A Five-Gene Stromal-EMT Signature Predicts Prognosis, Immunotherapy Resistance, and Therapeutic Vulnerability in Bladder Cancer

Abstract

Background Bladder cancer has entered an era in which immune checkpoint blockade (ICB) and antibody-drug conjugate (ADC)-based combinations are reshaping clinical management. However, transcriptomic scores that connect prognosis, tumor microenvironment state, and treatment response are incompletely defined. Methods Open-access TCGA-BLCA RNA-seq, clinical, mutation, copy-number, and RPPA data were downloaded from the Genomic Data Commons (GDC). Tumor-normal differential expressions, survival screening, LASSO-Cox modeling, train-test validation, GEO validation, pathway enrichment, immune signature scoring, mutation/CNV/RPPA support, drug sensitivity prediction, single-cell/spatial localization, and ICB validation were performed using reproducible Python and R scripts. A reduced model was derived using only genes shared by TCGA, GSE13507, and GSE31684. The fixed formula was then applied without refitting to IMvigor210 and GSE176307. Results A five-gene model composed of EMP1, AHNAK, TNFRSF14, CLEC2D, and GSDMB retained TCGA internal prognostic value (train C-index 0.693, test C-index 0.605, all-sample C-index 0.667; TCGA test log-rank p = 0.015), although GEO survival validation in GSE13507 and GSE31684 was modest. High-risk tumors were enriched for epithelial-mesenchymal transition (EMT), TNF-alpha/NF-kB signaling, inflammatory response, hypoxia, complement, CAF, macrophage, checkpoint, and cytotoxic programs. Single-cell and spatial analyses localized the score to basal tumor, endothelial, fibroblast, and perivascular compartments. In IMvigor210, risk scores were higher in ICB non-responders than responders (Wilcoxon p = 0.044; AUC for non-response = 0.580), high-risk tumors had a lower responder rate (17.6% vs. 28.0%), and high risk predicted poorer OS (log-rank p = 0.016; multivariate continuous risk HR = 3.15, p = 0.044). GSE176307 showed directionally consistent but non-significant response results (AUC = 0.576). Conclusions The five-gene score is best interpreted not as a standalone universal prognostic classifier, but as a compact stromal-EMT and immune-suppression phenotype associated with inferior ICB response. These findings support a framework linking prognosis, microenvironment biology, immunotherapy resistance, and therapeutic hypotheses in bladder cancer.