OR}\right)=5.67$ ; $95\%\text{CI}=1.57–7.23$ ; $p=0.024$ and GG: $\text{OR}=8.32$ ; $95\%\text{CI}=2.94–11.42$ ; $p=0.016$ ). These findings suggest that MMP-7 expression can be used to predict the prognosis of gastric cancer patients.

Construction and Validation of Convenient Clinicopathologic Signatures for Predicting the Prognosis of Stage I-III Gastric Cancer

Background

Patients with stage I-III gastric cancer (GC) undergoing R0 radical resection display extremely different prognoses. How to discriminate high-risk patients with poor survival conveniently is a clinical conundrum to be solved urgently.

Methods

Patients with stage I-III GC from 2010 to 2016 were included in our study. The associations of clinicopathological features with disease-free survival (DFS) and overall survival (OS) were examined via Cox proportional hazard model. Nomograms were developed which systematically integrated prognosis-related features. Kaplan–Meier survival analysis was performed to compare DFS and OS among groups. The results were then externally validated by The Sixth Affiliated Hospital, Sun Yat-sen University.

Results

A total of 585 and 410 patients were included in the discovery cohort and the validation cohort, respectively. T stage, N stage, lymphatic/vascular/nerve infiltration, preoperative CEA, and CA19-9 were independent prognostic factors (P < 0.05). Two prognostic signatures with a concordance index (C-index) of 0.7502 for DFS and 0.7341 for OS were developed based on the nomograms. The 3-year and 5-year calibration curves showed a perfect correlation between predicted and observed outcomes. Patients were divided into three risk groups (low, intermediate, high), and distinct differences were noticed (p < 0.001). Similar results were achieved in the validation cohort. Notably, a free website was constructed based on our signatures to predict the recurrence risk and survival time of patients with stage I-III GC.

Conclusions

The signatures demonstrate the powerful ability to conveniently identify distinct subpopulations, which may provide significant suggestions for individual follow-up and adjuvant therapy.

Fast screening method for early diagnostic of gastric cancer based on utilization of a chitosan - S-doped graphene - based needle stochastic sensors

Needle stochastic sensors were developed for the assay of carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) in different biological samples (e.g., whole blood, tissues, urine, and saliva). Sulfur doped graphene powders were modified with chitosan; paraffin oil was added to form a homogeneous paste that was used as active side of the stochastic sensors. High sensitivities and low limits of determination were achieved for the assay of CA19-9 and CEA in biological samples. The validation of the proposed screening method (which is utilizing the stochastic sensors as screening tools) was made by using real biological samples obtained from confirmed patients with gastric cancer; very good correlations for the concentrations of CEA and CA19-9 were obtained using the needle stochastic sensors.

Prognostic Value of Combination of Inflammatory and Tumor Markers in Resectable Gastric Cancer

BACKGROUND

Inflammatory response and tumor marker levels have been shown to correlate with the prognosis in several human tumors. However, only a few studies on these markers have been performed in gastric cancer (GC) patients; the clinical significance of the combined markers is unclear. We aimed to evaluate the role of the combination of preoperative neutrophil-to-lymphocyte ratio (NLR) and carbohydrate antigen 19-9 (CA19-9) for predicting the prognosis of patients with GC.

METHODS

This retrospective study included 458 patients who underwent gastrectomy with curative intent between January 2013 and July 2014 in the second hospital of Lanzhou University. Receiver operating characteristic curve (ROC) was performed to determine the cut-off values for biomarkers, and their prognostic values were assessed using the Kaplan-Meier curve. The combined score indicators were established based on the optimal cut-off values, which range from 0 to 2. Prognostic significances for overall survival (OS) were assessed by univariate and multivariate Cox regression analysis. Nomogram was used as a visual supplement for the prognostic score system, and the predictive accuracy and discriminative ability were determined by the concordance index (C-index) and calibration curve.

