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Zhu Y, Song B, Yang Z, Peng Y, Cui Z, Chen L, Song B. Integrative lactylation and tumor microenvironment signature as prognostic and therapeutic biomarkers in skin cutaneous melanoma. J Cancer Res Clin Oncol 2023; 149:17897-17919. [PMID: 37955686 DOI: 10.1007/s00432-023-05483-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/18/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND The incidence of skin cutaneous melanoma (SKCM), one of the most aggressive and lethal skin tumors, is increasing worldwide. However, for advanced SKCM, we still lack an accurate and valid way to predict its prognosis, as well as novel theories to guide the planning of treatment options for SKCM patients. Lactylation (LAC), a novel post-translational modification of histones, has been shown to promote tumor growth and inhibit the antitumor response of the tumor microenvironment (TME) in a variety of ways. We hope that this study will provide new ideas for treatment options for SKCM patients, as well as research on the molecular mechanisms of SKCM pathogenesis and development. METHODS At the level of the RNA sequencing set (TCGA, GTEx), we used differential expression analysis, LASSO regression analysis, and multifactor Cox regression analysis to screen for prognosis-related genes and calculate the corresponding LAC scores. The content of TME cells in the tumor tissue was calculated using the CIBERSORT algorithm, and the TME score was calculated based on its results. Finally, the LAC-TME classifier was established and further analyzed based on the two scores, including the construction of a prognostic model, analysis of clinicopathological characteristics, and correlation analysis of tumor mutation burden (TMB) and immunotherapy. Based on single-cell RNA sequencing data, this study analyzed the cellular composition in SKCM tissues and explored the role of LAC scores in intercellular communication. To validate the functionality of the pivotal gene CLPB in the model, cellular experiments were ultimately executed. RESULTS We screened a total of six prognosis-related genes (NDUFA10, NDUFA13, CLPB, RRM2B, HPDL, NARS2) and 7 TME cells with good prognosis. According to Kaplan-Meier survival analysis, we found that the LAClow/TMEhigh group had the highest overall survival (OS) and the LAChigh/TMElow group had the lowest OS (p value < 0.05). In further analysis of immune infiltration, tumor microenvironment (TME), functional enrichment, tumor mutational load and immunotherapy, we found that immunotherapy was more appropriate in the LAClow/TMEhigh group. Moreover, the cellular assays exhibited substantial reductions in proliferation, migration, and invasive potentials of melanoma cells in both A375 and A2058 cell lines upon CLPB knockdown. CONCLUSIONS The prognostic model using the combined LAC score and TME score was able to predict the prognosis of SKCM patients more consistently, and the LAC-TME classifier was able to significantly differentiate the prognosis of SKCM patients across multiple clinicopathological features. The LAC-TME classifier has an important role in the development of immunotherapy regimens for SKCM patients.
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Affiliation(s)
- Yuhan Zhu
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 127 Chanle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Binyu Song
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 127 Chanle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Ziyi Yang
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 127 Chanle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Yixuan Peng
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 127 Chanle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Zhiwei Cui
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 127 Chanle West Road, Xi'an, 710032, Shaanxi Province, China
| | - Lin Chen
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 127 Chanle West Road, Xi'an, 710032, Shaanxi Province, China.
| | - Baoqiang Song
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 127 Chanle West Road, Xi'an, 710032, Shaanxi Province, China.
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Demidova EV, Serebriiskii IG, Vlasenkova R, Kelow S, Andrake MD, Hartman TR, Kent T, Virtucio J, Rosen GL, Pomerantz RT, Dunbrack RL, Golemis EA, Hall MJ, Chen DYT, Daly MB, Arora S. Candidate variants in DNA replication and repair genes in early-onset renal cell carcinoma patients referred for germline testing. BMC Genomics 2023; 24:212. [PMID: 37095444 PMCID: PMC10123997 DOI: 10.1186/s12864-023-09310-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 04/13/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Early-onset renal cell carcinoma (eoRCC) is typically associated with pathogenic germline variants (PGVs) in RCC familial syndrome genes. However, most eoRCC patients lack PGVs in familial RCC genes and their genetic risk remains undefined. METHODS Here, we analyzed biospecimens from 22 eoRCC patients that were seen at our institution for genetic counseling and tested negative for PGVs in RCC familial syndrome genes. RESULTS Analysis of whole-exome sequencing (WES) data found enrichment of candidate pathogenic germline variants in DNA repair and replication genes, including multiple DNA polymerases. Induction of DNA damage in peripheral blood monocytes (PBMCs) significantly elevated numbers of [Formula: see text]H2AX foci, a marker of double-stranded breaks, in PBMCs from eoRCC patients versus PBMCs from matched cancer-free controls. Knockdown of candidate variant genes in Caki RCC cells increased [Formula: see text]H2AX foci. Immortalized patient-derived B cell lines bearing the candidate variants in DNA polymerase genes (POLD1, POLH, POLE, POLK) had DNA replication defects compared to control cells. Renal tumors carrying these DNA polymerase variants were microsatellite stable but had a high mutational burden. Direct biochemical analysis of the variant Pol δ and Pol η polymerases revealed defective enzymatic activities. CONCLUSIONS Together, these results suggest that constitutional defects in DNA repair underlie a subset of eoRCC cases. Screening patient lymphocytes to identify these defects may provide insight into mechanisms of carcinogenesis in a subset of genetically undefined eoRCCs. Evaluation of DNA repair defects may also provide insight into the cancer initiation mechanisms for subsets of eoRCCs and lay the foundation for targeting DNA repair vulnerabilities in eoRCC.
