Clinical utility of tumor marker cutoff ratio and a combination scoring system of preoperative carcinoembryonic antigen, carbohydrate antigen 19-9, carbohydrate antigen 72-4 levels in gastric cancer

Pretreatment controlling nutritional status (CONUT) score and carcinoembryonic antigen level provide tumor progression and prognostic information in gastric cancer: A retrospective study

This study explores the role of combining the controlling nutritional status (CONUT) score and the carcinoembryonic antigen (CEA) level on predicting tumor stage and prognosis in gastric cancer (GC) patients. A total of 682 GC patients were included in this retrospective study. CONUT scores and CEA levels were combined to establish a new scoring system: CONUT-CEA score. cutoff values for distinguishing patients between stage IV and non-stage IV were established by receiver operating characteristic curves. cutoff values for predicting prognosis were determined by maximum χ2 method. The CONUT and CEA cutoff values for discriminating stage IV patients from non-stage IV patients were 2.0 and 5.58 ng/mL, respectively. Logistic regression model demonstrated that high CONUT-CEA score was related to advanced tumor stage. Among non-stage IV patients, CONUT and CEA cutoff values of 2.0 and 9.50 ng/mL predicted overall survival (OS), respectively. The Cox proportional risk model revealed that high CONUT-CEA score was notable related to decreased OS (2 vs 0: hazard ratios (HR) = 2.358, 95% confidence intervals (CI) = 1.412-3.940, P = .001) and decreased disease-free survival (2 vs 0: HR = 1.980, 95% CI = 1.072-3.656, P = .003). The CONUT-CEA score may be a good biomarker for predicting tumor stage and prognosis in GC patients.

Capitalizing glycomic changes for improved biomarker-based cancer diagnostics

Cancer serum biomarkers are valuable or even indispensable for cancer diagnostics and/or monitoring and, currently, many cancer serum markers are routinely used in the clinic. Most of those markers are glycoproteins, carrying cancer-specific glycan structures that can provide extra-information for cancer monitoring. Nonetheless, in the majority of cases, this differential feature is not exploited and the corresponding analytical assays detect only the protein amount, disregarding the analysis of the aberrant glycoform. Two exceptions to this trend are the biomarkers α-fetoprotein (AFP) and cancer antigen 19-9 (CA19-9), which are clinically monitored for their cancer-related glycan changes, and only the AFP assay includes quantification of both the protein amount and the altered glycoform. This narrative review demonstrates, through several examples, the advantages of the combined quantification of protein cancer biomarkers and the respective glycoform analysis, which enable to yield the maximum information and overcome the weaknesses of each individual analysis. This strategy allows to achieve higher sensitivity and specificity in the detection of cancer, enhancing the diagnostic power of biomarker-based cancer detection tests.

Serum p53 antibody: useful for detecting gastric cancer but not for predicting prognosis after surgery

PURPOSE

To establish the clinicopathological importance of serum p53 autoantibody (s-p53-Ab) titrations in patients with gastric cancer.

METHODS

Preoperative s-p53-Ab titers were analyzed in 448 gastric cancer patients between 2010 and 2017. Seropositive patients were divided into three groups based on their antibody titers: 1.31-10.0 U/mL (low group); 10.1-100 U/mL (medium group); and > 100 U/mL (high group). We evaluated the associations between the s-p53-Abs and clinicopathological factors, carcinoembryonic antigen (CEA) levels, and cancer antigen 19-9 (CA19-9) levels. Overall survival was analyzed by multivariate analyses.

RESULTS

A total of 72 patients (16%) were positive for s-p53-Abs. The rate of positivity for s-p53-Abs + CEA + CA19-9 was significantly higher than that for CEA + CA19-9, even in stage I gastric cancers. Gender, tumor depth, lymphatic node metastases, and distant metastases were all significantly associated with the presence of s-p53-Abs; however, overall survival was not associated with the antibodies. The patients in the high titer group (> 100 U/mL) had a relatively worse survival than those in the other groups.

CONCLUSIONS

Based on our findings, s-p53-Abs improve the overall rate of positivity for detecting gastric cancer, but the prognostic value of a high s-p53-Ab titer for predicting overall survival is limited.

