Front. Med. DOI 10.1007/s11684-015-0402-2
RESEARCH ARTICLE
Exploring the diagnosis markers for gallbladder cancer based on clinical data Lingqiang Zhang1, Runchen Miao1, Xiude Zhang2, Wei Chen1, Yanyan Zhou1, Ruitao Wang1, Ruiyao Zhang1, Qing Pang1, Xinsen Xu1, Chang Liu (
✉)1
1
Department of Hepatobiliary Surgery, the First Affiliated Hospital, School of Medicine, Xi’an Jiaotong University, Xi’an 710061, China; Department of Endocrinology, Xian Yang Center Hospital, Xianyang 712000, China
2
© Higher Education Press and Springer-Verlag Berlin Heidelberg 2015
Abstract Presently, no effective markers are available to facilitate gallbladder cancer (GBC) diagnosis. This study aims to explore available markers for GBC diagnosis. Clinical data of 144 GBC and 116 cholelithiasis patients were retrospectively reviewed. Logistic regression analysis was performed to evaluate GBC risk factors. A receiver operating characteristic (ROC) curve was used to assess the diagnosis value of the risk factors. By comparing the characteristic of GBC and cholelithiasis patients, the following factors exhibited statistical difference: age, gender, gallstones, total bilirubin (TB), alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelet count (PLT), CA125 (carcinoembryonic antigen 125), and CA199 (carbohydrate antigen 199). Logistic regression analysis indicated that age [odds ratio (OR), 1.032; 95% confidence interval (95% CI), 1.004 to 1.061; P = 0.024], gender (OR, 0.346; 95% CI, 0.167 to 0.716; P = 0.004), gallstones (OR, 0.027; 95% CI, 0.007 to 0.095; P < 0.001), ALP (OR, 1.003; 95% CI, 1.000 to 1.006; P = 0.032), TB (OR, 1.004; 95% CI, 1.000 to 1.009; P = 0.042), and CA125 (OR, 1.007; 95% CI, 1.002 to 1.013; P = 0.011) were independent risk factors for GBC. According to the ROC curve, CA125 [area under curve (AUC), 0.720], ALP (AUC, 0.713), TB (AUC, 0.636), and age (AUC, 0.573) were valuable diagnosis markers. Additionally, based on the independent risk factors, the GBC diagnosis model was established. Age, TB, ALP, and CA125 can be used as auxiliary diagnosis factors of GBC. The diagnosis model provides a quantitative tool for GBC diagnosis when comprehensively considering various risk factors. Keywords
gallbladder cancer; diagnosis; marker
Introduction Gallbladder cancer (GBC) originating from biliary duct epithelia is a highly malignant tumor ranked first in bile duct cancers and sixth in digestive duct cancers [1]. Although the molecular mechanism is still unclear, risk factors of this lethal disease include chronic inflammation, aging, and the female gender [2,3]. The number of new GBC cases increases every year worldwide, but the treatment outcome is far from satisfactory, and such lack of efficiency mainly results from advanced diagnosis. Some GBC patients are unexpectedly diagnosed in the early stages of GBC during laparotomy or laparoscopy procedures for cholelithiasis, and could obtain good
Received January 29, 2015; accepted May 11, 2015 Correspondence:
[email protected]
treatment effects. Therefore, at present, the treatment outcome of GBC patients mainly depends on early diagnosis. However, the early diagnosis for GBC is very difficult in clinical practice. Around 20% of GBC patients’ cancer was confined to their gallbladder at the time of diagnosis, whereas the rest usually have infringed adjacent organs or the cancer has spread to distant sites [4]. The possible reasons for this may be as follows. First, early symptoms are vague and non-specific; thus, we are usually not vigilant against GBC. Second, effective markers for early GBC diagnosis are lacking. Researchers conduct numerous studies to search for diagnosis markers to improve GBC prognosis. Considering the familial aggregation of GBC, some scholars conducted related investigations on the gene level [1]. Jiao et al. revealed that the exonic variants of xeroderma pigmentosum complementation group C (XPC) were associated with GBC risk in the
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Chinese population [5]. In the mice model, interaction between liver X receptor-β, estrogen, and TGF-β signaling may play a crucial role in the malignant transformation of gallbladder epithelium [6]. Additionally, single-nucleotide polymorphism of related genes is implicated with GBC risk [5,7–12]. Nevertheless, these findings are far from routine utilization in clinical practice. In view of the facts reviewed above, we attempted to determine effective markers for GBC diagnosis based on clinical data to prolong the survival time of GBC patients.
