# A Prognostic Model for Brain Glioma Patients Based on 9 Signature Glycolytic Genes

Authors: Xiao Bingxiang; Wu Panxing; Feng Lu; Yan Xiuyou; Ding Chao
Journal: BioMed Research International
 (2021)

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## Abstract

Objective. To screen glycolytic genes linked to the glioma prognosis and construct the prognostic model. Methods. The relevant data of glioma were downloaded from TCGA and GTEx databases. GSEA of glycolysis-related pathways was carried out, and enriched differential genes were extracted. Screening out prognostic-related genes with conspicuous significance and construction of the prognostic model were conducted by multivariate Cox regression analysis and Lasso regression analysis. The model was evaluated, and cBioPortal was used to analyze the mutation of the model gene. The expression of the model gene in tumor and normal colon tissue was analyzed. The model was used to evaluate the prognosis of patients in different groups to verify the applicability of the model. Results. 339 differentially glycolytic-related genes were enriched in REACTOME_GLYCOLYSIS, GLYCOLYTIC_PROCESS, HALLMARK_GLYCOLYSIS, and other pathways. We obtained 9 key prognostic genes and constructed the prognostic evaluation model. The 3-year AUC values of the ROC curve display model are greater than 0.75, which indicates that the accuracy of the model is good. The relation of age and risk score to prognosis is shown by univariate and multivariate Cox analysis. The expression of SRD5A3, MDH2, and B3GAT3 genes was significantly upregulated in the tumor tissues, while the HDAC4 and G6PC2 genes were downregulated. The mutation rate of MDH2 and HDAC4 genes was the highest. This model could effectively distinguish the risk of poor prognosis of patients in any age stage. Conclusion. The prognostic assessment models based on glycolysis-related nine-gene signature could accurately predict the prognosis of patients with GBM.


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## Body

## 1. Introduction

Cerebral glioma, the main lethal tumor in neurosurgery, is the primary malignant tumor of the brain [1, 2]. Surgery, chemotherapy, and radiation therapy are mainly used to treat malignant brain tumor, including glioma [3, 4]. There are also some significant progress in the basic research, and comprehensive therapy of glioma has been made in recent years. However, the prognosis of patients with glioma has not been significantly improved as glioma induces an immune infiltrating environment [5, 6]. In general, poor glioma prognosis shows a high rate of recurrence after treatment [7–9]. Thus, it is important to find novel targets for the treatment and prognosis of patients with glioma.In normal cells, when the oxygen content is normal, pyruvate enters the tricarboxylic acid cycle; glucose changes to pyruvate and then to lactate in the absence of oxygen. However, glycolysis is the main energy source for the growth of tumor cells [10].The glucose uptake and intracellular lactic acid accumulation of tumor cells will gradually increase even with normal oxygen content [11]. Tumor cells mainly convert glucose into lactic acid to get ATP by glycolysis [12, 13]. Regulating glycolysis-related genes to affect the activities of glycolysis rate-limiting enzyme and hypoxia-inducible factor can inhibit glycolysis process. Previous clinical studies have discovered that the characteristic dysregulated tumor cell metabolism can be found in a variety of cancers [14, 15]. Regulating the expression of glycolytic genes is expected to become a new method of cancer treatment. At present, studies have explored glycolysis gene targets related to the treatment of glioma and the prognosis of patients [16–18]. However, the accuracy of usage of glycolytic-related genes to predict the prognosis of patients with glioma remains unknown. Therefore, it is critical to analyze how these genes are related to the prognosis of patients with glioma.In this study, we used gene set enrichment analysis (GSEA) to explore the main signaling pathways of glycolysis-related gene enrichment. We extracted glycolytic-related gene expression data from transcriptome data of glioma in The Cancer Genome Atlas (TCGA) database and mRNA expression data of normal brain tissue in the GTEx database for differential analysis. We established the nine-gene risk model to predict the prognosis of patients by univariate and multivariate Cox regression analysis. The reliability and accuracy of the model were verified by ROC and survival analysis. We found that this risk model can independently identify patients with poor prognosis in the high-risk group. In addition, it was confirmed that the performance of the risk score model is better than that of age, gender, and other clinical indicators in evaluating the prognosis of patients with glioma and it has a good prognostic evaluation effect.


## 2. Methods

### 2.1. Data Acquisition and Processing

First, download all data of glioma from the UCSC-Xena (https://xenabrowser.net/datapages/). The Xena-GBM dataset (TCGA http://www.tcga.org) contains 5 normal and 168 cancer samples. Download the data of normal brain tissue from the Genotype-Tissue Expression database (https://gtexportal.org/) as a control. GTEx database contains 115 normal brain tissue samples which are located in the cerebral cortex. By merging, 120 normal and 168 tumor samples were obtained. The combined gene expression profile data and clinical data in Xena were used to train the model of the prognosis of patients. The number of patients (n=589), sex, age, and other clinical information of patients were included in the analysis.