Clinical significance of serum tumor markers for advanced gastric cancer with the first-line chemotherapy

Background

Tumor markers play an important role in the diagnosis, monitoring and prognostic prediction of cancers. But the predictive value of serum tumor markers in gastric cancer is still unclear.

Methods

In this study, we detected serum levels of tumor markers to evaluate their relation to treatment response and prognosis in patients with unresectable advanced or metastatic gastric cancer.

Results

We collected the clinical data of 109 patients with unresectable advanced or metastatic gastric cancer who had received the first-line chemotherapy in Peking University Cancer Hospital from July 2013 to May 2015, and collected the value of serum carcinoembryonic antigen (CEA), carbohydrate antigen 199 (CA199), carbohydrate antigen 72.4 (CA72.4) and carbohydrate antigen 125 (CA125) before and after chemotherapy. At diagnosis, the positive rates of CEA, CA199, CA72.4 and CA125 were 46.8%, 40.2%, 53.5% and 35.0%, respectively. And the positive rate of combined detection of the four markers was 87.2%. Although patients with prechemotherapy CA199 ≥80 U/mL (92.3% vs. 68.5%, P=0.016) or CA72.4 ≥20 U/mL (91.4% vs. 62.5%, P=0.003) had higher clinical benefit rate after chemotherapy, they showed poorer prognosis (P=0.023 and P=0.006, respectively). CA72.4 ≥20 U/mL was an independent unfavorable prognostic factor (Hazard Ratio 4.84; 95% confidence interval: 1.910–12.262; P=0.001). In patients with increased levels of tumor markers before treatment, the levels of tumor markers decreased after chemotherapy, especially in those with clinical benefit (CEA, CA72.4 reached statistical significance, P=0.013 and P=0.029, respectively). A decrease of CEA ≥35%, CA199 ≥30%, or CA72.4 ≥40% after chemotherapy had positive prediction value for the response to chemotherapy (P=0.016, P=0.029, and P=0.008, respectively).

Conclusions

The results showed that both high pre-chemotherapy serum levels of tumor markers (CA199 ≥80 U/mL or CA72.4 ≥20 U/mL) and a substantial decrease in tumor markers after chemotherapy (CEA ≥35%, CA199 ≥30%, or CA72.4 ≥40%) could predict a higher clinical benefit rate in patients with unresectable advanced or metastatic gastric cancer. However, this advantage in short-term response to chemotherapy failed to convert into prolonged survival benefits.

Clinical Evaluation of CA72-4 for Screening Gastric Cancer in A Healthy Population: A Multicenter Retrospective Study

Early detection is important for improving the survival rate of patients with gastric cancer (GC). Serum tumor markers have been widely used for detecting GC. However, their clinical values remain controversial. This study aims to investigate the role of serum cancer antigen 72-4 (CA72-4) in the diagnosis of GC in a healthy population. A total of 7757 adults who underwent upper gastrointestinal endoscopy and serum CA72-4 level measurement in multicenters in Taiwan from January 2006 to August 2016 were recruited in this retrospective study. Risk factors for GC, serum tumor markers, and esophagogastroduodenoscopy (EGD) findings were evaluated. High serum levels of CA72-4 were found in 7.2% of healthy adults. CA72-4 level showed lower sensitivity (33.3%) but higher specificity (92.8%); however, the positive predictive value was quite low (0.18%). After adjustment of clinical risk factors for GC using EGD findings, gastric ulcer (adjusted odds ratio (aOR) = 2.11), gastric polyps (aOR = 1.42), and atrophic gastritis (aOR = 1.27) were significantly associated with high serum CA72-4 levels. Furthermore, both age (OR = 1.01) and Helicobacter pylori infection (OR = 1.44) exhibited a significant association with high serum CA72-4 levels. These results indicate that routine screening of CA72-4 levels for diagnosing GC in asymptomatic patients may be ineffective due to low sensitivity and low positive predictive value. The clinical utility of EGD findings along with serum CA72-4 level for screening healthy individuals with GC is warranted.

