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The important role of circulating CYFRA21-1 in metastasis diagnosis and prognostic value compared with carcinoembryonic antigen and neuron-specific enolase in lung cancer patients

  • Li Zhang2,
  • Dan Liu1,
  • Lei Li1,
  • Dan Pu3,
  • Ping Zhou1,
  • Yuting Jing1,
  • He Yu1,
  • Yanwen Wang2,
  • Yihan Zhu2,
  • Yanqi He1,
  • Yalun Li1,
  • Shuang Zhao1,
  • Zhixin Qiu1 and
  • Weimin Li1Email author
Contributed equally
BMC Cancer201717:96

https://doi.org/10.1186/s12885-017-3070-6

Received: 20 November 2015

Accepted: 18 January 2017

Published: 2 February 2017

Abstract

Background

The roles of carcinoembryonic antigen (CEA), cytokeratin 19 fragments (CYFRA21-1) and neuron-specific enolase (NSE) in metastases occurrence and poor diagnosis in specific histological classifications of lung cancer need further exploring. In this study, we investigated relationship between elevated levels of three biomarkers of CEA, CYFRA21-1 and NSE (individually and in combination) and metastasis, survival status and prognosis in lung cancer patients.

Methods

Eight hundred and sixty eight lung cancer patients including adenocarcinoma (ADC, N = 445), squamous cell carcinoma (SCC, N = 215), small cell lung cancer (SCLC, N = 159) and other types (N = 49) were categorized into negative, moderate and high groups according to serum levels of biomarkers, and were then categorized into negative, single, double and triple groups according to any positive combination of three biomarkers. The cutoff values of three biomarkers for groupings were developed on the training group (N = 432) and verified in a validation group (N = 436). Clinical and laboratory characteristics were then assessed for correlation with occurrence of metastasis, survival status and prognosis between the two groups. Further correlation analyses were also conducted by different subtypes (ADC, SCC and SCLC) and tumor stages (I + II, III and IV) of lung cancers.

Results

The consistent results between training and validation group confirmed the rationality of grouping methods. CYFRA21-1 levels had stronger association with metastases and survival status than CEA and NSE in all lung cancer patients. When stratified by subtypes, these significances only existed in ADC patients for CYFRA21-1. Cox regression analyses showed that CYFRA21-1 and NSE were independent prognostic factors for lung cancer patients. However, only CYFRA21-1 was an independent prognostic factor in ADC and SCLC patients subtypes. Cox-regression results also indicated that CYFRA21-1 could act as independent prognostic factor in different stages (I + II, III and IV) of lung cancer.

Conclusion

CYFRA21-1 was more important in metastasis occurrence and in predicting poor prognosis in lung cancer patients than CEA, NSE and positive numbers of biomarkers.

Keywords

Lung cancer patients Biomarkers CYFRA21-1 CEA NSE Metastasis Prognosis

Background

Globally, lung cancer has the highest associated mortality among all malignant cancers [1]. The 5-year survival rate in advanced stage cancers is 15%, as compared to 80% in early stage lung cancers [2]. One of the reasons is that most patients are diagnosed at advanced stages due to lack of sensitive and specific early diagnostic biomarkers [3]. Non-small-cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancers; the remaining 15% cases are classified as small cell lung cancer (SCLC) [4]. Although chemotherapy and targeted therapy are the main clinical treatment especially of stage IV patients, yet there is only 4–5% improvement in 5-year survival rates for stage I-III patients, and no significant improvement for stage IV patients [5]. The diagnostic methods include chest x-ray, computed tomography (CT) and needle biopsy of lung [6, 7]. However, the high cost and/or invasive nature of these investigations limit the widely use in clinical diagnosis.

During past decades, many advances have been made in the identification of tumor-associated markers in body fluids such as plasma, serum or bio-aerosols such as exhaled breath condensate (EBC) [8, 9]which could facilitate early detection and help for treatment monitoring [10]. For lung cancer diagnosis, the leading markers used are carcinoembryonic antigen (CEA), cytokeratin 19 fragments (CYFRA 21–1) and neuron-specific enolase (NSE). CEA, which is closely related to histological classification, is considered valuable for diagnosis of ADC [11]. CYFRA 21–1 and NSE are used for the diagnosis of SCLC [12, 13]. Increasing trend in levels of CEA, CYFRA21-1 and NSE have been associated with metastasis and poor prognosis [1416]. However, limitations of previous studies are either in small sample sizes (N = 200-300) or not analyzed in combinations.

In this retrospective study we evaluated the predictive values of serum levels of CEA, CYFRA21-1 and NSE for prognosis and occurrence of metastasis, and the association of these biomarkers with clinical characteristics.

Methods

Patients

This study recruited 868 lung cancer patients who were admitted to West China Hospital between 2008 through 2012. All data were obtained from medical records within 2 weeks of diagnosis, and information regarding metastasis was obtained through reports of whole-body CT scan, bone scan, lymph node and fiber optic bronchoscopy biopsy. Survival time was obtained during subsequent follow-up visit or telephonic inquiry. Those patients who did not receive CEA, CYFRA21-1 and NSE determinations and lack of follow-up data were excluded. Data on stage were according to the TNM Classification of Malignant Tumors, 7th Edition [17].

The overall survival time was calculated as time from the date of diagnosis through the date of death or last follow up visit (if the exact date of death was unavailable). Prior to surgery or any other treatments, serum concentrations of CEA, CYFRA21-1 and NSE were measured by immunoassays. Based on the reported literatures, the threshold values for CEA, CYFRA21-1 and NSE levels were 3.4 ng/mL, 3.0 ng/mL and 15.0 ng/mL, respectively [17].

Study design

Depending on the levels of CEA, CYFRA21-1 and NSE, the study subjects were divided into three groups (negative, moderate and high). For CEA analysis, moderate and high groups were defined as 1–10 folds and >10 folds cutoff value, respectively. For CYFRA21-1 analysis 1–3 folds and >3 folds, respectively. For NSE analysis, 1–2 folds and >2 folds, respectively. This analysis was performed in a randomly selected training group (N = 432), reserving the left 436 cases for validation. The cutoff values of three biomarkers for groupings were developed on the training group and tested in a validation group.

Next, we determined the correlations of biomarker levels with three main histological subtypes, ADC, SCC and SCLC. The association analyses of other tumor types (N = 49) such as large cell lung cancers and adenosquamous carcinoma were also performed which showed no positive prognostic value (Data not shown).