### 2.2. Gene Set Enrichment Analysis (GSEA) of Related Pathways of Glycolysis

Pathways related to glycolysis (GLYCOLYSIS_PATHWAY, HALLMARK_GLYCOLYSIS, GLYCOLYSIS_GLUCONEOGENESIS, GLYCOLYTIC_PROCESS, and REACTOME_GLYCOLYSIS) were found from the GSEA website (http://www.broadinstitute.org/gsea/index.jsp) [19]. The GSEA was performed in the gene expression data of the training set including normal samples and glioma samples.


### 2.3. Differential Analysis and Modeling of Glycolytic-Related Genes

Glycolysis-related genes (GRGs) were extracted from the training set based on GSEA results, and differential analysis was performed using limma packets in R (3.61) (P<0.05, logFC≥1 or ≤-1). Prognosis GRGs (FDR<0.01) were screened by the logarithmic rank test in combination with survival time. The candidate GRGs were analyzed by using Cox risk regression analysis and glmnet in R (3.61) for 10-fold cross-validation. The survival data of Cox analysis was processed by the glmnet package, and the object of survival analysis was identified to construct the Lasso regression model (the best λ value was selected by the cv.glmnet function, and the gene screening was carried out by the coef function). The optimal genes were constructed as a GRG gene pair model. We extracted the relative expression of model genes in samples and plotted the heat map. We evaluated the model’s accuracy through the receiver operating characteristic curve (ROC) and distinguished the high- and low-risk groups by cutoff value of the model.


### 2.4. GRG Model Validation

GRG model was used to analyze the training set in terms of single-factor and multifactor Cox proportional hazard analysis and survival analysis.


### 2.5. Expression and Mutation of Model Genes

Use the limma package in R (3.61) to analyze the expression of 9 model genes in the training set. Use cBioPortal (http://www.cbioportal.org/) to analyze the mutations of 9 model genes in GBM samples in TCGA database.


### 2.6. Correction between GRG Model and Clinical Characters

Analyze the relationship between clinically relevant characteristics such as age, gender, and survival rate in the training group. Analyze the survival rate of patients with different clinical characteristics classified according to the model.


### 2.7. Expression Verification of Prognosis-Related Genes

Verify the expression of selected model genes related to prognosis. Use the Human Protein Atlas (HPA) (http://www.proteinatlas.org/) to validate the expression of model genes related to prognosis in glioma tissues and normal tissues and compare the consistency of previous analysis and expression differences. 50 cases of patients with glioma were screened out from our hospital from June 2018 to June 2020. Inclusion criteria were as follows: (1) pathologically confirmed; (2) new cases diagnosed by this hospital for the first time. Exclusion criteria were as follows: (1) with other malignant tumors; (2) patients who have received radiotherapy, chemotherapy, or other antineoplastic drugs before surgery [20].Nine differentially expressed genes in tumor and normal tissues of patients with glioma were verified by qPCR. Primers were synthesized according to the PCR primer information provided by the Primer Bank database (Table1). GAPDH was used as an internal reference, and a two-step method was used. The expression of GAPDH was detected by qPCR. Using the expression level of GAPDH as the standard value “1,” the relative expression levels of each differential gene in tumor and normal tissues were calculated. The real-time PCR kit was used to detect the expression of these genes in tumor and normal tissues and to draw statistical charts. The reaction procedure was as follows: hold (predenaturation): 95°C, 30 s, 1 cycle; two-step PCR: 95°C, 5 s, 60°C, 30 s, 40 cycles; dissociation: 95°C, 15 s, 60°C, 30 s, 95°C, 15 s, 1 cycle [20].Table 1
PCR primers for 9 RNAs and internal reference.
GeneG6PC2STC1HDAC4COG2SRD5A3Forward primerCCCAAATCACTCAAGTCCATGCCACGAGCTGACTTCAACAGGACCTGGGAATGTACGACGCCACAAAGTAAGACCGCGTATAGCTGGCTGCACAGCTTACGAAGReverse primerGGTTACCATGACATACCAGACACGGATGTGCGTTTGATGTGGGCCCGTCTTTCCTGCGTAACAAGCAGTGCCGTATTATATCGACTCAGCACAGTTAGGCCAACAAGeneMDH2IL13RA1TGFBIB3GAT3GAPDHForward primerTCGGCCCAGAACAATGCTAAAGTCCCAGTGTAGCACCAATGACACTCTCAAACCTTTACGAGACCAAGGAGTCGTCTACTTTGCTGAACAACTTTGGTATCGTGGAAGGReverse primerGCGGCTTTGGTCTCGATGTGCTCAGGTTGTGCCAAATGCCGTTGCTAGGGGCGAAGATGGGGCATTGGGCTTATCTAACAGGCCATCACGCCACAGTTTC