RESULTS

The Kaplan-Meier survival analysis showed that the 1-, 3-, and 5-year OS were 66.2% (n = 303), 42.8% (n = 196), and 40.2% (n = 184) in all 458 patients, respectively. The high NLR (≥1.96), PLR (≥126), CA19-9 (≥27 U/mL), and CEA (≥ 5 ng/mL) were associated with poor prognosis of GC patients. The NLR + CA19-9 score indicator proved to be related to tumor size, lymph node metastasis, vascular invasion, perineural invasion, T stage, N stage, TNM stage, PLR, and CEA in patients with GC and an independent prognostic factor for prediction of 5-year OS (score 1: HR = 1.423, 95%CI: 1.049-1.929, P = 0.023; score 2: HR = 2.740, 95%CI: 1.882-3.990, P < 0.001). NLR + CA19-9 has a better predictive ability than other combined or single score indicators based on inflammation and tumor markers (AUC = 0.662, 95%CI: 0.616-0.705, P < 0.001). Moreover, a nomogram was established by the significant characteristics in the multivariate analysis for OS, which represented high accuracy (C-index = 0.692, 95%CI: 0.675-0.708).

CONCLUSION

NLR + CA19-9 can independently predict the overall survival of patients with gastric cancer after surgery. The prognostic nomogram based on NLR + CA19-9 is a convenient, economical, and effective prognostic system for clinical practice.

Reduced expression of circRNA hsa_circ_001888 in gastric cancer and its clinical significance

Background

Circular RNAs (circRNAs) are a novel family of endogenous RNAs. Recent studies have demonstrated that circRNAs are potential novel biomarkers for diagnosing cancers. However, little is known about the role of circRNAs in gastric cancer (GC). This study aimed to identify the relationship between GC and a new circRNA named hsa_circ_001888.

Methods

Hsa_circ_001888 expression levels were measured by quantitative reverse transcription‐polymerase chain reaction (qRT‐PCR) in GC cell lines, tissues, and plasma samples. Then, the associations between the expression level of hsa_circ_001888 and the clinicopathological features of patients with GC were further investigated. A receiver operating characteristic (ROC) curve was generated to evaluate the diagnostic value of hsa_circ_001888.

Results

In this study, hsa_circ_001888 was first found to be significantly downregulated in GC cell lines (AGS and MKN‐45), tissues, and plasma samples compared to control samples. Clinicopathological features showed that the expression of hsa_circ_001888 in GC tissues was associated with differentiation and in GC plasma linked with serum CEA and CA19‐9 levels. The areas under the ROC curves of hsa_circ_001888 in tissues and plasma were 0.654 and 0.66, respectively.

Conclusions

Hsa_circ_001888 may serve as a potential biomarker in the diagnosis of GC and may be involved in GC development.

Circular RNA hsa_circ_0001874 is an indicator for gastric cancer

BACKGROUND

Recent studies have indicated that circular RNAs (circRNAs) are novel endogenous RNAs whose 5' and 3' ends are covalently linked and play critical roles in gastric carcinogenesis. However, the significance of circRNA hsa_circ_0001874 in gastric cancer (GC) is still unclear.

METHODS

Therefore, we first detected hsa_circ_0001874 levels in GC cell lines and tissues and analyzed their potential correlation with clinicopathological factors. Then, a receiver operating characteristic (ROC) curve was established to evaluate its clinical value. Finally, we further predicted the biological functions of this molecule by bioinformatics analysis.

RESULTS

Our data showed that as an indicator, hsa_circ_0001874 expression was significantly decreased in 78.02% (71/91) of the GC patients. Combined with clinicopathological factors, the hsa_circ_0001874 level was strongly associated with cell differentiation (p < 0.001), tumor stage (p = 0.005), invasion (p = 0.024), lymphatic metastasis (p = 0.023), and CEA level (p < 0.001) in GC tissues. The area under the curve (AUC) was up to 0.673, with a sensitivity and specificity of 61.54% and 68.13%, respectively. Bioinformatics analysis showed that hsa_circ_0001874 harbors miR-593-5p, miR-103a-3p, and miR-107 seed sequences to regulate these three miRNAs and downstream target genes and exert its various biological functions in the carcinogenesis and progression of GC.

CONCLUSION

In summary, these data suggest that hsa_circ_0001874 is an indicator of GC and plays a significant role in gastric carcinogenesis and progression.

