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Early Biomarkers of Cancer: Diagnosis and Progression
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Early Biomarkers of Cancer: Diagnosis and Progression

A special issue of Cells (ISSN 2073-4409). This special issue belongs to the section "Cell and Gene Therapy".

Deadline for manuscript submissions: closed (31 January 2023) | Viewed by 17610

Special Issue Editors

Dr. Marta Lukaszewicz-Zajac

E-Mail Website
Guest Editor
Department of Biochemical Diagnostics, Medical University of Bialystok, Bialystok, Poland
Interests: inflammation; malignant diseases; diagnosis; tumor biomarkers; specific proteins; neurodevelopmental disorders
Special Issues, Collections and Topics in MDPI journals
Dr. Monika Gudowska-Sawczuk

E-Mail Website
Guest Editor
Department of Biochemical Diagnostics, Medical University of Bialystok, Waszyngtona 15A St., 15-269 Bialystok, Poland
Interests: biomarkers; non-invasive diagnosis; inflammation; tumor biomarkers; neuroinflammation; specific proteins
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

According to the American Cancer Society, in 2018 about 1.7 million new cancer cases and 610 thousand cancer deaths have been estimated. Malignant neoplasms are complex diseases with dysregulation of the cellular signaling that controls proliferation and apoptosis. These may be caused by various genetic, genomic, and epigenetic alterations at the cellular or tissue levels. Tumors of gastrointestinal tracks are among the five most common malignancies in both men and women worldwide, characterized by uncontrolled growth, rapid progression, and unfavorable prognosis. Survival for patients with malignancies has been improving worldwide due to advances in diagnostic evaluation and multimodality treatments. Routine strategies are based on a combination of imaging and biochemical diagnosis of cancer patients. However, there is still a need to find biomarkers that would help in the early diagnosis of cancer patients via a better understanding of the role of potential indicators in the pathogenesis of malignancies. Therefore, the further research of investigators should focus on the search for new biomarkers, which would be useful in the early detection of these diseases, and improved implementation of treatment.

This Special Issue aims to highlight new findings regarding biomarkers that could improve the diagnosis of cancer patients and resume their potential clinical application in the early detection.

The topics of this Special Issue will include (but are not limited to):

  • Cellular immunology in solid tumors
  • Intra- and extracellular signaling in solid tumors
  • Tumor cell movement and motility
  • Apoptosis in solid tumors
  • Tumor cell growth and differentiation
  • Biological mechanisms related to the link between cancer and inflammation
  • Proteolytic molecules and inflammatory proteins as prognostic factors in carcinogenesis
  • Proteolytic molecules and inflammatory proteins as novel tumor markers in malignant tumors of the gastrointestinal tract; and other solid tumors

Dr. Marta Lukaszewicz-Zajac
Dr. Monika Gudowska-Sawczuk
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Cells is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • tumor biomarkers
  • tumor progression
  • early cancers
  • inflammatory mediators
  • early diagnosis

Published Papers (9 papers)