Finally, the diagnosis, metastasis and prognostic values of combination patterns of three biomarkers were also evaluated. In brief, patients were grouped as negative, single, double and triple positive of biomarkers. Negative indicated that serum levels of all three biomarkers were below cutoff levels. Single, double, triple positive meant that concentrations of any one, two or all three biomarkers exceeded cutoff values.

Statistical methods

SPSS 19.0 for Windows (SPSS Inc, Chicago, USA) was used for data analyses. Chi-square test was performed to evaluate the inter-group differences. Kaplan-Meier test was used to calculate the survival status of different groups, and Log-rank test was used to compare the survival among three groups. Multivariate Cox regression analysis was used to determine the clinical characteristics, metastasis and survival status in order to estimate the hazards ratio for different serum levels of CEA, CYFRA21-1 and NSE and identify independent predictors of poor prognosis.

Results

Increased levels of CYFRA21-1 significantly correlated with metastatic disease

Total 868 lung cancer patients were randomly divided into training group (TA, 432 cases) and validation (VA, 436 cases) group to confirm the rationality of grouping methods. Among them, 320 patients tested negative (TA: 164, VA: 156) (<3.4 ng/mL) while 365 (TA: 179, VA: 186) and 210 (TA: 89, VA: 94) had moderate and high levels of CEA, respectively. For CYFRA21-1, 231 patients tested negative (TA: 115, VA: 116) while 390 (TA: 190, VA: 200) and 247 (TA: 127, VA: 120) had moderate and high levels, respectively. For NSE, 412 patients (TA: 206, VA: 206) tested negative while 256 (TA: 128, VA 128) and 200 (TA: 98, VA: 102) had moderate and high levels.

The results indicated strong correlations of increased levels of CEA, CYFRA21-1 and NSE with histological classifications in both TA and VA groups (All P < 0.001). CEA and CYFRA21-1 were also related closely to TNM stages in TA and VA groups (P < 0.05, P < 0.01 and P < 0.001), while NSE had dramatic correlation with smoke status (TA: P < 0.01, VA: P < 0.05). CEA correlated closely to bone metastasis (TA: P < 0.05, VA: P < 0.01) and NSE had significant correlation with metastasis of bone (TA: P < 0.001, VA: P < 0.01), liver (TA: P < 0.001, VA: P < 0.01), lymph node (TA: P < 0.01, VA: P < 0.01) and mediastinum (TA: P < 0.01, VA: P < 0.05) (Table 1, Additional file 1: Table S1A and B).
Table 1

The analysis of CYFRA21-1 in all lung cancer patients

 

No. (%)

  

Neg

Moderate

High

Total

P Value

 

1–3 fold

>3 fold

  

(n = 115)

(n = 190)

(n = 127)

(n = 432)

 

Basic Characteristics

 Age

   < 45

5 (4.3)

16 (8.4)

7 (5.5)

28

0.101

  45–60

58 (50.4)

72 (37.9)

46 (36.2)

176

 

   > 60

52 (45.3)

102 (53.7)

74 (58.3)

228

 

 Sex

  Male

79 (68.7)

134 (70.5)

83 (65.4)

296

0.623

  Female

36 (31.3)

56 (29.5)

44 (34.6)

136

 

 Histological classification

  SCC

21 (18.3)

42 (22.1)

56 (44.1)

119

 

  ADC

64 (55.7)

103 (54.2)

58 (45.7)

225

<0.001**

  SCLC

22 (19.1)

34 (17.9)

7 (5.5)

63

 

  Others

8 (6.9)

11 (5.8)

6 (4.7)

25

 

 Stages

  I

12 (10.4)

6 (3.2)

0 (0.0)

18

<0.001**

  II

7 (6.1)

8 (4.2)

2 (1.6)

17

 

  III

40 (34.8)

50 (26.3)

38 (29.9)

128

 

  IV

49 (42.6)

115 (60.5)

79 (62.2)

243

 

  #Un.

7 (6.1)

11 (5.8)

8 (6.3)

26

 

 Smoke status

  No

55 (47.8)

80 (42.1)

56 (44.1)

191

0.621

  Yes

60 (52.2)

110 (57.9)

71 (55.9)

241

 

Metastasis

 Brain

  No

104 (90.4)

162 (85.3)

105 (82.7)

371

0.212

  Yes

11 (9.6)

28 (14.7)

22 (17.3)

61

 

 Bone

  No

101 (90.4)

142 (74.7)

92 (72.4)

335

<0.01**

  Yes

14 (9.6)

48 (25.3)

35 (27.6)

97

 

 Liver

  No

113 (98.3)

170 (89.5)

108 (85.0)

391

<0.01**

  Yes

2 (1.7)

20 (10.5)

19 (15.0)

41

 

 Adrenal gland

  No

113 (98.3)

173 (91.1)

119 (93.7)

405

<0.05*

  Yes

2 (1.7)

17 (8.9)

8 (6.3)

27

 

 Lymph node

  No

66 (57.4)

68 (35.8)

37 (29.1)

171

<0.001***

  Yes

49 (42.6)

122 (64.2)

90 (70.9)

261

 

 Intrapulmonary

  No

105 (91.3)

163 (85.8)

111 (87.4)

379

0.360

  Yes

21 (9.1)

58 (14.9)

35 (14.2)

53

 

 Pleural

  No

100 (87.0)

170 (89.5)

98 (77.2)

368

<0.01**

  Yes

15 (13.0)

20 (10.5)

29 (22.8)

64

 

 Mediastinal

  No

113 (98.3)

185 (97.4)

120 (94.5)

418

0.208

  Yes

2 (1.7)

5 (2.6)

7 (5.5)

14

 

 Peritoneum

  No

115 (100)

178 (93.7)

116 (91.3)

409

<0.01**

  Yes

0 (0.0)

12 (6.3)

11 (8.7)

23

 

Validation group

No. (%)

 

Neg

Moderate

High

Total

P Value

 
 

1–3 fold

>3 fold

   

(n = 116)

(n = 200)

(n = 120)

(n = 436)

  

Basic Characteristics

 Age

  8 (6.9)

13 (6.5)

10 (8.3)

31

0.073

 

  52 (44.8)

61 (30.5)

36 (30.0)

149

  

  56 (48.3)

126 (63.0)

74 (61.7)

256

  

 Sex

  74 (63.8)

139 (69.5)

94 (78.3)

307

<0.05*

 

  42 (36.2)

61 (30.5)

26 (21.7)

129

  

 Histological classification

  15 (12.9)