A New Scoring Method for Personalized Prognostic Prediction in Patients with Combined Hepatocellular and Cholangiocarcinoma After Surgery

BACKGROUND AND AIM

Combined hepatocellular and cholangiocarcinoma (cHCC-CCA) is a rare but aggressive primary liver cancer with dismal prognosis. We aim to develop a new scoring method for personalized prognostic prediction in patients with cHCC-CCA undergoing surgical resection.

METHODS

Between January 1993 and December 2015, a total of 296 Allen type C cHCC-CCA patients who had received surgical resection in Liver Cancer Institute, Zhongshan Hospital were retrospectively enrolled. A novel prognostic scoring method for cHCC-CCA (PSM-CHCC model) was established and validated. The predictive value of the new model was compared with current prognostic staging systems.

RESULTS

The scoring model was developed based on the independent prognostic variables identified by Cox regression model. Based on the PSM-CHCC model, patients were stratified into three prognostic subgroups according to their individual score: A (scoring 0-2), B (scoring 3-5), and C (scoring > 5). The prediction performance of the PSM-CHCC model outperformed the widely accepted TNM staging system and other staging systems in both training and validation cohorts. Subgroup analysis also verified the discrimination efficacy of the PSM-CHCC model.

CONCLUSIONS

The newly established PSM-CHCC model may facilitate prognostic stratification and clinical decision-making in patients with cHCC-CCA.

Association of preoperative and postoperative CA72-4 with gastric cancer outcome

BACKGROUND AND OBJECTIVES

Carbohydrate antigen 72-4 (CA72-4) is widely used and has been associated with poor prognosis in gastric cancer (GC), but the prognostic significance of elevated preoperative CA72-4 that normalizes after resection remains unknown.

METHODS

This retrospective cohort analysis was conducted at the Sun Yat-Sen University Cancer Center (SYSUCC). Consecutive patients (n = 1179) with GC who had undergone curative resection for stage Ⅰto Ⅲ gastric adenocarcinoma. The patients were grouped into three cohorts: normal preoperative CA72-4 (C1), elevated preoperative but normalized postoperative CA72-4 (C2), and elevated preoperative and postoperative CA72-4 (C3).

RESULTS

In total, 1179 patients were identified. Kaplan-Meier analysis showed that patients with normal preoperative CA72-4 had a longer overall survival (OS) (p < .001) and recurrence-free survival (RFS) (p < .001) than those with elevated preoperative CA72-4. Patients with C1 had a longer OS and RFS than those with C2 or C3. Moreover, patients with C3 had the lowest OS, but had similar RFS to patients with C2. Multivariate Cox regression analysis showed that elevated pre- or postoperative CA72-4 was independently associated with shorter OS (hazard ratio [HR] = 1.273; 95% confidence interval [CI], 1.026-1.580; p = .029) and RFS (HR = 1.333; 95% CI, 1.064-1.668; p = .012).

CONCLUSIONS

Both elevated preoperative and postoperative CA72-4 can well predict the poor prognosis of patients with GC. Therefore, routine measurement of both postoperative and preoperative CA72-4 is warranted.

A novel prognosis marker based on combined preoperative carcinoembryonic antigen and systemic inflammatory response for resectable gastric cancer

Background: Carcinoembryonic antigen (CEA) is one of the important indexes for the diagnosis and prognosis of gastrointestinal cancer. Systemic inflammatory response (SIR) is closely related to the occurrence and development of gastrointestinal cancer.

Methods: A total of 803 patients who underwent radical gastrectomy in Qinghai University Affiliated Hospital from January 2012 to December 2016 were included as training set. Multivariable Cox proportional hazard regression was used to identify associations with outcome of gastric cancer (GC). CNLR was established by combining CEA and the neutrophils to lymphocytes ratio (NLR, a typical parameter in SIR) to generate a novel prognostic score system and its prognostic value was externally validated.

Results: Multivariate analysis showed that CEA and NLR were independent prognostic factors for GC patients (both p < 0.05). A higher CNLR was significantly associated with older age, male sex, larger tumor size, vascular invasion and advanced stages (all p < 0.05). Patients with higher CNLR had poor prognosis than those with lower CNLR (p < 0.05). Multivariate analysis showed that CNLR was an independent prognostic factor (p < 0.05). Incorporation of the CNLR into a prognostic model including age and TNM stage generated a nomogram, which predicted accurately 3- and 5-year survival for GC patients. And similar results were obtained in the external validation set.

