| IntroductionLung cancer has become the worldwide No.1malignant tumor with highest mortality. Studies have shown smoking is the main risk factor of lung cancer. Understanding of the molecular pathogenesis of lung cancer and identifying specific biomarkers have become the most active areas of research, results of which are important for clinical and translational studies, as well as for personalized medicine. A biomarker is defined as’a readout that can be objectively measured and evaluated as an indicator of normal biologic or pathological processes, or of pharmacologic/pharmacodynamics responses to a therapeutic intervention’. Different measures have been used to identify biomarkers, including immunohistochemistry, genomic variations (such as gene amplification, mutation, or rearrangement), single nucleotide polymorphism (SNP) and global or targeted gene/protein expression.Regarding to early diagnosis of lung cancer, low dose spiral computerized tomography (LDCT) scan could provide information on most small nodule in the lung, however it is difficult to determine whether the lesions are early stage of malignant tumor or not, and is burdened with high false positive rates. Even with combined positron emission computed tomography (PET) and non-open biopsy, the sensitivity of true-positive is still very low and it is associated with surgical risks of biopsy. However, by introducing bio-molecular detection to the current radiological examination, the specificity of early diagnosis could be significantly improved. Such biomarkers include detecting certain tumor biomarkers in peripheral serum samples or in exhaled breath volatile organic compounds (VOCs) or exhaled-breath condensate (EBC). In one of our clinical cohort studies, we found that by combining currently accepted tumor biomarkers (CEA, SCC, Cfyra21-1) with a new biomarker, ProGRP, it could significantly improve the sensitivity and specificity of diagnosis, which helped to rule in patients with questionable radiology findings from CT scan. Similarly, molecular analysis of exhaled breath improved the quality of radiological examination.With respect to treatment effect, biomarker plays important roles in lung cancer therapy. In lung cancer, the response rate to single dose chemotherapy or other anti-tumor drugs was usually lower than in other diseases. And the therapeutic drug concentration is often close to or even overlaps with the toxic concentration. Therefore, it was very important to stratify the patients and segregate those who are most sensitive to treatment, benefiting both the patients and physicians. Currently, molecular targeting drug are being used in clinical application, following biomarker screening, which predicts the patients’response [including response rate, progression free survival (PFS) and overall survival (OS)]. For example, by detecting epidermal growth factor receptor (EGFR) mutation, we could screen out the small population of patients carrying this mutation and who will be more sensitive to the tyrosine kinase inhibitor (TKI) treatment than other lung cancer patients. And this protocol has now been included in the guidelines of lung cancer diagnosis and treatment. Meanwhile, other biomarkers, such as K-RAS mutation, EML4/ALK mutation and assay for anti-vascular endothelial growth factor (anti-VEGF) treatment are under studies to gather more convincing proofs. In the near future, biomarkers will also provide us with information and proofs in new drug discovery, lowering the economic cost and shortening the lead time.In the field of system biology, many databases of previous studies on the network of protein functions are freely open to us. We can use mathematical computer model to screen these databases and define proteomics that are important to lung cancer carcinogenesis. In one of previous studies, three groups of such biomarkers were identified. These include cell growth related biomarkers, such as MAPK (MAPK1/ERK2, MAPK3/ERK1and MAPK14/p38α), SMAD (SMAD1, SMAD2, SMAD3and SMAD4), RTKS (EGFR, FGFR1and INSR); transcriptional regulators (CREBBP, CTNNB1/β-catenin, E2F1and MYC); cell survival related biomarkers include TP53/p53, TRAF6, BRCA1, SP1, AKT and CSNK2A1(CK2); and finally cell migration related biomarkers include PTK2/FAK, TSC2, PLCG1and EZR/ezrin.In this study, we examined two cohorts of lung cancer patients, who were studied either with multiple serum tumor biomarkers or with protein profiling of chemokine to search for important early diagnosis and prognosis related biomarkers in lung cancer. In addition, in our project, we also analyzed the underlying causes of prolonged diagnostic lead time (DLT, defined as the time period from symptom to clinical diagnosis) in China and established a set of Digital Evaluation Score System (DESS) for transferring clinical data into clinical informatics. By comprehensively integrating proteomics and clinical data, we have identified a panel of lung cancer biomarkers with high sensitivity and specificity