Biochemical studies in head and neck cancer

Cliical Biochemistry, Vol. 27, No. 4, pp. 2X-243, 1994 Copyright _. _ 0 1994 The Canadian Society of Clinical Chemists Printed in the USA. All rights reamed 0009-9120/94 $6.00 + .OO

Pergamon 0009-9120(94)EOOOl-B

Biochemical

Studies in Head and Neck Cancer HARBANS LAL

Biochemistry

Department, 15/8FM, Medical College, Rohtak-124001, India

uring the course of tumor development, quantitative changes have been shown to occur in a variety of substances in serum. These substances are collectively referred to as biochemical serum markers or tumor markers. The potential use of tumor markers include early detection of cancer, monitoring reduction in tumor mass, detecting recurrence or metastasis, and predicting prognosis based on initial level of a marker or changes in serum after therapy. The tumor markers can be classified as belonging to one of the several major groups, for example, oncofetal proteins, hormones, enzymes, and proteins, etc. Some of the known tumor markers and the type of cancer in which these are altered are given in Table 1. Although many of these parameters are also elevated in diseases other than cancer and are considered as nonspecific, some of these have been shown to be of value in the diagnosis and management of various types of cancers. Few substances have been evaluated as indicators of tumor presence in untreated or followup patients of cancer of head and neck. This review gives an account of the various biochemical studies reported in patients with such malignancies.

D

Head and neck cancer Cancers of the head and neck region include tumors of the areas with various cavities not clearly defined in terms of either anatomical boundaries or clinical activities such as tumors of the larynx, cervical trachea, hypopharynx, nose and sinuses, ear, lips, oral cavity, oropharynx, nasopharynx, salivary glands, and thyroid gland. Essentially these lesions are different in etiology, behavior, and prognosis. When expressed as percentages of body carcinomas, the incidence has been shown to vary considerably

Manuscript received September 2, 1993; revised November 30,1993; acceptedDecember 22,1993.

CLINICAL

BIOCHEMISTRY,

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27, AUGUST

1994

throughout the world with extremes from about 1% in Europe (particularly in Germany) to nearly 45% in India (1). A patient with the nonhealing ulceration or spot, unilateral epistaxis, persistent hoarseness, odynophagia and sore throat, dysphagia or lump in the neck may have a tumor in the head and neck region. It is particularly so in subjects with high risk factors such as those who smoke or chew tobacco, alcoholics, or individuals involved in leather, wood, mineral acids, mustard gas, and nickel refining industries. While the incidence of other sites of cancer in the head and neck region has remained stable, the incidence of cancer of the sites that are more susceptible to tobacco and alcohol use has increased, becoming parallel to the patterns of their consumption over the last decade (2). Relative risk of cancer of the oral cavity increases with the increasing amount and duration of tobacco use in the form of smoking, chewing, or snuff. Further risk of cancer of the upper digestive tract remains elevated even after controlling the smoking habit. Moreover, the risk increases with the greater alcohol consumption at every level of smoking (3). Only a small number of dietary factors have been reported to affect risk of head and neck cancer. Some studies have suggested that low intake of foods containing vitamin A or its precursors and vitamin C is associated with increased risk (4,5X However, the intake of fat has not been shown to be associated with cancer of the head and neck region (6). Excluding cancer of the thyroid, salivary glands, and nasopharynx, over 80% of cancers of the head and neck region are squamous cell carcinomas (2). Besides squamous cell carcinoma, histopathologitally other tumors of the head and neck region include adenocarcinoma, sarcomas, anaplastic carcinoma, plasmacytoma, lymphomas, and malignant melanoma. In providing a prognosis for the patient, increasing severity of the disease is described in the form of TNM stage (7), representing primary tumor (T), regional lymph nodes and their condition (N), and distant metastasis (M). These tumors have been graded histologically as moderate to well differentiated. The degree of differentiation however, has

235

LAL TABLE 1 Some Known Tumor Markers

Type of Cancer

Tumor Marker Hormones 5 HCG Calcitonin HPL Oncofetal proteins CEA AFP Enzymes CPK (BB) and acid phosphatase Placental alkaline phosphatase Secreted tumor antigens CA 125 pz Microglobulin Immunoglobulins

the head and neck regions. Histologically about 75% of the patients studied had squamous cell carcinoma. Nearly 75% of the cases were in stage III and IV. Metastasis was observed in about 70% of the patients studied.

