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Xu J, Zhang R, Peng Q, Jia Z, Xiao S, Sun N, Peng M. The profile and prognostic value of circulating lymphocyte subsets in metastatic colon cancer. Int Immunopharmacol 2023; 117:109848. [PMID: 36812670 DOI: 10.1016/j.intimp.2023.109848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVE Colon cancer (CC) are the most common malignant cancer in human digestive system, however, the profile and prognostic value of circulating lymphocyte subsets in CC patients has not been systemically clarified. METHODS In this study, 158 patients with metastatic CC were enrolled. Chi-square test was used to analyze the relationship between baseline peripheral blood lymphocyte subsets and clinicopathological parameters. Kaplan-Meier and Log-rank tests were used to analyze the relationship between clinicopathological parameters and baseline peripheral lymphocyte subsets and overall survival (OS) of patients with metastatic CC. Univariate/multivariate COX regression analysis was used to identify the independent factors in metastatic CC. RESULTS The baseline peripheral blood CD3+T cells, CD4+T cells, NK cells and B cells of BRAF mutant patients were significantly lower than those in BRAF wild-type patients; The baseline CD8+T cells of KRAS mutation group was lower than that in KRAS wild type group. Peripheral blood CA19-9 > 27, left-sided colon cancer (LCC), KRAS and BRAF mutation were poor prognostic factors, and ALB > 40, NK cells were protective prognostic factors for metastatic CC. In patients with liver metastases subgroup, higher NK cells also indicated a longer OS. Finally, LCC (HR = 0.56), CA19-9 (HR = 2.13), ALB (HR = 0.46) and circulating NK cells (HR = 0.55) were independent prognostic factors for metastatic CC. CONCLUSION LCC, higher level of ALB and NK cells at baseline are protective factors, and higher CA19-9, KRAS/BRAF gene mutation are adverse prognostic factors. Sufficient circulating NK cells are independent prognostic factor for metastatic CC patients.
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Affiliation(s)
- Juan Xu
- Department of Oncology, Suqian Zhongwu Hospital/Suqian Cancer Hospital, Suqian 223800, Jiangsu, China
| | - Ruru Zhang
- Department of Oncology, Suqian Zhongwu Hospital/Suqian Cancer Hospital, Suqian 223800, Jiangsu, China
| | - Qing Peng
- Department of Oncology, Suqian Zhongwu Hospital/Suqian Cancer Hospital, Suqian 223800, Jiangsu, China
| | - Zhenghu Jia
- Guangzhou Purui Biotechnology Co., Ltd., Guangzhou 510660, Guangdong, China; The Biomedical Translational Research Institute, Faculty of Medical Science, Jinan University, Guangzhou 510632, Guangdong, China
| | - Shuang Xiao
- Guangzhou Purui Biotechnology Co., Ltd., Guangzhou 510660, Guangdong, China; The Biomedical Translational Research Institute, Faculty of Medical Science, Jinan University, Guangzhou 510632, Guangdong, China
| | - Niangen Sun
- Department of Oncology, Suqian Zhongwu Hospital/Suqian Cancer Hospital, Suqian 223800, Jiangsu, China.
| | - Mengqing Peng
- Department of Oncology, Suqian Zhongwu Hospital/Suqian Cancer Hospital, Suqian 223800, Jiangsu, China.