### 2.8. Statistical Analysis

Measured data were expressed asmean±standard deviation (x±s), and data were compared using a T-test. The Kaplan-Meier method was used for survival analysis [21]. The receiver operating characteristic curve (ROC curve) and ROC analysis were completed by survival ROC (1.0.3) [20]. A Cox proportional hazard regression model was used to analyze univariately and multivariately. The criterion for statistically significant difference is P<0.05. And P<0.01 indicates the difference has fairly significant statistical significance. A Cox proportional regression model was used to identify the predictive model with the best explanatory and informative efficacy. A risk score staging model was established using the R package survival function coxph (). The risk score formula is described as follows [22]:
(1)Riskscore1/4expressionofgene1×β1bexpressionofgene2×β2b⋯bexpressiomofgenen×βn:The R package was used for analyzing the relationship between different clinical characteristics and survival rate in high- and low-risk groups. All statistical analyses were performed with the Statistical Package for the Social Sciences software version 16.0 (SPSS Inc., Chicago, IL, the USA) and GraphPad Prism 7 (GraphPad Software, La Jolla, CA, the USA;http://www.graphpad.com) [23].


## 2.1. Data Acquisition and Processing

First, download all data of glioma from the UCSC-Xena (https://xenabrowser.net/datapages/). The Xena-GBM dataset (TCGA http://www.tcga.org) contains 5 normal and 168 cancer samples. Download the data of normal brain tissue from the Genotype-Tissue Expression database (https://gtexportal.org/) as a control. GTEx database contains 115 normal brain tissue samples which are located in the cerebral cortex. By merging, 120 normal and 168 tumor samples were obtained. The combined gene expression profile data and clinical data in Xena were used to train the model of the prognosis of patients. The number of patients (n=589), sex, age, and other clinical information of patients were included in the analysis.


## 2.2. Gene Set Enrichment Analysis (GSEA) of Related Pathways of Glycolysis

Pathways related to glycolysis (GLYCOLYSIS_PATHWAY, HALLMARK_GLYCOLYSIS, GLYCOLYSIS_GLUCONEOGENESIS, GLYCOLYTIC_PROCESS, and REACTOME_GLYCOLYSIS) were found from the GSEA website (http://www.broadinstitute.org/gsea/index.jsp) [19]. The GSEA was performed in the gene expression data of the training set including normal samples and glioma samples.


## 2.3. Differential Analysis and Modeling of Glycolytic-Related Genes

Glycolysis-related genes (GRGs) were extracted from the training set based on GSEA results, and differential analysis was performed using limma packets in R (3.61) (P<0.05, logFC≥1 or ≤-1). Prognosis GRGs (FDR<0.01) were screened by the logarithmic rank test in combination with survival time. The candidate GRGs were analyzed by using Cox risk regression analysis and glmnet in R (3.61) for 10-fold cross-validation. The survival data of Cox analysis was processed by the glmnet package, and the object of survival analysis was identified to construct the Lasso regression model (the best λ value was selected by the cv.glmnet function, and the gene screening was carried out by the coef function). The optimal genes were constructed as a GRG gene pair model. We extracted the relative expression of model genes in samples and plotted the heat map. We evaluated the model’s accuracy through the receiver operating characteristic curve (ROC) and distinguished the high- and low-risk groups by cutoff value of the model.


## 2.4. GRG Model Validation

GRG model was used to analyze the training set in terms of single-factor and multifactor Cox proportional hazard analysis and survival analysis.


## 2.5. Expression and Mutation of Model Genes

Use the limma package in R (3.61) to analyze the expression of 9 model genes in the training set. Use cBioPortal (http://www.cbioportal.org/) to analyze the mutations of 9 model genes in GBM samples in TCGA database.


## 2.6. Correction between GRG Model and Clinical Characters

Analyze the relationship between clinically relevant characteristics such as age, gender, and survival rate in the training group. Analyze the survival rate of patients with different clinical characteristics classified according to the model.