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Research

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28 pages, 5393 KiB  
Article
Plasma-Derived Exosome Proteins as Novel Diagnostic and Prognostic Biomarkers in Neuroblastoma Patients
by Martina Morini, Federica Raggi, Martina Bartolucci, Andrea Petretto, Martina Ardito, Chiara Rossi, Daniela Segalerba, Alberto Garaventa, Alessandra Eva, Davide Cangelosi and Maria Carla Bosco
Cells 2023, 12(21), 2516; https://doi.org/10.3390/cells12212516 - 25 Oct 2023
Cited by 1 | Viewed by 1200
Abstract
Neuroblastoma (NB) is the most common extracranial solid tumor during infancy, causing up to 10% of mortality in children; thus, identifying novel early and accurate diagnostic and prognostic biomarkers is mandatory. NB-derived exosomes carry proteins (Exo-prots) reflecting the status of the tumor cell [...] Read more.
Neuroblastoma (NB) is the most common extracranial solid tumor during infancy, causing up to 10% of mortality in children; thus, identifying novel early and accurate diagnostic and prognostic biomarkers is mandatory. NB-derived exosomes carry proteins (Exo-prots) reflecting the status of the tumor cell of origin. The purpose of this study was to characterize, for the first time, the Exo-prots specifically expressed in NB patients associated with tumor phenotype and disease stage. We isolated exosomes from plasma specimens of 24 HR-NB patients and 24 low-risk (LR-NB) patients at diagnosis and of 24 age-matched healthy controls (CTRL). Exo-prot expression was measured by liquid chromatography–mass spectrometry. The data are available via ProteomeXchange (PXD042422). The NB patients had a different Exo-prot expression profile compared to the CTRL. The deregulated Exo-prots in the NB specimens acted mainly in the tumor-associated pathways. The HR-NB patients showed a different Exo-prot expression profile compared to the LR-NB patients, with the modulation of proteins involved in cell migration, proliferation and metastasis. NCAM, NCL, LUM and VASP demonstrated a diagnostic value in discriminating the NB patients from the CTRL; meanwhile, MYH9, FN1, CALR, AKAP12 and LTBP1 were able to differentiate between the HR-NB and LR-NB patients with high accuracy. Therefore, Exo-prots contribute to NB tumor development and to the aggressive metastatic NB phenotype. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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22 pages, 14976 KiB  
Article
Cell Pair Algorithm-Based Immune Infiltrating Cell Signature for Improving Outcomes and Treatment Responses in Patients with Hepatocellular Carcinoma
by Xiao Zhang, Jun Xie, Dan He, Xin Yan and Jian Chen
Cells 2023, 12(1), 202; https://doi.org/10.3390/cells12010202 - 03 Jan 2023
Cited by 1 | Viewed by 2065
Abstract
Background: Immune interactions play important roles in the regulation of T cells’ cytotoxic function, further impacting the anti-tumor efficacy of immunotherapy. A comprehensive analysis of immune cell types in HCC and immune-cell-related signatures predicting prognosis and monitoring immunotherapy efficacy is still absent. Methods: [...] Read more.
Background: Immune interactions play important roles in the regulation of T cells’ cytotoxic function, further impacting the anti-tumor efficacy of immunotherapy. A comprehensive analysis of immune cell types in HCC and immune-cell-related signatures predicting prognosis and monitoring immunotherapy efficacy is still absent. Methods: More than 1,300 hepatocellular carcinomas (HCC) patients were collected from public databases and included in the present study. The ssGSEA algorithm was applied to calculate the infiltration level of 28 immunocyte subpopulations. A cell pair algorithm was applied to construct an immune-cell-related prognostic index (ICRPI). Survival analyses were performed to measure the survival difference across ICRPI risk groups. Spearman’s correlation analyses were used for the relevance assessment. A Wilcoxon test was used to measure the expression level’s differences. Results: In this study, 28 immune subpopulations were retrieved, and 374 immune cell pairs (ICPs) were established, 38 of which were picked out by the least absolute shrinkage and selection operator (LASSO) algorithm. By using the selected ICPs, the ICRPI was constructed and validated to play crucial roles in survival stratification and dynamic monitoring of immunotherapy effect. We also explored several candidate drugs targeting ICRPI. A composite ICRPI and clinical prognostic index (ICPI) was then constructed, which achieved a more accurate estimation of HCC’s survival and is a better choice for prognosis predictions in HCC. Conclusions: In conclusion, we constructed and validated ICRPI based on the cell pair algorithm in this study, which might provide some novel insights for increasing the survival estimation and clinical response to immune therapy for individual HCC patients and contribute to the personalized precision immunotherapy strategy of HCC. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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19 pages, 3037 KiB  
Article
Type XXII Collagen Complements Fibrillar Collagens in the Serological Assessment of Tumor Fibrosis and the Outcome in Pancreatic Cancer
by Emilie A. Madsen, Jeppe Thorlacius-Ussing, Neel I. Nissen, Christina Jensen, Inna M. Chen, Julia S. Johansen, Hadi M. H. Diab, Lars N. Jørgensen, Carsten P. Hansen, Morten A. Karsdal and Nicholas Willumsen
Cells 2022, 11(23), 3763; https://doi.org/10.3390/cells11233763 - 24 Nov 2022
Cited by 6 | Viewed by 1548
Abstract
Circulating fragments of type III collagen, measured by PRO-C3, has shown promising results as a tumor fibrosis biomarker. However, the fibrotic tumor microenvironment consists of many other collagens with diverse functions and unexplored biomarker potential. One example hereof is type XXII collagen (COL22). [...] Read more.
Circulating fragments of type III collagen, measured by PRO-C3, has shown promising results as a tumor fibrosis biomarker. However, the fibrotic tumor microenvironment consists of many other collagens with diverse functions and unexplored biomarker potential. One example hereof is type XXII collagen (COL22). In this study, we investigated the biomarker potential of COL22 by measuring this in serum. An ELISA, named PRO-C22, was developed and measured in two serum cohorts consisting of patients with various solid tumors (n = 220) and healthy subjects (n = 33) (Cohort 1), and patients with pancreatic ductal adenocarcinoma (PDAC) (n = 34), and healthy subjects (n = 20) (Cohort 2). In Cohort 1, PRO-C22 was elevated in the serum from patients with solid tumors, compared to healthy subjects (p < 0.01 to p < 0.0001), and the diagnostic accuracy (AUROC) ranged from 0.87 to 0.98, p < 0.0001. In Cohort 2, the high levels of PRO-C22, in patients with PDAC, were predictive of a worse overall survival (HR = 4.52, 95% CI 1.90–10.7, p = 0.0006) and this remained significant after adjusting for PRO-C3 (HR = 4.27, 95% CI 1.24–10.4, p = 0.0013). In conclusion, PRO-C22 has diagnostic biomarker potential in various solid tumor types and prognostic biomarker potential in PDAC. Furthermore, PRO-C22 complemented PRO-C3 in predicting mortality, suggesting an additive prognostic value when quantifying different collagens. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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19 pages, 4008 KiB  
Article
CXCR4-CXCL12-CXCR7 and PD-1/PD-L1 in Pancreatic Cancer: CXCL12 Predicts Survival of Radically Resected Patients
by Crescenzo D’Alterio, Alessandro Giardino, Giosuè Scognamiglio, Giovanni Butturini, Luigi Portella, Giuseppe Guardascione, Isabella Frigerio, Marco Montella, Stefano Gobbo, Guido Martignoni, Vincenzo Napolitano, Ferdinando De Vita, Fabiana Tatangelo, Renato Franco and Stefania Scala
Cells 2022, 11(21), 3340; https://doi.org/10.3390/cells11213340 - 22 Oct 2022
Cited by 4 | Viewed by 1777