43 (21.5)

38 (31.7)

96

<0.001**

 

  56 (48.3)

98 (49.0)

66 (55.0)

220

  

  40 (34.5)

47 (23.5)

9 (7.5)

96

  

  5 (4.3)

12 (6.0)

7 (5.8)

24

  

 Stages

  9 (7.8)

9 (4.5)

4 (3.3)

22

<0.05*

 

  15 (12.9)

20 (10.0)

3 (2.5)

38

  

  23 (19.8)

43 (21.5)

23 (19.2)

89

  

  61 (52.6)

115 (57.5)

86 (71.7)

262

  

  8 (6.9)

13 (6.5)

4 (3.3)

25

  

 Smoke status

  63 (54.3)

86 (43.0)

42 (35.0)

191

<0.05*

 

  53 (45.7)

114 (57.0)

78 (65.0)

245

  

Metastasis

 Brain

  102 (87.9)

183 (91.5)

93 (77.5)

378

<0.01**

 

  14 (12.1)

17 (8.5)

27 (22.5)

58

  

 Bone

  101 (87.1)

160 (80.0)

79 (65.8)

340

<0.001***

 

  15 (12.9)

40 (20.0)

41 (34.2)

96

  

 Liver

  110 (94.8)

177 (88.5)

96 (80.0)

383

<0.01**

 

  6 (5.2)

23 (11.5)

24 (20.0)

53

  

 Adrenal gland

  107 (92.2)

192 (96.0)

110 (91.7)

409

0.213

 

  9 (7.8)

8 (4.0)

10 (8.3)

27

  

 Lymph node

  58 (50.0)

68 (34.0)

41 (34.2)

167

<0.01**

 

  58 (50.0)

132 (66.0)

79 (65.8)

269

  

 Intrapulmonary

  105 (90.5)

169 (84.5)

101 (84.2)

375

0.262

 

  11 (9.5)

31 (15.5)

19 (15.8)

61

  

 Pleural

  107 (92.2)

168 (81.5)

95 (79.2)

365

<0.05*

 

  9 (7.8)

37 (18.5)

25 (20.8)

71

  

 Mediastinal

  114 (98.3)

192 (96.0)

112 (93.3)

418

0.161

 

  2 (1.7)

8 (4.0)

8 (6.7)

18

  

 Peritoneum

  111 (95.7)

189 (94.5)

99 (82.5)

399

<0.01**

 

  5 (4.3)

11 (5.5)

21 (17.5)

37

  

*p < 0.05, **p < 0.001, #Un., unknown

Among all three biomarkers, levels of CYFRA21-1significantly correlated with occurrence of organ metastasis. Besides metastasis to bone (TA: negative9.6%, moderate 25.3%, high 27.6%, P < 0.01; VA: negative 12.9%, moderate 20.0%, high 34.2%; P < 0.001) and liver (TA: negative 1.7%, moderate10.5%, high 15.6%, P < 0.01; VA: negative 5.2%, moderate11.5%, high 20.0%; P < 0.001), CYFRAY21-1 levels were also associated with metastases to lymph nodes (TA: negative 42.6%, moderate 64.2%, high 70.9%, P < 0.001; VA: negative 50%, moderate 66%, high 65.8%; P < 0.01), pleura (TA: P < 0.01, VA: P < 0.05) and peritoneum (TA: P < 0.01, VA: P < 0.01) (Table 1). However, CEA and NSE levels showed relative poor correlation with metastases (Additional file 1: Table S1A and B), which confirmed the importance of CYFRA21-1 in metastasis. Consistent results between training and validation groups also indicated the grouping rationality although several deviations such as sex, brain metastasis and adrenal gland metastasis in CYFRA21-1 and NSE, while brain and liver metastasis in CEA (Table 1, Additional file 1: Table S1A and B).

Correlation of CYFRA21-1 and NSE with metastases in ADC and SCC, respectively

In this study, the CYFRA21-1 levels showed a stronger correlation with occurrence of metastasis in ADC patients when compared with that of CEA and NSE. It also showed a significant correlation with presence of metastatic lesions in brain (P < 0.05), bone (P < 0.001), liver (P < 0.05), lymph node (P < 0.001), intrapulmonary (P < 0.05), pleural (P < 0.05) and peritoneum (P < 0.05) (Table 2). However, CEA positive levels correlated only with bone (P < 0.05) and liver metastasis (P < 0.05) (Additional file 2: Table S2A), while NSE levels correlated only with metastatic lesions in brain (P < 0.001) and bone (P < 0.001) (Additional file 2: Table S2B).
Table 2

The association analysis between CYFRA21-1 and ADC

 

No. (%)

  

Neg

Moderate

High

Total

P Value

 

(1–3 fold)

>3 fold

 

(n = 120)

(n = 201)

(n = 124)

(n = 445)

Basic Characteristics

 Age

   < 45 years

5 (4.2)

22 (11.0)

14 (11.3)

41

<0.05*

  45–60 years

57 (47.5)

66 (32.8)

38 (30.6)

161

   > 60 years

58 (48.3)

113 (56.2)

72 (58.1)

243

 Sex

  Male

65 (54.2)

112 (55.7)

71 (57.3)

248

0.889

  Female

55 (45.8)

89 (44.3)

53 (42.7)

197

 Stages

  I + II

24 (20.0)

14 (7.0)

5 (4.0)

43

<0.001**

  III + IV

91 (75.8)

181 (90.0)

116 (93.6)

388

  Unknown

4 (4.2)

6 (3.0)

3 (2.4)

14

 Smoke status

  No

79 (65.9)

119 (59.2)

68 (54.8)

266

0.208

  Yes

41 (34.1)

82 (40.8)

56 (45.2)

179

Metastasis

 Brain

  No

107 (89.2)

164 (81.6)

95 (76.6)

366

<0.05*

  Yes

13 (10.8)

37 (18.4)

29 (23.4)

79

 Bone

  No

102 (85.0)

141 (70.1)

75 (60.5)

318

<0.001**

  Yes

18 (15.0)

60 (29.9)

49 (39.5)

127

 Liver

  No

116 (96.7)

181 (90.1)

102 (82.3)

399

<0.05*

  Yes

4 (3.3)

20 (9.9)

22 (17.7)

46

 Adrenal gland

  No

115 (95.8)

191 (95.0)

116 (93.5)

422

0.713

  Yes

5 (4.2)

10 (5.0)

8 (6.5)

23

 Lymph node

  No

69 (57.5)

