Diagnostic and prognostic significance of receptor-binding cancer antigen expressed on SiSo cells in lung-cancer-associated pleural effusion

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1 Received: 1 May 2016 Revised: 19 June 2016 Accepted: 10 July 2016 DOI: /crj ORIGINAL ARTICLE Diagnostic and prognostic significance of receptor-binding cancer antigen expressed on SiSo cells in lung-cancer-associated pleural effusion Jian Yang 1 * Ying Zhu 1 * Liangquan Wu 1 Wenyan Zhu 1 Xiuwei Zhang 1 Yang Yang 1 Chunhua Xu 2,3 1 Department of Respiratory Medicine, Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu , China 2 Endoscopic Center of Nanjing Chest Hospital, Nanjing, Jiangsu , China 3 Clinical Center of Nanjing Respiratory Diseases and Imaging, Nanjing, Jiangsu , China Correspondence Xiu Wei Zhang, Department of Respiratory Medicine, Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu , China. zhangxiuwei_nj@163.com Chunhua Xu, Endoscopic Center of Nanjing Chest Hospital, Nanjing, Jiangsu , China. xuchunhua74@163.com Abstract Objectives: This study aimed to evaluate the diagnostic and prognostic value of pleural effusion levels of soluble receptor-binding cancer antigen expressed on SiSo cells (srcas1) in lung cancer patients with malignant pleural effusion (MPE). Methods: Pleural effusion samples were collected from 78 patients with MPE, and from 48 patients with benign pleural effusion (BPE). Pleural effusion srcas1 concentrations were measured by enzyme-linked immunosorbent assay. Results: MPE has significantly higher srcas1 levels than that of BPE (P <.01). With a cutoff value of 18.7 U/mL, srcas1 showed a good diagnostic performance for MPE. Univariate and multivariate analysis indicated that elevated srcas1 levels were an independent predictor of overall survival (OS) and disease-free survival (DFS). Kaplan Meier survival curves further confirmed that patients with high srcas1 have shorter DFS and OS (P and P 5.032, respectively). Conclusion: In conclusion, measurement of srcas1 might be a useful diagnostic and prognostic marker for MPE. KEYWORDS diagnosis, lung cancer, pleural effusion, prognosis, srcas1 Jian Yang and Ying Zhu are equal contributors. 1 INTRODUCTION Malignant pleural effusion (MPE) defines effusion from infiltration of the pleura by cancer cells. 1,2 The incidence of lung cancer patients with malignant effusion is 7% 23%. 3 Patients with malignant effusion have a short life and are difficult to be treated effectively. The management of MPE patients requires effective treatment based on timely and accurate diagnosis. In addition to diagnostic issues, patients with MPE are difficult to treat effectively and have a poor prognosis. Despite advances in treatment modalities, the survival remains still short. The present standard treatment is evacuation of the pleural fluid followed by intrapleural chemotherapy or intravenous chemotherapy. 4 However, it was found that not all patients were benefited from the chemotherapy. Therefore, prognostic assessment of the patient is necessary. Recently, molecular studies identified several markers as prognostic factors for pleural effusion. 5 Receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is present in various human cell lines. 6 In previous studies, RCAS1 was expressed in various malignant tissues, Clin Respir J. 2018;12: wileyonlinelibrary.com/journal/crj VC 2016 John Wiley & Sons Ltd 279

2 280 YANG ET AL. 2.2 Sample collection and determination of srcas1 concentrations Each sample of pleural fluid was collected in a syringe during a thoracentesis performed after written informed consent was obtained. Samples were centrifuged at 2,000 revolutions/min for 10 min, and the supernatant was frozen at 2808C until assayed. Soluble RCAS1 levels were measured by sandwich enzyme-linked immunosorbent assay using commercially available kits (Medical and Biological Laboratories Co Ltd, China). FIGURE 1 Levels of pleural effusion srcas1 in lung cancer patients with MPE. Among 78 lung cancer patients with MPE, the pleural effusion levels of srcas1 were ( ) U/mL, which were significantly higher than ( ) U/mL in patients with BPE (*P <.01) including lung cancer. 7,8 Soluble RCAS1 has been detected in a culture supernatant derived from a human bile duct carcinoma cell line. 9 There are few studies based on small numbers of patients have suggested that elevated pleural effusion srcas1 levels are associated with poor prognosis of pleural effusion patients. 