Conclusions: The CNLR prognostic scoring system established by combining CEA and NLR is an independent prognostic factor for GC, which can be incorporated into the traditional TNM staging to improve the prediction of long-term survival outcomes.

Circulating CEA-positive and EpCAM-negative tumor cells might be a predictive biomarker for recurrence in patients with gastric cancer

It has been reported that circulating tumor cells (CTCs) are beneficial for predicting tumor stage or treatment response. Although epithelial cell adhesion molecules (EpCAMs) and cytokeratin (CK) have been often used for the identification of CTCs, other tumor markers have not been fully investigated as detecting tools for CTCs. Thus, this study aims to clarify the significance of carcinoembryonic antigen (CEA, CD66e)-positive CTCs in patients with gastric cancer. A total of 150 patients with gastric cancer were enrolled in this study. The mononuclear fraction of peripheral blood was enriched by Ficoll. The number of cells was enumerated depending on the positivity of EpCAM and CEA or CK by flow cytometry. The association of these cells with clinicopathologic characteristics was investigated. The mean age was 70 (range 28-92). The macroscopic type of gastric cancer was classified as 0/1/2/3/4/5 in 59/11/22/38/16/4 patients, respectively. Seventy-one patients (47.3%) were diagnosed with intestinal-type cancer, while 76 patients (50.7%) were diagnosed with the diffuse type. The mean numbers of cells with EpCAM-CK+, EpCAM+CK-, EpCAM+CK+, EpCAM-CEA+, EpCAM+CEA-, and EpCAM+CEA+ were 618, 237, 19.9, 1147, 291, and 7.41, respectively. The number of EpCAM-CEA+cells was significantly higher in patients with stage II-III and IV than in patients with stage I. The 3-year RFS rate in patients with a high number of EpCAM-CEA+cells (>=622) was 57.5%, while it was 79.3% in patients with a low number of EpCAM-CEA+cells (<622) (log-rank p = 0.0079). Thus, we conclude that CEA-positive CTCs will be a clinically beneficial biomarker in patients with gastric cancer.

Adenosquamous carcinoma of the digestive system: a literature review

Adenosquamous carcinoma (ASC), containing both adenocarcinoma and squamous cell carcinoma components, is rare in the digestive system. Limited data is available on ASC of the digestive system (AS-ASC), and the current evidence is available mainly in the form of case reports and case series. We performed a thorough search of the available literature and compiled a review on the epidemiology, histopathology, pathogenesis, clinical manifestations, diagnosis, treatment, and prognosis of AS-ASC. Non-specific clinical and imaging presentations and low diagnostic accuracy of biopsy lead to difficulties in preoperative diagnosis in a high proportion of patients and high malignancy. The pathogenesis remains obscure. Surgery remains the mainstay of treatment for AS-ASC. The role of chemoradiotherapy as an adjuvant treatment is still inconclusive. Key messages Metastatic linings and the lack of efficacious treatments lead to an unfavorable outcome in AS-ASC patients. Further research could help us understand the pathophysiology of AS-ASCand the unique needs of AS-ASC patients.

Which is the optimal management for locally advanced gastric cancer patients with TRG 0 and 1 after R0 resection?

Background

Neoadjuvant chemotherapy (NAC) followed by surgery currently offers promise as a strategy for patients with locally advanced gastric cancer (GC). However, there is limited evidence to guide treatment for TRG 0 and 1 patients with locally advanced GC after R0 resection. This study set out to explore the optimal management for TRG 0 and 1 patients with locally advanced GC after R0 resection.

Methods

The retrospective data of 154 TRG 0 and 1 patients with locally advanced GC following R0 resection who were treated between January 2012 and December 2018 were collected and analyzed. The Kaplan-Meier method was used to estimate the survival rate. Multivariate analysis was performed using the Cox proportional hazards model.