69 (34.3)

45 (36.3)

183

<0.001**

  Yes

51 (42.5)

132 (65.7)

79 (63.7)

262

 Intrapulmonary

  No

111 (92.5)

165 (82.1)

105 (84.7)

381

<0.05*

  Yes

9 (7.5)

36 (17.9)

19 (15.3)

64

 Pleural

  No

103 (85.8)

161 (80.1)

88 (71.0)

352

<0.05*

  Yes

17 (14.2)

40 (19.9)

36 (29.0)

93

 Mediastinal

  No

119 (99.2)

195 (97.0)

118 (95.2)

432

0.178

  Yes

1 (0.8)

6 (3.0)

6 (4.8)

13

 Peritoneum

  No

119 (99.2)

186 (92.5)

107 (86.3)

412

<0.05*

  Yes

1 (0.8)

15 (7.5)

17 (13.7)

33

*p<0.05, **p<0.001

An interesting finding which differs from those reported earlier is the significant correlation of NSE levels with occurrence of metastasis in SCC patients, as compared with that of CEA and CYFRA21-1. In the present study, NSE levels were associated with occurrence of metastases to brain (P < 0.05), bone (P < 0.05), lymph nodes (P < 0.05), mediastinum (P < 0.05) and peritoneal cavity (P < 0.05) (Table 3). However, CEA levels correlated only with lymph node metastasis (Additional file 3: Table S3A), while CYFRA21-1 was associated with metastasis to brain (Negative: 5.6%; moderate: 2.4%; high: 16.0%, P < 0.05), and lymph node (Negative: 41.7%; moderate: 60%; high: 74.5%; P < 0.05) (Additional file 3: Table S3B).
Table 3

The association analysis between NSE and SCC

 

No. (%)

  

Neg

Moderate

High

Total

P Value

 

(1–2 fold)

>2 fold

  

(n = 110)

(n = 70)

(n = 35)

(n = 215)

 

Basic Characteristics

 Age

   < 45 years

3 (2.7)

2 (2.9)

0 (0.0)

5

0.622

  45–60 years

40 (36.4)

23 (32.8)

9 (25.7)

72

   > 60 years

67 (60.9)

45 (64.3)

26 (74.3)

138

 Sex

  Male

101 (91.8)

61 (87.1)

30 (85.7)

192

0.463

  Female

9 (8.2)

9 (12.9)

5 (14.3)

23

 Stages

  I + II

26 (23.6)

6 (8.6)

1 (2.8)

33

<0.05*

  III + IV

80 (72.7)

62 (88.6)

33 (94.4)

175

  Unknown

4 (3.7)

2 (2.8)

1 (2.8)

7

 Smoke status

  No

22 (20.0)

16 (22.9)

9 (25.7)

47

0.753

  Yes

88 (80.0)

54 (77.1)

26 (74.3)

168

Metastasis

 Brain

  No

107 (97.3)

62 (88.6)

27 (77.1)

196

<0.05*

  Yes

3 (2.7)

8 (11.4)

8 (22.9)

19

 Bone

  No

100 (90.9)

55 (78.6)

27 (77.1)

182

<0.05*

  Yes

10 (9.1)

15 (21.4)

8 (22.9)

33

 Liver

  No

102 (92.7)

61 (87.1)

27 (77.1)

190

0.062

  Yes

8 (7.3)

9 (12.9)

8 (22.9)

25

 Adrenal gland

  No

106 (96.4)

64 (91.4)

32 (91.4)

202

0.316

  Yes

4 (3.6)

6 (8.6)

3 (8.6)

13

 Lymph node

  No

51 (46.4)

19 (27.1)

9 (25.7)

79

<0.05*

  Yes

59 (53.6)

51 (72.9)

26 (74.3)

136

 Intrapulmonary

  No

96 (87.3)

58 (82.9)

31 (88.6)

185

0.632

  Yes

14 (12.7)

12 (17.1)

4 (11.4)

30

 Pleural

  No

98 (89.1)

59 (84.3)

31 (88.6)

188

0.622

  Yes

12 (10.9)

11 (15.7)

4 (11.4)

27

 Mediastinal

  No

108 (98.2)

61 (87.1)

34 (97.1)

203

<0.05*

  Yes

2 (1.8)

9 (12.9)

1 (2.9)

12

 Peritoneum

  No

109 (99.1)

61 (87.1)

31 (88.6)

201

<0.05*

  Yes

1 (0.9)

9 (12.9)

4 (11.4)

14

*p < 0.05, **p < 0.001

In the present study, 18.3% of all subjects were small cell lung cancer (SCLC) patients. In these patients, we observed a correlation between increased levels of CEA and occurrence of mediastinal and peritoneal metastasis (P < 0.05) (Additional file 4: Table S4A); between increased levels of CYFRA21-1 and liver metastasis (P < 0.05) (Additional file 4: Table S4B); and between increased NSE levels and occurrence of lymph node metastasis (Negative: 42.1%; moderate: 60.1%; high: 77.8%;P < 0.05) (Additional file 4: Table S4C).

Increased positive numbers of biomarkers as predictors of metastases

The analysis of increased positive numbers of biomarkers in all lung cancer patients was performed in training group and validation groups. In training group, the numbers of negative, single, double and triple groups were 37, 101, 172 and 122 cases, respectively, while 27, 118, 161 and 130 in the validation group. The number TA and VA groups indicated less data deviation among different groups. The results suggested strong correlation of increased positive numbers with stages (TA: P < 0.05, VA: P < 0.05). In metastasis analysis, increased positive numbers related closely to occurrence of metastasis in bone (TA: Neg 10.8%, Single 13.9%, Double 26.2%, Triple 27.9%, P < 0.05; VA: Neg 0%, Single 12.7%, Double 23.6%, Triple 33.1%, P < 0.001) and lymph node (TA: Neg 32.4%, Single 55.4%, Double 59.9%, Triple 73.8%, P < 0.001; VA: Neg 29.6%, Single 50.8%, Double 68.9%, Triple 69.2%, P < 0.001) (Table 4).
Table 4

The analysis of positive numbers of biomarkers in all lung cancer patients

 

No. (%)

  

Neg

Single

Double

Triple

Total

P Value

 

(1–10 fold)

>10 fold

   

(n = 37)

(n = 101)

(n = 172)

(n = 122)

(n = 432)

 

Basic Characteristics

 Age

   < 45

2 (5.4)

5 (5.0)

12 (7.0)

9 (7.4)

