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Evaluation of serum fucose level in patients with oral cancer
Evaluation of serum fucose level in patients with oral cancer Madhumita Ghosh, M.D.S.,* M.R.V. Raghavan, M.D.S.,** B. R. Nayak, M.Sc., Ph.D.,*** and D. N. Bailoor, M.D.S.,**** KASTURBA
MEDICAL
Manipal,
India
COLLEGE
Serum fucose level was determined in 57 oral cancer patients and 25 normal persons before any treatment was performed. There was a significant rise in these levels in patients with oral cancer, and they correlated well with the clinical stages. This correlation is found to be exceedingly helpful in establishing the presence of and evaluating the extent of oral cancer. (ORAL SURC ORAL MED ORAL PATHOL 1988;65:418-20)
C
ancer is one of the most formidable health problems facing mankind today. Different cancers show different rates of incidence and distribution according to geographic parameters. On the Indian subcontinent, it is observed that, becauseof cultural, ethnic, and geographic factors and the popularity of addictive habits, the frequency of oral cancer is one of the highest in the world. Early diagnosis of cancer plays a life-saving pivotal role in the overall management of this disease. There is, however, a general dearth of specialized laboratory techniques that might give us prognostic pointers with respect to this perplexing disease. Biochemical studies involving the relationship of glycoprotein levels with malignancy’-s have been done, and in most studies, protein-bound hexose6and hexosamine6 in the carbohydrate-rich seromucoid fraction of blood has been measured. Because the carbohydrate of glycoproteins is composed of a relatively small number of different monosaccharides, a more recent trend has been to use the amount of a given monosaccharide as a measure of glycoprotein.‘,* One of these monosaccharides is L-fucose, a methyl pentose, which is usually a terminal sugar in most plasma glycoproteins and blood group substances as well as in tissue glycoproteins.9 The blood fucose level has been used as a biochem-
*Student, Department of Oral Medicine, Oral Diagnosis, and Radiology, College of Dental Surgery. **Associate Professor, Department of Oral Medicine, Oral Diagnosis, and Radiology, College of Dental Surgery. ***Reader, Department of Biochemistry. ****Lecturer, Department of Oral Medicine, Oral Diagnosis, and Radiology, College of Dental Surgery.
418
ical indicator of breast carcinoma7~10-‘3 and gynecologic cancers.I4 The t test has shown its rise to be highly significant when compared with the value for the normal control. There are few reports regarding oral cancer.‘5l16The concentration of serum fucose has also been found to be raised in certain other pathologic conditions such as tubercular meningitis,” Hand-Schtiller-Christian disease,” and rickets, but the number of patients studied was so small that statistical significance could not be determined. In light of the high prevalence of oral cancer, the present study has been undertaken to ascertain whether blood fucose level has any correlation to the existence of oral cancer and to determine whether the blood fucose level indicates in any way the prognosis and progress of this insidious disease. An attempt has also been made to further classify these casesinto different subgroups according to the clinical stagesdeveloped by the American Joint Committee for Cancer Staging and End Results Reporting and to see if there is any correlation between protein-bound fucose levels and progression of the disease. MATERIALS
AND METHOD
Fifty-seven oral cancer patients, with a mean age of 48.53 ? 11.95 years, who visited the Department of Oral Diagnosis, College of Dental Surgery, Manipal, were chosen for the study. The oral cancers were diagnosed on the basis of clinical and histopathologic evidence. Twenty-five adults (fifteen men and ten women), who had a mean age of 45.52 + 12.92 years and who were apparently normal, served as controls for our study.
Serum fucose level in oral cancer patients
Volume65 Number 4
I. Levels of serum fucose in normal controls and in cancer patients Table
(mean + SD)
Fucose (mg/lOO ml) (mean f SD)
45.52 + 12.92 48.53 k 11.95
8.64 k 0.56 19.38 IL 3.10
Age W Subjects
No.