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Affiliation(s)
- Elena V Demidova
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
- Kazan Federal University, Kazan, 420008, Russia
| | - Ilya G Serebriiskii
- Kazan Federal University, Kazan, 420008, Russia
- Program in Cancer Signaling and Microenvironment, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Ramilia Vlasenkova
- Kazan Federal University, Kazan, 420008, Russia
- Program in Cancer Signaling and Microenvironment, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Simon Kelow
- Department of Biochemistry and Molecular Biophysics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Mark D Andrake
- Program in Cancer Signaling and Microenvironment, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Tiffiney R Hartman
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
- Arcadia University, Glenside, PA, USA
| | - Tatiana Kent
- Department of Biochemistry & Molecular Biology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - James Virtucio
- Ecological and Evolutionary Signal-Processing and Informatics Laboratory, Department of Electrical and Computer Engineering, College of Engineering, Drexel University, Philadelphia, PA, 19104, USA
| | - Gail L Rosen
- Ecological and Evolutionary Signal-Processing and Informatics Laboratory, Department of Electrical and Computer Engineering, College of Engineering, Drexel University, Philadelphia, PA, 19104, USA
| | - Richard T Pomerantz
- Department of Biochemistry & Molecular Biology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Roland L Dunbrack
- Program in Cancer Signaling and Microenvironment, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Erica A Golemis
- Program in Cancer Signaling and Microenvironment, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
- Department of Cancer and Cellular Biology, Lewis Katz School of Medicine, Philadelphia, PA, 19140, USA
| | - Michael J Hall
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
- Department of Clinical Genetics, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - David Y T Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Mary B Daly
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
- Department of Clinical Genetics, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
| | - Sanjeevani Arora
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA.
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Hossainey MRH, Yaparla A, Uzzaman Z, Moore T, Grayfer L. A comparison of amphibian (Xenopus laevis) tadpole and adult frog macrophages. DEVELOPMENTAL AND COMPARATIVE IMMUNOLOGY 2023; 141:104647. [PMID: 36707039 DOI: 10.1016/j.dci.2023.104647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/30/2022] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
The amphibian declines are compounded by emerging pathogens that often preferentially target distinct amphibian developmental stages. While amphibian immune responses remain relatively unexplored, macrophage (Mφ)-lineage cells are believed to be important to both amphibian host defenses and to their pathogen infection strategies. As such, a greater understanding of tadpole and adult amphibian Mφ functionality is warranted. Mφ biology is interdependent of interleukin-34 (IL-34) and colony-stimulating factor-1 (CSF-1) cytokines and we previously showed that CSF-1- and IL-34-derived Mφs of the Xenopus laevis frog are morphologically, transcriptionally, and functionally distinct. Presently, we directly compared the cytology and transcriptomes of X. laevis tadpole and frog CSF-1- and IL-34-Mφs. Our results indicate that tadpole and frog CSF-1-Mφs possess greater non-specific esterase activity, typically associated with Mφ-lineage cells. By contrast, both tadpole and frog IL-34-Mφs have greater specific esterase activity, which is typically attributed to granulocyte-lineage cells. Our comparisons of tadpole CSF-1-Mφ transcriptomes with those of tadpole IL-34-Mφs indicate that the two tadpole populations possess significantly different transcriptional profiles of immune and non-immune genes. The frog CSF-1-Mφ gene expression profiles are likewise significantly disparate from those of frog IL-34-Mφs. Compared to their respective tadpole Mφ subtypes, frog CSF-1- and IL-34-Mφs exhibited greater expression of genes associated with antigen presentation. Conversely, compared to their frog Mφ counterparts, tadpole CSF-1- and IL-34-Mφs possessed greater levels of select Fc-like receptor genes. Presumably, these cytological and transcriptional differences manifest in distinct biological roles for these respective tadpole and frog Mφ subtypes.