28

0.057

  45-60

22 (59.5)

50 (49.5)

61 (35.5)

43 (35.2)

176

   > 60

13 (35.1)

46 (45.5)

99 (57.6)

70 (57.4)

228

 Sex

  Male

27 (73.0)

71 (70.3)

114 (66.3)

84 (68.9)

296

0.827

  Female

10 (27.0)

30 (29.7)

58 (33.7)

38 (31.1)

136

 Histological classification

  SCC

12 (32.4)

29 (28.7)

49 (28.5)

29 (23.8)

119

0.772

  ADC

19 (51.4)

53 (52.5)

90 (52.3)

63 (51.6)

225

  SCLC

3 (8.1)

12 (11.9)

24 (14)

24 (19.7)

63

  Others

3 (8.1)

7 (6.9)

9 (5.2)

6 (4.9)

25

 Stages

  I

5 (13.5)

8 (7.9)

5 (2.9)

0 (0)

18

<0.05*

  II

2 (5.4)

6 (5.9)

5 (2.9)

4 (3.3)

17

  III

14 (37.8)

34 (33.7)

43 (25)

37 (30.3)

128

  IV

14 (37.8)

47 (46.5)

109 (63.4)

73 (59.8)

243

  #Un.

2 (5.4)

6 (5.9)

10 (5.8)

8 (6.6)

26

 Smoke status

  No

16 (43.2)

54 (53.5)

73 (42.4)

48 (39.3)

191

0.178

  Yes

21 (56.8)

47 (46.5)

99 (57.6)

74 (60.7)

241

Metastasis

 Brain

  No

34 (91.9)

91 (90.1)

143 (83.1)

103 (84.4)

371

0.277

  Yes

3 (8.1)

10 (9.9)

29 (16.9)

19 (15.6)

61

 Bone

  No

33 (89.2)

87 (86.1)

127 (73.8)

88 (72.1)

335

<0.05*

  Yes

4 (10.8)

14 (13.9)

45 (26.2)

34 (27.9)

97

 Liver

  No

36 (97.3)

94 (93.1)

155 (90.1)

106 (86.9)

391

0.199

  Yes

1 (2.7)

7 (6.9)

17 (9.9)

16 (13.1)

41

 Adrenal gland

  No

36 (97.3)

98 (97)

154 (89.5)

117 (95.9)

405

0.086

  Yes

1 (1.7)

3 (3.0)

18 (10.5)

5 (4.1)

27

 Lymph node

  No

25 (67.6)

45 (44.6)

69 (40.1)

32 (26.2)

171

<0.001**

  Yes

12 (32.4)

56 (55.4)

103 (59.9)

90 (73.8)

261

 

 Intrapulmonary

  No

33 (89.2)

89 (88.1)

149 (86.6)

108 (88.5)

379

0.950

  Yes

4 (10.8)

12 (11.9)

23 (13.4)

14 (11.5)

53

 

 Pleural

  No

33 (89.2)

89 (88.1)

142 (82.6)

104 (85.2)

368

0.552

  Yes

4 (10.8)

12 (11.9)

30 (17.4)

18 (14.8)

64

 Mediastinal

  No

37 (100)

98 (97)

169 (98.3)

114 (93.4)

418

0.080

  Yes

0 (0.0)

3 (3.0)

3 (1.7)

8 (6.6)

14

 Peritoneum

  No

37 (100)

98 (93.7)

162 (94.2)

112 (91.8)

409

0.153

  Yes

0 (0.0)

3 (6.3)

10 (5.8)

10 (8.2)

23

 

Validation group

 

No. (%)

     

Neg

Single

Double

Triple

Total

P Value

(n = 27)

(n = 118)

(n = 161)

(n = 130)

(n = 436)

 

Basic Characteristics

 Age

  2 (7.4)

8 (6.8)

10 (6.2)

11 (8.5)

31

0.733

 

  10 (37.0)

46 (39.0)

48 (29.8)

45 (34.6)

149

  

  15 (55.6)

64 (54.2)

103 (64.0)

74 (56.9)

256

  

 Sex

  18 (66.7)

75 (63.6)

116 (72.0)

98 (75.4)

307

0.204

 

  9 (33.3)

43 (36.4)

45 (28.0)

32 (24.6)

129

  

 Histological classification

  7 (25.9)

31 (26.3)

37 (23)

21 (16.2)

96

0.386

 

  15 (55.6)

57 (48.3)

84 (52.2)

64 (49.2)

220

  

  1 (3.7)

5 (4.2)

11 (6.8)

7 (5.4)

24

  

  5 (18.5)

12 (10.2)

7 (4.3)

24 (18.5)

47

  

 Stages

  5 (18.5)

9 (7.6)

5 (3.1)

3 (2.3)

22

<0.05*

 

  5 (18.5)

16 (13.6)

10 (6.2)

7 (5.4)

38

  

  6 (22.2)

26 (22.0)

36 (22.4)

21 (16.2)

89

  

  11 (40.7)

58 (49.2)

103 (64.0)

90 (69.2)

262

  

  0 (0.0)

9 (7.6)

7 (4.3)

9 (19.2)

25

  

 Smoke status

  15 (55.6)

62 (52.5)

65 (40.4)

49 (37.7)

191

<0.05*

 

  12 (44.4)

56 (47.5)

96 (59.6)

81 (62.3)

245

  

Metastasis

 Brain

  27 (100.0)

107 (90.7)

134 (83.2)

110 (84.6)

378

<0.05*

 

  0 (0.0)

11 (9.3)

27 (16.8)

20 (15.4)

58

  

 Bone

  27 (100.0)

103 (87.3)

123 (76.4)

87 (66.9)

340

<0.001**

 

  0 (0.0)

15 (12.7)

38 (23.6)

43 (33.1)

96

  

 Liver

  No

26 (96.3)

111 (94.1)

140 (87.0)

106 (81.5)

383

<0.05*

  Yes

1 (3.7)

7 (5.9)

21 (13.0)

24 (18.5)

53

 

 Adrenal gland

  27 (100.0)

111 (94.1)

149 (92.5)

122 (93.8)

409

0.525

 

  0 (0.0)

7 (5.9)

12 (7.5)

8 (6.2)

27

  

 Lymph node

  19 (70.4)

58 (49.2)

50 (31.1)

40 (30.8)

167

<0.001***

 

  8 (29.6)

60 (50.8)

111 (68.9)

90 (69.2)

269

  

 Intrapulmonary

  26 (96.3)

105 (89.0)