Normal controls 25 Cancerpatients 57
II. Mean serum fucose levels in relation to clinical stage of disease Table
Clinical stage I I1 III
IV
About 4 to 5 ml of venous blood was drawn from patients, transferred to a plain tube, and allowed to clot. The clot was separated and the serum was centrifuged to get a clear serum sample. The assayswere performed within 12 to 24 hours of receipt of the samples.The protein-bound fucose was estimated by the method of Dische and Shettles,l* as adopted by Winzler.19 OBSERVATION
AND RESULTS
Data pertaining to the serum fucose levels in the oral cancer patients on the normal controls are presented in Tables I and II. An analysis of variance (ANOVA) was done with the hypothesis that all stages were equivalent. The results were as follows: F Source of variation df SS MS 3 296.8097 98.9366 24.3249 Between-stage 53 215.5675 4.0673 Within-stage 56 512.3772 Total SS stands for sum of square, MS for mean sum of square, and F for Fisher’s F-statistic. (Hence the hypothesis is rejected; i.e., there is significant difference between stages.) t values Stage IV Stage II Stage III Stage 1 2.71-c-2.565-3.78* 4 5.14 1 * 5.61 COMMENTS Between Stages I and II - Significant at 5% level of significance. - Insignificant at 1% level of significance. Between Stages II and III - Same as above. Between Stages III and IV - Significant. Between Stages I and III and Stages II and IV - Highly significant. DISCUSSION
The average serum fucose level in 25 controls in the present series was in accord with the findings of Winzler19 (average serum fucose level of 8.9 + 0.6 mg/dl) and Deyasi et al*O(mean fucose value of 8.56 mg/lOO ml). A marked elevation of serum fucose values was
419
No. of patients 06 10 21 20
Fucose (mg/lOO ml) Mean t SD 14.33 17.15 19.14 21.53
f 0.98 of- 0.82 + 1.64 k 2.75
Minimum 13 16 16 16
Maximum 16 18.5 22 25.5
observed in all patients in the present study, and this was in concurrence with the findings of Macbeth and Bekesi,‘,8 Rosato,** Barlow and Dillard,14 Deyasi et al.,*ODutta et al.,“j and Agarwal et al.‘j A correlation of the protein-bound fucose levels with the clinical stagesof oral cancer was done in the present study, and the changes in the serum fucose values at every stage correctly mirrored the clinical assessment of the patient’s disease (Table II, ANOVA table). The differences between control and the stages were subjected to the t test for statistical significance. The significances seen were as follows: Control versus stage II (p < 0.001) = Highly significant Control versus stage III 0, < 0.001) = Highly significant Control versus stage IV (p < 0.001) = Highly significant Before we discuss and evaluate the variation of serum levels of fucose, it is imperative that the basic pathophysiology of serum glycoproteins be understood and that a rational explanation be generated so as to get to the crux of this puzzling problem. Various views have been put forward by several workers. Seibert et a1.4advanced the hypothesis that elevation of serum glycoproteins above the normal level reflected processesof tissue destruction; Catchpole21was of the view that serum glycoprotein levels may rise as a result of the depolymerization of ground substance of the connective tissue, with the release of solubilized
components into the circula-
tion. Glycoproteins are believed to behave much like blocking antibodies; that is, by blocking tumor antigens, they may help the tumor escapedetection by the immune surveillance system.*?In fact, glycoprotein levels correlate better with the American Joint Committee staging system than any other tests, such as skin-testing, T lymphocyte counts, in vitro T cell activity testing, and study of lymph-node morphology from resected specimens.22This suggests that, in
420
Ghosh et al.
the future, a simple serum chemistry assay may assist in determining tumor stage and prognosis? SUMMARY
AND CONCLUSION
Serum protein-bound fucose level was measured in 25 normal persons and 57 oral cancer patients. The fucose value obtained for the normal subjects was 8.64 f 56 mg/lOO ml, and the fucose level of the sera of thecancer patients was 19.38 + 3.10 mg/lOO ml. It was also observed that there is a correlation between the stage of the carcinoma and the magnitude of elevation of the serum values. We are indebted to Atanushasan Basu, M.Sc., for assistance in computing the statistical part of this article. REFERENCES 1. Butler LO. The polarographic serum test and other serum tests in the prognosis of cancer. Br J Cancer 1951;5:225-34. 2. Riegel C, Jones Jr R, Welch KJ, Valentine J. Study of tryptophan-acid and iodoacetate index tests in patients with malignancy. Cancer Res 1951;11:453-6. 3. Seibert FB, Pfaff ML, Seibert MV. A serum polysaccharide in tuberculosis and carcinoma. Arch Biochem 1948;18:27995. 4. Seibert FB, Seibert MV, Anto AJ, Campbell HW. Variation in protein and polysaccharide content of sera in the chronic diseases, tuberculosis, sarcoidosis, and carcinoma. J Clin Invest 1947;26:90-102. 5. Shetlar MR, Foster JV, Kelly KH, Shetlar CL, Bryan RS, Everett MR. The serum polysaccharide level in malignancy and in other pathological conditions. Cancer Res 1949;9:5159. 6. Almquist PO, Lausing E. A study of serum glycoproteins in cancer. Stand J Clin Lab Invest 1957;9:179-89. I. Macbeth RAL, Bekesi JG. Plasma glycoproteins in various disease states including carcinoma. Cancer Res 1962; 22:1170-5. 8. Macbeth RAL, Bekesi JG. Plasma glycoproteins in malignant disease. Arch Surg 1964;88:633-7.
Oral Surg April 1988 9. Spiro RG. Advances in protein chemistry. Vol. 27. New York: Academic Press, 1973:350. 10. Arya DB, Bhatnagar JK. Evaluation of serum fucose levels. Ind J Surg 1974;36:224-8. 11. Rosato FE. Serum glycoproteins in the evaluation of breast cancer. Surg Gynecol Obstet 1967;124:1291-4. 12. Rosato FE. Glycoproteins in mammary cancer. Ann Surg 1968;168:818-20. 13. Rosato FE, Seltzer MH. Serum protein-bound fucose and carcinoma of the female breast. Am J Surg 1969;118:61-4. 14. Barlow JJ, Dillard PH. Serum protein bound fucose in patients with gynecologic cancers. Obstet Gynecol 1972; 391127-34. 15. Agarwal DP, Punia DP, Nawalkha PL, Khuteta KP. Effect of therapeutic irradiation on serum fucose levels in patients of oral cancer. Indian J Radio1 1980:34:255-9. 16. Dutta TK, Sengupta U, Gupta BD. Clinical evaluation of serum protein bound fucose as a diagnostic and prognostic index in malignant tumours. Indian J Cancer 1976;13: 262-6. 17. Sharma NC, Sur BK. Serum fucose and sialic acid levels in Indian children and adults under normal and pathological conditions. Indian J Med Res 1967;55:380-4. 18. Dische Z, Shettles LB. A specific colour reaction of methylpentoses and a spectrophotometric micromethod for their determination. J Biol Chem 1948;175:595-604. 19. Winzler RJ. In: Glick D, ed. Methods of biochemical analysis. Vol. II. New York: Interscience Publishers, 1955:294. 20. Deyasi SK. Aikat BK, Sengupta U. Serum fucose in the diagnosis of malignancy and its relative merits. Indian J Path01 Bacterial 1975;18:16-20. 21. Catchpole HR. Serum and tissue glycoprotein in mice bearing transplantable tumours. Proc Sot Exp Biol Med 1950;75: 221-3. 22. Dichtel WJ. immunologic aspects of head and neck cancer. Ear Nose Throat J 1981;60:97-106. Reprint requests to. Dr. Madhumita Ghosh Flat 202 Dover Co-Operative Housing Society 51D, Gariahat Road Calcutta-700019, India
MEDICAL
Manipal,
India
COLLEGE
Serum fucose level was determined in 57 oral cancer patients and 25 normal persons before any treatment was performed. There was a significant rise in these levels in patients with oral cancer, and they correlated well with the clinical stages. This correlation is found to be exceedingly helpful in establishing the presence of and evaluating the extent of oral cancer. (ORAL SURC ORAL MED ORAL PATHOL 1988;65:418-20)
C
ancer is one of the most formidable health problems facing mankind today. Different cancers show different rates of incidence and distribution according to geographic parameters. On the Indian subcontinent, it is observed that, becauseof cultural, ethnic, and geographic factors and the popularity of addictive habits, the frequency of oral cancer is one of the highest in the world. Early diagnosis of cancer plays a life-saving pivotal role in the overall management of this disease. There is, however, a general dearth of specialized laboratory techniques that might give us prognostic pointers with respect to this perplexing disease. Biochemical studies involving the relationship of glycoprotein levels with malignancy’-s have been done, and in most studies, protein-bound hexose6and hexosamine6 in the carbohydrate-rich seromucoid fraction of blood has been measured. Because the carbohydrate of glycoproteins is composed of a relatively small number of different monosaccharides, a more recent trend has been to use the amount of a given monosaccharide as a measure of glycoprotein.‘,* One of these monosaccharides is L-fucose, a methyl pentose, which is usually a terminal sugar in most plasma glycoproteins and blood group substances as well as in tissue glycoproteins.9 The blood fucose level has been used as a biochem-
*Student, Department of Oral Medicine, Oral Diagnosis, and Radiology, College of Dental Surgery. **Associate Professor, Department of Oral Medicine, Oral Diagnosis, and Radiology, College of Dental Surgery. ***Reader, Department of Biochemistry. ****Lecturer, Department of Oral Medicine, Oral Diagnosis, and Radiology, College of Dental Surgery.
418
ical indicator of breast carcinoma7~10-‘3 and gynecologic cancers.I4 The t test has shown its rise to be highly significant when compared with the value for the normal control. There are few reports regarding oral cancer.‘5l16The concentration of serum fucose has also been found to be raised in certain other pathologic conditions such as tubercular meningitis,” Hand-Schtiller-Christian disease,” and rickets, but the number of patients studied was so small that statistical significance could not be determined. In light of the high prevalence of oral cancer, the present study has been undertaken to ascertain whether blood fucose level has any correlation to the existence of oral cancer and to determine whether the blood fucose level indicates in any way the prognosis and progress of this insidious disease. An attempt has also been made to further classify these casesinto different subgroups according to the clinical stagesdeveloped by the American Joint Committee for Cancer Staging and End Results Reporting and to see if there is any correlation between protein-bound fucose levels and progression of the disease. MATERIALS
AND METHOD
Fifty-seven oral cancer patients, with a mean age of 48.53 ? 11.95 years, who visited the Department of Oral Diagnosis, College of Dental Surgery, Manipal, were chosen for the study. The oral cancers were diagnosed on the basis of clinical and histopathologic evidence. Twenty-five adults (fifteen men and ten women), who had a mean age of 45.52 + 12.92 years and who were apparently normal, served as controls for our study.
Serum fucose level in oral cancer patients
Volume65 Number 4
I. Levels of serum fucose in normal controls and in cancer patients Table
(mean + SD)
Fucose (mg/lOO ml) (mean f SD)
45.52 + 12.92 48.53 k 11.95
8.64 k 0.56 19.38 IL 3.10
Age W Subjects
No.
Normal controls 25 Cancerpatients 57
II. Mean serum fucose levels in relation to clinical stage of disease Table
Clinical stage I I1 III
IV
About 4 to 5 ml of venous blood was drawn from patients, transferred to a plain tube, and allowed to clot. The clot was separated and the serum was centrifuged to get a clear serum sample. The assayswere performed within 12 to 24 hours of receipt of the samples.The protein-bound fucose was estimated by the method of Dische and Shettles,l* as adopted by Winzler.19 OBSERVATION
AND RESULTS
Data pertaining to the serum fucose levels in the oral cancer patients on the normal controls are presented in Tables I and II. An analysis of variance (ANOVA) was done with the hypothesis that all stages were equivalent. The results were as follows: F Source of variation df SS MS 3 296.8097 98.9366 24.3249 Between-stage 53 215.5675 4.0673 Within-stage 56 512.3772 Total SS stands for sum of square, MS for mean sum of square, and F for Fisher’s F-statistic. (Hence the hypothesis is rejected; i.e., there is significant difference between stages.) t values Stage IV Stage II Stage III Stage 1 2.71-c-2.565-3.78* 4 5.14 1 * 5.61 COMMENTS Between Stages I and II - Significant at 5% level of significance. - Insignificant at 1% level of significance. Between Stages II and III - Same as above. Between Stages III and IV - Significant. Between Stages I and III and Stages II and IV - Highly significant. DISCUSSION
The average serum fucose level in 25 controls in the present series was in accord with the findings of Winzler19 (average serum fucose level of 8.9 + 0.6 mg/dl) and Deyasi et al*O(mean fucose value of 8.56 mg/lOO ml). A marked elevation of serum fucose values was
419
No. of patients 06 10 21 20
Fucose (mg/lOO ml) Mean t SD 14.33 17.15 19.14 21.53
f 0.98 of- 0.82 + 1.64 k 2.75
Minimum 13 16 16 16
Maximum 16 18.5 22 25.5
observed in all patients in the present study, and this was in concurrence with the findings of Macbeth and Bekesi,‘,8 Rosato,** Barlow and Dillard,14 Deyasi et al.,*ODutta et al.,“j and Agarwal et al.‘j A correlation of the protein-bound fucose levels with the clinical stagesof oral cancer was done in the present study, and the changes in the serum fucose values at every stage correctly mirrored the clinical assessment of the patient’s disease (Table II, ANOVA table). The differences between control and the stages were subjected to the t test for statistical significance. The significances seen were as follows: Control versus stage II (p < 0.001) = Highly significant Control versus stage III 0, < 0.001) = Highly significant Control versus stage IV (p < 0.001) = Highly significant Before we discuss and evaluate the variation of serum levels of fucose, it is imperative that the basic pathophysiology of serum glycoproteins be understood and that a rational explanation be generated so as to get to the crux of this puzzling problem. Various views have been put forward by several workers. Seibert et a1.4advanced the hypothesis that elevation of serum glycoproteins above the normal level reflected processesof tissue destruction; Catchpole21was of the view that serum glycoprotein levels may rise as a result of the depolymerization of ground substance of the connective tissue, with the release of solubilized
components into the circula-
tion. Glycoproteins are believed to behave much like blocking antibodies; that is, by blocking tumor antigens, they may help the tumor escapedetection by the immune surveillance system.*?In fact, glycoprotein levels correlate better with the American Joint Committee staging system than any other tests, such as skin-testing, T lymphocyte counts, in vitro T cell activity testing, and study of lymph-node morphology from resected specimens.22This suggests that, in
420
Ghosh et al.
the future, a simple serum chemistry assay may assist in determining tumor stage and prognosis? SUMMARY
AND CONCLUSION
Serum protein-bound fucose level was measured in 25 normal persons and 57 oral cancer patients. The fucose value obtained for the normal subjects was 8.64 f 56 mg/lOO ml, and the fucose level of the sera of thecancer patients was 19.38 + 3.10 mg/lOO ml. It was also observed that there is a correlation between the stage of the carcinoma and the magnitude of elevation of the serum values. We are indebted to Atanushasan Basu, M.Sc., for assistance in computing the statistical part of this article. REFERENCES 1. Butler LO. The polarographic serum test and other serum tests in the prognosis of cancer. Br J Cancer 1951;5:225-34. 2. Riegel C, Jones Jr R, Welch KJ, Valentine J. Study of tryptophan-acid and iodoacetate index tests in patients with malignancy. Cancer Res 1951;11:453-6. 3. Seibert FB, Pfaff ML, Seibert MV. A serum polysaccharide in tuberculosis and carcinoma. Arch Biochem 1948;18:27995. 4. Seibert FB, Seibert MV, Anto AJ, Campbell HW. Variation in protein and polysaccharide content of sera in the chronic diseases, tuberculosis, sarcoidosis, and carcinoma. J Clin Invest 1947;26:90-102. 5. Shetlar MR, Foster JV, Kelly KH, Shetlar CL, Bryan RS, Everett MR. The serum polysaccharide level in malignancy and in other pathological conditions. Cancer Res 1949;9:5159. 6. Almquist PO, Lausing E. A study of serum glycoproteins in cancer. Stand J Clin Lab Invest 1957;9:179-89. I. Macbeth RAL, Bekesi JG. Plasma glycoproteins in various disease states including carcinoma. Cancer Res 1962; 22:1170-5. 8. Macbeth RAL, Bekesi JG. Plasma glycoproteins in malignant disease. Arch Surg 1964;88:633-7.
Oral Surg April 1988 9. Spiro RG. Advances in protein chemistry. Vol. 27. New York: Academic Press, 1973:350. 10. Arya DB, Bhatnagar JK. Evaluation of serum fucose levels. Ind J Surg 1974;36:224-8. 11. Rosato FE. Serum glycoproteins in the evaluation of breast cancer. Surg Gynecol Obstet 1967;124:1291-4. 12. Rosato FE. Glycoproteins in mammary cancer. Ann Surg 1968;168:818-20. 13. Rosato FE, Seltzer MH. Serum protein-bound fucose and carcinoma of the female breast. Am J Surg 1969;118:61-4. 14. Barlow JJ, Dillard PH. Serum protein bound fucose in patients with gynecologic cancers. Obstet Gynecol 1972; 391127-34. 15. Agarwal DP, Punia DP, Nawalkha PL, Khuteta KP. Effect of therapeutic irradiation on serum fucose levels in patients of oral cancer. Indian J Radio1 1980:34:255-9. 16. Dutta TK, Sengupta U, Gupta BD. Clinical evaluation of serum protein bound fucose as a diagnostic and prognostic index in malignant tumours. Indian J Cancer 1976;13: 262-6. 17. Sharma NC, Sur BK. Serum fucose and sialic acid levels in Indian children and adults under normal and pathological conditions. Indian J Med Res 1967;55:380-4. 18. Dische Z, Shettles LB. A specific colour reaction of methylpentoses and a spectrophotometric micromethod for their determination. J Biol Chem 1948;175:595-604. 19. Winzler RJ. In: Glick D, ed. Methods of biochemical analysis. Vol. II. New York: Interscience Publishers, 1955:294. 20. Deyasi SK. Aikat BK, Sengupta U. Serum fucose in the diagnosis of malignancy and its relative merits. Indian J Path01 Bacterial 1975;18:16-20. 21. Catchpole HR. Serum and tissue glycoprotein in mice bearing transplantable tumours. Proc Sot Exp Biol Med 1950;75: 221-3. 22. Dichtel WJ. immunologic aspects of head and neck cancer. Ear Nose Throat J 1981;60:97-106. Reprint requests to. Dr. Madhumita Ghosh Flat 202 Dover Co-Operative Housing Society 51D, Gariahat Road Calcutta-700019, India