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is currently the most deadly cancer. Although characterized by 5–20% of neoplastic cells in the highly fibrotic stroma, immunotherapy is not a valid option in PDAC treatment. As CXCR4-CXCL12 regulates tumor invasion and T-cell access and PD-1/PD-L1 controls immune [...] Read more.
Pancreatic ductal adenocarcinoma (PDAC) is currently the most deadly cancer. Although characterized by 5–20% of neoplastic cells in the highly fibrotic stroma, immunotherapy is not a valid option in PDAC treatment. As CXCR4-CXCL12 regulates tumor invasion and T-cell access and PD-1/PD-L1 controls immune tolerance, 76 PDACs were evaluated for CXCR4-CXCL12-CXCR7 and PD-1/PD-L1 in the epithelial and stromal component. Neoplastic CXCR4 and CXCL12 discriminated PDACs for recurrence-free survival (RFS), while CXCL12 and CXCR7 discriminated patients for cancer-specific survival (CSS). Interestingly, among patients with radical resection (R0), high tumor CXCR4 clustered patients with worse RFS, high CXCL12 identified poor prognostic patients for both RFS and CSS, while stromal lymphocytic-monocytic PD-L1 associated with improved RFS and CSS. PD-1 was only sporadically expressed (<1%) in focal lymphocyte infiltrate and does not impact prognosis. In multivariate analysis, tumoral CXCL12, perineural invasion, and AJCC lymph node status were independent prognostic factors for RFS; tumoral CXCL12, AJCC Stage, and vascular invasion were independent prognostic factors for CSS. CXCL12’s poor prognostic meaning was confirmed in an additional perspective-independent 13 fine-needle aspiration cytology advanced stage-PDACs. Thus, CXCR4-CXCL12 evaluation in PDAC identifies prognostic categories and could orient therapeutic approaches. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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14 pages, 1134 KiB  
Article
Autoantibody against Tumor-Associated Antigens as Diagnostic Biomarkers in Hispanic Patients with Hepatocellular Carcinoma
by Yangcheng Ma, Cuipeng Qiu, Bofei Wang, Xiaojun Zhang, Xiao Wang, Renato J. Aguilera and Jian-Ying Zhang
Cells 2022, 11(20), 3227; https://doi.org/10.3390/cells11203227 - 14 Oct 2022
Cited by 3 | Viewed by 1485
Abstract
Background: Tumor-associated antigens (TAAs) have been investigated for many years as potential early diagnosis tools, especially for hepatocellular carcinoma (HCC). Nonetheless, very few studies have focused on the Hispanic HCC group that may be associated with distinct etiological risk factors. In the present [...] Read more.
Background: Tumor-associated antigens (TAAs) have been investigated for many years as potential early diagnosis tools, especially for hepatocellular carcinoma (HCC). Nonetheless, very few studies have focused on the Hispanic HCC group that may be associated with distinct etiological risk factors. In the present study, we investigated novel anti-TAA autoantibodies as diagnostic biomarkers for Hispanic HCC patients. Methods: Novel TAA targets were identified by the serological proteome analysis (SERPA) and from differentially expressed HCC driver genes via bioinformatics. The autoantibody levels were validated by enzyme-linked immunosorbent assay (ELISA). Results: Among 19 potential TAA targets, 4 anti-TAA autoantibodies were investigated as potential diagnostic biomarkers with significantly high levels in Hispanic HCC sera, including DNA methyltransferase 3A (DNMT3A), p16, Hear shock protein 60 (Hsp60), and Heat shock protein A5 (HSPA5). The area under the ROC curve (AUC) value of the single autoantibodies varies from 0.7505 to 0.8885. After combining all 4 autoantibodies, the sensitivity of the autoantibody panel increased to 75% compared to the single one with the highest value of 45.8%. In a separate analysis of the Asian cohort, autoantibodies against HSPA5 and p16 showed significantly elevated levels in HCC compared to normal healthy controls, but not for DNMT3A or HSP60. Conclusion: Anti-DNMT3A, p16, HSPA5, and HSP60 autoantibodies have the potential to be diagnostic biomarkers for Hispanic HCC patients, of which DNMT3A and HSP60 might be exclusive for Hispanic HCC diagnosis. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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23 pages, 5706 KiB  