## 2.7. Expression Verification of Prognosis-Related Genes

Verify the expression of selected model genes related to prognosis. Use the Human Protein Atlas (HPA) (http://www.proteinatlas.org/) to validate the expression of model genes related to prognosis in glioma tissues and normal tissues and compare the consistency of previous analysis and expression differences. 50 cases of patients with glioma were screened out from our hospital from June 2018 to June 2020. Inclusion criteria were as follows: (1) pathologically confirmed; (2) new cases diagnosed by this hospital for the first time. Exclusion criteria were as follows: (1) with other malignant tumors; (2) patients who have received radiotherapy, chemotherapy, or other antineoplastic drugs before surgery [20].Nine differentially expressed genes in tumor and normal tissues of patients with glioma were verified by qPCR. Primers were synthesized according to the PCR primer information provided by the Primer Bank database (Table1). GAPDH was used as an internal reference, and a two-step method was used. The expression of GAPDH was detected by qPCR. Using the expression level of GAPDH as the standard value “1,” the relative expression levels of each differential gene in tumor and normal tissues were calculated. The real-time PCR kit was used to detect the expression of these genes in tumor and normal tissues and to draw statistical charts. The reaction procedure was as follows: hold (predenaturation): 95°C, 30 s, 1 cycle; two-step PCR: 95°C, 5 s, 60°C, 30 s, 40 cycles; dissociation: 95°C, 15 s, 60°C, 30 s, 95°C, 15 s, 1 cycle [20].Table 1
PCR primers for 9 RNAs and internal reference.
GeneG6PC2STC1HDAC4COG2SRD5A3Forward primerCCCAAATCACTCAAGTCCATGCCACGAGCTGACTTCAACAGGACCTGGGAATGTACGACGCCACAAAGTAAGACCGCGTATAGCTGGCTGCACAGCTTACGAAGReverse primerGGTTACCATGACATACCAGACACGGATGTGCGTTTGATGTGGGCCCGTCTTTCCTGCGTAACAAGCAGTGCCGTATTATATCGACTCAGCACAGTTAGGCCAACAAGeneMDH2IL13RA1TGFBIB3GAT3GAPDHForward primerTCGGCCCAGAACAATGCTAAAGTCCCAGTGTAGCACCAATGACACTCTCAAACCTTTACGAGACCAAGGAGTCGTCTACTTTGCTGAACAACTTTGGTATCGTGGAAGGReverse primerGCGGCTTTGGTCTCGATGTGCTCAGGTTGTGCCAAATGCCGTTGCTAGGGGCGAAGATGGGGCATTGGGCTTATCTAACAGGCCATCACGCCACAGTTTC


## 2.8. Statistical Analysis

Measured data were expressed asmean±standard deviation (x±s), and data were compared using a T-test. The Kaplan-Meier method was used for survival analysis [21]. The receiver operating characteristic curve (ROC curve) and ROC analysis were completed by survival ROC (1.0.3) [20]. A Cox proportional hazard regression model was used to analyze univariately and multivariately. The criterion for statistically significant difference is P<0.05. And P<0.01 indicates the difference has fairly significant statistical significance. A Cox proportional regression model was used to identify the predictive model with the best explanatory and informative efficacy. A risk score staging model was established using the R package survival function coxph (). The risk score formula is described as follows [22]:
(1)Riskscore1/4expressionofgene1×β1bexpressionofgene2×β2b⋯bexpressiomofgenen×βn:The R package was used for analyzing the relationship between different clinical characteristics and survival rate in high- and low-risk groups. All statistical analyses were performed with the Statistical Package for the Social Sciences software version 16.0 (SPSS Inc., Chicago, IL, the USA) and GraphPad Prism 7 (GraphPad Software, La Jolla, CA, the USA;http://www.graphpad.com) [23].


## 3. Results

### 3.1. GSEA of Glycolysis-Related Pathways

The mRNA expression data and clinical information of 598 patients were obtained from TCGA. Glycolysis GSEA was performed on the GBM sample data in the training set. Results showed that the training set genes were significantly enriched in REACTOME_GLYCOLYSIS, GLYCOLYTIC_PROCESS, and HALLMARK_GLYCOLYSIS at normalizedP value < 1% (Figures 1(a)–1(e)) (P<0.05).Figure 1
GSEA results for the enrichment plots of five gene sets (BIOCARTA_GLYCOLYSIS_PATHWAY, GLYCOLYTIC, HALLMARK_GLYCOLYSIS, GLYCOLYSIS_GLUCONEOGENESIS, and REACTOME_GLYCOLYSIS) that were significantly differentiated in normal and GBM tissues based on TCGA. GSEA: gene set enrichment analysis; GBM: glioblastoma multiforme; TCGA: The Cancer Genome Atlas.
(a)(b)(c)(d)(e)


