ACER2 forms a cold tumor microenvironment and predicts the molecular subtype in bladder cancer: Results from real-world cohorts

Background: ACER2 is a critical gene regulating cancer cell growth and migration, whereas the immunological role of ACER2 in the tumor microenvironment (TME) is scarcely reported. Thus, we lucubrate the potential performance of ACER2 in bladder cancer (BLCA). Methods: We initially compared ACER2 expressions in BLCA with normal urothelium tissues based on data gathered from the Cancer Genome Atlas (TCGA) and our Xiangya cohort. Subsequently, we systematically explored correlations between ACER2 with immunomodulators, anti-cancer immune cycles, tumor-infiltrating immune cells, immune checkpoints and the T-cell inflamed score (TIS) to further confirm its immunological role in BLCA TME. In addition, we performed ROC analysis to illustrate the accuracy of ACER2 in predicting BLCA molecular subtypes and explored the response to several cancer-related treatments. Finally, we validated results in an immunotherapy cohort and Xiangya cohort to ensure the stability of our study. Results: Compared with normal urinary epithelium, ACER2 was significantly overexpressed in several cell lines and the tumor tissue of BLCA. ACER2 can contribute to the formation of non-inflamed BLCA TME supported by its negative correlations with immunomodulators, anti-cancer immune cycles, tumor-infiltrating immune cells, immune checkpoints and the TIS. Moreover, BLCA patients with high ACER2 expression were inclined to the luminal subtype, which were characterized by insensitivity to neoadjuvant chemotherapy, chemotherapy and radiotherapy but not to immunotherapy. Results in the IMvigor210 and Xiangya cohort were consistent. Conclusion: ACER2 could accurately predict the TME and clinical outcomes for BLCA. It would be served as a promising target for precision treatment in the future.