Article
The CDK1-Related lncRNA and CXCL8 Mediated Immune Resistance in Lung Adenocarcinoma
by Jinmin Xue, Yang Song, Wenwen Xu and Yuxi Zhu
Cells 2022, 11(17), 2688; https://doi.org/10.3390/cells11172688 - 29 Aug 2022
Cited by 8 | Viewed by 1893
Abstract
Background: Limited therapeutic options are available for advanced LUAD without driver gene mutations. Anti-CDK therapy has shown effectiveness in several kind of cancers, however, the mechanisms still need to be elucidated. Materials and Methods: The lncRNA associated with CDK1 and the immunomodulatory factors [...] Read more.
Background: Limited therapeutic options are available for advanced LUAD without driver gene mutations. Anti-CDK therapy has shown effectiveness in several kind of cancers, however, the mechanisms still need to be elucidated. Materials and Methods: The lncRNA associated with CDK1 and the immunomodulatory factors that regulate CDK1 were found by bioinformatics analysis and experimental verification. The prognostic model and immune resistance mechanism of lung adenocarcinoma were revealed by single cell analysis, immune infiltration analysis, and signal pathway analysis. Results: LINC00261 was found to be an important CDK1-related lncRNA with a better prognosis in LUAD. In addition, high CDK1 expression indicates a poor immunotherapy response, which may be associated with overexpression of CXCL8. CXCL8 decreased in patients who were immunotherapy-responsive but increased in patients who were immunotherapy-resistant. Signaling pathway analysis suggested that increased CXCL8 and decreased LINC00261 may participate in hypoxia-induced tumor angiogenesis and cause a poor prognosis for the patients. CXCL8 and CDK1 may change G2-M transformation and EMT and promote tumor proliferation. Conclusion: This study explained that LINC00261, CDK1, and CXCL8 may have a mutual regulation relationship, which affects the occurrence of LUAD and the efficacy of immunotherapy. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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13 pages, 2474 KiB  
Article
Integrated Multi-Omics Signature Predicts Survival in Head and Neck Cancer
by Ilda Patrícia Ribeiro, Luísa Esteves, Francisco Caramelo, Isabel Marques Carreira and Joana Barbosa Melo
Cells 2022, 11(16), 2536; https://doi.org/10.3390/cells11162536 - 16 Aug 2022
Cited by 4 | Viewed by 1699
Abstract
Head and Neck Cancer (HNC) is characterized by phenotypic, biological, and clinical heterogeneity. Despite treatment modalities, approximately half of all patients will die of the disease. Several molecular biomarkers have been investigated, but until now, without clinical translation. Here, we identified an integrative [...] Read more.
Head and Neck Cancer (HNC) is characterized by phenotypic, biological, and clinical heterogeneity. Despite treatment modalities, approximately half of all patients will die of the disease. Several molecular biomarkers have been investigated, but until now, without clinical translation. Here, we identified an integrative nine-gene multi-omics signature correlated with HNC patients’ survival independently of relapses or metastasis development. This prognosis multi-omic signature comprises genes mapped in the chromosomes 1q, 3p, 8q, 17q, 19p, and 19q and encompasses alterations at copy number, gene expression, and methylation. Copy number alterations in LMCD1-A1S and GRM7, the methylation status of CEACAM19, KRT17, and ST18, and the expression profile of RPL29, UBA7, FCGR2C, and RPSAP58 can predict the HNC patients’ survival. The difference higher than two years observed in the survival of HNC patients that harbor this nine-gene multi-omics signature can represent a significant step forward to improve patients’ management and guide new therapeutic targets development. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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Review