### 3.2. Model Construction of Glycolysis-Related Genes

Glycolysis-related genes were obtained, and these genes were extracted from the training set for differential analysis, and the results showed that there were 339 differential glycolysis-related genes. 19 genes were significantly correlated to OS (P<0.05) and were entered into a stepwise multivariate Cox regression analysis (Supplement Table 1) (results of multivariate Cox regression analysis of 19 genes which significantly correlated to overall survival). Combined with the clinical survival time, through multivariable Cox regression analysis and 10-fold cross-validation, we obtained the 9 optimal glycolysis-related genes, which are G6PC2, STC1, HDAC4, COG2, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3 (Table 2), and we constructed a prognostic model. According to the risk score formula, patients with GBM were divided into a high-risk group (n=80) and a low-risk group (n=80) with the median risk score as cutoff value (Figure 2(a)). Each patient’s survival (day) is shown in Figure 2(b). The patients in the high-risk score group had a higher mortality rate than those in the low-risk score group (Figure 2(c)). Figure 2(d) shows that the 5-year AUC value of the ROC curve of the model was as high as 0.763, indicating that our model had high accuracy. The heat map (Figure 2(e)) shows the expression profiles of these 9 mRNAs. With the increase of risk score in GBM patients, the expression of the risky-type mRNAs (STC1, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3) was all upregulated gradually, while the expression of the protective-type mRNA (HDAC4, COG2, and G6PC2) was downregulated.Table 2
Nine prognostic mRNAs significantly associated with overall survival in patients with GBM.
Gene IDCOEFHRG6PC2-3.1884589970.041235366STC10.2384920721.269333643HDAC4-0.5458740880.579335172COG2-0.6282816340.533507776SRD5A30.3815330751.4645281MDH20.7601429922.138581998IL13RA10.3511366961.420681514TGFBI-0.1990482180.819510378B3GAT30.575729861.778428057Figure 2
The nine-mRNA signature related to risk score predicts the overall survival of patients with glioblastoma multiforme. (a) mRNA risk score distribution. (b) Survival status. (c) Survival curves of patients in high-risk and low-risk groups. (d) The receiver operating characteristic curve (ROC) of 1 year and 3 years of the model. (e) Heat map of nine gene expression profile in The Cancer Genome Atlas.
(a)(b)(c)(d)(e)


### 3.3. Expression and Mutation of Model Genes

Use cBioPortal to analyze the mutations of model genes, and the results showed that the mutation rate of HDAC4 and MDH2 gene was the highest of 8%, while the mutation rates of G6PC2 were lowest as 2.8% (Figure3). Analyze the expression of 9 model genes in the training set; then, the results showed that these 6 genes, STC1, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3, were all highly expressed, while HDAC4, COG2, and G6PC2 genes were all downregulated in patients with GBM (Figure 4).Figure 3
The alteration proportion for the nine selected genes in clinical samples of glioblastoma multiforme in the cBioPortal database.
(a)(b)(c)(d)(e)(f)(g)(h)(i)Figure 4
Different expressions of nine genes in the normal tissues and tumor tissues based on Genotype-Tissue Expression and The Cancer Genome Atlas database. (∗∗∗ represents P<0.0001).
(a)(b)(c)(d)(e)(f)(g)(h)(i)


### 3.4. Validation of Model

The model was applied to the training set data for verification. It was shown that risk scores were significantly related to the prognosis (Figure5(a)) in the univariate risk regression analysis. Multivariate risk regression analysis showed that risk scores could be used as significant independent prognostic factors (Figure 5(b)). The results suggested that the risk score was effective in predicting the prognosis of patients with GBM (Table 3).Figure 5
(a) Univariate analysis of gender, age, and risk score. (b) Multivariate analysis of gender, age, and risk score. (c) Kaplan-Meier survival curves of the female patient group. (d) Kaplan-Meier survival curves of the male patient group. (e) Kaplan-Meier survival curves of theage<65 patient group. (f) Kaplan-Meier survival curves of the age≧65 patient group.
(a)(b)(c)(d)(e)(f)Table 3
Univariable and multivariable analyses for each clinical feature.
Clinical featureNumberUnivariate analysisMultivariate analysisHRHR.95LHR.95HP valueHRHR.95LHR.95HP valueRisk score (low-risk/high-risk)80/801.0001849150.6938825981.4416990250.9992091930.9910232450.6854476091.4328258790.961764674Sex (male/female)104/561.0252418531.0111522051.039527830.0004143491.021186731.0065770981.0360084080.004349668Age (≤65/>65)101/591.87018171.5717984522.22520871.67E−121.7828261121.4955968942.1252176691.11E−10


### 3.5. Model and Clinical Characters

After analyzing the relation between clinical traits and survival, we found that only age and risk scores were significantly related to the survival rate of patients (Figures5(a) and 5(b)). Group the clinical traits according to the model, and analyze the survival rate of patients in different groups. We can see that the GRG model can well distinguish the older than 65-year-old group, male group, and age<65-year-old groups of patients (P<0.001), while the difference was not so obvious in female subgroups (P=0.016) (Figures 5(c)–5(f)).