Results

The median follow-up was 34.1 (range, 6.6–90.9) months. Six patients (3.9%) were lost during follow-up. Of the 27 patients who experienced relapse, 12 died, including 2 patients who died of non-neoplastic causes. The 5-year recurrence-free survival (RFS) and 5-year overall survival (OS) were 71.6% (95% CI: 68.5–79.6) and 82.9% (95% CI: 76.9–86.1) for the whole cohort, respectively. Univariate analysis revealed that patients with carcinoembryonic antigen (CEA) <5.0 ng/ml after NAC (77.7% vs. 20.1%, P<0.001), distal gastrectomy (91.7% vs. 67.5%, P=0.046) had higher 5-year RFS. Meanwhile, combined resection (55.6% vs. 73.1%, P=0.042), major complications (42.7% vs. 80.50%, P<0.001), and lymph node metastasis (ypN+) (52.0% vs. 83.7%, P<0.001) had lower 5-year RFS. The multivariate analysis showed that CEA level after NAC (HR =2.876, 95% CI: 1.051–7.872, P=0.040), major complications (HR =2.432, 95% CI: 1.062–5.567, P=0.035), and lymph node metastasis (ypN+) (HR =3.183, 95% CI: 1.242–8.161, P=0.016) were independent prognostic factors.

Conclusions

TRG 0 and 1 patients with local GC after R0 resection following NAC had a good prognosis, especially patients with CEA <5.0 ng/mL after NAC, and those without major complications or lymph node metastasis. Monotherapy or no chemotherapy may offer options for treating TRG 0 and 1 patients without adverse prognostic factors.

Prognostic significance of pre- and post-operative tumour markers for patients with gastric cancer

Background

In clinical practice, carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 are the most common markers measured before and after surgery for gastric cancer (GC). However, which pre- or post-operative combined tumour markers (CEA and CA19-9) have more prognostic value remains unclear.

Methods

Consecutive patients undergoing a resection for GC at the Fujian Medical University Union Hospital were included as a discovery database between January 2011 and December 2014. The prognostic impact of pre- and post-operative tumour markers was evaluated using Kaplan–Meier log-rank survival analysis and multivariable Cox regression analysis. The results were then externally validated.

Results

A total of 735 and 400 patients were identified in the discovery cohort and in the validation cohort, respectively. Overall survival rates decreased in a stepwise manner in association with the number of pre- and post-operative positive tumour markers (both P < 0.001). Multivariable analysis revealed that the number of pre-operative positive tumour markers was an independent prognostic factor (P < 0.05). For patients with abnormal pre-operative tumour markers, normalisation of tumour markers after surgery is an independent prognostic protective factor (hazard ratio (HR) = 0.618; 95% confidence interval (CI) = 0.414–0.921), and patients with both positive post-operative tumour markers had double the risk of overall death (HR = 2.338; 95% CI = 1.071–5.101). Similar results were observed in the internal validation and external validation cohorts.

Conclusion

Pre-operative tumour markers have a better discriminatory ability for post-operative survival in GC patients than post-operative tumour markers, and the normalisation of tumour markers after surgery was associated with better survival.

Predictive value of E-cadherin and EpCAM for detection of metastatic lymph node in early gastric cancer

Objective

There has been a demand for a tumor-specific marker for metastatic lymph nodes in sentinel navigation surgery for gastric cancer. The aim of this study is to analyze protein expression in both primary tumors and metastatic lymph nodes in early gastric cancer patients.

Methods

We collected primary tumors and metastatic lymph nodes from 71 patients who underwent curative gastrectomy and pathologically diagnosed with T1N1 or T1N2 (8th Union for International Cancer Control 8th edition/American Joint Committee on Cancer staging system) gastric cancer. Immunohistochemistry was used to determine the expression of six cell membrane proteins, including carcinoembryonic antigen (CEA), E-cadherin, epithelial cell adhesion molecule (EpCAM), P-cadherin, CD44v6, and c-erbB2 in the patient samples.

Results

The expression of CEA, E-cadherin, EpCAM, P-cadherin, CD44v6 and c-erbB2 in the evaluable primary tumor samples was 75.4%, 97.1%, 100%, 89.9%, 11.1% and 7.2%, respectively. Among cases wherein both the primary tumor and metastatic lymph nodes were evaluable, double positivity (expression in both primary tumor and metastatic lymph nodes) was observed for CEA, E-cadherin, EpCAM, P-cadherin, CD44v6 and c-erbB2 in 53.2%, 97.9%, 98.1%, 76.6%, 0 and 6.8% of the cases, respectively. The proportion of metastatic lymph nodes positive for CEA, E-cadherin, EpCAM, P-cadherin, CD44v6 and c-erbB2 was 71.4%, 100%, 98.1%, 83.7%, 0, and 75%, respectively in primary tumors positive for the same markers.