10 Therefore, we presently studied 126 patients with pleural effusions to determine whether pleural fluid srcas1 levels could be used as a diagnostic and prognostic biomarker of lung cancer. We found that srcas1 is elevated in MPE, as well as being potentially predictive of survival outcome. 2.3 Statistical analyses All statistical analyses of differences between MPE and BPE were performed using the Mann Whitney U test. The diagnostic accuracies of sracs1 in discriminating between MPE and BPE were compared by constructing receiver operating characteristic (ROC) curves. Overall survival (OS) time was defined as the time interval from the date of diagnosis to the date of death. Disease-free survival (DFS) time was defined as the time interval from the date of diagnosis to the date of first recurrence. Survival curves were plotted by the Kaplan Meier method and compared using the log-rank test. Survival data were evaluated using univariate and multivariate Cox regression analysis. Values of P <.05 were considered to indicate statistical significance. 2 MATERIALS AND METHODS 2.1 Patients Between January 2012 and December 2014, the pleural effusion was available from126 patients. Diagnosis of lung cancer was histologically or cytologically proven in 78 cases (38 men and 40 women, aged years). In all the patients, cancer cells were found in pleural effusion by cytological evaluation. These patients comprised 60 with adenocarcinomas and 18 with squamous cell carcinomas. Patients with benign disease comprised 40 with tuberculous pleurisie and 8 with empyema (26 men and 22 women, years of age). Histological type was reclassified according to WHO classification, and the stage of tumor was based on pathological tumor-node-metastasis classification (7 th edition) of the International Union against Cancer. 11 Clinicopathological characteristics of the patients were collected by the retrospective review of medical archives. All patients were followed up by interview in hospital or phone call. FIGURE 2 ROC of srcas1 for the diagnosis of lung cancer patients with MPE. Pleural effusion levels of srcas1 among 78 lung cancer patients with MPE and 48 patients with BPE were determined. The diagnostic potentials of srcas1 were assessed by ROC curves. The AUC value was.947

3 YANG ET AL. 281 TABLE 1 Relationship between pleural effusion srcas1 levels and clinicopathologic characteristics in lung cancer patients with MPE Characteristics All cases srcas1 (U/mL) P Total Age (years) > Gender Male Female Histology Adenocarcinoma Squamous Lymph node metastasis Positive a Negative Tumor size >3 cm cm Tumor grade Poor Well-moderate Distant metastasis Positive a Negative a Significant difference. 3 RESULTS 3.1 Levels of srcas1 in pleural effusion The levels of srcas1 in pleural effusion were measured by ELISA from 78 MPE patients and 48 BPE patients. The levels of srcas1 were significantly higher in MPE patients compared with those in BPE patients ( vs U/mL, P <.01) (Figure 1). 3.2 Diagnostic value of srcas1 in patients with malignant effusion FIGURE 3 Overall survival (OS) and disease-free survival (DFS) curves according to pleural effusion srcas1 levels in lung cancer patients with MPE. (A) OS and (B) DFS stratified by srcas1 level. Cutoff points are 18.7 U/mL for srcas1. Log-rank test determined that the DFS and OS in high srcas1 group were significantly shorter than those in the low srcas1 group (P 5.026; P 5.032) An ROC curve analysis was carried out to assess the value of srcas1 in lung cancer patients with MPE. The area under the ROC curve was (95% CI (confidence interval), ). The best efficacy was observed at 18.7 U/ ml. Using a cutoff point of 18.7 U/mL, srcas1 had a sensitivity of 64.1%, a specificity of 85.4%, and an accuracy of 72.2% (Figure 2). 3.3 Relationship between pleural effusion srcas1 levels and clinicopathologic characteristics in patients with malignant effusion The relationships between srcas1 levels and clinicopathologic characteristics of lung cancer patients are shown in Table 1. The levels of srcas1 were significantly correlated with lymph node metastasis (P 5.034) and distant metastasis (P 5.006). Nevertheless, there were no significant correlation between srcas1 levels and other clinicopathological characteristics including age, gender, histological type, and tumor grade.