### 3.6. Immunohistochemical and qPCR Verification of Prognostic Genes

The data verification results of the HPA database indicated that the expression of IL13RA1 and COG2 in cancer and adjacent tissues had not been detected in the database, and the expression of the remaining 7 genes in cancer and adjacent tissues could be verified. Among them, STC1 and TGFBI genes were not significantly expressed in tumor and normal tissues, and there was no significant difference in expression. Compared with normal tissues, the expressions of SRD5A3, MDH2, and B3GAT3 in tumor tissues were significantly upregulated, and the expression of HDAC4 and G6PC2 in tumor tissues was significantly downregulated; the verification results were basically consistent with the research analysis results (Figure6(a)). Figure 6(b) shows the real-time quantitative PCR results of differentially expressed genes. The relative expression of each gene in the figure was calculated according to the relative expression quantity value of the internal reference gene (GAPDH). STC1, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3 were all upregulated in tumor tissues, while the expression of the HDAC4, COG2, and G6PC2 was downregulated. The experimental results are basically consistent with the analytical results.Figure 6
(a) Immunohistochemistry validated the expression of 9 prognostic-related glycolytic genes in glioma tissues and normal tissues. (b) qPCR experiments validated the expression of 9 prognostic-related glycolytic genes in glioma tissues and normal tissues.
(a)(b)


## 3.1. GSEA of Glycolysis-Related Pathways

The mRNA expression data and clinical information of 598 patients were obtained from TCGA. Glycolysis GSEA was performed on the GBM sample data in the training set. Results showed that the training set genes were significantly enriched in REACTOME_GLYCOLYSIS, GLYCOLYTIC_PROCESS, and HALLMARK_GLYCOLYSIS at normalizedP value < 1% (Figures 1(a)–1(e)) (P<0.05).Figure 1
GSEA results for the enrichment plots of five gene sets (BIOCARTA_GLYCOLYSIS_PATHWAY, GLYCOLYTIC, HALLMARK_GLYCOLYSIS, GLYCOLYSIS_GLUCONEOGENESIS, and REACTOME_GLYCOLYSIS) that were significantly differentiated in normal and GBM tissues based on TCGA. GSEA: gene set enrichment analysis; GBM: glioblastoma multiforme; TCGA: The Cancer Genome Atlas.
(a)(b)(c)(d)(e)


## 3.2. Model Construction of Glycolysis-Related Genes

Glycolysis-related genes were obtained, and these genes were extracted from the training set for differential analysis, and the results showed that there were 339 differential glycolysis-related genes. 19 genes were significantly correlated to OS (P<0.05) and were entered into a stepwise multivariate Cox regression analysis (Supplement Table 1) (results of multivariate Cox regression analysis of 19 genes which significantly correlated to overall survival). Combined with the clinical survival time, through multivariable Cox regression analysis and 10-fold cross-validation, we obtained the 9 optimal glycolysis-related genes, which are G6PC2, STC1, HDAC4, COG2, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3 (Table 2), and we constructed a prognostic model. According to the risk score formula, patients with GBM were divided into a high-risk group (n=80) and a low-risk group (n=80) with the median risk score as cutoff value (Figure 2(a)). Each patient’s survival (day) is shown in Figure 2(b). The patients in the high-risk score group had a higher mortality rate than those in the low-risk score group (Figure 2(c)). Figure 2(d) shows that the 5-year AUC value of the ROC curve of the model was as high as 0.763, indicating that our model had high accuracy. The heat map (Figure 2(e)) shows the expression profiles of these 9 mRNAs. With the increase of risk score in GBM patients, the expression of the risky-type mRNAs (STC1, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3) was all upregulated gradually, while the expression of the protective-type mRNA (HDAC4, COG2, and G6PC2) was downregulated.Table 2
Nine prognostic mRNAs significantly associated with overall survival in patients with GBM.
Gene IDCOEFHRG6PC2-3.1884589970.041235366STC10.2384920721.269333643HDAC4-0.5458740880.579335172COG2-0.6282816340.533507776SRD5A30.3815330751.4645281MDH20.7601429922.138581998IL13RA10.3511366961.420681514TGFBI-0.1990482180.819510378B3GAT30.575729861.778428057Figure 2
The nine-mRNA signature related to risk score predicts the overall survival of patients with glioblastoma multiforme. (a) mRNA risk score distribution. (b) Survival status. (c) Survival curves of patients in high-risk and low-risk groups. (d) The receiver operating characteristic curve (ROC) of 1 year and 3 years of the model. (e) Heat map of nine gene expression profile in The Cancer Genome Atlas.
(a)(b)(c)(d)(e)