Paeonol induces the apoptosis of the SGC‑7901 gastric cancer cell line by downregulating ERBB2 and inhibiting the NF‑κB signaling pathway

The purpose of the present study was to analyze the association between paeonol and the known genes related to gastric cancer (GC) using bioinformatics methods, and to investigate the role of paeonol in the potential impact on the nuclear factor‑κB (NF‑κB) signaling pathway, in order to provide a theoretical basis for further elucidating the effect of paeonol on cancer cells. Cell viability, morphology and apoptosis were detected using an MTT assay, an inverted microscope, and flow cytometry, respectively. The correlation between drugs and genes was analyzed using the Search Tool for Interactions of Chemicals (STITCH) gene‑drug interaction network. The expression levels of related mRNA and proteins were determined using reverse transcription‑quantitative polymerase chain reaction analysis and enzyme‑linked immunosorbent assay. The changes in protein expression were examined using western blot analysis. The correlation network between target genes directly affected by paeonol and known GC genes was determined by analyzing the association between the compounds and genes recorded in the STITCH database. The GC‑related epidermal growth factor receptor 2 (ERBB2) gene was at the core position of the paeonol interaction network and may be an important potential target gene for the effect of paeonol on cancer cells. The effect of paeonol on the viability of the SGC‑7901 GC cell line was detected using an MTT assay, which showed that the inhibitory effect occurred in a time‑ and dose‑dependent manner. The observations of cell morphology demonstrated that the cells were floating, abnormal in shape, had unclear boundaries and were sparse in arrangement following paeonol treatment. Flow cytometry indicated that paeonol significantly accelerated the apoptotic rate of the SGC‑7901 GC cells. The examination of clinical samples suggested that ERBB2 was expressed at a high level in GC samples, and was significantly downregulated following the addition of paeonol. The western blot analysis revealed that downregulating ERBB2 affected the activation of the NF‑κB signaling pathway, thereby upregulating the pro‑apoptotic factor B‑cell lymphoma‑associated X protein. Taken together, paeonol significantly downregulated ERBB2 and inhibited the activation of the NF‑κB signaling pathway, thereby inhibiting the proliferation of SGC‑7901 cells and inducing apoptosis.

Use of serum and peritoneal CEA and CA19-9 in prediction of peritoneal dissemination and survival of gastric adenocarcinoma patients: are they prognostic factors?

Introduction To evaluate the impact of serum and peritoneal levels of tumour markers on peritoneal carcinomatosis and survival in gastric adenocarcinoma. Materials and methods Patients with gastric adenocarcinoma were evaluated with regard to serum and peritoneal carcinoembryonic antigen (CEA) and CA19-9. Numeric values and groupings based on serum and peritoneal cutoff values were used. Development of peritoneal carcinomatosis, including positive washing cytology, was regarded as main outcome. Gastric cancer outcomes as disease free and overall survival were analysed. Results There were 67 patients with a mean age of 60 ± 11 years. Positive peritoneal washing cytology was significantly associated with serum CA19-9 and high serum CA 19-9 group (P = 0.033 and P = 0.011, respectively). High peritoneal CEA was shown to be significantly associated with peritoneal carcinomatosis (P = 0.032). After a median follow up of 17 months, 48 patients (71.7%) were alive. Patients with peritoneal carcinomatosis showed significant poorer prognosis as shown by overall survival rate of 28.6%. Only serum CEA was significantly associated with lower disease free and overall survival (P = 0.002 and P = 0.001, respectively). Discussion and conclusion Serum CEA is shown to be significantly associated with poor prognosis for gastric cancer patients. Serum level of CA19-9 and high peritoneal CEA levels are significant predictors for positive peritoneal washing cytology and the development of peritoneal carcinomatosis, respectively. Therefore, the possible impact of serum and peritoneal tumor markers especially on the staging and prognosis of gastric cancer remains to be clarified by future studies.

Combined preoperative concentrations of CEA, CA 19-9, and 72-4 for predicting outcomes in patients with gastric cancer after curative resection

In many cancers, prognostic factors are useful for identifying high-risk patients and in individualizing treatment. We sought to determine whether a combination of tumor markers (CTM) would improve prognostic accuracy in patients with gastric cancer (GC). The CTM score, which is derived from serum concentrations of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), and carbohydrate antigen 72-4 (CA 72-4), was tested retrospectively in 1134 patients with GC undergoing curative resection between October 2000 and December 2012. The CTM score was 2 for patients with two or three elevated markers, 1 for those with one elevated marker, and 0 for those no elevated markers. Overall survival (OS) in patients with CTM scores 0, 1, and 2 was 61.8%, 31.4%, and 15.1%, respectively (P<.001). The CTM score independently predicted OS on multivariate analysis (HR, 1.95; 95% CI, 1.73 to 2.21; P<.001). Moreover, the area under the receiver operating characteristics curve of the CTM score (0.67; 95% CI, 0.64 to 0.70) was higher than the values of any individual marker (0.63, 0.57, 0.57; P<.001 for all comparisons). The CTM score independently predicted postoperative survival in GC, and it may have better clinical utility than individual tumor markers for identifying high-risk patients with GC.