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Shi H, Wang K, Yuan J, Mao W, Wu Z, Liu Q, Xie J, Peng B. A high monocyte-to-lymphocyte ratio predicts poor prognosis in patients with radical cystectomy for bladder cancer. Transl Cancer Res 2020; 9:5255-5267. [PMID: 35117892 PMCID: PMC8798907 DOI: 10.21037/tcr-20-1060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND At present, it is well known that many hemogram parameters were related to the prognosis of a variety of cancers. Among them, monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have attracted more and more attention. The purpose of this study was to investigate the prognostic value of MLR, NLR, PLR, especially MLR, in patients with bladder cancer (BC) treated with radical cystectomy (RC). METHODS Between January 2009 and October 2018, 203 BC patients who underwent RC participated in the survey, and various clinical and hematological parameters were recorded. The optimal cutoff of MLR, NLR and PLR were determined by X-tile software, and Cox regression analysis was performed to investigated the effect of MLR, NLR and PLR on the overall survival (OS) and disease-free survival (DFS). RESULTS The optimal cutoff values of MLR, NLR and PLR were 0.54, 4.10 and 164.63, respectively. Patients with high MLR (>0.54) predicted shorter OS [hazard ratio (HR): 2.30; 95% confidence interval (CI): 1.36-3.89; P=0.002] and DFS (HR: 2.13; 95% CI: 1.21-3.75; P=0.009) compared with patients with low MLR (≤0.54). Multivariate Cox regression analysis showed that only MLR was an independent risk factor for OS and DFS in MLR, NLR and PLR. In addition, receiver operating characteristic (ROC) analysis showed that at most time points, the area under the curve (AUC) of MLR was greater than that of NLR and PLR used to predict OS and DFS. CONCLUSIONS Our results show that MLR can be independently used as a poor prognostic factor for OS and DFS in BC patients with RC. The prognosis of BC patients after RC can be predicted by measuring the level of MLR.
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Affiliation(s)
- Heng Shi
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Urology, People's Hospital of Putuo District, Shanghai, China
| | - Keyi Wang
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jing Yuan
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Weipu Mao
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Urology, People's Hospital of Putuo District, Shanghai, China
| | - Zonglin Wu
- Department of Urology, People's Hospital of Putuo District, Shanghai, China
| | - Qunlong Liu
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jinbo Xie
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Bo Peng
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Urology, People's Hospital of Putuo District, Shanghai, China
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Wang B, Gu W, Wan F, Shi G, Ye D. Prognostic significance of the dynamic changes of systemic inflammatory response in metastatic renal cell carcinoma. Int Braz J Urol 2019; 45:89-99. [PMID: 29570259 PMCID: PMC6442152 DOI: 10.1590/s1677-5538.ibju.2017.0500] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/22/2018] [Indexed: 01/04/2023] Open
Abstract
Purpose: To elucidate the prognostic value of systemic inflammatory response in patients with metastatic renal cell carcinoma (mRCC) who are treated with sunitinib, we evaluated the prognostic role of C-reactive protein (CRP) kinetics. This study also compared prognostic models containing CRP kinetics and neutrophil-to-lymphocyte ratio (NLR) kinetics. Materials and Methods: A consecutive cohort of 94 patients with mRCC who were treated with sunitinib was retrospectively included from Fudan University Shanghai Cancer Center. According to dynamic changes in CRP and the NLR, patients were divided into three groups for analysis of CRP and NLR kinetics. The associations between survival and potential prognostic factors were assessed. The incremental value of prognostication was evaluated. Results: A significant difference (P<0.001) in overall survival (OS) was observed among the three groups of CRP kinetics. The median OS of the non-elevated group was nearly 1.3-fold longer than that of the normalized group (33.0 vs. 26.3 months), and two times longer than that of the non-normalized group (33.0 vs. 14.0 months). Multivariate analysis showed that CRP and NLR kinetics were independent prognostic indicators. The model containing CRP kinetics had a better predictive accuracy than that with NLR kinetics, which was supported by the C-index (0.731 vs. 0.684) and the likelihood ratio χ2 test (79.9% vs. 44.9%). Conclusion: Our study suggests that dynamic changes in CRP can better predict survival in patients with mRCC who are treated with sunitinib. Routine assessment of CRP before and after targeted therapy would help identify patients at risk of a poor outcome.
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Affiliation(s)
- Beihe Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weijie Gu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Fangning Wan
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Guohai Shi
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Dingwei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Li T, Xu H, Yang L, Tan P, Wei Q. Predictive value of preoperative lymphocyte-to-monocyte ratio for patients with upper tract urothelial carcinoma. Clin Chim Acta 2019; 492:50-56. [DOI: 10.1016/j.cca.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 01/18/2019] [Accepted: 02/10/2019] [Indexed: 12/20/2022]
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D'Andrea D, Moschini M, Gust KM, Abufaraj M, Özsoy M, Mathieu R, Soria F, Briganti A, Rouprêt M, Karakiewicz PI, Shariat SF. Lymphocyte-to-monocyte ratio and neutrophil-to-lymphocyte ratio as biomarkers for predicting lymph node metastasis and survival in patients treated with radical cystectomy. J Surg Oncol 2017; 115:455-461. [PMID: 28105663 DOI: 10.1002/jso.24521] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 11/15/2016] [Accepted: 11/23/2016] [Indexed: 01/04/2023]
Abstract
PURPOSE To evaluate the role of lymphocyte-to-monocyte ratio (LMR) and neutrophil-to-lymphocyte ratio (NLR) as pre-operative markers for predicting extravesical disease and survival outcomes in patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). MATERIALS AND METHODS Data from 4335 patients undergoing RC for clinically non-metastatic UCB were analyzed. Multivariable logistic regression models were used to predict lymph node involvement and extravesical disease (defined as ≥pT3 and N0). Recurrence-free (RFS), cancer-specific (CSS), and overall survival (OS) were evaluated using multivariable Cox models. The accuracy of the models was assessed with receiver operating characteristics (ROC) curves and concordance-index. RESULTS Median LMR was 3.5 and median NLR was 2.7. Addition of LMR and NLR to a standard preoperative model improved its discrimination for prediction of lymph node metastasis by 4.5%. On multivariable analysis LMR and NLR independently predicted RFS, CSS, and OS. The discrimination of this model increased by adding LMR and NLR but was not significant. CONCLUSIONS LMR and NLR independently improved the preoperative prediction of lymph node metastasis and survival outcomes. As they are readily available, they could be integrated in a panel of preoperative markers helping selecting patients who have extravesical lymph node involvement and more aggressive disease.
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Affiliation(s)
- David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Marco Moschini
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Urological Research Institute, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Kilian M Gust
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner University, Krems an der Donau, Austria
| | - Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Mehmet Özsoy
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Romain Mathieu
- Department of Urology, Rennes University Hospital, Rennes, France
| | | | - Alberto Briganti
- Urological Research Institute, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Morgan Rouprêt
- Department of Urology, Pitié-Salpétrière Hospital, APHP, University Paris VI, Paris, France
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner University, Krems an der Donau, Austria.,Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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Albayrak S, Zengin K, Tanik S, Atar M, Unal SH, Imamoglu MA, Gurdal M. Can the neutrophil-to-lymphocyte ratio be used to predict recurrence and progression of non-muscle-invasive bladder cancer? Kaohsiung J Med Sci 2016; 32:327-33. [PMID: 27377847 DOI: 10.1016/j.kjms.2016.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/12/2016] [Accepted: 03/23/2016] [Indexed: 02/09/2023] Open
Abstract
The aim of our study was to evaluate whether neutrophil-to-lymphocyte ratio (NLR) is a predictor of disease progression and recurrence in patients with primary non-muscle-invasive bladder cancer (NMIBC). This was a prospective study of 86 patients with newly diagnosed NMIBC. The patients were classified by the number of points assigned by the European Organization for Research and Treatment of Cancer risk tables. The correlation between progression score, recurrence score, age, mean platelet volume, red blood cell distribution width and NLR was assessed statistically. The same parameters were compared between the risk groups. A significant difference in NLR and age values was observed between recurrence and progression risk score groups. The relationships between NLR and recurrence and progression risk scores were no longer significant after correcting for the statistical effect of age on scores. Age was significantly different between groups after adjusting for NLR. Our study revealed that NLR and age were associated with patient age and bladder tumor progression and recurrence risk scores. After correcting for age, the significant relationship with NLR was lost, in contrast to some previous studies. We recommend that patient age should be corrected to avoid misleading results in NLR studies.
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Affiliation(s)
| | - Kursad Zengin
- Department of Urology, Bozok University, School of Medicine, Yozgat, Turkey
| | - Serhat Tanik
- Department of Urology, Bozok University, School of Medicine, Yozgat, Turkey.
| | - Muhittin Atar
- Department of Urology, Bozok University, School of Medicine, Yozgat, Turkey
| | - Serhat Haluk Unal
- Department of Urology, Amasya Serafeddin Sabuncuoglu Education and Research Hospital, Amasya, Turkey
| | | | - Mesut Gurdal
- Department of Urology, Bozok University, School of Medicine, Yozgat, Turkey
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Zhang GM, Zhu Y, Luo L, Wan FN, Zhu YP, Sun LJ, Ye DW. Preoperative lymphocyte-monocyte and platelet-lymphocyte ratios as predictors of overall survival in patients with bladder cancer undergoing radical cystectomy. Tumour Biol 2015; 36:8537-43. [PMID: 26032095 DOI: 10.1007/s13277-015-3613-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 05/26/2015] [Indexed: 02/07/2023] Open
Abstract
Although pretreatment neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), and platelet-lymphocyte ratio (PLR) are reportedly associated with clinical outcomes of many cancers, their roles in patients with bladder cancer (BCa) who undergo radical cystectomy (RC) have not been widely investigated. We analyzed relationships between preoperative NLR, LMR, PLR, and overall survival (OS) in 124 BCa patients undergoing RC. OS curves were drawn using the Kaplan-Meier method and evaluated using the log-rank test. Relationships between OS and potential confounding variables were determined using Cox's proportional hazard regression model. Decreased LMR was associated with shorter OS (P = 0.012); OS in the low PLR group was significantly longer than that in the high PLR group (P = 0.029), and NLR was not significantly associated with oncological outcomes. However, after adjusting for confounding variables, patients in the high-LMR group indicated >30% decreased mortality than the low-LMR group (hazard ratio 0.674; 95% confidence interval 0.412-0.890; P = 0.003), and PLR was not an independent predictor of OS. Our results show that preoperative LMR is a better prognostic factor in BCa patients undergoing RC, compared with NLR and PLR.
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Temraz S, Mukherji D, Farhat ZAA, Nasr R, Charafeddine M, Shahait M, Wehbe MR, Ghaida RA, Gheida IA, Shamseddine A. Preoperative lymphocyte-to-monocyte ratio predicts clinical outcome in patients undergoing radical cystectomy for transitional cell carcinoma of the bladder: a retrospective analysis. BMC Urol 2014; 14:76. [PMID: 25234356 PMCID: PMC4171398 DOI: 10.1186/1471-2490-14-76] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 09/16/2014] [Indexed: 12/20/2022] Open
Abstract
Background Inflammation is a critical component of tumorigenesis, and many cancers arise from sites of infection, chronic irritation, and inflammation. Inflammatory cytokines triggered by tumors alter hematologic components, including neutrophil, lymphocyte, and monocyte counts. The neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios have been shown to be valuable prognostic markers in various types of cancers, including bladder cancer. Risk stratification based on clinicopathologic data is insufficient to support treatment-related choices in patients with bladder cancer. Novel prognostic markers are therefore needed. An elevated pretreatment lymphocyte-to-monocyte ratio (LMR) is reportedly associated with improved overall survival (OS) and a longer time to treatment recurrence (TTR) in some types of cancers. However, these data are lacking in patients with bladder cancer. The aim of the present study was to investigate the effect of the preoperative LMR on OS and TTR in a cohort of patients with bladder cancer. Methods Sixty-eight patients with transitional cell carcinoma of the bladder were included in this retrospective analysis. The associations between a high and low LMR with OS and TTR were analyzed using Kaplan–Meier curves and compared by the log-rank test. Results In our study cohort, an elevated preoperative LMR was significantly associated with an increased TTR (P = 0.001) and OS (P = 0.020). Patients with