## 3.3. Expression and Mutation of Model Genes

Use cBioPortal to analyze the mutations of model genes, and the results showed that the mutation rate of HDAC4 and MDH2 gene was the highest of 8%, while the mutation rates of G6PC2 were lowest as 2.8% (Figure3). Analyze the expression of 9 model genes in the training set; then, the results showed that these 6 genes, STC1, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3, were all highly expressed, while HDAC4, COG2, and G6PC2 genes were all downregulated in patients with GBM (Figure 4).Figure 3
The alteration proportion for the nine selected genes in clinical samples of glioblastoma multiforme in the cBioPortal database.
(a)(b)(c)(d)(e)(f)(g)(h)(i)Figure 4
Different expressions of nine genes in the normal tissues and tumor tissues based on Genotype-Tissue Expression and The Cancer Genome Atlas database. (∗∗∗ represents P<0.0001).
(a)(b)(c)(d)(e)(f)(g)(h)(i)


## 3.4. Validation of Model

The model was applied to the training set data for verification. It was shown that risk scores were significantly related to the prognosis (Figure5(a)) in the univariate risk regression analysis. Multivariate risk regression analysis showed that risk scores could be used as significant independent prognostic factors (Figure 5(b)). The results suggested that the risk score was effective in predicting the prognosis of patients with GBM (Table 3).Figure 5
(a) Univariate analysis of gender, age, and risk score. (b) Multivariate analysis of gender, age, and risk score. (c) Kaplan-Meier survival curves of the female patient group. (d) Kaplan-Meier survival curves of the male patient group. (e) Kaplan-Meier survival curves of theage<65 patient group. (f) Kaplan-Meier survival curves of the age≧65 patient group.
(a)(b)(c)(d)(e)(f)Table 3
Univariable and multivariable analyses for each clinical feature.
Clinical featureNumberUnivariate analysisMultivariate analysisHRHR.95LHR.95HP valueHRHR.95LHR.95HP valueRisk score (low-risk/high-risk)80/801.0001849150.6938825981.4416990250.9992091930.9910232450.6854476091.4328258790.961764674Sex (male/female)104/561.0252418531.0111522051.039527830.0004143491.021186731.0065770981.0360084080.004349668Age (≤65/>65)101/591.87018171.5717984522.22520871.67E−121.7828261121.4955968942.1252176691.11E−10


## 3.5. Model and Clinical Characters

After analyzing the relation between clinical traits and survival, we found that only age and risk scores were significantly related to the survival rate of patients (Figures5(a) and 5(b)). Group the clinical traits according to the model, and analyze the survival rate of patients in different groups. We can see that the GRG model can well distinguish the older than 65-year-old group, male group, and age<65-year-old groups of patients (P<0.001), while the difference was not so obvious in female subgroups (P=0.016) (Figures 5(c)–5(f)).


## 3.6. Immunohistochemical and qPCR Verification of Prognostic Genes

The data verification results of the HPA database indicated that the expression of IL13RA1 and COG2 in cancer and adjacent tissues had not been detected in the database, and the expression of the remaining 7 genes in cancer and adjacent tissues could be verified. Among them, STC1 and TGFBI genes were not significantly expressed in tumor and normal tissues, and there was no significant difference in expression. Compared with normal tissues, the expressions of SRD5A3, MDH2, and B3GAT3 in tumor tissues were significantly upregulated, and the expression of HDAC4 and G6PC2 in tumor tissues was significantly downregulated; the verification results were basically consistent with the research analysis results (Figure6(a)). Figure 6(b) shows the real-time quantitative PCR results of differentially expressed genes. The relative expression of each gene in the figure was calculated according to the relative expression quantity value of the internal reference gene (GAPDH). STC1, SRD5A3, MDH2, IL13RA1, TGFBI, and B3GAT3 were all upregulated in tumor tissues, while the expression of the HDAC4, COG2, and G6PC2 was downregulated. The experimental results are basically consistent with the analytical results.Figure 6
(a) Immunohistochemistry validated the expression of 9 prognostic-related glycolytic genes in glioma tissues and normal tissues. (b) qPCR experiments validated the expression of 9 prognostic-related glycolytic genes in glioma tissues and normal tissues.
(a)(b)