Conclusions

E-cadherin and EpCAM had an overlap of 100% and 98.1% between the primary tumor and metastatic lymph nodes, respectively. Thus, E-cadherin and EpCAM are potential molecular markers to detect metastatic lymph nodes in patients with early gastric cancer.

Clinical significances of hsa_circ_0067582 and hsa_circ_0005758 in gastric cancer tissues

BACKGROUND

Circular RNAs (circRNAs) are a special class of endogenous noncoding RNAs that have numerous biological functions in normal situation and diseases including cancers. However, the clinical significance of circRNAs in gastric cancer (GC) remains largely unknown. Here, we chose two representative circRNAs, hsa_circ_0067582 and hsa_circ_0005758, to investigate their clinical significance in GC patients.

METHODS

Using real-time quantitative reverse transcription-polymerase chain reaction (qRT-PCR), we explored the expression levels of hsa_circ_0067582 and hsa_circ_0005758 in tissues with different stages of gastric tumorigenesis. Then, the relationships between their expression levels and GC patients' clinicopathological factors were further investigated. Receiver operating characteristic (ROC) curves were established for evaluating diagnostic values of hsa_circ_0067582 and hsa_circ_0005758.

RESULTS

Compared with healthy control tissues, both hsa_circ_0067582 and hsa_circ_0005758 were significantly decreased in GC tissues. Besides, hsa_circ_0067582 expression was associated with GC patients' tissue CEA level (P <.001) and stages (P = .037); and hsa_circ_0005758 expression was relevant to tissue CEA level (P < .001) and perineural invasion (P = .048). The area under the ROC curve (AUC) of hsa_circ_0067582 was up to 0.671. The cutoff value was set at 10.61, with which the sensitivity and specificity were 55.2% and 75.0%, respectively. Similar to hsa_circ_0005758, the AUC of hsa_circ_0005758 was 0.721. The cutoff value was set at 10.20, with which the sensitivity and specificity were 75.0% and 67.7%, respectively.

CONCLUSION

These results showed that both hsa_circ_0067582 and hsa_circ_0005758 may play an important role in gastric carcinogenesis; and they may be potential indicators for GC diagnosis.

Prognostic significance of perioperative tumor marker levels in stage II/III gastric cancer

AIM

To evaluate the prognostic significance of perioperative carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels in stage II/III gastric cancer.

METHODS

From a multi-institutional retrospective database compiled by integrating clinical data from nine institutions, data of 998 patients who underwent curative resection for stage II/III gastric cancer between 2010 and 2014 were retrieved and analyzed. The prognostic impact of the preoperative and postoperative levels and chronological changes in CEA, CA19-9 and their combination were evaluated. To test whether postoperative adjuvant chemotherapy alters the prognostic impact of perioperative CEA and CA19-9 levels, the hazard ratios for mortality were compared between patients who underwent surgery alone and patients who underwent surgery followed by adjuvant chemotherapy.

RESULTS

The prognostic impact of postoperative CEA and CA19-9 was superior to that of the preoperative levels. Multivariable analysis identified high postoperative CEA and CA19-9 levels as independent prognostic factors for overall survival. Disease-free survival rates clearly decreased in a stepwise manner in association with postoperative CEA and CA19-9 levels, and patients with high levels of both markers showed significantly poorer prognosis than other patient groups. When we analyzed perioperative changes in serum CEA and CA19-9 levels, patients with high levels before and after surgery had the worst disease-free survival rates among all patient groups. Patients with normalized CEA levels after surgery had a significantly lower disease-free survival rate than those with normal perioperative levels, whereas patients with normalized CA19-9 levels after surgery had equivalent survival to those with normal perioperative levels. The prognostic impact of high CEA levels was observably smaller in patients who underwent adjuvant chemotherapy than in patients who underwent surgery alone, whereas that of high CA19-9 was greater in patients who underwent adjuvant chemotherapy. High postoperative CEA levels were significantly associated with an increased prevalence of liver, lung and bone recurrences, and high postoperative CA19-9 levels were significantly associated with increased frequencies of lymph node and liver recurrences.