130 (80.7)

114 (87.7)

375

0.064

 

  1 (3.7)

13 (11.0)

31 (19.3)

16 (12.3)

61

  

 Pleural

  25 (92.6)

107 (90.7)

129 (80.1)

104 (80.0)

365

<0.05*

 

  2 (7.4)

11 (9.3)

32 (20.8)

26 (20.0)

71

  

 Mediastinal

  27 (100.0)

116 (98.3)

152 (94.4)

123 (94.6)

418

0.229

 

  0 (0.0)

2 (1.7)

9 (5.6)

7 (5.4)

18

  

 Peritoneum

  27 (100.0)

110 (93.2)

144 (89.4)

118 (90.8)

399

0.269

 

  0 (0.0)

8 (6.8)

17 (10.4)

12 (9.2)

37

  

The application of 3-tier classification to all types of lung cancers revealed that lymph node metastasis was significantly associated with increased levels of biomarkers (ADC P < 0.05; SCC P < 0.001; SCLC P < 0.05) (Additional file 5: Table S5A-C). In ADC and SCC, increased levels correlated with metastasis to both lymph nodes and other organs (Additional file 5: Table S5A-C).

CYFRA21-1 levels correlated with survival in ADC, SCC and SCLC

Kaplan-Meier survival curves were used to analyze mortality at 3–5 years using SPSS19.0. The results of 3–5 year survival analyses indicated that presence of high concentrations of CEA (TA P < 0.01; VA P < 0.01), CYFRA21-1 (TA P < 0.001; VA P < 0.001), NSE (TA P < 0.05; VA P < 0.05) and positive numbers of biomarkers (TA P < 0.001; VA P < 0.01) were closely associated with survival status in both training group and validation groups (Fig. 1a-d).
Fig. 1

The survival status of lung cancer patients in training and validation groups a: CEA, b: CYFRA21-1, c: NSE, d: positive numbers *P < 0.05, **P < 0.001

For ADC patients, high levels of CEA (P < 0.001), CYFRA21-1 (P < 0.001), NSE (P < 0.05), and numbers of increased biomarkers (P < 0.001), were all closely associated with survival status of patients (Fig. 2). In SCC patients only CYFRA21-1 was associated with mortality (Additional file 6: Figure S1A). In SCLC patients, the high concentrations of CYFRA21-1 (P < .05) and NSE (P < .05) were closely associated with survival status (Additional file 7: Figure S1B).
Fig. 2

The survival functions in ADC patients correlated with different biomarkers *P < 0.05, **P < 0.001

Multivariate Cox regression analysis to identify poor prognostic factors

We observed a significant correlation between overall survival and CYFRA21-1, NSE and occurrence of metastasis. Compared with negative group, the hazards ratio increased 1.226 in CYFRA21-1 moderate positive group (Confidence Interval [CI]: 0.977–1.537) and 1.647 in CYFRA21-1 high positive group (CI: 1.273–2.130, P < .001) (Table 5). For NSE, we did not find a significant difference between hazard risk and NSE moderate positive group (HR: 1.010, CI: 0.808–1.263) but the HR increased 1.291 in NSE high positive group compared with that of negative group (CI: 1.032–1.715, P < .05). As expected, occurrence of metastasis was an independent predictor of poor prognosis (HR: 1.291, CI: 1.025–1.625, P < .05) (Table 5).
Table 5

The multivariate analysis of lung cancer patients

 

Multivariate HR (95% CI)

P value

Age

  < 45

1[Reference]

<0.001*

 45–65

0.714 (0.513–0.994)

  > 65

1.089 (0.793–1.495)

Sex

 Male

1[Reference]

0.529

 Female

0.942 (0.782–1.135)

Histological classification

 Squamous

1[Reference]

<0.05*

 Adenocarcinoma

1.113 (0.894–1.384)

 SCLC

0.970 (0.729–1.290)

 Others

1.654 (1.160–2.358)

Stages

 I

1[Reference]

<0.05*

 II

1.096 (0.624–1.925)

 III

1.218 (0.753–1.969)

 IV

1.976 (1.120–3.488)

Smoke statues

 No

1[Reference]

0.095

 Yes

0.823 (0.655–1.035)

CEA levels

 Neg

1[Reference]

0.233

 Moderate

1.171 (0.954–1.438)

 High

1.217 (0.945–1.567)

CYFRA levels

 Neg

1[Reference]

<0.001*

 Moderate

1.226 (0.977–1.537)

 High

1.647 (1.273–2.130)

NSE levels

 Neg

1[Reference]

<0.05*

 Moderate

1.010 (0.808–1.263)

 High

1.330 (1.032–1.715)

Metastasis

 No

1[Reference]

<0.05*

 Yes

1.291 (1.025–1.625

Positive numbers

 Neg

1[Reference]

0.649

 Single

1.075 (0.806–1.434)

 Double

1.102 (0.898–1.353)

 Triple

1.086 (0.773–1.524)

The specific histological grade analysis indicated that high and moderate levels of serum CYFRA21-1 significantly correlated with poor prognosis (HR: 1.860, CI: 1.036–3.338, P < 0.05) in both ADC and SCLC patients (HR: 1.365, CI: 0.514–3.624, P < 0.05) respectively (Table 6). In SCC and SCLC patients, only occurrence of metastasis was an independent factor for poor prognosis (Table 6). When compared with negative groups, the number of positive biomarkers meant increased mortality risk in SCLC (Single: HR 2.107, CI 0.460–9.644; double: HR 2.247 CI 0.386–13.077; triple: HR 2.508, CI 0.231–27.287) (Table 6) although the associated P value was >0.05.
Table 6

The multivariate analysis of different histological classifications

 

Adenocarcinoma

Squamous

SCLC

(n = 445)

(n = 215)

(n = 159)

HR (95% CI)

P value

HR (95% CI)

P value

HR (95% CI)

P value

Age

  < 45

1[Reference]

<0.05*

1[Reference]

<0.05*

1[Reference]

0.104

 45–65

0.733 (0.489–1.099)

 

0.866 (0.259–2.895)

 

0.769 (0.315–1.876)

  > 65

1.084 (0.741–1.587)

 

1.712 (0.523–5.607)

 

1.237 (0.510–3.003)

Sex

 Male

1[Reference]

0.338

1[Reference]

0.326

1[Reference]

0.354

 Female

0.986 (0.715–1.122)

 

1.312 (0.763–2.254)

 

0.758 (0.421–1.363)