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Affiliation(s)
| | - Amulya Yaparla
- Department of Biological Sciences, George Washington University, Washington, DC, 20052, USA
| | - Zarafsha Uzzaman
- Department of Biological Sciences, George Washington University, Washington, DC, 20052, USA
| | - Tyler Moore
- Department of Biological Sciences, George Washington University, Washington, DC, 20052, USA
| | - Leon Grayfer
- Department of Biological Sciences, George Washington University, Washington, DC, 20052, USA.
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Integrative proteogenomic characterization of hepatocellular carcinoma across etiologies and stages. Nat Commun 2022; 13:2436. [PMID: 35508466 PMCID: PMC9068765 DOI: 10.1038/s41467-022-29960-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 04/09/2022] [Indexed: 12/13/2022] Open
Abstract
Proteogenomic analyses of hepatocellular carcinomas (HCC) have focused on early-stage, HBV-associated HCCs. Here we present an integrated proteogenomic analysis of HCCs across clinical stages and etiologies. Pathways related to cell cycle, transcriptional and translational control, signaling transduction, and metabolism are dysregulated and differentially regulated on the genomic, transcriptomic, proteomic and phosphoproteomic levels. We describe candidate copy number-driven driver genes involved in epithelial-to-mesenchymal transition, the Wnt-β-catenin, AKT/mTOR and Notch pathways, cell cycle and DNA damage regulation. The targetable aurora kinase A and CDKs are upregulated. CTNNB1 and TP53 mutations are associated with altered protein phosphorylation related to actin filament organization and lipid metabolism, respectively. Integrative proteogenomic clusters show that HCC constitutes heterogeneous subgroups with distinct regulation of biological processes, metabolic reprogramming and kinase activation. Our study provides a comprehensive overview of the proteomic and phophoproteomic landscapes of HCCs, revealing the major pathways altered in the (phospho)proteome. Proteogenomic analyses of hepatocellular carcinomas (HCC) have focused on early-stage, HBV-associated tumours and lacked information about the phosphoproteome. Here, the authors present a comprehensive HCC proteogenomics and phosphoproteomics study in patient samples from multiple etiologies and stages.
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Pandey P, Arora S, Rosen GL. MetaMutationalSigs: comparison of mutational signature refitting results made easy. Bioinformatics 2022; 38:2344-2347. [PMID: 35157026 PMCID: PMC9004636 DOI: 10.1093/bioinformatics/btac091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 12/07/2021] [Accepted: 02/09/2022] [Indexed: 02/03/2023] Open
Abstract
MOTIVATION The analysis of mutational signatures is becoming increasingly common in cancer genetics, with emerging implications in cancer evolution, classification, treatment decision and prognosis. Recently, several packages have been developed for mutational signature analysis, with each using different methodology and yielding significantly different results. Because of the non-trivial differences in tools' refitting results, researchers may desire to survey and compare the available tools, in order to objectively evaluate the results for their specific research question, such as which mutational signatures are prevalent in different cancer types. RESULTS Due to the need for effective comparison of refitting mutational signatures, we introduce a user-friendly software that can aggregate and visually present results from different refitting packages. AVAILABILITY AND IMPLEMENTATION MetaMutationalSigs is implemented using R and python and is available for installation using Docker and available at: https://github.com/EESI/MetaMutationalSigs.
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Affiliation(s)
- Palash Pandey
- Ecological and Evolutionary Signal-Processing and Informatics Laboratory, Department of Electrical and Computer Engineering, College of Engineering, Drexel University, Philadelphia, PA 19104, USA,Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
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Szarkowska J, Cwiek P, Szymanski M, Rusetska N, Jancewicz I, Stachowiak M, Swiatek M, Luba M, Konopinski R, Kubala S, Zub R, Kucharz J, Wiechno P, Siedlecki JA, Markowicz S, Sarnowska E, Sarnowski TJ. RRM2 gene expression depends on BAF180 subunit of SWISNF chromatin remodeling complex and correlates with abundance of tumor infiltrating lymphocytes in ccRCC. Am J Cancer Res 2021; 11:5965-5978. [PMID: 35018236 PMCID: PMC8727810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 10/12/2021] [Indexed: 06/14/2023] Open
Abstract
About 40% of clear cell renal cell carcinoma (ccRCC) cases carry the pbrm1 mutation inactivating BAF180 subunit of the SWI/SNF chromatin remodeling complex (CRC). Here we show that the majority of transcriptomic changes appear at the stage I of ccRCC development. By contrast, the stage II ccRCC exhibits hyperactivation of DNA replication demonstrated by the overexpression of several genes, e.g., RRM1 and RRM2 genes encoding subunits of ribonucleotide reductase (RNR) complex. We found that the degree of RRM1 and RRM2 upregulation in ccRCC patients depends on pbrm1 mutation. We show that the BAF180 protein product of the PBRM1 gene directly binds to RRM1 and RRM2 loci. The BAF180 binding regions are targeted by regulatory proteins previously reported as SWI/SNF CRC interacting partners. BAF180 binding to RRMs loci correlates with enrichment of H3K27me3 in case of RRM1 and H3K14Ac on RRM2, indicating the existence of differential regulatory mechanism controlling expression of these genes. We found that the strong overexpression of RRM2 in ccRCC patient samples correlates with T cell infiltration. Surprisingly, the majority of tumor infiltrating lymphocytes (TILs) consisted of CD4+ T cells. Furthermore, we show that exhausted CD4+ T cells induced the expression of the RRM2 gene in the primary ccRCC cell line. Collectively, our results provide the link between PBRM1 loss, RRM2 expression and T cell infiltration, which may lead to the establishment of new treatment of this disease.
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Affiliation(s)
- Joanna Szarkowska
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Pawel Cwiek
- Institute of Biochemistry and Biophysics, Polish Academy of SciencesWarsaw, Poland
| | - Michal Szymanski
- Department of Urology and Urological Oncology, Central Clinical Hospital of Ministry of the Interior and Administration in WarsawWarsaw, Poland
| | - Natalia Rusetska
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Iga Jancewicz
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Malgorzata Stachowiak
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Monika Swiatek
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Maciej Luba
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Ryszard Konopinski
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Szymon Kubala
- Institute of Biochemistry and Biophysics, Polish Academy of SciencesWarsaw, Poland
| | - Renata Zub
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Jakub Kucharz
- Department of Uro-oncology, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Pawel Wiechno
- Department of Uro-oncology, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Janusz A Siedlecki
- Department of Molecular and Translational Oncology, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Sergiusz Markowicz
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Elzbieta Sarnowska
- Department of Experimental Immunotherapy, Maria Sklodowska-Curie National Research Institute of OncologyWarsaw, Poland
| | - Tomasz J Sarnowski
- Institute of Biochemistry and Biophysics, Polish Academy of SciencesWarsaw, Poland
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Zhang X, Dong W, Zhang J, Liu W, Yin J, Shi D, Ma W. A Novel Mitochondrial-Related Nuclear Gene Signature Predicts Overall Survival of Lung Adenocarcinoma Patients. Front Cell Dev Biol 2021; 9:740487. [PMID: 34760888 PMCID: PMC8573348 DOI: 10.3389/fcell.2021.740487] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/28/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Lung cancer is the leading cause of cancer-related death worldwide, of which lung adenocarcinoma (LUAD) is one of the main histological subtypes. Mitochondria are vital for maintaining the physiological function, and their dysfunction has been found to be correlated with tumorigenesis and disease progression. Although, some mitochondrial-related genes have been found to correlate with the clinical outcomes of multiple tumors solely. The integrated relationship between nuclear mitochondrial genes (NMGs) and the prognosis of LUAD remains unclear. Methods: The list of NMGs, gene expression data, and related clinical information of LUAD were downloaded from public databases. Bioinformatics methods were used and obtained 18 prognostic related NMGs to construct a risk signature. Results: There were 18 NMGs (NDUFS2, ATP8A2, SCO1, COX14, COA6, RRM2B, TFAM, DARS2, GARS, YARS2, EFG1, GFM1, MRPL3, MRPL44, ISCU, CABC1, HSPD1, and ETHE1) identified by LASSO regression analysis. The mRNA expression of these 18 genes was positively correlated with their relative linear copy number alteration (CNA). Meanwhile, the established risk signature could effectively distinguish high- and low-risk patients, and its predictive capacity was validated in three independent gene expression omnibus (GEO) cohorts. Notably, a significantly lower prevalence of actionable EGFR alterations was presented in patients with high-risk NMGs signature but accompanied with a more inflame immune tumor microenvironment. Additionally, multicomponent Cox regression analysis showed that the model was stable when risk score, tumor stage, and lymph node stage were considered, and the 1-, 3-, and 5-year AUC were 0.74, 0.75, and 0.70, respectively. Conclusion: Together, this study established a signature based on NMGs that is a prognostic biomarker for LUAD patients and has the potential to be widely applied in future clinical settings.
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Affiliation(s)
- Xiangwei Zhang
- Department of General Thoracic, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wei Dong
- Department of General Thoracic, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jishuai Zhang
- Department of General Thoracic, Feicheng Hospital Affiliated to Shandong First Medical University, Feicheng, China
| | - Wenqiang Liu
- Department of General Thoracic, Shenxian County People's Hospital of Shandong Provincial Group, Liaocheng, China
| | - Jingjing Yin
- Department of General Thoracic, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Duozhi Shi
- Lifehealthcare Clinical Laboratories, Hangzhou, China
| | - Wei Ma
- Department of General Thoracic, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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