4 282 YANG ET AL. TABLE 2 Univariate and multivariate Cox proportional hazards model for OS and DFS in lung cancer patients with MPE Variables Univariate Multivariate HR 95% CI P HR 95% CI P OS Age (>60 vs 60 years) Gender (male vs female) Histology(adenocarcinoma vs squamous) Lymph node metastasis (positive vs negative) < Tumor size (>3 cmvs3 cm) Grade (poor vs well-moderate) Distant metastasis (positive vs negative) < <.001 srcas1 (18.7 U/mL vs <18.7 U/mL) < <.001 DFS Age (>60 vs 60 years) Gender (male vs female) Histology (adenocarcinoma vs squamous) Lymph node metastasis (positive vs negative) < Tumor size (>3 cmvs3 cm) Grade (poor vs well-moderate) Distant metastasis (positive vs negative) < <.001 srcas1 (18.7 U/mL vs <18.7 U/mL) < <.001 Abbreviations: CI, confidence interval; DFS, disease-free survival; HR, hazard ratio; OS, overall survival. 3.4 Association of pleural effusion srcas1 levels with survival Using a cutoff point of 18.7 U/mL, patients were divided into high and low pleural effusion parameter groups. As shown in Figure 3, 1 year OS and DFS analysis in the overall patient population showed a shorter OS and DFS for patients with high srcas1 levels as compared with those patients with low srcas1 levels (log rank test, P for OS, P for DFS, respectively). As shown in Table 2, univariate analysis revealed that histological subtype (P for OS and P for DFS), lymph node metastasis (P <.001 for OS and DFS), distant metastasis (P <.001 for OS and DFS), and srcas1 levels (P <.001 for OS and DFS), were significantly associated with poor prognosis. Multivariate analysis showed that srcas1 was independent prognostic factors for OS and DFS. 4 DISCUSSION To the best of our knowledge, this is the first study on pleural effusion in which srcas1 levels were simultaneously investigated for their diagnostic and prognostic power of MPE. Our findings suggest that elevated pleural effusion concentrations of srcas1 correlated with shorter survival in patients with MPE. Furthermore, multivariate analysis of prognostic factors identified pleural effusion srcas1 concentration as an independent prognostic factor for overall survival in MPE. These results suggest that pleural effusion srcas1 level is an indicator for both presence of MPE and survival outcome. RCAS1 is important in tumor progression or metastasis. Recent studies showed RCAS1 was expressed in various cancers RCAS1 expression also has been associated with poor differentiation and advanced stage. 15,16 Furthermore, RCAS1 expression was reported to be related to overall survival of patients with cancers of the lung, esophagus, and stomach. 7,8,12,16 Thus, the level of RCAS1 may indicate the aggressiveness of human tumors behavior. However, the prognostic value of srcas1 in MPE remains few. 10,19 The rational for investigating srcas1 as the prognostic markers in MPE is based on its ability to promote proliferation. A lot of reports have shown that high level of srcas1 in tumor is associated with adverse outcome in patients with

5 YANG ET AL. 283 different types of cancer. In our study, we demonstrated that high pleural effusion srcas1 level was correlated with the poorer OS and DFS. Moreover, we demonstrated that by using multivariate analysis with OS and DFS, srcas1 showed to be the independent prognostic factor for MPE. Differentiating MPE from BPE is a clinical problem, and conventional methods have proven inadequate. 20,21 Areliable marker for diagnosis of pleural effusion is urgently needed. In this study, the srcas1 concentrations in MPE were higher than those in BPE. Our results suggest that srcas1 should be a tumor marker for the diagnosis of MPE. The diagnostic value of srcas1 in MPE was 18.7 U/ml and had a sensitivity of 64.1%, a specificity of 85.4%. This shows that the srcas1 is a valuable marker in the differential diagnosis of MPE and BPE. In conclusion, srcas1 concentrations in MPE were significantly higher than those in BPE. Determination of srcas1 concentration in the pleural effusion is diagnostically informative, while srcas1 concentration is an independent prognostic factor that shows promise in follow-up of lung cancer patients who develop effusion. CONFLICT OF INTEREST The authors declare no any conflicts of interest in this work. AUTHOR CONTRIBUTIONS Study design: Xiuwei Zhang, Chunhua Xu Data collection: Jian Yang, Ying Zhu, Liangquan Wu, Wenyan Zhu Manuscript writing and study performance: Chunhua Xu, Yang Yang ETHICS This research was approved by the Ethics Committee of the Jiangning Hospital. All patients gave their informed consents. REFERENCES [1] Roberts ME, Neville E, Berrisford RG, et al. Management of malignant pleural effusion: British Thoracic Society Pleural Disease Guideline Thorax. 