Materials and methods Study population and samples The clinical data of 144 GBC patients (34 with choledocholithiasis, 23.61%) and 116 cholelithiasis patients (19 with choledocholithiasis, 16.38%) treated at the First Affiliated Hospital, School of Medicine, Xi’an Jiaotong University from January 2009 to December 2013 were retrospectively reviewed. Approval of the ethics review committee of the First Affiliated Hospital, School of Medicine was obtained in advance. Eligibility criteria are stated in the following sentences. GBC patients must be confirmed by pathological results after surgery without other malignancies or other infections. The following tumor markers need to be detected: CA125 (carcinoembryonic antigen 125), CA199 (carbohydrate antigen 199), AFP (alpha-fetoprotein), and CEA (carcinoembryonic antigen). For cholelithiasis patients, tumor markers (CA125, CA199, AFP, and CEA) must be detected, and must be without malignancies or other infection diseases. Data of routine blood test and liver function test were collected, and these data were the first detections obtained when patients enrolled in the hospital. Blood samples were obtained by peripheral venous puncture before breakfast. Statistical analysis All statistical analyses were based on Statistical Package for Social Science (SPSS Inc. Chicago, IL, USA) Version 18.0. For categorical variables, Fisher’s exact test or Chisquare test was used to detect statistical differences. For continuous variables normally distributed, independent t test or one-way ANOVA was used to compare the mean difference, and if the variables were not normally distributed, a Wilcoxon rank test was conducted. A receiver operating characteristic (ROC) curve was performed to evaluate the sensitivity and specificity of different markers in GBC diagnosis. Logistic regression analysis was performed to evaluate the association between different factors and GBC. A probability (P) value less than 0.05 was considered statistically significant.
The diagnosis markers of gallbladder cancer
Results Characteristics of subjects Characteristics of the subjects are shown in Table 1. The entire cohort was composed of 116 cholelithiasis patients and 144 GBC patients. The two groups were not matched in terms of age (58.90 114.87 vs. 63.26 11.15, P = 0.008) and gender (P = 0.003). Additionally, the following factors exhibited significant statistical differences between the two groups: total bilirubin (TB), alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelet count (PLT), CA125, and CA199 (P < 0.05). No statistical significance was observed in terms of albumin, red blood count, hemoglobin, white blood count, neutrophil count, lymphocyte count, CEA, and AFP. Evaluation of GBC risk factors
In univariate analysis, age (P = 0.009), gender (P = 0.003), gallstones (P < 0.001), TB (P < 0.001), PLT (P = 0.003), AST (P = 0.020), ALT (P = 0.040), ALP (P < 0.0001), CA125 (P = 0.001), and CA199 (P = 0.010) were risk factors for GBC. In multiple analysis, age (P = 0.024), gender (P = 0.004), gallstones (P < 0.001), TB (P = 0.042), ALP (P = 0.032), and CA125 (P = 0.011) were the independent influencing factors associated with GBC (Table 2). Evaluation of diagnosis values among different risk factors for GBC Risk factors with OR > 1 in multivariate analysis were selected to evaluate the diagnosis significance for GBC, as shown in Fig. 1. The area under curve (AUC) of CA125, ALP, TB, and age were 0.72, 0.71, 0.64, and 0.57, respectively. The sensitivity and specificity of each factor are shown in Table 3. CA125 had the best sensitivity (88.2%), and TB had the best specificity (94.8%). Additionally, ALP had better sensitivity (68.8%) and specificity (64.7%). We further investigated whether a distribution difference of these risk factors was observed between early stages and advanced stages, such as stages 1 and 2 vs. stages 3 and 4, high and moderate differentiation vs. low differentiation. Unfortunately, there was no statistical difference between different groups. Fig. 2 shows that although the ALP level exhibited an increasing tendency from early stage (T1 and T2) to advanced stage (T3 and T4), there was no statistical difference among the different groups.
Lingqiang Zhang et al.
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Table 1 Comparison of clinical and biochemical characteristics between GBC patients and cholelithiasis patients Parameter
Cholelithiasis patients (n = 116) (meanSD)
GBC patients (n = 144) (meanSD)
P value
Male, n (%)
58 (50)
46 (31.94)
0.003
Age (year)
58.9114.87
63.2611.15
0.008
Gallstones, n (%)
116 (100)
78 (68.42)
0.001
AST (U/L)
75.98156.01
123.27152.95
0.015
ALT (U/L)
73.98137.36
111.16139.15
0.032
ALP (U/L)
139.27124.68
328.92321.36
57 years old) may not represent the entire population. Therefore, our findings need to be confirmed by conducting similar investigations in other parts of the world. Such investigations need to include larger samples and multiple ethnic populations. In conclusion, age, gender, TB, ALP, and CA125 can be used as the auxiliary diagnosis factors, and the risk model
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would facilitate GBC diagnosis when comprehensively considering the various risk factors.
Acknowledgements This study was supported by the Hospital Foundation of the First Affiliated Hospital, School of Medicine, Xi’an Jiaotong University (Xi’an, China) (No. 2013YK36).
Compliance with ethics guidelines Lingqiang Zhang, Runchen Miao, Xiude Zhang, Wei Chen, Yanyan Zhou, Ruitao Wang, Ruiyao Zhang, Qing Pang, Xinsen Xu, and Chang Liu declare that there were no potential conflicts of interest. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and the Helsinki Declaration. Informed consent was obtained from all patients included in the study.
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