Stages

 I + II

1[Reference]

0.415

1[Reference]

0.475

1[Reference]

0.902

 III + IV

1.703 (1.035–2.802)

 

0.832 (0.495–1.399)

 

1.091 (0.465–2.556)

Smoke status

 No

1[Reference]

0.177

1[Reference]

0.878

1[Reference]

0.076

 Yes

0.807 (0.592–1.102)

 

1.037 (0.651–1.651)

 

0.518 (0.251–1.071)

CEA levels

 Neg

1[Reference]

0.773

1[Reference]

0.295

1[Reference]

0.940

 Moderate

1.085 (0.679–1.736)

 

1.244 (0.620–2.497)

 

0.850 (0.317–2.280)

 High

1.169 (0.713–1.916)

 

0.700 (0.260–1.885)

 

0.894 (0.271–2.942)

CYFRA levels

 Neg

1[Reference]

<0.05*

1[Reference]

0.195

1[Reference]

<0.05*

 Moderate

1.161 (0.678–1.989)

 

1.057 (0.511–2.185)

 

1.365 (0.514–3.624)

 High

1.860 (1.036–3.338)

 

1.502 (0.673–3.353)

 

0.907 (0.285–2.880)

NSE levels

 Neg

1[Reference]

0.400

1[Reference]

0.329

1[Reference]

0.642

 Moderate

1.025 (0.727–1.446)

 

1.025 (0.727–1.446)

 

0.952 (0.390–2.323)

 High

1.154 (0.777–1.714)

 

1.154 (0.777–1.714)

 

1.342 (0.590–3.052)

Metastasis

 No

1[Reference]

0.477

1[Reference]

<0.05*

1[Reference]

<0.05*

 Yes

1.131 (0.806–1.585)

 

1.682 (1.052–2.688)

 

2.172 (1.180–3.998)

Positive numbers

 Neg

1[Reference]

0.852

1[Reference]

0.334

1[Reference]

0.814

 Single

1.334 (0.672–2.649)

 

0.748 (0.300–1.863)

 

2.107 (0.460–9.644)

 Double

1.491 (0.557–3.992)

 

1.115 (0.327–3.803)

 

2.247 (0.386–13.077)

 Triple

1.652 (0.517–5.276)

 

0.901 (0.183–4.449)

 

2.508 (0.231–27.287)

Lung cancer patients were then divided into three groups according to stages (I + II, III and IV) and Cox regression was conducted to analyze which biomarker could act as independent factor of poor prognosis in specific stage. The results indicated that CYFRA21-1 correlated dramatically with poor prognosis in all stages of lung cancer patients (Stages I-II: HR 3.666 CI: 1.095–12.279, P < 0.05; Stage III: HR 1.919 CI: 1.200–3.071, P < 0.05; Stage IV: HR 1.473 CI: 1.056–2.053, P < 0.05) (Table 7 A-C), which confirm the importance of CYFRA21-1 in poor prognosis in different stages of lung cancer besides in specific histological classifications.
Table 7

Cox regression analysis of CEA, CYFRA21-1 and NSE in different stages of lung cancer

 

Multivariate HR (95% CI)

P value

A I + II

 Age

  

   < 45

1[Reference]

0.405

  45–65

0.390 (0.043–3.577)

   > 65

0.664 (0.075–5.874)

 Sex

  Male 1[Reference]

 

0.997

  Female

0.998 (0.358–2.779)

 Smokes

  No

1[Reference]

0.828

  Yes

1.091 (0.496–2.400)

 Histological classification

  SCC

1[Reference]

0.400

  ADC

0.692 (0.294–1.631)

  SCLC

1.000 (0.347–2.884)

  Unknown

0.943 (0.242–3.670)

 Metastasis

  No

1[Reference]

0.992

  Yes

0.997 (0.505–1.967)

 CEA

  Neg

1[Reference]

0.483

  Moderate

1.213 (0.555–2.651)

  High

1.442 (0.519–4.009)

 NSE

  Neg

1[Reference]

0.592

  Moderate

1.064 (0.542–2.090)

  High

0.718 (0.214–2.411)

 CYFRA

  Neg

1[Reference]

<0.05*

  Moderate

1.696 (0.848–3.390)

  High

3.666 (1.095–12.279)

B. Stage III

 Age

   < 45

1[Reference]

0.147

  45–65

0.492 (0.189–1.283)

   > 65

1.230 (0.491–3.083)

 Sex

  Male

1[Reference]

0.934

  Female

0.976 (0.555–1.718)

 Smokes

  No

1[Reference]

0.758

  Yes

1.075 (0.680–1.699)

 Histological classification

  SCC

1[Reference]

0.272

  ADC

0.974 (0.624–1.521)

  SCLC

0.796 (0.445–1.424)

  Unknown

1.439 (0.752–2.756)

 Metastasis

  No

1[Reference]

0.094

  Yes

1.444 (0.939–0.221)

 CEA

  Neg

1[Reference]

0.423

  Moderate

1.047 (0.715–1.532)

  High

1.260 (0.716–2.218)

 NSE

  Neg

1[Reference]

0.165

  Moderate

0.738 (0.480–1.134)

  High

1.333 (0.796–2.323)

 CYFRA

  Neg

1[Reference]

<0.05*

  Moderate

1.279 (0.844–1.938)

  High

1.919 (1.200–3.071)

C Stage IV

 Age

  

   < 45

1[Reference]

0.285

  45–65

0.818 (0.566–1.182)

   > 65

1.052 (0.739–1.499)

 Sex

  Male

1[Reference]

0.452

  Female

1.125 (0.827–1.531)

 Smokes

  No

1[Reference]

0.130

  Yes

1.261 (0.934–1.702)

 Histological classification

  SCC

1[Reference]

0.090

  ADC

1.299 (0.960–1.756)

  SCLC

1.182 (0.801–1.744)

  Unknown

1.811 (1.082–3.030)

 Metastasis

  No

1[Reference]

<0.05*

  Yes

1.494 (1.034–2.160)

 CEA

  Neg

1[Reference]

0.332

  Moderate

1.132 (0.881–1.456)

  High

1.074 (0.802–1.439)

 NSE

  Neg

1[Reference]

0.060

  Moderate

1.042 (0.806–1.346)

  High

1.319 (0.989–1.759)

 CYFRA

  Neg

1[Reference]

<0.05*

  Moderate

1.107 (0.822–1.489)

  High

1.473 (1.056–2.053)

Discussion

Although several tumor markers for lung cancer have been identified, none of them is specific for lung cancer diagnosis. CYFRA21-1 has been reported as a poor prognostic factor in various cancers, while NSE has been associated with metastasis, and also used for monitoring response to treatment in multiple myeloma. However, these important biomarkers have not been thoroughly investigated in lung cancer patients. In our study, analyses were performed to confirm the correlations between serums CEA, CYFRA 21–1, NSE, as well as the number of positive biomarkers and metastasis and survival status of lung cancer patients.