an LMR of ≤2.87 showed a median TTR of 2.0 years (95% CI, 0.27–3.73), whereas patients with an LMR of >2.87 had a median TTR of 11.1 years (95% CI, 2.31–19.88) (P = 0.001). Patients with an LMR of ≤2.81 showed a median OS of 2.7 years (95% CI, 0.63–4.70), whereas patients with an LMR of >2.81 had a median OS of 6.0 years (95% CI, 3.60–8.40) (P = 0.020). The clinical stage at diagnosis was the only clinicopathologic feature associated with the LMR, while tumor invasion depth showed borderline significance. Conclusions The LMR is an easily measured and inexpensive prognostic marker that was significantly correlated with OS and TTR in the present retrospective analysis. However, because of the small sample size in this study, larger multicenter, prospective studies are needed.
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Affiliation(s)
- Sally Temraz
- Departments of Hematology-Oncology, Riad El Solh, Beirut, Lebanon.
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Koestler DC, Marsit CJ, Christensen BC, Accomando W, Langevin SM, Houseman EA, Nelson HH, Karagas MR, Wiencke JK, Kelsey KT. Peripheral blood immune cell methylation profiles are associated with nonhematopoietic cancers. Cancer Epidemiol Biomarkers Prev 2012; 21:1293-302. [PMID: 22714737 PMCID: PMC3415587 DOI: 10.1158/1055-9965.epi-12-0361] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Blood leukocytes from patients with solid tumors exhibit complex and distinct cancer-associated patterns of DNA methylation. However, the biologic mechanisms underlying these patterns remain poorly understood. Because epigenetic biomarkers offer significant clinical potential for cancer detection, we sought to address a mechanistic gap in recently published works, hypothesizing that blood-based epigenetic variation may be due to shifts in leukocyte populations. METHODS We identified differentially methylated regions (DMR) among leukocyte subtypes using epigenome-wide DNA methylation profiling of purified peripheral blood leukocyte subtypes from healthy donors. These leukocyte-tagging DMRs were then evaluated using epigenome-wide blood methylation data from three independent case-control studies of different cancers. RESULTS A substantial proportion of the top 50 leukocyte DMRs were significantly differentially methylated among head and neck squamous cell carcinoma (HNSCC) cases and ovarian cancer cases compared with cancer-free controls (48 and 47 of 50, respectively). Methylation classes derived from leukocyte DMRs were significantly associated cancer case status (P < 0.001, P < 0.03, and P < 0.001) for all three cancer types: HNSCC, bladder cancer, and ovarian cancer, respectively and predicted cancer status with a high degree of accuracy (area under the curve [AUC] = 0.82, 0.83, and 0.67). CONCLUSIONS These results suggest that shifts in leukocyte subpopulations may account for a considerable proportion of variability in peripheral blood DNA methylation patterns of solid tumors. IMPACT This illustrates the potential use of DNA methylation profiles for identifying shifts in leukocyte populations representative of disease, and that such profiles may represent powerful new diagnostic tools, applicable to a range of solid tumors.
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Affiliation(s)
- Devin C. Koestler
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Carmen J. Marsit
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Pharmacology and Toxicology, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Brock C. Christensen
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Pharmacology and Toxicology, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Scott M. Langevin
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI
- Department of Epidemiology, Brown University, Providence, RI
| | | | - Heather H. Nelson
- Division of Epidemiology and Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Margaret R. Karagas
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - John K. Wiencke
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Karl T. Kelsey
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI
- Department of Epidemiology, Brown University, Providence, RI
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