CONCLUSION

The evaluation of serum CEA and CA 19-9 levels both before and after surgery provides useful information for precise risk stratification after curative gastrectomy.

Proposal for a New TNM Stage based on the 7th and 8th American Joint Committee on Cancer pTNM Staging Classification for Gastric Cancer

Background: The 8^th edition of the American Joint Committee on Cancer (AJCC) staging system for gastric cancer incorporated several new changes. We aimed to assess the comparative prognostic values of the 7^th and 8^th AJCC pTNM staging systems in patients with gastric cancer (GC), and accordingly, to put forward a refined staging classification. Methods: The SEER database was queried to identify GC patients between 2004 and 2009. GC patients from Sun Yat-sen University Cancer Center (SYSUCC) were used as external validation data. The Kaplan-Meier method and Cox proportional hazards regression models were used to analyze cause-specific survival (CSS). The prognostic performance of different staging schemes was assessed using the concordance index (c-index), Akaike's information criterion (AIC), and likelihood ratio χ² test. Results: In the SEER cohort, stage migration occurred in 8.74% of patients. Survival analysis showed that it was better to treat T4bN0M0 + T4aN2M0 as stage IIIB and T4bN3bM0 as stage IV. Based on this, we established a new staging system which exhibited a superior c-index (0.7501) to the 7^th and 8^th AJCC staging systems (0.7498 and 0.7500, respectively). The new staging system also outperformed the 7^th and 8^th AJCC staging systems in terms of AIC and the likelihood ratio χ² test. The predictive superiority of the new staging system remained valid in the SYSUCC database. Conclusions: We demonstrated that some stage modifications in the 8^th AJCC pathologic staging were unnecessary. Therefore we established a new staging system, which was superior to the 7^th and 8^th staging systems.

Serum microRNA signatures and metabolomics have high diagnostic value in gastric cancer

BACKGROUND

Many novel diagnostic biomarkers have been developed for gastric cancer (GC) recently. We chose two methods with high diagnostic value, the detection of serum microRNAs and metabolomics based on gas chromatography/mass spectrometry (GC/MS), and aimed to establish appropriate models.

METHODS

We reviewed the diagnostic accuracies of all microRNAs identified by previous diagnostic tests. Then appropriate microRNAs and their combinations were validated the diagnostic value. We included 80 patients with GC and 82 healthy controls (HCs) and detected the expression of the microRNAs. GC/MS analysis was conducted, and we used three multivariate statistical analyses to establish diagnostic models. The concentrations of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) were detected for comparison with the novel models.

RESULTS

Sixty-seven published studies and 70 microRNAs were finally included in the systematic review. MiR-18a, miR-19a, miR-21, miR-92a, miR-199a and miR-421 were chosen to further validate their diagnostic efficiencies. Five of those microRNAs in GC patients had significantly different expression. The combination of miR-19a and miR-92a had the highest area under the curve (AUC) at 0.850 with a sensitivity of 91.3% and a specificity of 61.0%. The GC/MS analysis performed an excellent diagnostic value and the AUC reached 1.0.

CONCLUSION

There is a good potential for microRNAs and GC/MS analysis as new diagnostic methods in view of their high diagnostic value compared with traditional biomarkers.

Decreased expression of hsa_circ_0001895 in human gastric cancer and its clinical significances

Circular RNAs are a special class of endogenous RNAs characterized by jointing 3' and 5' ends together via exon or intron circularization. Recent studies found that circular RNAs are involved in the development of some human diseases. However, little is known about their roles in human gastric cancer. In this study, we chose hsa_circ_0001895 as a targeted circRNA to investigate its clinical significances in gastric cancer patients. Hsa_circ_0001895 expression levels in five gastric cancer cell lines and 257 specimens of tissues were measured by real-time quantitative reverse transcription polymerase chain reaction. Then, the potential relationship between hsa_circ_0001895 expression levels and patients' clinicopathological factors was investigated. A receiver operating characteristic curve was constructed for evaluating the diagnostic value of hsa_circ_0001895. Hsa_circ_0001895 expression levels in five detected gastric cancer cell lines (AGS, BGC-823, HGC-27, MGC-803, and SGC-7901) were all significantly downregulated than those in normal gastric epithelial GES-1 cells. Besides, compared with healthy control tissues, it was downregulated not only in 69.8% (67/96) gastric cancer tissues but also in gastric precancerous lesions. Moreover, hsa_circ_0001895 expression levels were significantly correlated with cell differentiation, Borrmann type, and tissue carcino-embryonic antigen expression. Our results suggested that hsa_circ_0001895 may play crucial roles during gastric cancerogenesis and is a potential biomarker for clinical prognosis prediction.