Testicular carcinoma Medulary thyroid carcinoma Trophoblastic tumors

Tumor markers The substances reported to be altered in patients with head and neck cancers include serum enzymes, proteins, tumor specific antigens, immunoglobulins, immune complexes, and erythrocyte polyamines.

Carcinoma breast and GIT Hepatoma Carcinoma of prostate Carcinoma uterus and ovary Ovarian cancer Multiple myeloma B cell lymphoproliferative disorders

been shown to be inversely related to the cervical node metastasis and survival of the patient (8). The incidence of lymph node metastasis has been shown to vary from 10 to 50%. Further in 20-80% of the patients the survival has been reported to be up to 5 years. The most common mode of treatment is radiotherapy (Telecobalt-60). We have studied nearly 400 histopathologically proven cases of head and neck cancers for the various biochemical investigations before and after radiotherapy. The results were previously published (9-18) and are compared with healthy controls in Table 2. It was observed that about 20% of the patients studied were of carcinoma of the larynx, 15% each of nose and paranasal sinuses and of oropharynx, 30% of laryngopharynx and esophagus; the remaining 20% comprised cancers of the other sites in

SERUMENZYMES Warburg in 1930 was the first to demonstrate an increased rate of glycolysis in neoploastic cells. Thereafter various workers have reported that the activity of one of the glycolytic enzymes, that is, phosphohexose isomerase (PHI), an enzyme predominantly present in liver and bone, is elevated independently or along with a few other enzymes in a variety of cancers. Increased levels of serum PHI have been reported in nearly 80% of the patients with metastatic carcinoma of the breast and changes in enzyme level were always in conformity with other evidence of alterations in the progress of cancer (19). They suggested that when elevated, the PHI would appear to be the more reliable index of tumor activity, both in assessing the cancer at a given time and in following its course. In various other types of cancer such as that of the prostate, liver, lung, oral cavity, bone, chronic myelocytic leukemias, and bronchogenic carcinomas, a nearly l- to l&fold rise in mean serum PHI has been reported (19-22). In nearly 80% of the patients with head and neck cancer a rise in serum PHI was also observed. The

TABLE 2

Biochemical Parameters in Sera of Patients of Head and Neck Cancers Before and After Radiotherapy Patients Control Subjects

Biochemical Parameter Phosphohexose

Isomerase(U/L) Ahesterase (U/mL)

5-Nucleotidase (U/L) (U/L) Adenosine deaminase

y-Glutamyl transpeptidase(U/L) Lactic dehydrogenase(u/L) CeruIoplasmin(mg/dL) CEA (i@IJ Immunoglobulin E (III/n&) Sites other than tonsil Carcinoma tonsil Magnesium (mg/dL)

54

Before Radiotherapy

? 2.5 (25)

140 -c 9.7” (25)

After Radiotherapy

65

‘- 5.4b

1.9 ”

0.13”qb

2.4 + 0.06 (25)

1.1 + 0.13” (38)

8.0 + 0.7 (25) 9.7 f 0.6 51 -c 1.8 (25) 99 + 8.6 (25)

40.5 2.3” (40) (50) 27.8 + 2.9” 118 + 4.6” (40) 155 ? 24.3” (26)

9.9 it f. O.Bb 1.8”*b 18.3 87 * 5.1-b 127 + 13.8

71

643 rt 83”

644

17 f 1.1 (25) 2.9 + 0.27 (25)

*8

(25)

2.4 &TO3 (25)

40 f 5.5 f

39 + 13 . -+

1.4” (40) 0.33” (25)

(41) 8” 0 .04 * ::b,

34 + 3.1 +

l.la*b 0.39s

-+ 74”

1.6 -

0.05”*b

Reference Number

9 10 1’4 13 14 15 16 17 18

Mean + SE; number of observations given in parentheses. * Difference &atistica.Ily significant when compared with the control subjects @ c 0.001). b Difference statistically significant when compared with the levels before radiotherapy @ < 0.05). 236

CLINICALBIOCHBMISTBY,VOLUME 27, AUGUST1994

BIOCHEMICAL STUDIES IN HEAD AND NECK CANCER

mean value was found to be increased by nearly twofold when compared with the mean value for the control subjects. The extent of the rise in serum PHI in patients with head and neck cancer was to nearly the same extent, irrespective of the type or histopathology of the lesion but was directly related to the TNM stage of cancer, that is, tumor mass, in nearly 70% of the patients (9). Increased PHI levels may be a result of leakage of the enzyme from primary tumor cells or from other tissues involved with its spread. The patients were followed up during the course of radiotherapy that was completed (3750 rads) in nearly 15-20 equally divided doses over a period of 4-6 weeks. On completion of radiotherapy there was a gradual and significant decrease in serum PHI and the levels returned to normal in 9 out of the 10 patients who received treatment. The decrease in serum PHI correlated well with the improvement in the general condition of the patient as assessed clinically and was suggestive of tumor inactivity as a result of radiotherapy (9). Aliesterase is the only enzyme whose serum levels have been shown to be reduced even in the earlier stages of cancer. The changes varied according to the type and site of cancer and with the presence of metastasis (23,241. Aliesterase is an e&erase of the type that acts preferentially on simple aliphatic esters and glycerides. Although it is difficult to elucidate the exact mechanism of decrease of serum aliesterase in patients with cancer, the decrease suggests disturbed fat metabolism. In all patients with head and neck cancer, reduced serum aliesterase activity was observed. The decrease in mean value was nearly 50% of the control group. In all the patients with nonmalignant growths serum aliesterase activity was comparable with the controls. The decrease in activity was greater in patients with ulcerative growths. The activity was found to be inversely correlated with the advancement in the stage of the cancer. Although the mean levels were significantly low in stages II-IV, the decrease was maximum in patients with stage IV. A progressive increase in serum aliesterase activity was observed with the course of radiotherapy and about one-third of these patients showed values nearing that of the controls. After the completion of radiotherapy, although serum aliesterase levels were found to be increased by nearly 75% of the pretreatment values, the mean value was not significantly different than the mean value for the control group (10). Adenosine deaminase (ADA) levels have been shown to be raised by nearly one- to threefold in a majority of the patients with carcinoma of the prostate, bladder, liver, and lung (25). It is an enzyme of purine metabolism that reacts especially on adenosine and several adenine nucleoside analogues. ADA is predominantly present in tumors rich in lymphoid cells such as lymph nodes and spleen and is an index of T-lymphocyte maturation. Increased levels of serum ADA in malignancy suggest altered adenosine metabolism. It is reported that adenosine is toxic to cultured mammalian cells and interferes CLINICAL BIOCHEMISTRY, VOLUME 27, AUGUST 1994

with pyrimidine biosynthesis (26). In nearly 90% of the patients with head and neck cancer, serum ADA concentration was found to be increased. The increase in the mean value was nearly threefold. However, comparatively there was more of an increase in cases having ulcerative growths. Further, the average activity increased with the advancement in the stage of the cancer. A progressive decrease in serum ADA with the increasing dose of radiotherapy was observed. After completion of radiotherapy nearly a 35% decrease in serum ADA was observed in 85% of the patients studied. The mean postradiotherapy levels however, were nearly twofold higher than the controls (11). Serum 5nucleotidase levels have been shown to be increased nearly 4- to 32-fold in cancer of the pancreas, breast, gastrointestinal tract, prostate, lung, and liver and in lymphomas and leukemias (27,281. It is suggested that the rise in serum 5’nucleotidase in malignancy could be due to its release into circulation from the solid tumors. Further it has been reported that serial estimation of the enzyme has a prognostic relevance. It is a well established plasma membrane marker and is present in mammalian cells as an ectoenxyme (29). The enzyme specifically catalyzes the dephosphorylation of nucleotide phosphates having a phosphate group attached to the C-5 position of the ribose ring. An increase in 5’-nucleotidase was found in all the patients with head and neck cancer (12). Compared to the control group the mean value was found to be increased by nearly fivefold. The mean rise was proportional with the advancement in the stage of the cancer suggesting that the increase in the tumor mass may be directly responsible for the increased levels of the enzyme. Further, the patients with cervical metastasis had higher levels of 5’nucleotidase compared to those without cervical metastasis. There was a gradual and significant decrease in serum 5’-nucleotidase activity with respect to the course of radiotherapy. The levels fell to normal in about 90% of the patients studied and the mean value after completion of radiotherapy became comparable with the control group (12). Gamma-glutamyl transpeptidase (gamma-glutamyl transferase, r-GT) levels have been reported to be elevated in various primary and secondary malignancies of the brain, liver, gastrointestinal tract, breast, lung, and oral cavity (30,311. r-GT is an oncofetal protein because its activity changes during development as well as carcinogenesis (321. The enzyme catalyzes the transfer of the gamma-glutamyl group from gamma-glutamyl peptide to other peptides, to amino acids, or to water. The increase in r-GT was found in 85% of the patients with head and neck cancer. The rise in the mean value was more than twofold. The rise was nearly the same in all the patients studied, irrespective of the site, character or histopathology of the lesion but in most of the patients it varied according to the TNM stage of cancer or with the extent of lymph node metastasis (increased with the advancement of disease). Following 237

LAL

radiotherapy, although a decrease in serum y-GT was observed in all 11 patients studied, the levels remained higher than the controls (13). Lactic dehydrogenase (LDH) levels have also been reported to be increased in various types of cancers including those of head and neck cancer (33). Higher mean values of LDH were observed both in serum as well as in malignant tissues of patients with head and neck cancer. The increase in serum LDH was noted in nearly 50% of the patients only, with the increase in tissue LDH seen in 90% of the patients. Serum LDH activity, however, was found to be inversely related to the change in the tissue LDH activity of the patient. The rise in serum as well as tissue LDH was nearly to the same extent irrespective of the site, character, histopathology, or stage of cancer. Further, the serum LDH levels remained higher even after radiotherapy (14). Elevated mean value of serum alkaline phosphatase has been reported in head and neck carcinomas. Ninety percent of the head and neck cancer patients with alkaline phosphatase levels greater than 100 U/L were responders to induction chemotherapy whereas only 50% of the patients with alkaline phosphatase levels less than 60 U/L were nonresponders. The possible source of the enzyme is suspected to be hepatic tissue. Increased levels are produced in association with a more rapidly growing invasive malignancy (34). Ornithine decarboxylase activity has also been shown to be increased in biopsies from patients with head and neck cancers and was found to be positively correlated to the aneuploidic compartment size (35). Tumor cells of the squamous cell carcinoma of the head and neck region have also been shown to possess an active trypsin-like enzyme (36). The mRNAs encoding two metalloproteinases, stromelysin-2 and collagnase I, have been detected by in situ hybridization in head and neck carcinoma. Collagenase mRNAs are present in individual invasive cancer cells and in tumor cells at the periphery of poorly differentiated clusters suggesting the role of stromelysin produced by both stromal and tumor cells in the breakdown of basement membrane and the involvement of both collagenase and stromelysin in stromal invasion in carcinomas of the head and neck in uiuo (37). Two cell lines established from tumors of the head and neck area at different clinical stages have been reported to differ in the expression and in the tyrosine kinase activity of the epidermal growth factor (EGF) receptors. It is suggested that the basal tyrosine kinase activity of the EGF receptors from a tumor that metastasized to lymph nodes may be more active than the EGF receptor kinase from an early stage tumor (38). SERUMPROTEINS Serum levels of some of the specific acute phase proteins have been studied in patients with solid malignancies. It has been demonstrated that serum 238

levels of haptoglobin, ol,-acid glycoprotein, and dlantitrypsin show differing relations with tumor extent and clinical stage in head and neck cancer. Levels of o.,-antitrypsin and a,-acid glycoprotein increased progressively with increasing tumor extent and correlated significantly with tumor stage. Serum haptoglobin levels were significantly increased in all tumor stages. Levels of HS-glycoprotein decreased progressively with increasing tumor stage. Prealbumin and albumin levels were decreased in all patients and did not differ by stage (39). Ceruloplasmin is a late acute phase reactant, copper carrying globulin, with essential oxidase activity. It is synthesized in the parenchymatous liver cells and has a role in angiogenesis and cell growth (40). Its serum levels have been reported to be raised in carcinoma of the lung, gastrointestinal tract, colon, thyroid, and lymphomas (41). In 95% of the patients with head and neck cancer also, serum ceruloplasmin levels have been found to be increased. The rise in the mean value was more than twofold. The rise however, was the same irrespective of the site, character, or histopathology of the lesion but in most of the patients increased with worsening stages of cancer. After radiotherapy, although a reduction in serum ceruloplasmin was observed in 16 out of the 17 patients who received treatment, the levels remained higher than the controls (15). Ferritin is the major iron binding and storage protein of human tissues. It has been shown to be a tumor marker for carcinoma lung as well as head and neck cancer where its mean levels have been shown to be raised compared to the normal controls. The levels have been reported to be significantly higher in patients with an advanced stage of cancer (stage III or IV) than in those with stage I or II cancer. A significant decline in serum ferritin was seen 5 months after the completion of successful treatment. In patients with no evidence of clinical disease, 5 years after treatment, ferritin levels essentially returned to normal. Furthermore, ferritin levels showed a tendency to increase or remained at higher levels in patients with a poor prognosis and decreased in those with a favorable prognosis (42). The average level of cellular retinol binding protein in the marginal areas of head and neck tumors has been reported to be higher than in the central area of the tumor (43). A wide range of CAMP binding proteins have been shown to be present in the tumor tissues from different sites of the head and neck suggesting that there appears to be a subgroup of parotid adenomas with increased CAMP binding activity (44). TUMORSPECIFIC ANTIGENS Elevated levels of purified tumor antigen (TA-4) have been observed in 77% of the patients with known squamous cell carcinoma of the uterine cervix (45). Its serum levels correlated well with the extent of the disease as well as with successful therapy (46,47). Because it was found that TA-4 is not a CLINICAL BIOCHBMISTBY, VOLUME27, AUGUST1994

BIOCHEMICAL STUDIES IN HEAD AND NECK CANCER

single substance but a combination of at least 14 proteins with a common antigenic site, it was further purified by isoelectric focusing and termed as squamous cell carcinoma antigen @CC-antigen). Although a majority of the head and neck cancer patients are of squamous cell carcinoma, only about 50% of the patients with head and neck carcinoma had elevated pretreatment levels. The levels however, correlated with the stage of the disease (48). At the time of clinical recognition of recurrence, the SCC-antigen level was normal, but metastasis to regional lymph nodes or to remote organs was generally accompanied by an increase in SCC-antigen (49). The serum levels of SCC-antigen, trypsin protease activator (TPA), and carcinoembryonic antigen (CEA) have been studied in patients with head and neck neoplasia and healthy patients. SCCantigen concentrations were significantly increased in 43.4% of the cancer patients with respect to the cut-off point value of the control group; the speciflcity was 96.7%. The data varied according to the evolutive phase of the disease. The combined evaluation of SCC-antigen, TPA, and CEA increased the sensitivity that was 71.0% (50). The clinical value of SCC-antigen has also been evaluated with plasma lipid associated sialic acid (LASA) in patients who were receiving care for: untreated, nonrecurrent cancers of the head and neck; routine surveillance for recurrence of such cancer; or in a few, treatment of chronic nonmalignant otolaryngologic conditions. For comparison the patients were divided into two groups according to their disease status, that is, with disease who had histologically confirmed cancer of the head and neck or disease-free who showed no evidence of cancer according the routine follow-up that consisted of history, physical examination, and standard laboratory (including biopsy in some cases) and radiological tests for a follow-up period of 6 months after determination of the tumor marker levels. It is reported that neither SCC nor LASA alone is sufficiently sensitive to effectively detect early cancers of the head and neck. Applying standard normal limits used alone, LASA test sensitivity was 63.4% and specificity was 77.9%. For SCC-antigen alone, test sensitivity was 27.6% and specificity was 85%. When results of both the tests in series combination were positive, sensitivity was 18.7% and specificity was 95%. If either was positive in parallel combination, sensitivity was 72.4% and specificity was 68%. They suggested that further evaluation is required that applies different definitions of normal and that determines longitudinal changes with disease status (51). The diagnostic value of different carbohydrate antigens, CA 19-9, CA 125, and CA 15-3, with CEA and SCC-antigen have also been evaluated for the detection of recurrent tumors in patients with head and neck cancer. An increase in SCC-antigen was found in 33% of the patients with cancer of the oral cavity but in those patients in whom the tumor recurred, the increase was observed in 75% of the patients. Although CEA alone was elevated in 45% of CLINICAL BIOCHEMISTRY, VOLUME 27, AUGUST 1994

the patients, it failed to drop after treatment as SCC-antigen did. Nor was there, in contrast to the SCC-antigen, any evident correlation with tumor volume. It is suggested that the estimations of CA 19-9, CA 125, and CA 15-3 exhibit poor sensitivity because these were not found to be significantly altered (52). Carcinoembryonic antigen (CEA) is an oncofetal glycoprotein that occurs physiologically in the fetal large intestine and in some other tissues. From these sources it makes its way into the peripheral circulation. Pathologically, CEA is synthesized primarily by tissues of entodermal origin in both malignant and benign processes, limiting its use as a single-stage screening test. It is reported that CEA levels are not predictive of survival and are not likely to assist in prognosis after therapy but did correlate with tumor burden and may have a value in monitoring tumor response (531. Elevated CEA levels are seen in the serum of one-third to one-half of the patients with squamous cell carcinoma of the head and neck and with breast cancer (53,541. Further, the increase in CEA has been shown to be directly proportional to the stage of cancer in patients with adenocarcinoma of the colon, breast, and esophagus. CEA levels in serum, usually accurately mirror the state of the malignant process. A clinical response to treatment is matched by a decline in serum CEA level. Total remission is signaled by a fall in CEA level to within the normal range (54). Compared to the controls, a nearly twofold increase in mean serum CEA concentration was observed in the group of patients with head and neck cancer. The rise, however, was nearly the same in all the patients studied, irrespective of the site or character of the lesion, but in a majority of them it was directly proportional to the stage of cancer or to the presence of lymph node metastasis. After radiotherapy, serum CEA levels were reduced to normal in all patients (16). Serum levels of immunosuppressive acidic protein (LAP) have also been assayed in patients with head and neck cancer. The mean value of IAP has been found to be significantly higher in patients in advanced stages than in the early stages. A further significant increase in the mean concentration of serum IAP was also observed in patients with a recurrence than in those in the advanced stages. In the end-stage patients, IAP concentration was considerably elevated and the blastogenesis response showed a significant fall, The authors suggested that the combination of serum IAP with other immunological parameters aids in planning and assessing clinical staging in head and neck cancer patients (55). Patients with head and neck primary cancers also demonstrate various degrees _of oncofetal antigen (OFA) positivity. These oncofetal antigens are proteins expressed during periods of embryonal/fetal development and on malignant cells. These are proposed to represent protooncogenes, active during fetal development and malignant growth in head and neck squamous cell carcinoma (56). 239