## 4. Discussion

These nine biomarker genes (STC1, SRD5A3, MDH2, IL13RA1, TGFBI, B3GAT3, HDAC4, COG2, and G6PC2) were screened by the model; STC1 was associated with the occurrence and development of various cancers [24–26]. Chen et al. had found that STC1 was related to the prognosis of colon adenocarcinoma [24]. Kamata et al. found that fibroblast-derived STC-1 could modulate tumor-associated macrophages and lung adenocarcinoma development [25]. Zhao et al. provided an overview of (a) the possible mechanisms through which STC1 affected the malignant properties of cancer in their article [26].SRD5A3 was reported as one of the six genes associated with P4 metabolism in the liver [27]. In breast cancer, SRD5A3 was decreased significantly and primarily enriched in the hormone metabolic process [28]. Typically, the MDH2 gene was considered to play a key role in glycolysis and fatty acid metabolism [29]. The activity of the MDH2 gene was different in prostate cancer and benign cell lines at the basal level [30]. Shelar et al. found that L2HGDH suppressed both cell migration and tumor growth and these effects were mediated by the activity of malate dehydrogenase 2 (MDH2) [31]. Studies have found that the IL-13 and IL13RA1 interaction promoted cancer cell growth and metastasis, and IL13RA1 expressing in tumor cells was related to poor prognosis in patients with invasive breast cancer [32]. IL13RA1 had been previously reported to be associated with glioblastoma and was associated with multiple survival events [33, 34].TGFBI had been found as an index of CAF abundance, which was an effective indicator of the survival of patients in various cancers [35]. Du et al. found that TGFBI related to prognosis of patients with ccRCC may become the novel prognostic biomarkers and immunotherapy targets [36]. The study had also found that tumor-associated macrophages could promote ovarian cancer cell migration by secreting transforming growth factor beta induced (TGFBI) and tenascin C [37]. High expression of B3GAT3 was related to poor prognosis of liver cancer [38]. It had been reported that HDAC4 participated in the occurrence and development of various cancers [39–41]. Low levels of AMPK could promote epithelial-mesenchymal transition in lung cancer primarily through HDAC4- and HDAC5-mediated metabolic reprogramming [39]. The knockdown of S6K1 was predicted to reduce the tumorigenicity of HCC through the regulation of hubs of genes including HDAC4 [40]. RGMB-AS1 long noncoding RNA could act as a microRNA-574 sponge thereby enhancing the aggressiveness of gastric cancer via HDAC4 upregulation [41]. Jung et al. reported that genetically elevated G6PC2 was associated with reduced risk for breast cancer in phenotype-specific analysis [42]. There was no report about the study of COG2 in any cancer so far. And COG2 may be regarded as a novel biomarker for the prognosis of patients with GBM.GSEA is a gene set enrichment analysis that integrates data from different levels and sources. In this study, we used GSEA to analyze the mRNA expression data of 598 patients with GBM and found that five functions had significant differences. According to the NES,N, and P value, the GLYCOLYSIS with the minimum P value was selected for further analysis. We focused on selecting GSEA genes to predict specific functions of patient survival and explored these genes extensively. By analyzing the enrichment of the expression profile of GBM patients in glycolysis-related pathways, and using Cox regression analysis, we successfully screened glycolysis-related genes that are closely related to the survival of colon cancer patients and constructed a prognostic model. ROC analysis proved that this model had a high accuracy rate and could distinguish patients with GBM very well. By univariate and multivariate Cox regression analyses [10], 9 gene combinations rather than a single gene combination were determined to be valuable for the prognosis of patients with GBM. Compared with some known prognostic biomarkers, this selected risk marker may be targeted and more powerful prognostic in supporting clinical outcomes acting as an effective classification tool for patients with GBM.In recent years, researchers tried to use bioinformatics methods to analyze sequencing results to detect biomarkers related to survival in glioma patients and predict their prognosis [43–46]. Jiang et al. identified genes related to low-grade glioma progression and prognosis based on integrated transcriptome analysis [44]. Liu et al. used lncRNA expression profiles to predict the prognosis of patients with glioblastoma [45]. There are also some researches focusing on the relationship between glycolysis and tumor oncogenesis, development, proliferation, and invasion [47, 48]. Most studies have focused on the relationship between glycolysis and tumor oncogenesis, development, proliferation, and invasion [49]. However, no study has investigated the relationship between glycolysis-related genes and the survival of patients with GBM. Our study first used the public TCGA database to identify and comprehensively analyze glycolysis-related mRNAs that are significantly associated with the prognosis of patients with GBM.Although the model with nine-gene signature can be used to predict the prognosis of patients with GBM, some limitations still remain. The biological functions of the predicted genes were annotated using computational methods, and additional experiments should be performed to further reveal the mechanisms by which genes are involved in GBM tumorigenesis. The risk score model was established based on TCGA database and should be validated in other cohorts in future studies. We planned to supplement the following experiment: collect tumor samples from patients with glioma in stages I and III, and use qPCR and immunohistochemistry to detect the expression differences of nine genes in tumor samples with different clinical stages (significant prognostic differences). In addition, although the gene signatures may be most effective in the early stages, their prognostic role in early GBM needs to be further evaluated.


## 5. Conclusion

In this study, we identified nine glycolysis-related genes associated with survival in patients with GBM using multivariate Cox regression analysis and Lasso regression analysis. The results of analysis revealed that prognostic assessment models based on nine glycolytic-related genes could accurately predict the prognosis of patients with GBM.



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