and significantly shorter DLT.Part Ⅰ Role of a serum based biomarker panel in early diagnosis of lung cancer in a cohort of high-risk lung cancer patient presenting with cancer related symptomsObjective:In this study, we applied a lung cancer specific panel to provide the clinical physicians with diagnostic information distinguishing small-cell lung cancer (SCLC) from non-small cell lung cancer (NSCLC).Methods:Serum levels of four factors (ProGRP, CEA, SCC and Cyfra21-1) were determined in89healthy subjects with high risk factor of lung cancer,12patients with SCLC, and52patients with NSCLC. The DLT information was collected by interviewing all the study participants.Results:It is observed that significantly higher serum levels of ProGRP (p<0.0001) was found among SCLC patients; significantly higher CEA levels (p<0.0001) among adenocarcinoma and SCC patients (p<0.0001); and significantly higher Cyfra21-1levles (p<0.0001) in SCC. We have established the cut off values of ProGRP, CEA, SCC and Cyfra21-1at300pg/mL,7.3ng/mL,3ng/mL and6.5ng/mL, respectively. Sensitivity and specificity of ProGRP in diagnosing SCLC was75%and100%. With the inclusion of ProGRP, the specificity of these tumor markers for NSCLC was increased (from88.1%to94.1%) with the unchanged sensitivity (75%). Among64 patients, the median DLT was17days in patient delay (IQI=2-33days), compared with a median DLT of18days in system delay (IQI=14-33days). Only78.1%patient received positive CT scan result on; therefore, combining the diagnostic panel of the four factors discovered eight false-negative NSCLC cases, whom would be missed the diagnosis.Conclusions:This panel of serum tumor marker increased the diagnostic specificity among high risk factor healthy subjects (excluding renal failure) and increased sensitivity in patients with malignant lung tumor. These results might be applied to shorten the diagnosis delay both in primary health care and in hospital specialty in China. Part Ⅱ Protein profile of serum chemokine correlates with tumorgenesis and prognosis in non-small cell lung cancer patientsRationale:Inflammation plays an important role in lung cancer development. In this study, multiple serum cytokines were quantified and analyzed in order to identify biomarkers for prognosis in non-small cell lung cancer (NSCLC) patients receiving chemotherapy.Methods:Sera of healthy non-smokers (n=14) and of patients with NSCLC (n=50,14female and36male, with an average age of58.0±11.4years;36with adenocarcinoma, stage Ⅰ, Ⅲ and Ⅳ; and14with squamous cell carcinoma, stages Ⅰ to Ⅳ) were collected on first hospital admission for diagnosis. Sera of the five stages Ⅳ adenocarcinoma patients were collected again on second and third admissions following one to two course of chemotherapy (21and42days post-diagnosis). The cytokine protein concentrations were measured using multiplexed cytokine immunoassays. Clinical informatics was achieved by a Digital Evaluation Score System (DESS) for assessing severity of patients. All patients completed follow-up for up to two years. Student T-test and Mann-Whitney U test was applied to compare the different cytokine level in different groups of samples. Mann-Whitney U test was applied to compare the value of DESS, Stepwise regression and Kaplan-Meier survival analysis were used to determine independent risk factor of non-small cell cancer over survival.Results:Among the40inflammatory mediators measured,13showed statistically significant differences between total lung cancer patients and healthy controls;18showed statistically significant differences between adenocarcinoma patients and healthy controls; and11showed a difference between squamous cell carcinoma patients and healthy controls. Among patients with adenocarcinoma (stage Ⅳ),9mediators showed a difference between untreated and post1st time chemotherapy and13mediators showed a difference between untreated and after2nd time chemotherapy. On DESS evaluation, the value of ’primary tumors caused symptoms’ showed significant difference between adenocarcinoma and squamous carcinoma patients (p=0.005). Among29patients with adenocarcinomas (stage ⅢB and Ⅳ), higher levels of MCP-4, growth-regulated oncogene (GRO), thymus expressed chemokine (TECK) and macrophage stimulating protein a (MSPa) were associated with higher risk of death compared with those with normal serum levels. Conversely, higher levels of lymphotoxin-like inducible protein that competes with glycoprotein D for herpesvirus entry on T cells (LIGHT), cutaneous T-cell attracting chemokines/CCL27(CTACK), C-C motif ligand28(CCL28) and interleukin-29(IL-29) were associated with a lower risk of death compared with those with normal serum levels.Conclusion:There is a disease-specific profile of inflammatory mediators in this group of NSCLC patients. This pattern might be useful for aiding cancer sub-classification, prognosis, evaluation of chemotherapy effects, and overall survival. |
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