2010; 65:ii32 ii40. [2] Heffner JE, Klein JS. Recent advances in the diagnosis and management of malignant pleural effusions. Mayo Clin Proc. 2008;83: [3] Cheng D, Kong H, Li YH. Prognostic values of VEGF and IL-8 in malignant pleural effusion in patients with lung cancer. Biomarkers. 2013;18: [4] Su WC, Lai WW, Chen HH, et al. Combined intrapleural and intravenous chemotherapy, and pulmonary irradiation, for treatment of patients with lung cancer presenting with malignant pleural effusion. A pilot study. Oncology. 2003;64: [5] Hsu IL, Su WC, Yan JJ, et al. Angiogenetic biomarkers in non-small-cell lung cancer with malignant pleural effusion: correlations with patient survival and pleural effusion control. Lung Cancer. 2009;65: [6] Nakashima T, Sonoda K, Watanabe T. Inhibition of cell growth and induction of apoptotic cell death by the human tumor-associated antigen RCAS1. Nat Med. 1999; 5: [7] Xu CH, Zhan P, Zhang Y, Yu LK. Serum-soluble receptor-binding cancer antigen expressed on SiSo cells as a clinical marker in lung cancer. Tumour Biol. 2014; 35: [8] Timotheadou E, Skarlos DV, Samantas E, et al. Evaluation of the prognostic role of a panel of biomarkers in stage IB-IIIA non-small-cell lung cancer patients. Anticancer Res. 2007;27: [9] Enjoji M, Nakashima M, Nishi H, et al. The tumorassociated antigen, RCAS1, can be expressed in immunemediated disease as well as in carcinomas of biliary tract. J Hepatol. 2002;36: [10] Aoe K, Hiraki A, Yamazaki K, et al. Elevated pleural fluid RCAS1 is a diagnostic marker and outcome predictor in lung cancer patients. Int J Oncol. 2006;29: [11] Groome PA, Bolejack V, Crowley JJ, et al. The IASLC Lung Cancer Staging Project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumours. J Thorac Oncol. 2007;2: [12] Coban S, Ozkan H, K okl u S, et al. The utility of serum receptor-binding cancer antigen expressed on SiSo cells in gastrointestinal tract cancers. Can J Gastroenterol. 2006;20: [13] Popiela TJ, Rudnicka-Sosin L, Dutsch-Wicherek M, et al. The metallothionein and RCAS1 expression analysis in breast cancer and adjacent tissue regarding the immune cells presence and their activity. Neuro Endocrinol Lett. 2006;27: [14] Enjoji M, Nakashima M, Yamaguchi K, et al. Significance of RCAS1 antigen in hepatocellular, cholangiocellular and pancreatic carcinomas. J Gastroenterol Hepatol. 2005;20: [15] Ozkan H, Akar T, K okl u S, etal. Significance of serum receptor-binding cancer antigen (RCAS1) in pancreatic cancer and benign pancreatobiliary diseases. Pancreatology. 2006;6: [16] Giaginis C, Efkarpidis T, Alexandrou P, et al. Increased RCAS1 expression is associated with advanced histopathological stage and poor prognosis in patients with gastric adenocarcinoma. Dis Markers. 2013;35:

6 284 YANG ET AL. [17] Nakamura Y, Yamazaki K, Oizumi S, et al. Expression of RCAS1 in human gastric carcinoma: a potential mechanism of immune escape. Cancer Sci. 2004;95: [18] Rupesh P, Manoj P, Vijay Kumar S. Biomarkers in carcinoma of the gallbladder. Expert Opin Med Diagn. 2008; 2: [19] Hiraki A, Aoe K, Murakami T, et al. Clinical significance of the expression of tumor-associated antigen, RCAS1, and its soluble protein in pleural fluid in malignant mesothelioma. Oncol Rep. 2005;14: [20] Aoe K, Hiraki A, Murakami T, et al. Diagnostic significance of interferon-gamma in tuberculous pleural effusions. Chest. 2003;123: [21] Hiraki A, Aoe K, Eda R, et al. Comparison of six biological markers for the diagnosis of tuberculous pleuritis. Chest. 2004;125: How to cite this article: Yang J, Zhu Y, Wu L, et al. Diagnostic and prognostic significance of receptorbinding cancer antigen expressed on SiSo cells in lungcancer-associated pleural effusion. Clin Respir J. 2018;12: