Zhang J, Zhu ML, Xie YX, Fan YQ, Zhang W, Liu SS, Yu XM, Wang W, Fu XY. Development and validation of a tongue image-clinical nomogram for detection of advanced colorectal adenoma. World J Gastroenterol 2026; 32(33): 119646 [DOI: 10.3748/wjg.119646]
Corresponding Author of This Article
Xiao-Yan Fu, MD, Chief Physician, Department of Gastroenterology and Hepatology, The Second People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, No. 282 Wusi Road, Fuzhou 350003, Fujian Province, China. fxy001@sohu.com
Research Domain of This Article
Gastroenterology & Hepatology
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research-article
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Zhang J, Zhu ML, Xie YX, Fan YQ, Zhang W, Liu SS, Yu XM, Wang W, Fu XY. Development and validation of a tongue image-clinical nomogram for detection of advanced colorectal adenoma. World J Gastroenterol 2026; 32(33): 119646 [DOI: 10.3748/wjg.119646]
Jing Zhang, Mei-Li Zhu, Yu-Xuan Xie, Ya-Qin Fan, Wei Zhang, Shi-Shi Liu, Wei Wang, Xiao-Yan Fu, Department of Gastroenterology and Hepatology, The Second People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou 350003, Fujian Province, China
Xiang-Mei Yu, Department of Public Health Fundamentals, Fujian University of Traditional Chinese Medicine, Fuzhou 350122, Fujian Province, China
Co-corresponding authors: Wei Wang and Xiao-Yan Fu.
Author contributions: Zhang J designed the research study and wrote the first draft of the manuscript; Zhu ML, Xie YX, Fan YQ, Zhang W, Liu SS contributed data collection; Yu XM contributed to the analysis; Wang W and Fu XY conceived and supervised the manuscript, and shared responsibility for correspondence as co-corresponding authors; all authors have read and approved the final manuscript.
Supported by Fujian Provincial Financial Subsidy Special Program, No. X2023010; and Natural Science Foundation of Fujian Province, No. 2024Y0020.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Second People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine (No. SPHFJP-Y2025106-01).
Informed consent statement: Written informed consent was obtained from all participants.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at fxy001@sohu.com. Participants gave informed consent for data sharing.
Corresponding author: Xiao-Yan Fu, MD, Chief Physician, Department of Gastroenterology and Hepatology, The Second People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, No. 282 Wusi Road, Fuzhou 350003, Fujian Province, China. fxy001@sohu.com
Received: February 3, 2026 Revised: April 9, 2026 Accepted: April 28, 2026 Published online: September 7, 2026 Processing time: 189 Days and 21.8 Hours
Abstract
BACKGROUND
Colorectal cancer largely arises from advanced adenomas (AA), yet current noninvasive risk stratification tools, including the Asia-Pacific colorectal screening (APCS) score, exhibit limited discriminatory ability, particularly for AA detection. Traditional Chinese medicine tongue diagnosis, supported by emerging evidence of the oral-gut axis and microbial translocation, offers a potential noninvasive phenotypic marker. Computerized tongue image analysis enables objective quantification of tongue features. We hypothesized that a nomogram integrating quantitative tongue-image characteristics with clinical risk factors would improve AA detection beyond established APCS-based risk scores.
AIM
To develop and validate a tongue image-clinical nomogram for AA detection and compare it with conventional risk scores.
METHODS
This prospective observational study randomly divided 880 adults into training and validation cohorts (7:3). Quantitative tongue phenotypes were extracted via deep learning from standardized images. Univariate analysis, least absolute shrinkage and selection operator regression, and multivariate analysis established the nomogram. Calibration curves, the area under the receiver operating characteristic curve (AUC), and decision curve analysis assessed discrimination, accuracy, and clinical utility. Additionally, fixed-specificity classification was applied within the high-risk (APCS score ≥ 4) subgroup.
RESULTS
In the training cohort (n = 616; 226 AA), the nomogram achieved an AUC of 0.739, significantly superior to the tongue-only model (0.694), APCS score (0.663), and modified APCS (M-APCS) score (0.658) (all P < 0.002). In the validation cohort (n = 264; 92 AA), the nomogram maintained an AUC of 0.711, exceeding conventional scores (AUC: 0.640-0.654). Within the high-risk subgroup (APCS score ≥ 4; n = 213), the nomogram retained moderate discrimination (AUC: 0.75-0.76) and performance comparable to the tongue-only model, whereas conventional scores approached chance levels (AUC: 0.52-0.57). Using cutoffs targeting approximately 80% specificity in the high-risk validation subset, the nomogram detected 58.33% of AA vs 19.44% for APCS score and 25.00% for M-APCS score.
CONCLUSION
The tongue image-clinical nomogram may complement conventional scores for noninvasive AA risk refinement, especially in APCS-defined high-risk individuals.
Core Tip: This study developed and internally validated a noninvasive nomogram integrating quantitative tongue phenotypes with clinical factors for advanced adenoma detection. In the validation cohort, the nomogram showed higher discrimination than the Asia-Pacific colorectal screening (APCS) and modified APCS scores. In the high-risk subgroup (APCS ≥ 4), where conventional scores had limited discriminative value, the nomogram maintained moderate performance and detected 2-3 times as many advanced adenomas as the conventional scores did at approximately 80% specificity, suggesting potential as a noninvasive risk-refinement tool for opportunistic screening.