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20 pages, 1041 KiB  
Review
Promises and Challenges of Predictive Blood Biomarkers for Locally Advanced Rectal Cancer Treated with Neoadjuvant Chemoradiotherapy
by Joao Victor Machado Carvalho, Valérie Dutoit, Claudia Corrò and Thibaud Koessler
Cells 2023, 12(3), 413; https://doi.org/10.3390/cells12030413 - 26 Jan 2023
Cited by 4 | Viewed by 2165
Abstract
The treatment of locally advanced rectal cancer (LARC) requires a multimodal approach combining neoadjuvant radiotherapy or chemoradiotherapy (CRT) and surgery. Predicting tumor response to CRT can guide clinical decision making and improve patient care while avoiding unnecessary toxicity and morbidity. Circulating biomarkers offer [...] Read more.
The treatment of locally advanced rectal cancer (LARC) requires a multimodal approach combining neoadjuvant radiotherapy or chemoradiotherapy (CRT) and surgery. Predicting tumor response to CRT can guide clinical decision making and improve patient care while avoiding unnecessary toxicity and morbidity. Circulating biomarkers offer both the advantage to be easily accessed and followed over time. In recent years, biomarkers such as proteins, blood cells, or nucleic acids have been investigated for their predictive value in oncology. We conducted a comprehensive literature review with the aim to summarize the status of circulating biomarkers predicting response to CRT in LARC. Forty-nine publications, of which forty-seven full-text articles, one review and one systematic review, were retrieved. These studies evaluated circulating markers (CEA and CA 19-9), inflammatory biomarkers (CRP, albumin, and lymphocytes), hematologic markers (hemoglobin and thrombocytes), lipids and circulating nucleic acids (cell-free DNA [cfDNA], circulating tumor DNA [ctDNA], and microRNA [miRNA]). Post-CRT CEA levels had the most consistent association with tumor response, while cfDNA integrity index, MGMT promoter methylation, ERCC-1, miRNAs, and miRNA-related SNPs were identified as potential predictive markers. Although circulating biomarkers hold great promise, inconsistent results, low statistical power, and low specificity and sensibility prevent them from reliably predicting tumor response following CRT. Validation and standardization of methods and technologies are further required to confirm results. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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23 pages, 890 KiB  
Review
The DARC Side of Inflamm-Aging: Duffy Antigen Receptor for Chemokines (DARC/ACKR1) as a Potential Biomarker of Aging, Immunosenescence, and Breast Oncogenesis among High-Risk Subpopulations
by Nikita Jinna, Padmashree Rida, Tianyi Su, Zhihong Gong, Song Yao, Mark LaBarge, Rama Natarajan, Tijana Jovanovic-Talisman, Christine Ambrosone and Victoria Seewaldt
Cells 2022, 11(23), 3818; https://doi.org/10.3390/cells11233818 - 29 Nov 2022
Cited by 7 | Viewed by 2669
Abstract
The proclivity of certain pre-malignant and pre-invasive breast lesions to progress while others do not continues to perplex clinicians. Clinicians remain at a crossroads with effectively managing the high-risk patient subpopulation owing to the paucity of biomarkers that can adequately risk-stratify and inform [...] Read more.
The proclivity of certain pre-malignant and pre-invasive breast lesions to progress while others do not continues to perplex clinicians. Clinicians remain at a crossroads with effectively managing the high-risk patient subpopulation owing to the paucity of biomarkers that can adequately risk-stratify and inform clinical decisions that circumvent unnecessary administration of cytotoxic and invasive treatments. The immune system mounts the most important line of defense against tumorigenesis and progression. Unfortunately, this defense declines or “ages” over time—a phenomenon known as immunosenescence. This results in “inflamm-aging” or the excessive infiltration of pro-inflammatory chemokines, which alters the leukocyte composition of the tissue microenvironment, and concomitant immunoediting of these leukocytes to diminish their antitumor immune functions. Collectively, these effects can foster the sequelae of neoplastic transformation and progression. The erythrocyte cell antigen, Duffy antigen receptor for chemokines(DARC/ACKR1), binds and internalizes chemokines to maintain homeostatic levels and modulate leukocyte trafficking. A negative DARC status is highly prevalent among subpopulations of West African genetic ancestry, who are at higher risk of developing breast cancer and disease progression at a younger age. However, the role of DARC in accelerated inflamm-aging and malignant transformation remains underexplored. Herein, we review compelling evidence suggesting that DARC may be protective against inflamm-aging and, therefore, reduce the risk of a high-risk lesion progressing to malignancy. We also discuss evidence supporting that immunotherapeutic intervention—based on DARC status—among high-risk subpopulations may evade malignant transformation and progression. A closer look into this unique role of DARC could glean deeper insight into the immune response profile of individual high-risk patients and their predisposition to progress as well as guide the administration of more “cyto-friendly” immunotherapeutic intervention to potentially “turn back the clock” on inflamm-aging-mediated oncogenesis and progression. Full article
(This article belongs to the Special Issue Early Biomarkers of Cancer: Diagnosis and Progression)
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