Polypeptide N-acetylgalactosaminyltransferase-6 expression in gastric cancer

Gastric cancer (GC) is one of the leading causes of cancer-related deaths, with limited improvement in its clinical outcome worldwide. Aberrant mucin-type O-glycosylation is a critical event widespread in the development of GC. Polypeptide N-acetylgalactosaminyltransferases (GALNTs) regulate the initial step and determine the sites of mucin-type O-glycoprotein bio-synthesis. GALNT6 has considerable potential as a biomarker in various cancers. The roles of GALNT6 in GC were analyzed, and the results showed that GALNT6 expression markedly increased in GC tissues compared with those in adjacent gastric tissues. High intratumoral GALNT6 density was associated with the clinicopathological parameters of TNM stage and distant metastasis. GALNT6 was identified as an independent prognosticator for the poor prognosis of GC patients. Moreover, the high expression level of GALNT6 was significantly associated with the low expression levels of E-cadherin and β-catenin and the high expression levels of MMP9. These findings indicated that GALNT6 could provide new insights into the characterization of GC as well as contribute to the development of an efficient prognostic indicator and novel therapeutic modalities for GC.

Clinical significance of expression of proliferating cell nuclear antigen and E-cadherin in gastric carcinoma

AIM

to investigate the expression of proliferating cell nuclear antigen (PCNA) and E-cadherin in gastric carcinoma and to analyze their clinical significance.

METHODS

A total of 146 patients were selected for this study, including 38 patients with intestinal metaplasia, 42 with dysplasia, and 66 with primary gastric cancer. In addition, 40 patients with normal gastric tissues were selected as controls. The expression of PCNA and E-cadherin was detected by immunohistochemistry. Differences in PCNA and the E-cadherin labeling indexes among normal gastric mucosa, intestinal metaplasia, dysplasia, and gastric carcinoma were compared. Subjects with normal gastric tissues were assigned to a normal group, while gastric cancer patients were assigned to a gastric cancer group. The difference in PCNA and E-cadherin expression between these two groups was compared. The relationship between expression of PCNA and E-cadherin and clinicopathological features was also explored in gastric cancer patients. Furthermore, prognosis-related factors, as well as the expression of PCNA and E-cadherin, were analyzed in patients with gastric cancer to determine the 3-year survival of these patients.

RESULTS

The difference in PCNA and the E-cadherin labeling indexes among normal gastric mucosa, intestinal metaplasia, dysplasia, and gastric carcinoma was statistically significant (P < 0.05). During the transition of normal gastric mucosa to gastric cancer, the PCNA labeling index gradually increased, while the E-cadherin labeling index gradually decreased (P < 0.05). The PCNA labeling index was significantly higher and the E-cadherin labeling index was significantly lower in gastric cancer than in dysplasia (P < 0.05). The expression of PCNA was significantly higher in the gastric cancer group than in the normal group, but E-cadherin was weaker (P < 0.05). There was a negative correlation between the expression of PCNA and E-cadherin in gastric carcinoma (r = -0.741, P = 0.000). PCNA expression differed significantly between gastric cancer patients with and without lymph node metastasis and between patients at different T stages. E-cadherin expression also differed significantly between gastric cancer patients with and without lymph node metastasis (P < 0.05). High T stage and positive PCNA expression were risk factors for the prognosis of patients with gastric cancer (RR > 1), while the positive expression of E-cadherin was a protective factor (RR < 1). The sensitivity, specificity, and accuracy of PCNA positivity in predicting the 3-year survival of patients with gastric cancer were 93.33%, 38.89%, and 0.64, respectively; while these values for E-cadherin negativity were 80.0%, 41.67%, and 0.59, respectively. When PCNA positivity and E-cadherin negativity were combined, the sensitivity, specificity, and accuracy were 66.67%, 66.67%, and 0.67, respectively.

CONCLUSION

Combined detection of PCNA and E-cadherin can improve the accuracy of assessing the prognosis of patients with gastric cancer.

Use of Tumor Markers in Gastrointestinal Cancers: Surgeon Perceptions and Cost-Benefit Trade-Off Analysis

BACKGROUND

Gastrointestinal cancers constitute the third most common cancers worldwide. Tumor markers have long since been used in the postoperative surveillance of these malignancies; however, the true value in clinical practice remains undetermined.

OBJECTIVE

This study aimed to evaluate the clinical utility of three tumor markers in colorectal and esophagogastric cancer.

METHODS

A systematic review of the literature was undertaken to elicit the sensitivity, specificity, statistical heterogeneity and ability to predict recurrence and metastases for carcinoembryonic antigen (CEA), cancer antigen (CA) 19-9 and CA125. European surgeons were surveyed to assess their current practice and the characteristics of tumor markers they most valued. Data from the included studies and survey were combined in a cost-benefit trade-off analysis to assess which tumor markers are of most use in clinical practice.

RESULTS

Diagnostic sensitivity and specificity were ranked the most desirable characteristics of a tumor marker by those surveyed. Overall, 156 studies were included to inform the cost-benefit trade-off. The cost-benefit trade-off showed that CEA outperformed both CA19-9 and CA125, with lower financial cost and a higher sensitivity, and diagnostic accuracy for metastases at presentation (area under the curve [AUC] 0.70 vs. 0.61 vs. 0.46), as well as similar diagnostic accuracy for recurrence (AUC 0.46 vs. 0.48).

CONCLUSIONS

Cost-benefit trade-off analysis identified CEA to be the best performing tumor marker. Further studies should seek to evaluate new tumor markers, with investigation tailored to factors that meet the requirements of practicing clinicians.

Preoperative serum CEA and CA19-9 in gastric cancer--a single tertiary hospital study of 1,075 cases

To evaluate the clinical impact of preoperative serum CEA and CA19-9 on resectable gastric cancer (GC), a total of 1,075 consecutive cases with gastric adenocarcinoma were obtained retrospectively from January 2012 and December 2013 in a single tertiary hospital, and the relationships between serum CEA, CA19-9 and clinicopathologic features were investigated. Positive preoperative serum rates of CEA and CA19-9 were 22.4% and 12.3% respectively, levels significantly correlating with each other and depth of invasion, lymph node involvement, pTNM and stage. The CEA level also presented a remarkable association with lymphovascular invasion. Both CEA and CA19-9 positivity significantly and positively correlated with depth of invasion, nodal involvement, pTNM stage, lymphovascular invasion, tumor size and tumor location. Stratified analyses according to gender or tumor location showed preoperative CEA or CA19-9 had different associations with clinicopathologic features in different gender subgroups or location subgroups. Preoperative serum CA19-9 positivity may be more meaningful for tumor size rather than CEA. In conclusion, preoperative serum CEA and CA19-9 correlate with disease progression of GC, and may have applications in aiding more accurate estimation of tumor stage, decision of treatment choice and prognosis evaluation.

Differences and correlation of serum CEA, CA19-9 and CA72-4 in gastric cancer

The sensitivity of three biomarkers, carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9 and CA72-4, in combination has been identified to be greater than that of any of the biomarkers considered in isolation in cases of gastric cancer (GC). However, the fundamental cause underlying this phenomenon remains to be fully elucidated. In the present study, the differences and correlation of these three biomarkers were investigated in patients with GC in order to determine how the three biomarkers in combination work more effectively compared with any of the biomarkers considered alone. The serum levels of CEA, CA19-9 and CA72-4 of 216 patients with gastric adenocarcinoma were analyzed on admission to hospital. The differences in positive rates and the serum levels of CEA, CA19-9 and CA72-4 were analyzed using the χ² test and the non-parametric Wilcoxon two-sample test. Phi (f) correlation analysis was used to study the correlation among the expression (positive or not) levels of CEA, CA19-9 and CA72-4. The correlation among the serum levels of biomarkers was analyzed using Spearman's test. The results demonstrated that the combined positive rate of CEA, CA19-9 and CA72-4 was significantly higher compared with the individual CEA, CA19-9 and CA72-4 positive rates (44.91% vs. 22.69, 18.98 and 22.69%, respectively; all P<0.05). The positive rate of CA19-9 and CA72-4 in the extent of the primary tumor/involvement of regional lymph node/distant metastases (TNM)-III/IV stage subgroup was higher compared with that in the TNM-I/II subgroup (χ²=5.902, P=0.015; χ²=8.009, P=0.005), although not the positive rate of CEA (χ²=0.302, P=0.583). A significant correlation was identified between the expression level of CEA and CA72-4 (f correlation coefficient=0.182; P=0.008) and between that of CA19-9 and CA72-4 (f correlation coefficient=0.189; P=0.006), although not between that of CEA and CA19-9 (f correlation coefficient=0.048; P=0.482) in the total number of patients with GC. A significant correlation was also identified between the serum levels of CEA and CA19-9, of CEA and CA72-4 and of CA19-9 and CA72-4 (Spearman's correlation coefficient=0.231, -0.271 and 0.167; P=0.001, P<0.0001 and P=0.014, respectively). The present study indicated that there was only a weak correlation between the positive rate of CEA and CA72-4 and between that of CA19-9 and CA72-4, and no correlation was identified between the positive rate of CEA and CA19-9, even if a correlation was identified between the serum levels of the biomarkers. The present study suggested that the evidence that the sensitivity of the three biomarkers in combination is greater than that of any of the biomarkers taken in isolation is due to less co-presentation of CEA, CA19-9 and CA72-4 in patients with GC.

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

PURPOSE

The aim of this study was to assess the significance of the correlation among tissue carcinoembryonic antigen (CEA) expression with serum CEA (sCEA) levels and long-term survival to highlight the clinical prognostic significance of tissue CEA expression in gastric cancer patients.

METHODS

Immunohistological method and radioimmunoassay were used to assess tissue and sCEA expression, respectively. Univariate and multivariate analyses were performed to determine correlations, and the Kaplan-Meier method was used to investigate the prognostic significance.

RESULTS

Our results demonstrate that tissue CEA in gastric cancer is significantly correlated with preoperative sCEA levels (p = 0.031), depth of invasion (p = 0.001), lymph node metastasis (p < 0.001), distant metastasis (p = 0.001), and TNM staging (p < 0.001). The 5-year survival rates were 67.6, 53.9, and 40.1 % for negatively, moderately, and intensely positively stained tissues (p < 0.001), and 57.0 and 37.9 % for serum with normal and elevated CEA expression (p = 0.031). Multivariate analysis revealed that tissue CEA can be considered an independent prognostic factor. Further analysis illustrated that patients with negative expression in both tissue and serum had better prognosis compared with those positively expressing CEA in both tissue and serum and/or those positively expressing CEA in either tissue or serum (p < 0.001). Our results also demonstrated that patients with negative tissue CEA staining and elevated sCEA expression had a better 5-year survival.

CONCLUSION

Tissue CEA expression in gastric cancer is directly correlated with sCEA levels and long-term prognosis. Thus, tissue CEA expression can be considered as a useful biomarker to improve the interpretation of sCEA levels in predicting long-term survival.

Perspectives on new biomarkers in gastric cancer: Diagnostic and prognostic applications

Gastric cancer is considered one of the most deadly tumors worldwide. Even with the decline in its incidence, the mortality rate of this disease has remained high, mainly due to its late diagnosis and to the lack of precise prognostic markers. The main purpose of this review is to present genetic, epigenetic and proteomic molecular markers that may be used in a diagnostic and prognostic manner and to discuss the pros and cons of each type of marker for improving clinical practice. In this sense, we observed that the use of genetic markers, especially mutations and polymorphisms, should be carefully considered, as they are strongly affected by ethnicity. Proteomic-based markers show promise, but the higher costs of the associated techniques continue to make this approach expensive for routine use. Alternatively, epigenetic markers appear to be very promising, as they can be detected in bodily fluids as well as tissues. However, such markers must be used carefully because epigenetic changes may occur due to environmental factors and aging. Despite the advances in technology and its access, to date, there are few defined biomarkers of prognostic and diagnostic use for gastric tumors. Therefore, the use of a panel of several approaches (genetic, epigenetic and proteomic) should be considered the best alternative for clinical practice.