Hypoxia-Associated Integration of Epigenetic, Metabolic, and Immune Biomarkers in Blood and Urine for Early Colorectal Cancer Detection: A Multimarker Panel

Background: Early detection of colorectal cancer (CRC) still relies mainly on invasive screening. Tumor hypoxia induces epigenetic, metabolic, and immune changes via hypoxia-inducible factor (HIF) signaling in experimental models. Building on these insights, this study evaluated whether hypoxia pathway biomarkers—plasma methylated SEPT9 (mSEPT9), urinary N¹, N¹² diacetylspermine (DiAcSpm), and systemic inflammatory indices (NLR, PLR, LMR)—could be combined into a noninvasive diagnostic panel compared with standard serum tumor markers. The study focused solely on diagnostic performance; it did not directly assess tumor hypoxia or HIF expression in patients. Methods: This prospective single-center study enrolled 382 participants: 142 with CRC, 62 with colorectal polyps, and 178 non-malignant controls. Plasma mSEPT9 was quantified by real-time PCR, urinary DiAcSpm by ELISA, and inflammatory indices from blood counts. Serum tumor markers (CEA, CA19-9, CA125, AFP) were measured by immunoassay. Diagnostic accuracy was assessed using ROC analysis and multivariable modeling. Results: mSEPT9 (AUC 0.843) and DiAcSpm (AUC 0.831) demonstrated significantly higher diagnostic accuracy than CEA (AUC 0.660) and CA19-9 (AUC 0.649). A combined panel including mSEPT9, DiAcSpm, NLR, PLR, and LMR achieved an AUC of 0.947, with 85.9% sensitivity and 92.9% specificity. This panel also showed strong performance for early-stage CRC (AUC 0.905).” Conclusions: A multimarker panel of previously reported hypoxia-associated biomarkers (mSEPT9, DiAcSpm, NLR, PLR, and LMR) provides a scalable, noninvasive approach for CRC detection with high diagnostic accuracy. These findings are associative; direct evidence that tumor hypoxia drives these biomarker changes in patients was not obtained and requires future investigation.