LAL

Of the five major classes of immunoglobulins, only IgA and IgE have been reported to be involved with the host tumor interaction in head and neck cancer patients (57). A significant elevation in mean level of serum IgA and IgE has been observed in these patients, compared to the healthy controls and to patients with chronic laryngitis. Levels above the upper limit were detected in 40.9% for IgE and 43.9% for IgA in the cancer patients. Serum IgG and IgM levels however, were found to be in the range of the control group. The patients with relapses in the follow-up, were found to have pretherapeutically significant higher levels of both IgA and IgE in comparison with those without evidence of the disease for more than 6 months (58). They suggested that determination of serum IgA and IgE in patients with head and neck cancer might be applicable as parameters for monitoring malignant disease being additionally of some prognostic significance. When compared to the normal population, the mean serum IgA levels have been shown to be increased in squamous cell carcinoma of the head and neck. The levels remained elevated well into the posttreatment period of 5-7 months. The mean IgG and IgM concentrations were significantly elevated pretherapeutitally but returned to normal in the posttherapy period (59). On the other hand it is also reported that the young adult head and neck cancer patients (~40 years-of-age) had significantly increased lymphocyte numbers and mean serum IgG, IgA, and IgM levels (60). They suggested that these young cancer patients cannot be considered to be immunosuppressed. IgE is only about 0.004% of the total immunoglobulins present in the blood. There are various reports about it in different types of cancer. The levels have been shown to be raised in patients with Hodgkin’s disease and reported to remain normal in various other types of cancers but reduced in B-cell malignancy, multiple myeloma, and chronic lymphocytic leukemias. Increase in serum IgE was observed in all patients with various sites of cancer in the head and neck region other than carcinoma of the tonsil. The mean rise was nearly sixfold larger than the controls. The increase in serum IgE in these patients was directly proportional to the stage of cancer. The levels did not change and remained higher even after the completion of radiotherapy (17). It is suggested that the elevation in serum IgE in these patients could be due to a reduction in T-cell regulators of IgE production (61). In patients with carcinoma of the tonsil, although IgE concentrations were within the normal range, the mean value was found to be reduced to about 50%. The reduced levels of serum IgE in carcinoma tonsil could be a result of the reduced rate of IgE synthesis, due to the production of tissue specific humoral mitotic inhibitors or chalones (17). Immunoglobulin allotypes Gim, Gzm, Gsm, AIM, 240

and Km(l) have also been determined in patients with head and neck cancer with or without multiple primary tumors. In head and neck cancer patients with multiple primary tumors, Km(l) is absent. It is suggested that head and neck cancer patients lacking Km(l) are susceptible to the development of new cancer and therefore should be screened thoroughly for more tumors (62). Circulating immune complexed IgA (IgA-IC) levels have also been studied in patients with various types of cancers. There was no significant difference between the benign surgery patients tested and the normal blood donors. The mean IgA-IC for each cancer group tested, that is, head and neck cancer, nasopharyngeal carcinoma, lung cancer, and colon cancer, was significantly elevated over both the normals and the benign surgery controls. The mean IgA-IC levels remain elevated throughout the follow-up period of 2 years, regardless of treatment. It is suggested that the prolonged IgA-IC response abnormal in head and neck cancer patients could be the result of continued host IgA antibody production directed against tumor cells that have escaped therapy an&or other unidentified stimuli, that is, viral antigens (63). MAGNESIUM Reduced levels of serum magnesium have been reported in patients with different types of cancers (64). There are also reports about higher contents of magnesium in malignant tissues as compared to normal tissue (65). It is well known that magnesium has an important role in duplication of DNA (66). Furthermore the malignant cells are characterized by uncontrolled multiplication and that their requirement of certain nutrients, particularly involved in cell multiplication, is increased. A significant reduction in serum magnesium level was observed in all the patients with head and neck cancer. The decrease in the mean value was nearly 50% of the mean value for the control group. The decrease was independent of the site or histopathology but was more pronounced with the advancement in the stage of malignancy. The decrease in serum magnesium during malignancy might be a consequence of the enhanced cellular uptake of magnesium by the malignant cells. Following radiotherapy, although levels were found to improve in 24 out of the 25 patients studied, the mean value remained lower than the controls (18). POLYAMINES It is suggested that the measurement of erythrocyte sperimidine and/or sperimine may offer potentially a simple and effective means of monitoring the course of therapy used in patients with head and neck cancer. Although only 31% of the patients studied had elevations of erythrocyte polyamines above the reference ranges determined for normal persons, a positive correlation was observed between the CLINICAL BIOCHEMISTRY, VOLUME27, AUGUST1994

BIOCHEMICALSTUDIESIN HEAD AND NECK CANCER

erythrocyte spermidine level and the clinical tumor stage. The small number of patients having elevation of erythrocyte polyamines concentration is in accordance with the relative infrequency of large tumors in the head and neck. After surgery as well as radiotherapy the levels of these polyamines were found to be decreased in 11 out of 12patients studied (671. Conclusion From the data reviewed above it can be concluded that the levels of a number of substances are raised while aliesterase and magnesium are reduced in patients with head and neck cancer. Some of them do alter with the site, stage, or histopathology of the cancer. Some of the parameters are normalized after radiotherapy. Table 3 summarizes the pretherapy (diagnostic) as well as posttherapy (prognostic) sensitivity of the various biochemical parameters studied in patients with head and neck cancer. As shown in the table, the estimations of serum PHI, &nucleotidase, and magnesium may aid in the diagnosis as well as prognosis of the disease. The decreased levels of aliesterase or the increased concentrations of TABLE3 Pre- and PosttherapySensitivity of Tumor Markers in Head and Neck Cancer Patients Sensitivity (%) Tumor Marker

Pretherapy

Posttherapy

Reference No.

Phosphohexose Isomerase Aliesterase Adenosine deaminase 5Nucleotidase y-Glutamyl transpeptidase Lactic dehydrogenase Ceruloplasmin SCC-antigen Lipid associated sialic acid (LASA) CEA SCC-antigen + TPA + CEA SCC-antigen + LASA IgA IgE (in all head and neck

80

90

9

100

30

10

90 100

NS 90

11 12

85

NS

13

50 95 25-50

NS

14 15 48,50-52

63.4 30-50

100

cancers)

IgE (in site other than tonsil) Magnesium Polyamines

::

51 16,52

71

-

50

72.4 43.9

-

:;

40.9

-

58

NS

17 18 67

100 100 31

z

NS, not significant @ > 0.05). CLINICAL BIOCHEMISTFtY, VOLUME 27, AUGUST 1994

adenosine deaminase, yv-GT, ceruloplasmin, SCCantigen in combination with TPA and CEA or SCCantigen with LASA may be some of the useful tumor markers for screening head and neck cancers. The estimation of IgE may be helpful in the diagnosis of the patients of head and neck cancers other than carcinoma of the tonsil. The estimation of these parameters however may not help in assessing the prognosis during follow-up. The estimations of CEA in serum or polyamines in erythrocytes may not be useful in the diagnosis of the disease but their serial estimations may help in the assessment of the prognosis of the disease. Presently, there are only isolated reports in patients with head and neck cancer. Due to the increasing incidence of the disease, the review may be a starting point documenting the need for more elaborate studies in such patients. References 1. Sellars SL. Epidemiology of oral cancer. Otol Clin NA 1979; 12: 45-55. 2. Cann CI, Pried MP, Rothman KJ. Epidemiology of squamous cell cancer of the head and neck. Otol Clin NA 1985; 18: 367-88. 3. Stevens MH, Gardner JW, Parkin JL, Johnson LP. Head and neck cancer survival and life style change. Arch Otolaryngoll983; 169: 746-9. 4. Marshall J, Graham S, Mettlin C. Diet in the epidemiology of oral cancer. Nutr Cancer 1982; 3: 145-9. 5. Sporn MB, Roberts AB. Role of retinoids in differentiation and carcinogenesis. Cancer Res 1983; 43: 3034-40. 6. Graham S, Mettlin C, Marshall J, Priore R, Rxepka T, Shedd D. Dietary factors in the epidemiology of cancer of the larynx. Am J Epidemioll981; 113: 675-80. 7. Brill AH. The TNM system for clinical staging of oral malignant tumors. Otol Clin NA 1979; 12: 69-72. 8. McGavren MH, Bauer WC, Ogura JH. The incidence of cervical lymph node metastasis from epidermoid carcinoma of the larynx and their relationship to certain characteristics of the primary tumor: A study based on the clinical and pathological findings in 196 patients treated by primary enbloc laryngectomy and radical neck dissection. Cancer 1961; 14: 55-66. 9. Goel H, Kohli GS, La1 H. Serum phosphohexose isomerase levels in patients with head and neck cancer. J Layngol Otol1986; loo: 581-5.

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