Global circular RNA expression profile of human gastric cancer and its clinical significance

Circular RNAs (circRNAs) are a new class of noncoding RNAs. However, the expression profile and clinical significance of circRNAs in human gastric cancer is unclear. The global circRNA expression profile in human gastric cancer was measured by circRNA microarray. Hsa_circ_0014717, one of the most downregulated circRNAs in microarray, was selected as a targeted circRNA to explore its levels in gastric tissues and gastric juice. Freeze-thaw experiment and incubation experiment confirmed the stability of gastric juice circRNAs. A total of 308 circRNAs, including 107 (34.74%) upregulated and 201 (65.26%) downregulated circRNAs, were found significantly aberrantly expressed in gastric cancer tissues. The top ten upregulated in gastric cancer tissues were hsa_circ_0035445, hsa_circ_0003789, hsa_circ_0063809, hsa_circ_0074362, hsa_circ_0006282, hsa_circ_0011107, hsa_circ_0084606, hsa_circ_0005556, hsa_circ_0050547, and hsa_circ_0006470, while the top ten downregulated ones were hsa_circ_0007099, hsa_circ_0001897, hsa_circ_0007707, hsa_circ_0008832, hsa_circ_0001546, hsa_circ_0002089, hsa_circ_0004680, hsa_circ_0000154, hsa_circ_0004458, and hsa_circ_0008394. The hot-point chromosomes were chr1, chr2, chr3, chr9, and chr17. Hsa_circ_0014717 was significantly downregulated in 77.2% (74/96) gastric cancer tissues. Its levels in gastric cancer tissues were related to tumor stage (P = 0.037), distal metastasis (P = 0.048), tissue carcinoembryonic antigen (P = 0.001), and carbohydrate antigen 19-9 expression (P = 0.021). More importantly, hsa_circ_0014717 can stably exist in human gastric juice; and its nature meets the requirements of clinical detection. Our study uncovered the circRNA expression profile in human gastric cancer. Moreover, some circRNAs can stably exist in human body fluid, and has the potential to be used as novel biomarkers for the screening of high-risk gastric cancer patients.

Evaluation of the Clinical Significance of Serum Carcinoembryonic Antigen in Patients with Resectable Gastric Adenocarcinoma

BACKGROUND AND AIMS

Carcinoembryonic antigen (CEA) is the most commonly used tumor marker for gastrointestinal cancers but its value for resectable gastric adenocarcinoma (RGA) patients in areas of high GA incidence is uncertain.

METHODS

We retrospectively studied 400 subjects with RGA from the Fujian Province in China, which has a high incidence of GA. Patients had surgery between January 2010 and December 2013. CEA was measured and correlated to pathology.

RESULTS

High pretreatment serum CEA (>5 ng/mL) was associated with patient age (p = 0.000), tumor size (p = 0.008), and T and N stages (p = 0.002, p = 0.032, respectively), alpha fetoprotein (p = 0.014), and CA19-9 (p = 0.000). High CEA was significantly associated with poor overall survival. Overall survival in the whole group of patients was 63.8%, whereas it was only 42.9% in the high CEA group (p = 0.0001). Mean overall survival for high CEA patients was significantly shorter than patients with low CEA (36.5 ± 2.63 months vs. 47.4 ± 0.98 months, p = 0.000). Multivariate analysis confirmed that pretreatment serum CEA was an independent prognostic factor for increased death risk. Additionally, mean CEA in 45 high CEA patients was reduced after surgery.

CONCLUSIONS

Pretreatment serum CEA may help to predict survival for patients with RGA in high GA incidence areas.