All patients were randomly divided into training and validation groups to confirm the grouping rationality of this study. In brief, survival curves and associations with clinical characteristics in the validation group were generally similar to those in training group, though there were some non-significant inconsistence in sex and several organs of metastasis. The results indicated that the increased levels of CYFRA21-1 were strongly associated with metastatic sites and histological grades of lung cancers in both training and validation groups. In specific histological subtypes (ADC, SCC and SCLC) analyses, we also found that CYFRA21-1 correlated more closely to metastasis and survival status than CEA and NSE. To our knowledge, these results have not been reported in any of the earlier literatures.

In multivariate Cox regression analysis, only CYFRA21-1 and NSE were found to be independent predictors of prognosis in lung cancer patients. When sub-grouped, only CYFRA21-1was an independent predictor of poor prognosis in ADC (1.86-fold increased risk in high concentration group) and SCLC (1.365-fold increased risk in moderate group) but not CEA and NSE. Finally it was found that CYFRA21-1 could act as independent factor in early (I + II) and advanced stages (III and IV) of lung cancer. Thus, CYFRA21-1 appears to be more important as a prognostic predictor than the other two biomarkers.

Several reports have reported the useful roles of CEA in diagnosis of ADC, CYFRA21-1 in SCC and NSE in SCLC [1821]. The increased levels of biomarkers are known to correlate with cancer progression, with their sensitivity depending largely on tumor stage and histological classification [22]. In contrast with the previous reports [25], we found no correlation between increased CEA levels and brain metastasis; however, we did observe a correlation with bone, liver, pleural and peritoneal metastases. The inconsistency could be explained by the smaller sample size (approximate N = 300). Research also indicated that high circulating concentrations of CYFRA21-1 and CEA were associated with advanced stages of lung cancer; levels that were two times higher than cutoff value were associated with stage III and IV lung cancer patients [23]. Although CYFRA21-1 appears to be the most sensitive and specific marker for NSCLC [26], its relationship with different histological lung cancers has largely remained unknown. An earlier report suggested that CYFRA was a more sensitive and specific marker for SCC diagnosis and was found to be of prognostic values in patients with recurrent NSCLC receiving gefitinib therapy [27, 28]. In our study, however, high levels of CYFRA21-1 correlated with survival status in ADC and SCLC but not in SCC patients. It also could be used as an independent predictor of poor prognosis in ADC and SCLC patients. Currently, NSE is the most widely used marker for diagnosis and prognosis of SCLC patients [24]. In our study, although positive levels of NSE significantly correlated with survival in SCLC, it did not qualify as an independent predictor for poor prognosis.

Conclusions

We designed this study to evaluate whether positive levels of biomarkers correlate with occurrence of metastasis and poor survival. The retrospective design and cross-sectional nature of our study are limitations that did not permit correlation analysis for all clinic pathological parameters. Our study suggested the important role of CYFRA21-1 in predicting occurrence of metastasis as well as poor prognosis in lung cancer patients. Our results could provide important perspectives for diagnosis, prognosis and management of lung cancer.

Abbreviations

ADC: 

Adenocarcinoma

CEA: 

Carcinoembryonic antigen

CT: 

Computed tomography

CYFRA21-1: 

Cytokeratin 19 fragments

EBC: 

Exhaled breath condensate

HR: 

Hazard ration

NSCLC: 

Non-small cell lung cancer

NSE: 

Neuron-specific enolase

SCC: 

Squamous cell carcinoma

SCLC: 

Small cell lung cancer

TA: 

Training

VA: 

Validation

Declarations

Acknowledgements

We acknowledged to Medical Records Department for help in collecting and analyzing the all patients’ data.

Funding

This work is supported by Sichuan province science and technology support program (2014SZ0148, 2014SZ0126 and 2014SZ023) and the Nature Science Foundation of China (81201851).

These four fundings are all non-commercial research fundings and granted by nation and province. The research contents and participants of these four fundings are interconnected.

Funding 2014SZ-148 was granted to lung cancer database establishment. The part of clinical data of this research was extracted from this datablse.

Funding 2014SZ0126 and 2014SZ023 were involved the follow up data of this cohort patients in this research. These follow up data of lung cancer patients were also collected by participants of these two funding.

Funding 81201851 was granted to the research of role of exhaled breath condensate in diagnosis of early lung cancer. In this manuscript, values of plasma tumor markers including CEA, CYFRA21-1 and NSE for those diagnosed lung cancer were collected and classified according to tumor stages.

Availability of data and materials

All data generated or analyzed during this study are included in this published article (table, figure, as well as supplement tables and figures).

Authors’ contributions

All authors have read and approved the manuscript. ZL - acquisition of data, analysis and interpretation of data; manuscript writing; LD - acquisition of data, analysis and interpretation of data; manuscript writing; LL - acquisition of data, analysis and interpretation of data; PD - acquisition of data, analysis and interpretation of data; ZP - acquisition of data for follow up, interpretation of data; J-YT - acquisition of data for follow up, interpretation of data; HY - acquisition of data for follow up, interpretation of data; W-YW - acquisition of data, analysis and interpretation of data; Z-YH - acquisition of data, analysis and interpretation of data; H-YQ - acquisition of data, analysis and interpretation of data; L-YL - acquisition of data, analysis and interpretation of data; ZS - analysis and interpretation of data; Q-ZX - analysis and interpretation of data; L-WM - conception and design; interpretation of data, manuscript writing; final approval of manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

This study was approved by ethics committees of West China Hospital, Sichuan University.

For those survival data were followed up via outpatient visit, written informed consents were obtained. Part of the survival data were obtained thorough telephone follow-up, the written informed consent could not be available due to the long journey from their resident to our hospital. Under these conditions, only verbal informed consents were obtained from these subjects or their legal guardians.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Respiratory Medicine, West China Hospital, Sichuan University
(2)
Lab of Pathology, West China Hospital, Sichuan University
(3)
Clinic Skill Center, West China Hospital, Sichuan University

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Copyright

© The Author(s). 2017

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